Volume XXXVI
JANUARY
1938
Number
1
>
9
United States "
Naval
Medical Bulletin
Published for the Information of
Medical Department
of the Navy
■
THE MISSION OF THE MEDICAL CORPS OF THE NAVY
•
TO KEEP AS MANY MEN AT AS MANY GUNS
AS MANY DAYS AS POSSIBLE
Issued Quarterly by the Bureau of Medicine and Surgery
Washington,
D. C.
Vol. XXXVI
JANUARY
1938
No.
1
UNITED STATES
NAVAL
MEDICAL BULLETIN
Published Quarterly for the Information of
the Medical Department
of the Navy
Issued by
l^ j,
DIVISION OP PUBLICATIONS
THE BUREAU
OF MEDICINE
AND SURGERY
A
NAVY DEPARTMENT
Compiled
and published
under the authority of Naval Appropriation
Act for 1937-38, approved
April 27, 1937
i
UNITED
STATES
GOVERNMENT PRINTING
OFFICE
WASHINGTON : 1937
For sale by the Superintendent
of Documents,
Washington,
D. C.
See page 11for price
Navy Department,
Washington,
March 20, 1907.
This United States Naval Medical Bulletin
is published by
direction of the Department for the timely information
of the Medi
cal and Hospital Corps of the Navy.
Truman H. Newberry,
Acting Secretary.
Owing
to exhaustion
of certain
numbers
of the Bulletin
and
the frequent
demands from libraries,
etc., for copies to complete their
files,
the return
of any
of the following
issues will be greatly appreciated:
Volume IX, 1915, No.
1.
Volume X, 1916, No.
2.
Volume XI, 1917, No.
3.
Volume XII, 1918, Nos.
1 and 3.
Volume XXIV,
1926, Nos.
1 and 4.
Volume XXV,
1927, No.
1.
Volume XXVII,
1929, Nos. 3 and 4.
Volume XXVIII, 1930, No. 3.
Volume XXXIV,
1936, Nos.
1, 2, and 4.
Volume XXXV, 1937,
No.
1.
Subscription
Price of the Bulletin
Subscription
should
be
sent
to
Superintendent
of
Documents,
Government
Printing Office, Washington,
D. C.
Yearly
subscription,
beginning
July
1,
$1; for foreign
subscriptions
add
35
cents for postage.
Single numbers,
domestic,
25 cents; foreign,
35 cents, which
includes
foreign
postage.
Exchange
of
publications
will
be
extended
to
medical
scientific
organiza
tions,
societies,
laboratories,
and
journals.
Communications
on
this
subject
should
be addressed to the Surgeon
General, United States Navy,
Washington,
D.C.
n
TABLE OF CONTENTS
Pig*
PREFACE
vn
NOTICE
TO SERVICE
CONTRIBUTORS
viu
SPECIAL ARTICLES:
Diabetes
and Protamine Insulin.
i
By Elliott P. Joslin, M. D., Boston
1
J Compbessed-Air Illness.
By
Charles
W.
Shilling,
Lieutenant,
Medical
Corps,
United
States Navy
9,
Treatment
or
Hay
Fever
With
Alum-Precipitated
Pollen
Extract.
By Robert F.
Sledge,
Lieutenant
Commander,
Medical Corps,
United States Navy
18
Malaria.
By W. H.
Michael,
Commander,
Medical Corps,
United States
Navy
29
Barbiturate
Poisoning.
By F. L. McDaniel,
Commander,
Medical Corps, United States
Navy, and Robert A. Bell,
Lieutenant,
Medical
Corps, United
States Navy
32
Cahboxide Poisoning.
By J. D.
Blackwood,
Jr.,
Lieutenant
Commander,
and
E.
B.
Erskine,
Lieutenant,
Medical
Corps,
United States Navy
44
The Sulfanilamide Therapy
op Gonorrhea.
By R. H. Snowden,
Commander,
Medical Corps, United States
Navy, and Robert A. Bell,
Lieutenant
Medical Corps, United
States Navy
45
Sulfanilamide Treatment of Ludwig's
Angina.
By James E. Fulghum,
Lieutenant,
Medical
Corps, United States
Naval Reserve
68
Psychosis Precipitated by Sulfanilamide.
By Bartholomew
W. Hogan,
Lieutenant,
Medical Corps, United
States
Navy,
and
Philip J.
McNamara,
Lieutenant,
junior
grade, Medical
Corps, United States Navy
60
Sulfanilamide Poisoning.
By J. T.
O'Connell,
Lieutenant
Commander,
Medical
Corps,
United States Navy
61
Results of Sulfanilamide Therapy of Gonorrhea.
By
E.
R.
Hering,
Lieutenant,
Medical
Corps,
United
States
Navy
63
Chondrodystrophy
Fetalis.
By Willard S. Sargent,
Lieutenant
Commander,
Medical
Corps,
United
States Navy
67
The Cancer Problem
in the United
States Navy.
By
Otis
B.
Spalding,
Lieutenant
Commander,
Medical
Corps,
United
States Navy
74
m
IV
TABLE
OF
CONTENTS
SPECIAL ARTICLES—Continued.
Fig.
Carcinoma op the Lung.
By Irving J. Warmolts,
Lieutenant,
Medical
Corps, United
States
Navy
79
Bronchogenic
Carcinoma.
By Irwin L. Norman,
Lieutenant,
Medical
Corps, United States
Navy, and William M. Sffliphant,
Lieutenant,
Medical
Corps,
United
States Navy
. -
89
CLINICAL NOTES:
Krukenbergs Spindle.
By Raymond
W. Hege, Lieutenant,
Medical
Corps, United States
Navy
95
Dental Neurosis.
By V. A. LeGlair,
Lieutenant,
Dental
Corps
United
States Navy.
97
Passive Algolagnia Masochism.
By James E. Fulghum,
Lieutenant,
Medical
Corps, United
States
Naval Reserve, Louieburg,
N. C
99
Atypical Lobar Pneumonia.
By A. J. Walter,
Lieutenant,
Medical
Corps, United States Navy,
and J. L. Holland,
Lieutenant,
Medical
Corps, United States
Navy
101
Atypical Meningococcic
Infection.
By W. H. Funk, Lieutenant
Commander,
Medical
Corps,
United
States Navy
104
Tularemia.
By Julian Love, Lieutenant,
Medical
Corps, United States Navy,
and Alfred
W. Eyer, Lieutenant,
Medical
Corps, United States
Navy...
105
Neutropenia
Following
the
Administration
of Neoarsphen-
amine.
By Albert R. Behnke,
Lieutenant,
Medical
Corps,
United
States
Navy
108
NAVAL RESERVE:
Symposium,
Humphreys
111
NOTES AND COMMENTS:
The
Twelfth
Surgeon
General,
United
States
Navy— The
Fleet
Hospital
Ship-— Blunders
of Plain Muscle —Treatment
of Surgical
Shock
With
Neo-Synephrin —The
Common
Cold —Cancer — Skin
Irritation
and Cancer
in the U.
S. Navy—Syphilis
Prophylaxis —
Articles
on Professional
Subjects —Articles
of Special Merit, 1937—
College
of Physicians
115
BOOK NOTICES:
The
Practice
of
Medicine,
Meakins —An Introduction
to
Medical
Science,
Boyd —Clinical
Allergy,
Manifestations,
Diagnosis
and
Treatment,
Rowc —Operative
Surgery,
Horsley
and
Bigger —Pre
operative
and
Postoperative
Treatment,
Mason —Handbook
of
Orthopaedic
Surgery,
Shands and Raney —Injuries and Diseases of
the Hip,
Albee
and
Preston —Diseases
of Infants and
Children,
Griffith
and
Mitchell—Medical
Treatment
of
Cataract,
Davis —
The Ocular
Fundus
in
Diagnosis
and
Treatment,
Atkinson — Mi
croscopical
Technique,
McClung— Flying
Vistas,
Jones —Dental
Pharmacology
and
Therapeutics,
Blayney — Essentials
of
Oral
Surgery, Blair and Ivy
125
TABLE
OF
CONTENTS
V
PREVENTIVE MEDICINE:
Pw
Toxic Effects of Arsenical Compounds
as Administered
in the
United States Navy,
1936.
By C. S. Stephenson, Commander,
Medical
Corps, United
States
Navy,
and E.
H.
Wingo,
Chief
Pharmacist's
Mate,
United
States Navy
131
Anti-Tetanus Toxoid.
By C. S. Stephenson, Commander,
Medical
Corps, United
States
Navy, and W. W. Hall, Commander,
Medical
Corps,
United
States Navy
150
Food Poisoning
on Board the U. S. S. "Nevada"
162
STATISTICS:
Health of the Navy
155
Injuries
and Poisonings
158
Morbidity
159
Deaths
160
Mental
and Physical Qualification of Recruits
161
PREFACE
The United States Naval Medical Bulletin was first issued in
April
1907
as a means for supplying medical
officers of the United
States
Navy with
information
regarding
the
advances
which
are
continually
being
made
in
the
medical
sciences,
and
as
a medium
for the publication of accounts
of special researches,
observations,
or
experiences of individual
medical
officers.
It is the aim of the Bureau of Medicine
and Surgery to furnish in
each issue special
articles
relating to naval medicine,
descriptions of
suggested
devices,
clinical notes
on interesting cases,
editorial com
ment
on current medical
literature of special professional
interest to
the naval
medical
officer,
and
reports
from various sources,
notes,
and comments
on topics of medical interest.
The Bureau extends an invitation
to all medical
and dental
officers
to prepare
and forward, with
a view to publication, contributions on
subjects of interest
to naval medical
officers.
In order that each service contributor may receive
due credit for
his efforts in preparing matter for the Bulletin of distinct originality
and special merit, the Surgeon
General of the Navy will send a letter
of commendation to authors of papers of outstanding merit.
The Bureau
does not necessarily
undertake to endorse
views
or
opinions which may be expressed in the pages of this publication.
P. S. Rossiter,
Surgeon
General, United States Navy.
vn
NOTICE TO SERVICE
CONTRIBUTORS
Contributions
to the Bulletin should
be typewritten,
double
spaced,
on plain
paper, and should have wide margins.
Fasteners
which will not tear the paper
when removed
should
be
used.
Nothing
should
be written
in the manuscript
which
is not intended
for publication.
For example, addresses,
dates, etc., not
a part
of the article,
require
deletion
by the editor.
The Bulletin endeavors
to follow
a uniform
style in heading and captions,
and the editor can be spared
much time and trouble, and unnecessary changes in manuscript
can be obviated
if authors will follow in these
particulars
the practice of recent issues.
The greatest accuracy
and fullness should
be employed
in all citations,
as it
has sometimes
been
necessary to decline articles
otherwise
desirable
because it
was impossible for the editor to understand
or verify references, quotations,
etc.
The frequency
of gross
errors in orthography
in many contributions
is conclusive
evidence that
authors
often fail to read over their manuscripts
after they have
been typewritten.
Contributions
must be received at least 3 months prior to the date of the issue
for which they are intended.
The editor is not
responsible for
the safe return
of manuscripts
and pictures.
All
materials
supplied
for
illustrations,
if not
original,
should
be accompanied
by reference to the source and
a statement
as to whether
or not reproduction
has been authorized.
The Bulletin intends
to print only original
articles,
translations, in whole
or
in part, reviews,
and
reports
and
notices
of Government
or
departmental
activities,
official announcements,
etc.
All original
contributions
are accepted
on the assump
tion
that
they
have
not
appeared
previously and
are
not
to
be reprinted
elsewhere
without an understanding to that
effect
and that editorial
privilege
is granted
to this
Bureau in preparing all material submitted for publication.
Eben
E.
Smith,
Editor,
Commander,
Medical
Corps, United States Navy.
vm
U S. NAVAL MEDICAL BULLETIN
Vol. XXXVI
January
1938
No.
1
SPECIAL ARTICLES
DIABETES
AND PROTAMINE
INSULIN
»
By Elliott P. Joslin, M. D., Boston
Insulin
was
wonderful,
spectacular,
miraculous.
Think
of
it,
children as
a
result of insulin, instead of dying within the year of the
onset
of their disease, now have
a life expectancy
above
30
years.
Coma, which used to carry off more than 60 percent of all the diabetics,
today
is
acknowledged
to be needless, and the mortality
has dropped
to about
10 percent,
and in the better clinics even during an attack
is
almost as low.
The age at death of diabetics as
a
whole has risen
from 44 to 63 years.
Truly, the metamorphosis
of the disease diabetes
is
stupendous.
A hint of what we may expect for diabetics in general
has
been
furnished by the course of the disease in doctors during this same period.
Some 300 of these have consulted
me for diabetes and the comparison
between
the
doctors
and
all patients for corresponding
age
groups
shows that whereas the mortality between the ages of 25 and 39 years
for doctors
is
10 per
1,000,
it
is
45 per
1,000 for all diabetics.
Even
at later age periods doctors far exceed the average diabetic.
A
proper
understanding of the disease should
dispel
coma and,
as
a
matter of
fact, but
3
percent of the doctors have succumbed
to
it
in recent years,
and there has not been
a
single death of a doctor in the group from
diabetic
coma
since
1925.
The
average
age at
death
for
doctors
generally,
is
63 years, but for my diabetic doctors,
68 years.
I
shall
never
cease to be grateful to the Metropolitan Life Insurance Co. for
the analyses by their statistical department of this group of doctors,
because
it
indicates how
much
better
the
possibilities
are for all
diabetic patients and forces us to revise our measures of medical
care.
Furthermore,
it
should
be remembered
that these advances
have
been accomplished
with regular insulin, dated from its first discovery
when
it
was an unknown quantity,
and do not depend
on the more
modern methods which have been introduced in the last
2
years.
The factor which has accomplished
so much for diabetics as
a
class
is
insulin, and for diabetic doctors in particular
is
insulin plus
a
knowl
edge of the disease.
That
is
the key to improvement in treatment.
'An
Informal
address
delivered
at the United
States Naval Medical Center, Washington,
D. C.
Pub
lished
concurrently
In the Military
Surgeon.
1
2
JOSLIN —INSULIN
THERAPY
We must make
the knowledge
of diabetes
more universal, so that in
the first place patients who have it will be discovered
more
closely
to the onset of the disease; second, that when they do acquire it they
will be able to take
advantage
of all modern
ways of alleviating it,
and third, so that both public and patients will grasp the idea that there
are simple measures which are now available for this purpose.
Above
all, however,
stands insulin which more than anything else has brought
this change
about and
therefore
whatever will promote
the
use of
insulin will improve the status of the diabetic.
The greatest impetus
to the extension of the use of insulin has been
the discovery of protamine insulin by Dr. Hagedorn of Copenhagen.
Already diabetics have caught the essential
feature of this discovery,
namely,
that instead of injecting many doses of insulin each day, one
injection will suffice.
It is true
this could not
be
accomplished
at
first with the protamine insulin as described by Doctor Hagedorn, but
it is a fact today, because of the improvement in protamine insulin
by combining it with zinc.
The simplicity of treatment with prota
mine zinc insulin as compared
with regular insulin is obvious to all.
Furthermore,
it is
safer
because reactions on
the
average
are less
frequent
and less severe, and as a rule are accompanied
with a warning
which the observant patient can recognize.
The control of the diabetes with protamine insulin is far better than
with regular insulin.
Regular insulin
acted for 8 hours
or less and
two
doses would only protect the patient for two-thirds of the day.
With protamine
insulin the duration of action and consequently
the
protection are for 24 and more hours.
The difference may seem slight
at first thought, but when
one considers
the duration of life of the
diabetic today which is certainly
12 years for all and for the average
new case more likely
20 years, it is evident that for 4 to 7 years
the
diabetic treated
with regular insulin would
be out of control.
And
it is the uncontrolled diabetic with whom we know that complications
are
more
frequent.
Before
the
discovery
of protamine
insulin I
almost shuddered
at the thought of what might happen
to the mass of
diabetics who lived for years because of the complications they might
develop,
but now with protamine insulin this worry to a large extent
can subside.
The diabetic taking protamine insulin stores glycogen
in his liver,
his muscles,
and skin, so that he resembles a normal individual.
He
begins his day with
a normal blood
sugar and without
the handicap
of a mild acidosis which took place to a greater or less extent during
the night when
his diabetes
was uncontrolled with regular insulin.
Indeed, being
so closely like a healthy individual,
when
he exercises
violently
he is exposed
to all the danger
a marathon runner would
undergo if he started his run fasting before breakfast.
JOSLIN —INSULIN
THERAPY
3
The original protamine insulin of Hagedorn acted for about 12 or
14 hours, so that most of us at first gave regular insulin before break
fast
and
protamine
insulin
in
the
afternoon.
The
improvement
through the addition of zinc has prolonged
its action for a day or more
so that little by little regular insulin has been rendered
unnecessary.
This advance in insulin therapy seems very simple but it dates back
to Miescher's work in 1868
when
he discovered
protamines, and to
Kossel's work in the final decade of the last century when he observed
that a protamine was a protein precipitant.
Still more recently it has
depended upon a whole group of workers chiefly in the United States
from Toronto to California.
Protamine
zinc insulin
does not deteriorate
as was first thought.
I have tested specimens which worked perfectly well after
6 months.
(Writing in July 1937, I can add that it will act much longer.)
The potency of the insulin is in the precipitate and therefore great
pains must be taken that the precipitate in the vial is carefully rotated
so that the particles are uniformly
diffused
in the bottle before it is
injected into the patient.
It is wonderful to me how well the patients
are able to do this, and it speaks much for the skill of the manufac
turers,
but I suspect it will not be long before even simpler prepara
tions will appear.
Incidentally I will add,
we have tried protamine
zinc insulin U80 and demonstrated
that it works perfectly well.
The technique
of administration of protamine zinc insulin is simple
providing one will bear in mind that its action is slow and persistent
for 24 and more hours.
One must remember
that diet must be ad
justed to this slow action.
This means that much food should not be
given at any
one meal but rather spread out through the day with
three meals and often
three lunches,
and second, that provision must
be made for exercise.
The
diabetic patient
taking protamine zinc
insulin is so nearly normal that with exercise he bums up his carbo
hydrate completely like a normal person,
and therefore
he must have
carbohydrate to burn.
One can lessen regular insulin by a few units
if exercise is contemplated,
but it does no good to lower protamine
insulin by a few units because the effect of its reduction would not be
manifest for many hours.
Consequently, instead
of lowering prota
mine zinc insulin by a few units for adjustment to exercise, one gives
extra carbohydrate.
Exercise favors the combustion of carbohydrate
with insulin, when either endogenous or exogenous insulin is available,
and therefore
this also must be borne in mind.
I think that most of
the reactions which I see from protamine insulin are due to the neglect
of this feature.
The patient is doing so well, is burning up his carbo
hydrate so entirely that when he exercises and demands
a little more
glycogen
there is none available and the blood sugar drops to an insulin
reaction level.
4
JOSLIN —INSULIN
THERAPY
The dietitian
has much more to do for the patient on protamine
insulin than for the one on regular insulin.
She can spread the meals
throughout the 24 hours, an earlier breakfast and a later evening meal.
She can see to it that the carbohydrate peaks at meals are reduced
by-
lunches
between meals and upon retiring, thus averting night acidosis
as well as reactions.
Furthermore,
by this spreading
of the carbo
hydrate throughout
the day its utilization
is improved.
Protamine
insulin is adaptable
to any diet but on the whole we have adopted
as an
optimum about 150 grams, although there are frequent exceptions.
In daily practice, protamine insulin
is ideal
for the fresh
case of
diabetes.
In various publications I have reported
a diabetic who was
placed on protamine insulin taking 10 units the first day,
20 units the
second day,
30 units the third day,
and 40 units the fourth day,
and
have noted a quick response in lowering of his glycosuria and his blood
sugar.
Such patients, however,
must be kept under close observation
because from day to day the protamine accumulates
and one must be
alert to see when
the dose required has been reached.
Thus, one of
our patients eventually took 50 units, but within
1 or 2 weeks,
she
dropped to 28 units, and several months later required but
12 units.
Similarly, I have seen patients drop their peak from 60 units of prota
mine insulin to
18 units and even less.
With such early discovered
patients, showing a high percentage
of
sugar in the urine, it is dramatic to have the sugar quantitated for the
first 24 hours and show the patient exactly how much he voids.
One
of our patients reported
having drunk
32 glasses of water before
the
diagnosis
was made and I computed
she was voiding
1 pound of sugar
daily.
When she saw its equivalent in a bottle and how day by day
the quantity
decreased
to
0 you can imagine
what an education
in
diabetes it was to her and what an example her case was to my diabetic
class.
There
are certain elderly
people
who
have
taken regular insulin
twice daily, 10-0-6 or even 10-0-10 units, and some of these patients
can be changed over to the protamine zinc insulin with the dose of 20
units injected before breakfast.
This is by no means always the case
and never should
one attempt to make
a transfer from regular insulin
to protamine insulin even when dealing with a mild diabetic unless he
is under daily observation, even though not in the hospital.
Cases like the two
groups
mentioned
above,
however,
include the
great
mass of diabetics
in
the country
and it is for
them
insulin
should
be used to the fullest extent,
because if they will learn how to
use
it,
certainly the danger of complications will drop.
For patients who
have
taken insulin for years
and
have
become
expert in its use
I
hesitate
to alter their course
and change over to
protamine zinc insulin
as long
as they are doing
well.
Otherwise
I
ask them to give us
1
or
2
weeks in the hospital and with the under
JOSLIN —INSULIN
THERAPY
5
standing that for a month or more after discharge
they will cooper
ate closely.
Unless this is done,
one is bound to get into difficulty
and if one single
case gets into difficulty it causes so much trouble
and talk that the 90 and 9 patients who rejoice
and are successful in
their use of protamine insulin are forgotten.
Please
remember
that
these cases above described
are often your best patients,
the most reli
able, and from whom you have learned much, and therefore have done
so well that the chances for a betterment
of their state
are far less
than for many others.
Consider how much these patients
have
learned
to adjust their
daily life to three doses of regular insulin, often
feeling
free to lessen
or raise the dose according
to whether they plan to go to a dance or a
dinner or both combined.
They understand
their reactions
to regu
lar insulin so well that they change it almost automatically according
to
their
needs.
Protamine
insulin
acts very differently,
however,
and it is not easy for these patients to learn how to adjust themselves
to it and we doctors cannot tell them easily.
In general when transferring from regular to protamine insulin the
patient, who before the transfer might be taking regular insulin 24-
0-18, would continue the same morning dose of regular insulin, but
would
be given
at
the
same
time
the
remaining units
of regular
insulin employed
during the day as protamine insulin.
Dr. Priscilla
White
says that with the children she often
doubles
the balance
of
units for the day ; thus the above patient might be given a prescription
of regular insulin,
24 units plus protamine insulin 36 units.
Gradu
ally thereafter,
one attempts to lower the regular insulin and often to
do
so one must increase
the
protamine insulin
to
offset
it.
Fre
quently one is gratified to find a patient who will react exceptionally
well to the change and others in the course of months who will change
from 10 units of regular insulin plus 40 units of protamine zinc insulin
to
50 units of protamine zinc insulin.
This of course
makes
treat
ment
very simple
for the patient and will
be still
easier when
U80
protamine zinc insulin is on the market.
Our
dependence
upon
the laboratory
is even greater
with prota
mine zinc insulin than with regular insulin, but in a somewhat
differ
ent manner.
Thus we use 24-hour specimens
with the total glucose
as guides of treatment much
more than for the last few years.
We
have
reverted
to carbohydrate and glucose
balances
of the Naunyn
and Allen eras.
A patient might be taking 150 grams of carbohydrate
and his urine is examined
several times
a day, some of the tests may
have
been yellow, or red, or orange with Benedict's solution.
The
patient gets discouraged,
but if.it is demonstrated
to him that these
specimens
represent
a small fraction of the 24 hours,
and the loss of
glucose is very slight, he is reassured.
The patient may void a single
specimen of urine containing even
3 percent
sugar but the aggregate
6
JOSLIN —INSULIN
THERAPY
glucose excreted very likely would not exceed 15 grams and if his diet
contained 150 grams carbohydrate it would show that, as a matter of
fact, he is 90 percent
controlled.
And this takes no account of glu
cose formed
from protein or fat.
More
and more I believe you will
see that the 24-hour tests of urine for patients using protamine zinc
insulin are valuable.
The second specimen
test is also most useful.
For years we have
utilized
that in differentiating between
coma and insulin
reactions.
The first specimen
voided might be confusing,
because during a reac
tion the urine might show
sugar,
because
hours
might have
inter
vened since the bladder was emptied, yet a second specimen would be
sugar-free.
This is in contrast to diabetic coma, in which the second
specimen
invariably
would
contain
sugar.
Then,
too,
the
second
specimen
is valuable for the patient on rising in the morning for the
same reason.
Repeatedly when we began with protamine zinc insulin
we made mistakes
and added regular insulin to the dosage with pro
tamine insulin for the patient
before
breakfast, when if we simply
had done a second test following the voiding of urine which collected
during the night we would
have found the patient sugar-free.
Capillary
blood sugars in contradistinction
to venous
blood
sugars
must be used far more extensively
in this country than hitherto, not
only for the sake of little children whose lives will be saved thereby,
but because you can do more
tests in one day with less annoyance
to the patient.
Furthermore,
so often patients with protamine zinc
insulin
are sugar-free
that
one is in
a quandary whether or not the
dose should
be changed,
but with
more
frequent blood
sugar
tests
one can
act
more
rationally.
The fasting capillary
blood
sugar
is
identical with that done upon venous
blood.
But after a meal one
must make
allowance
for
the
capillary,
blood
to
be
higher.
Arbi
trarily we have put the difference at 0.03 (30 milligrams) percent, but
of course this is not at all accurate.
I cannot say enough for the necessity
of a laboratory being avail
able day and night and holidays for diabetics.
In this way one can
secure
tests
which
are
of
the utmost
help
in treatment of coma.
Presumably
we have
had
at the New England
Deaconess
Hospital
about as many diabetic comas to treat as anywhere
and yet not one
of my colleagues
would forego
the help which we receive
from the
tests
of
blood
sugar,
carbon dioxide
combining
power,
salt,
and
nonprotein-nitrogen.
We cannot help
wondering how others
(who
have had less experience)
can get along without these aids.
We are
as
anxious
to
simplify
treatment
as
anybody.
We
report
every
death of diabetic coma, even though he may not die for 3 or 4 months
after treatment for
the
coma
and
from complications,
because
we
want
everyone
to
see
that
we
lean
over backwards in
reporting
deaths.
We have had one death in 83 children we have
treated
for
JOSLIN —INSULIN
THERAPY
7
diabetic
coma from
1923
to September
1936.
One
of our patients
recovered from diabetic coma who was 75 years old, but the mortality
for 338 cases has averaged
17.1 percent.
One can practice
guess medicine,
but in general it is not justifiable.
I make enough mistakes
as it is without deliberately taking chances.
Insulin reactions
occur with protamine insulin but as a rule
they
come
on more gradually
and
are less severe.
They
are distinctive
because
of two symptoms
not met with in the
course of reactions
with regular insulin, namely,
nausea and headache.
It is particularly
unfortunate that nausea is a symptom, because that is also a symp
tom of diabetic coma and it makes
the diagnosis
between
coma and
a protamine insulin reaction more
difficult
and,
at
the same
time,
between
these
two
and
appendicitis.
The
nausea
may persist
for
hours
and greatly interferes
with the taking of food.
At such times
one must place
the patient on quite a free choice of liquids, but it is
unlikely
that he will take too much carbohydrate, because
even if
500 cubic centimeters of orange juice or gingerale
and
1 quart of milk
are consumed
during the greater
part of the day,
one is giving the
patient only about
100
grams
of carbohydrate.
The
headache
is
likewise
disagreeable.
Headaches
are so uncommon
in diabetes that
this symptom is particularly
annoying to the patients and interferes
with a gain in health.
Look out therefore not to overtreat the patient
and
thus make
him
as
wretched
as
he made
himself
with
under-
treatment.
Keactions from protamine insulin are more apt to occur in the mid-
afternoon or during the night, and rarely just before breakfast.
To
avoid them,
one takes
5 or 10 grams of carbohydrate between meals
and
also upon retiring.
Sometimes
patients take 5 or
10 grams
of
carbohydrate
upon
going
to
bed with
30
grams
of
cheese.
Other
patients
take
30 grams
of nuts,
and still others,
180 grams
of milk
so that
they
will
be
afforded
protection from
an insulin
reaction
during the night.
If regular insulin
is
given
along
with
protamine insulin
before
breakfast one must look out that a reaction does not occur before the
meal.
Under such
circumstances
patients should take their regular
insulin only
15 minutes before
breakfast
because the blood sugar is
apt to be low at that time.
Deaths from protamine insulin
reactions
certainly must be rare
because I have seen but one in the literature, and none have occurred
in our group of cases taking this form of insulin, although the present
number certainly must reach
1,600
patients.
Treatment
of
a reaction of any
sort should be prompt and if re
covery
is
delayed
for more
than one-half hour
glucose
should be
given intravenously.
If the reaction
is really severe, glucose may be
administered
continuously
in
5 percent
salt solution during several
8
JOSLIN —INSULIN
THERAPY
hours.
It is
a fact that both with reactions
due to regular insulin
and to protamine insulin, recovery
does not take
place coincidently
with a rise of the blood
sugar to normal.
The
blood
sugar
may
almost
disappear
during
a reaction with
either regular or protamine insulin, if one actually
determines
the
fermentable
blood
sugar.
Furthermore
occasionally
the blood
sugar
may fall to very low levels with children and sometimes with adults,
and yet scarcely
any symptoms
may be noticeable.
For a discussion
of hypoglycemia, with
literature, I would
refer
the
reader
to
the
sLxth edition of my monograph
on diabetes.
I think diabetes
is a good disease for a great many reasons.
First
of all, one is dealing
with
facts.
Carbohydrate in the diet can be
calculated
with
reasonable
accuracy
and
the
excretion
of
sugar
in
the urine balanced against it.
The blood sugar is normal or abnormal.
The carbon
dioxide combining power is normal, high, or low.
If the
patient does not do well there is a reason.
Recently I had difficulty while transferring one patient to protamine
insulin, and it turned
out at this time catamenia
came on and upset
the program
for several
days.
As you are aware
diabetes
is apt to
be
worse
during menstruation
and
occasionally
coma
develops
at
such times.
While struggling with this patient I had complaints from
another
that the protamine
insulin was not working well, but before
the day passed a telegram came and the patient apologized
and said
that
she
had
made
a
mistake
in measuring
her
insulin.
A third
instance
of trouble
developed and poor protamine insulin was blamed,
but when
the shingles
broke out 2 days later the
explanation
of the
difficulty
was at hand.
In the fourth instance,
so soon
as the site
of the injection of insulin was changed
so that absorption
was more
marked,
the
diabetes
responded
better
to
treatment.
Finally
a
telegram
was received that a patient had died of an insulin reaction.
Persistence
in following up this tragic telegram
and sending
a pathol
ogist some 200 miles demonstrated
to all that there was an absolute
occlusion
of the coronary artery showing
the cause of death.
There
fore, when there is anything unusual in diabetes, I say there is a reason
and we must
always
find out the reason because diabetes
is a good
disease.
Prevention counts in diabetes.
One cannot
alter heredity but one
can arrange for one's posterity.
Two diabetics should not get married,
because theoretically all their offspring
would develop
the
disease.
We should not say too much about this, because even if they did have
100 children only 44 of the hundred
would live long enough
to come
down
with the disease.
The others would succumb
to other
causes
before
they
reached
the decade they
were destined
to show it.
As
you are aware,
the onset of diabetes
throughout the world appears
quite
uniformly in the same percentages
per decade of life.
If the
SHILLING —COMPRESSED-AIR
ILLNESS
9
heredity is less strong, of course, the percentage of those developing
the
disease would be correspondingly less.
The inciting cause, moreover,
in the
hereditarily
predisposed
is well known.
It is obesity
which
becomes increasingly manifest after the
age of about 30 years.
Be
tween
60 and
70 years of age only one of my patients developed
the
disease who had been thin throughout his life.
Statistics
such
as
those
collected
by Dr. Matz of the Veterans'
Bureau
are ideal,
because the follow-up of the patient is so perfect.
A veteran
acquires
diabetes,
and
there
is little
doubt but he will
draw
a
pension
as
long
as
he lives,
and
consequently
there
is no
difficulty
in tracing him.
I think
the work that Colonel Matz has
done is most valuable along this line and that he has started something
the importance of which none of us can foresee.
Who would have
thought that in his group of patients the duration of the disease would
have already reached the average of 9 years?
I look for great progress
and advance in the treatment of diabetes from the studies which will
be carried on in the Army and Navy.
Of course, the number of cases
will increase
many, many
times
because
two-thirds
of all diabetes
develop
the disease above the age of 40 years, and as yet the veterans
are only beginning
to march past that landmark.
Cooperation in diabetic treatment is just
as important
as coopera
tion in the Army.
Nothing
can
be accomplished
of value
without
officer and private, doctor and patient, working hand in hand.
But
this principle
extends
further.
A diabetic does not live to himself
alone.
If he lives safely
he has health, but if he lives carelessly,
he
develops
coma, hypoglycemia, or a multitude of complications.
COMPRESSED-AIR ILLNESS
i
By Charles W. Shilling, Lieutenant,
Medical Corps,
United States Navy
Introduction
The purpose of this paper is to present
an impartial review of all of
the available literature on compressed-air
illness.
This material has
been collected,
translated,
read,
analyzed,
and classified,
and
a brief
review of its forms the basis of the paper.
No new
ideas, original
studies,
or unpublished researches
are reported.
The study has
been divided into
the following sections:
History,
cause,
symptoms,
treatment,
prognosis,
prophylaxis,
and
general
bibliography.
Immediately following the introduction
there appears
a list of those books and
articles
covering all phases of the subject
i This work
was made possible by the assistance given by N. J. Cahana,
machinist
mate,
second class,
U. S. Navy; Mr.
Walter
Oliver,
Panama
City; Mr. M. C. Roemer, Navy Yard, Washington,
D. C.; and
Mrs. C. W. Shilling in translating
the various works,
and by F. E. Lusk, first class pharmacist
mate, U. S.
Navy, in collecting
the references.
24140—87
2
10
SHILLING
COMPRESSED-AIR
ILLNESS
which are recommended
for a general consideration
of this entire field,
although they do not, in every
case, give
the latest advances
in all
phases of this subject.
Then, following each section
there appears
a
double bibliography;
the first being
those references from which the
ideas incorporated in this review have been taken,
the second being
references
on the same phase of the subject but considered
to be of
secondary
importance.
At the conclusion
of the paper, in order that
the bibliography may be complete,
there
appears
a list of references
so
general
in their concept
and
treatment that they could not
be
included under any single
heading,
and which are considered
to be
valueless in a study of this nature.
In order to focus our attention exclusively on compressed-air
illness
the articles
covering
the following commonly associated subjects have
been excluded:
1.
Accidents
to divers other than compressed-air
illness. —Under this
heading
are articles
concerning
asphyxia,
blowing up, drowning, ex
haustion, mechanical
injuries
and squeeze.
2.
Oeneral articles
on
deep
sea diving
not primarily
concerned with
compressed-air
illness. —This
also
includes
all
articles
concerning
diving
suits,
bells,
caissons,
diving
ships,
recompression
chambers,
salvage of sunken
wrecks,
and treasure hunts involving diving.
3. Ear conditions. —Although it is well recognized that increased air
pressure
affects the ears, inasmuch
as this is not considered
a part of
compressed-air
illness
these studies
have been excluded.
4.
Oxygen poisoning. —These articles
deal with poisoning caused by
breathing high pressure oxygen, or with oxygen effects of high pressure
air.
5. Normal physiology
and pathology under increased air pressure. —
Under
this heading
are
the
articles
on
the
effects of increased
air
pressure on the pulse, blood pressure, blood volume, velocity of blood
flow, vital capacity, metabolism, etc.
Bibliography fob General
Consideration.
Bert,
Paul.
La
Pression
Barometrique;
Recherches
de
Physiologie
Experi-
mentale.
G. Masson,
Paris,
1878.
Bornstein,
A.
Erfahrungen
uber
pressluftkrankheit.
Vrtljschr.
f.
gerichtl.
med., Berlin,
n. F. 44:
357-375;
1912.
Bornstein,
A.
Physiologie
und
Pathologie
des
lebens in
verctichteter
luft.
Bull. klin. Wchnschr.,
51:
923-928;
1914.
-
Erdman,
S.
Aeropathy,
or Compressed Air Illness
among Tunnel
Workers.
J. A. M. A., 49:
1665-1670;
1907.
Heller,
R.
Die caissonkrankheit
(Eine Monographic).
Schweiz.
arztl.
Mitt,
a. Univ. Inst. Zurich.,
357-419;
1912.
Heller,
R., Mager,
W. and von Schrotter,
H., Luftdruckerkrankungen
met be-
sonderer berucksichtegung
der sogeannten Caisson krankheit.
Wien 2 v. 8°, 1900.
Hill, Leonard.
Caisson sickness and the physiology
of work in compressed air.
Longmans,
Green and Co.,
Neve York,
1912.
SHILLING
COMPRESSED-AIR
ILLNESS
11
LeCaplain.
Accidents
de l'air comprime au cours des travaux
de reconstruction
•du viaduc
d'Eauplet.
Normandie
med.,
Rouen,
30:
288-301;
1914.
Keays, F. L.
Compressed
Air
Illness.
Ann.
Labor Legist. Rev., N. Y.,
2:
192-205;
1912.
Kober and Hanson.
Diseases of Occupational
and Vocational
Hygiene.
Pub
lished by Blakiston.
,
Martini, R.
Delia Malattia dei Caisson.
Med.
d. lavoro.,
24:
201-215;
1933.
v] Oliver, T.
Diseases due to Working in Caissons and Compressed Air.
Diseases
of Occupation,
Chapt.
I11.
Pi y Lleonart,
J.
Paralisis
de los buzos;
el trabajo
a altas presiones atmos-
fericas.
Bol. mens. d. Col. de med. de Gerona, 1-60;
1910.
Waller,
G.
De ziekten der werklieden
bij pneum, fundeeringen
under boogeren
luchtdruk
(ook-caissonziekten
genoemd),
en baare voorbehoeding.
8°
Amster
dam.
1932.
J
Wright, W. and Brady,
W.
S.
Compressed
Air Illness
or Caisson
Disease.
Forcheimer's
Therapeutic
of Internal Diseases.
D. Appleton
& Co., 35:
690-706;
1932.
I.
HlSTORY
Classical historians record for us many stories of the employment of
"naked"
divers, even as early as 460 B. C.
In the intervening cen
turies men have continued to dive to great depths without
aDy type
of suit and even today in many parts of the world similar practices
are employed
by those engaged
as pearl or sponge divers.
From the
days
of Aristotle
attempts were
made
to construct
a
satisfactory diving dress so that the divers could breathe under water.
It was not until
1819,
however,
that
a practical diving helmet was
produced and not until
1837 that a satisfactory complete diving dress
was made by Siebe of England.
Diving bells
were referred
to
as early as 360 B. C, but the first
practical one was built by Taisner in the sixteenth
century.
In 1665
attempts,
were
made
to recover
portions of the Spanish Armada by
the use of a diving bell.
However, it was not until the introduction
of compressed
air by John Smeaton
(1678) that the use of the diving
bell became
successful.
The use of compressed air in the treatment of disease was proposed
by Dr. H. Henshaw in
1664 but it was not until
1836
when Junod
published his
exhaustive
study on the same subject that it became
widely
used.
The pressure
of the
air
used,
however,
was
so low
that
compressed-air
illness
was
impossible.
Robert
Boyle
in
1670
was the first to observe
gas bubbles
in the blood as a result of sub
jecting
animals
to suddenly decreased air pressure.
,* Compressed
air was first used in
a mining project by
a French
ongineer, M. Triger (1841), and he mentions symptoms experienced by
the workers after their exposure
to increased
air pressure which were
undoubtedly
due to compressed-air
illness.
Similar symptoms were
observed by the physicians Hamel
(1820) and Colladon
(1826) which
they attributed
to neuralgia.
The first report of scientific value was
published by two French doctors,
Pol and Watelle (1845) who recog
12
SHILLING
COMPRESSED-AIR
ILLNESS
nized clearly the nature of the
illness
and presented
a complete
dis
cussion with many case histories.
In addition to the well
established
use of compressed
air in diving
and mining, in 1850 it had its first use in pier building in England, and
in 1879 in tunnel construction under the Hudson in the United States.
With the increasing
use of compressed air in construction there were
many occurrences
of this strange
new
illness,
which
was variously
known
as diver's palsy, diver's paralysis, caisson
disease, aeropathy,
"bends,"
and compressed-air
illness.
Among
the workmen, accord
ing to Aldrich
(1904), the illness
was known by various names,
each
usually
significant
of
some
prominent
symptom.
Thus
we
find
"bends" for abdominal pain (loosely
used for any attack), "chokers
or chokes" for dyspnea or a choking feeling,
"staggers" for vertigo,
"itch," "prickles,"
or "lice" for pruritus
of the skin, and "fits" for
convulsions.
Bibliography
Aldrich,
C. J.
Compressed Air Illness, or Caisson Disease.
Med. News, N. Y.,
85:
1020-1024;
1904.
Colladon, L. T. F.
Relation d'une Descente en mer dans la cloche des Plongeurs
Paris,
1826.
Hamel.
Bibliotheque
de Genver.
1820.
Pol,
B.
and
Watelle, T. J. J.
Memoire
sur
les
Effets
de la Compression
de
l'Air.
Annal.
d'Hyg. Publique
et Med.
Legale, Paris,
1: 241-279;
1854.
Smeaton, John.
Historical Report on Ramsgate
Harbor,
London,
70;
1791.
Triger,
M.
Memoire
sur un appareil
a air comprime.
Compte
rendus Acad,
des Sci.
13: 884; 1841.
11.
Cause
op Compbessed-Aib Illness
From
a study of the many theories
advanced
as to
the cause of
compressed-air
illness it is evident
that most of the authors were not
familiar with
the literature
and
so laboriously
developed
individual
theories.
The most unusual is that of Bouchard
(1869) which has to
do with the expansion
of gas in the intestine causing rupture and fatal
hemorrhage.
Jaminent
(1871)
attributed
the
cause
to
exhaustion
from excessive tissue-waste
brought about by increased
absorption of
oxygen.
MacMorran
(1902) believed
the cause to be due to hyper
emia of the nerve centers from mechanical
pressure
and accumulated
CO2 in the blood owing to imperfect interchange
of gases in the lungs.
Merget
(1905) believes the condition to be due to air embolism
from
rupture of the alveoli upon rapid decompression.
Abbamondi
(1906)
said
that rapid
compression
caused
tissue
damage
predisposing to
compressed-air
illness
on
final
emergence.
MacNaughton
(1906)
attributed
the
disease
to
frictional
electricity
encountered
while
exposed
to compressed
air.
Conroy
(1910) attributed
the illness
to
"nothing
else than
a toxemia,
due to excessive catabolism."
SHILLING
COMPRESSED-AIR
ILLNESS
13
However, most of the theories
as to cause fall under the following
three
classifications:
1, The
theory of exhaustion
and cold;
2,
the
theory of mechanical
congestion
with
sequelae;
and,
3,
the gaseous
emboli
theory.
«
1. The theory of exhaustion
and cold has for its proponents Bouhy
(1848), Barella
(1868), Lampadarious
(1891), and Woodward
(1881).
They said that when
the pressure
was reduced
and
the temperature
of the air dropped
there
was produced
a very marked exhaustion
of
the body system
causing
neuralgic and rheumatic symptoms.
The
spinal cord
damage
was the result of reflex action caused by "spon
taneous refrigeration" of the whole system.
2. The mechanical
congestion
theory states, in general,
that when
the body is exposed
to air pressure
the peripheral blood vessels are
compressed
or collapsed
by the pressure
on the skin surface
and the
blood is driven into the visceral
organs and especially
those organs —
the brain and spinal cord —which are protected
by bony cases
from
this external
air pressure.
The sequelae which are the specific cause
•of the illness
are: "Black blood," "evolution of gas," "hemorrhage,"
"acute revulsive anemia," or "comparative stasis."
"Black blood,"
held
to be the cause by Gueard
(1854), Limousin
(1863), and Bauer (1870), was the blood deprived of its oxygen which
was held in the congested internal vessels and caused
a "stupefying
action" on the tissues.
The sequela, "evolution of gas," advanced
as the cause by Boucquoy
(1861) came very close to the true theory, but he says that the gas
liberation is due to internal congestion
followed by sudden
release of
pressure,
and
that it is only liberated in
the internal
organs
and
tissues.
"Hemorrhage"
was the cause advanced
by Babbington
and Cuth-
bert
(1863), and Febvre
(1879).
It was due to rupture of the dis
tended internal
vessels by the pressure
of the blood being
forced
in
from the periphera.
"Acute revulsive anemia," according
to Moxon
(1881) and Twynam,
(1888) was due to the great rush of blood from the congested internal
to the empty external
vessels upon rapid reduction of the external
air
pressure, thus leaving the internal organs
a prey to dangerous
anemia.
"Comparative
stasis"
was
the
causative
sequela
supported
by
Smith
(1873,
1894), Nixon
(1889), Knapp
(1891),
Edelheit
(1896),
Snell
(1897),
and Porter
(1907).
This theory holds
that the gorged
internal vessels have become paralyzed due to overdistention and are
unable
to
regain
their elasticity
when
the external air pressure
is
released and the peripheral blood flow reinaugurated ; thus there is a
comparative stasis existing in the internal organs which leads to tissue
damage.
Van Rensselaer
(1891) supports this theory and also gives
& most complete
review of the entire
literature
on the cause of the
14
SHILLING
COMPRESSED-AIR
ILLNESS
illness.
Meigs (1885) says the disease is due to a combination of the
foregoing
causes.
3. The gaseous emboli theory, in one form or another,
has had the
following
advocates:
Boyle
(1670),
Musschenbrock
(1755),
Hoppe
(1857), Francois
(1860), Bert
(1873), Leyden (1879), Cassaet
(1886),
Catsaras (1888, 1889,
1890), Zuntz (1897), Greenwood (1908), Grim-
bach
(1909),
Oudard
(1911), Hill
(1912),
and
Keyser
(1916).
All
authors writing since 1916 have accepted this theory and of course all
of the authors mentioned in the introduction to this paper were ardent
advocates
of
the
gaseous
emboli theory.
Experimental
work
was
performed
by Oliver
(1906) and Quincke
(1910) to demonstrate
the
truth of bubble formation.
The gaseous emboli theory is based on the fact that as the individual
breathes
compressed
air, whether it be in a diving suit, bell, caisson,,
or tunnel, the blood circulating through the lungs is exposed to a partial
pressure of nitrogen and oxygen proportional to the air pressure,
and
takes up an extra amount of nitrogen and oxygen proportional to this
increased
pressure.
As
the blood circulates
through
the body the
extra oxygen is used by the tissues but the extra nitrogen is not used,
and gradually saturates
all of the tissues until they are charged with
nitrogen at the partial
pressure
existing
in the air breathed.
It is
evident at once that there are two factors involved in this saturation,
namely, the depth or degree of pressure and the length of time exposed
to this pressure.
If the air pressure is lowered slowly (decompression)
then the process -
is reversed and the nitrogen is given off through the lungs and equilib
rium again established
with atmospheric air pressure.
But if decom
pression
is too rapid, the blood and tissues, which are supersaturated
with nitrogen, are left with an internal partial pressure far above the
external
atmospheric
pressure.
Under these conditions the nitrogen'
tends to leave the blood and tissues in bubble form and produce local
or general
blockage
of the circulation;
or as pointed out by Brooks
(1907, 1907-08)
they may produce
painful pressure or tearing
of the
tissues. - The symptoms of the illness vary according
to the location
of these bubbles
and the local tissue damage produced.
Thus we have three principal factors involved in the production of
compressed-air
illness:
Degree of air pressure to which exposed, length
of time exposed to this pressure, and the length of time taken to come
out from this pressure to atmospheric
pressure.
In addition to these
we have
certain
physical predispositions having
a seondary
bearing
on the production of the illness which are:
Age. —The
ideal
age
for air-pressure
workers is considered
to
be
between
20 and
40 years, for during that period the cardio-vascular
system
is at its greatest
efficiency
and is best able to withstand thfr
trauma of taking air pressure.
SHILLING
COMPRESSED-AIR
ILLNESS
Systemic
disease. —Individuals
with
any
weakness,
abnormality,
or disease of the heart,
lungs, or kidneys, or other general disorders
are subject
to
caisson
disease and are
to
be ruled out at the first
examination.
Degree of fatness. —As pointed out by Vernon
(1907) and Boycott
and Damant
(1908), fat at body temperature
dissolves more than five
times
as much nitrogen as an equal volume of water or blood
plasma.
Thus a fat man would be a poor risk since his tissues would not only con
tain more
nitrogen but also give it up more
slowly
because
of the
poor blood
supply
to
adipose
tissue,
and
thus
be
more
likely
to
bubble formation during decompression.
Alcoholic consumption.— All authors agree that alcoholics
should be
excluded
from increased
air pressure
work
because
of
the
changed
cardio-vascular responses produced
by consumption of alcohol.
^-Fatigue or general malaise. —No man should
be exposed to increased
air pressure
who feels below par physically, for careful history taking
has demonstrated
a definite relation between
a feeling of indisposition
and the incidence of compressed-air
illness.
For the same reason acute
upper respiratory
disease
or other acute
disease should
exclude
the
individual until recovery is complete.
/ Gallivan
(1907) points out that
lowered vitality of any part means lowered metabolism and circulation
and thus slower
elimination of the nitrogen stored
in the
tissues of
that part.
In this connection
it should be noted that during decom
pression if the person, who has been working hard under pressure and
thus saturating rapidly, vceases
to exercise
or becomes
chilled there
may be such a drop in the metabolism, heart rate and volume output,
and velocity of blood flow that the excess nitrogen is not eliminated and
bubble formation ensues.
In addition
to these physical causes Thomson
(1913), O'Donnell
(1929), and many others have pointed out that excessive dampness and
foul or vitiated air are contributing
causes of compressed-air
illness.
All of these points will be considered in more detail in the section on
prophylaxis.
Primary Bibliography
Abbamondi,
L.
Researches into the causes
which tend to bring about serious
accidents to divers.
J. Ass. Mil. Surg., U. S. Carlisle,
18:
170-184;
1906.
Babington,
T. H.
and
Cuthbert.
Paralysis
caused by
working
under
com
pressed
air in sinking
the foundations
of the Londonderry
new bridge.
Dublin
Quart. J. of Med.
Sci., 36:
312-318;
1863.
Barella, H.
Du travail dans 1'air comprime.
Bull, de l'Acad. Roy. de med. de
Belgique,
2:
593-647;
1868.
Bauer, L.
Pathological
effects upon the brain and spinal cord of men exposed
to the action
of a highly
increased atmospheric
pressure.
St. Louis Med.
and
Surg. J. 8:
234-245;
1870.
Bert, Paul.
Communication
sur les effects de l'air comprime.
Bull, de la Soc.
Med. de l'Yonne, 8:48-55;
1873.
Bouchard.
Pathogenie
des Hemorrhagiea.
Paris,
1869.
16
SHILLING — COMPRESSED-AIB
ILLNESS
Boucquoy,
E.
Action de l'air comprime
sur l'economie
humaine.
These
de
Strasbourg,
1861.
Bouhy.
Annales
des travaux
publics
de Belgique,
t. 7;
1848.
Boycott,
A. E., and Damant,
G. C. C.
Experiments
on the influence of fatness
on susceptibility
to caisson disease.
J. Hyg., Cambridge,
8:
445-456;
1908.
Boyle.
New
pneumatical
experiments
about
respiration.
Philosophical
Transactions,
5:
2011-2058;
1670.
Brooks, H.
Caisson
disease.
Long Island Med. J., 1:
149-158;
1907 (Part I)
and
1:
196-208;
1907 (Part II).
.
Brooks, H.
An experimental study of caisson disease.
Proc. N. Y. Path. Soc,
7:
58-87;
1907-8.
Cassaet, J. E. T.
De la pathogenie
des accidents
de l'air comprime.
Bor
deaux, 4°,
1886.
Catsaras,
M.
Recherches
cliniques
et experimentales
sur
les
accidents
sur-
venenant
par l'emploi
des scaphandres.
Arch,
de neurol.,
16:
145-194;
1888,
18:
80-109;
1889, and
19:
48-77;
1890.
Conroy,
P.
Etiology of caisson disease.
Maritime M. News, Halifax, 22: 330-
334; 1910.
Edelheit,
S.
Physikalische
Erklarung der Caisson-krankheit.
Aertzl.
Centr.-
Anz.,
Wien.,
8:
257;
1896.
Febvre,
Alphonse.
Experiences comparatives
sur la decompression brusque, et
sur l'injection
d'air dans les artères.
Nancy,
77:
1-39;
1879.
Francois.
Des
effect
de l'air
comprime
sur
les ouvriers.
Ann.
d'Hygiène.
14:
289-319;
1860.
^ Gallivan, J. V.
The etiology of caisson disease.
Long Island Med. J., 1:
181-
184;
1907.
Greenwood,
M.
Physiological
and pathological
effects which follow
exposure
to compressed air.
Brit. Med. J.,
1:
914-918;
1908.
Grimbach,
R.
Zur kasuistik
der pneumatischen
erkrankungen.
Zentralbl.
f.
innere. Med.,
Leipz.,
30:
1169-1176;
1909.
Gucrard,
A.
Note sur les effects physiologiques
et pathologiques
de l'air com
prime.
Ann.
d'Hygiène,
1:
279-304;
1854.
Hill, L. An
address
on
compressed
air
illness
and
experimental
research.
Brit. Med. J.,
1: 348-353;
1912.
Hoppe, F.
Ueber
den
einfluss,
welchen
der wechsel des luftdruckes
auf das
blut ausubt.
Arch. F. Anat. Phys. und Wissensch. Med., Leipz.,
24: 63-73;
1857.
Jaminent,
A.
Physical
effects
of
compressed
air.
Monograph.
St.
Louis,
1871.
Keyser, T. S.
Compressed
air
disease
with
notes on a case
and discussion
of
etiology
from the standpoint
of physical
laws.
Cleveland
Med. J.,
15: 250-255;
1916.
Knapp, C. P. The caisson disease.
LeHigh Valley
Med.
Mag.,
3: 1-12;
1891.
Lampadarios.
Accidents
arrivant aux
pecheurs
d'eponges.
Cited from
Van
Rensselaer.
Leyden, E.
Ueber
die
durch
plotzliche
Verminderung
des
Barometerdrucka
enstetehende
Ruckenmarks-Affection.
Arch
f.
Phychiato.,
Berlin,
9:
316-324;
1879.
Limousin.
Action
de l'air comprime,
apoplexie
de la moelle epiniere.
Union
Med.
de la Gironde,
1863.
MacMorran,
A.
H.
M.
Observations
on caisson
disease
and
its prevention.
Brit. Med. J., Lond.,
1: 1018-1020;
1902.
MacNaughton, G. W. F. Frictional
electricity;
a
factor
in
caisson
disease.
Lancet,
London,
2: 435-436;
1906.
SHILLING
COMPRESSED-AIR
ILLNESS
17
Meigs, A. V.
Caisson
disease.
Med.
News, Phila., 47: 589-592;
1885.
Merget,
M.
Death
of a diver from air embolism.
Lancet,
2: 1738;
1905.
Moxon.
Croonian
Lectures.
Brit. Med. J.,
1: —
; 1881.
Musschenbrock.
Collection
academique,
1755.
Nixon, C. J. Drivers' paralysis.
Dublin J. M. Sc., 87: 376-380;
1889.
O'Donnell, F. J.
Caisson disease
as experienced in construction
of Liffey tunnel.
(1926-1928) Irish J. Med.
Sc., 6: 618-622;
1929.
Oliver, T. La maladie
des caissons.
Bull. Med.,
Paris,
20: 437-439;
1906.
Oudard.
Accidents
de
decompression,
relation
d'autopsie.
Arch,
de
med.
Nav., Paris,
96: 63-72;
1911.
Porter, W. H.
Compressed
and
rarefied air illness.
Diet.
& Hyg.
Gaz.,
23:
135-144;
1907.
Quincke,
H.
Experimentelles
zur
Frage
der
Luftdruckerkrankungen.
Ver-
handl.
d. deutsch. Kong. f. innere Med.
Wiest.,
27: 250-253;
1910.
Quincke,
H.
Experinientalles
uber
Luftdruckerkrankungen.
Arch.
f.
exp.
Path.
u. Pharm.,
Leipz.,
62: 464-493;
1910.
Van Rensselaer, H. The
pathology
of
the
caisson
disease.
Med.
Record,
N. Y.,
40:
141-147;
1891 (Part I.), 40:
147-150;
1891
(Part 11.),
40:
178-182;
1891 (Part 11I.).
Smith,
A. H. The effects of high
atmospheric
pressure, including
the caisson
disease.
N. Y. and Brooklyn Bridge
Co., 8°, 1873.
,♦Smith,
A. H.
Caisson
disease.
Med.
Record,
N. Y.,
45:
130-133;
1894.
Snell,
E. H. The Blackwall tunnel
from
a medical
point
of view.
Hospital,
London 22: 126-
; 1897.
Thomson,
T. K., An unsuspected
cause
of caisson
disease.
Tr.
15 Internat.
Cong. Hyg. & Demog..
Wash.,
3: 608-610;
1913.
Twynam, G. E.
A case of caisson disease.
Brit. Med. J.,
1:
190;
1888.
Vernon, H. M. The solubility of air in fats, and its relation
to caisson disease.
Proc. Roy. Soc.
Lond.,
79: 366-371;
1907.
Woodward,
C. M. History of the St. Louis bridge.
St. Louis,
1881.
Zuntz, N.
Zur pathogenese und therapie der durch rasche Luftdruckanderungen
erzengten Krankheiten.
Fortschr.
d. Med.,
Berlin,
15: 632-639;
1897.
Second Bibliography
Altschul,
A. Beitrag
zur
Kasinstik
der
Taucherkrankheiten.
Wien
med.
Wchnschr.
45:
1977-2020;
1895.
Citroen,
S.
Over het ontstaan van caissonziekte.
Nederl. Tijdschr. v. Geneesk.,
Amst.,
1: 1916-1924;
1908.
DeVeaux,
O. F.
Observations
on caisson
disease.
Maine Med.
J.,
21:
138-
141;
1930.
Feilchenfeld,
L.
Zur
Begriffsbestimmung
des Unfalles.
Arztl.
Sachverstandi-
genztg.,
9: —
; 1907.
Gruber,
M.
Zur
Aetiologie
der Caissonkrankheit.
Oesterr. San.-Wes.,
Wein.,
7: 111—
; 1895.
Hepburn,
M. L.
Caisson
disease.
Brit. Med. J., Lond.,
1: 1179;
1902.
McWhorter, J. E. Etiological factors
of compressed air illness.
Am. J. Med.
Sc.,
139: 373-383;
1910.
VonSchroetter.
Zer pathogenese der sogenannten Taucherlahmung.
Verhandl.
d. deutsch. Path. Gesellsch,
8: 136-138;
1905.
Sparr, R. Ein Beitrag
zur Lehre
von der Caisson-myelitis.
Kiel, 8°, Alsfeld,
1910.
18
SLEDGE—HAY
FEVER
THERAPY
TREATMENT
OP HAY FEVER WITH ALUM-PRECIPITATED
POLLEN EXTRACT
By Robert F. Sledge,
Lieutenant
Commander,
Medical
Corps, United
States Navy
The history of hay fever begins with Botallus, who in his writings
on the Duties of the Doctor, published in
1565, gives
an account of
the ill effects, headache,
sneezing,
and coryza, produced
by smelling
roses.
Following Botallus, the next step forward did not occur until
1819, when John Bostock read
a paper at a meeting of the Medical-
Chirurgical
Society of Boston giving
a minute
and accurate clinical
description of his own
case of hay
fever.
Bostock, in his
second
paper, read in 1828, referred to his malady as "summer
catarrh" and
thought that the condition was due to heat
and sun rays.
Also, in
this second paper,
the term "hay fever" appears for the first time in
medical
literature.
Elliotson
did not agree with Bostock
as to the
causation of hay fever,
and in 1831 he gave
a lecture
at St. Thomas
Hospital
in which
he referred
to
flowers
and
pollen
as the
cause.
In 1870 Dr. George
Moore claimed
credit for the discovery
of what
he called
the pathognomonic sign of the disease, i. e., excessive cold
ness of the tip of the
nose.
About
this
time
Von
Helmholtz
ad
vanced
the opinion from experiments
on himself that the condition
was
due
to "certain
vibrio-like
bodies
(infusoria)",
and
thus the
bacterial theory
of the disease was born.
Due to Von Helmholtz's
standing in the scientific
world,
the microbic theory of the disease
became very popular,
thereby
retarding
the
discovery
of the
real
causation.
Dr. Swett, an American, in
1852 gave an account of an
"autumnal catarrh";
and
as early as 1854 Morrill Wyman
described
the ailment in his clinical lectures
at Harvard.
Charles Harrison
Blackley,
a physician of Manchester,
England,
was the outstanding investigator of hay fever during
the nineteenth
century.
By many experiments
he proved
that hay fever was due to
the pollen of grasses.
He produced
hay fever by placing pollen in
fhe
nose of hay-fever
subjects
during
the months
when
pollen was
not usually
present
in the air.
He rubbed
pollen into the skin of
the arm
and leg and
produced
violent
reactions.
This
is the first
record
of skin tests made with
pollen.
Blackley
also made pollen
counts
and
showed
that pollen had their
greatest
concentration
in
rural
sections.
In 1881 Dale, of Pittsburgh,
advanced
the idea that
hay fever was due to
a pathological condition in the
nose, that cer
tain sensitive
areas were responsible
for its initiation,
and that treat
ment
should
be directed
locally
to the
nose.
It was not until
1903
that the controversy as to the etiology of hay fever was finally settled
by the work of W. P. Dunbar and the germ and nasal theorists
were
converted.
Dunbar extracted
an albuminous substance from pollen capable of
producing
symptoms
of hay fever in
susceptible
people
which
he
SLEDGE—HAY
FEVER
THERAPY
19
thought was
a toxin.
He then
attempted
to elaborate
an antitoxin
by injecting horses and other animals with increasing doses of pollen,
endeavoring to duplicate in hay fever the beneficial
results of anti
toxin in diphtheria.
The serum
was patented
and
marketed
under
the trade name Pollantin.
Not long after this, "Weichardt
introduced
Graminol,
a serum obtained
from herbivorous animals that had not
))een intentionally immunized, the idea being that such animals would
automatically "create the antitoxin" from eating the various grasses.
Neither of these sera was of much
value in treatment,
although this
method of therapy was the one of choice for many
years.
The cur
rent method
of therapy followed the work of Noon, who published
-a paper in 1911 reporting the results
obtained
by subcutaneous
injec
tions of pollen
extracts.
The
concepts
of Noon
and
Freeman,
as
reported
in this paper,
led to the treatment of pollinosis on a scien
tific and practical basis.
Noon's work, interrupted by his death, was
carried on by Freeman.
Following a paper by Noon and Freeman,
many
other
writers
reported their
experiences
with
polen-extract
therapy.
In
1934
Harrison
(1)
published
the
results
of
experiments
on
guinea
pigs with
alum-precipitated
pollen
extracts.
Guinea
pigs
were
sensitized
by injecting
an aqueous extract of giant
ragweed
pollen, and then attempts
were made to desensitize
them with alum-
precipitated pollen extract.
Harrison
found that alum-precipitated
pollen
extract was
a more certain sensitizer
than was
the
aqueous
'extract.
He further found that alum
up to 0.3 percent
did not in
terfere
with desensitization,
but that alum in concentrations
of 0.6
and
0.8
percent
definitely
retarded
or prohibited
desensitization.
Caulfeild
(2), in July
1936,
published
a
report
confirming
that
part of Harrison's
experiment
relating to alum-precipitated
pollen
extract being an efficient sensitizing agent.
In the fall of 1934 Har
rison
suggested
that we treat some of our hay-lever
patients
with
alum-precipitated pollen extract and furnished the following formula
for the manufacture of the extracts
:
To one volume of the pollen add three volumes
of ether ; shake well,
allow
to
settle,
decant
the
supernatant
ether,
and
discard.
Repeat
this
operation
three
times.
After
the third extraction
decant all ether possible
and remove
the
remainder
by evaporation
in
a
warm
(not
hot)
water
bath.
The
pollen
is now
ready for extracting.
Solution
no.
1:
Extracting fluid
NaCl
grams..
2. 5
NaHCO.
do
2. 7
Aqua
dist.
(qs)
cubic centimeters..
1,000.0
Solution
no. 2:
Solution
no.
1
parts
55
Glycerin,
C. P
do
45
Solution
no.
2
is designated
the extracting
fluid
and
is filtered
through
a
Berkefeld filter
and
tested
for sterility.
20
SLEDGE—HAY
FEVER
THERAPY
Add
two
grams
of
pollen
to
every
100
cubic
centimeters
of
extracting
fluid.
Allow
this
to stand for 10 to 14 days
at room temperature
with
occa
sional
shaking.
It Is now filtered,
first
through
coarse filter
paper
to
remove
as
much
pollen
debris
as
possible,
then
through
a
medium
Berkefeld
filter.
The extract
Is tested for sterility by aerobic and anaerobic cultural methods.
We
have
been combining
the
various
pollens
from
the
spring
grasses in one extract and the ragweed
in another,
as :
Spring
type
Orchard
grass-
Sweet
vernal
grass
June
grass
Timothy
Red top
English
plantain
Extracting
fluid .
4.0
Cubic
centimeter!
200.0
Fall type
Oram
1. 00
Ragweed,
common
2. 0
. 60
Ragweed,
giant
2. 0
.50
.
2.00
.50
.50
5766
Cubic
centimeter)
Extracting
fluid
250.00
The pollen of Bermuda grass, and, at times, any desired
combina
tion of other pollens,
may
be prepared
as
a separate
extract for
treatment
of particular
cases.
This extract contains
approximately
20,000
pollen units per cubic
centimeter,
the pollen unit in this in
stance having been arbitrarily chosen as the equivalent
of 0.001 mgm
of pollen based upon the amount of nitrogen per cubic
centimeter
as
determined
by
the Kjeldahl
method.
Assuming
that the
finished
extract
contains
20,000
pollen units per
cubic
centimeter,
the dilu
tions are made in the following
manner
:
10 cubic
centimeters
of 20,000
unit
extract
plus
10 cubic
centimeters
ex
tracting
fluid equals 10,000 units per cubic centimeter.
2 cubic centimeters of 20,000 unit extract
plus
18 cubic centimeters
extract
ing fluid equals 1,000 units per cubic centimeter.
0.2 Cubic
centimeter
of 20,000 unit extract
plus
19.8 cubic
centimeters
of
extracting
fluid equals 100 units per cubic centimeter.
Prepare
a
10-percent
solution of potassium
aluminum
sulphate in
distilled water.
Filter through Berkefeld filter and test for sterility.
This is added to the various dilutions of pollen extract so as to give
0.25 percent of alum.
Schedule of doses of alum-precipitated
pollen extract
as used at the V. S. Naval
Medical
School
Deso no.
Vial,
units
per cc
Amount
in co
Units
Dose no.
Vial,
units
per cc
Amount
in cc
Units
100
100
100
1,000
1,000
1,000
1,000
0.05
. 10
.23
.035
.00
.10
.19
5
10
20
35
60
100
190
8
10,000
10.000
10,000
20,000
20,000
20,000
0.035
.07
. 135
.13
.25
.80
350
700
1,Sju
2,600
5,000
6,000
9.
8.
10
11
12
6
13
7
The schedule of doses, as listed above, was agreed upon by Harrison
and Lt. Comdr. F. M. Rohow, Medical Corps, United
States Navy.
SLEDGE—HAY
FEVER
THERAPY
21
It is only
a guide to treatment and must
be varied according to the
needs of the patient and whether or not reactions
occur.
The dose in
cubic centimeters
is very small so
as to give a minimum
amount
of
alum.
The total amount of alum for a full course of spring and fall
treatment is less than one-quarter gain, distributed
over a period of
several months
so there is no danger of cumulative effects.
We have
not
exceeded
2,600
units of the spring,
and
6,000 units of the fall
type,
as a maximum dose, and
have found this dosage sufficient
to
give complete
relief
in
the majority
of
cases.
In the District of
Columbia we begin treatment
for the spring type of hay fever about
April
1.
Treatments
are given
twice
weekly
until
the
maximum
dose of 2,600 units is reached, after which treatment
is given weekly
until
about
the middle of June.
In the
case of fall hay fever,
we
start treatment
about July 1 ; the injections are given biweekly until
a dose of 6,000
units is reached,
and thereafter
treatment
is given
once a week until frost.
Due to the slower rate of absorption of alum-precipitated
pollen
extract, we expected to accomplish the following
beneficial
results by
its use:
(1) An increase in therapeutic efficiency due to the constant
and even rate of utilization
by the patient ; (2)
an abolition of con
stitutional
reactions, or at least a reduction in frequency and severity ;
(3)
a decrease in the number
and frequency of treatments
required.
The first cases treated
with alum-precipitated pollen extract received
the initial treatment
after the beginning of the hay-fever
season in
the fall of 1934 under the supervision of Rohow.
There were only
five of these cases,
so the dosage, reactions, if any, and the results of
the treatment
will be given in detail.
Case 1.—Mrs. C. J. M.
Complaint
: Hay fever yearly,
beginning
on or about
August
15 and continuing
until after frost.
Skin test gave the following reac
tion : Ragweed,
common, 4 plus ; ragweed, giant,
3 plus ; and 4-plus reaction
to
the
following
grasses:
Orchard,
June,
sweet
vernal,
timothy,
and
redtop.
Patient denied having
symptoms of hay fever in
the
spring
and early
summer.
Treatment
was begun with alum-precipitated
ragweed pollen extract
on August
10 and continued
as follows:
Data
Unit of
pollen per
co 1
Amount in
cc
Unit
dose
Remarks
Aug. 10, 1934
100
0.05
5
Headache
and
local
reaction
lasting
24 hours.
Aug. 13, 1834
100
.15
15
No reaction.
Aug. 16, 1934
1,000
.04
40
Local reaction
lasting 24 hours.
Aug. 20, 1934
1,000
. 10
100
Do.
Aug.
23, 1934
1,000
.24
240
Do.
Aug.
27, 1934
10,000
.05
500
Do.
Aug. 30. 1934
10,000
.05
600
No reaction.
Bept. 4, 1934
11).000
.05
500
Do.
Sept. 8, 1934
10,000
.05
500
Do.
8ept. 10, 1934
10,000
.05
500
Do.
Sept. 17, 1934
10,000
.06
500
Do.
Oct. 1, 1934
10.000
.06
600
Do.
Oct. 8, 1934
10.000
.05
500
Do.
11 unit equals 0.001 mgm of pollen.
22
SLEDGE —HAY
FEVER
THERAPY
In this
case not more than 500 pollen units
were given as
the maximum
dose-
because treatment
was
started
after
the
beginning
of
the
hay-fever
season.
Although
this patient
had an occasional
attack of sneezing, the treatment
from
her standpoint
was highly
successful.
Cast
2.—Miss G. Du V.
The usual
history
of hay fever was obtained.
Skin
test gave a 4-plus reaction
to common ragweed ; a 1-plus reaction
to giant
rag
weed;
4 plus to redtop and timothy; and 3 plus
to orchard
grass.
Treatment
was started
on August 11.
Unit of
pollen
per
CO.
Amount
in on.
Unit
Remarks
Aug.
30, 1934....
Sept. 5, 1934
Sept. 8, 1934
Sept. 11, 1934...
Sept. 15, 1934...
Sept. 20, 1934...
100
100
1,000
1,000
1,000
10,000
1,000
1,000
1,000
1,000
1,000
1,000
0. 05
.15
.04
. 10
.24
.08
.24
. 24
.24
. 24
. 24
.24
15
40
100
240
500
210
210
240
240
240
240
Local
reaction
at
site
of
injection
lasting
24
hours.
Local
reaction;
36 hours.
Do.
Do.
In addition
to the local reaction
patient
devel
oped hives which lasted about 3 hours.
Mild
constitutional
symptoms
with
hives
rapidly subsiding.
No reaction.
Do.
Do.
Do.
Do.
Do.
Although
this patient
had a local
reaction
about the site of inoculation
for
the first six injections,
and mild constitutional
reactions
with
the fifth
and
sixth
treatments,
she obtained
so much relief she desired to continue
her treat
ment.
Also,
this patient
requested treatment
in the fall of 1935 and
1936, and
had no further reactions.
It is believed that
the mild
constitutional
reactions
in this
ease
were
the
result
of too rapid
an increase
in
dosage or
the time
Intervals
were spaced too close together.
Case 8.—Mr. W.
E. L.
Gave
a typical history of fall hay
fever
beginning
about
August
15.
Skin
tests
gave 4-plus
reactions
to the
common
and
the
giant
ragweed.
There
was no reaction
to the spring
grasses.
Treatment
with
alum-precipitated
pollen extra began on August
27, 1934.
Date
Unit of pol
len per
cc
Amount
in cc
Unit
dose
Remarks
Aug. 27, 1934
100
100
1,000
0.05
.15
.04
.10
.24
.05
.06
.05
.05
.05
5
15
40
100
240
500
500
500
500
500
No reaction.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Aug. 30, 1934
Sept. 4, 1934
Sept. 6, 1934
l.ooo
Sept.
10, 1934
1,000
10,000
10.000
10,000
10,000
10,000
Sept.
13, 1934
Sept. 17, 1934
Sept. 20, 1934
Sept. 25, 1934
Sept. 27, 1934..
It will be noted
that
the season was
well
under
way
when
treatment
was
begun and
that
the
doses
were
administered
at frequent
intervals
and with
rapid
increase in amount without reactions occurring.
The patient
experienced
marked
relief of symptoms.
SLEDGE— HAY
FEVER
THERAPY
23
Case
4.—Mr. P.
It.
Appeared
for treatment
September
6, 1934, with all the
symptoms
of
hay
fever
present
Treatment
with
alum-precipitated
ragweed
extract was
begun on day of reporting.
Date
Unit of pol
len per so
Amount in
cc
Unit dose
Remarks
Sept. 6, 1934
100
100
1,000
1,000
1,000
10,000
10,000
10,000
10,000
a 05
5
I5
40
100
240
500
500
600
600
No reaction.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Sept. 9. 1934
.15
.04
.10
.24
.05
.05
.05
.05
Sept.
18, 1934.
Sept. 21, 1934.
Sept. 24, 1934
Sept. 28, 1934
Oct. 1, 1934
Oct. 8, 1934
Although
this
patient
was
suffering
from
hay
fever
before
treatment
was
begun
and had surpassed
his
threshold
of tolerance from absorption
from
the
mucous
membranes, he gave no local or constitutional
reactions
even
though the
doses were increased rapidly and given at short intervals.
The patient
received
marked relief from
symptoms.
Case
5.—Miss H. P.
This case was very similar to case
no.
4.
The treatment
was begun on September
6, 1934, and ended October
8, 1934.
There were neither
local
nor constitutional
reactions.
There
was
marked
relief
from
symptoms.
This patient
has been treated with alum-precipitated
pollen extracts of the spring
and fall groups for the years 1935 and 1936, with complete relief.
As
the
results
of treatment
of these five
cases
were
so satisfac
tory, even though treatment
was not started
until
late in the season,
we decided
to use this preparation in the treatment
of all our cases,
both spring and fall types, for the season of 1935.
The same formula
was used for 1936.
Many of our cases received treatment for both the
spring and the fall type of hay fever during the seasons 1935 and 1936.
Table I shows the results of treatment with alum-precipitated pollen
extract of some of our cases of the spring type and Table II the fall
type.
The treatment in a number of cases was not completed,
due to trans
fer, illness of some nature other than hay fever,
etc., hence are not
included in the report.
Some of these patients
were supplied with
extract which was given at other hospitals or naval stations after they
had left this locality.
We have received
some favorable individual
reports from these patients,
but no accurate follow-up
data has been
kept.
In our series the following
cases merit individual
comment
:
Case
6.—Mr. W.
D. B.
Tolerated
the increase
in
doses
as in table of doses
without trouble until reaching
2,600 units on May
6.
Within
30 minutes follow
ing the dose of 2,600 units the patient
had a rather
severe reaction characterized
by lacrimation and itching of the conjunctivas,
sneezing, rhinorrhea,
and itching
of the mucous membranes of the nose,
tingling
and Itching of the body surface,
and a typical
asthmatic
attack.
Treated
with adrenalin,
with rapid
disappear
ance
of symptoms.
Following the constitutional
reaction,
the next
dose
was
reduced to 350 units
and then gradually increased
to 900 units
and held at this
dose for the remainder
of the season.
24
SLEDGE —HAY
FEVER
THERAPY
is
w
£7
5.
s
1 2
tj I
SI
' 3
D
B £
M
is I
a ■
£s
* —
4, a, c L.
B
MM
siii u
-til
5
a
3
3
I
B
B 3
aI
c5
5=
~
§
S°l,
sill
2 » 5
^ C ■C3 c
.
11
J
0
Eg
£«"
e —
si
8"
o
o
.2 *
■
1-
*
^ 3 iI «
£3?E
IFI
fill
(rt of
ss is
E aj p
o
o
OO
O
a
s
<i
£
Bg p
3*3^8 oS
E be
c 3.
i^.4i5 won
B»q oa
o
E^E-JS1frO
5
»
Et=E_
bS£
fi»
«l2sE,'fe
oagfi&sf ill*
o
o
o
O
'
Srfl
Co— O
tb
20
uaits.
iid
not rc-
•tion
with
\
B
i
i
o
O
s,<
itutional
local
reaction
bi
Constitutional
i
tion
Apr.
2», 1'j
iction
May
8,
1»1
itutional
reaction
I
9
■
*
-
a
Si
"
9
CTJI.2
sajlll
d
c
all
3*1
S3
§
§83
aoO
t"
,o ©<tf
25
B{
-• -
:'
w
-
- j
©
oir^
corf
o
«'dc{
off
I?
3
E£g
K
n
'<
H
ifII
sasg
oooo
r--,o
r-
t—r-
II
ej*3
8«
i>3
o3
11
E£g
li5
gg
§
gss
8
8g§
82
28
|
KR8
8
g
WW
<M
'
'
OJ
O "i >i
M"
Ci M
0i
3^
a
—
c4
CVC- 31
"
0 0(i
f*:c-3co
c»cs=i
|«
«
" loI
aCO>O
a
a
U L L
SLEDGE —HAY
FEVER
THERAPY
v.
5 1
* =
* *
S3
- =
S.2
ho
38
8
8
5 S
5
S
jr.i - -~-
-3.2 I
S32-5
1 II
>>Sj
Jul
3
=
"1"-*
s
sis
a
a
sssss
8
24140—37-
26
SLEDGE— HAY
FEVER
THERAPY
S
2
H 3
- e =
9 134
«alj
ga
BHI1 -it
c5?
E 5
£7
-a =
c e
B c * 3
= 5
§s
fifiS
Ii
If
J-Sfl
•2 3 Q
c ^<5
s §
z
SLEDGE —HAY
FEVER
THERAPY
27
Cu-xe 8.— Miss H. P. (same as rase 5 of 1!)34 series).
Had
a mild constitutional
reaction on April
19 following a 2(i-unit dose.
The 20-unit dose was repeated on
April 23 without
symptoms, after
which
the
regular
increases were given with
out producing
reactions.
It is believed that the reaction in this case was due to
the accidental
injury
to a blood
vessel
or lymph
channel,
causing
a
too
rapid
absorption of the pollen extract.
Case
9. —Mrs.
A.
G.
H.
Suffered
with
"rose cold"
every
spring
since
a girl.
Skin tests gave marked
reactions
to .lune grass, lamb's-quurters,
orchard
grass,
plantain,
redtop,
sweet
vernal
grass,
and
timothy.
Negative
reactions
were
obtained
to all the tree pollens and a moderate reaction
to both ragweeds.
Treat
ment
with
pollen
extract
tnot
alum-precipitated)
on
two
previous
occasions
without
benefit.
Had ionization
(or iontophoresis)
of nasal
mucosa in France,
with
slight
improvement for the remainder
of the season.
This
patient
was
markedly
sensitive,
as
shown
by
violent
skin
reactions
occurring
within
2
minutes
by
the
scratch
method.
Treatment
was
started
with alum-precipitated
pollen
extract
20 days earlier than
usual.
This
early
start
was made
in order that a more gradual
increase of dosage
could
be given,
yet giving
sufficient
time to reach
the
maximum
dose
before
the
beginning
of
the hay-fever
season.
She tolerated
the gradual
increase
without
even
a local
reaction,
and there
was
no reaction of any kind until May
29, when
she had
a mild constitutional
reaction
following
the
twenty-first
dose.
She reached
the
maximum
of
2,t500
pollen units
on May
4, after
which
date she received three doses
of
2,t500 units
without
trouble,
but
on
the
fourth
dose
of
2,t500
units
the
reaction
occurred.
It is believed that this reaction
was precipitated
by overfatigue,
for the patient
had
been
very
busy
the
week
preceding
superintending
the
storage
of
her
household
effects.
The following doses
were
not
reduced
and
were
tolerated
by
the patient
without
ill effects.
Case
10. —Mr. J. W.
This patient
was
one of those extremely
sensitive indi
viduals,
so the initial
dose
was
2.5 pollen
units
instead
of
the
usual
5 units.
The
increases
were
more gradual
than
in
the
table
of
doses.
Following
the
(50-unit
dose
the
patient
asked
that
he
be
given
a certificate
requesting
that
he
be excused from
gym classes,
as
the
exercise
made
his arm
quite
red and
painful.
Thinking probably
the symptoms
were exaggerated,
the
request was
not granted.
Three
days after the 60-unit
dose
he
was given
100 units,
and
again
he complained
of a sore arm.
The next dose,
190 units, produced
a mild
constitutional
reaction, and it was realized
that the patient
was not exaggerat
ing
his sore arm.
He
was excused from
gym class
and
treatment
continued.
On reaching
1.200 units, patient
again complained
of a red and painful arm,
so
this
dose
was
repeated
a
second
and
third
time,
then
the
doses
gradually
increased.
Case 14— Mrs. I). B. B.
This patient suffered
a local reaction
with
350 pollen
units.
This dose
was repeated, followed
by
a more gradual
increase.
Ou May
8 the patient
received
1,200 units, and within
30 minutes
had
a mild constitu
tional
reaction.
She
next
received
1.500
units,
then
2,(300
units
for
the
re
mainder
of the
season
without
reactions.
Case
27.—Mrs.
I'.
A
very
mild
constitutional
reaction
with
5,000
units
occurred
on
August
S.
The
dose
was
then
reduced
to
4.0IH)
units,
given
at
weekly intervals,
without
further reaction.
Case 33.—Mr. P. B.
On August
S there
was
a mild
constitutional
reaction
with
2,000 pollen units.
The
dose of 2,000 iMillen
units
was repeated on August
11
without
reaction.
On
August
18 the
patient
again
had an extremely
mild
constitutional
reaction, consisting
of
a tickling sensation in the
nose and throat,
28
SLEDGE —HAY
FEVER
THERAPY
with an increase of nasal secretions, with a dose of 4,000 units.
The 4.000-uuit
dose was repeated,
then
doses
were increased
by
500 units
per dose
until the
maximum
of 6,000 units
was reached.
Cage
37.—Miss
B.
S.
Had
a mild
constitutional
reaction
with
1,000
units
on August
14, consisting
of a hacking
cough and general itching of the body.
The patient
stated that the cough was due
to a tickling sensation in the chest.
Hives and urticaria
were absent.
Symptoms
subsided within
1 hour
without
treatment.
The
dose of 1,000 units was repeated August
18, 21, and 25 without
recurrence
of
symptoms.
Following
this,
the
dose
was
gradually
increased
and reached
2,000 units
on
September
8, at which
time the patient
again
had
the
same
type of reaction
as
described
above,
except
that
on
this
occasion
hives appeared over chest and neck.
No treatment
was necessary.
On Septem
ber
11
she
received
2,000
units
and
on
September
15,
1,900 units;
and
eac*
time
a milder
reaction
occurred.
Thereafter,
1.800 units
were
given
without
reaction.
In this
case
the
dose of aluui-precipitn
led pollen extract
plus the absorption
from
the mucous
membranes surpassed
the patient's
tolerance,
producing
the
reactions.
Even
though
this
patient
received
comparatively
small
doses
of
alum-precipitated
pollen extract,
she had only
an occasional
attack
of tickling
of the mucous
membranes of the
nose
and throat
followed
by
sneezing.
She
was highly
pleased with
the results
of the treatment.
While the treatment
of hay fever with
alum-precipitated
pollen
extract leaves much to be desired, it gives better results in our hands,
in the short series of
cases
treated
by this method,
than with
the
non-alum-precipitated extracts.
The patients rarely complain of pain
or discomfort around the site of injection.
Constitutional
reactions
are mild, as a rule, when they occur at all.
In ouv series of 96 cases
we have
had
only
2
severe
reactions,
both readily
controlled
by
adrenalin.
The patients
have
experienced
greater
freedom
from
symptoms;
in fact, most of them were entirely relieved.
Even those cases start
ing treatment
late in the season, after the appearance
of symptoms,
obtained
almost
complete
relief.
,:
SUMMARY
1. A
method
of treating hay
fever
by alum-precipitated
pollen
extract is described.
2. The rationale of this method
and its probable
results
are dis
cussed.
3. Case histories are reported.
CONCLUSIONS
1. In our
hands,
this
method
of
treatment
has
given
decidedly
better results,
so far as the relief of symptoms
is concerned, than has
the non-alum-precipitated pollen extract.
2. Constitutional
reactions
were reduced in frequency
and severity.
3. The number
of treatments
necessary
to control symptoms
were
reduced in some cases but not in all.
MICHAEL—MALARIA
29
References
(1)
Harrison, W. T.: Public Health
Reports,
U.
S. Public Health
Service,
vol.
49, no.
14, Apr. 6, 1934, p. 462.
(2) Caulfelld, A. H. W.: The Journal
of Allergy, vol. 7, no. 5, July 1936, p. 451.
MALARIA
By W. H. Michael,
Commander,
Medical
Corps,
United
States Navy
Two fallacies are rooted in the minds of a majority of the population
and of a considerable
portion of the medical
profession:
first, that ma
laria
equals chills and fever; second, that the diagnosis
of malaria is
not difficult.
Eight consecutive
cases of malaria were sent to a naval hospital by
naval medical
officers, that
is,
by physicians who have more than the
average
experience with that disease.
Five of these were diagnosed,
catarrhal
fever acute;
one, migrane;
one, fever,
cause undetermined;
and only one, diagnosis
undetermined,
malaria.
Of course these diagnoses were made hurriedly in the course of large
routine sick-calls.
Confronted by acute symptoms,
the doctors
right
fully
considered
hospitalization
more
important
than
diagnosis.
However,
this did occur in
a
district where malaria
is
known to
be
common.
During the same period as the above admissions,
two non-naval cases"
came in who were treating themselves with chill tonic.
Neither had
malaria.
One had syphilis and the other,
who had taken chill
tonic
for
6
months,
soon died with acute nephritis.
Necropsy showed
no
malaria.
More recently
a
case
was sent in by
a
civilian physician with the
positive
diagnosis
of malaria.
The
case
had
received
intravenous
quinine.
Thick smears were negative
and remained
so.
Pie proved
to have an appendiceal
abscess—hence his chills and fever.
Failure in the diagnosis
of malaria accurately
is
not limited to the
present
generation.
The writer recalls
spending
two uncomfortable
days in
a
Canal Zone hospital (1913) before his case was diagnosed by
himself.
Several thin smears had been reported
negative.
Malaria,
like the gamut of diseases,
is
diagnosed
by: history, sub
jective
symptoms,
physical
findings,
and
most
conclusive
of
all,
laboratory examination.
History
alone may clinch the diagnosis.
In
a
patient exposed at
night in
a
malarious
district malaria must
either
be
determined
or
excluded.
Frequently,
week-end
camps, night bathing parties,
or
a
stalled
automobile
will fix both the time
and place of infection.
In
Port au Prince, Haiti, many cases among the white foreign population
could be traced directly to open air dinner parties on
a
picturesque
but
badly infected
hotel
terrace which overhangs
the bay.
30
MICHAEL
MALARIA
Subjective symptoms may
be
conclusive
or misleading.
The
so-
called typical cvery-other-day chill is not the rule, but when it occurs
it makes the diagnosis.
However, urinary chills are frequent
and may
simulate
a
double
tertian infection,
and
a
chill
may
be
the
first
symptom
in almost
any of the
acute
infections from
erysipelas
to
typhoid fever.
The more important and constant
subjective
symptoms are: head
ache,
general
malaise,
nausea,
and
fever;
and
these usually occur
without cough or other localized infections to account for them.
But neither does another
disease exclude .malaria, nor does malaria
exclude
another
disease.
The
most
beautiful malarial
blood
smear
that
the writer ever saw, was taken
from
a convalescent
pneumonia
;
and
his
most
embarrassing
moment
was
when
his
chief
of service
pulled down
the bedclothes
from
a malaria patient
and
uncovered
syphilitic leg ulcers.
Physical
findings
indicating
malaria
are rather
the
exception
in
active
military
service.
They
are:
a
large
spleen,
anemia,
and
a
subicteric tint.
These
can only be expected in chronic cases.
One
palpable
spleen was found
in the
15 cases which inspired these notes.
He was
a war veteran
who had
been treating himself
intermittently
for 6 months,
incidently, with both quinine and atabrine.
Beware
of the supposed pneumonia
with
a comparatively low pulse
rate and slow respiration, with a "central" lung envolvement,
and low
white count.
Who
among
those who have practiced
in the Tropics
cannot
recall
acquaintances
who have gone to the States
on summer
vacation and have not come back?
Pneumonia is so often the official
diagnosis.
If questioned,
sometimes
a relative
will answer:
"No. his
chest did not seem to hurt
a great deal and he hardly coughed at all."
Laboratory examination would save many of these.
The examina
tion of a thick smear of the patient's blood
is the only sure way to
diagnosis
malaria.
If
he
has
acute symptoms due
to malaria, the
experienced
eye will find parasites
in two thick smears.
If no para
sites are found in two thick smears, there is no reason to treat the case
for malaria.
Experience has proved
the thick smear
32
times more
effective
than
the thin smear.
The thin smear has the advantage
of
rapidity
of preparation, but a negative
is not conclusive.
When the diagnosis
of malaria, is made in a case,
the most pressing
thing is to find
the mosquitoes
that infected
him and kill them if
possible.
If the history points to infection in his home or in military
barracks, the mosquitoes
are probably still in the building.
Look for
them under and behind
the bed, in the closets, dark corners,
and in
the early morning inspect
the screens.
From
this point the strategy
of mosquito
war would lead
too far
afield, and perhaps, divert too much attention from the next important
procedure:
Find
the
humans
who
infected
the mosquitoes.
They,
MICHAEL
MALARIA
31
too, are probably in the house.
If that house is a military barrack,
beware.
If not
in
the
house,
they
are
close
neighbors.
Suspect
particularly
the colored neighbor.
If white and truthful,
the malaria
carrier will give a history of headache, fever, or even chills.
If colored,
supplement the history with
a search for
a spleen.
A thick smear
will
do
the rest.
One of the most
astounding
common
breaches
of
hygiene
on expeditionary duty in the Tropics, is the custom
of enforc
ing the use of mosquito
nets by all camp personnel
except the malaria
infected native camp follower.
Moreover, it is a waste of time to cure
the patient and send him back to be infected
again.
When
this
small
epidemic
of malaria
appeared,
the
writer
was
befuddled by
a
mass
of contradictory
propaganda.
Further
com
plicating
the situation
was
the
recent
death
of
a malaria patient
treated writh
atabrine.
No autopsy
was obtainable.
Post hoc may
not
be propter hoc; nevertheless,
the routine treatment
adopted
re
served
that drug for those cases
who reacted badly to quinine.
Ac
cording to recent literature individuals sensitive
to quinine are more
common.
None occurred
in the present
series and not a dozen have
been observed in 7 years of tropical service.
Ten grains
of quinine sulphate
were given
three times
a day for 7
days.
No acid was given because it is unnecessary
and increases
the
tendency
to nausea.
During
the last
3
days
of these
7
days,
the
patients received
one-sixth
grain of plasmochin
three times
a day in
addition to the quinine.
There were some exceptions
to this routine:
In
a heavy malignant
infection, the treatment
was begun with
0.7 gram
of quinine hydro-
chlorosulphate and
100 grams
of glucose in
a liter of salt solution.
Reaction was excellent.
This
case
and another
continued
to receive
quinine intravenously
until
they
could
tolerate
it by mouth.
The
above routine of treatment was repeated
after 4 days rest in one case,
because parasites
were still present
after the regular
course.
One
case
relapsed.
On
his
first
admission
he
showed
a
mixed
infection with many sexual forms
of both P. falciparum
and P. vivax.
All,
including
the
relapsed
case,
have
been
returned
to
duty
for
several months.
After
having
undergone
the
old
Canal
Zone
treatment
(liquid
quinine for 6 weeks) the writer confesses enthusiasm
for the results in
this very small
series which was treated
(with an exception)
for only
one-sixth
of the
time.
The
chances
of blackwater
fever
or
other
complications should
be greatly reduced by the adoption of the short
course, while
1 relapse in
15
cases would be expected
even after
the
Canal Zone treatment.
32
McDANIEL
AND BELL
BARBITURATE
POISONING
BARBITURATE
POISONING
A Review
with Report of Two
Cases 1
By F. L. McDaniel, Commander,
Medical Corps, United States Navy, and Robert A. Bell, Lieutenant,
Medical Corps, United States Navy
In preparing this paper
the temptation has been great
to wander
afield and discuss allied
topics.
In selecting
and discarding from the
mass of literature it has been a problem to decide what to accept and
what to discard.
We have tried not to commit the error, as the Brit
ish say, of throwing out the baby with the bath.
The
most
common
hypnotics
of
today
belong
to
the barbituric
acid
group.
Introduced
about
30
years
ago
by
Fisher
and
Von
Mering
(1), who established
that barbituric acid, a derivative of urea
and
malonic acid,
while physiologically
relatively inactive in itself,
could, by replacement
of two hydrogen
atoms with ethyl radicals, be
made into a powerful hypnotic for both animals
and man.
The use
of these derivatives therapeutically dates
a little
over
20 years
ago.
The first one extensively
used was veronal.
There is now a long list
of preparations put out under different trade names and sold directly
to the public.
Their
use is becoming
more
and more popular with
the laity.
If some
check
is not instituted
these
drugs
may run
a
close race with aspirin as a popular form of self-medication.
In the field of mental
study the patient is questioned
very closely
about drug habits and it is astonishing
to learn how widespread
the
use of the barbituric
acid derivaties is becoming.
It is the favorite
medication of the restless
and emotionally unstable,
of the worried,
the weary,
and the jaded, and of chronic drunks to temper the natural
physiological reactions
of the morning after.
As a rule the fatal dose of the barbiturates averages about
15 to 30
times
the
therapeutic
dose.
Clinically
and
experimentally
this
ratio has been found to vary greatly.
As pointed
out by Weiss
(3),
pain, sympathetic excitement,
worry,
and fever
act antagonistically
to
the
effect of the barbiturates;
whereas
anemia
(4) and
cerebral
depression
are synergistic,
making
the patient more
susceptible
to
their
depressant
effect.
Since
the liver
detoxifies
the
unsaturated
barbiturates and
the kidneys excrete
the saturated
series, disease of
these organs
accentuates
and
prolongs
the effect of any
given
dose.
Inactivation
or elimination of the drug
requires
an efficient
circula
tion; hence in cardiac
failure, shock
or collapse,
narcosis
is usually
prolonged.
An idiosyncrasy
to
the
drug
may
cause
toxic
manifes
tations
as
confusion,
psychotic or dermal
reactions,
although
such
symptoms are usually seen only after excessive dosage.
The
most
popular
of
the barbiturates, both with
the
profession
and
the laity,
is
the amytal
group.
It shows
the
largest
interval
>This paper was presented at staff conference,
U. S. Naval Medical Center,
April 2, 1937,by the senior
author.
McDANIEL
AND BELL—BARBITURATE
POISONING
33
between
the lethal and
the
effective
dose in animal tests.
Sodium
amytal,
the sodium salt of iso-amyl-ethyl
barbituric
acid
was
pre
pared
and
used in animals
experimentally in
1926
(2).
Its intra
venous use in
350 psychotic patients has been reported
by Lorenz,
Reese,
and Washburne
(5), who found that an average
dose of 9%
grains
was
required
to
obtain
complete
narcosis.
The
functional
group
required
somewhat
more
than
the
organic
group.
You will
see later that one of our patients took
13
times
this
amount with
recovery.
The anesthetic
dose of the drug is about 50 to 70 percent
of the so-called fatal dose and 23 to 37 percent of the fatal dose (3) is
required to produce
sleep, moderate
muscular relaxation, and partial
anesthesia.
Instances
of
fatalities
from
very
moderate
doses
are
recorded.
In one case reported
(6) a patient being prepared
for thy
roid operation was given
7}i grains of nembutal in divided doses,
1%
grains at night and
6 grains in the morning; fatal poisoning resulted.
Hyperthyroidism,
renal or hepatic deficiency
make
the patient very
susceptible.
This same article reports
a patient who took 475 grains
of assorted barbiturates and the fact was not discovered
for 14 hours,
so
that
the drug
had
become
well
absorbed.
He
recovered,
alter
very
vigorous
treatment,
with
apparently
no
serious
after effects.
This patient developed
numerous
urticurial
blisters around the arms,
wrists,
and
chest
12 or 14 hours after the drug was taken.
In our
case (R. O.)
a marked
urticurial
reaction
with blister formation and
ulceration appeared in the right auricle.
A point not given
the attention it deserves and of special interest
from
the
medico-legal
aspect
and
in
the Navy
is
the question of
deciding upon misconduct and line of duty.
Weiss (7) warns of this
and
Dr.
Richards,
lecturer on
forensic
medicine
in
the
University
of Aberdeen, Scotland, records
several
cases which have
come to his
attention
and
which
he
labels
"barbituric
acid
automatism."
It
occurs
among
habitual
users
of
barbital
derivatives
who usually
keep a supply at their bedside.
Apparently
after one or two
tablets
a normal
narcosis
develops
and
while still
unconscious
they
auto
matically
continue
to
take
additional
tablets.
Should
the patient
take
a fatal dose in this manner
the obvious conclusion
upon finding
the body would be suicide.
The
general
action of these hypnotics is to produce
a descending
depression
of the central nervous
system
beginning
with the cortex.
It has been found that individual
compounds
act at slightly different
levels
and
some exhibit
earlier
subcortical
action
than others.
As
the
dosage
is
increased
the
depression
deepens
and
gradually
the
action
on the medullary or vital centers supervenes.
This is usually
first manifested
by respiratory
center
depression.
Some authorities
say that cardiac
depression
is paramount but apparently paralysis of
respiration
is
the
most
prominent
symptom.
In
overdosage
with
34
M.DANJEL
AND BELL
BARBITURATE
POISONING
other
hypnotics,
as
chloral
hydrate
and
paraldehyde,
circulatory
collapse may occur initially and the onset may be sudden and dramatic.
Experimental
work in pharmacology indicates that we may divide
the barbiturates into three classifications.
1. In
order of increasing
toxicity. —Barbital,
dional, dial, amytal,
pheno-barbital, allonal.
2. In order of increasing
efficiency. — Barbital, pheno-barbital, dional,
dial, amytal, allonal.
3. In order of increasing
margin of safety. —Phenol-barbital, barbital,
allonal, amytal, dial, dional.
Most of these compounds
are produced
by varying the alkyl group
of radicals.
It has been found that by lengthening the chain of alkyl
groups
the toxicity
is decreased.
The
toxic
effects from the
use
of
the barbiturates are most often the result of taking an overdose with
suicidal
intent
or from
the
indiscriminate
administration
for
the
induction
of
anesthesia.
Adequate
warning
has
been
sounded
against
the latter (8) (9), and while the former
is increasing
in popu
larity it still ranks rather low in the list of drug suicidal agents, being
about eighth in the list for the United Kingdom
(9a).
The barbiturates taken orally are absorbed
in from
15 to 60 min
utes.
Toxic manifestations may
be delayed
since nausea may induce
pyloric spasm and slow absorption.
Early hypnosis
is attended
by a
feeling of extreme well-being
and serenity,
a sense of warmth and genial
friendship towards the world in general.
Fears
and
apprehensions
vanish.
Hallucinations
do not
seem
to occur.
There is no dream
state.
Pain is absent.
As absorption increases the depression
deep
ens,
coma
supervenes,
and
consciousness
is lost
in about
15
to
20
minutes.
The
pupils
become
constricted,
contrary
to
the
com
monly held idea that in poisoning with this drug the pupils are dilated,
and that it can thus
be readily differentiated
from opium poisoning.
In
the
cases
wc
have
seen
the pupils
are
always
moderately con
tracted,
some
very
much
so,
and
light
reaction
is
absent.
The
respiration becomes slow
and shallow, the pulse feeble but not
espe
cially rapid, and there is a pronounced
fall in the blood
pressure
and
body
temperature,
though
the latter
may
be
elevated
(10).
Fre
quently
there
is suppression
of the urine
and retention may occur.
Occasionally
convulsive
seizures
occur,
probably
due
to
cerebral
edema.
The
rellexes
are
usually
absent in
the
deep
stages.
The
fall in blood pressure is not as striking in narcosis with sodium amytal
as with chloral hydrate or paraldehyde,
but when
it occurs
the sys
tolic falls more in proportion
than
the diastolic.
There is increased
capillary permeability with swelling of the eyelids,
lips,
cheeks,
and
ears, erythema,
urticaria, blebs and other exudative
and even ulcer
ative
skin
lesions.
Localized
areas
of
edema
may
develop
and
edema
of
the
lungs
is
an
expected
complication which
predisposes
McDANIEL
AND BELL—BARBITURATE
POISONING
35
to convalescent
bronchopneumonia.
The blood chemistry shows
no
change
of blood sugar;
there
is
a fall in calcium content
and
an
increase
in
the
C02
tension.
The
hydrogen ion
concentration
is
ncreased.
Renal function
shows
a diminution
of output without impairment
of glomerular activity
as shown
by the phenosulphophthalein excre
tion.
Liver function shows little change.
Few observations
have been
made on the gastrointestinal tract.
There appears
to be no decrease
in the tonus or amplitude of contraction of the small intestines.
Neurologically, we have mentioned
the disturbances
of the pupillary
reflex.
Just before narcosis
sets in the patient may show evidence
of
vertigo,
a staggering
gait,
and diplopia.
Individuals
picked up
on
the street by the police
may
present
a typical picture of inebriation.
In
the
case
of one patient who had
been taking
veronal,
and
was
admitted
to
this
hospital,
a vigorous but
unsuccessful
effort
was
made
to get
a positive Bogan's
reaction.
The
speech is thick
and
as narcosis
proceeds
there is a very decided
tendency
for the tongue
to fall back into the pharnyx.
This was
a particularly
troublesome
factor in the cases
reported
below.
It is a grave development
which
must be relieved,
and ranks in seriousness
with loss of the pharyngeal
reflex.
The
pathological findings have
been
determined
chiefly through
experimental pharmacology.
There is congestion
of the brain, con
siderable
perivascular
edema,
and
small
scattered
hemorrhages.
Histologic
changes are present
in the cortex
especially
in the deeper
cell
layers.
The Nissl bodies
tend
to disappear.
The cortical cells
show
degeneration
of
the
cell
membranes
and
nuclei.
The
entire
brain shows
degenerative
changes with cellular damage
which seems
to be due to the direct action
of the drug rather than secondary
to a
disturbed
circulation.
The
lungs
are
always
congested
and
many
authorities feel that there is a direct toxic
action
of the drug
on the
lung
tissue
itself.
Bronchopneumonia
and
pulmonary
edema
de
pendent upon
prolonged
coma, increased
capillary permeability,
and
circulatory
collapse,
are frequent
complications often
responsible
for
death.
In the kidney most of the damage is seen in the convoluted
tubules,
less in the glomeruli.
In the liver we observe fatty degener
ation, especially
of the central portion of the lobules.
In
diagnosis
Weiss
(4)
states,
"The
differences
in
behavior of
patients intoxicated with various types
of hypnotics are inadequate
for the clinical diagnosis
of the nature
of the poisoning."
He says
that the diagnosis should always
be determined
through circumstantial
evidence
and
the finding of the barbiturate in the excretion
of the
patient.
We now have a very prompt and reliable method
1 for detec-
»H. Oettel, Arch. Pharra.
1:10, 1936.
36
McDANIEL
AND BULL
BARBITURATE
POISONING
tion of the barbiturates and this should
be made use of in all cases of
suspected
poisoning
with hypnotic drugs.
In the treatment
of the acute poisoning with the barbiturates,
we
recognize
two
stages, that of coma and that of reaction.
Energetic
therapy is essential
in early
coma.
The
method
of attack can
be
reduced
to three fundamental procedures.
Firstly: Attempt to elim
inate the drug from
the body
either before or after absorption.
Sec
ondly: To combat
the
action
of the drug,
which has
already
been
absorbed,
by antagonistic drugs
and supportive
therapy.
Thirdly:
To prevent
the onset of complications and combat any untoward after
effects.
Unfortunately
most
of these cases
are first discovered
after
the drug has been absorbed from the alimentary canal.
It
is,
however,
always well to do
a
gastric
lavage
and
after
the stomach
has been
thoroughly
washed
to introduce 60 cubic
centimeters
of
a
saturated
solution of magnesium
sulphate.
Do not remove
the tube but allow
it
to remain for continuous drainage
because gastric juice as secreted
is
saturated
with
the barbiturate
and
drainage
constitutes
an easy
method
of drug removal.
Patient may
be fed through
the tube and
aspiration of vomitus
is
prevented
by its use.
The barbiturates not
detoxified
by the liver are principally
excreted
through the kidneys
(4)
and in smaller
percentages
in
the following
order
according
to
Koppanyi,
Murphy,
and
Krop
(11):
Dial,
neonal,
phenobarbital,
pernocton, and amytal.
They report on the excretion
of barbital in
dogs and were able to confirm previously reported work by recovering
in the urine
from
42 to 91
percent
of the dose administered.
In the
lowest output, that of 42 percent,
it
was revealed at autopsy
that the
animal had infarcts of the kidneys.
These investigators found,
also,
that recovery
from
experimental
barbital poisoning
closely
paralleled
the amount excreted in the urine,
and that the rate and percentage
of
total excretion
did not vary with the size of the dose.
They further
found that recovery
was not influenced
by
increasing
diuresis
with
dextrose
and conclude
that maintainance of normal kidney functions,
and not diuretic mensures,
are
necessary
for shortening
time
of re
covery from
coma due to those barbiturates eliminated
primarily by-
urinary excretion.
Previously reported
work
(12) (13) (14) (15) has
emphasized
the value of diuretic measures, especially with saline solu
tion intravenously.
Diuresis should
be adequate and continuous with
out overtaxing cardiac
or renal function.
Moderate prolonged
stimu
lation
of
renal
function should
be
a
chief
aim
of therapy in
acute
barbiturate
poisoning.
Diuresis may
be aided
by repeated
phleboc-
lysis using
glucose
and saline solutions to add calories and replace the
chloride lost through
gastric
aspiration and perspiration.
Damaging
the kidneys or removing
one kidney increases
the toxic
effect of the
drug.
It
is
reported
(11) that amytal
is
recovered from the urine in
only small amounts.
Neither amytal nor neonal
are excreted
as such
McDANIEL
AND BELL—BARBITURATE
POISONING
37
in the urine (16) and (20a).
We recovered from the urine considerable
quantities of a substance
giving
a positive test for the barbiturates
(case 2, amytal poisoning).
We may also recover barbiturates from
gastric contents,
saliva, sweat,
cerebrospinal
fluid and from most of
the organs
and body tissues.
It has been found that the concentra
tion of barbital in the cerebrospinal
fluid and the saliva is about
the
same as in the blood plasma.
The concentration of barbital in the
blood during the first
2 hours
shows
a sharp decline and then
a very
slow drop.
The first is due to fixation by the organs, and the second to
renal
elimination.
In
bilaterally
nephrectomized
dogs
the
second
•
decline does not take
place.
Spinal fluid drainage
is recommended
(17) (18).
We found no case reports in which forced spinal fluid drain
age had been given.
Since the concentration of drug in the cerebro
spinal fluid is about the same as in blood plasma
(19) and low in com
parison with that in the urine, this procedure would not seem especially
indicated.
There
are no
chemical
antidotes
for acute
poisoning
with
barbi
turates.
Pharmacodynamically
antagonistic
drugs
are
used
and
should be given in large doses.
Since
the barbiturates act upon the
subcortical centers in the mid-brain, drugs which simulate
these areas
are employed.
Among these used are caffeine, strychnine, coramine,
brucine, cocaine, physostigmine,
ephedrine,
calcium gluconate,
pictro-
tosdn,
benzedrine,
and
insulin.
All
of
these
have
been
used with
reported favorable results,
in many
cases
the reasoning
was post .hoc
ergo propter
hoc.
The
motor
depressant,
antispasmodic
and
peripheral
action of
physostigmine
seem
to render it unessential
and probably
harmful.
Since amytal in anesthetic
dosage inhibits the action of the vagus
(20)
atropine is contraindicated.
The use of cocaine appears to add insult
to injury and calcium gluconate
is not essential.
There is no definite
indication
for
using
insulin.
The
use
of brucine,
less active
than
strychnine, has no advantage
over the latter, used experimentally (21)
to save animals given
three
times
the fatal dose of phenobarbital,
sodium.
Strychnine excites the ventral horn cells of the spinal cord
lowering the threshold
for stimuli ; and in view of this site of action its
use has been condemned
(22).
A definite and therapeutically valuable
antagonism
does exist as demonstrated
by its use in the case
(23) of a
young woman who ingested
17 grams of barital (veronal)
and
10 hours
later was given strychnine in does of 10 milligrams every hour or two
to a total of 0.39 gram in the following 60 hours.
The smallest lethal
dose of strychnine for a normal person is 30 milligrams.
It has been
used successfully
by Weiss (4) in dosage of 10 milligrams hourly, and
by others
(24).
The use of ephedrine
which stimulates
the respiratory center
(32)
and counteracts
sleep by stimulation
of subcortical centers,
appears
38
McDANIEL
AND BELL
BARBITURATE
POISONING
sound and is beneficial
experimentally (26) and therapeutically (26b).
Use of benzedrine,
which has greater central
and less peripheral
action
is also indicated.
Ephedrine should
be particularly valuable in these
cases
with vasomotor collapse,
rapid pulse, low blood pressure
and
urinary
suppression.
It is in these cases
that camphor and caffeine
are especially
useful; for while they fail to improve cases profoundly
hypnotic they do have
a beneficial
effect on the circulation.
The hypnotic antagonist pyridine, beta-carbonic
acid diethylamide,
synthesized
by Hartman,
studied
pharmacologically
by
Faust
and
Uhlm»»o, and introduced in therapeutics
by Thannhauser and Naunen-
bruck over
12 years ago, is known under
the trade name of coramin.
It has been studied
extensively
on the Continent,
more recently in
this country.
Its use was initiated
in
1892 by Koppen while studying
the relatively new drug coramyrtin.
Its action,
pharmacological not
chemical,
effects
the
medulla
and
diencephalon,
stimulating
the
respiratory, motor, coughing
and vomiting centers.
It causes yawning,
salivation,
and
bronchial
relaxation
with
increased
secretion
and
expectoration.
Respiration
is particularly
stimulated both in
rate
and
depth.
The
cardiac
excursions
and
blood
flow
are increased.
Toxicity
is
low,
cumulative
effects
absent,
and
action
evanescent
(26).
The depth
and duration of sleep
are diminished and the drug
is capable
of improving respiration when
the depression
is
so
deep
as not to respond
to carbon
dioxide.
Once improvement occurs
the
center will then respond
to carbon
dioxide.
It is less useful in amytal
hypnosis (26).
The usual dosage is 5 cubic centimeters
intravenously
every
5 or
10 minutes.
Untoward
effects
are
hiccough,
vomiting,
and flushing of the skin but tbey are not alarming. It has recently been
reported
upon favorably
(27) in a large series of cases.
In action cardiazol resembles and is considered
superior
to coramin
by continental workers
(28)
(29) but it causes convulsions
in larger
doses (26a).
The
respiratory
effect
of alpha-lobelin
is
brief.
It
is
a
cardiac
depressant.
Its
emetic,
respiratory
and
vasomotor
effects
are
similar
to
those of nicotine.
Even
in Europe,
where
it
was
used
extensively,
it
is
giving
way
to
inhalational
treatment
which
is
safer and more efficient
(30).
The respiratory depression
in barbiturate narcosis
is so refractory
to the normal stimulus, carbon
dioxide,
that doubt has arisen whether
it really
plays
a major
role
in
the regulation of respiration.
Its
antidotal effect is minimal.
Oxygen
exchange and cellular metabolism
are at a low ebb.
Breathing continues
mainly under the influence
of
anoxia.
The administration
of oxygen,
by removing this stimulus,
may induce fatal apnea
(39).
The oxygen
is needed, however,
and
should
be supplied
in a carbon
dioxide-oxygen
mixture.
MrDANIEL AND BELL
BARBITURATE
POISONING
39
There is frequent failure of therapeusis
in employment
of all these
analeptics.
This
is
explainable
by
the
observation
(31)
that
in
increasing
narcosis
the
analeptic
effects
of
epinephrine,
caffeine,
strychnine, cardiozol (mitrazol), coramine
and strophanthin diminish,
and finally cease; and in deep narcosis they impair the circulation and
respiration in the rabbit.
In the neutral poisonous
principle of the
fish berry, Cocculus indicus,
discovered by Boulay in 1812, we have
a
medullary
and
autonomic center
stimulant
apparently superior
to
those mentioned
above.
This
drug
is very poisonous
in large
doses
causing clonic convulsions.
Its favorable effect on barbiturate narcosis
in rabbits and dogs (33) (34) and in humans
(26b)
(35), led Lilly
&
Co. to market it in ampoules containing 1/100 grain each.
It can be
administered orally, subcutaneously,
intramuscularly or intravenously.
If the narcosis be from a quickly absorbed barbiturate as pentobarbital,
pernocton, amytal, alurate or evipal,
a single large dose,
1 or 2 cubic
centimeters
of the Iilly preparation,
may be given intravenously in a
person
weighing
150 pounds.
If there are no toxic symptoms
such as
twitching
of the arms, unduly increased
respiratory rate,
or rise in
blood pressure,
the dose should
be repeated
in 20 minutes.
As the
patient improves
the drug can be given orally in 3-milligram doses as
needed.
It is useful
in chronic
poisoning
to detoxicate
the patient.
In view of
the incomplete
knowledge
and
poisonous
nature
of this
drug it has
been
withdrawn
from
the market
(36).
However
the
Council
on
Pharmacy
and
Chemistry
of
the A.
M.
A.1
(37)
and
others
(38) have recently
reemphasized
the value
and limitations
of
picrotoxin.
The
untoward
effects of
the
prolonged
barbiturate
narcosis
are
frequently
responsible
for the fatality.
The indications for therapy
are definite.
The respiratory failure, as noted above, being character
istically
refractory
to carbon
dioxide-oxygen,
some other
medullary
stimulant is essential.
The patient must be kept warm
and adequate
fluids administered.
Continuous gastric
suction
and suction removal
of secretions which collect
in the pharynx, prevent
aspiration pneu
monia and interference
with free respiration.
The
tongue must be
prevented
from
falling
back
and
thereby
strangling
the
patient.
The body tonus
as
a whole
is lowered;
and in conjunction with the
central
vasomotor
depression,
favors
the
development
of broncho
pneumonia
and circulatory collapse.
It is here that ephedrine, through
its central
stimulative effect and peripheral
circulatory support, and
strychnine, by increasing
general body tonus, find their chief indica
tion
and
usefulness.
Camphor
and
caffeine
are
likewise
useful,
caffeine
as
coffee introduced into
the
stomach,
or
caffeine
sodio-
benzoate,
7.5 grains
subcutaneously,
may
be repeated
at 30-minute
intervals.
It is such measures, aided by frequent changes in position
' The Council
on
Pharmacy
and
Chemistry
while
recognizing
its prohable
value, felt the drug
should
not yet be distributed
to the general practitioner.
40
McDANIEL
AND BELJ>— BARBITURATE
POISONING
which increase
body tonus,
which ward off or minimize circulatory
collapse, cause full inflation of the lungs and which prevent pulmonary
oedema,
atelectasis
and
bronchopneumonia.
Catheterization
when
necessary and protective ointment to eyes, lips and mouth are obvious
indications.
With this review in mind two recently
followed
cases are presented.
Case
1.— W. K. K., storekeeper second class,
U. S. S. Relief.
(Seen
by F. L.
McD.).
This patient had caused
no previous suspicion as to his mental condition
or any drug habit.
He
was on duty on the vessel and one afternoon
was found
asleep in his bunk
by a shipmate.
He did not turn
to at the usual hour next
morning
but was apparently
in a state of coma with stertorous breathing, labored
in type, and was thought to be drunk.
As he slept in a small compartment
with
one or two other shipmates who were his friends, they decided to "cover him up"
and allow him to "sleep it off" thinking
to arouse him later in the day.
When they
attempted to arouse him for noon mess he was more comatose and was immediately
taken to the medical ward.
An abstract
of the medical history
follows:
Diag
nosis: Poisoning
acute, barbital,
classification
A.
1. Within command.
2. Not
work.
3.
Due to own negligence or misconduct.
4.
Used barbital
(veronal)
in
excess,
self-administered.
Admitted
at 11:30 a. m., from his bunk.
An ordinary
tablet bottle was found on his person and he is reported to have purchased veronal
tablets a few days ago.
Dose estimated at 2 dozen 5-grain tablets or 120 grains.
Physical
examination. — Patient
comatose.
The
face
is
flushed
or
slightly
cyanotic.
The breathing
noisy
and
the flaccid
tongue
tends to obstruct
the
passage.
(This
is mentioned
in the literature
as a very common
symptom
of
barbiturate
poisoning.)
Pupils
equal,
3 millimeters
in diameter,
react slowly
to
light.
Eye grounds — no gross abnormality.
No evidence of corrosive poisoning
in the mouth or odor of alcoholic liquors on the breath.
Blood pressure, 105/75;
pulse, 90 to 100.
No abnormal
sounds noted.
Some moist rales
heard over the
bronchi.
Abdomen
negative except Madder
distended,
900 cubic centimeters
of
clear urine obtained
by catheter.
The deep
reflexes
of arms were sluggish and
the right
knee jerk
very sluggish.
The superficial
reflexes
not elicited.
Impression. — Barbital
poisoning.
Treatment. — Gastric
lavage,
2 ounces of magnesium
sulphate
left in stomach.
I do not recall that strychnine
was given in this case.
Caffeine-sodium-benzoate
and coramin
were given freely.
The respiration
became
more shallow and super
ficial,
cyanosis appeared, and
he was placed in an oxygen tent.
Pulse
became
more rapid,
110 to 120, and the patient died at 11:50 p. m.
Laboratory findings. — Urine
positive
for barbiturates.
Autopsy findings. — Edema
and
congestion
with stasis of the lungs.
Conges
tion and venous stasis in the solid viscera
with
acute degeneration
due
to
the
chemical
(barbital).
Moderate
dilatation
of
right
heart,
mainly
the
auricle.
Petechial
punctiform
hemorrhage
in
the
serous
cavities.
Cause
of
death —.
poisoning,
acute,
barbital.
The
diagnosis
was
considered substantiated
by the
history,
the physical findings, the clinical course, the presence
of a barbituric
acid
derivative
in the urine, and the autopsy
findings.
COMMENT
This patient took
an undetermined
amount of veronal —approxi
mately
twenty-four
5-grain
tablets.
(About the same amount
as that
(amytal) taken by our second case).
Treatment was started about
18 to
20 hours after taking drug.
When seen he was in fairly good condition
except for evidence of failing respiration.
He did not respond
to any
McDANIEL
AND BELL—BARBITURATE
POISONING
41
treatment,
including gastric
lavage with injection of magnesium
sul
phate,
coramine
and
caffeine-sodium-
benzoate by hypo, and
oxygen
inhalations.
The urine was positive for barbiturates.
Death occurred
approximately 30 hours after taking the drug.
Case
2.—R.
O.,
a young
naval
medical
officer.
Diagnosis:
Psychoneurosis,
reactive
depression.
For several days prior to this episode patient had appeared
brighter
and more cheerful.
At
8 a. m.( on the 18th of January he could not be
aroused
for
breakfast.
The officer
of
the
day
was
notified
and
patient
was
promptly seen.
Coramine,
5 cubic centimeters given intravenously,
because
the
respiration
was shallow and irregular.
There
was apparently
no response to the
intravenous
coramine.
Within
5 minutes
a large urticarial
wheel was noted
on
the right face and
auricle.
He
was given
0.5
cubic
centimeter
of
adrenalin
intramuscularly.
Gastric
lavage done and 2 ounces of magnesium sulphate
with
10 milligrams
of benzedrine and 300 cubic centimeters of black
coffee
were left in
stomach.
We saw the patient
at
8:30
a. m., respiration
was shallow
and ster
torous
and the tongue continued
to fall back in throat;
3.75 grains of caffeine-
sodium-benzoate
were given subcutaneously.
Three
hundred
cubic centimeters
of urine, obtained by catheterization,
contained 40 milligrams percent barbiturates.
Given intravenous
injection
of 500 cubic centimeters
dextrose in normal
saline
and hypodermoclysis
of 1,000 cubic centimeters in thighs.
Shortly
after 11a. m.,
the patient stopped breathing and artificial
respiration
by the Shaeffer method was
carried on for 30 minutes before a shallow respiratory
rate was resumed.
At tin's
time strychnine,
grains
1/32, was given and followed in 30 minutes by picrotoxin,
grains
1/100.
The blood pressure reading was 92/56.
Within
20 minutes
after
using picrotoxin
blood pressure was 110/70.
Patient
began to breathe well and
deeply, 95 percent oxygen and 5 percent carbon dioxide was administered.
Blood
pressure continued elevated.
Catheterized
specimen at 2 p. m., yielded only
200
cubic centimeters of urine, showing 20 milligrams
percent of barbiturates.
Strych
nine grains
1/32 and picrotoxin
grains
1/100
were given each
hour alternately
for
two doses of each.
Patient
placed under oxygen tent about
3 p. m.
The pupils
began to react fairly well to light
but general flaccidity
and collapse continued.
At 10 p. m., he was breathing well, color good, face flushed, respiration
and cardiac
function
continued
to improve.
Blood
pressure continued
up during
the night.
At 4 a. m., January
19, patient
tried to move hands and legs,
yawned
and at
tempted
to move head.
This was the first evidence of voluntary
movement
ex
hibited
since his discovery
almost
24 hours previously.
At
7 a. m.,
500 cubic
centimeters of normal saline with
50 cubic centimeters of 50 percent glucose
were
given
intravenously.
Catheterized
specimen
urine
at
8:30
a. in., of
500
cubic
centimeters,
showed
20 milligrams
percent
barbiturates.
During the morning
the patient became more restless,
opened his eyes, and there was occasional mum
bling response to loud questioning.
He received 1,200 cubic centimeters of normal
saline and glucose intravenously
at 11:30 a. m.
During late afternoon the oxygen
tent was removed.
The temperature
was
100.6 by axilla; pulse, 96; respirations,
20.
At 4:30 p. m., patient
asked to speak to medical
officer.
He was confused
but appeared to be recovering consciousness.
During
evening he was able to take
liquid nourishment
by mouth.
Voided
voluntarily
for first
time at
6:15
p.
m.
250 cubic centimeters.
This specimen contained
15 milligrams
percent barbitu
rates.
He was visited by his wife at 10:30 p. m., and although there was consider
able clouding
of consciousness,
he recognized
her and could respond in a fairly
rational manner.
During the third day, January 20, patient was confused, showed
moderate clouding
of consciousness and
was
disoriented
as to time, thought
he
24140—37-
42
McDANIEL
AND
HELL
BARBITURATE
POISONING
had only been
asleep
one night.
Said he felt dizzy and light headed and ached in
all of his joints.
Specimen of urine through
the third and fourth
days continued
to contain from
15 milligrams
percent to a trace of barbiturates.
On the fourth
day the patient had made
an excellent recovery with exception of persistent feeling
of dizziness and the complaint
that he could still taste barbital,
especially when he
smoked cigarettes.
He admitted
taking forty
3-grain capsules of sodium amytal
at
8 p. m. January
17.
SUMMARY
We have attempted
to review
the symptomatology, pathology and
diagnosis
of acute poisoning with barbiturates.
The problem of treat
ment and prognosis
has not yet been standardized.
The use of thera
peutic
agents is reviewed
in some detail.
The histories
of two rep
resentative
cases are presented.
It is seen that prognosis depends upon
the
type
and quantity
of drug taken,
the
time
that elapses before
therapy is instituted , the condition of the patient, and
the adminis
tration of antagonistic drugs in heavy dosage, as guided by the depth
of respiratory depression
and degree of vascular
collapse.
CONCLUSION
It is our opinion that patients may recover
from enormous
doses of
the barbiturates but that they will do so only after prompt, energetic,
and persistent
treatment has been carried
out.
Bibliography
1.
Fischer, E., and Von Mering, J.: Therap.
d. Gegenw.
5: 97,
1903.
2.
Page and Corrylen:
Am. J. Pharmacolo.
and Exp.
Ther.,
1926.
3.
Weiss, S.: Am. J. Med. Sc., 188: 731,
1934.
4.
Weiss,
S.:
The
Clinical
use and
Dangers
of Hypnotics,
J.
A.
M.
A.
107:
2106,
1936.
5.
Lorenz,
W. F.,
Reese,
H. H., and Washburne,
A.
C.:
Am. J. of Psychiatry
13:
1205,
1934.
6.
Purves-Stewart,
James:
Lancet
1:
6,
1934.
7.
Ref.
4, p. 210S.
8.
Weiss, S.: Am. J. Med.
Sc.
178: 390,
1929.
9.
Report
of Council
on Pharmacy
and Chemistry, J. A. M.
A.
101: 208,
1933.
9.
(a)
Gillespie,
R. D.: Lancet
1: 337-345,
1934.
10.
Chang, D. K., and Tainter,
M. L.: Case of Barbital poisoning.
J. A. M. A.
106:
1386,
1936.
11.
Koppanyi, T., Murphy,
W.
S., and Krop,
S.:
Arch,
internat.
de Phanna-
codyn.
et de therap.,
46: 76,
1933.
12.
Gower,
Walter
E., and Tatum,
Arthur
L.: J. Phann.
and
Exp.
Therap.
37: 481,
1929.
13.
Johnson,
Luckhardt and Lighthill: J. A. M. A. 95: 576,
1930.
14. Sanderson: J. A. M. A. 96: 642,
1931.
15.
Gower, Walter
E., and Van de Erve: J. Pharm.
and Exp. Therap.
48:
141,
1933.
McDANIEL
AND BELL— BARBITURATE
POISONING
43
16.
Herwich: J. Pharm.
and Exp.
Therap.
39: 267,
1930.
17.
Purves-Stewart,
James, and Willcox,
William:
Cisternal
drainage in coma
from barbitone poisoning,
Lancet
1: 500,
1934.
18.
Ref.
4, p. 2109.
19.
Ref.
11,
p. 90.
20.
Lieb, C. C., and Mulinos,
M. G.: Proc.
Soc.
Exp.
Biol,
and Med.
26:
709,
1928-1929.
20.
(a)
Shonle, H. A., Keltch, A. K., Kemp,
G. F., and Swanson, E. E.: Ibid.,
49:
393,
1933.
21.
Haggard, H. W., and Greenberg, L. A.: J. A. M. A. 98: 1133, 1932.
22.
de Barenne, J.: Physiol.
Rev.
13: 325,
1933.
23.
Bertrand-Fontaine,
and Claass,
A.:
Bull,
et Mem.
Soc.
Med.
d.
hop.
de
Paris 49:
1177,
1933.
(Reported
editorial
Brit. M. J. Dec.
16,
1933).
24.
Quoted
by Weiss (Ref.
4).
Denechau,
D., and Bonhomme,
R.: Ibid., 49:
1587,
1933.
Laigncl-Lavastine,
and Bidun,
S.: Ibid., 49:
1624,
1933.
Brule, M.:
Ibid.,
49:
1328,
1933.
Flandin,
C., and Bernard, J.: Ibid., 49:
1550,
1933.
Ber
nard,
E., and I-eroux-Robert:
Ibid., 49:
1418,
1933.
25.
Raginsky,
B. B., and Bourne,
W.: J. Pharm. and Exp. Ther.
43:
209,
1931.
26.
(a)
Killian,
Hans:
The
use of coramin
for combating
poisoning
from nar
cotics and hypnotics,
Anesth. and Analg.
14:
23, 1935.
(b)
Arnett,
John H.:
Ephedrine
and Picrotoxin
Used Successfully
in Amytal
poisoning, J. A. M. A.
100:
1593,
1933.
(c)
Chen,
K.
K.,
and
Schmidt,
C.
F.:
Ephedrine
and
related
substances,
Medicine
9:
1,
1930.
(d) Airila,
Y.:
Ueber
die
Einwirkung
Verschildener
Erregungs
mittel
der
Grosshinrinde
auf den Chloral hydratschlaff,
Arch, internat.
de. pharinacodyn.
et
de therap. 23: 453,
1913.
27.
Shube, P. G.: New Eng. J. Med. 214: 926, 1936.
28.
Steininger, H., and Gaubatz, E.: Klin. Wchnschr.
14:
159, 1935.
29.
Weiss, O. L.:
Munchen.
Med.
Wchnschr.
82:
748,
1935.
30.
Norris,
V. H., and
Weiss,
Soma:
The
Pharmacological
and
Therapeutic
Properties
of Alpha-Lobcline,
J. Pharmacol.
& Exper. Therap.
31: 43, 1927.
31.
Von Brandis:
Arch. F. klin. Chir. 177:
17,
1933, quoted by Council
on Phar
macy and Chemistry,
Amer.
Med.
Assoc.: J. A. M. A.
108:
1173,
1937.
32.
Schmidt,
C. F.: J. Pharmacol.
& Exper.
Therap.
35:
297,
1929.
33.
Maloney,
A. H., Fitch, R. H., and Tatum, A. L.: Picrotoxin
as an antidote
in acute poisoning
by the Shorter Acting
Barbiturates,
J. Pharmacol,
and Exper.
Therap.
41: 465,
1931.
34.
Maloney,
A. H.,: A Comparative
Study
of the Antidotal Action
of Picro
toxin,
Strychnine,
and
Cocaine
in
Acute
Intoxication
by
the
Barbiturates,
J.
Pharmacol,
and Exper.
Thereap.
49:
133,
1933.
35.
Maloney,
A.
H.:
Acute
Barbiturate
Poisoning
with
Picrotoxin,
J.
Nat.
M. A., May 1933.
36.
(a)
Council on Pharmacy
and Chemistry:
Report on Picrotoxin, J. A. M. A.
107:
354,
1936.
(b)
Personal communication
from Eli Lilly and Co., to F. L. McD.
37.
Council
on Pharmacy
and Chemistry:
Evipal Soluable, J. A. M.
A.
108:
1172,
1937.
38.
Grabfield,
G. P.: The use of Hypnotics, J. A. M. A.,
107:
1381,
1936.
Bar
low: J. Pharmacol,
and Exper.
Therap.
55:
1,
1935.
39.
Marshal,
E. K., Jr., and Rosenfeld,
Morris:
Depression
of respiration
by
oxygen, J. Pharmacol,
and Exper. Therap.
57: 437, 1936.
44
BLACKWOOD
AND ERSKINE— CARBOXIDE
POISONING
CARBOXIDE POISONING
By J. D. Blacewood,
Jr.,
Lieutenant
Commander,
and E. B. Ebseike,
Lieutenant,
Medical
Corps,
United
States Navy
Since
the use of carboxide
gas (ethylene
oxide
1 part and
carbon
dioxide
10 parts) has been adopted
by the Navy for fumigation pur
poses, it is of interest
to note the effect on personnel
who have been
subjected
to its fumes, of unknown concentration, for a period of 2 to 3
hours.
A search of the available literature failed to reveal any reference
to
any toxic effects due to carboxide.
The toxicity of ethylene
oxide has
been determined experimentally on the guinea pig and Barber (1) cites
the records of five fatal human cases
of poisoning due to di-ethylene
di-oxide in which the
characteristic findings
were
a central necrosis
of the liver without fatty
degeneration
or jaundice and
terminating
in about a week with a hemorrhagic
nephritis and uremia.
As the
articles
published in the Naval
Medical
Bulletin
also did
not describe
any toxic effect on human beings, the following report is
made.
On May 21,
1936, the ship's company of the U. S. S. S-36 at
the Navy Yard, Cavite, P. I., fumigated
all spaces forward of the engine
room (15,000 cubic feet), using six 60-pound
cylinders of carboxide
at
725 pounds pressure per square inch at 70° F.
Fumigation was begun
at 6:15 p. m. and was stopped at 9:15 p. m.
The watertight door in
the forward bulkhead of the engine room was dogged.
There was a
vent in the flapper valves from the torpedo
room to the after-motor
room in which six men had been working since 4 p. m.
At about 9:30 p. m.,
these men
appeared
at
the yard dispensary
complaining of headache,
nausea,
and vomiting.
These
symptoms
continued for the next 2)i hours after which they were discharged
to
their homes.
As no other cause for their condition could be found, it
was decided
that there was
a leakage
of the carboxide
through the
vent into the compartment where they were working.
As the toxic
substance
was inhaled in the form of a gas, the resulting vomiting was
considered
as of central origin.
It was therefore
decided
to examine
die respiratory tract, the heart, the blood, and the urine of the patients
for evidence
of any resulting ill effects.
The respiratory tract was
examined physically and by X-ray, the heart by physical examination
and blood pressure, the blood by blood chemistry and blood counts, and
the
urine
by routine examinations.
These
examinations
were
con
ducted
the following day and failed to show
any ill effects resulting
from the inhalation of the gas.
SUMMARY
1. After
exposure for about
2}{ to
3 hours
to inhalation of a weak
concentration of carboxide
fumes,
the toxic effects consisted
of head
ache, nausea, weakness, and vomiting.
SNOWDEN
AND BELL—SULFANILAMIDE THERAPY
45
2. The symptoms lasted for about 2 % hours.
3. The treatment consisted of gastric lavage.
4. No permanent ill effects were noted in examination
of the respira
tory and circulatory systems, blood, or urine.
5.
Precautions should
be taken to confine the fumes to the parts of
the ship being fumigated.
6. Men should not be allowed
to work where there is any possibility
of even a weak concentration of the fumes to reach them.
Our thanks are due to Lt. Comdr. W. H. Whitmore (M. C), United
States Navy, for the X-ray reports
and to Lt. (Jr. Gr.) F. W. Farrar
(M. C), United States Navy, for the reports on the blood chemistry.
BlBLIOGRAPHT
1.
Barber,
H.
Hemorrhagic
nephritis
and necrosis
of the liver from dioxan
poisoning.
Guy's
Hospital
Reports,
London,
84:
257-386,
1934.
THE
SULFANILAMIDE
THERAPY
OF GONORRHEA
By R. H. Snowden, Commander,
Medical
Corps,
United
States Navy, and Robert A. Beu, Lieutenant,
Medical
Corps, United States Navy '
In recent decades rapid progress has been recorded in preventive and
curative treatment of many diseases.
There have been several groups
including streptococci,
genococci,
and virus diseases remaining resist
ant to therapeutic efforts.
The original work of Domagk
(1) on the
azo-dye
derivative Prontosil
has developed
a promising line of attack
(2) (3) on at least the first two of this hitherto resistant
group.
The
therapeutic effect of the azo-dyes apparently resides in the reduction
derivative
para-amino-benzene-sulfonamide
(4)
(6f) (7)
(13b) called
sulfanilamide (5) from which they are formed.
This reduction occurs
both in vitro and in vivo.
The use of this drug is not yet on a scien
tific
basis.
The
mode
of action is not
understood.
Solutions
of
sulfanilamide
1 : 13,000 and
1 : 18,000 in defibrinated human and monkey
blood or serum
were found free from implanted
cultures
of
beta-
hemolytic streptococci
in 2 days (11) (13a).
In controls there was an
increase
of organisms.
Frequent repetition of the experiment
using
different strains of streptococci
and
different
bloods
gave
similar
results.
With the blood
of rats,
mice,
and guinea
pigs results
were
less
favorable.
Sulfanilamide inhibits
growth
and
causes death
of
pneumococci
in 24 to 48 hours in solutions of
1:10,000 or stronger.
It is effective in less marked degree in 1:100,000 dilutions
(12).
No
effect was demonstrable
on virulent hemolytic streptococci
in 1:1,000
dilutions,
or on
staphlococcus
albus
or E.
coli.
However,
larger
doses of streptococci
wore used than by others (11) (14b) who obtained
inhibition of organisms.
i We are indebted
to W. L. Ainsworth,
Commander,
U. S. Navy, executive
officer, U. 8. S. Mistlstippi
lor the supply of sulfanilamide
used in this study.
The authors
wish to express appreciation
to 11unh Li-
Smith, pharmacist
mate, third-class,
for his thorough technical assistance.
46
SNOWDEN
AND BELL—SULFANILAMIDE
THERAPY
In vivo
experiments
(11)
(14) (confirmed
(15) and
(13b) including
pneumococci
types I
and II
and
certain
Neisseriae)
show
good
therapeutic
results with sulfanilamide in mice infected with hemolytic
streptococci
of
high
virulence.
Little
effect
was
observed
with
strains
of low virulence.
Favorable results
have
been
obtained
(16)
with
strains
of
medium
virulence
by
using
from
1-10
minimum
lethal
doses.
Animals
experimentally
infected
intraperitoneally
with
pneumococci
exhibit
prolonged
life
incident
to
sulfanilamide
therapy.
While
they
show
peritonitis with
a purulent
exudate
at
autopsy
(12) the infection
is more markedly localized
than in controls
which
present
intense
bacteriemia.
Xo
bacteriostatic
effect
was
noted
(13b)
on staphlococcus
aureus, E. coli,. E. typhi
and certain
other
gram
negative
organisms.
The
sulfanilamide
therapy
of
guinea
pigs
infected
intradermally
with hemolytic
streptococci
has
shown
(16)
less
dissemination,
greater
localization, and
more
rapid
healing
as compared
to untreated
controls.
The drug
possesses
marked
bacteriostatic and bactericidal action
in vitro.
If this is the mode of action
in vivo it is unproven.
Diaz-
otization
and
aeetylation
of sulfanilamide
destroys
its activity
in
vitro
and
in
vivo
indicating
a similar
mode
of
action
(12).
The
results of in vitro experiments
cannot
however
be applied
directly to
those
in vivo.
This
is apparent
(12)
for sulfanilamide in
the
test
tube is more than
100 times as bacteriostatic
and bactericidal against
pneumococci
as
compared
with
streptococci
whereas
in mice
it
is
more effective
against
streptococci.
This action in vitro is adequate
to
explain
the
chemotherapeutic
effect
against
pneumococci
in
animals
if dosage of
1 gram
per kilo
is given.
The concentration
thus
obtained
in
the body
is comparable
to that in
the test
tube.
However it has
been
shown
(1)
that
against
streptococci
in
mice,
from one-tenth
to one-fiftieth of the tolerated
dose
gives
a distinct
effect if treatment
is
continued
for
3
to
5
days.
To
explain
the
variance
of action between test-tube
and animal experiments
enhanced
bactericidal
action
of the blood,
supplemented
by that of the tissues
of the whole animal,
has been
supposed
(11).
However, Meyer
(19),
injecting
streptococci
intraperitoneally
in
guinea
pigs,
concluded
that prontosil does not prevent
the growth of bacteria,
for in treated
pigs,
killed
after
a
time,
billions
of
organisms
were
found.
The
treatment
promoted
phagocytosis
and
seemed
to diminish virulence
and inhibit
toxin
formation.
It is believed
(13b)
the stimulation of
granulocytic and monocytic phagocytosis
is favored
by injury
to the
organisms
rendering
them more susceptible;
or that capsular
produc
tion by streptococci
may
be
interfered
with
(17)
and
a neutralizing
effect upon
the leucocidins
and hemolysins
of streptococci
in vitro is
shown.
However, in an excellent study
(16)
of the effects of sulfan
ilamide
upon
hemolytic
streptococcus
infections
("Stoddard"
and
SNOWDEN
AND BELL— SULFANILAMIDE
THERAPY
47
"Pion" strains) in mice and guinea
pigs no qualitative differences
in
histologic
response
were
noted
in
treated
and
untreated
animals.
There was little or no evidence
of increased
phagocytic activity h\
either
granulocytic
or
reticuloendothelial
cells.
The
presence
of
masses of organisms
in both
treated
and untreated
animals
does not
favor
the
suggestion
that
the
bactericidal
activity
of
the
blood,
supplemented
by that of the tissues
as
a whole,
can account
for the
favorable effect of sulfanilamide.
There was no evidence
that phago
cytosis was a factor in obtaining favorable
therapeutic
results.
Possibly
some of these variable results
can
be explained
by exper
imental
results
rc"nntly
reported
by
Finklestone-Sayliss
and
asso
ciates.
(18)
These
investigators
report
that
the
bacteriostatic
action
of sulfanilamide on streptococci
seeded
into fibrinated serum
varies markedly depending
upon the age of the culture.
Using an 8-
hour strain
the action
during the first 4 hours
is that of
a marked
growth
stimulation.
During
the
next
4
hours
the
growth, curve
presents
an even more precipitous fall.
Older cultures
are propor
tionately
less responsive.
These
investigators
noted
that
sulfanil
amide
is far more
soluble
in
the fatty
envelope
of the streptococci
than it is in aqueous solution, and that, the fatty envelope
decreases
with
age.
They
are of the opinion that the chemical
acts first
as
a
stimulant
and later
as
a
depressant.
This
stimulatory
action was
also
demonstrated
in
animal
experimentation.
They
could
demon
strate
neither stimulation nor depression
of phagocitic
activity,
and
confirmed
Colebrook's findings
that the bactericidal action of sulfan
ilamide
does not
require
the presence of leucocytes.
Sulfanilamide
was found to have
a definite
stimulatory
action
on the granulocyte
production in that crises would
occur when the total white cell count
might reach
30,000.
They report
that the chemical's
action
on
the
bone marrow
has little effect on hemopoietic
function although
showers
of abnormal nucleated
red cells may occur during the crises.
There
was
apparently
no stimulation
of
the
reticulo-endothelial
system,
although the phagocytic activity of these cells was definitely increased.
Animals that died under
treatment
had petechial
hemorrhages
in the
gastric
mucosa, muscles,
and connective
tissue.
Certain conclusions
are apparent:
1. Sulfanilamide
is bacteriostatic
and bactericidal
in vitro.
2.
Results
relative
to destruction
of organisms
in the peritonea!
cavity
are
contradictory.
3. A diffuse peritonitis
does
follow
the intraperitoneal
injection
of organisms
in spite of therapy.
4. Sulfanilamide
therapy
none the less does
preserve life despite the multipli
cation of organisms.
5. It results in less dissemination,
greater localization,
and more rapid healing
of the infection.
48
SNOWDEN
AND BELL
SULFANILAMIDE
THERAPY
6.
The evidence suggests its action
in vivo is antitoxic,
possibly
also antibac
terial.
7.
That phagocytosis
is an important
factor
is questionable.
A colorimetric method
has been devised
(24) for deternuning the
concentration
of sulfanilamide in the body fluids.
The human ex
cretes
the
drug
in unchanged
and
conjugated
form.
The latter is
mainly
para-acetylamino-benzene
sulphonamide.
Their
relative
importance in
effecting
a
clinical
cure
remains
conjectural.
The
conjugated
derivative
is
nearly
inactive
(24).
Acetylation
and
diazotization of sulfanilamide destroys its activity
(12).
The urine of
patients excreting
sulfanilamide has no bactericidal activity
against
beta-hemolytic
streptococci
(20) but it has
been found
capable
of
destroying the bacteria
usually causative
of urinary infections (21).
Experimental
results
(6),
(13b),
(16) indicate that the maximal
curative result
is exerted by maintaining
a high concentration of this
substance in blood
and tissues for several days.
A blood level of sul
fanilamide of 10 milligram percent is therapeutically satisfactory (6f).
The optimum dosage for this attainment varies.
It lies near
15 or 20
grains four times daily.
This is much less than
the
1 gram
per kilo
dosage commonly used in animal experiments.
It compares favorably
with the results obtained
in streptococcus
infections in mice (1) using
one-tenth
to one-fiftieth of the tolerated
dose.
Differences
in absorp
tion
rate
exist in humans
(24).
Absorption
is nearly complete
in 4
hours.
For
this
reason
divided doses are preferable.
Equilibrium
between
intake
and output
is established
in
2 to
3 days
and
then
nearly
100 percent of the intake may be recovered from the urine.
The toxic effects of this drug are frequent but usually not alarming.
They
soon subside after withdrawal.
Large amounts
of fluid act as
an
antidote.
Apparently
few
fatalities
have
occurred
(36).
The
toxicity is low.
The minimal lethal mouse dose following single sub
cutaneous
injections in olive oil is
6 grams
per kilo of body weight.
Two grains or more
per kilo produces
spasticity of the extremities,
excitability,
and incoordination.
They
tolerate
1 grain per kilo in
definitely.
Similar
symptoms
have
been
noted
in
humans
(26)
including
toxic
optic neuritis
(27), mental dullness,
confusion,
lassi
tude, giddiness,
and sleepiness are common.
These
toxic
effects are
usually mild, appear early during drug ingestion,
and either disappear
or are well tolerated
after 48 hours even if treatment
is continued.
Cyanosis occurs in up to
75 percent
(6f) of cases.
It is best ob
served
by slaty nail beds and bluing of the lips of varying intensity.
It may
be associated
with methemoglobinemia,
an aniline effect, not
unexpected,
since sulfonanilamide
is
an
aniline
derivative.
It also
contains
a sulfamido group.
Sulfhemoglobinemia occurs
(6f),
(15),
(21), (22), and
the administration
of sulfates
is thought
to
be pre
disposing.
The
sulfhemoglobin
is slowly
removed
from
the blood
SNOWDEN
ASD
BELL
SULFANILAMIDE
THERAPY
49
having
been
observed
6
weeks
after
drug
ingestion
ceased
(21).
Methemoglobin
disappears
in
24 hours.
Spectroscopic
examination
of the blood is a more delicate means of detecting
sulfhemoglobinemia
than is clinical observation of cyanosis
(21), (24).
A fall in the blood COi combining power
is frequent
(6f) having
been found in 15 consecutive
cases
(23).
A febrile reaction
was noted in 15.6 percent of cases
(33), and must
be differentiated from
a bacterial effect.
It may develop
during the
first day or two of drug ingestion
but occurs more frequently following
prolonged
therapy.
Various
subjective
symptoms
of toxicity
ac
company the fever and other objective findings
are commonly present.
A dermatitis
was noted in 9 of 21
cases
(33).
Cutaneous eruptions
are frequent
(28), (29), (30), (32), (34), (35) and vary from a maculo-
papular
erythema
to purpuric
areas (29), (33) with intense
pruritis
often present.
These eruptions usually occur
on exposed
areas and
are attributed
to exposure
to sunlight (30), (34), (35) due to a photo
sensitizing property of the drug.
Both dermatitis and febrile reaction
may
appear
after reduction in dosage or even after the drug is dis
continued.
They may disappear
even though
treatment is continued
and rapidly
subside
after
drug withdrawal.
The administration
of
small
doses of the drug has been noted
to induce
toxic
recurrences
(29), (30), (31), (32) and positive patch tests are reported.
However,
this evidence of cellular sensitizing
properties
is not universally found
for
negative
intradermal
and patch
tests,
absence
of precipitins
in
the blood serum and passive senistization tests in humans
and guinea
pigs have yielded negative
results
(33).
A depression
of hepatic
function is revealed by the bromsulphalein
test (37) and jaundice may develop
(13a)
(33).
This subsides
upon
drug withdrawal.
In one case (13a)
the subsequent
administration
of large doses of sulfanilamide failed
to provoke a recurrence.
Renal irritation
does not occur
(6f) but the drug is excreted slowly
by damaged
kidneys.
In such patients cessation
of therapy is indi
cated when blood
levels reach
15-20 milligram percent.
The drug may exert a profound effect upon the hematopoetic
system.
Since it contains
a benzene ring this is not unexpected.
Apparently
certain persons
are more
susceptible,
i. e., have
a sulfanilamide idio
syncrasy.
Granulocytic maturation may be inhibited and one death
has
been attributed
(36)
to
agranulocytosis.
However, many
case
reports indicate that granulocytic stimulation also occurs
and leuko
cyte counts up to 83,000 have been reported.
The relative importance
of the underlying infection must
be
assessed
but some cases show
an
increase of immature granulocytic
cells after institution
of therapy.
A moderate
eosinophilia
is not uncommon.
The red blood
cells are
also attacked, producing acute hemolytic anemia,
5 cases
(38), 5 cases
(37), and
1 case (31).
Skin
testing
and repetition
of therapy after
.-)()
SNOWDEN
AND
HELL — SULFANILAMIDE THERAPY
recovery
has
failed
(37)
to provoke
a
recurrence.
The
anemia
is
associated
with
the
appearance
of
nucleated
red
blood
cells,
poly-
chromatophilia,
anisocytosis,
and
poikilocytosis.
The
serum
bili
rubin is increased
and urobilinuria occurs.
The drug sulfanilamide has been
accepted for New and Nonofficial
Remedies
(3)
as a therapeutic
agent for the
treatment
of infections
by hemolytic
streptococci
of Lancefield's
serologic
group
A.
This
includes
most of the hemolytic streptococci
causative
of acute
severe
infections in man.
It has been
used successfully
in mouse protection
experiments
with meningococcus
infections
(6a, b, d, e) and in similar
infections in humans
(6c,
f).
Another
compound
(disulfanilamide)
possesses
a
better
therapeutic
index
in
streptococcus
and
menin
gococcus
infections
if given
subcutaneously
(6d).
The
effectiveness
of
sulfanilamide
in
meningococcus
infections
suggested its use in those due to the gonococcus which is closely related
biologically.
A
series
of
47
cases
of
various
types
of
gonococcic
infection of
the genito-urinary
tract has been reported
(9).
In 36
cases
the
gonococci
and
the urethral discharge
disappeared
in less
than
5
days.
In
five
cases
the
subjective
symptoms
disappeared
completely; there was a marked diminution in the urethral discharge,
but the gonococci were still present.
Three cases
showed no response
to the drug.
Three other
cases
showed prompt response, but treat
ment
was discontinued
and
the infection recurred.
In two
of these
cases
it disappeared
following a second course of treatment.
In no
instance
was there
a progression
of the infection.
The possibility of
late recurrences
was recognized.
The prompt subsidence
of burning
and frequency
was noted.
Alcohol and sexual excitement
were pro
hibited.
Another report
(10) of
100 sulfanilamide treated
cases
(40
grains daily) included 40 new infection cases with 3 treatment
failures
and
60 old infection
cases
with
7
treatment
failures.
The
average
length of time for clinical recovery
was 5 days.
The criterion for cure
was the disappearance
of microscopic
pus from the urine,
absence of
pus from
the prostate
gland,
loss of all symptoms
and the failure of
recurrence.
In
a third report of
31
cases
of gonorrhea
(25)
4 were
classed
as failures.
Two
failures
were males with symptoms
after a
week
of
therapy.
Two
were women
with
positive cultures
at the
conclusion
of treatment.
One case of arthritis responded
nicely.
In
these
cases once clinical cure was established
a daily dose of 20 gi ains
was continued for
10 to
14 days.
The
clinical
observations
reported
present
unusual
optimism.
There
is need for reporting
of clinical
controls.
A survey
of
sul
fanilamide treated
cases
is presented.
The diagnosis
of gonococcic
infection
was
made
on
the demonstration of gram
negative
intra
cellular
diplococci
of
typical
morphology
and
distribution
in
the
stained
smear of yellowish
urethral discharge which appeared in from
SNOWDEN
AND BELL
SULFANILAMIDE
THERAPY
51
3 to
10 days following sexual exposure.
All cases
were restricted to
the ship thus restricting alcohol
and sexual exposure.
No local, oral
or
dietary
measures
were
instituted.
These
patients
continued
ambulant
and
performed
their routine duties.
The only treatment
given
during
the
period
covered
by
this report
was
sulfanilamide
orally.
The dosage varied slightly in certain
cases but approximated
4 grams daily for 2 days,
then
2 grams daily for
G days and
3 grams
daily
for
6
more
days.
Each
case
was
observed
daily.
At
least
every other day the amount of urethral discharge
was noted and gram
stained and the two-glass
urine test recorded.
Each case was charted
but due to lack of space only one representative
chart is presented for
each group.
CASE REPORTS
The
15 cases studied
are subdivided as follows:
Recent infection cases reacting
favorably,
5
Case
1.—J. F. M., seaman second class.
Exposed July 1, 1037; initial symptoms
July
3,
1937.
Presented
with
profuse
purulent
urethral
discharge.
Meatus
acutely
inflamed.
Two-glass
test,
cloudy— clear.
July 6, 1937:
Sulfanilamide
started.
July 14. 1937:
White blood cells 6,650,
hands
5, segs. 60, lymphs.
32, monos. 2,
eoains.
1.
July
16,
1937:
Two-glass
test,
clear— clear.
Discharge—
none.
Smear
of
urethral scraping positive.
July 20,
1937:
Smear of urethral
scraping positive.
July 23,
1937:
Smear of urethral
scraping positive.
July 25,
1937:
Sulfanilamide
discontinued.
July
30,
1937:
Smear of urethral
scraping
negative.
Prostate
normal
to pal
pation.
Secretion contains
1-2 leukocytes
per high-dry
field.
No organisms.
August
5,
1937:
Prostate
normal.
Smear negative.
Cane
2. —J. Y.
M., seaman
first
class.
Exposed
July
12,
1937.
Presented
July
17,
1937 with
a slight urethral
discharge.
Meatus
not
inflamed.
Two-glass
test, cloudy —clear.
Sulfanilamide
started.
July 21,
1937:
Smear positive.
July 22,
1937:
Smear negative and continued
so through
August
5,
1937.
August
1, 1937:
No discharge.
Two-glass
test,
clear— clear.
August
4,
1037:
Prostate
normal.
Expressed secretion shows many leukocytes,
no organisms.
Sulfanilamide
discontinued.
Cafe ?..—A. D. H., ship's cook third
class.
Exposed June 22,
1937.
Presented
June
29,
1937
with
slight
purulent
urethral
discharge.
Meatus
not
inflamed.
Two-glass
test, shred— clear.
Sulfanilamide
started.
July
12,
1937:
No discharge;
two-glass
test,
clear— clear.
Smear
negative.
Sulfanilamide
discontinued.
July
21,
1937:
Smears
continue
negative.
Prostate
slightly
enlarged,
not
indurated.
Expressed
secretion contains
1
2 leukocytes
per high-dry
field.
No
organisms.
Toxic symptoms-
slight dullness.
Case
4-—U. S. S. Mississippi,
11. R. B., seaman first class, Division C.
Exposed
July
12,
1937.
Initial sympton July
14.
1937.
Reported
for treatment July
16,
1937.
Present
symptoms:
Slight
yellowish
urethral
discharge.
Burning
upon
52
SNOW'DEN
AND BELL
SULFANILAMIDE
THERAPY
urination.
Meatus
not acutely
inflamed.
Laboratory
report
shows many
intra
and extracellular
gram negative diplocoeci.
Many pus cells.
Chart I
No. dais infected
1| s, r,
9,111s16|1719,212s 262729 ,s1,sss0,s7,s;'1143M 47496115sbl 6759
2 Class test
|[J
|
1 1 1 1 1 1 .
1 1 J
1 1
Cloud
ill .od
.?
"
1 1
1 1 1
1 1 ,
1 1
Cloud
Cloud
1 i
1
1 1 i
1
1 1
1
1 1
I
Cloud
Haxe
lei
1 1 1 1
1 1
1
[
i
i
i
i
1 1
Hue
Haze
1 |
111
i
1
C1..U.1
Clear
ivl
1 |
1 1 1 1
1
|
Hate
Omj
>
1
1
|
1
Shred
Clear
1 1
1 1 '
1 1
1
1
1
Clear
Clear
_i
|
:
1
1
1
1 gl...
2 01Hss
i
>
1
a
34
1 1
I'rofose Purulent
> 1
1 1
Slirtt
1vl
1 1 1 1 1 1 1 1 1 >
1 1
1 1
Intermittent
Kl
I
1 1 1 1 1 1 1
1 1 1 1 1
A. M. Tear
1 1 1"V :
1 1 1 1 1
1
1 1 1 1 1 1 1 1 1
1 1 1 1 1
None
I11
Ml
1 1 1
1
1 1 1 1 1
Sulfainlamide
16|
1
i
i
i
i
i
i
i
i
i
i
i
i
1 1 1
drams daily
«_ 1 1 1 1 1 1 1 1
i
i
1
1 1
1s1 1
t-i
i
i ii
i
i
1
1 1 1 1
1"
1
1
i
i
I
i .
- L
1 1 1
111 1 1 1 1 1 1 1
i
i
i
i
i
i
i
1
1 1 i
1
GcDocoeel.
Laboratory report
ooel.
Many
~T"
gram nt-K intra or extra cellular diplo.^or *
jeLLL
i
i
IX1'
1. July
22,
1937:
W.
B.
C.
6,350.
Hgb.
85 percent.
Differential:
Bands
8,
seg.
66, lymph.
24, mono.
2.
2. July 28, 1937:
W. B. C. 7,800.
Hgb.
85 percent,
R. B. C. 4,580,000.
Differ
ential:
Bands
5, seg. 64, lymph.
27, mono. 3, baso.
1.
3.
August
1, 1937:
Prostate
normal.
Expressed
secretion normal.
4.
August
3, 1937:
Prostate
normal.
Expressed secretion normal.
Cast'
o.—J. C. F., seaman
second
class.
Exposed July
25,
1937.
Presented
July 28,
1937 with
scanty urethral
discharge.
Two-glass
test, haze— clear.
Sul
fanilamide
started.
July 31,
1937:
No discharge.
Two-glass
test, clear— clear.
Smear of urethral
scrapings negative.
August
6, 1937:
Sulfanilamide
discontinued.
August
12,
1937:
Prostate
enlarged,
not indurated.
Expressed
secretion
con
tains
many
leukocytes,
no
organisms.
Smears
of
urethral
scrap ngs
have
re
mained negative.
Recent infection cases reading
unfavorably, 6
Case 6.—J. K. K., ship's cook second class.
Exposed June
12,
1937.
Presented
June 23, 1937 with a profuse purulent
urethral discharge, meatus acutely inflamed.
Two-glass
test, cloudy —clear.
Sulfanilamide
started.
July
1,
1937:
White blood cells 7,100,
bands 8, seg. 62, lymphs.
26, monos.
4.
July 21, 1937:
White
blood cells 7,500, bands 10, segs. 60, lymphs.
23, monos. 4,
eosins.
1, baso.
2.
Two-glass
test, haze — haze.
Discharge— morning tear.
Smear
positive.
July
27,
1937:
Differential
white
blood
cells:
Bands
2,
segs.
68,
lymphs. 18,
monos. 3, eosins. 9.
Two-glass
test, haze—haze.
Discharge
consists of morning
tear.
Sulfanilamide
continued.
August
5,
1937:
Morning
tear
positive
for
gram
negative
intracellular
dip
locoeci.
Prostate
slightly
indurated
and
nodular.
Secretion
contains
many
leukocytes,
no organisms.
SNOWDEN
AND BELL
SULFANILAMIDE
THERAPY
53
Cafe
7.—E. E. C., seaman first
class.
Exposed June
8,
1937.
Presented June
11,
1937
with
a profuse
purulent
urethral
discharge,
itching
and
burning
on
urination,
meatus acutely
inflamed.
Two-glass
test, cloudy — cloudy.
Sulfanila
mide started.
June 30,
1937:
Epididymitis, acute right — in bed
4 days.
July 22,
1937:
White blood cells 7,450,
bands 8, segs. 65, lymphs.
25, monos. 2.
August 9,
1937:
Prostate
slightly
enlarged,
irregular,
not tender.
Expressed
secretion contains
many leukocytes
and gonococci.
Two-glass
test, haze —haze.
Discharge slight and positive for gonococci.
Sulfanilamide
discontinued.
Case
ft.—T. N. J., seaman first class.
Exposed July 4, 1937.
Presented July
7, 1937, with a purulent
urethral
discharge and acutely
inflamed meatus.
Two-
glass test, shred—clear.
Sulfanilamide
started.
July 11, 1937: Two-glass test, cloud —haze.
July
15,
1937:
Two-glass
test,
shred— clear.
Discharge
had
decreased
to
morning
tear.
July 19, 1937: Discharge profuse and purulent.
July 27,
1937:
White
blood cells 7,000,
bands
2, segs. 43, lymphs.
50, monos. 2,
eosins.
2, basos.
1.
July
31,
1937:
Discharge
profuse, positive
for gonococci.
Prostatic
infection
present.
August
6, 1937: No change.
Sulfanilamide
discontinued.
Case
9.—H.
G. M., seaman first
class.
Exposed
June
27,
1937.
Presented
July 4, 1937, with a scanty yellowish
urethral discharge.
Two-glass
test, cloudy —
clear.
Sulfanilamide
started.
July 21, 1937: White blood cells 4,700,
bands 10, segs. 70, lymphs.
16, monos. 4.
July
29,
1937:
Urethral
discharge
intermittent
and
positive
for
gonococci.
Two-glass test, haze —clear.
Sulfanilamide
discontinued.
Case
10.—U.
S. S. Mississippi, H. E. L., fireman
first
class,
division
B.
Ex
posed June
20, 1937.
Initial symptom
June
22, 1937.
Reported
for treatment
June 23, 1937.
Present symptoms:
Profuse purulent
urethral discharge.
Meatus
inflamed.
Laboratory report shows many leukocytes, many gram negative intra-
and extra-cellular
diplococci.
See chart II.
Chart
11
i
1335 .7J 1!14s4 . 17rj 5153.74575'J
No. days
113: 5| 7
11113IS :T 19|212s 25-2729 31
2 Glass teat
1
1 1 1 1 1 1 1
M
i
1
Cloud
Blood
-ft!-
1
1
1 1 1 1 1 1 1
1 1
1 1 l
1 1
Cloud
Cloud
Cloud
Haw
'n
/\
1 1 1 1 1 1 i
1 1 1 1 1 1 1 1 1 1 1 1 1 1
1 1
1 1 1 1 1
Ii
Sua
Haze
r4.
1
i
1
1
1
1
,
1
1
1
i
1
1
M
1
1
1
i
1
1
Cloud
Clear
I
l
1
i
i
i
1
1
1
1
l
1
i
Hale
Clear
i
i
i
i
l
l
1
i
l
i
l
ll
1
1
1
1
1
1
1
1
1
1
1
Shred
Clear
1
1
1
1
1
1
I1
1
1
1
1
||
1
1
i
1
1
l
1
I
1
1
Clear
Om
l
1
l
l
.
i
;
i
i
1
l
1
Mill
1
gla»
2
C.1.M
1
i
il
2
1
i
,3
i
1
.
111
i
Discharge
Purulent
□
i
l
l
ll
l
i
1
|
—ShJEht—
ill!
•
1
ill;
;
i
i
i
i
i
i
i
i
i
i
1
1
i
i
i
i
1
Sulfanilamide
61
1
Ml
1
1
M
1
1
1
M
1
1
1
1
1
Grams dally
4-
1
i
i
l
i
i
i
i
i
i
1
1
1
1
1
1
1
1
i
'
1
'
1
'
'i
1
i
r*
—
i
—
i
—
1
—i—1— -t-
1
1
1
1
1
1
1
1
1
1
i
'
1
l
l
l
i
l
l
i
i
i
i
l
l
1
i
i
i
i
l
ll
1
1
M
1
1
1
1
1
1
1
1
1
1
1
1
1
'
1
1
Laboratory report
,
ny
Laboratory re;
Gonooocei. jjg
Moderate .
□
1X1
1
1
1
1
M
1
3d
X
1
Gram neK intra or extracellular diplo. •or
*
1XJX
XX
J
X1 X
!
3
1X1
1
1
1
1
1
1
1
1
1
1
1
1
I
1
1
KXX
X
1X1
□
1
1
1
5-1
SNOWDEN
AND BELL
SULFANILAMIDE
THERAPY
1. July
1,
1937:
White
blood
cells
8,100.
Differential:
Bands
8,
segs.
68,
lymphs.
18, monos. 5, cosin. 1.
2. July
15,
1937:
White
blood
cells
6,500.
Differential:
Bands
5, segs.
47,
lymphs.
35, monos. 6, eosins.
5, basos.
2.
3. July 31, 1937: Prostate
increased in size, nodular and indurated.
Expressed
secretion shows many leukocytes and scattered groups of gram negative diplococci.
4.
August
12,
1937:
Prostate
is indurated
and nodular.
Expressed
secretion
shows a few gonococci.
Case It.—S.
N.
L., seaman first class.
Exposed
June
22,
1937.
Presented
June 29,
1937, with
a profuse urethral
discharge and an acutely
inflamed meatus.
Two-glass
test, cloudy — clear.
Sulfanilamide
started.
July
15,
1937:
Discharge
profuse.
Two-glass
test,
cloudy — cloudy.
White
blood cells 7,300, bands 8, segs. 50, lymphs.
26, monos. 5, eosins.
10, baso.
1.
July 23,
1937:
Complication — acute inflammation
of distal tendinous
insertion
right rectus femoris.
July
29,
1937:
Discharge
slight
but
positive
for
gonococci.
Two-glass
test,
cloudy —cloudy.
Sulfanilamide
discontinued.
Old infection cases reacting favorably,
2
Case
12 — T.
M.
G.,
private.
Exposed
April
2,
1937.
Treated
by
local
injections
until June
6,
1937. at which time he presented a purulent
urethral
dis
charge
with
an
acutely
inflamed
meatus.
Positive
for
gonococci.
Two-glass
test, shred— clear.
There
was
a subacute prostatitis
and he was recovering from
a right epididymitis.
Sulfanilamide
started.
June 11, 1937: No discharge.
Two-glass
test, clear— clear.
Smear of urethral
scraping positive
for gonococci.
June
17,
1937:
Has continued
to show no discharge.
Two-glass
test, clear—
clear.
Urethral
scraping
negative
for gonococci,
for
past
5 days.
Prostate
is
normal
in size,
shape,
and consistency.
Expressed
secretion contains
clumps of
gram negative diplococci.
June 25,
1937:
Three
prostatic
examinations
negative.
Sulfanilamide
discon
tinued.
June 29, 1937: White
blood cells
9,300,
bands 8, segs. 43, lymphs.
43, monos. 4,
eosins.
2.
Case
13. — C. G. H., seaman
first class.
Exposed April
15,
1937.
Treated
by
local injections
until June
7,
1937, at which
time he presented a slight, purulent,
G.
C.
positive,
urethral
discharge,
inflamed
meatus,
a
large,
boggy,
regular,
slightly
tender
prostate
and
a
two-glass
test,
cloudy —clear.
Sulfanilamide
started.
June 15, 1937: No discharge.
Two-glass test, clear—clear.
June
23,
1937:
Prostate
normal
in size and consistency.
Expressed
secretion
loaded with leukocytes.
No organisms.
June 27,
1937:
Prostate
same.
Expressed secretion contains
10-12 leukocytes
per high dry field.
June 29, 1937:
White blood cells 6,000,
bands
5, segs. 55, lymphs.
28, monos
7,
eosin. 1, basos.
4.
Sulfanilamide
discontinued.
July
1,
1937:
Prostate
normal.
Old infection cases reacting
unfavorably, ?
Case
l.'i. —1. N. R., seamen
first class.
Exposed May 28. 1937.
Treated with
local injections
until June
19,
1937 at which time he presented a profuse, purulent.
G.
C.
positive
urethral
discharge
and
an
acutely
inflamed
meatus.
Two-glass
test, dourly — cloudy.
Sulfanilamide
started.
SNOWDEN
AND BELL
SULFANILAMIDE
THERAPY
55
June 29,
1937:
No discharge, urethral
scrapings
G. C. positive.
White blood
cells 8,100, bands
6. segs. 45, lymphs.
38, monos.
5, eosins.
3. basos.
3.
July
21,
1937:
Discharge — purulent
morning
tear, G. C.
positive.
Two-glass
test, haze —clear.
White blood cells 9,300, bands 8, segs. 42, lymphs. 44, monos. 3,
eosins.
3.
Sulfanilamide
discontinued.
Cane
15.— E. L. R.,
seamen
second
class.
Exposed
May
1.
1937.
Turned in
May 31,
1937
because
of an acute vasitis,
right.
Presented a scanty,
yellowish,
purulent,
G.
C.
positive
urethral
discharge.
Two-glass
test,
cloudy — cloudy.
Prostatitis, acute.
Seminal
vesiculitis,
acute.
Sulfanilamide
started.
June
7,
1937:
Epididymitis,
right, acute—9 sick days.
Discharge
consists of
morning
tear, G. C. positive.
June 22, 1937: Discharge
same.
Prostatitis still present.
July
1,
1937:
Prostate
normal
in size and consistency,
not tender.
Expressed
secretion contains many leukocytes,
no organisms.
Vesicles not palpable.
Right
epididymis
presents slight residual induration
of globus major and minor.
July
30,
1937:
Discharge
of morning
tear, G.
C. positive
Prostate
normal.
Expressed
secretion normal.
White blood cells 6,100,
bands
8, segs.
42, lymphs.
40, monos.
6, eosin.
1, basos.
3.
Sulfanilamide
discontinued.
SUMMARY
Of the
15 cases studied 4 were old cases in that their infection had
been treated locally prior to the use of sulfanilamide.
Eleven of the
cases were
recent
infections.
Of
the old infection
cases
2
reacted
favorably,
2
unfavorably.
Of
the
new
infection
cases
5
reacted
favorably,
6 unfavorably.
A patient's reaction was considered
favor
able if all symptoms and signs (including negative
gram stain of the
urethral
scrapings)
disappeared
and
there
was
no recurrence.
The
favorably reacting recent cases were definitely mild infections.
They
did not present
profuse
urethral discharge
or the
acutely
inflamed,
pouting urethral orifice
so commonly noted.
The two chronic cases
wliich
reacted
favorably had been
under
treatment for some
time.
They were improving
at the time this therapy was instituted.
No
severe
toxic manifestations were noted.
All patients complained of
one
or more
of
the
symptoms:
Lassitude,
giddiness,
confusion,
or
sleepiness.
These were particularly
noticeable
during
the first
few
days of therapy and tended to become less troublesome.
One patient
reported with an acute vasitis, right, and went on to develop
an acute
right epididymitis in 7 days in spite of sulfanilamide treatment.
His
course
was unsatisfactory
throughout.
The epididymitis,
however,
proved
quite
mild
and
pain
was
not
preeminent.
Another
case
developed
an acute teno-myositis which cleared up in 4 days.
White
blood cell
and differential counts
were
done
on
12 of the
15
cases.
Four
cases
presented
eosinophilia
of
3
to
10
percent.
No
case
developed
jaundice, dermatitis, neuritis, or hemolytic anemia.
The
examination of many
smears of the urethral discharge
did not reveal
any increase of phagocytosis
of gonococci.
56
SNOWDEN
AKD BELL
SULFANILAMIDE
THERAPY
CONCLUSIONS
In cases of gonorrhea sulfanilamide therapy causes:
1 . Prompt disappearance
of urethral discharge in some cases.
2. Gonococci persist
in urethral
scrapings
for several
days
after
the subsidence
of the urethral discharge.
3. Prompt subsidence of symptoms of burning and frequency
in all
cases.
4. Metastatic extension of the infection does occur.
5. Disabling
complications which have
occurred
have run a short
course,
subsided
quickly,
and were attended
by less fever,
less pain,
and less discomfort than usual.
6. No evidence of increased phagocytosis
of gonoccoci
was observed.
7. The
rapid
subsidence
of
discharge,
symptoms,
and
urethral
inflammation in favorably reacting cases suggests control of gonotoxin
(19).
8. If a case does not react favorably within
2 weeks it is not likely
to do so.
Bibliography
(1)
Domagk,
G. : Kin Beitrag
Zur Chemotherapie
der bakteriellen
Infektionen.
Deutsche
Med.
Wchnschr.,
61:
250-3,
1935;
Domagk,
G.:
Chemotherapie
der
bakteriellen
Infektionen.
Angew.
Chem.,
48:
657-67,
1935.
(2)
Chemotherapy
in Streptococcic
Infections,
editorial, J. A. M. A.
108:
48
1937;
Treatment
of Streptococcic
Infections
with Sulfanilamide,
ibid.; p. 976.
(3)
Council on Pharmacy
and Chemistry,
A. M. A.: Sulfanilamide
and Related
Compounds, J. A. M. A.
108:
1888,
1937.
(4a)
Trefouel,
J. et Mme.
J., Nitti,
F.,
et
Bovet,
D. : Activity der P-amino-
Phenylsulfamide
sur les Infections
Streptococciques
experimentales
de la souris et
du lapin,
Compt.
rend. soc. biol.,
120:
756-8,
1935.
(4b)
Nitti, F., and Bovet, D. : Les Septicemics Streptococciques
Experimentales
et leur traitement
par le p-amino-phenylsulfamide.
Compt.
rend.,
202:
1221-3,
1936.
(5)
Council on Pharmacy
and Chemistry:
"Sulfanilamide"
(the Council name
for Para-amino-benzene-Sulfonamide),
J. A. M. A. 108:
1340,
1937.
(6a)
Buttle, G. A. H., Gray,
W. H., and Stephenson,
D.: Protection
of Mice
Against
Streptococci
and Other Infections
by P-amino-benzene-sulfonamide
and
Related Substances.
Lancet,
1:
1286-90,
1936.
(6b)
Proom, H : The Therapeutic
Action of Para-Amino-beuzenesulfonamide
In
Meningococcal
Infections
of Mice,
Lancet
1:
16, 1937.
(6c)
Schwentker, F. F., Gelman, S., and Long,
P. H.: The Treatment
of Menin
gococci Meningitis with
Sulfanilamide,
J. A. M. A. 108:
1407,
1937.
(6d)
Rosenthal,
S. M., Bauer, H., and Branham,
S. E. : Comparative
Studies of
Sulphonamide
Compounds
in
Experimental
Pneumococcus,
Streptococcus,
and
Meningococcus
Infections,
Pub.
Health
Rep.,
52:
662,
1937.
(6e)
Branham,
S. E., and Rosenthal,
S. M.: Sulphanilamide,
Serum, and Com
bined Drug and Serum
Therapy
in Experimental
Meningococcus
and
Pneumo
coccus Infections
in Mice,
Pub. Health Rep.,
52:
685,
1937.
(6f)
Long,
P. H., and Bliss, E. A., Sc. D. : The Use of Para-Amino-benzenesul-
fonamide or Its Derivatives
in the Treatment
of Infections
due to Beta-Hemolytic
Streptococci.
Pneumococci
and Meningococci,
Southern
Med. J., May
1937.
SNOWDEN
AND BELL—SULFANILAMIDE
THERAPY
57
(7)
Fuller, A. T.: Lancet,
1:
194,
1937.
(8)
Gley and Girard:
Presse med. 44:
1775,
1936.
(9)
Dees, J. E., and Colston, J. A. C.: The Use of Sulfanilamide
in Gonococcio
Infections, J. A. M. A.
108:
1855,
1937.
(10)
Reuter, F. A.: The Use of Sulfanilamide
in Treatment
of Gonorrhea,
Med.
Annals of District of Columbia,
Washington,
6:
117-152,
1937.
(11)
Colebrook,
Leonard,
Buttle,
G. A. H., and O'Meara, R.: Lancet
2:
1323,
1936.
(12)
Rosenthal,
S. M.: The Effect of P-amino-benzene-sulphonamide
on Pneu-
mococci in Vitro, Pub. Health Rep.,
52:
192, 1937.
(13a)
Long, P. H., and Bliss, E. A.:
Para-Amino-Benzene-Sulfonamide
and Its
Derivatives,
Archives of Surgery,
Feb.
1937.
(13b)
Long, P. H., and Bliss, E. A.: Para-Amino-Benzene-Sulfonamide
and Its
Deiivatives,
J. A. M. A.
108:
32,
1937.
(14) NItti, F., and Bovet,
D.:
Compt.
rend. Soc. de biol.
119:
1277,
1935.
(15)
Colebrook,
L., and Kenny, Meave:
Treatment
of Human Puerperal
Infec
tions and Experimental
Infections
in Mice with Ptontosil, Lancet
1:
1279,
1936.
(16)
Mellon, R. R., Gross, Paul, and Cooper, Frank B.: Experimental
Studies
with Sulfanilamide
and with Prontosil, J. A. M. A.
108:
1858,
1937.
(17)
Levaditi, C., and Vaisman,
A.: Compt.
rend. Acad. d. sc. 200:
1694,
1935:
Compt. rend. Soc. de biol.
119:
946,
1935
(quoted
by (14) and
120:
1077
(1935)
quoted
by (12)).
(18)
H. Finklestone-Sayliss,
C. G. Paine, and L. B. Patrick:
The Bacteriostatic
Action of p-Aminobenzenesulphonamide
upon
Haemolytic
Streptococci,
Lancet
2: 792-795,
1937.
(19)
Meyer,
F.:
Quart.
Bull. Sea View
Hosp.,
2:
148,
1937.
(20)
Hill, Justina H.:
Personal
communication
to authors
of article
(9).
(21)
Paton, J. P. J., and Eaton, J. C: Sulphemoglobinemia
and
Methemo
globinemia
Following Administration of P-Amino-benzenesulfonamide.
Lancet,
1: 1159,
1937.
(22)
Discombe,
G. : Sulphemoglobinemia
Following Sulfanilamide
Treatment,
Lancet,
1:
626,
1937.
(23)
Southworth,
H.:
Proc. Soc. Exper. Biol. & Med.,
36:
58, 1937.
(24)
Marshal,
E. K., Jr., Emerson,
Kendall, Jr., and Cutting, W.
C.: Para-
aminobenzenesulfonamide,
J. A. M. A.
108:
953,
1937.
(25)
Buchtel, H. A., and Cook, E. N. : The use of Sulfanilamide
in Treatment
of
Urinary
Infections.
Proc.
Staff Meetings
of The Mayo Clinic, 12:
444,
1937.
(26)
Whitby, L. : An Experimental
Assessment of the Therapeutic
Efficacy
of
Amino Compounds with Special Reference to P-Benzylamino-benzenesulfpnamide;
Lancet 1:
1517-1519,
1937.
(27)
Bucy,
Paul B. : Toxic Optic Neuritis Resulting
from Sulfanilamide,
J. A.
M. A. 109:
1007,
1937.
(28)
Salvin, Monte:
Hypersensitivity
to Sulfanilamide,
J. A. M. A. 109:
1038,
1937.
(29)
Goodman,
M. H., and Levy, C.
S.:
The
Development
of a
Cutaneous
Eruption
1Toxicodermatosis),
J. A. M. A.,
109:
1009,
1937.
(30)
Frank, L. J.:
Dermatitis
From Sulfanilamide,
J. A. M. A. 109:
1011,
193/.
(31)
Kohn, S. E.:
Acute
Hemolytic
Anemia
During Treatment
With Sulfanil
amide, J. A. M. A.
109:
1005,
1937.
(32)
Schonberg,
I. L.: Purpuric and Scarlatiniform
Eruption
Following Sul
fanilamide,
J. A. M. A.
109:
1035,
1937.
(33)
Hageman,
P. O., and Blake,
F. G.:
A Specific
Febrile
Reaction
to Sul
fanilamide,
J. A. M. A.
109:
642,
1937.
24140—37
5
58
FIJLGHUM —SULFANILAMIDE
THERAPY ANGINA
(34)
Menville, J. G., and Archinard, J. J.: Skin Eruption in Patients
Receiving
Sulfanilamide,
J. A. M. A.
109:
1008,
1937.
(35)
Newman,
B. A., and Sharlit, H. : Sulfanilamide:
A Photosensitizing
Agent
of the Skin, J. A. M. A.
109:
1036,
1937.
(36)
Borst, J.:
Death
from
Agranulocytosis
After Treatment
with Prontosil
Flavum, Lancet
1:
1519-1520,
1937.
(37)
Harvey,
A. M., and Janeway,
C. A. : The Development
of Acute Hemolytic
Anemia
(during the administration
of Sulfanilamide),
J. A. M. A. 109:
12, 1937.
(38)
Long (6f)
quoted by (31).
SULFANILAMIDE
TREATMENT
OF LUDWIG'S ANGINA
By James E. Fulghum,
Lieutenant, Medical Corps,
United States Naval Reserve
Ludwig's
Angina
is
a diffuse
cellulitis of submaxillary
region
and
floor of the mouth which may
eventuate
in gangrene
of the skin or
mucous membrane.
The swelling usually progresses rapidby, spreading
toward the neck and upwards into the floor ot the mouth.
The swelling
is board-like resembling
that seen in carcinoma
of the neck.
The floor
of the mouth
and tongue
are elevated with the latter pushed toward
the affected
side.
Sepsis
is marked.
In unchecked
cases,
the mor
tality
rate is high.
The condition is usually secondary
to extraction
of teeth or infections of throat or tonsds
and
the invading organism
is
usually
the
streptococcus.
The
treatment
heretofore
has
been
early
and
adequate
incision
with
drainage
and
hot
fomentations.
Streptococcus
serum has been used.
CASE
REPORT
This is a case report of a white female child, age
3 years, who had
always been healthy with no history of any illness before the onset of
present infection.
Present illness. —Parents
give
a history
of a fall
1 week prior to infection
in
which
a small
area of skin
was
abraded
from
the anterior
surface of the chin.
This was given
first-aid
care by the mother
who applied
mercurochrome.
On
August
22,
1937, during
the late morning,
the parents noted that the child
was
drowsy,
ill,
and fretful,
had anorexia
and
some
temperature.
She
refused food
during the day of the 22d.
She was put to bed on the same evening.
During that
night,
she was extremely
restless,
cried out, and complained
of pain in the sub
maxillary
region.
The mother noticed
a firm swelling in this region but thought
that it was glandular.
By early morning,
the swelling had increased alarmingly
fast and was then the size of an egg.
The temperature
rose steadily and by early
morning
was quite high.
She could not eat or drink anything
after
5 a. m. on the
morning
of the 23d.
Physical
examination. —I saw her at my
office
at
6 a.
m.,
August
23,
1937.
The swelling of the submaxillary
region was about the size of a lemon and felt like
carcinoma
of the neck.
It was
quite tender and not movable.
The tongue was
pushed up into the roof of the mouth and the mouth could not be opened except
FULGHUM —SULFANILAMIDE
THERAPY
ANGINA
59
enough to insert
a tongue
depressor between the teeth.
The temperature
was
102.5°
and the child
was acutety ill.
There
was a scab on the chin
which
was
lifted off and a small amount of pus was obtained for a microscopic
study.
Smear
showed
short-chain
streptococci.
Gentian
violet
was painted
on
the abraded
area.
Blood:
White blood cells, 16,300;
red blood cells, 4,496,000; polys,
85 per
cent; lymphs,
15 percent;
haemoglobin,
80 percent.
Urine:
Reaction,
acid;
sp.
gr.,
1.020;
albumin,
negative;
glucose, negative;
micro,
negative;
color,
red.
Treatment. —I decided to use sulfanilamide
as treatment
since other diseases
of
streptococcic
etiology
have
yielded
to this
preparation.
Accordingly,
5
cubic
centimeters of 25 percent sulfanilamide
was given intramuscularly
each 4 hours
for
4 doses.
The swelling
did not increase any in size during
the day of the 23d.
The only sign of improvement
was the fact that the child asked for water about
4:30 p. m. and drank freely.
On August
24th, the child was seen again at 6 a. m.
She was
much brighter,
temperature
was 99.6°,
and she was able to take liquid
diet and fluids freely.
By 12 noon, she was able to eat solid food in small quan
tities.
The swelling
was decreasing in size slowly and the board-like
hardness was
not quite as evident.
Blood:
White blood cells, 18,050;
polys, 94 percent; lymphs,
6 percent.
During that day, three doses,
3.5 cubic centimeters each, of 2.5 percent
sulfanilamide
were
given.
The morning
of the 25th, the child had improved
rapidly,
was playful,
tempera
ture was normal, and the swelling was still regressing.
She was able to eat and food
was asked for.
Blood:
White blood cells,
16,500;
polys,
68 percent;
lymphs,
26
percent; endothelial,
1 percent;
eosinophils,
5 percent.
On the 26th, the child
was given
2 injections
of 2 cubic centimeters each of 2.5
percent
sulfanilamide.
She
was feeling well except for a mild
acute bronchitis.
She had a temperature
of 99.5°
which l thought
probably
due to the bronchitis.
Blood:
White blood cells,
11,000;
polys,
64 percent;
lymphs,
34 percent;
eosin
ophils,
2 percent.
On the
27th,
she was given
one
injection,
2 cubic
centimeters
of 2.5 percent
sulfanilamide.
The child appeared normal except for a small swelling of about the
size of a small marble in the submaxillary
region.
This was not hard, neither did
it fluxate.
It seemed
to be resolving without pus formation.
Blood:
White blood
cells,
10,600;
polys, 60 percent; lymphs,
38 percent; eosinophils,
2 percent.
Patient
was seen
again
on the morning
of the 28th.
Temperature
was still
normal and the child appeared to be well.
Further rapid regression had occurred
in the swelling,
and still no pus formation.
Sulfanilamide
was given in 1.5 cubic
centimeters
dose and the patient
discharged to return again in
3 days for further
examination.
Blood:
White blood
cells,
9,200;
polys,
61
percent;
lymphs,
38
percent; eosin,
1 percent.
SUMMARY
Ludwig's
Angina in a 3-year-old child due to streptococci entering
from lesion on chin,
treated with sulfanilamide intramuscularly,
with
an arrest of the
progress
of the
disease,
and gradual regression
of
swelling without pus formation and rapid return to normal as compared
to the usual surgical treatment.
Although I am reporting only one
case, I feel that we have
a valuable medical treatment for Ludwig's
Angina due to streptococci,
and that by its use, the mortality
rate of
this dreaded condition will be greatly decreased.
60
HOGAN
AND
McKAMARA
SULFANILAMIDE
PSYCHOSIS
PSYCHOSIS
PRECIPITATED
BY SULFANILAMIDE
By Bartholomew
W.Hooan,
Lieutenant,
Medical Corps, United
States Navy, and Philip J. McNamara,
Lieutenant,
junior grade, Medical Corps, United States Navy
This is a preliminary report of one of the cases of a series now being
studied under the direction of the urological service,
United
States
Naval
Hospital,
Washington, D. C.
The object of the series is to
aid in the determination of the role of sulfanilamide in the treatment
of gonococcus
infections.
Complete results
of this series will appear
at
a later date.
CASE REPORT
'
A. C, private,
United
States
Marine
Corps;
age,
21;
was admitted
to
this
hospital
August
27,
1937,
from the marine detachment
on duty at this ho-pital.
Chief
complaint. —Urethral
discharge,
frequency,
burning
and
stinging
on
urination,
and rattier constant
severe
pain in the perineum of
1 week's duration.
Family history and past
history. —Noncontributory as regards this illness.
Present illness. — May
be considered
to date back
to
December
1935, at which
time he had
his first diagnosis of gonococcal
infection
of urethra.
A concurrent
prostatitis
complicated
his
condition,
but
he was finally
considered
apparently
well after extensive treatment
ending June
1936.
He entered the United States
Naval Hospital,
Washington,
D. C, October
17,
1936, with diagnosis of gonococcus
infection
of prostate.
He received treatment and was returned to duty
December
28,
1936,
with
instructions
to
continue
treatment
as
an
ambulatory
patient.
About July
1. 1937, he was again considered apparently
well but advised to have
a periodic check-up on his prostate.
On August
27,
1937, he was admitted
again
to thN hospital
with the chief complaint
mentioned
above.
Further information
showed that
he had occasional
recent sexual exposures.
Physical
examination on admission was essentially
negative except for a profuse
purulent
urethral
discharge
and
a moderately
enlarged,
tender
and indurated
prostate.
A
smear
of the
urethral
discharge
was
positive
for
gram
negative
intracellular
diplococci.
Blood
studies were all normal.
Kahn and Wasserman
reaction
were
negative.
Urinalysis
was negative except for
3 to
6 white
blood
cells per high-power
field.
His diagnosis was considered to be gonococcus infection of prostate.
Clinical course. —In the hospital
consisted of bed
rest and general supportive
measures
until August
30,
1937,
3 days after
admission,
at which
time it was
decided to start him on a course of sulfanilamide.
He received 80 grains of sul
fanilamide
daily for
2 days; 60 grains daily for
9 days; and 40 grains daily for 6
days.
On September
16,
1937, sulfanilamide
was stopped
because
of disappear
ance
of complaints.
Total dosage,
940 grains.
On September
21,
1937, his pro
static secretion was found to contain gram negative intracellular
diplococci
and a
morning
tear had returned.
He was again started
on sulfanilamide
September
21, 1937, 80 grains daily for 2 days; 60 grains daily for 2 days.
On September 24,
1937,
he
presented
himself
to
the
ward
medical
officer
requesting
something
be done about
"conditions
in general",
and in particular
"the attitude" of his
fellow
patients
and the hospital
corpsmen.
He
was
of the opinion
that
a con
spiracy
was
on foot to bring about his discharge from the Marine Corps and he
threatened
to jump ship
if action
on his behalf
wa.s
not immediately
obtained.
He wondered if he was "slipping
mentally
and wanted to check up on this before
things
went too far."
Further administration
of sulfanilamide
uas discontinued
i Submitted
for publication
Oct. 25, 1937.
O'CONNELL —SULFANILAMIDE
FATALITY
61
this date and patient
was transferred
to the neuropsychiatrie
service for observa
tion and treatment.
Total dosage
sulfanilamide,
second course,
280 grains.
Up to this time his reactions
had
been
normal
and
his conduct
in the ward
had
been
satisfactory.
Complete
blood
studies,
including
quantitative
blood
sulfanilamide
determinations
had been done biweekly.
Temperature,
pulse, and
respiration
were charted daily.
He remained under constant medical supervision
and was restricted
to the urological
ward.
He seemed
to be tolerating
the drug
very
well as far
as could
be determined
by physical
signs and laboratory
date.
The highest blood sulfanilamide
concentration
was 7.7 milligrams
per 100 cubic
centimeters.
The lowest
red blood
count
was
4,240,000
per cubic
millimeter,
with
a hemoglobin
of
81
percent.
The lowest
COj
combining
power
was
52
volumes percent.
Quantitative
urine sulfanilamide
determination
showed good
elimination.
Eisumi of psychiatric findings. —Patient's
past history
shows him to have been
somewhat
unstable,
a behavior
problem,
making
a poor adjustment
in his home
and school life.
He gave no history
of previous
nervous or mental illness.
His
father
is
a practicing
physician.
No
family
history
of mental
illness.
While
on active duty with the marine detachment at this station and for 3 weeks follow
ing admission
to the sick list he exhibited
normal
behavior.
His psychotic
picture
was
characterized
first
by mild
paranoid
feelings with
apprehension
and restlessness.
He became
acutely psychotic,
entertaining
audi
tory and visual hallucinations
with
a fairly clear sensorium.
He stated that
he
saw, his relatives
around
the hospital
and that
his mother was talking
from the
floor
above.
The
picture
continued
to
resemble
a
toxic
delirium,
dreamlike
fancies and bewilderment.
Because of his desire to escape
to locate his mother,
he was transferred
to St. Elizabeths
Hospital, where he has made and maintained
a gradual
improvement
at this writing (Oct.
25,
1937).
SUMMARY
1. A case
of gonococcus
infection of prostate
was
treated
over
a
period of 3 weeks with sulfanilamide.
2. An acute onset of a psychotic condition was apparently precipi
tated by the administration of sulfanilamide.
3. The
psychotic
picture
resembled
that
usually
seen
in
toxic
psychoses.
4. One month later, following the withdrawal of the drug,
there is
a definite
improvement in the mental
state.
SULFANILAMIDE
POISONING
Report op Fatal Case
By I. T. O'Connell, Lieutenant
Commander,
Medical
Corps,
United
States Navy
R. S. C., seaman, first class,
was admitted
to the United
States naval hospital,
San
Diego, Calif., September
25,
1937.
Chief complaint. —Sore throat and fever.
Family history.— Father died of influenza at 35.
Mother died of influenza
at
30.
No brothers or sisters.
Denies familial
diseases.
*tr#tp*i&S »^f'*t«**|(i
Past
history.—Born
in
Texas.
Had the usual
childhood
diseases.
Enlisted
October
1934, and has had continuous service since.
Operations:
appendectomy,
1936.
Illness,
gonorrhea,
1935-37.
Denies syphilis.
62
OCONNELL
SULFANILAMIDE
FATALITY
Present illness. —Last night
patient
had
a severe
chill followed
by fever, and
he reported
to the sick bay.
This morning
his throat became sore and
he
was
transferred
to this hospital.
Temperature
on arrival, 104.4; pulse,
126; respira
tion,
28.
Patient's
health
record shows that
he had
been
under
treatment
for
chronic gonorrhea treated with sulfanilamide
as follows:
September
1,
1937,
70 grains.
September
2, 1937,
70 grains.
September
3, 1937,
55 grains.
September
4, 1937,
55 grains.
September
5, 1937,
55 grains.
September
6, 1937,
30 grains.
September
7, 1937,
30 grains.
During this
course
of treatment
blood
counts
were
made and
no change
was
noted.
On the sixth day of treatment
he had white blood cells,
5,650; 75 percent
polys;
red
blood
cells
and
hemoglobin
normal.
Treatment
was
discontinued
after
the seventh day
because
he developed acute catarrhal
fever.
ln
a couple
of days
he was feeling
well and the urethral
discharge had stopped.
When
he
reported
to the sick
bay on his ship last night
he had
a mild
sore
throat
and
was given routine
"cold"
treatment.
His temperature
was
102.0.
This morn
ing his temperature
was
104.4;
pulse,
130;
respiration,
34.
White
blood
cells,
3,500; polys,
0 percent;
lymphs,
99 percent;
monocytes,
1 percent;
red blood
cells, 3,910,000; hemoglobin,
80 percent.
He
was transferred
with a diagnosis
of agranulocytosis.
Physical
examination. —Well-developed
and
well-nourished
young
white
male
of 22 lying in bed and appearing acutely ill, but rational
and clear mentally.
Head:
Eyes: Pupils equal, regular, and react normally.
Conjunctivae
icteric.
Nose and ears:
Negative.
Mouth:
Tongue
negative.
Teeth
in good repair and hygiene.
Throat
red
dened
and
inflamed.
No ulcerations.
Tonsils
inflamed
but
not
mark
edly.
Neck:
Anterior cervical glands palpable.
Chest:
Lungs:
Negative
to percussion and auscultation.
Heart:
Normal
position.
Rate
and
rhythm
regular
and
very
rapid.
No
murmurs.
Blood pressure,
110/60.
Abdomen:
Rounded
and soft.
Appendectomy
scar, right rectus incision.
Genitals:
Negative.
No urethral
discharge.
Extremities:
Reflexes normal.
Rhomberg
negative.
Treatment
and clinical
course. —September
25,
he received 1,000 cubic centime
ters of saline solution
intravenously.
At 9:30
p.
m.
he received
10 cubic centi
meters of pentnucleotide.
September
26.
He
was
made
a strictly
bed
patient
with
forced
fluids
and
liquid diet and pneumonia
jacket.
White blood count,
650; lymphs,
100 percent;
urine,
20 milligrams
albumin.
He received
10 cubic centimeters of pentnucleo
tide at 9:30 a. m., 2 p. m., 6 p. m., and 10 p. m.; deep X-ray therapy, long bones;
and morphine
p. r. n.
At 4 p. m. his temperature
was
105.0;
pulse, 140; respira
tion,
32.
September 27.
Twenty-four-hour fluid intake,
2,905 cubic centimeters,
output
1,690
cubic
centimeters.
Red
blood
cells,
3,110,000; hemoglobin,
90 percent.
Patient had considerable
edema
of the throat
for which
an ice collar
was used.
HERING
SULFANILAMIDE
THERAPY
GONORRHEA
63
He received
5 cubic
centimeters
of ieucocytic
extract
intramuscularly
at
11
a. m., 4:30 p. m., and 10:30 p. m.
He was given 325 cubic centimeters of blood
by
indirect
method
at noon,
and
1,000
cubic
centimeters
of normal
saline
by
hypodermoclysis
at
4:30
p.
m., and
a similar
amount
with
5 percent
glucose
intravenously
at 10:30 p. m.
September
28.
Swelling
of the neck increased; patient
became semicomatose
and
was placed
on the critical
list.
Oxygen
tent
was applied
at
5:20
a.
m.
Temperature,
102.0;
pulse,
142 and
weak;
respiration,
33.
Red
blood
cells,
3,240,000; white blood cells, 500; lymphs,
100 percent.
At 1:40 p. m. his blood
pressure
was
84/58
and
white
blood
cells,
650;
lymphs,
100
percent.
Urine,
specific
gravity,
1.015;
albumin,
30 milligrams;
positive for red blood
cells and
occult
blood with a few granular
casts.
Kahn, negative.
Patient
received
morphine
one-fourth
grain
at
0040
a.
m.
and
9:45
p.
m.;
leucocytic
extract,
5 cubic centimeters
at 10:30 a.
m. and
10 cubic centimeters
at 6:10 p. m. intramuscularly;
blood transfusion,
200 cubic centimeters of citrated
blood
at 11:45 a. m.; normal saline
1,000 cubic centimeters
by hypodermoclysis
at 5:00 p. m. and 1,000 cubic centimeters
normal
saline
with
5 percent
glucose
intravenously
at 10:00
p. m.
At
10:50
p.
m. patient
became
cyanotic,
and
an
airway
device was inserted
for relief.
He failed
to respond to coramine
at 11:15 p. m. and died at 11:34
p. m. September
28,
1937.
Autopsy findings. — 1. Agranulocytosis.
2. Edema
of the glottis.
SUMMARY
This patient was hospitalized because
of
a sore throat and
fever
of overnight duration.
The blood picture showed
a total absence of
granulocytes, confirming the diagnosis
under which he was admitted.
There was a history of taking 365 grains of sulfanilamide over a period
of 7 days 3 weeks ago.
The patient was critically ill with ulceration
and swelling
of the throat.
The hemopoietic
system failed to respond
to X-ray therapy to long bones, "Pentnucleotide"
Ieucocytic extract,
or
two
blood
transfusions.
The
leucopenia
with
agranulocytosis
persisted
and
the patient
died
after
3
days'
illness.
A
100-tablet
bottle
of
Prontylin
(Winthrop)
containing
22
5-grain
tablets
was
found in the patient's effects.
This finding would suggest
that he
may have
taken
an unknown amount of sulfanilamide in addition to
that prescribed.
RESULTS
OF SULFANILAMIDE
THERAPY
OF GONORRHEA
By E. R. Hering,
Lieutenant,
Medical Corps, United States Navy
The use of sulfanilamide in the treatment
of gonococcus
infections
was instituted
at the United
States
Marine
Corps Base,
San Diego,
Calif., on June
9,
1937.
The observations
noted in this paper
cover
the period from that time until August 28,
1937.
The data reported
in this paper covers the observations
on 46 cases of gonorrheal
infec
64
HERING
SULFANILAMIDE THERAPY
GONORRHEA
tion and a group of 15 cases of post-gonorrheal
involvement where no
positive smears could be obtained,
streptococci
infection of the throat,
and cellulitis of various parts of the body.
These
15 cases are included
to show the percentage of reactions occurring in a total of 61 individuals
treated with sulfanilamide.
NEW
CASES
This group
comprised
29
cases which were
seen within
the first 2
days of beginning
of symptoms,
and which had had no other
type of
treatment.
Table I shows
the
results
obtained in
these
29
cases.
Classification A, table I, includes
those
cases
which
were symptom
free within
5 days and which, after observation of from
1 week to 2
months,
have
remained
so.
Two-glass
tests
and
smears
on
these
cases have all been negative,
and they have been considered
as cures.
Classification
B,
table I, includes
those
cases
which
were
cleared
up within 30 days.
Most of these cases showed negative
smears after
15 days, and the infection ran a very mild course.
In some of these
cases silvol,
5 percent,
was given
by urethral injection
and served to
dry up the
mucous
discharge
after smears
were
negative.
Classi
fication C, table
I, includes
those
cases
which still
showed
positive
smears after 30 days' treatment with sulfanilamide and were considered
as failures, although the sulfanilamide was considered
of possible value
in preventing complications.
Table I
Cases
Percent
12
7
10
a
Classification
B
34
34
Classification
C
CHRONIC
CASES
This group
comprised
17
cases
which had
had
more
or
less
con
tinuous urethral discharge
for a period
of from 2 months
to
2 years.
All of these cases had positive smears when treatment
with sulfanila
mide
was
started.
Table II shows
results
obtained
in this
group.
Classification
A,
table
II, includes
those
cases
in which
discharge
was completely
stopped
and smears were negative
after 6 to
8 days'
treatment.
It is not presumed
that all these cases
in classification
A were completely
cured.
However,
most
of these cases
were ones
that reported
to the sick bay as soon as they learned that sulfanilamide
was being used
{2){ months
ago), and have since that time shown no
clinical evidence
of gonorrheal
infection.
Classification B, table II,
includes those cases that showed no clinical response to sulfanilamide
within
30 days.
This
group
is especially
interesting because
of the
complete
and
rapid
amelioration of symptoms
after various other
HERING
SULFANILAMIDE
THERAPY GONORRHEA
65
forms of treatment over
a period
of from 2 months to
2 years
had
failed.
Table
11
Cases
Percent
I5
88
12
Cassiflcation
B
2
Total
17
MISCELLANEOUS
CASES
This is a group of
15
cases including streptococcic
infection of the
throat, cellulitis of various parts of the body, and
nonspecific
ure
thritis and prostatitis.
They were not of a sufficient
number to form
a basis for any definite
conclusions,
but are included in order to com
pile the
percentage
of reactions
in
the
total of
61 cases which were
given sulfanilamide.
DOSAGE
When the drug was first used, it was customary to give
30
to 45
grains daily for the first 2 days and then raise the dosage to 60 grains
daily for the next
3 days, depending
on how the case was progressing.
As we became more familiar with the drug, we started with 80 grains
daily for the first 2 days followed by 60 grains
daily for the next
3
days, and then gradually decreasing
the dose until
10 days' treatment
had been given.
No better results
appeared
to have
been achieved
by this method,
and we now give the drug in the following manner:
Grains
daily
3 days
*
60
3 duys
45
3 days
30
3 days.-
15
Total,
12 days
450
The
tablets
are given
three times daily, after meals.
REACTIONS
Reactions from sulfanilamide were divided roughly into three main
types, viz., skin, constitutional, and renal reactions.
Some of the cases
showed
a combination of the skin and constitutional
types, but they
are listed under the classification
of their most predominant symptoms.
Skin
reactions. —These
reactions
varied from a slight papular rash
on the hands, arms, face, and neck to a severe involvement of the same
areas with
marked
edema
and
weeping
eczematoid
lesions.
These
reactions
occurred
from the second to the eighth day of treatment
and
lasted from 2 to 5 days, depending
on their severity, following discon
tinuance
of the drug.
Figure
1 illustrates
a severe form of this skin
reaction.
66
HERING —SULFANILAMIDE
THERAPY GONORRHEA
In all there were
12 skin reactions
in the group
of 61 cases.
How
ever, there were only three which could be classified
as severe, the other
nine
being of very little consequence.
It is interesting to note that
the manifestations appeared
on the surfaces
of the body exposed
to
the weather,
and the three severe cases had been exposed to the direct
rays of the sun during the whole
day
previous
to the occurrence
of
the eruption.
Constitutional
reactions. —This group
consisted
of four cases which
gave symptoms of general
malaise,
headache,
nausea,
and some ver
tigo.
They were very mild, showing
no rise in temperature,
or pulse.
Practically
half of the cases in the entire series, on questioning,
stated
that they experienced
some drowsiness,
but these four were the only
ones that had
sufficient
subjective symptoms to complain of volun
tarily.
The
symptoms
disappeared
within
24
hours
after
discon
tinuance of the drug.
Renal
complications. —This group
consisted
of four
cases
which
developed
what
is believed
to have been, for want of a better
term,
an irritative or chemical
pyelitis.
They showed
a rise in temperature
to 100°-103° F., and the urine showed
a heavy concentration
of pus
cells.
No casts or erythrocytes were found in the urine.
All four of
these cases developed
their symptoms
after the gonorrheal
symptoms
had
disappeared,
within
6
to
8 days
after starting
the
treatment.
Constitutional
symptoms
disappeared
and the urine promptly became
free of pus cells within
2 days after discontinuance
of the drug.
Classification of these four cases under the heading of renal complica
tions
may
be misleading,
but the fact that these four were the only
ones of the entire
series that showed
a concentration of pus cells in
the urine along with constitutional symptoms seems
to point to some
irritation
of the kidney in this group.
All of the Gl cases were given
a complete
blood count at least once
during
the
course
of
treatment.
At no
time
was
there
found
any
decrease in the blood
elements.
In fact, in most of the cases which
had reactions,
the leukocyte
count showed
a rise of from 3 to
5 thou
sand with very little shift to the left.
TREATMENT
OF REACITONS
The only treatment of reactions
consisted
of rest in bed, forcing
fluids to aid
in elimination of the drug,
and
large
doses of sodium
bicarbonate.
During the latter part of this series, sodium bicarbonate,
from 60 to 90 grains, was given daily in conjunction with the treatment
as
a prophylactic
measure, but it is impossible
to state at this time
whether
or not it was of much value.
CONCLUSIONS
1. Sulfanilamide
appears
to
have
a specific
effect
on gonorrheal
infection in a great majority
of the cases.
Figure
11 —Chondrodystrophy Fetalis.
SARGENT—CHONDRODYSTROPHY
FETALIS
67
2. It is most efficacious when
used at the earliest
possible moment,
and its most striking effects take
place within
the first
5 days.
3. Sulfanilamide is especially
efficacious in producing clinical cures
in long-standing
cases of gonorrhea.
4. Sulfanilamide appears
to eliminate complications and lessen^the
severity
of the infection, even in those cases which do not respond
immediately to the drug.
5. Sulfanilamide is capable
of causing
severe reactions,
and should
only be given under the strict supervision of a medical
officer.
6. Direct
exposure
to intense sunlight appears
to have some effect
in increasing
the severity of skin reactions.
CHONDRODYSTROPHY FETALIS
By Willabd
S. Sargent,
Lieutenant Commander,
Medical Corps,
United States
Navy.
This condition
is
also
called
achondroplasia or microlelia.
It is
more of a cartilage dystrophy
than achondroplasia, therefore
chon
drodystrophy is probably a better
term.
It is a congenital
affection in which the stature is small and at birth
the
legs and
arms
are proportionately
smaller
than
the trunk;
the
latter may be of nearly normal size.
ETIOLOGY
The
real
cause is entirely problematic
and unknown.
Some
say
heredity plays a part in this disease and some say it does not.
Both
sexes are affected and it has been said that males transmit the disease.
It has been attributed to placental changes or to intrauterine infection
with
consequent
epiphyseal
changes
or destruction, which
changes
probably
occur
in the first half of intrauterine
existence.
Some,
as
might
be
supposed,
blame
the internal
secretions
and
others
have
suggested
a toxic basis.
It has been present
in as many as three successive
generations
of
males.
A person with
the condition may have normal or abnormal
children.
PATHOLOGY
It is essentially
a dystrophy of the epiphyseal
cartilages
of the long
bones — a disturbance of normal ossification.
The cartilage
atrophies
and ossification occurs
early,
causing
the bones to become distorted,
the joints limited and growth retarded,
and since it begins in utero,
the earlier it starts the more marked
the deformity.
The cartilaginous
skeleton
essentially
suffers
and it rarely involves
the
membranous
bones.
The
bones of the arms
and legs are the ones mostly affected,
but
the tribasilar bone in the floor of the skull may be involved and ossify
68
SARGENT
CHONDRODYSTROPHY
FETALIS
early, causing
disproportion
of the vault.
The long bones
become
bowed
and shortened
and as the periosteum
continues
its usual func
tion of bone formation the bones enlarge in diameter
and the connec
tive tissue from the periosteum
invades
the epiphysis,
which unites
prematurely with the diaphysis, stopping growth.
The growth makes
the arms
and legs stumpy, while the head
and trunk
are apt to be
normal.
The epiphyses are frequently enlarged.
The ossa innominata
and ribs also frequently suffer.
The glands
of internal secretion
are
rarely involved, and a few cases may have precocious
sexual develop
ment, but this is not an essential of the disease and other evidences of
pituitary affection
are not present.
The genitalia are apt to be normal.
It is
a malformation
of bone
and
the enchondral matrix may
be
defective
in its development.
The nasal
bone depression
is due to lack of development
in which
it differs from lues which is due to diseased bone.
SYMPTOMS
The fetus may
be aborted, it may be still-born, it may die while an
infant, or may live a few years and then die.
If it lives beyond child
hood it is likely to grow
to adult life and die at any age from other
causes;
being usually robust and well muscled,
but dwarfed.
As
a
child it walks late
and,
while it is usually somewhat
disabled,
the
muscles
are apt to be well-developed
later even though in some cases
movements
are painful.
The number reaching adult life are few; they
have average intelligence
; the head is of normal size or larger.
As the
person
grows
from childhood
to adult
life the condition
gradually
becomes more marked
as the limbs and deficient
cartilage
areas do not
keep pace with the parts
of the body unaffected.
The vault of the
cranium is prominent at the parietal and frontal areas and the nose
being depressed makes the forehead
seem still more prominent.
The
trunk appears long but is actually shortened,
the back is flat, lordosis
is present
and
the scapulae
short.
The buttocks
are enlarged
and
prominent.
The belly is usually prominent due to the marked
exag
geration
of the lumbar curve.
The hand has fingers
of short length
and the so-called
trident hand is caused by a separation
of the second
and third fingers at the second phalangeal
joint.
The arms are short,
the humerus
is especially
affected,
the radius
is longer than the ulna,
which is usually deformed
and
shortened,
and
the hands
are thick.
The legs arc short,
and the femur is proportionately shorter than the
bones of the leg.
The fibula is longer than the tibia, and the limbs may
be considerably bent or bowed .
The bones are very thick at points of
muscular attachment.
The relative shortening of the ulna and tibia
tends to produce
bowing of the arms and legs.
The joints are promi
nent,
hyperostoses
may form about the
epiphyseal
line, and
joint
disability may occur.
SARGE N T
CHOS DRODYSTHOPH Y FETALIS
69
French describes
the body as of the dachshund
type.
The normal
curves
are exaggerated
which may
make caesarean
section
necessary
in pregnant
women.
The
vertebrae
often
are
effected,
producing
spinal deformity.
The ribs may show
deformity
suggestive
of the
"rosary."
The
fontanelles
often
close late in childhood and
there
may
be a
mild internal hydrocephalus.
The eyelids
and lips are apt to be thick.
DIAGNOSIS
The history, the age of appearance of symptoms,
the size, the X-ray,
and
the facies help
to rule out acromegaly,
leontiasis
ossium,
gout,
arthritis, fragilitis
ossium,
osteomalacia,
osteitis
deformans,
multiple
exostosis,
and osteogenesis
imperfecta.
Oxycephaly has an enlarged
head, impaired vision and exophthalmos.
Progressive
facial
hemia
trophy is not congenital,
it shows discoloration of the skin, wrinkled
and furrowed cheeks, the skin glands
are functionless,
and
the teeth
and
eyebrows
may
fall out.
This leaves cretinism, rickets, syphilis,
and
yaws
to
be
differen
tiated.
Rickets is usually, though not always postnatal.
The bones
are soft, fracture easily,
and the suture
lines are insecure.
There is
no
pug
nose,
and
the spleen
is apt to
be
enlarged.
The limbs are
not necessarily
shorter
than
normal,
and
the
stature
may
be little
affected.
Some
have
thought that
achondroplasia
is fetal rickets,
but it is essentially
different; at birth it simulates
a case of severe
grade of rickets which has run its course.
In true achondroplasia
the bones remain distorted, the joints are limited in range of motion,
general body growth is retarded,
and only the milder cases may reach
adult life.
The X-ray shows
greater
enlargement
of the
epiphyses
in rickets.
In chondrodystrophy
the enlargement
of the
epiphyses
may be slight or absent and the lesions are in the
cartilage,
but
exo
stosis may form at this region or at muscular attachments
on the bone.
The lesions are complete at birth and the later deformity is the result
of the early
lesions.
The X-ray further shows the curved
and short
bones
in
the chondrodystrophy.
The
latter
has
the disproportion
between
the trunk and extremities
and the more striking deformities.
Most cases of rickets appear
after
the sixth month;
excess
cartilage
is produced, the periosteum
fails to lay down
bone, bone is absorbed
from the canal,
and ossification
is irregular.
The
muscles in rickets show lack of tone,
the lymph glands
may
be enlarged,
the liver is often
enlarged,
and the patient is subject to
complications.
Deformities
are more frequent in the lower than the
upper extremity because of weight bearing.
The humerus
is rarely
deformed,
the wrists
are
broad,
the knees and
ankles
are large,
and
70
.SARGENT
CHONDRODYSTROPHY
FETALIS
bowlegs
or knock-knees
are apt to
develop.
Necrosis never
occurs
in rickets.
Cretinism
has the so-called
myxedematous
cachexia
and defective
growth of the bony skeleton.
The patients
are mentally slow,
have
a peculiar blank
facies,
enlarged
tongue,
small stature, old-looking
appearance,
and are benefited by thyroid therapy.
The hair is scanty
and
coarse,
while
in
achondroplasia
it is abundant
and
soft.
The
thyroid is apt to be absent, atrophied, or goitrous.
The skull bones
are thick,
the
sutures
remain
open,
and
the
fontanelles
close
late.
Symptoms
are not usually noted
till
1 year of
age
or more.
The
skin
is dry, coarse, thick, and does not pit on pressure.
The extrem
ities are apt to be short and stubby but lack the characteristic deform
ity of chrondrodystrophv.
Tho affection
is general and not selective.
Syphilis and yaws
are the same disease or else very similar.
It is
lesions
of the nasal
bones in these that give
the depression
and not
lack
of
development
as
in
chondrodystrophy.
Necrosis
occurs
in
lues but not in chondrodystrophy.
In congenital
lues tlie long bones,
especially
the
tibia,
are
most
frequently
affected, particularly
near
the epiphysis, which causes a broadening.
Proliferating changes occur
in the periosteum,
with periostitis.
The tibiae often have nodules or
show
roughening.
Gumma
are rare,
although
pain
at night
often
occurs in lues of bones and the Kahn test is usually positive.
Yaws
as seen in the tropics with such extensive
bone involvement
would
probably involve the nose, throat, and face and produce
gan-
gosa.
PROGNOSIS
The condition is present
at birth and becomes
accentuated
as age
progresses.
Abortion
may occur before
the
fetus
is developed
or it
may
be still-born.
It may die soon after or in the first few years of
life.
The prognosis
as to life is not good till after the first year or
so of existence but after this the prognosis
as to life is good, but as to
altering
or curing the condition it is hopeless.
TREATMENT
No treatment is of any avail.
CASE REPORTS
Cane
1.— M. J. M.
Male.
Age 69.
Height,
o7 inches; weight,
164 pounds.
No history
of yaws.
Kahn negative.
Father
and one uncle, who are now dead,
had the
same
affliction
and he is very sure he was born with
this condition.
He
is the father of cases 2, 3, 4, and 5.
See illustration,
figure 2.
His skull measures
23 inches around.
His arms and legs, including
the bones,
are short, curved,
and
deformed
and he has a tilt to the body.
The bones by measurement
show
the
right ulna to be ti inches and the right radius
7 inches long, while the left ulna is
7 and the left radius 8 inches long.
This together with
a shorter humerus on the
right
side gives a right arm 2 inches shorter than the left.
An osteophyte appears
SARGENT— CHONDRODYSTROPHY
FETALIS
71
at the insertion
of the right deltoid.
The distal end of both
ulnse taper and give
narrow wrists.
Case
2.— M. J. M.
Age 27.
Height,
65 inches; weight,
135 pounds.
The right
side of his face is smaller than his left.
His skull is 20 inches in circumference.
The right half is 9^2 and the left 10% inches.
There is no discoloration
of the skin,
no wrinkled
or furrowed
cheek,
no falling
out of the teeth or eyebrows,
and no
lack
of function
of the skin
glands
as there
is
in facial
hemiatrophy.
I was
unsuccessful in trying to get a picture of the tribasilar bone of the skull.
Case
3.— M. A. M.
Age
23.
Male.
As seen
by the picture
he is a marked
case
of tuberculosis.
Since I got the picture
he had died.
I did an
autopsy;
the lung infection
was marked
but nothing
else abnormal
was found except these
numerous or multiple
exostoses.
He is not a dwarf
but he shows these exostoses
in
the neighborhood
of epiphyses,
so I put him
in the picture
since
he shows
cartilage
dystrophy.
It goes
without
saying that he is not
a case of chrondro-
dystrophy
fetalis
but
being
a cartilage
abnormality,
I thought
it might
give
a
small point of suggestion of heredity
here.
He had these exostoses
all his life.
Case
4-— M. M. M.
Female.
Age
22.
Height,
5 feet; weight,
115 pounds.
The circumference
of the skull
is 21 inches, the face
is normal,
and the mentality
is normal.
The right humerus
is shorter than her left humerus.
Her family
are
very sure she was born this way since her father took notice at birth of all children,
because
of his own affection.
The right humerus
is
10 inches and the left is 11%
inches long.
As shown by the picture her left wrist is narrow.
There are exostoses
in the center of the right
humerus
at the insertion
of the coracobrachialis
and
deltoid.
The chest cage
is normal.
The second and third right toes are shorter
and of equal length.
The lower end of each ulna is tapered.
There
is no sign of
yaws or gangosa and her Kahn is negative.
Case S.—M. J. M.
Age 25.
Single.
Male.
There
is no history
or evidence
of yaws
or
gangosa,
and his Kahn
is negative.
The right
side of his
body
is
smaller than his left but it is not an hemiatrophy
or hemihypertrophy
because
both
sides of his body are affected.
His condition
was present at birth but has become
more evident
as he grew older.
His mentality
is normal and there is no internal
glandular
affection.
His head measures 21J4 inches around,
the right
half being
10 and the left half IIJ2 inches.
The right
side of his face
is smaller;
the X-ray
of his skull also shows this.
All his teeth are present including
the wisdom teeth.
The hair on the head is soft and abundant.
The bridge of the nose
is sunken in.
His eyelids and lips are thick.
The right arm is 22 and the left 26 inches long, the right humerus being
10 and
the left
1CJ4
inches.
The two prominences on the outer side of the right forearm
are bone ends; the upper is the radius projecting
beyond the joint, and the lower
is the short distal
end of the ulna.
The right radius is T/2 and the right ulna is 5
inches long, while the left radius
is 7'4 and the left ulna is 6% inches long.
The
left radius
is prominent
distally
yet both wrists
are narrow
and the metacarpals
are short.
The right index finger is shorter than the others and both hands show
the
trident
effect.
Lordosis
is
present,
the
genitals
are
normal,
the
inguinal
crease
and the gluteal fold are lower on the right
side,
and the trunk is 25 inches
from the first dorsal spine to the end of the coccyx.
