VOL. XIII NO. 1 UNITED STATES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PUBLICATIONS CAPTAIN J. S. TAYLOR, MEDICAL CORPS, U. S. NAVY IN CHARGE JANUARY, 1919 (QUARTERLY) WASHINGTON GOVERNMENT PRINTING OFFICE 1919 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. r Truman H. Newberry, Acting Secretary. NOTE. Owing to the exhaustion of certain numbers of the Buixetin 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 X, No. 1, January, 1916. Volume XI, No. 1, January, 1917. Volume XI, No. 3, July, 1917. Volume XI, No. 4, October, 1917. Volume XII, No. 1, January, 1918. Volume XII, No. 3, July, 1918. Volume VII, No. 2, April, 1913. Subscription Pbice of the Bulletin. Subscriptions should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. Yearly subscription, beginning January 1, $1 ; for foreign subscription add 25 cents for postage. Single numbers, domestic 25 cents; foreign, 31 cents, which includes for eign postage. Exchange of publications will be extended to medical and scientific organiza tions, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy. Washington, D. C. ii TABLE OF CONTENTS. Page. PREFACE vii FRONTISPIECE: Thomas Henry Huxley. SPECIAL ARTICLES: Heart sounds and their value. By Lieutenant Commander H. A. Hare, Med. Corps, U. S. N. R. F. . 1 Eliminating the epileptic from the navy. By Lieutenant L. E. Biach, Med. Corps, U. 8. N. R. F 6 The use or serum in lobar pneumonia. By Lieutenant E. W. Gould, Med. Corps, U. S. N. R. F., and Lieu tenant M. Shaweker, Med. Corps, U. S. N 16 Diagnosis and treatment of pneumonia and empyema. By Commander F. A. Assereon, Med. Corps., U. S. N., and Lieu tenant W. L. Rathbun, Med. Corps, U. S. N. R. F 26 Development of specific serum therapy in pneumonia. By Lieutenant W. R. Redden, Med. Corps, U. S. N 36 Flatfoot. By Lieutenant Commander L. R. G. Crandon, Med. Corps, U. S. N. R. F 43 Treatment op flat feet. By Lieutenant (J. G.1 S. B. Burk, Med. Corps, U. S. N. R. F 46 Ear protection. By Commander G. B. Trible and Lieutenant S. S. Watkins, Med. Corps, U. S. N 48 HISTORICAL. .Thomas Henry Huxley (1825-1895). By lieutenant Commander F. J. B. Cordeiro, Med. Corps, IT. S. N., Ret 61 EDITORIAL. Accuracy. —Military titles and military behavior. —Shell shock. 71 SUGGESTED DEVICES: Typhoid prophylaxis cards. By Lieutenant Commander R. B. Henry, Med. Corps, U. S. N 77 A SURGICAL DRESSING TRAY FOR SHIPS. By Lieutenant M. J. Price. Med. Corps, U. S. N 78 A USEFUL FLYTRAP. By Lieutenant H. V. Hughens, Med. Corps, U. S. N 80 Scale for measuring flatfoot. By Lieutenant (J. G.) B. Dunham, Med. Corps, U. S. N R. F 82 CLINICAL NOTES: A CASE OF STATUS LYMPHATICU8. • By Lieutenant E. L. Rice, Med. Corps, U. S. N 85 Some practical and theoretical considerations. By Lieutenant Commander J. J. A. McMullin, Med. Corps, U. S. N. 87 ni 1 IV TABLE OF CONTENTS. CLINICAL NOTES— Continued. Page. Pain in right hypochondrium and pernicious anemia. By Lieutenant Commander H. M. Stenhouse, Med. Corps, U. S. N.. 89 Perforating wound op intestine and mesentery. By Lieutenant G. G. Ross, Med. Corps, U. S. N. R. F 93 Treatment op scarlet fever. By Lieutenant Commander W. C. Newton, Med. Corps, U. S. N. R. F. 94 Illustrative cases of atypical acute abdominal conditions. By Lieutenant Commander G. D. Hale and Lieutenant J. C. Adams, Med. Corps, U. S. N 95 Varieties of hypersusceptibility. By Lieutenant L. K. McCafferty, Med. Corps, U. S. N 98 Varix simulating inguinal hernia. By Lieutenant E. J. Cummings, Med. Corps, U. S.N 103 Appendicitis and ruptured meso-appendix artery. By Lieutenant F. H. Bowman, Med. Corps, U. S. N 104 Unusual wound contamination. By Lieutenant E. A. Stephens, Med. Corps, U. S. N 105 Subluxation of vertebra by muscular action. By Commander I. S. K. Reeves and Lieutenant M. K. Miller, Med. Corps, U.S.N 107 Fracture of the skull. By Lieutenant Commander R. I. Longabaugh, Med. Corps, U. S. N.. 108 Report of case of stenosis of wharton's duct. By Lieutenant J. A. Halpin, Med. Corps, U. S. N 108 PROGRESS IN MEDICAL SCIENCES: General medicine. —Status lymphaticus. —Epidemic of intestinal infec tion. —New pathology of syphilis Ill Mental and nervous diseases. —Temperament and psychosis. War neuroses. —Traumatic and emotional psychosis. —War neuroses. —In stinct distortion 117 Surgery. —Fascial transplants. —Chloralose as a general anesthetic 131 Military, legal and industrial. —Treatment of mustard-gas poison ing. —Conference on medico-military administration. —Illegitimacy in Norway. —Prevention of blindness.- —Aniline poisoning. —Immigration statistics. —Preservation of fruit.—Economic and financial assistance given by the United States 133 REPORTS: SUKOICAL EXPERIENCES AT THE FRONT. By Lieutenant G. G.Ross, Med. Corps, U. S.N. R. F 145 Details of transport service. By Lieutenant Commander R. I. Longabaugh, Med. Corps, U. S. N.. 149 Plan of a regimental field hospital. By Lieutenant Commander C. B. Camerer, Med. Corps, U. S. N 156 The preparation of blood stain at the u. s. naval medical school. By Lieutenant Commander G. F. Clark, Med. Corps, and Chief Phar macist's Mate L. F. Shabek, U. S. N 157 Preparation of identification tags. By Lieutenant Commander R. H. Laning, Med. Corps, U. S. N 157 A death following salvarsan. By Lieutenant R. C. Christiansen, Med. Corps, U. S. N 158 Sanitary report on the Island of Corfu. By Lieutenant Commander H. Shaw, Med. Corps, U. S. N 163 TABLE OF CONTENTS. V REPORTS—Continued. Paw. The march and the shoe. By Lieutenant Commander W. L. Mann, Med. Corps, U. S. N 164 Tuberculin test in young adults. By Lieutenant E. Moody, Med. Corps, U. S. N. R. F., and Lieu tenant C. F. Carter, Med. Corps, U. S. N 165 Bed screens in barracks. By Commander P. S. Rossiter, Med. Corps, U. S. N 167 Influenza on a natal transport. By Lieutenant W. F. McAnally, Med. Corps, U. S. N 168 The treatment op chancroids and the prevention of buboes. By Lieutenant G. W. Millett, Med. Corps, U. S. N 170 Record of the navy recruiting station, Pittsburgh, pa. By Lieutenant C. C. Ammerman, Med. Corps, U. S. N. R. F 171 Strength of the navy 172 BOOK NOTICES 173 NOTICE TO SERVICE CONTRIBUTORS 175 PREFACE. The publication and issue of a quarterly bulletin by the Bureau of Medicine and Surgery contemplates the timely distribution of such information as is deemed of value to the personnel of the Medical Department of the Navy in the performance of their duties, with the ultimate object that they may continue to advance in proficiency in respect to all of their responsibilities. It is proposed that the Naval Medical Btjlletin shall embody matters relating to hygiene, tropical and preventive medicine, pa thology, laboratory suggestions, chemistry and pharmacy, advanced therapeutics, surgery, dentistry, medical department organization for battle, and all other matters of more or less professional interest and importance under the conditions peculiar to the service and per taining to the physical welfare of the naval personnel. It is believed that the corps as a whole should profit, to the good of the service, out of the experience and observations of the individual. There are many excellent special reports and notes beyond the scope of my annual report being sent in from stations and ships, and by communicating the information they contain (either in their entirety or in parts as extracts) throughout the service, not only will they be employed to some purpose as merited, but all medical officers will thus be brought into closer professional intercourse and be offered a means to keep abreast of the times. Reviews of advances in medical sciences of special professional interest to the service, as published in foreign and home journals, will be given particular attention. While certain medical officers will regularly contribute to this work, it is urged that all others co operate by submitting such abstracts from the literature as they may it any time deem appropriate. Information received from all sources will be used, and the bureau extends an invitation to all officers to prepare and forward, with a view to publication, contributions on subjects relating to the profes sion in any of its allied branches. But it is to be understood that the bureau does not necessarily undertake to indorse all views and opinions expressed in these pages. W. C. Braisted, Surgeon General United States Navy. THOMAS HENRY HUXLEY. 1825-1895. . R^prd'duced from Garrison's History of Medicine by t tie courtesy of W. B. **• - • Saunders Co., Philadelphia, Pa. U. S. NAVAL MEDICAL BULLETIN. Tol. XIII January, 1919. No. 1. SPECIAL ARTICLES. HEART SOUNDS AND THEIR VALUE. Bj Hobart Asiory Hare, M. D., Lieutenant Commander, Medical Corps. United States Naval Reserve Force. A number of years ago I placed the following words on the fly leaf of the seventh edition of my book on " Diagnosis in the Office and the Bedside : " " In the diagnosis of a given disease it is essential that the physician rest his opinion not upon one or two symptoms, but upon a series of symptoms which when properly put together give him a complete, or nearly complete, picture of the malady. It is as futile for a physician to base a diagnosis upon a single symptom as for an architect to attempt to determine the appearance of a house by seeing one of the stones that has been removed from its walls." I quote these words because at the present time it is of infinite importance to the country as well as to the individual that men really capable shall not be classed as incapable, and because the opinion of an examining physician, if in error, may work great harm. It is not many years since the presence of a murmur in the heart was supposed to indicate cardiac therapy, whereas we now know that many hearts which greatly need treatment give rise to no murmur at any time, and in some instances only when the heart becomes strong enough to make a murmur audible. There is in no examination greater need for putting together all of the symptoms before reaching an opinion than when determining the state of the heart, and I am induced to emphasize this point be- eause many persons have been rejected for service when in reality perfectly fit for it. For the sake of brevity I take the liberty of separating heart cases into groups. First, those in whom a mitral systolic murmur is definite, distinct, constant, and well transmitted, and in whom there is a history of rheumatism more or less remote. These patients undoubtedly have an actual valvular lesion and their good health depends upon ade quate compensation, which is only attained by hypertrophy and the 2 Vol. XIII. HAKE HEART SOUNDS AND THEIR VALVE. utilization of some of their cardiac reserve power. It is hardly necessary to state that such persons should be turned down. They are bad risks for service or life insurance. Second, those in whom a definite presystolic purr, or short murmur, is heard inside the nipple line at about the fourth or fifth rib, accom panied by accentuation of the pulmonary second sound, which mur mur is usually made louder by exercise or a fairly full dose of digi talis. If the heart is not tired out, sharp exercise, like the 100-hop test, usually exaggerates this murmur. When the heart is on the verge of fag, however, sharp exercise may cause this murmur to dis appear and the patient becomes dyspnoeic and distressed. This type is also to be definitely turned down. Third, those in whom there is a definite murmur, diastolic in time and clearly aortic in origin. The apex beat is distinctly displaced to the left, downwards, and the heart is manifestly enlarged. Here again there can be no doubt that the man is unfit for service. Fourth, the individual who has an irritable and rapid heart, with poor development as to the vascular and muscular tissues. All the lines of his body slope sharply from behind forward. The line of the jaw drops sharply, the shoulders droop, the ribs droop, and the knees droop. The figure as he stands presents the lines of a cadaver that hangs from. hook or chain. The apex beat of his heart is diffuse, and there is much apparent thrill to the eye of the observer, but little, or none, to the finger tips. Here is a man who lacks tone in his muscular, vascular and nervous systems. He can not stand stress of any kind, he sweats while being examined, particularly prof usely in the axillary spaces and on the hands. He bleeds readily into his great vessels. In such a case, the heart may be devoid of murmur, of arrhythmia, or any other sign of lesion, but its sounds lack tone. Such a case perhaps should be classed as one of " neuro-circulatory asthenia " of Lewis, but it does not belong to the class called by DaCosta the " irritable heart of soldiers " since in these persons the cardiac state is often due to great physical and mental strain, whereas in the type I have described it precedes strain and is practically a congenital defect. Such a case is well represented by a youth who entered the cavalry. Placed on a horse and ordered to charge over a field, in squadron formation, he lasted the charge but fell off as it ended, in a dead faint. He remained cold and pulseless for some hours. He stated that he had had no sense of fear but that it seemed to him as if he could not get his breath and as if all the blood had left his head. Doubtless this was largely true. His neuropathic vas cular system did not meet the strain of excitement and effort. These cases are of course unfit for service, although a gradual course of neurocirculatory training may greatly improve their value as citi zens. No. X. 3 IJARE —HEART SOUNDS AND THEIB VALUE. At this point we approach the border of what may be called " the land of doubt," namely, as to the value of the systolic murmwr at the aortic cartilage transmitted up into the carotid artery, because while it is true that most of these patients should he rejected, many of them are capable of service, and if examined again it may be found that the systolic hum may have disappeared. If the man is over 30 or 35, or there is a history of syphilis or rheumatism at any period in his life, rejection is needful, particularly if the palpable vessels are thickened. It is not necessary in the types so far discvssed to look for collat eral symptoms of cardiac origin, for up to this point he who runs may read what should be done. But now we come to a very considerable class of cases in which much difference of opinion can be conscientiously adhered to. We. are now in the land of doubt and just as any one in doubt looks for all signs which may guide him well, so is it imperative that he study not one but all the stones which will form the arch upon which the decision will rest. Here again we may take up types. First, the well-built, lithe youth, with no rheumatic history, who presents missed beats or extra systoles, which irregularities disappear upon taking the 100-hop test. At times the disorder of these hearts when at rest, and particularly when they are being examined, is very great, but exercise does not cause dyspnoea. These hearts are often met w ith in athletic youths who have begun to lead sedentary lives and who may or may not be still using the amount of tobacco which it may have been their custom to use when leading an out-door life. Occasionally a short, quick, murmur, inconstant, is discoverable, be cause a valve "does not seat well," to use a machinist's phrase. I have watched cases of this kind for many years after first seeing them and they do not come to grief by strenuous exercise; thus one of them was for a number of years a celebrated hockey player, then the captain of one of the great university foot-ball teams, and for more than a year he has been flying in France where he has won the Croix de Guerre. When I last saw him he had found that the only thing that ever caused cardiac irregularities was lack of exercise. This type is a good risk. When, however, such irregularities occur in men past the fourth decade of life and do not pass away on exer cise or increase on exercise they possess great importance. They may be due to the excessive use of tobacco, but if they are associated with high blood pressure are usually grave in nature and deserve very careful study with particular reference to the effect of exercise, the. condition of the blood vessels, and the state of the urine. None of these cases, however, should as a rule be rejected, unless there are evidences of cardio-vascular-renal lesions, until they have been ex 4 HARE HEART SOUNDS AND THEIR VALUE. Vol. XIII. amined with the aid of the electro-cardiograph, or at least with the aid of the polygraph, since a purely physical test may be given an erroneous value. Second, the type that under stress develops a mitral systolic purr. This type was often seen before the war in football players imme diately after a hard game, and in oarsmen after a contest. This murmur disappears on rest. It is "a safety valve murmur," due to relaxation of the mitral ring. This type, other things being equal, is a good risk. The persistence of this murmur for more than an hour or two, particularly if the person be over 30 years of age, raises a question as to the quality of the muscular fibers forming the ring at the base of the mitral leaflets, and indirectly raises a question as to the quality or ability of the entire heart muscle to withstand strain. Third, the type that under the excitement of a physical test pre sents at a point about 1 inch to the left of the sternum, at or above the nipple level, a short flapping or tapping sound, single or double, not transmitted to the nipple, nor up or down. It is not a murmur but a valve sound ; in one sense resembling, except that it is not so loud, the valve sound heard in a motor when climbing a hill which is a little too steep for the high-speed clutch. I wish to put special stress on this sound, as in my experience it has no more significance as to the pres ence of a heart lesion than the twitching of one of the voluntary muscles justifies a diagnosis of chorea. It is sometimes a sign of nervous stress, and may pass away while the patient is being examined. Exercise may or may not dissipate it. Mental quiet often dissipates it. This is a type of case most frequently turned down without ade quate cause. Twenty grains of bromide a few hours before the next examination, alone or with aconite or digitalis, will often let this man pass another test, but even if this tapping valvular sound, heard in the area described, persists, I have never found it to indicate in capacity of the heart for severe effort. This type should not be rejected. Closely allied to this is a systolic sound, not a murmur, heard, when a towel is used for auscultation, between the base of the heart and the apex beat. It is met with in a nervous person with a rapid heart action and resembles the sound " ching ". Often it is heard better on light pressure than on heavy pressure. I described this sound before the Association of American Physicians some years ago. At times it is like a friction sound with a metallic tone. As a rule it is inconstant and is often lost if the patient lies down. It has no evil import. A cardio-pulmonary murmur, heard below the left clavicle on full inspiration or on full expiration, is without significance as to the heart, although it may in some cases indicate trouble in the lung. No. 1. B ISC II—ELIMINATING THE EPILEPTIC EEOM NAVY. 5 Finally, I would like to emphasize two points, one of which has been especially insisted upon by Sir James Mackenzie, who said : " A perfectly sound heart can give rise to murmurs. If the heart is not otherwise impaired, if it is normal in size, normal in rate, and the response to effort is good, ignore the murmur, it makes no difference where you hear it." From what I have already said it is evident that I do not go as far as this very eminent expert in the study of the heart, but his statement is quoted to emphasize the fact that all unusual heart sounds are not evil things. The second point is to recall that the heart is not an isolated organ independent of the nervous system and the rest of the vascular sys tem, nor is it like a piece of machinery made of unyielding metal. Its muscle fibers have play, they vary with every need of the body in that play. Its valves are not rigid, the bases on which these valves rest are not fixed or rigid, and the chordae tendineae constantly vary in their tension ; so, too, do the musculi papillares vary in their form. Last of all it is as important for health and for service that the ves sels shall be elastic and well controlled as that the heart shall be nor mal, for unyielding vessels weary the heart not only by offering undue resistance but by failing in their own contractility to help in the circulation of the blood, as Ludwig and Brunton showed many years ago. Conversely, a vascular system which relaxes unduly when effort is made also exhausts the heart, which works to excess to keep the vessels properly supplied. ELIMINATING THE EPILEPTIC FKOM THE NAVY. By L. E. Bisch, Lieutenant, Medical Corps, United States Naval Reserve Force. In eliminating nervous and mental diseases from the service, one of the puzzling problems that presents itself to the medical officer is the discovery and certain diagnosis of the epileptic. Naturally, a typical grand-mal attack, actually seen by a physician, ought to pre clude beyond peradventure any doubt whatever as to the nature of the disorder. But, unfortunately, it seldom happens that a medical officer has the opportunity of witnessing a seizure throughout its entire course. As a rule, one's judgment must depend largely upon the reports of a man's shipmates, who are untrained observers, and very often the patient's own account is the only source of informa tion. This latter may bear but little semblance to accuracy because of the man's ignorance of what really happens to him, because of memory defect which is present in varying degree in all epileptics, or because his story may be deliberately colored with a view to bringing about a medical survey. Then, again, epileptic seizures seldom fol low the classical picture drawn up in the textbooks, while, lastly, if 6 BISCH ELIMINATING THE EPILEPTIC FROM NAVY. Vol. XIII. one were to include as epileptic only those having definite convulsive seizures, man)7 incipient cases would go by undiagnosed only to be recognized after the disease had developed in all its possibilities, per haps at a stage where deterioration had already worked incurable havoc with the mentality, and perhaps even only after the epileptic's ever-increasing irresponsibility had done definite injury to himself or his associates. For a year, in the course of neuro-psychiatric duties, the writer has come into direct contact with the epileptic as he appears in the naval service. These cases have comprised men in the detention unit, cases revealing themselves in the training stations, men from the re ceiving ship, men from the fleet and patrol boats, cases sent to the naval hospital, court-martial prisoners, and men returned from over seas. Epilepsy appears in all branches of the service, and one may add here, it manifests itself in all degrees of severity, in all forms, and is recognized or discovered at various stages of development. Epilepsy has always been a mysterious and baffling disease. All sorts of theories have been held as to its causation. Being apparently a disturbance of the nervous system and being attended by some degree of violence in its commonly recognized form —the " fit "—may have led to the idea that it was due to some sort of irritation somewhere in the body, causing in some sort of way a nervous explosion. At any rate, on this vague hypothesis surgical interference has fre quently been resorted to and, I dare say, practically every part of the human anatomy has been attacked. Disturbances of the alimentary tract have received considerable attention and without a doubt de fective chemical digestion, toxic states, secretory anomalies, peristal tic sluggishness, ptoses, dilatations and flexions of the organs are found in many epileptics. Circulatory disorders have been suspected and claim has also been made for the isolation of the " bacillus epi- lepticus." The glands of internal secretion, particularly the pitui tary, have been looked upon as possibly bearing a causal relationship to the disease. Lastly, brain lesions, tumors, hemorrhages—all pres sure phenomena in the sensorimotor region of the cortex—have had their particular advocates. Suffice it to say that the cause of epilepsy remains about as baffling as ever. Operations and treatments along such lines have resulted in benefit in isolated cases, but nowhere has the causal relationship between pathology and symptoms remained constant, logical, and clear. At the present time the exact pathology and pathological physiology of epilepsy remain unknown. Epilepsy has been subdivided in various ways by different authors and perhaps the commonest classification is that of grand-mal, petit-mal, Jacksonian seizures and hystero-epilepsy or psychic epi lepsy. The Navy nomenclature employs but two terms : Epilepsy and Jacksonian epilepsy; presumably grouping grand-mal and petit-mal No. 1 BISCH ELIMINATING THE EPILEPTIC FROM NAVY. 7 together, designating as Jacksonian the "cases of localized spasms, and putting the psychic seizures under the heading of hysteria. A grouping like the latter has at least one merit—its simplicity. Yet if it tends to imply that these conditions are definite and well- defined clinical entities, the assumption is not warranted by our pres ent knowledge of the numerous clinical varieties of the disease. If anything at all certain can be said about this strange malady, one may venture to state that epilepsy is not a single disease with but slightly varying symptomotology. Quite the contrary, epilepsy is strikingly variable in its manifestations. There is no set rule as to the age at which it may appear and scores of cases give a history of the first convulsion from babyhood up into the thirties. It seems to be precipitated by manifold causes from such as " indigestible " food to worry or emotional excitement. Its clinical picture is not exactly alike in any two patients and even successive attacks in the same individual show differences. It is but natural that most consideration has for years been given to the convulsion. Its striking dramatic quality was sure to fix the attention and accordingly treatment has often, and still is, directed to this symptom alone. Yet the muscular paroxysm of epilepsy is not the disease. It is about as scientific to say that the convulsion is epilepsy as to say that a rise of temperature means pneumonia. In many cases a careful study will reveal what might be termed the precipitating or exciting causes of the paroxysms. In some patients it will be certain kinds of food, in others constipation, heat exposure, etc. Simply by removing these causes the frequency of attacks can often be reduced. On the other hand, such therapy, even if the usual administration of bromides and a salt-free and meat- free diet be added, does not bring about a cure. Another type of case in which the apparent cause seems close at hand are the traumatic epilepsies. A man falls down a hatch and afterwards suffers periodic convulsions. One naturally deduces that the epilepsy resulted from the fall. Yet this man may have had epi lepsy before he fell, the accident occurring solely because he became dizzy or unconscious and lost his balance. Furthermore, in such cases even a decompression operation may not effect a cure. Again, a man has a convulsion and somehow we suspect specific disease and do a Wassermann. The test shows a strongly positive reaction. How tempting it is to link the two together and diagnose the case as epilepsy due to syphilis. However, we treat the syphilis, finally render the Wassermann negative, and still the convulsions persist. Surely we have not cured the epilepsy. Undoubtedly there are many similar examples where the precipi tating cause or the apparent cause is treated without avail. On the other hand, cases have responded to treatment where one has been 8 BISCH ELIMINATING THE EPILEPTIC FEOM NAVY. VoL XIII. working completely in the dark because neither exciting causes nor apparent causes could be made out. Munson1 puts it this way, " Therapeutic failure is due in such cases to the fact that the syn drome is not the result of one definite factor but rather to the sum of the activity of other causes besides the apparent cause." In a graphic way he goes' on to express the various factors that combine to produce epilepsy in the following mathematical formula : (a plus b, plus c, plus — , plus m, plus n, plus p, plus — , plus se, plus y, plus z) the brain equals the syndrome. In other words, "the sum of certain known causes of epilepsy (a, b, c) added to certain variable quantities (m, n, p) and to certain unknown agencies (x, y, z), all acting together on the brain, produce (=) the syndrome we call epilepsy." As he states further, the value of such a fanciful formula "em phasizes the multiplicity of factors which may be active in any case ; it shows, too, that since the component etiological factors may differ, there may be an almost indefinite number of etiological complexes at the basis of epilepsy syndromes, and hence points out that to some degree each patient with epilepsy is peculiar to himself and is both similar and different from all others; at the same time, by demonstrating the plural nature of the conditions underlying the syndrome, it indicates a comprehensive mode of treatment and ex plains why treatment along narrow conventional lines is so often unsuccessful." With these viewpoints in mind it is obvious that the number of epileptics surveyed from the service would be conditioned largely upon the medical officers' conceptions of what constituted the condi tion. If older theories and groupings were adhered to comparatively few men would be so classified, especially if to make a diagnosis it should be considered necessary to accurately witness a convulsion. But if a broader interpretation of the disease as a syndrome with multiplicity of causes and determinants were adopted, no doubt many more cases would be classified as epileptic than now appear in the health records. The following table shows the classification of 130 epileptics diag nosed by the author. The chief complaint for which the patient was examined is given in each instance, and the tabulation is made according to ages. The cases are classified according to the exist ing nomenclature which ipso facto emphasizes the conclusive seizure or repeated attacks of dizziness, and whenever there were witnesses to such paroxysms they were interviewed. All cases were given an intensive psychiatric examination, consisting of a complete survey of mental and neurological status, of family and personal history, 1J. F. Munson : Modern treatment of nervous and mental diseases, Vol. II, p. 228. No. X. 9 BISCH —ELIMINATING THE EPILEPTIC FROM NAVY. together with the performance of psychological tests. Those that revealed confusion, memory, concentration, or other defects are noted as showing " mental deterioration." The term " recruit " is restricted to men who had but recently entered a training station. a Sun exposure. Observed by witnesses. XXXXXX | Mental deterioration. Petit-mal. 1 Jacksonian. 1 I X W | X X X X X X X X X X X X X X X X X X ...... XXXXXXXXXXXXXXX xxxx ;\ X X X X X X X ... X ... X X ... X ' : xxxx| X X XXXXXX j X ... X X X X X X X X X X X xxxxx X X X X X X ... X X X X X X X X X X X* X X ... i 16 16u 17 13 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 Complaint reported. Selected at " mast "—asleep on duty Fainting spell History of epileptic attacks Fainting spells Slow at drills and irresponsible Tremor in both hands— had a convulsion History of nervousness and fainting spells History of fainting spells Had two epileptiform seizures Had a fainting spell. Had a spell in detention Had an epileptiform seizure i Had a convulsion Peculiar behavior Had fainting spell in examination room Had a convulsion in hammock Had a convulsion in hospital Had a maniacal attack Had an epileptiform seizure Had a fainting spell do : Nervous and fainting spells Had a convulsion in dentist's chair Selected at "mast" because he gave peculiar excuses for being over leave History of epileptic attacks History of dizzy spells Had "fainting spell " History of having epileptic attacks do Had an epileptiform seizure Dizzy spells Epileptic attack Ear trouble and fainting spells History of epileptic attacks Fainting spells Had a convulsion Nervousness Failure in preliminary testa Tremor in Lands and positive Romberg Selected at "mast" charged with being over leave Illiterate, slow, and childish History of epilepsy Lazy and shiftless Had" a fainting spell Headaches Fainting spells History of epileptic 88977—18 2 10 BISCH —ELIMINATING THE EPILEPTIC FEOM NAVY. Vo Complaint reported. Fainting spells Had a convulsion History of dizzy attacks Nervousness and history of dizzy spells. Fell in a creek and not knowing now it hap pened Low score in preliminary psychological tests — History of having been in an insane asylum Fainting spell ....do do Dizzy spells Fainting spells History of epilepsy History of epileptic attacks Fainting spells and nervousness History of epileptic attacks Diagnosis of epilepsy in health record Had a fainting spell Inability to control mind and having dizzy spells History of epileptic attacks Diagnosis of epilepsy in health record Selected from sick bay because of fainting spell. Convulsions Had an epileptic seizure Fainting spells do do Had a convulsion in operating chair History of epileptic attacks History of fainting spells Having a convulsion Had a "fit" in his hammock Gave history of epireptic attacks Had three epileptiform attacks Had an epileptic attack in detention Convulsions Fainting spells History of epileptic attacks Had an epileptiform attack Childish and silly behavior and always teased . . Had a convulsion Fainting spells Had an epileptic attack in detention Had an epileptiform seizure Diagnosis of epilepsy in health record Epileptiform attacks Had an epileptiform attack in hammock History or dizzy spells History of epilepsy History of epileptic attacks History- of fainting spells and weak heart Convulsions History of convulsions do X X i X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X - X No. 1. 11 BISCH—ELIMINATING THE EPILEPTIC FROM NAVY. Complaint reported. Fainting spells Convulsions Had a convulsion. M M 26 26 26 26 27 27 27 27 27 28 29 29 29 30 30 30 31 32 32 33 33 33 33 33 33 Pains around heart . 33 History of fainting spells 33 Dizzy spells . Pains in head and eyes History of epileptic attacks... Had a convulsion on board ship Had an epileptic attack in building Selected when asking for advice Pains around heart and fainting spells Dizzy spells History of epilepsy Fainting spells - •- Paine in cardiac vicinity and fainting spells . . History of fainting spells Dizzy spells ■ Diagnosis of epilepsy in health record History of epilepsy fdull and apathetic expres sion Fainting spells Dizzy spells Convulsions Continual headache Fainting spells. History of convulsions Fainting spells X X X 1 X X X X x X X X X X X X X X X SUMMARY. 130 77 Number of cases Number observed by witnesses Number of recruits 85 Number having grand-mal attacks only 66 Number having petit-mal attacks only 13 Number having both grand-mal and petit-mal attacks 51 Number of cases diagnosed Jacksonian 2 Number of cases diagnosed hystero-epilepsy 5 Number of cases due to sun exposure 3 Number of cases in which aura was present 13 Number of cases in which mental deterioration was present 70 In the list only three cases appear in which the precipitating cause seemed to be " sun exposure." One of these was a petit-mal case with no deterioration, although the history and general make-up clearly proved epilepsy. The other two cases showed distinct mental deterioration following repeated major seizures. One would naturally suppose that drilling in the sun would be a very favorable cause in precipitating epilectic attacks in one already predisposed before enlistment. As a matter of fact, many cases of 12 BISCH ELIMINATING THE EPILEPTIC FKOM NAVY. Vol. XI IS. fainting and dizziness while at drills were reported and, although notations of the facts observed and the facts brought out by examina tion were made in the health record, the evidence at hand did not seem to warrant a definite diagnosis of epilepsy according to pre scribed standards. The handicap of not being able to secure a previous history from a reliable source free from bias or design other than that of the pa tient himself was especially forceful in these cases. Many of the patients presented what might be called suggestive epileptic consti tutions, but it was felt that here the risk of wrong diagnosis was too great to recommend medical survey. Undoubtedly some of these " sun " cases were truly epileptic. On the other hand, some undoubtedly adjusted themselves later on and, although of epileptic make-up, their ability to adapt themselves *.o their new surroundings and duties was sufficient to prevent further explosions of the " fit-gun." In nine other cases epilepsy was diagnosed in which there were neither witnesses nor mental deterioration. In these, however, the evidence was positive that an epileptic make-up existed, and this make-up alone, aside from the paroxysms, was considered of suffi cient moment to render the men unfit for service of any kind, if not perhaps even dangerous. And this brings up the question of malingering —so important in a military organization. In diagnosing epilepsy its possibility should be held constantly in mind, especially when seizures have not been observed by reliable witnesses and when no mental defects of any kind are present. The whole question of malingering is a fascinating psychological study but the limits of this paper restrict me to stating merely that in my own experience in the Navy not a single case of epilepsy- simulation was found although it was often suspected. "Dejerine1 found no instance of actual malingering among all the nervous cases seen by him during the first six months of the war." And it is in teresting to quote Buzzard * in this connection. He defines a malin gerer as one " who with perfectly clear and well-balanced mind con fesses to himself quite frankly that for some definite purpose he will assume a certain disability." He concludes that persons of this type are extremely rare. Reference has been made in this paper to the epileptic make-up— in other words, the predisposing groundwork which acts as a favor able soil for the sprouting of essential epilepsy as it is commonly conceived. Clark,2 who has studied epilepsy from all points of view » Dgjerine ; Buzzard : Noted In War and Neurosis, by Capt. C. B. Farrar. C. A. M. C Nat. Com. for Mental Hygiene, 1018. •Clark, L. Pierce: Some Suggestions for More Accurate Mental Therapy in Epilepsy; Jour. Am. Med. Assn., July 27, 1018. No. 1. 13 BISCH ELIMINATING THE EPILEPTIC FROM NAVY. for years and is undoubtedly an authority on the subject, describes this summation of predisposing factors as follows: The epileptic constitution, or make-up, has long been recognized as tlie endur ing mental stigma of essential epilepsy itself. Only recently have studies dis closed that the main tenets of such a character are present years before the nervous disorder of epilepsy is shown in fits. The chief instinctive defects of the potentially epileptic individual are egocentricity. supersensitlveness and emo tional poverty. The potential epileptic is intensively self-centered and fails to project his life Interests into his environment in a normal and healthy manner. Partly because of this innate character fault, he is or soon becomes unduly sensitized to all forms of extra stress and annoying demands. He either ex troverts his supersensitlveness by exhibitions of rage and tantrums beyond those which may be seen occasionally in passionate children, or, he introverts this feeling and represses the feelings engendered by his environmental con flict, causing him to develop a very unstable, irritable and sensitive emotional life. This emotional state paves the way for larger and more difficult adapta tions which he can not meet ; outspoken fits may then occur. Previously en dowed with these defective instincts, the increased demands of adolescence and adult life enlarge the difficulties which such Individuals are compelled to meet until they reach the breaking point in a fit or seizure. A disintegration of habits and character, known as deterioration, occurs more easily, in one thus handicapped by a defective endowment. Therefore, mental or behavior de terioration often precedes actual epileptic seizures for a considerable time. The men entering the naval service are young men and many are still in their adolescent period or have but recently emerged from it. A large number come from farming districts where emotional stresses and life's complexities are at a minimum. Very suddenly new and more exacting duties are thrust upon them; many for the first time have left their homes; their altered method of living and even thinking must needs appear cold and severe. Surely, we have here a very exacting test of an individual's ability to adjust himself. And given an epileptic constitution —a tendency to faulty adjust ment—it is small wonder that many cases are overwhelmed, that something breaks, and that the epilepsy at last appears in its more glaring symptoms. This, it would seem, should adequately explain the relatively large number of epileptics found among recruits. Aside from the " chief instinctive defects of the potentially epilep tic individual " rather well-defined behavior characteristics can be discovered after the convulsions have actually developed. These changes are present irrespective of the frequency of attacks —in fact, constitute the behavior noted in epileptics between seizures —and should be distinguished from the well-known mental symptoms when definite dementia has set in. Such epileptics are generally unreliable. They are irritable, unstable, frequently suspicious, and often fly into a rage at the slight est provocation. Some are good-natured and philosophic but even here there is a tendency toward periods of depression and ill-humor, when they are rude and quarrelsome. The disease necessarily re 14 BISCH—ELIMINATING THE EPILEPTIC FROM NAVY. VoL Xlir. stricts freedom of activity and this narrows the field of interest and makes the epileptic self-centered. Due to the chronicity of the seiz ures the epileptic is constantly reminded that he is handicapped, and often this leads to self-pity combined with hypochondriasis and sen- timentalism. They may develop a sympathy-seeking attitude and, in institutions, distinct laziness is common. To maintain self-respect stern discipline is often necessary while others again are most effi cient and happy under gentle guidance. Religious fervor lacking in true piety is not uncommon. As a rule, the sex feelings of epileptics are easily aroused and by many varied stimuli. Ethical judgment is frequently lowered. Between seizures epileptics sometimes display periods of marked confusion in which they may wander off and lose themselves not unlike the automaticlike states seen during grand-mal attacks. Sudden episodes of maniacal excitement have also been noted as well as periods of exaltation with delusional ideas concerning their own cure. Such episodes may have a marked religious coloring. The heredity of epilepsy also throws interesting light on the con dition, and studies of the family trees of epileptics seem to support the view that the epileptic constitution is a thing that can be transmitted. C. B. Davenport and David E. Weeks,1 have carefully investigated 177 pedigrees of epileptics. These findings would seem to indicate that what is transmitted from the parents to offspring in the case of epilepsy is not something present in the germ plasm, but rather that the inherited germ plasm is deficient in something the presence of which in nonepileptics makes for normality. The summary of conclusions in this study follows : 1. The method of field-study of epileptic families combined with the modern biological methods of analysis of hereditary data constitute a vastly improved means of inquiry into Inheritance of epilepsy. 2. Epilepsy and feedle-mindedness show a great similarity of behavior In heredity supporting the hypothesis that each is due to the absence of a pro toplasmic factor that determines complete nervous development. 3. When both parents are either epileptics or feeble-minded all their offspring are so likewise. 4. The conditions named migraine, chorea, paralysis, and extreme nervousness behave as though due to a simplex condition of the protoplasmic factor that conditions complete nervous development; i. e.. persons belonging to these classes usually carry some wholly defective germ cells. Such persons may be called " tainted." 5. When such a tainted individual is mated to a defective about one-half of the offspring are defective. 1 "A First Study of Inheritance in Epilepsy," by C. B. Davenport and David F. Weeks, M. D., Jour. Nerv. and Ment. Disease, vol. 38. no. 11, pp. 641-670, 1011. The study Is on cases at the New Jersey Stale village for epileptics at Sklllman. IhL BISCH—ELIMINATING THE EPILEPTIC FROM NAVY. 15 6. When a simplex normal Is mated with a defective about one-half the offspring are normal ; the others are defective or neurotic. 7. When both parents are simplex in nervous development and tainted about one-quarter (actually 30 per cent) are defective. 8. The proportion of tainted offspring is not noticeably higher when both parents show the same nervous defect. 9. Normal parents that have epileptic offspring usually show gross nervous defect in their close relatives. 10. While we recognize that epilepsy Is a complex, yet there is a classical tjpe numerically so preponderant that, in the mass, epilepsy acts like a unit defect Epilepsy of long standing always leads to dementia. By dementia is meant gradual deterioration of intellectual and emotional proc esses, marked by sluggishness of thinking, haziness of mental im- igery, lowering of the emotional tone, and memory defect. The per sonality of the patient which differentiates him as an individual dis tinct from others gradually disappears; life becomes an existence ind the end-result is a vegetative state in which the patient must be cared for in every way—fed, clothed, and cleansed —the mind no longer being a dynamic, controlling mechanism, but to all practical purposes little more than a functionless organ. This picture of dementia is not overdrawn but its application must be restricted to prevent misconception. There are various degrees of dementia. It is true that all epilepsy leads to dementia but the rap idity of its appearance and the swiftness of its development depends upon the age at onset of the disease, the degree of native mental en dowment, the frequency and severity of attacks, the efficiency of the treatment employed, and the span of life of the patient Only a comparatively few epileptics live long enough for the severe stages of dementia to become manifest, many being carried off by intercur rent diseases, such as pulmonary tuberculosis, pneumonia, etc. The mental effects of epilepsy, in other words, dementia in greater or lesser degree, may be summarized as follows : 1. Sluggishness of thinking. 2. Lengthening of reaction time. 3. Paucity of associations. 4. Lack of productivity. 5. Haziness of mental imagery. 6. Impaired attention and concentration. T. Narrowing of the field of interest. 8. Monotonous speech and thinking. 9. Impaired judgment, reasoning, and powers of inference. 10. Memory defect marked. (a) Immediate or rote memory often tolerably good but soon failing after a few hours or days, except for daily routine impressions. 16 GOULD AND SHAWEKEB SERUM IN LOBAR PNEUMONIA. Vol. XIII. (b) Remote memory fair, but mainly for vivid impressions of childhood or early life, especially as regards mat ters of personal interest, while matters of general in terest and school knowledge are forgotten. (c) Logical memory uniformly poor. 11. General motor retardation and often clumsiness of movement. 12. General emotional deterioration and inadequacy marked by in difference, lowering of emotional tone, etc. Often certain physical signs are of help in diagnosing a doubtful case of epilepsy. Among these may be mentioned a lifeless disin terested expression : vasomotor disturbances ; tendency to obesity ; scars on the tongue, face, and head; "sore" muscles due to nocturnal convulsions; general awkwardness of gait; and the so-called "epilep tic voice sign." which is described by Clarke and Scripture1 as "an expressionless quality of the voice " rendering the speech monotonous, and instead of there being "the continual rise and fall in melody T the vowels and phrases run along on even tones." CONCLUSIONS. 1. Since the epileptic is a peculiar and unreliable individual at any stage of his development—whether actual convulsions have appeared or not—it would seem that, whenever he can be discovered and diagnosed, he should be considered unfit for the naval service, and recommended to a board of medical survey. 2. The obvious places to weed out such cases are the recruiting and training stations. 3. Special attention should be directed toward a previous history of epilepsy in the patient or his family, to the epileptic make-up, to mental deterioration, and to suggestive physical signs. THE USE OF SERUM IN LOBAR PNEUMONIA. By E. W. Gould, Lieutenant, Medical Corps. United States Naval Reserve Force, and M. SrtAWKKEit. Lieutenant, Medical Corps, United States Navy. The use of serum in the treatment of lobar pneumonia during the past few months at the United States Naval Hospital, New York, has followed the generally accepted belief that it is contra-indicated, except in those cases that have been demonstrated to belong to Type I. It has been very difficult to reach definite conclusions in regard to the value of serum in this particular type, because of various factors which it is frequently impossible to control. In spite of specific orders that, when any case of pneumonia is admitted, strenuous efforts should be made at once to secure a satis- 1 Clarke, L. Pierce, and Scripture, E. W. : The Epileptic Voice Sign ; Med. Rec. New York, Oct. 81, 1908. fel. GOULD AND SHAWEKER— -SERUM IN LOBAR PNEUMONIA. 17 factory specimen of sputum and that it be sent to the laboratory with the request that the pneumococcus grouping be determined, Satisfactory specimens frequently can not be secured, many cases sre admitted several days after onset, and unavoidable delays are frequent. The results of typing are, therefore, received in many cases at or about the time of crisis and no serum is indicated. Never theless, it frequently happens that a day or two and sometimes a longer period elapses before results can be obtained. During the past four months 45 cases of Type I have been ad mitted and of that number 25 have received serum. Four deaths have occurred among cases belonging to Type I since we began to demonstrate the type, and these cases will be further described be low. Although this is a very low mortality rate, great credit can not be given to the serum, for there has been undoubtedly a radical change in the virulence of the pneumococcus of all types during the past few months. During the first quarter of 1918 when 155 cases of pneumonia were treated our mortality rate was 21.93 per cent, while only 4 deaths have occurred in the last 85 cases of pneumonia treated at this hospital. The fatal cases all belonged to Type I. It is not the purpose of this short report to express any opinion in regard to the efficacy of serum treatment, but several cases have re cently shown clinical symptoms and definite results which it has seemed advisable to record. The use of serum has brought to our attention several possible criticisms of the ordinary methods employed and has resulted in the adoption of an apparatus devised and described below by one of our number. In all our cases the anaphylactic reaction is determined by the in tradermal injection of a 1 to 10 dilution of normal horse serum with a normal saline control. The serum used was furnished by the Bureau of Medicine and Surgery and was prepared by two commer cial drug firms. Both the Krumweide and mouse methods have been used in de termining the types, and in all cases in which the Krumweide method was successful the mouse method gave the same determina tion. Case I ; T , Eng. 1c. ; age. 45 years. This case was admitted on the first day of his illness, showing physical signs of consolidation in the left lower lobe. There was considerable cardiac embarrassment and stimulants were necessary. There was very marked agglutination by the mouse method, deter mined on the third day of illness. Serum was at once administered ud one-half hour afterward the patient had a severe chill and his temperature rose to 105°. Two hours thereafter, however, his symp 18 GOULD AND SHAWEKER SERUM IN LOBAR PNEUMONIA. Vol. XIII. toms were markedly improved and he made a rapid and uneventful recovery. The severe reaction and chill in this case was thought to be due possibly to the temperature of the serum injected and led to the more exact method of determining this factor, as described below. Only one dose of serum was given. CLINICAL CHART ...CA5..L_-..J.:T. (name.) ' (MAtWiTY) JEttGJ* (R. 'c Sate.) PNEU' 45 _ W. (AGE.) (COLOR) JULY 1 5 H c: B (OtDtPOOPpOpPS HLMATLK8 f zz r" 5 -0 1 AM&ULANCL3TR.lTCHLKA5[ l 4Pf 120 28 ! 6 no 40 \ 5LD BATH. li I 8 11254 ; x 12 I2f 60 : ! 4 11260 1i / 8 IOC 50 < 12 10430 ii 24 3 4 98 52 : 8 102M i ||4p AM.«te«ANTIPNLUM0C0CCU6 I2£B I1C 5b k E.CT\l 6LR.UM. 2J0 15058 i 12.15 T0 |2« CH|LL i 4 96 52 i 2*? vSPONGL 8 96 54 12 m 22 > 25 4 a so 24 12 74 20 4 72 22 8 66 22 \ 26 5 8 90 ZA 12. 88 22 i 4 80 54 8 82 24 I 27 k 8 80 26 v*n 12 92 26 H 4 90 38 i 8 8fi 56 i\ 26 7 8 12 96 40 i 86 54 4 66 52 i u 8 84 64 I i i Case II; F , M. M. 2c; age, 25 years. This case was admitted on the first day of illness and he was not so seriously ill, although he had distinct signs of consolidation in the left lower lobe. He showed immediate response to the serum, though not so marked as in the preceding case, and four doses were given before satisfactory results were obtained. No. 1. GOULD AND SHAWEKEB SEBUM IN LOBAR PNEUMONIA. 19 Case III ; C , Sea. 2c. ; age, 18 years. This patient was admitted on the second day of his illness, and shewed signs of consolidation in his right upper and lower lobes. He wTas actively delirious, seemed very toxic, required urgent stim ulation, but in spite of several attempts, the typing was not deter- CAflt.-T-T- (MAKZ.) CLIN1CALCHART ...W.. OUtTt) -H 2 e s M r" i .•73 u n i 5TM 28 \ OTKLTCHLR. Cft^L. 8 34 M ✓ oPM-50ccANTIPNLUMOCOCCU5 12 ice 56 v3LR.UM. ie a KM 52 11*5 VM.50ecdI.UAJM. ia IOCiO 11*5 fi.M. DLOOD PHLSA.5II2-564 4 92 2e * 2- P.M. 5L00D PRL55URt.59fr&K / 8 94 24 : V 44-§ P M. 6L00P PR.L»U1U.534H5( 12 96 26 r- ■ s 5^P.M.50co.6LR.UM ;9 a 8 66 26 12 96 56 \ 4 86 50 : L 4^ p.M-50cc .5I.R.UM 8 HO 56 \ .SPONGC 12. ICfi 50 i / BO 4 8 90 52 12. 60 26 4 84 28 —L 8 76 26 2! 5 8 76 24 26 12. 80 L | 4 68 22 8 72 20 12 6 8 66 22 / ; 12 62 24 4 70 20 8 70 20 25 7 8 78 20 ) 12. 78 20 4 78 20 ■ 8 72 ie \ 24 8 8 72 18 12. 72 4 mined until the fourth day of his illness. The serum was adminis tered and a distinct chill followed soon afterward. Within a few hours, however, the symptoms had markedly improved, but the tem perature rose the succeeding afternoon, when another dose of serum, the temperature of which was very closely watched, was given, and all the symptoms rapidly improved. 20 GOULD AND SHAWEKER—SERUM IN LOBAR PNEUMONIA. Vol. XIII. I Case IV ; R , B. M. 2c. ; age, 20 years. This patient was admitted on the first day of his illness with. consolidation in the middle lobe of the right lung. The typing; -was determined by the Krumweide method on the second day, and five CLINICAL CHART (NAME} 3 % (rXtl) :. _i8 w C»CL) • (COLOR.) PNtUMONIA- L06AR,. (bio t Kit) 8 5 s COCDCOOOOOOOOO ft.-LMAR.K5. 5 pi : July. 50 2. 4» 128so / 5ATH tt BO 48 \ -5PONGL 51 5 17 126 42 : \ 4 120 56 / 6 104 as / 12. 104 40 \ 4 10040 \ A DO 56 \ * CIAL -5PONGL .AUG 1 4 8 102 52 i / R. 12. 10442 —1 \ R 4 100 56 —1 / R 6 tt4 42 : \kk •5PONGL 2 5 12. 114 42 1 w 4 114 42 ft 8 3b 54 t IZ 10056 k 4 106 55 R 6«?PM.-T0 7~PM. CHILL fc4b 12666 \r 6* PM.soccANTIPNLUMOCCCCU? 8 IZfl 44 R. 5LRUM. 5 6 IZ 96 22 4 84 26 / 8 72 26 V 12. 84 24 N 4 96 42 4 55PM. 50cc 5t.-R.UM. ! R 6 104 54 1 R. A 7 8 112 52 : IE 92 52 / IZ~N-50cc-5l.BOJM. : < 4 66 52 '\ ft : 60 22 / : L doses of serum were administered. He showed a slight maculo- papular eruption on the second and third days, but no distinct ana phylactic reaction till the twelfth day, when a marked urticarial rash appeared over his entire body. He had a rise of temperature lasting five days and a severe general arthritis. The temperature No. 1. 21 GOULD AND SHAWEKER— SERUM IN LOBAR PNEUMONIA. rose to 104° on the fourteenth day. A blood culture on that day proved to be sterile. The rash persisted for several days, and later resembled closely a severe case of measles. CA-3L-H-H, (WMrj CLINICAL CHART, 5. M % 20 '(*«)' ~nxTt$' PhlLUMONIVLObAR,. JfliLKX-)"" . w (color.) I -:• 73 -a r" -j. o>. to. o- -. i«. w. Q. Sk 19 4 6 108 40 / * 12 102 42 \ 4 96 ae \ +P.M 50cc ALR.UM 6 IOC 56 / OPONGL 12 lit. 40 sx 20 a 6 96 34 12 84 50 4 78 28 / 6 00 22 21 b ti 30 22 / 12 64 2S /: 4 54 20 8 54 ?.(. \ ] This patient was admitted on the second day of illness with small area of consolidation in left lower lobe. The typing could not be determined till the sixth day on account of unsatisfactory specimens of sputum. He had then begun to defervesce and no serum was given. Soon thereafter he showed a distinct suppression of urine, became No. 1. 23 GOULD AND SHAWEKER SEBUM IN LOBAR PNEUMONIA. actively uraemic, and died on the 17th day of his illness. A post mortem examination showed large white kidneys with marked paren chymatous changes. Several areas of consolidation had not resolved. No predisposing cause nor previous history of involvement of kidneys could be elicited. QtAMt) CLINICAL CHART ML Mm gNJA-;1S>bA "(cou5r5 i S.LMAR.KO. 1 r». C9 u 5 ',06 25 E>ATH 6 30 22 / ia 102 22 t 4 124 56 ----- •»«. _ CHILL e C6 26 6 36 24 \z 64 22 1 4 92 24 T 8 60 22 i &ATH 6 72 20 i 12. 72 16 4 16 J6 i 8 74 16 I \ 1 8 72 16 ie 72 16 St 4 64 16 6 76 20 \i bATH » 6 72 16 \Z 70 16 ! 4 20 1 ■ 8 fcC 16 6 60 16 12 62 16 ■ 4 70 18 6 56 16 bATH 8 64 20 IZ 68 24 : 66 20 8 89122 V _- i Case VIII; M , Sea. 2c; age, 18 years. This patient was admitted on fourth day of illness with involve ment of left lower lobe and a temperature of 106°. It was impossible to determine the typing till the third day of illness, and no response was detected to the two doses of serum which were given. He died 24 GOULD AND SHAWEKER—SEBUM IN LOBAB PNEUMONIA. Vo on the fourth day of his illness from extension of process to the lung, and consequent cardiac failure. In all of our cases the serum was given in the following ma considering as an ideal method one which would deliver the 6 by the gravity method in high dilution at or slightly above th tient's temperature. A ring stand is used with two rings, one to accommodate a f and the other a serum container. To the funnel is attached th( ductor tubing to the needle. To the container is attached a length of rubber tubing on which is placed a Hoffman clamp, this tubing is placed a dropping device similar to, that used ii Murphy drip method for proctoclysis. A very efficient drop device can be made by employing a discarded 20 c. c. serum syr a two-holed rubber stopper to fit same and a short length of tubing. On the ring stand the dropping device is placed at the of the apex of the funnel or slightly above. A Y-tube from the ( ADMINISTRATION OF SERUM IN PNEUMONIA. 24-1 No. I. GOULD AND SHAWEKEE—SEBUM IN LOBAB PNEUMONIA. 25 ping device connects the conductor tube from the funnel. Below the Y-tube is placed an ordinary hemostat until the vein is punctured and all is ready for administering serum. The conductor tube is 65 inches long from the Y-tube to the needle, 24 inches of which is placed in a container of water at 115° to 117°, about 36 inches from the needle, in order to regulate the tem perature. The tube is interrupted a short distance from the needle and a tube thermometer placed to determine temperature. We have found that it is important to have the temperature very nearly or slightly above the patient's temperature and never below, as low temperatures seem to cause considerable reaction in the form of chill and temporary rising temperature. The toxicity of a foreign pro tein has also been offered as a cause of this occasional chill. How ever, the same phenomenon has been noticed when normal salt solu tion or Fischer's solution has been given intravenously. It has also been suggested that the water used in the salt solution may cause same if not freshly distilled. A 200 c. c. flask is provided for the normal salt solution. This filled flask is inverted into the funnel. It will be noted that the fluid passes into the Y-tube and rises in the dropping device to the level corresponding with the mouth of the said 200 c. c. flask. The serum is placed in the container above the dropping device, 50 to 100 c. c. being given as a dose. The apparatus having been set up and the containers filled, as de scribed above, the arm is sterilized in the usual manner for veni puncture, and a tourniquet applied to the arm above the elbow. A salvarsan or similar needle is convenient to use. After the puncture is made and the blood flows freely from the needle, the tourniquet is removed, the conductor tube is attached, and the hemostat removed. Be certain that all air has been forced out of the conductor tube be fore adapting it to the needle. It will now be noted that as fluid enters the vein, bubbles of air will arise in the salt solution container inverted into the funnel. When this flow is satisfactory, gradually release V. . Hoffman clamp below the serum container, allowing the serum to drop at about 150 drops per minute, depending on the size of the drops. The rate of flow of the salt solution is in inverse proportion to the rate of flow of serum. A small amount of adjusting will be required to control the dilution. By observing the glass Y-tube, the mixing of the two fluids can be seen. After the serum is exhausted, the rate of flow of salt solution will again be the same as before the serum was allowed to drop into the conductor tube. No adjustments are required for the salt solution; it automatically adjusts itself inversely to flow of serum, as indicated above. S8977— 18 3 26 ASSERSON AND BATHBTJN —PNEUMONIA. Vol. XIII. The apparatus is sterilized without disconnecting any parts except ing the needle, the rings on the ring stand having small arcs sawed out so as to allow the funnel and container to be slipped in and out without disconnecting. This same "method has been used for ad ministering salvarsan and other intravenous medication. The advantages of this method are : I. We have a visible index of the rate of flow of both fluids used, any irregularities in the flow being at once apparent. II. The adjustment of the dilution is made with a single Hoffman clamp. III. A careful control of the temperature is obtained. IV. All manipulations of finding vein, etc., are done using salt solution alone, the diluted serum being sandwiched, as it were, be tween the trial flow of normal salt solution and the after flow of the salt solution. After the serum solution has been exhausted, the re maining salt solution washes down the serum which may remain in the tube. V. The serum being introduced high in the tubing gives ample op portunity for thorough mixing of solution. VI. Apparatus is easily assembled from materials always on hand in hospitals. DIAGNOSIS AND TREATMENT OF PNEUMONIA AND EMPYEMA AT THE UNITED STATES NAVAL HOSPITAL, NEWPORT, R. I. By F. A. Asserson, Commander, Medical Corps, United States Navy, and W. L. Bathbhs. Lieutenant, Medical Corps, United States Naval Reserve Force. During the past fall, winter, and spring months the training camps of both services were visited by very serious epidemics of pneumonia. These epidemics were universal, apparently affecting camps located in every section of the country, showing that climate had very little to do with their spread. Numerous articles have been written on the subject, all emphasizing the widespread virulence of the infection and the prevalence of the streptococcus haemolyticus. Rufus Cole (1) in his report to Surgeon General Gorgas on the epi demic at Fort Sam Houston, Tex., divided the cases into acute lobar pneumonia, broncho-pneumonia, and a combination of the two. A large majority of the cases of broncho-pneumonia followed measles and was caused by the streptococcus haemolyticus. Influenza bacilli as well as streptococci were found in the sputum of 13 cases and in 5 cases coming to autopsy, influenza bacilli were present in the lungs of all. The streptococcus haemolyticus was seldom found in the blood stream, and according to McCallum is rarely engulfed by leu cocytes. W. G. McCallum (1) in a pathological study of the pa tients dying at Fort Sam Houston, divides the broncho-pneumonia No. 1. 27 ASSERSON AND RATHBUN —PNEUMONIA. into the usual lobular type and an " interstitial " type. Eleven out of 15 cases studied were of the latter class. McCallum emphasizes the importance of the streptococcus haemolyticus as the causative agent in "interstitial" broncho-pneumonia. This form of broncho pneumonia has been described before, but the importance of the streptococcus haemolyticus in connection with its etiology has been overlooked. McCallum alludes to the " organization of the exudate," which he states is very common in the " interstitial " form and also says that on micrcscopical examination of cross sections some of the areas closely resemble miliary tubercles. He feels that this appear ance accounts fcr many diagnoses of pulmonary tuberculosis made at autopsy following deaths from measles. This is a very important observation, as it exonerates the tubercle bacillus (an organism that needs no mistakes to bolster up its reputation) from at least a small part of its mischief. In a recent letter to Lieutenant Martin B. Hiden, Medical Corps, United States Navy, Major A. G. Wilde, Medical Corps, United States Army, in charge of the camp hospital at Douglas, Ariz., stated that the deaths there have been approximately 25 per cent, which, he said, was about the average mortality in the other Army camps. In cases devel oping empyema he states, without giving figures, that the mortality was very high. The greater portion of his pneumonias and empyemas was apparently due to the streptococcus hnemolyticiis. Most of the cases treated at this hospital came from the Southern States, and a large number (as many as 60 per cent in one command, comprising a brigade) were infected with hookworm. Major Wilde is sure that hookworm, by its devitalizing influences, has been an important factor in connection with the poor reaction of his pneumonia patientsr predisposing them to development of empyema, as 100 per cent of the latter cases had hookworm ova in their stools. Alexander (2) states that at Camp Zachary Taylor definite- changes occurred in the type of the predominating infecting organism^ from time to time since last fall. During September and October, the infection was principally due to one of the various types of pneumo- cocci. Following an epidemic of measles, infection by streptococcus haemolyticus became prevalent, and likewise there was a decided in crease in the percentage of empyemas (30 per cent) at the base hos pital. Alexander found the streptococcus haemolyticus present in the throats of 24 out of 34 men convalescing from bronchitis and infections of the upper respiratory tract, in the dust from the floors of barracks where most of these men were quartered, in specimens of cow's milk, and from the nasal secretions of three out of four sick, horses. The horses were stationed several miles away and apparently had no connection with the epidemic. 28 Vol. XIII. ASSERSON AND RATHBUN —PNEUMONIA. Hamburger and Mayers (3) at Camp Zachary Taylor found hemo lytic streptococci in 52 out of 93 empyema fluids. These organisms were- also found in the blood stream, pericardial pus, lung smears, and the heart's blood. Lieutenant Samuel Kennison, Medical Corps, United States Navy, of the United States Naval Hospital, Newport, R. I., also found these organisms in the blood from the cerebral arte ries at autopsy, and in three cases in the spinal fluid. Our morbidity and mortality from broncho-pneumonia following measles were very low during 1918 as compared with a like period in 1917. The measles patients are protected from droplet infection by a sheet screen attached to the side of each bed, and are also sprayed with argyrol solution a number of times each day. We know nothing about the effect of argyrol upon the streptococcus haemolyticns, hut there is no contradicting the fact that a plentiful supply of this infec tion was present, and broncho-pneumonia was an infrequent compli cation of our patients with measles, only 7 cases developing in 211 consecutive patients admitted to the measles pavilion. From January 1, 1918, to July 23, 1918, 28 cases of broncho-pneu monia were treated at the United States Naval Hospital, Newport. R. I., with a mortality of 25 per cent. This low mortality was evi dently due to our low percentage of infections following measles. Only seven measles patients developed broncho-pneumonia, and four of these died. The majority of our patients were very ill and then convalescence was slow, but most of them were not handicapped by i measles infection and were able to pull through. From January 1 to August 1, 1918, 183 cases of pneumonia, lobai including those with complications of pleurisy, suppurative, wei treated at this hospital with a mortality of 32,1 or 174 per cent.1 Tl total number of deaths from pneumonia, lobar alone (166 cas were treated) , was 19, or 114 per cent.2 The number of cases operat< upon for pleurisy, suppurative, was 50, with 12 deaths, or 24 p cent. Of our pneumonia cases (up to July 23) 3.4 per cent de\< oped tuberculosis, chronic pulmonary. Hamburger and Mayers (3) in classifying their fulminant atypi< lobar pneumonia, described two types based on the prodromes : " Fii those starting with ' sore throat,' ' cough,' and ' grippe ' for a f days, progressing gradually until frank signs of consolidation co be elicited; second, cases starting abruptly, severely with sudi overwhelming prostration and collapse; profoundly toxic; progr ing rapidly to death within three or four days with symptoms profound as to suggest a general sepsis." We had many cases i responding to their hist class at Newport, the majority admitted -v bronchitis acute, influenza, and pleurisy, acute fibrinous. T 1 Five of these patients were found to have pleurisy, suppurative, at autopsy. •This includes eases recovering from pneumonia, but that developed empyema la Mhl. ASSERSON A.ND BATHBUN PNEUMONIA. 29 patients puzzled us a great deal at first until we found that in prac tically all instances the pneumonia was located centrally along the larger ramifications of the bronchi and slowly extended toward the surface. In most of the cases it was possible to locate these lesions by careful comparison of the whispered voice and breath sounds of corresponding areas on the two opposite sides. The distant pecto riloquy and high pitched bronchial breathing could often be made out a day or two before the frank signs of consolidation appeared. Another mistake often made is to depend too much upon the lower lobes, particularly posteriorly in the region of the angle of the scapula, to furnish us the signs we are looking for, when the lesion is so located that the signs are best heard in the axilla, over the upper lobe, or occasionally at the anterior base. This is particu larly true in lesions on the right side. Percussion, inspection, and tactile fremitus were not always helpful during the first stages. Crepitant rales generally appeared fairly early. In the second group of cases these observers noted an extremely high percentage of empyemas. This was not true of our cases corresponding to this group, as most of them had little or no fluid, even when there was extensive fibrinous pleurisy present. The development of effusions in our cases seemed to be an indi cation of an attempt at resistance on the part of the body and our patients of the second class were powerless to assist themselves in the slightest degree from the very beginning. Among those pa tients developing fluid, those with a pleural reaction sufficient to pro duce large quantities of effusion did better than those developing svere fibrinous pleurisies, with but little or no effusion. It seems only reasonable, when we consider the severe pleural shock that «ometimes follows the insertion of a needle into an acutely inflamed pleura, to assume that the prostration, as well as discomfort caused by the constant rubbing of roughened pleurae is very considerable and is bound to have a decidedly bad influence upon the patient's general condition. When these layers are separated, this debilitat ing influence is removed and with a good flow of fluid, the mechani cal effect on the lungs by producing more or less immobility is a therapeutic factor of no mean importance and will be referred to later. According to our observations, the absorption of toxin from the plural fluid is not very great and is more than counterbalanced by the lessened absorption from the immobilized lung. Owing to the layer of plastic lymph coating the pleurae in these cases, it is quite possible that the absorption of toxin is very much interfered with. We have divided our cases into four types : First, uncomplicated lobar pneumonia caused by types one, two, and four pneumococci. that invariably terminated favorably. The temperature reaction 30 ASSERSON AND RATHBUN —PNEUMONIA. Vol. XIII. was often fairly high but the pulse and respiration remained rela tively low during the entire illness. Some of these cases had upper lobe involvement- (In upper lobe pneumonias very low pulse and respiration was noted in a number of cases.) Some of those with upper lobe lesions had a temperature swing resembling that of pulmonary tuberculosis and a few of the cases required careful observation to rule out this disease. Patients of this type occasionally developed pleural effusion, but those going on to empyema invariably recovered with drainage and some were cured by Potain treatment. Second. Same as the second class mentioned above, invariably fatal in spite of any treatment. Both lungs were usually involved and the infection appeared to be of the creeping variety, spreading from one lobe to another until the patient was practically asphyxiated. Most of these cases were haemolytic streptococcus infections or infections of haemolytic streptococci mixed with pneumococci. At autopsy oc casionally only a portion of the upper lobes were found uninvolved. Lieutenant M. B. Hiden, Medical Corps, United States Navy, observed that the blood expectorated by these patients was much darker than in our other cases, apparently due to the amount of lung tissue in volved and the resulting deficient oxygenation of the hemoglobin. Third. Lobar pneumonias that were between the first two classes in severity. The symptoms were severe but not such as would lead one to expect a necessarily fatal outcome. The great majority of these cases recovered. Delayed and false crises were noted in a large num ber of these cases and their convalescence was slow. Fourth. A pneumonia similar to class 3, but with pleural involve ment and complicating empyema. These cases are difficult to handle, but with conservative treat ment, until the pleural sac is well walled off, a very great majority of them can be pulled through. Early operation gives much poorer results and a big reduction in recoveries. After observing the effect of early operations upon our empyema cases, conservative treatment became our routine. Experience at the United States Naval Hos pital, Newport, R. I., in the management of pleurisy with effusion •complicating pneumonia developed the following method of treat ment : The exudate is allowed to accumulate until there is evident me chanical embarrassment of the heart or lungs, when from 200 to <>00 c. c. are removed by the Potain procedure. This operation is repeated from time to time as indicated by symptoms of overloading. Our technic for removal follows : The skin is prepared by painting the area of operation with tincture of iodine. The sixth or seventh interspace in the midaxillary line is generally selected and the tissues along the track of the needle, including the parietal pleura, No.l. ASSEBS0N AND HATHBUN —PNEUMONIA. 31 are infiltrated with a generous amount of novocain (0.5 per cent) in jected through a long, fine hypodermic needle. After waiting for about 10 minutes, a small caliber needle (spinal puncture needles are excellent for this use) is introduced while attached to a syringe containing about 2 c. c. of novocain (0.5 per cent). If the patient complains of pain a small amount of novocain is injected as the needle is slowly inserted, particularly when the parietal pleura is reached. This procedure not only helps to control pain but, in case of an erroneous diagnosis, tends to protect the lung by pushing it away from the needle point. The needle should not be pushed from side to side, after the pleura is reached, unless there is a free flow of fluid. Ethyl-chloride spray is contraindicated, as it fails to control pleural shock. The fluid should be withdrawn slowly and, if the patient . complains of thoracic pain or has a coughing attack, the needle is removed and aspiration stopped for the time being, on the assumption that the pain and cough are due to contact of roughened pleural sur faces. It has been found unwise to remove large quantities of exudate, owing to the pleural shock which occurs when any consid erable areas of parietal and visceral pleura are approximated. This has been the cause of considerable prostration and discomfort, two things that should be avoided if possible. In addition, the resulting increase of cough has a decidedly bad influence on the cardiac action and draws upon the reserve power of the heart. There is also danger of tearing the lung, in case organized pleuritic adhesions are present, when too large an amount of fluid is withdrawn and the lungs are forced down violently by severe coughing. As a result of our experience we feel that the effusion per se has no harmful influence upon the patient's condition that would neces sitate any considerable removal, so its mechanical action has been made use of as a therapeutic measure in the same way as nitrogen is used in the artificial pneumothorax treatment of tuberculosis. We found that pneumonias did very well when the affected lung was collapsed by an effusion, and of late it has been a part of our plan to keep the lung compressed until the pneumonic process was well under control and the effusion had become purulent. The keeping of visceral and parietal pleurae apart during the acute stage tends to obviate the formation of adhesions and thereby facilitates operative procedure when the effusion is ripe for surgical intervention. By the above method it has been found possible to tide over even the very severe pleural cases, provided there was profuse exuda tion. It seems probable that the amount of pleural effusion is a good index of the patient's reacting powers, and a profuse flow should be looked upon, not as a menace to the life of the patient, but as nature's 32 ASSERSON AND RATHBUN PNEUMONIA. VoL XIII. metliod of combating the infection. This should be curbed, during the acute stage, only when nature becomes too radical in her fluid production. In lobar pneumonia we found auscultation of the whispered voice and breath sounds; percussion; inspection and tactile fremitus, with careful comparison of coresponding areas on the opposite sides, of importance as diagnostic measures in the order given. In empyema, cardiac displacement was frequently of great assistance in diagnos ing effusions. Marked flatness, with the characteristic resistance offered to the percussing fingers by fluid accumulations, also pec toriloquy (aegophony) and tympany above the fluid level, were very constant signs. In accumulations filling the left pleural sac, tympany disappeared last in the second and third interspaces, near the ster- • num. Inspection and tactile fremitus were of service. The latter was not always absent over the fluid, as stated in most textbooks, but there was a characteristic relative difference in intensity in favor of the unaffected side. In pneumonia this difference, when accompanied by other physical signs that wrould lead one to expect a marked in crease, is a valuable diagnostic sign of fluid. The breath signs are usually transmitted clear to the base, but comparison of the breathing from the fluid level to the base will show a gradual diminution of the sounds downward. The X-ray was also of service in some cases, but could not be made use of. in severe cases as it was considered unsafe to move them to the X-ray room. On many occasions reflex abdominal pain and tenderness from diaphragmatic pleurisy have been mistaken for symptoms of acute abdominal conditions, such as appendicitis, gall bladder conditions, etc. This error has frequently been responsible for needless opera tive interference and has affected materially the patient's chances of recovery. The following procedure has been found of great service in differentiating between reflex abdominal pain and tender ness caused by diaphragmatic pleurisy and the pain and tenderness resulting from an acute abdominal condition. The abdomen is first examined while the patient is breathing normally and the point or points of maximum pain and tenderness are mapped out. The pa tient is then instructed to take a breath and hold it. If the pain is reflex from diaphragmatic pleurisy the abdominal pain and tender ness disappear until respiration is again commenced. The explana tion of this phenomenon seems to be that when the diaphragm is immobilized there are no afferent impulses of an irritative nature passing to the nerve centers. When the diaphragm is in motion the irritation caused by friction of the roughened pleural surfaces ex cites an afferent impulse that is transmitted to nerve centers lying So.1. ASSERSON AND RATHBUN PNEUMONIA. 38 in close juxtaposition to centers supplying the abdominal wall. This impulse is referred to the abdominal centers and efferent impulses ire ser.l out to the abdominal skin areas supplied by these nerves, producing the symptoms of an abdominal lesion. This sign has been present in 100 per cent of our diaphragmatic pleurisies with reflex abdominal symptoms. In so far as we can rind out, this procedure has never been used before. Reflex abdom inal symptoms occur in tuberculous diaphragmatic pleurisy and i!,t-re have been many abdominal operations performed, only to find normal viscera present. One of the chief methods of diagnosis used :o demonstrate this condition has been tha use of X-ray examina tions to demonstrate diaphragmatic adhesions. We found the history of chill; cough, with bloody expectoration; pleuritic pain; prostration and high temperature; accelerated pulse id moderate dyspnoea to be the most constant symptoms. In ad dition to some of the above symptoms, cyanosis, marked dyspnoea, narked restl ssness, high pulse, great prostration, tympanites, and delinum were always present in the severe type. It was interesting to note that some of our patients with severe pleuritic pain were very uncomfortable while lying on the affected side. Patients with pleurisy, complicating pulmonary tuberculosis, are practically always relieved by lying on the affected side. In the Army camps it was found that a large percentage of pa tients were infected with streptococci in the wards with a few days ifter admission. Cole (1) found 11.4 per cent positive for strepto coccus haemolyticus on admission to the ward ; 36.6 per cent positive 3 to 5 days later, and 56.8 per cent positive in from 8 to 16 after ad mission. Cole says that conditions in hospitals are not unlike those •irrounding puerperal fever and surgical wound infections. While ra measles, raw surfaces do not exist on which infection can occur, this disease renders the respiratory mucous membranes especially T;lEerable to infection. Levy and Anderson (4) feel that the cubical method of isolation is cot successful in protecting measles patients from carriers of ■toptocomis haemolyticus. when they are quartered together in the «me ward. They advise that carriers be segregated in separate 'irds and that throat cultures be taken on noncarriers from time to time to insure that they are still free from this infection. A further precautionary measure that would seem to be of the utmost impor- Unceisthe institution of a more gradual scale of exercise for harden '*/ the men immediately after entering the service. A large number °f our pneumonia patients developed the disease very shortly after •nival at the training station. Many of these men are. thoroughly ^hausted after a long trip on the train, with but little sleep for 48 Ixwrs or more. In addition a great number of them are not accus 84 ASSEBSON AND BATH.BUN —PNEUMONIA. Vol. XIII. tomed to the heavy exercise incident to the training which is started at once. While in this condition they are exposed to heavy doses of infection, which they are totally unable to overcome. Furthermore, many of them are not acclimated, which also predisposes them to infection. It would seem fair to assume that fewer cases of pneu monia would develop if the hardening process was commenced with easier stages. Lynch, Cummings, and Spruit (5) advocate the active immunization of all men (presumably on entering the service) by the administration of streptococcus vaccine, combined with type one and two pneumonococcus vaccine. The medicinal treatment was purely symptomatic. Digitalis and its alkaloids were used for a flagging heart and morphine or codeine for pain, severe cough or restlessness. Tympanitis, always a bad symptom, was controlled by milk and molasses enemata (1 cup of milk and 1 cup of molasses) ; by turpentine stupes and by the admin istration of compound jalap powder in the severe cases. Sponging for high temperatures was found useful. Careful nurs ing and judicious feeding are of the utmost importance and the patient should be given the maximum amount of nourishment that can be assimilated. The drain on the patient's reserve is excessive and a high calory diet, composed of easily assimilable nourishment is of vital importance. The well recognized stimulating properties of food are also an additional indication for its administration in maximum amounts. Except in a very few instances, our patients were able to take very satisfactory quantities of food, if proper at tention was paid to the bowels. The pain of diaphragmatic pleu risy was controlled by a tight abdominal binder. REFERENCES. (1) Pneumonia at Base Hospital. Rufus Cole, M. D., and W. G. McCallum. M. D. .Tour. Am. Med. Assn.. April 20, 1918, p. 1146. (2) Hemolytic Streptococcus Causing Severe Infections at Camp Zachary Taylor, Ky. H. L. Alexander, l.ieut., M. K. C. U. S. A. .Tour. Am. Med. Assn., March 16, 1918, p. 775. (3) Pneumonia and Empyema at Camp Zachary Taylor, Ky. Walter W. Hamburger, Maj., M. It. C, U. S. A., and Lawrence H. Mayers, Lieut, M. R. C, TJ. S. A. Jour. Am. Med. Assn., March 30, 1918, p. 915. (4) The Predisposition of Streptococcus Carriers to the Complications of Measles : Results of Separation of Carriers and Non-Carriers at a Base Hos pital. Robert L. Levy, Capt., M. R. C. U. S. A., and H. L. Alexander, Lieut., M. R. C, U. S. A. Jour. Am. Med. Assn.. June 15, 1918, p. 1827. (5) The Pneumonias: Streptococcus and Pneuniococcus Groups. Charles Lynch, Col., M. C. U. S. A.. James G.. Cummings, Maj., M. R.' C, U. S. A.. Charles B. Spruit. Lieut., M. R. C. TJ. S. A. Jour. Am. Med. Assn., April 13. 1918, p. 1066. No. 1. REDDEN SPECIFIC SERUM THERAPY IN PNEUMONIA. 35 DEVELOPMENT OF SPECIFIC SERUM THERAPY IN PNEUMONIA. By W. R. Redden, Lieutenant. Medical Corps, United States Navy. As early as 1891 Foa and Carbone, Emmerich and Fowitsky, and Klemperer discovered that animals rendered immune to pneumococci produced a serum which caused a passive immunity against pneu mococci when injected into animals or man. From that time until 1910 antipneumococcus serum produced without any conception of groups was used in the treatment of pneumonia in man, with indif- , ferent results. Then Neufeld and Handel in 1910 discovered that there were cer tain strains of pneumococci which fell naturally into one group be cause of common immunological and serological reactions and cer tain other strains which fell into a second group because of common immunological and serological reactions and which were not related to the first group by such reactions. With strains of this latter group Neufeld immunized a horse, whose serum he named Serum Franz. This serum later was found to correspond to the Type II serum of the Rockefeller Institute. The organisms of the first group which Neufeld sent Cole all fell into the Type I group, later developed by Dochez and Gillespie. However, no attempt was made to work out this group problem or to place specific serum therapy on a rational basis until Cole and his coworkers at the hospital of the Rockefeller Institute for Medical Research took up the problem in 1912. Then it was that Dochez and Gillespie, by immunizing rabbits against numerous strains of pneumococci obtained from pneumonia patients, were able to pick out two distinct types and a group which included a large number of races without common immunological characteristics. For convenience they arbitrarily called races that fell into a definite group Type I pneumococcus, those that fell into another definie group Type IT; then because streptococcus mucosus of Schotmuller was known to cause a certain number of lobar pneumonias and because it exhibits the characteristics of a pneumococcus, it was called pneumococcus mucosus and Type III. All pneumococci not included in these three types were designated Group IV. The basis for calling an organism a pneumococcus was bile solu bility, inulin fermentation, methemoglobin formation in the presence cf hemoglobin, and encapsulation. The next logical step was to determine the frequency of occur rence of these types in lobar pneumonias, not only in New York but elsewhere. In New York 150 cases showed the following percentages . 36 REDDEN—SPECIFIC SERUM THERAPY IN PNEUMONIA. Vol. XIII. Type. Number of cases. Percentage. I 57 44 17 32 38 II 30 Ill 11 IV 21 That is, about 80 per cent fell among the so-called fixed types I, II, and III, and about 20 per cent into the IVth or heterologous group. As I have mentioned above, the predominating German strains supplied by Neufeld proved to be of Types I and II. Walker at the Peter Bent Brigham Hospital, Boston, Lewis at the Penn sylvania Hospital, Floyd and myself at the Boston City Hospital, and Lister in South Africa produced similar evidence, to say nothing of the more recent confirmatory evidence from the numerous military camps where correct grouping has been carried out. Following the grouping of cases in New York, the workers at the Rockefeller Institute developed a high titer immune horse serum against Type I and a weaker serum against Type II. Then, by pre liminary protection experiments on mice, established justifiable grounds for specific serum therapy in man. Results with the use of Type I serum against Type I pneumonias in man have proved satisfactory, reducing mortality from about 25 to 30 per cent to about 8 per cent. These results, now more or less universal, have placed Type I antipneumococcus serum in the class of specifics, and make it almost unpardonable for a practitioner to treat a case of pneumonia without attempting to work out the type, and to administer Type I scrum if the organism be of that type. This is further emphasized by the following statistics for New York in 1914. The approximate number of pneumonias was 15.000. The probable number of Type I would be 5,000. Of the deaths due to pneumonia, in all likelihood. 1.500 were of this type. This number of deaths is considerably more than all the deaths from typhoid fever, scarlet fever, and cerebro-spinal fever combined dur ing the same period. (Cole, 1915.) If the Type I serum prevented death in only half instead of three-fourths of this 1,500 one can readily see the justification for Type I antipneumococcus serum. However, the case is not the same with Type II serum. From the beginning the Rockefeller workers found it practically impossible to produce a Type II serum abo%*e one-tenth the titer of Type I serum as demonstrated by protection tests in mice. Moreover the thera peutic results in man showed a less potent serum, for instead of reducing mortality to one fourth of that before serum treament, it barely cut it in two. Then Moore, and Moore and Chesney spent two years or more attempting to enhance the therapeutic value of Type No. 1. 87 REDDEN SPECIFIC SEBUM THERAPY IN PNEUMONIA. II serum, by the use of ethylhydrocuprein, a quinine derivative which had been shown to have a marked germicidal action on pneumococci But it was found that the margin between an effective therapeutic dose and marked toxicity was so small that one could not tell whether the result would be blindness, death, or recovery. Moore himself feels that its use is not justifiable. On the other hand, the Type II antipneumococcus serum produced for Massachusetts by Dr. Kohn at Forest Hills shows a protection in mice equal to the Type I serum produced by the Ro kefeller Institute and the results in the patients look promising. However, it is still too early to make a statement stronger than this. If a patient has Type II pneumonia, give him the benefit of the Type II serum, es pecially if early in the disease, or if extension is going on in the lung tissue. I have seen excellent results. Up to the present time no satisfactory antiserum has been developed for Type III. Wardsworth of the New York State Research Labora tories at Albany, first produced a serum sufficiently strong to use in grouping. In all probability further attempts will be made to make a higher titer Type II serum. Turning to Group IV, one readily recognizes the impossibility of producing a therapeutic antiserum in view of the fact that every Group IV strain produces a serum which has absolutely no effect on any other strain. A brief consideration of some of the .factors involved in producing passive immunity may shed some light on the subject of serum therapy In pneumonias. The standard potency of antipneumococcus serum Type I is measured as fol lows : 0.2 c. c. of the .serum introduced into the peritoneal cavity of a mouse with 0.1 c. c. of a Type I culture, 0.000001 c. c. of which kills a mouse in 24 to 48 hours, should prevent death In that mouse for at least a period of 5 days. Thus far 0.2 c. c. of Type II serum protects against 0.01 c. c. of Type II culture. A curious phenomenon is noted here. If more than 0.1 c. e. of a virulent culture of pneumococci Is Injected into a mouse, no amount of homologous antiserum will save him, thus showing a limit of protective power. Yet as far as active immunity is concerned in all types of pneumococci, the limit of protection has not been reached (Cole), for animals may be actively immunized so that they will stand many times the maximal dose above described. I might say In passing that this indicates excellent possibilities for prophylactic vaccine treat ment in the prevention of the fixed types of pneumonia. It Is evident from the above that there are at least two immunity factors, one which is transferable in serum and a second which may or may not be trans ferable. It would appear that with Type I -serum the second factor is not so essential. That with Type II serum the second is more important, and with Type III absolutely essential. (Cole.) There is another important point which may throw some light on the failure of Type II serum to react as well as Type I. Last year Cole found that empyema fluids resulting from pueumococcus in fection contained large amounts of soluble substances which have the property of neutralizing pueumococcus antibodies. He also showed that when immune serum is administered to patients severely infected with pneumococci, the im mune bodies may also disappear very rapidly; that is. as soon as 8 to 12 hours 38 REDDEN SPECIFIC SEBUM THERAPY IN PNEUMONIA. Vol. XIII. after intravenous Injection, as shown by the disappearance of agglutinins. This disappearance is probably due to the presence of such a soluble substance in the blood. Apparently the serum only becomes effective when these sub stances are neutralized. A study of the agglutination curve of the patient's serum is of value in showing why, in some cases, favorable results have not fol lowed the use of immune serum. Xow it is possible that Type II serum is less effective than Type I, not only because the immune bodies are not so "well developed, but because the power of Type II pneumococcus to produce these soluble substances is more highly developed. Administration of serum. —As soon as a pneumonia patient is seen he should be given 1/10 c. c.' of a 1/100 dilution of horse serum in- tradermully. If there is no reaction to this test within 15 minutes to an hour. 0.5 c. c. of horse serum may be given subcutaneously as a desensitizing dose. The sputum is washed and injected into the peritoneal cavity of a mouse, where the pneumococcus develops rapidly and produces an exudate. This exudate is removed from the cavity at the end of 12 to 18 hours and centrifuged. The clear supernatant fluid contains a specific precipitinogen, which, if caused by Type I, II, or II, pneu mococcus, will precipitate out of the corresponding immune serum a specific precipitin, which shows up as minute white particles or definite flakes, which later settle out and leave a clear fluid. With proper dilutions of sera there is no cross precipitation; in other words, the reaction shows definitely whether the organism belongs to Type I, II, or III. If there is no reaction and the organism is a pneumococcus it is called Group IV. If the case is a Type I or II, 100 c. c. of the proper type serum, diluted with an equal amount of fresh sterile physiological salt solu tion, is slowly injected intravenously, at body temperature, either by a large syringe or preferably by gravity. It is essential that the first 15 c. c. should be given slowly, over a period of 15 minutes, in order to avoid the possibility of a sudden anaphylactic reaction which may not have been evident in the preliminary tests. The remainder of the serum may then be given rapidly enough to finish the amount within a half hour. Usually a chill with a rise in temperature and pulse follows within 30 to 60 minutes the intravenous injection. Although violent at times, it is never fatal. If the case is Type I and the patient is sensitive to serum, it is worth while desensitizing as follows : First give 0.025 c. c. horse serum subcutaneously ; in one- half hour to an hour give 0.05 c. c, etc. ; continue increasing the dose each period until 1 c. c. can be given intravenously, then it is safe to proceed slowly with the whole amount. It usually takes about 8 to 12 hours to carry out this procedure, but in Type I infection it appears to be worth while. No. 1. 39 REDDEN SPECIFIC SERUM THEBAPY IN PNEUMONIA. The second injection of serum should be given about 8 to 12 hours nfter the first, nnd the third about 8 to 12 hours after the second. If by this time temperature, pulse, and respiration have dropped to normal, no further injections need be given. But in the light of present knowledge, it is dangerous to stop short of three doses, even if the symptoms have subsided after the first or second. On the other hand. Cole has given as high as 1,600 c. c. of serum at 8-hour intervals in some of his cases. If the symptoms subside, then appear again, even during serum treu^ment, complications such as empyema, pericarditis, or meningitis, or involvement of other lung tissue must be looked for'. One of these is usually found. While discussing the question of empyema after pneumococcus infection. Cole told me that there has been a definite increase of empyemas in Type I pneu monias after serum therapy, an increase from 1 to 2 per cent up to 16 per cent. In all probability this 16 per cent represents a definite number of cases formerly fatal, but which by aid of the imnfune serum are now able to develop a resistance sufficient to localize the infection in the pleural cavity. May I state here that I believe free drainage of an empyema fol lowing a lobar pneumonia due to pneumococcus is still the proper procedure as soon as pus is found ? For after carefully following the reports from various camps as well as considering the facts presented in previous reports here, it appears that the rapidly fatal empyema cases have been those which developed pneumonia after measles, or those in whom the pneumococcus had not been demonstrated, but whose chest fluids have yielded pure cultures of streptococcus. In both types the pneumonia is usually broncho-, and the causative agent streptococcus. Frequently there has been no demonstrable pneu monia, just a primary streptococcic empyema. Attempts have been made to concentrate the immune principles of the type sera. Gay and Chickering, in 1915, demonstrated that " a water-clear extract of pneumococci added to homologous antiserum produces a voluminous precipitate which carries with it practically all the protective bodies against pneumococcus infection in animals. This precipitate washed and resuspended in saline solution protects as well as whole serum, but contains only 0.09 to 0.34 per cent protein as against the original 6 per cent." However, no use has been made of this concentrated precipitin. Avery has demonstrated that the im mune bodies of antipneumococcus serum are completely precipi tated by 38 per cent to 42 per cent saturation of ammonium sulphate. Yet no use has been made of this fact. It is interesting to note that whereas the diphtheria antitoxin is associated with the pseudo- globulin fraction of horse serum antitoxin, yet the immune bodies of antipneumococcus serum are associated with both the englobulin and the pseudoglobulins. In all probability the time will come when 40 BEDDEN—SPECIFIC SEBUM THEBAPY IN PNEUMONIA. Vol. XIII. these less toxic globulin fractions will be used to combat pneumo- coccus infection. Nature of the infection, —We know that mere growth of organisms does not necessarily mean disease. Note the ever increasing number and varieties of carriers who rarely ever come down with the disease. It was formerly thought that either people carried parasitic organ isms more or less constantly in the upper respiratory tract, and that under conditions of lowered resistance these invaded the blood stream and lungs, or else people carried saprophytic organisms which under certain conditions suddenly acquired virulence and became parasitic with a resultant invasion of the body, or that dis ease was caused by a pathogenic organism different from the ordinary mouth organisms, acquired by the individual from outside his own body. Recent studies, by Avery and Dochez and others, have demonstrated that 'although pneumococci are present in 80 per cent of normal mouths, in no case out of 20 first studied were types I, II, or III found. All were group IV. Later studies showed that patients ill with the fixed types of pneumococci carry the same fixed type in the sputum from a few weeks up to 00 days after crisis. It was noted that delayed resolution or complications such as empyema favored the persistence of the fixed type. It was further noted that people associated with such patients often became carriers of the same type of organism, yet without coming down with the disease. When the type which caused the disease disappears from the sputum, Type IV is frequently, though not always, found. It would appear from the above that in all probability the ordinary mouth variety of pneumo cocci are Type IV: that these are usually saprophytic, but under conditions of lowered resistance, such as exposure or devitalizing work, became parasitic: but that the large majority of pneumonias, as high as 70 to 80 per cent are caused by the introduction of fixed types of pneumococci, which are usually parasitic, though they may remain harmless to certain resistant individuals called healthy car riers; that the chief epidemiological factor of lobar pneumonia is the transmission of fixed types from people recently ill from the disease, or from those associated with them and who have become carriers of the fixed types; that aside from the organism itself, lowered resistance due to exposure, exhaustion, etc., plays an im portant part. Let lis consider for a moment how disease develops. We know that diphtheria bacilli and tetanus bacilli in their growth produce a definite toxic substance both within the body and in the media. Apparently this is a part of the growth process. We also know that the chief symptoms of these two diseases are caused by the elaboration of the toxins and their action on the tissues. But as far No. 1. KEDDEN —SPECIFIC SEBUM THERAPY IN PNEUMONIA. 41 as is known, no such toxin is produced, by the pneumococcus either inside or outside of the body. However, it has been definitely dem onstrated that when pneumococci are ground up with salt solution, or dissolved by sodium cholate, then filtered through a Berkfeldt filter to remove all bacterial bodies, a clear solution of high toxic and hemolytic titre is obtained. This is called pneumococcus hemo- toxin, and has been demonstrated to be a definite preconstructed en dotoxin, and not a toxin elaborated by enzymatic action on the bac teria] protein after autolysis has taken place. In other words the substance is a true endotoxin, as named by Pfeiffer. There is con siderable evidence that the initial symptoms of pneumonia are not due to the dead organisms with the subsequent release of this hemo lytic endotoxin, but that rather the symptoms are produced only when living organisms are actively multiplying. Peabody has demon strated that during the terminal stages of fatal cases of pneumonia there occurs a progressive decrease in the oxygen content and oxygen combining capacity of the blood. This evidently is due to the ability of the growing pneumococcus to transform oxyhemoglobin into methemoglobin. Now if growing pneumococci are able to produce this change in red blood cells merely by contact, by changing oxida tive processes, it is possible they may in a similar way produce other important changes in other tissue cells. It may be that the entire specific action of the pneumococcus on the tissues is in the lung or in the local lesion, and that the general symptoms may then be non specific in character like that produced by any similar local lesion in duced by any cause. This is a bit of Cole's theory. However, Cohn of the Institute has demonstrated by the electrocardiogram that cer tain changes take place in the heart muscle, changes which can be reversed to normal by digitalis. Porter of Harvard has also demon strated that serum from pneumonia patients has a toxic effect on the hearts of experimental animals, which causes death if the hearts are not subsequently perfused with normal serum before the toxic action has gone too far. This would seem to indicate that the endotixin of the pneumococci may play an important role in cardiac failure after or during pneumonia. If this substance causes symptoms which can be demonstrated in the above manner, there is some ground for belief that it may affect other tissues in a detrimental manner. I have already mentioned the fact that certain soluble fixing substances which have the power to neutralize antibodies are also developed by pneumococci. These soluble fixing substances may appear in the urine of pneumonia patients in the form of a precipitinogen which acts the same as that developed in pneumococcus cultures, or in the peritoneal cavity of a mouse injected for typing purposes. That is, it will cause a precipitation in a specific homologous antipneumo- 88977—18 4 42 EEDDEN —SPECIFIC SEBUM THEEAPY IN PNEUMONIA. Vol. XIII. coccus serum. This has been used for diagnostic purposes. When found it is usually a bad prognostic sign. The question naturally arises, how does the specific immune serum act toward the pneumococcus and its products? In the first place. Bull has demonstrated that it clears the blood stream of organisms and causes agglutination; that it opsonizes the organisms so that after agglutination they are phagocyted in enormous numbers. Blake showed that when pneumococci were agglutinated by specific antiserum, methemoglobin formation was diminished or lost. In vitro, antipncumococcus serum inhibits the growth of the homo logous organism, inhibits or markedly delays fermentation of inulin, and the splitting of protein. And lastly, Cole has demonstrated that the. immune serum has a high antitoxin and antihemolytic titre. which in all probability play an important role in combating the strong endohemotoxin. I simply present this data and offer the sug gestion that here is at least one possibility why specific antipneumo- coccus serum is of use in combating type pneumonias. In order not to confuse the grouping of pneumococci, I have dis cussed the. four main groups first. Now just a word about Avery's subgroups of II—namely, Ila, lib, and IIx. All these sub groups are included in type II because of agglutination in type II antiserum, but they are subgrouped because specific serum de veloped for " a " will not agglutinate " b " or " x," nor is there- cross agglutination with specific serum developed for " b " or " x." Moreover, type II serum has no protective action against IIx strains. Type IIx shows another peculiarity which suggests an approach to group IV, namely, each strain is different from every other strain in its immunological and serological reactions. In passing, I might suggest that some of the earlier cases of type II pneumonias were really subgroups of type II, and that the failure to get results with type II antiserum was due, in some degree ai least, to this fact. However, within the past month we treated two cases of type II subgroups with excellent results. Aside from giving an opportunity for serum treatment in favor able types, grouping aids in prognosis for group IV almost always run a mild course or recovers. About one-fourth of type I die, about a third of type II die, and nearly half of the type III die. To summarize, then, the etiological factor in 98 per cent of all lobar pneumonias is the pneumococcus. Eighty per cent fall seriologically into three groups called fixed Types I, II, III. II is further sub divided into a, b, and x. The remaining 20 per cent is called Group IV and is made up of numerous distinct races. Group IV may be found in 80 per cent of normal mouths. But the fixed types are found only in the mouths of those recently ill with such a type or in one who has been in contact with such a type No. 1. 43 CRANDON—FLAT FOOT. case. This points to carriers of the fixed types as the chief epidemio logical factor. About 38 per cent of all cases are Type I ; about 30 per cent of all cases are Type II; about 11 per cent of all cases are Type III. Against Type I an immune serum has been produced which reduces mortality by three-fourths. Against Type II a less potent serum which reduces mortality by about one-half has been produced. All cases of pneumonia should be typed as early as possible in order to give patients the benefit of antiserum, if of Type I or II. Prac tically all cases which fall into these two groups can be given serum without danger. Even if one of the Type I cases shows sensitiveness to the serum, an attempt should be made to desensitize in order to make serum 1 available. Serum should be given as early as possible and in 100 c. c. amounts at eight-hour intervals for at least three doses, intravenously. Probably the action of the growing pneumo- occus plays an important part in producing the local lesion. There is little doubt but that the endotoxin of the pneumococcus plays an important part in the cardiac failures of pneumonia pa tients and may affect other tissues in a detrimental manner. It is likely that the curative power of antipneumococcus serum depends much on its agglutinating action, its opsonizing power, its antitoxic effect, its ability to inhibit the growth of the organisms, and to retard methemoglobin formation. It is also probable that there is an action not measurable by present methods. Serum not only cures but also shortens the course of disease by three to five days. Grouping not only makes serum therapy available but aids in prog nosis, the order of increasing mortality being IV, I, II, III. Experience points to crowded quarters, exposure to severe weather, and devitalizing labor as important predisposing factors in the de- veloment of the disease.1 FLAT FOOT, A NEW STATEMENT OF OID TRUTH. By L. R. G. Ceasdon, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. " Nothing is settled till it is settled right " is as true in the surgical world as in the ethical. Since 1906 the writer has practiced and written on the concept that weak foot, pronated foot, and flat foot should be treated not as an anatomical but as a physiological entity. From the practical side of function and treatment the human foot has no more fixed arch * The writer lays no claim to originality, but has used freely data gathered during a year's stay at the Rockefeller Institute, and from the numerous reprints and lectures pub lished by Doctor Cole and his coworkers. The attempt has been to present briefly the problem of serum therapy in pneumonias. 44 CRANDON —FLAT FOOT. VoL XIII. than the extended hand till the muscles make one. Every detail of our mental attitude toward the care of feet changes if, always, for the word arch we substitute the word arching. In short, as far as examination and treatment go, with certain exceptions, flat foot is not organic but functional only. In 1903 at one large orthopedic hospital, 10 to 15 pairs of plates were made for feet daily; in 1914. 2 pairs were made in the whole year! Except in the practice of those who will not see, the flat-foot plate has gone. So, also, the shoemaker has begun to recognize the human foot not as the stumpy end of a limb, but as a live, flexible, prehensile extremity. Thus, in place of the stiff-shanked shoes which our new Filipino soldiers used to sling over their shoulders on a hike, Army and Navy bootmakers now produce a roomy, flexible shoe which allows all the 23 interrelated joints of the foot a chance to work. The whole surgical world is coming to see anew the demands of the bony and muscular complex of the foot and to restore to it, so far as modern underfoot conditions permit, some of its barefoot freedom. The bare foot on nature's own surfaces—sand, turf, and in forest— comes down on the round unstable heel, falls forward on the outer edge, then the whole plantar surface grasps the surface beneath and pushes backward. The ideal shoe, to allow the simulation of this sequence on the hard planes of man-made surfaces, must have an unstable (rubber or partly rubber) heel, a broad outside curve, a wide toe and is shankless to allow a gripping action by the whole foot. Ideal shoes of this type are made; regulation shoes of Army and Navy approximate it: surgeons approve; those who wear such shoes become disciples; but a definite lack of practical application of this knowledge still prevails in draft boards and enrolling offices. In time of peace or in a country unendingly rich in men, it may be defensible to reject applicants on inspection or on anatomical measurements of their feet, but when the whole man power of a nation is drafted, when so many hundreds of valid disqualifications appear, it is both ignorant and wasteful to reject a man for an anatomical variation in feet which are functionally good. The perfect foot of a baby gives the complete print of "flatfoot." A foot with an arch which appears perfect may have no muscles and collapse on the first hike. The man who has tramped all winter in a logging camp or a professional athlete may have a pronatcd foot and yet can march 30 miles. Excepting for those feet where the astragulus is practically on the ground, the test should be; Does he walk with the splay-footed shuffle of the obviously collapsed foot? If so, reject. If not, can he balance with any degree of steadiness on one foot straight forward, with the other foot curled round the CRANDON— FLAT FOOT. Fig. I. Fig. 2. Fig. 3. Fig. 4. Fie. 5- No. 1. 45 CRANDON—FLAT FOOT. ankle? (Fig. 3.) If he can. so far as the feet are in question, accept him. Men accepted by this standard, with graded training up to the maximum use of the feet, are less likely to be invalided by foot trouble than those taken by inspection only. The care of the foot of the recruit, outside of cleanliness and right shoeing, as described, should include the prevention of that form of .break-down commonly called "flatfoot." This preventive cure should consist in three exercises added to the daily setting-up drill : 1. Stand with feet parallel, about 4 inches apart, with the weight on the outer edge of the feet; let the big toe grasp the ground, " break " the knees slightly ; bend the knees outward as if bowlegged. (Fig.l.) This is the position of greatest stability, unconsciously taken when using binoculars on deck at sea. 2. Stand with feet crossed, the weight divided equally between th& two, then cross the feet in the opposite way. (Fig. 2.) 3. Stand on one foot straight forward, curl the other foot behind the standing ankle and balance. (Fig. 3.) The last two exercises bring into use all the muscles of the leg and especially the intrinsic muscles of the foot. The absurd so-called " military " stance with feet at a 60-degree angle, based only on the whim of Napoleon, contrary to all instinctsr should be abolished. Guard duty in this position precedes a large number of the cases of acute flat foot seen in military practice.1 The treatment of an actually developed case consists in : 1. Rest for a few days with not too much hot bathing (which will reduce muscle tone). 2. The use of the exercises given above in graded amounts, up to 50 times a day. 3. Flexible shoes, preferably low-cut (Oxford). 4. Obstinate cases may call for S-strapping or rubber sponges under the arches for a short time. SUMMARY. 1. Acute flat foot, especially in young men, is not anatomical but is functonal only. 2. It should be recognized in enrolling offices by functional tests and not by inspection. 3. Experience shows that few young men are rejectable for fiat or weak foot. 4. It is to be treated by exercises to restore muscle tone and never by apparatus such as built-up shoes or plates. 1 So far as the naval service Is concerned, the attitude to which the writer very properly objects 1b not assumed to any great extent and plays no conspicuous rfile in tb» production of the disability under discussion. (Editor.) 46 BUBK—PRESENT STATUS OF TREATMENT OF FLAT FEET. Vol. XIII. 5. These exercises (described above) should form a part of daily drill. 6. The so-called military stance (60°) for the feet should be abol ished. THE PRESENT STATUS OF THE TREATMENT OF FLAT FEET. By S. B. Bi-rk, Lieutennnt (J. G.), Medical Corps, United States Naval Reserve Force! The causes of flat feet may be considered as predisposing or con stitutional and local. The constitutional or predisposing causes are usually grouped under (1) congenital (a shortened tendo Achillis diminishes the flexion of the foot in walking and causes weakening of the dorsal structures if pronation of the foot and abduction of the toes do not compensate); (2) neurotic; (3) inflammatory; (4) traumatic; and (5) toxic conditions resulting from altered physiological processes, with the production of an overstrain in using the lower extremities. Occupation, unless accompanied by other conditions, is rarely respon sible for flat foot (Merrill). The local changes are knock-knee, poorly fitting shoes, and such other conditions which produce "toeing out." The latter forces the body weight obliquely on the arch of the foot, producing an inward cross strain. The position of the leg in which the toes fall outside of the line of progression shortens the stride, lessens the important element of thrust of the great toe, and diminishes the force of propulsion. Toeing out produces: (1) External rotation of the legs. (2) Twisting of the knees and straining of the joints. (3) Outward rotation of the femur, which favors backward rota tion of the pelvis on its transverse axis, with elevation of the pubis and a decrease in the normal lordosis. (4) Forward displacement of the hips and shoulders, thereby in creasing the lower thoracic curve, and a stoop-shoulder position is favored. Meisenbach describes two types of flat foot, the flexible and the rigid. The flexible is associated with a low posterior or longitudinal arch, pronation or weakness of the ankle, and a general atonic con dition of the muscles of the leg and foot, the toes usually being straight. There is pain over the metatarsals in the weight-bearing position. The rigid or reversed arch is caused by (1) thickening of the metatarso-phalangeal girdle, (2) apparent shortening of the flexor tendons of the second, third and fourth toes, and (3) the presence of deep-seated callouses on the under surface of the arch. No. 1. BUBK PRESENT STATUS OF TREATMENT OF FLAT FEET. 47 Katzenstein holds that the weakness is primarily in the ligaments. Soule summarizes the pathology as an ultimate change in the astra- galo-navicular articulation, which is readily seen on X-ray examina tion. At the same time he urges an examination of the foot for old inflammations of the tarsus as the underlying factors. The symptomatology depends upon the degree of involvement with the production of pain and the objective phenomena resulting from toeing out. The shoes show an unequal wearing down. The trudging gait and the stooping shoulders are characteristic. In addi tion, the patients are easily fatigued and are mentally apathetic. On taking a tracing in the weight-bearing position the inner margin of the foot is prominent. The treatment depends upon the degree of the flat foot. In all cases attempts should be made to relieve local and underlying constitutional causes. For the mild cases adhesive strap ping, proper shoes, and graded exercise are recommended. These exercises as described by McKenzie are : (1) Patient sitting, leg extended nnd supported just above the ankle. Grnsp the right foot just above the ankle with the left hand. Place the right hand on sole of foot, with thumb pointing townrd the toes, grasp foot firmly, cir cumduct foot slowly as follows : Extension, Inversion, flexion, and everslon. This should be done by the attendant with as much force as can be used without pain, and repeated 30 times. (2) These same movements should be done by the patient without help. (3) Patient standing, toes in and heels out, and about 12 inches apart; rise on toes and press out slowly. Repeat 30 times. (4) Patient standing, feet parallel and 6 inches apart. Raise the inner side of the feet, throwing the weight on the outer side. Repeat 30 times. (5) Patient standing with feet parallel, weight resting on outer side of the feet Walk forward and backward 30 steps, keeping feet parallel and forcing down bail of feet. (6) Patient standing, feet 12 Inches apart and parallel, knees bending and outward pressing. (7) Patient standing, feet 6 inches apart and turned In, rise on toes and walk forward and backward 30 steps, crossing feet and keeping toes In. (8) Stnndlng firm, right lunge forward, neck firm, bend right knee until heel is forced from floor, keeping weight on outer side of foot. Repeat 10 times and do same with the left. (9) Standing, feet parallel, 6 inches apart. Sway slowly forward and back ward on heels and ball of feet, chest active, and chin In. (10) Raise heel 1 inch from floor and walk without bringing heel down, as If heel was painful. This may be done repeatedly with both heels. For the severe cases operative treatment is advised. Katzenstein in jects 0.5 c. c. of 4 per cent formaldehyde into the weak points of the tibio-navicular ligament, with the idea of hardening this ligament, and then puts the foot in a plaster of Paris cast for a month. Local anesthesia is necessary in this treatment. He often gives small amounts of morphine also if necessary. 48 TKIBLE AND WATKINS —EAR PROTECTION. VoLXUI. Meisenbach operates on the rigid type. He performs an osteotomy of the second, third, and fourth metatarsal bones, places a felt pad under the arch, and then a plaster of Paris cast up to the knee. He claims good results, and claims the following advantages for the op eration : (1) The Immediate relief of the symptoms and a dropping off of the callouses. (2) The straightening of the toes, with a high anterior arch and no deform ity of the foot. (3) The metatarsophalangeal joints are not opened and the heads of the metatarsal bones are not resected. (4) It is a bloodless procedure, and the danger of infection is negligible. Arnd transfers the tendo Achillis to a deeper groove chiseled into the posterior aspect of the scaphoid. If the tuberosity of the sca phoid does not protrude enough for the purpose, the articulation between the scaphoid and the astragalus can be opened and a groove dug for the tendon here, suturing the tendon again. The results of this method of correcting have been satisfactory during the 18 months to date. Soule denudes the head of the astragalus and the concave surface of the navicular bone and unites them with an autogenous bone peg from the crest of the tibia. He claims excellent results. BEFEKENCES : 1. Anderson, W. L., Med. Times, New York, 191G, XLIV, 144. 2. Arnd, C, Cor. Blatt f. schweiz Aerzte, 1916, XLVI, No. 34, p. 175 Ab. Jour. Am. Med. Assn., LXVII, No. 14, 1049. 3. Bendixen, P. A., Med. Herald, 1915, XXXIV, 368. 4. Katzenstein, M., Therap d. Gegenw., Dec. 15 ; Jour. Am. Med. Assn., LXVI, No. 7, 543. 5. Lovett, R. W., Pediatrics, 1916, XXVIII, 16. 6. Meisenbach, R. O., Amer. Jour. Orthop. Surg., 1916, XIV, 206. 7. Merrill, W. J., Surg. Gyn. & Obstet., 1916, XXII, p. 366. 8. Packard, G. B., Colorado Med. Jour., 1914, XL, 406. 9. Roberts, P. W., New York Med. Jour., Aug. 28, 1915. 10. Soule, R. E.,-Amer. Jour. Orthop. Surg., XV, 4, 292. EAR PROTECTION. By G. B. Tkible, Commander, and S. S. Watkins, Lieutenant, Medical Corps, United States Navy. Conditions surrounding the present conflict are radically different, so far as the weapons are concerned, from those of any previous time in history. The increasingly large proportion of high-explosive shells, grenades and bombs, and the relatively confined spaces occupied, such as trenches and dugouts, all tend to an augmentation of ear injuries. Last, but not least, the employment of corrosive and No. 1. 49 TRIBLE AND WATKINS EAR PROTECTION. noxious gases has caused a limitation of the available means of ear protection. Injuries to the ear, ni:iy be classified broadly, as: 1. Direct — (a) Loss of tissue. (6) Injury by missiles. (c) Gas injuries, producing irritation or caustic action in the external canal or drum. 2. Indirect — (n) Rupture of drum from changes of pressure. ( 6 ) Commotion of the labyrinth. (c) Deafness from long-continued or excessive noise. (d) Driving in of the foot-piece of the stapes, with an intact drum. All variations and combinations of these types may be encountered. So far as the direct injuries are concerned, no practical method of protection is available against the first two, and some devices may increase the danger by acting as secondary missiles, or by becoming fragmented or embedded in the tissue of the canal. It is likely, however, that with such direct injuries, the ear condition will be but a minor part of the damage sustained. With regard to the third, gas injuries, the corrosive gases, such as chlorine, render the efficacy of metal protectors with delicate springs or parts that should coapt, rather problematical and mustard gas, through its action and affinity for fats and oils, as well as its persistence in these substances, makes useless employment of cotton impregnated in vaseline, or similar substances, and makes it necessary to change rubber protectors fre quently. This opinion is substantiated by the following report from Dr. J. Gordon Wilson to Lieutenant Colonel Milliken, under date of July 20, 1918: 1. In regard to the action of mustard gas on rubber and metal, I had a talk with Stieglitz. The action on copper or any metal is negligible, especially in such dilutions as are used in warfare. At the chemical laboratory of the uni versity it was found that a very strong concentrated solution had no effect on copper which enters into the nmke-up of the protector. If it does anything at all, it forms a thin coating of sulphide, not harmful. 2. The action of the gas on the spring is now undergoing investigation, but it does not appear to have any effect. 3. The rubber of the protector will absorb the gas ; if the rubber be left In the ear long there will probably result injury to the canal, but if at the end of the gas attack the rubber be removed, which can easily be done, and replaced with fresh rubber, which can easily be supplied, there is no fear of injury. 4. As the ear contains usually a lot of fatty matter, sebaceous secretion and wax, the gas, getting into this material and being absorbed, will probably act in a very harmful manner on the canal for an Indefinite period. The ear plug will protect from this, as the gas is not likely to get past the rubber. By far the most important, and those which to a certain degree can be prevented, are the indirect injuries. Rupture of the drum is 50 Vol. XIII. TRIBLE AND WATKINS EAR PROTECTION. Cs a very frequent injury, may occur in any portion, though commonly thought to be more often found in the lower half; whether in the anterior or posterior quadrant, is a matter of dispute. Ruptures are made more easily with a previously existing catarrh, or its sequelae, or in those cases with scars and atrophic areas. Strangely enough with the ruptured drum, or one with a previously existing perfora tion, fewer internal ear complications are found after exposure to heavy detonations. The status of the partial vacuum following an explosion and the role it plays, if an}', in the production of perfora tions, has up to the present remained uninvestigated so far as can be learned. Protection against the above form of damage is theoreti cally very simple, as any agent that will stop the inrush of air and prevent the change of pressure will suffice, and it is believed that no other will. All half-way measures are only relatively useful. Cotton saturated with vaseline or glycerin and compressed, or molded with wax or clay, if air-free, protects. The various plasticine preparations protect against this form of injury. Of the patented devices, those that simulate or are modified ear plugs, and make less pretense of allowing slight sounds and air waves to pass, show excellent results on tests. Among these are the British "Tommy" and the later produc tions of Baum. The lust have been so modified that at present they represent diametrically opposed ideas to the ones originally exploited, and consist simply of a filled cylinder capped, and inserted in the ear. Commotion of the labyrinth, organic disturbance of the internal ear, and interference with the central nervous system and cerebral pathways, are very hard to prevent. The part played by bone con duction is in dispute; the matter has been thoroughly presented pro and con in recent literature, but apparently no decision can be reached. So far as trauma, from changing pressure or intense sound aerially conducted, is concerned, and against changes causing driving in of the foot piece of the stapes as well, protection is secured by interposing an object to break the impact, and the more nearly complete the break is the more nearly perfect the protection. Protec tion against constant noise is, for practical purposes, out of the ques- Baum's Ides! model , (rubber) Ear-prolccior^ No. 1 51 TR1BLE AND WATKINS EAB PROTECTION. tion, particularly on ships. It would involve ear stoppage and insula tion by rubber-soled shoes and rubber gloves. Gradual deterioration of hearing developing from this cause must be considered a profes sional deafness similar to that of ironworkers in general. So far as ear protection can be secured, the conditions surrounding naval warfare are highly favorable for its adoption. The time of an engagement is limited, the element of surprise is practically elimi nated, the question of interfering with the hearing is of little impor tance; the noise around the ship renders sharp distinction in sound out of the question, so that actual protection is the main item to be considered. The explosive effect and disturbance in air pressure would be intensified in close compartments, so that protection must be secured even at the expense of loss of acuity of hearing. One of the most common methods of protection, and that shown in nearly all pictures taken at the front where batteries are engaged, consists in stepping back, half opening the mouth, and stopping the ears with the fingers, probably one of the best methods of protection, but naturally not practicable for those being shelled. Cotton is in common use in nearly all services, and while tests show.that it affords scant protection when used dry, practical experience seems to indi cate that it is of some value: its efficacy undoubtedly depends to some extent upon the individual and his skiH in successfully intro ducing it so as to exclude air. Cotton-wool or lamb's wool was used as a means of protection in the British Navy, and reported April 26, 1916, as follows: For protection of hearing, cotton-wool or lamb's wool is chiefly relied upon. This simple method is still found to be the best for general purposes, and the great majority of officers iind men still continue to prefer it. The wool should be upplied in layers or flakes, nnd should not be rolled into a hard ball. The men are Instructed to keep (heir mouths open during exposure to the noise of gunfire. The Mallock-Armstrong patent ear defender is supplied to ships, nnd any officer or man c:m provide himself with this contrivance on payment. Though In theory the Mallock-Armstrong defender should give better results than wool, experience does not show that it is in any way superior as a protec tion, though possibly orders may be heard more distinctly with it than with wool. The objections to the Mnlloek-Armstrong defender are its rigidity and the difficulty of insuring an accurate fit. Cotton possesses the advantages of simplicity and cheapness, and for use in a campaign of rapid movement, it is probably the most practical measure, though surpassed in tests by other substances. In the tests carried out by Guild at Ann Arbor, it showed up very poorly, the excursions or tambour tracings being 56.50 mm. using dry cotton plugs, while they were only 61.67 mm. with the ear open. Water- soaked cotton gave a reading of 1.17 mm., glycerin-soaked cotton 0.35 mm., and vaseline-soaked cotton 0.30 mm. The results of experi ments here and at Indianhead will be tabulated later. 52 TBIBLE AND WATKINS—EAR PROTECTION. Vol. XIII. The Elliott Perfect ear protector has been more or less extensively used in the Navy for several years, and has given a certain amount of satisfaction. The principle underlying these patented protectors, with the exception of the " Tomm}7," and the old ear stopple of Frank, is the production of a sort of double chamber, guarded in some cases by p. valve, or with the inlet and outlet at right angles, or guarded by a tortuous channel. The idea is to admit ordinary sounds, but to interfere with the free entrance of intense and powerful air waves and sound vibrations. The theory seems correct, but experience and practical results do not show the protection desired. The Elliott " Swimmer " differs from the " Perfect " ear protector, in that the central column is not perforated, and it is supposed to be water-tight. Theoretically, it should give excellent protection, and does show up better than the " Perfect." Guild's experiments showed an excursion cross- sectioN M~A Ma 1lock - Armstrong % Dummy Mr-A Wilson ^Micheldon l.Swimmer Safety Elliott E Cross sect. ft on the register of 48.77 mm. with the " Swimmer," as compared to 54.G5 mm. with the " Perfect." Both have the disadvantage of act ing as secondary missiles, and the same criticism applies to the next type patented under the name of " Safety," which is very similar to the Elliott types, and on superficial examination differs from the Elliott " Swimmer " only in that the discs are perforated to admit air waves, these perforations being so situated that the under ones are 90° on an arc away from the upper. The discs are not fixed, and it can readily happen, that they may rotate, so that the holes are in a straight line, one above the other. On similar principles is the obturator of Verain, a French device, which is an ovoid pro longed at one end by a conducting cylinder. Air enters at a small orifice, which leads into an interior chamber, where the effects of vibration are supposed to be diminished ; air escapes through a small No. 1. 53 TMBLE AND WATKINS EAR PROTECTION. orifice leading out at right angles to the entrance. None of these could be secured, and no experiments were carried out with them. The Mallock-Armstrong ear defender has been used quite exten sively by the British. It consists primarily of a body resembling an ear speculum, closed off by two screens of fine wire gauze, and be tween them a vibrating membrane. This device was gotten up by Mallock for his own personal use at the Armstrong Gun Factory, and has been used by their employees for a number of years with satisfactory results. Its relative value in the Guild experiment was 1.02 mm. compared to G1.67 mm. with the ear open. The "Tympan- ophile " which might be considered a French counterpart, consists of a metallic mounting, with a hard rubber speculum attachment, having mounted over the entrance a thin, mica disc. None could be obtained and no record of their tests could be foimd. The Wilson-Michelspn may be considered representative of another group, based upon a valve action which is theoretically so adjusted, that waves produced by detonation, will cause the valves to move in ward and close the inlet. The entrance is protected by a fine wire gauze, and the portion to be inserted into the external canal is covered by a layer of rubber sponge. In Guild's experiments, the excursions with the Wilson-Michelson, measured 13.42 mm. Against this type, there are many disadvantages; rust, dirt, corrosive gases or liquids, would all interfere if not destroy the valve action, and the protector itself could easily become a secondary missile. The Perd-Son is similar in construction, having a small concave aluminum disc, supported by a spring. It was devised with the idea of allowing ordinary sounds to pass wthout diminution but to arrest loud sounds, and violent displacements of the air. It is open to the same objec tions and probably more than the Wilson-Michelson. The next group embraces the. "Tommy," and similar non-per forated ear protectors, made of rubber for the most part, and mak ing no pretense of allowing direct transmission of sound waves. The " Tommy " is patented in Great Britain and France, and con sists of a hollow, soft rubber bulb, resembling a miniature nipple, or rubber cap of a dropper. In the Ann Arbor experiments, the ex cursions on the registering paper were only 0.27 mm., surpassing in theoretical protection the wax cone and impregnated cotton. The Baum as now made, consists of a fluted rubber bulb with a sort of flange or collar, and the top is covered with a thin, rubber mem brane. As made in the tests reported, it consisted of a similar shaped contrivance made of oiled silk or muslin, and was impracticable, not durable, and unless filled with silk floss or made of double thick ness, did not protect. A gelatine capsule was tried out, following an idea reported from the French service, but was of no use as it shattered from a simple 54 Vol. XIII. TRIBLE AND WATKINS— EAR PROTECTION. concussion produced by pistol shot. Various mixtures of wax and clay have been recommended, and undoubtedly protect. One in use Monture meialliyue Larnede mica. Le tLjmpznophile Conduit de caoutchouc Le Perd-Son Caoutchouc Obturateur a chamBfe de detente. ©-1=3 Jamnn EarDrum Protector. in the Italian Navy, consists of yellow wax with 36.4 per cent of liquid vaseline. They are issued in cone-shaped gauze bags. Xo. 1. 55 TRIBLE AND W ATKINS EAR PROTECTION. The matter of protection of the hearing of aviators or others obliged to work around aeronautical engines has been considered, and Lieutenant Colonel C. W. Richardson, forwarded some protectors to Engineer of Tests, Aeronautical Engine Testing Laboratory, and a copy of his report is inserted. Similar experience was had at a naval air station and the medical officer recommended plugs of treated cotton, whose effect would be practically the same as cotton and vaseline. The possibility of the constant use of an ear protector with comfort is rather slight. From : Engineer of Tests, Aeronautical Engine Testing Laboratory. To: Bureau of Steam Engineering. Via : Officer in Charge, Engineer Officer and Commandant, Navy Yard, Wash ington, D. C. Subject : Report of test of Wilson Ear Protector, Bauni Ear Protector, ana Elliott Ear Protector. , 1. The ear protectors noted above were tested as follows: (a) Wilson ear protector. Pair No. 1 was given to one of the men wiir* instructions to use during live-hour test of Curtiss 200 horsepower motor, i', of the noisiest motors in use. At the end of 1J hours the protectors had to be removed, the man complaining of a headache and stating that there was practically no reduction In sound as compared with the unprotected ear. Pairs Nos. 2, 3. and 4 were tested by three different members of the labora tory force. The protectors were used in close proximity to the engine for short periods of time. In every case the result was unsatisfactory, the reduction of sound as compared with the unprotected ear being very slight. Besides being ineffective, these protectors are very uncomfortable to wear and are apt to full out of the ear. (6) Bauiu ear protector: One pair of these was tested by use in close proximity to the engine for short periods. This protector gave absolutely no reduction in sound over the unprotected ear ; therefore, further tests were not conducted. It also has the serious disadvantage that it required special in struments to Insert and remove it. (c) Elliott ear protector: This protector was tried out by using In a flve- hour test of the Curtiss 200 horsepower engine. At the end of the test, the user complained of a headache and only a slight reduction In sound over me unprotected ears. These protectors were also used close to the engine ior short periods by three other members of the laboratory force. The reduction in sound was found to be less than when ordinary absorbent cotton was used. It is more convenient to use and slightly more effective than the other two types. None of the above ear protectors are suitable for use In testing airplane en gines. Ordinary dry absorbent cotton is as effective as any of them. Cotton, soaked with vaseline. Is the most satisfactory protector that has been found at this laboratory. DESCRIPTION OF MECHANICAL TESTS FOR EAR PROTECTORS. These tests were made at the United States Naval Medical School. Washington, D. C, and at the United States Naval Proving Ground, Indianhcad, Md. 56 Vol. XIII. TRIBLE AND WATKINS EAR PB0TECT10N. The following ear protectors and substances were tested. The tests were made during the firing of a United States Marine Corps revolver and the following guns: 3 in. 50, 4 in. 50, 13 in. 50, and 14 in. 50. The apparatus used for the tests consisted of a human auricle and membranous canal (resewed to a rubber tube, 2 inches long and one- fourth inch in diameter) removed from a cadaver, an Eyster tam bour, and a kymograph with a revolving drum and smoked paper. The auricle and membranous canal were connected by means of a piece of rubber, and glass tubing to the tambour, 10 inches long, which in turn was so set up that the aluminum lever (or needle) recorded on the smoked paper as the drum of the kymograph slowly revolved. All connections of the tubing were made air-tight with wax and carefully tested to prove it. ^The revolver tests were made at the United States Naval Medical $f hool. AVashington, D. C. In some of these tests a small hemi sphere of rubber 1$ inches in diameter was used, instead of the auricle, to collect the concussion waves. In all of this group of tests a large wooden partition, measuring 7 feet by 4, by £ inch was used to protect the tambour membrane from waves other than those transmitted through the ear protectors. It was placed lengthwise upon a concrete floor and made steady by means of heavy crosspieces at each end. The crack between it and the floor was filled with closely packed soil on each. A hole one-half inch in diameter was bored at a height of 1 foot from the floor and on an equal distance from each end. The auricle was placed against this hole on one side of the partition and the apparatus on the other side of it, the rubber tubing passing through the above-described hole, which was just wide enough to permit passage of the tubing without constriction. There was a layer of closely packed soil 1 inch thick between the concrete floor and the kymograph, and also the iron stand holding the tambour. On the other side beneath the auricle a wooden block was set up, which was used as a rest for the revolver when firing. With this arrangement no external concussion waves affected the tambour, as was proved by the following test. The auricle was completely plugged with wax. and a number of shots fired with the revolver in the same position as in the tests of the ear protectors. Xo excursion of the tambour lever was recorded in the tracings. Then the wax was removed and very definite excursions of the lever were recorded in the tracings. Thus, it was proved that the partition completely protected the apparatus from external concussion waves and that there was no perceptible vibration of the floor. Also, it proved that the above-described apparatus successfully registered the concussion waves. The position of the revolver in the tests was with the muzzle 2 inches outward and 1 inch behind the auricle. No. 1. 57 TREBLE AND WATKINS—EAB PHOTECTION. All of tha above-named protectors and materials were in turn inserted carefully in the auricle and a number of shots fired while each was in place. Also, records were made without anything in the auricle, in order to determine the maximum excursion registered and for comparison. (The records will be described later.) The tests with the guns were conducted at the United States Naval Proving Grounds, Indianhead, Md. The same apparatus was used as in the revolver tests, but the partition was discarded. Because of the great increase in air pressure and vibration during the firing of heavy guns, it was found necessary to entirely inclose the apparatus in a box, with only the auricle on the outside. A small hole one-half inch in diameter was made inside of it, through which ran the rubber- tubing connecting the auricle with the tambour. The box measured 3 by 2^ by 2 feet and was made of wood three-fourths inch thick. On the side opposite to the small hole there was a door which swung from the top. All seams were tightly covered over with strippings and the entire inside of the box, including the door, was lined with heavy felt 1 inch thick. (The iron stand which held the tambour was firmly fixed in place and there was a platform upon which the kymograph rested.) On the bottom there was a layer of felt 2 inches thick, underneath which was a heavy cardboard. The door was so arranged that it could be quickly closed and tightly locked. The entire outside of the box was covered with heavy tar paper to pro tect it against the weather. In all of these tests the box was placed on a concrete foundation of 4 or more feet in thickness, and during the firing of the 13 and 14 inch guns it was on a separate concrete brick foundation of about 15 feet thickness. This box was found to be practically proof against concussion and vibrations, for when the ear was completely stopped with wax practically no excursion (ex cept one-half mm. when the heavier guns were fired) of the tambour lever were made on the tracings. The same ear protectors and substances as were used in the revolver tests were tested with the heavy guns and in the same way, except for the use of the box instead of the wooden partition, and that the distance of the apparatus from the guns was, of course, much greater than from the revolver in the tests with it. Because of the limited number of shots fired with these guns, only two or three were fired with each ear protector in place. Also because of the small num ber of shots fired (or the rapidity of the firing) from the 1, 5, 6, and 7 and 16 inch guns, tests were not made with these guns. Again, more records could not be made because many times the firing was at plates to test them on the shells when, of course, it was impractical to carry on the tests. Using the rubber bell as a collecting agent, firing the Marine serv ice revolver, fixed charge, 2 inches out, and 1 inch behind bell, using a 88977—18 5 58 TEIBLE AND WATKINS^-EAB PROTECTION. Vol. XIII. t cotton packing, six charges, caused tracings ranging from 28,106 microns to 38,585, an average of 31,832; cotton saturated with vase line had a variation from 1 to 3 mm., an average of 1.917 mm. Cotton and glycerine had a range from 3 to 6 mm., averaging 3,666. Cotton impregnated with wax, a tracing ranging from 0.978 to 1.931, an aver age of 1.333. Taking the patented protectors, under these conditions, the Wil- son-Michelson varied from 2,311 to 9.546 microns, averaging in six shots 6,349f, Baum, original type from 15,691 to 32,771, averaging 23,147§, Mallock-Armstrong from 18,320 to 25,459, averaging 22,661$ , while the " Tommy," gave a negative tracing ranging from -9,435 to 17,210. (Below the line.) On checking the work, under the same conditions, using first, a gela tine capsule, no diminution could be noted ; in fact, there was an exag geration of the tracing ranging from 29,858 microns to 37,054 and this broke in many fragments. Wilson-Michelson ranged from 2.259 to 6,488, plain cotton, from 5,760 to 21,068— while nothing in collecting bell gave tracing ranging only from 7,674 to 14,305. The Elliott under these conditions and in this series gave from 1,997 to 2,465 microns. Baum again ran very erratically, ranging from 1.734, one tracing, to 32,621. Mallock-Armstrong ranged from 19,977 to 28,939, while no protector gave a tracing of only 17,437 to 22,882. It can be readily seen that an accurate approximation of human conditions, or a relatively constant finding, could not be secured, but the idea was merely to conduct a comparative examination to determine the efficiency of each as a means of protection, under iden tical circumstances. Cotton impregnated with glycerine, vaseline or wax showed up well ; the " Tommy " cut off sound waves so effectu ally that it gave a negative pressure resulting from the partial vacuum. Approximating human conditions so far as possible, except in an in vivo experiment, which naturally is impossible, the dissected human auricle was next used as a sound collecting agent, other condi tions being identical with the foregoing. Using the Baum original type in 14 successive shots, a varia tion ranging from 2,429 to 14,279 microns was recorded. Mallock- Armstrong. five shots, gave from 2,245 to 6,867, Elliott from 0.689 to 2,516, plain cotton from 4,372 to 7,186, Wilson-Michelson from 4,696 to 8,954. There was no protection from 26,407 to 28,512, while using cotton and vaseline. In two series of shots, one showed practically no excursion, and the second a slight negative pressure, while the " Tommy " showed practically no excursion. This record is consid ered to be the most accurate of all, the variations in excursion with no protection were slight, and the results of the individual tracings No. 1. TBIBLE AND WATKIN8—EAB PROTECTION. in a series varied but slightly, except in the Baum, which as origi nally made was extremely light and practically impossible to main tain in accurate position. Transferring the work to Indianhead, where the tests were carried out in the manner noted above, the first series was run with a 3-inch, 50-caliber fixed charge ; distance, 18 feet. The following results were obtained : The "Tommy," two tests, averaged 10,952 microns; cotton and vaseline, two tests, averaged 14,148$; cotton and wax, two tests, averaged 14,316; Wilson-Michelson, two tests, averaged 19,025$; Elliott, " Perfect," two tests, averaged 29,571$ ; Baum, " Uncle Sam," averaged 40,502$ ; no protection, 50,432 ; Mallock- Armstrong, 54,302. This last gave evidence of very little protection. Under these con ditions, same membrane, Elliott " Swimmer," gave in another test, 21,415, somewhat better than the Elliott "Perfect"; Safety gave 20 mm.; Wilson-Michelson, 8,690 microns; no protection, 37,172; cotton and vaseline, 26,532. Using a new drum, the results varied; wax averaged 11,004; cotton ran 22,401; Wilson-Michelson averaged about 17' mm.; Mallock-Armstrong, 27,692$; "Tommy," 20,652; El liott, 19,664. In another series, cotton showed up best with 16,535; cotton and vaseline, second, with 17,808; cotton and wax, third, with 19,521; Elliott, fourth, with 19,677; Baum, double thickness, fifth, with 20,- 798; " Tommy," sixth, with 21,005$ ; Wilson-Michelson, seventh, with 31,648$; Baum, single thickness, eighth, with 34,851$; Mallock-Arm strong. ninth, with 51,061; while no protectors ranged from 38,898 to 52,001. The cotton in this case was undoubtedly very firmly packed in. One series of tests was made, using the various types of Baum's. as then designed, and in his presence in order to demonstrate the technique used. This was done with a 3-inch 50-caliber gun. dis tance 18 feet, Buum double thickness; ranged from 8,125 with cap, to 21,247 microns; no protection showed a tracing of 32,724, one test, and 33,354 another; three tests with the "Safety" gave an nvc:;.ge of 13,521. Fourteen-inch, 50-caliber, at 19 feet, gave the allowing records: Microns. " Tommy " 34, 404 Cotton and wax 42,239 Cotton nml vaseline 44,287 Elliott 51,861 Microns. Wilson-Michelson 53. 288 Safety 56,137 Cotton 56,151 No protection 53, 047 From this, it can be seen that very little protection was afforded by anything except the "Tommy." and the cotton wax or cotton vase line. Plain cotton and the Wilson-Michelson registered actually higher than no protection ; the Elliott was slightly under. Another test with the 14-inch. 50 caliber, at 90 feet, gave the following . 60 TBIBLE AND WATKINS —EAB PROTECTION'. Vol. XIU. Microns. "Tommy'." 29,164 "Tommy"1 30,893 "Tommy"1 33,820 Baum, double thickness and with rim 41,571 Microns. Baum, "Uncle Sam" 48,132 Baura, single thickness 47, 173 Baum, double thickness 41,663 Mallock-Armstrong ' 42,724 Mallock-Arnistrong ' 49,000 These tests differ to some extent in results from those reported by Guild, of Ann Arbor, who was a pioneer in this work, and to whom great credit is due. From a practical standpoint, endeavor was made to try out various types of protectors around the guns, distribu ting them to the men engaged in work with them. The results were rather contradictory, some of them appeared to like the Baum, as it was then made, chiefly because of the ease with which it was worn. It is apparently not possible to wear many types of these protectors with comfort. The Mallock-Armstrong showed up particularly badly in these tests, and the Wilson-Miehelson did not perform as well as expected. Cotton and vaseline, cotton and wax, and cotton and glycerine to a less degree, show that they afford protection against changes of pressure. Of the patented protectors, only one. the " Tommy," was a consistent performer and is the only one that can be recommended as a result of these tests. For use on shore with landing parties, or with the Marines serving in the Army, or in any capacity in those likely to be exposed to the action of mustard gas, protectors containing oil or fats, and probably wax, are unsuitable. This probably applies to clay as well. This leaves only those made of rubber, since other gases with a heavy chlorine clement would render metallic protectors unsuitable, and, in addition, such pro tectors or similar ones, such as the Elliott or the " Safety," could act as secondary missiles. It is impossible to delay the tests further, to work out the new Baum, which is made of rubber. It should be satisfactory, as the design and principle are good. Up to the present, it is only possible from a standpoint of safety, simplicity', and cheap ness, to recommend the " Tommy." Great credit is due to Rev. Father Torndorf, of Georgetown Uni versity, who kindly put the instruments of his laboratory at our dis posal, and who so accurately made the measurements of the various tracings. Lieutenant Commander F. P. Hough, Medical Corps, United States Navy, cooperated in this work up to the time of his detachment from the naval proving grounds. Lieutenant Colonel C. W. Richardson, Medical Corps, United States Army, has worked in conjunction and along similar lines in the Army for the past year, and his conclusions as reported to the Surgeon General of the Army are in favor of the " Tommy." Experimental work with animals was contemplated, but found impossible owing to pressure from increased office work, due to the great number of war workers who, as members of the enlisted personnel, are entitled to treatment. •Averaging 31.294J microns. 'Averaging 45,862 microns. HISTORICAL. THOMAS HENRY HUXLEY. (1825-1895) By F. J. B. Cobdbibo, Lieutenant Commander, Medical Corps, United States Navy, retired. Thomas H. Huxley was born in Ealing, a suburb of London, the son of a schoolmaster. He received a little schooling in the public schools, but got most of his education from his father, his brothers-in- law, who were physicians, and from his own efforts. He said that at 12 years of age he used to get up before dawn, pin a blanket round his shoulders, light a candle, and sit up in bed reading Hutton's Geology. "He discussed all manner of questions with his parents and his friends, for his quick and eager mind made it possible for him to have friendships with people considerably older than him self." "As I grew older my great desire was to be a mechanical en gineer, but the fates were against this, and while very young I began the study of medicine under a brother-in-law. But though the In stitute of Mechanical Engineers would certainly not own me, I am not sure that I have not all along been a sort of mechanical engi neer. The only part of my professional course which deeply inter ested me was physiology, which is the mechanical engineering of living machines; and notwithstanding that natural scienc? has been my proper business, I am afraid there is very little of the genuine naturalist in me." In 1841 he went to live in the East End of London, where he func tioned as assistant to the district physician for the poor. This was preliminary to "walking the hospitals of London" in order, finally, to obtain his medical degree. He says, " It so happened that the shortest way between the school which I attended and the library of the college of surgeons, where my spare hours were largely spent, lay through certain courts and alleys 9 or 10 feet wide, with tall houses full of squalid drunken men and women and the pavement strewed with still more squalid children. The place of air was taken by filthy exhalations and the only relief to the general dull apathy was a war of words—filthy and brutal beyond imagination —usually ending in a general row. Nobody would have found robbing me a profitable employment in those Gl 62 HISTOBIOAL. Vol. XIII. days, but I used to wonder why these people did not sally forth in mass and get a few hours eating and drinking and plunder to their hearts' content before the police could stop them and hang a few." We can hardly doubt that it was the practice then, as it is to-day, for young medical students, when visiting in such quarters, to make learned diagnoses, consisting of two Latin terms, which were followed by elaborate prescriptions in which the drugs were compounded, secundum artem. We get a glimpse of the sound common sense which was ever the basic characteristic of Huxley's mind, in the fol lowing: Of one of his visits in these slums, he says, "After due examination, even my small medical knowledge sufficed to show that my patient was merely in want of some better food than the bread and bad tea on which these people were living. I said so as gently as I could, and the sister turned upon me with a kind of choking passion. Pulling out of her pocket a few pence and half -pence, she said, ' That's all I get for 36 hours' work, and you talk about giving her proper food.' " Huxley was now attending lectures at Sydenham College in prepa ration for the matriculation examination at the University of Lon don. He attained considerable success, winning, besides certificates of merit, a prize —his first prize —in botany. Speaking of these stu dent days, he says : " I worked extremely hard when it pleased me and, when not, I was extremely idle or wasted my energies in wrong directions. I read everything I could lay my hands on." He was particularly interested in physiology and, recognizing that this study was nothing more than the physics and chemistry of living bodies, delved deeply into these branches. He had not been deeply grounded in mathematics or physics, but one of the matters which he speculated upon much in those days was the possibility of free energy, or perpetual motion. He says: "I remember how my long-brooding perpetual-motion scheme had been working upon me, depriving me of rest even, and heating my brain with chateaux d'Espagne. I finally tremblingly betook myself one afternoon to the Royal Institution and asked the porter, ' Is Dr. Faraday here?' 'No, sir; he has just gone out.' Strange to say, I felt relieved, but as I was hurrying out a little man with a brown coat came in at the glass door. ' Here is Dr. Faraday,' he said, and he turned to me and courteously inquired what I wished. ' To pre sent to you a matter, if your time is not occupied,' I said. ' My time is always occupied, but step this way.' He examined my drawings, but did not think my plan would answer. Was I acquainted with mechanism —what we call the laws of motion? He said that, were perpetual motion possible, it would have occurred spontaneously in nature and would have overpowered all other forces. I saw it was all up with my poor scheme and, after trying a little to explain, in No. 1 HISTORICAL. 63 the course of which I certainly failed in giving him a clear idea of what I would be at, I thanked him for his attention and went off as dissatisfied as ever." We have here a truly historical incident. We can picture in our minds the room in the Koyal Institute. The great physicist, entirely impersonal and unaffected with any sense of his own importance, courteously and patiently listening to the earnest young man whom he knew to be entirely astray in the field in which he was supreme. The young man, who was destined later to contribute fully as much to science as his kindly adviser, going away " dissatisfied " but not crushed. He adds, " I do not appreciate the force of his objection, but did not feel competent enough to discuss the question. However, he exorcised my devil and he has rarely come back to trouble me since." Huxley now. after having passed his M. B. examinations at the University of London, obtained a commission as assistant surgeon in the Royal Navy. After some months at Haslar Hospital, he was detailed to the Rattlesnake, which was about to be sent out to New Guinea on an exploring expedition. Besides his strictly medical duties he was to do work as a naturalist. It is a curious coincidence that, like two other leaders in science, Charles Darwin and Joseph Hooker, their close friend Huxley be gin his scientific career on board one of Her Majesty's ships. He lived in the gun room (steerage) with the middies, some of whom were hardly yet in their teens. A man in the midst of a lot of boys with hardly any grown-ups has an unenviable position, but one of these middies, writing afterwards as Captain Heath, said that " Hux ley's constant good spirits and fun, when he was not absorbed in his work, as well as his freedom from any assumption of superiority over them, made the boys his good comrades and allies." The Rattlesnake did not return to England for four years, and during that time Huxley was able to keep contented by hard work He made a great number of drawings of various kinds of animals and sent a number of scientific papers to England, but worried greatly about the latter, as no word ever reached him as to their fate. There were times in the monotony of the cruise when he envied greatly those who were actively engaged in the work of surveying when he could do nothing. His diary and his letters home were intensely human. He writes: " Of all extant lives, that on board a ship-of-war is the most arti ficial —whether necessarily so or not is a question I will not under take to decide —but the fact is indubitable. How utterly disgusted you get with one another ! Little peculiarities which would give a certain charm and variety to social intercourse under any other cir cumstances, becomes absolute sources of pain and almost uncon 64 HISTORICAL. Vol. XIII. trollable irritation when you are shut up with them day and night. One good friend and messmate of mine has a peculiar laugh, whose iteration in our last cruise nearly drove me insane. There is no being alone in a ship. Sailors are essentially gregarious animals, and don't understand at all the necessity under which many people labor —I among the rest—of having a little solitary converse with oneself occasionally. Hence all sorts of petty intrigues, disputes, grumblings, and jealousies which to the eye of an ' idler ' give to the whole little society the aspect of nothing so much as the court of Irenaeus in Kater Murr's inestimable autobiography." He thus describes sea life in the Tropics: "For weeks, perhaps, those who were not fortunate enough to be living hard and get ting fatigued every day in the boats were yawning away their ex istence. Rain ! rain ! encore et toujovrs —I wonder if it is possible for the mind of man to conceive anything more degradingly offensive than the condition of us 150 men shut up in this wooden box and being watered with hot water as we are now. Moving about in the slightest degree causes a flood of perspiration to pour out; all energy is completely gone, and if I could help it I would not even think ; it's too hot. It's too hot to sleep and my sole amusement con sists in watching the cockroaches which are in a state of intense excitement and happiness." On returning to England Huxley found that his scientific papers had been duly received and much appreciated. The Royal Society shortly took steps to publish them under Huxley's superintendence. He was made a fellow of the Royal Society (F. R. S.) and the next year was awarded the Royal Medal for his work while on the Rattle snake. He had now been in the Navy eight years and he was forced to choose between a career in pure science or remaining in the service. Happily, after much deliberation, he decided for the former. It was a momentous decision and he knew very well that it meant for him a life of strenuous toil and incessant fighting. The mere existence of a man of science at that time was apt to be precarious and from his intimate acquaintance with the leaders of English science he knew that such a life must be one long battle in which he must expect to take and give many heavy blows. His life, in fact, was one long fight, but there was nothing he delighted in more than a fight for truth. He only demanded fair play and the only com plaints he ever made were when this was not forthcoming. Before leaving the Navy, he had, in 1852, delivered his first lecture at the Royal Institution and had sent his Memoir on the Morphology of Cephalous Mollusca to the Royal Society. Writing of this to a friend, he says : " It is perhaps the best thing I have done, but I do No. 1. HISTOBICAL. 65 not know whether they will print it or not. That will require care ami a little maneuvering on my part. You have no notion of the intrigues that go on in this blessed world of science. Science is,I fear, r o purer than any other region of human activity, though it should be. Merit alone is" very little good ; it must be backed by tact and knowledge of the world. I am sure if the paper I have sent in is referred to the judgment of my particular friend , it will not be published. He won't be able to say a word against it, but he will pooh-pooh it to a dead certainty. The necessity for these little stratagems utterly disgusts me. I am so utterly unable to comprehend this petty jealousy, but I see that is determined not to let me rise, or any one else, if he can help it. Let him beware. On my own subject I am his master and quite ready to fight half a dozen dragons. And, although he has a bitter pen, I can match him in that department also." And he adds, " Science in England does everything but pay. You may earn praise, but not pudding. Last year I became a candidate for a professorship at Toronto, and pre sented many testimonials, but have heard nothing of the business. I believe the chair will be given to a brother of one of the Canadian ministry. Such a qualification as that is, of course, better than all the testimonials in the world." Huxley's life now became one of so many interests and his work was so diversified, that to follow his purely scientific investigations alone would give a very inadequate impression of his labors. Great as was the impression left by those researches in purely scientific cir cles, it is not by them alone that he made his impressions upon the mass of his contemporaries. They were chiefly moved by something over and above his wide knowledge in so many fields — by his pas sionate sincerity, his interest not only in pure knowledge but in hu man life, by his belief that the interpretation of the book of nature was not to be kept apart from the ultimate problems of existence; by his love of truth, both theoretical and practical, which gave the key to the character of the man himself. One of the most extraordinary intellectual combats which the world has ever witnessed, took place in England 30 years ago. It was the celebrated religious controversy which Huxley started by his lepeated attacks on systemic theology. As in all such controversies, it was out of the question that he should have convinced the church men, but it marks a great advance that those churchmen should have abandoned their attitude of former times, viz. that their position being absolutely unassailable, there was nothing to argue about. They admitted with Huxley that where the truth was concerned all sincere and honest arguments were permissible, and they answered his arguments to the best of their ability. It is further much to '.he credit of all the participants that they displayed usually the greatest 66 HISTORICAL. VoL XIII. courtesy and the highest breeding. They gave and took hard blows, uut always in a knightly manner. There was a time when Huxley's pointed thrusts would have been answered by the faggot and torch. It was during this controversy (hat he added the word " Agnostic. " to the English language. What astonishes us most in Huxley's life is his ceaseless and untir ing energy, both mentally and physically —his enormous capacity for work. The popular idea is that genius is spontaneous and that it accomplishes its work automatically —that some men are born great, others achieve greatness, while still others have greatness thrust upon them. In scientific matters, nothing could be further from the truth. The outstanding difference between the giants of science and their lesser brethren seems to be their capacity for withstanding strains, both physical and mental, of which the latter are incapable. Xewton, when asked how he was able to make his extraordinary dis coveries, replied, "By intending my mind." In other words, his was what would have been an everyday mind, had it not achieved great ness through the discipline of hard work. And so, in looking over Huxley's busy life, we find that for 13 years he was examiner in physiology in the University of London, Hunterian professor of com parative anatomy in the College o± Surgeons, Fullerian professor of physiology in the Royal Institution, and an officer in so many other institutions, both public and private that the list is bewildering. We can get a slight idea of some of his activities from a letter written to Charles Darwin in 1863. " You ask me what I am. doing, so I will enumerate a few of them : A. Editing lectures on Vertebrae skull and bringing them out in the Medical Times. B. Editing and rewriting lectures on elementary physiology just delivered here. C. Thinking of my course of 24 lectures on the mammalia at College of Surgeons next spring and making investigations bearing on same. D. Thinking of and working at a manual of comparative anatomy (may it be d d), which I have had in hand these seven years. E. Getting heaps of remains of new labyrinthadonts from the Glas gow coal field, which have to be described. F. Working at a memoir on Glyptodon based on a new and entire specimen at College of Surgeons. G. Preparing a new decade upon fossil fishes for this place. H. Considering writing up a lot of Indian fossils. I. Being blown up by Hooker 1 for doing nothing for the Natural History Review. K. Being bothered by sundry editors just to write articles " which you know you can knock off in a moment." 1 Sir Joseph Hooker, the great naturalist. No. 1. 67 HISTORICAL. L. Conscious of having left unwritten letters which ought to have been written long ago, especially to Charles Darwin. M. Ten or twelve people taking up my time all 'day about their own affairs. N. O. P. . . . W. X. Y. Z. Societies, clubs, dinners, evening parties, and all the apparatus for wasting time, called ' Society.' Finally pestered to death in public and private because I am believed to be what they call a ' Darwinian.' " His ideas on medical education arc as valuable now as they were when given, and there could be no more competent judge. Strange to say they have never received any attention. He had a good knowledge of mathematics and physics and he recognized that the exact science of " mechanics " was the substratum upon which the more inexact sciences must perforce rest. He was generally credited with being a hard examiner, but he says " I have asked for some knowledge of the physics and mechanics of the human body and I have been met with a talk about cells. I declare to you I be lieve it will take me two years at least of absolute rest from the business of examiner to hear the word " cell," " germinal matter," or " carmine," without a sort of inward shudder. It is a comparatively easy matter to learn anatomy and to teach it; it is a very difficult matter to learn physiology and to teach it. It is a very difficult mat ter to know and to teach those branches of physics and those branches of chemistry which bear directly upon physiology. . . . . . . I do not believe that all the talking about and tinkering of medical education will do the slightest good until the fact is clearly recognized that men must be thoroughly grounded in the theoretical branches of their profession, and I would cut down these branches to a very considerable extent. The next thing to be done is to go back to primary education. The great step toward a thorough medical education is to insist upon the teaching of the elements of the physical sciences in all schools, so that medical students shall not go up to the medical colleges utterly ignorant of that with which they have to deal ; to insist upon the elements of chemistry, and the elements of physics being taught in our ordinary and common schools, so that there shall be some preparation for the discipline of the medical colleges. And if this reform were once effected you might confine the " Institutes of Medicine " to physics as applied to physiology —to chemistry as applied to physiology —to physiology itself, and to anatomy. Afterwards, the student, thoroughly grounded in these matters, might go to any hospital he pleased for the purpose of studying the practical branches of his profession. But you may say, " This is getting rid of a good deal; you are get ting rid of botany and zoology to begin with." I have no doubt they 68 HISTOBICAL. VoL XIII. ought to be got rid of as branches of special medical education. They ought to be put back to an earlier stage and made branches of general education. I believe that comparative anatomy ought to be abso lutely abolished. Make it part of the arts teaching if you like, but abolish it. I recollect that when I was first under examination at the Univer sity of London, Dr. Pereira was the examiner, and you know that " Pereira's Materia Medica " was a book de omnibus rebus. I recol lect my struggles with that book late at night and early in the morn ing—I worked very hard in those days—and I do believe that I got the book into my head somehow or other, but then I will undertake to say that I forgot it all a week afterwards. Not a trace of the knowledge of drugs has remained in my memory from that time to this ; and really, as a matter of common sense, I can not understand the arguments for obliging a medical man to know all about drugs and where they come from. Why not make him belong to the Iron and Steel Institute, and learn something about cutlery because he uses knives? " Huxley's greatest service was, of course, the placing of the doctrine of evolution upon an impregnable foundation. Broadly, this doctrine is that after the earth had acquired, on its long evolution from the original nebula, conditions where life was possible, such life did ap pear in its most primitive forms, and that from these primitive be ginnings our present fauna and flora have gradually evolved. The palaeontologist does not concern himself with the actual beginnings of life, for he recognizes that no records of such an actual beginning could possibly have been preserved, but only in tracing the gradual development of such records as exist. It is natural that mankind should have believed until yesterday, as it were, that all the different types of animals and plants which we find upon the earth were created originally exactly as they are now and that they will persist forever in their present forms. Even such learned naturalists as Buffon and Cuvier could find no other explanation and looked upon every animal and plant as a special creation. Tn other Words, there was an instant when these organisms were nonexistent and an in stant directly after when they possessed their present unalterable forms, and, according to the Scriptures, they wort all created at the same time, or practically so, in various groups. Palaeontology showed that many of the forms which once existed no longer exist, and that many other forms did not come into ex istence until long after certain other forms. Hence it was evident that if every form was the result of a special creation, the:o creations were not simultaneous but distributed over immense periods of time. As long as it was generally held that all science (or knowledge) must be based upon the biblical account of the creation, there was N«. 1. 69 HISTORICAL. an irrepressible conflict between "science" and "religion," and science was forced to stand still and deny the evidence of its senses under various dire penalties. As Huxley says, "It is, indeed, a conceivable supposition that every species of rhinoceros and every species of hyena in the long success- sion of forms between the Miocene and the present species was separately constructed out of dust, or out of nothing, by supernatural power; but until I receive distinct evidence of the fact, I refuse to run the risk of insulting any sane man by supposing that he seriously holds such a notion." In many cases there was evidence of a gradual and almost, insensi ble change of one form into another, but in many more instances all " links " of evidence were entirely wanting and seemingly undiscov- erable. Granting the probability or only the possibility of a gradual chain of descent, it was a priori evident that many of the links must have been irrevocably destroyed and lost forever. But it was the work of evolutionists, by slow and painful toil, to build up these chains wherever possible, and in this Huxley did yeoman service. Of the links still existing, but as yet undiscovered, it will take cen turies of the most difficult labor before a majority of them are un earthed, and many of these can never be unearthed. Nevertheless, the science of probabilities, upon which, after all, all our positive knowledge is founded, tells us unmistakably that all forms of life, our own included, have developed from simple and primitive forms through a long chain of gradations over immense periods of time. " If that is contrary to religion," said Huxley. " then so much the worse for religion." It would be impossible in a sketch like the present one to give a list of even his more important papers and scientific activities. These were each separate insets into the general mosaic of his life- work. Likewise to give a record of his degrees and honors, and the various positions he occupied in learned societies of the most diverse character would be to present a catalogue which would weary the reader. But more important than these things is an appreciation of the character of the man, which alone made his work possible. In his mind no compromise was possible between truth and untruth. His passion for truth 1 was his strongest characteristic, with complete dis regard of personal consequences in uttering unpalatable facts. Against authorities and influences he published his "Man's Place in Nature, " though warned by his friends that to do so meant ruin 1 Once when writing a eulogy of a dead friend, he Raid, " The only serious temptation to perjury I have ever known, has arisen out of a desire to be of some comfort to people I cared for In trouble. Mrs. Is such a good devoted woman, and I am so doubt ful about having a soul, that It seems absurd to hesitate to peril It for her sake." 70 HISTORICAL. VoL XIII. to his prospects. The lie from interested motives was only more hateful to him than the lie from self-delusion or foggy thinking. With this he classed the " Sin of faith," as he called it—that form of credence which does not fulfill the duty of making a right use of reason: which prostitutes reason by giving assent to propositions which are neither self-evident nor adequately proved. Truthfulness, in his eyes, was the cardinal virtue, without whicK no stable society can exist. He wrote: "Warfare has been my business and my duty," and when he died, unlike the great mass of individuals whose existence is entirely immaterial as regards the progress of mankind, he left the world distinctly richer. EDITORIAL. ACCURACY. One is sometimes forced to believe that Lord Bacon's famous dic tum : " Writing maketh the exact man " is more honored in the breach than the observance. One of the startling surprises, and it must be said also one of the pleasant disappointments, of the writer's early service in the Navy was the discovery that one could be guilty of truly appalling errors and of many sins of omission and still go unpunished. The outsider often has an exaggerated idea of the severity of Navy discipline. Perhaps after all the discipline is severe as regards the punishment inflicted but the people higher up considerately omit to act upon all of the omissions of the people lower down. " I hate that accurate, methodical fellow," you say. " This other chap is careless and absolutely unreliable, but I love him." Very true; but if you robbed the first man of his accuracy you would still dislike him, and if the second man mended his ways he would be just as lovable. Virtue is not a crime, but it is very unattractive in uncongenial people. Many young officers turn up their noses at paper work and disdain to take pains with regard to reports. " I am a surgeon, not a clerk," says one. " I'm hanged if I will drive a quill all day for anybody," says another. The former is often less of a surgeon than he is pleased to suppose and might perhaps be of some positive value in the world if he had in him the making of a good clerical assistant; the latter might be in real danger of suspension if he did write. Recently in looking over some hundreds of death reports and health records it was astounding to note how common were errors due to carelessness and how willing medical officers were to sign their names to papers they had not read over, or that charity pre sumes they had not read over. If accurate reports were wanted merely for dry statistical charts, one could perhaps forgive the man who is guilty of errors, but reports are for something more than the annual statement or the weekly bulletin. Accuracy in the tabulation of facts and phenomena and in their proper interpretation is the basis for any legitimate inferences to be drawn from them. Every clinical case inaccurately reported and every record failing to make its significance clear have to be thrown out by the seeker after truth. An incident of sickness and treatment which might furnish a strik 71 72 EDITORIAL. Vol. XI II. ing illustration and convincing argument in some important advance in the profession is often useless as evidence in the form, in which it is reported. A concrete example may make clear the far reaching and often unexpected result of an apparently trivial omission. A certain medi cal officer desiring to reply to the frivolous charge that anesthetics were not competently administered in the Navy undertook to look up the number of deaths following anesthesia in the service and it was naturally incumbent upon him to discriminate between the effects of the operation itself and the effects of the preexisting condition on the anesthesia. Naturally in a limited number of anesthetizations the cause of death in the case of two or three patients affects the per cent enormously. In one report many details were omitted and doubt was entertained as to the actual cause of death. It was care fully stated that death occurred at 3 p. m., but there was no state ment as to the hour at which the operation had taken place. As a mere death certificate the document was clear enough and the writer of it doubtless had an opinion of his own as to what killed his patient, but it contained no data of value for the investigator. Failure to make the necessary entries in a health record resulted recently in a young man's getting no less that eight inoculations against typhoid fever within a period of six months. He was a recruit for war service, a college man, and evidently a chap with something more than the ordinary allowance of good nature. Appar ently the subject of these repetitions assumed that they were a part of the Navy routine and in the spirit of true discipline endured them without complaint. Later a civilian physician treating him for some obscure form of jaundice stumbled upon the history of these repeated inoculations and tried, not without a show of reason, to i , establish a genetic connection between the antityphoid treatment and the disturbed gall bladder. Had the patient or physician been given to what the Italians call pettegolezza there might have been results "to the prejudice of good order and discipline." Parentheti cally it may be remarked that, if our figures can be relied on, there is no 'evidence of any increase of jaundice or gall bladder infection in our personnel since antityphoid vaccine was introduced into the Navy. It would be interesting if one could go further and declare that cystic disturbances have actually been less prevalent since the antityphoid injection became general in view of the important role played by Eberth's bacillus in gall bladder infection. The medical officer should make it a point to be painstaking, me thodical, and accurate in all written reports. If he can not have that larger view of the question which these paragraphs aim to inspire then he should have sufficient personal pride to make his reports carefully. Most of us have pride, but we often discredit ourselves No. 1. 73 EDITOBIAL. through not understanding how and when pride may properly modify conduct. Many a man is reticent of speech and slow to com promise himself by uttered words, thus passing for wise until he puts on paper some vulgar, ungrammatical or impossible statement and signs his name to it. Those who heard the spoken word forget or .forgive it or better still die and so become unable to cherish it against him, but the written word may remain to provoke mirth or scorn or pity from generation to generation, whether he referred to the deep Palmer arch, or spoke of a recommendation for waifer of physical defects, or described a movement in space as horizontally upward. JIITITAKY TITLES AND MIMTABY BEHAVIOB. By a recent ruling staff officers are henceforth to be addressed by the titles of their rank. The discussion of the wisdom and pro priety of this radical innovation has no place here, but, as it was undoubtedly intended to enhance the standing and facilitate the per formance of duty, some reflections on the altered situation may be in order, and it is certainly pertinent to consider whether the change in question involves an obligation for the staff officer to modify his conduct in any particular. For years it has been the contention of many members of the medical corps that their position in the Navy entailed duties essen tially different from those discharged by physicians in civil life. It has been insisted by many and perhaps felt by all that if a doctor was a member of a military organization he necessarily had a certain military status in that body and had a right to a clear definition of his duties in respect to all and not merely in respect to part of his duties and that justice was not done him if there was not official recognition of all of them. Being, necessarily, from his very presence on board a participant in military drills, having frequently to per form duties by no means medical (for example, sitting as member of a court-martial) and having to receive and give orde/3, even though the latter were in a restricted field, he deserved the full recognition of his military status. Whatever the justice of this and other claims might be there was one argument which could too often be properly advanced against them. The doctor brought with him from civil life much of that dislike for business, for orderliness, for methodical procedure which is a common failing of physicians. The medical officer did his duty by the sick but often chafed under military restrictions and require ments and neglected or escaped them whenever he could. The un- military spirit was often most conspicuous in matters that related to his own corps. The younger men, who of course consider them- 88977—18 6 74 EDITORIAL. Vol. XIII. selves vastly superior in knowledge to their seniors in years, liked to think that they were all doctors together and could simply relax and lay aside military etiquette when there were no outsiders present. The doctor who was scrupulously careful to salute his executive officer or the commanding officer on board ship felt no compunction in pass ing his corresponding superiors in the hospital with a friendly nod, a wave of the hand, a grimace, or a familiar jest. When differences of professional opinion arose the medical officer was prone to say to himself and even to say aloud that a doctor was a doctor and that in the matter of treating the sick rank did not count. This may or may not have been the proper spirit but it was in marked contrast to the attitude maintained by the medical officers to their superiors in the line whose orders were always received with respect and deference even when they derived their source from vested authority rather than from special knowledge, and it was in marked contrast to the bearing of the best military men. The best military men not only render what is due to their superiors but have the moral courage to exact what is due from their subordinates. In a word, medical officers constantly showed that while they understood discipline and were able to observe military etiquette toward those in other corps they regarded these things very lightly among themselves, and yet they showed surprise or resentment if others declined to make careful the distinctions toward them which they themselves laid aside in their dealings with each other. It never seemed to occur to them that or ganizations and bodies of men, just as is true with individuals, are taken by others at their own valuation. When an assistant surgeon was ordered to duty as the relief of a medical inspector, while other officers at the station where he reported were carefully assigned ac cording to rank, the effect upon them was to emphasize the fact that rank was a secondary consideration in the medical corps, and the conduct of medical officers often bore out this belief. As a Nation we are not inclined to attach much weight to the externals of military life, forgetting that supposedly minor details of outward bearing are often the index of vital things under the surface. The man who despises the essentials of military organization and is incapable of conforming to them should not masquerade in a uniform. The med ical officer, alas, needs too often to be reminded of the old saying about the depravity of those feathered folk who are careless as to the hygienic standard of their own nests. What we owe to others we also owe to ourselves. A proper sense of dignity includes our corps and our calling. Whatever we render to Caesar we should render also to Herod. No. 1. EDITORIAL. SHELL SHOCK. Those whose good fortune may not take them to France and even those who may never be called on to treat a case of this kind should attempt to gain some idea of its nature. Whenever a case of nervous disorder is returned from the American Expeditionary Forces abroad the fact gets out through relatives and friends and makes an impres sion on the local community to which the patient belongs. Medical officers are likely at any time to be asked questions on the subject and so they should be fully informed about it. There are so many sad truths about' the Great War that it is most undesirable for any false ideas to gain credence and circulation in regard to it. In another section of this magazine an attempt has been made to present the views of a number of authorities on the subject of so- called shell shock. This term is objectionable, if taken to mean that a condition resembling traumatic shock and one involving some molec ular disturbance of brain matter or nerve elements results from the near-by explosion of a shell, but it hits the popular fancy and would do well enough for popular use if it were made clear that it simply typifies the whole complexus of disconcerting, overwhelming expe riences of modern war tending to bring out any latent nervous insta bility or weakness and to break down the acquired fortitude necessary to' endure hardships and trials greater than any previously known in war—experiences operating with especial force on a civilian sol diery whose whole mode of life has been subjected to the most radical change. SUGGESTED DEVICES. TYPHOID PROPHYLAXIS CAEDS. By E. B. Hbnby, Lieutenant Commander, Medical Corps, United States Navj. Naval Instructions, Article 3212, provide that : " Typhoid prophy lactic shall be administered to all persons upon their first entry into the Navy or Marine Corps," and that " The only acceptable evidence of administration of the prophylactic shall be the entry on the health record signed by the medical officer." In spite of the above, out of the last 500 health records received on the receiving ship at Norfolk, Va. (not including records of recruits or others due to receive the prophylaxis after arrival here), 64, or more than 12 per cent, were defective in that they contained no entry of the administration of the typhoid prophylactic, or only an incomplete entry. Sometimes an entry of this kind is found : " States that he re ceived typhoid prophylaxis on the U. S. S. John Doe, in March, 1918," a statement doubtless entirely correct, but which, in view of the second paragraph of instructions quoted above, is valueless as evidence. In a case of this sort the medical officer has no choice but to administer the prophylactic, and men frequently complain tEat they have been compelled to receive several series of injections be cause of defective records and through no fault of their own. In other instances the instructions have been strictly complied with and the entries carefully made, but the health records have been lost. It is manifestly unfair to such a man to compel him to take the injections again, and yet there is nothing else to do, there remaining no record of the previous administration. Incidentally, this useless revaccination results in much waste of valuable vaccine. The remedy is simple ; let an order be issued directing that every man already in the service who has received the prophylactic be given a certificate of prophylaxis, with dates of injections as gath ered from the health record, and that every man inoculated in the future be furnished with such a certificate at the time of inoculation. The men should be enjoined to carefully preserve these cards and informed that they must be shown in order to get liberty ; then they will take care not to loose them. 77 78 vol. xii r. PRICE — SURGICAL DRESSING TRAY. For the medical officer the situation would be much simplified, as he would have only to direct that prophylaxis cards be shown at muster to learn the number of men still unprotected. Below are the facsimiles of two cards in use on the receiving ship at Norfolk. One is a certificate of prophylaxis, and the other a "temporary" card for issue to men pending the arrival of health records, or while undergoing inoculation. No man can go on lib erty unless he has one or the other of these cards in addition to his liberty card. THE RECEIVINO SHIP AT NORFOLK. TYPHOID PROPHYLAXIS CARD. (Name "in full.')" (Rate.) let Dr 2d Dr 3d Dr C. P. Vac Date THE RECEIVING SHIP AT NORFOLK. TYPHOID PROPHYLAXIS CARD. (Name In full.) (Rate.) TEMPORARY. Not good after. A SURGICAL DRESSING TRAY FOR TRANSPORT AND HOSPITAL SHIPS. By M. J. Price, Lieutenant, Medical Corps, United States Navy. With the increased transportation of wounded from overseas re quiring extensive and repeated surgical dressings, there is a great need for some type of a portable dressing tray that can be handled with dispatch in crowded surroundings. With this in view the following tray has been devised for use on board the U. S. S. Northern Pacific, and has met with such satisfac tion that two are in constant use. The tray consists of a box made of one-half-inch pine. It is 28 inches long, 17 inches wide, and 6 inches deep. (Fig. I.) The back part of the tray is divided into seven equal compart ments, 3J by 3J by 6 inches. The left side is subdivided into four spaces 5$ by 5f by 6 inches. At the right side are four divisions 2§ by 3 by 3 inches. Brass handles are located on either side. Projecting from the left side of the tray is a roller for adhesive tape. (Fig. I.) Two iron bands, 1 by 1J inches, extend from the front of the box around the bottom and end at the back in two hooks. These hooks HANDY TRAY FOR SURGICAL DRESSINGS TO BE USED ON TRANSPORTS. ETC. 70-1 No. 1. PRICE—SUKGICAL DBESSING TRAY. 80 HUGHEN8 —USEFUL AND INEXPENSIVE FLY TRAP. VoL XIII. have a radius of f inch, extend 1^ inches above the level of the box and are padded. These iron bands are placed 2-£ inches from either end of the box. (Figs. II and III.) Extending between the iron strips on the posterior surface of the box and flush with the bottom is a rubber strip 2$ by f inch. (Fig. III.) In use the hooks are attached to the upper rail of the bunk and the rubber strip acts as a bumper against the lower rail of the bunk. From past experience we have arranged our trays as follows : The four large spaces are used exclusively for sterile dressings and band ages. The after compartments hold: Zinc oxide paste; 01. tere binth; alcohol sponges; Dakin's Sol. or eusol; tongue depressors; applicators; sterile Carrel and drainage tubes; sterile gauze drains and packs. The smaller right-hand spaces contain: balsam Peru; thymol iodide; talcum; and smaller bottles of silver nitrate, iodine and potassium permanganate, etc. The big compartment contains 20 to 30 sets of sterile instruments and one instrument tray. This dressing tray can easily be modified to suit surroundings and should prove a great time saver. A USEFUL AND INEXPENSIVE FLY TRAP. By H. V. Huohens, Lieutenant, Medical Corps, United States Navy. The sanitation officer of Camp Lewis, Wash., whose name I do not recall, when here in the early summer stated that he was using discarded boxes for making fly traps. An accurate description of the type of trap made by him was not obtained. From his sugges tion that discarded boxes be used we perfected the trap shown in the accompanying illustration. We compared this trap with others and found that it caught a larger number of flies, everything else being equal, than the other traps. The trap is simple and inexpensive, costing about 45 cents when copper wire is used and 30 cents when common iron wire is used. The cost is less for smaller boxes because of the smaller amount of wire required. Any kind of box may be used in the manufacture of the trap. The smaller traps, being about as efficient as the larger and costing less, are preferred. The construction is simple. An opening one-half inch deep is cut on all sides of the bottom of the box, starting about 3 inches from the corners. This space is to be used for baiting the trap as well as for the flies to pass in. A hole 2 inches in diameter is bored near the top and one corner of the box for emptying the flies, should it he desired to do so. This hole is covered by a piece of board about No. 1. HUGHENS—USEFUL AND INEXPENSIVE FLY TEAP. 81 3 inches square, fastened to the top by a screw. I consider it un necessary to empty the trap of flies, because it works much better btSHtUtb bv Arr*r. fusion H. v. Hupmc-u. c. U. bUMtlU bV H. T b£.LL. when dirty and full of flies. The flies when trapped only live four or five days. A piece of screen is cut an inch longer than the length 82 DUNHAM—SCALE FOE MEASUBING FLAT FOOT. Vol. XIII. of the interior of the box and wide enough to form a roof, the ridges of which will come about the center. The screen is then tacked in at ends and sides of the box. Next some one-fourth by one-half-inch strips are mitered and tacked around the edge of the screen in such a way as to pull it taut. The screen is tacked over the top, the one- fourth by one-half inch is mitered and tacked around the edge. Along the ridge of this inside screen one-fourth inch holes are made about 1 inch apart by taking a pair of pointed scissors, clip ping one wire and turning the scissors, making the round hole. The platform is made about 2 inches wider and longer than the box and is nailed to the box at all corners. Trap may be painted green and stenciled " Sanitation." SCALE FOE MEASURING FLAT FOOT. By B. Dunham, Lieutenant, Medical Corps, U. S. N. R. F. The device illustrated below has been employed at the recruiting office in Buffalo with marked success. It effects a saving of time and gives accurate, uniform results. 1. DESCRIPTION OF 6CALE. (n) A right angle piece (ale, Fig. I) consisting of a horizontal arm (ab) and a vertical arm (he) with graduations on left edge. (6) A vertical sliding piece (dc. Fig. I) with graduations on left edge pro duced to right in arcs of circles radiating from end d and with lines radiating from end d. (c) A diagonal piece {fg, Fig. I) sliding laterally to right and left and slid ing upward and downward between ends d and c. (d) The opposite side of the scale is similar in all respects to that of the view presented. (e) It has been found that the scale constructed of metal (German silver) Is preferable to celluloid. 2. OPERATION OF SCALE. («) Have the applicant stand on a smooth table in a good light. To measure the left foot, for example, grasp the scale at c (FMg. Ill) between the index finger and thumb of the left hand. Stand to left of applicant and with right hand posteriorly to ankle palpate the scaphoid tubercle (r) with the right index finger. Place and keep the lower end of scale d (Figs. II and III) opposite tubercle r, and depress scale abc to the surface of the table (hh). (6) With the third and fourth fingers of the left hand (Fig. IV) hold the base ah to surface of table and with the right hand slide bar fg along slot In scale ab until pin k is opposite the center of the prominence formed by the articulation of the great toe with the first metatarsus (Fig. II). (c) With the right index finger (Fig. IV) palpate the lower border of the internal malleolus and depress bar fg until the lower edge is opposite the lower border of the Internal malleolus (Figs. II and IV). As constructed the lower No. 1. 88 DUNHAM—SCALE FOE MEASUBINO PLAT FOOT. edge of bar fg, produced coincides with the line pm connecting the lower border of the Internal malleolus p with the lower tubercle m of the first metatarsus (Feiss line). 3. READINGS OF SCALE. (a) Feiss measurement: This is the depression (rn, Fig. II) of the scaphoid tubercle below the Feiss line and is equivalent to the reading at point o on the A scale de on which n Is the point of tangency of the lower border of the bar fg (Feiss line) with the circle whose radius Is rn and whose arc is no. (6) Height of arch : This is the elevation (rft, Fig. II) of the scaphoid tuber cle above the weight-bearing surface of the foot or plane of the table hh and Is equivalent to the reading on scale 6c opposite the lower end of scale de. CLINICAL NOTES. A CASE OF STATUS LYMPHATICUS. By E. L. Ricb, Lieutenant, Medical Corps, United States Navy. Lieut. C. C. N., age 29, was and had been in good health when he was given one-half cubic centimeter of standard United States Army typhoid bacterin containing paratyphoid A and B about 4 o'clock on the afternoon of August 13. 1918. The bacterin was given under the subcutaneous tissue of the left arm over the deltoid, and he neither complained nor demonstrated any symptoms of shock, but during dinner he complained of a headache and indefinite hot and cold flashes in his lower limbs. Without eating as much as usual he left the table and went to his room, after which he was not seen during the evening. Nothing unusual occurred in his room, but one of the officers thinks that he went to the bathroom and vomited about 11 p. m. The following morning he did not come to breakfast, and some one went to his room about 7.30 a. m., where he was found dead in his bunk. I arrived at the ship about 8.45 a. m. and the body had not been touched. He was lying on his back in a comfortable position, one hand resting on his abdomen, the other at his side, the fingers relaxed. His pupils were equal and normal, and neither the tongue nor lips had been bitten, nor were there any signs of a struggle or of violence about the body. There was still considerable warmth along the under surfaces, and T thought that he had been dead for four or five hours. Ecchymotic hemorrhages had filled the subcutaneous tissues of the back; there were smaller areas on the posterior surfaces of the but tocks and legs, and the ecchymoses extended up over the neck and face, the body being in a position of dorsal decubitus. At 4 o'clock that afternoon, August 13, I did an autopsy in the officer's room, and found a complete picture of status lymphaticus. The body was that of a well-nourished male weighing 185 or 190 pounds, and of an apparent age of 30. Excepting for the large sub cutaneous hemorrhages there were no unusual external marks. I roted a small wart on the right sternum and a 4-inch linear scar on the right shin that had no significance. Subcutaneous fat was heavy, 85 86 Vol. XIII. BICE—A CASE OF STATUS LYMPHATICUS. and the muscles of the abdomen were not well developed. The heavy muscles of the chest were dark red in color. There was no excess of fluid in the abdomen or pleural cavities, and the lungs were free from adhesions. There was a small excess of straw colored fluid in the pericardium, the right heart showed some dilatation and the musculature was flabby, but there was no hypertrophy. All valves were normal except the aortic and they showed some thickening of no importance. The aorta was strikingly small in contrast with the size of the man, and measured 6 centimeters in circumference. There were several atheromatous patches in the arch, and one of them encircled the right coronary, but the coronary was patent throughout its length and showed no evidence of sclero sis, nor was there any sign of an embolus. The thymus was large, thickened, and extended down over the right auricle. On cross section it was congested and meaty. Its di mensions were: Length, 7 cm., width, 4.8 cm., with an average thick ness of 1 cm. to 1.2 cm. The lungs showed no fibrosis and were crepitant throughout, but they were dark on section and full of blood. Stomach and intes tines were normal, the mesenteric glands were large, and the spleen was twice its normal size, dark red and bloody on section, and the follicles were prominent. The liver and kidneys were congested, but otherwise normal. I cut down on the brachials, femorals. and carotids. None of them Mere more than two-thirds the normal size, the right brachial being the smallest, and none of them were sclerosed. To summarize: The lymphatic system showed hypertrophy and the thymus was very prominent in this change. The heart, although dilated, was not larger than normal, and the whole arterial system had been dwarfed. An atheromatous change beginning in the arch of the aorta had not extended to the kidneys and the smaller vessels. The exciting cause of death was the first injection of triple vaccine, but since we know that the body tolerates well the foreign protein contained in dead typhoid and paratyphoid bacilli, there was no true anaphylactic reaction, and the cause of death was a toxemia which might have, during the course of the next two or ihrae months, been induced by any of the infectious fevers or follicular tonsillitis with the same fatal results. At the same time that Lieut. N. received his injection of typhoid bacterin, 18 other men were given injections from the same ampoule, with no unusual symptoms or abscess formation, and since the bac terin was not cloudy, we must conclude that it was sterile. That remaining in the ampoule was immediately discarded, and to culturo it was impossible. No. 1. McMULLIN —PRACTICAL- THEORETICAL CONSIDERATIONS. 