L VOL. XI N0.4 UNITED ST A TES NAVAL MEDICAL BULLETIN PUBLISHD FOR THE INFORMATIO~ OF THE MP.DICAL DEPAR"I Mt NT OF THE SERVICE !'\SUED BY THE BUREAU OF .\\EDICINE AND SURGERY 1'AVY DEPARTMt::\T OIVISIOS OF PURl.l\.ATIONS MF.()ICAI 1:-.;sPFCTOR J. S. TAYLOR, l'. S NAVY I" CHARGE OCTOBER, 1917 ( Ql.'ARTERLY) WASHl!o!GTON GOVFRN.\IEST PRISTING OFFIC.F. 1917 VOL. XI N0. 4 UNITED STATES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY TllE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PUBLICATIONS MEDICAL !!\SPECTOR J . S. T AYLOR, U. S. NAVY IN CHARGE OCTOBER, I 9 17 (Q!JARTERLY ) W ASHINGT ON GOVJ::RNMENT PRINTING OFFICE 1n 1 ~AVY DEP.\RT){F.:'\T, Tl'ashington, March idO, 1907 . . Thi~ l.JxrrJ::o S1'ATES NAVAL MEm;-AL Bm,LETIN is published hy direction of the depnrtment for the timely information of the .Medi- cal nnd Hospital Corps of the X a:vy. TRU:\IAN H. NEWBEitnY. Acting Sec:retary. NOTE. Owlni? to the ex11aust 1on of certain number>< of the BuLu;nN nncl the fnqa<> 1t dem:rnds from libraries, etC'., for copies to complete their file.~. the retnrn of um· ot tlie following issues will be greatly appreclntE>tl: • Yolume I. Xo. 1, April, 1007. Yolurue. I, No. 2 .. Jul~·. 1907. Yolumc I, No. 3, October, 1907. Yolume II, No. 1, ,Jnnunr.1•, 1908. Yolume II, No. 2, April, 1908. Volume IV, No. 2, April, 1910. Volume IV, No. 3, July, 1910. Volume VI, No. 3, July, 1912. Volume \II, No. 3, July, 1913. Volume VIII, No. 3, July, 1914. SvnscmJ?TION PRICE OJ•' THE But.r.B'rIN. Suhsl.!rlptiom; shoultl Ile sent to Super!nteutlent of Documents, Gowrnment Prlntlt.g Office, Washington, D. C. Yem·J~· subscription, heglnning Jnnuary 1, $1; for foreign subscription nu 1 !!a •·tmh for postage. ~ln:!1e number", dome.~tlc, !!3 c<>nts; fore:gn, 31 cent~. wltlch lnclutles forelen JIOslnge . • Exchnngc of publications will be extended to me19 HISTORICAL: OSWALDO CRUZ1 1872-l!ll7. By \Villiam C. Wells.................................. . .... ... . .... 521 EDITOHIAJ,: Tue lllXOR AlLMESTS...... .............. ...................................... .. {l27 :5UGGE~TED DEVICES: .-\ CO~V f:~U:~T DEVICE FOR TESTING VISION. By Assistant Surgeon W. S. Thomas, Medical Reserve Corps, U.S. X. i33 A .~lloll!LffIED EYg·TEST!NO CASE. Dy Passed Assistant Surgeon R. B. Henry, U.S. X. ... . . . . • . . . . . . . . . .:;33 T:nE YOTOR·OPERAT!NO FIEI,D THEATRE. By Assistant Surgeon E. K. Tullidge, U.S . ~...................... ii:» i"'Ll~IOA L NOTES: ,\ DIUTU FROlt SUARK Bin:. Uy Assistant Surgeon P. F. Prioleau, U. S. N....... . ............... .>3!1 DEn\1.\TJ'rIS l•ltOM MATCHES CAURIED IN THE POCKET. Dy Passed Assistant Surgeon W. E. Eaton, U. S. N................ ... 640 AMO!i.UIASIS WITH CONSTIJ'A1'ION. Dy Passed Assistant Surgeons E. A. Vickery and J. J. A .. McMullin, U.S. N.... . .. .. ......... . ..................................... 540 II I JV CO~TENTS. CLIXICAL XOTES-Continucd. ~fULTIPLE O\TX. UOT WOU:'\D!" PROll DEFLECTED BULl.l.°T"· By Pa.'\Service, out of the experience and observations of the individual. There are many excellent special reports and notes beyond the scope of rn~ annual report being sent in from stations and ships, and by communicating the information they contain (either in their entire'y or in part as extracts) throughout the serYicc, not only will th£'y he emplowd to some purpose n5 merited but all meclicer it mt"ty be there can be no question that the feeling for determined action has heen aroused l1nd that the conviction gains adherents daily that measures in order to be effective require careful and unimpassioned consideration, expert and systematic application by agencies which prnctically have to be created. It is the time for tremendous oppor- tuuities to take the right or the wrong path. That the problems of physical fitness and health are bound to attract painstaking attention will hardly need emphasis if it were not for the well-known tendency to give the questions involved a secondary consideration. The time, however, is bound to come when the medical services will have to shoulder the heaviest responsibilities. Thanks to a persistent propaganda the problem which tuberculosis presents to civilized populations has been kept in the foreground of the public interest in health matters. The antituberculosis movement in this country, very active and ably managed, has come to cover p1 :1ctically every phase of modern life which directly or indirectly is thought capable of making new victims of the disease. Its >igorous advocacy of measures of personal and public hygiene has had already visible success, especially the bad habit of indiscriminate spitting has been restrained nnd fresh air has lost some of its terrors to those formerly apprehensive. That its success is also measurable spe- cifically by an effect on the death rate, is an opinion which some maintain by a persuasive display of figures held to be unconvincing by others. The latter argue with equal plausibility that death rate 439 440 KLEBS--TUBERCULOSIS. '\'ot. ::n., from a given cause is no reliable index of public health bee . does not appraise. or only inadequately, the cnu:-:es of ~hysi:l~ •t ficiencies during life, and also because it is computed from fi e.. who:,,e vnriations are influenced by many uncontrollable f;:res (especially lacking uniformity and standards of the pntholog·o~ nomenclature). But even if the success of the movement is '.:\ accurately determinable by vital statistics it undoubtedly constitut one of the most potent influences in the promotion of henlthv lhin es conditions in a wide sphere which is constantly widened fu;ther b; cooperation with other agencies. Like every campaign, this one against tuberculo:-is hal' to lune its formula, its platform. This is naturally based on the :::cicntific con- cepts of the day, but not always applied in the ~pirit of true sCJence, which furnishes only approximations, contin11011sly subject to reYision. It brings out the salient features: emph:u;ize them, :mm~ to be needed for the success of public mensurcs; be th<'y suffrage. prohihi- tion, or nntituberrulo."is. Its comitc-rprrt is arherti emcnt in budi- ne.ss. 'Vaste of energy and money. false i:- is is a ,·ery prernlent crease in ncttral war conditions. Since the warning in the antituberculosic; formula i:; largely based on the infectiousness of the disease, we can not hut recall the dismal experience the Army has had with an- other idectious disease during the Spanish-American 'Var. There :!0,000 :-oldiers, or about 1 in G of the Army in the South, although they ne er saw hostilities, became infected with typhoid fewr, a higher r,ltio of incidence than that in the British Army in active sen·ice (luring the South African \Var (1 in 9). It was the opinion then of many authoriti~s that proper camp sanitation and hygiene ou~ht to haYe prevented the calamity. 'fhe chief representative of the antituberculosis movement, the X ational Association for the Study and Prevention of Tuberculosis, hns lately been requested to appoint a committee which in cooperation with the War and Na ''Y Departments and with the antituberculosis aJ!<:'ncics of the country was to devise and execute a war program for tlw :)1 eYeution irncl control of tuberculosis. This progrnm 1 i~ before u.,;; it elaborates for the special purpose in view the formula outlined aboYe. It concerns itself: (1) With recruiting examinations, (~) with reexaminations during service, (3) with the treatment of incitlenbl cases in the sen·ice, and (4) with their clispo. ·11 after treatment. The greatest stress is placed. on (1) and (2), the com- mittee being of the opinion "that any mun with even a V('ry limited 1 A war tub\>rrulosl11 program for the Nation. The Amcrlcno Review for Tuben·uloels. naltlmorc, llll 7, I, 2118-:!0G. 1 For tbe lhe yenra ending with 1906, Inclusive, the morbitllty per tbousaud men wn!< the followlni:: Oermnu Nnvy, 2.4; English Navy, ::.2; UnltPd StutNI Nnvy, :i.6. !'lee G. II. Butwr: •rb<> lnchlencc of tuberculosis In the Navy, etc., :'\AVAL MEDICAL Rt:I.Lt.'TIN, lOli, xi, :!90. 442 KLEBS-TUBERCULOSIS. v :at!' amount of pulmonary tuberculosis that is latent or arrest<:-d is al certain to break down under the physical strain of military t .ln_Olt and army life and u focus of dise:1se prl!Yiously Inteut 0~ rauung ·11 l . l be . ,. Tl . n rrest~ w1 1 a. mo:stbcertadm y cdomb e .actn e. 1 . i~ com1111ttee does not Ftate w int is to e un erstoo y ·a very nu h. l ~.mount of pulmo tuberculosis that is latent or arrested ,, and ": focus of disl'a e llary viously latent o~· ~1:reste~,,, that "almost certainly·· ,, ill ll'll:r;~ trouble. The ummtrntecl 1s not supposed to grn:-p the iutricaC'i f a cla~ification to which an excessiYe craving for mnthl'matical 0° curacy in things biological or pathological has drin'H the speciali ~ Therefore in tl.rn program no disqualifyi~g ~onditi ons are mention£> per cent under- weight, or (5) has a history of chronic catarrh, or n cough or nny symptoms of chest disease, or (6) has abnormal physical signs of any k·nd in the chest. How these voluntary examiners have to qualify as experts and how far they are e:-."Pecled to Juve knowlt'uge of service conditions is not mentioned in the progr'lm: it simply offers to furnish the War Department with a list of ll Jnrge number of ~uch expNts who would volunteer; because the committee is of the opinion thnt "the work of the Medical Corps of the .\.rrny and Navy could he much facilitated and expedited and this corps, nlr<'ady greatly overworked, could be gi>en much needed nssistnne<>. • • • '' From this it is seen that the program presupposes two condi- tions: One, that the Medical Corps is qnantitntfrely in:ulequnte to the task of recruiting, and the other, that qualitatively it does not possess the expert knowledge necessary to detect whether or n :>t certain anamnestic features in the history of recruits or physical signs in their condition are to be regarded as disqualif.ving them for military serYice. As regards the first point, of quantitative inadequacy of the Medical Corps for recruiting service, we have no accurate data. A~ an expression of patriotism the proffer of expert assistance will no doubt be highly appreciated. We ha>e been under the impres..,ion that the creation of a Medical Officers' Resen e Corps and its organi- zation was intended to supply competent men, especially for rt>cruit- ing service, whicli has to go on more or less independently of the medical service of the enlisted body of troops, although under the :.nrne genernl direction. As regards the qualitative inadeqmtcy of the Medical Corps, which the program does not express specifically, although it is clearly implied so far as tuberculosis is concerned. we have no means of judging the force of the implication. It is evident that the creation of a. new Army and new Navy on principles essen- :>o. -'· KLEBS-TUBERCULOSIS. 443 tially different from pre,·ious ones will necessitate Yariou::; adjust- ments in this regard as in so many others. Xe\"ertheles-s: whnte\'er experience we ha ,.e gained, whatever guiding principles "\\"e have cYolved therefrom. mu::.t be of prime importance in the shaping of a future policy, if for no other reason but that it cotTe:spontls to our own and peculiar needs, which no other experience::. can !-llJ>ply. That the :Medical Corps, individually as well as collectively, has not been unmindful of the problems which tuberculosis presents in both Army 11nd X avy is clear from the publications by members of the corps, which show both insight and expert knowledge, some of them to a. very high degree. As a collective expression of past experience we have various oflicinl publications 1 and reports. As a test of how far the experience has been utilized in practice, and especially in the rec;uiting scnice, we may find an index in the variou:s rules and regulations go,·erning the sanitary service. The rules for the ex:uni- nntion of recruits are brief and to the point. Their careful study :.hows that the subject of tuberculosis was throughout in the mind of the writer or writers and that the difficulty of the task of discovering conrlitions behind which tuberculosis may be hidden was fully np- preciuled.2 There is a wholesome absence of intricate definitions and subtle ll· cation bas exerted n world-wide loflueoce on military i;nnltatlon. The Tn1IPX Cntalogue or the 1-lnrgeon Gt•nernl's library is another wo1·k o! lnestlmnhtc wortll to t:ic "hole medical world. •War Il<'pnrlmcut: Gencrnl Ol'(lers, No. GG. Ilule~ ro1· tile Exomlnotlnn ot nccru't'. Washington, Ap1·. lA, 1010. Navy Department: Clrcnlor lt<'lntln;; to th•~ l'h~·skal Ex· amlcatlon oc Uecrults tor Enlistment in tllc Navy and Marine Corps. Washington .. July 10, l!llO. 444 KLEBS-TUBERCULOSTS. Vol XI. ufter enlistment. let us for a moment, based on the concepts out]' aho•e, meditnte oYer the aC'tnal role of importance which this di Ine.d plays among the multiple phenomena that determine the effic~~ and well-beiug of Army und Kavy. Quite g-enernlly it mu(.t be .} C'eded that the line di,·iding h ::ilth from sickne::.~ is one thnt dO(';;~~~ alwny .... nppear dearly and sharply marked becausP the two eonditio which we are in the habit of distinguishing are determined not 011~: by inherent differences but by individual consciousne:-s nnd nttitlid~ ns well. Modern medical science concerns itself almost exclusivch· with those factors, symptoms, or signs discernible and mensurable 0~ physical methods. The accent put on these not only limits our unde;- stnnding of conditions where the physical factors are not clearly dis- cemible, but it wetlkens our effective interference. The good physician instinctively evaluates both the pondcrablcs and imponder. nbles: his interest and solicitude is focused in the whole man not in isolated phenomena. "\Ve are aware that these nrc elementary. self- e,·ident c:oncepts, and still we feel they bear repeating again nnd ngain, especially in the subject under c:orn:ideration. For the fact that tuberculous infection is cxcPcclingly premlent. we have abundant nncl reliable e\·idenc1" Thi , howrwr, is con.1.;tnnth- disrcgar intr•· .. "tecl in th~ ::-pl'cificity of the disease and the effecti P'nc of spccilil' me:isures. 'Ye need not examine here the details of the statistics, but only wi-.lt to recall the significant findings by tube1·culin tests applieutuct with it, but receh'es lesions ~o distinct thnt years after they are still discoverable. What does that mean? It means that prnc- ticnlly everyone some time in his life must present symptom::; and signs, discernible and measurable by physical methods, at le.l"t by the expert, of what we are taught to call "incipient tuberculosis: · And it is certainly not unreasonable to presume that a greater (kgree of expert skill would eliminate the qualitative "practically" anu allow us to spea~ of tuberculosis as a universal disease. But does 11<1t this lead inevitably to the conclusion that the specificity of the disease i · of relative unimportance unless there is, discernible uncl mea~ m·~abk a specificity of resistance against the infection? KLEB::Y-TUBERClJLOSIS. 445 En~n n supcrficinl consideration of the :,,uuject of specific re- sistance to tubcrculo:,,is would lealy to the no11enforce- mcnt of wcll-triecl measures by the responsible a uthoritics. \\'h~n once the time has passed tlrnt the authoi·ities c1o not longer ··deem it uuwisl! to publish certain figures," an..l we 11111)· i11ld. "or deem it wise to publish others." then, bnt only then, shall we be ahlc to ap- praise correctly the amount of damage inflicted on the French forces nnd population by t11uercnlosis. Nowhere in the world ns in France hn~ nu antitnberculosis c·1m11aif_rn been wugecl i'or a longer time, in· fluen1'i1 f! research. legislatnrl·, and every ngNwy of public or~:rniza. tion nn·l welfare. \s it would be preposterous to ll'akc this fact rc~-pou:,ihl«> for the present calamity, ju!'t ns mt!cb. aml more so. i::> I N.