The left leg is
1 inch longer than the right and the right
kneecap is lower than
the left while the right tibia projects at the upper and inner end.
The left femur
is
13!$
inches while
the right is
1 inch shorter.
The left tibia is
13
and
the
fibula ll1-! inches but the right
is U inch shorter in each
bone.
The first metatar
sals
arc
only
2
inches
long
and
the
toes
are
all
short;
the second
and third
right
toes
are of the same
length and relatively
shorter.
The
bones
throughout
are
distorted
somewhat
and
show
thickening
at
muscular
attachments
with
hyperostoses in many places.
72
SARGENT
CHONDRODYSTROPHY
FETALIS
Case
6.—Female.
Age
22.
Height
57
inches;
weight
90
pounds.
The
circumference
of her head is 20}i
inches.
Her family were all normal,
but her
father's
father
had a similar condition.
There
is no history
of yaws but her
Kahn is 4 plus; this case is the only one in the entire group I am reporting
that
has a positive
Kahn test.
Her mentality
is normal
or above average.
Her legs
and arms are short and her trunk is proportionately
longer than the limbs.
The
legs are not grossly deformed
but the bones are shorter than normal,
and
a few
exostoses
are present.
The ribs are normal and the pelvis is contracted and small.
The buttocks
are large and prominent,
some lordosis is present and the abdomen
is large on side view.
Her right
arm is longer than
her left
by
1% inches.
The fingers are short,
especially the right thumb,
index finger, and little finger.
The arms and forearms
are short and the wrists
are narrow,
especially
the right.
The right humerus
is
10 and the left humerus 9H inches long.
The right ulna is 5 and the right radius
is 6H inches long.
The left ulna is 5 and the left radius is 6 inches long.
In both
forearms the ulna is larger above and very small and pointed below.
The radius
in each
case
is bent and the head of each
bone projects
beyond the joint and is
forward.
Case
7.—J. R. S.
Female.
Single.
Age 34.
Sister to cases
8 and 9.
She is
54 inches tall and weighs
108 pounds and has normal mentality.
Her father
is
dead; he had
a similar
affection.
There
is no history
of yaws in the family or
herself, and her Kahn
is negative.
Both
legs and arms arc short and the body
relatively
long
with
a small
pelvis.
The left
humerus
and
forearm
are
much
shorter
than the right.
The
wrists
are
narrow
and the fingers are short.
The
right hand
shows the trident effect.
There
is
a small projection
on left elbow
which
is the head of the radius covered only by skin.
The right humerus
is 10%
and the left
10
inches long.
The right radius
is 8 and the ulna S'A inches long;
the radius
is bowed, and lower
ulna tapers and. is deformed
slightly.
The left
ulna tapers, is small distally,
has no styloid
process,
is deeply placed at the wrist
region,
hardly
extends
to
the wrist,
and
is
6
inches long.
The
left
radius
is
curved, large distally, projects beyond the joint, and is seen projecting at the elbow.
The circumference of the head is 21
inches.
All the toes are short, the left second
and third markedly
so.
Case
8. —J. R.
S.
Male.
Age
36.
Married.
This
case
is
57K
inches
tall
and
weighs
102 pounds.
Brother
to
case
7.
The
Kahn is negative.
He
has
good
intelligence.
The
skull
measures
inches.
He
has
short
arms
and
legs and his body is proportionately
longer.
The hands, especially the left, show
the trident
effect.
The wrists
are narrow and the fingers are short.
The meta
carpals are short.
There
are osteophytes on several bones.
Both
bones
in both
forearms
are
deformed
and short,
and the ulnar
bones
are small distally
so that
the ulnar prominence
is lacking.
The right ulna is 6 and the right radius
7 inches
long.
The left ulna is 6 and the left
radius
7}$ inches
long.
The humeri
are
short and are each
10J£ inches long.
The right
second
and third toes
are shorter
than the others.
Case 9.—J. R.
S.
Male.
Single.
Age 30.
Brother
to cases
7 and
8.
This
case is 61 inches tall, or a few inches taller than the others.
The skull
measures
22J4 inches.
Kahn, negative.
No past history
of yaws.
He has tuberculosis.
He
has
the trident
right
hand.
This
case
has
short
metacarpals,
the peculiar
distal
ulnar
deformity,
exostosis around
some
epiphyses,
but
he is not typically
short.
His humeri
are
about
11 inches.
His ulna and radius
of each
arm
are
about
8H inches long.
His left
second
and third toes
are shorter than normal,
compared to the others.
Case
10— G. J. G.
Male.
Single.
Age
26.
Height
56 inches;
weight
112
pounds.
Kahn, negative.
There
is no family
history
of yaws, gangosa, or this
SARGENT
CHONDRODYSTROPHY
FETALIS
73
affection.
He has no past
history
of yaws.
His skull measures
23
inches in
circumference.
His
arms
and
legs
are short;
his
body
is
actually
short,
but
relatively
long.
His left arm
is shorter
than
right.
His chest cage
is normal,
but his lungs show tuberculosis.
The femur and humeri
are short and also his
lower legs and forearms.
The fingers and toes
are short, but the trident
hand is
not definite.
The third and fourth
toes of the left foot are shorter than the others.
There
are
exostoses
about
the epiphyses
of several
of the bones;
a large one
springing
from the right upper epiphysis of the humerus presses
against the chest
wall
and deforms
the upper ribs.
The metatarsals
and metacarpals
are
short.
The right humerus
is
10J4 inches long
and the left
is
10.
The right
radius
is
6}i and the ulna
6 inches long.
The left radius
is 6 and the ulna
5 inches long.
SUMMARY AND COMMENT ON THESE
CASES
As only few cases
reach adult life, we would not expect to find the
worst cases in adults and
we might
say that only the milder
cases
reach
even puberty.
Some of the cases may only have partial affec
tions.
I have not been able to find any children with this dystrophy
and at autopsy on children no cases have been noted.
The children
of those in the group, except those of case
1, are normal.
There are
marked variations in the type and appearance
of different cases.
To
illustrate this point I would refer the reader to pictures in the books of
French,
Graham,
Bradford
and
Lovett,
Spear
and
Coplin.
The
condition is said to be transmitted by males, which has been verified
in these cases.
Cases
1 to 5 are one family, Cases
7, 8, and
9 are a
family
in which
the father
(now
dead)
was
affected.
The grand
father of
case
6 was
affected.
No
relation with
case
10 could
be
established.
We must not overlook the fact that illegitimacy might
fill in an otherwise
unexplainable gap.
Case
5 is the most typical of
all.
Cases 2 and 4 show changes less marked.
Case
3 was put in to
lend weight to an hereditary
tendency.
The faces of cases
2 and
5
are not hemiatrophy for reasons already
explained.
Case 6, the only
one with a positive Kahn, has characteristics of the affection.
Cases 7,
8, and 10 are types of it.
Case
9 has only a few of the characteristics.
A superstitition held by some of the natives is that some tune back
some son struck his father and his punishment was handed
down.
There being no signs of internal glandular affection,
no thyroid was
thought necessary
as a therapeutic test.
The mentality, in all cases,
was normal, and other signs of cretinism were absent,
and all these
cases
were congenitally affected.
In lues, necrosis
occurs,
the X-ray looks different, and
a positive
Kahn with
some other evidence
ought to
be
present.
No
case
or
relative has had
a history of disease or treatment.
Yaws
is apt
to
involve the nose in late neglected
cases.
In rickets a broad wrist is usual and the humerus
is rarely deformed.
In this condition
a narrow wrist is present
and
the humerus
is de-
24140—37-
74
SPALDING — CANCER
formed
frequently;
and
the hair is abundant and
soft
in
all
cases
reported,
while in rickets it is apt to be scanty
and coarse.
A point
noted
in the literature is the frequency of bone thickening
at muscular attachments
and
the
exostoses
at epiphyses,
both
of
which were noted frequently in these cases.
In these cases we note the frequency
of a long radius with the head
projecting beyond
the joint at the elbow,
and
a deformed
short ulna
with the ulnar distal prominence
missing
and
a narrow wrist
thereby
being
produced.
The head in circumference
is large for the rest
of
the body in all the group.
THE CANCER PROBLEM IN THE UNITED
STATES
NAVY
By Otis
13.Spalding, Lieutenant Commander,
Medical Corps, United States Navy
The cancer problem
in the Navy must be viewed from three differ
ent aspects,
as regards
the active
personnel;
the military,
the social,
and the economic.
From
a military
standpoint
the Navy is the fleet,
and
the great
problem
of the naval medical
officer is largely
one of preventive medi
cine.
With
thousands
of
officers
and
enlisted
men
afloat in
the
Battle Fleet, which for the past
5 years has based in the San Pedro-
San Diego area, and with additional
thousands
afloat
and ashore
in
our widely scattered
naval stations and ships in the far distant ports
of Samoa, Guam, the Philippines, China, and Hawaii, and our impor
tant shore stations along the Pacific coast, the management
and con
trol
of malignancy naturally
depend
on
the
early
recognition
and
prompt
transfer
of all such
cases
to the nearest
naval
hospital for
treatment and final disposition.
Prior to July
1, 103G, it was the custom
to send all inoperable
cases
that could
be safely
moved,
to
the United
States
Naval
Hospital,
Brooklyn,
N. Y., for further treatment at
the Memorial
Hospital,
New
York.
But
here
the
social
and
economic
feature
affecting
these
unfortunate
patients
complicates
the
problem.
Transfer
of
these cases
from stations and hospitals on the Pacific coast, either by
transport or train
to New York, meant in many
cases
the breaking
up of families,
with
the inevitable lowering of the patient's morale,
which we all know to be of such vital importance in the treatment of
such cases.
The financial
aspect was a serious problem
to the families
that follow patients
to the east coast,
and there is also the transpor
tation cost to the Government of the patient and his attendants.
Taking
these varied
factors into consideration,
the Bureau of Medi
cine
and
Surgery
issued
orders
designating
the
Naval
Hospital,
Brooklyn,
N. Y.,
as
the
cancer
center
of
the
east coast,
including
the Great Lakes-Chicago
area;
and
the Naval
Hospital,
San
Diego,
SPALDING
CAN CER
75
as the cancer
center for the west
coast and insular possessions.
In
compliance with this order
the commanding
officer of the Naval Hos
pital,
San
Diego,
appointed
a
permanent
cancer
board
on July
1,
1936, this board
to consist of the following members:
Chief of Medi
cine, president
of the board
; members, Chief of Surgery,
Dermatology,
Bacteriology
and Pathology, Dental Surgery,
and Radiology.
Since
its inception the board
has met
at regular intervals in the
auditorium of the Red Cross Building.
All medical
officers
and visit
ing and local physicians have been welcomed
and encouraged
to enter
into discussion
of the cases.
All suspicious
skin lesions
and
new growths admitted to the hos
pital
or referred
by medical
or dental officers,
afloat
or ashore,
are
reviewed
by the board at these meetings,
and a decision
made in each
case as to
probable
diagnosis,
and
necessary
treatment.
All
cases
requiring surgery,
or combined
surgery
and radiation, are treated
by
the
staff.
Biopsy
is made in all
operative
cases,
immediate frozen
sections in all doubtful cases.
Since
the cancer
board
at the San Diego Naval Hospital
was offi
cially organized, July
1,
1936,
a total of 463
cases have been treated,
requiring 2,322 treatments.
Of these 463 cases,
356 cases were benign
lesions or infections;
107
cases
were malignant, proven
by operation
or biopsy.
Of
these
107 malignancies,
20 percent
of all
cases
were
basal
cell epitheliomas,
8 percent
epidermoid
carcinomas.
15
percent
adenocarcinomas,
and
10 percent sarcomas.
There are 32 titles in the Navy nomenclature
in the class of tumors
covering malignant and
benign
neoplasms.
Most of the admissions
included in this class are recorded under such titles as simple retention
cyst or wens, or other cystic growths.
A review of the annual
reports of the Surgeon
General
of the United
States Navy for the 5-year period
1931 to 1935, inclusive, reveals that
there were
1,960 original admissions
for all types of tumor.
Of these
1,566 were benign conditions and 394 were malignant or of malignant
tendency.
In the benign
group
there were
2 deaths,
1 with benign
mixed
tumor and
1 with lymphangioma, and
15 were invalided from
the service.
Of the 394 malignant cases
there were 65 deaths and 43
were invalided from the service.
The more common malignant tumors
were represented
as follows:
Tumor
Admissions
Deaths
Carcinoma.
-
70
48
IS
18
13
8
36
0
Epithelioma
Sarcoma
....
;
10
5
4
5
Tumor,
malignant,
mixed
76
SPALDING
CANCER
The admission
rate per 100,000
for all tumors was as follows:
Admissions
Deaths
1931.
1932.
1933.
1934
1035.
2r$
291
462
419
400
S
12
20
IS
9
From the above survey it will be seen that the admission
rate for the
active list of the Navy per
100,000 is certainly no higher than
the
average rate for the same age group in civil life.
The selection
by the Bureau of Medicine
and Surgery of the San
Diego Naval Hospital
as the cancer center of the west was the logical
result of not only its favorable location with regard
to the fleet, but
also due to the fact that it is a large and well-equipped hospital with a
bed capacity of
1,070
and with
an ultimate capacity when
the new
wing
now
under
construction
is
completed
of
1,270
beds.
The
X-ray department has recently been completely
modernized
with the
installation
of an oil-immersed
shock
proof deep therapy unit, acti
vated by a special moisture-proof transformer of 300,000-volt
capacity,
8 hours continuous operation
at 20 m. a.
This modernization was in
line with
the Bureau's policy
to maintain all departments
in naval
hospitals at the highest
point of efficiency,
by purchasing the latest
and best scientific apparatus for all departments.
From
1932 to 1936 the standard technique
employed
in our therapy
clinic for the treatment of deep seated lesions was 200 KVP, 25 ma. at
50 cm. distance,
with
0.5 mm. cu. and 1.0 mm. aluminum, an equiva
lent of 35.4
(r) units per minute, measured
in air, and an estimated
tumor dose at 10 cm. depth
of 10 percent of the threshold
erythema.
Quimby
(1) of the
physics
department of
the
Memorial
Hospital,
New York, has found that: —the threshold erythema with 200 KVP,
100 sq. cm. field,
50 cm. distance
(T.
S. D.) and
0.5 mm. copper plus
2.5 mm. aluminium is 500 to 525 roentgens.
The
therapeutic
erythema,
on the other hand,
varies from 600
to
1,000
roentgens,
depending
on
the
skin
type.
Failla
(2)
of
the
physics department of Memorial Hospital, whose work on the effective
wave length
of radiation is internationally known, has found that the
relative depth doses at
10 cm.
depth,
obtained
under
comparable
conditions with 200 KVP, 700 KVP, and Gamma rays are respectively
29 percent,
41.2 percent
and
56.7
percent.
However, the advantage
in percent
depth dose in favor of radium is not
realized
in clinical
practice
because it is not practical to apply radium at the
focal dis
tances used in roentgen therapy.
Articles by Quimby
(1), Failla
(2), Coutard
(3), Pack
(4), Ruggles
(5), and Merritt and Rathbone
(6), during the past year, inspired us
SPALDING
CANCER
77
with the desire to obtain a greater effective tumor dosage compatible
with skin safety.
Most observers
who
have
had
an opportunity
to
compare skin reactions
and results
obtained
with 0.5 mm. copper and
2.0 mm. of copper filtration,
are convinced
of the latter's superiority.
Merritt and Rathbone
(7) state:
Following
the work
of Thoraeus
(8)
we have
been
using at the Warwick Clinic
a filter
composed of 1.25
mm.
tin,
0.25
mm. copper, and
1.0 mm.
aluminum.
This filter
has
been
used at 220 KVP,
20 ma., 50 cm.
distance with an intensity
of 10 r. per minute,
measured in air.
This filter
has
a maximum
wave length
of
0.21 A,
which
is the same
maximum
wave length as
5 mm. of copper.
Copper
absorption
curves show that this filter has a half layer value of 2.9 mm. copper at
220 KVP, which is the same
as 5 mm. copper at this voltage.
This tin filter is very
transparent
to hard roentgen rays generated at 220 KVP, and gives an intensity
35
percent greater than 5 mm. of copper.
With this filter we have found the intensity
of 10 r. per minute at 50 cm. distance to be practical
and economical in the treat
ment of selected deep seated malignancies.
With these facts in mind and with the desire to secure the greatest
tumor dosage possible in a given case, using the maximum power at our
disposal,
we have now standardized our technique
at 220 KVP and 20
ma., using Thoraeus filters equivalent to from 2 to 5 mm. of copper, at
50 cm. distance,
thus increasing
the actual tumor dose at 10 cm. depth
from 10 percent of the threshold
dose to approximately 45 percent, and
furthermore, as a result of skin protection resulting from such heavy
filtration, it is now possible
to deliver from 4 to 10 erythema
doses to
the tumor, in effect,
a dose sufficient
to sterilize
the growth without
permanently
damaging
the
skin
and
adjacent
tissues.
The
skin
reaction may, in the
average
case
be
described
as
a second
degree
burn, which gradually fades out, with the skin completely
restored in
from 6 to 8 weeks.
In view of the fact that 28 percent of our series of
107 malignant
neoplasms
were skin cancers,
we have
attempted
to standardize
our
method of treatment with due regard
to the essential features of each
individual
case.
Results obtained
by surgery,
surgery
followed
by radiation, cautery
excision,
preceded
by or followed
by irradiation,
or radium, over
a
period
of
4 years,
were all considered.
Now,
due
to
the brilliant
results
reported
by Dr. Lyell Kinney
and Dr. Ray Lounsberry of San
Diego, in their private practice,
and at the San Diego County Cancer
Clinic,
we have adopted
their method
of cautery excision followed by
unfiltered radiation, in basal cell lesions, and cautery excision followed
by copper
filtered radiation in epidermoid
carcinomas,
with excellent
clinical results in every
case.
Impressed
by the results
obtained
in
the treatment of leukemias,
Hodgkin's
disease,
lymphosarcoma,
and
multiple
myeloma,
by
continuous irradiation, at the Memorial Hospital, New York, we have
modified Heublein's technique
to fit our equipment,
so that we are able
78
SPALDING
CANCER
to spray our patients
at a distance of 115 cm., using 200 KVP, 0.5 mm.
cu. and
1.0 al. filter, with an intensity of 5 r. per minute, measured in
air.
Heublein cites as possible advantages
of his method:
(1) The nearly uniform distribution
of the rays throughout
the body, in treating
generalized neoplasms.
(2) The possibility
that great protraction
of treatment
would make possible the
irradiation
of all the tumor
cells during their period of mitosis, when they are most
sensitive.
(3)
The assumption
that despite the protraction
of treatment,
the intensity
of
radiation affecting any given cell would nevertheless remain sufficient to sterilize it.
In the small
series of cases that we have
treated
so far, we are in
clined to believe that this method is superior
to any heretofore attained
in the treatment
of chronic lymphatic
leukemia.
Favorable results
have also been obtained in the treatment of Hodgkin's disease.
RADIUM
All cases that the cancer board decides should
be treated by either
contact or interstitial
radium,
due
to
the location or character of
the lesion,
are so treated.
Having
obtained
the necessary authority
from
the Bureau
of Medicine
and Surgery to defray the
necessary
expense, the case is referred
to a civilian radium therapist
for treat
ment.
This method,
in use during the past year, has proved entirely
satisfactory to the board, and the results obtained
have been excellent.
CONCLUSION
A
review of
the
Surgeon
General's
report
covering
the
5-year
period
from
1931-35,
and
of the San Diego Naval Hospital
Cancer
Clinic from 1936-37, would tend to show that
the incidence
of malig
nant neoplasms
in the fleet per 100,000 has remained
relatively the
same, and compares favorably with the rate per
100,000
in the
same
age groups in civil life.
The
present
method
of disposition
and
treatment
of
cases
has
proven
to be eminently satisfactory, both
to the patients and to
the
service.
By the
use
of filtration
equivalent
to from
2
to
5 millimeters of
copper, at 220 KVP it is believed
that with such filtration inoperable
intra-abdominal tumors can be brought into the field of radiotherapy.
A permanent
cancer board,
with full power
of function, is of vital
importance
in the successful treatment
of malignancy.
Bibliography
(1)
Quimby,
E. H., and Marinclli, L.
D.
The Influence
of Filtration on Sur
face and Depth
Intensities
of 200 KV X-rays.
Radiology,
21:
21-39,
1933.
(2)
Failla, G.,
et al.
The
Relative
Effects
producted
by
200 KV Roentgen
Rays,
700 KV Roentgen
Rays
and
Gamma
Rays.
Am.
Jour.
Roentgenol.
&
Rad.
Therapy,
29:
203-366,
1933.
WARMOLTS —CARCINOMA
LUNG
79
i'3)
Coutard,
H.
Roentgen
Therapy
of Epithelioma
of the Tonsillar Region,
Hypopharynx
and Larynx from
1920 to
1926.
Am. Jour.
Roentgenol.
& Rad.
Therapy,
28:
313-331,
1932.
Roentgen
Therapy of the Pelvis
in the treatment
of Carcinoma
of the Cervix.
Am. Jour. Roentgenol.
& Rad.
Therapy,
36:
003-
609,
1936.
(4)
Park, G. T.
Principles
governing
Radiation Therapy
of Cancer,
Geo. T.
Peck Memorial
Hosp.,
N. Y.
Am. Jour. Roentgenol.
& Rad.
Therapy,
36: 233-
244,
1936.
(5)
Ruggles, H. E.
A Year's
Experience
with
800 KV Roentgen
Rays.
Am.
Jour. Roentgenol.
& Rad.
Therapy,
36:
366-367,
1936.
(6)
Merritt, E. A., and Rath hone,
R. R.
The Treatment
of Epithelioma in
volving
Cartilage,
using 220 VKP and heavy filtration.
Radiology,
24:
701-707,
1935.
(7)
Merritt. E. A., and Ralhbone,
R. R.
The Roentgen
Treatment
of Malig
nancy
using filtration
Equivalent to '5 mm. copper.
Am. Jour.
Roentgenol.
&
Rad. Therapy,
35:
334- 343,
1936.
(8)
Thoraeus,
R.
Study
of Ionization
Method
for
Measuring
Intensity and
Absorption
of Roentgen
Rays and of Efficiency
of different filters used in therapy.
Acta. Radiol. Suppl.,
15:
1-88,
1932.
CARCINOMA
OF THE LUNG
By Irving J. Warmolts,
Lieutenant, Medical Corps, United States Navy
The
startling
increase
in incidence
of carcinoma of the lung en
countered
in the past 3 years has prompted this attempt to summarize
the outstanding features of this serious disease, with emphasis
on the
roentgenologic
diagnostic
features.
In contrast to the relative rarity
of the condition
a decade
ago, when it was an uncommon
autopsy
finding and diagnosed
antemortem
in only about
5
percent
of
cases,
lung carcinoma now comprises
from 6 to 8 percent of all carcinomata
and
stands
next in frequency
to malignancy of the gastro-intestinal
tract.
At
the
Philadelphia
General
Hospital,
which admits both
sexes
and
all
ages
in
about proportionate
numbers,
it is now
the
most
frequently
encountered
malignancy.
At
the
United
States
Naval Hospital, Philadelphia,
in 218
autopsies
performed
in the past
2 years there were 52 cases of malignancy of which
10 were carcinoma
of the lung, an incidence
of
19
percent
of all malignancies
and
4.5
percent
of all autopsies.
These
figures, of course, are not representa
tive of the general population because of the large admission
rate of
veterans in the cancer
age, but it serves to emphasize
the incidence
of
the condition in males of this age group
and proves its importance to
the naval medical
service.
ETIOLOGY
The
etiology
at
present
is largely
a matter of conjecture.
The
great
preponderance
of males
to
females
may
be significant,
being
approximately the ratio of 10 to
1.
Negroes
appear to be less suscep
tible
than
whites.
Approximately
75 percent
of cases
occur between
80
WARMOLTS —CARCINOMA
LUNG
the ages of 41 and 60, altho, cases between
20 and 30 are not uncom
mon.
The hazard
appears
to
be
increased
in industries involving
inhalations of irritating
dusts and fumes.
It does not appear however,
to be an especially
frequent sequel of pneumoconiosis.
In the cases
reported
in the literature
there
does not appear
to be a convincing
relationslup to the smoking of tobacco.
The continuous irritation
of
the respiratory mucous
membranes
by exhaust
and industrial
fumes
in our modern life appears
a plausible cause.
PATHOLOGY
Practically
all primary
carcinoma of the lung is bronchogenic
in
origin, arising
in the main bronchi, their branches,
or in the terminal
bronchioles.
Both lungs are about equally involved
and
the upper
lobe bronchi about as frequently
as the lower.
The primary
lesion
may
be pedunculted,
sessile, or ulcerative.
Classified
according
to
malignancy, grades
3 and
4, Broder's, greatly predominate.
Histo
logically
the squamous
cell
type predominates; the undifferentiated
type, including the spindle, round, and "oat" cell types,
are almost as
frequent,
and adenocarcinoma
comprises
a small
percentage.
Exten-
tion of the growth
takes
place
by direct contiguity,
by retrograde
lymphatic
permeation,
by lymphatic
metastasis
to the peribronchial
and
thence
to the hilar periaortic and abdomuial lymph nodes,
and
by the blood
stream
to all parts of the
body.
Peripheral growths
reaching
the pleura rapidly involve the serous
surfaces,
studding the
parietal pleura, especially
with fiat nodular secondary
implantations.
Contralateral pleural involvement is common.
Subserous
metastases
to
the
abdomen
may involve
extensively
the
peritoneal
surfaces.
Hematogenous metastases involve especially
the brain, bone, and the
heart.
The bone lesions are osteolytic.
Pulmonary
suppuration is
the
outstanding
pathologic
feature
in
many cases.
Obstruction of the bronchi
results in stasis of secretions
beyond
the
stenosis
with
secondary
infection, giving
the picture
of
bronchiectasis
or multiple
abscesses.
Abscess
formation is also fre
quently
due
to central necrosis
of the tumor
mass with
secondary
infection.
Death occurs as a result of cachexia, long-continued second
ary pulmonary suppuration,
hemorrhage,
or from metastatic lesions
to brain or heart.
SYMPTOMS
Symptoms due to the primary lung lesion
are quite constant and
rather
suggestive.
The
onset
is insidious,
the
symptoms existing
usually 4 to 8 months before becoming
so severe as to lead to a thorough
physical
examination.
Many
cases
present
the
symptoms
of
an
acute respiratory infection at the start, from which recovery
does not
take
place
normally,
or intermittent
periods
of apparent well-being
WARMOLTS —CARCINOMA
LUNG
81
may take place for some time.
Many cases are diagnosed
unresolved
pneumonia,
abscess or bronchiectasis
due
to failure of
a supposed
infection to resolve normally.
Cough, either productive or dry and
brassy, is present in over 80 percent
of cases.
Pain, in the chest, or
referred
to back or shoulder,
occurs in over 60 percent,
may be dull,
aching
and
constant,
or severe
and paroxysmal.
Pain may be in
creased on percussion
over the involved portion of the chest,
a sug
gestive
sign.
About one-half of the cases complain of dyspnea
and
it is most marked in
cases with
massive
pleural
effusion
or with
tracheal compression
from gross glandular metastases.
Hemoptysis
occurs in 40 to 50 percent; it may consist only of blood streaking of
the sputum or of gross or even fatal hemorrhage.
The temperature
is elevated in approximately 30 percent, which, along with misleading
physical signs, frequently leads to be erroneous or incomplete diagnosis
of chronic pneumonia, abscess, or tuberculosis.
Night sweats
and
hoarseness
are not uncommon.
Clubbing
of the fingers is reported
in about 15 percent of cases.
In addition there later occurs the usual
findings of malignancy, weight loss in 50 to 70 percent, loss of strength,
pallor, secondary
anemia,
etc.
Frequently, however,
the primary lesion causes few early symptoms
and the first symptoms are due to metastatic lesions elsewhere in the
body.
The primary site may be entirely overlooked for long periods
or may be first detected
by routine chest roentgenograms.
In the
absence of pleural involvement or of gross bronchial obstruction the
primary
lesion
may grow
to
considerable
size
without
prominent
symptoms.
A pathologic fracture may cause the first suspicion
of a
malignancy.
Metastatic
brain
lesions
occur in
24
percent
and
the
lungs should be considered
as
a primary
source in this type of case.
Gastro-intestinal
symptoms from metastatic lesions may simulate the
symptoms of peptic
ulcer
or primary gastric malignancy.
Jaundice
may occur from liver involvement
and dysphagia from erosion
into
the oesophagus.
PHYSICAL FINDINGS
The
physical findings are exceedingly
variable depending
on
the
location of the tumor.
In general,
most
cases
may
be grouped
into
three types:
The lobar type,
the hilar and the nodular.
In the lobar
type a large bronchus becomes obstructed by the growth with resulting
atelectasis
of a whole or part of a lobe.
Malignant
invasion tends to
occur more rapidly into the collapsed
lung with progressive
replace
ment
by tumor
tissue.
There
is
dullness
on
percussion
over
the
atelectatic
and infiltrated
lung; breath
sounds
arc absent
as
a rule.
Voice sounds
and fremitus
arc usually
decreased
or absent.
Rales
may be noted.
In the lrilar type the growth may attain considerable
size without
entirely
blocking
a*
bronchus,
tbe
growth
breaking
through
the
82
WARMOLTS —CARCINOMA
LUNG
bronchial
wall
and
infiltrating
widely into
the surrounding
tissue.
Atelectasis
tends
to
occur
later.
The
physical
signs
may
be
dis
proportionately
slight
compared
with
the
extent
of involvement.
The
partial
obstruction
may
cause
asthmatoid
wheezes;
rales
are
frequent.
The para-vertebral dullness
may be perceptibly widened
on percussion.
However, the remainder
of the lung may be normally
resonant
and voice sounds very little impaired.
At times emphysema
may be present for a while on the involved side due to partial obstruc
tion, especially
in the expiratory phase.
The nodular type is a more or less circumscribed type toward the
lung periphery and
when involving
only
a small bronchus or bron
chiole may
cause
but slight
atelectasis
and,
when
normal lung
is
present between chest wall and the tumor, auscultation and percussion
may fail to reveal any evidence of the lesion.
Most
carcinomata
of
the
lungs
eventually
involve
the
pleura,
either by
extension
or metastisis.
The
findings
of pleural effusion
are
then
present.
The fluid on tapping is usually sero-sanguinous
and tumor cells may be discovered
upon
microscopic
examination.
Metastasis
to the mediastinal nodes leads to progressive
dyspnea,
frequently
causes
venous
congestion
due
to
pressure
on
the
vena
cava,
and
oftentimes
dysphagia
due
to pressure
on the oesophagus.
The paravertebral dullness
tends
to be widened.
Evidence
of pulmonary
suppuration
commonly
develops
due
to
stasis
of
secretion
in
the
traeheo-bronchial
tree peripheral
to
the
stenosis
followed
by
bronchiectasis
and
abscess
formation.
Fre
quently central necrosis of the tumor mass occurs with expectoration
of large amounts
of fetid pus and blood.
Evidence of cavitation may
be elicited.
Fragments of tumor tissue may bo detected
by micro
scopic
examination of the sputum.
Rupture
of
a large
vessel may
result in rapidly
fatal hemoptysis.
Supraclavicular
nodes may
be
enlarged
due
to metastasis.
Dia
phragmatic palsy due to involvement of the phrenic nerve in medi
astinal metastasis
is common,
as is also laryngeal paralysis due
to
involvement
of
the
recurrent laryngeal
nerve.
Horner's
syndrome
may
bo observed
when
the sympathetic system
is involved.
The roentgen findings are bizarre in their variability
and in appear
ance.
In the lobar type there is progressive
atelectasis
of a part or
whole
of
a lobe.
The opacity diminishes
toward the periphery and
at the apex and is densest about the hihirn.
A hard film may demon
strate
two superimposed
densities,
the inner due to tumor mass with
usually a ragged irregular outline, the outer lesser density being cast
by
the surrounding
atelectatic
lung.
The heart, trachea
and
medi
astinum are displaced
toward the side of the lesion;
the diaphragm
tends
to be elevated
and
the interspaces
usually narrowed.
I have
however
seen a number of advanced
cases with
displacement
of the
WARMOLTS —CARCINOMA
LUNG
83
mediastinum toward the lesion
while
the interspaces
were widened.
I have
seen this in no other lesion
and
consider
it diagnostic.
A
marked
pleural
effusion
with
displacement
of
the
mediastinum
toward that side is also peculiar to the condition.
It may be due to
fixation of the mediastinum by infiltration
after the mediastinum has
migrated
following
atelectasis.
Progressive
growth
or
massive
effusion
following this fixation of the mediastinum may cause widen
ing of the interspaces
or even intercostal bulging.
In the hilar type a dense mass is present in the hilus, usually roughly
semicircular in shape with sometimes
a rather regular, sharply defined
outline,
but
more
commonly
ragged
and
irregular,
poorly
defined
with strands of infiltration
into the surrounding lung.
A variant of
this type occurs
when
the primary
mass is small and
obscure
but
extensive
lymphatic
permeation
has
occurred
throughout
the lung
fields
causing
a generalized
coarse reticulation resembling
pulmonary
fibrosis
or bronchopneumonia.
A
beading
at
the
points
of inter
section may simulate miliary
tuberculosis.
Relatively
large
lesions
near the bifurcation
of the trachea
may be entirely obscured
by the
heart
and mediastinum and no charges may be evident on the film
until gross glandular enlargement
or atelectasis
takes place.
The nodular type usually forms fairly distinct, rounded or triangular
shadows at the apex or toward the periphery of the lung.
There is
little or no surrounding atelectasis
and the shadows have no surrounding
zone of pneumonitis which helps to differentiate them from tuberculosis
lesions
and abscess.
The outlines may be regular and sharply defined
or ragged,
irregular, and indistinct.
Upper
lobe
lesions
are usually
free of complicating pleural effusion
until
late in the coarse and are
the easiest to demonstrate.
Glandular
enlargement
at the hilus and mediastinum may occur
early with little
evidence
of the primary lesion
and carcinoma must
be considered in the differential diagnosis of mediastinal gland involve
ment in the cancer
age.
The opposite
hilus may also
be prominent
and
nodular
due
to glandular
metastasis.
Metastasis
to
the heart
and
pericardium
is frequent
and may cause
a marked irregularity
or nodular appearance
of the cardiac silhouette.
Pleural
effusion
is
a frequent and
annoying development
and by
masking the lung fields
makes
the
diagnosis
difficult
and
at times
impossible.
Bronchogenic
carcinoma
should
be
considered
in
the
differential
diagnosis
in every
case
of pleural
effusion
in
an adult.
The
fluid
reforms
extremely rapidly
after withdrawal,
but,
when
replaced
by air, a roentgenogram
taken immediately may reveal
the
underlying
pathology
and
is
of
great
aid
in
diagnosis.
Effusion
occurs
much
less commonly with upper
lobe lesions.
In these cases,
however, pneumothorax may also give aid in delineating the outline of
the
tumor
mass
and
also
demonstrate
the
presence
or absence
of
84
WARMOLTS —CARCINOMA
LUNG
pleural adhesions
and probable chest wall involvement, an important
factor in prognosis.
Bronchography by intratracheal instillation of lipiodol may show the
exact site of broncheal
obstruction or may only show failure to enter
a certain portion
of
the
lung.
I
have
repeatedly seen
the latter
phenomenon
in early pulmonary abscess before it communicates
with
a bronchus
and I have not been able
to distinguish
the appearance
between
the two conditions except
where
a definite
bronchial block
can be demonstrated.
At times this blockage
is sharply defined
and
definite
and the margins of the intrabronchial
defect can be made out.
Abscess
due to central necrosis of lung carcinoma usually is rather
characteristic with a dense surrounding zone of infiltration with ragged,
irregular outer margin of the mass.
There is lacking the soft shadow
of surrounding pneumonitis
seen
in simple
abscess.
Except
where
complicated by
a
coexisting
tuberculosis
the
fibrotic
or exudative
infiltrations
of that disease are lacking.
The cavity usually presents
a fluid level, tending to differentiate it from a tuberculous
cavity.
A
differential point of value
is that displacement
of mediastinum and
trachea seldom occurs with simple abscess, frequently with carcinoma.
Abscesses
secondary
to obstruction
occur especially
in
the lower
lobes
and
are frequently multiple.
There is nothing characteristic
about
their
appearance
but
a
tumor
mass
may
be
demonstrable
between
the
abscesses and
the lulus or bronchography may reveal
blockage
of the
bronchus
to
the involved
area
At other
times
a
typical picture of bronchiectasis
may be obtained.
Serial observa
tions
reveal
an abnormally rapid progression
of the lesion,
however,
and should
suggest the cause.
Obstruction
due
to
foreign
body
aspiration
produces
effects
in
distinguishable by the roentgenogram
but the history of abrupt onset,
coughing
and choking,
is usually obvious
and broncboscopic
examina
tion reveals the cause.
Associated roentgen
findings
frequently found
are
diaphragmatic
palsy due to involvement of the phrenic nerve,
evidence of osteolytic
metastatic lesions
of bone,
compression
of
the
oesophagus
by
the
mass or enlarged
glands
demonstrated
by swallowing of barium, and
at times erosion of the ribs adjacent to the involved lung.
DIAGNOSlS
An antemortem
diagnosis
was
made
10
years
ago in only about
5 percent
of cases.
Today
as high as 50 to 75 percent
are correctly
diagnosed.
The percentage
of
cases
so diagnosed
will depend
upon
the index of suspicion
and the degree of cooperation between clinician,
roentgenologist,
pathologist
and
bronchoscopist,
all
of whom
con
tribute
by their peculiar
approach
to
the
problem.
Bronchogenic
carcinoma should
be suspected
in any adult, especially
over
the
age
WARMOLTS —CARCINOMA
LUNG
85
of
45, with
progressive
cough,
pain in
the
chest
and
hemoptysis.
Pleural effusion
should
be suspected
when other
cause is not obvious
and
the lung should be considered
as
a primary
locus in metastatic
malignant
lesions,
especially
of
the
brain
and
mediastinum.
The
greatest
responsibility
lies with
the radiologist,
who may detect
an
unsuspected
or asymptomatic primary lesion
on routine chest exam
ination.
All
suspicious
appearing
chests
should
be
subjected
to
bronchoscopy.
Biopsy
by this means
clinches
the diagnosis
in the
majority
of cases
except
those
near
the lung periphery.
Roentgen
findings of particular significance
are atelactasis
with displacement
of
the mediastinum heart,
and trachea
to the side of the lesion.
Farrell
(6) goes so far as to state:
Whenever
evidence
of pulmonary
collapse
is detected
in an adult,
one
should
consider it as due to bronchial
occulsion of neoplastic origin until the presence of
neoplasm has been excluded.
A progressive
bronchiectasis
should
also be regarded
with suspicion.
Serial
roentgenograms
should
be
taken
in all
suspicious
cases.
A
dense,
thick-walled
single
cavity
without
frank
evidence
of tuber
culous
origin
should
always
be
considered
neoplastic
until
proven
otherwise.
Microscopic
examination of all hemorrhagic
pleural exudates
will
reveal
neoplastic
cells
in
a
large
percentage.
Lung
puncture
for
diagnostic material has not been
so successful.
Biopsy
of enlarged
supraclavicular
nodes when found gives
a high
frequency
of involve
ment
and
aids in diagnosis.
The differential . diagnosis
is concerned
primarily
with metastatic
malignancy of the lung from
a primary lesion elsewhere in the body,
infectious
processes
of
the lung
and
pleura,
and
neoplasms
arising
primarily
in
the
mediastinum
and
involving
the lung secondarily.
The most frequently encountered
mediastinal lesion which is difficult
to differentiate is Hodgkins
disease.
Primarily
the lesions
are dis
tinctly nodular, confined
to the glandular structure with fairly well-
defined,
tabulated
widening of the mediastinum.
However at times
it
breaks
from the
confines
of
the glandular
structures,
assumes
a
distinctly
invasive character
into
the hilar
structures
and
at
times
radiating
into
the
lung via
the
lymphatics, making differentiation
very difficult.
Biopsy of involved peripheral glands
allows
a micro
scopic diagnosis
when these are enlarged, but many cases are confined,
at least for awhile,
to the mediastinum.
Moreover metastatic
lesions
to bone may
be impossible
to differentiate
by X-ray although
biopsy
of the bone will reveal its true nature.
Intrathoracic thyroid adenoma
may resemble neoplasm
at first appearance
but there is usually thy
roid enlargement
in the neck; the intrathoracic
mass moves upward
upon
swallowing or grunting
when
seen
under
the
fluoroscope.
I
have
recently
seen
a
case
diagnosed
as
carcinoma
of lung due
to
8G
WARMOLTS
CAKCINOMA
LUNG
parenchymal neoplastic involvement of the lung which upon necropsy
showed
a small primary lesion in the thyroid.
This type of involve
ment in the chest is rare.
Tuberculous adenitis of the mediastinum
may at times cause a dense shadow
at the hilus simulating neoplasm
and in a case recently seen caused atelectasis
of the lower lobe due to
compression
and
occlusion
of the lower lobe bronchus and
an erro
neous
diagnosis
of
bronchogenic
carcinoma
was
made.
Broncho-
scopic examination in such
a case will reveal
the obstruction
as due
to extrinsic pressure
and the true nature may be surmised.
Thymomas
arising from the mediastinum may protrude into
the
lung fields but are circular in outline, sharply defined, and are homoge
nous
and
much
less dense than
carcinoma.
They are characterized
by extreme sensitivity to X-ray irradiation.
Reticulum-cell
sarcoma
may invade the lung,
tends early to produce pleural effusion and may
be
diagnosed
only
by
biopsy.
It
is
also
relatively
insensitive
to
irradiation.
Advanced cardiospasm
with dilatation
of the oesophagus
produces
a bulge of the mediastinal shadow
to the right but this has a rather
smooth
outline and
barium meal
shows
the shadow
to
be due
to
a
greatly
diluted
oesophagus.
Carcinoma
of
the
oesophagus
with
ulceration into
the left bronchus or trachea
produces
a mottling
at
the bases due to aspiration and at times may obstruct the bronchus.
The primary complaint of dysphagia and the demonstration of com
munication
of
the
oesophagus
and
tracheo-bronchial
tree
by
the
fluorscopic ingestion
of barium reveals
the true nature of the lesion.
Diaphragmatic
hernia produces
a nonhomogenous
opacity at
the
left base and at times upward almost
to the apex.
There is also often
evidence
of fluid at the base.
The barium meal shows the opacity as
due to herniated
bowel in the thorax.
Metastatic malignancy of the lung is usually multiple.
The lesions
tend to be rounded and more or less circumscribed.
There is no sur
rounding atelectasis
and usually no symptoms
referable
to the chest
until
late.
The hilar glands
are not enlarged.
The primary
lesion
may
be
discovered,
usually in
the kidney,
testes,
or thyroid.
At
times
extension
of
a breast
carcinoma
through the chest wall may
invade the lung parenchyma simulating primary
carcinoma due
to
its invasive character.
The history
and physical examination how
ever will prevent error in these cases.
Among the infectious processes, pulmonary tuberculosis is the most
frequently encountered
and can usually be easily differentiated by the
history,
physical,
and laboratory
findings
and
the character of the
infiltration.
Lung
abscess
usually
has
a
more
abrupt
onset
with
acute febrile course.
The roentgen film shows
a small abscess cavity
with surrounding zone of soft exudative reaction
while malignancy is
of longer duration with signs of suppuration only later in the course.
WARMOLTS —CARCINOMA
LUNG
87
«
However, it must be remembered
suppuration
is
a
most
frequent
sequel of carcinoma of the lung and
evidence
of it
does not aid in
excluding
malignancy.
Abscesses
due
to
advanced
Friedlander's
pneumonia may present
thick walls resembling
neoplastic
abscesses
but are usually multiple and tend to involve both lungs, while culture
of the secretion
reveals
the causative
bacillus.
Progressive
bronchi-
ectatic lesions
should always
be regarded
with
suspicion
and bron
choscopy
resorted
to in all cases
to rule out a causative
malignancy.
Chronic pneumonia and the progressive
fibroid pneumonias
are rather
rare and many so diagnosed
are found at autopsy to be due to carci
nomatous involvement of the lung.
Primary neoplasms
of the lung, other than bronchogenic
carcinoma
are
rare.
Chondroma
appears
as
a sharply rounded opacity with
densely calcified
center.
Primary
sarcoma
was formerly
more
fre
quently
diagnosed
but reconsideration
of many of the
cases
in the
light of what is now known of bronchogenic
carcinoma
has led in many
of these cases
to a revision of the diagnosis.
Neurofibromata
appear
as soft shadows
usually obviously arising
from
the
vertebral margin,
are
quite distinctly
outlined,
and
not
invasive.
Diagnostic pneumothorax shows
them to be extra pleural
and outside of the lung as the latter collapses.
Hydatid
cyst appears
as a sharply outlined circular shadow usually of distinctly less density
and calcification in concentric
layers is demonstrated
at the periphery.
Dermoid cysts are usually seen
to arise from the mediastinum, are
rounded or oval, sharply defined
and thin walled.
Layering
of the
fluid contents can often be demonstrated
roentgengraphically.
PROGNOSIS
Surgery
appears
the
best
hope
of survival
at the
present
time.
However, the operative
mortality approaches
50 percent and, of those
surviving, late evidence of recurrence
in the mediastinal glands or of
hematogenous
metastasis
supervenes
to a discouraging
extent.
How
ever,
cases
free of disease for as long as
7 years after operation have
been reported.
As in malignancy elsewhere in the body, all efforts
must be made
to attempt earlier
diagnosis
and with our increasing
knowledge of its characteristics
such will undoubtedly
be possible
in
a larger percentage of cases.
Death in untreated cases occurs in from
2 months
to
7 years.
The condition
as
a rule is slowly progressing
and the average case lives about
8 months after the diagnosis
is made.
The prognosis
appears to be somewhat
better in lesions involving the
primary bronchi where the cartilage
appears to have some restraining
effect
and
the
cell
type
tends
to be somewhat
more differentiated.
However, the localized parenchymal lesion before it has involved the
pleura
tends
to involve
the hilar glands
late
and if removed
before
blood stream
metastases
take place appears
the best surgical
risk.
88
WARMOLTS
CARCINOMA
LUNG
TREATMENT
Lobectomy has been successful in eradicating small localized growths
toward
the periphery.
In larger growths and in all those involving
the hilar glands total pneumectomy
is required.
The shock of opera
tion is less than one would expect.
The third interspace
is the usual
avenue
of approach.
Ligation
of the pulmonary
vessels and of the
bronchial stump offers
some difficulty
and
effective
removal
of the
glands
considerably more.
Adherent
pleura
due
to invasion
is
re
moved
; these cases offer little hope of permanent
cure.
Later thoraco
plasty is frequently necessary
to obliterate the cavity.
In children
and young adults considerable
migration of the heart and opposite
lung takes place after pneumectomy
and may entirely fill the space.
Preliminary pneumothorax is induced
before operation to determine
the presence of adhesions
and the involvement of the chest wall and
pleura,
to more accurately delineate
the outlines of
the tumor and
also
to stabilize intrathoracic
pressure
and
thus
decrease operative
shock.
After operation the chest wall is tightly closed and pneumo
thorax
reinduced
with slight positive pressure
to prevent mediastinal
fluctuation and also exert pressure on the bronchial stump and ligated
vessels.
This
tends
to
decrease
postoperative
hemorrhage
and
decreases the postoperative pleural exudate which invariably
follows
operation.
This
must
be removed
by aspiration if too extensive;
if
infection
follows
siphon
drainage
must
be instituted.
Preliminary
irradiation of the chest is of doubtful value and appears not to warrant
the loss of time involved.
Roentgen
irradiation has been very disappointing up to the present.
However
the
cases
have
almost
all been
advanced
and
possibly if
earlier
lesions
are treated
by the Coutard
technic
better
results
may
be obtained
in the future.
Bronchoscopic implantation
of radon tubes
has been successful
in
removing the primary growths in small especially
pedunculated
lesions
which protrude
into
the
bronchial
lumen,
and
offer
a method of
approach
combined
with irradiation where operation is not feasible.
In inoperable
cases little can be done except nursing care and opiates.
Bronchoscopic
drainage
is
advised
when
suppuration
supervenes,
especially
if irradiation
is given.
Bibliography
(1) 1 Arkin, A. and Wagner,
D. H.
Primary Carcinoma
of the Lung.
Journal
A. M. A.
106:
587-591,
1936.
(2)
Edwards,
A.
Tumor.
Malignant Disease of the Lung.
The Journal
of
Thoracic
Surgery.
4: 107-124,
1934.
(3)
Eggers,
C.
Lobectomy
for Carcinoma
of
the
Lung.
J. Thor. Surg.
4:
211-217,
1934.
(4) 1 Ehrlich, D. E. and
Hauptman.
H. A.
Primary Carcinoma
of the Lung.
Radiology,
26:
563-573,
1936.
1These
references furnished
the essential source material
for this article.
NORMAN
AND
STTJ.TPHANT —BRONCHOGENIC
CARCINOMA
89
(5)
Ewing,
James.
Neoplastic
Diseases, 3d. Ed. pp. 851-859.
(6) 1 Farrell, J. T., Jr.
Diagnosis
of
Bronchogenic
Carcinoma.
Rad.,
26:
261-269,
1936.
(7)
Flich, J. B. and Gibbon, J. H., Jr.
Total Removal
of the Left Lung for
Carcinoma.
Annals Surg.
103: 130-134,
1936.
(8)
Graham,
E. A.
Carcinoma
of Lung.
Ann. Surg.
103:
130-134,
1936.
(9)
Herley,
Peter.
Recent Advances
in Radiology,
pp. 158-165.
(10)
Jackson, C. L., and
Konzclmann,
F. W.
Bronchogenic
Carcinoma.
J.
Thr. Surg.
4:
165-186,
1934.
(11)
Lyle, H. H. M.
Carcinoma
of Right Lung; Pneumonectomy
in One Stage.
Ann. Surg.,
103:
124-129,
1936.
(12)
Miller, J. K.
Bronchogenic
Carcinoma,
case report,
Am.
Rev. Tuberc,
34:
433-436,
1936.
(13)
Overholt,
R.
The Total
Removal
of
the Right
Lung for
Carcinoma.
J. Thr. Surg. 4:
196-210.
1934.
(14) 1 Pancost,
H.
R.,
Pendergrass,
E.
D.,
and
Tucker,
G.
Bronchogenic
Carcinoma of the Lungs.
A. J. Roentg.
and Rad. Ther. 27: 357,
1932.
(15)
Rabin, C. B., and Neuhoff, H. A.
Topographic
Classification
of Primary
Carcinoma of the Lung.
J. Thor. Surg. 4: 147-164.
1934.
(16)
Roberts,
S. R., and Gray, J. D.
Primary Cancer
of Lung and Difficulty
in Early Diagnosis;
case.
J. M. A. Georgia,
25:
275-278,
1936.
(17) 1 Tuttle,
W.
Mac,
and
Womach,
N.
A.
Bronchogenic
Carcinoma;
a
Classification in Relation to Treatment
and Prognosis.
J. Thor. Surg., 4: 125-146,
1934.
(18) 1 Vinson,
P. P.
Primary Malignant Disease of Trachea-bronchial
Tree.
J. A. M. A. 107:
258-261,
1936.
BRONCHOGENIC CARCINOMA
WITH METASTASES
TO HEART AND PITUITARY
CASE REPORT
By Ikwin L. Norman,
Lieutenant,
Medical Corps, United States Navy, and William M. Silliphant,
Lieutenant,
Medical Corps, United States Navy
A
generation
ago
carcinoma of
the
bronchus
was
considered
a
rarity.
At that
time most of
the
malignancies of
the
lung
were
considered
to be metastatic from
a primary
growth in some other
organ.
Today it is estimated
that about 5 percent
of all carcinomas
arise primarily in a bronchus (1).
Metastasis from this primary site
may
occur to any organ
in
the body.
In
a study of 374
cases
of
bronchogenic carcinoma, Adler
(2) found
the
metastases
were
dis
tributed
as follows: Bronchial
lymph nodes,
117; liver,
103; kidney,
58 ; bones, 57 (in the order of ribs, spine, skull, and sternum) ; brain, 53 ;
pleura,
52; pericardium,
39; adrenals,
38; heart, 30; tracheal
lymph
nodes,
26 ; cervical lymph nodes,
23 ; retroperitoneal lymph nodes,
23 ;
spleen,
18; and voluntary
muscles,
9.
Other organs
found less fre
quently involved by metastases
were skin, nasal septum,
eye, urinary
i These
references furnished
the essential source material
for this article.
24140—37
7
90
NORMAN
AND SHJJPHANT —BRONCHOGENIC
CARCINOMA
bladder, fallopian tubes, ovary, uterus,
pancreas,
thyroid, spinal cord,
and pituitary
gland.
Metastases were absent in 33 cases.
The following
case
of bronchogenic
carcinoma is reported
because
metastasis
occurred
to two
of the organs
less frequently involved —
to the heart and to the pituitary
gland.
As is usual in cases of metas
tasis
to
the pituitary gland
(3)
there
was
an
associated
diabetus
insipidus.
CASE REPORT
The patient,
a white male aged 41, was admitted
to the United
States naval
hospital,
Chelsea,
Mass., on July 31,
1936, for treatment
of what he stated
was a
lung abscess
that had been present for
1 year.
The chief complaints
on admission
were cough with purulent
expectoration,
excessive
thirst with the passage
of much
urine, and pain in the back of the neck in the region of the fifth cervical vertebra.
The patient
gave a history
of having
had pneumonia
in
1934 with
complete
re
covery,
and dated the onset of the present cough and expectoration
to a mild
respiratory
infection
that
had occurred
in May
1935.
Cervical
pain
had
been
present for
3 months
and
excessive
thirst and the passage
of large amounts
of
urine for
1 month prior to admission.
There had been
a weight loss of about
15
pounds the past year.
Physical
examination
revealed a pale middle-aged
man acutely ill.
There was
dullness to percussion over the lower left lobe of the lung with diminished
breath
sounds and occasional
moist rales.
The blood pressure was 100/64.
The heart
was not enlarged, there were
no murmurs,
and the rhythm
was normal.
On pal
pation,
the liver
was found
to be enlarged to the level of the umbilicus
and was
definitely
nodular.
There was marked tenderness over the lower cervical vertebra
and the neck was held rigidly.
The reflexes
were normal.
The Kahn blood tost was negative, and urinalysis
was negative aside from a low
specific gravity
varying
in different
specimens from
1.001 to
1.004.
The white
blood count was 21,700,
with
polys,
87 percent; lymphs,
6 percent; large monos,
5 percent; and eosins,
2 percent.
The red blood cell count was 3,350,000 with a
hemoglobin
of 70 percent
(Tallquist).
The sputum
showed no tubercle
bacilli,
but at times contained elastic fibers.
The sedimentation
index was 31 millimeters
in 1 hour.
X-ray of the chest showed an indefinite shadow at the left base partially
obscured by the heart.
X-ray of the cervical spine showed complete destruction
of the fifth cervical
vertebra by what appeared to be a metastatic
tumor.
Stere
oscopic plates of the skull
showed an enlarged sella turcica
with
destruction
of
both the anterior
and posterior
clinoid
processes
on the right side.
The patient
went down hill rapidly,
running
a septic temperature
from 99° to
104°.
There
was excessive
thirst and polyuria
which
was relieved
by pitressin
given hypodermically
in
1 cubic centimeter
doses
several
times
daily.
Several
days after admission
there was noted a drooping
of the right eyelid and dilation
of
the right pupil.
Neurological
examination
revealed
no
other
pathological
findings referable to the central nervous system.
Examination
of the eye showed
no contraction
of
the
visual
fields and
the fundi were
normal.
The patient
became comatose and died August
23,
1936,
23 days after admission.
Although
a bronchoscopic
examination
was not performed,
the diagnosis based
on clinical
and laboratory
findings was bronchogenic
carcinoma,
with metastases
to the liver, fifth cervical vertebra, and to the brain in the region of the pituitary
gland.
Autopsy performed
by W. M. S. showed the following
findings:
Left lung.—Was densely adherent to the diaphragm.
There was a mass about
the size of a large walnut near the hilum in the upper part of the lower lobe.
On
NORMAN
AND
SILUPHANT —BRONCHOGENIC
CARCINOMA
91
section a constricting
new growth was found, having its origin in the left descend
ing bronchus,
0.5
inch
from
the bifurcation,
and
which
had all
but
closed the
lumen.
The tumor
mass was confined to this area, no other masses
being found
in either
lung.
The lung parenchyma,
peripheral
to the tumor,
was atelectatic
and
gangrenous,
and
contained
small
multiple
abscesses
which
exuded
thick
foul-smelling
pus.
Microscopical examination
of the primary lesion showed a tumor
arising from
the bronchial mucous
membrane,
practically closing
the lumen,
and extending
through the wall into the lung parenchyma.
The cellular structure
was that of a
fairly
well-differentiated
squamous
cell
with
large
irregularly
shaped
hyper-
chromatic
and vesicular
nuclei and abundant
pink staining
cytoplasm.
Actual
intercellular bridging
could
be observed.
The cells were arranged
in sheets of
varying
sizes separated
by
a fibrous
stroma
containing
lymphocytes.
Fairly
well-developed
epithelial
pearls
were
present.
Mitosis
was
not
a prominent
feature.
The lung parenchyma
beyond
showed a severe degree
of secondary
infection,
there
being many
areas
of abscess formation,
and most of the bronchioles
were
filled with pus cells.
Lymph glands.—There were many enlarged mediastinal
and mesenteric lymph
glands,
some as large as golf balls.
The structure
of these glands was destroyed
by tumor growth.
Heart. —An oval shaped firm tumor mass was found in the posterior lateral wall
of the right ventricle, the upper edge of which encroached upon the right coronary
artery
about
2 centimeters
from
its
orifice.
It was
4 centimeters
in greatest
diameter
and occupied practically the whole thickness of the ventricular
wall.
It
could readily
be
seen
from
the
endocardial
surface
as
whitish
in color.
Mi
croscopical
section revealed
a cellular
structure
resembling
the primary tumor.
That portion of the coronary
artery
adjacent
to the neoplastic
growth
was com
pletely occluded by tumor tissue.
Liver.—Was three times normal size and was studded with innumerable
tumor
masses of all sizes
up to that of a walnut.
The right lobe was practically one
solid tumor mass.
Microscopical
examination
revealed
widespread
metastasis
to the extent that it was difficult
to recognize the tissue as liver.
Pituitary
gland.—This organ was enlarged to about
three times average size,
the right side showing
more enlargement
than the left.
It had eroded into the
sphenoidal
sinus.
There
was also erosion of both anterior
and posterior
clinoid
processes.
Microscopical
examination
showed
little
normal
pituitary
tissue
remaining,
the gland being largely
replaced
by sheets and
masses
of metastatic
cells.
Fifth
cervical
vertebra. —The body
of the fifth cervical
vertebra
consisted
of
soft boneless tissue, which when removed, left only a thin shell of bone along the
upper
posterior
margin
connecting
the
two
lateral
processes.
Microscopical
examination
revealed tissue resembling
the primary tumor.
DISCUSSION
This case is of interest clinically
because it illustrates how a lung
abscess
occurring secondarily to
a carcinoma of the bronchus may
obscure
the
primary
lesion.
When
this patient
presented
himself
for diagnosis the carcinoma had occluded
the bronchus to such
an
extent that there was atelectasis of the area supplied by the bronchus
with
secondary
pyogenic
infection
resulting
in
multiple
abscess
92
NORMAN
AND SILLIPHANT —BRONCHOGENIC
CARCINOMA
formation.
There was not complete occlusion
as there was a moderate
amount of purulent sputum which on microscopic examination showed
the
presence
of
elastic
fibers.
This
secondary
purulent
infection
had been present for at least a year and had given rise to a diagnosis of
lung abscess.
In the presence of chronic purulent pulmonary disease
the presence of carcinoma
of a bronchus must always
be suspected
(4, 5).
Vinson
(4,
5)
states
that neither the history,
physical
ex
amination,
nor X-ray
appearance
are sufficient
to distinguish
car
cinoma of the bronchus from chronic pulmonary disease.
He makes
the
interesting
observation
that
distant
breath
sounds
over
the
affected lung area is the most important physical finding of carcinoma
«of a bronchus and states:
This finding
is noted rarely
in other pulmonary
diseases
without involvement
of the pleura and when it is observed without corresponding
impairment
of the
percussion
note over the area involved,
carcinoma
should
be suspected at once.
This
case
is
also
of interest
because
of
the
unusual metastases.
The sympton of diabetus insipidus
was readily
explained
when
at
autopsy the pituitary
was found to be greatly enlarged by a metastatic
growth
which
completely
replaced
the
normal
gland
structure.
Metastatic
lesions of the pituitary
are not extremely
rare (6).
When
metastasis
occurs
in
the posterior lobe
of the pituitary
it usually
gives
rise
to
the
clinical
signs
of
diabetus
insipidus
(3).
Indeed
Fink (3) goes so far as to state that when diabetus insipidus develops
in a case of malignancy it is an almost pathognomonic
sign of metastasis
to the posterior lobe of the pituitary
gland.
This author in a review
of the literature in 1928 was able to find reports of 107 cases of diabetus
insipidus in which necropsies
had been performed; of this number 16
were
due to metastatic lesions
of the pituitary.
In reviewing the
literature since
1928,
we have found the following authors who have
reported
cases of malignancy with metastasis
to the pituitary
gland:
Grossman (7), Benhamon, Montpellier,
and Curtillet
(8), Johnson
(9),
Amstein
(10),
and Macchioro
(11).
These
matastatic tumors may
arise from any organ,
but from
a survey of the literature
seem to
arise with
greatest
frequency
from primary
growths of
the
breast
and bronchus.
The finding in this
case
of a metastatic nodule
in the wall of the
myocardium was unexpected,
as there had been no history of cardiac
pain or symptoms
referable
to the heart.
The nodule
was
4 centi
meters
in greatest
diameter
and
had
completely
occluded
the right
coronary artery.
The occlusion
had apparently taken place gradually
with development
of collateral circulation
from
branches
of the left
coronary artery and from those of the right above the site of occlusion,
as there were no signs of cardiac infarction.
It is unfortunate that an
'electrocardiograph
had not been taken
to compare
the electrocardio
graphic findings with this interesting anatomical lesion.
Metastatic
tumors of the heart occur with greater frequency
than is
ordinarily
believed.
Blumensohn
(12), in a review
of 1,078 cases of
NORMAN
AND
SILLIPHANT —BRONCHOGENIC
CARCINOMA
93
carcinoma in general, found cardiac metastasis
in 34, or 3.17 percent,
while of 160 cases
of sarcoma,
12, or 7.5 percent,
showed
metastasis
to this organ.
These metastatic lesions arise with greatest frequency
from primary
or secondary
intrathoracic
neoplasms
(13)
viz
lung,
pleura and mediastinal lymph nodes, and are probably best explained
by retrograde extensions
to the heart from the tracheobronchial nodes
which also drain the lungs and pleura and in the case of the pericardium
by direct implantation
(14).
Cardiac
metastasis
even though involving
large
areas of the myo
cardium may occur without
clinical symptoms
(15) as in this case.
This
illustrates
the
great
functional
reserve
of
the
myocardium.
When symptoms do occur
the prevalent symptoms are cardiac pain
and
cyanosis
associated
with
frequent recurrent hemorrhagic peri
cardial effusion
(16).
SUMMARY
A case of bronchogenic
carcinoma is reported with metastasis
to the
pituitary gland giving clinical symptoms of diabetus insipidus and
metastasis to the myocardium with
complete
occlusion
of the right
coronary artery without
the production of cardiac symptoms.
Bibliography
(1)
Fried, B. M.
Primary Carcinoma
of the Lung.
Williams & Williams Co.,
Baltimore, Md.,
1932.
(2)
Adler,
quoted by J. Ewing in Neoplastic
Diseases.
W. B. Saunders Co.,
Philadelphia, Pa.,
1931.
(3)
Fink,
E.
B.
Diabetus
Insipidus.
A Clinical
Review
and
Analysis
of
Necropsy Reports.
Arch, of Path. 6:
102,
1928.
(4)
Vinson,
P. P.
Discussion
of Significant
Signs in Early
Carcinoma
of the
Bronchus.
Proceedings
of the Staff Meetings
of the Mayo Clinic 11:
353,
1936.
(5)
Vinson,
P. P.
Primary Malignant Disease of the Tracheobronchial
Tree.
Report of 140 cases.
J. A. M. A., 107: 258,
1936.
(6)
Simonds, J. P.
Metastatic Tumors of the
Hypophysis.
Endocrinology
and Metabolism.
D. Appleton
& Co., New York,
1922.
(7)
Grossman,
W.
Diabetus
Insipidus bei Tumor Metastasen
in der Hypo-
physe.
Frankfort Ztch f. Path. 42: 384,
1931.
(8)
Benhamon,
E.,
Montpellier J.,
and
Curtillet,
E.
Cancer
du
corps
do
pancreas
avec metastases vertebroles,
cutanees et hypophysaires.
Bull, et Mem.
Soc.
Med.
d hop de Paris, 54:
1516,
1930.
(9) Johnson, G.
Metastatic Carcinoma
of Pituitary
Gland;
report
of
case.
J. Ner. & Men.
Dis.,
70:
285,
1929.
(10)
Arnstein,
A.
Diabetus
Insipidus
bei
Metastatischer
Karzinose
der
Hypophyse,
Namentlich
de
Hinterlappens
bei primaren
Bronchus
und Mama-
karizonom.
Med.
Klin.,
29:
1679,
1933.
(11)
Macchioro,
G.
Su un caso di diabete insipido
da tumore metastatico
della
regione ipofisario.
Minerva Med., 1: 668,
1935.
(12)
Blumensohn,
quoted
by H. Le B.
Peters
and L. S. Milne.
Secondary
Tumors of the Heart.
N. Y. M. J., 94:
383,
1911.
94
NORMAN
AND SILLIPHANT —BRONCHOGENIC
CARCINOMA
(13)
Morris, L. M.
Metastasis
to the Heart
from Malignant Tumors.
Am.
H. Journal, 3: 219,
1927.
(14)
Peters, H. LeB., and Milne, S.
Secondary
Tumors
of the Heart.
N. Y.
M. J., 94:
383,
1911.
(15)
Link,
quoted
by
Averbach,
O.,
Epsteen,
H. and
Gold,
H.
Metastatic
Carcinoma
of the Heart.
Am. H. Journal,
12: 467,
1936.
(16)
Mead,
C. H.
Metastatic
Carcinoma
of the Heart Secondary
to Primary
Carcinoma
of the Lung.
J. of Thoracic Surg.,
2:
87,
1922.
CLINICAL
NOTES
KEUKENBERG'S
SPINDLE
By Raymond
W. Heoe, Lieutenant, Medical Corps,
United States Navy
In
1898
Krukenberg
made
a report of cases
of an anomalous
pig
mentation
of
the
cornea.
The
special
characteristics of
the
cases
reported were
as follows: An oval-shaped
brownish pigment deposit
on the posterior layer of cornea of both eyes, arranged
in a vertical
direction.
His patients were myopes,
females,
and over
45 years of
age.
He believed
that the pigmentation was the result of a fusion of
the pupillary membrane
with the cornea in fetal life.
Edgerton
in
1829
made
an extensive
search
of the literature
and
his
report
discloses
37
such
cases
with
slight
variations
from
the
originals
reported
by Krukenberg.
The variations included
cases,
in
hyperopes,
in males, with one eye involved, in which the pigmented
spindle was in the horizontal position, and in patients as young as 22
years of age.
However, these variations were in the minority.
Edger-
ton's review of the literature included reports made by 22
authors.
The
greatest
number of cases
reported by any one author was
six,
made
by Augstein in
1912.
His
6
cases
were
seen
among
12,000
patients examined.
A further search of the literature after Edgerton's report
discloses
the
following
cases reported:
Srinivasan,
in
the British
Journal
of
Opthalmology,
November
1930,
reported
one case.
Ardwell
in Jan
uary
1930
presented
a case report at the Royal
Society of Medicine
of London,
and Doggart reported
a case to the same society,
March
1930.
Several theories
as
to the origin of the condition have
been pro
pounded.
Some
authors
accepted
the
pupillary
membrane
fusion
theory of Krukenberg.
Stock thought the cells of the posterior layer
of the cornea possessed some anomalous
pigment developing power.
Koby
in
1927
reported
observing
the
development
of
typical
spindles in a patient with iritis
4 months after an infection
and
a
second which developed
from a few dots of pigment into
a complete
spindle in a period of 18 months.
He believed that the spindle-shaped
pigmentation was due
to breaking down of the pigment of the iris,
facilitated by such condition
as myopia, senility, and chronic inflam
mation, and he believed
convection currents resulting from tempera
05
96
HEGE
KRUKENBERGS
SPINDLE
ture changes carried the pigment to the cornea, where it was deposited.
In cases with existing inflammatory condition the pigment was depos
ited
rapidly,
hut
if
the
inflammatory
condition
was
absent
the
deposition was slow and dependent
upon scratching of the cornea
by
the granules
of pigment carried by the convection
currents.
Other
theories have been proposed
to explain
the origin of this rare condition
and are referred
to in Edgerton's report.
REPORT
OF A CASE
Patient LWF,
fireman
third
class,
United States
Navy,
age
28,
male,
was
admitted
to United States naval
hospital,
Washington,
D.
C.,
March 4,
1936,
with
diagnosis
Dementia
praecox.
The original
diagnosis
was made August
13,
1935, when admitted
to Mare Island
Hospital,
California.
History disclosed that
patient
had worn
glasses
for past 2 years at intervals
for double
vision.
There
was no history
of eye
disease.
Glasses did not improve
vision and he discarded
them
recently.
Vision
20/20
either
eye
on entry
into
the
naval
service.
No
history
of
eye
diseases
in family.
General
physical
examination
was negative
except for psychological
and
neurological
findings
and
marked
gingivitis
and
pyorrhea, alveolaris.
Weight
130 pounds, and height 68 inches.
An examination
of the eyes revealed the following:
No evidence of acute or chronic inflammatory
disease.
The color of iris is brown.
VOD 20/20, VOS 20/30.
Color vision normal.
Visual and color fields, right eye normal; in left there was concentric contraction
of
visual and color fields and interlacing
of colors.
Under homatropine
VOD 20/15,
VOS 20/15.
During the retinoscopic examination,
bilaterally,
a vertical
elongated
shadow was noted which did not move with the retinal shadow.
The opthalmo-
scope
showed this to be a brownish
pigmentation
of the cornea extending in the
vertical
direction,
opposite the pupillary opening.
This pigmentation
was about
5 millimeters
in length and 2 millimeters
in width, each eye, and appeared tapered
toward
each
end.
The
opthalmoscopic
examination
was
otherwise
negative.
Neutralization
of the patient's
glasses
showed them to be OD 0, OS 3D prism,
base
down.
An examination
by the phorometer
revealed at
6 meters esophoria
0, exophoria
0, left hyperphoria
.2D
and at 33 centimeters, 8D exophoria.
An
examination
with the slit lamp disclosed the pigment to be in the posterior layer
of the cornea.
The pigment
had a brownish
appearance identical
to that
seen
among the muscle bundles of the iris.
The pigmentation
was more extensive than
it appeared to be on examination
with the opthalmoscope,
for scattered particles
were
seen over the greater part of the cornea.
On the lower and mesial aspects of
the cornea it extended as far as the limbus.
These deposits were more numerous
toward the center where they were sufficiently
dense to show
macroscopically
as
described above.
No pupillary membrane or other anomalies were noted.
Laboratory
tests: Kahn
and
Wassermann
negative.
Urine
negative.
White
blood cells 14,000,
neutrophiles
69 percent, lymphocytes
22 percent,
eosinophiles
3 percent, monocytes 6 percent.
Sedimentation
time, 8 millimeters
in 60 minutes.
SUMMARY
1. Krukenberg
made
the first report of cases
of this condition in
1898, reporting three cases in that year.
Since that time
26 authors
have reported
41 cases of this condition.
2.
Several
theories
as to the origin of the pigmentation have
been
propounded.
LeCLAIR— DENTAL NEUROSIS
97
3. A typical case is reported
with the following characteristics:
(a) Vision slightly impaired.
(b) There is a brown, oval-shaped pigmentation of the cornea, both
eyes, vertical in direction and central in position, seen macroscopically.
(c) Examination
by means of the slit lamp shows the pigmentation
to be in the posterior layer of the cornea, involving
the greater part
of the cornea.
Below and to the nasal side the pigmentation extends
as far as the limbus.
The pigment is more concentrated
as the center
is
approached,
where
the
spindle
or
deep
pigmentation
appears
macroscopically.
(d) On refraction the eyes are emmetropic.
Bibliography
Illustrated Guide to the Slit Lamp, T. Harrison Butler, page 47.
Archives of Ophthalmology,
1:
591-593;
3:
380,
496, 599-619;
4: 151; 5:
808,
996; 6:
771.
American
Journal of Ophthalmology,
13:
326,
334,
534,
654,
722,
1930.
DENTAL
NEUROSIS
By V. A. LsClaib, Lieutenant, Dental Corps, United States Navy
Impacted
teeth
cause
subjective
neuralgic symptoms,
in
many
cases, where
a lobical explanation of these symptoms cannot be given.
It is problematical if all the conditions existing
that are apparently
caused by the teeth can be directly traced to the teeth.
The following
is a report of two cases that fall in this category:
Case 1.—D. H. C., seaman, second class,
age 25 years, married,
white male.
Chief complaint: Pain in the ear and "cold in the eye."
Noticed
eye would not
close.
Shipmates
accused him of being a "wise guy" by talking out of the left
corner of his mouth.
Past
history: Scarlet
fever and diphtheria
at the
age of
8 and measles at 10.
Uses alcohol sparingly.
History of present illness: Three days prior to reporting
to sick bay he started to
talk out of the corner of his mouth.
The night before he reported
he felt pain for
the first time in his ear and attributed the pain to a "blackhead" in the ear.
The
day after
the pain
appeared
the eye commenced
to water freely.
Three
days
before onset of illness the patient
drove about
240 miles round trip in a roadster
with windbreakers.
These trips were weekly events prior to this period.
Two
days after this trip he developed accentuated talking out of the side of his mouth,
lacrymation right eye and slight
pain
in the ear, and reported
to the sick
bay
where he was treated by the duty corpsman for a cold in the eye.
The following
day, April
18, he was admitted
to the sick list with a diagnosis of Bell's
palsy.
Physical
examination: A well developed white adult male.
Rhomberg
negative,
no conscious stiffness of the face, pupils equal, react to light and accommodation.
Ear normal,
taste normal.
All muscles of expression on right side of the median
line of the face completely
paralyzed.
Phlegmatic,
all muscles supplied
by the
facial nerve on right side involved.
The wrinkles
of the forehead and nasolabical
fold, on the right side, flattened out.
Deviation
of the nose to the left.
Inability
9S
LeCLAIR—dental neurosis
to whistle,
bare the teeth,
or close
the eye.
Cannot
elevate the right
eyebrow,
cannot drink water without drooling.
No pain on deep
pressure in the styloid
region or behind the ramus of the jaw.
Oral cavity
normal.
Treatment: Patient remained
on the sick list for
2 weeks with no apparent
improvement.
X-ray
examination
of the oral
cavity
disclosed the upper right
wisdom
tooth
horizontally
impacted,
with the occlusal
surface
flush with the
crest of the alveolus.
No clinical,
radiographical,
or palpable signs of pathological
involvement.
May
1, the upper wisdom
tooth
was removed
under
local
anes
thetic,
taking
care to cause
minimum
of trauma.
The following
day, the right
eyebrow
showed
evidence
of
movement.
Four
days
later
the
patient
could
whistle and bare his teeth.
One week from the date of operation
the patient
was
apparently
normal and has remained
so to date.
Case
2.— C. R. E., Lieutenant,
U.
S.
N.
age
31 years, married,
white
male,
medium
size and build.
Chief complaint:
Aggravating
pain
behind
ear with an inability to raise voice
above normal tone without loss of sound.
Family history: Father died at the age of 67, mother living and well.
Three
sisters all living and in good health.
Past history: Chickenpox
at 8 and scarlet fever at the age of 10.
Appendec
tomy and herniotomy
in 1925.
Health record in Navy negative.
About January
1932
he first noticed a slight aggravating
pain on the left side of the face in the
region
of
the
submaxillary
gland.
These
symptoms
came
on intermittently
thereafter.
The symptoms
were aggravated
and intensified
when subjected
to a
draft as driving a closed
car with the driver's
window
open.
These symptoms
subsided completely
for a considerable
time following
the first attacks.
Present illness: About a month before reporting for treatment
the above symp
toms reappeared and progressively
became worse, being aggravated
by exposure
to drafts.
September
15, the patient
reported to sick bay with pain centered in
the ear;
bothersome but not clearly defined
as to location,
with swelling
of the
submaxillary
region on the left
side,
and complaining
of complete loss of voice
when speaking in a forceful
manner.
Combination
of intense pain with a sensa
tion it was impossible
to talk,
comparable
to someone grabbing
hold of the vocal
cords.
No soreness
of the submaxillary
gland.
"Like
the sensation
of a con
traction
of a throat muscle; when I stopped to clear my throat
the impediment
would
disappear."
The speech
impediment
has been
steadily
becoming
worse.
These symptoms
are practically
constant
at the present time.
Physical
examination:
Mouth normal,
excellent oral hygiene.
No evidence of
clinically demonstratable
pathology
of the hard
or soft tissues.
Apices
radio-
graphically
negative.
Considerable
swelling of the left submaxillary
gland region
with tenderness posterior
to the ramus of the mandible,
anterior
to the external
auditory
meatus.
Radiographic
examination
revealed
tooth
No.
16 in
slight
lingual
version below the line of occlusion with a super impacted
supernumerary
third molar lying distally
and above the roots of tooth No.
16 in close proximity to
the maxillary sinus.
No clinical, radiographic,
or palpable signs of infection
in the
area could
be demonstrated.
Treatment:
On September
16, the normal third molar was removed under local
anesthetic.
Forty-eight hours
after
the removal
of the tooth
symptoms
disap
peared with no recurrence to date.
It is not assumed that the above
cases
were
definitely
caused by the existing
dental condition;
coincidence
must always
be considered, however, in view of the
complete cures immediately
following
treatment —they strongly
point to a dental
origin.
Dental literature
is full of
case
reports
of widely
divergent
subjective
symptoms of dental origin.
FULGHUM —MASOCHISM
99
COMMENT
The etiology and nature of the pain caused by impactions is not
known.
In my opinion, the chain of symptoms is caused by an over
stimulation
of the vital structures supplying
the tooth germ
as the
roots grow downward into the bone structure.
The teeth are found
in crypts in the bone, and when they begin
to erupt the roof of the
crypt is removed
by absorption, making room for the crown to pass.
The
tooth
germ
remains
relatively
stationary
during
the
entire
growth of the normal tooth.
If in the normal growth the tooth be
comes
impacted, the growth
takes
place
in
the
opposite
direction,
causing a disturbance of the physiological balance of that surrounding
structure.
The capillary and nerve plexes of the tooth germ and the
future
dental pulps become impinged between
the developing
tooth
and
the
bone
of
the
maxillae.
This
disarrangement
of
the
vital
structures
supplying
the
tooth
causes
an overstimulation
of
these
structures producing a conscious
recognizable
chain
of symptoms, or
the irritation may be tolerated by the patient.
All impacted teeth
produce
this
overstimulation
whether
subjective
symptoms
are
present or absent.
The degree of tolerance
to irritation
varies in different individuals ;
irritation
always
exists
where
impactions
are
present.
The
reflex
nervous
conditions
of dental etiology
oftentimes
present
no
local
symptoms and as a result the dental aspect is not considered
until all
other lines of treatment are exhausted.
In the words of Dr. E. Roy
Bier, D. D. S.:
The presence
of local or referred pains in or about the head of the patient in the
following regions: Temple,
back
of head or neck,
top
of head, ears, dull pain
around
the
eyes;
or
should
even
a
general
neurasthenic
condition
exist,
the
diagnostician
is justified
in ordering
the removal
of any impacted
teeth, whether
they show infection or not.
PASSIVE ALGOLAGNIA
MASOCHISM
By jAMea E. Fulohum,
Lieutenant,
Medical Corps,
United States Naval Reserve, Lonlsburg, N. 0.
This report is made because of the rarity of this type of case outside
of the cosmopolitan districts, the rarity
of the passive
algolagnia in
the male, and the unusual type of lesion produced
by a patient upon
himself.
Algolagnia
is divided into two classes,
active
and passive.
Active
algolagnia or sadism
is the gratification of the sex urge by infliction
or sight of pain real or simulated.
This abnormality is found most
frequently
in
the
male.
Passive
algolagnia
or
masochism
is
the
gratification
of
the
sexual
feeling
by suffering pain either real
or
simulated.
This
is
found
most
frequently
in
the
female.
Many
100
FULGHUM —MASOCHISM
sadists and masochists
are potent only when
they are subjected to
suitable stimuli.
In some instances,
sadism
and masochism
coexist in the same indi
vidual; however,
one usually overshadows
the other.
Krafft-Ebling
has
defined
sadism
as "an
association
of cruelty
and
violence
with
lust."
The condition obtained its name from the notorious Marquis
de Sade whose obscene novels treated extensively of lust and cruelty.
Masochism obtained its appellation from the writer, Saches-Masoch,
who wrote at great length of this form of perversion.1
REPORT
OF CASE
L. A., a barber,
age 25, unmarried,
called me to his room in the early morning
and asked me to take him to my office.
He was standing
in his room fully un
dressed except for a towel which was closely pressed
to the genitalia.
There were
many towels soaked with blood upon the floor which showed evidence of consid
erable hemorrhage.
Upon questioning
him, he admitted
that he cut his scrotum
with the scissors "for the purpose of seeing
what his testicle looked like."
Imme
diately,
he was taken to the office where a more thorough
examination
was made.
There
was an incision about
2 inches long on the left anterio-lateral
side of the
scrotum
through
the skin,
subcutaneous
tissue,
tunica
vaginalis,
and
into
the
testicle.
The incision
in the skin had been
closed by the patient
with
a needle
and cotton thread.
These stitches were taken out and a large blood clot removed.
The hemorrhage was found to be coming from
a severed vein in the tunica
vagi
nalis.
Under aseptic conditions
the wound was closed in three layers; 1st, testicle,
2d,
tunica
vaginalis,
3d,
skin
and
subcutaneous
tissue, without anesthesia.
I
explained
to him that I could novocainize
the wound and he would suffer no pain
but
he desired to
be sutured without anesthesia.
There
was not the slightest
flinching
or other outward
evidence of pain experienced by the patient.
The wound
healed by
primary
intention
without complications,
the sutures
being removed on the sixth day.
Upon
close examination,
four identical
healed
scars and
numerous
pinpoint scars
were
seen
on the scrotum.
These
former
experiences will be discussed in the personal history.
Personal
history.—He
is the third child
born of unrelated
parents.
His birth
was normal and occurred in a small eastern North Carolina town.
He has three
brothers
and five sisters.
His preschool
days were void of any unusual
circum
stances
except that
he
never liked to play
with other
children.
He loved
his
mother
better than his father.
His school life was normal.
He was
an average
student.
His education
is limited
to the eighth
grade and training
in a barber
college.
He
took
no part
in
the school social life.
He bad
measles,
mumps,
whooping
cough during
childhood
but since then,
he has had no serious injuries
or operations.
He does not use alcohol, tobacco, or drugs in any form.
His work
is satisfactory
but he does not enjoy it particularly.
He has no recreation
except
the theater.
He has no hobbies nor does
he enjoy or play any form of athletics
or sports.
He has no religious
affiliation
or interests.
He
has no friends
and
when not working
he likes to be alone in his room.
He does
not care for books,
music,
or current
events.
He admits
that
he likes to read sordid
and obscene
magazines.
He was reared in a small town and lived there all of his life except
2 years when he was in school in Baltimore.
His sex life has been abnormal.
He
began the practice
of masturbation
at the age of 14.
He has attempted
normal
coitus
on
2 occasions but could not attain an erection.
Erections
can
be secured
1 Patten, C. A.
"Psychopathic Personality,"
Cyolopedla
of Medicine, vol. X, F. A. Davis Co., 1934.
WALTER
AND HOLLAND—PNEUMONIA
101
In his room
under suitable
stimuli
such as pinching
himself
or sticking
himself
with
pins.
The first scrotal
operation
was done 4 years ago.
The others have
been done at intervals
of several months.
One of these done in 1935 was followed
by an abscess
which had to be opened by his family physician
to evacuate the pusv
He used no form of antiseptic
in these operations.
He stated reluctantly
that he-
derived
sexual pleasure and gratification
from the operations
which
he had done-
and that they had been accompanied
by erection and ejaculation.
He has never
seen
the
same
thing
done by other
people but
began
to do so
because
of the
pleasure derived at first from pinching
the scrotum
and later by perforating
the
scrotum
with
pins.
Girls are disgusting
and
repulsive
to
him
and make him
nervous.
Mental
examination. — Negative.
Physical examination. —Well-developed
and
well-nourished
white
adult
male
who shows no abnormal
findings except the scrotal wound.
COMMENT
This patient is greatly concerned
about himself.
He says that he
knows that he should not do these things but feels compelled
at time*
to indulge.
The fact that he is impotent
has
increased
his worry.
He expresses a desire that I help him to overcome
these abnormalities,,
and he has confidence
that he can
overcome
them
with
the proper
help.
A supplementary report of the
outcome
will
be
made
at a
later date.
ATYPICAL LOBAR PNEUMONIA
By A. J. Walter,
Lieutenant,
Medical Corps,
United States Navy,
and J. L. Holland,
Lieutenant,
United States Navy
This case is reported
as it is believed
to
be of interest due to the
following:
(1) The unusual prodromal signs and symptoms.
(2) The remarkable reaction following
the administration of anti-
pneumococcic serum
with
subsequent
rapid
disappearance
of chest
findings.
(3) The clinical course and laboratory findings.
REPORT
OF A CASE
Case of J. "T" B.—Patient reported to sick call at 8:30 a. m. complaining
of a
cold in head and chest of 4 days' duration,
also severe occipital
headache, stiff
ness of neck, and general malaise.
He stated that 2 days ago he had shore patrol
on a cold rainy night from
10 p. m. until
2 a. m., and at 4 a. m. he began his
duties
in the galley.
He stated that the night
before admission
while at home,
he had
a severe
chill,
was nauseated,
vomited
twice, and had a severe
occipital
headache which was not relieved by 10 grains of aspirin.
The
patient's
physical
appearance
was that
of
a
well
developed
and
well
nourished
white male of about 26 years of age.
He had a distressed look,
marked
pallor,
and
appeared
quite
toxic.
The
physical
findings
were not
compatible
with the above appearance.
Temperature
and respiration
were normal, pulse 90.
Examination
of eyes, ears, nose, and throat was negative except for a moderate
102
WALTER
AND
HOLLAND
PNEUMONIA
nasopharyngitis.
There
was
no
stiffness
of
the
neck.
Heart
normal,,
blood
pressure 100/66.
The lungs disclosed a few scattered mucous rales,
and abdomen
was negative.
Extremities
and reflexes
were normal except for slight pain in hip
joints on flexion of thighs on abdomen.
Skin negative.
White blood cells 11,050.
The patient
was admitted
to sick bay as an absolute
bed patient
under close
observation.
Symptomatic
treatment
was instituted.
At
10:30
a. m.
he
had
a moderately
severe
chill, and the occipital
headache increased in severity.
The
temperature
rose
to
101. 6°, pulse
100,
and
respiration
21.
One hour
later
a
slight
erythema
was noted
on his arms
and
chest.
Temperature
was
102.6°;
pulse,
112; respiration,
22.
He was immediately
transferred
to the Hankow International Hospital, Han
kow,
China.
While
en route
he perspired
profusely
and on arrival 20 minutes
later
his temperature
was
101.6°; pulse,
87;
respiration,
20.
Spinal
puncture
revealed
clear fluid
under
normal
pressure with five cells per cubic
millimeter.
The headache disappeared
after spinal puncture.
There was no evidence of the
rash or erythema.
The patient
minimized
his condition
and felt very comforta
ble.
The white blood cells was 11,400;
myelocytes,
1 percent; bands, 39 percent;
segments, 35 percent; lymphs,
14 percent; and large monos,
1 1 percent.
Repeated
examination
for malarial
parasites were negative.
Five o'clock
in the afternoon
he had
a severe
chill
which
was followed
by a
temperature
105.2°; pulse,
140; respiration,
30.
The headache returned
and the
heretofore
mild
cough became quite
harsh and
deep.
His breath
had a strong
fetid odor not noted before.
Chest examination
elicited marked
congestion, and
slight
dullness
over right
middle
and lower,
and left
upper lobes.
There
were
loud
mucous
rales,
with
fine
crepitant
rales
at
the
end
of
inspiration.
The
expiratory
sound
was
prolonged.
Sputum
examination
revealed
many
gram
positive
diplococci
in almost
pure
culture.
As
there
were no typing facilities
and
after
sensitivity
test which
was negative,
10,000
units
of Mulford's
poly
valent
serum type I and II were given at 8:40 p. m.
One hour later
he had a
terrific
chill,
pulse
150 and
very thready.
He
had
Cheyne-Stokes
respiration.
One cubic
centimeter
of adrenalin
chloride
was given
hypodermatically
which
increased
the strength
of
the pulse and
accelerated
the rate to
180.
Axillary
temperature
was
108° and respiration
40.
The patient became irrational and had
to
be
restrained.
One-half
grain
of
morphine
sulphate
administered.
After
patient's
condition
subsided
a second spinal
puncture
revealed clear fluid under
moderately
increased
pressure.
There
were
11
cells per cubic
millimeter
and
subsequent
spinal
fluid
cultures
were
negative
and
Kahn
was
negative.
He
perspired most profusely and by midnight
his temperature
was 100.4°; pulse, 112;
respiration,
14.
He was also rational.
At 2.30
a. m. his temperature
was 95°;
pulse,
80; respiration,
12.
He had no complaints.
By 9 a. m. his temperature
was 97.6°;
pulse,
80;
respiration,
20.
Examination
at
this
time
revealed
the
patient
resting comfortably,
the cough was only slight, and most remarkable
was
the absence of the physical
signs of congestion noted the evening before.
There
were
a
few
scattered
mucous
rales
throughout
the
chest;
white
blood
cells,
9,800;
myelocytes,
1 percent;
meta-myelocytes,
1 percent;
bands,
42
percent;
segments, 33 percent; lymphs,
15 percent; large monos, 8 percent.
There
was an
afternoon
rise
in
temperature
to
105°;
pulse,
140;
respiration,
28.
He
then
perspired
profusely
necessitating
frequent
changes of
bed
clothing
during
the
night.
Nine
o'clock
the
following
morning,
which
was
the third
day
of
his
illness,
the temperature
was 97.6°; pulse,
80;
and respiration,
20.
During the
day the temperature,
pulse, and respiration
gradually
increased until at
5 p. m.
the temperature
was 104.8°; pulse,
140; and respiration,
28.
The patient was looking quite toxic by the fourth day.
At nine a. m. tempera
ture
was
100°; pulse, 96, and respiration,
24.
The white blood cells had dropped
WALTER
AND
HOLLAND
PNEUMONIA
103
sharply to 6,800,
with also a marked shift to the left.
There was one basophils;
myelocytes,
2 percent, meta-myelocytes,
3 percent, bands, 35 percent, segments,
21
percent,
lymphs,
23 percent,
and large monos,
16 percent.
At
7
p. m.
250
cubic centimeters
of blood were given by the multiple
syringe method, which was
followed by a chill with temperature
rise to 105.2°,
pulse, 104, and respiration,
27.
This
reaction
was followed
by
a subnormal
temperature
of 95°,
pulse,
60,
and
respiration,
18.
His general condition
on the morning
of the fifth day showed
slight
improvement,
with an increase in white
blood
cells
to
8,200,
basophiles,
1 percent,
myelocytes,
1 percent, meta-myelocytes,
1 percent, bands,
32 percent,
segments,
35 percent,
lymphs,
22
percent,
and
large
monos,
8 percent.
The
above slight gain shown in blood picture
and clinical
findings
were only transi
tory,
and by the sixth
day
he was looking
quite
toxic,
with
his blood
picture
showing granulocytic
shift to the left.
The white
blood
cells
had
decreased
to
7,800,
myelocytes,
1 percent,
meta-myelocytes,
1 percent,
bands,
35
percent,
segments,
30 percent,
lymphs,
22 percent,
large monos,
11
percent.
A second
transfusion of 450 cubic centimeters of blood and 100 cubic centimeters of normal
saline solution
was given.
There
was no chill following
this transfusion
and his'
temperature
only rose to 103.6°,
pulse, 110, and respiration,
26.
On the following
day the patient
showed decided improvement,
he felt much
better
and
his afternoon
temperature
was 103.8°.
The white
blood
cells
were
9,200;
myelocytes,
1 percent;
meta-myelocytes,
2
percent;
bands,
39 percent;
segments,
31 percent; lymphs,
15 percent; large monos, 12 percent.
Examination
of chest
revealed only
a few scattered
mucous
rales.
From the seventh to the
tenth day of his illness there was a gradual
decline in the afternoon
rise in tem
perature,
steady marked
improvement
in his general condition,
and no marked
change
in blood picture until this date.
However,
on the morning
of the tenth
day
his
white
blood
cells
were 13,400;
myelocytes,
1 percent;
meta-myelocytes,
1 percent;
bands,
20 percent;
segments,
56 percent;
lymphs,
17 percent;
large
monos,
5 percent.
The first
X-ray
of chest was taken
this
date
as
patient's
condition was such that it was not advisable
to move him
to the X-ray
room
before
this
time.
The lungs
were essentially
negative
except
for
a moderate
increase
in
infiltration
of
bronchi
extending
toward
periphery.
The
heart
showed
marked
dilation
of the left
ventricle.
Next morning
the patient
com
plained of a
severe
pain
in right
chest.
Examination
revealed
a loud friction
rub.
The pain
was much
relieved
by
immobilization
of
chest with adhesive
plaster.
The white
blood
cells
showed an increase to
17,200
with
granulocytic
shift to the left.
On the thirteenth
day examination
revealed decrease
in sound
of friction rub, but an area of dullness was noted along costal margin, mid-axillary
line.
The temperature,
pulse, and respiration
gradually
subsided to normal
by
the seventeenth
day.
The pain
had disappeared,
no dullness could
be elicited,
and the patient's
general condition
showed
marked
improvement.
The blood
picture was compatible
with the clinical
course and on this date the white blood
cells were 8,600;
eosins, 1 percent; meta-myelocytes,
1 percent; bands, 12 percent;
segments, 52 percent; lymphs,
27 percent; large monos, 7 percent.
The tempera
ture
continued
to
remain
normal,
no
other
complication
developed,
and
the
patient
made an uneventful
recovery.
DISCUSSION
The diagnosis
in this case was very confusing because the charac
teristic clinical findings and blood picture were lacking.
No diagnosis
was made until after sputum examination, the afternoon chill,
and
rise
in
temperature
to 105°, with
the
accompanying chest
findings
104
FUNK —MENINGOCOCCI
INFECTION
confirmed
it.
Patient's past history was negative
except for malaria
and repeated
careful examinations
were made of the red blood
cells
to rule out this condition.
Repeated blood
cultures were negative
for
pneumococci.
Meningitis
was
ruled
out after
repeated
spinal
punctures,
spinal fluid examinations,
and cultures of spinal fluid, as
being
a complication.
One of the most interesting laboratory find
ings was the fact that proteus X 2 was positive in
1 to 250 dilution
while proteus X
19 was negative.
Another
examination with new
stock of proteus X 2 and ONX
19 were positive
1 to 100 dilution, but
proteus X
19
was
negative.
A local
doctor had
four cases which
agglutinated proteus X 2,
1 to 100, but not proteus X 19 or ONX 19.
It was noted
that of this group,
this case had
the highest
tempera
ture and perhaps
there may be some relation between the temperature
and
the agglutinating power
of his serum
to cause precipitation in
both proteus X 2 and proteus ONX
19 up to
1 to 100 dilutions.
ATYPICAL
MENINGOCOCCI
INFECTION
By W. H. Funk,
Lieutenant
Commander,
Medical
Corps, United States Navy
H. J. A.—C. C. C. white,
age
21, entered the United
States Naval Hospital,
Great Lakes,
111., on January
9,
1936, for treatment
of a left inguinal
hernia.
On
his way to the hospital,
he caught cold and his complaint
on admission was head
ache, cold in his head and on his
chest.
On physical
examination
at entrance
there was noted on his extremities
a papular
eruption,
with breaking
down and
scab formation
at the center and surrounded
by a zone of erythema.
During his
stay at the hospital
he had febrile
rises to 102 or 103 about every third day, pre
ceded
by chilly sensations but not by a definite chill, with a new crop of skin lesions
typical of erythema multiforme.
Even
with febrile accessions his pulse was low,
never going over
100.
With the later febrile
episodes there was definite joint involvement,
redness,
tenderness, and pain similar
to acute rheumatic
fever.
Repeated
blood cultures
were negative.
Repeated
blood smears
were
negative for malaria
and a thera
peutic test was tried with quinine.
Because of the joint manifestations,
salicylates
were given over a long period of time with no improvement.
There were no signs suggesting meningeal involvement
until February
27, when
a spinal tap was done because
of rigidity of the neck and a positive Kernig.
No
organisms were seen on smear or culture and because
of the low chlorides, T. B.
meningitis
was suspected.
On the next tap a Gram negative extra-cellular
diplo-
coccu8
was seen
on smear but did not grow on ordinary
media.
The Abbott
laboratories
very kindly took
some
of the fluid and on specially
enriched media,
were able to get a culture which gave an agglutination
with antimeningitis
serum.
Intra-spinal therapy with antimeningitic
serum was started on the 8th of March
and convalescence was uneventful
after
5 days of this therapy.
It is believed that this was a case of atypical meningococcus
septice
mia giving an irregular temperature
chart with erythema
multiforme
and arthritic manifestations
for about 7 weeks and constituted a diag
nostic puzzle
during this period.
After localization in the meninges,
the organism
could
only be grown on specially
enriched
media,
but
responded to serum.
LOVE
AND
EVER—TULAREMIA
105
TULAREMIA
Report of Two
Cases Occurring
Among
Active
Naval
Personnel
By Julian
Love,
Lieutenant,
Medical Corps,
United States Navy and AIMED W. Era, Lieutenant,
Medical Corps,
United States Navy i
Tularemia
as
a disease entity
was
established
by Francis
(1) in
1921.
It
appeared
in
the
United
States
Navy
Nomenclature
of
Diseases
in the
1923 revision.
An excellent
discussion
of the disease
was
presented
by Simpson
(2) in the United
States
Naval
Medical
Bulletin in October
1928,
and in that same issue four cases
were re
ported by Bunkley
and Smith
(3).
One of these cases
occurred
in a
retired
medical officer
and
two others
apparently in nonnaval
per
sonnel in the United States Naval Hospital, Washington, D. C.
The
fourth
case was a mild attack in the nephew of the first individual.
It is probable that other cases
have occurred
among our naval es
tablishments, but to date
no report of the disease occurring in the
active list of the Navy has been recorded
in the "Surgeon General's
Annual Report of Disease
and Injuries in the Navy for the Calendar
Years 1918-35," inclusive.
Therefore, the appearance
of this entity
in two enlisted
men on active service is considered sufficiently unusual
to warrant its presentation.
Case
1.-— R. J., seaman first
class,
United States Navy.
White male, age
21.
This sailor reported on April
19, 1936, to the dispensary, United States Naval Air
Station, San Diego,
Calif., complaining
of "painful and tender lumps in the left
armpit."
He first noted the lump on April
15 accompanied
by general malaise,
headache, stiffness of neck, chills, fever, sweating, and a moderate degree of weak
ness.
These
symptoms
became
progressively
worse
and
the axillary
kernels
larger until he reported to the sick bay.
In company with R. N. D. (case
2) and a civilian this man went on a week-end
hunting trip near Bakersfield,
Calif.
They shot five wild rabbits,
three of which
were skinned
by this patient
while two were skinned
by his companion.
They
had been
warned
by local residents
to examine rabbits
carefully
for "boils"
or
"ulcers", and not to handle or eat animals
so afflicted.
No lesions were so noted
on these rabbits,
and the meat was thoroughly
cooked.
There was nothing
in the family history,
habits,
or past illnesses which
had
any bearing on the case.
Venereal
diseases
were denied.
On physical
examination
a young
white
male with feverish
appearance
was
noted.
His temperature
was 99.4°
F; pulse,
80;
and respiration,
18.
Positive
findings were injected
conjunctivae,
three
very
painful,
freely
movable
pea to
marble
size lymph nodes in the left axilla, and a slight reddish mark about twice
pinhead
size on ring finger left hand, dorsal surface at junction of proximal
and
middle
phalanges.
There
were no other
abnormal
physical
findings,
and there
were no other enlargements of other lymphatic chains.
Laboratory findings
on April
19 were as follows:
White blood
count,
8,900;
differential
count,
segments,
35 percent;
bands,
3; lymphs,
54; monos,
5; and
1Our appreciation
is expressed for the cooperation
and assistance of Lt.-Comdr. F. C. Hill (M. C.), U. S.
Navy, and
Lt. E. P. Madden (M.
CO, U. 8. Navy, of the U. S. Naval
Hospital, San
Diego,
Calif.,
during
the hospitalization
period of these patients,
and, also, to Commander
L. L. Adamkiewicz
(M.
O.)
U. S. Navy, for the biopsy
and laboratory
studies involved.
24140—3"
8
106
LOVE
AND EYEB—TULAREMIA
eosins,
3.
The urinalysis
showed a faint trace of albumin,
a few leucocytes,
and
and occasional
erythrocyte.
On April
20 the white
blood count was 6,000; dif
ferential
count, segments, 21 percent;
bands,
16; lymphs,
50; monos,
10; eosins,
1; Turck cells,
1; and Rieder's
cells,
1.
The urinalysis
showed a faint trace of
albumin,
a few granular
casts,
and a few leucocytes.
On April
19 his temperature
rose to 101° F., and pulse to 90, and on April
20
he was transferred
to the United States Naval Hospital, San Diego, Calif.
On
April
21
a small
denuded
area appeared
over
the
reddened
mark
previously
noted accompanied
by swelling and tenderness of the proximal
and middle
pha
langes.
From
April
23
until
May
7
his
temperature
showed
an
afternoon
rise from
102°
to
103°
F. with a corresponding
increase in pulse.
Headache,
extreme
weakness, some chills
and sweats were
also noted.
One axillary gland
continued
to enlarge and on May
1 began to soften
but was not incised until
June 2 when 10 cubic centimeters of pus were evacuated.
His temperature
began
to recede
by lysis on May
7 and after May
16
he was afebrile.
His weakness
persisted
even
after discharge on July 21,
1936.
The laboratory
studies at the naval hospital
were as follows:
April
21:
Red
blood
count,
4.46
million;
hemoglobin,
85
percent.
White
blood
count, 8,750; segments,
30 percent;
bands,
27;
juveniles,
5; lymphs,
37;
eosins, 3; and monos, 4.
Urinalysis showed only a few leucocytes.
April 22: White blood count, 7,450; segments, 35 percent; bands, 38; juveniles,
1; lymphs,
12;
eosins, 2;
and
monos,
12.
The
Kahn
test was negative.
The
serum
showed
no
agglutination
for
Pasteurella
tularense
or
Brucella
group
organisms.
The serum was submitted
to the Scripps
Metabolic
Institute
and
California State Public Health in addition
to the local hospit
1 laboratory.
May
4: Cultures
of ulcer on finger were positive
for staphylococci.
May 5: A guinea pig was innoeulated
with serum aspirated fiom the ulcer on
the finger;
1 cubic centimeter
of the suspension, intraperitoneally,
and 0.5 cubic
centimeter,
subcutaneously.
On May
11 the pig died.
Autopsy report: "The
pig
appeared to
be
losing
weight.
The liver revealed
numerous
nodules
and
discolored
ulcerated
areas.
The
lungs
appeared
congested.
Cultures
made
from liver and lungs were negative for Pasteurella
tularense."
June
2:
Serum
agglutination
positive
for
Pasteurella
tularense
in dilution
1 to 640.
Highest
agglutination
with Brucella
group organisms,
1 to 80; positive
for tularemia.
Bunnell
test
was negative.
Guinea
pig
innoeulated
with pus from
axillary
abscess.
One cubic centimeter
was given intraperitoneally
and
0.5 cubic centi
meter subcutaneously.
June 9 : Smear from axillary
abscess was negative.
Culture of the same material
revealed no growth.
June 23: The guinea pig was killed.
Autopsy
report: "The pig was apparently
healthy
and fat.
It shows no apparent
pathology.
The internal
organs were
of normal
appearance.
No
nodules
were
present.
The lymph
glands
were
normal."
On July 21 the patient
was returned
to duty with scanty drainage left axilla.
He complained
of slight asthenia.
Case
2.—R.
N.
D.,
seaman, first
class,
United
States
Navy.
White
male,
age
18.
This sailor
reported
to the dispensary
on April
19 accompanying
R.
J.
(case
1).
His complaints
were similar except that his "lumps"
and
tender
ness
were
in the right axilla.
Physical findings
were essentially
negative except
for enlarged lymph nodes about
the size of a large marble
in the right axilla.
No external
abrasions
were noted on right hand,
wrist,
or forearm.
His white
blood
count
was 7,400; the differential
count,
segments,
45 percent;
bands,
4;
lymphs,
37;
monos,
8; eosins, 5; and basos,
1.
The urinalysis
showed only a
LOVE
AND
EYER —TULAREMIA
107
few leucocytes
and squamous
epithelial
cells.
By evening
his temperature
rose
to 101.6°
F. accompanied
by sweating
and on April 20 he was transferred
to the
United States Naval Hospital, San Diego, Calif.
From April
21 until May
1 his temperature
rose
daily
to
103° F.
His main
complaint
was weakness with chills and sweats.
From May
1 until May
16 his
temperature
declined to normal,
and he remained afebrile until July 21, the date
of discharge.
The right axillary lymph node increased in size and induration,
and
became immovable
and quite tender.
On May
7 it began
to soften, and on May
22
10 cubic
centimeters
of
creamy
pus
were
aspirated
from
the
abscess.
On
June
22 the fluctuant
area was widely
incised for drainage.
There
was gradual
improvement
until
he
was
returned
to
duty.
Laboratory studies while in the hospital were as follows:
April
21:
Red
blood
count,
4.46 million; hemoglobin
85 percent, white
blood
count,
7,650;
segments,
32
percent;
bands
32
percent;
juveniles,
2
percent;
lymphs,
24 percent;
eosins,
6 percent; and monos, 4 percent.
The urinalysis
revealed
some
mucus and leucocytes.
April
22:
White blood count,
6,050; segments, 50 percent;
bands,
15 percent;
lymphs,
29 percent; and monos, 6 percent.
The Kahn was negative.
May
22:
No agglutination
for
Pasteurella
tularense
or Brucella
group
organ
isms
was
noted.
Serum
reported
by
the three
laboratories
was negative.
A
guinea
pig was innoculated
with
pus from
the right
axilla,
1 cubic
centimeter
intraperitoneally,
and 0.5 cubic centimeter subcutaneousiy.
May
29:
The Bunnell
test was negative.
June
2:
Serum
agglutination
for
Pasteurella
tularense
antigen
was
positive
in dilution of
1 to 2560.
Highest dilution for Brucella
group organisms was
1 to
80.
June
23:
The guinea pig was killed.
Autopsy
report:
"The pig was normal
and
healthy
in appearance.
The internal
organs were surrounded
by fat.
No
nodules
or
discoloration
were present.
The lymph
nodes were
normal.
The
pus inoculated
May
22 was apparently
sterile."
The patient
returned
to duty
well July 21 1936.
DISCUSSION
Tularemia
may affect
an individual
in one of four ways; namely,
ulceroglandular,
oculoglandular,
glandular,
or
typhoidal.
Case
1
would be classified
as ulceroglandular though actually it appeared
to
be "glandulo-ulceral."
Case
2 represents
the rarest
clinical variety
which is the glandular.
Case
1 is a right-handed individual
and held
the rabbit in his left hand while skinning with his right, while case
2
is left-handed and so held the rabbit with his right hand.
This may
account for the presence of the adenitis in the left axilla of the former,
and in the right axilla of the latter.
The civilian who accompanied
the sailors on the hunting trip must
have
handled
the rabbits, too, since he was affected with the ulcero
glandular
type of the
disease.
He
was
treated
by
a physician in
Bakersfield who incised
the axillary
abscess while under the impres
sion it was one of nonspecific
suppuration.
It was not until the cases
reported above wrote the true diagnosis
to their civilian friend that
he received
specific therapy which consisted
of injections of Foshay's
antiserum.
These injections were reported to have
been ineffective
108
BKHNKE —NEUTROPENIA
as they were probably given
too late.
Foshay (4) states that for the-
serum to be efficacious it must be used before the twelfth day of tho
disease.
The
above
cases illustrate
very clearly that
the
organisms
can
penetrate
the unbroken skin, the incubation period
of about 4 days,
and
the delay in formation of specific
antibodies (agglutinins) until
after the tenth day of the
disease.
In these
cases
positive
agglu
tinations were not obtained until after the third week of the disease.
The
diagnosis
was readily made in
these two
cases, because
the
medical
officer
who
first saw
the patients had the
disease in mind
and
questioned
them
about contact with
rabbits.
A
suspicion
of
this disease should
always
be aroused by the presence of unexplained
axillary or femoral
adenitis.
Bakersfield, Calif.,
is in Kern county,
350
miles
from San Diego,
and only 25 miles from Tulare County where Chapin and McCoy first
isolated
Pasteurella tularense in 1912 and so named it for the county
in which it was discovered.
CONCLUSION
1. Two cases of tularemia occurring in active
Naval
personnel
are
reported.
These apparently are the first to appear
among the active
list of the Navy.
Bibliography
1.
Francis, E.
The Occurrence of Tularemia
in Nature
as a Disease of Man.
Pub. Health Rep.
36:
1731,
1921.
2. Simpson,
Walter
M.
Tularemia
(Francis
Disease).
U.
S.
Nav.
Med.
Bull. 26; 825,
1928.
3.
Bunkley,
W. 0. and Smith, E. E.
Tularemia.
U.
S. Nav.
Med. Bull. 26:
901,
1928.
4. Foshay,
Lee.
An Antiserum
for the Treatment
of Tularemia.
J. A. M. A.
101:1447,
1933.
NEUTROPENIA
FOLLOWING THE ADMINISTRATION
OF NEOARSPHENAMINE
By Albert R. Behnke,
Lieutenant,
Medical Corps, United States Navy.
This clinical report describes
an uncomplicated neutropenia indica
tive either of an early involvement of the leucopoietic
function of the
bone marrow or of
a destruction of granulocytes in the peripheral
circulation
following neosalvarsan
administration.
While
the
blood
platelets,
and
on
one occasion
the lymphocytes, were
decreased
in
number,
the primary involvement
was
characterized
by
a decrease
in granulocytes.
The interesting features of this report are the specific neutropenia
with
little
involvement of the
red blood cells,
the
freedom
of the
BEHJfKE
NEUTBOPENIA
109
patient from upper respiratory tract infection,
the absence of other
serious manifestations of neoarsphenamine
toxicity, including purpura,
jaundice, and skin ractions,
and the rapid, spontaneous
recovery.
From
a partial survey of medical
literature it is evident that the
arsphenamines
may depress
the function
of any or all of the
cells
formed by the bone marrow.
This comparatively rare reaction
com
plicating
the administration of the arsphenamines
is probably caused
by the action of the double
benzol ring present in these compounds
since inorganic arsenic does not depress bone marrow function.
Kob-
erts (1) quotes Farley
(2) who considers it likely that, in certain
per
sons, there is a disintegration, in vivo, of the arsphenamine
molecule
setting free the benzol radicle so that a benzol-like action takes place.
The action of neoarsphenamine
on the peripheral cells and blood
platelets rather than on the bone marrow should also be considered
in view of the rapid and spontaneous
recovery
(3).
The excellent
papers and case reports on blood dyscrasias
following
the use of arsphenamine
compounds
appearing
in previous issues of
the Naval Medical Bulletin
render further discussion
unnecessary.
CASE HISTORY
D. W., electrician's
mate, first class,
age 37, was first admitted to the submarine
base dispensary,
Pearl Harbor,
on December
11, 1935, with multiple
ulcers on the
prepuce;
dark field examination
was positive for treponema, the blood Kahn was
negative.
Nine
hours after
the first
injection
of neosalvarsan
(0.3
gram)
and
thiobismol
(0.2
gram)
the patient
developed
fever
and
malaise.
White blood
cells 6,050 with neutrophils
56 percent;
lymphocytes
42 percent; and eosinophils
2 percent.
Recovery
was rapid and uneventful.
The following
antiluetic
treat
ment was then administered over a period of a year:
25 injections
of neoarsphena
mine
(14.1 grams) and 29 injections
of bismuth
salicylate
(4.4 grams).
On December 26,
1936, the patient complained
of intermittent
nausea and pain
in the upper
abdomen
of about
3 weeks' duration.
All treatment
was discon
tinued until February
20,
1937, when the patient
felt well and appeared to be in
good condition.
From February
20,
1937, to March 13,
1937, four injections
of
iodobismitol,
total 8 cubic
centimeters,
were given.
Following these injections
the patient
complained
of soreness
over the hypothenar
and metacarpal
areas of
the
left
hand.
Iodobismitol
was discontinued
and
neoarsphenamine
was ad
ministered
in the following
manner: February
20, 0.3 gram; March 27, 0.6 gram
(patient
was nauseated following
this injection); April
3,
0.15
gram;
April
10,
0.3 gram.
Present illness.—On April
13, 1937, the patient
complained
of chilliness,
head
ache, abdominal
soreness,
and malaise.
He stated that the chills
began on the
previous
day
or about
48 hours
after
the last
injection
of neosalvarsan.
The
physical
examination
was negative except for a fever of 100.4° F.
The symptoms
rapidly subsided with
bed rest and a high caloric
diet.
On April
17 the patient
was up and about, and in good condition
except for a slight evening rise in tem
perature.
Urine analyses were repeatedly
negative, icterus index was 6, and the
110
BEHNKE —NEUTROPENIA
blood sedimentation
time was within normal
limits.
The blood picture
was
as-
follows:
nb.
Red blood
cells
Plate
lets
White
blood
cells
Seg.
Band
Mono.
Lymph;.
April 14
85
4,240,000
3,500
3,650
2,200
3,950
4,650
4, 750
5,300
5,400
980
1,022
1,012
1,619
2,511
2,375
3,233
2,430
140
146
132
158
186
142
212
324
280
401
44
2,100
2,080
990
2,054
1,767
1,995
1,590
2,376
April 15
84,800
April 16
April 17
79
186
190
106
216
April 19
90
95
4,640,000
4, 980,000
4,900,000
5,030,000
279,000
179,000
215,000
285,040
April 22
April 23
May 14
95
On April
24,
1937, the cerebrospinal
fluid
was negative for syphilitic involve
ment, and 2 days later the patient
was discharged to duty in good condition
with
the recommendation
that arsenical therapy
be permanently
discontinued.
Bibliography
(1)
Roberts,
L.
J.
Aplastic
Anemia
Following
Arsphenamine
Therapy.
U. 8. Nav.
Med. Bull. 29:
441,
1931.
(2)
Farley,
D. L.
Depressed
Bone
Marrow Function
from
Arsphenamines,
Including Type of So-called
Agranulocytosis.
Am. J. Med.
Soc.
179: 214,
1930.
(3)
McCarthy, F. P., and Wilson,
R., Jr.
The Blood Dyscrasias Following the
Arsphenamines.
J. A. M. A. 99:
1557,
1932.
(4)
Mink, O. J., and Campbell,
H. D.
Toxic Effects of Arsenical
Compounds
Employed
in the Treatment
of Syphilis
in the United
States Navy, 1931.
U. S.
Nav.
Med. Bull. 31:
177,
1933; Toxic Effects of Arsenical
Compounds
Employed
in the Treatment
of Disease in the U. S. Navy, 1932.
U. S. Nav.
Med. Bull. 31:
383,
1933.
(5)
Cook,
S. S., and Campbell,
H. D.
Toxic Effects of Arsenical
Compounds
Employed
in the Treatment
of Disease in the U.
S. Navy,
1934.
U. S. Nav.
Med. Bull. 34:
97, 1936.
NAVAL RESERVE
PROMOTIONS, THIRD
QUARTER,
1937
James
Dominic
Viecelli,
450
Sutter
Street,
San
Francisco,
Calif.,
promoted
to lieutenant
commander, MC-V (G), U. S. N. R., September
27,
1937.
Edward Lee Alexander,
Medical
Arts Building, Newport
News, Va., promoted
to lieutenant,
MC-F, U. S. N. B., September
7, 1937.
Herman
Maurice
Garnett,
3019 Thirty-fifth
Street, Long Island Citv, N. Y.,
promoted
to lieutenant,
MC-F, U. 8. N. R., September
14, 1937.
Albert
Hanly
Held,
415
Jackson
Street,
Huntingburg,
Ind.,
promoted
ta
lieutenant,
MC-V
(G), U. S. N. R., September
27,
1937.
John Claude
Hull,
4011
South
Presa
Street,
San Antonio.
Tex.,
promoted
to
lieutenant,
MC-V
(G), U. S. N. R., September
30,
1937.
William Chunn
ParsoDS, 420 Woodward
Building,
Birmingham,
Ala., promoted
to lieutenant,
MC-F,
U. S. N. R., September
24,
1937.
Keitt Hane
Smith,
206
East
North
Street,
Greenville,
S. C.,
promoted
ta
lieutenant,
MC-F, U. S. N. R., July 30,
1937.
RESIGNATIONS, THIRD QUARTER,
1937
Lawrence
P. Engel,
1228 Professional
Building, Kansas
City, Mo., lieutenant,
MC-V
(S), U. S. N. R., resignation
accepted August
19, 1937.
Hal Elson Freeman,
the
University
Hospitals
(Lakeside),
Cleveland,
Ohio,
lieutenant, junior grade, MC-V (G), U. S. N. R., resignation
accepted August
19,
1937.
Walter E. Hennerich,
4030 Chouteau
Avenue,
St. Louis,
Mo., lieutenant
com
mander, MC-F, U. S. N. R., resignation
accepted August
2, 1937.
Willard H. Kinney, 315 South Seventeenth Street, Philadelphia,
Pa., lieutenant
commander,
MC-V
(S), U. S. N. R., resignation
accepted August
26,
1937.
Charles F. McCaffrey, 44 Summer Street, Somerville,
Mass., lieutenant,
junior
grade, MC-V (G), U. S. N. R., resignation
accepted August
29, 1937, in order that
he might
accept appointment
as lieutenant,
junior grade, Medical
Corps, United
States Navy, effective August
30,
1937.
John
S. McKee, c/o Western
State Hospital, Morgantown,
N. C., lieutenant,
junior grade, MC-V
(G),
U. S. N. R., resignation
accepted
September
15, 1937.
Thomas
T.
Sheppard,
530-532
Medical
Arts Building,
3700
Fifth
Avenue,
Pittsburgh,
Pa.,
lieutenant
commander,
MC-V
(S),
U.
S.
N.
R.,
resignation
accepted September
22, 1937.
Wallace B. Smith,
490 Post Street, San Francisco, Calif., lieutenant
commander,
MC-V
(S), U. S. N. R., resignation
accepted August
2, 1937.
HONORABLE
DISCHARGES,
THIRD
QUARTER,
1937
Lloyd
W.
Bishop,
698
Congress
Street,
Portland,
Maine,
lieutenant,
junior
grade, MC-V (G), U. S. N. R., honorably
discharged August
19, 1937.
Ill
112
THE NINTH
ANNUAL
MEDICO-MILITARY
SYMPOSIUM
Henry A.
Cromwell,
30 East Seventy-sixth
Street,
New
York
City,
N. Y..
lieutenant, junior grade, MC-V (G), U. S. N. R., honorably discharged August 26,
1937.
DEATHS,
THIRD
QUARTER,
1937
Guy D. Conover,
225 Santa Monica
Boulevard,
Santa Monica, Calif., lieutenant,
MC-V
(S), U. S. N. R., died May 1, 1937.
THE NINTH
ANNUAL
MEDICO-MILITARY
SYMPOSIUM
By Lincoln Huuphbkys,
Lieutenant
Commander,
Medical Corps,
United
States Navy
The 1937 course of military, naval, and scientific training conducted
at the Mayo
Foundation,
Rochester,
Minn., for medical
and dental
officers
of the Army
and Navy
Reserve,
occupied
the period
from
October
3 to
17,
1937.
This,
the ninth annual
training course,
the
fifth in which the Navy has participated, was attended
by medical
and dental
officers of the Naval Reserve from widely distant portions
of the United
States,
including representatives
from California,
the
District
of Columbia, Illinois,
Indiana,
Iowa,
Massachusetts,
Mich
igan,
Minnesota,
Missouri,
Montana,
Nebraska,
New York, Ohio,
Oklahoma,
Oregon,
Pennsylvania,
Texas,
Virginia,
and
Wisconsin.
The Navy
and Navy Reserve
attendance
was 42 but this figure does
not include
the
15 members
of the Naval
Reserve
specialists
units
normally
attached
to
the
Mayo
Foundation
on
the
staff
of that
institution, who attended
and contributed to the success of the meet
ing by scientific
papers
and clinical demonstrations.
Distinguished guest speakers included
the Surgeon
General
of the
Navy; Maj. Gen. Charles R. Reynolds, Medical Corps, United States
Army;
Surgeon
General
of the Army; Maj.
Gen.
Stanley H. Ford,
United States Army ; the Commanding General
of the Seventh
Corps
Area, with headquarters
at Omaha,
Nebr. ; and Dr. S. L. Christian,
Assistant Surgeon General of the United States Public Health Service.
Instructors
for the Army
were Col. Kent Nelson, Medical
Corps,
United
States
Army,
surgeon
Seventh
Corps Area,
and
Lt.
Col.
John R. Hall, Medical Corps, United States Army, Medical Inspec
tor,
Seventh
Corps
Area.
Instructors
for
the Navy
were
Capt.
Ausey H.
Robnett,
Medical
Corps,
United
States
Navy,
district
medical
officer, ninth
naval
district,
and
the
author who
also col
laborated
on
program
preparation
with
the
Seventh
Corps
Area
surgeon
and medical
inspector,
and represented
the Bureau of Medi
cine and Surgery in allocation of Navy medical
participation.
The
Navy Department
was most
generous
this year in ordering medical
officers of high rank to represent
the Navy Medical Department.
As during previous years,
Lt.
Fred L.
Smith, Medical
Reserve
Corps, United States Army, a member of the Mayo Foundation staff,
served
as plans
and
training officer.
Through
the collaboration
of
THE
NINTH
ANNUAL
MEDICO-MILITARY
SYMPOSIUM
113-
this efficient
officer with the Army
and Navy representatives
a well
balanced program was prepared
and published prior to the beginning
of the course.
This course like those previously reported,
was con
ducted
as a joint training course for the medical and dental officers
of the Army
and Navy Reserve,
with
the surgeon
of
the
Seventh
Corps Area
as the administrative
head,
and with whom the author
worked as the Navy representative.
A new plan was effected this year in arranging the morning session.
A reservist could
witness
a surgical operation, then proceed to Plum-
mer Hall and receive instruction
in the allied specialties
by leading
members
of the Mayo clinic staff.
Naval
reservists
who lectured at
these morning sessions were: Lt. Comdr. W. McK. Craig, Lt. Comdr.
C. H. Watkins,
and Lt. Comdr. H. M. Weber, all members
of the
staff of the Mayo Foundation,
and Lt. Comdrs. E. H. Bruening and
Milton J. Waas.
The Navy received
a generous allocation of instruction
periods
on
the program.
A well balanced
schedule of instruction
was presented
and included
a number of outstanding Navy speakers.
The papers
presented
by these
naval
participants
on
the
program
were
well
received.
The civilian
physicians
in
attendance
were enthusiastic
over
the
medico-military
discussions
and
many
questions
resulted
from the lectures
on naval subjects.
There were also inquiries made
about steps necessary
to join the Navy Reserve,
Medical
Specialists
units.
This, it is believed
emphasizes
the importance of this type of
joint Army
and Navy
training
course,
given in conjunction
with
clinical conferences at well established
medical institutions.
Through
cooperation of the civilian
medical institutions
reserve medical and
dental officers are enabled
to attend the medical,
surgical and
other
special clinics and to avail themselves
of the advantages
of scientific
discussions
by
leading
civilian
medical
specialists.
A
summary
of medical officers of the Navy
and
Navy Reserve who
presented
papers during the afternoon and evening
sessions is as follows:
Rear Admiral P. S. Rossiter,
Surgeon General of the Navy, and Chief of the
Bureau
of
Medicine
and
Surgery,
Subject:
Logistics,
Interrelation
Aboard
Ship and Tactics.
Capt. A. H. Robnett,
district medical
officer, ninth naval district.
Subject:
Some Problems
of the Naval Medical Officer.
Capt.
G. W.
Calver,
Physician to Congress.
Subject:
Administration of a
Naval
Hospital.
Captain
Calver
also
showed
moving
pictures
of
Spain
and Shanghai
before and after
bombing
which
made
an indelible
impression
upon all those present.
Capt.
E.
W. Brown, Naval Medical center, Washington,
D. C.
Subject:
Naval Medical Aspects of Chemical
Warfare.
Commander
Joel J. White,
Chief of
the Medical Service, Naval Hospital,
Philadelphia.
Subject:
Present
Status
of
Artificial
Fever Therapy
in
Medico- Military
practice.
114
THE
NINTH
ANNUAL.
MEDICO-MILITARY
SYMPOSIUM
Commander
Kemp
C.
Christian,
District
Headquarters,
Great
Lakes,
Illinois.
Subject:
Navigation.
Lt. Comdr. Lincoln Humphreys,
Assistant
Instructor.
Subject:
The United
States Fleet.
Lt.
Cmdr.
W.
McK.
Craig,
Mayo
Foundation
Staff.
Subject:
Relief of
Intractable Pain.
Lt. Cmdr.
Frederick A. Jostes,
President
of the St. Louis Clinical Society.
Subject:
Backache
and its Treatment.
Lt. Cmdr.
U. S. Widman,
New Albany, Ind.
Subject:
European
Cruise
of
the U. S. S. Charleston.
Lt. Cmdr. E. H. Bruening,
Professor
of Dental Anatomy, Creighton
Dental
School,
Omaha,
Nebr.
Subject:
Governmental
Public Health Relations.
Lt.
R.
B.
Phillips,
Fellow
of
the
Mayo
Foundation.
Subject:
Medical
Advertising of the Civil War Period.
Lt. R. B. Phillips,
MC-V
(S)
United
States
Naval Reserve,
a
fellow of the Mayo Foundation,
served in the capacity of adjutant
and
aided greatly in securing
pictoral and editorial publicity
for the
meeting.
He arranged
a luncheon at the Hotel Arthur at which the
Naval
Reservists
honored
the
Surgeon
General of
the Navy,
and
attended not only by the Naval
Reservists from out of the city but
also by the majority
of the members
of the two specialists
units of
the Mayo Foundation.
This was quite an accomplishment consider
ing that the latter are busy specialists
and their spare time is greatly
limited.
At this
time
the
Reservists
were
given
the
opportunity
to meet Rear Admiral
Rossiter,
and
to hear from him his personal
and official interest in these training courses.
The Admiral
expressed
hearty approval of the course
as presented
at Rochester, and it was
with regret that he was unable to remain,
due to the fact that he had
to proceed
to Los Angeles,
Calif.,
to deliver the presidential address
before the Association of Military Surgeons.
His tribute of gratitude
to the Mayo Foundation
for extending
the clinic facilities
so gener
ously was the general sentiment of those in attendance.
NOTES AND COMMENTS
WILLIAM
KNICKERBOCKER
VAN RE7FEN
By Louis H. Boddis, Commander,
Medical Corps,
United States Navy
The twelfth Surgeon
General, U. S. Navy, and the sixteenth
Chief
of the Bureau of Medicine
and Surgery, was born in New Jersey in
1840, and was appointed from that State as an assistant
surgeon
on
Christmas
Day,
December 25,
1861.
After
a short period of duty
at the naval hospital, New York, he served
on the steam frigate St.
Lawrence in the East Gulf Blockading Squadron and so saw active war
service at sea in the blockade of the southern ports.
He was pro
moted passed
assistant
surgeon in May
1865,
and
surgeon
in May
1868.
His
service
included
duty
at
the
naval
hospital,
Chelsea,
Mass.,
Norfolk,
Va., Annapolis, Md., and New York.
His sea duty
included both the European Squadron and the Asiatic Station.
He was
promoted to medical inspector in August
1887,
and medical director
just 6 years later, in August
1893.
He was appointed Surgeon
Gen
eral by President McKinley
on October 23, 1897,
to succeed Surgeon
General Newton L. Bates, who died in office after serving but 18 days.
Van Reypen
served
until January
25,
1902,
and
was thus Surgeon
General during the Spanish-American War and under two Presidents,
McKinley
and Theodore Roosevelt.
He was an excellent
economist.
His regime
was marked by many important
measures
affecting
the
Medical Department.
A hospital ship, a separate Hospital Corps, and
increased rank for medical
officers had been strongly urged by Surgeon
General Tryon,
and Congress
now passed legislation providing for all
three of these measures.
The steamer Creole of the Cromwell line was
purchased and named
the U. S. S. Solace.
This vessel was selected,
purchased, and fitted out for service
as a hospital at the beginning of
the Spanish-American War in just
16 days.
It was the first of our
naval vessels to fly the Red Cross flag.
It was of the greatest
service
to the fleet in Cuban waters,
and remained
in active commission
until
1920.
In
1899
the Surgeon
General was given
the rank of rear admiral,
though the pay and allowances
were still those of a commodore.
The
following
naval hospitals were
commissioned
during Van
Reypen's
term of office:
Naval
hospital, Newport,
1897; Sitka, Alaska,
1898;
Port Royal,
S. C, 1898; Cavite, P. L, 1898.
115
116
NOTES
AND
COMMENTS
After retirement, Admiral Van Keypen lived in Washington, where
he died in 1920.
THE FLEET HOSPITAL
SHIP
The
characteristics of
a hospital
ship
should
be
based
upon
its-
objective.
No one type of craft would be equally suitable to function
as a fleet hospital ship, hospital transport, hospital ship for advanced
base, or rescue ship.
Furthermore
the problem arises of meeting the
peak load of wartime demand
without
creating a top-heavy peace
time organization.
Of
these various
types
of hospital
ships,
Johnson
1 discusses
in
detail
the fleet hospital
ship.
This author has written
extensively
on subjects of interest to the naval medical
officer
and this article
summarizes
his recent
and mature experience
on a fleet hospital ship.
In -his opinion this type of vessel should
be about 10,000
tons in size,
have
a speed somewhat
in
excess
of the train,
be designed
for fleet
hospital-ship duty, that
is,
accommodate
patients satisfactorily while
conforming to fleet operating conditions such as darken ship.
This vessel should operate with the fleet in peace and in war, provid
ing hospital and specialty service.
The author comments
at length
on the extent to which this vessel should
conform with Hague Con
vention provisions to gain immunity
to hostile attack.
Based
both
on its intimate function with the fleet and the World War experience,
particularly
of the British,
he definitely recommends
that this type
vessel waive its immunity
and accept
the hazards common
to
the
fleet.
Other type hospital ships should continue to conform to Hague
Convention provisions.
BLUNDERS
OF PLAIN MUSCLE
"The frustrated
subconscious
uses
the
autonomic system
as ita
secret
avenger,
and
spasm
is
commonly
its
sword."
Thus
does
Eve
2
call attention to the vegetative
nervous
system which induces
a smooth muscle hypertonus, particularly
during anxiety state in the
sensitive
intellectual,
ambitious,
and idealistic
temperament.
The
maiden's blush
and
the
diarrhoea
of
the
nervous
examinee
may
result from different stimuli but they are actuated
by the same mech
anism.
This muscle
spasm may be more accurately described
as an
inability
to relax with sympathetic tonus dominating the antagonistic
vagus.
A wide variety of intestinal, vascular, and genito-urinary svmptoms
result.
No age
is
immune.
The newborn infant may have pyloro-
spasm.
In . males
it
is
always associated
with
phimosis.
It may
accompany
the anxiety of
a
nervous
mother.
In adults the mani-
i
Johnson,
L. W., Captain (M. C), U. 8. Navy.
The Fleet
Hospital
Ship, XT. S. Naval Institute Pro.
eeedings, S3: 1225-1235,1937.
>
Eve, Frank C.
Blunders
of Plain Muscle Due to Allergy or Anxiety States, Linnet
Z13:M0. 1837.
NOTES
AND
COMMENTS
117
festations
are many and usually multiple.
If there
is hunger
pain
due to pylorospasm,
look for palpable,
cordlike tender colon, urinary
frequency,
cold
extremities,
and
spastic
dysmenorrhea.
The
cause
is probably exhaustion,
chill, worrry, or alcohol.
If coronary spasm
is suspected,
look for intermittent
claudication
and
"dead
fingers."
Raynaud's
disease
and
probably migraine result from angiospasm.
If migraine
occurs
in early life look for intestinal or cardiovascular
spasticity
in later life.
Asthma is one of the conspicuous
blunders.
Allergy must
be considered
as
a
possible
factor in
causation
of
smooth
muscle
spasticity.
Allergy may be considered
as a stormy
immune reaction in
a subject of sensitive
temperament
to various
chemical
stimuli
so
great
that
marked
clinical
symptoms
result.
It is associated
with histamine production and is relieved
by adren
aline, in contrast with anxiety states which are associated
with pro
duction of choline
and relieved
by atropine or ergotamine.
The author postulates
the suggestion
that individuals
of sensitive
temperament respond most successfully
to the demands of civilization
and that the price of this sensitivity is neurosis
and allergy.
TREATMENT
OF SURGICAL SHOCK
WITH NEOSYNEPHRIN
Loss of vascular tone with consequent
vasodilatation is one of the
more or less conspicuous
etiological
factors
causing
the hypotension
of
surgical
shock.
Its
prominence
may
be roughly
estimated
as
proportional
to
the
nervous
trauma
experienced.
Rational
treat
ment of surgical shock would, therefore,
indicate the use of vasocon
strictor
drugs
for the vasogenic
phase of hypotension.
Adrenaline,
epinephrine,
and
ephedrine
are
effective
and
have
been
employed
to
increase
vascular
tone.
Unfortunately
each
has
objectionable
effects.
In the search for
a more
effective
drug Johnson
3 has
used neo-
synephrin hydrochloride
for shock
due
to trauma
and
hemorrhage.
This drug is very closely
related
to epinephrine
hydrochloride.
It is
preferable to the other vasoconstrictors in that (1) its action is more
prolonged,
lasting
1
to
2 hours,
(2) it has no ill effect
on
cardiac
rhythm, (3) in shock cases the heart rate is not affected —in the normal
individual it is slowed,
(4) it does not cause nervousness or palpitation,
and (5) it has a much greater margin of safety.
It is employed
in a
dosage of
1 cubic centimeter
of a 10-percent solution subcutaneously,
from
1 to
23 doses being
administered
to patients in
the
author's
series.
It was employed in surgical,
traumatic, and spinal anesthesia
cases.
In the latter group it was used both to restore normal blood
pressure
and
as
a
preliminary
prophylactic
measure
to
prevent
the
usual
>Carl A. Johnson.
Surgery,
Gynecology
and Obstetrics,
66: 463-463, 1937.
118
NOTES
AND
COMMENTS
resultant hypotension.** It is interesting to note
that the drug was-
useless in combating the hypotension resulting from
foreign
protein
anaphylactic shock.
There is general
agreement
that shock
is due
to loss of effective
blood volume.
Opposed
theories
attribute this loss to stagnation in
the vascular
system
and
to actual
loss from
the vascular system.
Action
of this drug would tend
to support the stagnation theory in
Johnson's opinion.
THE COMMON
COLD
The common
cold continues
as a major cause of physical disability.
At best it is an embarrassing
condition and not infrequently it is the
forerunner of complications that endanger life.
Evidence is becoming
more conclusive
that this infection is due to a filterable virus and that
this virus activates pathogens
present in the upper respiratory tract.
It has been the subject of extensive
investigation
and
the resultant
findings are still far from consistent
and
conclusive.
There is like
wise no unanimity of opinion as to proper treatment.
Medication is
largely empirical, if taken at all, and much
of this is self-supervised.
A
well-balanced
diet
with
liberal
vitamin
content
and
hygienic
mode of living may be safely recommended.
Beyond this, treatment
may
be
regarded
as conjectural
and controversial.
Unfortunately,
whether treated or untreated,
the victim is usually ambulant and his
activity constitutes a menace to his health and a public-health hazard
to his associates.
This condition is usually ushered in by a feeling of chilliness,
sneez
ing,
and
a dryness
in the nasopharynx.
In the normal individual
exposed
to cold
there is
a temporary blanching of the nasal mucosa
which is transient.
In the susceptible
individual,
made susceptible
presumably by presence of a filtrable virus to which for various reasons
the individual
has a low grade of immunity,
this blanching persists
for an extended period.
As a result there is a loss of mucous secretion
with a sense of dryness
and a loss of ciliary action with a correspond
ing stagnation in the normal flow of nasopharyngeal
secretion.
It is
a fair presumption that this stagnation of nasopharyngeal
and sinus
drainage
is at least
a factor in promoting the propagation of naso
pharyngeal
pathogens.
The
normal
sequence
of
events
is for
the
ischemic
state
to progress
to an hyperemia with
more or less nasal
and
sinus
obstruction.
Rational
treatment would
suggest
combating
the
ischemia
and
ciliary
paralysis in
the
early stage,
and
combating
the hyperemia
with
its
associated
obstruction
and
hypersecretion later.
Rest in
bed
and
heat
to the lower extremities
are particularly
effective
for
the initial eschemia, and should be continued until the patient responds
normally
to chilling effect.
NOTES
AND
COMMENTS
119
There seems to be little rhyme or reason for the local medication
applied in either stage.
It varies from heroic measures
to no treat
ment
due
to
the
patient's
indifference
or
fatalistic
resignation.
Various investigators have reported on the action of normal cilla, and
on ciliary response to various drugs.
Water and water solutions such
as the silver proteinates inhibit ciliary activity.
Oil and the various
oily preparations prevent ciliary action mechanically.
Silver nitrate
destroys the cilla.
Atropine,
adrenalin, and cocaine paralyze ciliary
action.
The
aromatic
oils,
particularly
thymol
are
depressing.
Methiolate
and
mercurochrome
are
also
depressant.
Codeine,
morphine, and the barbiturates cause little if any depression of ciliary
action.
Normal
saline
has
a favorable effect on ciliary
action, and
used
alone
can
be recommended
and may be combined
with
about
1 percent ephedrine
for local use.
The saline solution is best applied
with a medicine
dropper in head-low posture.
Vaccines of various
types
and
administered
by various
routes —
subcutaneous,
oral, and
nasal —have
had
advocates
for years,
par
ticularly among
grateful
patients.
The
use of
vaccines
has
some
scientific justification
on the basis that they
have
a favorable effect
on control of the pathogens
activated by the virus.
This action helps
explain
the results noted
in their
use.
The
estimate
equation of
prophylactic
value of vaccines
includes
variables from allergy to zeal.
Obviously in such
a poorly controlled group much dependence
must
be
placed
on
the patient's subjective reaction
and
reports
whether
favorable or unfavorable should be evaluated
accordingly.
Bristol,4 health director for the American Telephone & Telegraph
Co., of New York, reports
interesting studies
on an industrial group
to whom vaccine
was made available.
He states that an industrial
group can be roughly classed as follows:
(1) The cold-proof who seem
to never have
colds,
(2) the person of average susceptibility having
one or two minor colds a year, and (3) the cold-prone who have several
colds a year often with complications and disability.
This third class constitutes about 25 percent
of the entire group.
It serves
as a year-round reservoir for the common
cold and presents
a public-health
problem both from the standpoint of absenteeism
of
the individual
and
as a source of infection for associates.
The treat
ment results reported
by Bristol
were not limited
to this class of
patient.
However, it is a fair presumption that vaccinated individuals
from this group
were materially in excess of 25 percent.
Bristol summarizes
the results obtained in six different companies.
The material
used
consisted
of commercial
standard stock
vaccine
or
sero-bacterins
administered
by
local
practicing
physicians
to
employees
requesting
treatment.
Each company reported treatment
* Bristol, Leverett D.
Vaccines
Against the
Common
Cold,
American
Jour, of Public
Health, and
the Nation's Health, 27: 987-990, 1937.
120
NOTES
AND
COMMENTS
of more than
1,000
employees
over a period
of several
years.
One
company reported treatment of about 13,000 over a period of 17 years.
All reports were
favorable,
none
were
enthusiastic.
There
was
little evidence that vaccination had reduced
the incidence
of common
colds.
There was
an apparent
reduction in the severity, duration,
and complications of acute respiratory diseases in the treated.
Recently an oral vaccine has been introduced in a naval dispensary
service.
As noted
above,
there is difficulty in obtaining an accurate
estimate
of prophylactic value from the patients' statements.
How
ever,
the popularity
of this oral
vaccine
in this dispensary
would
indicate that it has sufficient
merit to continue its use on trial.
CANCER
The physician and layman
are both
becoming
more
cancer
con
scious.
This tendency
has already
improved the prognostic outlook
for the patient.
Recent developments
have been particularly
encour
aging.
The United States Public Health Service
has obtained funds
and
site for a Cancer Institute
at Washington, which will soon
be
functioning.
This will permit a long awaited
concerted attack on the
vexing
problem of malignancy.
Past
progress
has largely been
the product
of individual
effort.
Much has been accomplished
with
a surprisingly meager outlay.
A
patiently
scientific,
coordinated attack, comparable
to that used
so
effectively in industrial research may now be anticipated.
However,
investigation has already proven the problem to be so intricate that
a conservative
attitude should be assumed
on prospect
of solution
of the etiology and treatment of malignancy at an early date.
Cancer is not a major problem in the active service from the stand
point of sick days or retirements
and
surveys
involved.
However,
it is of sufficient
importance that cancer clinics have been established
on each coast.
The October issue of Annals of Surgery presents
an excellent
sym
posium on cancer.
Various authorities comment
on the latest develop
ments in the etiology and treatment of malignancy.
It can be highly
recommended
to those interested
in cancer.
SKIN IRRITATION AND CANCER IN THE UNITED STATES NAVY
6
This is a statistical review
of morbidity
and mortality statistics of
the United States Navy covering
the 8-year period from 1929 to 1936.
It involves 875,000 person
years of active
service
and
469
cases of
cancer.
It is known that in rural districts epitheliomata of the skin and lip
are more frequent than in the cities.
Animal experiments
have dem-
» Siglsmund
Pellet and
Charles
S.
Stephenson.
American
Journal
of The Medical
Sciences,
1W:
3 26-333. 1037.
NOTES
AND
COMMENTS
121
onstrated
that ultraviolet rays play a part in the genesis of skin cancer.
Therefore,
the
present
study
was
undertaken
to
ascertain,
first,
whether a group of adults between
16 and
45 or 50 years of age, ex
posed intensively to open air, to sun
rays,
and to salt water suffer
from skin and Up cancer more than the average;
second,
whether
or
not this group shows the same probability of dying from cancer of the
inner organs
as does the general
population;
third, whether or not
young men cured of a skin or lip cancer are later as much disposed
to
cancer of the internal organs
and of the surface
as men of the same
age group.
In this review it was found that the incidence
of cancer of the skin
and lips was eight times and the mortality was three times the normal
expectancy
of the average population of like age group, with melanoma
predominating.
In answer
to the second question it was found that
morbidity and mortality from all other cancers was greatly diminished
in this group.
In answer to the third question,
the investigators found
three
cases
of fatal cancer of internal organs in cases
cured of skin
epithelioma.
One had squamous
cell carcinoma
of the nasal septum
and
the
second
died
of carcinoma of the
aesophagus.
Their
third
case
was
a carcinoma
of lung which they
regard
as probably
being
synchronous with
the skin
lesion
rather than
metachronous.
The
three
cases were over 50 years
old.
Also they noted
that of all the
cases of cancer of the internal organs in patients from 30 to 50 years
of age none gave a previous history of cured skin or lip cancer.
These statistics would imply that these skin lesions confer a certain
protection
against
the more
malignant cancer of internal
organs in
later years.
The authors propose that this phase of the investigation
needs study on a larger scale.
SYPHILIS
PROPHYLAXIS
Syphilis
has become
a popular issue and it behoves
the profession
to keep
well-grounded on scientific fact in educating the public
on
this dread disease.
The initial lesion is of prime importance if subsequent
sequellae and
prolonged
treatment would
be avoided.
Much of the knowledge
of
the initial lesion has been based on the experimental
work of Metch-
nikoff and Kolle.
On the basis of this work the former developed
a
very
effective
calomel
ointment prophylaxis.
Kolle,
later,
demon
strated
the rather spectacular
rapidity with which the syphilis spiro-
chaeta
penetrates
the
tissues
of the
experimental
animal where
an
abrasion
is present.
He applied
the virus to a scarified
area and re
covered
the organisms
5 minutes later from the lymphatic
glands
8
centimeters
away.
24140—37
9
122
NOTES
AND
COMMENTS
On
the
basis
of several
years
experimental
work
Surgeon J. A.
Mahoney, United
States Public Health
Service,
reports on tissue in
vasion by
the
spirochaeta.
They
deposited
the syphilis organism
upon
the intact genatile
mucosa of the male rabbit.
One hour later
the organisms
were found upon
the surface of the mucous
membrane
and occupying a more or less protected
position in the crypts and folds
of the integument.
After 2 hours,
there was evidence of penetration
of the deeper tissues.
At the end of 3 hours the organisms
had pene
trated to
a depth
which would have
rendered
them immune to the
direct influence
of any agent applied
to the surface.
In contrast with this penetration of uninjured genatile mucous mem
brane this investigator reports that they were never able to demonstrate
penetration of stratified squamous
epithelium by the spirochaeta.
Data
on prophylaxis are consistant with these findings.
This in
vestigator
demonstrated
that
mechanical
cleansing
with
soap
and
water gave very effective
protection for exposures not exceeding
1%
hours
and beyond
2 hours was completely
ineffective.
After 3 hours
use of disinfecting agents of more drastic type such as tincture of iodine
were relatively ineffective.
Interesting features of calomel
ointment
are reported
by this investigator.
He found that the prophylactic
effect of this chemical
was dependent
upon applying it as an inunction.
When applied
to the genatile
mucosa without rubbing it was not pro
tective.
When thoroughly rubbed in it gave
a high percentage
of
protection, and was even protective when
the virus was not applied
to the treated
area.
The inference of this work is that the efficacy of
calomel
is probably due to its systemic
spirochaeticidal action.
It would seem from this experimental
work that our present system
of prophylaxis, consisting
of soap and water wash followed
by calomel
inunction
has
a sound
scientific
background.
To
be
effective
this
method
demands prompt application, preferably within the first hour
after initial exposure, and thorough inunction of the calomel ointment.
ARTICLES
ON PROFESSIONAL
SUBJECTS
Recently
several
articles
on
professional
subjects
have
been sub
mitted
to
the
Navy
Department
for
permission
for publication.
Article
113
ofNavy
Regulations
and
General Order No.
9 do not
require
this permission.
Authors
are required
by these references
to publish no
secret or
confidential information
or information
that would support a claim
against
the
Government.
These
regulations
carry
two
additional
specific
provisions.
Any
published
article
represents
the
personal
views of the writer and not those of the Navy Department and shall
so state.
Second,
when the article is accepted for publication
a copy
shall be forwarded to the Navy Department for information and file.
To this should
be added
the
advice
to avoid domestic
and
foreign
politics, and comment
that is derogatory to the service.
NOTES
AND
COMMENTS
123
A naval officer
on his own personal
responsibility
is permitted to
present
his article to a publisher for publication.
The Navy Depart
ment
does not exercise censorship
on such material;
it,
on request,
merely advises
as to propriety of publication.
When under the provisions of reference regulations the author has
doubts as to the advisability
of dissemination of information
to the
general public of any matter through the medium of books, magazines,
press, or radio, he may submit his article to the Navy Department.
This must be done prior to submission
to the publisher and
the
ac
companying letter of transmittal
shall
designate
the specific
passages
about which doubt exists and the reasons for said doubt.
The Navy
Department
will then inform the author as to the propriety of pub
lishing the designated
passages.
ARTICLES
OF SPECIAL
MERIT,
1937
It has become
an established
practice for the Surgeon
General
to
present
letters
of
appreciation
to
authors
who
have
contributed
articles of outstanding merit to the Naval Medical Bulletin.
The Surgeon
General takes this opportunity
to express to all con
tributors
his satisfaction with the excellence of their articles and his
appreciation of their support of the Bureau's publication.
For the
calendar
year
1937
the following
authors have
received
letters
of appreciation.
Lt. Albert R. Behnke,
(M. C.), U. S. N.
The Application of Measurements
of
Nitrogen
Elimination
to
the
Problem
of
Decompressing
Divers.
April 1937.
Lt. H. O. Cozby,
(M. C.), U. S. N.
Naval Delinquency.
April
1937.
Lt.
Comdr.
Paul F.
Dickens,
(M. C.), U. S. N., and Lt.
Omar J. Brown,
(M. C.), U. S. N.
Present Day Concepts of Endocrinology.
January 1937.
Lt. Comdr.
W.
W. Hall, (M. C), U. S. N.
Active Immunization Against
Tetanus
with Tetanus
Toxoid.
January
1937.
Commander
F. S. Johnson, (M. C.), U. S. N., and Arthur
G. Vallee, Phar
macist's
Mate,
First
Class,
U.
S. N.
Liquid
Insecticides,
Report
of
Comparative
Study
of.
July
1937.
Commander
R.
P.
Parsons,
(M. C.), U.
S.
N.
An
Estimate
of
Arsenox-
ide (Mapharsen)
in the Treatment
of Early Syphilis.
April
1937.
NEW MEMBERS AMERICAN
COLLEGE
OF PHYSICIANS
The Secretary
of the American College
of Physicians has notified
the
Surgeon
General
that the following naval medical
officers
have
been elected
to membership
in the American College
of Physicians:
To Fellowship
Comdr.
John Harper (MC),
U. S. N.
Comdr.
Frederick
L. McDaniel (MC), U. S. N.
TO
ASSOCIATBSHIP
Comdr.
Earl Richison
(MC), U. S. N.
Comdr.
William P. Mull (MC), U. S. N.
Lt. Comdr.
James
G. Dickson
(MC), U. S. N.
Lt. Bartholomew
W. Hogan (MC), U. S. N.
Lt. Julian
Love (MC), U. S. N.
BOOK NOTICES
Publishers
submitting
books
for review are
requested
to
address
them as follows:
The Editor,
United States Naval Medical Bulletin,
Bureau
of Medicine
and Surgery,
Navy Department,
Washington,
D. C.
(For review.)
The Practice
of Medicine,
by Jonathan Campbell Meakins,
M.
D., L. L. D.;
professor
of
medicine,
McGill
University;
physician
in
chief,
Royal
Victoria
Hospital,
Montreal,
etc.
Cloth.
1343
pages.
5050
illustrations,
including
35 colored
plates.
C. V. Mosby Co., St. Louis.
Price
$10.
This book is really a unique volume in many respects.
The author
has set out to write a clear concise treatise
on the practice of medicine
in one volume, which in itself in this day of specialization would at
first appear to represent
a heroic task.
He has succeeded in producing
a work of inestimable value to the internist, general practitioner, and
medical
student, in that without
discussing
the various diseases in
monographic
form, he has covered
the field of medicine
in a nearly
encyclopedic
manner,
and at the same
time,
due
to this extremely
concise and clear English, and especially
due to his faculty of stressing
essentials,
he has compiled
what amounts to a system of medicine
in
one volume.
In a large way this book reflects considered
opinions of
a master of medicine
whose perspective
has been widened
and deepened
by many years of clinical experience
and teaching.
The
numerous
and
well-chosen
illustrations
constitute
a
novel
feature of great value.
An Introduction
to Medical Science, by William Boyd, M. D., M. R. C. P.
(Edinburgh),
F. R. C.
T.
(London),
professor
of pathology
in
the
University
of
Manitoba.
307
pages,
illustrated
with
108
engravings.
Lea
&
Febiger,
Philadelphia.
1937.
Price
$3.50.
This is, as the author well states in his introduction,
an "aeroplane
review of diseases."
It is intended for the premedical
student, nurse,
and the intelligent laymen who desire to gain
a general picture of the
human body, the diseases which afflict
it,
and
the defenses which
it
makes against
them.
The whole
is
well- told in
a
brief way and with
a
number of simple but excellent illustrations.
125
126
BOOK NOTICES
Clinical Alleroy,
Manifestations, Diagnosis,
and Treatment,
by Albert H.
Rowe,
M. S., M. D., lecturer
in medicine in the
University
of California Medical
School, San Francisco, Calif.; chief of the Clinic for Allergic
Diseases of the Ala
meda
County Health
Center,
Oakland,
Calif.; president
of the Association for the
Study of Allergy,
1927-28.
Published
by Lea & Febiger,
Philadelphia.
Price
$8.50.
This book contains
16 chapters
and
an appendix,
with
a total of
706
pages of subject matter.
In addition there is
a most
extensive
and
complete
bibliography
of 80 pages.
Dr. Rowe has covered
the
subject of allergy exceptionally well, especially
the part foods play in
allergic
conditions.
He stresses the fact that a particular
food may
be the causative
factor in an allergic
condition, yet give
a negative
skin test by both the scratch and intradermal methods.
The chapter
dealing with "Rowe's Elimination
Diet" and other diatetic manage
ment of food allergy is very valuable as an aid and guide in treatment.
Operative
Surgery,
by J.
Shelton
Horsley,
M.
D.,
LL.
D.,
F.
A.
C. S.,
attending surgeov,
St. Elizabeth's
Hospital,
Richmond,
Va. and Issac A. Bigger,
M.
D.,
professor
of surgery,
Medical
College
of Virginia.
1,350
pages
with
numerous
cuts, illustrations,
photographs,
charts, and drawings.
2 vols. (4th
edition).
Publishers,
C. V. Mosby
& Co., St. Louis.
Cloth.
$15.
This is the fourth edition of a work on operative surgery
which,
since 1921, has been recognized
as belonging in the front rank of works
of this kind.
Dr. Horsley has secured the services
of five contribut
ing authors,
all well known in surgical writing, for this newest edition.
The result is a two-volume set which is very beautifully and expertly
done.
The paper,
and especially
the type,
are exceptionally good.
The chapters
on intestinal surgery,
operations
on the chest, plastic
operations on the face, flap transplantation,
grafts,
and brain tumors
are most
interesting.
We should like to have
seen
more
emphasis
laid
upon
the
transurethral
method
of prostatectomy,
as
we
are
acquainted with one large clinic which performed
but two suprapubic
operations
in a series of over 500
cases
in
1 year,
with
a very high
degree of success.
We recommend
these two books, without reserve, to
all
surgeons
desiring
a
neat,
compact,
and
competent
account
of
modern
operative technique.
Preoperative
and
Postoperative
Treatment,
by
Robert
L.
Mason,
A.
B.,
M. D., F. A. C. S., assistant in surgery at
the
Massachusetts (Jeneral Hospital.
495 pages,
123 illustrations.
W. B. Saunders Co., Philadelphia.
1937.
Price
S6.
Dr.
Mason
presents
a valuable
and
very
useful
book
covering
the pitfalls of both the patient and surgeon in and out of the operating
room.
With brilliant
contributions
by his Harvard
and Massachu
setts General Hospital associates, he has developed
a book that covers,
in general,
the
preoperative
and postoperative management
of
the
surgical patient.
Estimation
of the surgical risk, anesthesia,
shock,
blood transfusion, water balance,
diet,
and immediate and secondary
complications
are dealt with
in
a practical
yet thorough
manner.
BOOK
NOTICES
127
The
chapter
devoted
to
burns
is
outstanding
in merit.
Then, in
masterly fashion, part 2 takes up regional
surgical problems,
presents
many excellent
guides for the surgeon.
Handbook of Orthopaedic
Surgery,
by Alfred Rives Shands, Jr., B. A., M. D.,
associate professor
of surgery
in
charge
of orthopaedic surgery, Duke
University
School of Medicine;
in collaboration
with,
Richard
Beverly Raney, B. A., M. D.,
instructor in orthopaedic surgery,
Duke University School of Medicine.
593 pages.
169 illustrations.
The C. B. Mosby Co., St. Louis.
1937.
Price
$5.
The need for a complete handbook of orthopedic surgery
is definite,
not only for undergraduate orthopedic instruction but for the general
practitioner
as
well.
Dr. Shands
in collaboration
with Dr. Raney
gives us a text book,
elementary
in type yet rich in helpful diagnostic
guides and useful
therapeutic suggestions.
The book has been care
fully prepared
and covers the entire
scope of congenital
and acquired
deformities.
Each chapter has been critically reviewed
before publica
tion
by
leading
American
instructors
in orthopedic
surgery.
The
work covers well the
needs of this important field of surgery.
Injuries and Diseases qf the Hip, by Fred H. Albee, M. D., LL. D., F. A. C. S.,
past president,
American
Orthopedic Association.,
assisted by, Robert L. Preston,
M.
D.,
associate
in orthopedic surgery, Columbia
University.
298
pages.
100
illustrations.
Paul B. Hoeber, Inc., New York.
Price
So. 50.
A master
bone surgeon
delves
into
30 years of pioneer
experience
in the difficult field
of hip joint diseases and injuries.
From wisdom
born of operative and
teaching
experience
unexcelled
in the field
of
orthopedic
surgery,
he presents
the first book ever written
devoted
entirely to the treatment of hip conditions.
Twelve brilliant
chapters
detail his conservative
and operative procedures.
The book stresses
the merits of his famous
bone graft and the advantages
obtained
by
the
development
of motor-driven
tools,
the modern fracture ortho
pedic table, and the double plaster spica.
Diseases of Infants
and Children,
by J. P.
Crozer Griffith,
M.
D., Ph. D.,
emeritus
professor of pediatrics,
University
of
Pennsylvania,
and
A.
Graeme
Mitchell,
M.
D.,
B. K. Rachford
professor
of pediatrics,
College
of
Medicine,
University
of Cincinnati.
One octavo of 1154 pages,
with 293 illustrations,
in
cluding
18
in
colors.
Second
edition
thoroughly
revised.
1937.
W.
B.
Saunders
Co., Philadelphia.
Price
$10.
This work, by two eminent
authors,
contains a wealth of informa
tion, well organized,
well written, and well edited.
It covers the whole
field, clearly and concisely,
without undue
verbiage
and is printed in
a style that makes easy reading.
The discussions
of many topics
have been expanded,
including dis
turbances
of the acid-base
balance, diabetes mellitus, and dehydration
in gastroenteritis.
The matter of artificial feeding
has been put on a
simpler basis in
a 65-page
monograph
and particular
attention has
been devoted
to the sections concerning
growth and development
and
anatomy and physiology.
128
BOOK NOTICES
Medical Treatment
of Cataract, by A. Edward
Davis, M. D.
F. A. Davis
Co.. Philadelphia,
Pa.
161 pages.
Price
$3.
This volume is mostly concerned
with senile cataract.
The author
advances
the idea that senile cataract is a pathological process con
sisting of chemical
changes in the protein of the lens fibers
and not
a physiological change incident
to old
age like graying of the hair
or wrinkling
of the skin.
These chemical
changes
are the result of
toxins
acting upon the individual
fibers of the lens.
The toxins are
engendered mainly by faulty metabolism
which may result from some
general
disease, overeating,
malnutrition,
insufficient calcium, phos
phorus,
potassium
or
vitamines,
or
by
endoctrine
disturbance,
especially
the thyroid or parathyroid.
In the treatment
the author
stresses early diagnosis
and
claims
that the progress of this type of cataract can be arrested in about 81
percent of the cases.
Treatment
consists
of subcutaneous
injections of the lens antigen
in increasing
doses over a period of 6 months with local hot com
presses
and
instillations
of dionin.
Diet
is
considered
important,
also plenty of vitamins and water.
The
ideas
advanced,
if proven correct,
should prove
a valuable
adjunct to our treatment of cataract.
The Ocular Fundus in Diagnosis
and Treatment,
by
Donald
T.
Atkinson,
M.
D., F. A.
C. S.
258
pages
with
106 illustrations,
including
58 plates in
natural
colors.
Lea & Febiger,
Philadelphia,
1937, Price
$10.
This is said to be the only book in English
covering
this subject
in which the illustrations
are wholly the work of the author.
There
are
142
pages of printed matter, divided into
8 chapters,
viz:
(1) The
Ophthalmoscope,
(2)
The
Normal
Fundus,
(3)
The
Retinal
Vessels,
(4)
The
Optic
Nerve,
(5)
The
Vitreous
Humor,
(6) The Retina,
(7) The Choroid,
(8) Usual Ophthalmoscopic Mani
festations
in Special
Disease.
The subject matter is each chapter is briefly and concisely
discussed.
There is
a short discussion
of the anatomy, the anomalies,
diseased
conditions, their appearance,
and
a few words
on the latest methods
of
treatment.
The
58
natural-color
illustrations
are
beautifully
done.
Each illustration
is accompanied
by an adequate
description.
The book should prove
a very useful
and practical addition to the
ophthalmologist's library.
Microscopical
Technique.
Edited
by
C.
E.
McClung,
Ph.
D.,
professor of
zoology
and
director,
Zoological
Laboratory,
University of Pennsylvania.
Cloth.
Second edition,
revised
and
enlarged.
698
pp.,
with
82 illustrations.
Paul
P>. Hoeber, Inc., 1937.
Price
$8.
There
are
34 well-known,
highly
specialized
contributors
to this
excellent volume.
BOOK NOTICES
129
The various
procedures
and other data are given
in a clear
and
concise manner.
The bibliography is ample and well selected.
In the opinion of the reviewer
some of the most valuable additions
of the second edition are a complete,
new dioxan technique
for paraffin
sections,
methods
of staining
boutons
terminaux,
the
fused
quarta
rod
method
of illuminating
living
structure, microincineration,
the
centrifuge microscope,
and fluorescent
microscopy.
This
book should
be of particular
interest
and
great
value
to
workers in microscopic
anatomy, bacteriology, cytology, embryology,
histology, and pathology.
Flying Vistas. —The human being as seen through the eyes of the flight surgeon.
By Isaac H. Jones, M. A., M. D., military aeronautics, U. S. A., during the World
Wor; medical examiner. Bureau of Air Commerce,
U. S. Department of Commerce.
250
pages,
9 illustrations.
J.
B.
Lippincott
Co.,
Philadelphia
and
London.
Price $2.
The book presents an interesting review of the problems confronting
aviation at the beginning of the World War, together with the accom
plishments of the War Department in devising and standardizing the
physical
requirements
for flying, under the able direction of General
Lyster.
It explains
in an interesting manner the various aspects
of
the physical examination for flying, and gives to the aviator and lay
man
a practical understanding of the examination and
the reasons
therefor.
The development
of the specialty of aviation medicine
and
the flight surgeon
are described.
The book is nontechnical and is of
particular interest to the flyer.
Dental Pharmacology
and
Therapeutics,
J.
R.
Blayney,
B.
S.,
D.
D.
S.,
M. S.
Second edition.
C. V. Mosby Co., St. Louis,
Mo.
Price
$4.
In the text of this volume, the names and compositions have been
made to conform with
those of the eleventh
edition, United
States
Pharmacopoeia, and the sixth edition, National Formulary.
The text is divided into three parts.
Part
1 is devoted
to a general
consideration of drugs,
principle action, methods
of administration,
average
doses, and prescription writing, in which the author recom
mends
the use of English,
the only exception
being
the use of some
common
Latin abbreviations;
therefore,
he has eliminated
medical
Latin from this volume.
Each main division of part
1 is followed by a number of problems
which will make this work of especial value to the student.
In part
2, the consideration
of drugs
arranged
according
to their
chief dental uses, still maintaining the usual pharmacologic grouping,
which will
be
appreciated
by both student and
practitioner.
The
author presents an interesting and valuable introduction to each group
of drugs as to their mode of action and standardization of efficiency.
Part 3.
The student will find ia this part valuable and interesting
laboratory exercises.
130
BOOK
NOTICES
This is
an
excellent
presentation of the subject for
the
purpose
intended.
Its size alone will recommend it to those who would not
undertake a more extensive
discussion
of the subject.
The
printing
is
good,
large
type,
well
spaced,
and
well-selected
illustrations bring it up to the usual standards of the publisher.
Essentials or Oral Surgery,
by Blair
and Ivy.
Second
edition,
606
pages,
illustrated.
C. V. Mosby & Co., St. Louis,
Mo.
Price
$6.50.
This edition brings up to date the advances that have been made in
the
surgery
of
the
mouth
and
jaws
since
publication
of
the
first
edition.
The order in which the different subjects
are presented
has been
changed, primarily
as an aid to the undergraduate,
but should prove
equally helpful to the general practitioner, who should be stimulated
to recognize
and better understand the many conditions of the mouth
requiring surgical treatment.
The chapter on fractures of the jaw will be of invaluable assistance
to many who
are nowadays
called
upon
for
this
service
to
their
patients in this fast-moving
age.
The
chapter on
surgical preparation
of
the
mouth for artificial
dentures is a concise presentation
of a subject that should be of benefit
not only to the oral surgeon but equally to the general practitioner,
as well as the prosthodontist.
This volume is well written, spendidly illustrated, and the printing
and binding are of the usual high standard of the publishers.
THE DIVISION OF PREVENTIVE
MEDICINE
C. S. Stephenson, Commander,
Medical Corps, United States Navy, in charge
TOXIC
EFFECTS
OF
ARSENICAL
COMPOUNDS
EMPLOYED
IN THE TREAT
MENT
OF
DISEASE
IN THE UNITED
STATES NAVY,
1936
By C. S. Stephenson, Commander,
Medical Corps,
United States Navy, and E. H. Winoo, Chief
Pharmacist's
Mate, United States Navy
Since
November
1924
medical
officers
of
the
Navy
have
been
required to make monthly reports of the number of doses of arsenicals
ad^ministered and a separate
account
of each case in which ill effects
are noted.
During
the
12 years,
1925-36, in which this information
has been compiled
1,202,261 doses of arsenicals have been administered
and 924 reactions have
been reported.
Previous
articles
dealing
with the information obtained from these
reports were published in the September
1925, January 1927, January
1929, July
1930,
October
1931,
October
1932,
April
1933,
October
1933,
October
1934,
January
1935,
October
1935,
January
1936,
October
1936, January 1937, and October 1937 numbers
of the United
States Naval Medical Bulletin.
Cases of arsenical
dermatitis occur
ring during the year 1936 were published in the October 1937 number
of the Naval
Medical
Bulletin.
The
present
article deals with
all
cases,
except
arsenical
dermatitis,
which
were
reported
during
the
year
1936.
. Comparative
figures
from
the
experience
of previous
years are also presented.
Table
1.—Arsenical
reactions, 1936
Arsphenamine,
neoarsphenamine,
sulphars-
phenamine,
aml tryparsamide
reactions
Classification
MUd
Severe
Fatal
Total
Arsenical
dermatitis
'
14
18
2
34
28
1
0
29
4
0
0
4
1
2
0
3
1
1
0
2
0
1
1
2
0
1
0
1
0
1
0
1
TotaL
48
25
3
76
1Case histories
were published
in the October
1937number
of the Bulletin.
Included
in the above table
is 1severe reaction caused by arsphenamine,
4 reactions, 2 mild and 2 severe, caused by sulpharsphenamine,
and 1severe reaction caused by tryparsamide.
131
132
PREVENTIVE
MEDICINE
Table 2.—Arsenicals
administered during
the year 1936 for all diseases,
including
syphilis
Drug
Dose
0.9 to 3
grams
0.9 gram
0.6 to 0.9
gram
Less than
0.6 gram
Total
Acotarsone:
0
0
0
140
140
Arsphenamine:
0
0
0
0
0
0
0
0
2,603
2,603
0
0
0
8
8
Bismnrsen:
0
0
0
341
341
Mapharsen:
0
0
0
68
68
0
0
0
1,555
1,558
Neoarsphenamine:
0
0
0
747
747
0
275
32,046
46.826
79, 147
Silver arsphenamine:
0
7
3,560
10,193
13,760
0
0
0
61
61
Sulpharspbenamine:
0
0
0
14
14
0
0
98
1,456
1,554
Tryparsamide:
0
0
0
971
971
4.148
0
0
0
4,148
924
0
0
0
924
6,072
282
35,704
64,983
106,041
Table 3.—Arsenicals
administered during
the 5-year period, 1932-38, for all
diseases,
including
syphilis
Drug
Don
0.9 to 3
grams
0.9 gram
0.6 to 0.9
gram
Less than
0.6 gram
Total
Acetarsone:
0
0
0
140
140
Arsphenamine:
0
0
76
729
805
0
0
81
9,121
9,202
Bismarsen:
0
0
0
111
111
0
0
0
752
752
All others
0
0
1
548
549
Mapharsen:
0
0
0
1,993
1,993
All others
0
0
0
882
882
Neoarsphenamine:
0
4,758
198,435
284,296
4S7.489
Sliver arsphenamine:
0
380
24,584
78,969
103,933
0
0
0
340
340
Sulpharsphenamine:
0
0
0
204
204
0
18
241
6,801
7,060
Tryparsamide:
0
3
43
8,810
8,856
15,931
0
0
10
15,941
8.970
8,965
0
0
5
24,896
5,159
223,461
393,711
647,227
PREVENTIVE
MEDICINE
133
Table
4.—Deaths
and
severe reactions following
the
administration
of 1,087,083
doses neoarsphenamine, 1925-86.
Ratio of deaths and severe
reactions
to doses
Classification
Deaths
Number
Ratio to
doses 1to -
Severe reactions
Number
Ratio to
doses 1to -
Deaths
and severe
reactions
Number
Ratio to
lto-
Hemorrhagic encephalitis
--
Arsenical
dermatitis
Vasomotor
phenomena
Blood
dyscraslas
Acute renal damage
Acute yellow atrophy
of the liver. .
Vascular
damage
(prohable
renal
hemorrhage)
Liver damage...
Jaxisch-Herxheimer
Polyneuritis
-—
Border-line
hemorrhagic
encepha
litis
Arsenical neuritis
Oastrointestinal
Optic neuritis
--
Total
72,472
108,708
181,181
217,417
543,542
543,542
1,087,083
1
170
5C
18I
0
0
14
2
1
1
1
2
1
1,087,083
6,395
19,412
60,394
217,417
77,649
543,542
1,087,083
1,087,083
1,087,083
543,542
1,087,083
16
180
02
23
7
2
67,943
6,039
17,534
47,264
155,298
543,542
1,087,083
77,649
543,542
1,087,083
1,087,083
1,087,083
543,542
1,087,083
26, 514
272
3,997
313
3,473
Table 5.—Deaths folloieing
administration
of arsenical compounds, 1919-86
Year
Arsphen-
amine
Neoars
phenamine
Total
Year
Arsphen-
amine
Neoars
phenamine
Total
1919
3
0
3
1929
0
3
3
1920
1
1
2
1930
0
3
3
192i
3
1
4
1931
0
0
0
1922
0
4
4
1932
0
4
4
1923
0
1
1
1933
0
7
7
1924
1
2
3
1934
0
3
3
1925.
0
2
2
1935....
0
2
2
1926
0
4
4
1936
0
3
3
i£:v::
:
1927
1
0
4
6
5
6
Total....
9
50
59
NUMBER
OF PERSONS TREATED FOR SYPHILIS AND OTHER
DISEASES
Annually on December 31 each activity
records
and reports to the
Bureau of Medicine and Surgery, on N . M. S. Form A, the number of
persons in that command
who have a history of syphilis, and the num
ber of those in the command
who were treated during the year with an
arsenical
compound,
heavy
metal,
or
other
antiluetic
treatment.
The census also requires
the recording
and reporting of the number of
persons who were treated during the year with an arsenical compound
for
a disease other than
syphilis.
This census
does not
take
into
account those individuals who left the service during the year.
In the table which follows, treatment data have been separated into
that given to active service
personnel
and that given to all others.
The
term "All other"
includes Veterans' Administration
patients,
dependents
of naval
personnel,
retired naval personnel,
and native
populations of insular possessions.
134
PREVENTIVE
MEDICINE
Table 6.—Syphilis and arsenicals,
U. S. Navy,
1986
United
States Navy
and Marine
Persons
Corps
All other
Total
Strength,
Dec. 31, 1936
126,583
14,427
126,583
.4,427
Syphilis census, Dec. 31, 1936
Number of persons treated for syphilis with—
Arsenicals:
Arsphenamine
163
16
141
5,402
23
25
101
1,173
2
42
71
178
40
242
6,575
8
209
296
Jltsmarsen
.
Neoarsphenamine
Silver
arsphenamine
. .
Sulpharsphenamine
.
167
225
Heavy metal compounds:
6,110
1,437
7,647
Mercury compounds
6,289
527
142
214
863
36
6,152
563
142
224
Mixed treatment
(specific
mixture,
etc.)...
-.
10
Total persons treated with heavy metal compounds
6,172
909
7,081
Number of persons treated
for disease other
than syphilis with
arsenicals:
30
164
1
1, 199
74
30
1,363
75
193
192
Total persons treated with arsenicals
387
0
1,273
69
1,660
69
Heavy metal compounds:
Bismuth compounds
In table
6 it will
be
noted
that
387
service
personnel
and
1,273
nonservice
personnel
were
treated
for
diseases
other than syphilis
with arsenical
compounds
during the year 1936.
Of the 387 naval personnel,
323 were treated for Vincent's infection,
8 for furunculosis,
6 for dermatitis herpetiformis,
5 for acne,
5 for
yaws, and 9 for other diseases.
Of the
1,273
persons in the group "all others,"
1,195
were treated
for vaws,
76 for Vincent's infection, and
2 for other diseases.
VASOMOTOR PHENOMENA
Neoarsphenamine. — (35— 1936.)
This patient (supernumerary,
native of Guam)
was given a diagnosis of syphilis
because of clinical
and serological findings.
Arsenical
treatment
began
December
18,
1935,
with
a 0.25
gram injection of
neoarsphenamine.
Two
hours
after
the
injection
the patient
developed
chills
and headache, a temperature
of 103.4° F.;
pulse,
120;
and respirations,
28.
Recovery within 24 hours.
Arsenical
treatment
was continued
and after
the fourth injection
of neoars
phenamine
the patient
developed
severe
exfoliative
dermatitis
and died 20 days
after the onset of the first symptoms.
(Case No. 33-1936 —U. S. Naval Medical
Bulletin, October
1937).
(36— 1936.)
After exposure to infection
February
10, 1936, a patient developed
several small abrasions on the shaft of the penis.
One month later he was given a
diagnosis of syphilis
because of secondary rash and a 4-plus Kahn blood test.
PREVENTIVE
MEDICINE
135
Arsenical
treatment
was begun and he received three injections
of neoarsphena-
mine, a total of 1.5 grams, and six injections
of bismosol between March 9 and 26,
and 0.45-gram injections
of neoarsphenamine
on April 2, 9, and 16.
About 1 hour
after the last injection,
and after eating dinner, the patient
developed chills with
a numblike sensation over the entire body, followed
by nausea and vomiting.
He
was given
1 gram of sodium thiosulphate
intravenously.
Recovery
within 6 hours.
Arsenical
treatment
was continued
and
he
received
a 0.2
gram
injection
of
neoarsphenamine
and a 0.2 gram injection
of bismosol on April 23 and a 0.3 gram
injection of neoarsphenamine
on April 30.
Five hours after the last injection
of
neoarsphenamine
the patient developed symptoms similar to the previous reaction,
followed
in
3 days by a severe exfoliative
dermatitis.
(Case No.
18-1936—U. S.
Naval Medical Bulletin, October
1937).
(37— 1936.)
A patient,
exposed to infection
November
1,
1935,
developed
a
lesion
on the penis.
Repeated
dark-field
examinations
were negative for
Tre
ponema pallidum.
He was given a diagnosis of syphilis
2 months later because
of
a 3-plus Kahn blood test.
Arsenical
treatment
began January 30,
1936, with a 0.25 gram injection
of neo
arsphenamine.
Six hours after the injection
he developed nausea and vomiting.
Temperature
102.4° F.
He was given 1 gram of sodium thiosulphate
intravenously.
Temperature
returned to normal within 6 hours.
Recovery
within 24 hours.
(36,
39— 1936.)
This
patient
(supernumerary,
native
of
Guam)
experienced
two
mild vasomotor
phenomena
reactions
during
the
first
course of arsenical
treatment.
The patient
was given a diagnosis of yaws because of an ulceration
on the left foot, lymphadenopathy,
and a 4-plus Kahn blood test.
Arsenical
treatment
was started December
27, 1935, with a 0.25 gram injection
of neoarsphenamine.
Two
hours
after
the
injection
the
patient
developed
a
severe headache.
Temperature
103° F.; pulse,
110; and respirations,
26.
Recovery
within 24 hours.
Arsenical treatment was continued with a 0.4 gram injection
of neoarsphenamine
January
8, 1936.
Two hours after this injection
the patient
developed moderate
chills and headache.
Temperature
of 102° F., pulse, 106;
and respirations,
26.
Recovery
within
24 hours.
(40— 1936.)
This patient (supernumerary,
native of Guam), was given a diagno
sis of yaws because
of clinical and serological findings.
Arsenical
treatment
began January
30,
1936,
with
a 0.25 gram
injection
of
neoarsphenamine.
Two injections
of bismosol were given as concurrent
treatment.
Three hours after the injection
of neoarsphenamine
the patient developed chills,
headache, nausea, and vomiting.
Temperature
105° F.; pulse,
150; and respira
tions,
45.
One gram of sodium thiosulphate
was given intravenously.
The following
day the patient
complained
of slight
headache, had four liquid
stools during the day.
Temperature
102.8° F.; pulse, 100; and respirations,
26.
Recovery
in 2 days.
(41 — 1936.)
A patient,
exposed to infection
March
1934, developed a primary
lesion on the penis May
1, 1934, and was given a diagnosis of syphilis
because of
clinical
and serological
findings.
Arsenical
treatment
was instituted
June 5,
1934, with a 0.2 gram injection
of
sulpharsphenamine,
followed
by a 0.4 gram injection
on June 12.
From July 3,
1934, to July
23,
1935, he received
30 injections
of neoarsphenamine,
a total
of
17.4 grams, and 40 injections
of bismuth
salicylate
as concurrent
treatment.
On October
25,
1935, the fifth course of arsenical
treatment
began with a 0.3
gram injection
of neoarsphenamine, followed by a 0.45 gram injection
on November
1, and 0.6 gram injections
on November
22, 29, December 6, 13 and 23, 1935, and a
0.3 gram injection
on January
4, 1936.
136
PREVENTIVE
MEDICINE
During the progress of the last injection,
the patient
complained
of Sching
in
the arm followed
by slight faintness
and nausea.
He was given 0.5 cubic centi
meter of adrenalin
hypodermatically.
The patient
continued
to complain
of the
arm aching.
There was no evidence of leakage into the tissue.
He was treated
locally with sodium thiosulphate.
All symptoms
other than the pain in the arm
subsided.
Red
blood count,
4,450,000; white
blood count,
11,300;
hemoglobin,
90 percent; segments 63; lymphs,
21; bands,
13; juveniles,
3.
Recovery
in 6 days.
(42—1936.)
A patient who was exposed to infection
February
10, 1931, devel
oped
a small
indurated
ulcer
on the penis
which
was positive
for Treponema
pallidum.
From
March 7, 1931, to May
18, 1934, he received
33 injections
of salvarsan
and 33 injections
of bismuth salicylate
(total amount not recorded) ; from March 8
to November
8, 1935, 22 injections
of neoarsphenamine,
a total of 11.8 grams, and
10 injections
of bismuth
salicylate
as concurrent
treatment;
and on January
16,
1936, a 0.45 gram injection
of neoarsphenamine,
the first injection
of the seventh
course of arsenical treatment.
Twenty minutes after the injeotion
he suffered a
severe
chill and complained
of a choking feeling.
Temperature
100.8° F.; pulse,
100; and respirations,
19.
He was given
1 gram of sodium
thiosulphate
intra
venously, and 1 gram by mouth, repeated the following
day.
All symptoms disap
peared within 3 hours after sodium thiosulphate
was administered
January
16.
Recovery
in
1 day.
(43—1936.)
The source of infection in this case is unknown.
The patient was
given
a diagnosis
of syphilis
because
of general adenopathy,
falling
hair
of the
eyebrows and head, and repeated 4-plus Kahn blood tests.
He was given a 0.25 gram injection of neoarsphenamine on January 16, 1936, and
a 0.3 gram injection on January 23.
Two injections
of bismosol were given as con
current treatment.
Five hours after the last injection
of neoarsphenamine
the patient
developed a
slight chill, followed by a temperature of 103.6° F.; pulse, 108; and respirations,
25.
Examination
showed injected
conjunctivae
and flushed face.
He complained
of
dizziness and intense aching of the joints.
One-half cubic centimeter of adrenalin
was administered
subcutaneously.
White blood count, 10,800;
bands 8; segments,
68; lymphs,
17; monos, 5; eosins, 2.
It was believed that the patient had a mild
reaction
coincident
with catarrhal
fever.
All
symptoms
disappeared
within
3
days.
He was given
0.1 gram of sulpharsphenamine
intramuscularly
on February 2,
1936.
Six hours later he complained of slight headache and chills.
Examination
showed the eyes injected and mucous membranes of the mouth and throat injected
and edematous.
Temperature,
99°
F.; pulse,
80;
and
respiration,
20.
White
blood
count,
16,200;
bands,
14;
segments,
75; lymphs,
5; monos,
5; eosins,
1.
Symptoms
disappeared the following
day and the patient felt well.
The patient
was considered
recovered
in
13 days
but
was kept
on
the sick
list 20 additional
days for observation
and treatment
with sulpharsphenamine.
No reaction occurred following
the next four injections
of sulpharsphenamine.
(44— 1936.)
A patient was given a diagnosis of syphilis
because
of positive dark-
field examination
of
a
sore
on the penis,
general
adenopathy,
and
secondary
skin rash.
From
March 26 to May 11, 1936, he received eight injections
of neoarsphena
mine, a total of 4.5 grams, and eight injections
of bismosol.
The second course of arsenical treatment
was started June
15, 1936, with a 0.3-
gram injection
of neoarsphenamine,
followed
by a 0.4-gram injection
on June 22,
and 0.6-gram injections on June 29, July 6, 13, and 20.
He was given six injections
of bismosol as concurrent
treatment.
PREVENTIVE
MEDICINE
137
Two minutes
after the last injection
of neoarsphenamine
the patient
became
dizzy, weak, and faint.
The face was flushed, pulse rapid, and blood pressure low.
Recovery
within
6 hours.
(45— 1936.)
A patient
exposed to infection
October
11,
1934, developed several
Email ulcers on the glans penis which were positive
for Treponema pallidum.
The
glands
were moderately
enlarged and a Kahn blood test was 4-plus.
From
November
27,
1934,
to
February
26,
1936.
he received
a total
of 8.6
grams of neoarsphenamine
and 4.19 grams of arsphenamine
(number of injections
not recorded).
As concurrent
treatment
he was given 23 injections
of bismosol,
20 mercury
inunctions,
and potassium
iodide daily for 2 months.
The fourth
course of arsenical treatment
was begun January
22,
1936, with
a
0.3-gram
injection
of neoarsphenamine,
followed
by
a 0.35-gram
injection
on
January
28;
0.3 gram of arsphenamine
February
8, 0.4 gram February
15, and
0.3 gram February
20; and 0.27 gram of neoarsphenamine
February
26.
Three
and
one-half
hours
after
the
last
injection
of
neoarsphenamine
the
patient
reported complaining
of chills and fever.
Examination
showed convulsive
movement
of the right arm, which
he was not able to control.
His temperature
rose to 103° F. and fell rapidly after he received 5 minims of adrenalin
intramus
cularly,
and
1 gram of sodium thiosulphate.
Recovery
in
1 day.
(46— 1936.)
A
patient
who
was
exposed to
infection
on January
28,
1934,
developed a small ulcer on the penis and glandular
adenopathy.
Repeated Kahn
blood tests were 4-plus.
From March
20 to May 29,
1934,
he received eight injections
of neoarsphena
mine
(total amount not recorded).
From November
6, 1934, to October 22, 1935,
he was given
24 injections
of neoarsphenamine,
a total
of
13.05
grams.
Thirty
injections
of
bismosol
and
13 injections
of mercury
bichloride
were given
as
concurrent
treatment.
The fifth course of arsenical treatment
began January
7, 1936, with a 0.3-gram
injection of neoarsphenamine,
followed
by a 0.45-gram
injection
on January
14
and 0.6-gram injections
on January 21, 28, February
4, 11, 18, 27, and March 2.
Within V/i hours after the last injection
the patient developed a sense of chillness,
mild headache, and a heavy feeling in the abdomen.
One-half
hour later he had
a distinct chill, after which
he slept for 2 hours.
Recovery
within
6 hours.
(47— 1936.)
A patient
was exposed to infection
August
1934.
Two months
later
he
developed
a
secondary
skin
rash
and
generalized
adenopathy.
The
Kahn blood test was 4-plus.
From October
19, 1934, to October
17,
1935,
he received
20 injections
of neo
arsphenamine,
a total
of
9.9 grams,
and
15 injections
of bismuth
salicylate
as
concurrent
treatment.
The third course of arsenical
treatment
began
January
30,
1936, with
a 0.3-
gram injection
of neoarsphenamine, followed by a 0.45-gram injection
on February
6, 0.6-gram injections
on February
13 and 20, and a 0.3-gram injection
on March
12, 1936.
Three minutes after the last injection
he became nauseated and vomited
bile-stained
stomach
contents.
He complained
of weakness and aching
of the
spine and extremities;
the eyes
were dilated
and conjunctivae
injected;
the face
was cyanotic;
the heart
beats
were
barely
noticeable,
the radial
and
temporal
pulse not obtainable;
respirations
were
slow and shallow;
involuntary urine and
bowel movement.
The patient presented a typical
picture of profound
shock.
He was apparently
unconscious for about
10 minutes and was in a semiconscious condition
for
1 hour.
Red blood count,
4,910,000; white blood count,
16,400;
hemoglobin,
90 percent;
myelocytes,
3; juveniles,
8; bands,
34;
segments, 47; lymphs,
8.
He was given
24140—37
10
138
PREVENTIVE
MEDICINE
0.5 cubic centimeter
of adrenalin
and
1/100
grain
of atropin
subcutaneously
at
intervals
as appeared to be indicated.
The patient felt normal the following
day.
Recovery
in 4 days.
(48— 1936.)
A patient, exposed to infection
on November
14, 1934, developed
a sore on the penis which was positive for Treponema pallidum.
From November
19, 1934, to November
16,
1935, he received
16 injections
of
neoarsphenamine, a total of 6.9 grams; 10 injections
of arsphenamine, a total of 3.7
grams; and 33 injections
of bismuth
as concurrent treatment.
The
fourth
course of arsenical treatment
began February
29,
1936, with a 0.3-
gram injection
of arsphenamine,
followed by a 0.3-gram injection
on March 7, and
a 0.3-gram injection
of neoarsphenamine
on April
7.
Thirty
minutes
after
the
injection
of neoarsphenamine
the patient
developed weakness, nausea, and light
vomiting.
Recovery within 5 hours.
The
patient
complained
of
slight
reaction
following
each
attempt
to
give
neoarsphenamine but had no complaint
after receiving arsphenamine.
(49—1936.)
This patient was exposed to infection
in November
1935.
He was
given a diagnosis
of syphilis
January
18,
1936,
because of secondary
skin
rash,
mucous patches in the mouth, generalized adenopathy, positive dark-field examina
tion of a penile lesion, and a 4-plus Kahn blood test.
From January
21 to March 3, 1936, he received 6 injections
of neoarsphenamine
(amount not recorded) and 10 injections
of bismuth
salicylate.
The second course of arsenical treatment
began May 21,
1936, with
a 0.3-gram
injection
of neoarsphenamine,
followed
by a 0.45-gram injection
on May 28, and a
0.11-gram
injection
on June 4.
Seven injections
of bismuth
were given as con
current treatment.
Approximately
1 minute after the last injection
of neoarsphenamine was started,
and after receiving
0.11 gram of the 0.6-gram dose, the patient
remarked that the
neoarsphenamine
must
be stronger
than
usual
because
he could
taste it much
more than before.
It was noted that he was becoming somewhat
cyanotic
and
the
injection
was
stopped.
The patient
collapsed
a few
seconds later
losing
consciousness.
Breathing
became stridulous
and difficult,
the face cyanotic
and
puffed.
He
was given
5 cubic
centimeters
of adrenalin
hypodermatically,
re
peated in
3 minutes.
Breathing
became easier and
he recovered
consciousness
within 5 minutes.
He complained
of a choking
sensation and severe
pain in the
right chest and was given 0.7 gram of sodium thiosulphate
intravenously.
In 40
minutes there was a slight chill and a temperature
of 101° F.
Recovery
within 24 hours.
(50— 1936.)
The diagnosis of syphilis in this case was not established.
Physical
examination
showed
no evidence
of primary
or secondary
lesions
in the skin,
mucous membranes, or glandular involvement.
The patient had negative monthly
Kahn blood tests during the past year and a half while on the donors' list.
A Kahn
blood test was 3-plus May 2 and 4-plus May 4 and 5.
Treatment
began on May
7 with a
2 cubic
centimeters
injection
of bismuth
sodium tartrate, followed by 2 cubic centimeters injections on May 8, 12, 15, 19, 22,
and
26.
Arsenical
treatment
began with
a 0.35-gram
injection
of neoarsphena
mine on May
12, followed
by a 0.35-gram
injection
on May
19, and a 0.7-gram
injection
on May 26.
Three days after the last injection
of neoarsphenamine
the patient
complained
of sore throat, fever, and general malaise.
He stated that he had not felt well the
past week or
10 days, and thought it was the after effect of a spinal
puncture.
Examination
revealed the throat and gums slightly reddened, tonsils elevated, and
a temperature
of 103° F.
He was given
1 gram of sodium thiosulphate
intraven
PREVENTIVE
MEDICINE
139
ously twice
daily for
9 days.
All symptoms
subsided by June 7,
1936,
and the
patient felt well.
The patient
was
considered recovered in 8 days, but
he remained on the sick
list 21 days for observation and treatment with bismuth compounds.
The admin
istration
of sodium thiosulphate
was continued
and he received
1 gram intraven
ously daily for
5 days, a total of 32 grams within 21 days.
(51— 1936.)
After exposure to infection
in May 1927 this patient
developed
a
penile lesion which
healed under local treatment.
He was given
a diagnosis
of
syphilis
3 months later because
of repeated 4-plus Kahn blood tests.
He received seven
injections
of neoarsphenamine
during the months of August
and September 1927 (amount not recorded).
From October 5, 1927, to September
5,
1933,
he received 73 injections
of neoarsphenamine,
a total
of 48.6
grams;
65
injections
of bismuth salicylate;
14 injections
of bismosol;
12 injections
of mercury
salicylate;
and 37 mercury inunctions.
From January
15 to November
26,
1935,
he was given 19 injections of tryparsamide,
a total of 57 grams, and 21 injections
of
bismosol.
The thirteenth
course of arsenical treatment
began with a 0.3-gram injection
of
neoarsphenamine
on May 5,
1936, followed by 0.6-gram injections
on May 12, 19,
and June 2.
Forty-five minutes after the last injection
the patient complained
of
weakness and dyspnea.
Examination
revealed anxiety, suffused skin, rapid pulse,
and a temperature
of 101° F.
He was given
1 gram of sodium thiosulphate
intravenously
and
1 cubic centi
meter of adrenalin
hydrochloride
subcutaneously.
Recovery within 24 hours.
(52— 1936.)
A patient,
exposed
to infection January 6, 1936, developed a lesion
on the prepuce which was positive for Treponema pallidum,.
The inguinal
glands
were enlarged and discrete and a Kahn blood test was 4-plus.
From January 27 to March 24, 1936, he received eight injections of neoarsphena
mine,
a total of 4.7 grams, and three injections
of bismuth.
The second
course of arsenical treatment
began June 2, 1936, with a 0.35-gram
injection of neoarsphenamine,
followed
by 0.7-gram injections
on June 9, 16, and
30.
Thirty
minutes
after
the last
injection
the patient
complained
of general
malaise,
nausea,
and
vomiting.
Examination
otherwise
essentially
negative.
The patient
stated
that
he had felt
chilly,
ached all over, and had sometimes
been nauseated following
the three previous injections
of neoarsphenamine.
Recovery within 18 hours.
(53— 1936.)
This patient experienced two mild vasomotor phenomena reactions
during
the first
course
of
arsenical treatment
in
1934 (Case no. 12, U. S. Naval
Medical
Bulletin,
January 1936).
He was given a diagnosis of syphilis
because
of
repeated 4-plus
Kahn blood tests, inguinal
lymphadenopathy,
and a healed pri
mary lesion of the glans penis.
From February
23 to April
5,
1934, he received
13 injections
of neoarsphena
mine, a total of 5.45 grams.
The reactions followed the last two injections;
the
first followed
a 0.45-gram
dose and the second followed
a test dose of 0.3 gram.
Recovery
in both cases was within 48 hours.
From April
12 to June 11, 1934, he was given 18 injections
of bismosol.
From
February
8 to May 28,
1935,
he was given
17 injections
of mercury
succinimide,
a total of 3.4 grains.
The second course of arsenical treatment
(five injections
of neoarsphenamine,
a total of 1.8 grams) was given between June 5 and July 11, 1935.
Neoarsphena
mine was discontinued
because
of slight reactions following
the fourth
and fifth
injections.
From July
12,
1935,
to June
12,
1936,
he received
30 injections
of bismuth
salicylate
and 20 injections
of mercury
succinimide.
140
PREVENTIVE
MEDICINE
A third course of arsenical treatment
was
attempted
on July 8, 1936, with a
0.15-gram injection
of neoarsphenamine.
On July
15,
\){ hours after a 0.3-gram
injection
of
neoarsphenamine
had
been
administered,
the
patient
developed
headache,
burning
of the
eyes,
and
general
weakness.
Temperature
100°
F.
Two hours later he became
nauseated and vomited several times.
He was given
1 gram of sodium thiosulphate
intravenously.
Recovery within 10 hours.
(54— 1936.)
This patient
gives a history
of repeated exposures to infection sev
eral weeks prior to the appearance of a lesion on the glans penis on June 20, 1936.
Repeated
dark-field
examinations
of
the
lesion
were negative
for
Treponema
pallidum.
A Kahn blood test on June 23 was 4-plus.
Arsenical
treatment
began
with
a 0.6-gram injection
of neoarsphenamine
on
June 29, followed by 0.6-gram injections on July 6, 13, 20, and 27.
As concurrent
treatment
he was given six intramuscular
injections
of bismosol.
Immediately
following
the last injection
of neoarsphenamine
the patient
com
plained
of feeling weak, dizzy,
and faint,
following
which
he became nauseated
and
vomited.
Examination
showed
the
face flushed,
pulse
rapid,
and
blood
pressure low.
He was given
1 gram of sodium
thiosulphate
intravenously
and
kept on the sick list for observation
and complete rest.
On August
10 the patient
was given a 0.6-gram injection
of neoarsphenamine,
following
which the patient suffered a mild shock, became
nauseated, and vomited.
One-half
gram of sodium
thiosulphate
was given intravenously.
Recovery in
16 days after onset of the first symptoms.
(55-1936.)
The source of infection in this case is unknown.
The patient denies
venereal
infection
though
he
admits
exposure to infection
during
the past
12
weeks.
He was given
a diagnosis
of syphilis
because
of repeated 4-plus Kahn
blood tests.
Arsenical
treatment
began with
a 0.3-gram injection
of neoarsphenamine
on
June 29,
1936, followed
by a 0.4-gram injection
on July 6, 0.6-gram injections
on
July 13 and
20,
and a 0.3-gram injection
on July 27.
Five injections of bismosol
were given as concurrent
treatment.
Immediately
following
the
last
injection
of
neoarsphenamine
the
patient
vomited
and suffered shock, fall in blood pressure, and pulse rate.
The eyelids
and
lips
showed
angioneurotic
edema.
He developed
difficulty
in
breathing,
cyanosis,
and
weakness.
He was given
1 gram of sodium
thiosulphate
intra
venously,
followed
by
1 cubic centimeter
of epinephrine
hydrochloride
every
15
minutes for three hypodermic
injections.
Recovery within 48 hours.
(56 and 57— 1936.) This patient experienced two mild vasomotor reactions during
the first course
of arsenical treatment.
He was infected on August
23, 1936, and
14 days later developed a lesion on the penis which was positive
for
Treponema
pallidum.
He received a 0.3-gram injection
of neoarsphenamine, and a 0.13-gram injection
of bismuth
salicylate
on September
8,
1936.
Twelve
hours
after
the injection
of neoarsphenamine
the patient complained of headache.
Temperature
103.6° F.
The face was flushed and the mucous membranes were injected.
Recovery
within
24 hours.
Arsenical
treatment
was continued
with a 0.15-gram injection
of neoarsphen
amine on September
14.
Seven hours after this injection
the patient complained
of headache.
Temperature
99.8°
F.
The following
morning
his temperature
was normal and all symptoms
had subsided.
Recovery within 24 hours.
Neoarsphenamine
was discontinued
and bismarsen
administered
intramuscu
larly.
There
were
no signs of further
reaction.
PREVENTIVE
MEDICINE
141
(58— 1936.)
A patient
exposed to infection
in October
1927 developed a lesion
on the penis which was positive
for Treponema pallidum.
From
May
10, 1927, to April
7, 1928, he received
16 injections
of neoarsphen-
amine
(amount
not
recorded)
and
from
May
10,
1930,
to July
17,
1936,
36
injections
of bismuth
compounds.
The third course of arsenical treatment
began September
1,
1936, with
a 0.1-
gram
' injection
of neoarsphenamine,
followed
by a 0.3-gram
injection
on
Sep
tember 4, and a 0.45-gram injection
on September 8.
About 10 minutes after the
last injection
the patient
became nauseated and vomited
profusely,
followed
by
severe chills and collapse.
The skin was flushed and pulse weak and rapid.
He
was given
1 gram of sodium
thiosulphate
intravenously
and
5 cubic centimeters
of adrenalin
subcutaneously.
Recovery
within 24 hours.
(59— 1936.)
This
patient
was
exposed to
infection
in
December
1931.
He
stated that a small sore developed on the penis 3 weeks after exposure and healed
without treatment.
He was given a diagnosis of syphilis on June 1, 1932, because
of 4-plus Kahn blood tests and old scar on the glans penis.
From June
8 to August
3,
1932, he received eight injections
of neoarsphena
mine and eight injections
of bismuth
salicylate;
from September
7 to October
11,
five injections
of neoarsphenamine;
and from
November
30 to December
27, five
injections
of neoarsphenamine
(total
amounts
of the above treatment
were not
recorded).
The patient
stated
that
the second and third courses of arsenical
treatment
were discontinued
after
the fifth injection,
because
of slight
gastro
intestinal
upsets, and fever.
From October
12, 1933, to July 24, 1936, he was given 22 injections
of bismosol,
15 injections
of bismuth
salicylate,
and
12 injections
of mercury.
The fourth
course of arsenical
treatment
began
with a 0.3-gram
injection
on
August 12, 1936, followed
by a 0.45-gram injection
on August
19, 0.6-gram injec
tions on August
26 and September
16, and a 0.3-gram injection
on September
23.
One
hour
after
the last injection
the patient
complained
of headache,
became
nauseated,
and vomited.
He vomited at frequent intervals
for 2 hours.
He was
given
1 cubic
centimeter
of adrenalin
subcutaneously
and
1
gram
of sodium
thiosulphate
intravenously.
Recovery
in 2 days.
(60— 1936.)
This patient
was exposed to infection
on March
26,
1934, and
developed an indurated
ulcer of the glans penis which was positive for Treponema
pallidum.
From April
17 to June
19,
1934,
he received 8 injections,
a total
of 3.6 grams
of neoarsphenamine;
from June
19 to July 9, 4 injections
of sulpharsphenamine,
a total of 1.3 grams; and from April 17, 1934, to January
15, 1935, 36 injections
of
bismosol
On February
5,
1935,
he received a 0.3-gram injection
of sulpharsphenamine,
followed
by
a 0.4-gram
injection
on February
12 and
a 0.3-gram
injection
on
February 19.
A mild vasomotor
phenomena reaction followed
the last injection.
Recovery
within 5 hours.
(Case
no. 42— 1935, U. S. Naval
Medical Bul
letin, January
1937.)
From January
15,
1935,
to September
22,
1936,
he received
74 injections
of
bismuth
compounds.
On September 29, 1936, he was given a 0.045-gram injection
of neoarsphenamine,
followed
by
a 0.09-gram
injection
on October
13. Five minutes
after
the last
injection
the patient
complained
of headache, and pain in the epigastrium,
back,
and legs.
He vomited several times, followed
by three watery bowel movements
within 2 hours.
One and one-half
hours
later
he developed
a severe
chill
and
temperature
of 101.4°
F.
He was given 5 minims of epinephrine
hydrochloride,
142
PREVENTIVE MEDICINE
1-1000
solution
subcutaneously,
followed
by
1
gram
of sodium
thiosulphate
intravenously.
Recovery
within 24 hours.
(61-1936.)
A patient,
exposed to infection
on March 10, 1936, developed
three
indurated
ulcers on the glans penis which
were positive
for Treponema pallidum.
Arsenical
treatment
began with a 0.3 gram injection
of neoarsphenamine
on
April 20, 1936, followed by 0.4 gram injections
of arsphenamine
on April 23 and 30.
From May 6 to June 3 he received five injections,
a total of 2.55
grams of neoars
phenamine.
On June 13 he was given a 0.4 gram injection
of arsphenamine
and
on June
25, a 0.3 gram injection
of neorasphenamine.
From September
12 to
October
3, 1936, he received four injections
of arsphenamine,
a total of 1.2 grams.
As concurrent
treatment
he was given
10 injections
of bismuth
salicylate.
On October
12, 1936, the patient was given a 0.27-gram injection
of neoarphcna-
mine and
15 minutes later
he complained
of general weakness and pains in the
epigastrium.
He became nauseated and vomited.
He vomited twice and passed
three watery stools within
1 hour.
He developed a chilly sensation which lasted
45 minutes.
Temperature,
99.4° F.
Recovery
within 24 hours.
(62-1936.)
After exposure to infection
this patient
developed a small punched-
out ulcer on the inner surface of the foreskin
which
was positive for Treponema
pallidum.
Arsenical
treatment
began with a 0.3 gram injection of neoarsphenamine
on
November
27,
1936.
Two days after the injection the patient
was admitted
to
the sick list with a temperature
of 102° F. and pulse 120.
Examination revealed
a bubo in the right inguinal
region, probably
the result
of the chancre
and the
cause
of the elevated
temperature.
The patient
had
no other
complaints
or
symptoms.
Temperature
returned
to normal
within
2 days.
'Arsenical treat
ment was continued
and he was given a 0.6 gram injection
of neoarsphenamine
on
December
3, 1936, without signs or symptoms
of further reaction,
followed
by a
0.6
gram injection
on December
10.
Three
hours
after
the last injection the
patient
complained
of general malaise.
Temperature,
103° F.; and pulse,
120.
Examination
negative
other than
high fever.
He was given
1 gram of sodium
thiosulphate
intravenously.
The patient
slept confortably
during
the night and
the following
morning
his temperature
was
100° F.
He was given the second
1 gram
intravenous
injection
of sodium
thiosulphate.
Temperature
gradually
returned to normal.
Recovery
in 8 days.
Sxdpharsphenamine. — (63-1936.)
This
patient
was
given
a
diagnosis
of
syphilis
on June 24,
1932,
because
of a secondary skin eruption,
large indurated
inguinal
glands, 4-plus Kahn blood tests, and a history
of exposure and a primary
lesion of the penis in April
1932.
From June
24,
1932,
to July
12,
1933,
he received
28 injections
of arsenical
compounds
(type and amount not recorded) , 42 injections
of bismuth compounds,
and
19 injections
of mercury.
It was noted in the health record that arsenicals
were discontinued
in 1933 because of severe
reaction
to treatment.
During the years
of
1934
and
1935
he
was given
54 injections
of
bismuth
compounds.
On February
11,
1936,
he was given
a 0.1
gram
intramuscular
injection of
sulpharsphenamine,
followed
by a 0.2 gram injection
on February 19.
One hour
after
the
last injection the
patient
developed
a chill
which
lasted
1% hours.
Temperature,
101.2°
F.
Three
hours after
the injection
he became nauseated
and vomited.
The patient complained of a slight headache the following
morning.
Recovery
in 2 days.
PREVENTIVE
MEDICINE
143
GASTROINTESTINAL
Sulpharsphenamine. — (64— 1936.)
The source and date of infection
in this case
is unknown.
The patient
was given a diagnosis of syphilis
because
of a secondary
skin eruption
and repeated 4-plus Kahn blood tests.
Arsenical
treatment
was instituted
and from March 17, 1933, to May 4, 1934,
he received a total
of 11.65 grams of arsenical compounds
(type and number
of
injections not recorded),
24 injections
of bismosol, and
10 injections
of mercury.
From January
14 to August
3,
1936. he was given
16 injections
of bismuth
com
pounds.
He
was given
0.3
gram
intramuscular
injections
of
sulpharsphenamine
on
August
11 and
17,
1936.
One-half hour after the last injection
of sulpharsphena
mine the patient
developed
nausea,
followed
by vomiting
and diarrhea.
The
vomitus contained
macroscopic
blood.
One gram of sodium
thiosulphate
was
administered
intravenously.
Two days later
he developed slight
bleeding from
the
gums and
rectum.
Physical
examination
otherwise
negative.
Red
blood
count, 4,100,000; white
blood count,
5,650;
hemoglobin,
80 percent;
bands 33;
segments 42; lymphs
17; monos 5; eosins 2; juveniles
1.
Blood platelets, 341,000.
Recovery
in
11 days.
Neoarsphenamine. — (65— 1936.)
This
patient
was
exposed
to
infection
on
March
27,
1929, and developed a primary
lesion on the prepuce which was posi
tive for Treponema pallidum.
A Kahn blood test was 4-plus.
From May
7,
1929, to November
9, 1930, he received three courses of neoars
phenamine,
a total of 15.9 grams, and 6 grains of mercury intramuscularly.
The fourth
course of arsenical
treatment
began
with
a 0.3 gram injection
of
neoarsphenamine
on June 6,
1936, followed
by a 0.4 gram injection
on June
13.
On June 22,
1936, the patient
reported for the third injection
of this course
of
neoarsphenamine.
He stated that slight nausea and vomiting
followed the injec
tions
given on June
6 and
13.
He was given
1 gram of sodium
thiosulphate
intravenously
followed
in
1 hour
by a 0.4 gram injection
of neoarsphenamine.
Immediately
after
the injection
of neoarsphenamine
he became pale and nau
seated,
followed
by
abdominal
colic
and
watery
stools.
The
patient
was
in
moderate shock, with a temperature of 97° F.; pulse weak and rapid and the skin
pale and cold.
He was given
1 gram of sodium thiosulphate
intravenously
the
following
day.
Recovery
in 9 days.
JARISCH HERXHEIMER
(66 — 1936.)
This
patient
was
exposed
to infection
December
18,
1935,
and
developed
a lesion
on the penis
which
was
negative
for
Treponema pallidum.
Under
treatment,
the lesion healed within
10 days.
He was given a 0.6 gram injection
of neoarsphenamine
on
January
21, 1936.
One hour
after the injection
the patient
complained
of general body pains and
chills.
Temperature,
102° F.
He was given
0.5 cubic centimeter
of adrenalin
hypodermatically
at
2 p.
m. and 4:30
p. m.
Temperature
normal
the following
morning.
A typical
secondary
skin
rash
present.
Recovery
within
10 hours.
(67-— 1936.)
This patient,
exposed
to infection
on
December
20,
1935,
devel
oped two small lesions on the penis which
were positive
for Treponema pallidum.
A Kahn
blood test was 4-plus.
Arsenical treatment
began
with
a 0.3 gram injection
of neoarsphenamine
on
January
30,
1936, followed
by 0.45
gram injections
on January
7 and
14.
He
was given three injections
of bismuth
as concurrent
treatment.
144
PREVENTIVE
MEDICINE
One hour
after
the last
injection
of neoarsphenamine
the patient
developed
nausea, followed
by a temperature
of 101.2° F., flushed skin, and a typical Herx-
heimer skin reaction.
He was given
1 gram of sodium thiosulphate
intravenously.
Recovery
within 48 hours.
(68— 1936.)
After exposure to infection
this patient
developed a small sore on
the penis.
He stated that he treated the sore for some time but it would not heal.
Examination
showed a small ulcer on the penis, generalized lymphadenopathy,
and a generalized secondary skin rash.
A Kahn blood test was 4-plus.
He was given a 0.25 gram injection
of neoarsphenamine
on April 21,
1936, and
experienced a mild therapeutic
shock and a decided flare-up of the rash the follow
ing morning.
Temperature,
102.2° F.
Recovery
within 24 hours.
The patient
was given
0.4 gram
injections
of neoarsphenamine
on April
25,
30, and May 7, 1936, without signs or symptoms
of further
reaction.
(69— 1936.)
The source of infection
in this case is unknown.
The patient
was
given a diagnosis of syphilis because
of several lesions in the mouth which were posi
tive for Treponema pallidum,
general adenopathy,
and a healed scar on the penis.
Arsenical
treatment
began with
a
0.34-gram
injection
of neoarsphenamine
August
18, 1936, followed
by 0.45-gram injections
on August
21 and 25.
Twenty
hours after the last injection
the patient complained of chills and general malaise.
Temperature
104° F.; pulse,
140; and respiration,
40.
A slight
papular
rash appeared
over
the trunk the following
day;
subsided
within
2 days.
Temperature
gradually
returned
to normal.
Recovery
in 8 days.
LIVER DAMAGE
(70— 1936.)
This patient,
exposed
to infection
on November
5, 1935, developed
a lesion on the penis which was positive for Treponema pallidum.
Repeated Kahn
blood tests were negative.
Arsenical treatment began with a 0.3-gram injection
of neoarsphenamine Decem
ber 19, 1935, followed by a 0.45-gram injection
on December
24, a 0.6-gram injec
tion on December 27, 1935, and a 0.45-gram injection on January 3, 1936.
He was
given six injections
of bismuth
salicylate
as concurrent
treatment.
About 4 hours after
the last injection
of neorarsphenamine
the patient com
plained
of nausea.
Temperature
103° F.
Several hours later a mild
skin rash
appeared and the conjunctivae
were injected.
The following
day the conjunc
tivae continued
to show redness,
there was slight fever, and a subsidence of the
skin rash.
He was given
1 gram intravenous
injections
of sodium thiosulphate
on
January 4 and
6.
January
15: The skin
and
conjunctivae
show
marked
increase
in jaundice.
Red
blood count,
3,880,000; white
blood
count,
8,100; hemoglobin,
85 percent;
segments,
61;
bands,
4; juveniles,
2; lymphs,
25;
eosins,
8.
Urinalysis:
Color,
dark
amber;
reaction,
acid;
specific gravity,
1.020;
bile, positive,
with dilution
1-50;
much mucus;
many
leukocytes;
many epithelial
cells.
Icterus
index,
48.
January
23:
Icterus
index, 37.
January
27:
Red
blood
count,
3,600,000;
white blood count,
12,150; hemo
globin,
75 percent; segments, 40; bands, 16; lymphs,
28; eosins,
8; monos, 7; basos,
1.
Icterus
index,
28.
Urinalysis,
negative.
February
5: The patient shows rapid improvemnt.
Icterus index, 10.
The
patient's
condition
gradually
improved
and
he was returned
to duty 50
days after the last injection
of neoarsphenamine.
PREVENTIVE
MEDICINE
145
BLOOD DYSCRASIAS
(71 — 1936.)
Two months
after exposure to infection
this patient
developed a
lesion on the glans penis which was positive for Treponema pallidum.
From March 7 to September
8, 1936,
he received
16 injections
of neoarsphen
amine,
a total of 7.5 grams, and 23 injections
of bismuth
salicylate.
The third course of arsenical treatment
began with a 0.3-gram injection
of neo-
arsphenamine
December
1,
1936, followed by a 0.45-gram injection
on December
16, and 0.5-gram injections
on December
22 and 29.
Immediately
following
the
last injection the patient
became nauseated and dizzy, and there was slight bleed
ing from the gums.
Examination
showed a single purpuric
spot on the right buccal
mucous
membrane.
December
30:
There
are several small purpuric
spots in the mucous membrane
of the mouth
and blood is oozing from the gingival lines.
The skin on the inter
nal surface
of the thighs and legs bears a mass
of purpuric
spots which
at some
points
are
so
close
together
they
form
purpuric
patches.
Red
blood
count,
4,330,000;
white blood count, 9,550; bands, 6; segments, 70; lymphs,
24.
He was
given
1 gram of sodium thiosulphate
intravenously.
December
31: The purpuric spots are fading and the oozing of the blood from
the gums has gradually
decreased during the past 24 hours.
The patient
has no
complaint.
Recovery in 4 days.
(72— 1936.)
The source of infection
in this case is unknown.
The patient
was
given
a diagnosis of syphilis
because
of a general body rash, inguinal
adenopathy,
injected pharynx
and soft palate, and an indurated
ulceration
at mucocutaneous
border
of anus anteriorly.
Repeated
dark-field
examinations
of the ulceration
were negative for Treponema pallidum;
Kahn blood test was 4-plus; and a Wasser-
mann
test was strongly
positive.
Arsenical
treatment
began with
a
0.3
gram
injection
of
neoarsphenamine
December
24,
1935, followed
by 0.45 gram injections
on December
31,
1935, and
January
7 and
14,
1936.
Four injections
of bismuth
salicylate
were given
as
concurrent
treatment.
About
50 hours after the last injection
of neoarsphenamine
the patient
com
plained
of general malaise and slight chills.
Temperature,
99.8° F.
January
17: The patient
complains
of sore throat.
Examination
shows some
injection
of the pharynx and soft palate, infected ingrowing
toenail,
and lymphan
gitis of dorsum.
January
18: The
patient
continues
to
complain
of
sore
throat
and
slight
chilliness.
January
19: The patient
complains
of sore and painful
gums.
Temperature,
102° F.
He was given saline mouth washes every
2 hours, and hot baths and hot
water bottles to induce sweating.
January
20:
The patient's
condition
is about
the same.
Laboratory reports
revealed absence
of granular
type cells.
He was given
1 gram of sodium thiosul
phate intravenously,
3 cubic centimeters
of liver
extract,
Fischer's
solution,
500
cubic centimeters by Murphy drip, and 250 cubic centimeters of blood, by direct
method.
January 21:
Treatment
continued
as above, including
250 cubic centimeters of
blood.
The patient's
temperature
ranges from
100.4°
F.
in
the
mornings
to
103.6°
F. in the afternoons.
The gums show
ulceration
at the margin
of the
teeth.
The soft palate is injected and mildly
edematous.
The sublingual
lymph
glands are swollen and tender.
146
MEDICINE
January
22:
The patient's
condition
is about the same.
Temperature,
104.2°
F.
He complains
of pains in the teeth and neck.
Above
treatment
continued,
except the blood transfusion.
January
23:
The patient
continues
to complain
as above.
Morning tempera
ture,
102° F.
Two ulcerated
areas of the hard palate opposite the molars noted.
Above treatment
continued,
including
X-ray therapy to the glands of the neck.
January
24:
The patient's
general condition
is about the same.
Above
treat
ment continued.
A small spot of erythema
appears at each
point of injection
of
hypodermic
needle.
There
is an extension of ulceration
of the gum on the upper
left side into the hard palate.
January 26:
The patient's
general condition
shows improvement.
The greater
part of the brachial
vein is involved.
January 28: The patient shows marked improvement.
Semisoft diet.
Intake
and output
satisfactory.
Temperature
ranges between 98.6°
F. and
99.6°
F.
February
1:
The patient continues to improve.
Temperature
normal through
out
the day.
Some residual
induration
about
the left
brachial
vein.
General
condition
excellent.
Blood
Red cell count
White
cell
count
'
Hemoglobin
Segmented
Lymphocytes
|
Eosinophlles
Basophiles
Mouocytes
Juveniles
Myelocytes
J5
i
Turck's
cells
Keticulocyte
count
Date
.S
g
8
=
8
1
January 20, 1936
5,
240,000
5,
450,000
4.
930,000
5,
500,000
4,
680,000
4,
940,000
4,
400,000
4,850,000
4,
350,000
4.
550,000
4,650,000
8,500
3,
500
2,600
2,900
1,700
3,
300
5,000
6.000
18,000
8,200
6.000
90
100
95
100
90
95
85
90
90
80
90
14
16
11
19
1
1
1
1
2
83
83
88
80
72
33
14
17
2
8
19
M
January 21, 1936
January 23, 1836
.
January 23, 1936
January 25, 1936
26
"i"
0.3
January 27, 1936
9
16
10
13
18
22
40
57
64
46
8
8
3
1
1
6
6
7
1
6
2
6
4
1
1
January 28, 1936
2^
21
14
22
21
January 29, 1936
....
1
February
3,
1936
February
4.
1936
4
2
8
February
29, 1936
s
The
patient's
condition
gradually
improved
and
he
was
returned
to duty
27
days after onset of the first symptoms.
(73— 1936.)
After exposure to infection
this patient
developed
a penile lesion
which
was positive for Treponema pallidum.
From
May 26 to June 16, 1928,
he
was given two injections
of ncoarsphenamine
(amount
not recorded),
and daily
mercury
inunctions.
October
31,
1935:
Examination
showed
a
secondary skin eruption
and general
ized adenopathy.
Although
the patient
presented
no
primary
lesion
this
was
considered to be
a
reinfection.
A
Kahn blood test was 4-plus.
From
November
2,
1935 to February
5,
1936 he received
16 injections
of neo-
arsphenamine,
a
total of
9
grams.
Twelve injections
of bismuth and an unstated
amount
of mercury
inunctions
were
given as concurrent
treatment.
The third
course of arsenical treatment
began
April
14, 1936, with
a
0.3 gram
injection
of neoarsphenamine,
followed
by
0.6 gram injections
on April
21,
28,
May
5,
12,
19,
26, June
2,
9,
and
16.
As concurrent
treatment
nine injections
of
bismuth salicylate
were given.
Following
the
last
injection
of
neoarsphenamine
the
patient
complained
of
headache, dizziness,
and general lassitude.
Spinal
fluid
examination
was essen
tially negative.
The
patient
stated on July
7,
1936 that
he was not able to do his work,
and
became very tired on little effort.
Also stated that he often developed headaches
in the evenings and had lost weight due to loss of appetite.
Physical
examination
PREVENTIVE
MEDICINE
147
was negative except for signs and symptoms
of severe
anemia and marked pallor
of the skin and mucous membrane.
Further
examination
revealed
an anemia of the aplastic
type with
depression
of all formed
elements of the blood.
At intervals
there was bleeding from
the
gums and petechial hemorrhages.
There
was no pathology
of the heart or lungs.
Urine examination
was negative.
In spite of the treatment
indicated
below there
was little
improvement
in
the anemia
until
about
November
11,
1936,
when
evidence
of blood
regeneration
appeared.
This improvement
was gradual
but
continuous
and
was
associated
with
a
complete
disappearance
of
symptoms.
At the
time
of discharge
the red blood
count
was
3,400,000,
with
69 percent
hemoglobin.