87 I have no library and no access to the recent literature, hence refer ences can not be submitted, and my conclusions may be wrong. Without being able to read the French literature, we are pretty well isolated over here, and depend upon the quarterly Bulletin and the confidential bulletins for our recent information.1 SOME PRACTICAL AND THEORETICAL CONSIDERATIONS. By J. J. A. McMuclin, Lieutenant Commander, Medical Corps, United States Navy. There are certain points which may profitably be emphasized in connection with the widely different topics of dengue fever, the transfusion of blood, the intravenous injection of oxygen, epididy- motomy, urethroplasty, and lastly lesions of the brain following external injury, and erroneously attributed to fracture or dural hemorrhage. (A) Dengue. —The cause of dengue is unknown. The general be lief is that it is caused by a filterable virus. Transmission of the disease through the culex fatigans seems to be a well-established fact. Demonstrated facts are immeasurably better than theories, but I would like to advance the idea that dengue is due to some protein poison in the salivary secretion of the mosquito, which is injected by the mosquito into man, causing sensitization; and that some time later the man is bitten by the mosquito having a similar protein in his salivary secretion, and that this particular protein produces the sym'ptoms of the disease. Perhaps a somewhat similar explana tion may be advanced for smallpox, mumps, measles, trench fever, etc., substituting insects other than the mosquito as the carrier of the anaphylatoxin or foreign protein. A fact connected with dengue, which is not mentioned in the text books, is enlargement of the spleen, occurring usually about the time of the secondary rise of temperature. The patient should lie on his back, flex his legs, relax his abdominal muscles, and breathe deeply in and out through his mouth. If carefully and properly sought for the edge of the spleen will glide back and forth over the ends of the fingers. Sometimes the spleen is markedly enlarged. It is not possible that the enlargement of the spleen noted is due to error in diagnosis or because the patient had previously had malaria. The writer observed an epidemic of dengue in a draft of men all of whom had recently arrived from the United States, had never had malaria, and showed the text-book symptoms of dengue —the initial chill or chilly sensation, erythema, the pains and aches, the " saddle- 1The health record shows that typhoid prophylaxis was administered on board the V. S. S. Sterrett, June, 1914. 88 McMULLIN —PRACTICAL-THEORETICAL CONSIDERATIONS. VoL XIII. back " temperature curve, the morbilliform eruption, and the leuko- poenia. (B.) Transfusion of blood. —Medical publications are teeming with articles on the transfusion of citrated blood. Transfusion is much abused, but it has come to stay, especially in acute hemorrhage I recently gave an exsanguinated patient a transfusion of de- febrinated blood, and feel certain that the measure was life saving. Aboard ships or in out-of-the-way places, if no sodium citrate is available, the blood of the donor may be collected, allowed to clot, and the clot broken and strained. In otber words, defibrinated blood, which has not been mentioned very much recently, is a useful sub stitute for whole blood. In the service some definite arbitrary plan for grouping blood should be adopted, and each officer and man should hare his blood group ascertained and stamped in his health record. (C.) Intravenous injection of oxygen. —Various experiments have been performed by the writer, which prove that oxygen may be slowly injected into the veins of animals without harm. Anyone who has given very much intravenous medication can vouch for the fact that the injection of small amounts of air intravenously cause no harm. Intravenous oxygen is suggested in the treatment of gas poisoning, anaerobic infections and pneumonia. (D.) Urethroplasty for stricture of the urethra.—Operations for stricture of the urethra are less common than formerly, because there are fewer strictures, and also because surgeons prefer to dila.te stric tures with sounds rather than to cut them. The operation of urethro plasty is not new, but the results are so satisfactory that after divid ing a stricture in external urethrotomy the insertion of a fascial flap should be a matter of routine. I recently used a fascial flap in an impermeable stricture of the membranous urethra. The stricture was divided longitudinally, a piece of fascia was cut from the perineum, the edges of the divided urethra separated, and the piece of fascia united to the cut urethra by a continuous suture of fine chromic gut. The catheter was left in the urethra 21 days. The result was most satisfactory. (E.) Epididymotomy. —This operation is not sufficiently employed in the service for gonorrheal epididymitis. The saving in sick days and damage to the service would be stupendous if it were generally carried out. In our cases we most frequently find pus in the globus minor. Physical examination often shows adhesions of the skin and underlying tissues to the testicle or epididymis at the point of maxi mum inflammation. The best results are obtained at the beginning of an attack, before free pus is formed. The epididymis is incised in several places with a small knife. The tunica vaginalis is invariably turned inside out, No. 1. 89 STENHOUSE —PAIN IN HYPOCHONDBIUM. and sewed back of the epididymis. There are usually numerous ad hesions uniting the tunic to the testicle. A small rubber drain is in serted for two or three days. (F) Lesions of the brain erroneously attributed to fracture or dural hemorrliage.—These cases are of medico-legal importance, be sides being at times puzzling from the standpoint of diagnosis and treatment. The last case of this sort which came to my notice was a white man 50 years old who had been in a fist fight and who bore no marks of external violence at the end of the fight except a right ■'black eye." Shortly thereafter he suddenly developed an incom plete right hemiplegia, with aphasia, but was not unconscious. Sys tolic blood pressure 160, diastolic 65, temperature 98, pulse 84, respira tion 20. Physical examination showed more marked sensory than motor paralysis on the right side, but on examination of the heart a loud diastolic murmur was heard at the aortic cartilage, and there was dullness over the arch of the aorta. The diagnosis of aneurism of the arch of the aorta and cerebral embolism was made. The fol lowing day the fluoroscope showed a large aneurism of the arch, which confirmed the physical examination. The blood and spinal fluid were positive to the Wassermann test. Lange's colloidal gold test gave a typical paretic curve. The possibility of rupture of damaged cerebral vessels from in creased blood pressure during or shortly after a fight, or the possi bility of an embolus from a valvular vegetation or a clot from an aortic aneurism, causing paralysis, unconsciousness, or death under similar circumstances is of vital medico-legal importance. I re cently gave testimony in a case of this sort which saved an innocent man from being convicted of homicide. PAIN IN HYPOCHONDBIUM WITH PERNICIOUS ANEMIA. By H. M. Stbnhouse, Medical Corps, United States Navy. Ah S., ship's cook, 1 C. ; age 39; native of Canton; 15 years in United States Navy. Reported at sick bay, December 3, 1917, com plaining of pain on both sides of the belly, which seems worse after eating; he has no appetite, had a chill on the previous afternoon, and vomited once or twice during the night; he had no cough; he weighed 125 pounds on enlistment. Physical examination.—Nothing worthy of note was found in the heart or lungs; he was slightly jaundiced; tongue was heavily coated and breath foul; no swelling of his feet or ankles; belly tender beneath the ribs on both sides; spasm of right rectus on palpating near the gall bladder; liver dullness extends up to fifth i. c. s. in 8S977— 18 7 90 Vol. XITI. STENHOUSE —PAIN" IN HYPOOHONDRIUM. midaxillary line; unable to detect downward enlargement because of muscle spasm; spleen not palpable; temperature, 98.8 F.; weight 107.5 pounds. Previous history and family history. —fiays he has had dysentery three times. Seven years ago he had "sore teeth and sore eyes." No previous attacks of pain in the belly. Entry on the health record of "chancroid" in 1914. No other entries in the health record. Mother still alive and well. Father, who was alcoholic, died at 42. One brother died of "bubo." One sister died at birth. Patient is married and has one child 9 years old and well. Wife is well and has had no abortions or children born dead. Discussion. —Pain and rigidity, as found in this man, might mean gall stones, liver abscess, syphilis of the liver, hypertrophic cirrhosis, and possibly malignant disease. The history alone favors either syphilis of the liver or liver abscess. Gall stones seemed improbable because there was no history of any previous attack, nor was there the intense pain, frankly expressed, radiating out from the gall bladder, as in a case of gallstone colic. The " sore teeth and sore eyes," which the patient mentioned, the history of " chancroid," and the racial incidence of syphilis, make one consider this seriously. The chill and the pain over the left side might lead us to inquire about malaria; but the absence of splenic enlargement tends to dis courage that idea. It looked more like a case of beginning liver abscess than anything else. The history of dysentery, the pain, the enlargement of the liver upward, the chill, and the slight fever; the jaundice, and the preponderence of pain over the liver all pointed to this diagonosis. 313 'S3iisvu*d iviavnvw 'ONiiddiis 'sm3D Q3U oaivsnanN noiivniiaivxs aooia ♦.V - •- • 0 & ,% N».l STENHOUSE —PAIN IN HYPOCHONDBIUM. 91 Laboratory findings.—These made the diagnosis even more diffi cult. On December 5, 1917, the leucocytes were 18,000. Temp, was 99. On December 6, the white count showed 16,000; but to add to the difficulties, nucleated reds, stippling, and other signs of red- cell degeneration were found along with tertian malarial parasites in the stained smears. The red count was 3,400.000. Hb. 75 per cent. Urine was of high specific gravity, small in amount (400 c. c.) ; no sediment, no albumen or sugar. Feces: Ova of clonorchis sinensis, Ascaris, and Trichiuris found ; no ameba motile or encysted. On these findings a tentative diagnosis of pernicious anemia was made. But what was causing the anemia ? The most likely answer to this question seemed, " rapid destruction of red cells in the liver from some process due to the small fluke." The anemia proved to be progressive, while the leucocytosis gradu ally fell to a normal white count. By the 17th the reds had fallen 5 6 7 a IO 11 12 13 1+ «r 1 i ! : * M- A i : : : : : . ■ : i : to 1.200,000. Hb. 70 per cent. Fowler's solution was being given with the hope that it would serve the double purpose of stimulating red-cell production and at the same time exert some destructive in fluence on the flukes. It was also believed that it would to some extent combat the malaria. On the 17th and 18th a large dose of quinine was given. This was followed by chilly sensations, ringing in the ears, dizziness, and enuresis. On the 20th the patient was no better. Although no 92 STENHOUSE —PAIN IN HYPOCHONDRIUM. VoL XIII. ameba had been found 30 miligrams of emetin was given to note the effect. The pains, which had subsided somewhat, returned, as did the rigidity over the right rectus. The temperature remained around 99 without any great change from day to day. On the 20tl a course of santonin was given. No worms were passed. On the 21st santonin was given again. On the 26th there were signs of improvement. E. b. c, 2,920,000. Hb. 75 per cent. Leucocytes had fallen to 11,000. Whether this was the actual turning point we do not know. Possibly he would have recovered without further medication. On the 26th the patient was seen by Dr. McCartney, an American doctor at Chungking, who advised a mixture of iron with 4 grains of quinine to the dose t. i. d. He did not favor the beginning-abscess theory. The prescription was given as advised. On December 30 Dr. S. Sakamoto, medical officer of H. I. J. M. S. Toba, was asked to give his opinion on the case. He went over the man carefuly and emphasized the following points: (1) Liver enlargement, (2) ane mia, (3) icterus. He believed the fluke infection of the liver respon sible for the anemia. Outcome.— January 7, 1918, Kbc 3,800,000; Hb 85 per cent; leuco cytes, 8,700. January 26, 1918, Rbc 4,230,000; Hb 80 per cent; ap petite good ; walks about considerably. February 2, 1918, salvarsan, 0.6 gm. intravenously. February 16, 1918, returned from French hospital. February 18, 1918, Rbc 4,800,000; Hb 80 per cent; clon- orchis and ascaris in stools. The future for this man does not seem bright, certainly not so far as total recovery is concerned. But the case illustrates the great resistance that the Chinese exhibit against the inroads of disease. The man may live along in moderate health for a number of years. This case, along with contemporaneous observations on the Yangzte River, has awakened the writer's interest in the question of the multiple effect of a number of infections on a living organism. One who knows China will readily appreciate the fact that an in dividual in his lifetime must be inoculated with all manner of in fections. At some time or other in life he therefore lias malaria, smallpox, tuberculosis, typhoid, and in fact everything there is in the country in the way of disease. He takes each infection as a matter of course, unless it results in gangrene of the face, loss of eyesight, paralysis, or other quite evident complication. It is impossible to think that a Chinaman can reach adult life without thus accumulating antibodies and immunity against all manner of maladies to which the ordinary white man would doubt less succumb. That accounts for the statement which medical offi cers on Yangzte gunboats like to repeat : " Perform any operation on No. 1. 93 BOSS—PERFORATING WOUND OF INTESTINE. a Chinaman and he will get well. Do the same thing to an Ameri can and he will die." This man had a history of chancroid in 1914. He may have had syphilis. He had malaria, intestinal parasites, and it appears a nuke in the liver. He seems to have had a secondary infection resulting in inflammation and leucocytosis. And he gives a history of dysen tery. He had a combination of several things which for a time seemed to thrive, a sort of symbiosis. Then the bodily resistance be gan to respond to the calls made upon it, and either the opposite effect from symbiosis ensued, the parasites starved out some dis turber, or else we must give credit to the medication for eliminating the offender. PERFORATING WOUND OF INTESTINE AND MESENTERY. By O. G. Ross, Lieutenant, Medical Corps, United States Naval Reserve Force. F. G., B. M. 2d class, age 25, from U. S. S. Bridge. Admitted January 11, 1918, at 10 a. m., to United States Navy Base Hospital, Brest, France. On January 11, at 9 a. m., while working in the gun room aboard ship in the harbor of X, a .45-caliber Colt automatic was accidentally discharged, the bullet striking the patient in the right lower abdo men after having passed through the chest wall of another sailor. The wound of entrance was one-half inch to the inner side of and 1 inch above the anterior superior spine of the ilium. The bullet ranged downward, inward, and backward. Patient was in a mild state of shock. Temperature 97.4, pulse 108, respiration 26. He showed evidence of acute anemia, presumably due to hemorrhage. The abdomen was opened at 11 a. m. by a right rectus incision just outside the linea alba. On opening the peritoneum, blood and intes tinal contents escaped. The small intestines were delivered into hot towels and nine holes in the ilium and two rents in the mesen tery were discovered. The holes were closed by through and through sutures of catgut and oversewn by Lembert sutures of linen thread. Further examination disclosed a hole in the sigmoid, which was closed by the same method. The bullet was not found, although it was certainly in the patient's body, there being no wound of exit. The pelvis was drained by a rubber tube and cigarette drains. The wound of entrance was treated by debridement. Before closure the wound was sprayed with dichloramin-T, 7£ per cent. The patient had a rather stormy convalescence due to suppuration along the drainage tract and to a sharp attack of acute bronchitis. Bowels moved on the third day. On the 10th day he was put on full diet. The wound healed slowly by granulation. He was dis charged to full duty April 2, 1918. 94 NEWTON —TREATMENT OP SCABLET FEVER, Vol. XIII. Two of the openings in the ilium were about 2 inches apart and their closure seriously diminished the lumen of the gut. It was a grave question whether to resect this portion of the gut or to be satisfied with the closure. The lesson we learned from this case was that the reparative power of the small intestines is very considerable, and that what seemed to be an almost complete occlusion of the lumen was sufficient for this man's physiologic needs and permitted a complete recovery. NOTES ON THE TREATMENT OF SCARLET FEVER.' By W. C. Niwtox, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. It is very interesting to observe how successfully cross-infections may be prevented by the employment of the unit system. In the in stitutions visited cross-infections have occurred only when inexpe rienced attendants were employed. The use of antiseptic solutions and gaseous disinfectants is slowly giving away to the cleanliness which follows the generous use of soap and water, fresh air and sunshine. Formaldehyde gas is used in some institutions for disinfection of mattresses and blankets. Place, of Boston, is very enthusiastic over results obtained by doing tonsillectomies in the early days of scarlet fever. This was done quite accidently at first. A few cases having been operated upon during the incubation period, it was noted that these patients had a smoother convalescence, in that there were fewer ear, heart, and kidney com plications. So, encouraged by these facts, a number of cases were operated on during the febrile stage which also did particularly well. These were selected cases with obviously hypertrophied tonsils and large adenoid growths. There were no operative complications such as hemorrhage or sepsis following the procedure. There was no case of lung abscess. The use of the naso-pharyngoscope is a most efficient means of detecting areas of diseased tissue —adenoids, turbinates, etc., and upon the removal of these infective areas the muco-purulent discharge will cease, whether from anterior nares or naso-pharynx and tht patient may be released from quarantine much earlier than would otherwise be possible. At the Boston City Hospital and at the city hospital at Providence, it is a universal rule that patients sick with scarlet fever, of however mild a type, should remain in bed at least three weeks in order to avoid kidney complications. 1 Extract from report of inspection of contagions hospitals at Boston, Newport, and Providence. H». 1. HALE AND ADAMS—ATYPICAL ABDOMINAL CONDITIONS. 95 It would seem that the use of the Moshier speculum should be more universal, for in no other way can a satisfactory culture from the larynx be made in cases of laryngitis, which present the symp toms of expiratory distress. Such cases are worthy of the most careful consideration and the presence or absence of the Klebs-Loffler bacillus must be demon strated. Dr. Place believes that neglected cases of diphtheria with marked edema of the neck, pallor, prostration, and rapid pulse should receive a dose of 70,000-80,000 units of antitoxin given intra venously. He has never seen a case of anaphylactic shock follow the use of large doses of serum. Dr. Richardson at Providence is allowing his patients a fairly generous proteid diet during the convalescence of scarlet fever, and the cases that are allowed white meat and fish show no increase in the number of cases of nephritis as compared with those recovering from the disease that have been placed on a fairly free meat and egg diet. XLLtTSTBATIVE CASES OP ATYPICAI ACUTE ABDOMINAL CONDITIONS. By G. D. Hale, Lieutenant Commander, and J. C. Adams, Lieutenant Medical Corps, United States Navy. In the diagnosis of acute abdominal conditions requiring prompt surgical interference there is probably no class of cases of more inter est to the medical officer and more commonly met with than that composed of appendicitis, peritonitis, and intestinal obstruction. While this group is by no means the only class of surgical cases met with in the service, yet it is fairly typical of those requiring prompt surgical measure and with which every medical officer should con stantly be familiar, both as to the correct diagnosis and the necessary surgical procedure. Ordinarily in making a diagnosis the information is derived from the history of the case, the symptoms, the physical findings, and the laboratory findings, all of which in the typical case tend to point to a clear diagnosis. The other group of cases, the atypical, may be classified as follows: (1) Those in which the history of the case is obscure or confusing; (2) those in which the symptoms are wanting or possibly contrary; (3) those in which the physical findings are confusing; (4) those in which the laboratory findings may prove negative or confusing; and (5) the group in which there are few symptoms and physical findings together with negative laboratory findings. It is to the last two groups that particular attention is called, and the following illustrative cases are reported : Case No. 1.—B.—R. H., private, United States Marine Corps. Ad mitted June 17, 1918, complaining of slight nausea and pain on right 96 HALE AND ADAMS—ATYPICAL ABDOMINAL CONDITIONS. Vol. XIII. side. Patient stated that he vomited once before coming to sick bay. Physical examination disclosed a distinct tenderness on right side in appendix region. No rigidity and no history of previous similar attack. Otherwise the physical examination was negative. Temperature on admission was normal. Pulse, 68. W. B. C. 13,400. Differential count showed 67 per cent polynuclears. A warm enema was given and no food was allowed. On the following day, June 18, patient rested well, having been much relieved by the enema. Tenderness over appendix still present. Very little rigidity. W. B. C. 12,800. Pulse and temperature remained nor mal. June 19, condition apparently improving. W. B. C. 6,600. Tem perature and pulse normal. S. S. enema daily. June 20, patient in excellent condition. Has not vomited since admission. Pulse remains around 68. Temperature normal. W. B. C. normal. Owing to the persistent tenderness and slight rigidity over ap pendix it was decided to operate. At operation two-thirds of the appendix was found to be in a gangrenous condition. There was a well-defined local peritonitis, well walled off and containing a small quantity of sero-purulent fluid. The appendix was ligated and removed but no attempt was made to invaginate the stump. The abdomen was drained. Patient ran an uninterrupted and rapid convalescence. The interesting point in this case is, of course, the abdominal con dition found at operation, with such few diagnostic signs. Case No. 8. —H.—E. F., private, United States Marine Corps, age 33. Admitted May 1, 1918, complaining of abdominal cramps, nausea, and vomiting. Patient vomited a large quantity of clear green fluid a few minutes after admission, and stated that the cramps and vomiting began the previous evening. Examination shows a well-nourished and developed man. Gen eral tenderness over entire abdomen but no distention and only slight rigidity in epigastric region. Reflexes normal. Temperature 98, pulse 60. Laboratory findings: W. B. C. 19,600. D. C. . Polys. 72 per cent Urine negative. Past history : Acute appendicitis July 28, 1917, and appendix re moved at United States Navel Hospital, Mare Island, Cal., same date. Restored to duty in 23 days and had been well since. History other wise negative. Patient was given soapsuds enema, which returned with good results. No food allowed. May 2, patient continues to vomit bile-tinged fluid. Vomitus de void of fecal odor. Soapsuds enema and gastric lavage with relief No.l. HALE AND ADAMS —ATYPICAL ABDOMINAL CONDITIONS. 97 of cramps. Abdomen still tender but no rigidity or distention. General appearance of patient excellent. Pulse 60. Temperature normal. W. B. C. 18,400. May 3, general appearance of patient good. No change in physi cal signs. Vomited twice during forenoon. Temperature normal. Pulse 70. W. B. C. 22,000. May 4, no vomiting for 36 hours. Soapsuds enema returned clear. Temperature normal. Pulse 98. W. B. C. 9,000. Proctoclysis given at regular 4-hour intervals to relieve thirst. Albumin water and chicken broth given toward evening. May 6, on the sixth day after admission patient appeared bright but showed signs of exhaustion. Has not vomited for 72 hours. Has been taking liquid food for past two days. Temperature normal. W. B. C. normal. Soapsuds enemata continue to return clear. Ab domen tender but soft. During the early part of the afternoon patient vomited profusely. The vomitus contained all the food eaten the previous day. No fecal odor. It was decided to operate, and in transferring patient to hospital he vomited a large quantity of decidedly fecal matter for the first time since admission. At operation the upper part of the small intestines was found moderately distended. A double obstruction was disclosed, caused by two firm omental bands. The first obstruction, just below the duodenum was only partial, while the second, situated about 5 feet lower down, was quite complete. Following operation, for the first week, patient ran an irregular temperature ranging from 100 to 102 ; pulse 120 to 130, which grad ually returned to normal. June 21, to duty well. The points of interest in this case are the confusing laboratory findings, the mild general symptoms, and the delay in fecal vomiting. Case No. S.—S.—private, United States Marine Corps, age 20. Patient reported complaining of constipation and dull pain over entire abdomen. The symptoms had existed for several days. Past history otherwise negative. Examination showed a well-nourished young man with a decidedly prominent abdomen which was tender but soft. All other physical signs were normal. Temperature was normal. Pulse, 78. Urine normal. Blood examination normal with exception of hemoglobin per cent of 75. During the next four days abdomen became rapidly more dis tended, with very definite signs of fluid. Tapping and removal of 3.500 c. c. of clear fluid gave relief. No masses or other abnormalities could be made out in the abdomen either before or after the removal of the fluid. The temperature reached 99.2 on two evenings, but the remainder of the time it was normal. 98 McCAFFEBTY —VARIETIES OP HYPERSUSCEPTIBILITY. Vol. XIII. Examination of the fluid showed a preponderance of lymphocytea. No erythrocytes and only a very few polynuclears were seen. No organisms could be found. The albumen content was exceedingly high. The patient was in excellent condition throughout, but on account of the commencing reaccumulation of the fluid in the next few days he was transferred to a naval hospital. The interesting point in this casa is the presence of a large amount of fluid in the abdomen of a young man apparently in good health. An exploratory operation or animal inoculation would probably have confirmed the tentative diagnosis of tubercular peritonitis, but these methods were not possi ble in camp. Recent report from the hospital, 14 days later, stated that the man was in excellent shape, although the fluid seemed to be increasing. No operation had been done nor were there any labora tory findings to report. The above cases demonstrate the fact that diagnosis should not only mean the determination of the disease or malady but should also take into account the severity of the illness. In other words, how sick is the patient ? In the typical case it is usually possible to arrive at a correct diagnosis, but the actual seriousness of the case is often never determined until operation, when the pathological findings will often prove most serious. In this respect there is of course no possi ble means of describing a method whereby the seriousness of the con dition can be determined and undoubtedly the most dependable resource in an instance of this kind is experience. The apparently mild cases, also the obscure and atypical, should be the ones to receive the greatest care and attention and should be re garded with suspicion. They are the ones which should receive the special attention of the experienced medical officer lest operation be postponed too long. VARIETIES OP HTPEKSTISCEPTIBIIITT: THREE CLINICAL CASES. By L. K. McCaffekty, Lieutenant, Medical Corps, United States Navy. The following are selected from the many interesting cases seen at the United States Naval Dispensary, Washington, D. C, from Jan uary to July, 1918 : Cane I. Angio-neurotic edema, or Quincke's disease. —This patient was referred to the naval dispensary by a relative in the Marine Corps, who desired to know if his condition would prevent him from enlisting in either branch of the service. He is a civilian, 24 years of age, single, white ; nationality, Hebrew ; occupation, business. K». 1. McCAEFERTY —VARIETIES OF HYPERSUSCEPTIBILITY. 99 His main complaint was of local swellings, limited in extent and of transient duration. His family history is entirely negative. Past . history elicits nothing of importance, as the patient has never been seriously ill in his life. The present illness began two years ago when the patient noticed a swelling on his arm about the size of a hen's egg, which came on insidiously and remained for several hours. There was no pain con nected with it, and if it had not been in a prominent place he would never have noticed it. There was no change of color over this swell ing; when pressed small indentations would remain for several min utes, although this was not a true pitting as seen in edema. One morning two years ago the patient awoke and to his surprise found his scrotum markedly swollen, being about the size of a coconut; this frightened him so that he consulted a physician. At another time he had an engagement to play golf the following morning, but when he awoke, to his astonishment, both hands were swollen three times the ordinary size so that the patient was unable to bend his fingers. On one occasion his tongue swelled to such an extent that he was unable to contain it within his mouth. As the patient says, u practically every feature of the face has undergone a similar fate." There has been no premonitory sign nor any disturbance of the gastro intestinal tract accompanying these attacks. Except for the un sightly swelling, the condition would probably never have caused him difficulty, unless the larynx were involved. Preceding each one of these attacks there was a history indicative of an error in diet, which will be discussed subsequently. On physical examination we found a robust, healthy man, some what plethoric. His examination was entirely negative throughout. Urinary and blood examinations were negative. Wassermann was negative. The special laboratory tests proved to be quite interesting and important. As we saw from the clinical history that certain foods produced this transient edema it was therefore advisable to test the patient's susceptibility to certain food proteins. There were given intradermally minute amounts of protein from the hog, such as pork, ham, and lard, and soon after administration, the patient gave a positive cutaneous reaction. Fish, crab, lobster, and chicken were also tried with positive results. Lamb, veal, beef, and egg were tried with negative results. This proved conclusively that the patient was hypersensitive to the above articles of diet, both intradermally and when ingested in large amounts. It might be added here that soon after the protein was given intradermally there appeared a small papule surrounded by an ery thematous areola. This was considered a positive reaction. 100 McOAFFEETY —VARIETIES OF HYPEESUSCEPTIBILITY. Vol. XIII. As was said in the beginning of this paper, the patient came to us for our opinion as to his fitness for military service. We therefore had to reject him, as it would be practically impossible for him to secure the necessary diet in order to maintain a normal life. Case II.—This case is very closely allied to Case I, being another example of anaphylaxis. The patient is a male, age 24 years, occupation, sailor, who pre sented himself to the dispensary complaining of severe headache. The usual routine examination was made and nothing remark«able was found, except hypertension. We prescribed aspirin, grains v, at once, and within one hour the patient returned to the dispensary, appearing quite alarmed about himself. At this time he was complaining of shortness of breath, a sensa tion of pressure over the top of his head. He said his scalp felt tightly compressed and that his face felt flushed. He also had a severe pain over his epigastrium. The skin over his body felt warm and there was a sensation of itching present. On examination we found the patient quite nervous, having a marked tremor of his lips, tongue, and hands. He spoke rather anxiously, having some trouble in articulation. His face and neck presented a diffuse erythema. There was some edema around his naso-labial fold, lips, and tongue. His lips ap peared quite cyanotic. On the trunk, upper and lower extremities, palms, and soles of feet was a pronounced urticarial eruption. The urticarial wheals were so diffuse that the tip of the index finger could not be placed on the cutaneous surface without overlapping an urticarial papule. The papules were white on their summit with , an erythematous areola. The intervening cutaneous surfaces were erythematous. Some of these lesions appeared on the face and neck, but were not so numerous. Intense itching accompanied the appear ance of these lesions. There was a marked tachycardia; the heart sounds at apex were rather distant. The diastolic phase was reduced to such an extent that it was quite hard to distinguish first and second sounds. The blood pressure at this time showed a systolic of 170 mm. Hg. and a diastolic of 110. This whole picture developed in two hours after the ingestion of 5 grains of aspirin. The condition had never occurred before, but the author produced the same picture twice since. The patient gave no history of this idiosyncrasy in his family. The whole picture disappeared within 12 hours. The eruption gradually faded so that there was no trace 12 hours thereafter. The epigastric pain was relieved by sodium bicarbonate. The tachycardia and cyanosis disappeared soon after he returned home and reclined. No. 1. McCAFFEKTY —VARIETIES OF HYPEHSUSCEPTIBILITY. 101 There was another interesting feature which was discovered while we were making the routine examination, namely, hypertension. The patient is 24 years of age, of very good habits. He has never worked with lead in any form nor is there any history in his family of early degeneration of the cardio-vascular system. He has com plained occasionally of headache, nausea, and dizziness, all of which could be ascribed to this hypertension. On physical examination we found the cardio-vascular system entirely negative. Repeated examinations of the urine have been negative. Eye grounds are entirely negative, thus ruling out any encephalopathy condition. Wassermann was negative. The only finding was a systolic pressure averaging around 170 mm. Hg. and a diastolic pressure of 100 mm. Hg. by the auscultatory method. We have had him under close observation for two months, taking blood-pressure readings three times a week at different times during the day. The finding always remained practically the same. The etiology of this condition is quite obscure, as we have been unable to find any pathological condition to account for this hyper tension, except a vague vasomotor disturbance and a tendency to a neurasthenic state, both of which might produce this so-called idiopathic hypertension ; but the hypertension in either one of these conditions would probably not be permanently present, nor would we expect to find the diastolic pressure quite so high. There was a suggestive thyroid enlargement which might possibly produce this hypertension, but the various authorities disagree as to the blood-pressure findings in hypertrophy of the thyroid. Whatever the etiological factor is, the fact remains that he has a hypertension, which was not discovered on entrance to the Navy, and only accentuates the importance of auscultatory blood-pressure readings, both systolic and diastolic, when a recruit is examined. It is hardly possible that his hypertension will be reduced to normal, as we have placed him on a meat-free diet, moderate exer cise, and potassium iodide for some two months, and it has made no appreciable change. In all probability he will eventually be sur veyed from the service, an unnecessary procedure had the blood pressure been taken on his first examination. Case III. Hay fever.—This case is of interest merely from the point of view of desensitization treatment and because it falls in the same group as cases I and II. He is 36 years of age, a marine by occupation, of good habits, and married. His complaint is hay fever. The family history is nega tive, as there is no tendency to hay fever or asthma. The past history is essentially negative. The present illness began at the age of 12 years, when late in the summer the patient developed the typical symptoms of hay fever. 102 McCAFFEBTY—VABIET1ES OF HYPEBSUSCEPTIBILITY. Vol. XIII. He had paroxysms of lacrymation, rhinitis, and laryngitis through out August, September, and sometimes late in October. These attacks were present late each summer unless he sought another climate, either in Europe or by the seashore. In 1915 he visited Dr. Robert Cooke in New York City, who began his pollen protein tests upon him to determine which one he was sensitive to. These tests were carried out as follows : One would take the various pollen proteins, and after making an extract of them with normal salt solution a minute amount would be given intradermally. Wherever there occurred a subcutaneous, reaction it would be called positive to that particular pollen protein. By ophthalmic test we would determine the degree of sensitiveness. This would be the plant to which the patient was hypersensitive, and to what degree. It was found by intradermal injection that this patient was sensi tive to ragweed. As ragweed is one of the plants whose pollen pro duces hay fever, especially in this case, the patient was given desensi- tization treatment for this plant. This treatment is best given in small subcutaneous injections one© weekly until 12 doses are given, gradually increasing the dose each time, usually beginning the treatment about six weeks prior to the onset of symptoms and continuing throughout the season. This will produce an active immunity in many cases, but occasionally slight symptoms occur. At the present time I am administering the pollen protein extrac tion of ragweed to this patient, and have been doing so for the past six weeks, and up to the present time he has shown no symptoms, nor did he show any symptoms in 1915, 1916, and 1917 while under the treatment of Dr. Cooke, of New York. It may be added here that this active immunity which is produced will usually last one or two seasons, but by the third symptoms arise unless prophylactic treat ment is again begun. In summarizing Cases I and III it can be stated that they are due either to a toxin or to a protein reaction in sensitized indi viduals; in other words, anaphylaxis. In Case II the reaction is due to a drug which may be classified under hypersensitiveness. Dunbar maintains that the protein of the pollen in hay fever is a toxin belonging to the albumen group, but Cooke, of New York, and others are inclined to believe it a true anaphylaxis. Assuming, then, that any individual, for reasons still unknown, has become naturally sensitive to some protein or drug, the production of symptoms is readily understood. Many believe the reaction is cellular and not humoral. For example, the clinical reaction depends largely on the cells that are sensitized. Thus we have in hay fever a sensitization of the mucous membrane of the eyes, respiratory tract, together N«.l. CUMMINGS —VARIX SIMULATING INGUINAL HERNIA. 103 with a general cutaneous sensitization, whereas in urticaria follow ing aspirin the sensitization is essentially in the cells of the epi thelium. In angio-neurotic oedema the sensitization is of the con nective tissue cells in the subcutaneous tissue. While each case is distinct, producing different symptoms, they may all be classified tinder anaphylaxis or hypersensitiveness. REPORT OF A CASE OF VARIX SIMULATING INGUINAL HERNIA. By E. J. Cumminos, Lieutenant, Medical Corps, United States Navy. Several months ago my attention was called to the report of a case of saphenous varix simulating a femoral hernia, written by E. H. Richardson, of Baltimore, published in the April number, 1J>18, Annals of Surgery. Since the report of his case I have had the good fortune to come in contact with a case of varix simulating inguinal hernia. Like Richardson's case, this one is also the con fession of a mistaken diagnosis. The patient was a young man 21 years old, admitted to the sur gical service of the United States Naval Hospital, Washington, D. C. The diagnosis on admission was right inguinal hernia. In the region of the right inguinal canal there was a definite swelling pbout the size of a small hen's egg, which showed some increase in size when the patient changed from the recumbent to the standing posture. The swelling apparently took up the entire length of the inguinal canal, transmitted an impulse on coughing, but could not be reduced by taxis. In the recumbent position the tumefaction, though reduced in size, stood out prominently. The history of the condition is interesting, inasmuch as the patient firmly states that he was never aware of the existence of any swell ing until about one week previous to the time of entrance to the hospital. There were no subjective symptoms associated with the existence of the swelling. No varicosities were noted in either leg. For the preoperative diagnosis two views were shared : One, that the tumefaction was an inguinal hernia; two, that the tumefaction was an encysted hydrocele of the cord. Commander H. F. Strine, Medical Corps, United States Navy, operated, making the usual incision as for inguinal hernia directly over the mass. In the subcutaneous tissue lying directly over the inguinal canal and slightly above the external ring a circumscribed mass of fatty tissue and dilated veins was encountered. The lower limit of the mass was about the level of Poupart's ligament. The mass was excised and reserved for pathological inspection, the report later showing the tissue consisted chiefly of dilated veins. To insure against the possibility of an associated hernia, the external oblique 104 BOWMAN —ACUTE APPENDICITIS WITH HEMOBRHAGE. Vol. XIII. was split, and no sac being found, a hernia suture with a cord trans plant was then done. The vein involved was unquestionably the superficial epigastric with some adjacent tributaries. The condition was indeed unusual, and I must frankly say that the possibility of a varix never entered our heads. After a careful search of the literature in an endeavor to find re ports of other cases, I have only been able to find one writer who has reported a somewhat similar case. A French writer has published two cases of lymphatic varix simulating inguinal hernia under the title " Pseudo hernies inguinales dues a des varices lymphatiques des op erations qui conviennent et qui peuvent etre faites avec succes." It is interesting to note that the writer in his dissertation on these cases states that the tumor, which descended into the scrotum as far as the testicle, had all the characteristics of an inguinal hernia containing a small quantity of fluid. The condition also led observers to believe that there was adherent omentum in the sac. There have been re ported several cases of varix of the superficial epigastric vein, of which I have appended references. None of these cases, however, of varix of the superficial epigastric vein have simulated hernia. HEFEKKNCES. Lucas Champlonniere : Assoc. Franc, de chir., Proc. Verb., Paris, 1904, XVII, 662-661. Roth, A. H., and Guide, A. : New York Med. Jour., 1905, LXXXII, 851-854. Somnier, G. : Philadelphia Med. Jour., 1902, X, 201. McGavin, L. : Proc. Roy. Soc. Med., London, 1910-11, IV, Chin, Sec. 51. Richardson, R. R. : U. S. Nav. Med. Bull., 1910, IV, 196. ACUTE APPENDICITIS COMPLICATED BY IDIOPATHIC HEMORRHAGE FROM RUPTURED MES0-APPENDIX ARTERY. By F. H. Bowman, Lieutenant, Medical Corps, United States Navy. P. S., fireman, second class, was admitted to the United States Naval Hospital, New York, N. Y., on July 16, 1918, with the follow ing history : Previous history. —The patient stated that as far back as he could remember he had had attacks of cramplike pains, similar to the present one in character, but that they had always passed off within a few hours. With these attacks he had never had nausea or vomiting nor elevation of temperature. Present history. —On July 16, 1918, the evening of the day of ad mission, the patient was walking along the street, when he experienced a severe, cramplike pain over the entire abdomen. This pain was general at first but soon became localized in the epigastric region. No No. 1. STEPHENS—WOUND CONTAMINATION WITH GONOCOCCUS. 105 nausea or vomiting was present, but the patient experienced a feeling of fullness in the upper portion of the abdomen. He went to bed and, in order to relieve the pain, drank a considerable amount of whisky, but without any relief. The pain became more and more intense. He was then brought to the United States Naval Hospital, New York. On admission his temperature was 97.6 F., his pulse 84, and the respirations were 20. His skin presented a pale ocher color. Lungs and heart were negative. The abdominal walls showed no marked rigidity, but there was an arc of decided tenderness over McBurney's point. Dullness was marked in both flanks. Urine negative. Blood count: white cells 6,200; polynuclears 62 per cent; lymphocytes 34 per cent; eosinophiles 1 per cent; transitionals 3 (200 cells counted). July 17 : Operation. Ether anesthesia. Righ rectus incision. The abdomen was found filled with blood, both fresh and clotted. The bleeding point was located in the meso-appendix, near the base, in i* ruptured vessel. The appendix showed an inflammatory area at the base with much congestion of all the blood vessels in that loca tion. All other organs were negative. The bleeding vessel was ligated and an appendectomy performed. Wound closed. The patient made a rapid recovery. AN UNUSUAL CASE OP WOUND CONTAMINATION WITH THE GONOCOCCUS. By E. A. Stephins, Lieutenant, Medical Corps, United States Navy. History.—F. M. D., age 27 second lieutenant, United States Army, received September 23, 1918, for passage to the United States. In a French hospital on July 21, 1918, he had an amputation of the right thigh following a gun-shot wound. The following morning hot normal saline solution was, according to the patient's own statement, given subcutaneously in left thigh ; the solution was too hot, result ing in a burn of that area. Two days later the superficial tissues sloughed, leaving a second degree burn. The burn was circular and about 3 inches in diameter. He had gonorrhea at 17, but has had no active symptoms since then. Examination. —The stump of the right thigh has entirely healed except for a small, oval, granulating area about one-half inch in size. The wound is clean and has made good progress since the amputa tion. On left thigh, anteriorly in the middle third, is a circular area 3 inches in diameter, with an angry, granulating base and under mined edges, the result of the burn from hot saline solution, men tioned above. The base is covered with thick yellow pus but is with out any distinctly offensive odor. The wound has drained profusely 88977—18 8 106 STEPHENS—WOUND CONTAMINATION WITH GONOCOCOUS. Vol. XIII. since the beginning, eight weeks ago. A burning sensation has been present almost continually during the past five weeks and at times it has been very painful. There has been no tendency toward healing. Smears made from the pus revealed Gram negative, intracellular diplococci. Some of the leukocytes contained 8 to 12 pairs. The smear was made primarily in order to do a bacterial and cell count. A count of 10 fields showed an average of 120 pairs of diplococci and an abundance of pus cells per field. The nuclei of the polymorpho nuclear cells were not destroyed. A few pairs of diplococci were found extracellularly but no other organisms were present. Cultures on ordinary media at 37° were negative. Cultures on blood serum and blood agar were negative. It did not ferment glucose. The organism grew slowly as minute dew-drop colonies on blood streaked agar. It was agglutinated by serum from a known gonorrhoeal blood. Complement fixation test was not done. It seemed to me reasonable to identify this organism as the gono- coccus. Smears of the healing stump showed a few staphylococci but no diplococci. " Smears from the anterior urethra were negative. The anterior urethra was irrigated with sterile water, the washings caught upon return and centrifuged. Examination of sediment revealed no organ isms. Successive smears of urethra and urinary sediment following prostatic massage were negative. Course and treatment. —Dichloramine-T was used for four days with no material change in bacterial count or cell count. Silver ni trate in 10 per cent solution was then applied, followed by wet dressings of silvol 10 per cent for three days. Organisms per field 35, pus cells 28. Ten fields counted. Discharge has lessened con siderably. Same treatment continued. Four days later there were organisms per field, 7; pus cells, 4. Discharge scanty. October 5, 1918, smear shows two diplococci per field and an occasional pus cell. The wound has stopped draining. Healing has progressed, until now only an area about one-half inch in diameter remains. Conclusions. —While it is true that the identification of the organ ism is not absolute, nevertheless the only other organisms, the meningococcus and micrococcus catarrhalis, have been excluded as etiologic factors. The gonococcus will attack any mucous surface, but its appearance in a wound of this nature has been rare. It is probable that the moisture and warmth beneath the undermined edges furnished a suitable medium for their growth. The source of contamination can only be problematical. It is fair to assume that the urethra of the patient does not harbor the organ ism, although the proximity of the lesion to the penis would make contamination from that source easy. VoL XIII. BEEVES & MILLEB— SUBLUXATION OF CEBVICAL VEBTEBBA. 107 It has been shown that the gonococcus can be transmitted by un clean dental instruments.1 This organism is known to have little resistance to drying or exposure to air, yet one can easily imagine how a highly virulent germ could be quickly transmitted by means of the fingers of a careless attendant or nurse. The patient has been dressed by scores of attendants, and during a rush period in the hospital the wound remained uncovered for two weeks. The result following more specific treatment confirms the opinion that the infection was Neisserian. There is no ground for assuming that the infection might have been hematogenous. A CASE OF SUBLUXATION OF CEBVICAL VEBTEBBA BY MUSCULAB ACTION. By I. S. K. Reeves, Commander, and If. K. Millee, Lieutenant, Medical Corps, United 'States Navy. N., R. C, F-3c, was walking down a low incline on board the U. S. S. Delaware on September 2, 1918, when both his feet slipped. He fell flat on his back and in order to prevent injury to his head threw it forward with a jerk. He immediately noted severe pain " in the bone " of his neck with complete loss of motion in the cervical vertebrae. Guarding his head against movement he turned in. The next morning the pain was so severe that he reported for treatment, When seen he walked with great caution, holding his head rigid be tween his hands with face looking a little to the right. The facies showed great suffering and anxiety. The muscles of the neck were rigid and a distinct prominence could be felt to the left of the middle line and above the sixth cervical vertebra. Any attempt to manipulate the head casued such pain that the patient was anesthe tized. Under the anesthetic the fifth cervical vertebra appeared to be in unilateral subluxation forward, the left side being pushed forward until its posterior edge passed the anterior of the sixth and the upper articular surface of the sixth cervical vertebra became prominent. The motion in the cervical region was much limited even under com plete anesthesia. To reduce the subluxation the face was turned to the right, the head abducted and rotated backward while traction was made. At the stage of backward rotation a distinct snap was felt by both the operator and assistant, the latter at the time having his finger on the prominence of the sixth cervical. The deformity disappeared and motion became normal. When the patient recovered from the anesthetic he could move his head in any direction, but flexion caused 1 Mayhew, J. N. : Gonococcus Infection of the Mucous Membrane of the Oral Cavity. Jour. Am. Med. Assn. Apr. 27, 1918, p. 1223. 108 HALPIN —STENOSIS OF WHAETOn's DUCT. VoL XIII. severe pain. The patient was kept in bed until the next day, when he could walk a bit with caution, having a splint of reinforced plaster from occiput to mid-dorsal region. For several days motion of the head caused some pain, but the patient soon made a complete recovery. REPORT OF A CASE OF FRACTURE OF THE SKULL. By K. I. Lonoabaugh, Lieutenant Commander, Medical Corpa, United States Navy. Q. K., corporal, Company G, Three hundred and sixty-seventh In fantry, was brought to the sick bay on June 15, 1918, having been in jured in a row over a crap game. Another soldier during the progress of this row seized a bayonet by the blade and drove the ring which fits over the rifle barrel into R.'s forehead. The bayonet guard was so firmly embedded that the assailant was obliged to call upon another soldier to help him pull it out. R. walked up two ladders to the sick bay accompanied by other soldiers but unaided. Examination showed a hole in the frontal bone, a small trickle of blood down the face, but no symptoms that would point to brain injury. Under ether I explored the wound, which was almost centrally located in the frontal bone, the uninjured roof of the frontal sinuses, mostly the left, forming the lower margin. The depressed and roughened edges of bone were removed. The probe disclosed fragments of bone at a depth of about 1 inch in the left frontal lobe. These I proceeded to remove as gently as possible. Two were approximately about one-half inch square and very rough and there were several smaller ones. The dura was so badly lacerated that it was not possible to make any attempt at sutur ing it. A piece of rubber dam was laid in the wound and a cigarette of rubber dnm brought to the surface. Recovery uneventful. Rubber dam removed after 48 hours. Transferred to a hospital in Franco after five days; wound entirely closed. No loss of memory, or in fact any symptoms of brain injury apparent. Inquiry at the above hospital one month later shows this man as cured and with no bad after results. My reasons for reporting this case are: (1) To again invite atten tion to the amount of trauma and abuse the frontal lobes will with stand without any discoverable symptoms; (2) to show again how promptly the dura takes care of injuries to it, even where the surgeon is unable to offer it help. REPORT OF CASE OF STENOSIS OF WHARTON'S DUCT. By J. A. Halpin, Lieutenant, Medical Corps, United States Navy. Patient E. H., age 27, sea. 2c, entered hospital with "diagnosis undetermined, probably mumps." He stated that some two weeks No.l. HALPIN —STENOSIS OP WHABTON's DUCT. 109 before, about the 10th of November, 1917, his jaw suddenly became swollen and painful while he was eating. Reporting at the sick-bay he was isolated for mumps and transferred to this hospital for isolation, observation, and treatment. Between meals he noticed that the swelling of jaw receded slightly, but as soon as he began to eat a mass appeared just below jaw and rapidly extended upward on the face. It was painful to the touch and felt hard and indurated. On admission to hospital the right side of face was swollen, tense, and tender on pressure. Examination revealed a hard mass just below the ramus of jaw which extended upward on the face to about the region of the angle of jaw. He was given a piece of dry toast to eat, and while masticating same this mass began to swell rapidly. Examination of mouth and teeth was negative. The temperature, pulse, and respiration were normal. A fine lachrymal probe was introduced into Wharton's duct, which was found to be constricted about 1 inch from the external orifice. On withdrawing the probe and at the same time applying pressure on the submaxillary gland a large amount of saliva was expelled, the gland collapsed, and only a small mass about one-half an inch in size was left. The probe was then reintroduced and an X-ray taken, which showed that no stone was present either in the gland or duct and that only a stenosis existed. This condition of swelling after the ingestion of food continued for two days, and each day a larger probe was introduced into the duct and it gradually dilated until after the fifth day it remained patent and saliva did not accumulate in the gland, but was expelled through the duct into the mouth during the act of mastication. As far as I can trace the history of the case, this is the first time - that such a condition has occurred. There is no history of trauma, infection, or injury. The only incident apparently bearing on the case is a severe attact of tonsillitis six months ago. The infectious process may have extended down the duct where an inflammation was set up unnoticed by the patient, and the consequent proliferation may have caused narrowing of the duct. On the other hand the sud denness of the onset casts some doubt on this explanation. The case is interesting from (1) The negative history with sudden onset; (2) the rarity of the occurrence; and (3) the ease with which the condition could be mistaken for mumps, as it was in this particu lar case. PROGRESS IN MEDICAL SCIENCES. Reviewebs. Lieutenant Commander R. B. Henby, Medical Corps, United States Navy. Lieutenant Commander W. A. Bloedobk, Medical Corps, United States Navy. GENERAL MEDICINE. Gabbaqhan, E. F. Status lymphaticus. Illinois Med. Jour., October, 1918. The writer reviews the history of the subject from the time of Felix Plater, in 1614, down to our own time. Carl Eokitansky con sidered that the abnormal enlargement was almost entirely restricted to children and it was associated with the general enlargement of the lymphatic system, rickets, and enlargement of the brain. Many cases of sudden death without apparent cause were shown by autop sies to be connected with enlargement of the thymus gland. Sudden death during the course of surgical narcosis established for tonsil lectomy and the removal of adenoids can be explained in this way. In 1895 Kundrat reported 10 cases of death during or after anesthesia collected from the autopsy records of Vienna which all showed a distinct lymphatic diathesis. All showed enlargement of the thymus, of the spleen, and of the retroperitoneal and cervical glands. The follicles at the base of the tongue were prominent, the tonsils were enlarged, and the heart muscle was flaccid. While the possible exist ence of status lymphaticus is the cause of sudden death in children operated on for defects of the naso-pharynx, the abnormality is of a more general interest in connection with the administration of diph theria and other antitoxins to adults. Much attention was attracted to this subject on the occasion of the sudden death of the son of Prof. Langerhans, of Berlin, after the injection of a small dose of diph theria antitoxin. The post-mortem examination gave evidence of the existence of status lymphaticus and death was ascribed to this tmveo by prominent pathologists consulted. Hassler reported in the California State Journal of Medicine for May, 1917, a case of great interest. The health department was called upon to administer a prophylactic dose of diphtheria antitoxin to a 7-year-old boy whose sister had been ill with diphtheria and had ill 112 GENERAL MEDICINE. Vol. XIII. been removed to an isolation hospital. The boy was apparently in sound health. One thousand units of a standard brand of antitoxin were injected under the skin. Ten minutes later the child was seized with violent cramps, had difficulty in breathing, and died in the midst of what his mother called " a severe convulsion." It should be noted that on the previous day this boy's sister, the actual sufferer from diphtheria, had received 2,000 units of the same antitoxin by intravenous injection, followed in 24 hours by an additional 1,000 units. At the post-mortem examination of the boy the existence of status lymphaticus was clearly demonstrated. As a direct result of this fatal case, the health department of California now requires the written consent of parent or guardian prior to the administration of antitoxin to the child. Furthermore, the sanitary inspector must remain in close touch with the patient for at least one hour after the antitoxin is given. The author recites other interesting cases and comments upon the lamentable fact that in all the cases recorded the existence of status lymphaticus was clearly demonstrated after death. He points out that an effort should be made before operating on children and before administering sera or antitoxins to discover the presence of status lymphaticus by looking for abnormalities of tongue, tonsils, and pharynx. Investigation of the child's previous health may disclose a history of attacks of dyspnea. Some writers claim that a large area of dullness may be found to the left of the manubrium sterni. Friedlander maintains that an enlarged thymus may be diagnosed by the use of the X-ray. Until recently thymectomy was the only curative measure available, and according to the statistics of Parker these operations had a mortality of 33$ per cent. Now it is claimed that the roentgen ray is not only of great value in diagnosis but is a therapeutic measure which can be used with safety. In' 100 cases in Cincinnati, reported by Friedlander, there were but four deaths. The dose depends upon the severity of the case, and in mild cases a single exposure is often sufficient and leads to improvement within 48 hours. Salisbury, B. I. Epidemic of an unknown intestinal infection. Proc. Med. Assn. of the Isthmian Canal Zone. Meeting of February 17, 1917. The author describes in detail the mysterious epidemic of gastro intestinal disturbance which occurred in the Panama Canal Zone shortly after the Christmas holidays, and was at once regarded as due to the dietary indiscretions with which the modern world is in the habit of celebrating the birth of Christ. The first case to appear did not suggest the development of an epidemic, and therefore a correct count of the cases was not made from the beginning, but it is estimated N». 1. 113 GENERAL MEDICINE. that 450 adults and 250 children were affected, the cases being about equally divided between the Atlantic and Pacific ends of the canal. The figures given include cases from the crew of the U. S. S. Charles- ton, which was at that time at anchor in the harbor of Colon. The tiajority of the patients were white people. Among the children the girls affected outnumbered the boys, but of the adults more males were affected. Fully one-third of the men on the U. S. S. Charleston were taken sick. Many of the cases were mild, and did not entail the cessation of work. The symptoms were headache, loss of appetite, slight fever, general malaise, pain in the abdomen, mild bronchitis, and pharyngitis; vomiting was rare, and was usually a sequence to the ingestion of oil. ■The severe cases were admitted to the hospitals and for a majority of them the diagnosis of appendicitis had been made. The onset was marked by colicky pain in the abdomen, fever ranged from 100° to 103 F. and an exaggeration of the symptoms previously named. The marked prostration and toxicity amounted almost to a typhoid state in the case of many children. Tenderness in the right lower abdominal quadranf was marked and there was decided rigidity of the right rectus. In 13 of the cases a distinct mass could be palpated in the region of the appendix. The leucocytes ranged from 10,000 to 50,000 and the lymphocytes in uncomplicated cases ranged as high as 75 per cent, the small cell variety preponderat ing. Blood cultures were made for the patients with a high tempera ture. They were all sterile except three, which showed streptococcus. Acetonuria and indicanuria were present, the former being most pronounced among the children. The ordinary case ran its course in from one to four weeks, be ginning with an elevation in temperature, commonly 102° to 103 F. (39° to 39.5 C), and remaining so for a few days, then becoming intermittent in type, lower in the morning and rising in the evening, and finally becoming remittent and then normal in the average case by the second week. With but few exceptions these patients seemed and felt quite comfortable, complaining only of headache. After the fourth day about 50 per cent of the children had mucus, pus, and less frequently blood in the stool ; a diarrhea developed in some, and these represented the most severe cases among the children. At the onset of the epidemic many cases were operated on for appendicitis and these all recovered, 14 of the operative cases with palpable masses in the abdomen, which proved to be enlarged gland* of the mesenteric and appendix region. Six men of the U. S. S. Charleston were operated on for supposed appendicitis, but the con dition of the appendices demonstrated that the symptoms were not traceable to the incriminated organ; of the three cases whose cultured blood showed a streptococcus, two were from the U. S. S. Charleston. No diagnosis was agreed upon. Typhoid fever was excluded by 114 GENERAL MEDICINE. Vol. XIIU the high leucocyte count. The colon bacillus infection would show in the blood cultures. The first step in the treatment was isolation. The 450 men of the Charleston were examined and 143 suspects were put in camp at Coco Solo. At some of the military bases the soldiers were pro hibited from swimming, as some of the cases had manifested their first symptoms just after coming out of the water. The diet was limited to liquids. The preliminary purge was followed by an ex hibition of alkalies, bismuth and an intestinal antiseptic. In con clusion the author declines to make a diagnosis, but considers that the symptoms resulted from infection rather than from poisoning. In the discussion which followed the reading of this paper Dr. L. B. Bates laid stress upon the fact that sections of the appendices and glands did not show any streptococcus. He considered it estab lished beyond a doubt that the cases were not typhoid or paratyphoid in spite of the gross appearance of the gut. He pointed out that the epidemic of influenza with symptoms limited to the gastrointestinal tract was unknown. Major Russell thought that the symptoms were particularly suggestive of a severe disease and one that is not sup posed to affect human beings, namely, hog cholera, and he adverted to the fact that the bacillus of hog cholera is not the etiological agent in hog cholera, but merely the secondary invader. Wabthin, A. S. The new pathology of syphilis. Ain. Jour. Syph. July, 1918. The author has conducted extensive investigations into the patho logical anatomy of syphilis and has brought forth facts regarding the microscopic pathology of latent syphilis which are of great interest. The statements in our own textbooks concerning the pathology of this infection are based almost without exception upon the occur rence of the gumma, and syphilis of an organ is said to be frequent or rare according to the frequency of gumma of that organ. Virchow in 1858 clearly distinguished the simple inflammatory and the gummatous lesions of syphilis and showed for the first time the part played by this disease in producing inflammatory conditions of the most varied organs and tissues. This article really laid the foundation for the modern knowledge of the pathology of syphilis obtained since the spirochete was discovered. But his separation of syphilitic lesions into the two types made little impression upon the syphilology of the next 40 years. As the relationship of tabes and paresis to syphilis became more evident during the next two decades the conception of "post syphilitic," " metasyphilitic," and " parasyphilitic " processes arose in explanation of this relationship. Fournier was chiefly responsible No. 1. 115 GENERAL MEDICINE. for the use of this term and for the view that a large number of pathologic conditions bore a definite relationship to syphilis, but were not syphilis and were not necessarily caused by it. With the discovery of the etiologic agent of syphilis in 1903, it was to be expected that a change would take place in our concepts of the pathology of the disease. Parasyphilis has disappeared as the various parasyphilitic affections have been shown to be active syphilis with living spirochetes still present in the affected tissues. The author has demonstrated that the gumma is not the type of lesion of late or latent syphilis, and that the viscera are involved in all cases of latent syphilis, not by gummatous processes, but by specific inflammatory processes, eventually fibrosis, usually mild in character, but acquiring pathologic importance because of their pro gressive character. In studying the pathology of congenital syphilis, the author has shown the constant presence of spirochetes in the hearts of cases of congenital syphilis dying before or at birth, the occurrence of focal fatty changes in the myocardium due to the colonization of the organism, and of a specific type of interstitial myocarditis due to the same cause. In acquired syphilis it was not possible to demonstrate the presence of spirochetes so readily, but the demonstration of the organism was successful in such a large number of cases as to make the specific syphilitic nature certain. In the progress of these studies the author found specific inflam matory lesions of spirochete localization in the myo-, endo-, and peri cardium, the large arteries, nervous system, liver, pancreas, adrenals, testis, prostate, prevertebral, and mesenteric tissues. These lesions vary greatly in size from minute collections of cells to larger infiltra tions just visible to the naked eye. Every stage of development, from early active lesions to complete healing and fibrosis was ob served; but no case was found in which there was no active lesion. Complete healing throughout the body was never observed. The author gives a detailed description of the lesions of latent syphilis in the various tissues of the body. In the nervous system the most constant changes were those found in the meninges. In practically every case of latent or clinical syphilis autopsied some degree of thickening of the meninges was found. Focal infiltrations of lymphocytes and plasma cells were found in both brain and cord in cases not regarded clinically as paresis or tabes. The character of these minute scattered lesions is precisely identical with those found in the brain and cord, in paresis "and tabes, the difference being only those of number and degree. This raises the question as to whether every case of syphilis is not, 116 GENEBAL MEDICINE. Vol. XIII. to a slight degree, at least, a paretic or a tabetic. Similar infiltra tions were frequently found in and about the spinal ganglia, spinal nerves, and the sympathetic nerves and ganglia. The heart in every case showed microscopic lesions characteristic of spirochete localization, and in this organ more frequently than in any other has the spirochete been demonstrated. The essential lesion of cardiac syphilis is an interstitial myocarditis characterized by in filtrations of lymphocytes and plasma cells along the vessels between the muscle fibers. All of the author's cases of angina pectoris were syphilitic. Clinically these heart lesions showed disturbance of rhythm of every variety. " Functional " murmurs were common. The clinical picture in all was that of an insufficient heart. The majority died a cardiac death as shown by hypertrophy and dilatation of the heart, and the chronic passive congestion of lungs and other organs. The chief pathological findings at autopsy were those of myocardial in sufficiency ("fibroid heart") without, in the great majority of cases, accompanying valvular lesions. The aorta when examined microscopically showed in every case of old syphilis characteristic syphilitic infiltrations in its media and adventitia. The author insists that no positive exclusion of syphilis of the aorta can be made without a microscopic examination. The pancreas in all of the old cases of syphilis showed a greater or less degree of atrophy and interstitial fibrosis. Syphilitic pan creatitis may be a common cause of diabetes. The adrenals showed characteristic infiltrations of plasma cells and lymphocytes in all cases of known and latent syphilis. The liver showed chronic passive congestion and atrophy in every case. In all male cases the testes showed varying degrees of atrophy and fibrosis; many of the cases had complained of premature loss of sexual desire. Changes in the kidneys were found in practically all cases. The proportion of cases of chronic parenchymatous nephritis was very striking. It appears then that syphilis as a latent infection is much com moner than generally supposed and the author estimates that about one-tenth of all deaths occurring in the United States can be attrib uted to syphilis. It is further evident that infection with syphilis means spirochete carrying in many, if not all cases. The spirochete carrier is immune to new infection only as long as he carries spirochetes. The author states that he has never seen pathologically a cured case of syphilis. Ne. l. 117 MENTAL AND NERVOUS DISEASES. The syphilitic is pathologically " damaged goods," and the damage is a progressive one. The author arrives at the following conclusions : 1. The gumma is not the essential typical lesion of old or latent syphilis. It is a relatively rare formation; and the great majority of cases of syphilis run their course without the formation of gum matous granulomata. 2. The new pathology of syphilis is based upon the demonstration that the essential tissue lesion of either late or latent syphilis is an irritative or inflammatory process, usually mild in degree, charac terized by lymphocytic and plasma-cell infiltrations in the stroma, particularly about the blood vessels and lymphatics, slight tissue proliferations, eventually fibrosis, and atrophy or degeneration of the parenchyma. 3. These mild inflammatory reactions are due to the localizations in the tissues of relatively avirulent spirochetes. 4. Syphilitic inflammations of this type occur in all tissues and organs, but are most easily recognized in the nervous system, heart, aorta, pancreas, adrenals, and testes. 5. The syphilitic is a spirochete carrier. In this respect the spirocheta pallida is to be classed with the trypanosome, the malarial organisms, lepra and tubercle bacilli, streptococcus, etc. 6. Syphilis tends to become a mild process, but at any time the partnership between the body and the spirochete may become dis turbed and tissue susceptibility or virulence of the spirochete become increased so that the disease again appears above the clinical horizon. 7. Immunity in syphilis depends upon the carrying of the spiro chete. A price is paid for this immunity in the form of the defensive inflammatory lesions previously described. 8. Syphilitic death occurs most frequently in males between the ages of 40 and 60. Chronic myocarditis is the most common form of death due to syphilis. 9. The pathologic diagnosis of syphilis is essentially microscopic. Only in a relatively small number of cases are the gross lesions (tabes, gumma, aortitis, etc.) typical enough to be recognized by the naked eye. (W.A.B.) MENTAL AND NERVOUS DISEASES. Rogers, A. W. The relation of the temperament to the psychoses. Wisconsin Med. Jour. September, 1918. The author adverts to the history of the classification of tempera ments and holds that we have advanced considerably beyond the point where varieties of temperament were restricted to the san 118 MENTAL AND NEEVOUS DISEASES. Vol. XIII. guine, the lymphatic, the bilious, and melancholic and he declares that the extreme optimist is just as incapable of forming sound judgments on any proposition in life as the pessimist. The extreme optimist inclines to egotism and recognizes no difficulty as unsur- mountable. When people of this type are patients, while their phy sical functions may be excellent, in other respects they incline to vascular disturbance which manifests itself in mild cerebral conges tion and the tendency to insomnia. Just as the men of sanguine temperament may develop periodic states of exaltation, so men of pessimistic temperaments have states of undue uneasiness and de pression. These individuals tire easily and will be bothered by de pressing dreams whose effects extend into the waking hours. They are discouraged by trifles and are overwhelmed by events which the average person meets with pleasure. In this type there are alter nating varieties of depression and exhilaration with an intervening period of normality in between. Temperament and personality not only influence the functional psychoses but play a part in the de velopment of the organic mental disturbance known as paresis, though this form of insanity is invariably due to syphilis. Temperament plays a large part in the development of the psy- choneuroses of war.' The author cites a series of 100 cases of war psychoneuroses and of 100 cases of somatic injuries produced on the firing line. In 74 per cent of the first series the family history of neurotic or psychotic stigmata, including insanity, epilepsy, alco holism and nervousness was obtained. In 72 per cent of that series the patients themselves gave evidence of a very neuropathic con dition. The author concludes his interesting paper with the declaration that while heredity plays a permanent part in temperament, parents, teachers and physicians can do much to mold the individual make up by proper training and education. Kennedy, F., Salmon, T. W., Roussey. G., Holmks, G., and Marie, P. War neu roses. War Medicine, Am. Red Cross, Paris, August, 1918. In the able report of the meeting of the Research Society of the American Red Cross in France, June 28-29, 1918, published in No. 1, vol. 2 (August, 1918), of War Medicine, there is an interesting symposium on war neuroses. Major Foster Kennedy, R. A. M. C, criticizes the term " shell shock " as inaccurate and misleading and calculated to do harm, as conferring a brevet of respectability on symptoms which though not necessarily blameworthy actually represent a certain degree of inferiority from the point of view of military efficiency. He admits the extreme difficulty in many cases of positively excluding a minor coexistent physical injury, but points No. 1. 119 MENTAL AND NERVOUS DISEASES. out the extreme rarity of generalized psychoneuroses in soldiers suffering from gross physical wounds. In the normal soldier fear is consciously or unconsciously submerged beneath loyalty to officers, regiment, and nation, dominated by ideals. In the victim of so-called " shell shock " personal considerations have obtruded themselves through and obscured the gregarious instinct. Maj. Kennedy holds that the distinct interval so common between the date of the sup posed physical injury and the manifestation of the symptoms under discussion proves the psychogenetic character of those symptoms and points out how readily unwise suggestion from medical officers may tend to originate or perpetuate somatic symptoms of psychic origin. He points out that among enlisted men a single external catastrophe is the exciting cause of psychic manifestations, whereas in officers these are more often the result of prolonged strain and mental con flict. He lays stress on the extreme importance of accurate technical knowledge on the part of the medical attendant. Suggestion plays so important a role in the disorder under discussion that any doubt on the part of the medical officer as to whether he is handling an organic or a functional trouble is sure to be reflected in the patient and tends to intensify the nervous weakness. Therefore the first step in curative treatment of these cases is a definite and positive diagnosis. This strengthens the hand of the physician and contributes in no small degree to restoration of inhibitory power in the patient. Maj. Kennedy rejects the term " hysteria " as unsuitable because it has a different meaning for patients and doctors. He favors the use of the simple word " nervousness " to designate all neurotic manifes tations seen in war, and believes that such a term would appeal to the sense of discipline in armies and by promoting proper public opinion would be of prophylactic and therapeutic value. The diag nosis would be divided into " nervousness (sick) " and " nervousness (wounded)." In conclusion the author alludes to the physical changes, such as disturbed cardiac rhythm, dyspnea, and reduced alkalinity of the blood, which often accompany violent emotional disturbances. Lieutenant Colonel Salmon, Medical Reserve Corps, United States Army, spoke of the importance of (1) a rational attitude toward these disorders on the part of the medical officers, line officers, enlisted men, and the general public; (2) careful selection of the human material brought across the Atlantic for the war; (3) determination that everything undertaken at this time shall aim not to prove or dis prove a theory but to restore or conserve fighting men for the line. He recognizes the importance of having patients suffering from war neuroses reach the hands of experts in the earliest stages and the danger which attends the admission of such cases to the general wards of a hospital. When patients are ready to return to their 120 MENTAL AND NEEVOUS DISEASES. VoL XIII. organizations or detained after cure through administrative reasons, it is undesirable to have them transferred to ordinary convalescent camps, as there is then a tendency to recrudescence of symptoms. Major G. Rousey (professor in the Faculty of Medicine of Paris), speaking of the psychoneurological disturbances affecting the limbs during war, adverted to the reflex disturbances associated with secondary phenomena, which may be considered as phases of hysteria. They develop in subjects who give evidence of a special psychic condition which existed previously or else was acquired or accentuated by the actual circumstances under which they lived at the time of the disturbances. This psychic condition gives rise, on the occurrence of traumatism or some other slight commonplace factor, to the appearance of motor disturbance of a hysterical nature. Should such an influence be exerted on a limb whose circulation is normal or without incurable muscular lesions the motor trouble may be the only symptom, and it is pithiatic. If, on the contrary, it develops in a previously abnormal circulatory field acquired or accentuated by military life, it may give rise to secondary phenomena. Lieutenant Colonel Gordon Holmes, R. A. M. C, speaking on the treatment and management of the psychoneuroses in armies, dwelt on the serious waste of man power liable to occur if steps are not taken ( 1 ) to check the development of neuroses; (2) to relieve with promptness the functional and nervous symptoms which appear. After showing the importance of this subject from the point of view of society, and the likelihood that many of the cases of war neuroses returning to civil life will become social parasites and lay a heavy moral and financial burden on the country, he quotes a statement made in the British Parliament to the effect that more than 20,000 men have been invalided from British armies with so-called " shell shock." A large proportion of these men were evacuated from the army before it was generally recognized that early and vigorous treatment under rigid military discipline is indispensable. The proportion of recoveries is smaller when active therapy is delayed. In 1916 neurological centers were established in army areas and as near the front as safety per mitted to enable treatment to be given before the symptoms became fixed and organized. This permits of prompt return to fighting units. When patients pass through a series of hospitals and con valescent camps and come under the care of officers not fully ac quainted with their previous conditions a recurrence or remission of symptoms is likely. Cases of slight concussion, though they may be abnormally emotional and present the symptoms common to concus sion, usually require only a brief period of rest and light duty under the medical officer's direct supervision. If instead they are herded among men with severe neurotic manifestations they are liable No. 1. 121 MENTAL AND NEHVOUS DISEASES. through subconscious minicry to imitate their associates and develop the symptoms suggested by them or their surroundings. Prof. Pierre Marie inclined to a slightly different view from that propounded by the English and American speakers. He said that in the first year of the war French neurologists had inclined to consider war neurosis without concomitant mark or injury on some part of the body, especially the skull, as an indication of malingering or at least of the refusal on the part of the soldier to meet his full obligations. A wider range of view had led to the opinion that cases of commotion might be neither neuropaths nor malingerers. Marie believes that without any local lesions commotion may be caused by organic altera tions of the nervous centers which can be observed by such clinical methods as lumbar puncture. The spinal fluid may or may not con tain blood. The albumen content may be increased or the number of cells reduced. In a considerable number of cases there is a slight tendency to hyperglucosis. He believes in the existence of a diffuse micro-traumatism, that is a traumatism involving only the micro scopic elements. Db Fubsac. J. R. Traumatic and emotional psychoses. Am. Jour. Insan. July, 1918. The following paragraphs are quoted from this valuable article: " Traumatic psychoses " and " mental disorders supervening at the occasion of traumatism " are not the same. It is proper * * * to exclude those post-traumatic mental disorders which, by reason of their clinical manifestations or a char acteristic morbid anotomy, find their place in a definite pathological group, such as general paralysis, dementia precox, or a constitu tional psychopathic state. In such cases we are dealing not with traumatic psychoses but with general paralysis, dementia precox, or a constitutional psychopathic state in the etiology of which the trau matism has played a part the importance of which is variable and for the most part merely contributory and indirect. It has, however, also been customary to include among traumatic psychoses the many cases in which mental disorders have broken out after a traumatism which is in itself but slight, perhaps insig nificant, but which is accompanied by an intense emotional shock. This is an abuse of language. The effectual cause here is the emo tional shock. The physical trauma is nothing; the psychic trauma— to use an expression which is more than a mere figure of rhetoric- is everything. This is true to the extent that mental disorders ob served in cases of this sort are identical in nature, in severity, and in their course with those known to be produced by a violent emotion acting alone, i. e., independently of any somatic injury. The term 88977—18 9 122 MENTAL AND NERVOUS DISEASES. Vol. XIII. " traumatic psychoses " in application to these cases is, therefore, in appropriate and should be replaced by the term "emotional psy choses." Emotional war psychoses (so-coMed shell shock). —Explosions oi projectiles or mines are capable of producing in subjects, showing outwardly no wounds or only insignificant wounds, neuropsychic symptoms more or less severe and lasting. The cases of this sort fall into three groups. In the first group, the soldier is thrown by the explosion, with a resulting injury to the brain, either by fracture of the skull or by concussion, direct or indirect. The explosion has simply played the part of an agent of propulsion. The neuropsychic symptoms pre sent no special character and vary according to the lesion which has been produced. In the second group there is no external violence. The subject presents signs of a cerebral or spinal lesion, generally a paralysis (hemiplegia, monoplegia, paraplegia). Lumbar puncture reveals the presence of blood in the cerebro-spinal fluid. One deals hen. with a hemorrhage in the central nervous system, which must be con sidered a direct effect of the explosion, that is to say, of the changes of atmospheric pressure resulting from the enormous liberation of gases produced by the instantaneous combustion of the explosive substance. It is not the same with cases in the third group, which is by far the largest. Here there is no external violence, no hemorrhage, no sign whatever of any organic lesion. The victim of the explosion, generally an excessively emotional subject, exhausted by the hard ships of the campaign, perhaps just recovered from a more or less severe illness, loses consciousness. For two or three days he remains in a state of confusion, most often accompanied by dreams. Then he becomes lucid, but remains asthenic, emotional, living over again in his dreams his past terrors, and complaining of headaches and dizzi ness. This state may disappear in a few days, or it may persist for weeks or months, with or without complicating functional symptoms centering upon some organ, region, or function (deaf-mutism, par alyses, contractures). These conditions, of which some have tried to make a sort of psychosis peculiar to war, were at first attributed to cerebral or cerebro-spinal concussion, hence the expression " shell shock," by which they have been designated. This interpretation is erroneous and the concept of concussion in relation to cases of this sort inappropriate. The explosion has not only physical effects, but also a psychic one, which consists in an emotional shock. In certain cases this emotional shock dominates the situation to the point of being alone responsible for the neuropsychic symptoms which a hasty and super No. 1. 123 MENTAL AND NEBVOUS DISEASES. ficial consideration at first placed in relation to cerebral concussion ; and it is because both give rise to an emotional shock that the ex plosion of a shell and a terrifying sight find expression in the same syndrome. The war psychoses which have been called shell shock are nothing but emotional psychoses, and they might best be studied under the name " emotional war psychoses." The etiology of emotional war psychoses comprises, accordingly,, all the factors capable of producing an emotional shock : Explosions- of projectiles (shells, bombs, aerial torpedoes, hand grenades), mines, ammunition stores; terrifying sights (cadavers, conflagra tions, etc.) ; imminence of danger; death of comrades; and injuries (wounds, contusions, sometimes concussion in the correct sense of the word) , for the most part not of a serious nature. These different factors, whether acting alone or in combination, show no efficacy except as they light upon a soil prepared in advance to undergo their action, a predisposed soil. The predisposition re sults most often from a constitutional defect consisting in emotional instability. "The individuals destined for shell shock are, before all, the emotionally unstable in whom the constitutional peculiarity has mostly manifested itself in their lives at occasions of painful emotion, and who react to events of the war as they have reacted to events of ordinary life, but in a manner infinitely more intense, be cause the excitants are infinitely more powerful." In the mild cases the symptomatology of emotional war psychoses is reduced to a brief dazed period; the subject is for a moment stunned, dull, inert, speaking in monosyllables, his voice scarcely audible, articulation indistinct and hesitating. At the end of a few hours, sometimes one or two days, of rest he returns to his usual condition. Where the disorder assumes a certain gravity one can distinguish, as in ordinary emotional psychoses, two phases: The first, acute (phase of confusion), the second, subacute (psychasthenic phase). The natural course of emotional war psychoses, as of emotional psychoses in general, is toward recovery. It is necessary, however, to make some reservations. I have seen, in four cases, chronic psychoses follow an explosion of a projectile or a mine: two general paretic syndromes, classical in their clinical manifestations, one dementia prsecox, and one chronic hallucinatory psychosis. It is quite possible that in cases of this sort we are dealing with simple coincidences. An individual about to develop general paresis, dementia prsecox, or a chronic hal lucinatory psychoses may, like any other, become the victim of a shell explosion and show emotional phemonena. As the latter dis appear, the signs of the chronic psychosis appear and develop. If 124 . MENTAL AND NERVOUS DISEASES. Vol. XIII. the explosion has played a part in the etiology, it is infinitely prob able that the part is but a contributory one. It has but opened the way for a morbid process long prepared either by an infection (syphilis) or by a constitutional predisposition, or by any other pathogenic factor. " * * * Nothing in all that we know of the etiology of mental diseases would justify the proposition that a purely emotional shock or an explosion could have for its consequence general paresis, demen tia praecox, or a chronic hallucinatory psychosis. One might at most attribute to it the value of a contributing cause, but one could go no further than that. It is conceivable that an emotional war psychosis, like an ordinary emotional psychosis, might develop into a delusional state centering about a prevailing fixed idea. In such a case the idea of damage sus tained through an explosion or any other cause would become the fundamental fixed idea upon which the delusional state would de velop. I have as yet not met with a case of this sort and I know of none published in the literature. But it would surprise me if such cases did not develop. It is probable that they will be seen spring ing up after the cessation of hostilities. Finally, it should be recognized that there are patients in whom the syndrome characteristic of the second period lasts a year or longer. I know a case of emotional psychosis—by purely emotional shock—which has lasted over two years without any appreciable improvement or change. Is it, then, possible for the course of emo tional war psychoses to be toward incurability ? I should withhold an affirmative answer. I should even say that I do not believe it. There exists at the present time a factor by which the prognosis of emotional war psychoses is radically biased ; it is the war itself. The prospect of returning to the front constitutes, for many of the emo tionally unstable, an obstacle to recovery of such power that it is im possible to say if it alone might not suffice to keep up the neuro- psychic symptoms and to impart to the disease the appearance of chronicity which has been noted in some cases. The fate of these patients will not be settled until peace has been signed. The treatment varies, naturally, according to whether the disease is in its first or second phase. In the first phase, rest in bed, quiet, reconstructive medication. The treatment here suggests itself. The indications are not so simple in the second phase, which we have designated the psychasthenic period. At first these patients were treated like ordinary psychoneuras- thenics ; that is to say, medically, utilizing all the dietetic, medicinal, and physical therapeutic resources available to medical art. Now, it No. 1. 125 MENTAL AND NERVOUS DISEASES. has happened that in the medical organizations at the front, where the equipment is necessarily meager, the patients recovered rapidly and, in the majority of cases, were at the end of a few days well enough to rejoin their company ; whereas in the hospital units in the rear, which are far more completely equipped, in spite of diets, douches, and electric currents of all forms and all strengths, the symptoms dragged on tediously, the patients remaining months in the hospital and often, after a cure obtained with difficulty, relapsing either in the course of convalescence or shortly after return to duty. This experience has been constant and, though apparently paradox ical, is readily explained. First of all, that which has been found in ordinary emotional (pseudo-traumatic) psychoses holds true for these victims of the war. A treatment which is too medical, if not followed by prompt and notable improvement, results in anchoring in the mind of the patient the notion of a grave pathological condition and in the development of hypochondriacal tendencies which are so often a part of the emo tional syndrome, whether the latter be due to a common occurrence in ordinary life or to an event of the war. The idea of a grave patho logical condition becomes quite naturally associated with the idea of damage sustained for the future as well as for the present ; and just as a subject of an accident in times of peace can become obsessed with the preoccupation with indemnity to be turned over to him, so the subject of a war accident, exaggerating, like the first, his physical and mental damage, worries about the future, is often upheld in his hypochon driasis by ill-applied commiseration of those about him and the more or less interested pessimism of his relatives, and ends by hypnotizing himself with thoughts of retirement and pension; these then become obstacles to recovery, and in this way develops a sinister war case, in every way comparable with the sinister cases of ordinary accidents. But aside from factors causing aggravation or preventing recov ery, which are common to all sinister cases of whatever origin, we nave to consider, in connection with emotional war psychoses, a fac tor peculiar to them alone. Recovery means more or less prompt return to the trenches. This prospect appears natural to the soldier who has remained at the front. It is otherwise with the one who has been evacuated to the interior. " By keeping the patient at the front one leaves him in the atmosphere of a combatant, in contact with the features which impart to this atmosphere its peculiar char acter—simplicity, and sometimes" even restricted conditions of mate rial existence, rigid discipline, close proximity of danger. He re mains in the environment to which he has more or less fully be come adapted. By evacuating him to the interior one breaks this contact and destroys the adaptation. When, upon recovery, he re 126 Vol. XIII. MENTAL AND NERVOUS DISEASES. turns to the trenches, he has to readapt himself. One can conceive how this readaptation. painful for many, may prove impossible for some. It will prove impossible, notably for the emotionally unstable, in whom a morbid imagination stirs up. amplifies immeasurably, and converts into obsession tragic spectacles of the war, causes him to live over again the fears once experienced, and projects into the future the terrors of the past. This is true of the graver cases of '•shell shock" and explains the fact that recurrences occur almost always at the end of convalescence or shortly after returning to quar ters, yet without one being thereby justified in speaking of simula tion. The subject sees himself on the way back to the trenches, and. owing to an emotional and imaginative erethism, this perspective revives the elements of the shell shock syndrome." Accordingly, subjects affected with emotional psychoses should be kept on psychiatric services at the front. The confused phase once passed, and the patient having become lucid and accessible to favor able suggestion, he must be convinced that he is due to get well, and that because he is due to get well he is not evacuated to the interior. This psychic therapy, associated where necessary with medication or such physical therapeutic means as may be available under the conditions (cacodylate in general weakness, electricity in deaf- mutism, paralysis, and all other pithiatic manifestations), will lead to a rapid recovery and an early return of the soldier to his company. Nevertheless there will always remain a certain number of sub jects who, by reason of a particularly marked emotional instability, will not get well quickly. The first indication in these cases is to segregate them from the others, oh whom they can have but a de plorable influence, or if their isolation is not readily practicable, to evacuate them. The hospitals in the interior will, consequently, continue to receive victims of emotional shock. They should be treated as patients, but as nervous patients, subject to military discipline, and not as insane and irresponsible for their acts. In the interior, as at the front, the principal part in the treatment falls to psychotherapy. The patient must be convinced that the symptoms which he presents are curable, quickly curable; he must be made to note the progress he has made: and he should be granted the privileges he asks (visits, walks, participation in common amuse ments, etc.) only as rewards for further progress, and, as the crown ing reward for complete recovery, a' real convalescence. One should avoid, as the worst danger, giving him a glimpse of the possibility of retirement, especially retirement on a pension —this would but switch him on a sinister course. No. I. 127 MENTAL AND NERVOUS DISEASES. The patient, as has been said, should remain a soldier, subject to discipline. He should keep his uniform and should maintain a cor rect bearing. He should remain in touch with superiors, toward whom he should observe the same deference as if he were normal. Finally, as was very properly recommended by Grasset. he will gradually be placed on the road back to a soldier's life by being made to take part in military drill in formation under command of noncommissioned officers. This military therapy—the association of these two words has nothing in it that is shocking—is essential. It is enough that the soldier has lost his adaptation to life at the front. It would be a grave error to let him lose also his adaptation to military life. When the pathological condition has lasted many months, when the emotional balance remains gravely affected, and when hope of an early cure has to be given up. what course should be taken? Retirement should not be considered. * * * the patient must * * * be kept in the Army. But he must also be elimi nated from hospital wards, where his presence constitutes for the really sick a cause of discouragement and for the others encourage ment in persisting. What. then, should be done? Certain subjects when sufficiently improved, can be transferred to the auxiliary troops. This solution commends itself particularly for the older retired men or men of the old auxiliary troops who have been— though to but a slight extent —brought into the service of the Army. For the others, for those who retain grave symptoms and must still be in institutions, it will be best to provide services for chronics, a sort of lazarettos, where they might be kept until a solution for their case might become available; that, is to say, until the end of the war. However, it is probable that if not more than a minimum of the emotional psychoses are evacuated into the interior, and, if, in the hospitals which receive this small number, the authorities will pro ceed with firmness and prudence, this remnant of incurables or, more correctly, pseudo-incurable, will be quite limited. Payne, C. R.. and .Telliffe. S. K. War neuroses. Jour. Nerv. and Ment. Dis., September, 1918. The authors, in the course of an article on war neuroses and psy- choneuroses, call attention to the fact that new types of wounds and casualties in war, due to new types of weapons and new methods of attack, have lead to new methods of treatment and new surgical pro cedures designed to cure, and they call upon specialists in diseases of the nervous system to rise in a similar way to the demands of the situation to-day and develop curative treatment for mental and nervous cases, since the time has passed when the community would 128 Vol. XIII. MENTAL AND NERVOUS DISEASES. consent to the presence in its midst of cases of this type as though it were proper to pass them over untreated as mere anomalies, while men who had suffered loss of a limb or some mutilating wound were made the recipients of the most painstaking attention. They call attention to the fact that '; in one sense the war has presented no new problems in this element." "Though there are no new forms of psychic disturbances there are these causes of many varieties, which do not exist in times of peace, when often a latent psychoneurotic disposition is not brought to the test and the danger of such a breakdown has been quite ob scured. These special and very trying situations produce sometimes marked psychoses but often of a curable nature, because they repre sent only inability to adjust to such extraordinary demands and con ditions and to withstand their constant pressure. It is so also with the psychoneuroses many times. They, too, represent not a chronic nonadaptability and nonresistance, even a latent one, but rather fail ure only temporary and more easily readjustable to withstand in the face of cumulatively trying conditions." They very pertinently suggest that " Perhaps something could be done in our training camps to establish a better psychic adaptability and an increased resistance power. Of course all the physical train ing tends to that, but reports prove that it has not always been well regulated to that end. It has sometimes tended in just the opposite direction." Cobe, D. E. "Instinct Distortion" or "War Neurosis." Lancet, London. Au gust 10, 1918. The distinction is made between functional nervous disorders due to environment and those which are not. Hysteria and war neurosis belong to the former category. Neurasthenia or functional nervous disorder brought about by exposure of the nerve cells to prolonged poisoning by the products of microorganisms and certain reflex neu roses belong to the latter. Under the strain of modern warfare two emotions are called into frequent violent activity, the emotions of fear and disgust. These emotions are sudden and intense and insist upon being given free play, but are forbidden both by the idealistic conceptions acquired during childhood and early life and by the vigorous punishment they would receive from one's fellowmen. In modern warfare men constantly face hazards which render death almost a certainty. Normally constituted men then experience fear and under ideal conditions of such a position would run away. How ever, self-respect and military discipline prevent this normal end result and men proceed to fight in direct disobedience to their in stinct. The emotion of savage anger against the adversay would be No. 1. 129 MENTAL AND NERVOUS DISEASES. helpful if it were felt with any intensity. Disgust at the unaccus tomed sights and sounds of conflict is not allowed to manifest itself so that under its conditions the main powerful instinctive activities are distorted. The author accepts MacDougall's classification of the seven pri mary instincts, but considers that they should not be separated by any hard and fast line. These instincts are : 1. The instinct to run away under the emotion of fear. 2. The instinct to fight under the emotion of anger. 3. The instinct of repulsion under the emotion of disgust. 4. The instinct of curiosity under the emotion of wonder. 5. The instinct of self-abasement under the emotion of subjection. 6. The instinct of self-assertion under the emotion of elation. 7. The parental instinct under the emotion of tenderness. These seven primary instincts may be divided into two groups, the impressions of one group reinforcing each other and antagoniz ing those of the other group. • In one of these groups may be placed the emotions of fear, disgust, and self-abasement with their associ ated impulses; in the other anger, self-assertion, wonder, and tender ness. The sense of inferiority, combined with disgust, strengthens fear and the emotion to run away. On the other hand, fear may be diminished by anger and the sense of superiority, and now the tend ency of modern war is to give play to the emotions of the first group without developing those of the second and to produce emotional tone without the associated impulses. It is harmful to the proper functioning of the nervous system and liable to produce functional disorders of this system to suppress the emotion which normally should follow its associated impulses. The author makes the interesting observation that while normally the conative aspect of an instinct follows the emotional aspect, it is equally true that the performance of appropriate action tends to produce the associated emotion. The clenching of the hands and the setting of the teeth help to induce the feeling of anger. He asserts that patients suffering from war neuroses have always, at one time or another, experienced fear. In the early, untreated, and acute ;ases the fear may be obvious and openly expressed. As the patient improves, fear is present only during sleep and the terror dreams are an important factor in the case. A relatively different type of case was observed in Mesopotamia and in India in 1916. It was characterized by complete indifference to surroundings and current events. The mental state was one of dullness and inertia. The sufferers from this form of neurosis were the victims of monotony and routine; of the deadness of country, camp, occupation, and food. Here the emotion of wonder in the instinct to curiosity had been in complete abeyance. 130 MENTAL AND NERVOUS DISEASES. VoL XIII. The: author makes these distinctions between hysteria and war hysteria and war neurosis. Clinical manifestations of hysteria re sult from the improper suppression of a tendency inherent in every one and determined by our position in the scale of evolution; it is manifested as the result of an emotional activity which is normal as far as the emotion is concerned. War neuroses, on the other hand, follow the improper strain on the emotions themselves, causing the wrong emotional tone and disturbing the bodily mechanism which is associated with the conative aspect proper to the emotion con cerned. The diagnosis of instinct distortion or war neurosis is usually easy. It may be made in the case of any patient without organic disease who shows symptoms of nerve irritability and in whom also the element of fear is or has been present. Where distortions of nerve irritability exist and there are no signs of fear, either in the waking hours or in dreams, the war neurosis is in the late or habit stage and the terror dreams were present at the beginning of the illness. If no such history is obtainable the case is one of sugges tion-hysteria. The treatment of instinct-distortion neurosis is simpler and more successful than the treatment of hysteria because with the latter one treats symptoms, but the underlying hysterical conditions con tinue through the patient's lifetime. The harmony of the nervous system can usually be restored without much difficulty, provided the symptoms have been corrected before the distortion has amounted to the magnitude of habit. This point emphasizes the necessity of early treatment. When all ideas of war as an imminent factor have disappeared the more troublesome of these symptoms will be done away with and the patient will become a useful individual in his surroundings. The patient should be removed from the fighting area, and he must be impressed from the start by the assertion that his ultimate recovery is certain. When he has arrived at the ultimate base the patient should be put to bed in a quiet ward, preferably in company with two or three other patients while the active stage continues. The writer employs trional with or without aspirin to promote sleep. The medical attendant should see the patient fre quently, and at each visit should reiterate the assurance of complete recovery. With the first signs of improvement convince the patient, that he still has power in his legs by making him take a few steps every day. As insomnia passes and the dreams become less painful the patient should leave the ward each day and begin to mix with other patients. By this time special measures should be instituted to correct special defects, such as disorders of gait, tremors, dis ordered speech, and mental depression. These require carefully No. 1. 131 SURGERY. regulated exercises and reeducation. For the mental depression "therapeutic conversations" are indicated. In the "therapeutic conversations" the atmosphere of "doctor and patient" should be in abeyance. Tact and ingenuity should be used. It is usually not hard to discover what the patient has on his mind. Many sources of worry are irremovable, but depression due to obtrusive symptoms can often be removed by occupation in experimental workshops. To convince the patient that he is not utterly disabled always lessens the depression. Graduated exercises offer the best hope' in cases of rapid heart action and other affections of the sympathetic system. SURGERY. Baixeuil, L. C, and Jack. W. D. Fascial transplants in war surgery. Ann. Surg. July, 1918. The authors call attention to the use of fascial transplants for repair of deformities, the result of fibrous overgrowth following wounds attended with much tissue destruction, whether traumatic or from infection. They report 50 cases operated on successfully, in cluding painful adherent scars of the extremities (with and without involvement of the muscle tissue and tendons), muscle hernias, and a hernia of the synovial membrane at the knee joint. The authors have also applied grafts to the dura, and they consider the method suited to all classes of plastic surgery. The operation is divided into four steps : * JL The resection of the scar. 2. The liberation of the muscles and the margins of its aponeurosis. 8. The cutting of the graft, its application and fixation. 4. The reconstruction of the subcutaneous tissues and skin. The scar and all unsound tissue are completely excised ; the muscle is freed from its fascia. A graft of suitable size is obtained from the fascia lata, which is reached through an incision along the outer aspect of the thigh 28-30 em. in length. This is placed in a sponge soaked with warm saline, while the fascia lata is united with mattress sutures of catgut, and the skin is sutured. The graft is anchored in the fascial breach by sutures of 00 catgut at four points, after which it is united all around by a continuous suture of the same catgut, and the subcutaneous tissues and skin are united by ordinary methods. The part is immobilized in plaster for ut lecst 10 days. A number of cases are reported in detail, with illustrations of the different stages. (R. H. B.) 132 Vol. XIII. SURGERY. Chloralose as a general anesthetic. Dr. W. F. Durand, scientific attache of the American Embassy, Paris, reports that at a recent meeting of the French Academy of Sciences Dr. Charles Kichert presented a paper detailing his experi ences with chloralose as an anesthetic especially available for use in cases of traumatic shock or extreme weakness resulting from loss of blood. In 1893, in conjunction with M. Henriot, Richert brought forward a new substance, which he designated chloralose, obtained by com bining glucose with anhydrous chloral, and he established the fact that it possesses special hypnotic properties in doses much smaller than were needed to produce sleep with chloral, while its use by intravenous injection caused prolonged general anesthesia. This substance came into more or less general use for the production of anesthesia in animals used in laboratories, because it did not eliminate the reflexes, diminish the force of the heart, or lower arterial tension. In 1894 A. Pinard gave it to some of his patients to relieve the pains of labor without impairing the contractile power of the uterus. Absorption in the digestive tract is so slow and irregu lar that results were not very satisfactory when chloralose was given by the mouth. Recently Richert has employed chloralose in 50 cases to produce general anesthesia for surgical operations. The chlora lose is given in saline solution with or without the addition of very minute quantities of chloral and sodium bromide. The ordinary injection is made in a vein of arm or foot. The solution consists of 7.91 grams to the liter of common salt and 6 grams to the liter of chloralose. About 350 cubic centimeters, a total of 2.1 grams of chloralose, may safely be given. Doses of 2.5 and 2.75 grams of chloralose have been given, and 3 grams represent the maximum dose for safety. The injection is made in the usual manner through a sterile rubber tube, through which the liquid runs slowly, the container not being raised higher than 1 meter above the patient. The fluid enters the vein through a fine metallic needle. The injection should last about six minutes. It causes no pain, nor reac tion, nor discomfort. The patient drops off to sleep without know ing it. At the end of the injection anesthesia is complete. Immo bility is not concomitant with anesthesia. Rhythmic, automatic, choreiform movements are characteristic of the action of chloralose. Half an hour after the injection the movements cease, and it is then time to operate. Sometimes the rhythmic movements do not cease in half an hour, but anesthesia is complete, nevertheless. Thus chloralose has an advantage over other anesthetics that it does not destroy medullar tonicity. It is an advantage to have the reflexes spared and at the same time violent movements may be No. 1. MILITABY, LEGAL AND INDUSTRIAL. 133 checked by the addition of 6 grams of chloral hydrate and 24 grams of anhydrous sodium bromide to each liter of chloralose solution. The patient wakes only at the end of 5 to 8 hours after a profound sleep marked by heavy breathing. He awakes without nausea, headache, or any recollection of pain and showing a good appetite. There is often profuse perspiration. Kichert summarizes the advantages and disadvantages of the new anesthetic. Chloralose is absolutely without toxic effect upon the heart and does not lower arterial pressure, in contradistinction to other anes thetics which weaken the cardiac systole and reduce arterial pres sure. These facts make chloralose peculiarly appropriate for use in operations of great severity or where the patient's condition is alarming from excessive hemorrhage or many and serious wounds (naturally in such cases chloral and bromide of soda are not added). Eichert considers the administration of chloralose without danger, though it may and often is attended with certain inconveniences. In the first place a certain variability in the results has to be ad mitted. Chloralose seems to be in a way an indicator of latent nervous troubles. Sometimes its administration causes extreme agi tation and sometimes absolute calm results. Elderly patients do not stand it so well as young patients. Manifestly when the in travenous injection is complete there is no suspending the prodecure, as in the case of inhaled anesthetics. In 10 to 15 per cent of the cases observed (particularly on patients 50 years of age or more) there is an exaggerated secretion in the nose, pharnyx, etc. There may be spasm of the glottis, labored, difficult breathing, while the tongue tends to fall back into the larynx and fill it up. Breathing is noisy, difficult, and convulsive; the patient inclines to become cyanotic. The large increase of bronchial secretions is an unfortunate feature of its use. However, from the point of view of safety no comparison can be made between an injury to the respiratory system and to the heart. The writer recommends that chloralose, though he considers it harmless, be reserved for very severe cases. MILITARY, LEGAL AND INDUSTRIAL. Amantea, G. A new treatment for lesions due to dichlorethyl sulphide. Poli- clinico, Rome. September 22, 1918. Following extensive study of the subject and experiments both on animals and upon himself with mustard gas, the author reports excel lent results from the use of topical applications of silver nitrate. Without pretending to furnish the chemical formula of the reaction 134 MILITABY, LEGAL AND INDUSTRIAL. . Vol. XIIL that occurs when the two substances are brought together, he believes that the formation of a silver chloride demonstrates the decomposi tion of the yprite and consequent loss of toxic power. This is true whether the skin wet with dichlorethyl sulphide is treated immedi ately or only after a lapse of one to nine hours. Even after the skin is blanched the employment of a silver nitrate solution hinders vesica tion ; if the blistering has begun the process is arrested. Instead of using, as has been done in the past, ether, chloroform, or alcohol to remove the excess of dichlorethyl sulphide, Amantea pre fers to mop the affected part with a cotton sponge soaked in the silver solution, working centripetally from the margins. When the excess of poison has been sponged off, the surface may be painted with silver or sponged with a fresh tuft of moistened cotton. No chlorine-con taining substance should be employed. For ordinary cutaneous surfaces a 3 to 5 per cent aqueous solution is indicated. For lesions of the eyes a solution of -0.25 per cent strength is used to flush them out, or a 1 per cent solution may be cau- 'tiously instilled. Open wounds are treated with these weaker solu tions, and if they are very extensive and deep it may be proper to restrict the silver applications at the margins and introitus. Research Society of the American Red Cross in France. Conference on surgery in battle areas. Session of September 6, 1918. Paris, France. At the meeting of the Research Society of the American Red Cross in France, participated in by representative medical men from the military forces of France, Great Britain, and America, a number of questions wei"e propounded to those in attendance regarding the various problems connected with the handling of the wounded and the answers appended to the questions given below report the con sensus of opinion of the meeting, but many of those present dis agreed with the findings. I. PROBLEMS RELATING TO ORGANIZATION. 1. Personnel of a standard surgical team: (a) Surgeon. (6) Assistant physician. (c) Anesthetist (nurse or M. O.). (d) Two hospital corpsmen. 2. How many tables shall be allotted to each team ? Two. 3. What is the best arrangement of hours for a considerable pull! Twelve-hour shift most practical. 4. What is the best means of transport teams? Nc. I. 135 MILITARY, LEGAL AND INDUSTRIAL. Ambulance. 5. Shall teams furnish any instruments or apparatus? No. 6. What shall be the proportion of X-ray operators? One to three teams. 7. What shall be the proportion of general nurses in the operating room? Two nurses to three or four teams. 8. Shall each surgeon be responsible for the aftercare of his cases ? Ideal, but impossible. 9. Shall there be a day and night chief of surgical service ? Yes. 10. Under whose direction shall the resuscitation team work? Consulting surgeon. 11. Shall abundant reserves of teams be in readiness? Yes. 12. What is the most available type of mobile unit for purely tem porary emergency reinforcement? Field Hospital (American,). Auto-chir (French). Tent section of filed ambulance (British). II. PROBLEMS RELATING TO WAR WOUNDS. 1. In cases suitable for primary closure it has heretofore been agreed that patients should remain under the care of the operating surgeon until there is sound healing. Are there any new facts sug gesting a modification of this principle ? Yes; when possible; but for transportation every wound wide open. 2. If a suturable case must be evacuated and if there is opportunity for making surgical revision before evacuation shall the surgeon in troduce stitches, leaving them untied or shall the wound be left wide open without stitches placed ? Wide open; without sutures, tied or untied. 3. Shall such wounds be protected by dry sterile gauze? Or shall an antiseptic dressing be applied ? If so, what antiseptic ? Dry gauze. No standard antiseptic treatment. The French strongly advocate the gauze dressing. 4. Shall wounds be packed with gauze? No; unless for hemmorrhage. 5. Shall splints be placed on limbs having wounds of the soft parts only? Yes; wounds of nerves and tendons when sutured. 136 MILITABY, LEGAL AND INDUSTRIAL. VoL X1IL 6. Is a bacteriologic examination of the wound required in mak ing primary suture during the period of contamination, which usually lasts from 10 to 12 hours? No. 7. If, owing to rush, no surgical treatment of a wound can be given before evacuation, shall the wound be covered with dry sterile gauze only? Shall any antiseptic be used ? If the latter, what? Dry sterile gauze only. 8. If there is a larger number of wounded than the surgeon can give a complete revision to, shall he give ideal treatment to as many as he can, leaving the remainder of the wounded unaided, or should he distribute his services among all, giving everyone a better chance for survival of life and limb but not a maximum of good result ? Complete in selected cases. Triage must be good —greatest good to greatest numbers. 9. In the latter case would the surgeon take the time to scrub and clean the field, or would he merely make provision against retention of wound secretion, make prophylactic incisions to provide against future tissue tension, deep infection, etc.? No. 10. Shall there be evolved a "battle" technique as well as a " peace warfare " technique ? Yes. 11. In battle stress shall the surgeon with the ripest experience and the most matured judgment do operations, or shall he utilize his experience and judgment in making important decisions; in advanc ing less experienced operators; in directing treatment of critical cases; in deciding the schedule of operating —in short, acting as a surgical manager operating with bis head, not his hands? With Ms head and to superintend triage. 12. Shall the wounded receive morphia? Yes. 13. If inexperienced anesthetists are used in emergency, what method of giving ether anesthesia is safest ? Ether-drop method on gauze. III. PROBLEMS RELATING TO THE LIGHTLY WOUNDED. 1. Shall the lightly wounded be segregated and dealt with inde pendently of the seriously wounded? Yes; v)hen push is on. 2. Shall they be kept in the forward area ? No; unless needed as donors for transfusion. 3. Suggest a Ford-factory plan of dealing with them. Not discussed. No. 1. 137 MILITARY, LEGAL AND INDUSTRIAL. 4. Shall they claim the attention of the best surgeons under the best conditions, or otherwise? No; except for organization. Maonusson, L. Laws regarding illegitimacy in Norway. U. S. Department of Labor, Children's Bureau. The Norwegian illegitimacy law of April 10, 1915, is a radical measure, and the principles laid down in it are in the nature of a return to those recognized in the early folk law of Norway, under which the illegitimate child had a qualified right of inheritance from the father and enjoyed substantially all the legal family rights of the legitimate child. These rights of the illegitimate child were, however, wiped out about the middle of the seventeenth century and were not fully restored and enlarged until the passage of the law of 1915. The most radical change made by this new legislation consists in putting the burden of establishing paternity and fixing the obliga tion of maintenance upon the State instead of upon the mother as under the act of 1892. The mother of an illegitimate child is re quired by law to report the facts to the local authorities, and the court will then summon the alleged father to answer the charges. For the first time an attempt is made to establish paternity as a biological fact, which when established carries with it all the obli gations of legal paternity; failing in this, and merely establishing the fair presumption of paternity, the law puts upon the alleged father the obligation of maintenance or economic support of the mother and the child. Further changes consist in (1) requiring the economic support to accord with the means of the better situated of the parents and not with their average means; (2) extending maintenance until the child has completed 16 years of age instead of 15, and in some cases even beyond that period; (3) equalizing the burden of contribution by requiring contributions from the mother if circumstances of wealth justify that; (4) requiring the contribution of benefits to the mother for three months before confinement and also during confinement; (5) payment of special nursing expenses for nine months after birth if the child is with the mother. The law fixes certain minimum and maximum amounts for these contributions to prevent abuses in local administration; (6) forced collection of contributions on the initia tive of the State and not that of the mother as formerly. Changes in the laws of succession give full rights of inheritance and transmission to an illegitimate child in the line of the father and the father's heirs next of kin. and a child of an illegal or void mar riage is granted legitimacy. 88977—18 10 138 MILITARY, LEGAL AND INDUSTRIAL. Vol. XIII. The property relations of husband and wife are changed to pre vent any child which may be born out of wedlock from inheriting the property of either spouse which has been brought into the marriage by the other. A change similar in intent is made in the divorce law by which the innocent party may demand the division of the com munity property in such a manner that the illegitimate child of the other shall not inherit the property. The grounds for divorce are also enlarged to include the birth out of wedlock of a child whose paternity can be definitely established by law, but not if merely the presumption of paternity can be established, which latter carries with it the obligation of maintenance only. The law on the rights of parents and children, July 6, 1892, is merely changed to conform to the changes made by the illegitimacy law in the corresponding rights of legitimate children. The amend ment makes no change in the legal status of legitimate children. The act on the care and maintenance of children, which applies both to legitimate and illegitimate children, provides for State care and supervision for destitute mothers and children whose fathers neglect to make the contributions for their maintenance. It is based on the assumption that there will be mothers who will get no con tributions because the father has absconded or because he has no property. Such State contributions do not carry with them the stigma and loss of certain rights of citizenship attaching to poor re lief, as there is no fault on the part of the mother or the child. These contributions, commonly termed maternity benefits, are payable by the local authorities from local taxation. The general administration of this series of laws is by the depart ment of social affairs, commerce, industries, and fisheries (departa- mentet for sociale saker, handel, industri og fiskeri), which issues orders to supplement the law and acts as a central clearing house for the information of local police courts and other authorities which are directly concerned in enforcing the law. The immediate administra tion of the law is through the police authorities in the counties and in the lesser rural subdivisions whose activities are in turn supervised by the amtmand of the larger political divisions. The amtmand appoints the police authorities referred to. .Besides the department of social affairs, the department of jus tice is concerned in the administration of the act to the extent of court processes involved, the issue of citations or summonses, and punishing violations against certain provisions of the law, such as taking the child out of the country without leave, absconding, or failing to contribute. The ecclesiastical department is concerned with the registration of births. The medical department provides the State physicians, who act as chairmen of the local boards of health, whose duty it is to su No. 1. 139 MILITARY, LEGAL AND INDUSTRIAL. pervise all foster children and to oversee the activities of midwives and physicians and secure reports from them when attending births of illegitimates. Special advice on the medical and medicolegal aspects of problems connected with the adjudication of paternity may be sought from the State medicolegal commission. (W. A. B.) Fbench, W. J. Prevention of blindness, Work of the State indnstrial accident commission. California State Jour. Med. August, 1918. The National Safety Council estimates that there is one worker killed every 15 minutes, day and night in the United States and one injured every 16 seconds, day and night. This gives us more than 30,000 killed and about 2,000,000 injured. It is estimated that out of this number there are 200,000 eye injuries. The National Com mittee for the Prevention of Blindness states there are 100,000 blind persons in the United States and that more than 50 per cent are needlesly blind. There are, in round figures, 1,000,000 employees in the State of California. There are 300 industrial injuries each working day, in cluding Sundays, in the State. We thus have approximately 100.000 industrial injuries each year in California. In 1914. 1915, and 1916 there were 23,451 eye injuries. Of this number 549 were permanent injuries and 22,902 temporary injuries. There were 11 cases of total blindness. The medical and compensation costs for these eye in juries will be about $788,000. It is impossible to give a definite amount at this time, because the 11 cases of total blindness call for life pensions, and we have simply computed the amounts that would be paid the injured men, based on the mortality tables used by the insurance companies. The time lost by the 22,902 temporary in juries was 234.2 years. This means, that we found just what each man lost; one man might lose a day from work, another man a week, and another man six months, and so on. We added the total together and got the 234.2 years. We have in California 26 eye in juries each working-day and the number will grow larger as there is an increase in the total of employees, especially when we consider the large groups of men that are employed in the shipbuilding plants who are more likely to sustain eye injuries because of the con tinual chipping of steel and the use of emery wheels and machinery used in the construction of ships. The Industrial Accident Commission advocates the wearing of goggles whenever workmen are liable to have their eyes injured. An individual pair of goggles for each man is advised because of the advantage of interesting him in what is practically his property and for the further good reason that men naturally object to wearing 140 MILITARY, LEGAL AND INDUSTRIAL. Vol. XIII. goggles that have been promiscuously used. The use of masks is urged for welders and babbitters. These goggles and masks are so strongly constructed that they not only fit the eyes but have shields at the side of each lens to prevent flying chips from entering the eyes from the sides. Harrington, T. F. Anilln poisoning. Boston Med. and Surg. Jour. October 17. 1918. The author describes poisoning by anilin occurring in the industrial plants of Massachusetts. The manufacture of anilin in this country is one of the direct results of the war, anilin and allied sub stances having previously been imported almost exclusively from Germany. There is a distinct danger of poison in connection with the manufacture of anilin and there has been a sufficient number of cases in Massachusetts to make it possible to speak definitely on the treatment and consequences of such an accident. Anilin or anilin oil (amido-benzene. C„Hr,NH2) is a colorless fluid turning dark on exposure to light and air. It has a slightly irritating aromatic odor, volatilizes at room temperature and boils at 182 C. Anilin is manufactured from coal tar, which is a mixture of benzene, toluene, xylene, etc., all volatile poisons. Benzene treated with nitric and sulphuric acid forms nitro-benzene, itself poisonous, and nitro benzene is reduced to anilin by means of iron filings and hydrochloric acid. Important colors are made by the action of nitrous acid on anilin and allied aromatic amins. Pure anilin does not cause poisoning but pure anilin is not em ployed in the industrial arts. What is usually known as anilin is a mixture of amido-benzene with meta-toluidin, paratoluidin, and ortho-toluidin and xylidin in varying proportions. Poisoning from anilin and its derivatives occurs in the manufacture of all dyes, drugs, photographic materials, rubber goods, etc. The poison may be ab sorbed through the unbroken skin by direct contact or through satu rated clothing, by inhaling vapor and dust or by swallowing dust with food or saliva. Toxic symptoms may follow the inhaling of from 1 to 0.25 gram of anilin. The effect is greater in warm work rooms or during hot, sultry weather. Anilin produces a destruction of the red blood corpuscles. Pallor followed by a striking bluish color, especially in the lips, is the initial symptom. Next come lassi tude, and a sense of fullness in the head. Slight mental confusion, difficulty in swallowing, weakness and rapidity of the pulse, subnormal temperature, headache, dizziness, nausea, dyspnea, unconsciousness, convulsions, coma, and death. The No. 1. 141 MILITARY, LEGAL AND INDtTSTEIAL. more chronic cases of poisoning by anilin are marked by anemia, headache, tinnitus, vertigo, disorder of digestion, and cramps in the muscles. Skin eruptions also occur. The changes in the blood are characteristic. The spectroscope shows a band which comes close to that of metahemoglobin. There is a transient leucocytosis reaching from 30 to 40 thousand. Megalo- blasts, nucleated reds, and basophilic granules appear in the circu lating blood and in the bone marrow. Small repeated doses of anilin cause an increase in the number of red corpuscles, and a reduction of polymorphous leucocytes. Hemoglobin and color index are re duced. In the later stages hemoglobinuria is characteristic. In acute cases the first step in treatment is the removal of the patient to the open air and keeping him awake. The heart should be stimulated by black coffee and camphorated oil and the inhalation of oxygen. The patient should also be stimulated by warm saline solu tions injected under the skin or into a vein. The prevention of poisoning is important. The factory or work shop should be well ventilated, all dust and fumes being thoroughly removed. Vacuum sweeping is better than dry sweeping and the workrooms should have ample washing facilities. The hands should be protected by long sleeves and gloves. Respirators should be worn and the workmen should be forbidden to eat in the workrooms or store rooms. All persons handling anilin should be taught the early signs of poisoning. Immigration Statistics. Monthly Review, U. S. Bureau of Labor Statistics. March, 1918. Immigrant aliens admitted into the United States in specified months, 1913 to 1917. 1917 Month. 1913 1914 1915 1916 Por cent Increase Number. over preceding month. 46,441 44, 708 15, 481 17, 293 24, 745 19.9 59, 156 46, 873 13, 873 24, 740 19, 238 22.3 96, 958 92, 621 19, 263 27, 586 15,512 19.4 136, 371 119, 885 24, 532 30, 560 20, 523 32.3 137, 262 107, 796 26, 069 31, 021 10, 487 48.9 176, 261 71, 728 22, 598 30, 764 11, 095 5.5 July 138, 244 60, 377 21,504 25, 035 9, 367 15.6 126, 180 37, 706 21, 949 29, 975 10,047 7.3 136, 247 29, 143 24, 513 36, 398 9, 228 8.2 134, 440 30,416 25, 450 37, 056 9,285 6 104, 671 26, 298 24,545 34, 437 6, 446 30.6 95, 387 20, 944 18, 901 30, 902 142 Vol. XIII. MILITARY, LEGAL AND INDUSTRIAL. Immigrant aliens admitted into and emigrant aliens departed from the United States, November, 1916 and 1917. Hace. African (black) Armenian Bohemian and Moravian Bulgarian, Serbian, Montenegrin — Chinese . Croatian and Slovenian Cuban Dalmatian, Bosnian, Herzegovinian . Dutch and Flemish East Indian English Finnish French German Greek Hebrew Irish Italian (north) Italian (south) Japanese Korean Lithuanian Magyar Mexican Pacific islander ." Polish Portuguese Roumanian Russian Ruthenian (Russuiak) Scandinavian Scotch Slovak Spanish Spanish- American Syrian Turkish Welsh West Indian (except Cuban). Other peoples Not specified Admitted- Novem ber, 1916. 720 150 43 7G 153 32 154 Total. 866 9 3,604 942 4,642 1, 342 2,009 1, 908 2,046 492 5, 531 741 15 71' 72 1,683 Novem ber, 1917. 406 :!0 :S in 112 5 31 Departed. 283 173 40 408 94 2, 576 1,516 33 1, 104 160 91 102 OS no 320 108 12 S20 258 5S0 144 105 344 345 55 130 776 20 10 5 84 Novem ber, 1916. 52 58 9 110 5 730 324 2 350 127 IS II 71 12 34,437 6, 446 244 3 2 101 15 207 46 83 614 178 218 51 131 13 210 561 1, 327 112 13 12 50 6 325 5 542 503 214 1 334 50 7 9 20 23 26 804 Novem ber, 1917. 150 100 OK 252 125 1 125 2 38 4 1, 140 77 412 30 520 ' 33 231 265 2, 476 131 6 3 I 58 1 205 521 9 100 8 140 250 38 214 00 9 10 11 47 10 7, 164 8, 136 Dubham, H. E. Preservation of fruit. Brit Med. Jour. June 22, 1918. Fruits may be preserved for a more or less indefinite period by bottling or canning as jam, by making into paste, or by simple drying. Some fruits may be kept for months if properly stored. The author, who is the president of the Fruit Growers' Association of Hereford shire, suggests that as the making of jam in factories is now largely under Government control the manufacturers should be required to No. 1. 143 MILITARY, LEGAL AND INDUSTRIAL. make a declaration as to the substances other than the fruit named used in making the jam. Thus if the basis of jam is the pulp made from apples, plums, or vegetable marrow, the named fruit serving more as a flavoring agent, these facts should be declared. Jam is supposed to afford a ready means of adding vitamines and other avail able food substances to the diet in winter when fresh fruit is not available. Where fruits are pulped and kept and later recooked the vitamines may not be lost. The so-called " currant jam," supposed to be made solely from sound fruit and sugar, is often obtained simply by the use of pulp combined with apple or vegetable marrow with currant flavoring. At this time when economy in sugar is vital the following notes have an unusual interest. When water without sugar is used in bottling, a diffusion takes place until an equilibrium is established. The individual fruits then become little more than tasteless bags, and can only be served at table when mashed into a puree. It is therefore necessary to make juice from some of the fruit and use it to fill up the bottles. The juice may be prepared by cooking some of the fruit in a small amount of water and squeezing the residue through a cloth by means of the fruit press. The paste from fruit can be made into sauces for puddings, etc. To prepare an apple paste cut up the apples and cook with the least possible amount of water. When soft, after culling, pass through a fine cloth or sieve. Now continue the cooking with constant stirring until reduction is complete. Reduction is indicated when the wooden spoon used for stirring will stand alone in the pulp. If sugar is available, add from one-tenth to one-fifth of the weight of the pulp. Pour the pulp into well greased baking trays and place them to dry in a slow oven or in bright sunlight. Then the residue may be rolled or cut up into squares and stored in paper bags or cardboard boxes in a dry place. Tomatoes are to be boiled without breaking the skin, the water drained away completely and seeds and skins are then to be removed. Add salt, cayenne, and allspice. The puree is then slowly reduced to a thick jam, poured into trays, dried, and rolled up. This paste keeps well. The simple drying of fruit needs no elaborate outfit. The ordinary baking oven serves for drying fruit on a simple scale. When dried to hardness the fruit will keep perfectly in paper bags. Fruit to be dried should be of good size, free from defects, and ripe or nearly so. Fruit which is not perfectly ripe may be spread out on trays made of gauze or wood and kept over the range for a few days. For the first dryinp the temperature should not exceed 115° to 120 F. For the second or third heating the temperature should not exceed 150 F.. and for the final a temperature of 160 F. is the maximum. If the 144 MILITARY, LEGAL AND INDUSTRIAL. Vol. XIII. temperature is too high the skin of the fruit breaks, the sticky juice runs out, and a general mess results. At the end of each day's drying the oven may be allowed to cool for a little. The fruit should be left in over night. On the next day the fruit is taken out and cooled. It is well to leave the oven door ajar at night, and this must be done during the day when the fire is on. It is essential to have intervals of cooling between the temperatures in the oven. Potatoes, young broad beans, and green beans dry rapidly and give a good product. Paris Chamber of Commerce. Economic and financial assistance given by the United States. Bulletin of Information, Paris. September, 1918. No. 86. In the course of a year— July 1, 1917, to July 1, 1918—10,000,000 tons of foodstuffs were exported to the allies, including 150,000,000 bushels of wheat. The cereals sent from America to France between May, 1917, and May, 1918, represented sufficient bread for 11,000,000 Frenchmen for a whole year, and the voluntary restrictions made throughout the country enabled the States to place 840,000,000 pounds of provisions at the disposal of the allies. The steel exports for the year ending June 30, 1918, amounted to a thousand million dollars, against $621,000,000 only in the preceding year. In May, 1918, copper exports figured at $29,065,347. In 12 months, thanks to the launching of special cistern boats, the exports in benzine, paraffin, and petroleum amounted to 650,000 tons. The United States before the war had never loaned to any foreign States. The total of their advances to the allies now exceeds six thou sand million dollars. REPORTS. SURGICAL EXPERIENCES AT THE FRONT.' By G. G. Ross, Meutenant, Medical Corps, United States Naval Reserve Force. Under orders from Admiral Wilson, two operating teams from United States Navy base hospital No. 5 left for Paris on the morning of July 18. Upon our arrival in Paris at 8 p. m. we received verbal orders to report to United States Army base hospital No. 2, where we operated all night. The following morning we were ordered to field hospital No. 12 at Pierrefonds, arriving there by ambulances at 8 p. m. There were approximately 700 wounded lying on stretchers on the ground awaiting operations. All had been fed and tetanus antitoxin had been administered. The hospital was situated in a small hotel, the onty available building in the town. The operating room was located in the dining room of the hotel and allowed space for three tables with barely room for the litters to pass between. The sterilization consisted of boiling instruments over a gasoline stove. The autoclaves were heated and the water boiled by the same method. They had a gasoline engine which supplied power for the electric light and the X-ray outfit. The speed of operating was hampered at night by the difficulty of selecting and transporting patients to and from the operating rooms, as lights were prohibited owing to the fact that the hospital was being bombed at regular intervals. The work continued for five days and nights, teams working on 12-hour shifts. On one occasion Drs. Curl and Eoss operated for 18 consecu tive hours. The wounds were massive and associated with more or less severe hemorrhage, loss of skin, muscle, and bone. The most hopeless cases were the wounds of the head and abdomen. In one shift, one table had occasion to do three intetinal resections and one anastomosis between the ileum and transverse colon, the cecum having been shot away. The through-and-through wounds of chest were not operated unless the wound was large and the pleura opened. Here the blood was allowed to escape, ragged ends of rib removed, packed with gauze, and the muscles and skin brought together by sutures. Every wound of the extremities, buttock, or loin spaces was treated by mechanical cleansing (debridement), and antisepticized by chemical means, iodine or Dakin solution being used. Foreign bodies, 1 From report received from United States Navy Base Hospital No. 5. US 146 BEPOBTS. VoL XIII. shell fragments, bits of clothing, bullet (rifle, machine gun, and shrapnel) were removed when quickly located. Every wound re ceived on the battle field is potentially or actually infected with the organisms of gas gangrene, and so every wound is allowed to remain wide open, the incision must be very large, and the debridement thorough. The last 36 hours at Pierrefonds were devoted to the care of Scottish troops who had been sent in to relieve the First and Second Divisions of our Army. The English authorities requested the hospital to remain, as their hospital equipment had not caught up with their rapidly moving troops. We received 32 Scots, wounded at night by a bomb dropped on their column by a Boche aeroplane. The target was supplied by a Scot who struck a match to light his pipe. Eight of them were killed, and the balance, 32, we looked after. We also operated on a number of Hun prisoners after having cared for our boys and the Scots. A German officer upon whom we operated, and who had been lying on the field for four days before he was found, told us that in Germany the general opinion was that France was in the war to secure Alsace-Loraine, and the Americans " for souvenirs." . About 3,500 men passed through this station in six days, about 300 of whom were operated on. The average operations per patient were not less than two, such as double amputations, multiple shell wounds, compound comminuted fractures of several extremities, or multiple of the same extremity, etc. The function of a field hospital is to care for severe wounds and the nontransportables, but under the conditions we had to meet we were doing the work of an evacution or base hospital. On July 30, 1918, United States Navy operating team No. 1 was ordered to evacuation hospital No. 6 at Chateau Thierry, and team No. 2 was ordered to evacuation hospital No. 7 at Coulommiers. As the Army had no means of transportation at hand we were sent out in automobiles supplied by Navy headquarters in Paris. We arrived at Chateau Thierry, but, as we were unable to locate No. 6, we were assigned to field hospital No. 116 for the night, and worked at the operating table until midnight. One of our nurses, Miss Hurst, con tinued on duty all night and handled instruments for three teams, and. on one occasion, three abdominal sections were going at the same time. We found No. 6 the following morning and reported to the com manding officer, Colonel Baker. For 12 days we operated in 12-hour shifts, and during the last period were on duty for 24 hours. Neither the cases brought to Chateau Thierry nor to Coulommiers were of so severe a nature as at Pierrefonds, the field hospitals be tween us and the line having cared for the nontransportables, such as abdominal cases and bad head injuries. There were comparatively No. 1. 147 REPOETS. few amputations necessary. The most important work consisted of debridement and chemical sterilization of the wounds and placing the man by position or apparatus in condition for comfortable and safe transportation. For wounds of the extremities and especially of compound fractures of the femur and humerus, the Thomas splint is the best method for the field. It is easily applied and is very efficacious, but when improperly applied is very painful. Many cases came to us with the splint improperly placed, and the man thereby suffering unnecessary pain, especially at the instep and heel, the extension having been applied over the shoe. One must be chari table, however, because the work had been done under shell fire, a sufficient excuse for haste. We were surprised at the number of men whose large vessels had been shot away and who had not bled to death. We had occasion to ligate the femoral in Hunter's canal twice, to ■control by hemostats the internal pudic twice, the radial once, the brachial twice, the perineal once, the posterior tibial twice, the com mon femoral once, and the deep and superficial palmar arch twice. In all these cases a well-formed thrombus was present and hemorrhage had been checked, although most of these men had traveled from 15 to 20 miles in an ambulance. A very serious problem is the use of the tourniquet. It is usually applied on the field and it may be hours or even a day or two before the man can be brought to an operating unit. The day and hour of the application of the instrument should be noted on the man's field card and he should be transported to the rear with the greatest expedition, for after six hours' constant con striction it becomes a serious menace. One case we amputated had had a tourniquet on for 48 hours. Most of the men had been given tetanus antitoxin on the field or at the advanced dressing station and the fact was noted on the field card, or by a " T " painted on the forehead. No case passed through the stations without having this matter checked up. The result is that tetanus is practically eliminated as a battle risk. Many of the wounds contained maggots, but while such a wound presents an un pleasant appearance, maggots are not detrimental to the wound, as they attack only the dead and devitalized tissue and bacteria. The elimination of tetanus has been offset by the ever present anaerobic gas bacilli, as every wound involving muscle is potentially so infected and the surgery of the wound must be approached with this fact in mind. It is not a difficult diagnosis to make. The odor of the wound is very characteristic, as is its appearance. The odor is a peculiarly sweet sickening smell, and when associated with a wound having the appearance of grayish-yellow slough and muscle that is dark purplish red and lusterless, and which does not contract when touched, and which when cut gives the sensation of going 148 BEPOBTS. Vol. XIII. through soft mush, the diagnosis is established. Associated with the other symptoms there is an area around the wound which gives a crackling sensation to the finger, due to the presence of gas and this area shows discoloration varying from a curious gray dead look to that of subcutaneous ecchymosis. Experience has taught that the circular-chop amputation is the most practical method and gives a higher percentage of recoveries. In the presence of the universal gas gangrene infection flap ampu tation is prohibited. The final results of chop amputations, if the Martin method of treating the stump is correctly carried out, is ex cellent and assures the patient the maximum use of an artificial limb. In some cases of amputation of the thigh in the upper third in the presence of gas gangrene, it was necessary to make long lateral incisions with debridement. Penetrating wounds of the skull are very serious injuries as the fragments of the shell or bullets carry with them pieces of bone which are driven into the brain sub stance. Their removal requires great care and patience, as well as special skill and training. There is usually a great loss of brain substance. These cases should be drained and the scalp wound left wide open after debridement of the edges, and the final surgery be longs to specially equipped hospitals farther back from the line. To spend three hours in doing a finished brain operation in a front-line hospital, when scores of. patients are waiting for the operating table, seems entirely out of place and is depriving men, who offer a much better prognosis, of an opportunity for recovery. We saw several through-and-through wounds of the lower abdo men, in which the missile had traversed the bladder without opening the peritoneum. In one case the bullet had entered anteriorly and made its exit in the buttock near the crest of ilium. Through the tract, urine was escaping in a constant dribble, constituting perfect drainage. The patient was not operated upon, but evacuated to a base hospital. One very unusual case came to Dr. Curl. A man was hit by a bullet which struck the cap of a shell in his bandolier, exploding it in his left lumbar region. The badly distorted shell case and bullet were removed from the loin space and back, the wound given debride ment, and left open. The peritoneum was uninjured. It is unnecessary to open and pare all through and through wounds caused by rifle or machine-gun bullets. The comparative size of the wound of entrance and exit will be the deciding factor. If the wound is caused by a bullet at the height of its flight when it has steadied down to a revolving motion, it will perforate soft tissue and bone with a minimum of destruction and the wound of exit will be but little larger than that of entrance. If, on the other hand, the bullet strikes the man at the beginning or toward the end of its No. 1. 149 REPORTS. flight, it will be wobbling as well as rotating and will cause a tre mendous destruction of tissue, causing severe comminution of bone and purification of muscle and fat and shredding of the connective tissue planes. Here the wound of exit is much larger than that of entrance and will give the appearance of an explosive force. This class of wound should be freely opened, pared, and cleaned by anti septics, for it is the wound which presents the most favorable oppor tunity for the development of the gas gangrene bacilli. All through-and-through wounds caused by shell fragments should be treated by free opening and debridement and left wide open with drainage. , Several cases of narrow escape from death or very severe wounds came to our notice. One case complained of severe pain in his neck. There was a slight wound on the side of the neck, and just below it, firmly bound by a bandage was a shell fragment 3 by 2 by 2 inches, causing pain by pressure. Another man, Lieut. S., had a shell frag ment, roughly, 2 cubic inches in size, resting in a pocket of skin on the abductor side of the arm. The humerus was uninjured, the brachial artery was intact. Another man had a machine-gun bullet enter just below the right eye, fracturing the floor of the orbit, pass ing through the superior maxilla, around the side of the neck, and lodging in the muscles in the mid-line of the posterior surface of the neck. DETAILS OF TRANSPORT SERVICE.1 By R. I. Lonqabacgh, Lieutenant Commander, Medical Corps, United States Navy. It is probable that every medical officer on transport duty has been reporting details of his work as they arose, because the situations we are handling present so many new aspects. However, the assembling of many ideas and suggestions will in time make it possible for the authorities to lay down certain rules of conduct that will be of great assistance to any of our men assuming the duty for the first time. With this in view I am inclosing two form letters which I had printed on board, one for the commanding officer of troops and his various commanding officers and the other for the medical officers of the Army. In addition, I have managed to hold a "get-together meeting" with each of these sets of officers when they came aboard, for the purpose of having them thoroughly understand in detail the ends for which we are working and realize the cordial relations which we desire to have exist.- 1 From Report of IT. S. S. America of April 20, 1018. The marked disparity In the ships, both as to capacity and internal arrangements, has made It Impossible to lay down hard and fast rules for the administration of the medical department of naval transports. 150 BEP0BT8. Vol. XIII. The senior medical officer has also submitted to me a list of the medical officers under him, together with any specialties they may have been following, and in this way we have been able to give all seriously sick special consideration through consultations. As an. example of this, Drs. Stellwagen and Dorrance, both of whom are Philadelphia men well known to the service, consulted with me on several occasions on the way over. Our sick list varies between, say, 20 and 100 persons, depending- upon conditions. Among these sick are many men requiring liquid diets and special diets. In the past it has been the custom to make use of canned soups as part of this diet. We now carry some canned soups for emergencies, but we learned that, with the large number of troops aboard, the serving of soups to them as part of their ration was impracticable, and the bones were therefore a loss. We, in the sick bay, took advantage of this situation by having the paymaster make fine rich soups for the sick from the bones, thus we not only save our canned soup but, in addition, we get something much more palatable. However, the question of diets for the sick does not yet satisfy me. I believe that as a new departure the department should in some way secure cooks for the sole purpose of running the sick bay diet kitchens and preparing such special dishes as from time to time may be ordered on board transports, especially on the return voyage. This much is certain, at no other place in the service would we attempt to care for a large number of sick without special provi sions as to cooking for them. Through the efforts of Captain C. N. Fiske, Medical Corps, United States Navy, we now have access to practically all of the good clinics in New York. I laid before the commanding officer the following plan to be followed in port and he immediately gave it his hearty approval : The officer of the day to be on duty during the entire 24 hours, the relief officer of the day on duty during working hours. The remaining two junior medical officers are to be excused from quarters and to, attend the clinics. As a check they report to me the clinics attended and the number of hours spent therein. In order to show our appreciation of the efforts of Capt. Fiske I intend to submit to him each time upon departure a copy of this report. Speaking of the duties of the medical officers, another plan, which I have passed on to some other transport surgeons, is that at sea the officer of the day is on from 8 a. m. to 8 p. m. and the night is divided into three watches, which are stood at the sick bay. During each watch our medical officer accompanied by a medical officer of the Army makes an inspection of troop spaces to assure himself that men are sleeping under proper conditions. We have found that the presence of a medical officer at the sick bay at all times while troops No. I. 151 REPORTS. are aboard has not only created a very favorable impression, but has assured the sick prompt and complete attention. In dealing with the soldieis it has been our plan as far as possible to avoid direct orders to them. On all inspections we are accom panied by an officer of the Army, who issues such orders as we nitty desire. We seem to feel that the soldier recognizes the uniform of an Army officer and obeys promptly, whereas he is unfamiliar with our uniform and it means nothing special to him. Then, too, it gives the Army officer a feeling that he is something more than a figurehead and stirs up a lively interest in his job. From my viewpoint the Transport Service is at the present time the most important field for a naval surgeon. It therefore seems to me that he' should be encouraged and helped to gather together and train a most efficient personnel and that once his system is estab lished and getting results it should not be disturbed. For instance, during my first trip so many duties fell upon me personally that I found I lost what Dr. Fiske so aptly described as "the big point of view." On this trip, therefore, I began to train Lieu tenant Dearing, Medical Corps, United States Navy, as sanitation officer. He has been performing the duties most satisfactorily, has been able to work out to completion many small details which origi nated with me, and has made many valuable suggestions himself. Between inspections of troop spaces with the Army officers, which take the entire morning, and inspection of crew spaces and the ship in general with the first lieutenant, taking up the afternoons, he has been kept very busy. In all this, however, his medical work has not been forgotten, for he is given an opportunity (which he is glad to have and seizes) to continue to work on the medical side of the ward. As many hospital corpsmen as can be spared are ordered while in New York to attend the special courses provided by the com mander of the cruiser force. In addition, while on board we have arranged for two classes daily on the return trips, when work is light, and have placed some of the reliable men as " heads of depart ments " on the surgical side, on ward management, paper work, dis pensary work, etc., under the immediate supervision of the pharma cist. We expect to continue these trained men in their special jobs and have them train other men as fast as the men can absorb the work. Naturally we have been endeavoring as far as possible to coop erate with the executive officer and assist in all matters relating to sanitation, for his duties are heavy. The inclosed bill of cleaning instructions is a sample of one which we got up for posting in every troop compartment to give the Army cleaning details a concise idea of what is expected of them and the extent of their work. 152 BEPOBTS. VoL XIII. Troop Compartment F-6. The following allowance of cleaning gear and buckets Is made to this com partment : Three swabs for cleaning the deck. Three scrubbing brushes for the deck. Three brooms. Three buckets for scrubbing and cleaning, blue. Three buckets for sputum and vomltus, black and white. One trash can. Daily soap allowance of one-half bar of salt-water soap. One spray pump. All pumps, buckets, etc., are marked with the number of the compartment and shall not be used in any other except in authorized cases. The daily allowance of soap, toilet paper, etc., shall be obtained from the issuing room, Just aft of the troop's canteen, on D deck. Brooms and scrubbing brushes shall be kept Inverted In the wooden rack when not in use. Swabs must be kept hung up in the wooden locker and the buckets and hand scrubbing brushes stowed in this locker when not actually In use. The black and white spit buckets shall be distributed In the compartment as needed. Under no condition shall cleaning buckets be used as spittoons or spit buckets be used for cleaning purposes. Trash cans shall be emptied at the Incinerator on the starboard side of D deck, aft, as soon as filled. Pump for spraying the deck will be found hanging near the swab rack. This pump shall be brought to the ship's dispensnry on B deck for filling and for Instruction as to Its use. Officer in charge of this compartment shall be responsible for the cleanliness and sanitary condition of the following items: Entire compartment. Shower No. 5, with urinal. Stairs leading to E deck— No. 20. Scuttle-butt. Sanitary Instructions. Immediately after breakfast all the lower bunks shall be taken out or lashed up to the middle bunk to leave room for proper cleaning. All rifles, equipment, clothing, etc., shall be picked up off the deck and piled neatly on the bunks. At 9.30 a. m. all men except the cleaning detail shall go on deck for exercise and remain there at lenst an hour. During this time the cleaning detail shall clean the compartment and ladders according to following instructions: Thoroughly spray the decks with cresol solution. Sweep thoroughly, being careful to include all nooks and corners. Shave the soup into small chips and put into the water. Scrub tiie deck and ladders thoroughly, using plenty of water and " elbow grease." This scrubbing shall include all ladders, corners, and spaces between the frames and shall extend up on the walls to a distance of at least 1 foot. Swab up the deck with the swabs, getting it as dry as possible. At 3 p. m. spray the deck again and sweep thoroughly. The swabs shall be taken to the cleaning room just aft of No. 1 sick-call quarters on E deck, thoroughly boiled and cleaned once a day. No. 1. 153 REPORTS. INSTRUCTIONS FOB CLEANING UBINAL AND SCUTTLE-BUTT. Urinal shall be cleaned every day. Wire gauze shall be taken out, laid on the deck, and thoroughly scrubbed with lye solution. The trough shall be scrubbed with soap and water on the inside and outside. TO CLEAN SCUTTLE-BUTT. Keep the drip pan free from tobacco, paper, and other refuse. The metal cones Bhall be removed (unscrewed) and thoroughly scrubbed and polished on both sides every day. U. S. S. Amebica. INFORMATION FOB THE COMMANDING OFFICES OF TROOPS, COMMANDING OFFICEBS OF DETACHMENTS, AND MEDICAL OFFICEBS, RELATING TO 8ANITABY AND OTHER MATTERS. The following information as to rules for sanitation on board this transport ire the result of careful thought and consideration. A copy will be furnished: the commanding officer of troops, the commanding officer of each detachment aboard, and each medical officer in order that all may immediately know and Institute the sanitary measures which must be carried out. GENEBAL. Prior to embarkation Army medical officers at the port of embarkation detailed there for that purpose carry on a very thorough examination of the men to weed out sick and start with only healthy men. Close attention In carrying out the following sanitary rules and early detection of disease must be' observed if you expect full healthy units upon arrival at the port of debarkation : 1. Every man to take a shower dally. 2. Every man to change his underclothes at least once during the voyage. 3. All troops to spend at least an hour and a half dally on deck, erich man bringing his blankets to be aired. Commanding officers to see that men receive 30 minutes of physical exercises during this period. In fact, oblige your men to stay In the open as much as the weather will permit. 4. The troop spaces to be sprayed, swabbed, and otherwise thoroughly cleaned by your cleaning details while the above (par. 3) Is In progress. This In addi Hon to the ordinary routine sweepings twice daily. 5. Inspection of all men and their effects twice weekly by your medical and commanding officers to weed out sick and be sure that men are keeping them selves clean and not harboring disease. During the airing on deck this can be carried on most successfully. ' 6. All men to sleep " heads and points " to prevent as far as possible spreading of infections by coughing. 7. See that your men sleep properly covered and that above all they are not allowed to sleep on the decks or anywhere else unless properly protected. 8. The eating of food in berthing spaces Is strictly prohibited, and, in fact, food will not be served In rooms or other unauthorized places unless so ordered by the senior naval surgeon in cases of sickness. 9. See that your men do not close the ventilators or stuff their clothing into them to stop the flow of air. 88977—IS 11 154 BEP0BT8. VoL XIII. 10. Army regulations require the protective vaccination of ail men prior to embarkation. Despite the preliminary examination there have been " last minute " requests for vaccinations, because although the men declared they had been protected, the records did not show It. The commanding officer of troops therefore will cause to be submitted to the Senior Naval Surgeon within five days of sailing either (a) a statement that all men have been protected or (6) a list of the men whom he desires vaccinated. 11. Upon arrival in foreign waters the following are required for all men who are to be sent to hospital: (1) Service record, (2) field equipment, neatly packed (and barrack bag when possible). If barrack bag is not available, com manding officers should arrange to have them secured when sorting out baggage at port of debarkation and sent to the hospital later, properly tagged. No rifle or pistol ; no bayonet. I do not give a receipt for the man, his service record or his effects, for I simply turn them over to the hospital as I receive them. The general plan is that he is returned to you directly from hospital as soon as well. CARE OF BEBTHING SPACES, DBINKING FOUNTAINS, WASH BOOMS, LATRINES, URINALS, ETC. 1. Reliable guards to be stationed day and night at each drinking fountain, in each wash room, latrine, and urinal to see that they are kept clean and no nuisances committed. 2. The cleaning details for the troop spaces, the latrines, urinals, wash rooms, etc., to be permanent for the trip so that they will be able to cooperate more intelligently. Each detail to be in charge of a noncommissioned officer, who in turn will be held strictly accountable to the police officer and to any Army medical officer acting as sanitation officer for the proper carrying on of his work. 3. Troops spaces to be sprayed, swabbed, and thoroughly cleaned as pre viously described while troops are on deck. 4. Water-closet seats to be scrubbed with lye water (or 5 per cent formalin) daily. Seats are hinged or under side can be easily scrubbed. 5. Wash basins and troughs to be thoroughly scrubbed each morning with soap and water and troops Instructed to clean basins after using. 6. All spitting on decks to be watched for and punished. (In this connection .the drinking fountains seem to be favorite place for expectoration.) 7. Drinking fountains to be scrubbed thoroughly with hot 5 per cent formalin once daily. Note. — Spray pumps for spraying compartments, soap for cleaning, brooms, swabs, toilet paper for latrines, etc., are under the care of the first lieutenant of the ship. See him and he will arrange for the issue of these things to you. On the port side of the ship on E deck, just forward of the troop's galley and officer's scullery are two wash tubs with lots of hot lye water and a wringing machine for the cleaning of swabs. See that the cleaning details find this place and keep their swabs clean. U. S. S. America. MEMO FOB MEDICAL OFFICEBS OF THE ABMY ON BOABD. The regulations under which the naval medical staff is acting (and which also covers you) have been promulgated by the Surgeon General of the Navy after consultation with the Surgeon General of the Army. The regulations make the senior naval siirgeo.i responsible for the sanitation of the ship, and also for the routine care of all men who are sick enough to require treatment other than first aid. These regulations also place at his disposal the services of any No. 1. 155 BEP0RT8. or all of the medical officers of the Army on board, together with the hospital corps, sanitation corps, etc. I therefore desire that the senior Army surgeon on board keep in most intimate touch with me to advise and cooperate con stantly so that the highest degree of medical efficiency may be maintained. With this end in view the following rules, which experience seems to indicate are good, have been laid down : (a) The senior naval surgeon to be furnished within 24 hours after em barking a roster of all persons of the Army Medical Service on board. (6) From these persons the senior Army surgeon will make suitable per manent details of enlisted men for work in the sick bay en route. (c) He will have a commissioned officer report to the senior naval surgeon for duty as sanitation officer, supervise and report upon all Army sanitation, and carry out any special orders which may from time to time be given him. (d) He will detail Army medical officers for duty as medical officers of the day and for night watches 8 to 12, 12 to 4, and 4 to 8, In company with the Junior medical officers of the Navy; these night . watches to be stood in the office of the medical officer of the day, adjoining the sick bay. le) He shall cause a venereal Inspection to be made one week after sailing to discover such cases as may have appeared since embarking. Sick call will be held daily at 8.30 a. m. and at 3.30 p. m. by such Army medi cal officers as the senior army surgeon may detail. A small black desk and locker (with red cross) is provided at the after end of each mess hall. The senior army surgeon will have a reliable hospital corpsman stationed at this place (sleeping there nights) to look out for sick, to find Army medical officer on duty, etc. This hospital corpsman to have the Army medical officer of the day see all sick before sending them to the sick bay. The cabinet contains only the simplest articles, for it is to be desired that all really sick men be sent to the sick bay for treatment. All dressings (no matter how trivial) will be sent to the sick bay. The sick-call desk is provided with a Navy prescription pad and with blanks (copy attached). The Army medical ADMISSION CARD, WHICH THE PATIENT TAKES TO SICK BAY. Name in full Co E Age Natiyity_. Tentative diagnosis Bat Service, yrs Rank Reg Reg. No U. S. Army (A) Admit to ward, date Tentative diagnosis Final diagnosis Final disposition (B) Treat and return to duty. Diagnosis Per No Per No_-_ Other treatment Per No Date Surgeon, U. S. N. Do not soil or bend this card. officer holding sick call may prescribe things other than those in the locker and send his man to the dispensary for the medication. In this connection, however, attention is invited to the fact that special vigilance is demanded in order that 156 Vol. XIII REPORTS. men may not be treated for " a slight headache " who have meningitis or for " mild sore throat " who have diphtheria. Endless trouble has resulted from careless filling out of the attached card form, particularly errors in spelling the patients' names. In all cases you send to the sick bay for possible admission, please fill in the top four lines carefully and sign your name and rank In the fifth line. In addition on the back of the card record the temperature, pulse, and respiration. Unless a case is particularly urgent it will not be received at the sick bay until seen by an Army medical officer and the form properly filled out All the official papers (Form 52 and others connected with your men who are on the sick list are made out by us and forwarded to the Navy Department and by them to the War Department) so that the data you furnish must be correct. It has been found to create endless confusion to have too many medical officers in the sick bay and in my office. Medical officers of the Army therefore must not enter the sick bay to work upon or examine patients or the office of the senior naval surgeon unless specifically requested to do so by him. The foregoing plans were formulated after consultation with other Army medical officers on other trips -with the idea of giving you something tangible to work upon immediately, so that the best possible sanitation and general medi cal cooperation would be had from the start, for after all the health of the troops must be our first consideration. FLAN OF A REGIMENTAL FIELD HOSPITAL. By C. B. Ca merer. Lieutenant Commander, Medical Corps, United States Navy. Fl E.LD HOSPITAL 4 TH. ILL^IHEWT U . S M.G. DE.CJL POIMI ClUAUTAUAMO bM, LU&A. blawu by «/ohu. a. UE_w&Aue_iuo.rV H. v. s u. rtAotD bv m.t.e>. 6ATH,. trfMtWCWpW — ' 1 1S.TT0U. TtUT. *iTA I ft£iiT*L•rru.e.utuiuu). 14 weut much. Z lt(,iHtUTfcLm^lODr 6FFK.I. 15 wtitifhiy t,bUSS~ 5 MiX fMJ,E0l!r V"LT£LT. -'U<*UWULUUiD. 4 lift fNjftAltf QJtAtTilX t UCIMtUTAL KLA6~ ft j DtuTAL 141011. -tyAuiir. * 4 C P.H.H9JJ*»_TE.Lr, * UlUV- <-AlU\ , 7 VtUElUL TtMT- • tLKJUL U^ITrOLLTl ;>; t Mt.0U.AL MALI(.SlUI.Ue.kJ^ES L1TTLA-Lit-*-. Bf.l OttUTIU^ LOOHC/CULUU). O WATLLLC0LF_A_, XVI4IUAI.WALI. X 6AUALLfl»H0llFlLTtlu "$l FltLI HOSHTAL fLA4_ tm -TWAftLM-iC. ^Vll ClOTHtX LlUt. CT-i-OTf. ntL» HWHTAL WSH Vl. •lUUULLATOir. MAIU CAHf 100vir- The accompanying plan shows the arrangement of the field hos pital of the Ninth Regiment of United States Marines, at Deer Point, Guantannmo Bay, Cuba. The field hospital is 100 yards away No. 1. 157 11EPOHTS. from the main camp on one side and 200 yards away from the in cinerators on the other. The isolation ward consists of two hospital tents, erected on the point to leeward of the quarters for hospital corpsmen and does not appear on the plan. The latrines are 60 yards away from the camp, at the foot of the cliff and built over the waters of the bay. The water supply is derived from the naval station and at present, owing to the prevalence of typhoid fever in the vicinity and the poor condition of the plumbing system at Guantanamo, the water is boiled before use. REPORT OK THE PREPARATION OF BLOOD STAIN AT THE U. S. NAVAL MEDICAL SCHOOL. By O. P. Clauk, Lieutenant Commander, Medical Corps, and Chief Pharmacist's Mate L. F. SnABEK, United States Navy. For the past few months we have had considerable difficulty in the preparation of blood stains. American dyes were used and the polychroming was carried out by the use of silver oxide after the method of Balch or that of Wilson. So many batches of the stains proved unsatisfactory that we decided to try repolychroming them instead of throwing them away. For this purpose we used sodium bicarbonate after the method of Wright, using 1.75 grams of the finished stain to 100 mils of \ per cent sodium bicarbonate solution. The stains that had been unsatisfactory were readily repoly- chronied despite the fact that eosin was present as well as methylene blue. In order to see what the action might be we tried mixing untreated methylene blue, bac. (1 gram) and untreated eosin y. w. s. (0.5 gram), then polychroming with solution of sodium bicarbonate 100 mils \ per cent, container being placed in the Arnold sterilizer for one hour. Polychroming was readily brought about. After polychroming, the usual method of Wright was followed : Filtration, saving filtrate, and drying it. For use 0.3 gram are dissolved in 100 mils of methyl alcohol. We are in hopes that the stain will have as satisfactory keeping qualities as when made with foreign dyes. PREPARATION OF IDENTIFICATION TAGS. By B. H. Laming, Lieutenant Commander, Medical Corps, United States Navy. The supply of powdered asphaltum was exhausted but identifica tion tags had not been made for all the officers and men of the U. S. S. South Carolina and as it was important to complete the work 158 Vol. XIII. REPORTS. we decided to experiment with other materials. Pharmacist Mc- Callum (T.), United States Navy, went on a voyage of discovery in Norfolk, Va., and returned to the ship with some so-called " dragon's blood," printer's ink, and asphaltum varnish which he had gotten from a printer there. Pharmacist's Mates, third class, Osuch and Lyons experimented with these materials and perfected a method of making the imprints on the monel metal which is easier and cheaper than the regulation method. I understand that the pow dered asphaltum is scarce and difficult to obtain at present and I would recommend the method with dragon's blood, asphaltum varnish and printer's ink as an alternative or substitute. I have not been able as yet to ascertain the composition of dragon's blood. The method worked out by Pharmacist McCallum and Pharmacist's Mates, third class, Lyons and Osuch is as follows : 1. To prepare the ink to make finger prints take 2 grams of powdered dragon's blood and add it gradually to 6 grams of printer's ink and stir thoroughly until there is an even mixture. To this mix ture add gradually about 15 drops of asphaltum varnish and stir well. z 2. To prepare the ink for the name prints take 10 grams of asphaltum varnish and add 2 grams of dragon's blood and mix thoroughly, then add to this mixture enough turpentine so that it will flow freely from the pen. 3. To prepare the acid mix the HC1 and HN03 in the following proportions: One-quarter part HC1, one part HNO., and two parts H20. Use about 200 c. c. of this preparation to 50 tags. To make the tag proceed as in the regulation way, inking the finger print with No. 1 preparation, printing name, rate, etc., with No. 2 preparation, dusting both sides with the dragon's blood, blowing off the excess, heating over flame until prints take a glossy appear ance, then immersing in No. 3 to finish the etching. After coming out of etching acid the tags have a dirty appearance, and to polish them, immerse the tags for about 2 minutes in a solution of equal parts of HNOa and H20. HISTORY AND AUTOPSY FINDINGS IN A CASE OF SALVARSAN ADMINISTRATION. By R. C. Christiansen, Lieutenant, Medical Corps, United States Navy. Before discussing the case at hand it is considered advisable to briefly review the literature pertaining to the untoward effects and the cause of the same following the administration of salvarsan and neosalvarsan. Very soon after the introduction of these compounds by Ehrlich clinicians realized that their use was attended by a certain factor of No. 1. 159 EEP0ET8. danger, severe symptoms of shock, and even death occurring in a percentage of cases. Wilcox and Webster have divided these symptoms into three classes" as follows : 1. Slight; nausea and vomiting, rise in temperature of 1 to 2 de grees, headache, diarrhea, and occasionally albuminuria. 2. Severe; an exaggeration of the above symptoms with rigor, pain in the limbs, hemorrhages from the mucous membranes, dysp nea, weak, thready pulse, coma or delirium, and occasionally an urticarial rash. 3. Symptoms of acute arsenical poisoning; observed in cases re ceiving a second dose before the arsenic contained in the first has been excreted. In as much as arsenic is chiefly eliminated by the kidneys, individuals suffering from some form of nephritis are the type of patients concerned in this class. An idea of the frequency of severe and fatal reactions may be obtained from the following reports, selected from the voluminous literature pertaining to this subject. Ellis obtained severe reactions in 50 per cent of a large series, the exact number not given. One case developed severe nausea, which persisted for four days. Ormsby and Mitchell report 28 severe reactions in 127 injections of neosalvarsan. Most of the patients complained of a taste and smell of ether as well as of gastrointestinal and nervous symptoms. Moody reports a death following the injection of neosalvarsan. The patient was a woman in poor physical condition. Coma de veloped in 12 hours, and she died 4 days later. The autopsy was negative. Kerl reports the death of a young male and attributes the fatality to a weakened condition of the circulatory system due to the abuse of alcohol. Kahle reports a death following the use of neosalvarsan, the autopsy showing acute nephritis. All of these observers are of the opinion that the present supply of both drugs is much more toxic than the original German prepa ration. This is emphasized by Fleet Surgeon Kilroy's report of 1913. Kilroy administered salvarsan to 1,000 patients, with no deaths and a very small number of severe reactions. The causes of the reactions may be conveniently grouped under two headings, those relating to the patient and those having to do with the preparation used. Certain individuals apparently have an idiosyncracy for arsenical compounds. Wechselman in 1910 pointed out that healthy young adults may succumb and at autopsy show slight or no pathological changes. 160 REPOET8. Vol. XIII. Patients suffering from organic heart disease or an impaired car diovascular system due to alcohol or long standing lues are especially prone to develop severe reaction. A number of instances of encephalitis following the injection of these drugs to cases of advanced cerebral syphilis are recorded. By far the most important cause of profound shock or death is an impaired kidney function, due to an acute or chronic nephritis. Ar senic compounds act in two ways in such cases. As noted above, they may exhibit a cumulative action, due to delayed excretion. A uremia and intoxication may develop due to an acute nephritis caused by the action of the compounds on the kidneys if these organs are already impaired by an old process. Brown and Pierce have proved that all arsenic compounds used therapeutically are capable of producing nephritis in animals when injected in doses considerably below the lethal. Salvarsan and neo-salvarsan are both complex chemical compounds and unless carefully made by experienced chemists can contain very toxic substances. Both of the drugs as obtained on the market contain some amino-oxyphenol arsenoxid, usually less than 1 per cent. On exposure to the air or from improper preparation this oxidation prod uct is rapidly formed. Amino-oxyphenol arsenoxid is some 20 times as toxic as the hydrochloride salt. It is for this reason that the drug can not be used after being dissolved for any length of time. Early workers attributed many severe reactions to the use of im pure water. Yakinoff points out that if the water used contains bac teria or their proteins, the addition of salvarsan renders these pro teins toxic and the solution becomes 2 to 8 times as toxic as normally. This is essentially the " wasser fehler " theory of Wechselman. Neisser and others believed that the symptoms were due to the ac tion of the endotoxins contained in the bodies of the treponema and liberated when these organisms were destroyed. Numerous workers have proved that exactly the same syndrome may occur in nonluetics and can be produced in animals. To summarize, severe reactions are due to an unusually toxic prep aration. To quote Wechselman, " insufficiency of the kidney and not hypersensitiveness of the brain is the point of the entire question of salvarsan fatalities." Following is a report of an unusually interest ing case of death after the second dose of salvarsan : M. V. M., pharmacist's mate, third class; age 24; white. Enlisted from New York February, 1914, and was transferred to the naval hospital at Canacao, P. I. History uneventful until October 23, 1914, on which date he con tracted gonococcus infection of urethra, which ran an unusually severe course. On recovering he was transferred to the U. S. S. Brooklyn. Gives a history of repeated sprains of joints. No I 161 REPORTS. May 23, 1916, developed gonococcus arthritis of sacro-iliac and both ankle joints, and was transferred to the naval hospital at Yoko hama, Japan. Bedridden until July 9. History at this time of ex cessive alcoholic indulgence. On September 20, 1916, was discharged from hospital but still had slight trouble with ankle joints. Transferred to the receiving ship at San Francisco. While on this duty he had a reputation among his shipmates for habitual alcoholic and sexual excesses. On one occasion a corpsman saw his companion administer to him an infusion of digitalis while he, M., was partially intoxicated. He complained frequently to other corpsmen of being short of breath and of palpitation following any unusual exertion. On field days he was forced to rest frequently due to symptoms noted above. He withheld this history from the medical officer on being admitted to this hospital (Mare Island). Heart examination negative; urine was not examined. December 28, 1917, admitted to this hospital with a relapse of old urethral infection. December 27, 1917, following Christmas leave, he developed a chancre on glans. Wassermann at this time was negative On January 15, 1918, he complained of intense headaches, necessi tating the administration of morphine. He was given mercury iodide pills gr. $ t. i. d. and mercury inunctions drachms i once daily. Headaches cleared up under this treatment. January 18, 1918, Wassermann double plus. Secondary rash well developed. January 21, 1918, given 0.6 grams salvarsan. Has a moderate re action with nausea and anorexia. January 28, 1918, given 0.6 grams salvarsan, at 10 a. m. Twelve other patients received salvarsan from the same packages on this date. No other severe actions resulted. At 1 p. m. had a severe chill with sweating lasting 45 minutes followed by fever 102° and weak pulse. The same evening he complained of air hunger and was delirious at times. January 29, 1918. Complained of feeling of suffocation and dis tress over entire chest. Considerable amount of dark bloody ma terial coughed up. During the day he vomited bile and stained material, and complained of intense pains in knees, calves, and toes. At times he was delirious. During the afternoon 350 c. c. of urine were voided. At 9 p. m. he became convulsive and it was necessary to restrain him. Ten minutes later death occurred. Autopsy report.—Subject is a well-developed, muscular, young adult. Lividity and rigor mortis present. A large chancre with indurated margin present on glans. Skin and membranes are other wise negative. Usual median incision reveals a fair amount of sub 162 REPORTS. Vol. XIII. cutaneous and omental fat. No excess of fluid in peritoneal or pleural cavities; a slightly excessive amount in the pericardial sac. The heart had stopped in diastole; the right auricle is moderately dilated. A milk plaque 5 cm. in diameter is present on the anterior aspect of left ventricle. The musculature of the heart appears lighter in color than normal and is rather flabby in consistency. The coronary arteries appear normal. Both cusps of the mitral valve are distinctly thickened, especially at the area of approxi mation ; thi§ thickening is well organized. No acute vegitations are present. The valve was apparently in a functioning condition. The remaining valves appear normal. The first portion of the aorta shows numerous small areas of very early atheromatous degenera tion. These do not appear to be syphilitic in origin. Microscopi cally the musculature shows numerous small areas of fibrosis. There is no fatty degeneration present. The lungs are voluminous and did not collapse when the chest was opened. No pleural adhesions. The surfaces are dark red in color; the entire lungs are firm, less crepitant than normal, and on palpation water-logged. On sectioning a considerable quantity of blood-tinged fluid escaped. No evidences of tuberculosis noted. The liver appears slightly enlarged and is softer and lighter in color than normal. On section the surface is a light yellow, uniform throughout. The lobules are not discernible. Microscopically the nuclei of the cells around the central vein stain poorly and contain many fat droplets, denoting early central necrosis. The spleen is normal in size, but distinctly softer than normal. The Malphigian bodies can not be seen. Microscopically this organ is negative. The appendix is about 8 cm. long and presents an acute kink. It is firmly bound to caecum. No evidences of acute process are pres ent. The remainder of the gastrointestinal tract is negative. The kidneys are normal in size ; the capsule strips easily ; on sec tion the capillaries of the cortex and medulla are very distinct. Mi croscopically the tubules appear normal. The capillaries of the Malphigian bodies and the tubule capillaries are intensely con gested. There is a large number of red cells present in the intes tinal tissue. The ureters are normal. The bladder contains 100 c. c. of dark urine. No pathological changes. The prostate is enlarged; on section no abscess forma tion is noted. Microscopically it shows an excess of fibrous tissue; also small areas of scar formation. The tubules of the testes strip normally; microscopically negative. Post-mortem diagnosis: Chronic myrocarditis. Chronic produc tive endocarditis, affecting mitral valve. Edema of lungs. Early No. 1. 163 REPORTS. central necrosis of liver. Acute hemorrhagic interstitial nephritis. Chronic prostatitis. Chronic appendicitis. The cause of death in this case was doubtless the toxic action of the arsenic on a heart weakened by the valvular condition and the myocarditis. Both of these conditions are easily explained by the history of gonococcic bacteraemia. It is probable that a cumulative action occurred, as the nephritis and central necrosis of liver point to this. Had the individual had an idiocyncracy to the drug, the first dose should have been followed by more severe symp toms. The preparation of salvarsan injected may have been slightly more toxic than usual, but the fact that no very severe reactions occurred in the other 12 patients tends to invalidate such an assump tion. SANITARY REPORT ON TEE ISLAND OF CORFU. By. H. Shaw, Lieutenant Commander, Medical Corps, United States Navy. According to official figures obtained at the mayor's office the present population of the city is 30,000. No epidemic diseases are prevalent at this time. It is estimated that 15,000 Serbians died here from cholera and typhus two years ago. Malaria is endemic. There is much poverty in Corfu, and the price of food is exceed ingly high, which may in part explain the immorality and many degenerate practices so common here. According to the observations made at the meteorological bureau of Corfu the maximum temperature for 1917 was during the month of August 35.2 C. and the minimum temperature was in December ber — 1.1 C. During eight months of the year the prevailing winds are south-southwest. In the city of Corfu the anopheles mosquitoes are rare, but in the country and in marshy districts they are very numerous. Both flies and fleas abound and are the source of much annoyance. Cock roaches, bedbugs, and lice are present in large numbers. The city is practically without sewerage but has good natural drainage. There is a varying elevation above sea level of 50 to 100 feet. There are numerous good camping sites in the country, but in the city itself the only vacant space is the esplande, which has an ex tent of about 15 acres. No definite information is available in regard to the quantity of the water supply but His Britannic Majesty's consul reports that it is ample for the present population. The quality of the water is excellent. It is collected from uncontaminated sources in the hills and brought to the city by a system constructed by the English during their occupation of the island. Purification of the water does not seem necessary. 164 Vol. XIII. REPORTS. The quality of the food is very poor and it is very expensive. Bread is made principally from maize. Meat can only be procured in small quantities, mutton being the commonest variety and retailing at about 70 cents a pound. At this writing coffee can not be bought in the open market. Sugar sells at several francs per pound. Tea costs 8 francs per pound. Beef when obtainable costs $1.40 per pound. Eggs cost 10 cents apiece. Fortunately fruit is abundant and of good quality, and cheap. Medicines can be obtained in small quantities from the numerous drug stores in the city. There are two large buildings suitable for use as emergency hospitals. One of them is the former residence of Prince Andrea, of Greece, known as Mon Bepos, and located in the suburbs. The other is the governor's palace which stands in the heart of the city. The quarantine regulations which obtained under the Greek Government are no longer in force since the English and French assumed the jurisdiction of the place. There are no provi sions for cremation, and bodies can not be disinterred until three years after sepulture, police permission being necessary. The Eng lish have a small cemetery just beyond the city limits. The languages commonly spoken in Corfu are Greek, French, and Italian. THE MARCH AND THE SHOE.' By W. Tj. Mann, Lieutenant Commander, Medical Corps, United States Navy. It appears to be almost impossible to give too much attention to the care of the feet. There has been some work done on this subject at this station, and it is our desire to devote more time to this im portant subject. The post surgeon has kept in touch with the ortho pedic department of the United States Army and has utilized to some extent the results of their studies of this question. At present the entire command are having their feet measured and the measurements are being recorded in the enlistment record for future reference in drawing new shoes. The process is as follows : (a) The size of the shoe the man is now wearing in heavy marching order is recorded; (b) the foot is measured by an automatic measuring device, which gives the length and width; (e) then the inch stick measurement is used as a check; and (d) finally the results of the above are verified by the actual fit of the shoe by an experienced shoe fitter. The data obtained from the last three sources correspond very closely. The size of shoe now being worn by some of the men was found to be one-half to two sizes shorter than the actual foot measurements. 1Extract from monthly sanitary report, June, 1918, Marine Training Camp, Quantlco, Va. No.l. 165 REPORTS. The results of this series of foot measurements strongly indicate that the company commanders have failed to personally supervise the fitting of shoes, as is required by Marine Corps regulations. A comparison of the foot measurements of the hospital corps with the marines showed that the hospital corps averaged a half size smaller and almost one width narrower. This was presumably due to the fact that the marines have done more inarching and have developed the military foot to a certain degree. The hike of the artillery regiments to Fredricksburg and return furnished some interesting data for observing the effects of misfitting shoes and improper footwear. It is interesting to note that these 1,000 men on the fifth day of the hike made the entire trip from Fredricksburg to Quantico in one day, a distance of 31 miles, carry ing the heavy pack and rifle, a total weight of about 40 pounds, nearly the entire distance. This was rendered possible by the stamina and morale of the men in withstanding a large degree of foot injuries without incapacitation. About 90 per cent of the men presented some form of foot trouble. In many cases the cause was the lining of the shoe wrinkling or becoming torn and worn, creating roughened places which causes friction. In about 40 per cent of the men, injuries were noted about the tendo Achillis. The chief source of this trouble seemed to be the leggings, either due to a misfit about the ankle or caused by the leggings becoming wetted with perspiration and " wilting," forming wrinkles which rubbed the back of the leg. In about 25 per cent of the cases, blisters were present on the great toe. This was possibly due to the pattern of the Marine Corps shoe. It seems to be universally accepted that the Munson last gives the most desirable results. This type of shoe permits the great toe, the ball of the foot, and the heel to act in a straight line (" Gibson " line). In the Marine Corps style of shoe the great toe is bent slightly outward, and this often results in injuries to the inner side of the toe. It also acts to some extent in preventing the maximum leverage action of the big toe. It is proposed to have one of the medical officers of each of the regiments which are to be formed at this station designated as " regimental orthopedic surgeon," who will formulate the necessary rules and regulations for the care of the feet. THE INTRACUTANEOUS TUBERCULIN TEST IN YOUNG ADULTS. By E. Moody and C. P. Carter, Lieutenants, Medical Corps, United States Naval Reserve Force. A great deal of work has been done within the past few years to prove the relative efficacy of the various skin tests for tuberculosis 166 REPORTS. Vol. XIII. with the result that a vast amount of literature on the subject has been published. Veeder and Johnston (1) working with children in St. Louis found that the skin tests were of undoubted value and drew the conclusion that the intradermal test was of somewhat greater value than the ordinary von Pirquet test. Bass (2) has recently verified their conclusions on a large series of children in a New York City orphan asylum and states emphatically that the intradermal test is of much the greater value of the two. He also went to a great deal pains to prove that the positive intradermal reaction was not the result of a particular skin sensitiveness other than the actual reac tion to tuberculin. Wittich (3) does not believe that there is specific value in the skin tests in adults for differentiating between infection and disease, while Kyan (4), reporting on the modified Detre test, feels that a great deal can be expected from skin tests in the adult in both diagnosis and prognosis. Our series is reported, not because we think that any special conclusions can be drawn from our observations, but because we feel that such material as was used for this test—that is, young men between the ages of 18 and 25 who have passed at least two rigid physical examinations before their admission to this hospital and who have been under careful observation since their transfer here— should prove valuable for such work in establishing normal stand ards and in the hope that it may be of value to others carrying out similar work. We have used as a standard test the intradermal injection of TTJ4nr mg. of old tuberculin given in -^ c. c. of normal salt solution. Observations were made at the end of 8, 24, and 48 hours, and only those cases where the reaction appeared within the first 24 hours and reached a maximum redness in 48 hours were considered positive. The positive reactions were verified by a second test, and by a positive von Pirquet. The results in all cases are shown in Table No. 1 and the results classified according to disease in Table No. 2. Table No. 1. Total number of cases 187 Positive clinically (tuberculosis) 8 Positive intradermal 10 Positive von Pirquet 12 Positive intradermal and von Pirquet 7 Positive intradermal, von Pirquet, and clinically 6 Positive von Pirquet, negative intradermal 4 Positive von Pirquet, negative intradermal, positive clinically 1 MAIN DRILL HALL AS A DORMITORY, TRAINING STATION, SAN FRANCISCO, CAL. I ' i v DRILL HALL WITH SCREENS ON EACH COT TO PREVENT SPREAD OF DISEASE BY SNEEZING AND COUGHING. 1B7-1 tfo. 1. REPORTS. 167 Table No. 2. Positive intrader mal and von Plr- quet. Diagnosi Number of cases. Positive intrader mal. Positive von Pir- quct. Pneumonia 8 7 38 60 12 11 32 6 13 7 8 7 Skin disease (Bcabies, ringworm) 1 1 Syphilis 2 1 1 1 Total 187 10 12 7 It is interesting to note that the cases clinically positive gave positive reactions to both tests. Cases considered clinically positive were diagnosed either on fairly positive chest findings borne out by the X-ray, temperature reactions, etc., or by the finding of the tubercle bacilli in the sputum. Thirty-three cases reacting negatively to both tests were given jtJ'fo- and mg. of old tuberculin subcutaneously and the tempera ture recorded carefully for 48 hours while the patients were in bed. None of the 38 gave positive reactions. REFERENCES. (1) A'eeder and Johnston: The Frequency of Infection with the Tubercle Bacillus In Childhood. Am. Jour. Dis. Child., lx, p. 478. (2) Bass: Cutaneous and Intracutaneous Tuberculin Tests. Am. Jour. Dis. Child., xv, p. 818. (3) WIttich: Comparison between Skin Tuberculin Tests. Am. Rev. of Tu berculosis, I, No. 11, Jan., 1918. (4) Ryan : Tuberculin as a Diagnostic Test of Tuberculosis In Man. Jour. Am. Med. Assn., lxx, p. 982. BED SCREENS IK BARRACKS.1 By P. S. Rosbitbr, Commander, Medical Corps, United States Navy. The accompanying illustrations show what has been found to be a very satisfactory sneeze screen for use at this station. One of the pictures illustrates the method of berthing in the main drill hall prior to use of the sneeze screens. In this method men are berthed head and feet on 5-foot bunk centers. With a sneeze screen heads are all in the same direction. 1 Fxtrnct from rteport to Surgeon General. Oct. 10, 1918. 