\YI! ~11:01('.\I, IlULLl:'l'IN, l!lli, xi. :.!!.lO. •'\feel. Hee., New York, Hll!i. lxu1·lll. 10:,7 to IU. 446 KLEBR-TUBERCULOSIS. it absurd to put the blame on negHgent nuthoritil's.1 If the t" enr came-may God forbid-thnt we had to fucc three cruel y~ine of intensest wnrfnre, had to bear the bruut of the battle unnide.l f rs the fir,..t months, our bert men killed in it. our mo:,i pro perou5 & tor ocenpie n fow-say, CYen four or five in a hun "? What are "well-tried measures" in the midst of a eyclone or a. cataclysm? It is the entire Yitulity and power of re. sii;t:mco of a. nation that is on trial a.t such times. To learn hm, to strengthen nnd husband these is the task of true pl'cpnrntion in n 1- rnnre. In this the so-called tuberculosis problem is s11bmerged. The main fault we have to find, therefore, with tho" wa1· tubercu- losi:; progrum" is that it proposes against this disease the same measures that hase been found effective against the acute infection~ disenses and attempts to justify them by the order of reasoning per- taining to them, and especially that it is apt to becloud the main i:--::,11e J.y insisting on n minor one or. as we may put it, Ly trying to sub:-titnte tactics for strategy. The all-important tnsk of al'snring nnd maintnining the health of Army and Navy has to be di10Ctl•d by proper au horities, and much depends on their wisdom of coord as much us possible. It is almost a tradition in military sen-ice to look dmvn upon the sanitary brunches. Nothing shonld be left un· may be admitted to hospital for treatment" with a 'iew lo their enlistment upon recovery"; (r) "candidates for spe- cial ratings" are not expected to possess" the phy:;ique nnd endurance of those actively engnged in strictly military duties." Ncvcrthele..,s it mu•-t he remembered that they are" enlisted for the performance of nll duties to the naval S(>rvice ashore and afloat." (!l) "EVIDf:NT l'REDJSPOSITION TO PUT.l[Q.'IAllY TUBERCULOSIS." Tlus phrase: we belie,·e, sho"·s clearly how much definiteness i~ stili locking in our concepts about the disease anated by the use of anatomic and bncleriologic terms to design;1tc clinical conditions. The old terms of "status phthisicus.:: ·· ~cro:fulc us complexion," or "tuberculous din thesis'' con ,·eyed to the pn•-Kochin11 examiner u. picture which had fully as definite a sig- 1 We quotr. from the regulntlons cited in note 2, p. 443, not verbntlm, however, be<:aott 1••e are more after the prlnclples gove1·ning them tbnn nfter the vnrlous expregslons they may have received In the several services. KLEBS-Tt;BERCUI.OSIS. nificancr as the nboYe phrnse. The X avy Regulations in which phrase occur:-; do not mention tuberculosis among the ''general dia. qualificntiom:," although here under the heading of constitutioJla.l diS('nscs we find noted ·· freblene" of constitution (poor phy,..ique) :-.yphili ·· (HHH). In his r mnl report for l!lOi the Surgeon Gen~ ernl oi the X n ,.y stated that a material reduction of tuberculosis in the sen ice could not be expected "until it is more fully realized that tuberculosis is a disease of nutrition, and until a minimum standard of physical requirement is more consistently exacted." The Army Re~lntions are more explicit; they name "tuberculosis of whnte"er degree and whether general or localized" among the general diseases which a.re causes for rejection. They also attempt to define (under '·chest") tho conditions which "usually coincide with a somewhat enfeebled constitution and n. predisposition to disease of the. lungs." 1111 l«r '· lungs." definite signs, data from the history, and temperature variations are enumerated as leading to "suspicion" of pulmonnrv t11berc11losis. In the Navy Regulations "incipient tuberculo::.is ., is noted in the examination of the organs of the chest by percu..,sion nnd nu:-cnltntion. ,,.E' luwe already hnd occasion to speak of the condi. tions which Barber considers as marking the "phy:;ical defceth·e '' and to which he refers as "the source of the firbt increment of our rntio of tuberculosis for the service." The author thinks thnt liUCb Ca!l':es ~hould under no circumstances be accepted for any brunch of thl• ~Hvice . '\Ve may take this to be an individual expression of how tlw I hrase "evident predisposition" might be defined. Barber lnrthl r on in his paper,1 when discussing the positive eviical examination. Lawra:-on Drown, TmJcau's ex- cellent pupil. n mnn of great practic.\l experience, expressed this clenrly in n recent paper: 1 "Sympcoms arc n b~tter and more aL'Cll- rutc guide to activity than are physical !'igns .. nnd ··symptoms "ithout phy:-ical signs demand treatment, while physical signs with- out symptoms require often nnly cnrcfnl watching.'' A more pointed expression in this direction we find in u notnlile paper. nlso quite recent. by Louis Hamman of the medical clinic of Johns Hopkins Hospital. 'Jhe painstaking analysis of the ;;ubjecl, coming from u man who lins hatl a most extensive clinical e_xperience iu the tuber- culo:;is out· patient department, which he hus ntilizcd both practicnlly and scientifically, nnu '"ho has now worked for some time iu the wider field of the general medical clinic, merits the most careful considcr:ition.2 'Ye can give here only briefly some of his pertinent remarks: .. The undue emphasis that has been put upon the phy8cnl examination by distracting attention from other no less importnnt fnrtors, has rather obstruct<'d than :facilibtcd early diagnosis" nnd ··there must be some inherent traits in the progress of tubercu}o,,,is that render the det*'ction of early stages difficult and: irnleeJ, in mnny instnnces impossible"; and '·I nm conYinceerculosis means one thing to the laboratory worker 1 TubPrculo$IS tbt>ses, cllagnostlc, prognostic, thernpeullt'. American Review ot Tn· hettt1losls, Baltimore, 1917, I, 194, tbe•es 12 and 13. •The dlsgnOllls of 11ulmonary tubercuto ... 1s. American Review of Tubnculo•I~, Baltl· more, 1917, I, 206-217. 8551-li--::! 450 KLEBS-TUBERCULOSI::;. I.mt :oomething essentially and fundamentally different to the Pta _ titioner and to society in general. '· Infection:• aner-changing conditions of the t.>nvironment, "~~th the. use of terms an~ names current n,t presei:it our recruitin~ of11ccrs will undoubtedly discover that we are a nation of defecti\"ei:. Anyone who has his eyes open on his walks in the streets of our cities, on our popular bathing beaches, in our offices. will see if he wishes to, stigmata of degeneration, predisposition to tuberculosis. W'e o,·er here who for decades have attracted to our shores the out- put of what is most enterprising, tough, and persevering in the white race of the whole world, continue h1sisting that the highe,t stand- ard of human efficiency is to be found in the tn>e of tlu Apollo of BelYedere. w·c see our athletes, prize fighters. and others who come up to the""t- physical ideals ending pitifully as consumptin!s. while the under:-izc. underweight, narrow-chested clerks and laborers out work nnd outli n! th~m. But we refuse to learn from snrh e,·erydu., obscrrntion:>; tenaciously we stick to our test-tube and guinea-pig stan suffe.ring from a "temporary illness" in existing recrnitinl! reguln- tio11s probabl~·. had not in view the cases which we h:n-e been con- sidering. With the increasing anxiety to keep everybody out of the '~l'e the cxcrllent article by W. O. Farwell on the Important subjrct, " llordrr-llnt' C'a&CS at the recrultlng omce," Illustrated by photograph~ of the Ru~~rll s~1r-1 Institute, whldt urr most angge tlvc us to h•1w WC' may arrln! it a mnrc exact tleterrolnatlon of pbysleal stantlnrO·_rallcd •· defecti,·es" or "suspicious cases" presenting themsehes for senice and otherwise fulfilling certain minimn stnndnrck A" for :t:-. tuber- culosis is concerned, we have already shorni that the ascertainl'd prevnlence of tuberculous lesions among modern populations inevi- tably forces the conclusion that praatically everybody is :;omctimes tempornrily ill from tuberculosis and that only a Yery small percent- 11~e of them succumb to it. Every practitioner of expc-riencc cnn gh·e direct proof of this and can testify to the fact that the later immunity of such cases was by no means always insured by propt'r treatml'nt or the hygienic ideals of the propagandi!'its, that indeed it persisted often despite eYery infraction of ru h•s nncl nncler actunl hard-.hips nn not take these things into account is not science but sterile dogmu. To the unbiased it will be evident that among those rejected for such :ms- picions there must be a large number of just such cases, some uo doubt precious human material for every kind of senice. Toward these the Xution has not only a right but also a cluty. Obserrntion in u hos- pitnl, howeH>r, would not serve either. We belieYe that thc-sc c:i!':es- nnd we would not limit ourseh·es to the tuberculosis suspccts-onght to oo enli tecl and entered in a service to be created especially for the purpose of observation under working conditions. Such a corps should be officered the same as any other military unit, nncler strict military ornts. If this is so. it is e\'iclcnt that a systematic and careful distribntion of recrnits of known physique among different ratings of known demands will allow the proper utilization of many border-line cuses. Maximum stnndnrhb: Brit !sh e'Cptrlenre, !or Amerlc:inir. IT. .\tl1tntlc 'lontl.ly. 1 !Hi. Au- cust. p. 108. 454 K LEBS- TUBERC ULOSIS. in wnr nn; A!'\D CARE FOil THE 1 Uilll!Cl l.t.>l'"· The precaution<: during enlistment and He en orccment of :-nnitut'\· n'gulntions in the :,;enice ought to, theoretically at l<':lf•t: prcnnt th.e development of tuberculosis in Army and Navy. Certain nuthoi·i- ties. some of whom we have quoted, assert that this is even pos:,.ible in prnctice. This is obviously a fallacy: not only on the !!enernl g1·ouncl of humnn imperfection, but because tuberculosis lot infre- qnent ly llc\·clops snd111·cs come unider the 11ah11·<' of the disease. T...iet ns and rcco,·cries in the one nntnmlly immune to tu~r­ cuJo,.,is. It is the factor of inherited :rn'. those are questions which " ·ill ha'e to be settled in accord with the general policy and financial nnd administrati,·e considerations. •Boris J). Bogen: An nd(·quntc rcl!c! ptogrum for tuberculosis cru. ~. Journal of Out- door Ltrl', !'\ew York, 1017, xiv, 232. •King 1111'<1 Jnn!\ :?4, Hll ';'. To him l>clong• the honor for Im\ Ing 11 t evolved an<.I e:sP<:Ut«I a IYI'" of Rimple lean-to tor the accommodation ol a group o! patlPnt., pro- viding for out' on, wlde all the other co nu it ious short of it ought to be accommodated or better employed in institutiom,, which might be cnllt'cl ·' s:urntoria,'· '· health work camps,·· a vocntional colonies." in accord with their fundamental purpose nnd method which mnkes useful vocational training and work its prirnnry nim. re.;,t nncl rccrrntion, prerniling in ~xisting ~annt0:·i:1. h,~i11g a~si!?:ned to a econd11ry. 1:omplcmen,a. :"' l'' ition. B l!bH~l'll the t wo type"' of institution-. there ought to be closest cooperntion and exchange of patients. The mention in the "war tuberculosis program" that "the ('Stah- r I nt of GoYcmment :farm cofonies * ~· * is worthy of careful con · d ration:: is n. timid and insufficient recommendation of n meas- ure the efft>cti \·cness of which docs not need any further c:xperimentn- tion nml theoretical consideration. It needs purposeful und energetic intrc duct ion. follo,ring example:;; which ha Ye prored eminently suc- cessful abroad und \rbich to a limited extent ha.Ye found successful imitators in this country. Farm colonies provide satisfactory oppor- tunilie.:.. only during the summer months. But the scheme of organi- zati<'ns such n.~ we lrn \ ' C in 'it w must provide for such opportunities continuou!?ly throughout the year and also be fairly independent of particular cli1m1tic a far-re.1ching 1 Horner Folks, onr ot our ruo~t experienced workers le tbc llcltl of sodal control of 1ubcrculusl•, In ndvoc1\llng the coo1·dl11ntlon of gcncrnl nod tullerculo.ts relief, lately 1>IJc<1I bis nn~er on thlg F• r(' spot In our rell,•f '·ork 11t h11nU.' nn1l nt prcs~nt alects huYe hitherto been con idererimposed upon the chronic degenerative change in the kidney which so impair:- its ncth ity that acute nephritic symptoms promptly ckl't•lop and often cause dcnth within n few hours or clays, :i !though the paticut hit11erto mny hnYe been looked upon as one in perfect health berau:-e of his efliciency nnd general appearance. The finding of albumi1,1 constantly in any quantity associated with the presence of g1·anu]a1 casts shoul. Where renal <'hanges are manifestly present and where laboratory facilities, e\eu of modernte degree, are at hand it is of very considerable importanc~ ~o. 4. IIARE-OARDIO-VASCULAR RE:XA.L PATI.E~ TS. 461 thnt nn e:;timation of the nonprotein nitrogen of the blood should be made, nncl if the nonprotein nitrogen content of the blood is incren*d -the danger to the man is mnrkecl. Thus. n prominent lawyer of 58, with a blood pressure systolic lSO. din:stolic 110. whose urine contilined only n trnce of albumin 11nd n few hyaline casts. hut "ho!"oe blood showed ():l milligrams per cent nonp1·otein-nitrogen, felt H> well that he insisted on ::,tnrting on n pleasure trip. but he was seized by an uttack of pulmonary eclemn within ~4 hours of the es:uninntion of his blood and died before he could be gotten to hi:s bed in the hotel \\ i1c1·e he was staying, yet I think thnt nuyone who hod simpl~· in:-peC"tecl this incliYicluul would haYI! passed him us being more than a foir specimen of manhood at hi;; uge. It \\011lcl seem to be pn1tty clearly established that in patients ::;uttering from fail- ing circulation resulting in renf!l con!!e:st ion there is 110 increase in the nonprotein nitrogen of the bloocl eren if some hynline casts and nlbnminuriu are present with edema of the lower extremities, but in chronic nephritis oi either type at the stage when the patient is in dnnger the nonprotein nitrogen is greatly incretsccl. ~omctimcs being :is high as 180 milligrams per cent. and if il b" only 40 milli- grmus per cent he is out of bounds. ·when the!':e cases thnt hn\'e blood as well ns granular casts recoYer from an attack they nre nlwnys prone to other attacks of pulmonary edema or other e\'idenccs of uremic poisoning, so called, which attacks mny come on with the suddenness of apoplexy on slight exposure after some nerrnu;; strrstitinl nephritis with associatt>d cardiovascular change that the physicinu 462 HARE- CAllllO-VASCCL.AU REXL\l. P.