Response
to exercise
was normal
and the patient
experienced
no
fatigue.
His weight was slightly
above the normal level.
The patient
was discharged to duty under observation
and treatment
165 days
after onset of the first symptoms.
Treatment.—Throughout
hospitalization
the patient
received whole liver three
times
a week with
20 grams of liver extract,
equivalent
to 200 grams of whole
liver daily; ferrous carbonate,
2 grams daily; ultra-violet
radiation,
three times a
week;
15 blood
transfusions,
a total
of
6,440
cubic
centimeters
of blood;
from
August
16 to September
3
he received
8 injections
of pentnucleotide,
10 cubic
centimeters,
and 0.5 cubic centimeter
of adrenalin
twice daily.
Blood
Rod
coll
couut
White
cell
count
Hemoglobin
T5
Lymphocytes
Monocytes
2
Reticulocyte
count
o
a
2
a
Juveniles
Date
■
C
on
B
§
E
'§
M
1
si
s
OS
e
DQ
m
July
7,
1936
1.810.000
2,660,000
2.360.000
2,070,000
2,000
2,700
60
75
70
52
52
56
56
56
48
64
47
51
60
46
50
49
3
10
25
38
69
45
3
3
4
July 10, 1936
(')
Jaly 13, 1936
Aug. 13. 1936
Aug. 21. 1936
1.
790,000
1,
810,000
2,
310,000
2,680,000
2.100,000
2,960,000
1,980,000
2,180.000
2,990,000
2.
470,000
2,900
1,850
2,250
2,300
2,800
3.550
1,800
9
19
14
34
24
34
31
40
29
27
67
51
51
64
50
60
69
Aug.
2S, 1936
1
4
i
0.6
.4
.4
.8
.7
.5
.15
.3
Sept.
4,
1936
1
Sept.
11, 1936
5
10
Sept.
18, 1936
Sept.
25. 1936
6
2
2
1
Oct.
2.
1936.
4
Oct.
9,
1936
Oct.
16, 1936
Oct.
23. 1936
Oct. 30. 1936
2,
780.000
2,700,000
Nov.
6,
1936
Nov. 10. 1936
2.5
Nov. 12. 1936
X
M0. 000
2,340.000
2,880,000
3,080,000
3,200,000
3.400.000
55
41
64
60
69
66
^iS::::::::-:::::
.9
Dec.
11, 1936. .
Dec.
18. 1936
Jan.
4.
1937
1
Blood
picture:
Red blood count:
Anisocytosis,
moderate with macrocytes
predominating.
Poikilocy-
tosis, very mild.
Hypochromasia,
absent.
Other than the above there
is
no abnormality
in the red cells.
White blood count: No toxic degeneration.
Marked leukopenia,
with lymphocytosis
and mildeosinophilia.
Platelets,
decreased.
HEMORRHAGIC
ENCEPHALITIS
(74— 1936.)
After exposure to infection
on November
22,
1935,
this patient
developed
a
lesion on the glans penis which was positive for Treponevia pallidum.
Arsenical
treatment
began
with
a
0.3
gram
injection
of
neoarsphenamine
December
24,
1935, followed
by 0.4 gram injections
on December
31,
1935, and
January
7,
1936, and a 0.45 gram injection
on January
15, 1936.
He was given
4
injections
of bismuth,
a total of 0.52 gram, as concurrent
treatment.
148
PREVENTIVE
MEDICINE
On January 20, 1936, the patient was admitted to the sick list because
his room
mates complained
that
he had
been
acting
peculiarly
for 3 days.
The patient
refused to talk to any one except to say "I am sick."
Upon admission the patient
looked ill, his eyes were glassy with a staring
expression, and his beard showed
about
3 days' growth.
He stated that he had been sick for 3 days, complaining
of pains in the abdomen, vomiting
and diarrhea, and had not urinated during this
period.
Examination
revealed a large tumor-like
mass in the region of the urinary
bladder.
He was catheterized
and
1,150
cubic
centimeters
of urine
obtained.
The tumor-like
mass
disappeared.
The patient
was oriented
as to place and
position
but completely
disoriented
as to time.
On further questioning, it was
plainly evident that his story could not
be relied upon.
January 21:
The patient appears somewhat clearer mentally
but disoriented
as
to time.
He has vomited
about three times since admission,
the vomitus
con
sisting of clear undigested food.
He was catheterized at 10 p. m. last night and
again this morning,
after
he had made numerous
unsuccessful attempts
to void.
The right nostril
is obstructed
by nasal secretion and watery pusy secretion, with
edema of the mucous membrane
and turbinates.
The soft palate and pharynx
show injection
and inflammation
with
a slight foul odor to the breath.
January 22.
The patient
complains
of headache which prevented his sleeping
during the night.
Spinal puncture
done, prone position;
initial pressure 22 milli
meters of mercury, with a fall and rise to 34 millimeters
of mercury
on bilateral
jugular pressure.
The fluid is clear throughout
and possibly
30 to 35 cubic centi
meters withdrawn.
Spinal
fluid cell count, polys,
13; lymphs,
82; monos,
1, and
unclassified,
4.
The spinal pressure was 6 millimeters
of mercury.
The patient
stated his headache left him after the spinal fluid withdrawal.
The impression of
this case is that it is possibly a reaction of neoarsphenamine with cerebral edema
and meningovascular
syphilis involving the basal portion
of the brain, as there is a
disburbance
in the patient's
speech
and his ability to enunciate
clearly.
Possi
bility of brain abscess.
January
23.
The patient
stated that he feels
better
than he has for several
days.
Complains
of mild
headache, which
prevented
him
from
sleeping
well.
Examination
shows injection
and edema of both nerve heads with tortuosity of the
vessels.
The bowels have not been evacuated or the bladder emptied since admis
sion, there being an overflow when the bladder becomes
distended.
Temperature,
normal;
pulse, 60.
January
24.
The patient
had a comfortable
night, sleeping most of the time.
During the late part of the morning
he complained of increasing headache, stating
"It is worse than it has ever been before."
Temperature
97° F., pulse between 48
and 50; respirations,
16 to 18.
There
is still present an injection
of the mucous
membrane
of the nasal pharynx
and the Boft palate with
a catarrhal
discharge
from
the posterior
pharyngeal
wall.
The patient
is still unable
to empty
the
bladder
or bowels voluntarily.
Spinal
puncture
done and 25 to 40 cubic centi
meters of clear spinal fluid withdrawn.
Initial pressure, 36 millimeters of mercury.
Jugular compression of the right side failed to bring about any rise in the mercury
column,
on the left side the mercury
rose
2 millimeters
to 40 millimeters.
The
patient
stated
that
the headache disappeared
following
the withdrawal
of
the
fluid.
Blood pressure,
102/70.
January
27.
The patient
feels
well.
He
is sleeping satisfactorily
and has a
good appetite.
He was able to empty the bladder last night and this morning.
The patient's
condition
gradually
improved
and by February
8 he was able to
urinate and control
the bowels without
difficulty.
By February
18 he was up and
about, eating and sleeping well, correctly
oriented at all times, and has no com
plaints.
He was returned to duty March 20, 1936,
64 days after onset of the first symp
toms.
PREVENTIVE
MEDICINE
149
(75-1936.)
This
patient
was exposed to infection
October
26,
1935,
and
7
weeks later a lesion appeared
on the glans penis.
Repeated
dark-field
examina
tions of the lesion
were negative
for
Treponema
,pallidum.
Kahn
blood
tests
were 4-plus, December
16, 1935, and January 6, 1936.
A spinal fluid examination
showed
1,174 cells and gold curve,
1222222343.
Arsenical
treatment
was instituted
January
8, 1936, with
a 0.3-gram injection
of
neoarsphenamine,
followed
by
a 0.3-gram
injection
on January
10, and
a
0.6-gram
injection
on January
17.
Four intramuscular
injections
of
bismuth
salicylate
were given as concurrent
treatment.
Approximately 56 hours after the last injection
of neoarsphenamine
the patient
complained
of slight headache and nausea.
Temperature
of 100° F.
January
19: The
patient
felt
better
at
morning
sick
call.
Headache
and
nausea
had subsided.
Temperature,
99.2°
F.
Several
hours later
the patient
appeared
to be disoriented
and restless.
His temperature
rose to 101° F. at noon
and
returned
to normal
within
6 hours.
The patient
was seen
by the medical
officer
of the day at 10 p. m., and he appeared quiet and comfortable.
He had
no complaint
and slept through
the night.
January
20.
At 8:30 a. m. the patient
was semiconscious, did not understand
or answer
questions,
and
could
not
be aroused.
Examination
showed:
Heart
sounds,
normal;
blood
pressure,
130/78; lung
sounds,
negative;
pupils,
dilated;
Babinski,
Kernig's,
ankle clonus, and knee jerks,
negative;
and biceps reaction,
positive.
Spinal
puncture
shows clear fluid,
not under
pressure, dripping
very
slowly,
and
about
10
cubic
centimeters
drained.
Patient's
unconsciousness
became gradually
more profound.
During the morning
he appeared better after
the
injection
of epinephrine
hydrochloride,
and
the
pulse
and
blood
pressure
were good.
Urinalysis:
Color,
amber;
reaction,
acid;
specific
gravity,
1.024;
albumin,
2
plus; few fine granular
casts;
few cylindroids;
few leukocytes;
few epithelium.
Autenrieth's test, negative.
Blood:
11
a.
m.—Red
blood
count,
4,500,000;
white
blood
count,
4,800;
hemoglobin,
90 percent; monos, 2; lymphs,
12; segments, 68; bands,
18; platelets,
160,000.
I p. m.—Red blood count,
4,610,000; white
blood count,
22,500; hemoglobin,
90 percent;
lymphs
7; segments, 73; bands,
17; juveniles,
3; platelets,
170,000.
7 p. m.—Red
blood count,
4,200,000; white blood count,
17,200;
hemoglobin,
80 percent;
segments, 72; lymphs,
9; bands,
19.
During the afternoon the blood pressure dropped steadily.
He was unconscious
and the lower limbs paralyzed.
At 6 p. m. breathing
was of the Cheyne-Stokes
type,
the pulse weaker and more rapid.
Treatment given January 20,
1936:
9
a.
m.—Epinephrine
hydrochloride,
1-1000
solution,
1
cubic
centimeter
subcutaneously.
Two ounces of magnesium sulphate
by mouth.
9:30 a. m.—One gram of sodium thiosulphate
intravenously.
II
a.
m.—Epinephrine
hydrochloride,
1-1000
solution,
1
cubic
centimeter
subcutaneously.
Two ounces of magnesium sulphate by mouth.
11:30
a. m.—Twenty cubic centimeters of 50 percent glucose intravenously.
1
p.
m.—Epinephrine
hydrochloride,
1-1000
solution,
1
cubic
centimeter
subcutaneously.
2 p.
m.—Epinephrine
hydrochloride,
1-1000
solution,
0.5
cubic
centimeter
subcutaneously.
3 p.
m.—Epinephrine
hydrochloride,
1-1000
solution,
0.5
cubic
centimeter
subcutaneously.
Fischer's
solution,
125 cubic centimeters by proctoclysis,
at the
rate of 30 drops per minute.
4 p. m.—Epinephrine
hydrochloride,
1-1000 solution,
1 cubic centimeter
sub
cutaneously.
150
PREVENTIVE
MEDICINE
6 p. m.—Epinephrine
hydrochloride,
1-1000 solution
1 cubic centimeter
sub
cutaneously.
8 p. m. —Twenty cubic centimeters of 50 percent glucose intravenously.
Epine
phrine hydrochloride,
1-1000 solution,
1 cubic centimeter subcutaneously.
9 p. m. —Fischer's
solution,
125 cubic centimeters
by proctoclysis,
at the rate
of 30 drops per minute.
9:30
p.
m.—Epinephrine
hydrochloride,
1-1000 solution,
1 cubic
centimeter
subcutaneously.
11:30
p.
m. —Epinephrine
hydrochloride,
1-1000 solution,
1 cubic centimeter
subcutaneously.
The patient died at 12:25
a. m., January
21,
1936, within 4 days after the last
injection
of neoarsphenamine.
Autopsy
findings:
(1)
Acute
hemorrhagic
encephalitis.
(2)
Acute
congestion
of all viscera.
Tryparsamide. — (7(5— 1936.)
This
patient
(supernumerary,
retired,
U.
S.
Navy) was given a diagnosis of syphilis
because
of clinical and serological findings.
The patient stated he was probably
infected in 1920.
From March 25 to April 29, 1935, he received 12 injections of bismuth salicylate;
from May 2 to July 2, 1935, 8 injections
of neoarsphenamine,
a total of 4.2 grams;
and from July 16 to November
12, 1935,
16 injections
of bismuth
salicylate.
He complained
of vomiting
when he was admitted
to the sick list on December
20, 1935, stating that the vomiting
occurs early in the morning and is followed by
four
or
five
retching
spells.
Physical examination
essentially
negative.
The
patient
was kept under observation
and treatment.
He was given 1.5 grams of tryparsamide
on December 27, 1935, and 3 grams on
January
7.
Six days after the last injection
of tryparsamide
the patient
stated
that he could not see and read well.
Eye examination —Vision:
O. D. 20/40—1,
J 14; O. S. 20/50 +4, J 18.
Ophthalmoscopic
examination
shows vitreous humor
clear, except for round floating
vitreous
opacity
in left eye, and disks paler than
normal.
Fields
for form
decreased
concentrically
4/8.
It is believed
that
the
color of disk may
be accounted
for in part by the age of the patient
and some
loss of field by ametropia.
January
27.
Vision:
O. D. 20/50-1, J
14;
O.
S.
20/70, J
16.
Visions
and
fields continue to decrease.
No change
in fundus picture.
February
11.
Fields
for form V. O. D. has increased approximately
one-third
over last report;
V. O. S. approximately
the same
size.
March 2.
The vision about the same.
The patient
is up and about the ward.
He can read newspaper captions but not the ordinary
print.
March 17.
The fields for form V. O. D. has increasedly markedly
over the last
report, within 20° circle and V. O. S. increased with 30° circle.
March 27.
Vision:
O. D.
20/50 + 4; O. S. 20/70—1.
The fields are virtually
stationary.
It is considered
that further diminution
will probably
not take place
or that improvement
will
progress further.
He
has received
20 injections
of
bismuth salicylate,
2 grains each,
between December 31, 1935, and April 21, 1936.
The patient
was transferred
to the Naval Home,
Philadelphia,
Pa.,
78 days
after the onset of the first symptoms,
with
diagnosis "optic neuritis,
from try
parsamide,
condition
stationary."
ANTITETANUS
TOXOID
By O. S. Siephknson,
Commander,
Medical Corps, United States Navy and W. W. Hall, Commander,
Medical Corps,
United
States Navy
Active immunity in man animal against
tetanus
can be developed
by the injection of tetanus toxoid as demonstrated
a few years ago by
Ramon of the Pasteur Institute
Ramon had
developed
diphtheria
PREVENTIVE
MEDICINE
151
toxoid
and later the refined
alum-precipitated diphtheria toxoid was
developed, now so universally used in immunization of children against
diphtheria.
Evidence from both animal and human immunization
with alum-
precipitated
tetanus
toxoid (quite analogous
to that of diphtheria)
indicates
that
a
satisfactory
active
immunity
can
be
developed
against
tetanus
by
two injections
8
weeks
apart.
The
immunity
thus
produced
diminishes gradually
but
persists
at
a satisfactory
protective level for at least 2 years and probably much longer.
In handling wounded
patients who have been previously immunized
against tetanus by toxoid injections, it is now recommended
that they
be given
a stimulating
or "pick-up" injection
of alum-precipitated
tetanus toxoid in case there is any doubt about the immunity
level.
Immunized
individuals
even
those
with
very low antitoxin
titers,
respond to a secondary
immunization
by a sharp
rise to high levels
within
a
week.
This
sharp
rise
on
secondary
stimulation
means
ample
protection against
possible
tetanus
at the time,
and
a higher
level of immunity
for the future.
Possibly, lifetime immunity
may
result after two or more "pick-up" shots.
Work
which supports
the
above
has
been
published
by Ramon
(France),
Sneath
and Kerslake
(Canada), Bergey and Etris (United
States), Hall (U. S. Navy), and more recently Leach, Zia,
and Lim
(China).
Tetanus
toxoid is thermostable —not deteriorating
when
exposed
to heat, as for example with expeditionary forces.
Tetanus toxoid
is
serum
free, not producing reactions,
anaphylaxis, or serum
sickness.
As there is no simple means of estimating immunity against
tetanus
such as the Schick test in diphtheria, patients must be bled and the
serum
titrated for antitoxic strength
by the protection it affords
test
animals against
known amounts
of tetanus
toxin.
Because
of these
difficulties,
the data from work with
man
is accumulating slowly,
though much animal experimental
data are available.
Mass-immunization
and data on tetanus
incidence
in the protected
group, compared
with unprotected
groups, will be convincing.
Such
work is now in progress in the United States.
In France this method
of immunization
against
tetanus
has, by recent legislation, been made
mandatory in
the Army
for men
and
animals.
Accurate data ob
tainable only by animal titration of serum antitoxin
are needed and
can only be accumulated
by the efforts of many laboratories.
The Medical Department, United
States Naval Academy, and the
Naval Medical School are now cooperating
in the study of a group of
137 volunteers,
including the football squad at the Academy who were
immunized early this year by
two injections
of alum-precipitated
tetanus toxoid.
152
PREVENTIVE MEDICINE
FOOD
POISONING
ON BOARD THE
IT. S. S. "NEVADA"
The outbreak occurred
among
the enlisted
personnel
on June 26,
1937, and involved 131 men.
All men reporting and those found sick
about the ship were treated, admitted to the sick list, and put to bed
in the ward and adjoining compartments assigned for the purpose.
From those affected it was found that the first symptoms,
consisting
of nausea and mild abdominal cramps,
began approximately
2 hours
after eating
the noon meal.
The symptoms gradually became
more
severe, until
at the end of 3 hours
most of the men began vomiting
and complained
of severe abdominal cramps.
Four of the men were
unconscious
when brought to the sick bay and one of these four had
not vomited,
7 hours after eating.
His entire
body was rigid and at
intervals
respiration
would
cease
for
an
alarming
period of time.
His pupillary
reflexes were present
and the pulse was of normal rate,
full and regular.
Following
the induction of emesis he responded
to
the routine treatment.
Hysteria was considered
a factor in this case.
All of the first vomitus consisted
of ham and other articles
of food
from the noon meal.
In some cases after the food had been ejected,
retching would continue and some bloody material was vomited.
The usual
symptomatic treatment was instituted
and response in
all
cases
was satisfactory.
On June
28,
the
second
day after
the
outbreak, all patients were examined
and it was necessary
to retain
only one man on the sick list.
He was discharged
to duty the following
day.
The following menu was served for noon meal on June 26.
Opposite
each item on the menu
is indicated the number of men eating
that
article of food, who became ill:
Bean soup
46
Turnips
17
Boiled
ham
..
131
Potatoes.
71
Boiled
cabbage
59
Pickles
70
Carrots
and peas
52
Bread, butter,
and coffee
99
It will be observed
that 131 men became ill, all of whom ate ham.
Ten of these men
ate only ham
sandwiches
and did not partake of
anything
else
served.
All
messes
except
the
chief
petty
officers'
were involved, from
1 to 15 men per mess becoming ill.
A total of 636 men were on board for the noon meal,
505 of whom
suffered no ill effects.
The men who did not become ill partook of the
foods
on the menu
to the same extent
as those who did become ill.
This is indicated by the following summary:
Bean soup
180
Turnips
150
Boiled ham
476
Potatoes
399
Boiled
cabbage
256
Pickles
452
Carrots
and peas
238
Bread,
butter, and coffee
476
Forty-two
hams were boiled Thursday
afternoon,
June 24, and cold
water poured
over them
to cool them off.
One hour later the water
was drained off and
the hams left until
4 a. m., June 25, at which
PREVENTIVE
MEDICINE
153
time
they
were
removed
to steep tubs.
Between
10 and
11
a. m.
they were skinned
and boned and four of the hams given to the chief
petty officers'
cook.
The tubs of hams were left on the galley
deck
until field-day was completed.
At 4:30 p. m. the hams were put in a
cool oven where they remained
until about
11 a. m. the next day, at
which time they were removed,
sliced, and issued to the various mess
cooks for the noon meal.
From the foregoing it is obvious that the ham was responsible
for
the outbreak.
The ship's cook who boned the hams was found upon
examination to be a carrier of the organisms
of food poisoning
group
(staphylococcus albus-poisoning strain).
Bacteriological examination
of specimens
obtained from cooked
hams from the same lot served
for the meal in question
showed no contamination by organisms
of the
food-poisoning group.
The opinion of a board appointed to investigate this outbreak was:
"That during the process of skinning and boning on June 25,
1937,
the
hams
which
had
been
cooked
on June
24,
1937
became
con
taminated."
24140—37
11
STATISTICS
HEALTH
OF THE NAVY
The following
tables
are summaries
of morbidity
rates
per
1,000
for
the
second
quarter of
1937
in
comparison
with
rates
for
the
corresponding
quarter of the preceding
5 years:
Entire
Navy
Year
diseases
ah
Injuries
Poison
ings
All
causes
Communicable
diseases
Venereal
diseases
A
B
470
51
0.33
521
(')
(')
141
1933
407
62
1.51
470
18
76
100
1S34
385
67
.45
452
35
116
64
371
66
1.88
438
28
85
62
1936
337
49
.07
386
30
140
42
1937
276
36
.31
313
18
98
59
FOBCES ASHORE
1932.
1933.
1634.
1935..
1936.
542
44
0. 31
586
(')
(')
92
480
-
78
.91
565
23
96
79
621
87
1.15
709
76
230
58
491
78
1.53
571
54
110
45
518
50
.09
568
59
226
26
312
36
.50
347
34
131
27
FORCES AFLOAT
431
64
0.34
486
(')
(0
369
54
1.80
424
16
64
271
57
. 11
328
15
62
312
58
2.06
372
16
72
229
49
.05
278
13
89
256
37
.20
293
8
78
1932.
1933
1934.
1815
1936
168
111
(57
71
51
78
' Not available.
Common
infectiom
diseases
of the respiratory
type. —A total of 2,617
admissions
for
these
diseases
were
reported
from
the
entire
Navy
during the second quarter of the year
1937, or a 68-percent
decrease
from
the number of cases
notified for the
preceding
quarter.
Ca
tarrhal
fever
was responsible
for
1,645
of
the total
admissions
for
these diseases.
Ships
and
shore
stations reporting
the
largest
number of
cases
were as follows:
April
May
June
Total
Naval Training Station,
Newport, R. I
-
Naval Training Station,
San Diego, Calif
Naval Training Station.
Norfolk Va
--
-
Marine Corps Ban,
San Diego, Calif
-
U. S. 8. Oklahoma
Naval Training Station,
Great
Lakes, Hi
Naval Academy,
Annapolis,
Md.
(other
than
midshipmen;
Fourth Marines, Shanghai,
China
Naval Air Station,
Pensacola.
Fla
Naval Air Station.
Norfolk, Va
Marine Barracks,
Quantico,
Va
0. S. S. TtKMUtt
Marine Detachment,
Peiping,
China
U. S. S. Lexington
---
105
S3
57
21
12
11
13
8
IT,
Ill
10
12
240
194
79
,i3
48
47
46
45
42
z;
35
35
35
155
156
STATISTICS
Of the 2,617 admissions
for the entire Navy,
1,401
admissions
were
reported
by forces ashore and
1,216 for forces afloat.
Influenza was the cause of two deaths, complicated in one instance
by
pneumonia,
broncho
(U.
S.
Naval
Hospital,
Chelsea,
Mass.),
and in the other by meningitis, cerebrospinal,
acute (U. S. S. Tennes
see).
Tonsillitis,
acute,
was
recorded
as
the primary
cause of one
death,
the contributory
cause being
abscess, lung.
Several
rather severe
cases
of gastrointestinal influenza occurred
during the month of June at the Navy Yard, Charleston, S. C.
The medical
officer of the United
States
Naval
Training
Station,
San
Diego, Calif.,
comments
as
follows in
the
sanitary
report for
June 1937:
The health
of the personnel
during
the month
of June has been
good.
Al
though
the
personnel
has
been
increased
approximately
20
percent
over
the
previous
2
years
the
acute
respiratory
infections
(bronchitis,
acute)
which
required
hospitalization
has increased approximately
60 percent.
This is attrib
uted to the more severe type of respiratory
infections
over the previous
2 years
and to the climatic
conditions.
Cerebrospinal
fever. —Seven
cases
of cerebrospinal
fever
were
re
ported
in April, May, and June 1937,
as follows:
Rate
Age
Place of original
admis
sion
Date of
admission
Length
of
service
Disposition
Yrt.Moa.
Seaman, first -class
21
24
24
26
20
20
21
U. S. S. Nerada
Apr.
7, 1937
.... do
1
6
8
7
Duty, June 22, 1937.
Duly, June 4, 1937.
Dutv, July 17, 1937.
Duty, June 28. 1937.
Duty, July 20, 1937.
Duty, Sept.
14. 1937.
Duty, July 8, 1937.
Seaman,
first-class
U. S. S. Chaumont
May
13,1937
do
2
3
7
6
Seaman, first-class..
.
U. S. S. Hanger
Seaman, second-class...
Seaman,
first-class
U. S. S. Trenton
May
12,1937
June
14.1937
June
8,1937
0
6
2
7
U. P. S. Dobbin
U. S. S. Pope
1
6
Mumps. —One hundred and sixty-six cases of mumps
were reported
for the quarter.
The United
States naval training station, Norfolk,
Va., reported 28 cases in April, 34 in May, and 21 in June; the U. S. S.
West Virgmia,
13 in May and
16 in June; the Marine
detachment,
Peiping, China,
16 in April and
1 in May; the Submarine Base,
New-
London,
11 ; the Marine Barracks, Quantico, Va., 6; the naval training
station, San Diego, Calif., 3; the naval training station, Great Lakes,
1ll., naval air station, San
Diego, Calif.,
naval air station, Seattle,
Wash., and
the fleet air base, Pearl Harbor, Territory of Hawaii,
2
each; and
1 each from 9 shore stations.
The Sanitary Report for the month of April from the United States
naval training station, Norfolk,
Va., stated
that "mumps, which has
been highly prevalent in
the population of Norfolk,
increased
and
affected widely scattered
units."
German
measles. —The Fourth
Marines, Shanghai,
China, reported
eight
cases
of German measles in April and
two
in May;
and
the
naval training station, San Diego,
Calif.,
two in May.
STATISTICS
157
Scarlet fever. —One case of scarlet fever was reported from the third
naval district headquarters,
New York, N. Y., in April, and one each
from the Receiving Ship, San Diego, Calif., and the Marine detachment
Peiping, China, in May.
Chickenpox. —Ten cases of chickenpox were reported for the quarter
as follows: In April, one each from the Marine Corps base, San Diego,
Calif., Navy Yard, Mare Island, Calif., and the Marine
detachment,
Peiping, China; in May, one each from the Naval Research Labora
tory, Anacostia, D. C, United
States
Naval
Academy, Annapolis,
Md. (other than midshipmen), Receiving Ship, New York, N. Y., naval
training station, Great Lakes, 11l., naval training station, San Diego,
Calif., and the U. S. S. Argonne; and in June, one from the Navy Yard,
Washington, D. C.
Typhoid fever. — A
fireman,
third-class,
23
years
of
age,
with
8
months' service, was admitted on June 2,
1937,
to the U. S. S. Ranger
with
diagnosis
"Undetermined
(typhoid
fever)."
The patient was
transferred to the United
States
Naval
Hospital,
San Diego, Calif.,
on June 11, where
the diagnosis
of typhoid fever was established
and
he was
discharged
to duty
on August
31,
1937.
Probable
place
of
infection was Honolulu, Territory of Hawaii.
One course of typhoid
prophylaxis had been completed
November 2, 1936.
Malaria. —The
general
health conditions
of
the Submarine Base,
Coco Solo,
Canal
Zone, during the month of June 1937,
were satis
factory,
except
for malaria.
The rainfall
for this month has
been
exceeded in amount in only
1 year in the past 30.
The Senior Medical
Officer reports:
Eleven
cases
of malaria
were
placed under treatment
for the moiith
of June,
nine from this base and two from the U. S. S. Hannibal.
During the correspond
ing month
in
1936 there were
2 cases
from
shore activities
on this side of the
Canal,
but no cases from the U. S. S. Hannibal or U. S. S. Nokomis.
There
were
no relapses during
the month.
It would appear that
the outlook
regarding
ad
missions for malaria
during the coming months
is bad.
The
station
medical
officer
of
the
United
States
naval
station,
Olongapo, P. I., reports:
Twelve
cases
of malaria
treated at the Camilla Simpson Hospital during
the
month.
Of these
six can trace their
infections
to towns in the northern
part of
the Province,
where they
have been
employed
in mines and
in lumber
camps.
Five of the cases apparently
received their infections
in the heavily
wooded out
lying barrios,
which afford
a harborage of mosquitoes
close to the dwellings..
In
one case the source of infection
cannot
be traced.
Venereal
diseases. —The
medical
bulletin
of
the Battle
Force
for
the month of July 1937 announces:
That the venereal rate in ships of the Battle Force is steadily
declining.
The
annual
rate per
1,000 for the calendar
years
1934,
1935, and
1936
was
111,
92,
and
58, respectively.
For the first half of 1937 the rate shows a slight
decrease
158
STATISTICS
over that of 1936, and it is hoped that the second half of the year will show an
even greater reduction.
The following data for the first half of 1937 are submitted
:
(a)
Annual rate per
1,000 for all venereal diseases
for entire
Battle
Force for
the period January
1 to June
30,
1937,
inclusive,
was 49 as compared
with
58
for
1936.
(b)
Monthly
average
number
of gonorrheal
infections
for the entire
Battle
Force
during
the first
6 months
of
1937
was
100.6
as compared
with
118.8
for
1936.
(o)
The
highest total
number
of admissions
for gonorrheal
infections
during
any one month
was
128.
There
were
2 months in which this high rate, occurred,
namely, January and June.
(d)
Thirty-five
admissions
represented
the lowest
total
for
any
one month;
this was during
the month of May
1937.
The
following
table
of statistical
data
for battleships
and
larger
vessels of the Battle Force indicates
the frequency
of occurrence
of
venereal
diseases during
the second quarter of
1937,
as reported
in
monthly reports of communicable
diseases received
in the Bureau:
Ship
Arizona
California
Cincinnati
Colorado
Concord
Idaho
Marhlchead
. . .
Maryland
Memphis
Milwaukee
Mississippi
Nevada.
New Mexico...
Oklahoma
Omaha
.*
Pennsylvania..
Richmond
Tennessee
Trenton
West Virginia.
Annual ad*
mission
rate
per 1.000,2d
quarter,
1937
63. 18
.18.95
0
83.93
1I. 77
57.23
74.07
38.38
112.56
.'12.17
79.30
17.11
71.30
63.94
168.19
30.88
72.58
78.18
06.38
59.18
Annual ad
mission
rate
per 1,000,2d
quarter,
1936
43.58
84.42
78.77
61.67
38.91
91.21
112.31
53.79
291.73
51.17
54.69
43.16
56.48
76.85
92.82
41.33
60.34
60.05
101.75
58.97
Weighted
average
per 1,000,
2d quarter.
1933-36
84.55
105.15
71. 17
123.63
90.87
104.99
120.69
99.85
154.40
79.74
107.98
79.90
89.18
95.05
82.19
81.74
176.47
92. 15
135.73
88.76
Food poisoning.— In the monthly sanitary report for June 1937,
the
post surgeon of the Marine Barracks, Quantico, Va. reported:
On June 28, seventy-seven
men
were brought to sick quarters from F. M. C. R.
camp
suffering
from
abdominal
cramps,
nausea, and
diarrhea;
many
vomited.
All returned
to duty
next morning
save three, two of whom had three sick days
and one of whom
had four
sick days.
Staphylococci
alba were cultured
from
stomach
contents,,
feces,
and from minced ham used
in sandwiches,
cf which all
had eaten
about
12:30
p. m. on June 28.
INJURIES
AND POISONINGS
Admissions for Second
Qttartek
Ending
June 30,
1937
The
following
table,
indicating
the
frequency
of
occurrence
of
accidental injuries and poisonings in the Navy during the second quar
ter,
1937, is based upon all Form F cards covering
admissions
in those
months
which have reached
the Bureau:
STATISTICS
1.59
Admissions,
April, May,
and June,
1937
Admission
rata per
100,000
per annum
Admission
rate per
100,000,
INJURIE"
year 1937
Connected with work or drill
520
398
257
1,010
1,232
796
2,513
1.924
1,760
Occurring within command
bat not associated with work
..
.
Incurred
on leave or liberty or while
absent without leave
1, 175
3.R3S
6,197
Industrial
poisoning
POI"ONINGS
4
12
16
3
7
211
18
Occurring
within command
but not connected with work...
Associated with leave, liberty, or absence without leave..
. .
5
1
10
31
236
Total injuries
and poisonings
1,185
3,669
6,434
Percentage
relationships
Connected with the
performance
of
work, drill, etc.
Occurring
within command
Not connected with
work
or
pre
scribed
duty
Occurring
out
side
command
-leave, liberty,
or A. W. O. L
April, May,
and June
1937
Year
1931!
April, May
and June
1937
Year
1936
April.May.
and
June
1937
Year
1936
Percent of all injuries
44.2
40.0
40.6
33.9
50.0
31.0
89.5
21.9
10.0
28.4
7.5
Percent of all poisonings
Percent
of total
admissions,
injury
and
poisoning
titles
3.0
44.2
39.2
34.0
33.2
21.8
27.6
Notm. —Poisoning
by a narcotic
drug or by ethyl
alcohol is recorded under the title "Drug addiction" or
"Alcoholism," as the case may be.
Such cases are not included
in the above figures.
Three
members
of service
personnel 'sustained
injuries
when
the
German airship Hindenburg burned
at the naval air station, Lake-
hurst, N. J., on May 6, 1937.
MORBIDITY
Summary for the Second Quarter Ending June 30,
1937.
Forces afloat, 81,417 Forces ashore, 47,781 Entire navy,
129,198
Admis
Rate per
Admis
Rate per
Admis
Kate per
sions
1,000
sions
1,000
sions
1,000
All causes
5,967
293. 1G
4,140
346.58
10.107
312.92
5.201
255.62
3,721
311.50
8.922
276.23
Injuries
762
37.44
413
34.57
1, 175
Wi.38
Communicable
diseases transmissible
by
4
.20
6
.50
10
.31
oral and nasal
discharges
(class VI11):
(A)
166
8.16
404
33.82
570
17.65
(B)
1,590
78.41
1,560
130.60
3,156
97.71
1,584
77.82
317
26.54
1,901
58.86
160
STATISTICS
DEATHS
During the
Second
Quarter
Ending
Junb
30,
1937
Cause
Navy
Marine
Corps
Nurse
Corps
Total
Primary
Secondary or contributory
Offi
cers
Mid
ship-
men
Men
Offl-
cers
Men
DISEASE
9.670
1,994 99.080
1,304
16,754
396
129,198
1
Aerogcnous
capsulattis
In
fection, thigh.
1
1
2
1
do
1
1
1
Carcinoma,
liver
. ... .do
Endocarditis,
acute
ulcera
tive (malignant).
Arthritis,
acute,
wrist
and phalangeal.
1
Oonococcus
infection,
ure
thra.
Endocarditis,
acute
ul
cerative (malignant).
1
1
Hyperthyroidism.
1
1
2
1
Do
Meningitis,
cerebrospi
nal, acute.
1
i
Otitis,
media, acute
Meningitis,
cerebrospi
nal, acute.
I
Nephritis, chronic
.
1
Do..
1
Pancreatitis,
acute,
hemor
rhagic.
..
.do
5
1
1
1
1
1
1
1
1
2
Do
Do
Do
.
1
Sarcoma, pubis and ischium.
Thrombosis,
cavernous sinus.
Do
do
Otitis,
media, acute
Do
Tonsillitis, chronic
1
Thrombosis,
coronary artery.
None
2
3
Myocarditis, chronic
1
1
1
Tuberculosis,
pulmonary,
chronic,
active.
Tuberculosis,
peritone
um.
Do
Hemorrhage,
duodenum
Hemorrhage,
intestines..
Peritonitis,
general,
acute.
1
1
1
Do
Do
1
Valvular heart disease, com
bined
lesions,
aortic
and
mitral.
1
INJURIES
AND POISONISOS
7
1
34
2
6
1
51
Crush,
chest...
1
1
1
.. ..do
1
. ..do
4
11
2
1
15
3
1
Fracture,
compound,
sttull.
do
1
Do
Meningitis,
ccrebrospl-
nal, acute.
Fracture,
compound,
tem
poral.
1
1
Fracture,
simple, temporal..
iremorrhage,
traumatic,
1
1
intracranial.
Edema,
lung
Do
Intracranial
injury. -
1
2
1
1
2
I
Do
Rupture,
traumatic,
lung.
STATISTICS
161
Deaths
During
the
Second Quarter
Ending
June
30,
1937 — Continued
Cause
Navy
Marine
Corps
Nurse
Corps
Total
Primary
Secondary or contributory
Offi
cers
men
Mld-
ship-
Men
Offi
cers
Men
INJURIES
AND POISONINgS—
continued
Fracture,
simple,
vertebrae,
1
cervical.
Injuries,
multiple,
extreme
do
1
1
1
4
1
1
3
Strangulation,
neck
Do
Wound, gunshot,
abdomen..
1
1
1
Wound, gunshot,
chest
do
1
Wound, gunshot,
head
do
1
1
1
3
1
2
do
Poisoning
acute,
carbon
Totaljor Iniuries
and
Grand
total
do
2
10
31
1
8
50
Annual death rate per 1.000:
17
1
65
3
14
1
101
7.03
2.90
1.8S
2.01
2.01
2.62
1.37
.44
.08
.73
9.20
6. 13
3.34
1.43
10.10
10.10
3.13
1.58
.46
.06
2.48
3.07
1.91
1.02
MENTAL
AND PHYSICAL
QUALIFICATION
OF RECRUITS
Statistics for Second Quarter
Ending
June
30,
1937
The following statistics were taken from sanitary reports submitted
by naval training stations:
April, May, and June, 1937
Recruits
received during
the period
Recruits
appearing
before Board
of Medical Survey
Recruits
recommended
for discharge from the service...
Recruits
discharged
by reason of medical survey
Recruits
held over pending
further
observation
Recruits
transferred
to the hospital
for treatment,
oper
ation,
or further
observation
for conditions
existing
prior to enlistment
United States naval training
station—
Norfolk,
Vs.
Newport,
R. I.
Great
Lakes, Hi.
San Diego,
Calif.
1,421
754
810
1,471
1
0
9
0
1
0
9
0
3
0
0
0
0
0
0
0
0
18
84
74
The following table was prepared
from reports
of medical
surveys
in which disabilities or disease causing
the surveys were noted existing
prior
to
enlistment.
With certain
diseases, survey followed enlist
ment
so
rapidly
that it would
seem
that many might
have
been
eliminated
in the recruiting office.
162
STATISTICS
Cause of survey
Absence,
acquired,
teeth.
Acne,
vulgaris..
Amblyopia, both eyes
Arterial hypertension
•
Arthritis, chronic.
-
.
Asthma
-
Astigmatism
Cardiac
disorder,
functional
Caries,
teeth
Chorea,
progressive,
chronic
Color
blindness
Congenital
heart disease
Constitutional
psychopathic
Inferior
ity, without psychosis
Constitutional
psychopathic
state,
emotional
instability
Curvature, spine
Deafness, bilateral
Deafness, unilateral
Deformity,
acquired,
left leg
Dementia
praecox.
Ellort syndrome
Enuresis
-
-
--
Epilepsy
Flat foot
Oastroptosis
Oonococcus Infection,
epididymis
Oonococcus infection,
urethra
Hernia, inguinal
Hernia,
inguinal,
recurrent
after opera
tion
Hydrocele,
spermatic
cord
Malformation,
congenital,
cervical rib.
Number
of
Cause of survey
Malformation,
congenital .left kidney. . .
Malocclusion,
teeth
Montal deficiency,
moron
Meta tarsalgia
Migraine
Myopia
Myositis, chronic
Nephroptosis
-
Narcolepsy
Otitis,
media, chronic...
Pes cavils
-
Prostatitis,
chronic
(nonveuereal)
Psychoneurnsis,
hysteria
Fsychoneurosis,
neurasthenia
Psychoneurosis,
psychasthenia
Pyelitis, chronic,
left
Somnambulism
Sprain,
sacroiliac Joint
Stammering
Strabismus
Syphilis
Tic
Union of fracture,
faulty
Urethritis, chronic
(nonvenereal)
Valvular
heart
disease,
combined
lesions, aortic and mitral
Valvular
heart
disease,
mitral
insuf
ficiency
Valvular heart disease, mitral
stenosis..
Varicocele
--
Vincent's
infection,
oral
Wart
Number
of
11
o
Volume XXXVI
APRIL 1938
Number
2
United States..
Naval
ip.
Medical Bulletin
Published for the Information
of the
Medical Department
of the Navy
THE MISSION
OF THE MEDICAL
CORPS OF THE NAVY
•
TO KEEP AS MANY MEN AT AS MANY GUNS
AS MANY DAYS AS POSSIBLE
Issued Quarterly
by the Bureau of Medicine and Surgery
Washington, D. C.
Vol. XXXVI
APRIL
1938
No. 2
UNITED STATES
NAVAL
• MEDICAL BULLETIN
Published Quarterly
for the Information of
the Medical Department
of the Navy
t
Issued by
DIVISION OF PUBLICATIONS
THE BUREAU
OF MEDICINE
AND SURGERY
NAVY DEPARTMENT
Compiled
and published
under the authority of Naval Appropriation
Act for 1937-38, approved
April 27, 1937
*
UNITED
STATES
GOVERNMENT
PRINTING
OFFICE
WASHINGTON : 1938
For sale by the Superintendent
of Documents,
Washington,
D. C.
See page n for price
Navy Department,
Washington,
March 20, 1907.
This United
States Naval Medical Bulletin
is published by
direction of the Department for the timely information of the Medi
cal and Hospital Corps of the Navy.
Truman H. Newberry,
Acting Secretary.
Owing
to exhaustion
of certain
numbers
of the Bulletin
and
the frequent
demands from libraries,
etc., for copies to complete their
files,
the return of any
of the following
issues will be greatly appreciated:
Volume IX,
1915, No.
1.
Volume X, 1916, No.
2.
Volume XI, 1917, No.
3.
Volume XII,
1918, Nos.
1 and 3.
Volume XXIV,
1926, Nos.
1 and 4.
Volume XXV,
1927, No.
1.
Volume XXVII,
1929, Nos. 3 and 4.
Volume XXVIII,
1930, No.
3.
Volume XXXIV,
1936, Nos.
1, 2, and
4.
Volume XXXV, 1937, No.
1.
Subscription
Price
op the Bulletin
Subscription
should
be
sent
to
Superintendent
of
Documents,
Government
Printing Office, Washington,
D. C.
Yearly
subscription,
beginning
July
1,
$1;
for foreign
subscriptions
add
35
cents for postage.
Single
numbers,
domestic,
25 cents; foreign,
35 cents, which
includes
foreign
postage.
Exchange
of publications
will be extended to medical
scientific
organizations,
societies,
laboratories,
and
journals.
Communications
on
this
subject
should
be addressed to the Surgeon General,
United
States Navy, Washington,
D. C.
ir
TABLE OF CONTENTS
Page
PREFACE
v
NOTICE
TO SERVICE
CONTRIBUTORS
vi
SPECIAL
ARTICLES:
Logistics:
Interrelation
of
the
Medical
Service
Aboard
Ship
and
Tactics.
By Rear Admiral Perceval
S. Rossiter,
Surgeon General, United
States Navy
163
Medical
Supply Procurement
in the Navy.
By W. H.
Michael,
commander,
Medical
Corps,
United States
Navy
168
Medical Department
Function in a Naval Engagement.
By C. J. Holeman,
captain, Medical Corps, United States Navy..
179
Fleet
Medicine.
By George F. Cottle, captain, Medical
Corps, United States Navy.
193
Hospital
Ships.
By Lucius W. Johnson, captain,
Medical Corps,
United
States
Navy
197
The
Making
op a Bluejacket.
By Griffith E. Thomas,
captain,
Medical Corps,
United
States
Navy
233
Compressed-air
Illness.
By Charles W. Shilling,
lieutenant,
Medical Corps, United
States
Navy
235
NAVAL RESERVE
261
NOTES AND COMMENTS:
The Thirteenth Surgeon General, United States Navy—International
Congress on Military
Medicine
and Pharmacy —Classified matter —
New
members
American
College
of Surgeons —Hospitalization of
dependents
263
BOOK NOTICES:
Clinical
Allergy,
Tuft —Introduction
to
Dermatology,
Sutton
and
Sutton —Approved
Laboratory
Technic,
Kolmer
and
Boerner —
Diseases of the Blood and Atlas of Hematology, Kracke and Garver —
Atlas
of
Hematology,
Osgood
and
Ashworth —The Cerebrospinal
Fluid,
Merritt
and
Fremont-Smith —Clinical
Urinalysis
and
Its
Interpretation,
Kilduffe—Embryology,
Jordan and Kindred—Dis
eases of the Nose and Throat,Thomson and Negus—Practical Meth
ods in the Diagnosis
and Treatment
of Venereal Diseases, Lees and
Lees—The Treatment
of Gonorrhea
and Its Complications
in Men
and Women, Robinson
271
ill
IV
TABLE
OF
CONTENTS
PREVENTIVE MEDICINE:
United States
Navy Submarine Service.
By W.
C. Harrison,
New York Life Insurance
Co.,
New York,
Paga
N. Y
277
Observations
on Staphylococcus
Food Poisoning.
By E. M. Wade, lieutenant,
Medical
Corps, United States Navy..
306
Food Poisoning, United States Naval Station, Guantanamo Bay,
Cuba.
By
W.
D.
Small,
commander,
Medical
Corps,
United
States
Navy
316
STATISTICS:
Health of the Navy..
319
Injuries and Poisonings
-
322
Morbidity
322
Deaths
323
Mental
and Physical Qualification of Recruits
324
PREFACE
The United States Naval Medical Bulletin was first issued in
April
1907
as a means for supplying medical
officers of the United
States
Navy
with
information
regarding
the
advances
which
are
continually
being
made in the
medical
sciences,
and
as
a medium
for the publication of accounts
of special researches, observations,
or
experiences of individual
medical
officers.
It is the aim of the Bureau of Medicine
and Surgery to furnish
in each issue special
articles
relating to naval medicine,
descriptions
of suggested
devices, clinical notes on interesting cases, editorial com
ment on current
medical
literature
of special
professional
interest
to the naval medical officer,
and reports from various sources, notes,
and comments
on topics of medical
interest.
The Bureau extends an invitation
to all medical
and dental officers
to prepare and forward, with
a view to publication,
contributions
on subjects of interest to naval medical
officers.
In order that each service contributor may receive
due credit for
his efforts
in preparing matter for the Bulletin of distinct
origi
nality
and special merit, the Surgeon
General
of the Navy will send
a letter of appreciation to authors of papers
of outstanding merit.
The Bureau
does not necessarily
undertake
to
endorse
views
or
opinions which may be expressed in the pages of this publication.
P. S. Kossiter,
Surgeon General, United
States Navy.
7
NOTICE TO SERVICE
CONTRIBUTORS
Contributions
to the Bulletin should
be typewritten,
double
spaced,
on plain
paper, and should have wide margins.
Fasteners
which will not tear the paper
when removed
should
be
used.
Nothing should
be written
in the manuscript
which
is not intended for publication.
For example,
addresses,
dates, etc., not
a part of the article,
require
deletion
by the editor.
The Bulletin endeavors
to follow
a uniform
style in heading and captions,
and the editor
can be spared
much time and trouble,
and unnecessary changes in manuscript
can be obviated
if authors will follow in these particulars
the practice of recent issues.
The greatest accuracy
and fullness should
be employed
in all citations,
as it
has sometimes
been
necessary to decline articles
otherwise
desirable
because it
was impossible for the editor to understand
or verify
references, quotations,
etc.
The frequency
of gross errors in orthography
in many contributions
is conclusive
evidence that authors
often fail to read over their manuscripts
after they have
been typewritten.
Contributions
must be received at least 3 months prior to the date of the issue
for which they are intended.
The editor is not responsible
for the safe return
of manuscripts
and pictures.
All
materials
supplied
for illustrations,
if not
original,
should
be
accompanied
by reference to the source and
a statement
as to whether
or not reproduction
has been authorized.
The Bulletin intends to print only original
articles,
translations, in
whole
or
in part, reviews,
and reports
and notices
of Government
or
departmental
activities,
official announcements,
etc.
All original
contributions
are
accepted
on
the assump
tion
that
they
have
not
appeared
previously and are
not
to
be reprinted
elsewhere
without an understanding to thai effect and that editorial privilege is granted
to this
Bureau in preparing all material submitted for publication.
Eben E. Smith,
Editor,
Commander,
Medical
Corps, United States Navy.
VI
"I— 2
DEPOSlTED BY THE
UNITED STA icS OF AMERICA
APR t 8
1938
U. S. NAVAL MEDICAL BULLETIN
Vol. XXXVI
April
1938
No.
2
SPECIAL ARTICLES
LOGISTICS
INTERRELATION
OF THE MEDICAL
SERVICE ABOARD SHIP AND TACTICS i
By Rear Admiral Perceval
8. Rossiter,
Surgeon General, United States Navy
There can be no logistics
if we do not have
trained personnel
to
develop
them.
A
perfect
system
of
logistics
for
mobilization
of
personnel
and material and for our casualty evacuation is impotent
without
professionally competent
personnel
to apply them.
Hence,
in developing
its logistic policy the Medical Department of the Navy
places
primary
emphasis
and
dependence
upon
officers
skilled
in
their
profession.
Applicants
for
commission
are carefully
chosen.
Members of the corps after indoctrination, primarily
as naval medical
officers,
are encouraged
to advance
themselves
professionally
in their
chosen
medical
specialties.
This is necessary
because we must man
ships
and dispensaries
and hospitals continually
and we endeavor
to
do a high class of work.
However, great
as is the contribution
of our Navy
to national life
in peace time,
we must never
lose sight of its primary objective to
successfully
execute national policy in case of war.
When a national
emergency
develops, our armed forces serve as a nucleus around which
a
much
larger
number of
reserves
and
civilians
may
crystallize.
It, therefore,
behooves
the regular service
officer, particularly in the
latter
half of his
career,
to
obtain
a well-grounded experience
in
military
medicine.
He
must
be
prepared,
should
war
come,
to
surrender his purely professional
detail to a readily available,
equally
competent
specialist
of
the
reserve
and
assume
duties
requiring
long, well-grounded military
experience.
Since
the World
War
the Navy
has
developed
a
well-organized
reserve.
This reserve includes
medical
officers, some of considerable
service
experience,
who would be immediately available in case of a
national
emergency.
Organization
of these reserves
by naval
dis
tricts facilitates a peace-time
training program
and simplifies
mobili
zation.
Many of these officers have
had
active
duty training with
regular and
reserve
forces.
Our service
anticipates
no difficulty in
obtaining
sufficient
medical
officers
during
a
national
emergency.
• Address
by Rear Admiral Percevil S. Rossiter,
Surgeon
General,
U. S. Navy, delivered
October
4,
1937at The Ninth Annual Medico-Military
Symposium,
held In Rochester,
Minnesota.
163
164
ROSSITER—LOGISTICS
No
system
of logistics
can
succeed
which
ignores
the
simple
but
fundamental problem
of trained personnel.
Another
essential
factor
is
morale.
In
a
Naval
engagement,
particularly, it is a reasonable
assumption
that vessels of the defeated
fleet will suffer
most
severely
and it is well
recognized
that morale
will
be
an important,
possibly crucial,
factor
in
determining
the
victor.
Morale
is
an intangible
sentiment
that
requires
a careful
and long build-up.
It is the fruit of a leadership
that inspires
con
fidence,
trust and enthusiasm
in a crew.
The psychology of a crew
is difficult
to
analyze
or predict.
The
men
live in
close contact,
information
is
contagious
and
they
have
a
surprisingly
accurate
estimate
of the military situation and of their superior officers.
Few
officers aboard
ship can contribute more to the upbuilding of morale
than a medical
officer
who
has the trust and good will of the men.
High
morale
makes
a combat unit more effective
and, when
such
a
unit
suffers
damage,
tends
to minimize casualties
by more prompt
and efficient
action.
Morale
is one of the important intangible and
unpredictable variables in our logistic equation.
Incidentally,
one
of the modern
effects of war is to make
the morale
of our civilian
population
of increasing
importance.
Recent
developments
would
indicate that in future wars enemy objectives will include attacks on
civil
populations in
an
effort
to break down
morale.
Offense
and
defense are so delicately balanced
with the odds sufficiently in favor
of defensive
forces that war is becoming
a matter of attrition
of a
nation's entire
resources rather than defeat
of its armed
forces.
Military
science
is
a progressive
dynamic
force.
It presents
an
ever-changing
picture of eventualities
in which obsolescence of equip
ment appears conspicuously.
If reports from the Spanish front are to
be credited,
an antitank projectile has been developed
which pene
trates
the tank and
explodes with disintegrating effect on tank and
crew.
Should
a high explosive
shell
penetrate
a turret or magazine
the
effect would
be
comparable.
Logistics
are of slight utility in
such eventualities.
The
fleet that gains air control can anticipate comparatively
few
casualties
from
gas
of
men
exposed
in
the
superstructure.
The
opposing
fleet will
be
less fortunate.
Light unarmored forces
like
destroyers,
submarines,
and
cruisers
are likely
to be either sunk or
escape with little damage.
Heavy and unpredictable casualties may be
anticipated in our air force.
Here, too, probably few casualties will
require treatment or evacuation.
Comparatively
speaking,
a
badly
damaged
battleship
will
not
present
a worse
casualty list than that of a regiment
after a hard
drive.
The enemy's objective is to put it out of action.
He will very
probably be too busily engaged to expend the additional effort neces
sary to sink it.
This will tend to minimize the number of casualties
on
ROSSITER—LOGISTICS
165
the one hand and
to increase
the number of survivors on the other.
The battleship is still the backbone
of the Navy.
If this were not so
nations would encourage
each other to build bigger and more costly
dreadnaughts, instead
of laying
special
stress
on their limitations.
When
two
fleets
meet
for decisive
action this type
of vessel must
absorb much punishment.
They
are built
to take it.
However,
a
fair percentage
of the crew must man battle stations in the super
structure, that
is,
above
the armored
deck.
Casualties in this force
will
be unavoidably
high.
Should the ship survive the engagement
those
injured will present
a problem.
The
medical
organization
is
aware of this possibility
and
is
disposed
and drilled
to handle the
emergency,
each battleship acting
as
an
independent
self-sufficient
unit.
Prompt evacuation of such casualties
would be ideal.
Unfor
tunately,
the action
is
too likely to occur far from
a
protected
base,
the train which includes our hospital ships
is
too likely to be at a dis
tant point or destroyed,
for us to base our plans on the premise that
these casualties
can be promptly
evacuated.
Therefore, each vessel
must be prepared
to care for its own casualties
and hope subsequently
for assistance from more fortunate vessels in the vicinity.
The function of a front line fighting unit
is
intimately
connected
with, and dependent
upon, its source of supply.
It
is
not practical to
consider these two
items
separately.
The Bureau of Medicine
and
surgery
is
organized with the objective of solving the medical problems
and supplying the medical needs of the fleet.
To this end
it
maintains
divisions for war plans,
personnel,
and supplies.
The Planning Divi
sion
is
advised of characteristics
of ship types projected by the general
board and makes recommendations
and takes necessary
measures
to
coordinate Medical Department policy with anticipated Navy needs.
This division
also coordinates
Medical
Department war plans
with
those of the Office of the Chief of Naval Operations.
Naturally
this
involves solution of many intricate, detailed,
and confidential problems
affecting both personnel and materiel.
This work
is
never ending, due
to continuing development
of the plans.
In general,
it
may be stated
that the whole problem of procurement
of supplies and equipment
is
on
a far better footing than that which obtained during the last war.
It
is
primarily
in
this
division
that
our logistics
are
developed.
The
details are too involved to permit discussion
in the brief time
I
have.
Most of these details would prove
an uninteresting recital of factual
material were
I
at liberty
to discuss
them.
Furthermore,
should
I
give
a
detailed report now, my account would soon be inaccurate due
to
a
high obsolescence factor.
The Navy maintains a close liaison with the Army in our procure
ment program.
This includes assignment
of naval medical
officers as
students at the Army Industrial
School.
166
ROSSITEK—LOGISTICS
We maintain
medical
supply depots
at Brooklyn,
San Francisco,
and
at Cavite in
the Philippines.
These
bases keep
a substantial
supply of consumable
and nonconsumable
supplies.
The former we
speak of as supplies,
the latter equipment.
These depots are manned
by personnel
experienced
in procurement and testing
of material for
quality.
This organization
can
be
readily
expanded
to
meet
the
needs of our fleet.
With few exceptions,
our needs in an emergency
will
be as at present, except for quantity.
In fact, the tendency will
be to simplify stock to permit carrying of larger quantities of essentials.
The objective of this entire organization is to promote
the fitness of the
fleet for action.
There is a close coordination between
the Bureau of Medicine
and
Surgery
and
other shore
activities
and
the
fleet.
This is
effected
through the fleet surgeons and reports
from the fleet medical
officers.
The Bureau receives a large volume of reports from forces ashore and
afloat which is correlated
by the Bureau and permits an accurate
ap
preciation of fleet conditions and serves as a basis for estimating future
needs.
There is a medical
officer on the staff of the commander
in chief of
each fleet.
He is in a strategic
position where he can anticipate fleet
movements
and
consequently
estimate
Medical
Department
needs.
Through
reports
and personal
contact he has intimate knowledge
of
the
medical
activities in
the
fleet.
He maintains liaison with
the
Bureau and with military and civilian medical activities ashore.
After
action he is in a position to make sound plans and recommendations
as to procurement
and disposition of personnel
and supplies
and mo
bilization of relief forces and disposition of casualties.
In addition
to information
from
the
fleet
surgeons,
the Bureau
receives reports from all medical
officers afloat.
These officers submit
many practical
suggestions
of great
value
in formulating
Medical
Department logistics.
Obviously, Medical Department logistics must be predicated
on the
type of campaign
anticipated.
The brief time at my disposal
and the
nature of the subject require
that I limit my comments
to a general
discussion.
Therefore, we will consider
our logistics
from the stand
point of a first-line vessel.
To man this vessel will require,
as a maxi
mum, an increase of about one medical
officer and six enlisted
men.
The Bureau maintains a liberal policy toward the fleet in the alloca
tion of supplies
and the variety is such that few, if any,
new items
should be necessary.
It is the present policy of the Bureau to main
tain aboard each ship a stock of all items which will never fall below the
requirements
for 6 months under normal conditions and in addition a
reserve of the supplies
necessary for operation of battle dressing
sta
tions
and for first aid at the various battle stations.
To outfit
the
ships for war service it will only be necessary to augment
the stock on
ROSSITER—LOGISTICS
167
hand sufficiently to provide for the increased
rate of usage which will
result from war conditions.
Provision
has been made whereby this
augmentation may be accomplished
expeditiously for mobilization.
Equipment
in addition to that normally aboard should not be neces
sary.
The war stock is based on the presumption that while the vessel
may be required to subsist for months on medical stores aboard, it will,
prior to resupplying, experience only one major engagement.
There
fore, provisioning
a ship for action with medical
supplies
presents
no
serious
problem,
particularly
in view of the fact that our hospital
ships will accompany
the train of the fleet and serve
as
a source of
supply.
Preparation for action will include intensive training of the crew in
first-aid measures.
During action the duty of all hands is to promote
the offensive
and defensive
power of the ship and as many effectives
as possible,
or necessary, must be kept at their battle stations.
The
Medical
Department is equipped
and deployed
to promote this objec
tive.
After action casualties will be collected
at the most
accessible
dressing station.
We make only a generalizing
attempt to predict the
number or nature of the casualties.
The important issue is to provide
each ship with competent
medical
officers and ample supplies.
That
we can do and have the confidence that whatever happens the Medical
Department
will
render
the
best
service
that
conditions
permit.
Evacuation
will
depend
on directions from the higher command
on
consultation with the fleet surgeon.
The Medical Department of a vessel may be required
to accompany
a landing
force.
The fleet is prepared
to put armed
forces
ashore.
When Long Beach was paralyzed by an earthquake in March 1933, the
fleet had
a patrol force of more than 1,000
armed men ashore in less
than an hour.
The organization of this force is very similar to that of
the Army.
Each first-line vessel furnishes
a battalion accompanied
by a medical officer, hospital corpsmen,
and stretcher bearers.
Equip
ment consists
of medical
and
surgical
supplies
packed
in
cases
and
first-aid pouches provided and reserved for this particular use.
Should
a large force be involved,
the hospital ships will carry supplies
and
equipment, including
tentage,
to set up field
hospitals
ashore.
Our
planning division has devoted much effort to developing
landing force
equipment which was recently reviewed by a board
to effect improve
ment and modernization.
Duty with marines has proven an excellent
field
test for this equipment,
and
excellent
training for our medical
personnel.
Many of our medical
officers
have
served with
marines
and some I regard as experts on field service.
On service of this type
also we must be opportunists.
Few con
tingencies,
or the means of meeting
them,
can be anticipated with
exactitude.
For
instance,
the
Managua
earthquake
was
a tragic
affair in which
one of our experienced
medical
officers
was killed.
i
168
MICHAEL—MEDICAL
SUPPLY
PROCUREMENT
IN NAVY
This emergency
was met by flying medical
personnel
and supplies
to
Managua from one of our large aircraft carriers which fortunately was
not far off the coast at that time.
This emergency
assistance
was
later augmented
by reenforcements
from the hospital ship.
You have probably noted
that I have
quoted
few figures.
There
are some that I dare not quote; there are others that I frankly do not
know.
In either case they will probably soon be obsolete.
My real
concern
is with policy, personnel,
and
practice.
If I can
keep
the
Medical Corps soundly grounded
in these I have confidence
that our
logistics will be effective.
MEDICAL
SUPPLY PROCUREMENT IN THE
NAVY
By Commander
W. H. Michael,
Medical Corps, United States Navy
Naval
medical
procurement began for the
then un-United
States
when, in
1776, Massachusetts built
10 sloops of war and provided a
surgeon
for each.
The captain at first picked his surgeon,
and
the
surgeon
procured
his medical and
surgical "case."
The literature
contains many curious descriptions of the drugs
and
the formidable
array of instruments, tools would be a more exact word, that the sur
geon's case should contain.
What it actually did contain was left to
the surgeon and the captain.
In sailing-ship days if the sailmaker needed canvas for a sail, or the
ship's
surgeon
peruvian bark, each would tell the "old man."
The
purser had charge of the ship's moneys.
Accordingly, if the "old man"
approved,
he would authorize the sailmaker and the surgeon to see that
the purser bought for them what they wanted.
Today the Navy buys few sails and no peruvian bark.
The purser's
title has been changed
to supply officer.
In routine
cases
the "old
man" usually delegates some of his authority
to his executive
officer.
"Plus ga change,
plus e'est la mime chose."
The centralized
procure
ment for the ship remains
the same.
And because the wants of the
Navy are presented as ship's wants, the centralized
procurement
for the
ship has been extended to centralized
procurement
of the Navy.
This centralized
procurement
is largely achieved
by the Purchase
Division of the Bureau of Supplies and Accounts.
The head of that
Division
put it essentially
this way: "The Bureau
of Supplies and
Accounts is a service organization: to coordinate
the needs of the Navy;
to unwind
the
required
'red
tape' in procurement
contracts to
the
satisfaction of Navy regulations
and the Comptroller General; to fore
cast from our accumulated
data where and how wants can be satisfied
;
and to make purchases
to the best advantage
through our many pur
chasing
officers.
We
make
no
pretense
of
having
the
necessary
technical
knowledge.
We get
that from the requiring
bureaus
by
turning over bids to them, or in simpler cases, talking over the case by
telephone."
MICHAEL —MEDICAL
SUPPLY
PROCUREMENT
IN
NAVY
169
The Purchase Division
of the Bureau of Supplies and Accounts is
divided into the following subdivisions:
1. Schedule
section, which receives requisitions and, if they cannot
be satisfied
by transfer from existing
Government stocks,
determines
where purchase
is to
be made.
Schedules
are prepared
if standard
specifications do not
exist.
These
schedules
are sent out to listed
bidders by
the mailing
subsection.
If standard specifications
and
contracts exist for the item, the requisition is handled by the specifica
tion subsection.
2. Award section, which opens bids and places contracts, or consults
with a technical
bureau
and is guided by the recommendation
of that
bureau in placing awards
when
the lowest bidder is offering
an alter
nate item or an item not meeting
the required specifications.
3. Contract section,
whose function is evident.
4. Adjustment
section,
whose
function
is
best
portrayed
by its
unofficial name "Grief section."
Being centralized
and experienced in
the various difficulties arising between contractors and bureaus, usually
through misinterpretation
of specifications,
this section is especially
qualified to adjust differences.
Central
Control
of Procurement
Central control of procurement for the Medical Department of the
Navy is the function of the Finance Division of the Bureau of Medicine
and Surgery.
This office operates under the direct supervision of the
Assistant Chief of the Bureau, assisted by chief pharmacists and phar
macists.
These
officers have invariably
been trained by long experi
ence in the Medical Department and most have had special instruction
in purchasing and accounting.
Many in the naval hospitals and all
holding important positions
in the Finance Division of the Bureau of
Medicine
and Surgery hold diplomas in their specialty of accounting
and commercial
law.
This division has the following sections.
1 . Administrative, including preparation of Bureau annual estimate
of expenditures.
2. Procurement,
which
reviews
and
recommends
action
on
all
medical requisitions, except emergency requisitions.
3. Auditing,
which controls the accuracy
and form of all medical
expenditures.
4. Bookkeeping, which has its obvious function.
Annual Estimate
of Expenditures
The Constitution
of the United
States
empowers
the Congress
to
appropriate
the
general
funds
of the Treasury
for public
expense.
This power is coupled
with a corresponding
duty, namely,
to provide
the general funds.
This situation gives birth to the two-sided
device
commonly
known
as
the "Budget."
The Bureau of the Budget,
a
170
MICHAEL—MEDICAL, SUPPLY
PROCUREMENT
IN
NAVY
division of the Treasury Department, was created by an act of Con
gress in
1921.
This office, under the direction of the President, is
charged
with
the duty of assembling,
arranging,
and
presenting
the
National Budget to the Congress.
This act also required
the head of
each
governmental
department
and
establishment
to
designate
a
"budget officer"
to
assemble,
arrange,
and
present
that activity's
estimates
to the Bureau of the Budget.
The Chief of the Bureau of
Medicine
and Surgery is charged with
the preparation of an annual
estimate
of expenditure
for funds
needed
to carry out the duties
of
the Bureau for the following fiscal year.
The preliminary estimate
of expenditure
by the Bureau of Medicine
and Surgery for probable
requirements
for a fiscal year is based upon
past experiences, Navy policy, operating force plan,
and the advance
year estimates of expenditures
which the Bureau requires
to be sub
mitted by each activity,
except ships, for sums desired
to carry out
their respective
duties.
These field estimates must be prepared
and submitted on or before
March
1, 16 months prior to the fiscal year.
They are presented in a
form closely
resembling
that submitted by
the Bureau of Medicine
and
Surgery
to
the
Bureau
of
the
Budget.
These
estimates
are
examined
carefully,
due
weight
being
given
to
past
performance,
probable
future duties,
and supporting data.
Unsupported estimates
for nonrecurring items
are given little attention.
Detailed informa
tion concerning
these items is necessary
to favorable action.
On the basis of this correlated
data the preliminary annual estimate
of expenditures
is prepared
for the Surgeon
General
by the Division
of Finance.
It is submitted to the Navy budget
officer who prepares
and presents
a summarization of all estimates
to the Secretary
of the
Navy for approval.
Here
the policy of the Navy Department
is
determined
and conflicting interests
adjusted.
The limit of all esti
mates is fixed and each bureau
is instructed to revise its estimates if
such is indicated.
The final draft of the preliminary estimates is then prepared
by the
respective
bureaus,
returned
to the Navy
budget
officer,
where
they
are summarized
and
presented
with supporting data, break-downs,
and
other
informative
facts
to
the
Director
of
the Budget
about
September
1, prior to the fiscal year concerned.
The estimated
ex
penditures
of all bureaus comprising the Navy
are then grouped
into
one "bill"
and referred
to the congressional
subcommittee
on Naval
Appropriations.
Each
chief
of bureau
appears
before
the subcom
mittee
to clarify or substantiate
the estimates.
After
the "bill"
be
comes
an "act"
the Treasury
Department
issues
a warrant
to
the
effect that the funds appropriated by Congress
have been, or will be
provided, subject
to the limitations
imposed
by the act.
Then, and
not until then, may the funds
be obligated.
MICHAEL —MEDICAL, SUPPLY
PROCUREMENT
IN
NAVY
171
The Bureau then compares
the funds
allocated
by act of Congress
with the revised
estimate
of expenditure.
If the latter exceeds the
former, adjustment downward of the tentatively
approved
estimates
becomes
essential
and
these estimates
are again
reviewed.
The less
desirable items
are deferred
in order to reduce
the total to approxi
mate the funds
available.
Allotment
cards
are
then
prepared
and
mailed to field activities, authorizing expenditure
of funds for specified
purpose.
Allotments
as employed
by the Bureau of Medicine
and Surgery
may be classified as (a) money credits and (6) material credits.
Money
credits
are actual allocations of funds
from
a specific
congressional
appropriation
for
the
current
fiscal
period.
Material
credits
are
authorizations
for withdrawal
of supplies
and equipment from stock
(naval medical
supply depots)
measured
in terms of money
for the
sake
of convenience.
The actual cash expenditure
for supplies
and
equipment
issued
from stock may involve
either
current
or
past
appropriations.
Thus, requests for nonstocked
material under supply
depot allotments (material
credits) require
a rearrangement
of Bureau
procurement plans and additional allocation of funds
to the procuring
agency, United States Navy Medical Supply Depot, Brooklyn, N. Y.
Example of Equipment Procurement
The method of purchase
and installation of a new X-ray equipment
for a naval hospital will serve both to illustrate the functions of the
Purchase Division
in its relations with medical
procurement,
and
to
show the steps taken by the Medical
Department itself.
While
the
procurement of many medical supplies is almost automatic, the follow
ing example
represents
the painstaking procedure
that must be fol
lowed for procurement of equipment:
1. The commanding officer of a hospital first justifies replacement
of the
present X-ray
equipment
on
account
of obsolescence,
costly
maintenance,
unsatisfactory
performance,
or other sufficient
cause
and
places in the hospital advance
year estimate
a budget
item
of
$7,000—$12,000 for
a new outfit.
The Bureau reviews
the recom
mendation, approves
the replacement,
and
incorporates
the item in
the annual
estimate of expenditure
for the hospital.
2. The chief surgeon,
the roentgenologist,
and
the materiel officer
have already
studied available catalogs and have written up specifica
tions to cover type of outfit required
by the hospital.
The command
ing officer examines
these, and
as an example,
adds the requirement
that the bidder guarantee
certain servicing
conditions.
He then for
wards the requisition, floor plans,
and
other
essential
details
to the
Bureau of Medicine and Surgery and appoints a board
of survey to
recommend
disposition of the old equipment.
3. The Finance Division examines the specifications,
and other data
submitted,
gets
technical
advice
from
the
medical
supply
depot,
172
MICHAEL —MEDICAL
SUPPLY
PROCUREMENT
IN
NAVY
engineers,
and manufacturers, consults
with the Bureau inspector of
Medical
Department
activities,
and
investigates
all the
features
of
procurement preparatory
to laying
the proposition
before
the chief
of bureau
who passes upon all prospective
replacements
of such
a
nature.
If the chief of bureau
approves
the procurement
the requisi
tion
may
be
forwarded directly
to
the
Purchase
Division
of
the
Bureau of Supplies and Accounts, or if the specifications
have
been
modified,
it may first be returned to the hospital for concurrence
in
the modifications.
4. The schedule
section of the Purchase Division
of the Bureau of
Supplies
and
Accounts
verifies
the form
of
the
specifications
and
prepares
schedules inviting bids from the several X-ray firms
on the
accepted list.
The mailing subsection
sends them out.
The bidders
make up their bids, execute a bond, and send in both.
5. On the day
specified
in the schedule,
the bids are opened
and
classified by the award section of the Bureau of Supplies and Accounts
and are sent to the Bureau of Medicine and Surgery for recommenda
tion.
The latter bureau
finds that the lowest bidder, "A," does not
assure sufficient
protection against radiation and that the next lowest
bidder,
"B,"
does
not
have
satisfactory
service
and
replacement
facilities near the hospital.
Therefore the Bureau returns the specifi
cations
to the Bureau of Supplies
and Accounts recommending
bidder
"C."
6. The award
section of the Bureau of Supplies
and Accounts may
assure itself of the Comptroller
General's
approval, if there is doubt
about the reasons for refusing "A" and "B."
7. The contract section
draws
up the contract because the amount
is over
$500.
The contractor
executes
a performance
bond which
begins
at
50
percent
of
the contract
price
at $500
and
decreases
inversely
with
the
amount of
the
contract,
to
10
percent.
The
contract is then signed by the contractor and by the Bureau of Sup
plies
and Accounts.
The original
signed copy is filed.
Copies are
circulated to all concerned.
8. The X-ray apparatus
is installed.
It is inspected
and
demon
strated by the roentgenologist
who knows how it should function, and
by the material officer aided by an electrician,
probably borrowed
from
Yards and Docks, to check the details of the specifications.
9. If difficulties are encountered in installation, test, or performance,
the matter is taken
up directly with the contractor, and then if nec
essary,
through
the
adjustment
section
of
the
Purchase Division,
Bureau of Supplies and Accounts.
The contract price
is paid when
the
commanding
officer
of
the hospital
states
that
the installation
satisfactorily meets specifications.
10. The amount is paid by the Bureau of Supplies and Accounts
out of the Bureau of Medicine
and Surgery's appropriation
and
the
MICHAEL—MEDICAL
SUPPLY
PROCUREMENT
IN
NAVY
173
amount is reported
as
an expenditure
by the hospital.
The
same
amount is taken up on the hospital inventory as representing
the cost
of X-ray equipment.
11. The
Board
of
Survey
can
recommend
either
that
the
old
X-ray equipment
be destroyed
as of no value, or estimate it's value
and
recommend
that
the
apparatus
be turned over
to
the supply
officer
for
sale.
This survey report
is
made
on
the
appropriate
supply and account
form and forwarded to the Bureau of Medicine
and
Surgery
either
with
or prior
to
submission
of requisition
for
new equipment.
12.
The
equipment
is
disposed
of
as
directed
by
the Bureau of
Medicine
and
Surgery
endorsement
on
the
form
returned
to
the
activity
initiating
the
request.
This
is
essential
because:
"The
medical officer in command
of each hospital and
the medical
officer
of each station and ship
shall
be responsible
and accountable
for all
public property under
his control belonging
to the Medical
Depart
ment of the Navy."
Approximately
the
same
procedure
is followed in all important
nonstandard installations.
Should the serviceability of any construc
tion or installation
be questionable
(particularly in naval hospitals),
the Bureau of Yards and Docks (which is charged with all construction
ashore)
should
be called
upon to inspect,
and
make
estimates
and
recommendations
as
to repairs,
replacements,
and
improvements.
The commanding
officer of the hospital will then act on his estimate
of the situation, by forwarding to the Bureau of Medicine and Surgery
the recommendation
of the public works officer
and his own recom
mendation.
These
recommendations
will
be
considered
by
the
Navy Department and the public works officer will be authorized to
effect
such
changes
as
the Department
approves.
The cost will
be
charged
to appropriate funds.
Payment
in all cases:
"All purchases
and payments
therefor
shall
be made under direction of the Bureau of Supplies
and Accounts and
orders directing such purchases
and payments
shall
be given only by
that Bureau.
When
purchase
requisitions have
been
approved
by
chiefs of bureau,
they shall be transmitted to the Bureau of Supplies
and Accounts for action."
Supply
officers
represent
the Bureau of
Supplies and
Accounts.
In medical
activities
attached
to Marine
Corps units, the quartermaster of the Marine Corps exercises for the
medical
activity
the same local functions as would the supply officer
of a naval unit.
Role, Bureau of Medicine and Surgery:
But although the Bureau of
Supplies
and Accounts procure,
the Bureau of Medicine and Surgery
"shall require for all supplies,
medicines,
and instruments used in the
Medical
Department
of
the
Navy.
It shall
have
control
of
the
preparation, reception,
storage,
care, custody,
transfer,
and issue of
46202—38
2
174
MICHAEL—MEDICAL, SUPPLY
PROCUREMENT
IN
NAVY
all supplies of every land used in the Medical Department for its own
purposes."
Medical
Supply
Depots: To facilitate
these functions
as regards
medical
materials
the Bureau of Medicine and Surgery has created
the
following central sources of supply:
Naval Medical Supply Depot, Brooklyn, N. Y.
Naval Medical Supply Depot, Mare Island, Calif.
Naval Medical Supply Depot, Canacao,
P. I.
The Brooklyn
Depot is the main supply depot
and
keeps on hand
Supply Table and Supplementary Supply Table material.
There are
specified limitations on the items kept in stock by the other depots.
Certain
special
supplies,
itemized
in
the
Supplementary
Supply
Table,
as antigens,
culture material, bacterial emulsions,
containers
for specimens,
typing sera, and colloidal gold,
are prepared
and sup
plied
by the Naval Medical Center in Washington, D. C.
The
medical
supply
is predominately
automatic.
These
supply
facilities render almost automatic the acquisition of at least 90 percent
of medical
supplies
used by the various medical
organizations.
This
is accomplished
by the supply table,
adopted in 1926
and revised
in
1938.
In addition to individual
items it lists a score or more of as
sembled outfits, viz: Aircraft first aid, emergency surgical,
box medical,
chest operating
and expeditionary outfits, etc.
It includes
a complete list of ordinary dental supplies.
Requisitions from each activity for every need on the supply tables
are made on the prescribed
form.
This shows the amount of the items
on hand
and the amount required.
The requisition is forwarded to
the Bureau of Medicine and Surgery where it is approved
or revised
and forwarded to
a medical
supply depot for execution.
An emer
gency requisition goes direct to the supply depot for execution
and
a
copy goes to the Finance Office for record, or it may be made by radio
and
the
red
tape unwound
at
leisure.
Medical
supply
depots
re
plenish
their
supplies
by
requisition
approved
by
the
Bureau
of
Medicine
and Surgery and procured
by the Bureau of Supplies
and
Accounts, usually in New York City markets.
Factors governing
requisitions: There must be a specified minimum
of supplies
on hand in each activity and aboard combatant ships and
an additional reserved stock of such unopened,
original units of sup
plies and items
as may be specified
by the Bureau of Medicine
and
Surgery.
This minimum stock for ships is
6 months' supply, based
on
a 3-year
average
consumption.
For hospital ships
and all shore
stations,
the minimum prescribed
is
1 year.
An "order point"
has recently
been established.
The stock of an
item has reached the order point when it has been reduced
to a point
that,
considering
average consumption and time required
to requisi
tflCHAEL—MEDICAL
SUPPLY PROCUREMENT
IN
NAVY
175
tion and receive
new stock aboard,
the stock on hand would be de
pleted to the minimum supply on estimated
date of replenishment.
Routine orders for deficient
items should be made following quarterly
inventory
with
such
minor variations
to facilitate delivery,
as
are
dictated by the movement
of the ship.
On receipt
of supplies,
that
portion
of the reserve supply which deteriorates
should be replaced
by new material and the old reserve removed
and designated
for cur
rent use.
In other words, always
use the oldest stock, first.
A careful
attention to this method will bring about a decrease in dead stock and
insure
fresh material in reserve.
Formerly
there
was
often
an ac
cumulation
of unreasonable
supplies.
An inspection of one hospital
revealed
a supply of quinine hydrochlorosulphate
sufficient
at
the
average rate of use for several hundred years.
The medical
officer
is expected
to requisition what he needs pro
vided his requirements
do not exceed his annual allowance
for supply
depot items.
This allowance
may be increased
on request,
in emer
gency, by the Bureau of Medicine and Surgery.
He is expected to be
governed by the prospective
mission
of his ship, his own methods
of
treatment and other conditions affecting his requirements.
If he is a
genitourinary
specialist
he will order his favorite catheters
from the
Supply
Table.
If his ship is
going
up
the Yangtze
he will order
cholera vaccine; if she is going on a long "shake down" cruise, he may
wish to take along a couple of caskets for the care of the dead.
Supply Depot material awaiting transfer to ship or station is deliv
ered to the Supply Department which supervises shipment and delivery
and pays transportation costs.
The Medical
Department of a naval unit obtains material from
sources
and by methods
other than on regular supply depot requisi
tion.
In emergency
medical
material may
be transferred
directly
from one Navy medical activity
to another on regular transfer form a
copy of which is forwarded to the Bureau of Medicine and Surgery.
In case of transfer of equipment
prior permission
should be obtained
from the Bureau or, in case of emergency, an explanatory letter should
accompany the copy of property transfer.
Numerous
items
of sick bay equipment
such
as
office furniture,
lockers,
steam
and
electric
sterilizers and various ward installations
are
the property of other divisions.
They
are issued to the medical
division
on custody receipt
signed
by
the
senior
medical
officer.
Cleaning gear and other sanitary supplies
are issued by the first lieu
tenant on signed request without charge to the Medical Department.
The Bureau of Medicine
and Surgery has endeavored
to be suffi
ciently liberal in the variety of supply table and supplementary supply
table items
offered
and
the allocation of funds for their acquisition.
It views with disfavor the indiscriminate
use of emergency
and other
irregular forms of requisition.
For
the
exceptional
situation
that
176
MICHAEL —MEDICAL
SUPPLY
PROCUREMENT
IN
NAVY
demands irregular procedure
one of the following described methods of
obtaining material may be employed:
(a) Supply
table items may be obtained in emergency
by making
requisition on regular form or by radio directly on the nearest supply
depot.
Copy of requisition
with
explanatory letter should be for
warded
to the Bureau of Medicine and Surgery.
(6) For
ships
and
stations
essential
materials not
listed
on
the
Supply
Table
or Supplementary Supply Table
may
be obtained by
forwarding
a
special
requisition,
using
the standard
form,
to
the
Bureau
of Medicine
and
Surgery.
If funds
are available and
the
requisition
is
approved,
the
Bureau will direct
a
medical
supply
depot
to make procurement.
If a detailed
explanatory letter accom
panies
the requisition the Bureau of Medicine and Surgery will
be in
a better position to evaluate
the necessity
for providing
the special
material.
(c) Material
may
be
obtained
on
purchase
requisition
approved
by
the
commanding
officer
and
purchased
by
the
supply
officer.
Actually,
in
this type
of emergency
procurement,
the
purchase
is
usually
made immediately by the supply officer
and
the
necessary
red tape is unwound afterward.
(d) Procurement
by
"improvision"
is
a
method
of importance,
especially
aboard
ship, by which the efficient
medical
officer obtains
material through the cooperation
of other departments.
If in great
emergency
he wants a baking box for stiff joints,
a violet-ray lamp,
a walking splint for a broken femur,
a suspension
apparatus for a
broken back, or even an oxygen tent for a pneumonia
patient, he has
only to exercise the necessary diplomacy and ingenuity.
Procurement by improvision
has played an important part in the
Medical Department of the Navy.
The first two naval hospitals and
the first hospital ship were of natural or improvised birth.
Edward
Cutbush,
surgeon
of
the
Constellation
then
operating
against
the
Barbary
States,
established
and
conducted
the first United
States
Naval
Hospital,
in Syracuse,
Sicily,
1806.
In
1810
Surgeon
Lewis
Heerman
was
sent
to
New
Orleans.
Seeing
the
necessity,
and
fortified by a personal
fortune, as an adjunct to a lucrative practice
he purchased
a suitable house and a few slaves and started
the second
naval hospital.
The first hospital ship
was a Confederate
vessel on
the Mississippi
captured during the Civil War.
This
ship,
the Red
Rover, was equipped
by Admiral Porter and put under the command
of Surgeon Pinkney.
Insofar
as procurement by improvision
represents
a constructive
and
expedient
opportunism for the good of the service
and
to meet
local emergency
and
unanticipated
needs,
the Bureau of Medicine
and Surgery cannot object to this
method,
but cautions that use of
this expedient
should
be reserved entirely to meet such needs.
MICHAEL —MEDICAL
SUPPLY
PROCUREMENT
IN NAV?
177
Dental equipment and supplies
are furnished in the same ways
as
medical supplies
and
the dental officer
has the same responsibilities
in regard
to
them
as
has
the
medical
officer
in regard
to
medical
materials.
Procurement
Functions
of Medical Department
Units
Medical
activities which make
up what might be called
the "con
suming echelon" of the Navy Medical Department vary in importance
from
the
Naval
Medical
Center,
through
hospitals,
sickquarters,
field hospitals, sickbays,
and dispensaries,
to the medical
officer of a
recruiting station.
The first two procure
everything necessary for a
separate
self-sustaining
command; the last buys only a few things from
the nearest
drug store.
With the exception
of the medical
officer on
recruiting duty
(who does not require
a requisition form for medical
supplies though he is furnished a recruiting outfit),
the procurement
of purely medical
material is the same and has been explained.
But
there
is considerable
nonmedical
procurement
by medical
activities
which a short description of the procurement organization of a naval
hospital
and of the installation
of the sickbays aboard
a ship
and
ashore
should clarify.
Naval Hospital:
The procurement
functions of a naval hospital are
vested, under the commanding
officer, and executive
officer in:
(a) The first lieutenant, who has general
supervision and
upkeep
of buildings
and
grounds.
Improvements
and
repairs,
beyond
the
capacity
of the hospital force,
are estimated
by
a representative
of
the Bureau
of Yards
and
Docks
and
paid for out of the hospital
allowances by the supply officer.
(6) The property
officer, who is responsible
for storage,
property
cards,
and
requisitions.
He
obtains medical
supplies
as described
above.
Other
supplies
are
obtained
by
stub
requisition
from
the
supply officer; bid and purchase with or without contract; or purchase
requisition for specified limited amounts,
usually $50.
The hospital
if authorized by the Bureau can procure
the professional
services of
a civilian
specialist.
Naval
hospitals
procure
and
maintain
their
own ambulances
and other vehicles.
(c)
The commissary
officer supervises
the purchase,
storage, prepa
ration
and
cash
accounting of commissary
material.
He uses the
local contracts of the supply officer, or makes small open purchases
as
above.
(d) The accounting officer, who in addition to accounting for and
submitting
the
required financial
returns,
keeps
the
commanding
officer informed of the relation of allocations to expenditures
under
the various appropriations.
Frequently two, or even three, of these functions are filled by one
officer.
178
MICHAEL
MEDICAL
SUPPLY
PROCUREMENT
IN
NAVY
Ship: When
a Navy ship
is being put in commission
the Medical
Department
is
furnished
only
the
standard
medical
and
surgical
equipment for that type of ship plus any additions which the medical
officer might deem necessary.
However, the Bureau of Construction
and
Repair
(or
the contractor)
installs in
the sickbay
and
in
the
dressing
stations, not only the ordinary living accommodations
(lights,
bunks, plumbing, etc.), but also sterilizers
(except dental sterilizers),
bacteriological incubators, and operating-room lights, as specified
by
the
ships'
design.
Even
splint
stretchers
are
charged
against
the
Bureau of Construction
and Repair
as is the material necessary
for
the fumigation of ships.
The wise medical
officer will constitute himself as procurement and
property
officer.
He will,
as required by regulation, keep personal
custody of the medical storeroom key and personally supervise custody
and issue of alcohol and narcotics.
He will assign property accounting
to a reliable corpsman
and will assure himself beyond
doubt that the
property records
are accurate,
that the stock conforms
with Bureau
policy and has not deteriorated.
Shore station: Like the sickbay of a ship,
shore sickbays and dis
pensaries
are furnished certain items by other departments
than the
Bureau of Medicine and Surgery,
because these medical
activities are
considered
an integral part of the naval establishment.
The
items
include buildings, furniture, light, heat and water,
cleaning
material,
floor polishers,
etc.
The Medical Department's problem of procurement for shore sta
tions is simplified by a system of 3-year planning.
In March,
each
year,
the estimates for the following fiscal year are reported
in detail.
Later, provisional estimates
for the following
2 years
are submitted.
In this way the Bureau reduces unpleasant suprises to the minimum.
This 3-year
estimate
is not required of ships
whose yearly expendi
tures vary somewhat,
but ship variations do not assume the fantastic
proportions
as
do
those of some hospital
and
other shore
station
estimates.
Source
of Funds
The funds of the Bureau of Medicine and Surgery are derived from :
1. Annual appropriations for "Medical Department,"
"care of the
dead" and "salaries,
Bureau of Medicine
and Surgery."
2. Naval hospital trust fund: This trust fund derives its revenues
from within
the naval service, namely:
20 cents
a month levy on all
naval
personnel,
fines
and
forfeitures,
pensions
relinquished during
hospitalization,
forfeitures by deserters,
and
the ration value of all
naval patients.
"Every
expense for
the proper establishment and
maintenance
of a naval hospital may be paid from this fund except
as
Congress may provide for certain expenses by specific appropriations."
The revenues of this fund approximate $800,000 annually.
HOLEMAN
MEDICAL
DEPT. FUNCTION IN NAVAL
ENGAGEMENT
179
Procurement
Preparedness
The minimum
supplies
required at all naval
activities
and
the
"1 year, plus procurement time" minimum required
(and
exceeded
especially in strategic
drugs)
at naval medical
supply depots,
would
furnish a substantial outlay on M-day.
Ships actually have prepared
and sterilized a reserve supply of shell-dressings.
War plans are pre
pared for the naval districts with complete requisitions to take care of
expansion.
It is believed
that
these requisitions
can
be promptly
filled with the exception
of about a score of items of technical
nature.
An
effort is
being
made
to provide
such
items
but, owing to
the
rapidity
of their obsolescence,
this
acquisition,
even if authorized,
will
be limited
to
5
years
peacetime
consumption.
The
medical
department is prepared
to
equip
the
fleet
and
the auxiliary
ships.
Gaps in the shore establishments
can be filled later.
MEDICAL
DEPARTMENT
FUNCTION IN A NAVAL ENGAGEMENT
By Capt. C. J. Holeman, Medical Corps, United States Navy
As stated
on the cover of this Bulletin
the Mission of the Medical
Department is "To keep as many men at as many guns as many days
as possible."
Surg. H. E. R. Stephen,
R. N., has thus
defined
the
duty of a naval surgeon aboard
a fighting ship: "To render the ship an
efficient fighting unit as far as lies in his power."
This is true, but such
a definition might be applied
to every person aboard
a fighting ship.
Specifically,
the medical
officer should,
in peace time, bring the crew
of his ship
to the best possible physical condition and the ship itself
to conformity with highest
possible sanitary standards.
By his pre-
battle arrangements
he should
seek to maintain these levels of fitness
during
action.
By
the
execution
of his previously
prepared,
and
sufficiently rehearsed, battle plan he must strive to keep the greatest
possible number of officers and men in physical condition to execute
their assigned
tasks
unhampered
by those rendered
unfit for further
service by severe injuries.
Hence,
for the medical
department of a
naval vessel in battle there might properly be assigned
the
MISSION
To Sustain the Physical Fitness of the Personnel in Order to Maintain
the Fighting Efficiency
of the
Ship
To
accomplish
this mission
three major
tasks
devolve
upon the
medical department.
1. To preserve
the
highest
level
of physical fitness
at all battle
stations,
2. To promptly and efficiently care for the wounded
during lulls in
action or after battle,
3. To evacuate
noneffectives.
180
HOLEMAN—MEDICAL
DEPT. FUNCTION IN NAVAL
ENGAGEMENT
Progress in naval architecture whereby,
as the result of an extensive
system
of compartmentation, fighting ships
have
gained
greatly in
floatability
; improved weapons
of
such
power
that
the
watertight
integrity
of compartments may not
be impaired
without
hazard;
and probable use of chemicals,
which has added requirements
of fume
tightness,
have led to the development
of the present system of damage
control on ships of the Navy.
These have complicated the arrange
ments of preparing the medical department for battle, and drastically
modified its functioning during action.
During
the past
3 years this matter has been made the subject of
study by many boards
and individual
officers in the fleet.
The latest
study has resulted in the promulgation of Fleet Memorandum 29M-37,
by the commander
in chief, during November
1937.
In this memo
randum two fundamental principles were enunciated:
(1) The watertight
integrity
of
the
ship,
regardless
of wounded,
must be preserved.
(2) Fire power,
as delivered
by the batteries
of the ship, regardless
of wounded,
must be maintained.
These principles must determine
methods
employed
to accomplish
the tasks enumerated.
Analysis op the Tasks
Task 1.
To preserve
the highest
level of efficiency
at battle stations
With rigid
enforcement
of regulations governing watertight
and
fumetight integrity,
not only during actual fighting but during the
periods
when conditions Affirm or Baker must be maintained, mem
bers of the crew at most battle stations will be isolated from the medi
cal department personnel
of the vessel.
Hence,
the only manner in
which the medical
department can contribute to sustaining physical
efficiency
of the combatant force during these phases is :
(a) By careful
and thorough (pre-battle) instruction of all hands in
first-aid
treatment
of
wounds,
burns,
and
contact
with
chemical
agents, so that first-aid may
be effectively
applied by the injured man
or by a shipmate
at his battle station;
(6) By
having
adequately
stocked
first-aid
outfits
at all battle
stations;
(c) By providing
a team of well-equipped competent
first-aid men
attached
to
each
damage
control party who shall, whenever
these
parties gain
access to
a battle station, inspect
personnel
casualties,
administer
or correct
defects
in first-aid
treatment,
do everything
possible
to combat shock and relieve pain, and, if practicable, remove
the seriously wounded
from the compartment.
HOLEMAN—'MEDICAL DEPT. FUNCTION IN NAVAL
ENGAGEMENT
181
Task 2.
To promptly and efficiently
care for the
wounded
during
lulls in action or
after
battle
The
execution
of this task will demand
the maximum of effort,
skill, and judgment on the part of every officer and man of the medical
department.
In
the proper performance
of duty at this
time
the
medical department has,
perhaps,
its greatest
opportunity
to
con
tribute directly to military
efficiency
of the ship.
This contribution
consists
not only of a manifest conservation
of man power but of a
strong support to morale at a critical period.
The operations
necessary are:
(o) To restore
to fighting efficiency
the wounded,
men made ill by
prevailing battle conditions, and
those incapacitated by the milder
effects of chemical
agents.
These will find their way by designated
routes to the proper dressing stations.
(6) To clear the gun and other battle stations of the more seriously
wounded.
These
must be helped
or carried
in litters
to the battle
dressing
or chemical decontamination stations.
(c) To
treat
those
whose
injuries
incapacitate
them
for
duty.
These operations
are set down in the chronological
sequence in which
they must be completed; actually there will be some overlap
in their
execution.
Task 8,
To evacuate
the noneffectives
This consists of two phases :
(a)
Clearance
at first opportunity from battle stations.
(6) Evacuation
after treatment from the ship to a hospital ship or
hospital.
Detail
as to the manner in which these major tasks are to be accom
plished
must
be worked out for
each
ship
by its
medical
officer.
Approval
by the commanding officer must be obtained as a matter
of
routine.
Such
planning
and
approval,
however,
must not
be
perfunctory
for the successful
execution
of the tasks
demands
com
plete cooperation
between
the medical
department and other depart
ments aboard
ship.
Instruction
in first-aid
of
the nature required
demands
joint interest of the
medical
officer
and
division
officers;
treatment and clearing of patients during action requires full coopera
tion between
the medical
officer,
damage-control
officer,
and central
control, and when the battle is over, between the medical department
and practically all hands.
Means of Accomplishing
the
Tasks
Task 1 (a). — Training in first aid assumes, under present conditions,
greater
importance than has
been heretofore
attributed
to it.
Its
value
in controlling
hemorrhage,
guarding against
infection, dimin
ishing mortality
rates and
lessening
total sick days must be clearly
182
HOLEMAN
MEDICAL, DEPT. FUNCTION IN NAVAL
ENGAGEMENT
explained
to all hands.
But the two
fundamental principles enun
ciated
by the commander
in chief impose
a new responsibility
upon
medical
officers
to instruct
and division officers
to know that their
men understand not only the value of first aid but that each member
of a gun
crew or other unit engaged in fighting the ship knows the
use and mode of application of every item in the battle station first-aid
locker or bag.
Fleet Memorandum 29M-37
prescribes
that men detailed
to serve
as collecting
parties of stretcher
men shall
be "sufficiently trained in
first aid to act as relief hospital corpsmen
in emergencies,
especially
the emergency
of battle."
During
battle,
persons attached
to repair
parties will,
when
access
to
compartments
is
gained,
provide
the
maximum relief that the medical
department can afford at this phase
of the battle.
Treatment of shock
is of such vital importance that careful pro
vision should
be made
therefor.
This implies,
at the present
state
of our knowledge,
immediate
use of morphine.
There may be cases
in which seriously
wounded
will have
a considerable
wait before help
may
be brought to them.
Decision should be reached
as to whether
or not first-aid instruction to officers, to leading men in battle stations
where no officer may
be present
and
to the collecting parties
should
include
the administration of morphine.
Task
1
(b) —Battle station first-aid material. —Major ships
are now
provided
with
metal
containers
for
the
first-aid
outfits
of battle
stations.
Greatest care should
be exercised
to see that an outfit is
provided for every isolated
group
of men.
The
problems
of
storage
at
a central point for issue
at
general
quarters or their permanent
distribution throughout the ship, periodic
overhaul,
keeping
them stocked with material in no wise deteriorated
or keeping them partially stocked in peace time with earmarked material
in
the
storeroom
to
complete
their allowances,
are all matters for
individual
ship decision.
Unless
containers
are kept locked they will
be broken
into and undesirable
self-treatment will spring up.
Since
they may
be used in minor emergencies during drill with benefit,
on
several
ships
a scheme of sealing
them with easily broken seals, the
damage
to which is easily
observable
has
proven
satisfactory.
In
any
event,
a certain
number must be used for instruction
purposes.
No useful purpose would be served by listing contents of the lockers.
Provision must be made for wounds
from projectiles,
burns, damage
from chemicals
(whether
thrown aboard by the enemy or from gases
generated by explosion of enemy shells or by own propulsive charges),
contusions
and other injuries by mechanical
devices.
Types of injury
most likely
to occur
at each battle station should be considered
and
the locker for that station fitted up accordingly.
HOLEMAN
MEDICAL
DEPT. FUNCTION IN NAVAL ENGAGEMENT
183
The relative importance of burns should
be borne in mind.
At the
battle of Jutland, omitting killed,
the ratio of burns
to wounds on
major
ships
was
as
154.5
: 100.
This ratio is not due to especially
large contributions by fireroom
and engineroom
casualties
but rather
to the flash
of enemy
shell explosions
within
the
ships.
At present
the tannic acid treatment of burns is in favor and has much to recom
mend it.
Quick
availability,
simplicity
of application,
sufficiency
without
waste or jeopardy to stock by haste or nervousness
were the indica
tions which led to the adoption of item Sl-190,
tannic acid jelly, for
inclusion
in
the
supplementary supply
table.
Should
service
test
prove
the
value
of this item,
it offers
an excellent
solution
to
the
problem of caring for burns.
Reports
on its use will,
therefore,
be
appreciated by the Bureau.
Medical
officers should
give immediate attention to the segregation
of
sufficient
stores
for
their
battle
station
outfits.
By
Bureau's
Circular Letter, Serial No. 640-1937,
ships are directed
to maintain a
minimum stock plus a working stock in addition to their reserve stock
stored at battle dressing stations or in other emergency units.
Task
1
(c)—First-aidmen.— Provision
of
nonmedical
first-aid
personnel
for collecting parties
has been considered
under (a) above.
It is highly
desirable
that
to each such
party
there
be
assigned
a
pharmacist's
mate who shall be in charge of the task of caring for
personnel
casualties
in any compartment to which the
damage
con
trol party may gain access.
The administration
of morphine is a
matter in which the judgment of
a hospital corpsman
is apt to be
safer than in less experienced
hands.
The presence of a member of the
hospital
corps
in whom his
shipmates
feel
a degree
of
confidence,
directing these operations,
will tend to support morale.
Furthermore,
the training of the corpsman
is such that remedial
measures known to
him may be used to add to the safety
and comfort of the wounded
or
those made ill by prevailing conditions.
Task 2.— Treatment of wounds
at the earliest
possible
moment
is
important in reducing
mortality rates, shortening duration of ineffec
tiveness,
and relieving pain, and requires
no comment.
Likewise that
efficiency of medical officers and methods
employed contribute directly
to such results
is patent to all.
Yet there must be some definition of
efficiency
since
personnel
and facilities
are limited at best
and
the
first may be reduced by casualties
while the latter may be well nigh
destroyed.
Furthermore, in precisely
those cases
where faculties are
most completely wrecked
the task confronting the medical department
is apt to be greatest.
The percentage
rates of wounded
vary greatly
on individual vessels, and by ship types ; in fleet actions
as opposed to
single
ship duels
and
most appallingly
as
between
victorious
and
vanquished
units.
184
HOLEMAN—MEDICAL
DEPT. FUNCTION IN NAVAL ENGAGEMENT
It has long been assumed
that for a victorious ship engaged in a
decisive
fleet action
a fair
assumption
of total casualties
would
be
20
percent
of complement,
of these that
4 percent
would be killed,
that
8 percent
would be seriously
wounded.
That in single
cruiser
encounters
approximately 15 percent would be killed or wounded,
the
ratio of killed and wounded
being about the same.
At Jutland total British
casualties
fell considerably below expected
rates.
Of the total strength
of the fleet the percentage
of casualties
was
11.16
(10.04
killed
and
1.12
wounded).
These
figures
over
emphasize
a trend, which had previously been noted, toward a greater
ratio of killed to wounded.
It must be remembered,
however,
that
Jutland was an undecisive
battle, all ships did not participate and the
death rates
were greatly increased
by the explosions
and sinking of
major ships with all hands aboard.
Differences
in armor protection accounts
for variances
in casualty
rates, in proportion of killed to wounded
and the nature of casualties.
H.M.S.Zion,
a battle cruiser
had a percent casualty rate, at Jutland,
of 11.85
(7.7 killed, 4.15 wounded); H. M. S. Barham, a battleship, had
a percent casualty rate of 6.04 (1.93 killed and 4.11 wounded).
Burns
by flash, appear,
on the other hand, to increase in relation to wounds
by projectiles in direct proportion to the thickness
of armor.
As for difference
between
rates for victorious or vanquished ships
they may be practically zero on the one hand and approach
100 percent
on
the other.
At Tsuishima
the defeated
Russian force
had about
30 percent
casualties,
while
16 percent
has been assigned
a? the prob
able Japanese rate for the whole campaign.
In the single ship action
between
the Sydney
and
Emden,
the former had 4 men killed
and
12 wounded,
the defeated Emden
had 40 percent
casualties.
These
data are introduced
here only for
the
purpose
of calling
attention to the possible magnitude of the task presented.
Faced with the immediate
care of 16 percent of the crew, obviously
efficiency
of immediate
treatment precludes
the possibility of finished
surgery.
Of this Fleet Surgeon
Christopher L. W. Bunton, M. B.,
R. N., says:
My experience
in a double
role,
that
of an operating
surgeon
in a hospital
receiving
wounded
from
ships after an action,
and that
of a surgeon in charge
of a ship sustaining many casualties in the battle of Jutland, leads me to deprecate
strongly the performance in dressing stations of operations which could be deferred
with safety till patient
had
been
transferred
to the more favorable
conditions
obtaining
in a hospital
ship or shore hospital.
The surgery best adapted for dressing stations during
or immediately
after
an
action would
seem to be an amplified
first-aid
treatment.
Operations
should be strictly confined to those of an imperative
nature, and all
efforte
be directed
to rendering
wounds
as aseptic
as possible, with a view
to
facilitating the work of the surgeon who eventually
receives the case.
*
*
*
Provided
they are not causing
untoward
or dangerous
symptoms
from their
presence,
pieces
of shell deeply embedded are better left in situ.
*
*
*
HOLEMAN—MEDICAL
DEPT. FUNCTION IN NAVAL ENGAGEMENT
185
The question of amputation
of limbs is certainly
best postponed till the patient
is transferred
to a hospital or hospital ship.
Of course, where a limb is practically
severed, and all hope of its preservation
out of the question, it may
be quickly
snipped
off with
a view to facilitating patient's
locomotion.
*
*
*
Task
2
(a)—Restore
effectives
to
battle
stations. —It
is
assumed
that the personnel
of the medical
department are thoroughly indoc
trinated
regarding
the
imperative
necessity
of
giving
immediate
attention
to those, whose wounds being properly dressed, may carry
on.
To accomplish
this during lulls in battle will be of direct military
importance.
Will
there
be a lull in action?
Estimates of the probable
dura
tion of a battle between modern fleets vary from 20 minutes
to
1 hour,
such estimates
are predicated
upon favorable weather conditions and
a desire to fight to a finish on the part of both commanders.
In such
event probably no lulls of sufficient
length to warrant relaxation in
enforcement
of
strict
watertight
integrity
would
occur.
But,
at
Jutland,
the only
engagement
in which
entire
modern
fleets
have
participated,
the
battle
largely
consisted
of
lulls
punctuated
by
minutes of fighting.
Under such conditions, subject to central con
trol, on vessels equipped
with modern quick-acting doors, moderately
wounded might well have their wounds
dressed, men made ill by com
bustion gases or with eyes inflamed by tear gas might receive attention.
Task 2
(6)—Evacuation
of casualties. —Under
the same conditions
as would permit the slightly wounded
to have their injuries dressed
during
a lull,
the battle stations might be cleared
of the seriously
wounded.
The
movement
of
all
collecting
parties
is
subject
to
central control.
The need for special training of the collecting
parties
is again emphasized
for most important
tasks devolve
upon
them in
recognition of injuries from chemical
agents, in transporting or aiding
such cases
to the decontamination stations,
in avoiding contamina
tion of themselves, and in guarding against taking contaminated Utters
into the battle dressing stations.
Fortunately, if the battle be of short
duration most of the cases injured by the now-known vesicant
chemi
cals will not be incapacitated until after the fight is concluded.
Task
2
(c)— Treatment
of noneffectives. —The fact that
the para
mount duty of the medical
officer is to promptly restore to his station
every man capable of fighting the ship does not mean that the suffer
ing of the seriously
wounded
shall be ignored.
The
battle-dressing
station
country
must be in
readiness
so
that
men may
lie
down.
Blankets, hot water bottles, morphine (or perhaps,
stimulants) must
be distributed
to control shock
as necessary.
Their
dressings
must
be inspected
and
hemorrhage
checked if this
has not
been accom
plished
at their battle stations or if moving them has disturbed their
dressings or tourniquets.
Also care must be taken
that tourniquets
are not left too long in situ.
186
HOLEMAN
MEDICAL
DEPT. FUNCTION IN NAVAL
ENGAGEMENT
These tasks must, of course, be performed by hospital corpsmen until
such time as the medical officer and his immediate assistants
complete
task 2 (a).
The nature of the surgical
work to be undertaken has
been
considered.
There
may
be
cases
in
which
something
more
radical than high-grade
first aid is clearly indicated.
The probable
time when clearance to a hospital ship or hospital may be accomplished
should be carefully considered,
and if the delay would be too prejudi
cial,
formal
operations
decided
upon
should be thorough and
per
formed in strict accordance
with approved
technique.
Task 3 (a)—Evacuation of noneffectives from battle stations. —Evacua
tion of seriously
wounded
from their battle stations should be accom
plished,
as indicated under task
1
(c) at the earliest
opportunity
in
order that morale of gun crews
(or other working units) may not be
impaired by their continued presence in
the compartment,
and in
order that the best treatment possible may be promptly initiated.
Task
3
(b) —Evacuation
of
noneffectives
from
the
ship. —At
first
thought evacuation of casualties
from
the ship might not be con
sidered
as falling within
the
purview
of
a study of "Function
in
battle"
since, of necessity,
the battle is over before it is undertaken.
But to omit it would be to fail in fully considering
the duties of the
medical
department incident
to
the
battle.
The
care of casualties
in reality consists of three phases:
1. First-aid
treatment at a battle station.
2. More thorough first-aid treatment at a battle dressing
station.
3. Definitive treatment in a hospital or aboard
a hospital ship.
Only in such exceptional
instances
as those cited under task 2 (c),
or when it is impossible
to evacuate
the casualties
should definitive
treatment
be
conducted
aboard
a
fighting
ship.
Fleet
Surgeon
Bunton,
previously quoted,
says that after Jutland evacuation was
accomplished
in 48 hours and adds:
I should
be
inclined
to
consider
this
period
as
representing
the maximum
delay of wounded
on board, since to more or less exceptional
circumstances
the
fleet remained for a considerable
time in the vicinity of the original
action
with
a hope of
cutting
off the enemy for his
base
and
resuming
the engagement.
Under
ordinary
circumstances
a period of 24 or 36 hours would probably
be the
more usual time to count on as available for examining and dressing the wounded.
Supporting
Measures
Personnel. —Restudy
of
personnel
requirements
on naval
vessels
has been undertaken by the Bureau of Navigation
and requirements
of hospital corpsmen
to carry on battle activities will doubtless
re
ceive careful
consideration.
The article on Logistics by the Surgeon
General in this issue of the Bulletin refers to the necessity for about
six
more
corpsmen
on
battleships.
Such an
increase
would
make
HOLEMAN—MEDICAL
DEPT. FUNCTION IN NAVAL
ENGAGEMENT
187
available
19 or 20 hospital
corpsmen.
A logical apportionment of
these would appear
somewhat
as follows:
It is evident that men
detailed
to
accompany
collecting parties
will later be available for other duty and perhaps
the decontamina
tion station may not be needed.
On the other hand,
that station
may
receive
many
cases
and
require
additional
assistance;
also
as
cases
accumulate
there
or at the battle dressing
station more
men
will
be
needed
as nurses;
furthermore,
no
allowance
is
made for
casualties
in this tabulation.
As
a result of the study, both exten
sive and intensive,
which the efficient employment of medical
depart
ment personnel
in connection
with
effective
damage
control during
action, has received,
a considerable
volume
of opinion has arisen to
the effect that the Medical Department's work begins after battle or
during
a major lull therein;
and that, therefore,
all such
personnel
should seek refuge behind
armor until
the action
is over when
they
should emerge and begin
the performance
of their duties.
Such
conception
is repugnant in
that,
were it
accepted,
morale
would
unquestionably
be lowered
in
a force
thus
isolated
without
information
as to progress
of the battle and with
no tasks directly
connected
with fighting
the
ship.
Furthermore,
such
a conception
falls short of a visualization of requirements
to accomplish
the mis
sion of the Medical Department in battle.
During action,
on many ships, repair parties
are stationed
in spaces
immediately
adjacent to
or,
indeed,
actually in
the
area
assigned
battle
dressing
stations.
When
their
collecting
parties succeed
in
evacuating seriously
wounded
patients from battle stations they may
be brought in for treatment immediately.
While it would
be most
desirable
to have
a medical
officer detailed
to supervise
treatment of
all injuries
at battle stations
and
the
transportation
of the
more
seriously wounded,
the principles of economy
of force
and security
prohibit
such employment.
Medical
officers must perforce
stand by
the
battle dressing
stations.
These stations
must be kept manned
and
equipped,
in constant readiness
to—
(a) in the event of a lull in action, immediately treat those capable
of restoration to duty, and
(b)
attend to the immediate
needs of noneffectives
brought in by
the collecting
parties.
Throughout
the action hospital
corpsmen
attached
to
collecting
parties
must be alert to maintain
the physical efficiency
of men at
battle stations and to assist in evacuation
of noneffectives
from these
stations.
To assist the operating
surgeons at battle dressing stations
To receive and care for sick and wounded
To accompany
collecting
parties
To man the chemical decontamination
station (s)
1 or 2
10
2
6
188
HOLEMAN —MEDICAL
DEPT. FUNCTION IN NAVAL ENGAGEMENT
Battle
dressing
station.—Modern
battle
dressing
stations
are
the
result of a continuous evolution through the years of development
of
modern
navies
to reach
the proper solution of the dual problem
of
best caring for the wounded
and supporting morale
of survivors.
Fleet Surgeon
Bunton
stated
(about
1 year after Jutland) that a
battle dressing
station "should be fully protected,
easily
accessible,
thoroughly ventilated, and
have
a good supply of both hot and cold
water with fixed basins
and effective water service."
To this should
be added:
"Adequate
space for the injured
to lie
down
and
to
be
cared for in" (Fleet medical
officer's
comments
on Medical Depart
ment in battle):
fixed sterilizers
or at least facilities for plugging
in
portable
instrument sterilizers
and water heaters,
and storage facili
ties for complete
logistic support of the station.
Do
the
existing
battle dressing
stations possess these character
istics?
As planned
on newer battleships they
did.
At present they
are protected
by armor and review
of plans
of battleships indicates
that battle dressing
stations
are as accessible
as any place thus pro
tected could
be.
They are generally
well located
one deck below
the
sick bay, where exists the greatest likelihood of conservation
of their
facilities— lights, water supply, and sterilizers.
Access
is reasonably
free by companionways
from the upper
decks,
and quite generally
crew's living spaces are near
at hand.
In peace time,
except for drill purposes,
the Medical
Department
requires but a fraction of the original battle dressing area assigned by
approved
plans of the vessels.
In fleet medical
officer's comments on
Medical Department in battle, July
1,
1937,
reference
was made
to
"dual purpose
assignment"
of space.
This dressing station space is
a most pertinent instance
of the value
of such
a conception.
Con
servation
and efficient
use of space does not permit allocation to the
Medical Department for its exclusive peace time use all the space that
it will require in action.
However, the dual function of the area assigned to battle dressing
stations
on approved
plans of all ships should
be such that the deck
space may be used as necessary by other departments
until the battle
dressing stations
begin to function.
After battle the need for exclusive
use of the entire
space by those engaged in personnel
rehabilitation
will probably be imperative.
In order
that traffic
through battle dressing
stations
may
be re
duced to a minimum after battle, the allocation of storerooms
should
be carefully studied.
Those used for storage
of items which will be
required
for material repairs
should
not open into these areas.
Re
view of battleship plans shows that, in many cases, material which will
be immediately needed is now stowed in rooms opening into the battle
station areas; while nearby
storerooms,
equally commodious,
are used
HOLEMAN—MEDICAL
DEPT. FUNCTION IN NAVAL
ENGAGEMENT
189
for supplies
and
accounts
stores
which would not
be immediately
required.
A judicious interchange
could probably
be effected.
Sufficient battle dressing station space and storage facilities in con
nection therewith will be provided on new construction.
If, on exist
ing
ships,
encroachments
upon
battle
dressing
stations
and
their
required storage
space, without due regard
to the principle of "dual
function"
have occurred,
medical
officers should
exert themselves
to
effect
an adjustment with other departments
aboard
their ships
to
reestablish the adequacy
of their battle dressing
stations.
In order
that such adequacy may be demonstrated
it is suggested that periodi
cally
there
should
be held
drills in which the number of personnel
casualties handled
as directed
in Fleet Memorandum 29M-37,
shall
equal 16 percent of the crew.
Ventilation
presents
a problem new since 1918.
With ships' venti
lating systems shut down obviously they could not be considered well
ventilated —with
the ship
opened
up
after
action, with
the system
functioning and its intakes uncontaminated by chemicals,
they are as
well ventilated
as any regions on the third deck.
A matter demanding
special study is the protection of battle dressing
stations against
chemical
contamination.
The Bureau of Construc
tion and Repair is giving this
careful
consideration
in planning new
construction.
Contamination
must
be guarded
against in two ways:
(1 ) The best defense obtainable must be provided by regulation of
the
ventilating
system
and
such
structural
protection
as
may
be
devised.
(2) Prevention
of contamination by entering
personnel.
This
has
been touched
upon
when instruction
of litter
squads
was discussed.
A corollary
to
the
rule
excluding
chemical
casualties
from battle
dressing
stations is that chemical
decontamination
stations
must be
provided.
Such stations,
either
as designed for new ships, or extem
porized on older vessels must meet minimum requirements
of:
(a) Best possible protection compatible
with easy access from upper
decks.
(6) A space for disrobing and disposition of contaminated clothing.
(c) A treatment room.
(d) Showers
and soap to permit abundant lathering.
Fresh water
is highly
desirable,
but abundant salt water and salt water soap are
preferable
to
a scanty supply of fresh water faculties.
(e)
Space for dressing in fresh clothing.
Water is supplied
to the battle dressing stations and water heaters
are
provided.
As
a
safety
precaution
the
stations
have
reserve
tanks —the rule for these being that the capacity of tanks at the for
ward and after stations shall
be
1 gallon per man for 20 percent of the
complement;
for
the
amidships
station
the
capacity
is
approxi
mately one-half this amount.
45202—88
8
190
HOLEMAN —MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT
Quite generally
a cargo light is included in the prescribed
equipment
for operating
table illumination — the remainder
of the space must be
left to the ship's lighting circuits.
In case of failure, battery operated
lanterns must be provided.
In response to a recommendation
of the
commander
in chief, the Bureau of Engineering has developed
a special
lighting
fixture for
the
operating
table,
two experimental
units of
which have been sent to the fleet for service
test.
In an excellent
study made
by Commander H. L. Jensen (MC),
in
December
1937,
particularly
in
reference
to
the
battle
dressing
stations on the Maryland
and incidentally
to those of other battle
ships,
that officer stated
that:
"The storeroom
which formerly
was a part of the after dressing station
has now
been
taken away from the medical department
and turned
over to the damage
control
officer.
*
*
*
The
floor
space
available
(at
the
forward
dressing
station)
will just permit
the erection of a dressing table with
two men working
on each side.
There
is
no floor
space
left
on
which
to deposit
stretcher
cases
before
or after
operation."
To
this
statement
is added
data
concerning
the
over-running
of this
area by personnel
of other
departments.
The
statement
regarding
the available
space
was verified by examining
blue prints of the Mary
land.
While
the area described
is somewhat
irregular
in outline,
the
present
assigned deck space
appears to be less than
20 percent of that
allotted
thereto
on the original
plan of the vessel.
Encroachments
on these spaces
have occurred
on other battleships.
Accepting
the
practical
obliteration
of
useful
battle
dressing
stations
as a
fail accompli, Jensen
adds: "It
is assumed that
a naval
engagement today
will
mean
great material
damage, what
with
hits by major
shells, bombs, and tor
pedoes.
Obviously
then, it would
be a great mistake to concentrate
the medical
activities,
particularly
instruments
and
dressings,
in any
certain
parts
of
the
ship without making
ample provision
for the rapid
transfer
of these activities
to some other part of the ship less seriously injured."
From these considerations
he concluded
"*
*
*
that permanently
equipped
dressing stations
and per
manent
storerooms
should
be
abolished
on the
newer ships
in
new construc
tion
*
*
*."
The solution
presented
was:
that after
battle
the two
surgical
teams,
each
headed by a medical officer should
seek out "A suitable area on the second deck
or above, set up his outfit and go to work.
The area chosen must have sufficient
space
in which
to work advantageously,
be readily
accessible to that end of the
ship and be off the main arterial
routes.
On the newer ships in the Navy, there
is no such
space
below the second deck."
"A mop-up
squad"
headed by
the
dental
surgeon
or
other
competent
person
was also
described
whose duty
it
was to bring the wounded to the selected stations.
To equip
these
extemporized
battle
dressing
stations.
*
*
*
"In
lieu of storerooms
medical
equipment
should
be
stowed
in
lockers,
the
largest
consistant
with
portability.
There
should
be
a minimum
of
14 such lockers,
scattered
about
the ship near access
hatches,
so that
after
the battle,
certainly
some
of them would
be left intact.
Each
locker
should
contain
as
a minimum
the following:
(a list of proposed
contents
was here supplied
by the author).
Two men can easily carry
such a
locker
(one has been made upon this ship and portability proven) and can quickly
bring them to the areas chosen by the medical officers as dressing stations.
Each
locker
would
be
a complete
small
surgical
dressing outfit in itself,
and,
with
several of them, a large number of wounded can be cared for.
*
*
*
Likewise
HOLEMAN
MEDICAL
DEPT. FUNCTION IN NAVAL
ENGAGEMENT
191
several portable
operating
tables, on the order of the present field table would
have to
be provided,
six would
be sufficient.
It must
be remembered
that
no
great
or
finished
surgery
would
be
undertaken
immediately
after
the
battle,
merely enough to preserve life until the patients could be evacuated to a hospital
or hospital
ship, or until the wounded
have all
been
treated,
and then, if time
permits,
a more finished surgical outfit could be provided
for more finished work."
Concerning
water it was stated that it "*
*
*
could be put up in tins and
scattered throughout
the ship.
Not only
is it imperative
to have water at the
dressing tables, but drinking
water will be at a premium.
These cans of solu
tions can be sterilized
in the large mattress sterilizer,
30 or more at a time.
The
inside of the cans would probably
need
some
sort of plating
or other protection,
but that is a minor technical
problem."
The merit of the suggestion, which has been voiced by other officers
than
the author quoted,
that fixed battle dressing
stations be abol
ished should be critically
examined.
In favor of portable outfits and
the setting up of the stations at
sites to be selected after battle in the manner
suggested are:
(a) The
assumed
greater
probability
that
a
number
of
small
portable outfits scattered
throughout the ship would escape destruc
tion than that fixed battle dressing
stations would so escape.
(6)
The assurance
of great flexibility
and mobility
of the medical
department.
(c)
The
ease
with
which
stocks
of dressings
and
other surgical
material may be concentrated
at places
chosen
for setting up
the
dressing
stations.
(d) Adequate
space,
off
main arterial
routes
accessible
to
both
ends of the ship may be found on the second
deck
or above while
crowded
conditions
and
general
inaccessibility
of
present
dressing
stations render
them worthless.
In favor of battle dressing
stations as at present
provided are:
(a)
The locations are known
to
the
crew
and
with
well-marked
access routes, ambulant patients may promptly report for treatment.
(6)
Ample
dressings,
operating
facilities
and
water
reserve
are
localized.
(c)
Manifest
provision
for care of wounded
will
support morale
and tend
to promote efficiency.
(d) Protected by armor (on major ships),
unless
the vessel suffer
excessive
damage,
at least
one station will probably
remain
fit for
use.
It is believed that:
(a) Prompt
and
effective
treatment
may
best
be
achieved
by
planned rather than extemporized
facilities.
(6) The value
of permanently located battle dressing stations has
been clearly demonstrated
in modern naval warfare.
(c) Interludes in battle may permit access to these stations
where
wounds may be treated,
effectives
restored
to duty, and lives saved.
This will be facilitated if the slightly
wounded
and
the stretcher
192
HOLEMAN
MEDICAL
DEPT. FUNCTION IN NAVAL ENGAGEMENT
bearers know precisely
where medical
officers will
be found and how
to reach them by established
clearly blazed routes.
The record
of British ships at Jutland would seem to fully justify
the existence of battle dressing stations—in fact there would seem to
have arisen no doubt in the minds of their medical
officers as to their
efficacy.
From
descriptions
given they were no more accessible and
certainly no better equipped
than those in our own Navy.
In any event it has been decreed that on new major ship construc
tion battle dressing stations,
with adequate storerooms
at the forward
and after stations and locker space amidships
shall
be provided and
that they shall be retained
on ships now in being; that on cruisers two
stations with sufficient
locker space shall be provided.
This decision
has been made by the Chief of Naval Operations on the recommenda
tion of the Commander in Chief, Bureau of Construction
and Repair
and the Bureau of Medicine and Surgery.
Additional
dressing
station
facilities. —While
permanent
battle
dressing
stations
are
considered
essential,
to
provide
against
the
destruction of one or more of them, by joint action of the Bureaus of
Construction
and Repair
and Medicine
and Surgery there
is being
developed,
along
the line of the postulates
prescribed
by Jensen,
a
portable locker-type outfit to contain sufficient material for setting up
one or more dressing stations in such spaces as may be found suitable.
The present intention is to provide about six such lockers
for battle
ships and a proportionate number for cruisers.
It is also the intention
to place one such locker in a convenient place upon each new destroyer.
While battleships only have been considered
in discussion
of battle
dressing
stations, quite similar arrangements
are provided on aircraft
carriers.
On cruisers
such deviation from the principles enunciated
as exist are based upon lack of protection by armor and comparative
crowding of general facilities.
Since armor protection is not available
the sick-bay area is the best possible battle dressing
space.
Because
deck
space
is at such
a
premium,
officers'
or chief
petty
officers'
pantries and living spaces are generally
utilized for the other station.
Such fixtures
as reserve water tanks,
water heaters,
and lockers
are
installed in these areas
as may be required.
On destroyers,
in suit
able locations, at each end of the ship, water heaters and outlets for a
small sterilizer are provided.
It is assumed that on these vessels the
wardroom will be used as a battle dressing station; the fittings in crew
spaces
are provided in event of the officers'
country being
rendered
unusable.
Battle station facilities.
(a) First aid lockers
have been sufficiently considered.
(6)
Water should be provided for drinking.
Should the battle be
prolonged
all hands will probably
need it, but particularly
will the
wounded
demand
it.
Canteens
will
hold
a
sufficient quantity;
COTTLE —FLEET MEDICINE
193
however,
a 10-gallon
container with faucet
and hooks for hanging it
upon
a
bulkhead
is
being
considered.
The
additional
weight and
demand for storage space may prevent its adoption.
(c) A sanitary stool, capable of being lashed down, has also recently
received
consideration,
but
again
weight and
storage
problems will
probably debar it.
In any event buckets provided for this
purpose
should
be lined with impervious
paper,
to
be immediately thrown
overboard
after use.
The Bureau of Construction
and Repair
has
given attention to production of a type of lining to fit the regulation
Navy bucket.
Necessity of guarding battle stations from gross con
tamination require
no comment.
(d) Protective clothing and gas masks
are not the responsibility of
the medical officer;
but,
as all preventive measures
against
disease
and injury
are within
his province
to
the
extent
that appropriate
recommendations
are to be made by him if occasion demands, observa
tion as to adequacy
and cooperation
in maintenance
of efficiency
of
these items should not be neglected.
FLEET MEDICINE
By Capt.
George
F. Cottle, Medical Corps. United States Nuvy
Fleet medicine
is founded
on the need to liberate medical
activity
through cooperation,
to strengthen
it by coordination, to harmonize
it with naval administration,
to fit it to the requirements
of naval
tactics and to make it contribute to the success of naval strategy.
It
seeks
to interpret
medical
principles
to naval
commanders
and
to
explain
naval
requirements
to
medical
personnel.
It
is practiced
through inspections,
through study of problems,
through conferences,
and
through indoctrination.
It attempts
to
lessen
the number of
casualties
due to disease and
accident,
to build positive health and
vigor in naval personnel,
to enhance morale
and to find how to select
persons able to stand the stress and strain of naval warfare.
Fleet medicine
deals with ships, divisions, squadrons,
flotillas, and
forces.
It includes
preventive medicine,
emergency
medicine,
hos
pitalization,
and
medical
logistics.
It
encompasses
aviation,
sub
marine,
and field medicine.
It provides for medical
disaster relief and
for the
care of war time
casualties.
It studies
the
causes of fleet
morbidities and mortalities.
It considers diet, food, clothing, bedding,
living conditions, work schedules,
athletics,
and recreation.
It takes
into consideration safety devices,
safety mechanisms,
and habits.
It
studies
the ebb and
flow of quarantinable
and
other
communicable
diseases in the ports visited by the units of the fleet.
It is interested in
hygiene,
sanitation,
quarantine,
and
pratique.
It
is
interested
in
immunology
and epidemiology,
in liaison with health departments
and
with medical
activities ashore.
It is interested
in the distribution of
194
COTTLE —FLEET MEDICINE
medical
personnel,
in the environment provided for medical personnel
at sea, in the sufficiency
and economy
of medical
supplies
and equip
ment.
Fleet
medicine
strives
to
study medical
problems,
to
give
timely information on medical
matters,
and to be prepared
to provide
consultation when indicated.
From the day when lime juice pushed scurvy off the sea to the day
when
a few
tablets
of common
salt stopped
the incidence
of heat
cramps in fire rooms, fleet medicine
has year by year seen morbidities
and
mortalities
reduced
and
eliminated.
The
seven
quarantinable
diseases, including smallpox,
yellow fever, and cholera
no longer enter
the Navy because fleet medicine
has long been coordinated with
the
activities of the United
States
Public Health
Service
through whose
activity
those
diseases
are kept at bay.
Typhoid
fever
has
been
almost eliminated by inoculation, dysentery by precautions surround
ing the supply of drinking
water and
food
in ships.
Attention
to
safety precautions and devices while men are at work, to living condi
tions
aboard
ship,
to athletic
and
recreational
opportunities
have
in combination with improved methods
of control of the spread
of
disease, reduced morbidities and mortalities year by year and encour
aged healthy, wholesome,
normal, ambitious young men to enter the
naval service and to remain in it.
Fleet medicine
attempts to develop
fleet
medical
sufficiency,
the
ability to meet the emergencies of surgery, of medicine, and of preven
tive medicine.
It provides for intership consultations, for transfer of
the sick and injured at sea.
It hopes to so influence its ships' medical
officers
that the fleet, each force and even each ship will be able
to
complete
its assigned
task, perform
its tactical mission without
the
disturbance
that
can
be
produced
by inability
to
handle
medical
emergencies.
Fleet medicine
attempts to visualize its war mission.
It studies
the
history
of
naval
warfare,
the
battle
of Jutland,
the
overseas
combined operations
at Gallipoli,
the history of transportation over
seas of troops
from Australia, Canada, India,
and the United
States.
It realizes that sick lists in transports rise to 5 percent of all on board,
that attempts to seize defended
beaches
result
in 20-40
percent
of
casualties
which must be evacuated
along lines of naval communica
tion without too great slowing of the military and naval advance.
It
discusses
the movement
of hospital ships,
the preparation and place
ment of field hospitals.
It takes cognizance of the professional
ability
of naval
reserve
medical
personnel
and
prepares
to
give
them
an
understanding
of
the
seagoing
environment in which
they
are
ex
pected
to function.
Naval
personnel
at sea live within
the iron walls of ships
where
workshops,
enormous
power
plants,
complicated
machines,
high-
tension
electricity,
guns
large
and
small,
high explosives,
airplanes,
COTTLE—FLEET MEDICINE
195
small boats, tall masts, contain the threat of accident
even of disaster.
On deck,
fog, rain, snow,
sleet, storm, heat,
and cold
produce
their
effect.
Inside the ship, officers and men eat, sleep, bathe, play, work,
study,
and drill crowded
together
too close for comfort.
Fleet medi
cine is
interested
in the prevention of disease
transmission,
in the
prevention
of accidental
injury.
Closed
tight against
storm
and wet
or against enemy attack the ventilation, heating,
and cooling of living
and working spaces require study and supervision
of a special sort.
Fleet medicine
is interested
in the medical
care available to families
of officers
and
men
on
shore.
The
better
medical
care available
loved ones ashore the more free from worry and the more able a crew
becomes for the work at sea.
Fleet medicine
is interested
in health conditions at and near shore
bases and ports of call.
The efficiency of public health
officials
ashore
directly effects the health of the fleet.
Fleet medicine
learns of the
incidence
of world-wide disease through reports
of the United States
Public Health
Service.
It learns of local
disease incidence
through
scanning
the weekly and monthly reports
of State,
city, and county
health
boards.
Thus it can anticipate, slow up, or perhaps
even pre
vent sudden
unexpected
entry of epidemic
disease to the fleet.
Some
of its problems
can be solved by the receipt and dissemination
of news,
some by study and indoctrination, some are capable of solution in the
fleet only in part, some wait upon solution of public health problems
ashore, some must wait until new therapies, new preventives
are found.
Nearly one-half of the total yearly incidence
of disease and injury
in the Navy is due to causes that are not directly within fleet or Navy
control.
Of the 55,614 primary admissions
to sick list in the year 1936,
17,725
were due to communicable
diseases transmissible
by oral and
nasal secretions
the great majority
of which
were of the "common
cold"
or
according
to
the
Navy
nomenclature
"catarrhal
fever";
S,148 primary admissions
to sick list were due to the venereal diseases
and 802 were caused by accidents from vehicles.
The dangers of crowded living conditions are constant.
Cleanliness
of mess gear, of food handling, scuttle
butts, clothing, persons,
bed
ding, supervision of ventilation,
of heating,
of laundries,
of barber
shops;
these and other hygienic
mechanisms
reduce
somewhat
the
opportunity for rapid spread of many diseases but the common
cold
still sweeps unhindered
through
ships and fleets and influenza is still
entrenched behind its power to fell large numbers of men and even to
slay a few.
Medical literature is scanned in vain to find
a preventive
of value against this foe to fleet efficiency,
this invader which returns
year after year to bother,
and to disturb, to initiate, and to do damage.
Against
the
second
common
cause of fleet disease incidence,
the
venereal
diseases, we have some useful weapons and of late some hope
of better days ahead.
To attempt control of these invaders
we teach
196
COTTLE —FLEET MEDICINE
and warn our men, we give them ready access to chemical and mechani
cal preventives.
We improve our therapy as it improves in civil life.
We are ever alert to find and use new remedies.
We have
achieved
a
degree of success.
For 4 years the incidence of these diseases has been
continuously
lowered
each year.
Further
reduction depends
upon
successful
action
in civil communities
where
these diseases ebb and
flow practically uncontrolled.
However, hope is here, civilian
com
munities are awakening,
out of the dark of defeatism
a new day ia
dawning.
The light of this new day has for 10 years been shining in
the Scandinavian countries
where
the incidence
of venereal
disease
has been falling, where syphilis has become a rarity.
The light of this
new day has penetrated
to England.
It has reached
the Common
wealth of Massachusetts, the State of New York.
Reflected
from the
brilliant
service of Doctor Parran, the Surgeon
General
of the Public
Health
Service, it is spreading
throughout the United
States.
The
new light
has
begun
to glow where
inertia,
ignorance,
false piety,
silence, let well enough alone policies
have lived in darkness.
Gover
nors, legislators,
cities,
towns,
and counties
have taken notice.
State
boards
of health
have turned from discouragement
to hope, old laws
have been given new life, new laws have come into being.
The people
have begun to listen, to open their purses, to lend their support.
News
papers,
periodicals,
books,
and people have become articulate.
The
battle is on in earnest, in the open.
These
age-old
enemies must be
and will be conquered
when the citizens
and physicians are stirred to
act in line with public health leadership.
In 1936, 860 of our officers and men were striken on the public high
ways and 56 of them died from this cause.
The fleet can exert but slight
control over the hazards of the highway.
Condemnation and punish
ment of offenders,
in occasional
instances,
warning against
careless
ness, are the limits of our control, hope for reduction in these losses of
man
power
lies only in civil life.
Fleet medicine
is interested
in human conduct, in the prevention of
mental aberration and mental disease.
Our aviation specialists
tell
us that there
is
a recognizable
type
that cannot take
the stress of
aviation.
We feel that there is opportunity to study human behavior
more intensively,
to find
and try out more
exact
measurements
of
psychic and emotional states among officers and men.
Every year we
see suicide,
discharge
from the service
for mental
disease,
and
dis
charge from the service for disciplinary reason.
Fleet medicine
faces
this problem
of the ability
of human beings
to become adjusted to
naval life with the firm belief that some of these losses of man power
originate in types that are emotionally unstable.
It is believed
that
some of them can be discovered
and eliminated
from the service before
their conflicts
and maladjustments reach
the tragic end of suicide,
JOHNSON—HOSPITAL
SHIPS
197
mental
disease,
or disciplinary
discharge.
In statistical
form the
losses for the year
1936, from these causes were:
Suicides
29
Separated from service for mental
disease
241
Separated from service by disciplinary
discharge
919
The senior
medical
officer of a ship,
the division medical
officer of a
group of destroyers
sees fleet medicine
from his station aboard
one
ship.
He is absorbed in the care of the sick, in attempts
to influence ship
hygiene, to control the spread of disease, to save life and limb.
In this
outline of fleet medicine
he may find a widening horizon.
He may find
a means to focus his attention on the unsolved
problems
that persist.
He may find a way to lead us forward one more step toward reduction
of the morbidities and mortalities not yet eliminated from the sea.
HOSPITAL
SHIPS
'
By
Capt. Lucius W. Johnson, Medical Corps,
United
States Navy
Introduction
Down through the centuries
there has been gradual development
of
a mental
concept
that has
been aptly
termed
the Ked
Cross idea.
This idea, briefly stated, is that adequate care for the sick and wounded
of naval and military
forces is not only good
as a humanitarian
act,
but it is of distinct advantage
to the organization.
It prevents
the
spread of disease, restores men to the ranks who would otherwise
be
lost, and helps to maintain morale.
In remote
times it was customary for military leaders to take with
them to war, but only for their own personal
service,
men who com
bined
the
duties
of
barbers
and
surgeons.
Their
soldiers,
when
wounded or sick, were left to the tender
mercies or the evil devices
of
the camp
followers.
Ambroise Pare,
best
of
the
early
military
surgeons, describes
an impressive
incident which occurred
at Turin
in
1563.
He
saw
an
old
sergeant
cut
the
throats of
three
of his
wounded
men, gently and without malice, remarking that he hoped
somebody would do as much for him if he were ever in their condition.
Numerous historical records
leave us in no doubt that the lot of the
wounded soldier of that day was not a happy one.
By the middle of the eighteenth
century, most
governments
had
begun to feel the obligation to protect the health of their soldiers
and
to organize
for the care of the sick and
wounded.
As
the general
standards of medical
and surgical
care and hospital treatment have
i The conclusions
reached and the opinions
expressed are entirely
those of the author.
They must not be
regarded as in any way representing
the official opinions
or administrative
policies of any bureau or govern
mental
department.
Editor's note.— The author
is particularly
competent
to write on hospital
ships.
His service Included
duty as senior medical
officer of a large troop transport
and as senior medical
officer on the U. S. 8. Relief,
and he has obviously
made a thorough study
of his subject.
This article as submitted
included
an excellent
historical
review
which
the Bulletin was unable
to use.
198
JOHNSON—HOSPITAL
SHIPS
advanced
through the decades, provisions for the care of men in the
armed forces have made parallel progress.
(1) We have it on the au
thority
of no less a personage
than Sir John Pringle that, in 1743,
before the battle of Dettingen, the Earl of Stair proposed
to the Duke
of Noailles,
of whose humanity he was well assured,
that both
the
English and French hospitals should
be considered
as sanctuaries
for
the sick, and mutually protected.
This was readily agreed to by the
French general, who took the first opportunity
to show
a particular
regard for this engagement,
and it was strictly observed on both sides.
The idea continued to spread and finally, through the persistent efforts
of Mons. Henri Dunant,
a Swiss, culminated in the Geneva
conven
tion of 1864.
(2) A series of conferences
and conventions
at Geneva
and The Hague followed,
with The Hague convention of October
18,
1907, giving special
consideration
to the evacuation of the wounded
in naval warfare,
and to hospital ships, which is our present interest.
This recognition
of hospital
ships,
and
the clarification
of their
status, marked an important step in their evolution.
It focussed
the
eyes of the military world on a matter that had been gradually taking
form for centuries —floating hospitals for naval personnel.
Some of the most commendable
of humanitarian ideas weave them
selves so gradually into the fabric of human thought that their presence
is not even suspected
until long after they
have
become thoroughly
incorporated
into
the
pattern
of
community
opinion.
They
are
usually brought to the fore when
somebody
discovers
that they are
not only of philanthropic interest,
but of great practical value.
Thus
the hospital idea germinated
very gradually for more than 250 years
and then burst into full bloom
about the turn of the century, when
the practical importance of conserving
the lives of trained
naval and
military
men began to be appreciated
by governmental
authorities.
We have made great
advances
since the days
when
the dead and
seriously wounded
in naval battles
were thrown overboard,
to avoid
weakening
the morale of those who continued
to fight.
The trail of
our progress is marked
by numerous publications dealing with hospital
ships, and so extensive is the literature on the subject that more than
200 books
and articles
were read in assembling
material for this dis
sertation.
Two of them are of sufficient importance to deserve special
mention.
Hidden away under
the title "Medical
Tactics in Naval Warfare"
is the most complete
and authoritative
study of hospital ships
and
their employment that I have been able to find.
In this book, which
was published by Capt. W. L. Mann,
Medical Corps, United States
Navy,
in
1926,
there
are
80
pages devoted
to consideration of the
subject of floating hospitals.
His profound research and clear reason
ing have produced
a work which no student of this topic can afford to
underestimate.
It has been of the greatest
assistance
to me, and I
JOHNSON—HOSPITAL
SHIPS
199
am
reminded of
a passage written
by
a distinguished
professor
of
biology
in
the
University
of Cambridge.
In
the
1909
edition of
Mendel's
Principles
of Heredity,
Professor Bateson recounts
an inci
dent of his early years in research.
"I well remember
receiving
from
one of the most earnest of my seniors the friendly warning that it was
a waste
of time for me to study variation, for Darwin
had swept
the
field."
I have some hesitation in approaching the matter of hospital
ships, where Mann has swept the field, but am encouraged
to continue
and to test the old
adage that "fools rush in and win where
angels
fear to tread."
Surgeon-Rear Admiral Edward Sutton, R. N., is the author of the
other outstanding book.
It is entitled "The Fitting-Out and Admin
istration of a Naval Hospital Ship,"
and was published in 1917.
Hi3
experience
in command
of H. M. S. Rewa and H. M. S. Drina during
the world war formed
the background for this excellent
work.
In
1918
he was in command
of the naval hospital at the navy yard,
Haulbowline,
Queenstown,
Ireland,
and the many medical
officers of
the United States Navy who made his acquaintance
there have reason
to
remember
with
pleasure
and gratitude his helpful and
courteous
demeanor.
There
are
also many important
articles
by Pickthorn,
McNabb,
Chambers, zur Verth,
Pleadwell, Holcomb,
Chastang, Averous, and
others, which the student of this subject must not fail to read.
They
will be found listed
among
the references.
I am greatly indebted
to the Army
medical
library for the loan of
many books
and periodicals which could not be found in any of the
west coast libraries to which I had
access.
Particular
thanks are due
to Commander L. H. Roddis,
Medical
Corps, United
States Navy,
for
tracking down many elusive
references.
This is
being
written
during
a 2-year cruise on the U. S. S. Relief, much of the time remote
from sources of information.
In such a case,
one needs a friend who
is familiar with the libraries where naval and medical history may be
found.
Dr. Roddis has been such a friend and has seldom failed to
dig up the information that was needed.
A leading nation, engaged in a major naval war, will require
several
types of hospital ships, each differing from the others in certain impor
tant characteristics.
There
should
be fleet hospital
ships,
floating
hospitals for advanced
bases, hospital transports, perhaps rescue ships
and small craft for inland waterways.
Each of these demands
accen
tuation of certain
details
that are most important for the work that
it is called upon to do.
We have examined,
sometimes with a critical eye, the hospital ships
of the past.
It is with no disrespectful
thought that we summon back
those forgotten ships,
to learn from them the secrets of their failures
and successes, of their good and bad features, hoping to observe them
200
JOHNSON—HOSPITAL
SHIPS
with that nicety of discrimination that will enable us to take profitable
advantage of their virtues while avoiding their faults.
A hospital
ship, like every other human achievement,
represents
a series of com
promises
between
the ideal and the practical.
This point is empha
sized by Mahan, in commenting
on the design of combatant ships.
You cannot have everything.
If you attempt it, you will lose everything;
by
which I mean that in no one quality will your
vessel
be as efficient as if you had
concentrated
purpose on that
one.
On a given tonnage
*
*
*
there cannot
be had the highest speed,
and the heaviest battery,
and the thickest
armor, and
the longest coal endurance,
which the tonnage would
allow
to any one of these
objects by itself.
This principle applies equally to hospital ships.
You cannot
have
the highest
speed,
the greatest
steadiness,
the largest
bed capacity,
economy
of operation,
and the most
efficient
arrangement
of medical
department spaces, all combined
to the maximum
degree in any one
ship,
so
compromises
will be required
to make
the
individual
ship
best fitted for its purpose.
I. The Fleet Hospital Ship
The
fleet hospital ship should
be, above
all
other things,
a ship
specially built for its intended function which is to accompany
the
fleet and provide it with hospital facilities.
The hospital transports
may well be converted
liners, but the ship that is to serve as hospital
for a fleet has requirements
that cannot be completely
met except by
special
construction.
No one would expect
a house or a factory on
shore to be converted
into an ideal hospital, for there would have to
be many makeshift arrangements
which would reduce its usefulness.
Even
more
is this true
of ships,
and writers on hospital ships
have
repeatedly criticised their converted
vessels, stating that the highest
efficiency
would never be reached until
a specially designed and built
ship was provided.
Our experience with the Relief,
the only hospital
ship afloat that was
designed
and built
especially
for this purpose,
indicates that the useful life of such
a ship will be at least
30 years,
and any first-class
nation would find that the specially built hospital
ship had paid large dividends, which would justify the money invested,
long before its period of usefulness was ended.
Size is
a very important
consideration,
which has been discussed
by many writers and with very little
agreement.
But it is notice
able
that, whereas
before
the World
War
most
authorities
recom
mended
ships of 3,000 to 5,000 tons,
recent
writers advise
ships
of
8,000
to
10,000
tons.
The
disadvantages
of
oversize
were clearly
shown by the France IV (29,000 tons), the Aquitania and Mauretania
(30,000 tons),
and the Britannic
(47,000 tons), which were employed
during
the Gallipoli
campaign.
They
were
too
large
to enter
the
harbors at Alexandria
and Malta
and
their capacity
was
so great
JOHNSON— HOSPITAL
SHIPS
201
(3,500
to 4,000 patients) that a full load of sick was not always avail
able, resulting in uneconomical
employment.
Their daily consump
tion of coal and water was so enormous that it was difficult to supply
their needs.
The Maine, of the British fleet, and the Relief, of ours,
have proved
to be sufficient
in capacity for the needs of the fleet in
times of peace, and reasonably
economical in cost of operation.
They
are
both
approximately
10,000-ton
ships.
In
time
of war, rapid
evacuation by hospital transports and hospital facilities on shore at
an advanced
base would be necessary, in addition to the fleet hospital
ship,
if overcrowding
were
to
be
avoided.
A large
ship
provides
steadiness,
which
is valuable for
the
comfort of
the
patients,
for
surgical
operations,
and
other
procedures,
and it is easier
to bring
patients aboard
a large steady ship.
Capacity
is closely
related
to size, and must always
be considered
as being very elastic,
varying with the requirements
of the moment.
Recent hospital ships have accommodated
one patient for each 20 to
40 tons and, if the requirement
of 300 to 500 cubic
feet of air space
for each patient is met,
this proportion cannot be greatly exceeded.
It must always be borne in mind that the level of efficiency of medical
care falls rapidly
as the normal capacity is approached
or exceeded.
For this reason, prompt evacuation,
before the hospital ship becomes
overcrowded,
is very important and will save lives.
Speed should be sufficient to enable
the hospital ship
to maintain
her place with
the train, and
a few knots in addition.
It would be
highly desirable
to give her speed enough to keep up with the fastest
unit of the fleet, but this would entail such great sacrifice
of capacity
and
cruising radius that it must
be relinquished in favor of more
essential
features.
High
speed also entails
increased
vibration
and
greater
unsteadiness
in a seaway,
both undesirable
attributes for a
hospital ship.
None of those who have written on the use of hospital
ships
during
the
World
War has
mentioned
high
speed
as
being
necessary
while several
have
spoken
of its
disadvantages.
Sutton
makes the important comment
that high speed, inasmuch
as it implies
greater cost, absorption of space and production of heat, larger crews,
and increase
of discomfort in bad
weather,
is undesirable,
and war
experience
has shown it to
be
unnecessary.
He
regards
a cruising
speed
of
10 or
12 knots, with
an extra
3 or 4 for emergencies,
as
suitable
for
a hospital ship.
Ability to remain with the fleet includes
the requirement that she
be so constructed
that she can darken
ship at night and still maintain
habitable
conditions in wards,
clinics,
operating rooms,
machinery,
and
living
spaces.
This condition
cannot
be
completely
obtained
unless
the ship
be designed
and built with this feature
in mind.
A
very large part of her usefulness
to the fleet is lost if she cannot re
main with it by night as well
as by day, and if she can darken ship
202
JOHNSON—HOSPITAL
SHIPS
only
with
intolerable
discomfort
to
patients
and
workers,
it will
quickly
be reflected in the death
rate on board.
Electric-power
production should
be greatly in excess
of that ap
parently necessary
at the tune of construction of the ship.
Count
less new
electrical
gadgets
of all
sorts
have
been
installed
in
the
Relief since she was commissioned,
and
there is nothing to suggest
that this flood of new devices will slacken in the future.
Both alter
nating and direct currents
will
be necessary
and outlets
will
be
re
quired in all wards,
clinics,
and rooms for such machines
as portable
electrocardiograph,
short-wave
diathermy,
ophthalmoscope,
radio,
portable X-ray,
vacuum
cleaner,
deck
polisher,
and
others.
An
auxiliary
lighting
system,
entirely independent
of the main power
plant
and
assuming
the
load
automatically
whenever
the
voltage
drops below
a certain
level, will
be an essential.
It should
supply
the operating
room,
engine
room,
and bridge.
In most other parts
of the ship the necessary work can be carried
on by lantern or flash
light if the main circuit fails.
Distilling
capacity should
be greatly in excess
of that provided for
other ships
of similar
size.
Care of the sick requires
much
more
fresh water than a similar number of well persons would need and a
very large quantity will be consumed in the laundry, laboratory, and
other activities.
Baths and other outlets
will
be much more numer
ous than on ships of other types.
The fleet hospital ship
should be
entirely independent
of outside
sources in the matter of fresh water.
The
hospital
spaces should
be
concentrated
amidships.
Clinics,
offices,
treatment
rooms,
laboratory,
operating
rooms,
convalescent
wards,
and other activities in which patients
do not spend their whole
time, may well be located
below
the main deck.
Wards for the sick
should all
be
located
on or above
the main
deck
and
should
have
open
deck space immediately adjacent to them.
This is one of the
most
essential
features
and should
be the last to be sacrificed
when
compromises
are necessary.
Both
open
deck
space
and
glassed-in
solaria will
be
required
and it is important
that
they
be made
as
accessible
as possible,
so that patients
can
be wheeled
out on deck
without
too much handling.
Throughout
the parts of the ship which are devoted
to hospital
use, the ladders,
elevators,
passages, and doorways
should
be
so de
signed
that
they
give
convenient
passage
to patients on hand or
wheeled
stretchers,
in wheel
chairs
or on crutches.
Wide doorways
with low coamings
are essential
and should
be installed wherever
the
naval constructor will
allow
them.
Stairways,
instead
of ladders,
will make going about much easier for convalescent
patients.
Rooms for patients will
need to be large
enough
and have
doors
wide enough
so that a wheel stretcher
can be brought inside the room
and alongside
the bed for transfer of the patient.
A narrow door into
JOHNSON—HOSPITAL,
SHIPS
203
a small room requires
a great deal of awkward handling of the patient
between stretcher
and bed, and this may be a very serious thing if the
patient
be severely
wounded,
in shock,
or in a plaster
cast.
The
height
of rooms
and wards
should
be
7% to 8 feet, to allow for satis
factory ventilation.
Air space of 300 to 500 cubic feet per patient is
the present standard but, with more advanced
air conditioning, it is
probable
that this amount may be reduced
considerably
and
still
maintain adequate
aeration.
Laundry
capacity should
be very large.
On the Relief,
with
200
patients
present,
about 2,000 pounds
of Medical
Department linen
are sent to the laundry each day.
This activity,
together
with the
galley,
bake shop, butcher shop, blacksmith shop, morgue,
and other
spaces which are likely
to give
off wild heat,
unpleasant
noises, or
undesirable
odors,
should
be located
well aft, where
they will cause
the least possible
annoyance
to patients.
Boats, davits, and all gear
associated with
them
should
receive
the most
careful
consideration.
They are important for bringing patients aboard,
and doubly import
ant for rapid evacuation
in case it becomes necessary to abandon
ship.
Public opinion will not easily
be appeased if there is unnecessary
loss
of life among the patients,
in case of a disaster
to a hospital ship.
Elevators
are essential
equipment
and separate
ones are desirable
for patients,
provisions,
baggage,
and
contagious
cases.
Elevator
wells are
to be completely
enclosed,
so
as to make
them
as nearly
noiseless
as possible.
Careful study is required
to have
the wards,
clinics,
and
passageways
so
grouped
that
they
will
be most
con
veniently
accessible from the main
elevator
which is to be used by
patients.
Indirect lighting is most desirable for the wards, and separate read
ing lights
are needed for the bunks.
Lights near the deck, similar to
those used in theaters, are required
for night use by attendants.
Out
lets for attachment
of individual radios, or head sets connected with a
central receiving station will provide amusement for the patients and
help to keep them contented.
Some type of silent call system with a
push button at each bunk and
an annunciator in the nurse's
office
will be a necessary part of the equipment.
Entry ports
should
be constructed
in the hull, at least one in each
side, to permit easy entrance of patients.
A gangway
60 inches wide
will be found to aid greatly in the handling of patients on stretchers.
Several
cranes especially
designed
and fitted for hoisting-in patients
will be necessary.
Boats in large number are required,
for it may be
necessary
to take
aboard
many
patients from sinking ships or from
those whose boats have been shot away.
All possible provisions
should
be made for rapid
reception
of large
numbers
of patients or ship
wrecked men.
204
JOHNSON
HOSPITAL,
SHIPS
A study of the records
of the Relief for the past 16 years, giving
consideration to the patient loads at different times
of the year,
in
port and at sea, indicates that the following percentage
distribution
of beds in the different wards will be most satisfactory:
Perctnt
Officers
3
Contagious
and acute medicine
10
General medicine
9
Operative
surgery
15
Traumatic surgery
15
Eye,
ear,
nose,
and throat
7
Insane
1
Urological
and skin
15
Convalescent
wards
25
Total
---
100
Plans are to be prepared
in advance
for rapid shifting of patients
and
reassignment
of beds in emergencies,
such
as epidemics
of con
tagious disease, a large influx of badly burned
men, or many suffering
from
exposure
after
shipwreck.
These
are
among
the
everyday
hazards
of life at sea and they provide the best test of the efficiency
of the organization and
the ability
of the staff
of the hospital ship.
If suitable
spaces are available, it will be found very advantageous
to make special provisions for certain types of cases which need special
care, such
as the insane,
tubercular, patients in plaster
cases,
those
with
cardiac
and
renal
disorders
and
patients
requiring
skeletal
traction.
The
most
modern
equipment
is required
for X-ray,
elec
trocardiography,
basal
metabolism,
bronchoscopy,
physiotherapy,
photography, cystoscopy,
dental clinic, and laboratory.
No attempt
will be made here to list the individual items of equipment
or supplies,
because
they will vary so much,
according
to the time and place
of
outfitting
the ship
and
the stock
that may
be available.
The most
important
thing is that they
should
be the
articles
best suited for
the persons who are to use them.
A library of recent medical
books
and periodicals
is a very important adjunct.
A list of the work done on a hospital ship in active commission
will
undoubtedly bring to the mind of the interested
reader many details
which have not been mentioned
here.
The Relief provides the
fol
lowing figures for the first 10 months
of the calendar
year
1936:
Total patients
hospitalized
—
2, 027
Total sick days
---
39,903
Major operations
475
Eye, ear, nose,
and throat operations
320
Eye,
ear,
nose,
and throat
treatments
2, 197
Total laboratory
examinations.
13, 949
X-ray examinations
and treatments
2, 002
Dental
examinations
and treatments
5, 639
Dental
plates, splints,
and other devices made.
341
Physiotherapy
treatments
4,366
JOHNSON—HOSPITAL
SHIPS
205
These figures
are for active service with the fleet, both at sea and
in port, during peace times.
In time
of war we should
anticipate
greatly increased
demands
on the fleet hospital ship.
Thousands of
newly-recruited
men will
join
the
fleet and
this will inevitably
be
followed by epidemics
of contagious
diseases, perhaps
crippling
the
combatant ships unless the sick can be removed
to the hospital ship.
The new men will develop
numerous
physical weaknesses
as a result
of their new activities, and many of them will require hospitalization.
Advanced bases will probably be established
overseas, at places where
there
are no hospital facilities on shore, and so the fleet will become
completely dependent
on
the hospital ship.
Prolonged
cruises
are
likely
to occur, with the hospital ship accompanying
as a part of the
train.
All these activities will add to the work load.
Shall
female
nurses
be
employed
on
the
fleet hospital ship?
In
time of peace, their presence is desirable.
They create an atmosphere
more
conducive
to
recovery
and
their presence
ensures
the main
tenance
of a higher level of nursing efficiency.
In time of war, they
will
be needed on the hospital transports,
but with the fleet hospital
ship, accompanying the fleet on long
cruises,
or remaining for long
periods at an advanced
base, they might easily become a liability.
A
French writer, discussing
this problem, refers
to the many tempera
mental and sentimental
episodes which occurred
on his ship and con
cludes
that, if female nurses are allowed
on hospital ships, they should
be not only physically sound, professionally able and morally strong,
but also of very advanced
age.
The writer has much sympathy with
his point of view.
If provision is to
be made for them,
each nurse
should have
a separate room; there should be elaborate
bathing and
toilet
facilities and
also
a space where
they may launder and iron
their clothing.
Deck space,
where
they
may relax
and
sun
them
selves in privacy, is an essential.
One must not forget
to arrange
an
interior route to the wards
so that they can go back and forth between
their
quarters
and their duties
without
being
exposed
to inclement
weather.
Ample provision
should
be made
for storerooms
and
large
ones,
centrally
located,
will
be found
better
than
numerous,
scattered,
small spaces which require
more room,
more
time
and more clerical
work.
There should
be separate
spaces for bulk medical
stores and
open stock for issue.
The linen room
should have
plenty of shelf
room
and
a very large
table for sorting, also ample
floor space, for
this is one of the busiest places on the whole ship.
It should be con
venient
to the laundry and to the wards.
One should
plan to carry
a year's supply of medical
stores and linen, for the ship may be away
from sources of supply for indefinite periods
and, in war times, it may
be impossible
to replenish
stocks
of essential
items.
Cold
storage
rooms
should be ample
in size
and
conveniently
located.
Special
45202—38
1
206
JOHNSON—HOSPITAL
SHIPS
compartments
axe required for cold storage of biological preparations,
a large
stock of which will be necessary
to provide for prolonged
absences from sources of supply,
and for cold storage
of the
dead.
A strong room for alcohol and
narcotics
will reduce
administrative
difficulties in their care and issue.
A tent hospital to be set up on shore when needed, is
a valuable
adjunct, for which many
uses
will
be found.
A disaster
in an
ad
jacent civil community,
an expeditionary force
landed
on
a foreign
shore,
an epidemic
of contagious
disease that overtaxes
the facilities
of the ship, or any other condition that requires
additional hospital
work on shore
can well be served by a tent hospital carried by the
ship.
Plans should be laid to make it as independent
of the ship as
possible,
in the matters of commissary,
fresh
water,
personnel,
and
medical
supplies.
Plenty
of deck space, both open and covered,
is a prime requisite.
It is essential,
both for their own health and for proper administra
tion of the wards,
that ambulant patients be kept out of the wards
as much
as possible
during the day, so it should be made
as easy as
possible for them
to get on deck and take advantage
of the sunlight
and
fresh
air.
A comfortable recreation room,
where
the convales
cent patients and the crew in their time off duty may read, write, and
play games will aid greatly in maintaining morale.
Consideration should
be given to the harmful effects of noise
and
the increased
suffering
which it may cause the sick.
Soundproofing
of the decks and bulkheads
will help to reduce this.
Cranes, winches,
and other machines
should
be removed
as far
as possible
from the
spaces for the sick and every effort made to have the most silent type
of machines
installed in such a way as to reduce noise and vibration
to the minimum.
Ratproofing,
telephones,
facilities for showing moving pictures,
air
conditioning
of
wards
and
rooms,
equipment
of
galleys
and
diet
kitchens, quiet rooms, plumbing fixtures,
plaster room, venereal treat
ment room,
bronchoscopic
facilities, floor coverings,
and canteen
are
a few more of the myriad details that must be considered
when plan
ning the construction or the conversion of a hospital ship.
In general,
our aim
should
be
to provide
a vessel having all the
facilities, all the equipment
and the trained personnel
of a completely
modern
shore
hospital.
In addition, it
should
carry
a
reserve
of
stores for issue to other ships,
a field hospital to be set up on shore to
serve an expeditionary force or to aid in case of disaster in the civilian
community,
and
equipment
for rescuing
those who are required to
abandon sinking ships.
Employment. —It is universally
recognized
that, in time of peace,
the sole function of the fleet hospital ship
is to provide
a complete,
mobile, base hospital for
the
fleet, whether in port
or at sea.
In
JOHNSON—HOSPITAL,
SHIPS
207
carrying out this function it helps combatant ships to avoid danger of
epidemics by removing their cases
of contagious
disease.
It provides
facilities for disinfection, special
laboratory work, consultation with
recognized specialists,
and care of the dead.
It benefits the morale of
fighting ships
by removing their
sick
and
wounded.
Sir
Cyprian
Bridge, in the Art of Naval Warfare, recommends
that the base hos
pital facilities be mobile,
in the shape of hospital ships, rather than
stationary on shore, which could not readily be expanded
and would
doubtless
be too remote from the scene of battle.
He also states that:
The problem
of expanding
sufficiently
the Medical
Department
of the Navy
When war
comes,
will be most effectually
solved by the employment
of hospital
ships in time of peace, provision
being made for an increase of their number as soon
.as hostilities
are imminent.
Hospital ships steadily
worked
in peacetime will
habituate the service to their use in war.
This will go a long way toward rendering
« fleet or squadron independent of fixed bases which it may be impossible to form
.except at inconveniently
distant points.
It will perhaps appear more costly than
the
plan of establishing
Government
hospitals
at fixed
bases;
but
in the first
place this ie not certain, and in the second place the excess of cost, if any, may be
justifiably
incurred,
because
it will be due to the adoption
of a plan promising
increased
efficiency in war.
These are the benefits which flow from the employment
of hospital
ships with the fleet in time of peace, as the Relief is now employed.
In time of war,
the functions of the fleet hospital ship will be con
siderably
expanded.
Not only
will
she
provide hospital
facilities
while the vessels remain
in port but when
the fleet, or an expedition
ary
force,
goes
to establish
an advanced
base, she will
accompany
them, to provide the necessary
establishment
for the care of the sick
and
wounded
at that
base.
When
the
fleet
moves
on
to
another
base
the hospital
ship
will
accompany
the
train,
perhaps
leaving
behind, in the field hospital set up on shore, those unable
to resume
duty, for return to the home bases by the hospital transports.
Prac
tically all writers agree that, like the other auxiliaries,
the hospital ship
lias
no
place with
the
fleet during battle or when it is imminent.
Mahan
writes
that
the
proper disposition
of
the
transports
and
hospital
ships, until the end of the battle, is to dismiss
them out of
mind
and presence.
If beaten,
the loss of them will not be of the
slightest consequence;
if successful,
they can
be summoned
from an
appointed rendezvous.
Before
and after the engagement,
however,
the hospital ship may play her most important role.
When contact with
the
enemy
force
impends,
all
disabled
men
should be cleared from the combatant ships.
This will save such men
from the discomforts
and anxiety they would suffer as nonparticipants
in the midst of the battle; it will improve the morale
of those left to
fight; it will make
the whole hospital space of the ship
available
for
the injured after the battle.
The battle being
over,
every
effort will be made
to remove
the
disabled
from the fighting ships
as quickly
as possible,
and this in
208
JOHNSON
HOSPITAL
SHIPS
volves the consideration
of a multitude of varying conditions, suclr
as rough
or smooth
sea, the distance
of the fleet from the base, pres
ence or absence of enemy submarines,
decisive or indecisive
outcome
of the battle, victory or defeat for our fleet, number of wounded,
and
the number of seaworthy
boats left for their trans-shipment.
It may
be advisable
for the hospital ship to proceed and join the fleet; or for
both to proceed
to the
base before
transferring the patients; or to
send medical
officers
and supplies
from the hospital ship
to the sur
viving
ships
to aid in the work, instead
of bringing the patients to
the hospital ship.
No rules for this work can
be laid down
in ad
vance because of the myriad conditions that may influence
the choice
of the means to be adopted.
Arrangements
for
loading
and
unloading
patients
deserve
long
study.
No completely satisfactory method or device
has yet been
developed.
Ever since the Battle of Beachy Head in June 1690,
the
importance of this problem
has been recognized
and dozens of schemes
have been tried, but no completely satisfactory method
or device has
been developed.
When the Relief was built, an elaborate
apparatus
was installed for hoisting patients aboard; but its use was abandoned,
and it was eventually removed
because it worked too slowly and it
failed to raise the two ends of the stretcher
at the same rate of speed.
At present
we are using
a very
simple
means;
a davit is swung
out
and
from it a twofold
fall is dropped.
At its lower end
are four
finger
ropes,
each with
a snatch
hook at its end.
The
hooks
are
secured
to
the four corners
of the
Stokes
stretcher,
and it is then
hoisted hi by hand.
The Stokes splint stretcher
has been the Navy's
standard for more
than
25 years,
and it is still regarded
as the best
for moving disabled
men.
Transportation
of patients from
ship
to ship
at sea is best accom
plished
by using
a motor whale
boat and putting
the patient in it
before
lowering.
When patients are received
from or discharged
to
a dock or a lighter alongside,
cradles carrying two or more stretchers
may
be employed.
Countless devices have been tried, but still there
is no satisfactory means of transferring wounded
men from ship to
ship
in
a rough
sea.
This fact,
and
the possible
presence of enemy
submarines,
impose
the most important limitations on the usefulness
of the fleet hospital ship
after a battle.
Mann has suggested
that
over-age
destroyers
be fitted out for the work of carrying patients
from combatant ships to the hospital ship, and that they accompany
the fleet for this purpose.
II. Fleet Hospital
Ship,
United
States
Ship "Relief"
This is the only hospital ship maintained permanently with
a fleet
in time of peace.
She is the only modern hospital ship to be designed
and built, from the keel up, for this single purpose.
Since her recent
extensive
overhaul, she represents
the most advanced
ideas in hos
JOHNSON—HOSPITAL,
SHIPS
209
pital ship arrangement
and equipment.
For these reasons, consider
able space will be devoted
to a detailed description.
The
sentiment
has often
been expressed by those writing
of hos
pital ships,
that
a vessel designed
for carrying
cargo or passengers
had many limitations when
the time came to convert her to care for
the sick.
Even
the most costly and extensive
alterations produced
a result far from ideal.
Many have
wished
for the opportunity
to
design
and build
a hospital ship which should
approach
perfection.
The United
States Navy finally did build such
a vessel, and it was
the happy lot of Commanders E. M. Blackwell
and R. C. Holcomb,
,of the Medical Corps of the Navy,
to put their dreams on paper
and
to see them
transformed at last into the substance
of the U. S. S.
Belief.
The
present
ship
was
named
for
the earlier Relief,
a converted
liner which
served
the
same purpose
during
the Spanish-American
War,
the
Philippine
Insurrection,
and
the
Boxer
uprising.
On
August 29,
1916,
the act of Congress
which authorized the construc
tion of the new hospital ship
was passed and, on the same day,
the
contract
was
awarded
to the Philadelphia
Navy Yard for the con
struction.
While the World War continued,
other building was con
sidered more important and the work on the Belief lagged.
The keel
was laid on July
14,
1917; the first frame
was
erected
on May
15,
1918, and she was launched
on December
23, 1918.
Mrs. William C.
Braisted, wife of the Surgeon
General of the Navy,
was her sponsor.
On December
28, 1920, she was finally commissioned.
The hull of the Relief is built on the standard naval-auxiliary
plans
and it is 484 feet over all, 61 feet beam, 20 feet 6 inches draft, and 9,750
tons full-load displacement.
The twin screws are driven by Parsons-
type geared steam turbines of 5,000 horsepower.
The steam used by
these turbines is generated by three Babcock and Wilcox, oil-burning
boilers, which have
a capacity of 5,500 horsepower.
The extra
500
horsepower generated
by the boilers
is used to run the auxiliary ma
chinery, such as the two 300-kw generators,
steam pumps for various
uses, galley, laundry, heating circuits, sterilizers
and evaporators.
There is an auxiliary lighting system for the operating room,
two
dressing rooms, engine and fire room.
When the generators fail, or the
voltage drops, it switches
automatically
to the 300-ampere
batteries,
which are sufficient
for 6 to 8 hours
at
120 volts.
In addition, there
is a generator driven by a Kohler four-cylinder gasoline engine, which
is sufficient
to light these same spaces for an indefinite time.
A40-kv-a
steam-turbine
driven
generator
furnishes
alternating
current
elec
tricity for the X-ray machines,
radios,
and short-wave therapy ma
chines.
This arrangement
is not as satisfactory as a large rotary con
verter would
be.
Installation
of additional
electrical
devices
from
year to year has taxed the capacity of the generators
to the limit, and
210
JOHKSON —HOSPITAL
SHIPS
this
suggests that generous
provision for such
expansion
should be
made when planning hospital ships.
Two passenger and two freight elevators
are provided.
The main
elevator runs through all decks from the medical storeroom in the hold
to the superstructure
deck.
It serves the convalescent
mess hall, the
medical
and surgical
wards,
the operating room, sick officers' quarters,
and
the
cabins
on
the
superstructure
deck.
Its
rated
capacity is
3,500 pounds and it is large enough to accommodate
wheeled stretchers,
food carts, and other vehicles.
A second passenger elevator
connects
the contagious
wards with the main deck,
so that patients can be ad
mitted directly to those wards.
A freight elevator,
of 2,500 pounds
capacity, runs from the main deck down to the cold-storage
spaces
and the morgue.
An additional lift for baggage runs from the main
deck down to the bag room.
The ship has four decks in the hull, including the hold; two above
and two below
the water line.
There are four decks above
the hull,
including the bridge deck.
The spaces on the respective
decks, which
relate to the Medical Department, are as follows:
On the superstructure
deck, from forward aft, are quarters
for the
executive
and senior
medical
officers,
the commanding officer,
6 line
officers, and the quarters
for 12 nurses.
On the extreme after part of
this deck, four sets of officers' quarters
have recently
been constructed,
to provide for two more medical officers, one dental and one line officer.
On the upper deck are located
the operating suite,
the sick officers'
quarters
with
9 rooms
and the wardroom, with quarters
for
11 staff
officers.
Then comes a well which is 6 to
12 feet in width, separating
the main superstructure
from the contagious
wards.
Abaft these are a
locked
ward with four beds and
then
the animal house.
The last
provides
cages for white mice and guinea pigs.
The main deck has, under the forecastle,
carpenter
and paint shops,
canteen, crew's
recreation
room, barber shop, seamen's
quarters,
and
ship's service store.
Abaft
this comes the quarter-deck, 30 feet fore
and aft.
Here are the hatches leading to the wards below, and a cargo
hatch leading to the medical store room.
Then comes the dental clinic,
running athwartship, with the X-ray clinic on the port, and the eye,
ear, nose, and throat clinic on the starboard side.
Abaft these are the
medical
record
office, dispensary,
galleys,
and various ship's
offices.
Then comes the well which separates the contagious
wards from other
parts of the superstructure.
In the after deck house we find a ward
with eight bunks and three quiet rooms, which is used for the overflow
from
the
contagious
wards
or from sick
officers'
quarters.
Then
comes
the laboratory,
the autopsy and
embalming
room,
the large
steam
disinfectors,
and
the incinerator.
Covered deck space, about
15 feet wide, extends from the quarter-deck to the stern on each side
of the superstructure,
on the upper and main decks.
JOHNSON—HOSPITAL
SHIPS
211
The second deck, which is the first deck within the hull, is devoted
largely
to
the
wards.
Under
the
forecastle
are
quarters for
the
hospital corps men and the crew.
Then come
2 wards with 29 bunks
and
1 quiet room in each.
On the starboard side is the medical ward
and
on the port side is the eye, ear, nose, and throat ward.
Abaft
there is an athwartship passage, with a cargo port in each side of the
ship for reception
of patients.
Doors in the after bulkhead of this
passageway
give
access
to the 2 large surgical
wards
of
GO beds each,
on the port side for operative surgery
and on the starboard for trau
matic surgery.
Along the wing passages outboard of the engine-room
uptake are, on the port side, the physiotherapy clinic, scullery, and
messroom;
on
the starboard side, the
cystoscopic
room,
special
diet
kitchen, and post office.
Abaft this, on the port side, is the urological
ward.
The first platform has quarters for crew and hospital corpsmen,
2
convalescent
wards with
56 and
64
bunks,
mess room for hospital
corpsmen
and convalescent
patients, bag room, laundry, and refrig
erating space.
The second platform has a large storeroom
for medical department
supplies in bulk, 33 feet fore and aft, and extending
the full width of the
ship.
There is a second storeroom,
nearly as large,
used as an issue
room.
Then comes a large space used for storage of patients' baggage.
Abaft the engineroom
bulkhead are rooms for storage and handling of
linen, also large cold-storage
spaces.
Certain of these compartments
have features which deserve special
mention for various reasons.
They will
be
considered
in the same
order that they have
appeared
in the
preceding
paragraphs.
Tho
comments
are not to be considered
as criticisms reflecting
unfavorably
on
those who have
had
to do with
the designing,
construction, or
alterations of the ship.
It is now more than 20 years since the plans
of the Relief were approved
and, during that time,
there have
been
many
changes in the requirements
of hospital ships.
The relative
importance of many of the characteristics
has altered.
Details which
were considered
to be of paramount importance in earlier
days have
dwindled,
while new
developments,
then
unthought
of,
have
made
necessary
many adjustments.
I purpose
to emphasize
the good and
bad points of the ship, and thus provide a useful
guide for those who
may be called upon to design and build similar structures.
The nurses' quarters are inadequate.
They are placed two in a room,
which is unsatisfactory.
Privacy is a matter of small moment
to most
men, but to women it is predominant.
The size of the room is of less
importance than the fact that each nurse should
have a room to her
self.
There is no way by which the nurses can descend to the wards
without
going out on deck
and
down
an exposed ladder.
The wet
garments which result are uncomfortable during the hours of duty and
212
JOHNSON
HOSP1TAL
SHIPS
also endanger
their health.
In spite of these defects, they consider
duty on the hospital ship
as desirable
and appear
to enjoy it.
Their
presence on the ship certainly maintains the standard of nursing at a
higher level and I feel that none of us would want to run a hospital of
this nature, where patients remain for long periods, without them.
The operating suite fits its purpose admirably, but space is wasted
which could
be better employed.
The operating room
is
17 feet fore
and aft, and 45 feet from side to side.
The height is 13.5 feet.
There
are
75
deadlights,
18 inches
in
diameter,
to provide natural light.
These
are fitted with
shades
and inner glass sashes to control light
and
dust.
Two
operating
tables
with Operay lights
overhead
are
fixed, one on each side, and a third may be placed in the center line if
needed.
There are tile decks throughout the suite.
The equipment
is complete in every imaginable
detail.
From
the outside,
the operating
room structure gives
the ship an
unconventional
appearance
and
navigators
complain
that,
when
coming
alongside
a dock with a wind blowing, it acts as a sail.
This
provides an
excellent
alibi for
a poor landing.
Natural
light,
for
which such elaborate provision was made, is now entirely disregarded
and
the
deadlights
have
been painted over to
make
them
opaque
during darken-ship maneuvers.
The inner shades
and
sashes were
controlled by a mechanism
so elaborate
that it was constantly out of
repair.
They are now drawn and fixed.
The height
is greater
than
necessary,
though it undoubtedly aids proper ventilation
and makes
it more comfortable for the surgeons.
I believe that it would be better
to place the operating suite below the main deck, amidships,
where the
motion of the ship would
be at
a minimum,
and that two
separate
rooms,
about
12 by 15 feet each, would be better
than the one large
space.
Accessory
areas in the operating
suite are the scrub room,
11.5 by 10
feet; sterilizer room,
10.5 by
15 feet; etherizing
room,
11.5 by
10 feet,
and linen-room,
10.5 by
15 feet.
A central
fore-and-aft passageway
gives
access
to all
the spaces.
The
most
important
change in this
area since construction of the ship is the installation of a shower bath
for the
use of the surgeons.
Considered
a dangerous
fixture for an
operating
suite at that time, it required
16 years of intermittent effort
to secure this very important detail.
The sick officers' quarters
have
a central lounging space and mess-
room,
18 feet fore-and-aft by
17 feet athwartship.
Outboard of this
are, on the port side, 5 rooms and the toilet facilities; on the starboard
side, 4 rooms and the office of the chief nurse.
The forward room on
the starboard side has its own toilet and bath, being two rooms
con
verted into one for high-ranking officers.
At the forward end is the
main elevator
and, in
the after part, is
the pantry.
The latter
is
fitted with
electric
refrigerator
and
electric
range.
A dumb-waiter
JOHNSON—HOSPITAL
SHIPS
213
formerly
ran from this pantry
down
to
the
passageway
abaft the
galleys
on
the
deck below.
About
1926,
this
dumb-waiter
was
re
moved because it was inconveniently placed
and the mechanism
was
so frequently out of order.
The rooms average
10 by 8 feet 8 inches,
with doorways only 30 inches wide.
This makes it impossible
to bring
a patient into the room on a wheeled stretcher,
so a great deal of awk
ward handling is necessary in getting a helpless patient in or out.
The
rooms
are fitted
with iron beds,
30 inches
wide, having sliding sides
like a baby's crib.
The
contagious
area consists
of
5 separate
wards.
The forward
one runs athwartship and is fitted for 22 bunks.
On the starboard
side is an 18-bed ward, while on the port side are 8-bed, 4-bed,
and
2-bed wards.
The diet kitchen is equipped, like those of all the wards,
with electric
refrigerator, electric
stove,
and running water.
It also
has a large utensil sterilizer for dishes and other gear.
When the ship was designed it was intended
that access
to the con
tagious wards should be only by the special elevator, which runs from
the main deck.
But, about the time she went in commission,
a bridge
was constructed
at the level of the upper deck, which gives access
to
those
wards.
Many modern
contagious-disease
hospitals no longer
segregate such diseases in different wards.
They may be safely placed
in adjacent beds, and with proper
screening
and precautions
on the
part of the attendants,
no more cross-infection
will occur than if they
were in different wards.
So the elaborate
precautions
that were taken
to isolate this entire area from the rest of the ship are no longer
con
sidered
necessary.
The forward ward, running athwartship, is usually used for pneu
monia and other respiratory infectious diseases.
The four-bed ward
is mostly occupied
by sporadic
cases
of cerebrospinal
fever.
This
leaves
three wards for the other exanthemata,
and when we have four
or five such diseases, it constitutes
a very lively problem.
It would be
much better for a hospital ship which serves a fleet as large as this, to
have
more
space for contagious
diseases.
In suitable weather,
the
wide decks outside
the wards
may have
a dozen or more patients
on
cots, the overflow from the wards.
The locked ward has four bunks,
two of them within an inner space
which is separated
from the other
two bunks by a heavy wire-mesh
partition
and
a door which also locks.
Thus violent patients can be
separated
from each other.
This ward has its own toilet and wash
basin.
A watch is constantly maintained when
there are patients in
this ward,
and
the man on watch remains
at all times in the ward.
He is provided with a whistle
and there is a button on the bulkhead
which rings a loud gong outside, for use if help is needed.
The X-ray, dental,
and eye, ear, nose, and throat clinics are grouped
on
the main deck, with separate
entrances
so that out-patients can
214
JOHNSON—HOSPITAL
SHIPS
be
treated
without
entering
the ward
areas.
The
laboratory
was
originally
located
here, but the clinics proved
too small for the work
they were called
upon
to do, which has increased
from year to year.
So the laboratory was moved and the clinic space rearranged
in 1935.
The
dental
clinic
has four
cubicles,
each containing
a standard
navy dental chair and other equipment.
One of them has a modern
shock-proof X-ray outfit.
There is also a prosthetic laboratory with
complete
stock of everything
necessary
for making
plates,
crowns,
bridges,
splints, and inlays.
Until very recently, the hospital ship
provided prosthetic service for the entire
fleet.
The eye, ear, nose,
and throat clinic is located
on the starboard side, and is divided into
two compartments.
The forward one,
24 feet long,
is used for eye
examinations.
The after room,
14 by 18 feet, has a tile deck and is
used for operative and bronchoscopic
work.
The X-ray clinic has
a main radiographic room,
14 by
16 feet, in
which the apparatus
is installed.
The walls, floor,
and overhead
are
lead lined.
Forward of this are the viewing room and the dark room.
New types of apparatus, developed
since the ship was commissioned,
have been installed and
so the space is quite crowded.
In designing
a hospital ship,
allowance
of space must always
be made for new de
vices that will be evolved during the life of the ship.
A ward with
1 1 bunks and 4 quiet rooms is located aft on the main
deck,
and is used for the overflow from the contagious
wards or from
the sick officers'
quarters.
One of the quiet rooms contains the in
stallation for electrocardiographic and basal metabolism
estimations.
The laboratory was moved
from its former position to its present
location, well aft on the main deck.
It is
12 by
30 feet, and has
a
tiled annexe,
5 by 9 feet which contains the still, and a refrigerator for
the emergency
stock
of biologicals.
The furniture for the laboratory
was designed
and built for this space and is very satisfactory.
It is
equipped
to perform all the tests required of a public-health laboratory
in a large city, in addition to many purely naval requirements.
The autopsy and embalming room,
adjacent to the laboratory,
is
a tiled compartment,
9 by
16 feet.
The table is of the pedestal
type,
with slate top.
Since this room is seldom needed for its designed use,
it serves as an adjunct to the laboratory.
The two large steam disinfectors are of the Kinyoun-Francis
type.
A soiled linen chute
on the port side leads
down
to them from the
contagious
wards
above.
After disinfection, the articles
are removed
from the starboard side.
One of the two large wards
on the second deck was originally
de
signed for a medical ward, but the great amount of traumatic surgery,
largely due to motor-vehicle accidents,
has made it necessary
to em
ploy both of these large wards for surgery.
A smaller,
30-bed ward
suffices for medical
cases.
The surgical ward on the port side has
a
JOHNSON—HOSPITAL
SHIPS
215
tiled
room,
10 by
16 feet, which is used for dressings
or for minor
operations.
On the starboard side, a room,
8 by
16 feet, is used for
a plaster room,
and is fitted with the latest type of fracture table.
The physiotherapy clinic is equipped
with
several
types of lights
and diathermy machines,
and a tub for continuous baths.
The two large medical
storerooms
are a source of constant joy and,
since it is the policy to carry at all times a 2-year supply of all Medical
Department
supplies
and
equipment,
we
are fortunate
to
have
so
much storage space.
In the forward storeroom
is a complete
50-bed
tent hospital, with all necessary
articles,
ready
to be put ashore for
duty with an expeditionary force, or to give
aid in a civil disaster.
In the after storeroom
is a steel locker,
6 by 10 feet, which is used for
alcohol, narcotics, and dental gold.
Throughout
the ship,
the wards
are fitted with
pipe-frame
bunks
hung
on vertical stanchions.
The
hooks
on
the stanchions
are
so
arranged that either one or two bunks may be rigged.
The single bunk
hangs 33 inches from the deck, the same height as the standard hospital
bed.
When two bunks are in place,
the lower one is
18 inches
and
the upper 55 inches from the deck.
Nursing
care is very awkward
with the double-bunk arrangement,
so this is reserved
for use with
convalescent
patients.
The patient capacity of the Relief is:
Sick officers' quarters
9
Urological
and skin
40
Contagious
52
Convalescent
wards.
120
Eye,
ear, nose and throat
30
Overflow
ward
8
General
medical
30
Operative
surgery
60
Total
409
Traumatic surgery
60
When
an
emergency
demands
more
beds,
there
are folding
cots
and
hammocks
which can be used
to bring the capacity to
500 or
more.
Ordinarily, only about 300 bunks are kept rigged, since nursing
is
more
conveniently
done
with
only
one
bunk
rigged
on
the
stanchions.
The capacity of the ship has always been adequate,
and the propor
tion
of bunks
assigned
to
the
different
services
is about
correct.
Occasionally, during the first 3 months of the year, contagious
diseases
provide more patients than there
are bunks in the isolation wards.
This temporary demand is met by combining other groups of patients,
so that another
ward is made available for contagious
patients.
Messing is on
the
cafeteria
plan.
Each
man
takes
a tray with
plate, bowl, and cup,
and passes along
a counter on which are the
food containers
set in a steam table.
He indicates which articles
of
food he desires and they are served to him by the mess cook behind
the counter.
He then sits down at a table, on which are bread, butter,
coffee, condiments,
dessert, and other special items.
This system has
216
JOHNSON—HOSPITAL
SHIPS
proved
most satisfactory since it provides hot food in just the quan
tity desired,
and reduces waste.
Mess rooms for the deck force
and
the engineer's
force are located aft on the second deck.
Convalescent
patients and
men
of the hospital corps
are fed in the convalescent
mess hall.
Cripples
are sent
down
by the elevator in
advance
of
others.
Bed patients are served with trays, which are prepared
in
the diet kitchens.
Each ward has
three lighting
systems:
Ceiling lights for general
illumination,
night lights placed
near
the deck
and portable utility
or reading lights, attached
to outlets near each bunk.
A general antenna
system
has recently been installed, with outlets
in wards
and rooms, where individual
radios
may
be plugged in.
There are 27 different ventilation systems, with blowers which pass
the air over
steam
pipes for heating.
Several
spaces,
such
as
the
special
diet kitchen, sterilizer room
and laundry, have exhaust blow
ers, recently
installed, to ameliorate
conditions of excessive heat.
In
the wards
there
are supply louvers overhead
and
exhaust
openings
near
the
deck.
Heads
and
diet
kitchens have
exhaust
ventilation
only.
In the Relief,
as in other hospital ships,
a number of pet gadgets
were installed at considerable
cost which have proved
of little utility.
Just forward of the boiler room is a space
18 by 35 feet and
14 feet
high, in which it was planned
to place a gyroscopic
stabilizer to reduce
the amplitude of the ship's motion in rough weather.
The stabilizer
was never installed, but this 7,820 cubic feet of space remains unused,
because the requirements
of water-tight integrity will not permit the
necessary
openings
to be made for access
to it.
There is little
need
for a stabilizer, for she is a very steady
ship,
and also she is reputed
to be a very lucky ship as regards rough weather.
I know of only one
occasion,
off New Zealand,
in
1925,
when
she encountered
a storm
severe enough
to interfere
with her normal work.
There was also an elaborate vacuum-cleaning system, with four sets
of motor-driven exhausters
and piping running to outlets
throughout
the ship.
It had
15 sets of vacuum-cleaning tools, thirty-five
50-foot
vacuum hoses, and 35 hose-and-tool lockers.
For a number
of years
it had
been out of use and, in
1935,
the machinery and
a large part
of
the
piping
were
removed.
It
seems
probable
that it
was
too
complicated
and had
too many accessories
to get lost and
to wear
out, and
so it fell into disuse after
the first enthusiasm
faded.
The
modern
portable electric
vacuum
cleaner
has proven far superior to
this system.
A very
complete
and costly hydrotherapeutic equipment was also
provided.
This was later removed
because it required more
fresh
water than
the distilling capacity of the ship.
Salt water could
not
be
used because
the
ship
remains,
for
a large
part of the
year,
in
JOHNSON—HOSPITAL
SHIPS
217
harbors that are too heavily polluted for the water to be used in this
way.
Swinging cots were
also provided in some of the wards,
with the
idea that their motion would neutralize that of the ship.
This is a
most persistent
delusion
for, as far back as
1873,
they were installed
in Great Britain's
hospital ship,
Victor Emanuel, and I have read
a
recent article in which a theorist suggests their use in hospital ships.
It is recorded
that, in the Victor Emanuel, the swinging cots swung
too much and the patients were thrown out on deck, and so the cots
had to be fixed.
On the Relief there was a similar experience.
One
has
only
to watch these cots
swing,
to understand why
they
fail.
Their motion is
governed
by
the law
of
the pendulum, but their
oscillation
period
is not synchronous with that of the ship,
and so,
when a certain combined
motion of the two occurs
the swing of the
<;ot is accentuated
and the patient is violently ejected.
One medical
officer
suggested
that
a gyroscopic
stabilizer
be
installed
in
each
swinging bunk, and perhaps
that would
be the best solution of the
problem.
The idea of swinging cots
seem
so plausible that we will
surely see it proposed for future hospital ships,
and other enthusiasts
wall rejoice that they have originated the wonderful project of swing
ing cots for the comfort of the sick on board
ship.
But all the defects of the Relief have proved
to be minor ones and
most of them were easily
corrected.
She has served with complete
satisfaction
as
the hospital for
the
fleet during
16
years
and
her
material condition is such that she may well
continue for
as many
years more.
Those who had to do with her design and building may
regard with complacency
the success of their work.
Personnel. —Present allowance
tables provide for 9 line officers,
10
medical officers,
3 dental officers,
2 supply officers,
1 chaplain, 7 war
rant officers,
10 nurses,
and
349 enlisted
personnel,
of which
124 are
attached to the hospital corps.
During
the
year
1935
there
were
1,814
patients hospitalized
on
the Relief, with a daily average of 110 patients and average sick days
per patient
15.88.
Three hundred and fifty-one were transferred
to
hospitals ashore;
1,237
returned to duty;
59 were returned to their
ships to complete
convalescence,
and
there
were
17
deaths.
Four
hundred and eighty-one
operations
were performed
in the main oper
ating room
and
417 in the eye, ear, nose, and throat clinic.
There
were
3,266 examinations
and
treatments
in
the eye, ear, nose, and
throat clinic, 13,865 laboratory examinations
and tests, 5,423 physio
therapy treatments,
and 2,915 X-ray examinations
and treatments.
In the
San
Pedro-Long
Beach
area
there
are
no naval hospital
facilities
on shore, although a large number of navy ships
are based
there.
The Relief acts
as base hospital for these
ships
and spends
218
JOHNSON
HOSPITAL,
SHIPS
several months each year in this port.
When the fleet goes on a cruise,
the hospital ship
accompanies
it.
It is the policy to transfer
to shore hospitals only those
patients
who will probably never return to duty or who, for climatic or other
reasons, may
be
benefited
by
treatment
in other hospitals.
The
Relief is
equipped
and
staffed
to
offer
definitive
treatment
for
all
conditions.
III. The Hospital Transport
The purpose of this chapter is to provide a guide for those who may
be charged with the duty of converting merchant vessels into hospital
ships.
The experience
of others
shows that there
are many details
which greatly effect the efficiency
and usefulness of the ship and may
easily
go unnoticed or receive
scant consideration while the work is
being
done.
It is only after
the
vessel
is
commissioned
and
has
entered
on her new duties that important
defects
appear,
at a time
when it is too late to correct
them.
Those who planned
and carried
out the alterations have seldom been present after the ship was com
missioned,
to learn
of her faults, and
so
the same errors
have
been
repeated over and over.
Articles listing and commenting
on tbe good
and bad points of the individual
vessels have usually appeared
after
the end of a war,
at a time when everybody was too fed up with the
whole thing to bother any more about details,
and wanted
only to be
allowed
to forget it.
When the next war came along,
the lessons of
the old one were forgotten and nobody had time to look up the maga
zine
articles
and
books
in which those lessons were embalmed.
So-
similar faults recur from war to war, with each complaining medico
believing himself
the first to be so plagued.
Those countries
which have been far-sighted
enough to plan intelli
gently in times of peace for the hospital ships needed when war comes
were indeed wise and fortunate.
Such planning has usually followed
one of two
lines.
Arrangement
was
made with
commercial
steam
ship companies
whereby
certain
of their ships would be delivered
to
the government
immediately on
the declaration of war.
Complete
plans
of all
necessary
structural
alterations
were
made,
and
the
required
equipment was assembled at the dockyard where the altera
tions
were to
be accomplished.
The other plan involved
a govern
ment subsidy at the time of building
the ship.
Compromises were
made in hull design and arrangement
of spaces, which would best fit
her for the dual
role of passenger liner in time of peace and hospital
ship in time of war.
The subsidy to the owners compensated
for her
faults
as
a commercial
vessel and
they
agreed
to deliver her to the
government
upon
the outbreak of war.
Both of these plans worked
very well during the World War.
But it happens in every large warr
that governments,
relief
societies
and other organizations are called
upon
to provide hospital ships without
such previous arrangements.
Handling Stretcher
Cases.
214-1
Clerical OFFice.
218—2
I
Surgical
Ward.
218—3
JOHNSON—HOSPITAL
SHIPS
219
The persons put in charge of the work are frequently inexperienced,
some knowing little of ships,
others unfamiliar with hospital require
ments.
My hope is to aid them to avoid the more serious blunders.
Before we can
decide
anything about the
details
of the hospital
transport, we must know what work she will be called on to do.
Her
function
is to transport
the sick,
from the fleet, from an advanced
base, or from an expeditionary force
to the base hospitals at home.
She
may
be required
to remain with
the
fleet
to
supplement
the
facilities of the fleet hospital ship, or be attached
to a home base to
provide
additional
hospital
beds.
Contrast
these
duties
with
the
mission of the fleet hospital ship, which is to provide complete
mobile
hospital
facilities for the
fleet,
and you will better
understand
the
differences
in characteristics
and equipment of the two types of ships.
Selection of the ship. —If possible,
one should
choose a vessel which
is adapted
to the part of the world where she will probably
be em
ployed.
Thus,
a vessel
designed
for tropical
cruises
would not
be
ideal for duty as a hospital ship in the Aleutian area in winter; and one
which
was designed
for the transatlantic run might be too large
to
enter the harbors of the Pacific Islands.
The size should bear some
relation to the duty she is to perform.
If she is to serve a fleet or an
expeditionary force which is operating near a home base, two or more
smaller vessels may serve better for this work; while if she is to operate
in distant waters,
a vessel of
10,000
tons or larger
should
be chosen.
But, too often,
the one who has to select the ship does not have com
plete
information
about her projected
use,
and
the choice
of ships
may
be very restricted.
An oil-burning
ship
has many advantages
over a coal burner for hospital purposes, but one must always consider
the availability
of oil or coal in the area where she is to operate.
On
one shore of the Pacific, for instance,
oil is cheap and abundant while,
on the other,
coal is cheaper and more easily available than oil.
Speed is an important matter but it is not likely to be the deciding
factor in choosing one ship or another.
The greater the distances over
which voyages are to be made, the more important is speed.
Freedc m
from vibration at the higher speeds must be considered
since coustant
shaking adds greatly to the discomfort of the sick.
A passenger ship
is infinitely more desirable
than a cargo carrier.
The latter, with her
large holds,
could
perhaps carry more patients
for the same tonnage,
but the lack of heating, ventilation, toilet, and lighting facilities would
give rise to many serious problems in the care of the patients.
And the
matter of cargoes previously carried
is not to be ignored.
We may
agree with Thomas Moore that you may
break, you may shatter the
vase, if you will, but the scent of the roses will hang
around it still;
however, few of us appreciate
the tenacity with which the aroma
of
copra, guano, hides, horses, and other fragrant commodities
can cling
round
a ship.
Flies, ants, roaches,
and other vermin,
not forgetting
220
JOHNSON—HOSPITAL
SHIPS
the cimices,
should
be sought
and the degree of infestation estimated.
Adequate measures
should
be taken
to free the ship from such pests
before placing her in commission
as a hospital ship, otherwise her use
fulness may be seriously impaired.
Careful attention should
be given
to the auxiliary machinery and,
if possible,
a ship should be chosen that has plenty of reserve power in
excess
of that required
for propulsion.
Heat, light, distilled water,
cold-storage plant, laundry, and hot-water circulating system will all
have greater loads to carry while the ship is functioning as a hospital
than during her passenger-carrying
days.
A passenger vessel is likely
to be much better equipped
with these facilities than is a cargo ship.
Twin-screws
are reputed
to cause less vibration
than a single
pro
peller, while turbines
produce less noise and vibration than reciprocat
ing engines.
Fuel capacity should be sufficient
to give a steaming
radius of at least 8,000 miles.
Steadiness
in a seaway is a most important attribute in a hospital
ship, and careful inquiry should
be made to determine
the reputation
of the vessel in this respect.
If she is unsatisfactory because of exces
sive or abrupt motion in rough weather,
an expert should be employed
to determine
the cause, whether or not it can be corrected,
and at what
cost.
Changes
in ballast, bilge keels, and other devices will often be
sufficient
to correct
this defect.
Since mines
and torpedoes
are the principal war-time danger
to a
hospital ship, one that is subdivided by many strong water-tight bulk
heads offers much greater security than one which has large undivided
spaces below the water line.
In the World War, several of the hospital
ships that were sunk by torpedoes or mines had very little or no loss
of life because
their construction
was
such
that
they
sank
slowly.
If the ship is not satisfactory in this respect she should be made
so
before being used as a hospital ship.
After the choice of the ship is made, the next consideration
will be
alterations that are necessary.
Before making decisions in this matter,
we must try to get some idea of the service that she is to perform.
If
she is to make only short runs, up to 3 or 4 days, very much less space
will be needed for laundry, fresh-water storage, operating room, com
missary and medical
store rooms, X-ray, dental
clinic, physiothera
peutic equipment,
and many other items; and so room will be available
for a large number of additional beds.
It is a generally-accepted
rule
that the farther away from the home base she operates the more com
plete her hospital equipment and facilities must be.
Thus it follows
that
the longer
the run the
smaller
is the patient capacity, and
the
larger the number of ships required
to carry a given number of patients.
But it is seldom possible to predict with accuracy just what duties the
hospital ship will be called upon to perform,
and so compromises
will
JOHNSON—HOSPITAL
SHIPS
221
have to be made that will allow her to play various roles with reason
able success.
One of the first steps to be taken is to have some competent
person
inspect
the
bulkheads
and
partitions
to determine
which ones
are
structurally
necessary
and which ones represent
false work
that can
be removed.
Only a few cabins should
be retained,
aside from those
necessary
for the personnel
attached
to the ship.
By removing the
partitions
and making several
cabins into one ward for
10 or more
patients much space can be saved, and one nurse can care for several
times
as many patients in one ward as she can if they are separated in
individual
rooms.
A feature often overlooked
is accessibility.
A bed
in a room with a narrow door wbich one must approach down a narrow
corridor is accessible only to an ambulant patient and the number of
such rooms should be reduced to the minimum.
Every effort should be
made to arrange it so that a wheeled stretcher can be brought alongside
every bed.
Assignment
of spaces. —The main deck is extensively
used for ship's
work, handling stores and lines,
musters
and drills, so it is likely
to
be noisy and active, and sick patients will be disturbed if placed there.
But it is a suitable place for lounging rooms and convalescent
wards
for ambulant patients,
the admitting office and ward, baggage room
and other activities that have to do with the receiving
and discharge
of men and supplies.
Below the main deck should
be the operating
suite, X-ray, dental and other
clinics,
treatment rooms,
store rooms,
and offices for the various departments.
Here also may be located
wards
for
convalescents
and
quarters
for
the
ship's
officers.
In
general,
the
spaces below
the main deck
are utilized for activities
where those engaged are not present throughout the 24 hours,
while
those
above
that deck
are reserved
for the sick who
cannot
leave
their beds to seek light and air in the open.
Activities
which give
rise to wild heat, much noise, or disagreeable odors should be grouped
well aft of the wards.
This applies
to the bakery, galleys,
laundry,
butcher shop,
vegetable
lockers,
blacksmith
shop,
and
incinerator.
The forward part of the ship should
be reserved for quarters for the
ship's company
and
the innumerable things
which have
to do with
the running
and
upkeep
of
the
ship.
With
this
arrangement,
all
wards containing bed-fast
patients will be concentrated
in the center
of the ship, above the main deck.
This location of the wards will, in most
cases,
place them adjacent
to open or glassed-in
deck space, and it is important
to arrange
the
corridors
and
doorways
so
that
beds,
stretchers,
and
wheel
chairs
may
be
moved
out on
deck
with
the
least
possible
trouble.
This
means that doorways
should
be
wide
and sills low.
Access
to the
fresh air and sunlight on deck will
give great satisfaction and com
fort to the patients
and will aid greatly in their recovery.
It is our
45202—38
5
222
JOHNSON—HOSPITAL
SHIPS
experience with patients invalided home from France, the Philippines,
Guam, and Hawaii, that a large proportion, even of the most serious
cases,
improve wonderfully
during
the
voyage
home
and
there
is
little doubt that this rule will hold
in the future.
Sea air, sunlight
and the mental
effect of "heading for the barn" are powerful remedial
agents and should
be used to the utmost on our hospital ships.
Even
the ship
travels
faster when headed for the home port, believe it or
not.
Every available
inch of deck space should
be devoted to the use
of the patients
whenever
the weather
is suitable and one should plan
to make
access
to the deck
as easy as possible.
It is essential,
both
for their own health
and for the administration
of the wards, that
ambulant patients
be kept out of the wards
and
on deck
as much
as
possible
during
the
day.
This will
be
made
simpler if several
spaces are glassed in with types of glass used for this purpose
which
do not exclude ultraviolet rays.
On
a hospital transport it will not be
necessary
to make
such
a
rigid
assignment
of
special
wards
for
surgical,
medical,
or other
patients.
As a rule they will have already
received initial
diagnosis,
operation and dressing before being evacuated
from the fleet hospital
ship or base hospital on shore to the hospital transport, and continu
ance of the nursing care will be the essential thing.
Usually it will
make little
difference
if medical
and surgical
cases
are in the same
ward.
It is customary to provide a separate
place for sick officers,
and
a few cabins
may well be reserved for those of higher
rank and
for sick nurses.
Somewhere
well aft, and on one of the highest decks,
a small
space should
be
reserved
for contagious
diseases that may
develop
on board during the voyage.
It is better not to accept con
tagious
diseases for transportation if it can
be avoided.
Another
group
requiring
special
consideration
is
the
venereal.
In
all
the
hospital ships I have
seen
they have been located
down
deep in the
hold, between
the laundry and the steering-engine
room, or wherever
there
was
the most
noise
and
heat,
and
the least comfort.
Many
of our very best soldiers
will
be found in this group
and I strongly
believe
that
they
should
receive
the
same
consideration
as others
when
wards
are
assigned.
The
most
modern
facilities should
be
provided for their treatment.
Mental
patients
will also
require
a special
ward with
elaborate
provisions for their care and
safety.
A great
number
of men who
probably would cope successfully
with the daily routine of civil life
become mentally
unbalanced
in
the
process
of adjustment
to
the
irregularities
and hardships of
a military
regime.
Even
those who
are aware of this fact habitually underestimate
the number of insane,
so it is well
to provide lock wards
for at least
5 percent
of the bed
capacity of the ship.
If not needed for that purpose
they
are avail
able for general
use.
It is better
to have too many than
too few, for
JOHNSON—HOSPITAL
SHIPS
223
it is a source of never-ending
astonishment,
the number of annoying
and dangerous
things that a hyperactive insane
man can think of to
do to himself, to others, and to the ship, in a single unguarded
moment.
A few large wards can be administered
more easily
and with fewer
doctors and nurses than can many small ones.
Sixty-bed wards have
proved to be very convenient
administrative
units.
One doctor, one
nurse and 8 to 12 orderlies
or male nurses can care for 60 bed patients
of the type
that will probably
be
carried
by
a hospital transport.
Most passenger liners have large saloons and dining rooms which can
be converted into
excellent
wards.
Smaller wards
will also
be ar
ranged by removing cabin partitions.
Wherever a ward or a room
for a patient is placed,
one should
make
certain that patients can
easily
be brought alongside
each
bed in
a wheeled
or hand-borne
stretcher.
Unless absolutely necessary, do not place bunks in corners
or against bulkheads, where
they
can be approached
from only one
side.
This arrangement
makes nursing care difficult and the patients
are likely
to be neglected.
If it is deemed
necessary
to install such
bunks, they should be reserved for convalescent
patients
who require
little care, or who
are able to leave their beds during the day.
The
space along the bulkheads
can be used to better advantage
for traffic
and circulation of air.
Passageways
between the rows of bunks should
be at least
3 feet wide,
for if narrower than
this it will
be found
extremely difficult
to transfer the patients from stretchers
to beds.
One ward should
be provided with 4-foot alleys for patients in plaster
cases, double
spicas,
and elaborate
suspension
apparatus.
Several standard
types
of bunks will
be found available on
the
market.
Most of them have upright metal stanchions
which support
metal bunks on each side.
For the convalescent
wards those with
either
two
or three
tiers
of bunks,
such
as are commonly
used on
transports, are suitable,
but for those patients
requiring nursing care,
who must remain
in bed day after day,
something
more comfortable
is required.
A reference
to
the
photographs
of
the
wards
of
the
Relief will give
a clear
idea of her
equipment,
which is very satis
factory.
The bunk frame should
be 36 x 78 inches with the mattress
large enough
to fit snugly within
the
frame
and not leave
several
inches of empty space between it and the frame.
Whether that space
be at the head, the foot, or the side, the patient's whole body seems
always to
be trying
to gravitate into the empty place.
The bunks
should be hinged
so that they can be turned up out of the way when
vacant.
A few standard type hospital beds and
a few fracture beds
should be installed in one of the smaller wards, and these must be very
firmly secured to the deck for there is a powerful lateral thrust at the
end of a heavy roll that few shoreside
people appreciate.
Before
the
end of the first trip, the doctor in charge will know exactly what cases
he wants in these special beds, and he will be very grateful for them.
224
JOHNSON
HOSPITAL
SHIPS
All buuks should
be securely fixed in place.
Do not allow anybody to
induce you to have swinging bunks installed.
The idea is so plausible
that, as soon as it is suggested, everybody is willing to accept it at once
as being just the thing.
But experience says, "No, they do not work."
If the
movement
of
the
ship
were
a
simple,
rhythmic,
to-and-fro
motion, they might do ; but the real movement
is a combination of an
up-and-down, a lateral, a forward-and-back motion with an irregular
corkscrew jerk for which no bunk, unless hung in gimbals, could com
pensate.
Each ward should
have
a diet kitchen with shelf
room
enough
so
that trays
can
be set up for at least one-third of the patients at one
time.
Refrigerator,
stove,
sink, and
drain board must not be for
gotten.
In this and
many other
items,
an
experienced
nurse
can
provide an infinite number
of practical suggestions that no mere man
would ever think
of,
so this source of information
should never be
neglected.
Generous
provision must be made for toilet facilities and they must
be near at hand.
It has been a common
fault in converted
hospital
ships,
that the few toilets were
at
a long distance
from the wards.
This means
more
orderlies,
more
bed pans
to
be carried, more
un
pleasant
odors in wards
and passageways,
also
more
discomfort
for
patients.
There is no milestone
on the road to recovery that is more
eagerly anticipated by the patient than his first trip to the head,
and
it
is
a
feeling
worthy
of
encouragement.
Many
doctors,
writing
about their hospital ships, have warned
against the error of insufficient
toilets distant from the ward.
For 60 beds there should be
4 toilet
seats,
3 urinals, and
2 showers.
Bath
tubs
should
be replaced
by
fresh-water showers, for the tubs are seldom used; they require much
work to keep them clean and they serve fewer men in a given
time.
The showers
are better liked by the men;
a shower
uses only about
one-tenth as much water as a tub bath, and 3 showers can be installed
in the space required
for a bath tub.
All pipes and plumbing should
be out in
the
open
and
easily
accessible.
Armies
recruited
in
an
emergency always contain a goodly number of men from remote places
who are unfamiliar with the use of modern sanitary devices, and some
who take pleasure in causing inconvenience
to others.
Between them,
they will keep
the ship-fitter's
force
busy
unstopping toilets, wash
basins, and urinals.
So all toilet fittings should
be chosen and installed
with this in mind.
A large stock of spare parts should
be carried.
It can
be regarded
as certain
that the ventilation
existing
in the
ship will be found inadequate
for ward purposes.
In spaces contin
uously occupied,
one should
allow 300
to 500 cubic feet of space per
man, and there must be a continuous flow of air, not only for respira
tion, but to remove odors.
Natural openings, such as windows, ports,
and skylights will seldom
be sufficient
and must often
be closed,
so
JOHNSON—HOSPITAL,
SHIPS
225
blowers
and ducts will be required.
It is not worth while to enter here
into the mathematics
of cubic feet per second, for the knowledge
of
air conditioning
is progressing
so rapidly that it is better to employ
the best talent available in this specialty and follow his advice.
But
be sure that your expert is familiar with shipboard conditions.
Supply
ventilation
should being the fresh air into the wards while the exhausts
remove it to the topside from the heads, diet kitchens, and other spaces
where odors may arise.
This may seem too elementary
to need men
tion, but more than one ship has been rigged
so that the air flowed the
other way.
Lighting should be indirect in the wards, or so arranged that the man
as he lies in his bunk, does not gaze into a brilliant light, either over
head or at the side.
Sufficient fllumination must be provided so that
the patient can read easily, for that will be his chief diversion.
Night
lights, similar to those used to illuminate the aisles of theaters, will be
necessary
to allow the work of the ward to be carried on at night with
out disturbing
the sleep of the patients.
Every ward and room will
require alternating current and
direct current outlets conveniently
placed so that one can plug in the portable X-ray, electrocardiograph,
ophthalmoscope,
diathermy machine,
floor polisher,
vacuum cleaner,
infrared or ultraviolet lamp, dental apparatus or any of the thousand
and one gadgets that we depend
upon in our daily work.
Most pas
senger liners have an independent lighting system
on an upper deck,
to take over the load in case the engine room is flooded.
This system
should be employed
and extended
to take in the operating room, and
perhaps
certain
of the offices,
so that work can be continued during
emergencies, if the usual
source of light should fail.
The radio has
become a daily necessity
and this fact should be recognized
by install
ing either an antenna
system
to which individual
radios can
be at
tached, or a central receiving
set with outlets to plug in individual ear
phones.
If some such action is not taken,
the ship will
be festooned
with individual
aerials
hanging
from every porthole and attached
to
every stanchion on the open deck.
Consideration
should
be given
to
the harmful
effects
of noise on
the sick and
the increased
suffering
caused by it.
Worn
gears on
cranes,
winches,
and other deck machinery can
set up
a vibration
throughout the ship that will make the sick men writhe in agony.
This
matter should be investigated and steps taken
to correct it if neces
sary.
Sound proofing
should
be employed in partitions and bulkheads
when spaces for the sick are adjacent to noisy activities that cannot be
subdued.
Diet kitchens, lounging, and smoking rooms are noisy most
of the
time
and
partitions
separating
them
from wards
should be
covered with material to deaden sound.
Elevators will probably be found already in the ship and their loca
tion will largely govern
the assignment
of wards and
clinics.
It is
226
JOHNSON—HOSPITAL
SHIPS
essential that the main elevator
be large enough to carry stretchers
and
allow the bearers to stand at the ends of the stretcher with the elevator
doors closed.
Since the elevator is the main avenue of communication
between the wards above and the clinics and operating room below, it
is necessary that there be wide corridors on all decks so that patients
on stretchers
can be conveniently handled.
A careful
study of the
routes from one space to another should
be made before finally decid
ing on the location of the various activities.
It should never be neces
sary to use any ward or clinic as a passageway
to some other compart
ment.
Nothing is more likely to produce friction among the personnel.
The operating suite should
be amidships,
below the main deck, and
so located that patients can conveniently be brought to it by elevator
from
the
surgical wards
and
the
admitting
ward.
The
operating
facilities need not be so elaborate
as those of the fleet hospital ship,
but must be adequate
for any emergency
of a surgical nature that is
likely to occur.
Sterilizing equipment should be generous in capacity
for it is probable that a very large part of the patients carried on the
ship will require
surgical
dressings.
As the efficiency
of the medical
department of an
armed
force
increases,
the
cases
of preventable
diseases will be fewer and
the percentage
of battle casualties
among
the patients will increase.
So, the higher the ratio of wounded
among
the patients received
on our ship,
the more satisfaction we may feel
in the sanitary work of our colleagues.
Do not forget to provide toilet
facilities and a shower bath for the operating-room personnel.
A large steam disinfector is an essential.
It is probable
that a large
proportion
of the patients received
from a force
engaged in active
warfare on the beach will be filthy and lousy, as was the case during
the
Gallipoli
campaign.
Sterilization
of clothing
and
bedding
is
likely
to
be
a continuous process during the homeward
trip, and so
adequate facilities must be provided.
Dental work will consist largely of prosthetic appliances
for injuries
about the face,
so a dentist skilled in such work should
be selected.
Generous
provision for this work should
be made, because the modem
organization of units for the care of maxillo-facial injuries
requires
that
continuous
care
be
given
such
patients,
from
the
front-line
trenches until they reach the special hospitals at home.
Our hospital
ship will be an important link in that chain.
The same principle applies to provisions for the care of fractures.
A very large part of the cases will probably be compound
fractures,
of all degrees of severity.
Selection
of staff and equipment should
reflect
consideration of this fact.
Care of such patients will require
more
than the
average
number of nurses
and
orderlies,
as well
as
doctors.
The
chief
surgeon
should select his staff carefully and
be
sure that there
are plenty of the special
types of apparatus that
he
prefers.
JOHNSON—HOSPITAL
SHIPS
227
Much thought must be given
to the matter of receiving
and
dis
charging patients.
It is likely that several hundred disabled
men will
be put aboard
and disembarked
each trip.
They may be brought to
the
gangway in
boats;
or
a ship
may
come
alongside
with
them.
Shipwrecked
men may be swimming or clinging to wreckage.
Small
boats may bring them in a rough sea.
All of these require
different
methods and different apparatus.
Special davits should
be rigged for
hoisting in patients.
A large number of Stockes
stretchers,
or similar
devices,
should
be
provided
and
the
crew
constantly
trained
in
methods
of embarking
and
disembarking large
groups
of patients
in stretchers.
What shall be the source
of personnel
for our hospital transport?
Most of those
of the past
have
been under command
of a medical
officer, with
a sailing master
to run the ship.
Hospital
transports
will be notified to the enemy as complying with the requirements
of
The Hague Conference
of 1907, concerning
the immunities of hospital
ships.
It has always been
accepted
as
good
practice
not to -have
combatant officers or men on such ships, even though there is nothing
in the convention that prohibits
them.
The Red Cross Society has
frequently been called upon
to provide the doctors,
nurses, and other
professional personnel
of such vessels and these persons have always
been
accepted
as being noncombatants.
Reserve
naval officers have
sometimes
been employed
to run the ships, but it is not likely that
the
enemy would discriminate between
regulars
and
reserves,
so far
as their combatant status is concerned.
Most nations have played
safe by removing all combatant officers and men from duty on their
hospital
transports,
so
that
there
might
be
no
question
of their
neutrality.
Suggestions
for supplies
and equipment can always be obtained
by
addressing
the Red Cross Society,
the
army or the navy
medical
authorities of any country.
It is very important that, after the staff
is selected,
the members study the lists of supplies
to make sure that
the articles they are accustomed
to work with are provided
IV. Organization
and
Administration
No matter how intelligently
designed
and structurally
perfect
the
hospital ship may be, defective
principles of organization may nullify
its good features; for no machine
can run smoothly or efficiently if its
gears do not mesh.
So far as the internal affairs of the medical
de
partment
are
concerned,
there
should
be little
difficulty,
because
hospital
administration
is now
so
completely standardized,
in
the
United
States
and
Canada at least,
that doctors,
nurses, dietitians,
orderlies,
and others,
assembled from widely scattered
hospitals, will
find few details
that differ from their accustomed
routine.
It is in
228
JOHNSON—HOSPITAL
SHIPS
the relations between
the medical
department and the ship's
officers
and crew that friction is most likely to develop.
It is commonly observed
among us that the naval point of view and
the medical point of view move along widely divergent lines, and both
are sufficiently inflexible that it is found to be very difficult to bend
them to a focus on the common objective.
The medical
officer thinks
first of the patient and his welfare, while the line officer thinks first of
the ship, and of the organization that enables it to carry out its mission
with safety and certainty.
Each is likely to react with impatience to
any interference
in his field, so a kindly sense of humor in one or both
is devoutly to be wished.
The harmonizing of the two points of view,
without
too
much dominance
by
either,
is
the
prime
essential
of
hospital-ship administration.
It is the rock upon which have found
ered the success and good will of several vessels that started out under
most favorable auspices.
To avoid such failure, there must be agree
ment
on all details
of command
and authority
before
patients are
received
on
board.
Fleet hospital ship
Fleet hospital ships, being direct agencies of the governments
which
they serve, will usually be organized in accordance with the regulations
of their respective
navies.
Their personnel,
composed in large part of
officers
and
men
accustomed
to work under those
regulations,
will
experience
only slight changes from their peace-time
activities,
and
so there should
be relatively little friction.
In the administration
of the Relief, a detailed
scheme
has
been
worked out which is very satisfactory for a fleet hospital ship of the
United
States
Navy,
though
probably not appropriate for those of
other navies.
A list of the chapter headings
of the ship's regulations
of the Relief will suffice
to indicate some of the problems
that will
arise, and on which early decision will be required.
They are :
Organization —policy— personnel .
Berthing and stowage.
Messing.
Deck spaces and assemblies.
Divisional
duties and details.
Ship handling—ship's routine.
The medical
department.
Emergency drills.
Field hospital and mobile
emergency unit.
Leave and liberty —disciplinary procedures.
Communications.
General
regulations.
JOHNSON—HOSPITAL,
SHIPS
229
Hospital
transport
Organization and administration of a hospital transport is likely to
be quite a different proposition.
Since these vessels will probably be
required to make long voyages without protection of a convoy, it is
important that no slightest
act or condition should
be permitted that
may in any way jeopardize
their immunity under the tenth convention
of the Second Peace Conference,
at the Hague, 1907.
Therefore they
should
not be officered
or manned
by combatant personnel.
While
nothing in the convention expressly
forbids combatant persons in a
duty status on the hospital ship, belligerent nations in recent wars have
gone to considerable
trouble to make it known to the world that all
the officers
and men on their hospital ships were noncombatants.
It
appears to be the universally
accepted
belief
that
the
presence
of
combatants would cause them
to forfeit the immunities granted to
hospital
ships.
For this reason, hospital transports will probably be run by officers
and men of the merchant marine.
The medical
and nursing staff may
be army or navy personnel
or they may be assembled from civil life.
At present
there
are, in many countries,
organized
units of doctors
and nurses, trained to work together
and ready
to respond
at once, if
needed
for war-time
service
on
hospital
ships
or on
shore.
This
should greatly simplify the task of organizing the group for duty on
such
vessels.
The Red Cross Society has been very active in aiding
the work of hospital ships,
and many vessels in past wars have been
staffed
and
equipped
by this admirable organization.
The
Hague
Convention
of
1907
provides rules
for hospital
ships
belonging
to
philanthropic
societies,
as well as for government
vessels.
It has usually been found advisable,
when a merchant ship is taken
over for hospital duties,
to retain her officers
and men.
When the
medical
personnel
report on board,
the question
immediately arises,
which is the tail and which is the
dog;
who
has authority
to give
orders
to whom?
This must be definitely settled,
and a clear under
standing reached at the outset,
or else
the resulting friction will be
reflected in the quality of work of the ship.
A review of the historical
chapters will show that most hospital ships have been under command
of the medical
officer, while the captain was held responsible
for the
navigation and
the safety
of the ship.
In other words,
the doctor
decided
when
and where
to go, and
the rest was up to the captain.
Most of the friction
and difficulties of the past have
arisen between
these two.