168 Vol. XIII. REPORTS. The screen is cheap and simple in construction, easily erected, and very efficacious. It consists of unbleached muslin, 1 yard wide, tacked to three 1-inch uprights 4 feet long. During the day these are rolled up and stowed or aired on the air-bedding racks. At night the screen is unrolled and fastened by clothes stops to the legs of each bunk When pitched in rows as shown in the photograph, it has been found that stopping the outboard head upright of one to the outboard foot upright of the next bunk tautens and strengthens the line. INFLUENZA OH A NAVAL TRANSPORT. By W. F. McAnally, Lieutenant, Medical Corps, United States Navy. During the past six months we have treated over 100 cases of influenza and pseudo-influenza. These occurred in the proportion of about 30 per cent of the former and about 60 per cent of the latter. At no time did the disease tend to assume an epidemic form, which fact is possibly due to the thorough prophylaxis which is insisted upon. A typical case of influenza occurs after an incubation period of one to three days. The attack is generally marked by a chill of greater or less severity, followed by fever ranging from 101° to 104° or higher. The patient complains of aching pains in the trunk and extremities, headache, and general malaise. He looks and feels sick. Upon examination, in practically every case of our series, there has been found a more or less severe inflammation of the nasal mucous membrane and tonsillar rings; in some few cases there has been a distinct streptococcic tonsillitis, which was generally very obstinate to treatment and persisted even after the original influenza had cleared up entirely. These symptoms generally appeared on the third or fourth day of the disease. The treatment has been generally very satisfactory and was prac tically the same in all of our cases, i. e., rest in bed, free catharsis, Do- bell's solution or a 1 per cent solution of chlorazene as a gargle every two hours, aspirin grs. x and sodium bicarbonate grs. xx t. i. d., together with the subcutaneous injection of influenza bacterin mixed (Mulford), a primary dose of 1/2 c. c. being given upon admission and followed at four-day intervals by two or three secondary doses of 1 c. c. each. Following one, or in some cases two, injections of influenza bacterin and the general treatment as outlined, most of the typical cases were generally discharged to duty in three or four days. Injections of 1/2 c. c. of the bacterin upon admission, followed at four-day in tervals by injections of 1 c. c. has been productive almost invariably of exceedingly good results. From one to six hours after the primary No. 1. 169 REPORTS. injection there is a more or less severe exacerbation of the symptoms, but we have yet to see a case in which a serious reaction occurred. In the second type of cases, which we have called pseudoinfluenzal for want of a better name, our treatment has not given such good results, although they were seemingly the result of a much mildei infection. The following case illustrates this type : C— Frank, admitted to the sick bay July 15, 1918, complaining of sore throat, slight headache, and muscular pains; temperature, 100.4° ; there was a slight inflammation of the nasal and pharyngeal mucous membranes; heart and respiration normal. Treatment: Bed; magnesium sulphate, oz. li. aspirin, grs. x, sodium bicarbonate, grs. xx t. i. d. ; Dobell's gargle; silver nitrate (10 per cent) locally to throat t. i. d. Influenza bacterin 1/2 c. c. was given subcutaneously upon admission. There was apparently no reaction after the bacterin injection. July 16, 1918: There is very little change; temperature, 99.8 '; patient still feels badly, with aching pains in legs and headache. July 19, 1918: Improving slowly; temperature ranging from 99.8° to 100.2°; tonsillar rings and tonsils inflamed; influenza bacterin 1 c. c. injected s. c. ; no reaction; no muscular pains nor headache. July 23, 1918: Discharged to duty. No symptoms other than a slight redness of the tonsillar rings; slight variations in temperature from normal to 99.3°. Treatment continued. This case was mild throughout; there were never any severe mus cular pains nor headache; fever was low, and the respiratory symp toms were not marked. It and all the cases of this type resembled influenza very closely, except in the severity of the symptoms; fur thermore, all these cases of pseudoinfluenza give very little or no reaction to the influenza bacterin, and the course of the disease has. not been influenced by it. In our series of over 100 cases careful records were kept in only about 25 instances. While this number is entirely too small to be a basis for any definite statements, and while the cases were not worked out bacteriologically in the laboratory, it seems that we are justified in the following conclusions : 1. There are two varieties of infection giving practically the same train of symptoms, the only difference being in the severity of the process, one of these being influenza, with the classical symptoms and due to a specific infection. The other, pseudoinfluenza, seem* to occupy a position midway between a " cold in the head " and influenza and is not due to the same infectious agent. 2. That for the treatment of influenza we have a specific bacterin,. which in our hands and when given in a primary dose of 1/2 c. c. subcutaneously, followed by one to three secondary doses of 1 c. c. each, has given very satisfactory results, patients rarely remaining 88977—18 12 170 VoL XIII. BEPOBTS. in the sick bay over three to five days. Also, that this specific bacterin has no appreciable effect upon cases of the pseudoinfluenzal type. The above results would have been more satisfactory had we been able to follow up our cases bacteriologically, and it is hoped that some one will report a series of similar cases in which this data will be available. THE TREATMENT OF CHANCROIDS AND THE PRETENTION OF BUBOES. By Q. W. Mills tt, Lieutenant. Medical Corps, United States Navy. The object to be gained in the treatment of chancroidal infection is twofold. First, to heal the ulcer; second, to prevent the forma tion of a bubo. The time spent in hospitals from chancroidal in fections is largely due to infections of the inguinal lymph glands, and not due primarily to the lesions on the penis. When an ulcer is cauterized with heat or a strong reagent there is much necrosis of the surrounding tissue. In a short time this cauterized dead tissue affords a splendid medium for the growth of the organisms which are present in the vicinity. This secondary infection in many cases is as bad or worse than the first one, due to the fact that the tissues have lost their power of resistance. As a result the infection spreads to the lymph channels and is carried to the inguinal glands, and a bubo is formed. The majority of buboes contain sterile pus, or pus containing a mixed infection mainly of staphilococci or streptococci. In the ex amination of 24 consecutive cases of bubo, 20 contained staphilococci as the prevailing organism, and 13 contained only staphilococci or staphilococci and streptococci. Many observers have failed to find the Ducrey bacillus in the bubo, while some observers have with drawn the pus and inoculated it and failed to produce the character istic soft sore. All these facts tend to point toward the theory that buboes are usually formed by secondary infection of the ulcers. During the months of April, May, and June, the cauterization treatment was used on all cases of chancroid infection entering the United States Naval Hospital, Canacao, P. I. The number of sick days due to buboes during this quarter were 540. The total number of sick days for this quarter w*is only 4,150; therefore over 13 per cent of all the sick days were due to buboes. During the month of July cauterizing was not done, but after thorough cleansing of the chancroids with hydrogen peroxide or bichloride of mercury, they were treated with a 10 per cent solution of copper sulphate, and after 5 or 10 minutes a dusting powder, preferably aristol, was ap plied or they were dressed with a wet antiseptic dressing. The sore should be dressed in this manner night and morning, or oftcner. During this month we had only " jo viNOwnaNd vzNarndNi 'i aivid 9,.40,>i i*/>i »» 11 1j u i Hut^uBrluiosiy ,,.... m,| P«" •innwdpoof) No. 2. GOODPASTURE AND BURNETT—PNEUMONIA. 183 acter of exudate are obvious, no especial relation of the inflammation to bronchi is evident in the acute lobar inflammation. Gross sections, through partially consolidated lobes and through isolated areas of consolidation, may and usually do show evident relation of the in flammation to bronchi. One finds small, discrete, grayish-purple areas (up to 1 cm.) of consolidation grouped about a bronchus and slightly elevated above the surrounding tissue, or there may be a more diffuse consolidation occupying and extending from the region of a bronchus. These vary in color ; some are gray and grayish purple, others hemor rhagic. Such areas represent older lesions than the more extensive lobar inflammation, as indicated by the protocol given below. The mucous membranes of the larger bronchi are dark reddish purple in color, while those of smaller branches may appear pale and smooth. Their content is serous, and no pus is anywhere evident. The following protocol is appended because the progress of the pneumonia as recorded clinically may explain in part certain differ ences in the anatomical appearance of the lesions in various areas. In this case the first evidences of pneumonia were detected clini cally four days before death. The lungs are extremely wet and boggy. Both are voluminous and extensively consolidated. Not withstanding the extensive consolidation, it is remarkable that there is so little evidence of pleural involvement. Clinically the pneu monic process began in the upper portion of the upper right lobe, yet the pleural surface here is as smooth, moist, and devoid of visible exudate as the remainder of the lung. Both lower lobes are espe cially consolidated posteriorly ; also most of the upper left and right lobes, the middle lobe being almost free. The only evidences of pleural inflammation are found over the widespread consolidated regions. These consist of subpleural hemor rhages varing in appearance from minute innumerable purplish-red dots, over which the pleura appears smooth and shiny, to fairly extensive irregular red areas (2 to 3 cms.) over which the pleural surface by reflected light is faintly granular. The extensive edema of the lung generally is indicated by the wet, shiny, boggy appear ance of the surfaces. Between the lobes of the lung the edema is very apparent as a watery effusion in the loose subpleural connective tissue. Cut section through the consolidated areas in the right upper lobe where the pneumonia began presents a very wet surface and there are fairly well circumscribed patches of consolidation along indi vidual bronchi parallel with their course. Although these patches are fairly distinct, they fuse to a certain extent. They average one-half cm., and are slightly elevated above the surface and when the excess of fluid is scraped off they are finely granular, irregularly round and grayish purple in color. The thin-walled bronchi do not appear to be dilated; their walls are collapsed and pale gray. The larger 184 GOODPASTURE AND BURNETT—PNEUMONIA. Vol. XIII. bronchi are extremely congested. The alveolar tissue between the elevated patches is filled with fluid, has a solidified appearance and when pressed exudes a bloodstained serum. The unconsolidated portions are quite emphysematous. The lower right lobe, where pneumonia next became evident clinically, is almost completely con solidated, extremely wet and boggy. The inflammation seems to have spread more rapidly than in the upper lobe. The consolidation appears to be bronchial in distribution. The larger branches of the bronchi are surrounded by a wide zone, dark purple in color and granular on the surface. Between these areas the tissue is slightly depressed, paler purple and smoother. More fluid can be expressed from the intervening tissues than from the firmer areas, bu^ no air is present. The cut surface of the lowerfIfeft lobe, where the inflam mation last appeared and consequently not more than two days old, shows an even more uniform and diffuse type of solidification. The tissue is elastic and very wet, and one can not discern a definite bronchial distribution, though certain groups of lobules are darker purple and firmer than others.1 One is led to infer from such a case that in the areas of earliest extension from bronchi into alveoli there is more resistance to the injury of the infection than later in the disease. This is indicated by the circumscribed broncho-pneumonic patches representing the first lesions. Later the process spreads more rapidly and diffusely elsewhere, the exudate becoming less cellular. A still more rapid progress may result in a fulminating inflammation of an entire lobe, the exudate being largely serous, fibrinous, and hemorrhagic, the content of the various inflammatory elements varying some what in different areas. In sections studied microscopically from this early stage of pneu monia it is more evident than in gross that a general bronchitis, and especially bronchiolitis, precedes the infiltration of alveoli. One finds in unconsolidated areas bronchioles filled with an exudate composed of polymorphonuclear and mononuclear leucocytes, with varying amounts of fibrin and amorphous hyaline material. The mucosa may be intact or desquamated and ulcerated. The infundib- ula and air vesicles subtended by the bronchiole may contain an exudate of leucocytes with little or not^fibrin, forming a small focus of broncho-pneumonia. More characteristic of this stage of in flammation is a lesion of the walls of certain infundibula and air vesicles in the neighborhood of and within the latest areas of con solidation. A hyaline membrane partially or completely covers the walls of these air spaces. The membrane is irregular in thickness, sometimes stratified with occasional cells within narrow clefts. It tends to be thickest over the angles of the wall, though it may be so abundant as to fill an alveolus. There is no epithelial lining be- a E : o P N O 3 No. 2. GOODPASTURE AND BURNETT —PNEUMONIA. 185 neath; and it may be continuous with strands of fibrin. Its ap pearance gives the impression that it is composed essentially of fused threads of fibrin. This lesion is not uniformly distributed throughout the lung and is most prominent in the neighborhood of recent areas of consolidation, disappearing or becoming obscured with the advance of the inflammation. In the larger areas of lobular pneumonia and in the diffusely con solidated lobes there is a severe and widely destructive injury which has spread rapidly through the lung, destroying the epithelial lining y of alveoli, rupturing capillaries, and often in large foci completely destroying alveolar walls, rendering the pulmonary structure un recognizable. The air spaces are filled with coagulable fluid, fibrin is deposited in membranous fashion along alveolar and infundib ular walls or in a delicate or dense network within the lumina, the interstices of which contain serum, erythrocytes, and leucocytes in varying proportion. Where the injury is most severe a large area is filled with erythrocytes, fibrin, scattered epithelial cells, and remnants of alveolar walls. Elsewhere the capillaries are engorged with blood and erythrocytes are escaping in great numbers by dia- pedesis and vascular rupture. The proportion of leucocytes varies, but at this stage they do not constitute a conspicuous part of the picture. The majority are polymorphonuclear, though there is a relatively large number of mononuclear cells of various kinds, some of them desquamated epithelium and wandering phagocytes, others lymphocytes. In older foci of pneumonia, leucocytes are the predominant inflamma tory element, with small amounts of blood and fibrin, but in the dif fusely consolidated patches or lobes of short duration, serum, fibrin, and red blood cells are most conspicuous. Especially prominent are the large areas of hemorrhage from capillary rupture. Large mononuclear phagocytes containing blood pigment are frequently observed within these patches. Where the alveolar walls are more intact, leucocytes and erythrocytes lie beside the capillary channels from which they have escaped. In certain areas numerous focal necroses of alveolar walls, with fibrinous thrombi plugging the capillaries and fragmentation of nuclei, are observed. The smaller bronchi present older lesions than those within the alveoli. They contain plugs of leucocytes, fibrin, and hyaline material, and their epithelial lining is partially or completely ulcerated and covered by a fibrino-purulent membrane. One of the most impressive features of the section is the dilated, empty condition of many infundibula which stand widely open in the midst of alveoli filled with exudate. At times they are filled with coagulable fluid. In sections from such acutely inflamed lungs there may be no < demonstrable organisms either within the exudate of smaller bronchi 186 GOODPASTURE AND BURNETT—PNEUMONIA. Vol. XIII. or alveoli, although pure cultures of influenza bacilli -were isolated i from them. In somewhat later stages with similar injury and exu- J date, these organisms have been demonstrated in great numbers both intra- and extra-cellularly. They are ingested both by poly morphonuclear and mononuclear phagocytes. Within the latter they may be aggregated in minute spherical groups. Within the alveoli they stimulate an immigration of leucocytes. The nature of the above-described lesions and their presence in three very early cases in which micro-organisms were not demon strable in sections, and in one case with sterile cultures, indicate that the extensive injury may be brought about by an extremely toxic substance elaborated within and disseminated through the larger air passages to the more delicate structures of the lung. This hypo thetical toxic agent has little chemiotactic action toward leucocytes, but rapidly attacks the alveolar walls and their capillary bed, injur ing them to the point of rupture, and stimulating a fluid exudate in great quantity. The product of this preliminary reaction forms a favorable medium for whatever pathogenic organisms are at hand. Influenza bacilli enter through the bronchi, alone or together with pneumococci, streptococci, or staphylococci. These secondary in vaders, multiplying with great rapidity, give rise to further injury and inflammatory reaction more or less characteristic for the type of organism concerned. The recognition that there is a primary diffuse and extremely severe toxic type of injury to the lung in influenza affords a rational basis of explanation for the varied bacteriological and pathological results which have been so confusing, and at the same time establishes a pathological process which may be considered peculiar to this form of the disease. Following this initial injury the influenza bacillus may invade the alveoli over wide areas. Here they stimulate an immigration of polymorphonuclear leucocytes which rapidly ingest them. They are also actively phagocyted by large mononuclear cells. We have seen two cases in which these organisms were demonstrated in sections within the alveoli in large areas of consolidation. The exudate in these is predominantly cellular, with some serum and erythrocytes and little fibrin. But there is usually only a local invasion by these organisms within a group of alveoli about terminal bronchi. The localization of the infection begins four or five days after the initial injury. This is first evident in gross in the firmer, usually centrally situated areas of consolidation, which represent the earliest regions of involvement. A thin gray or yellowish gray zone appears about the bronchioles and infundibula, the width of each focus measuring 1 mm. or less, three or four of which are present in each lobule. No. 2. GOODPASTURE AND BURNETT—PNEUMONIA. 187 The intervening tissue is still purple, hemorrhagic, smooth, and firm. Later similar foci appear farther out toward the surface and within lobules which are not so firm, more edematous and less hemorrhagic. In contrast to the diffuse serous, hemorrhagic, fibrinous, and cellu lar exudate, these secondary foci are composed almost entirely of cells, polymorphonuclear and mononuclear, which fill the bronchi oles and several adjacent alveoli. If fibrin previously was present it is dissolved by the leucocytes. Influenza bacilli have been demon strated in such areas in great numbers within both bronchi and al veoli. As the foci increase in size, fluid exudate is absorbed and or ganization begins in the alveoli between them and within the exu date of bronchi where micro-organisms are less numerous. At the end of two weeks the most prominent feature of the fresh section of lung is the presence of numbers of these now yellow or grayish- yellow foci measuring 3 or more millimeters in diameter. In many of them a yellow opaque center with peripheral gray semitrans- lucent zone can be detected, representing organization about small abscess cavities. The fluid of the initial edema is absorbed so that at this time the surface is fairly dry. The surrounding alveolar tissue has a bright red color, from the reestablishment of circulation and the formation of new capillary channels within organizing exu date. One may find also bright red hemorrhages where blood has escaped into healing alveoli. In areas where the injury has been more severe an entire lobule or groups of lobules may appear yel low or grayish yellow, smooth, and firm. The yellow color is par tially due to large mononuclear cells within healing alveoli, the cyto plasm of which is filled with fat droplets. Two cases with pneumonia of 15 and 16 days' duration, the lungs of which yielded pure cultures of the influenza bacillus, have been observed in this series. The pathology in the lungs of each was es sentially the same. The following protocol is illustrative of this stage. Duration of pneumonia, 16 days. No excess of fluid in left pleural cavity; about 50 c. c. in right. Lungs are voluminous and pale pink anteriorly ; emphysematous between patches of consolidation. Inter lobular veins injected bright red. Left lung.—There is a thin fibrino-purulent exudate over anterior and lateral surfaces and between the lobes. Posterior half of lower lobe almost completely consolidated, light purple in color. Sub- pleural hemorrhages posteriorly over upper lobe. There is no edema. Section through posterior portion of lower lobe shows dif fuse broncho-pneumonia, characterized by the presence of multiple, •elevated, grayish and yellow foci of consolidation about terminal 103396—19 2 188 GOODPASTURE AND BURNETT—PNEUMONIA. Vol. XIII. bronchi, measuring 2 to 5 mm. The bronchi are moderately dilated, and their mucosa appears edematous and thickened. Thick yellow pus can be expressed from them. Intervening alveolar tissue is red or purple in color with a fine grayish or yellow stippling partially outlining alveoli. This tissue is elastic, moist, semitranslucent, and is devoid of air. There is no evident pleural inflammation over these areas. The surface is smooth, glistening, mottled purple and pink, corresponding to consolidated and air-containing tissue. Mucosa of larger bronchi only slightly injected. Anteriorly in the lower lobe are patches of consolidation, bronchial in distribution, measuring 2 by 3 cm.; some of these are quite hemorrhagic in appearance, that is to say, the alveolar tissue between yellow foci has a dark purple color. Over this region is a thin fibrino-purulent pleuritis. In the anterior half of the upper lobe the lung tissue on cut surface is very pale and grayish yellow in color. Here there are innumerable firm, yellow peribronchial areas of consolidation, which are larger and more diffuse than in lower lobe. Near the hilum is a patch of uniform, smooth, moist, gray consolidation. Right lung.—Lower lobe completely and firmly consolidated: posterior halves of middle and upper lobes completely consolidated but nodular. Anterior halves of these lobes almost entirely consoli dated, but mottled with groups of lobules which are pink, em physematous and air-containing. The cut surface of these lobes presents changes which are quite similar to those on the left side. The lungs in general resemble those of an extensive tuberculous broncho-pneumonia. Corresponding to the widespread injury and destruction noted in the early stages of the disease, one finds in these two cases of longer duration extensive organization and fibrosis of the lung. The fibrinous exudate in alveoli has been invaded and absorbed by fibroblasts and capillaries from adjacent alveolar walls. In many- places the architecture of the lung is completely obliterated, and there remains only a young vascularized fibrous tissue including particles of incompletely absorbed fibrin. Small areas of hemor rhage are present, and occasional contracted alveoli lined by vacuo lated cuboidal epithelium. Polymorphonuclear leucocytes are rela tively few, but numbers of lymphocytes and plasma cells have ap peared. They are numerous within the organizing tissue, about blood vessels and within bronchial walls. Organization is proceed ing also within the exudate of certain bronchioles and infundibula forming branching plugs of young fibrous tissue completely occlud ing these passages and extending out into neighboring alveoli. Alveoli about many terminal bronchi are filled with polymor phonuclear and mononuclear leucocytes containing numbers of in- PLATE III. PLATE IV. 7, Acute inflammation of lung —varied exudate; 8, catarrhal exudate In alveolus from broncho- pneumonic patch showing numerous influenza bacilli ; 9, necrosis of alveolar walls. No. 2. GOODPASTURE AND BURNETT—PNEUMONIA. 189 fluenza bacilli. The yellow opaque foci noted in gross represent small abscesses or dilated bronchi filled with purulent exudate con taining influenza bacilli. . Many dilated bronchi are surrounded by a zone of alveoli which are plugged with masses of fibrin. About others these masses of fibrin have been organized and absorbed by fibroblasts or replaced by fused epithelial cells. This reaction about dilated bronchi will be described more fully in considering bronchiectasis. These two cases present clearly the progress toward healing of an influenza pneumonia unaccompanied by other organisms, and they demonstrate in an illuminating manner the fact that the pul monary injury in the initial stages is of utmost severity, and the process of healing and repair one of organization of large areas which could never be of more than very limited functional value. Resolution as it usually occurs in croupous pneumonia is not observed. Although the most extensive injury takes place during the early stages, the inflammation is progressive, and there is continuous de struction of tissue locally about many bronchi with the resulting formation of more or less chronic abscesses and bronchiectatic cavi ties which harbor masses of influenza bacilli. This fact is of especial interest in view of the observations of Boggs and of Lord on chronic bronchiectacis associated with this organism, and is evidence for the assertion that many cases in this epidemic pursued a similar chronic course with intermittent recurrences. A mechanical lesion of interest which appears to be distinct from the immediate inflammatory process, is rupture of alveoli and inter stitial emphysema in unconsolidated emphysematous pulmonary tis sue. Three cases with this condition were found in this series, all of them early. In one of these there was subcutaneous emphysema extending from the superior mediastinum into the neck. The neck anteriorly and laterally from the angles of the jaw on each side to the second intercostal space over the clavicles, was greatly distended with air, crepitating and pitting on pressure. In other instances seen clinically, the subcutaneous tissue over a considerable portion of the trunk has been similarly affected. On removing the sternum of the above case the mediastinal fatty and connective tissue was found distended with air. Following rupture of alveoli, air escapes into the interlobular tissues and eventually finds it way to the hilum whence it enters the mediastinum. Sections of the lung show large air blebs especially numerous in the interlobular and subpleural tis sue, though large cavities up to 1 cm. may be present within the lobule, the surrounding alveoli being atelectatic. Hemorrhages are associated with these lesions. 190 GOODPASTURE AND BURNETT PNEUMONIA. Vol. XIII. INFLUENZA PNEUMONIA COMPLICATED BY SECONDARY INVADERS WHICH MODIFY THE PATHOLOGY. Given the primary acute toxic injury to the lung substance which appears to be the essential lesion in the early stage of influenza pneumonia of the present epidemic, any pathogenic micro-organism harbored by the air passages has a fertile field upon which to become implanted, and to multiply, producing injury and reaction more or less characteristic for the organism concerned. Since an acute in- Jflammation of the air passages always precedes the extension into the alveolar tissue, there are in most cases pathogenic organisms, other than the influenza bacillus, present in the injured bronchi ready for invasion. Consequently, in .a majority of instances mixed in fection is present in the lungs, and the older the pneumonia the greater the probability of secondary invasion. Most common of these invaders in order of frequency have been the various types of pneumococci, streptococci, staphylococci, and micrococcus catarrhalis. Pneumococci have been cultivated from the lungs together with influenza bacilli in 14 cases, and. once alone. In three instances the secondary infection was apparently of such short duration that they had not modified appreciably the gross or microscopic appear ances of the lungs. The pleurae were smooth, the lungs edematous, hemorrhagic, and partially or completely consolidated with acute exudate. In one case numerous pneumococci were found within the alveolar exudate, and in the other two in a narrow zone beneath and within the pleura, but not more deeply within the inflamed lung. In 11 cases the sec ondary infection had been of sufficient duration and extent to bring about a more or less characteristic reaction to their presence. The pathology in these is exceedingly complex ; for the lungs of a single individual show in different parts various stages and degrees of injury and intensity of secondary infection. In each of these 11 cases there was a fibrinous or fibrino-purulent membrane over the affected pleura, often with a sero-fibrinous effu sion on the side most involved, amounting at times to 500 to 1,000 cubic centimeters. Grossly, the lungs presented in a portion of one or more lobes the typical dry, gray, granular surface characteristic of croupous exudate. These areas contrast sharply with the accom panying lesions of influenza pneumonia which are always recogniz able in the same or other lobes. The areas of croupous pneumonia are more voluminous, dry, granular, and friable. Their color is more uniformly gray and opaque. The surface of adjacent areas of in fluenza pneumonia is smooth, moist, elastic, with a variety in colors and irregularity in density. No. 2. GOODPASTURE AND BURNETT- —PNEUMONIA. 191 Smaller foci of broncho-pneumonia in which pneumococci pre dominate are not distinguishable from similar patches in which influenza bacilli only are present. Such focal areas are not infre quent in these cases, the initial bronchitis and alveolar injury seem ing to predispose to a broncho-pneumonic type of inflammation whatever organism may be invading. Microscopically, croupous pneumonia is quite as distinctive as in gross. The alveoli, distended uniformly with dense plugs of leuco cytes and fibrin, contrast with those of influenza pneumonia, in which there is such an irregular distribution of the various inflam matory elements. One notices, however, a greater degree of injury to alveolar walls, in the form of thrombosis of capillaries and focal necrosis, than is usual with simple croupous inflammation. In two cases there was a healing influenza pneumonia in the lung on one side and an outspoken croupous pneumonia on the other. In the healing lung no organisms were found. Early organization and fibrosis were present, and numbers of plasma cells and lymphocytes. Another lung presented large regions of croupous exudate in the left lower lobe, while in the right lower multiple small abscesses and dilated bronchi were abundant. INFLUENZA PNEUMONIA COMPLICATED BY STREPTOCOCCUS INFEC TION. In five cases hemolytic streptococci were cultured from the lungs. In three of these multiple abscesses were present, measuring up to 2 centimeters. Streptococci and influenza bacilli were associated in the other two cases in the production of widespread bronchiectatic abscesses and bronchitis with ulceration. In the lungs of the first three cases there were large and small masses of lobular pneumonia, in the centers of which were yellow, opaque, soft areas of necrosis or excavation. Microscopically, the alveoli contain leucocytes and fibrin, with extensive necrosis in places of both exudate and alveolar walls. Here streptococci in short chains are present in enormous numbers.- A fibrino-purulent exudate con taining streptococci was present over the lungs, and in one case there was a left sero-purulent effusion of 2,500 cubic centimeters. ACUTE BRONCHIECTASIS. Even in the earliest stages of influenza pneumonia, that is from two to four days' duration, one of the most striking appearances is the gaping, dilated condition of infundibula and the general emphy sema in unconsolidated portions. In three cases rupture of alveoli had taken place with subsequent interstitial emphysema. This ten dency to dilatation of the air passages has manifested itself as actual 192 GOODPASTURE AND BURNETT—PNEUMONIA. Vol. XIII. bronchiectasis in four cases. Two of these were associated with pure cultures of influenza bacilli and have been described with the other cases showing this organism alone. In the other two bronchi ectasis was extensive, with abscesses and ulceration of many bronchi. The bronchiectasis in one instance was confined to the right side, the site of the older pneumonic process, the left lower lobe being firmly and almost completely consolidated in a state of gray hepatization with pneumococcus infection. In the remaining case bronchiectasis was extensive in each lobe on both sides. Cultures from this and the previous case demonstrated both influenza bacilli and hemolytic streptococci. The association of influenza bacilli with chronic bronchiectatic changes in the lung is well known, especially through the publications of Boggs and of Lord. It is of exceptional interest that dilatation of bronchi and the permanent changes incident to ulceration and abscess formation can proceed so rapidly as is evident in our cases. The following protocol describes the gross appearances of the lungs in the case which presented the most advanced lesions and in both lungs. The clinical evidences of pneumonia were of 10 days' dura tion. No excess of fluid in either pleural cavity, only a few cubic centi meters of thick yellow pus. Left lung.—There is an injection of the pleural vessels, especially between the lobules, so that they appear bright red and prominent. A thin slightly sticky exudate is over the pleural surfaces, and the lobes are adherent by a fairly firm fibrino-purulent exudate, scant in amount. Both lobes are almost completely consolidated by numerous small areas of consolidation which give the surface of the lung a coarse nodular feel. On cut section the larger and smaller bronchi are found to be very widely dilated giving to the surface a worm- eaten appearance. There are numerous fairly uniformly distributed nodular grayish -yellow areas of consolidation associated with the bronchi which are elevated above the surface. The intervening alveolar tissue is grayish-purple jn color containing some air and fluid which can be expressed easily. The bronchi are filled with a thick semifluid yellow pus. In the upper lobe there is a patch measur ing 1£ cm. in diameter in which is a widely dilated terminal bronchus surrounded by a rosette of gray elevated areas of consolidation. The dilated bronchus measures 3 mm. when opened; the areas of consoli dation 4 to 5 mm. Right lung.—Presents a similar appearance to the left on the surface. It is heavier and the consolidation is more extensive and diffuse. The cut surface on this side presents a similar but more advanced degree of the same changes noted on the left. The ter minal bronchi measure 2 to 3 mm. in diameter in cross sections. The PLATE V. 10, Healing bronchiole —epithlelial plugs in surrounding alveoli : 11, high magnification of epithlelial cells within alveolus from 10; 12. organizing bronchiole causing obliteration of lumen; 13, wall of dilated bronchus, showing surrounding alveoli, collapsed or filled with dense fibrin; 14. wall of small abscess in bronchiole. Surrounding alveoli tilled with fibrin. PLATE VI. 15, Organizing alveolar exudate; 16. hyal'ne necrosis and repair of rectus abdominis muscle; 17. focal necrosis of adrenal cortex with some polymorphonuclear exudate. No. 2. GOODPASTURE AND BURNETT—PNEUMONIA. 193 middle lobe shows early stages of bronchiectasis and broncho-pneu monia. With little consolidation there is noticeable dilatation of larger and small bronchi surrounded by a zone of dark purple, slightly elevated tissue. The mucosa of smaller bronchi is pale; of larger ones it is hemorrhagic. Microscopically the pneumonia in most places is evidently peri bronchial and lobular in distribution. Bronchioles and adjacent alveoli are filled with a leucocytic exudate and practically no fibrin. Peripheral alveoli contain increasing numbers of mononuclear leuco cytes. Both polymorphs, and mononuclears contain numerous influ enza bacilli. The smaller bronchi are dilated to 3 mm. The mucosa is totally or in part ulcerated and covered with a fibrino-purulent membrane. A wide zone of alveoli surrounding bronchi are filled with dense plugs of fibrin in which are a few mononuclear cells. Others of these alveoli are partially or completely collapsed. There is a beginning immigration of mononuclear wandering cells, which are more numerous about blood vessels and within bronchial walls. Many of them appear to be plasma cells. Within the exudate in the lumens of ulcerated bronchi and in the fibrino-purulent membrane are found many streptococci in short chains. Whereas within the alveolar exudate the prevailing organ ism is the influenza bacillus. In larger areas of consolidation there are in the exudate, in addition to leucocytes containing influenza bacilli, a good deal of fibrin and red blood cells and considerable destruction of alveolar walls. The presence of fibrinous plugs within alveoli adjacent to the bron chus seems to be a constant accompaniment of excessive dilatation. Just how this is brought about is not clear, though it seems likely that intermittent lateral pressure mechanically further injures the already weakened alveolar tissues. It does not appear to be due to direct injury from the absorption of toxic substances from the lumina, for it may be seen around fairly large bronchi whose epithelial walls are intact and in which no organisms or cellular exudate are demon strable. The presence of the fibrin tends to make the air tube more rigid and assists mechanically in limiting the infection in terminal portions where the bronchial walls may be partially or completely necrosed. The process of healing probably renders the dilatation per manent, if it does not actually accentuate it, for the fibrin about larger bronchi becomes organized and eventually converted into dense fibrous tissue, while about smaller bronchi it is replaced by masses of closely approximated or fused epithelial cells, which are sur rounded by thickened fibrous walls. The more or less extensive organization and subsequent contraction of intervening alveolar tissue will also dispose to fix the dilated state. 194 GOODPASTURE AND BUBNETT—PNEUMONIA. Vol. XIII. The importance of a secondary streptococcus infection in produce ing extensive ulceration and bronchiectatic cavities in the acute stages is to be emphasized. These organisms especially produce local necrosis, and in this way extend the margins of infection. The influ enza bacillus probably persisting much longer, may perpetuate the inflammation in a chronic state. CHANGES IN OTHER ORGANS. In the cases dying within four or five days after the onset of pneu monia, congestion and edema of the liver, kidneys, and adrenal glands are quite evident. The adrenals in a majority of instances contain focal hyaline necroses, usually quite small and situated either in the glomerular zone or the adjacent part of the fascicular zone. Rarely there is a narrow strip of necrosis extending parallel to the surface through many columns of cells. Occasionally a few polymor phonuclear leucocytes infiltrate the necrotic foci. In one instance in which the pneumonia was of longer duration and complicated by streptococcus infection, the focal necroses were accompanied by hem orrhage and fibrinous exudate* and a few streptococci were found within the lesions. The spleen in uncomplicated cases is not appreciably enlarged, though often congested. Where secondary infection with pyogenic organisms is present there is enlargement, with the usual swollen, gray appearance and soft consistency of acute splenic tumor. In one case an influenza pneumonia was coincident with a purulent cerebro-spinal meningitis, due to micrococcus catarrhalis. Five cases, only one of which was associated with a pure culture o f influenza bacillus in the lungs, showed extensive hyaline degenera tion, necrosis, rupture, and hemorrhage in one or both abdominal rectus muscles. In its inception this lesion is probably a result of extreme intoxication, but later the degenerative necrotic areas may be invaded by secondary micro-organisms. In one case pneumococci were found within the lesions, in another streptococci, but in neither were they in considerable numbers and there is practically no cellular reaction. Acute arteritis and phlebitis were seen within the injured areas. Repair by fibrosis is rapid. RESUME. The difficulties of analyzing the pulmonary lesions in any group of influenza pneumonias, as they have appeared in this epidemic, are very apparent to anyone who has had an opportunity to observe the bacteriology and pathology of this accompaniment of the dis ease. The uncertainty as to the nature of the infection, the varied character of the primary injury and reaction, the multiplicity of Ho. 2. GOODPASTURE AND BUBNETT—PNEUMONIA. 195 complicating micro-organisms, and the modifications presented at different stages of the lesions preclude a clear-cut picture of all the interrelated and consecutive changes. We have attempted, how ever, to present as clearly as they have appeared to us certain distinctive features of the disease, and to separate from them coincident changes obviously of a secondary nature. Careful bac teriological data have been essential because of the high frequency of these secondary micro-organisms. The very fact that so many complicating infections and their resul tant pathological changes occur in influenza pneumonia is a distinctive know that a foreign body is 8 or 10 centimeters deep in the gluteal region ; but it is important for him to know its relationship to thu- iliac bone or the sciatic nerve or other anatomic structure ; informa tion that the compasses can not give. 238 ROBIN EXTRACTION OF METALLIC BODIES. Vol. XIII. Both radiographer and surgeon must know their anatomical topog raphy. The anatomical localization is obtained by studying the re spective displacements of the foreign body on the one part and of the organs of the neighborhood, chiefly bones, on the other part, while the body is being rotated from one side to the other. The shadow of a foreign body situated in front of the general axis of rota tion will displace in the same direction as the part of the body which Is next to the screen and in an Inverse direction than the part of the body nearer the screen. If the foreign body is behind the axis, the contrary will take place. Besides, it is evident that the displacement of the shadow is more rapid when the foreign body Is more distant from the axis of rotation. During the rotation, the shadows of the skeleton move also. The relative dis placement of the shadow of a bone and the image of the foreign body is con siderable when they are widely separated ; If during the rotation, bone and foreign bodies keep at the same distance and move in the same direction, one may say that they are near each other. The displacements of the foreign body during spontaneous, induced, or psyslologic movements give very useful In formation. As an example, we may suppose the piece of a shell In the fleshy part of the limb ; if the radiologist moves it through the skin, these movements may be seen on the screen, and the propulsion will reach its maximum when the finger is as near as possible to the foreign body. The shadow of a bullet in the scapular region will displace on the ribs during the raising up of the arm, and this simple test will show that it is not Intra thoracic. A lot of information may be obtained by comparing the displace ments of the foreign body with the physiologic movements of the thorax. Every body knows that during inspiration the diaphragm goes down and the ribs go up. Hence If an Intrathoracic foreign body follows exactly the movements of the diaphragm, but at a distance from It, one can be sure that it Is intra- pulmonary- If. on the contrary, it goes up and down with. the ribs, it is depend ing on the ribs. Then we use the method of rotation to find out if it is extra or intrathoracic; in the latter case, it is either pleural or cortico-pleural with pleural adhesions. Foreign bodies near the mediastinum are not very mobile, but by rotation we can see at once what their position is Inside the thorax. Foreign bodies near the heart are the seat of transmitted beatings from the heart ; rotation will allow us to see if they are near, on, or in the pericardium. On the whole, the method of rotation associated with ordinary methods of common sense enables the radiologist and the surgeon to localize the exact position of the foreign body, and the surgeon has anatomical and clinical means of selecting his avenue of approach to It.—These de Gourion, Bordeaux, 1917. SURGICAL INDICATIONS FOR THE EXTRACTION OF FOREIGN BODIES WITH FORCEPS UNDER DIRECT CONTROL OF RADIOSCOPY. (a) In the ambulances, " auto-chirs," or hospitals at the front, the •extraction of foreign bodies is only a part of the general treatment of war wounds (large incisions, extraction of foreign bodies and pieces of clothing with primary suture, if possible). Under these conditions, if the foreign body is rather deep in the muscles, the X-ray is most useful in reaching it. No. 239 ROBIN—EXTRACTION OF METALLIC BODIES. (b) In very many cases, owing to overcrowding, the wounded are evacuated from the front to the hospitals at the rear with foreign bodies still in situ. These foreign bodies may develop infection and abscess around them, but, on the other hand, are often well tolerated and become surrounded more or less rapidly by an envelope of fibrous tissue. Should these cases come to the knowledge of the radiographer F.B.- jP\BLE TUBE FORCEPS TUBE, SHADOW OF F.B. AND TIP OF FORCEPS ON SAME VERTICAL LINE FORCEPS MORE SUPERFICIAL RAPIDLY PASSES OVER. THE SHADOW OF F.B. F.B. MORE SUPERFICIAL 3EPARATE3 FBOM THE TIP OF FORCEPS or the surgeon, they should be operated on for the reasons indicated above. The systematic extraction of foreign bodies would not be pos sible, if each one had to be reached by a large incision which opened widely plane after plane of fascia and muscle. Even with an experi enced surgeon, possessing full knowledge of the anatomical planes, 240 ROBIN —EXTRACTION OF METALLIC BODIES. Vol. XIII. the inconvenience resulting from such an open method of interfer ence, as far as small and deeply situated foreign bodies are con cerned, outweighs the disadvantages of leaving these missiles in place. Extraction under the direct control of the X-ray, with forceps passed through a small button hole in the skin, is most rapid, practical, and safe. The criticism that it is a blind method does not hold good and is only raised by those who do not know this method, or have failed in its application. Eight or ten foreign bodies of the extremities at different depths can be removed in a half hour; this time including sterilization of the skin in different areas. Usually 5 cubic centimeters of ethyl- chloride will provide sufficient anesthesia for the removal of a foreign body from a thigh or from a leg at any depth. This method is undoubtedly safe; I have removed more than 1,000 foreign bodies and I have never damaged a nerve or a blood vessel of importance. The surgeon must choose his route of access so as not to endanger important structures, such as blood vessels or nerves and to avoid obstacles such as bones and thick tendons. For instance, a foreign body in the thigh, in front of the obturator foramen, should not be attacked through Scarpa's triangle; but the introduction of a long forceps into the inner aspect of the thigh through the adductor muscles will be perfectly safe. When the surgeon appreciates that a foreign body is in the im mediate vicinity of a dangerous organ he will modify his technique accordingly. In certain cases he will operate through an open wound in order to secure direct vision, using the rays to direct the incision and thus save time. The principles on which this method of extraction is based are: (a) Penetration through the tissues by an aseptic blunt instrument (for instance, an ordinary artery forceps with closed blades) is per fectly harmless. It breaks nothing, it only displaces the cellular tissue or the muscular fibers through which it is introduced; and these tissues resume their place after the instrument has been re moved, leaving but a simple puncture, (h) At all times the radi ographer must be able to tell the surgeon whether or not his forceps is moving in the direction of the foreign body, guiding him until he touches it. This information is obtained by observing the displace ment of the shadows, using the method of rotation described above. OUTFIT NECESSARY FOR THIS METHOD OF EXTRACTION. Room and lights. —A radio-operating room with red light or feeble white light ; alternating with full light, artificial or natural. Instruments.— Knife and artery forceps or foreign-body forceps of different sizes. No. 2. 241 ROBIN—EXTRACTION OF METALLIC BODIES. Radio-operating table.—We use the table of le Coniac which con sists essentially of a plane revolving around its long axis. The pa tient is firmly fastened to the rotatory table, so that he may be turned from right to left and inversely around its axis without fall ing off. Our radiographers use Piloris tubes ; a Coolidge tube would be better. The tube can be moved in an horizontal plane beneath the rotatory table. Diaphragming is rapid and easy. STEPS IN THE OPERATION. 1. The position of the foreign body is ascertained. 2. The patient is placed on the movable table in the best possible position for the operation. 3. The inhalation of ethyl chloride will furnish sufficient anesthesia for a short, easy extraction. If the operation is liable to be long, if there are several missiles to be removed from the same patient, or if complete immobility is necessary, chloroform or ether may follow. It has been our practice to use chloroform with the Kichard appa ratus. In radio-surgery the Richard apparatus has two advantages : (a) Its long connecting tube makes it easier for the anesthetist to work while the table is being rotated; (&) the noise of its valves during inspiration and expiration enables one to hear the respira tion of the patient. Let me state here that anesthesia is always begun when the lights are on and should never be administered in the dark except by a skilled anesthetist. I have never seen any fatal accidents due to it. 4. The skin is antisepticized with tincture of iodine and sterile towels are put in place. 5. The surgeon, when his eyes have become accommodated to the dark, asks for the rays. The radiographer centers the tube and the diaphragms. Both look through the screen. The surgeon, placing the point of his knife on the shadow of the foreign body, asks for red light or feeble white light. Then, using his anatomical knowl edge, he chooses his avenue of approach, and, as a rule, makes his puncture a trifle to the right of the foreign bodies, that he may use his right hand to better advantage in manipulating the forceps. 6. The puncture is made. This is a small, buttonhole incision, not more than half a centimeter in length, and divides skin, subcutaneous tissue, and fascia. The forceps is now introduced through the punc ture in the direction of the foreign body. As a rule, an artery forceps is used. Kocher's forceps may be used in some cases, but the teeth are liable to catch in the tissues. Some deep foreign bodies require long bullet forceps. 7. The surgeon asks for the rays as soon as the forceps is in the incision, and through the screen he watches it as it penetrates the tissues and he advances it gently but firmly. When the tip of the 242 ROBIN —EXTRACTION OF METALLIC BODIES. Vol. XIII. forceps reaches the shadow of the foreign body, if the surgeon does not feel or does not see the contact with it, a localizing test must be made to learn whether the tip of the instrument is too deep or too superficial. 8. The surgeon immobilizes his hand on the skin and his forceps in the patient's tissues so that each displacement of the table will be transmitted completely to everything lying over it. The radi ographer now indicates the direction in which the surgeon is to move, while both of them watch the respective displacements of the shadows. When the tip of the forceps and the foreign body are on the same vertical line, if the table be made to rotate, that shadow which moves more rapidly in the direction of the rotation is the more superficial. (See figures.) By one or two rotary movements the surgeon ascer tains whether his forceps is too superficial (between the foreign body and the skin) or too deep (between the foreign body and the table). 9. When once the surgeon's forceps has reached the foreign body he will use it as a grooved stylet with which to separate the foreign body from the surrounding tissues. After months have elapsed a foreign body is included in a mass of fibrous tissue. As a rule, this decortication is easily made. 10. When the surgeon has achieved the "metallic contact" and the foreign body is free, he fixes it by pressing it against sound tissue, and, opening the blades of his forceps, he catches it. 11. As a rule, the foreign body is withdrawn with ease, but occa sionally a slight twist is necessary in order to break its last connec tions with the surrounding tissues. 12. No suture is used, merely a dry dressing, which is removed in three days. This method of extraction is simple and very rapid when the sur geon has acquired a little experience. In the soft parts it may be undertaken with safety by any surgeon knowing anatomy. Slight modification of technique permits the surgeon to remove foreign bodies from bones (with curettes after trephining the bone) ; from the brain (after craniotomy and opening of the meninges). EXTRACTION OF FOREIGN BODIES FROM THE LUNGS. Since the first extraction from the lungs made by Petit de la Villeon, with Dr. le Coniac as radiographer, in 1915, more than 200 foreign bodies have been removed at Brest. The method of extrac tion from the lungs is the same as for all foreign bodies, with some modifications in technique; it is only a special application of the general method. No. 2. 243 KOBIN —EXTRACTION OF METALLIC BODIES. Without entering into the details we may say that— 1. A very accurate localization must be made (vide supra). 2. Skin and intercostal space are cut by an incision not longer than a small buttonhole. 3. A long forceps (ordinary bullet forceps or, better, forceps with crocodile jaws) is introduced and, under the control of the X-ray, passes through the two leaves of the pleura without causing pneu mothorax, and enters lung tissue. The penetration of a blunt instru ment through lung tissue does not cause hemorrhage. 4. By rotary movements of the table the progression of the for ceps to the foreign body is made in one-half inch steps. The radi ographer and surgeon are able to appreciate the direction by the dis placement of the shadows as described above. 5. The foreign body is caught and taken out slowly to avoid cut ting the lung by the sharp edges of the fragment. 6. The passage through the skin, if the foreign body be big, neces sitates at times enlargement of the incision. 7. A silk-worm suture closes the small wound. Usually we give a little morphia. With very few exceptions there is no hemoptysis or hemothorax. In some cases, when the operation has been done rap idly, we may notice a little bloody sputum for two or three days after the extraction. There is, however, no rise in temperature, and, as a rule, the patient is out of his bed in less than a week. After a careful radioscopic examination of his chest, to make sure that lungs and pleura have resumed their normal condition, the patient goes back to his work. This method of extraction of foreign bodies from the lungs must appeal to every surgeon because it is simple, rapid, and safe. M6de- cin General Duval, directeur du service de sant£ de Brest, has given his support to this method which was originated in Brest, and we have had the opportunity of operating upon many cases before Amer ican and French surgeons. All agreed with us that it is the method of election, infinitely preferable to extractions after pleurotomies with or without rib resection. It is to be borne in mind (a) that the region of the hilus should not be operated on by this method ; but all other parts of the lungs are accessible; (&) that before operating upon a lung the surgeon must be trained to remove foreign bodies from the soft parts of limbs. I have personally extracted 50 foreign bodies from the % thorax with perfect results and no deaths. An objection may be made that the hands and face of the surgeon may suffer from exposure to the rays. In answer to this it may be stated (a) The eyes are protected by lead glasses ; and besides there is no necessity for the eyes to be directly over the screen, (b) As for the hands, the radiographer uses the diaphragm as much as possible 244 LeCONTE AMPUTATIONS AND PROSTHESIS. Vol. XIII. and, as a rule, the forceps only is in the rays. Besides, we wear heavy, thick rubber gloves (Chaput's gloves). The operator may use Manclair's gloves with lead in them. We may add that after two years of intensive radio-surgery the skin of the author's hands is perfectly normal. NEW WAR METHODS IN AMPUTATIONS, STUMPS, AND PROSTHESIS OF THE LOWER LIMES. By R. O. LhConte, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. One of the cruel results of the present war is the enormous number of mutilated men it has produced. The treatment of the amputated has changed but little in a century, except for the perfecting of me chanical devices by ingenious mechanics who lack surgical knowledge and education. The comfort and usefulness of a man without a leg was left to the artificial-limb maker, for the surgeon's interest ceased often before the wound was fully healed, and the orthopedist's in terest was not awakened or limited to the recommendation of a maker of limbs. By the time the unfortunate's wound was healed prac tically all scientific surgical supervision of him ceased. To Dr. F. Martin, of La Panne, Belgium, was given the inspiration to study the results obtained by such a system of treatment, and after more than a year of intensive work he has written a new chapter in pros thesis, placing this long-neglected subject on as firm a scientific surgical basis as the correction of refractive errors of the eye. I use this simile advisedly, for our treatment of the amputated has been about as logical and scientific as the giving of the address of an optician to a patient requiring glasses. Dr. Martin starts with the proposition that all legs differ in shape as much as the features of the face; that a man's walk is as char acteristic of an individual as his voice; and that this character is largely due to the shape of his legs. Therefore to reproduce sta bility and comfort in walking, the exact counterpart of the limb lost must be reproduced in the artificial member. The treatment of the stump, which eventually will actuate the artificial limb, is as important as the limb itself. The development of the muscles that control the joint above must be constant from the moment the wound is healed. This develop ment is best attained by making the patient walk with a temporary apparatus. Crutches will speedily develop a lateral curvature of the spine in a uniped. Martin has therefore discarded them. This lateral curve is an effort of nature to produce stability while standing on one leg. The lumbar spine bows toward the sound side. The curvature is No. 2. LeCONTE—AMPUTATIONS AND PROSTHESIS. 245 quite apparent in two months and steadily increases with the. use of crutches. For the correction of lateral curvature in childhood and youth, exercises with crutches walking on one leg are strongly recommended. The immediate treatment of the psychic condition, always present in the mutilated, is of primary importance to the patient's future social value. For the patient then the best ultimate result will be obtained only through a close liaison of the surgeon amputating and the orthoped ist, for to the latter is delegated the treatment of the stump, its de velopment, its temporary walking apparatus, its final fitting with the artificial limb, and above all the treatment of the psychic condition and professional reeducation of the patient. When such a correla tion is brought about, the beggary of maimed men following a war will cease. AMPUTATIONS. Amputations in war surgery are desirable when the loss of the limb is certain, or the attempted preservation would result in death. These two indications are due to traumatism (mortality 6 per cent) and infections (mortality 28 per cent). Before this war the tech nique of an amputation was taught empirically, and three funda mental ideas govern this classical procedure : 1. The amputation must be done in healthy tissue. 2. The shape of the flaps is prescribed (circular, oval, or of un equal length). 3. The stump must be well padded with soft tissues. These classical ideas must now be forgotten, for they no longer exist in war surgery. Amputation of the lower limb in healthy tissue is practically never done except when the entire foot has to be sacrificed. There is an optimum length of stump for the leg; otherwise, every bit of bone that can be saved is left. The infected soft tissues are cut on a level with the bone (chop amputation) without any attempt at flap for mation unless the wound lends itself to short flaps. The position of the wound and the seat of fracture will determine the point of ampu tation, and not the splintering of the bone above the fracture. The disinfection of the wound is at once started, and it is left wide open until the infection is controlled, when the wound may be closed by a late primary or secondary suture, the tension on the flaps being re lieved by traction on the skin by adhesive tapes. When revision of an amputation is necessary it will be done when disinfection is com plete and the soft parts have been given all the elongation possible. The usefulness of the stump depends on the length of the bony lever and the muscular attachments which control the joint above. Disar 246 LeCONTE —AMPUTATIONS AND PROSTHESIS. Vol. XIII. ticulation of the hip and knee should not be done unless the joint is invaded and infected, and then an amputation at the lower third of the thigh is preferable to the knee joint for the fitting of an artificial limb. One inch of femur, if it contains the muscular attachments to the trochanters, is invaluable to an artificial limb, and the same is true of the tibia if the extensor and hamstring attachments can be re tained. Should one or the other of these be stripped from the bone, their reattachment should be made when possible. The relation of the length of the stump to the prosthetic apparatus may be stated as follows: The length of the stump increases by arithmetical pro gression, while its action on the artificial limb increases by geomet rical progression. As none of the body weight is borne by the end of the stump, the padding of this with soft tissues is no longer con sidered. The surgeon's considerations in amputations are, therefore, first, to save life; second, to save all tissue that will aid in actuating the arti ficial limb; and, third, healing of the wound in the shortest possible time. The rapid healing of the wound is important for the exercis ing of the joint above and the muscles controlling it. To preserve the functions of this joint, passive motion should be made at each dressing and the joint kept in extension and not propped with pillows in a semiflexed position. If the stump needs support, pillows may be placed laterally, but not underneath. The muscles that actuate the joint should be exercised and massaged to keep them in their most efficient state. When adhesive tapes are employed to draw down the flaps, the muscles may be exercised against the weights making this extension. The length of the stump is determined by the operation, but its power and mobility depend largely on .the treatment. The wound should be healed in two weeks or not more than four weeks and the patient turned over to the care of the orthopedist. The orthopedist's first duty will be to fit a temporary apparatus and have his patient out of bed and walking on two legs. To walk with one leg and crutches ruins the static equilibrium of the am putated, for the center of gravity of the body must pass through the supporting foot. The body in attempting to compensate for this will develop a scoliosis of the lumbar spine, and as these war vic tims are young this will be apparent in a few weeks. It is therefore preferable to confine a patient to bed or a chair rather than allow walking with one leg. The provisional apparatus permits of imme diate walking; it replaces the mechanical or manual mobilization of the stump and massage of the muscles by natural and agreeable ex ercise; it has a profound influence on the mental attitude of the patient to his mutilation; it improves his general health; it per mits of an early reeducation ; and it exerts on the stump the necessary and beneficial action of supporting weight, hastening its shrinkage, No. 2. LeCONTE AMPUTATIONS AND PROSTHESIS. 247 and thereby shortening the time for the fitting of the artificial limb. For these reasons the temporary apparatus is an indispensable ele ment in the treatment and should not be considered as a makeshift of no special importance. PROVISIONAL APPARATUS. The provisional apparatus applied to an always sensitive, often painful, stump must be carefully molded to properly support the weight of the body. There must be no pressure on the lower portion and end of the stump, no friction and no pull on the skin that would tend to reopen the wound. It must permit of free movement of the articulation above. It must be applicable to double amputations as well as to single ones. It must be readily changeable to conform to the constantly changing stump. It should be light in weight, in expensive, and easily and rapidly made. The following description is for a midthigh amputation, and is given as an illustration of what can be done cheaply and quickly. The apparatus costs prob ably less than a dollar ; its weight is about 2 pounds ; it will last five or six months, but, owing to the shrinkage in the stump, it will require two or three renewals of the plaster mold. The materials needed are plaster of Paris bandages, plaster cream, two pieces of wire netting the size of the palm of the hand, an iron hook fastened to a short piece of strap iron, and two pieces of wood similar to the lateral supports of a crutch. These pieces of wood are beveled at their upper portion and longitudinally grooved, the better to incorporate them in the plaster. The patient is placed on the table, lying on the sound side, with the limb straight and the stump following this alignment. The stump, buttocks, and lower abdomen are covered with a thin coating of vaseline. The stump is encircled with plaster bandages and the plaster is carried well up on the buttocks and over the crest of the illium and made partic ularly strong in the region of the ischium. The wire netting is in corporated in the plaster over the great trochanter and on the inner side of the thigh just below the ischium. The inner stick is placed about an inch below the ischium and incorporated in the plaster. The outer stick rises to the level of the great trochanter, and just in front of it on a level with the trochanter the iron hook is placed. While the cast is drying the lower end of the stump is freed from all pressure by cutting away the plaster, and the upper level of the cast is outlined with a pencil. This should follow the fold between the buttocks to the crest of the illium, pass a shade below Poupart's ligament and a little below the perineum. The cast is then removed and allowed to dry for 12 or 15 hours. The upper portion of the cast is pared to the pencil line, and the cut 248 lecontk— amputations and prosthesis. vol. xiii. edges are made smooth with molded plaster or adhesive tape. In this way an open cone is produced in which the two supporting sticks are incorporated. The apparatus is completed by joining the two crutch pieces of wood with a cross bar 3 or 4 inches below the end of the stump, and fitting the ends with a cylinder of wood to walk upon. The length of the apparatus should correspond to the length of the other leg without its shoe. When the stump is thick the internal wooden support should be placed a little anterior to the mid line, and the outer support a little posterior to the mid line, so that the bulk of the apparatus will not rub the inner side of the other leg. For high amputations of the thigh, the apparatus must be stiffened with iron. To the hook which holds the waist band a curved iron strap is attached, which will partially encircle the stump. On the anterior inner end of this strap a metal support or flange is riveted, which will rise to within an inch of the perineum. This is incorpo rated in the plaster, and if still more rigidity is required it can be riveted to the lateral wooden supports. For a disarticulation of the hip the apparatus is still further strengthened by riveting metal flanges to the upper end of the two lateral wooden supports before they are incorporated in the plaster. The apparatus is applied as follows: A stockinet cover is drawn over the stump with the end toward the foot left long. The stump is fitted into the plaster mold and the long end of stockinet drawn down and fastened to the crossbar. This downward traction on the skin relieves the wound and the end of the stump from all pressure. A suspender passes under the crossbar and over the opposite shoulder and a belt under the hook and across the crest of the illium on the other side. This fixes the stump in its mold. The patient is assisted in his first attempts at walking until he acquires a static position; then he walks with two canes, and very soon he will discard the use of even a single cane. In a couple of weeks he should be able to walk a mile or two without a stop. As the stump shrinks in size a new plaster mold is made. This change will be needed two or three times before the form of the stump is sufficiently permanent for the artificial leg. The two things which will do more to bring the patient out of the slough of despond that always follows mutilation are walking and work. The orthopedic treatment of the stump is helpful, for it shows the patient that you are personally occupied with his welfare. The object lesson of seeing other mutilated people happy and at work will give him the moral support needed to overcome this psychic depression —a feeling that life in the future will be vegeta tive instead of animal. Too much stress can not be laid on the No. 2. 249 LeCONTE —AMPUTATIONS AND PROSTHESIS. treatment directed toward the patient's regaining his moral tone, for on this depends the necessary stimulant to keep him from beggary. ARTIFICIAL LEG. The value of an artificial leg is confined to its static and dynamic functions, and it is good or bad, depending upon whether these func tions are good or bad. Every individual has his personal charac teristics in these two functions, depending upon the length and angle of the thigh, the length and curve of the leg, the relation of the axes of the knee and ankle, etc., and in no two individuals are all these measurements and angles the same. It follows, therefore, that if the artificial limb is to reproduce the functions of the lost limb, it must copy exactly the lines and measurements of the lost leg. Therefore any artificial limb which is designed for all men and adapted to the individual's use will fit no one. If the comfort of a man walking and working is to be compared with a man wearing glasses, the same precise surgical and mathematical skill must be displayed in obtain ing a perfect result. In either instance it is not a province that should be relegated to a skilled but ignorant workman, and belongs solelj7 to the orthopedist and eye surgeon, respectively. Up to the time that Dr. Martin made his intensive studies of the mutilated, the so-called American artificial leg was considered the best in Europe. It was designed on the following principles : 1. The axis of the knee and the axis of the ankle are supsrinpos- able in all points, since they are on the same frontal plane. 2. The axis of the knee and the axis of the ankle are parallel to each other and to the ground. 3. The longitudinal axis of the foot passing between the first and second toes passes through the middle of the axis of the ankle and, therefore, the knee. 4. The longitudinal axis of the whole limb passes through the mid dle of the thigh, the axis of the knee, and the axis of the ankle. 5. The plane of the longitudinal axis of the foot and of the limb forms with the midplane of the body an angle of 18J degrees, directed forward and outward. 6. The anterior border of the great trochanter, the external con dyle, and the external malleolus are all on the same vertical plane. These are contrary, almost in their entirety, to the anatomic prin ciples of the lower limb. They produce a straight leg devoid of normal angles, a foot externally rotated 18.5 degrees beyond the mid line of the body, which necessitates the mounting of the foot on the leg at an angle of 110 degrees instead of at a right angle, making a pes equinus (figs. 1, 2, 3. 4). The stump, on being applied to a straight leg, must be vertical, therefore in a position of abduction and external rotation, as the abductors are also external rotators. 250 LeCONTE —AMPUTATIONS AND PROSTHESIS. Vol. XIII. This faulty position at once vitiates the normal walking movement of the stump. It therefore requires a reeducation of these muscles, changing their normal walking movement to abnormal ones, with the consequent rapid exhaustion of the muscles. The patient, uncon scious of the anatomic defects, blames the weight of the artificial limb for his exhaustion, and consequently seeks a lighter apparatus, which again fails. There are few cases of mid-thigh amputation that do not prefer to walk with a peg leg, or, discarding all pros thetic support, use crutches. Practically none of these artificial limbs will stand alone, while an anatomically correct apparatus stands erect, as firm on the ground as a riding boot with its tree. DR. MARTIN'S PRINCIPLES. His principles are to reproduce in the artificial limb all the lines, curves, angles of deflection and joint axes of the individual limb lost, and he models the new limb on the measurements and projections of the leg remaining, reversing the projections to produce its counter part. The stump enters his apparatus in its normal obliquity, down ward and forward, and the muscles which control the movement of the stump will conform to their normal movements of walking in actuating the artificial leg. The scope of this article is only to call attention to the monumental and epoch-making studies of Dr. Martin, and is not a translation of his 107 -page monograph (La Prothese du Membre Inferieur, Masson et Cie., 120 Boulevard Saint-Germain, Paris, 1918) or his 44-page article which has not yet appeared in print. For a detailed descrip tion of his methods the reader is referred to these two articles, as an outline only follows: . . The Belgian artificial limb is made on a plaster mold of the leg, with thin ribbons of beachwood, overlaid in various directions, and cemented together with water-proof glue. It is about 7 mm. (^ths of an inch) thick. To make this mold the leg must be modeled in clay with its circumferences reduced to conform to the thickness of the artificial limb. Art and precision are required for this, and only an outline of the technique can be sketched here. A cast is made of the stump on which the position of the ischium, the anterior border of the great trochanter, and the oblique axis of the stump are marked. When these points are noted on the patient with an aniline pencil, the color will be transmitted to the mold and in turn to the cast. A frontal and lateral projection of the sound limb is made and reduced in its dimensions by three-fifths of an inch. The projections are re versed and mounted on an easel. The following measurements are taken with the patient standing on a specially devised stand, which assures a normal upright, erect position (fig. 5) : (1) Perineum to the No. 2. 251 LbGONTE —AMPUTATIONS AND PROSTHESIS. ground; (2) end of stump to the ground; (3) the most prominent point of the internal condyle to the ground ; (4)' summit of the in ternal malleolus to the ground; (5) length of the stump from the perineum. The measurements 2 and 5 when added must be the same as No. 1 (fig. 6). From the measurements taken from the sound limb, a knee and ankle are carved from a block of wood, and, as these are destined to take their place in the artificial limb, they are made with a slightly decreased circumference. The knee block is made hemispherical at its base to articulate with the leg piece. These two blocks of wood later contain the mechanism to control their re spective joints. The cast of the stump is suspended from a gallows on the easel in front of and touching the frontal projection so that its outline fol lows the outline of the projection and its axis the axis of the limb. (Fig. 7.) The position of the knee joint and ankle joint are care fully noted, and the wooden knee and ankle are fastened to each other and to the stump by a wooden prop or brace in their correct situation. (Fig. 8.) All measurements and axes are carefully veri fied. Modeling clay is used to complete the leg. (Fig. 9.) A thin coating of the clay is applied to the lower surface of the cast of the stump, to avoid all pressure from the artificial leg on this sensitive * region. If the stump has other sensitive points a little, clay on the cast will relieve them from pressure. From this model a plaster cast is made and divided into a thigh and leg piece. On these the rib bons of beechwood are molded, with a hot copper roller and water proof glue. The surface is smoothed and varnished and the leg is completed by articulating the foot, leg, and thigh pieces together. (Fig. 10.) The Belgian artificial leg is the only one that reproduces the natu ral static qualities of the lower limb, and in accomplishing this it reproduces the esthetic qualities also. It is waterproof and therefore easily cleaned. It can be made without seeing the patient, if the proper measurements and projections are taken, and a cast of the sound limb and stump accompany them. Its mode of construction, the materials used, and the articulations are all new and founded on scientific principles derived from a study of the anatomy and physi ology of the leg. Few skilled workmen are required to make the ap paratus, as a matjor part of the labor at La Panne is furnished by the mutilated themselves, and all of it was unskilled at the start. The cost of the limb at La Panne is well below the price of the American- made leg. The life of the apparatus is at present unknown, but there is every reason to believe that it will last for m*ny years. To Dr. Martin belongs the -credit ef being the L 'C D (f £ L0/ JUAKL 1fe. a itomC.diP' No. 2. 257 PUGH— EDUCATION AND SANITATION. &XP05UR.E III Jiat is one war of tfettintf colds AND ftVOID GOLD5. J$L^_ • • • P HOPE It WAY WHEN MUNMIW AT THE KEEP YOUR II Rf OFF THE METAL PAR.T5. 258 PUGH—EDUCATION AND SANITATION. Vol. XIII. 3. Prevention : It Is a dangerous disease and will, if we should have many cases, make it difficult to " play the game." We have not a single case aboard. Help us to keep clear of It. When coughing or sneezing place a handkerchief In front of your face. Swing your hammock head to foot Keep out of crowds. Don't use anyone else's towel, handkerchief, or cup. Get lots of fresh air. Report at " sick call " If you have a " cold." If you rate a " 48," paste this In your hat : Avoid the hug, Avoid the lip, Escape the bug That gives the " grippe." Approved for publication. (Signed) B. F. Hutchison, Captain, V. 8. Navy, Commanding. The object of these bulletins, which are issued to officers and men, is to acquaint them with the facts so that they will be encouraged to report to the medical officers in the early stages of the disease, thus aiding us in obtaining early recoveries without complications. In the sanitary lectures given to officers much stress is placed upon communicable disease and its relation to sanitation. Officers are given instruction as to how this information may be imparted to the men without causing undue excitement. During the presence of the disease on board the moving-picture projection was utilized and between the reels points bearing on the situation were thrown on the screen. These were in the nature of advice and where possible were combined with cartoons. The lan guage used was that of the men—" real old United States "—so that there could never be any doubt as to its meaning. These or similar sketches were thrown on the screen every night and soon became a very interesting part of the show. A little later the following bulletin was issued: U. S. S. " Mississippi," 8 October, 1918. Subject: (a) Sanitary Bulletin No. 7. (b) Present Status of Influenza. 1. Influenza is with us, but It is mild. We have had very few cases, and the majority of these have not been severe. We have fared better than the other ships In the fleet. A number of deaths have been reported from other ships. We have not had a single death. Only three of our patients have been sick enough to necessitate transferring them to the hospital ship, and these are now on the road to recovery. We now have 15 cases, and 8 have been returned to duty. These fine results are not a matter of luck; they are due to the splendid cooperation of the officers and men of the Mississippi. Keep up the good work. 2. When coughing or sneezing place a handkerchief In front of your face. S. Swing your hammock head to foot Ji». 2. 259 PUGH—EDUCATION AND SANITATION. a Iceep t up beys. fbiLow w Doc torsJVC and THE WR0N6 WAY • THE COftfttU WAV 260 Vol. XIII. EUGH— EDUCATION AND SANITATION. MHTdPlTOH to qil5 ci(ifpit GiroOff ^HMttT "fed £Y HAVfMG CLEMT iOPlp" AND ClEiA ClOTflgT. AX SvSv / 103396—19 7 266 PUGH—EDUCATION AND SANITATION. Vol. XIII. 2. Hemorrhage, including the application of the tourniquet, partic ular emphasis being placed on the adjustment of this appliance, its proper use as well as its dangers. 3. Emergency treatment of fractures and dislocations. 4. Drowing cases. 5. Effects of heat and cold. 6. Common poisons. 7. Transportation of injured. -Sanitation. —Lectures on this subject will be given by the sanitary officer. This course is given with the idea that many officers will be ordered to ships or small camps where the services of a medical officer are not available. It will also assist the medical officer in obtaining the cooperation of his brother officers of the line. Without this union of effort on a ship, be it large or small, the health of the crew will suffer. This course will be given by an officer particularly con versant with this line of work. It will largely consist of general principles of health and hygiene that anyone will be able to grasp. 1. Air aboard ship, heating and ventilation. 2. Berthing of the crew and its relation to disease transmission. 3. Water supply and its care —scuttle butts, lavatories, wash rooms, etc. 4. Toilets and their care; their relation to disease transmission. 5. Clothing and bedding of the crew. 6. Dangerous occupations. 7. Sanitary police. 8. Landing parties and camp sites. 9. Sanitary policing of camps. 10. Water supply. The disposal of refuse, garbage, etc. 11. Diseases of camp and their prevention. HISTORICAL. JEAN DOMINIQUE LARREY, 1766—1842. Jean Dominique Larrey was born in the village of Baudean in the department of Hautes- Pyrenees on July 8, 1766, and at the age of 13 went to Toulouse to complete his preliminary education and later take up the study of medicine in the professional schools where his father's brother was in high repute as a teacher. At 21 Larrey went to Paris where he came to the notice of the eminent Louis.1 After due competitive examination Larrey was appointed a surgeon in the vroyal navy of France and went for a cruise in North American waters on the Vigilante. The voyage over, the young doctor resigned his commission, went to Paris and re sumed his professional studies at the Hotel Dieu and the Invalides. Three years later we find him in the Army of the Rhine serving under Kellerman and winning favorable comment from his mili tary superiors just as he had from his commanding officers in the navy. After the action of July 22 he was mentioned in despatches by Beauharnais and officially commended in the " Moniteur." It was during the campaign of 1793 that Larrey, painfully im pressed by the utter lack of system in caring for the wounded, con ceived the idea of organised effort on military lines to give imme diate and adequate succor to the victims of battle. Usually, the wounded remained where they fell until the fighting was over, rarely receiving the surgeon's attentions until 24 hours had passed. In case of defeat they were abandoned. The mortality in the field was tremendous. Larrey decided that the surgeon ought to go to the wounded and that aid must be a matter of routine, adminis tered with the same system and on the same status as any other military measure, deeming the hospital provisions three miles in the rear, called for by army regulations, wholly inadequate. The nearest approach to first-aid treatment in our modern sense was furnished by the " wurz " of Percy 2 " a sort of long, narrow caisson containing instruments and dressings with a top, round as a pudding, astride of which perched the surgeons who could jump 1Pierre Charles Alexandre Louis, who named typhoid fever and Insisted on the im portance of carefully prepared statistics In estimating the value of a given therapeutic measure. ' Pierre Francois Percy, 1754-1825. 267 268 HISTORICAL. Vol. xm. down and as quickly resume their places. Each ' wurz ' was drawn by six horses and manned by eight surgeons and eight attendants, the latter seated on the chests at the front and rear or riding the horses that drew the vehicle. The whole affair carried the necessary supplies for 1,200 wounded. Under the driver's box were stretchers to carry from the field such patients as could not walk. The ' wurz ' could maneuver with the speed of field artillery and went on the firing line." * Larrey modified the Percy idea as to the transportation of the wounded, but went far beyond him in arranging for a systematized service of ambulances and movable hospitals or dressing stations as an integral part of the organization of the army as a whole. His flying hospital legion was placed under the control of the chief surgeon of the army. It consisted of various medical divisions, the division being a unit designed to meet the needs of a military division. These units could be multiplied as required if divisions were com bined to form army corps or subdivided to accompany brigades and smaller formations. In any event medical personnel and ma teriel was always available at short notice. The administrative work of a division was handled in two sec tions. One was composed of a commissary and various subordinates, 12 mounted and 25 unmounted sick attendants, all soldiers, and a drummer. The other section consisted of 12 light carriages and 4 heavy vehicles, each with a man in charge, and a driver, a horseshoer, and a bugler. The personnel of the medical division numbered 113 persons. The division was formed of a number of subdivisions each with a directing surgeon and 15 subordinate surgeons of various ranks. The light vehicles drawn by one horse, or two if the terrain was difficult, were on springs, " easy running, furnished with mat tresses, padded sides and pockets for supplies." They collected the wounded and evacuated them to the heavy wagons which bore them to the principal dressing station or hospital beyond the battle area. The serious cases were attended to where they fell, and emergency surgery was done under fire. Larrey's scheme was put to the test for the first time during the operations before Metz in 1793 and gave such general satisfaction that he was ordered to assemble the necessary ambulance units for 14 armies of the Kepublic. Larrey was now designated chief surgeon of the expedition or ganized to wrest Corsica from the British. The British blockade of Nice, where the force assembled, interfered with the execution of the program, and Larrey profited by the delay to hurry to Paris for his marriage with a daughter of Laville-Leroux, a former min ister of finance under Louis XVI. 1J. Ambert : Le Baron Larrey ; Cosse et J. Dumaloe, Paris, 1863. No. 2. 269 HISTORICAL. At Toulon, Larrey acted as instructor in surgery and anatomy in a school gotten up for the benefit of the younger medical officers of the land and sea forces until his labors were interrupted by orders to occupy a chair in the newly created military medical school at the Val-de-Grace. Scarcely had he assumed his new functions when he was summoned by Napoleon beyond the Alps to superintend the oper ations of the " flying ambulance " for the Army of Italy. Bernadotte wanted him. besides, to take measures against the epidemic which was killing off the cattle of Friuli. Napoleon witnessed in person the evolutions of Bernadotte's " ambulance volante " and at their con clusion said to Larrey : " Your work is one of the happiest conceptions of our time." Returning from Italy, Larrey went to work again at the Val-de- Grace, but he was not left undisturbed for long. The campaign in Egypt was about to begin and his presence with it was now considered indispensable to the army. Some of the incidents of his adventurous and varied life at this period are worth recalling. After the battle of Aboukir Bay, Larrey had to amputate the right arm of Gen. Figuiere, who declared that he would never be able to draw his sword again and therefore presented the magnificent damascened blade to Napoleon who had attended him during the ordeal of operation. The latter accepted the gift and presented it on the spot to Larry with the remark : " He saves your life." Larrey established military hospitals in Cairo and a school of medicine and surgery for the medical officers of the army. During the stay in Egypt he made a painstaking study of Egyptian ophthal mia (trachoma) which threatened to become epidemic among French troops. On the expedition into Syria Larrey realized that his ambu lance carriages would be insufficient and had constructed a hundred long, open paniers, for a single patient each, to be carried as stretchers or drawn by mules. Napoleon has been reproached for his desertion of Kleber, but we may remember in his favor how, when means of transportation failed for the 10,000 wounded that complicated the evacuation of Palestine and a march of 180 miles across the desert, he assigned all the horses belonging to the staff to the use of the medical department and set an example of generosity by himself leading the way on foot.1 An example of Larrey's sense of duty to his patients is furnished by the following episode, unpretentiously set forth in his "Memoires de Chirurgie militaire et Campagnes." " I had barely time to load the wounded man 2 on my shoulders and bear him back toward our army, which was beginning to retreat. A series of holes or caper- tree trenches that I had to traverse saved me, for the cavalry could ij. Ambert : Loc. clt. *Gen. Silly, wbose leg had been crushel by a cannon ball. 270 HISTORICAL. Vol. XIII. not follow a route so cut up, and I reached our rear guard ahead of the enemy's dragoons. At last I got to Alexandria with my worthy patient on my back and there succeeded in curing him." After the campaign in Egypt, Larrey was appointed surgeon to the consular guard, and later made inspector general of the health de partment of the French armies. Meanwhile he had been selected for membership in the recently organized Legion of Honor, receiving the decoration at the hands of Napoleon himself, who remarked : "A well-deserved honor." When the Emperor collected a vast array of stores and assembled a huge army at Boulogne for the invasion of England, Larrey was at hand with a fully prepared medical service. " You came near being ready before I was," said Napoleon drily, as he remarked his chief surgeon's ceaseless activity. Larrey participated in all the principal campaigns after the rupture of the treaty of Amiens. He was present at Austerlitz, Jena, Eylau, Friedland, and Wagram. On the field of Eylau, Napoleon made him commander of the Legion of Honor. At Friedland, as everywhere, Larrey lavished his professional attentions on friend and foe alike. A wounded Eussian officer has described how he had been left for dead on the battlefield and robbed by marauders of his very clothing, and when he was finally found and carried to the dressing station the great French surgeon not only dressed his wounds, but supplied his deficiency of attire from his own wardrobe. The medical school of Jena conferred on Larrey the degree of Doctor of Medicine in recognition of his high attainments and no bility of character. During the peninsular campaign Larrey con tracted typhus fever and narrowly escaped death. On convalescing he rejoined Napoleon in Austria in time to be present at the battle of Essling. It was on the island of Lobau that Larrey concocted his famous broth for the sick and wounded. There was a dearth of all supplies, but he ordered his own chargers killed to supply the meat. There were no cooking utensils so the helmets of the cuirassiers were requisitioned. Gunpowder was substituted for salt as a condiment. Gen. Massena drank the first bowl of this concoction without suspect ing the nature of its ingredients. While Larrey was teaching and practicing his art during the French occupation of Vienna Napoleon made him a baron of the empire, with an annuity of $1,000. The great heart, the intrepid soul, the redoubtable energy of Larrey never showed to greater advantage than during the ill-fated campaign of 1812. His generosity, patience, tender devotion, and self-sacrifice were seconded by his ingenuity and resourcefulness. At Smolensk no lint was to be had for surgical dressings. A sort of tow made from the shred of the birch was used instead. Paper dressings replaced those of linen, the source of supply being the No. 2. 271 HISTORICAL. archives of the city. At Moskowa Larrey remained behind for 72 hours and worked day and night to relieve the sufferings of the thousands of wounded French and Russian soldiers. Thiers says that on this occasion he was " the benefactor of all sufferers." Speak ing of the retreat from Moscow Thiers, in his "History of the Consulate and Empire," recalls that the momentous decision to at tempt it was opposed by Larrey, " one of the best informed witnesses of the situation who believed that there were in the city ample provisions for a six months' sojourn." " Unfortunately, no attention was paid to his opinion," says Ambert.1 " Surgeon Larrey," says Thiers, " through his inexhaustible kind ness, had gone ahead to help the wounded at Kolotskoi as far as the brief stop there permitted. He arranged for the removal of those able to travel and lavished on the others the highest resources of his art. When he discovered there certain Eussian officers who owed their lives to his services and were profuse in their acknowl edgements, he required them to pledge their word of honor that from the approaching moment of their liberation, when they would become masters of the fate of those whose plight they had recently shared, they would repay to them the good they had received at the hands of the head surgeon of the French." In the memorable retreat from Eussia Larrey marched on foot, surrounded by his assistants, in the center of the long column of starving, shivering soldiers, setting an example of fortitude and cheerfulness to all. He put his own canteen to the lips of the dying and shared his meager ration with the hungry; he encouraged the weary by every means in his power; as the men fell to the ground he picked them up and revived them. He was everywhere sustaining, helping, cheering ; urging on the stragglers ; changing the dressings of the wounded, inspiring the disheartened with fresh hope. At night he wandered about among the wounded seeking to relieve their pain, and to those who were past all hope from surgery he addressed words of spiritual consolation. The passage of the Beresina was in the nature of a stampede under the decimating fire of the Bussians. Larrey got across with the remnants of the imperial guard, but had scarcely reached the farther bank when he discovered that the boxes containing certain important surgical instruments had been left behind. In spite of the urgent appeals of his companions Larrey retraced his steps and forced his way to the other side. When he finally sought to rejoin the main body his retreat was cut off by the dense mass of soldiery fighting for a foothold on the shattered bridge which the sappers and miners had finally been able to make passable. He would have been trampled to death by the maddened host of fugitives if some of the common 1 Loc. clt. 272 HISTORICAL. Vol. XIU soldiers had not recognized him and taking him in their arms forced a passage for themselves and their precious burden. In the campaigns that closed Napoleon's meteoric career his armies were made up to a large extent of raw young conscripts. Many of these were found after an engagement with mutilated hands. It was represented that these wounds were self-inflicted, and the Emperor was first overwhelmed with mortification and then fired with wrath. He proposed to make severe examples of the guilty. Terror invaded the ranks and the report was current that 1 man in every 20 would be executed. Larrey, who had carefully examined many of these wounds, stoutly maintained that they were not self-inflicted. He went before the Emperor and demanded an official inquiry into the subject before punitive measures were instituted. Napoleon grudg ingly consented, and some 2,000 youths, all suffering from wounds of the hands, were lined up in the precincts of the customhouse just beyond Bautzen. A painstaking examination was conducted by five army surgeons, a high ranking officer of the line, and a captain of the gendarmerie chosen by the provost marshal. For each man a care fully prepared report was drawn up after Larrey himself had in spected their hands and satisfied himself that the wounds were due either to the fire of inexperienced comrades in arms drawn up behind them or to the enemy's fire when the conscripts attacked up an in cline carrying their pieces high in front of them, covering face and chest, instead of at the hip. Larry went in person to report the results of the investigation. " Well, sir," said Napoleon in a tone of irritation, " do you still per sist in your opinion '( " " I do more than that," said the intrepid doctor, " I come to prove it to your majesty." He detailed the minute inspection to which the cases had been subjected and assured the Emperor that brave and worthy men had been grossly misrepre sented. " Very well, sir," said Napoleon testily, " I will attend to the matter myself." When Napoleon had satisfied himself of the soundness of Larrey's judgment he appeared before him in a state of profound emotion and paced the floor for some time, Ms arms crossed, his head sunk on his chest. Suddenly he halted before the surgeon exclaiming, " Good bye, Mr. Larrey. A monarch is fortu nate indeed who has near him a man such as you are. You will re ceive my orders later—wait." The Emperor seized Larrey's hands in his, then threw his arms around him in a warm embrace. The next moment he hurried from the apartment. An hour later Larrey was informed that he had been pensioned by the State and presented by Napoleon with a miniature likeness of himself set in diamonds. When Napoleon was banished to Elba Larrey wanted to accom pany him but the great leader bade him remain, declaring that he belonged to the soldiers of France. No sooner had Napoleon effected No. 2. 273 HISTORICAL. his escape than he summoned Larry to the Tuileries and publicly expressed regret at not having done more to reward his meritorious services. In the retreat from Waterloo Larrey's horse was shot under him by pursuing Prussians and he himself received two saber wounds. Later he was taken prisoner and at first mistaken for the Corsican, as he was wearing at the time a gray cloak exactly like Napoleon's. When his captors discovered their error they remembered that he had fired on them in attempting to escape and in their irritation promptly stood him up before a firing squad. Fortunately the Prus sian surgeon who advanced, handkerchief in hand, to bandage his eyes recognized Larrey from having been one of his pupils in Berlin. By threats and prayers he secured a stay of execution —or murder— and had the prisoner taken before Gen. Bulow, who in turn referred the case to Bliicher himself. During the Austrian campaign Larrey had been instrumental in saving the Prussian marshall's life and the debt was now discharged. Larrey was set at liberty and escorted to safety by one of Bliicher's own aids. After a brief period of oblivion following Napoleon's fall Larrey was restored to favor under the reinstated Bourbon government. A unanimous vote of the chamber of deputies renewed his pension. Louis XVIII appointed him surgeon of the royal guard. Under the government of Louis Philippe, Larrey was appointed senior surgeon to the Hotel des Invalides. About this time he worked out the de tails for the organization of the medical corps of the Belgian Army. In 1834 he went to Italy for the express purpose of seeing Napoleon's mother and other members of the Bonaparte family whom he loved for the sake of the fallen leader. When in 1840 Napoleon's remains were brought from St. Helena for interment in the splendid mausoleum prepared for them on the banks of the Seine, Larrey, now 74 years old, followed the procession, bareheaded and on foot, all the way from the Arc de Triomphe, though it was bitterly cold, the coldest day of the j^ear. He was dressed in the uniform he had worn at Wagram. Tears streamed from his eyes. At 76 Larrey, who for some years had been forgotten and ignored by the public in spite of all he had accomplished for his country (he never uttered a word of complaint), was sent on a tour of in spection of the military hospitals in Algeria. He died in Lyons within a few days of landing in France after completing the duty assigned. While his son was ministering to his last needs on earth a letter from Paris announced the death of Madame Larrey. In 1850 a statue was set up to the memory of Baron Larrey in the grand courtyard of the Val-de-Grace. This ceremony was an occa sion of national importance, and eulogies of the great surgeon and 274 Vol. XIII. HISTORICAL. good man were pronounced by many eminent in science or high in army and Government circles. Among the speakers was Roux,1 representing the Academy of Sciences. His estimate of Larrey is in teresting. He calls him the hero of humanity, the idol of the French soldier, and in quoting the famous words of Napoleon's will—" Larrey is the most virtuous, the most upright man that I have ever known "—recalls the fact that Marcus Aurelius used almost identical language in regard to Galen, and Louis XIV in regard to Lamoignon when urging him to accept the presidency of the parliament of Paris. On the professional side he credits Larrey with great ability as a military medical officer, as an organizer, as a pioneer in the adequate and systematic relief of the wounded. He calls attention to Larrey 's use of debridement (a word heard often to-day) in gun shot wounds, to his fine work in the treatment of fractures by im mobilization, his belief in the prompt amputation of limbs where the destruction of tissue has been excessive, his studies of frostbite, his method of disarticulation at hip and shoulder, but condemns Larrey's disinclination for the primary suture of wounds. The favorable and unfavorable comment are alike a panegyric of a sur geon who had neither aseptic nor antiseptic methods, much less an ancillary bacteriological laboratory at his command, but whose patients got well. Larrey left an imperishable name. Other men have devised op erations, worked cures, contributed to the progress of science, but their names are known only to the student who disturbs the dust on the worm-eaten records of medical history. Larrey's fame is a living inspiration, because back of his native talent and the skill acquired through laborious effort there shines a character made beautiful by purity, unselfishness, and unassailable integrity. A single sentence from Napoleon's testimony to Larrey's virtue has been quoted a thousand times. The rest of what he said is not so well known. The omitted sentences are practical and specific. They contain a wonderful rebuke to the military surgeon who can always be found at headquarters, to the Navy doctor who attempts to administer the sick bay from the wardroom and wins a favorable report by playing a good hand of bridge in the cabin. " In the most inclement weather and at all times of the night or day Larrey was to be found among the wounded. He scarcely al lowed a moment's repose to his assistants and kept them eternally at their posts. He tormented the generals and disturbed them out of their beds at night whenever he wanted accommodations or assist ance for the wounded or sick. They were all afraid of him, as they knew he would instantly come and make a complaint to me. He paid court to none of them." 1 Phllibert-Joseph Roux, who succeeded Dupuytren at the Hotel Dleu of Paris and was a pioneer In operative gynecology. No. 2. 275 HISTORICAL. EXTRACT FROM A SURGICAL MEMOIR READ RY BARON IARREY BEFORE THE ROYAL ACADEMY OF FARIS, FEBRUARY 19, 1819.1 Translated by G. A. Lcnq, Captain, Medical Corps, United States Navy. The merit in this translation is its value as an Incident In medical history. The operations described were performed by one of, if not the most famous of military surgeons known. They are conspicuous in that they were undertaken at a time when few surgeons had the hardihood to undertake such tasks. Anesthetics were unknown. Hemorrhage during operation, suppuration, and secondary hemorrhage were always likely complications that deterred many surgeons from entering into fields where now they safely venture. At the time that Larrey performed these operations the armamentarium of the surgeon, except for certain elegancies and refinements, was much as it is to-day. Suppuration was regarded as inevitable and accepted as a matter of course. Where it did not occur In abundance and for a protracted period it evoked some surprise and a profound 'sense of satisfaction in the surgeon. Such a happy condition, when It happened, was probably due to some fortuitous act in the ordinary effort at cleanliness, or some fortunate action of the various substances that were applied In the dressings. Of course, too, It Is to be ob served that certain patients in combination with other favoring circumstances may have been spared infection through their own natural powers of resistance. Larrey's success in this respect may have been largely due to his use, for a period prior to operation, of tonics to build up the health of the patient and thus increase his resistance to suppuration and shock. It is also possible that his practice of using mercury locally for a period prior to operating may have had something to do with the rapid recovery from the immediate effects of the operation. The case of Nicholas Moret is interesting because the detail and exactness of the description of his case by Larrey makes It resemble the record of a hospital patient of yesterday. He calls the affection a tumor, but implies that it was a cancer that had not yet undergone " cancerous degeneration." From his very careful description of its appearance, location, size, structure, i'nd duration, it was in all probability a lympho-sarcoma. The points conspicuous in Moret's case are: The surgeon's great anxiety to control the hemorrhage; that the wound was cleaned and a styrax ointment was applied covering the entire area of the operation; that the patient bore the operation with great courage, and that he suffered a period of what is now termed surgical shock ; that the operation was accomplished in 50 minltes ; that the wound healed in 31 days. In the volume from which this translation was made there appears a wood cut depicting the appearance of the tumor before operation. The case of Madame de L. is even more interesting. Judging from the descrip tion of Its appearance it must have been a carcinoma. Larrey's method of extirpation of the cancer was essentially the same as the accepted one of this day and described In text books as the Halstead operation. It is amazing to think of one undertaking these operations without an anes thetic, and equally so to read how promptly the patient recovered. The case of Madame de L. was one of several Larrey operated on successfully. In the record of the Moret case he states that he had removed the breasts of 15 or more women afflicted with cancer, and that no recurrence manifested Itself in periods of from 3 to 10 years following. »From "Tralte de la Maladle Scrophuleuse," by C. C. Heufeland, Paris, 1821. 276 HISTORICAL. Vol. XIIL In this translation the writer makes no claim to being proficient in Uk» French language. It was literally dug out with the use of the dictionary and, on occa-' sions, with other help. It is offered as a small contribution to the study of medical history. I am not aware that It has been translated. DESCRIPTION OF AN UNUSUAL OPERATION, TOGETHER WITH SOME OBSERVATIONS ON THE NATURE OF THE DISEASE NECESSITAT ING THIS OPERATION. If the nations have experienced deep afflictions as the result of the last war, which extended its theater of operation throughout all of Europe and over a part of the New and Old Worlds, humanity has found in French surgery a real source of consolation. And during this memorable war this art has made such great progress, it has, per haps, attained its highest degree of perfection. The numerous and bloody conflicts which our armies endured in all countries have supplied military surgeons, guided by leaders full of years of devotion, with numerous opportunities for experiments, whose happy results have served to simplify many surgical problems hitherto considered insoluble. But in order to reach this much- desired goal, military medical officers have had to unite genius and intelligence to a firm and indomitable courage, by which they have braved dangers, surmounting all obstacles and opposed by prejudice and routine. If we may presume to mention ourselves among those gentlemen who have distinguished themselves in these matters, we shall remind the Academy of Science of those memoirs on the principal points of our art which we have had the honor to communicate to it at various times. May it permit us, however, to refer again to the subject of some of the most striking of these memoirs. Some had undergone, according to a method of our own, amputa tion of the arm at the shoulder, others that of the thigh at its upper joint, others, again, opening' of the chest with resection of a rib for the extraction of missiles lost in that cavity. In short, many others, not less remarkable, have specially attracted the attention of the commissaires receiving these memoirs. The skill we have acquired in the practice of these large and difficult operations has made us undertake, against the advice of several famous surgeons at this capital, the one that is the subject we are about to report, and the observations which accompany it. Nicholas Moret, aged 40, farmer, born and living in the country about Louviers, of a robust constitution but with scrofulous idio syncrasy, presented on the left side of the neck a tumor, lobular, slightly mobile, indolent, and without any change of color of the skin. It stretched from the mastoid process, along the jaw, filling No. 2 277 HISTORICAL. all iho deep hollow of the neck to the larynx, forming in front of the maxillary bone a projection about the size of two fists. This tumor had developed 10 years before. The patient, after submitting in vain to several treatments, went to Paris during July, 1818, to consult the best doctors. Their opinions, heard separately, were very different. Some advised extirpation of the tumor without manifesting any desire to operate. Others regarded an operation as highly dangerous. Others again were undecided as to what to do. His hopes dashed, Moret left Paris and returned to his home in Normandy deeply distressed at his condition. However, he fell in, by chance, with one of our own soldiers whose arm had been ampu tated at the shoulder, and who strongly advised him to return to Paris to see the surgeon who had operated on him. And Moret came to seek us toward the middle of November of the same year. After having examined the tumor with great care it was easy to determine its character and to foresee the serious consequences it would entail if not promptly removed. This indication seemed positive and what made its execution more urgent was the fact that the disease had arrived at the stage where cancerous degeneration usually sets in. We had already seen three different patients die from the same malady and in which its spread had been so rapid that the surgeons consulted, not daring to operate, remained simply spectators of the sufferings and the process of strangulation which soon ended the days of these three unfortunates. On the other hand we might well have been deterred by the tragic accidents that had happened to several of those who had removed tumors similar to this of our patient. But we overcame this obstacle by the certainty of controlling the hemorrhage by means of ligatures and compression. We were not deterred by the fear of meeting the criticism of those who were probably less skilled in the exercise of their art. Having thus carefully considered the possibilities of the opera tion and its results, the patient being perfectly in accord, we decided to operate as promptly as possible. To this end we consulted with those two enlightened physicians, Messrs. Chaussier and Ribes, who coincided with us in the urgent necessity for removal of this huge tumor already producing mechanical pressure on the principal ves sels of the head, the larynx, the tracheal arteries, putting the patient in the greatest danger. All being arranged we proceeded to operate November 16, 1918, assisted by one of the consultants, by M. de Lacaze, surgeon major of the 2d Regiment of the Swiss Guard, and Messrs. Grinelles and Desrulles, major assistant surgeons to the Hospital of the Royal Guard. 278 HISTORICAL. Vol. XIII. The patient being laid on a specially made bed, we traced in our minds the plan of the operation such as we shall describe, anticipat ing above all to take every precaution necessary to prevent hemor rhage of the many arteries to be cut, the only dangerous accident to be feared. However, the intelligence and skill of the assisting sur geons reassured us as to this danger, and moreover we said with Celsus, " Melius est anceps experiri remedium quam nullum." 1 By means of an incision paralleling the edge of the jaw we first cut the skin covering the surface of the tumor. Three other in cisions crossed it at right angles, one followed the anterior edge of the sternomastoid muscle to the clavicle, the second, the center of the tumor, and the third smaller one followed the immediate line of the larynx. The strips resulting from these incisions were promptly detached from the exposed surface of the hardened mass. Several arteries cut in these incisions were successively tied and we continued the dissection until the tumor was isolated for about three-fourths of its circumference. Deep cellular furrows divided it into several lobes of different sizes. These were like so many paths by which we arrived at the roots of the tumor. Carefully following the layers of these furrows, we detached these glandular bodies, the tissues being easily cut by means of a button bistoury. The largest and most prominent part was thus soon shelled out. Its pedicle being two large vessels we passed a ligature about it before cutting them. Removal of this glandular body involved the jaw, which we found necrosed to a depth of several lines, disclosed the other tumors, and facilitated the rest of the operation. One of the glands was embedded in the interval of the transverse apophysis of the second and third cervicle vertebrae and was removed with the same precautions. The second one, of an egg shape, and the size of an almond, was involved in the sheath of the common carotid artery. Nevertheless, it had to be removed like the others or else the malady would have reproduced itself. After having firmly compressed this artery below the gland, we cautiously cut its sheath. We detached it by means of the button bistoury. Its removal completely bared this main ves sel, but everything was prepared for its ligation in case of accident. The third gland, composed of several lobules, adhered to the left side of the larynx, the genio-glossal muscle, and the hyoid bone. Its extraction, though difficult, was equally successful. We can even feel sure that not a single glandular fragment re mained within the seat of the infection. We can venture to guaran tee that there will never be the least recurrence of trouble in all this region of the neck and head. 1 It is better to try a hazardous remedy than none. No. 2. 279 HISTOKICAL. More than 15 arterial vessels were tied. Among them we may mention the external maxillary or common labial, the submaxillary, the occipital and superior thyroid, and a number of others of some size developed by the malady. Several nerve fibers of the facial, vagus, lingual, and Willis's ac cessory on its way across the sterno-mastoid muscle were cut. The incision washed and cleansed, we approximated the edges, fastened it with a score of sutures, adhesive plaster, and fenestrated linen, covering with a styrax ointment which covered all the region upon which we had operated. We were careful to fasten the liga tures at the open angles of the incision. Lint and an appropriate bandage completed the dressing. The patient had borne the operation with the greatest courage, although it lasted 50 minutes in all, but some moments afterwards he was seized with a marked syncope followed by a chill of a febrile nervous character, a transitory but unavoidable accident. Perfect calm succeeded this storm, and for the first time for a long while this farmer enjoyed the benefit of peaceful sleep. The happy outcome of this extensive operation made us forecast favorable results, and, as it was, the patient grew better and better, and the first three days passed without the least drawback, except a slight temporary fever the night of the third day following the op eration. The first dressing was lifted on the fourth day. It was saturated with purulent matter and without one drop of blood, all the stitches taken in the wound being already reunited, and, with the exception of the opening we had left in which to place the ligatures and favor the draining of the fluids, all the incisions were almost entirely healed. The ligatures fell between the ninth and tenth days, and shortly afterwards the edges of the wound corresponding to the passage of the ligatures were themselves joined, so that the patient was cured on the thirty-first day from the operation and left for home on the forty-first with every sign of perfect health. We examined the glandular tumors with great care. All were enveloped in membranous tunics of a dense tissue, red in color. The deepest layer of these was furnished inside with very thin partitions like those observed in the lemon. The substance interposed between these gray and white layers can not be better compared in appearance and density than to the pulp of that fruit. It was firm, elastic, like half-cooked albumen, so that in cutting one of the glands across the fleshy tissues of each of them, it swelled and exuded by a sort of erectility. It was hard to tear the tissue. These membranous en velopes evidently received nerves and vessels, and they also ap peared to be endowed with vital properties in varying degrees, so that irritability of the blood vessels and lymphatics had been in creased in our farmer, which were produced in the glands of the 280 HISTORICAL,. Vol. XIII. neck by some predisposing local cause unknown to us; first inflam mation, then stagnation of the lymph occurred in the interior of this glandulous system, whence there resulted permanent engorgement and tumefaction. During the first period this was slow and gradual; later the progress was more marked. In other respects this disease presented the same phenomena in all subjects attacked by it, with the excep tion of some variations depending on age, sex, and temperament. In general this morbid condition, without being accompanied by local pains, attacks the integrity of the neutritive functions and one of its principal effects which has not been noticed by writers is the unnatural and asthenic dilatation of the arteries, especially those near the tumors.******* Mme. de L., of Rouen, 62 years old, went to Paris early in the spring of 1816 to consult the best doctors about an enormous cancer of the right breast that she had had for several years. The cele brated Laumonier, chief surgeon of the Hotel Dieu, at Rouen, twice operated upon this case, amputating first the scirrhous breast and then the tumor associated with it which this lady developed after the first operation, the latter reproducing itself just as the first was healed. When we saw this lady for the first time the cancerous tumor was about the size of a child's head. It was depressed in the center, caused by its adherence about the cicatrix, which had contracted at this point, while its circumference presented a series of vesicular tubercles of bluish color and of different sizes, separated one from another by fissures from which oozed a yellowish ichorous humor of an extremely fetid odor. The skin covering this tumor was mottled with numerous and very large varicose veins. The glands on the same side were engorged and one of them formed part of the tumor. The arm on the affected side was engorged and almost immovable, and the patient suffered lancinating pains, depriving her of sleep and keeping her in a state of constant anxiety. The majority of physicians consulted had judged a third opera tion impracticable and useless. Madame deL., in despair, wa? on the point of returning to Rouen when, by the advice of one of the ladies upon whom we had operated several years previously, she came to consult us. In spite of the gravity of the disease, of which we have described the principal symptoms, we entertained a hope for the success of a third operation if preceded by the treat ment before mentioned. The patient accepted our proposition with joy, and that very same day submitted to this treatment, which was continued for six weeks. It resulted in marked diminution of the No. 2. 281 HISTORICAL. lancinating pains and the resolution of the axillary glands, except those forming part of the tumor, which remained about the same size. After these preparations we called in consultation the physicians who had aided us by their knowledge in the Moret case, Messrs. Chaussier and Ribes. They approved the operation that we sug gested, and, although its success was very uncertain and its execu tion difficult and dangerous, they agreed that it was necessary and preferable to the caustics that some doctors advise. In short, we per formed the operation in the presence of the doctors consulted, assisted by one of our pupils, M. Desruelles. In amputating the tumor we preserved as many of its inclosing integuments as possible, but we had to remove a layer of the large pectoral muscle, to which the cancer adhered. We then prolonged the incision toward the armpit to extract the glands tainted with the cancer. After having extirpated the roots we proceeded to tie the vessels and draw together the edges of the wound, which had a truly frightful appearance. The cancerous mass we removed weighed 2 pounds 3 ounces. It was composed of ovoid fungous bodies of different sizes, scattered inside with cells filled with a blackish and oleaginous fluid. These cells were separated by fibrous membranes, thick and opalescent. In short, this cancerous mass presented a peculiar aspect not ordinarily observed in cancer of the breast. The wound ran its course without any accident and reached com plete cicatrization before the sixtieth day. We doubtless prevented any recurrence by the care taken in operating not to leave a particle of scirrhous tissue and by the treatment with which we followed it during the first years succeeding operation. This lady, who recently came to see us in Paris, enjoys perfect health. The scar is white, firm, and painless, although adherent to the ribs. We presume to think that these facts and the observations that accompany them may suffice to encourage young practitioners and prove to the public that there are very few diseases, at least those not in their last stages, that may not be attacked with advantage, pro vided, of course, that treatment be administered with discernment. 103396—19 8 Fracture of inter-condyloid spine of tibia. No. 2. ROSS FRACTURE OF PELVIS. 295 the block, being used to hoist the anchor, was under heavy tension and flew about 10 feet. After striking the patient, who was thrown 8 feet in the air, the block glanced off and struck a large galvanized- iron bucket filled with sand. The impact was so great as to flatten this bucket. The patient was wearing a pair of high hip boots folded down in such a manner that the part of the leg struck was covered by about four thicknesses of rubber. For a moment, the patient was un conscious. Then, there was a severe pain in the leg—pain increased by motion. There was marked swelling, ecchymosis and a large hem atoma of both thigh and leg. Hot applications gave no relief. The following morning the patient was removed to the French hospital at L . The leg was extended and placed in a wire splint. On the third day the hematoma was evacuated by a large trochar, a pint or so of thick, bloody fluid being withdrawn. An attempt to walk failed and he spent two weeks in bed. After hobbling about for another two weeks without improvement patient was conveyed to this hospital. On admission, the knee was found to be somewhat swollen and slightly flexed and there were varicosities of the super ficial veins on the posterior surface of the leg. X-ray examination showed a transverse fracture of the intercondylar spine of the left tibia in good position and with some excess of callus. Persistency in passive and active motion has resulted in complete restoration of flexion and almost complete extension of the leg on the thigh, although there is still a sense of grating in the joint on motion. A CASE OF FRACTURE OF PELVIS. By G. G. Rosa, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. E. E. W., boatswain's mate second class, age 28, was admitted to United States Naval Base Hospital No. 5 on April 4, 1918. We were indebted to the medical officer of the U. S. S. Panther for the fol lowing history of the accident. At 4.30 p. m., April 4, patient was in a motor boat alongside the U. S. S. Panther. He was helping to transfer heavy sheet steel. Three sheets (6 by 9 feet,) weighing about 3,000 pounds, were low ered by tackle and pulley from ship's deck to motor boat. Upon reaching the bow of the motor boat one end of the sheet-steel pieces (which were slung together) struck the boat, jarring all three pieces, then fell about 15 feet and struck the patient, with their entire weight, on his left hip. The patient was thrown against his left hip and the side of the boat against his right hip. The motor boat yielded to the impact and thereby lessened the severity of the injury. The patient did not become unconscious and was carried to sick bay 296 MICHELS CHRONIC ARTICULAR RHEUMATISM. Vol. XIII. immediately. He had difficulty in voiding urine which was some what bloody. The medical officer was able to elicit crepitus in the left hip joint on straightening out the leg. There was no shock. The patient was admitted to the hospital two hours after the accident. He was catheterized and no evidence of rupture of blad der or urethra was found. The urine was bloody, but the blood was not clotted and it was well mixed with urine. This blood might easily have come from the kidney or from the contused bladder. Urinalysis was negative except for blood. On examination the man complained of pain all over the pelvic region, most marked over the left hip, in the right groin, and in the small of the back. The application of inward pressure simultane ously to both hips brought on extreme pain. He was especially ten der in the right groin and also over the sacro-iliac regions. - X-ray examination showed the following, April 5, 1918. Frac ture of descending ramus of pubis on both sides. Dislocation of left sacro-iliac junction ; partial dislocation of right. Whole left side of pelvis is pushed upward and backward about 2 inches. Stellate fracture at bottom of right acetabulum. Head of femur driven into acetabulum making a central luxation of first degree. He was placed on Bradford frame and the pelvis incased in an adhesive plaster belt, extending from above the crests of the ilii to below the great trochanter and completely encircling the body. At the end of a week an abdominal pelvic appliance, made of canvas and laced in front, was substituted for the adhesive plaster. Great care was exercised in moving the patient, as a false move could have resulted in puncturing the bladder or in cutting the urethra. Four men on the same side of the bed, all lifting at the same time, were able to raise him in a perfectly horizontal plane, and without dis comfort. At the end of two weeks he was able to sit up in bed and to flex both thighs on the abdomen. CHRONIC ARTICULAR RHEUMATISM CURED BY REMOVAL OF DISEASED APPENDIX. By H. H. Michels, Lieutenant, Medical Corps, United States Naval Reserve Force. This case is interesting on account of the sudden and complete relief from prolonged and intense suffering due to chronic articulai rheumatism afforded by an appendectomy. Sergt. L. R. , United States Marine Corps, while on dut} at Guam, was admitted to the sick list during March, 1918, with a diagnosis of chronic articular rheumatism. The knees, ankles, phalangeal joints, and right shoulder were the principal parts af fected. March 30, 1918, he was transferred to the United States 206-1 290-2 No. 2. 297 RYAN — MYELOID LEUKEMIA. Naval Hospital, Mare Island, Cal. He obtained sick leave during May, and while visiting his relatives in Chicago I was called and treated him for a severe recurrence of rheumatism, and later he was transferred to the United States Naval Hospital, Great Lakes, 111. July 27, 1918, he was discharged to duty and was attached to this recruiting district. He worked in the office on light duty, but with frequent recurrences of rheumatism, until November 4, 1918, when his disability required transfer to the United States Naval Hospital, Great Lakes. I recommended an exploratory operation on account of a constant tender area in the region of McBurney's point. All other points of possible focal infection being negative, it appeared probable that his frequent recurrences of rheumatism were due to some infective focus in the region of the appendix. Appendectomy was performed on December 6, 1918, at the United States Naval Hospital, Great Lakes, 111., and I was informed that the appendix contained three concretions and was in bad condition. January 2, 1919, he was discharged to duty, well. From the beginning of the chronic articular rheumatism, which really began about three months before his first admission, until December 6, 1918, he had never been entirely free from pain for a day. The patient informs me that he went on the operating table with rheumatic pains and stiffness, especially in the shoulder joints, and that was the end of it. Since January 2 his duty at this recruit ing station has required him to be outdoors in all sorts of bad weather, without even a reminder of his former trouble. I believe he is permanently cured. A CASE 07 MYELOID LEUKEMIA. By E. R. Ryan, Lieutenant, Medical Corps, United States Navy. L. R. G., seaman, age 21, married, came to sick bay on board the U. S. S. Arkansas on October 8, 1918, complaining of " stomach trou ble " and constipation. Family history.—Father, age 49, living and well. Mother, age 47, living and well. One sister, the oldest child, was stillborn. He has five brothers, all living and in good health. No family history of epi lepsy, insanity, or tuberculosis. Past history.—Had whooping cough at age of 4, mumps at age of 8, measles at age of 9, and diphtheria at age of 11. All these dis eases were uncomplicated and patient had complete recovery. Had malarial fever at the age of 13, and another attack at the age of 19. Nervous system.—Has had occasional headaches for past four or five years. No dizziness or tremors. No history of epilepsy. Hear ing and eyesight have always been good. 103396—10 9 298 RYAN—MYELOID LEUKEMIA. Vol. XIII. Respiratory system. —Has had frequent attacks of influenza. No history of cough or expectoration. No night sweats. Has lost some weight, approximately 10 pounds, during the last year. Circulatory system. —Has dyspnea on slight exertion. No palpita tion, edema, or swelling of feet. Gastro-intestinal system. —Appetite has always been good. Bowels were always regular until the past four months, when he began to be troubled with persistent constipation. Never troubled with nausea or vomiting. Genito-urinary system. —No history of gonorrhea or syphilis. No skin disease or alopecia. Has had to get up at least once a night for the past four weeks to urinate. No frequency of urination during the day. Habits. —Up to about six months ago patient drank about four glasses of whisky and a glass or two of beer daily. Smoked and chewed tobacco moderately. Present complaint. —Patient complains of pain in the stomach, which is continual, dull, and gnawing in character and aggravated by eating. He has frequently been nauseated during the past four or five days, but has never vomited. He has been persistently consti pated during the past four months. He also complains of a mass on his left side, which he first noticed two months ago, and which is slowly becoming larger. His color has been poor of late and he com plains of general malaise and loss of energy. There has been annoy ing pruritus of the scrotum and anus during the past two weeks. Physical examination. —Patient is about 5 feet 6 inches tall ; weighs 125 pounds. His complexion is sallow or yellowish white. Body is well nourished. Head and neck. —Scalp is negative. He has a few small palpable glands on either side of the neck, just below the clavicles. Pupils are equal and react to light and accommodation. Ears and nose negative. Tonsils are visible and the pharynx greatly injected. Teeth good. Gums negative. Chest. —There is a slight bulging of the chest on the left side, be ginning at the seventh rib and extending downward. Dullness of the left chest, which starts at the sixth rib and tapers to absolute flatness at the costal border. Dull area extends from the midclavicular to the posterior axillary line. Percussion negative over rest of chest. Breath sounds were normal over entire chest, except over the dull area. The sounds over this area were distant and a coarse leathery friction rub was heard. Patient complains of no pain in this locality and deep breathing gave him no pain. The apex beat was in the fifth interspace about 9 centimeters from the midsternal line. There was no enlargement or displacement of EDITORIAL. THE I.XSSON OF JOB'S WAR HORSE. The trend of American writers on war neurosis has been toward emphasizing the importance, as a preventive measure, of greater care in the selection of recruits. That too much care can not be taken at the recruiting office is generally admitted. The weeding out at camps and training stations of the vagrant, the ne?er-do-weel, the potential criminal, the mentally unfit, is of incalculable advantage to the mili tary services, but it is not enough in respect to war neurosis since the approximately normal are subject to this affection. A broader conception of the whole subject is suggested by the able paper of W. H. E. Rivers, in Mental Hygiene, October, 1918, entitled "War Neurosis and Military Training," which is a report to the Medical Research Committee, London. It should be read by all those who are particularly interested in war neurosis or concerned in a gen eral way with military training. While Rivers does not specifically make the statement, it may be legitimately inferred from his arguments that military unprepared- ness and the hurried and intensive training necessary to atone for that unpreparedness are no small factors in the production of war neurosis. It is known, of course, that such cases developed in the sea soned regulars, as well as in the raw recruits of the British Army, but this does not invalidate the proposition just affirmed if what he has to say about esprit de corps, the value of discipline, the relation of officers to their men, the importance of athletics is true. In all these things the element of time is an important consideration. To really play the part of elder brother or father to his men an officer must have something more than good will and good intentions. If he has not the wide range of information about his profession which will inspire confidence, he must have had experience in leadership such as the upper-form boys, acquire in the public schools of England — Rugby, Winchester, Eton, Harrow, etc. —which correspond in no sense to what we call public schools but rather to the academies at Exeter and Andover, to Culver, Groton, the Virginia Military Insti tute, etc. The world knows now, and we have always known, that the Ameri can will fight and fight well but, alas, a good fighter may be a poor soldier. We may see many reasons for this or merely regret the fact, but at any rate the good fighter who is a poor soldier will have to pay 283 284 EDITORIAL. Vol. XIII. the penalty of brief superficial training and intensive hot-house methods and so will the Government and the Nation. The word repression looms large in what the psychiatrists have to tell us about war neurosis. Rivers brings out the point that repres sion is a significant feature of the training camp. " A person who is being drilled is taken from our highly individualistic community, in which spontaneity and independence are encouraged, and is sub jected to a course of training calculated to produce a state allied to that of existing communistic peoples or of animals which are accus tomed to act in herds. One result of such a training, if it be not indeed also its chief aim, is to enhance the responsiveness of each in dividual to the influence of his fellows and the form which is taken by military training is especially designed to enhance his responsive ness to those who are immediately above him in the military hier archy. * * * The other aim of military training which espec ially touches the liability to different forms of neurosis is to fit the soldier to withstand the trials and stresses of warfare. One of the chief instruments by which this aim is met is the one already con sidered which makes the individual soldier act as a member of the aggregate to which he belongs in a closer sense than holds good in civil life. This does away with or diminishes greatly the tendency of any one individual in the group to react to fear or other emotional state in a way which would interfere with his military competence. * * * Repression forms a necessary part of all education and adaptation to social life. Perhaps the most important feature of the repression of military training is the relatively late period of life at which it takes place. (Italics ours.) The older a person is the more difficult it becomes for him to give up habitual modes of thought and action. It is where repression is incomplete and is the source of persistent mental conflict that it becomes a factor in the production and maintenance of neurosis. (Italics ours.) If the repression which forms part of military training is complete it probably helps greatly toward the success of the repression which will become necessary when the soldier enters upon active service, but if it is incomplete, so that the soldier enters upon active service accompanied by the active conflicts so aroused, his success in the, necessary repres sion of warfare will be prejudiced. * * * When the soldier is brought into contact with actual warfare a new set of repressions come into action. * * * It seems clear that different batallions show the incidence of neurosis in very different degrees, and this is probably clue more than anything else to the nature of the relations between officers and men by which the private soldier acquires toward his officer sentiments of duty and trust, while the officer is actuated, it may be dominated, by interest which could not be greater if those under his command were his own children. * * * Any- No. 2. 285 EDITORIAL. one having much to do with those who have taken part in the fighting of the present war must have been struck by the extraordinary manner in which an officer, perhaps only just fresh from school, has come to stand in a relation to his men more nearly resembling that of father and son than any other kind of relationship." From all of the foregoing we deduce that, so long as the country is under the sway of pacifists who deny the possibility and probability of war and of those who in practice, if not in theory, agree with them and reject all effort to prevent war by preparing for it, we shall go into war whenever it comes with a maximum risk of war neurosis, because soldiers can not be trained overnight to shoot straight and live straight or to practice repression, whatever may be their spirit as fighters when they actually go over the top. The power of repression spoken of by the psychiatrist is nothing more than the inhibition of ordinary pedagogic language. The train ing for this must begin in infancy and be continued to adult life. Universal physical training, a maximum of military training for those of military age, participation by all the students in our colleges who are not actual cripples in athletic games of one kind or another instead of the exaggerated training of the few to perform in a gladia torial way under the eyes of the many —these are other features of a serious and determined effort to prevent neurosis in our next war. With a far larger Army, Navy, and Marine Corps as a nucleus it will not be so necessary to employ the hasty methods made imperative by our predicament in 1917 and the life in camp, the special training of officers and men, can be lengthened, amplified, and rounded out so that they will not have to be rushed to the front before they have thoroughly accommodated themselves to the novelty, the restrictions, the trials of the early stages, so that they will not be subjected to the difficult process of accommodating themselves to the environment of war before they are even inured to the life of the camp. The successful prophylaxis of war neurosis lies in the cultivation of inhibition or repression beginning in the nursery or kindergarten and continued through the period of military age; in the general development of physical prowess through participation of all youth in games and athletics which have a disciplinary and moral value; in such regular and prolonged military training as is calculated to make its details matters of habit and routine. Incidentally, of course, the defective, the degenerate, and the habitually vicious should be excluded. To use plain language, war neurosis is in part based on some form of fear. Fear is practically universal in war, but it is controlled and dominated so it is not a matter of reproach. We have learned rather generally to call that man truly brave who with a full realization of the magnitude of a given peril faces it through subordination of fear 286 Vol. XIII. EDITORIAL. to other emotions. The war neurosis developing in the private is commonly due to defective inhibition of the instinct of self-preserva tion. In the officer the fear, equally real and disturbing, which in duces neurosis is usually not so much of bodily harm as of failure to meet the responsibilities of his position. He is able to inhibit the fear of bodily harm in part through the previous circumstances of his life and in part through the nature of his position, but yields to an anxiety neurosis in regard to that very position. That form of epidemic or contagious fear which we call panic leads to the precipitate flight and rout of regiments, of armies, and may wreck a cause with little damage to the individual. There is no consequent war neurosis because the disintegrating effect of internal conflict is lacking. A wave of emotion, sudden and transitory, affects a multitude at once and passes over it without mental or physical after effects. Overwhelming odds unexpectedly developed, errors of tactics or strategy so colossal and conspicuous as to be appreciable to the mass and destroying confidence in leaders, make the attempt at inhibition useless or seem useless to the multitude and solidarity still remains ; the men act en masse rather than as individuals. A homely illustration of the power of inhibition developed by training may be found in the horse, timidest of all animals, yet capable of becoming a valuable coadjutor of man in war, racing to the charge with keener relish the higher his spirit and breeding, the greater his nervous energy. What lover of horses but thrills at the following beautiful description : Canst thou make him afraid as a grasshopper? The glory of his nostrils Is terrible. He paweth In the valley and rejolceth In his strength; he goeth on to meet the armed men. He mocketh at fear, and Is not affrighted ; neither turneth he back from the sword. The quiver rattleth against him, the glittering spear and the shield. He swalloweth the ground with fierceness and rage ; neither believeth he that it is the sound of the trumpet He salth among the trumpets, Ha, ha ; and he snielleth the battle afar off, the thunder of the captains, and the shouting. —Job xxxlx, 20-25. Similar conduct in a charger of to-day is the result of long training in habits of obedience to the rider's will, of unabuscd confidence in that rider's judgment, of such prolonged familiarity with sights and sounds like the flash of gunpowder and the roar of cannon that they no longer terrify. On the other hand, instinctive horror of a dead animal of his own kind, the fear provoked by the. smell of a fresh equine carcass, often renders the best steed unmanageable. This is probably the one experience of battle for which he has not been pre pared by military training in time' of peace, and it is too painful an experience to be covered by a limited, undeveloped repression. SUGGESTED DEVICES. SANITARY DRINKING FOUNTAIN. By D. S. II i i.i.i s . Lieutenant Commander, Medical Corps, Dnlted States Naval Reserve Force. The sanitary drinking fountain designed by Captain C. M. De Valin, Medical Corps, United States Navy, is in use at the United States Naval Training Station, Great Lakes, 111. This design seems to fulfill the requirements better than any fountain so far devised. The illustrations show the usual and proper method of use and the action of the ring in preventing direct contamination of the spout. CLINICAL CHART HADE BY A RUBBER STAMP. By J. J. Cancblmo, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. For the medical officer who wishes to give his brother officer a better idea of a case, a simple means of showing temperature, pulse, respiration, and number of stools should be of value. A rubber stamp may be made which will print a chart; such a stamp does not take up too much room; it is easily written up and tends to make the medical officer more careful. The stamp need not be used in all cases, but only when a patient is transferred because of some complication which would be better treated at a hospital. Thus in figure 1 there is a case of pneumonia as a complication of influenza. The little effort in writing up a chart does more to make clear the patient's condition than a lengthy written statement. This is because the chart is graphic. Too fre quently patients are sent to hospitals with little more than a diag nosis. The hospital medical officer is entitled to more than this. He should be given all the necessary clinical data that will make the patient's condition clear to him. The chart would be of more value at sea, for it could be used with all febrile cases that are transferred. It might be also used in cases in which a permanent record is desirable because of some pending legal action. 287 288 Vol. XIII. GROVE AND CROW CLINICAL RECORDS. The rubber stamp was ordered through the quartermaster in the usual way ; that is, by drawing the necessary lines and figures on an N. M. C.-G. M. Form 637. &T0CU 105 o •V- O ■v- 104 / 103 / 101 J 101 p// 100 o 11 N w o© oo eO CD o o OO CO CO POISE OO oo O >~0 O oo OO o I— oo o— HL a.. -C a— O- ■ CsJ c-l o— a- a— o— m r»- - o— <=> No. 2. 289 GROVE AND CROW CLINICAL RECORDS. medical history. Jan. 6, 1919. Name of patient: K. G. K. Place: U. S. S. Ohio, at sea. A Scarlet fever. Origin in line of duty. Not due to his own misconduct. Symptoms : Characteristic punctate rash on chest and face ; circumoral pal lor, etc.; headache, severe sore throat; tongue heavily coated. Treatment : Isolation, sodium citrate gr. x q. 1. d. and gargle. To be sent to hospital on arrival in port. 1-8-19 Considerable itching. Treated with carbolated vaseline. T 1-10-19 Transferred to naval hospital, Philadelphia, Pa. 4 medical histoby. Jan. 11, 1919. Name of patient: A. V. M. Place : Marine barracks, navy yard, Philadelphia, Pa. A Influenza (458). Origin in line of duty. Not due to his own misconduct Symptoms: Prostration, myalgia and painful cough. Chest examination negative. Treatment: Calomel, followed by mag. sulph., aspirin gr. x and cough sirup. 1-13-19 Cough continues; suggestive signs of consolidation in right base. Sputum rusty. C 1-14-19 Diagnosis changed to— 3 A Pneumonia, lobar (667). Origin in line of duty. Not due to his own misconduct. Consolidation found in right base. T Transferred to naval hospital, Philadelphia, Pa. O A SYSTEM OF CLINICAL RECORDS. By W. B. Grove, Captain, Medical Corps, United States' Navy, and G. B. Cnow, Lieu tenant, Medical Corps, United States Naval Reserve Force. The following system of clinical records has been in use at the United States Naval Hospital, Norfolk, Va., since April 1, 1918. Samples of these records, together with brief explanatory notes were sent to the Bureau during the summer. The plan is briefly this: The clinical record of every patient ad mitted to the hospital is kept on a 5 by 7f inch clinical card. Labo ratory reports, X-ray reports, and records of operations are all made on additional blanks of the same size as the clinical cards. These various report blanks are printed on various colored papers to facilitate ease of recognition of the blanks. All such reports on a given case are sent to the ward and filed in a 5 by 8-inch jacket envelope, open at one side, provided for the purpose. Temperature charts and clinical records kept by the nurse are also folded once and filed in this same jacket when the patient is discharged or is transferred to another ward. The present forms of such charts and 290 Vol. XIII. GROVE AND CROW CLINICAL RECORDS. records supplied by the Bureau are 8 by 10£ inches and therefore do not easily file in a 5 by 8 inch jacket. We therefore cut these charts to 7f by 10 inches so that when folded once they are the same size as clinical cards, laboratory report blanks, etc. In other words, all the data on the case are kept together on blanks of uniform size, and filed in the envelope. The following instructions explain the method of handling in detail : INSTRUCTIONS REGARDING RECORDS OF PATIENTS' HEALTH RECORDS, CLINICAL CARDS, AND FILING SAME. All Medical Officers, Hospital Corps, and Nurses: 1. On admission of a patient to the hospital the Health Records Office force will fill out first two lines on clinical cards, attach card to health record and send to medical officer In charge of case. 2. The medical officer in charge of case will make an abstract on clinical card of such data given in the health record as seems most important. 3. After making such notes as are deemed necessary on clinical card, the health record will be returned to the Health Record Office and clinical card sent to ward for file in card index-filing box. Clinical records shall be kept in the ward at all times except when temporarily removed for use of boards of survey, etc. 4. Medical officers will make such entries from time to time on clinical cards as are necessary to show condition and progress of case, e. g., history, symp toms, clinical findings, important treatment, etc. Records should be kept up to date, I. e., complications or new developments should be promptly noted. 5. All laboratory reports, X-ray reports, operation reports, etc., will be filed with clinical cards In each case in jacket envelope provided for that purpose. Surname of patient to be entered in upper left-hand corner of envelope. In cases covered by a single card and without laboratory or other reports the card need not be placed In envelope. 6. When a patient is transferred from one ward to another the medical officer will bring card up to date and sign it. In all cases of transfer the clinical record (card or envelope with all data, including temperature chart) will accompany the patient. When a case is transferred from one medical officer to another the medical officer making the transfer will bring both the health record and clinical card up to date and sign them, transferring both to the medical officer receiving the case, who will send clinical card to ward, and after reviewing health record will send it to the Health Record Office for file. 7. Change of diagnosis will be entered on card and change diagnosis slip sent to Health Record Office, as at present. 8. The nurse or senior hospital corpsman in charge of ward will be respon sible for the proper filing of and care of cards, laboratory, and other reports and for transfer of all clinical records with patient to another ward. No one except medical officers and nurse in charge shall have access to clinical cards. 9. On final disposition of case the medical officer will send patient's name to Health Record Office and health record will be sent to him. He also notifies nurse in charge of ward to send clinical record to his desk. From clinical record he makes a brief abstract of case in health record, paying particular attention to " In line of duty " and points that may have a future bearing on health of patient. Health record and clinical record are signed and returned No. 2. 291 BUNKER—A DRESSING FOB WOUNDS. to Health Record Office for file of clinical record and forwarding of health record. 10. Requests for laboratory and X-ray examinations will be made by medical officers on blanks provided for that purpose. The red request blanks should be used only for emergency examinations. The two most Important points in the use of these records are : (1) It affords an easy means of keeping together nil the data on the case and of keeping It In the ward and easily accessible at all times. (2) These records are kept on file In the hospital by a card-Index system and will be available for reference not only for statistical purposes, but for reply to Inquiries frequently made from various sources regarding cases after the patient has been discharged from the hospital. Before the use of this system the health records of all cases In the hospital were kept by the medical officers In charge of the cases in their desks in the medical office. This had two seriousness disadvantages: (1) Health records were frequently lost. (2) As the records were not kept in the wards (keeping them in the wards would Increase the chances of their being lost) such entries as were made by medical officers were apt to be delayed and made from very hazy recollection of the points observed at the time the patient was examined. Furthermore, in a number of cases there are a great many points that arise that have a bearing on the case during that particular illness and should be noted for statistical purposes, but need not necessarily be entered on the health record. Under this system the clinical cards and reports give a more detailed and accurate picture of the case than it is feasible to give in the health record. Entries on the health record, therefore, need not be made until the patient Is ready to leave the hospital, or passes from the care of one medical officer to another, and such entries may be made comparatively brief, covering more particularly the question of " line of duty " and points that may have a bearing on the future health of the patient. On first thought it might be concluded that this system added materially to the paper work required of the 'medical officer. As a matter of fact this system docs not add to the work of the medical officers. If the notes on the case are made promptly, while fresh in mind, and at the time of sick call, a few minutes each day will serve to keep up the records on the number of cases ordinarily assigned for an officer after the case has been originally written up. As the original of all laboratory and X-ray reports are filed with the clinical cord, the medical officer is not called upon to copy any of these records. A DRESSING FOR WOUNDS. By C. W. C. Bunker, Lieutenant Commander, Medical Corps, United States Navy. The formaldehyde-phenol in camphor paraffin combination de scribed by Connell (Connell, K., Surg., Gynec. & Obst., July, 1918) impels me to call attention to a somewhat similar combination that I have used since 1912 with the greatest satisfaction. It was origi nally recommended to me by Lieut. Commander E. E. Curtis, Medi cal Corps, United States Navy, and I know that it has been used by others. I now take phenol (liquefied by heat), 45 parts, and gum camphor, 55 parts by weight, and triturate these in a mortar. A clear, perfectly stable liquid results. No diluent or solvent is used. 292 BUNKER —A DRESSING FOR WOUNDS. Vol. XIII. I consider it an ideal dressing for fresh wounds, and have em ployed it in all varieties up to severe lacerations of the extremities. The suturing or adjustment of the parts is accomplished after the usual methods, and the area freed from aqueous solutions by dry sponging. The part is dressed dry, and the phenol-camphor combi nation poured freely onto the dressing. I have never had occasion to use it inside a wound. Used in this manner, I have never seen development of clinical pus, injury to tissues (even normal skin) nor other untoward results. Dressing is required only every three days to a week, and each time one finds a clean, dry, granulating, and rapidly healing wound — one might almost say by first intention. As a matter of fact, habits acquired by the use of the older disinfectant solutions lead one to change the dressing much oftener than is necessary. There is a marked local anesthetic effect. The combination can be recommended as a dressing for venereal ulcers in the form of a dusting powder (5 per cent with a talc base), or as a 5-10 per cent ointment. It is also of service as a local applica tion for the trichophytoses. CLINICAL NOTES. EXTENSIVE ABDOMINAL WOUNDS FROM A HAND GRENADE. By J. M. Emmbtt, Lieutenant, Medical Corps, United States Navy. The following is a case of a penetrating wound of the abdomen ■with perforations of the stomach and small and large intestines. It is primarily of interest because of the relatively short time the patient was incapacitated for duty. The extensive wound in the abdominal wall was not treated with any of the chlorine preparations because early excision of the de vitalized tissue and free drainage was possible. J. C. P., 76th Co., Sixth Regiment United States Marine Corps, 18 years of age, was admitted to sick quarters, marine barracks, Quan- tico, Va., at 3 p. m. August 24, 1917. Diagnosis: Hand-grenade wound of the abdomen. Family history unimportant. Previous history : Usual diseases of childhood. He had had athletic training. Present condition: Admitted at 3 p. m. with a hand-grenade wound of the abdomen about 3 inches in diameter over the area of the um bilicus. Through this wound protruded a segment of the transverse colon and omentum. There was a history of an accidentally ac quired wound one hour before by the unexpected explosion of a hand grenade. The patient was holding the grenade in his hand at the time of the discharge. Symptoms of shock, so frequently seen in such cases, were becoming very pronounced. His pulse was 130, the extremities were cold, and he was begging for water. Because of the evident intra-abdominal injury and probable hemorrhage it was thought advisable to operate even in the presence of the symptoms of shock. He was given morphine, one-fourth grain, and prepara tions were made for an exploratory laparotomy. Through a high left median incision the abdomen was opened and a quantity of free blood was found in the peritoneal cavity. An offensive odor directed immediate attention to two large perforations in the transverse colon. After the escaped contents had been re moved with bichloride sponges, both perforations were closed with linen sutures. A small leak was found in the second portion of the duodenum. An abrasion found in the lesser curvature of the stom ach which extended down through the mucous membrane was re paired. 293 294 EOSS—FRACTURE OF INTERCONDYLAR SPINE OF TIBIA. Vol. XIII. The gastrocolic omentum seemed completely avulsed from the anterior surface of the stomach. Hemorrhage was arrested and the detachment repaired with interrupted catgut sutures. Two large bleeding vessels were ligated in the greater omentum and an effort was made to sponge out the blood in the peritoneal cavity. During the course of the operation several pieces of steel were found free in the peritoneal cavity. One fragment was found em bedded in the posterior wall of the stomach. Examination of the abdominal wall showed much devitalized tissue. This was excised and an effort was made to fill in the wound by transplantation of rectus muscle and fascia. A cigarette drainage tube was placed near the site of the colon perforation, another in the pelvic cavity, and the third in the right kidney fossa, where much blood was found. All drains were brought out through the injured abdominal wall. The exploratory incision was closed in the usual way, layer by layer. The time of operation was 1 hour and 20 minutes. The patient was in fairly good condition when removed from the operating table ; pulse, 120. Subcutaneous saline injections were begun and morphine was given freely for the first 24 hours. Twelve hours after the op eration the temperature was 100, the pulse 108. The wound showed free drainage of pus and blood. Small quantities of water were given by mouth in 36 hours and liquid diet in 72 hours. From the fifth day until the end of the second week the patient was septic, the temperature rising to 101 or 102 in the afternoon. At the time of removal of the drainage tube on the twelfth day a small fecal fistula became evident. The drainage from this lasted less than a week. At the end of four weeks the patient was up and about in a rolling chair; the wound was nearly closed. At the end of five weeks the patient was free from all symptoms and the wound had healed. He was able to walk about. On October 9, 1917, he was transferred to the United States Naval Hospital, Washington, D. C, for further disposition. A letter from the patient's mother 10 months after the operation assures me that the boy is in excellent health. A CASE OF FRACTURE OF INTERCONDYLAR SPINE OF TIBIA. By G. G. Ross, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. E. W. H., Ensign, U. S. S. Douglas, age 30, was admitted March 25, 1918, complaining of a swollen and painful left knee joint. He gave a history of having been struck on the posterior surface of the left leg, just below the knee joint, by a snatch block weighing about 45 pounds. His boat was in the harbor preparing to put to sea and No. 2. 299 CRANDON—PERICARDIOTOMY. the heart. No thrill. A soft blowing systolic murmur was heard in the fifth interspace about 4 centimeters from the midsternal line. Abdomen.—There was marked bulging of the upper part of the abdomen and distention of the costal arch. The liver extended to the lower border of the ninth rib. The spleen could be distinctly palpated and extended to about 1 inch below the umbilicus and about one-half inch to the right of the median line. Tympany over the entire right side, flatness over the tumor mass on the left side. Abdomen otherwise negative. Genitals were negative except for pruritus of scrotum. Cremas teric reflex normal. Extremities were negative. Knee jerks normal. No Babinski or ankle-clonus. No pain over the long bones. LABORATORY FINDINGS. Hemoglobin, per cent White blood count Differential : Neutrophils, per cent Eosinophils, per cent Large lymphocytes, per cent 70 325,000 Small lymphocytes, per cent TransIOonals, per cent— Mast cells, per cent Myelocytes : Neutro, per cent Eosino, per cent. 8 T 8 3 Several nucleated red cells were also encountered. Polkilocytosls marked. Stool was odorless, gelatinous in appearance and consistency and contained numerous bright-red blood specks throughout. Micro scopic examination showed a large amount of mucus and epithelium and a considerable number of white and red blood cells. Urine. —Slight cloudiness with very few shreds. Specific gravity, 1.024. Negative for albumin and sugar. Reaction, acid to litmus. The patient was transferred to a United States naval base hospital on the day following his admission, thereby making further observa tions aboard ship impossible. PERICARDIOTOMY. By. L. R. G. Cbandon, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. T. N. was admitted August, 1918, with endocarditis acute, with fever, following acute tonsillitis. Went on for two months, running practically the course of a malignant endocarditis, except that there were no emboli. Blood culture always negative. * In October symptoms of cardiac distress became worse. Extraor dinary ranges of temperature, sometimes to 105°. X-ray at this time showed a very broad triangular cardiac shadow, base down, con sistent with pericardial effusion. Pulse, 160; sounds barelv audible. 300 Vol. XIII. PERRET —KERATOSIS PLANTARIS. October 24. 1918, operation (one-half of 1 per cent cocain). Diag onal incision over left fifth costal cartilage 1\ inches long, beginning at the sternal edge. Cartilage nibbled away for about 1 inch with rongeur. At this point appears the only important matter of careful technic, namely, that the internal mammary artery runs 1 inch from the sternal edge and parallel to it, and it might be better to clearly reveal it at this stage than to puncture without seeing it, because if it were cut or torn it might retract under the closely adjoining car tilages and bleed to a perilous amount before it could be controlled. The pericardium was then lifted by forceps, external to the artery, incised, and a small piece of rubber dam drainage inserted. Practi cally no fluid escaped on the operating table, because, as it appeared later, the heart floated up in the wound like a ball valve and closed it. In the course of the next 12 hours in bed about \\ pints of clear sterile fluid escaped, with great relief to the patient. December 8, 1918, five days after a complete embolic hemiplegia, patient died of general failure of heart power. Necropsy showed acute and chronic vegetative endocarditis, with adhesive pericarditis ; heart about twice normal size. A CASE OF KERATOSIS PLANTARIS. By J. M. Perret, Lieutenant, Medical Corps, United States Navy. The feet are such important parts of the fighting man's make-up that anything unusual about them ought to be of particular interest to the military surgeon. Keratosis plantaris is, according to Stelwagon, a " somewhat un common malady." S. R. J., a white youth of 22 years, a native of Missouri, was ad mitted to the United States Naval Hospital, Pensacola, Fla., on July 8, 1918, with a diagnosis of influenza. While under treatment he complained of painful feet. The examination of these revealed the following interesting findings : The entire plantar surface, except that part forming the arch and therefore not touching the ground, was yellowish, painful, smooth, hard, and thickened (about \ inch). Near the outer edges of this hardened skin were vertical parallel fissures. The healthy skin just above formed a pinkish zone of about \ inch. The soles looked like enormous callosities. The patient said that his feet had always been like they were at present. He had frequently suffered from sore feet. He had been in the service for seven months and had had a great deal of trouble Keratosis plantaris. 300 No. 2. FOLKEN—INFLUENZA WITH COMPLICATIONS. 301 after marching. The skin of his hands and the rest of the body were normal. A Wassermann reaction was negative. The patient says that his father's feet are in a similar condition to his. As the patient was evidently unfit for the service he was given a. medical discharge and therefore nothing can be said as to the therapy of this interesting case. The accompanying photograph will give some idea of how the feet looked. BEFORT OF CASE OF INFLUENZA WITH UNUSUAL COMPLICATIONS. By F. Q. Folken, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. L. S. M. was admitted to the naval hospital on September 25, 1918. Prior to this he had been in a sick bay with the diagnosis of influenza. Upon questioning him it was found that he had had the usual symptoms of the disease and physical examination revealed nothing further, so the diagnosis was confirmed. The patient was at once put on the usual routine treatment for admission. On September 26, 1918, his general condition was fair, although the temperature still remained high. This continued with but one marked fall, to go down by lysis until October 1. On that date it was noted that the temperature dropped below normal, followed by a quick rise and there was a decrease in pulse rate accompanied by an increased respiratory rate. Physical examination of the chest brought out areas of dullness and bronchial breathing, particularly over the left lung. The patient was very restless, complained of difficult breathing, and became cyanotic later in the day. The diag nosis was then changed from influenza to broncho-pneumonia. From this date the temperature curve took a zigzag course. On October 2 the patient complained of violent sweating, which con tinued through the day. No blood cultures were made, but a general septicemia was believed to be present. • On October 3 the patient complained of severe pains in the right groin, but examination of the part was negative. Chest examination showed more extensive involvement of the left lung; the right lung was negative. A faint systolic murmur could be detected at the apex of the heart. It had not been heard at previous examinations. On the morning of October 4 the patient was found in a dull men tal state. Examination brought out a complete left-sided hemiplegia, 302 FOLKEN—INFLUENZA WITH COMPLICATIONS. Vol. XIII. which had come on during the night. Closer examination showed the deep reflexes exaggerated and superficial reflexes absent. Babin- ski's sign and ankylosis were present on the left side. The right side was normal, including reflexes. Pupils were unequal in size> the left being slightly larger and more active to light. There was also a nystagmus of the left eye toward the right ; however, this was •i • ..CLINICAL- CHAM- ■Hal] -l^A:J*i _2J_: J (NIMt) (kftTt) (AOL) (coloa.) ThativityT TbuiASiT *in" |mokth a i f c r 3 8 3 | § 8 8 | 8 * S •K.LIAKKK.S • 5 c p. 1 9 9 IS 24 94 24 V 4»M 97 2* i upm10414 6AMIOO24. ; WAHK>227 I / 'Ofeat i \ $PM 104IB ■ 1i I 9 27 2PMlOl 27 \ (.M 11121 / BAM11434 i —- i —-- 2PM92 24 —~ / 4.PMIOO21 / 9 2.S12pm00 24. lOt 32 ! \ »» 'O*»1 ! / IOOSI i \ 4.PM?* U — r \ f V IOO28 fcAMot 34, j / OAMK>4K ! I zpmIOO32 / 6 PMlOl 52 | \ B JO II PMIOO30 S &AM10432 f IOAM10232 V. 2 PMIOO32 1 tPM '9 34 IO l 12PM•9 J* *A« «A 38 I '\ IOAM90 40 v I.I. - o*. ZPMIOO3» : i bit. Mi >y [>..h2«jt« ».^utk nhrJv^i very uncertain, due to a depressed mental state. At this time there was no rigidity of the neck, and Kernig's sign was negative. Heart examination showed a more distinct systolic murmur at the apex. No loss of sphincter control. A diagnosis of endocarditis, acute, was made with an embolism lodging in the right brain. At 4 p. m. the findings were the same as in the morning, but in addition there was noted a depressed mental state and involuntary action of both sphinc No. 2. FOLKEN—INFLUENZA WITH COMPLICATIONS. 303 ters, indicating spinal irritation. There was no rigidity of the neck, and Kernig's sign was negative. On the morning of October 5 the patient was examined and found in the same mental state as the day before, with no change in reflexes or paralysis, but in addition there was a marked anesthesia on the left side, slight rigidity of the neck, and a positive Kernig's sign. A diagnosis of meningitis was made, a spinal puncture was per- •z- • CLINICAL- CHAM-- mi ) :kJLH: • A_3- 2.l_; J (KAMI) ~(».»Tt) (AOl) (COLOM s ; -* s c r E 3 2 8 | 2 2 8 2 8 * § l« (0 1 p I" —r i 1 • V • • • • • &f*rt11838 zpmin 32. I 1 90 H —r rtft « "I \ 1.1. -5 1 formed at once, and a milky watery fluid obtained under slight pres sure. Laboratory examination showed a high cell count and numer ous pneumococci (Type I). At 2 p. m. another spinal puncture was made and 80 cubic centimeters of milky fluid was removed under high pressure, and 75 cubic centimeters of antipneumococcic serum (Type I) were injected. The temperature continued to rise until 11 p. m., when the curve showed a drop of 3 degrees, followed at once by a rise. 304 FOLKEN—INFLUENZA WITH COMPLICATIONS. Vol. XIII. On the morning of October 6 the patient was found unconscious. At 4 p. m., same date, a third spinal puncture was made and 50 cubic centimeters of Type I antipneumococcic serum were injected. At this time 50 cubic centimeters of serum were also injected intravenously, which was followed by a rise in temperature to 108° by rectum. At 4 a. m. October 7 a spinal puncture was made and 4 cubic centimeters rT • CLINICAL- CHAPJ-- t_J-M- A- S- Zij_ ~MifTvTTY) rn/rog *ar I1 n •* I KLHikKtf.1 ; i crU i £ ,0 JO 44 w 7AM lit QAM fcfc 7ft f ? xw 5fV \ 4ft* $o ■4- HP* T 4i> \ | K>PM 4f 7 If* 2AM so AAM 48 5*m. y •,«. i- s CAM 4? O CAM 4-4 OAM M >-* "o" MAM **(( z L N dI 11V A T ———————-.- I of fluid removed under low pressure, and 20 cubic centimeters serum injected. At 11.30 a. m. October 7 the patient died. Post mortem findings : 1. A thin layer of pus over surface of entire brain. 2. Abscess in the right ventricle of the brain, involving the right thalamus. 3. Left lung showed marked congestion and small areas of consoli dation about the bronchi. No. 2. FOLKEN —INFLUENZA WITH COMPLICATIONS. 305 4. Heart findings showed numerous pinhead vegetations on the mitral, aortic, and tricuspid valves, the greater involvement being on the mitral. 5. Laboratory findings from smears taken from the brain abscess, valvular vegetations, and cut surface of the lung showed pneumo- cocci. Summary : 1. A true influenza, followed by broncho-pneumonia. 2. A broncho-pneumonia complicated by (a) general septicemia; (b) endocarditis acute; (c) hemiplegia, left side ; (d) septic embolism of the brain, most probably from the valvular vegetations (this would also account for the ventricular abcess) ; (e) meningitis, cere brospinal, coming on after the brain-abscess formation. PROGRESS IN MEDICAL SCIENCES. REVIEWERS. Captain J. 8. Tatlob, Medical Corps, United States Navy. Commander G. B. Tbiblb, Medical Corps, United States Navy. Lieutenant Commander G. F. Clark, Medical Corps, United States Navy. GENERAL MEDICINE. Rivas, D. Diagnosis, treatment and prophylaxis of malaria In Brlonl. New Or leans Med. and Surg. Jour., January, 1919. The author, who was at one time assistant to the Koch Institute in Berlin, gives with interesting detail the sanitary history of Brioni, an island in the Adriatic Sea, a few miles from Pola, and bearing southeast from Venice and south from Trieste, in the Province of Istria. Brioni has quarries which in the past gave it an importance dis proportionate to its size, and supplied building material for many of the palaces and public works of Venice, Vienna, and Berlin. At different times while the island was the property of private in dividuals, both Italian and Portuguese, malaria so decimated the population that cultivation and tenure of the land became impossible and Brioni acquired the sobriquet of " Island of Death." Brioni became a part of Austrian territory in 1866 and shortly afterwards was acquired for a trifling sum by a Swiss who attempted to cultivate the island but had only a temporary success. Malaria killed off his laborers and the project was abandoned. In 1880 Brioni was purchased by an enterprising and capable individual of the name of Kuperweisser, who proceeded to administer quinine to the inhabitants and to institute drainage. He further appealed to the authorities in Vienna for a commission to conduct a campaign against malaria in the island. As a result of this petition Dr. Koch took charge of the undertaking. After one year's work devoted to making blood examinations of the inhabitants and active treatment of all in fected cases the malarial patients were reduced 50 per cent. In 1901 the author formed part of a second expedition to Brioni. The work was now expanded by the treatment of chronic carriers and their quarantine or elimination from the island. (Fine for Brioni but not so advantageous for the localities to which the " eliminated " 307 308 GENEBAL, MEDICINE. Vol. XIII. betook themselves.) The third expedition in 1902 undertook the de struction of larval and adult mosquitoes and the screening of doors and windows and the island was subsequently declared free from malaria and has so remained. Herr Kuperweisser paid $40,000 for Brioni. By 1902 its value was estimated at $1,000,000. It soon be came the garden spot of the Adriatic region and a summer resort patronized by the wealthy and fashionable, filled with luxurious private residences^ villas, and castles owned by the Austrian aris tocracy. Dr. Kivas recommends the sulphate of quinine dissolved in dilute muriatic acid for oral administration as a routine measure and pre fers the hypodermic to the intravenous method in special cases. Qui nine by mouth should be taken on an empty stomach four or five hours after a meal —in the evening or on rising in the morning. The minimum dose for an adult is 15 grains and for children at the rate of a grain for eaph year. Rivas considers the time at which the quinine is given one of the most important points in the treatment. Based on a study of the changes in the parasite incident to the various stages of the asexual cycle the patient's period of crisis following the febrile period is the one in which quinine should be given, because it represents the begin ning growth of the trophozoite. The very young parasite is pecu liarly susceptible to the action of the drug and easily destroyed by it and as its metabolic activity is now great it seems proper to assume that it will take more quinine than in a later quiescent period when as schizont it is like the gamete actually refractory to the drug. The author considers the artificial lowering of high body tempera ture in pernicious types with prolonged fever a procedure of doubt ful propriety because a high blood temperature is unfavorable to the growth and metabolic activity of the parasite as it enters the erythrocyte. The administration of quinine should be continued for a certain period of time. It is recommended that a 15-grain dose be given when the fever begins to fall and repeated at the same hour for three days in succession. After four days without quinine repeat the treatment for three successive days and again give a free interlude. This should be kept up for two or better three months and thereafter a 10-grain dose once a week to the end of the season suffices. (J. S. T.) Dragotti, G. Epidemic lethargic encephalitis. Policlinico, Rome, XXV, 40, October 6, 1918. During the war human pathology has exhibited a multiform activity. Known diseases have increased, new types have developed, and forms of morbidity which had only a historical interest for the No. 2. 309 GENERAL, MEDICINE. present generation have reappeared. Among the latter may be the so-called epidemic lethargic encephalitis, which so far has manifested itself principally in England and France. The cardinal clinical symptoms of this affection which may be re garded as an infective process, are somnolence, fever, and paralysis of some of the cranial nerves. The cases have not been very numerous. Up to the end of May, 1918, 105 had been verified in Great Britain and 71 in France, but it must not be forgotten that some cases were probably not reported through error in diagnosis. The malady is not a new one. In the spring of 1890 when the pandemic of influenza was beginning to waver there occurred in Italy, particularly in the district of Modena, a number of cases of a lethargic condition styled nona. Synchronously with them similar cases were observed in Hungary, Bulgaria, Denmark, Germany, Switzerland, England, and in the United States where Young gave to the syndrome the name " grippal catalepsy." Camerarius, in 1712, observed at Tubingen a disease which he called sleeping sickness. More recently in 1916 an epidemic prevailed having symptoms identi cal with those seen in France and England to-day. Von Wiesner, in 1917, claimed to have isolated the etiological factor in the shape of a coccus. The recent epidemic has been studied by Harris and Hall (Lancet, London, Apr. 20, 1918) and by Saint Martin and Lhermitte, who assigned the name primary polioencephatitis with narcolepsy, while the more commonly employed designation is that of Netter. The symptom complex of the encephalitis in question varies in severity, in the duration of individual symptoms and especially in the matter of cranial nerves involved. However, the disease both in its positive and negative aspects is a distinct entity. It often be gins with vague manifestations attracting attention to the mucous membranes of the respiratory and digestive tracts such as are common in influenza. The conspicuous feature, however, is the somnolence which is ushered in by headache and vomiting. The patient ex periences a sense of prostration, the eyelids grow heavy, his whole being is invaded by an irresistible torpor. At first he is able to answer questions, but falls asleep the moment he is let alone. Gradu ally all movement becomes impossible and he lies helpless in bed. At intervals of two or three days he rouses himself to partake of food, but it may be necessary to feed him through a tube while still asleep. The sleep may become an actual state of coma, lasting weeks or months, interrupted by delirium, convulsions, paralysis of the sphincters, and profound decubitus. Almost as constant as sleep is the paralysis of certain external muscles of the eye evidenced by bilateral or unilateral ptosis, stra bismus, diplopia, and immobility of the globe of the eye. The onh 310 GENERAL. MEDICINE. Vol. XIII. thalmoplegia is central in origin. Nystagmus is common, while in ternal paralysis is relatively rare. The paralysis may extend to the muscles supplied by the trifacial when the patient will have a char acteristic facies varying with the particular muscles involved. Pa ralysis of the joints is rare, a catatonia being more common and like wise tremors and incoordination. Aphasia and paralysis of the sphincters have occasionally been noted. Disturbances of sensation are rare. Fever is present in all cases, but may be brief, attending the initial stages only, or else high and persisting throughout the attack. Rigidity of the neck is slight or absent, and the same is true of Kernig's sign and bradycardia, which characterize meningeal affec tions. Lumbar puncture yields a clear fluid under normal tension with normal sugar and albumin content. There is practically no lympho cytosis. These features of the spinal fluid have important bearings on diagnosis. The features enumerated are not constant, the only essential ones being sleep and paralysis of the cranial nerves. Epileptiform and apoplectiform seizures may occur, completely disguising the picture unless an epidemic is present. The duration of the disease is subject to great variation. It may be for a day or two, ending in recovery or in death from bulbar paralysis. As a rule the disease drags on for weeks or even months. When a favorable crisis does take place it is very marked, though psychic and somatic disorders persist for a long time. The mortality is placed by various writers at from 25 to 55 per cent. The pathological lesions are: Congestion and punctiform hemor rhages and cellular infiltrations around the vessels especially in the gray matter near the third, fourth, and lateral ventricles, and accord ing to P. Marie, especially at the level of the locus niger. The en cephalitis is diffuse, interstitial, of unknown origin, attacking by preference the vascular system. The pathology has some analogy to that of rabies, poliomyelitis, and sleeping sickness. An attempt has been made to connect epidemic encephalitis with poliomyelitis. The hypothesis is invalidated by the marked prefer ence of the latter for young subjects, by its higher mortality, and the lesser tendency to atrophies. On the other hand, in poliomyelitis the morphology of the spinal fluid is more distinctly altered and this feature permits the differential diagnosis from cerebro-spinal menin gitis. An attempt has been made to connect epidemic lethargic en cephalitis with botulism, but the dryness of the mouth and throat and the extreme dilatation of the pupil are lacking in encephalitis, while, on the other hand, lethargy and coma are not characteristic of botu lism. Where botulism is present there is usually a history of the in No. 2. 311 GENERAL MEDICINE. gestion of some suspected article of food by a more or less varied group of persons while cases of encephalitis are usually in separate families. The possible relationship between influenza and epidemic enceph alitis should be considered in view of the striking fact that in 1889-90 and now the diseases have appeared concurrently. Royal Society of Medicine. Encephalitis lethargic*. The Lancet, London, October 26, 1918. At a general meeting of the Fellows of the Eoyal Society of Medicine on October 22, 1918, the subject of encephalitis lethargica was exhaustively discussed, and the following notes are from the report in the Lancet. When cases began to develop in Great Britain they were reported as " botulism," but the failure to find the bacillus botulinus and the discovery of areas of perivascular infiltration in the central nervous system lead to the assumption in many quarters that the disease was a form of acute poliomyelitis of cerebral type. Clinical observers soon noted, however, that the cases developed a symptomatology all their own and essentially different from poliomyelitis. The exten sive investigations since carried out established the disease as sui generis with a definite pathology and distinct epidemiological pe culiarities. The onset is frequently sudden but oftener preceded by a few days of lassitude, headache, and sometimes vomiting of cerebral type. The patient then becomes lethargic but can be roused and is conscious of what is going on around him. Nocturnal wakefulness is not uncom mon. Asthenia is general with definite local paralysis, particularly of the ocular muscles, muscles of the face, and less commonly of pharynx. This results in strabismus, nystagmus, dysphagia, a mask like expression, disarthria of speech. First one and then another group of muscles is involved. The course of the disease is variable. Death may take place within a few days from failure of respiration or there may be recovery after months of illness. The disease occurs at all ages. The seasonal influence shows in the maximum of cases developing in the spring of the year. (J- S. T.) Royal Society of Medicine. Enceptalitis lethargica. Brit. Med. Jour., Novem ber 2, 1918. In a report of the meeting of the Royal Society of Medicine, Octo ber 22, 1918, Lieut. Col. F. W. Mott, Royal Army Medical Corps, is quoted as citing two cases studied by M. Marinesco of the depart 312 GENERAL, MEDICINE. Vol. XIII. ment of neurology, Bucharest, from the standpoint of pathology. In these cases disseminated miliary or punctiform hemorrhages visible to the naked eye existed in the gray matter in the neighbor hood of the floor of the fourth ventricle, the aqueduct of Sylvius, and even the third ventricle and were also found in the posterior part of the pons and peduncles. The cerebral cortex was practically nega tive in the two cases. On the contrary the first segment of the spinal cord, the portion available for study, presented the same histological lesions as the pons, bulb, and peduncles. The spinal fluid might or might not show lymphocytosis and albumin. Dr. P. N. Panton reported a series of cases in which the spinal fluid was clear and held that the examination of this fluid was a valuable means of making a differential diagnosis. Dr. A. S. MacNalty grouped the symptoms in three types. 1. General disturbance of the functions of the central nervous sys tem without localizing signs. 2. Localizing signs manifested in (a) third pair of cranial nerves; (b) affections of the brain, stem and bulb with local lesions of other cranial nerves; (c) affections of the long tracts—pyramidal, pre- pyramidal and up-coming afferent tracts; (d) ataxic types (cerebel lar mechanism); (e) affections of the cerebral cortex; (/) spinal cord involvement; (g) polyneuritic type. 3. Mild or abortive type. The acute manifestations are slight early rise of temperature, marked asthenia, catalepsy, stupor, changes in speech, choreic move ments of face, trunk and limbs, muscular pains, hyperaesthesia, skin eruptions dysphagia, constipation. The rapid complete or partial clearing of the paralysis was the most remarkable feature of cases with nervous manifestations. (J. S. T.) Bbown, G. E. Syphilitic aortitis. Am. Jour. Med. Sc, January, 1919. The author, in a concise and convincing way, brings out three important points. The disease is common, is easily overlooked or confused with tuberculosis and other thoracic diseases and is amen able to treatment only in the early stages. The first anatomical studies on the subject were made in the 18th century by Morgagni. The disease occupies somewhat the same posi tion in medical literature that tuberculosis did 30 years ago in that only the full-blown cases are deemed worthy of note. The diagnosis in each condition must be made in the incipient stage if treatment is to be of value. There is little or nothing to be done for aortitis when gross changes have occurred in the vessel wall. No. 2. 313 GENERAL. MEDICINE. In the past diagnosis has been relatively rare, though post mortem findings amply demonstrate the frequency of the condition. This was due in part to the indifference of the profession or to ignorance, as the textbooks contain few allusions to the subject. Then it is often a late manifestation overshadowed by coexisting paresis, athe roma, tabes. In the early stages the signs and symptoms are often slight and misleading. Brown quotes from various writers to show the frequency of aortitis. Thus Gruber reports a series of 6,000 autopsies with 4 per cent showing aortitis. Out of 256 autopsies on luetics reported by Marchand 82 per cent had the disease. Obendorfer found that 7 per cent of 1,436 autopsies on adults showed aortitis. The author made an antemortem diagnosis in 5.1 per cent of 136 luetics in whom a pos itive Wassermann or luetin reaction had been obtained. Brown quotes Heller's affirmation that syphilis, as compared with atheroma, is an inflammation with reparative reaction. The gross lesions consist of irregular folds and roughenings of the intima — translucent and pearly plaques. These cushions or wheals may be yellow in color. Aortitis does not show the fatty and calcareous de posits characteristic of atheroma, but the two diseases may be con current. Syphilis usually attacks the aorta at the orifice, and when the process extends centripetally serious damage to valves and coronaries is to be expected. It is least harmful when traveling in the other direction. While all portions of the thoracic aorta are liable to in volvement, the abdominal segment usually escapes, and this has not been explained. Klots has shown that there is a rich lymphatic supply to the ascending and transverse portions of the arch which are in close relation to the mediastinal glands invariably affected by retrograde movements of the spirochete, but the abdominal aorta also has close relations with the glandular system. Syphilis of the aorta may be confined to the first portion, may at tack the valves, cause aneurysm or obliteration of the coronaries. Brown discusses only the symptomatology of the first-mentioned type. In this the cardinal symptom is pain located under the sternum at the junction of the manubrium and gladiolus. There may be moderate or very severe sensations of compression or constriction. Pain radiates along the brachial plexus in one or both arms, com monly in the left arm only. Mental and physical fatigue is com plained of, the patient lacks energy, has a tendency to neurasthenia, and suffers from headaches. The early weakness is like that of in cipient tuberculosis. Dyspnea is variable in degree, but nearly always present. Hoarseness and fever are less constant. A dry non productive cough occurs. Cyanosis is relatively rare. All these 103396—19 10 314 GENERAL MEDICINE. Vol. XIII. symptoms approximate closely to those of beginning tuberculosis and may be very misleading unless great care is observed. The physical signs furnish the basis for positive, constructive, and differential diagnosis. The chief reliance is to be placed on X-ray examination by plates and the fluoroscope to determine if enlarge ment of the aorta is present. Enlargement is always present in aortitis and it is in both diameters. This may often be demon strated by percussion. The blood pressure is generally not elevated, which is an important differential point. The Wassermann or luetin test is usually positive. The last diagnostic measure is the thera peutic employment of mercury and the iodides. (J. S. T.) MacCullum, W. G. The pathology of the streptococcal pneumonias of Army camps. Medical Clinics of North America, September, 1918. It is interesting to learn that beginning with the early part of the sixteenth century there were numerous epidemics of pneumonia spreading over Italy, Spain, France, Germany, and other countries involving numbers of people and having a high mortality. It is dif ficult to determine the precise type of pneumonia that existed, but empyema was a frequent complication and it was probably strepto coccal in origin. In America similar outbreaks are recorded from the eighteenth century. In 1812 the troops in New York State and the civilian population of New England and of the Southern States were simi larly affected. The epidemic dragged along for three years in the North and did not disappear in the South for 14 years. During the Civil War, as recorded by Woodward and others, measles was extremely prevalent and was commonly followed by a broncho-pneumonia with associated empyema. During the four years 61,000 cases of pneumonia were recorded and many of them were separated as in some way related to measles. MacCallum has studied pathological specimens preserved at the Army Medical Mu seum, Washington, and finds that they correspond closely to the pathological material obtained in the recent epidemic. Streptococci were recognized in typical chains in the bronchi and pleural exudate and the gross appearance was that of the streptococcal broncho pneumonia of to-day. (J- S. T.) Stokes, J. II. The venereal problem and the war. Internat. Assn. Med. Mu seums Bull. VII, May, 1918. The author of that valuable and timely book, the Third Great Plague, reviewed in a previous issue, begins his comparative survey of the attitude to the problem of veneral disease of the participants in No. 2. 315 GENERAL, MEDICINE. the war, with a reference to the pioneer legislation on sociological lines of Denmark, Norway, and Sweden. The measures employed or contemplated by the belligerents fall into two groups. Group 1 : ( 1 ) Provision of universally available, reliable means of early diagnosis by the State. (2) Provision of universally available and efficient free treatment by the State. (3) Limitation of treat ment to competent hands, suppression of quackery, drug-store pre scribing, advertising cures, and patent medicines. (4) Moral and educational prophylaxis. Group 2: (1) Suppression or regulation of prostitution. (2) Dis semination of knowledge concerning venereal prophylaxis, and sale of the agents employed for this purpose, to the public at large. (3) Compulsory measures and penalties making treatment obligatory on the patient until he is cured, with or without preservation of his secret. (4) Reporting of venereal disease in open or anonymous form to the health authorities. (5) Indirect legislation bearing on transmission of infection in or out of marriage, professional medical confidence, marriage laws, etc. British activities are along the lines of group 1. Enactments in West Australia include all of 1 and a good deal of 2. Very little is known of what the French have done in this problem during the war. The Italian civil program antedates the English, and began in a Scandinavian type of provision for public treatment without com pulsory treatment in August, 1907, dispensaries being organized by the several communes with the cooperation of the minister of the in terior. In general, sentiment in France and Italy permits more drastic methods than would be tolerated in Anglo-Saxon communi ties. Up to 1903 Italian armies had the highest morbidity figures in Europe. In the present war Italy has passed rapidly from group 1 to group 2. Prophylaxis is carried out in connection with the houses of prostitution legalized as army institutions, thus imitating Japan in the Eusso-Japanese War. Marked success is claimed for this measure and morbidity figures have been brought down to about those of the British. The author considers that the Huns have incorporated into their public policy during the war a greater number of radical features than any other country, carrying them out with the painstaking attention to detail peculiar to the tribe. For a number of years prior to the war their army figures for venereal disease were the lowest in the world but the prospect of an increase due to campaign ing led to lively discussion of the additional means to be employed. Neisser favored indiscriminate specific treatment for all women who had had relations with soldiers even if infection could not be proved. 316 GENERAL MEDICINE. VoLXIH. He recommended the free distribution of condoms to the soldiers. Von Hindenburg signed an order for internment in prison camps or jails of all infected women. A regulated prostitution was enforced during the war for military districts. Many advisory clinics have been established to which army cases could be referred and over 70 special clinics have been established in Prussia by life insurance companies. Plans are being made to provide at least three years of active treatment for every syphilitic, and lifetime observation if necessary. The position of the United States in the world-wide movement against venereal disease is in some respects not altogether an enviable one. Our pub lic campaign has scarcely developed beyond the point reached by that of Eng land In 1898. Stokes lays down two facts of outstanding importance in the his tory of venereal diseases in armies and navies. (1) Increased inci dence in war; (2) efficiency of modern prophylaxis. In the Franco- Prussian war the venereal incidence in the First Bavarian Army Corps rose from 10.2 to 77.7 per thousand from January to May. British army morbidity for venereal disease has been given as 48 per thousand in November, 1916, and 43.5 in February, 1917. The Italian figures up to December 31, 1915, were 90.5 per thousand. From January to June, 1916, they were 46.2 as a result of methods of regulation or prevention put in force. From French writers various ■estimates are reported. Thibiege estimates 4,000 to 5,000 cases of syphilitic infection per month, which in three years of war would mean 150,000 to 200,000 new syphilitics for that country alone. The cases of venereal disease acquired by the Hun soldiery in Belgium during the period of occupation is estimated at 30,000. Allowing to Hun armies a rate of 40 per thousand this would give about 280,000 fresh venereal cases annually, 60,000 of them syphilis. Our own best figures (prior to May, 1918) are nearly double those of the British or Italians and are greatly in excess of foreign fig ures for peace times. The author quotes the Lancet as authority for the statement that in British educational prophylaxis the dis tribution of pamphlets and leaflets has been disappointing. The presentation of a concrete case of bad venereal infection was a much better deterrent. Stokes describes the prophylaxis of our Army and Navy as puni tive, in that there is a loss of pay for days lost for venereal disease, in that a man must use prophylaxis if required and is punished for neglecting to do so. Great Britain has not formally adopted a policy, but her navy tolerates the prophylactic packet. Italy conducts pro phylaxis in connection with its official military houses of prostitu tion. The Australian medical service claims good results from the prophylactic tents set up at the entrance of every camp. Riggs is No. 2. 317 GENERAL MEDICINE. quoted as giving the percentage of failures of prophylaxis admin istered within eight hours as 1.5 per cent. Exner is quoted as giving 1.4 per cent for the failures in 10,000 treatments for one American regiment in two and one-half years. Our author says, " * * * though not infallible, especially under conditions of Army life, medical prophylaxis is an indispensable weapon, and the nearer its application can be brought to the time of exposure, the higher will be the efficiency of the Army employing it, from a military standpoint." Next comes a review of the various indirect and moral agencies in operation here and elsewhere in the interests of enlisted men. (The reviewer notes with regret that in a majority of instances in America these efforts began with the war; before that our people cared for none of these things.) Reference is made to the effect of utter destitution in ravished Poland on the morals of her women : to the closing of "Animierknei- pen " in Berlin by police order, which in 24 hours left 700 women without their usual means of livelihood. Industrial readjustments in many localities have " thrown the women into a camaraderie with men in the civil population, which in the general lowering of moral tone induced by the war, has led to alarming consequences." As a result of general conditions, both industrial and military, clandestine prostitution has increased enormously in all war zones, and repressive measures scarcely meet the indications of this feature of the situa tion. The Huns have required a special military pass into military districts for all women not duly inspected professional prostitutes, but neither this measure nor wholesale arrests, deportations, and im prisonments have yielded commensurate results. On the other hand, the repressive measures of the British war zones seem to have done good, judging by the official figures on incidence of venereal disease. The real danger lies not in the fighting zone but in the cities whither men resort on furlough, the former being the domain of the clandestine, the latter of the professional prostitute. The occasions fraught with the greatest possibilities for harm are : (1) During mobilization and training; (2) during delays in transit; (3) during furlough; (4) during period of billetting in private houses, in towns and villages; (5) during convalescence outside of military influence. It has been estimated that in the Austrian service 5 per cent of infections took place at the front, 20 per cent on lines of communi cation and 75 per cent outside of the sphere of the army. The question of pay has an important bearing on the problem'.. The low pay of English and French troops makes them less attrac tive to the harpy than the soldiers of Australia, Canada, or the- United States, (j. s. T.) 318 Vol. XIII. GENERAL MEDICINE. Dbagotti, G. The cocaine habit. Pollclinico, Rome, XXV, 31 ; August 4, 1018. The cocaine habit became very general in Italy during the war. Cases of acute poisoning have been of almost daily occurrence in Europe. The habit of taking cocaine dates back some 30 years, when it was commonly used as a substitute for morphine in treating vic tims of the latter drug. The habit to-day is generally acquired deliberately and the number of addicts who drifted into the abuse of cocaine through the use of a physician's prescription, as for chronic rhinitis or neuralgia, is relatively small. The cocaine addict is prone to recruit companions in vice. The seekers of new sensa tions, the weaklings, the moral shipwrecks, readily become votaries of the drug. The habit is very common among prostitutes. A neu rotic or hereditary taint predisposes to its use. Degenerates take to the drug very readily. The effects of the drug on the human body are exerted particularly on the cardiac, circulatory, respiratory, and nervous systems. Pal lor of the face and coldness of the extremities are usual in cocaine addicts. Praecordial pains analagous to angina pectoris, dyspnea and arrest of respiration occur. The nervous phenomena are the most characteristic. While under the influence of acute cocaine poisoning, cerebral excitation is evidenced by loquacity, agitation, anger, or distressing emotion leading to tears. Vertigo is common. There may be a condition of stupor. Incoordination of movement and of tactile sensation is not infrequent. Visual and tactile hallu cinations occur though less commonly than in the chronic form of intoxication. Convulsions and even true epilepsy have been ascribed to cocaine. To the above must be added digestive disturbances such as ptyal- ism (followed by excessive dryness of the mouth) and very occa sionally vomiting and diarrhea, and urinary abnormalities (oliguria or anuria). Death may occur promptly or recovery be preceded by collapse, coma, or syncope lasting several hours. For months after acute poisoning a tendency to syncope, vague feelings of depression, dizziness, difficulty of speech, and incapacity for mental application may be manifest. The fatal dose varies as in the case of most poisons when taken into the stomach. A dose of 10 centigrams is usually tolerated. Serious and possibly fatal effects on heart and respiration may be produced by 45 to 50 centigrams. The subcutaneous injection of 5 centigrams is reasonably safe for adults. Alarming symptoms may develop from the use of larger doses, and when 20 centigrams are exceeded death may occur. Submucous injections, as in dentistry, are peculiarly active and the dose should not exceed 2 centigrams. Chronic poison ing by cocaine has a symptomatology all its own. A few individuals experience no effect from the first adventure, but for the majority No. 2. 