\TU:N'fS. will most frequently hn,·e to deal wit!1 a compll'X problem. The duration of life of the parench~·urntous nephritir is nearly alwnvl' brief; in inlcr:-,titinl nephritis it may I!" on for 20 ye.nr:-' and duri~f! the mnj01·ity of the::-' yenr .... the patient may he dlieicnt and pre ent no mnnifcstntions to himself or to his fellows of impairment of health. If he appear:; for a physical c.xnminntion it will be found that he hn!:!. as a rule. n blood pressure con~idernbly hif!her than norma 1, sometimes 'ery high, and it is a noteworthy fact that not infrequently u man with inter:;titinl nephritis oncl high blood pr!!!. sure feel:; t lint he has quite his usual vigor and. possibly, seem~ to be more energetic and to hnYe a greater feeling oi well-being thnn ~omc one whose hlood pressnre is in norm al bounds. Such a man is pre- cisely tlw one in which the most accurate diagnostic and prognostir skill is rl'qllircd. Under ordinary conditions his rlliciency may bent the maxiunun, lmt 110 sooner is he placed under nnnsnnl !,tram nnd stress thnn his faults become manifest. Either his pressure is sharply increnscbled nnd dyspneil· on Pxcrtion and pre~t>nt ~ l'\ ic1c we-. oft 1xemin. Tu -.n<"h u 1 n,1: thc1·e m::,v ht· few or 1w gra n11l111· 1·ast-- nlbuminurin mny 110 1 he crn:stant. and tLe ronclitinn of his l'L'tinal w els and hi:- rn:-;1:11lar syst<'m, as shown by t he fingers nnd the sphygmomanometcr. m:iy rcYeal to the physician that at :rny moment some ab!'olnlely incapucitutiug complication may arise or death ens11e. Rctinnl hemorrhagt>s nre not the only things to be looked for with the ophth:ilmoscope. Marked compression of the retinal Yeins by pressure e-xercised at the point where they are crossed by t he arteries is significnnt ·of threatened trouble. The prolrnblo durntion of life can to some extent be determined by the ~tate of tl1e retinal Ye~sels . De Schweinitz has studied this mat- ter mo~t carefully :from the standpoint of the ophthnlmologh;t and w" have followed a number o:f cases together. The! e facts are well emphasized by the following figure:>~ which illu~irnte the duration of life in chronic interstitial nephritis nfter tlrn occurrence of retinal changes. Belt rollected 419 cases, of which I~ per cent tlied within 1 year and no per cent " ·ithin 2 years. The ca--es reportccl from IT:rnb's clinic by Pos,.;tnwr showed that none of the men applying for treatment l iYccl more than ~ years; of the women. GS per cent died within the &nue period of time. Of prirntc patient:- who c~uld liYe comfortably, only :rn per cent of the men nnd .i3 per cent of the women had died at. the encl of 2 years. Gruen- ing collected 100 cases, none of which sunin::cl more than 2 ye:m- after retinal changes began, ancl Bull fou nd thnt {\f) out of 10:3 eases diet! within~ yenrs. Of the l'<'maining 34, J 7 died 'after a longer ~o.4. lI.\RE-C,\IlDIO-VASCCI-\R RESAL l'ATU!STS. 463 period. :mr the cliscon.•ry of retinal chang';,: a 1·cco,·ered. nn1l 1 regained hi:-. eY£'sight. although the urine wns albumiuom: at the cntitinl nephritis: in whom retinal changes hncl beE'n recogni7.ed 10 or 1.1 years befori~. and .. who is still living.:: nnd " "'-'rt ha of retinal le~ion!". Out of n:15 cas;.>s of renal disease, Uroe11011w found retiunl lesions in :!O!l, or ~2 .. 4 per cent. The age at which they most freqtll'ntly are met with is from .30 to r.o ~·ear:- . but they hnH' been ~ei.:n in :Hlolescents. Fi Ye types of these lesions are recognized hy ophthn lm okgi~ts: (n) ty piral :1lhmninuric retinitis; (b) degenerntiw :1 lb11minuric retinitis ; (c) hemorrhagic albuminuric retinitis; (d) nlbnminuric 11p111·on•tinitis, and ( e) nlbnminuric papillitis. In the first form irregnlnl'ly sl1ape.1 white dots or spots appeat· in ancl around the rnncula nnd mu~· take n, stellatc form. Whm the condition is well dt•\Cloped a zone of whitish yellow may smround the head of the optic ncrn. Flamelike hemorrhage may also nppe~1r. The con: at first one of hyper£'min., then of degeneration, an or 20 points higher than that usually present and, if the reading is 18.., systolic, undue importance may be attached to this, \Yherea:; :i set·- ond examination within a few minutes, or on a 11other oceJsion, par- ticularly after a period of rest, may show that the itvcragc pre.ssurl' h; probably as low as lGO or 165, which. in turn, is quite wiLhiu houncls for some persons. The point to be remembered about blood p1ess11re8 ranging from 160 to 180 is that their prognostic nn <( I c 0 :; c " UJ f- f- 0 ..J .>< " :r a:: <( :c -0 c (J " ~ z ., "' ~ 0 Ill <( 0 a:: 464-1 Butler and Hakansson-Vlriiln Islands. BIRD'S-EYE VIEW OF CHRISTIANSTED, SANTA CRUZ. A PICTURESQUE OLD WINDMILL. 464- :? Butler and Hakansson-Virgin Islands. HARBOR OF ST. THOMAS, LOOKING TOWARD WEST INDIA COMPANY'S DOCKS. GOVERNMENT HILL, ST. THOMAS. Government House Is where ttie flag is flying on the extreme right. the bulldlng on the apex of the hill. Blackboard's castle Is Butler and Hakansson-Vir&ln Islands. STILL FOR EXTRACTING THE OIL FROM BAY LEAVES, ST. JOHN. EXPERIMENTAL SUGAR CANE PATCH, SANTA CRUZ. 404-4 ~o.4. BUTLER A1'0 HAK .\NS~O"'-\" IHSul'e, put th1· physician in 11 po'-'ition to he ready fol" the storm thnt mny nris1>. SOME FIRST IMPRESSIONS OF THE VIRGIN ISLANDS, MEDICAL, SUJl.GICAL, AND EPIDEMIOLOGICAL. 11~ C'. 8. UUTLEll, Surgeon, nud E. 0. HAKA:ssso:s, A~slstnnt Surgeon, United l'ltt\ll'~ Navy. The Yirgin Islands were discovei-ecl by Columbus \\bile on hi~ sec- ond >oyag<.'. It seems that he gave them the name" Lns Yirgenes" in -- . . -r I I .. lio11or of 1-:;t. Ursula ~tll llAKA~S::.O:\' \IHI,).!\ 1::;1...u;u::;. Yo! ~ I near Cologne. (~<'e Encycloptl'dia Hritannicn: 1 lt h ed .. \. ol. XXYII. pp. u:!-... OJ.) '!'here nre ubout 100 i~lnrnl-.. iu tht• group. mo~th­ uninhnhitcu. nnd their total area i:,, not mer :;ou ::.qu.1rc mile:-. Th~ group bdoug::. to the Le<>warO:'<'d p05ition as regards the northeelong geo- grapbicn lly to this group and were in possession of the Unit<>d State ... befol'e the pnrcbase of the Danish I sland,.,. This purchase increase.l.H ·Hl ·l.\AY I JUIJL· JULY· ·AUG jLPT· ·OCT ·NOV· :n.c· la I L- '- -- ._..;;:;-::::;. ~~ fl1- ·-'- ~ v/J - 1 .. 1 I~ • ,,,~\. ·~// r ~, \\ \ l.tl.. ~ r---..... I ' ~ h / / ~ ~ ,,,, [/ '---'- 7~-: " iif 7 -- ~ ~~ ~ " ~ . - LJ'lf' ~ ~/ ,,,, ... , .. '\,_ lz ~ ---- --- 1$H •1'•1 ~~ ,_....... i:::1'/ ,.1,. , •• . ·- . 1e•1 ,., ,,,,, • 111 n MOOOMIOllQ .,. ......... IJ,,I •Ill ·CHu:r'I f.,!A/f1.;,, (11rv:.J TlxtJJ /'.I f:.t;:;.! .,, Iii tntJ' !tJ.'1. I.Ill) .>~fJJTI '~fl .. ~ of the ~n1nll (21 square miles) mass of land; und SL. C1·oix (~anta Crwr.), the lnrgest of the three populated islands. This islnnd. aft.er ib cli~covery in 1493, was owned in tum by Duich, British, Spanish nns. .. ... t. Croix .. il' uppnrently a name inherited from the French. '· ~!mta Cruz·· is the prior name and should be the only one. In ndtwecn ()-1-0 10' nnd 6fi 0 30' \\C.St. The mean temperature is 74° F. nncl Yn1 ·i~ bont :-;o . .f. Hl"'fLlm ..\~D 11 . .\K,\. '::-::'O::\- \.IROIX 1:-1.AXD:-.. 467 10 degrees on either side of this figure fol' ... ummcr und "int.el'. The trudc wind-.: blow owr the islands for u 1•1msidcmbl · part of the year 1rnd add materially to their healthfulne:>:- uud comf1111. Rain- fall on the ~everal islands i::> about the sunc and umounts on an nver- 11.,0 to 46 inche.;; in the year. .January. Feb1·u:U'y anil Murch nrc the d~v months, after whi<'h there is a gradual rise in the rnin cun·c till O~tober, which is the month of greatest rainfall. Thl· ruin curH· ~how:-. a slight rise in May, but there do not nppear to be two ruiny :-easons, and the cause of this secondary rise is unknown. .July . . \ugu:-t, September and October are the months during which hurri- l'anes nre liable to occur. The configuration of the thrN· islnuds j,., mountainous, so that water quickly ·tumbles homt- to the ,.l'a 111· "ot1J,., into the ground, usually not to appear ugnin. ·JAN ·fLD· - .I.t.- ii ,, I ,,. ' .. I .IL- I " ' ~'---- I I . ~.1- .1.,_ J ~ MH AP£ MAY· JUIJL JULY ·AUG SLPT ·OCT ·NO'I· I I \. I I \ I I \ I I \ I \ I \ I \ I \ I I I ' I I f \ I \ I , I I I / ""' I I ' / ,, / '"" /1'. v ......... / \ ., I / ,,_......__ ,__ (\ --- . --.:l _ ...... _,,/ \. I \. I I ' 'I ' ' / \. / ·~:;-t. "'- ·- - ·'- - ,,~,, ~---- i ·····-.. ······ ··· -~'" Ctwtr'L f1:~t11t Cue-.'~ (31•1>.u Yun) .JH;,N& TH~ /Jm:r Or f/.,cc1a~~ )[u< f>,;>.J /:'/6 ..J•< ~ C"e<'Z· ·t'LC - -- ., -1 There are few springs or running streams un the httll'l' allcrn.1ti\\.•. "~lieu one of th .. pits i:, cmptiL>d it di:4urb,.. the atmo,..phcrc of the :-tilly night f< . mnny square mil~ nml remind-. ont:> of dear old Baltimore n fe, ~·curs hack. 011 one oc<'a:-:iou one of the writer:, ''a~ :rn akcned from a :-ound sleep by the odor from one of tht'"'C e111ptyi11~'· lh• imn1c- <.liately reuclml for hb g1m. thinking it "u:-: a ga,; uttack by the Gernrnn:,. Thi::; i::, a ::ilight exaggerntiou, bnt, may gini p oint to th~ nssertion thnt pits are not good for the health and eomfo1 t of n communit~·· St. John j,, the best watered of the t.hree islands. and it i::. the~ thnt mo,..t of the malaria is seen. The Anopheline responsible for il;.. transmi--sion has not been identified; and though repeated Sl'nrcbe:; hn n bccu made, these hn ve hitherto been without success both there :iwl here on St. Thomas. It is notable that the few foci of mnlarin urc in the Yicinity of smnll swamps or brackish ponds. an for ship- ment abroad. In riding over the island one got~ some exquisite views of lnnd and sen. Tnrquoise-colo_red bays fringed with mnrble-whitt> corn! benches Yi<' "ith 11z1irc skies in the proflignc~' of tlwir bN\uty. 469 ()utlyin~ keyl'> protect llU!! little harbor:--, which m:ulr. th1• :--ection a parndi:-o for till' bu<'cnne~r in t?e s~Yenteenth centt~ry. _ ~inco ... fnniry wn:-: obolil-lw1l m IS-L. the population of ~t • • John hn:.; -u-ndilv dccreaS<.'d until now no more than !100 nativ~ remuiu. The .}oth ~f tho negro. combine-ti with bad land law~. ha:. reduced the remnant to u state of abject destitution. The :-oil in many places is fertile', rnttfo rni-.ing ic: en:-y owin~ to th~ guinea gra•-. and fish nbound in the snrrournling water:-i. Y(•t in the mi not widt•- -.pn•ad. however, nnd the reason is that the rural popul11tion i~ sparse. the people tending to live in the towns: lhc night soil from which. while pqorly disposed of, is nt least preYented from wimperamenl the negroes here :uc quite different from th<' negrne.-; of om· South or from those hrollght up 11nrl<'r Spanish. Frenrl1 ot· English rule. Two cash; are recognized-nt>groc.-. arnl colored, the latter not being pure blacks. Thei1· metho11 of speech i:- p0(!11fiar ancl not tlevoid of interec::t nncl amw::enwnt to tlw foreigner. It is Ene-lish mod to lw uble to work a conjure to the clisaclnmtagt' or l'n>n th" dPuth of tlwsc 11n1k1· the shadow- of tlwir displeasure. Filarial conclitiorn~ ::trl' widespread! the percentu.ge of people :-;h1h~- 111g m1e or lllOl'l' of them Yar~·ing in the di lfcrcnt islands. A l'Oll- ~en ath-e e~timnte of the extent of this infection is 2:> per eent. lllegitimncY is tlw rnlc. about one child in' fi\·e heing l<'gitirnate. <-Erle; of 13 or 11 often become mothers. Pellugrn is quite common 1rncl results in mnny deaths. Venereal diseases n re wides1weaH) J'OI lion re1H·e,..c11ts u mnjority 0£ the population. There re tln't'l' hospiti1ls in the islnnrls, one at each of the principal towns. JJ.id· of 11H>lll',\' 1.o properly build, equip, and m11intnin the,,e 1:stali· Ii ·hull'nb hns greatly haudicappecl thefr usefulness. All 0£ them aH' crmH!cd with poor pntients. nnd the doctor::; who haYe hilherlo h:11l (•luugc of them hnYe been so overworked and hnd snrh n mnlt.itudc of o11tsicll' duties that it "\\as impossible to look after the work as it should be quito hrcecling nnd other Rhortcomings have made of the Virgin Islands H'r it:tble lazarettos. Yet there is not a laboratory in the entire group. There is a mass of potential snrgi.cal work jn sight, but practically very little surgical work is ever nttempted. Imagine u hospi.tu 1 of 100 patients of all types, including insam·, with on 1~· <•IH' 11111·:,e who lrnows anything about prnctical nursing-. with no laboratory, no facilities for modern diagnosis and only one tlnctor to nm the place. This lli tlw stute of affairir. if all he has to do it with are his bare hands and a ther- mometer. O! course, st1rgical work must stnnd as it tlicl in tlw day:-. of Ambroise Pare, i£ such essentials as sterilized dressings must nP11b he prepared in Denmark ~nd shipped ont, supposedly rPo.c1.y for 11!-E'. There has been too much long-distance control of the medi- (':I I J>l'Oposition here, too much of the "you-do-it,, 1tltitudc, with uo pro\ i•.fon mnde for proper farilities :me, the disease incidence ic; high. There 11111st h1• nn outlay fo1· hospitals, medicines, midwives ancl doctors, and those cared for mnst include lunatic.c:, leper::;. pellagrinc: and tho!'P disabled from filariasis and syphilis. In other words. there is a l:tr~P number of chronics who are a perennial expense to the State :rnd nn economic burden long before death termiiHttcs their woes. Af'. regards the social and sanitary aspects of the Vfrgin Islands. it wouln seem that the causes which operate to give high morbidity :incl mortality are: (a) Lax obser\·ance of the lnws relating to mu- 472 Ill' rt.bit A!\l> J!AJ~A.);660."-\·rnm:r-; l::iLA~D:-;. Yo! XI. riagc. To this is a11rib11tahll• the high ruH• of ilkgitimncy anct ma) lny her eggs after 11 rain in the water-holding depres- sions c·ommon in house gutterings. The eggs stanse into the cisterns where they hatch nnd thus increase the numbers of insects in the cisterns. If correct. this would complicate the question of rendering cistem~ mosquito proof. Re~nrding the botanical features of tho islands, it should he :.tuk1l that the hurricane in October, 1916, wrought destrnction to the palm ... ancl other trees of the islands and the tlry season tlmt followed this calamity allowed the plant Ycgetation to lirn only by its root-:. So tlmt on their arrival. the .\.meric1rns fo1md barre11 islands with ashy gray hills. ,\ month l::iter the daily sho\\ er:, of the t·ainy seusou begun: ,, nd within a week the hills were green, cornred with thriving tufts of the nnturulizeil guinett grass (Panicum maximum), ttnd a multitude of tropien l plnnts which soon hnd their richly <'olored flowers giving fra:.r1·nnct• lo the nit-. Of the 1.000 floral species found on these islands, only a £cw arc important in pharmacology. Ricinus communis, from the seeds of whirh thl' ca:-tor oil is pressed, is •ery common. The natives are fumiliar with the physiological action of the seed$ nncl harYcst their dose of c:1~tor oil a~ nee l.a1·k of l 'olulmna reclinnt:i l the mahcc troo). Other phnrmacological plant.-,. fouml here ure: Capsicum frute:-5- ccns. or C"ayenne pepper. callecl hinl pepper by the natives i Cimm- rnonum z<•yl:rnicum: Focniculum vulgare, from which the fennel .;ecd nrc !!Otten; Chenopo limn nmbrof;ioidc:- b'TO\\..; in n few plnce::. on wall"'. .\ few ... pt•cie ... of Gossypium nre common: they were fonnerl,v c11ki' atctl on the island. Ci. harbn pri1wipl1• n1'<·ordina 4 74 DU'.l'I Ell ,\NU HAK XSSOX-nRGIN ISi.ANDS. to" hich dru!! .::tores ure e,,,tublishf'd i,.. thnt th<' popuh1tio11 should get their medicine wHl1011t too m11ch trawl nnd irn.:onn~nicnce . nnd yet that the apothecary ~honld get n trade that ini;:ures him n good income without the :,;train of competition. If locnl nuthoritic find their community in need of n clrn!! ~hm?. nu upplicntion for such ic: made to His Majesty the King. 'ia the supreme bo:ml of health. Should these uuthoritics find that the demand is justified and thnt the place can support a business of tli.: t kind: it is granted that a chug store be established in such and such corner or house. i.