Seagoing men resent being placed under a landsman, and
the doctor, with his unaccustomed
authority, can easily be tricked into
an embarrassing
and humiliating
position by hostile ship's
officers.
One of the principal arguments
in favor of placing the medical
officer
in command
is that this method is generally
accepted as best comply
230
JOHNSON—HOSPITAL,
SHIPS
ing with the spirit of The Hague convention of 1907, and insuring the
neutrality of the hospital ship.
Other matters that may be fruitful causes of disagreement
are berth
ing of the ship's
crew and the hospital attendants,
stowage
of ship's
gear
and
personal
effects,
responsibility
for
cleaning
various
com
partments, fuel and fresh water supply, use of ship's boats for trans
portation of patients and crew, assignment
of spaces for ship's work
and for recreation
of patients,
fire and abandon-ship drills, liberty for
crew and
patients,
disciplinary
procedures,
upkeep
of plumbing and
other fixtures,
handling of communications, uniform, pay,
authority
of the officer of the deck, and management
of visitors.
Many of these
questions
would
find
the
landsman entirely
unprepared
to
decide
them.
The essential
thing is that the duties
and responsibilities of
each department of the
ship
should
be clearly decided
and
put in
writing
before
the
vessel starts to function
as
a hospital ship.
In
emergencies,
when
everybody and everything is put aboard
at once
and the ship shoves off immediately, such an arrangement
in advance is
not possible,
but one should insist on it whenever it is practicable.
Examples
of
the
disadvantages
of uncertain or divided responsi
bility are found in
several
hospital
ships
in
the
past.
The Victor
Emanuel
had
a naval
officer,
Captain
Parkyn,
in
command,
with
Surgeon-Major
Dr. Bleckly
of the Army in
medical
charge,
while
the War Office
authorities contributed
a military
commandant and
an adjutant.
The
London
Lancet, in
an editorial
(1873, 11:824)
comments
satirically
on this arrangement,
"Whom
is
the major
to
command
and what will be the official or clerical duties of the adjutant?
We presume that the former is to have morning parades of the Army
Hospital
Corps, and that the adjutant
has strict instructions
to see
that there is no waste in drug department.
In fact,
we can hardly
imagine two fish so very much out of water."
The numerous authori
ties represented
here would afford ample opportunity for friction that
would interfere with the administraton of the vessel and the care of
the sick.
The Bay State was fitted out under
the direction of 25 different
committees,
while another committee
decided on policies
and directed
the movements
of the ship.
Dr. Burrell was surgeon-superintendent,
with orders placing the vessel entirely in his charge.
The safety
of
the ship,
from the navigation standpoint,
was in the hands
of the
master.
The point to which the vessel should go, and the immediate
control of the ship whenever it involved the welfare of the patients, in
these, the master was placed under the surgeon-superintendent.
It is
recorded that many difficulties arose from this divided responsibility.
The
steward's
department
and
commissary
were under the master,
while the cleanliness
of the ship "was suggestively
controlled by the
Medical Department, except in parts of the ship directly controlled by
JOHNSON
HOSPITAL
SHIPS
231
them."
Here
are fertile sources of constant bickering
and,
as one
might anticipate, disagreements
were frequent.
It is to be regretted
that we do not have more detailed
information concerning
the actual
working of
this
strange
and
complicated
organization, which must
have
been highly
charged
with
political
cross
currents.
The
brief
duration of the war alone would permit such
an enterprise
to end
harmoniously,
unless
the
heads
of
the
committees,
the
surgeon-
superintendent, and the master were supermen of tact and diplomacy.
Nishi relates that, in Japanese hospital ships, the chief medical officer
takes charge of medical
affairs and sanitation of the ship, and has the
right to direct
and command
the captain as to the movements
of the
ship.
The medical personnel
of these ships have been supplied
by the
Ked Cross Society.
Volunteer personnel,
serving without pay, have
been employed
on
some hospital ships, but this is not to be recommended.
Extensive ex
perience in disaster-relief
work has taught the writer that the fine enthu
siasm with which people throw themselves into such well-advertised hu
manitarian en terprises la sts for 1 0 days or less.
As soon as the work slacks
a little, and the volunteer workers have time to look about
them, and
to see
others
doing
less work or receiving
more
compensation
than
themselves,
the mantle
of self-sacrifice
wears thin and human nature
begins
to show
through.
Therefore, free
service,
or service for less
than
the standard wage,
should
be
regarded
as
a very temporary
thing.
It is better to inform those who desire to donate their services
that they will be paid the same as other workers,
but may return the
money to the organization if they so desire.
Such organizations as the
Volunteer Aid Detachment and Women's Auxiliary
Army Corps in
England, and the American Red Cross in America have proved invalu
able for their work in recruiting and organizing people for such enter
prises
as hospitals and hospital ships.
One who has been given the task of organizing the medical depart
ment of a hospital transport, or a hospital ship under the control of a
philanthropic
society,
without previous experience in such work, will
do well to follow standard hospital procedures
with the least possible
adjustment for conditions on board ship.
Such
a book as Dr. Mac-
Eachern's,
on hospital organization
and
management,
will
prove
a
very useful guide, and should
be followed
as closely as possible.
Prac
tically all the details
can be safely left to the chief nurse and the doc
tors in charge of the wards, and they will work better if not interfered
with by the senior, whose first few hours
would be more profitably
spent if he immediately went into
a huddle
with the captain of the
ship.
Here are some of the things which they should discuss.
Each man should
be assigned a bunk, mattress,
and a locker for his
clothing.
Bags, suit cases, and other containers
are not to be kept in
sleeping quarters,
but in a storeroom
provided for the purpose,
and to
232
JOHNSON
HOSPITAL,
SHIPS
which they can
have
access
at stated
hours.
Unless
the steward's
department of the ship is prepared
to carry the whole burden of prepar
ing and serving food,
1 man in each 20 should
be detailed for this pur
pose.
Peeling and preparing vegetables, washing dishes, cleaning the
mess room,
and other chores will keep them busy.
Special
arrange
ments will be necessary for preparing and serving
diets for the sick,
and the hours at which the various groups will have their meals must
be arranged
so that they will not conflict.
Night
and day watches,
and hours for liberty for all departments
must be arranged, and it will be found that they all are interdependent.
A cleaning
bill should
be worked out which will show in detail just
who is responsible
for cleaning
every compartment of the ship, other
wise there will be continual friction and complaints.
Who is to notify
whom, when there
is
a leaky spigot,
a stopped
toilet,
a burned-out
sterilizer, or a broken chair to be fixed?
Who has charge of the incin
erator and the disinfector?
Definite deck spaces are to be assigned to
ship's company, hospital attendants,
patients, nurses, and doctors,
and
notices
posted
so
that
there
may
be
no
trespass.
Running-boat
schedules,
telephone watches,
cleaning
and inspection
routines require
careful consideration.
Preparation must
be made to meet emergencies
such
as
fire,
col
lision,
and
shipwreck.
Drills should
be held frequently, until
each
person knows just what is his station and duty in any case.
The mat
ter of getting patients in and out of the
boats,
and bringing
them
aboard from boat or from dock requires constant
practice.
Abandon-
ship drill should be carefully planned,
with
a definite
place assigned
for each patient, as well as for those attached
to the ship.
A lifeboat
which is rated as carrying 30 persons will accommodate
only about 7 or
8 stretcher
patients.
Each boat should be tested with the stretchers
actually in place
to determine
its capacity in terms of stretcher pa
tients, together with the necessary boat's crew and attendants for the
sick.
Each time the ship puts to sea, the abandon-ship
drills should be
repeated until each knows his station and duties.
This discussion
gives some idea of the countless
details that will oc
cupy much of the time of the senior doctor during the first few weeks
of his duty on the hospital transport.
It is to be hoped that he and the
captain of the ship will be able to establish
a friendly and considerate
understanding, so that all of these points may be arranged
in an ami
cable manner.
Bibliography
Siegfried,
C. A.
Hospital Ships, The Bay State.
Boston M. & S. Journ. 139: 125,
August
11, 1898.
Burrell, H. L.
The Hospital Ship Bay State.
Boston M. & S. Journ. 140: 53, 13
July 1899.
Kishi,
I.
Hospital
Ships
and
the
Transport
of
the
Wounded.
Proc.
17th.
Internat. Cong, of Med.,
London,
1913.
Sec.
20, p. 18.
THOMAS
AND
PARKER —THE MAKING
OF
A BLUEJACKET
233
MacEachern, M. T., Hospital Organization
and Management.
Physicians'
Rec
ord Co., Chicago.
1935.
U. S. S. Relief, Ship's
Regulations.
1935.
THE
MAKING
OF A BLUEJACKET
By Capt. OsirriTB
E. Thomas, Medical Corps,
United States Navy, and Lieut. Charles M. Pareer,
Medical Corps, United States Navy
How many
stop to consider
the factors
concerned
in transforming
the
average
man into
a bluejacket, what he must be made of,
and
what
he must do?
That
the picture may be made
clearer
let us
dissect
the
entire
process
and
show how it is done.
Statistics
quoted
in this article are based
on recruiting statistics
compiled
by
the Recruiting
Division
of the Bureau of Navigation
and
the
Recruiter's
School
at
the
United
States
Naval
Training
Station,
San Diego, Calif.
Although
not accurate
to
the fraction,
they
are close enough
to make
clear our purpose.
About one-third of the men entering
a recruiting station are "sight
seeing" and
have
no desire
to enter
the naval service.
Out of 100
men who visit the recruiting office we shall take just 64 for this paper.
Of 64 men applying to
a recruiting station for enlistment,
32 will
be rejected
for physical defects, distributed
as follows:
Eyes
Face
Spine
Chest
Ears
Mouth
Lungs
Heart
Nose
Throat
Pharynx
Blood
Vessels
Height
Weight
Pelvis
Abdomen
Skin
Teeth
Genitals
Nervous
System
Head
Neck
Mind
Extremities
Of the
32 who qualify physically,
13 will fail to meet
the educa
tional requirements,
and
6 others will be rejected
for a record
of the
following :
Dishonesty.
Record of Court Conviction.
Vagrancy.
Unsatisfactory
Environmental
Factors.
Intemperance.
Family History of:
Criminal.
(a)
Insanity.
Bad Character.
(6)
Incurable
Disease.
The remaining
13 men will be accepted
and sent to a naval train
ing station, where
again
they will be examined
and
the probability
is that one will be rejected for defects either overlooked
at the recruit
ing station or which developed while en route
to the training station.
Twelve will
be vaccinated
and
placed
in quarantine for the next
3
weeks.
After
they
have
received
their clothing
allowance
their training
begins.
They
are
observed
carefully
for
communicable
diseases,
scabies,
venereal
disease,
ringworm,
trichophytosis,
and
other
dis
eases.
They
are re-vaccinated
until
a primary
reaction
takes
place
or the Medical
Department is satisfied
regarding
their immunity
to
234
THOMAS
AND
PARKER
THE MAKING
OF
A BLUEJACKET
smallpox.
They receive typhoid prophylaxis and are treated for any
ailments they may
have
acquired.
They
are instructed in care of
the feet and,
as their training progresses, in other hygienic measures.
Meanwhile
the Training
Department
has
begun
instructions
ac
cording to the following schedule:
Drill field; rolling clothing and bag
inspection; lectures
on what to do and what not to do to be a blue
jacket;
mess
cooking;
scrubbing
clothing
and
policing
up;
study
periods; watches;
recreation
periods
spent
mostly in well-equipped
libraries.
The station chaplains
assist during this period,
as shown
by
the
following schedule:
Holy service, Catholic and Protestant, each Sun
day; lectures
on morals
and marriage; advice
to the men on Govern
ment insurance; places
to go and places not to go, while on liberty;
sponsor
a happy hour
every
Tuesday
evening
for
singing
and
an
amateur
show;
allot
periods
for
personal
interviews
to
help
men
solve
their problems.
Our
12 men, at the end of 3 weeks, are transferred
from quarantine
to another unit and start more vigorous
training.
Having
been told
about the evils and many vices confronting them and informed by a
medical
officer
of the loss of health
as well as
time
and
money
by
venereal
disease, they are allowed
liberty on week-ends.
By this time they have
a general idea of what to expect and what
is expected of them.
The Medical Department continues
to observe
them
and their surroundings as it did during the quarantine period
and
cares for injuries and ills as may
be required.
The Red Cross
stands
ready
to be of
assistance,
the Army and Navy Y. M. C. A.
in the city exerts its every effort
to help
and, should it be necessary,
the Navy Relief Society stands
ready
to lend
a helping hand.
The Training Department works at double pace to make all possible
preparations for the
sea cruise,
near at hand.
The schedule
incor
porates:
Seamanship,
boat instruction;
ordnance
instruction; landing
force
instruction;
mess
duties;
guard
duties;
general
and
special
details.
During
the last
2 months of training the selection
officer looks over
the men and gives
examinations,
so that the outstanding men may
be sent
to a trade school for special training, then they complete
the
3 months' training period.
About this time the probability is that one
will be discharged
from the Navy,
due to inaptitude, bad conduct, or
as an undesirable.
One of the men selected for special training, will not care to take the
examination.
Two
of the men taking the examinations
will qualify
for the trade school and when completing the required
course will
be
sent
to sea.
The others will
be given
10 days' leave and upon their
return, sent to sea.
inspection
personnel.
inspection,
bag, in White.
234—1
234-2
SHILLING
COMPRESSED-AIR
ILLNESS
235
Each year 100 appointments to the United States Naval Academy
are allotted
to
the
enlisted
personnel
of the Navy,
and
each
man
knows he may take
examinations
for entrance,
if he qualifies.
The
qualifications for entrance
are as follows:
He must have not less than
2 years lugh-school
education,
9 months at sea, and be under
20 years
of age on April
1 of the entering
year.
A recent report shows that of
the 78 enlisted
men who in April 1937 took the entrance examinations
at
the
Naval
Academy
Preparatory
School,
United
States
Naval
Training Station,
Norfolk,
Va.,
G6
attained
passing
marks
in
all
subjects.
From
among
those recommended,
candidates
who
could not com
plete the required
9 months of sea service in time to be assigned to the
Naval Academy Preparatory School,
15 were successful in passing the
entrance
examinations
while at sea.
This total of
81
successful
candidates
is
the greatest
number of
enlisted men qualifying
by examination for entrance
to
the Naval
Academy since
1931.
Much lies ahead of this man we call a bluejacket.
As 2 men go to
trade schools
and the other
9 climb the gangway,
wo bid them good
luck, turn to start a new group,
but for a moment
we pause to think
of the 53 men who started, but failed.
COMPRESSED-AIR ILLNESS 1
By Lieut. Charles W. Shilling, Medical Corps, United States Navy
III. Symptoms of Compressed-Air
Illness
Since the presence of free gas in the blood or tissue fluids is the cause
of the illness, it is evident that the variety and severity of the symp
toms
will
depend
upon:
(1)
The
location of
the gas set free
and,
(2) the volume of this free gas.
Thus, unconsciousness,
collapse,
and
early
death
may result from
emboli
in the pulmonary or coronary
arteries, or in the
vessels supplying
the vital
centers of the brain.
Pain may result from bubble formation in any unyielding tissue such as
ligaments, fascia, periosteum,
muscle spindles,
or nerve sheaths.
Air
embolism either of the vessels or white matter of the spinal cord may
cause paraplegia;
while involvement of the cerebral
vessels or tissues
may lead
to
monoplegia,
hemiplegia,
aphasia,
or sensory
paralytic
symptoms.
Symptoms
rarely
develop
from
bubbles
in
the
liver,
spleen,
kidneys,
adipose
tissue
or veins.
These
"silent"
areas far
outnumber the "painful" areas, which in turn outnumber the "vital"
areas;
so except in cases
of massive bubbling, the chances
of serious
involvement are slight.
Time
of
on set .—Symptoms
have
been
known
to
occur
during
decompression,
however,
they
are most
commonly observed
during
the first
few
minutes
following
the
completion
of
decompression,
»Continued
from January 1938issue .
236
SHILLING
COMPRESSED-AIR
ILLNESS
although the onset
may
be delayed
several
hours.
The
old
adage,
"You don't pay until you leave," aptly expresses the usual sequence.
Erdman
(1913) in an analysis
of 3,692
cases
occurring at the East
River tunnels found that 50 percent
occurred
within
30 minutes
and
95 percent
within
3 hours,
but that
1 percent
were delayed
over 6
hours and 4 cases were said to have occurred
between
15 and 23 hours
after decompression.
A previously
mentioned
report
by
the same
author on
1.419
cases
places
the onset of symptoms
within
the first
30 minutes in 43 percent of the cases,
and between 30 to 60 minutes in
32 percent of the cases, that is 75 percent in the first hour.
Classification
of symptoms. —In the studies
of Heller, Mager,
and
von Schrotter
(1897), Hill and Macleod
(1903), Keays
(1909),
and
Bassoe
(1911),
the symptoms
were classified
according to the type
and frequency
with which they occurred.
In this study it is felt that
it is more advisable
to consider
symptomotology
as it relates
to the
various recognized
body
systems,
that is: (1) Cerebrospinal
system
(2) cardiovascular
system
(3) pulmonary
system,
(4)
visceral
and
urogenital system,
(5) structural system (to include oseous, connective,
muscular and fatty tissues),
and (6) dermal
system.
1.
Cerebrospinal
system. —Many of the early
authors thought that
this
was
the only system
involved
in
the illness.
Audibert
(1906)
says, "Diver's
paraplegia
is a single form and the variability of details
should not be permitted to obscure the regularity of the main clinical
stages."
However, in the same year, Boinet
(1906) reports
cases of
paraplegia,
monoplegia,
hemiplegia
with
aphasia,
quadroplegia,
and
facial
paralysis.
Previously,
Boinet
and
Audibert
(1905),
jointly
presented
many cases
of which the following are typical:
paresia
of
the left upper
limb with itching and
a sense
of pressure;
transitory
paraplegia
with
hyperesthesia,
anesthesia,
general
sensory
involve
ment, or with spasmotic
contractions; permanent
paraplegia
with re
tention of urine and obstipation; hemiplegia,
transient or permanent,
with facial paralysis,
or with
aphasia
and
temporary insanity;
and
quadriplegia.
Cazamian (1912) gives a most complete and interesting
history of a case of this illness characterized
by spasmotic
paraplegia.
Bassoe
(1913) presented
four cases: one showing
permanent
sensory
loss in the left ring and little finger; another,
permanent
analgesic area
on forearm; another,
persistant pain in legs and precipitate mictura-
tion; and another,
permanent
increased
reflexes and sensory disturb
ances of lower legs.
Rise in temperature
is considered
by some as an
important
symptom
associated
with
cerebrospinal
system
involve
ment.
Clark
(1870-71)
presented
35 cases
(predominately paralysis)
which occurred
during construction of the St. Louis bridge.
Further
presentation
of cases is unnecessary for it is evident from the foregoing
that symptoms
produced
by compressed-air
illness can simulate
those
due to almost
any other injury of
the
cerebrospinal
system.
Thus
SHILLING
COMPRESSED-AIR
ILLNESS
237
we may expect anything from numbness
and tingling of an extremity
to complete
unconsciousness
and collapse.
Envolvement
of the special
senses may also occur
and many cases
of labyrinthine
and apoplectiform deafness have
been recorded.
In
fact Meniere's symptom complex
is relatively
common
and
vertigo,
either alone or associated
with other symptoms is frequently noted.
Involvement
of the eye is relatively uncommon
but diplopia, nystag
mus, and transient blindness
have been reported.
Also Callan (1907)
reported
a case of double
chocked
disks,
Genet (1933) one of optic
atrophy, and Pflimlin
(1934) one of occular involvement with cataract
formation, all due to compressed-air
illness.
If
these
cases
terminate
fatally,
death
usually
occurs
weeks
or
months after the exposure
and is the result of complications such as
pneumonia, cystitis, pyonephritis, bedsores, exhaustion,
etc.
2.
Cardiovascular
system. —It is difficult
to classify
the symptoms
due to involvement of this system for the changes in any part of the
body may be due
to blocking of the arteries
in that locality.
For
example,
the blocking by air emboli of any endartery in the cerebro
spinal system
might lead
to infarction
in that area
and
a train of
symptoms similar to those mentioned
under involvement of the cere
brospinal system.
There is ample
evidence
to show
that embolism
of coronary or pulmonary vessels may precipitate cardiac failure, col
lapse and death ; or massive embolism
may cause fatal cardiac dilata
tion.
The bluish mottling of the skin in severe cases is undoubtedly
due to embolism of superficial
vessels with consequent
stasis.
Viguier
and Jean (1918) report a case of embolism
of the gluteal artery neces
sitating surgical
removal
of the resultant necrotic area, but usually
the emboli involve the smaller arteries.
Rupture of the overdistended
small
arteries
may occur
and
the resultant
eccymosis
cause
tissue
damage.
Lymphatic
damage may explain
the small superficial
areas
of localized swelling
or edema sometimes
seen.
3. Pulmonary
system. —Dyspnoea resembling
an asthmatic attack
and called "chokes" by the men, occurred
in 1.5 percent
of the 3,692
cases reported
by Erdman
(1913) and is undoubtedly due to multiple
small
gas
emboli
in
the
pulmonary
vessels with
resultant
edema.
This
is
always
considered
a
grave
symptom for it
is
evidence
of
massive
embolism.
4.
Visceral
and
urogenital
systems. —The
internal
organs
such
as
the liver, spleen, and kidneys do not usually give any signs or symp
toms
although
involvement
may
be
found
at
autopsy.
Nausea,
vomiting, and epigastric
pain are often encountered
and are probably
due to embolism
of the omental,
mesenteric or gastric arteries.
These
are usually considered
to
be grave symptoms for they
are also sug
gestive of extensive
embolism.
"Girdle
pain" is probably associated
45202—38
6
238
SHILLING
COMPRESSED-AIR
ILLNESS
with spinal cord involvement
as is constipation, retention of urine,
and impoteney.
5. Structural
system
(to include
osceous,
connective,
muscular,
and
Jatty
tissues). —Involvement
of
these
tissues
is
almost
invariably
associated with pain; and pain is by far the most common
symptom
in this illness —occurring in from 85 to 90 percent
of all of the cases,
either alone or associated with other symptoms.
In about 70 percent
of the cases,
the pain is in the lower extremities,
usually in the region
of the knees, and in the majority of the remaining cases in the elbows
or shoulders,
with
occasional
cases
involving
the
trunk.
Swelling
of the muscles or joints is sometimes
noted.
The myalgias,
arthral
gias and ostalgias are described
as tearing,
boring,
gnawing,
or lancing
in character
and when severe, only recompression
seems
to give relief.
Mild attacks of pain are experienced
at one time or another,
by almost
everyone
who
"takes pressure,"
but they
usually clear
up without
treatment
and leave no residuals.
However, Bornstein and Plate (1911-12)
report that chronic arthri
tis can result from repeated attacks of compressed-air
illness, through
bone necrosis from arterial emboli
and nutritional
disturbances
in the
surrounding
bony
parts.
Bassoe
(1913)
reports
several
cases
of
arthritis
deformans
resulting from
compressed-air
illness;
Twynam
(1888) reports
a case of bone necrosis; Plate (1912) reports
cases with
joint
symptoms,
muscular
atrophy
and
X-ray
evidence
of
bone
pathology; and Christ
and Basel
(1934) report bony
changes due to
repeated air embolism,
leading
to joint pathology.
6. Dermal system. —One
of
the most
common
symptoms
of com
pressed-air
illness
is pruritis or formication which is often
the first
and
may
be the only symptom noted.
This
is probably due
to air
bubbles in the subcutaneous
tissues or in the sweat glands.
Hemor
rhagic areas are noted
and
a rash is frequently-
seen resembling
that
of scarlet
fever.
Lividity
or marbling
of
the skin,
as
reported
by
Mellinghotf
(1934), is associated
with many of the serious
cases
and
is probably due to air embolism
of cutaneous
vessels.
Areas of swell
ing,
subcutaneous
emphysema,
and
crepitation
occur
in occasional
cases.
Diagnosis. —In spite of the multiplicity
of symptoms,
a diagnosis
of compressed-air
illness
can usually
be
made if the history
shows
exposure
to air pressure,
under
conditions capable
of producing the
illness,
during the preceding
12 hours.
It must be constantly borne
in mind, however,
that other injury or illness may occur; thus, a care
ful
differential
diagnosis
is
always
necessary.
For
example,
the
author knows
of a case
of acute appendicitis, one of fracture of the
femur,
and one of oxygen pneumonia
which were erroneously
treated
by recompression,
and of one man with paraplegia
due to a fractured
spine who
was transported
38 miles in a touring car seeking
recom
SHILLING
COMPRESSED-AIR
ILLNESS
239
pression,
because he had been diving—into the water from the super
structure of his yacht!
In most cases the men working under pressure
carry
cards
advising anyone
who
finds
them
unconscious
or acting
queerly, to return them at once to the company
doctor or the recom
pression
chamber.
In
commercial
work
simulated
accidents
and
hystero- traumatism must be kept in mind.
Pathology. —The pathology of compressed-air
illness
is almost
as
varied
as the symptomatology, but the fatal cases logically fall into
two groups: a rapidly
fatal group,
or those who die within
a few
hours after coming
out of pressure;
and
a delayed
fatal group,
or
those who develop
cerebrospinal
symptoms
and
die from secondary
complications after several
days,
weeks, or months.
Von Schrotter
(1898)
summarized
137 fatal
cases
occurring between
1854-97
and
70
cases with
18 properly
reported
autopsies
in
the rapidly
fatal
group, and 36 cases with 26 autopsies in the delayed
death group.
In the
18 autopsies
on the rapidly fatal group
he found
11 which
showed free gas in the circulatory system and in the other
7 congestion
of the lungs, liver, etc., which in some resembled suffocation.
Heiberg
(1878),
Gerard
(1884),
Nikiforoff
(1893),
and lie
(1904),
all
de
scribed
autopsies
on early death
cases with findings similar to those
above.
Rudge
(1907),
Nordmann
(1928),
and
Ghose
(1930)
have
described
autopsies
on early death
cases in which not only was there
bubble formation in
the
circulatory system
and in the
tissues,
and
marked congestion
of the visceral
organs;
but there was also micro-
and macro-scopic
hemorrhage
throughout the tissue of the cerebro
spinal system.
Necrosis due to emboli blocking the circulation, and
actual tearing and separation
of the fibers due to local bubble forma
tion
have
also
been
noted
in
the
cerebrospinal
system.
Boycott
and Damant
(1908)
in
an
exhaustive
experimental
study
demon
strated that bubble formation was more frequent in the blood
than
in any other tissue
or fluid, although bubbles
are found in lesser
quantity in all the body fluids.
Since the greater
the circulation the
more
rapid
the elimination of excess
gas, it follows that in bodies
dead
of
compressed-air
illness
the
bubbles
would
be found
more
numerous
in the parts with sluggish circulation and less commonly in
organs
with
an abundant blood
supply.
Thus,
bubbles
are seldom
found in the tissues such as glands or muscles, but are usually found
in the fat, the white matter of the cord and the myelin sheaths of the
nerves —all tissues with a poor blood supply.
Another factor in this
connection is that fat dissolves
more than 5 times
as much nitrogen
as water or blood at body temperature.
As regards
the segments of
the cord, the bubbles
appear to vary in number in inverse proportion
to the
blood
supply, while necrosis
is more or less directly propor
tional
to
bubble
incidence.
In
resume^
the
characteristic
patho
logical findings in the early deaths
are: Air embolism
(bubbles)
in
240
SHILLING— COMPRESSED-AIR
ILLNESS
the various arteries
and
veins,
more
commonly in
the smaller end
arteries, but in cases a massive embolism filling larger vessels.
Second
ary to this embolism
there may
be infarction,
necrosis,
edema of the
lungs, or dilation of the heart.
Bubbles are also found in the various
tissues
of
the
body
causing
stretching
and
tearing
(which in life
resulted
in pain or, if in the
cerebrospinal
system,
altered
sensory
and
motor function).
Marked
congestion
of
the
various internal
organs
is
also
often
found
and
frequently
hemorrhagic
areas
are
noted in the cerebrospinal
system.
The
delayed
or chronic deaths
occur
as
the result of secondary
infection
following
paraplegia
or
other
persistent
paralysis.
Ex
haustion and
septic infection from bed sores account
for the
three
deaths reported by Sewall
(1915).
The spinal cords in these patients
showed many areas of "softening and disorganization" in the lumbar
and lower thoracic regions.
Complete degeneration
of the ascending
fibers in the posterior columns
was noted in one case and destruction
of the descending
tracts in the lateral area in another.
Blick (1909)
noted fatal urinary tract infection in several of his paraplegic
cases.
Bauer
(1870)
presents
an
autopsy
showing
spinal
cord
softening
throughout
the
length
of
the
lumbar
segment
in
"the
posterior
columns,
posterior cornua
of
the
gray
substance,
and
the
lateral
column
of one side."
Granjon
(1880) reported
a case with softening
of the gray substance
of the cord in the upper lumbar region,
about
2 centimeters
long, and with a spot of complete
necrosis in the center.
This man had paraplegia,
retention of urine and bed sores and "stead
ily became worse," dying after 5 weeks.
In a case reported by Chau-
baud
(1883), dying after
1 month of paraplegia
and urinary retention,
an
area
of
softening,
2.5 centimeters
long,
was
found in
the
grey
matter of
the
cord
at
the lumbar
level.
Similar
autopsy findings
of chronic death cases were also reported by Sharples
(1894), Schaeffer
(1898),
Zografidi
(1907),
and
Noica
and
Paroulescu
(1933).
Of
course no bubbles of gas or acute congestions
are found in the autopsies
of these delayed death cases, for the pathology is limited to softening,
degeneration
or infarction of the cerebrospinal
system with occasional
infarcts of other tissues, and evidences
of secondary
infection.
Extensive experimental
work was performed
by Curcio
(1899) and
Battaglia
(1904),
who not only found the usual
cord pathology but
demonstrated
nerve cell changes due to the action
of compressed
air
even in the absence of embolism.
Cases
bibliography. —Many authors
presented
one or more
eases of
compressed-air
illness with a very general discussion
of the nature of
the illness,
which, although falling logically in this section, did not
appear
to
add
materially
to
the
detailed
discussion
of symptoms.
These
comprise
an additional or third bibliography which follows the
primary and secondary
bibliographies of this section.
SHILLING
COMPRESSED-AIR
ILLNESS
241
Primary Bibliography
Audibert,
L.
La Paraplegie
des Scaphandriers.
Montpellier,
8°,
1906.
Bassoe,
P.
Compressed Air Disease.
J. Nerv.
and Mental Dis.,
38:
368-369,
1911.
Bassoe, P.
The
Late
Manifestations
of
Compressed-Air
Disease.
Internat.
Cong. Hyg. and Demog., Tr.
15, 1912. Wash.,
3:
626-638,
1913.
Battaglia,
D.
M.
Alterazioni
traumatiche
primitive delia
Cellula
Nervosa.
L Alterazioni per azione dell'aria
compressa.
Ann.
di
Med.
Navale,
2: 701-
709,
1904.
Bauer, L.
Pathological
Effects upon the Brain and Spinal Cord of Men exposed
to the Action of a largely increased Atmospheric
Pressure.
St. Louis
Med. and
Surg. J., 7:
234-245,
1870.
Blick, G.
Notes on Diver's Paralysis.
Brit. Med. J., 2:
1796-1798, 1909.
Boinet.
La Maladie
des Scaphandriers.
Bull Acad,
de Med.,
Paris,
55:
756-
764,
1906.
Boinet and Audibert.
Les Paralysies
des Scaphandriers.
Arch.
gen.
de med.,
Paris,
2:
2689-2710,
1905.
Bornbtein,
A, and Plate.
Ueber chronische Gelenkveranderungen,
entstanden
durch
Presslufterkrankung.
Fortschr.
a.
d.
Geb.
d.
Rontgenstraklen,
Ham
burg,
18:
197-206, 1911-12.
Boycott,
A. E., and Damant,
G. C. C.
Some Lesions of the Spinal
Cord
pro
duced
by
Experimental
Caisson
Disease.
J. Path,
and
Bact.,
Cambridge,
12:
507-515,
1908.
Callan, L. W.
Double
Choked
Discs associated with Compressed-Air
Diseases
(Caisson Disease).
Arch.
Ophth.,
N. Y., 36:
509-512,
1907.
Cazamian.
Hematomyelie
par Decompression
brusque
Chez un Scaphandrier;
Paraplegie
Spasmodique.
Arch,
de med. Nav., Paris,
98:
212-224,
1912.
Chabaud,
N.
Des
Accidents
observes
dans
les
Appareils
a
Air
Comprime.
Quelques Moyens
practiques
d'g remedie.
Paris,
4°,
1883.
Christ,
A, and Basel.
Ueber Caissonkrankheit,
mit besonderer Berucksichti-
gung
einer
typischen
Erkrankung
des
Huftgelenkes.
Munchen.
med.
Wchnschr.,
81:
843,
1934.
Clark,
E.
A.
Effects
of
Increased
Atmospheric
Pressure
upon
the
Human
Body.
Medical
Archives,
St. Louis,
5:
1-30, 295-300, 1870-71.
Curcio.
Sulle
alterazoni
delle
Cellule
Nervose
del
Midollo
consecutive
alia
Rapida Decompressione.
Ann. di Med.
Navale,
2:
979-1021,
1899.
Erdman,
S.
The
Acute
Effects
of
Caisson
Disease.
Int.
Cong.
Hyg.
and
Demog., Tr.
15, 3:
619-625,
1913.
•Genet, L.
Partial Optic
Atrophy and Caisson
Disease.
Bull.
Soc.
d'opht.
de
Paris, 318-321,
1933.
Gerard.
Lea
Accidents
dans
les
Travaux
a l'Air
Comprime.
Rev.
San
de
Bordeaux,
2:
5-10,
1884.
Chose,
N. H.
Death
from
Compressed
Air Sickness
in India.
Indian
Med.
Gaz.,
65:
698-699,
1930.
Granjon, R.
Etude
sur l'Etiologie
des
Accidents
observes
chez
les Hommes
travaillant dans l'Air Comprime.
Paris, 4°, 1880.
Heiberg,
E. T.
Autopsie
d'un
Malade
Mort
en
sortant
de l'Air Comprime.
Gaz. Med.
de Paris,
7:
540,
1878.
Heller, R., Mager,
W., and von Schrotter, H.
Zur Kenntniss
der Todesur-
sache
von Pressluftarbeitern.
Deutsche
med. Wchnschr.,
Leipz.
and Berlin,
23:
375-379,
1897.
Hill, L, and Macleod, J. J. R.
Caisson
Illness
and Diver's Palsy; an Experi
mental Study.
J. Hyg., Cambridge,
3:
401-445,
1903.
242
SHILLING
COMPRESSED-AIR
ILLNESS
Keays, F. L.
Compressed-Air
Illness, with a Report
of 3,692
Cases.
Dept.
of
Med.,
Publications
of Cornell
Univ. Med. Coll., 2:
1-55,
1909.
Lie,
H.
P.
Uber
die
Veranderungen
des
Ruckenmarkes
bei Tauchern.
Vir-
chows Arch.,
178:
142—, 1904.
Mellinghoff,
K.
Cutaneous
Phenomena
in Caisson
Disease.
Ztschr.
f. klin.
med.,
127:
457-459,
1934.
Nikiforoff.
Beitr.
z. pathol.
Anat.
u. z. allg. Pathol.
12: — , 1893.
Noica and Paroulescu,
N.
Hematomyelia
prin Decompresiune.
Spitalul,
53:
99-101,
1933.
Nordmann,
Martin.
Hirnbefunde
bei
Presluftkrankheit.
Virchows
Archiv. f.
Path. Anat.
und Physiol.,
268:
484-491,
1928.
Pflimlin,
R.
Beteiligung
des
Auges
bei
der
Caissonkrankheit,
insbesondere
Kataraktbildung.
Klin, monatsbl.
f. augenh., 92:
54-58,
1934.
Plate.
Gelenkerkrankungen
durch
Pressluft.
Deutsche
Med.
Wchnschr.,
Leipz.
und Berlin,
38:
1768,
1912.
Rudge, F. H.
A case of Caisson
Disease.
Lancet, Lond., 2:
1675,
1907.
Schaeffer,
E.
Scktionsbefundc
bei
Pressluft-Arbeiten.
Ztschr.
F.
Med.-
Beamte,
Berl.,
11: 389—,
1898.
von Schrotter,
Herman.
Zur
Aetiologie
und
Pathologic
der
Decompres-
sionserkrankungen
(Caissonkrankheit).
Abstr.
Klin.-therap.
Wchnschr.,
Wien,
5: 1539-1540, 1898.
Sewall,
R. J.
Caisson
Disease on the Cuyuna Iron
Range.
The J.-Lancet,.
35: 265-269,
1915.
Sharples,
C. W.
Contribution to the Pathology
of the Spinal
Cord
in Divers''
Palsy.
J. Nerv. and Ment. Dis., N. Y., 21: 636—,
1894.
Twynam,
G. E.
A
case
of Caisson
Disease,
Prince
Aldred
Hospital,
Sydney,
New South Wales.
Br. Med. J.,
1: 190-191, 1888.
Viguier
and
Jean,
G.
Embolie
Gazeuse
de
l'Artère
Fessiere
(Accident
de
Decompression).
Bull.
Acad.
de
Med.,
Paris,
80:
377-378,
1918.
Abs.
J. A. M. A., 71: 2109,
1918.
Zografidi,
S.
Contribution
a l'Etude
des
Accidents
de
Decompression
ches
les Plongeurs
a Scaphandre.,
Rev.
de Med.,
Paris,
27: 159-187,
1907.
Secondary
Bibliography
Babington,
T. H.
Paralysis
caused by working
under compressed air.
Dublin
Quart. J. of Med.
sc.,
35: 312-318,
1863.
Barrington, J. L.
Caisson
Disease
(Diver's Palsy).
J. Trop.
Med.,
Lond..
9: 286,
1906.
Basboe,
P.
Compressed-Air
Illness.
111. Med. J., Spgfld.,
17: 462-469,
1910.
Berillon
and
Gosset.
La "Maladie
de
Caisson"
Presentation
de
Maladie.
Rev.
de psychotherap.,
Paris,
28: 144-146, 1913-14.
Bertillon.
Travaux
executes
dans l'Air Comprime.
Union
Med.,
10:
346-
350,
1861.
Bignami.
La Paralisi
dei Lavoranti
nei
Caissoni
ad Aria
Compressa.
Ann.
di Med.
Navale,
1899.
'
Boinet
and
Audibert.
Les
Paralysies
des
Scaphandriers.
Marseille
Med.
41: 693-694,
1904.
Cannady, R. G.
Double
Hemiplegia
in an Old
Case of Caisson
Disease.
Old
Dominion J. Med. Soc, Richmond,
Va.,
22: 90-91,
1916.
Cabnot,
Le Coup
de Pression.
Presse med., Aug.,
1906.
Charpentier, M.
Sur in Accident
Professional
Survenu
chez
un Scaphandrier.
Ann. d'Hygiène,
Paris,
9: 365-367,
1883.
SHILLING
COMPRESSED-AIR
ILLNESS
243
Charpentier,
M.
Observation
d'Ataxia
Locomotive,
consecutive
a
des
Ac
cidents de Decompression
Brusque par Rupture dun Scaphandre.
Union Med.,
36: 261-266,
1883.
Focrnay and Berbuyer.
Le Coup
de Pression.
Bull. Med. Aug.,
1904.
Gaudoin,
G. R.
Spinal
Paralysis
due to Deep-Sea
Diving.
Indian M. Rec,
Calcutta,
14: 358—,
1898.
Hodgen, J. T.
Effects of Compressed-Air
upon the Human
Body.
Med. Arch.
St. Louis,
5: 219-226,
1870-71.
Lepine,
G.
Sur
les
Lesions
Medullaires
de la Decompression
Atmospherique
Brusque.
Comp. rend. Soc. de Biol., 2: 873,
1900.
Lerebotjllet,
P.
Les Accidents
de l'Air Comprime;
Semeiologie et Pathogenie.
Progress
Med.,
Paris,
29: 587-593,
1913.
Lewis,
G. L.
The Effects of Compressed-Air
upon the Human System.
Trans.
Med. Soc.
of Kansas,
11: 10-21,
1875.
Littleton,
T.
Effects
of Submarine
Descent.
Assoc. M. J., London,
1:
127,
1855.
Magoire, R.
Caisson Disease.
T. M. Soc. Lond.,
23: 351, 1899-1900.
Oliver, T.
Caisson
Disease.
Northumberland
and Durham
M. J., Newcastle-
upon-Tyne,
13: 21,
1905.
Pagano,
F.
Contributo alio
Studio
delle
Malattie
dei Cassoni.
Med.
d'egli
inf. del Lav., Perugia,
2: 384-388,
1909.
Pepper,
W.
Caisson
Disease.
Med. Bull,. Phila., 8: 239-240,
1886.
Perez- Vento,
R.
Caisson
Disease
o Paralisis
de los Buzos.
Rev.
de med. y
circug.
de la Habana,
17: 417-419,
1912.
Rozsahegyi,
A.
A Munkalkodas
Comprimalt Levegoben.
Kozez.
es Torveny,
Orvos,
Budapest,
73-81,
1881.
von Schrotter, H.
Zur Kenntnis der Decompressionser-krankungen.
Beitr.
z.
innere Med. Festchr.
d. cong. f. in Karlsbad 1899, Wien, 4: 20, 1900.
von
Schrotter,
H.
Zur
Pathologischen
Anatomie
der
Decompressionser-
krankungen.
Verhandl.
d.
Dtsch.
pathol.
ges.
1904, Jena. G.
Fischer,
1905.
Scott, E. J.
Diver seriously
affected.
Customs
Med.
Rep.,
Shanghai,
1878.
Scott, E. J.
Deep- Water
Diving, a Curious
Paralytic Affection.
China Imp.
Custom
Med. Rep., Shanghai,
1887.
Silberstern,
P.
Zur Casuistik
der Caissonkrankheit.
Wien.
Med.
Wchnschr.,
30:
1305-1308,
1895.
Taylor, F.
Clinical
Lecture
on Divers'
Paralysis.
Clin. J., Lond.,
12: 1-5,
1898.
Taylor, F.
Diver's Paralysis.
Lancet,
1:
1549,
1898.
Veselitskago,
I.
A.
Caisson
Disease.
Nevrol.
Vestnik.,
Kazan,
19:
244-
277,
1912.
Cases Bibliography
Aguglia, E.
Su d'un Caso di Malattia del Palombari.
Riv. Ital. di Neuropat.,
Psichiatria ed Ellettroterapia,
13:
52-57,
1920.
Alorich,
C. J.
Compressed-Air
Illness
or Caisson
Disease.
Int.
Clin. Phila.
10-s,
2:
73-88,
1900.
^ Archambeault,
C. P.
Fatal Case of Caisson
Disease.
U. S. Nav. Med. Bull.
19:
167-168, 1923.
Barbe.
Accidents
de
Paralysie
Spasmodique
observe's
diez
les
Pecheurs-
d'Esponge.
Arch,
de Med. Nav., Paris,
73:
460-465,
1900.
Boinet,
M.
Hematomyelie
observe chez
un Pecheur
de
Moules.
Sitsungsber.
d. Assoc. franc, pour l'av.
des Sc. Congres de Marseille,
2:
756,
1891.
Bondet.
Paraplegie
chez
un
Scaphandrier.
Sitzungsber
der
Soc.
med.
des-
Hopitaux de Lyon, 13:
1905.,
vgl. Lyon Med.,
26:
1046,
1905.
244
SHILLING
COMPRESSED-AIR
ILLNESS
Bondet,
M. and Piery.
Sur un Cas
de
Maladie
des
Plongeurs.
Lyon med..
:
1406,
1905.
Cayler
and
Powell.
Diver's
Paralysis.
Middlesex
Hosp.
Rep.,
London,
37:
; 1898-99.
Damant,
G. C. C.
and
Thomas,
E. R. L.
A Case of Compressed-Air
Illness
cured by Recompression.
Brit. Med. J., 2:
881,
1909.
Drasche,
A. G.
Ueber Luftdrucklahmungen.
Wein. med. Wchnschr.,
48:
1-7,
1898.
Ellis, R.
Diver's Paralysis
with Scarlet Fever.
N. Y. Med. J., 84:
1273,
1906.
Express.
Ein
ungewohnlicher
Fall
plotzlicher
Dekompression.
Ref.
in
der
Neuen Freien
Presse,
14583:
8,
1905.
Freidricu.
Ein Fall von Taucherkrankheit.
Sitz-Ber.
d.
Phys.
Keil,
1906.
Fremont, J. P.
La Maladie
des Caissons.
Bull. med. de Quebec,
14:
145-161,
1912.
Grant, C. G. and Edin, S.
A Few Cases of Compressed-Air
Illness.
Brit. Med.
J.,
1:
1567-1568, 1908.
Hall,
M.
On
the Fatal Accident
to the
American
Diver.
Pract.
Obs.
and
Suggestions,
2:
301-305,
1846.
Hoche.
Zwei Falle von Ruckenmarkserkrankung
bie Caissonarbeitern.
Deutsche
med. Wchnschr.,
Leipz.
Ver.-Beil., 24:
14,
1898.
Hoskyn, D. T.
A Case of Caisson Disease.
J. Roy. Nav.
Med. Ser., 1:
473-475,
1915.
Klienberger.
Ueber
luftdruckerkrankungen
bein
Bau
der grunen
Brucke
in
Konigsberg.
Deutsche med. Wchnschr.,
Leipz.
u Berlin,
33:
1316-1318,
1907.
Ladd, L. W.
A Case of Caisson
Disease with Unusual
Hypopyrexia
and Recov
ery.
Cleveland
Med. J.,
1:
251-253,
1902.
Lapukhina,
V.
D.
Two Cases of Caisson
Disease.
Nevrol.
Vestnik.
Kazan,
20:
655-664,
1913.
Mackinlay,
A.
Case
of
Death
from
Syncope
caused
by
Caisson
Disease.
Statist.
Rep. of the health of the Navy, London,
:
102, 1901.
Minkoubki.
Caissonkrankheit.
Berlin
klin.
Wchnschr.,
49:
39,
1912.
Moriani,
G.
Di un Esito Eccezionale
di Malattia die Cassoni.
Riv. di med
leg., Pisa,
9:
175-187, 1919.
Oliver,
T.
Caisson
Disease
(Case).
Northumberland
and
Durham
M.
J.,
Newcastle-upon-Tyne,
7:
8-11,
1899.
Patrick, H. T.
Caisson Disease.
111. Med. J., Spgfld.,
7:
13-14, 1905.
Smith,
A. H.
Cases of Caisson
Disease.
Pres. Hosp., N. Y.,
1:
28-40,
1896.
Stettner, E.
Ueber Caissonkrankheit
mit Pathologischanatomischer
Beschrei-
bungeines
Falles.
Wurzb.
Abhandl.
a. d. Gesamtgeb. d. prakt.
Med.,
11:
285-
326,
1910-11.
Thompson,
W. G.
Notes on the Caisson Disease.
Med. Record N. Y., 45:
133-
134,
1894.
Van Der
Kevast,
T.
H.
Eenige
Ziekteverschijnselen,
die bij
den
Caisson-
Bouw
in
1905
te
Sluskil
zijn
voorgekomen.
Nederl.
Tydschr.
v.
Geneesk.,
Amst.,
44:
1097-1106, 1908.
Watson,
A. E.
Case of Divers'
Paralysis.
Lancet,
1:
1063-1064,
1893.
von Wenusch, F.
Ueber einen Fall
von Tauchertod.
Wien.
klin. Wchnschr.,
9:
774,
1896.
White,
W. Hale and Bainbridge,
F. A.
A Case of Diver's Paralysis.
Lancet,
4285:
1101-1102, 1905.
Wondra,
A. L.
Ueber Zwei Falle von Caissonkrankheit.
Konigsburg,
8°,
1908.
SHILLING
COMPRESSED-AIR
ILLNESS
245
IV. Treatment
of Compbessed-Air Illness
The treatment for this illness is recompression,
that
is,
a
return of
the patient
to compressed
air either
by lowering him in the water
again, returning him to the working chamber,
or placing him in the
medical lock or recompression
chamber
and raising the air pressure.
The relief obtained by
a
return to compressed
air was noted by the
laborers as early as 1854, and yet 70 years later an author (1924) says
of
two
cases
showing
paralysis,
"Treatment
was
with
potassium
iodid,
hexamethylenamin,
massage,
and
tepid
baths."
One
case
improved
after
a
month's treatment; the other showed
no improve
ment.
A
great
variety
of
treatment
was
suggested
by
Corning
(1890)
including
morphine, catharsis,
electrical
stimulation,
com
pression of the blood vessels of the lower extremities,
dry cups to the
spine,
and
the
use of ergot.
The
benefit
derived
from the
use of
ergot was also enthusiastically reported
by Knapp
(1891 —see sec. II).
The use of antipyrine
as
a
method
of ameliorating the pain was sug
gested
by
Sene
(1895-96).
Many authors recommended
massage,
friction,
and
heat
in one of the following
forms: Wet
compresses,
baths, sand bags, and hot drinks.
Various salves were recommended
as well as numerous
drugs for both external and internal use.
Recom
pression
was recommended
by many of the early writers only for the
most serious
cases,
and
several
wrote,
"The treatment
is
mainly
a
question of prophylaxis."
The first
recompression
chamber
or medical
lock in
the United
States was installed at the New York North River tunnel works in
1894 and its success was reported
as complete.
From
this
time on,
with
but
few
exceptions,
recompression
was
the
treatment
used
wherever pressure
work
was
conducted.
An excellent
summary of
cases treated by recompression
is
made by Wright and Brady
(1932 —
see introduction, p. 11) in which they show that of 3,067 cases treated
by recompression
89.3
percent
were completely
relieved,
9.9 percent
partially
relieved,
and only 0.5 percent
showed
no relief.
Medical
treatment of 211
cases gave no relief in 13.7 percent —
a
very definite
demonstration of the superiority of recompression.
Another report
presents
47
cases
of prostration
(the
most
severe
type
of illness)
treated by recompression
with relief or cure in 38 cases.
The recorded opinion
is
unanimous that the treatment recompression
should be started as soon after the onset of symptoms
as possible, for
it
is
felt that
the
benefits
derived
from recompression
are largely
dependent
upon
its early institution;
although treatment has been
known
to
be effective
even
when
instituted
many hours
after the
onset of symptoms.
Kropveld
(1907), who successfully
treated
77 of
his
98 cases
by recompression,
says that the greater
the delay after
the onset
of symptoms the higher the pressure
necessary
to relieve
them.
And
as pointed out by Langlois
(1911 —see sec. VI),
a
delay
246
SHILLING
COMPRESSED-AIR
ILLNESS
in recompression
may lead to permanent
cord lesions due to long con
tinued
anemia
caused by blockage
of tbe circulation.
Certain mild
cases will of course recover without treatment,
but as it is impossible
to predict when these mild cases will suddenly become severe it is best
to treat all definitely diagnosed
cases
by immediate recompression.
Although there is complete
agreement
on the advisability of imme
diate recompression
there is great divergence
of opinion on the man
agement
of
recompression.
The
first point
of
difference
concerns
the
rate of application
and
the amount or degree of pressure
to be
employed
for the recompression.
Some state that the pressure should
be applied
slowly, but the majority of opinion is in favor of rapid re
compression.
Concerning the degree of pressure,
one observation is
that
the
pressure
be
raised
only until
the
symptoms
are relieved,
another that
the
pressure
be raised
to one atmosphere
beyond
the
point of symptomatic relief.
Ryan
(1909) (1912) contends
that
the
pressure
must never
exceed
two-thirds that of the original working
pressure, but the cases he cites in support of this plan did not respond
to his treatment.
Cazamian
(1912 —see sec. Ill) recommends
rapid
recompression
to three or four atmospheres
and if there is no amelio
ration
of
the symptoms the pressure
may
be raised
to double
that
amount—nine atmospheres
having been used for one case.
The pre
dominance
of opinion, however,
favors recompression
to a pressure at
least
equal to that to which the worker was exposed.
Keays, Born-
stein,
Dominquez, Stott, and many others,
all of whom have
been
previously cited, recommend
this recompression.
Sakai (1934), after extensive
research,
offers two alternatives: One
that the pressure should be raised
to the same height as that of the
working chamber
and held at least 45 minutes
at that level; the other
that it should
be raised
10-15 pounds higher than the working pres
sure, thus hastening
the reabsorption of the gas bubbles
and allowing
the time of treatment to be shortened.
Normura
(1929), in animal
experiments,
also found that response
to treatment was better when
the recompression
was carried
to
a pressure
"slightly
higher"
than
that of the original exposure.
Opinion differs greatly as to the length of time
the patient should
be held
at this maximum treatment pressure.
Oliver
(1934) recom
mends slow recompression
to the original working pressure and
then
holding the pressure at this level for as long as 4 hours; but Cazamian
(1912 —see sec. II) says a wait of over 2 hours is useless and if paralysis
does not clear
in that time
the pressure
should be lowered.
Born-
stein
(1912— see
introduction)
says
that
under
no
circumstances
should the pressure be lowered at once but should be held at the maxi
mum level
at least
20-30
minutes
and sometimes
much longer; but
Keays
(1912 —see introduction)
says that after reaching
the working
pressure
the
treatment
decompression
should
be
started
"soon."
SHILLING
COMPRESSED-AIR
ILLNESS
247
Many of the authors do not mention any time element in this connec
tion but the majority
suggest waiting until the symptoms subside,
or
for at least 20-30 minutes.
The greatest difficulty in the treatment of the illness by air pressure
is encountered
in determining the type and length of the treatment
decompression — that
is,
the return to atmospheric
pressure from the
treatment recompression.
Among the authors already
mentioned
the
following are some of the methods suggested for lowering the pressure:
"2 minutes per pound,"
"2-3 minutes per pound,"
"about
a
minute
per pound,"
60 to 100 minutes per atmosphere —in nervous conditions
much longer," "% pound per minute,"
"quickly
to 10-15 pounds
and
then slowly at -the rate of
2
minutes
per pound," "very slow decom
pression,"
and
"long
continued
in
ominous
cases."
The
United
States Navy official treatment tables
(United
States
Navy Diving
Manual) are of the continuous decompression
type
and recommend
rapid reduction of pressure
down
to 60 pounds,
1
pound per minute
from
60 to 45 pounds,
1
pound in
3
minutes from 45 to 30 pounds,
1
pound in
5
minutes from 30 to 15 pounds,
1
pound in 10 minutes from
15 to
0
pounds (gage pressure).
However the proposed new treatment
tables are of the "stage decompression"
variety.
French (1916) gives
a good description of the United States Navy method
of treatment,
and Johnson and Bradlow
(1925) present
a
case treated by the British
Navy method.
As pointed out by several
authors
it
may be neces
sary to stop during the decompression
because of the reappearance
of
symptoms
and
again
raise
the pressure.
The author visited in the
former Cunningham Sanitarium in Cleveland and saw patients who
had spent months continuously at a pressure of 30 pounds
(gage) with
no ill effects, so
it
is
evident that
if
symptoms do reappear during the
return
to
atmospheric
pressure,
the
pressure
may
again
be
raised
slightly or held indefinitely.
The use of oxygen in conjunction with recompression
to hasten re-
absorption of the nitrogen was suggested 40 years ago in an article by
Zuntz
(1897 —see sec. II)
;
but because of the known toxicity of oxygen
at high concentrations its use was not widely
accepted.
However,
von Schrotter
(1906)
(1907)
again
suggested
its use at low partial
pressure
to hasten
decompression,
and Boinet
(1907) recommends
its
use in the treatment of "diver's disease."
More recently Behnke and
associates
(1936) (1937), in extensive animal experiments,
studied the
use of oxygen in the treatment of compressed-air
illness
and highly
recommended
its use in conjunction with
a
special form of recompres
sion outlined by them.
The use of mixtures of oxygen and helium in the treatment of com
pressed-air
illness
was
suggested
by Sayers,
Yant,
and
Hildebrand
(1925).
Because of the physical nature of helium
it
is
ideal for use in
displacement of excess nitrogen and thus
is
equally as effective
as pure
248
SHILLING
COMPRESSED-AIR
ILLNESS
oxygen in addition to being nontoxic (the usual oxygen concentration
of this mixture is approximately 20 percent that of atmospheric
air).
Adjuncts
to. the
treatment by recompression
were
suggested
by
Pelton (1907) as follows: Artificial respiration, exercise, massage with
various concoctions,
electric
stimulation, ironing muscles with
a hot
iron,
analgesics
for
pain,
hyperdermics
of
strychnine,
adrenalin,
caffein,
and general nursing care.
He recommends
breathing oxygen
only at atmospheric
pressure.
Others have
suggested:
Hot
baths,
hot wet dressings,
ergot injections, ether injections, camphorated
oil
rubs,
intracardiac
injection
of adrenalin,
etc.
It
is
evident
that
much
of this treatment
is handed
down
from early times but even
among more recent writers there seems
to be quite general agreement
that, in addition to and during treatment
decompression,
exercise is
desirable,
that hot applications and massage to the affected parts are
of benefit, that stimulation by drugs may be indicated in some cases,
that oxygen or helium-oxygen breathing is valuable,
and that general
nursing care is always
to be carried
out.
In summarizing
the treatment of compressed-air
illness
we
con
clude:
That
recompression
should
be
started at once
and
carried
rapidly
to at least
the
pressure
of the original
exposure,
that
this
pressure
should
be maintained until
symptoms disappear
or for
a
minimum of 30 minutes or a maximum of 2 hours, that the treatment
decompression
should be at a rate of not less than an average of 3
minutes per pound reduction
(the better type would
be
a stage
de
compression
calculated
for maximum saturation of the slowest
tissue
at
the
depth
of original
exposure),
that
oxygen
or oxygen-helium
mixtures
should
be
breathed,
that
massage
and
exercise
are indi
cated,
and that stimulation may be needed along with other nursing
care as becomes necessary for each case.
Primary
Bibliography
Behnke,
A. R., Shaw, L. A., Messer, Anne, Thomson,
R. M., and Motley, E. P.
The
Circulatory
and
Respiratory
Distuibances
of
Acute
Compressed-Air
Blness and the Administration of Oxygen
as a Therapeutic
Measure.
Am. J-
of Phys.,
114: 526-533,
1936.
Behnke, A. R. and Shaw, L. A.
The Use of Oxygen in the Treatment
of Com-
pressed-Air
Illness.
U. S. Nav.
Med. Bull., 35: 61-73,
1937.
Boinet.
Traitement
de
las
Maladie
des
Scaphandriers.
Marseille
Med.,
44: 357-370,
1907.
Corning,
J.
L.
Observations
on
the
Caisson
or
Tunnel
Disease.
Medical
Record, N. Y., 37: 513-521,
1890.
French,
G. R. W.
Diving Operations
in Connection
with the Salvage of the
U. S. S. F-4.
U. S. Nav.
Med. Bull., 10:74-91,
1916.
Johnson, J. E. and Bradlaw.
A Case of Caisson
Disease.
J. Roy. Nav.
Med~
Ser., 11:293-295,
1925.
Kropveld,
A.
Het
een
en
ander
omtrent
Caissonziekten,
Waargenomen
aan
het
Westelijk
Viaduct
te
Amsterdam.
Med.
Weekbl.,
Amst.,
13: 354-356,
1907.
SHILLING
COMPRESSED-AIR
ILLNESS
249
Nomura,
M.
Experiment
for
Prevention
and
Treatment
of Caisson
Disease.
Bull. Nav.
M. A. Japan, 18: 2-4,
1929.
Oliver,
T.
Compressed-Air
Illness
in
Colossal
Bridge
Building.
Arch.
f.
Gewerbepath.
u. Gewerbehyg
5: 313-318,
1934.
Pelton, H.
The Treatment
of Compressed-Air
(Caisson)
Illness.
Am J. Med.
Sc. 133:679, 1907.
Ryan, L. M.
Compressed-Air
Disease from a Clinical Aspect.
N. Y. Med. J.,
90: 193-198,
1909.
Ryan,
L.
M.
Compressed-Air
Illness
in
Caisson
Work.
Ann. Labor Legisl.
Rev.,
N. Y., 2: 350-355,
1912.
Sakai, Y.
Forschungen
uber Vorbeugung
und
Behandlung
der Caissonkrank-
heit.
Mitt.
d. med. Gesellsch. zu Tokio., 48: 73-76,
1934.
Sayers,
R. R., Yant,
W. P. and Hildebrand,
J. H.
Possibilities
in the Use of
Helium-Oxygen
Mixtures
as
a
Mitigation
of
Caisson
Disease.
Report
of
Investigations,
Dept. of Int. R. I. No. 2670,
Feb.
1925.
von Schrotter,
H.
Der
Sauerstoff
und
der
Prophylaxie
und
Therapie
der
Luftdruckerkrankungen.
A. Herschewald,
Berlin,
1906.
von Schrotter,
H.
Referat
uber
die
Berufskrankheit
der
Kaissonarbeiter.
Sitz.
ber.
d. sektion IV & XIV Int. Kong. Hyg.
& Demog. Berlin,
Sept.,
1907.
Bene.
Accidents
produits
par l'Air Comprime.
Cong.
Franc,
de
Med.
Paris,
2: 480-485,
1895-96.
Sjoblom, J.
C.
Caisson
Disease.
Finska
Lakaresallskapets
Handlingar Hel-
singfors,
66: 398,
1924.
Abs. J. A. M. A., 83: 654,
1924.
Secondary
Bibliography
Lividas,
S.
Sur la
Maladie
des Scaphandriers
et son
Traitement.
Bull.
Soc.
de Med. Athens,
1905, J. de la Sante, 22: 1137,
1905.
Merget, M.
Damming
of the Thames —Caisson
Disease.
Lancet,
4261:
1173,
1905.
Mourilyan,
E. P.
Compressed-Air
Illness and its Treatment
by the Inhalation
of Oxygen.
J. Trop. Med.,
London,
9:286,
1906.
Muto,
P. I.
Nota
circa
un
Palombara
Colpito
da Embolia
gassosa
tardiva.
Ann. di med. Nav., Roma,
2: 155-158, 1923.
von Schrotter, H.
Ueber die Bedeutung
der Recompression
bei Luftdrucker
krankungen.
Monatschr.
f. Unfallheitk. Leipz.,
5: 341-343,
1898.
V.
Prognosis
of Compressed-Air Illness
The incidence
of this illness
is almost
100 percent, if the trivial
as
well as the severe cases are counted.
In fact, in building a bridge over
the Eider in 1885, at a pressure of 2.6 atmospheres
above normal, there
were 380 cases of illness in 140 men.
In 1840 in the Strepy-Braqueg-
nies mine (+2.7 atmospheres)
all except one worker suffered the illness
and in the pressure work for the Bayonne bridge
over the Adour,
90
percent of the workers suffered.
Silberstein in 191 1 (all authors in this
section are mentioned
in the bibliographies of other sections)
reported
an annual
morbidity
of 200
percent
among
his workers.
Keays in
1909
reported
3,692 cases
among
10,000
men, that is 36.92 percent;
however, on the basis of man-shifts or individual
exposures
(557,000)
the percentage
of illness was only 0.66 percent.
Mortality in this illness is remarkably low at the present
time due
to the almost miraculous results
of recompression
treatment,
whereas
250
SHILLING
COMPRESSED-AIR
ILLNESS
prior to its use
the mortality
rate
was frequently very high.
Blick
in 1909 said that 60 out of 200 severe cases
among pearl divers were
dead before they reached a doctor and others died later.
Jeminet in the
St. Louis bridge work reported
119 cases of illness with 52 developing
permanent
paralysis and
14 dying, or a mortality of nearly 12 percent.
Dominquez reported
that among
550 men working on the foundations
of a building there were many mild cases,
106 cases of serious paralysis
and 14.9 percent deaths.
In the construction of the Brooklyn bridges
the mortality
was nearly
3 percent.
The value of recompression
is
well illustrated by the work on the Hudson River tunnel where
the
mortality
dropped
following the installation of the medical
lock from
25 percent to
1 percent.
In the extensive work on the New York East
River tunnels over a period of 2 years the mortality rate was 2 percent
on the basis of men employed but on the bais of working shifts was only
0.0035 percent.
In England during the construction of the Blackwall
tunnel there were 200 cases but no deaths.
It is of course evident that the prognosis
is much graver in a case
showing
early collapse
or unconsciousness
than in one with only pain
in a joint.
Also cases with severe paralysis are quite likely to be diffi
cult
to cure
and may end by having
permanent
paralytic
changes
(6 percent in one series).
Even here, however,
the prognosis
is much
better in
cases
of paraplegia
due
to
compressed-air
illness
than in
paraplegia
due to other causes.
From
the foregoing it is clear that if proper
treatment is given in
cases of compressed-air
illness the prognosis for complete cure is favor
able and the mortality rate is negligible.
VI. Prophylaxis of Compressed-Air Illness
In discussing
the cause of compressed-air
illness in section
11, it was
stated briefly that tissue nitrogen saturation was determined
by the
depth of pressure
and the length
of exposure
to this pressure.
In a
closer analysis
we find that in addition to these factors
there is the
very complex factor of body tissues and their physiology.
This prob
lem was taken
up in great detail by Boycott, Damant
and Haldane
(1908), who considered
such factors as blood
volume,
blood velocity,
heart
rate,
volume
of blood
passing thru the lungs and volume
of air
breathed per minute under circumstances
of rest or exercise, proportion
of blood
to the rest of the body,
proportion of fat, and
the relative
solubility
of nitrogen in
the various
tissues.
They
evolved,
after
much calculation, a logarithmic curve which demonstrated
the progress
of saturation with nitrogen for any part of the body.
They concluded
that for practical
purposes
they
would divide
the body into
those
tissues which attained 50 percent saturation (total saturation time for
any tissue is difficult to determine
because it approaches
infinity
as a
limit) in 5, 10, 20, 40, and 75 minutes.
From experimental
observa
SHILLING
COMPRESSED-AIR
ILLNESS
251
tions it was found that, for practical purposes,
after an exposure of 5
hours saturation was complete.
It is of course evident
from
further review of section
11 that the
cause of compressed-air
illness is the failure to properly eliminate the
nitrogen which has been stored in the tissues.
Thus prophylaxis de
pends
upon
the safe elimination of this nitrogen, and this process is
called decompression.
Whether or not the results
of decompression
are satisfactory will depend
upon
the following factors:
(1) The
ex
tent to which the blood
and
tissues have become saturated — (2) the
extent to which they have
become desaturated
during the stages of
decompression,
and
(3)
the
degree
to which
the
tissues will
stand
supersaturation.
By supersa titration
is meant
the property of the
tissues and tissue fluids to hold in solution excess
amounts of nitrogen
gas,
absorbed
under
increased
air
pressure,
after
the
external
air
pressure
has been lowered.
The phenomenon
which makes this pos
sible is probably the colloidal nature
of the tissue fluids.
By extensive
experimentation
it has been shown
that supersatura
tion to the extent of about 1.25 atmospheres
above normal atmospheric
pressure can be borne without the risk of nitrogen emboli formation—
which is to say that a diver can safely return to the surface from a
depth
of approximately
41
feet
sea water without
the necessity
of
decompression.
Therefore decompression
should be sufficiently slow
so that even the slowest
tissues do not have, at any
time,
a super-
saturation
greater
than
1.25
atmospheres
excess
pressure,
but
in
order to reduce the amount of exposure the decompression
must
be as
rapid as possible.
Boycott, Damant, and Haldane (1908) state —
A pressure of
1 to
1.25 atmospheres
above normal
corresponds
to from
2 to
2.25
times the normal
atmospheric
pressure;
but the volume
(not the mass) of
gas
(measured at the existing
pressure)
which
would
be liberated
if the whole
excess
of gas present in supersaturation
were
given off is the same
whether
the
absolute pressure is reduced from
two to one atmospheres, or from four to two,
or from eight to four.
Hence it seemed
probable that, if it is safe to decompress
suddenly
from two atmospheres of absolute pressure to one, it would
be equally
safe to decompress from four atmospheres absolute to two, from six atmospheres
absolute
to three, etc.
*
*
*
The process of desaturation
can therefore
be
hastened very greatly
by rapidly reducing
the absolute pressure to half, and so
arranging
the rest of the decompression that the saturation
in no part of the body
shall ever be allowed to correspond
to more than about double the air pressure.
On the basis of these facts new "stage" decompression
tables were
calculated
for various times
and
depths
of exposure
and
appear
as
Tables I and
11 of Appendix IV of the above article.
These
tables
are still in use by the United States
and British
Navies as well
as in
other diving activities.
Haldane (1908) (1922) describes
the method
of calculating the tables and demonstrates
the superiority of stage over
continuous or uniform decompression.
It is evident that when the reduction of pressure has been completed
there is still excess
nitrogen
held in supersaturation, which
is given
252
SHILLING
COMPRESSED-AIR
ILLNESS
off according
to the same curve
as that of saturation, provided
no
bubbles
have
formed.
Thus,
as
pointed
out
by
Stewart
(1913),
Perry
(1923),
and many others,
a second
exposure
before all of the
excess nitrogen has been eliminated is dangerous
and will require
a
longer second decompression.
Although
most
cases of compressed-air
illness
are due to faulty
or
difficult
decompression
the
examples
of
the
illness
given
by Earl
(1924), Baske (1929), and Beeching (1930), are considered
sufficient
for illustration.
A study
of
46
cases
of experimentally
produced
compressed-air
illness was presented by Shilling, Hawkins, Polak, and Hansen (1935),
in which the tissue saturation of the theoretical
5-, 10-, 20-, 40-, and
75-minute tissues was accurately determined
and it was found that
the saturation of the 5- and
10-minute
tissues had no bearing
on the
production
of the illness,
and that the saturation of the 20-minute
tissues might be allowed
to reach a ratio of 2.8 to
1 before symptoms
appeared,
rather than
the
2.25
to
1 ratio
advocated
by Boycott,
Damant,
and Haldane
(1908).
On the basis of these findings a new
method
of calculating decompression
tables
was suggested by Haw
kins, Shilling, and Hansen (1935), which materially shortens
the time
of decompression
for short and low pressure
exposures.
Numerous
other modifications have
been suggested:
Morrison
(1933)
demon
strated
the method
of calculating decompression
tables and suggested
shortening
the last stop; Kagiyama
(1934) on the basis
of a study
of the nitrogen
content of the urine following pressure exposure sug
gested
shortening
the
tables;
Shilling
and
Hawkins
(1936),
in
an
analysis
of 2,143 "lung"
escapes, found
that it was possible
to stay
37 minutes at
100 feet,
18 minutes at
150 feet, etc., and then safely
come to the surface without any decompression.
Hawkins
and Shil
ling
(1936)
presented
experimental
results
demonstrating the
feasi
bility of surface decompression,
that
is,
bringing the diver directly to
the surface
and
then immediately giving him the decompression
for
his dive in
a
recompression
chamber.
Dorello
(1934)
and Bchnke, Thomson,
and
Shaw
(1936) studied
the rate of nitrogen elimination in men breathing commercially pure
oxygen,
calculated
desaturation curves,
and suggested changes in the
decompression
tables.
Ham
and Hill
(1905),
Zuntz
(1909), Born-
stein
(1910),
and Hill
(1910),
all suggest oxygen
breathing in order
to
shorten
decompression
as
well
as
prevent
the
development
of
compressed-air
illness.
The breathing of helium-oxygen
mixtures to
shorten
decompression
was
suggested
by Sayers,
Yant,
and Hilde-
brant
(1925, see sec. IV), the Editor of "Umschau"
(1925),
Sayers
and Yant (1926), and Yant (1927).
Official
regulations
have
been drawn up by various countries
as
well
as
several
of our states.
German
regulations
are reported
by
SHILLING
COMPRESSED-AIR
ILLNESS
253
Heller
(1898),
Salessky
and
Libow
(1901),
and
Leymann
(1921);
Russian by Zalieski and Liboff (1901);
French by Wasserberg
(1905
and Silverstern
(1910);
Dutch
by Wintgens
(1907);
Swiss
by
the
Swiss National
Accident Insurance Department
(1933) ; New Jersey
and New York regulations by Erdman
(1918);
Detroit
tunnel
reg
ulations by King (1910);
and New York regulations by Japp (1913),
and Levy (1917).
Other than these official
regulations
governing
the conduct of pres
sure work
there
are many excellent
general
articles
concerning
the
problem
of prophylaxis.
De Mericourt
(1868)
(1869) suggested
the
necessity of a very careful
choice of divers
on the basis of physical
fitness,
the
regulation of the diet during diving
operations,
quick
descent, not over 2 hours exposure at 30 meters, slow decompression,
and the presence of a doctor on the premises of the diving operations.
Langlois (1906) (1910) (1911) discusses the value of the varius types
of decompression
and suggests the use of oxygen inhalation and exer
cise
as
adjuncts
to
the
stage
method
of
decompression.
Plesch
(1910)
recommends
the use of stage decompression
and stresses the
physical
examination
strongly,
saying
that
not
only
should
they
"reject cripples,
weaklings,
persons with infectious diseases, tubercu
losis, alcoholism,
lung, heart,
nerve, kidney, and stomach
ailments,"
but also special attention should
be paid to circulatory efficiency,
and
that fat men, men with heart failure or vasomotor weakness, chloro
sis, anemia,
diseases of the central
nervous
system, nephritis, or those
with ear disease should be barred from pressure work.
Glibert (1912)
(1914)
discusses
at length
the
value
of
the
uniform
method,
the
Holland
method,
and the stage method of decompression
and decides
in favor of the stage method.
Stewart (1913) considers
the following
points important:
adequate
air supply, rapid descent, limiting
time
on the bottom, stage method
of decompression,
and careful
physical
selection
of divers.
"Hygiene
of divers" is discussed in two
articles
by Moschini
(1934).
Cazamian
(1927) discusses the French regula
tions
and stresses the necessity
for medical control and supervision,
careful
physical
selection,
and
periodic
reexamination,
abstinence
from the use of alcohol,
and many other general and specific prophy
lactic measures.
Rigid physical selection
and frequent
reexamination
is required
of
deep-sea divers in the United States Navy
(1924)
(1927).
Not only
are
the
men carefully selected
according
to
the physical standards
laid down by the Medical Department but "qualified divers
shall
be
examined
physically
periodically
and
special
examination
shall
be
made in the case of all men prior to all deep diving operations
(in excess
of 36 feet)."
Age is considered
as important and divers are automati
cally disqualified when
becoming
40
years
old.
The British
Navy
(1930)
also requires
high physical standards
and even says, "If the
45202—38
7
254
SHILLING
COMPRESSED-AIR
ILLNESS
slightest doubt exists as to the physical fitness of a candidate
he should
be rejected."
According
to the British
Admiralty
(1933) they also
require
annual
medical
examination
as well
as medical
examination
before each dive.
Abstinence from the use of alcohol has been stressed by most of those
writing on prophylaxis.
In the United States Navy it is the custom
to
not only examine
before each deep dive but also to take
a short his
tory of the previous
24 hours to determine
whether
there is present
an
upper respiratory infection, if alcohol has been consumed, if the bowels
are moving normally, and if the diver feels fit.
No diver is permitted
to dive who is not, or does not feel, physically fit.
In summary
the written opinion seems
to be that careful
physical
selection
of divers is most important, periodic
reexamination
is essen
tial, medical
supervision
of pressure operations
is desirable,
descent or
entrance into pressure should
be rapid, time under pressure
(single or
multiple exposures) should
be held within safe limits, the stage method
of decompression
is the method of choice, and that oxygen inhalations
and exercise during decompression
hasten the elimination of nitrogen.
Primary Bibliography
Baske, H. F. A.
Caisson Disease Resulting
from Disregard
of Published
Instruc
tions and Established
Practice.
U. S. Nav. Med. Bull., 27: 514-518,
1919.
Beecbing,
C. L.
A Case of Caisson
Disease
Resulting
from
Insufficient
De
compression.
U. S. Nav. Med. Bull., 28:
236-241,
1930.
Bebnke,
A. R., Thomson,
and Shaw.
The Rate
of Elimination of Dissolved
Nitrogen
in Man in Relation
to the Fat and Water Content
of the Body.
Am.
J. of Phys.,
114:
137-146,
1936.
Bornstein,
A.
Versuchc
uber die Prophylaxe
der Pressluftkrankheit.
Berlin
klin.
Wchnschr.,
47:
1272-1275,
1910.
Boycott,
A.
E., Damant,
G. C. C.,
and Haldane,
J.
S.
The
Prevention
of
Compresscd-Air
Illness.
J. Hyg., Cambridge,
8:
342-443,
1908.
British Admiralty.
Divers —Examination
and Selection —Medical
Regulations.
J. Roy. Nav. Med.
Ser.,
19:
141-142, 1933.
British
Navy.
Medical
Qualifications
for
Men
Volunteering
for
the
Non
substantive
Rating of Deep Diving.
A. F. O., Deep Diver,
2449,
1930.
Cazamian.
Plonges en Scaphandre.
Arch, de med.
et Pharm.
Nav.,
117: 105-129,
1927.
Dorello,
F.
La Dcazotazione
nel Paloinbaro.
Ann.
di.
med.
nav.
e Colon.,
40:
650-662,
1934.
Earl, R.
Caisson Disease Resulting
from Complete Disregard for the Mandatory
Instructions.
U. S. Nav. Med. Bull., 21:
719-721,
1924.
"Editor."
Helium
fur Taucher.
Die Umschau,
29:
820,
1925.
Erdman,
S.
Standards
for the Prevention
of Compressed-Air
Illness.
Am. J.
Pub.
Health,
Concord,
N. H., 8:
431-434,
1918.
Glibert,
D.
Contribution
a la
Prophylaxie
du "Mai
des
Caissons."
Bull.
Acad.
Roy.
de Med.
de Belg., Brussels,
26:
640-662,
1912.
Glibert,
D.
La Prophylaxie
du "Mai de Caissons."
Bull,
de l'assoc. Beige
de
Med. Soc, Brussels,
2:
1-18, 1914.
Haldane,
J.
S.
The Hygiene
of Work in
Compressed-Air.
J. Soc. of
Arts.,
16 : 214-226,
1908.
SHILLING
COMPRESSED-AIR
ILLNESS
255
Haldane, J. S.
Respiration.
Yale Univ. Press.
1922.
Ham, C, and Hill, L. E.
Oxygen Inhalation as a Means to Prevent
Caisson and
Diver's Sickness.
Proo. Phys.'Soc,
London,
June, 8, 1905.
Hawkins, J. A., Shilling,
C. W., and Hansen, R. A.
Suggested Change in Cal
culating Decompression
Tables for Diving.
U. S. Nav. Med. Bull.,
33:
327-338,
1935.
Hawkins,
J. A., and Shilling,
C. W.
Surface Decompression
of Divers.
U. 8.
Nav. Med. Bull., 34:
311-317,
1936.
Heller,
R.
Hygienische
Vorschriften
fur Arbeiten
in
Comprimirter
Luft mit
Ausschluss
der Taucherarbeiten.
Monatschr.
f. Unfallheilk., Leipz.,
5: 140-144,
1898.
Hill, L.
Compressed air illness.
Brit. Med. J., 2:
785-786,
1910.
Japp, H.
Caisson Disease and its Prevention.
Tr.
15 Internat.
Cong. Hyg.
and
Dmog.,
1912, Wash.,
3:
639-654,
1913.
Kagiyama,
S.
Studies
on
Prevention
of Caisson
Disease.
J. Kumamoto
Med.
Soc,
10: 562-564,
1934.
King,
D.
M.
Compressed-Air
Illness,
Caisson
Disease,
bends,
diver's
palsy.
J. Am. Inst. Homoeop.
N. Y., 2:
106-111,
1910.
Langlois, J.
P.
Projet
de
Reglementation
du
Travail
dans l'Air Comprime.
Hyg. Gen. et Appliq., Paris,
1: 324-339,
1906.
Langlois, J. P.
La Reglementation
du Travail dans l'Air Comprime.
Prcsse
med., Paris,
18:
681,
1910.
Langlois, J.
P.
La
Prophylaxie
des
Accidents
dans l'Air
Comprime.
Rev.
Gen d. Sc. Pures et Appliq., Paris,
22:
54-60,
1911.
Levy, E.
Workers
in Compressed-Air;
Precaution"
Adopted
by the N. Y. Pub.
Ser. Comm.
for Protecting
Their Health.
Scient.
Am.
Suppl.,
N. Y.,
84:
73,
1917.
- Leymann,
G. 0.
Die
Verordnung
zuni
Schutze
der Pressluftarbeiter
vom 28.
Juni, 1920.
Zentralbl.
f. Gewerbehyg.,
9:
30,
1921.
deMericourt,
Le Roy.
Considerations
sur l'Hygiene
des Pecheurs d'Eponges.
Bull, de l'Academie
de Med.,
33:
786-789,
1868.
deMericourt, Le Roy.
Hygiene
des Pecheurs d'Eponges.
Annales
d'Hygiene
Publ. et de Med.
Legale.,
31:
274-286,
1869.
Morrison,
J.
K.
Decompression
of
Divers.
U.
S.
Nav.
Inst.
Proc,
59:
1695-1703,
1933.
Moschini,
M.
Igiene del Palombaro.
Ann.
d'ig.,
44:
554-572, 646-660,
1934.
Perry,
W.
R.
Case of Caisson
Disease or Diver's
Paralysis
Treated
by Com
pressed Air.
J. A. M. A., 80:
1455,
1923.
Plesch, J.
Zur Prophylaxe
und Therapie
der Caissonkrankheit.
Verhandl.
d.
Deutsch.
Kong.
f. Innere
Med.,
Wiest.,
27:
254-263,
1910.
Plesch, J.
Zur
Prophylaxe
und
Therapie
der Presslufterkrankungen.
Berlin
Klin.
Wchnschr.,
47:
709-712,
1910.
Salessky,
S. J.,
and
Libow,
B.
A.
Arbeiten
der
Komission
zur Verhfltung
der
sog.
Kaissonkrankheit.
Ref.
erstattct
anl. der
V. Tag.
der
russ
gesell.
f. Volk. Woyenaje
Med. J.
No.
10, 1901.
Sayers,
R.
R.
and Yant,
W.
P.
Value
of
Helium-Oxygen
Atmosphere
ia
Diving and Caisson
Operations.
Anesth.
and Analg.,
5:
127-138, 1926.
Shilling,
C. W., and Hawkins, J. A.
The Hazard
of Caisson
Disease In Indi
vidual Submarine
Escape.
U. 8. Nav. Med.
Bull.,
34:47-52,
1936.
Shilling,
C. W., Hawkins, J. A., Polak,
I.
B.,
and Hansen,
R.
A.
Caisson-
Disease and Its Relation
to Tissue Saturation
with Nitrogen.
U. S. Nav.
Med.
Bull., 33:
434-444,
1935.
Silber8tern,
P.
Gesetzlicher
Arbeiterschutz
bie Caissonarbeiten
in Frankreiob..
Amst.-Arzt., Leipz.
and Berlin,
2:
21-23,
1910.
256
SHILLING
COMPRESSED-AIR
ILLNESS
Stewart,
R.
W.
G.
Caisson
Disease.
Tr.
Int.
Cong.
Med.,
London,
Sect.
Nav. and Mil.
Med.,
19:
147-154,
1913.
Swiss Nat.
Accident
Ins.
Dept.
The proposed
Swiss
Regulations.
J.
Ind.
Hyg., 15:
83-84,
1933.
U. S. Navy.
Physical
Qualifications
of Divers.
U. S. Navy, Dept.
Bureau
of
C. and R. Diving Manual,
Sec.
13, Art. 3680 and 3681,
1924.
U.
S.
Navy.
Physical
Examination
of
Personnel
Selected
for
Deep
Diving.
U. S. Navy Manual of the Med.
Dept., Art. 1535,
1927.
Wasberbebg,
E.
Essai
de
Reglementation
Sanitaire
du
Travail
dans
1'Air
Comprime.
Paris,
8°,
1905.
Wintgenb, E.
Bericht
uber das Vorkommen
der Kaissonkrankheit
in Holland.
Sitz. d. Sek. IV and XIV. Int. Kong. f. Hyg.
u. Demog., Berlin,
1907.
Yant, W. P.
Helium in Deep
Sea Diving.
Ind. and Eng.
Chein.,
News.
Ed.,
5:
4, 1927.
Zaliebki,
S.
I.,
and Liboff,
B.
A.
Report
of
the
Commission
for
Finding
Measures
to
Prevent
Caisson
Disease.
J.
Russk.
Okhran.
Narod.
Zdrav.,
St. Petersburg,
11:
345-353,
1901.
Zuntz, N.
Die Verhutung
der Erkrankungen
Nach Aufenthalt in Komprimier-
ter Luft.
Fortschr.
d. Med.,
Berlin,
27:
561-563,
1909.
Secondary
Bibliogbaphy
Blattneb
and
Zanggeb.
Beitrag
zur
Frage
der
Prophylaxe
der
Taucher-
krankheit.
Schwez. Med.
Wchnschr.,
60:
1104-1106, 1930.
Cabdon,
G.
Contributo alio
Studio
Medico-Legale
della
Malattia
da Lavoro
in Aria Compressa.
Ramazzini,
Firenze,
2:
362-373,
1908.
Kuhneb,
A.
Caissonarbeiten.
Gesundheit,
20:
322-323,
339-340,
354-355,
1895.
Layet,
A.
Hygiene
des Plongeurs.
Rev.
san.
de Bordeaux,
3: 67,
1886.
Muller, H.
Die Gefahren der Gewerblichen
Arbeit unter Kiinstlich
Erhohtem
Luftdruck.
Monatschr.
f. Unfallheilk, Leipz.,
25:
4-14,
1918.
Rees, O.
Comm. Bericht iiber
Experimentelle
UntersUchungen
zur Prophylaxe
der Taucherkrankheit.
Erst, im Auf. der Adm.
der Kgl.
eng.
Kriegsmarine,
1907.
von Schrotteb,
H.
Zur
Prophylaxie
der
Taucherlahmung.
Sitz.
de
Cong.
intern, per le Malattie del Lavoro,
Mailand, 1906.
Schmittz,
N.
A.
Caisson
Air Hygienically Considered.
Vrach.,
St.
Petersb.,
8:
847-870,
1887.
Schmittz. N. A.
Sanitary
Conditions
for Work Performed
in Caisson.
Vrach.,
St. Petersb.,
9:
225, 245,
263,
1888.
Silberstein, P.
Hygiene
der Arbeit in Komprimierter Luft.
Jena, 8°,
1901.
Sulikowbki,
F.
Condition of the Health of the Caisson Workmen.
Czasopismo
lek., Lodz,
4:
97-101,
1902.
Sviontetske, I. O.
Caisson Work from a Sanitary
Viewpoint.
Vestnik Obshtsh.
Hyg., Sudet. i. Prakt. med., St. Petersburg,
2:
981-1005,
1900.
Waller, G.
De Hygiene
der Caisson.
Amsterdam,
12°,
1904.
Zburzhinbkiy,
K.
Sanitary
Conditions
in Work of Divers.
Voen.
san. delo
10:
1*6-37,
1932.
Unclassified Bibliography
(These references do not logically
fall in any particular section and are given
here merely for the sake of completeness.)
Abadir,
F.
Caisson
Disease on New Kasr
el Nil bridge.
J. Egyptian M. A.,
16: 811-825,
1933.
Aldrich,
C. J.
Caisson
Disease.
Cleveland
Med.
Gaz.,
14:
279-295,
1899.
SHILLING
COMPRESSED-AIR
ILLNESS
257
Belli,
C.
M.
Bericht
uber
Kaissongrankheit.
vgl.
Wien.
klin.
Rudsch.,
41:
760,
1906.
Bigoar, H.
F.
The Bends;
Caisson
Disease,
or Diver's Paralysis.
Tr.
Am.
Inst. Homoeop.,
1900, N. Y., 268-299,
1901.
Billstrom.
On Divers
Malady.
Svens Lak-Sallsk Ford-handling,
Stockholm,
83-88,
1910.
Brand,
J.
D.
Over
Ngevallen
bij
Pheumatische
Fundeeringen.
Nederl.
Tydschr. v. Geneesk., Amst.,
2 r. XLI., d., 2:
34-40,
1905.
Bbintizer, J.
Die Erkrankungen
der Taucher
und ihre Beziehungen
sur Unfall-
versicherung.
Hamburg,
Ackermann
& Wulff, 8°,
1913.
Gaffe, P. L. B.
Du Travail dans l'Air Comprime.
J. D.
Conn.
Med.
Prat.,
30:
385,
401,
415,
1863.
Carre, L.
Les Maladies
de l'Air Comprime.
Nature,
Paris,
30:
303-304,
1902.
Cattaneo,
F.
La Malattia dei Cassoni ad Aria Compressa.
Gaz. med. Lomb.,
Milano, 71:
33-37,
1912.
Charbostin, M. N.
Labors in Water and the Diseases of Divers.
Med. pribav.
k. morsk. sborniku,
St. Petersb.,
68:
126,
1888.
Clark, H. E.
On Caisson
Disease with some
Speculations
as to its Causation.
Glasgow,
M. J., 40:
17-28,
1893.
Dominquez, A. G.
Caisson
Disease o Paralysis
de los Buzos.
Rev.
de med. y.
cirug. de la Habana,
17:
359-368,
1912.
Editor.
Caisson
Disease.
J. A. M. A., 29:
392-394,
1897.
Elizalde,
P.
I.
Acoidents
Producidos
por
Aire
Comprimido
(Malades
des
Caissons).
Rev.
Assoc. med. Argent.,
Buenos
Aire,
23:
1018-1034,
1915.
Englebach,
P.
Les
Accidents
Consecutifs
au
Coup
de
Compression.
Rev.
med. de Normandie.,
Rouen,
3:
57-63,
1902.
Fontaine, M.
Accidents
et Maladies
causes par le Travail dans l'Air Comprime
au Havre de 1900-1906.
Rapport #20515,
4 Feb.,
1907.
Friedrich,
W. and Txuszk, F.
Caisson-Munkasok
Megbetegedeseirol.
Orvosi
heitil.,
Budapest,
40:
149,
162,
173,
186,
1896.
Friedrick,
W. and Tauzk, F.
Die Erkrankung der Caissonarbeiter.
Pest. med.
chir.
Presse, Budapest,
32:
674,
701,
722,
747,
1896.
Glibert.
Rapport
sur
les
Traveaux
du
Service
Medicale
en
Belgique
IV.
Influence
du Travail
a l'Air Comprime
sous Faible Pression.
Rapports
ann.
de. l'inspection
du Trav.,
11:
318,
1906.
Haaland, M. & Schaaming,
C. K.
Dodsfall hos Dykkere.
Med. rev., Bergen,
49:
260-276,
1932.
Haldane,
J.
S.
Experimentelle
Untersuchungen
uber
die
Taucherkrankheit.
In Druck J. Hyg.,
1907.
Halliday,
C. H.
Deep
Sea Diving and
its Relation to
Caisson
Disease;
an
Abstract of the Literature.
Am. J. Trop. Dis.,
New Orleans, La., 3:
502-512,
1915-16.
Heermann,
G.
Ueber
Caissonkrankheit.
Samml.
klin.
Vorto.,
n. F.,
Leipz.,
No. 334,
1902.
Chir. 95:
385-404,
1902.
Heller,
R.
et al.
Vorlaufige
Mitthelung
eber
Caissonarbeiter.
Wien.
klin.
Wchnschr.,
8:
475,
1895.
Hermel, E.
Des Accidents
Produits
par l'Usage
des Caissons ou Chambres
a
l'Air Comprime
dans les Travaux Sous- Terrains et Sous-Marins.
Paris, 8°, 1863.
Hill,
L.
The Physiology
of
Submarine
Work.
Rep.
Britt. Assoc. Adv.
Sc.,
London,
634-647, 1911-12.
Houderville,
L.
Contribution a l'Etude
des Accidents
du Travail dans l'Air
Comprime.
Paris,
8°,
1901.
Kluge,
A.
Caissonpsychose
oder
Simulation.
Monatschr.
f.
Unfallh.,
40:
286-291,
1933.
258
SHILLING
COMPRESSED-AIR
ILLNESS
Kober & Hayhurst.
Industrial Health.
By Blakiston.
Kropveld,
A.
Eenige
Twijfelachtige
punten
bij
Caissonzeikte.
Nederl.
Tijdschr. v. Geneesk, Amst.,
2:
1398-1404,
1907.
Kropveld, A.
Caissonziekte.
Nederl.
Tysdchr.
V.
Geneesk.,
Amst.,
1:
675-
683,
1907.
Kropveld,
A.
Bekopte
Mededeeling
omtrent
den
Aard
en
het
Aantal
der
Ziektegevallen
die Zich
Hebben
Voorgedaan
bij
den
Caissonarbeid
voor
de
Nieuwe
Westelijke
Viaduct
te Amsterdam.
Nederl.
Tijdschr.
v.
Geneesk.,
Amst.,
1:
1672-1675,
1908.
Langlois, J. P.
Referat uber die Berufskrankheit
der Kaissonarbeiter.
Sitz. der
Sekt. IV des XIV Int. Kong.
f. Hyg. u. Dem., Berlin,
Sept.
1907.
Leefman, H.
Compressed Air Illness.
Diet and Hyg. Gaz., N. Y., 13:
447—449;
1897.
von
Mouilland,
R.
Ueber
Caissonkrankheiten
und
Caissoneinrichtungen.
Deutsche
Vrtljschr.
f.
off.
Gsndhtspfl,
Brnschwg.,
36:
549-552,
1904.
Mummery,
N. H.
Diving and Caisson Disease; a Summary
of Recent Investiga
tions.
Brit. Med. J.,
1: 1565-1567, 1908.
Oliver,
T.
A Clinical Lecture
on Caisson
Disease or Compressed
Air
Illness.
Lancet, London,
1: 354-357, 1899.
Oliver,
T.
Discussion
on Compressed
Air
Illness,
or Caisson
Disease.
Brit.
Med. J., London,
2: 317-321,
1904.
Oliver, T.
Compressed Air Illness or Caisson Disease.
Vort. geh. in der Genoot.
ter Bevord.
van Nature,
Genees
en Heel-Kinde, Amsterdam,
Oct.,
1905.
Oliver, T.
On Compressed Air Illness.
Nederl. Tijdschr. v. Geneesk, Amst.,
41:
1463-1476,
1905.
Oliver,
T.
Maladies
Caused
by the Air
We
Breathe
Inside
and Outside
the
Home, Including Caisson Disease or Compressed Air Illness.
London,
Baillaire,
Tindall 4 Cox,
1906.
Oliver,
T.
Accidents
Causes par l'Air
Comprime
ou
Maladie
des
Caissons.
Ann. d'hyg. et de Med. Legale, Paris,
5: 385-410,
1906.
Oliver, T.
L'usage des Caissons dans la Construction
des Fonts et les Accidents
de l'Air Comprime.
Bull, et Men.
Soc. Med.
d. Hop.
de Paris,
23:
539-558,
1906.
Oliveb, T.
The Physiology
and Pathology
of Work in Compressed- Air.
Lancet.
London,
1:297-301, 1909.
Parkin,
A.
Caisson
Disease
or
Compressed-Air
Illness.
U.
Durham
Coll.
Med. Gaz., Newcastle,
3-4: 81-88, 1902-04.
Pettazzi,
A.
Osservazioni
Cliniche
e
Considerazioni
Medico
Legale
sulla
Pathologia
del Lavoro in Aria Compressa.
Ramazzini,
Firenze,
9:
118-152,
1915.
Poledne,
V.
Diseases of Divers.
Casop. lik. eesk.,
Praze,
52: 1635-1637, 1913.
Rosendo, PI, D.
Efermedad
de los Buzos.
Rev.
de cien. med.,
Barcel.,
13:
487-519,
1887.
Roucayrol.
Les Accidents de l'Air Comprime.
Paris med., 5: 289-291 , 1911-12.
von Schrotter, H.
Vereichnis
der seit dem Jahre 1900 erschienenen Literatur
uber Kaisson
und Taucherkranke.
Hyg. Zentralbl.,
Leipz., 3:397-403,
1907.
Sheinpain, M. G.
Caisson Works on the Big and Little Bolda rivers in Astrak
han, and Diseases Connected with Them.
Izviest. Obsk. Astrakhan
Vrach.,
8:
1-7,
1908.
Silberstern,
P.
Zur
Cauistik
und
zur
Prophylaxe
der
Caissonkrankheigt.
Wien. med. Wchnschr.,
66: 1894-1898, 1942-1945, 1896.
Silberstern,
P.
Referat
uber die Berufskrankheit
der Kaissonarbeiter.
Sitz.
d. sck. IV & XIV Int. Kong. Hyg. & Demog., Berlin,
Sept., 1907.
SHILLING
COMPRESSED-AIB
ILLNESS
259
Silberstern-,
P.
Die
Berufskrankheit
der
Caissonarbeiter.
Oesterr.,
San.-
Wes., Wien.,
21:
125, 133, 1909.
Silberstern,
P.
Die
Gefahren
der
Caissonarbeit.
Tr.
15, Int.
Cong.
Hyg.
A Demog.,
1912, Wash.
3: 610-619,
1913.
Smith,
A. H.
The Physiological,
Pathological,
and
Therapeutical
Effects
of
Compressed- Air.
Published
by G. G. Davis,
1886.
Skell,
E. H.
Compressed-Air
Illness
or So-Called
Caisson
Disease.
London,
8°, 1896.
Stephens, H. N.
Accidents and Diseases Caused by Diving Operations.
Report
of Health of the Navy, London,
1900.
Stott, A. A.
Caisson Disease.
Maine
Med. J. 25: 24-28,
1934.
Terni, C.
La Malattia dello Scafandro.
Ramazzini
Firenze,
5: 616-619,
1911.
Thienen,
G. T.
Zur
Frage dur Kaissonkrankheit
in Holland.
Sitz.
der sek.
IV & XIV Int. Kong.
Hyg. & Demog., Berlin,
Sept. 1907.
Thorst.
Caissonkrankheit.
Deutsche
Med.
Wchnschr.,
Leipz.
&
Berl.,
37:
1101,
1911.
Umber.
Kaissonlahumung.
Zeit. f. arztl. Fortbild, 3: 22, 1906.
Unknown.
Caisson
Work.
Ind. Med.,
3: 42-43,
1934.
Unknown.
Project de Decret
Reglementant
le Travail, dans l'Air Comprime.
Comm. de Hyg. Ind., France,
1906.
Unknown.
Regulativ
der Hollandsschen
Regierung
fur die Arbeiten
in Kom-
primierter Luft.
Staat van het Kon der Neider,
20:
1907.
Vilmos,
F.,
and
Tauszk,
F.
Caisson-Munkosak
Megetegedeseirol.
Orvosi
Heti.
Szemle, Budapest,
20: 177, 1896.
Wainwrioht, F. R.
Observations
on Compressed-Air
Illness.
Lancet,
London^
2: 1792-1799,
1900.
NAVAL RESERVE
PROMOTIONS, FOURTH QUARTER,
1937
Clarence
Andrew
Berger, 3015 Cherry
Street, Toledo,
Ohio, promoted
to com
mander, MC-V (G), U. S. N. R., November
20,
1937.
Rutherford B. H. Gradwohl,
3514 Lucas Avenue,
St. Louis,
Mo., promoted
to
commander,
MC-F,
U. S. N. R., November
18,
1937.
Joseph Henry Cannon, lOili Rutledge
Avenue, Charleston,
S. C., promoted to
lieutenant commander, MC-V
(S), U. S. N. R., December
17,
1937.
Sam Ardinger
Bassett,
1250 Big Bend Boulevard,
St. Louis,
Mo., promoted to
lieutenant,
MC-F,
U. S. N. R., November
15,
1937.
Charles
Bunch,
2214 East Seventh Street, Charlotte,
N. C, promoted
to lieu
tenant, MC-V (S), U. S. N. R., November
8, 1937.
Matthew
Remey
Furman,
230
West
Seventy-ninth
Street,
New
York
City,
N. Y., promoted
to lieutenant,
MC-V
(G), U. S. N. R., November
16,
1937.
Robert
Farjeon
Legge,
3135
Webster
Street,
Oakland,
Calif.,
promoted
to
lieutenant,
MC-V
(S), U. S. N. R., November
18,
1937.
Duncan Tracy McEwan,
Orlando,
Fla., promoted
to lieutenant,
MC-V
(G),
U. S. N. R., November
9, 1937.
Harry Carpenter Watkins, Jr., Aberdeen, Wash, promoted to lieutenant, MC-F,
U. 8. N. R., November
12,
1937.
RESIGNATIONS,
FOURTH
QUARTER,
1937
Moses
H.
Baker,
6045
Bunkerhill,
Pittsburgh,
Pa.,
lieutenant
commander,
MC-V (S), U. S. N. R., resignation
accepted December
2, 1937.
Horace W. Byers, 509 Woodlawn
Road, Baltimore,
Md., lieutenant commander,
MC-V (G),
U. S. N. R., resignation
accepted October
28,
1937.
Carl E. Dunaway,
Huntington Building,
Miami, Fla.,
lieutenant
commander,
MC-V
(S), U. S. N. R., resignation
accepted November
19, 1937.
Orion
Timberton Finklea,
405-9-16
Florence
Trust Building,
Florence,
S. C.,
lieutenant, MC-V
(S), U. S. N. R., resignation accepted November
5, 1937.
Vonnie
Monroe Hicks, Raleigh,
N. C., lieutenant, MC-V
(S), U. S. N. R., resig
nation accepted November
4, 1937.
Frank
C.
Hodges,
P.
O.
Box
1469,
Abilene
State
Hospital,
Abilene,
Tex.,
lieutenant, junior grade, MC-V
(G),
U. S. N. R., resignation accepted November
4, 1937.
Gilbert H. Mankin, 1726 Eye Street NW., Washington,
D. C., lieutenant
com
mander, MC-V (G), U. S. N. R., resignation accepted October
28, 1937.
Earl A. Orwig,
2467 Hempstead
Avenue, Toledo,
Ohio, lieutenant
commander,
MC-F, U. S. N. R., resignation
accepted December
14, 1937.
Samuel
B.
Potter,
Republic
Building,
Denver,
Colo., lieutenant,
junior grade,
MC-V (S), U. S. N. R., resignation
accepted November
2, 1937.
John Hollum Rathbone,
121 East Sixtieth
Street, New York City, N. Y., lieu
tenant, MC-V (S), U. S. N. R., resignation
accepted November
4, 1937.
Sydney K. Smith,
230 Grand
Avenue,
Oakland,
Calif.,
lieutenant
commander,
MC-V (S), U. S. N. R., resignation
accepted November
2, 1937.
261
262
NAVAL
RESERVE
Frank
W.
Smythe,
899
Madison
Avenue,
Memphis,
Tenn.,
lieutenant
com
mander, MC-V
(S), U. S. N. R., resignation accepted December 2, 1937.
Carl G.
Swendseen,
603
Syndicate
Building,
Minneapolis,
Minn., lieutenant
commander, MC-V (G), U. S. N. R., resignation accepted November
19, 1937.
Charles C. Thomas,
257 Park Avenue, Rochester, N. Y., lieutenant, MC-V (G),
U. S. N. R., resignation
accepted December
2, 1937.
HONORARY RETIRED LIST, FOURTH QUARTER,
1937
George P.
Lingenfelter,
1616 Tremont Place,
Denver,
Colo.,
lieutenant
com
mander, MC-V (G),
U. S. N. R., honorary
retired list December
1, 1937.
William A. Dalton, 243 West Seventieth
Street, New York City, N. Y., lieu
tenant commander, MC-V (S), U. S. N. R., honorary retired list December
1, 1937.
DEATHS,
FOURTH
QUARTER,
1937
Andrew J. Minaker, 200 Granville
Way,
San Francisco,
Calif., lieutenant
com
mander, MC-V (G),
U. S. N. R., died November
22,
1937.
Charles V. Townsend,
101 Dauphin Street, Mobile,
Ala., lieutenant, MC-V (S)
U. S. N. R., died October
28,
1937.
NOTES AND COMMENTS
PRESLEY MARION
EIXEY
By Commander
Louis n. Roddis, Medical Corps, United States Navy
The
thirteenth
Surgeon
General, United
States
Navy,
and
the
seventeenth
Chief of the Bureau of Medicine and Surgery, was really
the father of the modern
Medical Corps of the Navy.
He served as
Surgeon General
from
1902 until
1910,
through most of the period
during
which Theodore Roosevelt
was
President.
A recent
naval
historian put their relationship and the result of their work as respects
the Navy, in the following significant sentences: "Roosevelt was for a
great Navy, Rixey was for a fine Medical Department; they were both
successful."
Some of the important advances which were made during his term
of office included the renovation and modernization of all the naval
hospitals,
the
construction
of
new
ones
at
Puget
Sound
(1903),
Canacao, P. I. (1903), Las Animas, Colo., for tuberculosis
cases (1906),
the Naval Hospital, Great Lakes, 11l. (1907), and the Naval Hospital,
Guam
(1910).
He
also
established
the
medical
supply
depots
at
Brooklyn,
San Francisco, and Cavite, P. I., an extremely
farsighted
provision which during the World
War proved of tremendous
value
and would again
be of inestimable benefit during a time of national
emergency.
No Surgeon
General
has been more awake to the needs of the Medi
cal
Corps
and
the
Medical
Department.
Under
his
regime
the
strength of the Corps was doubled and he brought to it specialization
and postgraduate
training.
One of his first acts was to establish
the
Naval Medical School
where new medical
officers could
receive post
graduate instruction in services pertaining particularly
to naval medi
cine.
This school
is today the only center of naval medicine
in the
Western Hemisphere,
and its library the only important repository of
naval
and maritime medicine
in the New World.
He sent medical
officers
abroad
to study tropical medicine,
a particular
need of the
Navy and of the greatest
value
in the administration
of our then
newly
acquired
tropical
possessions.
He instituted
the
practice
of
sending
medical
officers
to important civilian medical institutions for
postgraduate
training in the leading professional
specialties
such
as
surgery, internal medicine;
eye, ear, nose, and throat; psychiatry, and
the
medical
sciences.
In
addition
to
their
special
training
they
brought back to the Navy the latest advances in their profession
and
263
264
NOTES
AND
COMMENTS
new
viewpoints in
the
prevention
and
treatment
of
disease.
He
established
the female Nurse Corps in
1908,
these nurses
being
em
ployed at our naval hospitals,
on the hospital ships, and at the nurses
training schools for native nurses in our island possessions,
as well as in
the Hospital
Corps training
schools.
He attempted repeatedly
to
establish
a Dental Corps, and, although this was not done until
1912,
his efforts had much to do with its early authorization after his term
of
office
had
ended.
Under
his
regime
the
United
States
Naval
Medical Bulletin
was founded
(1907).
This is a journal
devoted
to
naval medicine,
and, again, is the only important one in the Western
Hemisphere.
The bound volumes of this journal, which has now been
published
for nearly
a third
of a century, constitute
an important
archives of naval medicine.
Dr. Rixey's great energy and ability dur
ing a long, active,
and useful life were devoted
to the improvement of
the Navy and the making of its medical
service something
of which
the Navy could
be proud.
Dr. Rixey was the personal
physician of two Presidents.
He was
the White House physician when President McKinley was struck down
by an assassin's
bullet.
He took entire
charge
of the
care of Mr.
McKinley, was present at the operation,
and gave untiring professional
attention to his distinguished patient.
His report of this case consti
tutes an important medical historical record.
He was also the personal
physician of President Theodore Roosevelt as well
as his trusted
and
intimate friend.
Admiral Rixey was born at Culpeper, Va., July 14,
1852,
and died
June
17,
1928.
He was commissioned
an Assistant
Surgeon
in the
Medical Corps of the Navy on January
28, 1874, his commission
being
signed by General Grant.
He served through
all the grades, and was
appointed
to the office of Surgeon General on February
5, 1902.
His
term
as Surgeon General of the Navy ended February
4,
1910.
In
conclusion
we may
quote
the
emphatic
message
of Admiral
Dewey addressed
to Surgeon
General
Rixey.
"He (Admiral Dewey)
especially
requested
us to inform you that you are not only the best
Surgeon
General
the Navy has ever had, but you have done more for
the Medical Department and its development
than all of them.
He
was very emphatic
in his praise of you and
the most excellent
work
accomplished
by you as Surgeon
General
of the Navy.
It is practi
cally impossible for us to convey his message to you in the same forcible
manner in which he expressed himself to us."
INTERNATIONAL
CONGRESS
ON MILITARY
MEDICINE
AND PHARMACY'
The Bureau of Medicine
and Surgery is in receipt
of
a report on
the Ninth International
Congress on Military Medicine and Pharmacy
held in Bucharest, Rumania, June 1937.
The objective and function
' Compiled
and presented by
Capt.
William Seaman Bainbridge,
M. C.-F.,
U. 8. Naval Reserve
(re
tired).
United States delegate to the Congress and member of the permanent
committee.
NOTES
AND
COMMENTS
265
of this organization are tersely stated by Captain Bainbridge as: "So
that the lessons of the past war are not lost, and to make them avail
able for any future hostilities, and during peace when virtually
every
type of wartime injury
and disease is ever present,
the International
Congress
of Military Medicine
and Pharmacy
was created in
1921.
There
have
been
meetings
of the
Congress
every
other year since
then.
Its far-reaching importance and eminent
value are unchallenged
in the minds of those who have come in contact with the work of the
organization.
Delegates,
rich in experience,
come from many coun
tries to present
their viewpoints.
Such
an interchange
of ideas and
knowledge will eventually lead to the physical betterment
of mankind."
The
permanent
committee
of the
Congress
contributes very ma
terially to the success of its meetings and functions as its agent during
the interval between sessions.
It organizes
the Congresses,
publishes
the
Int€rnational
Bulletin
of Military
Medicine,
develops
relation
ships with
interested
organizations,
has
organized
a Medico-Legal
Commission, and has under its International Office of Medico-Military
Documentation
the
duties
of sending
speakers
abroad,
replying
to
international
inquiries, arranging conference
sessions, and keeping
a
bibliographic index
up to date.
The Congress
received official reports from delegates of the nations
represented.
The
following
comment
presents
a very
inadequate
summary of the material presented in these reports.
Organization
and
Functioning
of
the
Medical
Service
in
Combined
Military
and Naval Operations
This report was submitted by Capt.
William
L. Mann,
Medical
Corps, United States Navy
and Lt. Col. Edgar Erskine Hume, Med
ical
Corps, United
States
Army,
of
the United
States
of America
delegation.
It deals with regulating the relationship between medical
units of land forces and sea forces when they function with a common
objective.
Cooperation and coordination are the prime requisites
for
success,
and
to
secure
these conditions
each
medical
service
must
consider the general
and special situation and effect complete
under
standing.
Mere cooperation
is not enough.
The following principles
should govern
combined
operations
:
1.
There must be unity of medical control.
2. The maintenance
of proper
liaison
rests with
the
medical
service
not in
actual control.
3.
The senior
medical
officer
(administrative)
of each
medical
service
is
as
signed the responsibility
of initiating and preparing
medical
plans and arrange
ments for submission to superior authority for approval.
4.
Medical
organizations
with
their
equipment
should
be
maintained
and
transported
intact,
insofar as practicable.
5.
Measures for prompt relief of human suffering can be rendered more effective
by the standardization
of material,
thus providing
mutual logistic support.
266
NOTES
AND
COMMENTS
6. Common
indoctrination
of
the
medical
services
in
medical
procedures,
arrangements,
and practices.
7. For borderline
situations
supreme medical control should
be prearranged.
Standardization
of supplies
and
equipment
is essential
to permit
interchange
between
land and
sea
forces
at points of embarkation
and debarkation.
Supplies should be loaded in reverse order to that
in which they will be required,
so that the last material loaded will
be the first available for use.
Quarters at ports for troops in transit
should conform as nearly as possible with accepted sanitary standards.
On troop transports, all medical
organizations and troop functions
should be under control of the Navy.
Bed accommodations
of the
sick bay should
be computed
on the basis of 2 percent
of the total
number of crew and troops
carried,
with an additional
1 percent for
isolation facilities.
While
the vessels are en route, if not before,
the
senior medical
officers of the transport and of the troop contingents
should
be made fully
acquainted
with all the details
of the plan to
be followed
upon
arrival
at the destination.
Among other matters
to be considered
by these medical
officers and approved
by the staffs
of the respective
services prior to arrival at anchorage,
are :
1. The patient capacity
of each ship.
2. The types of cases each ship is to receive and retain temporarily
during
the
early
stages
of the campaign.
3. The adequacy of the medical supplies aboard ship for the patient load to be
accommodated.
4. The kinds and quantities
of additional
supplies that may
be needed.
5. How and when such supplies are to be sent aboard at anchorage.
6. The sufficiency
of the naval
medical
personnel aboard, including
those
to
remain afloat during the period of the landing
operation.
7. The number and kind of replacements that may
be needed
in order to care
for patients to be allotted
to the ship.
The
medical
units
attached
to each combatant organization will
debark with
such organization.
The
medical
regiment
will not
be
landed
until the force is fairly well established
ashore.
Shore hospi
tals should not be established
until warranted by conditions ashore.
The first medical
supplies
sent ashore should
be only those necessary
under existing conditions for the personnel
there.
Each unit debark
ing should leave behind
a representative
whose sole duty it would be
to check, from a specially prepared
list, all the property of the unit
as it goes ashore.
The casualties
should
be collected
at points at the beach head that
will not
interfere
with
disembarking
troops.
One
of
the
general
principles of evacuation
is to keep casualties
separated from the com
bat troops.
For purposes
of morale particular care should
be taken
to prevent the contact of troops with the unsightly wounded.
While
waiting evacuation
every effort should
be made to shelter
the casual
ties from gunfire to prevent shock.
Ambulant
casualties
are apt to
NOTES
AND
COMMENTS
267
cause
considerable
difficulty
and
confusion
unless
they
are closely
controlled.
The
land
force's
administrative
responsibilities
cease
when it has collected
and assembled the casualties
on the beach ready
for loading.
Army medical
personnel
should,
however,
assist in the
actual loading under the direction of the Navy.
A naval medical
officer should be attached
to the staff of each beach master
as medical
embarkation officer.
He will decide on the time and mode of evacua
tion by boats to the ship.
A naval medical
officer should be similarly
assigned
with
the
senior
army
medical
officer
to
assist
in proper
liaison.
The prompt evacuation of casualties from the beach is often
a military
as well
as
a humanitarian
necessity.
Slight
and
serious
cases should not be placed in the same boat.
The sick and wounded of troops while being transported on a naval
vessel are subject to Navy regulations and their treatment should
be
supervised
under the direction of the medical
officer of the transport.
Prior to debarkation all troops
should
be inspected
for vermin
and
communicable disease and those affected should
be segregated, nota
tion made in their health records,
and reported
to the proper author
ity at the port of debarkation.
Disposition of the sick and wounded
on arrival at the port of debarkation is in accordance
with the orders
of the Commanding General
of the port.
Coordination
of the medical
service of the air forces with that of
land
and
sea forces
presents
some problems
unsolved
by actual
ex
perience.
The same principles as discussed above should govern their
solution.
Increased
use
of
aircraft
for
ambulance
duty
may
be
anticipated.
When used for this purpose
they should
be manned by
noncombatant personnel
and the plane should otherwise conform with
Geneva Convention provisions.
Space
permits only
a brief review of the other excellent
official
reports presented at this Congress.
Transportation,
Hospitalization,
and
Treatment
op the
Gas Wounded
The question of the transportation, hospitalization, and treatment
of
those who
have
been gassed is dominated
by the condition
and
character of the
lesions.
Their transportation
involves no
special
problem.
It is possible
to assure treatment and hospitalization
either
in a
medical formation for the gassed, provided with surgical
service,
or,
in
the surgical
service,
provided with
a section
for the gassed.
As
the
surgical
technic
requires
a
great
specialization with
adequate
equipment and supplies, it would seem
that the second is the better
solution.
If circumstances
point to the possibility of a large number
of gas wounded,
the
creation
of specialized
medical
formations for
them
should
be faced.
The
treatment
of toxic
poisoning
of gassed
individuals
belongs properly to the Medical
Service,
whether it is a
question of prophylactic measures or other
treatment.
268
NOTES
AND COMMENTS
Organization
and Functioning of the Surgical Service
in Motorized
Troops
With swift moving motorized
units,
often isolated
and accomplish
ing difficult
duties
independently, it is necessary
that the attached
medico-surgical
formations follow at the
same speed,
and
be com
pletely equipped
and abundantly provided with supplies,
in order to
conserve
their independence.
Cases of urgency
will be treated,
but
in unfavorable tactical situations, the principal activity will consist
of rapid mass evacuations
to some suitable
medical
formation.
It is
especially
important that the chiefs of motorized medical
formations
should have, besides their necessary technical
qualifications, adequate
military
knowledge
to enable
them
to adapt themselves
rapidly
and
without error to the changing
conditions of battle.
The Use of Colorimetric
Methods
of Analysis
Colorimetric
methods
offer the advantage
of often
permitting
the
analysis
of minimal quantities of substances,
impossible
to accomplish
by ordinary
methods,
as is the
case in toxicological,
biological
and
even industrial
analyses.
In order
to obviate the inconveniences
of
colorimetry,
the volumo-colorimetric
method
or that of the photo
electric
cell may
be adapted,
according
to the necessities of the
case
involved.
Edentates
in the Armies — Definition —Treatment —Prosthesis;
Military
Employment in Times
of Peace
and War
From the military point of view,
an edentate
is a man whose func
tional lack of denture
is liable to react on his state of general health
and diminish his fitness for service.
Partial or total loss of the teeth
is not
a cause for exemption
from military
service, if it can be effec
tively
compensated
for by
prosthesis,
disregarding
all questions
of
esthetics.
The
preferable
treatment,
indispensable
from
the func
tional point of view, is the installation of adequate
prosthetic equip
ment, after having put the buccal cavity in good condition by remov
ing septic
foci of infection.
The artificial denture
ought to be made
and repaired
within the army zone.
A Comparative Study of the Supply of Food Stuffs and the Alimentation
of the
Sick
and
Wounded in Times
of Peace
and War
It is impossible
to standardize
rations, but it is very desirable
to
list and classify
them.
Conditions vary with the economic
resources
of each country and, above all, with national habits.
The alimenta
tion of the
sick
and
wounded
ought to
benefit
by
the
progress
of
science and
the research
in alimentary physiology by giving an im
portant place
to protective foods.
The preparation and serving of
food should
be by especially
trained
personnel provided with modern
equipment
for conserving
and preparing food stuffs.
NOTES
AND COMMENTS
269
Tenth Congress
Meets
Here in
1939
The International
Congress
of Military
Medicine
and
Pharmacy
accepted
the
cordial invitation
of
the
Government
of
the
United
States of America
to hold the Tenth
Congress
here in
1939.
The
following
subjects
by title and nation
have
been selected for study
and presentation
at the Tenth
Congress:
1.
Organization
and Functioning
of the Medical
Service in Colonial
Expedi
tions.
(Official
reporters:
Italy —United
States of America.)
2.
Forecast
of War Casualties
and
Methods
of
Computation.
(Official
re
porters:
Germany —United
States of America.)
3. Practical Procedures in Anesthesia and Analgesia in War Surgery.
(Official
reporters:
Brazil—United States of America.)
4.
Organization
and
Functioning
of
the
Military
Cheniico-Pharmaceutical
Service.
(Official reporters:
Argentine —Czechoslovakia.)
5.
Urgency
Treatment
and Basic Apparatus
for Maxillary Fractures
in
War.
(Official
reporters:
France —United States of America.;
6.
Technical
Specialization
of Administrative
Officers in the Medical
Service.
(Official
reporters:
Mexico — United
States of America.)
CLASSIFIED
MATTER
Members of the Medical
Department
in the performance
of their
official duty and through their service contacts
have frequent occasion
to acquire information of a classified nature.
It
is,
therefore,
essential
that personnel
of this department
be familiar with the nature of and
the regulations governing
the custody of classified
matter.
Careless
disregard of these safeguards
permits
the ever present possibility of
compromising the Naval Service.
Classified
matter
is
a
generic
term
used in
the Naval
Service
to
compromise
matter of
a
secret, confidential, or restricted
nature.
Secret
matter
is
matter of such
a
nature that its disclosure
might
endanger
the national security, or cause serious injury
to the interests
or prestige of the nation or any government
activity
thereof.
Infor
mation as to the existence, nature, or whereabouts
of secret matter shall,
except
as specifically
authorized by the Chief of Naval Operations, be
disclosed
only
to persons
in the Government
service
whose
official
duties require
such knowledge
and to persons not in the Government
service
under
conditions of absolute
necessity.
It
is
exclusively
for
the official use of the persons to whom
it
is
divulged and its distribution
or dissemination
must be confined
to the absolute minimum.
Confidential
matter
is
matter of such
a
nature that its disclosure,
while not endangering
the national security, would be prejudicial
to
the
interests
or prestige
of
the nation or any government
activity
thereof.
Confidential
matter
may
be
disclosed
to
persons
in
the
Government service who must be informed, and to other persons when,
under special
circumstances,
such
disclosure
is
to the interest of the
Navy.
45202—38
8
270
NOTES AND
COMMENTS
Restricted
matter
is matter of such
a nature that its
disclosure
should
be limited for reasons of administrative privacy; or, is matter
not classified
as confidential because the benefits
to
be gained
by a
lower
classification
outweigh
the
value
of
the
additional
security
obtainable from the higher
classification.
Restricted matter may be
disclosed
to persons
of discretion in the Government service
and
to
persons not in the Government service
under
special
circumstances
when it appears to be in the public interest.
The responsibility for maintaining the proper security of classified
matter rests upon each person having custody or knowledge
thereof,
no matter how obtained.
Any person having knowledge
or suspicion
that secret or confidential matter has been compromised
or come to
the knowledge of unauthorized persons is required
to make a full report
of the facts
to the Chief of Naval
Operations via his commanding
officer.
In
case
restricted
matter
is
compromised
report shall
be
made to the administrative head charged with custody of the subject
matter who
shall
take
appropriate
action.
Classified
matter shall
not
be discussed
in the presence of persons not authorized to have
knowledge
thereof.
An officer, by virtue of his commission
alone,
is
not authorized to have
knowledge
of secret or confidential matter.
Persons
within
the Naval
Service
who
receive matter originated by
another government
agency and designated
by that agency
as having
any degree of confidentiality shall safeguard
such matter in the same
manner
as if it had been so designated by naval authority.
NEW
MEMBERS,
AMERICAN
COLLEGE
OF SURGEONS
The Bureau of Medicine
and Surgery has been informed that
the
following naval medical
officers have been elected to Fellowship in the
American College of Surgeons.
Comdr. Jack S. Terry (M. C), U. S. N.; Lt. Walter
F. James
(M. C), U.
S.
N.; Lt.
Charles
R.
Wilcox
(M. C), U.
8. N.;
Lt. William
S.
Cann
(M. C),
U. S. N.; Lt. Warran
G. Wieand (M. C), U. S. N.; Lt. Charles R. Moon (M. C),
U. S. N.
HOSPITALIZATION
OF DEPENDENTS
Bureau of Navigation Naval Reserve Bulletin No. 82 of January 15,
1938 states:
The Secretary
of the Navy
has
approved
an opinion
of the Judge Advocate
General that dependents of Naval Reserve and Marine Corps
Reserve personnel
on active duty may lawfully be hospitalized
in certain designated naval hospitals
under the same
restrictions
and conditions
in all respects as now apply
to the
authorized
hospitalization
of dependents of naval personnel on the active list.
The Chief of the Bureau of Medicine
and Surgery will issue appropriate instruc
tions to the several naval hospitals which have been authorized
to hospitalize
the
dependents of naval personnel.
BOOK NOTICES
Publishers
submitting
books
for review are requested
to
address
them as follows:
The Editor,
United States
Naval
Medical Bulletin,
Bureau
of Medicine
and Surgery,
Navy Department,
Washington,
D. C.
(For review)
Clinical Allergy,
by Louis Tuft, M. D., Chief of Clinic of Allergy and Applied
Immunology,
Temple
University
Hospital;
Associate in
Immunology,
Temple
University
School of Medicine;
Director
of Laboratories,
Pennsylvania
Depart
ment
of Health,
Philadelphia,
First
edition.
711
pages,
illustrated.
W.
B.
Saunders Company,
Philadelphia,
1937.
Price
$8.
The author has written an excellent
text on a very interesting, con
fusing, and important subject.
Having reduced the perplexing
terms,
and what is known about the various phenomena
in connection
with
allergy!
to simple understandable
and workable language,
he has pre
pared
a book which is easy to read as well as easy to understand.
The section on "General principles" is especially well done and would
repay any one interested in the subject for the time spent in the study
of this section.
The various theories of the mechanism
of hypersensi-
tiveness
have
been
gathered
together
and
arranged
in
an orderly
manner.
Introduction to Dermatology,
by Richard L. Sutton & Richard
L. Sutton, Jr.;
Kansas
City, Mo.; Second edition,
566 pages.
190 illustrations.
C. V. Mosby
Company,
St. Louis,
Mo.
1937.
Price
$5.
In the preface
to the first edition the author states: "This book is
intended primarily
for students.
We have
endeavored
to combine
judiciously
the old and the new, retaining the original lattice work of
the fundamental
facts which contribute so much to the value of the
parent, and omitting
much descriptive and statistical matter which
is of interest to only the research worker and
the specialist."
This
was admirably done.
In the preface of this edition the changes, such
as reclassification,
additions of new diseases and illustrations with the
up-to-date methods of treatment
are pointed
out.
The first seven chapters are devoted to anatomy, embryology,
phys
iology,
general
etiology,
general
symptomatology
and
pathology,
271
272
BOOK NOTICES
general diagnosis and treatment.
Chapter VIII covers the new classi
fication.
Sixteen
classes are given.
The rest of the book,
chapters
IX to XXIV, is devoted
to a discussion
of the various diseases coming
under each of the
16 classes.
The illustrations are clear and the dis
cussions
on
etiology,
symptomatology, diagnosis,
and
treatment
are
to
the point.
It is an excellent
book
for the student and
general
practitioner.
Approved Laboratory Technic Clinical Pathological,
Bacteriological,
Mycologi-
cal,
Parasitological,
Serological,
Biochemical
and
Histological
by
John
A.
Kolmer, M. D., Dr. P. H., LL. D., L. H. D., F. A. C. P.; Professor of Medicine,
Temple University and Fred Boerner, V. M. D.; Assistant Professor of Bacteriology,
School of Medicine and Graduate School of Medicine,
University of Pennsylvania.
Second edition;
893 pages,
12 plates and 380 illustrations.
D. Appleton-Century
Company,
New York and London.
1938.
Price
$7.50.
The aim of the first edition was to promote
the practice
of scientific
medicine
by a wider application of clinical laboratory methods
to the
diagnosis
of disease and
to
encourage
a closer
cooperation
between
the practitioner
and
the clinical pathologist
by
the presentation
of
approved
methods
covering
the field of clinical pathology.
That it
attained
this
objective has
been amply demonstrated
by
the wide
acceptance
and the high regard
this excellent
text has held.
The second edition represents
a complete
revision
of all chapters
in which the many new methods which have been developed and which
have proved their value in the past 7 years have been included.
Many
new figures and illustrations have been added.
In the first edition the technic of the methods
given were approved
by
committees
selected from members
of
the American Society of
Clinical
Pathologists.
In
this edition they
have
been approved
by
members of a group
of 28 collaborators as well
as, in many
instances,
by the authors of the methods
themselves.
Approved Laboratory Technic
is,
in its second edition, again
a
book
no
well
equipped
clinical
pathological laboratory
will
want
to
be
without.
Diseases of the Blood
and Atlas
op Hematolooy,
by Roy R. Kracke, M. D.,
Professor
of
Bacteriology,
Pathology, and Laboratory
Diagnosis
and by
Horlense
Elton
Garver,
M.
S.,
Instruclor
in Laboratory
Diagnosis,
both
of
Emory
Uni
versity
School
of
Medicine,
First edition,
532 pages,
illustrated.
J. B. Lippen-
cott Co., Philadelphia,
1937.
Price $15.
The section of the book dealing with the diseases manifested
in the
blood
is
an excellent summation of the current opinion as to etiology,
haematological
findings,
and treatment.
The style in which
it
is
written makes
it
very readable.
The book
contains
a
section
on
technique
which
gives
workable
tests covering
the entire practical field of haematology.
The chapter
giving the normal
blood
pictures
of the common
laboratory animals
will be found
useful.
BOOK
NOTICES
273
In short, the Atlas completely
covers the morphology of blood cells.
In the matter of illustration, however, it must be noted that the nuclear
details are somewhat
schematic
and
the
colors
are not quite
true
reflections of the usual Wright's strain.
It is to be regretted
that so excellent
a text should not have
a bind
ing of corresponding
quality.
Atlas of Hematology,
by Edwin E. Osgood,
M. A., M. D., Assistant
Professor
of Medicine
and Head of Experimental
Medicine
and by Clarice M.
Ashworth,
Medical
Illustrator,
both of the
University
of Oregon,
First edition,
225 pages,
illustrated.
J. W. Stacey, Inc., San Francisco,
1937.
Price $15.
Upon
examination of this book one is immediately favorably im
pressed
by the
excellent
quality
of its binding
and
paper.
As
the
title states, it is truly an Atlas of Hematology, profusely illustrated with
colored
plates.
True shades of colors are extremely
difficult to repro
duce,
and,
as a whole,
the plates in this volume
are the best that we
have seen to date.
While there was no intention upon the part of the authors
to make
the
book
a text of hematology,
it nevertheless
contains numerous
useful
differential diagnostic tables,
excellent
descriptions of most
of
the blood dyscrasias,
and a section on hematological
technique.
It is
well indexed,
and the same identification numbers
of the cells on the
colored
plates are used in the descriptive matter throughout the book.
Unfortunately
several new names for cells have been introduced by
the authors in place of the ones in common
use, thus tending to further
confuse
an already
overburdened
nomenclature.
However this does
not detract from the value of the Atlas.
Any laboratory
worker dealing
with hematological problems
will
find this book invaluable, particularly
in the identification of blood
cells,
although, contrary
to
the author's system
for cell identifica
tion, no degree of experience will permit one to claim that he is capable
of designating
the type to which every immature cell belongs.
A comprehensive
list of references is given.
The Cerebrospinal Fluid, By H. Houston
Merritt,
M.
D., Assistant
Professor
of
Neurology,
Harvard
Medical
School;
Director
of
the
Cerebrospinal
Fluid
Laboratory,
Boston City
Hospital;
and Frank Fremont-Smith,
M.
D., formerly
Assistant Professor of Neuropathology, Harvard
Medical School; formerly Director
of the Cerebrospinal Fluid Laboratory,
Boston City
Hospital.
With
a foreword
by James
B. Ayer, M. D., Octavo of 333 pages,
illustrated.
W. B. Saunders,
Co.,
Philadelphia.
1937.
Cloth, Price
$5.
This new book is based on 21,000 spinal fluid examinations
done by
the authors, together
with
1,000
especially
selected fluids from Dr.
James B. Ayer's laboratory
at the Massachusetts General
Hospital.
The chapters
include anatomy, physiology, chemistry, and patho
logic physiology,
technic
of lumbar
and
cistern
puncture, routine
examination of the fluid, cerebrospinal
syndromes,
therapeutic
use of
274
BOOK
NOTICES
lumbar
puncture,
roentgenography
of
the
ventriculosubarachnoid
space, and methods of spinal fluid examination.
The chapter on spinal fluid syndromes
takes up
1 15 diseases and condi
tions.
This chapter alone is well worth the price of the book.
An
exceptionally fine bibliography is furnished.
Clinical Urinalysis
and its Interpretation,
by
Robert
A. Kilduffe,
A. M.,
M.
D., F. A.
S. C. P.; Director
of Laboratories,
Atlantic
City
Hospital.
428
pages
and 40 illustrations.
F. A. Davis Co.,
Philadelphia.
1937.
Price,
$4.
This
book,
by
a
master
clinical
pathologist,
covers
the
field
of
urine
examinations
for clinical
purposes
in
a
most
complete
and
satisfactory manner.
Practical
proven
methods
have
been selected
for each
test
or examination;
alternates
are given
where it would
seem advisable.
Technic in each case has been completely
detailed.
Interpretation
is briefly and clearly given.
Especially
valuable for
the physician or technician
in tllls field will be found the fact that
the inherent
fallacies
of methods
are pointed out and
the
possible
causes of false
and
misleading
results
given.
The book will be found a most valuable tool in the clinical urinal
ysis laboratory.
Embryology,
by Harvey Ernest Jordan, A. A/., Ph. D., Professor of Histology and
Embryology and by James
Ernest Kindred,
M. A., Ph. D., Associate Professor of
Histology
and Embryology,
both of the
University
of Virginia.
Third
edition,
613
pages,
Illustrated.
D.
Appleton-Century
Company,
Inc.,
New
York.
1937.
Price,
$7.
This
book is primarily
a student's
textbook of embryology, for
which purpose
the subject matter is excellently
presented
and well
arranged.
There
is included
a
most
useful
chapter of laboratory
exercises.
It is almost
needless to say that any physician at times
will find it necessary to refresh his memory
of embryology and, upon
such occasions, will find this book of value.
The chapters
dealing with teratology, the recapitulation theory, or
the
so-called
biogenetic
law,
and
eugenics
touch
so
lightly
upon
these subjects
that they
might well
have
been omitted.
The chapter on
sex
determination
and
that part of the
one on
teratology,
concerning
twinning,
are of general
interest.
The book contains
504 illustrations,
most of which are schematic.
The volume
is well bound
and printed.
Diseases of the Nose and Throat, by Sir St. Clair Thomson, M. D., F. R. C. P.,
Lond., F. R. C. S. Eng., L. L. D. (Hon.)
Winnipeg,
Medicine
diplomi
en Suisse
and V. E. Negus, M. S. Lond., F. R. C. S. Eng.;
fourth
edition revised; Buck
ram,
920
pages,
386 figures,
13 color and
16 radiographic
plates,
Index.
D.
Appleton-Century
Company,
Inc., New York.
1937.
Price,
$14.
This fourth edition (first in
1911)
by Thomson with the coopera
tion of Negus,
has modernized
what has been described
by Chevalier
Jackson as, "the greatest textbook on nose and throat ever published."
BOOK NOTICES
275
It expresses not only the experience of the authors in minute detail
but also gives the opinion ol world-wide authorities, as quoted or set
down in the footnotes
of nearly every
page.
This
and
a complete
bibliography
makes
the
book
an
excellent
reference.
Clarity
of
description
and
concise
presentation
provide a veritable storehouse
of knowledge
of diseases of the nose and throat in a very readable
form.
The contents
are divided into 15 parts,
namely:
Introduction,
dis
eases
of the nose, diseases of the accessory
sinuses
(paranasal
sinus
diseases),
tumors
of the nose and
accessory
sinuses,
diseases of the
nasopharynx,
diseases
of
the pharynx
and
tonsils,
diseases of
the
larynx, diseases of the trachea and bronchi, diseases of the oesophagus,
chronic infective diseases, acute specific fevers in the nose and throat,
the nose and throat in some general affections,
foreign
bodies, peoral
endoscopy,
some operations,
and
formulae.
Each of these
15 parts
has its subdivisions, the whole subject being related
in 61 chapters.
There is an excellent index of 56 pages.
In his preface to the third edition the author quoted
Samuel John
son's
Preface to his Dictionary
of the English
Language,
1775,
as
follows: "In this work, when it shall be found that much is omitted,
let it not be forgotten that much likewise is performed."
Again, in
his preface
to the fourth edition Sir St. Clair quotes
Bacon, "Were
it not better far for a man in a fair room to set up one great light,
than to go about with a rush light into every dark corner?"
In end
ing his preface
to this edition he concludes,
"My task has consisted
chiefly in trying
to
exercise
the right judgment which we all pray
for in all things,
no easy matter in medicine,
even after 55 years of
practice, of which
44
have
been entirely
devoted
to laryngology."
Any student after reading this book will
feel that
the author has
fulfilled his ideals
and "well done" can be applied
to the completion
of his task.
Practical
Methods in the Diagnosis and Treatment
of Venereal Diseases,
by David Lees, Third edition, edited and reviesd
by Robert
Lees, M. B., F. R. C. P.
(Edinbourgh)
. Cloth, 608
pages,
85 illustrations,
appendix
on pharmacopoeia,
index.
William Wood & Co., Baltimore,
Md.
1937.
Price
$5.
The subject of venereal
diseases, from a clinical point of view, is
well and
extensively
covered.
The
colored
plates
and illustrations
should be of value
to the medical
practitioner and student.
On page 220, the following statement
is made relative to the treat
ment
of syphilis:
"There
appears
to
be
little
essential
difference
between
'continuous'
treatment,
and
'intermittent'
treatment
in
which the drugs are given in a series of injections with a rest interval
between
courses."
This is not in agreement with the finding of the
cooperative clinical group of this country.
This group
found con
tinuous treatment to
be the
most
efficient
method.
On page
330,
276
BOOK NOTICES
the author gives
a good evaluation of the complement
fixation
test
in gonorrhea.
From the text following this evaluation, one is apt to
get the impression
of more importance being placed on the test than
is justified from the evaluation.
In the treatment of gonorrhea,
espe
cially its complications, emphasis
is placed
on
the
value
of vaccine
therapy.
This should be taken
as an opinion of the author and not
as an entirely accepted
fact.
The Treatment
of Gonorrhea
and its Complications
in Men and Women,
by William J. Robinson, M. D., Fourth edition enlarged.
331 pages.
Eugenics
Publishing
Co., Inc., New York, N. Y.
1933.
Price
$3.
The author states in the Preface: "The book is distinctly
a personal
book,
and
represents
how Dr. Robinson
treats
gonorrhea
and
its
complications and not how A., B., and C. treat them."
This thought
is carried
through the entire
text and this reviewer
is of the opinion
that exaggerated
emphasis of this thought detracts
from some of the
valuable information
contained
therein.
According
to
the title
the
book
was written for the general practitioner.
However, the unini
tiated in this specialty should
read the text critically
and
accept
the
author's
statements
cautiously.
For instance,
after giving
a good
description of making
a proper smear
and
staining with Loeffler's
solution of methylene
blue the following statement
is made:
"And if
the typical diplococci are present,
the patient presents
the ordinary
history
and symptomatology of gonorrhea,
the diagnosis
is settled,
and no further investigations are necessary."
THE DIVISION OF PREVENTIVE MEDICINE
Commander
O. S. Stephenson, Medical Corps, United States Navy, in charge
UNITED
STATES
NAVY SUBMARINE
SERVICE
'
By W. C. Harrison, New York Life Insurance
Company,
New York, N. Y.
It is to John P. Holland,
who launched
his first boat in 1875, that
credit is given
by the authorities for bringing the submarine
to its
present state of practical value.
The earlier diving boats of the Hol
land
type
had
a reserve
buoyancy of only about
6 percent,
which
meant that they practically ran awash in the surface position.
These
early level-keel
torpedo
boats
were designed wholly for under water
work and made shallow
dives by means of horizontal rudders.
Later
the submersible
type
was
developed.
This
was characterized
by
a
reserve
buoyancy of
30
to
40
percent
permitting
more
rapid
and
steeper
dives.
Such
distinctions are not applied in the present-day
submarines,
as these two
types have
been modified now by merging
into
one
type
the
level
keel
and
reserve
buoyancy
submerging
principles.
Holland
boat,
No.
9, known as the Holland built
and thoroughly
tested over a 2-year
period,
1898-1900, was the first submersible
com
bining
these
two
principles.
When
turned
over
to
the
Navy,
it
proved to be the first really practical submarine
and served as a model
for the early American
and British
submarines.
The boat was
53
feet in length,
11
feet wide
at midship, had
a single propeller and
usual stern diving rudders.
It was driven by gasoline motor on the
surface,
and batteries
when
below
water.
This boat utilized for the
first time
the principle of dividing
the ballast tanks
into compart
ments permitting better handling.
Surface cruising radius was
1 ,500
miles;
while
submerged,
about
40
miles.
As
no
periscopes
were
available the boat was brought to the surface
for observations.
It
had
no clinometers
to determine
the diving angle,
this
device
being
invented in the next
year,
however.
Another
device originating in
this boat was the compensating
tank, which filled immediately when a
torpedo
was discharged.
It is interesting to know that the building,
' Editors Note.— This article in original
form was not written
for the service.
It has been edited with
apology
to the author,
by eliminating
some historical
material
and items of less interest
to the Bulletin
read ore.
277
278
DIVISION
OF
PREVENTIVE
MEDICINE
operating, and testing
of these nine experimental
Holland
boats were
completed
with no serious accident,
and no loss of life.
In
preparation
for
the
first
fleet
of
submarines
for our
Navy,
another
experimental
boat
named
the
Fulton
was
constructed
by
Holland.
Based
on this craft
the first submarine
flotilla
was
con
structed in 1903, composed of seven submarines,
the Adder, Moccasin,
Porpoise,
Shark,
Grampus,
Pike
and
the
reconstructed
Plunger
(Holland
No.
7).
These
boats
incorporated
the first early
form of
periscope.
The
average
length
of
these
boats
was
65
feet,
with
submerged
displacement
of
120 tons.
In 1905
three more submarines
of 170 tons, known as the B class
were added.
The Octopus, first of the C class boats, was launched
in
1906
and
was considerably
larger
being
105 feet long
and
270
tons
displacement.
This craft was tested at 200 feet depth,
the first sub
marine
to withstand this pressure and also remained
under water for
24 hours with full crew aboard.
The B boats
and the Octopus com
prising the second flotilla of the Navy
were the last to use gasoline,
the Government requiring Deisel engines in later boats
to eliminate
danger from gasoline, and resulting in a doubling of the radius of action
because of the fact that with the heavier fuel the number of horsepower-
hours was twice that from a like quantity of gasoline.
The third flotilla
was comprised
of four boats of the C type
and
three
of the D class, accepted
in
1909.
This last class registered
a
further advance, being 340 tons submerged.
These boats accomplished
a submerged
run of 150 miles,
coming
to the surface
at night to re
charge.
One of these made the first open sea trip of 1,500 knots from
Boston to Bermuda and
back
under
its own
power.
From
1909
to
1912 six additional submarines
were acquired,
the two E boats Skip
jack
and
Sturgeon
and
the F-l
to F-4.
Great improvements had
been
made
and
although submarines
seldom
travel at a depth of
more than
100 feet, they are built to stand
200 feet of pressure with
a safety factor of two, yet the F-l made a cruise of 6 hours at a depth
of 283
feet.
In these last
boats
the displacement
had
increased
to
550 tons, the surface speed to
14 knots and the underwater maximum
to
10 knots.
These
submarines
were divided with bulkheads, had
4 torpedo
tubes and a 4-inch gun on the superstructure.
During
the next
few years
the G, H, and K series of submarines
were built.
These
were the submarines
used in the World War and
their
operations
extended
over both oceans.
They
were
sold,
dis
mantled, or otherwise
put out of commission
in 1922.
The
somewhat
larger boats
designated
as
the L series were
also
employed
during the World
War.
The R series came next
and in
cluded some 30 boats, a few of which were constructed in time to see
some service in the war.
This series has practically
been decommis
DIVISION
OF
PREVENTIVE
MEDICINE
279
sioned with the exception
of six which are now used at New London
for training purposes.
Between
1919 and
1922 some 50 boats of the
S series were built
and
added
to the
service.
They
average
1,000
tons displacement
and are powered by twin engines of approximately
1,000 horsepower
each.
The latest and largest
of the submarines,
the V type
such
as the
Cachalot,
Narwhal,
etc., are from 260
to 370 feet long and with dis
placement of 1,700
tons
to 4,000 tons.
The power
plant comprises
four Diesel engines installed in each boat totaling some 8,000 horse
power.
The Diesel engine has made possible
the development
of the
submarine and conversely
the necessity of building lightweight, high
speed Diesels for submarines
has been a great factor in bringing this
type of engine
to its present
compactness
and reliability.
The old
marine standard of some
200
revolutions
per minute has
been in
creased
by the Diesel engine in submarines
to
600
revolutions
per
minute.
To summarize,
we find the Navy now (as of July
1, 1936)
possesses
87 submarines.
Six are of the fleet cruiser type.
These are the largest
submarines
in our Navy and average 350 feet in length with 2,700 aver
age tons
displacement.
This tonnage
represents
the total displace
ment when
submerged.
They mount two 6-inch guns and have
six
torpedo tubes.
These
boats
are expected
to accompany
the battle
fleet.
They
must,
therefore,
possess seaworthy qualities of a fairly
high order, have good habitability,
excellent surface speed, and a large
radius of action, though fuel supplies
could be obtained
from the sur
face vessels, preferably from auxiliaries.
Included in this group is the
mine-laying
submarine
Argonaut, which together
with its guns
and
torpedoes,
also carries mines.
The next group in size is made up of cruising submarines
which run
from 800 to 1,600 tons.
They are large enough to remain at sea for a
month or two
and
operate
independently for long distances
from
bases.
These boats generally
carry 4 officers and a crew of from 35 to
50 men.
The smaller submarines,
30 in number,
average
600
tons, carry an
average
crew of 3 officers and
30 men, and are generally
assigned
to
coast
defense.
They
are designed
to operate
from
a base which is
near at hand so that the cruising radius and habitability
can be sac
rificed without loss of efficiency.
There are no quarters
for officers or
crew, all possible
space being devoted
to machinery and torpedoes.
As an indication
of the rapid growth of submarining from
1900,
when only
a few
experimental
craft were in existence,
to
1914,
the
280
DIVISION
OF
PREVENTIVE
MEDICINE
first war year, and with further comparison
to July 1936 the following
figures for the various navies are illuminating:
War submarines July
1914
Lost dur
ing war
As Of July 1936
Built
Building
Built
Building
United
States
44
31
0
87
12
78
22
54
60
16
64
22
14
80
«
13
2
0
59
8
Russia
30
19
20
50
20
Italy...
-
19
8
8
72
12
Germany
27
18
203
22
14
From
1900
to the opening
year of the World War (1917, United
States;
1914,
other
powers)
the following
submarine
disasters
have
occurred
where
lives were
lost or injuries
sustained.
(Figures
in
parentheses
are injuries.)
Submarine
Owned by-
Deaths
and in
juries
1904..
1904.
1905.
1905.
1905.
1906.
1909.
1909
1909.
1910
1910.
1911..
1912.
1912.
1912..
1913.
1914.
1915..
Fulton.
A-l....
....do..
Delphine.
A-5
A-8
Farfudct-.
Lutin
Foca
Kambola..
C-ll
No. 8
Pluvioso.
.
U-3
A-3
V'cndemaire.
n-2
K-5
A-7
F-4.
United
States.
British
....do
Russia.
.
British..
...do...
French...
....do...
Italian. ..
Russian.
British...
Japan
French...
German.
British
French
British
do
....do
United
States.
(4)
(i)
n
a
4(7)
14
14
13
13
20
II
14
38
3
14
24
15
3
11
Battery
gas explosion.
Gas oxplosion
due to motor.
Collision due to faulty
periscope.
First major
submarine
disaster.
Swamped
by swells from passing steamer enter
ing open hatch.
Gasoline
explosion
through
neglect
of closing
vents when filling
tank.
Sudden
dive and filling
through
open hatch.
Foundered
by water entering
open hatch.
Sank stern first.
Sprung
leak in hull.
Gas explosion,
sparking
in
Collision
with hattleship.
Collision
at night.
Sluice-valve
mechanism
broke.
Collision,
periscope not adequate.
Ventilator
left open; 27 men aboard,
all but
3
escaped through
torpedo tubes.
Collision.
Collision.
Run down while emerging.
Collision
at night.
Battery
explosion.
Exceeding
critical
speed
on
surface
caused
21
Battery
corrosion;
cblorine
explosion.
For over
15 years the submarine
forces of our Navy operated with
out
a serious
catastrophe
in great
contrast to
the records
of other
navies.
The
loss of the F-4 during underwater maneuvering
near
Honolulu
Harbor
was caused through
corrosion
of the lead lining of
the batteries
permitting the acid
to weaken rivets in the side of the
ship.
The sea water entered, evolving chlorine gas by reaction
with
battery acid, causing
an explosion
which admitted more water.
Rig
orous
inspection
and adequate
equipment
have
prevented
the recur
rence of this type of accident,
the only one of its kind recorded
over
a
36-year
period in our submarines.
DIVISION
OF
PREVENTIVE
MEDICINE
281
From
1919
through
1936
the following peacetime
submarine
acci
dents have occurred.
(Figures in parentheses injuries.)
Submarine
Owned by-
Deaths
and in
juries
Cause
K>5..
H-42.
0-5
L-24
Veniero.
S-51
M-l
H-29— -
S-4
-
F-14
Ondine
H-17
No. 9
Poseidon..
M-2
Promethee.
Porsee
L-28
Ariane...
Nautilus.
B-3
U-18
British.
do-
Japanese
United
States.
British
Italian
United States.
British
....do
United States.
Italian
French
British
Russian
British
....do..
French..
....do
British
French
United
States.
Russian.
Oerman
2(27)
2 09)
(12)
(11)
55
8
Lost on a dive.
Collision.
New boat lost during
undersea
maneuvering.
Collision.
Do.
Unknown.
Collision.
Do.
Misunderstood
order resulted
in incorrect
han
dling ol submarine
apparatus.
Collision.
Do.
Do.
Collision
with submarine
L-12.
Unknown.
Collision
with
Chinese
merchant
steamer
"Yuta" in China waters; 36 men were saved,
some by using the submarine
"lung."
Lost on dive —cause unknown.
Lost off Cherbourg
during
under-water
maneu
vers.
Explosion.
Explosion
and tire.
Explosion.
Crankshaft
explosion.
Collision
with warship.
Sank during
torpedo practice.
The submarines
generally
operate from four main bases: New Lon
don, Conn.;
Coco
Solo,
C. Z.; the Hawaiian
base
at Pearl Harbor,
and in Asiatic waters from Cavite, P. I.
There are, of course, other
naval
bases
both in this country and in Asiatic
waters from which
our
boats
may operate.
The policy
of
the
Navy
high
command,
however,
is to
use
these four
bases
as headquarters
for the several
submarine
divisions and squadrons.
The
base at New London
is used
as
a training school
and has
7
submarines
with
30 officers
and
195 men.
Other craft located
here
relating to submarine work are the U. S. S. Falcon and U. S. S. Sommes
which
are submarine
salvage
and
rescue
vessels whose
officers
and
men are engaged in diving and salvage work not strictly
submarine
duty.
There is also a mine depot and torpedo
school here, an activ
ity not necessarily
involving submarine
duty.
At the Coco
Solo base there are 6 submarines
with
a personnel
of
30
officers
and
240
men.
There are also rescue vessels and miscel
laneous craft for service to submarines.
The largest
fleet of submarines
is stationed
at Pearl Harbor in the
Hawaiian
Islands.
Thirty submarines
are stationed
here, the force
allotted being
76 officers
and some
1,500
men.
Most of the experi
mental work in submarine
rescue and efficiency is carried
on here due
to the favorable
factors of the comparative warmth and calmness of
the
adjacent
waters.
A complete
equipment
of
a large
dry dock,
282
DIVISION
OF
PREVENTIVE
MEDICINE
rescue
and
experimental
vessels,
diving
tank,
and
training
school,
make
this station one of the largest
and most
thoroughly equipped
submarine
bases in the world.
The Asiatic squadron
of
6 submarines
manned
by 25 officers
and
228 men work from the base at Cavite just outside Manila.
The above location of the submarine
personnel
brings
to our atten
tion the fact that
this duty requires
practically
all the men in the
service
to be stationed
for periods
in tropical ports.
This fact need
not be unduly stressed, however,
as most of the men are in the Hawai
ian Islands where, of course, no real tropical conditions apply.
Real
tropical conditions are prevalent at Coco Solo and Cavite where men
generally
stay for 2 years only.
Submarines
are either
single,
or
double
hulled.
In
general,
the
single-hull type submerges more quickly, the double hull is heavier and
costs much more.
The single type hull is now limited to the smallest
submarines,
the double
type to the largest, while the intermediate size
has a partial double hull.
In the single hull type of submarine,
the
ballast tanks
are
located
inside
the hull, whereas in the double-hull
type, the space between the two hulls is used for ballast tanks.
By t he
removal
of these ballast tanks from
inside,
the double hull type
has
increased
capacity for other purposes.
In addition, better
speed for
surface
propulsion
and
added
seaworthiness
are attained from
the
better shape of the outer hull.
On the earlier submarines
there were
no watertight subdivisions.
On the later types the hull is subdivided
to the maximum extent,
experience
having proved
the value
of the
feature in case of accident.
The superstructure
consists of a light structure built above the outer
hull.
Cable
holders,
boats,
and
other equipment
are
stored
here
because they would bring undue resistance when submerged
were they
not housed.
This superstructure
is also fitted with a deck including a
raised portion amidships which is used for a navigating bridge.
This is
reached from inside
the submarine
by a conning tower.
The super
structure is generally
"free flooding," that
is,
it
is
flooded
and vented
when submerged
through open holes along its
sides, the air escaping
through numerous
holes in the superstructure
deck.
The periscope,
or
eyes of the submarine,
projects
up through the
conning tower.
Before
1902, when the periscope was first introduced,
submarines
had
to come
to the surface
to do their navigating.
In
those days
the circular tower,
as
it
was called,
was fitted with glass
windows around its circumference.
Then came the periscope
consist
ing of
a
long tube with
a
window and
a
glass prism at the top and
a
similar arrangement
at the bottom.
Various lenses are fitted in the
tube to increase the strength of the image.
By rotating the periscope
the entire horizon can be scanned.
Today's submarines
carry two and
sometimes
three periscopes,
some of them
35 feet long.
The
use of
DIVISION
OF
PREVENTIVE
MEDICINE
283
aircraft in fighting submarines
has made it necessary to fit periscopes
with a prism which will give a vertical view as well as a horizontal one.
In order to submerge
the modern submarine
several tanks known as
"main ballast tanks" are completely
flooded.
Since these filled tanks
sink the vessel from
the surface
to under
water, their total volume
is
the reserve of buoyancy of the submarine
when on the surface, hence is
a measure
of her
seaworthiness.
To maintain
proper balance
and
buoyancy lost
through the consumption
of fuel oil, shells,
and tor
pedoes, auxiliary ballast or compensating
tanks are provided.
The
main
ballast tanks
are the most important
since their filling
destroys
all positive buoyancy.
There is a valve at the bottom for
entry or exit of water; a vent-valve at the top for the escape of air; a
pipe through
which the compressed air enters the tank and drives out
the water.
Some tanks also have drain pipes for emptying by pump
ing.
Modern
warfare
necessitates quick submersion
so these valves
have been increased until
1 or 2 minutes
is generally
sufficient
to put
the submarine
below the surface.
The
compressed
air for blowing tanks
and for torpedo
service
is
stored
in reservoirs,
or air bottles
at 2,500 pounds
per square inch.
The reservoir capacity varies, but is in the neighborhood
of 3 cubic feet
and
this
compressed
air is sufficient
to blow
the ballast tanks
three
times.
At least two motor-driven pumps,
capable of pumping against
any pressure,
up
to
the
pressure
at
the greatest
depth
the ship
is
designed
to navigate,
are also provided.
After the submarine
is submerged,
the batteries supply current to the
motors
for propulsion.
Their
batteries
are of the lead
pasted
type.
In small submarines,
two batteries
of 55 to 60 cells are installed and in
the larger,
two or three of 110 to 120 cells each.
For convenience
and
transfer,
the cell containers
have standardized dimensions.
When the
battery is being charged, hydrogen is evolved and to obviate explosions,
exhaust
fans discharge
this into the open.
All charging
is done either
at the base, or while running on the surface.
Safety Measures
and
Devices
Medical supervision. —Officers
and enlisted
men who
are candidates
for submarine
service
are given
a
careful
physical
examination,
as
detailed
in the Manual
of the Medical
Department, paying special
attention to the conditions which are cause for rejection.
The medical officer attached
to submarine activities makes periodical
inspections
and examinations
of the submarine
and its personnel,
and
he accompanies
the submarine
occasionally
to observe the function of
personnel
and materiel.
He checks on ventilation of the submarine
under:
(1) Surface
conditions.
The
adequacy
of air supply
to all
compartments
when cruising on the surface
with all hatches
closed,
except
the conning tower.
(2) Submerged
conditions.
Air purifica
tion apparatus.
Depending on the size of the boat and personnel,
air
284
DIVISION
OF
PREVENTIVE
MEDICINE
purification will be required
after a definite
period,
the upper limits of
C02 being set at 2 percent.
The hydrogen
detector
supplied
to each
submarine
is used under conditions of exceptionally long submergences
and during and after charging
the batteries.
About 4 percent hydro
gen in the air is considered
the critical point.
In view of the physical
requirements
and medical
care, there can be no doubt but that this
group is a select one and under
the most rigorous health supervision.
Submarine
escape appliance. —Safety devices on a modern submarine
are many and varied.
Safety devices come under
the cognizance
of
the Bureau of Construction
and Repair.
This Bureau and its publi
cations,
especially its manual and circular letters,
should
be consulted
for
the
latest
information
relative
to safety
regulations
and
appli
ances.
In. 1928
a special Navy board
was appointed to study these
safety
measures
and reviewed
in the neighborhood
of 5,000 sugges
tions.
The most valuable device in the opinion of the board
is the
Momsen
submarine
"lung."
This
is in effect
a miniature
diving
apparatus which, when worn, permits the wearer to rise safely from a
sunken submarine
without danger of suffocating or drowning.
Train
ing and
experiments
with this lung are carried
out at Washington,
D. C, Navy Yard in a vertical cylindrical diving tank,
10 feet
1 inch
in height and
9 feet
10 inches in diameter
with walls of 2-inch steel,
tested to a pressure of 400 pounds
per square inch.
When in use the
tank is filled with water to a height of 8 feet to allow an air pocket
above the water.
It is fitted with an airtight hatch on the upper end
which opens downward into the tank.
There are six 4.5-inch
ports
in the side for observation purposes.
The tank on the inside
is well
lighted
by
electric
lights
and
is
equipped
with
loudspeakers
and
telephone.
The men are exposed in the diving tank to air pressures
equal to various depths of sea water.
During the exposure time they
breathe
in the air pocket
and
exercise by swimming in the
water.
Prior
to
the
end of the
exposure
the
man
puts
on
the submarine
escape appliance,
charges it with oxygen or air, submerges completely
in the water and breathes into the appliance
for 2 minutes after which
ascent is simulated
at the rate of 50
feet per minute by reduction
of air pressure.
It should be borne in mind, however,
that experi
mental work is done only by the Experimental Division,
and that men
studying for submarine
assignment
at New London and Pearl Harbor
do no experimental
work with this apparatus.
All they are given is
enough
training to familiarize themselves
with this escape lung.
Training
tanks. —The diving tanks and training of submarine per
sonnel at New London and Pearl Harbor is described in the following
official report:
The training
tank is a structure about
130 feet in height and
18 feet in diameter.
It is filled with heated salt water.
Escape locks are located at points
18 and 50
feet from the top.
A cylinder
at the bottom of the tank represents a submarine
compartment
with standard door for entering and a standard
hatch for escaping.
DIVISION
OF
PREVENTIVE
MEDICINE
285
At the top a diving
bell is suspended by a wire cable.
The bell is operated by an
electric motor
so that it can
be raised or lowered in the water.
Its capacity
is
three men.
Normally t wo men and an instructor
go down in the bell to the desired
depth when the men are sent out to practice the escape.
The student
first
goes into the decompression
chamber and
is subjected
to a
pressure of 50 pounds.
Men
with sinus trouble,
chronic
ear
disease
are
usually
eliminated
at this
stage,
having
to come
out before the first atmosphere
or
14
pounds,
is reached.
Should
the man not
be able to stand
the pressure he is
eliminated
at this
stage.
After passing this test the student
is taken to the top
of the tank and learns to use the lung by practising
on the ladders, which extend
about
15 feet into the water from the top of the tank.
When he has done this to
the satisfaction
of the instructors,
he is taken down to a depth of 10 feet in the
diving bell and escapes
up a line to the surface.
After completing this, he is taken down in the bell to a depth of 18 or 20 feet or
into the 18-foot lock, and escapes
up a line to the surface, making
one stop on the
way up.
At the present time the applicant
for submarine
qualification
is only
required
to make two
18-foot escapes.
If the man wishes he may take further
training
at the 50-foot and
100-foot depth.
If so two 50-foot
escapes
are
next
made, either from the diving
bell or the 50-foot lock.
In coming up from this
depth he makes three stops, the first at 30 feet,
where he counts
10 breaths, at 20
feet, for
20 breaths,
at
10 feet for
30 breaths,
and then to the surface.
This
amount of decompression is not necessary at this depth, but it is given as practice
for the next step, which is 100 feet.
When ready for the 100-foot escape,
the man
goes into the 100-foot compartment
and escapes
up a line to the surface, making
the same stops as in coming up from 50 feet.
Since training with the submarine
escape apparatus
was instituted
there have been two fatalities directly or indirectly attributable to this
training.
One
case,
a
quartermaster,
first
class,
24
years
of
age,
occurred
while undergoing
instruction at Pearl Harbor in May
1930.
During
the morning the man made
two descents
to depths of 7 and
15
feet, respectively.
On the third
escape the diving bell was sub
merged
to 28 feet with pressure within of about 12.4
pounds.
The
length of time required
for the descent of the bell and in the inflation
of the lung by the man preparatory to emerging
was approximately
oli
minutes.
The other
fatality
occurred
on May
22,
1931,
at San
Diego, Calif.
In this case the deceased made an escape from
a depth
of 15 feet in 3 seconds.
After appearing
on the surface he closed the
shut-off
valve
and
reached
the ladder to ascend
the float,
but was
unable to grasp it.
On being rescued
he breathed
a few
times
and
expired.
It is the consensus of opinion among authorities that exposure
to
1 atmosphere
gage or 33 feet of sea water
does not involve any danger
of
caisson
disease
even
with
unlimited
exposure.
The
standard
diving
tables
do not prescribe
decompression
even for 42 feet if the
exposure
does not exceed
3 hours.
The above-mentioned
fatalities
cannot, therefore,
be ascribed
to caisson
disease.
Lt. Comdr. I. B.
Polak,
Medical
Corps, United
States
Navy,
discusses
the causes of
accidents which occurr in submarine
escape training as follows:
45202—38
S
286
DIVISION
OF
PREVENTIVE
MEDICINE
Etiology
(1)
The symptoms
and fatalities
resulting
during
lung training
are not due to
failure
of the right
ventricle
from inability to cope
with
high pulmonary
blood
pressure.
(2)
Increased
intrapulmonic
pressures causing
overdistcntion
of the
lungs, sufficient to rupture alveolar walls, are the factors concerned in the produc
tion
of air embolism.
(3) Air emboli
originating
in the pulmonary
circulation
are carried to the left side of the heart and then distributed
through the systemic
circulation.
This alone is the cause for the accidents that have occurred.
(4) Se
verity
of the symptoms
from air embolism
depend on the amount
of air in the
circulation
and the vital
areas involved.
(5) Position
of the body determines the
distribution
of these
emboli.
(6) Under experimental
conditions
in animals
and
under
natural
conditions
in man air embolism
can be prevented,
except under
extremely abnormal conditions
of pressure, by limiting the chest
distention.
Prevention
(1) All men being trained
in the use of the submarine
escape
apparatus
should
become
thoroughly
familiar
with
the
problem
of breathing
while
wearing
the
"lung"
under water prior to attempting
an escape.
(2) It should
be emphasized
that continuous
and rapid breathing must go on during the ascent.
(3) The men
should be completely familiar
with the method and purpose of venting the "lung"
through
the flutter valve.
Treatment
(1)
Absolute
rest
with
the body in modeiate
head-down
position.
Warmth.
(2)
Immediate
compression to at least 6 atmospheres gage.
(3) Artificial respira
tion.
If
necessary
oxygen
COJ
inhalation
may
be
used.
(4)
Intravenous
adrenalin
0.5 cubic centimeters physiological
saline.
Submarine
escape,
chambers. —All
submarines
are fitted with
two
escape chambers which are built in fore and aft and rise from the floor
of the ship to the outer casing, through which a hatch opens direct!}'
to the sea.
There are two escape lungs supplied each man on a sub
marine
one at each end of the boat.
The method
of escape from
a
sunken
submarine
as outlined by Lt. C. W. Shilling, Medical Corps,
United
States
Navy
is as follows:
(1) The "lungs"
are distributed
individually and tested
for working
condition.
(2)
The "hatch skirt"
is then placed in position
under the escape
hatch
so that
an air pocket may be maintained.
The newer type submarines
have the "hatch
skirt"
permanently
attached.
(3)
The hatch
is undogged
so that it will spring
open when the external
and internal
pressures become
equal.
(4) Flooding the
compartment
with sea water is now started and continued rapidly
until the inside
pressure equals the external
pressure at which
time the hatch opens and water
pours in and air escapes
until
the level of the water in the compartment
leaches
the lower edge of the "shirt,"
air above the water level in the compartment
thus
being trapped.
(5)
A buoy
carrying
a line is released and when it reaches the
surface the end of the line in the submarine
is secured.
(6) The "lung"
is now
charged with oxygen, the individual ducks under the edge of the "shirt"
and grasp
ing the line slides slowly up through the hatch to the surface.
It is evident that a hazard of caisson disease
is incurred
under this condition
of
continuous ascent.
A study was undertaken
to determine how long an individual
could remain at
a given depth,
as in a submarine
during
preparation,
flooding,
DIVISION
OF
PREVENTIVE
MEDICINE
287
and
escape
described
above,
and then make
continuous
ascent to the surface,
at the
rate
of
50
feet
per minute,
without developing
caisson
disease.
As
a
result of this study "it was found safe under experimental
conditions
to remain 37
minutes iit a simulated
depth of 100 feet,
18 minutes
at 150 feet,
17 minutes
at
167 feet, 14 minutes at 185 feet, and 13 minutes at 200 feet,
the subjects coming
to the surface at the rate of 50 feet per minute."
Other
safety
devices
and
appliances, —Another
safety
measure
is
that salvage
air connections
to ballast tanks and
all compartments
are permanently located
on the deck of the submarine.
This enables
divers
to make
the proper connections
easily
and
"blow"
the sub
marine to
the surface.
A large
closed
pressure "bell" is part of the equipment of Navy
salvage
ships.
This rescue
chamber
can be lowered
to the sunken
submarine where
contact is completed
and
the men may be taken
out through the motor room hatch or the torpedo room hatch.
Each compartment of a submarine
is supplied
with a high-pressure
air cock
so that the compartment struck will
have
avadable
all of
the ship's high-pressure
air to help hold
the water out while repairs
or plugging of the hole is attempted.
Quick-closing
doors
are pro
vided so as to rapidly isolate
the damaged
section.
Pontoons are available at each submarine
base for the raising of a
sunken submarine
which cannot
be raised by the blowing in of salvage
air.
Buoys
are carried
by the submarine
which may be released from
inside the ship.
This buoy carries
a telephone
cable for communi
cation with the surface.
It would prove
of material aid in the loca
tion of a sunken
submarine.
Signal bombs
are also carried
in con
nection with
this
device.
Sound devices for the detection
of an approaching ship or obstruc
tion arc built in on all our submarines.
For shore or longer
range
communication
the
antennae
must
be
above
the
surface
and
the
wireless
used.
Two types of gas masks are provided the men aboard all submarines,
one chlorine gas mask and one general protective mask.
Duplicates
are
placed
at
each
end
of the
ship.
Chlorine
only
escapes when
salt water comes in contact with the batteries
which can only occur
in the event of an accident
to the boat.
No special chlorine detector
is used or needed
as
the odor
is so characteristic that it would be
immediately noted.
A
hydrogen
detector
is permanently located
in each of the
two
battery compartments.
It is run constantly during the charging
of
the batteries.
A C02
detector,
known
as
the Higgins-Marriott
is
supplied
to
every submarine
and the men are all qualified in its use.
288
DIVISION
OF
PREVENTIVE
MEDICINE
Training
and
Submarine Service
Requirements
Department
records
show that the average duration of continuous
service
on submarine for officers is approximately
5 years.
There is
no set limit as to the time
an officer or enlisted
man may spend
on
submarine
work.
The desire of all-around experience
on other types
of
vessels,
however,
generally
so
acts
as
to limit
Ins
submarine-
service
time
to this 5-year
period.
The
average
age for this group
is indicated by the facts that of the 1936 personnel
of 302 officers, 76
were lieutenants with
an
average
age
of
34
or
35
years,
and
189
lieutenants, junior
grade,
with
an
average
age
of
28
or
29
years.
These two ranks comprise
approximately
90
percent
of the officers
attached
to submarine
duty.
Officers
after volunteering are ordered
to the submarine
school
at
New London for a 6-months' period
of instruction.
Then they are
assigned
to a submarine
where they must serve aboard
for a period
of
1 year, not counting navy yard overhaul periods,
before they are
eligible
for
examination
for
submarine
qualification.
Apparently
officers of the rank of lieutenant, junior grade, are in the great major
ity in applying
for this training.
Torpedo
instruction
is given
at
Hew London.
After an officer is qualified he will spend
3 years on submarine sea
duty between
the intervals of shore duty.
When an officer qualified
for submarine
command
or assignment
goes on shore duty he is not,
for the
time
spent
on shore duty,
technically
assigned
to
the
sub
marine
service.
While
on shore duty he does not receive his extra
submarine
pay but he never loses his submarine
qualification
except
for
physical
disability.
Extra
pay
for
the
qualified
submarine
officer
on active submarine
duty is 25
percent
increase
of the
base
salary.
The average
shore duty is
2 years.
Submarine officers with the rank of captain have little occasion
to
actually
be
aboard
or ride
in
a submarine.
In very rare
cases
a
captain
might
ride
but not in any
repeated
routine manner
and
probably
only during
fleet
exercises.
Submarine
officers
with
the
rank of commander
have little
occasion
for routine submarine trips
but would ride
a little more frequently.
At present
each submarine
division
has
a division commander
who may be an officer with
the
rank
of commander.
There would not
be
over
seven
such
officers
in the Navy at one time.
In 1936 there were only two captains and
four
commanders
assigned
to
submarine
executive
duty.
Navy
doctors assigned
to
the supervision
of submarine
personnel
usually
ride
the
tender
or
the
salvage
ship
accompanying
the
submarines
and occasionally make trips on these boats.
A submarine
officer
of lower
rank
than
the
above
when
on
sub
marine
duty
is
generally
stationed
aboard
the
submarine.
His
assignment
to any one submarine
generally
lasts for 2 years per boat.
DIVISION
OF
PREVENTIVE
MEDICINE
289
The
turn-over
of officers
on any particular
submarine
is generally
about two
changes in officer
personnel
per year.
At the present
time the enlisted
man qualified for submarine
duty
receives extra pay of $25 to $30 a month depending
on his rating while
on
such
assignment.
Men
volunteering
for
this
work
attend
the
submarine school at New London for a 6-weeks' period.
Some of the
higher ratings
such
as machinist
mates
may spend
as
long
as
36
weeks
there.
Then
these men
are ordered
to some submarine
and
after serving
aboard
satisfactorily for 6 months are eligible
for sub
marine qualifications after they have passed an examination.
I was
advised
that
men
came from all
branches
of
the
service
into
this
submarine work
and
that
there
was
no
noticeable
tendency
of
a
greater
proportion
of men from the
submarine
tenders
and supply
vessels to enter this service than other general officers and men.
The
average yearly turn-over of petty officers
and other enlisted
men on a particular submarine
would be over
100 percent,
although
some men might stay aboard
for several
years.
There would prob
ably be a turn-over of two chief petty officers per year.
No warrant
officers are ever attached
to submarines.
While
this paper
is not being
prepared
to cover
Navy
divers
as
such, I thought it would be of interest
to include at this point some
information about Navy divers.
In reply to a question
as to whether
Navy diver applicants were likely
to be qualified submarine
men, or
whether the diver applicants are just as likely to be from the general
fleet, I was advised
that all divers
come from
the fleet.
I was also
informed that the Navy has "30 officers who are on diving duty but
who practically
never
dive;
several
of these are
doctors
who
may
have
to take
pressure in case of the development
of compressed-air
disease in one of the divers.
Then
there
are
21
master
divers,
91
first-class
divers,
and
484
second-class
divers
allowed
in the
entire
Fleet.
This quota is approximately filled.
This group
will dive
an
average of at least
20 dives a year, including their qualification
and
requalification
dives
and
their salvage
dives.
So in all we would
average about 12,520
dives per year by the 626 qualified divers
and
you will see that in the Statistics of Disease and Injuries in the United
States Navy for the Calendar Year of 1936 there were listed 15 cases of
caisson
disease
(we prefer
to call it compressed-air
disease)
and
1
death.
Now this in itself is not a bad average but if you go into it
further you will find that all of this trouble,
i. e., the caisson disease
and the one death occurred
at the experimental
diving unit where the
work we were doing forced
us to carry the experiments
to the stage
of producing caisson
disease in a certain number of the subjects
in
order to know when the end point in the experiment
had been reached.
I think you will find that out in the regular
diving game in the fleet
290
DIVISION
OF
PREVENTIVE
MEDICINE
there
was
no
trouble
whatsoever.
Experimental
work
is
always
hazardous,
as you know, but even there we had but one death in over
6 years of constant daily diving."
Mortality and Morbidity
Record
Beginning with the calendar year 1919 and extending
through 1936
we were able to obtain a complete
record of deaths among submarine
officers.
These deaths were divided into occupational accidents,
non
occupational accidents
and
disease,
the findings summarized,
and
a
tabulation
made in table I.
A similar summary was made for the
enlisted
men over a period
1922-36 in table II.
A morbidity
and
invaliding
record
for submarine
men
over
the
years
1923-32
was prepared
and
contrasted
with
the general Navy
average.
The details for the respective
years follow.
For the calendar year 1922 three occupational deaths were recorded,
one accidental
death on leave, and two deaths from disease.
In 1923 there were 25 admissions
for accidental
injuries associated
with duty on board submarines.
These
were all that were reported
under
the key letter "S," denoting connection
with submarine
duty.
The instructions regarding
the use of this letter are that it shall be
used for disease
as well
as injuries incidental
to peculiar living
con
ditions aboard
the submarine
and to actual
maneuvering
of, or acci
dent to the vessel.
There were no admissions
for disease reported as
dependent
upon living or working conditions in submarines.
Of the 25
cases of accidental
injuries recorded,
7 cases
were fatal.
Four of the deaths
were caused by drowning, and
the other three,
resulting
from multiple injuries, were all caused by an explosion
of
hydrogen
gas in the after battery compartment of the U. S. S. SS7.
Three of
the
men
drowned
were lost when
the U.
S.
S. 0-5
was
rammed
and sunk by a merchant
vessel in the harbor of Cristobal,
Canal Zone.
The other man
who lost his life by drowning was at
tached
to the U. S. S. R-23.
He fell overboard while the boat was
at sea, striking his back on the hull of the boat.
No one attached
to
the submarines
was reported
as invalided from the service.
In addi
tion there were two accidental
drownings on leave and one death from
disease.
In
1924
there were
18
admissions
for injuries recorded
from sub
marine
hazards.
One
man injured in
a battery explosion
was sub
sequently discharged
for permanent
disability.
There were 502 sick
days.
There wore no admissions
from disease of any kind incident to
the
peculiar living
conditions
aboard
submarines.
Three
occupa
tional deaths were recorded, one caused by bursting of a Diesel engine,
one
from
gasoline
explosion,
and
one drowning.
In addition
two
fatal nonoccupational accidents
and three deaths from disease.
DIVISION
OF
PREVENTIVE
MEDICINE
291
Iii
1925
the S-5t
was rammed
by the steamship
City of Rome off
Block Island on the Atlantic
seaboard.
The history of this disaster
and the diving activities
connected
with
the salvage
work
are de
scribed in Commander Ellsberg's book "On the Bottom."
Six officers
and 27 enlisted
men were drowned.
Apart from this disaster
there
was one other occupational death due to a fall.
There were 17 admis
sions from submarine
hazards.
One man was injured by a fall through
a hatch and nine were for injuries caused by submarine
engines, other
machinery,
and
batteries.
The
remaining seven
admissions
were
attributed
to hazards
more or less peculiar to living or working
con
ditions
on submarines.
The injuries in
these
cases
were
burns,
or
lesions
of minor importance resulting from falls,
or stumbling over
obstacles
on
board.
One
case of heat
exhaustion
occurred
which
was the only admission
other than for injuries, there being no admis
sion for disease attributable
to the working and living conditions of
submarines.
There
were
nine
accidental
deaths
among
the
men
on
leave
or
liberty,
one suicide,
and
one death
from disease.
One
suicide
was
also recorded
among officers.
Injuries of a minor nature were more completely
reported during the
year
1926
and injuries resulting from falls on board
submarines
and
those caused by like hazards, which might be encountered
in any type
of vessel, have been charged
to submarine
hazards,
whereas formerly
they were in some cases simply recorded
as caused by falls.
These
changes in practice
largely account for the increased number
of admissions
and sick days in
1926.
Of the
59 admissions
for this
year, only 23 were for injuries occurring while submarines
were operat
ing, but in all except
2 of the 59 cases,
the injured person was working
when the accidents
occurred.
One enlisted
man was invalided from
the service because of faulty union of a fracture caused by an explosion
of hydrogen gas from storage batteries
in the U. S. S. S-49.
The ex
plosion occurred
while the vessel was moored
alongside
the dock
at
the submarine
base, New London, just as a pilot cell cover was being
removed
for the purpose of testing
the specific gravity of the electro
lyte.
The battery deck
was blown up.
Twelve enlisted
men were
injured.
Three died a few hours after the accident
from multiple in
juries and one man died 4 days later.
Two other occupational deaths
occurred this year.
An enlisted
man who was working on the bridge
of a submarine
anchored
at sea outside of San Francisco Bay lost his
footing when
the vessel took a sudden
roll, fell overboard,
and
was
drowned.
Another
fell
overboard
from submarine
in port and
was
drowned.
Injuries making up the total of 59 admissions
were caused
by machinery,
engines, falls, and other miscellaneous
accidents.
One
case of heat
exhaustion
was reported.
In addition
there were
two
292
DIVISION
OF
PREVENTIVE
MEDICINE
accidental deaths
among the men on leave and two
deaths from dis
ease.
There were no deaths recorded
among officers.
Of the 90 admissions
in 1927,
54 were injuries occurring while sub
marines
were operating,
and in all except
5 instances
the injured per
sons were working when the accidents
occurred.
Thirty-eight
of the
ninety
admissions
occurred
in
connection
with
the
sinking
of
the
U.
S. S.
S~4,
which resulted
through the collision with
the United
States
Coast Guard cutter Paulding.
The
submarine
was running
submerged
during
standardization
trials
in
Cape
Cod
Bay
near
Provincetown, Mass., at the time.
The cause of death was recorded
as asphyxiation in the
case of
1 officer
and
5 enlisted
men,
and
as
drowning in the
case of the remaining 4 officers
and
28 men.
One
other occupational death reported for the year occurred
near Tsingtao,
China;
an enlisted
man lost his balance
and fell overboard
while lift
ing a guard rail on a submarine.
He could not swim and was drowned.
The remaining injuries resulted
from operating machinery and engines,
falls, heavy seas, striking against objects,
and so forth.
Another case
of heat exhaustion
in the engine room was also reported.
Four enlisted
men were invalided from the service.
A contusion of
the leg received
while handling lines in mooring
a submarine
led to
invaliding
in one case,
and injuries received
on board
a submarine in
1926, during an explosion
of hydrogen
gas from storage
batteries,
in
three
cases.
In addition
there
were six nonoccupational accidental
deaths
and four deaths from disease.
In
1928,
69
admissions
were
reported.
Twenty-six
were
for in
juries occurring while submarines
were operating and in all except one
instance
the injured
persons
were working
when
the
accidents
oc
curred.
There
were
43
admissions
for injuries
received
while sub
marines
were moored.
The accidents
show the typical miscellaneous
distribution of causative
agencies, i. e., machinery, engines, falls, etc.
There were no deaths
and
no person
invalided from the service
on
account
of injuries due to submarine
hazards.
There were four acci
dental deaths on leave and five deaths due to disease.
Of the 73 admissions
in
1929,
26 were for injuries occurring while
submarines
were operating and in all except
2 instances
the injured
persons
were working when
the accidents
occurred.
There were
47
admissions for injuries received while submarines
were moored.
There
were two deaths from drowning caused by falls overboard,
one while
the submarine
was at sea, and the other while moored.
At this point
I would note that in examining
these miscellaneous
injuries that only
a very small percentage were caused by work around
batteries.
Prac
tically all of the injuries were sustained
through general
hazards
of
operating a boat which could just as well have been experienced on any
craft as well
as on submarines.
In addition three fatal accidents
oc
DIVISION
OF
PREVENTIVE
MEDICINE
293
curred on leave and
two
deaths from disease among
the men.
One
death from disease was recorded for a submarine
officer.
The
57 admissions
in 1930 showed
22 occurring while submarines
were operating and 35 while moored.
There docs not seem to be any
tendency for more injuries to be sustained while maneuvering
the sub
marine than while moored
along the dock.
One death occurred
from
drowning, washed
overboard.
There are only a few admissions
from
injuries
sustained
while handling
torpedoes
in the
record
for these
years.
Apparently no more than might be caused in the ordinary gun
drill.
No
deaths
have
resulted
from
torpedo
drill
or handling in
submarines for the years
under review.
There were
also five
acci
dental deaths on leave and seven deaths due to disease, including one
from
caisson
disease.
One
death
from disease was recorded
among
officers.
1931 had 65 admissions,
20 for injuries while submarines
were operat
ing and
45 while moored.
There were two
deaths
from drowning,
caused
by falls
overboard.
No
invalidings
were
reported.
There
were
three nonoccupational accidental
deaths
and
one due
to trau
matic air embolism
while using the training "lung."
For
1932
there
were
62
admissions,
17 while operating,
45 while
moored.
One death was caused by electric shock while the submarine
was at dock.
There were three
accidental
deaths
on leave and one
death among officers was of accidental
nature while on leave.
After
1932 no separate record of admissions
and sick days for the submarine
service as distinct from the general
navy figures
is recorded
in the
Annual Reports of the Surgeon
General
so it was thought advisable
to
summarize the data at this point in the following table.
Admissions,
sick dnys, invalided, due
to submarine service hazards
Year
N'umber
of officers
and men
Admis
sions
Rate
per
1,000
Sick
days
Rate
per
1,000
Invalided
from the
service
Rate
per
1.000
1923
2,472
2.925
3,292
3.332
3. 245
3.447
3.44.1
25
18
50
59
90
69
73
640
502
290
1,947
1.560
1.419
1.007
908
2, 193
790
0
1
0
1924
1926
1927
4
0
0
0
2
0
1928.
3 5M
57
1931
2, 70S
2.468
65
62
1932
3,089
57
18
1, 132
354
0.8
0.26
We may
compare
these figures
to a general
average for the entire
Navy, if we take the results for 1933 which are very close to the Navy
means for the preceding
5 years.
294
DIVISION
OF
PREVENTIVE
MEDICINE
Your
Number
officers
and men
Admis
sions
Rate
per
1,000
Sick
days
Hate
per
1.000
Invalided
from the
service
Rate
per
l.0C0
1933
108,183
6.800
63
15,661
1.448
139
128
As presented above the figures exclude homicidal injuries and suicides
(both
actual
and
attempted)
and poisoning
by food.
These
figures
for the Navy
should
be further
adjusted
to obtain
a picture more
nearly similar with that of the submarine
service.
For this purpose
Mie figures for accidents occurring on "leave or liberty"
were deducted
from
the Navy
totals
leaving
only
the exposure
occurring "within
command" and similarly for sick days and invalidings from service.
Year
Number
officers
and men
Admis
sions
Rate
per
1,000
Sick
days
Rate
per
1,000
Invalided
from the
service
Rate
per
1,000
1033
108,183
4,671
44
89,474
820
55
0.51
This permits
a comparison
for accidents
and accidental
poisonings
for a 10-year
period
of submarine
service
and the same for a 5-year
period for the entire Navy.
We find that the rate per thousand,
for
admissions
in the submarine
service
was
18; for the Navy
44.
The
rate
per
thousand
for sick
days in the submarine
service
was
354,
while the Navy figure is 820.
Invaliding from the service was 0.26 per
thousand,
from submarine
hazards
and
0.51
per
thousand
for
the
entire Navy from causes occurring "within
command."
These results while by no means conclusive indicate very definitely a
favorable
comparison
for the submarine
service
as against
the figures
for entire
Navy
service.
This may be due in some measure
to the
care exercised in selecting
men for the submarines
and
to the very
rigorous
application of all safety
measures.
There is also the prob
ability that these men as a class are more
seasoned in safeguarding
themselves
against
the average nautical accident
as there is a great
preponderance
of technical
men among them.
They are all experts in
their particular line as must necessarily
be the case for those connected
with
submarines
where
carelessness
or
inexperience
could
not
be
tolerated.
Continuing
the mortality
data
we note
for
1933
two
accidental
deaths on leave among enlisted men and one suicide.
There were also
two
nonoccupational
accidents
for
officers
and
one
disease
death.
In
1934 an enlisted
man was killed by an explosion
of a signal shell.
There were
three nonoccupational accidents
and
three
deaths
from
disease.
No deaths among officers.
In
1935 one occupational, three
nonoccupational, and
one suicide
among
enlisted
men.
No
deaths
for officers.
For 1936 there was one nonoccupational accident
and one
DIVISION
OF
PREVENTIVE
MEDICINE
295
death from disease.
Among officers the only death recorded
resulted
from an airplane accident.
Table I.—Officers — United States Submarine
Service
MORTALITY DATA
Year
Num
ber of
officers
1919
1920
1921
1922
1923
1924
1925
1925
1925
1925
1925
1925
1925
1926
1927
1927
1927
1927
1927
1928
1929
1930
1931
1932
1933
1933
1933
1934
1935
1936
245
266
252
250
272
306
309
314
321
333
370
382
325
313
297
300
302
Rank
Station
or
ship
Lt
Ens
Lt., J. G.
Lt., J. O
Lt., J. G
Lt., J. O.
Lt., J. G
Lt. Com.
Lt., J. O.
Lt. Com.
Lt., J. G
Lt., J. G.
Lt., J. G.
Lt., J. O
Lt., J. O
Lt., J. O.
Lt., J. G.
Lt , J. O.
Lt
S-51.
S-51.
S-51.
8-81.
S-51.
S-51.
S-51.
S-4..
s-c.
S-4..
s-«.
S-4..
S-34
8-47
New Lon
don.
Dolphin.
Age
at
death
Accidental
deaths
Occupational
None
do
do
....do
do
do
Collision—
drowned
do
do
....do
do
do
None
do
Collision—
drowned
....do
do.
do
do
None
....do
do
....do....
do
do
do
....do
....do
Airplane
crash.
Nonoccupational
None.
.
....do.
....do.
do
....do...
....do...
.— do...
....do...
..-do...
....do...
....do...
....do...
tin
-1"
....do
....do
....do
....do
do
....do
.-
....do
....do
....do
Auto accident— leave
None
Auto accident —leave
do.
None
Disease
None.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Do.
Da
Do.
Do.
Suicide.
Nunc.
Do.
Do.
Do.
Do.
Do.
Do.
Osteomylitis.
T. B.
Septicemia.
None.
Streptococcus.
None.
Do.
Do.
Do.
Do.
Years
Total ex
posed
Average age
at death
Total occu
pational
Total non
occupa
tional
Total dis
ease
18
5,467
29
12
3
5
Over
the
18-year
period
1919-36,
inclusive,
we have
a total life
years of exposure for officers of 5,467.
The average
age at death was
29.
There were
12 occupational deaths,
6 lost on the S-51 in
1925,
5 lost on the S-4 in 1927 and
1 death as a result of an airplane crash in
1936.
The
accidental
occupational death
rate
is 2.2 per thousand.
Over this period
there were three accidental
deaths
due to nonoccu
pational causes, all automobile accidents
while on leave.
The result
ing rate being 0.55 per thousand.
The total accidental
death rate was
2.75 per thousand.
There were five deaths
as a result of disease all
differing as to cause.
The percentage of active officers in the various ranks was determined
to be
as follows: Ensigns
3
percent,
age
group
20-24; lieutenants,
junior grade
60 percent,
age group 25-29; lieutenants 25 percent,
age
group 30-34
; officers of higher rank 9 percent, average age group 35-39.
On this basis and using the J. O. S. Basic Table 1915-26 for compari
296
DIVISION
OF
PREVENTIVE
MEDICINE
son, the succeeding
table was drawn.
In each case the fifth year of
duration was assumed
as representative.
(1)
Exposed
to risk
(2)
Actual
dead
(3)
Expected
dead
Rank
Age
Ratio per
cent (2)+3
Pcrcrnt
Ensign
20-24
164
3.444
1
0.44
224
157
45
100
Lieutenant
commander
25-29
30-34
35-39
1,367
492
15
2
2
9.5«
4.38
2.02
Commander
. ..
5,467
20
16.40
122±18
If the hasic table 1920-34had been used, the mortality ratio would
have been 129percentile
DIVISION
OK
PREVENTIVE
297
MEDICINE
■,8
X
^
"3
5
3
r.::
COig
"3 «"0
- -
> 2 E
ciSo
- Stj
©> c
a5|
if £ .*
- -
sec
•c* *
o o o
Is?
J-
2fiQ
M ©
o -
h §
£!.§,§
30"O '
IT
OS
,
E o
,
so
:
*5
ai ss
4,8
S * c32 S 1S?! S
?i ~i
ri ri « ^7^ ~ ri
ri roVi ~»~j
'f'i
ri
^
^
^
^
ri
?]
—
rl
1-J
>
O
.
»o*
'
.
'
cs«
,'
—.J
,
i
i
,
!
—
,'
t
JaS JOOrn-nOaSoliOM3
0Of--i>iOO
r
r
r
f
r
i
i
i
r
71X COX 73X X COCO
I
298
DIVISION
OF
PREVENTIVE
MEDICINE
-2:
^
a
n
'Z
a
&
Pi
1
-
a
|
Si}
M
[1
fl«
I
—3
. °
1
-a
.-^
o « o
.
a
c « 0
3.8,93
J
I*
SJ?f?33
T
?
3
T
7?
7
7
.
T
7
T
T
„
.
X X X X X X X V.X X X X XvX X * X X X X * •>ai7^TT7.' "77TT7
""T^TT
x^i:naiai-^flCajaiMxtn
O 3*aoO « x
8
oOo
o
:
:
Ph
i
:
idci
o
:
3
b
i
aid0.
oo
a.
a;
l5^iMsltfillrfl»'aflllilj
P
;°
gaaaaaaaaaaaaaaasaaaagssr.sr,
sss sssssg
DIVISION
OF
PREVENTIVE
MEDICINE
299
is c e!c «
m£ ■
3 a ° as
3"°
-
O O C 0 o
cocccocco
ssd a si si "i sv
s^n si si 333.3-J. J. I 3: 3:e si 3:31313>si I si 3i si I. I 3.I si I ai ^ 34s c*.si J. ? o a J- 5 3. as»'
DIVISION
OF
PREVENTIVE
MEDICINE
H
.8
"3
if «
Iffl
. ^
UN
SP
2o
<
Q
9 g E
.2 = 3
2
I o
! o
B I
-os
is oJ o
- - 7.-
1
3
at«
O CJBCD■cc1
3
, .
9 c Sa
1
«ElSfl
21asa: > O vi ccC > i£ > x > cnSSO 'h X.
IP"P"aossisifis Smite line
o x P"x-
£ abx otci P3< JJ
s
><
2: — 5 5 £"H:£:^
i-"
£:
2
Hj
£:
I
£:
£i
£-
I
£:
£:
r
£
£;
£:
£;
£|
-~-I- - ' I- ^ Ii I- ^ - I
-
DIVISION
OF
PREVENTIVE
MEDICINE
a
,
a §g a
5 o S
-
?i ~5?i ct c't?
313 C ~' 3
Grand
total
disease
3
Grand
total
nonoccupational
Grand
total
occupational
3
Orand
total
exposed
39,061
45202—38
-10
302
DIVISION
OF
PREVENTIVE
MEDICINE
Enlisted
men— United States Submarine
Service
MORTALITY DATA
Chief
[Jetty officers
Petty ofBcers
Other enlisted men
Year
Total
Occu
pational
Non-
occupa-
lional
acci
dents
Occu
pational
acci
dents
Non
occupa
tional
acci
dents
Occu
pational
acci
dents
Non
occupa
tional
acci
dents
ex
posed
acci
dents
Dis
ease
Dis
ease
Dis
ease
1922
2.554
1
None
2
2
1
None
1
None
None
None
1923
2,200
None
1
None
None
4
•i
3
None
None
1924
2,619
None
1
None
2"
2
3
None
None
None
1925
2.982
4
None
6
3
1
1926
3,018
1
1
None
4
3
3
1
1
3
1927
2.924
3
None
1
19
6
12
None
1
1928
3, 114
None
1
None
None
1
4
None
1
1929
3.073
1
Xuri,.
1
None
1
3
1
1
None
None
1930
3. 172
None
None
None
4
7
None
None
1931
2.384
None
None
Nunc
None
None
1
2
None
1932
2. 155
None
None
None
None
2
j
1
1
None
1933
2. 115
None
None
None
None
1
2
1
Nono
Nono
None
1934
2.200
None
None*
None
3
3
None
None
None
1935
2.250
None
None
None
None
2
None
1
1
1936
2.300
None
None
1
None
None
None
None
1
None
Total
39,001
11
3
5
54
37
c
28
24
12
7
The total life years
of exposure for enlisted
men was
39,061
over
the period
1922-36.
There were
89 accidental
deaths
due to occu
pational
hazards.
Nonoccupational
deaths
of
accidental
nature
while on "leave or liberty"
totaled
52.
There were 40 deaths due to
disease, among which only 2 may
be directly ascribed
to occupational
conditions.
These
two
deaths
occurred
during
training
with
the
submarine
"lung"
and have already
been considered.
In this service
approximately
10
percent
of
the
enlisted
personnel
are
chief
petty
officers
of age group
35-39.
These
are the highest ranking enlisted
men in submarine
work, there
being no warrant officers
assigned
to
this branch.
Among this group of chief petty officers
there were
11
occupational accidental
deaths,
3 nonoccupational,
and
5 deaths
due
to disease.
The percentage
of petty officers is very high in subma
rine service, approximately 65 percent of the enlisted personnel having
a petty officer's rank.
Among this group
there were 54 occupational
accidental
deaths,
37 nonoccupational
accidents,
and
28 deaths
due
to
disease,
the
age
group
being
25-29.
Other
enlisted
men,
such
as seamen, firemen,
mess attendants,
and cooks third class, represent
25 percent
of the service enlisted
personnel.
Among this group with
ages 20-24
there were 24 occupational
accidents,
12 nonoccupational,
and
7 deaths from disease.
The above figures are summarized
in the
following table with
the J. O. S. 1915-26 basic table for approximate
comparison.
DIVISION
OF
PREVENTIVE
MEDICINE
303
Rats
Age
group
Exposed
to risk
(1)
Actual
dead
(2)
Expected
dead
(3)
Ratio,
percent,
2-5-3
Petty officers...
35-39
25-29
20-24
3,906
25.390
9,765
19
119
43
16.2
70.5
25.9
117
169
166
Total
39.061
181
112.6
159
The chief petty officers evidence
a ratio of 117 percent.
The five
deaths due to disease were from varied
causes.
The occupational accident
rate was 2.81
per
1,000,
the nonoccupa
tional
accidental
death
rate 0.77.
The total accident
rate 3.58 per
1,000.
Among petty officers
the ratio is
169
percent,
45
percent
of the
deaths being caused by accidents
from occupational hazards,
with a
rate of 2.12 per
1,000.
Nonoccupational
accidents
caused
31
per
cent of the deaths,
with
a rate of
1.46
per
1,000.
As
a matter of
coincidence
the total accidental
death rate is 3.58 per 1,000,
the same
as for
chief
petty
officers.
Deaths
due
to
disease
are low in this
petty
officer group,
comprising
only
24 percent
of the total deaths.
The
higher
death
ratio
being
practically
entirely
due
to
accident.
Of the 28 deaths
resulting
from disease there were 5 due to tubercu
losis of the lungs
and
1 case of tuberculosis
other
than
pulmonary.
The
pulmonary
tuberculosis
rate
is well
under
normal, being
0.20
per
1,000.
Exposure deaths,
such as pneumonia
and influenza,
were
low
and
the
other
disease
deaths
were
evenly
distributed
over
a
variety of miscellaneous
causes.
Other enlisted men had an occupational
death rate of 2.46 per 1,000
and
a nonoccupational rate of
1.23,
comprising
a total rate
of 3.69
per
1,000.
On
the basis of the J.
O.
S.
there
were
expected
19.5
deaths
from
disease, whereas
the actual
was 7, indicating the higher
death
rate to be due to accident.
Seventy-five
percent
of
the
fatal occupational
accidents
among
officers
and
men
occurred
as
the result of collisions.
There
were
seven deaths due to the explosion
of hydrogen
gas from the batteries.
This hazard
has apparently been minimized by safety
precautions
and is probably no greater
than
explosions
from various agencies on
other war vessels.
For the purpose
of comparing
the accidental
death rate for officers
and men of the submarine
service with that of the entire Navy
the
following material is added.
304
DIVISION
OF
PREVENTIVE
MEDICINE
ACCIDENTAL DEATH
RATE
Commissioned Personnel entire
Navy
Year
Exposed
Deaths
Rate per 1,000
0)
(2)
(3)
(1)
(2)
(3)
1923
7.704
8.058
8.210
8,839
8. 742
S. 793
16
5
12
7
8
5
S
9
1924
28
29
21
29
34
1925
1928 .
1927
1928
1929
8.925
19
1930 .
9.013
9, 184
9. 503
9, 458
22
14
14
41
3
1931
8
7
1932...
1933
+9
Total
94.227
267 |
80
89
2.8
0.83
0.93
This
table of officers excludes
those of the Marine Corps, midship
men,
and
cadets,
but includes
warrant
officers.
Column
(1)
under
deaths
includes
all
casualties
from
injury,
poisoning,
suicide,
and
homicide.
Here the result
is 267
deaths with rate
per
1,000 of 2.8.
Under column
(2) deaths from aviation, both lighter and heavier
than
air,
suicide,
and
submarine
activity,
are
excluded.
This
naturally
brings
the rate
down
substantially
and we have
SO deaths with
the
rate of 0.83
per
1,000.
The final figure
for comparison
purposes
is
under
column
(3);
here
the figure
in column
(2) has been adjusted
to include
25 percent
of the suicides.
This final figure under column
(3) indicates
a fatal accident
rate
among
Navy
officers of 0.93 per
] ,000,
as
against
2.75 for submarine
officers.
For
the
purpose
of
record I have listed hereunder
the deaths
from
aviation and suicide
used in obtaining this final figure.
Suicides
entire
Navy and Deaths
due
to Navy Aviation
Aviation deaths
Suicide
Year
Officers
Men
Officers
Men
1923
8
7
3
18
1924
14
12
2
22
1925
11
14
4
13
1926
13
2
0
11
1927
17
12
2
21
1928
20
8
5
13
Aviation deaths
Suicide
Year
Offl cers
Men
Officers
Men
1929
s
6
2
13
1930.
13
5
6
13
1931
4
9
2
12
1932.
4
11
3
13
1933
26
66
8
20
DIVISION
OF
PREVENTIVE
MEDICINE
305
Similarly for enlisted men the following table is added :
Enlisted Personnel entire
Xary
Year
Exposed
Deaths
Rate
per 1,000
(1)
(2)
(3)
(1)
(2)
(3)
1923
85.217
87.442
84.467
83.461
84.672
84,940
85,999
85.813
81.274
81.534
79.726
194
162
180
107
104
109
119
107
119
138
110
112
1924
215
161
122
177
138
127
138
161
135
199
1925
1926
1929
1930.
1931
1932
1933...
+42
1.409
Total
924,545
1.767
1.367
1.9
1.48
1.53
The fatal accident
rate here is 1.53 for enlisted
men in the Navy as
compared
with an average of 3.60 for enlisted men in submarine
serv
ice.
The
difference
is
a little
less than
2
extra
deaths
per
1,000.
The mortality
other than
from
accident
appears
to
be low for both
officers and men in the submarine
service.
Bibliography
Vital statistic*
Annual
Reports, Secretary of the Navy.
Annual
Report*,
Surgeon General of the Navy.
Statistics
of Diseases and Injuries in the U. S. Navy, Navy Department,
Bureau
of Medicine
and Surgery, Annual.
Medico-Actuarial Mortality Investigation,
1913.
Joint Occupation
Study,
1928.
Mortality of the Army and Navy, John S. Thomson, T. A. S. A., Vol. XXX.
Underwriting Military
and Naval Risks,
Samuel
G.
Hopkins,
H.
O. L.
U. A.,
Vol. V.
Safety and health
studies
Report on Submarine
Safety, U. S. Submarine
Board,
1928.
Traumatic Air Embolism
in Submarine
Escape Training, U. S. N.
Medical
Bull.,
Vol. 30.
The
Physiological
Effects of High Pressures, Journal of Industrial Hygiene
and
Toxicology,
Vol. XVIII, No.
8, October
1936.
Circulatory and Visual
Effects of Oxygen at 3 Atmospheres
Pressure, Journal of
Physiology,
Vol.
114, No.
2, Jan.
1936.
A Study
of
the
Convulsive
Seizures
Caused
by
Breathing
Oxygen
at High
Pressures,
C. W.
Shilling
and B. H. Adams,
U. S. N. Medical
Bull., Vol.
31.
The
Psychological
Effects
From
Breathing
Air
at
4
Atmospheres
Pressure,
American Journal of Physiology,
Vol.
112, No. 3, July 1935.
Studies
of the Effects
of High Oxygen
Pressure,
American
Journal
Physiology,
Vol. 107, No.
1, January 1934.
306
DIVISION
OF
PREVENTIVE
MEDICINE
A Pressure
Chamber
Installation for Studying
Physiologic
Effects
of Pressures,
etc., Journal of Industrial Hygiene,
Vol. XIV, No. 2, Feb.
1932.
Caisson
Disease and Its Relation
to Tissue
Saturation
With Nitrogen,
U.
S. N.
Med. Bull.,
Vol. 33.
The Influence
of Increased
Barometric
Pressure on the Pulse
Rate and Arterial
Blood Pressure, U. S. N. Med. Bull., Vol. 34, No.
1.
Medical
Aspects of Submarine
Lung Training, U. S. N. Med. Bull., Vol. 29.
Distention
of Lungs During Training With Escape Apparatus,
U. S. N. Med. Bull.,
Vol. 29.
Observations
on Submarine Lung Training,
U. S. N. Med. Bull., Vol. 29.
Analysis
of Accidents
Occurring
in Training With the Submarine
Lung, U. S. N.
Med. Bull., Vol.
30.
Traumatic
Lung
Lesions
Produced
in Dogs by Simulating
Submarine
Escape,
U. S. N. Med. Bull., Vol. 31.
The Hazard
of Caisson
Disease in Individual Submarine
Escape, U. S. N. Med.
Bull.,
Vol.
34.
Breathing
Resistance of New Submarine
Escape Apparatus,
U. S. N. Med; Bull.,
Vol.
34.
General
information
and history of submarine
development
Submarine
Warfare,
Herbert
C. Fyfe,
1902.
Our Many-Sided
Navy, R. W. Neeser, 1914.
The Submarine
Torpedo
Boat, Allen Hoar,
1916.
Submarines
and Sea Power, Charles Domville-Fife.
Submarines of the World's
Navies, Charles Domville-Fife.
The Submarine in War, Charles Domville-Fife.
Submarine
Engineering
of Today,
Charles Domville-Fife.
The Birth and Development
of the American Submarine, Frank T. Cable,
1924.
On the Bottom,
Edward
Ellsberg,
1929.
I Like Diving,
Thomas Eadie,
1929.
The Story of the Submarine,
Farnham
Bishop,
1929.
The Romance Of The Submarine,
G. G. Jackson,
1930.
Proceedings,
U. S. Naval Institute,
Annapolis,
Annual.
U. S. Navy Register,
Annual.
U.
S. Navy Directory,
Annual.
Jane's Fighting
Ships, Annual.
Brassey
Naval Annual.
Army and Navy Uniforms
and Insignia,
Colonel Dion Williams.
U. S. Navy Diving Manual.
OBSERVATIONS
ON
STAPHYLOCOCCUS
FOOD
POISONING
REPORT
OF AN OUTBREAK
By Lieutenant,
E. M. Wade, Medical Corps, United States Navy
A number of cases of acute gastroenteritis
which occurred during the
years 1909-13 on a certain farm in Nueva Ecija Province, Luzon, P. I.,
were investigated
by Barber
(1)
and
wyere reported
by him in
1914.
His investigations revealed
that only occasional
attacks occurred
in
American residents and Filipino employees of the farm, but more often
visitors were attacked.
It was observed that cream from the milk of
one particular cow had been ingested in each instance before the at
tack,
the attacks
were limited to warm summer
months,
and no re
DIVISION
OF
PREVENTIVE
MEDICINE
307
frigerating facilities were in use on the farm.
Bacteriological anaylsis
of samples of fresh milk revealed
numerous
colonies of both staphylo
coccus albus and aureus.
Transfers were made from pure cultures
of
each
organism
into milk, incubated
at 36.5° C. for
8% hours,
and
a
50-cubic centimeter
dose of the inoculated
milk was ingested by Barber
himself on successive
days.
In
1% hours after ingestion
of the milk
inoculated with the yellow variety of staphylococcus,
an acute gastro
enteritis
appeared,
with violent symptoms
lasting between
7
and
8
hours.
Subsequent
to the report of Barber, little mention
of the staphylo
coccus
as
a cause of food
poisoning
appeared
in
the literature until
1930.
Following
this date numerous
outbreaks have been observed,
a number of which have been reported
and are hereinafter
listed
:
Author
Food
Year
Hack et al
(t)
Jordan (.1)
Ramsey
and Tracy (4)
Jordan and Hall (6)
Jordan (6)
Tanner and Ramsey
(7)
McDurney
M)
Jordan and Burrows
(9)
Crabtree
and Lltterer (10)
Corpening
and Foxhall (II) —
Oeiger
et al. (It)
Deck ot al. (IS)
Dcnison Ui)
Shaughnessy
and Grubb (16)-
Sponge cake
Cheese
-
Milk
Chicken
gravy
Cake
Milk
Chocolate
eclairs..
Custard-filled
hakery
goods,
hakery
goods, custard-
filled
coffee cakes, doughnuts,
chocolate
eclairs
(5
outhreaks).
Milk
Custard-filled
cake
Ice cream
Tongue
sandwiches
Cream
pun's
—
Milk
Custard
cake
1930
1930
1931
1931
1931
1932
1933
1934
1934
1935
1935
1935
193fi
193G
1937
An outbreak of food poisoning
involving over 250 men at the marine
base,
Quantico, Va.,
was
mentioned
in the section
on preventative
medicine in a recent issue of this publication
{17).
The first symptom
in the majority
oT cases
occurred
4 hours
after
eating
the suspected
food, which in this
case
was ham
that had
been cooked
the night
before,
and had been left overnight in the container to gradually cool.
A staphylococcus
albus was isolated
from a whole ham.
A report of
an additional outbreak of staphylococcus
food
poisining due
to in
gestion
of cold boiled
ham which wae contaminated with a hemolytic
staphylococcus aureus, involving
124 men aboard
the U. S. S. Arizona
on December
12,
1936, will
be included in this article.
Of particular
significance
is the constant observation
that in the
outbreaks of staphylococcus
food
poisoning
that have
been reported
in
the literature,
the
infected
food
was
unchanged
in
appearance,
odor,
and flavor.
In their work in experimental
staphylococcus
food
poisoning, Kelly and Dack (18) found that there was no change in the
taste, appearance, or odor of meat and bread inoculated
with staphylo
cocci and incubated
for 5 hours
at 37° C, confirming an observation
of numerous
investigators of actual
outbreaks
of this condition.
308
DIVISION
OF
PREVENTIVE
MEDICINE
Clinical
Picture
of
Staphylococcus
Food
Poisoning
With
Important
Differential
Points
There are
two
important
differences
between
the staphylococcus
type of food
poisoning
and
the more familiar
type
due
to
the sal
monella
group.
First,
from
a
clinical
standpoint,
the incubation
period in staphylococcus
food
poisoning
is commonly between
2 and
4 hours,
while in salmonella
food
poisoning
the onset of symptoms
average between
6 and
12 hours
after ingestion
of the infected
food.
In many cases of the salmonella
type
the incubation period
is more
than 24 hours.
The second,
and perhaps
most important
difference
between
the staphylococcus
and salmonella
types of food
poisoning
is that staphylococci
isolated
from the former
type have certain cul
tural characteristics
which will
be described
subsequently,
and from
which a sterile broth filtrate may be obtained
which, when swallowed
in small
amounts
by human volunteers,
reproduces
the symptoms
of an acute
gastroenteritis.
Large amounts
of bacteria-free
filtrate
from salmonella
cultures
have been fed to humans without producing
any symptoms
(19).
The history, subjective symptoms,
and objective signs in an attack
of food
poisoning
due
to
a staphylococcus
are quite uniform,
and
except for the uniformly short incubation period
do not differ in any
large
measure
from attacks due
to
other
organisms.
The
onset
is
characterized
by severe nausea
and abdominal cramps,
followed by
vomiting and diarrhea.
The patient may vomit from a few to 20 or
more times during a period of a few minutes
to
8 or more hours.
At
times the vomitus may be streaked with blood.
During
the vomiting
stage, frequent
watery stools are passed.
The appearance
of blood in
the stool is common.
Early there is normal or subnormal temperature
with cold sweating
and marked
prostration.
Severe cases may show
an elevation
of temperature
up to
100° F. on the second
day.
Oc
casionally severe cases
will suffer with cramps
in the flexor
muscles
of the legs.
The acute symptoms
generally
last from
1 to
8 hours,
although some weakness may
be present for
1 or more days.
Prompt
recovery
is the rule, no fatal cases having been reported.
The treat
ment is symptomatic.
Experimental
and
Laboratory
Viewpoint
of Staphylococcus
Food
Poisoning
Live cultures
of staphylococci which were isolated
from milk were
swallowed
by Barber
(1) with reproduction of the symptoms
of acute
gastroenteritis.
It was not until
1930
when Jordan
(S) fed human
volunteers
bacteria-free
filtrates from cultures
of staphylococci iso
lated from
a sponge cake which caused an outbreak of gastroenteritis
reported
by Dack
et al.
(2), with duplication
of the characteristic
clinical picture.
DIVISION
OF
PREVENTIVE
MEDICINE
309
For many years
there has been a degree of uncertainty
regarding
the unicity or multiplicity
of the
toxic
factor in staphylococcus
fil
trates.
It is now believed
that
the hemolytic,
dermonecrotic,
and
lethal components
are the attributes of a single factor.
Dolman
(20)
studied bacteria-free
filtrates from 200 different strains of staphylo
cocci.
In each instance
the filtrate obtained
was found
to possess a
staphylococcus exotoxin
of specific
pathogenic
and antigenic
proper
ties.
Forty-two
human
volunteers
drank bacteria-free
staphylococcus
filtrates on
110 occasions with relative impunity.
It was found that
only occasional
strains were capable of producing a filtrate containing
a factor that produced
gastroenteritis
in human
volunteers,
suggesting
thereby that the "enterotoxic"
factor is distinct from the hemolytic,
dermonecrotic,
and lethal components,
and
is characteristic of only
certain strains of staphylococci.
Jordan (6) reports
that he observed
a strain of staphylococcus
that
retained the ability
to produce
an enterotoxic
factor for as long
as
1 year.
Other investigators have
found
that the ability
to produce
this enterotoxic
factor may be lost after
repeated
transplantation of
certain strains.
Jordan
and Burrows
(21) found
that by the
use of
starch
or custard
media,
it
was
possible
to
produce
bacteria-free
filtrates containing enterotoxic
substances
from
certain
strains which
had not yielded
enterotoxic
filtrates in previous
laboratory tests.
In
addition, strains that apparently had lost the power to produce entero
toxic filtrates through successive transfer,
although originally positive,
were found to regain
that characteristic when
transferred
to custard
medium or to ordinary medium
to which starch
had been added.
Whereas
negative
results
were
obtained by Woolpert
and
Dack
(22) in Macacus rhesus monkey feeding
experiments
using staphylo
coccic filtrates which were definitely toxic
to humans,
positive results
were obtained
when
a filtrate was prepared
from organisms
cultured
in an atmosphere
of 20-25 percent
carbon
dioxide.
One of the most important experimental
observations
on the toxic
effects of staphylococcus
filtrates was reported
by Borthwick
(23) in
1933.
Using rabbits and
guinea
pigs, he obtained
uniformly
nega
tive
results
in
feeding
experiments
except
when
the
hydrogen ion
concentration
of the
stomach
was
previously
adjusted
to pH
7.3.
Positive
results
were
obtained
with
intrarectal
injection
of toxin,
only when the rectum
had been irrigated with saline and the reaction
adjusted to pH 7.3.
He also found that staphylococcus
toxin when
added to gastric
juice in vitro,
a slightly acid (pH 6.8) or a slightly
alkaline (pH
7.8) reaction
impaired its activity,
while there was no
attenuation when
the reaction
of the juices was pH 7.3.
This work
suggests one of the possible
causes of the infrequency of this type of
gastroenteritis in humans,
and
the frequent failures
in human and
animal feeding tests.
310
DIVISION
OF
PREVENTIVE
MEDICINE
Dack et al (2) report that the viability of staphylococci is destroyed
by exposure
to 80° C. for
15 minutes,
while the potency
of the toxic
factor is slightly attenuated
but not eliminated
in filtrates subjected
to
100°
C. for 30 minutes,
as tested by subsequent
intravenous in
jections in rabbits.
Jordan's work (3) indicated that staphylococcus
toxin is destroyed
by boiling, although he further
reports
(6) that
sterile
toxic
filtrates retain
their original strength when
stored
at
low temperatures
for
3 to 4 weeks,
and that the toxic
qualities
aro
not altered by strong chlorine solutions.
Jordan
and Burrows
(21) and Stritar
and Jordan
(24) conclude
in
their reports
published in 1934 and
1935, respectively,
that the ability
to produce
an enterotoxic
substance
is not limited to any particular
kind of staphylococcus,
and that food poisoning strains possess neither
biochemical,
hemolytic, or agglutinative characteristics
to indicate any
degree of homogeneity.
A brief report of what is believed
to be the first practical cultural
method of differentiating
enterotoxic
and nonenterotoxic strains of
staphylococci,
which was developed
by Stone
(25), appeared in 1935.
It had been known for some time that upon
a combined
agar and
gelatin medium
there could
be demonstrated
zones of altered gelatin
around
the
colonies
subsequent
to
incubation.
Stone
and
others
found that the characteristic liquefication was variable when occurring
in the usual
beef and veal infusion, or 0.3 percent
beef extract, but
was specific
when
beef extract
alone was included in a high concen
tration
with
the
gelatin.
With
a
combination
of
3
percent
beef
extract, 3 percent gelatin,
and 1.5 percent agar, he found an improved
method
using
ammonium sulphate
solution
as
a developer,
for the
demonstration
of
this
characteristic principle.
Tlus work
has not
been published,
but the results of his studies
are incorporated in the
new Difco medium,
Bacto-Stone's gelatin agar.
Detailed method of
preparing this medium
and developer, with interpretation of reactions
is quoted
(26) :
1. Procedure.— (a)
The
medium
is
prepared
for
use
by
slowly
addiug
7.5
grams of Bacto-Stone's
extract
gelatin
agar to
100
cc of distilled
water
in an
Erlenmeyer
flask.
The
flask
should
bo
rotated
gently
to
assure
a
thorough
wetting
of the powder and to avoid the formation
of lumps.1
Sterilize
in the autoclave
for 20 minutes
at
15 pounds pressure
(250° F.).
If
larger
individual
units
are
prepared
it
is
recommended
that
the
medium
be
heated to the boiling
point
immediately
before autoclaving.
1 If basic ingredients
are used in preparing
this
medium,
the following
procedure
is recommended
by
Stone in a personal communication
to the author:
1. 3 percent Difco (Dacto)
beef extract (other beef extracts have not been compared with the Difoo product
by Stone).
2. 3 percent Difco granular
gelatin.
3. 1M percent granular
agar.
4. Dissolve
ingredients
in boiling
distilled
water.
Sterilize
in autoclave
for 20 minutes
at 15pounds
pres
sure.
Do not adjust
for pH.
Do not include
other ingredients
unless salt and blood are used for a blood
agar base.
DIVISION
OF
PREVENTIVE
MEDICINE
311
(b)
Plates can be poured for streaking
suspected foods on in the study of pure
cultures.
Care should be taken to pour the medium at a temperature
(45-50° C.)
at which
it will flow but at which
excessive
water
of condensation
is avoided.
The
use of porcelain
tops on petri dishes is recommended.
When time permits,
such plates for Btreaking can be kept for a day or more in the refrigerator
before
using, in order to secure
a dry surface, discouraging
the development of spreaders.
Plates
should
be streaked
so that in
some
portion
of the plate
well-developed
isolated colonies will appear.
(e)
Incubate
plates for
24 hours at 37.5°
C.
Pigmentation
is quite vivid on
this medium.
After incubation
the developer
is poured gently upon the surface
of the medium
so that all colonies are completely
covered.
Let plate stand until
the reaction
is well defined.
Typical reactions
are
complete,
as a rule,
in
less
than
5 minutes.
2.
Preparation
of developer. — (a)
Place
1 pound of C. P. ammonium
sulphate in
&
1,000
cc
graduate.
Add distilled
water
at
70°
C.
to bring
the
volume
to
1,000
cc.
Stir with glass rod until solution
is complete.
This developer should
be stored in glass-stoppered
bottles.
Vaseline
on the stoppers prevents freezing
of the stopper within the bottle neck.
3. Reaction.— (a)
After developing
not over
5 minutes,
the background
of the
medium
assumes
an
opaque,
yellowish
color.
Colonies
producing
"gastro-
enterotoxic
substance"
are surrounded
by
a clear
zone
of transparent
medium
which approximates
a radius at least one-eighth
fr>ch from the edge of the colony.
Experience
to date indicates that zoning of a lesser
degree
is significant,
but not
necessarily
definitely
positive.
The
large
definite
clear
zone
parallels
active
liquefication
of Stone's original
beef extract gelatin medium, and the weaker zoning
colonies parallel slow liquefications
or slight liquefications
in the same medium.
(6)
Since the ammonium
sulphate
does not destroy the viability of the organ
isms, zones colonies can be picked direct and planted onto two new culture plates.
Such spot colony planting
can be observed by developing
one culture
and using
the
undeveloped
correlated
culture
plate
for
pure
culture
study
later.
Con
tamination
of one colony
by rinsing
organisms
from adjacent
colonies
does
not
seem to be a serious hazard to pure colony isolation.
Care should be exercised to
avoid too active stirring when introducing
the platinum loop during colony picking.
(c) B. subtilis, yeast, and possibly other organisms, give active zoning.
Gram
staining
of the suspected staphylococci
colonies is therefore essential as a primary
step in working with all unknowns.
4.
Feeding experiments. — (a)
The
beef extract gelatin agar does not represent a
better "toxin"
producing
medium.
It simply
provides
a practical,
and
so far
specific cultural
reaction for typing.
For animal feeding tests, starch medium
is
generally considered superior to other methods.
(b) In checking
zone
reactivity
against
animal
or human
feeding tests, com
parison
should
be conducted
concurrently
rather
than
some
weeks apart.
Old
cultures occasionally
lose both their animal and cultural
reactions, and if a feeding
test positive strain
some time later is checked for zone reactivity,
a failure in such
a zone behavior
should
bo substantiated
with another feeding test.
5.