319 GENERAL, MEDICINE. the immediate sensations are most delectable, and the craving for the drug is quickly established. The desire for cocaine may not be so compelling as is that for morphine, but it develops sooner. The general sense of wellbeing, the joy of life, the intellectual vivacity, the increased muscular energy begotten by cocaine are so delightful that once tasted these joys are hard to renounce for the future. In chronic habitues the sensations of wellbeing which marked the early indulgences do not persist. On the contrary, there is a general weakening of psychic activity and a general bodily weariness. The memory is impaired, especially as regards dates, and hence there is a disorientation as to time. The cocaine addict is commonly without appetite, undecided, listless, incapable of exertion. The disposition changes. He becomes moody, irritable, and unresponsive. Periods of activity are brief. Gradually there is an undermining of the moral sense, the deterioration showing itself most conspicuously in those whose financial situation makes it hard for them to procure the drug. They stoop to any baseness or crime to get cocaine, life having no purpose or ambition except in that direction. Sleeplessness and hor rible dreams like those of the dipsomaniac; auditory, visual, gusta tory hallucinations, make the periods between indulgencies occasions of intense suffering. The addict has various paraesthesiae, among them the sensation of a moving foreign body under the skin or of hot or cold water applied to the body surfaces. Worms and insects are felt crawling over their persons. With time the victim accepts these things as realities. Delusions come on varying in type with the indi vidual temperament. Hypochondriacal ideas and delusions of perse cution are frequent. While a certain lucidity of thought survives in the cocaine habitue, excessive indulgence in the drug or other forms of excess, such as an overindulgence in alcohol, bring on a delirium not unlike that of the chronic alcoholic. It is during such crises that occur the dramatic scenes, the acts of violence, and uncontrolled agi tation in public places which sooner or later lead to arrest and re straint in an asylum. It is by no means uncommon for the users of cocaine to be the slaves of morphine or liquor as well. In appearance the cocaine addict is pale, thin, haggard, and hollow-eyed. Tremors of the extremities, twitching of the lips, disordered articulation, and an explosive type of speech are noted. There is a tendency to hyper- hidrosis. The pulse is rapid and irregular. The eroticism of the early stages is followed by loss of sexual power. Among habitues who employ the drug in nasal tampons perforation of the septum is a common event. The prognosis in cases of chronic cocaine poisoning is extremely grave, the majority of them eventually reaching the insane asylum. 320 SURGERY. Vol. XIII. Many end their lives by suicide. Others languish in a state of pro gressive mental, moral, and physical decay. They are ready victims to intercurrent infections. Withdrawal or voluntary abandonment of the drug does not always result in complete cure, the constitution having been so undermined that mental and physical disorders per sist and complete return to normal is rare. The offspring of the users of cocaine are physical and moral degenerates. In acute poisoning by cocaine the patient should be put in a recum bent position with the head low. Nitrite of amyl has a valuable countereffect upon the basoconstrictor action of cocaine, but in serious cases its employment is not advisable. In cases marked by convul sions chloral may be given, or inhalations of chloroform or etber. When cocaine has been swallowed give a solution of tannin. Hypo dermic injections of caffeine, camphorated oil, or ether are recom mended to counteract the depression. For chronic cases the essential step is to withdraw the drug abso lutely and immediately. This measure does not involve the painful sequelae attendant on the sudden deprivation of morphia. The patient is put to bed and watched, and mild disturbances are met by the occasional administration of a stimulant. Gradual deprivation is advisable, however, in the presence of marked cardiac or renal disorders or of advanced cachexia. The cocaine habit should be studied and handled from the political and sociological standpoint, since the victims are weaklings with organic defects of the central nervous system. The most important measures are those looking to the prevention' of the habit, since its diffusion threatens the integrity of the race. (.1. s. T.) SURGERY. Parin, M. Sterilization of wounds by eleotro-ions. Presse mM., November 14, 1918. All surgeons now agree on the value of wound suture for short ening the period of cicatrization or improving the functional re sult by shortening the period of immobilization. Some surgeons at the front obtain excellent results with primary suture after extirpa tion of suspected tissue. Sometimes, however, primary suture can not be employed because the patient's temperature or the appearance of the tissues and the results of the bacteriological examination make the procedure undesirable. Finally this technique has been found impossible when the number of wounded men requiring im mediate attention was very large. When the primary suture has not been employed the patient usually reaches the base hospital with wounds that have become secondarily infected even if they were No. 2. 321 SUBGERY. not primarily infected. Such an infection retards the possibility of secondary suture. Indeed with serious infections and wounds containing pure or mixed growths of streptococci the surgeons ab stain entirely from suturing until extensive disinfection has been made. The resulting delay is in marked contrast to the immediate sterilization of wounds which can be obtained by the use of electro- ions even where the streptococcus is present. Prof. Leduc, of Nantes, in 1900 gave the first positive demonstra tion of the possibility of utilizing electrolysis to transfer the ele ments of a saline solution from outside the body to intimate con tact with the internal tissues. Leduc studied the action of different ions but Dr. Parin discusses only the results obtained in connection with the use of zinc ions. A very simple and instructive experiment consists in fastening to the positive pole of the source of electricity anodes made of different metals bathed in an albuminous solution. It is thus possible to esti mate the action and the penetrative power of different ions. Thus the zinc rod will become surrounded by a compact and adherent collar of coagulated albumin, the albumin having appeared rapidly and uniformly around the pole, whereas the iron rod has caused no coagulation but led to the formation of an albuminate of iron pre cipitated at the bottom of the containing vessel. The platinum rod likewise gives rise to no coagulation but liberates oxygen. The size of the cylinder of coagulated albumin proves the facility with which the zinc ion travels through it. Now, the coagulated albuminoids and the penetration of antiseptics into the heart of a tissue represent the essential features of wound treatment, the attainment of the very object in view when wounds are cauterized, curetted or dressed. Chemical antiseptics actually interfere with the penetration of the tissues by the coagulation of the albumin but the zinc ion is not thus hindered. Its penetration can be controlled at will by the operator. Leduc was the first to use this method with success in the treatment of boils and of anthrax. He also employed the zinc ion to cauterize and sterilize the uterine mucosa and to arrest hemorrhage. The English physician, Dr. Friel, head of the nose and throat clinic of the Johannesburg Hospital in the Transvaal, who had be come familiar with the new therapy of the Nantes school, was able by the use of the zinc ion to clear up suppurations of the middle ear and of the frontal and maxillary sinuses at one sitting. When Dr. Friel entered the English Army he used the ion method of steriliza tion of war wounds and in his surgical service at Abbeville war wounds were prepared for suture and healed up after one treatment. Dr. Parin has employed this method for the wounded who come to him directly from the front. The source of the zinc ions was a 322 Vol. XIII. SURGERY. solution of zince sulphate but any salt of zinc in solution, the chloride for example, would answer as well. He begins by cleaning the surface of the wound to be disinfected with a gauze compress soaked in the solution of zinc to be employed for the electrolysis, rubbing the wound vigorously so as to remove the contaminations—all the dead tissue which might prevent intimate contact between the wound and the solution. This intimate contact and the removal of foreign particles is an essential step in the pro cedure. The wound is then covered with 10 or 12 thicknesses of compressed gauze saturated with the zinc solution. Upon this is placed the electrode fastened to the positive pole, the whole retained in position by a few snug turns of a bandage. The adjacent integu ment is protected by the introduction between the skin and the com presses of a sheet of rubber dam cut so as to follow exactly the con tour of the wound and resist the passage of the current through the undamaged skin. The negative electrode should have a wide area and may be applied to any part of the body. Sterilization is ob tained at a single sitting. This is a distinct and indispensable fea ture of the treatment and Parin proceeds immediately to suture the wound, both the muscular and superficial layers, after widely free ing the integuments so as to promote the most accurate coaptation. Parin uses local anesthesia, stovaine either subcutaneously or by spinal puncture. He claims that the passage of the electricity causes no pain provided the intensity of the current is increased at the start and diminished at the end very slowly. When the current is carefully regulated the patient can stand 100 milliamperes during the time necessary for treatment if the intensity of the current is changed very gradually. Sudden increase to 5 or 15 milliamperes occasions considerable pain. Parin reports 15 cases treated successfully by this method after bacteriological examination and culture had demonstrated the pres ence of streptococci and other pus germs in the wounds. He gives the details of several cases. V.—Wounded July 19, 1918, by the explosion of a shell came under his care July 21 with a long deep wound of the left buttock which was kept open by contraction of the muscular fibers. On July 26 he was given a treatment of 3 milliamperes for 30 minutes, after which the lips of the wound were brought together with Michel hooks. The patient left the hospital completely cured an August 5. Dr. Friel has introduced a new electric unit milliampere-minute- square-centimeter and called it the Leduc. The Leduc, therefore, is the quantity of electricity produced by the current of 1 milli- ampere acting for a minute on 1 square centimeter of surface. Dr. Friel considers that a thorough sterilization can be obtained by the employment of about 4 Leducs. Ku.2. STTRGEBY. 323 Another case entered Dr. Parin's service with four bullet wounds which had a combined area of 146 square centimeters. He was treated by the Leduc method on July 30 and cicatrization was com plete on August 14. Perhaps the most interesting feature of Dr. Parin's report is the failure of the zinc to accomplish complete sterilization in two cases where bacteriological examination showed that streptococci were present in unusually large numbers. Recalling the fact that salts of copper had proved particularly destructive to streptococci in skin infections he substituted the copper ion for the zinc ion and obtained immediate results in the two cases which had previously proved refractory. Parin does not claim that the zinc ion can be regarded as having universal bactericidal power. He considers it probable that each type of germ is peculiarly sensitive to some particular ion and sug gests the propriety of determining this by a series of experiments. He concludes his paper with the further suggestion that in order to employ primary suture to the best advantage ion sterilization of wounds be employed at the front, as the method is simple and would be available for a large number of wounded. (J- S. T.) Caliceti, P. Abscess of thyroid following septico-pyemia from otitis. Poli clinics Rome, XXV, 50, December 15, 1918. Writing from Field Hospital 204 Dr. Caliceti reports the unusual and interesting case of an infantry private of the Italian Army without history of previous illness who reported for treatment in March, 1918. Mild symptoms of aural disturbance covering several months had been disregarded, but the development of pain, the ap pearance of discharge from the ear and swelling of the mastoid brought the patient to sick call. March 21, 1918. No pus found in auditory canal. Tympanic membrane red and infiltrated; scars in forward lower quadrant; bulging of upper quadrants. Redness, edema and tenderness over mastoid. Patient thin and not over muscular. Abdominal and thoracic organs negative. Paracentesis gives exit to a few drops of pus mixed with blood. Active treatment failed to arrest mastoid symptoms and on March 30 the mastoid was operated on and cleaned out under general anes thetic. The curetting was carried well back to the wall of the lateral anus which was normal. The patient showed marked improvement after the operation but on April 4 there was an evening rise of temperature and complaint of pain in the front of the neck. The next day slight redness and 324 Vol. XIII. SURGERY. swelling of the front of the neck was observed and the patient be gan to complain of difficulty in respiration and deglutition. From day to day there was progressive increase of the following symptoms: Palpitation and tachycardia ; pain on movement of the larynx ; dif ficulty of respiration and deglutition; nausea and vomiting; tremor of the hands; marked psychic disturbances; nervous irritability; widening of the palpebral fissure; eyes glistening and moist; no exophthalmos; weakness of the internal recti with deficient con vergence ; daily evening rise of temperature ; cough ; increasing loss of flesh and general debility. No fluctuation but increasing enlarge ment, redness and tenderness over thyroid. Mastoid wound doing well. On April 11 under ethyl chloride anesthesia the thyroid was in cised and odorless pus evacuated containing a pure culture of strep tococci in short chains identical with that obtained from the mastoid. The opening of the thyroid abcess produced a general alleviation of symptoms but nervous excitability continued marked. Weakness extreme. Sweating. On April 18 severe pain in left loin developed with tenderness on pressure. No tumor. Lateral decubitus. Evening rise of tempera ture. Both wounds healthy. By April 22 all symptoms were aggra vated and a swelling in the loin was apparent. Urinalysis showed albumen, cylindroids, granular and epithelial casts, leucocytes. Un der general anesthetic an incision was made into the peri-renal fat and a large abscess evacuated. General improvement followed this intervention but on April 27 pain in the right buttock developed and there was limitation of movement in right hip. Ah incision over the point of greatest tenderness brought a few cubic centimeters of choco late colored pus. A deep incision over the right trochanter gave access to a large abscess. From now on slow but continuous improvement set in and by June 16 the patient was able to be transferred to a territorial hospital for convalescence. The elaborate and detailed report by Caliceti from which the above outline of this interesting case is derived is followed by a discussion of the etiology of the pyemia and the various theories to account for the metastasis. 1. Was the infection transmitted through small intraosseous venules ? 2. Did the infective agent travel by the blood direct from the capil laries of the mastoid or the tympanic membrane ? 3. Was a small thrombus present in one of the minute vessels of the temporal bone ? No. 2. 325 SURGERY. Mayo, W. J. Acute perforations of the abdominal viscera. Surg. Gynec. and Obst., January, 1919. Three important surgical conditions—the relation of appendicitis to general septic peritonitis, perforations of the pancreas from fat necrosis, infections and perforations of Meckel's diverticulum —were made known to us by the late Reginald Fitz of Boston. As his re searches were wholly by autopsy a somewhat exaggerated idea of the fatality of these conditions gained credence. The operating surgeon by the study of living tissues has developed a more hopeful view. The prognosis depends on the quantity and virulence of the extravasated material, the general resistance of the patient and the anatomical location of the perforation as it bears on the possibility of adhesions, walling off, etc. The progress in surgical treatment is shown by the present attitude as to time of interference. An operation done from three to six days after perforation is not for the perforation but for the generalized peritonitis consequent upon that disaster in the hope of removing a still active focus or secondary deposits and so limiting the spread of the disease. Acute perforations of the abdominal viscera may be considered in three stages: (1) Stage of contamination evidenced by shock, local pain and tenderness; (2) reaction, a stage in which apparent ameliora tion creates the delusive hope that intervention may not be needed; (3) general peritonitis. In appendicitis 70 per cent may indeed recover from perforation that is from the one attack, but 30 per cent of fatalities is very high. The suposed recoveries are temporary. Subsequent attacks are com mon and may prove fatal. Mayo comments on the occasional coincidence in time of acute per forations of appendix and gall bladder. In such cases a gall stone has usually been present and the flora of the two organs correspond. It is well to bear this in mind when operating for either single con dition, since a successful treatment of the appendix or gall bladder may be followed by death of the patient if a rupture of the other organ passed unnoticed. Early operations for perforations of the gall bladder are frequently declined by the patient because he does not recognize the increased gravity of this over previous incidents con nected with, chronic cholecystitis or calculus. It is the delay that is fatal in these cases and not the inherent gravity of the accident. The anatomical surroundings of the gall bladder are excellent from the standpoint of protection. There is a close association between diseases of the gall bladder and biliary tract and diseases of the pancreas. In Mayo's cases of 326 SURGJBBY. Vol. XIII. chronic pancreatic disease 90 per cent were associated with infected gall bladder usually containing calculi. The danger of acute pancreatic processes "which may be spoken of pictorially as acute perforations" depends on whether or not infection is present. The prognosis depends largely on the question of infection. Mayo inclines to conservatism in the surgical treatment of acute pancreatic disorders preferring an anterior approach looking to drainage when indicated to incising the organ for anticipated trouble. Duodenal perforations into the abdominal cavity are the com monest of acute perforations. Happily the fluid contents of the duo denum are more or less sterile and of small bulk. These cases are often operated on for acute appendicitis, recovery following though the true cause of the symptoms was not discovered. An incision to the right of the mid-line through the rectus muscle enables the sur geon to examine appendix, gall bladder, duodenum, and stomach and engage in the procedure indicated regardless of the preoperative diagnosis. Mayo notes a marked difference between results from intervention undertaken within 10 hours and those delayed from 10 to 30 hours. When the operation is performed within 10 hours the perforation will usually be found closed and contamination may be prevented. Perforations of the stomach are more serious owing to the larger capacity of that organ and the greater likelihood of spread of con tamination, especially if they occur in the anterior surface. Chronic conditions usually precede perforation and give warning of the ever- present possibility of sudden acute dangers, but this has not been so generally recognized for gall bladder as for appendix cases. (J. S. T.) Soresi, A. L. The use of paraffin for drainage in surgery. Pollcllnlco, Rome, XXV-G 12, December 15, 1918. While the absolute necessity of giving escape to pus wherever or however produced and accumulating in different parts of the body is universally recognized, the daily experience of surgeons demon strates the futility of the great majority of devices used for drainage and what is worse the frequent liability of these devices to be of positive harm. The following propositions regarding the essential features of any method of drainage will doubtless meet with general acceptance: (1) The method employed must actually facilitate the flow of pus or other liquid to the surface. (2) It must not be the immediate or remote cause of local or general disturbance either at the moment of employment or at any later period. (3) It must not interfere with the healing of the diseased part. No. 2. 327 SURGEKY. As it can easily be proved that none of the methods now employed for drainage fulfill the three requirements given above, the author feels justified in publishing an account of the method of drainage by means of paraffin which he has employed for over five years, three of which were devoted to the treatment of thousands of wounds handled in the present war. Before describing the procedure in detail Soresi adverts to the complicated character of the fluids of the human body, all of which have the common property of tending to adhere in a greater or less degree to the parts with which they come in contact and of deposit- 1 ing on these parts either their organic or inorganic content. He notes further the familiar fact that nature has provided the blood vessels, lymphatics, and mucous surfaces of hollow organs and canals with special types of cells to which the liquids they transmit or contain will not adhere. To obtain adequate drainage therefore we can not do better than to imitate the performance of nature by employing devices which will have a minimum of affinity for the fluids to be withdrawn. Paraffin meets this requirement inasmuch as it does not fasten itself to the tissues and organic liquids do not adhere to it. In this connection the reader is reminded that trans fusion as employed to-day relies largely on the fact that the coating of paraffin on tubes and containers permits the blood to flow without coagulating. In brief, the advantages of paraffin for drainage may be summar ized in the statement that it does not stick to the tissues with which it comes in contact nor with the secretions from them. It follows from this that between the paraffin drain and the cavity to be drained there will always without any exception be a free space along which secretions from the walls of the cavity to be drained will have outlet. The interval between the paraffin drain and the walls of the abscess cavity will in every case suffice for drainage no matter what quantity of pus or secretion is produced. While the application of the proposed principle varies with the different types of wound, it requires no difficult technique, but on the contrary is so simple and so independent of special apparatus that it is within the reach of the humblest practitioner. The paraffin available for this method of drainage is the ordinary paraffin of commerce —any paraffin will do splendidly. The par affin to be used is prepared in the following manner : Water is set to boil in a tray, such as photographers use for developing, placed over an alcohol lamp. In this place a second smaller tray, making a water bath for dissolving the paraffin. The water bath prevents the paraffin from reaching too high a temperature and burning the patient. By this method the temperature of the paraffin will not 328 SURGERY. Vol. XIII. exceed 100 C, which will usually drop to 70° or 80 C. by the time the local application is actually made. Take an ordinary muslin bandage, a strip of linen, or a piece of tape of the length and breadth required and holding it by the two ends pass it through the liquid paraffin by a series of up and down movements until the paraffin is equally distributed along the mate rial. If the meshes are large two thicknesses of bandage may be used. Repeat the immersion until the drain has taken up the amount of paraffin desired. Now hold the drain by one end and dip the other into the paraffin. Drains prepared in this way can be used immediately, or after cooling can be put away between two sterile towels or preserved in some antiseptic liquid such as alcohol, to which a little iodine, bichloride of mercury, etc., has been added. Another type of drain can be prepared by folding the edges of the strip of bandage on themselves and submitting the strip to a pre liminary paraffin bath; then roll it between the hands and coat it with more paraffin. The last step should be performed quickly to prevent the first and inner coating of paraffin from being dissolved. By going over these steps several times a small, smooth rod some thing like a candle is obtained. The last step, of course, consists, as before, in paraffining one end of the drain. As the rod is withdrawn for the last time the excess of paraffin runs off the lower end and leaves a nicely rounded extremity which can be introduced into the tissues without pain or inconvenience. For more minute drains strands of linen, silk, cotton, or metal can be prepared as described above. Another way of using paraffin for drainage is to pour or inject the liquid directly into the cavity. The liquid paraffin can be drawn up from the container by a syringe, ladled with a spoon, or allowed to drip from a piece of gauze. When the paraffin is injected with a syringe into a wound having an entrance and exit aperture the most dependent one or both openings may be temporarily closed by a bit of gauze until the paraffin solidifies. Paraffin employed in this way when solidified becomes a " block " of paraffin ramifying through all the sinuosities of the wound. No fear need be entertained lest the paraffin becomes embedded in the tissues. It is expelled little by little as the cavity fills in. This will take place with a rapidity which will surprise anyone employing the method for the first time. Soresi has largely abandoned the use of tubing for drainage ex cept in those cases where the material to be abstracted comes from a considerable depth and where it is undesirable for the intervening tissues to be bathed in it. Tubing coated with paraffin is employed to advantage in draining the gall bladder and biliary ducts. T bandages and many-tailed bandages treated with paraffin are of use in special cases, e. g., drainage of the prevesical space. No. 2. 329 SUBGEBY. The paraffin method can also be profitably employed to drain cavities which at the same time require to be packed. With a piece of paraffined gauze of suitable width line the walls of the cavity somewhat as a paper hanger puts on the wall paper. Then use or dinary gauze for packing. When there is occasion to remove the latter it can be done easily and painlessly. Special indication for the use of paraffin threads of cotton, linen, or silk has been found in the closure of the abdominal wall by layers. Between the layers put a thread or two, leading the lower ends to the surface through a small special incision. This prevents those annoying accumulations of serum and blood which tend to make dead spaces in the depths of a wound and interfere with prompt healing either by the mechanical separation of the layers or by furnishing a culture medium for bac teria. The threads are withdrawn a little each day and completely removed by the eighth or ninth day after the operation. In perforating wounds the " block " method may sometimes effect a removal of minute foreign bodies such as bits of dirt, shreds of clothing, etc. The wound of exit is occluded and slight pressure is maintained over the wound track while the cavity is being injected with paraffin. When the cavity is distended pressure on the lower opening is discontinued and more paraffin is forced in. The vis a tergo now causes the paraffin to exude from the distal opening bring ing with it small foreign bodies. While far from claiming that this simple treatment will remove all foreign bodies the author does assert that it will bring away a great many of them and so reduce the trauma of operative interference looking to that end. The paper concludes with a detailed description of drainage of empyema, of mastoid, of prevesical space, summarizing the arguments in favor of the method described, (j. s. T.) Elmer, W. G. Surgical technic In orthopedic surgery. Ann. Surg., December, 1918. The extensive and varied procedures of surgery often involve forcible manipulation and more or less trauma of the parts. Hence perfect asepsis is indispensable. The following points made by Elmer are of interest to the general surgeon. He considers the rubber glove as ordinarily sterilized a serious menace. To wrap this article in gauze often partially folded on itself and sometimes folded twice and boil it perhaps in the center of a pile of other gloves, for 10 minutes after a " clean " and 20 minutes after a " dirty " case is to fall far short of the requirements. While steam may reach all parts of the outer surface of a glove, the author believes that air pockets are to be found inside the fingers which the steam never reaches. Such parts are therefore subjected, on the in- 103396—19 11 330 SUBGERY. Vol. XIII. side, only to dry heat and for the destruction of all germs and their spores by dry heat a temperature of 350 F. for one hour is re quired whereas boiling water (212 F.) for five minutes answers the purpose if all parts are reached. The proper treatment consists of a thorough preliminary washing with soap and water inside and out. The glove is then filled with water to expell all air, immersed in boiling water and held down by a piece of wire gauze. After five minutes boiling and when the water has cooled the nurse, wearing sterile gloves, removes the glove with forceps, dries it with a sterile towel, powders it inside and out with sterile talcum powder and folds back the gauntlet. Into this is now to be tucked a small gauze pad covered with talcum for the surgeon to use on his hands. The glove, now folded, is covered with muslin and laid in a large glass jar. When wanted for use gloves prepared as above, still wrapped in gauze, are laid in loose rows and not packed together in the auto clave, and sterilized for 20 minutes. The head nurse should personally and directly supervise the work of her assistants and the directress of nurses is responsible for the head nurse. The directress should occasionally go unannounced into the operating room while an operation is in progress and re main throughout the seance watching with critical eye every de tail of the work of her subordinates. Silk to be permanently imbedded in tissues will defeat the pur poses of the operation unless perfectly sterile. It should be boiled for 10 minutes in a 1-1000 bichloride solution and then for 10 minutes in plain water. If boiled with instruments the soda will impair tensile strength. In opening a joint two knives should be used; one for the skin incision, and one for the deeper structures. Sand pillows and operat ing tables should have rubber covers sterilized with the same care bestowed on rubber gloves and then be covered with sterile cloths. Instruments should not be provided in any considerable excess of actual needs. This complicates their proper handling and increases the wear and tear on them. Knives are not to be boiled but im mersed for 20 minutes in 5 per cent carbolic and then transferred by sterile forceps to a tray containing 85 per cent alcohol. The glass tubes containing catgut are to be boiled and then placed in a tray of 5 per cent carbolic or 3 per cent formalin. Nurses should not put their fingers into a tray but remove needed articles with forceps. Talcum powder can not be sterilized in milk. (J. S. T.) No. 2. 331 PATHOLOGY, BACTERIOLOGY, PARASITOLOGY. PATHOLOGY, BACTERIOLOGY, AND ANIMAL PARASITOLOGY. The laboratory diagnosis of gonococcal infections. Methods for the detection of spirochaetes. Pamphlet published by His Majesty's Stationery Office, 1918, for the Medical Research Committee (National Health Insurance). METHODS FOR THE DETECTION OF SPIBOCHAETES. Collection of material.. —Fluid freshly expressed from the lesion, after cleansing with salt solution or water, is to be used. If possi ble, the material should be collected before the use of any antiseptics. Puncture of the nearest enlarged gland and collection by syringe may yield results. Salvarsan and like remedies should not be used before the examination. (a) For superficial lesions take up exuding serum in a capillary pipette. Avoid getting blood. (b) Lesions of mouth. Same as (a) but care must be taken to avoid getting saliva, as it may contain organisms difficult to dis tinguish from the specific organism. (c) Skin lesions. Scarify or scrape papule and obtain serum by cupping or squeezing. Macules may be blistered. Blister fluid is to be thrown away and fresh serum obtained. (d) Lymph glands. Inject about 5 minims of salt solution into gland. Massage gland and withdraw fluid. DEMONSTRATION* OF THE SPIBOCHAETES. TJie dark-ground condenser. —The use of the dark-ground con denser is considered the ideal method. A note is made that the first application of the principle of the dark-ground condenser was due to English scientists. There is a discussion of the principles of the dark-ground condenser and the technique of the examination. Plates showing the appearance of the specific organisms, in comparison with S. dentinum and another organism, are shown. The S. dentinum is stated to have coils somewhat more angular and its motion is stiffer. The other organism has five coils to the diameter of a red cell while the specific organism has seven. The motion of the other organism is more active than that of the specific organism. Stained films. —Prepare film and fix as soon as it is dry, by apply ing absolute alcohol, methyl alcohol, or osmic acid. Stain by Giemsa's method or by Leishman's or Wright's modifications. India ink may be mixed with an equal amount of secretion and smears made in the- usual manner. Permit ink and secretion to dry. Examine with oil- immersion lens. Two per cent Congo red solution can be used instead! of India ink. In the use of India ink or Congo red the organisms are distorted. If the film is thick, they appear as fine filaments ;. if 332 PATHOLOGY, BACTERIOLOGY, PARASITOLOGY. Vol. XIII. the film is thin they appear thick. Characteristic movement of or ganism can not be determined by any staining method. Silver method. —Thibondeau's modification of Fontana's method is the one chosen. Technique.—Prepare films and dry them in the air. Fix by formol- acetic acid solution (acetic acid, pure, 1 cc. ; commercial formalin, 40 per cent, 2 cc. ; distilled water 100 cc.) , for one to five minutes. Treat with mordant (tannin 1 gram dissolved in 20 cc. hot distilled water) and heat until vapor arises, then allow mordant to act 30 seconds. Wash with tap water for 30 seconds and with distilled water for 30 seconds. Treat with silver solution for a few seconds in cold silver nitrate 1 gram, cold distilled water 20 cc. When solution is complete add ammonia water drop by drop. A brownish precipitate is first formed. On further addition of ammonia the precipitate begins to dissolve. Stop addition of ammonia when solution is faintly opalescent. Pour off silver solution and flood with fresh silver solution. Heat until solution steams gently and allow to act for 15 seconds. Wash in distilled water. Soft chancre and balanitis. —The committee finds no sufficient evi dence that soft chancre is a disease induced by a single species of micro-organism. It recommends that clinical observation of cases of soft chancre be continued for 12 weeks to exclude syphillis. A sim ilar recommendation is made with respect to conditions of balanitis. GONOCOCCAL INFECTIONS. Introduction. —The venereal diseases act has caused an increase in laboratory diagnoses of gonococcal infections. To reduce incorrect diagnoses to the minimum the committee has recommended that cer tain methods be followed. It is thought that such methods will pre vent grave injustice to individuals whose cases might be wrongly diagnosed. Gonococcus infection and on the other hand will serve to protect the families of men having the disease but in whose cases the diagnosis of gonococcus infection was not made. Recognition of gonococci in films.—A positive diagnosis may be justified from microscopic examination of films alone 1. When the clinical history and appearances are those of an acute gonorrhea. 2. When the proper technique has been employed. 3. When the observer is so thoroughly familiar with the appear ance of the gonococcus in stained films as to be beyond the danger of confusing other micrococci with it. There is a discussion as to the regions involved in the male and female. A note is made that a smear from the vulva is of absolutely no value, except in vulvo-vaginitis in children. It is recommended No. 2. 333 PATHOLOGY, BACTERIOLOGY, PARASITOLOGY. that the smears be made from urethral discharge. Cultures are to be made after cleansing with alcohol. Staining of smears.—Gram's stain is recommended. The commit tee thought the best results could be obtained by staining thin,, evenly spread smears with 0.5 per cent solution of methyl violet; pouring off, and without washing, applying a strong iodine solution (iodine 1, potassium iodide 2, water 100), then washing with absolute- alcohol and applying a solution of neutral red (neutral red 1, dis tilled water 1,000; 1 per cent glacial acetic acid 2). Cultivation. —The media found most satisfactory were : 1. Thomson's human plasma glucose agar. 2. Cole's tryptic blood agar. 3. Gordon & Hine's trypsinised pea extract agar. As the materials for (1) are most easily obtained in the service it is chosen for this review. (a) Beef heart free of all fat, minced, and placed in an equal weight of distilled water. Heat to 40 C, stirring constantly. Maintain temperature at 40 C. for 20 minutes, raise to boiling point and boil for 10 minutes. Strain through four thicknesses of butter muslin. (b) Dissolve 10 grammes disodium hydrogen phosphate (Na2 HP04) in 1 liter of sterile distilled water. ( H—h or H—h+? according to whether the diameter was from 0.5 to 1 centimeter, 1 to 1.5 centimeter, and over 1.5 centimeter. Red ness and induration proved valuable guides in judging the extent of the reaction. Where both arms showed a similar reaction, the test was put down as a pseudoreaction. These were found to be 9.3 per cent of all cases. Neither from the rapidity with which the reaction ap peared nor in the redness or induration could any material difference be detected in this group of cases. It is therefore our belief that the reading of a pseudoreaction without a control is an extremely hazard ous undertaking, if not impossible. Fully 5 per cent of the pseudo- reactions persisted for a week or longer. Our experience has taught us that as late as six weeks after the appearance of a positive Schick the induration will persist, the pri mary redness gradually becoming an area of brownish pigmentation and scaling. As will be seen from Table II, 2,643 Schick reactions were made. Of these, 1,342, or 50.7 per cent, were positive and 1,301, or 49.3 per cent, were negative. Pseudoreactions were included under the nega tive and comprised 9.3 per cent of all cases. Table II.— Table of Schick tests. Group. + + + +++ Nega tive. Total tests. Per cent positive. Midshipmen, first 182 239 345 138 35 115 210 2 9 10 3 255 305 371 370 474 46.2 543 60.3 34.5 Reina Mercedes crew 54 668 936 565 Total 904 414 24 1,301 2, 643 50.7 Further study of Table II reveals the fact that of the fourth class of midshipmen, where was all the active clinical diphtheria, as well as 85 per cent of carriers in this group of men, 60.3 per cent were found nonimmunes, in contradistinction to 46.2 per cent and 54.3 per cent in the first and third classes, respectively. The low per centage of positive Schick tests on the Reina Mercedes can, in part at least, be attributed to the fact that the average age of the personnel was higher than among the midshipmen. No. 2. 363 KEPOKTS. Twelve, or 27.9 per cent, of the carriers gave positive Schick re actions. Of these only one had had a previous attack of diphtheria eight years ago. From an epidemiological standpoint several points of interest were observed. The entire seven cases among the midshipmen oc curred in the fourth class. Of the 23 carriers found in the fourth class 4 said they had had diphtheria varying from a period of 2 to 10 years previously. Six carriers admitted contact with clinical cases. It is also to be remembered that all clinical diphtheria was among the young unseasoned individuals who had just entered train ing from civil life. In all instances the disease developed in from two to five weeks after entering the academy. Two of the 20 carriers from the crew of the Reina Mercedes gave a history of diphtheria, one having had two attacks, the last being 22 j'ears ago, and he has given continued positive cultures over a period of more than six weeks. All carriers from this crew were found to come under three groups, consisting of nine in the fire-room force, seven seamen, and four privates in the Marine Corps. All these men stated that they had been in more or less constant associa tion with the other members of their respective group. In fact, five of the seven seamen group belonged to a boat's crew. As in the case of the midshipmen, the three men who developed diph theria had been attached to the station from two to four weeks. One of these gave a history of a previous attack of diphtheria six years ago. By consulting Table I it will be seen that 1.82 per cent of the fourth class were carriers, while in the first and third classes less than 0.5 per cent were found to harbor virulent diphtheria bacilli. Again, with only three clinical cases on board the Reina Mercedes, the percentage of carriers increased to 3.52 per cent, due in part to the closer billeting and association. The midshipmen involved had at no time come into contact with the crew of the Reina Mercedes, All efforts to hojd the mess gear accountable were futile. No mess attendant, cook, or baker proved to be a carrier. Cultures from the drinking fountains yielded no growth of B. diphtheria. There was nothing about the outbreak which suggested the milk supply, but for sake of completeness the milk was cultured at various intervals and found to be devoid of diphtheria organisms. None of the milk handlers at the Academy dairy could be put down as . a carrier. All attempts to trace the more or less sporadic case to extramural sources were of no avail. Since the work was inaugurated no new cases have as yet developed on the station. The administration of the toxin-antitoxin mixture to those having positive Schick reactions was necessarily delayed by the advent of 364 Vol. XIII. REPORTS. influenza among the personnel. It is our intention to give three doses of 1 cubic centimeter subcutaneously at weekly intervals. Three months subsequent to the last injection it would seem expedient to do Schick tests on all those who receive the toxin-antitoxin mixture. The carrier situation has presented the same problems which other investigators have encountered. We were afforded the opportunity of observing the carriers and cases, following them by cultures from day to day. Of the 43 carriers and 10 cases which were in the diph theria isolation wards, all but 20 have returned to duty. There was no case or carrier permitted to leave isolation until at least three consecutive negative cultures had been obtained at not less than 24-hour intervals. Here again we have experienced what others have observed, that a case may yield a negative culture one day and a positive one the next. It was found that unless careful vigilance was maintained the carriers, in their ambition to return to duty, would hasten to gargle their throats immediately prior to taking the cultures. Therefore it was necessary to eliminate all opportunity for such procedure. By this precaution several carriers were found to be repeatedly positive which previously had given negative results. Other factors enter into the carrier state, however, these being par ticularly pathological conditions, and of these hyperlrophied ton sils, with deep crypts, and adenoids, seem to play the leading role. Most of them were found to maintain the infection in both nose and tonsils. Various methods were employed such as gargling and spraying with antiseptic solutions, local applications of silver nitrate, iodine, and dusting powders (kaolin). The efficacy of the local applications of diphtheria antitoxin in our hands is highly problematical. It is our conviction that a large percentage of the so-called " chronic " car riers will continue to be so until all pathological conditions of the nose and throat are corrected. In a few instances it has been possible to exterminate the organism by application of 10 per cent silver nitrate or tincture of iodine into the crypts of the tonsils. Our ex perience is confirmatory of the work of others that the efficiency of any method lies largely in the thoroughness of the application, rather than the agent employed. In the examination of the throats at the time of culturing a direct smear was taken from any suspicious condition. In addition to cul tures, a direct smear was made from 567 men cultured as a matter of routine. It was our purpose in this to ascertain in what percentage fuso-spiral (so-called Vincent's) organisms were present. Gram stain and dilute carbol fuchsin were used and 10 per cent of all smears showed long fusiform bacilli and evenly undulating spirilla. From brief notes taken at the time, the vast majority of these oc curred in those cases where small caseous plugs were noted in the crypts of the tonsillar lacunae. No. 2. 365 REPORTS. STUDY OF AN EPIDEMIC OF INFLUENZA AT PENSACOLA. By J. M. Ferret, Lieutenant, and C. M. Shaar, Lieutenant, Medical Corps, United States Nary. The great pandemic of influenza, which originated in Spain dur ing the spring of 1918, made its appearance at the United States Naval Air Station, Pensacola, Fla., on September 11, 1918. On that date 17 Marines came down with the disease. Why the Marines should have been the first victims can not be satisfactorily explained. There had been no new drafts among them for three months, and although the}' were somewhat crowded in their barracks, they fared no worse than the sailors. For four days preceding the outbreak of the epidemic 160 men were received at Camp Bennett, which is a detention camp about a mile from the Air Station, 30 of whom were a draft from Cambridge, Mass., and 3 from Great Lakes, 111., at which place influenza was then epidemic. As the epidemic first started at the Air Station, and among the Marines, we do not think that the blame can be laid on incoming drafts. It would be futile to try to determine absolutely how the station became infected. The men go on liberty in Pensacola, which is about 6 miles from the station, and may have become infected from the civilian population. The disease follows the lines of travel, and naturally when it crossed the Atlantic Ocean our big seacoast cities were tfie first attacked. Afterwards the cities in the interior got their share. This could have been easily noticed by reading the news papers. The war, with its massing of great numbers of men in Army camps, naval stations, shipyards, munition plants, etc., offered favor able conditions for the rapid spread of the disease. At the Naval Station, Pensacola, Fla., a good many men live in tents, two occupants to a tent. It was interesting to note that the number of cases was about evenly divided between men living in tents and those living in somewhat crowded barracks. It is well known that of all pandemic diseases influenza is the one which attacks the greatest number of the population. The com plement of the Air Station is 5,359, and as we had 1,451 cases of influenza, this shows that 27 per cent of the personnel became in fected. These 1,454 cases developed between September 11 and Oc tober 27, 1,018 of which occurred between September 22 and Octo ber 4, a period of 13 days. The epidemic reached its height on the nineteenth day, September 30, when 117 cases were admitted to the sick list. It was under full control on October 27, seven and one-half weeks from its onset. Chart No. 1 shows graphically the number of cases developing daily and also the daily temperature of the weather and the rainfall. It will be noticed that the temperature and rainfall did not seem 366 Vol. XIII. REPORTS. to have any important bearing on the course of the epidemic. The mortality rate of influenza is put down by Osier as being very low. He cites 55,263 cases in the German Army, with a mortality of 0.1 per cent and 22,972 cases occuring in the civilian population of Munich with a mortality of 0.5 per cent. These figures do not have reference to the present epidemic. Unfortunately in this outbreak the disease has exacted a much higher toll. Thus in the October 5, 1918, number of " Notes on Preventive Medicine for Medical Officers, United States Navy," 39,503 cases are tabulated, with a mortality of 4.26 per cent. Our deaths at Pensacola numbered 24 out of 1,454 cases, a death rate of 1.6 per cent— a comparatively low figure for f Identic of lalluuza Ccroeltmcnl3331 CrtAB-T U« 1 III. Narol Ait Jlc'ion. Ptn«c«!a ft, Mf\ -Ocl-HIS Tofol Mumfcir qu)»^»f •d|4'oio3dcus SAvoqs g 'o^ ?J^qO •sasBO a"ubui ut qSiq sbav jbasj aqj, •umjnds eqj ^noqB opsija^DBjBqo Suiq^ou paAjasqo 8jV\ "qsiuiunp ppaoAV suiBd )saqo aq? aAipnpojd auiBoaq q3noa aqi sy qqouojq puB BaqoBJ^ eip 370 Vol. XIII. REPORTS. The fastigium would not always be reached within the first 24 hours, as the following illustrates : Admission. Third day. Fourth day. Fifth day. Sixth day. 102.1 101.3 101.5 101.5 103.2 102 103 102.1 104 105.5 105 103.5 In some cases an early marked remission was noted, which was soon followed by a secondary rise. The next table makes this clear : Admission. Second day. Third day. Fourth day. Fifth day. 104.3 99.2 101.3 104 98 101 103.4 99.2 100 100 103 103 103 103 101 103.3 99 102 102 101.3 99 101 103.2 99 103.2 99 103.2 99.3 103 103.2 99.3 103.2 98 102.2 103 98 In the vast majority of cases, however, there was nothing remark able in the fever, which was usually at its height within the first 24 hours and then terminated by lysis, reaching normal usually in from three to six days. We have found the pulse rather slow, as can be seen from the fol lowing : Number of counts. 103°-104 F. 102M03 F. 102MO4 F. 100 100 200 93 86 89 The following table will show the respiratory rate : Number of counts. 103M04 F. 102M03 F. 102M04 F. 100 100 200 22 21 2i+ No. 2. 371 REPORTS. Eighty- four and five-tenths per cent of 200 cases, with a tem perature between 102° and 104 F., had respirations between 20 and 24. The marked predilection of the influenza bacillus for the respira tory tract has been a noticeable characteristic of this epidemic. Only a few cases had any gastric symptoms and in these it was no easy matter to decide whether the nausea and vomiting were from the disease or from the medication which had been given, such as calomel, Dover's powder, sodium salicylate, etc. Physical findings in most cases have been conspicuous by their absence. Injection of the conjunctivae and slight redness of the throat were usual. The lungs were clear in most cases. A table of the total white count per cubic millimeter is given below : Number of counts of uncomplicated casos. Average white blood count. Highest count Lowest count. 40 7,800 17,600 4,000 The urine examination of 200 uncomplicated cases follows : Number ofcases. Nega tive. Per cent. Number with al bumin. Per cent. Number ofcasts with al bumin. Per cent. Number ofcasts without albumin. Per cent. 200 142 71 32 16 16 8 10 5 It is interesting to compare these urinary findings with those of the pneumonia cases as tabulated a little later in this paper. The cases at the onset and when the epidemic was at its highest were the most severe ones. The first complication to appear was an acute otitis media, which occurred nine days after the onset of the epidemic. The following day four cases of pneumonia developed. The follow ing table will show the complications and sequelae that we noted : COMPLICATIONS AND SEQUELAE. 1. Pneumonia, 79 cases. Unresolved pneumonia confirmed by X-ray, 2 cases 2. Empyema; 1 case. 3. Nephritis with pneumonia ; 7 cases. 4. Otitis media acute ; 13 cases. Otitis media acute with pneumonia ; 4 cases. 5. Subcutaneous emphysema; 1 case. 6. Psychosis infectious ; 2 cases. 7. Frontal sinusitis ; 3 cases. 8. Acute thyroiditis; 1 case. 372 REPORTS. Vol. XIII. 9. Phlebitis of left leg ; 1 case. 10. Acute cholecystitis; 1 case. 11. Corneal ulcer ; 1 case. 12. Acute laryngitis with aphonia lasting two weeks ; 1 case. Pneumonia. —This has been our most frequent as well as most serious complication. Pneumonia has accounted for all of our fatali ties. All of the seven nephritis cases have been associated with pneumonia and had they existed alone would undoubtedly have been responsible for some of our deaths. The average number of days from the onset of influenza to the development of pneumonia in 63 cases averaged 5.6 days. The onset was insidious. A chill, pleuritic pain and herpes were very uncommon. Delirium was frequent. A dusky color of the skin and cyanosis were earljr and striking features. The rusty, thick, and sticky sputum characteristic of penumococcic lobar pneumonia was rarely noticed. A few cases early in the course of the disease ex pectorated bright, bloody sputum. The fever was high —102.5° to 105 F., continuous, and having slight remissions. In the majority of cases it terminated by lysis. The respirations were increased as in ordinary pneumonia cases. The physical signs were fairly con stant. They were always bilateral but far more marked in one lung in most cases. The first evidence of the trouble would be found at the bases posteriorly. In one lung there would be evidence of a small consolidated area deeply seated, i. e. : slight dullness, bron- chovesicular breathing, distant bronchial breathing or whispered pec toriloquy. At the opposite base one would hear subcrepitant rales. If the case was reexamined at the end of 24 to 48 hours evidences of a massive consolidation could now be made out in one lung and the physical signs would not be well marked in the other lung. This will explain why in our table we show broncho-pneumonia in one lobe. This really only means that this was the lobe most affected. Whis pered pectoriloquy was our most valuable aid in arriving at an early diagnosis of lung consolidation. Although the cases as we have gathered them from the records show a large number of lobar pneumonias, we believe that the re verse was the real state of affairs. It must be remembered that the broncho-pneumonia in this epidemic was not typical and that so much lung tissue was involved that the diagnosis of lobar pneu monia made on clinical findings was excusable. Usually a diagnosis of broncho-pneumonia has to be made on signs of a localized bron chitis with symptoms of pneumonia. The insidious onset, the rarity of the pleural involvement and rusty sputum together with the low blood count ought to have made us favor a diagnosis of broncho instead of lobar pneumonia. The autopsy findings which are being reported have shown that the lesions were those of broncho-pneu monia. No. 2. 373 REPORTS. The following tabulations of our pneumonia cases are of some interest. LOBAR PNEUMONIA. Num ber Site of lesion. > Resolution. Total num ber of pneu monia. Aver age age. Per cases noted. of Right lung. Left: lung. Crisis. Lysis. Deaths. deaths. of 25.... Upper lobe, 0; middle lobe, 2; lower lobe, 10. Both lowei Upper lobe, 0; lower lobe, 9. 14 14 47 25 13 31.9 lobes, 5. BRONCHO-PNEUMONIA. 19.. Upper lobe, 0; middle lobe. 1 ; lower lobe. 3. Both lower lobes, 10. Upper lobe, 0; lower lobe, 5. 14 32 24 28.0 The following table shows the results of our blood counts : Infliienza cases with pneumonia. Total number of counts made. Average count. Lowest count. Highest count. 29 10,200 2,777 65,000 It will be recalled that the average count of 40 uncomplicated cases was 7,800. The kidneys in our pneumonia cases have suffered severely as the following will show : Number of cases. Nega tive. Per Albumin without Per cent. Albumin with casts. Per cent. Casts without albumin. Per cent. cent. casts. 51 3 5 14 27 32 62 2 3 Of our influenza cases 5.4 per cent developed pneumonia. We be lieve that as high as this figure appears it would have been much higher had the epidemic occurred during the winter. The treatment of uncomplicated influenza cases was on the fol lowing lines: Calomel, gr. 5, followed by magnesium sulphate, was given at the onset. Aspirin, gr. 10, t. i : d., and Dover's powder in gr. 10, b. i:d, were used in some cases. Another class was given sodium salicylate, sodium bromide, and sodium bicarbonate; still others re ceived phenacetin, salol, and quinine in capsules. Kest in bed, hydro- theraphy (internally and externally), and a nutritious, easily di 374 . Vol. XIII. REPORTS. gested diet were the main factors in the treatment of the disease. Of the drugs used aspirin and Dover's powder were probably the best. During convalescence elixir of iron, quinine, and strychnine was em ployed as a routine measure. The treatment of pneumonia cases was symptomatic, plus the routine administration of creosote 1 drop on crushed ice every four hours, kept up for a few days after the temperature reached nor mal. Captain G. T. Smith, Medical Corps, Unted States Navy, the commanding officer of the United States Naval Hospital, Pensa- cola, Fla., says that he has seen excellent results with creosotal in about 50 cases of lobar pneumonia, not losing a patient. As we did not have creosotal, creosote was used instead. We could not see that it had any effect on the course of the pneumonia. It is worth noting that creosote was tolerated and caused nausea in but very few cases, and this subsided promptly when the drug was discon tinued. Creosote was stopped in the nephritis cases as we did not wish to increase the work of the kidneys, which were already over taxed by the toxemia of the disease. Our main reliance was on fresh air, hydrotherapy, plenty of fluids, liquid diet, stimulants as needed, and last but not least, careful nursing. To facilitate the handling of all cases they were placed in one ward. An ice cap was applied to the head and chest on the side that had the most trouble. Tepid sponging was used every three hours for a temperature of 102.5 F. or over. In some cases compresses wrung out in water at 60 F. were applied to the chest every two hours and seemed to do good. Although we believed that the cases should have a liquid diet while the temperature was very high, we did not hesitate to give the patients solid food with a temperature of 101° to 102 F., if this occurred during a protracted lysis. We are of the opinion that, be sides calories a patient needs plenty of food even if he has fever, to supply him with antibodies to overcome the infection. The solid food was well tolerated and we could not see any bad effects that could be charged to its use. The treatment was begun wtih calomel 5 grains, followed by a saline. The calomel was given in one dose as we did not wish to disturb the patient any more than was absolutely necessary. As our patients were young adults and in good physical condition before the onset of their present disease this treatment did not seem too drastic. We have gone over 780 routine urinalyses made at the United States Naval Hospital and found indican in 450, or 57 per cent of the urines. This gives us an idea of putrefaction going on in the bowel and makes us feel that a purgative at the onset of an infectious disease is not superfluous. Whisky, one-half ounce, well diluted with water was used every four hours as a matter of routine when the pulse became weak. We could notice no striking beneficial results following its use. No. 2. REPORTS. 375 Tincture of digitalis, 30 drops every four hours by mouth, or 10 to 15 minims by hypodermic in very bad cases, seemed to be of real value. If we were asked which was the one best stimulant in pneu monia we would have no hesitation in saying that it was digitalis. The tincture by needle is a little irritating and painful and is some times followed by some induration, but we did not see any abscesses. Another drug that appeared to do good when the patient was rest less and could not sleep was codeine sulphate one-half grain by hypo dermic. Trional in 5 to 10 grain doses acted well. In the early days of the disease, when bright red blood was expectorated a hypodermic of atropine sulphate acted beneficially. Later on when there were coarse rales present and edema of the lungs was developing atropine would do no good. The patient would drown in his own secretions. Camphor in oil, grains 5 ; strychnine sulphate, grain 1/30 ; caffeine and sodium benzoate, grains 2, by hypodermic, were all tried, but seemed to be of very little value. Spinal puncture, using cocaine i per cent solution as a local anes thetic was used in one case with delirium which had lasted three weeks. Twenty cubic centimeters of clear fluid were removed under pressure and the patient was quiet for six hours after the puncture. Spinal puncture to relieve delirim in pneumonia is based on good grounds and is a valuable procedure which ought to be used more fre quently. Venesection was done in two cases, showing cardiac embarrass ment. From 180 to 200 cubic centimeters were removed. The pa tients were relieved for a few hours. Both cases died. We believe that venesection should be kept in mind and used more often than is the present practice. Oxygen was given by inhalation when the patient became cya- nosed, and proved useless. In two cases we gave it by needle in the subcutaneous tissues of the abdominal and thoracic walls. An im portant precaution in carrying out this procedure is to insert the needle subcutaneously and see that no blood flows out, as the giving of oxygen directly into a vein would cause an air embolus. The purpose of using this method is based on the theory that the red blood cells are capable of utilizing the oxygen and make up for the difficulty of oxygen absorption in a lung which is extensively in volved and where the exudate is so excessive as to diminish the sur face of contact between the blood and oxygen inhaled ; that the latter is not absorbed in sufficient amount to sustain life. Another advan tage is that the oxygen is held in a reservoir as it were, and can be utilized continuously. The patient would be allowed to sit up in bed for one hour, using a back rest, seven days after the fever had been normal. The time was gradually lengthened so that in about two weeks after the fever subsided he would be walking about. 376 Vol. XIII. REPORTS. Bacteriological work.—The present pandemic of influenza has been characterized by the great divergence of bacteriological findings as reported by various workers. Influenza vera is a disease caused by the bacillus of influenza. Influenza nostras on the other hand is a disease, the cause of which has not been definitely determined; the micrococcus catarrhalis, streptococcus, etc., have all been incrimi nated. A considerable amount of bacteriological work has been done dur ing this pandemic to determine the cause of the infection, and in a majority of the reports the evidence seems to be in favor of influenza nostras. Bacillus influenza has been reported at times, but in many of the reports it was not blamed as being the chief mischief maker. We have examined the sputum of 120 patients who had been clin ically diagnosed influenza (respiratory type) and 28 out of 66 un complicated cases 'and 33 out of 54 cases complicated with pneumonia showed an organism which morphologically and tinctorially was con sistent with that of the influenza bacillus. Pneumoccus, micrococcus catarrhalis, staphylococcus, and streptococcus were also found. The following technic was used in collecting specimens for cul tures: The patient was instructed to cough and the sputum which came from deep down in the bronchi was immediately received in a sterile Petri dish. A small amount of this material was at once taken up with a platinum loop and planted on freshly prepared blood agar and blood-streaked agar. This media has a slight alkaline reaction. The Petri dish was then incubated at 37 C. After 24 hours incu bation the colonies were barely visible, but after 36 to 48 hours they appeared as minute dewdrops. When touched with a loop the colony could easily be picked up and formed a smooth and even suspension with a drop of water on a slide. The microscopical examination of the smear showed that the in fluenza bacilli prepared from the culture were much larger than those prepared from the sputum. Another striking feature was the variation in the size of the bacilli in smears made from both the sputum and the cultures. The staining that gave the most satisfactory results was Gram's stain, using dilute carbol-fuchsin as the counter stain. Four cul tures out of 31 uncomplicated cases and one out of eight cases com plicated with pneumonia showed the influenza bacillus, micrococcus catarrhalis, pneumococcus, staphylococcus, and streptococcus were also found. Agglutination test. —In five cases the influenza bacilli obtained from subcultures on blood agar and blood-streaked agar were ag glutinated by the serum of convalescent pneumonia patients. The method consisted in picking up the influenza colony and emulsify ing in normal salt solution. This emulsion and the serum of a pa No. 2. REPORTS. 377 tient recovering from influenza were mixed on a slide in dilution of 1 to 40. At the same time horse serum and the bacterial emulsion ■were mixed on another slide in the same dilution and was used as a control. Both slides were examined after 20 minutes incubation. Only the slide with the patients' serum agglutinated. The slides were then dried, fixed and stained and the results confirmed the above observation. Bacteriological findings. —The sputum of 120 patients clinically diagnosed influenza (respiratory type) were examined. The follow ing information was obtained : Number examined of uncomplicated cases, 66. 1. Influenza-like bacilli, 28—42.4 per cent. 2. Gram negative diplococcus, probably M. catarrhalis, 20—30.8 per cent. 3. Pneumococcus, 51—70.3 per cent. 4. Streptococcus, 4—6.6 per cent. 5. Staphylococcus, 3—5 per cent. Number examined of influenza cases complicated with pneumonia, 54. 1. Influenza-like bacilli, 33—61.1 per cent. 2. Gram negative diplococcus, probably M. catarrhalis, 7— 12.9 per cent. 3. Pneumococcus, 48—88.4 per cent. 4. Streptococcus, 4— 7.3 per cent. 5. Staphylococcus, 2—3.7 per cent. Thirty-nine cultures were taken from bronchial secretions, col lected in sterile Petri dishes and planted on blood-streaked agar and blood agar. The 39 cases showed the following flora : Number examined of uncomplicated influenza cases, 31. 1. Influenza bacilli, 4—12.9 per cent. 2. M. catarrhalis, 29—93.8 per cent. 3. Pneumococcus, 20—64.5 per cent. 4. Streptococcus, 11 —38.6 per cent. 5. Staphylococcus, 9—29 per cent. Number examined of influenza complicated with pneumonia, 8. 1. Influenza bacilli, 1— 12.5 per cent. 2. M. catarrhalis, 6— 75 per cent. 3. Pneumococcus, 4— 50 per cent. 4. Streptococcus, 1—12.5 per cent. 5. Staphylococcus, 5—62.5 per cent. Ten nasal cultures were negative for influenza bacilli. SUMMARY AND CONCLUSIONS. 1. Complement of station 5,359; total number of influenza cases, 1,454 —27 per cent. Number of pneumonias, 79; number of deaths, 24. Mortality, 1.6 per cent. The epidemic was under control within seven and one-half weeks. 2. The number of cases at the isolation camp has been much smaller than that of the station (not previously mentioned in text). 103396—19 14 378 REPOBTS. VoL XIII. 3. The men living in tents at the Air Station have suffered equally with those living in barracks. 4. The present epidemic has had a higher death rate than preced ing ones, as noted in the literature. 5. The very low white blood count leads us to believe that most of the pneumonias were due to influenza bacillus, as pneumococcus, streptococcus, or staphylococcus would have caused a leucocytosis. 6. The pneumonias are in the majority of cases massive broncho pneumonias. TBAINING SCHOOLS FOB NURSES IN HAITI. By L. D. Jordan, Chief Nurse, UDited States Navy. The treaty of September, 1915, between the United States and Haiti provided among other details for the establishment of a public- health service under the control of a sanitary engineer nominated by the United States. In December, 1916, Surgeon N. T. McLean, United States Navy, was appointed to this detail, and plans for the organization of the service were begun. In July, 1918, Chief Nurse L. D. Jordan, and Nurse J. Y. Kay- mond, United States Navy, were detailed to duty in connection with the establishment of a training school for Haitian women. The necessity for Haitian trained nurses was early appreciated, but until the development of the service had been brought to a point where the school could be properly administered it was deemed inadvisable to begin this work. The negro Republic, with over 2,000,000 inhabitants, the great mass of whom are illiterate and without the most elementary ideas of hygiene, had no organization from which even inexperienced nurses could be obtained. The deplorable hospital situation in Haiti at the time of the forma tion of the public health service gave great concern. During the time of the occupation the naval medical officers attached to the Marine regiments in Haiti undertook such improvement in the local hospital as was possible. Their work brought the city general hos pital in Port au Prince from a condition of filth and squalor to a real working basis. This hospital, as most others in the Republic, had been more or less under the general administration of French Sisterhoods, who, in the face of greatest difficulties endeavored to attend to the needs of the sick. The Sisters were not trained nurses and at best could but administer such funds as they were able to obtain from the Government and private sources. No organized plan existed in relation to the care of the sick. if? fy t f \ Mw n ... >> if f | f Nurses' training school, Haiti. The school building. Group of nurses, sisters, and pupils, 37* • I No. 2. BEPOBTS. 379 Preliminary work having been accomplished, one of the buildings of the city general hospital was set aside for a training school. Interest among the better class of Haitian women was established by means of a number of articles in the daily press, and the influence of the Sisters actually in the hospital and through their associations at the various schools throughout the island. As a result, from a large number of applications from all parts of the country, 38 were selected, and on October 15 the school was opened with 24 pupils in attendance. French being the national language, all instruction is given in it. The school is conducted as nearly as possible along the lines adopted by standard American schools with such minor changes as were advis able to meet local conditions in a tropical country. The uniform is blue with large soft white collar and cuffs. The first three months are the period of probation, after which the cap is received. Lectures and practical demonstrations are given. The course extends over two years with a diploma at the end of that time to those who have satisfactorily completed the course. The usual in struction will be given in medical and surgical nursing, operating- room technique, children's diseases, dietetics, and a special study of nursing in tropical diseases. The first month's work at the school shows that the pupils possess a high ideal of the qualifications of a nurse. They show great in terest in their practical work and already give evidence that they have the ability to understand and put into use the instructions which they have received. Two Sisters live in the nurses' quarters and maintain discipline. The pupil-nurses will receive their practical experience in the wards of the city general hospital, which has a daily average of over 300 patients. In addition to the hospital instruction proper, an out patient dispensary, located in one of the poorer sections of the city, will be used to give instruction in social service. It is believed that this training will be of inestimable benefit in teaching the poorer classes the elementary principles of hygiene. From the interest taken by the pupils themselves, their families, the Sisters, and the people generally, it is evident that the spread of a knowledge of the hygienic principles necessary for good health will be increased as the pupils graduate and return to their homes in the various towns of the Republic. 380 REPORTS. Vol. XIII. OBSERVATIONS ON 200 MEN EXAMINED FOR CANDIDATES FOR THE LISTENERS' SCHOOL. By F. B. Galbraith, Lieutenant, Medical Corps, United States Navy. After having examined a large number of men for the Listeners' School I noticed that about only one in every five qualified. To de termine the cause of the failures I decided to keep records of all the men examined. The records of 200 men examined consecutively were taken for the basis of this report. The following instructions furnished by the Bureau of Navigation were followed, with slight modifications. (The numbers and letters are not the ones given in the examination for obvious reasons.) DETAILED RECOMMENDATION FOR THE EXAMINATION OF CANDIDATES FOR THE LIS TENERS' SCHOOL. 1. Qualifications of candidates for examination. (a) The general training of a seaman, especially military discipline, care of seaman's belongings and person, and the ability to handle firearms effec tively. (ft) General Intelligence sufficient to profit by an Intensive course of school work. (c) Loyalty to and interest in naval work. (d) Enough self-reliance and initiative to carry the responsibility of the listener's task (e) Enough team spirit to make him livable in cramped quarters. 2. On the basis of these requirements, the best available men should be recommended for examination by the drill officers from the senior companies at the several training stations. (a) It should be made clear to the officers In charge that all candidates for this examination should be selected men. It is a waste of time to examine men who do not meet the above requirements, at least presumptively. (6) At least four times the quota required by the communication on the "quota of men for Listeners' School" under date of January 29 should be ex amined at each naval district. (c) In the absence of other clear indications the requisite general intelli gence to profit by school training (1, 6) may be decided by actual school ex perience. Wherever practicable candidates should have had at least two years' high-school experience, but any other indication of superior intelligence should be regarded as satisfactory. 3. The examination of the selected candidates should consist of two parts, (a) A general medical examination to determine the candidate's general fitness for the tasks of the listener, with especial reference to the Integrity and normal functioning of the auditory apparatus, and possibly with less em phasis on the visual equipment. (6) A special examination to determine by approximate trial the men who seem to be best fitted for the special and peculiar task of a listener. 4. The ideal special examination would probably mean to try out every candi date with the special apparatus used under the actual conditions of service. Since that seems to be impracticable, a set of tests had to be developed that would correspond to these tasks as closely as possible. After a considerable ex perience with the men selected by these tests, consequent to which the tests have been checked and corrected, it seems important to give them as uniformly No. 2. BEPOKTS. 381 as possible In all naval districts and to make no Intentional changes either in substance or method until that change has been fully considered by the Bureau of Navigation and checked by correlation with the actual work of the man at the school. 5. Examination blanks similar to the inclosure should be used as far as prac ticable for all examinations. Until enough printed forms can be supplied for nil the districts, sufficient similar blanks for one or two examinations may have to be prepared by hand. In this case It will be unnecessary to duplicate the 6-inch rule at the bottom. The graded examination papers should be forwarded to Pelham Barracks with the successful candidates. It is important in the final selection to take all available data concerning the candidate into account. 6. Groups of 12 to 20 men may be examined together. Each group examina tion requires from 15 to 20 minutes. 7. The examination room should be at least 30 feet long. It should contain (1) a table at least 8 feet long for the examiner's sound screen; (2) provision for seating 20 men in two rows, the nearer row being 20 feet from the sound screen; (3) provision for the candidates to write their papers, including pen cils and appropriate tables or lap tablets; (4) no disturbing noises should be permitted either inside or outside the room ; (5) a petty officer and an orderly should be present throughout all examinations. 8. Introductory statement: Before the examination of any squad begins the examiner should state (o) that the object of the examination is to select those men who have the special qualifications for a special and very important naval task which demands the best possible hearing and the ability to locate the direction of sounds; (h) that the closest attention is required and instructions will not be repeated; (c) that looking at the paper of another will disqualify a candidate immediately. Note it is the business of the orderly and petty officer to see that this rule is enforced. 9. The first two lines should then be ordered filled in by the candidates as in dicated by the printed directions. (a) The first line should have the candidate's name in full, and the date. (6) The second line should give the candidate's rating, billet number, bat tery station, and the name of the naval district or training school. 10. Test 1.—The memory span, 7, 8, and 9 place digits. Procedure: The examiner should state— (a) "The first test is your ability to remember numbers. ( & ) "In column 'A' you will write 10 series of numbers, one series on each line, after I have read them to you and given the order to write. (c) " I shall give the order, ' Pencils up.' On that order you must raise your pencils from the paper at least 2 inches. Then I shall read 7, 8, and 9 place number digits, each second. You should remember these numbers and write them In the order that I gave them, when I give the command ' Write.' " (d) For example: Pencils up; 1, 9, 4, 7—write. (e) Now pay attention: Pencils up ; 3, 7, 2, 8— write. Pencils up ; 0, 8, 6, 9—write. Pencils up ; 5, 1, 8, 3—write. Pencils up ; 9, 4, 1, 6, 3—write. Pencils up ; 2, 8, 9, 4, 1— write. Pencils up ; 3, 7, 4, 8, 5—write . Pencils up ; 6, 8, 2, 7, 1, 9— write. Pencils up ; 0, 3, 6, 2, 4, 2— write. Pencils up ; 7, 9, 1, 3, 0, 5— write. Pencils up ; 5, 9, 2, 8, 3, 6— write. 382 REPORTS. Vol. XIII. This series of numbers may be used for all examinations until further notice. 11. Test 2.—Ability to read a circular scale to an error of 1 degree. (A) Apparatus: (a) A circular scale at least 15 inches in diameter, di vided into 5-degree arcs and numbered every 30 degrees with number that should be legible at 30 feet; (6) a hand lying close to the scale and capable of being set with an accuracy of 1 degree: (c) both scale and hand may be constructed of heavy cardboard divided and lettered by hand. (B) Procedure: The examiner should say— (a) " In the column B you will write the setting of this hand on this circu lar scale, when I give the command ' Write.' (6) " Note that the circular scale Is like a compass scale, reading from 0 to 360 degrees. Each division marks off 5 degrees. Each 30 degrees is numbered. (c) " You are expected to read to an accuracy of 1 degree. For example, this (setting the pointer to correspond) would be 90 degrees, this would be 95 degrees, and this could be 92 degrees. (d) "Now pay attention to the settings and write each on a separate line In column B when I give the command ' Write.' Set the scale at 180 degrees ; give the command ' Attention,' and after 5 seconds give the command ' Write.' " Set the scale at 0 degrees ; command " Attention " and after 5 seconds " Write." Set the scale at 50 degrees. Set the scale at 65 degrees. Set the scale at 70 degrees. Set the scale at 27 degrees. Set the scale at 133 degrees. Set the scale at 107 degrees. Set the scale at 201 degrees. Set the scale at 96 degrees. 12. Test 8.—The location of sound. (A) Apparatus: (a) A cotton cloth screen about 8 feet long and 30 inches high, on which are printed six vertical lines 1 foot apart and about 8 inches high. Above these lines should be printed numbers 1 to 6, one for each line. The numbers should be legible at 30 feet. ( 6 ) A steel snapper such as Is some times used In elementary telegraph instructions. Any other convenient source of uniform sounds would do which can be made to give separate clicks close to the cloth screen, (c) Since it is important that no other indication of the source of sound be given other than the sound itself, It must be carefully arranged that no part of the examiner is visible above, below, or through the screen. The snapper must not touch the screen, though It should be as close as possible without touching to avoid parallel. Neither experimenter nor snapper should cast shadows on the screen. (B) Procedure: The experimenter should say— (a) "Now we shall test your ability to locate the direction of sounds. This is the most difficult and the most important of all the tests. (&) "I shall sound the snapper (sound it) behind that cloth screen, directly behind one of those numbered lines. In each case I shall make six slow clicks and six rapid ones. (c) "You must try to tell by the sound which number it is behind, and when I give the command ' Write,' set it down in column C. Do not try to guess. Do not look at one number and try to make it seem behind that one. Turn your head slowly from side to side, looking at each number in turn, to tell whether you are getting nearer or further away. No. 2. REPORTS. 383 (d) " Now we shall try It once just for practice." (e) The experimenter should then hide himself behind the screen, taking par ticular care not to indicate by his eye or by the direction of his disappearance where he intends to sound the snapper. He should then sound the snapper as previously described (six slow and six fast snaps) behind the line numbered 4. Raising the snapper above the screen vertically above No. 4, he should say, " I sounded that behind No. 4. Those who got it right, raise their hands. Those who made it either 3 or 5 raise their hands." According to the showing he may then say, " That was pretty good," or " That was poor. Now, try it again for practice." This time it should be sounded behind 2 and demonstrated as be fore. (/) The examiner should say: "Now we shall try it in earnest Pay strict attention, and when I give the command ' Write,' write the number where the sound seems to be in column C. 'Attention.' " Sound the snapper as before behind line 3 and give the command " Write." Then in exactly the same way behind 2, 5, 1, 3, 1, 4, 6, 1, 4. 13. Test 4- —The discrimination of familiar sounds. The examiner should say— (o) "In the last column, D, you will write the syllables that I shall pro nounce. For example, I shall cover my mouth and speak a syllable very softly." (Covers his mouth and speaks the syllable KAZ, then spells it and asks how many got it right.) (b) Then the examiner should take up his position directly in front of the cloth screen and say, " Now pay attention when I cover my mouth and write the syllable that I speak in column D when I give the command ' Write.' " Attention. (Clovers mouth and speaks softly) DON —Write. " Attention. (Covers mouth and speaks softly) EY —Write. " Attention. (Covers mouth and speaks softly) DER—Write. " Attention. (Covers mouth and speaks softly ) LY—Write. " Attention. (Covers mouth and speaks softly ) PU—Write. " Attention. (Covers mouth and whispers softly ) CNT—Write. " Attention. (Covers mouth and whispers softly) TARA —Write. " Attention. (Covers mouth and whispers softly) MAR—Write. " Attention. (Covers mouth and whispers softly ) DES—Write. " Attention. (Covers mouth and whispers softly ) SEA—Write." (c) The exact degree of force with which the syllables are spoken by the sev eral examiners is incapable of standardization, and it doesn't matter how they differ, provided each one maintains the same standard for all the groups that he examines in filling one quota. 14. After this test, candidates should be ordered to leave their papers and pencils, rise and file out. Another group should take their places and the ex amination be repeated until all the candidates are examined. 15. Grading the papers is best done by making first a complete list of answers, (a) Grading test 1.—Begin at the bottom of the list of figures. Mark each error. Inability to get tvjo or more figures of a series counts minus 10. Fail ure to get one of the numbers of a series counts minus 5. Numbers all right but with one inversion counts minus 5. If the six place numbers are right the others may be graded correct without reading. (6) Grading test 2.—An error of 1 degree in reading the scale counts correct. It may easily result from differences of position. An error of 2 to 4 degrees counts minus 5. An error of 5 or more degrees counts minus 10. (c) Grading test S.—An error of any sort counts minus 5 for each place. For example: The first source of sound was line 3. If the answer is 2 or 4, the 384 BEPORTS. Vol. XIII. answer is graded minus 5; if the answer is 1 or 5, the grade is minus 10; if the answer is 6, the grade is minus 15. It is evident that one question may count minus 25, as for example, if the place were 6 and the answer were 1. (d) Grading test 4. —If one sound is wrong the answer counts minus 5. If two sounds are wrong, the answer counts minus 10. 16. Total grades. — (o) The highest possible grade is 400. The highest grade that I have ever seen is 370. Passing grade is 300. (6) There are some exceptions to this. Thus, if a paper Is marked perfect on the first two tests and only 100 on the second two, the paper Is lacking in the most essential part. So the last two tests are regarded as unsatisfactory if they fall below 120. Again a candidate may fall down completely in reading the scale. This is a serious matter, but it may readily be learned and if the rest of the paper, especially the sound tests, are excellent the paper should be passed. But In this case the candidate should be shown the paper and passed only on the promise of learning to read the scale immediately. It should be borne in mind that the main point of the tests Is to find listeners. Any correctable errors should not invalidate a candidate. Memory span for figures does not improve with practice to any considerable degree. A candi date who makes serious errors with 5 place figures is probably not fitted for the school work. Two errors of two or more points in the location of sound Is a serious matter. Two errors of three points should disbar a candidate, even if the rest of the locations are all accurate. If other evidence shows that the candidate is an otherwise exceptionally good man, he may be given another test in the location of sound. 17. Individual examination for the listeners' school. (A) Purposes: The purposes of the individual examination are: (a) To check other sources of information concerning the personal fitness of the candi date, (b) To test the auditory discrimination of differences of intensity with the same type of apparatus that they must rely on in actual service. (It ap pears that the ability to locate the source of sound is not infrequently greater than the ability to discriminate the differences on which the location chiefly depends.) (c) To test the quickness and certainty of the reactions to differ ences of Intensity. (Slow hesitating and uncertain reactions appear to be fatal to a good listener.) (B) Apparatus consists of a stethoscope earpiece to which is attached a rubber tube about a yard In length. This should be marked at its middle point. When scratched with a quill toothpick faint sounds are produced which may be located as at the middle or toward one side or the other. (C) Procedure: (o) The candidate should be watched with care to discover any Indications that may appear of personal unfitness. (6) Seated opposite the candidate with a table between, the experimenter should say: "We are going to test your hearing with this apparatus. When you have put these ear pieces in your ears, I am going to scratch this tube with a quill. If it seems to be more in your right ear raise the fingers of the right hand ; if in the left ear raise the fingers of the left hand ; If It seems Just the same to both ears, exactly In the middle of the forehead, raise both hands. The point of the trial is to find quickly and accurately when it Is in the middle. But If It seems just a shade over one eye or the other, raise the corresponding hand, (c) Now put this earpiece in your ears, bow your head, and shut your eyes." (d) The first test should be for practice, 6 inches on one side, 6 Inches on the other, ana then In the middle. If the candidate gets them right, he should be told so. If there are errors that distance, the existence of gross differences in the two ears No. 2. REPORTS. 385 should be suspected. The reactions of the appropriate hands should be Im mediately decided. If these reactions are correct, the examiner should say: " That was good ; now we will make It a little finer." From now on, no informa tion should be given whether the answer is right, (e) Various points around the middle should now be scratched and occasionally the middle. Starting from 2 or 3 inches to one side move by half-inch stages to the other side, well beyond where It is correctly discriminated. Then back again until the ex aminer Is convinced that he can tell how wide the candidate's center is, and whether the center is displaced toward either ear. (D) Grading these performances. A perfect performance would be con sidered when no personal fault was discovered, when the reactions were im mediate and certain, when the middle exactly corresponded to the middle of the tube, and when a displacement on either side of one-half inch was uniformly accurately discriminated. Such cases exist, but they are not common, (a) Five grades are given for each of these characteristics, perfect, fair, average, poor, impossible. I represent them on the alphabetical list by symbols rather than by numerals. (6) Five points are noted: Personality, quickness or reaction, and assurance, breadth of the apparent center, displacement of the center, consistency, (c) There can be no fixed rules for grading personality. The possible varieties of criticism are too numerous. But most of the clearly bad cases should have been eliminated before the individual examination, (d) Quickness and assurance of reaction is also difficult to give rules for grading. But a little experience will enable the examiner to make a pretty accurate judgment. In practice, this quality may very properly be left to the final reviewing officer, (e) Breadth of center: Average is 1 inch, poor Is 2 inches, anything more than that is impossible. (/) The same dimensions hold for displacement of the center, (g) Consistency is determined by the number of different variations. Impossible consistency is usually a matter of pure guesswork. The Intermediate grades will be proportional parts of the total number of stimuli which lie just outside the candidates center, and those which He just Inside the center. Mixing right and left of the true centers is poor. One-third of centers called right or left and of the proximate rights and lefts called centers is average. Anything between that and perfect is good, (h) No one should pass this test with less than an average " good." Permission was given any man on the station to take the ex amination, irrespective of his education, as it was necessary to do this in order to fill our quota. I found that the same percentage of men passed with only a grammar-school education as there were men with one or more years in high-school in the first series. In the second series the high-school trained men did better. The room used for the examination was on the third floor of a concrete warehouse, where the accoustic properties were very poor, allowing a great deal of echoing. There was also considerable noise from the streets below, of mechanics working and men drill ing. This was considered, however, somewhat of a desirable feature in that it compelled the men to concentrate their minds on their work and to eliminate extraneous sounds, as they might possibly have to do on board ship in eliminating noises from machinery and the propellers of their own ship. 386 REPORTS. Vol. XIII. The procedure in test 3 was varied somewhat. Before beginning the test, the snapper was sounded in front of each number where the men could see and hear the location of the sound, and then twice behind the screen, allowing them an opportunity to tell the number and then telling the correct one. In the test of auditory discrimination of differences of intensity I believe that a method I have adopted is a little more satisfactory than that given in the instructions as a better opportunity is given to determine the candidates mental alertness, since invariably the candidates that did not grasp the instructions, failed in one or more parts of the test as well as the individual test. The candidate seated in a chair in front of the examiner was told to " Hold up the hand on the side on which you hear the noise the loudest; if it is equal in both ears, hold up both hands. Fit these in your ears." Hand him the stethescope connected to the rubber tube. " Now watch where I scratch." The center and each side, 6 inches from the center, is scratched. " Do you get the difference ? " If the candidate answers " Yes," he is then told to close his eyes and the test is proceeded with. I graded candidates on assurance and reaction in this manner. If the candidate responded quickly I credited him with excellent reac tion ; the other marks good, fair, and poor in keeping with the time in which the candidate responded. Assurance was excellent if he showed no element of doubt. If he apparently hesitated it was " good," if he showed plainly noticeable signs of doubt it was " fair," and if he changed from one to the other side in indicating the side on which the sound was louder it was considered " poor " assurance. A candidate of poor assurance and reaction usually failed in other parts of the test. The men taking this examination were those who were not able or who did not wish to qualify for the officers' class or other special training branches offered at this station. This accounts for the low number of college-trained men. Two series of 100 men each were taken. The second 100 were used as a check for the first series. By comparing the two columns it will be noticed that there was very little difference in the results ob tained. The results of the first series of 100 men are shown in the first column, the second 100 in the second column of each table. The following are the tabulated results : Soccxid scrios. Number of men examined 100 100 Number of men passed ' K H Number of men failed No. 2. 387 REPORTS. OCCUPATIONS REPRESENTED. Farmers. Mechanics.' Students. Clerks.' Laborers.' First series. Second First series. Second series. First series. Second series. First series. Second series. First series. Second series. series. Passed 4 5 1 3 8 3 15 2 6 2 8 3 23 7 26 6 30 1 Failed 11 26 Total 9 12 11 18 8 10 26 33 36 27 1 Mechanics included electricians. 2 Clerks included business men, newspaper men, and bookkeepers. ' Laborers included painters, miners, railway men (street-car men, etc.), teamsters, firemen and the like. This classification reduced to a minimum the number of profes sions and trades given as the occupation of the candidates before enlisting in the Navy. Passed. Failed. First series. Second First series. Second series. Education: series. Grammar school 8 9 2 1 37 26 11 42 57 College 2 3 4 Grammar school included up to the ninth grade, included those of one to four years' training. Results of those who passed. High school First series. Second Number of men that passed Average total grade Average age (years) A—Memory test B—Reading circular scale C—Location of sound D—Discrimination of familiar sounds. Breadth of center: No breadth of center Breadth of center J inch Breadth of center 1 inch Breadth of center 1J inches Displacement of center: No displacement of center Displacement to the right only Grouped as follows— J inch 1 inch 14 inches 18 315 21 85 97 07 09 G 6 0 4 5 4 3 1 14 317 21 84 94 08 68 4 2 2 3 388 Vol. XIII. EEPORTS. Results of those who passed—Continued. First series. Second series. Displacement of center—Continued. Displacement to the left only Grouped as follows — i inch 1 inch 1J inches Displacement to the right and left. . . Grouped as follows — £ inch to right and J inch to left.. J inch to right and 1 inch to left. 1 inch to right and J inch to left. Reaction: Excellent Good Fair Assurance: Excellent Good Fair Consistency: Excellent Good Fair 5 . 2 3 3 14 1 3 2 "i 2 12 13 1 5 13 1 13 The highest mark was 360, made by a clerk with two years' college training. His marks were as follows : A—Memory test 100 B— Reading the circular scale 100 C—Location of sound 80 D—Discrimination of familiar sounds : 80 Breadth of center None. Displacement of center * None. Reaction Excellent. Assurance Excellent. Consistency - Excellent. Results of those who failed. Number of men who failed Average total grade Average age A—Memory test B—Reading circular scale C—Location of sound D—Discrimination of familiar sounds Breadth of center: No breadth of center Breadth of center, $ inch Breadth of center, 1 inch Breadth of center, 1J inches Breadth of center, 2 inches Breadth of center, 1\ inches Breadth of center, 3 inches Breadth of center, 3J inches Breadth of center, 4 inches First Second series. series. 82 86 252 251 21 21 70 73 76 78 42 44 53 45 2S 43 15 10 11 17 3 4 15 8 0 2 1 1 1 0 1 1 No. 2. 389 REPORTS. Results of those who failed—Continued. First Second series. series. 30 31 7 12 7 8 0 2 0 2 13 13 7 8 5 2 1 1 0 1 0 1 32 30 10 15 3 1 0 2 15 6 0 2 0 2 1 0 1 1 1 0 1 1 18 13 53 01 5 10 6 2 15 12 47 58 11 13 9 3 6 17 46 48 14 11 16 10 61 72 15 10 9 3 6 2 14 12 27 17 Displacement of center: No displacement of center Displacement to the right only Grouped as follows — J inch 1 inch 1J inches Displacement to the left only Grouped as follows — Jinch 1 inch li inches 2} inches 3 inches Displacement to the right and left Grouped as follows — J inch to right and J inch to left i inch to right and 1 inch to left 1 inch to right and 1J inches to left 1 inch to right and 1 inch to left 1 inch to right and J inch to left 1 inch to right and 1* inches to left li inches to right and i inch to left li inches to right and 1J inches to left. 2 inches to right and 1J inches to left. . 2 inches to right and 2 inches to left. . . Reaction: Excellent Good Fair Poor Assurance: Excellent Good Fair Poor Consistency: Excellent Good Fair Poor Causes of failures: "C" and"D" at or below 120 Consistency poor Assurance poor Reaction poor Breadth of center 2 inches or more Failed in two or more parts CONCLUSION. I find that very few college men take this examination, because they can qualify for better ratings. It is not desirable to exclude a man from qualifying for a listener if he has only a common-school education. All but 7 candidates of the first series and 11 of the second series were able to pass the membory test and circular scale test satisfactorily. The test for the location of sound and the discrimi nation of familiar sounds was the cause of the greatest number of failures. 390 Vol. XIII. REPORTS. In the test of auditory discrimination of differences of intensity it seemed very difficult for many of the candidates to discriminate between i inch to either side of the center with the following pro cedure : Scratch the center of the tube, then 2 or 3 inches to right or left of center, then £ inch to right or left of center. This manner of testing appeared to be more difficult than scratching on the tube at i inch intervals, beginning at 2 inches to the right and passing through the center and to 2 inches to the left. Very few of the candidates knew anything about the kind of work to be done, where they were going, or their rating and pay, as prac tically the only information that has been received was from men of this station who had been to the " listeners' school " and had written to their friends here regarding it. Most of the men took the exami nation because it seemed to offer a good opportunity to be trans ferred to an eastern station and early sea duty, the ambition of practically every man on this station. I believe that it would be a greater incentive to the men if definite information could be given them regarding their status in case they pass the examination. Following is a sample of the form of examination paper used : NRF. Examination of candidates for listeners' school. Name in full Rate (Surname first.) V. 8. NAVAL RESERVE TRAINING CAMP, SAN PEDRO, CAL., TWELFTH NAVAL DI8TRICT. Date , 1918. Examination. Marking!i. A. B. C. D. A. B. C. D. Total. Grand total Final examination — Sound test: Personality Reaction Assurance Breadth of center Displacement of center Consistency Candidate{^ed} Examiner Age Occupation Education. U. S. N. No. 2. BOOK NOTICES. 391 BOOS NOTICES. The principles and practice of obstetrics, by J. B. DeLee, A. M., if. D., pro- lessor of obstetrics, Northwestern University. Third Edition. W. B. Saun ders Co., Philadelphia, Pa., 1918. This is a superb volume, thanks to the author's direct, clear style and the completeness with which the subject is handled and owing also to the excellence of the many illustrations, the good type, and other features of the bookman's craft. The procedures described are primarily those of the writer and have all the force of his authority, but the reader enjoys in addition a wide survey of the methods in vogue in Europe which are referred to with truly judicial discrimination. The many historical refer ences and the summary of the literature of the subject at the end of each chapter give to this work a scholarly finish lamentably rare in the medical press of America. Massage and the original Swedish movements, by Kurre W. Ostrom, from the Royal University of Upsala, Sweden. Eighth Edition. P. Blaklston's Son & Co., Philadelphia, Pa., 1918. A small, handy volume written for those wishing to employ this valuable therapeutic measure under the direction of physicians. The author's ethics appear to be sound, and he makes a very earnest and proper plea for the regulation, by competent authority, of mas sage in this country. Paper work of the Medical Department of the United States Army, by R. W. Webster. M. D., Ph. D., Major, Medical Corps, United States Army. P. Blaklston's Son & Co., Philadelphia, Pa., 1918. Physiology and biochemistry in modern medicine, by ■/. J. R. Macleod, M. B., assisted by Roy Q. Pearoe, B. A., M. D. C. V. Mosby Co., St Louis, 1918. The tendency of modern medicine is to place less and less emphasis on pathological anatomy and more on pathological physiology. We are, for instance, beginning to classify diseases of the heart, kidneys, and many other organs according to the studies made while the patient is still alive rather than according to the autopsy findings. Macleod has therefore written " an advanced text in physiology for those about to enter upon their clinical instruction, and at the same time a review for those of a maturer clinical experience who may de sire to seek the physiological interpretation of diseased conditions." There is a real need for a book of this sort which will emphasize the newer laboratory studies of clinical importance. "Physiology and Biochemistry in Modern Medicine" furnishes an excellent re view of a large mass of work which should be more or less familiar to every physician who pretends to keep up with his profession. Many hours can be profitably spent in skimming over the whole 392 BOOK NOTICES. Vol. XIII. book and reading carefully the more important chapters, especially those which deal with respiration. The medical man will be disappointed in finding the work con tains comparatively few clinical references. The physiologist, in turn, will consider that certain subjects are treated rather sketchily and hastily. The ordinary reader can obtain but little informa tion from the brief discussion of the clinical applications of the electrocardiograph and polygraph. The endocrine organs are treated with reticence. Apparently the authors feel that much nonsence has been written about internal secretions and hesitate to expand on the subject. This is somewhat disappointing because a critical review by such careful workers as Macleod and Pearce would be more than welcome. We must remember that the field covered by this book is vast and that only a portion can be included in 900 pages. On the whole the style is good, the type is clear and the illustrations excellent. (B. F. DuB.) Information fob the tuberculous, by F. W. Wittich, A. if., M. D., in charge, Tuberculosis Dispensary, University of Minnesota Medical School. C. V. Mosby Co., St. Louis, 1918. It is a very dangerous thing to put a medical work into a patient's hands, as he usually lacks the ability to get the proper focus on a topic which so vitally concerns him, and the medical phraseology proves a serious stumbling block. The task of preparing for the tuberculous a special volume free from technicalities and not likely to fasten the sufferer's attention unduly upon his symptoms has been very successfully accomplished by Dr. Wittich, who writes without dogmatism, simply and clearly. The volume is, however, distinctly one for the patient of intelligence, education, and means. Mental diseases, byW. T". Oulick, M. D., Assistant Superintendent, Western State Hospital, Washington. Illustrated. C. V. Mosby Co., St. Louis, 1918. The subtitle of this modest volume of 139 pages is " A Handbook Dealing with Diagnosis and Classification." The book aims to stand ardize nomenclature and classification of mental diseases and to be an outline guide to the study of this branch of medicine. It is dim- cult for the general practitioner to get his bearings in the intricate mazes of the larger and completer workes on mental disease, and for one who desires to begin the study of this subject by a prelimi nary review and to seize only the cardinal points of the principal types of mental alienation it should prove of service. The sub heading would have made a better title than the one chosen, for it is manifestly impossible to present any adequate picture of mental dis eases in a work of this size. No. 2. U. S. MEDICAL SCHOOL LABORATORIES. 393 Dietetics fob nurses, by Fairfax T. Proudfit, former Instructor in Dietetics, Lucy Brinkley Hospital and Baptist Memorial Hospital, Memphis, Tenn. The Mncmillan Co., New York, 1918. Books on this topic should be based on sound scientific principles and yet be thoroughly practical and simple in style. The present volume appears to meet these requirements fully. Section I treats of food and its selection. Section II is entitled : " The Human Ma chine and its Relation to Food." Section III discusses nutrition in disease and includes formulae for infant feeding, the regimen of the obese, etc. U. S. NAVAL MEDICAL SCHOOL LABORATORIES. Additions to the pathological collection. United States Naval Medical School, October, November, December, 1918. Acces sion No. 1552 1555 1557 1558 to 1574 1575 1576 1577 1578 1579 1580 1584 1586 1588 1590 1593 1594 1595 1599 1600 1601 1602 1604 1606 1607 1608 1609 Tissue. Ovarian cyst. . Various organs. do Appendices. Goiter Bladder (cancer).. Kidney - - Caecum and ascending colon (gangrene). Submaxillary calculus. . ....do '. Tumor Testicle Mesentery Ovary and tube Humerus Dog's breast Kidney Diagnosis. Small tumor. . . Lymph glands. Cervix Appendix Breast Lymph glands. . . Epithelial tumors. Breast Lymph glands. . . No report Malaria Tuberculosis. No report .do. .do. .do. .do. ....do ....do Mole, benign Tuberculosis ....do Subacute inflammation. Benign tumor Carcinoma Genito - urinary and nephritis. Adeno-myoma Hodgkin's disease Collected by or received from— Adeno-carcinoma . Appendicitis Carcinoma Lymphangioma. . Carcinoma Myxoma Tuberculosis Lieut. J. J. Mundell. Lieut. T. T. Gately. Capt. L. W. Spratling. Capt. R. Spear. Do. Do. Do. Do. Do. Do. Capt. J. G. Field. Lieut. T. T. Gately. Gulfport, Miss. Capt. R. Spear. Key West, Fla. Lieut. T. T. Gately. Norfolk, Va. Lieut. J. J. Mundell. Lieut. Commdr. L. M. Schmidt. Capt. C S. Butler. Capt. J. D. Gatewood. Do. Capt. C. S. Butler. Do. Paris Island, S. C. Commdr. H. F. Strine. Reports made on all cases, except those sent only for museum collection. 103396—19 15 NOTICE TO SERVICE CONTRIBUTORS. When contributions are typewritten, double spacing and wide margin are desirable. Fasteners which can not be removed without tearing the paper are an abomination. A large proportion of the articles submitted have an official form such as letterhead, numbered paragraphs, and needless spacing between paragraphs, all of which require correction before going to press. The Bulletin endeavors to follow a uniform style hi headings and captions, and the editor can be spared much time and trouble and unnecessary errors can be obviated if authors will follow in the above particulars the practice of recent issues. This is not only important in special articles, but still more so in reviews. 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 typwritten. Contributions must be received two 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 material supplied for illustrations, if not original, should be accompanied by a reference to the source and a statement as to whether or not reproduction has been authorized. Only the names of actual reviewers for a current number appear. 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 arc not to be reprinted elsewhere without an understanding to that effect. 394 o ■ vol. xm NO. 3 UNITED STATES NAVAL MEDICAL BULLETIN INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PUBLICATIONS CAPTAIN J. S. TAYLOR, MEDICAL CORPS, U. S. NAVY IN CHARGE (QUARTERLY) WASHINGTON GOVERNMENT PRINTING OFFICE 1919 PUBLISHED FOR THE 1919 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. NOTE. Owing to the exhaustion of certain numbers of the Bulletin and the frequent demands from libraries, etc., for copies to complete their flies, the return of any of the following issues will be greatly appreciated : Volume VII, No. 2, April, 1913. Volume X, No. 1, January, 1916. Volume XI, No. 1, January, 1917. Volume XI, No. 3, July, 1917. Volume XI, No. 4, October, 1917. Volume XII, No. 1, January, 1918. Volume XII, No. 3, July, 1918. Subscription Pbice of the Bulletin. Subscriptions should be sent to Superintendent of Documents, Government Printing OfBce, Washington, D. C. Yearly subscription, beginning January 1, $1; for foreign subscription add 25 cents for postage. Single numbers, domestic, 25 cents; foreign, 31 cents, which Includes foreign postage. Exchange of publications will be extended to medical and scientific organiza tions, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy, Washing ton, D. C. ii TABLE OF CONTENTS. Page. PREFACE VII SPECIAL ARTICLES : Preventive medicine at training camps and stations. By Captain C. E. Riggs, Medical Corps, U. S. N 395 With marines in France. By Lieutenant F. E. Locy, Medical Corps, U. S. N 41T Bone grafts. By Lieutenant Commander E. M. Foote, Medical Corps, U. S. N. R. F 433 Internal derangements or knee joints. By Lieutenant ( J. G.) C. F. Painter, Medical Corps, U. S. N. R. F_ 442 Clinical manifestations of tropical sprue. By Lieutenant Commander E. J. Wood, Medical Corps, U. S. N. R. F 449 Isolation and cultivation of Pfeiffeb's bacillus. By Lieutenant DeW. G. Rlchey, Medical Corps, U. S. N. R. F 453 Nervous element in aviation. By Lieutenant G. U. Pillmore, Medical Corps, U. S. N 458 Administration of the U. S. hospital ship Solace. By Commander E. E. H. Old, Medical Corps, U. S. N 478 HISTORICAL : Devices and uniforms of the Navy Medical Corps 505 EDITORIAL : The reform of funerals —The apotheosis of dungarees 515 IN MEMORIAM : Henry G. Beyer. By Lieutenant (T.) P. J. Waldner, Medical Corps, U. S. N 521 Washington Berry Grove. By Lieutenant Commander L. M. Schmidt, Medical Corps, TT. S. N_ 522 SUGGESTED DEVICES : Improvised mess tables. By Captain H. C. Curl, Medical Corps, U. S. N 1 525 Apparatus for submersion cases. By Captain G. F. Freeman, Medical Corps, U. S. N 525 Recording dental operations. By Lieutenant W. F. Murdy, Dental Corps, U. S. N 527 CLINICAL NOTES : Rupture of the esophagus. By Lieutenant Commander L. Sheldon, Medical Corps, U. S. N 529 Anthrax cured by vaccine. By Lieutenant (J. G.) J. K. Leasure, Medical Corps, U. S. N. R. F 581 Foreign body in antrum. By Lieutenant J. B. Greene, Medical Corps, U. S. N. R. F 534 m IV CONTENTS. CLINICAL NOTES—Continued. rage. Traumatic rupture of kidney. By Lieutenant Commander P. H. Bowman. Medical Corps, IT. S. N., and Lieutenant Commander H. D. Meeker, Medical Corps, U. S. N. R. F 53G Thrombosis of popliteal vein. By Lieutenant C. A. Frink, Medical Corps, U. S. N. R. F 538 Alopecia Universalis. By Captain A. R. Alfred, Medical Corps, U. S. N 539 Operations for rupture of kidney and spleen. By Lieutenant C. O. Tanner, Medical Corps, U. S. N 539 Traumatic aneurism : Five cases. By Lieutenant Commander F. H. Bowman, Medical Corps, U. S. N.. and Lieutenant Commander H. D. Meeker, Medical Corps, U. S. N. R. F 541 A DEATH FROM 8ALVARSAN. By Lieutenant E. F. Crofutt, Medical Corps, U. S. N. R. F 543 Perforation of Meckel's diverticulum. By Lieutenant W. F. Pearce, Medical Corps, U. S. N 546 Syphiloma of cererrum. By Lieutenants A. W. Hoaglund and P. F. Prioleau, Medical Corps, U. S. N 547 Extra-genital chancre. By Lieutenant Commander C. B. Camerer and Lieutenant J. R. Poppen, Medical Corps, U. S. N 551 Chancre of the thumb. By Lieutenant (J. G.) L. Herman, Medical Corps, U. S. N. R. F_. 553 Typhoid fever with severe complications. ' By Lieutenant F. N. Martin, Medical Corps, U. S. N. R. F 554 Cholangitis followino influenza. By Lieutenant R. S. Reeves, Medical Corps, U. S. N. R. F 557 Diphtheria complicating fractured mandible. By Lieutenant (J. G.) J. B. Goodall, Dental Corps, U. S. N. R. F__ 559 PROGRESS IN MEDICAL SCIENCES : General medicine. —Tests of physical efficiency —Malaria as a mili tary problem —Anthelmintics as tested on earthworms —New treat ment of bichloride poisoning —Corpeus luteum and vomiting of pregnancy 561 Surgery. —Post-operative parotitis —The empyema problem — Skin dis infection by picric acid — Reconstructive surgery of the hand and forearm 573 Pathology, bacteriology, and animal parasitology. — Bacteriology of tuberculous kidneys —Hermann-Perutz reaction — Experiments with virus of grippe 578 Eye, ear, nose, and throat.—Perineural anesthesia for surgery of maxillary sinus —Intraocular pressure and tonometry 5S2 NOTES AND COMMENTS : Transmission of venereal disease may constitute assault — Interde partmental Social Hygiene Board—Sir Charles Wyndham —Har vard surgical unit—Retail druggists and quack remedies — School of Hygiene, Johns Hopkins University — Legal decision re vaccina tion —American merchant marine —Meningococci in blood —Radium conservation —Andre Chantemesse 585 CONTENTS. V REPORTS : The U. S. hospital ship " Comfort." By Captain A. W. Dunbar, Medical Corps, U. S. N. Page. 591 Voyage of the U. S. S. " Leviathan." By Commander F. A. Asserson, Medical Corps, U. S. N 602 Ship life in Constantinople. By Lieutenant Commander E. P. Huff, Medical Corps, U. S. N 605 A record ship. By Lieutenant Commander A. E. Lee, Medical Corps, U. S. N 609 D. S. Naval Aib Station, Patjillao, France. By Lieutenant Commander H. A. Garrison, Medical Corps, U. S. N 611 U. S. Naval Air Station, Rockaway Beach, L. I. By Lieutenant ( J. G. ) A. A. Shadday, Medical Corps, U. S. N. R. F__ 616 Increase of weight under service conditions. By Lieutenant H. Halstead and Lieutenant (J. G.) E. A. Mallon, Medical Corps, U. S. N. R. F 620 Poisoning by trinitrotoluol. By Lieutenant (J. G.) A. Saska, Medical Corps, U. S. N. R. F 624 The marine shoe. By Lieutenant Commander W. L. Mann, Medical Corps, U. S. N__ 625 X-RAY WORK AT A NAVAL HOSPITAL. By Lieutenant C. H. Jennings, Medical Corps, U. S. N. R. F 628 Dental work at the navy yard, New York. By Lieutenant Commander R. Barber, Dental Corps, U. S. N 631 Dental work at the navy yard, Mare Island, Cal. By Lieutenant Commander J. L. Brown, Dental Corps, U. S. N 632 BOOK NOTICES 633 NOTICE TO SERVICE CONTRIBUTORS 635 PREFACE. The publication and issue of a quarterly bulletin by the Bureau of Medicine and Surgery contemplates the timely distribution of such information as is deemed of value to the personnel of the Medical Department of the Navy in the performance of their duties, with the ultimate object that they may continue to advance in proficiency in respect to all of their responsibilities. It is proposed that the Naval Medical Bulletin shall embody matters relating to hygiene, tropical and preventive medicine, pa thology, laboratory suggestions, chemistry and pharmacy, advanced therapeutics, surgery, dentistry, medical department organization for battle, and all other matters of more or less professional interest and importance under the conditions peculiar to the service and pertain ing to the physical welfare of the naval personnel. It is believed that the corps as a whole should profit, to the good of the service, out of the experience and observations of the individual. There are many excellent special reports and notes beyond the scope of my annual report being sent in from stations and ships, and by communicating the information they contain (either in their entirety or in part as extracts) throughout the service, not only will they be employed to some purpose as merited but all medical officers will thus be brought into closer professional intercourse and be offered a means to keep abreast of the times. Beviews of advances in medical sciences of special professional interest to the service, as published in foreign and home journals, will be given particular attention. While certain medical officers will regularly contribute to this work, it is urged that all others coop erate by submitting such abstracts from the literature as they may at any time deem appropriate. Information received from all sources will be used, and the bureau extends an invitation to all officers to prepare and forward, with a view to publication, contributions on subjects relating to the profes sion in any of its allied branches. But it is to be understood that the bureau does not necessarily undertake to indorse all views and opinions expressed in these pages. W. C. Braisted, Surgeon General United States Nwy. vn • U. S. NAVAL MEDICAL BULLETIN Vol. XIII. July, 1919. No. 3. SPECIAL ARTICLES. PREVENTIVE MEDICINE AT TRAINING CAMPS AND STATIONS. UNUSUAL OPPORTUNITIES IN THE MILITARY SERVICES FOR THE STUDY OF EPIDEMICS: OUTLINE OF A WORKING PLAN. By C. E. Rioos, Captain, Medical Corps, United States Navy. About two and a half centuries ago Sir Thomas Browne wrote, "Physic is either curative or preventive." This classification of medical knowledge and activities is scarcely made nowadays, and yet it conveniently meets modern needs. It was made a century and a half before Jenner's discovery which marks the beginning of pre ventive medicine, and, of course, centuries after the establishment of the curative branch of medical science. Browne was both a physi cian and a philosopher. He spent much time serenely absorbed in metaphysical speculation on the mysteries of life. It is therefore fitting and to be expected that his division of the medical sciences should be both comprehensive and fundamental and likely to suffice for all time. It is the preventive branch of medicine rather than the curative one that appeals to military interests and actually marks military efficiency. It is no longer proper for the military physician to with hold his activities till disease or injury has reached the threshold of a disabling manifestation. His highest military duties require that he use the special knowledge he has obtained in the study and treatment of past incapacitating disorders to the prevention of their recurrence ; that he surround the soldier with the protection of mod ern sanitary science so that through good health the soldier can con tinue to enjoy his maximum efficiency as a fighting machine. The glamour of surgery has been cast over the duties of the physician in war time; but, as a matter of fact, the work of a surgeon usually begins only after the duty of the soldier is done and he is out of the fight and consequently a military burden. On the other hand, preventive medicine belongs with the healthy, active soldier or sailor. The association begins at the recruiting 395 396 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. office by selecting for the service only those who may be expected to stand the test of military hardships. It continues and is especially watchful during the period of training. This surveillance follows even to the front-line trenches. Besides present military efficiency, a further object is to return the discharged soldier to his home a healthier and stronger man than he was when he enlisted, and also a more valuable citizen to the community. Of course, any means to this desirable end should be encouraged. In the prevention of ill health and in the promotion of good health the military surgeons should use the knowledge they now have —all of it. Furthermore, the excellent opportunities for investigation and research along preventive lines which a military organization affords should be utilized to the fullest possible extent. When the funda mental causes as they relate to disease and injury are better under stood in their relation to known results the fatalism which is now associated with accidents and epidemic visitations will be largely eradicated. " Even accidents, viewed largely, are not isolated causes, but the outcome of events which we can understand and control." 1 Preventive medicine is so new a study that its existence and mean* ing are still unknown to many informed persons. Human psychol ogy has seemed to prefer for our ills curative and remedial agencies rather than prevention. As an act of public caution quarantine is more familiar than medical inspections, and appeals for the support of hospitals and sanitaria are still more urgent and general than demands for the spread of knowledge of the rudiments of sanitation. It has not yet been properly understood that the manifestation of disease is a last call, not a first call, to action.2 A new viewpoint should be acquired. It is preferable to recognize that disease is a terminal condition which has been brought about by the occurrence of one or, perhaps, a considerable number of preced ing events. These events, in most instances, lie within the very recent past and a proper analysis of them, if it were possible to make it, would demonstrate the actual incident by means of which they were brought about. It is safe to assume that a specific knowledge of the usual mechanism of a particular infection would be followed by the solution of the problem of avoiding it. Unfortunately, with most persons the happenings of the predisease period are marked with considerable complexity. Many difficulties are encountered in attempting to ascertain from the infected person the source and mode of his infection. Memories are particularly short for the smaller incidents of everyday life and events are crowded. Also, the amount of variability in the period of incubation of a dis ease gives just that same degree of latitude as to the time of infection. i Cooley : Social Progress. New York, 1918. p. 165. ' King : Industry and Humanity. Boston and New York, 1918. p. 356. No. 3. 397 PREVENTIVE MEDICINE AT TRAINING CAMPS. It is rare that circumstances are such that the time and method of infection may be actually demonstrated. But when these instances do occur they should be carefully recorded, as they are likely to throw useful light upon practical means for avoiding the disease. The newer science of preventive medicine is more dependent upon the causes of disease than is the curative one. It requires a study of that period of time prior to the oiiset of disease and of sufficient remoteness to include the causal incidents. In making this study medical science has found itself in some new and unexpected relation ships with other branches of science. For instance, former Surgeon General Gorgas has pointed out that low or high wages have an im portant bearing upon the health of a community; that a poor eco nomic situation is reflected in a low state of public health. Also epidemiology is intimately associated with sociology. Practically all germ diseases come under the head of " social diseases," as they are disseminated through physical or social contact of men with each other, and hence spread most widely and rapidly where social rela tionships are closest.1 This broadening of the scope of preventive medicine by the neces sary inclusion of parts of other interdependent sciences tends to com plicate its study. The cause of the spread of an epidemic is often so completely hidden in a complexity of economic, sociologic and other related factors that it is impossible to unravel. Opportunities for the observation of an unobscured phase of an epidemic are rare. Where they have occurred they have generally added to our knowledge of the epidemiology of the disease. For instance, the first introduc tion of measles among the inhabitants of the Faroe Islands was so helpful in determining the period of incubation of this disease that the incident now has historical importance. Simplicity of situation, in particular as manifested by uniformity of the activities of indi viduals composing a community, is a very desirable condition when carrying out research work in the cause and prevention of disease. The military services excel in this respect as compared to civil com munities, and, therefore, offer practically unequaled opportunities for students of preventive medicine. When a group of men is assembled under military control, such as that existing at a training camp, for instance, they present a greater uniformity of physical and social conditions than can be obtained in any other community. The reason for the presence of this uniformity is, of course, the singleness of purpose of a military organization. The different ways in which its results are manifested in the behavior of the individual are so numerous as to be almost incalculable. Such factors pertaining to social conditions as age, sex, and occupation may 1 Fatrchlld : Applied Sociology. New York, ]916. p. 245. 398 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. for practical purposes be considered as reduced to single components. There is uniformity of housing, food, drink, clothing, exercise, work, and play. Also, there are for all the same environment, discipline, routine, and drills which have a strong tendency to mold to a likeness all activities of the individuals who compose ths organization. Another feature of military camps is the marked concentration of individuals that it is necessary to have in order to satisfy military requirements. This concentration is so great that it frequently amounts to five times that obtaining in the worst civilian rookery.1 This increased density of population naturally increases the intensity of human intercourse. Therefore, a military camp exhibits not only an intensity of physical and social relationships on the part of the individuals therein, but also those relationships are fixed and unvary ing as compared to those met with in civil communities. These comparatively fixed physical and social conditions of a mili tary organization can be utilized to great advantage for the study of the methods of transmission of the acute infectious diseases. Given the presence of an epidemic disease its further transmissibility is prob ably more dependent upon the social comminglings of its locality than upon all other attributes that may be present. In fact, modern prac tice for the control of infectious disease consists not in the physical surveillance of whole communities, but in the sociological study of infected persons in them.2 In other words, an epidemiological study in any community is fundamentally mingled with the applied sociol ogy of that community. A study of the means of spreading of a germ disease in any location requires a considerable acquaintance with the sociological conditions with which the disease is coexistent. This modern conception of epidemiology has been made possible only by means of the knowledge obtained through the new and wonderful science of bacteriology. It is only a few years since this science was little more than a " germ theory of disease." Yet nowadays one does not stop to think that bacteria have an essential influence upon all forms of living matter and that life upon our earth is actually dependent upon the continued activities of these tiniest living things. It is not to be wondered at that the science of bacteriology has been the great reconstructing force in pre ventive medicine. Credit for the correct application of bacteriology to the problems of infection is largely due to Chapin and to others who sat at the feet of Chapin. His " Sources and Modes of Infection ' marks the real beginning of scientific public health in America. The great value of Chapin's work to public health consisted in the new methods which he applied to the study of the means of trans mission of the communicable diseases. These methods, through keen 1 Lelean : Sanitation in War. London, 1917. p. 96. • Hill : The New Public Health. New York, 1916. p. 77. No. 3. 399 PREVENTIVE MEDICINE AT TRAINING CAMPS. analysis, gave new and admittedly correct values to many of the different factors that promote or retard the processes of infection. As a result several theories that were based largely upon the germ theory of disease in its early stages had to be abandoned. For instance, the air-borne theory, which seems to have been a combi nation of bacteriology and demonology, was no longer applicable in explaining epidemics. The supposed efficacy of terminal fumiga tions did not stand the test of critical analysis. When these and other theories of infective processes were no longer workable it be came necessary to find substitutes. The epidemiologist assumed this task and he has already made considerable progress. He has found that the field is broader than it was in the early bacterial days. He is endeavoring to answer the question as to when, where, from what source and by what means did the recently infected individual receive the germs causing his disease. The reward sought is great, for it seems safe to assume that when these processes are understood the menace of acute infections will be practically destroyed. The path of the progress of science is paved with abandoned theories. These theories were for the most part abandoned because in the light of present knowledge they are absurd; some on account of newly discovered facts, no longer serve even the purpose of theories.1 A theory has been defined as an explanation founded upon inference drawn from principles which are established by evi dence. This definition of theory gives emphasis to* the first impor tance of evidence. In epidemiology, opportunities for collecting evi dence are to be found only in field work. If anything of value is to bo discovered it is to be expected that it must be done by those whose duties are in the midst of epidemic devastations. They, so to speak, are on the firing line, or to use a more up-to-date term, in the trenches. Particularly advantageously placed are those who are engaged at training camps among the well and the sick before hospitalization takes place. This constitutes the zone where infective processes are actually operating before one's eyes. In such places the collecting of data should be most rigid. Any medical officer who has had the golden opportunity of watching the course of one of the infectious diseases at a training camp and, in the end, has nothing new to add to the knowledge of preventive measures can well afford to " count that day lost," for the sun has set upon his opportunity. The achieve ments made by Lynch and Gumming,2 and Rossiter, during the recent influenza epidemic, in attempting to solve the problem of the trans mission of infection as they found it in their respective units, strik ingly demonstrate the assistance afforded by the definiteness and ]I>ay: Man's Unconscious Conflict, p. 51. •Lynch and Cummlng: The Role of the Hand in the Distribution of the Influenza Virus, etc. Military SurKeon, December, 1918. 400 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. simplicity of a military organization for the carrying out of re search work in preventative medicine. It goes without saying that every military organization should have some relatively definite plan to study and to control the progress of any epidemic disease that may appear among its personnel. Such a plan for the acute infectious diseases may be conveniently viewed in two general aspects —the sociological and the bacteriological. The sociological side will depend largely upon local conditions as they exist in the military organization and have lo do with the social relationships of men with each other. Here local conditions vary considerably and are created by the purpose and function of the group of men under consideration. A receiving ship, on account of its continuously changing personnel and comparatively unfixed or ganization, offers almost the same difficulties in tracing a source of infection as are met with in civil communities. On the other hand, ideal conditions are to be found among a group of men in a permanent camp or barracks having a fixed organization and few changes in personnel. Whatever the organization and its purpose may be, it is incumbent upon the medical officer to be conversant with it, so that he may intelligently act immediately upon the incipiency of an epidemic. The classification of the bacterial aspect of an epidemic situation is based largely upon the available knowledge concerning the known germs of infection. Unfortunately, the bacteriology of the seven prominent camp diseases—measles, mumps, influenza, tonsillitis, diph theria, scarlet fever, and cerebro-spinal fever— is not fully understood. For measles, mumps, and scarlet fever it is practically nil, and for the four other diseases it has a wide range of completeness. On account of this lack of knowledge any plan for opposing the bacterial forces of disease during an epidemic can not be marked by a high degree of definiteness. But some plan or classification is desirable, even though it have no further merit than to state the order of the oc curring of events. The plan to be submitted here attempts to take up the bacteria at their original source and to follow them through out till their final destruction by disinfection. It may be roughly classified as follows: I. Location of the germs before Infection takes place. 1. Aside from the human host. (a) Fomites borne Infection. (6) Air-borne infection. (c) Food and drink borne infection. (d) Insect-borne Infection. 2. Within the human host. (a) Recognized cases. (6) Missed cases. (c) Carriers. (d) Latency. No. 3. PREVENTIVE MEDICINE AT TRAINING CAMPS. 401 II. Method of transmission of germs. 1. Direct contact. 2. Indirect contact. III. Germs subsequent to time of infection. 1. Period of incubation. 2. Earliest symptoms. IV. Methods for control of epidemics. 1. Isolation. 2. Disinfection. The theory of infection by fomites such as toys, books, or clothing was practically demolished upon the appearance of Chapin's classical work in 1910. It is singular that only a few years past yellow fever furnished what seemed to be the strongest support for the fomites theory in the transmission of disease. Now newly discovered evi dence has shown that fomites will not transmit this infection, and the actual method of transmission by means of the mosquito has been established beyond cavil. The fomites theory was no longer tenable when it became understood that bacteria aside from their normal host are extremely short lived. In other words, the real danger con sists in contact with persons, not things. The theory, however, can still serve a useful purpose in the warning that frequently associa tion has been mistaken for causation. The air-borne theory of infection has been discarded even more remotely than the fomites theory. It is an interesting fact that from time immemorial, the air as a causative agent has appealed to the imagination of those who have attempted to explain natural phe nomena. The air served primitive man as an instrumentality for the greater number of his few beliefs. With the exhalation of his last breath his soul was thought to depart from him.1 His demons were resident in storms, solitary chasms and other uncanny places. The evil spirits supposed to cause sickness and other ills were of various kinds, and each class appears to have had its special function. Some clearly represented shades of the departed, who return to earth to plague the living; others are personifications of disease.2 It is not to be wondered at that in the beginning scientific men accepted the air to explain the contagion they only imperfectly understood. There is more cause for amazement in the fact that the superstitious be liefs of primtive man should so closely conform to the findings of modern science. Indeed, primitive demonology has been repeatedly associated with modern bacteriology by the ethnologist as a parallel etiological concept.8 Nowadays the former belief that the air was the habitation of agents which had the power to injure man's physi cal welfare forms a fascinating study, if not a practical one. 1 Wundt : Elements of Folk Psychology. New York, 1916. p. 192. * Jaatrow, quoted In The Scientific Monthly. Vol. 4, No. 6. p. 505. • Wright : " Demonology and bacteriology in medicine." The Scientific Monthly. Vol. 4, No. 6. p. 494. ■ 402 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. Food and drink are now considered less important factors as car riers of infections than formerly. At the time of the beginnings of bacteriology there were a few striking demonstrations of the spread of disease through the medium of drinking water. Among such instances were the Broad Street well in London, which became in fected and caused the dissemination of cholera, and the North Boston well, which was instrumental in spreading typhoid fever. These and other spectacular instances led to unwarranted generalizations giv ing undue importance to drinking water in the spread of disease. Of course, good food is of great importance in maintaining the health and contentment of a command. But food and drink are spoken of here only as carriers of infection. Naturally any medical officer of experience is able to recall several occasions when food or drink has caused outbreaks of sickness. Since the time when typhoid fever was stricken from the list of military diseases these outbreaks are important only for the moment and immediately disappear with the removal of the cause. Recently, at a training station there was a severe outbreak of so-called ptomaine poisoning involving several hundred men, or more than a third of the command. By question ing the sick and the well as to whether they did or did not eat of the different dishes of the menu it was easily demonstrated that the ice cream was the contaminated article of food. This was confirmed when the ice-cream factory was inspected and found to be very in sanitary. Another instance of an acute outbreak which might have been considered as caused by food or drink was witnessed on board ship. This was the complete subsidence in a tropical climate of an epidemic of about 40 cases of tonsillitis, which subsidence was coinci dent with the thorough cleansing of the ship's scuttle butts and fre quent sterilization by boiling of their drinking-fountain cups. If this were not a mere coincidence, it is likely that the epidemic was kept alivo by contaminated drinking-fountain cups. In such case it should be considered as an instance of indirect contact infection and not as caused by food or drink. The point to be made of these in stances is that in the military services food and drink infections form a factor of relatively little importance. Insects may transmit disease as biological carriers or they may do so by acting in a merely mechanical manner. Malaria, yellow fever, typhus, and plague are instances of insect-borne diseases of which it is generally believed the insect acts as a true biological carrier. The role of the house fly in the spread of typhoid fever is an instance of the mechanical transmission of germs. That insects could transmit infections has been known to science for only a comparatively brief period of time. Yet a record was recently made of 226 organisms of disease that could be transmitted by insects to man or animals. Two hundred and eighty-two species of insects were recorded as capable of disseminating the 226 infections. Notwithstanding the great de No. 3. 403 PREVENTIVE MEDICINE AT TRAINING CAMPS. velopment of the subject, Dr. Howard declares that there is a dan gerous tendency to exaggerate the importance of insect transmission as compared to other modes of infection. In the military services, aside from special circumstances such as duty in the Tropics, for instance, the number of infections caused by insects is insignificant. The recognized or known cases of an epidemic form that part which is directly visible and tangible. They are practically the only means that define the epidemic in size, location, and progress. It is estimated that recognized cases form not more than half the total sources of infection.1 The percentage varies, of course, for different diseases and probably for different epidemics of the same disease. For instance, the percentage of known cases is relatively high in an epidemic of measles ; at the other extreme, it is so low in cerebro-spinal fever as to present the curious anomaly in which a contagious disease appears to be contracted from the well instead of the sick. Other things being equal, it is naturally easier to deal with an epidemic if the percentage of recognized cases is high, or, in other words, if a greater number of the sources of infection is known. Known cases are the basic points in epidemiology and every endeavor should be made to ferret ouj; and convert unknown into known cases. Also, an accurate statistical record of the epidemiological data of each case, and of the doubtful cases as well, should be made upon prepared forms. As this information is being compiled it should be carefully studied not only for the immediate needs in controlling the epidemic, but to "throw invaluable light upon the problems of preventive medicine and guide us in our preparation for the next great conflict." 2 Lelean recommends an elaborate blank form for the purpose of collecting epidemiological data from those who have just been stricken with an infection. This form asks for information upon more than 40 items. If so extensive a blank form is used it re quires considerable training to properly fill it out. At our training stations it is more satisfactory to use a simpler form that can be placed in the hands of a hospital corpsman for execution. A form that was recently satisfactorily used at one of our training stations asked for information concerning each epidemic disease that ap peared, as follows: Name - Rate Date Diagnosis Camp Street Bungalow No Company School section Date taken sick Date isolated Date of appearance of rash Source of infection Names of exposed 1 Hill : The New Public Health. New York, 1916. p. 93. * Lelean : Sanitation In war. London, 1917. p. 106. 116025—19 2 404 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. This blank form, when completed, is immediately sent to the office for examination. At the office the name of the infected individual is given a number and written in its proper place upon the " epidemic sheet." This sheet summarizes the epidemic, the cases appearing in numerical order in accordance with the date of onset of a previously determined important symptom. For instance, if the epidemic be measles, the time of appearance of the rash would give the case its place in the progress of the epidemic. Also, in practice, the prepara tion of these forms indirectly serves a further important object— that is, to educate the personnel in proper epidemiological principles. It is interesting to observe how quickly those who are engaged in collecting this epidemiological data grasp the new and real signifi cance of what is meant by " catching " a disease. " Pin maps " of epidemics are sometimes made and kept up by insertion upon a diagram of the locality, a pin representing the loca tion and giving the date of appearance of each case. These maps are of no real value and may even do harm, because they tend to en courage the false idea that mere physical propinquity is responsible for infection. However, any diagram which shows the proper social relationships of the cases to each other, if it be a messing plan or a seating arrangement, is of real value. By "missed cases" is meant those infectious diseases which are a part of an epidemic but for some reason fail to become recognized. Failure to recognize these cases is due, as a rule, to the mildness of the disease. No doubt a majority of these slightly indisposed indi viduals never apply for treatment, or to be excused from duty. Their infectivity is probably equal to that of recognized cases and, being ambulant, their opportunities for disseminating infection are greatly superior. Also, atypical cases may fail of diagnosis and never be identified as a part of the epidemic. There is also a small class of persons who do not seem to know when they are ill. They are likely to apologetically present themselves for treatment or a " a little rest," when it will be found that the infection has almost completed a course of disease. Such persons have done, probably, as much harm in disseminating infection as is possible, because, contrary to former beliefs with acute infections, the early part of the disease is the period of greatest infectivity. The percentage of unrecognized cases in an epidemic varies for different diseases and also, probably, for different epidemics of the same disease. Scarlet fever is kept alive largely through mild and unrecognized cases.1 Missed cases are a prolific source of spreading infection and they are an important factor in preventive medicine. A " carrier " may be defined as a person who harbors and dissemi nates the normal germs of a disease without manifesting signs of 1 Rosenau : Preventive Medicine ami Hygiene. New York anil London, 1918. p. 179. No. 3. 405 PREVENTIVE MEDICIKE AT TRAINING CAMPS. illness from that disease. Carriers may be temporary or chronic, and their germs probably possess normal infectivity. The proportion that the number of carriers during an epidemic bears to the number of recognized cases in the epidemic varies greatly, depending largely upon the disease causing the epidemic. In measles and smallpox there are probably few carriers. There are many in cerebro-spinal fever and diphtheria. The diphtheria bacillus is carried by about 1 per cent of healthy school children.1 The carrying phenomenon is probably closely allied to the phe nomenon of latency. Also, in certain instances, at least, there is some relationship between the carrying period and the period of incuba tion of the disease. Individuals may act as carriers before they have experienced the disease of that particular germ, or the disease may terminate as a carrier instead of by normal convalescence. Theoretically, the ability to become a carrier would appear to depend upon the presence of a proper balance between the virulence of the bacteria and the degree of normal immunity present in the individual. If the immunity is comparatively high, the bacteria are immediately thrown off upon entrance. If the immunity is com paratively low, disease follows, resulting, generally, in establishing a high degree of immunity which usually throws off the germs before the disease has even run its full course. But there might be a certain balancing of forces on account of which the germs could neither incubate into a disease nor could they be thrown off, and in this manner a carrier might be formed. Of course, this is only theory, but it is difficult to abstain from speculation when dealing with a problem so practical and yet so abstruse. Without doubt, the per sistent, nonmanifesting carrier, when present, is the most dangerous of the four circumstances in which the germs of disease may exist within the human host. The military services offer excellent condi tions for work in the detection and elimination of carriers, and much work in these services has already been done along these lines. While the phenomenon of carrying is pretty well understood, yet in practice the solution of the problem of detecting and disposing of carriers does not seem to have reached satisfactory results. Latency is the least understood of the four classified circumstances under which the bacteria of disease may inhabit the human host. The phenomenon of latency has not yet assumed practical importance in epidemiological work. Latency is said to be quite general,2 and to be closely allied to the carrying phenomenon.8 In medical litera ture most germ diseases are spoken of as at times existing in a latent condition. Latent tuberculosis, tetanus, and malaria are among the 1 Rosenau : Preventive Medicine and Hygiene. New York and London, 1918. p. 163. * Chapln : Sources and Modes of Infection. Boston, 1912. p. 122. * Rosenau : Preventive Medicine and Hygiene. New York and London, 1918. p. 403. 406 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIIL most typical instances. Latent tuberculosis is of little practical importance to the health officer, as it is not a source of danger to others. On the other hand, persons having latent malaria are to a certain extent typical carriers and should be actively treated from a standpoint of malarial prophylaxis.1 It is conceivable that under a considerable number of circumstances it is impossible to distinguish between the phenomenon of latency and the carrying phenomenon. Even though the two phenomena may be related there are practical circumstances under which one has no hesitancy in deciding that the person is a carrier, or that he has harbored the germs of disease in a latent state. For instance, one enjoying good health and from whose throat the bacillus of diphtheria could be persistently cultured would be considered a typical carrier of the germs. On the other hand, when a previously healthy individual manifests a disease provoca tively induced (as an attack of malarial fever following a change of climate) it seems eminently proper to consider these germs as having been thus aroused from a state of latency instead of exhibiting a diversion from the carrying phenomenon. The theory of contact infection presumes a certain physical rela tionship by means of which the bacteria of disease are transmitted from the sick to the well. If the healthy individual does not possess sufficient immunity to throw off the disease the contamination may result in establishing one of the four conditions just described —a recognized case, a missed case, a carrier, or, perhaps, latency. As repeatedly stated, this physical relationship is something very different from mere physical propinquity. A susceptible person may be in the closest proximity to the sick and not catch the dis ease. On the other hand, a person may become infected in the ab sence of proximity to the source of infection; for instance, by the method of indirect contact. The causal relation between the re cently infected and a source of infection has long been recognized as expressed by the popular term " catching " a disease. The causal mechanism has not been known and the theory of contact infection is a step in the direction of explaining this mechanism. The fact that a mechanism is required to bring about an infection implies that there are hindrances to overcome in the processes of infecting an individual. If the human economy had made no pro vision to protect itself against attacks of ubiquitous bacteria it would furnish a startling exception in evolutionary processes and probably there would be no humanity to protect. As a matter of fact, every normal person is provided with ample barriers against in fection. There are two such barriers, one anatomical and one physio logical. The skin forms an effective anatomical barrier. It is so efficient in this respect that probably no germs of disease have the 1 Stltt : Diagnosis and Treatment of Tropical Diseases. Philadelphia, 1919. p. 84. No. 3. 407 PREVENTIVE MEDICINE AT TRAINING CAMPS. power to penetrate the unbroken skin. The other and physiologically protective process exists in the immunizing properties of the fluid and organized elements of the blood. As a result, then, of ages of evolution nature has built up for man two protective systems—one anatomical, general, and passive; the other physiological, specific, and active. Without doubt hundreds of exposures to infection occur which fail to break through these natural barriers. When bacteria succeed in surmounting these barriers and causing disease, the oc currence should be classified according to the latest views, as an accident in which man has flown in the face of nature and not merely as an incident. It is very exceptional that the mechanisms of a particular invasion and infection are fully known. Many difficulties are encountered in attempting to trace the progress of bacteria from the time they leave one host till they reach the seat of their pathological activities in the next host. Bacteria have little motility and no power of trans porting themselves, so their part in reaching the new host is purely passive. After the bacteria have been brought into contact with the person about to be infected there is a certain period of time consumed by them in reaching the particular lodgment within the body where they produce disease. During this period of time the germs of dis ease exhibit considerable individuality. Ordinarily the blood is considered the battle ground of infectious processes. But the blood is not the ultimate destination of all disease-producing bacteria. For instance, the typhoid bacillus reaches the blood early, but leaves in about two weeks to carry on its pathological processes from other seats. Also the germs of cholera and diphtheria probably never reach the physiological interior of the body in a considerable quan tity. They seem to do harm by opening ways in mucous membranes and sending forth toxins which attack vital centers. With rabies it seems that the microorganisms themselves select the nervous sys tem. In the case of a disease like acute anterior poliomyelitis, where our knowledge of the microorganism which causes the disease is yet in its infancy, it is impossible to decide whether the injuries noted in the motor areas of the cord and medulla are due to toxins or to the lodgment of the germs themselves.1 Not only do the different bacteria of disease have particular locali ties within the human body, where they carry out their infectious processes, but also certain bacteria, in order to produce disease, require to be introduced through certain portals of -entry. Some germs, as those of typhoid fever &nd cholera, for instance, have a preference for admission by way of the digestive tract, and yet others are not infectious if introduced through this path. Also, there is a 1 Zinsser : Infection and Resistance. New York, 1918. p. 40. 408 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. minimum as to quantity and virulence below which infection can not be successful. In the progress of germs from the abandoned host to the seat of their infective activities in the susceptible indi vidual it is difficult to say at what point infection may be considered as having established itself beyond the possibility of prevention. It would seem that for practical epidemiological work the susceptible person may be considered as infected when a quantity of contagion above the minimum requirement has been introduced into the body by the normal path. This statement does not take into consideration the fact that even when the bacteria have gone this far they still have to overcome the immunological processes of the blood and tissue cells, which may throw them off and there may be no resulting disease. Without doubt, this " second line of defense " (Zinsser) throws back more infections than it permits to pass. The bacteria of disease, then, must overcome two important natural barriers before they can thrive within the body as infective processes. As a means of defense the first barrier, the skin, in two respects may be likened to a military wall. That is, entrance must be made either through a break in continuity or through one of its normal portals. There is no such thing as scaling this wall. It is assumed that in the great majority of instances the route of infection hag been through one of the natural openings, as the eyes, nose, or mouth. Even after the germs of infection have passed through the first line of defense there is a general belief that they still can be directly destroyed by the use of artificial means. For this purpose pre sumably infected wounds of the skin are hurriedly cauterized; in the presence of communicable diseases, antiseptic solutions are used in the mouth and throat; and, for the other apertures of the skin, instillations of the silver salt solutions are used almost exclusively as prophylactic agents and often with fortunate results. In the vast majority of communicable diseases the route of infec tion lies by way of the eyes, nose, or mouth. Past ideas as to the rela tive importance of these portals of entry have varied considerably, depending upon the then prevailing conception of the mechanism of invasion of the germs of disease. While the air-borne theory was in ascendancy it was naturally assumed that the poisons were taken in in the inspired air. This idea was followed by an unwarranted prominence of the food and drink borne theory of infection. At present the droplet theory of infection is accepted for that large group of so-called respiratory diseases, and also many other diseases are evidently transmitted by this method. This theory draws par ticular attention to the exposed conjuctivae as avenues of infection. It is surprising that the eyes remained for so long a time practi cally unnoticed as avenues of infection, notwithstanding the fact that there were numerous recorded instances in which accidental contami No. 3. PREVENTIVE MEDICINE AT TRAINING CAMPS. 409 nation of the conjunctiva by certain germs had resulted in producing the disease. Also, the character of these diseases has been quite varied. For instance, Dodge reports the case of a laboratory worker who got some of a culture of the dysentery bacillus in his eye ; the tears ran profusely and were swallowed, and in 24 hours an attack of dysentery developed.1 Also, the accidental instillation of a drop of a fluid culture of the infective agent of poliomyelitis into the eye caused an abortive attack of the disease in an experimenter.2 In the case of hydrophobia it is related that in Paris a young man con tracted hydrophobia by rubbing his eyes with a finger contaminated with the salvia of a rabid dog.8 Also, plague and glanders may be transmitted by simple instillation of infectious material into the uninjured conjunctival sac.4 In view of the wide dissimilarity of these five diseases, it seems reasonable to infer that when the germs of most diseases have reached the conjuctiva the external part of the mechanism of infection may be considered as having been accom plished. The use of face masks during the recent influenza epidemic has drawn popular attention to the droplet theory of the transmission of infection. The availability of an innocuous, easily identified bac terium like the B. prodigiosiis has permitted the performing of non- hazarding experiments to demonstrate the mechanism of the phenom enon of droplet infection. Investigators have used this harmless microorganism to parallel experimentally various conceptions of the droplet theory. They have measured the distance that bacteria may be carried by unhampered droplets under various conditions as to talking and coughing, and also counted the number of infected droplets thus deposited upon a definite area at each ensuing foot of distance from the mouth. Also, the same has been done for droplets obstructed by gauze face masks having different layers of material and different mesh. In fact, it seems that the mechanism of the propulsion of droplets has been determined with almost mathematical accuracy. Having determined that infected droplets are projected for a number of feet into the surrounding atmosphere, it seems safe to assume that their portal of entry into the body of the susceptible individual is through the eyes, nose, or mouth. Maxcy5 has at tempted to measure the exposed areas of these portals. He estimates that when the eyes are open and the lips separated in talking the exposed areas of the eyes, mouth, and nose amount to 600, 500, and •Chapin: Sources and Modes of Infection. Boston, 1912. p. 183. 'Greeley: Boston Med. Rnd Sur>!. Jour. jSpril 12, 1917. •Zinsser: Infection and Resistance. New York and London, 1918. p. 13. • Ibid, p. 13. • Maxcy : " The transmission of Infection through the eye." Jour. Am. Med. Assn., Vol. 72, No. 9. 410 PREVENTIVE MEDICINE AT TRAINING CAMPS. VoLXIIL 200 square millimeters, respectively. But taking into consideration the hindering influence of outward currents of air and the time dur ing which the lips are closed, he expresses their relative, practical importance as eyes 6, and nose and mouth 1 each. In other words, a perfect face mask covering the nose and mouth alone would be only 25 per cent efficient as a protection against infected persons talking into the face of a susceptible one. Face masks have a twofold function in preventing the transmission of droplet-borne diseases. In the first place, they provide the healthy wearer with a certain degree of protection. Again, when worn by recognized cases, missed cases or carriers, they prevent to a great extent the projection of infected droplets into the faces of well but susceptible individuals. When worn by the infected they pre vent the indiscriminate distribution of germs and thereby lessen opportunities for infection by indirect contact. When infected droplets are projected directly from the sick to the well by talking, coughing, laughing, sneezing, or sobbing, it is consid ered as a form of direct contact infection. Indirect contact infection means that some object has been interposed to assist in conveying the germs on their passage to the new host. Formerly, many innocent articles, as toys, books, and letters, presumably acted in this capacity. This belief is no longer held, as it is now known that in general the lives of disease germs aside from their normal host is exceedingly short, and that to keep them alive under such artificial conditions often taxes the great skill of the bacteriologist. It can safely be assumed that the bacteria of disease having es caped from one host must be transferred quickly to a new one in order to maintain their viability. In general, their portal of entry for the new host is the eyes, nose, or mouth. The droplet method of infection is practically invisible to the unaided eye and consequently entitled to be regarded with some mystery. The agents of the indi rect contact infection are probably always visible. The part played by dust in transmitting infection is very insignificant or entirely negligible as compared with infection by contact.1 Probably in all instances the agents of indirect contact infection are visible ones. Then, what are these visible household agents which transmit dis ease ? It must be confessed that the search for them has not met with much success. The common drinking cup, the telephone mouthpiece, and the freshly moistened pencil point have long been suspected and justly condemned. I can recall but one instance of infection in which the pencil point is believed to have acted as the transmitting agent. This single instance is contrasted with several instances in which the droplet method could be practically conclusively proven as the means of transference. For instance, at a training station a petty officer met a 1 Chapln : Sources and Modes of Infection. Boston, 1912. p. 295. No. 3. PREVENTIVE MEDICINE AT TRAINING CAMPS. 411 new recruit returning from the drill ground before the drill hour had expired. He inquired the cause, and the recruit explained that he was feeling sick and on his way to the sick bay. From the sick bay he was sent to the hospital with measles. Thirteen days later the petty officer had measles. Investigation could discover no other contact than this brief one in the open. These two persons were quartered in separate buildings, had separate messes, different associates, and the recruit had been at the station only a few days. The absence of other known sources of infection would seem to prove the droplet method as the only possible one in this case. Such instances can be multi plied, and from a practical point of view it does not appear that the visible agents of indirect contact of infection are nearly as important as direct contact in spreading disease. The wearing of face masks has an educational value, as their pres ence distinctly points to that invisible but most important factor (droplet infection) in the spread of disease. Also, face masks serve to keep the fingers from the mouth and nose and eyes. The hands are without doubt the greatest single factor in the method of indirect con tact infection. Chapin 1 in civil life and McCulloch 2 in the military service have pointed out with emphasis the important role played by the hands in the dissemination of the bacteria of disease. There is a great need for further education as to the methods by which the hands may transfer germs and in how to avoid the danger of droplet infec tion. To see a physician, while descending in a crowded elevator, turn to talk into the face of a companion during the height of the influenzia epidemic, reminds one that there is much to be accomplished among all classes by teaching the real importance of these dangers. So very little is known about the so-called period of incubation of a disease that that portion of the medical history of a case may be likened to the Dark Ages. The " incubation period " may be defined as the expression applied to the interval of time, usually quite definite in length, between the moment of entrance of bacteria into the body and the first appearance of the symptoms of consequent disease.* It is reasonable to suppose that as soon as the bacteria of disease have entered the body they begin at once those processes of the incubation period that are required to establish their particular disease. How ever, it is not unlikely that in some diseases, as cerebro-spinal fever, for instance, there is at times a carrying period of more or less indefi nite length before the germs and the body take up those steps which definitely lead to the first manifestation of disease. The selection of the time of appearance of the first symptom of the disease as the time of termination of the incubation period is an arbi- 1 Chapin : How to Avoid Infection. Cambridge, 1917. •McCulloch: Military Hygiene. Med. Rec. New York. Vol. 91, No. 22. p. 947. ■Editorial. Jour. Am. Med. Assn., 1916. Vol. 47. p. 1805. 412 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. trary one. Without doubt, some pathological activities begun in the incubation stage, carry through into the stage of symptoms. The incubation period is practically without signs as contrasted with the succeeding period which is replete with signs. Therefore, it seems likely that the termination of the period of incubation marks a con siderable change in the nature of the pathological activities which the bacteria have set up within the body. The period of incubation, in particular its length, is of special in terest to the epidemiologist. Most diseases are considered nonin fectious during this period. Smallpox is said to be contagious dur ing its period of incubation. The length of the incubation varies in different infections and in different individuals having the same in fection. With scarlet fever and diphtheria it is from 2 to 6 days. With rabies it has wide fluctuations, and is usually counted as from 4 to 6 weeks. With smallpox and measles it is comparatively uniform in length. In general, measles has an incubation period of from 9 to 11 days and smallpox has one of from 10 to 14 days. The length of the period of incubation of a disease is influenced by the quantity and virulence of the infecting bacteria, and also by their path of introduction into the body. Spontaneous smallpox has an incubation period of " oftenest 12 days," the inoculated variety 8 days, and the modified germs (vaccinia) develop their disease in from 3 to 4 days. In the case of vaccination a previous attack shortens the period of incubation, giving rise to what is known as the accelerated re action. Also, it appears that vaccination performed subsequent to infection by true smallpox may lengthen the period of incubation of modified smallpox to as much as 25 days.1 The delay required by bacteria after they have entered the body and before they can manifest disease is quite definite and character istic. This period is probably in no sense a resting stage but per haps a period of considerable biologic activity. The quantity of germs introduced by the original infection is evidently quite small. Therefore, it is natural to assign a part of the incubation time for the purpose of multiplication and distribution of the bacteria. Also, true bacterial toxins when introduced do not act immediately like other poisons but require a certain incubation period before mani festing their characteristic symptoms. On account of these two different factors the incubation period may be considered as made up of two definite divisions —one the time necessary for growth, dis tribution, and accumulation of the bacteria, the other the time neces sary for the action of the toxin or poisons which may be secreted.2 1 Uiuss : " The epidemiology of virulent oriental smallpox." Military Surgeon, 1918. Vol. 43. No. 5. p. 492. 'Zinsser: Infection and Resistance. New York, 1918. p. 26. No. 3. PREVENTIVE MEDICINE AT TRAINING CAMPS. 413 Bull1 in some interesting experiments upon the clog attempted among other things " to follow quantitatively the fate of the in jected bacteria from the beginning to the end of infection." He found that intravenous injection of pneumococci was followed by their rapid disappearance from the circulation : and that, before the disappearance was complete, there was an increase in number which was followed by the complete disappearance of the microorganisms. He believed the first rapid decline in the number of bacteria present to be due to the action of the natural antibodies of the blood, and that the second decline and disappearance was due to the action of ac quired antibodies. As a result of his experiments he suggested that— the incubation period of infectious diseases is due to the fact that the infecting agents must become adapted to the adverse conditions encountered in the newly infected host before they cau multiply sufficiently to produce the symptoms of disease. It is further suggested that epidemics may arise because the in fectious agent is passed from person to person in the ascending stage of the disease and thus enters the new host in a slate of maximum resistance to the natural antibodies of such individuals. When early contacts are avoided epidemics tend to subside because the infectious agent Is weakened by the action of acquired antibodies during the period of convalescence. It is interesting that the deduction of Bull, to the effect that the communicable diseases probably have their greatest infectivity dur ing their ascending stage, or, in other words, when the bacteria are in the state of their maximum resistance, has received confirmatory support along other and independent lines. Recently, field workers in epidemiology have come to look upon the early stages of the in fectious diseases as the period of their greatest communicability. Earliest symptoms, for the purpose of making a diagnosis, are of twofold importance. It is desired to know as soon as possible the nature of the ailment at hand, not only for the care of the afflicted person but also to protect others. Without doubt the sooner proper care is instituted the better for the patient. Yet the relation of early care to the warding off of complications —in measles, for instance — seems problematical, according to two recent experiences. Two small epidemics of measles were studied, one of 65 cases and the other of 81 cases. A record was obtained from the hospital of those individuals who developed complications. It was presumed that the complications would be found among those who had not had the ad vantage of early hospitalization. This assumption did not square with the facts. Relatively, complications appeared as often in those sent to the hospital in the early stages of the disease as in those sent when the disease was more advanced. It would seem from this that the appearance of complications is determined by some other factor than the absence of early care. 1 Bull : " Immunity factors In pneumococcus infection of the dog." Jour. Kxper. Med., 1B1B. Vol. 24. p. 7. 414 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. The principal object in the early detection and removal of in fectious cases from among a group of men is to protect others. For the carrying out of this work much depends upon the skill and expe rience of the inspecting officer. In the presence of an epidemic this work is essentially practical, has to make many adaptations, and requires considerable cooperation. Ordinarily, fever is the first symptom of an infection. Yet, nowadays, it does not seem practi cable to take temperatures and to segregate all men showing a rise of temperature. Medical officers when searching a group of men for a particular infection under the various conditions found in the service soon develop lines of action best suited to meet the situation at hand. For instance, inspecting officers who are intensively en gaged in detecting cases of measles get into the habit of looking, in the first place, for a finely congested conjunctiva, then a coryza, or Koplik spots, or a negative history of a previous attack, and, finally, a search is made for the rash and other signs. By giving proper weight to the first signs of infection, on many occasions a case of smallpox has been isolated on account of the presence of the initial symptoms alone, even when no probable source of infection was known. The task of going among a group of men for the purpose ot selecting out for isolation those who have a real or suspected infec tion is a very practical one. From the nature of this work it is evi dent that its efficient performance does not depend so much upon the observance of any set of rules or routine as it does upon the skill, experience, and adaptability of the inspecting officer. Recognized cases are sent to the isolation hospital under proper surveillance. Contacts with recognized cases and suspected cases are preferably isolated at camp. The isolation of so-called contacts is of doubtful efficiency. In two epidemics of measles the per centage of new cases occurring among contacts was higher than for the rest of the camp, and yet the difference did not seem sufficiently large to warrant the considerable trouble. Contacts need not be iso lated at once. Each instance should be investigated and a date set for beginning isolation. The time at which to begin isolation may be calculated by subtracting the number of days exposed from the minimum number of days of the period of incubation of the disease. During an epidemic a good plan for the handling of suspected in fections is to have a number of small isolation units. Each unit should contain men having about the same degree of suspicious in volvement in particular as regards the time at which the disease is expected to develop. Contacts should not be isolated with suspected cases. At best any scheme of isolation offers many disappointments. Isolation is always enforced in the military services for measles, mumps, diphtheria, scarlet fever, and cerebro-spinal fever. It is seldom enforced for tonsillitis or influenza, though these diseases No. 3. 415 PREVENTIVE MEDICINE AT TRAINING CAMPS. are spread in the same manner as the others. Isolation is a failure in measles and cerebro-spinal fever;1 it is not always practicable in influenza. The frequently long incubation period of mumps and the probability that mumps, like other acute infections, is most con tagious in its early stages, render isolation difficult of application for this disease. Isolation is a failure because it is only applicable to recognized cases. It is with difficulty that carriers are isolated to a limited degree only, and missed cases probably receive no amount of isola tion. Even with known cases isolation has restricted application, because most germ diseases are infectious for a certain period before they have developed sufficiently to be recognized. This is particu larly true of measles. In a recent epidemic of 63 cases of measles isolation was given the fairest trial that has yet come under my observation. The epidemic began with 3 primary cases, which were followed by two generations of 30 cases each, as follows : MEASLES. Date. Cases. 4.25 1 4.26 1 4,28 1 5.6 4 5.7 2 5.8 8 5.9 9 5. 10 3 5.11 3 5.12 1 5,15 5 5.17 1 5.18 7 5.19 6 5.20 6 5.21 3 5.22 2 All cases that had not been previously isolated were, of course, isolated upon the appearance of the eruption. By carefully ferreting out persons having symptoms more or less suggestive of measles it happened that 32 persons were selected out for isolation at periods prior to the appearance of their rash, as follows : Cases. 1 day prior to rash 10 2 days prior to rash 13 3 days prior to rash 7 4 days prior to rash 1 5 days prior to rash 1 1 Cnapln : Sources and Modes of Infection. Boston, 1912, pp. 145-6. First generation ; 3 cases. Second generation ; 30 cases. Third generation ; 30 cases. 416 Vol. XIII. PREVENTIVE MEDICINE AT TRAINING CAMPS. Measles is communicable for 3 or more days before the rash ap pears. Let it be assumed that it is just 3 days, and then the degree of efficiency of isolation in the above instance may become a matter of mathematical calculation. Three days for each of the 63 cases gives 189 infectious days, and from this it is permitted to subtract only G3 days, which is the total number of days the 32 cases were isolated while infectious prior to the appearance of the rash. Then, in this instance, not considering possible carriers, and also " missed " cases, isolation was at best only one-third efficient. It is now generally believed that terminal disinfections are of no value in preventing the spread of any of the diseases of this group. Chapin has stated that he can see no use in disinfecting after measles, influenza, or cerebro-spinal fever; that disinfection after diphtheria is absurd, and that disinfection after cerebro-spinal fever is also absurd. The practice of terminal disinfections was adopted when the germ theory of disease became accepted. It was based upon the false hypothesis that places and things held the contagious entity of dis ease and that disease germs have a considerable power of maintain ing their viability aside from the human host. This theory was ac cepted so completely that buildings were constructed for the special purpose of disinfecting articles which had been in contact with the sick and which it was desired to return to general use. Some of these buildings contained immense autoclaves and chambers for the reception of toys, books, tools, bedding, clothing, and other inani mate objects to be subjected to live steam or pungent gases which would destroy the lives of those disease germs that were supposedly clinging to the surfaces and crevices of these objects in wait for their next victim. Disinfection was adopted entirely from theoretical considerations. It now seems strange that the practice prevailed so long while no tangible results were being obtained to justify, even in a small way, the considerable inconvenience and expense. In explanation, it does not seem unlikely that the practice of fumigations and disinfections filled a psychological want. The beliefs of primitive man abound with the idea of the potency of malodorous substances for the cure and prevention of disease. In further support of this view it may be pointed out that " the Egypto- Assyrian prototype of the Jewish and Christian censers, smoking with resinous drugs which developed the antiseptic vapors of ethereal oils, forms some sort of a parallel with the now discarded weapons of the fumigators of our boards of health in their early bacterial days. Nevertheless, even though no more than a coincidence, other things taken into consideration, it is rather remarkable that antiseptic ethereal oils were let loose in fumigation to exorcise the little demons of disease in old Judea some 3,000 years No. 3. WITH MABINES IN FRANCE. 417 ago, and let loose again some 30 years ago to exorcise the little red and blue devils we saw under our microscopic objectives. The effi cacy of the fumigating performance, so far as the disease is concerned, doubtless was the same, but there is no occasion for scoffing at the performance of either date, but rather for reflection on the transitori- ness of theorv and the evanescence of facts." 1 WITH MARINES IN FRANCE. By F. E. Locv, Lieutenant, Medical Corps, United States Navy. GENERAL OPERATIONS OF THE REGIMENT. The past year has been one full of the greatest activity for this regiment. During January the battalions and companies which had been scattered in various towns in France joined the Second Division in a training area near Bourmont, Vosges, France, and on February 11 the regiment was completed by the arrival from the United States of the Second Battalion. Here the regiment, united for the first time since September, 1917, began intensive training in preparation for a tour of duty in the trenches. On March 14 the regiment entrained for a quiet sector south of Verdun. During the two months of our stay the battalions alternated in the front line, our casualties were not large, and a great many plans were worked out which were to stand us in good stead during the darker days to come. On our relief on May 12 we proceeded to a new area near Vitry-le-Francois for a week and then to another area about 40 miles north of Paris. On May 31, after having been out of the Verdun trenches for only 18 days, we hurriedly entrained on motor trucks and after a ride of approximately 75 miles arrived near the now famous town of Bouresche and the Bois de Belleau, where the entire regiment was rushed in among the retreating French soldiers and fleeing civilians to help stop the headlong German advance on Paris. During the first two weeks of our six weeks' stay in this locality came our heaviest casualties, and the care and evacuation of the wounded became an enormous problem. After a total of 10 days " en repos " the regiment was again suddenly entrained and rushed northward to a point near Vierzy, south of Soissons, to participate in the great allied counter offensive starting July 18. After sustaining casual ties approximating 50 per cent on the 19th, the regiment was relieved to rest, refit, and replace losses. After several movements the regi ment entered a quiet trench sector at Pont a Mousson, north of Nancy, for nine days. 1 Wright : " Dcmonology and bacteriology In medicine." The Scientific Monthly. Vol. 4, No. 6. P. 506. 418 WITH MARINES IN FRANCE. Vol. XIII. About the middle of August we entered a new training area about 15 miles south of Toul and except for interbattalion movements the regiment remained in place. It was here that for the first time opportunity presented itself to attempt to bring our uncompleted clerical work up to date. However, comparatively little was accom plished. On September 2 the regiment started to march by easy stages to the front, 15 miles north of Toul. On September 12 the regiment advanced with the general attack which resulted in the closing off of the St. Mihiel salient. After four days we were relieved and proceeded gradually to rest billets near Toul, where we stayed six days. From this point we proceeded by rail to the Cham pagne region near Chalons-sur-Marne. After various moves we attacked on October 3, advancing about 3 miles and taking Blanc Mont Ridge, a strategic point for the sur rounding country. After making small further advances and hold ing this point until the line was consolidated on either side we were relieved and had six days in billets near Chalons-sur-Marne. On October 20 we started moving again, not to stop for nearly two months. After several tactical moves in the Champagne, the regi ment started across the Argonne Forrest to join the American First Army, which had been fighting along the Meuse Eiver north of Ver dun. On November 1 the regiment again attacked, advancing about 6 miles the first day against determined resistance, and making further advances to the Meuse River near Mouzon, until the cessation of hostilities on November 11. On November 17 the march to the occupation of the Coblenz bridgehead was started, and we passed through the remaining portion of France, through Belgium and Luxembourg, and across Germany, reaching the Rhine on December 9 and settling down in our present location on December 16. PERSONNEL. The medical personnel of this regiment has changed greatly dur ing the past year. Of the original 8 medical officers, 2 dental sur geons, 1 pharmacist, and 50 hospital corpsmen at the beginning of 1918, there are still attached on December 31, 1918, 1 medical officer and 16 hospital corpsmen now doing duty with the regiment. Twenty-four different Navy medical officers and dental officers and 165 hospital corpsmen have been carried on the rolls of the medical department during the year. Of the officers that have left the regi ment several have returned to a naval status, or are still in base hos pitals or on duty in the Service of Supply after having been evacu ated on account of wounds or sickness. Three officers are now on duty with the Division Sanitary Train. One dental surgeon and four hospital corpsmen have been killed. in action, 5 officers and 53 hospital corpsmen have been evacuated, wounded, or gassed. No. 3. WITH MARINES IN FRANCE. 419 There was at first little opportunity offered naval medical officers to serve with other than one of the two marine regiments or the ma chine-gun battalion. However, during the past six months a few have been attached to the various field hospitals and ambulance com panies of the division, and thus have had an opportunity to widen their experience. It is the opinion of the writer that more opportu nity should be offered for the relief of medical officers and hospital corpsmen serving with a combat infantry regiment. For example, after having served in such a capacity for three to six months they should have an opportunity to alternate with personnel of like grade serving in ambulance companies, field, evacuation, or base hospitals. In this way relief could be had from intense nervous st: lin and phys ical hardship of work in the line, and they would secure the benefits of better surroundings, and have an opportunity of doing something more in a medical way than is possible in a first-aid station. Dr. W. G. Farwell, Lieutenant Commander, Medical Corps, United States Navy, was the regimental surgeon until July 21, 1918, when he was evacuated, sick. Up to this time the medical work under battle conditions was being systemized and developed. In this work he was ably assisted by Lieutenant J. T. Boone, Med. Corps, United States Navy, who succeeded him as regimental surgeon. Working under continually bettering conditions, methods of evacua tion were reorganized and a plan developed by which part of our Navy records could be kept while the regiment was in combat. On September 23, following the St. Mihiel engagement, Lieutenant Boone was detached and appointed assistant division surgeon and was succeeded by the undersigned. During February and March Lieutenant Boone attended the Army Sanitary School of the Ameri can Expeditionary Forces, studying the hospital and evacuation methods of the French and British. The regimental medical detachment has been fortunate at all times in having an abundance of well-trained, willing, and cour ageous hospital corpsmen, and to them belongs the greatest share of the credit in giving first aid to the wounded in the most advanced posi tions. Sixty-nine citations for bravery in action have been given members of the hospital corps of this regiment and over half of them have been made by line officers. There have been a number of distinguished service crosses and croix de guerre awarded. Many . have been mentioned in divisional orders and many citations have not as yet been heard from. The naval hospital corpsmen serving with marines and the Army in the American Expeditionary Forces are still at a disadvantage in the question of pay. They do not receive the 20 per cent increase for foreign service which both the Army and Marine Corps receive. When transferred or evacuated to a hospital or an Army unit they 116025—19 3 420 Vol. XIII. WITH MARINES IN FRANCE. can not receive their pay until transfer pay accounts are in the hands of some marine paymaster, who often must make a special trip to pay them. Army enlisted personnel have service records which con tain their pay accounts, and these go with the man or are sent after him when he is transferred or evacuated and any Army disbursing officer may pay them. Fortunately the marine paymasters have been paying many hospital corpsmen $10 to $20 a month until their trans fer pay accounts are received. There has been little opportunity for textbook instruction during the past year on account of so much work in the field and recently through lack of textbooks. The work has been almost all of a prac tical nature, especially in first aid, minor surgery, nursing, and sick-bay duties. It is believed that the training these hospital corps- men received has been of the greatest value in developing their initia tive, self-reliance, and dependability. Their courage and spirit of self-sacrifice has always been in accordance with the best traditions of the Navy. CASUALTIES AND SICKNESS. All infantry organizations in modern warfare suffer constant changes in personnel, and the Sixth Regiment was no exception to the rule. Approximately 2,000 officers and men of the regiment were evacuated on account of sickness, 593 were killed in action, 4,345 wounded, 239 missing in action, and 19 taken prisoners. Some 205 officers and men have been reported as having died of wounds or from the effects of gas while patients in hospitals in the rear. The reports of those dying in hospitals are known to be very incomplete. The chief causes of evacuation of patients on account of sickness were respiratory diseases and diarrhea. Our battle, casualties, although often severe, have never been out of proportion to the tactical advantages gained. According to the best available records, the casualties according to engagements are as follows : Engagements. Dates. Officers. Men. Toulon Sector, Verdun .. CMteau Thierry Soissons, Vierzy St. Mihiel, Thiaucourt... Champagne, Blanc Mont. Meuse-Argonne Mar. 15 to May 12. June 1 to July 7 . . . July 18 to Jul v 20. Sept. 12 to 16 Oct. 2 to 10 Nov. 1 toll Total, exclusive of missing and prisoners 12 46 51 12 28 23 172 350 1,752 1,213 381 788 487 4,971 At Verdun about 300 out of the total casualties known were due to enemy poison gas. On April 13, during the early morning hours No. 3. WITH MARINES IN FRANCE. 421 some of our rest camps near the front line were bombarded. One of the camps in a hollow about 2 miles from the front line was bombarded for four hours with yellow and blue-cross gas shells and high explosives, approximately about 1,000 shells being thrown in all. About 300 men were billeted here in wooded shacks. The onset of the attack was at about 4 o'clock in the morning, and so it caught most of the men asleep. Practically all of these men were evacuated during the day on account of the effects of the gas. Thirty-three deaths occurred amongst these men. The cause of most of the deaths was a secondary pneumonia. The great majority of the men who lived have not returned to the regiment, as they have not been physically fit to perform heavy duty. According to the regi mental gas officer at that time the causes of the casualities were: Shell bursting in a shack, 60 cases; respirators not put on in time, 25 ; premature removal of respirators, 75 ; disobedience of orders, 75 ; insufficient clothing for change, 60. During the actions about the Bois de Belleau (Chateau-Thierry) there was much gas thrown by the enemy; however, as a rule the casualties were light on account of our added experience. On the nights of the 13th and 14th of June a large area was gassed for about four hours with what was apparently chiefly mustard gas with some phosgene added. Approximately 600 gassed cases were evacuated through the aid stations of the regiment on the 14th, but only about 250 were our own men. Most of the cases were gassed while lying in close support of the front line in the woods or in the small ravine that ran along the back of the woods. The enormous casualities at Soissons practically all occurred in 18 hours on the 19th of July. On account of the almost complete lack of evacuation facilities for the wounded the aid stations were rapidly congested, and soon presented a condition that anyone who ever saw it will remember as a nightmare. The regimental aid sta tion was in a large cave and there, for most of the day, several hun dred wounded lay without morphine, proper bandages, water, or any comfort. Principally on account of the roads being so crowded and the primary necessity of bringing up guns and ammunition, ambulances did not run during the day. During the afternoon re turning ammunition trucks took most of the seriously wounded, placing them on a layer of straw over the bottom of the truck. Under cover of darkness ambulances came forward and evacuated the aid stations. During our part of the Argonne-Meuse attack a severe epidemic of diarrhea developed in the regiment. Practically the whole com mand was affected and several hundred men were evacuated to the rear. The supposed cause was bad water, but sleeping in wet cloth ing on wet ground aggravated the symptoms. Most of the cases 422 WITH MARINES IN FRANCE. Vol. XIII. returned to duty in three to five days. The disease was character ized by frequent watery, often bloody stools, malaise, prostration, and anorexia. Nausea, vomiting, and low fever were present in a few cases. Venereal disease has not been a large factor in this regiment since our arrival at the front last spring. The chief reason for this has no doubt been the lack of opportunities for exposure. Practically all of our new cases come from men returning to the regiment from base hospitals in the rear, returned from leave, or from detached duty in the Service of Supply. Every opportunity is offered to the men to avail themselves of the benefits of prophylaxis. Nearly every village or town in which our troops are quartered has a well marked prophylaxis station which is available for use at all times. Talks have been given to the men of this regiment by the medical officers at regular intervals. Venereal inspections are held twice a month. FOOD, WATER AND KITCHENS. Under the varying conditions encountered on the different fronts and in the rear our food naturally varied much as to quality and quantity. As a rule, when in rest or reserve the food has been good. However, at the front, especially in our early days near Verdun and in the Bois de Belleau, food was occasionally scarce and on a few occasions very bad. As the line of communication developed and we became more experienced in preparing and handling food at the front, conditions grew much better. While serving with the French during May and June we drew their rations minus the red wine. Since then we have had the American ration, which is well balanced and satisfying. Kecently we have been drawing the following ration : Fresh beef, 20 ounces. Fresh mutton, bacon, and fresh pork may be t substituted. Bread, soft, 16 ounces. Fifteen per cent of this ration may come In the form of flour, cornmeal, oatmeal or macaroni. Baking powder, 0.08 ounce. Beans, dry, 4 ounces. Rice or hominy, 2 ounces. Potatoes, fresh, 20 ounces. Twenty per cent of total issue may be sub stituted by onions, canned tomatoes, fresh vegetables, canned corn or peas. Jam, 1.12 ounces, or tea, 0.32 ounce. Sugar, 3.2 ounces. Milk, evaporated, unsweetened, 0.16 gill. Salt, 0.64 ounce. Pepper, 0.02 ounce. Cinnamon, 0.14 ounce. Butter, 0.50 ounce. Candy, 0.80 ounce. Tobacco, 0.40 ounce. May substitute four cigarettes. No. 3. 423 WITH MARINES IN FRANCE. The reserve ration carried by the men has changed during the year. At the present time two days' supply is carried in the pack. One ration includes the following : Canned moats, 16 ounces. This may be corned beef, canned fresh roast beef, corned-beef hash. Sardines or other canned flsh may be sub stituted. Bread, hard, 16 ounces. Coffee, soluble, 0.75 ounce. Salt, 0.16 ounce. Sugar, 3.20 ounces. Soup, cube, 1 ounce. Solid alcohol, 2 ounces. It has been noticed by everyone who has been close to the front that often when large cans of meat from the reserve rations are opened only about one man's share is eaten out of the can and the rest is left to spoil. It is the opinion of the writer that canned meats for the reserve ration should be separately put up, with just enough in one can for one man's meal. The can should be flat, similar to an ordinary sardine can, so that it will fit well in the pack. The water in France is said to be often highly contaminated. Occasional cases of typhoid fever have developed among the troops in the American Expeditionary Forces. While in the rear it has often been possible to treat the water with calcium hypochlorite or to boil it, but during an action, or even while on an active front, it is impossible to use Lister bags, and usually, of necessity, any water available is drunk by the men. The " Magorcar " and the " Steinburn " rolling kitchens have been used by this regiment. The kitchens that can hold the fire in the fire box while on the move are the best. When the command is moving from place to place with such a kitchen the men can be supplied at noon with hot coffee and the evening meal may be started during the afternoon, so that on their arrival at their destination they will not, as a rule, have to wait any longer than an hour for their supper. CLOTHING AND EQUIPMENT. No Marine Corps clothing has been issued to this regiment since our training area was left. When the existing Marine Corps issue had been rendered unserviceable Army clothing was substituted. The campaign hat was discarded in this regiment during March, and since that time the overseas cap and the steel helmet have been worn. There has been much discussion as to the suitability of this type of cap. The chief point in its favor for use at the front in France is that it is small and easily carried in the pocket or pack or may be worn beneath the steel helmet. This is, no doubt, a great advantage 424 WITH MARINES IN FRANCE. Vol. XIII. :at the front, as a larger hat or cap would surely be lost or thrown away on the first day of the attack. Its chief disadvantages, as noted by the writer and many others, were encountered on either very sunny or warm days or on rainy days. When the sun shines there is abso lutely no protection afforded the eyes by the cap. This has been obviated by making a paper visor or putting a paper between the cap and the forehead, so as to shade the eyes. When it rains one is equally unprotected ; the rain beats directly into one's face and eyes and the cap rapidly becomes like a wet rag over the head. A soft cap with a visor, similar to that worn by the Canadians, is much superior to our overseas cap in the opinion of many. The Marine Corps overcoat is heavier, longer, and better made than the Army overcoat but not so suited to active service. The length of the marine overcoat is a distinct disadvantage in most trench sectors. It is so long that it interferes with active movement and the lower foot or so of the coat becomes rapidly saturated with mud and water. The coat then gains many pounds in weight and it is almost impossible to clean or dry the coat while in the line. Our experience with the shorter Army coats has shown them to be more suited for that kind of work. A so-called " trench coat " worn by almost all of the officers here is worthy of mention on account of its many good qualities. It is a lined raincoat cut in the loose "Raglan" style, gathered at the waist by a cloth belt and extending usually to the knee or a point just below. The outer layer is of a smooth, tough material, which does not easily tear and is easily cleaned by scrubbing with soap and water. Between the outer layer and the thin inner lining of the coat proper is a layer of oiled silk. A detachable lining of a thick woolly material may be buttoned on the inside of the coat, thus add ing great warmth to the rain-proof qualities of the garment. The chief advantages of this coat are that it is readily rain proof, com fortable, easily cleaned, and may be made into the warmest of over coats by buttoning in the detachable lining. This type of coat has been worn by our officers under all sorts of weather conditions, and it appears to be the best coat yet devised for use in the field. The question of footwear has been a very important one, particu larly to us. When a man drops out on a march we have learned to look for ill-fitting and wornout shoes. The United States Army field shoe is the best all-around shoe for everything except looks. We have used the Marine Corps hobnail shoe and the British field shoe and find them very inferior. The marine hobnailed shoe has a lining which wears through and then causes irritation of the foot at that point. The British shoe is too stiff and is not fitted properly around the heel. No. 3. WITH MARINES IN FRANCE. 425 Wrap puttees have been used almost exclusively by our men since last February. On the whole, they are rather satisfactory. Their points of advantage are comfort, warmth, softness, and usually neat appearance. Mud can not work up between the puttee and the leg as in canvas or leather puttees. The disadvantages of the wrap puttee show themselves especially when wrapped too tight, as is often done, especially about the calf of the leg. This shuts off healthy circulation and the legs become tired more easily and in cold weather the feet chill more easily, and thus the men are more predisposed to frozen feet and possibly to trench foot. When the wrap puttee is exposed to water and mud it readily becomes satu rated through, thus tending to constrict the leg more, and as the puttee dries it becomes as stiff and uncomfortable as a plaster cast on the leg. MEDICAL AND SURGICAL SUPPLIES. Each of our battalions brought over a complete standard Navy " regimental medical and surgical expeditionary outfit." The qual ity and selection of both drugs and instruments was excellent, and while in our training area the best of the material that we used was from these outfits. However, when we left for the trenches in March our transportation was limited and only parts of the outfits could be carried by the battalions. What we could not take or did not consider necessary was stored in our training area and was later taken over by the Army. The medical material that we did not take along was in most part soon expended, lost in action, or turned over to Army hospitals or supply depots and we drew all further supplies from Army sources. The transportation question with an active infantry regiment is a great one for all concerned. During April we were issued a small two- wheeled mule-drawn cart for each battalion and finally reduced our supplies so that all might be carried on these carts. However, we found that, while the supplies carried on these carts were of great value in the rear, when going into action everything from the carts that was intended to be used must be carried in on the backs of the hospital corpsmen. In explanation of the small amount of supplies of drugs and instruments found to be actually needed by us it must be said that at the front all wounded, gassed, or sick, except the slightest cases are evacuated to a field hospital as soon as possible, while in the rear there are rarely facilities for the care of bed pa tients, and all except the slightly sick are evacuated to field hospitals daily. In the field hospitals most of the more pretentious medical and surgical work is done, and the chief work in the regiment con sists in diagnosing cases, caring for the slightly sick, supervising and organizing the care and evacuation of the wounded from the battle 426 WITH MARINES IN FRANCE. Vol. XIII. field during action. While on the line, stretchers, splints, bandages, and morphine are carried in by stretcher bearers and hospital corps- men. These supplies usually do not last more than a few days and replenishments are brought up by ambulances coming from the am bulance heads and from there are carried to the line by returning litter bearers. As a means of carrying first-aid material the Navy Hospital Corps first-aid and dressing pouches have proved a blessing and are in our opinion much superior to the Army Hospital Corps belts. The reason for this is that Navy pouches hold more, are just as easy to carry, may be taken off without removing the pack, and are much more handy to get things out of. The Thomas leg splint when it was available was a godsend to put on a fractured thigh or leg in the line. The patient's relief has always been pronounced. Of all the types the large straight-leg splint has been the only one for which we have found use. The arm splints are not practical at the front because, with one of them on, it is difficult to carry the patient on a stretcher and usually im possible to load him on an ambulance. In our experience the Thomas leg splint can usually be put on in the battalion aid stations and al ways at the regimental aid station or ambulance head. The chief advantages of this splint are that it immobilizes the limb and at the same time allows the application of extension and by drawing apart the ends of the injured bone further laceration of the surrounding tissues and the accompanying pain is obviated. The Greely units of morphine supplied us through the American Red Cross have been the only practical, and often the only possible, means of giving morphine at the front. The United States Army litter is almost universally used at the front. The French have a litter of the same type with the addition of a contrivance for a raised headrest. It is generally thought among us that the Navy Stokes splint stretcher would have great advantages for use at the front. However, we have never had one to make the experiment with. It is not practical to have two stretchers of such entirely different type at the front, however. As the stretcher goes to the rear with the patient and he is not usually changed from one stretcher to another, because this is of necessity often an awkward move, it delays his evacuation to a safer spot and in the more serious cases will further endanger his life. Thus a wounded man may be picked up on the field, placed on a stretcher and remain on it until he arrives at a base hospital far in the rear, one or two days later. We have had a great deal of difficulty in carrying typewriters with us. The large Underwood typewriter with its wooden case is too bulky for the battalions to carry in the field. We have only been No. 3. WITH MARINES IN FRANCE. 427 able to carry one such typewriter for doing the entire paper work of this regiment. The battalion medical unit has to do the paper work of over a thousand men with no typewriter. For use in the field a small folding typewriter such as the Corona could be trans ported easily and would prove of the greatest assistance in getting out reports, forms, and memorandums. AID STATIONS AT THE FRONT AND CARE AND EVACUATION OF WOUNDED FROM THE FRONT LINE. Apparently very little has been written by medical officers con cerning treatment and evacuation of the wounded before they arrive at a field hospital. It is true that, from a purely medical standpoint, little of interest occurs forward of the first emergency operating team in one of the more advanced field hospitals. This point is usually 5 to 8 kilometers back of the front line. The work forward of the field hospitals is done by medical officers and hospital corpsmen of the combat regiments and ambulance companies. During the last months before the signing of the armistice, the fighting engaged in by this regiment assumed more and more the character of open warfare. Our front line usually advanced from day to day, some times as far as 10 kilometers. These movements necessitated fre quent change in location of aid stations and routes of evacuation, thus greatly increasing the difficulties and dangers in the care and evacuation of the wounded. From a medical standpoint the well- planned and well-carried out engagements of St. Mihiel, Cham pagne, and the Argonne-Meuse are more typical of what may bo done than the earlier and more heroic battles near Chateau-Thierry and Soissons in which the regiment also participated. Our authorized personnel consists of 7 medical officers, 3 dental surgeons and 48 hospital corpsmen. During the last three engage ments we entered with an average of 7 medical officers, 1 dental sur geon, 60 hospital corpsmen and 156 litter bearers, the latter being marines permanently assigned and trained for their duties as litter bearers at the front. The personnel usually was distributed as fol lows: Regimental aid station and regimental headquarters. Regimental surgeon. Assistant regimental surgeon (none after Sept. 23, '18). Dental surgeon. Chief pharmacist's mate. Hospital corpsmen (6 or 8). Battalion aid stations. Two medical officers. Chief pharmacist's mate. Hospital corpsmen (5 to 7). Each company. , Hospital corpsmen (2 to 4). Litter bearers (12). 