\ n announcement of the vnc.nncy is made and applications from pharmacists ore in order. There nre three grades of diploma issued from the Danish College of Pharmncy. Only p'harmacists rated one or two aro q11ar ii ·d for the privilngo of running n drug store. The grade of diploma. mnn- ber of yenr~ or experience, professional merits nnd srientifh- work done urc the main factors to determine a choiee. Tlw pridlege of hnving :t clrng store is granted fo1· a lifetime to the successful candi- date. Ht• pays no tax for this monopoly a11d. spending the remainder 0£ his day - in a -.;uburb of Copenhagen in his magnifiC'ent Yilln! " t. Thomas," entertaining royalty and nobility. Bis sons managed the b11sine:-;s np to 1913. when the pre~f'nt ownPr bought 1t for $i6,000. Th ;!'l skPtchy and unsatisfactory article will perhupf> suggl'"t to the reader some idea of the problems pertaining to medicine : nrl the public health which must be solved here. Under the Dunes medi- cal matters have e>olved to the condition of paternalism. This was. in ~ome wnvs. n matter of necessity. In others it woulcl seem thnt there hns b;en u failure to make the island population aR>ume all the responsibility it should bear and to educate it to :t complC'te scnst• of self-re-"pon~ihility. To bring thic; nbout will tnke mnny yen~ OARPENTER-TllE TRAIN ING CAMP. 475 and mnny kind of teachers. It is our opinion thnt the medical teachers 1111d nursing teacher:; should not come to the Virgin Islands "ith the idea of monl'y-!!etting. but rather with thnt of serv:ice- serdcci whiPh will cYentunte in better thinu::,. Jn the preparntion of thi article the writer,,, hu,·e to thunk Lieut. ( ommnnclrr William R \Vl1ite. "Gnited States Xnvy; Dr. Oliver L. Fnssig. of the United Stnte::. W eather Bureau: and Mr. J omes .\. Donohoe. Fnitccl States Ntn·y, each of whom hn:- renderr d much • :-.-.1!;111ncc in its preparation. THE TRAINING CAMI', NAVAL RESERVE FORCE, SECOND NAVAL DISTRICT. By D. N. CAlll'fJSTf11. 'kdlc,il In-r cctvt, l 11itnl litalt .:-;"a,·y The pn·:scut interest in training-camp organizatirn1 und lrnildings y, a1·rtrnts the publication of this description of the Xnrnl Reserve trnining camp at Newport, R. I. 'When it became necessnry to em·oll a large number of men for the defense of this Second Naval Districti it was found difficult to -.ecure i:;uitable buildings ns barracks in Newport. The mission of the mili- tary ('Ommandcr of the district was to call into active sen ice nnro,·ided. I t wu:s a source of considerable anxiety to the medical oflicers that the personnel was scattered through the town in various bonrding houses. hotels, Army and Navy Y. M. C. A., Newport Y. M. C. A .. and chnrch parish houses. During the first three weeks of organization the men wero attached to the naval training station, but, owing to the great influx of recruit::. for the regular service, it soon became necessary for the Ticserve Force to move to Newport: where headquarters were established in a State armory on Thames Street. At first this armory wns used to quarter men bnt, :i,, it is dark and gloomy, it is now nsed for members of the reserYe crew while on duty. In this armory, which i,.; nt the head of the wharf where the patrol boats come in, is located the were several Rchemes :for housing till' mc11 pending the cou- ,.,truct ion of barracks that for one reason or :mother fell throu~h. such ns utilizing a Fall Rh·er lin<.'r. renting hotel:-: at .T:imc-.town. ll'as- ing the bathing eslnblishmcnt of the Newport Ileach A'-sociation, etc. The <'amp ::;ites nvai.Jablc in the Yicinity were lirnite11. The Cloyne ~choo l nthlPtic firld lwtw«:>en th<' T!·ninin!!" ~tntion Hoad nncl t he hos- t'ARPE::-\'l'f.R-TllE '.fRAlXI"G C,\Ml'. pitul \\ n~ ti.nally otlc•rctl. free of chargl!, tlmn1gh the patriotic "tll- pro,.:ity of the nw1wr. D1·. 0. """· Huntington. Thi:; field ,..]op~ iu two din'clions- toward die \\ater nnd town rd the mnin road. "'at •r nn di:-ensc._ iu the :-ame grounds and eYcn in the rnml' huilding of n gt-n- eral hospital this objection was not suffici<'nt to onl weigh the• '<'Yer ii ncicled tn build wooden barracks. Plans £or these barracks were modified to '-'llit the :c.1wcinl needs of this camp. The general plnu wa-; thnt of the type for mobilization camps issued by the (_Juurtcrma~ter DPpurt- ment of the Un itecl State~ .Army. The appended skPtches h11 ve bCf·u tnken from the blue prints of the plans used in the conslru('tiou of t he~l' hnilt in~s. ~\. general description. furnished by tlu• public works ullker. :;amuel Gordon. C'ivil Engineel', United State,, i. ~nvy. 1 ~ n:- follows: 'ill~: Two pieces 2 by 6-inch ~prncc , supported t'\t'I'.\' T feet by i:. inch cedn r po!'>ts. Floor joist: Two hy 6-inch spruce, 17 inchrs on ce11lerfl, 10-foot ,..pan. Stud-.: Two by -!-inch sprnce, 7- foot ('e11t111·s, with :2 hy Ci-itwh plate. Rnflt•rs: Two by ·~-inch spruce. ~1 i ncht•s on C'Cnt{11·s: pitch of rnof. 1/ 4. Si1h•-. of building,, are coYered with 1 by 1~ - inclt lwniloC'k. plun•d "•rti1·:1lly. and one layer of single-ply ready i·oofin:r. Batten:- of 1 by :3-inch i:;pruce are nailed over the joints of thr l b.\ l:.?-i1wh boards, holding the ready roofing in plact'. Roof consists of 1 by 12-inch hemlock boanls. 1·on'l'Pthod to quickly :fmnish hot mealc;. Outsiclc the kitchen doors an' "4'J"el'lll'rl racks for garbage cans. :Each halTacks can accommodutc-. without O\'<'rcrnwcling, 80 men. ·whi1·h provid(1S n minimum 1fr-ram·e of :! ft'l'l betW<'<'ll cot frames. CA.Hl'E~TEH-'.lHI': TUAl~lNG GA IP. -!ii .\lt]iough tJ1t• barracks .lre da:,;:-;ccl a:; ·· tempurnry :· they cnu be mn used ior the cases of trivial illness not sick enouf!h to :,end to the hospital. Such a building permits ca~s to be rt-moved from bJrraclrn ancl placed under observation. This is considered to Le of special value to check contagious cases early in their incuba- tion nnd ~ecnres a certain amount of isolation. The 1lnily ~ick call i~ held in this building and dispensary service rendered for the cnmp. J<'or the destruction 0£ garbage and refuse the Guthrie incinerator of the type re{·cntly used by the Army on the Mcxicun border has been built. The following recommendations made by the senior medical officer of the Newport section. Surg. "William D. Owens, United Stn tl'., • ya\')\ go cm the sanitary n AT BltOOJ\L) ~. X. Y. 4 79 rendering tlint ::,crvice to hi:; ~ountry for "hich he c11 I btl'd i in the s.une category as the mnn who intentionally rni:-1.?l hi, hnml aboYe the trenches thnt he may be shot nnrvice. 1 des.ire to imprc:;s upon every man the need to keep him,elf l'icnn of \enerenl diseases, and also by hi" good exnmple to help encourag-c his shipmates to avoid temptation. If we are to be victoriou..; in the pre.-;e.nt struggle, it will be nece&ary for everyone to inculcate sti'<'ngth of chnrncter so as to resist temptation, for only by giving the Ue;t cun we win the war.'' Surgeon Owens also keep" u watchful eye on the <'Ornmunicable diseases by means of a diagram in hi~ office. A measles census was made of the camp and is kept a\:ailahlc for consultation in cases of transfer of men. The conlrnct for building the camp was awanled to Darling & :-;lade. n111l on :\fay 14 the work of construction hl•gun. The fir:,l two unit~ were ready for occupancy on .June 21, and :320 men were mo\'ed into the camp. The remaining units are being occupi<.'il ns fast as they nrc completed. Close by the camp is the Cloyne llou~ school: 6 large Mmmodions building with beautiful grounds, filled with rare plants nnd trees. When the resel"rn force began to enroll Dr. and Mrs. Olh·er W. Huntington established a clnbroom in the gymnasium of the school, with books, mngazines. games. etc., nnd pro' icled a lunch counter for the use of the men. .\..t pre1'ent tlw l luntingtonc: are u~ing Cloync School for n cooking clnss. n sc·hool for 1·obbling ud repairs for dothes, which 'the~· conduct under tht! auspice.-.: of the Go,·ernmrnt. A roarl at one side of Glo~'Jle School lcn1l~ to Cod- dingf 011 Point, over a bridge that was coni-trnctecl to 1·1·1)5." 11 :-111nll e,,(11ary. 'I'he Pl:iy~rnund :l!H] Herrcatinn .Association of ~\mericn h11il1 lhi,; bridge 11n1l lnicl ont t'ecrl'nfion gromHlii, and i11 !'001wrntinn with thP Nc\Yport ( 'hnptl.'r of the Red Cross sec1u·ctl aml equipped 11 hou. e which has been opened as a senice club for the men. The barracks on Cloyne Field will proYide quurters for li600 men until the buililings are sheathed and ceill'd for winter use: when the cubic oir space pel' man will make it necessary to refluce the 1rnmbcr of men in cuch barracks from 80 to fiO. The camp will then prO\ ide quarters for 1.200 men. TEMPORARY :BARRACKS AT CITY PARK, BROOKLYN, N. Y., A PRE- LIMINARY SANITARY SURVEY. B7 W. S. l'ucn, Sur~eon, and R. JAss&.s. Assistant Snr!:t?on, United :-:tatl!I! ~.n·y. General conaideration.q.-The temporary barrack-; nt Cit,r Park nr~ located in the heart of o. congested clistrict. On the Xa,·y Street nnd St. Euwnridc are n numher of diln.pi- 480 l'PGll AXIJ ,J \~:,.;gx-B.\llR.\ l'K~ AT lll!O(JKl.YX, X. Y. dated. two-~tory buildings. ubo occnpicd by lt-1lia11'. The neighbor- hood. from n sanitary ,tnnclpoint. l" 1111clesirnhle. Tlw park l'Orn- µri:-e:, about li nC're~. The followiug buildings con:-Litute tlw e. tnhli hmital: 11 guardlwu~: nn administration .... ILl a: J. ... :I ... 0 0 "' "' ., .. - ft > " < " < z .;. "' < "' Luiluiug; a canteen, untl :1 public-com!<: rt --lntion. Collectively they occupy 114,240 square feet, or about 35 per cent of the pnrk area. The buildings nre disposed about a t•entrnl aclministmtion build- ing. Six of the barrncks are located 011 lim•s radiating from the ad- ministration building. Three of them and the mess halls nre situ- ated parallel to the sides of the park. Thi• latrines: of \\ hieh there nre three. :ire T-shapcd, and are phicc·ll with the \'et-tiC':tl extension$ rnc1inting from the ndmini~tration building nnieces Ned. l'l'tlll \NU .J;\NSEX- BARR..\CK::i .\'1 lHlOOKLYN, X. Y. 481 purolld to the :-.ide:. of the yark. The granite publi~-comfort :,t:ttion. the boiler hon,.e, and the kitchen are located on the St. Edwnrtud~ spaced 16 inches apart. heavy paper, and i-inch sheathing. The roof is of ~-inch ,..heathing covered with heavy tar paper. The <"eiling is of t-inch sheathing. Doors and tr.msoms arc cut in the inner side and windows in the outer side. The kitchen and mess halls h:He a clear :::tory with window::; cut in both sides. On the iru1er side of the barracks the roo.f projects about 8 feet and the ground is covered with concrete. The floors of the latrines nre to be of concrete instead of wood. The kitchen floor is mnrbeloid. The buildings ure painted ~rny without, and with linseed oil within. The construction of these bulidings is as good as one c:rn l'Xpcct in i temporary cantonment, and wm meet the various sanitary require- ments. The thickness of the tar paper on the roof will prevent leakage for a long time. The three thickuesses o.f wood. two thick- 11P-.ses of paper, and the air space between the inner and outer sheath- ings of the walls will afford good insulation to pre,·cnt the escape of ht>nt. The floor will probably be dry. although it would have been much more desirable to have concreted the ground beneath the har- rnck~. '/'ho ban·acka.-The various buildings for barracks arc di\·itled into compartments 40 feet long. A detailed study of nHy of them is applicable to nll. They are 26 feet wide and 12 feet high, except at the -.icles. where the roof, which slopes to both i-::ide~. cuts off the cor- m•r::. The floor space is l~O!O square feet. The gro:-!~ nir space iR 12,000 cubic fC'et. Each barrack is being equipped with 2-l clo11ble· dnck beds: the frames of which nre of iron piping. R<.'ing plnnnecl 8551-17--4 4 ~ l'l'c:11 \~ ll .l \,·:--11\ H.\.lrn.:\l'l(:- \ '! »HOOK!.\.:-;. x. Y. \'ot :XJ for 4o 11w11 1•J1ch will ntfonl 11 floor :-pace of :H.U :-qunrc foot per 111111• or 43.2 ::.q11nrt' feet per clonble-deck bed. nnd an nir space of ::!:iO cubir feet per man . • \.., will bl• :-cen below. the >entilation b rather bett~r than ,, hat 11:-11ally obtains in barrur.ks. Ilut. npart. from ,-entilntion. there l"(I sanitary rc1p1ircments rclati•e to nir :-pace and lloor :-pucl'. Double. deck beds are very objectionable, for. in spite of libP.ral n·ntilntion in a compartment or in the absence of o. separate JouYe1 for each lowt.>r hunk. the circulation of air in these i:; Yery slight. The :;preud of tlw orclinar~- contagious diseasm,, ns measles, m11mps nnJ menin- gitis. und of tonsillitis, influenza and pnetu11oni11, is fa H11-ed L, cromling hoth as regu1·ds floor space and air spucc. At ll•a:.t th.e nose nnd mouth, as in sneezing, coughing, and even in t11lking. Their firing 1listllnce, so to spenk, is not very great, OO cubic· fe<'t of air space per man should be met. It wo11hl lw eHn bettet· to meet the recommendation of Army meclieal officers :for n minimum of GOO cubic feet. However, ns planned we shnll have only :H.6 ~qunre feet of floor space and 250 cubic feet of air space p('t' mnn. To meet the higher requirement the medical -0fficN· recommends thnt Pach compartment be used by only 2J. men instead of by ±8. The nat urn I ,·ent ilntio11 of each compartment is quite ample a~ regarcls tlw Yoltnne of air that may enter and escape. The distribu- tion of pure air, however, will not be so satisfactory owing to tbe nse or cloublc-deck beds. Each compnrtment hllS two door!': two transoms, and fonr wi uci.ows. Collecti \'cly, I hl'Sl' measure 14,:; J i -..qunrl' i1whes. By figuring on the basis that 8 c;q11:1re inches of inlet and squa1·e inches of outlet permit the extrnnce and exit of 1.000 <·ubic feN or air per hour in natural ventilatio11 und1.1r a ,·erag1' con- clitions, t.'nough nir will circulate through the room for 7;1 complct{' renewal~ of i1i1· per ho11r when all the aboYe npel'tnre;; :ll'<' fully oprn. Thi" is mon• tlrnn snffiC'ient. Howe\'et'. it j~ not to lie expectcilll't ion \'C'nts of tlw Larsen type placed on the roof and opening into the attic O\'t'I' the 1·ompnrt111e11t. Between the nttic nnmpartml'nt thPrl' n1·p nitw eeili11!! 't·nt-... ttich !llCH!-11 entHeatcr part of r:i,•h hall is tak1•11 11p liy tables. Tlw ceiling is \'t'l'~' hi[.!h thrnu!!h dt1• C'l'llll' I'. 1 hPn' tlw rnof ltai:; n clo11hl1· f'lopP. and lmH•r to Pither ,.j1[e. '' hPrP the 1·oof hns a single ~lope. 'l'h1• tlool' spn1·e of t•:wh hn !I is 7.fili8 :-;1p1;11·1• l\•cl. Thi• :1i1· ... J>:l<'l' 1s :1s.n:r1 1·11liil' l't•t>t. The area of window::,. door:', a11d u·:tn:-m11:- i:-; l ~\!l,ifi·t ~ pinn· indws. Thi::, "·ill permit alio1tf ~.i rem·wnls of air per hour 1111dcr 01·1linal'y conclitions \vhirh is quik ;unple. The pro\ ision for :1rlifirial 1·t·11til:1tion of r:lCh hall consists of th1'l't' :!1-irwh :-11cti•m H'Ilt nf tlw Lar'-'Pll t,\ pe, 10 ceiling Yents, mensnring Hi ind1e,.. sq1111re. wlail'h l'' no.,t1tutc the outlets, and 12 radiator n'nt,,, 111<':hm·i111! ;tt their 1111 ,.t c·on~t.rictetl portion 10 hy 1+ inches. These r:1dintol' \Cmt ... '' ouhl ndmit enough air to permit l wo renew a ls per hour under m··li11:1 ,.,,. coucl it innc;. but with the added i 111 pet us of c·om·1•ctio11 cur- n nt ... w Ill' rt tit<' ste•1m is on they rnn he rel iect on to deli H'r -.t•\ 1•1-.tl time,., that nrnm Yolmne:-- of air. Hence the~· wi II probably fnrui:-h the 111cr,.;sary l~ renewals of ni1· per hour. 'fhc t·eiling ''<'lit' utford 1111 arP•t ~u flicieut. irt'l'SpectiYe of theil' location, to pcl'mit thl' dis- chnrgl' of nbont thrN' times the nil' l'Ol11me per hou1. But owing to tlwil' loculi(ln i11 llw pnth of natnral ('Oll\'N'Lion l'111·1·<•11t .... tl1l·~· can ht• r1•lied 11pon lo dischn.l'g<> 1:2 Yol11me~ nf ail' per h1111r. Th~ pl'O- ,·h-ion for Yl'ntilation is thrreforc considered 11tleq11nh. l'H'll when the \\l':tthe1· will 1wce<.- proviilelc-. mea,..urin!! ::W fcl't and " i twill'-. h~ :! l'PC't n ncl () ind1es. Bt>,.;idr:- tlw o ho,·p thr1·c 1111: t 1hlt• .. and shelves for mess gear nnd food. l>Por~. ,,·indows, trnnsonrn. and radiator wnts nre prm ided ''ith 11y ~l'l'el'llS. TIH kitchrn. /)(lkuy. f f1·.- There is a kit<'hen. hakl'l'.''. h11td1er :-hop. 11wnt rl'fri2'ern tor. ~E'tll'r:l l n'friµ-t'l'n tor. \ i>gptn h Ir -.torrrnoni, 4b 1 l'l GH A::s'D JAN!i~:X-.BAIUL-\UKS \ '.I' Hl!OOI'1.YX, N. Y. 't•!!etnblt! prepnmtion room! flour room. hrend room. rccch·ing room. i~suin.!! room: nml office. These are to be situated bebn~e.n the 1nes:.; halls uud behind the boiler house. The ceiling of the kitchen is to be wr~· high, us the building hns a clcnr story. The roof has a rlouble slope toward th<' me.