Reactions on
blood
agar. — (a)
The addition
of 0.9 gram of sodium
chloride
per 100 cc of medium provides an excellent base for uncooked blood agar.
Degrees
of hemolysis are first noted, then the plate is developed with ammonium
sulphate.
This method must
be used
with
caution until the combination
of reactions
that
can occur is fully understood.
In the study of staphylococci
suspected of produc
ing "gastro-enterotoxic
substance"
one may note the following
reactions:
(1)
No hemolysis,
no
zoning.
(Considered
"potentially nontoxic")
312
DIVISION
OF
PREVENTIVE
MEDICINE
(2)
No
hemolysis,
moderate
to
active
zoning.
(Considered
"potentially
toxic")
(3)
Hemolysis,
no zoning.
(Considered "potentially nontoxic")
(4)
Hemolysis,
moderate
to active
zoning.
(Considered
"potentially toxic")
Source
op Staph ylococc us
Contamination
in Food
Poisoning
It has been shown that milk obtained from the udders of apparently
healthy cows contains varying numbers of organisms, including various
strains
of
the
staphylococcus.
A number of outbreaks have
been
investigated wherein
the suspected
food was found to have been pre
pared
under
generally
insanitary
conditions,
including
improperly
cleaned
equipment,
nearby insanitary
toilets,
excessive handling
of
the food,
numerous
flies,
and
other
factors.
While human carriers
of staphylococci are legion, no attack of this type of food poisoning
has
been
traced
to
such
potential foci of infection
as chronic purulent
otitis media,
chronic tonsillitis, chronic pulmonary
disease, osteomy
elitis,
furunculosis, or other
suppurative
processes.
Contamination
of food, other than milk, presumably
takes place during manufacturing
and
cooking
processes.
It appears
that the common
modes of con
tamination include respiratory droplet infection, handling of food and
equipment with contaminated
hands,
use of previously infected
ma
terials, improperly cleansed and sterilized
equipment,
and transfer of
organisms
by flies and other insects.
Prevention of Staphylococcus
Food Poisoning
in the
Navy
Adequate supervision
of
the handling,
storage,
preparation,
and
consumption of all foods will reduce the incidence
of all types of food
poisoning.
The absence of flies, roaches,
and vermin in commissary
spaces is of great importance.
Personnel
involved in the preparation
and serving
of food should
be educated
on this subject with special
reference
to personal
cleanliness
and
hygiene,
the
avoidance
of han
dling food with their hands, proper refrigeration of all foodstuffs,
the
necessity
of
thorough
and
recent
cooking,
and
the
importance
of
promptly reporting all personal
illness including skin diseases to the
medical
officer.
In the Naval Establishment, particularly
in the general
messes of
ships
afloat,
outbreaks of food
poisoning
have
occurred
at various
times.
In such outbreaks there has been noted
a fairly uniform and
characteristic history
and
sequence
of events.
The
most
common
story is that of the preparation of various articles of meat, meat prod
ucts,
gravies,
custards,
and
various
other
items with
a high protein
content,
from
6 to 24 or more hours
before consumption,
with exces
sive handling and slow cooling
at room temperature
in the galley,
and
neglected refrigeration before being served.
The noon meal on Satur
day aboard numerous
ships will be found to consist of cold boiled ham
with vegetable salads or perhaps boiled vegetables.
In some instances
DIVISION
OF
PREVENTIVE
MEDICINE
313
the ship's cook is allowed
to boil the hams for Saturday dinner during
the Friday morning watch.
Such a practice
doubtlessly
has a tend
ency
to
make
the
galley
appear
more
orderly
during
the regular
Saturday morning inspection,
but also provides the basis for not in
frequent outbreaks of acute gastroenteritis due
to
the various food
poisoning
organisms.
This
is particularly
true
when
the
meat
it
allowed
to cool slowly, then
handled
in the process of removing the
bone, and subsequently
allowed
to remain in a warm atmosphere
until
served
20 or more hours later.
If boiled ham is to be served, it should
first be boned, and then placed in the boiler for cooking
at such a time
that it may be served hot, immediately after having been cooked.
If
it is desired
to serve it cold,
the hams should
be transferred
from the
boiler immediately after having been cooked
to
a refrigerator with a
temperature
of about 32° F., to remain
there until just before meal
time, when it may be removed
for the necessary
slicing.
Outbreaks of food
poisoning
due
to infected
salads
that contain
chicken or turkey meat left from a previous
meal demonstrates
what
has been mentioned
as excessive handling of food.
Frequently
such
left-overs have not been stored in the chill room,
but have been al
lowed
to remain
in some part of the galley
where
the temperature
is
favorable to contamination and to the rapid growth of bacteria.
This
type of meat provides an even better culture medium when it is cut
in small pieces and mixed with the various ingredients
characteristic
of such salads.
Experience has long since shown
us that hash made
from materials cooked
on the previous day,
is liable to produce
an
explosive
outbreak of vomiting, abdominal cramps,
nausea, prostra
tion, and diarrhea.
It is important
to supervise
the preparation of
box lunches provided rifle-range
parties,
target-repair parties,
picket-
boat crews, and other groups that commonly leave their station early
in the morning, and do not have the facilities to properly store highly
perishable
articles of food.
The
manufacture
of
custards
and
custard
fillings in
the
Navy
must be given attention to insure
the use of fresh materials,
properly
cleansed
and
sterilized
equipment,
adequate
cooking,
prompt
cool
ing, avoidance
of unnecessary
handling, and other possible
sources of
contamination, and the adequate storage of the finished product under
refrigeration with
early
consumption.
These
same precautions
also
apply to the local manufacture of ice cream.
Due to their highly perishable
nature
and the frequency
with which
they
are involved in outbreaks of food
poisoning
of varying
mag
nitude, the source of commercially produced
bakery goods, including
items with cream or custard
fillings, all types of sandwiches,
and ice
cream, should
be investigated
and their sale in the ship's service stores
regulated
by competent
medical
authority.
314
DIVISION
OF
PREVENTIVE
MEDICINE
Report on
an Outbreak
On December
12,
1936, while at anchor at San Pedro, Calif., an outbreak
of
acute gastroenteritis
occurred aboard the U. S. S. Arizona involving
124 members
of the ship's company.
All individuals
that applied for treatment
gave a history
of eating cold boiled ham for dinner aboard the ship on the day of the outbreak.
The onset of symptoms was sudden, between 2% and 3J-2 hours after ingestion of the
suspected ham, and was characterized
by adbominal
cramps followed
by nausea
and
vomiting.
Prostration
was marked,
and an occasional
man suffered
with
severe
cramps
in
the
flexor
muscles of the
legs.
Although
the
symptoms
of
gastroenteritis
were
violent
in the majority
of cases,
except for some
weakness,
all but two
men
were well within
a period of about
8 hours.
Two individuals
vomited
frequently
and passed
watery
stools repeatedly
for about
24 hours, fol
lowed by marked
weakness which
gradually
subsided
on the third day.
Treat
ment
consisted
of
saline
catharsis,
camphorated
tincture
of
opium,
bed rest,
external heat, and bland diet, depending upon the severity of symptoms.
Laboratory study:
1.
Suspected ham: Under sterile precautions,
specimens of meat were obtained
from a whole ham immediately
after the onset of the outbreak.
Samples of ham
were examined in the laboratories
of the city of Long Beach, Calif., using Stone's
differential
medium.
Colonies of a food poisoning type of hemolytic
staphylococ
cus
aureus
were
obtained.
Colonies
of this
staphylococcus
were
transplanted
from Stone's medium
to broth,
which
in turn
was fed
to a kitten,
producing
an
acute diarrhea
in approximately
3 hours.
2. Stool examination:
Cultures
from stool specimens obtained
from two
cases
with severe
symptoms
were reported negative for food poisoning organisms of the
salmonella
group.
3. Serum agglutination
tests: Serum agglutination
tests made on sera obtained
from two cases of marked severity
were
reported
positive
in dilutions
as follows:
Case 1
Case 2
Serum ob
Serum ob
Serum ob
Serum ob
tained 8
tained
M
tained 6
tained
14
days after
days after
days after
attack
days after
attack
attack
attack
E. typhi
1:32
1:20
1:64
1:20
1:16
1:20
1:16
1:10
S. schottmulleri
1:16
1:10
1:16
1:20
Facts
regarding
the
suspected
ham:
The suspected hams
were
purchased
under
contract
No. N 244 S 1935-6, and were
received on board ship in acceptable con
dition
on
December
1,
1936.
This
shipment
totaled
1,906
pounds,
and
was
composed of sweet-pickle
cured hams, type
1, regular or short cut, grade No.
2.
Although
these
hams were
of the "cured" variety,
upon receipt aboard ship they
were
placed
in
a cold
storage
room,
the
temperature
of which
is maintained
between 14° and 22° F.
At 3 p. in. on December
10,
1936, about
500 pounds of
this ham were removed from cold storage anil placed in the butcher shop adjacent
to the galley for thawing.
On December
11, 1936,
these
hams were
boiled from
9 a. m. to
1 p. m., then allowed
to cool until
about
3 p. in., at which
time they
were
boned and placed in open pans on gratings in a passageway adjacent
to the
galley, where
they reamined until about
10 a. m. on the following
day, December
12, at which time they were
returned to the galley for slicing and were
served to
the general mess at noon of that date.
DIVISION
OF
PREVENTIVE
MEDICINE
315
Interview of the personnel involved
in the boiling, boning, slicing, and handling
of this ham revealed no instance of diarrhea,
upper respiratory
tract
infection,
furnnculosis,
boils,
or
other
presumptive
source
of
staphylococcus
infection
Flies were not present in the galley, but occasional cockroaches had been
noted.
In addition
to the general mess,
all special messes
of the ship served ham ob
tained
from the same
lot on the same
day of the outbreak,
although
they
were
cooked
in different
galleys,
and
were
handled
in
a somewhat
different
manner.
The
hams
used
by
the wardroom
mess,
junior
officers'
mess,
and
chief petty
officers' mess were boiled on December
11,
but were again baked on December
12,
before being served.
The hams used
in the warrant
officers' mess also boiled on
December
11, were placed in a refrigerator
until served at noon of the following
day.
No individual who ate ham in any of these
special
messes
suffered from
symptoms
of food poisoning.
The remaining
portion
of the specified shipment
of ham
was consumed
in the general
mess
during
the subsequent
3 weeks at
approximately
500 pounds per week, without untoward
symptoms.
Summary
1 . Staphylococci are frequently the causative
organism in outbreaks
of food poisoning and in isolated
cases of acute gastroenteritis.
Prac
tically
any food
may
be infected
with staphylococci, although such
infection
ordinarily
causes
no
change
in
the
appearance,
odor,
or
flavor of the food.
Fresh milk, custards,
and unrefrigerated
cooked
meats are frequently incriminated.
2.
Differences
between staphylococcus
type and salmonella
type of
food poisoning
include:
(a) Incubation
period
in staphylococcus
food poisoning
is between
2 and
4 hours
as
a rule, while in salmonella
infection the period
of
incubation is commonly 6 to
12 hours.
(6) From the staphylococci isolated from that type of food poisoning
may
be
obtained
a bacteria-free
filtrate, which when
swallowed
by
human volunteers reproduces
the
symptoms
of
an
acute
gastroen
teritis.
Bacteria-free filtrates from salmonella
cultures
have been fed
in large amounts
to humans without producing any symptoms.
3. Only certain strains of staphylococci are capable of producing an
enterotoxic substance
and this characteristic is not entirely constant
in any
one strain.
Staphylococcus enterotoxin is neutralized when
added
to gastric juice with
a slightly acid reaction,
suggesting
one of
the possible
causes of the infrequency of this
type
of food
poisoning
in relation to the widespread
presence of this organism.
4. A detailed quotation of Stone's cultural method
of differentiating
the
enterotoxic
and
the
nonenterotoxic
strains of staphylococci
is
given.
5. The source of infection in this type of food poisoning
is generally
unknown, although respiratory droplet infection, contact with hands
or objects contaminated with the discharges from various suppurative
processes, and the transfer of organisms
by flies and other insects have
been implicated.
Staphylococci have
appeared
in large
numbers
in
the milk from apparently healthy cows.
316
DIVISION
OF
PREVENTIVE
MEDICINE
6.
The
watchwords
in
the
prevention
of
staphylococcus
food
poisoning are cleanliness
and freshness of all foods, thorough cooking
with
a minimum amount of subsequent
handling, pasteurization
of
milk, and the careful
protection and refrigeration of all foodstuffs.
7. An outbreak of food poisoning
due to ham, which was found by
cultural
and
feeding
tests
to
have
been infected
with
a hemolytic
Staphylococcus
aureus, is reported.
Bibliography
(1)
Barbeb, M. A.
Philippine J. Sec,
9:
515,- 1914.
(2)
Dack,
G. M., Carey,
W. E., Woolpert, 0., and Wiggers,
H.
J. Prev.
Med., 4:
167,
1930.
(3) Jordan, E. O.
J. A. M. A., 94:
1648,
1930.
(4)
Ramsey, R. J., and Tracy,
P. H.
Proc.
Soc. Exper.
Biol. & Med.,
28:
390,
1931.
(5) Jordan, E. 0., and Hall, J. R.
J. Prev.
Med.,
5:
387,
1931.
(6) Jordan, E. O.
J. A. M. A., 97:
1704,
1931.
(7) Tanner, F. W., and Ramsey,
R. J.
Am. J. M. Sc., 184:
80,
1932.
(8)
McBurney, R.
J. A. M. A.,
100:
1999,
1933.
(9) Jordan, E. O., and Burrows,
W.
Am. J. Hyg.,
20:
604,
1934.
(10)
Crabtree, J. A., and Litterkr, W.
Am. J. P. H., 24:
1116, 1934.
(//)
Corpening,
A., and Fqxhall,
E. P.
Am. J. P. H., 25:
938,
1935.
(12)
Geiger, J. C., Crowley, A. B., and Gray, J. P.
J. A. M. A.,
105:
1980,
1935.
(13)
Dack, G. M., Bowman,
G. W., and Harger, R. H.
J. A. M. A., 105:
1598,
1935.
(14)
Denison, G. A.
Am. J. P. H., 26:
1168,
1936.
(15)
Shaughnessy, H. J., and Gruhk, T. C.
J. Infect.
Dis.,
58:
318,
1936.
(16)
Geiger, J. C.
Public Health
Reports, 52:
765,
1937.
(17)
U. S. Naval Med. Bul., 35:
148,
1937.
(18) Kelly, F. C, and Dack, G. M.
Am. J. P. H., 26:
1077,
1936.
(19)
Dack, G. M., Carey,
W. E., and Harmon, P. H.
J. Prev.
Med., 2 : 479,
1928.
(20)
Dolman, C. E.
J. Infect.
Dis.,
55:
172,
1934.
(21) Jordan, E. O., and Burrows,
W.
J. Infect.
Dis.,
57:
121,
1935.
(22)
Woolpert, O. C, and Dack, G. M.
J. Infect.
Dis.,
52:
6, 1933.
(23)
Borthwiok, G. R.
Brit. J. Exper.
Path.,
14:
236,
1933.
(24)
Stritar, J., and Jordan, E. O.
J. Infect.
Dis.,
56:
1, 1935.
(25)
Stone, R. V.
Proc.
Soc.
Exper.
Biol. & Med.,
33:
185,
1935.
(16)
Bacto-Stqnk's
Extract
Gelatin
Agar,
Difco
Laboratories,
Detroit.
Mich.
FOOD
POISONING,
UNITED
STATES
NAVAL
STATION,
GUANTANAMO
BAY,
CUBA
By Commander
C.
\V.
D. Smill. Medical
Corps,
United
States Navy
On August
12, 1937, an outbreak of food poisoning
occurred
among
men subsisted
at the receiving
barracks
branch
of the general mess of
this
station.
The
suspected
food
was
corned-beef
hash
served
for
breakfast
on that day.
Members of no other mess were affected.
The menu in that mess was as follows:
Fresh milk and cereal,
corned-beef hash,
catsup, hot cakes
and sirup and coffee.
The hash was prepared in the following
DIVISION
OF
PREVENTIVE
MEDICINE
317
manner:
12 pounds of potatoes
were
boiled at 1600, August
11, and placed in the
refrigerator
overnight.
At 0530,
August
12,
the
hash was prepared
from
one
6-pound
can of issue corned beef which appeared intact and the contents of which
presented no unusual features to the cook on duty; 12 pounds of potatoes prepared
as shown above; four fresh onions
(U.
S.) ; two 2-pound
cans of tomatoes which
appeared normal in all respects; Yi pint of Navy issue catsup.
The hash was baked
for
1 hour in an oven temperature
of 350°
to 400° F. and served over a period
from 0650
to 0830.
There
was about
half of a platter
of hash left over at the
conclusion
of the meal, but, by the time patients
began to report for treatment,
this had
been
collected
with
the garbage and consumed
by the hogs.
It was
therefore impossible to secure samples of the suspected food.
Out of a total of 55 men who ate breakfast in that mess on August
12, 20 reported
as having eaten the hash in varying
amounts.
Of these
20,
16 were admitted
to
the dispensary
for treatment,
and while there was considerable
variation
in the
other
articles
of food consumed
at the meal, all
16 ate the hash.
The earliest
appearance of symptoms was recorded as 0930 and the latest 1200.
Those report
ing early appearance and greatest violence of symptoms
were quite consistently
those who consumed the greater amounts of hash.
Of general clinical features the following
figures were obtained from the 16 men
admitted for treatment:
Chills
6
Bitter taste
13
Fever
12
Vomiting
12
Headache
9
Diarrhea
15
Faintness
13
Treatment given was symptomatic,
eliminative,
and supportive.
One man who
had
eaten considerable
amounts
of the hash developed
alarming
symptoms
of
collapse but responded promptly
to appropriate
treatment.
Two men lost suffi
cient
fluid
to require
intravenous
normal
saline for
the relief
of
severe
muscle
cramps.
All patients were sufficiently
recovered to be able to resume their duties
early the following
morning
and were consequently
carried on the binnacle list for
August 12.
Although a sample of the suspected food could not be obtained,
cultures
were
made on similar
cans of ingredients in the galley.
All were negative.
Numerous
cultures of vomitus and stools were made in nutrient
broth and on plates of Endo's
Media but all were negative.
The epidemiological
features
and clinical
aspects
of the outbreak,
however,
were
considered
consistent
with an infection
by Sal
monella
enteritidis.
Agglutination
reactions
done August
18,
6 days
after
the
outbreak,
on the three patients
who were most severely affected gave results
as
follows:
From all data obtained, the following conclusions
are drawn:
1. The contaminated food was corned-beef
hash.
2. The causative organism was Salmonella
enteritidis.
3. There was no direct evidence of contamination of any particular
ingredient of the hash, but suspicion
falls strongly on the corned
beef.
4. There were no irregularities in the method
of preparation of the
Case No. 1.. Salmonella
enteritidis
positive
agglutination.
Case No.
2
do
Case No. 3
do
Dilution
1-640
1-320
1-320
hash.
45202—38
11
STATISTICS
HEALTH
OF THE
NAVY
The following tables are summaries
of morbidity rates per 1,000 for
the third quarter of 1937 in comparison
with rates for the correspond
ing quarter of the preceding
5 years:
ENTIRE NAVY
Year
1932.
1933.
1934.
1935.
1936.
1937.
All dis-
549
.101
51(1
373
33R
377
Injuries
Poison
ings
0. 63
7. ID
4.28
.29
7.18
.40
All
causes
(Ki4
47f1
580
420
41M
4311
Communicable
diseases
(0 hi;
120
92
88
101
FORCES ASHORE
544
85
0.93
629
Cl
(')
107
1933
382
74
10.81
468
7
66
72
637
91
1.35
730
31
181
64
1935
426
57
.20
484
14
127
43
416
60
19.19
486
29
120
38
1937
508
63
.50
571
31
168
37
FORCES AFLOAT
1932
552
37
0.45
590
(0
(')
159
414
61
5.32
481
10
95
136
1934
44P
53
5.69
507
16
91
125
1935
343
51
27
395
11
72
92
1936
291
66
!so
357
21
70
55
1937
302
60
.43
362
13
63
72
' Not available.
Common
infectious
diseases
of
the
respiratory
type. —There
were
2,406
admissions
for
these diseases
reported
from
the
entire
Navy
for
the
third
quarter of
the
year
1937 — 1,214
from
forces
afloat,
1,043
from shore stations in the United
States,
and
149 from foreign
shore
stations.
Catarrhal
fever
was
responsible
for
1,626
of
the
admissions.
319
320
STATISTICS
Ships and shore stations
reporting the largest number of cases were
as follows:
July
1 August
September
Tota
Naval
Traming Station,
San Diego, Calif.
Naval Training Station,
Newport,
R. I. . .
Naval Training Station,
Norfolk,
Va
Biigade
Hospital,
Shanghai,
China
Marine Barracks,
Quantico,
Va.
Naval Training Station,
Great
Lakes,
Hi
ll. S. S. Tcnntstte
U. S. S. Sara/osa (fleet air detachment)
U. S. S. Ranger
Marine Corps
Base, San TMego, Calif
Fleet Air Base, Pearl Harbor,
Hawaii
2M
is:
121
>.?
84
SI
SI
Mumps. —The U. S. S.
West Virginia reported
39 cases of mumps
during the quarter,
12 in July,
19 in August,
and
8 in September;
the U. S. S.
Tennessee,
2 in July,
12 in August, and
5 in September;
and the Naval Training Station, Norfolk, Va., 6 in July,
12 in August,
and
1 in September.
Chickenpox. —Eight
cases
of
chickenpox
were
reported
for
the
quarter, as follows:
In July,
1 each from the U. S. S. Idaho,
U. S. S.
Medusa,
U. S. S. Oklahoma,
and the Submarine
Squadron No. 4; and
in August,
2 from the U. S. S. Detroit,
1 from the U. S. S. Pensacola,
and
1 from the U. S. S. Smith.
Cerebrospinal fever.—Two cases of cerebrospinal
fever were reported
for
the
quarter.
An
apprentice
seaman,
19
years
of
age,
with
4
months'
service,
was
transferred
from
the U.
S.
S.
Tuscaloosa
on
August
13,
1937.
No disposition has been made of this
case at the
end of the third quarter.
A midshipman first class, 20 years of age, was transferred
from the
U. S. S. New York to the Norfolk
Naval Hospital,
Portsmouth, Va.,
on August 13, and discharged from the sick list on September
4, 1937.
Typhoid
and
paratyphoid
fevers.—A
moderately
severe
case
of
typhoid fever
(a fireman,
first class, 26 years of age, with 7 years and
9 months'
service)
was admitted to the sick list at the Naval Proving
Ground,
Dahlgren, Va.,
on
September
23,
1937,
and transferred
to
the
Naval
Hospital,
Washington,
D.
C.
Two
courses
of straight
typhoid
vaccine
had
been
completed
in January
1930
and
March
1935.
The questionnaire
in this case states:
Place and source of infection unknown.
There had been an epidemic of typhoid
fever in the county and the patient
had been drinking questionable
water.
Relative
to the incidence
of typhoid
fever in this
section
of Vir
ginia,
the
medical
officer
of
the Naval
Proving
Ground,
Dahlgren,
Va., under date of August 3,
1937, reports
as follows:
During the past
2 weeks,
an epidemic
of typhoid
fever has occurred
in King
George
County,
Va.
It was first
reported
to this
office
by
a member
of the
county
board of health on July 27, 1937.
As closely as could be estimated, there
are 27 cases
*
*
*
all about
15 miles distant from this station.
STATISTICS
321
One mild
case
of paratyphoid
fever B, without complication, was
admitted
to
the
sick list from
the Marine
detachment,
American
Embassy, Peiping, China, in July.
A course of typhoid vaccine
had
been completed
in December
1935.
Poliomyelitis,
anterior,
acute. —One
case of poliomyelitis
occurred
in an enlisted
man while on leave from the United
States Naval Air
Station,
San Diego, Calif.
The senior
medical
officer of the Naval
Training Station, Great Lakes,
11l., reports that "he is being carried
at this station while a patient in the United
States Army Hospital,
Fort Leavenworth, Kans."
During
the month of September
1937,
three
cases
of poliomyelitis,
anterior,
acute,
occurred
in
one
company
on
the
Naval
Training
Station, San Diego, Calif .
The first case was admitted on September
8
and transferred
to the hospital on September
11 where diagnosis
was
confirmed.
The swimming pool was closed;
the entire company and
company
commanders
were
placed
in
strict
quarantine;
separate
messing
facilities were provided; members
of the company were ex
amined
by a medical
officer twice daily, and a nasal spray given daily
for
3 successive
days and weekly for the following
2 weeks;
contacts
were
placed in quarantine; all bedding
was aired
and sunned
daily;
and the
men
were
encouraged
to restrict close or intimate contact
with each other.
On
September
13,
the
day quarantine
was
established,
another
member
of this company complained
of general malaise and symptoms
of a common
cold.
A complete
physical examination at this time by
the medical officer of the day showed normal reflexes and no symptoms
other than those indicated above.
He was transferred
to the hospital
and
diagnosis
of
poliomyelitis
was
established.
He
developed
paralysis of the muscles of deglutition, then of the deltoids,
and later
of the muscles
of respiration, and died on September
16.
The third
case was transferred
to hospital on September
15.
The
patient complained
of nausea and general malaise and later developed
stiffness
of the lumbar muscles.
In summarizing, the medical officer reported
as follows:
1.
Three cases of poliomyelitis
were found in one company of recruits containing
97 men.
2. The source of infection
points to San Diego and vicinity where 39 cases have
been reported during
the last 3 months.
3. The value of the preventive
measures employed
is not known.
Scarlet fever.—One case was reported
in July by the U. S. S. West
Virginia and one case in August by the Naval Training
Station, San
Diego, Calif.
Diphtheria.—In July,
a private, Marine
Corps,
25
years
of
age,
with 2 years and
1 1 months' service, was admitted to the sick list with
diphtheria from the Marine detachment,
American Embassy, Peiping,
China.
He was discharged
to duty after 8 sick days.
322
STATISTICS
INJURIES
AND POISONINGS
Admissions Fob Third Quarter
Ending
September
30,
1937
The
following
table,
indicating
the
frequency of
occurrence
of
accidental
injuries and poisonings in the Navy during the third quarter,
1937,
is based
upon
all Form F cards covering admissions
in those
months which have reached
the Bureau:
Admissions,
Admission
Admission
July, August,
rate per
rate per
and Septem
100,000,per
annum
100,000,year
ber. 1937
1937
INJURIE"
Connected
with
work or drill
744
2,264
2,513
Occurring
within command
but not associated with
work
544
1.960
1.924
Incurred
on leave or liberty or while
absent without leave
615
1,872
1.760
All injuries
2.003
6,006
6. 197
POI"ONING"
Industrial poisoning
2
6
7
Occurring
within command
but not connected with work
9
27
211
Associated
with
leave, liberty, or absence without leave
4
12
18
15
46
236
2,018
6.142
6,434
PERCENTAGE
RELATIONSHIPS
Connected
with the
performance
of
work, drill, etc.
Occurring
within command
Not connected with
work
or
pre
scribed duty
Occurring
out
side
command —
leave,
liberty,
or
A.
W.
O. t.
July,
Au
gust, and
September,
1937
July, Au
gust, and
September,
1937
July, Au
gust, and
September,
1937
Year
1936
Year
1936
Year
1936
Percent
of all injuries
37.1
40.6
32.2
31.0
30.7
28.4
Percent
of all poisonings
13.3
3.0
60.0
89.5
26.7
7.5
Percent
of total
admissions,
injury
and
poisoning
titles
37.0
39.2
32.3
33.2
30.7
27.6
Note.— Poisoning
by a narcotic
drug or by ethyl
alcohol is recorded under the title "Drug addiction'
"alcoholism," as the case may be.
Such cases are not included
in the above figures.
MORBIDITY
Summary for the Third Quarter
Ending
September
30,
1937
Forces afloat, 83,195
Forces ashore, 48,238 Entire navy, 131,433
Admis
Rate
per
Admis
Rate per
Admis
Rate per
sions
1,000
sions
1,000
sions
1,000
7,532
362.14
6,884
570.84
14.416
438.73
6,275
301.70
6, 123
507.73
12.39S
377.32
1,248
60.00
755
62.61
2,003
60.96
Communicable
diseases transmissible
by
9
.43
6
.50
15
.46
oral and
nasal discharges
(class VI11):
(A)
272
13.08
370
30.68
642
19.54
(B)
1,300
62.50
2,026
168.00
3,326
101.22
1,495
71.88
445
36.90
1,940
59.04
STATISTICS
DEATHS
Durino the Third Quarter
Ending
September
30,
1937
Cause
Navy
Marine
Corps
Nurse
Corps
Total
Primary
Secondary or contributory
Offi
cers
Mid
ship
men
Men
Offi
cers
Men
Average strength.
9,813
2,190
100,651 1,335
17,045
MM
131,433
DISEASE
Abscess,
intra-abdominal
Peritonitis,
general,
acute.
1
1
1
Addison's disease
1
Alcoholism, acute
.
Exhaustion
from
over
exertion.
None
1
Appendicitis, acute
1
Do..
Obstruction,
intestinal,
from
spastic
or
para
lytic causes.
1
1
Do
Peritonitis,
general,
acute.
Arteriosclerosis,
general
Heart
block
1
1
Carcinoma:
Lung.
None
Pancreas
. -
do
1
1
1
Cellulitis, face
Embolism,
mesenteric
ar
tery-
Endocarditis, suhacute
Varicocele,
leg
None. -
1
i
do
Hodgkin's disease
do
1
1
1
1
Leukemia
...do
Myocarditis, chronic
Arteriosclerosis,
general.
Otitis media, chronic
Pneumonia,
lohar
None
1
Poliomyelitis, anterior, acute
Thermic fever (therapeutic).
. do
1
1
Oonococcus
Infection,
joint.
None
.
1
Thrombosis,
coronary
...do
i
l
Do
Arteriosclerosis,
general.
Tonsilitis, chronic
Abscess, lung
Tuberculosis,
pulmonary,
chronic.
Do
None. -
2
1
l
Tumor,
malignant,
mixed,
(adenocarcinoma)
stomach
Meningitis,
cerebrospi
nal, acute.
None
i
do
1
Sarcoma,
thymus,
heart and
do
1
1
pericardium.
Ulcer,
stomach..
Atelectasis
5
21
6
1
33
INJURIES AND
POISONINOS
Burn, entire
body
(steam)..
None
..
.-
1
1
1
1
17
1
6
1
do
Drowning
do
3
1
1
12
2
Fracture,
compound,
frontal.
do
Fracture,
compound,
skull
...do ..
4
1
Fracture,
compound,
femur—
Fracture,
compound,
ribs —
Hemorrhage,
traumatic,
1
Fracture,
compound,
tem
poral.
femoral artery.
Hemorrhage,
pulmonary
1
1
1
1
2
Fracture
near joint with dis
location, cervical vertebrae.
Fracture
simple,
hyoid
Intraspinal Injury
1
1
Fracture,
simple,
occipital..
Fracture
simple
skull
None
1
1I
1
1
1I
1
Do
Intracranial
injury
1
Fracture,
simple,
vertebrne,
None
.
...
1
cervical.
Injuries,
multiple,
extreme
do
8
1
9
3
20
1
Aerogenes
capsulatus
Infection,
ankle.
324
STATISTICS
During
the
Third
Quarter
Ending
September
30,
1937 — Continued
Cause
Navy
Marino
Corps
Nurse
Corps
Primary
Secondary or contributory
Offi
cers
Mid
ship
men
Men
Offi
cers
Men
Total
INJURIES AND POI
SONINGS—
Continued
Intracranial
injury
None
2
2
2
Intraspinal
injury
do
1
3
Rupture,
traumatic,
liver
do
Rupture,
traumatic,
lung-...
Sunstroke
Emphsyema,
traumatic,
mediastinum.
None
Strangulation,
neck
do
I
1
Wound,
gunshot,
chest
do
Do
Hemorrhage,
traumatic,
Wound,
gunshot,
heart
axillary
artery.
None
Wound,
gunshot,
head
do
1
Wound,
lacerated, abdomen .
do
Wound, lacerated, perineum
Poisoning,
acute,
sulphani-
lamide.
do
Total for injuries
and
poisonings.
Agranulocytosis
and gon-
ococcus infection.
I5
40
14
75
Orand
total.
20
67
211
1
108
Annual death rate per 1,000:
All diseases.
8.15
2.04
1.22
2.06
.83
.48
.04
4.69
1.41
.47
10.03
10.03
3.29
1.00
.52
Disease only.
.
Poisoning
Other injuries
4.89
1.31
2.83
MENTAL
AND
PHYSICAL
QUALIFICATIONS
OF RECRUITS
Statistics for Third Quarter
Ending
September
30,
1937
The following statistics were taken from sanitary reports submitted
by naval training stations :
United States naval
training
station
July,
August,
and September
1937
Norfolk,
Newport,
Great
San Diego,
Va.
R.I.
Lakes,
1ll.
Calif.
Recruits
received during
the period. -.
983
745
851
1,274
Recruits
appearing
before Board of Medical
Survey
6
0
7
0
Recruits
recommended
for discharge from the service...
6
0
7
0
Recruits
discharged
by reason of medical survey
4
0
(')
0
Recruits
held over pending
further
observation.
0
3
0)
0
Recruits
transferred to the hospital for treatment, opera
tion,
or further
observation
for conditions
existing
0
20
58
56
1Not reported.
The following table
was prepared
from reports
of medical
surveys
in which disabilities or disease causing the surveys
were noted existing
prior
to enlistment.
With certain
diseases,
survey followed
enlist
ment so rapidly that it would seem that many might have been elimi
nated in the recruiting office.
STATISTICS
325
Cause of survey
, periapical
Absence,
acquired, teeth.
Acne, chronic
Adhesions (intestinal)
Adhesions, right leg
Amblyopia
Ankylosis,
tarsal,
metatarsal,
and
ankle
joints
-
Arterial hypertension
ill.il iti:. .
Astigmatism.
Atrophy,
muscle.
Bronchitis,
chi
Caries,
teeth..
Cholecystitis,
Cicatrix, skin
Colitis, chronic
Congenital heart disease
Constitutional
psychopathic
inferiority,
without
psychosis
Constitutional
psychopathic
state,
emo
tional
instability
Constitutional
psychopathic
state, Inade
quate personality
Constitutional
psychopathic
state,
para
noid personality
Deafness,
unilateral
Defective physical development
Deformity,
acquired,
left shoulder
Deformity,
acquired,
loss of flexion, finger.
Deformity,
acquired,
right
femur
(old
fracture)
Deformity,
acquired,
left ankle
(old frac
ture)
Num
ber of
surveys
Cause of survey
Dysinsulinism
Effort syndrome
Enuresis
Epilepsy
Flat foot
Goiter,
exophthalmic
Glycosuria
-
Hemorrhoids
Malformation,
congenital
Malocclusion,
teeth
M igraine
Myopia
-
Xepiiritis, chronic
Neurosis,
traumatic
Otitis,
me'lia,
chronic
Perforated
nasal septum
Pes cavus
-
Pollomyol.tis,
anterior,
chronic
Prostatitis,
chronic
(non venereal)
Psychoneurosis,
hysteria
Psychoneurosis.
neurasthenia
—
Rhiniti-, atrophic
Somnambulism
Stammering-
Strabismus
-
Syphilis
Trichophytosis
Tuberculosis,
pulmonary,
chronic,
active,
moderately
advanced-
Union
of fracture,
faulty
Valvular heart disease, mitral insufficien
cy
Valvular heart disease, mitral
stenosis —
Varicocele
Num
ber of
27
o
United States
Naval
Medical Bulletin
Published for
the Information of the
Medical Department
of the Navy
THE MISSION
OF THE MEDICAL
CORPS OF THE NAVY
•
KEEP AS MANY MEN AT AS MANY GUNS
AS MANY DAYS AS POSSIBLE
Issued Quarterly
by the Bureau of Medicine and Surgery
Washington,
D. C.
Vol. XXXVI
JULY
1938
No. 3
UNITED STATES
NAVAL
MEDICAL BULLETIN
Published Quarterly
for the Information of
the Medical Department
of the Navy
Issued by
DIVISION OF PUBLICATIONS
THE:BUREAlT
OF MEDICINE AND SURGERY
NAVY DEPARTMENT
Compiled
and published
under the authority of Naval Appropriation
Act for 1937-38, approved
April 27. 1937
UNITED
STATES
GOVERNMENT
PRINTING
OFFICE
WASHINGTON:
!938
For sale by the Superintendent
of Documents,
Washington,
D. C.
See page II for price
Navy Department,
.
Washington, March
20,
1907.
This United
States
Naval Medical Bulletin
is published by
direction of the Department for the timely information of the Medi
cal and Hospital Corps of the Navy.
Truman H. Newberry,
Acting Secretary.
Owing
to exhaustion
of certain
numbers of
the Bulletin
and the frequent
demands from libraries,
etc., for copies to complete their
files,
the return
of any
of the following issues will
be greatly
appreciated
:
Volume IX,
1915, No. 1.
Volume X,
1916, No. 2.
Volume XI,
1917, No. 3.
Volume XII, 1918, Nos.
1 and 3.
Volume XXIV,
1926, Nos.
1 and 4.
Volume XXV, 1927, No. 1.
Volume XXVII,
1929, Nos. 3 and 4.
Volume XXVIII,
1930, No.
3.
Volume XXXIV,
1936, Nos.
1, 2, and 4.
Volume XXXV,
1937, No.
1.
Subscription Pbice of the Bulletin
Subscription
should
be
sent
to
Superintendent
of
Documents,
Government
Printing
Office,
Washington,
D. C.
Yearly subscription,
beginning July
1,
$1 : for foreign
subscriptions
add
33
cents for postage.
Single numbers, domestic,
25 cents ; foreign,
35 cents,
which
includes
foreign
postage.
Exchange of publications
will
be extended to medical scientific
organizations,
societies,
laboratories,
and
journals.
Communications
on
this
subject
should
be addressed
to the Surgeon General,
United
States Navy,
Washington,
D. C.
TABLE OF CONTENTS
Page
PREFACE
T
NOTICE
TO
SERVICE
CONTRIBUTORS
vi
SPECIAL ARTICLE:
Field
Sanitation.
By Capt. W. L. Mann,
Medical
Corps, United States Navy
327
NAVAL
RESERVE
413
NOTES
AND
COMMENTS:
The
Fourteenth
Surgeon
General,
United
States
Navy—Yellow
Fever —Observations
on Burns Due to Explosion —Commendation —
The
New
York
Academy
of
Medicine
Graduate
Fortnight—The
American
Board
of
Radiology- — American
College
of
Hospital
Administrators — New Naval Medical Center —Committee
to Study
Serodiagnostic
Tests for Syphilis
415
BOOK NOTICES:
Practical
Tropical
Sanitation,
Kirk —Organization,
Strategy,
and
Tactics
of the Army Medical
Services in War, Nicholls
423
PREVENTIVE
MEDICINE:
The Effect of the Age of Neoarsphenaxtine
on Reaction
Ex
pectancy.
By Commander
C. S. Stephenson,
Medical
Corps, United States
Navy,
Associate
Pharmacologist
T.
F.
Probey,
and
Senior
Surg. W. T. Harrison,
United
States Public Health Service. . .
425
The Effect of Moisture and Age on Stability of Neoarsphen-
amine.
By Associate
Pharmacologist
T. F. Probey,
and Senior Surg. W.
T. Harrison,
United
States Public Health Service, Washington,
D. C
429
Insecticidal
Powders,
a Comparative
Study.
By
Commander
F.
S.
Johnson,
Medical
Corps,
United
States
Navy,
with
the
technical
assistance
of
Pharmacist's
Mate
First Class A. G. Vallee, United
States Navy
435
A Presumptive
Test for the
Potency
of Cow-Pox
Virus.
By Lt.
Comdr.
J.
B.
Moloney,
Medical
Corps,
United
States
Navy
445
STATISTICS:
Health of the
Navy
447
Injuries
and
Poisonings
450
Morbidity
451
Deaths
452
Mental
and Physical Qualification
of Recruits
453
Ul
PREFACE
The United States Naval Medical Bulletin
was first issued in
April 1907
as
a means for supplying
medical
officers of the United
States
Navy
with
information
regarding
the
advances
which
are
continually
being
made in the
medical
sciences,
and
as
a medium
for the publication of accounts of special
researches, observations,
or
experiences of individual
medical
officers.
It is the aim of the Bureau of Medicine
and Surgery
to furnish
in each issue special
articles
relating to naval
medicine,
descriptions
of suggested devices, clinical notes on interesting cases, editorial com
ment
on current medical
literature of
special
professional
interest
to the naval
medical
officer, and reports
from various sources, notes,
and comments on topics of medical
interest.
The Bureau extends an invitation to all medical
and dental
officers
to prepare
and
forward,
with
a view
to publication, contributions
on subjects of interest to naval medical officers.
In order that each service contributor
may
receive due credit for
his efforts
in preparing
matter
for the Bulletin
of distinct origi
nality and special merit, the Surgeon General of the Navy will send
a letter of appreciation to authors of papers of outstanding merit.
The Bureau
does not necessarily
undertake
to
endorse
views
or
opinions which may
be expressed in the pages of this publication.
P.
S. Rossiter,
Surgeon General,
United States Navy.
IV
NOTICE TO SERVICE
CONTRIBUTORS
Contributions
to the Bulletin
should
be typewritten,
double spaced,
on plain
paper,
and should have wide margins.
Fasteners
which will not tear the paper
when removed should
be
used.
Nothing
should
be written in the manuscript
which is not intended for publication.
For example, addresses, dates,
etc.,
not
a part of the article,
require
deletion
by the editor.
The Bulletin
endeavors
to follow a uniform
style in heading and captions, and the editor can be spared
much time and trouble, and unnecessary changes in manuscript
can be obviated
If authors will follow in these particulars the practice of recent issues.
The greatest accuracy
and fullness
should
be employed in all citations,
as it
has sometimes been necessary
to decline articles
otherwise
desirable
because
it
was impossible for the editor to understand
or verify references, quotations,
etc.
The frequency of gross errors
in orthography
in many contributions
is conclu
sive evidence that authors
often fail to read over their
manuscripts
after
they
have
been typewritten.
Contributions
must
be received
at least
3 months prior to the date of
the
issue for which
they are intended.
The editor is not responsible for the safe return of manuscripts
and pictures.
All materials
supplied for illustrations,
if not original,
should
be accompanied
by reference to the source and
a statement
as to whether
or not reproduction
has been authorized.
The Bulletin
Intends to print only original articles,
translations,
in whole or
in part, reviews, and reports and notices of Government
or departmental
activi
ties, official
announcements,
etc.
All original contributions
are accepted
on the
assumption
that they have not appeared previously
and are not
to be reprinted
elsewhere
without
an understanding
to that
effect
and that editorial
privilege
is granted
to this Bureau
in preparing
all material
submitted for publication.
Eben
E. Smith, Editor,
Commander,
Medical
Corps,
United
States NavV.
v
U.
S. NAVAL MEDICAL BULLETIN
Vol. XXXVI
July 1938
No.
3
SPECIAL
ARTICLE
HELD SANITATION 1
By Captain
W. L. Mann, Medical
Corps,
United
States
Navy.
Health is necessary in war, and cannot
be replaced
by anything
else —Napoleon
IHTBODUCTION
One of the prime requisites for victory is health.
An army to fight
has figuratively
and literally
to "take the field," consequently
field
hygiene and
sanitation
is one of the
most important
subjects
for
military sanitarians,
because
the laws of
preventive
medicine
are
then made applicable to war as a matter
of military
economics
and
this adaptability
to wartime conditions is the
supreme
test of all
military efficiency.
The functions of a military
medical
organization may
be roughly
divided into (a)
prevention
of disease and
(b) treatment
of disease
and injury.
Prevention of disease is of vast importance
to the mili
tary
personnel,
and
this function
only will
be
considered
in this
article.
To a well informed person, the laws of field sanitation may appear
so elementary
that
a
study
of them
would
seem
unnecessary
and
probably a waste of time, but when one stops to consider, for example,
that the simple measure of mosquito
control alone made the building
of the Panama Canal possible,
one may
obtain
a slight idea of the
vast economic importance
of such a preventive
measure.
It has been
stated
that
in
the construction of
the
28-mile
railroad
across
the
Panama Isthmus, the number of wooden railroad
ties approximated
1 Author's
Note. —The
major
portion
of this
information
was originally prepared for
instruction purposes
at
the Marine
Corps
Schools,
Marine
Barracks,
Quantlco,
Virginia.
The writer wishes to acknowledge the assistance
received
from Lieutenant
H. E. Olllesple,
Medical
Corps,
United
States
Navy,
and Chief
Pharmacist
R. N. Cheetham,
United
States
Navy,
in the compilation
of these data.
Editor's
Note. —This article
presents
the author's
prolonged
experience and extensive
research in
a
Held which
has
been
his primary
service interest.
It is
a major
revision
of
material
published
by the Bulletin
in
1023
which
has since
served
as
an
authoritative
reference
and
is particularly
valuable
in
that
it
presents
a compilation
of
Information
relatively
inaccessible
to
naval
medical
officers.
This
material
is
based
on
experience
gained
by
medical
officers
on
field
service.
Much
credit
is
due
and
is
extended with
appreciation
to the medical
services of the U.
S. Army
and His Majesties
medical officers
serving
with
the British
Army
for the wealth
of
information
on military medicine
they
have made
available.
327
328
FIELD
SANITATION
MANN
the number
of men dying from malaria
and yellow
fever,
diseases
transmitted by the mosquito.
In other words
a death
resulted
for
every few feet of construction.
It is not improbable that the World
War would have been terminated
by epidemic
diseases in the second
year had not certain,
apparently simple,
sanitary measures of waste
disposal
been observed.
The care of the feet and shoe fitting consti
tute other
simple
field
measures that assume great magnitude from
a military
standpoint.
At least 25 percent of a marching command
may
suffer
from foot injuries,
and
the European
Armies
estimate
10 percent of the marching army will
be incapacitated
from "sore"
feet when an army first takes the field.
Tact and a certain
amount of technical
ability are necessary quali
fications
for a successful
sanitarian.
Sanitation is so closely
inter
related with cleanliness that the major portion of the duty of a sani
tation officer consists in the supervision of cleanliness.
To induce other individuals to maintain their persons and premises
in a clean condition, without arousing a certain
amount
of friction
and antagonism,
is not always
an easy matter, hence the modus oper
andi should depend
upon
the circumstances.
As
a rule
friction
is
exceedingly
rare and there is complete
cooperation
of the combatant
forces
in enforcing all necessary
sanitary
recommendations.
How
ever, if cooperation
is not
as prompt
as desired,
there should be no
quibbling
over details, but a receptive
attitude should be cultivated.
The majority of the functions of the sanitation officer are considered
purely advisory, and here his responsibility
ceases.
As a general
rule sanitary recommendations
should be reduced
to
a minimum and should
be concise as possible.
All recommendations
should
be carefully
considered,
and those which are not of essential
importance
should
be
omitted.
If
practicable,
preface
sanitary
recommendations
with an explanation, as commanding
officers usually
desire
to know
the
reasons
for promulgating
orders
and
placing
restrictions on personnel.
Preventive
medicine
is not an exact
science nor is it possible
to
obtain
100
percent
efficiency.
However, if by
careful
attention to
the minor
details
the sanitation officer is able to increase
military
efficiency
from
96 percent
to 98 percent,
he
has not gained
a mere
increase of 2 percent
as it may
seem, but has effected
a gain of
50
percent —that
is,
the noneffective
rate has been
reduced
from
4
per
cent to
2
percent.
It
is
this little
difference
which sometimes
may
be the deciding factor between victory and defeat.
Field sanitation contrasted with sanitation of garrisons. —The
differences
between
field
sanitation and
sanitation of garrisons
are
marked.
WAR AND BIOLOGY
329
1. Field sanitation is easier to institute.
For example, the devices
used for the disposal of waste are of simple
construction, whereas
the installation of a water-carriage
sewerage
system
requires
more
expert
engineering
knowledge,
takes
longer
to
construct,
and
by
reason of its permanent
nature is more expensive.
2. Constant vigilance is required to maintain field sanitary devices
in proper sanitary condition.
3. Field sanitary appliances
are a potential menace, if not properly
maintained.
In established
garrison
life,
with
water-carriage
waste
disposal,
an adequate and potable water supply, permanent
housing facilities,
protective screening
for insect control, and similar
modern
develop
ments,
the duties of the sanitation officer are comparatively
simple
and more or less routine.
In the field, the conditions are such that the
field sanitary devices require constant and painstaking personal super
vision from both the line and the medical
officers in order that there
may not be a weak link in the chain of sanitary measures.
Barracks life may give us comparatively little
concern, but when
,we take the field, vigorous sanitary measures must
be instituted and
maintained and, if possible, improved from day to day.
The commanding officer of an organization
is responsible
for the
health of his command
and
the
enforcement
of sanitary measures.
The British Field Service Regulations
state:
"Every officer
is
re
sponsible that all orders affecting the health of an army
are rigidly
carried out by the troops under his command.
Neglect of sanitary
precautions inevitably
results
in great
loss of life
and
efficiency."
The regulations of United
States Army and United
States Navy are
equally explicit on this subject.
The medical
department
acts in an advisory capacity.
The medi
cal officer is charged
with the initiative in making necessary recom
mendations
to the commanding officer tending to the promotion of
health and prevention of disease.
For instance,
the medical
officer
should
recommend
the
type,
number,
and
regulation
of
sanitary
devices,
but the responsibility
for the
actual
construction
and
the
maintenance
of the same in a sanitary condition rests with the respec
tive unit commanders.
Likewise
the collecting company of the med
ical battalion exercises supervision over sanitation, but the latrines,
urinals,
incinerators,
etc.,
should be constructed
by
a detail from
other units.
War and biology.—Almost
without
exception,
it is characteristic
of all animal life to be gregarious.
As density
of congregation in
creases, natural laws tend
to limit excessive multiplication
by the
reaction
of infectious and autogenous
toxic products upon
the mass.
330
FIELD
SANITATION —MANN
Otherwise any species, increasing as it does by geometrical
progres
sion, would in
a short period of time, relatively speaking, tend to
inhabit the earth to the exclusion
of all other
species.
There
is
a constant
combat of species for existence,
each species
exists in its own little niche, and excessive multiplication
tends to be
limited by other
species.
In order to demonstrate
the excessive productiveness
of
a single
species, a biologist has computed
the unrestricted fecundity
of the
elephant,
the slowest
propagating
mammal.
This authority
claims
that if a pair of elephants
were allowed to multiply
under optimum
and unrestricted
conditions for 2,000 years, there would not be stand
ing room in the world for their descendants.
If we
assume the
number
of
generations
of
a breeding
female
fly as nine in a normal season, then
a single fly laying
150 eggs at a
time
might
conceivably
become
ancestress
to
5,000,000,000,000,000,-
000,000,000,000,000
descendants
in
one
season.
The
student
may
compute
the bulk of this mass and picture what would happen
in 10
years, if the fecundity of this single fly were not halted
by biologic
laws.
All species, including
man,
multiply
in geometrical
progression,
but the best we can expect of the increase in food supply is arith-
metrical
progression,
according to the Malthusian
doctrine (T.
R.
Malthus,
1766-1834).
To
show
that natural
laws must
inhibit
human
productiveness,
it has been stated that a man and wife at the time of Christ with two
children
and
each of their
descendants
have
two
children,
and
no
intermarriages of
descendants
take
place, allowing
34
years
for
a
generation,
or
a total of
57 generations,
the human
offspring
now
alive would total
72 quadrillion
persons.
If this number
passed in
review,
at the rate of 8 million
persons iier hour, the parade
would
last for a million years.
Rather fantastic but true.
Limitation of food supply, the spread of contagious
diseases, war,
and conflict of races, are methods
of restriction of excessive multi
plication of the human
species.
When we place
a million
men in the field and prevent
decimation
from
disease, we are defying
one
of the biological
principles
that
tends
to prevent
over-crowding of
a species.
The
methods
at our
disposal
to combat
these fundamental biological
principles
are
not
complicated
and may be classified
and will be discussed
as follows: —
1. Proper
food.
2. Potable water supply.
3. Hygiene of the march.
4. Conservancy —waste disposal.
5. Insect control —fly, mosquito,
louse, etc.
WAR AND EPIDEMIOLOGY
331
MODEKN PREVENTIVE MEDICINE
Wars are lost
by generals
and won
by epidemics
Victory, success in a military
endeavour,
is intimately interrelated
and
dependent
upon
personnel
losses;
in fact,
the
wastage
from
diseases frequently assumes such magnitude as to cause military
cam
paigns to terminate
in disaster.
According
to one writer,
the body
louse, transmitter of typhus,
won
the World War.
For
example,
the Austrian
Army feared
to
invade Serbia in
1915
due to
an
epidemic
of typhus which killed
150,000
persons
in
6 months
of that year;
and,
again,
in Russia
25,000,000
cases
with
3,000,000
deaths
from
this
disease
aided
the
spread of
revolution
and
the
complete
collapse
of
Russia's
huge
army.
"Typhus
and allied
diseases have
decided
more
campaigns
than
Caesar,
Hannibal,
Napoleon, and
all
the generals
in history.
The
epidemics
get
the
blame
for
defeat;
the
generals
the
credit for
victory.
It ought to be the other way around."
As examples of the
influence
of different diseases upon
the out
come of military ventures the following
are cited.
Yellow fever. —At the beginning of the last century (1802)
50,000
out of an Army of 58,000 died on Santo Domingo island from yellow
fever.
Typhoid
fever. —In
the
Spanish-American
War,
the
American
forces lost about
10 times
as many men from typhoid fever as were
killed in combat.
After compulsory vaccination against typhoid only
three
cases, and no deaths, occurred in the entire American Army of
90,000 men over a period of 5 years.
Cholera. —In the Balkan War, the Turks lost as many
as 500 men
daily
from
cholera.
The
allies lost
10,000
men
from
cholera
in
Crimea in 1854.
Plague.—The Persians under Xerxes were defeated in an attempt
to invade Greece by
an epidemic
of plague; Athens was
forced
to
surrender as
a result of this disease, and
the sieges of Syracuse
in
414 B. C. by the Athenians,
and in 396 B. C. by the Carthaginians
were failures caused by the plague in these armies.
In the war be
tween Russia and Turkey in 1828, plague
killed
over 6,000 Russians
in
1 month,
and from all causes the Russian Army of
100,000 suf
fered
85,000 deaths, and at one time had half of its total strength in
the hospital.
Typhus.—In the 1566 campaign
against the Turks, Maximillian II
of Germany failed on account of typhus.
A typhus epidemic
among
the Austrian
defenders
of Prague in
1741 enabled
the French
to
capture this city.
In the Bavarian
Army of
28,000
men in
1812,
332
FIELD SANITATION
MANN
25,000
died of typhus fever.
After the battle of Plovna,
the Rus
sians lost
60,000
men
from
typhus
out of
a strength
of
120,000.
Napoleon lost
40,000
from typhus during his retreat
from
Moscow
and after arrival in Paris.
Malaria. —Malaria,
probably introduced in ancient
Rome
during
the Carthaginian invasion, so debilitated the Roman forces that they
succumbed
to
the
inroads of
the
Barbarians.
In
the
Walcheren
Campaign of 1809, the English
forces had
10,000 sick and 4,000 died
from malaria.
The English
at Ashanti
in
1864 "were
defeated"
by
malaria before an enemy was seen.
The French expedition at Mada
gascar
(1895)
had
a death
rate of
320 per
1,000 from malaria,
yet
suffered
only
15 deaths in action.
In Macedonia,
the British forces
had
162,517
admissions
to hospitals from this
cause;
one division
reported
5,000
cases
in
1
month.
The
highest
annual
rate
was in
South Africa
in
1917,
when
the
rate
per
thousand
was
1,422.84.
Malaria
caused the death of 15,000 soldiers
in the Civil War, while
we lost only 25 during the World War from this cause.
Beri-beri. —This was once
a disease dreaded
by
the forces
afloat,
and has been a factor in deciding naval ventures.
Not so long ago,
one of the modern
navies
showed
an
incidence
rate
of
35 percent
from this malady, which
was
reduced
to
a negligible
rat© by the
introduction
of
vitamin
"B"
in
the
sea
ration.
In
the
Russo-
Japanese War, 1905, the Japanese army had 200,000
cases of beri-beri.
Scurvy.—In one of Commodore
Anson's naval ventures
19 out of
every
20 men failed
to return
to England,
the majority
dying
of
scurvy.
The American frigate Macedonia,
from April to September
5,
1827, lost
101
men out of
a crew
of
376.
In the Crimean War
(1854-56)
23,000
cases of scurvy
occurred
among
the French
troops
alone; in the American Civil War
(1861-65)
30,174
cases
were diag
nosed.
In
the
siege
of Port Arthur,
during
the
Russo-Japanese
War,
85 percent of the Russian garrison suffered
from scurvy.
Dysentery. —The siege of Bagdad by the Saracens
in
1439 failed
as a result of an epidemic of dysentery.
Metz was saved from Charles
V partly on account of dysentery.
Frederick Wilhelm II of Prussia
in 1792 was unable to fight the Army of the French Revolution
and
was forced
to retreat into Germany because of dysentery
among his
troops.
Dysentery caused
1,342 deaths
and
38,000
cases of sickness
during
the South African War.
At Gallipoli, during
August
and
September
1915, 78 percent of the British troops
were suffering from
dysentery
and other intestinal complaints.
Smallpox. —Mecca
was
saved
by
smallpox
which
decimated
the
Saracens.
Smallpox was one of the causes of the military
failure of
Benedict Arnold's campaign against
Quebec.
In 1870 the French lost
23,000
men from this disease, whilst the Germans
who were exposed
WAR
AND
EPIDEMIOLOGY
333
to the same contagion,
but were efficiently
revaccinated,
lost only 200
men— a striking illustration
of the military value of vaccination.
Smallpox took over 7,000 lives during the Civil War ; in the World
War it took only 14 lives in our troops.
Beginning
with the Russo-Japanese War, the ratio of deaths from
disease began to decrease due to improvement
in modem
field sani
tation.
This change
is particularly
evident
when this war is com
pared with the Chino-Japanese War occurring
10 years earlier.
The
following
table
demonstrates
the striking
improvement of
health of military
forces
due
to
employment
of
modern
sanitary
measures.
Ratio of killed in action
to deaths from disease in various
campaigns'
Approxi
mate aver
Ratio per 1,000per
annum
Campaign
agestrength
during
Killed in
Died
from
Crimean War— 1854-56:
campaign
action
disease
301,000
30.6
114.7
United States Civil War— 1861-65:
111,000
IS. 8
87.3
Austro- Prussian
War 1870-71:
600,000
38.3
75.9
Chino-Japanese
War 1894-95:
437,000
61.1
88.2
Madagascar,
1895:
227,000
7.3
88.1
Spanish-American
War 1898:
18,000
.48
373.3
Boer War, 1899-1902:
270,000
2.5
32.6
British troops
208,226
12.7
25.6
Russo-Japanese
War 1904-05:
Japanese
troops
420,000
88.5
40.8
Russian
troops
-
490,000
61.3
35.8
German
S. W. Africa 1903-06:
German
troops
18,000
13.5
12.9
Note,.—In France and Flanders,
during
the World War,
the British forces lost 585,533men killed by the
enemy
and during
the same period only 32,098died from disease.
FOOD IN THE FIELD
An army
fights
on its stomach —Napoleon
In war the supply of food is most important.
The men attached to
an organization on field duty are not likely
to have opportunity
to
supplement
the military ration by purchases from civilian restaurants
or other eating
places to supply any deficiencies in their daily ration.
Hence,
it is important that the field ration
be well balanced
in fats,
proteids,
and
carbohydrates
and
must
have
the
required vitamin
content.
An extended
discussion
of the component
parts of a well balanced
ration would be a departure from our subject
and,
as such data may
be found in textbooks, only certain aspects of a military ration which
are related
to field conditions will be considered.
334
FIELD
SANITATION
MANN
Caloric value of the military ration.—It has been found that a
ration consisting of 3,700 Calories is insufficient
for troops in the front
line.
It has been experimentally proved
that troops on a test march
can maintain weight on a ration of 4,100 Calories.
If troops must entrench after a day's hike, a total of 5,000 to 6,000
Calories per day is required.
It is often impractical for a soldier to
assimilate
such a large number of calories
per day, and consequently,
in time of war soldiers
are allowed a greater
amount
of food (often
at the expense of the civilian
population)
so that they
may
have
a
reserve supply of fat in the body to enable them to temporarily with
stand the unusual
expenditure
of foot-pounds of energy.
It is stated
that 20 pounds of reserve fat in a man's body will supply 3,000 addi
tional Calories per day for a period of 30 days.
The
following
is the caloric
value
of
the United
States
Army
ration :
Oaloriet
1. Reserve
(haversack
ration)
2,825
2.
Mobile
3, 500
3. Normal
4, 125
4.
Special
-
4, 850
The heat of hot drinks and hot food supply additional
calories,
1
pint of hot tea adding 50 Calories of direct heat to the body.
Hence
the stimulating effect of hot tea, coffee,
soup, and broth after a long
march.
A soldier at hard work requires
24 ounces of food, daily, exclusive
of water, made up as follows:
OuflOM
Proteins
4
Carbohydrates
17
Fats
3
In terms of articles of food, the above is represented by the follow
ing field ration :
Beef
ounces^-
11
Sugar
ounces
2
Cheese
do
3
Jam
do
2
Bread
do
16
Sago
do
4
Potatoes
do
10
Milk
pint
%
The nitrogenous foods
(proteins)
serve for the building
and
re
pairing
of tissues, and
also serve for the maintenance
of heat
and
energy.
The carbohydrates
and fats yield heat and energy.
The salts
are
essential
to life and
health,
and for the formation
of the skeleton
and tissues.
Water is as essential
a food as the foregoing, and serves
for the solution and conveyance of food to the various parts of the
body, and also for the removal
of the waste products formed in the
FOOD IN THE
FIELD
MENU
335
body, viz the solid and liquid excreta.
Water alone, by its evaporation
from the skin, assists in stabilizing the temperature
of the body.
A part of
the water required
by
every
one is contained
in the
solid food taken, of which it forms
a very large proportion;
meat,
for
instance,
contains
about
75 percent
water,
some
vegetables
as
much
as 90 percent, and bread about 38 percent.
The
amount
and
the particular
kind
of
foodstuffs
required
by
an individual
will vary with
his age,
his build, his work,
and
the
climate in which he works.
In cold
climates
a man will require more of the heat-producing
foods, especially
fats, and in a hot climate
he needs less of the nitro
gen-containing foods and fats, and more of the vegetable food stuffs.
The
greater
amount
of
muscular
energy
required,
the
greater
will
be the amount
of food necessary to supply this energy.
Energy
value
is generally expressed in calories,
a Calorie
(kilo
calorie)
being
the energy
in the form of heat, required
to raise
the
temperature
of
1 pound
of water
4° F.
(Or
1 kilogram
of water
1° C.)
It has been found by experiment
that
1 gram of protein or carbo
hydrate
is
capable
of yielding,
by
its oxidation
in
the
body,
4.1
Calories, and
1 gram of fat, 9.3 Calories.
The British army ration gives the following
:
Protein 175 grams
X 4.1 equals
717 Calories.
Fat 218 grams
X 9.3 equals 1, 927 Calories.
Carbohydrates
515 grams
X 4.1 equals 2, 111 Calories.
equals 4, 755 total Calories
Daily menu. —It is advisable
to prepare
the daily
menu
at least
24 hours in advance.
The medical
officer should carefully scrutinize
the menu, and not only inspect
the food as to quantity and quality,
but the necessary precautions
should be taken to see that there is a
variety of food prepared.
'
There is often
a tendency for cooks to prepare
an excess of stews,
which may cause dissatisfaction among the men.
When on the march
or otherwise heavily worked,
the men will have a craving for sweets;
a liberal amount of jam should
be provided to satisfy this craving.
The presence of much
refuse
food in the garbage
can is a good
indication that the men are not
receiving
the proper kind of food,
that it is not palatably cooked or served, or the quantity is excessive.
The
field
ration should contain tomatoes,
lemon
or orange
juice
whenever
practical.
Potatoes should
be cooked and eaten unpeeled,
thus supplying additional vitamins.
Fruit
and vegetables which are
to be eaten raw and unpeeled, should
have the exterior surface
steri
336
FIELD
SANITATION
MANN
lized by temporary
immersion
in boiling
water whenever
there
is
suspicion
of soil contamination being
present.
Every
effort must
be made to vary the field diet to the greatest
possible
extent, changing the food substances
as well
as the manner
of cooking.
The guard
at night
should have
coffee
and
bread
before
going
on duty, and this should apply to relief parties.
Field kitchens.—The
use of rolling kitchens
on the march
has
superseded the old method
by which each man cooked his own food.
One rolling kitchen supplies
food for
200
to
250
men.
The
field
kitchen should
be located
on the
opposite
side of the
camp
from
the latrines and urinals.
Some means should be used
to protect
the
food from dust and sand. If circumstances permit, the kitchen should
be
screened; if not,
other
precautions
should
be
taken
to
protect
food from flies and other
insects.
Burlap sacking may
be used for
screening
when more suitable
material
is not available.
There should
be on hand at all times
a sufficient
supply of pure
water and material for cleaning purposes, such as soap, soda, and soap
powder.
Scouring material, boiling
water,
and dishcloths should be
available.
If the kitchen
has a dirt floor it may
be oiled with used motor oil
to control dust.
The cooks and other attendants
working
in the kitchen and han
dling food
should
be instructed
in personal
hygiene.
Rigid supervi
sion is necessary to prevent
the cooks from becoming
lax in personal
cleanliness,
especially
in keeping the hands
and finger nails clean.
Physical examination
of all food handlers should
be made at regu
lar intervals; and if the laboratory facilities permit, an effort should
be made to detect and eliminate any
disease carriers among
them.
Routine venereal
inspections
should
be made.
Liquid and solid refuse should be disposed of as soon as practical.
The outside of all garbage
cans should
be kept clean, and covered
at
all times.
The object of cooking processes is—
(n)
To make food
more digestible
and appetizing.
(J) To destroy germs and parasites.
Mess halls.—The
mess
halls should be located
near
the kitchen.
Make
the
necessary
provisions
to
protect
the food in
the
mess
halls from flies, dust, and sand, using wire screening
if available.
Clothes
and toilet articles must
not
be stored
in kitchens
or mess
halls.
The
mess tables should be cleaned and sunned at regular intervals
and care must
be taken
to
see that food particles do not collect
in
the cracks of the tables.
FOOD IN THE FIELD—SAFEGUARDS
337
One of the best methods to prevent
the collection
of food particles
in the cracks of the tables is to construct
the tables with
a removable
center board which may
be lifted
off, and
thus permit the cleaning
of the cracks
between
the boards.
Another
method
is to construct
the tables with a 2-inch space between the boards.
Washing
mess
gear in the field. —After
meals
all
mess
gear
should be sterilized in boiling
water.
In a semipermanent
camp the
mess gear may be placed in wire racks and washed by immersion
for
5 minutes
in water that is kept boiling.
On the march
and under conditions where the mess kits from the
haversack
are in use, the following
method of washing the individual
mess gear is employed
:
Immediately after the men have finished
eating they should form
a line and
pass
a
garbage
can or pit
where
the refuse
liquid
and
solid food are disposed
of.
After disposing of this refuse food each
man
inserts his mess gear successively in three cans.
These cans are
placed
over
a trench in which
a fire is burning.
The first and second
cans contain boiling
soapy
water, while the third
can contains
boil
ing clear water.
A few moments insertion in each of these
cans is
usually sufficient to cleanse and partially
sterilize the utensils.
After
insertion in the third can. the mess gear dries by its own heat almost
immediately and
no wiping
is necessary.
Care
should
be taken
to
see that
the water
in
each
can is kept
at
a boiling
point,
as luke
warm dishwater is
a potent
factor in the
dissemination
of saliva-
borne
diseases.
It appears
that the military
sanitarians have
waged
a successful
battle
against
intestinal disease, but during
the Great War sputum-
borne
diseases
of the respiratory
tract,
such
as influenza
and
pneu
monia,
did
not
always
yield
so
readily
to
preventive
sanitary
measures.
During the Civil and Spanish-American
Wars
the intestinal dis
eases were prevalent,
while in the recent world conflict
more persons
died from respiratory diseases than any other group of diseases.
Protection,
storage,
and inspection
of food supplies. —Surplus
and
reserve food supplies
should be protected
from
insects
such
as
flies and roaches, from dust and dirt, and from rats and mice.
Per
ishable
foods should
be stored at a temperature
that will inhibit
the
growth
of moulds
and
bacteria.
For
camps of less than
1
week's
duration, storage devices for preservation
of food are not necessary.
1. In temporary camps food may
be stored in watertight contain
ers and immersed
in springs or streams, care being
taken
to prevent
water contamination.
Food may
be buried below
the surface
of the
ground
where
the
temperature
is lower, lining
a pit with burlap,
and
placing
boards
on
the
bottom.
In
addition,
food
containers
64743—88
2
338
FIELD
SANITATION
MANN
suspended
from trees or tripods and underground ice boxes provide
satisfactory means of protecting and storing food.
A suspended food container consists of a screened box that permits
free circulation
of air but
prevents
contamination by
insects.
The
cooling effect is increased
by wrapping
the box
in burlap which
is
kept damp.
Fresh meat, bottled
milk,
and
vegetables may
be tem
porarily
stored in such a container.
It should
not be used where the
air contains
any considerable
amount of dust.
2. In semipermanent
camps fresh or cured
meats, milk, and vege
tables should be kept in
an underground storage
room
constructed
similar
to an old fashioned
root cellar.
The floor consists
of well
tamped earth, or boards may be used.
The walls should
be boarded.
Ventilation
is secured by windows at the ends or an outlet through
the roof.
Vegetables
should be kept in vegetable bins, constructed
of
spaced slats to permit the circulation of air.
The bottom should slope
sufficiently
to permit the older vegetables to be used first.
Canned
goods
should
be kept in
the
storeroom
adjacent
to
the
kitchens.
Bread boxes which permit aeration
of the contents should
be used.
Quality
of meat can
be recognized
by the appearance,
odor,
and
texture.
Good meat is firm to touch, moist but not wet, and is red in
color for beef, pinkish brown for veal, dark pink for mutton,
and
light pink for lamb
and pork.
Good meat has
a fresh,
agreeable
odor.
The fat should contain
no watery juices or jelly, and should
be firm
and
white.
The fat interposed
between the muscle
fibers
gives
the
meat a mottled
appearance.
In the field we are liable to be called
upon for inspection
of the
freshly killed
carcass.
The most likely
place to look for signs
of
disease is the chest cavity, and to a lesser extent the abdominal cavity;
adhesions
of the lining membrane
indicate inflammation, probably
tuberculosis.
When
decomposition
of
meat
is
suspected
trim
off
the
tainted
parts of the quarter of beef and sink
a probe
into the shoulder or
hip joint.
The odor of the probe will
determine
whether decom
position has set in. A whole quarter of beef should not be condemned
because
part of it has begun
to decompose,
as it is often possible
to
trim
off
the
tainted portion
and
serve
the
remaining
wholesome
portion.
The
Eber
test
(ammonia
test)
is
used
to
detect
decomposition.
Place 2 cc of reagent
(1 part ether,
1 part concentrated
hydrochloric
acid, and
3 parts absolute alcohol) into test tube and shake.
A small
piece of meat to
be tested is lowered
to within
one-fourth inch of
surface
of reagent.
If ammonia
is present
white ammonia
chloride
fumes will appear
around
the specimen.
;— - r. -
:
FOOD IN THE
FIELD
VITAMINS
339
Meat may
be hung in cold
storage
but
it should not
be stacked
in the refrigerator
until it has been
thoroughly
chilled, preferably
frozen thoroughly.
When warm meat is stacked in the refrigerator
decomposition
develops
in
the
center
part
of
the
stack
before
it
can be frozen.
The hind quarters
and fore quarters
should be stacked
to permit issue alternately.
In the field
a percentage of the rations is issued in tin containers,
which, due to improper preparation, exposure
to excessive heat, and
lack of care in handling, frequently undergo
decomposition
and are
especially dangerous
to health if their
use is permitted.
Therefore
a. careful inspection
of all canned
goods should be required.
The terms "springers"
and "swells" are applied to bulged,
blown,
or swelled
cans.
These
cans, when
pressure
is applied at the ends
give a crackling sound.
"Springers"
are caused by overloading the
can, and though
not desirable,
the contents
are fit for use.
"Swells"
are caused by the formation of gas, due to decomposition
and may
be differentiated from "springers"
by a splashing sound
when
the
can
is shaken,
and
a hollow
note
when
the can
is gently tapped.
These should be condemned.
Occasionally the inside of a can may
present
a blackened
appear -
ence —so called
"can burn."
This condition
is not due to putrefac
tion, but is caused by the precipitation
of stannous
sulphide in an
acid medium.
Formerly
a can with two solder
holes was indicative of a "swell"
which had
been punctured to let out
the gas and
then
resoldered,
but now
many manufacturing
firms use two solder
holes in sealing
their cans.
It is well to reject cans with three solder
holes.
Vitamins. —Vitamins
are
accessory
food
factors
that
occur
in
minute amounts in natural foods and are in varying degree essential
for normal body growth and maintenance.
They are complex organic
compounds
which the body is unable
to synthesize.
Recent researches directed particularly
to determining the chemical
nature and
synthesis
of
these
compounds
has
been
extensive,
and
present
literature
on this
subject
is
voluminous.
Information
on
their
nature
and
physiological
effects
is
changing
progressively.
Consequently
the
reader
must refer to the
latest
current literature
for reliable information
on this
subject.
Due to
much
confusion
as to terminology and the prominence
this subject has attained
in the
popular
mind it is discussed
more fully than its
importance
as
a
food factor merits.
At
present writing vitamins, A, By C, D, E,
and F, have
been
classified
as accessory
food
factors.
The following
discussion
is a
brief
and
incomplete
summary of
present
information
on
these
vitamins :
340
FIELD
SANITATION
MANN
Vitamin
A.—This is
a fat soluble
compound
obtained
normally
from green leafy and yellow pigmented
vegetables, milk, butter,
and
eggs.
A rich concentrate
is obtained commercially from the livers of
codfish
and
halibuts.
This vitamin
is
commonly
associated
with
vitamin D and these two vitamins may be administered together
to
advantage.
Chemically it is closely related
to carotene.
It is moder
ately stable when subjected to heat.
Deficiency
of this vitamin causes
xerophthalmia
and
subclinical
deficiency
is
best
determined
by
biophotometer
test for nyctalopia.
Deficiency also causes
epithelial
changes of the skin and mucous membranes.
There is no proof that
deficiency
is a primary
factor that increases susceptibility
to infec
tion.
The
average
diet which
includes
vegetables,
dairy
products,,
and eggs, provides an ample supply of this vitamin.
Vitamin
B.—This water
soluble
vitamin has
been
identified
as a
vitamin complex of which at least six compounds
have been
isolated
with reasonable certainty.
Early investigations that deal with vita
min B as an entity therefore
present
inconsistent
findings.
Vitamin
B was
classified
as
heat stable.
However,
the
components
of this
complex vary in resistance to heat.
B2 is more stable than Bt in this
respect.
Heat that renders
Bs inactive does not effect B^
1. Thiamin
Chloride (Bi).—This is the antineuritic vitamin.
De
ficiency
causes
beri-beri, peripheral neuritis, gastrointestinal
atony,
nausea
and
anorexia,
and
altered
carbohydrate
metabolism.
It is
obtained from the following natural foods
: Pericarp of cereals, wheat
germ, tomatoes, eggs, yeast, prunes,
and meats.
It has been obtained
in pure crystalline form having antineuritic activity.
2. Riboflavin
(B,). — The history of this vitamin is interesting and
confusing.
Goldberger in his researches
on pellagra demonstrated
that his pellagra-preventing
factor differed
from vitamin B and he
designated
it as the P-P factor.
Other investigators have designated
this factor
as vitamin
G.
Therefore, vitamin
B3> P-P factor, and
vitamin G are synonymous.
However, vitamin B2 and riboflavin may
not
be identical.
Recent
work indicates
that vitamin
B2 may
have
two components
(a) riboflavin, also called lactoflavin, and (b)
a sup
plementary
substance designated
as B„.
Riboflavin
has been obtained
in pure crystalline form, identified
and synthesized.
In water solution
it
produces
a yellow-green
fluorescence.
It
is
widely
distributed.
Recent
reports indicate
that it is
a cell enzyme
concerned
with
cell
respiration.
It is normally obtained from yeast, dairy products, eggs,
leafy vegetables, and meats.
Deficiency
is manifested
as sore mouth
and dermatitis of the scrotum.
3. Vitamin
Bs.—This vitamin occurs in whole
grains, malt, yeast,
and liver.
Deficiency
causes a loss of weight
and
prevents
growth.
It has not been identified
chemically.
Recent work indicates that this
vitamin may have two component
factors.
FOOD IN THE
FIELD
VITAMINS
341
4. Vitamin Bt.—This factor has not been identified chemically.
It
has
been
found to
be intimately
associated
but
not
identical with
adenine.
It occurs naturally
in yeast, dairy products,
whole
wheat,
liver,
and
lettuce.
Deficiency,
experimentally,
causes
retarded
growth, muscular
weakness, and incoordination, with spastic gait.
5. Vitamin
Z?5. —This is a slightly
water
soluble
factor
obtained
from yeast.
Like Bs it is concerned with growth but it differs in that
it permits only maintenance
of weight.
6. Vitamin B9.—This is the supplementary substance found associ
ated
with
vitamin
B2.
This factor
is probably
identical
with
or
essentially similar to vitamins reported
by various investigators under
other alphabetical
designations.
In summary,
the vitamin B
complex
has only two components,
thiamin chloride and riboflavin that need to be considered,
and these
occur in
the
foods
commonly
included
as
elements
of
the
service
ration.
The other
alleged
components
of this complex
require con
firmation.
The special
actions attributed to Bsand
B4 may be due to
a larger supply of Bj.
Vitamin C—Cevitamic acid. —This food factor is antiscorbutic and
has
been definitely
identified
as
1-cevitamic
acid.
The
"d-form"
of this acid is inactive and
the "iso-form"
possesses
little
activity.
The present international unit of 1-cevitamic
acid
is 0.05 milligram.
This is the equivalent
of
0.1 cubic centimeter
of lemon
juice.
The
daily needs of this vitamin are about 250 units.
Scurvy
is
the typical
clinical
manifestation of vitamin
C
defi
ciency.
The natural siurces of cevitamic
acid
are all citrous fruits
and
green
vegetables
including
peas
and
spinach.
It
is produced
synthetically.
It
is
water
soluble
and
easily
destroyed
by
heat.
•Clendenning
lists the following
foods
as containing more
than
100
units of vitamin C per pound
:
Cabbage,
raw
320
Parsley
240
Grapefruit
240
Peppers
400
Lemons
240
Spinach,
raw
400
Oranges
240
Strawberries
160
-Tangerines
240
Tomatoes,
raw
and canned
240
Vitamin C differs from vitamins A, B complex, and D in that little
reserve is stored in the body tissues.
Hence,
an adequate daily intake
of this factor is particularly
important.
Approximately
70 percent
of quantities
in excess
of body needs
are reported
to be excreted in
the 3-hour period following
intravenous injection.
Vitamin D.—This antirachitic vitamin promotes
the deposition
of
calcium
and
phosphorus
in
bone
formation.
Consequently
it
is
needed primarily during
the years
of growth.
It is
a product of
ultra violet radiation.
This antirachitic
effect may
be obtained
by
direct exposure of the body or a product having
a high degree of
antirachitic
effect is obtained
by irradiating
ergosterol.
The irra
342
FIELD SANITATION
MANN
diation apparently alters
the molecular structure of ergosterol.
An
antirachitic crystalline substance
has been
obtained
from irradiated
ergosterol.
Vitamin E.—This vitamin occurs in yeast, wheat germs, and lettuce.
It promotes normal reproductive function.
Vitamin F.—This vitamin appears to be essential for the production
of linoleic acid, an unsaturated
fatty acid.
Conservation
of food vitamins. —Several
simple
but important
facts
must
be remembered in providing
troops
with an adequate in
take of vitamins.
Personnel charged
with preparing
food for con
sumption
should
be familiar with these facts and conserve food vita
mins.
The vitamin content of foodstuffs decreases with age and ex
posure
to heat, light, oxygen,
and alkali.
Since
vitamins are water
or fat soluble, the water or fatty liquids in which foods are preserved
or cooked
contain
vitamins
and
other
beneficial
extractives
which
should
be incorporated in
the ration, if
possible,
rather than dis
carded as waste products.
Prolonged cooking,
such as is apt to occur
with
field
kitchens,
tends
to
destroy
the
vitamin
content
of
the
ration.
The
vegetables for stew should
be
cooked
separately
and
not longer than 30 minutes; then they should be added
to the meat,
which requires
about
2 hours
of cooking.
Avoid the
use of alkali,
e. g., sodium
bicarbonate,
when cooking green vegetables
as this also
tends to destroy
the vitamins.
In Mesopotamia
during
the late war over
11,000
cases of disease
due
to food
deficiency
developed
in
6 months —hence the practical
import since of medical supervision of the field ration.
British troops
in Mesopotamia
during the late war, eating white bread, suffered from
beri-beri, while the Indian troops,
eating unmilled
wheat,
escaped.
During the seige of Kut the reverse was the
case, the British lived
largely on fresh
meat, while the vegetarian
Indians lived largely
on
white bread.
During the late war an outbreak
of scurvy occurred in
the British Army among the men of the South African Labor Corps.
Without the alteration of their diet, the period of cooking was reduced
from
6 hours to
45
minutes,
and
the
outbreak
was
immediately
arrested.
The vitamin-containing
foods of an exclusive military ration should
weigh at least 30 percent of the total.
WATER
IN THE FIELD
Officers
responsible for water
supply.—The
quartermaster
is
responsible
for the procurement
of water rights and for the delivery
of water to the camp site.
The medical
officer is responsible,
in an
advisory capacity,
for the quantity
and the quality of the water at
the source as well as at the ultimate point of consumption.
The unit
WATER
IN THE
FIELD
SOURCE
343
commander
is responsible
for the proper distribution
of the water
within the organization.
Water
consumption.—Water
constitutes
60 percent
of
the body
weight, or the equivalent
of
10 gallons, which
equals
100 pounds
approximately in the average man's body.
The loss of one gallon of
this water has serious consequences; if iy2 gallons are lost, the result
is fatal.
The quality
and quantity
of the water
supply is
a vital
factor
during field operations.
In a war of movement
the supply of water
is very apt to be inadequate,
which may mean that the consumption
of water will have to be restricted to a minimum.
The minimum allowance
of water for the
needs of men and ani
mals varies
according to the amount of daily labor performed and
also
the conditions of the
weather.
The
following
may
be taken
as an absolute minimum : Each man,
1 gallon per day, to be used as
follows —iy2 quarts for drinking,
2y2 quarts for cooking and drink
ing with meals.
In combat, a soldier can maintain physical efficiency
for 2 days only on one-half gallon of drinking
water each day.
The above is the minimum for soldiers on the march and in bivouac,
and provides no allowance
for the washing of person or clothing.
In camps of more than one-night duration the following
minimum
allowance should
be furnished:
Gallons
In
barracks
20
In
camps
5-10
Drinking and cooking only
2
The daily requirements
for animals
are :
Gallons
Horse
10
Mule
or
donkey
6
Source
of water. —The
sources
of
water
are divided
into
(a)
surface waters, such as lakes, ponds, rivers, streams, etc.;
(b) under
ground
waters,
which include
wells,
springs, etc. ; all
these
vary in
degree
as to purity
and potability.
Rain
water
is usually the most
satisfactory of all natural waters.
Large
bodies of water are more
likely
to contain
pure water than
small
ones,
because of the greater
dilution
of the contaminating material.
Water
which
is obtained
from
the center of a large lake
is very
apt
to
be pure, especially
where
the sun shines upon it.
One should
always be suspicious
of all surface waters
as the ap
pearance
of water
is no index to its purity.
Water should be con
sidered
contaminated
until tests prove it potable.
Also, water found
potable
may become contaminated
subsequent to test.
Consequently,
water used for drinking
and cooking purposes
should
be guarded
and tested frequently for contamination.
344
FIELD
SANITATION —MANN
Wells
are of two varieties,
"deep" and
"shallow."
Water
taken
from shallow wells is always
suspicious,
while water taken from deep
wells and deep springs is usually fit for human consumption.
1. If water from a running stream is used, it should
be taken from
a point where
there is considerable
depth,
and
where
the current is
strong,
always upstream,
or in
other
words, above
the
camp
site.
Upon arrival in camp,
a guard should
be posted over the water
sup
ply and the stream should be inspected
and marked for use.
Begin
ning upstream
the water should be assigned for use
as follows:
(a)
Drinking and cooking water.
(b) Water for animals,
(c); Water
for bathing,
(d) Water for laundry purposes.
To compute the volume of water of a flowing stream the following
may be used as a guide
: Sectional
area in square feet, multiplied by
0.8 velocity in feet per minute,
multiplied
by 7.48, equals gallons per
minute.
2. Rain water, though not very palatable,
is the safest and purest
of waters.
In warm countries
it may be necessary to use it for drink
ing purposes
but it
must
be properly
collected
and
stored.
Rain
water is easily
collected
from the roofs of houses or other prepared
surfaces.
These
surfaces
must
be kept free from pollution,
such as
excrement
of birds, dust, decayed
leaves, etc.
The first washing of
the rain should
never be used as it will probably contain
some pol
lution
from
the
roof.
In storing
the rain
water,
the
containers
should
be well covered and ventilated,
and frequently cleaned to pre
vent pollution.
One inch of rainfall produces
22,500 gallons of water
per acre.
The number of gallons of rain water expected to be recov
ered from a roof may be determined
by the following
formula:
Area
of roof in square feet, multiplied
by one-half the rainfall in inches,
equals number of gallons.
3. Well water usually
comes
from two sources.
The greater
por
tion filters in from the deeper strata of the soil and may be considered
as free from contamination.
However, wells are rarely properly
en
cased
near
the surface
and
properly
covered
as
protection
against
surface
water
drainage
and
other pollution.
Therefore
all
wells
should
be regarded
as contaminated
and should be cleaned
and dis
infected
prior to use by employing the following
measures:
(a)
Remove all refuse from well.
(b) Pour into well
about half-barrel of a solution of freshly
burned
lime
(or a
1 percent solution of chlorinated lime
can
be used).
(c )
Scrub sides of well with above solution.
(d) Wait 2 hours, pump well dry. and repeat above procedure.
(e) Wait 24 hours, pump out well, allow to refill.
WATER IN
THE
FIELD
STORAGE
345
(/)
Continue
to pump out
until
all
taste of
lime
has dis
appeared.
(g)
Sterilize water in well by adding a solution of chlorinated
lime —30 grains to every
100 gallons of water in well.
(h) To compute
number
of gallons in well use formula : The
square of diameter
of well in feet multiplied
by 0.7854,
multiplied
by depth of well in feet multiplied
by 6.25
equals gallons in well.
Transportation and storage. —Water carts employed
in the trans
portation of
water
should
be
subjected
to
the
following
sanitary
measures
:
(a)
The tank of water cart should
be scrubbed
out every
4
days with a
1 percent solution of chlorinated lime.
(b)
Water
carts
should
never
be
devoted
to
other
purposes
than to provide drinking water for men.
(c) A half-teaspoonful
of chlorinated
lime—30 grains—well
dissolved
as a paste, added to 100 gallons of water will
produce approximately
1 part per million of free chlo
rine,
and is sufficient to sterilize this quantity of water.
The
best storage
containers
are those made of concrete,
slate, or
galvanized
iron.
Wooden
containers
will, after
a
time,
give
the
water
a very disagreeable
taste.
Water
receptacles
should
be well
covered.
As
the ground
in
close proximity
to
a
water
faucet
is
likely to be wetted, it is best to build a sand or gravel pit, 2 feet square
and 1 foot deep, to absorb the waste water.
The
receptacles
should
be
cleaned
daily
with
boiling
water,
or
rinsed with
a solution of
potassium
permanganate
(one-third
tea-
spoonful
to
1 gallon of water).
A solution of chloride of lime is
also very good for this purpose,
in proportion of
1 to
1,000.
These
solutions are harmless
and more certain
in their action
than boiling
water used alone.
Canteens,
when
not in use, should
be emptied,
dried, and cleaned,
with
one of the above solutions.
Weak tea has been highly
recom
mended for drinking
purposes in canteens; it should be boiling hot
when poured
in, thus insuring
the sterility
of the canteen
as well
as of the contents.
Common drinking cups should not be used ; however, if individual
drinking cups cannot
be supplied, lip drinking should be practiced.
Should
conditions arise which
make it absolutely
necessary
to use
common
drinking cups,
a certain degree of safety
can
be
insured
by keeping the cup immersed in a solution of formalin
(1 percent).
Data regarding water. —The maximum density
of water
is at 4°
C, which explains the fact that ice is lighter than water.
One milli
liter of water at 4° C. weighs
1 gram.
Water when frozen liberates
346
FIELD SANITATION
MANN
80 Calories of latent heat, and expands
9 percent in bulk ; the latter
fact explains the bursting of water pipes in winter.
The addition of salt to water raises the boiling
point and lowers
the freezing point.
One cubic foot of water equals 7.48 gallons.
One gallon of water equals
10 pounds, or 70,000 grains.
One liter of water equals 0.26418 gallon.
Water Pubification
Purification of temporary water supplies.
General.—The water
supply
for moving troops,
for temporary camps
and
installations,
or for troops in the theater of operations
frequently must be purified
under conditions which do not permit the installation of permanent
or semipermanent
water purification
works.
The agencies employed
generally
for
this
purpose
are:
(1)
Chemical.
(2)
Heat.
(3)
Filtration.
Chemical
purification. —Chlorination
is
extensively
practiced
today.
Hypochlorite of calcium,
commonly
called
bleaching
powder,
is the substance
used, and
is
issued
by
the quartermaster
in small
glass tubes.
The ordinary calcium
hypochlorite (Calx Chlorinata)
or bleaching
powder
contains
33y3
percent,
of
available chlorine
when
freshly
prepared,
but
is an unstable
substance,
so that the supply received
may
contain
but little chlorine.
There are hypochlorites available,
however,
and
now
recommended
for
use,
which contain
well
above
60
percent
available chlorine,
are
very
stable
and
easily
miscible.
Bleaching powder tends to form small,
hard lumps when
placed
in
water.
In
preparing
a
hypochlorite
solution
just
sufficient
water
should
be added
to the powder to permit the easy formation of a
smooth thin
paste, which is then diluted
as required
and
placed
in
the chlorinator.
Twenty-five
pounds
of ordinary
bleaching
powder
added
to
1,000,000
gallons of water give one part
per
million
of
chlorine.
If 4,000 gallons of water
are to
be chlorinated one-tenth
pound
of
hypochlorite
is
sufficient.
A
drip
chlorinator
may
be
used in a small
stream, the size of the containers
and the strength
of
the solution being determined
by the rate of flow of the stream, how
ever the drip chlorinator
is not
recommended.
In case
water
is
so
turbid
as to make it unsatisfactory
for
use,
it may
be clarified
by
allowing
it to stand
for
some
time
in a reservoir and clarification
may be has'.ened
by the addition of chemicals.
Alum,
lime, and soda
ash are used for this purpose.
Chlorinating
water for small detachments. — Small detachments
separated
from the main
body of troops
and
its pure
water
supply
may
be provided with
safe water
by chlorination
of canteen water.
WATER
IN THE
FIELD
STERILIZATION
347
The contents of one tube of calcium hypochlorite
is dissolved
in
1
quart of water
and
preserved
in a glass bottle.
A metal
container
is not used as the concentrated
calcium hypochlorite
has
a chemical
nction
on the metal.
One teaspoonful of this solution
added
to
1
canteen of water
and allowed to stand for 30 minutes
renders
the
water safe for drinking.
If the tubes are not available,
then dissolve
1 teaspoonful of chlorinated lime, taken from
a freshly opened con
tainer, in
1 quart of water and
label
this "stock solution."
This
solution
deteriorates
very rapidly
and
fresh
solution
should
be
prepared every fourth
day.
One teaspoonful of this stock solution
added
to each gallon of water and allowed to settle for 30 minutes
will insure the destruction
of most bacteria.
Sterilizing
water by iodinization. —Two and one-half teaspoon-
fuls
(10 cc) of 7 percent tincture of iodine added to a sterilizing
bag
of water will purify it in
30 minutes.
Two drops of the tincture
added
to one canteen of water
and allowed to stand for 30 minutes
will render it pure.
There are two objections
to this method of sterilization:
1. There
is no reliable method
for titrating
the iodine in
a
test for sufficiency of the amount
added.
2. This
method
is
more
expensive
than
the
hypochlorite
method.
(The
excess
of iodine may
be neutralized
by
adding
1 gram of sodium thiosulphate.)
Water sterilizing
bag. —The
water
sterilizing
bag,
often
called
the
Lyster
bag,
is
made
of
specially
woven,
waterproof
canvas,
weighing
about
7 pounds,
and
can
be folded into
a compac
t
pack
age.
It measures 20 inches in diameter
and 28 inches in length, hold
ing about
36 gallons.
Its sole use is as
a stationary
receptacle for
water while being sterilized and distribution
of same
after steriliza
tion, without dipping.
This is accomplished
by
faucets
which
are
arranged around the bottom of the bag.
The Lyster bag is part of
the Marine Corps field equipment
and is issued on the basis of
1 bag
for each 100 men or fraction thereof.
(See fig. 1.)
To use, this bag is suspended from a tripod and filled with water.
To each bag of water
(36 gallons)
there
is added
the contents of
one ampule
of calcium hypochlorite.
The calcium hypochlorite
is
issued in sealed glass tubes, one tube sufficing for one bag of water.
The\ water
is then allowed to stand for at least
30 minutes
before
using, as the sterilizing
process is one of oxidation, and is not com
plete in less
time.
In water that contains
much
suspended
matter,
or is very cloudy, the sterilizing
action is not very satisfactory
so
that it is necessary
to clarify the water before
chlorination
which
may be accomplished
by means of a small filter cloth provided with
the bag.
348
FIELD
SANITATION —MANN
W1REHOOKTO SUPPORT
CENTER OF COVER,
WHICH GIVES * "PITCHED-
' EFFECT.
1. Arrange
bag
on tripod.
Strain
water and fill bag
to within.
about 4 inches of the top.
2. Procure
a clean stick, or cut a limb from a tree for, use in stir
ring of water.
Place this in water
and leave there during steriliza
tion.
3. Break
one of
the
glass
ampules
of calcium hypochlorite
and
shake
the powder into
a cup.
Mix with
water
until
a
fine
paste
results,
and then stir with
a spoon,
adding more water
until
the paste
is entirely dissolved.
4. Add the hypochlorite solution
to the contents of the bag and mix
thoroughly with the stick provided
for that purpose.
Draw
3 cupfuls
through
each
of
the
faucets
(to
clean and sterilize)
and pour back
•'nto the bag.
5. Draw
off
1 cup of water
and
add
to it the contents of one
am
pule of orthotolidine, stirring
with
a clean, dry spoon.
As the water is
stirred it turns yellow, the degree
depending
on the amount of hypo
chlorite
present.
An
orange
or
orange
red color indicates
a suffi-
j\
I
cient
amount
for sterilization.
A
'
'
canary yellow color indicates
an in
sufficient
amount
and hypochlorite
should
be added to the bag one tube
at
a time
until
the right
color is
obtained.
The
water
is then
al
lowed
to stand for 30 minutes
and
guarded
to prevent
use during this period.
6.
Excess chlorine gives the water
an unpleasant
taste.
This can
be
dispelled
by neutralization
with
sodium
thiosulphate.
Sodium
thiosulphate is provided in glass ampules.
The contents of one am
pule should
be added to a cup of water, stirred until
dissolved,
and
after sterilization of the contents of the bag is complete,
should
be
poured
into it.
7. The faucets should
then be rewashed for the last time, running
at least 5 cups of water through each faucet and returning the water
to the bag.
This treatment
renders
the water perfectly
safe,
even
though it was previously heavily contaminated.
FiaiRE
1.—Water
hag.
(Diagram
pre
pared
by
Lieut,
(jg)
James
B. Butler,
Medical
Corps,
U.
S.
Navy.
WATER
IN THE FIELD— STERILIZATION
349
8. Unless
precautions
are taken
men will drink directly from the
faucets.
They
should
be required
to
use their individual
mess-kit
cups.
9. The bag cover
may
be supported
in the center
by
means of a
wire to the apex of the tripod
support.
This gives
a pitched
roof
effect,
allows rain water to run off the top and
prevents
sagging of
the top and contamination of the contents.
Mobile
water
purification
unit. —The
United
States
Marine
Corps
has
procured two highly
efficient
mobile
purification
units,
and has placed
one on each coast.
Essentially
the unit
consists of
the following:
1. Gasoline engine driven centrifugal
pump.
2. Pressure filter.
3. Chlorinator.
4.
Soda
ash feeding device.
5. Suction hose and discharge
hose.
The above is mounted
on
a circle steer highway
trailer.
The pump has the following
capacities
:
1. Twenty-five
gallons per minute against
a 10-foot
delivery
head through filter.
2. When
filtration
equipment
is
bypassed —in
case
the
raw
water is sufficiently
clear —the pumping
equipment
and
solution feed chlorinator will deliver 50 gallons per min
ute of sterilized
water
against
a 50-foot
head.
3. When
filtration
and
purification
equipment
is
bypassed,
and the unit used as a pumping device, then
100 gallons
of water per minute can
be
delivered
against
a 75-foot
head.
Thus the mobile unit may be operated
as :
1. A simple pumping unit.
2. A pumping and chlorinating unit.
3. A pumping and filter unit, with or without chlorinator.
It
is rather spectacular
to
watch
the
operation
of
one
of
these
units
with the suction
hose placed
in
a muddy contaminated
pond
of water
deliver
a
clear
purified
stream of potable
water,
at
the
rate of a barrelful
each minute,
at the discharge
hose.
Boiling. —Boiling is a simple
and effective method of water sterili
zation and may
be used in the presence of an epidemic of intestinal
disease, such as dysentery
or cholera,
and when materials are lacking
for sterilization
by other
methods.
Boiling was used effectively
by
the Japanese in the Russo-Japanese War in controlling
water-borne
diseases.
350
FIELD SANITATION —MANN
However, boiling all drinking
water entails a considerable
amount
of fuel
and
time.
For
250
men nearly
three
barrels
of drinking
water
are required
each day and it would be a heavy
task upon the
rolling kitchen if the boiling is to be done there.
Boiled
water has
a flat
taste
unless it is aerated
after
cooling.
Its taste may
be improved by the addition of tea or coffee.
Each man can boil water in his canteen, by placing the canteen full
of water in a fire, or upon hot coals until the water
boils, after which
it is removed and allowed
to cool.
Troops can, after a day's march,
prepare their canteens full of boiled water for use on the next day.
Field
filters.—The barrel
filter
consists
of
a small barrel
in
serted into one of larger dimensions
and separated from the bottom
of the larger
barrel
by
about
3
inches
of
fine sand.
The smaller
barrel having
a perforated bottom, .is placed
upon
the sand in the
larger barrel:
then more sand is placed
around the small
barrel to
the height of about
6 inches.
A layer of charcoal
and
a layer of
gravel
may be placed above the sand.
The barrel filter may be sunk into a lake or spring;
water may also
be filtered
by pouring it into the larger barrel.
In
connection
with
drinking
water,
special
attention
should
be
given
the following:
1. Regard all water in the field
as contaminated
unless proved
otherwise.
2. Do not
let the men fill their canteens from any unauthor
ized source.
3. Place
a guard at the source of the water supply to prevent
its pollution.
4. Water discipline
on the march
should be rigidly enforced.
5. Remember
that not only the quality
of the
water
supply
but also its quantity should
be supervised
by the medical
officer.
6. The
amount
of water lost
by evaporation,
and
otherwise,
by a man marching for 1 hour, or 3 miles, is nearly 1 pint.
7. The
results
obtained
by
modern
military
organizations
demonstrate
that water-borne
diseases are preventable.
8. The
prevalence
of
a water-borne
disease in
a camp
indi
cates
a weak link in the chain of sanitary measures.
Summary
points to be covered ani> reponted on in a wateb
reconnaissance "
1. Location.—Sources
and works should be shown
on
a map, or
their location
given
by description.
» From
Pamphlet
No. 3, Medical Field Service School, D. S. Army.
WATER
RECONNAISSANCE
351
2. Character of sources. —Well, spring,
stream,
lake, or pond.
3. Quantity of water available. —
Eate of flow of streams.
Rate of flow and capacity of wells.
Rate of flow of springs.
Dimensions
and
estimated
depth
of
lake
or
pond
and, if
indicated, rate of inflow and outflow.
4. Quality of water. —
Turbidity.
Color.
Taste.
Result of bacteriological examination, if indicated, and if it is
practicable
to secure samples and have them analyzed.
5. Sources of bacterial contamination. —
Character of sources.
Location in relation to water supply.
Control measures indicated.
6. Accessibility.—
Accessibility of sources of water
to troops
by railroad, high
way, improvised roads, trails, or hand carry.
7. Wells.—
Diameter.
Depth of well.
Depth of water.
Distance
from surface of the ground to surface of the water.
Type, condition, and depth of casing or lining.
Kind of soil.
Nature of impervious
strata, if indicated, and
ascertainable.
Method of recovering water,
i. e., pump, windlass, etc.
8. Springs. —
Kind of spring.
Protection
provided, i. e., coping, watertight
basin,
ditching,
etc.
9. Stream.—
Mean velocity.
Mean width.
Mean and maximum depth.
Nature of bed.
Height of banks above surface of water.
Method of recovering the water provided.
10. Existing installations. —
Purification
facilities —chlorinating
apparatus, filters,
eto.
Pumps —number,
size, type,
speed,
and
capacity.
352
FIELD
SANITATION —MANN
Engines—type, size, speed, and horsepower.
Electrical
equipment.
Storage
facilities —type and capacity.
Pipe lines—length,
size, and material.
Present condition
(description).
11. Proposed
developments. —
Description.
Material
available.
Material required.
Time required.
FIELD
CONSERVANCY
"Field
Conservancy"
is
a
technical
term
employed
to
designate
the disposal
of waste products in the field.
The disposal
of waste products
is one of the most important
field
sanitary measures, and the importance
of proper waste disposal
was
known to the ancients.
Burial
was
the
earliest
means of
disposal
and
is
instinctive
in
many of the lower animals,
since animals
such as dogs and cats bury
their dejecta.
Moses —from his experience
with
a plague of flies in
Egypt —in his advice
to the Israelites, in Deuteronomy
xxii,
12-14.
lays
down
the sanitary directions, "Thou
shalt have
a place
also
without
the
camp,
whither
thou
shalt
go forth
abroad,
and
thou
shalt
have
a paddle
upon
thy weapon; and it shall
be, when
thou
wilt
ease thyself
abroad,
thou
shalt dig therewith
and
shall turn
back and cover that which cometh from thee."
Suppose
that no
precautions
were
taken
to
accomplish
sanitary
disposal
of waste products
in the field, then the danger of the spread
of contagious
diseases in an army
would
be in direct
ratio to
the
size and density
of the aggregation.
Thus when
an army
takes the
field
the
danger
from
epidemics
would
increase
with
the
square
of the number
of men.
In other
words,
under conditions in which
the measures of preventive
medicine
were not
employed,
the
possi
bility of an individual
soldier acquiring an infectious disease in an
army
of
1,000.000
men would be approximately
one thousand
times
greater
than
in
a
regiment
of
1,000
men
acting
independently.
Various
other
factors enter into
consideration
that tend
to
render
these statements
not mathematically exact;
however,
they
are
suf
ficiently accurate for purpose of illustration.
Field sanitary measures of modern
military
preventive medicine
has reached
a stage in development
in which it is now
possible
to
assemble
a million
men in
the
field
and
prevent
decimation
from
FIELD
CONSERVANCY
353
epidemics.
It is interesting to note that this achievement
has been
consummated only in comparatively
recent
years.
As an example
of this compare
the ratio of
death
rate
in battle
to
the mortality
rate from
diseases during the Civil War (1 to 2) to the ratio exist
ing in the World War
(1 to 0.06).
Waste products may
be divided as follows:
1. Refuse:
(a)
Garbage.
(b)
Rubbish
(boxes, paper,
etc.)
2. Excreta:
(a) Night soil (urine and feces).
(b)
Manure (stable litter).
Or they may be classified
as follows :
1. Solids:
(a) Human
feces.
(6)
Kitchen
garbage.
(c)
General
camp rubbish.
(d)
Stable
refuse.
2. Liquids:
(a) Urine.
(b)
Kitchen
sullage.
(c)
Ablution
water.
The proper disposal of waste constitutes
one of the most important
functions of the field sanitarian.
In
the disposal
of waste
the
following
objectives
are involved:
1. Prevention
of insect
breeding. —To change
the nature
or loca
tion of waste matter
so that
fly breeding
will be prevented,
and also
the breeding
of other disease-carrying
insects.
2. Destruction of microorganism*. —To destroy
or otherwise
elimi
nate the presence of organisms
which may
cause
disease.
3. Removal
of
a
nuisance. —Waste
matter
and
filth
are
almost
synonymous
terms; and,
as such, the accumulation
of waste creates
a condition which is offensive
to the senses of sight and smell.
The
methods
for
ultimate
disposal
of
waste
products
can
bo
grouped
into two main
procedures,
namely —
1. Burying:
(a)
Shallow —Temporary
camps.
(b)
Deep —Semipermanent
camps.
2. Burning —Permanent camps.
In camps not of a permanent
nature and with moving troops, burial
is a more convenient
and rapid means of waste disposal
and is uni-
6t743— 3fs
3
354
FIELD SANITATION
MANN
versally practiced in our modern
armies.
Incineration
has
the ad
vantage of complete destruction
of all waste and is the better method,
from
a sanitary standpoint, for permanent
camps.
Collection
and disposal or refuse. —Metal garbage
cans, if avail
able, should
be placed
at intervals in
the company
streets for the
deposit of waste paper, burnt matches, cigarette
stumps, fruit
peel
ings,
etc.
The
use of receptacles of this sort
accomplishes
primary
cleanliness
of the camp and inculcates
the habit of cleanliness
in the
men.
If metal
receptacles
are not
available,
wooden
or cardboard
boxes may
be employed.
Garbage
cans should be well covered and placed on raised platforms
at least
2 feet from the ground.
The soil beneath
these platforms
is easily
contaminated
by
the
overflow
of drippings,
and
requires
careful supervision to prevent pollution
and fly breeding.
The sur
face beneath garbage
cans should be scraped daily and shoveled into
the garbage cans.
Fresh dry earth should be spread over the scraped
area.
The promiscuous
use of lime to cover filth is not recommended.
Shallow
burial. —The
surface
of the
earth usually
consists
of
bacterial
soil varying
from
a few
inches
to
a few
feet
in
depth.
The
top
layer of the
earth's
surface
is
inhabited
by
millions
of
friendly
germs —the
germs
of
decomposition —which
break
up or
ganic
matter
into various gases
and
water,
and
so rid the earth of
the debris which would accumulate
on the surface.
It is part of the
scheme
of nature that it must
be so, for if constant
breaking up of
organic matters
were not going on, the surface
of the earth would
become
choked
and
we should
find ourselves
up to
the middle
in
leaves, which fall and accumulate.
The
surface
of the
earth
is
always
assisting
in this destruction
of organic matter.
This layer of germ-charged
earth
is known
as
the live humus
or living filter,
because
the germs
not only destroy
organic matter,
but
they
prevent
the passage of filth into the soil.
The live humus
varies in depth
according to the nature
of the soil,
and is deepest where the soil is very light and where air can percolate
through the surface.
In this case it may reach to a depth of 2 or 3
feet.
Usually, the depth of this humus-bearing soil is
1 to iy2 feet.
Below the level of the live humus
the earth
is sterile or free from
germs, and, if buried deep, organic matter such as excreta receives no
assistance from the earth in the matter of decomposition.
The live
humus
varies in its intensity from time to time, for if the germs
are
well
fed
they
increase
and
multiply,
whereas if
they
are
starved
they perish.
Germs
require
food, moisture,
and warmth for their growth,
and
if well supplied with these they will multiply
in proportion
to the
amount of food they obtain.
Thus the live humus
varies in intensity
LATRINES
355
according
to the time of year, for in a very
dry summer,
when
the
surface of the earth
becomes
bone-dry,
decomposition
may
be abso
lutely
arrested,
and
a body
may become mummified
or sun dried if
it is covered with sand to keep off flies.
(Moss-Blundell.)
Latrines
The allahabad system. —Nitrification
of excrement
in the sod is
the sole aim of sanitary science, and the more intimately
the excre
ment is mixed with the dry earth
the quicker will nitrification
occur.
The germs which
cause
nitrification
are in the upper few
inches
of the
soil
and this fact is taken
advantage
of in the
disposal
of
excreta
by the so-called Allahabad
system, as used in India.
An area 16 feet long and
5 feet wide is excavated
to the depth of
3 inches.
The
excavated
soil
is placed
at one end.
The
denuded
area is then loosened to a depth of nine inches.
The area is sufficient,
to dispose of sixty gallons of night soil, when dumped
in the center.-
The liquid waste is absorbed
by the loosened soil.
The solid matter
is spread
over
the area, and
then
covered with
the
3 inches of soil
previously removed.
This is tamped
down.
In
a few weeks, depending
on the temperature,
the solid matter
is completely
decomposed and all pathogenic
germs are destroyed.
The Allahabad
method
is useful
in
permanent
campsites —using
the bucket system—where fuel is limited for incineration, but under
the
usual
field conditions this method
is of more
academic
interest
than practical value.
Shallow latrines. — On the march: A marching
column
is
sup
posed
to rest for
10 minutes
every hour on the march,
and during
the rest period the medical
officer should see that some
place is pro
vided for the
men
to
relieve
themselves.
As soon
as
the column
halts,
a sanitary detail
from
the company
should immediately
pro
ceed to improvise latrines.
A few narrow
trenches
about
8 inches
deep and
1 foot wide will suffice,
and can be hastily constructed with
a sharp stick, spade, or bayonet.
The sanitary detail should
remain
to fill in the latrines with earth
when the march
is again
resumed.
In temporary camps : Camps which are to be occupied for 15 days
or less should
be provided with "straddle trench" latrines with di
mensions
as follows :
1 foot wide, 2 feet or less deep, 3 feet long.
The
straddle trenches are also called
the "One-two-three" latrines because
of their dimensions.
These shallow trenches
are more
effective in disintegrating
solid
waste than the deep trenches,
as the germs of nitrification
are found
only in upper few inches of the soil.
All excretion
and disease pro
ducing organisms,
even the toilet paper,
disappear in these shallow
trenches in 4-5 weeks, as one investigator reports.
356
FIELD SANITATION
MANN
Straddle-trench
latrines
should
be
constructed
parallel
to
each
other and
should
be 3 feet apart;
the loose earth
should
be heaped
close to one end of the trench.
A shovel, spade, tin, or other similar
articles should
be
on
hand,
and
each
man
should
be required
to
cover
his
dejecta
with
loose
earth
after
defecation.
Often
it is
necessary
to establish
a guard in the sanitary
area to prevent
this
•weak link in the chain of sanitation.
The straddle trench
latrine
may be designated
the open shallow latrine.
Deep
latrines. —The
open
deep
latrines,
similar
to
those
used
during
the Spanish-American
War. and which created
such insani
tary conditions and contributed to the spread of typhoid
fever, will
be omitted
from discussion,
for quite
obvious
reasons.
In semipermanent
and permanent
camps, deep covered latrines are
recommended.
These
latrines require
more
time
and labor to construct
than the
shallow-trench latrines, but have the advantage
that they
are easier
to make fly proof.
The dimensions
for deep latrines vary considerably,
but the follow
ing may
be taken
as
a standard
: 2 feet wide,
6 feet deep, 7% feet
long.
In loose soil it may
be necessary to revet the latrine pit.
The Army latrine
box is an excellent
type of cover for
deep la
trines.
The exact specifications
for building
this box will be found
in one of the diagrams in this chapter.
The box consists
essentially
of
an
inverted
open
box
built
to
a
convenient
height
above
the
ground, containing pear shaped holes in the top, with lids covering
these holes.
The lids are made
to
open
not
over
85°, which will
cause
them
to
close
automatically.
A
space of
one-fourth
inch
should
be left
at
the
seat
hinge to allow for the swelling of
the
wood.
(See fig. 2.) .
These deep latrines are usually
intended for use over
a long period
of time.
Most of the odors of latrines are due to ammoniacal
and
other decomposition
of urine and the separator
system is sometimes
used to separate
the urine from the feces.
A urinal
soakage
pit
is
built
close by, and by means of
a tin gutter, built in front of and
under the
seat,
the urine accompanying
defecation
is drained into
the soakage pit.
A urinal trough connected to a soakage pit should
be constructed
within the latrine enclosure.
The latrine
is improved by erecting
it on
a
mound
a
foot
high
composed of earth
removed from pit.
This mounding of earth pre
vents
surface
drainage into pit
causing
contents
to
overflow.
La
trines should
be abandoned
when filled
to
1
foot
from normal sur
face
level.
They
should
be
liberally
sprayed
with
crude
oil
or
LATRINES
357
covered with quick lime
and mounted
with earth.
Each abandoned
latrine should be labeled
with
a small
wooden
sign.
When dug in
wet soil
a foot or two of water often appears
in the bottom
of the
pit.
Such water aids in absorption
of the contents into surrounding
soil and many
such latrines exhibit septic action.
/mouno ofearthV
(
I"
ABO"E
Vgnound
LE"EL
/ BURLAP
SACK1NG V
/ SOAKED
1NCRUOE-O1iA
I
TO MAKE LATR1NE
I
\
LARVA
PROOF.
/
Florae
2.—Modification
of
standard
TJ
S
Army
latrine
box.
Diagram
prepared
by
Lieut,
(jg) James
B. Butler.
Medical
Corps, U. S. Navy.
Bill of materials
1 box and enclosure
2 boxes and enclosures
Top of box
Front of box
Rear of box
Ends of box
Beat covers
Do....
-
Battens and strips
Frame for box..
Do
Front plank
under box. .
Rear plank
under
box. . .
End plank
Do
End strip
Posts
Boarding '
Battens.
-if roof is used
Do
Rails
Nails
Do
Do
Strap hinges
-
Flat-bead screws
.
Qalvanized-iron
urinal trough...
Wrought-iron
pipe
---
Wrought-iron
pipe bent as shown.
L C. tin
™
Labor— Carpenter.
2 pieces 1" by 12" by 8'—0".
2 pieces 1" by 8" by 8"— 0"..
2 pieces 1" by 10" by 8'—0".
1 piece 1" by 8" by 8'—0"...
1 piece 1" by 12" by 7'—0"..
1 piece 1" by 2" by T—V'....
8 pieces 1" by 2" bv 8'—0"..
1 piece 2" by 2" by 4'—6"..-
2 pieces 2" by 4" by 9'—0"..
1 piece 2" by 10" by 8'—0"..
1 piece 2" by 6" by 8'—0"-..
1 piece 2" by 6" by 3'—0". . .
1 piece 2" by 12" by 3'—6"..
1 piece 1" by 6" by H— 9"..-
10 pieces 10'—0"...
48 pieces 1" by 12" by 6'—0"
48 pieces 1" by 2" by 6'—0".
2rolls....
1 piece 2" by 0" by 14'—0"..
2 pieces 2" by 4" by 14'—0".
8 pieces 2" by 4" by 12'—0".
3 pounds twentypenny.
8 pounds
4 poui
4 pair
4 dozen No. 8
1 piece 6" by 6" by 3'—0".
1 piece 1" by
by 1'—4'
1 piece 1" by
by 4'—0'
1 sheet 20" by 28"
20 hours
4 pieces 1" by 12" by 8'—0".
4 pieces 1" by 8" by 8'—0".
4 pieces 1" by 10" by 8'—0".
2 pieces 1" by 8" by 8'—0".
2 pieces 1" by 12" by V—0".
2 pieces 1" by 2" by 7'—0".
16pieces 1" by 2" by 8'—0".
2 pieces 2" by 2" by 4'—6".
4 pieces 2" by 4" by V—0".
2 pieces 2" by 10" by 8'—0".
2 pieces 2" by 6" by 8'-I0".
2 pieces 2" by 6" by 3'—0".
2 pieces 2" by 12" by 3'—6".
2 pieces 1" by 6" by H—9".
12 pieces ir—0".
66 pieces 1" by 12" by 6'—0".
66 pieces 1" by 12" by 6'—0".
3 rolls.
1 piece 2" by 6" by 12'—0".
2 pieces 2" by 4" by 8'—6".
2 pieces 2" by 4" by 8'—6".
4 pounds twentypenny.
12 pounds tenpenny.
9 pounds eightpenny.
8 pair 4-inch.
4 dozen No. 8.
1 piece 6" by 6" by 3'—0".
1 piece 1" by IVi" by V'
1 piece 1" by
by 4'
2 sheets 20" by
—0".
32 hours.
1If T and O material
is used omit battens.
11-inch boards or equivalent
in other widths
if boarding
is used.
358
FIFXP
SANITATION
MANN
Site and number of latrines. —Latrines should
(a) be constructed
at least
100 feet from
the camp.
Deep closed latrines may
be con
structed
at a distance of 50 feet,
(b) They should
be constructed
on
the side of the camp opposite
to the galley and kitchen,
and
(c) if
practicable,
located
so as to drain away from the water supply,
(d)
They should
be placed at a safe distance
from ditches
and gulleys to
avoid the overflow
which might be caused by a heavy rainfall,
(e)
Separate
latrines should
be
constructed
for officers
and
men.
(/)
They should
be located to leeward
of the comp, if practicable.
The seating
capacity
of the latrine
area,
as given
by various
au
thorities,
ranges
from
5 to
15
percent
of the command,
depending
upon
the conditions.
For commands
on the march, stopping for only
one
night
in
camp
and
breaking
camp
shortly
after breakfast,
a
latrine frontage of
1 yard for every 10 men is not an excessive allow
ance. It is not always practical to construct
this number,
and under
such circumstances
the medical
officer should
be satisfied with a 6- to
8-percent
frontage,
using
the latter figure
for commands
under 500.
In a semipermanent
camp estimate one seat for every
15 men.
The advantage
of straddle-trenches
is that
the sides are not sub
ject to contamination
by urine.
A trench
lasts
1 to 2 days.
For straddle-trenches
the frontages
required
in yards is six times
the complement
in hundreds —that is, 200 men will need
12 yards of
latrine
frontage.
The depth
in yards is two-thirds
the number
of
days stay in that camp.
Care of latrines. —When deep latrines are filled to within
1 foot
of the surface
with excreta,
they
should
be filled in with earth
and
abandoned.
The filled-in
latrines should
be covered with
a mound
of earth
and
labeled
with
an l'L" if practicable.
This marking of
the
abandoned
latrines serves to inform
future
occupants
of their
site.
The inside of deep trench
latrines should
be darkened
by the
use
of tar paper,
lampblack, or other
suitable
material.
The
use of
a
dark
substance
will
prevent
the
entrance
of
ova-depositing
flies.
This depends upon
the principle
that flies usually avoid dark places.
The box cover may
be removed occasionally
and the inside burned
out with kerosene or crude oil.
In order to prevent
the egress of any fly larvae which may develop
in the depth of the latrine and burrow through the ground around
the mouth
of the pit, an area of about
4 feet around
the pit should
be covered with crude oil, or a 5-percent solution of cresol.
A better
method
is to cover the area with burlap sacking
soaked with crude
oil.
It
is
very
desirable
that
some
provision
be
made for the
men,
especially
cooks
and
other
food
handlers,
to
wash
their
hands
SOAKAGE PITS
AND
GREASE
TRAPS
359
after
using the latrines.
Sufficient
toilet paper should always
be
available.
In order
to
prevent
the
possible
flooding of
latrines
by
storm
water,
a shallow
trench
should
be dug around
the
area
occupied
by the latrine.
Latrines should be surrounded by a canvas screen or a screen made
of shrubbery.
Soakage pits.—Soakage
pits are one of the greatest
developments
in improvised sanitary
appliances.
The writer
has installed
them
in cells and other compartments
of a tropical prison and found them
easy
to
maintain
in comparatively
good
sanitary
condition
over
periods of months
and years.
These pits are designed for the ultimate disposal
of liquid
wastes,
urine, sullage
water and ablution water.
These sanitary expedients
should
be
considered
in
the
establishment
of
semipermanent
and
permanent
camps.
Ant
heaps, or nests of
other
termites
have
been
used
as ready-
made soakage pits, and
have
been
found
capable
of absorbing
300
gallons of waste in 24 hours.
Soakage
Pits
and
Grease
Traps
Ukinal soakage pits.— (a) Dig a pit 4 feet square—easily
remem
bered —fill
to
within
6
inches
from
surface with
large
stones, or
empty perforated cans.
(b) Insert
4 pieces of iron piping,
1 to 2 inches in diameter,
and
iLy2 feet long at each corner of the pit, so that the upper end is at a
convenient
height above
the ground to serve
as
a urinal.
If iron
piping
is
not
available, long
tin
or
tar-paper
funnels
may
be
improvised for this purpose.
(c)
Cover stones with
oil-soaked
burlap
sacking,
tar
paper,
or
other material.
(d) Fill over burlap with earth.
(e) Insert replaceable
tin funnels in iron piping —preferably with
screening
over
apex
of
funnel
to
catch
cigarette
butts
and
other
debris.
(/) Surround urinal pit with white-washed
stones—to render
more
visible at night.
(ff) A vent leading into the pit may
be constructed
to give
exit
to
t he gases of fermentation and putrefaction.
(h) In porous
soil, one
urinal
soakage
pit will
dispose
of urine
of 100 to 200 men for an indefinite
period.
(See fig. 3.)
Night crinals. —If the urinals are located
some distance from the
camp,
it is a temptation
to
a man desiring to evacuate his bladder,
360
FIELD
SANITATION
MANN
particularly
on a cold night, to urinate
upon the adjoining
tent, and
so on down
the company
street.
To overcome this tendency, urinal
cans should
be placed in the company
streets at night, with
a lighted
(Modified from "Lolcon")
Figure
3.—Urine
soakingc
pit.
lantern to mark the location.
The cans
used
for urinals should be
cleaned
and
sunned during
the day.
Figure
4 represents
a simple
and easily constructed
night urinal, which we found most helpful in
the early days at Quant ico.
An ordinary
garbage
can top
is
per
forated
at
the
center,
and
a
urinal
trough is secured
by
solder.
Placing this converted
top upon the regulation garbage
can makes a
very
satisfactory night
urinal.
Or
a
more
simple
type
of night
urinal can be improvised
by making a hole in center of top of gar
bage container
and placing the inverted
top over the garbage
can.
Stallage
pits. —The sullage pit is for the disposal
of water
from
kitchen
garbage.
These pits are 4 by 4 by 4 feet.
They should
be
fitted with grease traps to remove the grease which tends to clog
the
interstices
of the soakage pit.
In
very
temporary
camps,
sand
and
gravel
placed
in
a can
or
bucket
with
perforated
holes
at
bottom
will
serve to
remove
the
major portion of the grease.
SOAKAGE
PITS
AND
GREASE
TRAPS
361
\/
/
<
rKinnn
1 innnofi
L
,
•
. J
- J U U U U u3
i
Figure
4.—Night
urinal.
The improvised
bucket
grease trap may
be placed
over
the open
soakage pit filled with stones.
Ablution
pits— If the ablution
water
is run through
a box
of
fine sand, before entering
the soakage pit, the major portion of the
soap is removed.
See Figure
5 for a combined
soap and grease trap.
(After "Ltlton")
Figure
5.— Waste
water
and
grease
trap.
362
FIELD
SANITATION
MANN
Ash barrel grease trap. —An
ash barrel grease trap is prepared
by using a barrel
of about
50 gallons capacity
and with
one head
removed, and boring 30 one-inch
holes in the remaining head.
Place
about
8 inches of gravel or stone in the bottom, the size of the stones
decreasing
from
1 inch at the bottom to *4 inch at the top, and over
this place
1G inches of wood ashes.
Fasten
a piece of burlap over the
open top of lhe barrel
by means of a hoop.
The trap may be placed
directly
on
the
soakage
pit or on
an impervious platform
which
drains into the pit.
The sullage
water is poured
into the barrel through the burlap,
food
particles
thus
being strained
out.
As the greasy,
soapy
water
filters through the ashes the greater part of the grease and soap will
be removed.
The burlap should
be removed
daily
and burned,
and
it will be necessary to replace the ashes every
3 or 4 days.
When more than
200 gallons of water
per day are to be disposed
if, additional
soakage pits and grease traps may
be necessary.
Waste Disposal
Disposal of garbage to farmers. —It is sometimes possible
to dis
pose of the kitchen
refuse by contract with the farmers in the vicinity
to haul it away to use as food for hogs, poultry, etc.
This method of
removal
is satisfactory at times, but
at other times it will
be found
difficult to induce
the farmers to remove the garbage
at regular in
tervals, thus allowing the waste to accumulate
and become
a nuisance.
Under these circumstances it is frequently advisable
to resort to other
means of disposal
and to burn or bury the kitchen
garbage
together
with the other
waste products.
Small
sewage disposal pl^nt. —In the field,
occasions
may
arise
that require
the construction
of small
sewage disposal
plants.
The
"filter type" is recommended
as simple
and easily
constructed.
This
type
embodies the essential
characteristics
of the method of sewage
treatment
known as "intermittent
sand filtration."
1. Excavate circular pit of not less than
5 feet deep
and
8 feet in
diameter.
2. The pit is lined with wall laid up of stones, old bricks or other
suitable
material without mortar in joints, leaving a space between
this wall and the wall of the pit.
3. Fill in space between this wall
and
natural
soil
with
coarse
sand and gravel.
4. Fill in pit with fine gravel
to provide a filter bed of at least 30
inches
deep
and allow 6 inches between bottom of soil pipe and top
of filter bed.
5. Construct a suitable
roof and sod over.
It is essential for suc
cessful
operation
that the water level be kept well below
the surface
WASTE
DISPOSAL
363
of the filter, and in rare cases where the soil is nonporous,
often joint
subsurface
drains should be installed.
Incineration
of waste products.—In order to illustrate
the fact
that the proper
disposal
of garbage
for large bodies
of
troops
is
sometimes a more difficult procedure
than it would appear, this occa
sion is taken to relate
a personal
experience
with this matter.
While this writer was serving as post surgeon
at the Marine Bar
racks,
Quantico, Va., in 1917, one of the problems
encountered, prior
to the construction
of the water-carriage
S3rstem, was
the
disposal
each day of several thousand
gallons of semi-liquid excremental
and
other waste products.
At fust an effort was made to dispose of this
matter,
from the camp of about 5,000 men and laborers,
by means of
burial, but here the soil was clay and of a limited degree of porosity,
which caused the pits to fill up more rapidly
than
a dozen laborers
were
able to dig them.
Later various types of incinerators, which
could
be found
described
in the medical
libraries
of Washington,
were tried out but all proved
rather unsatisfactory for the cremation
of such
a large mass of waste products.
The
attempt
to solve this
problem
by dumping the garbage
and excreta
in the Potomac river
turned
out
to
be even
more
unsatisfactory
and
insanitary,
as
the
40-inch
tide caused the beaches
in the vicinity
to be littered with this
refuse.
There was
a low degree of salinity
of the water,
and this,
together
with
the agitation, tended
to prevent
rapid disintegration
of the organic matter.
Finally
the
"hillside"
method
of
incineration
was
devised
and
proved simple
and satisfactory.
It was described
by the writer in
the Journal of American
Medical Association, April
6,
1918, from
which the following
is quoted :
This
method of garbage
destruction
consisted
of
a
series
of
six
parallel
natural ravines
located
on the south side of a 15 foot bluff, which
had
a decli
nation of from
50 to 60 degrees.
Two of the ravines
were used each
day, one
for kitchen
and one for excremental
refuse.
The
garbage wagon drove up to
the
end
of the
bluff
and
dumped
the refuse
on
a small
pile of brush
wood,
which
acted as
a strainer
to retain
the solids, allowing
the liquid to be partly
absorbed
while
the
excess
drained
downward
and was
collected
Immediately
beneath the brushwood
in a series of small pools
2 or 3 feet in diameter.
These
pools were increased
in
size and number
as
the necessity
demanded.
The fire was started
below
the lowest
collection
of liquid and then gradually
built upward.
It was
found
that
the lowest
collection
of liquid received
the
maximum
heat, being nearest
the Are,
and tended
to evaporate
first.
Consequently,
after
from
1
to
2 hours It was possible
to pile
fuel gradually
upward
and to completely consume the dry and semicarbonized
matter
remain
ing at the upper portion
of the ravine,
leaving
the soil hard,
dry,
and sterile.
At the close of each
day these
ravines
were easily cleaned by raking
the debris
downward,
using
the tin
cans and ashes to fill
up small
swamps.
As the heat penetrates only 2 or 3 inches of the soil, a portion of the infected
fluid may
escape
this
sterilization
action of the heat.
This,
however,
depends
364
FIELD
SANITATION —MANN
upon
the permeability
of the soil and the rapidity
with
which
the Are
is built
upward.
This type
of incinerator
was
constructed
at Quantico
and
func
tioned
very
efficiently
for several
months
in disposing of liquid and
solid
waste
products —including
both
excremental
and
kitchen
waste—prior to the construction
of sewerage system and a permanent
incinerator.
It served satisfactorily
a complement
of nearly
10,000
(See figs. 6 and 7.)
Aur€
Figure
6.— Hillside
incinerator.
Dig
trench
on
hillside
2
feet
wide,
.1 feet
deep,
and
6
feet
or
more
long.
Use
a
sheet
of
calvanized
iron,
or
other
metal
material,
as
a
replacable
cover,
to assist
in creating
a draft.
This mode of disposal
has the following
advantages:
1. Simplicity.
One unskilled negro laborer effectively
and efficiently
disposed of the excremental
and garbage refuse of 5,000 persons.
2. Availability.
Almost
every terrain
contains
a sloping hillside
or a small embankment
that may be utilized.
3. It requiries
a minimum amount of fuel as the fire is below
and
the heated air rises and comes
in direct
contact with the liquids and
semisolids.
4. The square area of the surface of the fluid which is exposed to
the heat
is greatly increased
because
of the earth's
absorption, and
this facilitates rapid evaporation.
In Quantico cantonment
of 1917-18,
each galley was equipped
with
its individual
permanent
incinerator alongside.
The idea of prompt
disposal
of
garbage
in
situ
was
another
noble
experiment,
but
unworkable in practice.
These permanent
incinerators were odoriferous, inefficient, and diffi
cult
to operate.
The use of these
incinerators was soon abandoned,
and no difficulty was found in disposal
of garbage from all kitchens
at a central
incinerator modified
hillside type.
INCINERATION
OF
WASTE
365
I
PLAN
Figure
7.—The
writer's
method
of hillside
incineration
for
semi-permanent
ramps.
The
incinerators
arc built
on the side of a hill with
a slope of about
45
degrees.
The gar
bage
empties
on
strainers
in
Incinerator
A.
After drying
the solids
are
shoveled
into
Incinerator
B and burned.
The
liquids
run
to the bottom of incinerator
and are partly
evaporated
by
the
hot
bricks.
Then
they
percolate
thiough
8
feet
of
ashes,
and
are
conducted through
sewer pllJe
to lake.
The hillside incinerator probably will prove
more useful if there
is a large
mass of semiliquid refuse
to dispose of, and under
condi
tions where pit latrines are not practicable.
Figure
8 illustrates
a method
of employing hillside
incineration
on level ground.
Figure
S.— Hillside
incinerator
on
level ground.
366
FIELD SANITATION —MANN
Types and characteristics of incinerators. —
Open
type.—
1. Easily
constructed.
2.
Requires
less material for construction.
3. Practical in semipermanent
camps.
Closed
type.—
1. More quickly started.
2. Not so liable to be put out by rain.
3. Not so productive of bad odors.
4. Produces more heat.
5. Practical
in permanent
camps.
The
cross
trench
incinerator.—This
type
of
incinerator
con
sists of two trenches
intersecting
each
other
at right
angles to form
a cross.
The dimensions
of each
trench
are 8 feet long,
1 foot wide
and
1 foot deep in the center, sloping upwards from center
to the
surface
at eitber end.
At
the
intersection
of
these
trenches
place
scrap
iron
to
act
as
a grate and serve as a support for a galvanized iron can with bottom
Temoved,
or
a
wooden
barrel,
covered
with
a layer of
wet
clay,
may be used.
The fire will destroy the wood and bake the clay which
serves
as a chimney.
The trench facing the wind is left open for ventilation
and three
other openings
beneath the barrel are closed with
a few shovels
of
earth.
The trenches are lined with large stones, which become
heated
when
the incinerator is in operation
and thus
assist in evaporation
of any liquid
waste.
Rock pile incinerator.—Dig a circular pit
15 feet in diameter
and
3 feet deep;
line the pit with boulders
or mashed tin cans.
In the
center of the pit raise
a pyramid of stones about
5 feet high which
will serve to create a draft.
A fire is built
around
the pyramid
of
stones and the garbage is later thrown on the pyramid where the solid
matter
is consumed and the liquid is evaporated
by the hot stones.
One
cord
of wood will
consume
about
4,000
pounds
of ordinary
camp
refuse, after the stones have been heated.
Closed type permanent incinerators.— Figure
9 illustrates a per
manent
incinerator
installed
in one of
the
camps
of
the Civilian
Conservation
Corps.
Acknowledgement
for
the drawing
is
made
to Lt. (Jr. Gr.) James B. Butler
(M.C.)
United
States Navy, who
is authority for the statement that this type of incinerator functioned
very satisfactorily.
An incinerator to dispose of all types of kitchen
garbage in per
manent
and semipermanent
camps
may
be constructed
as indicated
!kn
the
accompanying
diagram.
This
incinerator
should
be
con
structed
about
200
feet away
from
the kitchen,
and
in
a location
INCINERATION
OF
WASTE
367
where
prevailing
winds are least liable to blow smoke toward the
camp.
It is advantageous
to build the incinerator in a small
grove
of trees, if available.
Trees
serve as
a windbreak, preventing scat
tering of papers, ashes,
etc., and aid in carrying the smoke upward.
The incinerator
is
fueled
by logs,
the fire
hottest
at the middle
and
lower
end, to prevent
"burning out"
and warping of the iron
Low
«tock to prevent
CROSS
SECTION
OF FLUE
Fioube
9.— Incinerator
for permanent and semi permanent
camp.
plate.
Wet garbage
is deposited
on the plate
near the stack
where
it
steams
and
dries
slowly, agitation with
a
rake
hastens
drying.
Portions
which
have
become
sufficiently
dry,
and
large
chunks
of
material, are
raked
over
on
the iron
rods
where
they
are
burned
and fall into the fire
box.
All
but
solid objects
such
as tin
cans
are
reduced
to
ashes,
which
may
be
cleaned
out
occasionally
and
disposed
of,
preferably
by
burying.
An
incinerator
of
these
di
368
FIELD
SANITATION
MANN
mensions
should
be
large
enough
to
dispose
of all
the waste
in
a
camp of about
100 or 200 men.
Disposal of oaecasses of animals. —The labor involved in bury
ing
a dead
animal
is considerable,
consequently
a combination of
burial
and burning
is recommended.
A hole
is dug beside the body,
which
is then
disembowled
and
the internal organs
are buried.
The disembowled
carcass is then covered
inside
and outside
with
30-40 lbs. of dry hay, or other litter, saturated
with
kerosene,
and
set fire to.
This method
aims
at sterilization of the carcass and not
incineration.
If sufficient fuel, time and labor are available,
complete
incineration of the carcass may be accomplished.
Manure Disposal
Distribution
method
of manure
disposal. —This
method
is
ap
plicable only in warm
weather.
The manure
is spread in a thin layer
on hard level ground, care being
taken
not to have the layer more
than
1 inch
in thickness.
It is raked
over
a few
hours later and
all small lumps are broken
up.
This rapid drying
method
prevents
fly
breeding.
The
manure
of
500
horses will
require
an
area of
25 by
25 yards,
and
three such
areas
used,
one every third
day
in
rotation.
Close packing. —The close packing method
is also known by the
technical
name "bio-thermic"
method
of manure
disposal.
In this
method
the manure
is moistened
with
water
and closely
packed
by
gradually
adding
new
manure
and
beating
the pile with
shovels.
The center of the pile undergoes
fermentation
and heat of more than
150° F. is generated,
which heat is sufficient to destroy
the eggs and
larvae
(maggots)
of
flies.
Flies lay
eggs only
in
fresh
manure
which is dam]),
and do not lay eggs in fermenting manure
or dry
manure.
Eggs which are laid in fresh
manure
hatch
within
about
24 hours and the maggots migrate away from the hot center of the
pile to the cooler outer layers,
because
contact
with heat of fermen
tation kills them.
When the larvae
of the domestic fly are exposed
to a heat of 122° F. they die in about
3 minutes.
The gases of fer
mentation
kills them
in about
1 minute
at
124° F., in about
4 to 8
seconds at 139° F., and in from 4 to 6 seconds at 140° F.
The daily
amount of manure
produced
by one horse is from
1 to 2y2 bushels.
Maggot trap. —The manure
is stored on an elevated platform
com
posed of parallel slats, underneath
which is placed
a receptacle
con
taining water or some
insecticide
solution.
The pile is exposed, thus encouraging
flies to lay their eggs.
The
eggs
hatch
into
maggots,
and
the
maggots
burrow
through
the
pile in search of earth,
with
the result that they fall between
the
slats into the solution below, where they are destroyed.
This method
MANURE
DISPOSAL
369
of storage
has
been
utilized
over
fish
ponds,
or in poultry
enter
prises to furnish
food
supply
at minimum
cost.
The professor of
economic
zoology
at Columbia University
was
a strong
advocate
of
the economics of this method.
The maggots in manure of one horse
will support six chickens,
so it is claimed.
(See fig. 10.)
Larvae traps have been designed for use in manure
heaps.
Empty
tin cans with slits of
a
sufficient
size to admit maggot
forms
are
filled with dry hay and sunk into the manure
pile
so that the slits
are flush with the surface.
The larvae
seeking
a dry spot for pupa
tion crawl into the tins and are later destroyed
by burning.
Several
thousand
larvae
have
been caught in this type of trap in
1 day.
Figuue
10.— Fly larvae tiap.
Chemical treatment of manure.—Dissolve two-thirds of a pound
of borax in 10 gallons of water, using a little over
a gallon of this
solution to each
bushel of manure.
Powdered hellebore
is also used
in about
the same
proportions.
These
methods
are of questionable
value.
A mixture of one-half pound calcium cyanamid
plus one-half
pound of acid phosphate
to each bushel of manure
gives a larvacidal
action of 98 percent and adds nitrogen and phosphorus
to the manure
for use as fertilizer.
Incineration
of manure.—When the manure
is not
used as fer
tilizer,
a wire hammock
may
be improvised and slung between two
trees.
The requisites
are an amount
of heavy wire,
a pair of wire
clippers,
and
some
ingenuity.
The manure
is thrown on the ham
mock
and
burned.
The hammock
may
be swung with
a pendulum
motion in order to increase
the draft, which will facilitate
the de
struction
of
the litter.
The
hammock
incinerator
was
devised
at
Quantico, Va., and proved
very satisfactory method for the destruc
tion of manure of several hundred horses and mules.
64743—38
4
370
FIELD SANITATION
MANN
At one time
a
series of
a dozen of these
hammock
incinerators
were in operation in the incineration of corral waste. If the number
of horses is small, an old wire bed spring may be used as a hammock
incinerator.
Another
useful
method
of manure
incineration
is
to
place
the
manure
in
piles
about
2 feet high—known
as windrows —sprinkle
with oil and burn.
Rails
from
railroads
may
be
used
to
construct
an
incinerator
for the cremation
of stable refuse.
Persistently
wet
weather
may
delay
or
prevent
the burning
of
manure for some days, and during the rainy season
in some countries
incineration becomes impracticable.
Manure enclosure with maggot trap. —In case the manure
is to
be stored for some
time and
later
used
as fertilizer,
Captain
Baber,
R. A. M. C, has devised
a manure
storage receptacle
with
a trap to
catch
larvae.
This is somewhat
similar in principle
to the maggot
trap.
A screened enclosure,
4 by
4 by
4 feet, is erected over
a concrete
base,
surrounded
by a trench
with overhang
to catch and retain fly
larvae.
The fly larvae
are fed to chickens, or destroyed by hot water,
or chemicals.
The trench
is connected with
a small sump,
in order
to keep the trench dry.
The wetted manure
is packed tightly
in the
wire enclosure,
and
the fermentation of the organic matter gener
ates
heat,
so
that the fly larvae not
being
able
to withstand
the
interior heat, come tumbling out through the meshes of the enclosure
and fall into the maggot-retaining trench below.
Regarding
the temperature,
the following
is abstracted
from
an
article in the Journal of The Royal Army Medical Corps:
1. Fly larvae prefer
a temperature of 90° F.
2. They
quickly
succumb
to a temperature
of 115°
F.,
and under
moist
con
ditions
a temperature
of 108°
F. is fatal.
3. Frcsh manure
placed in a firmly
stacked heap will heat up to 140* F. In
side of 30 minutes.
4.
On the following
day a temperature
of
1t50° F. is reached.
5. On the
14th day the temperature
declines
to 130° F.
0. A temperature of 120°
to 130°
F. is maintained
for
5 weeks.
7. The
above
applies
to manure when wetted
regularly
with water.
8.
A heap of dry
manure,
under
identical
conditions,
consistently
registered
a temperature of 20° lower
than the moist manure pile.
Waste Disposal
Scmmary
1. Latrine construction. —
Straddle trench — 16 feet per
100 men.
Deep pit latrines using standard QM box—2 boxes per 100 men.
Pipe urinal — 5 pipes per
100 men.
Urine
soakage pit—i by
4 by 4 feet per 200 men, in favorable
soil.
INSECT
CONTROL—FLIES
371
H. Waste disposal (kitchen). —
Less than
1 week—burial.
Semipermanent
camps —field appliances.
Soakage pit—4 by 4 by 4 feet for 200 men in favorable soil.
Barrel grease trap— 1 per 200 men.
Cross trench
incinerator.
"3. Manure disposal,. —
Temporary camp—spreading.
Semipermanent
camps—close packing on oil soaked base.
Permanent camps —used as fertilizer —storage
bins
on imper
vious
bases.
Not used as fertilizer —incineration.
FIELD MEASURES
FOR INSECT
CONTROL
The
human
race
is
at
constant
warfare
with
hordes
of
visible
•enemies —insects—which frequently act as carriers of myriads of in
visible
foes—pathogenic
organisms
and
ova of
parasites.
This
is
,especially
true of conditions in the field,
and for an expeditionary
force to withstand successfully
the attacks of insects requires
detailed
consideration of field measures for insect control.
Flies
The
havoc
created
by
the
flies in the
dissemination
of typhoid-
fever germs
in camps
during
the
Spanish-American
War
is
well
known.
A veteran
officer of that war takes delight in telling
the
story that flies
were
so
prevalent
around
the
lime-covered
latrines
and the mess halls that the use of lime in the latrines was eventually
discontinued on account of the fact that the food
served at the mess
had a limelike flavor.
The
question
of fly control
is of tremendous
importance
in
the
prevention of disease in the field,
so extended
remarks
on the life
history
are appropriate.
Metamorphosis. —The
fly
develops,
by
metamorphosis,
through
successive
stages so dissimilar
as to suggest wholly
different forms
of life.
The stages and their duration in temperate
climates
under
the most favorable conditions are :
Duration
in days
Ovum or
egg
Larva or
maggot
4-8
Pupa or chrysalis
3-5
Adult
Total for complete cycle
7-14
In hot
climates
the
average
period is reduced,
and
the minimal
period given
above may
be taken
as the rule.
Cold may prolong it
for 3 months or more.
372
FIELD
SANITATION
MANN
The egg must be kept warm if it is to develop,
and it is therefore
usually laid in vegetable or fecal
matter
which is about to ferment,
the rapidity
of chemical
changes in which supplies
the needed heat.
The larva of the fly has no digestive
glands,
and is therefore de
pendent
upon
predigested
food or other
readily
assimilable
food—
another
reason for the fly depositing its eggs in
feces.
Its most in
teresting habit is that of burrowing.
It does
so first to reach moister
areas of its habitat; if disturbed, it hides with great
speed;
finally,
in the prepupal
stage, it comes
to rest an inch or two
beneath
the
surface
of the ground in the vicinity
of its feeding place.
Having
reached
this
haven
its skin
contracts,
hardens,
and
darkens,
thus
forming the pupa-case within which the change to the perfect insect
takes place.
The pupa remains
without
food for 4 days while developing into
the adult fly.
To enable it to escape
from the pupa-case
and force
its way to the surface
of the ground, the young adidt is provided
with
a temporary structure,
in the shape of a dilatable frontal
sac.
the so called
ptilinum,
the first
use of which is to pry open the an
terior end of the pupa-case.
The young adult then emerges, and will
escape
through
a depth of
6 inches of loose soil,
and even through
6 feet of dry sand—the latter being a truly heroic effort.
Anatomy
of the fly.—The adult
has
the
following
anatomical
points of interest —
It
is provided with
a nonpiercing,
retractile
proboscis
through
which food is sucked by the powerful pharayngeal muscles.
The salivary glands are large,
and
saliva is freely expectorated
onto dry foods,
which are thus
dissolved
prior to ingestion.
The alimentary tract is provided with
no other
digestive
glands.
In addition
to the stomach,
the insect
has
a large
crop
capable
of
holding
a 4 day's
reserve of food.
The hairiness of body
and legs
is remarkable.
The
feet are provided with
minute
hairs,
bristles,
terminal claws,
and
adhesive
pads.
The latter consists
of surfaces
covered
with
multitudes of
fine hairs,
and
moistened
by
a glary,
sticky substance,
by means of which
the fly maintains its foothold
when
inverted.
For the conveyance of organisms
in vast
numbers,
it would
be difficult to imagine
a more suitable
apparatus than
the
fly's foot.
Habits of the fly.—Having had no food for 4 days, the emerging
adult
is
so hungry
that it
seeks
the
nearest
feeding
ground,
and
gorges up to 70 percent of its weight at a single meal.
Its preference for certain foods is dictated
by anatomical
considera
tions.
It must either
get soluble
carbohydrates
or predigested
pro
tein;
the former from
kitchens
and swill
tubs
and
the latter pref
erably from feces.
When both sources are available,
the latrine and
INSECT
CONTROL
FLIES
373
kitchens
are
frequented
alternately, hence
the
danger
in
the
field
from flies transmitting intestinal diseases.
When
resting,
the fly can often
be
observed
to regurgitate
crop
contents,
until
there
is suspended
from
the end of its proboscis
a
drop nearly as big as its head.
This fluid is drawn in and out with
gusto
so long as the fly is undisturbed, but is dropped if alarm leads
to hasty flight.
A cropful of faecal fluid may thus
be deposited
on
the surface of food ready for human consumption.
Well-fed
house flies
evacuate
their
bowels
about
once every
five
minutes, which brings up the statement,
"There never was
a consti
pated fly."
A fly will go upward through a hole, but seldom downwards, hence
this fact is utilized as a principle in the construction of some flytraps.
Flies endeavor
to avoid strong sunlight
and tend to congregate
in
shady places in room light.
They likewise avoid
a dark place, hence
lampblack is used, as a fly deterrent,
to cover the interior of latrines.
These
insects
have
a tendency
to rest
upon
vertical rather than
horizontal
objects;
they
also
prefer
curved
surfaces
rather
than
plane
surfaces.
The latter two
facts
are utilized to catch the adults
by suspending
curved strips of fly-paper from the ceiling.
Flies tend to select certain
colors and shades of color.
In conducting a series of experiments
at Quantico, Va., by placing
baited flytraps in the center of large squares of plaster board,
each
square painted
a different color, the following
deductions
were made
from the relative number of flies caught
in the respective
flytraps.
(a)
Flies prefer a lighter
shade to a dark one of the same color.
(b) Flies have
a tendency
to avoid blue
colors.
(I have
subse
quently learned that this fact was taken advantage of by painting the
interior
of living quarters
blue.)
Flies can travel long distances —100 miles or more.
Temperature of
120°
F.
is usually fatal
to flies;
they
are most
active at
a temperature
between
80 and
90°
F.
and
are torpid
at
50° F.
Flies
feed entirely upon
liquid
food;
when
they
attack
a solid—
like sugar— the regurgitation of fluid from the crop
serves to make
a solution.
Prevention of fly
brekding. —Flies
breed
in horse
manure,
ex
creta,
decaying
organic matter,
and
even
in dirty rags
and
paper.
One neglected
stable may supply
a horde
of flics for an entire
dis
trict,
as
a cart
load
of
manure
may
harbor
as
many
as
200,000
maggots.
Chickens feed freely on fly larvae
growing in manure,
and it has
been claimed
that six chickens
per horse will keep down
flies around
a stable.
374
FIELD
SANITATION— MANN
Garbage
should
be
kept
in
covered
containers
to
prevent
fly
breeding
and
should
be
removed
frequently,
especially
in
warm
weather.
The
suppression
of flies
resolves
itself
into
a matter
of cleanli
ness —organic cleanliness
of the environment.
Grease
traps must
be
covered
and
the surroundings
kept
clean
and dry, or larvae will develop there.
The
proper
care, of
a picket line
is
a difficult
problem.
Daily
removal of the manure with cleaning of the picket
line and burning
over of the
area
are only partially
effective
measures
in
the
pre
vention
of fly breeding.
The heat of burning over the surface
pene
trates
only from
1 to
2 inches of
the ground and fails
to kill
the
developmental
forms which may be several inches under
the surface.
Digging
up
the picket line
and
saturating it with
crude
oil
and
tamping it down
is fairly satisfactory.
Protection of food and personnel. —
1. Prevention
of
access
to
flies;
filth
attracts
fiies.—Cleanliness
may
be considered,
in
a negative
manner,
as the chief deterrent
to
the presence of flies.
It may
be accepted
as
a maxim
that
: The
presence of an undue
number
of flies is indicative that food or filth is exposed somewhere
in the vicinity.
A
marked
reduction
in
the
number
of
flies
around
the
kitchen
follows the simple
measure of cleaning the outside of garbage
cans.
In the routine inspection
of a dozen or more
kitchens
in Quan-
tico
during
the early
days,
one kitchen would
be
surrounded
by
swarms of flies while another
nearby
kitchen
would be comparatively
free from this insect,
depending
upon
the degree of cleanliness of
each place.
2. Screening. —In
a
permanent
camp
the
kitchens,
mess
halls,,
and
garbage
cans should
be
screened.
In
a semipermanent
camp
screening
may
be impractical,
consequently
we must
depend
upon
cleanliness
and insect proof containers.
3. Leaking
screens.—Unless the screening
of a building
is main
tained
in an efficient state, the use of screens is apt to do more dam
age
than
good. I have
seen
persons
in quarters,
enjoying
a false
sense of security
by the mere presence of screening,
yet the interior
of the building
was infested
with more flies than it would have been
if the screens had
been removed.
Leaking
screens (especially
cracks
around
the screen
door) frequently convert
the building into a large
"flytrap" —flies are able to gain entrance
into the building
through
leaking screens but are unable to get out.
Screen
doors
should be made
to open outward
and
should
be in
direct sunlight, when practical.
INSECT
CONTROL
FLIES
375
During the malarial
season
in Quantico, Va., a man designated
as
the "screening
inspector" was assigned to each organization.
His duty
was to inspect screens at regular intervals and to repair faulty screens.
One of the places most apt to be overlooked
is the space
between the
bottom of the screen door and the floor,
a defect which may be reme
died by using extra
battens.
Some of the other faults to be looked
for include torn screens, warped
doors,
improper closing of doors,
broken door stops, etc.
4. Repellants.—The use of essential oils as fly deterrents
is unsatis
factory.
Crude oil
may
be used around latrines to repel
flies,
and
coating the interior of latrines with lampblack serves the same purpose
Destruction of Flies. —
1. Mmcicides.—
Formalin
(formaldehyde
40 percent),
50-00
cc, or
about
3
tablespoon fuls.
Sugar, 20-25 grams.
Filtered limewater,
250 cc.
Water, add enough to make 500 cc.
The effect of this solution
will not be very satisfactory in a humid
atmosphere.
The
flies
should
not
be
given
access
to
water when
using this formalin
solution.
A
1 -percent solution of sodium
salicy
late will also kill flies.
Fill
a dish with the solution and place pieces of absorbent
paper
in it so that the paper will absorb
the solution.
As the solution is
evaporated
more must be added.
A small
glass jar about half full of the solution is inverted
on a
flat bottomed
dish which is covered with
about
three layers
of ab
sorbent paper.
This is a very efficient method,
as the paper is always
kept
moist
by capillary
attraction.
A thick
rubber
band
placed
around the jar and plate will hold the jar in position.
Commercial
fly sprays are effective.
The basis of these insecticides
consists of pyrethrum in kerosene, or similar hydrocarbons.
2. Fly paper. —Fly paper
is very efficient for catching flies and is
prepared
as follows:
Heat
powdered
resin
8 parts and
castor oil
5
parts
(by weight)
; stir well while heating; the mixture should
not
be brought to a boil.
In hot weather
the proportion of resin should
be increased.
Sugar or honey
may
be added, but it is not essential.
The fluid is spread while hot over glazed
paper.
The mixture may
be painted
upon iron hoops or wire strands.
Wires
so painted
will
last for 2 or 3 days, when they should be cleaned and recoated.
3. Flytraps. —Fly traps consist of wire cones, glass-bell
traps, and
many other
varieties.
Flytraps are constructed
on the principle
that flies are attracted
by the sense of smell through
a dark opening in the bottom or side
376
FIELD
SANITATION
MANN
of the trap;
after feeding
they
attempt
to leave by flying upwards
towards the light and thus into the trap.
Traps should
be lifted
a certain
distance from the ground to allow
free access to the flies and should
alwajTs be baited with
some
attrac
tively odorous
substance.
Molasses
in water
(molasses
1 part to 3
parts of water) or brown sugar
(1 part of brown sugar
to 4 parts of
water) may be used as bait for flies.
Both the above solutions increase
in attractiveness
when
fermented.
The habits of flies should
be considered
in locating fly traps.
1. Flies will
go from sunlight
into
room
light,
and will
go
from a dark room to a lighter one.
2. They congregate on lee side of a shelter.
3. They tend to avoid
certain
colors, such as blue.
Judging from the experiments
conducted
by one observer it would
appear
that
the efficiency of flytraps is largely dependent
upon the
bait used in them.
In these
experiments
15 different kinds of bait
were used and a total of 45,000 flies were caught.
The following
are the results of 7 of the
15 types of bait used; the
results of the other
8 kinds of bait are omitted
for sake of brevity.
...
.
„
,
,
.
Percent of total
Kind of fly bait :
flits caught
Putrefying fish, kept moist with
one part molasses to three parts
of water, is said to make an excellent bait for fly traps.
The Ober -flytrap. — (Quoted by
permission
from
the
lectures
of
Maj. M. C. Stayer, Medical Corps, United States Army, Army Medi
cal Field Service
School.)
Thin
flytrap
is in no sense
new in principle,
since it is substantially
identical
with
some
of the commercial
forms.
It
is,
however,
in our
Judgment,
by far
the most
readily
constructed of any of them
and
the
method of construction
is
such
as to require practically
no tools other than a saw and hammer.
Two boards
of equal width,
best
11 to 12
inches,
are laid
off in triangles.
Each
pair of tri
angles
form
the
ends
of a trap
and
these
ends nre connected
by
three
sticks
of wood
of any desired length.
The usual way is to cut them of such a length
that the wire screening that is available
will Just
reach.
If
a 36-inch screening
is used it may be cut in two and an 18-inch
trap
be thus made.
A small triangle
is cut
out
of the
base of each
of
the
ends.
Beginning
at the base,
the netting
is tacked onto the top of this smaller
triangle,
then
onto
the
outer
side of the
base
and around
over the top of the trap
and down
to
the starting
point.
One
of the smaller triangles
is nailed back on again, after
the wire is tacked onto it.
The other triangle
is nol
nailed, but is held in place by two small
wood or iron
Fish
head
Overripe
bananas
Bran mixture
Canned
salmon
Molasses, water, and vinegar.
Sweet corn
Mashes, cheese, and molasses
31. 34
21.30
20. 72
14.00
1.00
.13
.10
INSECT
CONTROL—FLIES
377
buttons.
At the angle formed
by the apex
of the small triangle
small holes are
made by pushing
a lead
pencil through
the screen
at intervals
of about
1 inch.
A nail or screw is placed at each
corner
of the base
so
as
to raise the trap
a
quarter or three-eighths
inch off the ground.
The bait ls placed under the trap
and
the fly when
it finishes
feeding
crawls
up through
the openings into
the
trap.
Nothing
can be simpler
than
the
construction
of this little trap, it being
far easier to build than a box-shaped trap
and
requiring
much less lumber.
Its
efficiency is not different
from any other trap of similar size.
The ease
of building
is seen when it is stated that several hundred
of these
were
built
with
ordinary
fatigue
details
in
a very few days at
the Fort Riley
laboratory.
To remove the flies all that
is necessary to do is to turn
the two
buttons
holding
the loose
triangle
in
place,
to depress this
latter
slightly,
and,
on
raising
the other
end
of the trap,
the flies slide
right
out, being directed
to
the opening
by
the
screen
wire.
It can
be emptied
in
a very few
seconds
with very much less trouble than any other trap which
we have seen.
Window
screen fiy
trap. —As described
by Maj. A. P.
Hitchens
(MC) , United States Army, and published
in the Military Surgeon of
July 1933 :
Flies
have been
found
to
have
the habit
of finding
and
using
the
smallest
holes
to enter
a
room.
In
the window
screen trap this
habit
is
utilized
to
trap them.
The
window
screen
trap
takes
the place of
the
ordinary
screen
of window
or
door.
It
consists
of
a
shallow
box,
about
4
inches
in
depth,
covered
on
each side with
screen
wire.
Before
the screen
wire is tacked
on the box
it is
bent
so
as
to make small
grooves at 4-inch
intervals.
Small
holes are
punc
tured
through
the
apices of
these
grooves at 1-inch intervals.
The
grooves of
outer
screen
are
placed
pointing
inwards.
This
double
screened
box
is
then
placed
in
windows
or
doors
of
rooms
that
are naturally
attractive
to
flies.
In their effort to get in, and also to get out of this room,
they enter the grooves
and pass through
the holes into the trap.
Such traps are very efficient
on the
window and door oi>enings of stables.
Conical hoop trap. —Dr. F. C.
Bishopp,
principal
entomolo
gist
in charge,
division of in
sects affecting man and animals,
Bureau
of
Entomology,
De
partment of Agriculture,
illus
trates
(see fig. 11) and describes
this trap in Farmers' Bulletin
734.
The
trap
consists
essen
tially of a screen cylinder with
a frame
made of barrel hoops,
in the
bottom
of which
is in
serted
a
screen cone.
The
height
of
the
cylinder
is
24
inches,
the diameter
18 inches,
and
the cone is 22 inches high
and
18
incites
in
diameter
at
378
FIELD SANITATION —MANN
the base.
The apex of the cone is then cut off to give
an aperture
1 inch in diameter.
On the basis of extensive tests, Dr. Bishopp
reports
that this trap
is best for effective
trapping,
durability,
ease of construction
and
repair, and cheapness of construction.
At Quant ico we have found
the conical
hoop trap very effective.
Fly
swatting.—Flies
gaining
access
to
kitchens
and
mess
halls
should
be killed by swatting with fly swatters.
Fly swatters
consist
of a piece of wire mesh, leather or rubber,
tacked
to a long handle.
When
rubber
or leather
is used it should
be well perforated.
The
free edges of the wire mesh may be covered with leather if so desired.
Electrocution of insects.—Copper wires are interwoven
alternately
across
an
insulated
framework
and
spaced
one-fourth
of
an
inch
apart on screen doors.
The screens are supplied with a high tension
static charge of elec
tricity from a small transformer, which produces
a charge of approxi
mately
3,500 volts and less than
0.05 millampere.
These
doors
are said to have killed
as many
as
15,000
flies
on
a
summer
day.
Mosquitoes
The
field
measures
undertaken
to
combat
the
activities
of
the
mosquito in the transmission
of disease are as follows:
Medicinal prophylaxis.— It appeal's to be the generally accepted
opinion
that the
routine internal
administration
of quinine
as
a
prophylaxis
against
malaria
is of questionable
value, but the treat
ment of malarial carriers with quinine, plasmochin
or atabrine is an
important
factor
in
the
prevention of
the
dissemination
of
this
disease.
Personal
protection. —Screening
of living quarters in
perma
nent camps may
be utilized by using
mesh screen
having
16 meshes
to the inch for anopheles — 18 meshes
to the inch must
be used when
screening
against
stegomyia
mosquitoes.
The
female
mosquito,
which
is nocturnal
in its
feeding,
trans
mits
the malarial
germ,
consequently
sleeping
nets
are
our
chief
means of reducing the possibility of the transmission
of this disease
to troops
on field duty.
This article of equipment
is supplied by the
United States Marine Corps to every individual
of an expeditionary
force.
If the circumstances
warrant, all sentinels
should
wear
head
nets and gloves after sunset.
Culifuues.—Kerosene
is extensively
used in some
of the tropical
countries
as a repellent
to mosquitoes,
and some of the essential
oils,
such as oil of citronella, have been
used.
(One part of citronella to
4 parts of vaseline.)
These oils have little practical value in the field
as their effect will not last through one night.
INSECT
CONTROL—MOSQUITOES
379
A very good insect repellent
consists of :
Oleum anisi
Oleum eucalypti
Oleum
terbenthae
Lanoline
2 drops.
Do.
Do.
1 ounce.
Xiight
shades of color,
especially
yellow, are repellent
to anopheles
mosquitoes,
dark
shades
are
selected,
especially
navy
blue.
The
-stegomyia
mosquito
prefers a dotted white surface.
Mosquito
destruction. —The adult
mosquitoes
may
be killed
by
fumigation —burning
2 pounds
of sulphur for each
1,000 cubic
feet
of space.
Mosquitoes
are infinitely
more susceptible
to the action of insecti
cide sprays
thans
flies.
The standard Navy
issue insecticide
is the
best spray for this purpose
and should be carried in stock
by
the
supply
officer or quartermaster.
Mim's
culicide
consists
of
equal
parts
(by weight)
of
carbolic
acid crystals and gum camphor.
The acid is slowly melted
and then
poured over the camphor,
thus forming
a clear volatile liquid.
Vol
atilize 3 ounces of this mixture for every 1,000 cubic feet of space.
The following
formula has been reported
as an excellent
insecticide
spray
:
Naphthalene — % pound added to each gallon of above
mixture.
Mosquito traps and swatters
are sometimes used for the destruction
of adult mosquitoes.
Destruction of wintering
adults is said
to
be
very effective in reducing malaria.
Destruction of mosquitoes
in developmental
stage. —Mosquito-
breeding areas may
be controlled by oiling,
and crude
petroleum
is
the oil usually selected.
When the mosquito
larvae,
commonly
called
"wiggle-tails,
come to the surface for air the oil clogs their breathing
apparatus and kills them by asphyxiation.
About
one-half
ounce
of
oil
suffices
for
every
square
yard
of
water surface
under normal conditions,
e. g., small
areas where
the
wind does not blow the oil aside.
The application of this amount of
oil once a week is sufficiently
frequent
to destroy
each crop of larvae.
It requires
10 or more days for the cycle—from the egg to the adult
mosquito.
For ornamental
fish and lily ponds
use gasoline,
one-half
gallon to each 100 square feet.
There are several different methods for oil distribution upon water
.surfaces.
The "knapsack sprayer"
is
a well known
means of oil distribu
tion, and is often utilized.
Parts
Carbon
tetrachloride
Oil
wintergreen
(synthetic)
Kerosene
1
2
97
380
FIELD SANITATION
MANN
The "Panama dripper"
consists
of
an oilcan with
a faucet near
the bottom which allows the oil to fall on the water, drop by drop
(usually at the rate of about
30 drops per minute), and furnishes
a
means of continuous
oiling of a running
stream.
The "submersible
oil bubbler" devised
at Quantico, acts similarly
to
the
above, except
that the
device
is completely
submerged
and
the oil
comes
from below
upward.
The
advantage
of this method
lO/b.wttght
Figdre
12.— Quantico
type
of
submersible
oil
bubbler.
is that the device is
less apt to be interfered with by unauthorized
persons and the flow of oil tends to be more uniform and less affected
by
a change
in
temperature.
These
cans are removed
and
refilled
once a week.
The container
is filled with oil and sunk in the stream
of water.
The oil, at rate of 40 to 60 drops
per minute,
is released
and
comes
to surface,
forming
a uniform
film of oil to destroy the
"wiggle-tails"
of mosquitos.
(See fig. 12.)
The "oil soaked sawdust" method of petrolization
(also originated
at Quantico),
affords
a simple
means of distributing
oil over
mos
quito breeding areas.
This method
was worked out contemporane
ously and independently by the United States Public Health
Service.
The oil
soaked
sawdust
is placed
in
a wire
cage or in perforated
boxes which are partially
embedded in running
streams.
The cages
were found to be effective without renewal of the oil for a period of
from 2 to 3 weeks.
(See fig. 13.)
INSECT
CONTROL
MOSQUITOES
381
Oil soaked sawdust can be placed in paper bags, which are thrown
into marshy vegetation.
The bags rupture and liberate
the sawdust,
the particles of which
give
a widely
distributed
film of oil, scat
tered throughout the aquatic
vegetation.
Where
there
is
dense
surface
vegetation,
such
as
water lilies,
the oil impregnated
sawdust
may
be thrown
at random
among
the
vegetation
and
floatage;
each individual
particle
becomes
a means
of slowly liberating
oil.
(Vide Military
Surgeon,
November
1918,
for more complete details of the last two methods.)
Figure
13.—Quantico
method of petrolization
with
oil-soaked sawdust.
(Ebert.)
The Panama larvicide consists of carbolic acid, rosin, and caustic
soda combined
in such a manner that the product has approximately
the same
specific
gravity
as
water.
This larvicide
has the
advan
tage over oiling
inasmuch
as it kills the larvae
of one species, Man-
Jtonia titHans,
which does not
come to the surface
of the water but
gets its air from the roots of water plants.
One part of this prepara
tion to 5,000 parte of water will kill larvae.
Other
chemicals,
some
of
which
are
byproducts
in
the
manu
facture of gunpowder, have
been
employed
as larvacides.
Arsenic
dusting by hand, or airplane, is a more recent development.
Drainage and filling. —Where the mosquito
breeding
area is below
sea level and cannot
be drained, it may
be flooded with salt water to
prevent breeding.
In other undrainable areas deep canalization may
be used to reduce the water
surface
to a minimum, which may then
be easily controlled by oiling.
Small
swamps
and
marshes
may
be
filled
with
dirt,
ashes
and
debris.
A comparatively
small
amount
of
stagnant
water
will
furnish
sufficient
breeding
area to infest
a small
camp with mosquitoes.
A
camp
located
about
a mile
from
mosquito-breeding
areas
is
considered
fairly safe from anopheles.
In
the selection
of
a camp
site
one should
endeavor
to avoid
the proximity
of habitations,
as
these dwellings
are
apt
to harbor
mosquitoes
and
human
malaria
•carriers.
382
FIELD
SANITATION— MANN
All tin cans, broken
bottles,
and
other
receptacles
which will
re
tain water
should
be
immediately
disposed
of.
A well
recognized
authority
on mosquitoes
informed
the writer that he was unable
to
locate
the source of infestation of an isolated
dwelling
house until
he discovered
a broken
rubber
ball containing water;
the
removal
of this breeding
place
was followed
by
a reduction
in the number
of mosquitoes
at this place.
Biological
barriers. —It
has
been
demonstrated
that
anopheles
do not travel far from breeding
places if a food supply is close by,
and this fact is taken advantage of in the use of "biological barriers."
In Quantico, during
the World War there
were undrainable and
otherwise
uncontrollable mosquito
breeding
swamps to the north and
south
of the cantonment.
On
inspection
anopheles
were
found to
be
very
abundant
in
the
stables
to
the
northward
of
the
camp,
whereas the part of the cantonment
adjacent
to the stables was com
paratively
free of anopheles
when
compared
to
the southern
edge.
Shortly after placing a pig pen to the south there was a reduction in
the number
of anopheles
in the southern
portion of the camp
and
large
numbers
were found in the pigpen.
The camp
was protected
from mosquitoes
by "biological
barriers,"
stables to north, and pig
pens to the south which tended to stay flights of mosquitoes
in their
search for food.
Hence
it
does
not
seem
improbable that the
use
of
animals
as
biological barriers may
be put to practical advantage
by establish
ing the corral and stables
between the camp
site and
the mosquito
breeding
areas.
Mosquito
control
at quantico
by airplane dusting.—Airplane
dustings start on swamp
land of both
creeks about
the
1st of July
(depending
on anopheles breeding) and are continued
on a 10- to
14-
day
schedule
throughout
the summer
until
about
the
15th of
Oc
tober.
The mixture used is composed of
one part paris green
and
four parts powdered
soap stone, and is dusted in the proportion of
5 pounds of the mixture to the acre as follows :
Pound*
mixture
to
Acres
1 dusting
Chapowamsic
Creek
240
1,200
Quantico
Creek
100
800
Total
400
2,000
Cost per dusting:
Paris
green,
400 pounds
at
$0.21 per pound
$84. 00
Powdered
soap
stone,
1,600
pounds
at
$0.0082
per
pound
13. 12
Total cost per dusting
97. 12
Total cost per season
for dusting
materials
(10
dustings)
$971.20
INSECT
CONTROL
LICE
383
Oiling. —All breeding areas in the post proper, town of Quantico
and the areas surrounding for approximately one-fourth mile beyond,
are sprayed on a 7- to 10-day schedule with
a mixture of used crank-
case oil 4914 percent,
kerosene 49!/2 percent,
and castor oil
1 percent.
The
amount
of this mixture
used
is
about
500 gallons per season
from May
to October
inclusive.
Cost of Oiling:
Crankcase
oil,
5,000 gallons
at $0,000 per gallon
$0. 00
Kerosene,
5,000 gnllons
at $0,066 per gallon
330. 00
Castor
oil, 50 gallons at $1 per gallon
50.00
Total cost of oiling
mixture
per year
380.00
Cost of Labor :
3 laborers
at $4,128 per day for
a period of
30 weeks
1, 857. 60
Cost of mosquito control
exclusive of service :
Cost of airplane
dustings
971.20
Cost of oiling mixture
380.00
Cost
of
labor
1,857.60
Total cost
3, 20a 80
Lice
Various
methods
are employed
for delousing purposes.
N.
C. I.
powder, which is considered
very
efficient in the destruction
of lice,
consists of the following: Naphthalene,
96 parts;
creosote,
2 parts;
iodoform,
2 parts.
This powder is dusted inside of wearing apparel,
care being
taken
to avoid
the forks of trousers,
as this preparation, if used too freely,
is
an irritant
to
the
perineal
region
and
may
cause
a dermatitis.
After the
use of this mixture the soldier should
wrap himself up in
a blanket
in order to retain the fumes which are generated.
Vermijelli is
less irritating than
the
above mixture, and
is com
posed of the following
ingredients: Crude mineral oil, 9 parts; soft
soap,
5 parts ; water,
1 part.
This preparation will kill adult lice but
has no effect on the
eggs.
Clothing
may
be deloused
by
immersion
in kerosene or gasoline.
Ironing of clothes will kill both
the adults and
the eggs;
steam
heat will
accomplish
the same purpose.
The "Serbian barrel"
and
the "sack
disinfestor"
are two simple methods
of using steam heat
in the field.
The Serbian barrel disinfestor
consists
of
a barrel with
a perfo
rated bottom
and a tightly fitting removable
cover which is weighted
down
with
stones.
The
barrel
is
placed
over
a
tank of boiling
water;
the
steam
generated
from
the
boiling
water
flows
under
384
FIELD
SANITATION
MANN
pressure
into
the barrel.
The
water
must
be kept boiling
at all
times while this barrel is in use.
Clothes
and other articles may
be disinfested
by the above means.
The "sack disinfestor"
devised by Lt. Col. P. S. Lelean, R. A. M. C,
depends on the principle that steam entering the upper portion of the
inverted bag displaces
the air in its course downward and
produces
an extra atmospheric
pressure
(about
15
pounds
per
square
inch)
which pressure in turn raises the temperature
of the interior of the
sack
to
107°
C.
The sack disinfestor
is useful
for disinfection
and disinfestation.
For
a detailed
description of this device
see United
States
Naval
Bulletin for September
1922.
Head
lice. —For
the
destruction
of
the
head
louse,
Pediculus
capitis,
acetic
acid
(10-percent
solution)
is
applied.
Equal
parts
of kerosene and olive oil are sometimes employed in place of the acetic
acid solution.
The hair should
be combed with
a fine-tooth
comb.
Punic lice.—The methods for the destruction
of this louse are well
known and will not be considered
here.
Bedbugs
There are two species of bedbugs,
namely,
the Cime.v lectularim
and the Aeanthia rotundaia.
The Cimex lectularim
is the common
bedbug
found in the north
ern climates
while the Aeanthia rotundaia
is found in the tropical
regions.
The eradication of this parasite,
especially
in the tropical regions,
is a very difficult problem.
Fumigation
provides
very effective extermination.
It is a method
to be employed primarily in scaled spaces.
Carboxide gas is highly
recommended.
For detailed
information
on the employment
of this
agent
the
reader
is referred
to
articles
by
Captain E. W.
Brown
(MC), U. S. Navy, published in this Bulletin, Vol. XXXI, page 253
(1933), and Vol. XXXII, page 294 (1934).
Hydrocyanic-acid
gas is
equally efficient but should
be employed
only by personnel
skilled in
its use.
The blow-torch
is effective when applied to cracks of metal
beds.
Kerosene,
gasoline,
and other chemical
insecticides
may
be poured
into crevices
to exterminate
this pest.
The
beds
may
be
immersed
in
a solution of
caustic
soda for
a
period of
15 minutes
(strength
of soda solution is what is usually
employed
in washing clothes).
After
immersion
they
are washed
in clear
water
and allowed
to dry in the sun.
This method
is said
to kill both the adults and the eggs.
INSECT
CONTROL—ROACHES
AND
FLEES
385
Heating
rooms and even entire buildings to
a temperature
of 120°
to 125° F. for several hours will completely
eliminate bedbug infes
tations.
Superheating has been
resorted
to repeatedly
with
success
during
hot
summer
weather
when
advantage
can
be
taken of the
normally
prevailing
high
temperatures.
In
summer,
most
home
heating equipment
is sufficient
to raise
the temperature
of infested
rooms
to
120°
to
125° F., if not higher, without harm to the fur
nishings.
It is well to place
thermometers
in various parts of the
room or
rooms
in order
to
note
the
temperature
obtained.
The
temperature
in the cracks
where the bugs are secreted must
be held
as high
as 120° F. for several
hours.
In loosely
constructed
frame
buildings it may
not
be possible
to secure
a killing temperature
at
points close to wall spaces.
Some institutions, such as colleges operat
ing dormitories, find the heat treatment
effective and cheap.s
Cockroaches
There
are four
domesticated
species of this family,
namely,
the
Oriental,
German,
American, and Australian
roach.
Sodium fluoride blown in corners and crevices is a standard
poison
for this pest.
The roaches walk through the powder,
some of which
adheres
to their legs, and are killed
by the sodium
fluoride when it
gets into their mouths.
(They clean themselves with their mouths.)
Another cockroach
poison
consists of dry plaster of paris,
1 part ;
flour,
3 parts.
When
using
the
above mixture
a dish containing
water should
be close by.
The insect, after feeding upon this prepa
ration,
becomes
thirsty
and
seeks
water,
which
sets
the
plaster
of
paris
and kills by
clogging
the
intestines.
Pyrethrum
is
exten
sively
used
as an insecticide
for the extermination of
cockroaches
and
other
insects.
It
is
incorporated
in
the
Xavy
issue
liquid
insecticide.
Fleas
Pyrethrum
powder is effective
for removing
fleas, Pulex irritam,
from the body.
Iodoform
and oil of pennyroyal act as repellants.
An emulsion
of 5 percent cresol, with or without soft soap solution
(20 percent)
; gives excellent
results.
Sprinkling a flea-infested
floor with flaked
naphthalene
and clos
ing the room for 24 hours is very effective.
A solution of naphtha
lene
in
gasoline
should
be
poured
into
all
holes—such
as
mouse
holes —in treatment
of plague
infested
houses.
• United
States Department
of
Agriculture
Leaflet
No.
146.
64743—38
5
386
FIELD SANITATION
MANN
Common disease transmitting
insects
Common
name
Species
Common
dis
eases trans
mitted
Breeding
places
Life history
Flies.
Mosquitoes..
Musca
domes
tics.
Anopheles..
Do.
Stegomyia.
Lice.
Pediculus.
Typhoid
fever,
cholera, dysen
tery, diarrhea,
smallpox,
ery
sipelas.
Malarial fever..
Yellow fever
Typhus
fever,
relapsing fever.
Manure, garhage,
decaying organic
matter.
Rural stagnant
pools,
among
grass and rushes,
swamps
and
marshes.
Domestic,
develop
in water
in any
container
near a
house or in gut
ters,
cisterns,
spouts, etc.
Breed
and
spend
their
entire
life
on warm
blood
ed
animals,
in
cluding
man.
Eggs hatch out in
12to 24 hours in
larvae;
larvae
grow rapidly and
in 4 to 5 days be-
come
pupae
(resting
stage).
In
2 to
4 days
mature
into
adults.
Ova
deposited
in
mass of 250eggs,
2 to 4 days hatch
into larvae, and
in a week reach
pupae
or wing
lessresting stage;
in 2 or 3 days de
velop wings and
become adult
mosquitoes.
Female lays about
70 eggs,
larvae
hatch
out
in
2
days and devel
op
into
pupae
in 1 week; then
in 2 or 3 days be-
come
mature
adults.
Eggs cling to hair
or
clothing
of
host (man); they
hatch out in 3 to
4 days
and ma
ture
in
10 to 15
days.
HYGIENE
AND
SANITATION
OF THE MARCH
Military
Value
of Marching
The
ability
to
march
has
always
been —and
the
results
of
the
World War tend to show that this is still true—one of the determin
ing factors of victory.
The superiority in marching ability of troops
enables
the responsible
commander
to
secure
the preponderance
of
men at the critical
time
and place.
Infantry, in spite of the rapid
development
of other
branches
of the military
service,
is still the
dominant
arm.
Artillery
without
the
defense
of infantry
is vul
nerable.
It is stated
by authorities that well-trained infantry can
endure longer marches than cavalry.
As one leader
said
"Getting
there
first with
the most
men
was
the secret of his victories."
"Battles
are won
more
by
sweat than
by slaughter."
Strength of legs rather than
strength
of arms
won
battles.
General
Thomas Jonathan
Jackson —"Stonewall Jackson" —of the
Confederate
Army,
was
an
outstanding
military
leader
who
was
quite
familiar with
the
care
of
troops
on
the
march,
and
owed
much of his military
success
to this one fact.
He always
started
hi*
HYGIENE
AND SANITATION
OF THE
MARCH
387
organization
on
the march
at dawn unless—as one jovial
Confed
erate remarked —he started them the night before.
General
Jackson
gave his troops very frequent
but short rest periods and never broke
his soldiers
by long sustained
physical
effort.
At the rest periods
his men were compelled
to lie flat on the ground and thus
"rest
all
over."
Jackson
stated that he would rather lose one man in march
ing than five in fighting,
and
due to
the marching
ability
of his
organization
they
were
termed
"foot cavalry."
One
of his record
marches
was on March 23, 1862, when his troops
covered
40 miles in
1 day and fought
a battle
(Kernstown)
in addition.
In the Valley
Campaign, Jackson's Army covered
676 miles in
48 marching
days
(average
14 miles
per diem),
and fought
13 battles
and skirmishes
during this period.
The marching ability of his men thus
enabled
Jackson's
force of 15,000 to cause
175,000 Federals to be held out of
main operations
around Richmond.
In 1896,
a force of 3,000 Russians marched
3,000
miles
and
aver
aged
14 miles per day.
They arrived at their destination
in excel
lent
health,
with
only
33 men missing from
the original
number.
In 1805, the Grenadiers of Oudinot pursued
the enemy for 3 consecu
tive days, the daily marching being
30, 40, and 50 miles respectively.
Marlborough's
force in 1711 covered 40 miles in 18 hours; Friant's
Division
marched
78 miles in 46 hours
and next
day
(December
2)
fought in the Battle of Austerlitz.
The record march is that of the
Light Division
at Talavera, in July
1807, which marched
62 miles in
26 hours
and carried full equipment
weighing
50 to 60 pounds.
An
expenditure of energy equal to 1,600 foot -tons.
In modern warfare use has been made of mechanical
transportation
to effect great concentration
of men, but usually at the last moment,
due to congestion
of the arteries of traffic and to other
causes
of im
passibility of the roads, there is a call for
a test of physical endur
ance in marching.
In preparing for the Battle of the Somme on March
21,
1918, the
Germans concentrated
their troops
by maneuvering
them into posi
tion
by long
marches.
For
several
months
previous the
German
divisions
were
trained
to
endure
long marches,
and
only
5
days
before the battle
many
of the troops
were far from the battlefield,
and
some
covered
60 miles
in
3 nights of marching
preceding
the
battle.
To be able to endure long marching requires
careful training
and
attention to a host of trivial details.
The writer has endeavored
to
collect and compile
the data on this subject in hopes that the student
will carefully
study them in order to
be familiar with
the details
for
use in event of emergencies.
These
apparently
inconsequential
details assume great proportions to a weary,
footsore marching unit.
388
FIELD
SANITATION —MANN
According
to the Field Service
Regulations, United
States Army,
"Good marching is secured by careful preparation, strict discipline,
and observance of march sanitation."
Physics
and Physiology
of the March
Physics of the march.—A soldier weighing 160 pounds, carrying
40 pounds
and walking
15 miles at the rate of 3 miles per hour on a
level
surface
will perform an amount of work equivalent
to
353.57
foot- tons.
According
to Haughton,
as quoted
by Harrington,
this labor, in
walking over a level surface, is determined
by the following
formula :
(W+W')XD X C= foot-tons.
W= weight of person.
W' = weight carried.
D= distance in feet.
2,240= number of pounds in long ton.
C= coefficient of traction.
The coefficient of traction varies for different
rates of speed, with
the character of the terrain, and wind effect.
For 2, 3, 4, and 5 miles
per hour, on
a level
surface,
it
is approximately
1/26,
1/20,
1/16,
and
1/14, respectively.
(160+40) x79200_o.o
r—
2240X20
606bl
Physiology of the march.—Compared
to
the
steam engine
the
human
mechanism
is a bit more efficient,
as the engine is capable of
utilizing
only
13
percent
energy for useful
work from its fuel, our
body is able to utilize 20 percent of the energy value of our diet, the
80 percent balance goes in the production of heat which must be dis
sipated in order to keep the body temperature
constant.
The unit of energy is the calorie,
which is equal to the amount of
heat necessary to raise
1 gram of water
1° C.
This is the small
calorie,
and we generally use the kilocalorie, or
the large Calorie, represented
by a capital "C," which is the amount
of heat required
to raise
1,000 grams
(about
1,000 cc) of water
1° C.
A soldier at rest requires
3,000
Calories per
day,
of which one-
fifth
(600 Calories) actually
goes
into work, and four-fifths
(2,400
Calories)
is dissipated
as heat.
The
evaporation
of perspiration
acts in dissipating
heat of the
body
similar
to the radiator of the automobile
in maintaining
the
motor
near a constant
temperature.
The evaporation
of 1 cc of water requires
0.5 Calories, consequently
the evaporation
of a quart of water — (Imperial
measure,
1 quart=
HYGIENE
AND
SANITATION
OF THE
MARCH
389
1182.52
cc) —from the body's
surface
will
dissipate
600 Calories of
heat.
To produce
350
foot-tons
of work,
such
as our example
of
the
marching
soldier,
would require
the expenditure
of
254 Calories
as
muscular
energy.
Since
the
body
is only
20 percent
efficient
the
total
expenditure
of energy
to
produce
this work
would
be
1.270
Calories, of which 1,016 Calories are dissipated
as heat.
The soldier
normally
expends
1.000
Calories
in
8 hours.
Therefore,
the total
caloric need of the soldier during the 8-hour
march
is 2,270 Calories,
of which 1,816 Calories must be dissipated
as heat.
Of the 1,816 Calories, 30 percent
is disposed
of by radiation, con
duction, and convection,
while the remaining 70 percent of the
1,816
Calories
(equals
nearly
1,300
Calories)
must
be
disposed
of
by
evaporation
of
fluids.
Since
the
evaporation
of
1 quart of
water
takes
600 Calories, then
the total water which must
be lost in this
8-hour march
is approximately
2 quarts, provided the entire amount
evaporates
on the body surface.
Effects of water
loss :
Miles
marched
Quarts
perspired
Soldier's
condition
if water
is not replaced
Miles
marched
Quarts
perspired
Soldier's
condition
If water
Is not replaced
7M
1
Habit thirst.
Thirst of necessity.
Marked inefficiency.
30
4
Danger.
Death.
15
2
45
6
22
3
The
physiology
of
perspiration
is vitally
connected
with
heat
stroke and
heat
exhaustion
which result from
failure
to dissipate
the excess body heat.
As body heat increases due to increasing labor
or to increasing accumulation
from the environment,
a fireroom
for
example,
the function of perspiration
becomes
of greater
importance
in keeping body
temperature
normal.
Men should
be thoroughly
indoctrinated in a few simple
facts :
1. Perspiration
lowers
body
temperature
only when it evaporates
from the surface of the body.
Evaporation
is retarded
when the air
is still and
has
a high
degree of humidity.
Light,
loosely
worn
clothing promotes evaporation by retaining perspiration on the body
surface.
Water of perspiration that runs off the body or is wiped
off represents
a loss and the amount
of this loss should be added to
the second column
of the accompanying
table.
2. The body
has
a comparatively
small
reserve supply of
water
and when this reserve is exhausted the body ceases to perspire.
Since
this
is
the
major
factor
that
keeps
the
body
heat
normal,
heat
stroke or heat exhaustion
follows.
Therefore, water loss should be
promptly
replaced.
390
FIELD
SANITATION
MANN
3. Furthermore,
ordinary
table
salt
is an essential
factor in con
trol of body
temperature.
The
body
can neither absorb
nor per
spire salt-free
water.
The reserve stock of this salt is limited.
When
this reserve is exhausted
the body will cease to perspire even if the
supply of water in the body
is ample
and it will not
absorb
water
from the intestinal tract even though large quantities are drunk and
there is great need for the water.
This condition of insatiable thirst
and
diarrhea
can
be corrected
by adding
salt
to the water.
Pro
phylactic
treatment
consists
of
supplying
salt
to
men
perspiring
excessively.
Preparation for the March
It is remarkable
to note what improvement
in marching
ability
can
be effected in
a few weeks of graduated
exercise
and muscular
training.
One
investigator
conducted
a
series
of
experiments
on
an untrained man marching
a certain
distance in a given
time with
the following
results
:
Untrained
soldier :
Increase
in pulse
72 beats.
Increase
in temperature
2.2° F.
Loss of weight 2% pounds.
After
3 weeks' training
:
Increase
in pulse
28 beats.
Increase
in temperature
0.6° F.
Loss of weight 2% pounds.
The men should be trained in marching by increasing
the length
of the hike and the weight
of the pack.
They should be so trained
for several
months.
This training
means
the
development
of all
muscles in the body —an increase of capacity of the lungs and heart,
also strengthening of the foot arches, and the like.
It is at this time
that the medical
officer should keep close supervision over the men.
Overtraining
defeats our purpose
and leads to cardiac
dilatation
and
eventually to exhaustion.
Men under training
should
be given
periods
of mental
and physi
cal
relaxation
and
recuperation.
It
is
remarkable
how
quickly
the
human
mechanism
develops
with
progressive
and
systematic
exercises.
The raw recruit under proper supervision shows
rapid
development
within
a few weeks of training.
The men should be trained to breathe through the nostrils, as in
this way dust
and
other
foreign
bodies
are removed
from
the air
before it reaches the lungs,
and the air is warmed.
Mouth breathing
tends to dry the mouth
and thus
increase
the sensation
of thirst.
A person marching at rate of 4 miles
per hour inhales
five times
as much air as when reclining.
HYGIENE
AND SANITATION
OF THE
MARCH
391
Conduct
of the March
The
most
suitable
time
to start
a
day's
march
is
1 hour after
the break
of day.
Night marching
should
only
be practiced
when
military
necessity
demands,
and
then should begin
soon after sun
set.
The
canteens
should
be
filled
preferably
the
night
before
the
inarch.
The sick
and
the physically
unfit should be eliminated at
the morning sick call.
By all means avoid premature
assembly
of
the men—get them "under way" as soon as practicable after "falling
in."
A light breakfast should be served.
The sanitary officer, with
a police
detail, remains
for a few min
utes
after the
camp is cleared
to
see that all
waste
and
litter
are
disposed
of, latrines filled in and
labeled,
and
that the
camp
site
is otherwise
left in a clean and sanitary condition.
Rate of march.—The human
mechanism —similar
to the automo
bile motor—must
be warmed
up before
it can function
at its best
in marching.
The physiological
best temperature
for the body
in marching is
100.5°
F.
and
102° F.
is the maximum temperature
before
serious
symptoms
become noticeable,
such
as swaying, tremor,
nervousness,
etc.
Thus there is only 1.5 degrees range between the optimum body
temperature
and
danger
body
temperature
"and this narrow safety
margin
indicates
alike
the
delicacy
of
the adjustment mechanism
and the importance
of every means of aiding that adjustment."
A horseman
always starts
his horse
off slowly,
and
the
end of
the ride is made at slow
pace.
Likewise
the infantry
leader
should
start his men off slowly so as to warm up, and the last few minutes
should be at a slow
pace for the men to cool off.
Always
avoid
the
tendency
to the final spurt in nearing evening
camp.
The ordinary
Marine
Corps shirt
holds
a pint
of perspiration,
when
saturated,
this
is
equivalent
to
300
Calories,
which
energy
can
be conserved
by the simple
expedient
of slow
marching
at the
end of the day.
This permits
the moisture
to be evaporated
on the
body during
the marching period when
the chilling effect serves a
useful purpose.
The march
should
be completed
with
a nearly dry
shirt to prevent
harmful chilling
effect during the following
rest and
recovery
period.
The rate for infantry
is 100 yards
per minute.
To maintain this
speed,
one hundred
and
twenty
30-inch
steps
are
required,
which
gives an actual rate of 3.46 miles per hour (exclusive
of rest periods).
This may
be regarded
as the most economical
speed for experienced
troops.
For unseasoned troops
and for longer
hikes,
the economical
speed is a slower cadence than the above.
392
FIELD
SANITATION
MANN
With
a speed of
3.46 miles
per hour for the day's
march, if the
rest periods
are included,
from start to end of the march
an average
of 2y2 miles
per hour is considered
the maximum
expected
of foot
troops.
Douhle time is
a 36-inch
step at the rate of
180 steps per minute,
and should
never be used in routine marching.
In route step, there is no standard
stride or cadence, and the men
are out of step, which is often
a restful variation.
The marching
column
varies
with
route
step, marching in
time,
and marching to music or singing.
Mechanics
of marching. —Mathematical calculations show
that in
marching the best mechanical
advantage
is obtained
by
a stride the
length of which is six-sevenths
the length of the leg.
The stride is a
pendulum motion.
The
"flexion
marching"
of
the
French —where
it
was
claimed
that
men covered long distances
at
the surprising
speed of
6 miles
per hour—consists in keeping
the knee flexed, and inclining
the body-
forward —a continuous
falling forward.
This method has been prac
tically abandoned.
The correct
position for head and limbs in marching corresponds
to the attitude one assumes when
about
to ascend a flight of stairs.
The proper load for an infantryman
should not exceed one-third
of body
weight
or 50 pounds for a 150-pound
man.
The maximum
is
45
percent
of body
weight or
67
pounds
for the
average
man,
and any increase
above this 67 pounds
causes
expenditure
of energy
to be increased three times as rapidly
as the load.
The
load
should
be
adjusted
near
the
center of gravity
of the
body — i. e., in the erect position 0.6 cm front of the line connecting
femoral heads and opposite
center of third lumbar vertebrae.
The chest or abdomen
should
not
be constricted
by the load and
the load should
be borne by the shoulders
and back.
March formation. —If there is much traffic on the road the march
ing column should keep to the right and proceed in squad formation.
If circumstances
permit, it is much
better
to march
in open ranks—
half on
each side of
the
road,
which
order tends
to
decrease the
heavy
oppressive
cloud
of dust,
foul
odor,
and
water vapor from
perspiration which tend to hang over close-order
formation.
The taller
men at the head of the column
are apt to
set
a pace
uncomfortable to the shorter
men marching in the rear of the column,
and it is also easier marching
at the head than
in the rear,
conse
quently the column
should
be reversed from time to time.
The rear
files
as
a rule expend
about
6
percent
more
energy
than
those
at
the head.
HYGIENE
AND
SANITATION
OF THE
MARCH
393
Halts. —The first halt should
be after
30 minutes
of hiking,
and
should
be for
a period of
12 minutes.
The object of the first halt
is to permit the men to get their "second
wind,"
adjust shoe laces,
rearrange packs,
and to attend
to the calls of nature.
The
succeed
ing halts are made every
50 minutes
and are for a period of
10 min
utes
rest, except the halt for the noon meal, which is for
1 hour.
During the rest
periods
the men should remove
their
packs
and
lie upon their backs.
Their coats should be replaced
and unbuttoned
to avoid undue
exposure
to drafts
and winds.
An endeavor
should
be made to halt in cool shady
places, protected
from strong winds.
A place should be provided for the men to
attend
to
the calls of
nature during the rest periods —shallow trenches dug with
a bayonet
or sharp stick will suffice for this purpose.
Endeavor
to
select
locations
for
halts that
have
the
following
characteristics :
Clean
and dry.
Sheltered
from the sun.
Privacy.
If practicable
avoid halting the column
in towns, villages, or near
habitations.
Massage
and
kneading of
muscles of
legs during
halts
free
the
accumulated
waste
products
and
prevent
stiffness.
In difficult and
mountainous
country
the halt
periods
should
be
more frequent.
The order should
be given
to "remove
packs"
within 30 seconds
after halt—any
unnecessary
delay
irks
and
irritates
the marching
organization.
In considering rest periods,
the usually
accepted
practice
of
sev
enth
day
of
rest—Sunday—should
be
adhered
to.
Length of march.—The length of the day's march
is not measured
by miles, but according to the condition of the roads,
the weather,
the pace, the weight of the loads, experience
and physical condition
of the troops,
etc.
Miles per day
Average
for large
body of infantry
12
Average
for small
body of Infantry
15
Any
distance
beyond
the
above
is
regarded
as
a
forced
march.
Wagon
trains
march about as rapidly as foot troops.
Artillery
covers 15 to 20 miles per day.
Morale.—A fatigued body causes
a hypersensitive
state of mind,
which
is more susceptible
to real or imaginary
adverse stimuli.
To
inhibit the action of these stimuli calls for resourcefulness
and lead
ership in company
officers.
One
company
under proper leadership
will arrive in the evening
camp, tired but happy, whereas
another
394
FIELD SANITATION —MANN
company,
not
so
fortunate in the
selection
of
company
officers,
is
apt to come into camp tired and dissatisfied.
Singing
and
whistling
of popular
tunes
should
be
encouraged,
as this distracts the minds of
the
men from their fatigued
state,
and is one of the surest means of preventing them from succumbing
to exhaustion.
Straggling,
either from poor discipline
or fatigue, is always
to
be avoided,
as it is depressing
to the morale
of the entire
body of
troops.
Night
marching. —Marching
at night
should
be permitted only
for strong tactical reasons,
as marching at this time interferes with
the sleep routine ; in the darkness
men cannot
be sure of their footing
and accidents may occur.
The deleterious
results of night marching
are shown by the experiences of French's division in South Africa,
where the regiments
marching in the daytime
were better in health
and marched farther than those marching at night.
Marching in the tropics. —In warm countries
the march should
be started earlier, shortly after daybreak, if practicable.
Marching
in the middle of the day should
be avoided
by a midday rest period
of 2 to 3 hours.
Green leaves or a wet handkerchief in the hat serve to protect the
head and neck from the sun's rays.
It is particularly
necessary
to open
up shirt
fronts
and roll
up
sleeves.
Tests
were
conducted
on
an organization hiking
7
miles
with
a dry and wet bulb reading 79° F. and 67° F. and the men were
found to lose an average of 3 pints of water.
But with shirts opened
and
sleeves
rolled up the loss of fluid was reduced
from
3 pints to
2 pints
in
marching
the
same
distance
under
the
same
climatic
condition.
In warm countries
the loss of heat by radiation
is generally very
rapid
after sunset, consequently
a fall in body
temperature
and
a
chill results if the men are wet with perspiration and not given time
to cool off gradually before halting for the night.
An endeavor
should
be made to detect early appearance
of symp
toms
of
heat
stroke
which
frequently
occurs
during
hot
weather
marches.
The treatment
is :
1. Loosen
all clothing.
2. Remove
patient
to shade.
3. Strip to waist.
4. Fan patient.
5. Apply
ice
bag
or
cold
water
freely
to
head,
neck,
and
spine, and continue
until symptoms
subside.
6. Restore
body chlorides
by administering salt.
HYGIENE
AND SANITATION
OF THE
MARCH
395
In
the annual
maneuvers
of
a Marine
Corps
unit
at Quantico
recently,
26
cases
of
heat
exhaustion
occurred
1 afternoon
in
the
combat area.
About
10 percent of the unit was incapacitated.
This
shows what can be expected unless every precaution
is taken and rest
periods
allowed.
Among
some of the examples
of heat affecting
the marching com
mand, the following are cited
:
1. On July
8,
1853,
about two-thirds of
a Belgian
regiment
was struck down with heat on the march.
2. In 1878, one Austrian
regiment
had 320 cases and
31 deaths
from heat exhaustion
while on the march.
3. In
one of the
French
divisions
over
2,000
cases
of
heat
prostration
occurred.
4. In the forced
march
on Pekin,
a regiment
of United
States
Army— 1,200
strength —had
one-fourth of its men
tem
porarily
disabled
from heat, with
8 deaths ensuing.
Water Discipline
on the March
In marching one mile
a fully
equipped
soldier generates
90 cal
ories, which will require the evaporation
of
180 cc of water to dis
sipate the heat.
For 3 miles, or one hour of hiking,
he will require
540
cc of water,
which is a little over one pint
(473)
cc and for two
hours of hiking the soldier will lose two pints or the equivalent
of
one canteen of water.
In interpretation
of the
above, it must
be
remembered
that the
water requirements
are based upon the climate of middle and western
Europe.
In
a hotter and drier climate,
a larger
amount of water
should be used.
There
are
so many
factors
entering into the water requirements
that any attempt
to be dogmatic
or standardize the fluid intake for
the marching soldier is apt to result in more damage than good, if
a standard is too rigidly
adhered
to.
It is safe,
however,
to
use
the
following
as
a
guide,
since
the soldier
starts
the
march
with
about
1 pint of extra fluid in his stomach.
Drink
one pint, half the contents
of
the
canteen, for each hour
of marching, including
rest
periods,
the marcher to
take
the first
drink at the end of the second hour after leaving camp.
Since much
of the Marine Corps duties
are in the tropics where
the
hot
climate
considerably
increases
the
water
demands
of
the
infantryman,
the above must be increased.
Hilly, muddy, and rough
roads
also increase water demands.
The writer
has noted
a discrepancy
in the articles
on water dis
cipline
on the march.
The
articles
on this subject
are based upon
the British authorities who
use
the term
"quart"
according to Im
396
FIELD SANITATION —MANN
perial
measure, which
is about
25 percent
larger than the quart—
Apothecaries measure.
One quart (Imperial measure)
equals
1182.92 cc.
One quart (Apothecaries measure)
equals 946.3i cc.
The canteen should
be used only during
the rest period and
then
upon command.
Water should be slowly sipped
as thirst is quenched
better.
In
addition
to water consumed
from
canteens,
a pint
or
more is consumed with each meal.
The
experienced
soldier has instinctively
determined
the proper
amount of water which his system will require; it is the raw recruit
who
is
apt
to "water log"
his
tissues,
sweat
profusely,
and
tire
easily.
One
type of thirst
is due to dryness
of the mouth,
and
to over
come this factor the men are advised
to chew gum, or keep pebbles
in their mouths, which promote
the flow of saliva and tend to allay
this form of thirst.
Smoking
on the march
tends to increase thirst
and should
be limited to rest periods,
or, as some authorities recom
mend, should
be prohibited during the march.
As
a
rule
marching
troops
are accompanied
by
water
carts
con
taining
potable
water.
It is most important that only pure
water
be
used in the
canteens,
as
the
stomach
of
a marching
soldier
is
apt
to
contain
insufficient
hydrochloric
acid
to
destroy
infective
organisms.
The water
needs
of
officers
are slightly
less
than those of
men,
because
their equipment
is lighter, and marching to one side requires
less work than marching in ranks.
Upon arrival in camp, guards should
be stationed
over the water
supply.
Portions
of the running
stream
should
be designated
for
types of water supply, viz—up stream —drinking
water —white flag;
down
stream —watering animals —blue flag: further
down
stream —
washing and bathing— red flag.
3 hrs.
Drinks remain
ing half
8 hrs.
Drinks remain
ing half
1 hr.
/
canteen
6 hrs.
canteen
/
/
/
4 and
5 hours
/
7 hrs.
Drinks #
canteenful
0 hrs.
Start of
march,
1
pt. in
stomach.
2 hrs.
Drinks M
canteenful
Noon rest
refill can
teen,
leave
camp with
1 pt. in
stomach.
Camp-
refill
canteen.
9 hrs.
HYGIENE
AND
SANITATION
OF
THE
MARCH
397
Food on Mabch
A light breakfast —consisting of oatmeal,
tea or coffee,
bread
and
jam,
and
perhaps
some
bacon,
"to
stick
to
the
ribs."
The
food
should
be
easily
digestible.
A
heavy
breakfast
is
inadvisable
as
digestion is interfered with by the vascular demands of muscles used
in marching.
Exhaustion
retards
digestion
so
that
it
is well
to
have
a brief
interval
of rest just before
noon
and
evening
meal.
The
noonday
meal should
also be light and digestible,
and should
be served during
the noon rest period.
Upon arrival
in camp for the evening,
serving soup ahead of the
meal
increases the digestive
capacity
20 percent,
owing to the stim
ulation of the flow of gastric juices.
The main meal should
be the
evening meal.
Slowly cooked stew increases the digestibility
of proteins.
Foods
with
high
vitamin
content
such
as
fruits,
vegetables,
or
even canned tomatoes should
be served, because
the individual
soldier
in the field does not have the opportunity of supplementing his ration
by outside purchases of food.
Sugar.—In view of its rapidity
of digestion
and oxidation, is the
quickest restorative
of muscular energy.
A marching
man
craves
sweets, candies, jams, preserves, and sweetened coffee
or tea.
Choco
late or cocoa
are excellent muscular tonics.
Calories
Foot tons
of energy
4.1
S.3
4.1
6.3
14.2
6.3
From
the above table, data are furnished
as a basis of calculating
the food requirement
of the marching man.
The soldier in marching at the rate of 3 miles per hour does work
the
equivalent
to raising
one-twentieth
part
of
the
weight
of
the
body through the distance
he walked.
Work in tons
lifted
1 foot
18.86
37.72
188.60
377.20
If the soldier
carries
60 pounds
of
equipment,
the
foot-tons
are
increased
30 percent.
Carrying
60 pounds
and
marching
20
miles
the soldier expends the equivalent
to 518.60
foot-tons.
398
FIELD SANITATION*— MANN
Manifestly
the caloric requirement
of a marching soldier is higher
than at rest.
A
diet of
4,000
to
6,000 calories
should
be
planned,
depending on
the
length
of
the marches,
rate, condition
of
road,
terrain, weight of load carried and other influencing factors.
The use of tobacco and alcohol
by marching troops has proponents
and
opponents.
Smoking
should
be limited
to rest periods.
Alco
holic beverages should
be restricted
to the evening
after arrival in
camp and temperance
must be enforced.
Mabch
Sanitation
At the start.—
1. Fill and chlorinate
water
carts —canteens
should
be filled
the
night before.
2. Police camp, extinguish camp
fires.
3. Fill in, close and mark latrines.
4. Sanitary
officer and
police
detail remain
and
clear
waste
and
litter.
5. Final inspection
of camp site.
Halt.—
1. Designate
sanitary area.
2. Dig shallow pits for calls of nature —using bayonet
or stick
for digging implement.
3. Refill
canteens.
Selection of campsite
:
Toward
the end of the day's march
a staff officer, a medical
officer,
and an engineer
officer or a quartermaster
should
ride forward
and
select
a camp
site, unless this has
been
previously
arranged.
The
functions of
the medical
officer
are advisory in
the final
selection
of camp
site.
In time of war tactical consideration
is of primary
importance
in the selection
of
a camp
site.
It is impracticable to
locate an ideal
camp
site which will
be entirely satisfactory from
a
medical
viewpoint,
hence
the medical
officer must
consider
the
pro
and contra of the available locations.
1. Favorable
considerations:
(a)
Accessibility
to a supply of good water, fuel, and forage.
(b)
Sandy loam or gravel soil.
(c)
Elevated
site well drained, such
as sloping
plateau.
(d)
Shade
trees as
a protection
from the sun's rays in warm
weather.
(e) Hills and
forests
acting as windbreaks in cold
weather.
(/) The location
selected should
be large enough
to accomo
date the troops,
and crowding
should
be avoided.
(g)
Grass-covered
location.
MEDICAL
DEPARTMENT
ON
THE
MARCH
399
2. Unfavorable
considerations:
(a)
Site
recently
occupied
by
other
troops,
allowing
two
months'
vacancy
as an arbitrary
standard.
(b) Dry
bed of river,
ravines,
and
base
of hill if
there
is
likelihood of rain.
(c)
Clay, alluvial, or dusty
soil.
(d) Proximity
to
marshes,
swamps,
and
other
mosquito-
breeding
areas.
(e)
Steep
slopes.
(/)
Sites
where the ground water
is near the surface.
(g) Proximity
to
native
habitations
especially
in
malarial
regions.
In camp.—Remember —Today's campsite
may
be tomorrow's
line of
communication.
1. Proper waste disposal.
2. Insect control.
3. Water inspection.
4. Food inspection.
5.
Care of the feet.
6. Do not keep troops waiting in ranks after arrival
at destination.
7. Water responsibility:
Its purity —medical
officer.
Quantity
and delivery—engineer
officer.
Procurement—quartermaster.
Water
guards
and distribution —unit
commander.
MEDICAL
DEPARTMENT
ON THE
MARCH
Before starting,
the responsible
surgeon
should
see
that all sick
and unfit are eliminated
and that the campsite
is left in a sanitary
condition.
See that the quality of water in the canteens is satisfac
tory and that foot disorders
have been given
the requisite
attention.
The brigade
surgeon. —The brigade surgeon
proceeds forward
on
the staff of the brigade
commander.
( See fig.
14. )
The regimental
surgeon. —The regimental
surgeon occupies
a cor
responding place in the regiment
to the above, and the assistant regi
mental
surgeon marches in the rear of the headquarters
company.
The battalion surgeon. —The battalion surgeon
proceeds with the
staff of the battalion commander,
and the assistant battalion surgeon
marches
in the rear of the battalion.
If there
is only
one
surgeon
assigned
to a battalion, he should
march in the rear of the unit.
The junior medical officers marching in the rear should occasionally
proceed up and down the marching column of their respective organi
zations to observe the condition of the troops.
400
FIELD
SANITATION — MANN
Soldiers suffering from the effects of fatigue may
be dropped
at
the march
collecting stations,
ride in ambulances,
or they
may
be
Point [><J One
Support
Advance
Party
One platoon (Loss ono squad)
R D 1898
One company (Less one platoon)
(2 Aid nun with company)
1tt Battalion
(Less one
Bn. Surgeon and orderly with staff
at head
of"
reserve
Aid menwith respectivecompanies
Battalion Comdr
'»«
One platoon Howitzer Company.
BoMolion section 1st Battalion
L'
^—
J
Co. aid sqd.and wagoner.
|><1
Combat Train
1st Bn. and How. Plat
.ess Bn. Sur.
[^><^|Colonel ond staff
(Reg
Surg and mountedorderly)
2nd Battalion
Bn. Surgeon and orderly with staff
of
Bn.Cmdr.
■
,i
.
Bottalion section 2nd Battalion
(Less Bn. Surg.,
1
!
Co. Aid Sqd. and wagoner.)
p*<^) Combat train
2nd Battalion
^
I
J
Medical wagon and ambulance
3rd Battalion
(Same as
2nd Battalion)
!><! Howitjer Company and Combat Train
(Lee* pi.
0
I
I
1
Headquarters section (Less Reg Surg ond ord.)
1ll Medical
woqon ond ambulance
£><^l Regimental Field Train
|
Service Company
|
veterinary Section
Figure
14.—Regimental
Medical
Department.
Distribution of regimental
Medical
Depart
ment
on
the
march.
(Military
Medical
Manual.
U.
S. Army)
Reproduced by permission
of the copyright
owners. The Military
Service Publishing
Company, Pittsburgh,
Pa.
allowed to proceed
without their equipment —their equipment
may
be thrown upon one of the wagons of the train.
All sick and injured
patients
should
be properly
tagged
with
the diagnosis
tag
and
re
MEDICAL
DEPARTMENT
ON
THE
MARCH
401
corded.
A compilation of these
records
is made
at the end of the
day's march.
The
medical battalion.—The medical
battalion
will
proceed
in
two groups—one consisting of the mounted
and
foot
group,
which
will march in advance of the animal-drawn train, and the other, con
sisting of the motor-drawn group, which will proceed at the head of
the motorized
train of the brigade.
March collecting
stations. —If the marching command
is com
posed of a brigade
or larger organization, it is advisable
to establish
march collecting stations
every
3 miles.
The personnel for these
sta
tions consists of two or more hospital corpsmen,
who
are equipped
to give first-aid treatment
to the sick, injured, and exhausted,
and to
retain the patients until they are picked up by the ambulances in the
rear of the column.
The hospital
corpsmen
detailed
for the purpose
of
establishing
march collecting stations should
proceed with the head of the column
or advance party and drop off every
3 miles
to form collecting sta
tions.
They
remain
until
the tail of the column
has cleared
their
station,
then fall in with the rear units.
Towards
the end of the day's
march
the
necessary sanitary
per
sonnel should
join the advance guard to supervise
water purification
and make arrangements
for sanitation before
the main
body arrives.
Combatant
units of advance guards, rear guards,
and other security
detachments
are normally
accompanied
by
their
attached
medical
troops.
Poison ivy.—In view of the fact that poison ivy is a sourcs of dan
ger to a marching command,
detailed
consideration
is advisable.
In
one of the maneuvers of the United States Marine Corps ivy poison
ing caused many
sick days and
some of the recruits
present had the
misfortune to use this bush as toilet paper, with rather serious results.
Ivy poisoning is
a form of dermatitis venenata
due to exposure
to poison ivy (Rhus toxicodendron), and the excitant
is an oily com
pound called toxicodendrol,
belonging to the phenol
group.
As little
as 0.001 mgm of toxicodendrol may produce dermatitis.
All parts of
poison
ivy contain
the irritating principle, the leaf especially.
Poison ivy grows as
a woody
vine, trailing
shrub,
or erect bush,
growing in the woods or in the open, in moist or dry soil.
It climbs
trees and posts.
The plant is recognized
by its leaves which are divided into three
leaflets;
and by its white mistletoe berries, known as drupes;
the lat
ter remain on the plants into winter after the leaves have fallen.
All
of these plants do not bear the drupes
and it must be recognized
by
the leaves.
64743—38
6
402
FIELD SANITATION —MANN
The leaves are from
1 to 4 inches long.
The end leaflet of the triad
has a longer stem than
the two opposite
leaflets, which, as the leaves
are broad, though pointed, preserves the symmetry of the arrangement.
The mature
leaves are dark green on the upper surface
and lighter
underneath.
The crinkly young leaves are red when they first unfold,
becoming
green later.
In autumn
they turn to beautiful
shades of
scarlet and orange.
The innocent
sometimes pluck these leaves and to
their sorrow bear them off.
The old adage runs —"Leaflets three, let it be"—makes
a safe rule
for those of us who perhaps
have neglected "How to know the wild
flowers."
Babies are not susceptible
to poison ivy until they are sensitized
by
sufficient
contact.
The period of incubation, after contact in the susceptible, is usually
a few hours but may be delayed for days.
Redness and erythema
ap
pear, usually first on the face and hands.
Shortly, fine vesicles, clear
and closely
grouped,
are observed
in the thinner areas, such
as the
inner surface of the fingers.
Other areas of skin become affected, even
those where there has been no direct
contact.
The eyelids
and
sur
rounding
tissues
are frequently
greatly
swollen.
Probably
by in
direct contact the genitals
become
edematous and the rash has a pre
dilection for the looser and thinner skin.
As the active agent is fat and alcohol
soluble,
the irritant may be
largely removed if immediately
after exposure
the areas are washed
with soap and water.
Alcohol or ether, used on swabs, being careful
to clean the irritated areas from the periphery towards the center, is a
more effective measure.
Two readily
available
agents
ai'e recommended
for the treatment
of the lesions.
1. Potassium
permanganate
in
a
5-percent
solution
in
water,
applied
locally
by
cotton
swabs
or
cloths;
frequent
applications
should
be made, or if
a dressing
is used, frequent
changes
of
the
dressing.
2. Chloride of iron, a 5-percent solution in equal parts of alcohol
and water can be used in the same
way.
THE
FOOT
Anatomy
and Physiology
The human
foot
is
a specialized
organ
designed
to promote
ter-
restial locomotion
of the individual
by leverage
action
of
the
foot-
in lifting
the body's
weight and it plays such
a dominant role in
marching that a brief description is appropriate.
Considered
in its entirety,
the human foot is indeed a very wonder
ful anatomic
part of the individual.
In the smallness of its size and
THE
FOOT
403
weight, out of all proportion
to
the burden
borne
and carried, it
constitutes
a
mobile,
strong,
flexible,
and
efficient
member of the
organism
designed
to bear weight forwards,
backwards,
and
side
ways without
mishap.
Encased
in
a cloth covering,
the
sock,
and
in
a protective leather
covering,
the
shoe,
both
concomitants
of an
advancing and exacting civilization,
this member, the most uninten
tionally neglected
part of the body is expected
to do its full duty.
The foot is composed of a nicely adjusted
aggregation
of 26 bones
of various sizes and
shapes, each, however,
designed
to perform
a
certain definite function.
Seven of these are of a very irregular shape
STATIC
FORTIOir
*
OP THE
POOT
f
V
L
Here
the
shoe \J
should fit tangly.
rouxia pobxioi
/j
OP THE
POOT
1 \
HIHETEKH
BONES
>,
1
f
The
shoe should
.
te
roomy here to
\
pemlt
the intrinsic
1
muscles
to function,-
1
expend
and oontraot
1 1
«t eech step.
\ 1
Fiquse
16. — Bones of the foot.
and are located
in the hind part of the structure forming
the heel
and
a portion of the so-called
instep.
The remaining 19, situated
in
the forepart of the foot, form a portion of and radiate fan-like from
the instep.
These extend forward
and to the outer and inner sides,
finally ending in the toes.
These different bones are held together
in
a correct position by ligaments,
tendons, and muscles;
the ligamentous
support
predominating
in
the
posterior
7
bones which
form
the
static portion of the foot, while muscular action
predominates
in the
anterior
19 bones which form
the dynamic portion.
(See
fig.
15.)
The. posterior seven bones, forming
a compact
mass held
by liga
mentous
attachments,
move very slightly
when
a step is taken
and
serve to minimize the shock of impact and act as
a recoil mechanism.
On this mass—the static
portion of the foot—in the shod
man, all
the weight of locomotion
is first borne; first affecting
the heel and
center of the instep.
404
FIELD
SANITATION
MANN
The anterior
19 bones are controlled mainly by muscular
action —
the dynamic portion—and
when
in
use
bearing
weight
move
ex
tensively.
From the center of the instep
the weight borne
is shifted
to the ball of the foot which spreads medially and laterally presenting
an
enlarged
area
to
the walking
medium.
The
toes
also
spread
laterally, medially, and lengthen, gripping
the surface.
The anterior of the human
foot is composed of many tiny muscles,
many
sensory
and motor
nerves, and tendons.
Over the dorsum
or
upper
surface of the foot the muscles are few in number
and lacking
in development.
However, on the plantar or lower surface,
filling
the arch
beneath
the instep
there
are five layers
of well-developed
muscles
which
buttress
the
arch,
preventing
descent of the
latter
Fiucre
16.— A "figure of eight
strap" military shoe devised by the writer.
when continued
and excessive weight
is borne.
These muscles expand
and contract
in each
step of the marching soldier.
A shoe which fits
the anterior part of the foot too snugly causes
pressure on nerves and
muscles, and prevents
the muscle from functioning
and
causes
them
to atrophy—weaken
and shrink.
The
shoe
shown
in figure
16, fits
the static portion of the foot snugly and
at the same
time it allows
the intrinsic
muscles in dynamic
portion of the foot to expand
and
contract
at each step.
The posterior portion has very
few
muscles, tendons, or muscular
nerves.
The "after" portion of the shoe
should
fit the foot snugly—
as does
the United
States Marine Corps pattern
of shoe.
The longitudinal
arch,
on the inner surface
of the foot extends
from the heel bone (Os Calcis)
to the distal end of the first
meta
tarsal
bone.
This
is
definitely
formed
by
the
inherent
structural
THE
FOOT
405
concavity
of
the
bones
held
among
themselves
by
ligaments
and
supported from below by developed
muscle layers.
The
anterior
arch
is formed by
the distal
ends of the
metatar
sal bones.
The muscular development
concerned
in sustaining this
arch is not
so great
as in the longitudinal.
A tripod
is
formed
by
the
structure of the
foot;
the
apex of
which
is the highest
point of the heel bone (Os Calcis),
the inner
side of the ball of the foot at the base of the big toe (distal end of
first metatarsal
bone)
and the outer
side of the ball of the foot at
the base of the little toe (distal end of the fifth
metatarsal
bone).
The lifting
force
is exerted
at the
heel, H;
the
body's
weight,
W, is superimposed
at a position corresponding to that of the ankle;
and the lower corner
of the opposite
end is employed
as
a fulcrum,
F,
representing
the
position of the
heads of the first
and
second
metatarsal
bones.
When H is lifted,
the force
passing
through the
substance of the block is directed
upward and forward
in a curved
direction
toward
the W;
from there
it curves
forward
and
down
ward
upon
the fulcrum.
As before
mentioned
in this chapter,
the center of gravity of the
body must be considered
in the carrying of extra equipment.
When
the soldier is standing, stance, stable, or static equilibrium
is involved
as the center of gravity
is directly
above the
feet which
act
as
a
support.
When
locomotion
is started
as in marching, dynamic
equilibrum
is brought into
force
by
an
active
interplay
between
the
organic
energy of the soldier and
the
force
of gravity.
The
feet function
as a series of levers that act against
the body's
center.
In marching
the body's center is constantly being
displaced
forward,
and gravity
thus
assists
the forward
translatinal
motion
through
its
influence
upon the unbalanced
body
weight.