428 WITH MARINES IN FRANCE. Vol. XIII. The ambulance company personnel varied in numbers and loca tion but there were always at least one Army medical officer and about 60 litter bearers attached to the regiment during action, taking over most of the evacuations from the battalion aid stations. Neces sary ambulances were provided and came up to, or as near to the battalion aid stations as possible. When a man is severely wounded in the line one of the hospital corpsmen detailed with his company proceeds to him at once, if possible, or litter bearers bring the man back to the hospital corps- man. If it is impossible to move the man, often his rifle is stuck into the ground alongside of him by the fixed bayonet. If the wounded man can walk or crawl he usually starts out to the nearest hospital corpsman. The individual first-aid packet may or may not have been applied by the man himself or one of his com rades. At all events the hospital corpsman assures himself that the man has on a satisfactory dressing, always, if possible, gives the patient an injection of morphine, and writes out and attaches a diagnosis tag to his clothing and is occasionally able to apply a rough splint to a fractured bone. From this point the patient goes back to the battalion aid station, usually by routes marked with strips of bandages on bushes or sticks. If he can walk he goes back alone or is helped by a litter bearer, otherwise he is carried back by four litter bearers. The battalion aid stations are located as close to the front line as possible, the distance usually varying between one-half and 2 kilometers back, according to circumstances. On arrival at the aid station the medical officer or chief pharmacist's mate examines the man and the dressing, does whatever is possible under the circumstances, as improving the dressing, applying a Thomas splint, removing or applying a tourniquet. In other words, he gets the patient in the best possible position and condition to travel to the rear. Occasionally we have been able to give the pa tients hot coffee here. From the battalion aid stations the patients usually walk or are littered to the rear in charge of litter bearers from the ambulance companies or our own personnel. If ambu lances can come to the battalion aid stations the patients usually go through from there direct to the field hospital, sometimes, if neces sary, stopping at the regimental aid station or ambulance dressing station if they have been established. Antitetanus serum is usually given at the regimental aid station, ambulance dressing station, or field hospital, although sometimes it is given at the battalion aid stations if circumstances permit and it is necessary to keep the patient there for some time. Speed combined with care are essentials in handling patients un der fire. A wounded man is a noneffective and the sooner he gets back out of fire the better are his chances of not being hit again. No. 3. 429 WITH MARINES IN FRANCE. Chest and abdominal cases, especially, must be carefully and speedily evacuated to a field hospital for obvious reasons. The selection of an aid station is an important matter and there are many points to be taken into consideration regarding location. Conditions vary so much in various places that no set rules can be laid down and an ideal place is never found. In our various en gagements our aid stations have been in houses, cellars, dugouts, wooden shacks, culverts, ravines, ditches, and even in the open. In my opinion the most important considerations are as follows: 1. Proximity to the battalion being taken care of—ideally between flanks of the battalion as it is in position. 2. Nearness to roads or paths by which evacuation may be further continued. Just off a road along which ambulances can come is ideal. 3. The aid station itself should be large enough to work in; where a light may be burned at night without being seen, and where available protection from fire may be utilized. A bombproof dugout with wide steps, down which a litter patient may be carried easily, room enough below to work and keep a number of stretchers and sitting patients awaiting evacuation, Is ideal. Our regimental aid station during our Champagne attack was in such a place, having two fair-sized rooms In addition to passages having 60 bunks. It had been built by the Germans and was used by them as an underground aid station until our arrival. 4. Locations to be avoided if possible in the selection of an aid station : Close proximity to crossroads; active battery or machine gun displacements; ammu nition or ration dumps ; battalion or regimental headquarters or, where direct or balloon observation of the station is possible, or large deep hollows or ravines that may be shelled with gas. During an advance the question of moving the aid station forward becomes a problem. It has been found that a good station once es tablished should not be abandoned in an advance. As a rule medical officers of following units take over the next aid station ahead- reliev ing the medical personnel left there to go on ahead with their own unit. When moving an aid station forward into new territory it has proved a waste of time and to add needless danger for the doc tors and all of their aid-station personnel to move forward together to hunt for an aid station. The best way is to have a doctor or a dependable pharmacist's mate with one other hospital corpsman, and a runner go forward, possibly with the battalion commander; and, when a halt is made, or numerous casualties begin to occur, to recon- noiter the ground, and establish an aid station, and at the same time send back the runner to bring up the doctor and hospital corpsmen and litter bearers with the supplies, splints, etc. In this way an aid station is always in full operation, and the main part of the aid-sta tion personnel and supplies are not out wandering over the terrain, but when they move they go forward rapidly and directly to a definite place. 430 Vol. XIII. WITH MARINES FRANCE. We hear a great deal from the line officers about " liaison " and there is no doubt that in attacks and advances it is all important. We have felt the great importance of it in our medical work, as the best aid station in the world is not of much value if you are not in touch with the ambulance service and litter bearers to evacuate the rapidly accumulating wounded. A battalion aid station" should have its exact location known to everybody but the enemy. Good battalion aid stations have been established and received no patients because battalion and company commanders did not know their location. Other stations have accumulated dozens of litter patients and many more sitting patients who have stayed there for hours on account of poor liaison with ambulances. To improve our liaison with other units the following steps have usually been taken in this regiment : A consultation of all of the medical officers in the regi ment is held before the attack, the plan of attack is discussed, coordinated maps of the area on a large scale are given to each battalion medical officer, and the terrain over which the attack is to proceed is studied from the map. When a battalion medical officer locates a new aid station he sends the coordinates of his new station to this battalion commander and back by runner to the regimental surgeon or ambulance head so that wounded may be directed to the station and litter bearers, ambulances, and supplies may be brought up. NAVAL REPORTS IN THE FIELD— CLERICAL WORK. Since we first entered the trenches in March little has been done toward completing our naval records. We expected to spend only about a month in the line and then we were to return to our training area so that all of our health records, desks, etc., were left stored and we only took up to the front one typewriter, a field desk, blank forms, and loose leaves from health records. We expected to be able to keep our records in the rough journal and on the loose leaves. However, we never returned to our training area, and it was not until August that an opportunity presented itself to get the health records and attempt to catch up on the back work. From March until the end of July we had approximately 3,423 casualties, 1,000 evacuated sick or transferred, and had received several thousand replacements, most of the latter not having their health records. Lieutenant Com mander J. T. Boone, Med. Corps, United States Nav}-, sent to our training area and had the health records brought up, and while we remained two weeks in one place we started to bring our health records, Form F, smooth and rough, K, K2, and N, up to date. Form K2, for the action in the months of March, April, and May, were completed in so far as was possible and were sent to the bureau. However, as the work progressed it was soon realized that all of the back work could not be completed under existing conditions even if No. 3. 431 WITH MARINES IN FRANCE. we had all of the health records. During an engagement we have had over 1,200 casualties in one day. At all times during action it is not even possible to write out a diagnosis tag for the wounded. The care of the dead has not been a part of the medical cilicer's duties. In this way usually at the end of an engagement we have the c arbon copy of the diagnosis tag for the wounded and usually get a list of those buried by the chaplain or others. Little or no information about any man evacuated to a hospital is ever received by the regi ment, and it is practically impossible to trace the progress of a man from one hospital to another, where he may finally die or from which he may be sent back to the United States or be put on some duty in the Service of Supplies. On account of the above conditions it is impossible to complete an " F " card because the information required under Nos. 2 and 3 is not available on account of not having the man's health record or service record at hand. The sick days can not be estimated except as under a " T " disposition and no sick days. Health records were transferred with patients for a short time but they were often lost or returned without entries from the Army hospitals. So when it is impracticable to transfer a man's health record with him on transfer to an Army hospital, his health record has been available, he has been admitted and data entered and then the record left open. If he returns from the Army hospital, additional data has been added and the man discharged and sick days computed. An "F" rough can then be completed. However, only on rare occasions has this pro cedure been carried out, and there have been no health records avail able to make the proper entries or else the patient does not come back to the regiment. When we started to move up to the front again for our participa tion in the St. Mihiel offensive we experienced great difficulty in transporting the records that we had accumulated, and it was impos sible to set up an office and accomplish anything in a short halt. Even if the regiment had all of the health records of the men in the regiment or who had been in it, it would be impossible to bring all of the back work up to date in a reasonable time. While the regiment moved about from place to place and while in the line Lieutenant Commander J. T. Boone, Medical Corps, United States Navy, made attempts to have a more or less permanent office estab lished near the chief surgeon's office in Tours, France. Here all re ports for the regiment could be made out from data sent back from the front, access could be had to the Army reports from hospitals and occasional trips could be made to the various hospital centers in France. In this way accurate reports could be gotten of the diag nosis, sick days, etc., of our marines after they had left the regi ment. This proposed medical records' office never materialized, but 432 WITH MARINES IN FRANCE. Vol. XII I. during the last three engagements participated in a small brigade medical records' office was established consisting of two hospital corpsmen each from the Fifth and Sixth Regiments and one from the Sixth Machine Gun Battalion. This office was a great help when data could be sent back to it. Within a few days after our return to the rear our Forms K2 for the action would be completed. When we arrived on the Ehine on December 9, 1918, we immedi ately established our regimental office and started in again to catch up on back work. Unfortunately all cases transferred went to Army hos pitals, and their sick days could not be entered. In preparation for writing up the health records and making Form F, rough, N, and other required forms, health records known to be in France were sent for and our casualty lists were gone over carefully and card indexed alphabetically. Forms F and K for the months of March, April, and May were completed and sent in. At this point, by an order from the commanding general of the Fourth Brigade, all of our health records, card index, and casualty lists, one typewriter, and two hospital corpsmen were sent 'to the brigade medical records' office established by Lieutenant Commander R. J. Lawler, Med. Corps, United States Naval Reserve Force, the surgeon of the Fifth Regiment, Marines. Since that time, of course, nothing could be done by our regimental office toward catching up on back work. It is our intention during the coming year to keep all of our records up to date as much as possible, and we have made loose-leaf health-record sheets for approximately 4,000 officers and men now in the regiment, giving name, rate or rank, place and date of birth for all, and place and date of enlistment for enlisted men. We are ■ doing every thing possible to follow all evacuations through the local Army hospitals. We have now practically no Navy forms, such as F cards, but requisitions on Form O were sent in August and again in December. We have heard that these supplies were shipped, but as yet they have not been received. CONCLUSION. ; In conclusion the writer wishes to state that during the past year, fraught as it has been with many trials and tribulations, the medical | detachment of this regiment has always felt that it had the warmest and most whole-hearted support of the line officers of the regiment, who have been ready at all times to carry our recommendations into effect wherever possible. Special mention should be made of Colonel Albertus Catlin, United States Marine Corps, who was our original , commanding officer, and of Colonel Harry Lee, United States/ Marine Corps, who succeeded him on June 6, 1918, in the Bois de, , Belleau, and who has led the regiment since that time. i No. 3. BONE GRAFTS. 433 In compiling this report the writer has felt the almost complete lack of notes and accurate data in our own files. Most of the mate rial, except that relating to the Soissons engagement, is written from a memory on which the events and trials in most of the engagements are indelibly stamped. Lieutenant G. L. White, Medical Corps, United States Navy, who returned to the regiment since this report was started, has given valuable assistance in writing the fifth, sixth, and seventh sections and especially in regard to the Soissons engage ment, which was not participated in by the writer. BONE GRAFTS. By E. M. Foote, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. The operations which form the basis of this paper were all per formed at the United States Naval Hospital, New York. The subject of bone grafting, always interesting physiologically, has become of the greatest importance practically at the present time, on account of the desirability of supplying parts of bones which have been been carried away by projectiles or have been destroyed by the infection which has developed in compound fractures received in battle. The series of operations reported here is not a long one, but it is instructive in that there is quite a variety in the grafts employed and in the manner of their application. All of the patients operated upon were United States marines, and in every case the loss of bone was due to a gunshot injury. All of the patients were in good physical condition at the time of operation, sufficient time having elapsed since the receipt of their injuries to permit their wounds to heal and their normal health to be restored. Grafting, whether performed on a plant or an animal, is an opera tion full of mystery. One never ceases to wonder that a slice of bone or other tissue cut off from all of its own blood supply can remain alive long enough for a new circulation to be established. If osmosis can perform this miracle in the presence of a severe traumatism, why can it not keep alive the portion of kidney or spleen whose terminal artery has been blocked by an embolus? One would suppose that such vascular organs were far better fitted to do this than the bones. What are the conditions which are essential to the successful trans plantation of a slice of bone? In the grafting of plants and trees these are fairly well known. The chief points to be observed are these: (1) A time of year in which the plant naturally adds to its growth. (2) A minimum of traumatism. (3) Accurate approximation of the growing layers. 484 BONE GRAFTS. Vol. XIII. (4) Preservation of the necessary moisture and keeping away the agents of decay. (5) Immobility of the graft. The conditions for success in human grafting are very similar: (1) The time of year is not important, but the patient must be in sufficiently good physical condition to develop new tissue which, in the case of the plant, is produced chiefly in certain seasons. (2) A minimum of traumatism, both in cutting the graft and preparing the bed, makes for success. It is my practice to cut the slots in the broken bone first, and then to cut a graft to fit. It is easier to cut the graft to measure, than it is to cut the slots to fit the graft; and when this order of procedure is followed, there is no drying of the graft and it does not need to be placed in any solution. (3) Nurserymen lay stress on the accurate approximation of the inner layer of the bark in tree grafting, although they admit that this approximation need not occur throughout the whole length of the inserted portion of the graft. A corresponding approximation in the human subject would seem to require that the outer surfaces of the graft be just on the level of that of the bone in which it is placed; but experience does not support this theory, for the graft may live, become attached and grow new bone, either at the level of the bone in which it is placed, or above or below its surface. Take as an extreme example the case of a graft placed in the medullary canal of a broken bone. None the less in most cases it is desirable that the surface of the graft should be on a level with the surface of the bone in which it is placed; and that it should fit accurately into the slot prepared for it. The more broad and accurate the ap proximation of the bony surfaces, the more rapid and firm will their fusion be. It is just here that the double electric saw is of the greatest help, as it produces surfaces of slot and graft which are absolutely parallel. There is one other point in connection with accurate approxima tion, which seems to me of considerable importance. If slot and graft are cut with the double rotary electric saws, set at the same distance from each other in both cases, it is obvious that the graft will be thinner than the slot, in which it is to be placed, by an amount equal to the thickness of both saws. As a result, the graft will lie loose in the slot. Albee avoids this by marking out slot and graft with double saws, and then cutting them with slightly beveled sides, using the single saw for this purpose as it is obvious that one can not cut bevels with the double saw. He presses the graft into place until it is firm, and fixes it in position with bone pegs driven into small holes drilled in the sides of the slot. This technic requires con siderable mechanical ability, and even when performed by an expert takes a good deal of time. Naval Medical Bulletin No. 3, July. 1919 Naval Medical Bulletin No. 3. July, 1919. No. 3. 435 BONE GRAFTS. I hit upon a simple expedient to overcome this difficulty, varying the width of the space between the double saws by the use of washers, so that the saws when set to cut the graft shall be farther apart than when they are set to cut the slot, by just the thickness of both saw blades. The graft so cut will fit the slot so accurately that pegs and sutures are not needed to hold it in place, unless there is some strain on the fragments of the broken bone. (Figs. 1 and 2.) This raised the question as to the effect of pressure upon the vitality of the graft. If it is wedged tightly into place, will the blood circulation in it be impaired so that it is more likely to necrose? This is the effect of pres sure upon the skin when sutures are tied too tight. A similar effect has not thus far been observed in the bone grafts; possibly because bone is so rigid that its circulation is not af fected by pressure ; possibly because it does not swell after operation to the extent that the skin and other soft parts do when unduly con stricted. If further experience confirms the statement that tight wedging is no handicap to the nutrition of a bone graft, the method of grafting which gives an inlay which fully fills out the slot is surely the one to follow. The result is mechanically stronger from the start, and less new bone has to be formed to fuse the two bones into one. (4) When a tree is grafted the grafting wax prevents undue evaporation of moisture, and protects the wound from agents of decay. The carefully sutured flesh and skin render the same service to the grafted bone. But in neither fioote 2.-Position ofcase is such Protection absolutely necessary, ulna and radius 5 weeks One sometimes sees a tree in the forest whose after insertion of graft limb hag rubbed against another until the bark of both has been worn through and the equivalent of a grafting * process has grown them into one, without any wax to preserve the moisture and keep out destructive agents. Experience also shows that primary union of the wound in the flesh and skin, though most de- 116025—19 4 Figube 1.—Ulna, Injured by machine - gun bullet October 3, 1918 ; wound healed, nonunion. Graft from tibia Inserted Feb ruary 3, 1919 ; primary union. 436 Vol. XIII. BONE GRAFTS. sirable, is not absolutely essential to the success of a graft of bone. Figures 3 and 4 show the bones of the forearm of a patient whose wound suppurated slightly, and yet the graft remained in place and grew new bone. Pos sibly the infection did not extend as deep as the graft. In another case the grafts showed their ability to live in the presence of a mild sup puration in a very striking manner. This patient received a bad wound of the head from a high explosive shell, and his right forehead was trephined while he was still in France. He entered the United States Naval Hospital, New York, January 23, 1919, with a healed and adherent scar over a large tre phine opening directly above the right eye brow. Pulsation of the brain was very notice able. The X-ray showed no foreign bodies present. At operation the skin with its scar tissue was dissected from the brain, a thin layer being left to act as a dura. The skin with its central scar was sutured over the two portions of rib which were sutured into the defect in the skull. There was no suppuration at first, but after a few days bloody serum was discharged from the wound and the central portion of the flaps sloughed, leaving the grafts exposed in part. Yet in spite of this they remained in place, retained a pinkish color, and grad ually became covered by growth from the skin edges. (Figs 5 and 6.) (5) The final essential of success in graft ing is the immobility of the graft until it has time to attach itself firmly. This is often the hardest one of the five essentials to achieve. In a case like that shown in figures 1 and 2, or that shown in figures 7 and 8, in which the the bone ends are in line and are only a short distance apart, it is not difficult to put into place a bone inlay which will be almost as Figube 3.—Gunshot wound of radius June 8, 1918 ; Infection with gas bacil lus ; wound suppurated for 4 months. Bone graft from tibia Inserted December 22, 1918 ; slight suppuration of skin wound. Fiqube 4.—B one graft showing growth of new bone 7 weeks after op eration. 436-1 c ■ a ■ - in Naval Medical Bulletin No. 3, July, 1919. Compound fracture of skull from high explosive. Trephine opening healed with pulsation of brain and adherent scar. Operation eight months later. (See figure 5.) Naval Medical Bulletin No. 3, July, 1919. Two grafts from a rib remain in place five weeks after operation in spite of partial slough of the covering skin. (See figures 5 and 6.) 436-4 No. 3. 437 BONE GRAFTS. Figube 5.—Compound fracture of skull from high explosive shell, trephine opening healed with pulsation of brain and adherent scar. Operation 8 months later. Grafts from rib fixed In trephine opening. rigid as one that a cabinetmaker might insert ; but in these simple cases the broken ends usually heal of themselves without the help of a graft. When the gap in the broken bone is a long one, and if, as often happens, one of the broken ends has been drawn out of line and has become fixed in a false position, the insertion of the graft is more difficult and its hold on the bone fragments is less secure. In all of the cases thus far mentioned in this article the grafts were cut from other bones than the one to be grafted. It is, of course, possible to cut a graft from one end of a broken bone and slide it in its own groove into a slot cut in the other broken end of the bone, much as a bolt is slid from the door to the doorframe to hold the two together. The smaller fragment is sometimes placed in the gap caused by sliding the graft into place. There are several drawbacks to this method of grafting. The bone from which the graft is cut is more or less weakened by the injury and probable inflammation which followed it, so that it is not as strong nor as healthy as a graft cut from a sound bone. The slot cut in one end of the broken bone is much longer than would be necessary if the graft were cut from an other bone. This weakens unnecessarily the bone which one is endeavoring to repair. The damage done to a sound tibia by cut ting a graft from it is so slight that it can not be considered to counterbalance this disadvantage of the sliding graft, certainly not if the graft is to be inserted in one of the smaller bones. It is technically more difficult to make a sliding graft fit accu rately if the fractured bone ends are not exactly in line. These objections all have greater weight in the case of a smaller bone than in the case of the tibia or femur ; also in case the gap to be spanned is a long one. Figures 9 and 10 illustrate the only sliding graft that has been employed in this hospital during the period of this report. Operation was performed by Dr. Meeker December 2, 1918, a graft about 1\ inches long being cut from the upper fragment of the ulna and slid into a groove prepared in the Figure 6. — Grafts in place 5 weeks after operation, in spite of partial slough of the covering skin. 438 Vol. XIII. BONE GRAFTS. lower fragment and fixed with kangaroo tendon. The wound healed primarily and the early result was good. Figure 9 shows the condition of the bone after seven weeks. This patient wore a plaster splint, at first fixed and then removable. for more than two months, and the result appeared good. Three ...» months after operation motion was noticed about 4 inches above the lower end of the ulna, apparently due to a lack of union between the graft and the lower fragihent. It would not be fair to say that this was due to the type of graft em ployed, as it is one of the diffi culties which one has to con- Fioube 7.—Compound fracture of ulna from machine-gun bullet July 19, 1918. Arm entirely healed on entrance to New York Naval Hospital January 6, 1919. No bony union. tend with in any type of grafting. The operation of grafting is by no means difficult if one has an electrically driven small rotary saw with two blades adjustable at dif ferent distances from each other. The motor need not be sterilized, as it is readily held in a towel when used. The saws are fixed at a distance of one-quarter inch from each other, and sterilized. The stem on which they are fastened is slipped into the end of the motor and fixed by a screw. An incision is made directly down to the bone to be grafted. The periosteum is split and pushed back to either side. The slot is sawed and the frag ment removed. This is clone in each end of the broken bone. It is important, if the graft is to be cut from the tibia, that these two Fiocue 8. — Compound fracture (fig. 7) 1 month after Insertion of a bone graft from the tibia ; primary union of arm and leg ; graft firmly In position ; bone regenerating. Naval Medical Bulletin No. 3, July, 1919. Compound fracture of ulna from machine-gun bullet. July 19, 1918. Arm entirely healed on admission to hospital. January 6, 1919. No bony union. Naval Medical Bulletin No. 3, July, 1919. Radiographs one month after insertion cf bone graft from tibia. Graft in firm position. regenerating. Primary union of arm and leg. 438-2 Eo 438-3 E a. 438-4 Naval Medical Bulletin No. 3, July, 1919. Sliding graft of the ulna three months after operation. (See figure 10.) 43S 5 Naval Medical Bulletin No. 3, July, 1919. No. 3. 439 BONE GRAFTS. Figure 9.—Fracture of ulna by revolver bullet. Prompt healing. Operation 6 months later ; sliding graft of ulna 7 weeks after operation. slots shall be exactly in line. An attempt to cut one slot out of line with the other, in the hope that the graft can be used to prj^ the broken ends into line, is almost certainly doomed to failure, either by fracture of the graft or by one end of the graft slipping out of place. The distance between the saws is widened by the addition of two washers equal to the thickness of the saw blades, and the stem and saws are resterilized. An in cision is made down to the tibia, near the posterior border of its subcutaneous surface, but the periosteum is not cut. A graft is cut with the double electric saws. The periosteum remains attached to it if care is taken. The ends of the graft are cut across with a single electric saw, or a small chisel, and the graft is lifted from its bed and placed directly in the groove prepared for it in the broken bone. It may be necessary to chisel out this groove in places, or cut away more scar tissue in the gap between the ends of the bone, but if one takes the trouble to cut and fit a few grafts, using a basswood splint to practice upon, before attempting the grafting of bones, he can soon acquire an almost perfect technic in this respect. If the graft fits well and shows no tendency to ride out of one of the slots, two or three stitches of chromic catgut are all that need be used. They are passed through the perios teum or other soft tissues as close to the graft as possible. If the placing of the graft is less firm, or if a single bone like the humerus is grafted, the graft may be fixed more se curely by driving small bone pegs into holes drilled in the sides of the slot near the upper surface of the bone. The soft parts are sutured over the graft, if possible in two lavers, by a buried suture of plain or fine chromic catgut, and an intra- cuticular suture of plain catgut. A dry dress ing is bandaged in place, and the arm fixed in a light plaster splint, which should include the joints above and below the grafted bone. The wound of the leg is closed in the same manner as that of the arm, absolutely no drainage being employed. A blood clot fills the Fiocbe 10. —Sliding graft of ulna 3 months after op eration. 440 vol. xin. BONE GRAFTS. gutter cut from the tibia, and the wound heals aseptically with very little discomfort to the patient. One patient without permission got up and walked about on the second day. He was put back to be.d promptly, but no harm resulted from this early use of the leg, nor is it easy to see how any damage would be likely to occur, as no muscles are exposed and the incision is well awajr from the joints. If there are no symptoms to indicate other treatment, the plaster dressing on the grafted limb is not disturbed for two weeks or longer. It is then cut off, the wound dressed, and another light splint applied, circular or re movable as the case may be. There are three complications which may follow bone grafting. The first is suppura tion. This may amount to little more than a stitch abscess, and may not defeat the object of the grafting. If more active it will re quire drainage, and the removal of the graft. Thus far I have not had this complication in a form requiring re moval of the graft, but it may be neces sary in the case shown in figure 13 as one end of the graft is misplaced. Another complication is fracture of the graft. This occurred in a bone graft re moved from the tibia and implanted in the radius. The patient was operated upon by Dr. Bowman at this hospital. The wound healed primarily. Three months after op eration, the patient fell down and hurt his arm. The X-ray showed that he had broken his graft near the center. (Fig. 11.) Another X-ray taken two months later showed a good growth of new bone from the broken graft as well as from the ends of the radius. A third complication is loosening of the graft probably from one end. A poor fitting of the graft at operation; the bad align ment of the slots, so that there is a strain on the graft; and sup- Fioube 11. — Radial loss due to explosive shell July 19, 1918. Bone graft from Ubla October 4, 1918; primary union ; fracture of graft due to fall 3 months after operation. Floras 12.—Same case as figure 11, 5 weeks later, showing continued growth from fractured graft. E a. - O - E° Naval Medical Bulletin No. 3, July, 1919. Same case as 11. Radiograph taken five weeks later shows continued growth from fractured graft. 440-2 440-3 440-4 No. 3. 441 BONE GRAFTS. Figure 13. — Comminuted fracture of radius due to high explosive shell. Lower fragment badly shattered. Prolonged sup puration. Operation 1 month after suppuration ceased. Sluggish suppu ration ; graft loosened ; outcome uncertain. puration are the most likely causes of displacement. In the case figured in figure 13, the cause may have been a very slight suppura tion, or it may have been due to the fact that the lower third of the fractured radius was so badly shattered that the graft had a very poor hold in the slot. Foreign bodies, at least small metallic ones, do not seem to give rise to any complication in bone grafting. Many of the war wounds caused by high explosive shells heal up, al though there are numerous small bits of metal in the soft parts and even in the bones. Naturally, they are removed when accessible, but it does not seem to be good practice to cut the tissues into shreds in the hunt for every last bit of metal. The same pathology must underlie repair after bone grafting as operates during repair after injury. A good illustration of the indifference of a bone graft to a small foreign body is shown in figure 14. This patient had a fracture of the radius, which was wired, but without success, al though the wound healed perfectly. In this condition he entered this hospital. The X-ray showed a nonunion of a nearly transverse frac ture, with a double loop of silver wire. Unfortunately, the X-ray plate was broken. The broken bone was ex posed, and the greater part of the wire re moved, but it wr.s so firmly imbedded in the bone that it broke below the surface of the bone, and in order not to weaken the bone too much by their removal, the pieces of wire were left in the bone. A graft was inserted from the tibia and the wound sutured and the arm put up in plaster. Primary union resulted, and a firm bony union followed. One question remains to be answered. What bone in the body furnishes the best graft ? One thinks at once of the tibia. Cer tainly no other bone is so accessible, and none could give fewer symptoms after the graft is removed from it. But a tibial graft is brittle. It may be broken not only in an accident such as a fall on the grafted limb but it is sometimes broken in prying it from its bed in the bone, although no very great force is used. Moreover, it is absolutely rigid and can not be adjusted to a Figdre 14.—Graft Inserted in radius, which still con tained buried pieces of silver wire. Primary union ; firm bony union. 442 INTERNAL DERANGEMENTS OF KNEE JOINTS. Vol. XIII. slightly irregular alignment. A graft from the rib is quite different. It is very tough, so that it can be bent almost double without break ing, and yet it holds its shape. Its greater vascularity, and the per sistent way in which a rib reforms after a portion is removed for drainage in empyema, strongly suggests that it may have a valuable power of growth as a graft. The graft from it has to be chiseled out, but this is not difficult if one has a few thin chisels with sharp edges. If a graft from the rib will outgrow one from the tibia, this virtue alone will outweigh all the disadvantages of cutting and shap ing it in many cases. For if the gap to be spanned is considerable, a graft is of little use unless it will either grow thicker itself or induce growth in the grafted bone. If one of these two things does not hap pen, the graft is almost sure to be broken sooner or later. Further experience is needed to decide what bone makes the best graft for the long bones; for the skull the question seems to lie between the ribs and the costal cartilages. INTERNAL DERANGEMENTS OF KNEE JOINTS. By C. F. Painter, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. There are two periods in young manhood when there seems to be an unusual number of injuries of the knee joint which come under the heading of " internal derangements." These are at the two extremes of adolescent life. There is a notably greater incidence of semilunar-cartilage displacements in the period of boyhood when football is first played as a part of organized athletics in public, high, and private-school life. Boys at that age if they are big and husky are promising candidates for football teams, but are too poorly knit together to withstand the hard knocks of the game as it is played by young men in late adolescence, the period covered by collegiate training. This is noticeable in civil practice. On enter ing the service of the Navy I was quite surprised to find so many cases of semilunar and other knee-joint injuries among young men of from 20 to 24 or 26 years of age. On analyzing the cases it would appear that the greater incidence of these in this period, and in the naval service, is due to the strenuous existence lead by these young men and the traumatisms incident to the service and the athletic contests in which Navy men engage. The more common injuries among these men are semilunar-car tilage displacements, injuries to the bursa beneath the biceps femoris tendon just above its insertion into the fibula, and hypertrophies of the alar ligaments. 442 1 No. 3. INTERNAL DERANGEMENTS OF KNEE JOINTS. 443 These lesions all give symptoms more or less alike so far as the subjective features are concerned. Their objective signs may not be notably different except in the case of the bicipital bursas. The failure to discriminate between these lesions and simple traumatic ruptures of the lateral ligaments of the knee joint or synovitis of the knee are often attended by consequences which may be more or less serious as is shown by one of the cases reported later on in this communication. In this case the diagnosis had been " un determined " for several weeks and the patient had been returned to duty ; he had fallen twice because the knee suddenly gave out under him and he was sent to the sick bay with a diagnosis of fracture of the humerus. On another occasion he dislocated a thumb in the same manner. He had been confined in the hospital, or away from duty because of "leave" granted after these injuries, for several months all told. This represented a distinct loss of service to the Navy and an expense for carrying this man the 14 months which had elapsed since the injury, most of which might have been avoided had the correct diagnosis been made when it was first possible. Semilunar-cartilage injuries are of two kinds. In one variety the ligamentous connection between the tibia and the face of the semi lunar cartilage is torn away and the cartilage acquires a mobility which permits a catching in the joint at times, but seldom any lock ing of the articulation. Associated with this catch there is usually an effusion ; almost always in the earlier repetitions of the catching. There is pain at the time and lameness, with a definitely localized tenderness along the line of the ruptured ligamentous connections with the cartilage. This second class of cases is concerned, as is the above, with the internal meniscus of the semilunar cartilage in a great majority of cases, and besides having had the anterior ligament torn away the cartilage has been fractured. As a result of this there is a free end of cartilage, which flaps in and out of its normal position. This free piece may be detached from its anterior ligamentous connec tions for as much as an inch or an inch and a half. This break occurs at about the same place in all instances, viz, at the junction of the inner and middle thirds of the internal meniscus. The free end sometimes turns up at right angles to the direction in which it normally lies and projects itself in between the femoral and tibial condyles, where it becomes shredded by the traumatism of repeated crushes. This is observed more particularly in the old untreated cases. An inevitable effect of the looseness of this cartilage is in jection of the synovia in the region traumatised, effusion into the joint repeated with every redislocation, resulting at last in more or less thickening of the synovial membrane, and traumatism to and 444 INTERNAL DERANGEMENTS OF KNEE JOINTS. Vol. XIIL hypertrophy of the alar ligaments, causing an interference with the function of the joint from this alone. It is impossible to cause an injury which will tear or rupture the semilunar cartilage when the leg is fully extended, unless it is associated with a fracture or dis location of the knee joint proper. The force which produces it must be delivered while the leg is flexed to some extent and the pressure exerted upon the outer side of the knee or the inner side of the leg, directed either inward or upward and outward, as the case may be. If when the foot is held immovably on the ground and the body is turned forcibly outward, i. e., in the reverse direction of the hands of a clock as regards the knee in question, the leg is slightly flexed, at the same time the cartilage may be dislocated. Barely the outer semilunar meniscus is dislocated, and causes the same set of symp toms referred to the outer aspect of the knee. This external disloca tion is frequently associated with bicipital bursitis, the cartilage being found protruding into the bursa through the opening which so frequently connects the bursa with the knee joint. Given a history of injury to the knee joint sustained in the manner above described and especially if under similar provocation, there is repetition of the initial symptoms of pain, effusion, disability, flexion deformity, and tenderness referred to the internal or external menis cus, one is reasonably sure of the diagnosis of a semilunar dislocation. This needs to be distinguished from osteochrondritis dessicans (the ordinary " joint mouse") and hypertrophied alar ligament fringes. Kadiographic studies will assist in this differentiation and here it may be remarked that it will be found of much assistance in employ ing the X-ray to determine the presence of a displaced semilunar cartilage by the ordinary methods of exclusion of other things if oxygen is injected into the quadriceps pouch. This separates the synovial surfaces widely, leaving an absolutely black space wherever the joint surfaces could be separated, and if the cartilage is loosened from its moorings, the oxygen will work its way in behind it and show a black area there also. These appearances are identical with the black areas one sees in X-rays of the intestine where gas has accumu lated. Bodies possessed of any opacity are thrown into high relief against this background. This method I first saw in use in the clinic of General Sir Bobert Jones, of Liverpool, England. It has the merit of furnishing positive instead of merely negative evidence in a ma jority of cases of semilunar-cartilage displacements. Once this diag nosis is made, after careful study and examination, there is no treat ment at all satisfactory except excision of the displaced meniscus. Every knee joint should be gotten ready for operation by a two-day local preparation and by the administration of 20-25 grains of urotro- pine per day for two or three days before, and four or five days after No. 8. INTERNAL, DERANGEMENTS OF KNEE JOINTS. 445 operation. The technique of the operation is simplified if done with the leg flexed. The incision which affords the best exposure in a ma jority of instances is a slightly curved one with the curve toward the median line at its lower third. The upper two-thirds is parallel with the long axis of the femur and tibia and crosses the line of the joint after it has commenced to curve at a point over the juncture of the mid dle with the inner third of the internal meniscus. Nothing but instru ments should be inserted within the joint and it is better to perform the operation under a tourniquet. On only two occasions have I seen a hemorrhagic effusion in a knee joint after this operation when done under a tourniquet. If the vessels are caught up before the capsular stitches are taken, any possible trouble would be avoided, and the ad vantages of the clean field, which are secured by the use of the tourni quet, would be enjoyed. The capsule should be closed separately from the skin and without drainage. The first dressing should be applied with firm compres sion from an elastic bandage. Fixation in a cast or ham splint is not necessary, and early manipulation is desirable. At the end of a week passive attempts to secure flexion should be made and by the end of the second week right-angled flexion should be possible. When this has been attained walking may be permitted, and by the end of the third or fourth week, at the most, good function should be restored. Massage and resistive exercises should be directed to the thigh muscles (extensor and flexor) for a long period after the operation or until there is practically no atrophy remaining. The diagnosis of hypertrophied alar ligaments is suggested when, after a trauma to the front of the knee joint, or a severe strain unaccompanied by any history of locking at the time of the injury, the joint shows local swelling on either side the patella, and slightly below it. There is rarely any effusion in the articulation but capsular thickening is quite common. The symptoms develop progressively two or three days after the injury and consist of pain or ache in the joint, particularly after standing or walking for a time. Com plaint is made of a feeling of distention in the joint and stiffness which develops after keeping the leg in one position for a consider able time. When the trouble is marked there is often a sensation of pinching in the joint, but the carrying out of the motions is not prevented as it is in the semilunar dislocations. In the very chronic cases there may be some continuous inability to completely extend but without pain or sense of locking. If such patients are put to bed at the beginning of the trouble, within two or three weeks of the time that the trouble starts or a diag nosis made, and a cast applied so that no further trauma may result to the hypertrophied ligaments, the proliferated tissue will be absorbed and the ligament be restored to its normal size. These injuries are 446 INTERNAL, DERANGEMENTS OF KNEE JOINTS. Vol. XII L purely traumatic. The initial trauma may be slight, but once the ligament becomes hypertrophied it is very easy, through the everyday use of the joint, to add to the original injury little by little and create a situation from which it is hard to recover, necessitating opera tive interference in some instances. The alar ligaments serve as automatic distributors of the synovial fluid over the face of the femoral condyles. They are covered by synovial membrane and are made up of a mixture of fat and con nective tissue in such proportion and so arranged that a very plastic sort of a " sweep " is made useful for the purpose of keeping the synovial fluid properly distributed. Trauma causes proliferation of both the fat and connective tissue elements, and the entire ligament becomes converted into a gristly, hard substance that easily gets in the way of the flexion and exten sion of the leg. The synovial membrane becomes congested and injected, as does the synovia in the immediate neighborhood where the hypertrophied alar ligaments chafe against it. If operative treatment is indicated, and it is in the chronically irri tated ones at any rate, the best route to approach them is through a lateral incision on the inside of the joint, starting close up to the muscle near the top of the quadriceps pouch and about halfway between the edge of the patella and the adductor tubercle. With good retraction the hypertrophied ligaments are easily exposed and, with scissors, may be dissected out from the space between the front of the femoral condyles, the face of the tibia, and the inferior surface of the patella. Hemorrhage (venous) from this may be annoying, but can usually be controlled by washing out with hot water. The pre liminary and postoperative treatment should be the same as in the semilunar lesions. After removal of the stitches the joint should be manipulated daily until full motion is restored. Because of denuda tion of synovia a tendency to the establishment of adhesions is rather more noticeable here than after semilunar operations, and therefore attention to the " follow-up " treatment is imperative. Prognosis is good in these cases. The third lesion referred to above, viz, bicipital bursitis, is appar ently a purely traumatic affair, but the trauma is that of the inordi nate use of the biceps femoris, combined with the fact that there is a minute communication between this bursa and the knee joint. The typical bursitis is shown by swelling the size of a 25-cent piece over the outer aspect of the knee joint beneath the tendon of the biceps and about one-half an inch above its insertion into the fibula. This is hard, tense, and full of a gelatinous material. The lining of the bursa is commonly somewhat thickened. Apparently when trauma is inflicted upon the outer side of the joint the external semilunar may be dislocated; and as the normal communication between the No. 3. INTERNAL DERANGEMENTS OF KNEE JOINTS. 447 bursa and the joint opens right at the insertion of the cartilage along the head of the tibia, I have on two occasions found a portion of the semilunar actually pushed out into the bursa through this opening. The symptoms of this bursitis are pain over the region described above and tenderness to pressure. Sometimes the patients limp a good deal. In the Navy it has seemed to me the fact that all the cases seen have been in seamen who have been obliged to climb up and down ladders a great deal, which is an exercise calling upon the biceps femoris for a good deal of work. It may well be that this, coupled with the fact that a communication with the knee joint is of very frequent occurrence, would account for stirring up the bursa, and attracting fluid into it from the knee joint. The operative removal of this is the only method of treatment that gives permanent relief. The bursa should be dissected out and tied off from the knee joint. Care should be used in the dissection because the external popliteal nerve is close to the head of the fibula and the biceps tendon; it has been injured in this operation with a troublesome peroneal paralysis. The following cases are the ones referred to earlier in this paper, and are cited chiefly to indicate the importance of an early diagnosis in troubles involving the knee joint. Case I.—J , F-2, 22 years, March 29, 1919. While hoisting a timber with a jigger beneath a wharf the stick struck his lower leg from below and forcibly drove it up and out, knocking him off the girder upon which he was standing. Could not straighten the knee, but was .able to go to sick bay of his own accord. Iodine was rubbed on it, but nothing else was done for it. For 10 months there was nothing else done for it, and then he was sent to the City Hospital on Blackwells Island, but no recommendation for treatment was made, though at that time the leg was flexed and could not be ex tended. Shortly after this he was able to secure extension of it by his own efforts. After that he was sent back to duty and repeatedly since then there has been a redislOcation of the cartilage, which he has been able to manipulate back into place himself, but until he does there is no power to extend the leg completely. Sometimes it dislocates itself several times a day. Sometimes a long time may elapse between dislocations. There is now no swelling connected with the dislocation, but pain invariably occurs. The last time was a week ago. There have been a dozen or more X-rays taken, which are said to be negative. Physical examination: Well-developed and well-nourished man. Left knee appears normal, though the thigh and calf are slightly atrophied. In the sulcus between tibia and femur can be felt a resilient, slightly movable mass where the internal meniscus of the semilunar lies. It is slightly tender over this place. There is no 448 INTERNAL, DERANGEMENTS OF KNEE JOINTS. Vol. XIII. swelling of the soft parts or effusion in the joint. Flexion and ex tension of the leg are normal in extent and without spasm of muscle. Diagnosis : Dislocated internal semilunar cartilage. Case II.—G , U. S. M. C, 27 years, December 25, 1916. In practicing high jumping he fell on the left knee striking on the side, with the leg in a position of flexion. Had to be picked up and car ried to quarters. Leg could not be completely extended for three months. There was much swelling and pain with tenderness over the inner aspect of the left knee. He remained in bed with knee bandaged for four days, and was then returned to duty on December 30, 1916 with diagnosis of sprain. On January 6, 1917, reported again to sick bay because of synovitis and pain in knee. Then was transferred to hospital, where the diag nosis of synovitis was continued. He was kept in bed 10 days, where he was given exercises and massage. On January 17, 1917, there was limitation of motion in flexion of the knee. On the 28th there was still some swelling and disability. On March 9, 1917r it is recorded that he was " exercising freely without marked discom fort." He was discharged to duty on this date. From that time to November 18, 1918, no mention is made in his health record of any further trouble with the knee joint, though the patient says that after March, 1917, when the hospital discharged him to duty with a diagnosis of sprain of knee, there had been about a dozen occasions when a slip occurred in the joint accompanied by pain, swelling, and limitation of motion. In the above-mentioned interval he had had the diagnosis of mumps, urethritis, influenza, and chronic articular rheumatism. On March 3, 1919, he had a displacement of something in the left knee joint, which was accompanied by effusion and pain. On that occasion he stated that from time to time this had occurred, during the previous three or four months, with comparatively little provoca tion. He could do no bayonet drill without causing a slipping of the cartilage. On March 12, I had an opportunity to examine this man's knee. He stated that there had been recently three or four slips of the same sort that he had been having before. There was a moderate effusion, tenderness over the inner meniscus of the left semilunar and a pal pable mass to be felt filling up the sulcus between the tibia and the femur. Forced extension and flexion are slightly painful. Calf and thigh show slight atrophy. In view of the history and physical signs, it seems certain that this man's semilunar cartilage had been displaced on Christmas Day, 1916, but the diagnosis has been carried as a " synovitis " or a " sprain," so far as the knee joint lesion was concerned, ever since. No. 3. 449 TROPICAL SPRITE. THE CLINICAL MANIFESTATIONS OF TROPICAL SPRUE.1 By E. J. Wood, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. Before the Association of American Physicians in 1915 1 2 called attention to the occurrence of tropical sprue in the Southern States among those who had not lived nearer the Tropics and who had not visited there. Since that time the number of cases recognized has increased, and the disease is slowly becoming one of importance in these States. When the subject was discussed before the Medical Society of North Carolina 3 in 1918 it developed that quite a number had observed the condition, though not recognizing it as sprue. The evidence points to the existence of the disease in North Carolina, South Carolina, and Georgia at least. One of my series was from New Hampshire. He had lived in North Carolina 25 years ago, and had visited Florida once. Having nothing new to add about the nature of the disease, and no further suggestions in the treatment, it is with some reluctance that I bring the matter up again ; but, having in mind the location of so many of our larger Army camps in the South, it has seemed justifiable to point out the possibility of its existence in the hope that it might be of aid to medical officers who have had no acquaintance with it. By the term " sprue " is meant a chronic disease characterized by a sore mouth and tongue, diarrhea, anemia, and a marked tendency to remission. The diarrhea is peculiar in that the movements are large and soft, acid and filled with gas bubbles, light in color, and very of fensive. There is a marked tendency for the movements to occur in the early hours of the day with cessation in the afternoon and earlier hours of the night. Many conditions have been confused with sprue and the term has been used in a very elastic manner. The very synonyms of sprue have often been erroneous. For example, Cochin-China diarrhea is given as one of these, while this is a distinct disease entity. Added to this is more confusion brought about by the views of such men as W. E. Musgrave and T. W. Jackson who regard it not as a definite disease but as a condition or state which may occur in many of the intestinal affections. In spite of all this there is a generally recog nized, more or less definite group of symptoms under the name sprue. The inveterateness of the condition and the large number of deaths attributed to it certainly justify the most serious consid eration. The unsettled state regarding its place in medicine only tends to justify more investigation and more published records in order that the condition may be more generally recognized and con sequently more carefully studied. 1 Read before the Association of American Physicians in May, 1918. • Trans. Med. Soc. of North Carolina. 1918. ' Trans. Assn. Am. Phys., 1915, and Am. Jour. Med. Sc., November, 1915. 450 Vol. XIIL TROPICAL SPEUE. In the Southern States sprue is being very generally confused with, pellagra. This fact seems to justify the position which I have always assumed regarding the diagnosis of the so-called pellagra-sine-pel lagra.1 Owing to the large number of cases incorrectly diagnosed because the skin lesion was not counted essential in pellagra it seemed justifiable to assume the position that unless the skin lesion was present or there was a very definite history of it the diagnosis should not be made. In those sections where pellagra has existed for many years and the medical profession is very familiar with it the diagnosis might possibly be ventured, but our experience seems not to justify it. There are cases in which I have been utterly unable to distinguish between the two when the skin lesions were absent and the feces had not been studied. This difficulty is often lessened by a more careful study of the whole skin surface for inconspicuous lesions. I now have under observation a case which was diagnosed as sprue and referred to me. There was no history of a skin lesion nor any evidence of it on admission to the hospital. After five days' observation there is now a very slight indication over the knuckles and the webs of the fingers of a desquamating process which is enough to establish the diagnosis of pellagra. It is interesting to note in this case that the tongue is not typical of sprue but in itself suggested pellagra. The feces were liquid rather than soft and without the excess of fat. The anemia was not marked as is the case with sprue. The name sprue and the commoner understanding of the condition placed the emphasis on the mouth symptoms. As the disease is now regarded this is only one of a group of several s3'mptoms and, in deed, cases of sprue are recognized by some writers in which the mouth symptoms are wanting just as, again, there are cases of sprue without intestinal symptoms but with marked mouth symptoms. Such cases have been designated " incomplete sprue." The descriptions of the mouth symptoms in sprue are very numer ous and in many instances the variations are marked. Manson2 gave the most exact account of this group of symptoms, which may well be quoted. He said : " Tenderness, and often great soreness of the tongue, buccal mucous membrane, fauces, and sometimes of the gullet, depending on a complexity of surface lesions including (a) denudation of the epithelium of the mucous membrane generally; (b) the formation of minute* herpetic vesicles, single or in groups, with an inflamed areola, which quickly rupture, leaving (c) small, superficial but exquisitely tender, ashen-gray ulcers; (d) larger inflamed, bare, slightly eroded patches, smooth on the surface usually, or with a slight muco-purulent covering where in contact with the 1 Pellagra-slnepellaffra. New York Medical Journal. ' Sir Patrick Manaon In Albutt'a System, 1st ed., Vol. Ill, p. 778. No. 3. 451 TROPICAL SPRUE. teeth, as when on the inside of the cheeks or lips; often, when on the soft palate, they are markedly granular, probably from inflamed follicles; (e) congestion . and swelling of the fungiform papilla", especially about the lips and edges of the tongue; (f) superficial cracks on the dorsum and edges of the tongue; (g) during complete remission of the acute symptoms, as happens occasionally in most cases, an atrophied state of the entire body of the tongue; this organ then appears pale and almost cartilaginous, with a smooth, glazed surface as if coated with varnish, and completely denuded of papillae." Castellani and Chalmers1 say: "On examining the mouth, the dorsum of the tongue will be seen to have a whitish fur, through which the swollen fungiform papilla? are projecting. The sides and tip of the tongue are red and inflamed, with often small vesicles, small ulcers, and bare patches, which are very tender. Similar patches may be noted under the tongue near the frenum, on the inside of the cheeks, on the palate, and on the pillars of the fauces. A little ulcer, called Crombie's molar ulcer, may be seen near the two last upper or lower molar teeth." The tongue in pellagra differs markedly from the tongue in sprue. It is to be regretted that the published descriptions can not be made more helpful for learning the points of differentiation. One who has observed even a few cases of the two diseases soon feels a degree of confidence in deciding the diagnosis at a glance by the tongue alone, but to put the mental process which led to this conclusion on paper is a very different matter. I have now under observation a patient with diarrhea and sore mouth and tongue. The case was diagnosed sprue, but owing to the appearance of the mouth I made the tentative diagnosis of pellagra and subsequent developments confirm this opinion. In this case the color of the tongue approached a carmine tint in contradistinction to the color in sprue, which is a much lighter shade. In sprue the tongue is more flabby and less pointed. Ulceration occurs in both diseases. I have seen the two edges of the tongue in pellagra a continuous ulcerated area. In sprue Crombie's molar ulcers are counted distinctive, but good ob servers have recorded the same condition in pellagra. There is much more marked salivation in pellagra than in sprue. Thin was of the opinion that salivation did not occur in sprue, but others have recorded it. Certainly salivation is not the conspicuous symptom in sprue that it is in pellagra. In the latter disease there is often a continuous flow of saliva and the patient sits with a cup beneath the chin collecting remarkable amounts of saliva. The odor of a pellagra mouth is often very offensive and this I have not noted in 1 Manual of Tropical Medicine, 2d ed. 110025—19 5 452 TROPICAL, SPHUE. Vol. XIII. sprue. The suffering of the pellagrin from mouth symptoms is often very great. The taking of food is almost an impossibility. I have never seen this degree of suffering approached in sprue. The only two points in this differentiation about which I am confident are the shape of the tongue and the tint of the tongue. The diagnosis, if it must be made on the tongue alone, can best be decided on these two points. It must not be lost sight of, however, that in both sprue and pellagra the mouth symptoms are frequently very inconspicuous. Often tongue changes are noted in both diseases when the patient makes no complaint and the condition is found only by the routine examination. It must be recalled that tongue and mouth symptoms may be entirely absent throughout the whole course of pellagra and that there are cases of sprue reported without tongue lesions. Again, it must be noted that the mouth symptoms of pellagra, as well as of sprue, may occupy only a small portion of the time period of the attack. In the transactions of the Pan American Medical Congress for 1893, Cuthbert Bowen, of the General Hospital in Barbadoes, draws o good distinction between the mouth condition in " psilosis linguae et intestinal," which is, tropical sprue, and "psilosis pigmentosa." which is pellagra. There are two colored plates which bring out very nicety the two points of distinction mentioned above. Anyone interested will get more help from this than in any other way except the study of the actual cases. The diarrhea in sprue has been mentioned above. Just what part the pancreas plays in the production of the sprue stool is still an unsettled point. Certainly the sprue stool is essentially similar to the pancreatic insufficiency stool. It is quite voluminous, light in color, acid in reaction, contains much gas, and shows a considerable loss of fat as well as of nitrogen in a large proportion of the cases. In a previous communication on this subject reference was made to the report of Pratt and Spooner1 on a case of sprue from Porto Rico. They found a fat loss of 45 per cent and a nitrogen loss of 15 per cent. There was a definite reaction for hydrobilirubin by the Schmidt test. Pancreatic insufficiency was indicated by the Einhorn- Schmidt thymus test and the Sahli glutoid capsule (salol) test. The stools were yellow and voluminous and contained many oil drop lets as well as crystals and flakes of fat. P. H. Bahr 2 in his Ceylon cases found the fat absorption varying from 70 to 90 per cent, and there was an absence of all pancreatic ferments. Since this publica tion of Pratt and Spooner a case of Dr. Pratt's has shown a fat loss of 59 per cent without pancreatic insufficiency. 'Jour. Am. Med. Assn., llx, No. 3. 1 Soc. Trop. Med. and Hyg., London. 1914. No. 3. ISOLATION AND CULTIVATION OF PFEIFFER's BACILLUS. 453 In pellagra the utilization of fat and nitrogen is normal. This was found in my own cases * as well as by Myers and Fine.2 In pellagra the character of the diarrhea is very different from that in sprue. The stools are more liquid, usually more frequent, and occur at any hour of the day or night. In sprue, it will be recalled, the stools occur more frequently in the early hours of the day and very few after noon. There is no evidence of a deficiency of the pancreatic ferments in pellagra. One of the most distinctive points of aid in the differential diag nosis between sprue and pellagra is the blood picture. In sprue there occurs an anemia which is counted secondary. The color index is usually 1.25, though there are no changes in the morphology of the cell suggestive of pernicious anemia. Stitt says that the poikilocyto- sis resembles the blood picture of an aplastic pernicious anemia. In sprue there is a marked tendency to remission which might cause confusion with pernicious anemia. I have seen the hemoglobin as low as 20 per cent, and yet with little or no treatment the attack abates and rapid improvement begins. This may be repeated many times. Anemia is, in my experience, an invariable symptom of sprue. It is an important feature of the disease because in it one finds a definite aid in differentiating it from pellagra, which is not characterized by any blood change. Decrease in the size of the liver is frequently referred to in the literature of sprue. We find it in our cases but we feel that too much attention is paid to it as it is common to many other conditions with which the disease is confused. It might be added that we have had opportunity to observe sprue from the Philippihes, from Porto Rico, and from the Southern States. We are convinced that there is no difference in the disease depending on the geographical occurrence. The only possible varia tion might be found in a milder type of mouth symptoms in the Southern States. METHODS OF ISOLATION AND CULTIVATION OF PFEIFFER'S BACILLUS: A REVIEW. liy DeW. O. Rich i y, Lieutenant, Medical Corps, United States Naval Reserve Force. While the exact causative agent of the recent pandemic seems to be still shrouded in mystery, it is generally conceded that the so-called Pfeiffer's bacillus has been from time to time responsible for many of the inflammatory conditions of the respiratory tract. The failure of this organism to conform to Koch's postulates, as well as the extreme variability of its incidence in the various clinics and cantonments of 1 Am. Jour. Med. Sc., Nov., 1915, Vol. cl. ' First Progress Report, Thompson-McFaddcn Pellagra Commission. 454 ISOLATION AND CULTIVATION OF PFEIFFER's BACILLUS. Vol. XUI. this country and abroad, have served to cast the shadow of doubt as to its true role in the recent respiratory epidemic. As Park points out, in considering the etiologic factor in such a disease, one must not overlook the possibility of a filterable virus, an ordinary organism with undue virulence, or an as yet undescribed bacterium. Kruse and Foster were among the first to call attention to filterable virus as the cause of the " common cold." Nicolle and Labailly's investi gation on a filterable virus as the cause of influenza has recently been supported by Gibson. Bowman, and Connor, who report trans missions of the disease to rhesus monkeys. On the other hand. Rosenau, Goldberger, Keegan, and Lake, in Boston, and simul taneously McCoy and Richey. in San Francisco, were unable to reproduce influenza in human volunteers. Nuzum experienced the same results in both monkey and human beings. In considering streptococcus hemolyticus, pneumococcus, or the " green producing " streptococcus as the causal agent of this malady one must not lose sight of the fact that the real causative factor may be crowded out by other agents or may not lend itself to detection by the laboratory facilities at our command. Even B. influenzae may function as a secondary invader to an unknown underlying cause. M. catarrhali* has its champions in Gotch and Whittingham, who report two typical cases of influenza in individuals sprayed, intranasopharyn- geally, with freshly isolated strains from clinical cases of the same disease. Whatever the cause, there is some evidence to indicate that the marked diversity in results of nasopharyngeal and sputum examina tions for Pfeiffer's bacillus can be attributed to the differences in technique. For this reason it was deemed advisable to mention some of the more recent advances reported as aids to the recovery of the bacillus, so that those who are interested could avail themselves of any or all of them. The method of obtaining the material for culture is important. Experience has taught that this organism lingers high in the vault of the nasopharynx and posterior nasal passages, just as the menin gococcus seeins to prefer the posterior pharyngeal wall and B. diph theria? the supratonsillar fossa. Emphasis has been laid by some authorit ies on recovering a portion of the mucosa. This is particularly true at the autopsy table, where material from the trachea and bronchi is collected for culture. When sputum is examined, if it be nummular in character, an effort should be made to select the small, more tenacious mass, which, after washing in physiologic salt solu tion, should be planted on the appropriate medium. Ecker advocates the mixing of bronchial and pharyngeal secretions with a 0.5 per cent solution of sodium taurocholate for 20 minutes, because of its dis solving action on pneumococci and inhibitory effect on other organ No. 8. ISOLATION AND CULTIVATION OF PFEIFFER 'S BACILLUS. 455 isms. By this method the author says that the tiny colonies can be more readily seen, inasmuch as they are not overgrown on the sur face of the blood agar by the other organisms of the respiratory tract. Statistics would seem to indicate that the influenza bacillus is ob tained in a higher percentage of cases by microscopic examinations of direct smears than by culture. Lord reports, in his epidemic series, the finding of this bacterium in 84 per cent by microscopic examination, 78 per cent by culture, and in 36 per cent in over whelming numbers, whereas the bacillus was encountered, in the interepidemic series, in 59 per cent by microscopic examinations, 30 per cent by culture and in 25 per cent in overwhelming numbers. The Pfeiffer bacillus is a tiny, Gram negative organism with round ends, varying in length from coccoid to filamentous forms. In direct smears some investigators lay stress on parallelism and clumping. On a fresh blood agar plate, the colonies of the influenza bacillus are tiny, round, slightly elevated, colorless, translucent, and moist. As a rule they are pin point in size, discrete, and never coalesce. They appear along the line of inoculation. In the first 24 hours of incubation at 37 C, they may be very hard to see with the naked eye. The growth can usually be seen more readily in 48 hours. On " cooked " blood agar the colonies tend to become somewhat larger. Thev are most frequently confused with the colonies of certain diph theroid and leptothrix organisms. In culture, the morphological characteristics can be altered by the reaction of the medium. Dick and Murray found by reducing the acidity from 1.5 to 0.2 and neutral (phenolphthalein) , the long, threadlike forms of the so-called pseudo- influenza bacillus, became as the small bacilli, which could not be distinguished from the true influenza bacillus. Strains of the small bacilli tend to grow as long, leptothrixlike forms on the more acid media. Pleomorphic and involutional forms are more common on old cultures. Polarity can be frequently demonstrated with methy lene blue and dilute carbol-fuchsin. Pfeiffer was the first to recognize the hemoglobinophilic proper ties of his bacterium, and so much stress lias been attached to this fact that it has long been used as a differential point, to distinguish it from those morphologically similar bacteria, which will thrive on a nonhemoglobin containing medium. Human, pigeon, sheep, or rabbit's blood has been used in the form of plain or " cooked " blood agar or added to a nutrient fluid medium, such as glucose bouillon or a meat infusion broth. Some laboratories have obtained good growths by merely spreading a few drops of freshly defibrinated blood over the surface of plain agar plates, but Spooner objects to this, in that, as the organism is an obligate aerobe, the colonies only appear at the edge of the superimposed blood, and further, that they 456 ISOLATION AND CULTIVATION OF PFEIFFER'S BACILLUS Vol. XIII. are less distinct and less readily isolated. Probably the best medium for isolation is plain blood agar, made by adding from 3 to 10 per cent, preferably 5 per cent fresh citrated or defibrinated blood to melted 2 per cent agar (0.4 to 0.6), acid to phenolphthalein and cooled to 45 C. This can be made in bulk and poured into sterile Petri dishes, or made individually in tubes, mixed by rotating between the hands, and poured into plates. Slants are made in the same man ner, save that 1.5 to 3 c. c. are introduced into a test tube, which is then slanted. It is desirable to have as smooth and dry a surface as possible. Complete melting of the agar is as essential for the for mer as is an agar free from bubbles after gentle agitation while mixing the blood. Dryness can be accomplished by inverting the plates or interposing filter paper between the cover and base of the Petri dish. The so-called " cooked " blood agar is one of the simplest and most efficient of media for determining the presence of Pfeiffers bacillus or propagating it after its isolation. Levinthal was among the first to use " cooked " blood agar. He added fresh blood, in a proportion of 1.20 to melted, sterilized, faintly alkaline agar, and after thoroughly mixing by boiling the whole for a few minutes brought it twice more to the point of ebullition and then filtered. A more practicable method of preparing " cooked blood agar " is to add 5 per cent defibrinated or citrated whole blood to plain 2 per cent agar (0.3 to 0.G acid to phenolphthalein). Heat to 70 C. for 15 min utes and slant in sterile test tubes or pour into Petri dishes for plates. An opaque, chocolate-colored mass, with a smooth glistening surface can be thus obtained. There is but little doubt that the influenza bacillus grows more luxuriantly on this medium, and some investi gators maintain that it has a certain degree of selective action, par ticularly within the first 18 hours of incubation. Several attempts to arrive at a true selective medium have been made. Of these the one reported by Avery is worthy of mention. In this instance advantage is taken of the fact that sodium oleate inhibits the growth of many Gram positive organisms, notably pneu- mococcus and streptococcus, while the growth of B. influenzae seems to be enhanced by this substance. The formula for the medium is : c. c. Meat infusion agar (2 per cent) (Ph. 7.3 to 7.5) 94 Solution of sodium olente (2 per cent) 5 Suspension of red blood cells (devoid of serum) 1 The blood is added while the agar is hot. The same principle of preventing the growth of Gram positive bacteria has led Bernstein and Loewe to employ gentian violet in a 5 per cent mixture. The agar has an H ion of 7.1 and the content of the gentian violet is 1 : 5,000. taking a concentrated alcoholic so lution of the dye as unity. No. 3. ISOLATION AND CULTIVATION OF PFEIFFER'S BACILLUS. 457 Symbiosis has been inaugurated to facilitate the reproduction of the influenza bacillus. Robertson calls attention to the " alternate- drill method." Three straight drills are made, from bottom to top, on a smooth blood agar surface with, say, M. catarrhalis or pneu- mococcus. Between these, two drills of the culture of B. influenzae are inserted. This author uses sheep's blood in which the hemo globin has been liberated by freezing and thawing. It is then poured into the agar which is at 60 C. Spooner derived good results by streaking a blood agar plate, already inoculated with B. influenza', with Staphylococcia aureus. Similar results were obtained with B. subtilis, effected by connecting with two culture tubes, separately inoculated, by a short rubber tube. Symbiosis and partial tension, no doubt, can account for the greater growth in this contrivance. Sporadic instances of the recovery of Pfeiffer's bacillus from ante mortem blood cultures occur in the literature. Fleming reports two such cases, where 10 c. c. of blood, taken from a patient ill of in fluenza, were introduced into 150 c. c. of 1 per cent glucose broth (0.3 acid to phenolphthalein). After 48 hours incubation at 37 C, they were first detected. Spooner isolated it in 2 of 82 blood cul tures or 2.5 per cent, while Holman found an organism closely re sembling B. influenza in the heart's blood at autopsy, coexisting with a strain of pneumococcus. It is well known that the influenza bacillus will grow on a nutrient broth which is reinforced by blood. The contents of this communication have been compiled from the more recent literature on the subject. No attempt has been made to introduce any original work into its context. The sole object is to bring before those interested a brief resume of some of the more practicable and efficacious methods which have been utilized in the isolation and cultivation of Pfeiffer's bacillus. It is to be hoped that some of the difficulties so frequently encountered may be overcome and ultimately a standardized technique be adopted—as in the case of streptococcus hemolyticus in post-measles broncho-pneumonias and empyemas. BIBLIOGRAPHY. Avery: Jour. Am. Med. Assn., 1918, 71, p. 2050. Bernstein and Loewe: Jour. Infect. Dis., 1919, 24, p. 78. Dick and Murray : Jour. Am. Med. Assn., 1918, 71, p. 1568. Ecker : Jour. Am. Med. Assn., 1918, 71, p. 1482. Fleming: Ibid., p. 2137. Foster: Ibid., 1916, 66, p. 1180. Gibson, Bowman, and Connor : Brit. Med. Jour., 1918, 2, p. 645. Gotch and WhlttinKhnm : Ibid.. 1018, 2, p. 82. Holman : Personal Communication. Kruse : Munchen med. Wchnschr., 1914, 61, p. 1547. Levinthal : Jour. Am. Med. Assn., 1918, 71, p. 1578. 458 Vol. XIIL THE NERVOUS ELEMENT IN AVIATION. Lord, Scott, and Ely : Idem, 1919, 72, p. 188. McCoy and Richey : Bulletin No. 57, Bureau M. & S., U. S. N. Nlcolle and Laballly : C. R. Acad. Sc., 1918, p. 607. Photostatic copy to Surgeon General, U. S. P. H. S Nuzum : Jour. Am. Med. Assn., 1918, 71, p. 1564. Park : New York Med. Jour., 1917, 105, p. 529. Pfelfler: Ztschr. f. Hyg. u. Infeetions-Krbnkh., 1893, 13, p. 356. Robertson : Brit. Med. Jour., 1918, 2, p. 680. Rosenau et al. : Bulletin No. 57, Bureau M. & S., U. S. N. Spooner, Scott, and Heath : Jour. Am. Med. Assn., 1919, 72, p. 155. THE NERVOUS ELEMENT IN AVIATION. By O. U. I'iixmobe, Lieutenant, Medical Corps, United States Navy. Most of the discussions concerning aviation in the medical journals have been of a very special nature. The exhaustive researches and experimental work completed by the eye and ear specialists have placed this branch of medicine in an important position. The im portance of the eye and ear specialist's examination of the applicant for aviation is unquestioned. To their most thorough and diligent application we owe the present high physical standards in naval aviation. Their work has become so prominent and their study of the ear apparatus, for example, has become so thoroughly recog nized that when one speaks of the medical aspect of aviation the civilian physician at once thinks of the Barany whirling chair, and his mind turns to the eye and ear specialist. We had at the station at Bay Shore, Long Island, about 14,000 hours of actual flying time in the air and I investigated about 100 crashes. I watched the daily routine work with deep interest. I associated as closely as possible with these young fliers and tried to understand their likes, their dislikes, and their whims. I listened to their many tales of experiences and difficulties in the air and myself experienced many of these things with them. Now I can say firmly, that the best flier is the one with the best head and the most common sense, with good judgment, and a clear, healthy intellect which he keeps that way. As a result of my experience I believe that the importance of eye and ear tests has not diminished but that the principal place for their consideration is the recruiting station. Once a recruit is passed to the aviation training station as normal another phase of his medical recruiting begins and here the nerve specialist, using that term in its most general sense, becomes the most important examiner. Not only must functional changes in the nervous system itself be closely watched and studied but also the more subtle changes and vagaries, which frequently arise during the student's training and show them selves as emotional disturbances, should be observed. Naval Medical Bulletin No. 3, July, 1919. Pilot preserving machine's balance with his weight on one wing. A bad landing; high and dry at low tide. A group of instructors; hale and hearty men, all. 458-1 Xo. 3. 459 THE NERVOUS ELEMENT IN AVIATION. My first case having a definite relation to this aspect of aviation was a student flier sent to me by the officer on the beach in charge of flying. The young man reported to me alone, and said that he had been sent to me by the flight officer for an examination. I con cluded that I would phone to the flight officer for information, and soon I heard a voice saying, " Doctor, I have taken that boy whom I have just sent over to you up for a flight three times to-day, and every time I pushed the plane over the ' hump ' that young fool has frozen on to the controls. The last time up he hung on so tight that both of us nearly went to Davy Jones's locker. If you want my honest opinion about the case, I will say that the fool is about scared to death. Let me know what you find, will you?" I must confess that the information set me back a bit for a mo ment. But I kept the young fellow at the sick bay for nearly a half day making examinations of his eye and the ear. My report at the conclusion of the long examination was that the man, as far as I could see, was in fair physical condition. A careful questioning of the individual and a complete history of the case, however, revealed a man in a stage of nervous exhaustion, with a distinctly neurasthentic history. So I talked with the flight officer and told him all I could about the boy's nervous condition. I gained the flight officer's confi dence at once, and after that he sent me every man who showed any thing affecting his flying no matter what it was. There were two classes of men to be constantly watched. First were the instructors who had been flying for a long time and were the teachers on the station. The second group included the students who were still learning how to fly. The problem was comparatively simple with the instructors, for they were permanent officers of the personnel of the station and I was in constant association with them over a period of many months. With the students, however, the problem was more difficult, for as soon as they were qualified to fly they were sent south for more advanced flying and patrol instruction at another station. The course of instruction was essentially preliminary. It was here that we met the man who had his first trip in an aeroplane. In fact it was exceptional at Bay Shore to find an individual who had ever been in an aeroplane before. Two or three had had flights in some of the old types of the Curtiss plane. Of course, students were coming and going as fast as the exigen cies of the training school would permit. The average length of time existing between the attachment and detachment of the student at the station was a little below 40 days. All the information gath ered about a man had to be collected within that length of time. As far as possible they were placed in classes in so far as my depart 460 Vol. XIII. THE NERVOUS ELEMENT IN AVIATION. ment was concerned. There were the good fliers, the poor fliers, and, of course, all kinds of curious intermixtures of freak fliers and in consistent ones up and down the scale. The different cases investigated with relation to aptitude for fly ing were handled individually and were taken up as though the whole matter were an extremely personal affair. The failures were not advertised to the camp except in the case of a man who simply flunked out and could or would not fly, whereupon he was given the choice of reverting to the status of an enlisted man, or of leaving the naval service altogether as most of the total failures preferred. The disgrace attached to the latter occurrence affected the man very much as a rule, although several did not seem to mind such drastic measures, for their main desire was to get away from the sight of an aeroplane. The individual after having once enlisted for actual duty involv ing the flj'ing of heavier-than-air craft, and having successfully passed the final examination in the ground-school course, simply had to make good. The majority did make good and received their fly ing commission with the whole-hearted enthusiasm born of having enjoyed the entire course of instruction. A few completed the course and were successful because of plain grit and determination and a much less number could not make the goal at all. The latter group, practically always, did not like flying and made such failures in at tempts at it that they were excluded. Several in this latter group however did like it but could not master the art of flying at all. These generally made the doctor's life miserable by crashing up machines and getting into all kinds of wrecks one after the other. But they made good ground officers in aviation and were generally commissioned as such. The instructors at the training station were selected and assigned to the various training stations with care. Supposedly, they were the best fliers the Navy could produce, and were recommended for this kind of duty. There was very little changing about of in structors from one station to another. So month after month they went through the daily grind of teaching men to fly. Their students went across and did valuable patrol duty on the high seas, and as word came back of their excellent work over there, occasionally there would be outbursts of grumbling over the hard luck of being forced to stay in this country for training duty. But, of course, every one could not go, and duty was duty. In considering the important work of an aviator, we become im pressed with the fact that, to be successful, he must conform to a good mental and physical standard. Our physical standards are well established and in examining candidates for aviation we follow certain rules regularly. However, in regard to the mental state, No. 3. THE NERVOUS ELEMENT IN AVIATION. 461 ■which is of great importance, there is not at this time any fixed standard of examination. What is needed most in a flier is a high degree of mental efficiency with no departures from the normal manner of thinking, acting, and feeling. We can not imagine a good flier having a functional neu rosis such as psychasthenia, showing states of pathologic fear or anxiety with tics present and feelings or inadequacy, influencing his make-up. There are certain individuals with whom we come into casual contact daily who are not of the normal make-up, but who are not classed as having abnormal mentality. Such individuals often pre sent an appearance of brilliancy and originality, but with this betray, as a rule, defects of judgment, their plans often resulting in failure. They do not remain at one occupation long enough to obtain a thor ough knowledge of it and are forever changing from one manner of life to another. They lack the persistence or will power to com plete or carry to a logical conclusion any undertaking. Slight ob stacles will discourage them and often lead to radical alterations of their mode of life. They manifast but little sympathy or consid eration for others. They are self-absorbed, vain, egotistical, and self- assertive. An individual of this type often impresses his friends or relatives as a kind of genius. Time passes, however, and no results are achieved. The money of this or that relative is lost in various enterprises. He lies and swindles to obtain money. He neglects his family. The true condition is only disclosed by a painstaking study of his history. Quite commonly the family will scout the idea of the young fellow not being mentally well, particularly where a rich father, long-suffering and indulgent, is concerned. Again, an individual may inherit a tendency to nervous exhaustion. His resistance to fatigue may be very feeble. By the demands that aviation make on him, overfatigue is frequent. If he has inherited neuropathic tendencies he may be reduced to such a state that the rest or food required to restore a normal individual can not place him upon a normal base again. In time he develops a well-defined neurosis with definite symptoms. There will be a marked diminution of his capacity for sustained mental effort. He becomes chronically tired. He puts off matters requiring a decision, and finally with the development of marked uncertainty, hesitation, and habitual indecision the instructor pulls him out of flying and sends him to the doctor for examination. We will often discover cases which appear to be decidedly non- neuropathic but still experience nervous exhaustion. However, the individual does not develop a distinct psychosis. Fully as important as the psychoses of neurasthenia are the motor, sensory, and general somatic disturbances. 462 Vol. XIIL THE NERVOUS ELEMENT IN AVIATION. We find some men whose muscles reveal fatigue and the subject ap pears to have become suddenly weak. The statements of the student in regard to motor symptoms are evident. He will declare that the drilling on the parade ground seems to be the last straw on the camel's back. He thinks that if he can get out of drilling he will be all right. An examination of his tendon reflexes may reveal a diminution of the same. Commonly, however, the reactions are exaggerated. A very fine tremor of the hands may be found. Placing the man on very light duty does not improve him much. We know that it is not on ac count of lack of rest, for he has very little liberty and goes to bed early and sleeps the sleep of exhaustion. In the morning, however, in stead of feeling rested, he still retains a tired feeling. Again, various reports at the sick bay show many mild sensory dis turbances. The individual complains of obscure pains which refer to the limbs, trunk, or head. I remember one lad in particular who said that he felt as if the whole top of his head had been scooped out and a vacant space remained from just above his ears upward. A superficial examination showed stigmata of a degenerated nervous system. Complaints of dizziness are not often made. They should lead one to think of neurasthenia and not into examining the ear alone. Insomnia is very frequent, and a student will hear the con stant roar of the motor for hours after going to bed. He tosses about and has difficulty in procuring rest. A common symptom relates to the digestive tract. The individual at first feels no distress after taking food, but later he feels oppression with a sense of weight. As a result of the extremely high nervous output required, the excess stimulation of the innervation of his stomach will cause a hyperacidity. As we look over the circulatory apparatus of these individuals who represent the neurasthenic types with an insufficient number of nerv ous impulses delivered throughout the body, the results of this de ficient innervation become evident. We find cold extremities, for example. In marked cases, which are not common, the force and rhythm of the heart's action is not steady. The psychic phenomena bear a definite relation to the circulatory phenomena as, for example, in fear, where the individual's pulse suddenly quickens and even palpitation of the heart may occur. But as regards aviation, transitory palpitation may affect the strongest as death stai'es him in the face with the machine and pilot in a pre carious predicament. I have had palpitation of the heart as I watched a plane come tumbling into the water from a height of 4,000 feet. Another physical condition noticed in two weak-nerved individuals of this type was a sexual disturbance. Of course, the strain of flying does not bring the neurasthenic to the stage of the special No. 3. 463 THE NERVOUS ELEMENT IN AVIATION. phobias and marked obsessions. We get rid of him long before he completely breaks down, and I suppose upon going back to civil life he regains his normal status again. The psychology of flying covers a vast field which an ordinary observer will find extremely difficult to traverse. In the study of the mind and mental operations of an aviator we find ourselves ranging in our observations between two positions. The first is occupied by the flier who flies along with practically no- thought of danger, or, if it is present, it is such a part of his subconscious mind that he does not experience any sense of it at all. The second is occupied by the young fellow who, upon first going up and experiencing an unpleasant thrill with his pilot, immediately grabs hold of the controls and hangs on for dear life. The latter case represents a confusion of mentality both quantitative and qualitative. It is between these two positions that the doctor often has to work as a psychologist. There are a few conditions which it would be well to note as specific contraindications to flying. For example, there should be no history of attacks of malaria. Cold in high-altitude flights might precipitate a chill. Every man in the Flying Corps of the Navy must have a Wasser- mann done upon entrance. I think it would be a good thing to have the Wassermann taken every six months. Mental symptoms in the primary stage are, of course, infrequent; however, we may meet with dizziness, insomnia, headache, and depression. The psychic shock of the discovery of having contracted this disease might play some role. A man with a mild beginning of pellagra could easily escape the. attention of the recruiting office, especially in the North, where we see very little of it. In alcoholism there is a depression of functions —a confused and poor mentality —if the indulgence has been carried far enough. The young man who is subject to alcoholic debauches will break down eventually in flying. One man was discovered on the verge of delirium tremens. He was an instructor who is not flying now. The degree of resistance to alcohol in some individuals may be enormous or exceedingly slight, so it is a fixed necessity that it be cut out entirely. Any form of drug habit, disorders of metabolism, such as diabetes or gout and a vast category of visceral diseases, should exclude the individual from flying. Under visceral diseases, and particularly Bright?s disease, we find any number of conditions that would con- traindicate flying. Hence the value of giving fliers routine physical examinations. Other diseases which have a definite relation to mentality in flying are diseases of the ductless glands, epilepsy, hysteria, cerebral 464 THE NERVOUS ELEMENT IN AVIATION. VoL XIII. syphilis, multiple cerebro-spinal sclerosis, arteriosclerosis, and any pathological condition of the brain. The English observers lay particular stress upon the medical his tory. They believe that a more complete medical history of the applicant should be taken along with the physical examination. This should cover inquiry into previous occupations, habits (espe cially as to alcohol and tobacco), and mode of life as well as previous health and family history. The family history, especially with regard to diseases of the nerv ous system, might shed some light on the type of soil with which one has to deal, especially in relation to the strain of war flying. A candidate with a history of easily induced chilblains should not be allowed to fly at great heights. Inquiry should be made into the usual amount of sleep obtained, and whether this is disturbed or not. Any signs of restlessness should be noted as they might point to an unstable nervous system. It is believed that the psychological examination is of equal value to the physical examination in the profession of flying in heavier- than-air craft. The best examination that can be given to a prospective student for aviation is one given by a doctor having a good knowledge of special aviation tests combined with personal experience in handling the '; controls " of a plane of his own. The best method of having such a doctor look over the candidate completely is to order the candidate to a flying station immediately after he has met the preliminary phys ical requirements; and, once there, to allow the doctor who flies himself to continue the rest of the examination at leisure. It would not take long for the medical officer to reach a definite conclusion. This would indeed save the needless loss of many weeks to that man who, after going through a school of technology, flunks out later when the real flying begins. Send the man to technology after he has passed the medical officer's examination at a naval air station. If the student then likes the little flying he has seen and experienced with a medical officer, if he is enthusiastic to reach the goal, he will apply himself far more diligently at the technological school : and, furthermore, will have the proper attitude toward avia tion, namely the selection of it as a chosen profession. The student at the present time gets his physical examination first, and is then sent to the ground school of technology for many weeks, after which he is sent to an air station for training, and finally expe riences his first flight. Of course the above can not be accomplished if the medical officer doing duty at an aviation station is detached frequently and placed on medical duties other than aviation. A medical officer should be attached to aviation permanently. Many important and intelligent No. 3. THE NERVOUS ELEMENT IN AVIATION. 465 observations of extreme value have been spoiled because suddenly after a few months of this duty the medical officer is placed on some other kind of work altogether. I have on my desk several papers written by very intelligent observers all of whom were detached from aviation after a very short time at the flying fields. I am sure that their continuance with the aviation unit would have resulted in very good and exhaustive research. Unfortunately a medical officer new to aviation has to start at the very beginning when it comes to get ting experience in actual flying sensations himself. He can not begin where some one else left ofT. An editorial written in the Lancet of January 12, 1918, presented the idea of a medical department for aviation duty alone. I cer tainly believe that this should be done so far as is possible. There are many problems that one never dreams of until after one has had certain experiences in the air. As stated in the Lancet there is not a medical man with or without special knowledge who can not see that the strain on these young men is great, and that to allow unfit per sons to take the responsibility of flying, air scouting, and air fight ing may be to condone suicide. Questions of blood pressure, of cardiac affections, of muscular balance, and nervous stability are alike involved, and the flyer should not only be selected from the beginning for his sound physiological and particularly psychological make-up, but he should be submitted to regular scrutiny during the whole time that he continues to discharge his duties. A medical officer should investigate the causes of injuries in order that accidents may as quickly as possible be grouped according to their similarity in occurrence, or in other points, for in this way the existence of some common physical defect, which has led to a group of accidents, may be detected in other aviators before new tragedies have occurred from the same old cause. It is important that a medical officer should be a member of the board appointed by the commanding officer to investigate the cause of crashes. A medical officer arriving fresh on the station every few months will never help to solve the problems of flying as quickly as the medical officer who flies himself and has been with aviation for a long time. It is believed also that the medical officer for this detail should be selected with as much care as a student flier. He should be capable of becoming engrossed in air problems and see and experience them in the air himself, for aviators do not as a rule lay particular stress upon telling all their own difficulties and defects in the air, and to ask questions about certain things will very often bring you nowhere. Flie/s dissimulate well, if for no other reason than to protect their reputations as good fliers. Aviation at this date has gone far beyond the experimental stage. Few men make a success in medicine unless they like it, and the same 466 THE NERVOUS ELEMENT IN AVIATION. Vol. XIII. holds true with aviation. Many young medical students never get beyond the first year in college, and one sight of a leg amputation is enough. One sight of an aeroplane crash or one flight with " stunts " will do up a few of those prospective candidates, who upon applying; for aviation hold uppermost in their minds the tender spot some girl had in her heart for the bold aviator who after shutting off the power to his engine, as the newspapers describe it, " places his machine fear lessly into a long glide, and at last lands safely in a level 40-acre lot." There are undesirables in naval aviation who accomplished their courses during the time the Government was working at high pres sure to get fliers abroad. But they are being dispensed with. Many, at last, got in their so-called required number of hours who disliked flying, were afraid of it, and soon wanted to get out. But the thought of being a " flunk " drove them on, and rather than admit that they did not like it would crash any day. This was courage of a kind, indeed, but courage misplaced. A certain student flier who had a few hours of solo work could not properly describe to me how to get out of a tail spin. He said the problem had not occurred to him before, and he declared that the new sensation of suddenly finding himself really in an aeroplane was so exciting and there were so many things at the air station which lie had never heard of before and events were occurring so quickly one after the other that parts of it were a jumble in his head. Luckily for this boy the plane had practically flown by itself, and the air conditions were good at the time. Major Greene, in The Military Surgeon, suggests testing ability to qualify as an aviator by giving the applicant an opportunity to fly as a passenger. He may develop certain symptoms, not dis coverable in an ordinary medical examination, which would lead to prompt disqualification. On the other hand, an applicant of doubtful qualities might readily demonstrate peculiar fitness for flying. I have found this to be very true. The so-called attitude of staleness is observed not infrequently in some of the old fliers. When this is discovered, a most thorough investigation of the man's habits should be carried out. Occasionally too much indulgence in alcohol and the night lights of a great city will bring about a certain listlessness toward flying. A man can lower his physical condition to the point of uselessness by such de bauches. He can fly after his excesses, but he is decidedly not at his best. A flier should be trained as an athlete in order to bring out his best ability. Befuddled brains from "hang overs" should never direct an aeroplane. The ear specialists and the eye specialists have long since estab lished themselves in aviation and, it is believed, have swung the pendulum too far to the side of the eye and ear being the all-important No. 3. THE NERVOUS ELEMENT IN AVIATION. 467 organs in the profession of flying. It is time that a reaction were brought about and that the neurologist occupied as strong a foothold as do the eye and ear specialists. It is not out of order at this point to mention a few things a flier must bear in mind as you watch him gracefully playing hide and seek with the clouds way up yonder at a dizzy height. If you know him well and can have the expensive pleasure of flying about with him on some of his capers you will find him to be a very matter-of-fact individual who will wink and chuckle good-naturedly at you after he has scared you nearly to death by looping the loop a half dozen times or dropping into a tail spin. As said before, the natural accomplishment of flying is the result of the proper following of natural laws. I will describe to you as simply as I can the method of ordinary straight flying and not attempt to discuss the fancy tricks and "stunts'' that the young dare-devil performs. The instruction given to students is not along hard and fast lines that can be studied from a textbook. The instructor does not sit at a desk distributing typewritten circulars on the subject of how to fly. The instruction is carried out while actually flying. Faults and im provements are discussed while on the beach with the pupil, to whom is given all the additional information that the instructor possesses. The pupil is checked up as his defects appear. The individuality of the instructor affects the method of teaching. For example, one instructor believes that conservative flying is best when a student is on his first flight, and another believes that on the first flight the young fellow should be given real thrills. STRAIGHTAWAY FLIGHT: A BEE-LINE COURSE. While flying horizontally all fore-and-aft positions should be care fully maintained. Most attention should at first be given to the direction of the course. Considerable pressure must be applied to the right side of the rudder bar to keep the machine from sliding to the left on account of the torque of the motor. The amount neces sary must be determined by watching along the side of the fuselage and adjusting the pressure until the nose of the machine holds an absolutely straight course. The importance of steering an absolutely bee-line course, is due to the fact that the machine has a dished angle. This makes the machine automatically more stable. Thus, when right rudder is applied the shifting of the forces drops the right wing and raises the left wing. The opposite is true. Conversely, if our wing drops owing to unevenness in the air stratum the machine will turn in the direction of the low wing. Hence, the importance of steering a straight course for the rudder serves two purposes, not 116025—19 0 468 THE NERVOUS ELEMENT IN AVIATION. Vol. XIII. only steering the machine, but keeping it level. The instant the nose of the machine moves ever so slightly, to the right or left, the pressure on the opposite side of the rudder must be increased until the swinging is checked. But the pressure must be released and the rudder returned to neutral the instant the nose comes back in line with the course. If pressure is kept on too long, the machine will slide over the course to the other side and, if this is kept up, it will result in a snaky course. The best helmsman is the one who steers the straightest course and moves the wheel the least. The same is true of the pilot of a plane. Watch the nose of the machine like a hawk and stop the instant it starts. If enough attention is paid to this, it will soon become intuitive. Firm pressure should be kept on both sides of the rudder. Eventually the pilot should be able to " feel " the air on his rudder and allow for bumps as they first hit the machine. If the pressure against the right foot increases sud denly it means that the wind is pushing against the right of the rudder. If the rudder holds it place this pressure will swing the machine to the right, as it is the equivalent of right rudder. For this reifton if the pilot is wide-awake and eases off on his right rudder until he feels no thrust on his right foot the machine will fool the gust and keep a steadier course. Sometimes this sort, of gust is so strong that merely letting off on the right rudder will not suffice and left rudder will be necessary. If the pupil watches an expe rienced pilot's use of the riidder, he will see that the bar is almost never stationary in disturbed air, but is moving slightly to left and right through a very small arc. This is because the pilot is playing with his rudder to " feel " the air. The sooner this knack is acquired the better for the pupil. LATERAL BALANCE. i We have seen that lateral balance can, under ordinary circum stances, be maintained by making use of the fact that the rudder bar is operated by the feet and manipulates the rudder on the tail of the machine, turning the plane to right or left, aiding thereby in banking the machine. The rudder is the chief agent in controlling lateral balance in fairly calm air, but in bumpy air the ailerons must sometimes be used. Rudder control of lateral balance is at best slow, and in case of very bad air sometimes insufficient. Aileron control is faster but for this reason less finally controllable. A mix ture or coordination of rudder and aileron control is proper and often essential. Neither one will do alone. They will act together much more easily and quickly, as together they have more control surface and this surface is diverted between the three extremities of the machine. Thus if the right wing drops down suddenly, increase the pressure on the left rudder, and at the same time turn the wheel No. 3. THE NERVOUS ELEMENT IN AVIATION. 469 to the left until the pressure on the plane lets up, when you must instantly restore the control to neutral. You can feel the neutral position of the wheel, for there will be no pressure on the ailerons as they are in a straight line with the wing. The amount you must turn the wheel varies with the severity of the gust, but it is rarely more than a very small amount, and the neutral position will naturally be found, as the wheel is turned off as much as it was turned on to neutral. The importance of correct coordination of rudder and aileron can not be overemphasized. A pilot who does this well can go through any weather with full confidence. There are several means by which you can check your lateral balance. The way you should eventually tell is by feel ; that is, use of your sense of balance, but, until you acquire this, certain mechanical checks are necessary. As you steer your course by watching some two points of the nose of the machine, watch that these points do not roll down or up the horizon. At the same time watch your wings out of the corner of your eye and check any rolling that may occur. In machines with Cabaur struts (triangle), use the triangle formed by them for the same purpose. To be sure that you know what level is, look out at the furthest strut on the right wing, see how much of it shows above or below the horizon, and then check the left wing to see that the same amount shows. Here is lateral balancing of the machine as, in your steering, movements should be checked the instant they begin. LONGITUDINAL POSITION OP PLANE. This position is regulated and controlled by the forward and back ward movement of the wheel. There is no fixed position for the wheel, as this depends on many factors, such as the balance of the machine, the power of the motor, and the kind of flight. There is one- cardinal point to be remembered at all times. Disregard of this will immediately place the pilot and machine in a critical situation. The pilot must always bear in mind that the machine must have flying speed at all times. Flying speed is lost in straightaway flight . by allowing the nose to ride beyond a certain elevation, or in other words by climbing too steeply. Of course, the angle of flying differs for various types of machines because of the differing power, plane surface, resistance, etc. After some experience, you can determine the critical angle of any machine, but until you acquire this " feel," you must use the experience of your instructor. He will show you the proper flying angle for the type of plane you are flying, but this, of course, is true only when the motor is performing normally. Here again you must use some check of your own guidance until you get the feel. In our training plane, use the point on the nose by which you steer a plane, and note its position on the horizon. This point 470 THE NEBVOUS ELEMENT IN AVIATION. Vol. XIII. must never be raised above the horizon unless by orders of the in structor. This will insure you a conservative flying angle, and is the only correct one for you to use while under dual instruction for the first 15 hours of solo, but often you will have no horizon by which to check up your flight angle until you have acquired feel. There is one invaluable check which you must accustom yourself to use. You can always, except at night, fly so that you can see the plane of the water. This is often all that you can see, so this check makes use of this plane instead of the plane of the horizon, though when the horizon is invisible, the check may be used on either plane, as they are both perpendicular to gravity. As you look out at the wing tips, you will see that the outside struts on either wing cut the horizon or the plane of the earth at an angle dependent on the flying angle of the machine. This angle, by the forward edge of the outside strut and the plane of the horizon or earth's surface, should never exceed 90°. For really conservative flight, it should be nearer 80°. In clear weather with a good horizon, this angle will be checked more easily on the horizon, but in rain, haze, or whenever you can see no horizon, you should fly close enough to the water to check this angle on the plane of the water. As soon as you acquire " feel," you may disre gard this check. This particular check is for use only with a motor that is giving its full power. With an under-power motor, the ma chine's climbing angle will be lowered in proportion to the loss of power. Your lift is obtained by the power given by your motor. If this decreases, you must keep your lift by nosing down and gaining your full speed. You must accustom yourself to the sound of your motor, and train yourself to recognize the slightest peculiarity in its exhaust. If your motor misses or loses vigor, you lose speed, and upon speed solely depends your safety. So keep your speed by utiliz ing gravity and nosing over until you can feel a good lift. If .you lose all your power, you must put the machine in a glide to get flying speed, and keep this until you land. This matter of flying speed is the most important in all flying and is never to be forgotten. Play the game conservatively and always keep speed in reserve. Without speed your machine is as air worthy as a ship with its hull full of holes, because speed, is so absolutely essential. Keep this always in mind. TURNS. If rudder alone is applied, the machine will skid away from the direction you desire to turn in the same way as does an automobile traveling in a high rate of speed on an unbanked turn. In an aero plane a skid, if carried out far enough, will result in a complete loss of flying speed. A stall results and flying speed must be regained by a dive in a skid. Flying speed and lift are lost in proportion to No. 8. THE NERVOUS ELEMENT IN AVIATION. 471 its severity. If bank alone is applied, flying speed and lift will be decreased in proportion to the amount of bank until a stall occurs, when speed must be regained through a dive. A parallel illustration may be seen in the case of an automobile taking a turn banked too much. There are several good illustrations of the theory of a turn, such as the motorcycle in the eggshell track of the circus, a bank motordrome, the chairs suspended from ropes on a pole which are swung around the pole at increasing speed. You should study the theory of the turn until you have absolutely mastered it, for until you understand it, you will never be able to turn well. From a study of the turn, you will see that for one reason there is but one correct bank. There is a straight course with no bank, a most gradual turn with a most gradual bank, and the corresponding in creasing bank and radius until you get to the vertical bank and shortest radius. The actual method of making a turn is as follows: Level your machine to an absolutely horizontal flight. Note some point on nose of machine which is on the horizon. Apply rudder and bank simul taneously, and smoothly, not too fast. Machine will start turning and banking at same time. Keep your points all steady on horizon, note your bank, and when you have reached the desired degree, neutralize your ailerons and keep enough pressure on rudder to make nose of machine travel steadily around on horizon. Adjust pressure on rudder to suit bank, not vice versa. Watch nose, not wing. Occasional glances at wing if necessary are permissible, but you should be able to judge bank by angle of nose of machine relative to horizon. Too much rudder will make you skid, and you will feel , air on your outside cheek and also a tendency to lean in toward the center. Too little rudder will cause side-slip. You will feel first a tendency to lean outwards, and when slipping, a strong pressure of air on your inside cheek. In a correct turn you should feel com fortable in your seat with air on neither cheek and should end your turn, no matter how long, with the same amount of bank as you com menced with. Fully as important as the bank and radius of a turn is the elevation of the nose of the machine. The nose must be kept on the horizon, and altitude must neither be gained nor lost. You must guard against the tendency of the " torque " to raise your nose on a right turn, and pull it down on left turn. If you climb on a turn, you will gradually lose lift and stall, and you will then go into a spin. If you gradually lose altitude on a turn, you will eventu ally spin. In bumpy weather, use of ailerons may be necessary while turning, in order to keep bank constant, but this comes naturally. To come out of the turn, give opposite rudder and aileron until machine is level horizontally and the desired course is assumed, being 472 THE NERVOUS ELEMENT IN AVIATION. Vol. XIU. careful to keep the nose still level. Neutralize control instantly this is attained, and check up to see that wings are level and course is true. Fly level for a few seconds before resuming climbing flight. If bank and rudder are not taken off together, the machine will skid. Coming out of a turn well is as essential as going into one. You should practice coming out of turns onto a given course so as to gain accuracy, and you should practice turning through 360°. When you feel that your turns are falling, turn steadily to 720° and the fault will be exaggerated so that you can discover where it lies. Remember your flying speed in a turn as everywhere else, and remem ber that as you tend to decrease your lift rapidly in a faulty turn with a bad engine, you should be well on the side of excess flying speed. It is very advisable to adopt your own standard turns; that is, one that you can always be absolutely sure of. It may often come in handy. Never bank steeply close to the water, except in case of emergency. Play it safe, for you never know at what instant your motor may quit, and when it quits in a turn, you want room and plenty of it. Except, when unavoidable, no turn should be made under 300 feet. GLIDING. The machine glides when it utilizes the force of gravity instead of its motor to maintain flying speed. The machine is under fully as good control in a proper glide as in motor flight, and the old notion that when an engine stops in the air the pilot is doomed has of course been exploded. The pilot's life is in danger if, when his motor quits, he does not instantly maintain flying speed by gliding. Lift is attained by the thrust of the air and the wings, and if the motor can not give you this speed, the glide will. There are all degrees of glides from the minimum when the lift is least, to the maximum or nose dive, when the machine accelerates so quickly as to be of no value near the ground. The proper gliding angle is that which gives the machine a constant speed slightly in excess of that of motor flight. You can determine the speed of the machine in a glide in . two ways —first and best, by the whistle of your wires; second, by the air speed indicator. The former is better by far for it is always reliable, and no instrument is always reliable. Also the former is available at night* when you may be unable to use your instruments. The pitch of the whistle should remain constant after you once assume your glide and should be clearly audible. The instructor will show you what is the correct pitch, and you should never glide at a lower one. You must accustom yourself to glide by this sound, for it is absolutely essential and is furthermore important in spiral- ing. The essential fact to remember, as always in all flying, is to maintain plenty of flying speed. There is nothing so much to be No. 3. THE NERVOUS ELEMENT IN AVIATION. 473 avoided as a flat glide; that is, a glide so flat that your lift is just barely sufficient to keep the machine from falling. It is not safe to approach this point. The more speed you have, the more lift, hence the more control, hence the more safety. Take for instance the two following cases: One pilot glides down for a landing with a glide so flat that he has speed and no more. Suppose he is about to land when another machine comes suddenly and unwarrantedly in his way. To avoid a collision, he either tries to zoom or turns his machine. The instant he does either, he uses all his lift and stalls. Of course he crashes, all because he has no surplus lift. Now, take the second pilot, who comes down in a good glide with plenty of excess speed. When he zooms or turns he has full control over his machine, and enough lift to last him four or five seconds, long enough to avoid a collision and regain his speed by use of the motor. If Vernon Castle had had enough speed, he never would have crashed in zooming another machine. From this it is evident that the steep glide is better than a too flat one, by all means. RULES OF THE AIB. 1. A machine taking off "or tnxying" has the right of way over a machine in the air. 2. Pass another machine approaching you as you would if you were auto- mobiling. That is right wing to right wing. 3. Overtake another machine as if you were uutomobiling on his left. 4. Of two machines one above the other, the lower has the right of way. 5. A machine with a dead stick has the right of way. 6. A machine gliding or spiralling, or stunting has the right of way over one flying level. 7. Never trust the other man to do the right thing; he may be asleep. After thinking over the above, it is not difficult to realize that a man must be on the alert and have an active, cool mind at all times. The above outline of ordinary flying is rather crude perhaps and not meant to be sufficient knowledge for a man who intends to sit in a plane and begin to fly perfectly at once. One must overcome many difficulties. The finer points of stunt flying and tight places that a flier must get out of in order to save his life and machine, are not dwelt upon here, for in so limited a discussion the subject can not be handled properly. . It takes one some time to get over the feeling that there is a con siderable space between yourself and the earth as soon as you have left it. and the realization that ever so little a thing, such as the turn of the wheel, can place you in a position out of which under certain circumstances you can not recover, surely does arouse subconscious thoughts of the Valley of Shadows from which travelers do not re turn. True, just ordinary motions and sensible thoughts guide your 4*74 THE NERVOUS ELEMENT IN AVIATION. Vol. XIIL bands and feet to control the plane, but to the beginner the new sensation really does make his heart pound in his chest. You at first view the splendid panorama beneath you with wonder and awe, and then, as you thrust out your neck over the side of the plane and gaze at the terribly blank space directly between you and the earth, you naturally try to think of pleasant things to keep up your courage. Your pilot is a comfort. He grins good naturedly at you, and this reassures you pleasantly. I still have very kind feelings for the pilot who first took me up. He was a student who had had only three or four hours of solo work. I have always admired him for his nerve, for he did not acquaint me with his inexperience until we had reached terra firnia after a very bumpy ride. This ride occurred during the first few days after my assignment to an air station. Of course, my confidence in aeroplanes increased thereafter, and I was not satisfied until I had hold of the controls myself. But it took me some time to get over the feeling of being up so high. I know my head was not cool enough to fly a plane right, although the instructors would tell me carefully just what should be done and I would know how to do it. I suffered from what is called in the hunting districts " buck fever." I have also experienced " buck fever " while hunting. It occurs after you have hunted for a long time without success, and then suddenly a fine buck deer rises in front of you perhaps 75 yards distant. You become so excited that as you aim your rifle you begin to shake all over and must use all your will power to make a steady aim. After you have brought the deer down with your shot you feel weak. I believe that I had buck fever quite badly during several early flights. My mind was influenced more perhaps by some of the acci dent cases I picked out of the bay following crashes. During that time one poor lad in particular weighed upon my mind, for he was a friend. I assisted in removing his horribly mangled body from the wreck. He was beyond recognition. But I still kept going up as a passenger, and in time the unpleasant feeling wore off. I can say very frankly, however, that I always have possessed a subconscious feeling of impending danger while in the air. It has not hampered my sense of security, however, and I believe that I am as cool about such matters as the average person. I lay down these facts merely to show the feelings of the average individual in his attitude toward flying heavier-than-air craft. I do not consider myself overcalm or cool while meeting the exigencies of life, and being convinced that my nerve is about the average I have used the analysis of it as a sort of basis to work out the feelings of men who have made a profession of flying. No. 3. THE NERVOUS ELEMENT IN AVIATION. 475 I have found that the average number of fliers at first experience about the same sensation I felt myself. Some have more nerve and daredeviltry in them and they are the excellent fliers. They are so cool that it becomes almost a second nature in them to fly. Others are very sensitive and will never get over being afraid. I knew one instructor who, I was sure, hated the sight of an aeroplane, but he would not give up until after the armistice was signed because he did not want to be branded a quitter. Bumpy air scared him so that if he could possibly get out of it he would not fly. His students did not have the proper confidence in him. He was what is known as an inconsistent flier. One day he would fly fairly well and the next he would be porpoising all over the bay and doing other unin tentional stunts. He would climb exceptionally slowly and glide down like a shot, as if in a hurry to reach mother earth again, and then away he would go flying just above the water for a much longer distance than was necessary to land, then gradually begin to feel his way down with the back of his pontoon. He talked in a strained manner and was of a neuropathic make-up. But he always turned out his students, and got in the required number of hours. Luck seemed to be with him, for his planes avoided crashes somehow. Occasionally one finds a beginner who is hopelessly without nerve. Two men that I remember distinctly came to me and on being put through the grill broke down and cried. One lad in particular told me that if the Secretary of the Navy himself should order him out in an aeroplane he would not go. Of course, such cases were thrown out of the service as soon as discovered. Generally several days of inconsistent flying occurred among the students after a man had been killed by a fall. It is best to not stop the flying because of a fatal accident. It takes some of the weaker ones' nerve down a bit, but brooding over possibilities during inac tion is poor policy. With hands and feet on the control, confidence is regained. And this was war and not mere sport. Students were taken temporarily from flying upon the discovery of very minor defects. For example, the slightest strain or sprain of wrist or ankle would be sufficient to place a man on the sick list. Malingerers at sick call were uncommon, but when discovered, were watched with extra care. Often they were allowed to carry on for a short time until a thorough personal investigation could be carried out. The investigation would frequently reveal something of signifi cance in regard to the man's flying ability or nerve. The students, during the early summer of 1918, were often worked too hard. Many of them at that time averaged only five or six hours of sleep. Their duties consisted of more than flying and ground school. They handled lumber, barrels of gasoline, cement mixers, etc., and many were played out and did not maintain the best phys 476 THE NERVOUS ELEMENT IN AVIATION. Vol. XIII. ical standards. The system was changed, however, and the hours and amount of work was cut down considerably. I believe that the nearer we approach the Goshport system of train ing, the better will be the trained fliers turned out. This system al lows a student to fly only when he feels like it, and assigns only two or three men to an instructor. The old system gave 10 or 15 men to an instructor. Under this new system the instructor gets to under stand his students better through more constant and personal associa tion, and the students have time to figure out their problems at leisure. A medical officer's position at a naval air station is somewhat dif ferent from that of the medical officer at any other station. The medical officer must know all the men who fly, and know them well. He must be what is known as a good mixer. He must possess the faculty of obtaining the most intimate confidences from these young officers, and must spend hours in informal association with them. He must be liked, and go out of his way to obtain their good will and respect, and be ever ready to sit down, for example, to a lengthy discussion of the young fellow's domestic difficulties. By so doing you learn your man's make-up. You have an intimate idea of his caliber; so, when difficulties come up in his flying, you have a valuable stock of information to draw upon. To illustrate the bearing that your possession of his confidence and respect for you may have upon a boy's ability to fly, a simple case of a very young fellow comes to my mind at this moment. The lad was a very conscientious and gentlemanly young man. He had gone right from home to college and before finishing his course had taken to naval aviation. He was a delicate sort of boy and his intimacy with the hard knocks of the world was not overgreat. I began to notice that he did not eat very much and that he was dejected. He walked by himself a good bit and did not go to bed early. On the beach he seemed to have lost his former " pep." I watched him from a distance for some time and soon began to notice that he was very inconsistent in his flying. His instructor told nie also that the boy had evidently lost his " pep." One clay the in structor took me up and we followed the boy around the course to watch his flying. At about 10 miles from the station the lad shut off his motor and glided down for a landing, and after taxying a bit on the water we noticed that his propeller stopped its motion. We flew back to the station and reported his plane as having a " dead stick " and then again flew around the course. As we came back to the location of the boy and his plane the pilot spiraled down and landed a short distance away. I at once noticed that the boy's head was hanging to one side and resting on the fuselage. Thinking that perhaps he was ill. we taxied close in to him and began shout No. 3. THE NERVOUS ELEMENT IN AVIATION. 477 ing. He suddenly sat upright and rubbed his eyes in surprise. He had been sound asleep and had not been awakened even by the extraordinary noise of our motor. It took some shouting to awaken him, too. I requested that the instructor say nothing about my presence to the boy. He had not recognized me in the flying costume. The next day I joined him as he was walking up the street and we had a chat for a half hour as we covered the distance to town. The chat was about nothing in particular. In a. couple days, however, he was in my room smoking and telling me the most woeful tale you could imagine about how his girl, to whom he was engaged out West, had just given him the cold shoulder. He said " I am all broken up over it." Of course I had to bolster him up and help him forget it. I obtained three days' leave for him to go to New York, and gave him the names of several people to locate at different clubs. He came back a new man and went to flying like a veteran. The last time I heard of him he had a new girl, had finished his training, and had obtained his commission. He turned out to be an excellent flier. So I learned that tact and constant association play a great part in discovering the traits essential for making up a good flier. One of course must not go too far with the intimacy. That would not be policy. The medical officer in military branches should not breed too much familiarity. He is a doctor at all times and an officer in grade and rank. It takes the right kind of medical officer on an air station to help bring out success in flying. He must be on the job, and if he does his work properly, the sick call in the morning is not the all im portant event of the day. The number of flying hours can be in creased markedly through the influence of the medical officer. Dur ing the days when the rush was great to turn out fliers, and time lost in getting these men abroad meant a great deal, the doctor had to be on his toes to keep up with the work. Many trips he had to make through the sleeping quarters at midnight to watch them in their sleep and see that they had proper ventilation and sufficient bed clothing and were not disturbed by unnecessary noises. He had to watch them eat, watch them as they returned from liberty, and watch over countless other little things. In short he was one of the athletic trainers, and they all- knew that the doctor was working for them, for their health and welfare. They appreciated it, and there was no grumbling. As I have gazed down upon the lifeless bodies of some of the noble men whom it has been my lot to see crash to the earth from lofty heights to meet death instantaneously, my heart has gleaned the full 478 ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." Vol. XIII. meaning of patriotism, of right over might, and of the justice of a cause for which the best young blood of our land has been shed. Those lifeless features but a moment ago were set in grim defiance, those limp hands were clutching the wheel in steady control, and with nerves alert when the unexpected came. Did the flyer try to meet it ? Yes! to the very last precious inch of space allowed him he worked in frantic, grim desperation. Down swift as a shot he goes; the inevitable stares at him. He does not shut his eyes and wait. No ! he clamps his teeth and works to the very last moment, and then it is over in a fraction of a second. All great fliers expect this kind of death some day, and one who knows them can never doubt the ear nestness of that last grim effort before the fatal crash. THE ADMINISTRATION OF THE U. S. HOSPITAL SEIF " SOLACE.'' By E. E. II. OLD, Commander, Medical Corps. United States Navy. ROUTINE FOR MEDICAL OFFICERS. Medical officers will stand day's duty in succession beginning at 10 a. m. The day before coming on duty as officer of the day, each medical officer will be on duty as relief officer of the day. When ship is at a navy yard, or alongside wharf at hospital, the relief officer of the day will be allowed to leave the ship after 4.30 p. m. if his services are not required. The officer of the day shall remain on board while on duty; duties requiring a medical officer to leave the ship such as visiting a patient on another ship, in charge of patients being transferred by boat, fire, and rescue party, etc., will be per formed by the relief officer of the day. Whenever the officer of the day is performing some duty which will take him some time, such as an operation, etc., he shall inform his relief who will then take up the regular duties required until relieved. BECKIVING A PATIENT ON BOARD. 1. The officer of the deck will notify the officer of the day when patients are coming alongside and have the stretcher men notified. The master-at-arms will be at the gangway, when not otherwise per forming duty, to assist the officer of the day in receiving patients and, if more stretcher men are necessary, will detail extra men for that work. 2. Men, other than those sent as patients, requiring examination or treatment will report to the officer of the day. Those for whom appointments have already been made—such as eye, dental, X-ray, Wassermann, etc. —will be sent to the respective medical officers in charge of those departments. Other cases will be examined and No. 8. ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." 479 treated or referred to the medical officer under whose specialty their cases may fall. All cases of this class should bring their health records and a note made in same by the medical officer examining the case, and the records should then be turned in to the record office for approval by the commanding officer. Should it be considered advis able to retain a man on board as a patient, report to the executive surgeon for instruction regarding such admission. 3. Patients should wear a tag with ship, name, rate, and diagnosis. 4. Baggage should be tagged with patient's name, rate, and ship. ' ADMISSION OF MEMBER OF THE CREW TO SICK LIST. 1. When it is desired to admit to the sick list a member of the crew or hospital corps of this ship, send a memorandum to the record office immediately. Later obtain health record from record office, enter diagnosis, etc., and return to record office for information and for warding to the commanding officer. 2. When placing a member of the crew or hospital corps on the binnacle list, send name and rate to the record office and state " for binnacle list." If condition is such that the man will probably be off duty for more than 2-1 hours, he should be admitted to the regular sick list. Make a note in health record of any injury or other trouble which might produce symptoms or recur in the future. ASSIGNMENT OF PATIENTS TO WARDS. 1. All medical and genito-urinary cases will be assigned to ward A (medical ward) ; also cases of erysipelas. 2. All surgical cases, eye, ear, nose, and throat (except tonsillitis) , will be assigned to ward B (surgical ward). 3. All contagious cases will be assigned to wards C, D. E, (isola tion ward). 4. All officer patients, except contagious cases, will be assigned a room in sick officers' quarters. 5. The senior medical officer of a ward will be in charge of the ward and have full charge of the management of all patients and hospital corpsmen. He will make regular inspections and be responsible for the cleanliness of the ward and the preservation of property. Ward details should be submitted to him for approval by the chief pharma cist's mate in charge. All general orders relative to ward work shall be issued through the chief pharmacist's mate or pharmacist's mate in charge of ward. 0. Officer patients shall be treated by the medical officer under whose specialty their cases fall. The management, etc., of the sick officers' quarters is a part of the second, or surgical, division. 7. The officer of the day will notify in person or by messenger the medical officer of the ward to which a patient is sent. This shall be 480 ADMINISTRATION OF THE HOSPITAL SHIP SOLACE." Vol. XIH. done immediately in a case of serious illness or one requiring im mediate attention. ROUTINE FOB HEALTH RECORDS AND OTHER PAPERS. When a patient is received on board the officer of the day will see that the health record of each case is received. Send the health record and other papers (hospital ticket, pay accounts, etc.) to the record office. If no papers are received, take man's name, rate, and ship as a memorandum for the record office. The health records pass through the executive surgeon to the commanding officer and are then distributed to the medical officers. When health records are received by medical officers they will at the first opportunity verify them with patient and note any changes that should be made in red ink and initial. Medical officers will examine incoming cases as soon as practicable, prescribe treatment, and enter findings in health record. Consult with executive surgeon before making a change in diag nosis. When a diagnosis is changed the health record must be so completed and returned to the record office for necessary information. The attention of the executive surgeon should be called to incorrect or incomplete records. PROCEDURE IN DISCHARGING A PATIENT TO DUTY. Whenever a patient is ready for duty the form kept in the wards, " Patient ready for duty or transfer," shall be filled out by the medical officer in charge of the case and sent to the record office for the in formation of the executive surgeon. As soon as possible the health record of the case will be completed and signed, leaving blank the date of discharge and the number of sick days, both in history of case and in abstract, except for a number of the crew of this ship, ii which case fill in dates and number of sick days. TRANSFER OF PATIENTS. When patients are to be transferred the medical officers will see that full instructions are given the pharmacist's mates in charge of wards regarding the cases to be transferred correct diagnoses, which cases should go in stretchers or walk, and in case of the latter whether they should go up in ambulance. All cases transferred shall wear a tag giving name, rate, and diagnosis. If a body is transferred for preparation for burial, a tag giving full name, rate, and diagnosis shall be attached to the right great toe; a letter of transmittal shall go with the body giving necessary immediate information, and later the other necessary papers shall be sent. The officer of the day, assisted by the master-at-arms, will have charge of transferring patients and baggage under direction of the executive surgeon. No. 3. ADMINISTRATION OF THE HOSPITAL SHIP "SOLACE." 481 Lists of patients with diagnosis will be made in the record office. The officer of the day will check the names as patients are turned over to the medical officer from the hospital receiving them. He will see that all patients and baggage are handled with every considera tion and care. Hospital corps details of men to handle stretchers and baggage and accompany patients to look after return of property from hospital will be made out by master-at-arms. The executive surgeon will direct the order in which contagious cases are to be transferred and, if in boats, will make out a schedule for same. The assistant master-at-arms in charge of the bag room will break out the bags and hammocks of men to be transferred according to list furnished and see that they are properly lashed, secured, and tagged with the patient's full name and rate. Another check up of baggage will be made when it is removed from bag room and again when placed on wharf. He will be present to check it again when delivered to representative from hospital authorized to receive same and obtain a receipt. The pharmacist's mates in charge of wards will make a list of all stretchers, blankets, sheets, pajamas, etc., that are sent with patients and will give a list to the pharmacist's mate in charge of property who will be stationed on the wharf to receive and check up on same as returned, to be again checked up on return to ward. The officer of the clay will report to the executive surgeon when all patients and baggage, have been transferred; a later report will be made regarding property. All papers of transfer, as health records, hospital tickets, pay accounts, enlistment records, etc., will be taken direct to the hospital by the pharmacist in charge of the record office or his assistant and a receipt for same obtained after being checked. When such a transfer is made in boats the officer of the day will have charge of loading the boats, as outlined by the executive sur geon. The relief officer of the day will accompany the patients to place to which transferred, and will then turn over patients to the medical officer receiving them in the same manner as mentioned above. Hospital corpsmen will also accompany patients in order to handle stretchers and return all property. Baggage will be handled as mentioned above. SICK CALL AND .HORNING REPORT OF CASES. When aboard ship medical officers shall hold sick call at 9 a. m. and 6 p. m. and shall not delegate this duty to anyone else unless engaged in other official duties or absent from the ship. When a 482 ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." VoL XIII. medcal officer is to be absent from the ship at sick call he shall arrange with another medical officer to visit his cases or notify the officer of the day that he will be absent, and inform him of any cases that are seriously ill and may require some special care. Medical officers shall report to the executive surgeon immediately when the condition of a case is considered serious. They shall report in person, or by memorandum, the condition of such cases every morning after sick call. All orders given to pharmacist's mates relative to treatment of patients shall be written in an order book, kept in each ward for that purpose, and signed or initialed by the medical officer giving such orders. MEDICAL JOURNAL. The medical journal must be written up to date by 10 p. in. and closed and signed at 10 a. m. and turned in to the record office. It shall contain all items relative to the work of the medical depart ment of the ship, such as inspections, drills, " mast " for members of the hospital corps and punishments, court-martial of the hospital corps, receipt of bodies for embalming and inspection of same, deaths, movement of ship, transfer of patients, hospital corps reporting for duty or transferred, medical officers reporting or detached, medical boards, boards of inquest, etc. When the officer of the day desires to be relieved from duty he shall obtain permission from the executive surgeon, and must write up and sign the medical journal on being relieved. When the relief officer of the day desires to be relieved he shall obtain permission in the same way. INSPECTION OF MEALS. The officer of the day shall inspect the meals of the hospital corps and convalescent patients to see if thev are satisfactory in quality and quantity, and at same time to inspect mess gear to see if clean and in proper condition for serving food. When unsatisfactory he shall report the same to the executive surgeon, and make entry to that effect in the medical journal. When the officer of the day is unable to inspect the meals by reason of other official duties, the relief officer of the day shall be notified and make this inspection. Officers of the various wards shall exercise careful supervision over the diets of their patients, and see that they are getting proper food and that it is served properly. INSPECTION OF PROVISIONS. The officer of the day will make an inspection as to the quality of all provisions received on board ship. The inspection shall be a personal No. 3. ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." 483 one and a report made to the paymaster when any are condemned as unfit for use. The regular report certifying such inspection shall be signed. The chief commissary steward shall be present at such inspec tions. Whenever the officer of the day can not be present his relief should be notified. Bumboats, when allowed by the commanding officer, shall be care fully inspected by the officer of the day. Care should be taken to prevent smuggling of alcoholic beverages. PERMISSION TO LEAVE AND REPORTING RETURN TO SHIP. Permission to leave the ship will be obtained from the executive surgeon or, in his absence, from the senior medical officer on board. Before leaving report same to the officer of the day and to the officer of the deck or to the quartermaster on watch at the gangway when going over the side. When returning on board report to the officer of the day and execu tive surgeon or senior medical officer aboard. After 9.30 p. m. make such report before 8.30 a. m. the following morning. When returning from leave of absence or other leave granted by the commanding officer report return to him as well as to the executive surgeon. BREAKFAST HOUR. The wardroom mess table must be cleared by 9 a. m. No breakfast will be served after 8.30 a. m. QUARTERS. The master-at-arms shall see that the hospital corps is mustered at 6.45 a. m. daily at their stations in wards, etc., and report hospital corps and patients present or accounted for by 8.45 a. m. daily to the executive surgeon. Any absentees will be reported to the officer of the day for entry in the medical journal. At 9 p. m. an entry shall be made by the master-at-arms, or the chief pharmacist's mate on watch, to the officer of the day as to whether all are present or accounted for; prisoners reported (if any), lights out, No. 2 hold inspected, and any other report that might con cern the security of the medical department of the ship. The officer of the day will make his report to the executive surgeon who will then report to the commanding officer. LIBERTY PARTIES. All men going on liberty will receive their passes at the record office and will show same at gangway as authority for leaving the ship. 116025—19 7 484 ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." Vol. XIII. On return the passes will be taken immediately to the record office and placed in the box for liberty cards. Xo man will be allowed on liberty who is not wearing his identi fication tag properly suspended around his neck, or who is not in the prescribed uniform and neat in appearance. Patients going on liberty will be checked out and in from a list made of same. The officer of the day or master-at-arms will inspect all such parties of hospital corps men and patients. When alongside the wharf the quartermaster on watch, or super vising night pharmacist's mate, will report any man returning on board under the influence of intoxicating liquor to the officer of the day who will examine him immediately and report such exami nation. BOAT SCHEDULES. The commanding officer's gig is for the use of the commanding officer, and will not be used for any other purpose except by his permission. The boat schedule will be made out by the executive surgeon with the approval of the commanding officer. These schedules will be made to suit the convenience of all as far as possible and officers will conform to these schedules in making appointments and engage ments. Special boats will be allowed if necessary, when such will not interfere with the regular duties and other demands of the ship. No other than the regular boats shall leave the ship without the knowledge of the executive surgeon. SUMMARY OF ROUTINE DUTIES OF OFFICER OF THE DAY. 1. Inspection of meals and mess gear. 2. Inspection of medical department (wards, etc.) about 3 p. m. 3. Eeceiving and distributing patients. 4. Holding evening sick call on the patients of any medical of ficer who may be absent. ."). Inspection of provisions, bumboats, etc. 6. Examination of members of the hospital corps or crew for dis charge, transfer, or enlistment. 7. Inspection, together with the executive surgeon, of bodies pre pared for burial. 8. Eeceiving and making reports at 9 p. m. 9. Medical journal. ABANDON SHIP. 1. Patients will be mustered on the upper deck and forecastle oppo- »ite where the boats to which thev are assigned are lowered. The men Xo-3. ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." 485 who are not able to go down a ladder, and those who have to be put in boats in stretchers, such as fractured leg, etc., will be placed in boats when on falls opposite the rail. No others will get in boat at that point, but will wait until the boat is in the water, and then go down pilot ladders or hand-lines. 2. There will be assigned to each boat four men to be lowered in it; two to attend to the falK and two hospital corpsmen to assist in tak ing in helpless men and those in stretchers. Any man handled in stretcher, and who does not absolutely have to remain in one, will be immediately removed from it as soon as placed in the boat and the stretcher thrown away ; medical officers will decide this point. 3. The medical officers assigned to boats will take their stations on the upper deck with patients, and when the boats are stopped at that point will have the helpless men put aboard. 4. The helpless patients in the isolation ward will be placed in the whale boats before they are lowered. The patients there can always be carried by hand ; no stretcher is necessary. 5. The hospital corpsmen and supply division assigned to carry breakers, medical boat box, rations, and mess gear, will all go to boat deck to aid in lowering boats. All other hospital corpsmen will aid in looking out for the sick, carrying stretchers and helpless men, and will call on able convalescent patients to assist in this work. 6. The kapok mattresses in the ward will be brought up on deck to be thrown overboard when so ordered. 7. Boats shall not bo lowered into the water, or rafts launched, until the ship loses her headway and the order is given by the master. 8. If the emergency is such that the master passes the word to aban don ship as quickly as possible, the helpless shall be placed in the first available boats, and all others shall get overboard and away from the ship as soon as possible, depending on reaching rafts or floating wreckage. The sick shall be attended to as above before medical officers and hospital corpsmen leave the ship. 9. Life jackets shall be at hand for each patient, and all patients shall be provided for first. At sea the life jackets shall be placed at each bunk, and ready to be adjusted by patients at a moment's notice. This order shall also apply to crew and officers so that no time be lost. 10. Boats as soon as filled will be pulled away from the ship and stand by to assist. 11. After boats are lowered the men assisting on boat deck will reach boats or water by way of falls or from hurricane deck by way of ladders and hand lines. First and second whaleboat crews will assist in lowering first and second cutters before leaving boat deck. Those who jump or dive over will be careful to look first and not strike some man already in the water. 486 ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." Vol. XIH. 12. The boats and rafts will be manned and lowered under direc tions of the ship's officers and petty officers. The officer or petty officer assigned to a boat shall have a list of the men in his crew, in cluding hospital corps and supply division, and will account for ab sentees at drill. They shall have a list of what should be provided for each boat and see that it is actually brought up. 13. When being lowered, the first and second whaleboats and the first, second, third, and fourth cutters will be stopped at the rail of the upper deck to allow the helpless men to be put aboard. The first and second whaleboats will be stopped for only a short time, as they should be taken off the falls as soon as possible in order to allow lowering of the first and second cutters; if the ship is to be aban doned as quickly as possible, however, they will be placed in the water immediately and not stopped at rail. In the latter instance all the helpless will be mustered opposite where the second and fourth cutters are lowered and be placed in those boats when oppo site the rail of upper deck. 14. The pontoon rafts will be boarded by way of hand lines, pilot, ladders, or from the ship as soon as possible and stand by to assist. 15. The Carley life rafts, after being launched, will be manned and cast adrift as soon as ship loses headway, and will be paddled clear of the ship to stand by and pick up men in the water. INSTRUCTIONS FOR HOSPITAL CORPS. DAILY ROUTINE. 6.00 a. m. —Reveille for hospital corpsmen and convalescent patients. 6.45 a. m.—Muster at stations. Turn to. Baths for bed patients, etc. 7.00 a.m.—Ward diets. First mess. Draw ice. 7.30 a. m.—Breakfast. 8.00 a. m. —Turn to. Report number of patients, etc., to record office. Report any absentees to master-at-arms. 9.00 a. m.—Sick call. 10.00 a.m.—Inspection by executive surgeon. 11.30 a. in.—Ward diets. First mess. 12.00 a.m.— Dinner. 3.00 p.m.—Draw ice. f>.00 p. m.—Ward diets. First mess. 5.30 p. in.—Supper. 6.00 p.m. — Sick call. 8.50 p. m. —Muster patients. 9.00 p.m.—Taps. Report to chief pharmacist's mate on duty. Night watch report for duty. Ko.8. ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." 487 WEEKLY ROUTINE. Monday: Tuesday: Change linen. Examine bunks for vermin. "Wednesday : a. m.— Air bedding. Draw cleaning supplies. Gen eral field day for wards. 1.00 p. m.— Bag inspection. First Wednesday in month. Thursday : 10.00 a. m.— Inspection of hospital corps and supply di vision on hurricane deck. Inspection of wards and patients by commanding officer. First Thursday in quarter muster of whole crew for reading of Articles for the Gov ernment of the Navy. 1.00 p.m. — Fire and collision drill. Abandon-ship drill first Thursday in month. Friday: Change linen. General field day, excluding wards. Saturday : 10.00 a. m.—Inspection of ship, including wards, by com manding officer, p.m. — Holiday. Recreation parties; rowing and sailing when possible. Sunday : Divine service when chaplain is available. Recreation parties ; rowing and sailing when possible. DUTIES OF HOSPITAL CORPSMEN IN WARDS. 1. Every care and attention shall be given to patients. 2. Temperature, respiration, and pulse shall be taken promptly and recorded on chart. Take T. P. R. of every patient admitted to ward for medical officer's information; start chart on those cases for which ordered. 3. Medication shall be given as ordered. 4. Send to laboratory in morning a specimen of urine of every case admitted the day before. For this purpose the day watch will obtain clean bottles and turn them over to night watch with names of patients received on separate slips. Inform patients in regard to obtaining specimen. 5. Bed patients will be bathed every day. Notice skin over promi nent bony parts for possible beginning bedsore; report if becoming chafed. 6. Beds are to be cleaned, sheets smoothed, and otherwise made up properly every morning, and for bed patients as often as is necessary for the comfort of patient. 7. The pharmacist's mate in charge of wards will have in his pos session the keys to the poison locker, linen locker, etc., and shall be 488 ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." Vol.XIIL responsible for their contents while he is on duty. When relieved he will pass the keys to his relief, to supervising night watch, etc. 8. The pharmacist's mates will see that " Instructions to patients " are called to the attention of men as admitted and that they are obeyed. They shall study said instructions and be familiar with the orders, which also apply to hospital corps in many particulars, espe cially Nos. 6, 7, 8, 10, and 16. 9. The other hospital corpsmen will obey orders given by the chief pharmacist's mate and senior pharmacist's mate in charge of wards. 10. When a stretcher case is admitted the chief or senior pharma cist's mate will ascertain if patient has any valuables or money he wishes given to executive surgeon or paymaster for safe keeping; if patient is unconscious or seriously ill, he will search his effects and turn such over to either of the above officers, if any are found. If stretcher case has on a uniform, or a bundle of clothes is sent with him, these shall be tagged and sent to bag room to be stowed with patient's bag. 11. Pay particular attention to all orders given in regard to pa tients and see that the medical officer giving same signs or initials the order book. If a verbal order is given put it in order book later and state " Verbal order of Dr. ," and have him sign it at first opportunity. Note carefully instructions relating to ward books and index cards. 12. When a patient is received enter name, etc., on index card of " Roster of patients " ; make out " Report of patients received " and send immediately to record office; assign him a bunk and locker with number same as that of bunk. Each patient shall have only one locker and be allowed to stow in it only change of clothes and under clothes, toilet articles, and writing material. If ambulant, have him read " Instructions for patients " and note his bunk number. 13. In case of a death notify the medical officer in charge of case or, in his absence, the officer of the day. Cover the face and obtain stretcher for removal but do not prepare or remove body from bunk until pronounced dead by a medical officer. After a patient is pro nounced dead, cleanse body if soiled, place cotton in rectum, tie a piece of tape around penis, close eyelids and mouth and secure by bandage. Tie a tag to right great toe, giving name, rate, and ship. If noncontagious case wrap body in dry sheet and cover over with blanket if moved before 9 p. m. If contagious case first soak sheet in 1 : 5,000 bichloride solution before wrapping around body. Close roster card giving time of death .and send to record office. Notify chief master-at-arms or, in his absence, his assistant and send body to morgue. Send all his effects in locker to bag room. When a member of crew is admitted to ward state on " Report of patients received " if admitted to sick list or to be placed on " Bin No. 3. ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." 489 nacle list"; obtain this information from medical officer; also the diagnosis, which should be added to report. If only admitted to " Binnacle list " do not take up on " Roster of patients " ; can make a separate card for these cases headed "Binnacle list" and keep at hand for reference. TEMPERATURE HOURS. Q. 4 hrs 8 12 4 8, and during night if patient is awake. T. I D 8 2 8.. B. I D 8 8. MEDICATION HOURS. Q. 3 hrs 8 11 2 5 8, and during night if ordered. T. I D 8 2 8. Medications ordered at certain specified hours shall be so given. At 9 p. m. the master-at-arms or chief pharmacist's mate on watch shall take station in the lobby. The hospital corpsmen in charge of the several wards will report if all patients are present. The assist ant master-at-arms will report inspection of alcohol chests, No. 2 hold, prisoners (if any), patients in strong room (if any), and if the keys of brigs and strong rooms have been turned over to the super vising night pharmacist's mate. The hospital corpsmen going on night watch will report for duty in wards, and the supervising night watch will report that the watch is posted. The master-at-arms or chief pharmacist's mate on watch will then make above reports to the officer of the day, in addition reporting any member of the hospital corps or supply department if absent. The officer of the day will report to the executive surgeon, who will report to the commanding officer. CHANGE FROM DAY TO NIGHT WATCH DUTIES OF NIGHT WATCH. 1. At 9 p. m. the night watch will report for duty and take over charge of wards. The wards are to be thoroughly policed by the day watch before being turned over, and if the wards, dressing rooms, diet kitchen, etc., are not found in good condition, a report of same shall be made by the supervising night. watch to the executive surgeon. This order also applies to the night watch before turning over to the day watch. 2. All orders to be carried out during the night, that have been given the day watch, shall be turned over to the night watch in writ ing, in a book provided for that purpose. Any orders given during the night, that continue during the day, shall be called to the atten tion of the day watch when reporting for duty. Any cases seri ously ill or needing special attention will be visited and order regard ing same repeated. 490 ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." Vol. XIII. 3. The supervising pharmacist's mate on night watch shall make rounds of the Medical Department every half hour, giving particu lar attention to assistants being on watch and attending to duties, store rooms, pantries, galley, alcohol chests, paymaster's office, and other offices. When there is no watch in sick officers quarters or isolation ward, he will see if any patients there need attention. If any patient or member of the crew needs attention of a medical officer he will notify the officer in charge of case or officer of day. 4. One assistant will remain in medical and one in surgical ward. The supervising watch will remain in wards when not making rounds. Special watches will be detailed when necessary. 5. In case of fire the supervising watch shall immediately sound the general alarm, notify officer of the deck or quartermaster on watch of the location of the fire and stand by to release prisoners until relieved by the master-at-arms. He will see that keys of strong rooms are turned over to him when going on duty. 6. The supervising watch shall call the ship's cook on duty at 3 or 4 a. m. as ordered, and the baker and butcher at hours ordered. He and his assistants will call all hospital corpsmen and convales cent patients at 6 a. m., and remain on duty until relieved by the day watch at 6.45 a. m. 7. The night watch will draw their lunch at 4 p. m. 8. The supervising night watch will see that his assistants per form their duties properly. He will report any disorder or any other irregularities that may be noted on rounds, thus acting in the capacity of assistant master-at-arms. He will keep a written record of time of making rounds and notes shall be made of anything unusual found, and shall turn in this book to the executive surgeon's office before 8 a. m. WABD BOOKS AND INDEX CARDS. 1. Order book : In which shall be written all orders given by med ical officers for treatment of patients and shall be signed or initialed by the medical officer. Such orders shall be checked as they are carried out by the pharmacist's mate or recorded on medication sheet, diet sheet, etc. 2. Night order book : Will contain all orders in regard to patients that are to be carried out by the night watch. Such orders shall be entered by the senior day watch before turning over to night watch. These orders, as carried out, shall be checked by the night watch. 3. Drug book : Containing list of articles drawn from dispensary. This list shall be signed by medical officer in charge of ward. 4. Property cards (two sections) : card index. (a) Medical department : Containing a list of all nonexpendible property issued to the ward belonging to this department, such as No. 8. ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." 491 blankets, bed linen, pajamas, bedpans, buckets, etc. The card will show number and date received. When articles are received from store room or turned in date and number will be entered on card. (b) C. & R. and supply department: Containing list of all property issued to the ward belonging to this department, such as mattresses, pillows, mattress covers, pillow covers, etc. The card will show number and date received. When articles are received or turned in to supply officer for survey, this date and number will be entered on card. These cards will be kept up to date by the pharmacist's mate in charge of ward, directed by the chief pharmacist's mate. The pharmacist's mate or chief pharmacist's mate in charge of property will check up these cards the first of each month. 5. Roster of patients: A card index shall be kept in which the names of all patients will be entered on cards. This will give name, rate, ship, date received, diagnosis. It shall be kept up to date and ready for reference each day to check up on patients belonging to ward. When a patient is transferred, discharged, or dies the card will be closed with this information entered on it, with date, and sent to record office. The medical officer in charge of ward will see that the above books and cards are kept properly. They will be inspected occasionally by the executive surgeon, and regularly after each inventory. SCRUB AND WASH CLOTHES —BAGS AND HAMMOCKS. Clothing may be scrubbed every morning except Saturdays, Sun days, and holidays, and every evening except Saturdays, Sundays, and evenings before holidays when in port. For this purpose the pumps on the forecastle should be started at 4.30 p. m. and the decks dried down at 7 p. m. or before dark. At least one-half of the fore castle will be left dry. Bags and hammocks will be scrubbed when ordered, by watches. During winter months clothes, etc., may be scrubbed during above afternoon in the wash room. All clothing, etc., shall be hung on lines on forecastle, which will be triced up at 6 a. m. and 7 p. m. except Saturdays. Sundays, and holidays. Begin hanging clothes at head of line and not near lower end. None shall be hung in wards, bathrooms, or sleeping com partments. Bedding will be aired Wednesday and may be hung over the rail and awning lines abaft the record office and on the fore castle. Clothing and bedding will be piped down at 1 p. m. or when word is passed. All clothing shall be properly marked in accordance with Naval Regulations. LAUNDRY. 1. Count and turn in soiled linen, etc.. Tuesdays and Fridays and receive a fresh supply. 492 ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE. " Vol. XIII. 2. Whenever linen is changed examine bunks and mattresses care fully for bedbugs and if found notify the master-at-arms, who will have the necessary articles sterilized, then go over bunks thoroughly with blow torch where possible, and kerosene mixture where torch can not be used. 3. All linen from isolation ward shall be so marked, sterilized before going to laundry, and returned to that ward. Linen from beds of scarlet-fever cases and that soiled by any case in this ward shall be first soaked in 1 : 5000 solution of bichloride for one hour. 4. All linen belonging to operating room should be so marked and returned to that room. FBESH WATEB. All men shall be careful in use of fresh water, and especially to see that taps are not left running to cause waste. The capacity of evaporators is not sufficient for ship's purpose, consequently the excess has to be earned in tanks, which makes economy necessary. PASSAGEWAYS. 1. The medical and surgical wards must not be used as passage ways by the hospital corps, patients, and crew. 2. Men on duty carrying diets, laundry, ice, or other articles can use the starboard wing passage to the medical ward. 3. Men from the medical ward going aft must use the hatch leading on deck or below into convalescent mess compartment. 4. Men from the surgical ward going aft must go by the way of the starboard wing passage. 5. The lobby must not be used as a general passageway except by patients from the surgical ward going to and from the deck above, or hospital corpsmen on duty. 6. No loafing or loitering will be allowed on hurricane deck except in such places aft of deck house as may be designated in emergency. BAG BOOM. 1. An assistant master-at-arms shall be in charge of the bagroom. Hospital tickets will be sent to him for filing. He will keep a .card index, giving list of baggage of each patient received and containing full name of patient, rate, ship, date received, number of bag, ham mock, ditty-box, and number of rack in which stowed. All baggage received by him should have been tagged with owner's name, rate, and ship before being sent to bag room, but in case this was not done he will have such baggage identified by owner before tagging, listing, and stowing it. When a patient is discharged to duty he will be sent to bag room to stow his bag and properly lash bag and hammock, and will satisfy himself that all his property has been returned to No. 3. ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." 493 him ; he will then be required to date and sign receipt on his index card : this will also be required of those patients being transferred to ho-pital who are able to go to bag room —that is, in regard to stowing bags. etc. —as a receipt will be obtained from hospital for baggage. 2. AVlien patients are to be discharged or transferred the list of names will be given the master-at-arms for the bag room. Baggage will be broken out and delivered as stated in paragraph 1 in case of discharge. When transferred to hospital all the baggage of patients on list will be broken out, stowed, and lashed properly. A check, paying particular attention to names and rates, will be made as it is removed from the bag room, again when placed on wharf, and again when delivered to representative from hospital authorized to receive same, and a receipt obtained. All baggage shall be han dled with care: none allowed to be thrown about. The clothing list on hospital tickets will be made out by the assist ant master-at-arms in charge of bag room and returned to record office. 3. Each morning a list of patients admitted and discharged dur ing the last 24 hours will be sent to the bag room. This list will l>e checked with the baggage received and delivered and a report made to the executive surgeon as to whether all patients received had baggage and if such was complete, also if all patients discharged received their baggage. 4. The bag room card index will be kept at all times in the bag room. All entries shall be made promptly on admission or discharge of patients. A check on all baggage shall be made each Fridaj7. Hospital tickets shall be kept for at least one quarter and then destroyed. ' 5. The bag room shall be opened each day from 1 to 2 p. m. to allow patients access to their bags. Patients will be required to prop erly restow their bags and replace them, removing any trash left on deck. 6. No unauthorized person shall be allowed to enter the bag room. No loafing or smoking will be allowed. VALUABLES OF PATIENTS. 1. Patients having money or valuables should turn them over to paymaster or executive surgeon for safe-keeping. Those who keep them on their person do so at their own risk. 2. Whenever an unconscious or seriously ill patient is received the officer of the day or pharmacist's mate in charge of ward will search his effects and take any valuables the patient may have to the pay master or executive surgeon, with a memorandum of man's name and rate. 494 ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." VoI.XIIL ICE. Ice will be drawn at 7 a. m. and apportioned to the wards, etc., as follows: Medical ward, 5 cakes; surgical ward, 5 cakes; sick officers' quarters, 2 cakes; isolation ward, 2 cakes; commanding officer, 2 cakes; wardroom, 4 cakes; ship's officers' mess, 4 cakes; chief petty officers, 2 cakes. No ice shall be issued to any ward or any person in excess of the above allowance except by order of the commanding officer or execu tive surgeon. All ice left over will be placed in the cold-storage ice box for emergency use. When there are no patients the ward allowance will be reduced or cut off. Ice will be drawn from the cans by the deck and engineer's force and stowed in the ice box by the hospital corpsmen and mess- men. An assistant master-at-arms will be in charge of stowing and issu ing ice, under direction of the master-at-arms, and will see that ice is drawn at proper time and in amounts as outlined above. He will report, any infractions of this order to the executive surgeon. MESS GEAB, BEFUSE, SCULLERY. 1. Mess gear: There will be two messes for hospital corps known as first and second mess. First mess will be spread at 7 and 11.30 a. m. and 5 p. m. for those in the wards, etc., who are delegated for this mess: supplies will be drawn from galley about 10 minutes before mess. Second mess will be at 7.30 a. m., 12 m., and 5.30 p. m.: sup plies will be drawn from galley about. 10 minutes before mess. There will be only one mess for convalescent patients unless a large number require two; the hours will be as above. No meals will be served outside these hours without permission of the executive surgeon. One of the messmen will always notify the officer of the day when second mess is being spread in order that it can be inspected; this should be done promptly about five minutes before second mess. 2. Refuse: All refuse from mess shall be taken to garbage cans before 9 a. m., 2, and 6.30 p. m. The buckets shall not be filled to rim as this is liable to cause spilling on decks. The contents of buckets shall first be passed through strainer in slop chute, and only solid refuse put in cans. Always cover garbage cam after ushui. 3. Scullery : Mess gear must be thoroughly scraped of refuse be fore being sent to scullery, and shall be taken there promptly as soon as cleaned. The scullery shall be opened one hour before each meal. Ho. 3. ADMINISTRATION OF THK HOSPITAL SHIP " SOLACE." 495 SMOKING REGULATIONS. Smoking is allowed on the upper deck forward of the deck house: on the main deck abaft the surgical ward, except in the thwartship passage and wing passages forward of this: in seamen's quarters. Smoking is positively forbidden in the following places: (1) Wards and toilets; (2) operating room; (3) convalescent mess hall, except when allowed in bad weather; (4) cooks and mess attendants" quarters on berth deck; (5) all storerooms and holds; (6) in or around No. 1 or -2 hatches; (7) after part of upper deck where gaso line drums are stowed; (8) on hurricane deck around alcohol and ether chests; (9) no smoking after taps; (10) there shall be no smoking in an}7 boat at any time except steam launch when at boom, and then only in fire room section. LOBBY. The benches in lobby are intended for patients awaiting examina tion or treatment, and hospital corpsmen on stretcher duty. No smoking, loud talking, or loitering will be allowed. HOSPITAL COUPS UjUABTERS. 1. Shall be thoroughly policed after each mess and ready for in spection by executive surgeon at 10 a. m. 2. Men must not sit on clothes bags or hammock netting. 3. Men must not throw cigarette stubs or matches or spit on deck : they shall use the regular receptacles intended for same. Smoking not allowed after 9 p. m. GALLEYS, MESS ROOMS, ETC. No one except the cooks, stewards, and mess boys are allowed to enter the galleys or pantries except on duty. The galleys, scullery, and mess rooms will be closed at 9 p. m. and opened at 5 a. m., or when necessary. Any one found in these places or storerooms by the supervising night watch or quartermaster on duty will be taken to the officer of the day, or officer of the deck, who will investigate and report to the executive surgeon if necessary. Orders by the supervising night watch and quartermaster on duty must be obeyed. DISPOSAL Or GARBAGE, ETC. 1. In dry dock: Xo slops, garbage, or waste of any kind shall be thrown over the side or into waste pipes, sewers, or scuppers of this ship while in dry dock. Such shall be carried to cans on dock pro •196 ADMINISTRATION OF THE HOSPITAL SHIP SOLACE." Vol. XIII. vided for the purpose, and only solid garbage, etc., placed in cans, the liquid having been poured into the drain. All paper, boxes, etc., shall be placed in the box provided for such. All water-closets, heads, urinals, slop basins, etc., shall be closed, locked, and posted " Do not use." 2. Alongside of dock: The same disposal shall be made as men tioned above except water-closets, etc., are allowed to be used. 3. In port: All garbage shall be strained in slop chute and the solid matter placed in garbage cans and covered to be on garbage lighter. They shall be thoroughly cleaned whenever emptied. If no lighter is available the garbage shall be burned. All paper, trash, wood boxes, soiled dressings properly secured in paper bags, etc., shall be placed in trash cans in the thwartship pas sageway and forward of the fireroom uptake, and lowered into fire- room at — a. m. and 3 p. m. daily ; this work will be done by con valescent patients under direction of an assistant master-at-arms. 4. At sea : All garbage that will sink will be thrown over the side through slop chute. Tin cans shall be punctured with holes before being thrown overboard. All garbage that will float shall be thrown in furnace together with the paper, wood boxes, etc., as mentioned above. 5. The chief commissary steward will be responsible for the proper disposal of garbage, and will detail a man to keep the cans, stands, etc., clean when in navy yard, and will see that the deck and garbage cans in region of galley are kept clean at all times. DISPENSARY. The dispensary shall be open from 8 until 11.45 a. m.. 1 to 3 and 7 to 8 p. m., and at other times if necessary. UNIFOBM REGULATIONS. 1. When on liberty the prescribed uniform shall be worn and men shall be neat in appearance. The identification tag properly sus pended around the neck is a part of the uniform and shall be worn at all times. 2. Hospital corpsmen on duty in wards, scullery, and mess hall shall wear whites. 3. Men appearing on deck for the purpose of recreation shall wear whites. 4. Dungarees shall not be worn by hospital corpsmen at any time. SALUTING. 1. Men shall observe carefully regulations in regard to saluting. Salute the Commanding Officer every time he is met and other officers No. 3. ADMINISTBATION OF THE HOSPITAL SHIP " SOLACE." 497 at the first meeting during the day. If uncovered stand at attention. Always salute when speaking to, or spoken to by, an officer. 2. When ashore be careful to salute all officers of Navy, Army, and Marine Corps, and officers of our allies. 3. A. man's military efficiency can be estimated to a great, extent by his proper observance of saluting. GENERAL LIBEBTY BEGULATIOKS. 1. Libert}- will be granted by watches, alternating day and day. Regular liberty will expire at 8 a. m. unless sailing orders or other conditions render another hour necessary. One watch may be granted 48 hours' liberty Saturday and Sunday; the watch entitled to the 48 hours will remain on duty the Thursday and Friday imme diately preceding. 2. Men wishing to change watches or request special liberty shall make such requests at 10 a. m. on the day of going. 3. The liberty lists from the different departments will be placed in the record office before noon of the day such liberty is granted. When there are patients on board the list of those desiring liberty shall be made up in the wards before 9 a. m. and initialed by the medical officer in charge of their cases. These lists will be sent to the record office by 10 a. m. When alongside wharf the liberty of patients shall expire at 12 midnight unless special permission to remain over night is granted. 4. At navy yards requests for property passes shall be made before noon of the day on which they are to be used. 5. Whenever a man goes on liberty he will obtain his liberty card from the Chief Pharmacist's Mate on duty at the record office who will be there to hand out cards on the hour beginning at 1 p. m. on Saturdays and holidays, and at 4.30 p. m. other days. These cards will be used whether the ship is at navy yard, alongside hospital wharf, or at anchor in port. They will not be taken by men going on leave, furlough papers then taking the place of the card. On return to ship the liberty card shall be placed immediately in the box at record office labeled " liberty cards." 6. A list will be made of patients going on liberty and they will be checked in and out from this list. 7. Every man should take the best care of his liberty card and secure it against loss. This with his identification tag and marks on clothes should prove a ready identification regarding his status in the Navy and that he is on authorized liberty, should question arise. The loss of a liberty card means that some person may find it and impersonate the loser to the detriment of him and possibly of his 498 ADMINISTRATION OF THE HOSPITAL SHIP " SOLACE." Vol. XIII. country. Consequently every man who loses his card will be deprived of three to five liberties, depending on the circumstances of the case. He will also be required to purchase another celluloid holder for his new card. 8. All men going on liberty will wear the prescribed uniform. Their clothes shall be kept neat and shoes blackened. Neatness shows pride in self and ship. They shall show the liberty card at the gangway as authority for going on liberty. When at anchor in port or alongside a wharf at hospital or navy yard where rules require men to leave in parties, liberty parties shall be inspected before leaving the ship. Hospital corpsmen, com missary division, and patients will be inspected by the officer of the day or master-at-arms; deck and engineer's division by the officer of the deck or quartermaster. Such parties will march through the naval reservation in a body. Those men not complying with above ship's regulations will not be allowed on liberty. VENEREAL PROPHYLAXIS. All men who have exposed themselves to venereal infection while on liberty shall report to the supervising night watch for venereal prophylaxis as soon as they return to the ship. WORKING PARTIE8. General stores, etc., will be handled by the men of the division for which intended, when practicable, viz, hospital corps, all medical stores; deck division, all C. & R. and all navigation stores; engineer's division, all engineer's stores. Commissary stores will be handled by parties from all divisions. Working parties will be detailed by the heads of the several divisions, or their representatives. SAILING PARTIES. 1. No member of the hospital corps shall be allowed to go sailing who has not qualified in swimming. Sailing parties shall not go out of sight of the ship or land without permission. A coxswain shall be in the boat if possible. 2. A list of names of all men going in such a party will be made out beforehand and given to the officer of the deck when leaving the ship. MISCELLANEOUS. 1. Men must not loaf, loiter, or congregate in gangways of upper deck and will only be allowed there on duty or in passing forward or aft. 2. The port gangway shall be used in going forward and aft. No. 8. ADMINISTRATION OF THE HOSPITAL, SHIP " SOLACE." 499 3. Men shall not hang over the rail or out of ports when entering port or when boats are coming alongside. 4. Profane and vulgar language shall not be used. Such language is strictly forbidden by Articles for the Government of the Navy (art. 8). IJBRAHY. 1. Shall be in charge of assistant master-at-arms under direction of a medical officer appointed to direct this work and take proper care of books. A card index will be made of all books and kept up to date at all times. 2. When a book is removed from the library the name of borrower, with date shall be entered on the card in space provided for such entries, and the card then placed in compartment marked " Books out." When such a book is returned the card, with name scratched, will be returned to regular place. 3. The library will be open every day for issue of books from 10 to 10.30 a. m., 12.30 to 1 and 5.30 to 6 p. m. 4. Due care shall be taken by all to prevent abuse of books, and books will be returned as soon as they have been read. A report shall be made to the executive surgeon of any abuse or loss of books. INSTRUCTIONS FOR PATIENTS. 1. Orders of pharmacist's mates on duty shall be obeyed. 2. Reveille for convalescent patients at 6 a. m. Clean and make up bunks. Not allowed to sit on bunks. If you wish to lie down always remove shoes and fold spread ; bed to be properly fixed after using. 3. Report promptly at hours designated for giving medications and taking temperatures. 4. Stand by bunks at 8.45 a. m. and 5.45 p. m. for sick call: at 8.50 p. m. for muster. 5. Valuables and money should be turned over to the executive surgeon or paymaster for safe- keeping; otherwise no responsibility for loss is assumed. 6. No smoking allowed in wards and toilets. 7. Washing and drying of clothes in wards and toilets not allowed. Use forecastle and elothes lines. 8. Skylarking, loud talking, and profanity are forbidden. 9. Uniforms shall be as prescribed for the day. Dungarees are not allowed. 10. Lockers shall be kept clean and neatly stowed. 11. Patients will report in wards at fire, collision, and abandon- ship drill and take stations by bunks to await further orders. They will closely observe and obey all orders given. At sea they will wear or have close at hand a life belt for any emergency use. 116025—19 8 500 ADMINISTRATION OF THE HOSPITAL, SHIP SOLACE. Vol. XIII. 12. Patients will perform the detail duty as given them by the pharmacist's mate in charge of ward approved by the medical officer. 13. Bag room is open for patients to get at their bags from 1 to 2 p. m. 14. Library is open from 10 to 10.30 a. m., 12.30 to 1 and 5.30 to 6 p. m. Good care shall be taken of books. 15. Canteen open from 7.30 to 8 a. m., 12 m. to 1, and 5.30 to 6 p. m. 16. Do not use a different Lilly cup for each drink of water; keep one in locker and use the same one. 17. Patients allowed on forecastle and port side of deck forward of gangway. Not allowed in any compartments of ship occupied by ship's crew. SUPPLY DEPARTMENT. DAILY ROUTINE. 4.00 a. m.—Start fires in galley. Ship's cook on watch and butcher to be called by hospital corpsmen on night duty. Inform night watch if to be called earlier. 6.00 a. m.— Reveille^ 7.00 a. m.—First mess; issue stores. 7.30 a. m.—Breakfast. 11.00 a. m.—Issue stores. 11.30 a. m.—First mess. 12.00 noon.—Dinner. 4.00 p. m.—Issue stores. 5.00 p. m.—First mess. 5.30 p. m.—Supper. 0.00 p. m.—Galley closed; taps. GENERAL ORDERS. Canteen: To be open 7.30 a. m. to 8 a. m., 12 noon to 1 p. m., 5.30 p. m. to 6.30 p. m. Galley to be policed after each meal; to be thoroughly cleaned after supper ; that section of deck outside of galley, including garbage cans and slop chutes, to be given special attention. WEEKLY ROUTINE. Monday : Tuesday : Wednesday: a.m. —Air bedding. Examine bunks for vermin. 1.00 p. m.—Issue clothing and small stores. Bag and locker inspection first Wednes day in month. No. 3. ADMINISTBATION OF THE HOSPITAL SHIP " SOLACE." 501 Thursday: 10.00 a. m.—Inspection on hurricane deck by the com manding officer. 1.00 p. m.—Fire and collision drill. Abandon-ship drill first Thursday in month. Friday: . General field day. Saturday: 0.00 a. m.—Inspection No. 3 hold and cold-storage rooms by the commanding officer. 10.00 a. m.—Inspection of the ship by the commanding officer, p. m.—Holiday. Recreation parties. Sunday : Only necessary work to be performed. Divine service when chaplain is available. By order of the commanding officer. CREW. DAILY ROUTINE. 5.30 a. m.—Reveille. Except Sundays and holidays, when it will be * 6 a. m. 6.00 a.m.—Turn to. Sundays and holidays. 6.30 a. m. Trice up clothes lines. 7.15 a. m.—Knock off work. 7.30 a. m—Breakfast. 8.05 a. m.—Muster at bunks and lockers. 8.15 a.m.—Turn to. 11.30 a. m.—Knock off work. 12.00 a.m.—Dinner. 1.00 p. m.—Turn to. Pipe down clothes lines. 4.30 p.m.—Knock off work. Start deck hose. Scrub clothes, ex cept Saturdays, Sundays, and evenings before holi days. 5.30 p.m. —Supper. 7.00 p. m.— Stop hose. Dry down deck. Trice up clothes lines. 9.00 p.m.—Taps. There will be no smoking during working hours. Monday : Tuesday : Wednesday : WEEKLY ROUTINE. a. m.—Air bedding. Examine bunks for vermin. Scrub and wash bunk bottoms monthly, or every two weeks if necessary. 1.00 p. m.—Bag inspection first Wednesday in month; this includes lockers. 502 ADMINISTRATION OF THE HOSPITAL, SHIP " SOLACE." Vol. XIII. Thursday : 10.00 a.m.—First Thursday in quarter; muster of whole crew for reading of Articles for the Government of the Navy. 1.00 p. m.—Fire drill, collision drill, man-overboard drill (this while underway once a month ) . Abandon-ship drill first Thurs day in month. Friday : Saturday : General field day. 9.00 a. m.—Inspection of cold storage, No. 3 hold and engineer's department. 10.00 a.m.—Inspection of crew and engineer's force on hurricane deck. This followed by inspection of ship with men in quarters and lockers open, p.m. —Holiday. Kecreation parties; rowing and sailing to be encouraged. Sunday : Only necessary work to be performed. Divine service when chaplain is avail able. By order of commanding officer. LABORATORY. 1. All requests for laboratory work will be made on regular blanks found in wards giving (1) patient's name, (2) doctor's name, (3) nature of specimen, and (4) examination required. 2. Laboratory requests marked " emergency " will be attended to at once. 3. Routine urines will be reported twice daily. Any special exam ination required should be noted on blank such as for T. B., sperma- tozooa, etc. 4. Specimens received before 8 a. m. will be reported at 9 a. m. sick call. 5. Specimens received after 8 a. m. will be reported at 4.30 p. m. 6. Other routine laboratory work as blood smears, gastric contents, feces, dark fields, spinal fluids, sputum, etc., received before 8 a. m. will be reported at 9 a. m. sick call. 7. Those received after 8 a. m. will be reported at 11.30 a. m. 8. Those received after 11 a. m. will be reported at 4.30 p. m. 9. Wassermann requests will be filed at laboratory before 8 a. m. Saturdays. EMEI I ■ 0 HOSPITA I MASTER- DETAIL I LIBERTY No. 3. ADMINISTRATION OF THE HOSPITAL SHIP SOLACE. 503 10. Laboratory reports will be delivered to wards or officers' quar ters as desired. SCHEDULE OF LECTURES FOR HOSPITAL CORPS. Subject . Lecturers. Anatomy Medical officer. First aid and minor Do. surgery. Physiology Pharmacy and ma teria medica. Nursing, diets, etc Hygiene and sanita tion. Clerical work Thursday Pharmacy and ma teria medica. Do. Pharmacist, assisted by pharmacist's mate. Medical officer. Do. Chief pharmacist's mate detailed in record office. Pharmacist, assisted by pharmacist's mate. BARBER SHOP. 1. A separate towel shall be used for each man. 2. Razors, scissors, and clippers will be disinfected daily in '2 per cent carbolic acid solution for 15 minutes and will be cleaned after ?aeh use. 3. Brushes, combs, shaving bmshes, and mugs will be thoroughly cleaned after each use. 4. The room shall be carefully cleaned each day and be kept neat at all times. No smok'tny will be allowed in barber shop during working hours. ."». The barber will refuse to do any work on men with diseases of skin or scalp; all such cases should be reported to the executive sur geon. 6. The barber will not shave cases being treated for syphilis. In struments for cutting hair of such cases shall be immediately steri lized after use. and a. separate set be kept for this purpose. 7. All payments shall be made direct to the barber on the follow ing schedule : MKN. Hnir cut Shave Shampoo Massage Honing razor $0. 15 , ID 1." 15 15 OFFICERS. Hair cut $0. 25 Shave , . 10 Shampoo .25 Massage .20 Hours: 8 a. m. to 11.45 a. in. 1 to 4.30 after 3.30 p. m. and noon on Saturdays. p. m. No hair cutting HISTORICAL. DEVICES AND UNIFORMS OF THE NAVY MEDICAL CORPS, 1802-1905. This being the day of change and innovation, not to say upheaval, in military tailoring it may be a matter of interest to refer to some of the frequent oscillations of fashion that have marked our naval service in the past. Each permutation has doubtless had a very definite cause, but the origin of the earlier changes is veiled in obscurity like so many of the things in history which arouse special interest. As near as we can make out from the records on file the officers nnd gentlemen who frequented the quarter-decks of our men-of-war in the year of grace 1802 (at which time, by the way, the Navy ration included one-half pint of distilled spirits for each day of the week, including Sunday) wore knee breeches in conformity with the cus tom of the day. The breeches worn with the full dress coat were white. Gold or brass buckles adorned the knee. The stockings were white silk and the low shoes also had buckles. The full-dress coat was blue with long lapels and a standing col lar trimmed with gold lace beginning at the upper part of the collar and running along the lapels to the bottom of the coat. Gold lace was also applied to the sleeves and around the pocket flaps and down the folds. The sleeves1 and the pocket flaps were enriched with buttons of "yellow metal with a foul anchor and American eagle surrounded with 15 stars." The buttonholes were worked with gold thread. Captains of the line had nine buttons on the lapels, and one button on the standing collar, while surgeons had nine buttons with gold frogs on the lapels and two buttons with gold frogs on each side of the collar and three Navy buttons below the pockets and three gold frogs on the pocket flaps, and the buttons on the cuffs were three with gold frogs. The vest worn with the captain's full-dress coat was a single breasted white affair with flaps and four buttons to the pockets, similar to those in the coat, but proportionately smaller. Arguing from the silence of history the surgeon's waist 1 Buttons on the sleeves of uniforms were originally useful as well as ornamental. The ends of the sleeves were turned back as real cuffs and buttoned In place. When the cuff of the sleeve was abolished the buttons remained. It Is a pure canard to pretend thitt the buttons were there to prevent certain very young gentlemen from using the sleeve in lieu of a handkerchief. 505 506 DEVICES AND UNIFORMS OF NAVY MEDICAL CORPS, 1802-1905. coat had no buttons on the pockets but only the buttons required by the inherent character of the garment. The essential difference, then, of the two costumes lay in the absence of gold lace, the fewer buttons, the presence of frogs in various parts of the surgeon's uniform. The undress coat for captains was shorn of the gold lace and the gold- worked buttonholes and it is presumed that there were minor dif ferences of corresponding degree in the surgeon's everyday apparel. The full-dress coat of the surgeon's mate differed from his master's in lacking frogs on the collar, lapels, and pockets, but this lack was atoned for by the glory of gold-worked buttonholes. All officers wore cocked * hats with their full-dress coats. Parenthetically it is to be noted that lieutenants of the line were entitled to one epaulet,2 which was worn on the left shoulder, except when they were " in command," which position entitled them to shift the solitary shoulder embellishment to starboard. Apparently sur geons wore no epaulets at this time. The above costumes were authorized August 27, 1802, and are sete forth in the Navy Register of that period. The Uniform Regulations, dated November 23, 1813, specify that hospital surgeons should wear a blue coat with standing collar marked by two £-inch stripes of gold lace and a Navy button and a laced but tonhole, the broad lapels bearing nine Navy buttons and the cuffs three Navy buttons. The cuffs also bore two ^-inch stripes of gold lace. This year marks an advance in modesty as proved by the fuller protection from the public gaze afforded the nether parts of the offi cer's anatomy, for we see prescribed white pantaloons instead of breeches, or as an alternate for them since the latter were still in vogue in 1830. But long trousers are no novelty, for the monument in Trajan's Forum, Rome, has figures of men in trousers and there is extant a seal cylinder of Persian origin showing three prisoners in tight trousers. Another (Metropolitan Museum, New York) shows a victorious soldier in baggy trousers. There is another beautiful seal with two figures not of Persian nationality wearing long trousers. These seals are comparatively modern, as seals go, probably only dat ing back to about 500 B. C. The Uniform Regulations specify for hospital surgeons " half boots and small swords." The hospital surgeon's undress coat had, instead of a standing collar, a " rolling cape edged with gold cord," and there was no lace on the cuffs, and this " rolling cape " also characterized the surgeon's undress coat. 1 The cocked hat is an evolution from an earlier soft, wide-briuinied hat. First the brim was turned up on one side, then on the other. When still another portion was turned up the throe-cornered hat of colonial type was produced. ' The epaulet Is an amplification and glorification of the shoulder strap. The latter was originally a device to keep belt and bandolier from slipping off the shoulder. DEVICES AND UNIFORMS OF NAVY MEDICAL CORPS, 1802-1905. 507 The full-dress costume of the surgeon's mate had the necessary modifications in the matter of buttons and lace and for them a " dirk " was prescribed in lieu of small sword. All officers were permitted to wear blue pantaloons, round hats, and dirks in undress. In the course of these hurried researches there has not been time to investigate the subtle distinction between surgeons and hospital surgeons. The his tory of the Medical Corps of the Navy has never been written, and the greatest confusion prevails as to the early status of medical officers. However, there were formerly various ways of securing the services of a physician for the Navy. In the beginning a captain on being assigned to a ship would get a crew and a complement of officers together as best he could and apparently selected a civilian doctor to make a cruise with him. For duty at a naval hospital doctors were usually appointed by the hospital commissioners. Again, the Secre tary of the Navy could appoint a civilian physician for any special duty or period of service. The hospital surgeon referred to in Uniform Regulations was doubtless an , appointee of the hospital commissioners. In 1806 the peace basis of the Naval Establishment was fixed at 13 captains, 9 masters, 72 lieutenants, 150 midshipmen, 925 able seamen, seamen, and boys, but the President was authorized to appoint for the vessels in actual service as many surgeons, surgeons' mates, sailing masters, chaplains, pursers, etc., as he deemed necessary and proper. In 1821, in the pleasant month of May, the uniform of surgeons underwent certain modifications in the matter of buttons which make very difficult reading and may be passed over as not sufficiently mo mentous to require unraveling. We can get an idea of the relative standing in rank of the surgeon from about 1826 to 1832 by the Appendix to Naval Laws, printed in 1832. His full dress was in all respects like that of master com mandant except that no epaulets were worn by the surgeon and the embroidery of the coat was different. This consisted of a live oak leaf on the upper and front edges of the collar and around the cuffs. The club of ^sculapius was also embroidered on the collar. The full-dress coat of the master commandant was similar in all respects to that of a captain except for the embroidery on the pocket flaps and the buttons in various places were fewer in number—three instead of four on the pocket flaps and cuffs, one instead of two in the middle of the skirt fold. Full dress captains. —Coat of dark-blue cloth, lined with white, double- breasted, with long lapels; the width to be in proportion to the size of the ooat, and cut with a swell, to be buttoned back with nine buttons on each lapel, and an equal number of blind buttonholes worked in twist, as long as the width of the lapels will allow. Standing collar to be lined with white and embroid ered in gold around the upper edge and sides with a rope, and with leaves of live oak, interspersed with acorns, as per pattern. The cuffs to have four but 508 DEVICES AND UNIFORMS OF NAVY MEDICAL CORPS, 1802-1905. tons and to open underneath with two small buttons and holes of twist and embroidered as the collar, with a rope on the upper part above the button, and with the live-oak leaf and acorn, as per pattern. The pocket flaps to be em broidered in gold, the same as the collar and cuffs, the lower part and sides to have a rope, and the flap to be embroidered in gold with the live-oak leaf and acorn, as per pattern ; and the lower edge to be cut as may be prevailing in fashion, with four buttons underneath, one button on each hip, two near the middle of the folds, and one at the bottom of each skirt ; the pockets to be in the folds. Two gold epaulets, one on each shoulder. Vest : White, single-breasted, with as many small Navy buttons as are worn on the breast of the coat—standing collar coming to the edge of the breast, and sloping in a line with it—breast straight, with pocket flaps, under each of which are four small buttons. Breeches: White, with small Navy buttons, and gold or gilt knee buckles, white silk stockings, shoes, and gold or gilt buckles, or plain white pantaloons over short boots, or with shoes and buckles. Undress, surgeons. —Same as lieutenants, with the exception that the collar and cuffs are to be of black velvet, and a strip of gold lace half an inch wide, around the upper part of the cuffs. Undress, lieutenants. —Same as masters commandant with the exception of one epaulet In lieu of two. Undress, masters commandant. —The same as captains with the exception of the buttons, which will be designated for full dress. Undress, captains. —Coat of dark-blue cloth, lined with the same, rolling collar, and made according to the prevailing fashion of citizens for the time, with nine buttons on each breast, four under the pocket flaps, and around the cuffs, and in the folds, etc., as for full dress. Vests : Plain white or blue, single-breasted, with the same number of small Navy buttons on the front and pocket flaps as for full dress. Pantaloons : Plain blue, or in warm weather, white. To be worn over half boots, or with shoes and stockings. Surgeons in full dress are to wear cocked hats bound with black ribbon to show 1£ inches on each side, with gold tassels formed with five gold and five blue bullions each, a black silk cockade, with a loop formed with gold lace, and a small Navy button. But a startling change took place after July 4. 