~s ha lh-. Doors. winclo" s. Pl<' .. will ~ provided with screens. / 'fool' space, ai1· SJJUn room.................... ........ 3!1~ Batcher alwp..... ...... . . .. . . . . .. .. . . . . . . . .. . . . . . . . . . .. 3i2 lle:lt r<'lrl!?eiatlni: room................................ 32S ~~~~'.1'.:~~~~-1~ ...... ::::::::::::::::::::::::::: ~ I Receiving room.......... .. .. . .. . .. .. .. .. . .. .. .. .. .. .. . 2ill lssulni: room.. ...... . .. .. . .. .. .. . .. .. . . .. . . .. .. . .. . .. .. 168 r..ooks' rooms (11, t)a(·b . .... . .. .. . .. .. .. .. .. .. .. .. . .. .. . 140 .\ir 3,5i5 7,260 3, 069 1,848 1,6l0 Na turn I \'e!ltllaUoo. lnlots nncl outlets. Sq. In. ftJ,1112 11,0IG 6,69!1 ft, &00 6,e 1 water-closet to 21 men, 1 shower to 13 men: 1 la' a tor~· to 12 men, and 1 head to 21 men, which is sufficient. The compartment for water-closets is 39 feet long, iii feet wide, and 11 feet high, except at the sides where the ::.luuting roof cuts off the corners. The gross air space is 9,750 cubic feet. ProYision fol' ,·cntilation is similar to that for the barracks, with the unfortunate 1nni&>ion of the underground radiator vents. The doors, windows. aud tranf:oms afford 33,352 square inches of inlet and outlet, or about 100 sqnnre inches for each water-closet, which is ample. Thi:; per- mits about 210 renewals of air per hour. The ceiling \ ents afford un outlet of .376 square inches, or about 12 square inches for ead1 wnter-clof:et, which is not enough. Each water-closet in nntnrnl , rJ1tilatio11 should have an area 0£ inlet of at least 48 sq narc inches and un equal are:i. 0£ outlet, or 2,304 square inches for 4 water- clo:::ets. It is desirable to increase the outlets. Instead 0£ 4 ceilin!!; yenb there should be 16 and instead of 2 suction ,·cnts there should be li. In cold weather there will be a strong clruf t of col cl air blow- ing in at the doors, which is undesirable. It woulcl be better to hn ve vestibuled doors which would stop dra£ts and h:H e rndintor ,·ents, as in the barracks, to act as inlets. This compartment is prn- ,·ided with steam-heat radiators. The laYatory is 43 feet long~ 26 feet witle and 11 f•el high. except nt the sicks where the ceiling slopes. The gross air space is 10.l."10 cubic fef. t. There are the same ample provisions for natnml Yenti- lntion ns in the water-closet compartment. The recommendations for incn·nsing the artificial ventilation of the latter compartment npply here. There should be nt least 16 ceiling -vents nnd nt lenc;t l rmction vents. It would be desirn ble to have :lir admittctl hy rndi- ntor ''eds instead of from the door, which shonhl be doubled with vestibules between, to prevent drafts. There arc l stenm-heat l'lldiators. The compartment £or urinals is 26 feet square nn a, ample u-. in the \rnter-clo;-ct compartment. l<:uch compn11 mcut for -.bower::: i-. 40 fl.et long. 2fi f cet '' iJe. anti 11 fe<·t high. The gro-.,.; nir -.pace b 11.440 cubit} feet. Pr1nbion.., for natuml \'Pntilntion al"e a, mnple lb in the other 1.'0lllpartmentJ. A'quipntt nt.- Thc water-clo:oet::: uni to Le plncclc, Lecarn,e it permits both ::;i;aturnl "reDtilatlon Inlets nnd ootlets. Estimated l'til~WtlU olalr per hour. ··~ 204 2t~ 150 ~ 175 43~ 217 15.l !Ml 130 250 Ut The uir space in tlw t•ompurtmenb for the l:lick ba), isolation wurd nnd Ho::.pit.al Corp:; i:; in.ulequate. T he space per man i11 each is, re"5.1>edh·cly. 3~.I. :~80 nncl ~20 cubk feet. .\s the sick bay nnd i:-;ola- tion "uni wi LJ probabl~ · nerer be filled to their capacity. thb l.1ck of nil' &pncc is relativel~· unimportant. nut in the quarters for the lfo=:pital Corps oYercrowding should not be permitted. It is ~;ug; gestccl that the room assigned as a dental office he also usecl for the Hospitnl Corps nncl other provisions be made for the denti.-.t. Or only two Hospital Corpsmen should be quartered in the ho:::pital nnd the others should sleep in the barracks~ which ure only about 13 feet from thP- hospital. There is ample provision for heating. It is to bo regretted that only u few of the radiators nre provided with radiator \ cnts. There nre four suction vents on the roof and ceiling nm ts in the sick bay 11rnl some of the rooms . ._'ufficient toilet facilities will be provided. There will be n lnrge bathroom between the sick bay and the isolation ward. which will be a.ch in the other rooms. This will not be sufficient for the performance of dericnl "ork. It is recommended thd n lamp :rncl rt•flector be installed for ench desk and typewriter. The granite public-comfort station, which l111s eight w:1ter-c:Jo,l't::.1 fh·e urinnls, and two lavatories, will be dhrided for the use of officer", and room!:: nre being uddecl at each end for ofllcers nnd the nrmed guard. It is :idequntely provided with rncliators and lighting fixture!'. An oflicers' mess ball is being erected in the renr of the boiler hon:-::e. It mensures 32 by 22 feet, and will consist of n. pantry nnd mess room. The building is of the usual construction and has one :-11ction vent. Heating, lighting, and ventilation are. ndequntely JlfO\·i1''~-IUI!HAC'I\::. .\'J' BHnW c11111litio11-.. The other 1:0111pun111Pnt:s hn\t• hcatintr -.nrf1u·r ~ufticienc for f1 om HI to :20 re11t•\\ ul~ of air p r hoar. 'fhe ~mall miseelln11enm; lmilrlin!!'::-, ll<'h :ii;; the <'•llltl'l'll, Cfok · hou,,es. guanlhou~e and udmi'li-.1ratio11 buildin!!. have n prupor. tionntely !!renter he:1t1I1!! ~urfuc·t>. Tiu• kitcht>11 will he -.:i.1pplied \\ ith Loth ~t<.•tuu u11d ga~. l'hc 1,rng~ annry. A::- for as possible till' direct x1 osurc of irn'.andescent iilanwnt~ :-hould bl' :\\·oided, lit•cuusl' the.\ produce retinal strain. The~ an• th1• rhief s:initar~· conshle111t ion~. In natural lighting the transparent i:.urfoce of the wiurlo":;· ck . ... 1iould be about one-fifth of the floor surfocQ to 11dmit the tlec;in•d nmonnt of light. In lhe n1rious buildings this ratio is 11ot mnin- tniue AT BROOKLYN, :-;. l". Vol XI. cul officer recommemls the Utie of liU-\\ att lamps with distributi11,, shades. ~ The mess halls will be lighted by 40-wutt lamp::. plnceu T feet nbove the floor and pro,ided with G-inch bowl-shaped illuminate l steel shades. These will be arranged in rows over the tables. The distribution of light on the tables will range from 3.:J f oot-cnndle;; directly under a lamp to 1.3 at the ends of the table,... This i...; ample. Unfortunately all the light will be rcilected downward. The space abo>e the lights will remain in darkness, except for what littlo light may be reflected back from the floor und table. It would he much more desirable to use bowl-shaped holophane reflectors. With these the light would be more evenly diffused. It should be noted here that the lighting in the mess halls will be ample for reading. writing, and mending clothes. It is therefore recommended that ona of these halls be a"Vailable for these purposes. Tn the kitchen and bakery the lighting will be by 40-watt lamps, provided with bowl-shaped illuminated steel reflectors. This will giYe an a>erage illumination at a plane 3 feet from the floor of 2.5 foot-candles. The maximum will be 3.9 directly under the lamps, and the minimum 1.1. By using hcouunendations: (a) That in the barracks and the latrine>: liO·wntt l:nnp:- with dis- tributing shades be used instead of 40-wu.tt lamps without rcfl('ctor:->. (h) That holophnnc reflectors be used in the mes;; hall!';: kitchen, nnd ho~pital instead o.f opaque shades. (c.) Tlrnt a mess hall be nYailable for use for reading, writing 11nd mending. (d) That frosted tip bulbs be used in the hospit:d. Water .~upply.-Th.e disadvantages of locutiug a cnntomnent iu n lnr!!e city are compcm:nted for by the adnrntage of un nbunalL standard)--------------- ---- H Odor _ _ __ _ ----- ·---- -------------------------- 1 ,. t 'hcrulcul unnlp•is (purL'i per million) : ~ltrO~\'ll as allnnnlnol!l ammonia_. °Nltro~C'n ns frPe urumonia _ ____ _ _ • -------- ---- "ltrni::cn us nitrite -------------------- -- • Nitrogen ns nitrate ____________ ·------ --- --------- , 115 •rotnl rcsld11<> on eniporntion___________________ • Hnrtl11ess ___ ------------------- -- ..... ---- -- - ..,.. • ..:\Jltnllnlt~·--- .. __ _ ---------------------------- lS Chlorlnl' ------------------------ ·-. -- - -- - • 1. U frou ~llcro>11lating mut~l'inl l'Ompdsing paper, cork board nnd asphall cement. The floor is of c·onrrck. They each ha,·(• an air i::pa<'e of nhont ::,;,oo .. ubi(' fr•et. Thl' irl' platforms are aborc the floor. The drip pnns ore 0£ gal•anized iron and disch1trgc is by a Huor arc provided with t>ither S or P traps ond the honSl' sew('n; with an 8-inth hollsc tl'np. Ventila- tion of the wn~k pipes is arcomplished hy n>nt pipes of gukauized iron either 2 or !3 inche~ in dinnwtc>r·. These extend to I he roof where they dis<'hnrge foul gases. Dispot'al of slops and cxcretn from the kitchen ;rncl tht' hoi:;pita 1 j, :-imilarly accomplished. Food refuse and waHe will be disposed of by cal'tage to the offul d1)Ck. Previons to rnrtnge it will be storecl in C'OYcred gn l nmized-irou 1·an~ placed in the garhng<.' r<.'frigerator. Tlw garbage n•friger1:: or measures 1fl by G .fret and ha::; a height of 11 feet. Thii:; would !'.l'l'lll hardly large enongh to hold a clny's garbnge. It "ill ha ,.e a cenwnc floor and an ice compnrtment. Rubbish will be disposed of by cartage to the rubbish dock. T t j .. re<·ommPruh•il f hnt numerous receptacles be plncecl around the h:u·- :-;o. 4. iuck:s to l'l\{'t'i''' \\H"ll' papt>r and otlwr ruu!Jish 111111 that a larg1• n·- ceptndc he pluel'd lwhind th1• kitchen. \\ lwre fruit ('rnte::-. bnrreJ, uncl rulihi!-'h may h<' kept prior to <'artag1• withonr IH•roming 1111- ,jgbtly. frtJnNal CfJmiort. •llld sujety.-lt i:-- to be hoped thnt :-pit kit. ... will he i11 .... wllec1 in the h:irrnck.... There should he ahout t•iaht in eadt 1·omparl mcut. There j,.. one fountain with three ~nitary scuttle butt" in the park. It ,rnulrl he <.lt·sirable to haYe more. However. 1lrinking wat('r can b<' , bt:Jirwunrnc·e. it i,.. sugge:-;ted tha.t numerous receptacles be placed about the grounds for paper anCl rnbhiRh and that proper attention b<' ~iwn to tht>ir utilization. It. is :.11ggesterl thnt beuchPs be pla('ed :tloJJ!! tlw c·ont..-1•tt• \\a)k, 1111 the inuel' "ide of tlw barracks. ft j.; to be regrettecl that 110 pro,·i,..ion h tb ht· 11 mad<• for drui11i11!! nwny 1·:1in drippin:r 1'1·om the root:-.. It appear·s prnl1ahlP that wh<'ll tJ1ere i.._ hea\'y rninfnll grc>at pools of water 1vill l'ollcd i11 the :-pal.'l':. hctw1•1•11 huildin:rs :rnd ma.r PYen on•1·ilo'' tlw •'ollt'l'Ptl' pat It' n1111 ,o g-et 1111der the floors, which will be nr,r object iormhh•. nec:rn-.e of the inlfommable structure of thl' l111il1li11:!, \'\l'I',\ pit·· ( 0u11tio11 ,houlcl be taken to preYt>nt fin•. It j ... 1·t>1·on11111•111ll'Cl tl111t · smokin!.! incloo1·:- be prohibited and that nH.'11 d<>kd1·tl ut it or in throwiul! aw:ty lightNl cigarette:; he phu·1•tl 011 n•port. [t i:- ll!!ine>s whi<·h hn1·e '11><111 ,11ppliPtl. [111111P1liatl'l~· 496 PUGU A::-.""D JAN:::>EN-B.rnRACKS .\T .1rnookLYN, N. Y. \'ol out.<.ide of the park are 10 public pumps, some of which are cot nected with the local high-pressure fire mains. It is recommendc that a number o.f hose carts with fittings to attach to these pump be placed at the entrances to the park. It may be notecl in this con uection that the wiring system I:> nnticpiate ., z -5 " iii ! "' > ;; u 400-1 ::> Cl: u w Cl: IL 0 ~ w > w >-w J, 0 Cl: iii 406- 2 Calver-Sixth Naval District. MESS TENT. ~96-3 :-:o. 4. CAL\'ER-::ffXTH XAYAL DISTRICT. 497 Rbumi.-In this preliminary surny the metlical ollil'~r ha ... un- dertnhu to point out an1l corumenrily meet the 11,·crnge requit\:ments. The nil.Yance made from quartering men on ::-hip:- which are out of commission and umlergoing rc•pairs is cnor- IDOll"'· With this fine equipment and with an equnlly excellent "ani- cnry ::ur uvision the mest in pro\'icli11!! n :-ani- tnn· cn11tonment for them while on shore dntv. . . ORGANIZATION OF THE NAVAL MEDICAL CORPS, SIXTH NAVAL DISTRICT. By G. W. CALVER, .l~'lstant Surg~on, Vnlt1•d !4tnll's Xnvy. In 11 cliscu!':sion of this snhjl'f't it is thought. bettel' to di,·iclc it into lhree heads, giving the three important phases of the work pedormed by tlrn naYal medical oflicers of the regular corp1-; and Uesene Force. in pre} nring for nnd handling the rnrious situation!:) which ari~e in their territory: 1. Preparedness organization of the Sixth X arnl Di~trict. :?. Organizntion for reception and care of recruits. :t Emergency hospital facilities. l'reparrdm;88 orr;anization of the Sixth Naval JJist1'ict. -In the organization of the Sixth Naval District, preparing for fir-...t-uill work amt handling of wounded in cases of emergenc~·, or di~cm­ barkntion of troops or sailors, it was thought, adYisable to diYicle the territory into nine sections. establishing a section base with a founded upon the dispen~ary. In the organization of the section base di~pen ... :irie". plan ... were formulated to pro,·idc medical cal'e and attention for two !!ro11ps of personnel; first. those directly concerned \\ ith lhe nrlmin- i::-trntion of the Sl•ttion base. including the office force. de.. ancl. second. tho crews of the coast patrol boats. To fulfill thc:;c require- n ents an ofii ·c \\'lhi established in each seclion ba~l' for n medical officer. which was to consist of two rooms, wherc,·cr possililc. orn· lo be used as nn office and dispensing room and the other for :111 cx- am~mnl? room. S;;;>t-17--:l 498 CALVER-SIXTH NAVAL DISTRICT • ..\. medical officer of the Resene Force. with one llo~pital Corp,._ man and yeomnn. when nece::;sary, compri~e the per.::-ounel of eal'}1 section di:-pensary; nn out~t of IX:TH NAVAL DISTRICT. 499 ' .\. cann1:-s wns mnC'r of nurses agreed to se1Te if they were off of duty when the call c3me. while others have volunteered their entire scnices in case of emergency. One of the biggest questions was the prepnration of such places as might be M 1ailable for use as temporary hospitals or barracks. Such hospitals and sanitoria already in existence were usually unprepared for the handling of any great emergency and such an oYerload as might be thrown upon them had to be provided for in the location of meant buildings, such as might be used for temporary ho:,pital~ or barracks. Clubhouses, armories, schools and dormitories of Ya- rious kinds were the type sought for and desired. To make these buildings fit for temporary use, sanitary squnil~ wen: organized which were headed by business men who agreed to be rc~pousible for the appearance and remuneration of fi,·e negroe:-- who would do this work, each man paying and supervisinJ the men of his squad. To feed Lhe patients in these temporary quarters, u \'idualin~ rommittee was organized in each section base. These men agreed to sec that, in case oi emergency, all of the men quartered at auy point in the city would be properly fed. To assist in the more rapid organization and efficacy of this committee, a canvass was made of the hotels, reslauranls and bakeries for the loan of cooks or the promi~e of their assistance in preparing food wherever po:;sible. The proYision of equipment for these hospitals in cases of emer- gent•y "as met by securing promises of loans of beds and hc1lcling from 'arious hotels and the securing of estimates of quantities of artidcs the n1rious dealers would be able to clefo·er on notice. with the l'Urrcnt prices on each article. Last but not least, practicing physicians in each town who "·ere members of the medical society were asked for instruments: sterili- ze~. tables and such other equipment as they would volunteer to loan. They were also asked to volunteer their personal services in case of nC<.'essity. We found in some places that many of the physicians were members of the Red Cross and decided that they could not sene in both places. 