The walking
man,
so to speak,
tends
to fall forward
at each step, until
this action
is interrupted
temporarily
and
the body
is balanced
momentarily by
one foot
as
a support.
The marching soldier always has one foot on the ground.
Man,
more
often than
any
other animal,
in
upright
bipedism,
makes better
use of gravity
as an auxiliary
force in locomotion.
A comparison of the
feet of the
shod
man
and
the bare
footed
savage
is interesting and
instructive.
In
the
shod
man
the joints
are
not
as
flexible,
the muscles
are not
as well
developed
and
the
toes in walking
do not spread
and grip; being limited
by the shoe.
Taking a step he strikes
the heel
first, shifts the weight to the outer
border of the foot,
then full upon
the ball while the
toes,
as above
explained, are limited in their motion.
In that
the shoes
limit the
bearing surface of his feet
he
toes out
sometimes
slightly,
other
times
excessively,
to
preserve
his equilibrium,
thus
throwing
the
40G
FIELD SANITATION
MANN
weight
borne
backward
on
the
inner
border
of
the
foot—on
the
arch —where it should not all
be borne.
On the other
hand,
the savage
has very
flexible
joints, well
de
veloped
muscles
under
the arch
as are also the muscles of the calf
of
the
leg.
In
locomotion
he
has
his
feet
parallel —the
correct
posture —or toes in throwing
the weight upon
the ball of the foot,
center of the
instep
and
outer
border of
the
foot.
His
toes, un
hampered
by
a covering,
spread
widely, lengthen,
grip
the surface,
and
thrust vigorously
backwards.
He
walks
on soft, nonresistant
earth which conforms itself to the irregularities
of the foot forming
an
accurate
impression
which
lessens
strain
on
the
muscles
and
ligaments and minimizes the shock of impact.
The reverse is true
in the civilized individual
who, his feet encased and limited in motion
by
a covering,
the bottom of which does not conform to the irregu
larities of the foot, walks the greater part of his life on macadamized
roads
or rock pavements
where
muscle strain and
shock of impact
are
great.
(From
Foot
Care
and
Shoe
Fitting
by
Mann
and
Folsom.)
Care of the Feet
Shoes. —According
to the Duke of "Wellington,
the three most im
portant parts of
a soldier's
equipment
are
a pair of good
shoes,
a
second pair of good shoes,
and a pair of half soles.
New
shoes
should
not
be
worn
on
the
march
unless
they
have
been
broken
in.
An excellent
method of adapting new shoes
to the
foot consists in the soldier standing in his shoes in 2 inches of water
for 5 minutes.
This makes the leather
soft and pliable.
The man
then walks on level
surface
about
an hour, and the pressure
of the
body
weight
causes
the drying
leather
to conform to the shape
of
the feet.
This scheme
accomplishes
in an hour what a week of ordi
nary "breaking in" can produce.
Socks. —Light woolen socks in summer time, and heavy woolen ones
in winter, are preferable over cotton fabric.
Socks
too large will form folds and
thus
cause
pressure
foot in
juries
and if too small
tend
to produce
ingrowing
toenails,
hallux
valgus,
and clubbed
toes.
Refer to subjoined
tables for proper sizes
to be worn with the required
length of shoe.
Turning socks wrong side outwards,
and changing socks from
one
foot
to another
equalizes
wear,
and
is conducive
to comfort.
Holes
in socks are apt to cause
blisters
as the edges of the hole tend to curl
and
cause
pressure
damage
upon
the
subjacent
skin
area.
Avoid
using darned
socks.
The life of a good light-wool
sock is about
100 road
miles, but if
feet are wet the sock will wear through much sooner.
CARE
OF THE
FEET
407
It
is interesting
to
note that
the
Spanish, French,
and Italian
Armies do not wear socks.
(Blackham.)
Socks should not
be colored
with
analine
or other irritating dyes
which
wash
out
with
perspiration,
hence the regulation
grey
is
a
good color.
Eibbed
socks are better
than plain
ones,
as they
are more
elastic
and fit the foot better.
Some soldiers
grease their socks or rub the feet with candle,
vase
line, or unsalted
pork, and thus lessen the friction
between foot and
sock.
New socks should be washed
and shrunk before
use for marching
purpose.
A
series of tests were
conducted
at Marine
Barracks,
Quantico,
Va., on the shrinking
of Marine
Corps issue socks.
Heavy
woolen,
light woolen,
and cotton socks each were washed three times at same
temperature.
Three temperatures
were used 212°, 200°, and
75° F.
respectively.
Ivory soap was used.
The greatest amount of shrinka-
bility and lost elasticity was found in the heavy woolen socks.
After
the first washing at 212° F. and immersion for 15 minutes, shrinking
of
1 inch in height,
1 inch in width, and iy2 inches in length were
noted.
Second
and
third
washings
at
212°
F.
caused
a
further
shrinkage
1 inch in height,
one-half inch in width, and one-half inch
in
length.
Total
shrinkage
after
three
washings
at
212°
F.
as
follows
:
Washing
and
immersion
in temperatures
200°
and
75° F. caused
very little shrinkage and loss of elasticity.
Boiling seems to play a
great part in the production of shrinkage and lost elasticity.
Height
(from heel to top of sock leg)
Width
Length
Inches
2
1.5
2
Total loss of elasticity noted as follows :
Inches
Height
(from
heel
to top of sock)
Width
Length
2
2.5
408
FIELD
SANITATION
MANN
Iii the. light
woolen
socks after three washings
each in the differ
ent temperatures
as given
above there was total shrinkage noted
as
follows :
Inches
Height
(from
heel
to top of sock
leg)
0.5
Width
1
Length
1.2
Total loss of elasticity noted as follows:
Inchea
Height
(from
heel
to top of sock leg)
1
Width
1.5
Length
2.3
The
total
amount
of shrinkage
and
lost elasticity in
the
cotton
socks after three washings
and immersions
at each temperature
were
very inconsiderable
and not worthy of note.
1. Upon
arrival
in
camp,
remove
shoes,
clean, dry,
and
dubbin
them.
2. Wash feet in cold water
to tone foot
muscles.
Foot inspection
by company
commanders.
3. If feet are tender
bathe
in alcohol
or
1 percent
formalin
solu
tion, or 2 percent
alcoholic solution of salicylic
acid, or
10
percent
picric acid solution.
4. Put on clean socks and shoes.
5. Wash and knead soiled socks
for use next day.
C. Trim toe nails square,
so
as
to
prevent
ingrowing
toe
nails.
Another
method of prevention of
ingrowing
toe
nails
consists
of
scraping the upper surface
of the
toe
nail
in
center.
This
causes
the nail
to
be thinner in center
and leads to eversion of the outer
sides of the growing
nail.
This
method
is
practised
in
certain
rural sections of this country and
is claimed
to be an effective pro
phylaxis.
(See fig.
17.)
Treatment of foot disorders. —Puncture blisters
at dependent por
tions of
base —using sterile
needle— remove
serum
and
paint
with
tincture of iodine.
Cover blister with adhesive tape with small hole
in center to allow discharge
to escape.
For
smelly
feet
(bromidrosis)
use
2 percent
solution
of
forma
lin or apply 2 percent salicylic acid ointment.
CORRECT
INCORRECT
R. 0.1698
Figure
17.— Showing
the
correct
and
in
correct
method
of
cutting
the
nails
of
the
toe
in
order
to
prevent
Ingrowing
toe
nails.
When
the
nails
are
cut
at
right
angles,
the
flesh
is
less
likely
to
grow around
the
edges.
(Foot
care
and
Shoe
Filling,
Mann
and Folsom.)
SANITARY
INSPECTIONS
SUMMARY
409
Pare corns with
curved scissors after
treatment with:
Salicylic
acid
grains
CO
Ext. canabis iudica
do
8
Collodium
flexible
ounce--
1
A small amount of alcohol
to preserve above mixture can be added.
Corn
salve consists of:
Porta
Salicylic
acid
40
Vaseline
30
Lanolin
30
It is an old trick of the soldier to
lessen
friction
between
socks
and foot by soaping
the inside
of the sock,
so that perspiration of
the foot works a lather which serves as
a lubricant.
Another
means
of minimizing
the
shoe
rubbing
the
foot
is to wear
two socks on
each
foot.
In cold weather,
when there is less perspiration, dust foot powder
inside the sock to minimize friction.
This foot powder is issued by
the Quartermaster.
Parts
Talc
(mg
silicnte)
87
Boric
acid
10
Salicylic
acid
3
The French
figure
of
eight
strap
can
be
used to
lessen
friction
so that a man with
blistered
feet can often
march
in comfort.
It
is said that foot injuries
tend to heal
more rapidly
when marching
than
at
rest,
because
the increased
blood
supply
to marching
feet
causes healing to occur more promptly.
In some experienced organizations, sore feet are reckoned
as a mili
tary offense both for the individual
and for his company
commander.
The pied force of the French
is
a fracture of the second or third
metatarsal
bone at the junction of the anterior and middle thirds.
It occurs
in marching with
heavy
load,
especially
in double-time.
A short
first metatarsal
bone causes the second metatarsal
to act
as the principal
leverage
member.
The
stresses
converge
upon
the
base of the latter only, being transmitted
by it to the ground.
Under
the
increased
amount
of
function,
the
second
metatarsal
becomes
widened
and hypertrophied ;
a correspondingly
increased
strain is
imposed
upon its basal joint.
POINTS TO
BE
CONSIDERED
IN SANITARY
INSPECTIONS'
1. Mess
HALL. —
Is it screened ?
Are flies present?
What
measures are taken
for fly preven
tion ?
1 From
Essentials
of Field
Sanitation.
U.
S. Army
Field
Medical
Service Scliool.
410
FIELD SANITATION
MANN
Are mess tables scrubbed after each meal ?
Are tables
so constructed
that center
boards
can
be removed
for cleaning?
Are food particles found between boards
on tables?
Is floor clean?
What
method of cleaning is used to prevent
dust?
Are mess attendants
clean
as to person
and clothing?
Are dishes
and tableware
clean and
free from
grease?
What
provisions
are
made
for washing
dishes?
Is
soapy
water and
rinse
water
boiling
at
the
time
the
dishes
are
washed ?
2. Kitchen. —
Is it screened ?
Are flies or roaches
present?
What
insect control
measures
are used?
Are
work
tables
and
meat
cutting
blocks
scrubbed
after
using ?
Is menu posted?
Is diet varied?
Is it well balanced?
Is food served in an appetizing manner?
Is hot food served hot ?
Is cold food served cold ?
Are kitchen utensils
free from grease?
What
provisions
are made for washing pots
and
pans?
Is
rinse water boiling
at the time pots and pans are washed?
Is provision
made for
mess
personnel
to
wash
their
hands
after using the latrine?
How is garbage
handled
in the kitchen
?
Is floor kept clean ?
What method of cleaning is used to pre
vent dust?
Are the food handlers
examined
according to regulations?
Is the food handlers
list posted in kitchen
?
3. Garbage disposal. —
Is garbage
rack clean?
Are food particles found on rack or
on the ground under and around the rack ?
Do lids fit tightly
on garbage
cans?
Are garbage cans properly cleaned after emptying?
Are fly traps being used at the garbage rack ?
Are they prop
erly baited
?
What system of garbage
disposal
is used ?
If by incineration is the incinerator kept clean?
Is the area around the incinerator kept clean?
What method of disposal
is made of liquid wastes?
SANITARY
INSPECTIONS —SUMMARY
411
Is the grease trap kept clean ?
Is the soakage pit adequate ?
Are
cans
burned
and
flattened
dump?
4
Food storage. —
out
before
being
placed
on
Is ice box temperature
at 45° or cooler?
Is the ice box or cooler
clean?
If
a cooler
house is used is
it screened?
Is meat
suspended
so
that
there
is circulation
of air on all
sides?
Is cured
meat stored
so that there is free circulation of air on
all sides?
Are vegetables stored in bins off the floor with free circulation
of air on all sides?
Are the bins clean and is the floor under the bins clean ?
Is milk supplied in bottles?
Is milk kept at the proper temperature
?
5
Water supply.—
Is water source properly
protected
from contamination?
Is the method of chlorination properly
supervised
?
Is the water chlorinated satisfactorily
?
Is the water examined
bacteriological ly at frequent
intervals?
Is the water free from objectionable
color, odor, and taste ?
6. Showers. —
Are there sufficient
shower
heads ?
Is hot water available?
Are duck boards used ?
Are they scrubbed daily ?
Is shower room kept clean?
Are benches available for undressing?
What
provision
is
made
for
prevention
of
spread
of
skin
infections ?
7. Latrines. —
Are latrines screened if not enclosed in building?
Are latrines sprayed
daily?
Are seats and urinals scrubbed daily ?
Are lids kept closed at all times?
Is the latrine fly-proof?
Is the latrine floor clean?
If water carriage system of sewage disposal
is used, are flush
boxes and toilets all in working order?
What system of disposal
of sewage is used?
412
FIELD
SANITATION —MANN
If septic tank, is it adequate?
What method of disposal
of effluent is used ?
If tile field, is there evidence of over-charging the field?
If by dilution,
is the stream flow or other body of water
adequate at all times for proper dilution?
8. Barracks.—
Are barracks well lighted?
Are drafts noticeable?
Is ventilation
adequate?
Are floors
clean?
What
method
of cleaning is used to pre
vent dust?
Is floor space adequate for the number of men in the building?
Is heating adequate
and uniform
throughout the rooms?
Are heat deflectors used in disseminating the heat if stoves are
used?
Are beds or bunks
free from bed bugs?
Is bed clothing clean ?
Is bedding aired
twice
a week?
NAVAL
RESERVE
PROMOTIONS,
FIRST
QUARTER,
1938
Henry Amiss
Hornthal,
21
Massachusetts
Avenue
NW.,
Washington,
D. C,
promoted
to lieutenant, MG-F., U. S. N. R., February 1, 1938.
James Edward Wilson,
2075 Madison
Avenue,
Memphis,
Tenn.,
promoted
to
lieutenant, MC-V (G), U. S. N. R., February
1, 1938.
Albert Louis Bork,
8734 W.
National
Avenue,
West Allis,
Wis.,
promoted
to
lieutenant,
MC-V
(G), U. S. N. R., March
4, 1938.
Asa
Glenn
Churchill,
1300
Orange
Avenue,
Coronado,
Calif.,
promoted
to
lieutenant
commander, MC-F., U. S. N. R., March
4, 1938.
Edward Thomas
Gary,
U.
S.
Veterans'
Facility,
Togus,
Maine,
promoted
to
lieutenant, MC-V (G), U. S. N. R., March
4, 1938.
Benjamin
Bernhardt
Kies,
C. C. C. Camp, Wetumka,
Oklahoma,
promoted
to
lieutenant,
MC-V
(G), U. S. N. R., March
4, 1938.
RESIGNATIONS,
FIRST
QUARTER,
1938
Rudolph
E. Swenson, 2 North
Street, Plymouth,
Mass., lieutenant, junior grade,
MC-V (G), U. S. N. R., resignation
accepted
January
12,
1938.
Harve
M. Clodfelter,
6S3 East
Broad
Street, Columbus, Ohio, lieutenant,
MC-V
(S), U. S. N. R., resignation
accepted
January
19,
1938.
William L. Cruchett,
858 Ensenada Avenue, Berkeley,
Calif.,
lieutenant, junior
grade, MC-V
(G), U.
S. N. R., resignation
accepted
January
26, 1938.
Joseph
A. D'Allessio,
3 West Carrillo Street, Santa Barbara,
Calif.,
lieutenant,
junior
grade, MC-F.,
U.
S. N.
R.,
resignation
accepted
January
26,
1938.
Herbert Fay H. Jones, 808-815
Douaghey Building,
Little Rock, Ark., lieutenant,
MC-V (S), U. S. N. R., resignation
accepted
January
26,
1938.
William L. Weber, 924 Pacific Electric Building,
Los Angeles, Calif., lieutenant
commander, MC-V
(S), U. S. N. R., resignation
accepted
January
26, 1938.
William J. Kebler,
82 Clinton
Street, Tonawanda,
N. Y., lieutenant, MC-V
(S),
XJ.
S. N. R., resignation
accepted
January
27,
1!'38.
Ross
Sutherland,
617
West
Seventh
Street,
Los
Angeles,
Calif.,
lieutenant,
MC-V (S), U. S. N. R., resignation
accepted
February
2, 1938.
John Paul Medelman,
572 Lowry Medical
Building,
St. Paul,
Minn.,
lieutenant,
junior grade, MC-V (S),
U.
S. N. R., resignation
accepted
February
17,
1938.
Joseph
Fulcher,
210
Medical
Arts
Building,
Tulsa,
Okla.,
lieutenant,
MC-V
(G), U. S. N. R., resignation
accepted
February
17,
1938.
Thayer Lemoyne Parry, 1007 Second
National
Building,
Akron,
Ohio, lieutenant,
MC-V (8), U. S. N. R., resignation
accepted
March
9, 1938.
Frederick
Arnold Lowe,
1222 Vanderbilt
Avenue,
Niagara
Falls, N.
Y.,
lieu
tenant, junior grade, MC-V
(G), U. S. N. R., resignation
accepted
March
9, 1938.
William B.
Steen,
Desert
Sanitorlum,
Tucson, Ariz., lieutenant,
junior grade,
MC-V
(G), U. S. N. R., resignation
accepted
March
9, 1938.
Everett
Edward Kelly,
636 Church
Street,
Evanston,
111., lieutenant,
junior
grade, MC-V
(G), U. S. N. II., resignation
accepted
March
15,
193S.
413
414
NAVAL
RESERVE
HONORABLE DISCHARGES, FIRST QUARTER,
1938
Wells C. Cook. 1930 Wilshire Boulevard,
Los Angeles, Calif., lieutenant,
junior
grade, MC-V
(G),
TJ. S. N. R., honorably
discharged
January
12, 1938.
HONORARY RETIRED LIST, FIRST
QUARTER,
1938
Clifford E.
Henry,
523 LaSalle Building, Minneapolis,
Minn.,
captain,
MC-V
(S), U. S. N. R., transferred
to Honorary Retired
List January
1, 1938.
Knud Knud-Hansen,
Municipal
Hospital,
St. Thomas,
V. I.,
lieutenant
com
mander, MC-V (8),
U.
S. N. R., transferred
to honorary
retired
list March
1,
1938.
Charles Francis Stokes.
Surgeon General,
United
States Navy,
1910-14.
NOTES AND COMMENTS
CHARLES
FRANCIS
STOKES
By Louis H. Roddis,
Commander, Medical
Corps, United
States Navy
The
fourteenth
Surgeon
General, United
States
Navy,
and
the
eighteenth
Chief of the Bureau of Medicine and Surgery, was born
in Brooklyn,
N. Y., on February
20,
1863.
He received his medical
degree from the College
of Physicians
and Surgeons,
New York, in
1884, and was an interne
at Bellevue and the first house surgeon of
the newly erected Gouverneur Hospital.
He
was
appointed
from
New York
as an assistant
surgeon of the Navy on February
1, 1889,
his commission
being
signed
by President
Grover
Cleveland.
His
first duty was on the U. S. S. Minnesota, then the receiving ship at
the Navy Yard, New York.
He then served in the Naval Hospital,
Mare Island, Calif., and subsequently
at the Naval Hospital, Yoko
hama,
Japan.
During
the
Spanish-American
War
he
was
oper
ating surgeon
on the U. S. S. Solace,
the new hospital ship, and the
first of our hospital ships to fly the Red Cross flag.
He then served
as professor of surgery at the Naval Medical School, Washington,
D.
C.
During the
cruise
of
the Atlantic Fleet
around
the world
in
1908, he commanded
the U. S. S. Relief.
He was appointed by
President Taft as Surgeon General of the Navy on February
5, 1910,
and
held
office until February
6, 1914.
He was widely known
as
a
skillful surgeon
and is remembered
in the Navy today
by the Stokes
stretcher
which was devised
by him.
This stretcher
has proved of
remarkable
value in the transportation
of sick and injured
up and
down the narrow
ladders
and through small
manholes
and
hatches
on
board
ship, and
such
inaccessible
places
as
firerooms,
fighting
tops,
and
turrets.
In it a patient
can
be
lowered
into
a boat
in
comfort and safety.
By simple and ingenious
fittings
the stretcher
was made to combine
splinting
for fractures with
the function
of
a litter for transportation.
This stretcher
gave the Navy many
ad
vantages in the transport of patients,
and has been copied in foreign
navies.
There is an interesting story in regard to this stretcher
and
its inventor.
Doctor Stokes, who had retired in June
1917, was, in
1926, visiting
the display of naval
medicine
in the exhibits of the
American Medical Association held in Washington, D. C.
He mani
fested much
interest
in the Stokes
stretcher,
and the polite and effi
415
416
NOTES
AND COMMENTS
cient
hospital
corpsman
on
duty
with
the
exhibit
explained
the
stretcher
and its uses at great
length.
Admiral Stitt,
then Surgeon
General,
came
up at that time and greeted the former Surgeon Gen
eral,
and
the hospital corpsman
found that he had been explaining
the stretcher
to its inventor.
Stokes
praised
the corpsman
for his
knowledge
of the stretcher
and its uses, telling Admiral Stitt that he
hoped
all
members
of
the
Medical
Department
were
as
well
ac
quainted
with its use.
Surgeon
General
Stokes
carried
on
the
work
begun
by
Eixey
directed
toward
improvement
of
the efficiency
of
the Medical
De
partment
of the Navy.
High standards
were maintained for entrance
into the Medical
Corps,
and
only
candidates
who
were
graduates
from excellent
medical
schools and capable of passing
rigid physical
and professional examinations
were
accepted for
commission.
The
newly instituted Hospital
Corps School at Norfolk
was utilized
to
the utmost
in the training
of the Hospital
Corps
and
most of
the
chief pharmacists
of the Navy for many years were graduates of this
school.
Honolulu
and the Hawaiian
Islands
were being
recognized
as
a strategic
center of prime
importance,
and
in connection
with
the development
of naval
facilities
there,
the United
States
Naval
Hospital,
Pearl Harbor,
was planned
and built during
Stokes'
ad
ministration
of the Bureau.
As the former commanding
officer of
the hospital ship, Admiral Stokes had great interest
in these
vessels,
and plans
were made in his regime for additions to these important
auxiliary craft, which later materialized in the hospital ships Mercy
and Relief.
The latter was the first vessel of a modern
navy to be
designed
and laid down
as a hospital ship,
previous
vessels
of this
class having been converted
from liners.
After
retirement,
Admiral Stokes
lived in New York City until
his death, which occurred
October
29,
1931, in his sixty-eighth
year.
As may
be
seen
from
the portrait
accompanying
this sketch,
this
Surgeon General
was
a remarkably fine-looking man and
was often
referred to as "the handsomest man in the Navy."
The picture shows
also the old special
full-dress
coat well
known to older
officers, but
which
has not been worn since the World War.
YELLOW
FEVES
For
some
time the Rockefeller Foundation
has been investigating
the jungle variety of yellow
fever.
The Aedes
is known to
be
an
intermediate
host
of
this
disease
but
the
definitive
host
is
still
unknown.
The disease thrives in a warm humid climate
such
as the
summer
season
in Brazil
where
at
present
it has
assumed
serious
proportions.
NOTES
AND
COMMENTS
417
During the
2-month
period from approximately
mid-January
to
mid-March
120
deaths
in Brazil
were
definitely attributed
to this
disease.
This would indicate
that for the present
season both
mor
bidity rate and mortality
rate
(5 percent for 1937)
will exceed
those
for last
season.
The
disease in
present
cases
is
contracted
in
the
jungle and there have been no proven
cases of cross-infection within
the urban population.
It also differs from former epidemics
of yel
low fever in the lower mortality
rate.
To date the urban population has been free from attack and appears
comparatively
safe.
The
Rockefeller
Foundation
has
developed
a
new type of vaccine that is stated to confer immunity
for life and
its agency in Brazil
is promoting
an
active
campaign
of prophy
lactic inoculations.
Due
to
present
means of
rapid
transit
and
to
presence
of
the
yellow
fever
vector
within
our
borders
this
outbreak
is
a public
health problem
of serious concern
to our own services.
OBSERVATIONS
ON
BURNS
DUE
TO
EXPLOSION1
The authors
relate their experiences
with the casualties
sustained
in H. M. S. Hunter
and
the German battleship Deutschland.
The
former struck a mine
near Almeria
on May
17,
1937, sustaining
a
large
number
of casualties,
and
the latter was struck by two
aero
plane
bombs while lying
at anchor
on May
29,
1937.
A total of 20 cases was admitted
from the Hunter, and 55 from the
Deutschland.
Twenty-four
to forty-eight
hours
had
elapsed
before
the patients
were admitted
to the hospital.
They
concluded
that
explosive,
infected
burns
are
unsuited
for
treatment
with
tannic acid,
and
suggest
the first-aid
treatment
of
burns with
dry
dressings.
This prevents
extraneous
infection
and
presents for debridement
a burn which
has not
been
covered
with
oily substances
or chemicals.
The
bandage
impregnated
with
bis
muth,
carried
by the German ships,
was found
to
be worst of all
methods tried.
They preferred the vaseline and eucalyptus
oil dress
ing, applied after debridement
under
gas-oxygen
anesthesia.
COMMENDATION 2
On March
22, 1938. Horace Albeit Thomson, Ph. M. 2c. U. S. N.,
Puget Sound Navy Yard, was commended
by the Secretary
of the
Navy for his action
on the occasion of the wounding of His British
Majesty's Ambassador to China.
Sir Hughe Montgomery Knatch-
1 Anderson,
C.
B. C, and Douglas, J. P., Journal
Royal
Army
Medical
Corps,
70:
168,
March
1938.
2 Bureau of Navigation
Bulletin No. 260. April
23,
1938.
418
NOTES
AND
COMMENTS
bull-Hugessen. K. C. M. G., was struck by a machine-gun
bullet from
a Japanese
plane
while motoring
from
Nanking
to
Shanghai
on
August 26, 1937.
Thomson, on duty with the Fourth Marines, volun
teered and' donated
blood for a transfusion which undoubtedly con
tributed to the Ambassador's
recovery.
Such prompt and
generous
action is in keeping
with the best traditions of the naval
service.
THE
NEW
YORK
ACADEMY
OF
MEDICINE
GRADUATE
FORTNIGHT
The New York Academy of Medicine will hold its Eleventh Annual
Graduate Fortnight from October
24 to November
4, 1938.
The pur
pose of the Fortnight is to make
a complete
study
and authoritative
presentation
of a subject of outstanding importance
in the practice
of medicine and surgery.
All members of the medical profession are
eligible for registration.
The subject of this year's Fortnight is Diseases of the Blood
and
Blood-Forming
Organs.
The carefully
integrated
program will in
clude
clinics
and
clinical
demonstrations,
evening
addresses,
and
appropriate exhibits.
Twenty-three hospitals have accepted the invi
tation to participate by having prepared
afternoon
clinics and clinical
demonstrations
which will be coordinated
with the evening
meetings.
The evening
sessions at the Academy will be addressed by recognized
authorities in their special fields, drawn from leading medical
centers
of the United States.
There will be a comprehensive
exhibit of books,
pathological and research material, diagnosis,
treatment,
and preven
tion whenever
possible,
clinical
and laboratory diagnostic methods,
X-rays, action of drugs and other therapeutic
measures.
Demonstra
tions will be held at regular intervals.
Among the main
features
to be presented
at the meetings,
in the
clinics and in the exhibit, will be—
Pernicious
anemia.
Hudgkin's
disease.
Other
macrocytic
anemias.
Lymphoma told
diseases
(olher
neo-
Idiopathic
hypochromic
anemias.
plastic
diseases
of
the
lymphnodes
Other anemias benefited
by iron therapy.
and
bone
marrow)
Anemias
of
pregnancy.
The
polycythemias.
Aplastic
and hemolytic anemias.
Diseases
of the
blood
in
infancy
and
The
granulocytopenias.
childhood.
Formation
and fate of the blood cells.
The blood clotting
mechanism.
The
reticulo-endothelial
system.
The purpuras.
Diagnostic
significance
of
changes
in
The
splenomegalies —their
differential
erythrocytes.
diagnosis —indications
and results
of
Diagnostic
significance
of
changes
in
splenectomy,
etc.
leucocytes.
Irradiation
therapy
in
the
blood
dis
infections
mononucleosis.
eases.
The
leukemias.
It is suggested
that medical
officers desiring
to attend
this Fort
night
make
official
request
to
the
Bureau
for
authorization
and
NOTES
AND
COMMENTS
419
credit for attendance.
The Bureau can provide no relief for appli
cants
and can authorize no funds other
than
registration
fees.
THE AMERICAN
BOARS
OF RADIOLOGY'
At the annual meeting of the American Board of Radiology, held
in Atlantic City, June
1937, the following
requirements
and
recom
mendations
as to professional training
were
adopted
with
the pur
pose of outlining
the method
or methods
which
are
recommended
for
graduate
training
in radiology.
The
specific
requirements
to
which the Board of Radiology
is committed
at present are :
L Professional
education
:
(a)
Graduation
from
a medical
school of the United
States or Canada,
recognized
by the Council
on Medical
Education
and Hospitals of
the American
Medical
Association.
(b)
Completion
of an interneship
of not
less
than
1 year
in
a hospital
approved
by the same
council,
(e) Three years'
training in
radiology
or
sufficient
experience
in
lieu
thereof.
2. Special training (to be effective after January
1, 1940)
:
(a) A period of study after the interneship
of not
less
than
3 years
In
an institution or radiological
department
recognized
by the
same
council
and
the
Board
of Radiology
as
competent
to provide
a
satisfactory
training in the field of radiology,
or equivalent
train-
i
ing acceptable to the board.
(6)
This period of specialized
preparation
shall
include:
(1)
Graduate
training
in
pathologic
anatomy,
radiophysics,
and
radlobiology
;
(2) An
active
experience
of not
less
than
24 months
in
a
radio
logical
department
recognized
by
the
board
and
the council
as capable of providing
satisfactory
training;
(3)
Examination
in
the
basic
sciences of
radiology
as
well
as
In
the clinical aspects thereof.
In case of an applicant whose training
has been received outside of
the United States and Canada,
the credentials
must be satisfactory to
the advisory board for medical
specialties.
AMERICAN
COLLEGE OF HOSPITAL
ADMINISTRATORS
The Bureau is in receipt of the
1998 Directory
of the American
College of Hospital
Administrators,
and
a letter from its executive
secretary
relative to membership
in this organization.
Among the objectives of this organization are to provide, through
various
classes of
membership,
opportunities
for
enlarging
their
knowledge
in the
field of hospital
administration
for individuals
who desire
to follow
careers in this field of special
service
and
to
provide through
the conferring
of fellowships
for the recognition
•Radiology,
29:
734,
1937.
420
NOTES
AND COMMENTS
of individuals
who
have
done or are doing noteworthy
service
in
the field of hospital administration.
Membership
In order to qualify
for election
as
a member
the candidate
must
submit evidence of having had
5 years of successful
experience
as a
hospital administrator.
At the time of election
the candidate
must
be the chief administrative
officer of
a hospital of not
less than
50
beds, or the assistant
administrative
officer of a hospital of not
less
than 200 beds.
The hospital with which
the candidate
serves, if in the United
States or Canada,
must
be registered
by the American Medical Asso
ciation and/or
approved
by the American College of Surgeons.
The candidate
must hold membership
in local,
State
or regional,
and American hospital associations.
Such
membership
may
be per
sonal or through the institutional
membership
of his or her hospital.
The candidate
must present evidence of interest
and participation
in local,
State or regional, and national hospital activities.
The candidate
must present evidence of good moral character
and
ethical conduct.
The candidate
must
present
evidence of having had
an adequate
academic
education
as
represented
by
graduation
from
a
college,
university,
or
professional
school,
or
must
present
evidence
of
equivalent
preparation.
The
candidate
must
submit
an
application
setting
forth
his or
her qualifications and giving the names of five acceptable
references,
two
of
whom,
at
least, shall
be either
members
or fellows
of
the
College.
Initiation fee $25, annual
dues $20.
Felm>wship
In order to qualify
for election
as
a fellow
the candidate
must
have
been
a member
in good standing for at least 3 years.
At the time of election
the candidate
must
be the chief adminis
trative officer of
a hospital of at least
100 bed capacity
or the assist
ant administrative officer of
a hospital of at least 300 bed capacity.
In all other respects the qualifications prescribed
for members shall
apply also to candidates for fellowship.
Hospital
administrators of recognized
standing and who have had
at least
10 years of successful
experience
as the responsible
executive
officer of
a hospital may
be, until January 1, 1940, upon
the recom
mendation
of the credentials
committee, elected to fellowship directly.
Initiation fee $50, annual
dues $25.
NOTES
AND
COMMENTS
421
NEW NAVAL MEDICAL
CENTER
Encouraging
progress
has
been
made for the constuction
of the
new Naval Medical Center in Washington.
In April
1938 the Presi
dent approved the Navy Appropriation
bill which carried authoriza
tion for the purchase
of the land and construction
of the buildings
for this project.
The sum of $450,000
will
be available
during
the
fiscal year 1939 for purchase of site and preparation of plans.
The
ultimate
cost is limited to $4,850,000.
The Naval Medical Center will
provide facilities for the medical
school, dental
school, and hospital.
Suggestions
are solicited
for planning
and equipment
of the new
buildings.
Medical
and
dental
officers,
pharmacists,
nurses,
and
hospital corpsmen
are requested to submit
their ideas on faulty
de
tails of present buildings or equipment,
or features
which would be
desirable in the new institution.
Send them to the Officer in Charge
of
Hospital
Planning.
Bureau
of
Medicine
and
Surgery.
This
important
detail
has been
assigned
to Captain Lucius
W. Johnson,
Medical Corps, United
States
Navy, who
has recently
reported
for
this duty following
detachment
as Executive
Officer
of the U.
S.
Naval Hospital, San Diego. California.
COMMITTEE
TO STUDY
SERODIAGNOSTIC
TESTS
FOR SYPHILIS
Plans
are being
developed
by
the American
Society
of Clinical
Pathologists
and the U.
S. Public
Health
Service
for an assembly
of laboratory workers from the entire country to study serodiagnostic
tests for syphilis.
The proposed
meeting,
under
the auspices of the
Committee
on Evaluation
of Serodiagnostic Tests for Syphilis, with
•Surgeon
General
Thomas Parran. chairman,
is scheduled for October
21 and 22, 1938, at Hot Springs National Park, Arkansas.
The amis and purposes
of the assembly will be to consider
means
and methods
to improve and
to make
more
generally
available the
serologic
tests, which
are
so
important
in syphilis
control
work.
The intensive
campaign
to
stop
the
spread
of syphilis
nowT
being
waged throughout the country makes it imperative
that only those
serologic
tests of proved
efficiency be made available
to private phy
sicians and health
officers.
Diagnosis of syphilis must be prompt and
accurate.
The serologic
blood
test,
becoming
positive within two or
three weeks after the onset
of primary syphilis
and remaining posi
tive in the vast majority of untreated
patients
throughout the entire
course of the disease, is the most important evidence of the existences
of syphilis.
Tentative arrangements
call for the presentation
of the
program
in four sections.
The first section will consider
the
need for adherence
to conven
tional
technic
in the routine performance
of reliable serodiagnostic
tests.
This subject will be considered in papers by Drs. Harry Eagle,
422
NOTES
AND COMMENTS
William A. Hinton,
Reuben
Kahn,
Benjamin
Kline,
and John H.
Kolmer,
with
special
reference
to
the
tests
which
each of
these
workers has described.
Need for training
of laboratory
personnel
will
be the subject of
the
second
section.
The qualifications
and
training
for both lab
oratory directors and technicians
will be presented in separate papers.
The third section will discuss the prosecution
of the studies to eval
uate the performance
of serologic
tests within
the States.
The effi
ciency of branch
State laboratories and of municipal, hospital, and
private laboratories cannot
be studied
on a national basis.
The sub
ject is much
too large.
Should this be made a function of the State
or large
municipal
department
of health?
Actual
experience
with
such studies in the States of Maryland
and New Jersey
and in the
city of Cleveland will be described.
The fourth
section will
consider
the desirability
of licensing or
approving for the performance of serodiagnostic
tests for syphilis,
laboratories within
the
States
by
the
respective
State
departments
of health.
This discussion
will be conducted
from the standpoint of
the private laboratory director by Dr. Frederick H. Lamb of Daven
port, Iowa.
The
health
officer's
side will
be
presented
by Dr. A.
Wadsworth,
State
Department of Health,
Albany,
New York.
Committees
from each of the four sections will draft recommenda
tions for presentation
to the assembly.
General discussion
will fol
low the presentation
of each set of recommendations.
An additional feature
of the meeting will be an actual
demonstra
tion of the
performance
of
the Eagle,
Hinton,
Kahn, Kline,
and
Kolmer
tests by the originators of these procedures.
The work of the Committee
on Evaluation
of Serodiagnostic Tests
for Syphilis
is sufficiently
well known to
require
no comment.
It
is the opinion of this
Committee
that its studies of the efficiency of
the performance
of serologic
tests have progressed
to a point where
material gains would be made by
a thorough discussion
on common
ground in which all those interested in the control of syphilis through
laboratory methods
may participate.
BOOK NOTICES
Publishers
submitting
books for review
are requested
to
address
them as follows:
The Editor, United States Naval Medical Bulletin.
Bureau of Medicine and Surgery, Navy Department,
Washington, D. C.
Atlas op Hematology,
by Edwin E.
Osgood.
M. A.. M. D., Assistant
Professor
of Medicine and Head of Experimental
Medicine
and by Clarice
M. Ash worth,
Medical Illustrator,
both
of the University
of Oregon, First edition,
225 pages,
illustrated.
J. W.
Stacey,
Inc.,
San Francisco,
1937.
The price of this Atlas
is $10.00
and not $15.00
as reported
in the
April issue of the Bulletin.
Practical
Tropical
Sanitation,
by
./.
Balfour
Kirk,
U.
D.,
M.
B.,
Ch.
B.,
M.
R.
C.
P.,
D.
P.
U.,
D.
T.
M., d H. Director.
The
Medical
and
Health
Department,
Mauritius.
This book is convenient
in size and form, and contains
much that is
condensed from the author's
larger work, "Public Health Practice in
the Tropics."
The author has
succeeded admirably
in his purpose
of
putting
into
a
moderately
priced
book
in
the
English
language
material
suitable for the use of sanitary inspectors
working in the tropics.
The
book
might
further
be
reduced
in price by eliminating
the
first
two
chapters,
as the subject
matter
covered
in them
is easily
accessible
from other
sources.
In discussing the abuse of disinfectants Dr. Kirk
makes the fol
lowing
characteristic remarks.
"The
application
of disinfectants
is
no
substitute
for
cleanliness."
"Much
money
is
wasted
annually
in
the
disinfection
of
places
which
really
need
only
ordinary
cleansing."
Illustrations
are adequate and well chosen.
Oeoanization, Strategy,
and Tactics
of the Army Medical
Services
in War,
by
T.
B.
Nicholls,
M.
B..
Ch.
B.,
Lt.
Col.
Royal
Army
Medical
Corps.
William Wood
& Co., Baltimore,
Md., 1937.
Price
$4.
A comprehensive
selection
of medical
information
has been pre
pared by the author so as to provide a source of ready
reference for
the medical
officer.
Various
field
medical
problems
and their solu
423
424
BOOK NOTICES
tions are presented.
Much of the data are based largely upon actual
experiences in the World War, which renders
a book of this type of
great practical value.
The book is divided into four sections.
Part I. General Organization and Administration.
This part deals
with
general
organization
and administration
and
gives
the reader
a working
knowledge
of staff organization
and function.
It thor
oughly covers the general principles of war as applied to the medical
service, such
as orders,
reports,
returns,
casualty
estimates,
and
the
factors of time, space, and transport.
Part II. The Medical Units, Their Composition, Organization, and
Administration.
The composition,
organization,
and
equipment
of
each medical
unit is described.
The discussion
of each unit is taken
up
systematically
under headings
such
as
site,
capacity,
strength,
load
tables, organization, duties,
etc.
In this section hospital ships
are classified
and their tactical employment
is discussed.
One of the
most
useful
portions of
part
two
is
the
chapter
entitled
"Useful
Data," which contains
load tables, experience
tables,
etc.
Part III. Medical Tactics and Strategy.
This part is very instruc
tive in that it deals with the "big picture."
The duties of a staff medi
cal officer are painstakingly enumerated under the following
captions
:
The Strategical Reconnaissance
of the Base; The Embarkation;
The
Disembarkation;
The Strategical Concentration;
Approach March;
Contact with the Enemy ; and The Battle.
Part IV. A Selection
of Exercises
and Problems to illustrate the
above.
Part IV consists of several
problems
and exercises,
some of
which are solved and others which are left without solution as mate
rial for exercise.
The examples are complete and include an Appre
ciation of the Situation, a plan and appendices
(Annexes
are : Strength
of Force; Calculation of Sick;
Calculation of Number
of Wounded;
Table of Medical Units Required ; Table of Priority of Embarkation
;
Table of Extra Stores; and Methods of Evacuation.
The book as a whole is an excellent
one and is by far the most com
prehensive work on this subject that the reviewer has had the pleasure
of studying.
It would be more convenient
to
a foreign
reader if a
glossary of British medical abbreviations
and terms were incorporated.
As
a
matter
of
comparative
interest
it
is
noted
that
the British
"Appreciation
of the Situation"
parallels the American "Estimate of
the Situation" in phraseology
and procedure.
THE DIVISION
OF PREVENTIVE MEDICINE
Commander
C.
S. Stephenson.
Medical
Corps. United
States Navy,
in charge.
THE
EFFECT
OF THE
AGE
OF NEOARSPHENAMINE
ON REACTION
EXPECTANCY
By Commander
C.
S. Stephknson,1
Medical
Corps. United
States
Navy, Associate
Pharma
cologist
T.
F.
Probey,2
and
Senior
Surgeon
W.
T.
Harrison,'
United
States
Public
Health Service.
In a recent study
by Probey and Harrison
3 the stability of neo-
arsphenamine
is reported
to be affected adversely
by the age of the
material and by incomplete
drying
of the powder.
The percentage
of lots showing evidence of deterioration increased
as one, or both,
of these factors became
greater.
Although
animal toxicity
was not
investigated,
insolubility
being
the sole criterion of instability,
the
findings suggested the advisability of ascertaining
what
effect age of
the material
might have as a contributing factor in clinical reactions
following neoarsphenamine
therapy.
Roth
4 reported
that changes in the physicochemical
character
of
neoarsphenamine
were not accompanied
necessarily
by an increase in
animal toxicity and that an increase in animal toxicity was apparent
in material showing no evidence of deterioration.
The material was
under 3 years old.
Kolmer
5 noted that cloudy or opalescent
solutions
of neoarsphen
amine are invariably
more toxic for the lower animals
and man than
the perfectly clear solutions.
Probey and Harrison's
study
of the stability of neoarsphenamine
included
638 different lots ranging in
age
from
1 to 7 years.
De
terioration was noted in
15 percent of the 1-year-old
lots and
as the
age increased the percentage
increased to 66 percent of the 7-year-old
material.
Deterioration
of
neoarsphenamine
may
be
classified
as
being
of
two types: one with physicochemical
changes which may
be accom-
1Division
of Preventive
Medicine,
Bureau
of Medicine
and Surgery.
'National
Institute of Health.
• Probey,
T.
F.,
and Harrison.
W. T.
The
Effect
of
Moisture
and
Age
on
Stability
of
Neoarsphenamine.
Reported
on p. 429 of this issue.
* Roth,
G.
B.
Keeping
Qualities
of
Market
Samples
of
Neoarsphenamine
while
in
Ampule.
Pub. Health
Rep., 30:
2523
(October
14, 1921).
•Kolmer,
J.
A.
Chemotherapy,
p.
629.
Wm. B.
Saunders
Co.,
Philadelphia
(1920).
425
426
DIVISION
OF
PREVENTIVE
MEDICINE
panied by increased animal toxicity, and another in which the toxicity
has increased without evidence of physical change.
The former type
with visible physical evidence of deterioration offers
no problem to
the clinician, but the latter, which cannot
be detected by examination
of the powder or the solution,
is of importance
as it may be reflected
in the reaction
expectancy.
Unfortunately,
it is extremely
difficult
to show slight toxic change by the animal test unless very extensive tests
are made using a large number of animals and, moreover, it would be
difficult to interpret these findings in terms of human
toxicity.
The
only practical means of determining the actual
influence of this type
of deterioration is by an extensive clinical study.
An investigation showing the relation of age of the material
as
a
possible
factor in reactions
following
neoarsphenamine
therapy can
only be accomplished
with the cooperation
of a service with extensive
clinical material and the laboratory charged
with the official control
of the arsphenamines.
Since
1924 the medical
officers of the United
States Navy 8 have been
required
to report
all arsenical
administra
tions
and
to report
separately,
in detail, each
case of unfavorable
reaction
following
arsenical
therapy.
During
the
12-year
period
1925-3G
administration of
1,087,083
doses of neoarsphenamine
have
been recorded
with
854 reactions of all types,
the incidence
being
1
reaction
to every 1.272 injections.6
The National Institute of Health,
charged
with the administration of the arsphenamine
control, has
a
record of every lot of the several licensed arsphenamines
available for
clinical
use, including
the date that each lot was officially released
for distribution.
Only
this institute has the information
necessary
to identify
the age of every lot of the arsphenamines
in clinical
use
in the United States.
The clinical reports of the United
States Navy of all neoarsphena
mine
therapy for
the
5-year
period
1933-37, inclusive, were
taken
for study.
These
records
were
investigated
for all essential
infor
mation and
then
the
age of each lot
of neoarsphenamine
adminis
tered was ascertained
by the National Institute of Health.
The clin
ical reports were
classified
according to the year of administration
and the age of each lot was estimated
by the year of official
release,
i.
e.,
material
released
in
1935
and
administered
during
1937
is
recorded
as having an average age of 2 years.
Since the
material
is
taken
entirely
from
United
States
Navy
records and represents all neoarsphenamine
administered
by all of its
medical
services during
a continuous
period
of
five years,
it is
as
sumed that all other factors which might influence
the reaction ratio
• Stephenson.
C.
S.,
and
WIngo,
E.
H.
Toxic
Effects
of
Arsenical
Compounds
as
Ad
ministered
in
the United
States Navy
in
1D3G with
Special
Reference
to Arsenical
Derma
titis.
U.
8. Naval
Med. Bull.,
38:
517
(October
1937).
XEOARSPHENAMINE
STEPHENSON,
HARRISON AND PROBEY 427
are fairly constant.
During this period no essential change has been
made in the management
of antisyphilitic
therapy.
The material covered
(table
1)
comprises
all the neoarsphenamine
administered during the 5-year
period.
The clinical
record for each
year is detailed
separately,
showing the age of the material by years
with the number of doses administered
and the reactions.
The totals
give the summary for the entire period showing the number of doses
and
reactions
with
the reaction
expectancy
according
to the age of
the material.
The
total
number
of
administrations
was
541,381,
representing
326 lots of 3 different manufacturers.
The reactions
recorded
were
426, and
were classified
according
to severity
as mild, 270;
severe,
140;
and
deaths,
16.
The
reaction
expectancy
is
1 to
1,270
doses,
which is in agreement with
a previous
United States Navy report of
1 to every
1,272
doses.6
The reaction
expectancy
increases
as the
age of the material in
creases, excepting
lots with
an average
age of
3 years which
show
a slight
decrease.
The material with
an average
age
not in excess
of 3 years shows
a reaction
expectancy
of
1 to
1.312
doses
as com
pared with the ratio of 1 in 870 doses in material older
than
3 years,
an increase
of approximately
65 percent.
Analysis
of
541,381
human
doses
of
neoarsphenamine
from
all
medical services of the United
States Navy over a continuous
5-year
period shows that the reaction
expectancy
increases with the
age of
the
material.
This clinical
experience
agrees with
the
laboratory
observation that neoarsphenamine
changes with
age.
• See
footnote
on
p.
426.
428
DIVISION
OF
PREVENTIVE
MEDICINE
a
-
3
H—
1a
O
'A
c
-r
11
3
g!2
i
|
I
I
3
3
|
1
!
i
>
!
I
11
2
00
pH
j
r-
i
1
{
! i
s
i
1
?*
11
?,
1
1
SiiSg
1
I
1
a"
i
:
i
!
?,
:
!
11
E2S2*1
7
i
1
J.
i
§
11
i
|
I
1
I mns
=
1
253 = = '" i
11
§
I
1
!
:
1
a»g'2
3
j
11
iM " —'
'e
|
!
I
4,514
^
2
£27'
8'2
"i
i
'I
i
is"-i"
?5
:
!
MUd
Fatal
Year of clinical
use
1'33-'7 (totals"
'evere
Reaction
'tio
to
doses 1.
1
Reactions:
5:
2g
NEOARSPHENAMINE
—PROBEY AND HARRISON
429
THE
EFFECT
OF MOISTURE
AND
AGE
ON STABILITY
OF
NEOARSPHENAMINE
'
By Associate
Pharmacologist
T. F. Probet,1
and Senior
Surgeon W. T. Harrison,1 United
States Public Health
Service,
Washington,
D.
C.
The instability
of the arsphenamines,
especially
neoarsphenamine,
has
been
recognized
since they
were first developed.
To retard
as
far as possible
deterioration of neoarsphenamine
the United
States
Pharmacopoeia recommends
as follows : 8
Preserve
neoarsphenamine
iu
.sealed
tubes
of colorless
glass, from
which
the
air has been excluded either
by
the
production
of a vacuum or by displacement
with
a nonoxldizing
gas,
iu a cool
place,
preferably
not
above
10° C.
From
time
to
time,
the
National
Institute
of
Health
has
been
requested to reexamine
certain
lots of the arsphenamines
ranging in
age up to
15 years from date of manufacture.
Although
arsphena-
mine is relatively stable, the institute would be reluctant to recommend
use of
any
member
of
the
arsephenamine
group,
however
stable,
of such
unusual
age.
These
instances
illustrate
that it is possible
for the more unstable
arsphenamines
of this age to be available for
clinical
use.
This suggests the advisability
of restudy
of the entire
question
with reference to the adoption of an expiration date.
Because
neoarsphenamine
is generally considered
the least
stable
of the group, and
because
it is the most widely used, it was deemed
advisable first to concentrate
the investigation
on this drug rather
than attempt
a general
survey
of all the arsphenamines.
The
per
centage of lots of neoarsphenamine
which showed evidence of deterio
ration
by the survey
was surprisingly
high, indicating
that
a com
prehensive
study
was necessary to determine
the time limitation
for
neoarsphenamine
and to ascertain, if possible,
the factors which may
influence
this stability.
These factors
may be numerous,
especially
those of chemical origin
due to its delicate,
indefinite
structure,
but the physical factors, such
as storage, age, temperature,
dryness of the powder,
etc.. are to a large
extent controllable and reducible
to the minimum of effect.
Protec
tion against
deterioration due to exposure
to air, improper storage,
and
temperatures
are accounted
for by the provision referred to in
the United States Pharmacopoeia and generally followed and recom
mended by all manufacturers.
The effect
of age of the product and
incomplete
drying of the powder
were considered of principal impor
tance in this investigation.
Roth,4
1921, recorded
that neoarsphenamine
was unstable
and that
deterioration is a general
phenomenon
which may occur
in all prod-
1 Published
concurrently
In the Public
Health
Reports.
' National
Institute
of Health.
' Neoarsphenamine.
IJ. S. Pharmacopoeia,
p.
240.
' Roth,
G.
B.
Keeping
Qualities
of
Market
Samples
of
Neoarsphenamine
while
ln
Ampule.
Pub. Health
Rep., Sfli
2T,2-\ fOctober
14, 1921).
430
DIVISION
OF
PREVENTIVE
MEDICINE
ucts.
His experience with material
at the Hygienic Laboratory
(now
National Institute
of Health)
was that
2o to 30 percent of material
2 years old from two manufacturers had
become
insoluble.
It was
also recorded
that similar
experiences
were noted with products of
other countries.
Van den Branden and Dumont,"
1933, called
atten
tion to the influence
of time and
temperature
upon
the stability
of
neoarsphenamine.
Kolmer" recorded
changes in the powder
but
was of the opinion
that such changes were present in only a few ampules of a lot, found
only in 5 to 12 percent of the ampules.
He suggested the probability
that such deterioration was due to defective
handling
and ampuling.
The possible influence of "moisture" as a cause of deterioration was
noted by Roth
T in one sample of neoarsphenamine
consisting of two
different shipments,
one drier than the other.
The drier sample was
satisfactory
after
some
14 months,
whereas
the
other
sample
was
insoluble.
Kolmer6
called
attention
to humidity
at the time of ampuling
as
a possible factor in causing deterioration of neoarsphenamine.
The loss in weight
due to drying of the arsphenamines,
especially
arsphenamine,
was
recorded
as early
as
1911
by
Garbel.8
Subse
quently,
considerable
work was reported
and the nature
of the vola
tile substances
was discussed
extensively.
The loss in weight after
drying
neoarsphenamine
was
recorded
by Raiziss
and
Falkov9
as
varying from 3.63 percent
to 4.46 percent
(four samples).
Myers1"
reported
the loss for the other
salvarsan
substitutes
was practically
the same
as the reported
7.5 percent for salvarsan.
The material tested consisted of samples of neoarsphenamine
rou
tinely submitted
to the National Institute of Health for official
test
in
compliance
with
the
arsphenamine
regulations,11
during
the
8-year period from 1930-37. inclusive, and
a few samples of foreign
material, purchased
or obtained
by courtesy directly from the manu
facturers.
There were 1,004 different lot numbers of neoarsphenamine
examined.
* Van
den
Branden,
F..
and Dumont,
P.
Influense
Sunultanee
du
Temps
et
de la Tem
perature
sur la Conservation
des
914 Conserves en Ampule.
Ann.
Soc.
Beige de Med. Trop.,
13i
455-471
fDecember
31,
1933).
• Kolmer,
J. A.
Chemotherapy,
p.
629
W. B. Saunders
and Co..
Philadelphia,
1926.
' Roth,
O.
B.
The
Deterioration
of
Neoarsphenamine.
J. Am.
Med. Assn.,
T8:
1191
(April
22, 1922).
Also
see Reference No.
4.
* Garbel.
G.
O.
Die Quantitative
Zusammensetzung
des
Salvarsans.
Apotheku
zeitung,
26:
215
(November
22,
1911).
• Raiziss,
G.
W.,
and
Falkov,
M.
Chemistry
of Neoarsphenamine
and
Its
Relation
to
Toxicity.
J. Biol.
Chem.,
4«:
209
(March
1921).
"Myers,
C.
N.
Development
of
the
Chemotherapy
of
Organic
Arsenlcals
and
the
Related
Physical
Properties.
J. Lab. and Clin.
Med., 7:
17
(October
1921).
u Regulations
for
the
Control
of
the
Manufacture.
Importation,
and
Sale
by
Arsphena
mine and
its Derivatives.
Mis.
Pub.
22.
U.
S. Pub.
Health
Serv.
NEOARSPHENAMINE
—PROBEY AND HARRISON
431
The
products of
seven
manufacturers holding
American
license
make up the bulk of the material.
All lots of several manufacturers
were tested and for each of the others,
some
20 different
lots from
each year were picked
at random,
representing
even distribution
as
to the season of the year of manufacture.
The material representing
the period from
1930
to
1936, inclusive,
1 to 7 years old, consisted
of
638 different lot numbers.
The
326
lots
of
the current
(1937)
material
represented
practically
all lots
received for official
test.
All
material, except
1937
samples
tested
at
the
time
of
receipt
for official
test and
recorded
as current lots,
has
been
stored
in
a
basement room below ground level on the north side of a stone build
ing.
This storage
is considered
as being
better than average
store
room conditions with temperature
slightly
lower than 20°
C.
The foreign material was represented
by
40 different lot numbers
of neoarsphenamine
from
13 manufacturers
located in
8 countries.
Of the 40 lots,
31 may
be considered
as current material.
The re
maining
nine lots were old samples
from
the file of this institute.
The
evidence of stability
in this investigation
is
based entirely
upon solubility, i. e., the powder must
be completely
soluble
and the
solution clear and transparent
in a 10 percent
solution.12
The moisture
content is defined
as the loss in weight
caused by the
extraction of volatile substances by drying in vacuo over phosphorous
pentoxide
for 24 hours,
recorded in the percentage which the weight
loss bears to the original
weight.
The identification of the volatile
material is of no importance
in this study.
The
method
employed
consisted
of
exposing
approximately
0.9
gram of neoarsphenamine
in a weighing bottle of 25 millimeters di
ameter over fresh pentoxide in a vacuum desiccator of 250 millimeters
diameter,
at less
than
5 millimeters pressure,
for
24 hours
at room
temperature.
The pentoxide
was exposed in a 150-millimeter
culture
dish and was renewed for each batch of samples.
The procedure
per
mitted determinations
of not more than
15 samples at one time in a
desiccator.
This method
does not
reduce
the material to constant
weight, as was determined
by longer exposure,
but in order
to keep
the test simple and within reasonable time limits the time of exposure
to drying was fixed at 24 hours.
Adjustments can be made to obtain
constant
weight
but the additional time and necessary weighings
offer
no practical improvement
in the test
except to obtain
the loss com
puted
on dryness
to constant
weight
which would be slightly higher
than figures based on 24 hours of drying.
The moisture
content
of the
1,004 lots
detailed
in table
1 varied
from
less
than
0.5 percent
to
14.0 percent, only
4 lots
were greater
a Preparation
and Administration
of Arspbenamine
and Neoarsphenamine.
Pub. Health
Rep., 37:
1867
(August
i, 1922).
432
DIVISION
OF
PREVENTIVE
MEDICINE
than
7.0 percent, approximately 75 percent
1755 lots) were under 3.0
percent, and 43 percent
(426 lots) under
1.0 percent.
The distribution
of the material according to
age, previously described,
consisted
of
638 lots received during
1930 to
1936, inclusive, detailed
in table
2,
by age from
1 to 7 years,
326 lots received during current year, and
.40 lots of foreign manufacture which, except for
a few batches, is of
unknown date but believed
to be in current clinical
use.
The current
(1937) lots received from the manufacturers for official
test
were examined
at the time of their receipt.
All of the 326 lots
examined
were satisfactory.
The moisture
content
varied
from less
than 0.5 to 6.0 percent, only eight lots contained
more than 3.5 percent,
and approximately 64 percent
were under
1.5 percent.
Inasmuch
as
these
lots are not classifiable
by
age or instability
they
are included
only in table
1, giving the total lots tested with moisture
distribution.
The moisture
content of the 40 lots of foreign manufacture
indicated
considerable
variation
in
the
amount
of volatile material
present.
There
was insufficient
material,
however, for satisfactory comparative
appraisal.
The age of these lots not being definitely known, they are
recorded only in table
1.
In table 2 is detailed
the record of the 638 different
lot numbers of
neoarsphenamine
from
seven
different
licensed
manufacturers
re
ceived during the 7-year period
from 1930 to 1936, inclusive.
It will
be noted that
the stability of neoarsphenamine
is affected by age and
moisture
content,
deterioration
being
directly proportional
to
these
influencing factors.
As one or both
increases
the percentage
of in
stability
likewise
increases.
The influence of the age of the product, without consideration
of the
moisture
content,
is detailed
on the bottom
line of totals.
There it
will
be
seen
that
the unsatisfactory
lots
increased
from
15
percent
(14 of 92 lots)
in the 1-year old material to 66 percent
(68 of
103 lots)
in the material 7 years old.
The instability of neoarsphenamine
pro
gressively
increases as the age increases.
The effect of the moisture
content on stability without regard to the
age of the drug is shown in the last column — 1 to 7 years.
The record
clearly demonstrates
that as the moisture
content
increases
the sta
bility decreases,
for example,
all of the
12 lots having
less
than
0.5
percent
moisture
were stable, but
as the moisture
increased
the per
centage of stable lots decreased to zero at the 5.0 percent moisture level.
The deterioration due to age at a definite moisture
level or the effect
of moisture
for a specific period,
can be determined
by study of table
2.
The percentage of instability increases in both directions as the in
fluencing
factors increase, except that at the 0.5 percent moisture
level
all products
were satisfactory.
It is indicated
that
instability
of neoarsphenamine
is common
in
products after 2 years with a moisture
content in excess of 2.5 percent,
NEOARSPHENAMINE
PROBEY AND HARRISON
433
after
3 years with 2.0 percent moisture
content, and that after 4 years
only an extremely
dry product
(less than 0.5 percent
moisture)
may
remain stable.
Analysis of the report of the stability of the products
from
1 to 3
years old indicates
that there is little difference
in the deterioration at
the
0 to 1.5 percent
as compared
with the 0 to 2.0 percent
moisture
level, the former records 98 percent stable as compared with 96 percent
of the latter group.
The small number of lots at these two moisture
levels in the 3-year-
age period available
for study
does
not
permit
a definite
appraisal
of comparative
stability.
It is felt, however,
that in the interest of
safety the lower moisture
content should
be recommended
as being in
conformity with the general observation
that instability increases with
the moisture
content.
The adjustments
necessary for the manufacturers to produce
a prod
uct of low moisture
content are apparently not difficult to accomplish.
The several licensed manufacturers have been apprised
of these find
ings and
have proceeded
to accomplish
this objective.
The samples
received
during
the current year
are approximately
equally
divided
into two groups: the early products
before the results of the moisture
study were known and the latter products during
and after adjust
ment.
In the former group, approximately
48 percent
were under
1.5 percent moisture
content
whereas of the latter group
76 percent
are in this classification.
Recently this percentage has been materially
increased
and
now only
the
occasional
sample
is higher
than
1.5
percent.
Conclusions
This investigation indicates
that the stability of neoarsphenamine
is
affected by the age of the product
and by the moisture
retained
in the
powder and that instability increases directly as one, or both, of these
influences
are increased.
Neoarsphenamine
containing not more than
1.5 percent volatile material as determined
by the method
herein
de
scribed
may
be expected to remain
stable for
3 years when
stored
at
a temperature
slightly
less than 20° Centigrade.
Table 1.— Moisture
content distribution —1,00't lots of neoarsphenamine
Moisture content in percentage
dumber
of lots
Moisture content
in percentage
Number
of lots
0.0 to 0.8
33
191
202
136
108
85
78
57
47
4.5 to 5.0. . .
28
11
15
7
2
4
0.5 to 1.0
5.0 to 5.5. . . .
1.0 to 1.5
5.5 to 6.0
1.5 to 2.0
6.0 to 6.5
2.0 to 2.5
6.5 to 7.0
2.5 to 3.0
7.0 to 14.0
3.0 to 3.5
3.5 to 4.0
Total
...
1,004
4.0 to 4.5
64743—38
8
434
DIVISION
OF
PREVENTIVE
MEDICINE
=22
— 2S
a. £
5 S
r-it- r- io -r c-*iM
3*
r--o —,»o S3
=-
-5
OOMiQ
e*o
COW
COM
S'i
3 2?i?s
53
-.iOt-fCS ———.oooo
M -r
J
c -
- 2
z.a
.-2
- 2
« « >ckj « c rt r- ?i c
O
r- f- - r- M M T r- - 3
53 « po
35
1<s
- 31-f
ro« eo
i -
IIil
3 i
i.~3 c; o io
u
S3S3S33S3t
ct o -o a r-
e
a "a
232323
3838
§
o 6- —0-
^
1NSECTICIDAL
POWDERS
JOHNSON
AND VALLEE
435
INSECTICIDAL
POWDERS,
A
COMPARATIVE
STUDY1
By
Commander
F.
S.
Johnson,
Medical
Corps,
United
States
Navy,
with the
technical
assistance
of Pharmacist's
Mate,
first
class, A.
G. Vallee,
United
States
Navy
Crowded living conditions provide a market without
a dull
season
for an ant and roach killer which will do a thorough job.
Immensely
important is the fact that there are now available
preparations which
,can be effectively
employed
against
insects without
an
objectionable
or harmful
residue remaining to endanger
public health.
Sodium
Fluoride
Sodium fluoride, as
a constituent
of powders,
has been
one of the
xnost widely employed
insecticides.
The toxic properties
of sodium
fluoride have not been generally appreciated,
and it is probable
that
many
cases
of
poisoning with
this
compound
have
passed
unrec
ognized.
The
accidental
and suicidal
ingestion
of
insect
powders,
and chronic poisoning from contaminated
water supplies,
have estab
lished the fluorides as constituting
a definite
public
health
hazard.
The widespread
use of sodium fluoride in insect control makes it im
perative
that
all
be
aware
of
the
poisonous
properties
of
this
chemical.
It has become
increasingly apparent
in Europe, due largely to the
researches of Christiani,2 that the continued
ingestion
of small quan
tities of the salts of fluorine produces in animals
and in man
a clin
ical state evidenced
by cachexia,
anemia, fragility of bones, stiffness
of the joints, and respiratory paralysis in the fatal cases.
From the
mining of creolite, which is a fluoride of sodium
and aluminum with
quartz, workers principally
in Scandinavia and Canada
are exposed
to the hazard of swallowing
the dust.
Flemming-M0ller
and Guil-
jonsson
s have
made
a
remarkable
roentgenographs
demonstration
of bone changes occurring in these
workers.
They found the symp
toms
described
as
resulting
from
the
ingestion
of
fluorine
salts
exactly reflected in the creolite
workers.
Opacity of the bones and
calcification of the ligamentous
attachments
were in rough proportion
to the length
of employment
in this work.
There were silicotic
le
sions from the inhalation of the quartz
contained
in the dust of the
ore, gastric irritation from swallowing
the dust
(fluorine intoxica
tion), and
anemia
attributed to destruction
of
bone marrow.
The
1 From
the laboratories
of the United
States Naval
Medical
School, Washington,
D. C.
A
companion
article
on
liquid
Insecticides
by
the
same
authors
was
published
in
the
July
1937
Bulletin.
» Christiani,
H. :
Detection
and
Prevention
of
Flourine
Poisoning,
Presse
med.,
35 :
578,
1927.
Christiani,
H.,
and
Chausse,
P. : Chronic
Poisoning
from
Small
Doses
of
Sodium
Flourlde,
Compt. Rend.
Soc.
de Biol..
96 : 343,
1927.
• Flemming-M011er,
P.,
and
Gudjonsson,
Sk. V. : Massive
Flourosls
of Bones and Liga
ments, Acta
Itadlol.,
13 :
269,
1932.
436
DIVISlON
OF
PREVENTIVE
MEDICINE
authors
concluded
that
the
osseous
changes
observed
in
these
cases
were due to the fluorine contained
in the creolite.
In
America,
Reynolds,
Ross,
and
Jacob
4
have
estimated
that
90,000 tons of pure fluorine are added to the soil of this country each
year.
This is occasioned
by the extensive
use of phosphate
rock in
the
manufacture
of
superphosphate
fertilizers.
Phosphate
rock
contains
about
4 percent of fluorine.
Bishop
6 has recently
reported
pronounced
bone changes
in
a worker who handled
this powdered
rock.
It is also important to note that baking powder may
contain
perceptible
amounts
of fluorine,
since,
as Bishop
has pointed out,
rock
phosphate
has been
used extensively
as
a source of phosphates
in the manufacture
of baking powder.
The first report of dental
fluorosis
was made about
35 years
ago
by
Eager,0
a
public
health
officer
then
stationed
at
the
port
of
Naples in Italy, who noted
a permanent
discoloration of the teeth of
Italian emigrants
from
certain
communities,
and
in his report
he
commented
on the possibility of some toxic element in the drinking
water acting as the causative
agent.
A similar affection of the dental
enamel was first reported
in the United
States in
1916 by Black and
McKay,7
who
described
the condition
as "mottled enamel,"
distin
guished
pathologically
by
the
absence
of
cementing
substance
be
tween the enamel rods.
In 1931. Smith, Lantz, and Smith
8 produced
the
same
condition experimentally
in
rats
by feeding them
sodium
fluoride.
Since
then this condition has been
frequently reported
in
the
United
States.
Recent
studies
conducted
by
the
Ohio
State
Department
of Health
6 have
revealed
that
48 communities
in that
State have public water supplies containing toxic amounts of fluoride,
and that dental fluorosis
is endemic in these areas.
A
significant
experimental
study
was
reported
by
Brandl
and
Tappeiner
10 in
1891.
They fed sodium fluoride to a dog in increas
ing doses
from
0.1 to
1.0 gram
per
24 hours
over
a period of some
weeks
and
reported
that
the Haversian
canals
became
completely
filled with
crystals of calcium
fluoride,
and
that
the
ligamentous
' Reynolds,
P.
S..
Ifoss,
W. H.,
and
Jacob.
L.
D. : The Fluorine Content
of Phosphate-
Rock. J. Ass. Agr.
('hem..
2 : 237,
1028.
* Bishop.
P. A.:
Hone Changes in Chronic
Fluorine Intoxication,
Am. J.
Roent.
&
Rad.
Therap..
35 : 577,
1936.
•Eager,
J. M. : Denti
di Chiaie.
Pub.
Health
Rep., vol.
16,
No.
44, November
1901.
7 Black.
O.
V.,
and McKay,
F.
S. : Mottled
Teeth — An
Endemic
Developmental
Imper
fection
of
the
Teeth.
Heretofore
Unknown
in
the
Literature
of Dentistry,
Dental
Cosmos.
February
1916,
LVI11.
"Smith.
H.
V.,
Lantz,
E. M.,
and Smith.
M.
C. : Cause of Mottled
Enamel,
Defect of
Teeth., Univ. of Arizona
Agr. Exp. Sta. Tech Bull.
No. 32,
1931.
• Van
Horn,
A.
L. :
Chronic
Endemic
Dental
Fluorosis
in
Ohio,
Ohio
State
Med. J.
32 :
1207.
1936.
10Brandl,
J.,
and
Tnppciner,
H. : Urber
die
Ablagerung
der
Fluorverbindungen
1m
Organisinus
nach Futtering
mit
Fluornatrium,
Ztschr.
f.
Biol.,
10: 018,.
1891-1S92.
INSECTICIDAL
POWDERS
JOHNSON
AND VALLEE
437
attachments
to the bones were calcified.
Stanton and Kahn 11 have
more
recently
reported
the presence of calcium
fluoride crystals
in
the
bones of animals
after fluoride poisoning.
These
authors
also
describe
the sodium
fluoride poisoning of a baby,
aged
19
months,
who had swallowed some
of "Peterman's Roach Food,"
which
con
tained from 40 to 50 percent of sodium
fluoride.
The
whole
subject
of sodium-fluoride poisoning is well discussed
by Sharkey and Simpson 12 of Dayton, Ohio, by Carr 1s of the San
Francisco
coroner's
office,
and
by Geiger 14 of
the
department
of
public
health,
city
and
county
of San Francisco,
but it is difficult
to obtain
a
comprehensive
listing
of all
cases of sodium
fluoride
poisoning,
because most of the
States
in tabulating their statistics
merely
place
the suicides in one
column
and
the deaths from
acci
dental poisoning in
another
without
separation
as to the kind of
poisoning responsible
for the death ; there is no separate number for
specific
types
of poisoning
in
the
International
Classification
of
Causes of Death.
In most public health
departments
no distinction
is therefore
made as to the type of poison
used, all deaths from in
gested
poison being
assigned
to International
List No.
163.
The
records of the State Board of Health of Kansas show,, however, that
there
were three
deaths
from
sodium
fluoride
reported
during
the
year
1936,
all of which
were
due
to
sodium
fluoride having
been
taken
as
a laxative by
mistake.
In
the
5-year
period
1931-35 in
New York State, exclusive of New York City, there were four deaths
from accidental
poisoning by sodium
fluoride distributed
as follows :
Two in 1931, one in 1932, and one in 1935.
The reports of the chief
medical examiner
of the city of New York contain records of three
accidental deaths
from
sodium
fluoride poisoning in
1918-20, two
accidental
deaths in
1925, one accidental
and
one
suicidal death in
1926, one accidental
death in 1927, three in 1928, one in 1929, six in
1930, eight accidental
and
two suicidal
deaths
in
1931,
three
acci
dental
deaths
in
1932,
three
accidental
and
five suicidal
deaths in
1933,
one suicidal
death
in
1934,
and
five suicidal
deaths in
1935.
In Rhode Island
the only information
available on sodium
fluoride
is the death
certificate
of one patient in
1936 who took
by mistake
what he thought was bicarbonate
of soda.
Carr's article, referred to
above, reports
five new cases and alludes
to several others.
The arti
cle by Sharkey and Simpson reports
eight new cases
and makes ref
erence to many
others.
Geiger's
article reports
so many
new cases.
"Stanton. J. N., and Kahn, M. : Sodium
Fluoride
Poisoning, J. A. M. A. 64 :
1985.
1915.
a Sharkey,
T.
P.,
and
Simpson,
W. M. : Accidental
Sodium
Fluoride
Poisoning,
J. A.
M. A.
100,
97 :
1933.
» Carr, J. L. : Acute
Fluorine
Poisoning,
Calif.
& West.
Med.,
44.
S3 : 1936.
" Geiger, J.
C. : Poisoning
Due
to
the Ingestion
of
a Mixture
of
Sodium
Bicarbonate-
Sodium
Fluoride.,
Calif.
& West. Med., 44:
81,
1936.
438
DIVISION
OF
PREVENTIVE
MEDICINE
which
cause him to interrogate,
"Why do such poisonings not occur
with greater
frequency?"
He implies that
many
cases probably go
unrecognized
as "food poisoning," which in reality
may
be due
to
the ingestion
of small quantities of fluoride or other poisonous
insecti
cide on foodstuffs.
That
sodium
fluoride
is
extremely
poisonous
is
well
shown
by
McNally,15
who relates that incidence of one who mistook sodium
fluo
ride for a laxative powder and died in 45 minutes.
Bizot
10 reported
a
fatal case in a man who had taken
a teaspoonful
of sodium
fluoride,
and there are several records of entire families having been poisoned
by eating pastry containing sodium
fluoride.
But despite
these ex
periences sodium fluoride continues
to be widely used in this country
as an insecticide,
and it is still widely
dispensed
without
any indi
cation that it is a poisonous
substance.
The following
quotation
is from
a case report by Allen : 17
An accidental
death occurred
in
one hospital
when roach
powder,
a
mixture^
of sodium fluoride
and sodium silicofluoride,
was mistaken
for powdered
sugar
and
used
in
making
hard
sauce
to
go
with
the
noontime
dessert.
The
patient who was mixing
the
sauce,
tasted it on several occasions, and then com
plained of weakness and nausea.
He vomited copiously
and lapsed into
a state
of mild
shock,
which
responded well
to treatment,
though generalized
weakness
and muscular
cramps continued.
Some
5 hours later
he complained of dyspnea ;
and
expired
almost
immediately.
Autopsy
showed
subpleural
and
epicardial
hemorrhages,
as well as extravasations
of blood
into the lung tissue and intense
hyperemia
of
the kidneys.
The
blood
was
liquid
throughout
and
when
ex
amined for calcium
by
Mr.
E.
H.
Stotz, department
of biochemistry,
Harvard
Medical
School,
it
contained
only
5.8
milligrams
per
100
cubic
centimeters,
instead
of
the
normal
10
milligrams
per
100
cubic
centimeters —the
tetany
level is approximately
7 milligrams
per
100 cubic centimeters.
Dr. William
F.
Boos, toxicologist,
found
fluorides
present in all
the
organs,
as
w-ell
as
in
the
heart's
blood.
In
this
case
death was presumably
due
to
an artificial
tetany
brought
about
by
the
fluoride
combining
with
the
blood
calcium
to form
a
calcium
fluoride
which
is of extremely
low
solubility.
Since
this fatality,
all
the roach powder
used
in
the
Massachusetts
State
Hospitals
for Mental
Dis
ease is colored
so that a similar mistake will not occur.
The
symptoms
of
acute fluoride poisoning
seem
to
be
best
ex
plained on the basis of the ionization of the compound.
The extreme
gastrointestinal irritation
is undoubtedly enhanced
by the presence
of hydrofluoric
acid
formed
by the interaction between the ingested
sodium fluoride and the hydrochloric
acid in the gastric juice.
The
tetany
and
convulsive
seizures
so often
seen in these
cases
are
best
explained,
as Cobert has
so well pointed out in his "Lehrbuch
der
Intoxikationen,"
and
as Allen's
report has
so clearly shown,
by
a
* McNally,
W. D. : Four Deaths
Caused by Sodium Fluoride,
J. A. M. A.,
81 : 811,
1923.
"Bizot,
A.
R. : Sodium
Fluoride
Poisoning.
Kentucky
H. J., 2:
156,
1924.
" Allen,
A. M. : A Review
of the Variety
of Poisons
Which
Have
Caused Death
in
the
Massachusetts
State
Hospitals
for Mental
Disease. New
Eng. J. Med., 213:
1013,
1935.
INSECTICIDAL
POWDERS— JOHNSON
AND VALLEE
439
lowering of the blood calcium
due to the reaction
between the calcium
and
fluorine ions to form calcium fluoride,
which is deposited
and
stored in the osseous
structures.
The terminal petechial
hemorrhages
described
by Carr are probably favored by the anticoagulant action
of
sodium
fluoride.
Treatment
is
therefore
best
accomplished
by
copious
gastric lavage
with lime water,
and by the intravenous
in
jection of calcium chloride or intramuscular
injection
of
calcium
gluconate.
The complete removal of fluorine as an insecticide
would
seem to be the most effective remedy.
Sodium fluoride is
at
best
a
very
slow
acting insecticide.
It is
apparently
much
less toxic to insects than
it is to humans.
At the
Naval Medical School
cockroaches
have been exposed to large quanti
ties of sodium
fluoride for a period of 24 hours in glass containers.
While
so
placed
in
these
containers
with
sodium
fluoride
roaches
remained
alive and
active
for at
least
12 hours.
They
were
dead
at the end of
24 hours.
It is therefore probable
that crawling
in
sects may readily contaminate
food with sodium fluoride, which may
subsequently
be unsuspectingly
consumed.
As expressed
in
a
pre
vious report, the menace to public health
of residues of fluorine and
other inorganic materials
on fruits and vegetables demands
that in
secticides
of the future
be organic materials, which
are more toxic
to insects and
less toxic to mammals
than
are inorganic materials.
Debris
and Cube
Derris
root, of which there
are about
40 species, is grown chiefly
in
the East Indies.
Derris
ellyptica yields the highest
content
of
rotenone
(C*H*.0«), which is generally regarded
as the active prin
ciple in derris, although recent studies
18 indicate
that in derris there
are many
other
active principles.
An extensive
amount
of work is
being carried out to identify
these principles and to determine
their
potency.
Recently in Peru,
Loncho-carpus
nicou
(cube root)
has
been found to have
a high rotenone
content,
and the importation of
cube is rapidly
increasing.
Rotenone
has also been found in Cracca
virginiana (devil's shoestring), which is grown in America, but the
rotenone
content is low.
Purified
rotenone
is in the form of colorless
and odorless
crystals.
The real hindrance to the development
and
use of rotenone
has been
the very rapid rate of its deterioration.
Until the last
4 or
5 years
it was not
considered
to
be
a practical product
because
its killing
properties were lost
so quickly with exposure
to light
and air.
Ro
tenone
protected
in
the
cells
of
powdered
derris or
cube root
is,
1»Ambrose,
A.
M.,
and
Haag,
H.
B.
:
Toxicologlcal
Study
of
Derris,
Indust.
&
Eng.
Chem.,
28
:
815,
1936.
440
DIVISION"
OF
PREVENTIVE
MEDICINE
however,
much
less
prone
to deterioration than pure
rotenone.
To
assure
a uniform rotenone content, the powdered
derris or cube root
is blended after milling and it is then
assayed to contain
between
4
and
5
percent
rotenone,
as
determined
by
either
the
Jones
19 or
Rogers-Calamari
20 method.
Most
manufacturers
further
stabilize
the rotenone in the derris and
cube
by physical and chemical
means,
and thus most effectively
prolong its period of activity.
Like the pyrethrins,
rotenone
is chiefly
toxic to insects
and cold
blooded
animals.
It is extremely
poisonous
to fish and
reptiles.
It
is interesting to note that derris
root
has
been
used for centuries
by
the natives
in the East Indian Archipelago
and
the Antipodes
as
a means of catching fish.
They make
a milky
wash of the root,
drop this solution into the fishing area, and then gather
the dead and
stunned
fish into their boats.
It
is said
that
the
Chinese
farmers
in the Malay States use a decoction of derris on their crops.
Ameri
can
farmers are now
adopting derris powder to
replace
poisonous
inorganic chemicals.
With the increasing number
of deaths
due
to
insecticide
residue
poisoning, it is very
probable
that within
the
next few years the use of poisonous
inorganic chemicals for insecti-
cidal
purposes
will
be
completely
prohibited.
Powdered derris root is used extensively
in flea and
lice powders
for
domestic
animals.
For
these
purposes
the
derris
powder
is
usually diluted with talc
so as to give
a mixture of about
1 percent
rotenone
content.
Sometimes
10
to
20
percent
pyrethrum
powder
(assaying
0.9 percent pyrethrins)
is added to obtain
further insecti-
cidal action.
These flea and lice powders
are considered
to be harm
less to dogs, cats, poultry, and cattle.
Although
rotenone,
like the pyrethrins,
is relatively
innocuous
to
mammals,
direct inhalation of powdered
derris, such
as is likely to
occur
during milling,
may
be toxic.
There may
thus
be
a possible
health hazard to those engaged in milling and grinding
derris with
out the use of suitable
protective
measures.
Recently Mathews
and
Lightbody
21 of the United
States Department of Agriculture
have
shown
that rotenone
dissolved
in oil
does
become
really
toxic
to
mammals.
Haag
22 of
the department
of pharmacology.
Medical
College of
Virginia, has studied
the effect of prolonged
feeding of rotenone
and
derris powder.
He gave rabbits 60 milligrams of derris per kilogram
daily
without
evidence
of toxicity.
Haag
concludes
from
experi-
u Jones,
H. A.:
Assay
of Plant
Material
for
Its
Rotenone
Content.
Ind.
Enc.
Chem.
Anal.
Ed. 5:
23,
1933.
w Rogers,
11. D..
and
Calamari.
J.
A. : Rotenone
Determine
by
Colorimetiic Methods.
Ind. Eur. Chem. Anal.
Ed.,
8 : 135,
1935.
11Mathews, J. A., and Lightbody,
H. D. : Toxicity of Denis and Cube,
Ind.
Eng.
Chem..
28:
812,
1936.
3 Ilaag,
H.
B. : Toxicity
of Rotenone.
Soap.
January
1937.
INSECTICIDAL
POWDERS— JOHNSON AND VALLEE
441
ments
on
guinea
pips, rabbits,
dogs,
cats,
pigeons,
and
white
rats
that there is no danger
from the ingestion of rotenone.
He himself
swallowed about
2.5 grains of rotenone
without experiencing symp
toms.
Derris
is essentially
a stomach
poison
for insects.
Its activity
as
an insecticide
is comparable
to that of sodium
fluoride.
It is there
fore slow acting, but it is nevertheless
a sure killer.
Tests
at the
Naval
Medical School have
shown
that
when
cockroaches
were
ex
posed to either sodium fluoride or derris about 24 hours were required
for lethal
effect
; but the lethal effect was certain
in either instance.
Derris
is therefore
slower
in
action
than pyrethrum,
but it is un
doubtedly effective in ultimate kill of insect pests.
Pyrethrum
A wide demand has developed for pyrethrum (which is not poison
ous to man or animals) for insect control.
The American
consump
tion of pyrethrum varies from
10 to 15 million
pounds
per year and
is steadily increasing.
At present Japan supplies
about
80 percent
of the world consumption,
but Kenya
is now making
a fair bid for
the market.
The Kenya flowers
contain
a higher pyrethrins
content
than do the flowers grown in any other
area.
The insecticidal principles in pyrethrum are known as pyrethrins I
and II.
These pyrethrins are the esters of the monovalent
and divalent
chrysanthemum acids.
Pyrethrum
flowers of acceptable grade should
contain not less than
0.9 percent pyrethrins,
as determined
by either
the Gnadinger-Corl
2s or the Seil 24 method.
Just
as in the
case of
rotenone,
the pyrethrins
lose strength
rapidly
when
exposed to light
and
air.
It
is
estimated
that in
the
first
month
after
milling,
pyrethrum
powder
loses
as
much
as
15
percent
of
its
original
pyrethrins
content.
One of the triumphs of practical
scientific
re
search
is
the
stabilization
of pyrethrins
in
powdered
pyrethrum.
Stabilized
pyrethrum powder is now commercially available in con
centrated
form, which assays from
1.9 to 2.0 percent
pyrethrins.
An
insect, contrary to the higher forms of animal life, breathes
throughout
its body.
There are numerous
spiracles
of its breathing
system
located
all along its integument.
It
was formerly
thought
that the insecticidal effect of pyrethrum
was
due to the
insect
in
haling
the dust or spray through the spiracles,
but in
1933 Wilcox-
son and Hartzell
25 showed that pyrethrum kills primarily
by contact
B Gnadinger,
C. B., and Corl,
C.
S. : Studies
on r-yrethrum
Flowers
; Quantitative
Deter
mination
of the Active
Principles, J. Amcr.
Chem.
Soc, 51 : H054,
1929.
M Seil. H. A. : Estimation
of Pyrethrins, Soap,
10, May
1934.
80Wilcoxson,
F.,
and
Hartzell,
A. : Some
factors
Affecting
the
Efficiency
of
Contact
Insecticides.
III.
Further
Chemical
and
Toxicological
Studies
of
Pyrethrum,
Contrib.
Iioyec
Thompson Inst., vol. 5, No. 1, p. 115,
1933.
442
DIVISION
OF
PREVENTIVE
MEDICINE
with
the
integument,
independently
of
the respiratory
system,
the
effect being
due to paralysis
and
destruction
of
nerve ganglia.
When
concentrated
and
stabilized pyrethrum
powder
is diluted
with finely powdered
sulphur, an excellent
dust for
a wide
range
of
effectiveness is produced.
Experiments with sulphur and pyrethrum
by DeLong
26 have disclosed
that sulphur itself when applied to the
leaves of a plant will bring about the death of sucking insects.
He
found that finely ground sulphur
(300 mesh)
was easy to apply and
gave
the
best
results,
but
he found that
a combination
of sulphur
and
pyrethrum
gave
greatest
protection,
because
the
pyrethrum
brought about immediate kill of insects present
at the time of appli
cation,
while
the
sulphur
through
residual
effects,
killed
insects
hatching
or appearing
later.
He
used
a combination of sulphur
and pyrethrum (assaying 0.9 percent pyrethrins)
in
a ratio of 90 to
10.
Method of Piiockduri:
111 the tests conducted
at
the Naval
Medical
School cockroaches
were
dusted
with
sodium
fluoride, sulphur,
powdered
derris,
pyre
thrum
powder,
and
with
combinations
of derris
and
pyrethrum.
One
hundred
cockroaches
were
used for
these
tests.
The
results
are given in table I, in which the indicated percentages for rotenone
and
the
pyrethrins
were
determined
from
the
percentage
content
of these active principles in the percentage
proportions of powdered
derris or pyrethrum powder employed
in combination
with alkaline-
free sulphur
(300
mesh)
or nonalkaline
clay
(300
mesh).
For
ex
ample,
a mixture of
15
percent
derris powder
(assaying
5
percent
rotenone)
and 85 percent sulphur or clay was taken
as representative
of
0.75
percent
rotenone,
and
a mixture of
15
percent
pyrethrum
powder
(assaying
2 percent
pyrethrins)
and
85 percent
sulphur
or
clay was considered
as representative
of 0.3 percent pyrethrins.
Table I
Paralysis
Kill
None.
..
50 percent in 24 hours.
75 percent in 24 hours.
100percent in 45 minutes.
100 percent in 30 minutes.
100percent in 25 minutes.
100percent in 20 minutes.
100percent in 20 minutes.
None.
(2) 1.00 iiercent
rotenone
-
None.
(3) 0.23 percent pyrethrins
10minutes
(4) 0.30 percent pyrethrins
plus 0.75 percent rotenone
7 minutes
(5) 0.40 percent pyrethrins
plus 0.75 percent rotenone
6 minutes
(6) 0.40 percent pyrethrins
plus 1.00 percent rotenone
6 minutes
(7) 0.50 percent pyrethrins
plus 1.00 percent rotenone
6 minutes
(8) 325 mesh sulphur
None. .
This table shows time of onset of paralysis
and death.
Insects
were removed
to
wire
cages
away
from
insecticide
upon
appearance
of
symptoms.
Insects
M DeLong,
D. M. : Experiments
with
Sulphur
and Pyrethrum.
Crop Protection
Institute,
No.
44,
March
1934.
INSECTICIDAL
POWDERS —JOHNSON
AND VALLEE
443
exposed to rotenone in the absence of pyrethrum
were removed to cages
5 minutes
after beginning of exposure.
Table II
Paralysis
Kill
None
50 percent in 24 hours.
75 percent in 24 hours.
100percent in 45 minutes.
100percent in 30minutes.
100percent in 25 minutes.
100percent in 20 minutes.
100percent in 20 minutes.
None
10 minutes
(4; 15 percent pyrethrum
plus 15percent derris
7 minutes
(5) 20 percent pyrethrum
plus 15percent derris
6 minutes
(6; 20 percent pyrethrum
plus 20 percent derris
6 minutes
(7) 25 percent pyrethrum
plus 20 percent derris
6 minutes
This
table
shows
onset
of paralysis
and
death
from
the
combinations
of
pyrethrum
powder and powdered derris in alkaline-free
sulphur
or nonalkaline
clay
required
to obtain
the percentages of rotenone
and
pyrethrins
listed
in
sequence
of table I.
The derris
assayed
5 percent rotenone and the pyrethrum
assayed 2 percent pyrethrins,
except
No. 3 which
assayed 0.9 percent pyrethrins.
The
percentage
proportions
of
derris
and
pyrethrum
powder
in
alkaline-free
sulphur
or nonalkaline
clay employed to obtain
the percentages of active prin
ciples
enumerated
in
the
sequence
of table I.
The
25 percent
pyrethrum
75
percent sulphur
or clay,
No. 3 in table II, was
a pyrethrum
powder
obtained
from high-grade
flowers assaying
0.9 percent pyrethrins.
It is therefore
evident
that
25 percent
of this
pyrethrum
powder
(assaying
0.9
percent
pyrethrins)
yielded
only
0.23 percent pyrethrins
in the resultant
mixture.
The
pyrethrum
used
in all
the other
mixtures
was
concentrated
and
contained
2.0
percent
pyrethrins.
Hence the 15 percent pyrethrum
mixture,
No. 4 in table II, yielded
0.3 percent pyrethrins
; the 20 percent pyrethrum
mixtures,
No. 5 and No. 6 in
table II, yielded
0.4 percent pyrethrins,
and the 25 percent pyrethrum
mixture.
No.
7 in table II, yielded
0.5 percent pyrethrins.
The
derris
powder
contained
5 percent rotenone, and it is therefore evident that the
15 percent and 20 percent
mixtures
of derris
contained
respectively
0.75 and
1.0
percent rotenone.
Discussion of Results
It is apparent from a perusal of tables I and II that the optimum
pyrethrins content for insecticidal purposes
corresponded
to 0.4 per
cent pyrethrins.
This finding is in accord with the results
obtained
by Williams 27 and
is consistent
with
the report of
a comparative
study of liquid insecticides
recently
undertaken
at the Naval Medical
School.
To obtain
this optimum percentage
of pyrethrins
in
the
experimental
mixtures,
No.
5 and No.
6 in table II, required
that the
pyrethrum powder be concentrated
and contain
2 percent pyrethrins.
It was also stabilized in order to avoid the inevitable deterioration
of pyrethrins
which
so
rapidly
occurs
when
ordinary
pyrethrum
powder is exposed to light and air.
Although
the
1 percent
rotenone
gave only
a 75 percent kill, the
tests with rotenone were conducted
under fairly rigid conditions,
and
the 25 percent difference
in kill between the 0.75 percent rotenone and
"Williams,
C.
L.,
and Dreessen,
W.
C. : The
Destruction
of Mosquitoes
in
Airplanes,
Pub.
Health
Rep.,
50 :
683,
1935.
Williams,
C.
L.,
and
Dreessen.
W.
C. : A.
Nonflam
mable
Pyrethrum
Spray
for
Use
In Airplanes,
Pub.
Health
Rep.,
SO : 1401,
1935.
444
DIVISION
OF
PREVENTIVE
MEDICINE
1
percent
rotenone
is
regarded
as highly
significant.
Rotenone
is
essentially
slow acting.
It is a stomach poison, but it seems to appeal
to the appetite of the cockroach.
These insects ate it readily.
There
fore, the roaches were allowed
to remain in contact with the powder
only
5 minutes,
and at the expiration of this time they
were trans
ferred to wire cages for subsequent observation.
The working
percentage
of
rotenone
is of
course
dependent
on
the rotenone
content
in powdered
derris or cube, and hence on the
percentage
proportion of such powders
used in final mixtures.
Sta
bilized derris and
cube
powders
are
protected
physically
against
ex
posure
to light
and chemically
against
oxidation,
but
they
should
nevertheless
be packed
in light-proof
containers.
Since
the stabiliz
ing agent required
is used in the ratio of
15 percent,
to produce
a
powder
having
a
5 percent
rotenone
content
is more difficult.
Most
stabilized
derris and
cube powders
are therefore
assayed to contain
4 percent
rotenone
rather than
5
percent.
In
these
reported
tests,
since the powdered
derris contained
5 percent
rotenone.
20 percent,
of the powder represented
1 percent
rotenone
in
the final
mixture.
With a powder containing 4 percent rotenone,
25 percent of the pow
der would
be required
in the final mixture for
a yield of
1 percent
rotenone.
Similarly
33
percent
of
a
3
percent
stabilized powder
would be required for a
1 percent rotenone content.
Dusting cockroaches
with sulphur alone was without
lethal
effect.
However, in less than
2 minutes,
following
the application of either
combined
sulphur
and pyrethrum or pyrethrum
alone,
roaches dis
played
a most pronounced
degree of hypermotility, followed in a few
minutes
by complete paralysis.
When nonalkaline clay
(300
mesh)
was used in place of sulphur the results
were the same.
It is essential that the carrier of pyrethrum powder
be nonalkaline.
Lime,
for instance,
completely
destroys
pyrethrins.
Lime
is
also
deleterious
for derris
powder,
but
either
alkaline-free
sulphur
or
nonalkaline clay lends
itself admirably
to this purpose.
For thor
ough mixing of ingredients, the particle size of the sulphur or non
alkaline clay should
pass a 300-mesh screen
and
be so processed that
it will flow readily without lumping.
CONCLVSIONS
1. The
fluorides
have
been
established
as constituting
a
definite
public health
hazard.
2. The widespread
use of sodium fluoride as an insecticide
is dan
gerous.
If
it
must
be
used,
it
should
be
colored.
Nile
blue
is
suggested.
3. A mixture of 0.4 percent pyrethrins and
1 percent rotenone with
alkaline-free sulphur or nonalkaline clay
is
a safe insecticide
and is
more active than sodium fluoride.
TEST
FOR
COWPOX
VIRUS
POTENCY
MOLONEY
445
4. Stabilized
and
concentrated
pyrethrum
powder
(assaying
1.90
to 2 percent pyrethrins)
offers a ready source of pyrethrins.
5. Stabilized
derris
or
cube
powder
(assaying
3
to
5
percent
rotenone)
used in the percentage proportion
required
to yield
1 per
cent rotenone, adds to the ultimate insecticidal properties
of a powder.
6. Either specially processed alkaline-free sulphur
(300 mesh)
or
nonalkaline
clay
(300 mesh)
is an excellent
and
economical
vehicle
for
the carriage of pyrethrins
(pyrethrum
powder)
and
rotenone
(powdered derris or cube).
Clay is cheaper than sulphur.
A PRESUMPTIVE
TEST FOR THE
POTENCY
OF
COWPOX
VIRUS
By Lt. Comdr. J. B. Moloney, Medical
Corps, United
States Navy
Many conditions arise in which it is desirable
to test the potency
of cowpox
virus.
The fact that it is so perishable
at ordinary
tem
peratures
frequently means that some
delay in transmission through
the mails, or some
time lapsed over the marked
expiration date may
render the virus sterile
and worthless.
The following
test
has been
tried and verified
many
times and has been
found to be practicable
and reliable.
The technique
follows :
Two capillary
tubes of the virus to be tested are used.
One
tube
is inactivated
in a water bath at 140° F. for
1 hour.
The other tube
is used
unchanged.
The test consists
in observing
the difference
in
reaction in
a known immune
person
between
a questionably
potent
virus and a known killed virus.
The skin of the left arm in that region overlying
the insertion of
the deltoid is shaved
and scoured
with ether
to remove
the surface
oils and is allowed to dry thoroughly.
Then
1 drop of the inacti
vated virus and
1 drop of the un-inactivated virus is placed
on
the.
shaven
and cleaned area.
Identical
scarifications
are made through
each of the drops with
a sterile
needle, separately,
care being
taken
that no trace of the virus is carried over from
1 drop to the other.
In order to obviate
this possibility
2 needles should be used, or if
1
needle is used it should
be flamed between scarifications.
At the end of 48 hours
the test is read, although it is frequently
possible
to make
a reading at the end of 24 hours.
If there
is no
difference
between
the skin reactions,
the test is negative.
That
is,
the virus which was to have been
tested is dead, therefore
useless
as
far as immunizing against
cowpox
or smallpox is concerned.
If the
un-inactivated virus shows the typical reaction
of immunity, and the
inactivated virus does not, then the test is positive,
that is the virus
is living
and
potent,
and
will
inoculate
the
disease
cowpox
in
a
nonimmune
person.
The inactivated virus
serves
as
a
control
to
eliminate allergic reactions,
due solely to the serum.
STATISTICS
HEALTH
OF THE NAVY
The
following
tables are summaries
of morbidity
rates per
1.000
for the fourth
quarter
of
1937 in
comparison
with
rates
for
the
corresponding quarter
of the preceding
5 years :
ENTIRE NAVY
Yew
All dis-
Injuries
Poison-
All
causes
Communicable
diseases
Venereal
disease;
iDg"
A
B
502
54
0. I5
556
m
(')
129
1933
402
68
.57
471
9
109
89
554
62
5.43
622
26
171
114
1935
409
6I
.45
470
8
126
73
1936
474
74
1.62
550
15
118
96
1937
472
36
2.83
611
11
118
93
FORCES ASHORE
1932
629
63
0.31
692
(')
w
95
1933
523
85
.46
608
9
158
66
1934
610
77
.41
687
35
192
68
1935
427
63
.74
491
a
151
39
1936
459
97
1. 14
557
13
121
46
1937
535
42
6.60
583
n
169
55
FORCES AFLOAT
432
48
0.06
481
(')
(')
147
344
60
.62
405
9
86
100
1934
525
53
8. 12
586
21
160
139
1935
398
59
.28
457
8
111
93
483
61
1.90
546
15
115
125
1937
435
33
.62
469
10
89
116
' Not available.
Common
infectious diseases of the respiratory
type. —During the
quarter,
1,399
cases
of
the
common
infections
of
the
respiratory
type were reported from shore stations in the United States, 260 from
shore
stations
outside
the
continental
limits
of the United
States,
and 1.493 cases from the forces
afloat.
Catarrhal
fever was respon
sible for 2.221 of the 3.152 total admissions.
447
448
DIVISION'
OF
PREVENTIVE
MEDICINE
Ships and shore stations
recording the greatest
number
of admis
sions are shown in the following
tabulation :
Ship
or
station
October
November
December
Total
76
ill
125
312
Regimental
Hospital,
Shanghai,
China.
-
45
46
139
230
31
39
122
192
Naval
Training Station,
Great
Lakes,
111
-
28
98
55
179
Naval
Training Station,
San Diego, Calif
48
46
48
142
32
22
34
88
34
31
21
86
Marine Barracks,
Qunntico,
Va
-
24
13
27
94
32
9
22
SI
8
17
24
49
U. S. S. Colorado
14
24
10
48
The Naval Air Station, Pensacola,
Fla.,
reported
a fatal
case
of
tonsillitis,
acute.
An aviation machinist's
mate, third class, 29 years
of age was admitted
to the sick list on October
7,
1937, and died on
November
5,
1937.
The contributory
cause of death was recorded
as
septicemia.
Seven
cases
of chickenpox
were reported
for the quarter as
fol
lows: In November
one
case from the U. S. S. Houston;
and
in De
cember one each from
the Naval
Proving
Ground,
Dahlgren,
Va.,
U. S. S. Argonne, U. S. S. Mississippi, U. S. S. New York, U. S. S.
Northampton, and the U. S. S. Wright.
One
case
of
scarlet
fever
was
reported
by
the
Naval Training
Station, Newport, R. I., in December:
one case of whooping cough
by
the Naval Proving Ground, Dahlgren, Va., in October; and one case
of poliomyelitis, anterior, acute, by the U. S. S. Whipple
in October.
A fatal case of diphtheria was reported
by the Brigade Hospital.
Second Marine Brigade, Shanghai, China.
An officer of the Medical
Corps was admitted
to hospital on November
G.
1937, for the treat
ment of acute pharyngitis.
A culture taken immediaely
was positive
for diphtheria.
The patient
died suddenly
on November
If), 1937, the
contributory
cause
of death
being dilatation,
cardiac,
acute.
A case of encephalitis,
hemorrhagica,
was admitted
to the sick list
at
the Navy Yard, Boston,
Mass.
The
patient
was transferred
to
hospital with symptoms
of multiple neuritis, both lower extremities,
and acute confusional mental state with defective
memory
and partial
disorientation.
Herpes zoster
developed
and
mental
confusion
and
clouding of consciousness
increased.
A terminal broncho-pneumonia
developed
and
death
occurred
on
November
1G,
1937.
Diagnosis
was confirmed
by autopsy.
Typhoid
fever and partyphoid
fever. —There were
seven
cases
of
typhoid
fever
and
two
admissions
for paratyphoid
fever
reported
during
October,
November,
and
December
1937,
as follows:
STATISTICS
449
TYPHOID
FEVER
Rate
Age
(years)
Place of original
admission
Date of ad
mission
Severity
of case
Date of com
pletion
of
prophylaxis
Disposition
N. Seaman,
first class.
Private
26
21
Navy Yard,
Cavite,
P.
I.
Oct.
25,1937
Oct.
28,1937
Severe
May
7,
1931;
Aug.
16.1935
Dee.
4,
1936
Died, Nov. 12,
Marine Detachment,
American
Embassy,
Peiping,
China.
Moderately
severe.
1937.1
Duty, Nov. 26,
1937.
Chief Phar
macist-
Corporal.-..
39
Naval
Hospital,
Guam.
Oct.
28,1937
Nov.
4,1937
Not available..
Not available
Oct.
12,1934
Duty. Nov. 22,
25
Marine Detachment,
American
Embassy,
Peiping,
China.
Moderately
severe
(pro
longed).
1937.
Duty, Jan. 11,
1938.
Private
22
23
35
Nov. 17,1937
Nov. 24, 1937
Dec.
20,1937
Mild
Dec.
11,1936
Oct.
2,1936
Not available
Duty,
Jan.
3,
Private
do
do.—
1938.
Duty, Jan. 17,
Chief Phar-
macist's
mate.
Naval
Hospital,
Guam.
Not available..
1938.
Duty, Dec. 30,
PARATYPHOID
FEVER
"A"
1937.
Private
Private
21
M
Marine Detachment,
American
Embassy,
Peiping,
China.
Nov. 13,1937
Nov. 16,1937
Moderately
severe.
Dec.
11,1936
8ept.
14,1934-
Duty, Dec.
19,
1937.
Mild.
D193T
DeC'
1
Contributory cause of death "Hemorrhage,
intestinal."
Gastroenteritis, acute, Naval
Academy, Annapolis,
Md.—During
the first week of December an outbreak of gastroenteritis,
totaling 119
cases, occurred
among the midshipmen.
Ninety of the cases reported
on the first day.
The majority of the cases were mild
and required
hospitalization from
1
to
3
days.
Laboratory examinations
showed this outbreak
to have been caused
by the Gartner bacillus
(S. enteritidis)
which
was
recovered
from
samples of the fresh ham
used for luncheon
December
1.
It
is
be
lieved that the fresh ham in question
was infected
with this bacillus
prior to the
receipt
at the Naval
Academy.
The
absence
of this
bacillus from stool
cultures
of patients
indicates
that the outbreak
was perhaps
the result
of toxemia
rather than
a bacteriological in
festation
of the gastrointestinal tract.
The symptoms in general were nausea
;
vomiting
;
diarrhea
;
general
weakness, amounting to prostration in some cases; abdominal
cramps
and distention
;
some
cases of severe
muscle cramps of abdomen and
calves of legs, with pain in the back.
Temperature was normal in
about
10 percent and subnormal
in about 90 percent of cases.
Cerebrospinal fever and meningitis,
cerebrospinal,
acute.—There
were two cases of cerebrospinal
fever and three
cases of meningitis,
64743—38
9
4 50
DIVISION
OF
PREVENTIVE
MEDICINE
cerebrospinal,
acute, reported
during
the fourth
quarter of
1937
as
follows :
CEREBROSPINAL
FEVER
Rate
Age
(years)
Place of original
admission
Data of
Length
of
Disposition
admission
service
Yrt.
bio».
Fireman,
third
IS
U. S. S. California
Oct.
7,
1937...
l
l
Duty,
Oct. 2»,
class.
1937.
Seaman,
second
I0
U.S. S. Arctic
Oct. 29, 1937..
0
10
Died. Not.
7,
class.
1937.
MENINGITIS, CEREBROSPINAL,
ACUTE
Shipfltter,
third
class.
28
Naval
Hospital,
San
Diego,
Calif.
Oct. 28, 1937..
4
0
On sick
list at
(prolonged
treatment
of gonocoo-
end of year.
Mess
attendant,
29
cus infection).
Naval
Training
Station,
Great
Nov. 1,1937..
S
10
Died, Nov. 17,
first class.
Lakes,
I11.
1937;"
Mess
attendant,
29
U. S. 8. Vinctnnci
Nov.
4,
1937..
8
1
Died, Nov. 17,
first class.
1937.
>
Contributory cause of death, "Pneumonia,
broncho."
Food poisoning.—An outbreak of food poisoning occurred
on board
the XL'S. S. Philadelphia
on September
29, 1937.
A total of 108 men
"were
treated,
6
of whom were admitted
to the sick list and
kept
in
bed for
3
days.
Symptoms
were griping
pain in the lower abdomen
followed
by
frequent
loose, watery stools,
weakness,
nausea,
head
ache, and in the more
severe cases,
vomiting.
Symptoms
subsided
after the second day.
The food served
at the morning
meal included fried
fresh meat
hash
(meat
ground
the night
before), fresh milk,
oatmeal,
baked
beans with
bacon,
tomato
catsup,
hot
corn
bread
and
bread
and
butter.
The men affected were in all the general
messes
and of the
total number questioned only one denied having eaten hash.
None of
the men affected purchased
anything
at the ship's
service
store
on
that date.
From the nature of the symptoms,
the messing distribution of the
men affected, and
the time elapsing before
onset of symptoms,
it
is
believed
that the causative
agent
was the hash
served
at breakfast
and that
a
toxin apparently
developed
in the meat from
the
time
of preparation to the time of serving.
INJURIES
AND
POISONINGS
Admissions
for Fourth Quarter
Ending
December
31,
1937
The
following
table,
indicating
the
frequency
of
occurrence
of
accidental
injuries
and poisonings in the Navy
during
the
fourth
STATISTICS
451
quarter, 1937, is based upon all Form F cards covering admission
in
those months which have reached the Bureau :
Admissions,
Admission
rate per
Admission
October,
November,
and Decem
ber, 1937
100,000,per
annum
rate per
lOO.OOn.year
1937
INJURIES
482
380
349
1,451
1, 144
2,513
1,924
1,760
Occurring
within command
but not associated with work
Incurred on leave or liberty or while absent without
leave
1,050
All iniuries
1,211
3,645
6,197
POISONINGS
Industrial poisoning
3
80
1
9
271
3
7
211
18
Occurring
within command
but not connected with work
, . .
Associated
with leave, liberty,
or absence without
leave
94
383
236
1,305
3,928
6,434
Percentage relationship
Occurring
within command
Occurring
outside
Connected with the
performance of
work, drill, etc.
Not
connected
with work or pre
scribed duty
command— leave,
liberty,
or A.W.-
O.L.
October,
November,
October,
November,
October,
November,
and
December
Year
1936
and
December
Year
1936
and
December
1937
Year
1936
1937
1937
39.8
40.6
31.4
31.0
28.8
28.4
3.2
3.0
95.7
89.5
1.1
7.5
Percent
of total
admissions,
injury, and
37.2
39.2
36.0
33.2
26.8
27.6
Note.— Poisoning
by a narcotic
drug or by ethyl alcohol is recorded under the title "Drug addiction"
or
"Alcoholism," as the case may be.
Such cases are not included
in the above figures.
MORBIDITY
Summary for the fourth quarter ending Dec. 8I, 1937
Forces afloat, 83,768 Forces ashore, 49,117 Entire Navy, 132,886
Admis
Rate per
Admis
Rate per
Admis
Rate
per
sions
1,000
sions
1,000
sions
1,000
All causes
9,821
468.96
7,160
683.10
16,981
611.15
Diseases only
9,107
434.87
6,569
634.97
15,676
471.87
Injuries
701
33.47
510
41.53
1,211
36.45
Communicable
diseases transmissible
by
13
.62
81
6.60
94
2.83
oral and nasal discharges
(Class VI11):
(A)
213
10.17
141
11.48
354
10.66
(b5
1,854
88.53
2,070
168.58
3,924
118.12
Venereal
diseases
2,421
115.60
675
54.97
3,096
93.It
452
DIVISION
OF
PREVENTIVE
MEDICINE
DEATHS
During the fourth
quarter
ending December 31, 1937
Cause
Navy
Marine
Corps
Nurse
Corps
Total
Primary
Secondary
or contrib
utory
Offi
cers
Mid
ship
men
Men
OfB-
cers
Men
DISEASE
9,820
2,223
102,028
1,336
17,074
404
132.885
Appendicitis,
acute
Peritonitis,
general,
1
1
Carcinoma.
bronchus-
acute.
Pneumonia,
broncho--
1
Carcinoma,
gall bladder...
do
1
1
2
1
1
1
Carcinoma,
stomach
do
Coronary
heart
disease,
arteriosclerotic.
Pneumonia,
broncho-..
Dysentery.
amoebic-
1
2
Malaria,
quartan
1
Diabetes
mellitus
(therapeutic).
Mastoiditis, acute
1
Diphtheria
Dilatation,
cardiac,
1
1
1
Encephalitis,
hemorrhag
ica.
acute.
Pneumonia,
broncho-..
Olioma,
brain
Hemorrhage,
cerebral
Abscess, periproctic
1
1
Do
Arteriosclerosis,
gen
eral.
Jaundice,
acute
infective
Pneumonia,
broncho-
1
(Weil's disease).
Leukemia
1
1
1
Meningitis, cerebrospinal..
do
Do
Pneumonia,
broncho--
Thrombosis,
coronary
Myocarditis, chronic
artery.
Dilatation,
cardiac,
1
Do
acute.
1
1
1
Do
Pleurisy, suppurative.
Sinusitis,
ethmoidal
1
Status
lymphaticus
None
1
1
Thrombosis, coronary
ar
tery.
Arteriosclerosis,
gen
eral.
2
Thrombosis,
cavernous
sinus.
Cellulitis, face
1
Tonsillitis, acute
Septicemia
1
1
Tuberculosis,
pulmonary,
acute pneumonic.
None
Tuberculosis,
pulmonary,
acute general miliary.
do
1
2
1
Tuberculosis,
pulmonary,
chronic,
active.
Do
Hemorrhage,
pulmon
ary.
Tuberculosis,
kidney
1
1
Typhoid fever...
Hemorrhage,
intestl-
nal.
Ulcer,
duodenum
Obstruction,
Intesti
nal,
from
external
causes.
1
1
INJURIES
AND POISONINgS
6
24
3
10
42
Asphyxiation,
acute, gaso
line fumes (inhaled).
1
1
Avulsion, forearm (electric
water extractor) .
do
1
1
Crush, head-
do
1
4
1
I
Drowning
do
J
Fracture,
compound, ribs-.
Hemorrhage,
pulmon
ary.
Fracture,
compound, skull.
4
1
5
2
1
Fracture,
simple, skull
Intracranial
injury
2
1
1
Fracture^
simple, vertebra,
1
STATISTICS
453
Cause
Navy
Marine
Corps
Nurse
Corps
Total
Primary
Secondary
or contrib
utory
Offi
cers
Mid
ship
men
Men
Offi
cers
Men
INJCEnt" AND POISON
ING" —continued
Intracranial injury --
None
2
6
1
Do
Rupture,
traumatic,
Injuries, multiple,
extreme.
Do
liver.
None
5
15
2
22
1
1
1
1
Alcoholism,
acute
Do...
Cystitis, acute
Wound, gunshot, chest
1
Wound,
gunshot,
abdo
men.
do
Wound,
gunshot,
chest,
do
1
and heart.
Wound, gunshot,
head
do
3
1
1
Do
Psychosis, unclassified
Wound,
gunshot,
verte
brae, dorsal.
Wound, incised, neck
.
do
1
Wound, incised, wrist.
Hemorrhage,
radial
1
Poisoning,
acute,
carbon
monoxide.
artery.
None
1
2
1
1
Poisoning,
acute,
chloro
form.
Psychosis,
unclassified
None
Poisoning,
acute, cresol
Total for injuries and
poisonings.
5
49
7
61
Annual
death
rate
per
1,000:
10
73
3
17
103
Disease only
4.07
2.04
2.86
.94
.16
.12
8.98
8.98
3.98
2.34
3.10
1.26
.12
.11
1.60
23
Other injuries
2.04
1.66
1.41
MENTAL
AND
PHYSICAL
QUALIFICATIONS
OF
EECRTJITS
Statistics
for Foubth Quarter
Ending December
31, 1937
The
following
statistics
were
taken
from
sanitary
reports
sub
mitted by naval training stations:
U. S. Naval Training station
October,
November,
and December
1937
Norfolk,
Newport.
Great
San Diego,
Va.
R.I.
Lakes.
ML
Calif.
Recruits received during
the period
1,378
829
1. 150
1,403
Recruits appearing before Board of Medical
8urvey
I5
0
10
0
Recruits recommended
for discharge from the service
I5
0
10
0
14
0
0)
0
Recruits held over pending further observation
0
0
(')
(')
Recruits
transferred
to the hospital
for treatment,
oper
ation,
or further
observation
for conditions
existing
prior to enlistment
W
18
95
61
>Not reported.
454
DIVISION
OF
PREVENTIVE
MEDICINE
The following
table
was
prepared
from reports of
medical
sur
veys in which disabilities or diseases causing
the surveys
were noted
existing prior to enlistment.
With certain diseases, survey following
enlistment
so rapidly that it would seem that many might have been
eliminated in the recruiting
office.
Cause of survey
Abscess, periapical
Absence, acquired,
lens
Absence, acquired,
teeth
Acne,
vulgaris
Adhesions,
abdominal
Arterial
hypertension
Arthritis, chronic,
sacroiliac
Astigmatism
Asthma
Caries, teeth
Color blindness
Constitutional
psychopathic
state,
emo
tional instability
Constitutional
psychopathic
inferiority,
without psychosis
Cyst, sacrococcygeal
Dacryocystitis,
chronic
Deafness, unilateral
Defective
physical
development
Deformity,
acquired,
shortness of leg
Deformity,
acquired,
left wrist
Deformity,
acquired,
chest wall
Deformity,
acquired,
finger, loss of flexion
Dislocation,
articular
cartilage, knee
Effort syndrome
Epilepsy
Enuresis
-
Flat foot
Foreign
body,
thigh
(silver wire for treat
ment of fractured femur)
Oonococcus
Infection,
urethra
Hernia,
Inguinal
-
--
Num
ber of
surveys
Cause of survey
Malocclusion,
teeth
Metatarsalgia...
Myopia
....
Myositis, chronic.
Nystagmus
Osgood-Scblatter's
disease
Otitis,
media, chronic
Pansinusitis
Pes cavus
-
-
--.
Pleurisy,
fibrinous,
chronic
Psychoneurosis,
hysteria
-
Psychoneurosis,
neurasthenia
Psychoneurosis,
psyehasthenia
Psychoneurosis,
unclassified
Pyorrhea,
alveolaris
-
Retinitis
•
Rheumatic
fever
...
Rhinitis, atrophic
Somnambulism
Sprain,
left elbow
Stammering
.
Strabismus
.
Strain,
muscle, thigh
Stuttering
Synovitis,
traumatic,
left knee
Syphilis
-
Tonsillitis, chronic
.
Union of fracture, faulty
Valvular heart disease, combined
lesions,
aortic and mitral
Valvular heart disease, mitral
Num
ber of
surveys
o
Nl
Volume XXXVI
OCTOBER
1938
Number 4
United States
Naval
Medical Bulletin
Published for
the Information
of the
Medical
Department
of the Navy
THE MISSION OF THE MEDICAL
DEPARTMENT
OF THE NAVY
m
TO KEEP AS MANY MEN AT AS MANY GUNS
AS MANY DAYS AS POSSIBLE
Issued Quarterly
by the Bureau of Medicine and Surgery
Washington,
D. C.
Vol. XXXVI
OCTOBER
1938
No. 4
UNITED STATES
NAVAL
MEDICAL BULLETIN
Published Quarterly for the Information of
the Medical Department of the Navy
t
Issued by
DIVISION OF PUBLICATIONS
THE BUREAU
OF MEDICINE AND SURGERY
NAVY DEPARTMENT
Compiled
and published
under the authority of Naval Appropriation
Act for 1938-39, approved
April 26, 1938
UNITED
STATES
GOVERNMENT
PRINTING
OFFICE
WASHINGTON
: 1938
For sale by the Superintendent
of Documents,
Washington,
D. C.
See page II for price
Navy Department,
Washington,
March 20, 1907.
This United States Naval Medical Bulletin is published
by
direction of the Department for the timely information of the Medical
and Hospital Corps of the Navy.
Truman H. Newberry,
Acting Secretary.
Owing
to exhaustion
of certain
numbers
of the Bulletin
and the frequent
demands from libraries,
etc., for copies to complete their files, the return of any
of the following
issues will be greatly appreciated:
Volume IX, 1915, No.
1.
Volume X, 1916, No. 2.
Volume XI, 1917, No.
3.
Volume
X11,
1918, Nos.
1 and 3.
Volume XXIV,
1926, Nos.
1 and 4.
Volume XXV,
1927, No.
1.
Volume XXV11,
1929, Nos. 3 and 4.
Volume
XXVI11,
1930, No. 3.
Volume XXXIV,
1936, Nos.
1, 2, and 4.
Volume XXXV,
1937, No.
1.
Subscription
Price of the Bulletin
Subscription
should
be
sent to
Superintendent
of
Documents,
Government
Printing Office, Washington,
D. C.
Yearly
subscription,
beginning July
1,
$1;
for
foreign
subscriptions
add
35
cents for postage.
Single numbers, domestic,
25 cents;
foreign,
35 cents,
which
includes
foreign
postage.
Exchange
of publications
will
be extended to medical scientific
organizations,
societies, laboratories,
and journals.
Communications
on this subject should
be
addressed to the Surgeon General, United
States Navy, Washington,
D. C.
n
TABLE OF CONTENTS
Pago
PREFACE
-
--
vi
NOTICE TO SERVICE
CONTRIBUTORS-
vu
SPECIAL ARTICLES:
Gastric Surgery.
A Discussion
of the Present Day Trends.
By Commander
Frederick
R. Hook,
Medical
Corps, United
States
Navy
455
The Surgical Gall Bladder.
By Commander
M. D.
Willcutts,
Medical
Corps,
United
States
Navy
469
Acute Hemorrhagic
Pancreatic
Necrosis.
A Review
With Case
Reports.
By Lieutenant
A. R. Higgins,
Medical Corps, United States Navy.
477
Diagnostic
Errors in Diseases op the Colon.
With Illustrative
Case Reports.
By Lieutenant
(Junior Grade) John Burke, Medical Corps, United
States Naval Reserve
482
The Treatment
of Lung Abscess.
By
Lieutenant
Roy
M.
Mayne,
MC-F,
United
States
Naval
Reserve,
and
Lieutenant
Commander
T.
Gage
Clement,
MC-V
(S), United
States Naval Reserve
487
Ruptured
Cruciate
Ligaments
op
the
Knee.
Modified
Hey
Groves Reconstruction
Operation With Case Reports.
By Lieutenant E. M. Wade, Medical Corps, United States Navy..
491
Intranasal Procaine
Anesthesia.
By Lieutenant
Commander
Bruce
V.
Leamer,
Medical
Corps,
United
States Navy
498
Corneal Transplantation From the Standpoint of Final Results.
By Commander
Edwin C. Ebert,
Medical
Corps,
United
States
Navy,
and
Lieutenant
Robert
C.
Boy den,
Medical
Corps,
United
States Navy
499
An Improved Method
of Lip Fixation.
For
Harelip
and
Other
Defects.
By Commander
Edwin C.
Ebert,
Medical
Corps,
United
States
Navy,
and
Lieutenant
Robert
C.
Boyden,
Medical
Corps,
United
States Navy
SOI
Facial
Injuries.
Treatment
of
Special
Interest
to
the
Dental
Surgeon.
By Lieutenant
Merritte M. Maxwell,
Dental Corps, United States
Navy
--
501
Fractured Maxillae.
Description
of an Appliance for Reduction and
Fixation With a Case Report.
By Lieutenant
Commander
H. G. Ralph,
Dental
Corps,
United
States
Navy,
and
Lieutenant
Merritte M.
Maxwell,
Dental
Corps, United
States Navy
507
in
rv
TABLE
OF
CONTENTS
SPECIAL ARTICLES—Continued.
Pag,
Apicoectomy.
General
Considerations
and Subsequent
Root Canal
Therapy.
By Lieutenant
R. W. Taylor, Dental Corps, United States Navy..
511
Healing Time in Fractures of the Mandible.
By Lieutenant
C. C. Welch,
Medical
Corps,
United
States Navy,
and
Lieutenant
R.
W.
Taylor,
Dental
Corps,
United
States
Navy
513
Inhalation
Anesthesia.
Physiologic
Concepts
Underlying
Recent
Progress.
By Lieutenant
Albert R. Behnke,
Medical
Corps, United States
Navy
517
A Formula
For Immediate
Chemical Prophylaxis.
By
Rear Admiral H.
W.
Smith,
Medical
Corps,
United States
Navy
522
Active
Immunization Against
Tetanus.
Using
Alum-precipitated
Tetanus Toxoid.
By Captain R. Hay den, Medical
Corps, United States Navy, and
Commander
W. W. Hall, Medical
Corps, United States Navy..
524
Mental
Diseases in the
United
States
Navy.
A Comparative
Analysis
of the Incidence.
By Commander
F. L. McDaniel,
Medical
Corps,
United
States
Navy
536
-
Physiologic Studies
op Helium.
By Lieutenant
A. R. Behnke, Medical Corps, United States Navy,
and Lieutenant
O. D. Yarbrough,
Medical
Corps, United States
Navy.
542
The Health
Record.
By J. S. Marks,
Clerk in Charge, Medical
Record Section, Bureau
of Medicine
and Surgery
559
The Penalties op Upright Posture.
By Lieutenant
Reuben A. Benson,
Medical
Corps, United States
Naval Reserve
563
CLINICAL
NOTES:
An Unusual Case of Injuries Multiple Extreme.
By Lieutenant
Frederick
R. Lang,
Medical
Corps,
United
States
Navy
569
Acute
Traumatic
Diaphragmatic
Hernia.
A
Case
Report.
By
Lieutenant
Commander
J.
M.
Brewster,
Medical
Corps,
United
States
Navy
572
Lesions
of the
Cardiac
Portion
of the
Stomach.
Two
Case
Reports.
By Lieutenant
H. H. Carroll, Medical Corps, United States Navy.
576
Carbuncle of Kidney.
Case Report
With Atypical Symptoms.
By
Lieutenant
Commander
W.
S.
Sargent,
Medical
Corps,
United
States Navy
580
NAVAL
RESERVE
583
NOTES AND COMMENTS:
The Naval Medical
Center —Navy Exhibit Awarded
Special Citation
of Merit—Autopsies — Surgical
Knots—Influenza —Annual Session
of the American
College of Physicians
585
TABLE
OF
CONTENTS
V
BOOK
NOTICES:
Fag«
Surgical
Treatment,
Warbasse
and Smyth —Surgical
Diseases of the
Mouth and Jaws, Padgett —Practical Proctology,
Buie —The Man
agement of Fractures,
Dislocations
and Sprains, Key and Conwell —
Work-book in Elementary
Diagnosis for Teaching
Clinical History
Recording
and
Physical
Diagnosis,
Clendening —Synopsis
of the
Diagnosis
of the Acute Surgical
Diseases of the Abdomen,
Hardy—
Hernia,
Watson —Hemorrhoids,
Pruitt —Physical
Diagnosis,
Sut
ton— Methods
of Treatment,
Clendening —The Role of Chemiotaxis
in Bone Growth,
Bertwistle—The Injection Treatment
of Hernia
and Hydrocele,
Goldbacher —Everyday First Aid, Cobb —Injection
Treatment
of Hernia,
Rice and Mattison—Injection Treatment
of
Varicose
Veins
and
Hemorrhoids,
McPheeters
and
Anderson —
The
New
International
Clinics,
Piersol—Treatment
by Diet,
Bar-
borka —Athletic
Injuries:
Prevention,
Diagnosis,
and
Treatment,
Thorndike—Diseases of the
Nose, Throat, and Ear,
Medical
and
Surgical,
Ballenger
and
Ballenger —Practical Otology,
Rhinology,
and Laryngology,
Schlanser
693
PREVENTIVE
MEDICINE:
Toxic Effect of Arsenical
Compounds.
As Administered
in the
United States Navy in
1937 With Special
Reference
to Arsenical
Dermatitis.
By Commander
C. S. Stephenson, Medical Corps, United States
Navy,
and E.
H.
Wingo,
Chief
Pharmacist's
Mate,
United
States Navy
-
605
Traffic Injuries.
A Study
by
Post
Medical
Department.
By Captain
W. L. Mann, Medical
Corps, United States Navy..
616
Food Poisoning.
In the First Marine Brigade, Fleet Marine Force,
Culebra,
P. R.
By Lieutenant
Commander J. B. O'Neill,
Medical
Corps, United
States Navy
629
Fish Poisoning
in Culebra —Virgin Islands Area.
By Captain
W. L. Mann,
Medical
Corps, United States Navy
631
Food Poisoning.
On Board
the U. S. S. Philadelphia.
By Commander
Oscar Davis,
Medical Corps, United States Navy.
634
STATISTICS:
Health
of the Navy
637
Deaths
639
Mental
and Physical Qualification
of Recruits
640
INDEX
643
PREFACE
The United States Naval Medical Bulletin was first issued in
April
1907
as a means for supplying medical
officers of the United
States
Navy with
information
regarding
the
advances
which
are
continually
being
made
in the
medical
sciences,
and
as a medium
for the publication of accounts
of special researches,
observations,
or
experiences of individual medical officers.
It is the
aim of the Bureau of Medicine
and Surgery to furnish
in each issue special
articles
relating to naval medicine,
descriptions
of suggested devices, clinical notes on interesting cases, editorial com
ment
on current
medical
literature
of special
professional
interest
to the naval medical
officer, and reports
from various sources, notes,
and comments
on topics of medical interest.
The Bureau extends an invitation
to all medical
and dental
officers
to prepare
and forward, with a view to publication, contributions on
subjects
of interest to naval medical
officers.
In order that each service contributor may receive
due credit for
his efforts in preparing matter for the Bulletin of distinct originality
and special merit, the Surgeon
General of the Navy will send a letter
of appreciation to authors
of papers of outstanding merit.
The
Bureau
does not necessarily
undertake to
endorse
views or
opinions which may be expressed in the pages of this publication.
P. S. Rossiteb,
Surgeon General, United States Navy.
VI
NOTICE
TO SERVICE
CONTRIBUTORS
Contributions to the Bulletin should
be typewritten,
double spaced, on plain
paper, and should
have wide margins.
Fasteners
which will not tear the paper
when removed
should
be
used.
Nothing should
be written
in the manuscript
which
is not intended for publication.
For example,
addresses,
dates, etc., not
a part of the article, require deletion by the editor.
The Bulletin endeavors to
follow a uniform
style in heading and captions, and the editor can be spared much
time
and
trouble,
and
unnecessary
changes
in manuscript
can
be
obviated
if
authors will follow in these particulars
the practice of recent issues.
The
greatest
accuracy
and
fullness
should
be
employed
in
all
citations,
as
it has sometimes been necessary to decline articles otherwise desirable
because it
was impossible
for the editor to understand
or verify
references,
quotations,
etc.
The frequency
of gross errors in orthography
in many contributions
is conclusive
evidence that authors
often fail to read over their manuscripts
after
they
have
been typewritten.
Contributions must be received at least 3 months prior to the date of the issue
for which they are intended.
The editor
is not responsible for the safe return
of manuscripts
and pictures.
All materials
supplied for illustrations,
if not original,
should be accompanied
by
reference to the source and a statement
as to whether
or not reproduction
has
been authorized.
The Bulletin intends to print only original
articles,
translations, in whole or in
part, reviews,
and reports and notices of Government
or departmental
activities,
official
announcements,
etc.
All original
contributions
are accepted
on
the assumption that
they
have not appeared
previously and are not
to be reprinted elsewhere
without an
understanding
to that effect and that editorial privilege is granted
to this Bureau in
preparing all material submitted for publication.
Eben E. Smith,
Editor,
Commander,
Medical
Corps, United States Navy.
vn
In this
the last issue of the Bulletin which will appear prior to
my retirement
December
1,
1938, I
take
the
opportunity
to
say
farewell
to my shipmates
of the Naval
Medical
Corps.
Whenever
I have used the term "Naval Medical Corps" I speak of the Depart
ment as a whole;
medical
officers, dental
officers, nurses, and hospital
corpsmen, including not only the active service, but also our splendid
Reserve.
When I became
Surgeon
General,
nearly
6 years
ago, I took the
oath of office humbly and prayerfully, in the hope that I would
be
of use to the Country
and
to the Service
which we all love.
That
prayer has been answered, not through me, but through you, for the
Medical
Department of the Navy has developed
greatly during the
last
5 years.
I am justly proud of having had the honor and distinction to have
served
as the head of our corps, for I speak judicially
and informedly
when I say that I believe it to be the finest
medical
service in the
world.
My pride is in nothing I have
done, but in what the corps
stands for, what it
is,
and what
it
is
accomplishing.
In every
branch of the corps
the loyalty,
devotion to duty,
and
striving for betterment
cannot humanly
be
surpassed.
Many officers, nurses, and corpsmen
are my personal friends of long
standing.
All are known to me through their records.
I
have
been
a
member
of the corps for nearly 36 years.
I
have
enjoyed
every minute of that service;
I
have enjoyed
every duty
to
which
I
have
been assigned.
I
will retire from active service
with
the keenest
personal
regret.
Should there
ever be occasion
for my
recall
to active duty,
I
will
welcome
it.
I
need not ask, for
I
know, that you
will give my successor
the
same loyalty
and
assistance which you have given
me in upholding
the standard to which you have
brought
the United
States
Naval
Medical
Service.
May God bless each one of you.
vm
U.
S. NAVAL MEDICAL BULLETIN
Vol. XXXVI
October
1938
No. 4
SPECIAL
ARTICLES
GASTRIC
SURGERY'
A DISCUSSION OF THE PRESENT DAY TRENDS
By Commander
Fbxderice
R. Hooe, Medical Corps, United States Navy
Fifteen years
ago, the surgical
treatment of gastroduodenal
ulcer
was fairly well standardized.
The chief controversy at that time was
between
the gastroenterologist
and the surgeon
as to which patients
should be treated medically, and which should go to surgery.
Today,
there has been a realinement
of the battling forces, with the gastro
enterologist
sitting snugly on the sidelines.
For experience has taught
him that certain
types
of peptic ulcer cannot be cured
by medical
means alone, and that any extended attempt to do so is apt to end in
disaster.
He, therefore, frequently turns to the surgeon for assistance.
This has left the battle field cleared for the use of the surgeons.
On
the one side are alined
the defenders, members of the old school, who
favor what has
become known
as
the indirect
operations,
such
as
pyloroplasty
and gastroenterostomy.
Their opponents,
the invaders,
belong
to the newer school.
They
are the resectionists,
and believe
in more radical removal
of pathology.
The
proponents
of the old
school
are located in this and other English speaking
countries,
while
headquarters
for the new school has been in the German and Austrian
clinics, with many converts
in this country.
The literature has been so full of these arguments
for the past few
years that even those doing gastric
surgery at times must
become con
fused.
For this
reason
a brief review
of the more
recent
literature
on the subject
should
be of interest.
The basis for this present discus
sion
is a report upon
the gastric
surgery
done in the United
States
Naval
Hospital,
San
Diego,
Calif.,
during
a
recent
tour of duty
in that hospital.
This covers
a
period
of approximately
4 years.
It has often been said that one learns more from his mistakes than his
successes,
so, if in headlining some of our more glaring mistakes
we
can prevent similar errors in the future, this paper will have served a
useful purpose.
During
this period
99 operations
were performed
on
90 patients.
Ninety-six
of these operations
were undertaken for pathology in, or
i Read
before the Honolulu County Medical Society, January 14, 1938.
455
456
GASTRIC
SURGERY—HOOK
thought to be in the stomach
or duodenum,
the remaining three for
lesions outside
these organs.
As might be expected the major part of
the work was occasioned
in the treatment of peptic ulcer, its compli
cations and sequellae;
76 of the 90 patients
falling under this heading.
Malignancy
was a poor second with only nine patients.
PERFORATION
Acute perforation of gastroduodenal
ulcer is of common
occurrence
in the naval service.
It is a condition that any medical officer may be
called
upon
to
treat
at any time.
Some writers have
reported
its
frequency in as high as 7 percent
of all peptic
ulcers.
It is the most
dramatic of all acute surgical
conditions and also the most remediable
if
treated
early
and
properly.
Given
a
patient,
usually
a
male
commonly with a history of stomach
trouble,
who has sudden, severe,
agonizing
pain
in
the pit of
the
stomach
associated
with
shock,
sweating,
and boardlike rigidity of the abdomen,
one needs little more
to complete
the picture.
The shock usually subsides within
a short
while but the pain, boardlike rigidity
and tenderness
persist
and are
of such intensity that as a rule little difficulty is encountered
in making
the diagnosis,
especially in the younger age groups.
In older patients
however,
the diagnosis
may be more difficult,
as we will attempt to
show later in a study of our deaths.
In this
series there
were
36 acute
perforations.
Thirty-five
were
due to benign lesions and one to a malignancy.
Twenty-three perfora
tions
were on the duodenal
side of the pylorus and
12 were on
the
gastric
side.
The malignant perforation was in the stomach.
One
perforation occurred
in a gastrojejunal ulcer.
The perforations were
all on the anterior surface of the stomach or duodenum
except the one
due to carcinoma
which was in the posterior wall of the stomach.
The
youngest patient was 20 years of age and the oldest
71.
The average
for this group was 41 years.
Fourteen percent were under 30 years of
age, 36 percent were in their 4th decade, 22 percent in the 5th,
17 per
cent in the 6th, and
11 percent were more than 60 years of age.
In the
five deaths due to benign lesion perforations the ages were, 31, 47, 61,
66, and 71 years respectively,
an average of 55 years as against
41 years
for the entire group.
This would suggest that age is quite a factor in
establishing
the mortality
rate.
Age undoubtedly does play
a part
but probably only in an indirect manner.
In the older patients,
coro
nary, cholecystic,
and pancreatic
diseases are much more common
and
the diagnosis is frequently confused with these conditions, all of which
delays
the necessary surgery.
Seven
patients
(19.5 percent)
gave
no history
of gastrointestinal
symptoms
previous
to their perforation.
The remaining had
com
plaints ranging from 2 weeks to
17 years, and averaged
3.4 years.
Of
the 36 patients,
34 were operated.
In two patients the diagnosis was
GASTRIC SURGERY—HOOK
457
made only at the autopsy table.
The time elapsing between perfora
tion and operation
ranged from
3 to 48 hours,
and averaged about
1 1
hours.
In the
3 fatal operative
cases
the time
was,
19,
24,
and
34
hours respectively.
Three of the six fatal cases perforated while under
medical
treatment in the hospital.
With surgery
close at hand
this
would seem
to be the ideal
time to perforate.
The records however,
show that operation
was delayed in two of the patients by tardy diag
noses, and in the third the diagnosis
was arrived at only at the post
mortem examination.
On admission
the temperature
range in these patients was from 97°
F. to 100.6°, 98.8° being the average.
The pulse rates ranged between
78 and 120 and averaged 93.
The systolic blood pressure was recorded
as under
100 in only two patients.
The leukocyte counts
ranged
be
tween
5,600 and
24,900.
Schilling differential
counts
ranged
from
normal to a marked
shift to the left.
In one fatal case in which the
total leukocyte count was 5,600, the differential showed
96 percent
granulocytes.
Nineteen patients had radiographic examination
of the abdomen for
pneumoperitoneum.
Twelve showed
a positive gas bubble
and seven
were negative.
A positive radiograph confirms
the diagnosis
but too
much dependence
should not be placed
on negative
findings,
as even
with the best technique
only about
80 percent
show gas bubbles.
The amount of free fluid found in the general
peritoneal
cavity at
the time of operation
was estimated
at anywhere
from a few cubic
centimeters
to 800 cubic centimeters.
The perforations as a rule were
described
as small, being under
1 centimeter
in diameter.
There were
no multiple perforations.
Moderate to marked
induration about
the
perforation was the rule.
Plastic
exudate
was frequently recorded.
In the one patient in which drainage was instituted the surgeon did not
give his reason for doing
so.
In a few patients the ulcers were cauterized
with the actual cautery
previous to repair, but the majority of the lesions were simply closed
by fine chromic gut sutures
and then covered
over with an omental
patch.
Owing
to
the
marked
scarring
and
induration
about
the
pylorus, a partial gastrectomy
was done on one patient and a gastro
enterostomy
in conjunction with simple
closure in a second patient.
One patient in which a simple closure was done returned
a few months
later with obstructive symptoms
and was relieved
by gastrectomy.
The
combined
operative
and nonoperative mortality
rate in this
series is
16.6 percent.
In computing the operative
mortality
rate it
is only fair that we exclude the perforated
gastric
carcinoma
and the
perforated
marginal ulcer,
as we know that both of these conditions
give notoriously high
death rates.
The two patients
that died with
out operation, naturally,
cannot be included in operative
statistics.
We
therefore
have
2
operative
deaths
in
32
patients with
acute
458
GASTRIC
SURGERY—HOOK
gastroduodenal perforations,
a mortality
rate of 6.25 percent.
The
average rate given in the literature is from 10 to 15 percent in patients
operated
under 12 hours,
but some clinics report rates
as high as 47
percent.
Gatersleben
and
Zitzmann
were
able
to
reduce
their
mortalities from 31.5 to
21 percent
by discontinuing
gastroenteros
tomy in
conjunction
with
the
suture
of
the
ulcer.
Some
of
the
central European clinics favor partial gastrectomy as the operation
of choice in the treatment of acute perforations.
Judin has reported
the low mortality
rate of 7.8 percent in several
hundred resections.
For the conservative
operations
he reports
a mortality
rate of 32.2
percent,
and explains this by stating that gastrectomy was performed
in the more
recent
cases
and for the most
part in young patients,
while the conservative
operations
were performed
on elderly patients
in whom peritonitis
was advanced.
Primary
gastrectomy
was per
formed in over
80 percent of his patients with acute perforations.
There was a time when we thought that an acute perforation cured
the
ulcer.
This
undoubtedly
does
occur
at
times
but symptoms
continue only too frequently after perforation
to call it "a blessing
in disguise."
Following
is a brief review of our six deaths following acute
per
forations:
Case
No.
1.
D. J. C.;
Male,
31
years
of
age.
Developed
sudden,
sharp,
stabbing
pain
in upper
right
abdomen
18 hours
previous
to admission
to the
hospital.
There was no history
of previous
gastrointestinal
complaint.
He had
been seen
by
a physician
shortly
after
onset of symptoms
and given
capsules
without
relief.
At operation,
19 hours after onset, there was found
a prepyloric
perforation
with
green
pea soup
and
fibrin
in
the
general
peritoneal
cavity.
Death
occurred
on the 16th
postoperative
day.
Autopsy
showed acute general
peritonitis,
subphrenic
abscess
which
had ruptured
through
the diaphram
into
the base of the lung, lung abscess
and pneumonia.
Case No.
2.
I. Y.; Male,
61 years of age.
History of stomach trouble
for
10
years.
He was admitted
to the hospital
on December
11,
1934,
2 days after
a
severe
hemorrhage from the gastrointestinal
tract.
He did fairly well on medical
management
and in about
3 weeks a gastrointestinal
X-ray
study
was
made
and reported
upon as being negative except for gastroptosis, atony, and dilation
of the stomach.
On January
26,
1935,
the
patient
complained
of
heartburn
and got some
relief by inducing
vomiting.
The following
day he complained
of
cramps in the lower abdomen and marked muscular rigidity was present.
Lapa
rotomy showed a small perforation
on the gastric side and about
800 cubic centi
meters of fluid in the
general peritoneal
cavity.
The
patient
died about
30
minutes
after
completion
of the operation.
Death
was probably
due to shock
from the spinal anesthesia, superimposed
upon an old cardiac lesion.
This patient was a stoical old Japanese whose reaction to pain was
undoubtedly
unlike
that
found
in
our
average
patient;
however,
when
seen by the surgical consultant
24 hours after perforation, it
was difficult to understand
why the diagnosis
had not been arrived at
earlier.
GASTRIC SUKGERY—HOOK
459
Case No. S. D. R. ; Male,
66 years of age.
Admitted
to the surgical service of
the
hospital
on
December
3,
1934,
with
a
diagnosis
of
gallstone
colic.
The
patient had been perfectly well until the day of admission, when he was suddenly
seized with a severe
abdominal pain that felt as if something "burst" in his abdo
men.
Pain was aggravated
by deep
breathing
or any
change
in position.
The
blood
pressure
was
96/58.
The
abdomen
was diffusely
rigid
and there was ex
quisite
tenderness over the gall bladder region and the epigastrium.
The leuko
cyte count was 5,750 with
a normal differential.
He had had morphine
previous
to admission to the hospital and this was continued
by the ward surgeon.
After
2 days of observation
he was transferred
to the medical service, and 10 days after
admission
death occurred.
Postmortem
examination
showed a perforated duode
nal ulcer with generalized peritonitis
and a large abscess
in the right upper abdo
men.
Morphine
and the patient's age had much to do with confusing
the
diagnosis
in this patient.
Case
No.
4- J- H. K.;
Male,
71
years of age.
Admitted
to the hospital
on
November
1,
1935, with
a current
gastro-intestinal
complaint
of about
2 weeks,
duration.
He had been nauseated for 2 weeks
and had passed
some tarry
stools.
He
gave
a history
of
a similar
attack
2
years previously.
A gastrointestinal
X-ray study 6 months previous to this admission showed a third degree gastropto-
sis and visceroptosis but no ulcer.
On the day of admission
he had been awakened
by pain and vomited
coffee ground material.
Upon admission
his abdomen was
soft
and there
was
no
tenderness or palpable
mass.
Three
days later
he com
plained
of pain at 2 a. m. and this was controlled
by amytal
gr.
1%.
Nine days
after
admission
the
patient
had sudden
severe
pain in the epigastrium,
accom
panied
by vomiting.
This occurred at
10 p. m.
He
was
seen by the officer-of-
the-day who ordered H Sr- of codiene by mouth.
Forty-five minutes later
he was
still complaining and perspiring profusely and was given another M grain of codiene.
One hour later
% grain of morphine
was administered
by hypo.
The following
morning
the abdomen was tender to palpation,
especially in the left lower quad
rant,
but it was
not particularly
rigid.
He was still
complaining
of abdominal
pain and his general condition
was not good.
His temperature
was
96.4 and the
pulse rate was 120.
The leukocyte count was 5,600 with 96 percent granulocytes.
Supportive
treatment
was rendered and hypnotics
given
for
pain,
and
on the
following
day the paitent
died.
Autopsy
showed a perforated
prepyloric
ulcer
with acute generalized peritonitis.
Here again we have age and hypnotics, plus a recent negative gastro
intestinal X-ray study for ulcer,
confusing
the diagnosis.
It is well
to keep in mind that ptotics not only can, but frequently do have, ulcer,
and
that any
belief
to
the contrary
is entirely erroneous.
Several
writers have
noted
the absence of typical boardlike rigidity
in per
foration in the aged.
Case No. 5. A. J. J.; Male,
47 years of age.
Admitted
to the hospital
Septem
ber 13, 1934, with a history of current
gastrointestinal
symptoms of only
2 weeks,
duration.
Complained
of constant epigastric pain without
reference to the taking
of food.
Pain
was gnawing in character and there was localized
soreness
to the
left of the midline.
A diagnosis of peptic ulcer had been made in 1926 on X-ray
findings of spasm of the pylorus
with
a deformity
of the lesser
curvature.
Two
days after admission
to the hospital
he had severe
abdominal
pain for which he
was given two
injections
of morphine.
On the following
day
he continued
to
have severe
abdominal
pain and three injections
of morphine
were administered.
460
GASTRIC
SURGERY—HOOK
About 34 hours after onset of pain a surgical consultation
was requested and at
that time a typical
boardlike
abdomen was found.
Upon opening the abdomen a
large amount
of fluid and plastic exudate
was found, but an extended search by
the surgeon failed to locate the perforation.
The patient
died
2 days later and
autopsy showed a perforated
gastric ulcer 3.5 centimeters in diameter located on
the posterior wall.
Pathological
study of this ulcer proved it to be carcinomatous.
This patient was handled poorly from all angles.
The ward medical
officer
and the officer-of-the-day erred in repeatedly
giving morphine
in the presence
of severe abdominal pain
and rigid abdomen.
The
surgeon
erred in that, on finding fluid in the general peritoneal
cavity
typical of perforation, he did not explore
the lesser peritoneal
cavity.
Case
No.
6. T.
O.
M. Male
51
years of age.
llad had a gastroenterostomy
4 years previously.
Was free of gastrointestinal
symptoms
for awhile
but lately
symptoms
had returned.
On the day of admission
he developed
severe
upper
abdominal
pain and vomiting.
He
was operated shortly
after admission
to the
hospital
and a ruptured
jejunal
ulcer was found.
The
gastroenterostomy
was
unhooked, the ulcer repaired, and a tube inserted into the jejunum
for the purpose
of feeding.
The patient died on the following
day.
There is no criticism to offer in the handling of this case.
Perfora
tion of a jejunal ulcer is always
a very serious condition and carries
with it a high mortality rate.
Earlier in this discussion
we stated that an attempt would be made
to show that age in itself was not the chief factor in establishing
the
mortality
rate
in perforation, but that diagnosis
was made with less
ease
in the older
age
groups.
This
contention I believe
is proved,
as 4 of the 6 patients
were more than
50, and
3 more than
60 years of
age.
In three of these patients the finger points directly at hypnotics
as
a
contributing
factor
in
obscuring
the
diagnoses.
One
should
never lose sight of the fact
that morphine is an extremely
dangerous
drug to use in the acute surgical
abdomen until the diagnosis
is made,
for frequently the average sized dose will bring about marked
changes
in the clinical picture.
One patient was operated
upon for a chronic perforating ulcer and
perigastric
abscess.
The
perforation
was
closed
and
a
posterior
gastrojejunostomy
performed.
The
patient
made
an
uneventful
recovery.
Before leaving
the
subject
of
acute
perforation I would like
to
emphasize
the importance
of:
1. Early
diagnosis
and
operation.
The
operative
mortality
rate
will remain
low in patients
operated
under
12 hours.
2.
Simple
closure
of the perforation without
resorting
to further
surgery
at that time.
3. No drainage of the peritoneal
cavity as it is not only unnecessary
but increases the morbidity.
4. Judicious
use of the stomach
tube
in
the
early
postoperative
treatment.
If the stomach
is kept empty there is little danger from
GASTRIC SURGERY—HOOK
461
a blowout of a repaired
ulcer,
regardless
of the amount of narrowing
of the lumen
of the gut.
GASTRECTOMY
The records show that during this same period 28 gastrectomies
were
performed.
If less than 50 percent of the stomach was removed it was
classed
as a partial gastrectomy,
if more than 50 percent,
a subtotal
resection.
The
postoperative
diagnoses
in
these
patients
were:
chronic duodenal
ulcer
17, acute perforation of a duodenal
ulcer
1,
gastric ulcer
1, combined
gastric
and duodenal
ulcer
2, carcinoma
of
the stomach
4, lymphosarcoma
of the stomach
1, tuberculosis
of the
stomach
1, and diverticulitis of the duodenum
1.
These
patients
ranged from 21
to 59 years in age and averaged
39
years.
The
4
carcinoma
patients
averaged
49
years
of
age.
The
patient with lymphosarcoma
was
44
and
the one with
tuberculosis
25 years of age.
The peptic
ulcer patients
gave histories
of stomach
trouble
of
3
weeks
to
24
years
duration,
and
averaged
5.8
years.
The 4 cancer patients
had gastrointestinal complaints for 3 months,
6 months,
11 years, and
14 years respectively.
Of the
21
patients
that had gastrectomy
for peptic ulcer,
10 gave
histories of having
had
single
or repeated
hemorrhages
from
the
gastro-intestinal
tract.
Eleven
had
persistence
of symptoms
while
under medical
treatment.
Two had had previous
acute perforations,
and
7 of the 21 had pyloric obstruction.
Three of the four carcinoma
patients
had
gastric
retention.
The
type
of operation
employed
was: Billroth I
1,
Polya
3, Finisterer's
resection
for
exclusion
5,
and Polya-Balfour
19.
The amount
of stomach
resected in the duodenal
ulcers
was esti
mated at from 40 to 60 percent,
and averaged about
50 percent, while
in the gastric
ulcers and malignancies
it averaged about
80 percent.
In these 28 gastrectomies
there were three operative
deaths.
Two
followed resection
for cancer,
and
one for a very large peptic
ulcer
located
high on
the lesser curvature of the
stomach.
One
cancer
death
was
due
to
an
operative
accident
caused
by
a very friable
gastrohepatic
omentum, which made control of hemorrhage
extremely
difficult.
The other
cancer patient was doing
well
up
to 48 hours
and died suddenly
from a pulmonary embolism.
Death in the benign
gastric
ulcer patient occurred
100 days
after operation.
Following
the operation
he
developed
a pulmonary
atelectasis,
which in turn
was followed
by bilateral suppurative pleurisy,
bilateral rib resection,
and finally
death
from
general
sepsis.
Although
approximately
85
percent
of his
stomach
had
been
resected,
the
remaining portion
functioned well during his long illness.
Atelectasis,
clinically
demonstrable,
was
noted
during
the
con
valescence
of four
patients,
pneumonia,
in
two,
empyema
in
two,
462
GASTRIC SURGERY—HOOK
poorly functioning
stoma
in three,
and
acute jejunal obstruction
in
one
patient.
Absence
of
free HCl
or
marked
hypoacidity
was
a
common
finding following operation.
It is entirely too early in many of these patients to speak of end
results, but the early results
as a whole have been gratifying in resec
tions
for
benign
lesions.
The
immediate
convalescence
is
usually
quite smooth,
especially if the stomach
is kept empty with
a Levine
tube
passed through the nose.
This
may
be
allowed
to remain in
continuously
or the
stomach
emptied
at frequent
intervals.
It
is
not
unusual
for patients
to complain of fullness
and
nausea
after
meals,
but
this
complaint
persisted
in oidy
three of our patients.
These patients were 23, 24, and 30 years of age respectively,
and had had
symptoms
for only
1, 3, and 4 years.
Many writers have noted
the
unsatisfactoriness
of
pyloroplasties
and
gastroenterostomies
in
the
young,
possibly
this
also
holds
true
for
gastrectomy.
With
our
present
knowledge
it would seem inadvisable to offer surgery
to this
class of patients
unless an emergency
exists.
Reoperation has been
done
in
one of these
patients
with
the
establishment
of
a
stoma
between
the afferent
and
efferent
loops of the jejunum, which gave
relief from symptoms.
One patient in which a Polya
type of opera
tion was done developed
an acute obstruction 3 weeks after operation,
due to kinking of the proximal jejunal loop.
At reoperation
the loop
was straightened
out and
a diseased gall bladder
removed,
following
which the patient made
an excellent
recovery.
It is rather unusual
that a case of lymphosarcoma
should
appear in
such a small series as this, as it is supposed to occur in about the ratio
of
1 to
150 carcinomas.
This patient is in good
health
more
than
2 years after resection
and radiation.
The patient with tuberculosis
of the stomach is of interest.
He was
a young man 25 years of age, whose chief complaint was intermittent
vomiting
of
6 months' duration.
The X-ray
showed
a prepyloric
ulcer
with obstruction.
X-ray of the
chest
was
reported
as
being
negative
for lung pathology.
Following
a course of medical
treat
ment
the X-ray findings became more positive
and malignancy was
suggested.
At operation
an ulcer the size of a silver dollar was found
on the lesser curvature of the stomach.
Sections from this ulcer were
first reported
upon by the pathologist as being lymphosarcoma.
A
further study however,
showed tubercle bacilli in the deeper structures
of
the
ulcer,
and
a
few
months
following
the
gastrectomy,
small
shotty inguinal glands appeared.
Sections from these glands showed
typical
tuberculous
lesions
and
material
injected
into
guinea
pigs
produced
tuberculosis
in
those
animals.
Gastric
tuberculosis
is
seldom
found in
patients
who
do not
have
advanced
pulmonary,
osseous, or glandular
tuberculosis.
Eustermann
and
Balfour
state
that there has never been a proved
case of primary gastric tuberculosis
GASTRIC SURGERY—HOOK
463
reported.
Fortunately,
we were able to get a second roentgenologist
to report a healed lesion in the right upper
lobe of the lung,
which
relieved
us of the burden of attempting to prove that the disease was
primary in the stomach.
It has been almost
2 years now since the
patient's gastrectomy.
He has regained
his normal weight,
works
regularly, and is in apparent
normal health.
GASTROENTEROSTOMY
Seventeen
patients were subjected
to gastroenterostomy;
15 were
for peptic
ulcer,
12 being
on the duodenal
side and
3 gastric.
One
was done as a palliative measure in an inoperable
cancer, and the final
diagnosis in the other patient was pernicious
anemia.
The cause for
the
gastric
retention in
this
patient
was not determined.
In
this
group the patients ranged
from
23 to 67 years of age,
and averaged
44 years.
As a group they were 5 years older than the gastrectomized
patients.
Gastrointestinal symptoms
had been present on an average
of
5 years.
The indications for operation
were
given
as: —gastric
retention, induration and fixation of the duodenum
and pylorus, poor
condition of the patient which would make gastrectomy
inadvisable,
no improvement in complaint under medical
treatment,
hemorrhage,
previous
perforation, and inoperable
carcinoma.
Sixteen
of the gastroenterostomies
were of the
posterior
no-loop
type
and
one was
of
the anterior
type.
There
were
no
operative
deaths and satisfactory results
were obtained
in all but two patients.
In the cancer patient the operation was purely palliative and the patient
died
after
a few
months.
One
posterior
gastroenterostomy
was
a
complete failure and had to be taken
down
and a gastrectomy
done.
No reason could
be determined
for its failure to function.
Following
gastric
resection
the patient made
an excellent
recovery.
MISCELLANEOUS
OPERATIONS
In two
patients
simple
excision
of a peptic
ulcer
was done.
One
was for
a gastric
and
the other
a duodenal
ulcer.
Neither
proved
satisfactory.
Symptoms were not relieved
by excision
of the gastric
ulcer.
The patient in whom
a duodenal
ulcer was excised, returned
to the hospital in about 6 months
with jaundice which was thought
to be due to injury to the common duct at the time of operation.
A
cholecystgastrostomy
was done, which gave relief for awhile,
but the
stoma closed off later and had to be reformed.
The patient still has
recurring attacks of jaundice and intestinal hemorrhages.
In
one patient
a Judd
pyloroplasty
was
done
without
relief
of
symptoms.
Frequently
one is tempted
to do one of
these
so-called
minor operations
to evade
a more
serious
procedure,
but their
use
generally
has been disappointing, and
they carry an operative
mor
tality rate on a par with gastroenterostomy.
86860—38
2
464
GASTRIC
SURGERY—HOOK
Gastroenterostomies
were
un-hooked
in
four
patients;
once
for
perforated
jejunal ulcer, twice due to vicious circle,
and once because
both the stoma
and pylorus failed to function.
A gastrostomy was
performed
on one patient for the
purpose
of
feeding and dilatation of an esophageal stricture following an attempt
at suicide by drinking lye.
Two patients were explored
and found to
have inoperable
carcinoma
of the stomach
and nothing further done.
In three patients the clinical history, laboratory,
and X-ray findings
pointed
rather
definately
toward
organic
lesions
in
the
stomach.
However, exploratory incision into
these stomachs
failed
to
reveal
pathology that would warrant gastric resection.
In one patient
the
final
diagnosis
was chronic gastritis, in another hypertrophy
of the
gastric rugae, and in the third, subacute inflammation of the appendix.
All
returned
to duty symptom free.
Three
cholecystgastrostomies
were performed,
two in the one patient mentioned
previously following
an injury
to the common duct, and the third in a patient with cancer
of the head of the pancreas.
Until
someone
discovers
the
cause of peptic ulcer,
its treatment
must rest entirely upon an empirical basis.
Our aims at the present
time are to relieve symptoms,
to delay relapses, and to prevent com
plications.
Cure is only problematical.
When these conditions can
not be brought about by medical
management,
surgery
is then to be
considered.
It is not always
easy to know when this point has been
reached.
Lahey gives
us six reasons for considering
surgery
in the
presence of peptic
ulcer.
They are:
1. In patients with perforations.
2. In patients who cannot be relieved of distressing
pain associated
with ulcer.
3. In patients with
ulcer in whom treatment with alkalis cannot
be carried out because of the onset of alkalosis.
4. In patients with pyloric obstruction medically non-relievable.
5. In patients with serious recurrent hemorrhage.
6. In patients in whom
the
absence
of malignancy in the
lesion
cannot
be settled.
The chief
argument
at the present
time
is not
so much
when
to
operate,
as what type
of operation to employ,
especially
in chronic
duodenal
ulcer.
The
conservatives
insist that resection
of
a large
part of the stomach
in the treatment
of
a lesion
that is outside
of
that
organ
is entirely
too
radical.
The
resectionists
counter with
the statement
that, only by
resection
can the gastric
acidity
be re
duced
and
the incidence
of jejunal
ulcer
lessened.
Jejunal ulcer is
and probably always
will
be the big bugaboo
of all gastric
surgeons.
Just why there should
be such
a great variation
in its frequency as
reported
by
the
various clinics is entirely
unexplainable.
Its
fre
quency
following
gastroenterostomy
has
been reported
in literature
GASTRIC
SURGERY—HOOK
465
as low as
2 percent
and
as high as
51 percent.
Balfour
gives it as
3.2 percent
at the Mayo Clinic,
Straus,
as
20
to
30 percent
at his
clinic in Chicago, and Lewisohn of New York
as 34 percent.
Prac
tically all of the central European clinics report high rates,
and it is
for this
reason
that gastrectomy
has
become
so popular
there.
In
Berg's
clinic
they
were
able
to
reduce
the
incidence
of marginal
ulcer from
34
to
7 percent
by substituting
gastrectomy
for gastro
enterostomy.
Although
gastrectomy
has been used for years in the treatment of
gastric lesions,
it was not until
1920
that Haberer introduced
this
more radical method
of partial gastrectomy
as the method
of choice
in the treatment of duodenal
ulcers.
If gastrectomy
is to supplant
gastroenterostomy
it must answer
two requirements:
1. The
opera
tive mortality
rate
must be no higher than in
gastroenterostomy,
and 2. The number of recurrent ulcers must be lower than in gastro
enterostomy.
Operative mortality rates following gastrectomy
have been reported
as low as
1.5 percent
but in most clinics the rate will probably run
somewhere
between
5 and
10 percent.
The
average mortality
rate
given
for gastroenterostomy
is
2 to
3
percent.
Jejunal ulcer
with
its frequent complications is at times
a formidable condition.
Judd
pointed out years
ago the danger of depending
upon
medical
treat
ment in this type of ulcer.
Subtotal gastrectomy
for the eradication
of a marginal ulcer
is accompanied
by
a mortality
rate of at least
20 percent.
There is no question
but that lower acid
values
are obtained in
gastrectomy
than
in gastroenterostomy,
but here
again
authorities
disagree on why this occurs.
Some contend
that it is due to regurgi
tation of alkaline duodenal
juices into the stomach,
while others
say
it is due to resection
of acid bearing
portions of the stomach.
Paggi
concluded,
after an
extensive
study both
before
and
after gastro
enterostomy
and gastrectomy,
that the lowering of the gastric acidity
is due to modification of the gastric
secretion
produced
by resection
and not to neutralization of the secretion
by the presence of bile or
alkaline
fluids
backing
up
through
the
neostomy.
The
gastric
hypoacidity
is maintained for a long
period
of time
and
sometimes
increases
as time elapses.
The
antagonists
of gastrectomy
point
to
the
danger
of so-called
resection
anemia
developing
as late
as
5 or
10 years
after
extensive
gastric resection.
Manizade
studied
40
patients
in whom
extensive
resections
had
been done
5 to
12 years
previously, and found that
four
(10 percent)
had
anemic
blood
pictures.
Certainly
this feature
of gastrectomy
cannot be entirely ignored
and further studies
along
this line are in order.
466
GASTRIC
SURGERY—HOOK
Considerable
diversity of opinion also exists as to the treatment of
hemorrhage
in peptic
ulcer.
The incidence
of this complication has
been estimated
at 27 percent of all ulcers.
Under medical
treatment
there is a mortality
of about
1.5 percent.
As the operative
mortality
rate in any
type of gastric
surgery
is higher than
this,
conservative
treatment
would seem
to be indicated.
Keifer
reports
that 40 per
cent of his patients
that had one hemorrhage
failed to get good results
from medical
management.
Where a second
hemorrhage
occurred,
80 percent failed to get satisfactory results.
Most of the bleeding in
ulcers
arises from the
pancreatoduodenal
artery located
in the pos
terior duodenal
wall.
We know that gastroenterostomy
will not pro
tect against
further hemorrhage,
and
also that the location of these
ulcers frequently makes resection
extremely
difficult.
In acute hem
orrhage
the patient's age will frequently be the deciding
factor as to
whether
emergency
surgery
should
be
performed,
or conservative
treatment
carried
out.
The
young patient
will
seldom
die
from
hemorrhage,
while the patient of 50 or over with arterosclerosis
may
easily do so.
There is little
argument
against
gastrectomy in the treatment of
prepyloric
ulcers,
as many of them
perforate,
and
they
frequently
cause deformity and gastric
retention.
They
do not do well follow
ing gastroenterostomy,
and there is always
the danger of their becom
ing malignant.
Here again we meet with a wide diversity of opinions
as to the relationship of gastric ulcer to gastric carcinoma,
for McCarty
considers
68 percent of gastric
ulcers
as forerunners
of cancers, while
Wilensky
and Thalheimer think it is as low as
1 to
2 percent.
On
examination of a large series of gastric
ulcers removed
at operation,
Stewart found malignancy in 9.5 percent, Pauchet in
15 percent,
and
Finisterer in 26 percent.
Hinton
and Trubek,
after studying a large
series of cases
over an 8-year
period
of time, came to the conclusion
that about
5 percent
will
show malignant changes.
Others believe
that about
30 percent
of all prepyloric
ulcers
become malignant as
against
only
2
percent
in
the
corpus.
Two
of our gastric
cancer
patients
gave histories
of having had gastrointestinal complaints for
1 1 and
14 years respectively.
There is no proof that malignant degen
eration
occurred
in preexisting
prepyloric ulcers in these patients,
but
it is easy to believe that such might be the case.
The problem
of what to do with the chronic callus ulcer about the
pylorus and first portion of the duodenum
is at times quite trying.
This is the type of ulcer that causes marked
scarring
and deformity,
and frequently causes gastric
retention.
Technically, gastrectomy in
some of these patients
is extremely
difficult and frequently inadvis
able,
as irreparable damage may be done to the pancreas,
its ducts,
or to the common
bile duct.
At times it is impossible
to get enough
of
a normal
duodenal
stump
to infold
after
resection.
The
ideal
GASTRIC SURGERY—HOOK
467
operation for this type
of lesion
is the
"resection
for exclusion" of
Finisterer.
With it no attempt is made to resect that portion of the
viscus in which the ulcer is located.
The antrum with a portion of
the body is resected with the idea of lowering the acidity.
A primary
mortality rate in this type of operation
has been reported
by Friberg
as 4.4 percent,
as against
12.6 percent for the radical resections.
Per
manent results
were obtained
in 87.7
percent,
which was as good
as
with the radical resection
and better
than with gastroenterostomy.
Gastroenterostomy
undoubtedly has
a place in the treatment of
peptic ulcer,
and certainly much of the blame that has been heaped
upon it for causing jejunal ulcers should
be placed
where it belongs,
that
is,
on the surgeon.
It
is
a
fairly simple
operation
to do, but
is
frequently done poorly, and in patients
where the indications for
it
do
not exist.
The ideal
place for gastroenterostomy
would seem to be
in the patient beyond
50 years of age, who has few active
symptoms
and
a
fairly normal acidity.
In this type of patient the symptoms
are frequently due to gastric retention from a healed ulcer about the
pylorus.
One such patient in this series gained
60 pounds in weight
during the
2
months following his operation.
There
is
no place in surgery where individualization
is
more desirable
than in gastric
surgery.
Each
case should
be entered
upon with an
open mind, and the choice of operation deferred until the abdomen has
been explored.
The surgeon, then, should have the ability and exper
ience to carry out the work indicated.
Time will not permit more than
a
brief mention of the salient
fea
tures
in
the preoperative
preparation
and
the
postoperative
treat
ment of these patients.
The preoperative
features
that appear
most
important are:
1.
Correction of dehydration,
if
present.
2. Gastric lavage in patients with retention.
3. Transfusion in hemorrhage
patients.
It should
be remembered
that
a
poorly managed
preoperative
or
postoperative
regime may vitiate the most brilliant surgery.
The outstanding features in the postoperative
care are:
1.
Sufficient
morphine to keep the patient comfortable.
2.
Use of the Levine stomach
tube, either continuously or at fre
quent intervals for the first
2
or
3
days.
3.
Administration
of large
amounts
(3,500
to 4,000)
cubic centi
meters of glucose and saline solutions parenterally for
4
to
5
days.
4. Transfusions following extensive
operations.
5. Frequent changes of the patient's position in bed to prevent pul
monary complications.
6. Pulmonary hyperventilation by using carbon dioxide rebreathing
bag frequently for the first 48 hours.
7. Judicious feeding under the direction of the gastroenterologist.
468
GASTRIC
SURGERY
HOOK
SUMMARY
Many writers now consider peptic ulcer as nothing more than a local
manifestation of a systemic
disease.
The subject is so complex
that
few hard and fast rules, generally
applicable,
can be laid down for its
therapy.
Certainly,
surgery must be classed only as an adjunct, and
has no place in the therapeutic
regime until all medical
means of con
trolling
the disease have
been exhausted.
This means that a fairly
small percentage of all ulcers eventually come to surgery.
The chief role that surgery has to offer appears to be in the reduction
of gastric
acidity and the relief of gastric retention.
Gastroenteros
tomy fails to do the former in many cases, and it is probably due to this
reason that it has been found wanting.
On the other hand, by resec
tion of large portions of the body of the stomach,
hypoacidity or an-
acidity can
be brought about.
This
would seem to
be the nearest
approach
to, if not the ideal surgical,
treatment
at the present time.
There is always
a veil of enthusiasm
that helps to obscure
the real
facts in any new method
of
treatment.
The
present
popularity
of
gastrectomy is
no exception.
The
resectionists,
by experience
and
refinement
of operative
technique,
have markedly reduced
the mortal
ity rate in gastrectomy,
but the questions
of permanence
of cure and
the occurrence of late resection
anemia have not as yet been answered
to the complete satisfaction of the conservatives.
One might reason
ably prophesy that, when all of the facts are in and the final analysis is
made, there will be ample room in the surgeon's kit-bag for both gast
roenterostomy and gastrectomy,
and that the wise surgeon will be the
one who knows how, and when, to make
use of both.
Bibliography
Balfour,
D. C., Ann. of Surg.
Vol.
92:
638-639, October
1930.
Eusterman
and Balfour, Text book.
Stomach and duodenum.
W. B. Saunders
Co.
Friberg,
S., Acta.
Chirurg.
Scand.,
1936,
78:
157.
Gaterslcben,
H. and
Zitzmann,
K., Bruns'
Beitrage
zur klinischen
chirurgie,
163: 337-342, April
15, 1936.
Haberer,
H., Arch, fklin Chir., 114:
127, 1920.
Hinton, J. Wm., and Trubek, Max., S. G. and O. 64:
16-21, January
1937.
Judd, E. S., and Hoerner,
M. T., Ann. Surg. 102, December
1925.
Judin,
S. S., S. G. and O. 64: 63-68, January 1937.
Keifer, E. D., Surg. Clin, of N. A., 14: 1073-1083, October
1934.
Lahey, Frank H., Surg. Clin, of N. A. 14: 1085-1095, October
1934.
Lewisohn,
R., J. A. M. A., 106: 684-687, Feb. 29, 1936.
Manizade,
M. D., Wemer, klin.
Wochenschrift.
Vienna., 50: 1455, Oct. 22, 1937.
McCarty, W. C., S. G. and O.,
10: May 1910.
Paggi, Bruno, II Policlinico
(Sez. chir.),
43: 65-75 (Feb.
15),
1936.
Wilensky,
Abraham,
and Thalhimcr Wm.,
Ann. Surg., 67: February
1918.
SURGICAL
GALL
BLADDER
WILLCUTTS
469
THE SURGICAL GALL BLADDER'
By Commander
M. D. Willcutts, Medical Corps, United States Navy
The
trend
in
the management
of the diseased gall bladder
(and
gallstones)
has
changed
sharply during
the
past
5 years.
In
the
majority
of American
surgical
clinics,
early
and
complete
surgical
intervention
is
becoming
the
procedure
of choice.
Formerly
con
sidered
a medical
or an interval surgical
problem,
an attack of acute
cholecystitis, with or without
stones,
is now
widely rated
a major
surgical
emergency.
Prolonged medical
treatment
for cholecystitis
invites
liver
damage
and leads
to serious
postoperative
morbidity.
Early surgical
intervention
gives
no greater
mortality
than
that of
routine gall-bladder surgery
and reduces
to a remarkable
degree the
mortality
and
morbidity
arising
from
complications
incident
to
delayed
surgery.
The gall bladder
is an organ
of digestion
that functions in health
as
a reservoir
for bile.
During
this
period
of storage,
the
bile is
concentrated
as much
as eight times its original specific
gravity.
In
response
to
demands
of normal
fat
and protein digestion,
the gall
bladder
supplies
bile
in
timely jets
thus
providing
rich
bile
and
aiding in maintaining continence
in the common
bile passage.
The
temperate
individual,
he
who
eats
and
drinks
sanely,
may
enjoy his gall bladder
and healthy digestion
indefinitely throughout
life.
He will
know and
appreciate
the
pleasure
of good
digestion,
the relish
for simple
foods
and
the strength
and force
derived
from
them, and finally the unexcelled
satisfaction of a normal daily bowel
movement
resulting from good biliary digestion.
Now
let disfunction
ensue
and liver
function
become
impaired.
Enjoyment of living is seriously
affected.
The causes may
be many.
The
chief
predisposing
factors
are
sedentary
habits
of
advancing
years,
the
consumption of
unnecessarily
large
quantities
of
food,
gouty
tendencies,
certain
systemic
infections,
as typhoid,
and
con
ditions which delay or interfere
with the emptying of the gall, bladder.
Associated
gastrointestinal
lesions,
such
as
chronic
appendicitis,
splenic
disorders,
and chronic
heart disease definitely predispose.
The gall bladder
becomes diseased.
Ordinarily
we accept the term
cholecystitis
to denote
inflammation
secondary
to infection.
Judd
proved
that metabolic factors
free of infection may also produce
the
same
syndrome
of disfunction.
Infection
reaches
the gall bladder
by direct extension
through
the
ducts
from
the
intestines,
by the
systemic
circulation via the hepatic
artery and portal vein,
and by
lymphatic
extension
from the liver to the walls
of the gall bladder.
DaCosta
taught that healthy bile is sterile
and that when bacteria
are found in the bile the condition is one of disease.
Usually the bile
becomes infected
secondary
to gall-bladder infection.
' Read at the Staff Conference, V. S. Naval Hospital,
Washington,
D. C., on December
3, 1937.
470
SURGICAL
GALL
BLADDER—WTLLCUTTS
In disease,
the
gall
bladder rapidly
loses its muscular
tone,
the
bright
sheen
of health
becomes
lusterless,
the walls are flabby or
shrunken.
The normal emptying
power
is lost, bile
stasis
results.
The
predisposing
factors
for
the
formation
of gallstones
are now
present.
If infection is the main factor in the cholecystitis, stones will
be multiple
and
often
pigmented
and
layered.
If the pathological
changes are of metabolic origin then the single cholestrin stone occurs.
This type of stone arises from an excess
of cholestrin commonly seen
in
pregnancy,
diabetes,
arteriosclerosis,
jaundice,
general
obesity,
and chronic interstitial nephritis.
Gallstones
are not rare.
DaCosta
estimates
that 25 percent of all
females beyond
65 years have gallstones.
Germany reports
stones in
12 percent
of all post
mortems.
Women who
have
borne children
are far more
liable
than
those
who
have
not.
Breast
feeding
the
baby is said to curtail sharply the incidence.
Waterhouse 2 30
years
ago
observed
that
total
abstainers
(from
alcohol)
seem
to possess
a greater
predisposition than the
users of
alcohol,
probably
because
the abstainers
are more apt to
be larger
eaters.
A stone may be silent
and give no colic.
Then
sudden muscular
exertion,
external
pressure,
or the onset of a fresh inflammation may
dislodge
it and
cause it to descend.
A very
small
stone may pass
freely.
A larger
stone in passing
gives violent colic.
A still larger
stone remains in the gall bladder or becomes fixed in the cystic duct or
lodged in the common
duct.
The possessor of such a gall bladder now
presents
the
picture
of
a
progressive
dyspeptic.
Constipation
develops,
flatulence,
loss of
appetite,
especially
for
certain
foods.
Deaver often stressed the early intolerance
for raw apples.
Migraine,
upper abdominal distress
of varying degree of intensity, and a sallow
complexion
are noted.
Masked
symptoms
and
signs of associated
visceral
damage
confuse
the clinical picture.
The cholecystic
heart
develops
(not
unlike
the masked
thyroid heart), kidney damage
is
noted,
and
psychogenic
changes,
melancholia,
literally
black
bile,
occur.
Many think they have stomach
trouble
and complain chiefly
of indigestion, flatulence,
pain
after eating,
pyloric spasm,
and often
they
become
aspirin
and
soda-bicarbonate
fiends.
The
above
are
indirect symptoms bearing
no true relation to the size or number of
stones.
The
active
classical
symptoms
of
gallstone
occur
only
when
infection flares
up, when
the ducts
are occluded
and
cease
to
drain, or when
a stone starts to pass.
Thus the condition of chronic
cholecystitis with or without
stones, in the absence of colic
due
to
inflammatory
flare-ups
or to stone movements,
may give strikingly
similar group pictures of dyspeptic
unhappiness.
This is the period
for prophylactic treatment.
The gall bladder is now only potentially
1 Waterhouse:
Lancet,
May 8, 1909.
SURGICAL
GALL
BLADDER—WILLCUTTS
471
surgical.
Failure, however,
to respond
to medical
measures portends
serious progression
of pathological changes and renders
the condition
definitely surgical.
Unrelieved,
a chronically
diseased gall bladder
suffers sooner or later an attack of acute inflammation, a major surgical
condition attended
by serious morbity and an alarming death rate.
The dyspeptic
patient seeks
medical
aid early.
The medical
man,
alert to the causative
factors
of gall-bladder disease, will attempt cor
rection and resolution of the sick
organ.
He faces
a difficult
task.
The
intemperate
patient balks at
dieting,
soon
loses patience,
and
fails to cooperate.
The gallstone
of metabolic
origin may resolve
or
pass, but here also predisposing
and causative
factors,
long present,
are difficult to adjust.
The chronically infected
gall bladder is most
resistant.
Skilled men like Lyons, of Philadelphia, employ
duodenal
syphonage
to drain the gall bladder.
With the perfected
technique
of highly trained doctors
and
nurses
this
method
has succeeded in
arresting
cholecystitis
and
has
restored
the
gall bladder
to
some
degree of function.
In the hands
of the general run of doctors,
this
type of drainage
is not successful
and usually depletes only the poor
victim's pocketbook.
At any tune the patient faces the sudden crisis
of gallstone
colic
or
the
agony
of
an
acute
inflammatory
spasm.
Associated
visceral
damage,
pancreatitis,
ulcer,
or regional
hepatitis
weaken
the
patient's
reserve
strength.
The
heart
and
kidney
functions become impaired.
Mental
symptoms
of a toxic
psychosis
may occur.
Medical
management
of such
a condition is now futile
and may even prove
disastrous.
The delay incident to symptomatic
treatment may permit extension of the infection into the common duct,
start the formation of stones in the main biliary
tree with attending
grave liver damage and most difficult surgical
pathology.
And still the poor victim will continue
his search for medical
relief.
Even in well-regulated
hospitals rarely do we find the gall bladder case
admitted
directly
to
the haven
of the
surgical
ward.
He
falls
to
the medical
man
and is subjected
to
a check-up
incident to a com
plete physical examination and clinical observation,
blood
pictures,
sedimentation
tests, X-ray series, renal function, stools for parasites,
X-ray of chest for chronic pulmonary pathology, electrocardiograph,
and basal metabolic
tests.
A marvelous
chart of collateral informa
tion is collected
revealing
evidence of visceral
damage that may only
confuse the basic gall-bladder pathology.
My remarks may appear a
bit caustic; they
are not to be applied
specifically,
for certainly
the
closest medical
and surgical cooperation
obtains in our Navy.
But in
general
terms, I do decry
the serious
delay commonly found in the
medical
management
of advanced
gall-bladder disease.
The surgical
consultation arrives.
What do we find?
472
SURGICAL
GALL
BLADDER
WILLCUTTS
GALLSTONE
COLIC
The
bedside
picture is familiar
to all.
No
pain,
not even child
birth pains, may
be so acute.
The sudden
onset, usually hours after
a hearty meal,
absence of fever and leucocytosis,
presence of gastric
upset,
abdominal
distention,
restlessness,
and
characteristic
pain
radiating
to back
and right shoulder
blade
are classical
symptoms.
There
is usually
no
jaundice
(less
than
20
percent),
no
chills
or
sweating.
The outstanding feature
is pain, violently
sharp,
but not
prostrating.
The treatment is sedation, morphine in maximum doses
combined
perhaps
with nitroglycerine or pearls of amyl nitrite.
Keeping in mind the simple rule that gallstones
give
rise to colic
only when infection occurs, or when
the ducts
become occluded
and
cease
to drain, or when
a stone starts to pass, symtomatic treatment
is rational
only
when
directed
surgically,
because
of
the
serious
potentialities ever associated
with gallstones.
The dangers
are real.
Warning
signals
of the extension
of gall-bladder colic into an acute
inflammatory
process may be clear or obscure.
Definite signals
are
chills and fever, malarial-like reactions,
which Moynihan
3 termed the
"steeple chart" —sudden elevation,
precipitate descent, with complete
intermissions.
There is leucocytosis,
often
above
20,000.
The gall
bladder region
is
tense or rigid, abdominal surface
edema may
be
present,
and
tenderness
to
palpation
on
inspiration
is
exquisite.
Jaundice
is not the rule; was absent in 80 percent of DaCosta's cases.
It may develop
slowly following
the subsidence
of the
acute
colic,
this
the
result
of
blocking of the common
duct by posttraumatic
edema from
passage of the stone.
The pulse gives no constant pic
ture —the slowed pulse may indicate pancreatitis.
Moynihan
3 states:
"There
is no reduction in
the
pulse
rate
due
to jaundice
unless
a
degree of chronic pancreatitis exists."
Such
a patient is seriously
ill and looks it.
Surgery is definitely
indicated.
No longer
is accepted
the old
theory
that stones,
even
after resolution
of such
a picture described,
may
become silent and
cause no further trouble.
There is no tendency
whatsoever
to spon
taneous
cure.
Stones once formed
remain,
unless passed.
Medicine
cannot reach
them
to dissolve
them except by direct introduction
of
a solvent through a surgical
T-tube.
Early operations
are safe and
comparatively
easy,
less
dangerous
than
the
passage
of
a
stone
through
an
inflamed
duct.
Complications
are lessened or avoided
entirely by early surgery.
The operation
of choice is cholecystectomy.
ACUTE
CHOLECYSTITIS
This condition presents
a far more urgent
surgical
problem.
The
main etiological
factor is usually a chronic gall bladder,
with
a stone
» Moynihan:
Gallstones
and Their Treatment.
SURGICAL
GALL
BLADDER—WILLCUTTS
473
or stones
nursed
along
for years
only
to
become
impacted
in
the
cystic duct, so that edema, congestion,
necrosis,
and at times perfora
tion results.
A milder form, but still surgical,
develops without stones.
This is due
to inflammation
secondary
to infection, usually of low-
grade virulence and often of long standing.
The bedside findings of acute disease of the gall bladder may vary
widely from mild
to
severe
symptoms.
Fully
10 percent
will
not
present
acute symptoms at time of admission
to the hospital.
Afeb
rile, normal blood
picture, usual
digestion,
the surgical
diagnosis
in
this group must be established
by careful
past history, clinical judg
ment,
and X-ray findings of non- or poorly-functioning
gall
bladder.
This
10 percent,
clinically
mild, may reveal
startling
gross
patho
logical findings at operation or autopsy.
The severe cases are marked by sharp abdominal pain,
tenderness,
rigidity,
and
superficial
edema
limited
to
the
gall-bladder
region.
Jaundice may be present
and is a serious omen of impending perfora
tion or gangrene.
Chills
occur
frequently.
Often
a palpable mass
is noted,
indicating
empyema
or hydrops.
Temperature
reactions
vary, are never constant,
and fail to indicate the severity of the attack.
Leucocytosis ranges from high normal white count to 25,000 or more.
The blood findings,
however,
are never constant.
In fact no constant
factor occurs
that will indicate
the
severity or extent
of
the
gall
bladder
lesion.
Perforations
occur
far
more
frequently
than
was
formerly thought.
Kunath 4 reports
22 percent
with perforations in
103
cases
in
a recent
series collected
at the University
Hospital
of
Iowa.
Fortunately
most perforations of the gall bladder are limited
in extent
and are usually adequately
encapsulated
by adhesive plug
ging by the gastrohepatic
or colic omentum.
It is now generally
accepted that acute cholecystitis endangers
ad
jacent organs.
Varying degrees of pathological change may
be found
in the common
duct, pancreas,
and liver.
The pathological findings
usually exceed
the clinical symptoms.
Frequently
the clinical mani
festations
of the disease are subsiding
while the gall bladder continues
its
progress
to
empyema,
gangrene,
or perforation.
Observations
from our great
climes
reveal
that
a patient with
acute cholecystitis
has but one chance in three of having resolution of the pathological
process in the gall bladder.
The
trend
to operate
early for acute cholecystitis is sweeping
the
country.
Only 4 years ago the policy of most American surgeons was
postponement
of operation for
acute
cholecystitis
until
the
acute
inflammation
had
subsided
or rather until
the acute symptoms had
quieted,
provided the clinical picture showed
a tendency
to improve,
and the objective signs remained
confined
to the right hypochondrium.
• Kunath:
Surgery
Oenecology
and Obstetrics,
vol. 68, July 1937.
474
SURGICAL,
GALL
BLADDER—"WTLLCUTTS
There were a few outstanding exceptions —notably Erdman, Walton,
and
Kirschner,
who
courageously
advocated
immediate
operation.
The trend today is early
or immediate
operation.
Charles Gordon Heyd, in the leading
editorial of Surgery Gyne
cology and Obstetrics,
October 1937, makes
a striking plea for immedi
ate operation.
He
refutes
the
old law that operative
mortality
in
acute cholecystitis is prohibitive
and stresses that to delay operation
is to gamble with odds overwhelmingly against you.
He states:
Increasing
statistics
demonstrate
forcibly
that
the
operative
mortality
in
patients
who
are
operated
upon in the early
stage
of acute cholecystitis
is not
greater than
that
which
obtains
in routine
gall-bladder
surgery.
Furthermore,
the high mortality,
of approximately
20 percent, that occurs after late operation
is
largely
the mortality
that
arises from
the
complications —empyema,
abscess,
gangrene,
and
perforation —and,
when
operative
recovery
finally
takes
place,
there remains the permanent
damage to liver and associated
organs with con
tinued morbidity.
Stone and Owings,5 of Baltimore,
advocate immediate operation:
We think that
by prompt
operation
there
is a notable
saving
of time,
pain>
expense,
and danger as compared with the policy of delay.
*
*
*
Not only do
wc
regard
the
acute
gall-bladder
lesion,
whether
hydrops,
empyema,
torsion,
gangrene, or simple acute cholecystitis,
as best treated by prompt
operation,
but,
again contrary
to general opinion,
we believe that
in most
cases
the operation
should be a cholecystectomy.
Judd, Phillips,
and Walters,"
of Mayo
Clinic,
endorse early
opera
tion with reservations:
Although
we wish to subscribe to the plan of early operation in acute cholecystic
disease,
and although
this coincides with the opinion expressed in the more recent
literature
on the subject,
nevertheless we feel that there are certain instances in
which surgical treatment
should be postponed.
In some cases it should be delayed
for a long time.
In caring for these patients it will be necessary to consider each
one as presenting
an individual problem.
There
is no set plan that will fit all
cases.
*
*
*
Cholestectomy
will not
be permissible
in every
case, but this
procedure should be carried out whenever feasible.
*
*
*
No one would feel
that
a
deeply
situated,
inaccessible,
acutely
inflamed
gall
bladder
should
be
removed
from
an extremely
sick person.
Cholecystostomy
may
be all
that
is
warranted.
Dr. Fred B. Lund,7
of Boston, states:
That when I wait for cholecystitis
cases to subside I have many times been dis
appointed,
because
they gradually
got worse.
Dr. R. H. Miller,8 of Massachusetts General Hospital,
agrees with
Drs. Stone and Owings:
That in those in which more procrastination
had taken place there was a higher
mortality, whereas in those instances in which operation was performed early the
mortality was less.
« Stone, H. B., and
Owings,
J. C.: The Acute
Gall Bladder
as a Surgical
Emergency.
Tr. Am. Surg.
Assn.,
51: 281-286, 1933.
•Judd, E. S., and Phillips, J. R.: Acute
Cholecystic
Disease.
Tr. Am. Surg. Assn.,
51: 292-297, 1933.
' Lund, F. B.: Discussion.
Tr. Am. Surg. Assn.,
51: 297-298, 1933.
' Miller, R. 11.: Discussion.
Tr. Am. Surg. Assn.,
51: 298,1933.
SURGICAL,
GALL
BLADDER—WILLCUTTS
475
Dr. Hubert
A. Royster
8 supports
the theory that early operation
is the procedure
of choice.
Dr. Morris K. Smith,10 of New York, sounds
a warning note:
I have been impressed with the favorable postoperative
course of patients sub
jected to early cholecystectomy
and have operated before the fever subsided in a
majority of my own
cases without feeling that
an error of judgment
had
been
made until rather
recently,
when an obese
woman
of
52, who had had several
attacks,
succumbed
2 days following
a partial
cholecystectomy,
with
a rapidly
rising temperature
and failing
circulation.
*
*
*
Patients
with acute chole
cystitis should
not
be
operated
on,
immediately
upon
admission,
without an
urgent indication.
The surgeon should
be ready to intervene
promptly
if prog
ress is unfavorable.
Younger
patients
in good condition,
after
a day or two of
preparation,
may
be operated
upon
without
waiting
for the attack
to subside.
In poorer risks, if the course under observation
is satisfactory,
it is wiser to allow
the acute attack
to cool off.
At the 1936 meeting of the Southern
Surgical Association, Dr. Heuer
called
attention to the marked
reduction
in the operative
mortality
of acute cholecystitis since the institution of early surgical
treatment.
Dr. Frank Lahey
11 states:
If gallstones while in the wall of the gall bladder
were
destroyed, there would
be fewer patients with common duct
stones,
fewer patients with infection
of the
biliary tract, the mortality would be lower, the number of recurrent common duct
stones lessened,
and the completeness of the recovery greatly added to.
Physicians
should urge operation
upon patients with gallstones, providing
their
condition
permits,
as soon as they
are
demonstrated.
They
should
be demon
strated
earlier,
and
certainly
no
patient
without
a
fair
understanding
and
a
frank warning
as to the consequences should
be permitted
to pass
through
re
peated attacks of gallstone colic.
No operation
should
be done for cholelithiasis
without thorough
investigation
of the biliary tract
and removal
of any possible
common or hepatic duct stones.
We have in the Navy better control of our patients than is usually
seen in civil life.
Hospitalization
is instituted early and facilities for
complete
check-up
are readily available.
This permits prompt diag
nosis and surgery in the early optimum phase.
Decision for immedi
ate operation
or postponement
for a few days may rest upon a sensible
estimation
of the situation.
Associated
visceral
damage
should
be
known
so that impaired heart,
liver,
pancreas,
and kidney function
may be spared
excessive additional operative
load.
If delayed
sur
gery must be resorted
to in order to spare additional visceral
damage,
then the prognosis
is always
guarded.
Preoperative preparation is very important;
the fluid balance
must
be checked
within
normal limits.
Sugar
is important
and
may
be
given
as candy,
honey, sweetened fruit juices, or intravenous glucose.
The gall bladder should not be denied fat completely.
Preoperative
diet should
include fat and protein
as well
as sugar
so that biliary
stimulation
may approach
normal digestion.
• Royster,
H
A.: Discussion.
Tr. Am. Surg. Assn., 81: 299,1933.
Smith, M. K.: Treatment
of Acute
Cholecystitis.
Tr. Am
Surg. Assn. 51: 287-291, 1933.
i' Labey, F.: Surgical
Clinics of North America.
June 1937.
476
SUKGICAL
GALL
BLADDER—WILLCUTTS
The choice of anesthesia
must be carefully considered.
Spinal or
regional
block
and
local
infiltration
give
the greatest
safety
in
the
difficult
and
serious
risk
cases.
Combination
of
basal
anesthesia,
avertin with regional
block,
or gas inhalation
is safe.
Most of the
cases
tolerate
well basal avertin and inhalation anesthesia.
The
postoperative
reactions
demand
immediate
attention.
Post
operative
crisis in surgical
treatment
of acute gall bladders
are marked
by early
high
fever, failing circulation, and pulmonary edema.
This
condition is rapidly fatal unless failing circulation can
be supported.
Glucose
infusions and blood
transfusions
are indicated and must be
employed
heroically.
The easiest reactions
and
best results
usually
occur in
those
patients having
gallstones
and
severe
pathological
lesions.
Surprisingly stormy reactions
and poorest
results
are found
in
those
patients
having
mild
or
catarrhal
chronic
cholecystitis.
This latter group fortunately constitutes
only 10 percent of the general
run of cholecystectomies.
If abdominal distention
occurs,
employ
promptly
the
Wangensteen
siphonage.
Its routine
use
in difficult
cases
will
add
great
comfort
and
safety.
Biliary drainage
will
be
improved
and
restoration
of liver
function
hastened.
Safe
body
chemistry must
be maintained by intravenous glucose
and
salines
given freely.
A practical index is a daily urinary output maintained
at
above
1,000
cc.
Calcium
chloride
in
small
amounts
is
recom
mended
by Graham
12 for liver damage following postoperative
gall
bladder
care.
Morphine sedation
is indicated for pain or restlessness.
A bland but balanced diet is permitted early,
the patient's own desire
and appetite
governing
the selection.
CONCLUSION
Plea for assignment
of gall-bladder diseases to the surgical
service
is
made,
the
acute
conditions
being
considered
as
acute
surgical
abdomens.
Gallstones
are
stressed
as
surgical
lesions,
their
early
removal
affording safest
prophylactic
measures
against
biliary
tree
infection.
Prompt surgical
intervention is urged in acute cholecystitis provid
ing safety factors
exist, chief of which is good metabolism
as indicated
by blood chemistry and kidney function, conditions usually found in
the
first
48
hours
of
the
attack.
Operative
difficulties
and
post
operative
complications mount rapidly after second and third day of
the
disease.
Danger of perforations
as
against
postoperative
crisis
due to decompensated
liver, pancreas,
and kidneys must be carefully
weighed.
» Oraham,
E. A.; Illinois Med. Journal, 63: 196, September
1931.
PANCREATIC
NECROSIS—HIGGINS
477
ACUTE HEMORRHAGIC PANCREATIC
NECROSIS'
A REVIEW WITH
CASE
REPORTS
By Lieutenant
A. R. Hiqoins, Medical Corps, United States Navy
The
discussion
of hemorrhagic
necrosis
of
the
pancreas
appears
timely, especially
because of certain
newer ideas of its pathology and
critical
evaluation of therapy
advocated
in its attempted
cure.
A
review of recent views on the subject
leads one rapidly to the conclu
sion that there is still much information to be desired concerning
this
most catastrophic
of intra-abdominal
accidents.
The clinical picture of hemorrhagic
pancrea tic necrosis was described
first by Fitz in
1889,
and many workers
have
since
attempted
to
explain
the
etiology,
pathology,
and
especially
the
diagnosis
and
treatment.
The results,
as expressed in current writings, have been
disappointing.
There is evident
a dissimilarity
of views
concerning
even
the
exact
pathological
states
to
which
the
term
pancreatic
necrosis may be applied.
Especially
is this
true in the statistics of
operative
mortality
where
some authors
appear
to be discussing
the
milder
forms,
showing
edema, or patchy necrosis
or hemorrhage
of
the
pancreas,
while
others
are obviously
reporting
the
results
of
surgery
in more
fulminating
and clinically
overwhelming
types.
A
very considerable
statistical
error must be present
in
the reported
results of any individual surgeon because due to infrequent occurrence
of the syndrome
the statistical method suffers from lack of numerically
sufficient
cases.
The
etiology
of
acute
pancreatic
necrosis
has
been
debated
at
length
by
Opie,
Archibald,
Mann,
Giordano,
and
others.
It
is
generally
agreed
that
the histopathological picture is
the result of
the action
of an irritant on pancreatic
tissue, and it appears
reason
able
to suppose
that
the irritant
involved
is
developed
from
that
which
is
always
potentially
present
in
the
pancreatic
substance;
namely,
trypsin,
from
pancreatic
trypsinogen.
The
activation
of
trypsinogen
into
trypsin,
normally
brought about by
enterokinase
in
the
gut,
is
not
explained.
Experimentally,
it
was
shown
by
Archibald
that liver
bile without
the cholecystic
mucin, or heavily
infected
bile,
caused
a lesion
resembling
human
pancreatic
necrosis.
Obstruction of the ampulla of Vater with
a resulting back-up of
bile into the pancreatic
ducts,
was the first attempt at explanation.
At post mortem,
however,
blocking of the ampulla has been rarely
shown.
More
recently
the matter
was
investigated
by Archibald,
who found
that spasm
of the sphincter of Oddi
could
be induced
experimentally.
Mann
and
others,
however,
reported
that
in
a
relatively
greater
number
of
cases
this
explanation
was
untenable
because the sphincter was proximal to the opening
of the bile ducts.
' From the Surgical
Service, U. 8. Naval Hospital,
8an Diego, Calif.
478
PANCREATIC
NECROSIS—HIGGINS
Deaver's concept
of the
spread
of infected
lymph
from
the
gall
bladder
to the pancreas
has lacked anatomical proof.
Interesting is the observation made by Boyd
and others
that the
onset
of symptoms
has frequently
followed
a heavy meal.
In
at
least one of the cases covered by this report, the patient had been on
an
extensive
alcoholic
debauch,
showing
an
appreciable
amount
(1.5 mg) of blood alcohol.
The morbid anatomy of the condition is variable and
appears
to
extend
over
the milder grades
of edema,
scattered
patchy necrosis
or hemorrhagic
areas, through
massive death, with or without hemor
rhage
of a large part, or the entire
organ.
The pancreas
is usually
enlarged,
firm in the milder types,
and becoming
soft and friable in
the
more
severe
grades.
The
surface
shows
areas of fat necrosis,
areas of hemorrhage,
or it may be black and
gangrenous.
Micro
scopically
there
is
extensive
necrosis
of
pancreatic
parenchyma.
Sequelae may be resolution to integrity in the less severe types,
or
suppuration or so-called
pseudocysts
may occur.
A very constant finding at laparatomy
is
the
presence
of sero-
sanguineous
fluid in
the
omental
bursa
or peritoneal
cavity.
The
diagnosis
of pancreatic
necrosis
is at all times difficult, particularly
in
those
cases
not sufficiently severe
to
present
the classical
signs,
and it is only in
these cases
that therapy appears
of larger value.
The syndrome
will undoubtedly be diagnosed
more frequently with
a more
widespread
knowledge
of its character,
especially
in the less
severe types.
The classical
picture is that of acute abdominal pain, of a steady,
excruciating
type,
more
terrible
than
that
of
a
perforated
ulcer,
rapidly
developing
vomiting
and
cyanosis
and other evidence
of
a
toxemia.
The location
of
tenderness
in
a well
circumscribed
area
above
and to the left of the umbilicus has been highly suggestive
of
the condition.
Archibald has noted
a characteristically later appearance
of rigidity
in comparison
with the only serious difficulty in differential diagnosis,
a ruptured
ulcer,
a fact which
he
explains
by
the retroperitoneal
location of the lesion.
The test of Loewi, of securing mydriasis with instillation
of adren
alin is reported
as of value in the absence of thyrotoxicosis.
Many writers have noted that a hyperglycemia is a fairly constant
finding.
The stools
may
become fatty and bulky from loss of pan
creatic ferments.
The various tests for diastase,
in the blood,
urine,
and
duodenal
contents,
have
been disappointing.
The Todd
modification of the
Wohlegemuth
technic
for blood
or
urine
diastase
estimation is
be
lieved
to be of value
in
cases
where
a laboratory is sufficiently well
equipped.
PANCREATIC
NECROSIS—HIGGINS
479
At laparotomy, the appearance
of fat necrosis,
the patchy yellow-
white deposition
of fatty
acids in the splitting of fats by lipase,
is
pathognomonic.
Roentgen examination
for pneumoperitoneum
is of value
in dif
ferential diagnosis,
particularly in excluding
a perforation of the gut.
A leucocytosis
is present, ranging from 12,000-30,000
and certain
writers attach a prognostic
significance
to changes,
a sudden increase
to 30,000-35,000
indicating a bad prognosis.
In view of these conflicting and certainly far from definite
views
as to etiology,
pathology,
and symptomatology, it is not surprising
that scarcely
any writers are in accord
as to the therapy of choice.
Archibald
and
others,
following
the basic
belief
that a blockage
at
the sphincter of Oddi is the important etiological
factor,
report their
best results following drainage of the biliary tract by cholecystostomy.
Most adherents
to this idea also include tamponade
drainage of the
pancreatic bed through the gastrocolic
ligament.
Other writers, notably
the American group,
have
tended
toward
conservatism.
Whipple
outlines
this plan of therapy with the view
that,
given
a
reasonably
definite
diagnosis
of pancreatic
necrosis,
operation should
be deferred
for a few hours, until shock is overcome
and the electrolytic balance of the blood
restored
by saline infusion.
In many patients,
this improvement is marked,
and localization of the
lesion, with recovery,
or a less serious lesion, develops.
If conservative
therapy does not give
an improved picture, then
operation is indicated.
The operative
treatment
advised by Whipple
is essentially
drainage
of the lesser sac with no attempt at drainage
of the pancreas unless it can be done with the finger by blunt dissection.
An examination
of the gall bladder
and ducts is made, and drainage
of the gall bladder
is believed justified if the condition of the patient
and the ease of procedure warrant.
Jones,
quoted
by Whipple,
cites
the following significant figures,
collected
in 1922-24,
of
56 cases,
with
60.7
percent
gross mortality:
Cases
Severe
MUd
Deaths
Mor
tality
Percent
No operation
-
8
8
0
6
100
14
10
4
12
81
Drainage
of pancreas, including
abscess
28
25
4
8
28
Drainage
of pancreas without abscess
20
18
2
11
81
Drainage
of abscess alone
9
7
2
0
0
Drainage
of biliary system
3
2
1
2
66
Drainage
of biliary system and pancreas
3
2
1
3
100
Here again
the large factor of statistical
error
must be
borne in
mind.
Writers in most cases fail to classify
their cases as to severity,
and this fact must greatly influence
a statistical report of mortality.
88860—38
3
480
PANCREATIC
NECROSIS—HIGGINS
Klimk<5
has offered a classification
as a working basis, which appears
to have
much
merit.
Group I: Very
serious
cases
with
extremely
sudden onset, rapid
progress,
and usually an unfavorable
outcome.
In these
cases
the
autopsy
shows
widespread
fat and
pancreatic
necrosis,
colliquation
abscess,
hemorrhage.
Group II:
Less serious
cases with acute onset and
a tendency to
subside.
In
these,
necropsy
shows
edema
with
less extensive
fat
necrosis;
smaller
sequestration,
circumscribed
abscess;
and in later
cases,
pseudocysts.
Group III: Mild cases, with acute onset which ordinarily subsides.
Autopsy reveals edema with fat necrosis.
Case
Reports
Three
cases
of acute
pancreatic
necrosis
are presented,
with two
fatalities.
The
case which survived is believed
to have had
a mild
type, the third group of Klimk6.
Case
No.
1.— C.
G.
Male.
Age,
46.
A
private,
first-class,
TJ.
S.
M.
C.
Patient
was admitted
on June 5, 1937, with
the complaint
that at
1015
he had
been seized
with a pain in the left chest "so terrible that he thought he would die."
He had had several lesser attacks during the past 2 months, usually after smoking.
The
pain
was
not relieved by amyl
nitrite
and an opiate given for a supposed
severe
angina pectoris.
The pulse was 92 regular.
Heart
was slightly
enlarged
by percussion to left and a systolic aortic murmur
was noted.
BP 150/110.
The abdomen was slightly
distended and soft to palpitation,
without
masses
or tenderness to palpation.
An impression
was gained at admission of (1) angina
pectoris
(2) aortitis
(3)
acute cardiac dilatation.
At
1235 the patient
suffered
another
attack
of acute
precordial
pain,
radiating
down
the left
arm.
This
attack
passed
off
in
10 minutes,
after amyl
nitrite
had
been
given.
At
1255,
a similar attack occurred when the patient was described as cyanotic.
The pulse
became
feeble
and death occurred at 1300,
2 hours and
45 minutes
after
onset.
At autopsy,
there was about
500 cubic centimeters of clear straw fluid
in the
peritoneal cavity.
Liver,
spleen,
and kidneys appeared normal.
On opening the omental bursa, the whole pancreas was in a friable hemorrhagic
state, the tail appearing as a jelly-like blood clot.
There was very slight fat necro
sis adjacent
to the pancreas.
The pancreatic
tissue could
be easily lifted
away
from the ducts, exposing the duct system, throughout.
The heart appeared broadened, and weighed 450 grams.
The pericardium
con
tained
200 cubic centimeters of bloody
pericardial
fluid.
The
visceral
pericar
dium and myocardium
showed evidence of old infarction
in two
areas
of sclero
sis toward the apex,
with thinning
of the myocardium
beneath.
The
coronaries
were
tortuous,
showed
slight
calcification,
were
patent
throughout
the
larger
branches.
Case No. 2.— Male.
Age 36.
A taxi-driver,
F. N. R.
Admitted
February
20,
1937 complaining
of a pain in the abdomen of 2 days duration
which had lately
become
severe.
The pain was located just above the umbilicus.
Patient
vomited
10 times the day prior
to admission,
without
hematemesis.
He
denied
recent
alcoholic excess, but was a known alcoholic (previous admissions) and was patently
inebriated, with blood alcohol of 1.5 milligrams
per cubic centimeter
PANCREATIC
NECROSIS
HIGGINS
481
A previous
similar
attack
had resulted
in hospitalization
in
February
1937,
which subsided, and another
6 months prior to that (left hospital in 2 days against
medical
advice).
No symptoms
between attacks.
On
admission,
the patient
was extremely
nervous,
giving
impression
of mild
psychosis probably
alcoholic.
Pulse 100; temperature
97°; respiration
24; BP 156/98.
The abdomen
was distended
and there was marked
tenderness over
a small
area just above
the
umbilicus
with
upper
abdominal
rigidity.
Pressure
else
where caused pain in the epigastrium.
0230, WBC (admission)
7,600.
0700,
no change.
0930,
WBC
13,200
with marked
left
shift
in hemogram.
Blood
sugar
130
milligrams;
chlorides 412; C02 68 percent.
X-ray showed no pneumoperitoneum.
Urinalysis showed,
Sp. gr.,
1.030;
50 milligrams
of albumin;
glycosuria
of 2.5
percent;
occult blood; several coarse and fine granular
casts, with a few red cells.
An X-ray of chest was negative.
1400 WBC
13,250 with
same differential.
1900, WBC
17,900 with 98 percent polymorphonuclears.
The blood serum amylase (Todd)
was 20 units.
A diagnosis of acute pancreatitis
was made and patient prepared for operation
with an intravenous
of 1,000 cubic centimeters of 5 percent glucose-saline.
At laparotomy
100 cubic centimeters of brownish
fluid was present in the right
upper abdomen.
No fat necrosis noted.
The gallbladder,
gall ducts
appeared
normal,
without
stones.
The pancreas was enlarged 2-3 times normal
and felt
hard.
Exploration
through
the gastrocolic
omentum
showed the pancreas of a
beefy
red color
throughout
its substance.
Tamponade
was done through
the
gastrocolic
omentum and one drain brought
to Morrison's
fossa, through
a right
stab wound.
The patient
made a good recovery
from
operation
and the drainage
of sero-
sanguinous
fluid
from abdomen
was considerable.
He exhibited
psychosis
con
tinuously,
requiring
sedatives.
The man became cyanotic and died on July 13, 1937,
5 days after onset, 3 days
after
operation.
Autopsy showed
no obstruction
of the biliary system.
The
pancreas appeared as described at operation.
On sectioning the pancreas, drops
of pus could
be
expressed.
Slight
fat necrosis was now present.
Microscopic
examination
showed extensive necrosis throughout
the pancreas, less in the head
than in the body and tail.
Case
No. 3.—F.
S.
Male.
Age
48.
CPhM
(Ret).
Admitted
on May
19,
1937,
complaining
that on the morning
prior to admission
he noted
a "sinking
feeling"
in the pit of the stomach which lasted all day.
The sensation was not
painful
and there was no nausea.
At 2100 on the evening prior to admission,
a severe pain developed in the upper
abdomen.
He then vomited
three times and the pain
became
agonizing.
No
previous similar attacks.
Temperature
98°, pulse 104, respiration
20.
Examination
showed desperately ill male.
BP 130/78.
There
was generalized tenderness over the whole abdomen, most marked over
the epigastrium.
It was noted that no real rigidity was present.
Operation
was done immediately.
No
free
fluid
was present in the greater
peritoneal
cavity.
The gallbladder
was slightly
larger than normal,
very tense,
and could not
be emptied.
The pancreas, especially the body, showed marked
edema and there was subserous edema and bile discoloration
about the duodenum.
On opening the gallbladder several stones from Yi to 1 centimeter in diameter were
found
in
normal
bile.
Cholecystostomy
was done.
Convalescence
was
com
plicated by a wound
infection
and by disruption
of the right
rectus incision
on
May 29,
1937,
10 days after operation;
a pneumonitis
of the right lower lobe, and
482
DISEASES
OF THE
COLON —BURKE
on June 21, 1937, a laparotomy
was done for intestinal
obstruction
from adhesions.
A jejunostomy
was done at this time.
On July 31,
1937, the jejunostomy
tube
was removed and patient
has now completely
recovered.
A large ventral
hernia
is now present.
No abnormality
of blood sugar tolerance
is present.
CONCLUSIONS
1 . The syndrome
of acute pancreatic
necrosis is of especial interest,
from its cataclysmic picture, and very considerable
mortality.
2. The
causative
factors are not clear;
the symptomatology
and
morbid anatomy are variable;
and
the therapy is disappointing at
best.
DIAGNOSTIC
ERRORS
IN
DISEASES
OF THE
COLON
WITH ILLUSTRATIVE
CASE REPORTS
By Lieutenant (Junior Grade) John Bures, Medical Corps, United States Naval Reserve
An accurate
and
detailed
history,
a careful
physical examination
including
sigmoidoscopy,
proper laboratory
studies,
and
above
all,
modern
roentgen
technique
combine
to make
possible
an
accurate
preoperative
diagnosis
in the majority
of lesions of the colon.
For
tunately there are few diagnostic
emergencies in the natural history
of colonic
disease in wluch
the
time
element
is
so important
that
these aids cannot
be utilized.
Complete obstruction of the colon is as a rule slow in onset, and the
time
required
for
a carefully
administered
barium enema
does not
contribute
materially
to
the
operative
risk.
A flat
plate
for
the
determination of the location of gaseous distention
can
always
be
made
in any
case
where
operative
intervention is feasible.
In fact,
the necessary
delay for these elementary
roentgen ray studies
can be
utilized for the patient's benefit.
The treatment
of dehydration and
shock during this period
increases
the possibility of successful
opera
tive therapy.
There exist numerous
lesions which are not susceptible
to diagnosis
by the above
methods,
and others
whose symptomatology does not
suggest colonic disease, and whose true nature is revealed at operation.
In retrospect,
perhaps
most of these could
have been correctly diag
nosed.
In practice,
few of them are.
It would be futile to attempt to enumerate
all of the lesions which
might fall in this category.
There are a few, however,
which occur
not infrequently, and which I have encountered
and failed to diagnose
in
the past
few years.
It is possible
that illustrative
case
reports
may enable others to make correct preoperative
diagnoses.
NONSPECIFIC
INFECTIVE
GRANULOMA
This lesion
is not particularly
common
in comparison
with
tuber
culosis,
diverticulosis, or carcinoma
of the colon,
but it does occur
DISEASES
OF THE
COLON
BURKE
483
frequently enough to constitute a diagnostic
problem.
It occurs,
as a
rule, during
the
active
period
of life and
both
sexes
appear
to
be
equally affected.
The etiology is uncertain.
Foreign bodies within
and without
the colon,
abdominal trauma,
and
infected
mesenteric
lymphnodes are thought to be the most common
etiologic
factors.
Mock,1
1931,
gave
a most
comprehensive
resum6 of
this
subject.
It is difficult
to
make
the
diagnosis
from
the history
alone.
The
presence of a tumor is a more or less constant
finding but malignancy
and tuberculosis
must be ruled out before nonspecific
granuloma can
be
considered.
X-ray
examination
may reveal
an
irregular
filling
defect within the lumen of the colon but this is not constant.
Bargen
and Larson
2 state that exploration may
be necessary
to establish
the
correct
diagnosis.
Even
at
operation
the
lesion
may
be
confused
with malignancy.
Case
report
(Granuloma
of
the
Transverse
Colon). —A female,
age
39,
was
admitted
with the complaint
of a draining
sinus from an operative wound.
Her
past history
is rather interesting.
About 20 years ago a thyroidectomy
was per
formed at another hospital.
While
she was still in the hospital
she developed an
abscess in the pelvis.
She was operated upon and a left salpingo-oophorectomy
was performed.
Her convalescence was apparently
uneventful.
Six months ago
a hysterectomy
and a right salpingo-oophorectomy
was performed
for functional
uterine
bleeding.
The
convalescence was very stormy
and
she
was
discharged
from the hospital
with
a slight amount
of drainage from the lower angle of the
wound.
The pathological
diagnosis of the tissue removed was chronic salpingitis,
follicular and corpus luteum
cysts, hyperplastic
endometritis.
She was next seen about
6 months following
the operation when she stated that
the wound had continued to drain intermittently small amounts of fluid.
When
ever the drainage opening was closed, abdominal
pain followed
but disappeared
with resumption
of drainage.
She had lost from
70 to 80 pounds in weight and
suffered constipation
for the past month and one-half.
Relevant physical findings
at this time were confined to the abdomen.
"There is a scar from a supra-pubic
incision.
There
is
a
mass
underlying
the scar, about
5 centimeters
wide,
ap
parently
in the abdominal
wound, as it may be encompassed by both hands.
It is
only slightly
tender."
An attempt
was made to inject
the fistulous
tract with
sodium iodide but this was unsuccessful.
A flat X-ray showed an area of increased
density
in the region of the mass.
My impression at the time was that the fistula
was probably
caused by a foreign body overlooked at the previous operation, and
operation
was advised.
Under spinal anesthesia an incision was made through the old scar down to the
fistula opening which
was encircled.
Dissection
was then carried on down to the
fascia, and by combined blunt and sharp dissection the mass at the fistula opening
was dissected free from the scar tissue to the left and from the edge of the right
rectus muscle.
At this point
the peritoneum
was opened below the mass.
The
fistulous
mass
was then dissected free on both sides until the peritoneal
opening
was large enough to admit one hand.
On palpation it was found that the mass was
attached firmly to the abdominal
wall and extended upward to about
the level of
' Mock, H. E.: Infective
Granuloma,
Nonspecific
Chronic
Tumorlike Productive
Inflammation
of the
Gastrointestinal
Tract.
Surg:, Oyn. and
Obstet.,
52: 672-(!89, 1931.
• Bargen, J. A., and Larson, L. M.:
Difficulties
in Diagnosing
Certain
Lesions
of the Right Side of the
Colon.
Med. Clin, of N. Amer.,
15: 185-193, 1931.
484
DISEASES
OK THE
COLON
BURKE
the umbilicus.
The entire mass
was then dissected free, which necessitated pro
longing the incision upward about
1 inch.
It was then seen that the mass was at
tached to the anterior surface of the transverse colon and its appearance was defi
nitely
that of a carcinoma
of the colon.
After some
deliberation
it was decided
to attempt
a resection of the tumor-bearing
area.
The omentum was freed from
its adhesions below.
The colon was then isolated for 3 to 4 centimeters on either
side of the mass and was resected
between clamps.
Continuity was reestablished
by a side-to-side anastomosis.
A ceeostomy was
then done and the wound
was
closed
in layers.
Postoperative
diagnosis:
Carcinoma
of the Colon.
When the resected
colon was opened it was seen that the mucosa was intact and
that the mass appeared to originate from the outer layers of the colon.
The tumor
was studied
in the State Institute for Malignant Diseases, where a diagnosis of
chronic inflammation
in tissue surrounding
the colon was made.
The convales
cence was very stormy but the patient left the hospital at the end of 3 weeks with
dry wounds.
Some months later she developed a very marked ulcerative
colitis
and a fistula
reappeared in her operative
wound.
About
1 year after this last
operation she was reopcrated at another hospital and what was said to be a jejunal
fistula
was excised.
It reappeared, however, before her discharge from the hos
pital.
It
has
not
been
possible
to obtain
further
information
concerning
the
patient.
Comment:
Obviously,
from
the surgeon's
viewpoint,
she
should
never have
been subjected to operation,
as each operation
was followed by numerous and dis
agreeable sequellae.
In defense
of the hysterectomy,
she refused radiation
ther
apy.
Concerning
the second
operation, I was convinced that a forgotten
sponge
was responsible for the mass and the sinus tract.
The etiology of the granuloma
is still unknown.
VOLVULUS
OF THE
COLON
Volvulus of the small or large intestine
is a not uncommon
source for
acute intestinal obstruction.
In the large intestine
the most frequent
sites are the cecum
and
the sigmoid,
the other
areas being
less
fre
quently involved.
The first requirement
for a volvulus is abnormal
mobility of the bowel.
In this connection
anatomical
studies concern
ing the abnormal mobility of the cecum show an incidence which varies
from 10 to 90 percent.
Ten percent of all cases
seen at autopsy have
to some degree a common
mesenteiy
of the cecum and ileum,
and in
1
percent
there is a complete
common
mesentery.3
Violent peristalsis
following overeating
or purgation may precipitate the occurrence
of a
volvulus.
"The acute type
is ushered in with great suddenness
and
severe paroxysmal
pain,
with some abatement
of the symptoms
be
tween spasm."
"Huge distention and meteorism
which rapidly take
place are constant
and distinct features."4
This lesion is found twice
as frequently in men as in women and more than half of the cases occur
in the third
and fourth
decades.5
"Distinction
in many acute
ab
dominal conditions from acute volvulus is difficult."4
» Wandel,
quoted by A. W. Fisher:
Handbuch
der praktischen
Chlrurgie,
Kuttner, Oarre
and
Lexer.
Sixth edition.
3: 385, FerdinAnd
Enke,
Stuttgart,
1929
i Ranken,
Barren
and Buie:
The Colon,
Rectum, and Anus,
p. 110.
W. B. Saunders,
Philadelphia,
1932.
' Garre,
C. and Naegeli:
Th. liandbuch der praktischen
Chlrurgie,
Kuttner, Garre
and
Lexer.
Sixth
edition.
3:652.
DISEASES
OF THE
COLOX—BURKE
485
Case
report. —A
male,
age
49,
entered
the
hospital
complaining
of
severe
abdominal
pain.
The
night
before
he
had
severe
griping
pain in the upper
abdomen
for which
he took
castor oil with little effect.
There
was severe
and
constant
pain in the upper abdomen in the morning
up to the time of admission.
He
vomited
once.
There
had
been
occasional
episodes resembling
the present
attack in the past, but
these
had been
easily controlled
by a cathartic.
There
was an indefinite history of indigestion,
but its relation to meal time was uncertain.
He denied venereal
disease
and did not work with lead.
Upon
examination
he
was acutely ill, sitting
upright
in bed, holding
his abdomen with both hands and
groaning.
Essential
findings
were
limited
to his abdomen,
which
was retracted
and boardlike in its upper half, and fairly rigid in the lower half.
The epigastrium
was extremely tender.
Our impression at the time was ruptured
peptic ulcer.
The
patient
was operated
upon
immediately
under
spinal
anaesthesia.
As
this took effect a large sausage-shaped tumor
arose
in the right half of the ab
domen, extending from the iliac crest to the rib border and filling half the epigas
trium.
An incision
was made to the right of the midline,
extending from
1 inch
below the xiphoid
to the level of the umbilicus.
This was later extended above
and below until it was about
8 inches long.
Upon opening the peritoneum
there
was a deep red, distended
mass comprising
about a foot of ileum, the cecum and
ascending
colon
including
the
hepatic
flexure.
This was twisted
180
degrees
about its base, counterclockwise.
The colon and ileum were firmly adherent and
had
a common
mesentery.
This mass was delivered
out
of the
wound
with
difficulty and resection
was decided upon.
This was done at the noninvolved
portions
of the colon and ileum, and an end to side anastomosis
was performed.
A Witzel enterostomy
was
done in the proximal
ileum and the abdominal
wall
closed in layers.
There
was considerable spill of intestinal
contents
during
the
anastomosis.
The
convalescence was very
stormy.
Despite
the ileostomy
he developed
a
paralytic
ileus which
persisted for
5 days despite attempted
duodenal
drainage
and the various means usually employed to produce peristalsis.