1832. A naval gen eral order of January 20 of that year directed that the serpent and staff be removed from the collar of the full-dress coat of surgeons and assistant surgeons (the surgeon's mate no longer exists), a branch of live oak being substituted. It has not been possible in the time at our disposal to determine from the somewhat meager sources of information available the exact date of the adoption of the Club of JEsculapius with its entwined serpent as a collar device for the naval medical officer. It is safe to say, however, that this device was employed as early as 1820. The change made m 1832 was of doubtful propriety. The older device certainly conveyed a definite idea, had some historic justification, whereas the, oak leaf was a purely conventional affair, and its origin was merely artistic or, to be exact, merely sartorial. From the re motest times the serpent has been a symbol of growth, regeneration. DEVICES AND UNIFORMS OF NAVY MEDICAL CORPS, 1802-1905. 509 rejuvenation, immortality, health. Furthermore, the serpent is the symbol of /Kscuhipius. the god of healing. The iEsculapius of myth ology (there was a real living, breathing person of that name, too, a mortal, a physician) was the son of Apollo, and doubtless had inher ited a disposition toward medicine, seeing that his father was the sender and remitter of pestilence. At any rate. .ZEseulapius is usually represented holding a serpent, encircled by one, or having one stand ing on his beam ends in the background, or else his knotted staff bears a snake twined around it. Another symbol for JEsculapius is a vase surrounded by snakes, while his daughter Hygeia, goddess of health, is represented feeding a snake from a bowl. When we recall the venerable antiquity of serpent worship and the semi-religious character of early healers the appropriateness of the serpent as the physician's device seems established. The further back we go in the history of man the more universal is the reverence in which the serpent was held. The Babylonian myths associated the serpent with wisdom just as the story of Genesis does. In India serpents were held to be the progenitors of kings. Serpents were emblems of immortality, owing perhaps to the shed ding of their skins, and eternity was typified by a snake swallowing his own tail. Some ancient races considered that after death the human soul was reembodied in a snake. Others considered that to eat a snake was to acquire powers of healing. From Dahomey in Africa, where snake worship was active up to 1850 ; from India, where snake worship still survives; back to the Indians long before the dis covery of America; from Babylonia to China —everywhere the most remarkable powers were ascribed to the reptile. He was connected with all sorts of mysterious religious rites, and closely associated with the healing art. We have the Biblical record of Moses causing a brazen serpent to be lifted up before the children of Israel when they were afflicted with pestilence. Even in Christian times and among Christian nations this strange influence was felt. The Ophites, a despised sect of the Gnostics, made the serpent their emblem of wis dom. In India a ring or bracelet made in the fashion of a snake with a ruby in his mouth was a common love token, and the snake is fre quently found carved with an egg in his mouth. The oak leaf and acorn were extensively and indiscriminately used for both line and staff in the earlier days of the Navy and were in no sense distinctive.1 The full-dress coat collar of a captain in 1830 bore leaves of live oak interspersed with acorns, the pocket flaps like wise ; and the full-dress coat of passed midshipmen of the same period 1 Onk-Ienf lare Ik a feature of a general's cap in the French Army. An oak-leaf design marks the peak of undress caps of British staff and general officers. A laurel wreath surrounding crossed batons and surmounted by a crown Is the badge of a British field marshal. 510 DEVICES AND UNIFORMS OF NAVY MEDICAL CORPS, 1802-1905. was embroidered with live-oak leaf, acorns, a foul anchor, and a five- pointed star, disposed on various portions of the garment, while plain midshipmen omitted the star.1 (Pursers at this time were dressed like the surgeons, but had a cornucopia instead of the club of iEscula- pius.) Still the club was likely to be misunderstood, and might, to those critically inclined, have suggested the punishment meted out in all ages to the unsuccessful practitioner or the rude methods of primitive barber-surgeons, and the serpent may have been objected to on the ground that it harked back to the incantations and mystifications of theurgic medicine. The velvet of the collar and cuffs was to be removed from the undress of the surgeons and a button added to each side of the collar. The velvet from the collar and cuffs was to be removed from the undress of the assistans surgeons and a strip of gold lace, half an inch wide, added around the upper part of the cuffs and the lower part of the collar. In 1847, beginning June 1, the surgeon's full-dress coat was to be patterned on that of a commander, except that three sprigs of live oak, bearing acorns and leaves, were to be embroidered on each side of the collar and on each cuff, the cuff having no buttons. Passed assistants and assistant surgeons had the same coat as the surgeons except for the embroidery on the cuffs. The undress coat of all medical officers was now shorn of lace on the cuffs. Epaulets: All medical officers shall wear gold epaulets with worked edge and solid bright crescent and the letters " M. T>." in Old English characters in solid silver within the crescent. The bullion shall be of silver gilt; those of surgeons of more than 12 years to be I inch in diameter and 3 inches long; those of surgeons of less than 12 years, § inch in diameter and 3 inches long; those of passed assistants and assistants } inch in diameter and 3 inches long. The " surgeon of the fleet " will be designated by a rosette of burnished silver (as per pattern) worn above the letters on the strap of the epaulet. Shoulder straps : All medical officers shall wear shoulder straps of blue cloth, with gold-embroidered edge, and the letters M. D. In old English characters, in solid silver, in the center. For surgeons of more than 12 years the embroidery to be } inch wide and an embroidered acorn on each end. For surgeons of less than 12 years the same as above, except the acorn. For passed assistants the embroidery to be J inch wide and an embroidered bar on each end. For assistants the same as above, except the bar (all as per pattern). 1 One can not help wondering if this plastering ol the uniforms of all ranks ami corps with live oak was a reflection of the concern felt by the wise and foresighted (Jovern- lnent of earlier days lest the supply of live oak in the country should be Inadequate to meet the needs for building naval vessels. The Government bought tracts of land in Louisiana and eUewhere for the conservation of this tree. At Boston and other navy yards large numbers of onk logs for ship construction were preserved under water for many years. DEVICES AND UNIFORMS OF NAVY MEDICAL CORPS, 1802-1905. 511 " Surgeons of the fleet " will wear a small silver rosette on each end of the strap. Cbapeaux : Surgeons of more than 12 years will wear the same as directed for commp. rulers, and all others as directed for lieutenants. In 1852 the shoulder strap for the Chief of the Bureau of Medicine and Surgery consisted of a single star centered on dark-blue cloth surrounded by $-inch border of gold lace. The shoulder straps for other medical officers were also consider ably modified, and apparently it was at about this time that silver and gold were generally employed to differentiate grades and length of service, the more costly metal designating the junior. At this time the cap device for medical officers was a gold-embroidered " M. D.:' surrounded by a wreath of oak leaves. There is considerable diffi culty in determining exactly what were the uniform devices for this period, as the various illustrative plates for 1852 do not accord. It is not clear from corrections in the accompanying text just when certain changes were made. In this year the regulations as to uni forms contained a subtle distinction suggested by the words in paren theses (sea officers) and (civil officers). At some time between 1852 and 1865 the sprig of olive makes its appearance. Wreaths were part olive sprig and part live-oak sprig, and the shoulder strap bore an olive sprig with an acorn at each end for surgeons of over 12 years' service, without acorns for those of less than 12, while passed assistants had an olive sprig only. The earlier cap device consisted of an oak sprig surrounded by a wreath of olive and live oak. (The year 1852 deserves a place in the annals of Navy fashions through orders issued by Will A. Graham, Secretary of the Navy, under date of March 8, prescribing that " mustaches and imperials are not to be worn by officers or men at any time whatever," and speci fying that whiskers were not to extend below the tip of the ear.) In 1866 the cap device, a silver anchor surrounded by a wreath, was the same for all officers except naval constructors, chaplains, and professor of mathematics. In 1866 surgeons of the fleet of over 15 years' service in grade had on their shoulder straps a silver eagle in the center of a blue cloth field which was edged with gold. Surgeons in the second five years of service in grade had a shoulder strap of blue cloth edged with gold, with a silver oak leaf on each end. Surgeons in the first five years of service in grade had the gold oak leaf. Passed assistant surgeons had two gold bars at each end of the strap. Assistant surgeons had one gold bar at each end. These descriptions appear in the Uniform Regulations for 1866 and appar ently were in vogue five or six years before that. In 1869 silver oak leaves on the shoulder straps were for surgeons ranking with lieutenant commanders of the line, and two gold bars for the rank of lieutenant 512 DEVICES AND UNIFORMS OF NAVY MEDICAL CORPS, 1802-1905. In 1869 there was authority for officers in the Tropics or during warm seasons to wear white straw hats (the body not over 2£ inches high, the brim unlined and between 2 and 3$ inches in width, with a plain band of black ribbon) under the same restrictions as in the case of " white linen or grass jackets to be made like the cloth ones, but without straps or sleeve ornaments." These coats were allowed with hats in the Tropics, at sea and in port when the weather was, in the opinion of the commanding officer, such as to require it. They were not, however, to be worn ashore in foreign ports, nor by the officer of the deck for the time being in ports where the vessel was liable to be visited by strangers. In 1869 a band of cobalt-blue cloth between the stripes of gold lace was placed on the sleeves of frock and full-dress coats of medical officers. This was during the incumbency of A. E. Barie as Secre tary of the Navy. The year 1883 brought to the medical officer several novelties in the matter of costume. The cobalt-blue cloth on the sleeve was abandoned and maroon velvet was put on instead. What subtle dis tinction, what fine shade of feeling, is reflected in the disuse of the rich blue of 1869 and the substitution of maroon is not easily di vined. Was this to deprive the surgeon of so apt a suggestion of the ' sea or merely a display of erudition, to mark the venerable charac ter of his calling, by substituting for the " deep and dark blue ocean " of Byron the " wine- faced deep " of Homeric language ? The specific device of the corps now became a most complicated affair grossly violating the principles of simplicity and economy if not the laws of heraldry. It consisted of a small Geneva cross of maroon velvet on a silver Maltese cross so-called, for what is com monly known as the Maltese cross is really a cross patee and the genuine one has arms so deeply indented as to give eight points with acute angles. However, here at last was a very distinctly appropriate emblem. The Geneva or Red Cross was adopted by the Geneva Convention out of compliment to the Swiss Republic, on whose flag it appears, because it was in Geneva that the first organized international effort was made to render warfare more humane. The movement resulted largely from the philanthropic endeavor of M. Henri Dunnnt, who in 1862 published his telling paper, " Souvenir de Solferino." The movement was warmly supported by Queen Augusta of Prussia ( " * * * thou shouldst be living at this hour ") and the Grand Duchess Maria Pavlovna of Russia. The cross associated with the Knights of Malta was nn appropriate device for medical and sanitary officers because this order grew out of the Knights of Jerusalem, one of the many organizations that sprang up either during or after the crusades with a distinctly charitable, philanthropic, and semimedical object, DEVICES AND UNIFORMS OF NAVY MEDICAL CORPS, 1802-1905. 51 3 unci known in a general way as hospitalers. The Knights of St. John had charge, originally, of an establishment in Jerusalem founded by citizens of Aiu a Hi, Italy, as an asylum for pilgrims to the Holy Sepulchre. They became a rich and powerful body, including in their membership many men of exalted birth. One of the main offshoots from the Knights of St. John was the Knights of Malta, who established themselves at Rhodes, but were driven out in 1523 by the Turks and settled in Malta in 1530. Their obligations included fighting the Turks, and they did this to some purpose in 1565, defending their newly acquired island home through one of the memorable sieges of history. Soliman attacked in person, but was finally compelled to withdraw after suffering some 20,000 casualties, treble the loss he inflicted. The last grand master of the order, who resided in Malta, was a German, one Ferdinand Hompesh, elected in 1797. When Malta was seized by Napoleon the knights removed to Rome and there remained though the treaty of Amiens (1802) provided for their return to Malta. Anticipating that they would be dominated by the French the order abandoned its patrimony. The Maltese cross did not originate with the hospitalers. They merely modified and conventionalized an emblem in vogue for thousands of years, and, like all forms of the cross, this one antedated Christianity. While the cross was traced in secret by persecuted Christians in their haunts, in catacombs, etc., it was not publicly used as an emblem of the new religion until the third century, A. D. Crosses of various patterns were used as ornaments or symbols not only by -the ancient Egyptians, Syrians, Indians, Babylonians, but were almost universal in the primeval world and go back to the later Stone Age and were probably connected with some form of nature worship. It has even been claimed that the cross and more particularly the pattern from which the Maltese cross was modified was a phallic emblem, the four members rep resented by the arms of the cross springing from a common center. Perhaps the four arms stood for the four great Assyrian deities. Figures similar to the Maltese cross have been found on vases dug up in the plains of Troy. There are extant effigies of Assyrian kings having this cross wrought on their chests or suspended from their necks. The Geneva cross and the Maltese cross was a strong combination so far as symbolic meaning and a venerable antiquity are concerned. It was discarded, however, in 1886 when the present device —a spread oak leaf charged with a silver acorn —came in. Alas, not so short lived was the white helmet, which flourished from 1883 to 1905. This remarkable headpiece was in form like a mold for puddings or jellies- It was a fragile, grotesque affair, that added no dignity or beauty to the wearer and left face and neck entirely unprotected from rain or sun. When exposed to prolonged inclemency of weather it became deformed and mushy like a decayed orange. In 1886 the Navy overcoat was similar in pattern to the present one except that it boasted a hood. The present blouse, to be discarded in 1921, was adopted in 1876. - • Itu EDITORIAL. THE REFORM OF FUNERALS. A lady in Yokohama once gave her amah 24 hours' leave for the purpose of attending a theatrical performance. On being asked afterwards if she had enjoyed the spectacle the girl replied that she had had a lovely time and " plenty cry." The delectation derived from paroxysmal tears and a thorough harrowing and roweling of the feelings is not to be denied to those who desire the experience. While men do not resort to an emotional debauch as a means of restoring nervous equilibrium, it is of un questionable value to the gentler sex, which seems to get positive benefit from the periodic relaxation of tears and those manifesta tions which the women of French literature enjoy under the designa tion crise de nerfs. Hemorrhage stops of itself when it has gone on long enough to weaken the force of the heart and thus slow the blood current suf ficiently to permit clotting. The administration of cathartics to check diarrhea is often good practice. It may be that the lacerating barbarities of the ceremonies which mark modern sepulture have a good effect on the chief mourners by draining them dry of one form of emotion and stimulating the manufacture of a different type. Abeste profam. We are far from suggesting any modification of funeral rites on aesthetic or moral grounds. The clergy is deeply intrenched in its ritual ; the public holds strongly to traditional methods of testifying its grief for the departed. Sackcloth and ashes, rending the flesh, beating the breast, tearing the hair, fasting, feasting, drinking, wail ing, paid mourners, noise of tom-toms have had their place at differ ent times and among various races of men. Our catholic spirit only draws the line at suttee, because that is the immolation, forced by custom and not originating in the will of the living, of a survivor on the grave of the dead. We only register a protest against honoring the departed at the expense of the health and life of those who remain behind. That something may be done by way of reform as a purely sanitary measure is a reasonable hope in view of the fact th-' Lhe funeral of to-day is already shorn of features deemed essentia* 50 years ago. The funeral sermon and perfunctory eulogies have already gone by the board. 116025—19 0 515 516 Vol. XIII. EDITORIAL. A certain wit once explained the expression a " grinning skull " by saying that the skull grinned at the lies on his tombstone. Hap pily, now that we do not indulge in long public panegyrics of the worthy dead, we are not subject to torture by the contrast of ominous brevity or damning with faint praise when some victim of life's malignity passes to " the silence at last, life's dissonance past, and only pure sleep in the night." A small burying ground for foreigners, in a remote corner of Italy, has a tombstone with this among other trenchant couplets : What my name is It boots you not to know, What my deeds were the Judgement Day shall show. Beneath this flippancy, for so our habits of thought declare it, there is a profound philosophy. A tombstone without a name, a funeral without flowers, homily, or oration, sometimes without even the presence of the corpse, represent such a breaking of the bonds of custom that one dares to suggest a quiet campaign in the interest of public health. It would seem as though the time had come when a proper con sideration for the health of the living need not be construed as disrespect for the dead ; and yet what reader but can recall a st e of occasions when middle-aged or elderly men have had to stand bare headed in rain or snow while a grave was filled in or some long and painful ceremony was gone through with. Who is there that can not tell of coryza, tonsillitis, lumbago, rheumatism, pleurisy, bronchitis, pneumonia brought on or aggravated by enforced ex posure at a funeral. There is a big difference between what a man does to ruin his health voluntarily or through lack of courage to protest and what he is ordered to endure in a military service. If it is barbarous for men to endanger their lives by needless exposure out of regard for conventionalities just when the uncertainties of life are most con spicuous it is certainly criminal to condemn men by military author ity to do so. A certain medical director died once upon a time. The family at tached much importance to the military features of the funeral and the full escort allowed by regulations. Well in advance of the ap pointed hour some 800 and odd men were marched from the navy yard to the hospital and lined up before the main building. It was a bitterly cold day with high wind and rain coming down in tor rents. The services began after some delay and ran the usual tedious course, but were conducted under cover. The escort, however, re mained outside in the dowmpour, though there was ample shelter available in sun parlors, porches, basement corridors, etc. It is re markable that the irony of fate did not inspire the clergyman of the No. 3. EDITORIAL. 517 occasion to make a few remarks on the text " I will have mercy and not sacrifice " ! The officer in command of the funeral party was under orders to do thus and so, and nobody had the wit or temerity to suggest shelter, for there is something about these occasions which galvanizes common sense. So these 800 and odd lads stood at parade rest, then at attention, and finally marched back to barracks and ship after some hours of exposure to weather which was garnering its harvest of death in the population of the city. The officer paid for his fidelity to form by having to buy a new dress uniform, and among the men a dozen or more cases of severe tonsillitis and at least one pneumonia, that I know of, developed, while nearly every mem ber of the escort caught a heavy cold. Consider the grotesqueness of this performance. A man who for 40 years had ministered to the sick and inculcated the importance of earing for health was buried in such a fashion that scores of young men had to jeopardize their healths, their lives, to do him honor, a truly empty honor for a man of science. Leaving the civilian to do as he sees fit in this connection, it is urged that something be embodied in the Navy Regulations which shal>((make occurrences like the one described impossible. Why not say that : Whenever military honors are prescribed for a funeral conducted in severe <>rinclement weather the officer in charge of the ceremonies and the officer commanding the escort shall see that no unnecessary risks to health are in curred by the personnel under their command by uncovering or being unduly exposed to snow or rain and In the Tropics by prolonged exposure to the sun when adequate shelter is available. Before a funeral party leaves ship or bar- rucks those in authority shall see to it that the men are suitably clothed, and If necessary provided with gloves, overcoats, or rain clothes. On returning from a funeral under such circumstances the party, before being dismissed, shall be inspected, and any who are wet or exhausted shall be given directions about shifting into dry clothing or referred to the medical officer for other necessary measures. For many officers keenly alive to the importance of the health and Welfare of the men committed to their care such specific instructions are unnecessary, but there are always some without experience or initiative who would be benefited by such injunctions and authority in black and white. THE APOTHEOSIS OF DUNGAHKES. The random notes on the devices and uniforms of medical officers which appear in the historical section would have comparatively little interest or value if the gradual assimilation of all uniforms to a single type did not seem to show an ever-increasing recognition of the fact that all the corps are essential and integral parts of the Navy. Bishop Wykeham, founder of the great public school at Winchester 518 EDITORIAL. Vol. XIII. (1378), gave to that institution the motto "Manners make the man."' The motto " Clothes make the man " is considerably older, inasmuch as Adam was a sort of demigod, angel, or what not until he arrayed himself in fig leaves and left the Garden of Eden, a man. The efficiency of a military body depends on something more than the courage, zeal, and technical knowledge of the essentially military members thereof. The Navy's food and equipment, the design of its ships, the pattern of marine engines, the health of the personnel, the recruiting of men and their discharge in pursuance of law (taking cognizance of physical defects, invalidity, pension claims) and the general moral welfare of the personnel may in the hour of battle be subordinate to the interpretation of a signal, the handling of the ship, the aim of the gunners. But no Navy can be permanently suc cessful on a large scale without due attention to the features enumer ated above which were once regarded as noncombatant features. In this age of specialization no one officer or set of officers, how ever capable, can master the details of such a variety of subjects, yet they must be attended to or confusion, dissatisfaction, and disaf fection will ensue leading perhaps to failure in the supreme test of war. To be properly handled these details must be assigned to persons as capable in their several specialties as those who direct what, in the past, have been regarded as the only military concerns. There seems to have been a disposition in the past to act as though some officers were real naval officers and others vexatious and rather compromising accessories to be stamped by their garb and designation as distinctly beyond the pale. This was a most natural position to take and had much to justify it. The military officer, in the old re stricted sense, was mi generis. He differed essentially from the cap tain or first officer of a merchant ship in the range and character of his duties and obligations. With a small Navy of small ships and few shore establishments there was much truth in the contention that there was but one profession in the service essential and peculiar to it—that of the officer in command and of his direct representatives. The larger Navy of to-day with its dreadnoughts —machine shops, manned by artisans of every type—its huge plants ashore, its elabor ate method of selecting and training men on scientific principles, its many forms of enterprise has made the distinctly military officer more than ever a man apart, but it is not enough for him to call to his aid men picked up at random for a cruise or a brief period of duty. He must have men especially prepared to perform special functions who, like himself, have embraced the Navy as a career for life, so that they may bring to each new task in the handling of men and things the trained judgment and practical experience of previous service and some acquaintance with Navy life and procedure outside of their own immediate sphere. No. 3. EDITORIAL. 519 One of the essential lessons of the Great War is that a military enterprise of the first magnitude can not be conducted by a small military class alone. The whole Nation must contribute its talent, its industrial skill, its expert knowledge. This war —supposed and fondly hoped by many to be the last war—has done more than any thing in our history to demonstrate the need of universal mili tary training and to establish the idea that the Army and Navy of peace times constitute nothing more than a nucleus of men spe cially trained in all branches of military and naval endeavor for the leavening of the huge numbers of less-trained men who will form the mainstay of national defense. While it is not patent to all, it is nevertheless a fact that this war has also done much to break down both in America and abroad many time-honored but erroneous dis tinctions regarding the essential and nonessential in military life. There was a time when engineer officers of the Navy were looked down upon as mere mechanics who got their hands dirty and had to shift into dungarees when they went on duty. This prejudice characterized the period of transition from sails to steam. To-day military officers do duty in the engine room. The executive officer puts on dungarees for the painstaking inspection of his ship, and they are worn by those all-important people, the officers in the tur rets. Dungarees are as honorable as the raincoat or souwester worn on the bridge, and the operating gown and face mask are equally worthy. The strictly military officers of the Navy differ from those who follow the sea in merchant ships, but not more than the naval surgeon differs from his professional colleagues ashore —the naval surgeon concerned with the hygiene and sanitation of ships of war and of craft that cruise above and below as well as on the water; concerned with the physical and moral health of the per sonnel in Temperate and Tropic Zones, with the sanitary, social, and industrial problems of remote territorial possessions as well as of training stations, navy yards, ammunition plants at home. Public sentiment has long viewed the situation from this stand point, recognizing not only the limitations but the essential qualities and peculiar duties pertaining to the naval surgeon in his special field. And just as the public, which foots the bills, feels that courage and heroism are peculiar to no nation or class, so it considers it a matter of little moment, when defeat results from inferiority of numbers, whether the ships were prevented from engaging because of disabled engines or broken propellers or because of crews ren dered useless by sickness or from lack of proper food and clothing. IN MEMORIAM. HENRY O. BEYER—AN APPRECIATION AND A PORTRAIT. By P. J. Wai.dner, Lieutenant (T), Medical Corps, United States Navy. A figure, unique in the history of the Medical Corps of the Navy, passed away at Washington in mid-December last. In the rush and business of the times, and in the early days of the armistice, his going was almost unnoticed. But he was a virile figure in his day and had times been other than they are his death would have been mourned as his life deserved. Twenty and odd years ago Dr. Beyer was one of the prominent figures in the Medical Corps of the Navy, and throughout his career his comprehensive learning in science and his accomplishments as a linguist and translator gave distinction to his corps and the service wherever duty took him. In his later years, perhaps, his earlier luster failed, but those who remember him in his forties and early fifties recall a striking per sonality — a short, solid, strongly knit man, glowing with good health and energy: a big, fine head, prematurely gray, with flashing eyes, and a look of almost fierce aggressiveness, which, in the presence of one in pain or trouble, could swiftly soften to the gentleness of a woman. Quick to reprimand and as prompt to forgive and forget, there were many who did not like him, but many more who loved him for the. finer things they found under that austere surface. His was an arbitrary soul with a lofty mind, which often found itself in sharp and impulsively outspoken conflict with the modern more liberal way. a singularly Teutonic temperament, modified, however, and somewhat broadened by long contact with the best Americanism, found in the wardrooms of our Navy. This he showed in his rela tions with the enlisted men by whom, though he never yielded dig nity nor station, he was regarded as a real friend by many, indeed, almost as a father: and by all, primarily, as a good physician to whom their physical as well as their moral well-being was the chief concern. As a superior he was a martinet; as an instructor, a delight to hear, radiating his enthusiasms —some of them perhaps a little visionary —to the dullest of us, while he drove his points home with vigorous speech and gesture. This be it remembered was in his best years, when he was a pioneer in the instruction of crews in his favorite subjects, hygiene and first aid to the injured. To the 521 522 IN MEMOKIAM—WASHINGTON BEKRY GROVE. Vol. XIII. youngster he was in those days an inspiration, exemplifying in him self the robust health of body and mind which he taught us were the reward of the application of his teachings. His last years were sad. His spirited soul was torn by conflicting emotions —by his deeply rooted loyalty to America, which he served so usefully and faithfully, and his love for his wayward race. Henry Gustav Beyer was born October 28, 1850, in Saxony, Germany. He received his preliminary education and studied pharmacy in Germany. In 1876 he graduated from Bellevue, New York, and immediately thereafter entered the Navy as an assistant surgeon. He reached the grade of medical director In 1910 and was retired at 62 years of age. Of his 36 years on active duty, 3 were passed In connection with special work at the Smithsonian Insti tution, Washington, and nearly 13 years were spent at sea. Dr. Beyer was for 8 years instructor in hygiene at the United States Naval Medical School and delivered several lectures at the Naval War College, Newport, R. I. He was a Ph. D. of Johns Hopkins University and an honorary member of Royal College of Surgeons of London. He was also a member of the Association of Military Surgeons of the United States, the National Society for the Study and Preven tion of Tuberculosis, the American Public Health Association, and the American Association of Pathologists and Bacteriologists. Dr. Beyer was very proficient In foreign languages and contributed to the United States Naval Medical Bulle tin translations of foreign articles as well as papers by his own pen. A PERSONAL TRIBUTE TO WASHINGTON BERRY GROVE. By L. M. Schmidt, Lieutenant Commander, Medical Corps, United States Navy. Shrinking from publicity and praise, modest and unassuming, ever quietly submerging himself in his duties, yet exacting from his sub ordinates, as from himself, the fullest service cheerfully and freely rendered, Dr. Washington B. Grove filled with conspicuous success the position of executive surgeon at the United States Naval Hospi tal, Norfolk, Va., one of the most important and responsible posi tions in the medical service of the Navy during the war. Early in the war he requested an assignment to sea duty, but it was deemed unwise to sever his connection with a duty which he had performed so well and with which he was so familiar. It was my rare privilege to serve with and under Dr. Grove during the last two years of his life, to have his instruction and counsel, to profit by his wide experience and to have before me his example of patience, industry, and faithfulness. As I look back, I see more clearly now than I did then the effect of the great increase of work on our executive surgeon. The rapid expansion of the hospital from 250 patients to 1,700 put upon him a load of detail and responsibility. He keenly appreciated the neces sity of meeting the emergencies, and besides satisfying the actual 1ST MEMORIAM— WASHINGTON BERRY GROVE. 523 needs of the patients he tried to give them all the comforts obtainable. The sick man was ever his first consideration. I recall a marked change in the doctor in the summer of 1917. He had lost flesh, and lines of care appeared in his face. Once, when he was evidently ill, he yielded only when ordered by the command ing officer, who found him with fever, and took a few days' rest. Soon he was at his work again, protesting he was quite well. Sub sequently he evaded examination into his health, protesting he was well, but I feel sure that he kept on in an endeavor to prevent his work from falling on the commanding officer and others. In this unselfishness and devotion to duty he laid the foundation of a fatal illness, but he continued his full duties to the hour of his death.. The virtues most conspicuous in the life of this officer were loyalty, patience, thoroughness, and gentleness. He was loyal to those in authority and, while he always felt it his duty to express freely his own viewpoint, together with all the information at his command, be the orders to his liking or not he carried them out in letter and spirit. He was loyal to subordinates who were indiscreet from overzealousness or the impetuosity of youth. If convinced of the earnestness and sincerity of a younger officer he would, without his knowledge, plead his cause in time of trouble. Dr. Grove's patience with officers and men was frequently remarked by all. His willingness to consider each one's problem or trouble, either in or out of hours, and the time he devoted to the men of the hospital in this regard was rewarded in a measure by his knowledge that all of his people were happy and satisfied. In time of stress and overwork, when many of the staff consisted of young doctors with, as yet, but little knowledge of naval regulations and procedure, he showed the greatest tolerance of errors in this connection and took time to instruct and advise. Thoroughness in Tiis own work taught thoroughness to all of us. A few questions from the executive surgeon brought out whether an officer had a complete or but superficial conception of the matter in hand. A remarkable memory for detail in all the work of the hospital confronted those assigned to carry out the various forms of work. Although Dr. Grove wTas gentle, both in manner and conversation, I have never seen anyone try to take advantage of this. The officers appreciated it and the men loved him for it. All came to him with their troubles and found in him a sympathetic friend. Troubles capable of solution were solved and the others greatly softened by his kind words. I know little of his previous service, for he did not talk of the past but of the present and its problems. That his professional 524 IN MEMORIAM—WASHINGTON BEKBY GROVE. Vol. XIII. foundation was good and his experience broad was shown by his wise counsel and mature judgment as a physician and surgeon. He was quick to act in emergencies, conservative, conscientious and thorough in matters of doubt. As an officer he was efficient, im partial, tolerant, and kind. Dr. Washington Berry Grove was born at Berryville, Va.. June 13, 1875. He received the degree of doctor of medicine from the University of Virginia. June 17. 1896. He was appointed an assistant surgeon in the United States Navy June 9, 1897, and from then until October 29, 1915, when he was ordered to duty at the United States Naval Hospital, Norfolk, Va., he served at various hospitals and stations in the United States and on different cruising vessels, among which may be mentioned the U. S. S. Oregon, U. S. S. Brooklyn, U. S. S. San Francisco, U. S. S. Atlanta, U. S. S. Minnesota, and the U. S. S. Arkansas. On January 3, 1919, Dr. Grove, holding the rank of captain, Medical Corps, United States Navy, was ordered to command the United States Naval Hospital, Washington, D. C, where his death took place January 21, 1919. Capt. Grove's death came suddenly. Though he had been feeling badly for some time, he had not been on the sick list or missed an hour's work In the arduous task of taking over from his predecessor and then administering the command of the hospital. Naval Medical Bulletin No. 3, July, 1919. Apparatus for resuscitation of submerged cases. 525-1 SUGGESTED DEVICES. IMPROVISED MESS TABLES. By H. C. Curl, Captain, Medical Corps, United States Navy. The accompanying illustrations show the appearance and con struction of mess tables which I saw being used with great success at the United States Naval Air Station, Pauillac, France, where 3.000 men sat down to mess at the same time in one large mess hall. The special merit of this type of table lies in the facility with which the center board in the top can be removed to be cleaned. The plans for these tables were made by Chief Commissary Steward James P. McSweany, United States Xavy. APPARATUS FOR TREATMENT OF SUBMERSION CASES.' By G. F. Freeman, Captain, Medical Corps, United States Xavy. At stations where submersion cases are liable to require treatment— for example naval air stations*—-a baking oven for restoring animal warmth, such as that employed at Killingholme, England, will prove useful. The ovens are double, each built on the plan of an ordinary house with pitch roof. Each compartment is lined with sheet iron and the sliding doors are of wood and asbestos. The dimensions of each are 30 inches wide, 25 inches high, and 5 feet 3 inches long. Thus the patient's head is outside the baker and can be kept cool if necessary. The relatively short dimension of length was necessitated by the size of the building into which the ovens were built. A galvanized-wire frame separates the patient from the lights above. The lower part of these lights can be seen just below the edge of the drop sliding shutters. The vertical height from the horizontal of eaves to what would be the ridgepole is 9 inches. Each oven has its separate roof and the wires for the lights are at the angle. Each oven is supplied with 16 lights, placed in a double row, of the carbon resistance type for developing heat, the individual globe being 10 inches long and about 2^ inches diameter. In the illustration the switchboard is seen above the ovens, its buttons, one for every 4 lights, so arranged that 1Extract from annual sanitary report. United States Naval Air Station, Killingholme, England, 1918. 525 N oiivi5 miv "lVAvn j n nvH5S3w m Q95n won 119V1U0J ■$T3 A3<3 ^) nI M0 H5 (J01TK3VX Naval Medical Bulletin No. 3, July. 1919. 526-1 Mess tables adapted for thorough cleaning. MTJRDY—RECORDING DENTAL OPERATIONS AND TREATMENT. 527 alternate lights can be turned on. Above the switchboard is the fuse box with one fuse for each light. Above the fuse box is the current switch for turning the current into the oven circuit. This oven will generate a heat of 200 F. and with the space around the stretcher closed the temperature will rise to 250 F. When a person needs reviving after submersion his clothes are quickly removed, he is wrapped in blankets, placed on a stretcher, and slid into the oven. The favorable reaction after depression and loss of heat from submersion is rapid and satisfactory. The oven can also be used for " baking " a case when it is necessary to induce copious perspiration. The current at this station is of 220 volts, direct. METHOD FOR RECORDING DENTAL OPERATIONS AND TREATMENT. By W. F. MCBDY, Lieutenant, Dental Corps, United States Navy. The following scheme is suggested for keeping records of dental operations and treatments. When a patient reports for treatment, or is given an appointment, his name is entered on a dental appoint ment book, giving the following data : Time. Name and rate. Ship or station. 8.30 9.00 9.30 10.00 10.30 11.00 11.30 1.00 1.30 2.00 2.30 • 3.00 3.30 4.00 4.30 It will be noted that the fourth and fifth columns of the Dental Appointment Book, United States Navy, have been omitted. The first treatment and all subsequent treatments and operations are entered on a 3 by 5 inch, one-quarter-inch lined, index card of 528 MURDY—RECORDING DENTAL, OPERATIONS AND TREATMENT. about the same texture as M&S Form F (rough). The reverse side of the card could be used if necessarv. (Name, surname first.) (Rank or rate.) Date. Record of dental operations and treatment. . During the time the patient is under treatment the above card is kept in a file box, alphabetically arranged. A 2|-inch (inside meas urement) metal or wood box will hold about 200 cards. After each visit the card is removed and the treatment or operation recorded. When the case is completed, or the man or officer transferred, the card is marked " finished " and put in a 3 by 5 inch filing cabinet, later to be used in making out Form K (dental). When the statisti cal form is completed, the finished cards are then placed in a " dead " file for the permanent records of the hospital, station, or ship. Should a patient report again for treatment after his case is closed and his name reported on Form K (dental), his card can be removed from the permanent file, placed in the current or live file, his work noted, and later disposed of as above mentioned. The advantages of this card system are: 1. At the end of the month all the data for Form K (dental) Is complete. To obtain the information from the column. " Services rendered " in the Dental Appointment Book, United States Navy, would require considerable turning over of pages for a case that was under treatment during the whole month or longer. When men are transferred before the end of the month, the dental record fe not available, as it must accompany the health record upon transfer. 2. Keady reference for the last treatment given. It is practically impossible to recall treatment given if a patient reports a week later, especially where a dental officer has a hundred or more men who are receiving dental treatment. 3. Ready information to a dental officer relieving another dental officer This card could be known as Form F (dental, rough). CLINICAL NOTES. REPORT OF A DEATH FROM RUPTURE OF THE ESOPHAGUS. By L. Sheldon, Jr., Lieutenant Commander, Medical Corps, United States Navy. According to Osier, up to the year 1916 only eight cases of spon taneous rupture of the esophagus had been reported in the medical literature. Consequently, the rarity of the condition and the attend ing circumstances in this case make it seem sufficiently interesting to warrant the following report : The U. S. S. Kansas sailed from Brest, France, February 4 with troops for the United States. Rough seas were encountered immedi ately after leaving port, with the usual result that many men on board became violently seasick. At 7 o'clock on the evening of the 5th, W. K., corporal, United States Army, reported at the sick bay in a condition of partial col lapse. He was sweating profusely and his skin and mucous mem branes were very pale. His temperature was 90.6 F., pulse 78, and respirations 18. There was a very anxious expression on his face. He stated that he had had no bowel movement for three days, had been seasick, and had vomited several times during the day. In spite of this he had eaten a full meal at noon. His appearance was that of an intensely seasick man. About an hour before coming to the sick bay he felt a sudden sharp pain in his left chest. This, had become steadily worse and on admission was very severe. There was considerable difficulty in breathing. He was put to bed immediately, heat applied, and stimulants given. Examination of his chest showed diminished breath sounds, moist rales, and increased reso nance over the entire left chest. The abdomen was normal except for a very slight rigidity in the left upper quadrant. An enema was administered without result. However, the patient felt better, seemed stronger, and a serious condition was not suspected. The patient rested comfortably until 4.30 in the morning of the 6th, when he called for a bedpan. He was unable to defecate. A medical officer was called and found the patient in partial shock. At this time his abdomen was somewhat distended and tender and intestinal obstruction was thought to be present. He was given hypodermic stimulation and preparations were made to give a high enema. While these were being made, the patient suddenly jumped 530 SHELDON KUPTURE OF THE ESOPHAGUS. Vol. X lit out of bed, ran to the toilet, and sat upon the stool. He had no sooner reached the stool than he collapsed. He was caught by the hospital corpsman as he was falling and was carried back to his bed, where he died in about three minutes. Just before death it was noticed that the left side of his neck became swollen. Over the swelling there was the characteristic feeling of subcutaneous emphysema. Death occurred nine and one-half hours after the patient first reported at the sick bay. Although it seemed certain that intestinal obstruction in some form was present, it was felt that the pain in the chest, the emphysema of the neck, and the sudden death could not be explained by this alone, so it was decided to perform an autopsy. Autopsy was performed at 10.30 a. m., six hours after death. Upon inspecting the body, it was seen that the left side of the neck and upper chest were greatly swollen and emphysematous, the right upper chest also showing emphysema, but to a slighter degree. Upon incision over the sternum, bubbles of gas escaped. Upon opening the abdomen, the intestines appeared distended and slightly congested. In the region of the sigmoid flexure, for a distance of about 6 inches, the intestine was contracted to about one- fourth its normal size. Above this point the intestine was distended and contained hard masses of feces. No bands nor kinks were found, nor was there ap parent intussusception. It is thought that volvulus was the cause of the obstruction, although no definite twisting of the intestine could be seen. When the thoracic cavity was opened, there was an escape of foul-smelling gas. The left pleural cavity contained about 1 quart of dark-brown fluid, with the odor of feces combined with that of stomach contents. In the fluid were large pieces of undigested meat, corn, and beans. The left lung was totally collapsed and was no larger than the average man's hand. The right lung was normal except for slight acute congestion. Further search revealed a clean- cut rupture of the esophagus just above the diaphragm, involving1 about one-half its circumference and extending about 1 inch upward. Through this rupture the stomach and intestinal contents had passed into the left pleural cavity. One of the most interesting features of this case, aside from its rarity, is that the early vomiting of an acute intestinal obstruction was ascribed to seasickness, the surrounding circumstances making this seem most natural. It seems probable that the sudden pain in the left chest, occurring an hour before the patient reported at the sick bay, was due to a small rupture of the esophagus, with the consequent escape of a small amount of gas into the pleural cavity. This would account for the patient's condition and the physical findings at the time of his ad No. 3. 531 LEASURE —ANTHRAX CURED BY VACCINE. mission. With rest, heat, and stimulation his condition improved slightly. In the early morning, when he had the desire to defecate and could not succeed with the bedpan, he jumped out of bed quickly, ran to the toilet, and probably strained at the stool. The exertion required by these acts, combined with the presence of a large amount of gas in the stomach, was enough to cau.se an extension of the rupture and the passage through the enlarged opening of large quantities of gas. liquid, and solid matter into the pleural cavity. This was followed immediately by collapse of the lung, subcutaneous em physema, shock, and death. The esophagus in this case, except for the rupture, was normal in appearance, there being no scars nor evidence of former disease. It was therefore a case of spontaneous rupture due to the tremendous pressure caused by straining at stool when the stomach was dis tended with gas which had accumulated as a result of intestinal obstruction, the symptoms of which were masked for a time by apparent seasickness. A CASE OF ANTHRAX CURED BY VACCINE. By J. K. LlAiril, Lieutenant (J. O.), Medical Corps, United States Naval Reserve Force. A few years ago anthrax infection in man was looked for almost exclusively among hide and wool workers. Fifteen deaths were re ported in 1909 from England and Wales; all were among wool and hide workers. During the period of the war the etiological source has shifted to shaving brushes. It is natural to expect that the manufacturers could not be as particular during the stringent war times about the source of the material used in brushes. However, they should have been just as particular about the process of pre paring the hair. In the United States Public Health Report of July 12, 1918, there is a review of the anthrax cases reported in England by the local government board. From June. 1915, to October, 1916, there were 19 cases reported in civilian life. Fourteen of these were proved to have come from new shaving brushes. Among the English troops in France 28 cases occurred from 1915 to February, 1917. In 23 of these cases the malignant pustule was located on the shaving area. It could not be absolutely proved, however, that the infection came from shaving brushes. There were 18 cases reported among the troops in England, 12 of these were on the shaving area and 4 were proved to be from shaving brushes. The cases all had an incuba tion period of from 24 hours to 6 days. Two of the cases had a fatal anthrax meningitis, with no local signs except an apparently non- infected razor cut. There were 33 cases in which the outcome was 116025— 10 10 532 Vol. XIII. LEASURE —ANTHRAX CURED BY VACCINE. known, and of these 21 died, making a mortality of 64 per cent. The high mortality is, no doubt, due to the location of the malignant pustule. In the first place, the face and neck contain a large number of lymphatic channels, allowing the infection a splendid opportunity to spread rapidly. Secondly, the neck is so compact that it does not require much edema, which is a characteristic symptom of anthrax infection, to cause serious conditions. There are three general methods recognized for the treatment of external or cutaneous anthrax. These are local excision of the malignant pustule, injection of a devitalizing agent locally around the pustule, and intravenous or intramuscular injections of anti- anthrax serum. As the infection travels by the lymph stream it is logical to try and limit its spread by local treatment ; but by putting a combatant agent into the blood stream it is carried to all parts of the body. In the case reported the antianthrax serum was used both locally and generally. Ten or twelve cubic centimeters were injected locally into skin around the pustule. Doses of about 25 cubic centimeters were injected intramuscularly. Powdered ipecac in lotion was used locally for a dressing. The infection was kept localized and successfully driven out. The serum used was United States Government serum derived from sheep. CASE REPORT. E. L. T., seaman, aged 27 years, was admitted to the United States Naval Hospital, New York, on November 21, 1918, complaining of a severe frontal headache, a burning sensation in his eyes, extreme prostration, chilliness, and a swelling on the upper right part of the right side of his neck, near the mandible, which was very sore and tender. There was no soreness upon swallowing. His family history was irrelevant. His past history shows that he had the usual childhood diseases, including mumps. He had a gonorrheal infection three years ago. He never had typhoid fever, penumonia, smallpox, or any other acute infectious sickness during adult life. The present illness began on the evening of November 19, 191S. He says he felt as though he had " influenza." The condition started with burning of the eyes, frontal headache, sensation of chilliness, and extreme prostration. He had what he thought was a pimple or ingrown hair on the right side of his neck 1 inch anterior to the center of the sterno-cleido-mastoid muscle. The next morning he did not feel like getting out of bed and was admitted to the sick list. He felt a little soreness on the right side of his neck that morning and had a mustard preparation applied. The same night he noticed some swelling on the right side of his neck just below the lobe of his ear. He was sent to the hospital the following morning. Xo. 3. LEASURE —ANTHRAX CURED BY VACCINE. 533 When he arrived at the hospital the right side of his neck was swollen and very tender. The swelling extended from the midline anteriorly, below the jaw, to the anterior margin of the trapezius muscle posteriorly. Superiorly it reached the external auditory meatus, and inferiorly to the clavicle. The swelling did not involve the parotid gland particularly, but was located in the anterior and posterior set of lymph glands. The case might easily have been taken for mumps at first sight, but on palpation the swelling was hard, brawny and board like. There was a pustule just anterior to the middle of the sterno-cleido-mastoid muscle about the size of a dime, which had a hard brown crustlike center surrounded by a ring of yellow necrotic tissue. This was surrounded by an area of red inflamed tissue, around which were scattered many small vesicles. The pustule was elevated above the surrounding tissue and the skin was considerably indurated. His throat and tonsils looked normal and there was no pain on swallowing. The heart, lungs, and abdo men were normal. During the second day in the hospital his temperature rose to 104.1 F, his pulse was 100 beats per minute and his respirations 28 ; the swelling remained localized. His voice was a little husky, but here was no dyspnea. A smear was taken from the pustule and a ulture made. Both were sent to the laboratory for examination, and :he next day reported to be positive for anthrax bacilli and Staphylo coccus aureus. A urine specimen was reported normal. The patient's condition remained about the same, his temperature came down to 101 F, and the infection still remained localized. A culture was taken from the shaving brush which the patient had been using only for a short time. He reported having bought the brush on Forty-second Street, New York, 10 days before he became sick. While he was shaving one morning, seven days after buying the new brush, he cut himself at the exact spot where the present pustule is located. He brushed over the cut several times while lathering his face. The culture from the brush was reported to contain many cocci and anthrax bacilli. The urine showed many saprophytic organisms, but no anthrax bacilli. At 6 p. m. of the fourth day 10 c. c. of anthrax serum were injected into the tissue immediately surrounding the pustule. At 10 p. m. 25 c. c. of serum were injected intramuscularly into the buttock of the right side. For local dressings powdered ipecac in lotion was used. The temperature came down to 99°, and the infection was still localized. Following each intramuscular injection there was considerable soreness in the region of the injec tion. However, the tissue surrounding the pustule had a much better color and there was less induration. About 24 hours later a second dose of 12 c. c. of serum was injected around the pustule and into the 534 GREENE —FOREIGN BODY IN ANTRUM WITHOUT SYMPTOMS. glands at the angle of the jaw, where the tenderness and swelling seemed greatest. At the same time 30 c. c. were injected into the buttock. Following this injection the temperature rose to 101°, but soon fell and remained between 99° and 98°, for the remainder of the time. The sixth day after the patient entered the hospital he began to show definite signs of improvement. The swelling in his neck was noticeably smaller and was not nearly so tender. The pustule began to take on the appearance of an old vaccination, and the surrounding tissue looked healthy and normal. A third intramuscular injection of 30 c. c. was given a few days later, which was followed by a little local tenderness and enlargement of the inguinal glands on the right side. The patient continued to improve, slowly regaining his appetite and strength. The swelling gradually subsided, and the pustule took on the appearance of a scab. He was able to get out of bed 14 days after entering the hospital and is now up and convalescing. The blood stream was never infected. There is no doubt concerning the infecting organism or its source. The recovered organism is a characteristic Gram positive, spore- forming, nonmotile, large bacillus, which grows on agar media, pro ducing the medusa head fringe on the margin. When injected into laboratory animals it produced death in 1(5 hours, and the organism was recovered from the dead animal. The laboratory differentiated the bacillus from similar ones and identified all characteristics. A CASE OF FOREIGN BODY IN THE ANTRUM WITHOUT SYMPTOMS. By J. B. (jKBBNC, Lieutenant, Mod leal Corps, I'nited States Naval Reserve Forte. The following case would seem of sufficient interest to be re ported. Patient X, private in the United States Marine Corps, en listed at New York in January, 1918, and was sent to Paris Island, S. C, for training. Here his marksmanship was high, and he qual ified as a sharpshooter or sniper. He landed in France in May, 1918. and was soon sent to the front. It was at midnight on June 25 in the battle of Belleau Wood, now named for the American marines, that our patient received his wound from a high-explosive shell. Three marines occupied a shallow dugout, when the shell exploded over them, killing one and seriously wounding the other two. Pa tient was transferred to Base Hospital No. 6, where he was uncon scious till July 3. While in this hospital the patient had his left eye enucleated because of shell injury. He left France October 27, arriving at the Norfolk Naval Hospital November 9, 1918. Naval Medical Bulletin No. 3, July, 1919. Fragment of high-explosive shell in antrum of Highmore. Naval Medical Bulletin No. 3. July, 1919. Fragment of high-explosive shell in antrum of Highmore and bullet embedded in tissues of the neck, posteriorly. 534-2 GREENE —FOREIGN BODY IN ANTRUM WITHOUT SYMPTOMS. 535 Examination showed total loss of left eye, with a linear discharg ing sinus of left cheek over the malar bone three-fourths inch in length. There was noted a decided deviation of the nasal septum to the right, and a hard unyielding substance could be detected in the region of the attachment of the right middle turbinate by probing under cocaine. There was very slight discharge from the right nostril. Transillumination showed a slight difference in the two antra, the right slightly darker than the left. The X-ray examina tion showed a foreign body lying in the upper back part of the right antrum just under the floor of the orbit. This was quite surprising, for we had expected the fragment to be near the sinus on the left cheek, the point of entrance. There was another surprise in store for us, and the patient as well, when we discovered the shadow of a bullet in the patient's neck, slightly to the left side. The point of entrance was directly over the tip of the left mastoid. The symptom complained of was slight pain in the region of the left orbit. The patient's general condition was . good and he was up and about enjoying his rest in the hospital. There was no fever. On December 12 the operation for removal of the foreign body was performed under ether anesthesia, supplemented by injection of 2 per cent procaine with a few drops of adrenalin at the point of incision. The cheek was well retracted and a transverse incision was made through the mucous membrane over the right antrum (Caldwell-Luc) avoiding carefully the roots of the teeth. The bone was removed with a mastoid chisel, and the antrum was entered. The hemorrhage was slight, due to the injection of the procaine- adrenalin solution. The foreign body was soon found located largely in the antrum, though the end protruded into the right nasal cavity. It was so firmly embedded that its removal required the use of a curette. The mucous membrane of the antrum seemed surprisingly healthy. The cavity was packed with iodoform gauze and one suture was placed in the wound. As the bullet in the neck was embedded in the deep muscles and causing no symptons, it was not deemed advisable to remove it. Two days later the packing was removed. "There was only a slight post-operative rise of temper ature. The recovery was uneventful and the patient was soon dis charged from the hospital. The point of special interest is the fact that such a large fragment of shell could pass through the bony structure of the face and remain in the antrum so long without causing symptoms by its presence. The only feature of the opera tion worthy of note was the distinct advantage in the lessening of troublesome bleeding by the use of local anesthesia in conjunction with general anesthesia. 536 BOWMAN AND MEEKER—RUPTURE OF KIDNEY. Vol. XIII. TRAUMATIC RUPTURE OF KIDNEY: UNUSUAL COMPLICATIONS, RECOVERY. By F. H. Bowman, Lieutenant Commander, Medical Corps, United States Navy, and U. 1). Meekeu, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. G. M. F., cox., aged 24 years, of previous good health, was ad mitted to the United States Naval Hospital, New York, N. Y., on January 11, 1919, with the diagnosis of a fractured mandible, right radius, and left forearm. He was semiconscious and in profound shock. The health record showed that he had fallen two decks through an open hatch and had then walked to the sick bay. At the time of admission his temperature was 100 F., pulse 100, and respirations 22 per minute. Physical examination confirmed the admission diagnoses and in addition led to the suspicion of some intraabdominal complication. Palpation of the abdomen elicited tenderness in the left upper quadrant and a doughy feeling due to blood clot or confined fluid. He complained chiefly of pain in this region. There was no vomiting, no marked restlessness, and the patient answered questions sluggishly. Urine examination was negative for blood, but showed a cloud of albumin. He was watched carefully and treated for shock. He l-egained full consciousness during the day and complained bitterly of pain in the region of left kidney, was unable to empty the bladder, and had to be catheterized during the day. Injury to the left kidney was sus pected, although no signs of any contusion appeared on the skin of the abdomen or lumbar region. Five hundred cubic centimeters of urine were taken from him during the first day on three catheteriza tions. During the night he insisted upon sitting up in bed to uri nate, this being the first time he voided since the accident, and passed about 15 c. c. of urine dark red in color and containing free blood. Urinalysis for the first few days was rather interesting and as tabulated shows the appearance and disappearance of blood. Date. Color. React. Sp. gr. Albumin. Sugar. Blood. R.B.C Casts. 1-11-19 1-12-19 Amber. Dk. red. Acid. Acid. 1. 023 I. 029 A cloud. A cloud. Neg. Neg. Neg. Pos. Nolle. Many. Many gran. •Many gran, and blood. 1-14-19 1-15-19 Dk. amb Amber. Alk. Acid. 1.024 1.030 Neg. Heavy cloud. Neg. Neg. Neg. Pos. None. Few. Roentgenograms showed a fracture of the right ulna in the middle third, fracture through the styloid process of the right radius, frac ture of the left ulna and radius in the upper third, and fracture of the inferior maxilla (left) near the symphysis. No. 3. BOWMAN AND MEEKER RUPTURE OF KIDNEY. 537 Four days after admission it became very evident, from the in tensity of the symptoms and the urinary examination, that consider able damage had occurred to the left kidney and probably to other viscera. The patient's general condition had improved considerably and arrangements were made for a laparotomy. Operation. —Gas-ether anesthesia. Left rectus incision. Peri toneum opened in the usual manner. A small amount of blood-tinged serum was found in the peritoneal cavity, but no rupture of the peritoneum. A large retro-peritoneal tumor was very evident in the region of the left kidney. The peritoneum on the posterior wall of the abdomen was opened just outside the descending colon and a large blood clot and some fresh blood turned out. The incision was carried clown to the kidney, which was found completely ruptured into two separate portions. The larger and inferior portion was free in the renal fat and was lifted out. The superior and smaller portion was still attached by the pedicle to the vessels although very little circula tion was going on. The pedicle was clamped and ligated with heavy silk and this portion of the kidney also removed. Further examination of the abdominal viscera showed the liver, intestines, other kidney, bladder, etc., all uninjured. The spleen, however, showed a laceration at the lower pole about 1 inch in length. However, since all hemorrhage had ceased, no operative procedure was deemed necessary. Two gauze drains were placed in abdomen, one leading to the lower pole of the spleen and the other down into the bed from which the kidney had been removed. The posterior peritoneum was closed around the drain leading to the renal fossa, the peritoneum on an terior wall of abdomen was closed, the rectus returned to its bed and secured there, the fascia and skin closed around the drains. The fractures of the upper extremities were reduced and put up in plaster and the jaw was wired with silver wire after removal of several carious teeth. January 22, 1919: Drains removed, wound showed moderate dis charge, principally serum. Patient complained of discomfort from the wire which he had worked loose and which no longer held the in ferior maxilla in position. Impression taken for interdental splint. January 29, 1919 : Still some drainage from wound. Casts removed from arms. No union in right radius. Left ulna shows beginning union, but in malposition. Casts reapplied. Interdental splint ap plied. Since that time patient has been making a very satisfactory rccoverv. 538 Vol. XIII. FRINK THROMBOSIS OF POPLITEAL VEIN. SLOW OBLITERATING THROMBOSIS OF POPLITEAL VEIN. By C. A. FltlNK, Lieutenant, Medical Corps, United States Naval Reserve Force. A. G. was admitted to the United States Naval Hospital, New York, on February 22. 1919, with a diagnosis of multiple contusions to the left leg and fracture of the lower third of the left femur. These injuries were received as the result of his having been thrown against a winch while securing gear during a storm. Immedate examination revealed a simple fracture of the lower third of the femur with marked swelling of the entire leg, and it was thought at the time that the popliteal artery had been torn, as there was no pulsation below the knee ; but after 12 hours the circu lation returned to the leg. The patient was treated by extension and splints until he could be transferred to this hospital. Upon admission patient was in poor physical condition, having suffered severe pain in the injured parts from the vibration of the ship. The examination of the left leg showed it to be twice the size of the right, and roentgenograms confirmed the clinical diagnosis of fracture of the lower third of the left femur. The circulation of the leg was good and conditions continued favorable until the fifth day after the accident when the leg below the knee was found to be blue and cold. At no time did he have any abnormal temperature nor did the blood count suggest a septic condition. In view of the foregoing clinical findings operation was advised and then performed under gas-oxygen anesthesia. Antero-posterior flap incisions were made, and the femur amputated at the middle. A large venous blood clot was removed and two retention sutures put in to hold the flaps together; dressing applied. The patient's condition after operation was fairly good and did not show any evidences of any abnormal amount of shock. It remained good for about 24 hours when death from pulmonary em bolism suddenly occurred. Autopsy performed by Lieutenant B. K. Thomas, Medical Corps, United States Naval Reserve Force, showed a recent embolus in the lower lobe of the left lung and collapse of this portion of the lung. The kidneys showed acute diffuse nephritis and there was a moderate amount of cirrhosis of the liver. There was no other evi dence of injury and there were no signs of sepsis. Examination of the amputated leg showed the arteries to be nor mal, but the popliteal vein had been traumatized at the site of the fracture, as shown from examination of the intima of the vein. From that point downward all veins were filled with blood clot. A portion of the thrombus was of more recent origin than the rest and Naval Medical Bulletin No. 3, July, 1919. Alopecia universalis following scarlet fever. 538-1 Naval Medical Bulletin No. 3, July, 1919. Alopecia universalis following scarlet fever. 538-2 No. 3. TANNER —RUPTURE OF SPLEEN AND KIDNEY. 539 showed that it had been forming slowly from the time of accident until the entire return flow of blood had been cut off. The case is of interest from the causative factor and from the slowness of the obliterating thrombosis which caused complete obstruction. ALOPECIA UNIVERSALIS. By A. K. Alfbed, Captain, Medical Corps, United States Navy. The accompanying pictures illustrate a case of alopecia universalis resulting from scarlet fever in early childhood. This young man Avas a candidate for enlistment in the United States Navy, and was re jected. Experience has proved conclusively that it is no kindness to the individual, and not for the best interests of the service, to accept an applicant having any permanent abnormality of appearance suf ficiently marked to make him a constant subject of jest and ridicule for his shipmates. REPORT OF OPERATIONS: (1) FOR RUPTURE OF SPLEEN, (2) FOR RUP TURE OF KIDNEY. By ('. O. Tanner, Lieutenant, Medical Corps. United States Navy. On November 21, 1918, E. McC, MM-2, IT. S. N., was admitted to the United States Navy Base Hospital No. 5, Brest, France, with the following history : Early on the morning of admission he had been scuffling with a shipmate at the Carola Barracks. In the course of this action he fell on a stone pavement on his back, and his comrade fell with his full weight across the patient's abdomen. The patient got up with severe abdominal pain, and walked over to the sick bay at the barracks, a distance of 200 yards. Here he was put in a bunk and placed under observation. By noon his condition was becoming worse, and he was immediately transferred to this hospital for treatment. On admission temperature was subnormal, pulse rapid, thready and weak, and skin showed extreme pallor. He had abdominal dis tention, dullness in both flanks, and left side rigidity. There was great tenderness over the left upper hypochondrium, pain over the heart, and great shortness of breath. He was immediately prepared for operation, the writer assisting Lieutenant Commander G. G. Ross, Medical Corps, United States Naval Reserve Force. A high left rectus incision was made after the patient had been surrounded with hot-water bottles, and while nor mal saline solution was flowing into a vein. The abdominal cavity was filled with a mixture of clotted and fresh blood. A tear about '-' inches long was found, beginning on the diaphragmatic surface of 540 TANNER—RUPTURE OF SPLEEN AND KIDNEY. Vol. XIII. the spleen and extending into the center of the organ. A long pack of gauze was threaded into the wound and packed in tightly. The wound was closed with deep through-and-through sutures. For the first 24 hours following the operation he expectorated blood and had a very irritating cough, probably due to a trauma of the diaphragmatic pleura. On the fifth day after the operation the gauze pack was saturated with Hayenfs solution, and was removed the following day. There was no hemorrhage, and the wound healed rapidly. On the eleventh day after the operation he was out of bed and made an uneventful recovery. L. E. E., BM-1, age 23 years, was admitted to United States Navy Base Hospital No. 5, December 23, 1918, with the following history : A few hours previous, while on duty on a tugboat, he was struck across the left loin by a huge hawser which snapped in two while towing another boat. He was knocked across the deck, suffered extreme pain and was immediately sent to the hospital on a stretcher. On admission to the hospital he complained of severe pain just below the left twelfth rib, but showed no signs of hemorrhage. There was only slight pallor of the mucous membranes. Temperature was slightly subnormal but pulse normal. The skin area on the left side from the nipple line to mid thigh was ecchymotic. There was ex treme tenderness along the line of the left twelfth rib. The abdomen was normal to percussion and palpation. He was placed under ob servation. Three hours later he became pale, his pulse became rapid and weak, ecchymosis was more marked and the tension of the tissues over the loin area increased. The urine showed large quantities of blood and some albumen. There was marked dullness in the left flank but no- abdominal tenderness. A diagnosis of ruptured kidney was made, and the patient was immediately prepared for operation. Through an Israel incision I exposed the left kidney. The lower two thirds of the organ was a pulpy mass and the kidney space was filled with blood. After clamping the pedicle and removing the kidney the ureter and vein could be identified, but the renal artery could not be found. Evidently it had been torn off by the blow. The twelfth rib was found to be fractured. The area was packed with gauze and the wound closed. He was given 1,000 c. c. of saline intravenously on the table. The only explanation T can make for the delayed hemorrhage is that the torn renal artery might have been dislodged in transporting him to the hospital. He made an uneventful recovery until three weeks after the operation, when he developed a left-side pleurisy, which may be attributed to the lighting up of an old lung lesion by the blow at the time of accident. Ho. 3. BOWMAN AND MEEKER—TRAUMATIC ANEURISM. 541 TRAUMATIC ANEURISM: REPORT OF FIVE CASES. By F. H. Bowman. Lieutenant Commander. Medical Corps. United States Navy, and 11. 1>. Mekkkii, Lieutenunt Commander, Mtdkal Corps, United States Naval Reserve Force. Five cases of aneurism, traumatic in origin, came under the ob servation of the surgical division of the United States Naval Hos pital, New York, during the past year. Four of these were the result of wounds received in action during the war—three on the western front and the fourth aboard a torpedoed vessel. The fifth case was the result of an explosion of a water-gauge glass in the firerooni of the IT. S. S. Blakely in 1908. Two patients were operated on, one will be operated on as soon as the chronic osteomyelitis of femur has been overcome, one refused operation, and in the remaining case, because of the extensive involve ment, it is considered inadvisable to operate. Two cases were of the brachial artery, one of the femoral, one of the popliteal, and one of the left common carotid. Case I.—C. E., United States Marine Corps. Wound, gunshot, right thigh. This patient was wounded by a high-explosive shell at Chateau Thierry on June 15, 1918. He had a compound comminuted fracture of the lower third of right femur, which later became infected. He was admitted to the United States Naval Hospital, New York, Sep tember 14, 1918, with firm union in the femur, but the wound still draining from a chronic osteomyelitis. Temperature 99, pulse 84. respirations 17. He was operated upon December 6, 1918, and the bone curetted and better drainage established. December 15, six months after the injury, it was noticed for the first time that he had a small swelling in the popliteal space, which upon examination showed pulsation and a bruit extending down the leg along the course of the posterior tibial artery for about 3 inches. At the present time there is no disturbance in the circulation of the leg and no symptoms referable to the condition. It is intended to operate upon this case as soon as the chronic bone infection has been cured. Case II.—F. W. L., United States Marine Corps. Aneurism, brachial, left arm. This patient received a machine-gun bullet wound in the left arm at Soissons on July 19, 1918. The bullet entered just above the external condyle of the humerus and passed out about the middle of the arm on the outer side. The humerus was uninjured and no infection took place. Some time in September he first noticed an enlargement just above elbow joint, wrhich was diagnosed as an aneurism of the brachial artery. A distinct pulsation and a bruit extending down the arm as far as the division of the artery were present. There was no radial pulse, but some slight disturbance of circulation in hand and wrist. 542 BOWMAN AND MEEKER TRAUMATIC ANEURISM. Vol. XIII. Operation October 24, 1918. On dissecting out the mass, which was about the size of a hen's egg, the diagnosis was confirmed. The condition was an. aneurysmal varix, as the brachial artery, very much reduced in size, emptied into it from above, and two branches of the venae comites from below. The anastomotica magna, which came off above, was very much enlarged and was apparently taking care of the circulation. The aneurism was removed, and the patient made a good recovery with no disturbance of circulation. Case III.—T. W. M., Sea. 2. Aneurism, left brachial. This pa tient received a wound in the antecubital space of left arm, either by a shell fragment or a piece of steel from the superstructure, at the time the U. S. S. Tieonderoga was sunk by a torpedo on September 13, 1918. The wound healed with apparently no complications. About three weeks after the injury he noticed a lump in this region which was diagnosed as an aneurism. He was admitted to this hospital November 29, 1918. A distinct pulsation and bruit were present. There was no disturbance of the circulation in the arm. In order to dilate the vessels of the collateral circulation, preparatory to operation, digital pressure over the bra chial artery in the antecubital fossa was made for 20 minutes every two hours until December 10. 1918. Operation December 10, 1918. Upon dissection, the diagnosis was confirmed. The anastomotica magna came off above and was of good size. The brachial artery below the aneurism was very much reduced in size. There was no connection between the artery and veins. The aneurism was removed and the patient made a satisfactory recovery, although the circulation was considerably disturbed for some time. Case IV.—B. J. E., United States Marine Corps. Aneurism, right femoral artery. This patient was wounded at Soissons on July 19,. 1918, by a piece of shrapnel. The wound healed in about five \veeksr and on admission to this hospital three months later he still com plained of pain in the right inguinal region, particularly when the leg was flexed or rotated. On examination, the circulation of the leg appeared normal. There was no visible tumor mass, but upon palpation, a small, hard lump about the size of a walnut could be made out. This mass pulsated and there was a distinct bruit and thrill which extended down along the course of the femoral artery. This patient refused operative treatment. Case V.—F. J., age 52, formerly chief water tender, discharged from the Navy in 1908 on medical discharge. Aneurism, left com mon carotid. In 1908, aboard the torpedo boat Rlakely, this patient received a wound in the left side of the neck from the explosion of a water-gauge glass in the fireroom. Several weeks later, a swelling No. 3. CROFUTT —SALVARSAN (ARSENOBENZOL). 543 developed over the left side of the neck which was diagnosed as an aneurism of the common carotid artery. He was operated upon twice in the United States Naval Hospital, Mare Island, Calif., but what was done he does not know. The operations gave but tempo rary relief, for the aneurism has been gradually increasing in size ever since. At the present time, the mass covers the entire left side of neck and can be made out underneath the clavicle. Examination shows this mass to have a distinct thrill and pulsa tion. A bruit is heard over the area and over the upper part of the left chest. The circulation in the left arm and hand is very poor. Patient complains of headaches and dizziness and dyspnea. There is no specific history or other evidence of specific infection. On account of the extent of the condition, the fact that he has had two previous operations and his age, it is deemed inadvisable to operate. REPORT OF A DEATH FROM SALVARSAN (ARSENOBENZOL). Ily K. F. Ckofitt, Lieutenant, Mediial Corps, I'nlteil States Naval Reserve Force. Prencrm history. —Negative except for positive Wassermann +1 at Naval Training Station. Newport. R. I. Present illness: The patient presented himself at the genito urinary clinic aboard U. S. S. Leviathan stating that he had a " blood test " which was 1 plus at Newport and wished to have fur ther treatment. Examination showed no objective symptoms, but in view of the patient's statement a Wassermann was ordered; Novem ber 19. 1918, laboratory report showed Wassermann 1+; November 22. 1918, patient was admitted to the sick bay for usual preliminary treatment of calomel gr. iii followed by 1 ounce saturated solution mag. sulph. the following a. m. November 23. 1918, 0.6 gm. arsenobenzol administered intravenously in left median basilic vein at about 10.30 a. m. Arsenobenzol used was made by Dermatological Research Laboratory. 1818 Lombard Street, Philadelphia. Pa., United States of America, lot No. 95(5. Patient was removed to sick bay in good condition. Temperature, pulse, and respiration at 12 were 99.4°. 100. 22. Temperature, pulse, and respiration at 4 p. m. same day were 102°, 112, 24. Temperature, pulse, and respiration from this time on increased until they readied the maximum on November 24, 1918, at 4 p. m.— 103°. 160, 52. The following day at 12 noon they were normal. Maximum of pulse and respiration, during this time, pulse 134, respirations 36. From this time on his temperature ranged from normal to sub normal until November 30, 1918, 4 p. m.. when last taken previous to dissolution, when it was 100° by axilla. Pulse during this time ranged 544 CROFUTT —SALVARSAN (ARSENOBENZOL). Vol. XIII. from 134 to 96, respiration during this time from 34 to 32—all accord ing to clinical chart as recorded by the hospital corpsman. From November 25, 1918, until November 27, 1918, there was a period of anuria. At this time strychnine sulph. grain 1/30, and solu tion of adrenalin, minims 10, by hypodermic, q-3-h, was prescribed; also one glass of water every half hour, high saline irrigation (2 quarts) q-4-h, hot-water bottles to the feet. The mouth was swabbed with liq. alkalinus antisepticus. Sodium citrate, gr. vii, and infusion of digitalis, dram j, were given by mouth every four hours. During this period of anuria he was catheterized, 1 ounce of urine being obtained; on making a qualitative test for albumen, the speci men boiled solid. During this time there was constant and persistent vomiting. On November 27, 1918, at 6.45 p. m., he passed 1,000 c. c. of urine. The laboratory report showed albumen cloud ; microscopically a large amount of epithelial tissue, isolated cells, and groups of white blood cells were seen. On November 28, 1918, he passed 775 c. c. of urine. Laboratory report showed cloud of albumen ; microscopically white blood cells were seen in abundance. On this date his breathing became embar rassed. Upon examination it was found to be the result of a marked stomatitis and pharyngitis. This condition persisted and became exaggerated with the subsequent development of hemorrhage from the mouth and throat. During this time no blood was observed in the nasal passages, stools, or urine. There was no purpuric condi tion of the skin. At 11 p. m. November 28, 1918, the patient involuntarily passed a large quantity of urine. On November 28, hemorrhages from mouth and pharynx became so marked that it was impossible to keep mouth, lips, and throat clean. At 8 a. m., November 29, 1918, he relapsed into a comatose condition from which it was impossible to arouse him, the breath at this time being heavy, foul, and ammoniacal. At 8.25 this date passed 550 cc. of urine as recorded, also a large amount involuntarily. This comatose condition persisted as well as the involuntary passage of urine, until dissolution occurred at 7.34 p. m., November 30, 1918. The arsenobenzol used was of the same lot number as had been previously used in 81 cases without any complications whatsoever. The distilled water used was subjected to a careful bacteriological and chemical analysis. No growth was found on litmus agar, and tests for poisonous metals, copper, zinc and lead were negative. The operation throughout was conducted under generally ap proved aseptic conditions. No. 3. 545 CROFUTT ( ARSENOBENZOL ) . SALVARSAN i REPORT OF NECROPSY. Clinical diagnosis, nephritis, following salvarsan for syphilis. Pathological diagnosis: Acute nephritis secondary to syphilis and salvarsan treatment. It is a well-nourished body of a white man, aged about 30 years. Kigor mortis had set in and there was some mottling of the skin. There is a recent scar on the left tibia ; some ulceration between the toes; tattoo marks inside both forearms. In the left cubital space there is the scar of a recent puncture, the result of giving salvarsan. No chancre observed. There was a bloody discharge from the mouth and a sloughing of the mucous membrane of the mouth and lips. The panniculus is somewhat increased in amount and is yellow in color. The muscles are dark red and firm. The heart is enlarged downward and to the left. The auricles were distended with blood and the ventricles were in systole. The heart was not opened or removed. The lungs were full of air, no adhesions were found around them. No gross foci of hardening or of consolidation were found. There was no increase of fluid around the heart or around the lungs. Upon opening the abdomen the distended large intestine pro truded from the cut and a slight odor was noticed. The small in testine also was full of gas. The appendix was in normal position, in a normal condition. The bladder was small and contained less than an ounce of urine. The liver was smooth and did not show congestion nor adhesions. The stomach was pale and contracted and contained about two ounces of fluid and a few ounces of gas. The spleen was removed after the splenic vessels were tied. The splcvn was enlarged to about twice normal size. The capsule was adherent in two places. The surface showed irregular white areas about four centimeter's in diameter which were somewhat depressed below the level of the surrounding parts and felt somewhat thicker to the touch. Pieces of these were removed for microscopic examination. Cross section of the spleen showed engorgement and scraping the cut surface yielded a dark bloody fluid. Both kidneys were removed and parts of them saved for microscopic examination. The capsule of the left kidney was silghtly adherent over all of the surface. It was appreciably enlarged and was definitely lobulated. The lower branch of the pelvis was thickened and somewhat sclerotic. On mid section the differentiation between cortex and medulla was obvious. There was congestion throughout, but no infarcts were observer!. The right kidney was removed. It was not as enlarged as the left one but its lower lobe was relatively larger than its upper lobe. The capsule was adherent, it was congested throughout. Inflammation of the medulla and cortex. Xo signs of infarcts were observed. Further examination was not made. 546 pearce—Meckel's diverticulum. vol. xiii. Pathology : The spleen showed chronic passive congestion, prob able infarcts. The kidneys showed enlargement, inflammation, sclerosis, but no infarcts. Diagnosis: Acute nephritis. (Autopsy performed by Lieutenant H. S. Hulbert, Medical Corps. United States Naval Reserve Force.) PERFORATION OF MECKEL'S DIVERTICULUM AND ACCOMPANYING APPENDICITIS. By W. F. Pkabck, Lieutenant. Medical Corps, United States Navy. The following case has been very interesting to me as being the first such case I have seen in about 11 years of experience, mostly in civil work. For this reason it is thought it might prove of sufficient interest to others to warrant reporting. The vitelline duct persists occasionally as a band, less often as a definite pouch, as was present in the case about to be described. Unfortunately, it is impossible to present in this report data as to the frequency of occurrence of this pathological condition, as the literature is not at hand. S., R. L., Sea.-2, United States Naval Reserve Force, aged 19, was admitted to hospital from base dispensary late in the afternoon of December 25, 1918, transported in a hospital ambulance. History : Has had no previous illnesses save tonsillitis. States that his tonsils have been operated on three times. No history of any previous attacks similar to present one. For the past " two or three days " has noticed a slight discomfort in abdomen, which was re lieved by loosening trousers. History of present attack : About 10 a. m. on day of admission was seized with severe pain, which " doubled him up." This pain was in the region of the umbilicus. The pain shortty became less severe. It still continued, however, and about one hour after original onset again became more severe. At this time the point of greatest pain had shifted to the region of. McBurney's point. Pain con tinued severe from that time until admission, with its greatest in tensity over McBurney's point. He had vomited several times. Findings upon admission : Temperature 98.6 F.. pulse 120, regular, volume rather small. Fades: moderate pallor, " pinched expression." Abdomen; very sensitive, tenderness most marked over region of McBurney's point but pronounced over abdomen, especially lower quadrant. Marked muscular rigidity. Heart and lungs negative. Urine negative. White blood count 18,000. Blood pressure, systolic 118, diastolic 90. Immediate operation was decided upon and performed under ether anesthesia. Upon reaching the peritoneum it was seen to be edema No. 3. HOAGLUND AND PRIOLEAU —SYPHILOMA OF CEREBRUM. 547 tous and upon entering the abdomen, a moderately large amount of greenish gray fluid was encountered. Plaques of fibrin were seen upon cecum. After protective packing, appendix was isolated. It was ad herent and inflamed, sharply kinked about its middle portion and near the tip grayish brown in appearance. The appendix was re moved, stump not inverted. While there was apparently a beginning gangrene, there was no perforation and it was decided that there must be present some other pathological condition. Further careful examination disclosed the diverticulum, definitely inflamed and with a perforation about midway between tip and base. Diverticulum was ligated near intestine and removed. Stump was inverted, two drains placed and incision closed in layers. F or a few days after the operation there was some elevation of temperature at times, but never above 101.5° and varying between that and normal. Eight days after operation temperature became normal and remained so. Drainage has been very moderate yellowish pus. Drains were gradually removed, being dispensed with aftei four days. About 10 days after that, drainage ceased. Patient is now up and around and wound is closed. Description of specimen : Color congested in some portions, in others grayish, and in others still, especially about perforation, dark brown. Size: length 4 cm. Width ; 2.5 cm. at top, and 3 cm. at base. Perforation 1 cm. by 5 cm. Edges clean cut and indurated. The interior of the specimen is almost filled with a mass about the size of a cherry, which is free on all sides, but on incising side of specimen it is seen to be attached near extremity of diverticulum. This mass is moderately soft in consistency except at its attachment, where it is quite hard, of almost a cartilaginous consistency. The features of this case that seem to be of especial interest art the following: The presence of a tumor within the diverticulum. The induration of edges of the perforation indicating a probable preexisting ulcer, with absence of previous history of symptoms referable to right lower quadrant. SYPHILOMA OF THE CEREBRUM. T!y A. W. noAGi.rxn and P. F. Prioleav, nontenants. Medical Corps. United States Navy. The following case report is deemed of interest. It shows early cerebral syphilis, occurring in a young adult, beginning cerebral symptoms appearing three and one-quarter years following initial sore, rapidly progressing, with none of the usual outward clinical or laboratory manifestations of syphilis and proving fatal two and one- 116025—19 11 548 HOAGLUND AND PRIOLEAU —SYPHILOMA OF CEREBRUM. Vol. XIII. half months after slight premonitory signs of mental involvement. It also amply demonstrates lack of treatment, and haphazard treat ment conducted on patients transferred from place to place, par ticularly patients of the type who seem to think they know just when and how much treatment it is necessary for them to take, and who in this manner by failing to report and by more or less evading the medical officer, to a large extent regulate their own treatment. J. G. F., coxswain, United States Navy, age 30 years, admitted to U. S. S. Palos September 24, 1918, with a sudden attack of vomit ing followed by convulsions and unconsciousness for a few minutes. A diagnosis of syphilis was made June 7, 1915. Until this date there is nothing of any interest in the patient's health record relating to the case and we can think of his illness as having originated at this time. The diagnosis was based on the presence of a chancre on the penis, a luetic rash and mucous patches in the mouth. Two intravaneous injections of salvarsan were given and mercury was administered intramuscularly. To quote from the patient's state ment : " I received up to January, 1918, the following drugs ; First year, mercury all the year except for short intervals not exceeding two months and two doses of salvarsan; second year, same as first year but no salvarsan; third year, protoidid of mercury and inunc tions." However, referring to a previous entry of September 11, 1917, we are reminded that there is no record of treatment since November 18, 1915, other than the patient's statement, so that we can not be sure how much medication he actually received during the first three years. We also see a note to the effect that he once refused to take further treatment. This coupled with the general impression received from the patient leads us to believe that all statements made by the patient are absolutely unreliable, and his continued, at times voluntary, effort to assure us that he has had sufficient treatment, have been greatly encouraged by his present sudden realization of something wrong in his head. August 5, 1916, the patient was on the sick list two days with a diagnosis of neuritis, but this probably has no importance. On January 11, 1918, he com menced taking potassium iodide for two weeks and all treatment was then suspended. June 3, 1918, he was examined physically and found qualified for extension of enlistment. Wassermann reaction, June 26, 1918, was reported negative. The following symptoms as they presented themselves suggested sunstroke, neurasthenia, and cerebral tumor not of syphilitic origin until the correct diagnosis was made. It was about September 1, 1918, when the patient reported to me (P. F. P.) for the first time. He was complaining of frontal head ache, symptoms of eyestrain, and dizziness. He said that a few days before he was aloft painting and the sun was so intense he had to No. 3. HOAGLUND AND PRIOLEAU—SYPHILOMA OF CEREBRUM. 549 stop working. Rest and the usual headache remedies were success ful in bringing relief. September 24, 1918, he was taken suddenly with an attack of vomiting, followed by convulsions. He remained unconscious for a few minutes, during which time he was markedly cyanotic. The pulse was rapid and full. The urine, was negative for albumin and sugar. After the patient recovered somewhat an eye examination was made. Refraction as follows: O. D.=spheri- cal+1.50; cyl.+O.oO, axis 25°; O. S.=spherical-f 1.50; cyl.+0.25, axis 180°. The patient was warned to keep out of the sun and that glasses were to be worn. He continued to complain occasionally of nausea, and headache was a constant symptom. Tenderness was elicited on pressure over the epigastric region. Examination of the spinal fluid was impossible at this time. October 8, 1918, the patient first commenced to show mental symp toms. * He was easily excited and often hysterical. Crying spells were not uncommon. He was reluctant about taking any more syphilitic treatment, saying " he wasn't sure he had ever had syphilis and the trouble with his stomach was due to too much mercury he had taken." Examination then revealed pupils of equal size. They reacted normally to light and accommodation. Right patella reflex was more pronounced than the left but could not be considered as exag gerated. Photophobia was marked. He kept his eyes closed and refused to read, as this made his headache worse. October 13, 1918, 0.6 gm. of salvarsan was given intravenously. Mercury was also used. No improvement was noted; there was no fever; no albumin in the urine ; normal blood count. Headache, nausea, vomiting, and vertigo were now pronounced symptoms. Vomiting did not relieve the headache, and the former was independent of any food taken and might occur any time during the day or night. The vomitus was always free from blood. Bowels were usually regular, except for a period of 10 days, when diarrhea was very troublesome, and incon tinence occurred. Starch-opium enemas were required to relieve the condition. Pa tient was kept on a diet. Potassium iodide was repeatedly given by mouth, but even very small doses in the most palatable form seemed irritating to the stomach and had to be abandoned. It might have been wise to have attempted administering the drug by rectum. The patient was becoming progressively worse. October 31, 1918, he was transferred to the United States Naval Hospital. Yokohama, Japan. Upon arrival at hospital. November 14. 1918, examination revealed the general condition poor, the patient apathetic, pale, and emaciated, with eyes tightly closed and an expression of pain written on *he features. The early symptoms were accentuated. The head 550 HOAGLUND AND PRIOLEAU —SYPHILOMA OF CEREBRUM. Vol. XIII. ache was occipital now. as well as frontal. Pain in the abdomen was sharp and described as radiating up and down but never around the abdomen. There was no tremor or deviation of the tongue. There was slight evening rise of temperature. The left knee jerk was diminished as compared with the right but the latter could not be spoken of as increased. Babinski and Oppenheim signs were negative. There was spasm of both lids and extreme photophobia. Right pupil was slightly larger than the left. Both eyes reacted to light and accommodation. Vision was greatly reduced, right eye 8/20 and left eye 10/20. There was present homonymous hemianop sia showing that there was an interruption in the path to the central side of the chiasm and located on the left. The patient could only see objects to the left of the median line, as the right halves of the fields of vision were absent or blindness existed in the left halves of both retinae. Ophthalmoscopic findings were ; a hemorrhagic' zone around a pale optic nerve, distension and tortuosity of the retinal vessels near the disk. The disk did not seem swollen. Periphery of retina appeared normal. The left eye was the least involved of the two. Patient's condition was very serious. There was contin uous vomiting with inability to take even the slightest amount of food, this vomiting being always of a very characteristic cerebral type. Blood Wassermann was negative. Hemoglobin per cent 75; R. B. C. 4,080,000: W. B. C. 10,000. Differential count: Polys, 74, S. L. 20, L. L. 3, T. 2, L. M. 1. On November 16, 1918, 25 mils of spinal fluid were withdrawn with great improvement in symptoms. Head ache was relieved and nausea and vomiting disappeared for 12 hours. Arsphenamine, 0.6 gm. was given intravenously ; slight reaction. Laboratory examination of spinal fluid as follows: Slight globulin increase. A cell count of 70 cells to the centimeter. Lange's col loidal gold test was read as follows: 0012322210. Wassermann. negative. At this point a definite diagnosis of cerebral syphilis was made. By exclusion we narrowed the condition down to neuras thenia, cerebral abscess or a rapidly growing cerebral tumor, syphi litic in origin. Although the blood and spinal fluid Wassermann re mained negative and the pupillary reactions remained normal, though in view of the acute and rapid onset of the entire condition, a period of two months from absolutely no symptoms to the present critical condition, nevertheless the cell count of 70 in the spinal fluid combined with the suspicious Lange curve and the past history led us to believe that the condition was syphilitic in origin. November 24, 1918, there was slight improvement. Patient was able to take food. Potassium iodide gr. xx was given t. i. d., 0.6 gm. arsphena mine was administered intravenously with the idea of following it with an intraspinal injection of arsphenaminised serum but the No. 3. CAMERER AND POPPEN EXTRA-GENITAL CHANCRE. 551 patient's condition suddenly changed for the worse and the proce dure was not tried. Blood Wassermann on this date was again negative. On November 26, 1918, he sank into a stupor, becoming weaker and weaker and death ensued. Autopsy revealed the following: Evidences of increased intra cranial pressure. Slight exudative meningitis along border of su perior longitudinal sinus. A gumma 5 centimeters in diameter was found filling the whole center of left occipital lobe. Microscopical specimens revealed typi cal syphilitic changes. Other organs negative. This case of syphilis illustrates the importance of early consistent and continued treatment of syphilis. It aptly points out the occa sional case of syphilis which travels along apparently giving no signs of even the slightest disturbance, the case in which the aver age patient is so quick to believe that " He didn't even have syphilis," when suddenly it crops out, fortunately not always so violently or so quickly fatal as in this report. The case is interesting in view of the rapidity with which it in volved the nervous system, although intravenous, intramuscular, and internal treatment had all been given. The persistent and continual hlood and spinal fluid negative Wassermann, the absence of eye and other characteristic nerve syphilis prodromes, the rapid and abso lute organic nerve tissue destruction, as evidenced by eye background and vision examination and the persistent cerebral type of vomiting, together with the high cell count and suspicious Lange's colloidal gold test, firmly convinced us that we were dealing with organic de struction of some type. A CASE OF EXTRA-GENITAL CEANCRE. By C. B. Camerer, Lieutenant Commander, Medical Corps. United States Navy, and J. R. Poppen, Lieutenant, Medical Corps, United States Navy. S. S. S., private, United States Marine Corps, was exposed to venereal infection on July 13. 1918. Approximately four weeks later the patient noticed a small lesion on the perionychium of the index finger of the left hand, which he described as a " hangnail." It was associated with very little pain and developed gradaully until on August 27, 1918, it had assumed the proportions of a severe paronychia. On this date he was admitted to the sick list as with " cellulitis." (At this time the patient attributed the infection to an abrasion caused by the rear sight of his rifle at drill. Close questioning brings out the statement that he is " not sure " about this injury.) Practically the entire distal phalanx of the finger was in volved in an indolent purulent infection. Free drainage was afforded 552 CAMEEER AND POPPEN EXTRA-GENITAL CHANCRE. Vol. XIII. by liberal incisions. The patient was kept on the sick list for five days when he was " discharged to duty under treatment.*' The course of the process was not satisfactory, however, as is shown by the fact that nine days later (Sept. 10), 1918, he was admitted as with "Abscess unqualified." Beference to the health record shows. "Patient admitted with a well-developed felon on second (index) finger of left hand (distal extremity), resulting from a previous infection (see above). Treatment, free incision, drainage, hot soaks, and wet packs." The granulated indolent character of the lesion was noticed at this time but was attributed to the chronicity of the process. Failure to respond to prescribed treatment is shown by the fact that he remained on the sick list for eight days and was again "discharged to duty under treatment." The lesion gradually healed leaving an irregular stellate scar on the outer edge of the distal phalanx. Three months later (Dec. 17, 1918) the patient came to the sick bay complaining that his hair was falling out. Examination dis closed the presence of a typical luetic alopecia. The entire scalp was covered with irregular incomplete patches of loss of hair, giving it the " moth-eaten " appearance so characteristic of this form of alopecia. Further examination showed a generalized, copper-colored, maculo-papular eruption and a shotty adenitis involving especially the inguinal, epitrochlear, and posterior cervical chains. There was no " primary lesion " any where, and careful questioning failed to disclose any lesion, excepting the "paronychia," which might well have been a chancre. There had been no exposure for several months prior to July 13 nor since then. Blood was taken for Wassermann. A clinical diagnosis of syphilis was made and the patient given an intravenous injection of arsphe- namine, 0.06 gram. This was followed by two subsequent adminis trations of the drug at seven-day intervals. Since then the patient has been receiving weekly intramuscular injections of 1 grain of mercury salicylate. The eruption cleared almost immediately and the alopecia is practically unnoticeable at present. The patient has regained weight and strength and is far less irritable. Unfortu nately, no satisfactory Wassermann has been obtained, all specimens being reported on as " anticomplementary." The interesting features of this case appear to be the following: {a) History of repeated exposure to infection on July 13. at which time he admitted having handled the genitals of the prosti- tue; the patient's statement to the effect that he is left-handed, and that he recalls the presence of an abrasion on his left index finger at this time. (b) The fact that he had taken careful venereal prophylaxis within eight hours following exposure. Naval Medical Bulletin No. 3. July, 1919. No. 3. 553 HERMAN—CHANCRE OF THE THUMB. (c) The utter absence of a genital sore and. in fact, any other than the " paronychia'''' referred to, as appearing on the finger as stated, which doubtless was a mixed infection and the site of original inoculation. Digital chancres are by no means uncommon. The usual histon* corresponds to the case described. They begin as an insignificant " hangnail," a papule or ill-defined infiltration of the matrix or nail bed, and show a tendency to ulcerate and become secondarily in fected with mixed pyogenic organisms. The presence of considerable purulent discharge and unusually severe pain tend to obscure the picture of a typical primary syphilide. As in the above case, the diagnosis is often not made until the appearance of secondary symptoms arouse suspicion. CHANCRE OF THE THUMB. By I.. Herman-, I.ieutennnt (J. Q.), Medical Corps, United States Naval Reserve Force. Chancre of the thumb is so extremely rare that the following case is worthy of record : M. S., ship's fitter, was referred for diagnosis to Navy Base Hos pital No. 5, Brest, France, in August, 1918. He had been suffering for several weeks with a painless, indolent ulcer, situated over the terminal joint of the right thumb. This began as an insignificant scratch, which increased in size through ulceration and became rounded in outline with peripheral induration. The lesion had been treated with various cauterizing agents, but had lost none of its Hunterian characteristics. In fact, the case presented a pri mary lesion of syphilis with the most typical features of a true Hunterian chancre that the writer has ever seen in an extra-genital lesion. There was concomitant indolent enlargement of the asso ciated epitrochlear and anterior pectoral lymph nodes. Treponema pallidum was found in the serum expressed from the lesion. The blood Wassermann test was positive. The sore disappeared promptly after the administration of novoaisenobenzol. It is interesting to note that among approximately 1,000 cases of syphilis ob served during 14 months of foreign service, there were four in which primary sores appeared at sites other than the penis. Of these, one occurred in the midline of the anterior abdominal wall, just above the pubes ; a second occurred on the lower lip, a third on the scrotum, and a fourth on the thumb, as just described. The patient with the chancre of the thumb offered the suggestion that the lesion might have been acquired while he was working as a plumber in the ship's lavatories. The chancre of the scrotum was interesting, in that the lesion was thought to be a hair-follicle infection, and was incised and curetted twice, and had entirely healed over before the patient, 554 MARTIN—TYPHOID FEVER WITH COMPLICATIONS. Vol. XIII. a physician, had any idea of the nature of the lesion. A few papules eventually appeared on the abdominal wall. Several of these were excised and examined for the treponema, but with nega tive results. The blood Wassermann test, however, was strongly positive. There is no reason to doubt that the scrotal lesion was a primary luetic sore. A CASE OF TYPHOID FEVER WITH SEVERE COMPLICATIONS. lty F. N. Mautix, Lieutenant. Medical Corps, United States Naval Reserve Force. Since the universal employment of antityphoid inoculation in mili tary service, so well has it served its purpose, the occurrence of a single isolated case of typhoid fever becomes the subject of comment. It is hoped that the history of the following case presents sufficient points of interest to be worthy of report. S. J. C, fireman 1, age 29; born, Hyde Park, Mass.; enlisted, Salt Lake City, Utah, June 27, 1917; served one previous enlistment. History of present illness: Patient was admitted to sick bay, U. S. S. Savannah, on July 31, 1918, diagnosis undetermined, but with dysentery, probably of dietetic origin. On admission, temperature 103°, pulse 104, respirations 28. Examination of chest and abdomen negative; blood count normal. Note in health record August 4, "condition about same, temperature 104°, mucous diarrhea. Ex amination of stool negative." On August 6 diarrhea was marked and examination of stools showed presence of Lamhlla intentlnalis, and diagnosis changed to dysentery. Condition remained about the same. August 10, patient slightly improved, diarrhea less marked; temperature, however, remained as high as 103°. On this date patient was transferred from U. S. S. Savannah to a naval hospital, being admitted with diagnosis of dysentery (unclassified). History of sudden attack of diarrhea, beginning about 10 days before and marked by live to six bowel movements daily. Temperature 102° on admission; pulse and respiration in proportion. Examination otherwise negative. Examination of patient showed enlargement of spleen and several small spots (atypical rose spots) on abdomen and lower thorax. Examination of urine and feces for typhoid bacilli was unsatisfac tory. On August 30 temperature gradually dropped and reached normal for the first time. On September 2, during the day, patient seemed to be in very good condition, temperature ranging from 98° to 101.5° ; bowels moved twice early in the day, small, light-formed htool. without blood ; no pain. At 8.15 p. m. August 2 patient had n the medical wards. Even slight wounds provoke malarial recur rences and they are prone to follow chloroform or even ether anes thesia. Hemorrhagic phenomena are also common in malarious sub jects—epistaxis, hematuria, ecchymotic patches, hemoptysis. 566 Vol. XIII GENERAL MEDICINE. Conditions in Macedonia seem to prove that the customary devel opment of malarial symptoms within a fortnight of infection does not always appear. Infected persons may continue in perfect health until, after a more or less definite period, some fortuitous circum stance causes the latent infection to become active and manifest. This variable and partial immunity may be natural or the result of quinine administration. Wounds, surgical operations, fatigue, over exposure to the sun, even typhoid inoculations, may excite the malarial explosion. Malarial parasites have been found in the blood of healthy persons —at least they felt well, except for headache and lassitude — that had no fever. Malaria in troops has to be considered in regard to its active mani festations, then in regard to relapses, and lastly with reference to carriers. It is particularly with the latter that the author is con cerned, and he gives methods of detection apart from any clinical data. The ordinary blood film is not to be relied on wholly. It will lead to the detection of but a limited proportion of the carriers. The Ross thick-film method is to be preferred, but its results are also un satisfactory. A differential leucocyte count has auxiliary value. Fever and parasites may be absent, but a high mononuclear count and an occasional transient high leucocyte count without fever should lead to careful observation of the subject. The concentration and culture methods of Bass and Johns, modi fied by Row and the Thompsons, should be employed. Certain provocative methods have given good results —the use of drugs, bio logical products, and the quartz lamp. The object is to force the parasites out of the spleen, bone marrow, and elsewhere, and into the peripheral circulation, where they can be detected by the ordinary methods. Relapses are most common among those who have had a so-called spontaneous cure or who have had insufficient treatment. The importance of vigorous treatment at the start is very great. In time, of course, if there is no reinfection, the tendency is for malaria in the system to die out. Parenthetically it is interesting to consider the numerical mag nitude of an invasion of parasites necessary to produce fever. In benign tertian fever 100 adults per cubic millimeter of blood are necessary for a temperature of 99 F. and 300 or more adults are required to produce a fever of 100 F. or more. In malignant tertian fever 3,000 young rings per cubic millimeter are required for 99 F. and 5,000 to 30,000 young rings per cubic millimeter will give fever from 99° to 106 F. It has been claimed that in true malaria other than malignant tertian the microscope will invariably suffice for diagnosis provided the blood to be studied is taken at the time No. 3. GENERAL MEDICINE. 567 of the paroxysm or at least this instrument will establish the mild ness of the infection. This is not absolutely true. Patients may die of malaria who show no parasites in the circulating blood, and only a few in splenic smears. In cases dying after 3 to 5 days of treatment parasites were more frequent in the spleen and bone mar row when the quinine had been given orally, less frequently when the quinine was given hypodermically, least when given in three to four doses of 22.5 grains intravenously. Apparently the parasites in the spleen and marrow escape the full effects of quinine, so while those in the peripheral circulation are killed some still survive in spleen and marrow. When these multiply above a certain number they appear in the peripheral circulation and if numerous lead to febrile relapse. Adrenalin has been tried by the author and others to dislodge parasites from the capillaries of the spleen and other internal organs with interesting results. Some investigators have tried to cause contraction of the spleen by adrenalin, ergot, pituitary extract, nitrate of strychnia, and berberin salts. Latent infection has been disclosed by the injection of sterilized milk. In Albania injections of horse serum have been used with success, bringing about an increase of schizonts and gametocytes in tropical cases. Irradiation of the spleen with the quartz lamp has also been favorably reported on. The author adverts to the theory that quinine fails because the parasites are not in the circulation and so, except in relapses, are beyond the reach of medication. In relapses, a heightened blood pressure has swept them from sinuses and capillaries into the active stream. The author has long held, and announced in 1914, the belief that transient hyperglycemia might cause relapses, and the view has been confirmed by his labors and those of others. Finally the Wassermann test may be utilized ; but a positive reaction is not usual after the tenth day. The examination of recruits may therefore be summed up thus : First stage: Thick smears and leucocyte and differential count. Positives are sent to hospital. Negatives are passed on to the Second stage: Provocative methods, as ergot, adrenalin pituitary extract, strychnine, berberlne, quinine. Positives are sent to hospital ; negatives pass to Third stage: Injections of milk, horse serum, exposure to quartz lamp. Positives go to hospital. Negatives should be kept under medical surveillance for a definite period and watched for symptoms after fatigue or exposure. Experiments in India in 1911 on cases of severe malarial infec tion with splenomegaly and temperature above 104° show that the X-ray can relieve splenic pain and engorgement and reduce fever— usually permanently. The usual sequel of anemia did not appear and no quinine was employed with this treatment. This treatment 568 Vol. XIII. GENERAL, MEDICINE. has been used more recently by other investigators with partial or entire success. Reports have been received from a German military hospital in Turkey, which show the failure of quinine as a prophylactic both in benign and subtertian fever. Those patients who had not pre viously taken quinine responded readily to the regular treatment, while those who had taken it developed the parasites when the drug was discontinued or else showed no diminution in parasites during the therapeutic administration. A certain concentration of quinine is deemed necessary in order to accomplish any useful purpose and they prefer the intermittent use of quinine. In conclusion the author reiterates the menace of associating in fected troops or those from malarial areas with healthy nonmalarial soldiers as the work of military training involves the sort of strain best calculated to cause relapses and render these cases dangerous carriers. These carriers must be sought for with great care by the methods described. If they are rebellious to treatment they should be honorably discharged from the service, (j. s. t.) Soli.man, T. Anthelmintics: Their efficiency as tested on earthworms. .Tour. Pharmacol, and Exper. Therap. October. 1918. The war has created a shortage in the supply of the usual anthel mintics, which makes it advisable to utilize the available drugs to the best advantage. Trustworthy and convenient tests of efficiency will therefore be especially useful. Several methods of bio-assay have indeed been employed. The direct therapeutic test on man is not always feasible; it is not altogether reliable, because conditions are not easily controlled in human patients: it therefore requires a large statistical material. Earthworms resemble intestinal worms in their reactions toward anthelmintics, and have been used qualitatively for investigating the nature of the action of anthelmintics; for instance, by Straub and by Trendelenburg. Yagi proposed the liquefaction of malefern as a specific quantitative test for this drug. The general similarity of the reactions of earthworms suggested the hope that simple toxicity experiments would furnish valuable data, with certain limitations. This hope has been realized by the results of the following investigations. They show that all anthel mintics are toxic to earthworms. A substance that is not toxic to these worms is therefore scarcely worth further trial, and a substance that is toxic to earthworms is worthy of consideration as an anthel mintic. It will, of course, require very extensive investigation before its value as a clinical anthelmintic is established, for that involves also No. 3. GENERAL MEDICINE. 569 other considerations, such as the specific efficiency for human para sites in the intestinal tract; and the absence of excessive toxicity or irritation to the patient. It is not possible, therefore, to deduce the clinical availability or . even the clinical efficiency from the order of toxicity to earthworms, except in the sense that drugs that are not toxic to earthworms in fairly high dilutions are probably not anthelmintics, whilst those that are effective on earthworms will likely be useful clinically, pro vided that the conditions of absorption, irritation, and toxicity are favorable. This is illustrated by the confirmation of the time-honored pumpkin-seed treatment. The worms (species not determined) are kept in the laboratory in small crocks, partly filled with leaf mold. When experiments are to be made the crock is inverted and the worms, which are mostly at the bottom of the mold, are picked up in mass and dropped in a conical urine glass filled with tap-water and placed in urine glasses, 100 cc. in each, and five of the worms are introduced. The size of the worms makes remarkably little difference, but if they differ widely it is advisable to have several sizes in each glass. When only five worms are put into 100 cc. of water they keep alive and normally active for more than a week. Much larger quantities, however, become asphyxiated. In the experimental glasses the activity of the worm is examined for a few minutes. Irritants generally cause more or less agitation, increased movement, often " whipping." They are again examined after one or two hours, and again on the next day. The author has used a large number of substances in experiment ing on the earthworm and shows the fatal concentration and time necessary for each drug used. He calls particular attention to the following : 1. The high toxicity of mustard oil, explaining the anthelmintic use of the closely related onion and garlic. 2. The high toxicity of copper sulphate ; suggests its use in enemas against oxyuris. 3. The anthelmintics that are most efficient clinically also stand high in their toxicity for earthworms. 4. Anthelmintics of doubtful clinical efficiency stand low in their toxicity for earthworms. 5. Substances that are practically nontoxic to earthworms are not used as anthelmintics clinically. The following is a general summary of the results obtained and shows very interesting conclusions: All clinical anthelmintics are markedly toxic to earthworms. This simple test may therefore be used for determining whether a 570 Vol. XIII. GENERAL MEDICINE. given substance has any anthelmintic properties. It may also be used to determine the relative activity of different samples of a given drug. It could not be used to compare the clinical value of different anthelmintics, since this often involved factors other than simple vermicidal efficiency; such, for instance, as absorption, local and general toxicity, etc. For instance, the highest vermicidal efficiency is possessed by substitutes that are not clinically available for this purpose, viz, mercuric chloride, cupric sulphate, and mustard oil. Aspidium, chenopodium, pelletierin, thymol, betanaphthol, and chloroform are highly effective. So is santonin in the presence of an appropriate solvent (bile salts and sodium bicarbonate, simulat ing the intestinal fluid). Somewhat less effective, but still quite toxic, are kamala, kousso, and granatuni. Spigelium is rather feeble. Fresh (germinable) pumpkin seeds and squash seeds are highly efficient, the active principle being soluble in water and destroyed by boiling. In view of their cheapness, availability, and presumably low toxicity to man, renewed clinical interest in these is indicated. Spices and sharp substances, including mustard, pepper, onions, and cantharidin are quite toxic. Their use in the preparatory treat ment is therefore well justified (except, of course, cantharidin). Indeed, pepper potentiates or synergizes the effects of the more active anthelmintics. Mixtures of the active anthelmintics give simple summation of efficiency. This may be useful for decreasing their toxic effects on the hosts. It would need to be determined by further animal ex periments and clinical trial. Oleoresin of aspidium appears to be quite stable, although the dry rliizone deteriorates. Different samples agree fairly in activity. The deposit that occurs in some oleoresins appears to have little, if any, influence on the activity. Different samples of pelletierin tannate are also of fairly uniform activity. The " pelletierine tanret" is a secret preparation without any advantage. Most substances that are toxic to earthworms pro duce a primary irritation or agitation that results in the withdrawal of the worm from the neighborhood of the poison. This is observed with santonin, but is no more marked with this than with the other anthelmintics. By virtue of this effect, anthelmintics doubtless often " expel " the parasites when the concentration does not rise sufficiently high to kill the worms, (w. e. b.) No. 3. GENERAL, MEDICINE. 571 Rosen-bloom, J. Newer methods in the treatment of bichloride poisoning. Am. Jour. Med. Sc. March, 1919. After review of the literature and discussion of the principles involved the author gives the following summary of treatment: " 1. Administer the whites of three eggs beaten up in a quart of milk and then empty the stomach by siphonage. "2. Give 300 cc. of fresh calcium sulphide solution, containing 1 grain to 1 ounce of water by mouth. " 3. Wash out the stomach with fresh calcium sulphide solution, 1 grain to 1 ounce of water. •' 4. Administer in powder or tablet 0.36 gram of sodium phosphite and 0.24 gram of sodium acetate. If this is not available, give the following: Sodium hypophosphite 1. gram Water 10. mils Hydrogen peroxide 5. mils " Use ten times as much of the hypophosphite as poison taken. Give a copious lavage of stomach with the above antidote diluted twenty times. Give the above undiluted antidote every eight hours for two days. " 5. Pour through the stomach tube after the above lavage a solu tion of 3 ounces of sodium sulphate and 6 ounces of water containing 5 grains of calcium sulphide. Let these solutions remain in the stomach. "6. Give intravenously after withdrawing 600 cc. of blood, 800 cc. of Fischer's solution or of bicarbonate-glucose solution. " 7. Wash out the stomach morning and night, giving by the mouth after each washing 5 grains calcium sulphide dissolved in 3 ounces of water. Continue this lavage until the stomach washings are free from mercury when tested by Elliott's method and until the urine is free from mercury. " 8. Give high colon irrigations of warm water morning and night, using 8 gallons of the water for each treatment. *' 9. Give a hot pack twice daily. " 10. Give 8 ounces of milk every second hour. "11. Give every second hour 8 ounces of the following solution, by mouth, alternating with the milk : Potassium bltartrate dr. J Sodium citrate dr. J Sucrose dr. J Lactose dr. iv Lemon Juice oz. J Boiled water oz. xvj "12. Force the patient to drink large quantities of the alkaline waters, such as Celestin Vichy or Kalak water. 572 GENERAL MEDICINE. Vol. XIII. " 13. Give a low fat and low protein or high carbohydrate diet for four weeks. Avoid salt in food, as it increases the absorption of the mercury. " 14. Give by continuous proctoclysis a solution containing 1 dram potassium acetate, 4 drams glucose, and 3 drams sodium bicarbonate to the pint. " 15. Keep the urine alkaline to methyl red. " 16. Continue rest of treatment until recovery, usually a period of three weeks.'" (j. s. t. > Hirst, J. C. Corpeus luteum to control nausea and vomiting of pregnancy. Am. Jour. Obst. March, 1919. The report covers a series of 111 cases in the author's private prac tice. Of this number, 99, or 89.2 per cent, were favorably influenced by the intramuscular injection of corpus luteum extract, the relief being often marked and prompt. The employment of this agent is based on the fact .that during the period of sexual activity every woman is constantly absorbing corpus luteum. No sooner is the corpus luteum of one menstruation disposed of than another takes its place. With the onset of pregnancy this absorption ceases. The nausea of pregnancy beginning during the period of nonabsorption disappears about the time that the corpus luteum begins to decrease in size. The employment of the remedy by hypodermic prevents the alter ation incident to digestion and guarantees absorption in spite of gastric disturbance. The dose in mild cases is 1 mil every other day for five or six times. In severer cases 1 mil is given daily up to VI or 15 doses. In pernicious vomiting 1 mil may be given twice daily, the patient being confined to bed. The site of the injection is the deltoid muscle after cleansing of the skin with tincture of green soap and alcohol. A glass syringe is used. It and the needle should be boiled and allowed to cool. Alcohol is not available to sterilize the apparatus when animal ex tracts are to be administered. The injection should be deep into the muscle. Follow by gentle massage. The extract used has been de rived from various animals, as the cow, sheep, and sow. The latter source is the best, but no very marked difference was noted in the effects. Human corpus luteum, if easily procurable, would give the best results. The author reports many hundred injections without abscess for mation, though there may be an area of redness and slight tender ness. Analysis of the 111 cases show 65 entirely relieved and 34 so much benefited that after 12 doses the patients professed themselves No. 3. 573 SURGERY. so comfortable that further treatment was not desired. In 8 cases there was no beneficial effect of any kind and in 4 the nausea was alarmingly increased. Each of these four women had a marked goitre, and such a complication is considered a distinct contra indication to the treatment. Of the 111 patients, 4 aborted and 2 had distinct anaphylactic reaction. Of the total number, 11 were cases of pernicious vomiting, of which 6 were completely relieved by the treatment and 5 gave no response. In all the cases successfully treated corpus luteum was the only remedy employed and may be legitimately credited with the results. In favorable cases relief is usually apparent after the fourth or fifth dose. If no benefit is noted after 12 injections, it is useless to continue them. Cases of failure: (1) Large goitre present. (2) Dysuria at tenth week. Retroversion. Replacement relieved all symptoms. (3) Noth ing noteworthy. (4) Nothing noteworthy. (5) Anaphylaxis. (6) Large goitre. (7) Vomiting continued after emptying of the uterus. Had two tapeworms. (8) Large goitre with exophthalmus. (9) Large goitre with exophthalmus. (10) Previous transperitoneal hysterot omy. (11) Adhesions from previous gallstone operation. (12) Nothing noteworthy. The writer closes with the statement: "I would not willingly be without this means of treating a condition which resists most other forms of treatment —a means which to me has given such satisfac tory results." (.t. s. t.) SURGERY. Deavek, J. B. Post-operative parotitis. Ann. Surs. February, 1919. Parotitis secondary to surgical intervention has come into notice mainly in connection with the increase of abdominal operations. In 1880 Paget reported 101 cases of secondary parotitis, of which 50 per cent followed operations on the upper abdomen and 50 per cent followed operations on female generative organs. Deaver holds that the organ operated on is not the chief factor in causing secondary parotitis. He considers this complication due to post-operative wound infection, local conditions, or some peculiarity of the pathology encountered. A physiological explanation might be found in the absence of mucin from the salivary secretions of the parotoid. In other glands this constituent of the secretions is sup posed to have decided bactericidal power. But physiologists are not agreed on this point. The three types of secondary parotitis are (1) metastatic, occur ring only in pyemic conditions: (2) due to ascending infection by 574 SUBGERY. Vol. XIII. way of the excretory ducts; (3) traumatic, as from forcible manipu lation of the lower jaw in connection with anesthetization. The trauma incident to anesthetization is common and can be readily appreciated. Infection by way of the lymphatics or blood stream is due to disease of neighboring parts. Infection through Stenson's duct is easily understood if we remember the many bac teria harbored by the mouth. In recent times the majority of cases of secondary parotitis after operation occurred in connection with surgical interference with appendix, peritoneum, perforating gastric ulcer, etc. The latter is the commonest cause next to ovarian cyst. This may be due to absorption of intestinal contents where infection has resided for some time and become active; where secondary infection has taken place owing to defective surgical technique. The trauma already referred to may determine the parotid gland as the point of least resistance in such cases. Cases which develop within a couple of days of the operation may have been induced by the post-operative dryness of the mouth, but usually the parotitis develops between the third and seventh day after operation. Withdrawal of food by the mouth may have a bearing on the matter, since parotitis has been reported in connec tion with gastric cases treated by starvation instead of operation. Deaver disclaims having made an exhaustive discussion of the subject, having written mainly to invite attention to and stimulate study of the phenomenon, (j. s. t.) Beck, E. G. The Empyema Problem. Surg. Gynec. and Onst. April, 1910. Previous to recent influenza epidemics empyema was less common than lung abscess as a complication of pneumonia. The type of em pyema then occurring often only developed and sometimes was not diagnosed until the patient had apparently recovered. Reports from Army camps suggest the wisdom of adopting a definite uniform procedure where a great many cases of the same type occur. The two essentials for diagnosing influenza empyema are (1) punc ture and (2) stereorentgenograms. The differential diagnosis in volves excluding unresolved pneumonia, broncho-pneumonia fluid in pleural cavity, lung abscess, pneumothorax, advanced pulmonary tuberculosis. The roentgenogram should precede puncture in order to determine the best site for the latter. Indiscriminate probatory puncture is dangerous. It should not be made more than three times without returning to other methods of investigation. The character of the pus obtained is of great diagnostic value. No. 3. SUBGEKY. 575 Nonoperative treatment of empyema consists in an attempt to sterilize th« fluid without withdrawing it, repeated punctures and partial withdrawal of small quantities of fluid, vaccine therapy. The operative methods should not be resorted to too early. When the fluid is still serous, when the patient is still suffering from an acutely inflamed lung, the operation, however well conducted, is in itself a real strain on the patient's reduced vitality and there is danger from pneumothorax; furthermore, the wound surfaces are liable to serious secondary infection. Distressing pressure symp toms may be relieved early by withdrawing small quantities of fluid by cannula, but an attempt at cure should be deferred. The simplest operative interference is best and, therefore, the method of McKenna, of Chicago, has much to recommend it. It consists in perforating the thoracic wall by trocar and cannula and introducing through the latter a small catheter. Withdraw the cannula (which should be just large enough for the catheter) and leave in the tube. When the pus appears aspirate with a glass syringe. If the pus is too thick to flow readily run in a little dilute neutral chlorinated soda. (Dakin's solution.) For five years the author has used at the North Chicago Hospital the counterdrainage method of Dohrmann. This consists of making a posterior resection of 1 inch of the eighth or ninth rib under local anesthesia. The pleura is exposed and incised for half an inch. Be fore pus can escape, block the aperture with the index finger and introduce beside it a curved artery clamp directed forward and downward to the lowest point of the empyema cavity. The tip of the instrument is pressed, between two ribs, against the chest wall, raising the skin and indicating the site of the counterincision, which is made by an assistant. From front to back carry through a No. 12 to 14 rubber catheter. A larger rubber tube is slipped over the catheter introduced into the resection opening and sewed to the skin, making it air-tight. Fit a glass tube to the rubber one to drain the pus by suction or gravity into a flask. In four or five days remove the rubber tube, leaving the catheter in place for a fortnight. The next step is to draw a tape one-fourth inch wide through the cavity by fastening one end by a silk thread to the catheter and slowly pull ing out the latter. The tape now serves as a drain. It is to be soaked in -20 per cent argyrol. Beck is strongly in favor of a posterior resection, as then both the recumbent and sitting positions permit better drainage. Care should be taken not to carry the large tube too far. The preliminary inci sion over the rib should be curved, not straight. The next consideration is the promotion of disinfection and closure. The flushing of empyema cavities was given up 15 years ago but has been revived by the good results from the use of the Carrel-Dakin 576 Vol. XIII. SURGERY. methods. Certainly the solvent action on fibrinous adhesions of Dakin's solution is a strong point in its favor. As it has been cus tomary in the past to expect closure of the cavity in 19 out of 20 cases, the irrigation plan must yield that proportion of closures or be given up in favor of other methods. Cases which do not yield to flushing should be injected with bis muth paste. Bismuth paste has great diagnostic value, since it gives a clear and accurate picture of the shape and extent of the cavity and its ultimate pockets. Exploration with a catheter does not do this. The pus should be studied by culturing and. if necessary, by in jecting it into guinea pigs. While the tubercle bacillus is rarely found in pus from empyema cavities, it has been Beck's experience during the last 10 years that following injection of bismuth paste this or ganism, though slightly modified in appearance and staining quali ties, would promptly appear in the discharge, to diminish in numbers and finally disappear in the course of a few weeks. The author has only a theory to explain the phenomenon. He supposes that the paste, by stimulating leucocytosis of the walls of the cavity, leads to the extrusion of tubercle bacilli living in them. Beck holds strongly to the therapeutic value of bismuth paste, not only from 150 cases treated by him but from data collected from various sources. In the author's 150 cases 80 per cent were cured by the bismuth treatment alone. The paste must be prepared and used judiciously. It is a mixture of one part bismuth subnitrate and 10 parts vaseline, with a little white wax added (2 ounces to 10 pounds). The vaseline requires sterilization for 20 minutes in an autoclave, and all containers must be sterile and perfectly dry. Before pouring one part of heated, fluid vaseline on the bismuth the latter must be smooth and free from lumps. The stiff paste is stirred for half an hour until the mass is smooth, bright yellow, homogeneous. Liquified white wax is added to the nine parts of vaseline, which is then added to the other portion. The bismuth paste is not to be permanently retained. If it does not flow away little by little in the course of two to five days, it is to be gently drawn out by catheter and suction syringe. With the patient in the recumbent position and without previous irrigation of the cavity the paste is injected cautiously by means of a 2-ounce syringe, permitting the air to escape. Several full syringes may be required to fill the cavity. No plugging of the opening is at tempted. Merely apply a simple sterile dressing and a snug binder. Most of the paste will escape in 24 hours. The filling of the cavity may have to be repeated during the course of several months. If the cavity have a greater capacity than 200 grams of paste, treatment is not so likely to be effective. No. 3. SURGERY. 577 When closing is persistently delayed the pleural space must be obliterated, and the author prefers his skin-sliding method to the procedures of Estlander and others. Muscles, ribs, and pleura over the dead space are removed down to the retracted lung surface and a carefully planned skin flap is utilized as a starting point for regeneration of skin along the edges until the whole denuded surface is covered by epithelial growth. The favorite flap is made by a Y-shaped incision yielding three sections. Before making the skin incision a catheter is introduced into the sinus as a guide. Fat and muscle are left in the flap until the moment of attachment for nutritional purposes. Three to five ribs usually need resection and the greater part of the pectorals must be divided or dissected to give full exposure of the lung. The pleura is now incised along the catheter, going as high as the second rib. Parietal pleura is now dissected away up to the second rib level but the visceral pleura is not disturbed. The flap is now freed of muscle and fat. Now carry the tip of the skin flap by an artery forceps to the deepest part of the cavity and hold there by rather tight gauze packing, which may be left in place 24 hours. A further measure for insuring coaptation of the raw undersurface of the flap to the parietal pleura is to pass a stitch through the base of the skin flaps and the tissues over the second or third rib. The whole operation takes from 1 hour to 1 hour and 40 minutes. The packing is removed in 48 hours, keeping a spatula pressed upon the flap to prevent detachment as the gauze is being abstracted. This is sometimes a painful step, calling for gas anesthesia, hence the gauze for the second dressing consists of strips soaked in vaseline. Within a week begin the application of adhesive straps for skin regeneration. The strips are cut one-half to three-fourths inch wide and fastened so as to cover margin of skin and granulating surface. At the next dressing use gauze only, at the third reapply zinc oxide plaster strips, thereafter alternating the two at 48-hour intervals. (j. 8. T.) Gibson, C. L. Skin disinfection by picric acid. Ann. Surg. February, 1919. In 1910 the author advocated the use of skin disinfection by tinc ture of iodine, but occasionally in his surgical practice had cases in which iodine produced very disagreeable caustic effects. While stationed at a British casualty clearing station in 1917 he became familiar with the use of 5 per cent picric-acid solution in alcohol, which was as efficient as iodine without the occasional irrita tion due to the latter. A distinct advantage of picric acid is that its action is not interfered with by previous scrubbing of the operation 578 PATHOLOGY, BACTERIOLOGY, AND ANIMAL PARASITOLOGY. Vol. XIII. area with soap and water. The only precaution necessary is to per mit the treated surface to dry thoroughly before operation. The author has now employed the method in 100 consecutive oper ations at the Xew York Hospital with entire satisfaction, (j. s. t.) Gill, A. B. Reconstructive surgery of the hand and forearm. Ami. Surg January, 1918. • The author, in discussing the above subject, emphasizes the great importance of this branch of orthopedics in connection with indus trial surgery and lays stress upon the necessity of thoughtful plan ning and careful execution in undertaking any work of this charac ter. Much can be accomplished toward restoring a crippled member to usefulness, even though a long period has elapsed following in jury, but patience in conducting the aftertreatment (massage, elec tricity, hydrotherapy, active and passive movements, and the use of special splints) is essential to success, and a slight infection may destroy the finest work. Eleven cases are described and discussed, and the procedure, in general, has been to expose and free from adhesions the involved nerves and tendons, lengthening and suturing these when necessary, and to then surround the tendons with trans plants of fat from the thigh, to guard against future adhesions. The author's opinion is "that in any operation, primary or sec ondary, which requires a dissection of the structures of the forearm measures should be employed to prevent adhesions of these structures to one another and to the skin. The simplest and probably the best means of prevention is the free fat transplant." Most of the in juries described were the result of wounds from knives, steel shavings. etc., and no case of this character should be considered hopeless, as marked improvement can usually be brought about, even in the most unpromising, (r. b. h.) PATHOLOGY, BACTERIOLOGY, AND ANIMAL PARASITOLOGY. Spooneb, L. H. The Bacteriology of Tuberculous Kidneys. Jour. Med. Research, 1918, 39, p. 59. For years popular belief has held that the septic manifestations of tuberculosis were due to a mixed infection with pyogenic organisms; that cavities containing caseous and purulent material resulted from the action of such organisms. The positive proof of the existence or nonexistence of mixed infection in tuberculous processes can be ob tained only by bacteriological examination of such lesions. Inasmuch as the lungs lend themselves very poorly to investigation, because No. 3. PATHOLOGY, BACTERIOLOGY, AND ANIMAL PARASITOLOGY. 579 all such procedures must be conducted after death, and since the abscess cavities, in most instances, communicate with the upper and outer respiratory passages, which are normally the habitat of a large bacteriological flora, Spooner has elected the kidney as the most favorable organ for these researches. Ten kidneys, all of which were removed at operation, have been investigated. Cultures were made, under aseptic precautions, from the contents of the renal pelves, cav ities, and cysts, from the tissue of the cavity walls and isolated tuberculous lesions. The cultures were inoculated, aerobically, on plain nutrient agar, Loeffler's blood serum and Dorset's egg medium, and, anaerobically, on dextrose bouillon in fermentation tubes, with and without sterile animal tissue, and sealed dextrose agar. The tubercle bacillus was cultivated in 50 per cent of cases. Dorset's egg medium was the most satisfactory for primary growth, while 5 per cent glycerin agar was best for the secondary cultivation of the organism. Growth was obtained in from two to five weeks. In no instance was there any evidence, in the kidney or ureteral urine, of mixed infection. Twenty-three cultures were made from four kid neys, three with nephrolithiasis and one with pyelonephrosis. Of these, streptococcus was isolated in one and B. coli communis in the other three. The author concludes from this that nontuberculous in fection of the kidney is produced by one or more organisms which are always isolated from the renal tissue or ureteral urine on simple cul ture media. He goes on to say that the clinical diagnosis of renal tuberculosis is suggested by the presence of acid-fast bacilli in the urine. If a pus containing urine, obtained from the ureter, shows no growth upon simple culture media after 48 hours' incubation, an other and very important link is added to the chain of diagnosis of tuberculosis of the kidney, (de w. g. r.) Faibeb, J. A. The Hermann- Penitz reaction in syphilis. Jour. Roy. Nav. Med. Service. London. October, 1918. This is a chemical reaction, and the following is a brief summary of the technique : To 0.5 mil of blood serum in a small test tube, which has been in activated at 60 C for 10 minutes, add 0.5 mil of an alcoholic sodium glycocholate and cholesterin solution. Shake and keep in water bath at 21 C for 14 hours. A positive reaction gives a white deposit and if negative the solution remains clear. A positive and a nega tive control are used to check the reaction. The sodium glycocholate solution is prepared by mixing equal parts of the following: 116025—19 13 580 PATHOLOGY, BACTERIOLOGY, AND ANIMAL PARASITOLOGY. Vol. XIII. (a) A fresh 2 per cent aqueous solution of sodium glycocholate. The author performed 500 tests and summarized his results as follows : The result of this investigation lias been to confirm Jensen and Feilberg's statement that " the Hermann- Perutz test never gives a positive with a negative-to-Wassermann serum,7' for in 500 tests per formed no such case was recorded. The test can be performed with the greatest ease and simplicity on board ship. The apparatus can be constructed on board ship and is completed with one dozen agglutination tubes. It requires but three drugs—glycocholate of soda, cholesterin, and alcohol 95 per cent; £ ounce of glycocholate of soda, \ ounce of cholesterin, and | liter of 95 per cent alcohol will be sufficient for more than 500 tests. The result of this test can be obtained in 14 hours. In contrast to this, the time elapsing from the withdrawal of the patient's serum to the receipt of the communication of the Wassermann test is fre quently from 10 to 12 clays ; hence a delay of 9 to 11 days is obviated. It is acknowledged that early commencement of treatment gives the greatest chance of successful treatment. It follows that this test would be of the greatest value on board ship, and that when a positive result is obtained treatment could be immediately commenced without waiting for the confirmation of the Wassermann test. Information is requested as to whether any experiments have been made w7ith this reaction in our laboratories; and if so, the results obtained. (j. h.) Nicolle, C, and Lkbailly, C. Some experiments with the virus of grippe. Comptes Rendus des stances de L'Academle des Sciences, Paris, No. 17, October 21, 1918. The extension of the present epidemic of grippe to Tunis has en abled us to conduct the following experiments: Experiment 1.—The patient became ill with grippe after three members of his family had been infected. On September 1 (the third day of the disease) we inoculated with his sputum, which was albuminous and contained many varieties of bacteria; first, without filtration, a " bonnet chinois " monkey, under the conjunctivae of the two lower lids and by nasal instillation; secondly, after filtration two voluntary subjects: A subcutaneously, B intravenously. (b) Glycocholate of soda Cholesterin Alcohol (95 per cent) 2. 0 gins. .4 gin. 100. 0 mils No. 3. PATHOLOGY, BACTERIOLOGY, AND ANIMAL PARASITOLOGY. 581 In order to carry out the nitration the sputum was mixed with 10 times its volume of normal salt solution and agitated for five minutes in a flask containing glass beads in order to obtain a homogeneous mixture. It was then centrifuged at a slow speed for one minute and a half. The supernatant fluid was then decanted and filtered through a Chamberland filter L 2, under pressure of 30 to 40 cm. of mercury. The " bonnet chinois " monkey (whole virus) became ill on the sixth day; he did not eat and appeared depressed; the temperature rose to 40 Centigrade and remained elevated for three days; on the following days there was loss of weight and general malaise. A (filtered virus subcutaneously) became ill on the same day as the monkey with headache, stiffness of the back and limbs, and con junctival injection. The morning temperatures were: September 8y 39 C, 9 and 10, 38°, 38.5°. The evening temperatures were not taken. The course of the disease manifested the classical characteristics of grippe ; on September 12, recovery was complete. 13 (filtered virus intravenously) was not affected. The impermeability of the filter was demonstrated by negative cultures of the filtrate. An individual (C) inoculated subcutaneously with 3 cc. of blood taken from the " bonnet chinois " on the first day of the fever was not affected. Experiment 2.—Patient 2 presented the characteristic symptoms of grippe. On the second day of the disease, September 3, 3 cc. of his blood after defibration was injected intravenously into (D) without results. Experiment 3.—On September 15, experiment 1 was repeated with the bronchial expectoration of patient 3 (family epidemic), on the third day of the disease. A monkey (Macaccus cynomolgus) having received the whole virus under the conjunctivae and on the nasal mucous membrane pre sented on September 19 (fifth day) an elevation of temperature above 40 C. The fever persisted for three days, reaching 41.4 C, and then fell to normal. The general symptoms were not marked. A person (E) having been given the filtered virus under the skin became ill on September 20 (sixth day). We did not see her again until September 23; the symptoms were those of a mild grippe; the morning temperature was 37.5 C. : on the day following, 37.3 C. Complete recovery followed a convalescence of eight days. Experiment 4-—-With the sputum of patient 4 in the acute stage of grippe the experiment of filtration was repeated. The inoculation of the filtrate intravenously into a subject (F) did not cause any symptoms. Note. —One must not consider that A and E contracted srippe through epidemic contamination. They lived in separate houses: A with ;i companion, 582 Vol. XIII. EYE, EAR, NOSE AND THROAT. E with three; none of them had heen infected at the end of the febrile period. Moreover, A and E inoculated in the same manner (subcutaneous injection of nitrate) were the only persons infected in our experiments (B, C. D, and V inoculated differently remained well) ; lastly the monkeys inoculated at the same time as A and E became ill on the same day as the subjects. Conclusions.— 1. The bronchial expectoration of individuals suffer ing from grippe, collected in the acute period, is virulent, 2. The monkeys (" bonnet chinois," M. cynomolgus) are susceptible to infection by subconjunctival and nasal inoculation with the virus. 3. The causative agent of grippe is a filterable virus. The inocu lation of the filtrate has actually produced the disease in two per sons when injected subcutaneously ; intravenous inoculation appears, on the contrary, to be incapable of producing infection (two failures in two cases). 4. It is possible that the virus of grippe does not occur in the blood of the infected individual. The blood of a monkey having grippe failed to infect a man when inoculated subcutaneously; the negative result of the injection of the blood of patient 2 is not, on the contrary, conclusive, the intravenous inoculation apparently not being efficacious in the transmission of the virus of grippe. (m. e. h.) EYE, EAR, NOSE AND THROAT. Gatewood, L. Technique of perineural anesthesia for radical surgery of the maxillary sinus. Laryngoscope, 1918, XXVIII. The infra-orbital and the posterior superior dental nerves are in jected, with 2 per cent novocaine solution. To inject the infra-orbital nerve insert the needle in the buccal fold, distal to the apex of the canine teeth, passing the needle upward and inward for three-fifths of an inch, infiltrating the tissues slowly. This is the region of the infra-orbital canal. Here the remainder of the solution is in jected and the tissues gently massaged to hasten absorption. In injecting the posterior superior dental nerve the condyle of the palate process of the maxilla is used as a guide. The needle is inserted from the buccal fold corresponding to the disto-buccal route of the second last tooth from the condyle, and passed upward, back ward, and slightly inward at an angle of about 45° to the occlusal plane of the teeth. Tissues are infiltrated slowly as the needle is inserted, and the remainder deposited after the needle has disap peared for four-fifths of an inch. The author reports several advantages of this method over conductive anesthesia, (o. b. t.) No. 3. EYE, EAR, NOSE AND THROAT. 583 McLean, \V. Experimental studies in intraocular pressure and tonometry. Arch. Ophth., Vol. XLVIII, No. 1. After reviewing the experiments of the early observers of intraocu lar pressure, commencing with C. Weber in 1850 and the reference of McKenzie, who in 1830 noted that hardness of the eyeball occurred in glaucoma, the author discusses the two types of instruments de vised—one the impression type, which records the amount of inden tation by a known pressure, and the applanation type, which records the amount of flattening of the eyeball to a known pressure. In the author's tonometer the calibrations on the scale are in milli meters of mercury as determined by actual manometer readings. In his experiments it is noted that the tonometer gave a marked dif ference in intraocular pressure under local and immediately after deep general anesthesia, (o. b. t.) NOTES AND COMMENTS. The Journal of the Medical Society of New Jersey (February, 1919) reports an interesting decision in the case of State v. Lankford (Del.; 102 Atl. R., 63). The Court of General Session of Delaware holds that a husband may commit an assaidt and battery on his wife, notwithstanding the marriage relation. The suit in question related to the transmission from husband to wife of a loathsome disease, of whose existence the husband was well aware, and the which he concealed. In the charge to the jury it was pointed out that the guilt of inflicting upon the wife physical abuse and injury resulting in great bodily harm turned on the defendant's knowledge of his condition and concealment of the same. The jury brought in a verdict of guilty. The United States Interdepartmental Social Hygiene Board has begun the expenditure of the sum of $100,000 appropriated by Con gress for scientific research connected with the prevention and cure of venereal disease by assigning certain sums to educational institu tions undertaking work of this character and able to meet the board's requirements. The sum of $7,200 has been allotted to the Medical School of Leland Stanford Junior University and $6,000 to the College of Medicine and Surgery, University of Michigan. For a statement of the conditions entitling a laboratory or college to financial support from this source, application should be made to the executive secretary, Dr. T. A. Storey, 1800 Virginia Avenue NW., Washington, D. C. It may not be generally known to those readers of the Bulletin who in the past found recreation and relief from the daily round of duties by attending a performance participated in by the late Sir Charles Wyndham, brilliant English comedian, that before going on the stage he was for eight years a successful surgeon. He was a son of a Dr. Culverwell, a London practitioner. Charles hankered for the stage from early boyhood but studied medicine out of deference to his father's wishes, and passed the examinations for membership in the Royal College of Surgeons in 1857. At the out break of the Civil War he came to America and served as a surgeon 586 NOTES AND COMMENTS. Vol. XIII. in the Federal Army, being present at the battles of Chaneellorsville, Fredericksburg, and Gettysburg. At the conclusion of the war he returned to England and went upon the stage, and in the short period of four years had secured such a position in the theatrical pro fession that he was able to make a second visit to America and de light large and enthusiastic audiences by playing Surface in the School for Scandal. He was knighted by King Edward VII in 1902. Sir Charles Wyndham died January 12, 1919, at the age of 82. The British Medical Journal, January 18, 1919, contained a brief but appreciative synopsis of the work of the Harvard Surgical Unit, which functioned abroad from July 16, 1915. to January 16, 1919. During this period 175.000 sick and wounded British soldiers re ceived treatment by the unit. The Harvard Surgical Unit, located at Camiers, France, was un der the leadership of Dr. E. H. Nichols, who was succeeded by Dr. David Cheever, Dr. W. E. Faulkner, Dr. Hugh Cabot, and Dr. D. F. Jones. Up to the end of 1916 the unit had the status of a neutral medical unit under the terms of the Geneva Convention. After that, on the request of the authorities of Harvard University, it was carried on as a belligerent medical unit. Upon the entry of the United States into the war the status was again altered. The bed capacity, as officially stated, was 2,370, but as many as 4.000 patients were sometimes under treatment at Camiers at one time. According to the Social Hygiene Bulletin (New York), Volume VI, No. 3, by February 1, 1919, " fully 24,000 retail druggists, ap proximately 50 per cent of the total number in this country, had pledged themselves not to sell nostrums and quack remedies for the treatment of venereal diseases, and had signed the card furnished by the Public Health Service indicating such an agreement." The first session of the School of Hygiene and Public Health of Johns Hopkins University began October 1, 1918. This school offers classes of instruction leading to the degrees of Doctor of Public Health, Doctor of Science in Hygiene, and Bachelor of Science in Hygiene. (It is not a matter of prime importance but, except the first mentioned, the titles seem clumsy and to contain an antithesis. However, it is difficult to suggest good substitutes and Master of No. 3. NOTES AND COMMENTS. 587 Hygiene and Bachelor of Hygiene may be no better than those adopted.) There are definite requirements for admission of candidates for these degrees and for the special courses. A number of public and special lectures are provided for the scholastic year. Among the speakers scheduled for 1919 are Rear Admiral E. R. Stitt, Medical Corps, United States Navy, and Captain J. C. Pryor, Medical Corps, United States Navy. The right to temporarily exclude unvaccinated pupils from school while smallpox is unduly prevalent in a community is upheld in a recent decision of the Supreme Court of Illinois. (Hagler et al. v. Lamer et al., 120 N. E., 575.) According to official reprints published by the United States Ship ping Board " between June 30. 1914. and December 31, 1918. the total gross tonnage of the American merchant marine increased more than 30 per cent, and that engaged in overseas and foreign service prob ably increased not far from four or five fold." Observations on the presence of meningococcus in the blood. — In recent months evidence has been produced emphasizing the im portance of blood cultures in the incipient stages of epidemic menin gitis. Glowing accounts have been received from time to time of the very gratifying treatment of these cases by the early administra tion of antimeningococcus serum intravenously as well as intraspi- nally. Maxcy (Jour. Infect. Dis., 1918. 23, p. 470) reports the blood culture findings of 27 cases of possible meningococcus infection, se lected from a large number of admissions at the base hospital. Camp Beauregard, in January and February, 1918. All had fever, malaise, headache, and a history of contact with actual cases of epidemic meningitis. The results were entirely negative and it was concluded that the " abortive type " of meningococcic infection was not. of fre quent occurrence, and. if it occurred at all during the epidemic, could not be considered a factor in the spread of the disease. The technique consisted in planting 10-20 cc. of blood in 100 cc. of 1 per cent glucose, salt-free broth, enriched with a small amount of sheep serum water. The reaction was slightly acid, as finally deter mined by addition of solutions of phosphates of known H-ion con centration and titrating with cresol purple as an indicator. Atten tion is called to keeping the cultures warm until the incubator is 588 Vol. XIII. XOTES AND COMMENTS. reached. In 48 and 72 hours, 2 cc. of the supernatant fluid of the culture were pipetted off and poured over the surface of laked sheep blood dextrose agar plates. Cultures, if sterile, were discarded in 5 days. Two interesting cases are cited. One showed a menin- gococcemia within 18 hours after the onset, which disappeared in 24 hours. The organism was also isolated from the turbid spinal fluid. Both showed agglutination with the normal and polyvalent serum (1:400). Antimeningococcic serum was given intraspinally and intravenously. Having apparently recovered on the fifth day, the patient suddenly died, and, at necropsy, death was found to have occurred from a vascular accident. The second case was one of per sistent fever, nausea, and malaise after the spinal fluid, which had previously yielded the meningococcus, had boon rendered negative by intraspinal injections of serum. Four weeks subsequent to the onset, an eruption occurred and a blood culture revealed the presence of meningococci. After desensitization with horse serum, 490 cc. of antimeningococcic serum were given intravenously over a period of 10 days. The blood culture became sterile after the sixth injection and remained so. The patient was well in a month after the intra venous treatments were instituted. The author points out that such a case is the exception rather than the rule. Experience has taught us that transient meningococcemias are more frequent than per sistent ones. Positive blood cultures are rarely obtained late in the course of the disease. Large quantities of blood should be used in the culture. There is a possibility that the organism never gains a foothold in the blood stream in some cases, localizing directly in the meninges. The question of mode of transmission from the posterior nasopharynx is still an open one. (De W. G. Richey.) Aeroplanes are fitted with numerous dials rendered luminous by a paint containing radium. In time the paint loses its value but not the radium which can be recovered and utilized with profit. The discarding of a worn-out dial should therefore not lead to its being destroyed as valueless. Here is one more opportunity to practice that thrift and economy which many of us hoped would be acquired as a result of war. The inspiration to save radium is to be found in a consideration of some of the facts about this substance. One of the principal firms handling this element reports that it takes from 500 to 700 tons of carnotite ore, and as many tons of chemicals, not count ing water employed, to yield one grain of radium whose market value is in the neighborhood of $100,000. A good firm does well to extract 18 to 20 grains of radium in a year and 50 milligrams, worth $5,000, is an ample supply for a surgeon's work through a lifetime. No. 3. NOTES AND COMMENTS. 589 La Presse Medicale for March 10, 1019, contains a feeling tribute from F. Widal to the memory of Prof. Andre Chantemessc who died suddenly a few weeks ago, the immediate, cause of death being too early to return to wrork after an attack of influenza. Widal and Chantemesse were friends of long standing and asso ciated in many professional tasks, more particularly their invaluable researches on typhoid fever. Chantemesse was a native of LePuy and possessed many of the characteristics of the typical awvergnat — vigor of mind and body, sound common sense, combativeness, perseverance. With those traits he combined a sense of humor, cordiality, sympathy, and kindness. Emile Roux was one of his closest friends, their intimacy dating from boyhood. Pasteur admired and trusted him. It was through Pasteur that, in 1803, Chantemesse was chosen to devise measures for combating infectious diseases in the Ottoman Empire when assistance was requested by Abdul Hamid, and his stay in Constantinople re sulted in the founding of the Institute of Bacteriology th;-re. Chantemesse began the study of medicine at an age when others receive their diplomas, his family having destined him for a business career, and he became a hospital interne just as he reached the pre scribed age limit, but his capacity for work, his talent, his enthu siasm speedily brought him to the front. Four years later his ad vanced work won him a gold medal and he entered the laboratories of Bouchard and Cornil. Recognition of his varied talents lead to his appointment on the staff of various hospitals, and as professor first of experimental medicine, then of hygiene. In 1901 he was elected member of the section of hygiene of the Academie de Medecine. Widal became acquainted with Chantemesse in Cornil's laboratory. He says : " He initiated me in bacteriology and for years we were intimately associated in our work." Chantemesse's bacteriological researches and especially his original work on typhoid fever had a marked influence on the reforms in medical teaching which were introduced in 188G following the devel opments due to Pasteur. His laboratory courses were thronged by students from abroad and by men of his own country, not only under graduates, but professors and practitioners of advanced years, who, recognizing the far-reaching effect of new ideas and new methods, felt the necessity of sitting at the feet of this brilliant leader in the modern school of investigation. Chantemesse alone or in collabora tion with others wrote voluminously on topics connected with bac teriology and hygiene and he was singularly successful as a teacher, but he had also a remarkable clinical sense and but for his absorption in a special field would have been eminently successful as an internist. Typhoid fever was his special subject and it is in this connection 590 NOTES AND COMMENTS. Vol. XIIL that he will be chiefly remembered. He early recognized it as a peculiarly water-borne disease and was among the first to go deeply into the question of its prevention. The results of his experimental vaccination of animals against typhoid were published in 1888, and it was at his suggestion that in 1909 the Academy of Medicine appointed a commission to determine the value of the procedure for man. Chantemesse carried out the necessary experiments on the army personnel in Morocco and on the personnel of the French Navy. For years he was associated with the work of the Pasteur Institute. During the war Chantemesse labored with feverish devotion at the ficole Polytechnique and the Hotel Dieu and in countless medico- military enterprises essential to the health of the troops and of the civil population. The strain of his labors during the war and his prompt return to duty after but a few days of illness hastened his death. REPORTS THE HOSPITAL SHIP " COMFORT." By A. W. Dunbar, Captain, Medical Corps, United States Navy. This ship, formerly the S. S. Havana, of the Ward Line, was com missioned as a hospital ship on March 18, 1918. The displacement of the ship is 10,000 tons ; net tonnage 3,963 ; length over all 429 feet 10 inches ; beam 50 feet 2 inches ; draft when loaded 22 feet forward and 23 feet aft. The motive power consists of two triple-expansion engines of 10,000 horsepower. The maximum speed of the ship is 18 knots, and the coal consumption at this speed is about 175 tons per day. The economical speed is 14 knots at 100 tons of coal a day. The coal capacity of the ship is 1,060 tons in the permanent bunkers. Since coming into the naval service hold No. 2 has been used for a reserve supply. It holds 608 tons, giving a total capacity of 1,668 tons. The supply of coal at an economical speed in good weather conditions gives a steaming radius of 5.376 miles with a margin of 68 tons remaining. This radius of action is in practice materially reduced by head winds and seas, and on two west-bound trips it has been necessary to coal at the Azores in order to have a safe margin left. The complement of the ship is as follows: Medical officers 10 Pharmacists 2 Pay officers 1 Paymaster's clerk 1 Dental officer 1 Chaplain 1 Deck officers 6 Engineer officers 5 Total officers 1 27 Crew: Deck, engineer, and Hospital Corps 365 Total 392 Ten life boats are provided, calculated to hold 490 persons. In addition there are two ambulance boats holding 120 persons, one motor gig holding 27 persons, and life, rafts sufficient to sustain 700 additional. These figures represent the maximum capacity of these 'Extract from Annual Sanitury Report, 1918. 591 592 REPORTS. Vol. Ml I. boats and rafts and in all probability would be greatly reduced in. actual emergency. Normal capacity for patients is as follows: Sick officers 14 Isolation wards 44 Surgical wan! 5G Medical ward 36 General ward 142 Convalescent ward 28 Total normal capacity 320 The accommodation for patients in an emergency and for a short run of from 24 to 48 hours could easily be extended to 700 cases. As an ambulance ship for bringing home the wounded from abroad, 410 patients, of which 290 may be bedridden cases, can be carried by put ting 50 cots in the solarium and additional cots in the convalescent ward, hospital corps quarters and the mess rooms on the promenade deck. It is always necessary to leave some place to accommodate the sick of the ship's complement and also to allow for the isolation of infectious cases which may develop during a trip. At first sight it would appear that the normal capacity of this ship for the patients is small, but by comparing it with that of the Drina, of the British Navy, it is found that while the Comfort car ries one patient for each 12 tons of the net tonnage, the Drina car ries one for 38 tons, so it seems that the space has been comparatively well utilized. The ship was commissioned March 18, 1918. She left the Navy Yard, New York, April 22, 1918, and reported to the commander in chief, Atlantic Fleet, Base 2, April 24, 1918, for duty in connection with the fleet. On May 19, 1918, orders were received to proceed to the Navy Yard, New York, and fit out for special foreign dutj'. Arrived at the navy yard May 21, and on June 20. all necessary preparations having been made for distant service, the ship anchored off Staten Island, N. Y., awaiting orders. On July 24 the ship was assigned to the third naval district for temporary service, to take the overflow of pa tients from the U. S. Naval Hospital, New York. On October 5, orders were received to prepare for distant service. Under these orders, all marks identifying the ship as a hospital ship were, removed and it was given the status of a troopship. On October 10 the medical officer commanding was relieved by a line officer, and the former was ordered to the ship its a passenger. The ship left the navy yard on October 21, and in convoy sailed for Brest. France, arriving at that port on November 3. On November 4, in accordance with orders, the writer resumed command and hoisted the Eed Cross flag. No. 3. REPORTS. 593 The Comfort left Brest, France, on November 20 and arrived at St. Xazaire, France, on November 22, under orders to proceed to New York. Heavy seas and adverse winds were encountered, and it was found that the coal taken on board at Brest was of poor quality ; so it was necessary to put in at the Azores for coal. The ship arrived at Ponta Delgada, Azores, November 27, where 11 additional patients were received, and left on November 29, arriving at Hoboken, N. J., on December 9, where the patients were disembarked. On arrival at Hoboken orders were received assigning the Comfort temporarily to the transport force. While at Hoboken the ship was repainted as a hospital ship, in accordance with orders. The ship left Hoboken December 21 and arrived at Plymouth, England, on December 31. During the period of this report, 1,269 cases were admitted or re admitted. Of these, 494 were discharged to duty, 28 died, 2 were invalided from the service, 699 transferred, 1 deserted, and 39 changes of diagnosis were made and readmitted; remaining, 3. The total number of sick days is 16,475. Seventy-seven surgical opera tions were performed. The dental treatments and operations num bered 1,536. SHIPS COMPLEMENT. With the exception of the time this ship had the status of a troop ship she has been commanded by a naval medical officer. Up to December 18, 1918, the officers other than those belonging to the medical corps, pay corps, dental corps, and the chaplain were in the status of naval auxiliary officers, and in most instances these officers were members of the Naval Reserve Force but placed on an inactive status while assigned to this ship. On the above date orders were received by the supervisor. Naval Auxiliary Reserve, at New York to change the status of all auxiliary officers on this ship to Naval Reserves, which was done, the master being given the rank of lieutenant commander and directed to report to the commanding officer for duty. From the first, the members of the crew, other than those belonging to the hospital corps, consisted of regular service men and NaAral Reserves. This combination of naval auxiliary officers with a naval crew was, from a disciplinary point of view, an undesirable mixture, as there was some evidence that certain members of the crew felt that " civilian officers," as they termed the auxiliary officers, had no authority over them. The change of status of the auxiliary officers to that of Naval Reserves is a great improvement. Under the former status the officers felt a loss of prestige. There was, in the case of married men, a 594 REPORTS. Vol. XIII. loss of pay ; and as the auxiliary service is maintained only for two hospital ships, there was little or no chance for promotion, with the ultimate result that hospital ships would lose their best officers. ORGANIZATION. Under the existing conditions, with the deck and engineer officers in the Naval Reserve service, the crew consisting of regular service men and Naval Reserves, there are no Naval Instructions or Regula tions directly applicable to the administration of hospital ships. The organization of the ship's company, the administration of discipline, and the assignment of responsibility has been in com- formity with the spirit of the instructions relative to hospital ships with such naval regulations and instructions as may be applicable. On the hospital ship the interests and duties of the medical de partment take precedence, except that the master must be unfettered in the discharge of his duty as relates to the navigation and safety of the ship. It may be stated that the nonmedical part of the organization occupies on the hospital ship a position analogous to that of the medical department on a combatant vessel. In each case while occupying a subordinate position the navigator or medical officer is left free to carry out his specialized duties, and we have yet to hear of a line officer who would direct the medical officer how to operate or of a medical officer who would seek to instruct the navi gator as to the measures to take in an emergency affecting the safety of the vessel. The organization of this ship is regarded as consisting of two departments, a medical department and a nautical department. The former, directly under the executive surgeon, is divided into (1) hospital division, under the medical officer (nonspecializing), next in rank, having charge of the medical, surgical, and other activities directly concerned with the care and treatment of the sick and in jured; (2) dental division: (3) medical supply division; (4) supply division: (5) record division, religious, recreational division (chaplain). The nautical department is divided into the deck and engineer divisions, under the senior reserve officer acting as master. It has been desired to avoid any tendency on the part of any one to feel that the organization is divided into two, but rather that, as stated, it consists of two departments with but a single duty—to relieve the sick and wounded. To promote a feeling of unity and to remove any possible imputation of a discrimination, the separate messes for the wardroom and for the deck and engineer officers have been amalgamated. No. 3. REPORTS. 595 The mess room on the boat deck, formerly used by the auxiliary officers' mess, should be converted into staterooms for deck officers, and the rooms vacated by these officers should be assigned to the junior engineer officers who now occupy uncomfortable rooms on the main deck among the enlisted personnel, which is somewhat detri mental to discipline. The personnel and material records are kept by the medical de partment. The liberty list, approved by the head of the deck and engineering divisions, is combined in the executive officer's office with that of the hospital division. There is always a deck officer (officer of the deck) and an officer of the day (medical) on watch, each doing duty in accordance with regulations as far as practicable on a hospital ship. Reports of offenses are brought by the heads of departments to the executive surgeon who investigates each case and if such action is required brings the man to mast. During the year there were committed 170 minor offenses; 17 sum mary courts-martial and 39 deck courts have been awarded. In the medical department the executive surgeon is assisted by the junior pharmacist who, in addition to being in charge of the medical supply division and of the special-diet kitchen, acts as a first lieu tenant in making inspections and in the general upkeep of the spaces assigned to the medical department. The medical officer immediately junior to the executive acts as a staff director, giving his attention to the supervision of the care of patients and of their health records in addition to his duty in his particular service. This officer keeps the executive and commanding officers constantly informed as to the condition of patients, their readiness for duty, recommends changes in diagnosis and medical surveys and serves to coordinate the work of the various members of the medical staff. The supply division, under the paymaster, is conducted in accord ance with regulations. Under the commissary the food has been served in an appetizing condition, the bread and pastry being par ticularly good. The ship's store is a great convenience to all hands. The medical supply division is under a pharmacist. Issues have been made to ships urgently in need of certain supplies and to Naval Base Hospitals 1 and 5, to the U. S. Medical Supply Depot, Brest, France, and also to the naval medical officer at St. Nazaire. The chaplain, in addition to his regular duties, has been active in securing musical instruments, a moving-picture machine, films, books, and periodicals, and has assisted the patients in communicating with their next of kin. 116025—19 14 596 REPORTS. Vol. XIII. ADAPTABILITY OF THE SHIP FOR THE DUTY ASSIGNED. It is desired to preface the following remarks by stating that it is recognized that an ideal hospital ship is with difficulty made out of one built for other purposes. In the case of the Comfort it may be said that the transformation has been very effectively done. This vessel is probably as good as any of her tonnage and, properly handled, is entirely seaworthy, as has been shown by her behavior in a suc cession of gales recently encountered. Built primarily for coast wise trade, the construction, particularly of the deck house, is not as strong as in the regular trans-Atlantic steamers, and should be strengthened. On the first trip to Europe some, concern was felt over the four cargo ports, which open on the lower deck and are much of the time submerged. Being held in place by " dogs," and owing to the absence of three frames in each, these ports constituted weak points. The working of the doors was excessive, permitting a certain amount of leakage, which could not be stopped, as there was no way of calking these doors effectively. This defect was partially removed by build ing in the missing frames and riveting the doors to them. This, how ever, still leaves the projecting hinges, which are liable to be shorn off by craft coming alongside. The deck house works considerably ; much more, it is stated, than when the ship was in the merchant service. This is more noticeable forward where it is attributed to the heavy elevator and its equip ment and particularly to the elevator motor which is placed above the chart house. Additional weights carried high up, such as lift rafts and boats, two large sterilizers, aft, and the equipment of the operating suite, forward, all have added extra weights to the deck house. Between-decks space, which as a merchant ship was occupied by cargo, is now used for living spaces, representing little or no weight. To insure stability, extra water tanks, more bunker space (GC2 tons of coal), and additional ballast amounting in all to 550 tons has been added. This places the weights at the end of the vertical diameter and to it is probably attributable the increased working of the deck house. This condition shows the desirability, in planning a hospital ship, of avoiding the ever present inclination of building it up in the air and adding heavy weights on the upper decks. A considerable saving of weight could have been effected by in stalling a less massive laundry chute than the present one which runs from the promenade deck to the laundry. The elevator could easily have been omitted and a hand lift or inclined plane substituted. An elevator about one-half the size would have been ample. No. 3. 597 REPORTS. Carrying the two ambulance boats forward on the hurricane deck has been found to be impracticable and these boats were left behind at New York when last in port. The position of these boats forward makes it impossible to maintain speed with a head sea without en dangering the boats and possibly the water-tight integrity of the ship. It is understood that the Mercy on her first trip to Europe had one of these ambulance boats wrecked by a heavy sea coming over the bow. With the present arrangement of handling by means of booms, these boats would be of little or no service in abandoning ship in a seaway. The massive booms required to launch them have to be carried partially lowered and constitute a considerable menace to the safety of the ship. I have been informed by seafaring men that the marine underwriters would not permit a ship to go to sea with booms carried in such a manner. At least one of these ambu lance boats is necessary, and it has been suggested that it be carried aft of the hurricane deck abreast of the medical ward. All of the power boats are gasoline driven, consequently should the supply of gasoline fail the ship would be dependent on pulling boats. For this reason a small steamer to replace one of the gasoline- driven ambulance boats would be a desirable addition. Ten hundred and sixty tons of coal are carried in the permanent bunkers, sufficient under ordinary weather conditions for 10 days' steaming at 14 knots, which equals 3,360 miles. A reserve supply of coal amounting to 608 tons is carried forward in No. 2 hold. This space is filled by dumping the coal through all decks in the vicinity of the forward convalescent ward, convalescent mess hall, crew's quarters and medical storeroom, which is extremely disad vantageous. The coal then has to be passed aft by hand a distance of about 50 feet to the wing passages above referred to. The closing in of the cargo hatches is recommended, being desirable for several reasons. First it would add to the water-tight integrity of the ship and to its structural strength. Upon the hurricane deck this hatch, at present, is secured by heavy timbers covered by a tarpaulin, which allows a certain amount of leakage below when seas are shipped over the bow. Secondly, by decking over this hatch on the main, lower, and orlop decks 1500 square feet of deck space would be rendered available for some useful purpose, such as an increase in size of the forward convalescent ward, of the convalescent mess hall. This would provide for stowage space for deck gear and be useful in other ways. The storeroom spaces are ample and, in general, well arranged. It is to be regretted that the medical stores are not placed aft and the general supplies forward instead of the reverse, as now obtains. All supplies from the after storerooms have to be removed through 598 REPORTS. Vol. XIIL the after convalescent ward, which is disturbing to the patients, tends to keep the ward in an untidy condition, and subjects the crew to contact with the patients. The supplies handled by the pay officer have to be drawn daily, while access to the medical storerooms is infrequent. Access to the deck from the living space for the engineer's force is through the after convalescent ward and there is no other route available. It is recommended that the ladders from this space to the hurricane deck be inclosed by diamond-mesh partitions with a door which can be opened from the ward side, the latter being desirable in case of emergency when it is necessary to evacuate the ward quickly. This arrangement, while permitting the ward to utilize these hatches for ventilation, would prevent the use of the ward as a passage for men going on and coming off duty. The hurricane deck outside of the deck house, as well as in the crew's space and after convalescent ward have numerous cargo hatches with high coamings, which materially reduce the available floor area. As these hatches serve no useful purpose, it is recom mended that they be removed, leaving openings for ladders and ordinary supplies. This would allow considerably more room for ■bunks for the sick or for other purposes. The location of the insane and brig cells is inconvenient, in that they are accessible only by means of doors through a water-tight bulkhead, which should not be opened at sea, and in the case of acci dent involving the hull, might render it impossible to release the occupants of the cells. The construction of the cells is very light, as was demonstrated recently when an intoxicated man was confined. He not only broke out of one cell, but into another. These cells will have to be strengthened, and when this is done they should be made accessible from the space abaft of the water-tight bulkhead. It is believed, however, that except for the occasional use of these cells as a punitive measure, there is little need for them. As a matter of fact but few insane patients require solitary confinement and in most eases it is undesirable. If violent they are much better controlled with hot water baths and sedatives. What is required is that a small ward, such as the forward convalescent ward or a portion of it, be prepared for the insane by means of diamond-mesh partitions and doors, for most of the mental cases simply need sufficient restraint to prevent them from wandering about the ship, with the possibility -of doing damage to it or themselves. The laundry occupies a position which is well adapted for ward purposes. The laundry could be placed on the lower deck imme diately below its present situation, in which case it would be neces sary to make some provision for drainage other than into the bilges. This could be accomplished by means of a tank and a motor-driven No. 3. KEPORTS. 599' pump to carry the wash water overboard. The space now occupied by the laundry could be assigned for ward space, which would add approximately 30 bunks. As the after convalescent ward now has 142 bunks, to add 30 additional would make it rather unwieldy, so it would be better to divide this entire space into two wards of about 86 beds each, installing additional toilets and lavatories in the after part of the space now occupied by the laundry where there is now a single water-closet. The facilities for handling patients in stretchers from boats and from one deck to another are very poor; in fact, the use of the Army stretcher in which the Army sick are received is impracticable, re quiring transfer to the Navy wire stretcher. While the gangway ladders are broad and easy of ascent, the passageways abreast of them are too narrow for a stretcher to turn in conveniently. The' ladders should be placed so that the upper platform is abreast of the lobby, which, aside from being the station of the officer of the day and officer of the deck, is the most convenient place from which to distribute patients to the wards. The surgical ward is near by and the elevator can be utilized to transfer stretcher cases to wards on the promenade deck ; in fact, this is the only way in which patients- can be transferred to the promenade deck without great discomfort and inconvenience. When alongside a dock and tidal conditions permitting, the patients may be passed directly into the after con valescent ward through a cargo port; otherwise it is necessary to carry them by hand down the ladders or by the stairway amidship just forward of the wardroom space. The fore and aft passageways inside the deck houses on the hurri cane deck are too narrow to allow the passage of an Army stretcher^ and barely permit the use of a Navy wire stretcher; but, by having removable rails replace the present fixed wooden rails to the stair way, it would be possible to carry the patients down the stairway in the splint stretcher. There is no special contrivance for handlings patients in boats at sea as was installed on the Solace, nor is it known how practical this arrangement has proved. If required, cargo- booms or boat davits could be utilized for this purpose. The toilet facilities are generally adequate and satisfactory except in the two convalescent wards. If the proposed changes are made in utilizing the space now occupied by the laundry and the installation of toilets, the situation in the after ward would be relieved. The forward convalescent ward of 28 beds has to share toilets and water- closets with 105 hospital corpsmen, and the facilities are insufficient. From practical experience it is believed that the bathtul>s aboardi this ship are undesirable. A tub requires space sufficient for three shower baths, and uses at least 10 times the fresh waterT and serves 600 Vol. XIIL REPORTS. comparatively few men in a given time. Tubs are difficult to keep clean, and the shower is preferred by most men. It would be well to reserve one or two tubs for mental and other cases. If a patient is too weak to take a shower bath he is given a sponge bath. No mat- . ter how liberal the output of distillers may be there is always on board a cruising hospital ship the necessity for a reasonable economy in the use of fresh water. All fresh water faucets, with the exception of certain ones, as about the galley, scullery, and laundry, should be of a compression type. The white tiling in various lavatories, galley, and pantries is very effective from an esthetic point of view. It is certainly conducive to cleanliness, but in parts of the ship where there is much working, as in the deck house, these tiles are already rapidly becoming loosened and falling out. The use of sheet zinc and white enamel paint for the walls appears to l>e preferable and certainly very much less ex pensive. Tiled floors in the galley and pantries are undesirable. When the ship is rolling and pitching, it is impossible to keep these floors free from grease, particles of food, and soapy water which render them so slippery as to be hazardous. At times during heavy weather it has become necessary to stretch lines across the galley to prevent the cooks from being thrown across the range and to per mit them to get about. Concrete or brick flooring would be much better. SERVICE PERFORMED. The service of this vessel has been one of comparative inaction, alternating with periods of marked activity under adverse condi tions. While assigned temporarily to the third naval district the ship served to relieve the congestion of patients at the United States Naval Hospital, New York. During the epidemic of influenza 262 cases were admitted. Of these 24 died, giving a mortality rate of •over 9 per cent. The course of the disease was similar to that re ported elsewhere. Prior to receipt of the first case, screens had been prepared separating contiguous bunks. When the patients came aboard the cases were treated as highly contagious. The attendants were required to wear gauze masks, coats, and gowns and the hands were required to be sterilized after handling patients. The hospital corpsmen and the crew were instructed in the prevention of infection. It is of interest to note that, although liberty was given, very few of the ship's company contracted the disease. There were no deaths or serious cases among them. It is particularly worthy of note that there was almost no evidence of the transmission of the disease to those directly in attendance upon the sick. With the assignment of this ship to trans-Atlantic service to bring home the sick and wounded abroad, its duty as a hospital ship has No. 3. 601 REPORTS. been succeeded by that of an ambulance ship. As such, with its complete equipment and large medical staff, it is clearly the func tion of this ship to carry the most seriously injured who require fre quent and expert surgical attention. With this point in view, every effort has been made to impress upon the embarkation officers that the 300 bunks available for serious cases should not be utilized to carry patients who could equally well be carried by the regular transports, and from this number, up to 400 should be ambulant cases capable of (•limbing ladders and going to the mess room. It has been found difficult to convince some of the Army officials that the term ambulant with reference to a ship and the ability to climb ladders is not ap plicable to one-legged men, of which class some 50 were sent to the ship at St. Nazaire who had to be assigned to accommodations in tended for strictly bed-ridden patients. The majority of the cases received on this trip were such as could not have been properly attended to with the facilities usually afforded on transports. In order to take 400 patients, cots were placed in the solarium, forward convalescent ward and hospital corps quarters. The patients (Army wounded) were brought to St. Nazaire from base hospital No. 8, at Savenay, by ambulance train, from which they were transferred to the ship in ambulances. The embarkation up to the gangway was by the Army embarkation officer and was well conducted. In order to avoid confusion, through assigning patients to the wrong ward or to overfilling any one ward, and to be able to quickly locate any patient, the following system was inaugurated. A Denni- son tag was prepared, having the ward letter and bunk or cot number entered on it in duplicate. These tags corresponded to the number of ac commodations available. A medical officer was stationed at the gang way to make an assignment for each patient. The patient's name was checked off on the list furnished by the embarkation officer and was en tered on the lower part of the tag designating his billet. This lower por tion was then detached for the record office and files and the remain ing portion was attached to the patient. In this way it was impossible for a patient to get lost by being sent to the wrong ward and there was no possibility of any one ward receiving more patients than there were billets. In the record office, the files were then arranged to show the patients' names alphabetically. It is important in placing patients in bunks which are accessible on one side only that the cases be assigned so that the injured part will be most accessible and at the same time it is desirable to alter nate the head and feet in reference to the near neighbors in the same level as well as those above and below. 602 REPORTS. Vol. XIII. The necessity for taking every precaution against droplet infection ■was shown by an outbreak of diphtheria in three widely separated wards within two days after embarkation. Contacts were imme diately isolated and the personnel of the infected wards were cultured for diphtheria. In all, 12 positive cultures were discovered, of which 10 were clinically diphtheria. The death of 1 patient, found to have nasal involvement, occurred in spite of the use of antitoxin in large amount. There was practically no spread of the disease after the primary outbreak. Upon inquiry some of the patients stated that several patients who were suffering from " throat trouble " had been removed from beds adjacent to their own in the base hospital. Among the most seriously injured were 50 cases of gunshot frac ture of the femur. Extension was maintained by the Thomas splint and where indicated the Carrell-Dakin treatment was carried out. Over 350 daily dressings were made. Dichloramine-T was used to a considerable extent and with very satisfactory results. In spite of the excessive motion of the ship the fracture cases suffered no serious inconvenience and were disembarked markedly improved. No radical procedures were carried out, such as the removal of the dead bone, or fixation of bones because of the unfavorable weather conditions for operative work and the comparatively short time that the patients were to be aboard. On the second trip over, to Plymouth, England, the ship received 95 Navy cases and 238 Army wounded, a total of 333, which is 67 under the number desirable to take. Of these cases about one-half were in such a condition as to have been able to travel via transport. It is understood that at this time practically all of the serious cases had been evacuated from the English hospitals. A WESTBOUND VOYAGE OF THE U". S. S. " LEVIATHAIT." By F. A. Assebson, Commander, Medical Corps, United States Navy. During the westbound voyage from Brest, France, to Hoboken, N. J., February 26 to March 6, about 10,200 troops, including sick and wounded, were transported home. The passage was marked by an epidemic of influenza, during which 2 per cent of the Army per sonnel were treated for this disease. Two enlisted men were admit ted to the sick bay on February 25, a few hours after embarking, with undoubted symptoms of pneumonia. Another enlisted man embarked on February 26 with frank signs of consolidation in his left lower lobe and typical symptoms of pneumonia. One of the above had the preliminary chill on February 21 and another on February 22. The third had a temperature before leaving the Army camp and was advised by a medical officer not to make the trip. All No. 3. 603 REPORTS. but one of these cases recovered after a severe illness. A large num ber of the troops were coughing when brought aboard ship, but their great desire to return home with their commands prevented them from reporting at sick call for treatment. There were no cases of influenza aboard ship when the troops embarked. The following is a daily list of admissions to the sick list of the Army: Feb. 25 8 Feb. 26 11 Feb. 27 9 Feb. 28 ,._ 10 Mar. 1 50 Mar. 2 41 Mar. 3 35 Mar. 4_ Mar. 5_ Mar. 6- 26 8 11 Total 210 Of this number 43 developed pneumonia, the majority similar to the type occurring during the influenza pandemic of the fall of 1918. Ten of these (23 per cent) died aboard ship, seven after reaching Hoboken. Thirty-eight cases were retained aboard after reaching port awaiting crisis before transfer to an Army hospital. Those sent to the hospitals were later reported, with two exceptions, as doing •well. Report of the death of one other patient was received after sailing. The surgical ward of the sick bay (84 beds) was used for the first admissions and when this ward was filled 77 cots were placed on the starboard side of B deck, in the vicinity of the sick bay, for the addi tional cases. One hundred and ten patients were treated in the sick bay and 100 on the outside on B deck. Of those developing pneu monia, 35 (81 per cent) were in the sick bay and 8 (19 per cent) on the outboard deck. Only 1 death (11 per cent) occurred among the patients treated on the outboard deck and 9 (89 per cent) among those treated in the sick bay. Practically all of the patients admitted to the sick bay were given aspirin and codein for the control of the severe general pains. This resulted in profuse perspiration with many sharp drops in tempera ture, in one case 7° in 12 hours. The patients were clad in the regulation light Navy nightshirts, which give but little protection and are soaked by even a moderate amount of perspiration. In many of our cases the nightshirts were literally " wringing wet." Warm pajamas were substituted for the nightshirts as soon as possible after this was noticed. As it has been proved that direct draft playing upon the chests of healthy per spiring men camcause pleural reaction, with effusion into the pleural sac, it would not seem unreasonable to assume that similar conditions when applied to patients infected with the causative organism of in fluenza might result in changes that affect not only the pleura but the underlying lung tissue. With this in mind it was decided to discon 604 Vol. XIII. REPORTS. tinue the administration of drugs causing perspiration and to require all men treated on the outboard deck to wear their underclothing, top shirts, and socks. Investigation proved that the headaches, which in manj' cases were very severe, were due to marked congestion of the vessels supplying the scalp. This headache was readily controlled without the use of drugs, by a tight bandage (2-inch) applied around the head from directly above the eyebrows to the occipital region. This failed to control the symptom in only one instance, possibly due to faulty bandaging. One hundred and ten cases of tuberculosis, including 40 stretcher cases, were embarked on February 24. Four of these patients were in a very serious condition when brought aboard ship, and two died, one on February 27 and the other on February 28. In compartment E. R. S. 1, in standees, there were 1.002 sick and wounded transported home. Of this number there were 177 dress ing cases. There were in all 963 dressings done during the voyage as follows: CO cases daily for 9 days 540 55 cases every second day for 5 dressings 273 24 cases every third day for 4 dressings 96 In addition there were 52 cases that were dressed but once or twice, simply entailing changing or readjustment of splints, strapping of weakened arches, etc. The majority of these cases were lacerations of arms and legs occa sioned by high explosives, shrapnel, or machine-gun bullets: com pound fractures of arms and legs from machine-gun bullets and shrap nel ; and a number of amputations of arms and legs and fingers due to extensive wounds and from accidental causes as motorcycle, truck, and railroad injuries. There were a few cases of unrecovered appen dectomy wounds, mastoid, resections for empyema, two eye enuclea tions, and two chronic otitis medias requiring dressing. One of the appendectomy cases had a fecal fistula still active. All of these cases were ambulatory: all were well advanced in their convalescence, the majority having received their -wounds not later than October, 1918; and most of them showed marked improvement during the time they were aboard. In a number of instances among the compound fracture cases bone sequestra were removed, and in a few small pieces of shrapnel spontaneously worked to the surface of wounds that were still open, and in some cases causing wounds that had been healed for a time to reopen. The difficulty also of healing wounds that had been subjected to the influence of gas. either at the time they were received or very shortly afterwards, before receiving first-aid dressing, was very obvious. No. 3. REPORTS. 