500 O.\L\.ER-SIXTH XAVAL DISTRICT. Yol. XI. From thb it will UC ~een that an attempt has been maue Ht each !'.lt'ction ba~e to pro,·ide: 1. Docking facilitie,., for the wounded. :L A1·commont in eom. mi. ·ion or in such buildings us might be con\'erted. :t The proper cleausing and preparation of these builOO men, each with separate toilet facilities, and a large mess hall nccommodating the persm 1 el of h\CJ nnits. This comprises "·hat is l'alled a regimental unit. Small houses haYe been built accommodating 2.3 men each. Each of the,p houses, as will be seen, allo"·s 25 men. including 1\ petty ofli1.·cr in charge. to swing their hammocks and proYicles a maxim un cirl'nla ion of air 1rncl protection from the weather. ~\n aclditiona l pers•mnel of 15 men may be added to each house by the use of foltl- ing c:11np cots placed on the floor, thus accommodating 40 men p<-r house in <'nse of necessity. Owing to the exceptionally mild clim:itc in thi,.. locality, it is unnecessary to provide heating facilities for a !!reater period than two months. These houses will be heated by :;mall wood-burning iron stoves with Yentilation around them. Of nll the various types of heating apparatus which ha ,·e been under cc n- sicleration this appears to be the most economical for this climate anntire c.nmp. except in thO!"l' hou~e~ wlwre nn infec- tious case ocl'Ur". U111lrr t he:'e circumstant l's the f'ntire per,onncl in the hou:-e "hicl1 ha:. bet:n exposed to nn infol'tiou,.. dbl'n:-=e nre quar- nntined to the house, a separate toilet room being de-.i~nnted for thl'ir u.;;e. They form and march to the mess hall. to tlwir cm n par- tic11!:11· table ancl are kept together for work and i·ecn•ation. under thf' chnr!!C of their own petty ofiicer, during tlw n l'cesrn r~· qunrnn- tine per :o. l. Tlw 1·liject in dil'icling the cnmp into units of t hi~ ~mall :-ize i~ to prc,·ent n greater rlnmage being done by q11nruntining a lar:.re nnm- lwr of men. Instead o:f its being neces~ary t o quanrntinl' a hmulrr.l or more men, if n larger type of bar racks had been U;;l'd. it i" here only ncces'lnry to lose the services of about 25 men, dt:crca ing- th~ damage by 75 per cent. Tlw mess halls ha\·e been so constructed us to nllo\• l'ach ~quud holM' to ha,·e it;; own table. the men mnrcbing in to this tnhle and not h<'ing allowed lo Yisit or use other table:;. The me<:l:i gear of f'ach sqund of 25 is kept sepnr ate and, haYing been washed in ~calcl­ in!! hot water , n minimum chance of infection by this means of infec- tion <·xisls. Dish-washing machines arc to be installecl to l'nable thi~ work to be more expeditiously handled. The ml'«s hall j,.. screened to preYent the entrance of flies, anO hey the addition of fiYe 50-bed wnnb. This hospitnl "ill he in commission on July 20, 1917. A hospitnl or, rather, ambulance ship woulcl Ul' desirnbk in O!'cler to ct>ntrnlize the cure of the men of the naval l'OllSl patrol on this hospital. The enrly nrrirnl of snch n Yessel to fncililate the cure of thl' men of this scn·ice is earnestly desired . • \ school of instl'uclion has been organized at the nn vy-yard di ... - pen:-a ry. Charleston, S. C., for the pmpose of instructing both the new me1l ical oflicers and Hospital Corpsmen; besides this a special inten h·c school of instruction in recruiting has been or~anized :for the pmpose of preparing certain selected men for duty at section ha<:e,... Thl' nwdical officers receive instructions in na ml forms imd pro- cedure...:, drills and general routine of naYal life. They also haYe been giYPn a special course of instruction in Swedish moYement'. lumllina. wrestling, wall scaling, etc., to equip them as thoroughly as po-,:-.ible for nny field service. The Hospital Corpsmen are given a three months' intensive com:::e of trnining, co,·cring the course prescribed in the J\fonual for the ::\leclical Department. Besides this they are given drills, Swedish mo\"erm•nt!''- nncl other exercises to bring them into ns good physieal ~hnpe ns possible. THE PRESENT STATUS OF CEREBRO-SPINAL FEVER WITH SPECIAL REFERENCE TO DIAGNOSIS AND CONTROL.' 67 II. ~. CUM:\lllSO, Surgeon, 'Cnited Stutes Public IJealtb Rcr~k<'. Cereuro-spinal fever is one of the communicable clisenses whose ap- pearance hns been considered an almost ine' itaule conseqnence of the mobilization of large bodies of men under conditions of sudden change of en\'ironment, overcrowding and lack of adjustment, which usually jnitiate such action. The hitherto mysterious mode 0£ trans- 1 ~Ince this arll~le was prepared n v.a.luable cont1·lbuton to lhc knlowledgc or dlagnORls and treatment at lbe disease has been written by Dr. Simon l•'lcxner : " :Mode of Iufectlon. :\lean~ ot l'rcv<>nllou 11nd Spcclllc T reatment of Epidemic Meningitis." (The Rockefeller ln•tllutP fur .llledtcal Research, 1917.) Ct:l\DllXG-CEHEDRO-SPIXAI4 FEYI:R. 505 mi. .... jon ..... ml and imG. It has been reported present this year in nearly e?•ery State in thi' wuntry and, as was ineYitable. in consequence of cxtensin recruitin~ ol yo11ng men ancl boys for the Xtn-~·. it has appeart>e shown no clinical symptom ... of the di:-en ...... l'r1•tlisposi11g causes.-It is evident from the large numbt-r of persons without clinical symptoms who are carriers of the menin- ~OCO<.'<'llS, that something in addition to the presence of the orgirnism j,.: 1H'<'e::.sar~· to produce the disease. The disease is more prern lent rend by being carried in the nasopbarynx of normal incli\'iduals, conn\le:.cent patients, and those actually suffering from the di~ease. nntl is imparted to other individuals by direct contagion. ~uch con- tagion tnkes place either by absolute contact, snch as kissing. or by the spraying droplets or discharges of the nose and throat. tb in coughing, speaking, singing, or snoring. While there is a possibility that the organism might be spread by the contamination of cloth- ing, or of floors and walls, the extreme susceptibility of the menin- gococcus to drying renders such methods of spread quite unlikely. 606 CUMMING- CEREBRO-SPINAL FEVER. Yol. Xt. The fact that by fnr the greater number of carriers hnve normal throats and therefore no excessirn discharges from the no-,e or naso.. pharynx and that there is no inclination to spit is an aclDfJSG-CEREBR0·:5l'IX,\I. PEYER. \'ol XI. Any trocar :uHl cannul11 at lea::;t 4 inche" long will sene, if no :-pecial in::-trument i:-. at hantic a nil Foster m.r! Ga ~ kt:'ll adrnrn·e three reasons for making such practice ~cnernl : eac:e in making the pundure, increasecl amount of fluicl secured and temporary relief from intolerable pain. General amcsthesia ,, ob- \'iou~ly adYisable in active delirium and in cases wi1ere lumber p11nc- t11re has to be repented from day to atmcnt. The normal cerebro-spinal fluicl is a perfectly clear. colorless liquid of low specific gravity, being usually 1.001. with allrnlinc reaction. The normal pressure is such that when lumbar puncture is performed, the fluid flows nt the rote of only one drop t•\·ery two or three seconds. and never more than 10 c. c·. can I •e ob- tninecl: often lesR. Reduction obtained with Fehring's solution j._ appreciable; nllmmin is usually absent. The cellular con~titt1l•nt, of n normal :fluid are extremely scanty, averaging about one to :'enn lymphocytes and an occasional endothelial l'ell per cubiC' millimeter. Polymorphonuclear cells are absent in the normal fluid. Change in the cerebro-spinal fluid in epidemic meningitis con~i:-t in irn:1·cased pres.'-un•, alteration in chemical and ccllulnr constituent'. Increase of pressure is present in almost all stages of the rlis('af:'e. HNI on the first clay, and is often so great that the fluicl !"purts out and a~ much ns 40 to 70 cubic centimetc>rs nre often obtained in acute 1 Cl')Dil::\G-OEREBRO-SPl::\A.L FE\·En. 509 In wme d1ronil· t•a:-cs no Huid can be withcl111\\ll. :111<1 this ~n!.!C'· is of :-;c1;ou:- import a.., it indicate;; occlu..,ion. Hemrn al of ccn~bro- ~Pinnl f111icl can he continued .f'afely until the flow i:- l'c111al to or e,·en lc...,s than normal. In the acute stage the appenraIH'C of the fluid is profoundly altered. " 1hen tir--t withclrawn it j, 1·louded or opaJe ... - cent. or it may contain fragments of flvcc11lent material. 'Yhen tillowcd to ... tantl the "ells to which cloncline::.s i::, 1lue -.iuk and the :-upernntnnt fluid is clear. In acute stnges a small ::unount of pu ... h, of fu mm ule, a lnrge amonnt of nnfn rnrnblc, import. Tu cu~e,.; "hich do nut respond to treatment pus increases. while in lnh·r :,la~e of fn' ornhll' cn::.es the f111i i:- c:;.-.en- tml for n eomplete din:.,rnosi .... 1'crl111iquc.-,Yhen practicable a few cubic c:enti111ctcrs of the tluid .. iouhl he centrifuged and smears made of the sediment stained with methyknc blue or cal'liol-gcntian violet. arnl exnminecl 11ndc1· nil- immer-.ion ll'ns. It may be necessar~' to examine many field:- or e\·en many sliJes. If the organisms arc easily funnel in cn·r~ field, the outlook is gt'll\C and especially if many extracellulnr org:rni--111:- are pre:-enl. Staining by Gram's method should be done. The organisms are Gram-negative diplococci ancl they arc typi- rally fonml in polymo1·phonucleur cells, though in fnlminatin~. ' cry ~rn,·e. nnd in suppurating cases they are also extracellnhw. The cerclJro-spinal fluid should be placccl in tlw :31° incubator o\el'lli!!ht. m; a film from the sediment the nrxt morning will often show mcni11goeocci. mninly extrr..cellular, eYen when no11c we1e fouurl nt first. Cultures ~hould also he maential eletrent. Tl1e fn.•e-.t growth. perhaps, may be obtai11c1l h~· !;CC1li11!! 011 n~ar plate:- on which about three drops of fresh blood hnrn Ul'Cn n1hled . • \medium which has been iound satisfactory i..; ma1le a,., follow;;;: To ;, part!; of n n11trient, 2 per cent neutral agar rnade of hcef i11fusion. with 1 per 1•cnt glucose, is added at 50"-:i~ 1 part of -,Jwep sernm wuter (shet•p -.ernm 1 to water 2). X cntrality i., te-.tl'I 1 agn in4 phenolphthn le in. 510 Cl'l\ll\IIXG-CEREBRO-SPIN AL FEVER. • The gluco:,c agar i:; :-lerilizcd for lt hours in streaming steam and the serum water i-. autoclan~tl for 15 minutes at 15 pounus pre::.::.ure. The serum water awl agar are mixeu shortly before using with nsep. tic technique aud tubed. The tubes·shoultl be incubated previou:; t-0 use and kept moist at all times. Thi-. medium is comparafo &ly clear and permit:; ca y recognition of colonies on the plate. It is well adapted to the growth of the meningococcus so that visible colonies appear in six to eight hours and de,·elop from 2 to 3 millimeters in diameter oYernight. In the absence of sheep serum an excellent medium can be maue by the addition of laked human or rabbit blood to the above-de.-;cribed agar. The blood is laked in distilled water and added to the meltt.'.era in lo,~· di ~ution ; (b) no agglut mat10n by normal sermn. but partial ugglutmntton in dilu- tion:-: not c..-xceedinj! 1/100 by one or all ~tantlard sern (group " ng:rlu. tination "): (c) no agglutination by sem. normal or stundnrd. For further identification: aSC: galactose, mannite, clukite, dextrin. ancl inulin. ~1. fin n1.5 IJ I doe:-. not ferment saccharose. The gonococcus ferment... !!lucm;c only. The ~I. calarrhalis ferments none. The ml'11in!!ococ- c11:-; ferments gl 11eose and maltose ancl is negative for other Htgar~. Tht• USC' of glucose (dextrose) maltose, hP\'lllose, mnnno-.e and !'nccharose is sufiicient for differential 1rnrposes. One c. e. of n 10 per tt'llL ~.;olntion of et1ch sugar, previously sterilized by fractional UH.'thod. should be addccl to sugar-free n~nr meclinm with a rea<'tion of +O.:.! to +o .. ; ( phenolphathalein). to which jo.; ndded enough pur1• ;.terile litm11s solution to gi>e u decided blue tint. ThC' plnt<' or tube::- ::,houltl be obsen·ed for seYerul days for the production of ndd. The !!lul'o ... e re~\ction i1trpo-.c. Co11t rol of the disease may be cliscu~-.ed under menqures for the c:m·e of the patient and measures to prevent spread of the cli:;ea e. t '11rat i I'(' .-The most important an cl possibly essential nwn ure for the cnre of thr patient is the e11rly or immediate dia~nosi" with Jumhnr puncture and release of cerebro-spinal (luicl. with earl·· nd- mi11i:strntion of suitable nntimeningococcus thernpentic sernm. en- 1lo11bte appear. :t:::. well as when indientecl by hacteriolof!ical ohserrntions. Serum, either pol.n illent or the agglntinatin• for the infoctin!! type of organisms. l'honkl be used daily until the feY'-'l' tlisappc·nr-.. _\clminbtration of serum should follow the esc·ape of cerehro-'ipi11al fluid. ::,hould be of IC'ss quantity than the amount of ilui1l "ithdrnwn. nncl the serum :-ho111c1 lw ~iYcn ~Jo,rJy, l rt>frrahl,\ h,,. gn\\ it:-. .\n symptoms of vngnB inhibition, C'heynes-Stnkes lJI'<'nthing. ehan:.rt·~ in rhe pupil~ or fall in blood presure, threna"l'cl upon know! ·il~c that the mcningococcus is short lived outsicle of the body: thnt infection occnrs only by direct conyeyance of the na~ophnryn­ geal secretion from a patient or from a carrier without clinical mnnife~tations of the disease; that a patient is simply n carrier who has. thrrmgh lack of resistance, deYeloped clinical symptom-.: anrl that ~udden changes in meteorological conditions, particularly in cold weather with lack of proper clothing, overcrowding-. nud h:ul ,·entilntion, as well as other acute diseases, are concluci,·e to bringing nbout the necessary lack of resistance . • \ o:ocm ns a case of cerebra-spinal fever has been disco,·erc.1. all contncb should be isolated and swabs made from the nn'-ophar~·nx. particularly the region in which :1clenoids are found. Salim i" nutagoni~tic to the meningococcus and also it cont:iins rnnfusing organi:-ms. therefore care is necessary to preYent touching the tongue or fnuces with the swab, which should be of stiff wire with one-half to three-fourths of nn inch of the end bent to nn angle of about 45°. 8:>51-17--G 514 CU::\r:\HNG-cEREBRO-SPIN AL FEVER. The pnrt oi the swab which hns been rubbed thoroughly on the proper region should be sown immediately on the serum agnr plate previou:-,ly described. Use of the West tube, a glass or metal tu~ containing the wire and swab: may facilitate the operation and lessen the risk of contamination. Contacts which show no menin- gococei on the first examination may be released if they have had no other e..