On the fifth day
eserine was
suggested
and
its
use
was attended
with dramatic
and
gratifying
success.
The further
course was complicated
by separation
of the skin
wound
but the patient was able to leave the hospital
27 days after operation.
Comment:
If this man's history
had been properly
evaluated it is possible that
the
correct
diagnosis
might
have
been
made.
As I
see it now,
the
previous
attacks
of pain
were
caused by a twisting
of the adherent
cecum and ileum on
their common mesentery.
Catharsis
or perhaps a change in posture allowed the
loop to untwist.
This last time the weight of the distended
bowel was
so great
that untwisting
was impossible.
Nearly
24 hours of partial
strangulation
had so
reduced the vitality of the bowel that
despite hot packs it showed no signs of
recovery.
The ballooning
out of the loop through
the anaesthetized
abdominal
wall was most remarkable,
following
as it did the upward
progress of the spinal
anaesthesia.
We
were
aware that this was a strange occurrence in the natural
history
of a ruptured
peptic
ulcer but
we
were
entirely
unprepared
for the de
nouement.
PHLEGMON
OP THE
CECUM
Phlegmon of the gastrointestinal tract is seldom
seen.
There have
been
about
450
cases
reported.
The
incidence
of
phlegmon
ap
parently decreases in proportion to the distance from the stomach
to
the rectum.
The lesion has the same characteristics in the intestinal
tract as it does elsewhere throughout the body.
The submucosa
is
486
DISEASES
OF THE
COLON—BURKE
generally
affected
more
seriously
than the other layers.
The strep
tococcus
has
been frequently found in
the lesion
but its portal of
entry is quite uncertain.
The diagnosis
is scarcely
ever made before
operation
and in many cases
is made only by the pathologist.
The
symptomatology
is,
as
a
rule, that of the acute lower intestinal lesion
with
pain
and
fever
as
predominant
characteristics.
A
tumor
is
frequently felt and one gains the impression
that one
is
dealing with
an inflammatory lesion of the large intestine.
The diagnosis
might
be made
more frequently
if
the possibility of this lesion
is
kept in
mind.
I
have
recently reviewed
this subject in
an article in
the
Archives of Surgery
6
and
I
have reported
the following case in con
siderable
detail,
together
with an extensive
bibliography:
Case
report. —
A
female,
age
18,
4
days before admission
began
to have pain
around
the
umbilicus
and
in
the
right
lower
abdomen.
The
pain
gradually
increased
in
severity
but
was
somewhat
alleviated
by
walking
about.
There
was
no nausea or vomiting.
Administration
of a cathartic,
the day before hos
pitalization,
resulted
in many
loose
bowel
movements
the following
day.
On
admission to the Buffalo City Hospital her temperature
was
100° F., with
a
pulse
rate of 84.
The patient
was a well-developed,
well-nourished
white female, not
acutely ill.
Pathological
findings were limited to the abdomen which was negative
for distention
or spasm but had marked tenderness over the right lower quadrant
with
some
tenderness on palpation
of the right fornix
of the vagina.
Occasional
red blood cells were in the urine.
She had a leucocytosis of 13,300 with 70 percent
polymorphonuclear
leucocytes.
A
diagnosis of acute appendicitis
w-as made.
A
Battle
incision
was
made
under
spinal
anaesthesia.
Upon
opening
the
peritoneal
cavity,
there
was
no
free fluid.
The
omentum
presented
into
the
wound.
Palpation
revealed
what
was
thought
to
be
a
thickened
retrocecal
appendix.
When the omentum
was brushed away, a portion
of
it
was intimately
adherent to the cecum about an inch above the ileocecal valve.
This was left in
place and cut
free
from the remaining
omentum
after double ligature.
It was
then seen that the supposed retrocecal appendix
was, in fact,
a
portion of the wrall
of the cecum.
The cecum for about
3
inches was angry
red in color, its serosa
was rough
and
shaggy, and
its walls
were
markedly
swollen
and
edematous.
The
remainder
of
the
colon
was
normal
in
appearance.
There
was
definite
demarcation
between normal
and
pathological
bowel.
The
appendix
was
uni
formly
fiery red and somewhat edematous.
Its serosa
was smooth and glistening
and
it
was
nowhere
adherent.
At the time
of operation
the author
was not
acquainted
with the subject of cecal
phlegmon, and in view of the fact that the
involved
bowel did not seem to be tuberculous
or carcinomatous,
and did seem to
be an acute inflammatory
process, ileocecal resection
was
not performed.
An
appendectomy
was performed,
the omentum
was
wrapped
around
the inflamed
bowel, and the incision
closed in layers without
drainage.
At the time the post
operative
diagnosis
was acute perityphlitis, acute
periappendicitis.
Convales
cence
was
uneventful
and
on
the
eighth
postoperative
day
the
patient
was
discharged.
Comment:
While
we have no microscopic
preparations
of the wall of the colon,
the clinical
picture
is
identical
with that
presented
by
Hellstrom,
Konjetzny,
Demel, and others.
'
Burke, J.
Archives of Surgery,
in press.
LUNG
ABSCESS —MAYNE
AND CLEMENT
487
THE
TREATMENT
OF
LUNG
ABSCESS
By Lieutenant
Roy M. Mavne,
MC-F,
United States Naval
Reserve,
and
Lieutenant
Commander
T. Gaqe Clement, MC-V(S), United
States Naval Reserve, Duluth, Minn.
In presenting
this
paper
it is not our
purpose
to
advocate
one
dogmatic
type
of treatment for pulmonary
abscess, or to condemn
any other type of treatment.
We wish to give a brief general resume1
of the modern
concepts
of treatment
as obtained in a far from com
plete review
of the literature,
and
present
a
case
history
showing
the result of treatment.
There are, of course,
but two
general
methods
of treatment,
the
medical and the surgical.
Likewise, lung abscesses of nontuberculous
type are divided into two
classes,
those which are acute
and
those
which
are chronic.
During
recent
years
the conviction
has grown
that the acute abscesses should
be treated medically and that surgery
should be reserved for the chronic type, after a fair trial of conserva
tive
treatment.
One
is struck with
the wide
variety of treatments
recommended
which range from no treatment at all or only postural
drainage,
to drastic and extensive
thoracic surgery.
The variety of
treatments advocated
forces one to the conclusion
that no one treat
ment is eminently successful.
The
primary
object
of
treatment
is
to
establish
constant
and
complete
drainage of the abscess, while at the same time maintaining
and
conserving
the patient's strength
and resistance.
That type
of
therapy which will best attain this objective in each individual patient
is the treatment of choice.
From an etiological
standpoint, it is concluded
that 75 or 80 percent
of the cases are the result of foci of infection in or about
the head and
neck, or operations
upon these foci.
In fact,
one or two authors
go
so far as
to say that all are either
inhalation or embolic
abscesses.
However,
a
few
have
been attributed
to
bronchopneumonia,
par
ticularly
the
bronchopneumonia
complicating
influenza.
Abscesses
are practically
never
seen following
a lobar pneumonia.
Aspiration
or inhalation abscesses are most apt to communicate
with a bronchus.
Distant
infections,
such
as those which occur with infected
abortion,
phlebitis and abscesses
in the abdomen
and pelvis,
are more likely to
produce
metastatic lung infections,
and not single
abscesses.
Anes
thesia can be a causative
factor, although it is more probable
that the
pathology or condition which existed,
and for the treatment of which
the anesthetic
was given, is the true cause.
Abscessed
teeth, infected
tonsils and sinuses, and the treatment
of them, hold
the first place as
the cause of lung abscesses in all reports.
The pathology of the lung abscess is not complicated.
The lesion
is, at first, a solid
mass of inflammatory
tissue,
then
as liquification
occurs,
a cavity filled with pus is formed.
The walls are ragged and
necrotic at the beginning,
but as the abscess becomes more chronic
488
LUNG
ABSCESS —MAYKE
AND
CLEMENT
the walls become smoother
due to fibrous
tissue which is built around
them.
The wall of the acute
abscess is a dense infiltration
of poly
morphonuclear leucocytes,
and a greater or lesser number of mono
nuclear phagocytes.
The odor, which is usually present,
comes from
necrotic tissue.
When
drainage
is
established,
resulting in proper
ventilation, the odor rapidly diminishes.
Proper drainage
and venti
lation cause rapid collapse of the abscess walls,
the circulation to the
part improves and healing
begins.
Resolution of the inflammatory
process
occurs
and
in
time
the lung structure returns
to normal.
Little, if any, scar tissue or fibrosis results, but if the abscess has been
in contact with the pleura, chronic hyperplastic pleurisy, with fixation
to the chest wall, may persist.
The inhalation group of lung abscess is the largest,
and this group
usually follows operations
on the mouth, nose, or throat, regardless of
whether the anesthesia is local or general.
The embolic group is small
and the abscesses
are more apt to be multiple, being metastatic.
The
large majority of lung abscesses
lie well out in the lung parenchyma
and touch the chest wall.
A few lung abscesses,
and
these are rare
indeed,
lie close to the hilum or mediastinum.
As stated before, the treatment
of lung abscess is varied and depends
almost
entirely
upon
the
particular
specialty of
the physician in
attendance.
Specialists
in diseases of
the upper respiratory
tract
suggest that the best method
of treatment
is by means of drainage
with the bronchoscope.
The surgeons suggest that all lung abscesses
should
be
treated
surgically.
Most of
the
pediatricians
feel that
postural drainage and medication
are sufficient.
A few internists have
suggested the use of guaiacol
and other drugs combined
with postural
drainage,
and
with,
or without,
pneumothorax.
The
radiologists
recommend X-ray therapy.
Each reports satisfaction
with the special
type of therapy
as employed
by himself.
Statistics of results obtained vary.
Those cases treated by drainage
with the bronchoscope
show
a mortality of 8 percent.
The broncho-
scopists
are fair enough,
however,
in stating that by this treatment
only half the cases
show improvement.
The mortality
in the
cases
treated
surgically
varies
from
2.7
to
52
percent,
with
an
average
mortality
of 32 percent.
The severest
cases,
acute and chronic,
are
those which have been
treated surgically, hence the high mortality.
The drastic
surgical
procedures include everything from thoracotomy,
either in one or two stages, up through rib resection and thoracoplasty,
to lobectomy.
Any number of cases
are reported
in which broncho
scopy, postural drainage,
and medication
have failed,
and in the late
stages of the disease, after the abscess has become chronic, then, and
only then, has the surgeon been called in consultation.
Those cases
treated
by medication
alone, or in combination with
postural drainage only, show a mortality rate of 20 percent.
Authors
LUNG ABSCESS —MAYNE
AND CLEMENT
489
reporting
the
use of X-ray, with or without
medication,
and X-ray
treatment, with or without pneumothorax,
have had no fatal results.
Simple postural drainage
cases have shown no deaths.
The mortality
in cases reported
as receiving artificial pneumothorax alone is 1 percent.
The distribution of the lesions as reported,
show that the right lung
is the one usually involved.
Assuming that aspiration is the most
common cause of lung abscess it is readily understood
why the right
lung is the more frequently involved.
The proportion of right to left
lung involvement is 2 to 1.
In the literature reviewed only 12 cases of
scattered
or multiple lobe involvement were found.
In considering
the fact that 25 percent
is the value given
to those
cases which recover
spontaneously,
and taking into consideration
the
fact that only the simpler cases were treated by postural drainage
and
drugs, it would seem that probably
these simpler cases would have
recovered
spontaneously
without
such
treatment.
Not infrequently
an abscess heals spontaneously
after rupture
and
drainage
through
a bronchus.
In these cases
the favorable result
is,
no doubt, due to
the rapid collapse of the cavity, and its obliteration by the expansion
of the surrounding lung tissue.
Since
collapse
can result only when
the cavity wall
is
nonrigid,
it
is
evident that medical
treatment must
be instituted before fibrosis
has produced
a
thick, rigid wall.
This
is
especially
true
if
treatment by artificial pneumothorax
is
to be used
with the expectation
of securing favorable result.
That fibrosis
and
fibrotic adhesions
can, and do, form in an amazingly short period of
time will be demonstrated
in our case report.
The objections
to certain
types of treatment
made by authors who
are not in sympathy with other than their own
particular
type
of
treatment,
seems untenable.
For example, the objection of a surgeon
to the treatment
of lung abscess by artificial pneumothorax
is
that in
case of rupture of the abscess,
the pleural cavity becomes infected and
empyema
results.
However, statistics as given on the surgical
cases
show
that with
operation
this
same contamination of
the pleural
cavity occurs, and that about
12 percent of the post operative
deaths
occur from this very cause.
Either the pleural cavity was not well
enough
walled
off in the
two
stage thoracotomy operation,
or the
abscess ruptured into the pleural cavity after drainage was established.
All authors who mention
pneumothorax
state that this type of therapy
must be used in the early
stages,
if
at all, and that in those cases in
which hemorrhage
occurs,
it
should at least be attempted.
Most authors
fail to mention X-ray therapy.
This can be due to
the following reasons.
In the first place, X-ray therapy
is
more or
less new
as applied
to such
conditions,
and
secondly,
the action
of
X-rays upon infectious
processes has not been thoroughly understood
until
recently.
In
those
cases
reported,
22
have
been
treated
by
X-ray
only with
no complications and
no
relapses occurring.
The
490
LUNG
ABSCESS —MAYNE
AND CLEMENT
improvement was rapid and
started
immediately after
the first
ex
posure.
Progress
in
the
healing
of the
abscesses
was
checked
by
films.
Complete resolution
occurred and little or no scar tissue forma
tion resulted.
In the case which we are to report, the symptom which caused the
patient to visit
a physician was hemoptysis.
This was not the first
symptom noted, but was the first to cause alarm,
and in this he was
indeed fortunate in that it enabled treatment to be started very early
in the course of his disease.
Pneumothorax, X-ray therapy,
absolute
bed rest and supportive measures constituted the treatment.
Disa
bility was only 30 days total, and
14 days partial, although treatment
was continued
over
a total period of 90 days.
Case
Report
White, male, aged
41 years, married, salesman, first consulted one of us (RMM)
on June
10,
1937, complaining
of cough, bloody sputum,
and, at times, bright red
blood
expectoration.
Associated
with
these
symptoms
were
fever,
sweating,
chills, generalized aching and extreme malaise.
He stated that
he had felt per
fectly
well until June
8.
During the night
of that
date, which
he spent in
a
neighboring
city,
he awoke
with
a chill,
headache, and cough.
He considered
the symptoms
as the onset of a "cold."
He worked
the following
day, June
9,
as usual, although
he felt "sick all over."
After finishing his day's work he drove
home,
a distance
of
165 miles.
During this trip
home
he
began
spitting
up
bright red blood, and did so many times during the 4 to 5 hours en route.
During
the night of June 9 he developed pain in the right upper chest,
and called one of
us (RMM) to his home on the morning
of June
10.
Examination
at
that
time
revealed
the
following:
Temperature
101°
F.,
pulse 110, and respirations
18 per minute.
He did not look as acutely ill as one
would
expect in an acute lobar
pneumonia.
The
right
upper chest anteriorly
showed some
impairment
of resonance, and there were
breath sounds suggesting
a cavity.
There were definite course
rales at the level of the second rib anteriorly.
None was heard posteriorly.
A specimen of sputum
was obtained
and sympto
matic treatment
given pending the laboratory
report.
The report was as follows:
Specimen
consists
of
serous
fluid
containing
green
purulent
masses.
No
tubercle
bacilli
are
seen.
Gram
stain
shows
numerous
PMN's,
streptococci,
Gram positive dipilococci
and Gram negative rods.
Guinea
pig innoculation
was
made and subsequently
reported
as showing
no
evidence
of tuberculosis.
Close
questioning
relative
to his family
history
was
negative
and
there was
no
history
of known
contact
with
tuberculosis.
Past
medical history
discloses no major
operations, no illnesses
and no injuries.
On June 11, 1937, an X-ray of the chest was obtained and an extensive shadow
was revealed in the right upper lobe, with what appeared to be two cavities in the
center of the area of increased density.
While
there was no distinctive
odor to
the breath
the patient
volunteered
the information
that
the sputum
was foul
tasting and caused nausea.
Because of X-ray
findings
and the continued
hemoptysis,
artificial pneumo
thorax was immediately instituted on
the morning
of June
12, about
72
hours
following
his initial symptoms.
The skin and parietal pleura were infiltrated
with
sufficient amount
of
1 percent novocaine solution to produce local anesthesia
and
the needle
was inserted into the right
seventh interspace,
posterior axillary line.
There
was no difficulty
encountered
in entering
the pleural
space.
A marked
negative
initial
pressure,
which
fluctuated
with
respiration
from
minus
4
to
RUPTURED
KNEE
LIGAMENTS —WADE
491
minus 8, was changed to minus
1 minuB 4 by the introduction
of 400 cubic centi
meters
of
cotton
filtered
atmospheric
air—using
the
standard
pneumothorax
gravity bottles.
On the second day, June
14, 500 cubic
centimeters
of air was
introduced,
and 650 cubic centimeters on June
16 and June 19, respectively.
An
X-ray film was then taken, showing insufficient
collapse of the lung to have any
appreciable
effect upon the abscess
cavities.
Consequently
larger amounts of air
were given at more frequent intervals,
e. g.:
Cubic centimettrt
June 21
1, 050
June 23
-
-
1, 000
JuDe25
1,050
June 28
1, 050
Each of these refills brought
the intrapleural
pressure readings to plus one and
minus one,
or a slightly
positive
intrapleural
pressure.
An X-ray
at this time
showed
satisfactory
collapse of the cavities,
and smaller
refills
of from
400
to
500
cubic centimeters
were
given
at
weekly
intervals,
and
later
at
biweekly
intervals.
During the time between June 12 and July 2 the patient
was kept upon abso
lute bed
rest,
and the hemoptysis
ceased
within
36 hours following
administra
tion of the initial pneumothorax.
His temperature
reached
a normal
level on
June
14 and remained below
100° F. throughout
his treatment.
The cough was
less severe
but the amount
of sputum
became considerably
greater as collapse of
the
lung progressed.
This, of course, was expected, indicating
satisfactory
col
lapse of the cavities.
On July 7, X-ray therapy was given to the right upper chest
anteriorly,
and on July 9, another X-ray treatment
was given over the right upper
chest posteriorly.
During the course of treatment
the blood serology was negative, the urine was
negative, the hemoglobin showed 99 percent, the red blood cells numbered 4,900,000,
the
white
blood
cells numbered
12,150,
and the differential
count
was normal.
An intradermal
tuberculin
test was negative.
Several additional
sputum
exam
inations
were made with no appreciable
change to
be noted from
the original
report.
Convalescence
was without
incident.
In
all
he
received
18 pneumothorax
refills, amounting
from
400 to 1,050 cubic centimeters of air each.
He was called
from the city on business July 11, 1937, just 32 days after the onset of illness and
received pneumothorax
refills at biweekly
intervals
during July and August.
On
September
10, 1937 he returned
home and film and fluoroscopic
examinations
on
that date revealed very little collapse of the right lung.
There was no sign of the
original abscess
at the right apex.
Pneumothorax
was abandoned and aside from
occasional
films of the chest as follow-up
examinations
he has received no treat
ment.
Incidentally, the patient
gave
a history
to the effect that in March 1937, about
3 months prior to his illness, he had an abscessed
tooth extracted from the right
lower jaw under novocaine anesthesia.
He had not associated this incident with
his illness, as he had felt perfectly
well in the interval.
There is no other known
incident which might have been an etiological
factor.
RUPTURED
CRUCIATE
LIGAMENTS
OF
THE KNEE'
MODIFIED
HEY GROVES RECONSTRUCTION
OPERATION
WITH
CASE
REPORTS
By Lieutenant
E. M. Wade, Medical
Corps,
United
States Navy
The cruciate ligaments are of considerable
strength,
situated
in the
middle of the knee joint,
nearer
to its posterior surface
than to its
' From surgical service, U. 8. Naval
Hospital,
San Diego,
Calif.
492
RUPTURED
KNEE
LIGAMENTS —WADE
anterior surface.
They
are called
cruciate
because they cross each
other
somewhat
like the lines of the letter X, and have received
the
names anterior and posterior from the position of their attachments
to the tibia.
The anterior cruciate ligament is attached
to the de
pression
in front of the intercondyloid
eminence
of the tibia,
being
blended with the anterior extremity of the lateral meniscus; it passes
upward, backward, and lateralward,
and
is fixed into
the posterior
aspect of the medial nonarticulating
surface of the lateral condyle
of
the femur.
It checks forward displacement
of the tibia and hyper-
extension
of the joint.
The posterior cruciate
ligament is stronger,
but shorter
and less oblique
in its direction, than the anterior.
It is
attached
to the posterior intercondyloid fossa of the tibia, and to the
posterior
extremity of the lateral semilunar fibrocartilage and passes
upward, forward, and medialward, to be fixed into the anterior aspect
of the lateral nonarticulating
surface
of the medial condyle
of the
femur.2
The posterior cruciate
ligament checks
posterior displace
ment
of the tibia when
the knee
is flexed.
Injury of the cruciate
ligaments
of the knee has become more fre
quent with the popularization of vigorous
athletics,
particularly foot
ball and skiing, together
with
the advent of high-speed
automotive
transportation,
and
the constantly expanding
use of both civil
and
military
aviation.
In a series of 241
cases of internal derangement
of the knee joint,
Dickson reports that rupture of the anterior cruciate ligament occurred
12 times,
and in one instance
both cruciate
ligaments
were injured.*
That injury to a cruciate
ligament seldom
occurs without associated
injury to other parts of the joint structure, especially
the semilunar
cartilages,
the lateral ligaments,
and the patella and its tendon,
has
been observed
by many.
Injury to the anterior cruciate ligament is produced
principally by
overextension
of the
knee joint,
the
posterior ligament
being
fre
quently injured by direct trauma hitting from before, in the direction
of the axis of the thigh.4 s
Extreme torsion may rupture both cruciate
ligaments,
and trauma with hyperabduction, adduction, and torsion
may
rupture
all
ligaments
of
the
joint,
permitting
subluxation
or dislocation.6
It has been pointed out by Mitchell that in anterior
dislocation of the knee, the anterior and commonly also the posterior
cruciate
ligaments
are ruptured.
In posterior dislocations of this
joint,
the posterior cruciate ligament is ruptured.7
» Lewis,
Warren
H.: Anatomy of the Human Body, by Henry Gray, 21st edition,
p. 344, Lea and
Feblger,
Philadelphia,
Pa.
i Dickson,
Frank D.: Injuries of the Knee Joint.
J. A. M. A., 110: 122,Jan. 8, 1938.
• Felsenreich,
FriU:
Clinic of Injuries of the Cruciate
Ligaments
of the Knee.
Arch. f. kiin. Chir., 179:
378, Apr. 29. 1934.
» Felsenreich,
Fritz: Injury
of the Cruciate
Ligaments.
WIen.
klin. Wchnsch.,
48: 1058, Aug.
23, 1935.
• Strickler,
Frank P.: A
Satisfactory
Method of Repairing
Crucial
Ligaments.
Ann. Surg.,
105: 912,
June 1937.
' Mitchell, Joseph I.: Dislocation
of the Knee.
J. Bone and Joint Surg.,
12: 640-646,July 1930.
RUPTURED
KNEE
LIGAMENTS —WADE
493
The
outstanding
symptoms
of
cruciate
ligament damage
are in
stability
with chronic or recurrent knee-joint effusion.8
Objectively
there
is preternatural anterior-posterior mobility
of the joint.
This
is regularly present
immediately after the injury,
but tends
to dis
appear with
the limitation
of extension
that commonly follows,
due
to joint effusion,
periarticular
hemorrhage
and edema, incarceration
of a fractured or dislocated
semilunar
cartilage,
avulsion of the inter
condylar
eminence,
or
possibly
incarceration
of
the
torn
cruciate
ligament itself.
Injury of the cruciate
ligament is frequently over
looked in an injured joint,
since voluntary
muscular control of the
knee is
often
acquired,
and
examination
under general
anesthesia
may be necessary
to demonstrate
the typical findings.
As a result
of cruciate
ligament injury,
there may be abnormal lateral mobility,
particularly if there is an associated injury of the lateral ligaments.
The roentgen-ray
diagnosis
has been stated
as presumptively positive
in
13 percent of recent
cases
and in 53 percent of old
cases.
In the
former the changes are avulsion fractures
of the cortical layers in the
region of the femoral
and tibial sites of the cruciate
ligament attach
ments,
and
fractures
of
the
tibia,
particularly
the
intercondyloid
eminence.
In
the
old
cases
there
is
often
evidence
of abnormal
bone formation in the femoral
and tibial fossae of the cruciate
liga
ments
as a result of the looseness and abnormal mobility of the joint
due to the primary injury.
There may be evidence of an old fracture
of the intercondylar
eminence.
Kational
interpretation of the films
is possible only with comparison
with films of the opposite joint, and
if practicable,
views made early in the history of the case.*
Occasionally during arthrotomy for a recent internal derangement
of the knee joint,
there may be an occasion for an attempt to unite
the
ends
of
a ruptured
cruciate
ligament by
suture.
In
general,
however,
the
early
treatment
of cruciate ligament injury
is
con
servative with immobilization in a cast or splint.
Ordinarily,
asso
ciated
injuries
to the
external
ligaments
of the
knee
and
disorders
of the semilunar
cartilages
are treated
by conservative
surgery
prior
to reconstruction
operations
for ruptured
or injured
cruciate
liga
ments.
It is believed by many that a complete rupture of a cruciate
ligament never heals spontaneously,
although following conservative
treatment compensation
for this disability
is at times
effected
by
voluntary
contraction
of
the
quadriceps
femoris
muscle.910
This
occurs
particularly
in
young
adults
whose
adaptability
is
great
• Oold,
E.: Complete
Plastic
Substitution
of the Anterior Crucial
Ligament
and
Functional-Anatomic
Restoration
of the Same.
Deutsche
Ztschr. f. Chir.. 213: 120. 1928.
i Campbell,
Willis C.; Rupture of Crucial
Ligaments.
Dean Lewis' Practice
of Surgery,
2: 169, W. F.
Prior Co., Inc., Hagerstown,
Md.
Krida, Arthur:
Reconstruction
of the Anterior
Crucial
Ligament
of the Knee Joint.
S. Clin. North
America,
10: C77,June 1930.
494
RUPTURED
KNEE
LIGAMENTS —WADE
enough
to permit
the
quadriceps
femoris
to take on what may be
called
a vicarious or
compensatory
function
and
maintain
by its
sheer efficiency
the functional stability
of the joint.
In numerous
instances
there
is no muscular compensation,
and
there
is marked
disability
due
to lack of stability
of the knee, recurrent joint
effu
sions, and tendency
to subluxation.
In the chronic and
grossly
disabled
case
there
are three
possible
forms
of treatment:
(1) Permanent brace wearing;
(2) arthrodesis;
(3) operative reconstruction.
The common
present-day
operative
reconstructions of the anterior
cruciate ligament are based on the technic of Hey Groves,
published
in
1917 and
1920. 11
This operation
consisted
in the transplantation
of a pedicled graft of the iliotibial band, threaded through holes drilled
in the lateral condyle
of the femur and the head of the tibia in such a
manner
as
to anatomically
replace
the anterior
cruciate
ligament.
Operations for reconstruction of the posterior cruciate
ligament have
been
described
wherein
the
tendons
of
the gracilis
and
the
semi-
tendinosus
are
severed
from
their
muscle
attachments,
and
are
brought forward through the inner part of the posterior ligament of
the
knee joint,
and
threaded
through
a hole drilled in
the medial
condyle of the femur and subsequently
attached
to the anterior aspect
of the
medial
condyle
of the
femur.912
Free transplants of fascia,
tendon,
and the substitution of a ruptured cruciate
ligament by silk,
or an avulsed semilunar cartilage
13 have been reported,
but the value
of these procedures
is questionable.
By a single operative
reconstruction in vogue for at least the past
7
years in several United States naval hospitals,
it has been possible
to
restore
function
of knee joints
wherein
either
or both cruciate
liga
ments had been injured.
A description of the operative
technic with
illustrative
cases follows.
RECONSTRUCTION
OF
CRUCIATE
LIGAMENTS
Under subarachnoid anesthesia,
which may subsequently
be
sup
plemented
by
nitrous
oxide-oxygen-ether
inhalation,
a
large
U-
shaped incision is made in the front of the knee, the lower part of the
incision being just below
the tubercle
of the tibia.
The inner limb
of the U runs along the line of the hamstring tendons,
while the outer
limb is about one fingerbreadth
on the outer side of the patella.
The iliotibial
band
is defined
by prolonging the outer limb of the
incision upward.
A strip of fascia,
8 inches long and
1.5 inches wide,
n Hey
Groves,
E. W.: The Crucial
Ligaments
of the Knee Joint: Their Function, Rupture, and the
Operative
Treatment
of the Same
Brit. J. Surg.,
7: 505-514, 1920.
" Tees, Frederick J.: Injuries
of the Crucial Ligaments
of the Knee Joint, with a New Method
of Operat
ing for the Repair
of the Posterior
Ligament.
Canad.
M. A. J., 26: 853-658, June 1932.
Wittek, A.: Reconstructive
Surgery
of the Knee Joint.
Wein. klin. Wchnschr.,
50: 803, May 22. 1937.
RUPTURED
KNEE
LIGAMENTS —WADE
495
is
separated
by two longitudinal
and
one
transverse
incision,
the
band retaining its original attachment to the head of the fibula.
The tuberosity of the tibia is chisled off, taking a generous chip of
bone about three-fourths inch square
and about one-half
inch thick.
The patella is turned upward after cutting through the capsule of the
joint.
The knee is flexed, the joint explored,
and the ruptured liga
ment or ligaments
demonstrated.
All pathological semilunar carti
lages,
loose
bodies,
and
at
times
ligamentary
remnants
which
are
encountered
are removed.
A drill hole is made on the external
condyle of the femur,
the inner
hole being placed in the center of the medial nonarticulating surface
of the intercondylar notch.
A second drill hole is made on the head
of the tibia, just anterior to the intercondylar eminence, and with the
external
opening
over the most prominent part of the medial
condyle
anteriorly.
The strip of fascia
is pulled taut through the holes in the femur
and
tibia with
the knee
flexed at
90 degrees.
The free end of the
graft is passed upward over
the inner condyle
of the femur,
and is
fixed
with
interrupted
chromic catgut sutures.
The lower portion
of the defect
caused by the removal
of the graft from the iliotibial
band,
and the incision in the joint capsule are closed with a few inter
rupted
sutures.
The tuberosity of the tibia is fixed
to its original
bed with interrupted chromic catgut sutures.
The skin is closed.
Case
Reports
Case
1.—Y. C. W., private,
United
States Marine
Corps,
age
17, admitted
to
the hospital on July 21,
1937.
History: Injury to the right knee in 1931, but no serious symptoms until 6 days
ago when
he fell on the drill field.
This fall was followed
by weakness and in
stability of the joint with a tendency to lock.
Examination:
The
only
positive
physical
findings
were
abnormal
anterior
mobility of the proximal
head of the right
tibia,
tenderness on medial
side
of
right patella,
and loud crepitations
in joint during
movement.
The Kahn test
was negative and urinanalysis
revealed no abnormal
finding.
X-ray examination
of the knee was reported negative.
Impression:
(1)
Rupture,
right
anterior
cruciate
ligament;
(2)
dislocation
right internal
semilunar
cartilage.
Progress:
The
patient
was treated
conservatively,
with subsidence
of acute
symptoms,
but
he continued
to complain
of instability and locking
of the joint.
On August
31,
1937, arthrotomy
of the right
knee
was performed
under spinal
anesthesia.
The
anterior
crucial
ligament
was
found
ruptured,
the
internal
semilunar
cartilage
was loose,
and the prepatellar
fat pad was hypertrophied.
Excision of the internal
semilunar
cartilage
and the hypertrophied
fat pad was
performed.
Patient
recovered
satisfactorily
following
this
operation,
but
continued
to
complain
of weakness and instability of the knee.
On
October
28,
1937,
under
spinal
anesthesia
which
was supplemented
by
nitrous
oxide-oxygen-ether
inhalations,
the anterior
cruciate ligament of the right
knee was reconstructed
according
to the previously
outlined
technic.
86860—38
4
496
RUPTURED
KNEE
LIGAMENTS —WADE
The right knee-joint
motions returned
to normal with graduated
exercises
and
physiotherapy,
although
he continued
to complain
of weakness and he was dis
charged from
the United
States Marine Corps
on March
3,
1938,
for physical
disability.
Case 2.—G. R. T., fireman, third class,
United
States Navy, age 23, admitted to
the hospital
on April
13, 1937.
History: About 10 months previously
he had slipped and twisted his right knee
while taking a shower bath.
Following
this injury there was persistent
soreness
and the joint locked occasionally.
Examination:
The only positive physical
findings elicited
were tenderness over
internal
border of right patella with
some limitation of flexion of the knee.
The
Kahn test was negative and urinanalysis
revealed no abnormal
findings.
X-ray
examination
of the knee was reported negative.
Impression:
Dislocation,
right internal
semilunar
cartilage.
Progress:
On April
19,
1937,
a small Jones'
incision
was made in the antero-
medial aspect of the right
knee,
under spinal anesthesia.
The appearance of the
right femoral
condyle
was considered characteristic
of osteochondritis
dissecans,
and six pieces of loose articular
cartilage
were encountered and removed.
Postoperative
convalescence was slow, with tendency to recurrent joint effusion,
but
he was considered sufficiently
improved
on June
11,
1937, to be returned
to
duty.
Patient
did not improve on duty, and symptoms of locking and soreness
of joint
recurred.
He was returned to the hospital
on September
2, 1937, at which time
the physical findings
were similar to those noted at the time of the original admis
sion.
X-ray examination
of the joint was again reported negative.
It was felt
that the symptoms were due to the previously
diagnosed osteochondritis
dissecans.
On September
21,
1937,
the knee joint
was
explored under spinal anesthesia,
and the anterior
cruciate
ligament
was found
to be ruptured.
A pedicled strip
of the iliotibial band was passed
through
holes drilled
in the external condyle of
the femur and the head of the tibia and secured as previously
outlined.
Early in the postoperative
period
there was inability to fully
flex
the knee,
although
function
gradually
returned
with active
motion
and
physiotherapy.
He
was returned
to duty
on January
14,
1938, improved.
Case 8.—E. H. B., yeoman, third class,
United
States Navy, age 26, admitted
to the hospital
on February
16, 1936.
History:
Injured on day of admission
when the motorcycle
on which
he was
riding crashed into a heavy post.
Examination:
The positive
physical
findings
noted on admission
were tender
ness in lumbar
area, principally over lateral muscle groups, and swelling, deform
ity, and loss of function,
left knee.
The Kahn test was negative, and urinanalysis
revealed no abnormality
other than a transitory
trace of albumin.
X-ray exami
nation
revealed a comminuted
T-shaped
intercondylar
fracture
of the proximal
head of the left tibia and
a comminuted
fracture
of the left
second transverse
process
of the second lumbar vertebra.
Impression:
(1)
Fracture,
left tibia involving
knee joint;
(2) fracture,
simple,
transverse
process, second lumbar
vertebra.
Progress:
The left leg was put up in Russet's traction,
followed
by a posterior
molded splint, and later on April 22, 1936, he was allowed up with a Thomas caliper
brace.
There
was
preternatural
anterior mobility of the knee joint, but he was
free from symptoms
when he wore an elastic bandage.
His disability
was con
sidered to be a ruptured
anterior
cruciate ligament
of the left knee and he was
discharged
from
the Naval Service on November
27,
1936,
because
of physical
disability.
RUPTURED
KNEE
LIGAMENTS —WADE
497
On
August
28,
1937,
he
was involved
in
an automobile
accident,
and
was
readmitted
to
the
hospital
as
a
pensioner.
Physical
examination
revealed
preternatural
anterior mobility
of left knee.
The left knee joint was explored under spinal anethesia and the anterior cruciate
ligament
was found to be torn with only a small shred remaining.
The anterior
cruciate
ligament
was reconstructed,
using a pedicled fascia graft
as previously
described.
The result of the cruciate ligament
reconstruction
operation
was good.
Case 4-—F. A. M., age 20, electrician's
mate, third class,
United States Navy,
admitted
to this hospital on February
24,
1938.
History:
On January 5, 1938, while investigating
a casualty in a turret
powder
hoist, the motor was inadvertently
started, and his right knee was caught between
the flanges
of the hoist and the powder table.
He was treated aboard the U. S. S.
Relief,
with
rest and physiotherapy,
followed
by immobilization
of the leg in a
cast, until
transferred
to this hospital.
Examination:
Upon admission there were no abnormal
physical findings except
a circular
plaster-of-paris
cast encased
the right leg from groin to ankle, holding
the knee in a position
of extension.
The Kahn
test was negative,
and
urin-
analysis
revealed no abnormal
findings.
X-ray
examination
of the right knee
was unsatisfactory
because
of the cast.
Clinical Impression:
Deferred.
Progress:
The cast was removed on March 3, 1938, and X-ray examination
of
the right
knee was reported
negative
except for
a chip
fracture
involving
the
lateral aspect of the lateral condyle of the right femur, without displacement of the
fragment.
Physiotherapy
followed
by
active
motion
and
weight
bearing
was
instituted.
Function of the right knee improved
gradually,
permitting
90-degree
flexion and complete extension, but with an occasional sudden locking in a position
of incomplete
extension, which
was relieved by flexion and manipulation
of the
joint.
As mobility of the right knee improved,
a marked preternatural
anterior
mobility of the joint became apparent, and there was a marked sense of insecurity
while walking.
On March 24, 1938, the knee joint was explored with the belief that the patient
was
suffering
from
a
dislocated
internal
semilunar
cartilage
and
a ruptured
anterior
cruciate ligament.
The semilunar
cartilage was found to be normal, but
the
anterior
cruciate
ligament
was
ruptured.
The
exploratory
incision
was
lengthened and the anterior
cruciate ligament was reconstructed
according to the
previously
outlined
technic.
Examination
of the
knee
before patient
left
the
operating-room
table revealed no abnormal anterior-posterior
mobility of the joint.
The final results of this case cannot be evaluated at this time, since the patient
was operated upon just prior to the preparation
of this report.
SUMMARY
The operative
procedure
employed
in these four cases differs from
the original Hey Groves' technic
in that the distal end of the femur
and proximal head of the tibia are drilled in such a manner
that the
newly
constructed
cruciate
ligament
does
not
follow
the
oblique
course of the normal anterior cruciate ligament,
but passes from above
downward in almost a vertical plane.
This method has been found to
satisfactorily
stabilize
the
knee joint following injury to
either
or
both cruciate
ligaments.
498
INTRANASAL
PROCAINE
ANESTHESIA
LEAMER
INTRANASAL
PROCAINE
ANESTHESIA
By Lieutenant
Commander
Bruce V. Leameh, Medical Corps,
United States Navy
In
1932,
having
had
two near
fatalities while
using
10
percent
cocaine as an intranasal topical anesthetic,
we decided to use procaine
solution as a substitute.
It is a generally
accepted
theory that procaine
is poorly absorbed
through the mucous membranes.
We believe that the following report
will show that it is absorbed,
and that it is
a valuable
substitute for
cocaine.
Novocaine hydrochloride
(procaine)
was discovered
by Einhorn
in
1900.
Braun
tried it out on a large series of cases
and it is largely
due to his efforts that it has become so widely used.
He found that
the addition of adrenalin
to the drug not only diminished the rapidity
of its absorption
but also increased its potency.
After more than 30
years
of use it has
proven
to
be
the safest of all local
anesthetics.
Referring
to
the requirements
of a local
anesthetic,
as outlined by
Braun,1
novocaine
hydrochloride
meets
these
requirements.
It
is
less toxic than cocaine in proportion to its local anesthetic
value.
It
has been shown
that it causes no irritation
or tissue injury.
It is
absorbed
from
the
tissues
without
hyperemia,
inflammation,
or
necrosis.
It is soluble
in water; solutions
are stable
and possible of
sterilization by boiling.
It is compatible with
the
vaso-con stricter
principle of the
adrenal
gland.
It is slowly
absorbed
through
the
mucous
membranes.
Injected
locally,
it
exerts
a
pronounced,
prompt
anesthetic
action.
It
is not habit
forming.
Hooper
and
Becker
2 show
that
whereas
approximately
10 milligrams
of either
butyn or cocaine
per kilo
of
body weight was fatal, more than 45
milligrams per kilo of body weight of novocaine
was tolerated.
The investigating
committee
of the Therapeutic
Research
Com
mittee
of the Council on Pharmacy and Chemistry, in their summary
of deaths from local anesthesia, in 1924,3 report 43 deaths and of this
total 26 were caused by cocaine or the combined
use of cocaine
and
novocaine.
Novocaine, which was found to be used more frequently
than any other anesthetic,
was responsible for but one death.
There is little mention in the literature prior to 1933
of the
use of
procaine
as
a topical or surface anesthesia.
Labat*
and DeTakats5
note in their writings that if used in sufficient
concentration,
it has an
anesthetic
effect on the mucous membranes.
The following
procedure
was
used:
A 20 percent solution
of novocaine
hydro
chloride
was made up and to this was added an equal amount of 1:1000 adrenalin,
making a
10 percent solution
of novocaine
in adrenalin.
One hour prior
to the
' Braun
(Local
Anaesthesia).
Iiewis
Practice of Surgery, Vol. I.
1 Ilooiwr and Becker.
American
Journal of Medical
Sciences, Nfarch 24, 1924.
1Report
of Therapeutic
Research Committee
of the Council on Pharmacy
and Chemistry, 1924,
• Lahat.
Regional
Anaesthesia,
1923.
1DeTakats.
Local
Anaesthesia,
1923.
CORNEAL,
TRANSPLANTS —EBERT
AND BOYDEN
499
operation,
the patient
was given
5 grains of barbital
by mouth.
At operation,
strips of long fiber cotton
were saturated
in the solution.
After the excess
fluid
was expressed,
these strips
were inserted into the nose, taking
care that
one strip
was placed at the posterior end of the middle turbinate
in as close proximity
to the
sphenopalatine
ganglion as possible and another strip in the superior meatus of the
nasal cavity.
Then enough strips were inserted to completely plaster the septum.
Following the insertion
of the cotton strips,
1 percent novocaine
was injected
at
the
mucocutaneous
junction,
into
the floor and along the septum.
Then
after
waiting 15 minutes, the strips were removed and the operation carried out.
These
patients had
very
little
pain,
but were
somewhat
uncom
fortable.
After considerable
experimental
work, using
15 percent
to
20 percent solutions
of novocaine
with varying amounts
of adrenalin,
it was found that
3 parts of 20 percent
novocaine
solution to
1 part
of a 1 : 1000 solution of adrenalin
gave the best results.
Approximately
60
cases
were operated
on using this anesthetic.
All of them
were
free from pain during the operation.
The procedure
as already
described
is now
used, except that a full
20 minutes
is allowed for the anesthetic
to take effect rather than only
15 minutes
as was tried at first.
More
than
200
cases of intranasal
surgery
have
been
operated
upon
in
the
past
5
years,
using
this
anesthetic.
All of them have been free of pain and other discomforts
and there has been no evidence of any toxic manifestation.
In summarizing,
the toxicity
and anesthetic
value
of cocaine
and
novocaine have been compared.
A method
for the use of novocaine
as a topical anesthetic
has been outlined which has proven very satis
factory and has relieved
the writer of the anxiety attendant on the
use of cocaine.
CORNEAL TRANSPLANTATION
FROM THE STANDPOINT
OF FINAL
RESULTS
By Commander
Edwin C. Euert, Medical
Corps,
United
States Navy, and Lieutenant
Robert C.
Boyden, Medical
Corps,
United
States Navy
Surgical operations for the transplantation of corneal grafts have been
performed
with
various
degrees of clinical
success for
a
period
of
almost half a century.
Most glowing results have been reported by the
public press.
The unfortunate part of the publicity
is that it reports
only the immediate,
and usually gratifying results, and fails to investi
gate and report with equal
emphasis
the final results.
This incom
plete
reporting may engender
false
hopes in
those in need of new
corneas.
The surgeons' reports
are usually not so glowing, for usually
corneal
injuries are so extensive
and
complicated
by iris adhesions,
that conditions are not favorable
for transplant.
Rarely does a favor
able
case
present itself for corneal graft coincidentally with another
case having a healthy cornea available
for the graft.
Injuries of the eye due to the advent
of the machine
age and rapid
motorization, keratoplastic repairs
and
corneal
transplantations
are
becoming
an increasing
problem
in the United States Naval Medical
500
CORNEAL,
TRANSPLANTS —EBERT
AND
BOYDEN
Service.
Of the four cases here, three were done in Haiti (by E. C. E.)
and
the fourth
at the naval hospital,
San
Diego, Calif.,
by both
writers.
The writers consider their results of operations
on four cases
over a period of 12 years worthy of report.
Corneal
transplantations
are
done
for
two
principal
reasons:
1.
Removal
of central
leucomas
of
the
cornea
to improve vision.
2. Support of weakened
cornea
due
to ulcerations and lacerations.
Each has its place depending
upon the condition of the cornea requir
ing
the
transplant.
The
writers with
their four
cases,
and
very
limited
experience
find that the illustrated ribbon transplant
is the
most effective.
(See figs.
1 and 2.)
In all transplants the leaving of a
thin veil of Descemet's
membrane
for a shield
is very essential
for a
successful transplant.
The different technics which have found favor differ mainly in the
size and shape of the corneal graft used.
Total keratoplasty is defined
as
a transplant
of
the
entire
cornea
with
or without
Descemet's
membrane.
Partial keratoplasty, of course, denotes the transfer of a
portion only of the cornea.
This section may be square, rectangular,
round, or transcorneal
as noted by drawing.
There has been consider
able discussion
as
to whether the graft remains
permanently, or is
eventually absorbed
and replaced by ingrowth of corneal
tissue from
the host.
Suffice it to say that in either
case cicatricial and leukoma-
tous
changes frequently
supervene
and
eventually
reduce
the
area
grafted
to its initial state of opacity.
It is this final result which the
newspapers
do not report.
From the standpoint of nutrition,
the entire
cornea, with its fringe
of conjunctiva,
would
seem
to
offer
the most favorable chance
of
success.
However, this superior
blood
supply may act to defeat its
purpose
as it has been observed
that new capillaries invade the graft
between itself and its bed before complete
coherence has been accom
plished
and
produce,
circumferentially
at
least,
the
leukomatous
changes mentioned
previously.
Corneal transplants present
the following sequellae
as noted by our
observations
in the four cases:
1. During
the
first
48
hours
the
transplant
remains
clear
and
transparent.
2. After this period the transplant becomes edematous and misty.
3. After
10 days vascularization of transplant border occurs.
4. Later
and up to 6 months reorganization or cicatricial changes
take place along the border.
In
conclusion
we wish to state
that
corneal
transplant should
be
attempted in all favorable cases with hopes that a certain
amount of
visual perception
may be regained.
It is our impression
that no prognosis
should
be ventured until
at
least 6 months after the operations.
Figure
2.
Figure
3
Figure 4
METHOD
OF LIP FIXATION—EBERT
AND BOYDEN
501
AN IMPROVED
METHOD
OF UP FIXATION
FOR HARELIP
AND OTHER DEFECTS
By Commander
Edwin
O. Ebert, Medical Corps,
United States Navy,
and
Lieutenant
Robert C.
Boyden, Medical Corps, United States Navy
Satisfactory fixation of the lip for the operative
repair of injury and
the treatment of congenital
deformity is a troublesome
and difficult
task to perform without traumatizing the tissue by clamps and forceps.
This is due to the redundant nature of the lip, which causes it to roll
under the finger.
Due to this difficulty in immobilization,
the oper
ator finds that accurate incision lines, which are of such vital import
ance in reparative surgery of the lip, are a vexing problem.
During tours of duty in the West Indies and the Orient the writers
observed
the relatively
high incidence
of congenital
lip
deformities
among
the natives of those countries
compared
to that among Occi
dentals.
Whether this prevalence
is due
to dietary, hereditary, or
hygienic factors
is not within the scope of this short article.
It did,
however,
provide
a relatively
large
number of
cases
which
were
treated by the technic
described in the following paragraph.
As shown in figure
3 fixation is accomplished
by impaling the lip
on an ordinary wooden tongue depressor with heavy common banker's
pins.
Closure lines
having been marked
out,
the incision is made
along
these lines.
The authors
prefer
to employ a new sterile razor
blade held in a curved hemostat.
At this point another
advantage
of this method
becomes apparent;
approximation of the lip segments is rendered
more facile
and exact
by manipulation
of
the
free
ends
of
the
tongue
depressors.
The
edges
are brought into place and held there by an assistant
while the
operator places the sutures unhurriedly.
Figure 4 shows the sutures
in place.
Cosmetic and functional
results
in the
cases
operated,
using
this
procedure,
were
exceptionally satisfactory
and
it
is
felt
that
the
fixation described
was responsible
in a large measure for the success
obtained.
FACIAL
INJURIES
TREATMENT
OF SPECIAL INTEREST
TO THE DENTAL SURGEON
By Lieutenant
Mebbitte
M. Maxwell
(Dental
Corps),
United
States Navy
In these days of high speed transportation with the utilization
of
automobile,
motorcycle,
and
aeroplane
by
naval
personnel,
head
injuries of various types
and
degrees of severity are often
encount
ered.
Frequently
the jaws,
as
well
as
other
facial bones,
are dis
rupted in their continuity.
It is not uncommon
to find,
as an asso
ciated
complication,
the
more
serious
conditions of skull
fractures
and severe concussion.
502
FACIAL, INJURIES
MAXWELL
Quite often
the value
of the prompt reduction and
treatment of
fractures
about the face is overlooked.
To quote P. J. Aufderheide,
"We have all seen many patients lie around hospitals from
1 week to
2 months
without attention to fractures
with which we are dealing."
1
He further stresses the importance of calling to the attention of hos
pital medical
staffs the necessity of early treatment.
The
blood
supply of the
bones about the
face is abundant
and
regenerative
processes, in the absence of infection, are early initiated.
Fibrous union occurs within a short time and should
these bones unite
in malposition a permanent
facial deformity may result.
Malunion of the bones of the upper face is a serious matter and pre
sents a deformity difficult of correction.
Whereas,
in the case of the
malunited
mandible,
refracture
with
reestablishment
of
normal
relation of the parts can be much more easily accomplished.
In cases of severe head injury the life of the patient
is,
obviously,
the matter of first importance, and
if
he should
be suffering from con
cussion,
shock
or skull fracture, appropriate treatment must be in
stituted.
However,
after consultation
with
the
medical
officer
in
charge of the case,
and
as soon as the condition of the patient war
rants,
there should
be no delay in coaptating the variously fractured
facial bones.
This
procedure
has its chief
value in that
it
not only
makes
the patient more
comfortable,
but also serves
as
a
safeguard
against
complications and subsequent
deformities.
Kazanjian
states
"Fractures
should
be immobilized
as
soon
as
possible,
to hasten
the healing
process and above
all,
to prevent the
spread of infection into the fractured area."
2
A
large percentage
of
fractured jaw
cases
are compounded
within
the oral
cavity,
conse
quently prompt reduction will minimize the possibility of infection
from the bacteria
ever present in the mouth and will tend to circum
vent
a
possible
severe cellulitis or osteomyelitis.
Fractures of the maxillae
and adjacent facial bones are quite often
of the impacted
type.
With the bones contacting each other in this
malrelation ready union will usually occur.
It may
be well
to sound
a word of caution regarding emergency
head
bandages.
In
cases
of
the
fractured
mandible
it
has
been
noted that bandages are used which pass around the anterior surface
of the chin, thus drawing the fractured parts into
a
retruded
position.
This results in an overriding of the fractured ends of the mandible;
the tissues of the floor of the mouth together with the tongue are de
pressed toward the oral pharynx, thereby
adding to the patient's dis
comfort by interfering with normal respiration.
'
Aufderheide,
P. J.
Treatment
of Fractures
of the Maxillae,
Mandible, and
Other
Bones of the Face.
J.
A. D. A., 21: 950-961, June 1934.
i
Kazanjian,
V. n.: Traumatism
of the Face and Jaws with Special
Reference to Complications.
J. A.
D. A., July 1934.
FACIAL
INJURIES —MAXWELL
503
Various
types of head bandages
are employed
for stabilization
of
fractured jaws, the more commonly used ones being the Barton,
the
modified
Barton, Gibson, and
the four-tailed.
Where
there
is
dis
placement
of the fractured parts,
a head
bandage
cannot
be relied
upon to maintain reduction and if used at all it should be used only
for temporary or emergency immobilization.
Ordinarily
a simple
bandage
passing
under
the chin and over
the
vertex
of the skull will provide a state of rest for the fractured parts
and will suffice until more appropriate treatment can be rendered.
For the reduction and immobilization of fractured jaw cases, inter
dental wiring, splints, and
arch
bars,
used alone or in combination
with some type of headgear,
are recommended.
As a general rule it
may be stated that the best appliance
to use is the simplest
one which
will insure the desired end result.
In selecting
the
method
to
be employed
for
the reduction
and
immobilization
of fractured jaws, the thought of chief concern
is the
restoration
of normal function
of
the masticatory
apparatus.
To
achieve
this
end
a plan of treatment must be formulated whereby
the patient's teeth may be brought into occlusion
according
to his
specific norm.
It will be found that each case is an entity in itself and due con
sideration should
be given
to the following factors in the selection of
an appliance: —
1.
Selection
of
method
which
will
bring about
the
desired
end
result.
2. Ease of application.
3. Facility with which subsequent
adjustments may be made.
4. Adequacy in obtaining traction where such is necessary.
5. Once
reduction
is
accomplished,
the
means
to
maintain
im
mobility of the jaws with the teeth in normal centric
occlusion.
6. Comfort of the patient.
(a) An
appliance
of
the
least
intraoral
bulk
compatible
with
efficiency.
(6) Provision for proper oral hygiene
by the patient.
Several
methods
may be equally suitable for establishing
a suc
cessful restoration to normal.
If this condition exists it would seem
that the choice of the method
to be employed
should
be the one with
which the operator is the most familiar and which has given
the best
results in his hands.
With the majority
of fractured mandible cases, I have found the
hook method,
to be described
later, and the Oliver eyelet system
as
used by Ivy,3
to
be efficient.
In the more
complicated
cases,
arch
bars, cast splints, or other devices may be utilized to best advantage.
» Ivy, R. H.:
Surgical
Treatment
of Acquired
Deformities
of the Mouth and Jaws.
Dental
Cosmos,
February 1927.
504
FACIAL, INJURIES
MAXWELL
The
eyelet
method
of wiring
the teeth
was suggested
by Col. T.
Oliver in 1910.
Silverman and Eby in 1918 modified
the usage of the
eyelet by passing one of the wire ends through the
eye before twisting
the free ends together.
Ivy cites an outstanding advantage
of this
method
to be that in the event of a tie wire breaking it may be readily
replaced
without
the necessity
of changing
the base wires.
In cases
of emergency, or for any other reason, when the mouth must be opened,
the tie wires can be cut, leaving the base wires intact.
The outstanding advantages
in favor of the eyelet
system
are its
ease
of
application
and
convenience
of
subsequent
adjustment.
The certainty with which normal centric occlusion
is established
is
appealing.
From
the patient's standpoint,
the
eyelet wiring permits him
to
maintain a high degree of mouth hygiene
due to its lack of intraoral
bulk.
In lieu of the eyelet method,
a hook appliance
devised
and used at
this hospital appears to have some merit.
It can be used in any case
where
the
eyelet
is indicated, with
the additional
advantage
that
either
elastics
or tie
wires,
as may be necessary,
supply
the inter
maxillary binding.
The hook
wires are easily formed from any of the various types of
ligature wire used in jaw fracture work.
I prefer stainless
steel wire
0.014-0.008
inch.
Wipla rustless steel ligature
(0.008 inch) is very
satisfactory as it makes
a strong hook, although it is harder
to work
than some of the other types of wire which are more free from spring
and temper.
To form the hook,
a 6-inch length of wire is bent in the middle and
thus doubled
over on itself.
The doubled
end is grasped with a pair
of small straight hemostatic
forceps, about 2 mm from its extremity,
and a tight twist is made by once rotating the hemostat
figure
5 (C).
Adjacent
to this twist
an
eye is
formed
by
the interposition
of
a
straight explorer
or steel probe between
the two wires,
succeeded
by
two tight twists
as shown in figure
5 (D).
The hook is then shaped
from the doubled
end of the wire with the aid of the straight hemostat
figure
5 (E).
The hook wire is ligated
to the teeth in the same manner
as the
eyelet
wires
of Oliver,
except
that the free end of the wire passing
around
the distal anchor tooth is brought forward to pass through the
eye,
above described.
This will prevent
the hook from being drawn
into the interproximal embrasure
when
the final twisting of the wire
ends is being accomplished,
figure 6 (A and B).
In association
with fractured maxillae,
a fracture or fractures
of the
hard palate with
the occasional
loss of hard tissues in this area are
sometimes
encountered.
As a result there is established
a traumatic
FACIAL, INJURIES—MAXWELL
505
opening
into
the nasal cavity or into
one or both of the maxillary
sinuses.
In regard
to these and similar openings
into adjacent cavities
Ivy
states:
Losses of substance of hard tissue of the upper jaw of any considerable extent
are best replaced by intraoral
artificial
appliances attached to the teeth or held in
place
by
suction.
This
rule
applies
to defects resulting
from
excision
of the
maxillae
for neoplasm, large perforations
of the palate due to syphilis,
trauma,
etc.
However
small syphilitic or traumatic
openings can frequently
be closed by
mucoperiosteal
flaps loosened from each side of the defect and carried over to meet
each other.
Whenever
possible, surgical
corrections
is preferable
to the
use of
artificial appliances.3
To assist in the primary union of the closely
sutured
flap,
a pros
thetic appliance
covering
the roof of the mouth has been demonstrated
to
be of value.
This
covering
of
the
palatal
vault
prevents
the
patient's tongue from toying with the sutures,
as well
as minimizing
interference
with the healing
processes during eating.
Thus
a more
successful
"take" of the mucoperiosteal
flap is assured.
Intraoral
perforations into
the
maxillary
sinuses
are
somewhat
similarly
closed by the use of a flap taken
so as to meet the require
ments
of
the
particular
case
being
operated.
The
operation
of
Dunning
has been found to be very efficient.
By this method a tongue-shaped
flap is freed from the hard palate, its anterior
end running
well forward
of the antral
opening.
This flap is turned
across the
opening
and its end sutured
beneath
a previously
loosened curtain
of tissue on
the cheek side.4
It has been suggested that small antral openings, if not complicated
by antral infection, can occasionally be closed by the simple
use of
electro-cautery.
With this
conservative
method
there
was no
suc
cess.
With
10 cases
uncomplicated by infection and
so treated
not
a single closure was obtained.
After the flap operation for closure of antral openings,
a protection
for the flap, in the nature of base plate material or heavy tinfoil,
is
recommended
for the protection of the tissues during healing.
In the
event the patient is edentulous
and using dentures,
the upper denture
admirably
serves this protective purpose.
However, a denture
when
so used should
be relieved
so as not to bring undue
pressure
on the
palatine artery supplying the flap or the result will be a failure.
When infection and suppuration are present in the antrum, surgical
intraoral
closure
is
contraindicated.
In
cooperation
with
the rhi-
nologist the infection must first be aborted.
Infection obviously not
only
adds to the hazards
of operation,
but also with the welling up
of pus in back of the flap sutures,
closure
becomes impossible.
i Donning, H. 8.
Flap Operation.
J. A. M. A., 25: 1391,1920.
506
FACIAL
INJURIES —MAXWELL
Traumatic injuries of the head
quite often present
fracture of the
zygoma
and zygomatic arch,
in association
with fractured maxillae
and mandible.
A depressed malar fracture,
if seen early, is not usually difficult to
reduce.
However, after the elapse of several weeks time, with fibrous
union in malposition ensuing, reduction becomes much more difficult.
A number of methods
have
been advocated
for elevating
the
de
pressed zygoma.
The use of tenaculum
forceps,
the corkscrew,
or a
hook inserted into the bone with elastic traction to a facial bar, have
all been used with varying degrees of success by different
operators.
In hospital practice
the Gillies operation for reduction seems to be
commonly used.
The technique
involved here is to make
a curved
incision about
1 % inches long above and in front of the ear within the
hair-line.
The temporal
fascia is incised
and
a flat, thin, but sturdy
elevator,
is passed downward and forward over the temporal
muscle,
to engage the internal surface of the malar bone.
The bone is then
manipulated into its normal position.
An operation of more interest
to the dental surgeon is that of intra
oral reduction.
In this operation an incision is made in the buccal
fold above the apices of the upper molar teeth on the side of the de
pressed malar.
The tissues
are retracted
upwards,
posterior to the
malar eminence
and
a sturty
hooked
instrument is passed into
the
zygomatic fossa to engage the internal surface
of the zygoma.
By
exerting
pressure upward and outward the depressed bone can usually
be manipulated into its correct
anatomical position.
Ordinarily
no
fixation is required.
Reduction can be checked by palpation along the infraorbital ridge,
the zygomatic arch, and the frontal process, as well as by X-ray.
Intraoral reduction has the advantage
of being simple
to carry out,
with the additional advantage
that relatively unimportant structures
are passed through in traversing the route indicated.
Access to the
internal
surface
of
the malar is readily
obtained
by
the intraoral
method.
A disadvantage
exists in that a sterile field is difficult, if not
impossible,
to maintain.
In those cases where the malar requires fixation to retain its position,
kangaroo
tendon
may be used to ligate
the bone
to the pyramidal
process of the frontal bone.
Straith
e uses a curved antrum trocar for the intraoral manipulation
of the malar bone into position.
An instrument
for this purpose
devised at this hospital has been found useful.
It consists of a sturdy
curved
steei
shaft
(4}£
inches
long)
supplied
with
a
handle
large
enough so that a firm palm
grasp can be secured.
The extremity of
the shaft (% inch from the end) is so shaped that it can pass under the
maxillary
process of the malar bone so that the sharpened
end bites
»Straith,
C. L., and Straith,
F. E.:
Facial
Bone Injuries.
Dental
Digest,
October
1933.
U3^OJD C0MPRE3SE,J
2^r«r^:u1EXTREri[TY W1TH P'
Figure
5.
FRACTURED
MAXILLAE—RALPH AND MAXWELL
507
into the internal malar surface, figure
7.
With the working end of the
instrument in the position thus
described,
the shaft protrudes
from
the oral cavity at the angle of the mouth in such a manner that strong
traction can be applied to bring the malposed malar into position.
Some
cases
of head injury show
considerable
comminution of the
various facial bones and in instances
an actual loss of bone with which
the soft
tissues
are supported.
In order to simplify
and facilitate
subsequent
reparative surgery
the lost bony support of the soft tissues
should be replaced
by some type
of prosthetic appliance.
Various
kinds of splints and plumpers
are utilized for this purpose.
For the crushed
and comminuted
nasal
bones, Kazanjian
favors
a
nasal splint which derives
anchorage
from the upper teeth, providing
such teeth are free from injury and suitable for the purpose.
Another
point of anchorage may be provided by a bar extending down from the
midsection of a forehead headgear.
The matter of importance is not so much the type of splint used but
the maintenance
of the soft tissues in as nearly a normal position as
possible,
regardless
of the device
employed.
Bone grafts,
cartilage
transplants or plastic surgery
can thus
be more expeditiously carried
out at a subsequent
date.
FRACTURED MAXILLAE
DESCRIPTION
OF AN APPLIANCE
FOR REDUCTION
AND FIXATION
WITH
A CASE
REPORT 1
By Lieutenant
Commander
H. O. Ralph,
Dental
Corps, United States Navy, and Lieutenant
Merritte
M. Maxwell,
Dental
Corps, United States Navy.
Of the fractured jaw cases which the dental
officer is called upon to
treat, it is believed
that those
cases
in which there is
a transverse
fracture of the maxillae,
associated with a fracture or fractures of the
mandible,
belong
to
the
more
difficult
class.
The
problem
here
presented
is not only to obtain satisfactory occlusion of the teeth, but
to restore,
as nearly as possible,
a normal anatomical relationship of
the
displaced
and
sometimes
freely
movable
fractured
parts.
In
certain cases of impacted
fractures,
a method of traction must be em
ployed to obtain reduction.
It is obvious that the teeth, which may
be present,
can be brought into normal centric occlusion
by means of
an interdental splint, but yet there may
be a marked discrepancy
in
the vertical, as well as the horizontal, dimensions
of the head and face.
The ends sought
are:
1. Satisfactory occlusion
of the teeth, or, in
the
case
of an edentulous
patient,
an optimum relationship
of the
dental
ridges
for
the
accommodation
of dentures.
2. Reestablish-
ment of normal facial contour.
Hence
there is presented
the necessity
for a type of splint which
affords
a considerable
latitude
of adjustment in all directions,
with
» Clinical Photography
by D. W. Moyer, pharmacist's
mate, second class, United States Navy.
508
FRACTURED
MAXILLAE
RALPH
AND MAXWELL
anchorage
being
secured by means of a plaster
of Paris head cap or
other type of headgear.
Much has been written in the literature concerning
appliances
for
the reduction and immobilization
of these
cases,
notably
the older
types,
such
as the Kingsley
and modified
Kingsley
splints,
and
the
more
modern
contrivances,
described
by
S.
V.
Mead
and
Ivy
&
Curtis.
It
is
believed
that
the
simplest
and
least
cumbersome
type
of
appliance
which will accomplish
reduction and permit fixation of the
fractured parts will prove advantageous
for the following reasons:
1. It provides
maximum comfort to the patient.
2. It permits a higher degree of oral hygiene.
3. It supplies
the
operator
with
an
appliance
which
is
easy of
application and subsequent
adjustment.
An appliance
designed at this hospital is believed
to present some
merit.
It is with the hope that a description of this device, with an
attendant case report may be of service in handling certain fracture
cases.
The
case report cited in this
paper will give only the clinical and
roentgenography;
data
essential
to
a
proper
understanding of the
appliance
to be described.
Hence
such details
as the blood findings
and other laboratory tests will be omitted.
Case Report
Diagnosis. —Fracture,
compound,
maxillae, mandible,
frontal
bone,
nasal bones
and zygoma (left), traumatic.
D. A., RM 3-c, age
19.
Admitted
to naval hospital,
San Diego, Calif., December 26,
1936.
History. —On
December
12 the patient
was riding
a motorcycle
and collided
with an automobile.
He sustained severe head injuries and was taken to a civilian
hospital
in an unconscious
condition.
He remained unconscious for
5 days and
it was not deemed
advisable
to move him until December
26, at which time
he
was transferred
to this hospital.
Clinical examination. —Face of the patient
is markedly
deformed.
The nasal
bones are crushed and flattened.
The infraorbital
ridges are bilaterally
fractured.
Left maxilla
comminuted,
the anterior
wall
of the left maxillary
sinus crushed.
Immediately
below the supraorbital
ridge,
in the median
superior aspect of the
right
orbit,
is
a puncture
wound,
from
which
exudes
a seropurulent
discharge.
Lacerations
about the forehead,
nofse,
and chin have been sutured.
Intraoral
examination.— Transverse
fracture of both maxillae, with two vertical
fractures,
presenting
the upper
dental
arch
as three freely
movable
segments.
Fracture
of the hard palate with
rupture
of the 6oft tissues leaving an opening,
about the size of a quarter, into the nasal
cavity,
(fig.
8, A and C).
The maxillae
are apparently
depressed
posteriorly.
Teeth
numbers
9 and
12
are
evulsed.
The mandible
is fractured
in the following
areas:
1. Through the region of the
symphysis.
2. Through
the right
ramus
or condyle.
Teeth
numbers
26 and
24 are evulsed
(fig.
8, B and D).
There is evidently
some comminution
of bone
at the site of the fracture to the left of the symphysis,
the bone ends being visible,
and fragmentation
palpable through
the intraoral
tissues.
FRACTURED
RALPH
AND
MAXWELL
509
Roentgeongraphic
report. —There is fracture
of the nasal bones at their articula
tion with the nasal notch of the frontal
bone.
There is fracture across the medial
portion
of the orbital
plate and ridge of the left frontal
bone, with
fracture
into
the frontal
sinus.
There
is fracture
across right superior maxilla
from nasal notch to the inferior
margin
of the zygomatic
process,
with
fracture
line involving
the orbital
ridge
and surface.
There are fractures across the condylar neck of the right mandible, and coronoid
process.
Lower fragment displaced medially
one full diameter.
There
is fracture
across
the left mandible
approximately
1.0 cm from the sym
physis.
The
left
body
of the mandible
is elevated
about
1.0 cm and there
is
separation
of the fractured
parts of approximately
0.5 cm.
There
is fracture
across
the mid-portion
of the left zygoma.
Clinical
record. —On January
4,
1937,
the physical
condition
of the patient
was
deemed
satisfactory
for the application
of a splint.
The following
technic
was employed in construction
of a vulcanite
interdental
splint:
1.
Impressions
of upper and lower dental arches taken with Dentocoll.
2.
Models poured and separated
(fig.
8, A and B) .
3.
Models separated by sawing through
fracture
lines (fig.
8, C and D).
4.
Separated parts of models reassembled, so that, insofar as possible, the teeth
are brought into their normal occlusal relationship
with establishment
of normal
arch form.
The facets of the teeth serving as a guide to normal centric occlusion
(fig. 8, E and F).
5. Constructed
models
(E
and
F)
placed
on
articulator
with
the
teeth
in
arbitrary centric occlusion.
6.
Models tinfoiled.
7. Wax pattern for splint
constructed
by adapting
and carving
wax about the
buccal,
labial,
and lingual
surfaces of the teeth.
Occlusal
surfaces of the teeth
must
be in contact through
the wax pattern,
so that when union occurs patient
will have a satisfactory
occlusal relationship
of the teeth.
Brass escutcheon pins
(% by
18)
with
rounded
heads
are cut in half and inserted in the wax pattern at
three-fourths
inch intervals
along the mid-buccal
periphery
of the pattern.
The
brass pins are for the accommodation
of intermaxillary
elastics, after application
of the splint.
In the median line of the wax pattern
is imbedded a flat hexagonal
brass machine nut, fine thread
series
(10 by 32), for the fixation of the splint rod
to the splint
proper.
8. Splint pattern
vulcanized,
trimmed
and polished
(fig.
9, B) .
9.
Vulcanite
splint
tried on models to determine if it accurately
fits the teetb.
Necessary adjustments
for perfect adaptation
to the models made at this time.
In cases where there is no fracture of the mandible, immobilization
of the lower jaw is obviously unnecessary.
The splint is constructed
as above,
omitting
the
escutcheon
pins,
since
the only purpose
of
these
pins
is to retain intermaxillary
elastics
extending
to the lugs
of an arch
bar, which has been applied to the teeth of a fractured
mandible.
In the
case
of an intact mandible, the patient may be
permitted to masticate,
to a limited degree, by the lower teeth con
tacting their respective
indentations
on
the inferior
surface
of the
fixed splint.
In the case
reported
here,
there
was
a compound
fracture of the
mandible.
Hence we shall continue
with a description of the method
of fixation employed.
510
FRACTURED
MAXILLAE
RALPH
AND MAXWELL
An arch bar (Jelenko
fracture
splint)
was adapted and contoured
to the teeth
of the lower reconstructed
model
(fig.
8 F).
Adjustment
of the bar to the teeth
is thereby
minimized.
We shall
pass
over the technique
of securing the bar to
the patient's
teeth, inasmuch
as this phase of the procedure is commonplace
and
familiar
(fig.
9, A).
At this
point,
we
shall
assume
that
the arch bar is ligated
to the patient's
teeth, thereby bringing
the fractured
parts of the body of the mandible into their
approximate
normal
relationship.
Further reduction
is
obtained
through
the
medium of the intermaxillary
elastics bringing the lower teeth into their respective
indentations
on the under surface of the vulcanite
splint.
The finished vulcanite
splint
is cemented in correct position
on the upper
teeth, thus
coaptating
the
fractured
parts of the maxillae.
It now
becomes
necessary
to attach
the vulcarite splint
to
some
adjustable
type
of headgear, which will facilitate
the restoration
of normal
facial and jaw
relationships.
The
ideal would
be represented by having
the teeth in normal
centric occlusion with the condyles in their normal positions in the glenoid fossae.
Condylar
position
and success
in reduction
may be checked by roentgenograms.
Palpation
over the lines of fracture will also serve
as evidence that normal
bone
contour
has
been reestablished; displacements may be clearly palpable.
The headgear
employed is composed of the following
parts
(fig.
10):
1. Two lateral face
bars. — One for each
side
of the
face.
These
are made
of
aluminum strips
(9% inches long by % inch wide by }{0 inch thick).
With bending
pliers and plate scissors
these may be cut, contoured and notched for adaptation
and retention
in
a plaster
head
cap.
The plaster
cap is made in the orthodox
manner with the upper notched
ends
of the bars incorporated
therein,
so
that
they approximately
parallel
each
other on either
side of the face.
Parallcllism
may be facilitated
by placing the face bow rod in position in the swivel retainers.
The lower
end
of each
face
bar is provided
with
a swivel
retainer
for the re
tention
of the face bow rod.
By means
of this retainer, which
is pivoted
at
the
axis, a limited amount of anteroposterior movement is obtainable.
When correctly
adjusted
for the accommodation
of the face
bow rod, the retainers are fixed by
tightening
the knurled
nuts.
Slots in the swivel retainers serve as sleeves for the
free ends of the face bow.
Machine
set screws,
when tightened,
set the face bow
in its desired vertical position.
2. Face bow. — Made from a duraluminum
rod, three sixteenths inch in diameter,
and composed of two lateral
arms and a horizontal
part.
The lateral
arms fit
snugly
in their
respective
sleeves
in the swivel
retainers,
while
the
horizontal
part
is curved to form
an arc
across the front
of
the
face,
above
the resting
lip line.
3. Adjusting
block. — Made from a duraluminum
block, the base being one-half
inch
square by three-fourths
inch
in height
(fig.
10).
Through
the block
two
holes
are drilled,
the upper hole or sleeve
is for the passage
of the median section
of the horizontal
part of the face bow.
The lower sleeve accommodates the free
end of the splint
rod.
Machine
screw secures the adjusting
block to the face bow
and screw fixes the splint rod in position.
4. Splint rod. — Made
from
a duraluminum
rod, Jla inch in diameter,
and ap
proximately
1}i inches in length.
One end is threaded to screw into the machine
nut, which
has
been vulcanized
in the median line of the interdental
splint.
From
the foregoing description
it will be noted that the assembled head gear,
as illustrated
by figure
11,
is capable of a considerable latitude of movement in
all directions.
The function
performed
may
be compared to that of a universal
joint, and once the fractured
maxillae are in the desired position,
the appliance
may
be fixed by means
of the set
screws.
Subsequent
adjustments
are easily
accomplished, as may be necessary,
in view of roentgenogram and other check-ups.
Figure
8
Figure
10
APICOECTOMY
TAYLOR
511
A moderate
degree
of spring
is permitted
by the assembled appliance,
hence
where
gradual
reduction
by
traction
is
necessary
tension
may
be
applied
as
indicated.
To recapitulate.—The
arch
bar
is ligated
to the patient's
lower
teeth.
The
vulcanite
splint
is cemented in place over the upper teeth.
The lateral face bars
are paralleled
on either side of the face, and secured within
the plaster headcap.
It now
becomes
necessary to insert the free ends of the face bow in their
re
spective slots in the swivel retainers.
The splint rod is inserted through its sleeve
in the adjusting
block and the threaded end of the rod screwed snugly
into the
machine
nut.
The bilaterally
fractured
maxillae
are brought
forward
into what
is considered
to
be their
normal
position
and the screws, of the adjusting
block
and swivel
retainers,
are set.
A check-up
by
means of roentgenograms,
palpation,
and
observation
as
to
occlusion,
facial
dimensions
and contour,
will aid in determining
the success
of
the reduction.
Traction and subsequent adjustments
may be made as indicated.
When
the maxillae
are
considered
to
be in their
normal
position
and immo
bilized,
the intermaxillary
elastics are applied between the lugs of the lower arch
bar and the brass pins of the interdental
splint.
In
cooperation
with
the rhinologist,
it may
be advisable
to add an anterior
bar extending down from the plaster head cap for the splinting
of fractured
nasal
bones.
The appliance described is believed to be of value when used in selected cases
of horizontal
fracture
of the maxillae.
However,
inasmuch
as fractures
of the
facial bones are
so varied,
certain
modifications
must
be worked
out for special
cases.
APICOECTOMY
GENERAL
CONSIDERATIONS
AND SUBSEQUENT ROOT-CANAL
THERAPY
By Lieutenant
R. W. Tatlob,
Dental
Corps,
United
States Navy '
The purpose of this paper will be to present a time-saving technique
for the treatment of upper anterior infected
teeth.
Due to the large
number of patients each dental
officer must see, time becomes a very
*
important
consideration.
The following
technique
consumes
on the
average
of from
1 to
1^
hours.
This is for the complete
operation
and includes
the
apicoectomy,
root canal
therapy, and
filling.
In
discussing
the operation of root resection,
no attempt will be made
to credit or discredit the pulpless
tooth as a factor in the etiology of
disease, or to prove or disprove
the regeneration
of bone in the pres
ence of bacteria.
Nor will we consider
how much time must elapse
before
a sterile
pulpless
tooth becomes reinfected.
The indications
and contra-indications for root-canal therapy will also be omitted.
In any surgical
operation or root-canal therapy,
an aseptic
tech
nique is of vital importance.
Insist that all towels
and sponges
be
sterilized in
an
autoclave.
Towels
as
they
are returned
from
the
laundry
have
passed
through many
hands
before
they
are
placed
upon the patient.
Sponges
should
be kept in sterile
containers
and
i Acknowledgment
Is due Lieutenant
(Junior Grade) L. W. Colton, Dental Corps, United States Nary,
tor his assistance in taking
the photographs.
86860—38
5
512
APICOECTOMY —TAYLOR
placed upon
a sterile
towel on the bracket table with a sterile instru
ment.
All instruments should
be boiled,
dried
with
a sterile
towel,
and
transferred
to
a
sterile
tray.
They
are
then
covered
with
a
sterile
towel
and
are
ready
for immediate
use.
If
this
procedure
isn't possible,
then
all instruments should
be sterilized before
each
operation
and transferred
directly to the bracket table.
It must be understood
that the following method
of treatment is
intended
only for those upper anterior teeth in which ordinary root-
canal
therapy might well
be contra-indicated;
that
is,
where
a dry
canal
cannot
be
established
because of seepage.
This method
can
be followed
also in the
case of an acute alveolar abscess where
the
roentgenogram
exhibits
a radiolucent area at the
apex of the root.
The first
step in
the operation
is
to
establish
adequate
drainage.
Allow several days to elapse, during which time the acute symptoms
will subside and the apicoectomy
can then safely be performed.
After
anesthetizing
the patient,
a rubber
dam
is
applied,
including
two
teeth on either side of the one to be operated.
The top of the dam or
that section next to the upper lip
is
folded over so that the lip may be
raised.
Several
2
by
2
sterile
sponges
are placed
under the lip on
each side of the oral cavity.
(See fig.
12.)
This isolates
the field of
operation
and
also prevents
blood
from escaping
into the patient's
mouth.
The area between
the sponges
is
now painted
with iodine.
A
semilunar
incision
is
made in the muco-periosteum
just below
the
apical
region
and the flap retracted.
Using
a chisel or bur,
a
fairly
large window
is
cut in the bone overlying the apex of the root being
amputated.
When
the
apex
of
the
root
and
pericementum
are
irreparably
injured
the cementum
and dentin become exposed
and
infected.
There
is
often
evidence
of root resorption.
When
this
condition
is
present,
all the affected
area of the root should
be re
moved.
The
amputation
can
be
done with
a
bur and
the stump
smoothed
with
a
fine
stone.
The
granuloma
is
now
thoroughly
removed
with curettes.
The cavity in the bone which was formerly
occupied
by the root apex and granulation
tissue
is
tightly
packed
with iodoform gauze.
The top of the rubber dam
is
now pulled
up
over the upper lip and fastened
as in any root-canal operation.
The
exposed crowns
of the teeth and surrounding dam are painted
with
iodine
and alcohol.
The pulp tissue
is
removed
and the canal thor
oughly cleaned.
As the pus at the apex of the root has been elim
inated
and
the bone cavity
packed
with iodoform gauze,
the canal
may
now
be thoroughly dried.
The
canal
is
next
flooded
with
as
highly
a
concentrated
or
caustic
medicament
as
desired.
There
remains no tissue at the apex of the root to be damaged and the gauze
protects
the bone.
There will be no seepage from the apical area into
the canal
to dilute the medicament.
When the canal has been ster
ilized
to the operator's
satisfaction
it
may
be filled with any material
MANDIBLE
FRACTURES —WELCH
AND TAYLOR
513
which will hermetically seal it.
Great pressure may be used in filling
the canal, thereby obtaining good condensation
as the excess material
goes into the iodoform gauze.
The permanent
filling or restoration
is inserted
at this time.
The top of the rubber dam is again folded
down and
the lip elevated.
The iodoform gauze is removed
along
with the excess root filling material.
If gutta-percha
has been
a part
of the root filling,
a hot instrument is used to seal the apical
end.
The root stump
is silver nitrated and the bone cavity touched
with
phenol, which is quickly
followed
with alcohol.
The periosteal
flap
is sutured in place, and in no case
so far has it been necessary to use
a drain.
The results
obtained
by
this
method
have
been very gratifying.
In a number of cases follow-up roentgenograms
have been made every
few months
over
a period
of
2 years and in all cases
there has been
complete
regeneration
of bone in the apical region.
SUMMARY
1. It is admitted
that the treatment
of infected
pulpless teeth must
be considered
doubtful.
However, because of the evidence of com
plete
repair
as
exhibited
clinically
and
roentgenographically
an
attempt to save these teeth may be justified in selected cases.
2. In this method of operation
a reversal of procedure
is employed,
in that the root resection
is done
first,
followed
by the root-canal
therapy, thereby gaining the advantage
of a dry canal.
HEALING
TIME
IN
FRACTURES
OF
THE
MANDIBLE
By Lieutenant
C. C. Welch, Medical
Corps,
United
States Navy, and Lieutenant
R. W. Taylob,
Dental
Corps,
United
States Navy
The purpose of this paper will be to present
a few observations
on
the healing time of fractures in the mandible,
both from a clinical and
roentgenographic
viewpoint.
On several occasions we have seen jaws immobilized because there
was a history of an injury and the roentgenogram
exhibited
a fracture
line.
Upon further examination
it was discovered
that the fractures
reported roentgenographically
were old ones and that there had been
good
union
for weeks.
Diagnosing a fracture
of the mandible
isn't
usually
a very difficult procedure,
especially
if a good set of roent
genograms
is available.
However, there are times when
a diagnosis
is made from
the roentgenogram
alone and this
can result
in much
embarrassment.
If an accurate diagnosis is to be arrived at, one must
not depend solely upon
a roentgenographic
examination
but must in
clude a thorough
clinical examination
plus
a careful history as neces
sary phases of the routine.
The roentgenogram
is a very valuable
aid in determining
the loca
tion of the line of fracture,
position of fragments,
and relation of tooth
roots.
During
treatment
it exhibits
the presence of sequestra
and
callus formation.
But, in the roentgenogram,
callus formation in the
514
MANDIBLE
FRACTURES
WELCH
AND TAYLOR
immobilized mandible differs from that seen in some of the other bones
of the body.
In the mandible
where
there
is little
movement
and
not too great separation
of the parts,
there is an absence of such ex
tensive
peripheral
callus
as is present in the femur,
for instance.
It
has occurred
several times, that after a fracture has been immobilized
for several weeks, a check up roentgenograph^;
report will return with
the information that there is no evidence of either callus or new bone
formation.
Nevertheless,
in
these
cases,
upon
the
removal
of
the
fracture appliances
good union of the parts was found.
It has been stated
that the mandible
and
zygoma
are membrane
bones derived
from the old exoskeleton
or dermal bone.
These bones
develop
in membrane,
and
are, in growth and
fracture
repair,
fun
damentally different from
the
endoskeleton
with
its endochondral
type of ossification
and cartilaginous method
of fracture repair.
Grimson
1 in his experiments
on dogs found the following conditions
existing:
The fracture of the zygoma
with
the ends
fixed in close
apposition
healed
rapidly
by
a
condensation
of
the
intermediary
fibrous
callus into bony trabecular.
There was little or no peripheral
or periosteal
callus.
Five fractures
of the zygoma
that were widely
separated,
and all of the fractures of the mandible, developed a fibrous
intermediary callus with little new bone and an extensive
peripheral
callus with large
amounts
of new bone.
No method
of immobiliza
tion
was
used
in
this
experiment.
The
relative
difference
in
the
amount of motion present may explain
the large amounts of periosteal
callus in the mandible
and the small amounts in the zygoma.
Three
cases in the human
mandible
which came under our observation ex
hibited slight amounts
of periosteal
callus
formation.
These
cases
were also incompletely immobilized.
Several
authors
have
made
the statement
that they
remove
their
fracture
appliances
after 4 or 5 weeks and by that time they feel there
is bony union of the parts.
Before making further comment, however,
let us consider the time involved in the calcification of extraction
sockets.
Claflin
2 has found
that healing of extraction wounds
in dogs with
special reference
to bone changes are as follows:
1. First appearance
of osteoclasts,
3 days;
2, first bone formation, from
5 to
7 days;
3, new
bone reaching
the alveolar
crest
from
11 to
15 days;
4, sockets filled
with bone
(except
central
portion),
from
15
to
22 days;
5, bone at
crest
levelled
off,
from
28
to
31
days.
These
findings
correspond
very closely with the findings
of other investigators.
The fact has been demonstrated
histologically that new bone forma
tion in extraction wounds
of dogs takes place in the same manner
as
in man —only much more rapidly.
i Crimson,
K.
S.
Healing
of Fractures
of the Mandible and Zygoma.
J. A. D. 8. and
Dent.
Cos.
September,
1837.
' Claflin and Steinhardt.
Healing
of Disturbed
and Undisturbed Extraction
Wounds.
J. A. D. A.,.
June 1936.
MANDIBLE
FRACTURES —WELCH AND TAYLOR
515
Steinhardt
reports
two
cases
in man
in which death
in
the first
occurred
3
weeks
after extraction of the
teeth.
In
the histologic
specimens,
the socket was filled with young granulation tissue and the
fundus
with
uncalcified
bone.
He
compares
this
to
a
9-day
old
extraction wound in
a
dog.
The next extraction wound which he
describes histologically was an alveolus of a lower bicuspid,
3% months
old.
The depth of the alveolus
was greatly reduced by the presence
of new
bone.
The
central
portion still
contained
remnants
of
the
original blood clot.
This corresponds
to an 8-week extraction wound
in a dog.
Claflin
reports
histologically
a 6-week
old extraction wound
in a
human jaw of a lower molar in which the two sockets were well filled
with
granulation
tissue
but only
a small amount of new
bone
is
found in the fundi.
We have
noticed
that when
teeth in line of fracture are removed
prior to reduction, roentgenographically the alveoli become obliterated
before the disappearance
of the fracture line.
From
the above
evidence it seems quite plausible
to assume that
calcification is completed
in the extraction socket
more rapidly than
in the fracture line.
This then being the case, it is highly improbable
that in the human
jaw, bony union can be present at the end of a
few weeks.
We
feel it is only
a fibrous union.
It has
been our
observation that it requires
from several months to several years in
some cases for complete recalcification of bone in the fracture line and
obliteration
of this line roentgenographically.
Our findings in
the
mandible are similar to those described by Vance 3 in fractures
of the
skull.
It is his
impression
that fractures
in adult skulls disappear
roentgenographically in about
2 years.
In children the time is much
more variable, but the average time is probably
1 year, except in very
young children where complete healing may take place in 4 months.
It is of interest to note that the fracture line finally completely
disappears
and
becomes
the same density as the surrounding bone.
As the healing
takes place
the margins
of the fracture lines
become
less sharply outlined, also there is a change in the density of the inter
mediary zone, thus rendering
the fracture line less distinct.
Column
five in the table records
the time in our series in which the fracture
lines,
although still clearly visible are repaired
sufficiently to enable
them
to be recognized
as old fractures.
As will be seen the average
time was approximately
4.% weeks.
There are many factors
which might either
directly or indirectly
influence the healing
time of fractures.
Only
a few most likely
to
pertain to the mandible will be mentioned
here.
Delay in the reduc
tion of the fracture is one factor which should be eliminated as much as
i Vance, R. O.
The Healing
of Linear Fractures
ol the Skull.
Am. Jour.
Roentg.
Rad.j Therapy, 36:
744; December
1936.
516
MANDIBLE
FRACTURES —WELCH
AND TAYLOR
possible.
A fresh fracture is much easier to reduce than an old one
and the longer the delay the greater the chance of an infected
wound.
Poor approximation of fragments,
or insufficient fixation retards heal
ing or may cause nonunion.
It is our opinion that for the first 2 or 3
weeks fractures
should
be securely immobilized, allowing no movement
of fragments.
It is difficult to lay down
a set of rules or generalize
regarding the
procedure
to follow in the treatment of fractures
where
teeth are in
line of fracture.
However, it has been our experience that consider
able trouble may
be
encountered
by failing
to remove
such
teeth.
There
are
times
when
for various
reasons
these
teeth
cannot
be
extracted,
but it has been our observation
that the majority
of infec
tions
associated
with
fractures
have
resulted
from
leaving
these
teeth
undisturbed.
Whenever
conditions
permit,
they
should
be
removed
prior to the reduction of the fracture.
Chart
Case
No.
Date injured
Feb.
Aug.
Oct.
Feb.
Sept.
May
July
Apr.
Jan.
May
May
May
Apr.
Nov.
Feb.
May
May
Mar.
Feb.
Nov.
Oct.
Mar.
Feb.
Feb.
Oct.
Feb.
Aug.
May
21, 1937
8, 1936
2, 1937
19.1936
18,1937
13,1937
29, 1937
22, 1937
6,1937
5, 1936
12,1934
24,1933
6, 1933
5. 1933
26, 1934
24, 1933
23,1934
15,1935
22,1936
22,1934
31,1936
5,1936
27, 1936
14,1936
31,1936
6,1937
—
1936
— 1934
Apr.
13,1934
Mar.
8,1934
Width of separa
tion
Slight..
do..
do
0.1 centimeter.
0.3 centimeter.
Slight
.....do
do
do
do
do
do
0.3 centimeter.
Slight
0.4 centimeter.
Slight
.....do
Separated
0.1 centimeter.
Slight
0.1 centimeter.
Slight
0.6 centimeter.
0.4 centimeter.
Slight
do
....do
Overlapped
Comminuted.
Separated
Wired,
weeks
X-ray
evi
dence
of re
pair,
weeks
To
duty,
weeks
Fracture
lines (roentgenographically)
Plain
4 weeks.
4 weeks.
5 weeks.
4 weeks.
3 weeks..
.
4 weeks...
4H months
1 month
2 months..
1 year
l0months.
6 months.
7 weeks..
9 months.
7 weeks .
8H months
9 months.
Faint
8 weeks.
4 months..
2 months..
1 year.
l0months.
6H months.
6 months...
7 weeks
2months...
Absent '
8 months.
11 months.
3
years;
3
months.
3 years.
1Time it took line to become obliterated.
INHALATION
ANESTHESIA
BEHNKE
517
Infection
does interfere
with healing
to a certain
extent but union
of the parts usually takes place in spite of it.
Adequate drainage
is
necessary
and
the removal
of the
cause which will
be, generally,
a
detached
fragment of bone or tooth in line of fracture.
We have seen
osteomyelitis develop in very few jaw fractures.
SUMMARY
1. Healed
fractured
jaws
have
often
been
immobilized
because
too much reliance
was placed on the roentgenogram
and old fracture
lines have been mistaken for fresh fractures.
2. In the immobilized mandible callus formation differs from that
seen in many of the other bones of the body.
3. From available literature and our observations
in approximately
200 cases, 30 of which are presented in the chart,
we believe fracture
appliances are removed
in the majority of cases
before there is bony
union of the fragments.
4. In our present series of 30 cases
the average time of immobiliza
tion of the fractures was
5}{ weeks; average time for roentgenographs
evidence
of repair, 4K weeks and average length of time patient was
incapacitated for duty,
8 weeks.
5. Roentgenographically,
fracture
lines
are
clearly
visible
after
patients have regained normal function of the jaws and are returned
to duty.
6. There are several
factors which affect the healing
of these frac
tures.
Probably
the most important of these is the tooth in the line
of fracture.
Whenever conditions permit we believe it advisable
to
remove
the teeth in the fracture line.
7. We have found that the majority of compound
fractures require
very little
more
time
for healing
than
do simple
fractures
and that
a
high
percentage
of jaw
fractures
if carefully examined
are com
pound fractures.
8. It has
been our experience
that infection in
fractures
of the
mandible occurs in only a small percentage of cases.
INHALATION
ANESTHESIA1
PHYSIOLOGIC
CONCEPTS UNDERLYING
RECENT
PROGRESS
By Lieutenant
Albert R. Behnee,
Medical
Corps, United States Navy
The
striking
advances
made
in the administration
of inhalation
anesthetics
during the past
10 years consist mainly in the use of the
closed
or carbon
dioxide
absorption method,
the increased
employ
ment of carbon
dioxide as
a circulatory
and respiratory stimulant,
and
the
prevention
of
arterial
anoxemia.
These
advances
have
i Summary
of a paper
delivered
at the annual
meeting of the Medical Association
of the Territory of
Hawaii, May 1, 1937.
518
INHALATION
ANESTHESIA
BEHNKE
transformed a previously indolent art into a highly developed specialty,
a specialty whose importance has too frequently been overlooked
by
the surgeon and internist.
The
purpose
of this paper
is to present
a number of physiologic
implications connected with the recent progress in the field of inhala
tion anesthesia.
The carbon
dioxide
absorption method
of administering anesthesia
provides
for the rebreathing of anesthetic
gases in a closed system,
so
that surgical anesthesia once induced
can be maintained with little or
no
additional
gas.
Provision
is
made
for
the
absorption
of
the
exhaled carbon dioxide and for the addition of oxygen.
Underlying
this method
is the principle consisting
of the rapid establishment
and
maintenance
of equilibrium
between
a constant gas tension
in
the
lungs and the tension in the blood and other tissues.
The advantages
of this procedure
according
to Woodbridge 2 are that breathing
is
much
quieter,
the patient's energy is conserved,
loss of heat and fluid
in the
exhaled
gas is minimized, and
the exhaled
gases (frequently
explosive
and malodorous)
are not thrown out into the room in large
volume.
In considering
the physiologic implications involved in the carbon
dioxide absorption method
we shall examine first the manner in which
the body absorbs
inhalation
anesthetics.
According
to our present
knowledge
the
anesthetic
gases are chemically indifferent
and
owe
their
narcotizing
ability
probably
to
some
unexplained
physical
property.
The
Meyer-Overton
concept
postulates
that
for
anes
thetics
of the aliphatic series a definite
relationship in narcotic effi
ciency
exists in the ratio between
the solubility
of the substance
in
water and its solubility in fat.
Of the many hypotheses
attempting
to explain
narcosis
this concept
preeminently gives the anesthetist
a
working principle toward an understanding of narcotic action.3
Of great practical value,
however,
is the fact that the inhalation
anesthetics
are eliminated
without alteration almost
completely
from
the body in the manner in which they were absorbed.
Thus, in their
absorption and elimination they act as any inert gas coming in contact
with the lung epithelium.
They, therefore,
can be compared with the
nitrogen in the air which is dissolved
in the body in proportion to its
partial
pressure
in the lungs.
The air nitrogen fortunately
can
be
easily
measured
as it is eliminated from
the
body during
oxygen
breathing.4
' Woodbridge,
P. W.: Recent
Experiences
and Present
Trends
In Anesthesia.
Surg. Clin. N. A., 1513,
December
1935.
» Henderson,
V. E.: The Present
Status of the Theories
of Narcosis.
Physiol.
Rev.
10: 171, 193U.
i Shaw,
L. A., Behnke.
A. R., Messer,
A. 0, Thomson,
R. M., and Motley, E. P.: The Equilibrium
Time of the Gaseous Nitrogen
in the Dog's Body Following Changes
in Nitrogen
Tension
in the Lungs.
Amer. Journ. Physiol.,
112: 545,July 1935.
INHALATION
ANESTHESIA
BEHNKE
519
The curves
(fig.
13) obtained
by Behnke et al.5 represent
the elimi
nation of the gaseous body nitrogen during a 4-hour period of oxygen
inhalation by a young man weighing
132 pounds.
Since the nitrogen
solvents of the body are water and fat, which in the average
person
comprise about 70 and
15 percent
of the body weight,
respectively,
the broken line curves B and C can be drawn to represent
the elimina
tion
of nitrogen from these constituents.
If air is now breathed
by
the
nitrogen-free
individual,
absorption of nitrogen will
proceed
in
the same manner
as its previous elimination.4
Like the nitrogen of the air,
the commonly used inhalation
anes
thetics—ether,
nitrous
oxide,
ethylene,
and
cyclopropane—will
be
Figure
absorbed
and eliminated as represented
by the nitrogen curves, with
variation
dependent
upon
the
respective
solubility
of the
gases
in
fat and water.
Ether,
for example,
has
a water-fat solubility ratio
only about
one-third less than that for nitrogen.
The curves
of the
graph indicate that the body fluids will reach
complete
equilibrium
with
a given
tension
of ether in arterial blood in about
15 minutes.
The body fat, however,
continues
to absorb
ether
over
a period
of
6 hours.
Hence,
even in a closed system where only a small amount
of gas may be lost,
appreciable
quantities of ether
vapor must be
• Behnke,
A. K., Thomson,
R. M., and Shaw, L. A.: The Rate of Elimination of Dissolved
Nitrogen
in
Man
in Relation
to the Fat and Water
Content
of the Body.
Amer.
Jour. Physiol., 114: 137, December
1935.
520
INHALATION
ANESTHESIA
BEHNKE
periodically added in order to maintain the required
anesthetic
tension
in the lungs
and blood
stream.
Reference
should
be made at this point to the basic studies of ether
absorption by Shaffer
and
Ronzoni,6
and
Haggard.7
On
the
basis
of their quantitative data it should
be pointed
out that one of the
difficulties of inducing
anesthesia
with
ether
results
from
the
high
distribution
coefficient
of this anesthetic
in the blood stream
as com
pared with the lungs.
In order to maintain an ether tension of 2 1 mm
in the arterial blood,
45
volumes
percent
of ether
gas must be dis
solved in the blood in relation to the 3 volumes
percent present in the
alveolar
air.
Rapid
induction
with
ether
anesthesia
is dependent,
therefore,
upon
increased
lung ventilation,
and an initial
concentra
tion of ether in the lungs far in excess of the anesthetic
blood tension.
The small quantity of ether and other anesthetic
substances
neces
sary for the maintainance
of anesthesia in a closed or carbon
dioxide
absorption
system
should
be stressed.
With a 3-percent
anesthetic
concentration of ether in the lungs not more than
61 grams could be
absorbed by the body fluids nor more than
43 grams by the body fat
in an individual weighing
154 pounds.
Expressed
in terms of volume,
146 cubic centimeters
of liquid ether or 31 liters of ether vapor would
maintain
anesthesia
indefinitely.
For anesthesia
of
1 hour's dura
tion
100 cubic
centimeters
of
ether
should
suffice.
Of ethylene
the
anesthetized
patient would absorb
no more than
14 liters, of nitrous
oxide
32 liters,
and of cyclopropane
8 liters.
The increased employment
of carbon dioxide
and of carbon dioxide-
oxygen
mixtures marks a second
advance
in the recent
progress
of
anesthesia.
The
use of carbon
dioxide
as
a respiratory stimulant
is
too
well
known from the
studies
of Yandell
Henderson
to require
further comment.
Recent experiments
in addition have
shown
the
value
of
carbon
dioxide
as
an
augmenter
of
cerebral
circulation
*
and
hence
as
a means of rapidly removing narcotic gases
from the
central
nervous
system
Behnke et al.' were able
to show
that by
adding 8-percent
carbon
dioxide
to the pulmonary air, the pial vessels
of the cat exposed by trephining the skull according
to the method
of
Forbes
10 could
be made to dilate as much
as 30 percent.
Shaw and
his coworkers,"
moreover,
effectively
controlled the
toxic
effects
of
• Shaffer, P. A., and Ronzoni,
E.: Tbe Determination
of Ethyl Ether in Air and in Blood,
and its Dis
tribution
Ratio Between
Blood
and Air.
J. Biol.
Chem.,
57: 741, October
1923.
'Haggard, H. W.: The Absorption,
Distribution, and Elimination
of Ethyl
Ether.
J. Biol. Chem.,
59: 737, 1924.
' Gibbs,
F. A., Gibbs,
L., and Lennox,
W. 0.:
Changes in Cerebral
Blood
Flow Consequent
on Altera
tions in Blood
Oases.
Amcr.
Journ. Physiol.,
Ill: 557, 1935.
• Behnke,
A. R., Forbes, H. S., and Motley, E. P.: Circulatory and Visual
Effects ol Oxygen at 3 Atmos
pheres Pressure.
Amer.
Journ. Physiol., 114: 436, 1936.
« Forbes,
H. S.: Cerebral
Circulation:
Observation
and Measurement
of Pial Vessels.
Arch. Neurol,
and Phycbiat., 19: 751, 1928.
n Shaw, L. A., Behnke,
A. R., and Messer, A. C.: The Role of Carbon
Dioxide
in Producing
the Symp
toms of Oxygen
Poisoning.
Amer. Journ. Physiol., 108: 652. June 1934.
INHALATION
ANESTHESIA
BEHNKE
521
high oxygen tensions on the nervous system by either raising or lower
ing the alveolar
carbon-dioxide
tension.
The alert anesthetist,
there
fore, works on a sound physiologic basis when he administers
carbon
dioxide not only to "wash out" the anesthetic
from the lungs but also
to remove
the
anesthetic
gas from the brain by bringing about
an
increased
volume of blood flow.
The
most
important
contribution
in
present-day
anesthesia
un
doubtedly
is the prevention of arterial anoxemia
made
possible
by
discriminate preliminary medication, by the addition of ether to the
nitrous oxide-oxygen
mixture, and by the employment of cyclopropane.
It is remarkable
that the seriousness
of arterial anoxemia
associated
particularly
with
the
administration
of
nitrous
oxide
has
almost
wholly
escaped the attention of the surgeon
and
too frequently
the
attention of the anesthetist.
The breathing of an 86 percent nitrous
oxide-14
percent
oxygen
mixture
and
even
lower
percentages
of
oxygen
is physiologically unsound.
Insofar
as an oxygen percentage
of 14 is concerned, it is equivalent to breathing rarefied air at an altitude
of about 14,000
feet.
While a surgeon would not prescribe
an opera
tion
at an altitude of
14,000
feet, he does permit an anesthetist
to
change
in a few
seconds
the oxygen
tension
in
the patient's lungs
from that at sea level to that at the summit of Pike's Peak.
He may
even
allow the patient
to
breathe
a
90
percent-10
percent
oxygen
mixture,
and in condoning
this procedure
he allows
his patient an
oxygen
tension equivalent to that in the rarefied air at the summit of
Mount McKinley.
The necessity
of maintaining
a normal oxygen
tension
cannot
be
too strongly emphasized.
While many healthy individuals
tolerate
a reduction of one-third in the oxygen
tension
of the inspired air at
sea level, a patient suffering from an acute or chronic disease process
cannot tolerate
the additional
burden
of anoxemia
upon his already
harassed
circulatory
system.
Shock due
to
anoxemia
has
been re
peatedly produced
in
the laboratory
and
perhaps
as frequently in
the
operating
room.
When the percentage
of oxygen
is allowed
to
fall below
15, anoxemia rather than surgical
trauma may be the cause
of shock.
The quantitative
studies
of Eastman
12 proved
that there
was
a
definite
relationship
between
nitrous-oxide
anesthesia,
with
oxygen
percentages
below
15, and asphyxia of the newborn associated
with clinical signs of shock.
The
introduction
of
the
saturated
hydrocarbon
cyclopropane
(CjH») by Lucas and Henderson 13 in 1929 and its clinical application
by
Waters,
Sise,
Woodbridge,
and
others
have
tended
to divorce
anesthesia
from asphyxia by making possible
oxygen
percentages
as
i' Eastman,
N. J.: Role of Anesthesia
in the Production
of Asphyxia
Neonatorum.
Amer. Journ. Obst.
and Ony.. 31: 961, April 1936.
"Lucas,
J. H. W., and
Henderson,
V. E.: New Anesthetic
Oas,
Cyclopropane;
Preliminary Report.
Can. Med. Journ., 21: 173,August
1929.
522
FORMULA
FOR
PROPHYLAXIS —SMITH
high as 85.
It is indeed
a remarkable
coincidence
that cyclopropane
should come into use at a time when
thoracic
surgery,
the most pro
gressive of surgical specialties,
required
an anesthetic
that could be
combined
with a high oxygen
tension.
The sparing solubility of this
gas in the blood stream
gives it
a low distribution
coefficient
(0.5)
between the blood and the lungs.
In contrast with ether, equilibrium
is immediately reached
between
the tension
of gas in the lungs
and
the tension in the blood stream.
Hence, at no period in the anesthesia
is it necessary for the gas tension in the lungs
to exceed that in the
blood
stream.
This
characteristic assures
a high degree of safety,
since the anesthetic
need not be pushed at any stage of its administra
tion.
The
small
amount of
cyclopropane
necessary
for
anestiiesia
should
again
be mentioned.
With the
closed
technique
method of
administration less than
8 liters of gas will be absorbed by the body
during major operative procedures.
Finally, in thoracic surgery or
in operations
involving
the trachea or on the head,
the employment
of the tracheal
catheter
and the use of helium in the closed system
to
reduce the density of the anesthetic
mixture rounds out the technique
of the present-day
anesthetist.
SUMMARY AND
CONCLUSION
Physiologic
principles
have
been
outlined
which
underlie
the
excellent
progress made in the field of inhalation
anesthesia.
Atten
tion was directed to the manner in which anesthetic
gases are absorbed,
to
the
use of carbon
dioxide
to stimulate
respiration
and
cerebral
circulation,
and
to
the
necessity
of maintaining
a normal
oxygen
tension.
Future
progress
undoubtedly will
be characterized
by the trans
formation of the art of anesthesia into
a science principally
through
quantitative studies of absorption
and elimination of anesthetic
gases
to the end that a dosage as precise
as that employed
in intravenous
medication
can be prescribed
for inhalation anesthetics.
It should
be pointed
out that the progress made in the administra
tion
and
development
of inhalation
anesthesia
has
been
brought
about
by pharmacologists,
and by physicians engaged full
time in
this specialty.
While
nurse
anesthetists
can
develop
into
excellent
technicians,
the
discriminate
supervision
of
anesthesia
must
be
exercised solely by the physician trained
in this specialty.
A
FORMULA
FOR
IMMEDIATE
CHEMICAL
PROPHYLAXIS'
By Rear Admiral H. W. Smith,
Medical
Corps,
United
States Navy
During
the past
4 years,
there has been in progress
at the Naval
Medical
School
an investigation
undertaken
primarily
to
compare
' A preliminary
report of an investigation
conducted In the laboratories
of the U. S. Naval Medical
School.
Received
for publication
July 22, 1938.
FORMULA
FOR
PROPHYLAXIS —SMITH
523
for efficiency
and suitability
the many substances considered possibly
of value in the immediate
chemical
prophylaxis of venereal
disease.
These
substances
have
been studied
individually,
in various com
binations, and in varying proportions.
There have been included in
the study all compounds
and all constituents
known to be in use or
recommended
in available
literature during the past
35 years,
and
also others suggested by participants in the study or by other informed
persons —in all some 242 specimens including various vehicles such as
ointments, pastes, creams, water-soluble jellies, and solutions.
Since for several compelling
reasons it was not feasible to carry out
adequate
tests of all preparations
on animals,
a special rapid technique
was devised for estimating
quantitatively the efficiency of the materials
examined.
Our findings,
being
concerned
with artificial
media
and
common
laboratory
pathogens,
are not
necessarily
transferable
to
human subjects under natural conditions of exposure ; but it is believed
that they may be accepted as indicating correctly the relative efficiency
of preparations
the active
ingredients
of which have been proved
by
experiment
and
experience
over many years
to be effective
agents
in venereal prophylaxis.
Inasmuch as the base is the vehicle or medium
whereby
the active
ingredients
of a preparation are distributed and brought into effective
physical contact with whatever
pathogenic
organisms
there may
be
present
on
the skin, in its appendages,
or superficially in exposed
tissues,
particular
attention
was
given
to
the
properties
of
base
compounds,
upon
methods
of compounding,
upon
descriptive
speci
fications covering
individual
components,
and
the ultimate effect of
various agents
upon
the
finished
product observed
after prolonged
storage at low and at high temperatures.
-
It has
been
learned
through an
extended
series of experimental
observations
that a base comprising Petrolatum-USP
and Cholesterol
in a certain
determined
ratio is more effective in promoting activation
and clearance of incorporated antisyphilitic
and antiseptic
substances
than any physically
suitable
ointment base heretofore
described
or
known
to
the writer.
It has
been
demonstrated
further that
the
efficiency
of this base is reduced by any substitution or addition, by
any material alteration in the prescribed
ratio of its components,
and
by methods of compounding other than that advised.
A full account
of the investigation with detailed
description
of the
methods
employed
and the collateral
physical,
chemical,
and biological
studies
upon which our conclusions
are based, will
be published
at a
later date,
the purpose of this communication being to make known
without further delay
the formula of the preparation finally adopted.
The distinguishing features of the preparation are—
1. An ointment base of the required
physical
characteristics
which is
readily
miscible
with both fats
and watery colloidal solutions,
and
524
TETANUS
IMMUNIZATION —HAYDEN
AND HALL
which has
been found
the one most favorable to activity
of incor
porated
agents.
2. A form of calomel
about
30
percent
more
"active"
than
the
USP product.
3. An adjuvant
equal
to any antiseptic which is compatible with
the other ingredients
and which does not affect adversely
the required
physical characteristics
of the base.
4. The
several
other
desiderata
pertaining
to
a preparation
in
tended for personal prophylaxis having been adequately
met.
Formula
Mix by trituration without
heat:
Grams
Petrolatum
USP
98
Cholesterol
2
Of this base
67
Of "Colloidal"
calomel
33
Of mercuric cyanide -
0.1 25
ACTIVE
IMMUNIZATION
AGAINST
TETANUS
USING ALUM-PRECIPITATED
TETANUS TOXOID
By Captain
R. Hayden,
Medical Corps, United States Navy, and Commander
W. W. Hall, Medical
Corps,
United
States Navy
Active
immunization
is nature's method
of protection.
All nat
urally developed immunity
to infectious diseases, as well as all immu
nity
developed
by vaccination,
is active
immunity.
Passive im
munity, on the other hand, although it may be highly effective under
properly
controlled
conditions,
is merely
stop-gap
or substitution
therapy and is temporary
in nature.
In general,
the advantages
of active immunization over the passive
method
of protection scarcely
need to
be emphasized.
The limita
tions of passive immunization were recognized
by the early workers in
the field.
Soon after the development
of diphtheria antitoxic serum,
diligent search was begun for a method by which active immunization
could
be developed.
The success attained
in the fight against
diph
theria by
active
immunization,
and
the
value
of alum-precipitated
diphtheria
toxoid
in producing an active
immunity,
are attested
by
complete
freedom,
in some modern
cities,
from the menace of child
hood diphtheria.
The work with active immunization against tetanus
can
be said to be a direct outgrowth of the methods
and procedures
followed in the battle against diphtheria.
Both
diphtheria
and
tetanus
produce
soluble
toxins
or exotoxins.
Both of these exotoxins,
when
treated
with formaldehyde and
heat,
become nontoxic while still retaining their antigenic
powers.
These
detoxified
products were called anatoxins by the French, but since
have been referred
to by English speaking nations as toxoids in order
to avoid
confusion
with
the word antitoxin.
Both of these toxoids
TETANUS
IMMUNIZATION
HAYDKN
AND HALL
525
are precipitated by the
use of alum, and, though relatively insoluble,
when injected gradually go into solution.
Thus, antigenic stimulation
is exerted little by little
and over
a long period
of time.
Antitoxin
developed
as a result of this prolonged,
smooth,
and steady
reaction,
is eventually much
greater in amount than that produced
by several
injections of soluble
and rapidly
diffusible toxoid
(plain formalized
toxoid).
It is understandable
that immunization against diphtheria and tet
anus should
be coupled in our minds,
because of the similarities indi
cated and because of the fact that both were developed by Ramon in
the same laboratory.
An important
difference
exists between diph
theria and
tetanus
however,
in that subclinical diphtheria infections
do occur and result in natural active immunity, which is demonstrable
by negative Schick tests ; whereas there does not appear to be any such
thing as natural immunity
against
tetanus.
That
is,
subclinical in
fections of tetanus, with resulting immunity, do not occur.
The com
plete
absence of any titratable immunity
in large
numbers
of sera
from unimmunized
individuals
supports
this statement.
Unfortunately,
no simple method
of determining
immunity against
tetanus,
such
as the Schick test in diphtheria, exists.
This difficulty
has been an essential factor in slowing up the study of active immuniza
tion against
tetanus
by means of alum-precipitated
tetanus
toxoid.
However, the accumulation of data from many different
laboratories,
and from clinical and field observations,
now justifies the conclusion
that
such
induced immunity
can
be safely
relied
upon
to protect
against tetanus,
and that this disease, with its high mortality
rate,
may be practically eliminated
from the hazards
of mankind.
Although tetanus spores are widespread
in nature, even in the dust
of
a
modern city's streets,1
the importance of tetanus, from
a
public
health standpoint may be considered
negligible
in civilian
life; for
deep contused
wounds,
traffic injuries
excepted,
are not numerous,
and facilities for passive immunization are always available.
Further
more, the common
experience
of mankind teaches that most wounds
heal
without
tetanus.
However,
few
physicians
would
have
the
temerity to take the long chance of witholding an injection of tetanus
antitoxic
serum.
How
often
have
we, as doctors,
been faced
with
this
decision:
"Shall
I
give antitoxic
serum
and risk an immediate
reaction or late serum
sickness; or shall
I
let the patient go without
serum
and
risk
tetanus?
I
really
do not think
that
tetanus
will
occur in this
case, but
I
am not sure.
I
know that this patient has
had horse serum previously and serum sickness.
What shall
I
do?"
It
is
true that the menace of tetanus
is
greatly increased in certain
occupations.
The normal habitat
of
the
tetanus
bacillus
is
in
the
1
Gflles, J. A. M. A., 109:7,184(August 11) 1937.
526
TETANUS
IMMUNIZATION
HAYDEN
AND HALL
intestinal
tract
of
animals,
particularly
the herbivora.
Dubovsky
and
Meyer
2 even
found
the
spores in virgin
forest
soil.
Because
of the great resistance of the spores they are blown about in the dust
and are spread everywhere
in dirt and manure.
Thus, they are found
in barracks as well as in hospitals,
in clothing, on the skin, and in
a great variety of places.
Tetanus spores or toxins may contaminate
bacterial
vaccines,
vaccine
virus, or therepeutic
sera.
Unfortunate
accidents
from the use of such contaminated, improperly controlled,
biological products have occurred
in this country
as well
as abroad.
Eleven deaths from "cancer treatment," in which such a contaminated
serum was used, have recently been reported.3
The importance of tetanus
in civil life may be small.
In warfare,
however,
the conditions which minimize the importance of tetanus in
civil populations are completely reversed,
and high incidence
of teta
nus, with its great mortality
rate, becomes a major medical
problem.
In civil life, wounds are few, often superficial
and uncontaminated,
and antitoxin
is quickly available; war wounds,
on the other hand,
are notably deep with much devitalized tissue and soil contamination,
and serum is often not promptly
available.
The
accompanying
table
shows
the
important
role
tetanus
has
played in modern
wars.4
Tetanus in Modern Wars
Inci
dence
per 1,000
wounded
Military
force
Date
Mortality
(percent)
1833-40
1854-56
12.5
1.8
88.2
82.1
92.4
Italian War with Austria
-
1859-fll
10.0
2.0
3.5
5.2
1.5
3.8
.8
.2
American
Civil War
1860-65
1870-71
ss
German
in Franco-Prussian
War
.
British Expeditionary Force in France
and Belgium
1914
1915-19
British Expeditionary
Force, total
1914
1915-18
1917-18
50.0
75.0
51.4
11.1
German,
all fronts
United
States in France
and United States of America
-
It will
be noted that the incidence
of tetanus
has varied consider
ably according
to the type of war and the soil pollution in the theater
of war.
Prior to the World War, in those who
contracted
tetanus,
the mortality
rate
was close to
90
percent.
In the German army,
during 1914, when troop movements
were rapid and lines not stabilized
the incidence
was high and the mortality
reminiscent
of the Franco-
Prussian
War.
When
lines
were
stabilized,
and
medical
service
prompt
and
efficient,
the
incidence
of tetanus
dropped
to
0.8
per
thousand
in the German forces and
0.2
per thousand
in the United
» Dubovsky and Meyers,
Jour, of Inf. Dis., 31:614, 1922.
» Editorial Comment,
J. A. M. A., 110:15, 1183(April 9) 1938.
i Sneath, Jour. R. A. M. C., 66:311, 1936.
TETANUS
IMMUNIZATION
HAYDEN
AND HALL
527
States troops,
with mortality
in
the United
States
cases
as low
as
11.1 percent.
In view of the results
to be anticipated from active
immunization
against tetanus —namely,
that the general
use of this method
would
definitely prevent almost
every
case
of tetanus —even the low
rates
for tetanus
prevailing in the closing
years of the World War are far
too high.
Neither
the location nor type of our future operations
is known.
Wherever they may be, delay in antitoxin administration would cer
tainly cause increased
tetanus.
Such
delay
is favored
by the speed
and range of our air and surface scouting craft, the use of small groups
of men in landing forces, and by the trends in aviation and in ground
mechanization of troops; all of which are factors
tending
toward wide
range of action
and consequent
separation
from base
medical
atten
tion.
The
case
for
active
immunization
against
tetanus
with
alum-
precipitated tetanus
toxoid
(A. P. T. T.),
as opposed
to passive
pro
tection with antitoxic serum, rests upon the following:
OBSERVATIONS
A satisfactory
degree of protective immunity
against
tetanus
is
provided
by
2 injections
of alum-precipitated
tetanus
toxoid
(A. P.
T. T.) 8 weeks apart.
This immunity
drops slowly
but remains
at
protective
levels
for several
years
and
with
reimmunization
for
a
lifetime.8
A. P. T. T., being
serum-free,
eliminates
all possibility of allergic
and
serum
reactions
which are always
a matter of concern
and
are
often
serious
and
perhaps,
in
a
shocked
wounded
patient,
fatal.
The
repeated
use
of tetanus
antitoxic
serum
prophylactically
is
a
menace in the allergic,
and in the nonallergic
ultimately
builds up
more or less serious sensitization to horse serum.
This eventuality
is particularly important, as such induced
sensitization often seriously
handicaps the use of therapeutic
sera in other diseases.
Passive immunity
due to an injection of serum falls steadily and
rather rapidly after the third day and entirely disappears
within
2 to
3 weeks.
Thus, antitoxin does not protect in cases in which incuba
tion is long; nor does it protect against
the recrudescence
of tetanus
infection in war wounds,
in operations
or reamputations of limbs.
Active immunization
produced
by alum-precipitated
tetanus
toxoid
is continually present and constantly protects.
In persons with
an established
basic immunity,
though
it is low,
a single stimulating or pick-up injection of A. P. T. T. raises immunity,
in 7 days or less, to high levels, and in later weeks still higher.6
Tet-
>Ramon.
Presse Med., 44: 1625-1628(October
17) 1936.
•Jones and Moss.
Jonrn. Immunol., 30: 2, February
1936.
86860—38
6
528
TETANUS
IMMUNIZATION
HAYDEN
AND
HAUL,
anus
toxin from
a
developing
infection
has
been
demonstrated
to
have the same stimulating effect.
Alum-precipitated
tetanus
toxoid,
being
thermostabile,
can
be
stocked
in the field
where suitable refrigeration storage is not avail
able.
Antitoxin,
on the other hand,
is thermolabile,
and under field
conditions deteriorates,
becoming progressively
impotent or unreliable.
The advised
procedure
with A. P. T. T. is to give each immunized
person,
when
wounded,
a pick-up
dose of toxoid,
thus
raising his
blood antitoxin
quickly
and
increasing
his
basic immunity
for
the
future.
Should the medical
officer treating the
case
deem it advis
able, both antitoxin and toxoid
may
be given at the same time but in
opposite arms.
One agent does not interfere
with the action of the
other.
Systemic
reactions
from the injection of alum-precipitated tetanus
toxoid have been absent.
Local reactions,
at the point of injection,
are usually mild and consist of slight pain and induration, due appar
ently
to
the alum in
the
toxoid
suspension.
In
the
series on
the
U. S. S. Relief,
and in the largo group recently
titrated at the United
States
Naval Academy, not one man reported
sick or missed forma
tion.
Ramon
6 states:
"After having given
thousands
of injections
of tetanus
anatoxin (toxoid), the writer has still to see an untoward
local or general reaction
to speak of."
In a group
at the Naval Academy, immunized since the series of
titrations were completed,
four men reported
in with minor reactions
necessitating
a few days on the sick list.
One of these having had
a
general
reaction
with
malaise
and
fever
up
to
103° F.
The other
three men having had local reactions
consisting
of redness and swelling
of the arm about the point of injection.
As no such febrile reaction
had
occurred
in several
hundred
previous
injections, it was felt the
possibility of some other etiology should
be considered.
It was pre
sumed
that
these manifestations
of local irritation
resulted
from
shallow subcutaneous
placement
of the toxoid.
The alum contained
in the toxoid
is probably the principal cause of the irritation.
When
more
deeply
placed,
as in intramuscular injections, irritation
is not
so evident and
the induration
and soreness more transitory.
Alum,
with other simple
chemical
substances,
shares the possibility of some
individual idiosyncrasy.
The use of associated
vaccines, or the combination of a number of
antigenic
substances,
has been received with considerable
enthusiasm
in Europe;
and
the combination of diphtheria
toxoid
with
tetanus
toxoid,
or with
one or more
bacterial
vaccines,
has
been foimd
to
give excellent results.
It appears that the response to each individual
antigen
is
as great,
or greater,
when
they
are all used
together
as
when
used
separately.
In
the
United
States
the
combination
of
TETANUS
IMMUNIZATION
HAYDEN
AND
HALL
529
diphtheria
and tetanus
toxoid
has yielded
excellent results in the im
munization of children.
As diphtheria is not a problem
among adults
this combination for use in the Navy
would not be
as desirable
as
one of typhoid vaccine
and alum-precipitated tetanus
toxoid.
Work by Ramon,5 McBryde,7 Lincoln
and Greenwald,8
Sneath
and
Kerslake,8
Ramon and
Zoeller,10
Bergey
and Etris,11 Sneath,"
Hall,13
Jones
and
Moss,"
Gold,15
and
Sneath,
Kerslake, and
Scruby,16
and
others,
has
supplied
documentary
evidence
of
the satisfactory
re
sponse in man and animals
to active immunization with alum-precipi
tated
tetanus
toxoid.
Horses
and guinea pigs, both
as susceptible
to
tetanus
as is man, or more so, are protected
by active immunization
against
an
injection
of
tetanus
spores
even
though
the
antitoxic
levels are very low (0.01
to 0.001
unit) at the time.1'
17 18 19 20 21
Since
the adoption of active immunization with alum-precipitated
tetanus
toxoid in French cavalry horses,
the
previous
constant
in
cidence
of tetanus
has dropped
to zero in the immunized
animals,
while
maintaining
its
previous
level
in
the
unimmunized.
Active
immunization
against
tetanus
by means of A. P. T. T. has recently
(1936) been made universal
in the French army.5
AUTHORS REPORT
ON IMMUNIZATION
We present herewith a series of titrations on
152 midshipmen
vol
unteers
recently
completed
at
the
United
States
Naval
Medical
School in collaboration with the Medical Department, United States
Naval
Academy, Annapolis, Md.
Interest in active
immunization
against tetanus at the Naval Academy was stimulated by Commander
David O. Bowman (M. C.) United
States
Navy,
medical
officer
in
direct charge of medical
activities in the athletic department at the
Academy.
Commander Bowman's
desire
to avoid
serum
reactions
from prophylactic tetanus antitoxin, which had, on several occasions,
caused
loss
of
valuable
football
players
from
important
games,
prompted
a
consideration
of
active
immunization
with
tetanus
toxoid.
All of the volunteers
in group I are from the football squad.
' McBryde, So. Med. Jour., 30: 665-567 (June)
1937.
• Lincoln and Oreenwald,
Proc.
Soc. Exp. Biol, and Med., 30: 1241(June)
1933.
• Sneath and Kerslake,
Canad. Med. Assn. Jour., 32: 132(February)
1935.
Ramon
and Zoeller, Comptes,
rend. soc. d. biol.,
112: 347, 1933.
" Bergey and Etris, Jour, of Inf.
IJ is , 53: 331 (November
and December)
1933.
u Sneath, J. A. M. A., 102: 1288(April) 1934.
" Hall, Nav. Med. Bull., 35: 1 (January)
1937.
<1Jones and Moss. Jour. Immunol., 33: 3; September
1937.
" Oold., J. A. M. A., 190:481; August
1937.
« Sneath,
Kerslake,
and Scruby.
Am. Jr. Hygiene,
25: 3; May 1937.
" Jones
and Moss. Journ. Bact., 32: 1; July 1936.
Van Wagoner.
Military
Surgeon, 81: 5; November
1937.
>•Ramon
and Lemetayer.
Comptes,
rend. soc. d. biol., 202: 1465:April 27, 1936.
» Bergey and Etris.
Ann. Int. Med., 10- 11: May 1937.
« Cathala, J.
Paris Medlcale,
2: 355-361, November
6. 1937.
530
TETANUS
IMMUNIZATION —HAYDEN
AND HALL
This
series represents
the largest
number of titrations
on persons
actively immunized against
tetanus which has been reported
upon
in
the United States.
This, together with the series reported
by one of
us (W. W.
H.)13
from
the U. S. S. Belief,
now
brings
the
cases
re
ported
upon in the United States Navy to a total of 199 individuals.
The
volunteers
were divided into
three
groups.
The
53
men in
group I were given two injections of alum-precipitated tetanus toxoid,
0.5 cubic
centimeter
each,
8 weeks
apart,
as
basic
immunization.
They were then given an injection of 0.5 cubic centimeter of A. P. T. T.
14
weeks
later.
Just
before
this
stimulating
or pick-up
injection,
blood
was drawn for antitoxin
titration
(titration A),
and
1 week
afterward another
titration
was made
(titration B).
In titration A
of this group,
the lowest
value
obtained
was less than 0.01 unit, and
the highest
0.1 unit, with an average value for the group of 0.062 unit
per cubic
centimeter
of blood
serum.
In
the post-pick-up titration
(titration B),
the lowest
value
obtained
was greater
than
0.075 but
less than
0.1 unit, and the highest
value was greater
than
1.0 but less
than
1.5 units, with an average for the group
of 0.433 unit per cubic
centimeter
of blood serum.
The
77 men in group II were given
two injections of A. P. T. T.,
0.5 cubic centimeter
each,
8
weeks
apart,
as
basic
immunization.
They were then given an injection of 1.0 cubic centimeter
of A. P. T. T.
19
weeks
later.
Just
before
this
stimulating
or pick-up
injection,
blood
was drawn for antitoxin
titration
(titration A),
and
1 week
afterward another
titration was made (titration B).
It titration A of
group II the lowest value obtained
was 0.01 unit and the highest
was
greater
than
0.1 but less than
0.15 with an average of 0.055 unit per
cubic centimeter
of serum.
In the post pick-up titration (titration B)
of group II
the lowest
value
was
0.1 unit;
the highest
was greater
than
2.0 but less than
2.5 with
an average
of 0.684 unit per cubic
centimeter
of serum.
The
22 men in group III were given
two injections of alum-pre
cipitated tetanus
toxoid,
1.0
cubic
centimeter
each,
6
weeks apart,
as
basic immunization.
They
were
then
given
an injection of
1.0
cubic
centimeter
of A. P. T. T.
14
weeks
later.
Just
before
this
stimulating
or
pick-up
injection,
blood
was
drawn
for
antitoxin
titration
(titration A).
Only
13 of the 22 subjects
were available for
this
bleeding
and
titration.
One
week
afterward another titration
was made (titration B).
In titration A of this group,
the lowest value
obtained
was 0.05 unit, and the highest
0.5 unit, with an average for
the group
of 0.14 unit per cubic
centimeter
of blood
serum.
In the
post-pick-up titration (titration B), the lowest value obtained
was 0.1
TETANUS
IMMUNIZATION
HAYDEN
AND HALL
531
unit, and the highest value
1 .5 units, with an average for the group
of
0.552 unit per cubic centimeter
of blood serum.
To
appreciate
the really
considerable
amount of antitoxin
these
figures
represent, it must
be realized
that tetanus
antitoxin is meas
ured in units, each of which equals
a quantity of antitoxin sufficient
to neutralize approximately
1 ,000 minimal lethal doses (guinea pig) of
toxin.
For example,
1
cubic
centimeter
of serum
containing
one-
tenth of a unit of antitoxin contains
the amount necessary
to protect
a guinea pig against
100 minimal lethal doses of toxin.
An M. L. D.
is that amount of toxin which will kill a 350-gram guinea pig in just 96
hours.
To calculate
the total amount
of antitoxin in an individual's
body, one simply multiplies the titre of 1 cubic centimeter
by the total
volume of serum which is approximately one-half of the blood volume.
Thus,
a
70-kilogram
man,
having in his body approximately 2,700
cubic centimeters
of serum,
and having at the moment
only 0.5 unit
of antitoxin
per cubic
centimeter,
would have current in his
blood
stream
1,350 units of antitoxin.
The important point, of course,
is
that in addition to the amount his spot titration
represents,
he is at
any
time
capable
of producing more antitoxin
when
stimulated by
toxoid or by actual toxin from a tetanus infection.
Titration of antitoxic
potency
of each serum
sample
was carried
out according
to
the
standard
method
prescribed
by the National
Institute of Health, Washington, D. C.
The
product
used
in
this
series
was
Lolly's
alum-precipitated
tetanus
toxoid Qots number 928849 and 933313) prepared
according
to the requirements
of the National Institute of Health for a dose of
0.5
cubic
centimeter.
The
minimum
requirements
for
tetanus
toxoid, as denned by the National Institute of Health, file No. B-2207,
January 17, 1938, are:
1. The statement "No
U.
S. Standard
of Potency" should not appear
on the
label.
2. Horse meat shall not be used in preparing
the broth from which the original
tetanus toxoid is made.
3. Tetanus
cultures
for the production
of toxin
shall
be
incubated
for
not
longer than
14 days.
4.
The original
toxin from which tetanus toxoid is made shall have a test dose
of not more than 0.01 cubic centimeter or an M. L. D. for the guinea pig of not more
than 0.0001 cubic centimeter.
5.
Formalin
used
for detoxification
shall conform
to the requirements
of the
United States Pharmacopoeia
and the smallest amount
which will bring
about
complete detoxification
shall be used, not exceeding 0.4 percent.
6. Tests demonstrating
detoxification
shall be done as follows:
Five cubic
centimeters
of crude toxoid
given subcutaneously
in guinea pigs
weighing
300 grams shall
cause
no signs of spastic paralysis
at any time during
a period of 21 days.
A sufficient number of test animals shall be injected to insure
not less than four shall complete a given test.
532
TETANUS
IMMUNIZATION
HAYDEN
AND HALL
7.
Minium antigenic requirements for crude tetanus toxoid shall be as follows:
At least 10 guinea pigs weighing 300-400 grams shall receive, subcutaneously,
the
initial human
dose of crude toxoid.
At the expiration
of 6 weeks
each of these
guinea pigs shall be injected with
10 M. L. D.'s of a stable tetanus toxin, the toxic
ity of which shall be shown at the same time by injection
of
1 M. L. D. of toxin
into normal guinea pigs weighing
350 grams.
Eighty percent of the test animals
shall show no signs of spastic paralysis for a period of 10 days.
8.
Protocols
of preliminary
toxicity,
antigenic
and safety tests on each lot of
crude toxoid intended for distribution
shall be submitted
to the National Institute
of Health
with 100 cubic centimeters of the final product
and the lot held until
released
by report from the National Institute of Healtn.
The minimum requirements
for alum-precipitated
tetanus
toxoid,
as denned by the National Institute of Health are:
1.
Alum-precipitated
tetanus
toxoid
shall
bear
the designation
"Alum
Pre
cipitated"
on the labels of the finished package.
2. Alum-precipitated
tetanus toxoid shall be prepared only from crude toxoid
meeting the requirements
stated in Nos.
2, 3, 4, 5, and 6 above and in addition
shall meet the following
antigenic requirements:
The
human
dose
when administered
subcutaneously
to guinea pigs weighing
500 grams shall produce at least two units of antitoxin
per cubic centimeter
of
blood serum in not more than
6 weeks.
At least four guinea pigs shall
be used
for this
test.
Aliquot parts
of the blood
serum from all guinea pigs may
be
pooled for the test for antitoxic
content.
3.
Alum
used
for
precipitation
shall
comply
with
the
requirements
of
the
United
States Pharmacopoeia
and the finished product
shall contain
not more
than
20 milligrams
of alum per human
dose,
the calculation
being based
on the
total amount
of alum added for precipitation.
4.
For each lot of alum-precipitated
toxoid protocols showing detoxification
as
outlined
in No.
6 above, and antigenicity
as outlined
here in No.
2 shall be sub
mitted
to the National
Institute of Health
with
50 cubic centimeters of the final
product,
and the lot held until released
for distribution
by report from the Na
tional Institute of Health.
5.
Phenoloid
preservative
shall not be used in tetanus toxoid.
6. The
maximum
human
dose
of tetanus
toxoid
shall
not
exceed
one cubic
centimeter.
7.
The final container of alum-precipitated
toxoid shall contain not more than
10 human
doses.
The dose of 0.5 cubic centimeter
was doubled for the third injection
in group II and for all
three injections in group III.
Though this
increased
dosage did produce definitely increased antitoxin responses,
as noted above, and in the tables of titrations, these increased amounts
of toxoid did not produce proportionate increases in antitoxin response
within a week.
It is probable
that at a later interval, such as 4 to 8
weeks,
the steadily rising titre14 would have
mirrored
the increased
antigenic
stimulation.
The
few
local
reactions
noted
above
were
TETANUS
IMMUNIZATION —HAYDEN
AND HALL
533
probably
intensified
by the increased
amount
of alum
in these
1.0
cubic centimeter
doses.
Alum is limited by the National Institute of
Health
requirements
to a maximum of 20 milligrams per human
dose.
These doses contained
alum approximating this amount.
No individual in this series failed to respond adequately
to antigenic
stimulation
by A. P. T. T.
It may
be noted here that the literature
so far contains
no report of any person who has been found refractory
to immunization against
tetanus.
Standard toxin and antitoxin used in this study were supplied
by
the National Institute of Health.
We wish to here
acknowledge
the valued technical
assistance
of
Pharmacist C. C. Fowkes, U. S. Navy.
Table I.— Group I—53 subjects
[Units of antitoxin
per cc of blood serum]
No.
1-1
1-2
1-3
1-4
1-5
i-a
1-7
1-8
1-9
I-10-...
1-11....
1-12....
1-13....
1-14....
1-15....
1-16....
1-17....
1-18....
1-18....
1-20....
1-21....
1-22
1-23....
1-24
1-25....
1-26... -
1-27....
1-28....
Titration A
>0. 025-<0. 05
>
1 -
>.025-
>.075-
>.075-
>.075-
>.025-
>.05 -
>.075-
>1
-
>.05 -
>.01 -
>.075-
>.l
<.15
<.05
<1
<.l
<1
<.05
<.075
.025
<.l
<.01
<15
.025
. 025
.025
<.075
.05
<.025
<. 1
.025
.05
.075
.OS
<. 15
<01
.075
.025
Titration B
0.1
.1
.75
.1
X75 -<1.0
. 1
>.075-
<. 1
.25
. 1
>1.0
-<1.5
>.075-
<.l
>.25 - <.5
.25
.1
• <.25
2.0
• <.25
.1
<1.5
.1
. 5
• <.75
. 1
>.25 - <.5
>.075-
<.l
>.5
- <.75
.5
>.l
>.l
>1.0
>.5
No.
1-29
1-30
1-31
1-32
1-33
1-34
1-35
1-36
1-37
1-38
1-39
1-40
1-41.
1-12
1-43
1-44
1-45
1-46
1-47
1-48.
1-49
1-50
1-51
1-52
1-53
Average. . .
Titration A
.025
>.075-
<.l
.025
>.l
>.l
>.l
>. 1
>1
<.15
<.15
.025
.026
.1
.076
<. 15
.075
<.15
<15
.075
.078
'.025
.1
. 025
. 075
.1
. 075
.06
. 025
<. 15
.002
Titration
B
.1
.25
.1
.25
>1.0
-<1.5
>.075-
<. 1
.1
.5
.25
.5
.25
.75
.75
.25
.75
>1.0
-<1.5
. 1
.5
>.075-
<. 1
. 1
6
5
t
>.75 -<1.0
>1.0
-<1.5
>.25 - <.
.433
Nora.— The sign (>) means greater than;
and
the sign (<) means less than.
The 53 men in group I were given two injections of alum-precipitated
tetanus toxoid,
0.5 cubic centimeter
each,
8 weeks
apart,
as
basic
immunization.
They were then given
an injection of 0.5 cubic centi
meter of A. P. T. T.
14 weeks later.
Just before this stimulating or
pick-up injection, blood was drawn for antitoxin titration (titration A),
and
1 week afterward another titration was made (titration B).
534
TETANUS
IMMUNIZATION
HAYDEN
AND
HALL
Table II.—Group II—77 subjects
[Units of antitoxin
per cc of blood serum]
No.
Titration A
0.025
Titration B
0.25
.075
1.0
11-95
.05
.25
I1-9«
>
05 -<. 075
.75
.05
.75
11-98
> 05 -<. 075
.6
11-99
.05
.75
11-100
.025
>.75
-<1.0
11-101
.05
.5
11-102
.05
.25
11-103
.025
1.0
11-104
.05
.5
11-105
> 075-<. 1
1.0
H-106
.025
.25
11-107
>
1
-<. 15
>2.0
-<2.5
11-108
>
1
-<.15
>1.0
-<1.5
11-109
< 01
. 1
11-110
> 025-<.05
.25
11-111
>
1
-<. 15
1.0
11-112
> 025-<.05
1.5
11-113
.1
1.0
11-114
.01
.25
11-115
.01
.25
11-116
.025
.5
11-117
> 05 -<• 075
>2.0
-<2. 5
11-118
> 01 -<.025
. 1
11-119
.075
.5
11-120
.01
.6
11-121
.025
>1.0
-<1.5
11-122
> 025-<.05
>.075-
<. 1
11-123
1 -<!l5
>2.0
-<2.5
11-124
>
>2.0
-<2.6
11-125
.05
1.5
11-126
.075
>2.0
-<2.5
11-127
.025
.25
11-128
.05
.75
11-129
.025
1.0
11-130
. 1
1.5
.1
.5
1
.025
.1
No.
Titration A
Titration
B
11-54
11-55
11-56
11-57
11-58
11-59
11-60
11-01
11-62
11-63
11-64
11-65
11-66
11-67
11-68
11-69
11-70
11-71
11-72
11-73
11-74
11-75
11-76
11-77
11-78
11-79
11-80
11-81
11-82
11-83
11-84
11-85
11-86
11-87
11-88.
11-89
11-90
11-91.
11-92
11-93.
.01
. (123
.1
.05
>. 05 -<. 075
.025
>.l
>.l
Average.
. 075
-<. 15
.08
.1
<01
-<.I5
.05
.05
.075
. 05
.1
.05
.01
>.025-<.05
>.05
-<.075
.1
.1
. 075
.075
.05
. 023
. 05
. 025
-<. 15
.01
. 05
. 025
. 05
. 025
.1
.01
.055
>.l
>1.0
>2.0
.5
.25
-<1.5
.1
.5
.5
.75
.25
.5
-<2.5
.1
1.0
1 0
.5
10
. 25
. 1
.25
<.5
1.0
1.0
. 25
.75
. 23
.75
.75
>.075-
<. 1
1.0
.25
.75
.25
<5
.5
1 0
.25
>.25
>.2S
The 77 men in group 11 were given two injections of alum-precipi
tated tetanus
toxoid,
0.5 cubic centimeter
each,
8 weeks
apart,
as
basic
immunization.
They
were
then
given
an
injection
of
1.0
cubic
centimeter
of A.
P. T. T.
19 weeks
later.
Just
before
this
stimulating
or
pick-up
injection,
blood
was
drawn
for
antitoxin
titration
(titration A), and
1 week afterward another titration
was
made (titration B).
Table III. — Group III—22 subjects
[Units of antitoxin
per c. c. of blood serum]
No.
I11-131.
111-132.
I11-133.
111-134.
I11-135.
I11-136-.
111-137.
I11-138.
111-139.
111-140.
I11-141..
I11-143.
Titration A
>0. 05-<0. 1
>. l-<. 25
'coS
.1
>. 05-<. 1
.T
Titration B
0.1
>. l-<0. 5
>. l-<. 5
.5
1.0
. 1
<;.5
.1
1.0
>.5-<1.0
1.0
No.
111-144.
I11-145.
I11-146.
I11-147..
111-148.
11l-149.
I11-150.
I11-151..
I11-152.
nr-153.
Average...
Titration A
. 25
.1
>.05-<.l
.25
.05
. 140
Titration B
*<.«
1.5
.5
.5
.5
.5
1.5
. 552
TETANUS
IMMUNIZATION
HAYDEN
AND HALL
535
The
22 men in group III were given
two injections of alum-pre
cipitated
tetanus
toxoid,
1.0 cubic centimeters
each,
6 weeks apart,
as basic immunization.
They were then given an injection of 1.0 cubic
centimeter of A. P. T. T.
14 weeks later.
Just before this stimulat
ing or pick-up
injection,
blood
was
drawn for antitoxin
titration
(titration A).
Only
13 of the 22 subjects were available for this bleed
ing and titration.
One week afterward another titration
was made
(titration B).
SUMMARY
1. Alum-precipitated
tetanus
toxoid
(A. P. T. T.) has been repeat
edly demonstrated
to be a reliable
and satisfactory agent for the pro
duction of active immunity
against
tetanus.
The degree of this im
munity
drops
slowly
but
remains
at
protective
levels
for
several
years and, with reimmunization, for a lifetime.
2. Prophylactic antitetanic serum affords temporary passive immu
nity.
It is effective
only when given
promptly.
Its protection dis
appears rapidly
and is entirely gone in 2 to
3 weeks.
Thus,
a pro
longed incubation period
or recrudescence
of an infection may result
in clinical tetanus
when single injections of serum are depended upon.
3. Alum-precipitated
tetanus
toxoid
is thermostabile
and
can
be
carried in the field without refrigeration.
This is not the case with
thermolabile antitoxic serum.
4. Active immunity
against
tetanus
is peculiarly fitted to the con
ditions of modern
warfare
in which the speed and range
of modern
operations
tend
to constantly separate
personnel
from base medical
attention.
5. Accumulation
of data
now
justifies
the
conclusion
that
such
induced immunity can be safely relied upon to protect
against
tetanus
and that this disease, with its high mortality rate, may be practically
eliminated from the hazards
of warfare.
6. Alum-precipitated
tetanus
toxoid
is serum-free
and thus
avoids
the allergic
reactions
and serum sickness incident to passive
immuni
zation with tetanus antitoxin.
7. Reactions, local or general, with alum-precipitated tetanus toxoid
are rare and when
they
do occur
are minimal.
Irritation caused by
alum, an integral part of alum-precipitated
toxoid,
is the principal
cause of the mild local reactions.
8. A report of titrations on 152 United States Naval Academy vol
unteers is given.
Each man received
three injections of alum-precipi
tated tetanus
toxoid,
two
as
basic
immunization
and
a third
as a
stimulating or pick-up injection.
Titrations
of serum antitoxin were
made
before and after the final toxoid stimulation.
9. A satisfactory response was obtained
in all individuals.
10. This series brings
the total immunized, titrated, and reported
from United States Navy personnel
to 199.
536
MENTAL
DISEASES
McDANIEL
MENTAL
DISEASES
IN
THE UNITED
STATES NAVY
A COMPARATIVE
ANALYSIS OF THE INCIDENCE
By Commander
F. L. McDaniel, Medical Corps, United States Navy
Not long
ago the
question
was officially
discussed
by the Navy
Department
as to whether
or not there has been an unusual increase
of patients suffering
from mental diseases in the naval service.
For
several
years
the opinion has
been generally
held
by naval officers
that disabilities resulting from mental
disorders
are definitely on the
increase
in
the
Navy.
Several
months
ago
the matter
was
made
the subject of correspondence
between
the Chief of the Bureau
of
Navigation
and
the Chief of the Bureau of Medicine
and Surgery,
and
to quote,
"the Chief of the Bureau (Navigation)
requests
that
an analysis
of the situation be made to determine
the causes or reasons
for what appears
to be an unusual
increase of patients suffering
from
mental diseases."
Among
others,
this writer
was
requested
to
express
his
opinion
upon
the subject.
In order to make
an intelligent estimate
of the
situation concerning
mental
diseases in the Navy the writer believed
that it would be well
to make
a statistical comparison,
so far as the
data might be available,
with the admission
rate in the United States
Army and also for the population as a whole in the continental United
States.
In order to determine
whether
there
has been any definite
trend
in the rates of admissions
for mental diseases in the Navy,
the Divi
sion of Preventive Medicine,
Bureau of Medicine
and Surgery, fur
nished
the following admission
rates compiled
from Bureau statistics:
Admissions for mental
diseases,
U. S. Navy
Year
Average
strength
Admis
sions
Rate
per
100,000
Year
Average
strength
Admis
sions
Rate
per
100,000
1926
113.756
115,316
116,047
117.388
117,453
112,767
435
394
382
342
316
257
277
219
1932
110,717
108,183
109,383
114,188
124,408
244
264
246
256
271
220
244
225
224
218
1927
1933
1928
367
302
325
247
1931
1929
1935
1930
1936
1931
It will
be noted
from
the above that we have
a range of
11 years
covering
the
annual
admissions
for
diseases
of
the
mind.
This
table
shows
that from
1926
to
1929,
inclusive, there was
a gradual
decline
in the rate
of admissions
to the sick list for mental
diseases.
For
the
calendar
year
1930
there
was
a moderate
increase
in
the
admissions
per 100,000.
This may
be accounted
for by the fact that
the beginning
of the financial depression
drove many misfit, psycho
pathic,
and maladjusted individuals
to
seek refuge
in
the military
service.
During
the
calendar
year
1931
there
was
a rather sharp
MENTAL
DISEASES —McDANIEL
537
drop in
the
admission
rate.
It was during this period,
it will
be
recalled,
that the Navy adopted
a more intensive
policy of selective
recruiting.
The
various recruiting
stations
were
deluged
with
ap
plicants for enlistment and long waiting lists were maintained.
As
the result of this, the applicants for enlistment
were more thoroughly
investigated and the psychopaths
and incipient psychotics
eliminated
themselves
automatically
while
on the waiting list.
In referring to
chart
(fig.
14), it will
be noted
that since
1931
there has been very
little variation in the admission
rate, except that in the years
1935
and 1936 there was a slight downward trend.
In
studying
the
reports
of
the
Surgeon
General
of
the
United
States
Army,
it
is
noticed
that
the
groupings
do not
correspond
exactly with similar groupings
in the report of the Surgeon
General
of
the
Navy.
The
Division
of
Preventive
Medicine,
Bureau
of
Medicine
and
Surgery,
has regrouped
this list in order
to make
a
relative comparison
with our figures.
Below is a table
showing
the
admission rate
per 100,000 for mental
diseases in the United
States
Armv,
covering
a period of 1926-35, inclusive:
Admissions for mental
diseases,
U. S. Army
Year
Average
strength
Admis
sions
Rate per
100,000
Year
Average
strength
Admis
sions
Rate
per
100,000
1926
133,148
133,702
135,179
136,905
138,212
1,216
1,369
1.331
1,359
1,222
913
1,021
985
993
884
1931
136,321
132.736
137,188
135,320
143,158
1,094
904
834
1.000
1,091
803
681
608
739
762
1927
1932
1928
1933
1929...
1934
1930
1935
This table shows a relatively high admission
rate occurring in 1927,
and since that year there has been a gradual and steady decline in the
admission rate for mental diseases in the Army up to and including the
year 1933.
Since
1933 and through the statistics for the year 1935, a
rise in the admission
rate is shown.
In
a personal
interview with Dr. Truesdell, Chief Statistician for
Population,
Bureau
of the
Census,
the following information
was
obtained regarding
the admission
rate per
100,000
for mental
diseases
in the United
States.
These
figures
are based upon admissions
to
State hospitals only and are as follows:
Admissions for mental
diseases in the
United States
IState hospitals
only.
Rate per 100,000]
Year:
1926-
1927.
1928.
1929.
1930.
Rale
Year:
Rale
46. 2
1931
49.7
47.
5
1932
49.0
49. 6
1933
56.5
49.
8
1934
55.2
51.
1
1935
56.8
538
MENTAL DISEASES
McDANIEL
The first point noted
is that the
admission
rate to State hospitals
for the population at large is very much less than the admission
rate
for the Navy or the Army.
There are, however,
many factors to be
taken into consideration in making a comparison
of this kind.
Dr.
Truesdell
states: "It should
be clearly recognized
that statistics of
mental patients in hospitals do not directly measure the prevalence
of
mental disease, either in
the country
as
a
whole
or in
the various
States.
Many
persons
having
nervous
and
mental
diseases never
receive
hospital
treatment.
The hospital
cases
probably cover the
most severe type of mental
diseases, but fail to cover many cases of a
milder type."
Another
consideration in making
a comparison be
tween the military
services and
the population at large of admission
rates in this group of patients,
is the fact that the incidence
of mental
diseases in men is about 33 percent more than in women.
Also, men
tal disease is quite rare in childhood.
Available
statistics indicate
that mental disease is proably on the increase in the population as a
whole.
Figures given
above
show
a gradual increase in the rate of
first admissions
to State hospitals since
1926.
I have
compiled
figures
to show
the total number of Navy and
Marine Corps patients admitted to St. Elizabeths Hospital annually.
The figures from 1927 to 1936 inclusive may be tabulated as follows:
Total number
of Navy and Marine Corps patients admitted
to St. Elizabeths Hospital
Number
101
107
104
84
..
123
1927-86, inclusive
Year:
Number
Year:
1927
...
120
1932
1928
134
1933
1934
1935
1936.
1929
137
1930
163
1931
123
In the Navy,
under
our classification
of diseases of the mind, we
include all cases of mild psychoneuroses,
psychopathic states, etc., with
the major psychoses.
It is our policy in the Navy to transfer
to St.
Elizabeths
Hospital
only
those patients whose
condition
is serious
enough
to require
prolonged
hospitalization prior to final disposition.
Patients suffering from the milder mental conditions are either returned
to duty after treatment or are surveyed
with a recommendation
that
they
be
discharged
from the naval service.
Consequently
there
is
bound
to occur
a considerable
spread
between
the number of
cases
admitted
to
the
sick list
and
the
number
of patients eventually
transferred
to St. Elizabeths Hospital.
It is obvious that this ratio of
patients admitted to the sick list to the patients transferred
to St.
Elizabeths
Hospital
will
vary considerably
from
time
to
time.
In
the composite chart (fig. 14), it will be noted that this ratio does vary
to a considerable
degree from year to year.
The following table shows
MENTAL DISEASES
McDANlEL
FlODRI
14
540
MENTAL DISEASES
McDANIEL
the percentage of mental
cases
transferred
to St. Elizabeths Hospital
based on the annular number of admissions for mental diseases, United
States Navy, for the period
1927-36:
Annual
number
admissions,
mental
diseases,
Annual
number
patients
admitted
to St. Eliz
abeths
Hospital
Percentage
of mental
cases trans
ferred to
St. Eliza
beths
Annual
number
admissions,
mental
diseases,
Annual
number
patients
admitted
to St. Eliz
abeths
Hospital
Percentage
of mental
Year
Year
cases trans
ferred to
St. Eliza
beths
U. S.
Navy, all
cases
U.S.
Navy, all
cases
1927
394
367
302
325
247
120
134
137
163
123
30.5
36.5
45.3
50.2
49.8
1932
244
101
107
104
84
123
41.4
40.5
42.3
32.8
45.4
1928
1933...
.
264
246
256
271
1929
1934
1930
1935...
1931
--.
1936
As shown above, an average of 41 .47 percent of all patients admitted
to
the sick list with
a mental
disease have
been transferred
to St.
Elizabeths yearly for the past
10 years.
A glance at the table will
show
a variation from 30.5 in
1927
to
a high of 50.2 in
1930.
For
some reason a small
percentage of patients,
32.8 percent,
were trans
ferred
to St. Elizabeths in 1935 although the total number of admis
sions for mental
diseases for the Navy that year
were close to the
average since
1931.
Reference
to chart (fig.
14) shows an average of
104.1
patients
per
100,000
transferred
to St. Elizabeths annually for
the past
10 years.
From a study of available
statistics it appears that there is a gradual
increase in the incidence
of mental
disease among
the population at
large.
This
opinion
seems
to
be quite generally
held
but whether
this increase is more apparent
than real is a mooted question.
In the
composite
chart the figures covering
the population at large are based
on
State
hospital
admissions
only.
The
admissions
for
mental
diseases in the Army indicates
that the trend has been upward since
1933 and that this upward trend was preceded by a downward trend
from
1927.
In glancing
at the statistics for the Navy,
an
11-year
period
192G-36, inclusive, we note that there was, from 1926 through
1929,
a steady
decline
in
the admissions
for mental
disease.
There
was
a moderate
increase
during
1930
and
a sharp
decline
in
1931,
followed
by
a leveling-off trend which has tended downward for the
past
2 years.
Explanation
has already
been offered for this.
The
annual number of admissions
for Navy
patients
to
St.
Elizabeths
Hospital
showed
a gradual
decline
from
1930
through
1935.
During
1936
there was
a moderate
increase in the rate of admissions
to St.
Elizabeths.
As mentioned
before, it will be noted that the percentage
of mental cases
transferred
to St. Elizabeths
compared
to the total
number of admissions
for mental
diseases in the United States Navy
will
show
considerable
variation.
For instance,
in
1935
only
32.8
MENTAL DISEASES—McDANIEL
541
percent of all patients admitted to the sick list with a mental diagnosis
were eventually transferred
to St. Elizabeths Hospital.
In
1936 we
find that 45.4 percent of patients
admitted
were eventually transferred
to that institution.
It would require
a great deal of study, research,
and examination of all "individual
records
to enable one to offer
an
explanation as to the reason for this percentage variation in transfers
to St. Elizabeths.
It obviously
means
that
during
certain
years
there occurred
a greater percentage of serious mental cases among the
total admissions
for mental
disease.
It will be noted
however,
that
during
1936
the percentage
was only 4 points above
the average for
the past
10 years.
All in all it is apparent that there are considerable
swings
in
the
percentage
of patients
transferred
to
St.
Elizabeths
compared
to the total admissions
to the sick list in
the Navy,
and
deductions based on these figures cannot
be made at the present time.
Although
the statistics
show
that
there
is
a definite
downward
trend in
the rate
of admissions
for mental
diseases in
the United
States Navy it can be still further accelerated by observing
increased
vigilance in our recruiting
examinations.
It
has
been
thoroughly
demonstrated
that
selective
recruiting,
and
especially
a
thorough
investigation of each individual recruit, can serve in a large
measure
to weed out many of our potential mental patients.
It may be impos
sible at times to detect the existence of potential mental
disease in
a
recruit during the course of a routine examination.
A study of his
past history,
however,
particularly
concerning
his
social
relation
ships, school history, and occupational
adjustment, will throw a great
deal of light upon the individual recruit's psychological
make-up
and
potential trends.
It would appear that the Navy is now maintaining
an excellent
record
so
far
as its
admissions
for mental
disease
is
concerned
when this is compared
with other figures.
Regarding
transfers
of our psychotic
patients
to
St.
Elizabeths
Hospital, I believe that our percentage of admissions
to St. Elizabeths
Hospital
will
be
decreased
when
more
use
is
made
in our naval
hospitals of the modern methods for treating
the two largest groups of
psychoses
we have, that
is,
general paresis and dementia
praecox.
The successful treatment
of syphilitic meningo
encephalitis
(general
paresis)
has shown
such favorable
response to fever therapy and the
treatment of dementia
praecox
by hypoglycemic shock
has met with
such success, that
if
we continue
to avail ourselves of these and other
therapeutic procedures,
we may be able to discharge
many cases
to
civilian
life which would otherwise
be eventually transferred
to St.
Elizabeths Hospital.
Among both medical
and
line
officers
there
is
a
commonly held
belief
that the tendency
to break
down
on
the part of individuals
inherently weak
or potentially
abnormal
mentally
is
on the increase
inasmuch
as
the
Navy
personnel
has probably
been
subjected
to
542
HELIUM
BEHNKE
AND
YARBROUGH
more intensive stress and strain in the past few years due to unsettled
world conditions, more
intensive
training
and drill,
increased
com
petition and
tension of officer personnel
as the result of the present
system
of promotion.
While
the writer thoroughly
agrees that in
creased
stress
and
tension,
worry
over
promotion,
etc.,
may
be
precipitating factors in individuals predisposed
to mental
breakdowns,
he does not believe by any means that it plays
a major part in our
causes for admissions
for mental
diseases.
Be this
as it may,
the
figures show that there has been a decrease in the incidence of mental
diseases in the Navy and that the trend is still downward.
Attention
may again
be called
to these two salient
points:
First,
The average
yearly rate per 100,000
of admissions
to the sick list for mental diseases
1926- 36
inclusive,
is
266.
The
yearly
rate
has
been
below
this
average
since
1930.
Also,
the
average
yearly
rate
per
100,000 of
mental
patients eventually
transferred
to
St.
Elizabeths
Hospital,
1927- 36,
inclusive,
is
104.
The
yearly
rate
has
been
below
this
average since
1931.
PHYSIOLOGIC
STUDIES
OF
HELIUM
«
By Lieutenant
A. R. Behnee, Medical Corps,
United
States Navy; and Lieutenant
O. D. Yarbbouoh,
Medical Corps, United States Navy.
Introduction
Twenty
years
ago the cost of helium 2 was of the order of $2,500
per cubic foot.
Its present volume production at a cost of
1 cent per
cubic foot has made it available
for the flotation of airships,
for use
in medical
treatment,
and for the prevention and treatment
of com
pressed-air
illness.
In medicine
Barach
3 began
the study of the
therapeutic
use of
helium
particularly
in
the
treatment
of
asthma
and
obstructive
lesions of the larynx.
More recently
Eversole 4 tested its value in the
field of inhalation anesthesia.
The essential property making helium
of value in these treatments
is its decreased density compared with air.
In diving operations
Sayers
and Yant 6 suggested the breathing of
helium
because of its decreased solubility
and
more rapid
diffusion
rate.
They showed that animals could
be decompressed more rapidly
' From
the Experimental
Diving Unit, Navy Yard,
Washington,
D. C.
Submitted
for publication,
July 18, 1938.
The authors desire to express their appreciation
to Lieutenant
Commander
C. B. Momsen,
United States
Navy, for many
valuable
suggestions, and to members
of the Bureau
of Construction
and Repair for the
splendid
support
that they have given to these investigations.
The technical
work
of L. B. Lewis,
phannaolst's
mate, first class; T. Menitt.
pharmacist's
mate, first
class; and H. H. Snider,
pharmacist's
mute; third class; was especially commendable.
' Information
Circular about
Helium.
U. S. Bureau Mines Information
Circulai 6745, 1933.
» Barach,
A
L.
The Therapeutic
Use of Helium.
J. A. M. A., 107: 1273(Octobei
17, 1936).
' Eversole,
U. H.
Use of Helium in Anesthesia.
J. A. M. A., 110:87S (March 18, 1938).
» Sayets, R. R., and Yant, W.
P.
Value of Helium Oxygen Atmosphere
In Diving and Caisson
Opera
tions.
Anesth.
and Anal., 5: 127(June 1926).
HELIUM
BEHNKE
AND YARBROUGH
543
in a He-Oj atmosphere
than in air.
End
6 recently
has experimented
with helium in diving tests and his results are promising.
Some important
properties
of helium
are its inactivity,
since no
compounds
of helium
are known to exist; its decreased density,
one-
seventh that of nitrogen
; its rapid diffusion
rate, twice that of nitrogen
;
and its extremely
low liquefying temperature,
—267.9° C, or about
5.2° C. above
absolute
zero.
In
the following series of physiologic
studies additional facts will be presented
as they developed during an
investigation connected with the use of helium in diving tests in depths
up to 500 feet carried out at this diving unit under
the supervision
of
Lieutenant Commander Momsen, United States Navy.
I. RELEVANT
OBSERVATIONS
OF THE EFFECTS
OF HELIUM
ON THE
HUMAN
BODY
In the course of any extensive work with helium,
investigators
have
invariably
noticed
several
peculiar effects of this
gas on
the body.
First
among
these
effects
is
the
change
in
voice.
The
laryngeal
muscles
controlling
as
they
do
the
tension
of the
vocal
cords
are
trained from childhood
to
produce
different
tones.
This muscular
training, however,
is accomplished
in an air medium,
the density
of
which is considerably
greater
than that of helium.
Therefore, when
an individual
is breathing helium and attempts
to talk the muscles
respond
as they normally do in air.
The resulting sound is higher in
pitch
and nasal in quality
compared
with
sound
emitted
when
air
is breathed.
It is interesting
to note that divers who have repeatedly
breathed helium mixtures
have
overcome
these
voice
phenomena
somewhat so that the voice
tone approaches
normal.
Second among the bodily effects is a certain degree of chilling during
the exposure
to helium mixtures.
This chilling was more noticeable
during suit diving when in the water, although a lesser degree occurred
during
simple
breathing
under
pressure in
a dry chamber.
It was
thought that this chilling possibly might affect the required decompres
sion
time
by slowing
the circulation particularly
in
the skin area.
Measures have been taken to warm the body during helium breathing,
but there has not been sufficient
time or experimentation
to determine
the effect on gas uptake, or gas elimination, from the body.
With regard
to bubble
formation following exposure
to high
pres
sures it was reasonable
to believe that gas emboli might form following
helium
breathing in
a manner
similar to their formation in an air
atmosphere,
if sufficient
reduction in decompression
time were made.
"
, End,
E.
Rapid Decompression
Following Inhalation
of Helium-Oxygen
Mixtures Under Pressure.
Amer. Jour. Physiol., 120: 712 (December
1037).
86860—38
7
544
HELIUM
BEHNKE
AND YARBROUGH
This
belief
was
substantiated
by
the
occurrence
of bends
7 while
breathing
or following
the respiration of
helium-oxygen
mixtures.
Certain
differences,
however,
in
the
aspects
of the
cases
of
bends
have been noted.
Preeminently there has been an absence of grave symptoms in
a
large number of cases.
That is to say, symptoms
such as unconscious
ness and paralysis have not occurred.
By contrast such mild symp
toms
as itching
and
skin
rash
have
prevailed,
frequently
without
sequellae.
The occurrence of pain in about one-third of the cases
has
been promptly relieved by recompression
and oxygen
treatment.
To account
for the absence of grave symptoms it should
be noted
that immediate
treatment
undoubtedly was an important factor,
but,
in addition, the low fat-water solubility ratio of helium
compared with
nitrogen
is
also
an important
consideration.
Grave symptoms are
usually produced
when nervous
tissue is the site of bubble formation.
Such tissue having a high percentage of fat should absorb considerably
less helium
than nitrogen.
Bearing in mind the low fat-water solubil
ity ratio of helium,
we have postulated
further that in diving opera
tions employing helium
the important or controlling tissues concerned
in decompression
are those which are relatively rapid (tissues largely
fluid) with regard to saturation or desaturation,
whereas with nitrogen,
the relatively
slow
or fatty
tissues
are all important.
This theory
gleaned
from the laboratory
has
been one of the fundamentals in
formulating decompression
tables for use with helium.
In connection
with the treatment of bends it has been frequently
observed
that the bends respond
more quickly
to recompression
and
usually require
less pressure
for relief of symptoms than is required
for the treatment
of nitrogen
bends.
Of all the bodily effects of helium the most striking is the feeling
of normality,
in contrast with
the
usual
intoxication
and
sense
of
pressure and depth associated with high air pressures.
This improved
mental
condition of the diver has supplanted
the saving
in decom
pression
time
as
the
most
important
expected
advantage
in using
helium.
H.
SOLUBILITY
OF HELIUM
IN WATER AND OLIVE OIL COMPARED
WITH NITROGEN
The body solvents for inhaled gases are hemoglobin,
fluids, and fat.
Determinations of the solubility
of helium in fat are of importance,
therefore,
in estimating the time necessary for the body to come into
equilibrium with a constant
helium
tension in the lungs.
' Tho term, "bends," usually
refers to those symptoms
of compressed-air
iliness characterized by pains in
and around
the joints.
In this
paper the term, "bends," will be used because of simplicity to include
all
symptoms
(predominantly
pain)
arising from
gas emboli,
whether of helium
or nitrogen origin,
following
decompression
from high pressure atmospheres.
HELIUM —BEHNKE
AND YARBROUGH
545
Since
Campbell 8 has
shown
that
the
constituents of body fat,
namely stearin,
palmitin, and olein dissolve about the same amount
of nitrogen per hundred
cubic centimeters
of substance
as does bone
marrow (90 percent fat), or about 5 cubic centimeters
of nitrogen
per
100 cubic centimeters
when saturated with air at 38° C, and approxi
mately 6.6 cubic
centimeters
when
the nitrogen
tension
is corrected
to 760 millimeters; determinations of the solubility of helium in olive
oil containing about
72 percent
olein and 28 percent palmitin should
give an accurate
estimate of the solubility of helium
in body fat.
Experimental
Method
Olive oil, U. S. P.', was equilibrated
at a temperature of 38° by bubbling through
the oil pure nitrogen or helium
(97.65
percent) previously
dried and freed from
traces of carbon dioxide and oxygen by passage
through sulphuric
and pyrogallic
acids for periods up to
1K hours.
The inert gas was then extracted in vacuo by repeated shaking in the Van Slyke
apparatus.
The solubility
of helium and nitrogen in water was determined under the same
conditions
except that the respective gases were
passed
through
water in place of
sulphuric acid
before admission
to the tonometer
tube.
The type
of analytic
procedure
employed
in
these
determinations
was similar
to that
developed
by
Van
Slyke and his co-workers.10
Calculations
The volume percent of gas in the analyzed
solutions
was calculated
by means
of equations formulated
by Van Slyke and Stadie
11for reducing the pressure of a
gas extracted in vacuo to standard conditions of temperature and pressure.
For water, the calculation
simplified itself to—
Vol.
percent
gas = PXNa
factor
For oil, t, the reabsorption
coefficient, and a', the Ostwald distribution
coefficient
of a
gas between
gaseous
and liquid phases,
in the equation
of Van
Slyke
and
Stadie
were omitted in the calculations
since repeated gas extractions undoubtedly
reduced these factors to a negligible minimum.
The helium
in flasks was found
by analysis
to
be
97.65
percent
pure.
The
residual
gas was assumed to be nitrogen, and the necessary corrections were made
in the calculations.
Discussion
op Experimental
Results
The
analytical
data
are enumerated
in
table
1.
The solubility
coefficient,
a, represents
the cubic
centimeter
of gas
(0°,
760 mm.)
dissolved per cubic
centimeter
of liquid.
In the water analyses
the greatest
difference
between
the highest
and lowest values was 0.01 volumes
percent, while in the oil analyses
the greatest difference
was 0.036 volumes percent.
• Campbell. J. A. and Hill, L.
Quart. Journ. Exp. Physiol., 23: 197(1933).
• Analyzed
through
the courtesy of Mr. Qault at the 0. 8. Naval Medial Center,
Washington,
D. O.
>•Van Slyke, D. D., Dillon, R. T., and Margarla,
R.
Journ. Biol. Chem.
105:571(1934).
" Van Plyke, O. D., and Stadie, W. C.
Journ. Biol. Chem.
56: 765 (1921).
546
HELIUM
BEHNKE
AND YARBROUGH
Our solubility
value for nitrogen in water is only slightly
higher
than the usually accepted value (0.01272),
10 while the value for helium
in water is 0.022 volumes
percent higher than the average reported
by
Hawkins and Shilling.12
The following solubility ratios have been computed
from the values
in table
1:
Helium/nitrogen
in water
2 to 3
Helium/nitrogen
in oil
1 to 4.5
Helium in oil
1 7 to 1
Helium in water
Nitrogen
in oil
nitrogen in water
It is observed
that the oil/water solubility ratio for helium is only
one-third of the corresponding
value for nitrogen.
Fat/Blood Solubility
Ratios for Helium
and Nitrogen
The solubility of helium in blood
12 is about
1 percent higher than
our value for the solubility of helium in water.
Since the solubility of
nitrogen in blood
10 is also
1 to 2 percent
higher than the solubility
of
nitrogen in water,
and since the solubility of the gases in oil is of the
same degree as their respective
solubility in body fat, it can be con
cluded
that the fat/blood solubility ratio for helium is also only one-
third of the corresponding
ratio for nitrogen.
Application op Results
The comparatively low solubility of helium
in fat is highly signifi
cant.
Since fat and fatty tissue take up gas through the medium
of
the blood stream,
this type of tissue governs
the time required
for the
body as a whole to come into equilibrium with a given pulmonary gas
tension.
With reference to nitrogen
elimination from the body when oxygen
is breathed,
Behnke, Thomson,
and Shaw
13 have pointed out that
after
the first hour the eliminated
nitrogen comes mainly from fat
and lipoid
tissue.
At the end
of
6 hours
nitrogen elimination
had
decreased to a value of about
7.5 cubic centimeters
per hour.
These
measurements
indicated that after
9 hours
the body had lost 99 per
cent of its nitrogen content.
Campbell and Hill
14 using
an entirely different
method
of deter
mining tissue saturation concluded
that
12 hours
or more would
be
required
for complete
desaturation.
" Hawkins J. A., and shilling, C. W.
Helium Solubility in Blood
at Increased
Pressures.
Journ. Biol.
Chem.,
113: 649 (April,
1936).
» Bebnke,
A. R., Thomson,
R. M . and Shaw, L. A.
The Rate of Elimination of Dissolved
Nitrogen
in
Man In Relation
to the Fat and Water
Content
of the Body.
Amer. Journ. Physiol., 114: 187 (December,
19s8).
ii Campbell, J. A., and HOI, L. 1.
Quart. J. Exper. Physiol., 23: 197(1933).
HELIUM —BEHNKE
AND YARBROUGH
547
On the basis of a blood/fat solubility ratio one-third that of nitrogen,
helium should
require
from
3 to
5 hours
for 99 percent
elimination
measured
after the body had previously been in equilibrium
with a
given pulmonary tension of this gas.
The
Helium
Content of the
Body
In a man weighing 60 kilograms the water content may be estimated
at 70 percent or 42 kilograms, and the fat content at 13.2 percent or
7.92
kilograms.
The
helium
content of
the
body at
atmospheric
pressure
(helium tension
in the lungs,
570 millimeters) may then
be
computed in the following manner:
Cubic
centimeters
0.00654
(a,
H20, 570 mm.) X 42,000
273
0.0111
(o, fat, 570 mm.)X8,800 (corr. for S. G.)
98
Body total
373
In a man weighing
60 kilograms the nitrogen content was found to
be 840 cubic centimeters.
13
The helium content should
be, therefore,
about 45 percent
as high as the nitrogen content of the body when
the gas tension is the same in the lungs.
Possibility
of
Spinal
Cord
Injury Following
Decompression
From
a
Helium-Oxygen
Atmosphere
Nitrogen emboli interrupting
the blood supply to the thoracic and
lumbar areas of the spinal cord
produce
the gravest
complications of
compressed-air
illness,
namely, paralysis affecting
the lower extrem
ities,
intestines,
and
genito-urinary
tract.
Since
the
spinal
cord
consists
of 27.5 percent
fat,
13 a helium-oxygen
mixture breathed
in
place of air should materially
lessen
damage
to this vital
tissue as a
result of the comparatively low solubility
coefficient
of helium in fat.
SUMMARY
1. The solubility
coefficients
of helium in water and in oil have
been
determined
and
compared
with
the
coefficients
for nitrogen
stand in the ratio of 2 to 3 for water and
1 to 4.5 for oil, respectively.
From
these values
the helium
content of the body should
be about
45 percent
as high as the nitrogen content when
the same tension of
each gas is breathed.
2. The decreased solubility of helium in fat compared with nitrogen
should decrease the elimination
time
of this gas from the body and
lessen the possibility of spinal cord injury.
548
HELIUM —BEHNKE
AND YARBROUGH
Table
1.—Helium,
nitrogen solubility in water and in olive oil at
(
Water
Olive
oil
a He
aNi
a He
aNi
0.00869
0. 01274
a 01489
0.06689
0.00867
0 01269
0.01 182
0. 06653
0.00877
0.01273
0. 01477
0.06668
0.00874
0.01283
0. 01485
0.06669
Average:
0.01467
0.06685
0.00872
0.01275
0. 0148
0.06673
III. MENTAL
REACTIONS
IN A HELIUM-OXYGEN
ATMOSPHERE
COMPARED
WITH
THOSE OCCURRING IN AIR
Behnke, Thompson, and Motley 16 first attributed
the remarkable
narcotic (intoxicating) effects of air at high pressures
to the "atmos
pheric nitrogen."16
It is worthy of note
that although diving
and
caisson work had been in progress for a great many years, disturbances
in motor control and behavior while occasionally recognized
by alert
diving officers
(e. g. Saunders'
report of the salvage of the S~4) were
described
in the literature for the first time by Hill and Phillips
in
1932.17
In regard to the manner in which nitrogen affects these disturbances
it has been pointed out 16 that its action might be related
to its high
solubility
coefficient
in fat compared
with water.
Thus, an analogy
could
be drawn comparing nitrogen with
the aliphatic
anesthetics,
the activity of which according to the Meyer-Overton
law appeared
to be related
to their ratio of solubility in fat compared
with water.
The
practical
conclusion
drawn
from
these
observations
1S was
summarized by stating that—
An artificial gas
mixture
for divers
is essential if operations
at great depths
(below
300
feet)
are
carried
out
*
*
*
Such
a mixture,
of course, should
limit the oxygen concentration
to that in the air at sea level, and in addition should
provide
a rapidly diffusible, sparingly
soluble gas with
a low partition coefficient.
The gas contemplated
was helium but its cost at that time
(1935)
did not render it available for large
scale diving
operations.
Im
proved methods
of application made its use more practicable and
3
years
later an opportunity
was
afforded
at this unit
to substitute
» Behnke,
A. R.. Thompson,
R. M., and Motley, E. P.
The Psychologic
Effects
From
Breathing
Air at
4 Atmospheres
Pressure.
Amer. Journ. Physiol., 112:554 (1935).
Includes
Argon.
» Hill, L. and Phillips, A. E. J.
Roy. Nav. Med. Service,
18: 165 (1932).
HELIUM —BEHNKE
AND
YARBROUGH
549
a helium-oxygen
atmosphere
for air in depths
up to 500 feet
(16 at
mospheres).
It was possible,
therefore,
to test the belief that helium
would free divers from the untoward effects of air,6 16 and also to cor
roborate
the finding that atmospheric
nitrogen was responsible
for
these phenomena.
Essentially
the
helium-oxygen
atmosphere
abolishes,
or renders
negligible,
the
stupefaction
and impaired motor control
associated
with
air respiration
under
pressure.
At
a depth of
500
feet,
for
example,
the diver felt well and was conscious of being at a depth
of
not more than
100 feet.
The sensation of pressure or depth by which
experienced
divers
breathing air can
estimate
to within
50 feet the
actual depth is uniformly absent in a helium-oxygen
atmosphere.
In contrast to the feeling of normality
experienced
in the helium
atmosphere
at deep depths is the complete
change brought about by
replacement
of helium with air,
the oxygen concentration remaining
constant.
The sudden introduction of air at a depth of 300 feet to a
diver
breathing helium
produced
a
sensation
of "floating
away,"
dizziness,
and loss of muscular control, accompanied
by an insistent
demand
to
be brought to
the surface.
In effect
the diver was
ex
periencing
the first stage of inhalation anesthesia.
It would be of some value,
perhaps, if arithmetical tests could be
used to evaluate
the reactions
associated with the respiration of var
ious
gases
under
pressure.
Such
tests, however,
are not practicable
at the present time under our conditions of work.
We have observed,
for example, that arithmetical tests were of little value, since the effort
and practice
factors inherent in such tests rendered
the interpretation
of results difficult or invalid.
Since the air pressure disturbances
are similar in many respects
to
those
produced
by
alcohol,
another narcotic
substance,
it seemed
worth while to select a practical test of motor function from this care
fully investigated
field.18
It appeared that typewriting involving as it
does a complex,
continuous skilled act, would give data indicative of
the manner in which a diver would perform
his tasks under pressure.
In this test the continuous performance
renders subjective reinforce
ment (possible in intermittent
tests such
as marksmanship) difficult,
or detectable by a slower rate of typewriting.
The practice factor can
also be eliminated
by using skilled typists as subjects.
These
data were obtained
when
a skilled typist breathed
air and
a helium-oxygen
mixture alternately at various pressures
(depths)
in a large steel chamber.
Emerson,
H.
Alcohol
and Man, p. 237.
The MacMillen
Co., New York,
1938.
550
HELIUM
BEHNKE
AND YARBROUGH
Surface:
Words
per minute
Errors
per stroke..
200feet-
Words
per minute
Errors per stroke. .
210 feet:
Words
per minute.
Errors per stroke. .
Comparable to the alcohol
tests 18 are
the clumsy mistakes
made
in the copy
(whole
sentence omitted at 250
feet) greatly decreasing
its legibility
when air was breathed
under
pressure.
Impaired judg
ment,
a characteristic effect of high air pressure,
is brought out by
the fact that the typist realizing that he was making errors
while
breathing helium
slowed
down
his rate of copy.
Breathing air, on
the other hand, gave him the feeling that he was doing exceptionally
well and consequently
he made no effort to decrease his speed.
Manner of Action op "Atmospheric
Nitrogen" at High Pressures
The low partition
coefficient
(fat/water solubility ratio) of helium
(1.7 to 1) in contrast with nitrogen (5.24 to 1), and the comparative
freedom
from
pressure
effects
when
helium
is
breathed,
give
us
a
working hypothesis
toward an understanding of the action of nitrogen
discussed
in
a previous paper 15.
While
the nature of all narcotic
activity
is
obscure,
the
relationship
between
narcotic
potency
of
different alcohols
and
anesthetics
and
their relative fat and
water
solubilities as demonstrated
by Meyer and Overton, may
well apply
to
the narcotic action
of
gases.
Specifically,
an alteration brought
about by adsorption or concentration of these fat solvent substances
in the fatty components
of the surface film of the nerve cell is thought
to decrease cell membrane permeability with resulting narcotic effect.18
Other differences
between
the two gases
(argon should
also be con
sidered with nitrogen and is included in the term, "atmospheric N2")
as an explanation of their opposite
behavior may
be related
to
the
electronic
inertness
of the helium atom,
depriving it of valence
and
the ability
to combine
with any known substance,
in contrast with
nitrogen which is electronically active,
possesses
valences of 3 and
5,
and combines with many substances.
Limiting
Depth
When
Helium
Is Breathed
The limiting
depth
when air is breathed
may be placed at 300 to
350 feet.
If its narcotic action is related
to its partition
coefficient,
then helium with only one third the partition
coefficient
of nitrogen
should
enable divers
(considering
only the mental effects)
to descend
to a depth of about 1,000 feet.
HELIUM
BEHNKE
AND YARBROUGH
551
SUMMARY
In a helium-oxygen atmosphere
the narcotic effects of "atmospheric
nitrogen"
at corresponding
high pressures are largely dispelled.
The
comparatively low fat/water solubility ratio of helium compared
with
nitrogen suggests the applicability
of the Meyer-Overton
law toward
an understanding of the nature of nitrogen narcosis.
IV. HELIUM CONTENT
OF
THE
BODY
AND ITS
RATE
OF [ELIMINATION
Measurements of the rate of helium elimination from the body are
essential
for the calculation of decompression
tables for divers.
Experimental
Procedure
First-class
divers
representing
carefully selected
and
trained men
whose
ages
ranged
usually
between
25
and
35
breathed
a helium-
oxygen mixture for periods
averaging
3% hours
either at atmospheric
or
increased
barometric pressure.
Following
the
period
of helium
respiration
air or oxygen
was rebreathed
from
a spirometer
of the
Benedict
type.
Analysis
of spirometer
gas for its helium content
made
possible
the measurement
of the body's helium content,
and
its rate of elimination.
Analysis
of large
samples
of gas
(500
cc.)
enabled
us to measure
quantities of helium as small as 1.5 cubic centimeters
eliminated
from
the
body during
a half-hour
period
of rebreathing,
and
to recover
about 99 percent of the body's
helium content.
For our purpose
we
considered
helium elimination
complete
when
less
than
1.5
cubic
centimeters
were given
up by the body during a half-hour period.
The gas mixture breathed
by the divers
contained
73-76
percent
helium, 5-7 percent nitrogen, and
19 to 20 percent oxygen.
Analysis of Helidm
Helium can be separated from
other inert
gases
by
a physical
method based
on its low liquefying
temperature.
In the Cady
apparatus
activated
charcoal is
used to absorb nitrogen and gases other than helium at the temperature
of liquid
air
( — 189°).
By means of a high vacuum applied to the charcoal the helium can
be extracted, and subsequently
measured in a burette.
A spectrum tube serves
to identify
helium, or impurities
in the system, and to
determine
the approximate
concentration
of helium
gas.
Computation
of the
Helium
Tension
in the
Body
The helium tension in the body at the end of a 3^ hour helium-oxygen
exposure
was computed
from
the helium
content
of the urine instead of the helium
per
centage (73-76) of the inspired
gas.
After
90 minutes
of helium-oxygen
respiration
the tension
of helium
in the
urine
is in equilibrium
with
the helium
tension
of the kidneys,
arterial
blood,
and
alveolar
gas
(see part IV).
By analyzing
a sample of urine
voided
after
90 minutes for its helium content, and equilibrating
a portion
of the same
urine
552
HELIUM
BEHNKE
AND YARBROUGH
with
pure helium,
we can compute the tension
of helium
in the urine from
the
formula,
.
helium content urine
„
Tension helium- nelium content equilibrated
urine XB~W
where B is the barometric
pressure and W the tension of water vapor.
Table
2.— Helium
elimination
from
a
diver,
age
£9,
weight
7't kilograms
(162
•pounds)
[The average Initial helium
tension
in the body was 413millimeters]
Rate cor
responds
to a 50
percent '
desatura-
tion
time
in—
Rate cor-
50*
Time
nelium
Percent
of total
Time
Helium
Percent
of total
Cuiic
Cubic
desatura-
tion time
in-
centi
centi
meter)
Minutes
meters
Minutes
3
minutes
75
29.0
6.25
180minutes
247
94.6
43.00
20 minutes
.
147
169
201
56.5
17.00
20.00
27.50
31.00
36.00
40.00
210 minutes
251
96.2
97.3
98.3
99.4
99.5
43.00
43.00
43.00
43.00
43.00
30 minutes
64.8
240 minutes
254
60 minutes
.
77.00
270minutes
..
256.5
90 minutes
223
233
242
85.4
300 minutes
258.5
120minutes
89.3
330 minutes.
2fO.0
150minutes
92.7
i
A
tissue half desaturating
in 43 minutes will be 99.5 percent desaturated
in 330 minutes
(7.7time units).
Discussion
op Results
The graph (fig.
15) represents
the helium desaturation curve of a
diver, age 29, weight 74 kilograms (162 pounds).
The average helium
tension
in
the
body
(urine)
during
the
period
of exposure
in
the
helium-oxygen atmosphere
was 413 millimeters.
In table
2
are listed the data applying to fig. 15.
The helium given
up during the first
3
minutes
(lung-rinsing period) of oxygen breathing
was estimated
from
values
obtained
for the third minute and from
values computed
from the product of cardiac
output and the helium
solubility coefficient in blood.
From these data we conclude
that the quantity of helium dissolved
in the tissues of men of the same weight
is
about
40 percent of the
nitrogen
content
13 19 for corresponding
gas tensions
in the body.
The
time
required
for helium
elimination
is
about one-third to one-half
the time required for nitrogen elimination.13
14
The difficulty of meas
uring with
precision
tbe
end point of nitrogen diffusion
from
the
body in an oxygen
atmosphere
does not permit at this
time
a
closer
comparison
of desaturation rate for the two gases.
The decreased total elimination time for helium
as compared with
nitrogen
is
roughly proportional to the blood and fat solubility ratios
i• Behnke,
A. R.
Application of Measurements
of Nitrogen
Elimination
to the
Problem
of Decom
pressing Divers.
V. S. Nav. Med. Bui., 35: 219-240(April 1937).
HELIUM —BEHNKE
AND YARBROUGH
553
J
i
»
i
i
J.
1
1
1
1
l_
so
oo
90
120
(So
340
500
330
MINUTES
Figure is.
of the two gases (viz. part II).
Essentially
it is
the high solvent
capacity of body fat for nitrogen that delays
the elimination of this
gas.18
On the other hand, 50 percent
desaturation time in contrast
with total elimination time is about the same (20 minutes) for each
gas.
During
this first 20-minute
period gas elimination
is taking
place from body fluids.
Possible Error from the Absorption
of Helium in the Intestinal Tract
The
question
may
arise
as
to
whether
the
small
quantities
of
helium eliminated after fourth hour are given
up by the tissues or
alimentary
tract.20
Gas in the alimentary tract is mostly nitrogen,
residual
of swallowed
air.
When
helium
is
breathed
its
entrance
into the stomach
and intestines
occurs
either
by swallowing the gas
or through diffusion from the blood stream.
It is of interest to record
that at one
time
experimental
diving with helium
was
practically
discontinued because the use of a mouthpiece
for helium respiration
resulted in swallowing large quantities of gas.
During decompression
the rapid expansion
of the trapped
gas caused intense, griping pains,
and in addition created
the possibility of gastric rupture.
To eliminate this source
of error
a test
was
conducted
in which
500 cubic
centimeters
of helium were admitted to the small intestine
» Mclver, M. A., Redfleld.
A. 0., and Benedict,
R. B.
Amer. Journ. Physiol., 76: 108 (1926).
554
HELIUM
BEHNKE
AND YARBROUGH
through a Rehfuss tube.
A roentgenogram
of the abdomen
taken
a
half hour later
revealed
the
gas distributed
throughout
the
large
bowel.
Three and
one-half
hours
later about 4.4 cubic
centimeters
of helium were recovered
from air rebreathed
in a spirometer during
a half-hour period.
While these quantities of gas would undoubtedly
affect
a precise determination of helium diffusion from tissues, it was
doubtful
whether
or not such large quantities of gas would
be nor
mally
retained.
In
a
second
experiment
200
cubic
centimeters
of
helium were introduced into
the small bowel.
Between
the fourth
and fifth hour after the introduction of gas only
1 .6 cubic centimeters
were eliminated
from the lungs.
These
tests showed
that under
ordinary conditions helium either
swallowed
or diffusing into the intestinal tract during saturation will
not introduce significant error in measurements
of helium elimination.
SUMMARY
1. The
helium content of
the
body
is about
40
percent
of
the
nitrogen content for corresponding
gas tensions.
2. At
atmospheric
pressure
99
percent
of the helium content is
eliminated in five
and one-half hours
or in about one-half the
time
required
for nitrogen desaturation.
V.
THE NITROGEN
OR HELIUM
CONTENT OF THE URINE
AS A TEST
FOR
BUBBLE
FORMATION IN THE BLOOD BTREAM
A simple
test heretofore
has not been available for estimating the
efficiency
of a given
decompression
schedule in promoting the elimi
nation of
excess
gas from
the
tissues of the body without
bubble
formation.
Periodic measurements
of the inert gas content of the urine provide
a simple
and
effective
test for detecting
the presence
of
excess
gas
held in supersaturation or bubble form in the blood stream.
Leonard
Hill21
in
1907
made
analyses
of
the
gaseous
nitrogen
content of urine to determine
the time
necessary for kidney satura
tion.
Subsequent
investigators,
however,
have not continued
Hill's
work,
nor
have
they
applied
the
principle
underlying
the
urine
analysis
method
to the problem
under consideration.
Method of Procedure
Urine from divers
exposed
to
a helium-oxygen atmosphere
under
pressure
and air during decompression,
was
collected
before
a dive
(control
sample),
immediately
after
surfacing,
and
then
at hourly
« Hill, L.
Caisson
Sickness,
and the Physiology
of Work In Compressed
Air.
Longmans,
Green
and
Company,
New York (1912).
HELIUM —BEHNKE
AND YARBROUGH
555
intervals
until
equilibrium
was
again
established
between
the inert
gas tension in urine and lungs.
The manner of urine analysis
was essentially
the same as the tech
nique used by Van Slyke and his coworkers
in their nitrogen solubility
studies.
10
Since the solvent capacity of urine is decreased by the presence of
dissolved salts it was necessary to equilibrate a portion of each sample
by bubbling air through the urine for
15 minutes
at a temperature
of 38°.
The
difference
between
the gas content of immediately
analyzed
urine and the equilibrated portion denoted gas held in supersaturation.
Principles Underlying the Experimental Results
A condition of equilibrium through the media of arterial blood
and
kidneys is assumed to exist between the inert gns tension in urine and
lungs at constant barometric pressure.
Disturbance
of this equilib
rium
is effected
when
a diver is subjected
to increased
pressure by
diffusion of gas from the lungs into arterial blood, kidneys, and urine.
With
the
subsequent
release
of
pressure,
diffusion
in
the
reverse
direction occurs until equilibrium is again restored.
The time required for the reestablishment
of inert gas equilibrium
between
urine and lungs will be delayed if gas bubbles
are present in
the blood,
especially
in
the
arterial blood circulating
through
the
kidneys.
That bubbles
of gas circulate in arterial blood in the early
stages of compressed air illness
(bends) has been observed
by Behnke
and Shaw.22
In this paper experimental
data will be presented in support of these
statements.
Discussion
of Experimental Results
Inert
gas
(nitrogen)
content
difference
between
bladder
urine
and
equilibrated
urine at atmospheric
pressure. —In
76
analyses
the inert
gas content of bladder urine was found to average 0.015 volumes
per
cent higher than
the
gas content of urine through which air was
bubbled for
15 minutes.
The greatest
difference
was 0.039 volumes
percent.
In 8 analyses
the gas content of bladder urine was slightly
lower
(from
0.006 to 0.016 volumes
percent)
than the gas content of
equilibrated urine.
Inert gas
(nitrogen)
content
difference at increased pressure. —At 2.2
atmospheres
pressure
the same difference,
or 0.015 volumes
percent,
was found to occur
between bladder urine in equilibrium with lung
air and urine equilibrated with air at the same pressure.
" Behnke,
A. R., and
Shaw, L. A.
The Use of Oxygen
in the Treatment
of Compressed-Air
Iliness
C. S. Nav. Med. Bui., 35: 61-73 (1937).
556
HELIUM
BEHNKE
AND
YARBROUUH
Barometric pressure changes in relation
to equilibrium time.—Between
30 and
60 minutes
was required
for the establishment
of equilibrium
(saturation) between
the pulmonary and
urinary
gas tensions when
the barometric pressure was raised;
that
is,
in
a
pressure chamber or
diving suit.
When
the
excess
pressure
is
lowered
to normal the same time is
required for
the restoration of gaseous
equilibrium
(desaturation)
,
provided that the excess pressure
is
not too high (above 7.5 pounds) or
the return to normal too abrupt.
Desaturation
time
is
prolonged
by-
rapid decompression from higher pressures.
This delay
is
undoubtedly
the result of increased nitrogen tension in the arterial blood reaching the
kidneys and
is
possibly
indicative of gas embolism.
Variation
of
inert gas content in the lungs in relation
to the excess
gas
content in the urine. —In table
3,
values are given for the excess inert
gas in urine for periods
up to
4
hours following the decompression of
divers from
a
depth of 225 feet.
On the bottom the divers breathed a
helium-oxygen mixture and, during decompression,
air.
It
is
observed
that the higher
inert
gas tension
in the lungs
is
reflected
in higher
urinary gas contents.
Excess gas
content in the urine in relation
to bubble formation in the
blood
(bends). —In table
4,
data are presented showing the relationship
between
the gas content of the urine and
the occurrence
of bends.
The divers breathed
a
helium-oxygen
mixture on the bottom and air
during and following decompression.
The control values in column
3
were obtained by analysis
of urine voided immediately before
a
dive.
Immediately
following
a
dive
the bladder was again
emptied.
The
values in columns
1,
2,
and
3
thus represented
analyses of urine voided
at the end of the first, second, and third hours, respectively.
In these
specimens,
with one exception,
helium could not be detected by our
analytical methods.
We have come to regard
the gas content
values of the second hour
(column
5)
as of great importance
since under the system of decom
pression employed,
high values were associated with the development
of bends
while normal
values
(below
0.04
volumes
percent)
were
obtained
on divers
who remained
free from symptoms.
In only one
instance did bends occur following a normal 2-hour gas-content
value.
On
the
other
hand,
high
2-hour
values
may not be followed
by
bends.
Thus, diver Z. A. M., who
up to date has been immune to
bends, showed high values during the second and third hours.
How
ever M. A. C, who on the following day was subjected
to the same
diving conditions, developed
severe bends.
Some factor apparently enables certain
individuals
to hold gas in
supersaturation in the blood,
or,
if
bubbles
form,
the blood flow,
as a
result of increased
heart
action
or abundant collateral circulation,
is
sufficient
to maintain adequate
tissue nutrition.
In this connection,
HELIUM —BEHNKE. AND YARBROUGH
557
End 8 has called attention to the association
of bends and the presence
of high concentrations
of carbon dioxide in caissons as reported in the
literature.
At this unit Lieutenant Commander Momsen has had an
opportunity
to make
tests on two
occasions in which a high carbon
dioxide content in the diver's gas mixture was followed
by the develop
ment of
bends.
In control
tests duplicating
the conditions of the
previous dives except for a lowered
carbon
dioxide
tension in the in
haled gas mixture, the divers
remained
in excellent condition.
That the body can tolerate
gas bubbles in the blood stream is indi
cated by the inert gas values for the first and second hours
obtained
on B. U. G.
This excess gas was found on analysis
to be helium,
the
only
instance
in which we have
been able
to detect
helium in the
urine
1 hour after decompression
and about 2% after exposure in a
helium-oxygen
atmosphere.
The
existence
of
helium
in
bubble
form in the blood
is our only explanation for the prolonged
presence
of helium in the urine.
Further evidence of the presence of bubbles in blood associated with
minor, and frequently prodromal symptoms
of bends are brought out
in tests involving
a 2-minute return to normal pressure
after a 30-
minute exposure to a pressure of 4 atmospheres.
Transient sequellae
of such tests are skin itch and petechial
rash indicative of bubbles in
the cutaneous
vessels.
In explanation of this phenomenon
it appears
that gas in supersaturation is trapped in the skin vessels as a result of
vasoconstriction brought about by the chilling cold
associated
with
rapid decompression
in a chamber.
Subsequently,
with an increasing
differential pressure the gas in supersaturation is released in the form
of bubbles.
Diffusion of helium through the bladder wall. —An important consid
eration in any study of urinary gas content
is diffusion
of gas through
the bladder
wall when the urinary gas tension is higher than the gas
tension
in
the blood.
During
exposure
in a high
pressure helium-
oxygen atmosphere
the tension of helium in urine approaches
equilib
rium with
the helium
tension
in the lungs.
During
decompression,
however,
the bladder
urine loses about nine-tenths
of its estimated
helium
content.
This loss
of helium undoubtedly
takes
place
by
diffusion through the bladder
wall.
The fugacity of helium is also
greater in a distended bladder because, presumably,
the stretched wall
allows the gas to diffuse from urine more rapidly into the blood where
the tension of helium is lower.
In an experiment
designed
to measure
helium loss from retained
bladder urine,
153 cubic
centimeters
of normal saline saturated
with
1.63 volumes
percent helium at two atmospheres
pressure were intro
duced
by catheter
into the bladder.
Three hours
later the voided
urine-saline mixture contained
a helium
content
of only 0.07 volumes
558
HELIUM
BEHNKE
AND
YARBROUGH
percent.
Making
allowance
for
the dilution
of
saline
by
secreted
urine, it was computed
that nine-tenths
of
the original content
of
helium
had diffused into the blood stream through the bladder
wall.
Summary
Periodic measurements
of the inert gas content of the urine provide
a simple and effective test for detecting
the presence of excess gas held
in supersaturation
or in bubble
form
following the release of divers
from
high
pressure atmospheres.
By means of this test a quantita
tive estimate of gas elimination from
the body
can be obtained,
and
the occurrence of bends frequently can be prognosticated.
Data
are
presented
indicating
that
helium
diffuses
through
the
bladder wall.
Table 3.— The
225-foot
dives,
20 minutes
duration,
diver
breathing
helium-oxygen
mixture
on the bottom
Diver
Date
Excess inert gas in urine (volumes
per
cent)
1 hour
2 hours
3 hours
4 hours
Oxygen
percent-
ape in
helmet on
bottom
Remarks
M. A. C
C. O. T
D. U. N
T. H. O
M. E. T
F. O. R
F. R. Y
/.Mar.
24
Mar. 25
Mar. 24
Mar. 23
Mar. 22
Mar. 24
Mar. 22
Mar. 25
Mar. 23
fMar. 28
VMar.
29
/Mar.
23
\Mar.
22
Mar. 28
0. 186
.128
.266
.080
. 134
.122
. 132
.115
. 105
.312
. 104
. 115
. 110
. 149
0. 049
.035
.044
.009
.007
.002
.004
.020
.001
.044
.043
.031
.032
.050
0.042
.029
.031
.003
0.013
.013
47-minute decompression
42-minute decompression
47-minute decompression
.001
.009
.012
.021
.001
.01
.021
12.8
21. 1
11.5
20.6
12.8
22.9
12.8
21.7
21.0
9.8
21.4
12.0
21.0
10.0
Itch,1 rash,'
fatigue.'
' Indicative
of bubbles in blood
' Frequent
precursor of bends.
of skin.
Table 4.— Excess
inert gas in urine in relation to
the
occurrence
of bends
Diver
C. R. I
R. L E
D. V. N
M. E. T
O. K. E
C. R. O
B. U. Q
F. R. Y
M. E. T
B. U. O
C. R. O
Z. A. M
M. A. C
Depth
(feet)
350
350
1(H1
400
400
400
I75
225
225
300
350
350
H0
Time on
bottom
(minutes)
(2)
Excess inert g is in urine (volumes
per
cent)
Control
(3)
0.018
.000
.004
.004
.032
.029
.015
.009
.015
. hour
(4)
0 11
.05
.099
.13
. 1ft
.20
.15
.312
1.51
. 14
.17
2 hours
(5)
0. 05
.028
.048
.012
.111
.021
.073
.05
.044
1.35.
.077
.056
3 hours
(6)
0.017
.017
.041
.001
.001
.005
.051
Remarks
Bends.
No symptoms.
Bends.
No symptoms.
Bends.
No symptoms.
Bends.
Mild bends.
No symptoms.
Cold
during
dive.
Delayed
bends.
No symptoms.
Bends.
i Excess gas was helium.
HEALTH
RECORDS
MARKS
559
THE HEALTH
RECORD
1
By J. 8. Mares, Clerk in Charge, Medical Record
Section,
Bureau
of Medicine
and Surgery
INTRODUCTION
The individual
health
record
(form H) now in use was adopted
on
January
1,
1911,
with
a view to greater
accuracy,
conciseness,
and
convenience.
While on duty in the Bureau of Medicine and Surgery,
Chief
Pharmacist
Charles E. Alexander, United
States
Navy,
con
ceived
the idea, devised
the health record,
prepared
the instructions,
and was instrumental in introducing
this form to the naval service.
Prior
to
1911
an individual's
medical
record
was not
continuous,
entries being
made in
a number of different
medical
journals,
case
papers, hospital tickets,
and on other forms.
These were not directly
coordinated or, as a whole, generally
accessible.
The present form II was substituted for the above
papers in the
case of each officer and enlisted
man in the Navy
and Marine Corps
to
accompany
him
throughout
his
various
transfers
to
ships
and
shore stations
or during periods
of treatment in hospital; this record
to
be continuous
and
to contain the entire
medical
history in each
particular
case.
The information
thus available
to a medical
officer
when a patient presented
himself for treatment
and
a knowledge
of
the patient's previous
medical record were important factors in deter
mining the correct
diagnosis,
the origin
of the disease or injury,
and
in prescribing
an appropriate course of treatment.
The Bureau of
Medicine
and Surgery
was enabled
by this procedure
to furnish full
information in any case, without the necessity,
as previously existed,
of requesting
a
complete
transcript
of
service
from
the
Personnel
Divisions
of the Bureau of Navigation and Marine Corps.
On January
1, 1911, all medical journals were closed and forwarded
to
the Bureau
of Medicine
and
Surgery.
Medical
officers
imme
diately opened a health record for each patient on the sick list, noting
the
fact
that his medical
history was continuous from
a preceding
entry
in
a
medical
journal.
In
order
to
avoid
an
overwhelming
amount of clerical
labor,
health
records for other officers and enlisted
men in the service were issued only when they appeared for treatment.
For officers appointed
or promoted
and for men enlisted
on or after
January
1,
1911, health records
were immediately opened.
All case
papers
closed during the calendar
year
1910
were forwarded
to the
Bureau of Medicine and Surgery
where they were indexed
and made
a part
the permanent
files of the Bureau.
No new case papers were
employed
thereafter,
but cases
continued
from
1910 were carried
on
the
records
until
discharge,
without
the
issue
of
health
records.
i Editor's Note. —The new health
record form described
in this article
was developed
largely
by the
author.
Mr. Marks served as a chief yeoman during
the World War.
Both
before and since that enlist
ment he has served in the record section of the Bureau
of which
he is chief.
86860 —38
8
560
HEALTH
RECORDS
MARKS
Upon
completion of such
case
papers
they
were
forwarded
to
the
Bureau of Medicine
and
Surgery.
The library
of medical
journals
contains
over
5,000 irreplacable
books,
covering
a period
from
1812
to 1911.
Approximately 40 percent of these books have been re-bound
in canvas,
and as funds
become available
it is the Bureau's intention
to
have
the
remainder
of these valuable
records
re-bound.
These
records
are consulted
daily for medical
histories
as far back as
50
years.
In
1927
the procedure
in handling health records
of officers
pro
moted to the next higher grade was revised resulting in a conservation
of health-record
covers.
Prior to this time a new health record
had
been opened upon each promotion, only the abstracts
were detached
and appended
to the new health record,
while the old health record
minus
the abstracts
was forwarded
to the Bureau.
This procedure
was changed
to require
the opening
of
a new physical examination
sheet
(descriptive
sheet)
only,
to
be
retained
as
top
sheet by
the
medical
officer for reference purposes.
No part of the health record
was forwarded
to the Bureau.
The writer was instrumental in this
revision.
In
1930 Captain William E. Eaton, Medical Corps, United States
Navy,
revised
the physical examination sheet
(descriptive
sheet)
to
include additional physical examination entries which have proved of
great
value
to
the
Medical
Department
of the Navy and
to
the
Veterans' Administration in the adjudication of claims.
NEW
HEALTH
RECORD—COMMENT
AND
INSTRUCTIONS
A new health record
(Form H) will be issued to the service in the
near future.
This issue of the health record will be reconstructed
in
design.
It will result in
a
saving
of
thousands
of dollars
to
the
Medical Department of the Navy in time, labor, and material.
Of
particular
significance
is the continuous
use
of
the original health
record
cover
and
abstracts.
A
new
physical
examination
sheet
(descriptive
sheet) only, is prepared
in cases of reenlistments,
exten
sion of enlistments,
transfer to the Fleet Naval Reserve,
etc., in lieu
of opening a new health record in its entirety.
A new abstract for "Record of refractions
and physical qualifications
for special duties" has been added.
The provisions contained
in this
abstract will meet
a long standing need.
Concise
entries of special
examinations,
refraction
of
eyes,
physical examination for diving,
submarine
duty, and aviation will
be readily available as a part of
the permanent
record.
This abstract further provides
for the new
defects
encountered
on
subsequent
examinations
for
these
special
duties, thus becoming available
as a ready reference for the individual's
physical qualifications for such special duties.
HEALTH
RECORDS
MARKS
561
The dental record
will
be inserted
as the last page of the health
record and the directions of the Bureau are that the original
dental
record be recharted
as required.
New dental records
should
not be
inserted
in the health record
upon subsequent
promotions of officers,
appointment
to officers' rank, reenlistment,
and extension
of enlist
ments.
The present
practice
of the Bureau concerning
the preparation of
health records for filing will be materially modified
upon the adoption
of this new record.
Health
records will be filed in their entirety in
lieu of the present
policy of removing covers
and stapling sheets,
a
procedure
which has proved
unsatisfactory for reissue and for photo
static purposes.
The substitution
of a patented
fastener
will
be an
improvement and will eliminate
the unsatisfactory clipping process.
A circular letter giving full particulars in connection
with the latest
issue of the health record will be prepared
by this Bureau and mailed
to all medical activities.
The following instructions will be a part of
that letter:
Officers
A health
record shall
be opened
(issued)
for each
commissioned
officer, upon
first appointment,
by the president of the board of medical examiners, or a mem
ber designated by him.
Upon appointment
of a warrant
officer to commissioned
rank,
or an enlisted
man to warrant
rank,
a
new
physical
examination
sheet
(descriptive
sheet)
only
shall
be made out and inserted
as the top sheet.
The
health
record
shall
be
retained
in its entirety,
at this
time, with appropriate
notations
on the medical history
sheet and cover.
In
cases
of promotion
of commissioned
officers to a higher rank
the present
procedure shall be used.
(See paragraph
2202 (6), Manual of the Medical
Depart
ment,
1938.)
Upon
completion
of the annual
physical
examination
each
year,
the descriptive
sheet
of prior rank,
if promoted
since the last annual
physical
examination,
and all medical history
sheets
containing
entries shall be detached
from
the health
record and forwarded
to the Bureau
of Medicine
and Surgery
attached
to
the report
of annual
physical
examination.
(See
par.
2217
(a),
Manual of the Medical
Department,
1938.)
Nurses
The same procedure shall be followed
as in the cases of officers.
Enrollment
and Reenrollments
The same procedure shall be followed for reservists as in cases of officers of the
regular
Navy.
Midshipmen
Appointment. — A health record shall
be opened by the president
of the board
of medical examiners, or a member designated
by him, and shall
be continued
intact
until
termination
as midshipman.
Commissioned as ensign. — When commissioned
as ensign appropriate
notation
shall
be made on the cover, a new physical examination
sheet
(descriptive
sheet)
only
made out, and the medical and dental abstracts
retained.
The balance of
the health
record
(old descriptive
sheet,
medical
history
sheets,
and record
of
vision and hearing) shall be closed by appropriate
notation
and forwarded
to the
562
HEALTH
RECORDS
MARKS
Bureau
of Medicine
and Surgery.
Record
of vision
as a midshipman
should
be
noted on refraction
sheet.
Reenlistment
Upon
immediate
reenlistment
a
new
physical
examination
sheet
(descriptive
sheet)
only shall be made out by the medical officer.
The cover
and
abstracts
of previous
enlistment
shall
be retained.
The original
service abstracts
shall
contain entries
(red ink)
as noted on the cover of health record for each reenlist
ment.
The descriptive
sheet of prior enlistment
shall be closed under "termina
tion of health
record"
and forwarded
to the Bureau
of Medicine
and Surgery,
together with the medical history
sheets.
When the individual
does not reenlist
immediately
the health record shall be closed and forwarded
in its entirety
to the
Bureau
of Medicine
and Surgery.
Upon
delayed reenlistment
a
new
physical
examination
sheet
(descriptive sheet)
only shall be prepared by the medical officer
and the cover and abstracts of previous enlistment
shall
be requested from
the
Bureau
of Medicine
and Surgery.
Entries
shall
be made on
cover and service
abstract
indicating
reenlistment.
Extension
of
Enlistment
The
same
procedure
shall
be
followed
as
in
immediate
reenlistment.
The
physical examination
shall be made the day of expiration
of current enlistment,
or
immediately
prior thereto, and the findings shall be entered on a new descriptive
sheet.
Transfer to Fleet Reserve or Organized Reserve
When an enlisted man of the regular service is transferred
to the Fleet Reserve
or Organized
Reserve, a new physical examination
sheet
(descriptive
sheet)
shall
bo
opened.
The
descriptive
sheet
of
prior
enlistment
shall
be
closed under
"termination
of health record" and forwarded to Bureau of Medicine and Surgery,
together with medical history sheets.
Abstracts shall be retained.
Health record
shall
be
marked
"Fleet
Reserve"
or
"Organized
Reserve"
on the cover
and
forwarded
to Commandant
of Naval
District to which the man is attached.
Do not use a new health record cover or a new set of abstracts upon promotion,
reenlistment,
extension of enlistment,
or transfer
to Fleet Reserve
An annual
average of 300 health records of Navy and Marine Corps
personnel
are returned to ships
and stations
for proper
termination
of service.
The entry of
correct
and
complete
information
in the
health
record
is important
from the standpoint of adjudication
of
claims
by the Veterans
Administration
and
valuable
for statistical
study.
A letter should
accompany
a health
record forwarded to the
Bureau for any reason other
than termination of service.
The
personnel
of
the Medical
Department may
be
interested
to
know the magnitude
of the Medical
Records
Section
in the Bureau
which embraces the receipt,
classification,
and filing of health
records
and the routing of correspondence
pertaining thereto.
At the present
time there are on file over
1,400,000 individual jackets
and the same
number
of identifying
cards in the indices.
In addition the library
of
medical
journals
contains
over
1,000,000
case
histories
for the
period from 1812 to 1911.
The section in its entirety occupies 6.040
square feet of floor space and at the present rate of jacket expansion
POSTURE—BENSON
563
1over
100
per day)
an additional
144
square
feet will be required
annually.
During
the period July
1,
1937,
to June 30,
1938,
a total of 44,371
health records were received
and filed as a part of the permanent
file
of
the Bureau.
The
health
records
of
545
apprehended
deserters
were returned
to ships and stations
for proper disposition.
THE
PENALTIES
OF UPRIGHT
POSTURE
By Lieutenant
Reubbn A. Benson, Medical Corps, United States Naval Reserve
In
the
realm
of comparative anatomical
studies
the student
is
impressed
with
the
developmental
variations
which
have
been
directed toward the production of a more
efficient
and better-pro
tected organism.
This holds true throughout the vertebrate
phylum
particularly.
However, when the primate raised his anterior extrem-
ties from the ground
and assumed the behaviorism
which we charac
terize
as being peculiar to man,
he simultaneously acquired
for him
self ails we hear philosophically alluded
to as those to which the flesh
is beir.
Structurally
he is
a
marvel,
and
when
one considers
the
intricacy of his mechanism
we need only to be reminded of the untold
number of things concerning
our own bodies that we still do not know.
The human machine
is,
however,
extremely
vulnerable.
We may
use
the airplane
as
an illustration.
It
is
intricate,
it
is
complex.
It
is
a
phenomenon
of mechanical ingenuity,
yet
it
is
extremely
vulnerable—vulnerable to its environment and also by virtue of its
position
in its
environment.
Consider
the
abdomen.
It
forms
a
comparatively large portion of the body in which lie very vital struc
tures
that are clothed
by only
a
relatively thin and pliable wall of
soft
tissue.
In
addition
this
area
is
exposed
on
the
anterior
and
advancing wall of the individual.
Compare this with
the fowl, a
contrasting
bipedal
vertebrate
which
has its advancing wall
pro
tected by ribs,
a
heavy sternum
well clothed
with musculature, and
an integument
supplied
with
a
thick downy growth.
One of the phenomena
of biological science
is
the remarkable apti
tude
of the
organism
to adapt itself
to its environment.
This
is
demonstrable
in
many
ways—protective
coloration,
integumental
changes, skeletal variations, and rearrangements
in internal and vital
organs —all
occasioned
by
environmental
demands
and
directed
toward preservation of the specie through increased
protection and
efficiency.
But with this remarkable
adaptability of the organism
to
meet
the needs of its environment there has been an inadequacy
in
bodily adaptation to meet the requirements
occasioned by the change
in posture
from the horizontal
quadrupedal
to the vertical bipedal.
First,
let us consider
the skeleton.
In
the quadruped
the body
weight
is
supported
on all four extremities
with the anterior members
supporting the major portion of the weight and the posterior contribut
564
POSTURE —BENSON
ing the major portion of the motive force.
In man it is necessary for
the inferior extremities
to supply the entire motive power and support.
Further,
a quadruped is inherently
a mechanically stable
entity, as
would
be a triped were
there
such,
requiring nothing further than
points of support for stability.
However, with
a biped stability
is
dependent
upon equilibrium
and
a broad
base.
This has led to
a
laterally flattened foot in man which by virtue of its construction and
necessity
has increased in its scope of function and decreased in its
efficiency.
The structural integrity of the foot is maintained largely
by the long plantar, the calcaneo-scaphoid,
and the transverse
liga
ments.
The "spring" in the foot is provided by the muscles, and they
also are responsible
for the normal posture
of the foot.
The function
of the ligaments
around
the foot is also to limit the extremes of the
range of movements.
If the muscle
tone is lost the ligaments
are
called upon
to maintain posture
and are subjected
to unaccustomed
strain; this injures the ligaments
and gives rise to adhesion formation.
This and allied conditions are grouped
together for clinical purposes
as "foot strain."
This and the gross abnormality of pes planus (flat
foot) are common entities and directly traceable to the excess functional
demands made upon the inferior extremities of man.
The attempt to maintain equilibrium has led to further difficulties.
The rapid twisting
movements
which we
so deftly
perform
places
excess strain on the sacroiliac
articulation,
the hip, knee, and ankle
joints.
Dislocations
and
fractures
of
the semilunar cartilages
are
sequelae.
Fractures
and
dislocations
among
the
quadrupeds
are relatively
infrequent and rare when the animal
is permitted to rely on its own
resources, mental and physical, in its own environment.
Under these
circumstances
fractures
are limited almost entirely to those acquired
in combat.
Domestication
of animals
has increased
the hazard
of
fractures
many fold for two reasons:
first, the complex
environment
into which they have been induced,
and second, the inherent hazard
of work in which the superimposed
guidance of man takes precedence
over their own instinctive judgment.
A horse is ridden over rough
and uncertain ground
at a fast pace.
He stumbles,
falls, and breaks
a bone.
Every factor contributed to the misfortune— the weight and
presence of the rider, rough
and uncertain ground,
a fast pace, not to
mention the bit and bridle, none of which would have prevailed
had
the animal
been allowed
free in its own environment.
Man is nature's
number one aspirant for honors for frequency
and
types of fractures.
The reason for this being twofold.
His creative
ingenuity
has made
his environment dangerous
to his own
welfare
and
added
to this is his own inherent vulnerability.
The relation
ships between man and his implements
is somewhat
akin to the dog
that at first had a flea and later the fleas had the dog.
POSTURE—BENSON
565
Stimson analyzed nearly 15,000 fracture cases and found 46 percent
were of the upper extremity, 26 percent
of
the lower extremity,
12
percent of the trunk, 9 percent of the face and neck, and
5 percent of
the head.
Dislocations showed
a percentage frequency
of 89 percent
of the upper extremity, 6 percent of the lower extremity, and
5 per
cent of the head and trunk.
Forty percent of the entire total were of
the shoulder
joint.
From these figures we cannot but be impressed
with the frequency
of fractures and dislocations
of the upper extrem
ity.
To what can we ascribe this frequency?
Falls against
an out
stretched
arm
are a common
cause for Colles fractures,
fractures
of
the clavicle,
and fractures
of the humeral
head.
Hyperabduction
of
the upper
extremity
is another
common
accident,
producing frac
tures of the surgical
and anatomical
neck of the humerus
and disloca
tions of the shoulder
joint.
Both
of these causes
are peculiar to
man—the former because of his postural peculiarity and the second
because of his dexterity with his superior
appendage.
The shoulder
in both man
and
animals
is an enarthrodial joint.
We utilize
the
joint to the full extent of its motile ability —flexion, extension
abduc
tion, and adduction.
With the quadruped,
however,
the motion is
limited largely to flexion and extension,
as seen in walking and running,
with the extremity held closely to the body and a minimum of abduc
tion and adduction.
This aids in reduction of the hazard of hyperab
duction and therefore eliminates
a strong factor in humeral-head
frac
tures and shoulder-joint dislocations.
The frequency
of fractures
of
the phalanges
and metacarpi
can rather be attributed to our manual
specialization than to postural peculiarity.
Fractures of the femoral head and neck, the acetabular rim, and the
pelvis can unquestionably in a great number of cases be attributed to
the excess
transmission
of force
through
the involved bones due to
erect posture.
Sacroiliac and lumbosacral
disease are relatively common
in man.
These
include
strain, sprain,
subluxation, and
arthritis.
With the
entire
weight of the trunk, head, neck,
and
upper extremity trans
mitted
through
these
articulations
they
necessarily
are
subjected
to
a high
degree of stress which
is,
roughly speaking,
halved
by the
quadrilateral
weight
distribution.
Arthritis
has
been
mentioned.
We need not limit
ourselves
to the sacral joints in its consideration
but may include the spine, hip, knee, and ankle joints.
In frequency
of affection
the spine
and the knee joint
are undoubtedly the fore
most.
Whether the stress, strain, and trauma that these joints are
subjected
to by virtue of their weight-bearing relationship
is
a
factor
in
the
development
of arthritis
is
at
best
a
conjecture,
however,
worthy of consideration.
A
number of the conditions mentioned
are attributed
to postural
defects and to these may be added scoliosis, lordosis, kyphosis, certain
566
POSTURE— BENSON
pelvic
asymmetries,
genu varus,
and valgus.
It is undeniable
that
postural
perfection
will alleviate
or improve many of these entities.
Let us turn to the vascular
system.
What, if any, have been the
effects
upon
it by
the
assumption
of
the
upright
position?
The
vascular
system, consisting
of the heart, arterial, and venous systems,
has two basic requirements
to fulfill in order
to meet the functional
demands
made upon it, namely,
the maintenance
of blood
pressure
and the maintenance
of blood velocity.
In the living animal, espe
cially those like ourselves
that walk upright, the actual
pressure
in
the arteries of the various
tissues must vary much with the position.
In standing
erect the small arteries of the feet are, in addition to other
conditions, exposed
to
the weight
of the column
of blood
standing
above them.
In the pendant
arm the skin of the fingers is congested.
If, however,
the ami is raised
above
the head the skin may
become
blanched
because now
the column
of blood
from
fingers
to shoulder
exercises a hydrostatic effect in the opposite
direction.
The importance of
this
gravity
effect
is well
illustrated
by
the
splanchnic
circulation.
When an animal accustomed
to going on all
fours
is held
in
a vertical position, the great
vascular area of the
abdomen
is placed
under
an increased
pressure
due to gravity,
and
unless
there follows
a
compensatory
contraction
of
the abdominal
arterioles,
so much blood will accumulate
in this portion of the system
that the arterial pressure in the aorta will fall markedly or the cir
culation will
stop
entirely.