605 CONCLUSIONS. (a) That patients suffering from influenza should be treated when possible on a protected outboard deck, and should be well protected by clothing as well as bed clothing. (b) Medicines causing perspiration should not be administered. (c) Tight bandaging of the head for controlling headache, with local measures for general pains should be tried before administering drills for relieving these symptoms. (d) In obstinate, severe cough, nasal insufflation of heroin deserves a trial. (e) Men with symptoms of an acute respiratory disease or who are running temperatures should be retained at the Army camp until cured. The danger of the spreading of acute respiratory disorders aboard ship is too great to permit the embarking of any of these cases. (/) Cases of tuberculosis with only a poor chance of completing the voyage home should be retained at the hospital. The death of patients aboard ship, where there is practically no chance to isolate the dying cases, has a very bad effect upon the morale of the other patients. SHIP LIFE IN CONSTANTINOPLE.1 By E. r. Hcff, Lieutenant Commander, Medical Corps, United States Navy. During the year the ship has, with the exception of a period of about 10 days, remained continuously at anchor in the Golden Horn, on the Stamboul side of the harbor just below the inner bridge. The water at this point is badly polluted by a large sewer vrhich empties into the stream immediately above the ship. Per mission having been obtained to use one of the Government1 graving docks in the navy yard on the opposite side of the Golden Horn a . hort distance above the inner bridge, the ship was accordingly placed in dry dock on October 19, when some much-needed overhauling was done. During this four-day period, some 25 tons of marine growth were removed from the bottom, zincs were renewed, and paint applied. Several badly pitted areas were found, at which points borings were made. On October 28 the ship left for a two-days' cruise to Mudania, in the sea of Marmora, at which place the am bassador took train for a one-day's visit to Broussa, the ancient capital of the Empire. About 40 of the crew were given liberty and a special train was provided to convey them to Broussa. Those remaining on board enjoyed the time fishing, and the entire ship's 1 Extract from Annual Sanitary Report IT. S. S. Scorpion, 1016. (Through some mystery of the war this report was nearly two years In reaching Washington.) 606 Vol. XIIL REPORTS. company profited materially by the outing. At the time of this trip the entire Marmora coast was reported free from quarantinable disease. The health conditions of the city have remained good during the year. A few local epidemics of cholera and typhoid have occurred, but these have been satisfactorily controlled by enforced vaccina tion and quarantine and by proper sanitary supervision. Several sporadic cases of typhus have occurred in Constantinople, but these have in most cases been traced from the interior of the country, in some parts of which the disease has been very; prevalent. In the treatment of and prophylaxis against this disease some success has been claimed by the German workers in Constantinople by the. em ployment of injections of immune serum. The Plotz vaccine has not been tried here. Food of good quality has been abundant in the city during the year, but the extremely high price of the necessities and the lack of wherewithal to buy, especially among the poorer Greeks who are largely without work or municipal assistance, has resulted in extreme hardship, and in many cases death from actual starvation. Several soup kitchens have been established by foreign philanthropic or ganizations and these, working to the full limit of their endow ments, have accomplished great good. The work of the Turkish Red Crescent organization has flourished and this institution has maintained, in excellent condition, a number of military hospitals in the city. A Red Crescent exhibition, along the lines of those held by the Red Cross in other countries, is soon to be opened in the city and promises to be of great public interest and benefit. Many military patients, both sick and wounded, have been brought into the city during the year, principally from the Balkan fronts, but the exodus from the hospitals has been much greater than the influx, the result being that there are many vacant beds in the city. Many British (from Kut-el-Amara), Roumanian, and Russian prisoners have passed through the city, a number of the sick and wounded among them remaining to be cared for in the hospitals. Early in the year two American Red Cross hospitals (formerly the French and British hospitals) were commandeered by the Turk ish authorities and have since been in their hands. The Bulgarian and German hospitals have remained open to foreigners so that the loss of the two former has not been felt by the ship. The sanitary condition of the city has remained good. The streets have been well cleaned and, during the summer, well sprinkled. The police force, as usual,' has been most efficient and has maintained good order. While a curfew law exists for the belligerents (they must be in their homes by 9 p. m.) there have No. 3. REPORTS. 607 been no other restrictions on personal liberty. Music halls are obliged to close at midnight, and recently a law has been passed forbidding the sale of intoxicating liquors in public places after 9 p. m. Cinema shows and all public meetings are rigidly super vised. Prostitutes are subjected to periodical examinations, and many of them have been deported to the interior of the country. Venereal disease is still very prevalent, however, in spite of the efforts of the authorities to protect the soldiers, many of whom, from the interior, are enjoying for the first time the doubtful bene fits of city civilization. The climate of Constantinople, always an uncertain quantity, has been particularly mild and open during the winter months passed and the result has been a large number of cases of rheumatism and respiratory troubles. It has been well said that there are no seasons in Constantinople, but that there are two climates, that of the north wind and that of the south wind. The changes are often so sudden and so severe that one is seldom dressed appropriately to meet them, and the results are frequently disastrous. Overcoats, umbrellas, and overshoes are always justifiable encumbrances here during the fall and winter months. In this country, where smoking (especially of cigarettes) is universal, it seems rather strange that any regulation controlling it should be instituted. However, an order has recently been issued forbidding smoking in the cabins of boats plying the Bosphorus, and it is the intention to extend this also to include the tram cars. The native's intense fear of a draft of air results in these and other public places forever being closed, and as most of the peo ple suffer from catarrh or colds, the condition of the air and floors can be imagined. The native's personal habits leave much to be de sired, and even with the recent establishment of public urinals throughout the city, the condition of many of the streets, in the even ing especially, is disgusting. However, in a country where toilet paper is unknown among the natives and the individual employs the same fingers in eating out of the common dish, little better can be expected, and the great prevalence of filth-born diseases is not to be wondered at. There have been 17 reenlistments on board during the year, and 13 men are now doing overtime. Five men have agreed to pay their way home during the year. Ten members of the crew have married native Greek girls during the year, making a total of 22 who have married on this station during the past three years. Five of those recently married were under treatment for syphilis, and two con tracted gonorrhea shortly after marriage. Nine babies have been born to the wives of men on the Scorpion during the year, and there are four prospects for the near future. 608 REPOKTS. Vol. XIII. Sixty men have been immunized against typhoid fever during the year and HG for cholera, the latter measure being considered advisable owing to the presence of cholera in the city. The cholera vaccine used was from the Sachsisches Serum and Bacteriotherapy Institute, Dresden, and was in every way very satisfactory. No vaccinations against smallpox were indicated, the entire ship's company having: been vaccinated the preceding year. The water used on board at present is brought from the Beicos Springs, about 12 miles up the Bosphorous. Several specimens of other waters have been tested, but only this one was found satisfac tory. As heretofore, all water used for drinking purposes is first passed through Berkefeld filters. Food has been sufficient in quan tity and of good quality. There is at present no threatened short age, but the cost of all food has increased enormously and is still going up, the present average price of all foodstuffs being about 500 per cent above normal. Owing to the scarcity and high cost of coal, steam has been on the boilers but 145.8 days during the year. In consequence heating stoves have been installed one each in the crew's space, chief petty officer's quarters, engine-room, cabin and wardroom. These have proved satisfactory, but have added an element of danger from lire which has, however, been well guarded against. The wardroom stove being situated over the magazine, all fixed ammunition wTas broken down and the smokeless powder (of uncertain stability) thrown overboard. In the absence of a flushing system, tanks have been provided for the heads and are giving satisfaction. There have been no epidemics among the crew. There were, how ever, several cases of infective jaundice, this disease having been quite prevalent on shore during recent months. One case of typhoid fever occurred in a member of the crew early in the j'ear, the source of infection not having been ascertained. The disease ran a mild course and while a bacteriological examination was not made there was no doubt about the diagnosis clinically. This man had received typhoid prophylaxis about li months prior to the onset of tin: dis ease. A special report was made of this case at the time, with the recommendation that a mixed T. A. B. vaccine be adopted and that the injections be made at more frequent intervals than the present four-year period. The present German plan is to i-enew the immu nity by administering a small amount of vaccine at intervals of six months. The crew has suffered from a lamentable lack of athletics during: the year. During the earlier months parties of men were conducted on daily walks about the city and these were much enjoyed by both- the men and the accompanying officers. Many sites of historical interest were visited and an interest in local history stimulated. Dur No. 3. REPORTS. 609 ing the months of Jul}- and August about three-fourths of the crew- was given an outing at Robert College on the Bosphorus, where they were comfortably accommodated in one of the dormitories va cated during the summer holidays. Baseball, gymnasium exercises and walks were freely indulged in to the great physical betterment of all those who participated. The morale of the crew has not been of the best during their long isolation and the desire to get home of the many overtime men residted in much discontent. There have been seven courts-martial (two summary and five deck) during the year, one for assault, two for drunkenness, two for neglect of duty, and two for unauthorized absence. The embassy guard of eight men has been continued during the year, these men being housed and subsisted in the Scorpion Club, an institution maintained for and largely by the members of the ship's company. Separate guards have also been posted on the barge and the steamer which during the greater part of the year, have been moored alongside the old bridge, about 50 yards from the ship. A RECORD SHIP.1 By A. E. Lee, Lieutenant Commander, Medical Corps, United States Navy. The ship left Bremerton Navy Yard for New York January 1", 1918, stopping at San Francisco, where 435 German refugees and 1,506 sailors were taken aboard for delivery to the east coast. The ship arrived in New York February 9, 1918, where additional repairs and changes were made at the New York Navy Yard, completely equipping her for the transport service. She left New York March 12, 1918. for Brest. France, on her first trip, with 2.787 troops and 124 officers, arriving in Brest March 20, 1918. Since then she has made nine more round trips to France, carrying in all 28,1GC troop::. She arrived in New York November 19. 1918, from her last trip. Since then she has been at Fiedler's shipyard undergoing engine overhaul and other repairs. The ship bears the following record : (a) More men per day per thousand tons than any other ship. (b) Fastest round trip from New York to Brest. France, namely. 14 days, 3| hours. (c) Economical run, round trip, taking no oil or water on the other side. The health of the personnel lias been excellent: average com plement, 615: average percentage of sick, 2.5. Measles and mumps in the draft of sailors brought from San Francisco, sick and wounded from the President Lincoln, and wounded marines returned from overseas are mainly responsible for this high percentage. The 1Extract from the Annual Sanitary Keport of the I". S. S. Great Xorthern, 1918. '610 EEPORTS. Vol. XIII. living quarters were found to be somewhat crowded, so additional space was allotted to the engineer's quarters with an enlarged venti lating system. Also a section of the troop space was bulkheaded off for the supply division, with various other minor changes, all of which has given very satisfactory results and contentment to the crew. Sanitary drinking spigots were installed throughout the ship, and a careful search was made to find any break in the system. The engineer's force were occasioning most of the mumps cases aboard, and in searching for the cause a common spigot was found in the shaft alley. When this was remedied, no more mumps developed in the division. Messing for the troops has been by the cafeteria system. It has given excellent satisfaction. The system has been so well regulated that it is quite easy to feed 3,000 troops three times a day, taking about an hour and a half to a meal. The crew is fed on "A" deck by the old Navy system. The engineers have their own mess in part of their sleeping space. By this means the crew is kept separated from the troops, especially below decks, and this is considered an important point. It was on the ninth trip, about 500 miles off the coast of France, that the British ship Brinkburn struck the U. S. S. Great Northern at 2.30 a. m., October 3, 1918, killing seven of the Army contingent and wounding about 15 soldiers. The hospital corps responded quickly to meet the emergency. There was no confusion, no panic, no lost motion; the wounded were quickly removed from the com partment below on " C " deck and taken to the dressing and operating rooms, where everything possible was done to relieve their suffering and attend to them surgically. On November 18, 1918, while returning from our last trip, recom mendation was made to the commanding officer that the troop space 7-B be changed to accommodate stretcher cases, thus increasing the bed-carrying capacity of this ship for wounded from 38 to 312. Since our arrival in New York this change has been made. The standees were removed and hospital bunks installed. An ample dressing room, built in the after part of the compartment, and an increased lighting system has been installed. It has made an excellent surgical ward and given us an increase of 274 bods. Ample store room space was obtained by using two large wash rooms already in this compartment ; a linen room was built in.1 'The commanding officer in forwarding tbe report from which this extract is taken made the following comment: "Too much credit can not be given to the medical officer, Lieut. Commander A. E. Lee, Medical Corps, United States Navy, and his assistants for the excellent sanitary condition of the Great Northern, as this condition is due primarily to the execution of the sugges tions of Lieut.' Commander lye. Attention is invited to the small number of fatalities during the recent Influenza epidemic ; also to the action of the officers and men of the medical department at the time this vessel was struck by the Brinkburn." No. 8. REPORTS. 611 THE UNITED STATES NAVAL AIR STATION, PAUILLAC, GIRONDE, PRANCE.' By H. A. Garrison, Lieutenant Commander, Medical Corps, United States Navy. The station is called Pauillac but is about a mile from that town, in a village called Trompeloup. It is about 30 miles from the mouth of the Gironde River, or a little more than halfway from the mouth to Bordeaux. Trompeloup grew up around the docks which were installed here many years ago to save the wait for the tide to get to Bordeaux but political and financial influence at Bordeaux prevented their being used to any extent. The climate here is a very disagreeable one especially in winter. The thermometer never gets very low but the humidity is so high that the cold is felt very keenly. The rain is cold and disagreeable and occurs almost every day. There are also very heavy fogs. The camp site is not at all good from a sanitary point of view but it had to be here from an industrial and transportation standpoint. It had docks which would take six large ships and also fairly good railway connections and side tracks, as well as some warehouses. The purpose of the station was that of a receiving station for ma terial and personnel for aviation and to be an assembly and repair plant for planes and motors. The station really commenced its existence on December 1, 1917, with a personnel of 2 officers and 26 enlisted men who occupied an old stone building now used as administration offices. This was built originally as a steam laundry to cater to the trade of the trans- Atlantic liners which never came. The station did not begin to grow very rapidly for some months. On January 30, 1918, the sta tion had less than 1,000 men. From then on to May the increase was gradual and reached about 2,000. It then took a quick jump by the arrival of large drafts and ran up to around 5,000 by July 1. Many of these men stayed only a short time, as they were being distributed to flying stations up and down the coast. As they were distributed and our own construction became lighter we ran down to about 3,500 when the armistice was signed, November 11, 1918. About 800 men were shipped home December 1, 1918, and a few hundred were sent through from outlying stations, so that we ended the year with about 3,000. The great difficulty in the early part of the year was to get ade quate shelter. The camp was in the middle of a typical water-front village with all the usual undesirable qualities. Some of the houses were rented, some bought, and some commandeered later. We did not get all of them out until October 1, 1918. The buildings erected were barracks (fabricated) known as Dixie huts, measuring 20 by 1 Extract from Annual Sanitary Report, 1918. 116025—19 15 612 REPORTS. Vol. XIII. 106 feet. Their delivery was slow and they were not really adequate until about August 1, 1918. Before this there had been more or li % unavoidable crowding. Hammock stays were put up and men sl< in hammocks. The mess halls were completed about the middle or ' July and feed at one sitting 3,300. The assembly shops and hangars were well built, with concrete floors, and were entirely sanitary. Bv August 1 we had barracks in sufficient number to give each man between 45 and 50 feet of space, and stoves were ready to be put up for the winter. The messing at first was in the building intended for the garage, and while all concerned did their very best it necessitated practically continuous serving from daylight to dark —at one time 14 messes per day. The food has been plentiful and reasonably varied and, since the large mess hall and kitchen were installed, very well cooked and served. The supply department has done all that could be done at all times in this regard. The fresh-meat ration was gotten from the United States Army and consisted almost entirely of beef, as that seemed to be all the Army carried over here. Abundant water for the station has been gotten entirely from a fourteen hundred foot well. This water showed a bacterial count just a little above that considered safe, although no surface contami nation could be located, such as cracks in casing, etc. It has been chlorinated with liquid chlorine. Capt. H. P. Letton, Engineer Corps, United States Army (loaned to the Army by the United States Public Health Service), gave us invaluable help in this work. The distribution was at first unsatisfactory because of inability to get piping, but by July this was remedied. The toilets and showers are in separate buildings with concrete floors. These buildings had toilet seats and showers for 4 per cent of the personnel and ample urinal and scrubbing troughs. All sewage and bath water went through septic tanks (four in number, of the three-chamber variety) and emptied into the river through a small creek. The sewage came out thoroughly liquefied, but had a slight odor. The system was very satisfactory. The light ing of the station has been by electric lights entirely. The heating of necessity has been by stoves. Miles of board walks have been put down and have been a great comfort and of great value in promoting cleanliness. An energetic antifly campaign was carried out during the summer with screening for mess hall and sickbay. Mosquitoes were not very bad, and we had no malaria. The health of the station has been exceptionally good. The per centage of sick days may seem at first to be rather high, but the policy of putting mild cases to bed has been amply justified by the low mortality rates. There have been several isolated cases of mumps, No. 3. 613 REPORTS. measles, scarlet fever, diphtheria, and cerebro-spinal meningitis, but no deaths from these. Despite the fact that we had little confidence ii jqhe antimeningococcic serum because of the far from ideal way in winch it had to be sent to us, it acted perfectly. We had one death from undoubted typhoid in a civilian employee (American), who had no clear history of prophylaxis, and no other cases. The epidemic of influenza struck us about the middle of September, and we had fewer deaths and less severe cases than any other organi zation on the coast. We had about 4,500 personnel at the time and lost only 1 officer and 10 men. Since then we have had four deaths from pneumonia, which should be charged up to influenza. Because of the size of the station and the imperative industrial demands of war it was impossible to do any wholesale spraying of noses and throats or masking. The small percentage of deaths, I feel sure, is due to putting every case to bed as soon as he com plained of feeling badly, thorough purging and absolutely no mov ing or transfer. Our percentage of venereal disease has been moderately high. There are two reasons for this: First, liberty was given in Bordeaux the only near-by city of any size, and there is a great deal of venereal disease there; secondly, while the United States Army placed at our disposal their prophylactic stations in Bordeaux, there was a lack of really trained men for such stations and the results were poor in consequence. Another cause was that while on the whole our men were very orderly and well behaved, still plenty of alcoholic drinks could be secured in Bordeaux, and it is an axiom that no matter how much a man may know as to the value of prophylaxis, a little alcohol makes him careless of promptly carrying it out. The near-by villages while surely high in percentage of prostitu tion and venereal diseases, furnished very few cases because we were able to carry out thorough prophylaxis within a few hours. The drafts from Philadelphia were noticeably high in venereal percentages on arrival here. Some had primary sores and there, were a goodly number of secondaries. A most striking feature of the venereal sores was that nearly all showed treponemata on smears (we always treated with salt solution) and were later checked up by Wassermann. Our treatment was by the usual methods and carried out very thoroughly. We used the French manufacture of neosalvarsan and it was very satisfactory and practically took no time off from work, as there was little or no reaction, and we had no bad results whatever. There was never at any time a lack of sufficient medical personnel but there has been at times a lack of sufficiently trained (in the real 614 REPORTS. Vol. XIII. sense of the word) hospital corpsmen. We have been able, how ever, to get plenty of good bright men who were excellent material. All supplies asked for were given without question, but the actual delivery often left much to be desired. But in this the medical de partment was no worse off than the other departments. The Red Cross secured the Chateau Beaucaillon, six miles away, and prepared it for a hundred beds about February 1. They fur nished material, and housekeeping, and managing staff. The medical staff and hospital corps (4 and an average of 14 respectively) were furnished by the Navy. The Navy also furnished free coal and gaso line and gave the privilege of commissary purchases at issue prices and paid a money ration. The Red Cross deserves much credit for its work but it was ham pered by several things, the most marked being the owner's restric tions. No contagious disease, no erection of barracks, or tentage on grounds and no increase of kitchen facilities being permitted. A small sick bay and dispensary were established in the old stone building originally occupied and were used until June for the milder cases and for sick call. Major surgery was sent to the United States Army Base Hospital at Bordeaux until May when the Red Cross Hospital installed an operating room in which about 100 operations have been done very satisfactorily without a single infection. By June two barracks 20 by 106 feet had been constructed for use as a yard dispensary. These were very well laid out with partitions, baths, toilets, washbowls, etc. They furnished offices, bed room for officer of the day, pharmacy, two sick rooms, eye, ear, nose, and throat room, sanitary office, and beds for 20 patients. Another barracks next to them was asked for in July and this gave 40 more beds. Dur ing the influenza epidemic two more barracks alongside were given us and all cases were treated here. This worked out very well as we were within a hundred feet of the mess hall so that feeding was easy. The equipment could have been made to suffice but it left much to be desired. In June, the Red Cross offered to rent another chateau, about three miles distant, and install there a hospital of 300 beds but for many reasons this was declined after being care fully considered. It was decided in August to install large sick quarters of our own and the French Government gave us for this purpose five stone buildings adjoining our own camp in what was known as the lazaret. This is the French quarantine station. Due to unavoidable delays and to the great amount of work needed (there was no lighting, water, plumbing, or sewerage) the buildings were not ready to occupy until about the time the armistice was signed. They were completed as we left, since the United States Army would want this as an embarkation camp. In the first few days of Decern Mo. 8. REPORTS. 615 ber, the Red Cross hospital was closed and all patients were cared for on the station, several major operations being performed in the new place. It has a capacity of about 200 beds and is very well ap pointed. It seems now as though the United States Army would take over the camp as an embarkation camp. We have orders to ship all material (medical) to Bassens, which is the large dock for Bor deaux. There is a dispensary there now being expanded to 75 beds. Some of the personnel has already gone home and more will soon go. Our flying here is only by experienced men, and while we had a few falls no one was injured, except one man who received a slight scalp wound from getting too close to the propeller. The docks have furnished a few accidents, with only two deaths. It is interesting to note that death in three cases in drafts coming to this station by rail was due to men riding on the tops of cars and being swept off by low bridges and tunnels. Our Army lost scores and scores of men in this way. Our dead are buried in Pauillac Cemetery, in a plot assigned us. We had 38, which included about 18 from ships, etc., the U. S. S. Marietta losing 14 from influenza. We had one officer and one man buried at the United States Army hospital at Talence. The graves are marked with crosses. In addition there are brass plates on the coffins and bottles with names inside. Blue prints are now being prepared of the plot. The medical department has rendered medical and surgical assist ance to many of our own ships in the river, as well as to many ships of friendly powers, especially during. the epidemic of influenza; also to United States Army men in attached camps near us. It also assisted them in the burial of the dead. Owing to the mobilizatioi. of the French medical profession in its entirety, the medical officers here have treated many French people as a matter of common humanity. We have furnished a great many expendable medical supplies to our own ships stopping here and have received patients from them. Captain F. T. Evans, United States Navy, who took command in July, has been an inspiration. He is himself a sanitarian of no mean ability and has gone out of his way to lend a hand. His two executive officers, Lieut. Commander S. L. H. Hazard and later Lieut. Commander C. E. Battle, have both joined most heartily in carrying out sanitary and medical work. While I do not feel that my work here has been without value I consider that the real credit for having by energy and hard work, coupled with excellent training and abundant common sense, worked out the discouraging problems of the early days of construction should go to my very able assistant. Lieutenant Arthur C. Sinton, Medical 616 REPORTS. Vol. XIII. Corps, United States Navy. His was a real nerve-racking and dis couraging task, performed in a manner meriting the highest praise. January 15, 1919: The United States Army officially took over the camp on this day and we are sending out men and material as fast as possible, half the station having left on January 12. Maj. F. M. Browne, Medical Corps, United States Army, reported on January 3 as camp surgeon and his personnel and nearly all of his material are here. We turned over all of the buildings occupied by the Medical Department yesterday. Our material is all packed and the last was shipped to Bassens yesterday. Microscopes, scales, shelf bottles, etc., go to the United States Naval Medical Supply Depot, Brest. The medical and dental personnel, including enlisted force, have been reported ready for transfer with the exception of two medical officers, a pharmacist, and a few hospital corpsmen to look after records until transportation is secured to send out the remainder of the station's personnel. A great deal of credit is due to Pharmacist A. L. Crowder, United States Navy, not only for his care of records, etc., during the existence of the station, but for the masterly way in which things were inventoried and packed for shipment. THE UNITED STATES NAVAL AIR STATION, ROCKAWAY BEACH, LONG ISLAND, N. Y.1 By A. A. Shaddat, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. The United States Naval Air Station, Kockaway Beach. Long Island, N. Y., was commissioned on October 15, 1917, with 2 officers and 20 men. The station is located on the extreme west of Long Island, on the south shore of Jamaica Bay. The site is 15 feet above sea level, surfaced with coarse white sand which has been washed from the bay. The general health on this station has been excellent, except during the month of October and the first part of November, when the epidemic of influenza was flourishing. On September 26 the recreation room was taken over by the medi cal officer and put in order for a hospital ward. An emergency requisition was rushed through and a truck sent to the medical supply depot at Brooklyn, N. Y., on the same day for bedding to fit out this room. It has an area of 13,499 cubic feet; 25 beds were fitted out completely and the influenza patients isolated. Never at any time were there more than 25 patients, so we were able to handle them very nicely in the above room. The cases of pneumonia were iso lated in the sick bay. 1 Extract from Annual Sanitary Report, 1918. No. 3. REPORTS. 617 The men were urged not to take their liberty and forbidden to ride in the subway trains or to attend public gatherings. No meet ings or general assemblies were permitted on the station. Every man was forced to wear a gauze mask over the nose and mouth at all times, and every patient was isolated as soon as he showed any signs of coryza. Overcrowding in barracks was not permitted, the extra men being quartered in tents, and bedding was put out in the sunshine every day when the weather permitted. The barracks were scrubbed thoroughly each week with cresol. The duties of the crew were made as light as possible compatible with the upkeep of the station. Venereal disease.— -The proximity of the station to Rockaway Beach, which is a summer resort, and to New York City renders it particularly liable to diseases of a venereal type. Considering that the complement is composed chiefly of raw recruits, who have had very little, if any, training along the lines of venereal prophylaxis in the Navy, preventing venereal infection, presents rather difficult obstacles. Frequent venereal inspections have been held. We have found that 67 per cent of the gonorrheal infections have come in with the drafts from other stations over which we have no jurisdiction. There has been a tendency among a few medical officers in this district during the past year to permit men to be transferred with acute venereal diseases. A special effort has been made by the medical officer to apprehend all women afflicted with venereal disease (who associate with the men) according to the laws of the State of New York. This effort has met with only one satisfactory result, i. e., that these people now refuse to associate with the sailor. One room in the sick bay is set aside and equipped as a venereal room, which is kept open at all times for men who wish venereal prophylaxis. Printed instructions relative to the use pf different agents are posted in said room. It is my opinion that, while the training should be done in the home and public school, time spent on this subject is not spent in vain. Diphtheria. —The Schick test was given to 1,180 men in November to determine their susceptibility to diphtheria. Three hundred and six men, 27 per cent, showed a positive reaction. (The doubtful cases were counted positive.) To these men a prophylactic dose of diphtheria toxin-antitoxin was administered in two doses intra muscularly ; 1 c.c. for the first dose, 1^ c.c. for the second dose. The reaction was quite severe in some cases, but no serious results were observed. We do not expect to obtain any degree of immunity before 618 Vol. XIIL REPORTS. six weeks from the date of administration. This step was taken to preclude any epidemic of diphtheria. Athletics. —Athletics have been somewhat neglected here, due largely to the fact that the soil is not suitable for courts or baseball fields. No gymnasium has been provided. During the summer months a baseball team was organized, which played several games with neighboring stations. A basket-ball team was organized in season, which has played several games at different places away from the station. No contest can be held on the station, as there is no gymnasium. Games, boxing matches, and track sports have been held on such occasions as July 4, Thanksgiving, Christmas, etc. The equipment has been supplied by the American Red Cross Society and the Y. M. C. A. Swimming instruction was given during the sum mer months in Jamaica Bay. The men who could not swim were encouraged to avail themselves of this instruction. Sanitation. —The southern quarter of the field is taken up by a swamp which is rather difficult to drain. During the summer months the surface of the water is covered with kerosene every 13 days, which serves to kill the larvae of the culex mosquito. This mosquito is the only type found here. Small ditches are dug through the marsh in which the water collects; this saves oil by lessening the amount of surface ; the marsh should be drained. The total capacity of the various barracks, permitting 450 cubic feet per man, is 810 men. On December 31, 1918, there were 1,019 men, showing that the barracks were overcrowded by 209 men. These men were quartered in tents as long as the weather permitted. A very strenuous effort has been made throughout the year by the medical officer to prevent more men being quartered in the barracks than what was intended, but he met with only partial success except during the influenza epidemic. The tendency throughout the year has been to send more men here than could be properly quartered. A daily sanitary report in writing has been made to the commanding officer showing the cubic area, capacity, complement, and condition of each barracks. It is recom mended that the station complement be limited to 800 men. The men are well supplied with clothing suitable for the func tions which the various details perform. The men that are flying have fur-lined suits, gloves, shoes, etc., sufficient to protect them from exposure. The men on the beach who are in the water are supplied with rubber boots. All other details are equipped accord ingly. The texture and durability is apparently satisfactory. There is no ship's laundry provided as yet, but there is one contracted for. A wash room is provided that will accommodate 100 men at a time. It is supplied with both hot and cold fresh water. Naval Medical Bulletin No. 3, July, 1919. Ford automobile converted into ambulance for four patients in litters. S»a sled held in readiness for rescue work when flying machines are in the air. A hospital corpsman is on board with first-aid equipment. No. 8. REPORTS. 619 Sick bay.—This building is situated on the east side of the main street near the central part of the station yet far enough from the shops and hangars to avoid annoyance to the patients by the noise caused by the machinery. The building is a one-story frame struct ure. It is well equipped with windows and doors and heated by hot-water radiators supplied by the main station plant. This is sufficient and well regulated. Light, both natural and artificial, is sufficient. The electric light is supplied by the main plant. Ventila tion is ample. The building is finished with yellow pine which is kept in a neat condition by frequent applications of varnish. The laboratory, toilets, bathrooms, and diet kitchens are finished with white enamel. There is no dental surgeon attached to the station. During the first half of the year the men requiring such attention were sent to the navy yard at Brooklyn, N. Y., for treatment, a practice which consumed a lot of time and was expensive. For the past few months a hospital apprentice, first class, who is a graduate dental surgeon, has done most of this work. We have no dental supplies and are unable to requisition for any, which forces him to use his own in struments. He has no other duties. The plan has worked out very nicely. The present sick bay would be quite adequate to take care of the sick on a station with a complement of 120 men for which the one in question was constructed; but to care for the sick among 1,200 men is almost impossible. It is evident that isolation is next to im possible with only two wards. The men are isolated by means of screens at present. We have so far found some way around this difficulty, but we realize the pressing need of more room' to isolate patients. Patients who can not be cared for in the sick bay are transferred to the United States Naval Hospital, Brooklyn, N. Y., which is 32 miles distant, for treatment. This is done by means of an ambulance which was presented to the medical department of the station in July by the American Red Cross Society. This ambulance is of the Ford type; it is equipped, in a way, to carry four patients. The patients are placed on litters of Army style, which fit this type of ambulance. The machine is heated by an apparatus connected with the exhaust from the motor. When there is any aircraft flying a boat is held in readiness to put to sea. This boat is a sea sled which is quite rapid. A hospital apprentice is assigned to this boat with first-aid equip ment at all times when the operations demand. Every flying machine is equipped with a first-aid and emergency box, and each aviator is supplied with a life-saving jacket. 620 REPORTS. Vol. XIII. The pilots of seaplanes are required to pass a special physical ex amination upon taking up this work. They are closely observed by the medical officer and any man showing signs of " staleness " is asked to refrain from flying until such condition is relieved. Special clothing is issued which serves to protect them from the cold and other unfavorable conditions. Much complaint was made by these men at the time the Liberty motor came into use about the tremendous noise made by the ex haust, as tinnitus aurum, headaches, vertigo, and other symptoms were experienced. A preparation of absorbent cotton, wool fat, and powdered acacia, was used to occlude the external auditory canal. This relieved the annoyance. General hygienic conditions. —The grounds are covered with a white sand, which is very disagreeable when there is any wind, as it blows in the face and eyes, and into the barracks and mess hall. This is being partially overcome now by coating the sand with 6 inches of cinders in the vicinity of the buildings. At different times during the year the grounds have become littered with rubbish, which condition was of a temporary nature. Sewer system. —Most of the buildings, all of those, in fact, which have been constructed since July, including the mess hall and three barracks, are without sewer connections. This results in a very un satisfactory condition, as the water closets, baths, or washrooms must not be used, causing a dire shortage of the above necessities. Water.—The water is that supplied by the city of New York, which is satisfactory from a sanitary consideration. EXAMINATION OF 1,000 MEN TO DETERMINE CHANGES IN WEIGHT UNDER SERVICE CONDITIONS.^ By H. Halstead, Lieutenant, and E. A. Mallon, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. While examining men for release from the Navy and placing them on inactive service we noticed that, taken as a whole, they were in much better physical condition than were the recruits we examined some months or a year or two ago. This led us to question a number of them, and we found that a very large percentage had gained weight and were in better physical condition than on enlistment. This interested us greatly, so we re solved to weigh the men at the time of final examination and compare this weight with their respective weights on their entrance into service. The gain or loss of weight was used as the index of their gain or loss in well being, because it was the only accurate index we 1 Conducted at U. S. Naval Training Station, Pelham Bay Park, N. Y. No. 8. REPORTS. 621 had. On entry into service only the weight and chest measurements are recorded, and the chest measurements taken by any two men differ so widely that they are of practically no value for comparison. We decided to weigh carefully 1,000 men in order, and base our averages on this number, although some 11,000 men have been re leased from this station. We felt that a thousand taken in order would be a fair index of the whole. The results of this experiment were so interesting to us that we felt that they might be interesting to others, so we submit our results. As will be seen from reading the averages given below, nearly all the men (81.6 per cent) gained in weight, the gains running up as high as 33 pounds per individual. We feel that even this gain in the average weight does not fairly indicate the enormous benefit that the regular life and wholesome food of the Navy has done these men physically. A great many of the men who lost the most in weight were thereby benefited physically. For instance, there was one man, a heavy-weight prize fighter, who had lost 23 pounds in weight (from 190 to 167 pounds). When asked about this great loss, he said that it had done him a great deal of good, and that he had never been in better condition, which statement was borne out by subsequent events, for one week later we read in one of the morning papers that he had won a professional prize fight. A number of men who came in soft and flabby went out hard and in good condition, although weighing less. Many others who had lost weight gave the history of just re covering from influenza, sometimes complicated by pneumonia. Other impressions that we gained by simply questioning the men who had gained or lost weight, was that those whose time had been largely spent in stations in England, Ireland, and Scotland, gained less than those in France, and those in France less than those sta tioned in this country, or on our ships, but this is only an impres sion as no statistics were kept on this point. A large majority of these men had been stationed overseas. As was to be expected, a greater percentage of the younger men gained weight, and they gained a greater amount per man. This is largely due to the fact that quite a number of the older men were overweight on enlistment. We divided our figures into the various age periods because we thought it would add interest. One of the most surprising things to us was that there were so few older men — only one man over 45 years of age in a thousand ; one-half the men were between 21 and 25 years of age. All of these men were weighed on or between February 7 and 11, 1919. In the Bulletin No. 61 (Division of Sanitation) of Notes on Preventive Medicine for Medical Officers, United States Navy, dated February 15, 1919, there is a quotation from an article by 622 Vol. XIII. REPORTS. Lieutenant F. I. Ridge, Medical Corps, United States Navy, from the Great Lakes Bulletin, on the " Gain in health shown by men leav ing service," in which he reports a series of 500 men examined on leaving service. Their average gain in weight was 5.3 pounds, which is 0.533 pound less than the average gain in our series. The greatest single gain was 33 pounds. This man was between 21 and 25 years of age. Thirty-nine men gained over 20 pounds apiece. Our figures are appended. Ages. Gained. Lost. Stationary. Total. Under 21 136 7 63 45 24 1 22 16 144 21 to 25 427 512 25 to 30 195 256 30 to 35 44 2 70 35 to 45 14 4 18 Total 816 143 41 1,000 Percentage of men gaining weight 81. 6 Percentage of men losing weight 14. 4 Percentage of men maintaining stationary weight 4.1 Total 100. 0 Average gain in weight of all men, 5.833 pounds. Average length of time in service, 9 months 10 days. Average gain in weight of all men who gained, 8.2 pounds. Average loss in weight of all men who lost, 6 pounds. Under 21 years. Men examined. Pounds. Average, pounds. 136 men gained weight 7 men lost weight 1 man maintained stationary weight. M-l 1,427 35 10.49 5.00 Average length of time in service, 7 months 29 days. Average gain of weight of all men, 9.972 pounds. Percentage of men gaining weight 94. 44 Percentage of men losing weight 4. 86 Percentage of men maintaining stationary weight 69 Total 99. 99 No. 3. 623 REPORTS. Ages 21 to 25 years. Men examined. Pounds. Average, pounds. 427 men gained weight 63 men lost weight 22 men maintained stationary weight. 512 3.504 265 8.25 4.20 Average length of time in service, 7 months 18 days. Average gain of weight of all men, 6.32 pounds. Percentage of men gaining weight 83. 4 Percentage of men losing weight 12. 3 Percentage of men maintaining stationary weight 4. 3 Total 100. 0 Ages 25 to SO years. Men examined. Pounds. Average, pounds. 195 men gained weight 45 men lost weight 16 men maintained stationary weight. 256 1,412 394 8.2 8.7 Average length of time In service, 11 months 3 days. Average gain In weight of all men, 3.97 pounds. Percentage of men gaining weight 76. 17 Percentage of men losing weight 17. 57 Percentage of men maintaining stationary weight 6.24 Total 99. 98 Ages SO to 35 years. Men examined. Pounds. Average, pounds. 44Jmen gained weight 24"men lost weight 2 men maintained stationary weight. 70 237 150 5.38 6.25 Average length of time In service, 9 months 27 days. Average gain of weight of all men, 2.67 pounds. Percentage of men gaining weight 62.8 Percentage of men losing weight 34. 2 Percentage of men maintaining stationary weight 2. 85 Total 99. 85 624 REPORTS. Vol. XIII. Ages 85 to 45 years. Men examined. 14 men pained weight. 4 men lost weight. . . . 18 Average length of .time in service, 11 months 10 days. Average gain in weight of all men, 6.04 pounds. Percentage of men gaining weight 78 Percentage of men losing weight ' 22 Total 100 MEASURES TO PREVENT POISONING BY TRINITROTOLUOL.' By A. Saska, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. Approximately 80 men were engaged in the T. N. T. plant at this depot during the war, the number having now decreased to about 60 men. The T. N. T. plant is a one-story building. It is well lighted, clean, and naturally well ventilated. The T., N. T. dust occurs in negligible quantities. A sanitary wash room and shower baths with an abundance of soap and clean towels are provided and the men are strongly advised to avail themselves of them. Gloves, masks, and " casein " hand varnish are at their disposal. The wearing of gloves is condemned, for gloves induce perspiration of the hands, permit the entrance of the T. N. T. underneath, and promote absorption. Only men handling hot T. N. T. are permitted to wear gloves. The wearing of masks is permissible. Protective hand varnish, " casein," which is a mixture of fat-free casein, borax, and water is always available, and the workmen are required to varnish their hands before starting to work. The present medical officer " patrols " the plant every week with a view to observing the condition of the men. Whenever there is the slightest suspicion of ill effects of T.«N. T. on the workmen they are at once ordered up for a thorough examination at the dispensary. The practice of the present medical officer is to remove all men from the T. N. T. plant who present the slightest evidence of T. N. T. intoxication. A typical mild case presents the following symptoms: Bitter taste in mouth, slight frontal headache, perverted appetite, and " red " urine. Objectively slight pallor of the lips is observed. In more severe cases there is 1 Extract from the Annual Sanitary Report of the United States Naval Ammunition Depot, Fort Mifflin, Philadelphia, Pa. No. 3. REPORTS. 625 general weakness, shortness of breath, nausea, lack of appetite, cramps in the calves, moderate pallor of face, cyanosis of lips and fingers. Only two cases have been seen of the latter class. There have been no cases here approaching "toxic jaundice" or "aplastic anemia," because the men are closely watched and are not permitted to remain in the T. N. T. plant until that stage of poisoning is attained. The men removed from the T. N. T. plant are transferred to some other work at this post, preferably in the open air, and are required to report to the medical officer after the lapse of one month. At this time they are again examined and if deemed fit they are per mitted to return to the T. N. T. plant, otherwise they are kept out until their condition as determined by repeated monthly examina tions warrant their return to the T. N. T. plant. Most of the cases usually clear up in a month if the men are transferred to outdoor work and are not permitted to handle T. N. T. In August 23 men were taken out of the T. N. T. plant, and of these 17 were permitted to return to work one month later, while the remaining six were permitted to resume their work two months later. ' There is no definite period of T. N. T. tolerance or intolerance. It varies with each individual workman. The period depends upon his use or heglect of the hygienic measures offered for his protection and upon his susceptibility. Persons who were engaged in the T. N. T. plant but two weeks had to be taken out by reason of rapid development of symptoms characteristic of T. N. T. poisoning, while others have been continually at work in the plant without manifest ing any deleterious effects of the poison. Race does not seem to play any part as a predisposing cause. SUGGESTED MODIFICATIONS OF THE MARINE SHOE.' By W. L. Mann, Lieutenant Commander, Medical Corps, United StateB Navy. The fitting of shoes for the enlisted man and the care of his feet is a very important matter and should be seriously considered by the officers of the Marine Corps. All the men going overseas were carefully fitted with shoes at the marine barracks, Quantico, Va., and foot measurements were carefully entered in their service records until the advent of the influenza epidemic made it necessary, tempo rarily, to discontinue this work. Plans were made, however, to resume it and one building has been devoted exclusively to this purpose and an elaborate fool-proof system of fitting shoes inaugurated. In order to illustrate the importance of this subject it may be men tioned that experience justifies the belief that if the entire present ' Extract from Annual Sanitary Report, Marine Barracks, Quantico. Va., 1918. 626 Vol. XIII. RKPOKTS. personnel of this post were required to make a forced march to the firing line, for three days in heavy marching order, at least 1,000 men would probably be incapacitated by foot injuries. Parentheti cally it may be remarked that observations at this post indicate that a certain percentage of foot disorders, particularly abrasions near the tendo Achillis, are due to the leggings. A tentative outline of the features desirable in the military shoe includes (a) that the heel of the foot rest in a concavity; (b) that the transverse arch be supported by a convexity; (c) that the inner border of the foot be better fitted; (d) that the inner aspect of the heel be thicker; (e) that the sole of the shoe be canted out ward; (/) that the inner border of the heel extend forward for the increased support of the instep. The big toe, the ball of the foot, and the heel must be in one straight line. The shoe must be roomy in front and fit snugly at the back. The heel of the shoe should contain a concave rubber pad as a shock absorber. The toe should C /NT^--^ ^> be plain without tip or box. The \l\ / shoe should be unlined and laced up **^..3taoJL_===^27 through eyelets and not over hook- lets. The wearing parts of the shoe should be protected by hobnails and heel cap. The uppers should be de signed to minimize friction. It is generally admitted that the present garrison shoe of the Marine Convexity of sole; indentation of Corps has many commendable fea- lnner border. tures, but certain defects warrant an attempt to improve the type. The modern tendency is to specialize in types and provide a gar rison shoe, a trench shoe, and a field shoe, etc.; consequently two styles are suggested: (1) Semi-dress cantonment style of relatively light weight for use on parade or on liberty . In this shoe the smooth side should be exposed; (2) heavier field shoe intended for rough use as on extended marches. The rough side of the leather should be exposed. The human foot is distinctly asymmetrical, no two sides or sur faces being at all similar, so that in the average shoe the irregular surface of the foot rests directly on the plain surface. By putting the hand inside of an old shoe one can feel how the upper surface of the sole has in a measure adapted itself to the bottom of the foot. With the average shoe the weight of the body is supported as on a tripod at three points of contact —the heel, the ball of the big toe, and the outer aspect of the foot. A judicious increase in the number of points of contact will manifestly reduce the pounds pressure per No. 3. 627 REPORTS. square inch and lessen the danger of foot injuries. With the idea of making the upper surface of the sole conform as nearly as pos sible to the irregularities of the under surface of the foot the inner surface of the shoe at the 'heel should be concave instead of plain. The tension of the of the uppers inclines to convert the plain surface of the sole, where it supports the transverse arch of the foot, into a concavity. The shoe should therefore be built with a slight convexity at this point. Such an alter ation should minimize the tendency to rae- tatarsalgia. The indentation of the sole at the instep should be considerably deep ened and the heel of the shoe should be thickened along the inner edge and carried slightly forward. The sole of the shoe should be slightly canted outward. These changes will increase the support of the in step and weight-bearing area. The shoe con structed with these modifications will favor the unhampered use of the muscles of the foot, the weakening of which is one of the causes of flat feot. The human foot is not a passive means of support but an assemblage of muscles, ligaments, and l)ones having a definite function. The intricate muscles of the foot are designed to expand and contract at each step. The last of this shoe is really a modified "Munson last;" the hinder portion of the shoe is made thinner to give a snug fit. On the march the heel of the booted foot strikes the hard ground at a rate of nearly 7,000 times per hour, each step causing some jar to the spine. This repented concussion of the spinal column is not without influence in the production of fatigue. To reduce it a concave rubber inset in the heel of the shoe is recommended. The use of some plastic composition in the sole, as a substitute for cork filling, will automatically help to adapt it to the irregu larities of the bottom of the foot. The flexibility of the shank should be increased. It is needless to remark that this improvement could with pro priety be applied to the Navy shoe. The men who have to stand long watches at sea and move about on the hard iron decks of a 116025—19 16 Concavity for heel with rubber inset. 2. Trans verse aroh of foot. Showing suggested changes : 1. Heel carried forward, iuuer side. 2. Greater in dentation of inner border. 3. Sole canted out. 628 REPORTS. Vol. xm. ship ; who have to march in parades over cobblestones and who do a very considerable amount of walking when on liberty require as good a shoe as the marines. TEN MONTHS OF X-RAY WORK AT A NAVAL HOSPITAL. By C. H. Jennings, Lieutenant, Medical Corps, United States Naval Reserve Force. The X-ray equipment of this hospital was found to consist of an excellent transformer, a table with tube stand attached, a vertical fluoroscope, and a stereoscopic vie'wing apparatus. Plates were kept on the floor above, and the dark room w!t*4jj the cellar directly under the X-ray room. Working on three floors entailed considerable lost motion, and the tube could not be safely excited when undeveloped plates were in the dark room. To overcome these drawbacks a door was cut from the X-ray room to a small adjoining areaway, which provided a dark room. An illuminating panel was built on one of the side walls. This arrangement has fulfilled all requirements ex cept for the study of cases which could not be transported to the X-ray room. Portable apparatus is especially desirable vfor the study of chest cases and of fractures requiring sustained traction. During the 10 months, including April. 1918, and January, 1919, 3,072 roentgenograms were made of 1,036 patients, 154 cases were examined fluoroscopically, and 20 were given therapeutic roentgeni- zations. The 684 dental films and 176 dental plates furnished con vincing evidence of the prime importance of intelligent care of the teeth. Many apical and marginal abscesses were found. Numerous cases, varying from slightly troublesome pains to grave rheumatoid conditions, have cleared up after these sources of absorption had been remedied. One man whose health record showed 52 sick df.ys with a diagnosis of frontal sinusitis was promptly relieved by the extraction of an impacted third molar. This was the worst of three similar cases, none of which showed any cloudiness in the sinuses. It is evident that frequent dental inspections and the prompt remedy of beginning dental troubles would be a great benefit to the Navy. The X-ray was frequently used to determine the presence or absence of fractures and to verify the position of fragments within the perma nent dressing. Perhaps the most interesting case was a fracture dis location of the fourth and fifth cervical vertibrae. Fracture of the carpal scaphoid is an injury very troublesome to a medical officer and can be positively recognized only by means of the X-ray. Early fixation offers the only hope of bony union. They are too frequently treated as sprains, with resulting nonunion and perma nent disability of varying degrees. Eight cases have been demon strated at this station. No. 3. BEPOKTS. 629 Tuberculosis of the hip was demonstrated five times, and of the wrist and ankle, one each. The lungs should always be examined in such cases. Three of the above-mentioned cases showed active pul monary tuberculosis. An extensive syphilitic osteitis of the humerus nearly escaped detection. This man was referred for X-ray to remove the last doubt before ordering him back to duty. Painful backs are a continuous source of annoyance and uncertainty to medical officers. It is often impossible to distinguish the mal ingerer from the real sufferer. Severe myalgias may disappear without treatment. They usually react promptly when energetically baked. Sacro-iliac strain may be very painful, but if proper strap ping does not relieve this condition may be ruled out. Sacro-iliac luxations are easily demonstrated by X-rays; however, this is hardly necessary, as the pain is too severe and the luxation too apparent. Lumbosacral luxations and dislocations occur more frequently than was formerly supposed. These conditions may be indicated in antero posterior views, but good lateral X-rays are needed for a positive diagnosis. Anomalies in the bony structure are fairly frequent in this region and much uncertainty exists as to their accountability for the symptoms. Can any significance be attached to the fact that they are most frequently recognized incidental to examination of the urinary tract ? Urinary calculi, displaced kidneys and kinked ureters, may be eliminated by means of X-rays. The appendix was the cause in one case. After elimination of the urinary tract and osseous sys tem, and failure to discover any possible source for absorption, the gastro-intestinal tract was investigated. A long appendix was found adherent high up behind the caecum. The young man said he had had no trouble with his back five months after appendectomy. Hypertrophic arthritis of the spine demands a careful search for a focus of absorption. This is also true whenever there is no visible cause for pain. No man should be labeled a malingerer until all possible sources of absorption have been eliminated. In this con nection it has been customary at this hospital to examine the teeth, tonsils, accessory sinuses, lungs, geni to-urinary tract, and alimentary tract. Fracture dislocations are usually accompanied by deformity and marked symptoms. Compression fractures, may, however, be un suspected until the patient has been on his feet for some weeks, when a spinous process is noticed, and a lateral X-ray shows a wedge- shaped body. Fracture of transverse processes of the lumbar spine occurs more frequently than is generally supposed, and several such cases have been found at this hospital. Obviously no crepitus can be elicited ; there is no ecchymosis and little or no limitation of motion. There are no symptoms, save pain, intensified by motion, and points tender to deep pressure. X-rays are obviously necessary for a diag 630 Vol. XIII. REPORTS. nosis. That these fractures are all caused by muscle stress of the ilio-psoas is well illustrated by the following histories. A gunner was catapulted about 4 feet in the air by a heavy safe landing on the opposite end of a skid. A seaman was thrown about 50 feet by the sudden straightening of a hawser. One man hurt at a railroad crossing lost a leg and a finger and at the same time sustained frac tures of the frontal bone, a rib, third and fourth left lumbar trans verse processes, and a compression fracture of the twelfth dorsal. There was no evidence of direct violence to the spine. The most significant case was that of a fireman trying to break out a large chunk of coal. He said he was standing in rather an awkward position, one hand on the handle, the other near the blade of the shovel, pulling from the side and front, when something Miapped in the back. Another fireman, with a very similar story, presented a distinct tender point elicited by deep pressure just below the last rib on the right side, and complained of acute pain when he tried to bend to the lower spine. On the X-ray plates the ilio-psoas muscles were sharply defined, save that portion above the right first trans verse process, which was apparently ruptured. No fracture was demonstrated. Late plates of three of the above cases, treated by early fixation, show complete bony union. X-rays of sinuses and mastoids have been helpful in establishing a diagnosis and in determining landmarks for operations. Foreign bodies were scarce, only 12 being localized, four being in eyes. One calculus was located in a ureter. One case sent in as an enlarged prostate proved to be a vesical calculus the size of an ostrich egg ! No one save an experienced roentgenologist should be trusted to give authoritative opinions on X-ray findings. This is especially true regarding investigations of the alimentary , tract and of the heart and lungs. Complete gastro-intestinal investigations of 45 cases were con ducted. No pathology was demonstrated in '2'i of these. Of the pathological cases, one was carcinoma at the pylorus, and three were duodenal ulcers (all accompanied by pathological appendices). Twelve appendices were operated on and the X-ray findings verified. In two cases a pronounced visceroptosis probably accounted for the constipation and gastric symptoms. Two cases had a marked block ing due to post-operative adhesions. One case, also post-operative, showed a marked delay in the terminal ilium, and caused a sharp kink near the ilio-cecal valve. Hearts were studied both fluoroscopically and by means of the 6-foot plate. A marine who had lost his voice was referred for a possible mediastinal growth. Fluoroscopically could be seen a huge pulsating aneurysm of the aorta. Wassermann plus 3. No. 3. 631 REPORTS. It was very interesting to compare clinical findings with Roentgen findings on lungs. One case was particularly interesting. This man came in with a running ear of long duration, and the mastoid in volved. His tonsils were removed ; the discharge from the ear censed, and the mastoid was much improved. Subsequently a slight rise in temperature, accompanied by a cough, caused him to be referred to the X-ray department. No chest signs were found by the several men who examined him clinically. It was surprising to find an extensive left pneumothorax displacing the heart well into the right chest, the left diaphragm being 4 inches lower than the right. Laboratory report on sputum the next day showed many acid- fast bacilli. A few weeks later, respiration became very much em barrassed. Air pressure was reduced by means of a small needle. A few days later a rib was resected and a large quantity of pus e\ acuated. I shall always remember with pleasure the work at this hospital. The Navy spirit of cooperation, so ably instilled by the commanding officer, will, I hope, always remain with, and be a groat help to, all the memhers of Unit No. 9. DENTAL WORK AT THE NAVY YARD, NEW YORK. By K. IUkhek, Lieutenant Commander, lieutal C.'onw, l.'nited Slates Navy. The Form K dental report for the first quarter of 1919 embraces a greater amount of work than was ever reported before —1,637 cases of all classes—for this station. Besides these 1,637 cases there were 104 additional patients who were examined but not treated, making a total of 1,741 different patients handled during the quarter. The small proportion not treated —just 6 per cent—is particularly gratifying. Of this 6 per cent probably one-half did not require any treatment. The remainder either refused treatment or failed to keep their appointments due to being transferred, the sailing of their ship, or through indifference. The patients during the quarter came from "213 ships and stations. Attention has been paid to the sailing dates of ships, and patients of ships preparing for extended cruises have been given particularly expeditious treatment. This excellent record has been made possible by the organization of the dental department which permitted the dental officers to attain a high degree of efficiency, and which permitted an even distribution of patients, and by the excellent spirit of willingness and cooperation shown at all times by every officer and enlisted person. Sickness of officers and enlisted men and shortage of enlisted personnel were fac tors which prevented further accomplishments. 632 vol. xm. REPORTS. h mm ii ! mm* a I mm k I 888888 10" c^f—*^ OS X X iC "Is if * s AS— « S5"0 a — c2 N -' - N - - iiiiii C-f r-" 22SSS8 « si 0 8 Ntorion » «iS . 2q 1 - -r s — vr 10 Stq^, C9— O Irt OS 10 •2s2 « - - si £3 OSSOC1*SOOC«5 M » m « 00 — r- CO© OS - ■ aI a Jlsjll No. 3. BOOK NOTICES. 633 BOOK NOTICES. Landmarks and surface markings of the human body, by L. Bathe Rawling, M. B., B. C, F. R. V. 8. Fifth Edition, reprinted. Paul B. Hoeber, 67-69 Eiist Fifty-ninth Street, New York, 1918. This little volume of ninety odd pages, though it has passed through five editions in England, is perhaps not as well known as it deserves in this country. The text is simply explanatory for a series of very well made anatomical plates. Taken together they afford an extremely handy, rapid method of readily determining some impor tant point. Quarterly medical clinics, issued by Medicine & Surgery Publishing Co. (Inc.), St. Louis, Volume 1, No. 1. The first number of this new publication appeared in January and is devoted to a series of clinical demonstrations and lectures by Frank Smithies, of the staff of the Augustana Hospital, Chicago. The material is good. The clinical method of teaching is particularly valuable for the practitioner because it follows the course he must pursue in unravelling from symptoms often obscure, scant or confus ing the diagnosis which the standard textbook gives at the start in the form of a definition followed by a long and complete list of all the symptoms likely to appear in a large number of cases. A publica tion such as this has little or no permanent value to the physician who did not attend the given clinic in person unless it is supplied with a most elaborate and carefully compiled cross index. It remains to be seen whether the fourth number will contain anything of this kind. The ordinary table of contents is useless. Tech nic of the Carrel method, by J. Dumas and Anne Carrel, translated by A. V. S. Lambert, M. D. Paul B. Hoeber, 67-69 East Fifty-ninth Street, New York, 1917. The method is fully and conscientiously set forth in 77 small pages of large type elucidated by 11 plates. The little book should be of special service in teaching one's assistants and nurses the details of the method. Essentials of surgery, by A. L. McDonald, M. D. J. B. Lippincott Co., Phila delphia, Pa., 1919. This is intended as a textbook for use in the instruction of surgical nurses. Essentials of mf:dicine, by C. P. Emerxon, H. D. Third Edition. J. B. Lippin cott Co., Philadelphia, Pa., 1919. Also a teaching manual very carefully gotten up. Beverages and Their Adulteration, by Harvey W.. Wiley, H. D. Illustrated. P. Blaklston's Son & Co., Philadelphia, Ph., 1919. The author has fully succeeded in his avowed purpose of prepar ing a treatise for the " average, sober-minded, reasonably well-educa 634 Vol. XIII. BOOK NOTICES. ted American citizen who is daily taking a greater and deeper inter est in what he eats and drinks," but the book contains a great deal of valuable information that will be new to the most highly educated person anywhere and is thoroughly readable from cover to cover, being enlivened with bits of history, quotations, anecdotes, and com ments. These and personal observations of the writer impart a •' bouquet " like that of some of the wines described. Of the four hundred-odd pages some 65 are devoted to "'waters," 27 to " mineral waters." 77 to " soft drinks," and '2*23 to various types of " alcoholic beverages"—much of the latter having now mainly a historic inter est for this country. For the next edition the following minor cor rections are suggested. On page 130 write St. Andre des Arts for St. Abdre des Ares; on page 233 change "is" to "are" in the sen tence " is found the vineyards." The French word Pouilles, page 224, to refer to an Italian province, Puglie, is deprecated. Emilia (p. 223) is commonly spelled with one "1" and Charente without a terminal "s" (p. 346). Guynemkb, Knight ok the A IB, by Henry Bordeaux. Yale University Press. 1919. The advbnturk ok like, by H. U . MacKenna. II. A., M. 1). The Macmfllan Co., New York, 1919. Dr. MacKenna wrote this book while serving with British troops in France. Its purpose is to set forth the author's opinion that the goal of nature is life; the aim of life is the development of intelli gence, and the object of intelligence is a knowledge of God. Without preaching, without laying down set rules for thought or conduct, without setting up the confining limits of a definite creed, the author has sought, by marshaling the scientific principles temporarily ac cepted to-day as a working basis, to inspire the reader to look within and without and to think and feel with new intensity. There are no technical minutiae which woidd unfit his little volume for the general reader, yet the author has summarized the researches of Darwin, Lamarck, Haeckel, Huxley, and others and combined them with sug gestive quotations from philosophers and poets into an unformulated argument for hope and endeavor —an argument all the more cogent from being tinged with the emotions inspired by his surroundings in trench and hospital. The first chapter is the least inviting and the opening sentence trite, but the book gains in interest with each page ; and the sketches on the origin of life, the dominant role of intelli gence, heredity, and environment, man's freedom of action, etc., cunipel attention. The little volume should make a special appeal to the physician who desires to abstract himself for the nonce from the busy daily routine and work out from his experiences and observations a philosophy of life. NOTICE TO SERVICE CONTRIBUTORS. When contributions are typewritten, double spacing and wide margins are desirable. Fasteners which can not be removed without tearing the paper are an abomination. A large proportion of the articles submitted have an official form such as letterhead, numbered paragraphs, and needless spacing between paragraphs, all of which require correction before going to press. The Bulletin endeavors to follow a uniform style in headings and captions, and the editor can be spared much time and trouble and unnecessary errors can be obviated if authors will follow in the above particulars the practice of recent issues. This is not only important in special articles, but still more so in reviews. 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 two 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 material supplied for illustrations, if not original, should be accompanied by a reference to the source and a statement as to whether or not reproduction has been authorized. Only the names of actual reviewers for a current number appear. The Bitt.lktin intends to print only original articles, translations, in whole or in imrt, reviews, and reports and notices of Government or departmental activities, official annouttvemeuts, 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. 635 o VOL. XIII NO. 4 UNITED STATES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PUBLICATIONS CAPTAIN J. S TAYLOR, MEDICAL CORPS, U. S. NAVY IN CHARGE OCTOBER, 1919 (QUARTERLY) WASHINGTON GOVERNMENT PRINTING OFFICE 1919 Navy Department, Washington, March 20, 1919. 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. NOTE. Owing to the 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 VII, No. 2, April, 1913. Volume X. No. 1, January, 1916. Volume XI, No. 1, January. 1917. Volume XI, No. 3, July, 1917. Volume XI. No. -1, October, 1917. Volume XII, No. 1. January, 1918. Volume XII, No. 3, July, 1918. Subscription Prick of the Bulletin. Subscriptions should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. Yearly subscription, beginning January 1, $1 ; for foreign subscription add 25 cents for postage. Single numbers, domestic, 25 cents ; foreign, 31 cents, which includes foreign postage. Exchange of publications will be extended to medical and scientific organiza tions, 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 .. vii SPECIAL ARTICLES : Report on the influenza epidemic. By the Staff of the U. S. Naval Hospital, Philadelphia 837 Infectious and contagious diseases. Virgin Islands, 1918. By Lieutenant E. Peterson, Medical Corps, U. S. N 682 Naval ambulance trains in Great Britain. By Captain P. L. Pleadwell, Medical Corps, U. S. N 706 Bone surgery. By Lieutenant Commander A. L. Clifton, Medical Corps, U. S. N__ 718 An epidemic of mumps. By Lieutenant Commander R. B. H. Gradwohl, Medical Corps, IT. S. N. R. P. ; Lieutenant C. F. Carter, Medical Corns, U. S. N. ; Lieutenant W. S. Barcus and Lieutenant (J. G.) H. L. Fougerousse, Medical Corps, U. S. N. R. F \ 723 Constitutional inferiority in the Navy. By Lieutenant T. A. Ratliff, Medical Corps, U. S. N. R. F 728 Acute early appendicitis. By Lieutenant Commander H. E. Jenkins. Medical Corps, U. S. N., and Lieutenant L. A. Will, Medical Corps, U. S. N. R. F 733 Extra-genital chancres. By Lieutenant .T. M. Perret, Medical Corps. U. S. N. R. F 736 Incubation and choice of antigens in the Wassermann reaction. By Lieutenant E. D. Hitchcock, Medical Corps, U. S. N. R. F 740 HISTORICAL: The practice of medicine in Europe during the Middle Ages 747 EDITORIAL : Intangible damage—The "Attitude of the Bureau" 775 IN MEMORIAM : Abraham Jacobi (1830-1919) 781 SUGGESTED DEVICES : The construction of animal cages. By Lieutenant Commander G. F. Clark, Medical Corps, U. S. N 783 A ROTARY TOOTHBRUSH. By Lieutenant Commander H. E. Harvey, Dental Corps, U. S. N_ 783 Equipment of battle dressing station storerooms. By Commander W. S. Pugh, Medical Corps, U. S..N 786 CLINICAL NOTES : Poisoning by bay rum containing wood alcohol. .By Lieutenant N. S. Betts, Medical Corps, U. S. N. R. F 791 Arsenic poisonino following the use of novarsenobenzol. By Lieutenant C. M. Burchflel, Medical Corps, U. S. N 795 in IV CONTENTS. CLINICAL NOTES— Continued. Death following arsphenamine. Page. By Lieutenant A. Goetsch, Medical Corps, U. S. N 797 High temperature in influenza. By Lieutenant (J. G.) P. M. Williams, Medical Corps, U. S. N. R. F 799 Voiding of a bullet from the bladder. By Lieutenant Commander F. H. Bowman, Medical Corps, U. S. N_ 799 Depressed fracture of frontal bone. By Lieutenant A. W. Hoagland, Medical Corps. V. S. N 800 Colon ptosis. By Lieutenant G. U." Plllmore, Medical Corps, U. S. N" 01 Ideal tonsil operation. By Lieutenant Commander A. H. Robnett, Medical Corps, U. S. N 06 PROGRESS IN MEDICAL SCIENCES : General medicine. — Bacillus botullnus poisoning 800 Surgery.—Pathological possibilities of neglected gallstone disease 811 Hygiene and sanitation. — Historical Inquiry into the efficacy of lime juice for the prevention and cure of scurvy —The ship's water supply 813 Pathology, bacteriology, and animal parasitology. — Vaccine treat ment of filarial lymphangitis in British Guiana —Blood destroying substance in ascarls lumbrlcoldes 817 Chemistry and pharmacy. —New titration method for the determina tion of uric acid in urine — Modifications of Benedict's and Folin's quantitative sugar methods—Food ingestion and energy trans formations with special reference to the stimulating effect of nutrients —Nutritive factors In animal tissues 819 Eye, ear, nose, and throat. —Methylene blue in purulent discharge from the eye socket—Prophylactic use of pitultrin in nose and throat operations under general and local anesthesia —Colloidal manganese in gonorrheal ophthalmia —Hemorrhage following the removal of the tonsils and its treatment 821 NOTES AND COMMENTS: The devastation of France— Peking Medical School —Vaccination in California — Internal decoration of hospitals —Interallied confer ence on medical aspects of aviation —U. S. Interdepartmental Social Hygiene Board—War Risk Insurance Bureau —Boy Scouts — Legal control of motion pictures — Influenza statistics, Great Lakes, 111— Sixth Division, Bureau of Navigation 823 REPORTS : Naval railway battery in France. By Lieutenant Commander C. S. Stephenson, Medical Corps, U. S. Navy 831 Submarine Division Five. By Lieutenant Commander E. W. Brown, Medical Corps, U. S. N. 846 Preparation of artihuman amboceptor. By Lieutenant Commander G. F. Clark, Medical Corps, U. S. N., and Chief Pharmacist's Mate A. J. Mouton, U. S. N 853 Psychiatric work among recruits. By Lieutenant F. L. McDaniel, Medical Corps, U. S. N 854 Bacteriological experiments with acriflavine. By Lieutenant H. B. LaFavre. Medical Corps, U. S. N 858 CONTENTS. V REPORTS —Continued. AcRlFLAVINE IN THE TREATMENT OK GONORRHEA. Page. By Lieutenant C. M. Burchflel, Medical Corps. U. S. N 869 The army bedside x-ray unit. By Lieutenant H. R. Coleman, Medical Corps, U. S. N 866 Hospital service in Haiti. By Lieutenant Commander H. F. Lawrence, Medical Corps, U. S. N 869 Organization of the U. S. naval hospital, Charleston, S. C. By Commander W. M. Garton and Lieutenant Commander G. W. Calver, Medical Corps, U. S. N 876 BOOK NOTICES 897 NOTICE TO SERVICE CONTRIBUTORS 901 INDEX 903 PREFACE. The publication and issue of a quarterly bulletin by the Bureau of Medicine and Surgery contemplates the timely distribution of such information as is deemed of value to the personnel of the Medical Department of the Navy in the performance of their duties, with the ultimate object that they may continue to advance in proficiency in respect to all of their responsibilities. It is proposed that the Naval Medical Bulletin shall embody matters relating to hygiene, tropical and preventive medicine, pa thology, laboratory suggestions, chemistry and pharmacy, advanced therapeutics, surgery, dentistry, medical department organization for battle, and all other matters of more or less professional interest and importance under the conditions peculiar to the service and pertaining to the physical welfare of the naval personnel. It is believed that the corps as a whole should profit, to the good of the service, out of the experience and observations of the individual. There are many excellent special reports and notes beyond the scope of my annual report being sent in from stations and ships, and by communicating the information they contain (either in their entirety or in part as extracts) throughout the service, not only will they be employed to some purpose as merited but all medical officers will thus be brought into closer professional intercourse and be offered a means to keep abreast of the times. Reviews of advances in medical sciences of special professional interest to the service, as published in foreign and home journals, will be given particular attention. While certain medical officers will regularly contribute to this work, it is urged that all others cooperate by submitting such abstracts from the literature as they may at any time deem appropriate. Information received from all sources will be used, and the bureau extends an invitation to all officers to prepare and forward, with a view to publication, contributions on subjects relating to the profes sion in any of its allied branches. But it is to be understood that the bureau does not necessarily undertake to indorse all views and opinions expressed in these pages. W. C. Braisted, Surgeon General United States Navy. vn U. S. NAVAL MEDICAL BULLETIN Vol. XIII. October, 1919. No. 4. SPECIAL ARTICLES. REPORT ON INFLUENZA BY THE STAFF, U. S. NAVAL HOSPITAL, PHILADELPHIA, PA. Section I. GENERAL STATISTICAL STANDPOINT. By A. B. Clifford/ Commander, Medical Corps, United States Navy, and T. C. Kbllt and B. A. Thomas, Lieutenants, Medical Corps, United States Naval Reserve Force. This report is based on an analysis of 900 cases of influenza ad mitted to the U. S. Naval Hospital, Philadelphia, during the recent epidemic of that disease. The date of the first admission was Sep tember 16, the majority being admitted prior to October 15, with a few scattered cases with subsequent admission dates to November 15. This does not include the whole number of cases admitted during the epidemic, but comprises the first 900 men to be discharged from this hospital, and the percentage mortality, while accurate for the series under discussion, is somewhat high for the whole number ad mitted during the epidemic, as we have of necessity included most of the deaths which occurred during the period mentioned, but have left out many cases which recovered, which have been on leave and consequently were not discharged from the hospital. For purposes of critical study, it has been deemed advisable to divide our cases into four groups: Group I, including those cases which were admitted to the hospital within 24 hours of the onset of their illness ; Group II, those admitted within 48 hours ; Group III, those admitted within 72 hours; and Group IV, all those admitted at a later period of their infection. We have felt that by this means we would be able to show conclusively the great desirability of the early institution of rest and proper medical treatment in this disease, and the fallacy, which is more or less prevalent, of underestimating the seriousness of the possible consequences of delayed rest in bed under 637 838 CLIFFORD, KELLY, THOMAS INFLUENZA. Vol. XIII. proper supervision. The longer treatment was delayed, the more severe was the illness and the greater the liability to a subsequent pneumonia with probably fatal termination. Practically the whole number of deaths occurring in Group I were in those cases which came in during the beginning of the epidemic, when great numbers of practically moribund patients were admitted and when seemingly the virulence of the epidemic was at its height. These cases gave a history (whenever it was possible to obtain one) of being sick prob ably only 24 hours, and were accordingly placed in their proper grouping; but they showed no evidence, even from the beginning, of being in the slightest degree amenable to treatment, and pursued a rapid and progressive course toward death. This virulence of the epidemic occurring at its beginning accounted for a greater propor tion of the deaths in all the groups as, after the first three weeks, there was a marked diminution both in the number of patients and the severity of their illness. In the total number of 900 cases there were 885 whites, 11 negroes, and 4 Filipinos, about the average proportion of races among the enlisted personnel of the Navy in this district. Taking the cases up serially, it was found in Group I that the most frequently men tioned chief complaint was headache, which occurred in 52.2 per cent of the cases. Next in order of frequency were chills, general muscular pains, cough, backache, sore throat, weakness, and coryza. In Group II, headache was again the most frequently mentioned chief complaint, occurring in 34 per cent of the cases, and followed by general muscular pains, cough, chills, backache, coryza, sore throat, and weakness. In Group III, headache occurred in 32.7 per cent of the cases, followed by chills, general muscular pains, cough, coryza, backache, sore throat, weakness, and nausea. In Group IV, head ache was again the most common chief complaint, occurring in 30.6 per cent, followed by cough, chills, general muscular pains, backache, weakness, coryza, sore throat, nausea and vomiting, and dyspnea. Of the symptoms in Group I headache predominated, being men tioned in 82.6 per cent of the cases, followed in order of frequency by cough, general muscular pains, chills, backache, weakness, sore throat, coryza, nausea, dyspnea, vertigo, vomiting, and earache. In Group II, headache still predominated, being mentioned in 78 per cent; then cough, general muscular pains, chills, backache, weak ness, coryza, sore throat, dyspnea, nausea, vomiting, vertigo, and earache. In Group III, headache and cough were about equally men tioned, occurring, respectively, in 76 per cent and 75.8 per cent of the cases. They were followed in order by general muscular pains, chills, backache, dyspnea, weakness, coryza, sore throat, nausea, !»•. ■». CLIFFORD, KELLY, THOMAS —INFLUENZA. 639 vomiting, vertigo, and earache. In Group IV, cough occurred the most frequently in 83.4 per cent of the cases, followed by headache, general muscular pains, chills, weakness, backache, dyspnea, nausea, coryza, sore throat, vomiting, vertigo, and earache. On examination the physical sign most frequently encountered in Group I was rales, which occurred in 51.9 per cent of the cases, fol lowed by congestion of the throat and eyes and nose, and in a rela tively small number of the cases by cyanosis, toxemia, enlargement of the superficial lymphatic glands, pleuritic friction, herpes, and erythema. Delirium occurred in 23.3 per cent of the cases of pneu monia in this group, and 21 per cent of the cases in this group showed negative physical signs. In Group II rales occurred in 55.8 per cent of the cases, followed in order of frequency by congestion of the throat and eyes and nose, and in a smaller number of cases by toxemia, cyanosis, delirium, pleuritic friction, enlargement of the superfiicial lymphatic glands, erythema, and hiccough. In 15 per cent of the cases physical signs were negative and delirium occurred in 54.8 per cent of the cases of pneumonia. In Group III rales were still the most frequently found physical sign, occurring in 74.4 per cent of the cases, followed by congestion of the throat, toxemia, con gestion of eyes, cyanosis, delirium, congestion of nose, pleuritic fric tion, enlargement of the superficial lymphatic glands, herpes, and jaundice, and erythema. Four per cent of the cases showed negative physical signs, and delirium occurred in 57.1 per cent of the cases of pneumonia. In Group IV rales occured in 74 per cent of the cases, followed by toxemia, cyanosis, congestion of the throat, eyes and nose, delirium, pleuritic friction, herpes, enlargement of the super ficial lymphatic glands, jaundice, erythema, and hiccoughs. In this group 59.4 per cent of the cases of pneumonia showed delirium and 9.8 per cent of all the cases were negative on examination. COMPLICATIONS. The complication most frequently encountered in Group I was bronchitis, which occurred in 43.4 per cent of the cases, followed by pneumonia, which occurred in 8.5 per cent. Of the pneumonias, broncho-pneumonia was found in all the cases except one, and was almost distributed between right or left sides and both sides. The one case of lobar pneumonia occurred on the left side, and in both types the lower lobe posteriorly was the site selected. Of the other complications, epistaxis was the most frequent, occurring in 5.6 per cent of the cases. Myocarditis was a constant accompaniment of the fatal pneumonias. Pleurisy occurred in the same percentage as myocarditis (2.8 per cent), but in no case in this group was empyema found. Six cases showed a true nephritis and five an otitis media. 640 CLIFFORD, KELLY, THOMAS —INFLUENZA. Vol. XIII. There were two cases each of endocarditis, sinusitis, and marked abdominal distention, and one case each of meningitis and pulmonary hemorrhage. In Group II bronchitis was still the most frequent complication, occurring in 40 per cent of the cases, followed by pneumonia in 15.7 per cent. Of these 14.3 per cent were broncho-pneumonias and 1.4 per cent lobar pneumonias. The distribution of the broncho-pneu- nionias was about equally divided between right and left sides, with a smaller percentage of double, and in the lobar pneumonias two were right sided and one left. Of the other complications, epistaxis was next in frequency, followed by myocarditis, nephritis, pleurisy, otitis media, and abdominal distention. In Group III pneumonia was the most frequent complication, oc curring in 42.2 per cent of the cases, and of these 39.5 per cent were broncho-pneumonias and 2.7 per cent lobar pneumonias. Of the broncho-pneumonias there was an almost equal distribution between right and left sides and double. The lobar pneumonia occurred twice on the right side and once on the left. The next most frequent com plication was bronchitis, occurring in 31 per cent, followed by myo carditis, epistaxis, nephritis, pleurisy, otitis media, and abdominal distention. There was one case each of retention of urine, endocar ditis, and epididymo-orchitis. In Group IV the most frequent complication was pneumonia, which occurred in 42.8 per cent of the cases, of which 40.4 per cent were bronchial in type and 2.4 per cent lobar. Of the broncho-pneumonias 8.1 per cent were right sided, 16.6 per cent left sided, and in 15.7 per cent both .sides were involved. The lobar pneumonias showed an equal distribution between right or left side and both. The next most frequent complication was bronchitis, found in 31.1 per cent of the cases, followed by myocarditis, nephritis, epistaxis, pleurisy, endocarditis, otitis media, abdominal distention, and two cases each of cholecystitis and retention of urine, and one case of typhoid fever. I-ABOBATOKY FINDINGS. The detailed report from the laboratory will be considered else where. However, as regards the gross appearance of the sputum, it may be said that in Group I 56.2 per cent cases were muco-purulent and 43.8 per cent bloody in character. In Group II 52.6 per cent were muco-purulent and 47.4 per cent bloody. In Group III 8.7 per cent were watery, 17.3 per cent muco-purulent, and 74 per cent bloody. In Group IV 3.6 per cent were watery, 41 per cent muco purulent, and 55.4 per cent bloody. It was frequently observed that in many cases of true influenza before the development of a mixed infection, the sputum was watery and became muco-purulent or No. 4. CLIFFORD, KELLY, THOMAS INFLUENZA. 641 bloody on the appearance of the complicating infection. In many cases the absence of the true tenacious bloody sputum of lobar pneu monia was observed, and it was noted that even when the sputum was blood tinged it still retained its watery characteristics. As regards the blood findings, it was almost the universal rule that in the uncomplicated influenza cases a leucopenia was present, and that upon the appearance of the complicating pneumonia a leuco- cytosis appeared which rose in many cases to 30,000 cells per mm. In the urine it was noted that in the true uncomplicated influenza a trace of albumen without casts was often found, but that almost constantly a true nephritis was found in cases which developed pneumonia. KEVKH AND SICK DAYS. It should be observed, in comparing the number of sick days in the various groups, that the higher number of sick days was due in most instances to the fact that 30 days' sick leave, which was granted to the convalescent pneumonias, was included in the total of days in the hospital, and that in the groups which had a greater percentage of deaths there were consequently fewer cases to take advantage of such leave, and their stay in the hospital was necessarily much shorter. In Group I, the average number of fever days was 3.4 days, with the lowest 0 and the highest 19 ; the average number of sick days was 22.1, with the lowest 3 and the highest 75 days. In Group II, the average number of fever days was 4 days, with the lowest 0 and the highest 21 ; the average number of sick days was 21.5, with the lowest 3 and the highest 72 days. In Group III, the average number of fever days was 4.8 days, with the lowest 0 and the highest 21 ; the average number of sick days was 18.4 with the lowest 2 and the highest 71 days. In Group IV, the average number of fever days was 4.1 days, with the lowest 0 and the highest 25 ; the average number of sick days was 19.9 days, with the lowest 1 and the highest 72 days. TBEATMENT. As regards treatment in the various groups, it is to be noted that the mild cases, which number approximately two-thirds of the total number, require no stimulation and that almost without exception they recovered. This should be borne in mind in comparing the results of routine treatment with and without stimulation, as the higher percentage of deaths among the stimulated cases were among those which were most severe, which required stimulation and who very often died in spite of it. 642 CLIFFOBD, KELLY, THOMAS INFLUENZA. Vol. XIII. In Group I, which included 352 cases, 82 per cent recovered without stimulation and 0.3 per cent died; of those requiring stimulation 13.5) per cent recovered and 2.5 per cent died. There were 10 cases (2.8 per cent) treated with vaccine with recovery and no deaths. Five cases (1.4 per cent) were treated with salvarsan. with recovery and no deaths. There were 30 pneumonias in this group, with a mor tality rate of 33.3 per cent. The mortality rate of all the cases in this group was 2.8 per cent. In Group II, comprising 197 cases, 73 per cent recovered without stimulation and 1 per cent died. Of those requiring stimulation. 17.2 per cent recovered and 7 per cent died. There was one case treated with salvarsan which died. In this group there were 31 pneumonias, with a mortality rate of 54.8 per cent, and the mor tality rate for all the cases in this group was 8.6 per cent. In Group III, which included 11(5 cases, 47.5 per cent recovered without stimulation with no deaths. Of those requiring stimulation, 21.5 per cent recovered and 27.5 per cent died. Six cases received vaccine, of whom three recovered. There were 49 cases of pneumonia in this group, with a death rate of 72.9 per cent, and the total death rate for all cases in this group was 30.2 per cent. In Group IV, which included 235 cases, 48.1 per cent recovered without stimulation and none died. Of those requiring stimulation. 20 per cent recovered and 29.8 per cent died. Six cases received vaccine, all recovering, and one case received salvarsan with recov ery. There were 101 cases of pneumonia in this group, with a death rate of 70.2 per cent, and the total mortality rate for this group was 30.2 per cent. SUMMARY. In summarizing all the cases, irrespective of their groups, it was found that the chief complaint was headache; the most common symptoms were headache and cough; and the most constant sign found on examination was rales, either as an expression of bron chitis or pneumonia. Of the complications, bronchitis was found in 37.8 per cent of the cases and pneumonia in 23.3 per cent, of which 21.9 per cent were broncho-pneumonia and 1.4 per cent lobar pneumonia. Myocarditis occurred in 14.4 per cent of the cases, epistaxis in 9.6 per cent, nephritis in 7.3 per cent, and pleurisy in 4.1 per cent. There were eight cases each of endocarditis and abdomi nal distention, two cases each of cholecystitis, sinusitis, retention of urine, and meningitis, and one case each of typhoid fever and epididymo-orchitis. The death rate for the cases of pneumonia was 63.3 per cent, and the total death rate, irrespective of the complica tions, was 14.7 per cent. No. 4. 643 CLIFFORD, KELLY, THOMAS INFLUENZA. The total number of cases admitted during this period, including many whose records were not completed, and consequently not in this series, were 1,217. Of these 297 developed pneumonia, a per centage of 24.4 per cent. Of the pneumonias 141 died, a mortality rate of 47.5 per cent, and the total mortality for the whole number of cases admitted during the period under discussion was 11.6 per cent. Chief complaint. Group I. Group II. Per cent. Per cent. Headache 34.0 Chills 12.5 General muscular General muscular pains 15.3 pains 10.2 Cousrh 13.7 Couch 8.5 Chills 11.6 Backache 6.2 nack&i'he 9. 6 Corvza 6.6 Sorethroat 5.1 Group III. Per cent. Headache 32.7 Chills 18.1 General muscular pains 15.5 Cough 12.0 Corvza 9. 5 Backache 6. 0 Sorethroat 3.4 Weakness 1.7 Nausea 8 Group IV. Percent. Headache 30.6 Cough 23.4 Chills 16.4 General muscular pains 9.8 Backache 5.5 Weakness 4.7 Corvza 4.3 Sorethroat 3.0 Nausea and vomit- toft 1.7 Dyspnea t Symptoms. Group I. Group II. Group III. Group TV. Percent. 82.6 67.6 ular Per cent. 78.0 69.0 Per cent. Percent. Coueh 83.4 Headache Headache Headache 76. 0 Couch Couuh 75.8 General muse pains General muscula General muscular General muscula 53.9 48.8 34.6 24.4 20.1 r>ains 58.6 R3.0 48 5 Chills 46.2 42.fi 30.5 22.8 20.3 15.7 13.7 10.2 Chills 52 s Chills nai-kachc 46.5 42.2 37.0 24.1 19.8 18.1 15.5 6.8 8.4 Weakness 43.8 Weakness °--spnca Backache 4D.0 32.8 Corvra 18.4 Sore throat Cor -a 20.8 10.5 8.5 7.9 O'spnea Sire throat 19.6 Pvspnca Nausea Nausea 17.4 Vertico Vomiting Vomiting. Vomiting 15.6 9 8 2.6 Vomiting 5.9 Vertigo Earache 2.8 Earache 3.0 Farache Earache Physical sinns. Group I. Group n. Group III. Group IV. Per cent. Rales 51.9 Con gest ton of throat 30.9 Congestion of eyes.. 22.7 Con -est ion of nose.. 11.6 Cvanosis 5.3 Toxemia 4.8 Enhn;ement of su- pralachrymal glnnd 3.4 Pleuritlcfriction.... 2.8 Herpes 1.7 Delirium 1.9 Erythema 1.4 Percent. Rales 55.8 Congestion of thro.it 30.5 Congestion of eyes. 27.4 Congestion of nose. 14.2 Toxemia 11.2 Cviwats 8.6 Delirium 8.6 Pleuriti" friction.. 3.0 Enlargement of s u p r alachrymal gland 1.5 Erythema 1.5 Hiccough 1.0 Per cent. Rales 74.4 Congestion of throat 35.3 Toxemia 31.8 Congestion of eyes. 28.4 Cvnnosis 27.5 Delirium 24.1 Congestion of nose. 12.0 Pleuril if friction. . 8.5 Enlargement of suprahchrvmal rl:.nd 7.7 Herpes 2.5 Jaun li"e 8 Erythema 8 Percent. Rales 74.0 Toxemia 35.3 Cyanosis 34.0 Congestion of throat 31.1 Delirium 25.5 Congestion of eyes.. 22.6 Congestion of nose.. 11.2 Pleuritic friction ... 4. 7 Herpes 3.4 Enlargement of supralachrymal gland 3.0 Jaundice 2.fi Erythema 2.1 Hiccough 8 644 Vol. XIII. CLIFFORD, KELLY, THOMAS —INFLUENZA. Complications. Group I. Percent. Bronchitis 43.4 Group II. Pnoumonia 8.5 I Broncho: Right... Left.... Both... 3.4 2.5 2.2 Lobar, left. 8.1 •4 ! Epistaxis 5.6 Myocarditis 2.8 Pleurisy 2.8 Nephritis 1.7 Otitismedia 1.4 Endocarditis 6 Sinusitis Abdominal disten tion Meningitis Pulmonary hemor rhage .6 Percent. Bronchitis 40.0 Pneumonia 15.7 Broncho: Right.... 5.1 Left 5.6 Both 3.6 14.3 Lobar: Right.... 1.0 Left 4 1.4 Epistaxis 11.1 Myocarditis 8.6 Nephritis 6.0 Pleurisy 3 Otitismedia 1.0 Abdominal disten tion 5 Group III. Percent. Pneumonia 42.2 Broncho: Right.... 12.0 Left 14.6 Both 12.9 39.5 Lobar: Right.... 1.7 Left 1.0 2.7 Bronchitis 31.0 Myocarditis 30.2 Epistaxis 12.9 Nephritis 10.3 Pleurisy 8.6 Otitismedia 2.5 Abdominal disten tion 1.7 Retention of urine. .8 Endocarditis 8 Epididymo - orchi tis 8 Group IV. Percent. Pneumonia 42.8 Broncho: Riant 8.1 Left 16.8 Both 15.7 40.4 Lobar: Right 0.8 Left. 8 Both 8 2.4 Bronchitis 31.1 Myocarditis 28.5 Nephritis 15.3 Epistaxis 13.2 Pleurisy 4.7 Endocarditis J.1 Otitismedia 1.7 Abdominal disten tion 1.3 Cholecystitis 8 Retention of urine.. .4 Typhoidfever 4 SUMMARY. 900 cases. Complications : Per cent. Bronchitis 37.8 Pneumonia , 23.3 Bronchial — Right-sided 6. 1 Left-sided 8. 4 Both sides 7.4 21.9 Lobar— Right-sided . 66 Left-sided . 55 Both sides .22 — Myocarditis 14. 3 Epistaxis 9.6 Nephritis 7.3 Pleurisy 4. 1 Otitis media 1. 5 Endocarditis .8 Abdominal distention . 8 Cholecystitis .2 Sinusitis i .2 Retention of urine .2 Meningitis .2 Typhoid fever . 1 Epididymo-orchitis .1 Incidence of pneumonia (210 cases) 23.3 Mortality of penumonln 63.3 Total mortality of nil cases 14. 7 Ho. 4. HARE —INFLUENZA. 645 Total of 1211 cases. Per cent. Incidence of penumonla (297 cases) 24.4 Mortality of penumonla ' 47. 5 Total mortality of all cases 11.6 Section II (a). THE CLINICAL AND THERAPEUTIC STANDPOINT. By II. A. Hake, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. As statistical data concerning the epidemic of so-called influenza in the fall of 1918 are given elsewhere, this section does not attempt to deal with that aspect of the subject. The dominant fact is that in the vast majority of cases the illness was not the result of infection by one pathogenic organism, but was a multiple infection in which one of several organisms was the chief agent or in which all were approximately equally responsible. If the word " influenza " is used to indicate that this epidemic was simply due to the bacillus of Pfeiffer it is misapplied, for the symptoms were not those produced heretofore by this organism, and in many instances it was present in such small numbers as to be fairly considered a collateral infection of secondary importance. While the pneumococcus was constantly present, as it is in most human beings at all times, it did not, except in very rare instances, produce its characteristic pulmonary lesion or physical signs, nor did it produce the sputum of croupous pneumonia. The great num ber of cases suddenly taken ill prevented, to a great extent, the " typing " of this organism, but here again it may be said that if the pneumococcus was a predominant factor in any case it produced results widely different from any heretofore seen. The physical signs of disease, the symptoms, and the lesions recog nized at autopsy were much more those of the streptococcus hemo- lyticus than of any of the other associated organisms. The breaking down of the blood, its discharge from any orifice of the body in a state of hemolysis, the extravasations, not exudations, into the pulmonary parenchyma and smaller bronchial tubes closely resembled the changes caused by those poisons which, when intro duced into the body, cause hemolysis, such as snake venom or potas sium chlorate. My belief as a clinician, rather than as a laboratory worker, is that more of the fulminant cases, characterized by the putty-colored face and hands with mulberry-colored lips, were due to this germ with the others acting as secondary invaders. In some instances the smears of the sputum were almost entirely made up of the spirillum of Vincent, generally without lesions in 133354—19 2 646 HAKE INFLUENZA. Vol. XIII. the mouth, and it is interesting to note that when such was the case the daily use of 0.3 arsphenamin intravenously produced remark ably favorable results, as it did in other cases in which this spirillum was not demonstrated, although possibly present. I will not discuss the physical signs commonly found, except to say that the most characteristic pulmonary sign was an area, usually posteriorly, in the middle area of the chest, of remarkably well- defined tubular breathing without rales, which area often speedily spread over a wide portion of the lungs, so that at autopsy it looked and felt as if filled with melted currant jelly rather than a croupous exudate. It is a subject for regret that therapy seemed in many instances perfectly useless, probably because the poison of the disease so rap idly attacked the heart muscle and the muscular coats of the vessels that they were incapable of responding to stimulation. A large, voluminous, low-tension pulse in an artery so relaxed as to feel to the finger more like a pulsating vein was commonly met with, and in these cases it often happened that the heart seemed to beat vigor ously for a time in an endeavor to fill relaxed vessels. Indeed, I saw many cases in which the apex beat was still forcible on palpation and the heart sounds loud, yet in which the patient was pulseless at the wrist. The complete failure of digitalis in these cases led us at first to think that the preparation used was impotent, but subsequent trials showed that no form or preparation of the drug possessed any of its ordinary powers. Indeed, I saw many cases in which the end seemed to be hurried by its use. This is in accord with general experience in the sense that digitalis acts best for a tired heart in valvular disease, but often fails in the weak heart of acute infectious processes, particularly if associated with fever. The same statement is also true of strophanthus. The drug which seemed to act best as a stimulant was caffeine alkaloid in doses of 2 grains three or four times a day as a rule. Whisky also seemed to do good, provided it was not pushed too hard and did not upset the stomach. Caffeine by unlocking reserve energy, and alcohol by being burnt up in the body, probably acted indirectly in those cases. For the relief of the pains in the limbs and back, 2 grains of cinchidin with 5 to 10 grains of aspirin seemed most useful, but they had no specific effect and in the fulminant cases was not used or had no chance to do good. Proctoclysis with normal saline, or with glucose solution, was use ful to provide fluid to the tissues but had no definite effect otherwise. The great rapidity of the respiration, the great restlessness and delirium of many of the severe cases indicated the use of easily Mo. 4. BILLINGS INFLUENZA. 647 assimilated food. This was provided chiefly by the use of semi- liquid breakfast foods, diluted with milk, to which taka-diastase or pancreatin was added to hurry the first stage of carbohydrate di gestion. I believe this is a valuable measure. None of the ordinary hypnotics possessed power for good in my observation in any safe dose. Delirium or excessive cough were best controlled by morphine or codeine in full doses. Finally, the following observations made by me I believe to be correct. In addition to the great incidence of the disease in those between 20 or 30 years of age, red-haired or sandy-haired patients seemed to suffer the most, particularly if they were of the lymphatic type. Next to them came the very blond man, while negroes seemed partially immune. Of course, there were marked exceptions to this in the sense that dark-haired men sometimes suffered severely. Another point of interest is that some cases were stricken and died in a few hours or in two days; others began moderately and then without any apparent cause became fulminant after 48 hours or more; still others with temperatures as high as 105° on entrance speedily came to normal with little systemic symptoms or local lesions. Section II (6). THE CLINICAL AND THERAPEUTIC STANDPOINT. By P. T. Billings, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. The severe cases were beginning to be much diminished in number, although still very ill- patients were being admitted. The majority of the patients under consideration were young adults, seemingly in the height of physical fitness. Therefore, the general impression was the presence of large reserve force for resistance. On being ad mitted to this hospital many of the patients had been sick two or three days or longer. The examination revealed generally some cyanosis of the lips and fingers, extending to body in the bad cases, so that there was often a bluish color to the whole skin. In the large majority, either when coming to the hospital or later during the course of the disease, a papular eruption was observed on the back and to a lesser extent the front of the body. These papulars were frequently capped with minute pustules, varying in size from a pin point to a pinhead. In a few instances we observed a moderate jaundice, coloring the conjunctiva and the skin. In one case this occurred during a severe pneumonia in a colored man, and in my opinion was probably of the hemolytic type. The sclera was gen erally injected and there was some complaint of coryza. In our cases there were only a few nasopharyngeal infections. In one instance a frontal sinus infection occurred, with extensions to the frontal lobe. 648 BILLINGS INFLUENZA. VoL XIII. meningitis, and death. Otitis media was practically absent. The tongue usually showed signs of the toxemia, and in the bad cases was dry and leathery. The pharynx and tonsils were generally a dark red, but sore throat was not usually complained of. Hemorrhages from the nose to a lesser or greater degree were more or less common, and in one instance it was necessary to resort to packing and the in jection, intramuscularly, of serum. In nearly every case a general adenitis was discovered upon examination. This often included the whole chain of external glands—cervical, axillary, epitrochlear, and inguinal. These persisted during the course of the disease, but never became larger than a pea or a bean. In this epidemic the brunt of the invasion seemed to have been borne by the respiratory tract. Cough was probably the most gen eral symptom, and this was usually dry and unproductive at first, but later in the course of the disease the sputum became remarkably untenacious and fluid, ranging in color from rusty to red. This sputum was somewhat remarkable in that the amount for 24 hours was generally more than was customary and that the blood seemed to have undergone hemolysis. Pain in one or both sides of the chest was common and at times was most prominent. Physical signs discovered in the chest were restricted respiratory excursions, hyperresonance, hyporesonance to dullness or flatness, restricted, feeble, or absent breath sounds, patches, of bronchial or bronchovesicular breathing, moist rales, crepitant and subcrepitant rales, pleural friction rub, with later pleural creak. Therefore the findings of the typical cases of influenza (broncho-pneumonia, for the great majority of patients seen by us later developed broncho-pneumonia) showed at first at one or both bases in back, hyporesonance, very feeble breath sounds, and often on deep inspiration fine moist crepitant rales. Later these signs might develop into an impaired resonance, patches of broncho vesicular or bronchial breathing, limited to a greater or less extent, moist rales becoming larger and more pronounced. At times por tions of whole lobes were involved, consolidated. Particularly noticeable were the feeble or diminished breath sounds, frequently nearly absent. This in the early stages was in many instances the only sign on the first physical examination. In 24 or 48 hours, how ever, crepitant rales would appear. Mild cases did not go beyond these, while others showed those classical signs of patches of pul monary consolidation. Pleural effusions were relatively uncommon, although undoubtedly in many cases there was an accumulation of 100 to 800 c. c. not recognizable by physical signs. In two instances large effusions were found at autopsy which had not been clinically discovered. One case was gone over three days before death as care fully as possible, considering the desperate condition of the patient. No. 4. 649 BILLINGS INFLUENZA. I believe there was rapid accumulation of fluid in the intervening days. The other patient died on the day after admission. Fortunately, we were able to secure many X-ray plates of the chests of our patients. These corroborated the physical signs and are reported upon in full in Section III. In the great majority of cases the lower lobes were the portions involved. Seldom did the process commence or extend to the upper lobes. Where this did occur we were always suspicious of a tuber cular infection, and the sputum was examined regularly. In this series of cases there were but few complications of this character. There were observed by me no instances of lung abscess or gangrene. As a rule, the respiratory rate was not markedly raised. Of course, there were many exceptions to this, particularly in the ex tremely toxic. The temperature was not at all characteristic, some times remaining at a high point for several days consecutively, sud denly dropping, remaining approximately normal for a few days, and then rising again. Kelapses —that is to say, true relapses —were uncommon, but lighting up of new areas in the lungs where the old were subsiding was frequent. In fact, in this respect the picture was that of the ordinary broncho-pneumonic infections. It was sur prising the length of time marked pulmonary lesions, consolidations, feeble breath sounds, etc., persisted after the patients were seemingly on the straight convalescent road. At times these physical signs took weeks to clear up. In the examination of the respiratory apparatus and in classifying these patients, all those in which were found at the bases showers of fine crepitant rales were diagnosed as influenzar with broncho pneumonia. The general picture of a mixed infection and the sputum showed various organisms, streptococci, pneumococci, micro coccus, catarrhalis, influenza bacilli. A few spirochaetes were found, particularly in those cases in which there was a noticeable amount of blood in the sputum. Later, lung punctures were made and fre quently pure cultures of influenza bacilli were obtained from these. The cardio-vascular findings were interesting. No pericardial in volvements were found, but undoubtedly the heart muscle suffered at least temporary impairment in many instances, as shown by the poor quality of the sound at the apex and the loss of the muscular com ponent. Murmurs were not frequent At autopsy the valves were found intact. A rather remarkable and frequent observation was the relative slowness of the pulse compared to the temperature range and evident illness of the patient. The blood pressure was generally low—110 systolic or lower. The leucocyte count was also in the majority of cases low— 10,000 or less ; polys predominating, but showing granular changes. Blood cultures 650 BILLINGS INFLUENZA. Vol. XIII. were generally negative, although a few were positive for the pneu- mococius and streptococcus. The digestive apparatus was not materially affected. There was some nausea and vomiting. In a few cases, perhaps a dozen, there was diarrhea. In the majority of instances there was some abdominal distention and pain on palpation, particularly in the right iliac fossa. This latter symptom cleared up rapidly, however, but during its presence markedly simulated appendicitis. The former frequently persisted, particularly in the toxic cases, and was extremely difficult to overcome. There was great distaste for food, and one of the most encouraging signs was the gradually increasing appetite. The spleen and liver were seldom palpated—probably in not more than three or four cases. In nearly all the patients who were seriously ill the urine showed albumen and occasionally casts, but there was never an acute involve ment or any evidence of serious renal changes. In about 15 indi viduals the functional kidney tests were made with pheno-sulpho- pthalein. These were particularly unsatisfactory and did not give, us any information of importance. There were a number of cases of retention, necessitating catheterization a few times. In most of those seriously ill delirium was common, but definite involvement of the central nervous system was rare. This did occur, however, in three cases. In these undoubtedly we were dealing with a nervous type of influenza. The general examination was negative except for positive Koenig, Bruzinski, and stiff neck, somnolence, and complaint of headache. In all these patients punctures (spinal) were made, with negative results, and they all cleared up in a few days. Post- influenza psychoses were observed in about six patients of this series. All cases were given a thorough physical examination. The lat ter includes a routine Wassermann, leucocyte count, urine and bac teriological cultures. Concerning the latter, sputum, lung puncture, and blood culture were instituted, and are reported in detail under Section IV. All cases of consolidation were typed for pneumococcus. One case was of Type I. The majority of cases were of Type II. Serum was only given in one instance where the classification was un certain (either Type I or Type II) without benefit, and in the one definite case with immediate turn for the better. D. G. S. This patient developed a right-sided encapsulated empyema, which was needled. On the third needling 50 c. c. of Typo I serum was injected into pleural cavity and 50 c. c. given in travenously. Following these injections elevation of temperature and other clinical evidences of pus disappeared and patient went on to an uneventful recovery. During the routine examination of sputum of a number of patients a spirochaete was found. This seemed particularly the case where No. 4. DALAND INFLUENZA. 651 the blood in the sputum was marked. The use of salvarsan was begun. This was done at first only on those cases and later, particu larly after the middle of October, 1918, on practically all, with broncho-pneumonia. During the period covered by this report 75 patients received arsenobenzol, a majority two or more times. In 24 hours after being admitted 0.2 «nim was administered intra venously, followed by urinary test and leucocyte count. If the pa; tient did not show marked improvement and the kidney irritation was not pronounced, 0.3 gram was given the second day. If necessary, two more injections of the same dosage were given pro vided there was no particular complication. Many cases seemed to do extremely well under this treatment. There was in the majority a drop in temperature, and the patients themselves declared they felt easier, could breathe more freely, were better in every way, seemingly less toxic. For some weeks we seemed to have had uniformly successful results. Even those cases which at times ap peared almost hopeless reacted well and recovered. However, later we had quite a few failures —patients whom nothing seemed to benefit and who progressively became more and more toxic and eventually died. It is possible, however, and highly probable that there are groups of cases which salvarsan can not influence. In my opinion, use of this drug from the time of its administration, October 14, 1918, up to the present, has been of decided benefit to a comparatively large number. Of this series of 74 patients to whom this treatment was given 9 died, a mortality of a little more than 12 per cent. In a few of our cases quinine was given in large doses, intra venously or intramuscularly. These were so few, however, that we were unable to draw conclusions. Further treatment consisted of stimulation, elimination, and symptomatic measures. Section II (e). THE CLINICAL AND THERAPEUTIC STANDPOINT. By .1. Daland, Lieutenant Commander. Medical Corps, I'nited States Naval Keserve Force. These observations are based upon a study of the more serious of about 3,000 cases of influenza occurring among the officers and men in the United States Navy in Philadelphia. Most of the patients were between the ages of 20 and 26 years and were in unusually good physi cal condition. Influenza appeared in the British Army in May, 1918, and was brought to Philadelphia by ship. The first case of influenza was diagnosed on September 12, 1918, at the United States Naval Hospital. League Island, Pa., unrecognized cases having occurred earlier. At first the epidemic resembled that of 1889-90, but marked differences were quickly observed, such as a greater toxicity and mortality, sus 652 DALAND —INFLUENZA. Vol. XIII. ceptibility of young adults, and partial or complete immunity of those past middle age. The epidemic was characterized by extreme contagiousness, rapid onset, early and rapidly developing adynamia, cyanosis, and a high rate of mortality. The period of incubation averaged from 1 to 4 days. • The U. S. S. West Gaylock sailed from an uninfected port in Cali fornia, arriving at the Philadelphia Navy Yard on November 19, 1918. Although the epidemic was subsiding, 35 men were admitted to the United States Naval Hospital with influenza differing in no respects from cases observed during the height of the epidemic in October. This observation disposes of the theory that the virulence of influenza diminished at the end of an epidemic and supports the idea that the disease disappears because most nonimmunes have been infected. Influenza may be clinically classified as mild, ordinary, severe, or toxic. The toxic variety may be subdivided into pulmonary, circula tory, nervous, gastrointestinal, and renal. A typical example of mild influenza occurred in a 16-year-old girl, who was suddenly seized with headache, backache, pains in the ex tremities, malaise, and attacks of slight or moderate perspiration, oc curring daily for two or three days. In the beginning the cough was slight, infrequent, dry, later becoming more frequent and accom panied by a small amount of muco-purulent sputum, containing many influenza bacilli. Auscultation revealed a few dry bronchitic rales in both lungs and an extremely feeble respiratory murmur at both bases. The muscular element of the first sound of the heart was ex tremely weak, and this organ did not react to the stimulating effect of fever. The pulse was easily extinguished by slight pressure and was less frequent than the fever would indicate; the systolic and dias tolic pressures were low and the pulse pressure large. The fever lasted but a day, coryza and sneezing were absent, the eyes unusually bril liant, and the vessels of the ocular conjunctivae injected. During the first four or five days the only symptoms complained of were head ache, backache, weakness, frequent attacks of moderate perspiration, diminished appetite, and constipation. The urine showed no impor tant change. Despite these few symptoms and the brief duration of fever, weakness continued, necessitating rest in bed for 10 days. On the 10th day extreme fatigue was caused by sitting up for 30 minutes. Two weeks later the patient was improved, but weak, and required two weeks' rest at the seashore before complete recovery was secured. This case typifies an extremely mild influenzal infection, with ephem eral fever ocurring in one previously healthy, and illustrates the severity of the toxemia in a mild case of influenza. MO. 4. DALAND —INFLUENZA. 653 Ordinary influenza presented the same symptoms and signs as mild influenza, excepting that the fever, usually remittent in type, con tinues for four or more days, the pain in the head and extremities is more severe, cheeks are more flushed, conjunctival vessels more in jected, eyes brilliant, exhaustion more pronounced, lips cyanotic, and the few dry rales later become numerous and moist. The urine showed occasionally a trace of albumin and a few granu lar and hyaline tube casts. The sputum usually contained not only the influenza bacillus but also the pnucmococcus., streptococcus, staphylococcus, and the micrococcus catarrhalis. The leukocyte count usually showed a moderate leucopenia. Severe influenza was characterized by an exaggeration of the symp- tons, and signs of ordinary influenza and complications were frequent. The following incident illustrates the onset: Two well-developed unusually strong coal-passers who were in the best of health on a Thursday and when admitted to the U. S. Naval Hospital, League Island, were so weak the following morning that one fell on the floor and the other had scarcely sufficient strength to remain sitting on a chair. The lips, lobes of the ears, and finger nails showed cyanosis, varying in degree from blueness to blue-black, and occasionally extending to the extremities, trunk, and the mucous membranes of the pharynx and larynx. In many cases adynamia was so profound that normal breathing was impossible. When the patient was commanded to take a deep breath he would make an obvious effort and breathe slightly more deeply, but each succeeding breath was feebler than its predecessor, evidencing weakness and rapid exhaustion. It is probable that feeble or absent breath sounds, when no pulmonary disease exists, excepting a moderate bronchitis, is due to the excessive weakness of the inter costal muscles and diaphragm, due to deficient innervation and toxic myositis. Occasionally breath sounds were masked by numerous loud, sibilent, sonorous, and mucous rales. Auscultation in bronchitis revealed an extremely weak respiratory murmur, and in many cases the breath sounds in one or both of the lower lobes were absent. Vocal fremitus and resonance was dimin ished and bronchitis rales were few and scattered. Lobular pneumonia was very common and usually began in small areas disseminated throughout one or both lungs, frequently locat ing in the lower spinal half or the apex of one of the lower lobes and usually undiagnosable at first because of the feeble or absent breath sounds and emphysema. During ordinary respiration subcrepitant rales may be absent but may be induced because of cough or deep inspiration. Those rales are easily overlooked because of their small volume and low pitch or may be masked by loud, dry rales. Even when small areas of lobular pneumonia become larger, the phonen 654 Vol. XIII. DALAND—INFLUENZA. doscope reveals scarcely audible low-pitched bronchovesicular breath ing: and percussion dullness may be absent if these areas are located in the central portion of the lung; or the surrounding tissue is em physematous. When areas of lobular pneumonia coalesce and occupy the periphery or a considerable part or the whole lobe of a lung, the percussion note is dull, the breath sound bronchovesicular or bronchial and vocal resonance and fremitus is increased. Respira tion is superficial in all forms of this disease, but in severe influenza the respiratory murmur is not only feeble but remains feeble, even though one or both lower lobes of the lungs become congested or pneumonic. The unaffected parts show no compensatory overactiou so uniformly observed in lobular pneumonia. Passive venous con gestion of the base of the lungs was , 1918, inclusive. Number unvaccinated influenza rases 221 Number pneumonia ruses developing 78 Proportion influenza developing pneumonia per cent 35.3 Total deatlis from pneumonia cases 56 Number vaccinated Influenza cases 00 Number developing pneumonia 3 Proportion influenza developing pneumonia per cent.. 5 Number of deatlis resulting from pneumonia '. 0 Table 0. — Urinalysis report. Number of specimens examined 2,130 Albumin present 014 Albumin present per cent 28.8 Pus cells present (9.0 per cent) 204 Casts present (8.6 per cent) 182 In a series of 25 phthalein functional tests, a marked irregularity of renal efficiency was noted. 676 BORDEN AND LEOPOLD INFLUENZA. Vol. XIII. Bacteriology. —The striking feature of this epidemic has been the extreme difference of bacteriological opinions. Some claim a high percentage of B. influenzae, while others support ridiculously low or even negative findings. The very character of the reports, which have been so numerous and varied, mean either that the virus of this epidemic remains as as yet absolutely unrecognized, or that the cultural vagaries and pathogenic properties of the B. influenzae have been so incompletely developed as to mask the entire etiological picture. In spite of many discouraging features of the literature, as well as those of our own observations, unless some entirely n'ew agent is finally found, we feel that perfection of cultural requirements and especially intensive investigation of the pathogenicity and immune factors will finally determine the B. influenzae and some definite strain as the true causa tive factor. We also feel that our findings would have been of greater value had our technic been identical from the origin of the epidemic. Our final technic, many suggestions for which we owe to Lieuten ant P. A. Lewis, Medical Corps, U. S. N. K. F., was to plate on blood agar (0.4 per cent acid, glucose agar with 1 per cent de- fibrinated human cells), incubate for 24 hours at 37 C, and subse quently at room temperature. Kepeated inspection with lens, in reflected and transmitted light twice daily, for several days before discarding, has been our rule, as we have repeatedly discovered colonies four to five days later. Sus picious colonies were then cut out, planted for 24 hours in blood bouillon, and replated in blood agar for 24 hours, or until abund ant growth is returned. On the liquid medium many vague involution forms are seen, from long filamentous to broad convoluted bodies, very much re sembling contamination or anything but B. influenzae, but on replat- ing on agar these forms disappear and the characteristic minute glistening transparent colonies of a Gram-negative cocco-bacillus appear. We feel that many of our failures in early attempts were due to a failure to recognize the following sources of error: 1. Reincubation after the first 24 hours, instead of room tempera ture. 2. Unsatisfactory culture media. 3. Subculturing in solid media without interposing a liquid medium. .4. Failure to recognize young colonies. For this reason we have discarded many of our earliest efforts and confined our report to a period during which our technic was sufficiently exacting to satisfy ourselves. No. 4. 677 BORDEN AND LEOPOLD INFLUENZA. Several attempts at complement fixation were unsatisfactory in our hands, owing to an extremely narrow margin between the anti genic and anticomplementary units of the suspensions used. Necropsies. —Of 15 necropsies performed only 9 were studied com pletely, pathologically and bacteriologically, to warrant a report in full. These cases were all classical post-influenzal broncho-pneu monias. A composite necropsy picture of these would present a report somewhat after the following: A robust, well-developed young man with extreme cyanosis of the entire body, amounting in most cases to a deep purplish black and a characteristic foul odor. This gross appearance and odor was a constant characteristic of our morgue for the entire period, during which only epidemic cases were admitted to our hospital. Anatomically an extreme engorgement of the venous circulation, such as is seldom seen, was likewise constant. All subcutaneous veins are distended and disgorge freely a thin black fluid, watery in consistency and staining everything a dark mahogany color. The cava? and right heart are enormously engorged and overdistended and are filled with a blackish jellylike clot, while the abdominal veins are so extremely distended as to graphically demonstrate the extent of the venous slump into which the circulation is constantly overflowing. The heart muscles are all well developed, but have a glazed or scalded appearance, the pectoral and recti muscles presenting the same appearance. Few of the earlier cases showed pleural involvement beyond an occasional serous effusion. After the crest of the epidemic a few cases of sero-purulent pleuritis were seen. The lungs exhibited a constantly varying picture of broncho pneumonia from a peppering of discrete lobular areas well scattered throughout all lobes to large and ofttimes massive confluent broncho pneumonia areas involving approximately 75 per cent of the lungs. In the discrete type distinct areas of lobular pneumonia in various stages of development are seen, well defined, elevated, and firm, of a reddish brown, varying to a bluish gray color and surrounded by normal or collapsed lobules. The shades of color of the bulging pneumonia lobules, surrounded by the red congested uninvolved and pale collapsed areas, giving the whole a mosaic appearance. In this type often from 25 to 50 per cent of the lungs were involved, usually as single or at most two or three confluent lobules. The involved areas of a bluish-gray color were varied here and there by paler patches of later involvement or by dark streaks of subpleural hemorrhagic extravasation. 133354—19 4 678 BORDEN AND LEOPOLD INFLUENZA. Vol. XIII. In all types areas of extreme emphysema of a most marked degree are present in portions of the uninvolved lobes. On cross section the larger areas exude a thin black-stained watery fluid in great quantities, and the cut surface seems smooth, of a dark slate color, and with no mucous or fibrinous characteristics. The discrete areas are a mahogany or bluish-brown color, have 9 distinct granular appearance, and seem almost to bulge or pop out of their restraining alveolar capsule. The bronchi and larger roots contained a thin brownish mucoid membrane of a tenacious character and minute petechial hemor rhages are peppered in and apparently beneath the mucosa. Quite a nest of very hard and firm peribronchial glands are often found about the lung roots. The spleen, liver, and especially the kidneys, exhibit varying de grees of congestion. The spleen is somewhat enlarged and of a very deep purplish hue, while the cortex of the kidneys has a deep brown color and a glazed bulging surface. The adrenals are distinctly enlarged, very friable, and of a deep bronze shade. Microscopical. —Sections taken through smaller lobular areas and larger confluent masses reveal a fairly uniform picture of broncho pneumonia, the findings varying only in proportion to the degree of involvement. Everywhere the interlobular capillaries are intensely congested, in spots becoming broad hemorrhagic extravasations. The alveoli are packed with red cells, leucocytes, fixed cells, and debris, but no fibrin. Where the involvement is less extensive fewer cells, probably coagu lated serum, and larger mononuclear cells are found. Peribronchial and perivascular round-cell infiltration is especially pronounced about the broncho-pneumonia areas. The general appearance of the heart muscle is that of a faint-stain ing myocardium, marked congestion, and some groups of round-cell infiltration between bundles of the muscle fibers. The individual cell often seems swollen, of a faint granular appearance, the nucleus is clouded, and the capsule indistinct, while occasionally minute hemorrhages within the bundles, with small collections of leucocytes, are seen. An interesting feature of two cases is the distinct prolif erative activity of the intima of the larger vessels. The liver and spleen, while intensely congested, show no active inflammatory changes. Occasionally a sharp biliary pigmentation is present. The kidneys uniformly exhibit more advanced inflammatory changes. The congestion here is extreme ; the capillaries seem almost bursting, while extravasations from the same in and around the loops of the glomerular and intertubular vessels are quite common. An advanced cloudy swelling, especially of the convoluted tubules, No. 4. BORDEN AND LEOPOLD INFLUENZA. is noted in all cases. In a few cases glomerulo-tubular inflammatory changes are undoubtedly taking place. The adrenals exhibit the same intense congestion, but without progressive inflammatory changes. One case proved an interesting epidemiological study, the patient being one of about 25 men received from a ship which had been at sea during the height of the epidemic and on which within 48 hours of arrival at this port a large proportion of the liberty party became stricken. Postnasal cultures of a group of these cases have a high per cent B. influenzae, and this case had a very strikingly rich culture. One week later he developed the typical post-influenzal pneumonia. Two others exhibiting a sparser growth of B. influenzae also developed pneumonia but recovered. Table 7. — Occurrence of organisms in culture in 31 other lung punctures. B. influenzae (predominating) (35 per cent) 8 B. influenzae with strepto-pneumoeoecus 3 B. influenzae with M. catarrnalis 2 B. influenzae with staphylococcus aureus 1 B. influenzae with B. nuicosus 1 Total B. influenzae, 65 per cent. Pneumococcus (III, Ila) - B. mucosus 2 B. mucosus with pneumococcus (IV) 1 M. eatarrhalls * Staphylococcus aureus 1 Streptococcus Table 8. — Occurrence of organisms in culture from pleural fluid. Streptococcus Streptococcus hemolytlcus * Pneumococcus (I) * * Pneumococcus (III) * Pneumococcus (IV) * The cases of Type I were given intrathoracic administration of 50 c. c. of serum and a like dose intravenously with rapid and marked improvement for Type I pleurisy. In the lung puncture made during life-, care was taken to carefully outline areas of consolidation, using a powerful '20 mil. syringe, containing about 3 to 5 mils, citrated saline to plunge through sterilized skin surface directly into these. Cultures were made in blood agar and blood bouillon. Obviously it was quite impossible to obtain as uniform and satisfactory material as when made at necropsy. This operation was attended with very little discomfort and no unfavorable complications. Commentary.—Surveying the epidemic, our general impressions, as gathered from laboratory and clinical stud}-, may be summarized 680 BORDEN AND LEOPOLD INFLUENZA. Vol. XIII. as confusng and, broadly speaking, nonproductive, and our opinions as largely theoretical. Unfortunately, in our experience, as was the case with many others, we presume, we did not feel that our technic was sufficiently accu rate in the earlier days of the epidemic to detect the constancy of the influenza bacillus. Taken as a whole, however, our percentage of positive findings was sufficiently high to establish the term influenza for the epidemic. This with the clinical picture satisfies the uncomplicated cases. As to the high incidence and mortality of the postinfluenza pneu monias, we have only theories in explanation, namely : 1. That the pneumonia was a true primary B. influenzae invasion of the lung parenchyma. 2. That intercurrent with a very active influenza pandemic was carried a pandemic of pneumonia of unestablished origin. As to the first supposition, we have found a high percentage of pure B. influenzae in antemortem lung punctures, carefully made from localized areas of consolidation. More striking have been the results of necropsy, where on several occasions we isolated B. influenzae in pure culture from the discrete lobules of lobular pneumonia. From the peripneumonic areas and bronchi never-pure B. influenzae, but usually secondary invaders were gotten. We felt at the first few attempts that this was convincing evidence of the extension downward of the organism and were satisfied that the entire clinical complex was simply an inflammatory invasion of the respiratory tract, a priori of B. influenza; origin. Subsequently, however, we were not able constantly to demonstrate the B. influ enzae in the lobular patches of consolidation, and, unfortunately, by this time the crest of the pandemic had passed. We feel thoroughly honest in ascribing to the B. influenza; the causative factor in the influenza pandemic. To say that such was the case in the postinfluenza pneumonias is decidedly insufficient, unless we can demonstrate a particular strain or strains of B. influ enzae possessing a virulence and specificity as yet unknown. As to the second supposition, we can not, from our experience, feel honest in ascribing to the B. influenzae alone the full burden of the high incidence of pneumonia, nor can we glean from the mass of literature presented any proof that it is solely responsible. Several facts again present themselves: (a) No case of pandemic pneumonia that came under my obser vation failed to present the clinical signs of influenza well before any pneumonic symptoms were recognized, thus apparently demonstrat ing a distinct relationship of the causative factor (Bacillus influenzae) in the uncomplicated influenza and the post-influenzal pneumonia. No. 4. 681 BORDEN AND LEOPOLD—INFLUENZA. From a clinical standpoint this would seem sufficient evidence to establish the presumption of a simple extension of the B. influenzae into the lung parenchyma. Bacteriologically, however, the facts do not support this. (b) The post-influenzal pneumonias were all so clinically similar that the causitive agent, if known, should be relatively constant. This was again not the case. B. influenzae which was found in the highest percentage was decidedly not a constant factor, nor even in these high percentages are there any facts so far presented to estab lish its specificity. We are justified, therefore, with no further facts at hand, in pre senting theories in an effort to explain the nature of the recent pandemic. These would be: 1. That a true pandemic of influenza caused by the B. influenzae prevailed, differing only from the frequent sporadic outbreaks in its virulence and pandemic qualities. 2. That a certain percentage of these typical uncomplicated in fluenzas may have progressed to a true influenzal pneumonia. 3. That parallel with the influenzal epidemic there was present a pandemic of pneumonia, due to an unknown organism or agent, and one which may have existed symbiotically or by preference witli the B. influenzae, this agent causing the great majority of the fatal pneumonias. i. That, as suggested above, this agent may be some exhalted strain of a nonpathogenic mouth organism, the subject of inversion of transmutation as the result of the unusual interchange of respiratory organisms incident to the mobilization of military masses. 5. That supported only by our own thoroughly unestablished pre sumption, we believe this organism to be a spirillum, because: (a) A spirillum was found during the height of the pandemic strikingly unlike usual mouth organisms. (b) It is as thoroughly tenable to attribute pathogenic possibilities to mouth spirilla as to mouth streptococci, etc. (c) Pathogenic spirilla have been demonstrated in the lungs, kid neys, and liver incident to war infections. (d) Spirilla have been demonstrated in animals, notably the horse, while veterinarians assert that a pandemic in animals paralleled the influenza epidemic. (e) The morbidity age of 18 to 35 parallels that of the military age. We wish to reiterate that we present the above theories, unsup ported by facts, not with any claim for acceptance or originality, but only that in the light of totally negative or confusing reports some seemingly unopened direction may be presented along which to further extend our efforts to clarify the etiology of the recent con flagration. G82 PETERSON INFECTIOUS DISEASES, VIRGIN ISLANDS. Vol. XIII. INFECTIOUS AND CONTAGIOUS DISEASES ON THE ISLANDS OF ST. THOMAS AND ST. JOHN, VIRGIN ISLANDS OF THE UNITED STATES, MARCH SEPTEMBER, 1918. ISy E. Petebson, Lieutenant, Medical Corps, United States Navy. On entering St. Thomas Harbor a very picturesque panorama unfolds. The city of Charlotte Amalia, built on numerous small hills, with houses scattered on the hillsides and in the valleys, gives the impression of an extremely clean community. The sanitary conditions of St. Thomas will, however, on closer observation, be found far from satisfactorj7. The conditions as they exist now are primitive, indeed. The reason for this lies in the very limited funds that have been available for sanitation. The present regulations are broad and give the sanitarian a considerable amount of authority, but where no money was to be had no improvements could be made. The largest and most thorough work done on the island in a sani tary line is the very complete system of surface gutters. These are, on the whole, made in a first-class manner, and take care of the surface water during the rainy season. The whole system of these smaller gutters is connected with gutters of larger size, which extend from the hillsides down through the city to the harbor. During the rainy season these gutters serve their purpose well, being the only outlet for the large amounts of water pouring down from the hillsides. After a continued dry period, however, they prove to be the cause of no slight disturbance through the ever-present odor. Small collections of waste water, mixed with urine at times, are responsible for this far from agreeable smell. One interesting incident may be recorded in this connection. On inspection of certain property near one of the large gutters the owner prided himself on a very ingenious mode of cleaning his pit privy. It was located in the basement on a level with the bottom of the gutter. A ditch had been dug from the slanting yard through the pit out into the gutter. The owner never had to clean this privy because after every heavy rainfall it was washed thoroughly clean and the contents carried out into the gutter, and from there through the city down to the bay. The sewage disposal is a problem of extreme importance in St. Thomas. A certain number of properties are supplied with pit privies, no attempt having been made in previous years to make them fly proof. A very few properties are supplied with sanitary surface privies. In the large majority of cases the night soil was emptied in buckets or cans, with hardly any attempt to cover them properly, and accumulated here for weeks, in many cases, before the cans were emptied into the bay. In the outskirts of the city and in the suburbs No. 4. 683 PETEHSON —INFECTIOUS DISEASES, VIBGIN ISLANDS. the night soil is, in many instances, thrown in the bush. Attempts are at present under way to supply all properties with properly cov ered receptacles for night soil, which are to be cleaned at least once a week. The garbage of the city is well taken care of. Hardly any edible stuff is wasted by the natives. Whatever garbage is left is collected every day by the street-cleaning department in conjunction with the street sweepings and is burned on two public dumping and burn ing places, located one at each end of the town. Another problem that presents itself in St. Thomas is the water supply. The city is nearly entirely dependent on the collection of rain water for drinking purposes. This necesitates a large number of cisterns, barrels, and tanks on the different properties. Up to the time of the American occupation hardly any attempt had been made to make these mosquito proof. Hence the overabundance of mosquitoes, the Stegomyia being the prevalent one. Diseases. —During the period of Danish occupation a very strict system of reporting diseases was in vogue. The system was not very practical working from a sanitary standpoint, although it formed an excellent basis for statistical reports. It included such conditions as continued fever, intermittent and remittent fever, in testinal catarrh, and acute diarrhea. Below is a comparative list of diseases as they were reported during the whole of 1916, and for seven months each, during the years 1917 and 1918, April to October and March to September, respectively : Actinomycosis Acute poliomyelitis Anthrax Asiatic cholera Amebic dysentery Bacillarv dysentery Balantidic dysentery Bronchitis Broncho-pneumonia Chancroid Chicken pox Chronic alcoholism Croup . Croupous pneumonia Continued fever Dengue fever Diarrhea, cause undetermined Diphtheria Dysentery Delirium tremens Epidemic cerebro-spinal meningitis. 191fi, whole year. 0 0 0 0 0 n o 324 26 45 45 16 0 !) 21 19 1 70 9 0 0 0 1917, April- October. 0 0 0 0 0 0 0 61 18 16 8 4 0 2 7 it; 0 11 2 0 0 1918, March- September. 37 21 •:■', 95 8 0 Erysipelas Fifariasis :i (I 0 10 i Not reportable. 684 PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. Vol. XIII. Glanders Gonococcus infection of genito-urinary tract Gonococcus infection of conjunctiva Intermittent and remittent fever. . . » Impetigo neonatorum Intestinal catarrh and acute diarrhea Leprosy Lymphangitis, cutaneous, recurrent Malaria Malta fever Measles Measles, German Mumps Pellagra Plague Puerperal infection Rabies in animals Rabies in man Relapsing fever Rheumatic fever Scarlet fever Smallpox Sore throat Sprue Stomatitis Streptococcus sore throat Syphilis Tetanus Trachoma Trichinosis Tuberculosis, pulmonary Tuberculosis, all other Typhoid fever Typhus fever Uncinariasis Whooping cough Yaws Yellow fever 1916,whole year. 0 48 10 41 0 325 0 (l 2 0 0 0 0 16 0 1 0 0 0 !) 0 0 11(1 0 0 (I 3 9 0 0 20 0 JO 0 0 0 0 0 1917 April- October. 0 42 3 !) 1 101 0 14 59 0 1 0 1 20 0 0 0 o o 0 o o i;> 3 S 0 10 1 0 0 14 0 10 0 0 0 0 0 1918, March- September. ") (') I2) (') 0 38 0 '!» 11 0 1 0 0 2 0 0 0 0 0 (t n 3 :; 1 1 38 o 12 2 46 0 10 0 0 0 ■Not reportable. * Sec Diarrhea, cause undetermined. Several points of extreme interest may be noted. No attempts had been made in previous years to differentiate between the various types of dysentery. Other interesting points to be discussed later under the different diseases may be noted. Take, for .instance, the large number of cases of intestinal catarrh and acute diarrhea dur ing the years 1916 and 1917 —325 and 161 cases, respectively. It is to be noted that these cases include the diarrheas of infants, which are not reported at present. But if the reports of the 1917 period, which are available at present, are analyzed, it will be found that 66 are under 5 years and 95 over 5 years. Compare this with the 8 cases of diarrhea, cause undetermined, reported during the 1918 period. This marked reduction is hard to explain at present. Some No. 4. PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. 685 of the above cases undoubtedly were caused by an infectious organ ism not diagnosed at the time. This will, however, not explain all of them. Another point of interest in the same connection is the large number of cases of pellagra that were reported during the years 1916 and 1917 — 16 and 26, respectively. During the 1918 period 2 cases were reported. The marked reduction in this disease is also hard to explain, because the living conditions are practically the same. A considerable number of the cases of continued fever and inter mittent and remittent fever can be explained, however. If we look at the comparatively small number of cases of typhoid fever during the years 1916 and 1917, as compared with those of 1918, the ex planation does not seem to be illogical that a certain number of cases of typhoid fever went unrecognized during previous years. As will later be shown, facilities for serological and bacteriological diagnoses of this disease were not available until March, 1918. Hence the apparently marked increase in this disease during the latter period. Hookworm disease has received very little consideration during previous years. The same holds true with trachoma. The latter disease is extremely common in the younger generation. The large increase in dengue fever during 1918 is explained by the large influx of susceptible Americans, represented by the military forces. One point of extreme interest that is brought to our attention is the absolute absence of smallpox on the island. The reason for this is to be found in the thorough vaccination that has been kept up from year to year by the Danish physicians. It can be stated, almost without any qualification, that this is the most thoroughly vaccinated community in the world. At a recent survey of the population, made in connection with typhoid vaccinations, very few cases were found who did not present typical cowpox scars. The present system of reporting diseases was introduced in March, 1918, and comprises the following diseases: Actinomycosis, acute poliomyelitis, anthrax, Asiatic cholera, amebic dysentery, bacillary dysentery, balantidic dysentery, chancroid, chicken pox, dengue fever, diarrhea (cause undetermined), diphtheria, epidemic cerebro spinal meningitis, erysipelas, filariasis, glanders, gonococcus infec tion of genito-urinary tract, gonococcus infection of conjunctiva, leprosy, malaria, Malta fever, measles, measles (German), mumps, pellagra, plague, puerperal infection, rabies in animals, rabies in man, relapsing fever, scarlet fever, smallpox, sprue, streptococcus sore throat, syphilis, tetanus, trachoma, trichiniasis, tuberculosis, (pulmonary), tuberculosis (all other forms), typhoid fever, typhus fever, uncinariasis, whooping cough, yaws, and jrellow fever. 686 PETERSON —INFECTIOUS DISEASES, VIRGIN ISIANDS. Vol. XIII. DISEASES OP THE 1918 PERIOD. Chicken pox. —Quite a few cases of chicken pox appeared in St. (MCKEN POXtST. THOMAS, vr.of USA Thomas during the spring months. March had 3 cases; April, 10 cases; May, 7 cases, and June, 1 case. Partial isolation of these cases was attempted by keeping the children at home. Measles. —There is a question of the presence of this disease on the island at the present time. Some time ago a case of German measles was re ported. Further investi gation proved this to be a case of dengue fever with a well-marked rash. Not long ago a true case of measles was reported in fio. i.-chicken pox, i-.is. a negro boy, with sup posedly typical Koplik spots and a rash. The case was placed in the hos pital and the home was quarantined for two weeks. No other case de veloped, which speaks for a possibly mistaken diag nosis. The similarity be tween the eruption of dengue fever and measles, especially in children, will be spoken of later. A cu te 'poliomyelitis.— This disease has appar ently visited this island several times during years past. This year five cases were reported —four in March and one in April. fio. 2.—Acute poliomyelitis. Of these the youngest case was 8 months and the oldest 4 years. T 9l f fLo MAR. APR. MAY juNe JULY AUG. SEPT. OCT. NOV. DEC. 1 „ ;n 0 I ^ \ / 7 \ e, \ s \ 4 I 1 7 \ 1 \ 0 \ — . A. 12 MAE APR MAY JUNE JULY AUG SEPT. OCT NOV. DEC. II 10 9 ft 7 6 5 4- \ 3 > ? v v 1 V 0 \ No No. 4. PETERSON INFECTIOUS DISEASES, VIRGIN ISLANDS. 687 relation or possible connection could be established between the above cases. Hospitalization was enforced in all cases. Leprosy is at present very rare in the island of St. Thomas. This is the only disease of which we have a complete record covering a considerable period of time. The accompanying chart shows the gradual disappearance of this disease. The number of cases charted for 1897 indicates all the cases present on the island that year. After that only newly discovered cases are recorded. For a number of years all lepers have been sent to the leper asylum at St. Croix, Virgin Islands of the United States. This isolation, with thorough disinfection of the premises occupied by lepers, has apparently been responsible for the decrease in this disease. So far this year (1918) I F.PRaTY-ST. THOMAS. VI.dF US. ■■:Ki? 55 - j— 1 It" , i V 1 5»- A V& V ✓ Fio. 3.— Incidence of leprosy for 21 yearB. only one new case has been discovered —a young girl of 11 years, with typical nodular lesions, the bacillus leprae being present both in the uasal discharges and in the nodules. No history could be obtained to ascertain the possible source of infection. This patient was also sent to the leper asylum at St. Croix. The only case of leprosy known to the Department of Health to be in St. Thomas at present is an old Jewish woman suffering from the anesthetic type. She is one of 29 cases present in 1897, and has been kept in isolation ever since. It is to be noted that the disease has been prevalent in her family in the last generation, her brother, two nieces, and one nephew having died from the disease. At present she is the only member of the family suffering from leprosy. 688 PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. Vol. XIII. PULMONARY TUBERCULOSIS J& THOMAS VLoriMEUS. Venereal diseases.—Venereal diseases are extremely prevalent in St. Thomas. From March to September, inclusive, the following cases have been reported: Gonorrhea, 38; chancroids, 37; syphilis, 31. The control of these diseases at present is a difficult undertaking, due to lack of funds. The local law, however, is very broad in this re spect, leaving wide powers with the health authorities. It is criminal to have sexual intercourse when knowingly afflicted with venereal disease, and isolation of all contagious and infectious diseases is left in the hands of the health authorities. Due to the comparatively small area of the island, a complete control of the situation would be possible if funds and space for isolation treatment were available. The local mu nicipal hospital takes care of all virulent cases. Yaws. —This disease oc curs in St. Thomas. No case has been discovered, however, since March, 1918. Tuberculosis. — P u 1in o - nary tuberculosis is quite common in St. Thomas. The poor living conditions and extreme poverty of the inhabitants are un doubtedly responsible for the frequency of this dis ease. In spite of the warm climate, it is surprising how closed in the dwell ings are. Windows, shut ters, and doors are all closed during the night. The numerous persons living and sleeping in each room increase naturally to a marked degree the chance for infection. The poor quality of the food has lowered the resistance of a large number of the inhabitants. Tea and a piece of bread for breakfast; a little nourishment, consisting mostly of porridge or mush, for luncheon ; while supper, as a rule, is composed of fish. On the whole, it is astonishing how little food can keep some of these people alive. At present time, however, the wages are rapidly going up and a higher standard of living will, without question, in time replace the present rather low one. 12 II 10 9 6 7 6 5 4 3 2 I 0 -In In MAR. APR. MAY JUNE juy AUG. SEPT OCT. NCV. DEC. \\ V VAV Fio. 4. — Tuberculosis, 1918. No. 4. PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. 689 TRACHOMA.-ST.THOMAS VLtf US. MA!?APR MAYJUNE1 sept OCT NOV DEC — The following cases of pulmonary tuberculosis have been reported : March, 4; April, 1; May, 2; June, 0; July, 2; August, 1; and Sep tember, 2. Tetanus. —Only one case of tetanus lias occurred since March. Tmchoma. —Trachoma is extremely common in St. Thomas and St. John. The close relation between all the members of a family and the lack of personal cleanliness are the causes of this widespread condition. The following cases have been re ported on the two islands : April, 1 ; May, 33 (32 of which were found amongst school children in St. John) ; June, 0; July, 0; August, 1; Septem ber. 3; October, 3. A survey of all school children in St. Thomas is going to be made within a short time and will undoubt edly reveal a marked prevalence of this disease. FlQ 5._Trachoma, 1018. MOSQUITO-BORNE DISEASES. In spite of the extreme abundance of mosquitoes on the island, the mosquito-borne diseases are rather rare, with the excep tion of dengue fever and filariasis. The predominat ing mosquito present is the house variety (Stegomyia), which breeds in the cisterns, tanks, and barrels scattered over every property. Ex treme efforts are now being made to eliminate and de stroy all mosquito-breeding places, a truly difficult un dertaking. The people are at the present time abso lutely dependent on rain water for drinking pur poses. On a large number of properties no cisterns ex ist. The poor tenants col lect the water in barrels, A slight -Mr MAE. APR. JUNE AUG. oa. NOV. DEC. A / l\ A A V v \N 12 II 10 9 a 7 6 5 4- 3 2 J 0 Kio. C— Malaria, 1918. tubs, or pails, which soon become alive with mosquito larva; 690 PETERSON INFECTIOUS DISEASES, VIRGIN ISLANDS. Vol. XIII. headway is, however, made in rendering the different properties more or less mosquito proof. Yellow fever. —Yellow fever is extinct in St. Thomas and St. John at the present time. Filariasis.—Filariasis is endemic on the island. Occasional blood examinations of groups of patients at the municipal hospital have revealed the following number: June, 4; July, 3; August, 2; Septem ber, 1. Filariasis is reported to the sanitation service only when the infesting organism has been found. The majority of the above pa tients apparently suffer no ill effects from their infestation. Ele phantiasis is not so common in St. Thomas, although a few cases of lymphscrotum and " big leg " may be found. Malaria. —Malaria apparently appears at times on the island. Local physicians state that during the months of September and October malaria used to develop quite regularly. This year, how ever, comparatively few cases have been reported: March, 1; April T 4 ; May, 0 ; June, 2 ; July, 1 ; August, 2 ; September, 1. Cases. Address. 1 2 St. John 3 Estate of Elizabeth.. 4 Hansels have B. P. . . 5 Estate of Elizabeth.. li Dronningensgade 67a 7 Prinsensgade 1, K. Q. 9 Silkegade :5a Onset. 1918. Mar. 8 Type. Notes. Aestivo-autumnal (?) Apr. 4 ...do J Feb. Tertian. do.. (»)• (»)■ 10 11 Estate of Charlotte Amalia. Ship July 2 Aug.7(?) Aug. 28 (?) Aesti vo-au tu mnal Tertian Not found Tertian Aestivo-autumnal Tertian Aestivo-autumnal (?) Has been living on estate of Crown for 6 years; first attack in 1917; na tive and inhabitant of St. John. Child of 1 month. (See case 5.) Was working at Botany Bay for 3 weeks before taken sick; malaria is supposed to occur at mull place. Mother of case 3; first taken sick in Porto Rico, Feb. 2, 1918. Therapeutic test posi tive; formerly lived at hospital ground 3. I First attack in Quantico, Va. Possibility of receiving infection in Macoris, Dominican Republic; was there for 5 months in beginning of year; is not sure when he was first taken sick. Infected in Brazil (tran sient case). Of the above cases only half may rightly be charged to St. Thomas proper. They are cases 1, 4, 6, 8, and 10. The rest apparently are No. 4. PETERSON INFECTIOUS DISEASES, VIRGIN ISLANDS. 691 imported cases. Case 2 developed on St. John, a contiguous island. Cases 3 and 5, child and mother, are recent arrivals from Porto Rico, where, as the mother definitely states, she had the first chill. Case 7 is a marine who gave history of having received the infection in Quantico, Va. Case 9 gives a history of having visited Macoris, Dominican Republic, during the first five months of the year. He is not sure when he was first taken sick. The probabilities are, however, that he contracted the disease in Macoris. Case 11 is a transient, giving a history of infection in Brazil. Of the cases above reported, it seems that all living in the city proper give a pretty definite his tory of having been infected in foreign places. All native cases have developed in the rural districts, where in years gone by, according to local physicians, malaria had been more prevalent than at present. Spasmodic attempts to find the anopheles mosquito in St. Thomas have hitherto been fruit less. A more systematic search during the last few months has resulted in locating several breed ing places for anopheline mos quitoes. These are at present the subject of study and investiga tion. Dengue fever. —Dengue fever is extremely common in St. Thomas. During the period of discussion, the following cases have occurred: March, 2; April, 1; May, 4; June, 5; July, 15; August, 16 ; September, 52. The incidence dropped markedly dur ing October. The accompanying chart shows how the headquarters detachment of the United States Marines suffered the most. The main barracks are located in the middle of town by the shore. On the premises are five cisterns and three tanks, all of which have been screened. The men sleep in tents; all cots are furnished with mosquito nets. In spite of these precautions, mosquitoes appear in numbers. The East Point and Mosquito Bay detachments are located outside )-% 1 -i (i lac MAR APR MAY JtM 1 T OCT NOV. i 1 1 I ! II | |1 1 f » I i i I !1 / j .— - | I I 1 - ^ _ 1 - / 1 j j / J 1 r '■/ 1 ) i \ I ■J . V i \ f % V + - 1 i - Fia. 7.- H. Q., Bay. -Dengue. (A) Marine (B) East Point, (C) Barracks Mosquito 692 PETERSON —INFECTIOUS DISEASES, VIRGIN ISIANDS. Vol. XIII. the city. At these places mosquitoes are quite rare, with correspond ing falling off in the incidence of dengue. The most common mosquito present is apparently the Stegomyia calopus, very few Culex having been found. This fact seems to carry out the findings of Burton, Cleland, Bradley, and McDonald, of Australia, who proved that Stegomyia calopus was the transmitter of dengue (Manson, British Medicine in the War, 1914—1917, p. 101). The possibility of Stegomyia calopus being the transmitter of dengue was also recently emphasized by Lane (U. S. Nav. Med. Bull., Vol. 12, No. 4). A very interesting situation lias arisen during the month of Octo ber. The first of the month an eruptive fever occurred in a white family. A diagnosis of dengue fever was made. The rash was extensive, however, resembling markedly that of measles, so much so that the correctness of the previous diagnosis was doubted. The child was placed under quarantine and an investigation made of all sick children at the school attended by the patient. During the week 23 children were kept at home on account of sickness. Investi gation of these cases proved that all suffered from a respiratory infec tion and were sick for two or three days with fever and cough. All these cases were considered to be influenza. Two weeks later, how ever, the brother of the first-mentioned child was also taken sick. He had a typical onset of influenza with some cough. No Koplik spots occurred, but on the fourth day a marked erythematous rash appeared, identical in nature with that of his brother, resembling measles. A white blood cell count was made, and found to be 2,100 with about 45 per cent of lymphocytes. This case was then also re corded as a case of dengue fever. The child attended the same school as his brother, and a new investigation was made of all children absent from school. It was found that 26 children were absent. In spection of these cases revealed the same condition as during the previous week with the exception that three cases had eruption. One white child had identically the same eruption as the two children previously mentioned. Two others of mixed blood had the type of eruption often found in dengue fever. The question of a differential diagnosis now comes up. Measles, according to local physicians, occurs at intervals of several years. When an epidemic appears, it sweeps the entire island. The present condition certainly is a limited affair as far as the eruptive fever is concerned. In no one of the above cases were Koplik spots found. The case previously described as positive measles oc curred in another part of the city and was not followed by any sec ondary cases. These facts seem to exclude the probability of the No. 4. PETEBSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. 693 present cases being measles. Quarantine of all premises where the eruptive fever occurred was instituted, however. Influenza must be taken into consideration, due to its prevalence at present and on account of the respiratory complications. That many of the children absent from school and suffering from cough and fever for a few days were victims of mild attacks of influenza is un doubtedly the case, but the ones who had eruptions apparently suf fered from another disease. Dengue fever must not be lost track of in this connection. Dengue fever is endemic on the island. There were 52 cases reported during the month of September. The sudden onset, the typical leucocyte count, and the rash speak for dengue fever. The respiratory symp toms may be caused by a complicating influenza. It is to be noted that the marked eruption occurred only in white children. A very instructive case is brought to mind. Last year an officer's child was taken sick with eruptive fever. The junior medical officer, recently arrived from the States, made a diagnosis of measles. The diagnosis was soon changed, however, on advice of senior men, to dengue fever. Hence it seems that the rash of dengue fever is more extensive in the young child and may resemble that of measles. Influenza. —The pandemic of influenza of the present year has exacted its toll among the population of St. Thomas and St. John. The number of cases undoubtedly came up to several hundred. The exact number can not as yet be ascertained, because this disease was not one of the reportable ones, but, due to the exact records kept at the Municipal Hospital of not only the hospital cases, but also of the out patients as visited by the municipal physicians, a more or less complete report of the number of cases that actually occurred will soon be a matter of knowledge. Pulmonary complications have been quite common, and several deaths from broncho-pneumonia have occurred. It is to be noted that the warm climate decreased the virulence of the infection markedly. Comparatively few cases have developed among the white population, who, as a rule, live in a more hygienic manner than the natives. It is the poorer classes, afraid of the eastern wind, and given to closing up their sleeping quarters tightly, who are the biggest sufferers. The crowded conditions of their dwellings must also be emphasized. GASTROINTESTINAL INFECTIONS. Amebic dysentery. —Amebic dysentery apparently is not so very common on the island. Since March the following cases have been reported: March, 0; April, 4; May, 1; June, 3; July, 0; August, 1; September, 1. 133354—19 5 694 PETERSON—INFECTIOUS DISEASES, VIRGIN ISLANDS. Vol. XIII. Balantidic dysentery.— One case was discovered in the municipal hospital in May. This patient also suffered from uncinariasis. She AMEBIC DYSENTERY ST. THOMAS VI.of USA. rl-rO-r1_tG MAR APR MAY JUNE JULY AUG SEPT OCT NOV. dcc. A T / \\ A / V / V \ has never been away from the island. Schistosomiasis. — One case was discovered in June in a transient from one of the British West India Islands. Uncinariasis. —Hook worm disease is not com mon in St. Thomas. The discovery of the present cases is due to the routine feces examination as car ried out in the municipal hospital. Nineteen cases have been reported from March to September, in clusive. Of these, 10 are of foreign origin, 8 being discovered at one time among a shipload of col ored people en route to fio. 8.—Dyoentery, 1918. New York from one of the British West India Islands. Of the other nine, four were in the hospital for treatment of entirely different ailments. Four were also living in the city proper, while five were living in the rural districts. Of the whole series, 2 were white and 17 colored. Typhoid fever. —It has been stated by resident physicians that typhoid fever has never been as frequent as during the last six months. This state ment, however, must be ques tioned. No up-to-date methods of diagnosis have been in vogue, and a certain number of patients have died or re covered from such diseases as continued fever, intermittent and remittent fever, acute diarrhea, etc. Typhoid fever Km. ».- i;uctuuntt«». has been very common during the last six months. Facilities for 12 II 10 9 6 1 6 5 4 3 2 I 0 MAR APR MAY JUNE JULY AUG sen OCT NOV DCC e t vrrm h 1 v TOAN 9 / \ / / \ \ / f v / No. 4. PETERSON —INFECTIOUS DISEASES, VIBGIN ISLANDS. 69 5 serological and bacteriological diagnoses were made available at the United States Naval Hospital in April, 1918. Only a comparatively small number of families receive milk regu larly from a distributor, the big mass of the people buying theirs from different venders in the street. This may account for the unusually large number of supposed cases. The following numbers of cases occurred during the different months: March, 3; April, 7; May, 9; June, 16; July, 10; August, 1; September, 0. From an epidemiolog ical standpoint these cases make a very inter esting study. From the very peculiar local con ditions the common ave nues responsible for the spread of the disease may be excluded. The entire city is al most wholly dependent upon rain water for drinking purposes. The cisterns, barrels, etc., used for the collection of this water must, from a bacteriological stand point, be considered satisfactory. The chance for their infection is small. In this series of cases no positive evi dence whatsoever could picion of any cisterns, as being responsible for small epidemics, be proved to be the cause. This is not, however, due to the fact that the milk supply in St. Thomas is carefully guarded against infection. The most primitive means are used in its distribution. It is, as a rule, trans ported to town in bulk and dipped out to the consumers. Some is distributed in bottles. One dairy only uses the standard American milk bottle. This irregularity in distribution would make it very difficult in deed to trace an epidemic to any special source of milk supply. The TYPHOID FEVER ST. THOMAS VLoPUSLA, r9-r»-r8 2t MAR. APR. I1AY JJNE AUS. 5£P7 OCT. NOV. DEC. s 22 21 20 B 16 17 1;.' A K rt H / > O a I II 10 j 0 / a 7 / 6 / 5 / / 4/ 3 c 1 0 Fio. 10.—Typhoid fever. be obtained which would lead to sus- Neither could milk, so often described 696 PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. Vol. XIII. danger from this insanitary way of handling milk is, however, over come to a very large extent by the nearly universal habit of boiling the milk before consumption. Many other routes are open, however, for the spread of typhoid fever. The careless manner, previously described, in which night soil is removed from premises, together with absence of all ideas of cleanliness amongst the people at large are, it appears, the factors that have been mostly responsible for this epidemic. The habit of the people of placing their night soil in a little can or bucket, never properly covered, and keeping same on the premises for weeks before cleaning, seems, indeed, to be the cause of the present epidemic. Another factor of importance is the people's habit of moving from one place to another. The pauperism of so many of the inhabitants, together with loose family relations, are responsible for the lack of stability in this connection. The infected privies and other recep tacles for night soil are in this manner very much increased in num ber. The link between infected receptacles and susceptible indi viduals, namely the fly, is present everywhere. These same infected privies and buckets were found to contain large numbers of maggots. The following report represents a few epidemiological data in this epidemic: 2? OS Located. Kongensgade 6. Dronnin gensgade K. Q. 35b. Kronprinsensgade 65. Prinsensgade 18a. . . Norregade 12 K. Q. ....do ....do Rosa 18 Kongensgade 13 Admitted to hospital. 1918. Mar. 1.. Mar. 25. Mar. 30. Apr. 13. Apr. 24. Apr. 25. Apr. 24.. (a) Taken sick. 1918. Feb. 20. Mar. 21. Mar. 23. Apr. 7.. Apr. 3. . Apr. 18. Apr. 21. ...do.... Mar. 28. Discharged. 1918. Mar. 30. . Apr. 25.. May 11.. Apr. 17 (') June 9... . ..do Aug. 30.. Laboratory finding. Wid.+l-50 Cult.+B. t Wid.+l-80 Ant.+ Not made B. t. from stool B. t. from stool. Wid.+ Wid.+ Wid. not made. Clinical picture. • Death. Notes. Moved to Palmestraede No. 6 one week before taken sick. Milk from woman who sells for Mrs. M. V. Cid, of John Bruce Bay. No milk; no privy; house utensil with few flies. First in series of 3 cases on these premises; second, No. 6; third, No. 7; privy in very insanitary condition, with numerous flies; milk from Raimer estate. Note. — Moved to Comman- dantgade 22 three days before taken sick. Same premises as above Same premises as above; last two probably infected from Case No. 5. Ross 18 — suburb east of town Worked and ate at Kongensprade 13, where insanitary surface privy; slept at Norregade 34, where house utensil took place of privy. Note. — Nearest previous cases at Kongensgade 6. 7 yards distant and at Prinsensgade 18a, 5 yards distant. < Not In hospital. Milk. From Mr. Fabio; al ways scalded. From Mrs. Beretta; always boiled. Mrs. M. V. Cid. No milk. Raimer estate. Mrs. Gray from Jur- fensen's dairy Tutu, forregade 19. Maria Simmons. Seldom milk. No milk. 698 PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. VoL XIII. o a o := '•3 3 co o c a .> 5-/3 >>2 p. a 3 » > 9» 5 ■- ° - 9^ §~ CD •a >. CI •9 . e2 4 33 111 II C fc. c c c — . o o ^ o *S T . m os 0v «*. . . _ co cc c c « ! C)„ - a , C "j Cl ; &C13 .-a s = cj ^ a, a a o.a a -3 si " If H "is .. 0 5 tc |t| Z £ g o o S2iS .5 + + o + 15 o o •O 13 c oca ^"5 a c T3 < ■8a 2 a | E8 3 5 C5 ^ rl ft, It C 13 C 3 3 ■&, = a a o o CMCO a a c 13 CJ 13 5 c 3 » No. 4. PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. 699 9 o S5 3 3.fi . III f f.g $ £ to 03 3 -g ©a u to fe 3 §9 83 ■»5 o » 3 S O- §Z J3 S a ft «al O o a 9 5 3 55 m a .+ ® 2.8-; m 4>-9 1 +*1 ++ rOT3 Ma- -3 3 + •a •— — 15 oo_>> tffl 3 3 3 ■-» to 3 - 3 c a 3 3 ii EOT O 2§ o 3 3 | 3 3 H51-5 c- o a 3 3 a 3 3 3 3 3 Pi -1 s 5 o 3 B — 1 3 ■I 3 No. 4. PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. IS s iu 8 ±^ JSp« •o § 1 8-S •c It- 1 s 3CO CD 3 ■*-» 3H ~ a o moss "S S I .8 O ™- CP o OS*J c CP co I"sill's «.2 .c cp *• ja !li ■CI* y a 3: .2 ■o-a a So ^ o So cj ++ •6-6 J + 'is ++ + + + is ES I* + C5 S3 09 OB 09 S3 CN Aug. Aug. Aug. Aug. Sept. Aug. Sept. Aug. S 3 §3 S rH June June July June July July July July July July Aug. CO CO i-l CO rH CM CM CM CM CM CM rH CO July July July July July July July July July July CO >■ si >>o > P cc is, c S I! • Q rH CM > tP S)< .2 si CO^ o 2 ■0 702 PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. Vol. XIII. It is to be noted that the first five cases occurred in widely sepa rated places in the city. No connection could be traced between these cases. Cases 1, 3, 4, and 5 received milk from different sources. Cases 1 and 2 always boiled their milk and Case 4 did not use milk at all. It is also to be noted that Case 1 moved one week before being taken sick from Kongensgade 6 to Palmestraede 6, Queen's Quarter. Three and a half months later Case 25 developed at Palmestraede 5dd, two house lots from Palmestraede 6, and six days later Case 34 developed at Palmestraede 5aa, next property to 5dd. Three months after Case 1 was taken sick Case 18 developed the disease on property Kongensgade 6. Case 5 moved to Commandantgade 22 three days before being taken sick, up to whi( h time she had lived at Norregade 12. About two weeks later Cases 6 and 7 also developed at Norregade 12, and about eight weeks later Case 35 was taken sick at Commandantgade 8, just across the street from Commandantgade 22, to be followed about two weeks later by Case 26 on same propery. Diagrams shotcing the possible interrelation between the different cases of typlwid fever. y& —"30"— "42" 17 K"34 19 X18 J20 2— 23 3- 29—32 31 6 36 7 39 35— 26—"28"—38 41 8 33 45 —10 It is to be noted that Cases 5 and 9 were not isolated in the hospital, and farther that Case 9 was considered a doubtful case and escaped the rigid routine of later cases. Case 8 developed on " Ross estate," a suburb on the eastern side of the town. About two months later his brother, Case 33, developed typhoid fever. This patient was a sailor by occupation and came home regularly every week, when he visited his brother. Case 9 has proved to be a very important link in this particular epi demic. Whence this case possibly received her infection we are unable to state. The nearest cases are Case 1, Kongensgade 6, seven house yards distant, and Case 4, Prinsensgade 18a, five yards distant. The No. 4. PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. 703 following cases may without question be charged to Case 9: Case 10, who took sick two weeks later, lived at Dronningensgade 10, King's Quarter, just two lots distant from Kongensgade 13. Case 11 lived at Norregade 26, King's Quarter, when taken sick (Apr. 30, 1918), but had stayed with her sister at Kongensgade 13 between April 13, 1918, and April 22, 1918. The mother of Case 12 had worked at Kongensgade 13 since the illness of Case 9. Mother stated, however, that she never took any food home and that the son never visited these premises. Cases 13 and 14 lived next yard to Case 9, the privy used by Case 9 being directly under a hall window -of the house where these sases resided, Dronningensgade 13, King's Quarter. Cases 15 and 16 were taken sick approximately at the same time as Cases 12, 13, and 14- They lived just across the street from the last two cases. Case 24, at Prinsensgade 25, was taken sick about one month later. He lived just behind Dronningensgade 50 and Hospital- gade 2, where Cases 16 and 15 resided. Case 22 came down with ty phoid at Norregade 19 about May 28, 1918, one month after Case 11 was taken sick at Norregade 26, just across the street, where she had moved from Kongensgade 13. Later two other cases developed at Norregade 19, namely, Case 27 (June 17, 1918) and CaseS7 (June 24, 1918). The latter case resided at Kongensgade 51b, but associated closely with his playmate {Case 27) at Norregade 19. Case 40 developed at Dronningensgade 52, King's Quarter, six cases of above typhoids being within a radius of three house lots. One important factor in the epidemiology of these latter cases is that Case 9 was a private case, and consequently not taken to the hospital for isolation. Further, it was considered a doubtful case and escaped the rigid routine of the positive cases. The large number of secondary cases that developed and could be traced to this particular case may thus be explained. Compulsory hospitalization of all cases was soon after made the rule. Here it may also be stated that Case 5 was not isolated in the hospital. These two cases show the largest number of secondaries and emphasize the importance of hospitalization of typhoid fever patients in order to insure a satisfactory treatment of the excreta. Case 17 developed on a small contiguous island, St. John, and was sent to the municipal hospital, St. Thomas, with diagnosis of septic abortion. Cases 19, 20, 21, and 23 can not be traced to any definite source. They all four received milk from different parties. Case 19 was con sidered a doubtful case, was not in hospital, and had negative Widal reaction. Case 28 at Commandant Tvergade is difficult to trace. This child was taken sick (June 6, 1918). The nearest premises where typhoid fever had occurred was at Commandantgade 8. This is, however, about five house-lots distant from above place. Case 38, 704 PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. Vol. XIIL a brother of Case 28, lived at Commandantgade, O.V 12bb, but as sociated closely with his sister and developed typhoid about a month later. Cases 29 and 32 are also a brother and sister, living at Vester- gade 42, who developed typhoid practically at the same time. No possible trace to the source can be established. Case 30 presents a very peculiar aspect. This patient lived at Kronprinsensgade 49, but was in the habit of visiting his father who lived in Palmestraede not far from No. 6, where Case 1 had resided, and from No. 5dd, where Case 25 was taken-sick (June 14, 1918). Case 30 was reported as suspect typhoid June 12, 1918. On July 12, 1918, however, he was reported as not typhoid due to the absolutely negative results in all laboratory findings. Widal reaction was negative. Cultures from blood, urine, and stool all proved negative. Case 42 was taken sick with typhoid on July 15, 1918. This is a 2-year-old child, liv ing next door to Case 30, at Kronprinsensgade 48. This speaks for the possibility of Case 30 being a positive case. Cases 31, 36, 39, 41, 44, 45, and 46 all developed in widely sep arated places, except Cases 44 and 46, WQo were cousins, and taken sick at practically the same time. Types of infection. —In all cases where the causative organism was isolated from blood or feces the bacillus typhosus was found. No case of paratyphoid presented itself. Number of deaths. —Of the 46 cases of typhoid fever that occurred in this epidemic, four died, giving a death rate of 8-fo per cent. Methods of control.— Sanitary improvements on properties. This epidemic of typhoid fever served as a distinct reason for compulsory repair of all the properties where typhoid fever developed and also in the neighboring properties. As soon as a typhoid fever case was reported to the sanitation service, the premises on which it occurred was investigated and privies, receptacles, and water containers ren dered fly and mosquito proof as speedily as possible. Frequent in spections by the sanitary inspectors were made in an attempt to keep the premises up to standard. Many difficulties were encountered. The large majority of pits were found to be in anything but a sani tary condition. Some consisted only of the pits with the remnants of the old shade privy serving as some sort of camouflage, giving flies and all kinds of insects free access to the contents. The native night-soil receptacle was ordered to be covered, and at intervals to be sprinkled with kerosene. At the present time a uniform system of night-soil removal is being installed by the sanitation service, which system will supply every property with properly covered recepta cles, to be removed and replaced by a clean one at least once a week. The importance of sanitary improvements on the properties has now No. 4. PETERSON —INFECTIOUS DISEASES, VIRGIN ISLANDS. 705 been impressed upon all the property owners, and repairs of this kind are now in full swing all over the city. Hospitalization of all typhoid' fever patients. —Soon after the outbreak of this epidemic all cases were required to go to the hos pital. The importance of this in a community of this kind is seen in cases 5 and 9. This latter case was sick for two or three weeks before a physician was called. It further did not present a typical picture of typhoid and no Widal reaction was made. Hence it escaped the rigid routine of other cases. The patients were kept in hospitals until the excreta were found to be free from typhoid bacilli. Vaccination. —August 5, 1918, universal vaccination against ty phoid fever was instituted by the chief municipal physician. The vaccine was made in quantity at the U. S. Naval Hospital, St. Thomas, from local cultures. The vaccine consisted of 24-hour-old bouillon cultures, rendered sterile by heat and later tested for ste rility. The vaccinations were performed at the municipal hospital. All inhabitants of St. Thomas between the ages of 5 and 45 years who had not had typhoid fever recently, or who had not been previously vaccinated, were to appear at said hospital at designated hours and days. One hour a day, between 3 and 4 p. m., was set aside for this purpose. Two injections one week apart were con sidered enough to immunize for all practical purposes, the dose being 1 and 1£ c. c, respectively, for adults. Children were given correspondingly smaller doses. The inhabitants of the city proper were first vaccinated, then the suburbs and outlying estates. In this manner 6,784 people were vaccinated in about two months with no marked disturbance in the industrial affairs of the island. Forty persons presented certificates to the effect that they had recently had typhoid fever or that they had been previously vaccinated against typhoid. Of the 46 cases of the present epidemic, 39 belong to this group, 7 being excluded for the following reasons : 4 patients died, 1 was from St. John, and 2 were under 5 years of age. The total of immunized people then comes up to 6,863. The census of 1917 gives the number of people in St. Thomas between the ages of 5 and 45 as 6,999. Hence, 98.5 per cent of all people between the specified age limits have been rendered immune against typhoid fever. CONCLUSIONS. As a peculiar coincidence it may be stated that not a single case of typhoid fever developed since the day vaccination was started. The greatest number of cases appeared in May, June, and July—9, 16, and 706 PLEADWELL—NAVAL AMBULANCE TRAINS. Vol. XIIL 10, respectively. A sudden drop occurred in August, when only 1 case developed early in the month. The reason for this sudden disappearance of typhoid fever is hard to understand. The effect of the vaccination could not be established so soon, especially when it is considered that the same was begun in King's Quarter and from there extended westward to Queen's and Crown Prince's Quarter, and later to the country districts. It is to be noted that the later cases of typhoid occurred in Crown Prince's Quarter and in the country districts, where vaccination was not started until September. The natural decline of the curve must be taken into consideration, although no comparative figures are at hand to show when it occurs in these parts. One factor that undoubtedly has had marked bearing on the control of the situation is the hospitalization of all cases as soon as the disease was suspected. The importance of this has previously been discussed with regard to cases 5 and 9. Another factor that without question has played a role in checking the disease is the systematic improvement of the sanitary conditions on the infected premises. The early hospitalization, together with these improvements, less ened to a marked degree the danger from the ever-present fly, whose season is continuous in this climate. When typhoid fever occurs again a radical change in the curve will undoubtedly present itself. The effect of the typhoid vaccination will then be established, and from the figures previously submitted will protect 98.5 per cent of the population between the ages of 5 and 45. A compulsory vaccination every fourth year should keep the incidence of typhoid down to a minimum, or possibly completely eradicate the disease. NAVAL AMBULANCE TRAINS OBSERVED IN GREAT BRITAIN By F. I.. Plbadwbll, Captain, Medical Corps, United States Navy. The larger naval hospitals of Great Britain are placed in or near the southern naval ports, their location here having been the result of strategical considerations governing policy in the past. When, however, the strategy of this war placed the Grand Fleet well to the north, the evacuation of sick and wounded from the vessels of the fleet to the larger naval hospitals in the south involved the organiza tion of a new and special system of transport, unique in the history of the navy. The absence of hospitals with adequate bed capacity in Scotland was met partly by the use of hospital ships with the fleet These ships might have served to convey the excess sick and wounded to the southern hospitals, but this course was found to be imprac- No. 4. BLEADWELL—NAVAL AMBULANCE TRAINS. 707. ticable owing to difficulties of navigation, particularly in winter, through the narrow channels of mine fields, and finally because of the requirement that these ships should not be sent far from the fleet bases in the north, where they served as hospitals. Hospital ships did operate between the northern base at Scapa and the other bases at Invergordon and in the Firth of Forth, but for transport beyond this point ambulance trains became the routine medium by which the sick from the fleet were conveyed to hospitals. Four naval ambulance trains were organized and equipped for this service during the war. One, the smallest, did a shuttle service between the base at Ivergordon (Cromarty) and Leith, and the three remaining trains were operated on routine and emergency trips between Leith and the naval hospitals at Plymouth, Portland, Ports mouth, and Chatham. The naval hospitals at Queensferry and Leith, in the vicinity of Edinburgh, had a limited capacity, and the hospital projected for Rosyth had not been constructed. The shuttle train (No. 4) was inspected at Inverness, Scotland, on July 19, 1916, but a more extended experience was had in June, and again in September, 1916, in train No. 3, which will be described at length. On the first occasion the train was dispatched from Chat ham to Plymouth to meet the hospital ship Rewa, arriving from the Mediterranean with sick collected from Mudros and Malta. Distri bution of patients was made first at Gosport for Haslar Hospital, and then at Gillingham for Chatham Hospital. On the second occa sion the train was boarded at Craigentinny near Edinburgh. Stops were made at Leith and Newcastle and the patients distributed to the hospitals at Plymouth, Portland, Haslar, and Chatham. Train No. 3 was an improved type of one organized early in the war by Surgeon General (now Surgeon Vice Admiral) Sir James Porter, K. C. B., Royal Navy, former medical director general of the navy, who had resumed active service during the war as principal medical transport officer. To him and to his assistant, Acting Staff Surgeon (now Acting Surgeon Lieutenant Commander) A. Vavasour Elder, D. S. C, R. N. V. R., the writer is greatly indebted for the privilege of making two extended trips in this train and for the opportunity thus afforded of observing its construction, equipment, organization, and administration. The Royal Naval Ambulance Train No. 3 was converted for ambulance purposes by the Great Northern Railway and was commissioned on June 2, 1916. The train was in charge of two surgeons of the Royal Navy, temporary service, and comprised 12 coaches with a capacity of 146 patients, in the following classes, viz: Officers, cot cases, 20; officers, sitting, 10; men, cot cases, 116, making a total of 146. Four additional emer gency cots could be rigged if necessary. The sick berth staff, waiters, cooks, etc., numbered 36. By utilizing the spare room in the staff 708 PLEADWELL—NAVAL AMBULANCE TRAINS. Vol. XIII. coach and fitting two bunks, two nursing sisters could be accommo dated, but ordinarily women nurses were not carried in the comple ment of the train. The 12 coaches were all of the "bogey" type, converted to this use from ordinary rolling stock and marshalled in the train in the following order: 1. Crew and general coach. 2. Number 1 cot coach. 8. Number 2 cot coach. 4. Day conch. 5. Store, office, and kitchen coach. 6. Number 3 cot coach. 7. Special cot coach No. 4. 8. Cot coach No. 5. 9. Officers' cot coach No. 6. 10. Dining coach. 11. Staff coach. 12. Baggage and guard coach. Some of the coaches were 42 feet long, some 45, and some 50 feet. The total length of the train over all was 622 feet. It was provided with 11 water-closets; compressed gas for cooking, carried in six cylinders; and several water tanks with a total capacity of 1,140 gallons. The gas supply was sufficient for about 24 hours' service. There was a telephone system between the staff coach and the office and administration coach, and each coach was lighted independently by separate dynamo and accumulators. Heating was by steam from the engine, the piping for which in the wards was carried in the overhead space of the clerestory roofs. Theoretically, this principle of having a radiating surface overhead is wrong, but practically it was stated to work well, and by this disposal of the piping the floor space was left free of radiators, which arrangement also contributed to cleanliness. When cut off from the engine, a substitute system from a hot-water heater in the coach itself was provided. The floors of the coaches were covered with thick linoleum. Both vacuum and Westinghouse brakes were fitted to the train. The advantage to be gained from smooth running in an ambulance train is obvious, and for this reason the length of the coach was designed to be as great as possible without exceeding a length which it was possible to use over the various railway lines of the Kingdom. For easy communi cation the train was arranged on the corridor plan throughout, ves- tibuled, and with a special system of signals provided between the train and locomotive driver so that the speed of the train could be adapted to the requirements of the occupants of the train. Over good sections of roadbed a speed of about 60 miles was sometimes attained, but over a rougher roadbed 20 miles an hour was fast enough. An average running time of 40 miles an hour was supposed to be maintained, but over a good road the patients state that they ■• Interior view'of a'cot coach, British Naval Ambulance Train No. 3. 7CB-1 No. 4. PLEADWELL—NAVAL AMBULANCE TRAINS. 709 are more comfortable when a higher speed is made and on a bad way 40 miles would be uncomfortable or even dangerous. Stocked with linen, food supplies, medical equipment, etc., the train was quite independent of outside assistance for the period of a run from its base and return, except that in long runs certain stops are made for renewal of water and gas. Gas was only required for cooking purposes as the lighting was by electricity throughout. Tho internal surfaces were painted a hard, bright, firm enamel white and the exterior a naval gray with the red cross on a white ground on the sides of each coach. Each ward coach had four large sliding side doors, which, when open, were guarded with a bar and had a grab rope at each side to afford a handhold on entering or leaving the coach. The doors are in pairs and opposite so that stretchers and bearers are not cramped for turning space. Water-closets and lavatories are provided for each coach, and the staff coach has in addition a bathroom. This was the third run of this train, on which a mileage of 571 was made. On the second occasion on which I made a trip (No. 11 run) in this train, the mileage was 830, and the total mileage since commission, about three months, had then reached about 17,000 miles. In this time 1,198 patients had been carried. Three galleys were provided in the train —one in the staff coach, one in the ward-room coach, and one in administration coach. The number of meals which could be served in a day from the galleys on the train numbered 190 (includ ing tea). DETAILED DESCRIPTION OF COACHES. Crew and guard coach.—This accommodated the train crew and the noncommissioned officers, the former having 12 bunks and tho latter three, with collapsible mess tables, lockers and cupboards for clothing, etc. A lavatory and water-closet were fitted in one end. Cot or ward coach. —Five coaches of this description were in the train and each coach accommodated 24 cots, hung 12 in each side in two tiers. The cot used is much the same as the service canvas cot which was formerly issued to ships in our service, consisting of can vas stretched over a wooden frame and laced in position, with side pieces to hold a mattress in place and triangular end pieces terminat ing in an eyelet, to which a supporting rope or lanyard is rove. These cots are suspended from the roof of the coach by chains. The illustration will give an idea of the arrangement and appearance of cots and of their method of support in the coach. The supports were made the same length and the cots were readily interchangeable. They were held in place and kept from swinging by being fastened against two buffers or fenders by a chain and hook 133354—19 6 710 PLEAD WELL—NAVAL AMBULANCE TRAINS. Vol. XIIL with a spring attachment. The fenders were fitted to the sides of the coach and extended from the floor to a point above the upper cot. The face of the fender was padded with a cushion of horsehair or tow in canvas. This was mounted on a wooden fender block. In military ambulance trains the cots are of the fixed type ; that is, they are more or less permanent fittings of the train, too heavy as a rule to be unshipped and used as stretchers, even when designed and in tended to be so used, while in the naval train the movable cot may be said to be its distinctive feature. Naval medical opinion inclines to the view that the movable cot is decidedly better for the purpose than the fixed cot, and all naval trains use the movable cot system. The objections to the fixed cot are stated to be the following: 1. As the cot is rigidly fixed to the coach the patient is more subjected to Jars transmitted from irregularities of the roadbed, whereas in the movable cot this Is lessened by its flexible structure, as well as by the cushion on the side buffer, and by the spring grips and chain which hold the cot against the buffer. 2. With fixed cots patients have to be transferred to and from the train by stretchers, while In the movable-cot system the cot itself is used as a stretcher and no transfer of the patient from stretcher to bed or vice versa is required. Occasionally a patient with a serious fracture can not stand the transfer from stretcher to the fixed cot, and the stretcher then has to be placed In the cot and the journey made In this manner with a material loss of comfort and per haps less safely. The movnble-cot system, however, requires a larger num!>er of stretcher bearers, four to each cot and two to hook on in the train, and a large number of cots. For the military service, therefore, this system may not be appropriate, but for the naval ambulance trains It operates very satisfac torily. For instance, a patient for transfer, either in his own ship or in a hospital ship, is already in the service cot, which is unshipped and carried as a stretcher and rigged in position in the ambulance train, the train force leaving previously disentrained as many cots as there are patients to be received, the ship or hospital ship receiving one of these cots in exchange for the one carrying the patient. On arrival at the point of disembarkation for a naval hospital the train receives a clean cot from the hospital for every patient transferred to the hospital. On transfers between trains a similar procedure is fol lowed. Each cot is arranged with full equipment, namely, one mat tress, one pillow, one pillowcase, two blankets, and two wooden spreaders, and care is taken to see that cots received in exchange contain the standard equipment. Another advantage of this system is that the ward coach can be completely and readily emptied of cot equipment and the cleaning of the interior of a coach easily carried out, the cots being scrubbed and dried outside the coach (or disin fected, if necessary, at a neighboring hospital). To securely fix the cot in position is quite important, for if the lashings work loose No. 4. PLEADWELL—NAVAL AMBULANCE TRAINS. 711 there is too much play and swinging when the train sways or starts and stops. The attendant can easily remedy any undue motion by setting up the lashings as required. The cots when used as stretchers require a little more clearance than an ordinary stretcher, and inter ference of bearers with each other may result if a definite routine in loading and evacuating the coach is not adopted. Six bearers are required to place a cot in position, four as bearers and two to assist in hooking it on in the train. With the ordinary stretcher two bearers are sufficient to carry the stretcher and two train attendants to assist in transfer of patient to the cot in the train. The upper cot in this train was suspended direct by its eyelets to two hooks in the roof of the coach ; the lower cot was suspended from the same hooks by means of a chain and hook. In addition, each cot has its lanyard, which enables it to be slung centrally or elsewhere in the coach from any support. In front of each section of two cots is hung a curtain. If a ward coach is required for sitting cases only it can be readily converted by lowering the lower cot to the floor, placing another cot on top of this one, and a third placed to form a back rest, being secured in place by lashings. Twenty-four to 40 sitting patients are thus accommodated in the naval train. Day coach.—This is an ordinary coach fitted at one end with two water-closets and at the other end with two padded cells for mental cases. It also has a small surgical dressing room with appropriate equipment and a section for treatment, which can be screened off by a curtain. This is equipped with washbasins, cupboards, treatment couch, poison locker, etc. The remaining space of the car is fitted with 19 washbasins, which when not in use are covered over with a board, hinged to fall over the basins, and used as a table, on which meals can be served. In front of each table is a collapsible seat or a bench. The day coach is centrally placed so that it is about equally ac- ccessible both from the kitchen and from the cot coaches containing sitting cases, and it serves usually as a dividing line in the train between lying-down cases and sitting cases. A food carrier is used for carrying rations from the galley to this coach. This is a wooden box fitted with a handle and containing six removable shelves. Sick officers. —If required, one of the cot coaches can be fitted exclusively for officer cot cases, or a portion of a coach may be so fitted by screening off a section. Sitting-up cases among officers are provided for in the dining car, and 10 in number can be accommo dated there. If sleeping places are required in this car, cots are placed across two adjacent seats. Eight officers can be provided for in this manner. This car is also fitted with a pantry, kitchen, a heating stove, and a water-closet. 712 PLEADWELL—NAVAL AMBULANCE TRAINS. VoL XTIL Office, store, and kitchen coach.—This coach is fitted with a lavatory at each end, an office, linen store, kitchen, storeroom for provisions, and a pantry for steward and cook. The office contains a safe for valuables, a desk with a typewriter, and lockers for papers. It has telephone communication with the staff coach. The kitchen is equipped with a gas range and boiler, an ice box, sanitary can, sinks, water filter, and a work table. The store room has shelves for dry stores, groceries, and other provisions. The remaining compartment is allotted to the cook and the senior sick berth steward. Staff coach.—This coach provides accommodation for the two medical officers and two nursing sisters when carried. Two addi tional medical officers can be accommodated if double berths are shipped. This coach is divided into five compartments. The two end ones are fitted with sleeping berths for two persons with a lavatory and water-closet adjoining one, and a bathroom and water-closet ad joining the other. The two central compartments comprise a sitting and dining room and an additional sleeping compartment. Baggage and guard coach. —This coach is used for patients' kits and baggage, spare cots, train tools, stretchers, and four cots for emergency cases. Lockers are provided here for storage purposes and for cleaning gear, spare lamps, fuses, fire extinguishers, tool and ladder box, etc. ADMINISTRATION. With the exception of emergency medical and surgical work, pa tients rarely need elaborate professional attention on ambulance train trips, the chief concern of the surgeon being to render them comfort able, provide food and drink, and perhaps loosen a bandage, adjust a splint, or administer morphine when indicated. The opinion was expressed by the surgeons in charge that the extremely rare occa sions upon which the facilities of an operating room might have been used hardly justify its provision in ambulance trains, whose run be tween points where hospitals arc accessible is not much over four or five hours. It is realized that the situation is somewhat different when a train is called upon to assist in the evacuation of the wounded direct from a naval engagement. This situation, however, rarely arises, as hospital ships and northern hospitals endeavor to retain the more seriously wounded until fully able to be transported by train. DETAILS OF ROUTINE PROCEDURE. Hospital ships.