~posure. In udrlition to the known contacts, as many possible contacts as practicable should be examined. The circumstances surroundin<7 each case must necessarily suggest the extent of such procedure. If a patient hns been received within two or three days and JllJ pre- vious cases have appeared in the vessel or on the station, manifestly the probable extent of contact would be more restricted than if he has been on the ship or station for several weeks. During convalescence the meningococcus is generally prl'sent in the nasopharynx in progressively decreasing numbers for from one to three weeks, bnt in a considerable number of convalescents the or- ganisms may persist for months. Such individuals are "clronic carrieri::." In addition to these persons, contncts and other c· rriers whose nasopharynges contain the meningococci may be divided into temporary and chronic carriers. Fortunately most carriers-per- haps 0 to 90 per cent-fall into the temporary class, the organism disappearing in from a few days to three weeks. Unfortunately there are others in whom the meningococcus persists for months. Despite the evidence that varying numbers of the population of communities free from cerebro-spinal fever are carriers, there is con- clusive evidence that carriers are responsible for the dissemination of the disease and they should be isolated until the organism disap- pears. They i::ho11ld be 1soh1ted, q1rnrte1·erl, messed, and rillowed in- door communication in small groups only, the smaller the better. of 9 if possible, and of not more than 25. There is bnt slight danger of transmission during drills or other contact under discipline in the open air. They should be kept in the open air, given exercise: and be well clothed and nourished. It would seem that an organism of ::;uch low vitality as the meningococcus, which is easily killed by desiccation, by weak disinfectants, and even by saliva, could be read- ily caused to disappear :from the nasopharynx of a chronic carrier. but the great number of remedies advocated in itself suggests failure. Of all the remedies tried by the British authorities and tried at Chicago as well as at other training stations, including the Gordon- Flack zinc sulphate spray, bicarbonate of soda, iodine, glycerin-and· iron mixture, Dobell solution, and menthol, none have given con- sh.tently good results. Vaccines and sera nJso have apparently failed. The use of chloramine in 1 to lt per cent solution has been encourag- ing to the British workers, and it is possibfo that dichloramine-T in ~o.4. BARBER-DENTAL PATIENTS ABOARD SHIP. 515 cblorinnted eucalyptol (1.5 to Z per cent solution) mny be of service. The difficulty appears to be the impossibility hitherto of reaching the crypts and recesses. The organism frequently temporarily disap· pears after treatment only to reappear after n day or two; hence no culture should be made until at least 48 hours after treatment. The proper procedure woulU appear to be to cleanse thoroughly the unsophnrynx daily with some disinfectant which will not inflame the mucuous membrane and to build up the general re:;i:;tance by plenty of nourishment, moderate exercise, and exposure to sunshine and fresh air. In military organizations it is important not only to detect anl should be segregated in small groups. All personal contact should be reduced to the minimum, and possibility of mess gear and drinking utensils se1Ting as conveyances of moist secretions from the nose and throat should be borne in mind. SYSTEM IN HANDLING DENTAL l'ATIENTS ABOARD SHIP. Dy R. BAllBklR, Dental Surgeon, United Stales Nuvy. The many and varied activities necessary to sustain the li res of the thousand or more men and officers on board n. battleship, the work of upkeep of the ship, and the numerous all-important drills and eser· ci,es combine to make the organization of the ship highly complex. Lack of proper system in any one of the activities means that the efficiency of the ship as a whole is impaired to a certain extent. It j,, therefore necessary that all lines of work be systematized in such a manner that the highest efficiency be attained. The dental officer aboard ship finds that as yet no pro,·i!'ion has been made for the routine handling of dental patients. In planning such a l'y4em with a view to efficiency the following point~ are con· "'iden•d: First, that the system should enable the dental officer to rcnECTrcrT. ~[EI>TCAL DF:P.\RTM E~ T. • --------------------· 101-- --------------------------------------- --------• rate ________ , (Lnst name. Ill-st name, middle Initial.) is l"<'C >mmC'IHletl for dental treatment. Dental recortl sent. Health re<'ortl contains no dental reco1·u. Sm·gcon, U. S. N. (Pnllcot will tl\ke this slip to tbe dental opcmtlog room nt once.) r;o. 4. BARBER-DEXTA.L PATIENTS ABOARD SHIP. 517 It is ne1..·c;o;::o:uy that the dental officer be gi>en the patient's name n:- it appears on the health record in order that the name on the dental reconl nnd health reconl be exactly the same. Frequently when a 111311 i:- a::;kl'd his name he does nut giYe it ns it appears on the health record. The patients come to the dental surgeon immee treatment. This is nec- ""!'ll ry on account of the large number requesting treatment. Before noon of each day appointment slips are made out on the form gi,·en below for men having appointments during the following day as shown on the nppointment book and delivered direct to the patients by messenger : U. S. S. " CoNNECTICUT." MEDICAL DEPARTMENT. ------------------------------· 19l __ To: Division Officer, ---------- Division. It ls recommended that --------------------· rate ----------· be sent to the dental operating room at -------- M, on _______ ...., ----------------· lOL_, for dental tt·entment. Dentai Surgco1i, U. S Y. (Patient will bring this slip to the dental operating room at tlm\' 11peclfled.) The man receiving such a slip takes it to his division officer, who nppro,·es it. The diYision officer is thus informed that the man hns 518 BARBER-DENTAL PATIENTS ABOARD SHIP. an appointment for dental treatment nncl, when nec~ary, nnnnge. ments may be mncle for his relief from duty for the time of his appointment. By not giYing the::c slip:; until a dny before the appointment there is n'ry little chance for slips to be lost nnd np- pointmentg forgotten. This appointment slip, signed by the dental officer and approYed by the diYision officer, is considered an order to the man to appear in clean clothes, at the dent!ll operating room at the time specified' and a man failing in this i_._, liable to disciplinary action. Dentai treatment is not compulsory: but when a man voluntarily applies for dental treatment he is required to haYe done such treatment as the dental officer prescribes and to continue to keep his appointments until discharged by the dental officer. Were it not for this rule mnny men would £ail to return for completion of treatment nft('r hay. ing been relieved of pain. One hour is the time usually allottend1 paticmt ha Ying an UJJ})Oint mcnt during the followlni::- ,Iay. The pnUPnt shall take tl1is noti<'e to his Dii·ision Offlcc1·, who will sign It. This notice is au order to nppenr, in clean clothes, at the dental opera! Ing i·oom <1t the time speeiflcd. A mun haying an appointment for dentnl treatment ls conslllered as thouf!h he Wl'l'l' on the sick list autl is exeused from all work nn.J clrill for the time of his appointment. It is to be distinctly unuerstood that the Dental Officer shnll 1Je the sole judge us to what treatment ls nece~s1u·y (Art. R 2001), and men n1111J)·in~ :!or dental treatment will lJe requlrecl to have done such treatment as he prescribes. ApprO\'l'enient). Officers are treated only xo . .J. CRANDALL-BARIUM FORMALIN METHOD FOR DISINFECTION. 519 during those hours, and enlisted men's appointments are thus not interfered with. It has been found unsatisfactory to make appoint- ments long in advunce for officers. The list of officers under treat- ment is ne,·cr \'cry lnrge. The officer whose name is nt the top of the list is notified by messenger about an hour in adrnnce that he js wanted by the dental officer at a certain time. If impo. ,;::ible for him to keep the appoil!tment the officer so st.lt :-, and the next officer on the list is notified for the same hour. Officers usuallv are nble to say positirnly whether or not they can keep an appointment within on hom or less. By continuing to make appointment;; by mes~enger the dental officer is able to get as many otliccr patient:> us he can treat during the officers' hours. After a dental ofliccr has been on a ship for some time the number oi ollkers re"c111iring dental treatment will be so reduced that the time set aside for officers may be shot tened and more hours assigned to enlisted men. The system of handling dental patients aboard ship n~ has been outlined has the following features: There is a certain definite time of dnv when men may recefre urgent treatment and htwe appoint- ments ar:signed and be returned to duty promptly. Records l'eceive their proper attention and a check can be made by the medical officer on the number of patients received each day. No time is lost by the dental officer nnd thus more patients can be treated. The activities of the ship are interfered with to a minimum degree. During the greater part of the day not more than one man is taken from his work and then only for an hour. It is hoped that those dental officers who are aL thi::; time having their first experience of ship life ma,y find some helpful suggestions m thl' above which will facilitate the organization of their work. BARIUM-FORMALIN METHOD OF DISINFECTION. By R. P. CRANDALL, Medical Director, United States Nnvy. When the prohibitive cost of potassium permanganate made th1: perm:mg·mate-formalin method of disinfection no longer available, the Medical Supply Depot, New York, communicated with various likely sources of information to ascertain the possibility of adopting other satisfactory means for liberating formaldehyde gas from its aqueous solution. From the replies received it was evident that no other all-chemical process was known to be as suitable as the per- manganate method. The lime-formalin and the Dixon methods both h:n·e supporters. However, it requires no exhaustive study to de- termine that the efficiency and adaptability of each are not to be eomparcd with those of the permanganate-formalin method, espe- cially nuder :-cnice conditions. 520 CRA:SOALL-BARIU:\1-FOR:\L.\LI:S ::\IETHOD 01'' Dll:il!U'ECTIOX. \'ot. XI. A nilable information on this subject being rather limited. the depot undertook an investigation with a view to finding n cheap ~fe, and efficient process for the rapid e,·olution of formnldehvde' together with n required degree of moisture. .As a result. the d~P<>t developed the "barium-formalin~· method, which is as follows: 1 pint snlutlon of fornialdehyde (U ~. P.). H (ln is first transferred from its bottle to a pitcher or other suitable container, from which it is quickly poured over the barium dioxide. At 011ce close the room and keep closed for 6 to 12 hours. The method outlined above on repeated trials gave gratifying re- sults and showed conclusively that barium dioxide is in all respeets as efficient as potassium permanganate for liberating formaldehyde antl water vapor from formalin. An inexhn.ustible supply of barium dioxide is obtainable in the American market at n. price ranging from 30 to 50 cents per pound in pound bottles. In large quantities the price would be about 30 cents per pound, while potassium permangn.nate is aL present quoted at $5.uO per pound. The price of formaldehyde solution (U.S. P.) is about 25 to 30 cents per pound bottle. • The ataodard Medical Department bucket Is of 3·gallon capacity and may be em· ployed with amounts of material necessary to disinfect 2,000 cubic feet of space. ~o dllllculty will be experienced In washing real.Jue out of bucket. HISTORICAL. OSWALDO CRUZ, 1872-1917. By WILLIAM c. WELLS, Chief Stntistlcian, Pan American Unlf.n. To one who has seen Rio the old controversy, centuries olanlo. In 1900 there were 295; in rno1, mu; in l!l02. 215; und in 1003, :mo deaths from bubonic plugne in the city of Rio proper. In this Inst year the deaths from pl1lg11c wen~ nearly two- thirds a:-1 many as the deaths from yellow fever. On the outln'l'ak of the plnguc the municipality of Rio determined to create an estab- lishment for the preparation of antiplague serum and Prof. Baron Pedro Afl'onf:o. one of the bcc;t-known medical authorities in Brn.zil. undertook the inauguration of the enterprise. Prof. Pedro Affon,o went to Paris and consulted Prof. Roux, of the Pasteur ln!:>titute. n-- to the ehoice of a French specialist to whom should be giYen tl1e direction of the proposed establishment. The reply of Prof. Ronx wns that no French specialist was better equipped for undertaking thi" work than one of Prof. Pedro Affonso's own compatriots. u young Brazilian, Dr. Oswaldo Cruz, at that time e11gagcd in special lmC'tcriological work in the Pasteur Institute. Truly a prophet is not without honor save in his own country. o~waldo Gorn;nJes Cruz was born on August 5, 187~, ut Siio Luiz de P:1rahitingn, in the State of Sao Paulo, but removed to Rio in 1 'i2. He was the son of Dr. Benito Gon~ales Cruz, nt one time clir<:>ct< r genl.'ral of hygiene. Oswaldo Cruz obtainerl hi:- diploma in medicinP. in lSfl:? from the faculty of medicine of Rio. Immediately there!lfter he entered the X ationnl Institute of Hygiene. :founded by Prof. nochn Faria. and bPgan his studies in bacteriology. In 10::96 he 1'cnt to Paris anrl entered the Pasteur Institutl'. His \\Ork wn, mainly in the laboratory of toxicology and he became widel}' known to specialists through his experiments and studies in this field. He publi. he·l studies on the toxic properties of the castor-oil bean, n. method of discovering the· toxic properties of lighting gas. the Florence reaction and a pathologic history of poisoning by the cnstor-oil Lenn. The work of the American commission in Cuba in the sanitation of Ilnbana. "untiago, and other cities early attracted attention in 524 WELLS-OSWALDO CRUZ, 1812-1917. Vol.XL Paris. The ne\\ theol'y that the mo~quito was the yellow-fever con- Yeyiug agent, demon~trately convinced that the stegomyia mosquito wa::. the agent in the propagation of yellow fe,·er. He l1<:lieved that what bae years- until 1908. '·Give me the proper authority and a sufficient force and means to work with, and I will rid Rio of yellow fever in three years,,, he told President .Ales. To many this seemed a rash promise on the part of a young mnn just past 30 years of age, with no special reputation U" a yellow-fever specialist and no special knowledge of the disease or ib methods of propagation. But Cruz fervently believed in the re- sults obtained by the American commission in Cuba and in the theory that underlaid the work of this commission, and Ales believed in Cruz. Authority was given, new laws were enacted, money was pro- viclee been the other way. It is not nece~­ ~nry to make comparisons between the work done in Cnba nnd Pan- nmn and that in Ilio but it should not be lost sight of that Rio has a population much greater thnn the combined populations of Ilahann. Santiago, Pnnamn and Colon, and the work of Dr. Cruz wu::; not confin ·d to Rio, except in the beginning. It soon extended over n('nrly the whole of Brazil. His campaign against yellow fever was the 11101>t extended work of this kind that has yet been undertaken and it wns completely successful. When he did not himself personally supen ise tho work his assistants did or his methods were followed. The~e methods, as Dr. Vianna~ one of his chief coworkers has said, were tho-·e of the American commission in Cuba, modified hy condi- tions special to Brazilian localities. The O~wald Cruz Institute, so named by the Bra.zilian GoYernment in his honor, which was founded and organized by him and was until his death under his management, has acquired a reputation and a ~tnncling through its experiments and disco\·eries which has ex- tended to the whole scientific medical world. It is to he regretted. howen'r. that the work of this institute shonld be so much better known in London. Paris, Vienna and Berlin than it is in Xew York or 1Yn.;;Jiington. Dr. Cruz died in Rio, February 11, 1917, at the age of 44 years and Ci mouths. Truly a brilliant and useful life too early ended. .. EDITORIAL. TIIE )l:P.