In most
cases
compensation
does
take
place and no serious change in the circulation results.
For similar
physical
reason
the
erect
position
in
man
may
be
dangerous
when
the
compensatory
reflexes controlling
the
arteries
and reflexes of the abdominal wall are thrown out of action.
This
may happen
in a faint or in a condition of anesthesia.
Individuals
who have been kept in bed for long periods
suffer from giddiness
and
unsteadiness
when
they first attempt
to stand
or walk.
It seems
quite
possible
that the effect is caused by a fall in arterial pressure
brought about by the dilatation in the splanchnic area.
The added
weight
of the blood thrown on these vessels by the effect of gravity
is not compensated
by a constriction of the arterioles or an increased
tone of the abdominal wall.
This hydrostatic effect is also influential
in
the production
of
varicose
veins,
wherein
the
vessel wall
is no
longer
able
to maintain
the
weight
of
the
column
of
blood
which
these walls have
to support.
Varicocele,
hemorrhoids,
passive
con
gestion,
portal
stasis,
and
syncope
are
other
conditions which
an
upright position influences
and which are benefited
by recumbency.
Production
of phlegmacia
alba
dolens
(milk leg),
involving
usually
the left leg,
is favored
by the crossing
of the left common
iliac vein
by the right common
iliac artery acting
as a mechanical
obstruction
to venous return, and this condition is aggravated
by upright posture
POSTURE—BENSON
567
which puts the iliac arteries on a stretch
and brings them more firmly
against the underlying veins.
In order
to maintain the circulation in the head and neck of man
the heart is called upon to support a column of blood leading
to these
regions.
This situation,
coupled
with
the necessity
of raising the
column of blood from the trunk and lower extremities,
does not exist
in the quadruped.
The amount of additional work this requires
of
the heart is probably very small ; nevertheless
over a period of years
it represents many foot-pounds of energy.
Whether or not this fact
is of any importance as regards the strength and vitality of the heart
is
purely
a
conjecture.
Myocarditis
is,
nevertheless,
a frequent
invader in the domain of human pathology.
Organically,
there are numerous
entities
that are peculiar to and
common
in man.
Various degrees of prolapsus
are
a
not infrequent
condition.
The continuous weight of the viscera
bearing
down from
above
is
important in the production of this condition.
In prolapsus
ani and recti the fascial
and muscular supports have been insufficient
to bear this stress.
The position of defecation
adds further insult
to these tissues, wherein
the additional force of the contraction of the
abdominal
muscles
is
added.
In
the horizontal
animal
the
anus
usually
lies
quite well retracted within
the pelvic outlet
and
the
perirectal
fascia;
the urogenital diaphragm and
the extrinsic anal
muscles are not continually subject to the strain that they are in man.
The uterus
is
supported
by eight
ligaments
which serve
to fix
it
quite firmly in
the
pelvis.
The fixation, however,
if
analyzed,
is
much more competent
toward keeping the uterus from falling upward
into
the abdominal cavity
than
downward,
the former being
the
direction of fall were we quadrupeds.
Retroversion and retroflexion,
common
as they are, can attribute much
of their frequency
to the
weight
of
the
viscera
bearing
down
from
above.
Cystocele
and
rectocele with incompetence
of the pelvic floor are peculiar to us and
largely occasioned by the continuous weight from above.
Herniae in animals
are largely
confined
to the umbilical type and
occasionally
they
are
of
the ventral variety
caused
by traumatic
rupture of the abdominal muscles.
In addition to these varieties
in
man
we have
the very common
situation
of inguinal hernia in its
numerous
variations and also femoral
hernia.
The weakness of the
abdominal wall at the inguinal ring
is
patent.
This holds
true for
both man and animals.
However, in the latter this area of weakness
is
protected
by the thigh being folded
over
it
and no stress from the
abdominal contents
are directed
against
it.
In the
erect
posture,
however,
the region
is
entirely exposed
and in addition the weight
of the viscera bears down upon the area, giving
a
double factor working
toward the production of
a
herniation of the abdominal contents.
568
POSTURE—BENSON
In gastroenterology,
visceroptosis,
and gastroptosis
are two definite
and well-defined
clinical
as well
as pathological entities.
Obviously
the upright posture is responsible for the existence of these conditions,
for were the patient put to the "monkey walk", such as gynecologists
prescribe
for uterine malpositions, gravity
itself would correct the
displacement.
In our vocabulary we have two words which are quite
significant, namely,
"hypochondria",
alluding
to
the stomach,
and
"hysteria",
literally
translated
as "of the uterus."
Our application
of these
terms
relate
to abnormal conditions of the mind
and the
words are well chosen.
From the stomach and from the uterus comes
the impetus
to many abnormal conditions of both the mind and the
body, and many, if not the majority,
are occasioned by putting these
organs
in
a position in which their normal function
is hampered.
One need only to read the advertising pages of our press to be con
vinced
that the public is gastrointestinally conscious
to a point of a
neurosis.
The
reason
for
this
is manifold,
only
to
mention our
avarice
for a variety of food which
at best certainly must tax the
ingenuity
of
the
digestive
mechanism;
our
sedentary
habits;
the
awkward manner in which we force the stomach
to pass it on to the
intestine,
and the method
of its final elimination.
It might be sug
gested that after a full
meal we attempt to substitute the horizontal
position for the soda.
It is to
be
trusted
that
the
foregoing
discussion
has in no way
savored of cynicism
and to that end may we again be reminded of the
huge scope, function, and intricacy of the human machine
which is
capable of all this in all sorts and types of environment.
CLINICAL
NOTES
AN UNUSUAL
CASE
OF INJURIES
MULTIPLE
EXTREME
By Lieutenant
Frederick R. Lang, Medical
Corps,
United
States Navy
The following
case is presented
because of the extensiveness
and
unusual severity
of the injuries sustained,
together with the fact that
the patient survived and actually was returned to duty.
It illustrates forcibly
the tremendous
powers
of recuperation
and
repair enjoyed by youth during the first two decades of life, and demon
strates how important this factor is in the prognosis
of a case and the
ability
of the human body
to withstand
both
the
immediate
and
remote effects from severe injury.
On the morning
of June 25,
1937, the U. S. S.
Nevada
while proceeding north
along the California coast unexpectedly
encountered unusually
heavy seas which
were shipped over the forecastle.
A group of men working
there at the time were
caught,
swirled
about
the deck, and thrown
against the turrets
and deck
gear.
Three of these men sustained injuries of such severity as to require transfer to the
hospital ship later that day.
One of this group, A. R. G., age 19, seaman, second
class,
sustained
a combination
of severe
multiple
injuries,
each
of which
alone
caused sufficient
shock and hemorrhage that could have resulted fatally
despite
the prompt
treatment
rendered.
A. R. G. was admitted to the U. S. S. Relief on June 25, 1937, with the diagnosis
of injuries multiple
extreme, approximately
6 hours after being injured.
He was
in a partial state of shock.
He was semiconscious
and could
be aroused with
difficulty.
Respirations
were rapid,
shallow,
and of the air-hunger
type.
His
skin was cold and clammy
and his pulse rapid, weak, and thready.
There was a
large diffuse ecchymotic
contusion
overlying
the area of the sixth, seventh, and
eighth
ribs in the midaxillary
line.
Chest
expansion was limited,
unequal, and
shallow.
The percussion note was tympanitic
at the base of the left side of the
chest.
Breath,
voice, and whispered
voice
sounds were diminished
in the same
area.
On percussion, the right border of the heart was found to be 4 centimeters to the
right of the sternum.
The heart sounds were feeble,
distant, and of poor quality.
Palpation
of the abdomen revealed a marked
boardlike
rigidity, accompanied
by a generalized tenderness throughout.
There was dullness on percussion in both
flanks.
The abdomen
was not greatly
distended.
Peristalsis
was not audible.
There was a posterior dislocation
of the right hip, which was surrounded
by what
appeared to be a hematoma of tremendous size.
The right leg was approximately
2 inches shorter than the left, and was fixed in a position of eversion, with partial
flexion of the thigh.
The impression on completion
of the physical
examination
was—
1.
Intra-abdominal
injury of an extreme nature.
2. Intra-abdominal
hemorrhage.
3.
Massive collapse of the left lung.
4. Fracture,
simple, of the left sixth, seventh, and eighth ribs.
5. Posterior dislocation
of right hip.
6. Contusion,
severe,
left chest.
7.
Massive
hematoma, right thigh.
569
570
INJURIES
MULTIPLE
EXTREME —LANG
He was prepared immediately
for operation,
and while undergoing preparation
was given
1,000
cubic
centimeters
of
5 percent
glucose in normal
saline in an
effort to restore blood pressure.
Under
novocaine spinal anaesthesia, an explora
tory laparotomy
was performed.
The abdominal
cavity
contained
considerable
blood.
The chief source of this hemorrhage was from the
pedicle of the spleen
which
was
completely
fragmented
and
scattered
throughout
the
abdominal
cavity.
The largest piece was found to be about the size of a large walnut.
The
splenic pedicle was ligated and blood and fragments of spleen removed from the
abdominal
cavity.
Further exploration
revealed two traumatic
tears in the left side of the dia
phragm.
Both
were about
3 inches in length
and were situated
near the left
crus.
There was some oozing from ruptured
vessels
here.
These openings had a
valve-like
effect with each
respiration.
The
left lung could
be seen
in
a com
pletely collapsed state, and there was a large amount
of blood in the left side of
the thoracic
cavity.
In the abdominal
cavity
a large hematoma
had dissected
downward
along the left
common
iliac.
The
traumatic
herniation
of the dia
phragm were sutured after the blood had been aspirated from the thorax and the
abdomen closed.
While on the operating table the dislocation
of the right femur
was reduced and the patient
was given a transfusion
of 500 cubic centimeters
of
blood by the Scannell method.
At this time his red blood count was 2,170,000.
On leaving
the operating
room his condition
was very poor.
On the next day
his red blood count was 3,140,000.
Two days later, on June 27,
1937, he was again given 500 cubic centimeters of
blood by the same method.
Following
this, his pulse became full and strong, and
the
patient
became
mentally
clear
for
the
first
time.
His
temperature
had
gradually
risen to
104.2°,
and respirations
continued
to
be dyspnoeic.
On the
same
day his chest was aspirated
and 250 cubic centimeters of partially decom
posed blood
was removed.
An effort was made to create
a negative
pressure
in order to relieve the respiratory
embarrassment
resulting
from collapse of the
left lung.
An X-ray of the chest taken
on June 28,
1937, showed the collapse of the left
lung, a fluid collection at the base of the left side of the chest, and fractures of the
ninth and tenth ribs on the left side in their postero-lateral
aspects, with some dis
placement.
There were also fractures in the antero-lateral
regions of the eighth
and tenth left ribs.
On July 2, 1937,
he was given another transfusion
of 500 cubic centimeters
of
whole blood.
From this point
he began
a slow general uphill trend.
About this
time it was discovered that he had a partial paralysis of the right peroneal muscle
group.
Over
a period
of several days this gradually
became complete
and he
ultimately
had a foot drop.
His pulse and respirations
gradually
subsided to normal over a period of several
weeks.
The red blood count was 3,170,000
on July 2, 1937, after the transfusion.
On
the next day, July 3, 1937,
8 days after the operation,
a considerable fluctuation
was noted in the abdominal
incision.
Three
sutures were removed
and about
140 cubic centimeters
of sero-sanguinous
material
was evacuated.
Apparently,
this
came
from between the muscle layers and did not originate
from the peri
toneal cavity.
On July 3, 1937, red blood count was 3,720,000.
Physical findings and X-ray
showed a gradual reexpansion of the left lung.
Sero-purulent
discharge from the
abdominal
incision
gradually
subsided;
temperature,
pulse, and respirations
ap
proached normal;
and his general condition
showed a steady progressive improve
ment.
However,
despite mild
forms of physiotherapy,
there was no suggestion
of return
of function
of the right peroneal muscle group.
INJURIES
MULTIPLE
EXTREME —LANG
571
On August
2,
1937,
because
the hospital
ship was to undergo overhaul,
the
patient was transferred
to the Mare
Island
Hospital.
It is apparent from the first two survey board reports, that the medical officers
on the boards despaired of his returning
to duty
because
of failure
of the right
peroneal
muscle group
to regain full motor
function.
His abdominal
incision
finally
healed
completely
with
considerable
scarring.
His boaid
of survey
of
December
27,
1937, reported
that
he had shown
a slow, steady improvement,
except for the foot drop, that he was up and about with the aid of a cane, and that
bis probable
recovery to a duty
status was doubtful.
However,
he must have
shown a rapid return of function
between this date and February
26, 1938, when
he was discharged to duty, after having been on the sick list a total of 246 days.
REMARKS
Either one of the three major injuries
(fracture
of the spleen, ab
dominal
hemorrhage,
or
traumatic
massive
collapse
of
the
lung)
might have resulted fatally from shock or loss of blood.
Rupture of
the diaphragm
may result in death from shock,
because of the injury
to
the
delicate
network of sympathetic nerves
found
in
this
area.
Rupture of the spleen constitutes
an acute abdominal
emergency, and
it is one of the few instances in surgery in which minutes
count.
Sudden
massive collapse of the lung results in a very grave condi
tion in which the patient's life is feared for because such an accident
results in a tremendous
embarrassment
of the respiratory and circu
latory
systems, which requires
a tremendous
readjustment.
A com
bination of this, plus the resultant shock, will oftentimes
result fatally,
especially
in an older patient.
If the patient survives
the first stages,
he continues
to be in grave danger from sudden shock, because of the
continuous flapping
back and forth of the heart and mediastinal
con
tents with each cycle of the labored
respirations.
Furthermore,
the
loss of negative
pressure in one side of the thoracic
cavity results in
the mediastinum
being
displaced
toward
the
opposite
side of
the
chest.
This reduces the capacity of the remaining
lung and further
embarrasses
the respiratory system.
CONCLUSIONS
The
combination
of
dyspnoea,
diminution
in
voice
and
breath
sounds
in
the left chest,
tympanitic
percussion
note
in
this
same
area, and displacement
of the right border
of the heart
to the right
made the diagnosis of collapse of the left lung comparatively easy.
Diagnosis of intra-abdominal hemorrhage
was arrived at because of
the
findings
of
(1)
sighing,
"air hunger"
type
of
respirations;
(2)
board-like rigidity of the abdomen;
(3) dullness
on percussion of the
flanks.
572
TRAUMATIC
DIAPHRAGMATIC
HERNIA
BREWSTER
ACUTE
TRAUMATIC
DIAPHRAGMATIC
HERNIA:
A
CASE
REPORT
By Lieutenant
Commander
J. M. Brewster (Medical Corps),
United States Navy
The subject of diaphragmatic hernia has been so ably and thoroughly
presented by Captain L. W. Johnson, (Medical Corps), United States
Navy,
in an article
in the October
1936
issue of the United
States
Naval Medical Bulletin that no attempt will be made to discuss it in
this report.
Because it is a relatively rare condition which promises
to become more common
with the steadily rising number of violent
automobile
crashes, this case is being reported
to add to our collective
knowledge
and experience.
Case Report
History. —The patient, an enlisted man in the Navy, was injured
at about 3:30
p. m. on the 20th of October
1936, when the car in which
he was a passenger was
struck
broadside by a rapidly
moving truck.
He received emergency treatment
at a civilian
hospital
before being transferred
to this ship.
He stated that he
was rendered unconscious
but regained consciousness before leaving the civilian
hospital.
He was admitted
at about
10 p. m., complaining
of very
severe
pain
in the left side of the chest
and the region about the left hip.
The temperature
was
98.8°;
pulse
132;
and
respiration
18.
A
cursory
examination
disclosing
evidence of a fracture
of the pelvis and possible fracture
of the ribs on the left.
X-ray pictures of the pelvis and thorax were taken before the patient was put to
bed.
Physical
examination. —The patient was a well developed and nourished young
male adult
23 years of age.
There
was a generalized macular
rash over trunk,
face,
and extremities which disappeared
on pressure and did not itch.
Head:
There
was a lacerated scalp wound
1-inch long in right occipital
region
which
had been
closed
with a skin clip.
Eyes,
ears,
nose,
and throat
negative.
Pupils were equal, regular, and reacted to light and accommodation.
Ear drums
normal.
Neck negative.
Chest:
There was a small contusion
on anterior
wall below right nipple and a
brush
burn
2 by
8 inches on the right
side
in the posterior
axillary
line.
No
deformity
or
pain
on
compression
noted.
The lungs
were clear
with normal
breath
sounds throughout.
The heart sounds were normal
but
at rate of
132
per minute.
Blood
pressure
122/58.
The abdomen
was scaphoid
with
board-
like rigidity
of muscles, preventing
satisfactory
examination.
There
was a wide
contused area with pronounced
swelling over the lateral and posterior
aspects of
the left ilium.
Marked
tenderness and bony
crepitation
noted in this area on
palpation.
No dullness noted in flanks.
No hernia.
Genitalia
normal.
Anus
negative.
Deep and superficial reflexes
were present, equal, and active.
Extremi
ties negative except for pain on movement of left leg.
An
emergency
urinalysis
was negative
for
evidence of
gross
damage to the
genito-urinary
system.
Emergency
red
blood
count,
3,790,000;
Hgb,
75-80'
percent (Tallqvist).
X-ray examination of pelvis, hips, and ribs.—Radiographic
examination,
stereo
scopic study of the pelvis shows a comminuted
fracture
of the left
ilium.
The
approximate
anterior
two-thirds
of the ilium is broken off and displaced
inward,
the width of the fragment being approximately
three centimeters.
The posterior
third of the crest forms
a second
fragment
and
retains
approximately
normal
position.
The body of the ilium
is displaced inward and forward with the fracture
line
extending
downward
and
backward
to
the midportion
of the
sacroiliac
TRAUMATIC
DIAPHRAGMATIC
HERNIA
BREWSTER
573
synchondrosis,
resulting
in widening
of the anterior
half
of the synchondrosis.
There
is an impacted,
slightly
overriding
fracture
of the superior ramus of the
right pubic bone.
There
is also an impacted
fracture
near the junction of the
decending ramus of the pubic bone and ischium.
The fractures are smooth on the
inner aspect,
giving
no indication
of bladder
injury
from
bone displacement.
Radiographic
examination,
stereoscopic
study
of the rib
cage
shows the lower
nine ribs bilaterally
to be essentially negative for evidence of fracture.
Operation. —The high pulse rate, lowered red cell count and the rigid abdomen
led
us to believe that an intra-abdominal
emergency existed with
rupture
of the
spleen
as
the most likely condition.
Accordingly,
an
emergency
exploratory
laporatomy
was performed
under spinal
anaesthesia.
No
gas or free fluid was
found within
the peritoneal
cavity.
Injection of the omentum
and small areas
of the descending colon and portions of the small intestines were found indicating
contusion.
A
large
extraperitoneal
hematoma
surrounding
the-
site
of
the
fracture of the ilium
was noted and seen to extend well up along the posterior
lateral
wall of the abdomen.
The spleen
and all other organs were found to be
intact and apparently
undisturbed.
During the operation,
he was given
1,000
cubic
centimeters of
10 percent glucose
in normal
saline, and upon his return
to
the
ward
continuous
hypodermoclysis
of
normal
saline
was begun.
He
was
placed in a pelvic sling.
Postoperative. —The following
day the
fracture
of
the crest of
the ilium was
reduced and continuous
traction
by
use of a towel
clamp begun.
The
patient
continued
to complain
of pain
in the lower
part
of the left side of the chest.
Examination of the chest at this time was essentially
negative except that the
heart
sounds
seemed
muffled
and diffused
over the precordium
and a rattling,
clicking noise synchronous
with
the heart beat was heard at end of expiration.
Temperature,
99-99.6; pulse, 92-120; respirations,
20-34.
The second
day
following
the injury
he first
complained
of
dyspnea.
The
chest
findings
were essentially
unchanged.
He
was given
a
back
rest
which
relieved
the dyspnea.
He
seemed
much
improved
and accordingly
the hypo
dermoclysis
was stopped
and
he was put
on a liquid diet.
At 4:00 p.
m.
his
temperature
was 99, pulse 82, and respirations
20.
At about 7:00 p. m. he suddenly complained of severe pain in the left side of his
chest and became quite dyspneic
and cyanosed.
The temperature
had jumped
to 101° with pulse of 120 and respirations
of 32.
He was examined by the officer
of the day who found that the movements of the left side of the chest were mark
edly limited.
There was tympany
to percussion over the left chest up to the level
of the second rib anteriorly
with marked increase in the breath sounds over this
entire area.
The cardiac dullness at its widest portion
extended barely
2 centi
meters to the left of the sternum.
An X-ray picture was taken with the portable
machine
which
was
reported
as
follows:
"Radiographic
examination,
antero
posterior
positions of the chest.
Bedside examination
shows complete collapse of
the lower left lobe with
heart and mediastinal
contents
displaced
to the right.
The left diaphragm
is pushed downward.
The resulting
pneumothorax
appears
to be under positive pressure.
Accordingly
he was treated as a case of pneumothorax.
On October
23,
1936, the third day after injury, his condition
was essentially
unchanged,
there being marked dyspnea and cyanosis.
The physical
signs were
the
same
except for signs of beginning
hypostasis
at the base of the right
lung.
With the marked displacement
of the heart to the right and the apparent
down
ward displacement of the diaphragm, it was concluded that a flutter valve perfora
tion in the lung, creating a positive intrapleural
pressure, was a likely possibility.
With this in mind, the left pleural cavity
was tapped using a 23-gage
hypodermic
needle.
To our surprise,
300 cubic centimeters of air was all that could
be aspi
574
TRAUMATIC
DIAPHRAGMATIC
HERNIA—BREWSTER
rated, and this was not under pressure.
This gave
the patient
some
relief from
the dyspnea.
A 20-gage
needle
was then inserted
to a greater depth and about
1 cubic centimeter
of a dirty brown
fluid
was all that could
be aspirated.
The
true nature of the condition
was then first suspected.
The laboratory
immediate
ly confirmed our suspicion by reporting
the fluid as stomach contents.
A check
X-ray made with
needle
left in place
was
reported.
Radiographic
examination,
anteroposterior
position
of
the chest.
Check
bedside examination
with needle
inserted shows the point of the needle
in the pleural cavity.
The contour
of the
air outline area suggests
herniation
of the stomach into the pleural cavity.
The patient
was then given a small amount of thin barium mixture and another
X-ray taken to establish conclusive proof of the diagnosis was reported.
Radio
graphic
examination,
anteroposterior
positions
of
the
chest.
Further
check
films
with
barium
sulphate
introduced
into
the
stomach
shows
the
stomach
definitely
to be well above the dome of the right diaphragm.
The upper portion
of the barium
mass
is at the level of the seventh dorsal
vertebra
on
the left.
There
is considerable air above the barium filled area which may be the result of
a pneumothorax
or a dilated
loop of the small intestines.
There
is evidence of
beginning
patchy
pneumonitis
of the opposite
lung
suggesting
broncho-pneu
monia.
By this time the patient's
temperature
had risen to
102 F, the pulse to
132,
and the respirations
to
31
per minute.
The
dyspnea
had returned
with some
increase
in the pain, with clinical and X-ray signs of beginning
bronchopneumonia
in the lower lobe of the right lung.
It was
agreed
that an attempt
at repair by
operation
under
these
conditions
would
be too hazardous.
As an alternative
a
Levine
tube
was
passed
into
the stomach
through
the
nose
and
about
1,000
cubic
centimeters
of fluid and air aspirated
through
it.
This gave the patient
great relief from
the dyspnea
and cyanosis.
He
was
started
on a continuous
intravenous
clysis of 5 percent glucose
in normal saline.
About
1 hour later the
patient
suddenly
collapsed and died a respiratory
death.
At no time were
there
any symptoms
referable to the gastrointestinal
system.
Autopsy
report. —The positive autopsy findings
were
as follows:
The peritoneal
cavity
contains about
500 cubic centimeters of thin
hemorrhagic
fluid filling the
pelvis.
There is a large opening in the left diaphragm,
measuring
15 centimeters
in diameter
with
a greater portion
of the
diaphragmatic
muscle pushed to the
medial
line,
and only
a narrow
fascial
attachment
remains
along
the
costal
border.
The tear extends along the costal attachment
of the left leaf from
the
region of the external lateral
border of the quadratus
lumborum
forward
to the
region of the ninth costal cartilage.
For a distance of about
1 inch in the posterior
end of this tear there is a hematoma in the edges of both the leaf of the diaphragm
and the tissues
marking its attachment
to the thoracic wall, indicating
the original
wound in the diaphragm.
The stomach, the splenic flexure of the colon, the spleen,
and
the tail of the pancreas
have
passed
through
Ihc
tear in the diaphragm,
filling
the lower two-thirds
of the left pleural cavity,
causing pressure collapse of
the lower
lobe
and lower half of the upper lobe,
left lung.
Extending
from the
diaphragmatic
attachments
on
the left side
to the ilium,
there is extensive sub
peritoneal
hemorrhage, being especially marked about the diaphragmatic
attach
ments.
There
is also a subperitoneal
hemorrhage over the left half of the pelvic
region.
The
body of the ilium,
including
the crest, anterior superior spine, and
down to and including
the posterior spine, has been separated by a ragged fracture.
The line of fracture
is 4 centimeters from the crest and extends parallel to it.
The pancreas appears essentially normal with the exception of capsular ecchy-
mosis about the tail.
Upon
opening
the thoracic
cavity,
the left
pleural
cavity
is partially filled
with
stomach,
spleen,
splenic
flexure of
the colon,
and
tail
of
the pancreas.
TRAUMATIC
DIAPHRAGMATIC
HERNIA—BREWSTER
575
There are about
500
cubic
centimeters
of
ft thin
hemorrhagic
fluid
free in the
cavity.
The lower lobe, left lung is completely
collapsed and the lung is pushed
upward and
to
the
median
line.
Normal
crepitation
is present
only
in
the
upper half of the upper lobe.
The lower lobe and lower half of the upper lobe
are completely
collapsed
and
show a varying
amount
of hypostatic
congestion.
The right lung is free in the pleural cavity.
The cavity
contains about 500 cubio
centimeters
of bloody
serous fluid.
The lung is crepitant
throughout
with the
exception
of the lower
lobe
which
shows hypostatic
congestion
and
beginning
lobular consolidations.
Pathological
diagnosis.— 1. Traumatic rupture,
diaphragm,
along attachments
of the left leaf, extending from external lateral border of the qttadratus lomborum
forward
to the region of the ninth costal cartilage.
2.
Diaphragmatic
herniation,
stomach,
spleen,
splenic
flexure
of
colon, and
tail of pancreas.
3.
Collapse, lower lobe, left lung.
4.
Fracture,
left ilium.
5. Contusions,
multiple,
gastrointestinal
tract.
6. Terminal bronchopneumonia.
Comment. —Some of the observers
of the autopsy
believed
that
it
was the
jagged
bone edge of the fractured
ilium
that
caused
the original
wound
in the
diaphragm.
The majority,
however,
felt that
this would
have been
physically
impossible without a fracture of the vertebral column which was not demonstrated
and that the tear was the result of a bursting
force.
The patient
vomited
while
on the X-ray
table
just before the
first
picture
was taken and as a result the stomach inflated with air was strikingly
shown in
its normal
position,
demonstrating
that
actual
herniation
had not occurred
at
that time.
Mild
dyspnea and abnormal
chest findings
on
the second day fol
lowing
the injury may have represented a beginning herniation
but it is believed
that the wide secondary
tear and massive herniation
of abdominal
viscera
oc
curred on the evening of the second day, giving rise to the sudden pain, dyspnea,
and cyanosis.
The extreme displacement
of the heart and mediastinal
contents to the right;
the fact that
the upper lobe of the left lung had not completely
collapsed;
and
the reversal of the normal
curve of the diaphragm
were all strong evidence
as
to
the true
nature
of the situation.
The marked
accentuation
of the breath
sounds
heard
over
the
effected
area which
was tympanitic
to percussion
was
not consistent with
a diagnosis of pneumothorax.
The lesion was missed at operation
primarily
because
no free fluid,
blood,
or
other
evidence
except possibly
the bluish
discoloration
about
the site of the
fractured
ilium
was found
to
suggest
it,
and,
secondly,
because
we had
seen
the original
X-rays in which
the diaphragm
was noted to be in its normal posi
tion.
The rigidity of the abdominal
muscles may
have
been
a lead but
was
interpreted
as being the result of the fractured
ilium when nothing
was found
within the peritoneum.
Had
the lesion
been
discovered
at
operation it is be
lieved
that
repair would
have been
relatively
easy
and the patient's
life might
have been saved.
Gastrointestinal
symptoms
are given prominence
in most textbooks
as a diag
nostic sign of diaphragmatic
herniation.
They were entirely
absent in this case.
This probably
was due to the fact that the patient was given clear fluids by mouth
and fluids were furnished
by parenteral
routes in quantities
to combat possible
post operative distension.
It is hoped that the
lessons
learned in this
case will stimulate
interest in the
condition
and prompt
others to be on the alert for it in all
cases of the severe
trauma we so often see now as the result of automobile
accidents.
86860—38
9
576
LESIONS
OF
STOMACH —CARROLL
LESIONS
OF
THE
CARDIAC
PORTION
OF
THE
STOMACH
TWO CASE
REPORTS
I
By Lieutenant
H. H. Carroll, Medical Corps, United 6tates Navy
Observers
agree that most
cancers of the stomach
originate in the
region of the pylorus and the adjacent part of the lesser curvature.
Regarding the usual site of chronic gastric
ulcer, Boyd
2 states that
95 percent of chronic gastric ulcers are situated
on the lesser curva
ture
and posterior
wall, particularly in the pyloric region.
When it
is considered
that the ratio of incidence
of peptic
ulcer of the duo
denum
to that of peptic ulcer of the stomach
is approximately
12 to
1, and that of this relatively small number of gastric
ulcers
95 per
cent are located in the pyloric portion of the stomach, it is apparent
that an ulcer of the cardiac portion is unusual.
The
reason
for
this
predilection of both
benign
and
malignant
lesions
for the pyloric portion is unknown
and
consequently
many
theories
are encountered.
The cardiac
portion plays
a more or less
passive part in the process of digestion
and is relatively free from stress
and strain, either
chemical
or mechanical.
However, it is occasion
ally the site of pathological lesions, and two cases recently
under treat
ment
at this hospital are presented.
CASE
REPORTS
Ruptured ulcer of posterior surface of cardiac portion of the stomach.
Case
1.—S. B. S., naval
officer, age
41, was first
admitted
on September
10,
1937, with
diagnosis
undetermined
(duodenal
ulcer).
He complained
of upper
abdominal
pain and occasional belching.
History. —He stated that
10 years before he had been troubled
for a couple of
weeks with pains in the upper abdomen coming on 2 or 3 hours after meals, but
that
he finally
took
a course of calomel and this relieved him of his symptoms.
At
intervals
since then
he
had
had recurrences
of epigastric
pain
coming
on
about
2 hours after
meals and relieved
by
taking
soda.
For the past several
months
the relief from
taking
soda had not
been
so definite
as formerly.
His
pain usually started in the left upper quadrant,
well up under the costal margin
and radiated
down to the midline
in the epigastrium.
No history
of vomiting,
tarry
stools, or loss of weight.
He had had measles and mumps during childhood.
His systemic history, except
as noted above, was negative.
His father
died of apoplexy
at age
50, and
his
mother of Bright's
disease
at age 38.
Social history irrelevant
and habits normal
Physical
examination. — Orly positive findings reported.
Throat:
Some injection
of anterior
pillars.
Teeth:
Many cavities, marked pyorrhea,
and some
gingivitis.
Abdomen:
No definite points of tenderness noted although the skin of the entire
abdomen was hypersensitive
which made the abdomen difficult
to palpate.
Prostate:
Normal
size and consistency,
but secretion contained
30 to 40 white
cells per high dry field.
i From the Surgical
Service of the U. 8. Naval Hospital,
San Diego, California.
' Boyd, W.
A Text Book
of Pathology.
Lea and Febiger,
Philadelphia.
LESIONS
OF
STOMACH
CARROLL
577
Laboratory work was done as follows:
R. B. C., 4,350,000; hgb. 95%.
W. B. C>
17,200.
Gastric
analysis:
Fasting
contents,
45
cc;
free
HC1,
20°; total acids,
28°.
First specimen:
Free
HC1,
44°; total acids,
59°.
Occult
blood
positive,
lactic
acid negative.
Stools were negative
for ova and parasites.
One stool specimen was positive
for occult blood.
The blood Kahn was negative.
X-ray examination of the chest was reported
as follows:
Impression — Negative
gastrointestinal
series.
A gall-bladder
visualization
with oral
dye administra
tion showed a normally
functioning
gall bladder.
Clinical record. —The patient
was put to bed at time of entrance on a Lenhartz
diet.
This aggravated
his symptoms from the start,
as did the administration
of
alkaline powders.
After a few days of no improvement
under this therapeutic
regime, and in view of the patient's
statement that the fatty meal taken during
the gall bladder
visualization
had very definitely
caused an exacerbation
of his
symptoms,
he was placed on a fat-free diet and this quickly and completely relieved
him of all complaints.
Because of this marked
response to a fat-free
diet and
his intolerance
for the Lenhartz
diet and alkalis it was felt that
he did not have
a peptic ulcer.
The most plausible
explanation
of his symptoms
seemed
to be a
low-grade
chronic
cholecystitis,
and the diagnosis was so established.
A course
of prostatic
massages
was instituted
and
three
teeth
were extracted
because
of marked
pyorrhea.
His
pyorrhea
and gingivitis
were considered
to
be
the
source of the positive
occult blood tests in gastric contents and stools.
He was
discharged
to duty symptom
free on October
9, 1937.
Except for occasional distress following
a heavy meal the patient was symptom
free until 1-20-38 when, at 4:30 p. m., he was seized with a sudden severe pain in the
epigastrium.
He was seen by his medical officer about
5:30
p. m., who made a
diagnosis
of ruptured
duodenal
ulcer
and
sent him
to this
hospital.
He
was
admitted
at 6:45 p. m. in a state of mild shock.
His pulse rate was 100; his tem
perature
95° F.
The skin felt cold and clammy,
and
he was perspiring
freely.
The chest and heart were negative.
The abdomen was very rigid, especially in
both
upper
quadrants.
X-ray
examination
of the abdomen
showed the right
diaphragm
to be high, and there was evidence of free gas in the peritoneal cavity.
Operation. —He was operated at 8:30
p. m.
Under spinal anesthesia, later sup
plemented by ether, the abdomen was opened through the usual upper right rectus
incision,
and the peritoneal
cavity
was found to contain
about
a pint of gastric
contents
well distributed
throughout
the abdomen.
This was aspirated
and the
duodenum
and anterior surface of the stomach inspected for the perforation,
but
nothing
was found.
During manipulation
of the stomach, gastric contents were
noted entering the greater peritoneal
cavity
through
the epiploic
foramen.
The
lesser omentum was incised to enlarge the foramen and a large quantity
of gastric
contents rushed forth.
An exnloring hand could feel the ulcer on the posterior sur
face of the stomach, far to the left and nearer the greater curvature than the lesser.
It was decided that a better approach could be made through
a left rectus incision,
so this
was made.
The omental
bursa was entered through
an incision
in the
greater omentum
and the posterior
surface of the stomach
delivered
into view.
An oval perforation
3 by
10 millimeters
was found on the posterior surface about
6 centimeters
from
the cardia.
Its
edges
were approximated
by
a continuous
running suture, and the abdomen was closed with drainage.
Postoperative. —The day
following
operation
his
general
condition
appeared
very good, but from the second postoperative
day he showed signs of a gradually
increasing toxemia.
A copious, foul-smelling,
purulent discharge from the abdom
inal wound
developed.
Despite
daily
administration
of 3,000
cc of
10 percent
578
LESIONS
OF
STOMACH —CARROLL,
glucose in physiological
saline by vein, duodenal
suction,
digitalization,
and the
oxygen tent, his toxemia progressed and he died on 1-28-38.
Autopsy. —Excerpts
from the autopsy report follow: The left lung has partially
collapsed and the left pleural cavity contains approximately
200 oc of thin purulent
fluid, pale green in color.
There is a plastic exudate on the superior surface of the
left leaf of the diaphragm.
The peritoneal cavity
is universally
infected.
Coils of
intestines
are adherent
to one another
by recently
formed adhesions
and many
pockets of thin
greenish purulent
fluid are present within the coils of intestine.
The posterior surface of the stomach shows a recently closed perforation
which
is
covered by a plastic exudate and is closed by sutures.
On removing the stomach
and opening it, there is seen to be a large ulcer, triangular
in shape, measuring
1%
inches on each
side.
The base
is shallow
except at one point
where the above-
mentioned
sutured
perforation
has occurred.
The edges
of the ulcer are some
what elevated but are not firm or dense.
The shallow unperforatcd
portion of the
base of the ulcer also lacks the firm fibrous feel of an old ulcer.
Microscopic
report. — Microscopic
sections of the stomach through
the edge of
the perforated
ulcer
show the gastric
mucosa to
be
composed of mature
adult
epithelium
with no evidence of neoplasm.
The outstanding
feature of the process
is inflammation
and a very moderate amount
of fibrosis.
Anatomic
and micro
scopic
diagnoses:
1.
General
peritonitis.
2.
Bronchopneumonia.
3. Pleurisy
with
exudation.
4.
Gastric
ulcer,
with
perforation.
5.
Parenchymatous
de
generation of liver and kidneys.
Tumor,
mixed,
malignant
(adenocarcinoma),
of greater
curvature
of stomach.
Case
2.—R. L.
S.,
naval
officer, was admitted
on
10-15-37,
complaining
of
feeling weak and "run down,"
of pains in upper left quadrant
of abdomen,
and
of the loss of 18 pounds in weight during
the past 18 months.
History. —His pain started in May
1936; it was
never severe,
did not radiate,
and
had
no relation
to meals or foods eaten.
Shortly
after its onset he under
went observation
and treatment at a naval hospital,
where, he stated, the gastro
intestinal
X-ray examination
revealed nothing
of note, but the gastric
analysis
revealed the absence
of free HC1 in his stomach contents.
He was told to go on
a Sippy diet which relieved his symptoms somewhat.
In August
1936 he suffered
a recurrence and at this time he underwent
study at Letterman
General Hospital
where again the gastrointestinal
series
was negative.
He had had trouble
most
of the time between August
1936 and his admission
here, although
he would
have
occasional periods of a few weeks when he felt quite well.
Occasionally
he would
vomit,
but had not vomited
since June 1937.
He never vomited any blood and
never noticed
any
tarry
stools.
In general
he felt better
on a modified
Sippy
diet, and he noted that any kind
of alcoholic
beverage would
make him worse.
A week before his entrance here he had gone
to the Scripps
Clinic in La Jolla
where an X-ray study of the gastrointestinal
tract had revealed the presence of a
lesion of the stomach.
He had had measles
and chickenpox
in childhood.
His systemic history was
negative with
the exception
of the gastrointestinal
tract.
He had had enteritis
in 1934 while in the Philippines;
repeated search was made at that time and since
for
the
ameba
but
none
were
ever found.
Other
than
this
enteritis,
he had
always had a good
digestion prior to onset of present illness.
His father died of
cancer of the stomach at age 66.
Marital and social history
was negative and his habits were normal.
Physical
examination.-— Only positive findings reported.
Examination
revealed
a rather thin
man of 42 who appeared chronically
ill.
LESIONS
OF
STOMACH
CARROLL
579
Abdomen:
Musculature
is thin,
no definite
point
of tenderness, no masses
or
organs
palpable.
Laboratory findings. —Laboratory
work was done as follows:
R. B. C, 4,520,000;
hgb.,
85%.
W.
B. C,
7,350;
bands,
11; segments,
54;
lymphs,
27;
eosins,
4;
monos,
4.
Urine:
Normal.
Kahn:
Negative.
Stools:
Strongly
positive for occult blood.
Gastric
analysis:
Not repeated inasmuch as he had had one done at the Scripps
Clinic just
1 week before, and this showed no free HC1 after the administration
of histamine.
Blood
sedimentation
index:
20 mm in 60 minutes.
X-ray of the chest: No evidence of metastasis.
X-ray
of the gastrointestinal
tract,
following
barium
meal, was reported
as
follows:
Motor meal, distal
ileum,
cecum, ascending colon,
head
at the hepatic
flexure;
6-hour
residue,
small
amount
in
pyloric
antrum.
Cecum,
normal.
Esophagus,
normal.
Stomach, average size, high position, rugae very prominent.
There is channeling
as the barium
enters the pars cardia.
There is an irregular
filling defect involving
the pars media and cardia
on the greater curvature
side
and anterior aspect which
is brought
out prominently
in Trendelenburg
position.
No
tenderness.
There
is reduced mobility of the fundus.
Pare pylorica
and
duodenum
show normal excursion.
Cap weU visualized, normal size and contour,
fills and empties normally,
not tender.
Serial plates show very prominent
rugae
and
a
questionable
filling
defect,
pare
cardia.
Impressions:
1.
Carcinoma
of
stomach,
pars media and pars cardia.
2. Hypertrophic gastritis.
Clinical record. —All evidence pointed
toward
a tumor
growth
of considerable
size on the greater curvature
near the fundus.
Its position and evident
size and
probability
of extensive metastases to neighboring
glands made its operability
very doubtful.
Reasoning that it might
be a lymphoma
or other radiosensitive
tumor
and
that
in
event
of
later
operation
preoperative
radiation
would
be
advisable,
he was given 2,894.8
"R" units between 10-19-37
and 11-10-37.
On
11-27-37
he was fluoroscoped
following
a barium
meal, and although
there was
evidence
of improvement,
it was decided that
the
case
warranted
exploratory
operation.
Operation.—On 12-10-37,
under spinal procaine anesthesia, later supplemented
with ether, the abdomen
was opened through
an upper left rectus incision.
A
mass about the size of a lemon was found on the greater curvature
near the fundus.
An area of infiltration surrounding
it extended
onto
the posterior
surface and
down to the splenic pedicle.
This mass was excised
widely and the defect in the
stomach closed.
In removing the total area of infiltration,
the splenic pedicle was
so involved
that it was necessary to do a splenectomy.
No involved glands could
be palpated.
The
shock
of
the
operation
was
considerable;
in
fact,
on two
occasions cardiac massage
through
the abdominal
wound, together with artificial
respiration,
had to be resorted to.
He was given 500 cc of blood by the indirect
method while on the table.
Pathologist's report. —Specimen consists of a portion
of the stomach taken from
the greater curvature
near the cardiac end and measures approximately
9 cm in
length.
The wall is greatly thickened, very firm, and presents an ulcerated surface
1.5
cm in diameter
on the mucosa.
The
ulcer
does
not penetrate
more than
0.6 cm.
On sectioning the stomach wall through
this area the tissue is grayish,
mottled
with fat, and the entire wall of the stomach
measures
2 cm in thickness.
The serosal
surface is covered with
normal
appearing
fat.
There
is
a distinct
unpleasant
odor to the fresh specimen.
Microscopical:
Sections
show an ana
plastic
process in which there is marked overgrowth
of the epithelial
cells of the
580
CARBUNCLE
OF
KIDNEY
SARGENT
glandular
tissue.
The cells
are large, show hyperchromatism,
and are infiltrating
the muscularis.
Many areas
are degenerated, not only in the region of the ulcer
described in the gross specimen, but deep in the substance of the stomach as well.
The serosa
is not invaded
by the cells
and the proximal
and distal limits
of the
excision also appear free from tumor cells.
Diagnosis:
Adenocarcinoma,
stomach.
Postoperative. —His
convalescence,
though
stormy,
was uneventful
until
on
the eighth postoperative
day when he became
nauseated, vomited, and disrupted
his wound.
The anterior
surface of the stomach was visible between the edges
of the wound.
No attempt
at
suture
was
made, but
the wound
edges
were
drawn as tightly
together as possible with Murphy adhesive straps and a Scultitas
bandage applied.
The wound
filled
in by granulation.
On
1-4-38
the healing
was hastened by freshening the edges of the wound and suturing
them with silver
wire.
These
were removed
on
1-14-38
and his
convalescence
after that was
uneventful.
Between
1-24-38
and
2-23-38
he
received
2,679.6
"R"
units
of
deep
X-ray
therapy.
He
has gained weight slowly
but
steadily
since being up and about following
operation,
and has no gastric complaints
except that
he has to limit the size
of
his meals—the cardiac portion
of his stomach evidently
not being able to store
a full-sized
meal.
On 4-1-38 the X-ray of his chest was negative for metastases,
and there was no clinical
or physical
evidence of same.
He was invalided
from
the naval
service
on 5-12-38
and will
report
at
regular
intervals
for further
study.
CARBUNCLE
OF
KIDNEY
CASE
REPORT WITH ATYPICAL
SYMPTOMS
By Lieutenant
Commander
W. S. Sargent,
Medical Corps,
United
States Navy
Renal suppuration is usually caused by the colon bacillus,
staphyl
ococcus, or streptococcus.
Bacteria may
be destroyed
in, passed out
through, or lodge in the kidney.
The pyogenic
cocci lodge primarily
in the filter, that is in the cortex,
and especially
the glomeruli, and
are apt to cause
an
acute infection with
an alkaline urine
and very
few other urinary
changes.
The bilateral pyemic
infection with its
multiple
minute abscesses mainly in
the
cortex
and
the unilateral
carbuncle
with its localized
extensive
tissue
destruction
as well
as
perinephric abscess are usually of coccal origin.
The colon bacillus,
like the tubercle
bacillus,
lodges primarily in the medulla and pelvis,
particularly along the collecting
tubules and usually causes a less acute
infection with
an
acid
urine
loaded
with
pus.
The infection
may
spread
to
the
cortex
by
the
lymphatics
along
the
tubules
and
pyelonephritis or even pyonephrosis
may result.
A great
deal has been written
regarding
the routes
of kidney in
fection.
Hematogenous
is the accepted common route and the primary
focus
is usually in the
teeth,
tonsils,
skin, or mucosa
of
the
nose,
mouth, or bowels.
The gonococcus
is the only one that can climb,
as it were, up the lumen.
Ascending infection from the bladder only
occurs if stasis or obstruction is present
and then
the likely route is
up the lymphatics of the wall of the bladder and ureter to the capsule
of the kidney and
then to the blood stream
and back to the kidney,
rather than up the lumen.
Spread
from neighboring organs,
as the
CARBUNCLE
OF
KIDNEY—SARGENT
581
cecum
along
the lymphatics
is hard
to
prove.
Perirenal infection
may come from the
blood
stream
direct or from the cortex
of the
kidney along the cortical lymphatics and through the kidney capsule.
While
a renal
carbuncle
may
develop
in pyelonephritis or kidney
wounds it is most often secondary
to a skin boil, carbuncle,
or felon of
recent
or even remote
date.
In fact the skin lesion may have
been
forgotten
or may
have
been insignificant.
It
is
a
severe,
acute,
unilateral
and
localized
hematogenous
infection
of staphylococcic
origin.
It
is
a
coalescence
of multiple
smaller
abscesses
and it
becomes
a solitary
or conglomeration of larger
and smaller areas of
necrotic tissue separated from the rest of the kidney by a broad zone
of granulation tissue.
The relative freedom
of the urine from pus is
explained
by the destruction of the tubules in the lesion itself and the
intact condition of the glomerulotubular units at the periphery.
It
may interfere but little with renal function since it is circumscribed
and walled
off.
It may spread
to the perirenal tissue and then up
wards, downwards, or toward the abdominal cavity.
Renal carbuncle
may heal and not be recognized.
It may be found
at operation done for something
else; or it may be found only at
autopsy.
It may be insidious in on-set and if mild may even simulate
a tumor, especially
if it is large and
there is resistance
and fixation
on palpation.
Severe
cases may become very toxic or die
Most cases at the on-set have acute lumbar pain which may radiate
to the testicle or thigh; the latter often simulating hip disease.
On-set
may be sudden with chills, sweats, weakness, prostration, malaise, sep
sis, enlarged and tender kidney, and even intermittent fever.
The white
blood count and polymorphonuclears are increased.
The urinalysis
early may be nearly negative,
but later may show staphylococci and
some pus.
Local tenderness over the kidney may be the only positive
finding
and
the kidney may be fixed
and not palpable.
Perirenal
extension
is what usually gives
the reflex symptoms.
It is often mistaken for influenza,
infectious fevers, sepsis, pleurisy,
Pott's disease
and
intra-abdominal
conditions such
as appendicitis,
gall bladder disease, and ruptured ulcer.
Little help is obtained from the urine, X-rays, cystoscope, or ureteral
catheter although in some
cases
a pyelogram
may show distortion.
Signs and symptoms
of sepsis and kidney involvement such as dull
pain
and costovertebral tenderness
suggest staphylococcic infection
of the kidney.
Mild cases get well without operation but if one suspects staphy
lococcic infection of the kidney in a case that is not doing well, it is
better to explore.
Many operative procedures
have been tried such
as open drainage,
puncture and drainage,
resection,
partial
excision,
decapsulation,
nephrotomy
and
nephrectomy.
If
there
is
also
perinephric
suppuration it is
perhaps
better to just
drain
and
do
582
CARBUNCLE
OF
KIDNEY—SARGENT
nephrectomy
later,
if
necessary.
Nephrotomy
in early
cases
may
suffice for some but on
the whole
nephrectomy
is the operation of
choice,
and
especially
so in late cases
Occasionally an emergency
nephrectomy
is necessary
to save life.
Case Report
Adult male admitted
to hospital
September
28,
1937.
Chief complaint. —Pain in right upper abdomen.
Family history.- — Negative.
Past
history.— Appendectomy
14
years
ago.
Tonsillectomy
12
years
ago.
Lues about
15 years ago,
and his Kahn
is now negative.
For
2 months
he
has
been
bothered
off and
on with back
ache
which
he refers to the lumbar region
on each
side.
It occurred more after working.
Present
illness. — Began
September
20.
While
he
was painting,
he
became
nauseated, but had no vomiting,
colic, or diarrhea.
Next morning
he developed
a pain in right
upper abdomen which was also noted to run through
to the back
on the right
side.
The pain was dull, constant and made worse by any form of
body movement.
He thought
he had developed stomach trouble
so he went on
a fruit diet.
No jaundice or colic occurred at any time.
He has fever but no chills or sweats.
There
was
no
discomfort
on urination,
but
he
noted
he had to urinate
more
frequently
than formerly.
He had had a boil on the nose about
1 month
before; in fact
he has had boils
quite frequently
in the past.
Physical
examination—
Skin
was
clear, it
was free of
infections,
boils, and
jaundice.
Head
and
neck:
About
one-half
of
his
teeth
were missing,
and
several
of
those remaining
were
diseased.
The nose was then normal and his tonsils
were
gone.
Chest:
Normal.
Abdomen:
There was tenderness, rigidity, and rebound pain in the right upper
abdomen extending around
to the lumbar
area.
A mass
was felt about the size
of an orange at the gall bladder
area.
The rest of the physical
examination
was
normal.
Temperature
of
100.4°
F.;
pulse
90;
respiration
20
upon
admission.
The
urine showed no albumin;
no red blood cells; sugar a trace, and quite a few white
blood
cells.
The WBC
was
17,500,
with
3 juveniles,
17
band
forms, and
67
segmented cells.
Operation.—Operation
was done through the abdomen where it was found that
the gall bladder, duodenum, hepatic flexure, and kidney
were
one adherent
mass
and upon being separated, odorless pus was found above the kidney
and in its
upper pole.
A nephrectomy
was done, drainage inserted, and abdomen
closed.
Postoperative.— He
ran
a fever of
100°
to
102"
F. for
11 days
and
it
then
slowly
returned
to normal.
Drainage
was profuse for about
a fortnight after
which it gradually
lessened
and has now nearly stopped.
October
1, 1937.
Urine showed pus but no blood.
October
4, 1937.
Urine showed pus and occult blood.
October
9, 1937.
Urine showed pus and occult blood.
His urine is now gradually
clearing of pus.
The laboratory
report of the tissue
was as follows:
There is inflammation
of the tissue involving
the kidney substance;
it varies in different
areas
from the acute with
pus to the chronic with fibrous
thickening
and distortion
of normal structure.
There
is no neoplasm or chronic
granuloma.
NAVAL
RESERVE
PROMOTIONS,
SECOND
QUARTER,
1938
Douglas
B. Bell,
735 Bishop
Street, Honolulu,
T. H., promoted
to lieutenant,
MC-V (S), U. S. N. R., April
18, 1938.
Wyman Wilson
Harden,
c/o Florida National Bank
Building,
St. Petersburg,
Fla., promoted to lieutenant,
MC-V
(G), U. S. N. R., May 2, 1938.
Frank Weger Konselmann,
3638 North Twenty-first Street, Philadelphia,
Pa.,
promoted
to lieutenant
commander, MC-V
(S), U. S. N. R., May 3, 1938.
Dar Delos Stofer,
1414 Professional
Building,
Kansas
City, Mo., promoted
to
lieutenant
commander, MC-V (S), U. S. N. R., May 3, 1938.
Ferdinand
Christian Helwig,
4422
Mill
Creek
Parkway,
Kansas
City,
Mo.,
promoted
to lieutenant
commander, MC-V
(S), U. S. N. R., May 3, 1938.
Thomas
Francis
Welsh,
923 Boston
Building,
Salt Lake City, Utah,
promoted
to lieutenant,
MC-V
(S), U. S. N. R., June 7, 1938.
RESIGNATIONS,
SECOND
QUARTER,
1938
Clarence
E.
De
La
Chapelle,
Bellevue
Hospital,
Third
Medical
Division,
Twenty-sixth Street and First Avenue,
New York City, N. Y., lieutenant
com
mander, MC-V
(S), U. S. N. R., resignation
accepted April 28,
1938.
Edward D.
Hoedemaker,
706
Medical
and
Dental
Building,
Seattle,
Wash.,
lieutenant,
MC-V (S), U. S. N. R., resignation accepted April 28, 1938.
K.
G. Cooper,
Metropolitan Building,
Denver,
Colo.,
lieutenant,
MC-V
(S),
U. S. N. R., resignation
accepted April 28,
1938.
M. B. Wilson,
30 North Michigan
Avenue, Chicago,
111., lieutenant
commander,
MC-V (S), U. S. N. R., resignation
accepted April 28,
1938.
Oscar J. Raeder,
270 Commonwealth
Avenue,
Boston,
Mass., lieutenant
com
mander, MC-V
(S), U.
S. N. R., resignation
accepted April 28,
1938.
Asa
Elmore
Seeds,
2120
South
Monroe
Street,
Spokane,
Wash.,
lieutenant,
junior grade, MC-V
(S), U. S. N. R., resignation accepted June 2, 1938.
Oscar Oswald Miller, 2321 Alta Avenue, Louisville,
Ky., lieutenant
commander,
MC-V
(S), U.
S. N. R., resignation
accepted June 2,
1938.
Roy Glen Spurling,
2601 Tophill Road, Louisville,
Ky., lieutenant
commander,
MC-V (S), U. S. N. R., resignation
accepted June 2, 1938.
Nils O. Byland,
Battle
Creek Sanitarium,
Battle
Creek, Mich., lieutenant
com
mander, MC-V (S), U. S. N. R., resignation accepted June 25, 1938.
HONORABLE
DISCHARGES,
SECOND
QUARTER,
1938
William Henry Collis,
603 Medico-Dental
Building,
Stockton, Calif., lieutenant,
junior grade, MC-V (G), U. S. N. R., honorably
discharged June 2, 1938.
HONORARY RETIRED LIST,
SECOND
QUARTER,
1938
William Curtis
Newton,
2504
San
Marcus
Avenue,
San Diego,
Calif., com
mander, MC-V (G), U. S. N. R., transferred to honorary retired list June 15, 1938.
DEATHS,
SECOND
QUARTER,
1938
Jennings
Mead
King,
512
Hastings
Street,
Pittsburgh,
Pa.,
lieutenant
com
mander, MC-V (S), U. S. N. R, died April 9, 1938.
583
NOTES AND COMMENTS
THE
NAVAI
MEDICAL
CENTER
A long step forward has been achieved
in the selection
of a site.
On the fifth of July President Roosevelt, accompanied
by Admiral
Rossiter
and Captain Mclntire, visited the proposed
site in Mont
gomery County, Maryland.
They were so impressed with the beauty
and suitability of the place that they were unanimous
in their decision
to build there.
Mr. Paul Cret is the consulting architect.
Many bridges,
build
ings, and monuments
designed by him are already
regarded
as among
the most perfect in Washington.
He visited the ground with Admiral
Rossiter
on
the
thirteenth
of July
and
was
delighted
with
its
possibilities.
The
site
chosen is just
outside
Bethesda,
on the Rockville
pike,
which is the main highway between Washington and the west.
There
are approximately 230 acres of slightly rolling ground,
with a beauti
ful stand of first-growth timber on about one-third of it.
For 2,300
feet it fronts on the Rockville
pike,
and it runs back to Rock Creek
parkway
and
the Columbia
Country
Club.
About
300
feet
back
from
the pike is
a gentle
rise,
on which the
main
hospital will
be
erected.
Directly
across from
it,
the Public Health Service
is
erect
ing the National Health Institute
and the Cancer Research
Institute.
This appears to be the beginning
of
a
considerable
medical
center in
that neighborhood.
No matter who may be in the saddle when the structure
is
finally
completed,
the credit for its existence
will go to Admiral
Rossiter,
our
present
Surgeon
General,
whose
pet
enterprise
it
has been for
several
years.
Only through his persistent
support and enthusiasm
has
it
been
possible
to bring the project through the numerous
rocks
and shoals which blocked its path, to
a
point where its eventual
com
pletion
seems
assured.
The
accompanying
illustration
is
appro
priate, since
it
shows Admiral
Rossiter viewing
one of the proposed
designs for the Naval Medical Center.
NAVY
EXHIBIT
AWARDED
SPECIAL
CITATION
OF MERIT
Under
the
supervision
of Capt.
G. E. Thomas,
Medical
Corps,
United
States
Navy,
the Medical
Department
presented
an exhibit
at the annual meeting
of the American Medical Association held in
San Francisco in June 1938.
This exhibit illustrated medical
equip
585
58G
NOTES
AND
COMMENTS
ment
and practice
in naval training schools, hospitals, aviation, sub
marine,
and Marine Corps.
The success of this display is evidenced
by 6,940 visitors to the section during the 4-day session and the As
sociation's award
of a special citation of merit to the exhibit.
The
exhibit was not eligible
to compete
for a certificate
since
a similar
exhibit won that distinction in 1937.
A three-wall section with 20 by 28 feet floor space was allotted to
the
Navy
for exhibition
purposes.
The
Making
of
a Blue Jacket
was illustrated
on one wall.
This illustrated
percentile
selection
of
candidates,
causes for rejection and demonstrated
the number chosen
for duty
as
seaman,
hospital corpsmen
or for preparatory
schools,
indicating reasons for choice in these various fields.
On the end wall were mounted
photographs
of airplane carriers and
airplanes.
There were also two parachute
packs,
one of the combat
type
and one of the transport type; on the ledge below was an open
parachute
of the combat
type.
The south wall showed
photographs
of the new X life preserver
and the rescue dome for emergency
fires
or gas attacks on the surface of the water.
Six Munson lungs showed
the development
of that mechanism
from its origin to present
stage.
A large
plaque
of photographs
gave internal and
external
views
of
the San Diego Naval Hospital
and
a large map tabulated to photo
graphs
showed
the location and exterior
views of various base hospi
tals
of the United
States
Navy.
On the ledge
below
this
were
ex
hibited a still for the manufacture of fresh water from salt water,
the
old life belt and new X life belt,
and a regulation Munson lung for
workable demonstration.
The central
table
held
a scale model of the submarine
rescue bell
and on the floor before it was an auto-inflating, two-person
life raft.
On opposite sides of the table were two mannequins
dressed in helmets,
goggles, automatic life belts
and flying suits; one showing
summer
equipment,
the other the heavier winter paraphernalia.
To one side,
a third figure illustrated the one-piece aviation wading suit.
AUTOPSIES
A series of articles
on the autopsy appeared in Hospitals, which is
the official journal
of
the American Hospital
Association, for June
and July.
These articles throw light on the subject from many angles
that are not generally
appreciated
or understood.
Since
this peri
odical is not available to many medical
officers of the Navy,
some of
the more important points are abstracted
here by Capt. Lucius W.
Johnson, Medical Corps, United States Navy.
The medicolegal
autopsy may be defined as a postmortem
examina
tion which brings to light findings that may have
a bearing
upon
proposed or actual civil litigation or upon
a suspected or actual crimi
NOTES AND
COMMENTS
587
iial or negligent act.
The autopsy may be a routine hospital necropsy;
if it yields information that has a bearing
on a claim for insurance
or
compensation
it assumes a medicolegal
aspect.
No especial
problems
are presented by those cases in which infor
mation
obtained by postmortem
examination has
a
bearing
upon
civil
litigation.
Such information
is not privileged.
The
medical
examiner who acts in place of the coroner requires no permission
from
the next
of kin for the performance
of an autopsy.
The physician
should not assume
the responsibility of signing
a death
certificate
if called
to a dead or dying person whom he has not previously at
tended.
Such a case should
be referred
to the coroner.
The bitter criticism of physicians
and hospitals
which occasionally
emanates
from funeral directors
results from a lack of understanding
that the embalming
profession
presents
numerous
peculiar problems.
Most physicians feel that it is merely
a matter of draining the blood
from the body and injecting a fixing solution into the arterial system.
The funeral director must,
of necessity,
maintain
a more spiritual
attitude toward death
and burial.
He must
prepare
a body for the
close inspection
of perhaps hundreds
of mourners.
Destruction of the
circulatory
system
by autopsy
may
make
this impossible,
and
the
wrath of the people may be visited upon the undertaker.
Four post
mortem activities of greatest importance which counteract
the efforts
to
reproduce
a lifelike
appearance
are impairment
of circulation,
rigor mortis, livor mortis, and discoloration from decomposition
and
gas formation.
Time is often of greater importance
in the production
of these difficulties than even the most glaring mishandling.
When
bodies
are to
be
shipped
these
changes
become
more
pronounced.
Most embalmers
protest against
the custom
of putting a body into
the ice box while waiting the convenience
of the autopsy physician.
This produces
intravascular
clotting
and other changes which may
make it impossible
to do a good job of embalming.
Immediate injection of the arterial system is now done quite gener
ally,
the remainder
of the preparation being done after the autopsy.
The pathologist
has
certain
objections
to
this.
An autopsy
goes
beyond
clinical
diagnosis,
and frequently
reveals
disease
processes
which
were
unsuspected
before
death.
Bacteriological
studies
are
impossible
if embalming
has been done.
The characteristic color of
organs
is changed,
and
poisons
may be disguised.
The
smell
of
cyanide
poisoning
and
disturbances
of
pigment
metabolism
are
hidden.
Embalmed
tissues
may not
react
properly
to
the usual
staining and fixing solutions.
Another aspect of the time element is that the funeral director and
his men are often kept waiting for a considerable
time for the body,
and this also delays obtaining the death certificate.
588
NOTES
AND
COMMENTS
Repair of the body after autopsy
is an important matter.
During
the life of the patient,
no
careless
procedure
would
be condoned.
Death does not release the physician or the hospital from this obliga
tion.
The
Y-shaped
incision
should
be used.
If the upper limbs
of
the
Y are carried up to
the shoulders
it permits
the neck
and
mandible
to
be
examined
without
any local
scarring.
The
scalp
incision preparatory
to removing the brain should never
be made
without
considering
the shape of the head and the amount of hair.
In a scalp with insufficient hair to hide the incision, it should
be far
enough back so as to be invisible from the front.
Use are in choice of
suture
material.
Heavy
cord
is not suitable for
the
scalp
or for
incisions that cannot be entirely concealed.
Number 0 cotton thread
of the appropriate shade is better and can be used with intercuticular
stitch to make an almost invisible suture.
The work
of
the embalmer
is greatly facilitated if cannulas
are
inserted
into the cut ends of the major arteries,
with rubber tubes
connected
with them
and leading
to the outside
of the body.
The
internal
mammary
arteries
should
be
tied
routinely,
to
prevent
leakage of embalming
fluid into the chest.
As a general
rule,
embalmers
do not wish to have the viscera re
placed.
If an eye has been removed,
a very satisfactory substitute
can be made from paraffin.
It is inserted
from behind
after the lids
have
been sutured with
fine silk.
After
drying
the
inside
of
the
thorax and abdomen,
both cavities
should
be sprinkled with harden
ing
compound.
The
cavities
are
then
filled
with
cellucotton
or
crumpled clean paper towels.
Relations between
the pathologist and the undertaker are rendered
more cordial if a note accompanies
each body upon which an autopsy
has been performed.
The note should
apprise
the undertaker of the
efforts which have been made to cooperate with him and should urge
him to communicate
at once with the pathologist in the event that the
repair
has
not
been
satisfactory.
Courtesy
and
cooperation
are
usually reciprocated,
and it is to the interest
of every pathologist to
establish
cordial relations
with the undertakers.
Religious aspects of the autopsy,
if ignored,
may cause the loss of
many
cases.
The Jewish,
Catholic,
and Protestant rituals contain
mandates
which, if strictly
observed,
might be interpreted to forbid
autopsies.
But when
the autopsies
are meticulously
performed
by
specialists
who
never
overlook
the
interests
of
the
dead
and
the
survivors the injunction
may be laid aside.
There seems to
be far
greater
prejudice
among
Jews
than
among
other
religions
against
autopsy.
According to Jewish law, it takes
7 days to become clean
after touching a body.
Under the Jewish rabbinic law autopsies
are
permitted when
they
may
be an honor to the deceased or when
a
human life can be saved
thereby,
but not for purely experimental
NOTES AND
COMMENTS
589
purposes.
If it can be represented that another
person in the hospital
is suffering from the same disease as the deceased, and the cause of the
disease
and its treatment may be discovered
through the
autopsy,
permission can very
often
be obtained.
In nonsectarian
hospitals
the percentage
of
autopsies
on Jewish
bodies
is very low,
but in
Jewish hospitals it may be high.
The method
of approach
is impor
tant, and Jewish interns have a better appreciation of the psychology
of their own people,
so they are more successful in obtaining permis
sion.
The matter can be pictured to the relatives
as a religious
duty
to the community, offering
an opportunity
to the individual,
oven in
death,
to further the well being of the people.
The Catholic
religion does not prohibit
autopsies.
In fact there
is considerable
evidence of the interest
and cooperation
of the church
in the matter of postmortem
examination.
St. Francis is quoted
as
feeling privileged
to
offer his body, both living
and
dying,
a self-
humiliation
and self-sacrifice
to be carried out after his death, and he
begged his tutor to see that his body was given into the hands of the
surgeons
for
dissection.
This is
an
example
which
others
can
be
urged
to
follow.
In
some
Catholic
hospitals
the
sisters
play
an
important part in securing consent for autopsies.
Protestant
religions
provide
no
interdictions.
Respect
for
the
body is required,
but its destructibility is acknowledged.
Pseudo-religious tabus
are common.
The superstitious fear of the
body
may
influence
the ignorant,
causing
a reluctance
to permit
a
procedure
which might be distasteful to the deceased.
In medieval
times dissection
was limited to the bodies of criminals
and this tradi
tion may serve to suggest a reflection
on the character of the deceased
if autopsy be permitted.
Most laymen still believe that an autopsy
must be performed
on every
executed
criminal.
The great barriers
are seen
to be custom
which wrongly presupposes
interference
with
the ceremonial
of interment; prejudicial
tradition
which
associates
autopsies
with the stigma of crime; and sentiment,
which is unable
to
disassociate
the
inanimate body from the vital
personality of the
departed.
Success in obtaining permission
is directly proportional to the effort
and intelligence
put forth in trying to obtain them.
It must be a care
fully planned
program
in which the entire hospital personnel
is edu
cated to take a part.
Three fundamental objectives are to be attained.
First, the hospital must have the respect, confidence,
and good will of
the family of the
deceased;
second,
every
member
of the hospital
personnel
must
be convinced
of the value
and importance of autop
sies, and they must all work together
to obtain as many of them
as
possible;
third, the actual solicitors must be well
trained
in the tech
nique of making the request.
Whoever solicits the
autopsy
should
have
had contact with
the
family before the death of the patient and should be familiar with the
590
NOTES
AND
COMMENTS
details
of the case.
He should
be
a loyal supporter of the autopsy,
because a half-hearted appeal not backed by a firm conviction of the
humanitarian
and
scientific
value
will fail.
Telling
of an autopsy
upon the body of a noted physician or a member of his own family
does much to convince
the laity of its importance.
In most hospitals
the request is made by the interne, but he should have the backing and
encouragement
of his superiors.
The idea of the importance of the
autopsy should be sold to all internes when they first enter the hospital
for training, and they should be carefully trained and coached in the
technique
of making the request.
Each attempt should be followed
by a report stating his success or failure.
Requesting
an autopsy before
death
is justifiable
and
successful
only under very rare circumstances
such as long, chronic illness, uncon
sciousness of the patient, or the anticipated absence of the family at
the end.
The request is best made
15 to 30 minutes
after the death.
This gives the relatives
time to recover somewhat from the shock, but
will be before they leave the hospital.
It should
be made in a quiet
room, at some distance from where the patient lies, and should be made
direct to the next of kin, with as few others present
as possible.
It is
always
inadvisable
to
make
the request in the presence of the dead
or in the hospital corridor where there may be interruptions.
There
should
be no appearance of haste or coercion.
They may be asked if
they
would like to have
an autopsy performed,
stating that it is a
courtesy
offered by the hospital at no additional expense, causing very
little additional delay,
and usually gratefully accepted by relatives.
It is important
to present
the subject as a favor to the family.
In
some instances
the possibility of protection for other members of the
family may be mentioned.
The advisability of an autopsy as an aid in
collecting insurance
or compensation
may
be brought out, and it is
well to mention
the advantages
of having the examination conducted
by the unbiased
hospital pathologist rather than by one selected
by
the insurance
company.
It is usually useless to speak of the advan
tage to humanity or the contribution to the advancement
of science.
It is well to promise
the family a report of some kind, but it is not
well to send a copy of the official protocol because its unfamiliar terms
confuse and may antagonize
them.
A report in the form of
a simple
letter in plain terms is better, but should not be routine because it may
be used as the basis of a malpractice suit against
the attending physi
cian.
Best of all is a tactful interview with
the next of kin or the
strong member of the family.
There are certain stock objections which one should
be prepared
to
meet by having answers ready.
Among the most common
are: Dis
figuration of the body; mutilation of the body; he has suffered enough ;
let someone else have it done; he would not have wanted it; this is not
an unusual
case ; cancer is hopeless anyway ; our religion does not per
NOTES
AND
COMMENTS
591
mit it; it will not bring him back; we do not care what he had; etc.
The only fair way to obtain permission
for autopsies is by fair, logical
argument.
SUKGICAL KNOTS*
Because
of the disadvantages
of absorbable
sutures,
there has been
a noticeable
trend back toward the nonabsorbable
materials.
Taylor
was of the opinion that the occasional
untied knot was the result of
carelessness,
and
that all carefully
tied
square
and
surgeon's
knots
stayed tied.
But, at the conclusion
of this study, the startling feature
seemed to be that so many knots stayed secure, that there were so few
failures.
He devised
an apparatus
for testing knots, wet in various fluids or
dry, with or without tension, and with or without friction.
Plain gut,
of the nonboilable type, when
tied wet were found to be most unde-
pendable.
A reliable knot
could
be
tied
only
when
dry.
Square
knots
tied with chromic gut held much better than the plain gut.
Surgeon's
knots were
much
less dependable
than the square
knot.
Silk and linen showed very few failures.
The triple-throw knot, all
turns tied square was found the most reliable.
Tests of the coefficient
of friction were surprising.
Silkworm gut,
dermal,
and
the
strong,
hard twist
of silk
showed
no
increase
of
friction
value
after they had
been soaked in serum.
On the other
hand,
the coefficient
of friction
on linen and standard surgical
silk
increased
two and three times when wet in serum.
This means that
a knot tightly tied will stay, but it also means that the increased fric
tion may prevent pulling the knot tight.
Plain
gut increased
80
percent
in friction
value when
wet,
and
chromic gut was more than doubled.
This is one reason why chromic
gut knots are more
reliable.
Cutting
the suture
ends shorter than
5 mm for gut and 3 mm for linen or silk is a distinct hazard to the knot.
INFLUENZA
»
This extensive report is based on correlated
clinical and laboratory
investigations made on epidemics
of respiratory disease diagnosed
as
influenza during the years
1935-37.
Definite
diagnosis
is still
quite
impossible,
clinically, in mild and
sporadic cases.
There is no single sign or symptom pathognomonic
of epidemic
influenza.
However,
the disease
does
present
features
which permit a probable clinical diagnosis
during a major epidemic.
The diagnostic
problem
is complicated
by the common
association
of
a bacterial infection with the virus disease.
The fulminating
pneu-
I Taylor. F. W., Annals of Surgery,
107: 458, March 1938.
» Report
of the Medical Research
Council;
a study
of epidemic
influenza
with special reference to the
1936-37epidemic.
Special
Report
Series, No. 228.
86860—38
10
592
NOTES AND
COMMENTS
monia
seen in influenzal epidemics
is almost certainly due to staphy
lococcus
aureus
associated
with
the
influenzal
virus.
Moreover,
recent experimental
work has supported
early observations
that infec
tion with the pneumococcus
is particularly
severe in cases that have
recovered from influenza.
Apparently
the influenzal infection has no
direct influence in the development
of the pneumonia
but it does lower
the
body
resistance
to
pneumococcal
infection
during
the
post
influenzal
period.
Positive diagnosis of influenza virus as the etiological factor in epi
demics and as a factor in complicated
and sporadic
cases must depend
upon laboratory identification of the virus.
This is still a clumsy and
costly procedure.
Study
of an
epidemic
is further complicated in
that influenza is so erratic in its appearance,
so capricious
in attack
and lasts for such a short period in any one locality.
Recent advances
in diagnostic
methods,
using
mice and chick embryos,
may simplify
the problem
somewhat.
However, the problem
has been complicated
in that recent investi
gations
have
demonstrated
strains
of
the
virus
and
they
are not
identical in reaction.
The number of strains
is still unknown and the
degree of cross immunity
developed
by heterologous
strains
is under
investigation.
Some
cross immunity
is
developed,
but
the
virus-
neutralizing
potency
of
a serum
for
a homologous
strain
does not
represent
even
a crude
measure
of that serum's
virus-neutralizing
potency for a heterologous
strain.
This proof of the presence of a multiplicity
of strains conferring an
indeterminate
cross
immunity
is
of major
importance.
It
makes
experimental
work prior to this discovery subject to critical review.
It complicates
the problem
of prophylactic
vaccination both as to
evaluation of post
results
and
as
to developing
a method
of active
immunization for the multiple strains.
Fortunately
there are benefits
that may result from this discovery.
The epidemiologist
may be able
to
employ
the identification
of strains
to
advantage.
Also,
these
strains
may explain
experiments
in which vaccination failed
to confer
protection.
ANNUAL
SESSION
OF
THE
AMERICAN
COLLEGE
OF
PHYSICIANS
The twenty-third
annual
session of the American College of Physi
cians will be held in New Orleans,
with general
headquarters
at the
municipal auditorium, March
27-31,
1939.
Dr. William J. Kerr, of San Francisco, is president
of the college and
will have
charge of the program
of general
scientific
sessions.
Dr.
John H. Musser, of New Orleans, has been appointed
general chairman
of
the session
and will be in charge of the program
of clinics and
demonstrations
in the hospitals
and medical
schools and of the pro
gram of round-table discussions
to be conducted
at the headquarter
.
BOOK
NOTICES
Publishers
submitting
books
for review are requested
to address
them as follows:
The Editor, United
States Naval Medical Bulletin,
Bureau of Medicine and Surgery, Navy Department,
Washington,
D. C.
Suboical. Treatment,
by
James
Peter
Warbasse,
M. D.,
F. A.
C. S.,
special
lecturer
in
the
Long Island Medical
College,
formerly
attending
surgeon
to the
Methodist
Episcopal
and the Wychoff Heights Hospitals,
Brooklyn,
N.
Y.,
and
Calvin Mason Smyth, Jr., B. S., M. D., F. A. C. S., assistant professor
of surgery
in the Univeristy of Pennsylvania
Graduate School of Medicine, surgeon in chief to
the Methodist Episcopal
Hospital,
Philadelphia,
Pa., visiting surgeon
to the Abing-
ton Memorial
Hospital,
Abington, Pa.
In three volumes with 2,486 illustrations
on
2,237
figures,
some
in
colors.
Second
edition.
Thoroughly revised
and
reset.
W. B. Saunders Co., Philadelphia
and London,
1937.
Cloth,
$35 per set.
Twenty years ago James Peter Warbasse,
of New York, gave to the
practitioner
and student of surgery
a practical yet complete
guide
for the treatment of surgical disease.
The work was
dedicated
to
the surgical patient.
Matured
advice
and practical
treatment for
nearly
every
surgical condition
occurring
under
any
circumstance
were made readily accessible and understandable.
The work rapidly
earned
an enviable
reputation and the first edition exhausted several
reprints.
Now Dr. Warbasse,
in collaboration with Calvin
Mason
Smyth, Jr., of the University
of Pennsylvania
Graduate School
of
Medicine,
presents
the second edition of Surgical Treatment.
It is a
pleasure
to note that the general plan of the original work has been
retained, although complete
revision has been carefully
carried
out.
The work is in three volumes,
with
a supplementary general
index.
Intracranial
damage has been stressed in head injuries.
The surgery
of the
thyroid gland has
been completely
rewritten, and the detail
steps for subtotal thyroidectomy clearly pictured.
Thoracic surgery
is
discussed
briefly but in keeping
with
recent
brilliant
advances.
Abdominal
surgery
includes
the
use
of the Wangensteen
siphonage.
Cholecystectomy
is
considered
the
treatment of
choice
for
acute
cholecystitis but a rational basis for the time of intervention is out
lined.
The
section
on Bones
and Joints is invaluable ; at least one
method has
been
given
in detail for
every
known fracture.
The
subject of acute osteomyelitis is still considered
urgent
operative
sur
gery
and
delayed
surgical
intervention
a grave
surgical
sin.
For
593
594
BOOK NOTICES
blood
transfusion,
the indirect citrate method
is favored,
although no
mention is made of the late trend toward blood banking.
The section
on Anaesthesia
has been revised,
spinal anaesthesia
is discussed
in
detail but without
the force of mature
judgment so richly displayed
in other sections.
On the whole the work is a safe, compact, masterly
written treatise on the therapy of surgical
disease.
Surgical Diseases of the Mouth
and
Jaws,
by Earl
Calvin
Padgett,
B.
S.,
M. D., F. A. C. S., Associate Professor of Clinical Surgery, University of Kansas,
Kansas
City, Kans; Associale Professor of Oral Surgery,
Kansas
City
Western
Dental
College,
Kansas
City,
Mo.
790
pages.
334
illustrations.
W.
B.
Saunders Co.,
1938.
Philadelphia
and London,
1938.
Price,
$10.
Here is a most attractive book on a subject of very great importance.
When supplemented
by the lectures of the author, it should
prove a
valuable
guide
for
the
members
of his
classes.
For general
uses,
however,
it presents
certain defects which are, perhaps, inherent in
first editions of text books.
Certainly, they are unavoidable in a book
which, like this,
is designed
to fit the needs of the dental
student,
the medical
student,
the general
dentist,
the physician, and
the sur
geon.
To be acceptable
to all these groups,
a volume must contain
complete
elementary
matter, as well
as the most
advanced
technical
details, really too much to ask of a single volume.
As one result, many
subjects
are lightly touched
upon which should be entirely ignored or
else given
sufficient
space to allow for useful instruction.
Every duck hunter knows that, if you aim at a whole flock of ducks
you will get none.
To bring home
the meat you must concentrate
on a single
bird.
So the author's efforts
to adapt his book to
the
needs of many unlike groups
produces
certain glaring defects.
For
instance,
the instructions for extracting teeth,
unnecessary
for the
dentist,
are woefully inadequate
for the physician or surgeon.
After
reading
the paragraphs
on phenol,
mercurochrome,
and Dakin's
solu
tion, one might reasonably
conclude that the indications for one were
the same as for either
of
the others.
The method
described
for ap
plication of Dakin's
solution was discarded
by Carrell prior
to our
entry into the late war.
The bibliography is elaborate
and quite complete
so far as literature
prior to
1920 is concerned,
but references to publications within
the
last
10 years are relatively few.
Much
space is devoted
to methods
and appliances
used in the nineteenth
century which might better be
given
to developments
of the last few years.
One is led to suspect
that the author is gifted
with
a bent toward historical research,
for
an enormous
number of articles
appearing
in the last few years have
apparently escaped his notice.
Despite these rather meticulous
criticisms, an ambitious project has
been accomplished
in a praiseworthy manner,
and this book will find
a worthy place beside its few predecessors in this field.
BOOK
NOTICES
595
Practical Proctology, by Louis A. Buie,
A.
B., M.
D., F. A. C. S., Head of
Section on Proctology, the Mayo Clinic; Professor of Proctology, the Mayo Founda
tion,
etc.
493
pages.
152 illustrations.
W.
B.
Saunders
Co.,
Philadelphia,
1938.
Price,
$6.50.
There is such
a plethora of useful, practical, and interesting state
ments in this volume that the reviewer
can only record his general
admiration of the work and then touch lightly on a few high spots.
Preoperative purgation is deprecated,
and
the opinion is fortified
with substantial
reasons.
Sacral
block
anesthesia
is
preferred
for
rectal and anal surgery.
General
anesthesia is not considered suitable.
Certain
types of hemorrhoids are definitely surgical,
while others
just as definitely are better
treated by injection.
Thirty
pages
are devoted
to chronic ulcerative
colitis,
of which
disease the author has seen more than 2,000 cases.
He discusses the
various opinions
on its etiology —that it is a deficiency
state, a sequel
of acute dysentery,
a psychogenic
affair, or a specific infection.
His
conclusion is that it probably represents
a systemic
infectious
disease
due to a streptococcus.
The
chapter
on
malignant
diseases
records
the
cases
of many
patients with cancer in this region who have remained
well for years
after treatment.
Taken
as a whole,
the volume
records
the experience of the Mayo
Clinic for the past
10 years in its department of proctology.
It is a
record of value to both specialist
and general practitioner.
The Management of Fractures, Dislocations,
and Sprains, by John Albert
Key,
B.
S., M.
D.,
St. Louis,
Mo.,
Clinical Professor
of Orthopedic Surgery,
Washington
University
School of Medicine,
etc., and H. Earle
Conwell, M.
D.,
F. A. C. S., Birmingham,
Ala., Consulting
Orthopedic
Surgeon to the
Tennessee
Coal, Iron
<k Railroad
Company,
etc.
Second
edition.
1,222
pages.
1,222
illustrations.
The C. V. Mosby Co., St. Louis,
1937.
Prioe, $12.50.
The authors have
examined
and
tried
the methods
recommended
by all
surgeons,
and
indicate
those
which
they
have
found
best.
They make
little
claim
to originality,
but their comment
on
the
relative
values
of the various procedures
is authoritative
and
prac
tical.
There are separate
chapters
on the workmen's compensation
laws and medicolegal
aspects of fractures.
The chapter
on fractures
of the face and jaws is by Dr. James Barrett Brown, of St. Louis,
a
most competent
expert.
This is a very complete work, somewhat
smaller than an unabridged
dictionary.
It
provides
a
useful
guide
for
the doctor
who
treats
fractures only occasionally,
as well as for the specialist
in this field.
Workbook
in
Elementary
Diagnosis
for
Teaching
Clinical
History
Recording
and Physical Diagnosis,
by Logan
Clendening, M.
D., Professor
of Clinical Medicine,
University of Kansas.
C. V. Mosby
Co., St. Louis,
1938.
Price,
$1.50.
596
BOOK
NOTICES
A rather elementary
text
designed
for students.
It is written in
notebook style,
is sensible, practical, condensed,
and should
be found
useful
as
a
teaching
aid.
Of
particular
value
are
the
numerous
explanatory illustrations.
Synopsis of the Diagnosis of the Acute Surgical Diseases of the Abdomen,
by John A. Hardy,
B. Sc., M. D., F. A. C. S., El Paso,
Tex.
332
pages.
92
illvstrations.
The C. V. Mosby Co., St. Louis,
1938.
Price, $4.50.
This is a small book which can be carried in the coat pocket or in
the doctor's bag.
It is packed
tight with
an enormous
amount of
condensed,
practical information.
The
author
expresses
the
hope
that the use of such a book will obviate the present
tendency
toward
too much reliance
on
the laboratory
and not
enough
on
personal
study and observation.
The book appears to be excellently
arranged
to achieve this object.
It should
be most useful
to students
preparing for examination, and
also
as a pocket
companion
for the general practitioner.
With the
increasing
importance of family
practice
in the career of the naval
medical
officer, such a work should
render valuable assistance to him.
Hernia.
Anatomy, Etiology,
Symptoms,
Diagnosis,
Differential
Diag
nosis,
Prognosis,
and the Operative
and Injection Treatment,
by Leigh
F. Watson, M.
D.,
Member of Attending Staff of California Lutheran
Hospital
and Methodist
Hospital
of Southern
California,
Los
Angeles.
Second edition,
558 pages.
281 illustrations.
The C. V. Mosby Co. (St. Louis),
1938.
Price,
$7.50.
For many years, while the reviewer was actively engaged in surgery,
the first edition of this book was one of those that he kept always on
his desk
for ready
reference.
The
present
volume
presents
many
improvements
and
is even
more valuable than its predecessor.
It
summarizes
the trends in treatment
of hernia in an interesting and
authoritative manner.
Watson states that the use of fascia in herniotomy is already begin
ning to fade, because the recurrences have proved to be even greater in
percentage
than with classical
methods.
This is because the fascia
often
fails to live
and
is absorbed.
Great disappointment
is felt,
because so much was expected of this repair with living fascia.
The injection method
is spreading
rapidly.
More and more state
compensation
commissions
and
large
industrial
organizations
are
coming to require
this method to be used instead of surgery.
Reasons
for this
are that there is no time lost from labor; no anesthesia
is
required
because the method is practically painless;
a cure is available
for many people who otherwise
would never attempt it; there is no
danger
of
shock
or postoperative
complications;
the percentage
of
cures is greater than by operative
methods.
The surgeon may well view with alarm the rise of a tide which today
threatens his position as prima donna of the hospital troupe.
It is the
BOOK
NOTICES
597
rapidly
spreading
trend
toward
the injection
treatment of hernia.
Take
away
from
the
operating
room
the
1,300
herniotomies
per
formed in the Navy during 1936 and consider how greatly the prestige
of the surgeon would dwindle.
Hemorrhoids and varicose veins have
already been lost to the injectionists.
Let us hope they do not dis
cover an injection
treatment
for appendicitis, or the surgeon
may
retain but a shred of his former glory.
The author, who was formerly an enthusiastic operator
for hernia,
now considers that the injection treatment is indicated in 90 percent
of cases.
The following are favorable
groups:
1. Industrial
patients
with small
reducible
hernia; especially
those
who cannot
afford
to take the time from work required
by operation.
2.
Aged
and infirm patients,
for whom operation carries
increased
risk and hazard.
3. Infants
and children with small
hernia,
for whom
operation is
unsatisfactory owing to difficulties of postoperative
care.
4. Patients with small reducible
hernia who are fearful of an opera
tion.
5. Patients with hernias of moderate size with the external inguinal
ring measuring
less than
3 cm in diameter.
Larger than this, opera
tion is preferable.
6. Moderately obese patients.
7. Patients whose hernias show a tendency
to recur after operation.
A few injections properly placed will overcome the weakness that might
develop into a recurrence.
8. Patients with small postoperative
hernias usually require only a
few injections for a cure.
9. The injection
is particularly
suitable for small
direct inguinal
hernias because they have a higher postoperative
recurrence
than the
indirect variety.
10. Femoral hernia, if the hernia can be reduced
and kept reduced
continuously during treatment.
11. Umbilical hernia, if small and completely
reducible.
12. Epigastric and hypogastric hernias in the midline, if completely
reducible.
13. Small reducible
postoperative
ventral hernias.
The injection treatment
offers only a fair prognosis for the following
groups:
1. Large reducible
hernias
associated with poor musculature,
small
inguinal rings,
and the mass difficult to retain with a truss.
2. Small hernias with large rings.
3. Hernia
complicated
with diabetes,
hyperthyroidism,
tuberculo
sis,
hypertension,
prostatic
hypertrophy,
urethral
strictures,
and
chronic cough.
598
BOOK NOTICES
The injection method
is never indicated for the following groups:
1. All
irreducible
hernias —strangulated,
incarcerated,
or
ob
structed —and
those
with
intrasaccular
adhesions
of omentum,
in
testine, or other
viscera.
2. Hernias complicated
with cancer,
ascites, abdominal tumor, or
severe hemophilia.
3. Large hernias with rings measuring
more than 3 cm in diameter.
4. Sliding hernia,
true traumatio hernia,
and those associated with
undescended
testes.
Whatever may be our prejudices
against
a method which for so long
has been the standby of the quack,
no progressive
surgeon can afford
not to
be informed on
this
subject.
This book offers
an excellent
chance
to study
the relative advantages
of the various methods
of
treatment of hernia.
Hemorrhoids,
by Marion
C. Pruitt, M.
D., L.
R.
C. P.
and S.
{.Edinhurgh),
F. A. C. S., Atlanta,
Ga.; President,
American
Proctologic Society; Associate in
Surgery, Emory
University School of Medicine,
etc.
164 pages,
73 illustrations,
7 in color.
The C. V. Mosby Co.,
St. Louis,
1938.
Price,
$4
A very complete
essay
covering
all phases of the subject.
The
chapters
on
treatment
are
especially
noteworthy.
They
give
full
consideration
to the advantages
and disadvantages
of each mode of
treatment,
and there is a final chapter
on the choice of methods.
He considers
that a scientific
evaluation can come only from one
having much
experience in the use of all the different
forms of treat
ment,
while the enthusiasm
of one who employs
only one method
is
of little
value.
Surgery
is stated
to be preferable
for hemorrhoids
complicated
by spasm
of the
sphincter,
stricture,
fissure, or fistula;
for thrombosed
external
hemorrhoids,
and for cases
with
combined
external
and internal hemorrhoids.
Injection
is best for simple
in
ternal hemorrhoids; for patients
with hemophilia, purpura, or anemia
from bleeding
hemorrhoids;
for patients
with serious heart or kidney
lesions; for old people, and for those who cannot afford the time off for
operation.
The advantages
of the injection treatment are that it is particu
larly painless ; it is an office procedure, not requiring hospitalization or
absence from work.
But this method
is suitable
only for uncompli
cated
internal
hemorrhoids.
A
cure
by
either
method
can
be
ex
pected in
90 percent
of
cases.
Physical Diaonosis,
by
Don
C.
Sutton, M.
S., M.
D.,
Associate Professor
of
Medicine,
Northwestern
University School of Medicine;
Attending Physician
and
Chairman
of the
Medical
Division
of
the
Cook
County
Hospital;
Chief of the
Cardiac Clinic, Cook
County Hospital,
Chicago; Attending Physician,
the Evans-
ton
Hospital.
495
pages.
298
illustrations
and
8 color
plates.
The C.
V.
Mosby
Co.,
St. Louis,
1937.
Price,
$5
BOOK NOTICES
599
A book written primarily
to meet the needs of the student.
The
subject matter is condensed,
clearly stated,
and well illustrated.
It
will also be found of aid to the busy practitioner who desires to review
the subject of physical diagnosis.
Methods
op Treatment by
Logan
Clendening,
M.
D.,
Clinical
Professor
of
Medicine,
Medical Department of the University of Kansas; Attending Physician,
University
of
Kansas
Hospitals;
Consulting
Physician,
Kansas
City
General
Hospital;
Physician
to St.
Luke's
Hospital,
Kansas
City,
Mo.
Sixth
edition.
C. V. Mosby Co., St. Louis,
1937.
Price,
$10.
The fact that this book is now in its sixth edition since
1924 is not
difficult to understand
after one looks into its contents.
Within
the
compass
of
one
volume
the
author
has
admirably
succeeded in his
aim of bringing together
all therapeutic procedure
of practical value to the clinician.
The
contents
are divided into
two
parts.
Part I describes
each
procedure
under
the
headings
of
drugs,
diet,
hydrotherapy,
etc.
Part II considers
the application,
the results to be expected,
etc.,
under the heading of the various diseases.
New
to
this
edition
are
discussions
of protamine
zinc insulin,
scarlet
fever streptococcus
immunizing toxin, staphylococcus
toxoid,
pertussis
vaccine,
cyclopropane
anesthesia,
mandelic
acid,
sulfan
ilamide, and treatment of delirium tremens.
The Role op Chemiotaxis in Bone Growth, by A. P. Bertwistle, M. B., Ch. B.,
F.
R.
C.
S.
(Edinburgh).
(53
pagea.
32
illustrations.)
Henry
Kimpton
(London)
1937.
Prioe 8s.6d.
This speculative
monograph
is devoted
to the thesis that new bone
formation
is not a function
of the periosteum,
but occurs
wherever
a calcium formation
is
in
contact
with
young
connective
tissue,
particularly
young blood vessels.
On this basis he explains
healing
of fractures and of bone
tuberculosis,
myositis ossificatans,
calcifica
tion in cysts and in the walls of blood vessels.
The Injection Treatment
of Hernia and Hydrocele, by Lawrence Goldbacher,
M. D., Philadelphia,
formerly Chief of the Hernia
Clinic,
Shelter for the Homeless;
Lieutenant
Commander,
U. S. N.
R.,
etc.
(189
pages.
58
illustrations.)
L.
Aubrook & Co., Philadelphia,
1938.
Price,
$5.75.
This month the desk is piled high with new books on the injection
treatment of various disorders
which have been, for generations,
the
proving
ground
for
the
surgeon.
Varicose
veins,
hemorrhoids,
hernias,
hydroceles,
and
bursas
are
now
being
attacked
by
this
simpler
and
allegedly
safer
technic.
At
the
same
time
we
read
(Journ.
Amer. Med.
Assoc.,
110:
1,812, May
28,
1938)
a report of
two fatalities
following
injection
treatment of
hernia,
one patient
coming from an irregular practitioner
and
the other from a regular
physician specializing in the injection treatment.
600
BOOK NOTICES
Without
doubt, there will be an enormous
increase in the number
of cases of hernia and hydrocele
treated by injection in the next few
years,
just
as
there
has
been
a great
number of cases
of varicose
veins
and hemorrhoids injected during the years
since
1930.
This
treatment offers
a considerable
saving
in
money
and in sick days,
besides making curative measures possible
at the smallest
sick bays.
In the Medical Corps of the Navy we cannot close our eyes to this
strong trend toward the injection
treatment,
nor can we ignore
the
fact that it is based on successful treatment of hundreds
of thousands
of cases in the hands of practitioners of average ability.
Therefore
it is important that we study the subject thoroughly, to determine
whether or not it suits the needs of the service.
Dr. Goldbacher's book will be found a useful primer for beginning
this study.
It is quite elementary
in its description of hernia and
the
treatment by
injection.
He
prefers
a
solution
of
5
percent
phenol
in
corn
oil, with
ethyl
aminobenzoate
added
for its
local
anesthetic
action.
In hydrocele,
he claims
several advantages
for injection treatment
over
operation.
It is simple,
safe, and painless,
an office operation
which causes no loss of time to the patient.
Bursitis
in
the
olecranon
and
prepatellar
regions
has
also
been
successfully
treated
by injection,
and Dr. Goldbacher believes it to
be superior to operation.
Everyday First Aid, by Walter Frank Cobb, M. D., Medical
Examiner,
Depart
ment of Hygiene,
College
of the City of New York; Special Instructor,
American
Red
Cross
First
Aid
Service.
D.
Appleton-Century
Co.,
Inc.,
New
York.
Price,
$1.50.
An interesting and
readable
monograph
for the layman, utilizing
concrete examples of accidents
clipped from the daily news as chapter
leads.
It is full of sound
advice,
which is well emphasized
and sup
ported
by excellent
diagrams,
covering
all the common
emergencies.
While it is by no means
a manual of first-aid treatment,
it is well
indexed and could
be used as such or as a basis for lectures
to laymen
on first aid.
It is unique
among
first-aid literature because
of the
simple,
flowing,
conversational style.
Injection Treatment
of Hernia, by Carl 0. Rice, M. D., F. A. C. S., Instructor
in Surgery,
University
of Minnesota
School of Medicine;
Surgeon in Charge
of
the
Surgical
Oul-Patient
Department of
the
Minneapolis
General
Hospital,
etc.
With
the
assistance
and cooperation
of Hamlin Mattison, M. D.
83 illustrations.
250 pages.
F. A. Davis Co. (Philadelphia)
1937.
Price
$4.50.
Before the days of aseptic surgery,
the injection treatment of hernia
enjoyed
a deserved popularity.
With the advent
of modern
surgical
methods
it was
relegated
to the quacks
and
charlatans.
Recently
there has been an increased
interest
in the injection treatment, and
BOOK
NOTICES
601
it has been found to compare
very favorably with surgery,
both in
safety and permanency
of cure.
This book gives a very complete
exposition
of the various methods
and
solutions
used,
the
technic,
indications
and
contraindications,
complications and sequelae, and the results.
There is also a chapter
on the medicolegal
aspects of hernia and the workmen's compensation
laws of
the
several
States.
The
author recommends
the injection
treatment as a supplement
to our surgical armamentarium for those
cases in which operation is contraindicated and in those cases which
are suitable for this type of treatment.
His arguments
are based on
more than 6,000 cases of hernia treated
by injection.
Any surgeon
who is not completely
satisfied with his results in the operative
treat
ment will find this book a stimulant and a challenge.
Injection Treatment
of Varicose Veins and Hemorrhoids,
by H. 0. McPheet-
ers, M. D., F. A. C. S., formerly
Director of the Varicose Vein and Ulcer Clinic,
Minneapolis
General Hospital,
etc., and James Kerr Anderson, M. D., F. A. C. S.,
Instructor
in
Surgery,
University
of Minnesota
School of Medicine,
etc.
299
pages.
82 illustrations.
F. A. Davis Co.,
Philadelphia,
1938.
Price,
$4.50.
The advantages
of injection treatment over operation for suitable
cases of varicose veins and hemorrhoids are now so generally recognized
that it seems hardly necessary
to comment
on
them.
But here is a
book by one of the pioneers in this method,
giving the benefits of his
experience
in an
enormous
number of cases, which is really worth
while.
Indications,
contraindications,
anatomy,
theory,
and
technic
are
fully discussed,
and
opinions are stated
which
can
be accepted
as
coming from the very highest
authority.
No medical
officer
nowadays
can afford
to remain
ignorant of the
rapid
advances
that are
being
made in the injection
treatment of
many disorders.
Conditions that only a short time ago were treated
by major
surgical
operation are now being
treated
as
office
cases,
safely, simply, and without sick days.
Here is one of the best books
available for study within its field.
The New
International
Clinics,
edited
by
George
Morris
Piersol,
M.
D.
Volume I,
1938.
J. B. Lippincott Co., Philadelphia.
Price
$3.
This,
volume
1 of the
new
series
(old forty-eighth),
contains
25
articles by leading authorities on a wide variety of subjects.
The first paper is by Warfield T. Longcope on Some Observations
on
the
Course
and
Outcome of Hemorrhagic
Nephritis.
In sum
marizing,
he
states
in part: "Our studies
of hemorrhagic
Bright's
disease show that there is one form of this condition which is so closely
related
both in its onset
and in its progress
to infections caused by
hemolytic streptococci
that it is difficult to escape the conclusion
that
602
BOOK NOTICES
this organism is either directly or indirectly the cause, though probably
not the sole cause, of the disease."
Sulphanilamide in small doses was
administered
to
a
number of
patients in this group
and it is remarked
"There is no indication that
it had
produced
any harmful
action
upon
the kidneys themselves.
Indeed
convalescence
and
symptomatic
recovery
has
taken
place
quite rapidly in these patients.
It can only be said that our results,
so far, encourage
us to continue the use of the drug cautiously in the
patients who can be shown to have an active infection due to hemolytic
streptococci."
William H. Robey has an article on Recognition and Treatment of
Some Acute Cardiac Accidents.
Samuel
Weiss
discusses
Medical
and
Surgical Jaundice
With
a
Consideration of Liver Deaths.
Frederick
Christopher
contributes
a paper
on
the Treatment
of
Wounds.
Damasco
de Rivas writes on Treatment of Amebic Dysentery by
Means of Intracolonic Heat.
In addition
to these and many other interesting papers, A. Can-
tarow, in
the
section
on Review of Medical
Progress,
summarizes
recent
contributions
concerning
the
subject
of biliary
stasis
and
decompression.
Treatment
by Diet, by Clifford J. Barborka,
B. S., M. S., M. D., D. 8e., ¥. A.
C. P., Department of Medicine,
Northwestern University Medical
School,
Chicago;
formerly
Consulting
Physician,
the Mayo
Clinic.
Illustrated.
Third edition,
revised.
J.
B.
Lippincott
Co.,
Philadelphia,
London,
and
Montreal,
1937.
Price
$5.
A volume of distinct value
to the clinician and also to the dietitian.
It teaches the principles of nutrition in their relation to the practice
of medicine,
so that the physician may use these principles to formulate
his own dietary treatment.
The author rightly urges that the various diets outlined not be used
as a stock or printed list for a particular disease applied to all patients
afflicted
with the disease, irrespective
of the particular needs of the
individual patient.
The book is divided into five parts:
I. Diet in health.
This part giveB a brief account of the principal
foodstuffs
and their place in diet.
There are tables of food values of
certain
foods about which a working knowledge
is of importance.
11. The application of diet therapy discusses the method of calculat
ing all
the
diets
presented,
conception
of
servings
to
be
used
or
indicated in the diets outlined, with a list of suggested substitutions.
I11.
Diet in disease, attempts briefly to show the practical applica
tion of all the foregoing principles to the problem of selecting the food
needed for the treatment of each individual
case.
BOOK NOTICES
603
IV. Routine
hospital diets.
Six diets
are suggested
to meet the
various
needs of the average hospital.
Special
methods
of feeding
are included.
V. An appendix
of tables,
recipes, and other matters
of value.
A comprehensive
bibliography completes
the work.
Athletic Injuries,
Prevention,
Diagnosis,
and
Treatment,
by
Augustus
Thorndike, Jr., M. D., Surgeon in the
Department
of Hygiene, Harvard
Univer
sity; Assistant in Surgery, Harvard Medical School; Associate Surgeon, Children's
Hospital,
Boston,
Mass.
200
pages
with
104 illustrations.
Lea
&
Febiger,
Philadelphia.
Price,
$3.
An admirable
monograph
on the care of the athlete,
covering
more
material than is suggested in the title, is the above.
Part I brings up
to date, in compact
and easily understood
form,
the present status
of
knowledge
concerning
the changes in the muscular,
cardio-vascular,
and respiratory
systems
during
the
process
of training.
Modern
theories of muscle action and fatigue,
and the causation relation of the
latter
to injury,
are presented.
Part
11
covers
the more
common
types of athletic injuries, their pathology, diagnosis,
and treatment.
Part 11I covers in detail the regional
injuries incurred and uniquely
treats
sprains
as injuries
to individual
anatomical
ligaments.
Me
chanical methods of prevention
and treatment
of most of the injuries
are shown in detail in the photographs
and line drawings.
It should
be invaluable
to coaches,
trainers,
and physicians con
cerned with athletics
and the care of the athlete,
and might well
be a
valuable addition to the library of the military surgeon.
Diseases of the Nose, Throat, and Ear, Medical, and Surgical, by William
Lincoln Ballenger, M. D., F. A. C. S., late Professor of Otology,
Rhinology,
and
Laryngology,
College
of Medicine,
University
of Illinois,
Chicago,
III.,
etc., and
Howard
Charles Ballenger, M. D., F. A. C. S., Assistant Professor of Otolaryng
ology,
Northwestern
University
School
of Medicine,
Chicago; Surgeon,
Depart-
mrnl of Otolaryngology, Evanston, Hospital,
Evanston, III.; Fellow of the American
Laryngological,
Rhinological,
and
Otological
Society;
Fellow
of
the
American
Academy
of Ophthalmology and
Otolaryngology.
Seventh
edition,
thoroughly
revised.
Octavo,
1,030
pages,
illustrated
with
576
engravings
and
30 color
plates.
(Lea & Febiger, Philadelphia,
Pa.,
1938.)
Cloth.
Price $11, net.
This is the seventh edition of this standard
work on ear, nose, and
throat disease.
It has been completely
revised
and now is the most
up-to-date textbook
on otorhinolaryngology written in this country.
There is one chapter
devoted
to the discussion
and
treatment
of
petrositis,
which is commanding
so
much
discussion
among
auralo-
gists.
It is interesting to note that the authors of this text differentiate
between osteomyelitis
and osteitis of the temporal
bone, showing
that
the text has incorporated the most recent ideas regarding
the pathology
of the petrous pyramid.
The chapters
devoted
to Bronchoscopy, Esophagoscopy,
and Gas-
troscopy have
been written
by Drs. Chevalier Jackson
and Gabriel
604
BOOK NOTICES
Tucker.
These
chapters
are
general
in
scope.
There
is
a bibli
ography appended
to these chapters
giving references
to the subject
matter of this branch
of laryngology in much more detail.
The bron-
choscopist would prefer more extensive and detail writing for reference
than this text affords.
The chapter
devoted
to the diagnosis
of lateral sinus thrombosis
is
concise and the chapter
on treating this disorder
incorporates
all the
latest views,
such
as feasibility of ligation or resection
of the jugular
vein.
Practical
Otology,
Rhinology,
and
Laryngology,
by
Col.
Adam
Edward
SManser,
United
Slates
Army Medical
Corps.
(313
pages.)
Lea
& Febiger,
Philadelphia,
Pa.,
1938.
Price
$4.50.
This is an excellent
book, written by a medical
officer of the United
States Army, upon the treatment of ear, nose, and throat diseases.
It
is concise, clear, and will be of value especially
to interns in the ear,
nose, and throat services
and to medical
officers aboard
ship and on
independent
duty in handling diseases in this field of medicine.
This book is not intended
to replace
the more extensive
tomes in
otorhinolaryngology for the specialist
in this field.
Anatomy, physi
ology,
and detailed
symptomatology have been omitted in this book.
It deals with the practical handling of the routine cases of ear, nose,
and throat disorders.
THE DIVISION
OF PREVENTIVE MEDICINE
Commander
C. S. Stephenson, Medical Corps, United States Navy, in charge
TOXIC
EFFECTS
OF ARSENICAL
COMPOUNDS
AS ADMINISTERED
IN THE UNITED STATES NAVY IN
1937 WITH SPECIAL REFERENCE
TO ARSENICAL DERMATITIS
By Commander
C. S. Stephenson, Medical
Corps,
United
States Navy, and E. H. Worao, Chief Pharma
cist's Mate,
United States Navy
For the past
13 years
medical
officers of the Navy
have
been re
quired
to submit to
the Bureau
of Medicine
and Surgery monthly
reports of the number of doses of arsenicals administered
and the reac
tions therefrom.
This information has been compiled
and published
in the following United
States
Naval
Medical Bulletins:
September
1925, January 1927, January 1929, July 1930, October 1931, October
1932, April 1933, October 1933, October 1934, January 1935, October
1935, January
1936, October 1936, January
1937, October 1937,
and
January
1938.
In table
1 are shown
the number of doses of each arsenical
admin
istered in the year
1937,
the reported
reactions
which occurred,
and
similar data for the 13-year period
1925-37.
It is noted that in 1937
there was
1 reaction
to 2,194 doses and
1 death to 107,533
doses.
For
the 13-year
period
1925-37
there
was
1 reaction
to
1,346
doses and
1 death to 30,460 doses.
Table
1.— Arsenicals,
U. S. Navy,
1937 and 1925-37—type of drug,
reaction,
and
ratio of doses to reactions
Number
Reactions
Ratio of
Ratio of
of doses
reactions
deaths
adminis
to doses
to doses
Year 1937:
tered
Mild
Severe
Fatal
Total
1 to—
1 to—
Arsphenamine
1,846
0
0
0
0
0
0
631
0
0
0
0
0
0
:
0
1
0
1
10,660
0
85,760
36
9
1
46
1,864
85,760
Silver
arsphenamine
10
0
0
0
0
0
0
1,507
1
0
0
1
1.507
0
7,219
1
0
0
1
7,219
0
Total
107,533
38
10
1
49
2.194
107,533
13-year period 1925-37:
945
0
0
0
0
0
0
41.558
27
14
1
42
989
41,558
1.890
0
0
0
0
0
0
13,535
0
1
0
1
13,535
0
Neoarsphenamine
1,172,843
580
278
42
900
1,303
27,925
Silver
arsphenamine
1
586
0
1
0
1
586
0
26,544
17
8
0
25
1.062
0
51,893
3
1
0
4
12,973
0
Total
1.309.794
627
303
43
973
1,346
30,460
' First administered
during
the year 1932.
>First administered
during
the year 1929.
' First administered
during
the year 1935.
• First administered
during
the year 1931.
605
606
DIVISION
OF
PREVENTIVE
MEDICINE
Table 2.—Arsenical
reactions,
U. S. Navy,
1937
Classification
Cases
Deaths
Classification
Cases
Deaths
Arsenical
dermatitis
20
0
Jarisch-Herxheimer
1
0
Vasomotor
phenomena
13
0
Liver damage (jaundice)
1
0
Blood
dyscrasias
3
0
1
o
Oastrointestinal
2
0
Hemorrhagic
encephalitis
2
1
Total
4»
1
From
table
2 it may be seen that the most
frequent
reactions
are
those that are classified
as arsenical
dermatitis and vasomotor phe
nomena.
Dermatitis in some form
was observed in 53.06
percent of
the
cases.
In
1936 dermatitis in some form was observed
in 44.74
percent of the cases.
Table
3.—Proportion
of reactions
of various types,
1929-37
Classification
Number
of
reactions
Percent of
total
reactions
Vasomotor
phenomena
.
Arsenical
dermatitis
Blood dyscrasias
Liver damage
Table
reactions
Reactions
of minor importance
Jarisch-Herxhelmer
Oastrointeuinal
Hemorrhagic
encephalitis
.
Optic
neuritis
Arsenical
neuritis
Acute
renal damage
-
Border
line, hemorrhagic
encephalitis
Liver damage (douhtful
reaction)
Vascular
damage (prohable
adrenal hemorrhage)
Total
326
44.23
261
35.41
34
4.61
26
3.53
26
3.53
17
2.31
17
2.31
13
1.76
8
1.00
3
.41
2
.27
1
.14
1
.14
1
.14
1
.14
737
100.00
In this article will appear
a brief summary of the clinical history
of each of the 26 cases of arsenical
dermatitis.
Arsenical Dermatitis
The 26 cases of arsenical dermatitis reported in 1937 were classified
as
17 mild and
9 severe reactions.
The type of lesion was exfoliative
in
10 instances,
erythematous
in
10, macular in
4, maculopapular
in
1, and fixed exanthem
in
1.
MILD reactions
The
17
mild
reactions
occurred
after
the
following
number
of
injections:
3 after the second injection,
8 after
the third, 2 after the
twentieth, and
1
each
after
the fourth,
nineteenth,
twenty-second,
and fortieth.
The
interval
between
injection
and
appearance
of
symptoms
varied
from
2 hours
to
12 days.
DIVISION
OF
PREVENTIVE
MEDICINE
607
The length of time
required
for complete
recovery
varied
from
24 hours
to 124 days.
A brief history of each case is cited.
Neoarsphenamine
(1— 1937.)
One month following
exposure
to infection
on
January
6,
1937,
this patient
developed a lesion on the prepuce which
was positive for Treponema
pallidum.
A Kahn blood test was 4-plus.
The patient
was given 0.3 gram injections
of neoarsphenamine
on February
9
and
12,
1937, and
4 days after the last injection
of neoarsphenamine
complained
of
general
malaise.
Examination
showed
a
well-developed
morbilliform
rash
over the entire body
and slight
edema of the face.
He
was given
2 grams of
sodium thiosulphate
intravenously
at 9 a. m. and
1 gram intravenously
at 8 p. m.
The following
morning
(Feb.
17) the patient
complained
of malaise and slight
pruritis over the abdomen and back.
Temperature
100° F.
The skin eruption
is clearing rapidly.
He received
1 gram of sodium
thiosulphate
intravenously,
daily for 4 days.
Recovery
in
5 days.
(2—1937.)
Following
exposure to infection
on March
21,
1937,
this
patient
developed a small punched-out
lesion on the meatus extending inside the urethra.
A
dark-field
examination
of the lesion
was positive
for
Treponema
pallidum.
Repeated Kahn blood tests were negative.
Arsenical
treatment
began
April
20,
1937,
with
a 0.3 gram injection
of neo
arsphenamine,
followed by 0.4 gram on April 24, and 0.6 gram on April 27.
Two
hours after the last injection,
and after eating the noon meal, the patient
com
plained of headache and nausea.
About 8 hours later his temperature was 103° F.;
pulse,
100; and respirations,
20.
The following
day his temperature
was normal
in the morning
and
101° F. in the afternoon.
He was given
1 gram of sodium
thiosulphate
intravenously.
On April
29,
2 days after the last injection
of neo
arsphenamine,
an
erythematous
rash
appeared
on
the
hands
and
feet.
The
sclerae
were injected
and
the patient
complained
of headache.
Temperature
was 103° F. in the morning and 104° F. at 7 p. m.
He was given
1 gram of sodium
thiosulphate
intravenously,
followed
by one-half
cubic centimeter
of adrenalin,
every
3 hours during the day and 25 cubic centimeters of 50 percent solution
of
glucose intravenously
morning
and afternoon.
The
above treatment
was con
tinued and the clinical picture remained about the same until after the fourth day,
when the erythematous
rash became
generalized over the trunk and extremities
and the temperature
rose to 105° F.
Alcohol baths and cool enemata
were
given
and the temperature
dropped to 104° F. within an hour.
The
patient's
general
condition
was good and his temperature
gradually
returned
to normal.
Recov
ery in
12 days.
(.3—1937.)
Two weeks after exposure to infection on April 22, 1937, this patient
developed
a
typical
chancre
on the penis
which
was
positive
for
Treponema
pallidum.
He was given a 0.3 gram injection
of neoarsphenamine
on May 6, 1937, and 0.5
gram injections
on May
12 and 18.
He received 0.13 gram injections
of bismuth
salicylate on May 6 and
13.
The patient stated that
he felt nauseated about
4 hours after the last injection
of neoarsphenamine
on May
18 and was ill during
the next day.
He failed to
report
this condition
until the evening of May 20, at which
time his body was
covered with a fine macular rash and he complained of chills and severe
headache
and backache.
Temperature,
102.8° F.; pulse,
110; and respirations,
26.
86860—38
11
60S
DIVISION
OF
PREVENTIVE
MEDICINE
He was given
1 gram of sodium thiosulphate
intravenously
on May 20 and 21,
after
which
the
rash
disappeared
and
his
temperature
gradually
returned
to
normal.
Recovery
in 5 days.
(4— 1937.)
After several exposures to infection
this patient
developed
a lesion
on the penis which was positive for Treponema pallidum.
A Kahn blood test was
also positive.
He was given a 0.3 gram injection
of neoarsphenamine
on May
12 and a 0.45
gram injection
on May
18,
1937, and 2 injections
of bismuth
salicylate
as con
current treatment.
About 3 hours after the last injection
of neoarsphenamine the
patient
complained
of headache, chills, fever, and vomiting.
He was given
15
minims
of adrenalin,
and
15 minutes later
1 gram of sodium thiosulphate
intra
venously.
The following
morning
he complained
of weakness and was given
1
gram of sodium thiosulphate
intravenously.
Temperature,
102° F.; pulse,
110;
and respirations,
20.
Two days after the last injection
of neoarsphenamine,
a macular rash appeared
over the trunk and extremities;
1 gram of sodium thiosulphate
was given intra
venously.
Temperature,
100° F.; pulse,
96; and respirations,
20.
The follow
ing morning the rash became intense but the patient felt much better.
His tem
perature
returned
to
normal
and
the
rash
gradually
disappeared.
Recovery
within 8 days.
(5—1937.)
This patient was exposed
to infection on June 22, 1937.
Nine days
after exposure several lesions developed on the glans penis and scrotum.
Dark-
field examinations
of the lesions were positive for Treponema pallidum.
He was given a 0.3 gram injection
of neoarsphenamine
on July 1 and 0.45 gram
injections
on July 5 and 8, 1937.
Five hours after the last injection
the patient's
temperature
was 101° F.
He developed nausea and vomiting
and complained
of
headache and backache.
Two hours later his temperature
was
104° F. and
he
was given
1 gram of sodium thiosulphate
intravenously.
Sore throat
developed
2
days after the last injection
of neoarsphenamine.
Examination
revealed several
red spots of various
sizes
on the abdomen and arms.
Appearance
of the spots
suggested an early
secondary
syphilitic skin
rash.
One gram of sodium
thio
sulphate was given intravenously.
The skin condition
developed into a macular
rash involving
the abdomen and arms.
Recovery
in 5 days.
(6—1937.)
This patient
was given a diagnosis of syphilis
because
of secondary
skin
eruption,
generalized
adenopathy,
repeated
4-plus
Kahn
blood
tests,
and
history
of a chancroid
on the penis, May 5, 1937.
Arsenical
treatment
began
with
a 0.3 gram injection
of neoarsphenamine
on
June
25,
1937,
followed
by
a 0.45
gram injection
on June
29, and
a 0.6 gram
injection
on July
6.
Two hours after the last injection
the patient
complained
of headache and nausea.
His temperature
rose to 103° F. within 6 hours.
Ex
amination
showed an erythematous
rash over the entire body,
marked
redness
and itching
of the hands and feet
and swollen
eyes.
He was given
1 gram of
sodium thiosulphate
intravenously
daily for 5 days.
Recovery
in 14 days.
(7 and 8— 1937.)
This patient
experienced
2 mild
arsenical
dermatitis
reac
tions during the second
course of arsenical treatment.
He was given a diagnosis
of syphilis
because
of generalized
adenopathy,
a faint secondary
skin
rash,
re
peated 4-plus Kahn blood tests,
and a healed indurated
ulcer on the penis.
From March
5 to May 6,
1937,
he received
10 injections
of neoarsphenamine,
a total
of 5.4 grams, and
10 intramuscular
injections
of bismuth
salicylate
were
given as concurrent
treatment.
The second course of arsenical treatment
began
with a
0.3 gram injection
of neoarsphenamine
on June
12, followed
by
a
0.45
gram injection
on June 19, and 0.6 gram injections
on June 26, July 6, 10, 17, 24,
31, and August
7.
Eleven
days after the last injection
of neoarsphenamine
the
patient returned from leave complaining
of a body rash, and examination
revealed
DIVISION
OF
PREVENTIVE
MEDICINE
G09
an erythematous
rash over the neck,
chest,
abdomen,
and extensor surfaces of
the arms and hands.
The skin condition
was suggestive but not conclusive of
arsenical
poisoning and cleared promptly
within 2 days.
On August
21,
1937,
he was given
a 0.6 gram injection
of neoarsphenamine.
Twenty-four hours later there was a recurrence of the erythematous
rash which
was readily
controlled
everywhere except on dorsum of the hands.
A change to
a dermatophytic
condition
with extensive vesicle formation
was noted.
There
was a moderate degree
of edamatous swelling and considerable itching.
He was
given
1 gram of sodium thiosulphate
intravenously
on August
23, 24, 25, and 27.
Recovery
in 12 days.
(9—19S7.)
This patient
was exposed to infection
on July
16,
1937,
and
15
days later a penile lesion was positive for Treponema pallidum.
Repeated Kahn
blood tests were 4-plus.
He was given a 0.3 gram injection
of neoarsphenamine
on August
3, 1937, and
a 0.6 gram injection
on August
10.
Six hours after the last injection
the patient
complained
of chills and general aching.
His temperature was 104° F. during the
evening and returned to normal the following
morning.
Two days after the last
injection
of neoarsphenamine
an erythematous
rash appeared over the abdomen
and thorax;
the patient
complained
of
sore
throat; and the face was slightly
swollen.
He was given
1 gram of sodium
thiosulphate
intravenously.
His tem
perature
was
101°
F. during
the evenings
and
gradually
returned
to
normal
within
4 days.
On August
17,
1937, he was given a 0.6 gram injection
of neo
arsphenamine
to observe the reaction.
About
5 hours later
he vomited,
had a
rise in temperature,
and flushed skin.
He was given
1 gram of sodium thiosul
phate
intravenously.
The skin
condition
cleared rapidly
and his temperature
was normal
3 days later.
Recovery in
11 days.
(10—1937.)
One month following
exposure to infection this patient developed
a penile lesion and generalized lymphadenopathy.
A darkfield
examination
of
the lesion was positive for
Treponema
pallidum.
He was given a 0.3 gram injection
of neoarsphenamine on August
29, 1937, and
a 0.45 gram injection
on September
3.
Six hours after
the last injection
the
patient
developed
a mild
vasomotor
phenomena reaction,
with
recovery within
44 hours.
This reaction will be described in a later bulletin.
Arsenical
treatment
was continued
and he was given a 0.45 gram injection
of
neoarsphenamine
on September 7.
Five and one-half hours later he complained
of headache, and was restless
and nervous.
Examination
showed injected
con
junctivae
and a generalized itching
erythematous
macular
rash which
persisted
for
12 hours.
He
was given
1 gram of sodium
thiosulphate
intravenously
on
September
7 and 8.
Symptoms
disappeared within
24 hours.
(11— 1937.)
This
patient
was
exposed
to
infection
on July
15,
1937,
and
1 month
later developed
a penile lesion which
was positive
for
Treponema
pal
lidum.
A Kahn blood test was 4-plus.
He was given a 0.3 gram injection
of neoarsphenamine
on August
17, a 0.45
gram injection
on August
20, and a 0.6 gram injection
on August
24.
On each
of the above dates he received a 0.13
gram intramuscular
injection
of bismuth
salicylate.
On the morning of August 24, before receiving the injection of neoarsphenamine,
the
patient
complained
of fever
and
sore
throat.
Physical
examination
was
negative, and his temperature
was normal.
About
8 hours after the injection
of
neoarsphenamine
his temperature
was 104° F. ; pulse,
110; and respirations,
20.
He vomited
following
the administration
of
1%
ounces
of magnesium sulphate.
The following
morning he complained of headache.
His temperature was 101° F.,
but rose to 104.4°
F. in the afternoon.
Physical
examination
was negative other
than
a very red throat.
Three days after the last injection
of neoarsphenamiue
610
DIVISION
OF
PREVENTIVE
MEDICINE
a scarlatiniform
rash appeared over the chest
and abdomen;
conjunctivae
were
injected;
tonsils
were
buried and injected;
and temperature
was
102.2°
F.
He
complained
of severe
headache and
some
nausea.
The rash gradually
became
erythematous
involving
the face,
body,
and upper extremities.
He
was given
1 gram of sodium thiosulphate
intravenously
on September
1 and 3.
Recovery
in
11 days.
{12—1937.)
This patient
was exposed to infection
on
September
13,
1937,
and
3 flays later a small sore developed on the glans penis which healed without
treatment.
On October
3 the patient
complained
of a body rash, headache, and
general malaise.
Examination
showed
a characteristic
maculopapular
eruption
on the abdomen and chest; temperature
104.4° F., and a 4-plus Kahn blood test.
The secondary rash disappeared and he was given a 0.3 gram injection of neo-
arsphenamine
on October
4, and 0.4 gram
injections
on October
7,
10, and
14.
Five hours after the last injection,
the skin and conjunctivae
were flushed, tem
perature was 104.4° F. and pulse, 136.
He was given
1 gram of sodium thiosul
phate
intravenously.
The following
morning
a marked
erythematous
rash ap
peared
on the body
and extremities
and his temperature
ranged from
100°
to
103° F.
Two days later the rash began
to fade leaving
the skin very dry, fol
lowed
by
a fine brany
scaling.
His temperature
gradually
dropped
to
99° F.
Eight days after the last injection
of neoarsphenamine the patient was nauseated
and the sclera and skin showed a slight icteric tinge.
Recovery
in
14 days.
{13-1937.)
One month after exposure on August
1, 1937, this patient developed
a lesion on the shaft of the penis and general adenopathy.
A darkfield
examina
tion of the lesion was positive for Treponema ,pallidum and a Kahn blood test was
4-plus.
He was given a 0.3 gram injection
of neoarsphenamine
on September 26,
1937,
followed
by
a 0.45
gram injection
on October
1, and
a 0.3
gram injection
on
October
9.
Four injections
of bismuth salicylate
were given as concurrent
treat
ment.
Three
days after the
0.45
gram injection
of neoarsphenamine
on Sep
tember
26 the patient
developed
a mild
skin rash which
was thought
to be a
syphilitic rash.
He had no complaint
or symptoms
other than
the rash and a
slightly elevated temperature.
About
12 hours following
the injection
of neo
arsphenamine
on October
9 the patient
complained
of feeling warm and itching
skin.
Examination
showed a diffuse erythema of the skin, wrhich cleared in 2 days
and left a fine brany scaling.
Recovery
in 9 days.
On October
20,
1937,
he was given
a 0.1 gram injection
of neoarsphenamine
which
caused
a recurrence of the mild erythematous
rash.
Neoarsphenamine
was
discontinued
and mapharsen and bismuth therapy instituted.
{H-19S7.)
After exposure to infection
this
patient
developed
a penile lesion
and general adenopathy.
A darkfield
examination
of the lesion was positive
for
Treponema pallidum.
He was given a 0.3 gram injection
of neoarsphenamine
on October
4, 1937, and
0.45 gram injections,
October
8 and
12.
Three and one-half hours after the last
injection
the patient
complained
of headache, nausea, and weakness; within
6
hours there were chills and a temperature of 105° F.
Examination
showed a faint
generalized
macular
rash.
He was given
1 gram of sodium
thiosulphate
intra
venously.
His temperature
returned
to normal within 24 hours.
Recovery
in
72 hours.
{15-1937.)
Three
weeks after this patient
was infected
a lesion developed on
the
penis.
Repeated
darkfield
examinations
of the
lesion
were
negative
for
Treponema pallidum
and a Kahn blood test was 4-plus.
From December
18,
1928, to July 30,
1929,
he received
11 injections
of neo
arsphenamine
(total amount not recorded).
Between the dates of April 2, 1930,
and May 20, 1931, he received 5.05 grams of mercury
as daily inunctions.
From
DIVISION
OF
PREVENTIVE
MEDICINE
611
March
23 to May
19, 1937,
he received nine injections
of bismuth
salicylate
and
from May 26 to July 21, nine injections
of neoarsphenamine,
a total of 5.1 grams.
The fourth course of arsenical
treatment
began
with
a 0.3 gram injection
of
neoarsphenamine
on September
29,
1937,
followed
by
a 0.6
gram injection
on
October
6.
Six days after the last injection
the patient
developed
a slight rash
on the abdomen.
He did not report this condition
until the morning of October
13 when he appeared for the third injection
of neoarsphenamine.
Upon examina
tion a faintly pink, widely scattered, macular type rash was noted.
It was not a
typical drug rash.
Mapharsen
was substituted
for neoarsphenamine
and he was
given a 0.04 gram injection
on October
13 and a 0.06 gram injection
on October 20,
at which time the rash was disappearing.
On October
26, 20 days after the last
injection of neoarsphenamine and 6 days after the last injection
of mapharsen, the
skin of the arms and forearms was very red.
The following
morning
a maculo-
papular
rash appeared
on the trunk and extremities
and developed into an ery
thematous
skin
condition
which
responded to treatment.
He received
4 injec
tions of sodium thiosulphate
intravenously.
Recovery
in 52 days after the onset
of first symptoms.
(16-1937.)
This patient
was exposed to infection
on July 24,
1936, and devel
oped a lesion on the penis which was positive for Treponema pallidum.
Repeated
Kahn blood tests were negative.
He received the following
treatment:
From August
8 to 29,
1936,
3 injections
of neoarsphenamine,
a total of 1.05 grams; from September
5 to October
2, 1936,
5 injections
of bismuth
salicylate;
from
October
13 to December
4,
1936,
8 in
jections
of neoarsphenamine,
a total of
4.35
grams;
and
from
November
27,
1936,
to February
12,
1937,
10 injections
of bismuth
salicylate.
On February
12,
1937, the patient
complained
of a rash on the right arm and
leg involving tattooed
areas.
Examination
showed
a pruritic eruption
on the
arm
and
leg,
and
a discrete,
erythematous,
macular
rash over the trunk,
con
sidered to be a syphilid
condition
and evidence of relapse.
A course of neoars
phenamine
was instituted
with
a 0.3 gram injection
on February
12, a 0.45 gram
injection
on February
19, and 0.6 gram injections
on February
27, March 5, and
13.
The patient
received the first three injections
without
any noticeable effect
on
the
rash.
After the last
two
injections
the
macules
seemed
to
flare
and
become scarlet,
followed
later
by
central
desquamation.
The patient
had
no
complaint
and the rash showed signs of fading.
On March 25 he was given a 0.4 gram injection
of arsphenamine,
which caused
the rash to brighten
up for about
1 day, and following
a 0.4 gram injection
on
April
1 there was a recurrence of the rash coupled with some constitutional
symp
toms.
The rash faded but it was not considered advisable
to continue
the use
of arsenicals and a course of bismuth salicylate
was started.
Flushing
of the skin
followed
the first injection
on April
6 and no symptoms
followed
the second
in
jection
given on April
13.
The third injection
given on April
20 caused
an in
crease in the rash.
Treatment
was discontinued
but
the rash persisted.
The
skin condition
gradually
spread to the face and cleared after 3 weeks symptomatio
treatment.
He was given a 0.03 gram injection
of mapharsen
on July
1 and a 0.04 gram
injection on July 8, without
signs or symptoms
of further
reaction.
Recovery
in
124 days after onset of the first symptoms.
(17-1937.)
After exposure to infection
on October
17, 1936, this patient
devel
oped an indurated ulcer on the prepuce which was positive for Treponema pallidum.
From December
1, 1936, to August
5, 1937, he received 24 injections
of neoars
phenamine,
a total of 17.05 grams, and as concurrent
treatment
24 intramuscular
injections
of bismosol.
The third course of arsenical treatment
began with a 0.3
gram injection
of neoarsphenamine
on October
8,
1937, followed
by a 0.45 gram
612
DIVISION
OF
PREVENTIVE
MEDICINE
injection
on October
14, and 0.6 gram injections
on October
22, 28, November
5,
12, 18, and 26.
Three injections
of bismosol were given as concurrent
treatment.
Twenty days after the last injection
of neoarsphenamine
examination
showed
a mild
eczematous rash
on
both
legs
and slight
edema of the ankles
and
feet.
The dermatitis
was believed to be due to the entire treatment
and not the result
of any
particular
dose.
The face
and upper
extremities
became involved
and
the skin condition
gradually
developed into
a mild
exfoliative
dermatitis
which
showed steady improvement
under treatment.
Recovery
in 20 days.
SEVERE
REACTIONS
The nine
severe reactions
occurred
after the following number of
injections:
One after the first, fifth, sixth, and
seventh;
two
after
the eighth;
one after the ninth and thirty-eighth;
and one after the
seventh
injection
of
the
third
course
of arsenical
treatment
(total
number of injections not known).
The interval
between
the injec
tion and
appearance
of symptoms
varied from
6 hours to
10
days.
The length
of time required for recovery
varied from 24 days to
1 18
days.
Neoarsphenamine
{18-1987.) This patient
was given
a diagnosis
of syphilis
on April
2,
1937,
because of repeated positive
Kahn blood tests and a history
of a penile lesion in
July
1931.
Arsenical
treatment
began with
a 0.3 gram injection
of neoarsphenamine
on
March
10,
1937, followed
by a 0.45
gram injection
on March
17, and 0.6 gram
injections
on March 31, April 7,
14,
21, and 28.
Eight intramuscular
injections
of bismosol were given as concurrent
treatment.
Approximately
24 hours after
the last injection
of neoarsphenamine the patient complained of burning and itch
ing skin over the arms and legs.
Examination
on May 6, 8 days after the last
injection
of neoarsphenamine,
showed
definite
evidence
of
inflammation
with
duration and serous exudate from the extensor surfaces of the skin on the forearms
and legs.
RBC 5,250,000;
WBC
12,400;
hgb 90 percent; bands, 8; segments, 84;
lymphs,
21;
eosins,
5; monos, 2.
The skin condition
rapidly spread to the arms,
hands, and feet.
The patient was given 1 gram of sodium thiosulphate
intravenously
on May 6, 7,
8,
9,
10,
12, and
31.
The skin condition
gradually
developed into
a severe
ex
foliative
dermatitis involving
the scalp, without loss of hair or damage to finger and
toe nails.
Recovery
in 39 days.
(W-1937.)
Following
exposure to infection
on
March 25,
1937,
this patient
developed
a penile lesion which was positive
for Treponema pallidum.
Arsenical
treatment
began
with
a 0.3
gram injection
of neoarsphenamine
on
April 8, 1937, followed by eight weekly injections
of 0.6 gram each.
Four injec
tions of bismuth
salicylate
were given as concurrent
treatment.
Six hours after
the last injection
of neoarsphenamine,
given
on June 3,
1937, the patient
com
plained
of generalized itching
and reddening
of the skin.
Physical
examination
otherwise normal.
After questioning,
the patient stated that
2 days following
the
eighth
injection
of neoarsphenamine, given on May 27, he noticed a slight itching
over the shoulders which disappeared within
3 days.
The skin condition gradually
became worse and on June 11 examination showed an exanthematous skin eruption
over
the entire
body
more pronounced
on the chest and
shoulders
with some
oozing of serum from the areas most involved.
The skin has a thickened,
rough,
DIVISION
OF
PREVENTIVE
MEDICINE
613
and
red appearance with
a prominence
of the individual hair follicles.
He was
given
1 gram of sodium thiosulphate
intravenously
on June 8 and
11.
The skin
condition
developed into a severe
exfoliative
dermatitis
with areas most involved
showing
serous weeping.
Blood picture
Date
Red blood
count
White
blood
count
Hemo
globin
Band
forms
Lympho
cytes
Seg
mented
Eosino
phils
Baso-
philes
Mono
cytes
Juve
niles
June 7, 1937..
June
11. 1937.
June 29, 1937.
Julv 8, 1937...
July 12, 1937..
July 26, 1937..
4,110,000
4, 900,000
3,930,000
3,775,000
3.600.000
4, 175,000
12,850
3
17
13
8
21
20
19
75
42
57
55
53
65
2
4
2
3
6
22,800
80
30
13
10
2
3
5
2
7. 400
9.200
7.800
3, 31X)
80
20
31
25
11
3
80
90
2
The skin
condition
showed
steady
improvement
after
2
weeks
treatment.
Recovery
in 118 days.
(20-1937.)
One month
following
exposure to infection
this patient
developed
a penile lesion which was positive
for Treponema pallidum.
He was given a 0.3
gram injection
of neoarsphenamine
on May 29,
1937, followed
by seven weekly
injections
of 0.7 gram each.
Twenty-four hours after the seventh injection
given
on July 6, 1937, the patient complained of a maculopapular
rash over the trunk and
extensor surfaces of the extremities.
Patch tests on July
7 and 8 were
negative.
The patient
admitted
exposure to the sun and the use of an irritant soap.
The
rash did not appear typical
of arsenical poisoning and neoarsphenamine
was con
tinued.
Following the
eighth
injection
of neoarsphenamine,
given
on July
13,
the rash became worse with slight itching.
Macules confluent.
The rash gradu
ally developed into a generalized exfoliative
dermatitis.
He was given
1 gram of
sodium thiosulphate
intravenously
daily for 15 days.
Blood picture
Neutrophiles
Date
Erythro
cytes
Leuko
cytes
Hemo
globin
Eosino-
philes
Lympho
cytes
Mono
cytes
Platel-
Mature
Imma
ture
lets
July 13, 1937
9,500,000
9,200
90
55
27
60
37
63
37
76
54
17
14
6
4
3
1
4
5
7
45
19
12
26
18
30
48
12
30
2
2
8
1
4
4
4
1
July 16, 1937
318,750
July 23, 1937
11,800
8,800
9,500
7,700
8,200
8,900
Aug. 4, 1937
4, 850,000
4, 400,000
4,990.000
4,660,000
5,500,000
90
88
98
90
102
40
Aug. 10, 1937
Aug.
26, 1937
10
6
10
Sept. 8, 1937
«ept. 14. 1937
The skin condition
gradually
improved
after treatment.
Recovery
in 63 days.
(£1-1937.)
After exposure to infection on July 6, 1937, this patient developed a
sore on the penis which was positive for Treponema pallidium.
From
August
28 to September
18,
1937,
he received four injections
of neoars
phenamine,
a total of 1.9 grams.
Arsenical treatment
was
continued
and
he was
given
a 0.6 gram injection
of neoarsphenamine
on September
24 and October
1,
1937.
Ten days after the last injection
of neoarsphenamine
a mild pruritic, ery
thematous
rash appeared over the chest and arms.
No one dose can be selected
as the causative agent and it is believed that the condition
is due to the cumulative
effect of the arsenic in all doses.
The patient
had no complaint
other than the
rash.
Arsenical treatment was discontinued.
He was given 0.13 gram intramus
614
DIVISION
OF
PREVENTIVE
MEDICINE
cular injections
of bismuth
salicylate
on October
11, 15, and 22.
On October
8,
1937, examination
of the patient
showed extension of the eruption
to the lower
arms and legs,
with
weeping and excessive
desquamation
above the left elbow.
He was given
1 gram of sodium thiosulphate
intravenously
on October
28, 29, 30,
November
1 and 5.
The course of the disease
was uneventful
until November
9,
after
which
there was marked
swelling
of the
legs and ankles.
An exfoliative
dermatitis
developed
which
showed
steady
improvement
under
treatment.
Recovery in 35 days.
{22-1937.)
This patient was infected on November
22,
1933, and developed an
indurated
ulcer on the dorsal prepuce which was positive for Treponema pallidium.
A macular
rash appeared over the face and body.
Repeated Kahn blood tests
were 4-plus.
From January 18, 1934, to June 6, 1936, he received 25 injections of neoarsphen-
amine,
a total
of 11.7 grams, and
13 injections
of a bismuth
compound
and
10
injections
of mercury succinimide
as concurrent
treatment.
The
fifth
course of arsenical
treatment
began
with
a 0.45
gram injection
of
neoarsphenamine
on December
15,
1936, followed
by
12 weekly injections
of 0.6
gram each.
Ten injections
of bismuth salicylate
were given as concurrent
treat
ment.
Since January
1,
1937,
the patient
has
been
treated intermittently for
apparently
benign fungoid lesions on the dorsum of the hands and ventral surface
of the forearms.
Before each
injection
of neoarsphenamine
in the last course of
treatment
the patient
was
questioned
carefully
and no apparent
aggravation
of
these lesions was noticeable.
Eight hours after the last injection,
given on March
16, examination
of the patient
showed a maculopapular
rash over the body and
extremities,
with
confluent
lesions over the flexor surfaces of the elbows.
The
condition
gradually
developed
into
exfoliative
dermatitis
and
showed
steady
improvement
from beginning of treatment.
Recovery
in 69 days.
(S3- 1987.)
After exposure to infection on October
6, 1937, this patient developed
a penile lesion which was repeatedly negative for Treponema pallidum.
A Kahn
blood test was 4-plus on October
26.
Arsenical
treatment
began
with
a 0.3
gram injection
of neoarsphenamine
on
November
3, followed
by six weekly
injections
of
0.6
gram
each.
Four days
after the last injection,
given on December
15, the patient noticed a prickly heat
type of rash over the neck and forearms, which
was not reported until
December
21,
6 days after the injection
was given.
Examination
at this time showed an
erythematous
rash of the face,
neck, and forearms which gradually
spread to the
trunk.
He was given
1 gram of sodium thiosulphate
intravenously
on December
21, 22, and 23, following
which the rash showed signs of fading.
There were no
other
symptoms.
On
December
26
examination
showed
a more
severe
rash,
edema of
the face,
neck, and ankles, injected conjunctiva,
and a thick,
leathery
skin
presenting
a typical
picture
of
a generalized
exfoliative
dermatitis.
The
skin condition
was normal after 66 days of treatment.
Loss of considerable hair
over frontal
area of the head
was noted.
(24-1937.)
The
source
of
infection
in
this
case
is
unknown.
The
patient
(supernumerary,
Veteran,
U. 8. Army)
was
given a diagnosis of syphilis
because
of repeated 4-plus
Kahn blood
tests.
Treatment
began
with
0.13 gram intra
muscular
injections
of bismuth
salicylate
on June
19
and
22,
and
a 0.3
gram
injection
of neoarsphenamine
on June 23,
1937.
About 12 hours after the injec
tion
of neoarsphenamine
he complained
of headache and developed
an
itching
scarlatiniform
rash over the entire
body.
The
patient
stated
he had a similar
reaction about
10 years ago following
an injection
in the arm for treatment
of an
ulcer on the medial aspect of the thigh.
The scar has the appearance of a healed
tertiary
ulcer.
The skin condition
developed into a severe
exfoliative
dermatitis
which
improved
rapidly
under
treatment.
He
was
given
1
gram
of
sodium
DIVISION
OF
PREVENTIVE
MEDICINE
615
thiosulphate
in the morning
and
1 gram in the afternoon
on June 23,
24, 25, 26
and 1 gram daily for the following
9 days.
Recovery
in 26 days.
(23-1937.)
The
source
of
infection
in
this
case
is
unknown.
The
patient
(supernumerary
female) was given a diagnosis of syphilis
because
of a secondary
skin rash and positive blood tests.
From December
18,
1935, to August
18,
1936, she received a total of 4.1 grams
of neoarsphenamine and a total of 3.12 grains of bismuth salicylate.
The third
course of arsenical
treatment
began with
a
0.3
gram injection
of
neoarsphenamine
on January
12,
1937, followed by a 0.3 gram injection, January
26; a 0.45 gram injection,
February
2; 0.3 gram injections,
February
16, March 2,
and 16; and a 0.45
a gram injection,
March
23.
As
concurrent
treatment
11
injections
of bismuth
salicylate
were given.
Two days following
the last injection
of neoarsphenamine the patient developed
a lesion about
1%
inches in diameter
on
the right
tibia.
The
lesion gradually
increased in size and started to weep.
The face and upper and lower extremities
were
next
involved
with the lichenoid
type
of lesion.
One gram
of sodium
thiosulphate
was given intravenously
on April 9,
10, and 11, and 1 gram of calcium
gluconate
12 to
18 hours apart until 12 grams were
given.
The skin condition
gradually
developed
into
a
severe
exfoliative
dermatitis
and
showed
steady
improvement
under treatment.
Recovery
in 72 days.
MAPHARSEN
(26-1937.)
Three weeks after exposure to infection
on December 28,
1926, this
patient developed
a penile lesion
which
healed within
10 days.
Two months
later
a secondary skin rash appeared over the trunk
and extremities.
A Kahn
blood test was 1-plus.
He was given 0.45 gram injections of neoarsphenamine on
March 19, 26, and April
2,
1927, and 3 injections
of mercury
salicylate,
1 grain
each,
as concurrent
treatment.
Twenty-four hours
after
the last
injection
of
neoarsphenamine
he developed a severe exfoliative arsenical dermatitis.
Recovery
in
81 days.
On December
19 and
22,
1927,
he was given 0.13 gram injections
of bismuth
salicylate.
A mild exfoliative
dermatitis
followed
the two injections
of bismuth
salicylate
and all antiluetic
treatment
was discontinued.
Between July
27 and
August
5, 1935, he received five mercury inunctions
resulting in a dermatitis which
lasted 3 weeks.
The patient had received no arsenical treatment
or treatment
with metal com
pounds since August
1935.
Kahn blood tests were 4-plus on May
13 and June
1,
1937.
A 0.03
gram injection
of mapharsen was given on June
9.
Eight hours
after the injection
he noted a marked itching and burning of the skin over the lower
abdomen, flanks, buttocks, and upper thighs.
Two houis later the arms and fore
arms were involved, most marked in the region of antecubital
fossae.
The follow
ing
morning
a
diffuse
macular
rash
appeared
over
these
areas,
followed
by
generalized itching.
The skin condition followed the course of a typical exfoliative
dermatitis,
from June 21 to July
2.
He was returned
to duty July
3 with
no
evident kidney, liver, or skin damage.
Recovery in 24 days after onset of the first
symptoms.
Summary
In 1937 medical
officers of the Navy administered
107,533
doses of
areenicals and reported
the occurrence of 49 reactions
therefrom.
Of
these reactions
more
than one-half
(26)
were arsenical
dermatitis; a
ratio of one case of dermatitis to 4,135 doses.
Of interest in connection
with the etiology
of arsenical dermatitis is the number of instances in
616
DIVISION
OF
PREVENTIVE
MEDICINE
which premonitory signs were noted.
These signs are repeated below
and serve to indicate the necessity for careful
examination
and ques
tioning of each patient before administering an arsenical.
Case 3.—Unreported nausea and lassitude was followed by a macular
rash 2 days later.
Cases
7 and 8.—A mild erythematous
rash followed
the twentieth
injection of neoarsphenamine.
The next injection given
14 days later
caused recurrence of the rash.
Case
9.—An erythematous
rash
followed
the second injection of
neoarsphenamine.
The
third injection
given
7
days
later
caused
nausea and vomiting, rise in temperature,
and flushed skin.
Case
10. —A vasomotor
phenomena
reaction
followed
the second
injection of neoarsphenamine.
An
erythematous
rash
followed
the
third injection given 4 days later.
Case
13.—A mild skin rash followed
the second injection of neoars
phenamine.
An erythematous
rash followed
the third injection, and
the fourth injection caused recurrence of the rash.
Case
15. —Six
days
after
the last injection
of neoarsphenamine
a
faint macular rash developed.
Under observation
and after receiving
2 injections of mapharsen
the rash developed into a mild erythematous
dermatitis.
Case
16.—A pruritic
eruption developed
2 months
after
the last
injection
of
neoarsphenamine.
A
mild
arsenical
dermatitis
(fixed
exanthem)
followed
the next five injections of neoarsphenamine.
Case
19. —Unreported body rash
followed
the eighth
injection of
neoarsphenamine.
A severe exfoliative
dermatitis followed
the ninth
injection given
8 days later.
Case
20.—A maculopapular rash followed
the seventh injection of
neoarsphenamine.
A severe exfoliative dermatitis followed
the eighth
injection given
1 week later.
Case 23. —Unreported prickly heat type of rash followed
the seventh
injection
of neoarsphenamine.
Six days
later
a
severe exfoliative
dermatitis developed.
Case
26. —A severe arsenical dermatitis followed
the third injection
of neoarsphenamine.
Nine
months
later dermatitis followed
treat
ment
with
bismuth
and
mercury
compounds.
Ten
years
later
a
severe exfoliative dermatitis followed
the first injection of mapharsen.
TRAFFIC
INJURIES
A STUDY BY POST MEDICAL DEPARTMENT
I
By Captain
W. L. Mann,
Medical
Corps,
United
States Navy
The appalling loss of manpower
to the naval service due to traffic
accidents
has
been
receiving
more
and
more
attention
from
the
' Credit
Is hereby acknowledged
to U. W. V. Clark, Medical
Corps,
United
States Navy, for the com
pilation
and tabulation
of data.
DIVISION
OF
PREVENTIVE
MEDICINE
617
proper authorities.
Urgent and effective
measures have been taken
in an endeavor
to diminish local traffic
accidents.
A broad
conception
of the mission of a medicomilitary department
is to prevent any avoidable
loss in personnel
or diminution
in its
effectiveness.
Since
our
naval
medical
records
demonstrate
con
clusively
that
traffic injuries
constitute
the
large
majority
of all
accidental injuries, the primary purpose of presenting
this analytical
study is in hopes that it will serve in a minor manner
to demonstrate
in which direction efforts
should
be concentrated
in attempting
to
minimize
the loss of military
power
from accidental
injuries,
par
ticularly traffic injuries.
During the calendar
year
1937 this medical department has treated
127 patients suffering
from major and minor injuries due to motor
vehicles.
Our list of patients treated
for traffic injuries
does not
give a complete
picture of the number of accidents,
for the following
reasons:
1.
Some of the minor
cases
of injuries,
for
various
reasons,
failed
to report
for treatment
or sought treatment
elsewhere.
2. This list of patients
does
not include
all accidents,
as
in
some
accidents
there was often — miraculously —no injury to personnel.
For example, in
1935,
one member of this post was said to have
been
driving
a new automobile
at a
high rate of speed
(70 m. p. h.), when the car overturned,
rolled over 5 or 6 times,
then
skidded
upside down for
300
feet
along the concrete highway.
When the
upside-down
car,
completely
wrecked,
came
to
rest,
the
driver
stepped
out,
unhurt,
and hitchhiked
back to Quantico.
The writer
started
studies
of traffic accidents
in
1932,
and
since
that
time
the marked increased
speed of modern
automobiles
has
assumed
place
as a dominating factor in the cause of traffic injuries
as shown below:
1. At
25 miles an hour
a moving
car has developed about
enough energy to
roll over once.
Your body could probably
"take" this.
2. At
50 it has developed not twice,
but
4 times the energy—enough to roll
over 4 times.
You'd have to be lucky to come out of this one alive.
3. And at 75 it has developed not
3 times, but 9 times the energy—enough to
roll over 9 times.
Of course,
it probably
would hit a tree or a culvert long before
it did its ninth somersault and then the unused portion
of energy would
be spent
in ripping
the culvert,
the car, and its occupants to pieces.3
The various tables of local accidents
in this study are based upon
the number
of patients
treated,
not upon
the number of accidents.
For instance, if five patients are injured when an automobile
collides
with
a parked
truck, our records
will show
five patients and not a
single accident.
The reason for this sort of tabulation is that a medico-
military
department
is interested
primarily
in "avoidable personnel
loss" in relation to a specific
type of accident
and not in the type of
accident
per se.
• Death
Begins at Forty, published
by the Travelers
Insurance
Co , Hartford,
Conn.,
has been freely
utilized
in preparation
of this study,
particularly
In regard to national
traffic accidents.
618
DIVISION
OF
PREVENTIVE
MEDICINE
ECONOMIC CONSIDERATION
1. Roughly
estimating (a) the cost of burial expenses,
(6) cost of
medical
treatment,
(c) expense of the death gratuity,
(d) the loss of
the services of a trained and experienced
soldier, and
(c) that a certain
percentage of deceased individuals carry Federal life insurance,
it ap
pears not unreasonable
to assume that each fatal injury
represents
about $12,000 loss
to
the Government.
It is estimated
that each
case invalided from the service represents
a $10,000 loss.
2. Placing the value of a disabled
man's services at $2 a day, with
an additional expense of $3
a day for hospitalization
charges,
there
was an approximate
loss to the Government of $63,545 for traffic ac
cidents
in the
personnel
of this
organization for the calendar
year
1937
(fatal
and nonfatal cases), as shown by the following figures:
1935
1936
1937
1935
1936
1937
3
3
1
0
6
0
709
Deaths
at $12,000
$36,000
30,000
12,500
$12,000
0
$60,000
0
2,500
1,045
Hospital
sick days at $5
5,225
3,545
Total
78,500
17,225
63,545
The incidence
of service
traffic
accidents
showed
a progressive
in
crease until
1931,
from which year
until
1936
there
was
a gradual
decrease,
as demonstrated
by the following data from reports of the
Surgeon General,
United States Navy.
Year:
1927
1928
1929
1930
Admission
rate
per 100,000
Year:
659
1932
694
1933
861
1934
1,006
1935
1, 113
1936
Admission
rats
per 100,000
1,080
766
774
691
The
accident
statistics for United
States
Highway
No.
1
from
Fredericksburg to Alexandria, Va., for period January
1, 1936, to June
30, 1937, is as follows:
Number
of accidents
465
Fatal accidents.
30
Injury accidents
196
Property-damage
accidents
239
Fatalities
-
41
Injuries
422
Property
damage
-
$146,242
Vehicles involved
829
This portion is a three-way highway which is exceedingly
dangerous,
as it
passes
through
undulating
country,
which
causes
the north
bound traffic
to "fight"
with south-bound traffic on the hills for the
center roadway.
DIVISION
OF
PREVENTIVE
MEDICINE
619
The status of patients treated
for traffic injuries are classifiable
as
follows:
Nonlncapacitated
Incapacitated
Total
1935
1936
1937
1935
1936
1937
1935
1936
1937
39
18
14
73
39
36
112
81
57
05
50
77
Nonmilitary
(dependents
Total
193
152
127
The types of vehicles involved are listed below:
Number of accidents
Number of patients
1935
1936
1937
1935
1936
1937
Automobile— passenger
72
53
48
98
121
108
Trucks
3
11
5
8
20
7
4
5
3
4
8
5
Bicycles
2
0
2
2
0
2
Tractors
0
2
1
0
3
2
Tank
0
0
1
0
0
2
Trailer
0
0
1
0
0
1
Total
81
71
61
112
152
127
INTOXICATED WHEN TREATED
1936
1937
5
4
Civilians...
11
10
Hence,
alcohol
is considered
an unimportant contributory
factor.
Average
age of drivers involved in traffic accidents:
Aterage
in year»
Service personnel
26.
82
Civilians
-
..
30.00
Total average.
28. 41
Table
1
Total injured
11135 1936
1937
Number owning
motor vehicles
1035
1930
1937
Ratio of injuries
to owners
of motor vehicles
1935
1930
1937
Commissioned,
chief
warrant,
and
warrant
officers
First pay grade
Second pay grade
Third
pay grade
Fourth pay grade
Nonrated
men,
5th,
6th,
and
7th
pay grades
33(1
64
79
2t5
139
139
507
75
44
Oil
10(1
205
1-41.25
0-64
1-19.75
1-13
1- 9.85
1- 1.52
1-165
1- 21.33
1- 26.33
1- 26
1- 23
1-
3.09
1-283.5
1- 75
0-44
0-60
1- 12.5
1- 5.26
620
DIVISION
OF
PREVENTIVE
MEDICINE
Discussion
of table
1.—Note
the ratio
of injuries
to
the number
owning automobiles
is in inverse ratio to the ratings ; the same applies
to rank, but the small number of injuries in officer personnel
does not
warrant the detailed
classification.
Table 2.— Types of fractures, military
and nonmililary
patients
Broken
neck
Broken hack
Fractured
skull
Fractured
pelvis
Fractured
left
Fracture of arm and forearm
Fracture
of hand
1935
1936
1937
2
1
0
1
0
0
5
4
4
1
2
2
12
8
8
4
5
3
4
2
6
Fracture
of bones of face
Miscellaneous
(scapula,
clav
Icle, etc )
-
Injuries,
multiple
Fracture,
ribs
Fracture
of foot...
1935
1936
1937
One fracture of arm required
amputation, and two fractures of the
leg resulted in amputation in 1935-36.
Note in past
3 years
13 cases of fractured skull.
Table 3.— Types of accidents
Collision with:
Pedestrian
Bicycle
Motorcycle
Trailer
Train
Tractor
Automobile or truck:
Side swipe
Head-on
collision
Head-to- rear
Parked
automobile
truck
1935
1936
1937
Filed objects:
Lamp post
Tree.
Ditch
Emhankment
Underpass
Bridge
Cement
water trap
Fence
Telephone
pole
Overturned
Fall from
Miscellaneous
1935
1936
1937
0
3
3
7
4
I
0
1
4
24
3
3
This table is based upon the number
of patients
treated for injuries
caused by type of accidents
listed:
Cases of injuries
1936
1936
1937
30
18
88
34
Collisions
caused
140
62
Table
4
Total admitted
Rate per 1,000
Invalided from
service
Sick days
U.
8.
Navy,
calendar
1934-
1935..
1937
881
860
7.66
7. 74
fl.Ul
33.597
33,833
1935
1936
1937
Marine
Barracks,
Quan-
tlco,
Va.,
service
per
sonnel
only
(assuming
3,000
average
dally
strength)
73
1935
24.33
13.0
1937
1935
1936
1937
12
1935
1936
1937
0
2,
DIVISION
OF
PREVENTIVE
MEDICINE
621
In the above
table,
due allowance
must be made for the fact that
the larger proportion of the naval service is afloat, which restricts the
days
available
for
automobile
driving,
whereas
the
rate
admitted
from this post is based on 365 available
driving days per individual.
FUNDAMENTAL
CAUSATIVE
FACTORS
OF RECKLESS
DRIVING
While it is highly probable
that percentages of traffic
accidents
are
only slightly higher
among
the enlisted
class than among similar age
groups in civil life
(i.
e., high
school
and
college students),
yet the
sudden release of the restraint of military
routine on men going on
liberty
apparently produces
a
psychological
explosion
in some of the
younger men.
Unnecessarily
fast and
reckless
driving by
a
sailor may then
be
considered
a
modern
counterpart of the traditional manifestations
of
his prototype of days gone by.
The
irresponsibility
and
exuberance
of youth
as
another
funda
mental factor
is
demonstrated
by
the fact that slightly
over
88.9
percent of those injured were of second pay grade or below.
As to be expected, admonitions and disciplinary measures are more
effective
with older men
;
youth
is
apt to be indifferent and unrespon
sive.
Consequently, the results of disciplinary measures in the reduc
tion of traffic injuries are more noticeable
in the older age groups.
The statistics of the Minister
of Transportation in England reports
60 percent
of all fatal accidents
are caused by young drivers still in
their "teens."
Estimating
this
age group
as composing
10 percent
of drivers in England,
the danger factor of this age group
would be
1,400 percent
higher than for the average percentage of all other
age
groups.
NATIONAL
TRAFFIC
ACCIDENTS
Since traffic accidents constitute a national and
a
local problem,
it
may be interesting to include some of these figures in this report for
the purpose of comparison.
The number of persons
killed
and
injured
in
the United
States
during
1931
totaled
1,032,000, or as many people
as the population
of Nevada, Delaware, Wyoming,
and the District of Columbia com
bined.
The casualties resulting from automobile
accidents for an 18-month
period ended December
31,
1931,
is
compared
below for
a
like period
to the battle casualties of the American Expeditionary Force.
Killed
Injured
World War
50.510
63,650
122,674
1,576,840
Automobiles
622
DIVISION
OF
PREVENTIVE
MEDICINE
The national economic
loss due to automobile
accidents
is $2,500,-
000,000 or more than the annual cost of public school education in the
United States.
The automobile
accident
deaths by 5-year periods are as follows:
1916-21
58,522
1921-26
98,551
1926-31
152,732
1931-36
172,715
National statistics show that youth of the driver is a contributory
factor in causing
automobile
accidents —drivers 20 to 29 years of age
have
100 percent
more accidents
than drivers in the fifth decade.
Similar figures are shown in the Surgeon General's
report for United
States Navy for 1936.
The injury rate per
1,000 for officers
35 to 39 years old is 2.94.
The injury rate per
1,000 for officers
20 to 24 years old is 10.24 —
over
300 percent greater
than above.
The
attached
chart
(fig.
16)
illustrates
the high ratio of traffic
accidents in the low rate groups
as compared
with more mature
men.
Discussion
of Chart
1.
Correlation
in the findings for
5 different years and for two military organ
izations —one
on west coast and one on east coast—that the danger factor varies
inversely with the ratings.
2.
The chart presents indisputable
evidence that
automobile
driving
at least
for senior ratings
in these localities
is a fairly safe procedure.
3.
Consequently
the corollary
can be drawn,
viz, the vast majority of service
motor accidents are avoidable.
Table
5. —Principal
driving
errors,
entire
Nation,
1937,
and number
of injuries
and deaths resulting
killed
Percent
Persons
injured
Exceeding
speed limit
On wrong side of road
Did not have right-of-way
Cutting in
Passing
standing
streetair
Passing
on curve or hill
Passing
on wrong side
........
Failed to signal and
improper
signaling
Car ran away— no driver
Drove off roadway
5driving
IMO
Total
9,380
3, 440
3, 030
510
100
360
230
310
50
1.890
4,440
1,760
36.8
13.5
11.0
2.0
0.4
1.4
0.9
1.2
0.2
7.4
17.4
6.9
227.M
124.290
197,400
37,470
3,660
11,880
9,140
53,920
2,740
53.010
138.910
24.9
13.6
21.6
4.1
0.4
1.3
1.0
5.9
0.3
5.8
15.2
5.9
25,500
913,900
100.0
It will be noted in the table above that excess speed was the primary
driving error.
C
o
H
M
M
3
S
'A
CO w
1
N3W
-NON
■9C6T
/o
avax
nod
'va
'oou-nvo©
'sxovaavq
aNiavw
v
Q]
"ES6T
yo
»vaA
acM
"VA
'ooiXHVnb
's'Movaavg
awavw
?
^|
CSfet
yo
3.,
aod
'aoacy
a-ii.Lvg'saaAOaisaa
S
^]
Z<ibX
Jo
wvax
acy
'aoaoj
a-ULvq
'sa3Aoaj.Ma
T
H
S!
o
'dlHSySNAAQ
31igOWOinV
OL
S3IUnrNI
OI=l=lVbJ_dO
O'-L^d
39VXN3Da3<j
624
DIVISION
OF
PREVENTIVE
MEDICINE
Table
6. — Types of collision
accidents,
entire
Nation,
19S7,
resulting in injuries
and deaths
Persona
killed
Percent
Persons
injured
Collision
with—
17,410
43.2
31U.160
677.510
10,600
120
26.3
.3
4.3
.8
.3
11.3
2.0
10.7
.8
6,600
1,730
320
120
7,470
14,540
4,560
810
4,040
88.060
31.890
77,170
4,310
320
4.650
Total
40,300
100.0
1,221,090
Percent
WORSE
THAN
WAR
Our Nation has engaged in 6 major wars since its birth in 1776.
In
total, these wars extended over a period of 15 years.
The number of
American soldiers
killed in action or died of wounds
during these
15
years of war was 244,357.
Now look at our 15-year peacetime record of death on the highways:
1923
18,031
1924
19, 228
1925..
21, 628
1926..
23, 264
1927
25,533
1928
27,618
1929
30, 858
1930.
32,540
1931..
33,346
1932
29, 196
1933
31,078
1934..
35,769
1935
36,023
1936.
37,500
1937.
40,300
Fifteen years of war, 244,357 casualties;
15 years of peace, 441,912
traffic deaths!
In war,
our soldiers
fought
and
died
for
a purpose.
But what
purpose
can there be in the killing of these hundreds
of thousands
on
the highways?
Truly, this
traffic
slaughter
is worse than war.
SUMMARY
The foregoing
discussion of traffic injuries of the personnel of Marine
Barracks, Quantico, Va., is hereby
summarized.
1. The number of cases dealt with in this study is sufficiently large,
so it is believed,
to warrant the general deductions
herein expressed.
2. Traffic accidents
resulted in:
(a) Admissions
to sick list.
lb)
Men killed
(c) Invalided from service-
lit) Men hospitalized
1936
1936
1937
73
3
3
73
39
|
1
0
I
39
36
5
0
36
DIVISION
OF
PREVENTIVE
MEDICINE
625
3. Such accidents
represented
in loss to the Government approxi
mately
$78,500 in 1935; $17,225 in 1936; $63,545 in 1937.
4. The older officers
and higher ratings were strikingly
less pre
disposed
to traffic accidents.
5. The vast majority of accidents
may
be classed as avoidable
as
indicated by the fact that the higher-rated men
were able
to drive
automobiles with very few accidents
during
1937.
6. Youth was a most important contributory
factor.
7. Gratifying
results
are
already
in
evidence,
attributed
to
the
Commanding General's
campaign
against reckless driving.
The following tabulation
(tables
7 and 8) presents
the injuries and
disabilities
among
service
personnel
treated
by the Medical Depart
ment, Marine Barracks, Quantico, Va., during the calendar year 1937.
The tables in this report were prepared
from an analytical study of
these data.
Table 7.—Not incapacitated
Rate and age
Extent
of injury
Passenger or driver
and cause, etc.
Pvt., 23
Pvt., 23
Pvt., 21
Pvt., 28
Pvt., 20
Pvt., 23
1st. Lt., 27
ChMaran,47.
Sea. lc, 29
PhM 8c, 21...
PhM 3c., 22...
Pic, 29
Sgt., 30
CpL, 81
Contusion,
right knee..
Laceration,
lip, and broken
teeth
Laceration
left, upper
eyelid;
lacera
tion, chin and right knee.
Wound, lacerated left cheek, 2-inch....
Laceration
of thumb, ring finger, mid
dle finger of right
band.
Abrasions,
forehead and left hand
Laceration
(small),
each side of fore
head.
Fracture,
scaphoid
right wrist
Laceration,
K-inch,
chin;
laceration,
lH-inches,
left
wrist;
1-inch lacera
tion, right elbow.
Laceration,
1-inch, upper lip
Contusion,
right leg, foreign
body in
eye.
Laceration,
right upper
eyelid;
contu
sion, face.
Multiple lacerations,
face
Laceration,
H-lnch,
upper llp; contu
sion, right '
Passenger.
While
going
downhill, driver of
tractor
struck
a
rock,
overturning,
and
patient Jumped off, causing
the injury.
Passenger.
Car had to stop quickly and threw
patient into windshield.
Driver.
Forced off road by truck into ditch.
Passenger
on running
board.
Was standing
on running board of car while
backing
into
filling station
and
was caught
between
car
and door.
Driver.
Cranking truck and it kicked, throw
ing patient
against truck.
Passenger.
While returning
to Quantico
from
Triangle,
driver went to sleep, car hit post,
and overturned.
Driver of tank.
While driving tank
ran into
tree.
Driver.
Was driving along
highway,
another
car struck him head-on, due to going to sleep.
Driver.
Car in front
suddenly
stopped,
caus
ing
patient's
car to
swerve
and
hit bridge
abutment.
Passenger.
Ran into
back of parked truck to
avoid hitting oncoming
car.
Driver.
Head-on collision— curve at Dumfries.
Driver.
Struck
curbing
on
roadside
due
to
being blinded
by oncoming
car.
Passenger.
Car in which
patient
was riding
collided
with another
car
bead-on— due
to
other
car being
on wrong
side
of road
and
without lights.
Driver.
Head-on
collision
with another car on
a curve.
626
DIVISION
OF
PREVENTIVE
MEDICINE
Table 8.—Incapacitated
Rate
and age
Extent of injury
Final dispo
sition
and
total sick
days
Contributory or causative
agent
Pvt., 24
Pvt., 19
Pvt., 21
Pvt., 18
Pfc, 23
Cpl., 27
Pvt., 22.
Pvt., 22
Sgt., 26
Pvt., 20
Pvt., 24
Pvt., 23
Pvt., 30
Set. Sgt., 43.
HAlc, 21...
Pvt., 22
Pvt., 20
Pvt.,
19
Pvt., 21
Pfc, 21
Bgt., 32
Cpl., 28
Cpl., 23
Pvt., 22
Pfc, 26
Pvt., 21.
Sgt., 32
Cpl., 25
Sgt., 40
Sgt., 30
Asst. Ck., 38.
Pvt., 29
Pvt., 21
Pfc, 29
Pvt., -
Cpl., 41
Wound, lacerated
scalp and right
frontal
region.
Laceration,
1 inch,
palm
of right
hand; contusion,
right elbow.
Dislocation
right
femur
at
hip;
laceration,
M inch cheek; D. U.
fracture right uina.
Injury, right shoulder
Laceration,
forehead, right
cheek,
right hand; abrasion, right knee.
Punctured
wound, right cheek, M
inch.
Fracture,
simple
proximal,
pha
lanx right thumb.
Fracture,
simple
proximal,
pha
lanx right thumb.
Fracture,
simple
proximal,
pha
lanx right thumb.
Fracture,
fifth
metacarpal
bone,
right hand.
Laceration,
lower lip
Laceration,
left eyelid,
right
fore
arm, and left forearm.
Laceration,
left eyebrow
and right
knee.
Laceration,
left elbow;
laceration
right face.
Laoeration,
forehead
Laceration,
nose and left knee.
To duty;
6
days.
To duty; 18
days.
To duty; 12
days.
To duty; 23
days.
To duty; 48
days.
To duty; 5
days.
To duty; 19
days.
To duty; 23
days.
To duty; 23
days
To duty; 22
days.
To duty; 10
days.
To duty; 16
days.
To duty; 16
days.
To duty; 13
days.
To duty; 62
days.
To duty
days.
16
Laceration,
scalp and right
shoul
der; contusion,
hack.
Contusion,
left foot
Contusion,
lumbar
region
Laceration
over right eye
Laceration,
left elbow;
contusion,
left side of scalp.
Compound
fracture,
left clavicle;
laceration,
left
forehead
and
shoulder.
Fracture,
simple,
first
phalanx
right
fourth linger.
Laceration,
forehead,
nose,
and
upper
gums;
fracture,
simple,
fourth cervical
vert.
Laceration,
led elbow
and scalp;
fracture, ribs.
Lacerations,
lower
lip
and
right
forehead.
Fracture,
right patella; contusion,
right hip and right arm.
Fracture,
simple,
second,
fourth,
and fifth right metacarpals.
Laceration,
right
leg,
lower
lip;
three teeth knocked
out.
Fracture,
left clavicle
Compound
fracture,
nose
Burns
and
injuries,
multiple ex
treme.
Dead upon arrival.
Wounds,
multiple extreme
Injuries,
multiple extreme
Contusion,
occipital
region; lacera
tion, scalp.
Carbon-monoxide
poisoning
To duty;
2
days.
To duty; 13
days.
To
duty;
3
days.
To duty; 2
days.
To
duty;
4
days.
To duty;
90
days.
To duty; 15
days.
To duty; 19
days.
To duty;
15
days.
To duty;
44
days.
To duty;
42
days.
To
duty;
9
days.
To duty;
37
days.
To duty; 52
days.
To duty;
40
davs.
D.D.;0days.
D. D.;0days.
D.D.;0days.
D.D.;lday.
D.D.;0days.
Passenger
In car that
collided
with
railroad
underpass
due to fog.
Pedestrian—
was hit by oncoming
car
while
standing
on side of highway.
Pedestrian —was
crossing
highway
and staggered hackward
into car.
Pedestrian —crossing street in D. C.,
stepped
hack from oncoming
taxi-
cab into path of another
car which
struck
htm.
Pedestrian—
while
walking
was
hit
by car from rear.
Passenger— while
jumping
off
run
ning
car patient
fell on pavement,
causing the injury.
Passenger— while cranking
a liberty
truck,
it hackfired
and kicked.
Driver of car— while cranking
liberty
truck the crank
slipped
and hand
hit bumper.
While cranking
truck it hackfired.
While cranking
truck it hackfired.
Passenger— head-on
collision
with
another car.
Passenger— head-on collision.
head-on
collision
with
truck.
Driver of car in head-on collision
with
another car.
Passenger— driver
lost control
of ear
on curve and hit telephone
pole.
Driver—rounding
curve on left-hand
side
of
road.
Head-on
collision
with another car.
Passenger— driver hit a truck head-
on.
Patient
was
asleep
in
back
seat.
While
pulling
loaded
trailer,
foot
slipped
under
front
wheel.
Passenger —driver
collided
with rail
road underpass due to fog.
Passenger— driver
collided
with rail
road underpass due to fog.
Passenger— tire
blew
out
and
ear
overturned.
Driver of car which
was foroed
off
road into ditch.
Driver—while
cranking
truck
it
kicked
back.
Passenger
in
tank
which
struck
a
tree.
Driver
of
car
In
head-on
collision
with another car.
Driver— fell
asleep,
hit
post,
and
overturned.
Driver of car which collided with rail
road
underpass
while
rounding
a
curve in rain and fog.
Passenger— riding
behind
driver
and
could
not see what occurred.
Driver of car on which tire blew out-
car overturned.
Driver— blinded
by
oncoming
car
and ran off road, overturning.
Passenser of car which
ran into hack
of parked truck.
Driver of car which
collided
head on
with a truck.
Driver of truck
which
was struck by
a passenger train.
Driver of tractor which ran over large
stone and overturned.
Driver
of
motorcycle
which
drove
into car from rear.
Driver of car— found dead.
DIVISION
OF
PREVENTIVE
MEDICINE
627
The following tabulation
(table
9)
presents
the
injuries
and
dis
abilities among civilians treated by the Medical Department, Marine
Barracks, Quantico, Va., during the calendar year 1937:
Table
9
Age,
sex, and race
55, male, w hite .
30, female, white..
?, male, white
43, male, white...
88, male, white. --
31, male, white. -.
18, male, white...
28, female, white..
40, male, white
40, male, white
50, female, white..
30, male, white
20, female, colored.
27, female, white-
7, male, white
23, female, white..
25, male, Negro.. .
25, male, Negro...
25, male, Negro...
6J4, male, Negro..
22, female Negro. .
30, female, Negro .
50, male, white...
40, female, white..
52, male, Negro...
27, male, Negro...
40, female, Negro .
18, male, white...
—, male, white....
20, female, white..
Extent of injury
Fracture,
left femur;
fracture,
ribs
with
puncture
left
lung;
contu
sion,
forehead;
laceration,
right
leg and elbow.
Lacerations,
extreme
scalp;
intra
cranial
injuries;
fracture
ribs;
lacerations,
multiple,
both legs.
Wounds,
multiple
extreme (D. D.).
Wound,
6
inches,
forehead
and
scalp;
laceration,
2 inches,
occip
ital region.
Lacerations,
forehead..
Laceration,
6 inches, occiput;
lacera
tion,
2
inches,
right
forehead;
laceration
nose; contusion,
left eye
and left forehead.
Wounds,
multiple
extreme;
frac
tured skull
and mandible.
Sprain,
left ankle
and right
elbow;
large abrasion left hip.
Laceration,
3 inches, forehead; frac
ture, left upper rib.
Bums, second degree, right leg; frac
ture,
right
patella;
lacerations,
both legs, face, and scalp.
Laceration,
3
inches,
forehead;
laceration.
2 inches, left knee.
Laceration,
2ii inches, scalp
Contusion,
left hip
1-inch laceration, right eyebrow
Fracture,
left clavicle
Fracture,
right
radius
and
ulna;
lacerations,
face, scalp,
and
both
knees.
Fracture,
left
patella;
laceration,
chin.
Lacerations,
upper lip and left leg;
fracture,
mandible.
Pronounced
dead upon arrival
Multiple
laoerations, left scalp
Sprain,
right angle
Fractured
rib, right side; contusion,
back.
Multiple lacerations,
right leg, right
ear, and contusion,
neck.
Multiple lacerations,
right elbow
Contusions,
left hip; abrasions, right
occiput
and left shin.
Lacerations
and
contusions,
scalp,
face, and left shoulder.
Lacerations,
scalp and face
Contusion,
left eye with ecchymosis.
Contusions,
left shoulder
and face. . .
Contusion,
head.
Passenger or driver,
cause, etc.
Driver of car in head-on collision...
Passenger
in car involved
in head-
on collision.
Passenger in truck hit by train
Passenger in rear of car involved
in
head-on collision.
Driver
of car
which
skidded
and
overturned
on wet pavement.
Driver
of car
which
skidded
and
overturned.
Passenger in car which
ran into rear
of truck.
Passenger in car, and while attempt
ing to close door
she accidentally
fell out.
Passenger
in car involved
in head-
on collision.
Driver of car in head-on collision
Passenger
in
car which
sideswiped
another and overturned.
Driver of car which
was sideswiped
by another.
Passenger in car which
sideswiped
another.
Pedestrian —hit by car while
walk
ing along the highway.
Fell off bicycle and struck
sidewalk-
Passenger
in i
on collision.
' involved
in !
Driver of car which
collided
head-
on with another car.
Passenger
in car involved
in
head-
on collision.
Passenger
in car involved
in
bead-
on collision.
Passenger in car which
skidded,
ran
into bank, and overturned.
Passenger
in
car which
ran
out
of
control
while
rounding
a
curve
and ran into a bank.
Passenger
in car which
skidded
on
curve and overturned.
Driver of car involved
in head-on col
lision
with car on wrong
side of
road.
Passenger
in
car
which
collided
head-on with another.
Driver of car—lost control
on curve
and hit bank.
Passenger in car which
went out of
control on curve and hit a bank.
Passenger
in car which
went
out of
control
on curve and hit a bank.
Driver of car which hit an unknown
object head-on.
Driver of car which
caught
afire—
jumped
out while
car was in mo
tion.
Passenger
in
car
which
drove
oil
left-hand
side of road.
628
DIVISION
OF
PREVENTIVE
MEDICINE
Table 9—Continued
Age, sex, and race
Extent of Injury
Passenger or driver,
cause, etc.
31, male, white
32, male, white—
27, male, white...
65, female, white.
14, male, white...
44, male, Negro..
24, male, Negro..
36, female, Negro.
23, male white
35, male, white....
24, female, white..
26, male, white
24, female, Negro..
24, female, Negro..
22, male, Negro...
27, male, white
68, male, white
72, female, white. .
28, male, white
24,female, Negro..
18, female, white.
20, male, white...
22, male, white...
60, male, white...
21, male, Negro..
25, male, Negro..
25, male, Negro..
19, male, Negro. .
—.female, Negro.
22, female, white.
42, male, white...
21, female, white..
35, female, white.
22, male, white ...
24, female, white.
21, female, white.
Laceration,
\i
inch,
right
middle
finger.
Incised
wound,
W inch, left buttock
Contusion,
left chest.
Contusion,
chest
Abrasion,
left forearm
Contusion,
right
temple;
sprain,
hack.
No evidence of injury (intoxicated)
.
Wound lacerated,
forehead,
scalp,
face, and right hand.
Multiple lacerations,
scalp and face;
contusion
chest.
Fracture,
left thigh; laceration, scalp
Abrasions,
left
buttock,
left
shoul
der, right forearm, chin, and right
cheek; laceration,
1 inch, left eye
brow.
Laceration,
left knee, left wrist,
and
right elbow.
Lacerations,
face and forehead
Lacerations,
face
Incised wound, dorsum of right hand-
Shock
Contusion,
left knee
Compound
fracture, left tibia
Contusions,
right chest and knee—
Contusion,
hack
Lacerations,
scalp;
contusion,
right
foot.
Abrasion,
right
wrist
and
elbow;
contusion,
right leg.
Fracture,
left
femur;
laceration,
sc'Up. 4 inches.
Fracture,
mandible
and left Innoml-
naie; laceration,
left forehead.
Abrasion
of hands
-
Lacerations,
occipital
region;
2H
inches, right ear.
Lacerations,
forehead,
face, elbow,
and scalp.
Lacerations,
1 inch, right
arm; con
tusion,
pelvis.
Lacerations,
eyebrow,
right
shoul
der, right
arm
and forearm,
and
left elbow.
Prohable
internal
Injuries
Dislocation
left shoulder.
-
Compound
fracture
right
femur;
fracture
left
tibia;
fracture
left
fibula.
Facture
left humerus;
wound,
lac
erated
(2 inches) forehead.
Contusion
left chest
and
lacerated
left forehead.
Lacerations,
severe, nose and upper
lip; contusion,
left chest.
Lacerations,
face and neck
Caught
finger in car door while clos
ing it.
Driver of truck
which
skidded
on
wet pavement
and overturned.
Driver
of
truck — lost
control
and
ran off road.
Passenger
in car which
swerved
to
to avoid another, and in so doing,
overturned.
Bicycle
slipped
and
patient
was
thrown
off onto pavement.
Passenger in car which
ran off road,
overturned,
and struck
telephone
pole.
Passenger in car which
ran off road,
overturned,
and struck
telephone
pole.
Passenger in car which
ran off road,
overturned,
and struck
telephone
pole.
Driver of car which
ran Into rear of
truck.
Passenger In car which ran Into rear
of truck.
Passenger
on motorcycle
which
hit
gravel on a curve and overturned.
Driving motorcycle
which hit gravel
on a curve and overturned.
Passenger
in
car
which
struck
another head-on on a curve.
Passenger
in
car
which
struck
another head-on on a curve.
Driver of car
which
collided
with
another head-on.
Passenger in car involved In head-on
collision.
Passenger in car which skidded
and
ran into a hank.
Passenger in car which skidded,
left
highway,
and overturned.
Passenger in car which
skidded,
left
highway,
and overturned.
Passenger in car which slid on curve
and overturned.
Passenger in car involved
in head-on
collision.
Driver
of car involved
In head-on
collision.
Passeneor in car involved
in head-on
collision.
Driver of car which collided
head-on
with another.
Passenger in car involved
in head-on
collision.
Passenaer in car involved
In head-on
collision.
Passenger in ear Involved
in head-on
collision.
Driver of car which collided
head-on
with another iu middlelane.
Passenger ? (intoxicated)
—
Passenger in car 1orced off road by
another car.
Driver of car which skidded
on road
and overturned.
Passenger.
Circumstances
not
kuowu.
Driver
of
car
on
wet
pavement;
skidded
and sideswiped
a tree.
Passenger in car which
skidded
on
road and hit tree.
Passenger in car involved In bead-on
collision.
Passenger in car which collided with
truck.
DIVISION
OF
PREVENTIVE
MEDICINE
629
Table
9—Continued
Age, sex, and race
Extent
of injury
Passenger or driver,
cause, etc.
Retained
in sick
quarters
—yes or
no
32, male, white
Contusion,
right shoulder
and
hip;
fracture
of ribs, right upper
chest.
Passenger— thrown
from
car
after
catching
a ride.
No.
No.
31months,
female,
white.
Passenger incar which stopped sud
denly,
throwing
child
against
framework
of car.
18, male, white.
Contusion,
left
knee,
thigh,
arm,
and parietal
region.
Pedestrian—
while
placing
tools
in
telephone
truck, truck was struck
in rear.
No.
45, male, white.—
Contusion,
left thigh
and
elbow;
abrasions,
left thigh and elbow.
Pedestrian—
while
placing
tools
in
telephone
truck, truck was struck
in rear.
No.
2, female, white...
Abrasion,
lumhar region
Pedestrian—
was struck by car back
ing out of garage.
No.
No.
No.
No.
No.
18, male, white
Pedestrian— struck
from
behind
by
auto while
walking
down street.
Vri, male, white..
Abrasions,
right side and both great
toes.
Pedestrian—
walked in front of truck
from sidewalk.
19, female, white..
67, male, white.
Passenger in car of which
driver lost
control,
running
into ditch.
Wound,
lacerated
(M
inch)
right
cornea; abrasions,
face and hands.
Driver of car which
sideswlped
an
other.
FOOD
POISONING
IN THE FIRST MARINE
BRIGADE. FLEET MARINE
FORCE, CULEBRA, P. R.
By Lieutenant
Commander J. B. O'Neiu.,
Medical Corps, United States Navy
At noon on February 6, 1938, 20 persons at the brigade staff officers'
mess ate cooked fish, and from 1:15 p. m. to 7 p. m., all but
1 of the
persons who had eaten of the fish became acutely ill.
The responsible
fish, a female roe amber jack (Seriolafasciata),
was
caught between 2 and 3:30 p. m. February 5, about one-half
mile south
of Cayo Agua,
a small
cay about
2 miles
west of Culebra.
It was-
pronounced
by a native fisherman
to be an edible fish and was placed
in a live well of the boat.
It remained
there until about 4:30 p. m.,
when it was transported
to the camp
ashore and placed
on ice, less
than an hour after the fish died.
The fish was ordered cleaned before
being placed on ice but this was not done.
On the morning of Feb
ruary 6 the fish was cleaned and filleted.
The fillets were broiled
for
20 minutes,
baked in an oven for 2% hours,
and served at the noon
meal.
Most of the
mess ate heartily,
several
commenting
on
the
unusually fine flavor of the fish.
Some ate of the roe, cooked with the
fish, but most did not.
The symptoms
were predominantly gastrointestinal, geni to-urinary,
and nervous.
The symptoms
and signs during the first 12 hours were:
Metallic taste in mouth.
Burning
sensation in epigastrium,
spreading later over the entire abdomen.
Nausea and vomiting.
Profuse watery diarrhea with colic.
Frequent
scalding urination.
Weakness and aching of arms and legs.
Dizziness.
Flushing
of face.
630
DIVISION
OF
PREVENTIVE
MEDICINE
On the following morning (February 7), most of the gastrointestinal
symptoms had
ameliorated
and many of the patients ate breakfast
without distress.
All complained
of most the following symptoms:
Frontal headache.
Weakness and aching of arms and legs.
Hyperesthesia
of
extremities.
There
was
numbness,
tingling,
and
itching,
which was accentuated by washing in cold water or touching
a cool surface.
Hyperesthesia
of mouth and tongue without
disturbance
of taste.
Drinking of
cold water caused
severe
burning of the mouth and tongue and, in three cases, of
the teeth also.
Frequent
scalding urination.
Sleeplessness
and nervousness.
Diminished
patellar and Achilles
reflexes
in most cases.
Petechiae of upper arm and lower legs in several cases.
Urine
showed albumin,
granular
casts,
and mucus in most cases.
Some urine
specimens were tested for copper and found negative.
On February
8, the following symptoms
and signs were present in
most of the cases:
Hyperesthesia
of extremities, mouth, and tongue.
Nervousness and sleeplessness.
Diminished
or absent patellar
and Achilles
reflexes,
with negative Rhomberg.
On February
16, 10 days after the onset of symptoms,
no one case
had made a complete recovery
though none are incapacitated for duty.
The residual
symptoms
consist
principally
of burning of the mouth
and
tongue
on drinking
cold liquids, itching of the hands
and
feet,
weakness of legs, and diminished
reflexes.
The following treatment
was given:
Early elimination by the use
of purgatives; salt in
cases
showing
dehydration; stimulation
with
hot black coffee; relief of pain by hot-water bottles; morphine,
when
required; and for several
days
after
the attack, sedatives
and hyp
notics as required.
Amberjack
and barracuda from the same locality
as the fish
re
sponsible
for these cases
of poisoning
have
been eaten
a number of
times without causing symptoms
of toxicity.
One amberjack, caught
at the same time as the toxic fish, was cleaned, salted, placed on ice on
February
5, and eaten without ill effects on the following day.
Upon
inquiry
three
fishermen
made
statements
essentially
as
follows:
(1)
Until
10 years ago we never had this trouble
here and we could eat any fish
we caught
here.
We have always
known
that
fish caught around
St. Thomas,
near Sail
Rock,
near Culcbrita,
and on the north
coast of Vieques
sometimes
made people sick.
They all get over it, but it leaves
them with bad legs for some
time.
I never heard of anyone dying of it.
Most fish here
never make people
sick.
It
is only
some
kinds.
The
fish most apt to
be poison
are
the picuda
(barracuda),
the jurel
(skipjack),
the
medregal
(amberjack),
and
the
cojinua.
Three years ago I caught a barracuda
on the north coast of Vieques and before I
returned to Culebra in about
3 hours the fish died.
A man begged
me to sell him
some.
I did not want to do it but he begged
me so hard I did.
I cleaned the fish
DIVISION
OF
PREVENTIVE
MEDICINE
631
and while I was doing it my cat licked up some of the blood but did not eat any
of the fish.
The
next day the cat's legs
were
all limber
and it could not walk
straight.
The man that ate the fish was sick too and had much trouble with his
legs.
It took the man a month to get well and the cat died.
The lobsters never
give this sickness and most of the other fish do not.
It is only the big fish, the
old ones, that
do.
(2)
We only have this trouble
in 3 months — November,
December, and Janu
ary.
During these
months
the wind blows strong from
the east
(the northeast
trade
winds).
We know
that
fish to the
east
of Culebra
eat something
that
makes them poison, and when the water
gets
rough over there those fish come
around to the west side of this island.
When you catch one of those fish that
has
come
here and eat it, you get sick.
Many of these people get sick that way.
(3)
Most of the older people have had this trouble and we do not think much
about it.
You cannot tell by the taste of the fish whether it is poisonous or not.
Generally, people
put a silver spoon with the fish while it is cooking.
If the spoon
turns black the fish is bad and they throw it away; if it does not turn
black the
fish is good.
When they
get sick the people here
take the young leaves of the
mangre
and make a strong tea of it and put in some sugar.
They drink
a little of
the tea every little while, and the trouble
with
the legs
is gone
in
7 or 8 days.
Without this tea most people are all right in 3 weeks,
but some
have trouble for
3 months.
The mangre,
also called botoncillo,
is a kind of a mangrove,
but does
not grow in the water, but in the sandy soil close to it.
I have seen many
cases
of this sickness.
I have two pigs that ate jurel.
They had trouble
with
their
legs for weeks but are all right now only they eat too much.
The pigs are not as
big as the other ones of the same litter.
The jurel is nearly always bad and so is
the cojinua.
Young picudas are all right and so are the medregals,
it is only the
old ones that are bad.
Even the kingfish when it is big is sometimes bad.
Dr. Laujier, public health officer of Vieques,
stated "We never have
any fish poisoning
in Vieques.
I never heard of a case here."
Certain
data
regarding
the
toxic
substance
may
be
considered
definitely assured:
(a) It is not universally
present
in the fish of a species in these
waters.
(6) It is
thermostable,
having
resisted
20
minutes
broiling
and
2% hours of baking.
(c) It is a gastrointestinal irritant,
a genito-urinary irritant,
and
it is toxic to
the nervous
system,
apparently
affecting
chiefly
the
peripheral nerves.
FISH
POISONING
IN
CULEBRA-VIRGIN
ISLANDS
AREA
By Captain W. L. Mann, Medical Corps, United States Navy
The
outbreaks
of
fish
poisoning in February
1938
during
fleet
exercise No. 4 were similar in many respects to one observed in ward
room
mess of
the
cruiser
Tennessee
in
1909
at Honolulu,
T.
H.,
caused by toxic species of fish.
Historical. — Ciguatera
is the Spanish
term for fish poisoning in the
West
Indies.
The
word,
originally
written
Siguatera
in
1787,
is
derived
from
Cigua,
a
poisonous
marine
snail,
present
in
Cuban
waters.
632
DIVISION
OF
PREVENTIVE
MEDICINE
Peter Mayer,
the first historian of the West Indies, wrote in
1530
of a tree whose fruits were sure poison.
"When fruits fall into
the
water and are eaten by the fish, people who afterwards eat these fish
are attacked by divers strange maladies."
Gudger believes
this
tree to be the manchineel
(Hippomane man-
cinella).
One observer,
in 1675,
reports "Many of the fishes are poysonous,
bringing great pain, with several days of itching."
This
affection
was
described
several
times
in
the
1700's,
and
numerous
articles
appeared in the 1800's (Cudger).
Naval
medical
officers,
particularly
Walker,
have
made
detailed
description of the clinical syndrome
caused by ingestion
of fish caught
in waters off St. Thomas, Virgin Islands.
Icthyotoxismus
has been reported
for the West Indies by modern
authors—Rosenau,
Gudger,
and others.
The following toxic fish are found in Culebra, Virgin Islands area:
Family Carangidae —Pompano.
(a) Amberjack —Seriola fasciata.
Generally
called
medregal.
It
closely
resembles
the
California
yellowtail.
(b) Skipjack —Caranx
latus.
Generally
called
jurel or
cavalla.
Other
names
are
horse-eyed
mackerel,
horse-eyed
jack,
yellow
jack.
(c) Yellow-tail —Elongatus
bipinnvlatus.
Generally
called
cojinua.
2. Family Scombridae.
(a) Kingfish —Scomberomorus cavalla, regalis,
pintado,
or
sierra.
Generally
called
cera,
or
sierra.
The
giant
kingfish or spotted mackerel.
3. Family Sphyraenidae.
Barracuda —Sphyraena
barracuda.
Gen
erally called picuda or becune.
The fishermen in the Virgin Islands include the red snapper among
the list of toxic species.
Impression
of nature of toxin:
1. An alkaloid.
2. Thermostable
and resistant to drying.
3. A physiological
toxin.
4.
No connection with Salmonella enleritidis, or others of Gartner
group.
5. It is not a food toxemia due to botulism,
as cooking does not affect the toxin.
6. An unknown
local factor
causes
certain species to be poisonous.
7. The unknown
factor
is definitely
restricted
in
location
and
is sometimes
limited
to a water area of a few square miles.
The
localized
distribution
of
toxic
fish
has
been
attributed
to
feeding
of
fish
on
poisonous
food
in certain fishing grounds.
For
example:
1.
Algae plants in proximity
to old copper mine.
2. Berries from manchineel tree.
3.
Poisonous
moss or mollusks.
4.
Species
of marine plant called cobriza.
DIVISION
OF
PREVENTIVE
MEDICINE
633
Symptoms:
General. — Symptoms appear suddenly, from
1 to 6 hours after ingesting the fish.
The clinical
symptoms
are
severe,
and the patient's
general
condition
is more
critical than those observed in outbreaks of food poisoning in our naval service.
Gastrointestinal. — Nausea, vomiting,
diarrhea, metallic taste in mouth.
Cutaneous. — Flushing
of skin, tingling
sensation, and itching,
often severe
and
lasting
for several
days.
A British naval surgeon in Barbadoes reports a case of
skin
eruption
like
leprosy,
persisting
for years,
with
nails
of hands
and
feet
falling out.
Motor
system. — Weakness in legs.
In the case of a civilian
woman, paralysis
of lower extremities
existed for several months.
Diminished
or absent patellar
reflex.
In acute attacks
there
are cramps of muscles
of arms and legs.
Nervous
system. — Hyperesthesia
and
paresthesia
of extremities,
mouth,
and
tongue.
Cold
food and drinks
give a burning
sensation to mouth
and tongue.
A cold metal railing
feels
warm to the grasping hand — this symptom
is almost
diagnostic
and persists for
weeks.
Nervousness,
restlessness,
and insomnia
are
present.
Urinary system. — Albumin and casts in urine.
Frequent
micturition.
Diagnosis:
The clinical syndrome
caused by ingestion
of the toxic fish caught
in Culebra-St.
Thomas waters
may be
differentiated
from
the dis
order caused by Clostridium
botulinum by the following:
1.
Elevated
temperature.
2. Early onset of symptoms.
3. No detoxication
of food by cooking.
4.
Lower
case fatality rate.
5. Presence of sensory disturbances.
It may be differentiated
from "food infection"
by
the
Gartner
group bacillus by:
1.
Clinical
symptoms
are apt to be more severe.
2.
Prolonged
convalescence.
3.
Paresthesia of hands, mouth, and tongue.
4.
Cutaneous itching.
5.
Causative
factor not destroyed by cooking.
The diagnosis
of fish poisoning
may be made on:
1. History of eating fish within
1 to
10 hours.
2. Metallic taste.
3.
Paresthesia —contact with cold objects giving
a warm sensation.
4.
Prolonged
convalescence.
One
officer
who
had
eaten of an
amber jack
4
weeks
previously
noticed that when eating ice cream it felt so hot to his mouth that he
subconsciously blew his breath on the ice cream in order to cool it.
The burning sensation caused by cold objects is regarded
as pathog
nomonic of this type of fish poisoning.
SUMMARY
The tentative conclusions
seem to be warranted that:
1. Toxic fish are present in certain well-defined
areas.
2.
The same
species
may be nontoxic in other areas.
634
DIVISION
OF
PREVENTIVE
MEDICINE
3. There
is a seasonal
influence on the toxicity.
4. Individual fish of the same
species
caught in the same
area on the same day
vary in their toxicity.
5.
The
symptoms
are
caused by
a specific
toxin,
the
nature of which
is un
determined.
6. The symptoms
are
so severe
that
all visitors
should
avoid
eating any
fish
caught in Culebra- Virgin Island
area.
References
Walker,
F. D.:
Fish
Poisoning
in the Virgin Islands,
U. S. Naval Med.
Bull.
17:
193.
1922.
Gregory,
C. R.:
Three
Cases
of Food
Poisoning
Attributed to Eating Freshly
Caught
Fish.
U. S. Naval
Med. Bull. 23: 316.
1925.
Jarvis, N. D.:
The
Fisheries
of Puerto
Rico (Investigational
Report
No.
13)
Government
Printing Office, Washington.
1932.
Costa
Mandry,
O.:
Food
Poisoning
in
Puerto
Rico.
The
P.
R. Journal
of
P. H. and Trop. Med.,
Vol. IX, No.
1.
Sept.
1, 1933.
Gatewood, J. D.:
Naval Hygiene.
Gudger, E. W.:
Poisonous
Fishes, and Fish Poisoning,
With Special Reference
to Ciguatera
in West Indies.
Am. J. Trop. Med.
10: 43.
January
1930.
Mobray, L. L.:
Fish Poisoning.
Bulletin N. Y. Zoological
Soc.
19: 1422-23.
Rogers, J.
M.:
West
Indian
Poisonous
Fishes.
Popular
Science
Monthly,
55: 680-685.
1899.
FOOD
POISONING
ON BOARD THE
U. S. S. "PHILADELPHIA"
By Commander
Oscar Davis, Medical Corps, United States Navy
At about
1 p. m. on January
19,
1938,
the day of sailing from San
Juan, P. R., men began
to complain of colicky
pains
in the upper
abdomen,
weakness,
and frequent loose, watery stools.
Most of the
24 men admitted to the sick list had nausea, and vomited, and 8 com
plained of pain in the legs.
The symptoms
presented
on the first day were quite severe, all of
the patients
appearing
quite toxic and weak, with temperatures
rang
ing from 102° F. to 105° F.
The temperatures
of those admitted on
the second day were not as high, to 102° F., and for those admitted on
the third day the temperature
did not go above 101° F.
Investigation revealed that each man had been ashore and that 8 of
them
drank water,
23 drank iced drinks
at the ship's
service
store
aboard
ship,
and
those
men not drinking
iced drinks at the ship's
service store drank iced tea at meals aboard ship.
Ice obtained from
ashore in San Juan was used in iced drinks served at the ship's service
store and in iced tea served to the general mess at meals.
The medical
officer
was informed that the ice was certified
as
to quality.
This
statement
was accepted
as a reasonable
guarantee
that the ice was fit
for human consumption.
The above information covered
the period of time the ship was in
San Juan, P. R., from January
15
to
18, inclusive, which would
give an incubation period of from 3 to
5 days.
The ice was used in
DIVISION
OF
PREVENTIVE
MEDICINE
635
iced tea first on January
15 and the first symptoms
were noted by the
men on January
18 though not reported until they became quite ill on
January
19.
The onset was sudden,
with sharp
pains in the upper
abdomen.
The symptoms
in most instances
subsided in 4 days and
convalescence
was relatively slow
Intestinal colic and frontal head
ache were present
as was also a loose, watery diarrhea with frequent
stools.
There
was
moderate
prostration.
The
pulse
rate
was
in
normal relation
to
the
temperature,
regular,
and
of good
quality.
Blood pressures were within normal limits.
Respiration was not mark
edly
increased
and
blood counts
showed
about
15,850
WBC
with
differential of 18 bands,
66 segments,
15 lymphs, and
1 monocyte.
On the outbreak of symptoms
the question
of food
as a possible
source
was
investigated
and
could
not be connected
with
the out
break.
The ice aboard
was cultured, found contaminated
and was
thrown overboard.
Ice was
then
furnished
the ship's
service
store
from the ice made aboard
ship from ship's water.
The men affected
were in various messes
and no one mess showed
a majority of cases.
Some few men in the crew did not take iced tea but it is believed
the
majority
did.
No cases appeared
from the captain's, wardroom, or
warrant officer's
messes,
all of which used ice made aboard
ship.
The bacteriological
findings were as follows:
January 15, 1988. —Harbor water at San Juan, before and after passing through
the ship's evaporators,
cultured by Dominick
and Lauter method and found to be
contaminated
by organisms of the
Coli-aerogenes
group.
This was a test on the
ability of the evaporators to clear the water if contaminated.
January
18,
1938. —Water
from
city
lines
showed
slight
contamination
by
.organisms of the Coli-aerogenes
group, by Dominick
and Lauter method of culture.
After the addition of iodine the water was again cultured and showed no reaction —
negative.
January
17, 1938. —City water was conveyed to the ship's evaporators
and dis
tilled there.
Tests from ship's tanks by Dominick
and Lauter method showed no
.contamination.
January
19,
1938. —Ice taken aboard
at San Juan showed contamination
by
organisms of the Coli-aerogenes
group, by the Dominick and Lauter
method, with
50 percent of gas after
26 hours of incubation.
Broth culture
made from
ice,
and after incubation
gram stain was made, which showed numerous gram nega
tive bacilli, some with a tendency to bipolar staining.
January
SO, 1938. — Recheck on ice showed fecal contamination
with 50 percent
production
of gas
after
26 hours of incubation.
Culture
from
broth
made on
Endo's media for colony formation.
Growth
of small grayish colonies.
January
20,
1938. — Feces cultured
from patient
in sick bay shows some
small
grayish colonies on Endo's media.
Gram stain shows gram negative bacilli with a
tendency to bipolar staining.
Organism was similar in all respects
to that isolated
from the ice.
January 25, 1938. —Agglutination
test made, using serum from patient and anti
gen prepared from organisms isolated from
ice.
Agglutination
positive
in dilu
tion of 1 to 640.
STATISTICS
HEALTH
OF THE NAVY
The regular coding
work of the statistical section
of the Division
of Preventive Medicine has been delayed
by the installation
of new
statistical
machinery.
For this reason it has not been possible
to
prepare for publication in this issue the usual summary
of the Health
of the Navy.
Monthly reports
of communicable
diseases received in the Bureau
recorded
the following incidence
of disease:
Common infectious
diseases
of the respiratory
type. —During
the first
quarter of 1938 a total of 4,354 cases of the common infections of the
respiratory type were recorded for the entire Navy,
as compared with
3,152 admissions
for the preceding
quarter and 8,068 admissions
for
the first quarter of 1937.
There were
2,124
admissions
for these diseases reported
by shore
stations in the United
States,
286 from outlying naval stations and
activities, and
1,944 from the forces afloat.
The largest
numbers
of
cases were reported from the following ships and stations:
Ship or station
January
February
March
Total
12
13
545
•570
Naval training
station,
Norfolk,
Va
168
171
131
470
150
129
188
467
Regimental
hospital,
Fourth Marines,
Shanghai,
China
87
87
35
209
68
46
64
178
55
38
72
165
a
44
46
132
33
19
25
77
16
25
24
65
14
23
19
56
17
11
26
54
Marine detachment,
American
Emhassy,
Peiping,
China
24
17
7
48
11
23
12
46
10
20
15
45
' Form F cards received in the Bureau
Indicate a total of 595cases of upper respiratory
infections
admitted
to the sick list on the U. S. 8. Leiington
during
the epidemic from Mar. 10to Mar. 31, 1938. A check on in
cidence according to rate reveals no cases admitted
from the junior officers' mess, the warrant
officers' mess,
or the chief petty officers' mess, and only 1case, a supply
officer, from the wardroom
mess.
Scarlet fever. —Five
cases
of
scarlet
fever
were
reported
for
the
quarter—One in January and one in March from the naval training
station, Newport, R. L; one in January
from the U. S. S. Saratoga;
and in February one each from the Navy Yard, Boston, Mass., and the
U. S. S. Saratoga, fleet air detachment,
United States Naval Air Station,
San Diego,
Calif.
637
638
STATISTICS
Chickenpox. —There
were
16
cases
of chickenpox
reported during
the first quarter of 1938,
as follows:
Ship or station
January
February
March
V. S. S. Raleigh
1
2
1
0
0
1
U. S. S. Preston
0
0
1
0
0
1
U. S. S. Detroit
0
0
1
U. S. S. Mississippi
1
0
0
1
0
0
0
1
A
U. S. S. Philadelphia
0
0
1
1
0
0
1
U. S. S. Teat
0
o
One
case of diphtheria was admitted to the sick list on board the
U. S. S. Langley in March.
In reporting the occurrence
of malaria among
personnel
attached
to stations in
the
vicinity
of Balboa,
medical
officers
reported
as
follows:
DISTRICT
MEDICAL
OFFICER,
FIFTEENTH
NAVAL
DISTRICT,
BALBOA,
CANAL
ZONB
Sanitary
report
for
January
1938. —Health
conditions
within
the
fifteenth
naval district
have been good with the exception of increased malaria admissions.
The incidence of malaria shows the usual increase to be expected at the end of the
rainy season.
Bight cases developed during the month among personnel attached
to stations in the vicinity of Balboa.
Among
the personnel of the radio station
at Summit,
Canal
Zone,
three cases were admitted.
Five cases developed at the
naval
ammunition
depot,
Balboa —one malignant
tertian,
three benign tertian,
and one recurrent
benign tertian.
u. s. 8. "nitro"
Special report
dated January
27,
1938. —The dock at the new naval ammuni
tion depot is located in line of flight of the Anopheline
which are prevalent
in this
locality.
In
anticipation
of this
condition
the
Nitro,
prior
to docking
at
this
station
on January
10,
1938,
provided
individual nets,
and attempts
at screen
ing were instituted.
Ship's
personnel in going to and from
the station
about
2
miles distant and while attending
movies on deck during
the evening hours were
exposed.
Two admissions
for estivo-autumnal
malaria
were recorded
on Janu
ary 24 and one on January 25.
THE SANITARY REPORT
FROM THE NAVAL 8TATION,
GUAM MIDWAY ISLAND
The
January
1938
sanitary
report
contained
the
following
data
regarding
whooping
cough:
This disease
continues in epidemic form throughout
the towns
and villages of Guam — 55 deaths during
the month of January
1938.
A total of
109
deaths
have
been
recorded
since
the
beginning
of
the
present
epidemic.
The age group most seriously affected is from
6 months to 3 years, mostly
those
about
1 year old.
During the past month
the
disease
has
spread to
Merizo,
Umatac, and Inarajan in increased proportions,
due to the fact that the epidemic's
momentum
has
increased there, whereas it
is abating
somewhat
in Agana
and
Anigua.
Respiratory
infections
like pertussis
are almost
impossible
to control
after
once
introduced
into the island.
The
sanitary
report
for the month
of February
reported
27 deaths and the
report for the month of March reported 4 deaths from whooping
cough making
a
total of 145 deaths from this disease
since the inception
of the epidemic in 1937.
STATISTICS
639
DEATHS
During
the first quarter ending
Mar. 31, 1938
Cause
Navy
Marine
Corps
Nurse
Corps
Total
Principal
Contributory
Offi
cers
Mid
ship
men
Men
Offi
cers
Men
DI"EA"E
9,818
2,150
103.555 1,326 17,172
411
134,432
Abscess,
axilla
1
Abscess,
liver
None
Anomaly of form, coronary
artery.
do
Carbuncle, face
Septicemia
|
Oarbuncle,
neck
do
Carcinoma,
lung
Carcinoma,
general
and
abscess mediastinal.
Carcinoma,
pancreas
do
1
1
Do
Cellulitis, neck
Cerebrospinal
fever
Abscess, multiple,
brain
.
J
Gastroduodenitis,
acute. . .
Gonococcus
infection,
men
inges.
Myocarditis, chronic ana
enlargement,
prostate.
1
1
Leukemia
None
Meningitis, cerebrospinal,
acute.
do
Obstruction,
Intestinal,
do
from external causes.
Pericarditis
do
Pneumonia,
lobar
Dilatation, cardiac, acute.
1
None
1
Poliomyelitis,
anterior,
acute.
do
Purpura hemorrhagica
do
j
Sarcoma, lympho.stomach.
Peritonitis,
general, acute.
Septicemia
1
Syphilis
Poisoning,
neoarsphena-
mine
and
pneumonia,
broncho.
Thrombosis,
cerebral
Thrombosis,
coronary
-""do""";;;;";""""
1
i
Tuberculosis,
pulmonary,
chronic,
active.
Ulcer, stomach
Peritonitis, general, acute.
1
Total for disease
7
1
31
1
40
INJURIE" AND POISONINGS
Asphyxiation,
illuminat
ing gas.
Asphyxiation,
kerosene oil
smoke
1
1
Asphyxiation, vomitus
in
trachea.
Burn, multiple
do
1
3
Electric shock, injury from. 1
do
9
1
1
1
1
2
12
Fracture,
compound, skull.
do
1
2
2
2
2
Hemorrhage,
subdural
1
1
Meningitis, cerebrospinal,
acute.
Intracranial injury
Meningitis, cerebrospinal,
acute.
1
1
1
1
1
86860 —38
13
640
STATISTICS
DEATHS— Continued
During
the first quarter
ending
Mar. 31, 1933—Continued
Cause
Navy
Marine
Corps
Nurse
Corps
Total
Principal
Contributory
Offi
cers
Mid
ship
men
Men
Offi
cers
Men
INJUBIE" AND POI"ONINGS—
continued
Injuries,
multiple,
extreme.
Wound,gunshot.
abdomen.
Pneumonia,
lobar
4
14
1
18
Wound, gunshot,
chest
1
2
Wound, gunshot,
head
do
1
2
1
1
Wound, infected,
thigh
do
Wound,
incised, wrist
Poisoning,
carbon monox
ide.
Total
for
injuries
10
37
7
54
and poisonings.
Grand total..
17
1
68
8
94
Annual
death
rate
per
1,000:
6.93
2.85
1.22
1.86
1.86
2.63
1.20
.35
1.86
.23
2.80
1. 19
.36
Disease only
Drowning.
Poisonings
Other
injuries
2.85
1.08
1.63
""i."25
MENTAI AND PHYSICAL
QUALIFICATIONS
OF RECRUITS
Statistics for first quarter
ending
March
31, 1939
The following statistics were taken from sanitary reports
submitted
by naval training stations:
U. S. naval
training
station
January, February,
and March 1933
Norfolk,
Va.
Newport,
B.I.
Great
Lakes,
D1.
San
Diego,
Calil.
Recruits
received during
the period
...
1,144
8
8
8
0
845
0
0
0
0
866
3
1.340
0
0
0
Recruits
recommended
for discharge from the service...
a
Recruits
discharged
by reason of medical survey
(')
Recruits
held over pending further
observation
W
(')
Recruits
transferred
to the hospital
for treatment,
operation,
or
further
observation
for conditions
existing prior to enlistment.
0
22
113
39
' Not reported.
The following table was prepared
from reports of medical surveys in
which disabilities or diseases causing
the surveys
were noted
existing
prior
to
enlistment.
With certain
diseases, survey followed
enlist
ment
so rapidly
that it would
seem
that many might
have
been
eliminated
in the recruiting office.
STATISTICS
641
Cause of survey
Absence acquired,
teeth
Acne
vulgaris
Adhesions,
abdominal
Amblyopia.
Aneurysmal varix, superficial
vein, lore-
head
Arterial hypertension
Arthritis, chronic
Asthma
Caries, teeth
Cataract
-
Cicatrix, skin
Constipation
-
Constitutional psychopathic
inferiority,
without psychosis
Constitutional psychopathicstate,
emo
tional instability
---
Constitutional
psychopathic
state,
in
adequate personality
Deafness, bilateral
Defective
physical
development
Deformity acquired
Dementia
praecox
Dislocation,
cartilage, left knee
Dislocation,
chronic,
shoulder
—
Dyspituitarism
Eczema
Effort syndrome
Enterocolitis,
chronic
Enuresis
Epilepsy
Flat foot
Gastroptosis
Number
of
surveys
Cause of survey
Hammer-toe
Hemorrhage,
subarachnoid
J
Hernia,
inguinal
Hernia,
recurrent
after operation...
Metatarsalgia,
left
Myopia.
Myositis, chronic
Narcolepsy
-
Nephritis, chronic
Otitis media, chronic
Paralysis,
ocular muscle
Pescavus
Psoriasis
Psychoneurosis,
hysteria
Psychoneurosis,
unclassified
Retinitis
Rhinitis, atrophic
Somnambulism
Stammering
Strabismus
Syphilis
Tic
Trachoma-
Tuberculosis,
pulmonary,
chronic,
ac
tive (moderately
advanoed)
Tuberculosis,
pulmonary,
chronic,
ar
rested (moderately
advanced)
Ulcer, duodenum
Union of fracture, faulty
Valvular heart disease, combined
lesions,
aortic and mitral
Valvular heart disease, mitral stenosis. I
Number
of
INDEX TO UNITED STATES NAVAL MEDICAL BULLETIN
VOLUME
XXXVI
INDEX
TO SUBJECTS
Page
Abscess, lung, treatment
of
487
American
Board of Radiology
419
American
College of Hospital Administrators
419
American
College of Physicians
123, 592
American
College of Surgeons
270
Anesthesia,
inhalation
517
Anesthesia,
procaine, intranasally
498
/Antitetanus
toxoid
150
Apicocctomy
511
Arsenicals:
Toxic effects
of
131
Toxic effects
of with special reference to arsenical dermatitis
605
Articles
on professional subjects
122
Articles
of special merit,
1937
123
Autopsies
586
Barbiturate
poisoning
32
Bluejacket,
making of
233
Book notices
125, 271, 423, 593
Cancer
120
Problem
in U. S. Navy
74
Skin irritation and cancer in U. S. Navy
120
Carbuncle
of kidney
580
Carcinoma:
Lung
79
Bronchogenic
89
Chondrodystrophy
fetalis
67
Classified matter
269
Clinical notes
95, 569
Cold,
common
118
Commendation
417
Compressed-air
illness
9, 235
Corneal
transplantation
499
Cowpox
virus
445
Cruciate
ligaments,
knee, ruptured
491
Deaths—statistics
—
160, 323, 452, 639
Dependents,
hospitalization
of
270
Dental
neurosis
97
Diabetes and protamine
insulin
1
Diseases, mental, U. S. Navy
536
Diseases of colon, diagnostic errors in
482
Facial
injuries
501
Fever, yellow
416
Field sanitation
—
327
Fish poisoning
629, 631
643
644
INDEX
Paee
Fleet medicine
193
Food poisoning
152, 306, 316, 634
Fractures:
Mandible
513
Maxilla
507
Gall bladder, surgical
469
Gastric surgery
--
455
Gonorrhea:
Sulfanilamide
therapy
of
45
Results of sulfanilamide
therapy of
63
./Hay fever, treatment
18
Health
of the Navy— statistics
-
155, 319, 447, 637
Health
record, the
559
Helium,
physiologic
studies of
542
Hernia,
acute traumatic
diaphragmatic
572
Hospital
ship
116, 197
Hospitalization
of dependents
270
Illness, compressed-air
9, 235
Immunization,
active, against tetanus
524
Infection,
atypical
meningococcic
104
Influenza
591
Injuries:
Facial
501
Multiple extreme, unusual
case
569
Traffic
616
Injuries and poisonings —statistics
--
-
--
158, 322, 450
Insecticidal
powders
435
International
congress,
military medicine and pharmacy
264
Kidney, carbuncle of
580
Knots, surgical
591
Krukenberg's
spindle
95
Lip fixation
501
Logistics
163
Ludwig's angina, sulfanilamide
treatment
of
--
58
Lung:
Abscess, treatment
of
487
Carcinoma
of
79
Malaria
29
Mandible,
fracture,
healing time
513
Masochism,
passive algolagnia
99
Matter, classified
269
Maxilla, fracture,
appliance for reduction and fixation
507
Medical
Department
function,
naval engagement
179
Medical
supply procurement
-
168
Medicine,
fleet
193
Mcdicomilitary symposium,
ninth annual
112
Meningococcic
infection,
atypical
104
Mental diseases,
U. S. Navy
536
Mental and physical
qualifications,
recruits — statistics
-.
161, 324, 453, 640
Military medicine and pharmacy,
international
congress
on
264
Morbidity— statistics-
-
159, 322, 451
Muscle,
plain, blunders of
116
Navy exhibit,
A. M. A. convention
-
585
Naval Medical
Center
--
---
421,585
INDEX
645
Pago
Naval Reserve
1 1 1, 261, 413, 583
Necrosis,
pancreatic,
acute hemorrhagic
477
Neoarsphenamine:
Effect of age on reaction expectancy
425
Effect of moisture and age on stability
429
Neosynephrin,
surgical shock, treatment with
117
New York Academy
of Medicine
graduate fortnight
418
Neurosis,
dental
97
Neutropenia
Notes and comments
H5, 263, 415, 585
Pancreatic
necrosis, acute hemorrhagic
477
Penalties
of upright
posture
563
Physiologic
studies of helium
.
542
Pneumonia,
lobar, atypical
101
Poisoning:
Barbiturate
32
Carboxide
44
Fish
629,631
Food
152,306,315,634
Sulfanilamide
61
Powders, insecticidal
435
Preventive
medicine
131, 277, 425, 605
Procaine
anesthesia intranasally
498
Procurement,
medical supply
168
Prophylaxis:
Chemical
formula for
522
Syphilis
I21
Protamine
insulin,
diabetes and
1
Psychosis precipitated
by sulfanilamide
60
Qualifications,
mental and physical,
recruits —statistics
161, 324, 453, 640
Record,
health, the
559
Recruits,
mental and physical
qualifications —statistics
161, 324, 453, 640
Rixey,
Presley
Marion
263
Sanitation,
field
327
Ship, hospital
HO, 197
Skin irritation and cancer in U. S. Navy
120
Spindle,
Krukenberg's
95
Statistics
155, 319, 447, 637
Stokes, Charles Francis
415
Stomach, lesions of cardiac portion
576
Submarine
service
277
Sulfanilamide:
Poisoning
61
Psychosis precipitated
by
60
Results of therapy
of gonorrhea
63
Therapy
of gonorrhea
45
Treatment
of Ludwig's
angina
58
Surgeons General:
Rixey
-
-
263
Stokes
415
Van
Reypen
115
Surgery, gastric
455
Surgical gall bladder
469
Surgical shock, treatment
with neosynephrin
117
646
INDEX
Symposium,
ninth annual medicomilitary
112
Syphilis:
Committee
to study serodiagnostic
tests for
421
Prophylaxis
—
121
Tetanus,
active immunization
against
524
Toxoid,
antitetanus
150
Traffic
injuries
616
Tularemia
--
105
Upright posture, penalties of
563
Van Reypen, William Knickerbocker
115
Virus,
cowpox
445
Yellow fever
416
INDEX
TO AUTHORS
Page
Behnke,
A. R
108, 517, 542
Bell, R. A
32, 45
Benson, R. A
563
Blackwood,
J. D., Jr
44
Boy den, R. C.
499, 501
Brewster, J. M
572
Burke, John
482
Carroll,
H. H
576
Clement, T. G
487
Cottle,
G. F
193
Davis,
Oscar
634
Ebert,
E. C
499, 501
Erskine,
E. B
44
Eyer,
A. W
105
Fulghum, J. E
58, 99
Funk, W. H
104
Hall, W. W
150, 524
Harrison,
W. C
277
Harrison,
W. T
425, 429
Hayden, R
524
Hege, R. W
95
Hering,
E. R
63
Higgins,
A. R
477
Hogan,
B. W
60
Holeman,
C. J
179
Holland, J. L
101
Hook,
F. R
455
Johnson,
F. S
435
Johnson,
L. W
197
Joslin, Eliot P
1
Leamer, Bruce V
498
LeClair, V. A
97
Love, Julian
105
Lang,
F. R
569
Page
Mann,
W. L
327, 616, 631
Marks, J. S
559
Maxwell,
M. M
501, 507
Mayne,
Roy M
487
McDaniel, F. L
32, 536
McNamara,
P. J
60
Michael,
W. H
29, 168
Moloney, J. B
445
Norman,
I. L
89
O'Connell, J. T
61
O'Neill, J. B
629
Probey, T. F
425, 429
Ralph, H. G
507
Roddis,
Louis H
115, 263, 415
Rossitcr,
P. S.-
163
Sargent, W. S
67, 580
Shilling,
C. W
9, 235
Silliphant,
W. M
89
Sledge,
R. F.-
18
Small, W. D
316
Smith, H. W.
522
Snowden, R. H
45
Spalding,
O. B
74
Stephenson, C. S
131, 150, 425, 605
Taylor, R. W
511,513
Thomas,
G. E
233
Wade, E. M-
306, 491
Walters,
A. J.
101
Warmolts,
I. J
79
Welch, C. C
513
Willcutts,
M. D
469
Wingo,
E. H
131, 605
| Yarbrough,
O. D
542
o