—When the port of disembarkation is determined upon by the senior naval officer, telegraphic information is sent to the medical transport office, London, under the following heads: No. 4. PLEADWELL—NAVAL AMBULANCE TRAINS. 713 1. Diite and probable time of arrival and port of arrival. 2. Total number of patients carried, giving officers and men separately. 3. Details of cases belonging to the port divisions of Plymouth, Portsmouth,, and Chatham, shown categorically by numbers in the following sequence prefixed by the word " Cases " and name of port divisions : Officers —cot, noncot ; men —cot, noncot. The words " officer " or " men," " cot " or " noncot," are, however, not included in the telegram, as the same consequence is always adhered to and these terms are understood. For example: "Plymouth four nil twenty-two twenty-seven" is interpreted to mean that there are four officers patients, cot cases, and no noncot cases; and 22 men, cot cases, and 27 men, noncot cases for both. Whenever " nil " is used it means no cases of that category. Thus only four numbers need be telegraphed to each port division, the word " nil " being used to cover one category not present. When, however, the number of pa tients in any one category exceeds 100 it is necessary to use the word " and " to avoid confusion. Those wounded in action are not included in the above telegraphic arrangement, but are shown sepa rately in similar sequence, prefixed by the word " wounded " and the name of the port division. A similar arrangement is made to show infectious cases, and also mental cases, both shown in the total, pre fixed by the word " infectious " or " mental," with name of port di vision, the latter category using two numbers only —officer and men. If extra attendants besides the usual escort are required for mental cases, the word "escort" is added after the figure relating to the special case, the number of men required for an escort following the word " escort." The number of officers and men unfit to travel by train is in cluded in the information required. This is shown by a sequence of two numbers, the first for officers, followed by a specification of the disease, and the second for men, also specifying the disease. The sequence is prefixed by the word " unfit." The number of officers and men fit to travel by ordinary train is to be included and should be prefixed by the word "ordinary." The number of officers and men requiring low diet is to be shown similarly by two numbers, using the word " diet " as indicator. If there are any cases likely to require the services of sisters during the journey, this should be indicated by the word "sisters" at the end of the telegram. The following specimen telegram is an example of the above ar rangement : From hospital ship Bygeia. To Burned, Washington. Hospital ship Jlyycia due Key West ten a. m. twentieth July cases forty three one hundred and seventy five. Pensacola five nil thirty five twenty four. Norfolk nil two sixteen twenty five. New York ten three nil sixty four. Wounded Washington three two forty nine. Infectious Norfolk two nil nil 714 PLEADWELL —NAVAL AMBULANCE TRAINS. Vol. XIII. three. Washington nil nil nil five. Mental Pensacola nil two Norfolk two escort one nil Washington nil three escort one. Unfit four two fracture car- dine abdominal seven three abdominal two fracture cardiac. Ordinary nil twenty one. Diet seven seventeen sisters. This form of dispatch is adhered to strictly, and when no cases of any particular class exist no reference to same is necessary and the next class in the next sequence is dealt with. Procedure adopted when transferring patients to an ambulance train.—All cases are previously grouped by the senior medical officer of the hospital ship (or other establishment" forwarding cases) in a certain order, chiefly on a geographical basis, but men who have no port division or depot (home port) are sent to the port most con venient to their homes. Lists in triplicate are made out for each port division, giving name, rank or rating, official number, name of ship, and nature of disease or injury for each patient transferred to the train. One list goes with the patients to the naval hospital re ceiving the cases, one for medical transport office (via the officer in charge of the train), and one is retained by the officer forwarding the cases. Each patient is labeled, the labels having a distinctive and different shape for each port division. The label shows the patient's name, rating, ship, and disease or injury. If wounded, an additional label is used to indicate degree of wound sustained. A luggage label with no mark means "slightly wounded," with blue pencil cross "seriously wounded," and with red cross "dangerously wounded." The labels are tied on in a conspicuous place, and when morphine is given the dosage is recorded on the label. On the ordinary label the diet required for the patient is indi cated for the information of the train surgeon, by a letter, thus: M=milk diet; L=low diet; the cases on full diet having no mark. When the train arrival time at a hospital or hospital ship is cal culated to fall within the meal hours, any patients landed from the train will have had their meal, or if received from a hospital or hos pital ship should be given their meal prior to leaving the hospital. Under ordinary circumstances patients are not entrained after 11.30 p. m. or before 7 a. m. Baggage.—Bags, baggage, and hammocks are assembled in groups according to port divisions and distinguished by labels similar to those attached to patients and carrying the same data. After bag gage is checked into the train the surgeon in charge acknowledges receipt on a baggage summary. Baggage is stored in the train in the same order as the cases; that is, in such a way as to facilitate its delivery from the train without delay. Arms belonging to patients are handed over to the train baggage-master and the num ber is shown on the baggage summary. PLEAD WELL—NAVAL AMBULANCE TRAINS. 715 Instruction of officers in charge of trains.—Trains carry two medi cal officers, and one is required to be in or about the train—that is, within the station limits —at all times. When a train completes a trip and is stabled at Chatham, week-end leave is granted; but officers on ordinary leave are required to be within two hours' jour ney of the train. Whenever a train is stabled in a railway yard the ambulance-train force becomes responsible for the cleanliness of the immediate vicin ity, and the surgeon in charge carefully inspects the area occupied by the train during his routine daily inspection. Stores for the train are loaded at its home yard upon the comple tion of a trip and in sufficient quantity to last until the completion of the next routine trip. Fresh stores or perishable supplies are bought only from naval contractors as required. A daily log is kept by the surgeon in charge, in which are entered details of ad ministration, such as movement of train, gassing and watering, liber ties, etc. This log book is presented to the medical transport officer at the home yard of the train whenever time allows. This log is additional to ordinary routine reports. Orders from the medical transport office in the Admiralty relating to train movements come through the local medical transport officer, or if sent direct the latter officer is informed. An acknowledgement of " movement orders " is made by telegram to the medical transport officer transmitting the order. Passage in trains is not allowed to other than the sick or officials of the medical transport service. Passage for any other person must be by order, and the order and a report thereon forwarded to the principal medical transport officer at the Admiralty. Friends or relatives of the crew are not allowed to meet the train at any station except under special circumstances by prior permission of the surgeon in charge. Leave is usually granted to the train crew at the train depot upon the completion of a run, but not until the train has been made clean and ready for service. The petty officer of the watch musters the men for going on leave and sees that they are in regula tion uniform. When the train stands empty a guard of one petty officer and three men is kept by the watch on duty in four hours' watch. A guard book is kept and signed by each petty officer in turn, who records the watch detail and any unusual occurrence noted. The surgeon in charge signs the guard book after his inspection. Visitors to the train are only permitted by permission of the surgeon in charge on duty. All members of the watch on duty wear white gowns and white shoes, removing them when relieved. Only men actually on watch remain in ward coaches with patients and are not permitted to go on platforms in their gowns. If hands are required on a plat 716 PLEADWELL—NAVAL AMBULANCE TRAINS. Vol. XHL form they are told off from those " standing easy " by the petty officer of the watch. No man is allowed to leave his station without per mission of the petty officer of the watch, who is communicated with by passing the word along the train from coach to coach, and no mem ber of the " watch below " is to leave the train without permission of the surgeon in charge, obtained through the petty officer of the watch. Doors of the coaches are closed and fastened while making stops in stations. All ward utensils are placed in lockers or laboratories dur ing stops at stations. No gifts are allowed to be given directly to the patients from the public or buffets at stations. At the end of each running a report is sent to the principal medical transport officer at the Admiralty, through the medical transport officer Chatham, concerning the following : I. Remarks on the run. II. Abstract of cases transported. III. Abstract of railway notes (the original "train guard log"). IV. Nominal list of all patients carried. (1.) Remarks. —These should invariably include notes as to how pa tients stood the journey, cases given special attention during the run, restraint applied to mental cases, complaints, etc. In case of death, a full report of details is to be rendered separately for each case. (2) Abstract. (3) Railway log. (4) Nominal list. Runs are numbered consecutively and considered completed when all cases are landed. If a train has to make a second journey, say, to empty a ship, such a run is considered a separate one. All tele grams are worded as briefly as possible, and a duplicate of all tele grams and telephone messages is kept and filed with other documents on completion of the run. The surgeon in charge is expected to make the second medical officer fully conversant with all routine and duties of the train service so that the latter is ready to carry on in the absence of the surgeon in charge. Mental cases are never left unat tended, and special watches for these cases are furnished. No lcose valuables are accepted for transport, but are bulked in a sealed package and receipts given and taken when they change hands. Metal-bed frames, of which four or more are carried, are used for men over five feet 10 inches in height, or for other cases which might be considered more comfortable on them. In the event of a death occurring during a journey, the cot is screened off and the remains transferred quietly to the baggage coach, then landed at the first naval depot. The following menu represents the character of the meals served on this train : No. 4. 717 PLEADWELL—NAVAL AMBULANCE TRAINS. BREAKFAST. Porridge and cream. Fish, haddock or kipper, etc. Bucon and eggs. or tomatoes. sausages. kidneys. Jam and marmalade. Tea, coffee, or cocoa. Toast. Bread Butter. AFTEBNOON TEA. Tea. White and brown bread and butter. Jam and marmalade. Cake and biscuits. DINNER. Soup. Fish. Joint or poultry. Two sweets, including a milk pudding. Cheese, biscuits, etc. Coffee. Soup. Fish. Joint or poultry. Two sweets, including a milk pudding. Cheese and coffee. Bread. Biscuits. Butter. WORKING OF TRAINS. 1. Trains are worked throughout on a point-to-point timing, as described below. 2. As a general principle, throughout arrangements will be com municated to the first company, who will then advise the other company next concerned, and so on throughout the journey. 3. The medical officer in charge of the train notifies the station officials of the first station on the outward journey, as follows : (a) Time train is required to start as soon as determined. (6) The destination station of the loaded train. (c) Intermediate stations at which the train is required to stop to pick up cases and approximate time at each station. (d) Stations at which pis and water should be supplied. (e) Hour at which train should arrive at destination station if later than that time laid down in point-to-point timing, In order that the railway com panies concerned may deterndne upon which system the train should be stabled during the waiting period. In the event of this information being supplied by the naval authorities short of the company on which system the return train will start, the company receiving the particulars will communicate them direct to the starting company and not to the intermediate companies, the starting company in turn advising the forwarding company as set forth above. 4. The railway company at point of departure of return trip will at once transmit these particulars to the next company concerned, who in turn will advise the next company forward, and so on throughout the journey. 718 Vol. XIII. CLIFTON—BONE SURGERY. 5. The train can by prearrangement be gassed and material sup plied at any of the stations shown on a list carried or watered only at certain others. Sample index. Number of table. Page. Station between— Route. 1 6 8 Boston and Washington Mansfield, Providence, New 2 Washington and Pittsburgh London, etc. Baltimore, etc. Point-to-point timings. TABLE ROUTE NO. 1. H. M Boston to New York (N. Y. N. H. & H. Ry.) 5 10 New York to Washington (Pa. Ry.) 5 30 Note. —Ambulance train should be dealt with at Sta., and at TABLE NO. 2. H. M. Washington to Philadelphia (Pa. Ry.) 3 5 Philadelphia to Pittsburgh (Pa. Ry.) 3 15 For much material appearing in this paper I am greatly indebted to the articles on "Ambulance Trains," by Acting Staff Surgeon (now Acting Surgeon Lieutenant Commander) A. Vavasour Elder, R. N. V. R., appearing in the January and July issues of the Journal of the Royal Naval Medical Service for the year 1915. I am under obligations also to the managing editor of The Railway Gazette for the privilege of using data concerning hospital trains contained in that publication. BONE SURGERY: A STTJBY OF THREE CASES. By A L. Clifton, Lieutenant Commander, Medical Corps, United States Navy. The following cases are presented, not with the idea that the opera tions are by any means original, but that in each instance the terminal results were good after the patient had failed to respond to the ordi nary method of treatment for a long period of time. The first case is one of nonunion of the humerus after three months' treatment. The history is as follows: H. P., Sea-2c, was admitted to a civilian hospital June 1, 1918, following injury received in a trolley car accident. There was a frac ture of the humerus at the junction of the lower and middle third and fractures of the third and fourth metacarpal bones on the same side. Fig. 1.— Groove prepared for the inlay. Fig. 2.— Securing graft from tibia. Fig. 3.— Holes drilled and sutures in place. Fig. 4.— Graft securely tied in place. Fig. 5.— Drawn from X-ray plate. Shows final result In Case 1 after 8 weeks. Fig. 6.— Case 2. Shows overriding fragments. Fig. 7.— Case 2. Antero-posterlor vanadium Fig. 8.— Case 2. Lateral steel splint In position, steel plate In position. Figs. 9and 10.— Case 2. Recovery with good motion and J-lnch shortening. Mo. 4. CLIFTON—BONE SUBGERY. 719 The fracture of the humerus was nearly transverse. The fracture was put up in a plaster cast a few days after the injury, which cast was used more or less continuously for a period of three months. Patient admitted to the United States Naval Hospital, Philadelphia, September 19, 1918. On admission there was no attempt at union on the part of the humerus, but the metacarpal bones had united in malposition. In addition to the above findings there was fixation of the elbow joint, midway between flexion and extension, due to dense fibrous adhesions and a marked atrophy of the muscles of the arm and forearm. After carefully considering the merits of each possible operative procedure, a bone-graft operation was decided upon. Accordingly, the patient was operated upon on January 16, 1919, incision being made on the outer side of the arm. The humerus was exposed and a considerable separation of the fragments was found, partially filled in by fibrous tissue. The ends of the bone were cleared and held with clamps. With the twin Albee saws a groove was cut for the inlay (Fig. 1). The inner surface of the tibia was exposed and a graft was cut to fill the space made in humerus (Fig. 2). Holes were then drilled for the chromic catgut and the graft tied in place (Figs. 3 and 4). The arm was firmly fixed by splints and at the end of four weeks passive motion and massage were started. The patient carried a small tin bucket of sand in his daily trips around the hos pital. Six weeks after operation, fine union had taken place. The accompanying drawing of an X-ray plate, taken eight weeks after the operation, shows the final result (Fig. 5). It was necessary to move the elbow under gas anesthesia three times during the course of convalescence. At the present time the patient has recovered practically full flexion and extension, the musculature has returned to normal, and it is believed that he can be restored to duty after 30 days' sick leave. The operative technic described above is rather a simple procedure, the only difficulty being the question of holding the motor-driven saws accurately. If one is not doing this sort of work frequently enough to become proficient meat bones can always be procured from the galley and the necessary practice acquired in a surprisingly short time. It is hardly necessary to say that the bone inlay plays no part in holding the fragments in position and that splints must be used to secure fixation. The inlay only serves as a conducting path for the osteoblasts, and where there is a great separation of the frag ments the graft tends to take the shape and size of the bone in which it is engrafted. Absolute cleanliness is essential in this operation and instruments only should come in contact with the wound. Cases have been reported where union has taken place even with infec tion, but this is the exception to the rule. 720 Vol. XIIL CLIFTON—BONE SURGERY. Case 2.—G. P., Sea-2c. Patient was admitted to a civilian hos pital August 24, 1918, having been thrown from an ambulance in collision with another car. It was found that he had an oblique fracture of the left femur just above the condyle. Following the accident the patient was anesthetized and reduction attempted. The leg was put up in a double inclined plane and Buck's extension applied. This method of treatment was continued for several weeks. He was then given a pillow support for two weeks, after which he was allowed to sit up. Later on crutches were allowed, but pain and loss of function were so great that the patient had to return to bed. The case was admitted to this hospital about December 1, when the X-ray showed a complete overriding of the fragments with an absolute fixation of the knee joint (Fig. 6). Operation was decided upon and was done December 5, 1918. An incision was made over the outer surface of the femur. When the femur was brought to view, it was found that the end of the upper fragment had been driven into the knee joint and that it was firmly fixed in this position. The two opposing surfaces of the fragments were united together with dense fibrous adhesions and a small amount of callus. It became necessary during the course of the operation to open the knee joint to free the upper fragment. Just previous to the operation a Buck's extension apparatus had been applied to the leg, but, despite vigorous extension and counterextension at the time of operation, the fragments could not be pulled in place. The Albee single saw was then used and the rough ends of the fragments were removed. The original plan in this operation was to use a bone inlay as well as a plate, but as the anterior and posterior surfaces of the lower fragment were split off, it was found impractical to use the graft. When the two fragments were properly aligned, a vanadium steel plate was applied to the lateral aspect of the femur. The wound was then closed in the regular manner and the leg placed on a pos terior splint. Figures 7 and 8, drawn from X-ray plates, show the anteroposterior and the lateral results. After six weeks, when union had taken place, passive motion and massage were started. Under gas anesthesia the knee joint was moved once a week for three weeks. The accompanying illustrations (Figs. 9 and 10) show the final result. Union is good and the leg can be flexed at more than a right angle. There is three-fourths of an inch shortening. The interesting feature of this case is that although the upper frag ment had remained in the knee joint for almost three months there o No. 4. CLIFTON—BONE SURGERY. 721 was not sufficient injury to the joint to prevent excellent motion as the end result. After five months the plate is still in situ. Case 3.—T. A. S., ensign, U. S. N. R. F. The patient was struck on the left knee by a lump of coal on September 18, 1918. The knee immediately became swollen and painful and there was complete less of function for two weeks. He was admitted to this hospital December 18, 1918, with pleurisy (acute fibrinous), and stated that his knee was still painful and that it became stiff if left in one position for any length of time. If it was flexed and left in one position he was at times unable to straighten it out. Examination at this time showed some effusion in the knee joint, and the X-ray showed a transverse fracture of the patella in good position. The patient was discharged improved on February 21, 1919. He was readmitted on March 9, 1919. At this time he again com plained of the knee symptoms noted above. Wassermann and G. C. negative. X-ray showed two shadows in the knee joint, one above the patella and the other behind the patella, more or less oval in shape and about the size of a small marble. They were of about the same density as bone. At first it was thought that these shadows were sesamoid bones, but by getting them at various angles and by taking stereoscopic plates it was finally decided that one body at least was in the joint. On April 15 patient was operated upon. A curved incision was made over the outer side of the knee joint; the expansion of the quadriceps was divided in a longitudinal direction and separated as far as possible from the patella (Fig. 11). The old fracture was ex amined and there was found to be good bony union. The patella was then sawed through for about three-fourths of its depth in a longitudinal direction with a handsaw (Fig. 12), the patella being finally divided with an osteotome (Fig. 13). In order to get a good exposure of the knee joint, it is necessary to split the quadriceps tendon for some distance on either side of the patella. When this is done and the knee is flexed, allowing the two fragments of the patella to be moved to either side, the operator can then see any part of the knee joint. On opening the joint a dense body of the size described above was found attached to the synovial fringe in the lateral aspect of the joint. This was removed (Fig. 14). It is believed that this body was formed by a hypertrophy of the synovial fringe due to injury. Later on calcification had taken place. After thoroughly inspecting the joint the expansion of the quad riceps was closed (Fig. 15) and the operation completed in the usual 722 CLIFTON—BONE SURGERY. Vol. XIII. manner (Fig. 16). Passive motion was started on the fourth day without much discomfort, and at the present time there is full motion in the joint. I believe this open operation on the knee joint was first suggested by an English surgeon, and later on was used extensively by Sir Arbuthnot Lane, especially in pleating the crucial ligaments in certain injuries to the knee joint. After hearing Dr. Lane give the advantages of this method of approaching the knee joint, we tried it at the U. S. Naval Hospital, New York, on five cases, where the results were excellent. It is believed that many times the knee joint is opened laterally to remove a cartilage when there are pathological conditions in the joint demanding attention other than those of the cartilages. In the open method it is almost impossible to miss any pathology, as the joint can be so thoroughly inspected. Fracturing the patella in the longitudinal direction certainly does not interfere with the function of the joint, as the quadriceps pull tends to keep the fragments in position so that active motion may be started early, this, after all, being one of the greatest points in successful bone surgery. The only difficult point in the operation described above is to get a clean fracture of the patella. To do this it is necessary to saw about three-quarters of the way through the depth of the bone, then use an osteotome, tapping lightly until the final division is made. If care is exercised a clean break is secured instead of knocking off a part of the articular surface. Occasionally there is very troublesome hemorrhage from the fractured surfaces of the patella, which takes some time to control. I have been unable until recently to find a description or illustra tion of this operation in any textbook. It is now to be found described in Warbasse's new work on surgery. Operations on the knee joint under the best possible conditions give doubtful results, but it would seem that when we have the entire joint exposed we are in a better position to get a good result than if the joint is approached laterally, where there is only a limited view. If one is careful to use only sterile instruments in the joint the chances of infection are rather slight. One of the interesting features of this case is the fact that the patient had a transverse fracture of the patella with good union when he had received no treatment except two weeks' rest in bed. I am indebted to the artist, G. V. Schwartz, United States Naval Reserve Force, for the illustrations accompanying this article. o o ir A ^^_ ^/ . -^ \ i fifl vJfe s^*^ s*^7777^*^ x ^1^91 1^*.'- "".' ■;~^fr^ J v \ ^^^^SSl ^^^v^vl ^—i V vtf^ No. 4. STUDY OF AN EPIDEMIC OF MUMPS. 723 STUDY OF AN EPIDEMIC OF MUMPS. By It. B. H. Gradwohl, Lleuenant Commander, Medical Corps, United States Naval Reserve Force ; C. F. Carter, Lieutenant, Medical Corps, United States Navy ; W. S. B.wicus, Lieutenant, and H. L. Fuugluouse, Lieutenant (J. O.), Medical Corps, United States Naval Ueserve Force. The following observations were made in the course of a rather extended study of a group of cases of epidemic mumps, which were seen by us in the isolation wards and tents of the United States Naval Hospital, New Orleans, La., during the months of December, 1918, and January and February, 1919. Most of these cases were sent to this hospital from the West End Training Camp, a Navy training sta tion situated just outside the city of New Orleans. The total number of cases reported here was 120. Our interest in these cases displayed itself in the following manner: An attempt to isolate an organism from the blood of these patients, a study of the cases with a view of tabulating the prominent symptoms, a study of the blood picture of all cases, a notation of the complications of the disease, and an effort to apply specific medication in the shape of a convalescent serum. At the very outset we wish to emphasize the fact that our observa tions have thrown but little light on the disease beyond what is already known. The material was thrown rather unexpectedly upon our hands, and we did what could most conveniently be done to de velop whatever new facts suggested themselves to us that might be useful to other workers in this line. It is to be hoped that the nega tive character of our findings respecting the etiological factor of mumps may serve as a suggestion to others to pursue other lines of investigation in dealing with future epidemics. In scanning the literature we note that all attempts to find the specific microbic cause of mumps have resulted in failure. Charrin and Capitan (1), Laveran and Catrian (2), Busquet (3), and Tessier and Esdrian (4) have sought in vain for the etiological agent of this disease. The most systematic work that has been done is that of Wollstein (5), (6), and (7). This worker in her first publication showed that when cats were inoculated with bacteria-free parotid secretion into the parotids and testes definite pathological changes were produced in these organs, accompanied by fever, leucocytosis, tenderness, and swelling in the above-mentioned glands. Normal saliva used as a control did not produce these effects. The rise in temperature began 24 hours after the inoculation, reaching its maxi mum in from 7 to 14 days. The rise fluctuated between 1° and 2/5 C. The white cells showed a definite increase on the second day follow ing inoculation, consisting in the main of a polymorphonuclear leu cocytosis, followed by a small-lymphoc3'te increase of from 7 to 10 per cent. The histological changes in the glands were an edema of 724 Vol. XIII. STUDY OF AN EPIDEMIC OF MUMPS. the interlobular connective tissue with mononuclear interstitial infil tration. Wollstein in her first contribution concluded that the saliva of epi demic parotitis contained a filterable substance capable of producing definite pathological changes in the parotids and testes of cats. She affirmed that it was impossible to state whether this was or was not due to a microorganism. In a second communication, entitled "An Experimental Study of Mumps," in 1918, she came to the same con clusions. This last work was carried on with material secured from an epidemic in an Army cantonment. In a third communication later in 1918, in addition to the pre vious experiments, she did the following: Mouth washings in normal saline filtered through a Berkfeld filter candle N, with the filtrate proven sterile by aerobic and anaerobic cultural methods, were inoc ulated into the parotid glands of cats. She used half-grown cats and insisted that old males did not react. She observed the same symp toms as heretofore described, with an incubation period of from five to eight days. She showed that the period of infectivity of these washings was short, only seven days in all. Animals inoculated witfi material from men sick 9, 11, or 12 days showed very slight changes. These cats displayed an involvement of the parotids, submaxillary, sublingual, and adjacent lymph nodes. She also showed that the blood of these patients when cultured by the ordinary blood methods was free from bacteria. She likewise showed that defibrinated blood, proven sterile by tests, when inoculated into normal cats in the man ner just described, produced the same effects as the filtered saliva. A recent publication by Radin (8) in connection with an epidemic observed and studied at Camp Wheeler, Ga., describes among other matters an attempt to isolate the organism from the blood and in fected glands of mumps cases. No results were obtained. Inocu lation intraperitoneally into mice and guinea pigs were equally with out results. We wish to summarize our laboratory studies as follows: Urine analyses. —One hundred and thirty specimens were examined. Six teen showed a trace of albumin, without any reference to metastases. Sixteen showed casts, without any reference to metastases. Twelve showed pus, with out any reference to metastases. No other abnormal ingredients were ob served. Blood picture. —Complete blood picture was observed In 60 enses. In 44 cases the white blood count ran between 5,000 and 10,000 cells. In 15 cases the white blood count ran between 10,000 and 15,000 cells. In one we had a count of 20,000 cells. Differential counts.—Polymorphonuclears, below 40 per cent In three cases; 40 to 50 per cent in 12 cases ; 50 to 60 per cent in 23 cases ; 60 to 70 per cent in 14 cases. Small lymphocytes, below 30 per cent in 12 cases; 30 to 40 per cent In 19 cases; above 40 per cent in 29 cases. Eosinophilia was present In 12 cases, and was shown to be due to hookworm infection (stool examinations Mo. 4. 725 STUDY OF AN EPIDEMIC OF MUMPS. confirmatory). It is to be noted that this eoslnophilia was found in but half of the cases of hookworm . proven so by stool examination. Transitionals; the highest observed was 8 per cent. The normal figure for transitionals is up to 4 per cent. In our series it was above 4 per cent or above normal in 15 cases. Red blood count.—The counts ran about 250,000 above or below normal in all cases. Hookworm infection. —This occurred in 25 cases. It Is to be remembered that these men came from a hookworm country and were comparatively recent recruits. By hookworm country we mean Mississippi, Alabama, and Tennes see. The presence of hookworm Infection with mumps apparently had no un toward effect upon mumps. Throat cultures were made in 30 cases without any definite find ings pointing to an etiological agent of mumps resident in the throat. Gland puncture culture, blood cultures, and salivary cul tures were negative in all cases. Throat cultures were made on Loeffler media, blood cultures in regulation glucose bouillon, gland cultures on ordinary media and on saliva agar. The saliva was cultured on blood agar and saliva agar. It was noted that the occurrence of complications in glands such as testes, pancreas, and cervical lymphatics did not in any way affect the blood pictures. In studying the histories of these cases we found that the ages of the patients ran between 18 and 25 years. The general condition of these patients was good. A great majority came from the West End Training Camp, whose personnel was made up of comparatively new recruits, largely drawn from Mississippi, Alabama, and Ten nessee. On inquiry it was found that most of these patients up to the time of their enlistment had lived on farms and in rural districts, coming from large families, and had never been in contact with any outbreak of this disease. The outstanding feature of this epidemic was the mildness of the symptoms. These symptoms were: Rise in temperature in some of the cases, but some cases showed no rise in temperature at any time during the disease. In a tabulated study of 104 cases the following observations were made: At the time of admission — Forty-nine cases showed normal temperature. Thirty-six showed a temperature between 98.6 and 100. Nineteen showed a temperature of 100 or above. The maximum temperature recorded was 104.2 F., which occurred in but one case. In studying the temperature charts we found the maximum temperatures to be as follows: Temperature normal throughout the disease, 24 cases. Temperature 98.6 to 100 as a maximum, 18 cases. Temperature 100 to 102, 26 cases. Those running a temperature of 102 or over, 36 cases. 133354—19 7 726 STUDY OF AN EPIDEMIC OF MUMPS. Vol. XIII. Of these 26 reached their maximum temperature within the first two days after admission. Of those who reached their maximum temperature within the first two days, this maximum was in 17 cases between 98.6 and 100 ; in 18 cases between 100 and 101 ; in 9 cases be tween 101 and 102 ; in 7 cases 102 and above Of the total 104 cases studied 80 showed a febrile reaction, 24 showed none. Of the 80 cases showing over, 46 ran their maximum temperature within the first two days. The average duration of the temperature was 1.9 days. The longest duration was eight days, the shortest 12 hours. In every instance in which the temperature rise lasted for as long as 72 hours there was an involvement of one or both testicles. Involvement of glands.—At the time of admission there was an in volvement of glands, one or more, in every case. A .tabulated sur vey of this involvement showed the following : Right parotid alone, 22. Left parotid alone, 27. Right submaxillary alone, 2. Left submaxillary, none. Right and left parotids, 43. Left parotid and left submaxillary, 3. Right and left parotid and right submaxillary, 2. Right parotid and left submaxillary, 1. Both parotids and both submaxillaries, 3. From a study of these figures we find that the right and left paro tid combination is the most frequent glandular involvement, while the left and right parotids separately come second in about the same ratio. As to the gland most frequently involved, we find that the left parotid in 77 cases, right parotid in 70 cases, left submaxillary 1), right submaxillary 7. Pain.—As noted above, this epidemic was characterized by its mildness of symptoms. The factor of pain is included in this state ment. These patients showed very little discomfort, although in most cases the glands showed marked swelling. Therefore, we as sume that the amount of pain does not go hand in hand with the in crease in size of the glands. Contrary to the general popular idea, these patients were able to take acids, lemons, etc., with impunity, without any reference to increase in pain or any other disturbing symptom. Serum injections. —The question of the use of convalescent serum in the treatment of these cases came before us shortly after the be ginning of the epidemic. We were fully aware of the fact that this is a self-limited disease and that the use of a serum is hardly justifiable on the basis of severity of symptoms. However, there were two indications which we had in mind in contemplating this part of our investigation. No. 4. 727 STUDY OF AN EPIDEMIC OF MUMPS. First, the combating of the severer complications; and, secondly, the use of this serum as a prophylactic measure. We therefore pro ceeded to carry out this part of the work with these two ideas in view. Technic.—Blood was withdrawn from the superficial arm veins with the most rigid asepis possible, receiving the blood in large cen trifuge tubes. The blood was allowed to clot and placed in an incu bator for a few hours to accelerate the clotting, then centrifugalized, and pipetted off into sterile containers. The following tests were made on all the bloods withdrawn: The Wassermann and tests for agglutination and hemolysis between the donor and recipient. This permitted us to group the blood satisfactorily inasmuch as our first work was carried out by means of intravenous injections. Later we used subcutaneous injections, where, of Qourse, only Wassermann tests were required. Reaction.—Very little reaction was noted by us in using the sub cutaneous injections. In the case of the intravenous injections we noted an occasional severe reaction in the shape of a sudden rise in temperature, with chilly sensations and headache. This persisted in one case for about 12 hours. In most cases it lasted only a few hours. We used 5 c. c. serum for both subcutaneous and intravenous injec tions. In general we saw a slight difference in the temperature range of the uncomplicated cases treated by serum injection, but often not enough to justify any conclusions. We were particularly struck by the remarkable effects of these injections upon the complications of mumps, to wit, a lessening of pain and an earlier subsidence of swelling, together with an earlier drop in temperature. In one case, with localized pain in the region of the pancreas, extreme discomfort, and a very high temperature, the administration of 5 c. c. of convalescent serum was followed within two hours by a marked drop in the temperature and abate ment of pain. In this case we had administered opiates, local appli cations, etc., before using the serum without any success. In a parallel case, with extreme pain in the testis from orchitis, we saw relief within five hours. In general our observations were that the use of convalescent serum abated the pain and fever very promptly in complicated cases. As for the use of this serum as a prophylactic measure we have prepared a large quantity for future epidemics, and feel sure that it will find a very definite place in the prevention of the spread of this disease among susceptible persons. This statement seems to be justi fiable on the basis of the report of Hess (9) , who gives the following facts: Twenty children were inoculated with the blood of convales cent mumps cases. He used 6 to 8 c. c. intramuscularly. Bloods were taken from (a) patients just recovered from the disease, (&) 728 RATLIFF CONSTITUTIONAL. INFERIORITY. Vol. XIIL patients recovered 10 days, (c) patients who had had the disease sev eral years previously. All these children, none of whom had ever had mumps, were exposed to the disease and none contracted it. Inasmuch as the period of incubation of the disease is about 18 days it is possible to protect children against mumps very easily by this measure. We wish to render our thanks to Lieutenant Irvin Pope, Medical Corps, U. S. Navy, and Lieutenant (J. G.) D. S. McBride, Medical Corps, U. S. Navy, for valuable assistance in working out the blood pictures of these cases. REFERENCES. 1. Charrln & Capltan: Cited by Vedrenes —Mem. de MM. de chlr. et de pharm. mil, 1882, xxxvlll, 167. 2. Laveran and Catrlan : Compt. rend. Soc. de blol., 1893, v. 528. 3. Busquet: Rev. de med., 1S96, xvl, 744. 4. Tessler and Esdrian : Compt. rend. Soc. de blol., 1906, Mil, pt 1, 803, 853. 5. Wollsteln: Jour. Exp. Med., 1916, 353. 6. Wollsteln : Jour. Am. Med. Assn., Auk. 24, 1918. 7. Wollsteln : Jour. Exp. Med., Oct. 1, 1918, vol. xxvlll, 377. 8. Radln: Arch. Int. Med., September, 1918. 9. Hess : Pediatrics, 1915, vol. xxvil, No. 5, p. 230. CONSTITUTIONAL INFERIORITY IN THE NAVY. By T. A. Eatliff, Lieutenant, Medical Corps, United States Naval Reserve Force. In the Annual Report of the Surgeon General of the United States Navy for the fiscal year of 1918, under the statement for diseases for the year 1917, we find that constitutional inferiority has 427 admis sions witli 9,055 sick days. As a reason for discharge from the serv ice, constitutional inferiority stands second on the list, with a total bf 327. These figures are presented in order to emphasize the fact that this disease is an important problem to the medical officers of the Navy. Constitutional inferiority as a disease entity has not been clearly defined by psychiatrists in general. In the Navy nomenclature we have two terms, namely, constitutional inferiority and constitutional psychopathic state, which by many writers are considered one and the same. In the nomenclature adopted by the American Medico- Psychological Association the term constitutional inferiority is not given. All such conditions are included under constitutional psycho pathic states. However, having both terms in the Navy nomencla ture, it has been necessary to differentiate between the two. In the past year about 1,500 cases have been examined by the Psychiatric Division in the fifth naval district. Eighty-eight of these cases were given the diagonsis of constitutional inferiority. No. 4. RATLIFF CONSTITUTIONAL INFERIORITY. 729 A diagnosis of constitutional psychopathic state was made in cases other than those described in the following. This latter diagnosis was given especially in cases not showing a distinct psychosis or neurosis but whose symptoms showed mild mental disturbances, in cluding paranoid trends, episodes, indefinite neurotic types, and psychopaths. In the Navy nomenclature constitutional inferiority is listed under the Diseases of the Mind, Class XI. The diagnosis has often been used by naval medical officers to apply to physical inferiority or general physical defect alone. This has been necessary, perhaps, because there is no other diagnosis that would seemingly fit. While physical defect is evident in many cases, constitutional inferiority primarily means mental abnormality. In the majority of cases physi cal anomalies will be found.1 Practically all of our cases showed at least three distinct " stigmata of degeneracy." Anomalies of the face, mouth, and ears are especially noticeable. Poor general development may be a most evident condition, but it is not characteristic. Various functional conditions are frequently present as symptoms, such as neurosis of bladder, dizzy spells, and neurasthenoid complaints. Those cases showing feminine characteristics usually present distinct physical traits. Constitutional inferiority is a mental disease. The anomalies found are chiefly in the emotional and volitional spheres of the mind. In tellectual defect is not necessarily a characteristic. While the ma jority of our cases showed inferior intelligence, we may expect to find gradations varying from border line feeble-mindedness to intelli gence distinctly above the average. By the Stanford Revision of the Binet-Simon Tests many of the inferior type showed a mental age as low as 10 years. A diagnosis of feeble-mindedness was not made in these cases, because neither the clinical picture nor the character of the performance on the tests were typical. In this disease we find marked defects in the emotions. There is always a lack of equilibrium —an unbalance of this fundamental sphere of the mind, which varies from what is apparently total in adequacy to marked degrees of instability. We find the apathetic, stolid, or indifferent types in these cases, or the other extreme, the nervous, tearful, or excitable. The inadequate types predominate. There seems to be a lack of development of the emotions not only quantitatively, but also qualitatively, so that only simple feelings are observed to exhibit themselves. However, there may be present emotions which are labile and uncontrolled and show the degrees of instability that we would expect to find in a decided neurotic type. Constitutional inferiors are weak willed and possess little deter mination and stamina. They lack the will power and inhibition to 1 Mental Deficiency, Tredgold, chap. 7. 730 RATLIFF CONSTITUTIONAL INFERIORITY. VoLXIIL maintain a proper mental balance which will insure stability of thought and conduct. Deficient in powers of attention and concen tration, and capable of being affected by suggestion to a high degree, their thoughts are swayed by their desires or inclinations or the ob ject at hand. Although having an appreciation of right and wrong, their conduct is governed by unrestrained impulses. Such indi viduals can have little sense of responsibility, which means a failure to ever properly appreciate military discipline. Such attributes tend to aid in the development of certain character types as the tramp, sexual pervert, etc. The following brief summaries are taken from histories in our files and represent typical cases of constitutional inferiority. I re gret that lack of space prevents the presentation of more histories, because a clearer understanding of the symptoms can be gained from them than through a general discussion. No. 810. Eng.—Age 25, A. O. L for 5 days. History shows that during his first enlistment he received three district courts-martial and two summary courts-martial and Avas given a bad-conduct dis charge by the last summary court-martial. During the present en listment he has had three district courts-martials and one summary court-martial. He has had little schooling, and most of his life prior to his enlistment in the Navy has been spent wandering about. Examination showed that his emotional reactions are inadequate, and history of the case indicates that he has little sense of responsi bility. His attitude in general is indifferent, and he has little ap preciation of the seriousness of his misdeeds. He is somewhat below the average general intelligence, but tests given him show no intel lectual defects. Physically, he presents certain well-defined stigmata of degeneracy. No. 530. Bkr., 2d class. —Age 17. Irresponsible. Patient has been in the training station for about six months, and during that time has been in constant trouble. He has been the principal in two summary courts-martial and has been under discipline for numerous petty offenses. Has been charged with stealing on two occasions. History of his case shows that he reached the fourth grade at school ; was arrested on one occasion for running away from school ; and that he has been " bumming around," as he called it, for three years prior to his enlistment. He had entered a reformatory of his own volition, from which he escaped and joined the Navy. Examination indicates that he is a careless, lazy, and shiftless type of individual. Although mentally inferior, tests did not reveal gross intellectual defects. He is lacking in stamina, and his emotional reactions are inadequate to such a degree that the usual standards, responsibilities, and duties do not call forth normal responses. No. 4. KATLIFF CONSTITUTIONAL, INFERIORITY. 731 Physical examination shows patient to be well bui|t. He has certain stigmata of degeneracy. No. 62. AS.—Age 19. Irresponsible. Company commander states that he has been a source of continual trouble and does not seem to appreciate that he is in a military organization, and has little or no sense of responsibility. History indicates that he comes from poor stock. Although he finished the seventh grade in school, he states that he was compelled to repeat three years. Mental tests showed no gross defects or deterioration of intellectual faculties. During examination his mood was easily changed by the examiner, being in tears at one time and laughing shortly afterwards. He dis played marked emotional instability. He was plainly lacking in will power and inhibition and indicated that he had little sense of responsibility. He has many adolescent traits, being boastful, ego tistical, and talking in a boyish and naive fashion. Physical examination shows numerous stigmata of degeneracy. No. 356. AS. —Age 18. Irresponsible. Company commander re ports that he has been a continual source of nuisance and trouble, and has showed himself to be very irresponsible. Has been on report twice for being asleep on post. History shows he has finished one year of high school. He is of average general intelligence, and men tal tests given him reveal no intellectual defects. History also indi cates that he is irresponsible and that little dependence can be placed in him. Examination shows he is lacking in will power and his emo tional reactions are inadequate. Physical examination reveals numerous well-defined stigmata of degeneracy. No. 269. AS. —Age 18. Irresponsible. Left his post on two occa- aions without being properly relieved. States that he finished sixth grade at school and had no trouble in making proper progress. Kan away from home on several occasions, and has been arrested twice—once for jumping freights, another time for gambling. He is reported as having little sense of responsibility, being con tinually dirty and always endeavoring to shirk duty. Mental tests show him to be of normal intelligence. However, when confronted with the seriousness of his offenses and told of his responsibilities, he displayed no emotional reaction and appeared to be indifferent. Examination and history show that his emotional reactions are in adequate and that he is lacking in will power and inhibition. Physical examination showed stigmata of degeneracy. No. 201. AS. —Age 23. Masturbation. Examination revealed the fact that patient has been addicted to chronic masturbation, and he 732 RATLIFF CONSTITUTIONAL INFERIORITY. Vol. XIII. states that while in the service he has been compelled to masturbate several times a week, being unable to control his desires. He has never shown normal reaction to female companionship, and admits that he regularly permitted himself to be a passive agent in sexual practices with other men before he entered the service. He admits that his associations with men on the training station have aroused him sexually, but denies any misconduct with them. He states that the main deterrent to such practices in the service has been his fear of a court-martial. By investigation it has been learned that he has been teased and called many nicknames by his shipmates. Examination shows that his general manner is feminine. He is decidedly introspective, hypersensitive, and hypo chondriacal. He is lacking in stamina and is very suggestible. Dur ing examination he displayed emotional instability. Physical exami nation shows many decided stigmata of degeneracy and some so- called " secondary traits." No. 763. HA-lc. —Age 28. Sexual pervert. Patient is a graduate of a college of pharmacy and is above the average of general intel ligence. History reveals the fact that he indulged in homosexual practices prior to his enlistment in the service. He has been a subject of teas ing by his shipmates, having been called " sissy," " sweetheart," etc. Examination shows that patient is of a decided feminine type. During examination he displayed considerable emotional instability, and indicated that he was lacking in will power and virility. Physical examination reveals stigmata of degeneracy and some of the so-called " secondary traits," as feminine voice and manner. No. 484. AS.—Age 19. Nervousness. History shows that patient has had about four years of schooling, and since leaving school he has held numerous odd jobs. He complains of many subjective symptoms, for which there is no apparent organic basis, such as being continually nervous, pains in his legs, hips, and back. He is somewhat below the average general intelligence, but tests re vealed no gross intellectual defects. During examination he displayed emotional instability, and plainly indicated that he is lacking in stamina and poise. He is very susceptible to suggestion. Physical examination shows marked stigmata of degeneracy. He suffers from nocturnal enuresis. No. 154. AS.—Age 18. Stealing. History shows that the patient wlule in civil life has been arrested a number of times and was an inmate of a reformatory for a period of about 18 months. States that he was sent to this institution because he repeatedly ran away from home. While at home he went with a tough city gang. No.*. HITCHCOCK WASSEKMANN BEACTION. 733 . He freely confessed to chronic masturbation, and stated that while in the reformatory he had frequent homosexual relations with other boys. Examination shows that he is somewhat above the average general intelligence. Mental tests revealed no intellectual defects. He was detected in the act of stealing money from his shipmates' clothes. He lied during the examination. No emotional response could be «licited, his general attitude being indifferent. Physical examination showed stigmata of degeneracy. No. 398. AS. —Age 18. Nocturnal and diurnal enuresis. History shows that patient finished grammar school, but he had to repeat 3 years. Since leaving school he has held many odd jobs and has never stayed at any one place longer than a month. Although patient is below the average general intelligence, tests revealed no gross intel lectual defects. History and examination indicate that he is a weak character, possessing little stamina and sense of responsibility. His emotional reactions are inadequate. Physical examination reveals marked stigmata of degeneracy. He is suffering from diurnal and nocturnal enuresis for which there is no apparent organic basis. Just as we find that certain grades of intellectual inferiors are capable of performing their duties properly in some of the lower ratings of the service, so we find that there are certain types of con stitutional inferiors who are capable of doing their work satisfac torily. As a class, however, they should be considered a potential menace and always on trial. These cases are clearly a problem in any military organization. Not only should every medical officer be thoroughly conversant with the clinical symptoms, but every line officer should know something about them. They are not amenable to discipline or training and are not benefited by punishment. Civil law has not yet reached that point where it will entirely release these individuals from their responsibilities. Military laws are fortu nately broader. A constitutional inferior when he comes in conflict with military law should be a case for a board of medical survey and not a military court. ACUTE EARLY APPENDICITIS, DIAGNOSIS, OBSERVATION, AND CONCLUSIONS. By H. E. Jenkins, Lieutenant Commander, Medical Corps, United States Navy, and L. A. Will, Lieutenant, Medical Corps, United States Naval Reserve Force. It is with apologies that the writers of this article present it. As so much has been written and there is still so much to be learned we feel that by bringing forward a few points that are probably well known to the large majority, we will find some few who have not 734 JENKINS AND WILL APPENDICITIS. Vol. XIII. looked at this condition in this light. We have all been taught dur ing our days in the medical school, and some of us during our interne- ships, that appendicitis is a more or less clear, clean-cut disease with certain characteristics which are unmistakable. This to a certain, extent is true, but we see cases in which the early diagnosis is diffi cult and often overlooked or passed by with the giving of a dose of cil or other cathartic and telling the patient to report at sick call the following day if no better. This is often done because of the absence of certain signs and symptoms which we have been taught to look for and expect in all cases, but which are more often absent than present in the early cases. In this paper we are talking of early cases ; that is, the first 12 hours. Cases seen and diagnosed early, operative interference being instituted as soon as a diagnosis is made, all get well. If they do not, it is due to an error in technic or post-operative care, usually the former. Any case of acute abdominal pain, especially in the young, should not be diagnosed "gastritis," " indigestion," ptomaine poisoning," or whatnot, until appendicitis has been ruled out. The habit of giving salts, castor oil, and other cathartics to cases of this type is one that should be discouraged until acute appendix trouble has been definitely excluded. Textbooks speak of the different types of appendicitis, namely, catarrhal, gangrenous, suppurative, etc., and tell of differentiating one from the other by the temperature, blood count, pulse, and other kindred symptoms. It is the belief of the writers that it is absolutely Impossible to tell with any degree of accuracy what type of appendix you have to deal with until the abdomen is opened. Of course, at the end of three days or longer, when we have all the classical •ymptoms of a peritonitis, it is not difficult to tell that we are deal ing with a pus case ; but this is the typo we wish to avoid and can avoid, as there is no excuse for a case of this kind to develop where our patients are all under our observation at all times and within easy reach of competent surgical care. Our idea of the typical case as described in textbooks is that it is erroneous. They describe one of 24 to 72 hours' standing, in which all the classical symptoms are present, namely, sudden onset of gen eral abdominal pain, naupea, vomiting, temperature 101° to 104°, pulse 100 to 120, muscular rigidity, localized tenderness, knee flexed on the abdomen, anxious expression, coated tongue, thirst, etc., but when this picture is presented to us we have 9 times out of 10, not an early case but one of 48 to 72 hours, or longer duration, and this is the type we wish to eliminate, as often we find a ruptured, gan grenous, or pus appendix which had it been taken care of 24 or 48 hours earlier, would have been a clean case with no necessity for No. 4. 735 JENKINS AND WILL —APPENDICITIS. drains, long period of convalescence, post-operative hernia, and even death. We will classify our symptoms according to our estimate of their value. First. Acute general abdominal pain. —We place this symptom, which Is agreed upon by prnctlcally all textbooks, as the most prominent. The char acter, duration, and intensity varies In different cases, but the usual character of the pain is of the old-fnshloned "bellynche" type, more often located In the umbilical region and lower abdomen, but at times In the eplgastrum or over the entire abdomen. This pain may be very severe or not severe enough t» cause the patient to He down. We will not attempt to differentiate the pain of an early appendicitis from the pain of other Intraabdominal conditions, such as gall-bladder disease, renal colic, Dletl's crisis, etc., but merely state that in our estimation this sign should be placed first Second. Muscular rigidity.—This symptom comes early and if looked for carefully can be found. If we wait for the second or third 24 hours any hos pital corpsinan should be able to recognize this sign and its location. Usually we find a very slight muscular rigidity of not only the right rectus, but also of the entire right half of the abdomen. This rigidity is not as marked as we find it at the end of 18 or 24 hours, but by very close comparison of both sides of the abdomen It can be detected within the first few hours. Third. Localized tenderness.—This symptom following an acute abdominal pain and muscular rigidity Is the cardinal sign of an acute appendix. Tender ness localized at McBurney's point, with an absence of pus In the urine, and no localized tenderness over the right kidneys, Is almost pathognomonic of this condition. We should always rule out pyelitis, as undoubtedly a number Of appendices have been removed when the offending condition was a right- tided pyelitis or ureteral stone. But a careful noting of symptoms, taking a careful history, examination of the urine for pus, and attention to physical findings will rule out these conditions. Fourth. Leueocytosis. —Our observations have found that a leueocytosis Is • good guide In aiding us to make an early diagnosis, as we find very high white cell counts in ambulatory cases without temperature. The absence of • leueocytosis, providing the first three symptoms are present, may be dis regarded. Fifth. Absence of diarrhea. —Textbooks teach us that a number of cases begin with a diarrhea, but the presence of a diarrhea has always caused us to be very slow in making a diagnosis of acute appendicitis, as we believe that this Is more often the result of the ingestion of some form of contaminated food and seldom, If ever, a symptom of an acute appendix. Sixth. The absence of pus in the urine. —The absence of pus In the urine excludes a pyelitis, which as mentioned before is sometimes very hard to differentiate from acute appendicitis, especially where we have retro-caecal appendix. Seventh. Nausea and vomiting. —We find this symptom as often absent as present. Nausea is more often present in the first few hours and sometimes vomiting, but case after case has neither symptom until late In the attack or not at all. Eighth. Fever. —A large number of cases show an absence of any rise In tem perature; In fact, this type of case Is one to be watched more carefully than nny other as we have seen at least 12 cases within the past six months of afebrile appendicitis, which at operation showed either a gangrenous or pus 736 FERRET —EXTRA-GENITAL CHANCRES. VoL XIII. appendix (unruptured). These cases If allowed to get out of the acute stage, and go as far as the third or fourth day waiting for our old classical symptom of fever, would very probably rupture and be cases for drainage. Ninth. Pulse. —The pulse Is of no practical value in the condition. If it is rapid or slightly increased in rate, it may be due to the excitement of the patient. If it is normal, together with a normal temperature, it does not rule out an acute appendix or one that should be operated upon immediately, as some of the most pronounced pus and gangrene cases show an absolutely normal temperature and pulse. Temperature and pulse are of no value, as their absence has a tendency to minimize the condition and their presence is of no aid in determining the type of appendix. conclusions. First Early diagnosis (first 3 to 12 hours) and early operation mean a short convalescence and an early return to duty ; the elimination of post operative hernia, adhesions, fecal fistulas, and often of obstructions. Second. That no case of acute intraabdominal pain should be given a cathartic until carefully examined and acute appendicitis has been excluded. Third. Temperature and pulse are of no practical value in arriving at an early diagnosis of acute appendicitis. They should be completely Ignored, or not even taken, as they more often mislead than lead. Fourth. And, finally, the cardinal symptoms of this condition should be enumerated as follows: First Pain. Second. Muscular rigidity. Third. Localized tenderness. EXTRA-GENITAL CHANCRES. Bj J. M. Pbebst, Lieutenant, Medical Corps, United States Naval Reserve Force. Syphilis is such an important disease that the real student, be he surgeon or internist, never tires of studying it. Osier has well said, " Know syphilis well in all its manifestations and relations and all other things clinical will be added unto you." Extra-genital chancres are given a goodly space in textbooks on syphilology, urology, and dermatology. This is as it should be, for these lesions are very important because of the serious results which would follow did they go about unrecognized. Extra-genital chancres are of special interest to the military sur geon. In a military organization the men live under conditions which force them into close contact with each other. From a hygienic point of view the soldier or sailor who has a chancre on his lip is a source of much greater danger to the rest of the men than one who has a chancre on his genitals. A chancre may occur on any part of the body which has been ex posed to a syphilitic lesion. The contagion may be direct; or mediate by feeding utensils, smoking utensils, towels, latrines, surgical instruments, silver nitrate and alum sticks, syringes, pencils, penhold ers, etc. Contagion from any part of the mouth may be transmitted to any part of the mouth of the person who becomes contaminated. The saliva acts as the vehicle of transmission of the virus. No. 4. 737 PERRET —EXTRA-GENITAL CHANCRES. Syphilolgists are pretty well in accord that the chancre is merely the local manifestation of a systematic disease. Excision of the chancre would not cure a case of syphilis. It is probable that there must be a break in the skin or mucous membrane for infection to take place. As the chancre and mucous patches abound in spirochetes, they are the most contagious lesions. The gumma contains but few spiro chetes and hence it is not very contagious. Extra-genital chancres are by no means rare. They are uncommon enough, however, to arouse a little interest when we run across one. In Russia, on account of the poor hygiene of the people, they are very common. According to Osier (1) 8 per cent of chancres are extra-genital. He quotes Tarnosky as saying that in some parts of Russia 70 per cent of cases are transmitted by extra-genital contagion. Sequeira (2) says that continental authors give the proportion as 10 genital to 1 extra-genital chancre. In Russia the proportion is much greater, 4 to 1. Stokes (3) says that the older statistics estimate from 5 to 10 per cent of all syphilitic infections to be of nongenital origin, but he thinks that these figures are too low. He quotes Schamberg, who reports a case in Philadelphia of a young man who in one kissing game infected seven young girls, all of whom developed chancres of the lips or cheeks. Guiteras (4) tells us that 10 per cent of chancres are extra-genital, and of these 3 per cent occur on lips, 7 per cent on remaining parts of the body, especially the fingers. Stel wagon (5) cites C. M. Smith, who saw 64 tonsillar chancres in 16 years. He says that the relative frequency of tonsillar chancres varies from 1 to 75 per cent of extra-genital chancres, according to various authorities ; in the United States it is about 3.5 per cent. DaCosta (6) has had a number of interesting cases of extra genital chancres. One man was infected by the alum stick of a barber; two young girls by dental instruments; a policeman by a pipe; another policeman by striking a prisoner on the mouth and cutting his own knuckle on the prisoner's teeth; a street car con ductor from a borrowed whistle; a glassblower from a blowpipe; a hospital orderly by picking his nose with a contaminated finger. He quotes Bulkley, who collected 1,863 cases following vaccination, 179 following circumcision, 82 following tatooing, 745 following cup ping or venesection. Keyes (7) among 2,200 syphilitic men found 70 extra-genital chancres, while in 207 syphilitic women he found 21 extra-genital chancres, i. e., 3.5 per cent for men and 10 per cent for women, which shows that women are more often innocently contaminated. 738 PERRET —EXTRA-GENITAL CHANCRES. Vol. XIII. He quotes Fournier as having tabulated 10,000 chancres (96 per cent of them in men) of which 94 per cent were genital in men and only 63 per cent genital in women. Site of extra-genital chancres : Keyes. Arm 1 Female 21 Up 13 Finger , 2 Vaccination 2 Breast 2 Tonsil 1 Eyelid 1 Male 70 Finger—,., . 34 Lips 24 Tongue 4 Tonsil 2 Abdomen 2 Cheek 1 Chin 1 Eyelid 1 The following tabulation is taken from Fournier (8) : Chancre* of cephalic region 484 Chancres of cervical region 4 Chancres of trunk 21 Chancres of breast 19 Chancre* of upper limb M Chancres of lower limb 4 Chancres of anus and perineal region 01 •a Location of cephalic chancres: Mouth : OaM. Cam Lip 323 Tongue H Tonsil 40 Gums • Palate 4 4S5 Face : Chin 24 Cheeks - 10 Eye T Nose 5 Forehead 2 47 Scalp 2 434 Fournier says: "Iconfcss that I am unable to establish the diag nosis of a syphilitic chancre in its early stage." The laboratory in the last 14 years has added a great deal to our knowledge of syphilis. Schaudin and Hoffman discovered the treponema pallidum in 1903. Wassermann came out with his test in 1906. Noguchi, in 1912, cultivated the treponema pallidum in pure culture. The dark field illuminator, the India ink, and special stains now enable us to reach a diagnosis much earlier than our prede- No. 4. 739 PERRET —EXTRA GENITAL CHANCRES. cessors. Clinically we should always think of chancre when we see a lesion the cause of which is not at once obvious. The following table is inserted because so many men seem to have the impression that tha Wassermann reaction is usually negative during the primary stag* of syphilis: Investigators. Wassermann, Neisser, Bruck, and Schucht Cition and Blaschko Bruck and Stem Bruhns and Halberstadter Ledermann Ledermann Lesser Noguchi Eoehne Boas Detre and Brezovsky 41G Number of Per cent casos. positive. 25 91.0 64 90.0 27 48.2 9 88.9 19 52.6 46 61.2 56 69.0 33 66.6 44 38.6 50 60.0 43 98.0 69.8 The same investigators in 1,605 secondary syphilis cases had 89.4 per cent positive reactions. Noguchi also mentions a series of 208 primary cases of syphilis in which the Wassermann was positive in 88 per cent and his own modification in 94 per cent. A very brief history of my case follows : H. F. J., a white male of 23 years, was admitted to United Statei Naval Hospital, Pensacola, Fla., on February 27, 1919, with diagnosis undetermined. He complained of a slightly painful sore on the uppee lip. He denied all venereal diseases. At first the patient ascribed his trouble to a fight which he had had about two weeks previously) during which he was struck on the mouth with a brass knuckle. From that date a little blister formed, which soon broke down when ho brushed his teeth. Later on the patient admitted having asso ciated a good deal with a chorus girl and he felt sure that he must have contracted the disease from kissing her. Physical examination showed swelling of the upper lip, on the middle of which there was a hard, elevated ulcer, covered with a grayish membrane. There was marked induration of the edges of the ulcer. There was general glandular enlargement—cervicals, sub mentals, epitrochlears, and inguinals. On March 3 and 4 spirochaetes were readily demonstrated by Fon- tana's method. The spirals of five were counted and varied between 9 and 11. The Wassermann reaction was 4 plus on March 3. On March 5 there appeared a discrete, pinkish macular eruption on the chest, abdomen, and flexor surfaces of the arms and forearms. The patient was given vigorous antisyphilitic treatment. On March 13 the skin was clear. On March 16 the sore was about the size of a 10-cent piece, induration almost entirely gone, practically dry, scarcely more than a scab. 740 HITCHCOCK WASSERMANN REACTION. VoL XIU. REFERENCES. 1. Osier: Modern Medicine. 2. Sequeria : Diseases of the Skin. 3. Stokes: The Third Great Plague. 4. Guiteras: Urology. 5. Stelwagon : Diseases of the Skin. 6. DaCosta : Modern Surgery. 7. Keyes: Urology. 8. Fournier: Treatment and Prophylaxis of Syphilis. 9. Noguchi : Serum Diagnosis of Syphilis. TEE INFLUENCE OF INCUBATION AND THE CHOICE 07 ANTIGENS IN THE WASSERMANN REACTION.1 By E. D. Hitchcock, Lieutenant, Medical Corps, United States Naval Reserve Force. At the present time the Wassermann reaction is mainly carried on with the antisheep hemolytic system with the choice of one or two of three antigens, an alcoholic extract of human or other heart muscle, cholesterolized alcoholic extract of heart muscle, and Noguchi an tigen. There is, however, a great variation in the period of incubation, owing to the demand on the part of the physician for an immediate report on the sera sent in for examination. Because of this tendency by many laboratories to lessen the period of incubation below the time necessary for the complement-fixation reaction to be completed, many positive cases needing further treatment may be released. In this paper I shall present the results I have obtained with the Wassermann reaction under different incubation conditions and indi cate the antigens found most satisfactory, especially for the treated cases. Two series of 100 cases each, of known syphilitica, mostly men under treatment, were run under the following conditions and length of time of incubation. In series No. 1, as shown in table No. 1, two periods of incubation were used : (1) Four hours in the refrigerator, (2) one hour in water bath at 37 C. In series No. 2, as shown in table No. 2, four periods of incubation were used: (1) Four hours in the refrigerator, (2) one hour in the water bath at 37 C, (3) one-half hour in the water bath at 37 C, and (4) 24 hours at room temperature. Three antigens were used in each serum tested: (1) Alcoholic extract of human heart, (2) cholesterolized alcoholic extract of hu man heart, (3) Noguchi, or acetone insoluble antigen. The dosage of antigen, complement, hemolytic amboceptor, and red cells was the same throughout. Technic of our regular method. —The human serum to be tested is heated to 56 C. for 30 minutes. The test dose is 0.1 c. c. >Laboratory, U. 8. Nava] Hospital, Puget Sound, Wasb. No. 4. 741 HITCHCOCK —WASSERMANN REACTION. As complement, the mixed sera of three or more guinea pigs is used. The blood is centrifuged and the serum allowed to stand on the cells overnight in the refrigerator. Dosage, 2 units, determined by titration. Antigens used are (1) alcoholic extract of human heart, (2) cholesterolized alcoholic extract of human heart (as prepared by Kolmer,1 (3) acetone insoluble lipoids (Kolmer).* Test doses of antigen are diluted so as to be uniform, 0.1 c. c. being used throughout. Sheep blood corpuscles are washed free from albumin and are made into a 2.5 per cent suspension in 0.9 per cent salt solution. Test dose is 0.5 c. c. Antisheep hemolytic amboceptor is used in dosage determined by titration before each set of Wassermann tests are run. One c. c. of 0.9 per cent salt solution is added to each test as a diluent. The serum, complement, and antigen mixture is put in the refrigerator for four hours, after which 0.5 c. c. of the 2.5 per cent suspension of sheep cells are added together with 2 units of antisheep amboceptor. The tubes are well shaken and placed in the water bath at 37 C. for 30 minutes. The test tubes are gently shaken once or twice dur ing the 30-minute period of incubation. The results are read and then reread after the cells have settled and are then recorded. We have found the proper adjustment of the hemolytic system of great importance as the dosage of complement varies and the rela tionship of the antisheep hemolytic amboceptor to the sheep cell suspension is not constant. A greater number of units of amboceptor than are required to bring about hemolysis may result in a positive case becoming completely negative. Noguchi3 has shown that one antibody is made negative by six amboceptor units and three anti bodies by 10 amboceptor units with the Wassermann system. Table I. Num ber of scrum. ] Treatment. /Salvar. 3. \HK. + .... /None (Chancre . /Salvar. 4. d|lHR. + .... • '/None * I Chancre. c /Salvar. 3. 5 W.+.... /Salvar. 3. tHg. + .... /None (Chancre. . 4 hours tn refrigerator. A. E. }+ + + + }+ + + + }■ (i } + + + + }+++ }+ + + + 1+ + + + C. A.E. + + + + + + + + + + + + + + + + + + + + + + + + + + + Ac. I. + + + + + + + + + + + + + + + + + + + + + + 1-hour water bath at 37 C. A.E. + + + C. A.E. + + + + + + + + + + + + + + Ac. I. + + + + + + + + + + + + 1 Kolmer, J. A., Infection, Immunity, and Specific Therapy, 1017, p. 445. » Kolmer, J. A., Infection, Immunity, and Specific Therapy, 1017, p. 448. " Noguchi, H. A., Homohemolytlc System for the Strum Diagnosis of Syphilis, Jour, of Exper. Med., 1018. XXVIII, 43. 133354—19 8 742 Vol. XIIL HITCHCOCK WASSERMANN REACTION. Table /—Continued. Xum- bor of scrum. 9 10 11 12 13 14 15 16 Treatment. /Salvar. 2. \He.+.... /Salvar. 2. \HK /Salvar. 7. \HK.+ .... /Salvar. 3. \HK.+.... /Salvar. 3. \Hr.+.... Salvar. 3. Hg.+.... /Salvar. 3. 1%.+.... /Salvar. 4. \Hg.+.... /None \Chai 17 19 20 21 22 23 24 25 liancre /Salvar. 6.... JIHR. + ia /Salvar. 7.... 18 "Hg.+ Salvar. 6.... |\Hg. + fNone |\ Chancre /Salvar. 6.... \Hg.+ /None t Secondaries. /Salvar. 1.... \Hg.+ /Salvar. 2.... \Hr.+ /Salvar. 9.... lHg. + i hours in refrlserator. A. E. C. A. E. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Ac. I. ± + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + ± 1-hour water bath at 37 C. A. E. + + + + + + + + + + + + + ± + C. A. E. + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Ac. I. ± +++ + + + ++ + +++ ++++ + + + + + + + + ± + Explanation or table. —A. E.— Alcoholic extract; C. A. E.- CholcsterolUed alcoholic extract: Ac. I.— Acetone insoluble antigen; Salvar.— Salvarsnn; li'g.— Morcury; ±— Doubtful positive. In Table 1 the cholesterolized antigen in the refrigerator method is shown to be slightly more sensitive than the alcoholic extract or the acetone insoluble lipoids. Where the period of incubation is much shorter as in the one-hour method at 37 C, the cholesterolized anti gen proved much more sensitive. In Cases Nos. 3, 11, 14, 17, and 18 the cholesterolized antigen gave from -|—|—(- to -|—|—|—f- in the refrigerator at four hours, while at one hour 37 C. the complement was not fixed. In Case No. 9, at the one-hour incubation, the cholesterolized anti gen failed to fix the complement as completely as the acetone insoluble antigen. Plain alcoholic extract of human heart is shown to be reliable and constant where the four-hour incubation in the refrigerator was used, but less satisfactory than the acetone insoluble antigen in the one- hour incubation at 37 C. 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HITCHCOCK —WASSERMANN REACTION. 745 In Table 2, the cholesterolized antigen bound more firmly in all periods of incubation with the exception of Case No. 15, where in the four-hour method in the refrigerator the alcoholic extract and the acetone insoluble antigen fixed the complement slightly more than the cholesterolized antigen; also at the one hour in the water bath the acetone insoluble antigen proved slightly more sensitive than the cholesterin antigen. The plain alcoholic extract in Table 2 proved sufliciently sensitive and slightly more so than the acetone insoluble antigen in the cold, four-hour method or the 24-hour method at room temperature. In the shorter periods of incubation the acetone insoluble antigen is shown to be more sensitive. The one-half-hour period of incubation did not prove sufficient. In cases Nos. 1, 3, 4, and 25 sufficient time was not allowed to fix the complement, giving negative results throughout. In sera Nos. 2, 7, 10, 15, 20, 22, and 23, strongly positive cases, the one-half hour period proved sufficient. Here the unit of antibodies was very large. How ever, in treated cases and early cases this period of incubation is not sufficient and should not be depended upon. The 24-hour period of incubation at room temperature is shown to be satisfactory with all the antigens as to the fixation of the com plement, but the negative cases are less clearly defined and the num ber of sera becoming anticomplementary greatly increases. In a series of 558 cases with four hours in the refrigerator as incu bation period and using three antigens, alcoholic extract of human heart, cholesterolized alcoholic extract of human heart, and acetone insoluble lipoids, 176 cases were found positive in varying degrees. 1. Alcoholic extract proved less sensitive than the cholesterolized antigen In 40 percent. 2. Alcoholic extract proved less sensitive than the acetone Insoluble antigen in 0.22 per cent. 3. Acetone insoluble antigen fixed the complement to a less degree than the cholesterolized antigen in 60 per cent. 4. Acetone insoluble antigen proved less sensitive than the alcoholic extract in 33 per cent of positive cases. In the above series of cases the alcoholic extract proved reliable, but less sensitive than the cholesterolized antigen. The addition of cholesterin affords a better gauge as to further treatment than may be required. The acetone insoluble antigen has been less satisfactory in our hands where the refrigerator method of incubation was used than when the one-hour method at 37 C. was used. 746 HITCHCOCK WASSERMANN REACTION. VoL XIII. CONCLUSIONS. 1. Sufficient time must be allowed to complete the fixation of the comple ment ; where few. antibodies are present a longer period of incubation is re quired. This Is best accomplished by a period of not less than four hours in the refrigerator. 2. The one-half hour period of Incubation is not sufficient and will lead to false negative cases. 3. Twenty-four hours at room temperature fixes the complement completely, but may give false positives and anticomplementary reactions. 4. Cholesterolized antigen Is more sensitive than the other antigens and gives a better gauge as to treatment required and progress of case. 5. The alcoholic extract Is satisfactory as an antigen where a minimum In cubation period of four hours In" the refrigerator Is used. 6. The acetone Insoluble antigen Is especially satisfactory and more constant than the alcoholic extract where the period of Incubation is one hour or In the water bath or the Incubator at 37 O. ; HISTORICAL. THE PEACTICE OF MEDICIHE EST ETJEOPE DURING THE MIDDLE AGES. The first and most striking fact about medieval medicine in Eu rope is that it was very largely in the hands of the clergy. In the next place, it is to be noticed that during the thousand years between 500 A. D. and 1500 A. D. the practitioners of Europe added nothing of value to the sum of medical knowledge. Where they seem to have introduced new ideas and methods a close scrutiny shows that they were merely rediscovering or reviving something well known in the Hippocratic, Alexandrian, or Roman period and later for gotten, or else importing it from Moslem sources. To understand how medicine came to be one of the indirect activi ties of the Church of Rome, it is necessary to appreciate how com plete was the collapse of all of the old institutions when the Roman Empire was overthrown, as much through the decay within itself of all virtue and integrity as through the onslaught of enemies from without. Meanwhile there had been slowly developing a far greater power than Rome or the wild tribes which conquered it. This was the Christian Church. When darkness settled over the land of Caesar, Horace, Cicero and Virgil, the light of learning was kept alive by all the vivifying influences that emanated from the new religion. During the sixth century there is little evidence of secular schools, either literary or medical. Doubtless they existed, but they played a more and more insignificant part. Church institutions took their place. Thus at Bordeaux, Marseille, Toulouse, Aries, Nimes and Narbonne, in France; at Rome and Ravenna, in Italy, the original lay schools were succeeded by church schools. Similar institutions sprang up under priestly patronage in England, Ireland, and Wales, and likewise in Germany. Lay physicians such as flourished in Greece and Rome or later in Bagdad were displaced by the practicing priest and relegated to an inferior position because they were sure to be ignorant and untutored. The road to knowledge was through the church. The lay practitioner took to devious paths and became the professed quack, the itinerant vender of nostrums, the mechanic of medicine. The change did not come all at once. Theodoric the Great and Childeric, the Frank- ish King, each had private physicians who were laymen, and so later 747 748 EUROPEAN MEDICINE IN THE MIDDLE AGES. Vol. XIIL did Charlemagne, who was attended by Jews and Arabians. The fact that in the earlier period practice outside the church was more and more confined in Europe to the despised descendants of Abraham is sufficient evidence of changing conditions. The learning was in the church. Outside of it were lithotomists, herniotomists, occulists of a low order, and so forth. Various Burgundian, Frankish, and Gothic princes had their nonclerical attendants, and laws existed which secured to them a limited protection and honor. Saxoa chronicles record the names of various prominent leeches and tell of a certain Cynifred, who opened an abscess for Queen Aethyldyth and gave directions for operating on hare lip. Evidences of the affiliation of medicine with religious institutions survives in the names of our hospitals, a St. Luke's, St. Thomas's, St. Mary's, or St. Elizabeth's being common in every large city, though now direct connection with a religious body is often small or entirely lacking. In ancient times it was largely around the church that clustered those philanthropic enterprises which to-day are maintained by private munificence, corporate bodies, and the provisions of city and State governments. One of the salient features of the medieval church was monas- ticism. The monastery and convent not only furnished sanctuary for those who had fallen foul of the law and gave moral comfort to the poor and downtrodden mortals victimized by common bandit and highborn robber baron, but were centers of relief for physical distress, where the hungry were fed and the sick sheltered and cared for. A monastery usually had its infirmary and dispensary, where cordials, collyria, and healing salves were prepared. There was a garden, too, for the cultivation of medicinal herbs. The monks and nuns knew how to dress wounds and administer simple remedies. Travelers were hospitably entertained and afforded tran quility, security, and a clean bed, comforts not to be found in the wretched inns of the day. Among the earliest establishments were the hospices of Mont Cenis (825 A. D.) and St. Bernard (980 A. D.), which ministered to wayfarers across the Alps. Equally important were the libraries connected with the larger institutions, which were often perfect treasure houses of learning. In them one or more of the confraternity toiled through a lifetime at the slow task of translating, copying, and illuminating rare manu scripts, while the more gifted studied them and utilized their con tents for original work. (It is to be remembered that during the earlier part of the Middle Ages writing was an accomplishment which even the highborn did not always possess.) In the universal turbulence of the Dark Ages, amid the petty strife of rival families, and contending political factions using intrigue, the dagger, or the sword to attain their ends many a priceless historical document Ko.4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 749 would have been lost to us but for the monastery, an institution usually respected by all the contestants. If in time the scholar became a mere scholiast and the copyist waxed careless the fact remains that they were the custodians of medical and other archives that would have perished without them. In connection with the monastery and the convent, schools, hospi tals, almshouses, orphan and foundling asylums sprang up. The poverty, distress, and sickness engendered by constant warfare and unfavorable social conditions led pious people to establish hospitals — popes, bishops, and princes taking the lead. Sometimes hardened old warriors with deeds of violence to expiate were the founders or patrons of these charitable establishments, and the painters and archi tects of the clay beautified them to the best of their ability, giving their art to the cause of God and the poor. They were often con ducted on a large scale and provided asylum and food for the in digent as well as treatment for the sick. In 1198 Innocent the Third founded the great hospital of the Holy Spirit in Rome, in connection with which there developed a foundling and insane asylum. They are all three in operation to-day. More famous still and of greater antiquity was the Hotel Dieu, of Paris.1 Germany boasted 155 hos pitals or dispensaries during the Middle Ages. There were 10 hos pitals in Rome in the thirteenth century. In London St. Bar tholomew's was founded in 1137, St. Thomas's in 1215. With time a large proportion of these hospitals passed into the hands of the civil administration. The nuns were then, as they continue to be to-day in most Latin countries, the nurses for the sick, and even midwives obtained in struction from the clergy. A time came when the active practice of medicine by male members of the religious orders threatened to en gross them unduly, diverting them from their primary and paramount duties. Bulls and ordinances began to restrict their labors in this field, though not actually forbidding anything but surgery. A time came, too, when the church grew apprehensive of the effect upon belief of unhampered intellectual development and sought to curb scientific research, for which it had never cared, its medical work being carried on purely as a charity and not with any idea of investigation or advancement. But the nursing of the infant char ity, the toleration of the infant science, and the chastisement of their adult forms were equally valuable in different ways, and now science fights its battles alone, standing or falling according to the measure of its inherent worth, the truth or falsity of its postulates. Of the various monastic orders, that founded by St. Benedict (480- 544 A. D.) was by far the most important in so far as concerns the history of medicine. Benedict first established himself at Subiaco, a ■See D. 8. Nav. Med. Bull., Vol. XII, No. 4. 750 EUROPEAN MEDICINE IN THE MIDDLE AGES. VoL XI1L little town of Abruzzi, and later founded the famous Abbey of Mont© Cassino in the Kingdom of Naples. St. Benedict founded 14 monasteries in his lifetime, and these were perfectly independent establishments, merely observing the same rule. For 500 years this autonomy prevailed among the count less Benedictine monasteries and nunneries that sprang up through out Europe, beginning with their spread from Italy to England under St. Augustine. Many, while observing the rule of St. Bene dict, went by other names, the principal offshoot being the Cister cians. The Fourth Lateran Council provided for the federation of the various houses, and from the thirteenth century on we may with propriety speak of a Benedictine "order." The Benedictines were often spoken of as the Black Monks, and Blackfriar's Bridge in London is named for their monastery on the banks of the river. The Benedictine nuns were originated by St. Benedict's sister, Santa Scholastica. From the point of view of charitable enterprise the nuns were in a way more important than the monks for as they were prohibited by their sex from ministerial functions they were forced to one of two extremes, a purely contemplative life or an in tensely practical work in connection with almshouses, orphanages, schools, and hospitals. A later development of monasticism was the foundation of the Franciscan order by St. Francis of Assisi in the beginning of the thirteenth century. Francis had been a gay wordling prior to his conversion and one of his pet horrors had been a leper. He now devoted himself to a life of poverty, to caring for the poor and sick, especially lepers. His call was to " cure the sick, raise the dead, cleanse the lepers, and drive out devils." Out of the Franciscan order developed the Capuchins. The order of the " poor Clares " grew out of the Franciscan sisterhood. In contradistinction to the Benedictines the Franciscans or Minorites were known as Gray- friars. The practice of medicine was not contemplated in the original rule of the Benedictine order, but its study was encouraged, though prayer and conjuration were relied on for cures. Cassiodorus, some time secretary of state to Theodoric, joined the Benedictines and urged the study of the medical classics —Hippocrates, Discorides, Galen, Caelius Aurelianus, and others —from the Latin versions of the Greek originals. His advice was acted upon and Monte Cas sino attained and long held preeminence in the study of the medicine of antiquity and other classics. (After the sacking of Monte Cassino by the Longobards, the Benedictines temporarily repaired to the vicinity of the Lateran in Rome.) Alcuin, another Benedictine, urged on Charlemagne, who was a patron of learning, the founding of university schools, and the Em No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 751 peror acted on his advice and desired that medicine be one of the courses provided for the students. He also ordered that plants hav ing medicinal value be grown in all royal parks. The monastery of St. Gall, near Constance, Switzerland, had a school which was justly famous. The monastery was founded in 612 A. D. by the Irish saint of that name. In 820 A. D. the monas tery had a pharmacy, a house for physicians, special apartments for the sick, a permanent resident physician, and a garden where the lily, rose, gladiola, rue, cummin, and other plants were systematically cultivated for medicinal purposes. Other cathedral schools grew up at Fulda, Wurzburg, Metz, Paris. Lyons, Cremona, Florence, etc. So far as medicine was concerned, Monte Cassino eclipsed them all, but it was finally overshadowed by the medical school of Salerno, a lay school whose golden era lasted until the beginning of the thirteenth century.1 Here medicine was once more distinctly dissociated from the participation of the religious orders and returned to the hands of the lay practitioner. Its example contributed very decidedly to bringing about this result throughout Italy, but celibacy and holy orders were features of medical practice in France till the fifteenth century, and medical students throughout Europe tonsured their heads and wore long clerical robes even though they did not take holy orders. From the fifth century on we have increasingly rich records of the church's activity in medicine, a crude and unsatisfactory medi cine, indeed, but perhaps its rough and ignorant methods harmon ized with the attainments of the times in other matters. The list of abbots and bishops who played the part of physicians is a very long one and among them, alas, the ecclesiastical bias showed itself in one very lamentable particular. Their practice was too often bolstered up by the employment of amulets, symbols, relics, and ap peals to all the saints of the calendar. As incentives to faith and hope these measures were not to be condemned, but too often theur were placebos administered by ignorance to superstition. As a matter of interest, because illustrating the spirit of the times, we may list the saints who were invoked for particular ailments— heavenly specialists, as it were. St. Christopher was appealed to by those who had a horror of sudden death, and even a sight of his picture was like the modern travelers' insurance —good for a certain number of hours. (The Eomans, who did not have to undergo special spiritual preparation for the ordeal of death held, on the contrary, that only those whom the gods particularly love are accorded quick deliveance from the woes of life.) St. Eligius was good in fistula in ano. St. Just specialized on headaches. St. Stephen was the saint for sufferers from stone. St. Catherine of Alexandria helped >See U. S. Nav. Med. Bull., Vol. XII, No. 2. 752 EUROPEAN MEDICINE IN THE MIDDLE AGES. Vol. XIIL out in diseases of the tongue. Diseases of the eye required suppli cations to St. Ottilia, St. Clara, and St. Lucy, and to St. Martin of Tours. St. Ursmar could relieve the toothache and St. Matthias would keep the winebibber from getting hopelessly drunk. St. Margaret gave succor to the parturient, and relics of this saint were in use up to modern times to bring good fortune to the queens of France when in travail. Some of the marvelous cures accomplished in the earlier days of the church smack suspiciously of the "incubation" of temple healing in Greece. In 391 A. D. the nephew of Archbishop Theophilus of Alexandria built a Christian church on the site of the Serapeion his uncle had helped to destroy and provided it with the bones of St. John and St. Cyril of Edessa. Thither sick people resorted to spend the night and be advised in a dream by these particular saints as to what to do to get well. The Christian martyrs and physicians Cosma and Damianus had churches named for them, and equally striking mira cles .were performed in them, while in the eleventh century a German emperor-elect visited Monte Cassino and was there operated on by St. Benedict (died 543 A. D.), who appeared to him in a dream and told him that he was due to pass three stones from the bladder, which the fortunate patient duly found in his hand on awakening, his wound healed. Marcellus Empiricus in the fifth century was a Christian physician and too pious a man to be mistaken for a practical joker when he directs that the words socsocam sykma be whispered 27 times in a man's ear to check nose bleed. A practical joker! No; he had too large a following. Both Bernard of Clairvaux and Gregory of Tours, whose beauti ful hymns we still sing, objected, in their exhalted piety, to combin ing human agencies and prayer in seeking relief from suffering as this betokened lack of faith. On the other hand, many physicians, either because they distrusted their own powers or relied on the mental effect produced, were in the habit of reinforcing their pre scriptions with prayers and rhymes, while the bones of St. Matthew in the cathedral of Salerno were a real asset in attracting patients to that health resort. It is well enough to provide spiritual consolation to the sick and to strengthen hope of recovery by the ministrations of religion, but too many of the practices associated with the church's medical treat ment seems to have come directly from pagan sources like Sextus Placitus, who declared that for a child to kiss a horse's nose was a guarantee against toothache, but mentioned the risk of his being bitten in the act; like Apuleius, who with his list of herb-cures furnished also the spells to be used with each. No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 753 St. Hildegarde, who while a living being upon earth (1098-1179) was an abbess at Ruppertsberg, near Bingen, was a naturalist and physician who wrote on materia medica and therapeutics. She departed widely from many of the older methods and used galenical remedies almost entirely. Her favorite vehicle for the administration of drugs was flour in the form of pancakes. She was a capable and devout woman of strong character; but her singular credulity is illustrated by her belief in the unicorn. She ascribed great virtue to a belt made from the hide of a unicorn and worn next to the skin in protecting from pestilence and fevers. An ointment made from this animal's liver and the yolk of egg was a guarantee against leprosy. According to Hildegarde the unicorn is easily captured when, overcome at the sight of a girl—a creature in man's shape yet without a beard —he sits down on his haunches and stares at her. This truly pious and worthy woman appreciated the value of belladonna as an anodyne and recommends its local use for car diac distress. Less wise was her reliance on arnica as a promoter of love. To touch man or woman with green arnica was to inspire him or her with a passion for the person who applied it, which in creased to the point of folly as the plant withered. Pare" dispelled the belief in the medicinal virtues of the unicorn much to the chagrin of his protector and patron, Charles IX, who had quite a costly store of it. One wonders who perpetrated this fraud on him. The idea of the unicorn was probably based on travelers' reports of the rhinoceros. John of Gaddesden (fourteenth century) guarantees freedom from colic for those who will wear a specially constructed belt made from the skin of a sea cow. Throughout the Middle Ages a hound's tongue was regarded as a splendid sedative and was combined with opium, henbane, etc., in making the " dog-tongue pil." Francis I, a patron of art and admirer of beauty (he inherted his father's mistress, the famed Diana of Poitiers), used tlieriaca and always carried on his person a little powdered mummy, a specific against injuries from falls and accidents. Mumia owed its real or supposed efficacy as an astringent for hemorrhage, dysentery, and ulcers to the balsam and myrrh used when the body was first embalmed ! So enlightened a man as Francis Bacon was a great believer in it. Gentile da Foligno (1330) recommended the reading of the Psalms of David as an accelerator of labor. Fucinus of Florence regarded gold as the elixir of life. Peter Hispanus, commonly identified with Pope John XXI (died 1277), favored the use of amulets, and his pre scription for chronic diarrhea suggests a mind totally bereft of com mon sense. Other foolish beliefs could be cited without number. The Knights Hospitalers and Templars carried a piece of coral in their belts, not merely to bring good luck, but to have it handy, because 754 EUROPEAN MEDICINE IN THE MIDDLE AGES. Vol. XIII. palpitation of the heart, due to indigestion, was relieved by holding coral in the mouth. Arnold of Villanova tells how a priest cured him of over a hundred warts on his hands by making the sign of the cross over them, repeating the Lord's Prayer and burying a pellitary plant in a damp piece of ground. Gilbertus Anglicus treated warts by cutting open the back of a red snail and putting in salt. The juice which then came out of the snail was a sovereign remedy and so also was the application of a piece of burning wool; but he also recommended the knife. Pope John XXI recommended for gout that a frog, captured when neither sun nor moon was shining, shorn of his legs and wrapped in deer skin, be applied to the suffering member. It was rather commonly believed in the Middle Ages that precious or semiprecious stones were valuable remedies for disease. Needless to say they were not employed in charity practice, but the distinction conferred on a wealthy patient by ordering expensive remedies for him is clear, and the psychic effect of such elegant pharmacology was enormous. Lorenzo de Medici was unsuccessfully treated by this method in his last illness and his doctor committed suicide. Michael Psellus, a Byzantine physician (1020-1105), wrote a treatise on " The Healing Powers of Precious Stones " in which he made very careful and subtle distinctions. Thus amethyst was for delirium tremens, beryl for jaundice, jasper for epilepsy, amber externally for genito-urinary disease. Such ideas fitted in very well with dabblings in vague notions of alchemy and of astrology, and deserved a place in a practice of medicine which considered the movements and conjunctions of the heavenly bodies, the seasons, and the tides, and ascribed importance to the date of the patient's birth and the saint or star to which his life was a vital concern. Yet this man's learning was vast, ranging from theology to cooking, and he introduced the practice of public debates by physicians, which be came a feature of university life in the Middle Ages. Benivieni, the father of pathology, had a friend who consulted a priest about his hernia. The clerical practitioner made no pretense at taxis but applied a tight bandage. Benivieni was called at the end of a week and found his friend delirious, dying. He summoned the author of this fine piece of work and in his presence removed the bandage from the corpse, disclosing the ulcer and the gangrene of the bowel caused by the treatment. Fallopius records how he prescribed laxative pills for the abbess of the convent of St. Paul, at Pisa, and the worthy lady instead of swallowing them, moistened them with her saliva, flattened them out into little cakes, and applied them to the region of her stomach under a tight bandage. They acted in four or five hours. This went on for two years, greatly to the astonishment of Fallopius. His friend Vidius tells us how a certain Florentine came to Pisa to be No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 755 cured of a huge cirsoid aneurism covering the whole back of his head. Fallopius had an apparatus for cutting out the tumor, but hesitated to use it, fearing the man might bleed to death. He lived for years in spite of the untreated growth. Guy de Chauliac tells how one lord bishop who was medical treated another lord bishop suffering with strangury who was not. A little matter of 5 drachms of opium put him to sleep forever. A far more sensible type of prelate was that thirteenth century divine, Walter de Kirkham, bishop of Durham, who ordered the priests of his diocese to preach from the pulpit against the practice of a mother taking her baby to sleep in the bed with her, because this involved great risk of the infant being rolled on and suffocated. According to Baass, prostitution in London was for a long time regulated by the bishops of the city. A routine and indispensable feature of practice was the examina tion of urine—by inspection only. The most important part of th« procedure was to look wise and impress the patient or his friends. Undoubtedly, however, there were some doctors who really studied the sample submitted for books, even books in rhyme, were gotten out on the subject. Many a doctor, weary of night calls and the unsatisfactory char acter of general practice, could, as a canon, retire to his ecclesiastical niche for leisurely study, and by examining samples of urine sent from a distance and by letters of advice, pursue a profitable career by giving absent treatment only. Then, as now, the physician of scholarly tastes found it irksome to be at the beck and call of the public. To these men abstract science was the main thing in life and medicine a side issue with the results to be expected. The pursuit of alchemy or astronomy made the doctor a theorist, hindered clinical observation, gave him an aloofness from the practical aspects of sickness which had deplorable results. One of the venerable superstitions of the Middle Ages, surviving almost to our day, was the belief in the power of a king to cure scrofula by touching the patient. This belief was universal through out Europe. The number touched by a single king amounted to thousands in a year. It was one of the divine prerogatives associ ated with the divine right by which they ruled. One can not refrain from a smile over the secret disgust Louis XI and St. Francis de Paul must have entertained for each other since the king could not cure the priest of his scrofula nor himself be relieved of his own disability by the miracle-working saint, summoned from Italy for that purpose. The belief in the influence of the stars increased with the popu larity of Arabic medicine. Certain days were not favorable for bleeding and could be ascertained by consulting an almanac. The 756 EUROPEAN MEDICINE IN THE MIDDLE AGES. VoL-XIIt. phases of the moon determined the propitious time for collecting cer tain plants and the administration of others. Marcellus Fucinus, a Florentine celebrity of the fifteenth century, ascribed special virtue to medicines prepared during the conjunction of Jupiter and Venus. Most Rabelaisian of all the special measures of the fifteenth cen tury were those recommended in his practice of medicine by one Guainerius for the treatment of poisonous stings. Take a chicken, pluck out all the circumanal feathers, and apply the denuded part of the unfortunate bird's anatomy to the site of the sting. Hold the chicken's beak closed and the poison will be aspirated into its body from that of the patient. Of the follies and stupidity, the superstitions, and ignorance of both doctor and patient in the Middle Ages and after, volumes could be written, but there is every reason to believe that there wero then many physicians fully as sincere, as earnest, as faithful as any of our time. Much that they did seems erroneous, crude, barbaric to us, but can we be sure that 500 years from now we shall come off any better ? Most of the pioneers in the profession sinned by their servile adherence to ancient authority and blind conservatism, but their error was due to a misconception, a distorted sense of values, not to indifference or laziness. How hard they worked; how they traveled hither and yon in search of the truth (blind to the fact that it was close at hand for all to see in nature) ; what risks they ran ; what cour age of conviction they showed, venturing life itself for honest belief ; what thirst for knowledge, what pride in their profession was theirs. All honor to the misguided but zealous men of the Middle Ages ! There are several ways of interpreting the life and thought of antiquity. One is to assume that whatever differs from our views, accepted as right and final, was stupid or ridiculous. Another is to so twist and turn a phrase from some early writing as to make it harmonize with modern conceptions, as though this were a kind ness instead of a manifest injustice since, if progress is to continue, this course only robs error of its venerable age. The more correct method is to try first to find out what the men of former ages actu ally said and then what they really meant, taking into consideration their situation and other beliefs. Thus, if a man so intelligent and learned as Fracastor thought the stars had to do with epidemics, this is not a proof that he was superstitious, though it might suggest it in another man. He lived in a period when learning was prized as never before. New ideas were germinating, old ones were passing away. Copernicus was about to recast the most fundamental con ceptions about the universe. Fracastor's associates and contem poraries, Cardinal Bembo, Pomponazzo, and others, were either in different to all save the form of religion or had discarded it entirely. Men were turning to nature and asking questions of it instead of No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 757 evolving laws from their inner consciousness. Hence for a pioneer in geology, a mathematician, a serious student of contagion to ascribe a pestilence to the stars he had seen instead of to the saint he had not seen was a step forward, though a mistake. On the other hand, it would be very far-fetched to say that because the moon determines the tides and tides may effect the level of underground water near the coast, therefore a belief in the relation of the heavenly bodies to pestilence was in harmony with the theories of Metchnikoff ! In considering the medicine of the Middle Ages it is proper to re member that there was no anatomy and physiology worth the name. If the medical reader can conceive himself compelled to practice without any conception of these fundamentals, he will inevitably have a higher and more just opinion of the sagacity and intelligence of the practitioners of the period in question; he will recognize at every step their marvelous powers of observation and their close reasoning. Their conclusions were false, but they had no premises. The medicine of Europe was a mixture of Greek and Arabian medi cine up to the seventeenth century and there was nothing new in it or surgery until the eighteenth. In a general way, surgery was the better art of the two because it was more genuine, pretended less, made less assumption of a knowledge that did not exist, and was in the main less arrogant. The reputable surgeon renounced what was beyond his powers and did not, like the doctor, put all his trust and confidence in words and mummeries. His errors were costly, but he was working along sound lines. He looked, he listened, he smelled, he handled, he cut. He was in close contact with nature. Men might argue while a consumptive slowly lost strength and energy in spite of the potions, lotions, pills, and salves administered in profusion, but not while the blood spurted from a severed vessel. The crime of the Middle Ages was the complete separation of medicine and surgery, the latter being regarded as a low and vulgar calling unworthy of an educated man. There could be no greater mistake than to blame the church for this fatal error. At least three popes were themselves physicians, and the unfavorable attitude of Rome was not to surgery, as such, but to the practice of surgery by men in holy orders. This objection was a valid one. Surgery was in a backward state owing to the total lack of any real knowledge of anatomy, and as the results of bad surgery are conspicuous and hard to hide, as in the Middle Ages the surgeon who killed his patient or left him maimed for life was lucky to get off with nothing worse than the loss of a nose or ear and a good cudgeling or ducking, the church most wisely discouraged its representatives from using the knife. The real causes of the attitude of the physician to the sur geon were the influence of Arabian practice on the one hand; jeal- 133354—19 0 758 EUROPEAN MEDICINE IN THE MIDDLE AGES. Vol. XIII. ousy on the part of the medical fraternity on the other. The Faculty of Paris took the lead in this matter and for 400 years evinced a bigotry and bitterness almost beyond belief, even going so far as to take under its patronage the barbers and barber surgeons and pit them against the surgeons proper. The example of Paris was followed by Montpellier, Oxford, Cambridge, and the German schools, except perhaps Vienna, where surgery was taught with some zeal, even as for a while at Montpellier. The thirteenth century saw a revival of Arabian influence in Eu ropean medicine. This school counteracted in some measure the ascetic and monastic ideas which made nature a vile thing full of demons enticing men to explore its mysteries at the risk of their souls; which deemed the human body a mere instrument of sin. The " Canon " of Avicenna, the writings of Albucasis and Rhazes, together with those of Galen, now became the standard authorities in medicine and were the textbooks from which professors read aloud to their classes, this lifeless method being universal in the medical schools of the Middle Ages. Arnold of Villanova or Villeneuve (1235-1312) was a powerful champion of Arabic medicine. His birthplace is disputed and he may have been a native of Spain or France, countries in which new towns were constantly springing up, their foundation and civic status being fostered by royalty seeking to neutralize the power of an over grown and arrogant feudal nobility. The least imaginative burgher could put together the equivalents for " new " and " town " and get Villanueva or Villeneuve, and there were fully a score of towns in France and Spain bearing this name. At all events, Arnold studied and taught at Montpellier. He was at once a doctor of theology, of law, of philosophy, and of medicine, but his heart's love was for alchemy. He had begun his studies under the Dominicans, to whom medicine was forbidden. He knew Hebrew and other ancient languages. His theological writings, which in volved him with the Inquisition, were burned and the author might have shared their fate had not Pope Clement V befriended him and removed the charge of heresy. Boniface VIII, whom he treated for stone, had also been his protector. Clement, indeed, esteemed his professional skill so highly that he published an encyclical letter to the bishops of the church bidding them be on the lookout for a cer tain medical treatise composed by Arnold during his lifetime which His Holiness was most anxious to secure. One of the 14 deadly errors ascribed to the great scholar was his assertion that " the works of mercy and medicine are more acceptable to God than the sacrifice of the altar," though he had scripture authority for this belief. Arnold was an alchemist and his great ambition was to discover some universal remedy, some elixir of life. Alcohol, because of its No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 759 preservative qualities, seemed to promise something along this line and though to-day we believe that it is anything but a restorer of youth, we employ the alcoholic preparations of drugs, tinctures, founded on his recognition of the readiness with which alcohol extracts the active principles of many vegetable substances. Villanova was a Salernitan in his preference for simple and natural remedies and deprecated the too prompt resort to drugging. For example, his advice to sufferers from palpitation of the heart in cludes no special prescriptions but deals rather with personal habits, food, and exercise. Indigestible diet and exposure to cold are to be avoided. Beef, game, cheese, pastry, and poor bread are forbidden. Avoidance of cold is enjoined, and yet the patient must have fresh air, cooled in summer by decorating his apartment with branches of willow and grapevine sprinkled with water. Moderate exercise, as on a horse or gently trotting mule, is proper before, but not after, eating. Sleep immediately after a meal is not good either. One should lie first on the right side and then on the left side to assist the passage of food along the digestive tract. Strange to say, he admits salt pork to the menu, and this was the one thing that Dr. J. Marion Sims could eat with impunity when almost dying of chronic diarrhea. A favorite recipe of the Middle Ages was Arnold of Villanova 's pill of aloes, 4; saffron, 1; myrrh, 2 parts, which he wished never to be without. It survives in our pharmacopoeia. Peter of Abano (1250-1315) was one of the first men to reflect luster on his alma mater, the University of Padua, where he taught medicine after ranging over Europe from Constantinople to Paris. He was a man of strong religious convictions, to judge by his pre facing certain directions for treatment with an appeal to the " Giver of salvation," and by the conclusion to another direction, which reads : " Pray therefore that God, the Giver of health, will direct you to the choice of the proper remedy." However, because of his independence and disposition to express his views he, too, fell foul of the church and the flames devoured either his bones or his effigy. Tradition says that his devoted house keeper, Marietta, after his fine funeral and burial, disinterred and concealed the body so that the inquisitors might not get it. To deny the existence of the devil and suggest that Lazarus might have been in a trance and not actually dead when he was raised up was heresy, indeed. Peter seems also to have doubted the doctrine of free will. He was clearly outside the domain of his profession when he exploited novel ideas on life, conduct, and belief, and it would be narrow prejudice to charge that Eome condemned him as a physi cian. He lived at a time when to that institution alone was gen erally conceded the right to formulate creeds. 760 EUROPEAN MEDICINE IN THE MIDDLE AGES. Vol. XIII. Peter's principal written work was designed to reconcile the teach ings of the Greek and Arabian schools, being himself distinctly a professor of the latter. His learning, his freedom of speech, his great fame, raised up many enemies who found a ready basis for attack in his passion for astrology and magic. Before prescribing he considered the state of the weather and the hour of the patient's birth, employing all the mannerisms calculated to impress the patient and taking into consideration the movements of the heavenly bodies in determining the best time to gather the plants to be employed for a cure. On the other hand, he was a friend of Mondino of Bologna and undoubtedly did some dissecting on his own account. Bernard de Gordon, probably a native of Gordon, France, and not a Scotchman, began to teach at Montpellier in" 1285 and stayed there for 22 years. His textbook, " The Lily of Medicine," has neither the merit of originality nor soundness, but has historical value be cause of the reference to trusses for hernia and to spectacles. He claimed to have an ointment for the eyes, which made good vision possible without them. The Podesta, or chief magistrate of Padua, one Pietro Bonaparte, must have attracted considerable attention when he attended the marriage solemnized at Vienna in 1319 between Juta, Duchess of Austria and Louis of Oettingen, by wearing a pair of spectacles. He had obtained them from their inventor, Salvino degli Armati, of Florence. In 1574 Augustus, Elector of Saxony, wanted a pair of spectacles and sent agents to hunt for one in Leipzig and Augsburg. Finally he sent to Venice and after months of delay a set of convex lenses was ground for him at a cost of $250. Tt was only 200 years later that myopics could be accommodated. Gilbertus Anglicus, who lived at the beginning of the thirteenth century, was one of the first of English physicians to rise above the general level of ignorance and superstition that marked his col leagues. His compend of medicine contains a description of leprosy that remained authoritative throughout the Middle Ages. He as serted the contagiousness of smallpox. John of Gaddesden made a reputation when summoned to treat the Prince of Wales suffering with smallpox. He enveloped his patient and hung the couch and walls of the appartment with scar let cloths. This was characteristic of the man for he stooped to every trick to impress the world with his marvelous learning and originality. His writings do not display genuine erudition, and Guy de Chauliac, alluding to his " Rosa Anglica," says, contemptu ously : " Finally there sprang up an insipid English rose which was sent to me and by me seen. I had expected to find in it an odor of sweetness but it contained only the tales of Hispanus, Gilbertus, and Theodoric." Wo. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 761 A work of immense popularity was the " Treasury of the Poor." The authorship is in dispute but it is generally attributed to one Peter Hispanus, a graduate of Montpellier, some time physician to Gregory X and later himself pontifex maximus, as John XXI, his election being due in some measure to his good health and relative youth, three pontiffs in succession before him having been raised to the throne and died in a period of seven months. Peter has in his book one or two infallible remedies. Hysterical females are to be brought around by applying a large cupping glass —any big vessel will do—to the lower abdomen, and the lively use of the actual cautery. Syncope due to hysteria can be overcome by blowing pepper and salt up the patient's nostrils. The efficacy of such methods is incontestible and there is no fault to be found with his itch remedy, composed of sulphur, pitch, niter, frankincense, and oil, except its claim to be a " one-day " cure. We may note here the general character of the titles given to many of the medical writings of the period, which by their attempt at refinement and elegance reflect some of the least deserving features of Arabian medicine. The " Flower of Health," and " Rose of Eng land," the " Lilly of Medicine," the " Light of Lights," the " Rosary of Philosophers " suggest the vanity of their authors and of the foreigners they feebly plagiarized, for too many of the physicians of the day who pretended to transmit the knowledge of their masters knew little Arabic and not much Greek and got most of their lore at second hand. The style as well as the title of these writings was generally artifi cial and stilted like the bedside manner of the composers and their assumption of dignity and knowledge when ministering to the sick. Many of the writings were in verse, and no part or function 'of the human body was so humble but what it could be raised to honor if discussed in carefully composed couplets. Giacomo de Dondi, who died in 1350, commonly known in his day as the " accumulator," from the large number of remedies he added to therapy in a work called " Aggregator de medicinis simplicibus," was of a good family of Padua and there he spent the greater part of his life, highly esteemed for the versatility of his talent, which ranged over mathematics, astronomy, and philosophy. He was thus typical of the early style physician, concerned with much more than belonged to his calling. According to Leclerc he devised an astro nomical clock which told the hours, the course of the sun and moon, the days of the month, and the principal feast days of the year. It was set up on the palace of the Prince of Carara in the marble dis trict. He also went in extensively for salt works. Both his sons were physicians, one of them being a friend of Petrarch, who willed to him enough money to buy a ring to remember him by. Dabbling in 762 EUROPEAN MEDICINE IN THE MIDDLE AGES. Vol. XIIL all sorts of outside things was well enough in Italy at such a time, but in England and America a feeling was to develop later which made a generality of pursuits no recommendation for a physician. Harvey, Thomas Young, and Holmes (to mention only conspicuous examples) paid the penalty of not sticking strictly to the practice of medicine, but happily each was independent of practice and did more for the world by his collateral work than by his real fidelity in the daily round of calls. The Arabist example, the example and the rulings of the Catholic Church, were not the only influences that affected medicine. Kings and governing bodies had a considerable share in the molding of opinion and the control of conduct. Eoger II, of Sicily, in 1140 had promulgated a law to regulate the practice of medicine in his dominions. Regularly appointed officials granted the necessary license, and to prescribe without it was to incur the risk of a year's imprisonment and the confiscation of property. Roger's grandson, Frederick II, not only fixed the graduation examinations at Salerno and legalized dissection and anatomical instruction but regulated the sale of drugs and the relation of physician to apothecary. Under the Hohenstaufen, Angevine, and Aragonese dynasties, excellent laws were passed for the Kingdoms of Naples and Sicily, covering matters of sanitation and public health. The depth at which dead bodies were to be buried, the disposal of garbage, the raising of live stock within the. city limits, the slaughter and sale of diseased cattle were all covered by these enactments. Somewhat similar ordinances were passed in Spain and Germany, though both these countries were backward in medicine. Italy, indeed, was the leader in all that betokened civilization, and France came next. Germany was far behind England, which scarcely approached the best fea tures of life on the Continent. The medical schools of importance after the passing of Salerno's best period were Bologna, Montpellier, Padua, Pavia, Paris, and Bale, somewhat in the order named, but their fortunes fluctuated with politics, parties, and dynasties, now one now another being in the ascendant. Montpellier was the richest of them all in manu scripts whereas for a hundred years Paris boasted but nine. On the other hand, Montpellier was most dependent on political support, and in time it began to go down hill. Instead of standing or falling on sound principles of justice and right, it followed expediency. It had once been the resort of Jewish students; it now excluded them. It had once educated brilliant surgeons. Now, it subserviently bowed to the prejudices of the moment and went even beyond the bigotry of the Faculty of Paris and suspended its teaching of that branch. The foreign wars undertaken by Francis I and Louis XII were bar No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 763 ren of political results, but the invaders of Italy came back enriched with spoils from the libraries of Florence and Pavia. At Montpellier and Bologna the members of the faculty ran into the hundreds, the matriculates into thousands. The students con stituted largely self-governing bodies, which selected their studies as well as their professors and enlivened life by hazing and initia tions which, especially in Germany, often went to brutal lengths. They were in daily rows with the citizens of their respective towns and when the price of board went up or a pestilence threatened, they would move to some other town and set up their school in new quarters. Thus the faculty and students of Oxford, 3,000 strong, once boycotted the town of Oxford, for a space of several years going to Cambridge or foreign schools. Various cities of Italy had their communal or public-health doc tors, engaged to attend the poor and in some cases to serve with mili tary expeditions as occasion arose. Such an official was Ugo or Hugh Borgognoni of Lucca, of the early part of the thirteenth century. In the fourteenth century, Venice, as the great commercial and sea faring people of the day, Marseilles, and Bagusa established system atic quarantine against ships, passengers, and cargo from infected ports to save themselves from the Black Death, one of the scourges that repeatedly swept over Europe (notably in 1348) and carried off some 60,000,000 people. One of the truly marvelous achievements of the Middle Ages was the extermination of leprosy, which had appeared here and there in northern Europe in the sixth and seventh centuries, but became widespread at the time of the Crusades, so that France alone possessed 2,000 leper hospitals and the rest of Europe some 17,000 more. These establishments were at once the result of char ity and the means of self -protection for the community and by the simple process of isolation finally ridded Europe of the dreadful malady. Epidemics of dancing mania, sweating sickness, Plica Polonica, typhus, and influenza wrought frightful havoc. These visitations gave rise to the publication of " plague tractates " or short, concise directions for avoiding infection. They were sometimes as con tradictory as the theories of our own time. The prevalent belief, ascribed the origin of contagious disease to the air polluted by humors emanating from the bodies of those infected. Contagion was to be avoided by proper diet, avoidance of chilling, the use of acid fruits only, the inhalation of vinegar, etc. Disinfection by the combustion of aromatic substances was commonly practiced. We depend in large measure on works of physicians of the period for our knowledge of medieval medicine. But what a comparatively 764 EUROPEAN MEDICINE IN THE MIDDLE AGES. VoL XIII. few medical men write is not always a complete picture of what the many practice. We must distinguish between a few exponents of their own times and practices and the larger number who worked in silence. In that class there were many worthy men, though they belonged in what Oliver Wendell Holmes has beautifully described as " the magnificent constituency of mediocrities of which the world is made up—the people without biographies, whose lives have made a clear solution in the fluid menstruum of time instead of being precipitated in the opaque sediment of history." One may smile at suggestions of cupidity, avarice, and sharp dealing in some old text but must not deduce from it that all or even the majority of the writer's contemporaries were unscrupulous. Another possible mistake is to pick out the amusing, piquant, or anomalous incidents of some medieval practitioner and deem them characteristic of the period. Again, many a writer elaborated ideas and theories in his writings which he may have been far from try ing to put into execution at the bedside. Petrarch ridiculed the pretentious, ornate costume of his contem poraries of the medical profession, their rings, their tall horses, their golden spurs, and Gilles de Corbeil before him had satirized those of the twelfth century, but we do not have to rely on word pic tures for the appearance of the physicians and surgeons of the thir teenth and fourteenth centuries, since portraits of them survive in illuminated manuscripts. John of Arderne is represented with a blond beard, apparelled in a gown, cloak, and cap. Mondeville is handed down to us as tall, slender, and sickly (he died of tubercu losis) arrayed in a long purple gown, black skull cap, and red stockings. The physicians were certainly high and mighty in their bearing and affected that dignity which too often bespeaks the shal low character or poorly furnished mind. The best men everywhere are outwardly simple. Their imitators, who have nothing genuine to offer, must adorn the outer man, impose their importance by manner, on those who will never discover it by their deeds. One of the most interesting features of medical literature in the fourteenth and fifteenth centuries was the frequent publication of so-called concilia or letters of advice, which practically embodied the case records of the authors. Some of them were frank letters to inquiring patients, others wei%e addressed to students and country physicians to instruct them after the fashion of our correspondence schools. The collections in book form were simply a popular way of teaching clinical medicine. Three distinguished professors of Padua took the lead in this de partment. They were Gentile de Foligno, who died in 1348 of the plague; Antonio Cermisone (died 1443); and Bartolomeo Montag No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 765 nana, in whose family medicine was hereditary for several genera tions. The Montagnanas dispensed their remedies from an apothe cary shop of their own. Many of the consilia had a form very similar to the clinical record of a modern hospital patient, beginning with a description of the sick man, his habits, history, temperament and symptoms, and passing on to a discussion of his disease, its cause, and possible cure by diet and drugs. We can not recover much of direct value in modern practice from these old letters, but they throw an interesting light on the be liefs and practices of the day in which they were written and in some instances have real historical value. Gentile's advice about a man who had gone mad through excess of joy shows his partiality for dosing. First there is a decoction of endive, senna, and other substances in sugar and water, of which 2 or 3 ounces are to be taken in warm water. At bedtime this is reinforced by the addition of poppy heads. Then the patient's head Is to be rubbed with a lini ment of violets, aloes, camomile, water lilies, poppies, and lettuce prepared with a barley water. Cupping glasses are to be freely applied to neck, shoulders, and buttocks. Finally the attendant is told that it will benefit the patient if he can develop hemorrhoids! Whether this last detail of treatment would cure him of madness is doubtful, but it would certainly attack the cause of the disturbance and rob him of any surviving excess of joy. Montagnana wrote some 300 consilia. One of them discusses the case of a lady with a suppurating ear and impaired hearing. The writer gives a rather unfavorable prognosis as to the hearing but advises a depletive treatment. She is to avoid pastry, milk, boiled fish and eels, vegetables, and stewed meats, especially at night. Sweet wines are to be given up or diluted with water and the amount re duced. She must not hang her head down. A rhubarb pill in the morning, bleeding from the right cephalic vein or between the thumb and index of the right hand, daily poulticing, a purge on retiring, and locally sweet oil, alternating with cyclamen juice complete the carefully planned treatment which will result in a cure " to the glory of Almighty God. Amen." An English abbot, contemplating a pilgrimage to Jerusalem, makes inquiries about what he may expect and the measures he should adopt for his health. Montagnana recommends a confection of quinces and coriander before meals to prevent seasickness. If this fails, he should bandage arms and legs and apply dry cups to the abdomen and use a suppository of scammony and colocynth, while plunging his feet suddenly into cold water. There is a good deal more advice but what has been quoted suggests that the author may have rightly attributed seasickness to vasomotor disturbance. 766 EUROPEAN MEDICINE IN THE MIDDLE AGES. VoL XIIL Montagnana was opposed to the use of trusses for hernia—" iron rings with pressure over the groin "— and treated the condition by in cision, reposition, and cauterization without castration. He refers to a tumor of the groin which could not be hernia because pulsating, fluctuating, compressible, and feverish. To Montagnana's credit be it remembered that he had dissected or opened 14 human bodies dur ing the course of his professional career. Cermison recommends aloes and musk for eye affections, and foot and hand baths as revulsants. For catarrhal affections of the upper air passages cantharideal blisters are to be applied behind the ears. He gives directions for disguising a disagreeable taste by honey and melted sugar. His consilia also contain prescriptions clearly in tended for acute gonorrhea. Solid pessaries of irritating substances are recommended to induce the catamenia. Beverius de Baverius was another writer of consilia. He was sometime professor at Bologna and physician to the great humanist and art lover Pope Nicholas V. He treated chlorosis with iron. One of his consilia contains a description of an interesting case of par alysis of the arms, loss of speech and memory following acute ca tarrhal inflammation of the throat. Matthew Ferrarus de Gradibus, who died in 1472, treated Louis XI for hemorrhoids and Bianca Maria Sforza, Duchess of Milan, for asthma. One of his consilia relates the case of a youth who acquired paralysis of two fingers from excessive writing. Another describes the chronic rheumatism of Gaston, Prince of Navarre. Again he notes the hemorrhages from vesical calculus, from suppressed menses ; the sterility dependent on uterine displacements. Another form of clinical record was contained in the so-called observationes, or in books of cures. John Lange (1485-1565), a pupil of Leonicenus and physician of four Electors Palatine, mentions the prejudice against performing even minor surgery on certain unlucky days. In one of his letters of advice he tells about a girl who had to decline many advantageous offers of marriage because of ill health. Her case baffled the physi cians, some diagnosing it as heart disease and others as hysteria, dis ease of the liver, etc. Her symptoms were pallor, palpitation, a visible pulsation of the temporal arteries, dyspnea at dances, oedema of the ankles. He bade the anxious parents dismiss their fears, give the patient emmenagogues and purgatives, accept the most available suitor for the girl and invite the writer to the wedding. Amatus Lusitanus, a Jewish physician of the sixteenth century, was popular and prosperous until he incurred the displeasure of Matthioli of Siena by finding mistakes in the latter's edition of Dios- corides. The Siennese physician charged him with secretly following the religious practices of his race in spite of having been (forcibly) No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 767 baptized in childhood. This led to such active persecution that poor Amatus was not safe until he took refuge with the Turks in Salonica. He published some 700 cures, among which are head injuries which, due to the relative softness of the bones of children, turned out favor ably. One of these was a girl with ulcers of the tongue who fell downstairs and got a large depression of the skull. Another was a lad who fell from a great height and similarly dented his skull. Both recovered. A boy of 12 was hit on the left temple. There wa9 no local sign but severe constitutional symptoms with pain referred to the opposite side. Amatus trephined over the seat of pain, evacu ated pus, and cured his patient in 35 days. A case of melancholia was cured by bleeding, cupping, and friction combined with cathartics. It was proposed to cut off her hair, where upon the girl grew angry and vowed she would rather die than lose it. She was gotten to sleep by putting lettuce and poppy seed in her food and recovered. Though opposed to dyeing the hair, he admits the necessity of gratifying the public taste and recommends henna as an infallible measure, which a very dear friend of his, a Florentine lady, always used with success. Henna is to be made into a paste with water, rubbed into the scalp and left on for 24 hours. This is followed by washing with warm wine and the use of a long-toothed, ivory comb. A French noble imagined that he had an abscess in his side. There was none. The patient was in good health, with rosy face, good pulse, and the appetite of a bull. He made his will and gave away everything but a single flagon of wine, which he hugged to his side as if it had been a bewitching girl. Amatus pretended to operate and showed the pus he had withdrawn —a mixture of milk and hen's blood prepared in advance. He tells of being called in as an expert in the case of a woman accused of bewitching a young noble and causing him to lose his hear ing. Amatus testified that incantations could not produce deafness and that drugs had not been administered or their effects would have been noticed sooner. Further, he proved that the plaintiff was suffer ing from syphilis, which sometimes causes deafness, and so got the woman off. In Rome he was invited to treat Camillo Colonna, the head of one of the great patrician families. The patient suffered from gout and was put on a restricted diet and a course of purgatives, but he soon tired of this regimen and after the sixth treatment indulged in a huge meal of " fried eggs and all sorts of shellfish." This led to a night of torment, and when the doctor called next day, the servants, rushing up to help him dismount from his mule, told him all about it. " Always find out as much as you can from a patient's servants " is his wise advice, repeating what the Salernitans had taught long before. Lusitanus taxed the prince with having broken 768 EUROPEAN MEDICINE IN THE MIDDLE AGES. Vol. XIIL his promise to obey orders, a quarrel ensued, and the physician de parted in high dudgeon, vowing not to return. " And I would not have gone back to him again; no, not if he had offered me one of his estates," adds the Jew, with spirit, in spite of all he had undergone. A monk of Pesaro fell in love with a gardener's daughter, and having often besought her in vain on his knees to run off and marry him he drank some vitriol, bought of an apothocary, and died of it after suffering great pain, an erosion of the stomach, vomiting, diarrhea, blackness and swelling of the tongue. The science of Amatus availed nothing in this case. A young Jew of Salonica went insane with love. " I undertook his cure, prescribed the usual regimen for melancholia, together with a sirup of hellebore of my own composition and a purgative con taining lapis lazuli." The issue of the case was a cure but only after the violence of the lover's feelings had been relieved by climbing a rope ladder to the lady's chamber and attacking her relatives with his fists. The watch was called in and led the violent youth to prison, where his distemper soon subsided. The regime to which Amatus refers is that of Haly Abbas, a Moslem physician of the tenth century. Love being but a form of melancholy, a moistening treatment should be carried out, consisting of baths, moderate horseback riding, and anointing with oil of violets. For the victims of love inclining to melancholia sweet, low music of lute or lyre, the contemplation of gardens, meadows and flowers, entertainment by stories, and interesting news are prescribed. They must have some business to keep their thoughts off the loved ones, and quarrels and arguments offer a further distraction. The acquaintance of other young women is valuable, too. A great writer of observations was Peter Forest, professor of medi cine in the new University of Leyden. He tells how, following the death of the botanist Valerius Cordus, in his arms, he too fell sick with fever and sore throat and next day, his teacher, a visiting physi cian at the Ospedale della Consolazione, Kome, commented on the sudaminal or impetiginous eruption on his face, likening it to syphi lis. Patient' and doctor discussed treatment, but decided to do noth ing, and the former kept within doors, hating to be seen abroad with such serious looking sores. Things got worse with him until he re called Avicenna's prescription of camphor and saliva. Forest used saliva alone and with the blessing of God soon enjoyed a permanent recovery. He gives an account of the "sweating sickness" which existed in England for 40 years, and finally in 1529 spread to the Continent, prevailed there extensively, " entered Amsterdam on the afternoon of September 27 in a thick fog." and eventually passed back to England. No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 769 The chief symptom was " a rapid sweat, fiery and of most unpleasant odor, with pains in all the extremities and paralysis." Those who re sented the heat and opened all the windows died at once, and those who went to the other extreme and closed up every crack, lit fires, and piled on bedding were equally unfortunate. The middle course was the practical one. He notes that purgation, bleeding, barley water, and mild diuretics constituted the best treatment. The English phy sicians ordered no drugs but waited for the sweating. " When it is free, nearly all escape: if suppressed, the majority perish." Abso lute rest in bed was indispensable. He describes an epidemic (influenza) which appeared in Holland in June, 1580. It was very contagious, sudden in onset and marked by fever, inflammation of throat and lungs, hoarseness, and cough. " Many families were suddenly struck down." It was not serious unless complicated by pleurisy and pneumonia. It decreased in July and reappeared with severity in the autumn. In winter the pulmo nary cases were more serious and experienced pleuritic pains and expectoration of blood. Forest wisely calls attention to the im portance of recognizing early which cases required bleeding and which did not. He did not ascribe much benefit to the use of theriac and gold leaf, inclining to a rational treatment. He avoided wine and objected to treating all cases with a single routine drug. True, wine supported weakness, but there were other measures for this, and too much wine lead to delirium and mania. He did use wine in some cases to relieve the cough, adding sugar candy. Forest had been well educated in various schools, in France and Italy, and acquired great popularity in his own country. History distinguishes between the Middle Ages and the period of the Revival of Learning, separating them by the date of the fall of Constantinople (1453) into the hands of the Turks and the conse quent scattering of many scholars with their manuscripts throughout the rest of Europe. But in many ways this classic distinction between the older period and the new and brighter one is inappropriate in the history of medicine, whose revival or renaissance is foreshadowed by Vesalius and Fallopius and fully inaugurated by Harvey in the seventeenth century, when so many enterprises of far-reaching im portance were begun in the medical world. Certainly the proverbial ignorance of the Dark Ages persisted long after the renewal of scholarly interest in Greek and Latin lore, and medicine in a way suffered by its renewed dependence on antiquity when original work was the need of the hour. Hence reference has been made to men and things which, according to the accepted subdivision of past eras, do not belong to the Middle Ages proper, and this sketch concludes with an allusion to two men 770 EUROPEAN MEDICINE IN THE MIDDLE AGES. VoL XIII. who in some ways were typical of the time of their birth and in others far ahead of it. Girolamo Fracastoro * was born in Verona, 1478, and died in his villa near by in 1553. He came of a good family and received the best possible education. At the University of Padua he was thrown with the most brilliant minds of his day, among them Copernicus, Contarini, Ehamnusius, the brothers Delia Torre, etc., and came under the influence of Pomponazzo, a new order of being. Later Cardinal Bembo and the Farneses, one a pope as Paul III, the other a cardinal, were his friends. To many Fracastoro is known mainly as the author of a poem, "Syphilis or the French Disease," which sets forth the woeful conse quences of the amours of a young shepherd, Syphilis by name. Both the elaborate, high-flown, artificial style, in keeping with the taste of the day, and the general interest in the topic gave it an enormous popularity. It is the source of the word syphilis and affirms the sexual origin of the disease. Vastly more important and interesting was Fracastoro's book "Concerning contagions and contagious diseases," a conscientious and accurate study summarizing the prev alent ideas on the subject and clearly defining his own. The essential types of infection are: 1, Those due to contact alone, where a disorder of the relations of heat and moisture in the body lead to putrefaction, heat and moisture being regarded as entities rather than qualities ; 2, those due to contact and fomites, as scabies, leprosy, elephantiasis, etc., the clothes, linen, etc., called "fomites," not being themselves more than the agents which harbor and foster the growth of essential seeds of contagion; 3, those conveyed by contact or fomites and also transmitted at a distance, such as pes tilential fevers, phthisis, etc. It is by the closest and most accurate reasoning (on what he believed to be facts) that Fracastor proceeds to explain the propagation of disease by seeds thrown off from the body and either attacking directly or after an abode in fomites. The great difficulty (his successors have encountered it) was to explain the transmission through space without contact. Though carefully excluding supernatural agencies, he shows here his weak side and refers to the injury which a glance may do (belief in the "evil eye" is still common) as in some way analogous to the problem in hand and he suggests also the influence of the stars, of bad air and water, all causes acting from without. Fracastoro's use of the word seeds of contagion, his careful distinction between the poison which affects a single individual and can not reproduce itself in another body, and contagion whose seeds have a power to "multiply and propagate their like" is a groping after the germ idea which had to await the development of the microscope for demonstration. 1 C. ii nil D. Singer : The Scientific Position of O. Fracastoro. Annals of Med. Hist.. Vol. I. No. 1. No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 771 The book contains an admirable clinical description of typhus fever and the statement that the contagion of this disease is not con veyed through air. The onset, the cerebral symptoms, the eruption and its time of appearance, the character of urine, pulse, and fever, the prognosis, etc., are set forth briefly and clearly. Fracastor's in fluence on contemporary medical thought and throughout the suc ceeding century was enormous. All subsequent writings abound in references to him. In the general scientific world he was less appreciated though with a clearer title to fame. He grasped the true significance of fossil remains as related to changes of surface levels and was the first to suggest their secular variations. He appreciated the nature of re fraction of light, and while in no sense the equal of Copernicus he worked along similar lines and was prompt to accept the revolu tionary teachings of the great astronomer. He constructed the first orrery and anticipated Mercator's idea of rectilinear maps. He was the first writer to use the word pole as applied to the earth itself. With all his learning Fracastor was a kindly, simple, sociable be ing, rich in friends, rich through his enjoyment of poetry and music. Paul III appointed Fracastor physician to the famous Council of Trent, and it was on his advice that the sittings were transferred to Bologna when the plague made its appearance. The King of France and the German Emperor conferred honors upon him and Margaret of Navarre, who sought to surround herself with the lions of the day, did everything she could to attract him to her court, but the great man preferred the charms of his villa and its opportunity for quiet and study. Antonio Benivieni (1448-1502) was not a professor but a prac titioner of medicine and surgery in Florence, and this adds a flavor of interest to his career because so large a proportion of those who wrote on medicine up to the nineteenth century were professional teachers with the dictatorial spirit that stamps the class. Benivieni had a consuming desire to get at the reason of things and may be re garded as the founder of pathology, though his actual attainments in this field do not compare in magnitude with those of the great Morgagni. For his time, however, he was phenomenal. His story of a case of gangrene of the bowel due to malpractice has already been told. Benivieni's book, " Concerning the Hidden Causes of Disease," was very short, for he had not explored a great range of subjects, and this brevity is one of its charms. There was no padding, no display of learning, no quoting of what other men had said. He gives his notes on cases studied and that is all. He quoted nobody, for there was no one before him to quote. The book went to press after the author had been dead four years, so some of the credit be 772 EUROPEAN MEDICINE IN THE MIDDLE AGES. Vol. XIII. longs to the brother and friend who edited it. But Benivieni's merit lay in this, that he was the first to deliberately open the body (and he did so at every opportunity) to learn the cause of death, and, as Albutt says, not looking for secrets or mysteries but for things that were out of sight only. He describes senile gangrene for the first time and reports cases of biliary calculus, morbus coxae, mesenteric abscess, thrombosis of mesenteric vessels, cardiac cases, cancer of the stomach and bowels, rupture of the intestine, etc., a goodly collection for the world's first pathologist. Benivieni not only studied his own cases, but sought autopsies everywhere. With each report is a brief statement of etiology and symptoms. Benivieni was a successful sur geon practicing lithotrity, perforating the hymen for retained menses, cutting into the cicatricial tissue resulting from a burn of the arm, and making slow extension to improve motion. The question of whether syphilis existed in Europe before the dis covery of America seems to me to offer no difficult problem. That all the symptoms of this protean disease were grouped together as an entity and always recognized as having the same origin and given a definite name requires a different answer. Ugo Bentius, who flourished under Pope Eugenius IV (1431-1447), describes in his consilia a young man of 20 who suffered with severe headaches, foul sweats, and pains, often almost unendurable, in his limbs. His face, head, and back were covered with pustules; ab scesses developed first on the leg, then on the foot, and finally all over. There were reddish blotches on legs and back. Bentius died 45 years before the discovery of America and the supposed introduc tion of the disease from there into Europe. He called his case sci atica with pustular eruption, an unconscious euphony. Another in dividual was described as having painful swellings of the joints, atrophy of the muscles, and serious changes in nose and mouth. Menghus, in a rare work, " Concerning Every Variety of Fever (Venice, I486)," described symptoms strongly resembling syphilis and attributed them to sexual impurity. But the reader who has pursued the subject this far may still ask, "What was the medicine of the Middle Ages?" It was a medicine of incessant dosing with countless elaborately compounded drugs, of bleeding and purging, thanks to a huge pharmacopoeia and huge ignorance of the causes of disease. When the unusual, poetic, or disgusting remedy failed —the substances used varied from lilies, violets, and roses to the blood, excrement, and intestinal concretions of animals—resort was had to amulet and exorcism; to scripture, prayer, holy relics, appeals to Venus or Jupiter. Except in Italy, where, in spite of the Arabians, the best physicians were often good surgeons, no manual operations were undertaken by ethical members of the profession. The fashionable clyster was administered by the No. 4. EUROPEAN MEDICINE IN THE MIDDLE AGES. 773 apothecary, bleeding was done by the barber, and anything more elaborate called for a barber-surgeon. As for real surgery, a herni otomy or lithotomy, that was taught in the college classroom but never done. The surgical patient had to rely on the good offices of men who passed for charlatans. For the most part they were Italians or had learned their trade in Italy, where there had been a sort of apostolic succession of surgery. The anatomy of pigs taught by Copho of Salerno became the anatomy of human beings under Mondino de Luzzi, teaching at Bologna early in the fourteenth cen tury, but he only made a worthy beginning and the practical results have been greatly overestimated. The great medical centers rarely boasted more than one or two dissections a year and in most cases went for three and four years without one. When a rare cadaver was secured a barber opened the abdomen with a razor, a demon strator pointed out the viscera, and the professor, keeping at a safe distance, expounded in Latin the ideas of Galen or some Arabist as found in a garbled manuscript. The performance began with a brief religious service out of respect for the dead and was concluded with a sort of vaudeville to relieve the overwrought feelings of the stu dents after witnessing such an invasion into the forbidden mysteries of nature. The anatomy and physiology of the Middle Ages was little better than that of the fifth century before Christ save for what Galen had added by cutting up apes. Everybody, except and after Hippoc rates, was satisfied that the way to learn the truth was to argue about it, and in the public debates that constituted one of the fea tures of college life he who quoted from the oldest manuscript always carried the day. Albertus Magnus, a Dominican, used his knowledge of physics and mechanics to construct automatons and this, with his fondness for astrology, proved him a sorcerer. Roger Bacon, an English Franciscan, who had the instincts of a true naturalist and wanted investigation to take the place of speculation, went to prison. The great majority of men were content to philosophize about the humors of the body and never thought to look. The followers of the Arabist school came upon the scene in force armed with purer texts, a horror of surgery, and a strong racial in clination to casuistry. They added many new remedies. They were clever, earnest men and masterly clinical observers. For their period they were modern interpreters and revisers of the cherished ancient lore. We marvel, not that the physician of the Middle Ages knew so little, but, that knowing none of the essentials, he accomplished so much ; made such shrewd guesses, was so useful in spite of his limita tions. He bore to the modern practitioner about the relation that a 133354—19 10 774 EUROPEAN MEDICINE IN THE MIDDLE AGES. Vol. Xm. fourth- year medical student who had had no first, second, or third year would occupy. Or we may compare him to an intelligent, ob serving male nurse who for years has worked with a scientific doctor but never been, alio wed to use a stethoscope, look through a micro scope, or touch a specific gravity apparatus. The Revival of Learning in the middle of the fifteenth century technically concluded the period under consideration and was fol lowed by a disposition to look for material causes and to doubt the force of immaterial ones. The new-springing scholarship discovered that the texts of its venerated authors were inaccurate or spurious. Confidence in authority thus rudely shaken produced the inevitable consequences. While some men devoted a lifetime to bringing out faithful editions of Galen and Hippocrates, others rejected their broken idols altogether and started out on a new and untried road. Vesalius, disgusted with the superficial, crude, and bootless anatomy of Paris, could endure no longer to sit on a bench and listen to trivial ities. He "had to get his hand into the business." Vesalius, Fal- lopius, Eustachius, Columbo, Cesalpino, Servetus, and Fabricius of Acquapendente did not see the dawn but the stars of the ancient night were paling above their heads and soon Harvey, not so much by his wonderful discoveries as by his distinctly scientific way of making them, was to usher in a new day.1 . •The data for this paper were collected from data too numerous to mention. No originality Is claimed for It EDITORIAL. Intangible damage. He would be a poor physician indeed who failed to see a great difference in prognostic import between the behavior of two patients, both seriously ill, one of whom stoutly affirmed that he was deter mined to recover —" Do your best for me and I'll play my part ; my work is too interesting, too important for me to die yet "—while the other, soul-laden and heartsick, showed in his apathy and supineness, better than in words, his utter weariness of life. The autopsy does not always reveal the cause of death, though we may fasten the guilt on this or that departure from normal. To plead an ultramicroscopic lesion or agent is begging the question and there is such a thing as overdoing the endocrine business. Our ma terialism may lead us as far astray as the people of one or 25 centu ries ago, who had their " archeus," their " vital spirit," or their " pneuma " to explain the phenomena of life and death. Every clinician has seen people die who " ought to have gotten well," as far as their lesions were concerned, and vice versa. To claim that momentary depression of spirits causes a normal organ to discontinue its function would be an error, but certain phenomena, of such daily occurrence as to be forgotten in the search for remote ones, may be full of meaning. The modest girl blushes at a ques tionable joke or a relished compliment. Fear causes pallor, tremor, and perspiration, and the anticipation of a court-martial or a visit to a dentist produces marked disturbances of the splanchnic region. Joy, hope, despair, and avarice illumine or becloud the countenance. The constant recurrence of shades of feeling leaves unmistakable evidences in face and gait and bearing so that a mere child uner ringly recognizes a predominant expression in physical features and says : " What a sad old man," or " What a sweet, lovely lady," or "What a horrid, mean face." The physician recognizes the dys peptic by a selfish, peevish expression ; the cardiac case by a certain sadness, a haggardness of the eyes, and the drooping lines about the mouth; and there is unmistakable wistfulnoss and appeal in the eyes of the gravid woman nearing her term. That the constant recurrence of depressing emotions can trauma tize the cardio-vascular apparatus seems hardly open to question, and this conceded it follows that long-continued sorrow and anxiety 775 776 Vol. XIIL EDITORIAL. can secondarily play havoc with the whole organism to the shorten ing as well as embittering of life. The war recently forced on Europe and America has caused to be laid at the door of the world's enemy a bill for damages reckoned in dollars, pounds, and francs, but even should it ever be paid there will remain the debt for intangible damage which no cora- me.rcial activity, no enterprise in business, nor thrift nor economy can ever redeem. The man whose business was ruined, the bank rupt, the unemployed laborer, he whose education was interrupted, the girl whose lover was killed in battle—all these may recover from their destitution. A better business, a better education, a bet ter matrimonial arrangement may be realized for them in time. So-called prosperity will return, even as after other wars, and a few years hence silver-tongued orators will speak applause-provoking platitudes about the " fruit trees shedding their blossoms on the once devastated fields of France and Flanders " and tell how " hope burns again in countless hearts." But to many who have passed youth's zenith of buoyancy, to those whose ears strain from the general harmony the melancholy pulsing of the bass viols and hear only the plaintive notes in the mad waltz, to those whose eyes see in the beauty of the autumn leaf a hint of death and decay, for those to whose senses the crisp autumn air foretells the winter's chill, there will be no forgetfulness of the irremediable and intangible damage which kaiserism inflicted on an unoffending world. For how many struggling mortals life's burden has become a crushing load ! For how many in the great mass of average mankind has anxiety over financial matters meant sleepless nights and not mere meatless but tasteless meals ! What humiliations, what pertur bations of spirit, what blighting of lifelong hopes and plans have they not endured? How vain have proved the toil and privations endured through long years for some cherished aim that can never be compassed now ! These things the young and irresponsible, whose future still unfolds alluringly amid war's loud alarums, can never know, for love has helped devoted parents to gulp clown their sorrows, but the bitter cup has like a slow poison sapped the latter's resistance, killed enthu siasm, dimmed the brightness of life, and veiled the beauty and sunshine of earth. A few men here and there, bewildered by conflicting feelings of duty, have made a quick end of everything; a few, having no anchor age for their souls in the changeless principles of right, have blindly run riot in conflict with law and order, but these are isolated and negligible incidents compared to the thousands of unrecorded cases whose heads are bowed a little lower, whose step is less secure because Ho. 4. EDITORIAL. 777 of the day's distress and the night's vigil. On these people the blight of want and the agony of apprehension have left a permanent mark. For the dead and the maimed we mourn, for wrecked homes and dismantled shops payment may be asked, but how to calculate the loss through intangible damage, how count the number of those who with no fame, no glamour, no reward of ribbon or monument have simply lost their grip on life or been robbed of a few years of their allotted span? The attitude of the bubeau. There are few service readers who have not spoken or heard others speak about the "attitude of the bureau." When a medical officer gets back to hospital or ship after a visit to Washington his col leagues and shipmates gather around him begging for the latest item of news or gossip, and at such a time this expression is very apt to be heard more than once. It is safe to say that no two people outside the bureau or in it have the same idea about this "attitude," but those who are not affiliated with the organization agree in one thing; they conceive of the attitude as a stolid, resistant, homoge neous thing like the facade of a building looking north or south, east or west, in a certain block on a certain street, whose topo graphical location will not change unless the foundation collapses. This general opinion embodies all the error which it is possible to crystallize into definite form. If the Bureau has an attitude at all it is one eminently susceptible of change, being a sort of composite of many minds of the greatest diversity and far from a definite formula in black and white. Sitting in a niche in the wall past which men come and go, it has been interesting, amusing, rather saddening—everything laughable has its tearful side and the fountain-heads of the sweet and bitter waters of life are very near each other—to hear the comments of the passers-by. A. comes forth loud in his denunciations because a suggestion made by him received little or no encouragement and a moment later B. is heard grumbling for the same reason. The joke in this case is that the schemes of A. and B. are diametrically opposed and each would be much more incensed had the other's proposition been accepted than he is at the rejection of his own. Behold, now, C.'s bent head and clenched fists. He is about to shake the dust of the Capital from his shoes vowing never to return, not even for duty here. He is thoroughly angry at the scant con sideration paid to his flash of genius and far from suspecting that it was out of regard for his feelings that he was not told the facts of the case. The reform he contemplated is impossible because it is opposed to the expressed wishes of the President of the United States, the laws of Congress, and the published Regulations for the 778 VoL XHL EDITORIAL. Government of the Navy, with all of which C, apparently, has but a slight acquaintance. D. with a slight change in present meth ods would reform the Navy, but his scheme involves the appropria tion by Congress of a little matter of a quarter of a million. E. is spared the humiliation of being told that his plan was tried out and proved a dismal failure when he was still in the mud-pie and rocking-horse period of life. He returns to the scene of his labors satisfied that everybody in the department is a Bourbon for ignorance and inflexibility. F. actually lost his nerve in the ante room and talked about something else when his turn came, but in a month he will be telling about how he " put the thing up to the department and got turned down." G. made a splendid sug gestion and would have been surprised to learn that the bureau had already planned something of the kind and was only awaiting the settlement of a legal point to put it in force. And so it goes. The truth of the matter is that the bureau is not one man, nor two men, but a goodly number of men, ranging from civilians old or young, a lieutenant of the Medical Corps, members of the Hospital Corps, to an officer with stars on his collar. The report or letter that embodies a startling novelty circulates from office to office " for comment and return " and is passed upon by at least a dozen people each with a different viewpoint, each having had an experience of service conditions which makes his opinions different from those of the others. It is doubtful if the Navy could assemble a dozen officers of different ranks who would wholly agree on everything that came up, and in such a group a really good, practical suggestion is sure to find a champion. The bureau is not infallible. The men who compose it are human ; likewise the men who come to it with requests or counsel. Complete satisfaction for everybody could only be obtained if all requests were proper, all advice were sound, and all decisions made with divine wisdom. If there is any definite feature of the bureau which might be termed an attitude it is conservatism in relation to radical de partures which may promise the most gratifying results but are without guarantee of success and which, if they failed, would spell disaster for the medical department and undo the achievements of years of labor. The bureau labors under the disadvantage, where change and in novation are concerned, of being responsible, and that is the reason why it does not always give immediate acquiescence to plans which on the surface have everything to recommend them. The author of the suggestion is irresponsible so far as consequences go. He has only to show good intentions and honest motives and he is free to make any and every recommendation. To bear the brunt of the con sequences, to pay the price of failure, is an entirely different matter, No. 4. EDITORIAL,. 779 and it is so delightfully easy to assign all this to the other fellow that people forget that side of it entirely. The world abounds with men who are very daring for others but become extremely circumspect when the consequences of rashness are to recoil on themselves. It is one thing to plan, in the privacy of one's room, the first steps in a far-reaching scheme of operations, and it is altogether another mat ter to undertake the execution of all its ramifications in relation to a host of other people who are perhaps unsympathetic or hostile. The attitude of the bureau, then, is one of caution toward the un tried path which it must tread alone, particularly when only the first few yards are illuminated. It has a very healthy appetite for new ideas but hestitates to swallow things that may cause an acute indi gestion. It is receptive of ideas that have been viewed from all sides and tried out, if only on the dog. Now, no one asked the editor to undertake a defense of the bureau or suggested the need of doing so, but a chance visitor who chuckled with me over certain popular misconceptions offered this as a topic for an editorial. He will think it poorly done, of course, but he de clined the invitation to write it himself! IN MEMORIAM. ABRAHAM JACOBI. 1830-1010. When Abraham Jacobi died at his home on Lake George on July 10, 1919, there passed away one of the few remaining Germans of the type so respected and loved, a type that in recent years has been replaced by a wholly different one. We all know of the Germans who came to this country at and soon after the Kevolutionary period to become Americans, heart and soul, and transmit the instincts and traditions of loyal citizenship to their posterity. The Germans who came to America during and immediately after the political dis turbances of 1848 in Europe were of similar mold. When our Civil War broke out they played their part in the ranks of one or the other of the two great armies according to their conceptions of duty. For years, under the leadership of Carl Schurz, the influence of the Germans who had cast in their lot with us and the influence of the German press of America was an asset for good in our public and private life. The decay of the German American and of the Ger man press resulted from the secret propaganda of the pan-German policies of Berlin and of the wholesale migration of a very different class of people ; people who came to us not to share in a larger national and individual life and to become assimilated to what we had of good while toiling with us for the elimination of what was bad, but to further the interests of a foreign government while learning English, engaging in business, and profiting by the large fields available to frugality and industry. Like his friend Carl Schurz, Abraham Jacobi came to America fresh from a German prison, where he had been immured on account of political activities. He married an American woman and in 1860 was appointed to the first chair of diseases of children established in any American medical school. When in 1903 the land of his birth recognized his high professional standing and tendered him the position of professor of pediatrics in the University of Berlin it did not take Jacobi 24 hours to make up his mind to decline the supposed honor. Abraham Jacobi was born at Hartum, Westphalia, May 6, 1830. He studied at the Universities of Greifswald, Gottingen, and Bonn, receiving his M. D. from the latter school in 1851, and came to 781 782 IK MEMORIAM. VoL XIH. America in 1853. From 1860 to 1865 he taught pediatrics in the New York Medical College, in the medical department of the Uni versity of New York from 1865 to 1870, and in the College of Physicians and Surgeons of Columbia University from 1870 to 1902. The honors bestowed upon him by American colleges and societies were too numerous to mention, and his eminent professional attain ments were too widely appreciated to require circumstantial refer ence here. We mourn rather the loss of the citizen, the patriot, the man of high principle, of loyal spirit, of kind and gentle heart ; of the type that sought to broaden and ennoble our national life as compared with all the recent importations who wrought in secret to compass its destruction. ' ^c7r| 1 Rotary toothbrush and method of manipulating it. 783-1 SUGGESTED DEVICES. THE CONSTRUCTION OF ANIMAL CAGES. By Q. F. ("i. auk. Lieutenant Commander, Medical Corps, United States Nary. The accompanying cut shows the construction of an animal cage which has several advantages. It can be readily and cheaply con structed. It is easily cleaned and the surrounding floor space is not soiled, as the cage is placed in a pan containing a layer of sawdust. After folding the wire gauze over the wooden form, the redundant portion at the corners is folded across the front and across the back of the cage, thus serving to strengthen it. Since the bottom is com posed of gauze the cage is cleaned by merely lifting it and permitting the feces to fall into the sawdust. Fresh sawdust is supplied as required. The cost is as follows: Wire gauze Q-inch mesh), $0.34; tin, $0.05; brackets for corners, $0.20 ; hinges, $0.25 ; enamel pan, $1.65 ; rivets, $0.05 ; labor, $0.75 ; total, $3.29. A BOTABT TOOTHBRUSH. By H. B. Harvby, Lieutenant Commander. Dental Corpa, United States Navy. The importance of the care of the teeth and gums has increased directly in proportion to the development and researches in bacteri ology and the study of focal infections. One of the principal difficulties in the cleansing of teeth has been the inability to clean in between the teeth, that is, to loosen the bac terial plaques constantly present in the interproximal spaces. Sev eral methods have been given for doing this, those most used being careful manipulation of toothbrush after special instruction by the dentist, use of floss silk or tape charged with precipitated chalk or tooth powder, and the use of sprays under pressure. Becently a method has been advocated in which the bristles of a toothbrush are pushed directly into the interproximal spaces and withdrawn, in an endeavor to promote circulation in surrounding tissues and cleanse surfaces of teeth involved. The inventor of the rotary toothbrush about to be described was told by the dentist who 783 784 Vol. XIII. SUGGESTED DEVICES. 1. Shows wood form 01 x 15} x 10, over which wire gauze SO x SO Is fitted and riveted. 2. Shows cage edged with tin and hinges attached. 8. Cage complete with cover and placed In enameled pan containing sawdust. No. 4. SUGGESTED DEVICES. 785 was treating his gums* "to brush in between the teeth, and inside as well as out," but an easy and efficient way of carrying out these in structions was not to be found. The following is the result of that particular dentist's instruction to that particular patient : The idea involved is that of two revolving wheels which are par allel and have bristles projecting from the adjacent surfaces and a small tuft extending up between them to cleanse the biting surfaces of the teeth. The brush is placed over the upper right teeth and pushed up so that one wheel is on the outside of the teeth and the other on the inside, the handle projecting from the mouth. The handle is then gently pulled forward and to the left as the front teeth are reached. After the upper central teeth are passed over by the brush it is then pushed back until the back surface of upper molar is cleansed, the back-and-forth motion being performed several times. As the handle is pushed back and forth the wheels in which the bristles are set revolve and the brushes pass over the teeth and gums with gentle friction, where the teeth and gums are healthy, but going into spaces not occupied by gum, thus cleasing between teeth in which decay or gum recession is present. The brush is then pulled off of the teeth and shifted to the other side of the upper jaw, where the process is repeated. The lower teeth are cleansed by removing the brush from the upper teeth, turning it over and facing over the lower teeth, when further procedure is clear. After thoroughly brushing with precipitated chalk or some stand ard tooth powder, a glass of water is used to remove the loosened debris by forcing it in medium-size mouthfuls back and forth be tween the spaces about the teeth. One of the practical uses of this brush is the cleansing of the mouths of sick and injured men by the nurse. The nurse after a few moments instruction can cleanse more thoroughly the teeth and inter proximal spaces of a helpless patient than a normal individual him self can do on himself when using the ordinary toothbrush. The gums can be massaged at the same time as the brushing by pushing the brush a little farther over the teeth while using and thus brushing the gums as well as the teeth. For those who appreciate the feeling of exquisite cleanliness in the mouth and for the eighty odd per cent otherwise doomed to pyorrhea this method is especially commended. , For over two years this method of brushing has been under obser vation by the writer and is offered as a method worthy of con sideration. 786 EQUIPMENT OF BATTLE STATION STOREBOOMS. Vol. XIII. EQUIPMENT OF BATTLE DRESSING STATION STOREROOMS. By W. S. Pcgh, Commander, Medical Corps, United States Navy. The general plans and equipment of the modern battle dressing station have been so thoroughly covered in various department and fleet circulars that they will not be touched upon in this article. Practically nothing has as yet appeared on the subject of the neces sary stock for the storerooms of these stations, and as conditions have changed so greatly aboard ship in the last few years it is be lieved that an itemized list of necessary storeroom equipment would be of assistance to those about to go to sea, and particularly so if placing a new ship in commission. The list of articles should be kept on a card index, one set in each storeroom. The card box should be divided into two compartments, the first section showing a list of expendable and nonexpendable articles on white and salmon-colored cards, respectively, the rear sec tion containing a list of articles not on hand but which must be supplied. The following is a classified list of articles in each battle dressing station storeroom of the U. S. S. Mississippi, and is believed to be adequate for use in battle : MEDICINES. Add : Boric grams COO Boric (ointment) do 600 Picric do 125 Adrenalin bottle 1 Alcohol liters— 8 Ammonia, aromatic spirit bottle 1 Chlorazene bottles— 0 Chloroform do 10 Collodlum, flexile do 6 Hydrogen dioxid liquid do 8 Iodine (crystals) do 2 Iodine (tincture) mils— 200 Parafln-wax compound packages — 2 Petrolatum, liquid bottle— l Sapo mollis jars— 2 Sllvol (10 per cent) ounce— 1 Sodium carbonate bottle— 1 Zlhgiberis, fluid extract do 1 Whisky bottles— 3 ANTISEPTICS AND DISINFECTANTS. Oresol bottles— 4 Mercury, blchlorid of do 2 Phenol do 4 Wo.4. EQUIPMENT OF BATTLE STATION STOREROOMS. , 787 TABLET TBITUBATE8. Morphine sulphate (}) bottle.. 1 Saline transfusion do 1 HTPODERMIC TABLETS. Atropine, 1/100 grain tube— 1 Hyoscine do 1 Morphine and atropine, 1/8-1/200 do 1 Morphine and atropine, 1/4-1/150 do 1 Nitroglycerine, 1/100 do 1 Strychnine sulph., 1/30 do 1 SUBQICAL INSTRUMENTS AND APPLIANECS. Case: Medical 1 Surgical § 1 Forceps, hemostatic 1 Dressing container set— 1 Catheter, soft rubber , box— 1 Inhaler, chlor. (with drop bot) 1 Needles, suture, surgeon's bottles— 2 Shears, bandage 1 Sterilizer, electric 1 Syringe, hypodermic (complete) 1 Table, operating 1 SUBQICAL DRESSINGS. Bandages : Four-tailed 25 Flannel, 3-inch 25 Gauze, assorted doz 24 Head 25 Many-tailed 30 Muslin, assorted 28 Scultetus 55 Shell-wound, 1-inch 438 Shell-wound, 2-lnch 1, 428 "T" (5 in package) packages— 0 Triangular 10 Compresses, gauze: 4 by 4 (20 in package) 392 9 by 9 (25 In package) 2,875 9 by 9 (20 in package) 440 8 by 10 (4 In package) 88 Cotton, absorbent rolls 18 Gauze : Plain, absorbent do 24 Lap pads, 4 by 16 15 Lap pads, 12 by 12 20 Ligature, catgut: Plain, No. 1 _- tubes— 0 Plain, No. 2 do 12 Chrom.No. 2 do 3 788 EQUIPMENT OF BATTLE STATION STOBEKOOMS. Vol. XIIL Ligature, silkworm gut, assorted tubes 22 Packets, first-aid 106 Pins, assorted papers 4 Pins, safety doz 4 Plaster, adhesive rolls— 6 Pouch, Hospital Corps, small 2 Sewing outfit 1 Splint : Wire mesh for yards__ 8 Basswood for pieces 24 Wood, large do 12 Tubing, rubber, drainage 12 DISPENSARY AND LABORATORY EQUIPMENT. Brush, nail 4 Measure, graduated, 250 c. c 1 Medicine dropper 6 Pencil, hair 6 HOSPITAL AND NURSING APPLIANCES. Bag, hot-water 2 Bag, Ice 2 Basin, dressing agate : 4 Basin, pus, agate 1 Bucket, agate * .Close stool 1 Cup, sputum, paper package — 1 Gloves, operating pairs— 4 Irrigator, agate, with fittings 1 Irrigator, rubber, complete, FS type 2 Medicine glass 4 Mug, agate 4 Pad, operating rubber 1 Pitcher, agate 5 Razor 1 Razor strop - 1 Thermometer, clinical 2 Tongue depressor, wood package — 1 Tumblers 4 Toilet paper packages— 2 Bedding and Linen. Blanket 8 Gown, operating 6 Pillowcase, gum 1 Sheet, cotton 24 Towel, hand 36 Additional Articles. Binder boards sets.. * Candles 12 Cargo lamp's 2 Fracture pillows " No. 4. EQUIPMENT OF BATTLE STATION STOREROOMS. 789 Gun bags 50 lamps, extra (Mazda) 5 Litters, Army type 4 Litters, Stoke's splint 5 Matches, safety box 1 Oakum pads, 8 by 12 148 Sponges : Knit 40 Hand 124 Tags, white 88 Stock bottles, 1 gallon, unfilled, 8, labeled as follows: Acid, boric. Alcohol. Chlorazene. Distilled water. Bichlorld of mercury. Iodine. Normal saline. Tr. green soap. Clerical Box. Cord ball.- 1 Carbon paper 2 Battle station casualty report 50 Nomenclature 1 Envelopes, large 25 Erasers 3 Form " F " 50 Form " G " 25 Form " K2 " 50 Form " N " 25 Ink, red and black bottles 2 Medical history sheet 7 Pencils 2 Penholders 2 The clerical box is really a portable desk containing in suitable slots all the necessary medical department forms for use in the station. This enables one to have all the necessary papers prepared so that patients can be transferred from the dressing stations to a hospital ship should one appear after a battle. 133354—10 11 CLINICAL NOTES FOUR CASES OF WOOD ALCOHOL POISONING FROM DRINKING SAY RUM. By N. S. Betts, Lieutenant (J. Q.). Medical Corps, United States Navnl Reserve Force. During the week of March 9-15, 1919, three fatal cases of poisoning from drinking bay rum were admitted to the sick bay of the Marine Barracks, League Island Navy Yard, Philadelphia, and a fourth case, which is now convalescent, was seen on April 7. For many years bay rum has occasionally been used as an intoxi cant by sailors and other classes of men who are unable to procure the ordinary strong alcoholic drinks. The present high cost of grain or ethyl alcohol has apparently resulted in the substitution of methyl alcohol by some manufacturers. Some of the bay rum drunk by the cases here reported was purchased within the League Island Navy Yard ; other bottles were obtained from first-class drug stores in Philadelphia. With one exception, none of the labels on bottles seen by the writer made any note of the alcoholic content, of any of the in gredients, or of the fact that the contents were poisonous if taken internally. This single exception specified that the bay rum con tained 50 per cent " alcohol." While it is scarcely conceivable that our experience at this post is an isolated instance and that no other bay rum poisonings have occurred throughout the country, though the writer understands that a number of such cases have occurred, he has so far failed to note any official or newspaper reports of similar fatalities, and hence feels that it is worth while to draw attention to the possibilities arising from the substitution of wood alcohol for grain alcohol in an article so universally purchasable as bay rum. The prohibition of the sale of alcoholic drinks to enlisted men and the present high cost of distilled spirits would seem to make the danger from poisonous substitutes a very real one and worthy of widest publicity. The genera] symptoms seen in our four cases were fairly typical of wood-alcohol poisoning, yet if this possibility should not be borne in mind and especially if the case is seen in late stages the cause of the symptoms will probably be overlooked unless the history reveals the etiology or attention is drawn to visual impairment. All of our cases had vomiting and epigastric distress, intense nervousness, soft, 79J 792 Vol. XIII. CLINICAL NOTES. rapid, but regular pulse, and, -where the man was conscious, com plaint of dimness of vision and pains in various parts of the body. In the three fatal cases the end came very quickly after pro nounced toxic symptoms developed. They all had histories of hav ing been ill from 24 to 48 hours, chiefly with nausea and vomiting, but refused to go to the sick bay, probably from fear of punish ment. When serious symptoms developed they applied for treat ment, which was without avail, death occurring in from one-half to four hours. It may be only coincidental that the case which sur vived was seen within about 11 hours after drinking 3 pints of bay rum during an afternoon and evening. Since these cases came under our observation the widest publicity has been given throughout the marine reservation to the fact that bay rum and other toilet waters may contain substances which are poisonous if taken internally, and a recent post order has prohibited the sale of all articles which contain alcohol. It may be contended that the publicity given to the fact that bay rum contains alcohol and might be used as an intoxicating drink would do harm by drawing attention to a field of supply of which most men may have been ignorant. We are of the opinion, however, that a policy of publicity in a matter of such potential danger is the lesser of two evils until other and better deterrent measures may be taken. Chemical analysis of one sample of bay rum was made by Mr. C. H. LaWall, a civilian chemist of Philadelphia, who reported that it contained 50 per cent of wood alcohol. Examination of other brands was not made on account of the involved cost. The single analysis was made gratuitously. Following is a resume of the four cases : Case I.—F. P. McC, private, U. S. M. C, age 33, was brought to the sick bay at 0:30 p.m., March 9, 1919. His condition was as follows: Unconscious; slight muscular rigidity; skin cyanotic; ster torous breathing; pulse regular, rapid, and fairly strong; tempera ture, 94.8° (axillary); odor of breath normal; pupils dilated; no evidence of external violence. External heat was applied and atropine sulphate 1/100 gr. given hypodermatically. While this wTas being done the pulse suddenly became almost imperceptible and one drachm of aromatic spirits of ammonia was given hypodermatically at 9.50 p. m., at which time death occurred. A catheter-drawn specimen of urine was negative for albumin. The history which was obtained on this case is substantially as follows: On the day of his death the patient, having no duty, had laid all day in his bunk without taking food. He had vomited a No. 4. 793 CLINICAL NOTIS. number of times and complained only of gastric distress. No men tion was made of visual disturbance and no retinoscopic examination was made in the 20 minutes that he was alive in the sick bay. He had refused the advice of friends urging medical aid, saying that he expected to feel better shortly. Only when his condition appeared serious had medical attention been sought. An autopsy performed March 11, 1919, which included an exam ination of the peritoneal cavity, exterior of oesophagus, stomach, and intestines, the liver, spleen, pancreas, kidneys, adrenals, lungs, heart, coronary arteries, and pericardium revealed no apparent cause for death. This case, the first of our series, caused no suspicion of poisoning until later investigation revealed the probable cause of death. At the meeting of the board of inquest witnesses testified to the apparent good habits of the deceased and to having never seen him take an alcoholic drink. He had not been on liberty for at least eight days. We were puzzled as to the cause of death in this case. While in our care the only apparent symptoms were those of circulatory fail ure, and in the absence of other evidence the fatal outcome was at tributed to angina pectoris, though the age and autopsy findings gave small warrant for such a diagnosis. His appearance was that of a man considerably older than his stated age. It was later found that he entered the service under an assumed name, so that his given age may also have been fictitious. After this case had apparently been thoroughly investigated and the matter dropped as far as this office was concerned it was acci dentally learned through one of the man's acquaintances that he had been known as a bay-rum drinker. In the light of subsequent obser vation and comparison with the known cases of wood-alcohol poison ing we have no hesitancy in grouping the above case with the others. Case II.—W. W. B., private, U. S. M. C, age 36, reported at sick call, 8 a. m., March 12, 1919. While ascending the stairway he was partly overcome and had to be assisted to the third floor, where the sick bay is located. He complained of severe abdominal cramps, with vomiting, which had continued since the previous morning. After being put to bed the pain became so severe that he had to be restrained. While conscious and able to answer questions intelli gently his mental condition was peculiar. He cried out continually, asking if this were the end of the world, begging some one to help him, or groaning and screaming at the top of his voice. The man was evidently suffering frightfully ; the sweat literally poured from him and his expression indicated the most intense agony. A cursory physical examination was negative, but acute pancreati tis was suspected. No detailed investigation was made, as he was 794 CLINICAL NOTES. VoL XI1L immediately transferred to the U. S. Naval Hospital, Philadelphia. AVhile waiting for the ambulance a hypodermic of morphine and atropine was administered. When he reached the hospital he was unconscious and remained so until his death at 12.20 p. m. from '"respiratory failure." Examination of the eye grounds showed a papillitis, which was considered to have the appearance of chronicity. A spinal puncture was negative: the blood pressure a short time before death was normal and a blood culture was later reported as negative. Autopsy showed nothing to account for death. The stomach contents wore sent to Prof. Marshall, of the University of Pennsyl vania, who tested for antimony, mercury, and lead with negative results. When the clothing of this man was sent for on his transfer to the hospital an empty bottle of lemon extract was found in his locker. Case III.—E. D. L., private, U. S. M. C, age 28. This man re ported at sick call 8 a. m., March 15, 1919, complaining of abdomi nal pain and vomiting, with which he had been suffering all niirht. The pain was not extremely severe and the patient looked well, was quiet, perfectly rational, but very nervous. Except for a rapid, weak pulse a hurried physical examination was entirely negative. He told the writer that lie had been drinking large quantities of bay rum and whisky for the last few days. A hypodermic of caffeine and atropine was administered, and he was immediately transferred to the U. S. Naval Hospital in this navy yard. He became unconscious shortly after admission and died in li hours. Hypodermic stimulation and the use of the pulmotor were without avail. At autopsy nothing notable was found, but the stomacli contents smelled of bay rum. Chemical analysis of tissue from the brain, kidneys, and liver as well as the stomach contents gave positive tests for methyl alcohol. Case IV.— C. M. S., private, U. S. M. C, age 36. The writer was called to the brig to see this patient at 9.15 a. m. April 7, 1919. He complained of pains all over his body, nervous tremors, and partial blindness. He had vomited several times. The military police in Philadelphia had arrested him as drunk at 10.40 p. m. the previous evening, and he was retained in a police station until 12.45 a. m., when he was transferred to this post. He stated that he began to have pain while in the police station, but it had become progressively more severe. Examination revealed nothing noteworthy except a soft, rapid pulse, slightly dilated pupils, and partial blindness. He was not able to distinguish one finger from two when they were held two feet from his eyes. When asked what he had been drinking he stated that he bad had considerable whisky and 3 pints of bay rum during the previous afternoon and evening. Ho. 4. CLINICAL NOTES. 795 A hypodermic of caffeine and atropine was administered, and he was transferred to the U. S. Naval Hospital, League Island, Pa., at 9.45 a. m. At the hospital, to which the writer accompanied the patient, the pulse became distinctly better. Examination of the eye grounds was negative. Evidently the visual deficiency was due to retro-bulbar neuritis. Urinalysis was negative. This case was treated like one of acidosis, i. e., by enteroclysis, and alkalies and diuretics by mouth. Ho continued to improve, and at the end of a week seemed perfectly well except for some visual impairment. On April 14 his vision was 20/30 for both eyes. He told the writer that he had learned that a soldier with whom he had been drinking the bav rum had subsequently died in New York. The following simple test for the detection of methyl alcohol was devised by Pharmacist R. W. King, U. S. N., of the laboratory of the U. S. Naval Hospital, League Island, and depends upon the oxidation of methyl alcohol with the production of formaldehyde and the detection of the latter substance in the material under ex amination. To stomach contents or tissue extracts add 10 per cent NaCl solu tion to precipitate the albumin ; then filter. In the case of bay rum it is advisable to decolorize the same by shaking with magnesium carbonate and filtering. The reagents must be tested for formalde hyde to eliminate false results, and the material under examination should be tested before oxidation as well as after oxidation. Dilute a few cubic centimeters of bay rum with distilled water, add approximately 0.2 gm. of KMn04, and boil gently for about five minutes. During the boiling a funnel should be kept in the neck of the bottle to prevent evaporation of formaldehyde if any be present. More potassium permanganate .must be added if the fluid in the flask is decolorized M-hile boiling. After the boiling is completed de colorize the mixture with a few crystals of oxalic acid. Put 5 c. c. of this mixture in a test tube and add 2 c. c. of milk, mixing thoroughly. Underlay this with the sulphuric acid reagent (100 c. c. of concentrated sulphuric acid plus 1 c. c. of Fehling's copper solution). If formaldehyde be present a violet ring will form at the line of contact. ARSENIC POISONING FOLLOWING THE USE OF NOVARSENOBENZOL. By C. M. Bl'kchfiel, Lieutenant, Medical Corps, United States Navy. The patient was admitted to the sick list April 24. complaining of a slight headache, a mild diarrhea, and nausea. He had vomited twice. 796 Vol. XIII. CLINICAL NOTES. The history was negative except for syphilitic infection. Two months ago the patient developed a copper-colored macular rash, mucous patches in the mouth, and a general adenopathy. Blood Wassermann was 4 plus. He denied a primary sore, and entry in the health record stated that, examination had failed to reveal the site of the initial infection. As antiluetic treatment he had received intravenous injections of the French preparation of novarsenobenzol and deep muscular injections of mercury succinimide. Intravenous injections had been given twice a week. The first dose given was .30 gram; the second, .00 gram; the third, .75 gram; and the fourth and following doses, .90 gram. In all the patient had received 10 injections of novarsenobenzol and six deep muscular injections of % grain each of mercury succinimide, but had received no treatment for the two weeks previous to April 24. The patient stated that there had been no reaction following the treatment except for a slight rash and flushing of the skin a few hours after the fifth or sixth intravenous injection. Examination showed flushing of the skin and a macular rash over the body, most pronounced over extremities; puffiness of the eyelids and slight edema of the extremities; blood pressure, 105 systolic and 65 diastolic; urine analysis negative, except for a diminished 24-hour output. Treatment: To bed. elimination, alkalis. April 26.—Edema more marked; both arms markedly swollen. Temperature. 101 F.-; pulse, 110. Examination of urine and feces gave a positive qualitative reaction for arsenic. Urine analysis showed a trace of albumen and a few hyaline and granular casts. Twenty-four hour output, 1,400 c. c. May 2.—Edema subsiding. Average daily urine output, 1,500 c. c. or better. Urine and feces still positive for arsenic. Skin, especially over arms, shows a marked eczema w;th serous exudation and crust ing. Patient also gives some symptoms of a mild peripheral neuritis, complaining of numbness, intense burning, tingling and shooting pains in extremities, especially of feet. May7 8.—There is extensive crusting and scaling of skin and small multiple abscesses over the body, especially over right arm. Abscesses incised and drained, smears and culture from pus showing organisms to be streptococci. Urine and feces negative for arsenic. Urine, analysis showed a faint trace of albumen and occasionally a hyaline cast. May 20.—Abscesses fewer in number; skin clearing; general condi tion improving. June 10.—Patient convalescing. Eepeated urine analysis shows an occasional hyaline cast and trace of albumen. No. 4. CLINICAL NOTES. 797 A DEATH FOLLOWING ARSEPHENAMINE. By A. Goetscii, Lieutenant, Medical Corps, United States Navy. G. E. P., F., 3c, U. S. N., age 19, came to my attention on board the U. S. S. Vixen on December 13, 1918, after he had concealed his trouble. At this time he had a large ulceration, the size of a dime, with an indurated margin, on his foreskin. His body was covered ■with a maculo-papular rash and he had several mucous patches in his mouth. He stated that he had lost about 10 pounds in weight. He was sent to the United States Naval Hospital, St. Thomas, Virgin Islands of the United States, where on the following day he was given 0.6 grains of arsphenamine (Arsenobenzol D. R. L.), there being no contraindications in the way of demonstrable kid ney or special sense pathology. The result of this injection was very striking. His rash and mucous patches began to disappear as if by magic and there was marked systemic improvement. In two days there appeared a distinct Herxheimer phenomenon, which disappeared in 36 hours. Encouraged by the favorable progress of the case, he was given a second injection of 0.6 grams one week after the first injection. This was followed on the evening of the same day by a rise of tem perature to 102 F., but other untoward symptoms were absent and his case was not considered serious. The following day the patient showed mental confusion, and complained of headache and nausea. During the night he went into a stupor, which became progressively worse, and on the following morning he lapsed into coma. At 11 a. m. on the third day the patient went into convul sions, initiated by a cry such as sometimes precedes an epilepti form seizure. There was marked cyanosis, feeble pulse, and Cheyne- Stokes respiration. The muscles of the face began to twitch and violent convulsions of the body musculature, particularly the flexors and extensors of the upper extremities followed. Both knee jerks were hyperactive. The convulsions lasted about 10 minutes and were followed at intervals by several similar ones. During the entire comatose state the patient's breath had the odor of win§. Catheterization after the first convulsion gave 250 c. c. of urine, which contained a heavy cloud of albumin and numerous red blood cells. Lumbar puncture revealed a clear, limpid fluid under no increased pressure. Cytology was normal. Hemorrhagic encephalitis was therefore ruled out. Death followed a convulsion at 3 p. m. Autopsy showed an extensive nephritis of the acute hemorrhagic type. The kidney parenchyma, particularly the cortex, was densely hemorrhagic and the capsule was swollen. There was subcapsular 798 CLINICAL, NOTES. Vol. XIII. infiltration in parts. Punctated hemorrhages were numerous throughout the kidney substance. The findings corresponded pre cisely to the " arsenic kidney " of some authors. The other findings were quite negative. Even the gastroenteritis so frequently found in acute arsenical poisoning was absent. Under certain conditions, as incomplete neutralization of the arsphenamine solution or the presence of toxic split-products such as amino-oxyphenol-arsenoxid, it is conceivable that the normal blood protein might unite chemically with these products, causing to all intents and purposes the formation of a foreign protein. As ana phylaxis is a qualitative rather than a quantitative phenomenon, even minimal amounts of altered (and therefore "foreign") protein might render the patient sensitive to a subsequent injection with resulting nitritoid or anaphylactic reaction. Anaphylactic shock, however, could hardly have entered as a cause in this case, as death would then have occurred very shortly (prob ably a matter of minutes) after the second injection, with rapid, spasmodic breathing and complete arrest of breathing in inspiration with the heart in full dilatation. Such were not the observations in this case. The " Wasserfehler " theory of the Germans can not be applied as care was taken to use double-distilled water, free, therefore, from bacterial and other proteins. Also, there was subsequent complete neutralization (litmus indicator). It has been demonstrated that in the average individual, arsenic, when administered intravenously, may be eliminated completely in 24 hours and that the majority of cases are arsenic-free in 36 to 48 hours after injection. It is well known that early syphilis may produce a distinct nephritis of the "vascular type" with or without laboratory findings in the urine. During life it is difficult to estimate to what extent syphilis may interfere with arsenic elimination from the kidneys, particularly in the absence of urinary findings. It is likely, there fore, that arsenical poisoning with production of nephritis may oc cur as an accumulative effect, in some instances following a second injection of an arsenical when there has been retention of arsenic following the initial injection. Wechselmann states that " insuffi ciency of the kidney and not hypersensitiveness of the brain is the point of the entire question of salvarsan fatalities." The organic compounds of arsenic contain the metal in the nonionic form, and the effects differ materially from those of arsenic in the ionic form partly because the organic molecule acts as a whole and partly, perhaps, because the organic substances alter the selective action of the arsenic and hence prohibit its penetration in effective concentration. Briefly, it might be stated that the difference be No. 4. CLINICAL NOTES. 799 tween organic arsenic and inorganic arsenic is quantitative rather than qualitative. Incidentally, it is difficult to estimate to what extent and how rapidly organic arsenic is changed into the vastly more toxic, ionized pentavalent and trivalent inorganic arsenicals under certain conditions of altered metabolism. Obviously, the ex tent of these changes cannot be determined quantitatively. The cause of death in the case just reported was quite obviously acute hemorrhagic nephritis, due to acute arsenical poisoning. HIGH TEMPERATURE IN A CASE OF INFLUENZA. By P. W. Williams, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. The patient was admitted to the observation camp with a tempera ture of 103° and was immediately transferred to the isolation camp. He was given the routine treatment, which consisted of camphorated oil to the chest and a pneumonia jacket. Magnesium sulphate, fl. oz. 1£, and aspirin and sodium bicarbonate aa gr. X. His temperature continued to rise until 21 hours after admission, when it reached 108°, where it remained for 45 minutes. This was verified with two thermometers. The patient did not lose consciousness at any time. His temperature returned to normal in 72 hours after the maximum was reached. His mentality was somewhat hazy and sluggish for several days after his temperature became normal. He later developed a mild degree of bronchitis, and this was fol lowed by a right sided pleurisy, which yielded to treatment very rapidly. Patient was discharged from the hospital 2C days after onset. Urinalysis showed no albumin or sugar. Blood culture showed Gram-negative diplococci. Sputum analysis showed pneu-