\OR ;\ILUENTS. It is doubtful if during the course of a long profcs:;ional career either the lawyer or the clergyman has such opportunities for observ- ing the vagaries of human nature as present themseh·es to the physi- • cian, and especially to the military doctor whose clientl>le is composeu almost exclusively of officers and men with whom he is in close con- tact and daily association. Civilian practitioners usually have social relations with but few of their patients. They see them in bed, on crutches, on the operating table but do not sit down to breakfast, lund1 and dinner with them, meet them at tennis ancl golf, nor con- tend "ith them for a high score at bridge. They do not live within a r ~tricted area where for weeks and months they see only the same faces and are able to watch and study their patients at play and at work as well as when stretched on the bed of languishing. In the case of the Navy doctor every one he meets in official and unofficial capacity among messmates and shipmates is a possible or prospecth·e patient or has been his patient. This is a feature of life on ship- board not without serious drawbacks from tho point of view of both physician and patient. That familiarity breeds contempt and that a prophet is not without honor save in his own country are old say- ings that can find no illustrations more apt than those constantly afforded by the conditions of life at sea. A former Surgeon General of the Navy, speaking at the final exer- cises of the medical school, urged on the graduates about to embark on their first cruise the importance of cultivating tact and circum- spection. a friendly spirit and a dignified bearing so a:; to invite rather than repel the confidence and good will of those with whom they were soon to consort in the restricted quarters of n seagoing vessel. In ciYil life even the most eminent practitioner can exercise but little selection as to whom he will treat and whom he 'vill not treat. .A specialist may restrict his labors to a certain field but can ill afford to discriminate in that field. The patient, on the other hand, is free to choose his attendant and often, if too poor to go to a great man's oflice, he can be treated in free dispensary or hospitnl ward by that 527 528 EDITORIAL. \ol XI same great mnn. On a ship the patient's situation is entirely differ- ent, and however obnoxious the surgeon ·s personality and whateYer be his reputation for professional skill the sick mun must commit himself to bis ministrations or go without attention. In spite of efforts to be nccommodating und the mo:-ot sedulous at- tention to cluty on hi::. part the ship·s surgeon will constantly be im- pressed by the frequency 'vith which both officers and men, from the captnin to the colored cook, seem to enjoy consnlting a pharnuu:isfs mate or one of the subordinates of the sick bay about details of health and minor ailments. There may be an element of pervcr:;enc-.s in !'Inch conduct but criticism should be reserved until all the feature;:: of the 8ituation have been considered . • \s a class we are prone to find anomalies of behavior in the sick uncl to ignore the fact that what an overwhelming mnjority of human Leings do under given conditions may be considered normal. .\t any rate, whatever the ethical aspect of an act may be, if it is in line with tmiYersal behavior, it must not be charged up us a pecu- 1 i:u·ity against any given individual. Doctors nre notoriously indifferent to the triYial complaints of patients. Business necessity and financial considerations lea l them to hide their contempt and many a man is described as taking "so much interst in his cases" because he has the acumen and the. self- control thnt go to bnjlcling up a good practice. Of a less circum- spect individual it is often disparagingly and unjustly remarked: ·· Y 011 ha Ye to be ha If dead before he will do anything for you."' To the practice of medicine in a military senice there is no b 1 ness !'ide in the ordinary sense of the term. ·when 30 days have cl 1pser- tion of the contract doctor that there is nothing the matter. From the surgeon's point of view there may be nothing the matter. but nlurm is always worth allaying, and the more grnunclless it · · the ~tronger the call for effort to that end. and if ignorance and prei 1dice appe;\l to his lmowledge and dispassionate jucl:;ment he rem r:- a rl'al $CrYice by dissipating them. How often we deceive ourselves! How prone we are to lay the flattering unction to our souls that because we do not coddle aml pet our patients l\S they magnify their trifling ills we ure hon~:;t and straightforward, maintaining a high ethical standard and scornina to make capital out of the meretricious devices of quackery. ~\s a matter of fact, the salaried surgeon, just because he is far remo,·ed from the suspicion of improper ends in view, is the one of all others • :-.o.4. EDITORIAL. 529 from whom n kindly manner and a gratifying ~how of interest may be expected and he is in honor bound to display the kindly manner nnd the interest. however little scientific n1lne the case may hold for him. Officer:. and men may sometimes hesitate to bother the doctor over n minor complaint through consideration for him. but oftener it i::. through consideration for themselve.s. The doctor may be ::.urly or facetiou .... whereas the Hospital Corpsman, grntifieere illness or accident. until the hour and article of death never seriously requiring the good offices of surgeon or physician, the great bulk of mankind is more or les · con- :-tnntly acquainted with one form or another of physical discomfortr- catnrrh: sore throat, terrifying stomach aches, depressing el- i11~ scientist of to-dny. This cold creature 0£ accurate ralcnlntions is nncxcelled in the laboratory, but at the bedside we want some one \\ell tinctured with the milk of human h.rinessels carried from the boiler. In addition to closets, 10 full-size drum shelves for sundries, a drum stool for plaster of Paris, :ind a folding side table are available for use. Ventilation is obtained by anterior and posterior overhead flaps, an electric fan and windows. Electric lights from the batteries can be used when desired. It is to be hoped that the necessity of these theaters will be realized and that they will soon be introduced into our own service. Prioleau- Shark bite. EFFECT OF SHARK B ITE. LATERAL VIEW. EFFECT OF SHARK BITE. ANTERIOR VIEW. 539 CLINICAL NOTES A DEATH FROM SHARK BITE. By P. F. P1uOLEAU, .\ssistant Surgeon, United States Navy. Some people have the erroneous idea that sharks will not attack man and as a general rule the noise or commotion of a crowd of individuals in swimming is sufficient to keep them aw3:Y· Since in tropical waters sharks are quite numerous it is important that none of the men should be allowed to go in bathing alone. Swimming in !;hallow water or, better, within the inclosure of a "shark net," as prodded on some of the naYal reservations, is to be ·encouraged. The U. S. S. Dale at the time of the accident waR anchored in Canacao Bay, P. I. About 5 p. m., May 31, 1917, E. E., water tender, attached to the U. S. S. Dale, started out for a long swim. nccompanied by one of his shipmates. E. E. was a most excellent swimmer and, after a time. his companion becoming tired and not wishing to go further left him, and he continued to swim alone in the rlirection of the open bay. About 5.45 p. m. a seaman on the U. S. S. '/If onte1·ey happened to notice E. E .. who was then some 200 yards from the ship. fall suddenly on hie: back and then give two or three dolent strokes in the water. At the same time the observer saw a shark in close proximity to the bather. It was not hard to conjecture that some accident had occurred, and a boat was rapidly lowered and rushed to the vicinity where the man had last heen seen. The body was recovered, but it was evident from the extensi,,eness of the "ound that the man was dead. Ile was then taken to the morgue of the rnited States Ka Yul Hospital, Canacao, P. I. . Nearly the entire abdominal cavity had heen torn a"·ay. lncleed, the wound extended from the ensiform cartilage nearly to the brim of the peh·is. Laterally, from the right mid-axillary line to the left mid-axillary line. The stomach, the small and large intestine, with the exception of a few feet. most of the liYer and bladder. hnlf of the left kidney and all of the large abdominal blood vessels were re- moved. The illustration shows the wound as it appeared a few hours after the accident. A portion of the ribs had heen taken out with the nicety of a costotome. Some of the skin along the edges of the wounn wus in ribbons and bore the imprint of the monster's li:eth. 540 YICKERY AXD ~lc:Ml:LLIX-AMCEBIASIS. \"ol. Xi E. E. was of large stature. He was about 5 feet 11 inche~ tall and weighed approximately ::wo pounds. Xo doubt if he had been of much smaller dimensions the force of the nttack might haYe hl•en sufficient to ha ,·e cut thC' body in two. DER!CATITIS PRODUCED BY MATCHES CARRIED IN THE POCKET. By W. E. EA'l'ON, Pas~ed Assistant Surgeon, United States Navy. With the onset of hot weather five cases of dermatitis were brought to the attention of the writer. With one exception the dermatitis first appeared on the front of the thigh upon the area covered by the side pocket of the trousers, the exception appearing on the chest beneath the ,pocket in the shirt or blouse. The area involved ap- pearer! pink-reel, with slightly raised yet diffused edges which tended to spread and seemed moderately infiltrated. At times there wns intolerable itching, and again this was entirely absent. Upon appli- cation of mild protective remedies the condition subsided, only to recur upon neglecting treatment. Upon inquiry it was learned that in each case the patient had been in the habit of carrying a box of safety matches in the pocket over- lying the area involved. Upon remornl of the matehes, washing of the garments, and application of soothing remedy the dermatitis at once disappeared. In three cases, upon the patient again return- ing the matches to the pocket ornrlying the previously affected region, the dermatitis recurred. In one case a dermatitis of the fingers of the hand and the eye on the same side of the body as the affected thigh was attributed to the handling of the matches and rubbing of the eye by the hand affected. The outbreak disappeared upon removal of the irritant. • In this connection attention is invited to the apparent impurities and poor qualities of the safety matclws now on the market. It seems probable that impurities were dissolved by the perspiration and in this way deposited upon the skin, resulting in an irritation and acute dermatitis. All cases became well promptly upon removal of the irritant. AMCEBIASIS WITH CONSTIPATION. By E. A. VrcKERY and J. J. A. l\Icl\luLLIN, Passed Assistant Surgcous, United States XaYy. In connection with amoobic infection in the Tropics it is interest- ing to note a symptom-complex which has received very little atten- tion in the literature. The symptom-complex so closely simulates that of chronic intestinal obstruction that a tentative diagnosis of ~o. J. BLOEDORX-GUXSIIOT WOt;XDS FROM DEFLECTED BULLETS. 541 intestinal stasis with autointoxication was made in the two cases herewith presented. The symptoms were practically identical in the two cases and were as follows: Marked and obstinate constipation, lasting for about a year: movement of the bowels heing obtained only with a cathartic for variable periods lasting from one to two weeks; rngue pains referred to the abdomen: with a little tenderness in the neighborhood of the crecum; loss of weight and appetite; lassitude; mild general malaise, with markedly sallow complexion. Both cases showed indicanuria. ~\.t no time was there any diarrhea. One case presented no history of acute attack, and symptoms were somewhat relieYed by the administration of Russian paraffin. It was impossible to obtain bismuth plates, owing to the lack of a suitable X-ray machine. The other case had a hi!'.tory of amrebiasis one year prior to symptoms and bismuth meal showed no intestinal stasis. It is interesting to note that amrebic infection can occur in its chronic stage with absolutely no diarrhea. a point not generally con- sidered in the diagnosis of the infection. The question of infectiYity from such a canier is an important one, as in one of the cases men- tioned the amoebre were found encysted, with but few motile forms. It seems probable that a symptom-complex of this kind in a patient returning from the Tropics would easily escape diagnosis and might well be treated surgically as a case of mechanical intestinal stasis, particularly as encysted nonmotile amrebre are not easily detected during a routine examination of the feces. We consider the adminis- tration of a saline purgatiYe as a necessary preliminary to microscopic examination in these chronic case~. as amn,;. l'MtiNI ,\sslstanl Surgeon, United States ~ary. The follo"ing cases may be of interest in showing the effect of bullets deflected and ricocheting after striking a steel plate. While practicing with a Benet-Mercier machine gun on the quarter-deck of the /{ cntuel~y the tripod supporting the gun gave way, allowing the muzzle of the gun to be lowered to such an extent that the bul- leb. in!'tead of clearing the deck: c:truck the water"\lay. It appears that from 9 to 12 hnllets struck the waterway in thif' manner. The muzzle of the gun "! s approximately 11) inche,; from the waterway during the firina and wa,., clirectee of Guam, age 22. life-term prisoner for murrler, first seen October 16, 1916, complaining of pain in left inguinal region, duration two months. Physical examination revealed what was then thought to be a moderately large hernia, easily reducible. Operation two weeks later, under ether anresthesia. Sac easily lo- cated and incised. Inside of sac was a pedicle of tissue, traction upon which caused a mass of cysts to literally flop out of abdominal cavity through internal abdominal ring. The two larger cysts were so arranged that abdominal pressure would cause the upper cyst to invaginate into lower one, while scrotal pressure caused evagination into the abdominal cavity. The pedicle and sac were carefolly dissected toward testicle; here the condition was so obscured by adhesions that it was impossible to state exact origin of tumor. In addition to the cysts, there existed a small piece of omentum adherent to fundus of sac, thus causing it to be a bona fide hernial condition. The sacs were filled with clear, straw-colored fluid. Careful ex- amination of the tissue by two pathological laboratories fails to clear up the etiology of same. For a better idea of the tumor, see illustra- tion. The recovery from the operation was uneventful. 544 TOUSEY-METHOD OF LOCATING BULLETS BY X-RAY. Vol.XI. llll'ERJOABLE DRESSINGS IN THE TREATllENT OF BURNS. Dy J. J. A. MclluLLB11, Pasded AsRlstant Surgeon, Unlted States Navy. Skin grafts are usually covered with rubber tissue or some other impermeable material. Is it not probable that the satisfactory results are sometimes wholly due to the retentive fabric placed oYer them? The uniYersal interest aroused by De Sandfort's ambrine recalls to mind the following case, treated in the naval hospital, Olongapo, P. I.: C. P., native fireman, first class, admitted April 18, 1916, scalded with live steam from a burst steam pipe while working in the fire- room of the "G. S. S. Pompey. Both lower extremities, scrotum, penis and lower abdomen involved in burns of the first, second and third degrees (Dupuytren's classification). Worst burns on inner and anterior sides of thighs. Picric acid was applled upon admission and morphine given to relieve pain. At the end of four weeks skin grafting was contemplated, as there was no sign of epithelial regeneration anywhere. Instead of apply- ing skin grafts, however, the burned regions were cleansed with warm salt solution and the affected parts covered with rubber tissue. Each morning the rubber tissue was removed, the burns were washed with salt solution, covered with freshly sterilized rubber tissue and bandaged with muslin. ~\.fter four days islands of epithelium were apparent everywhere, and the burns rapidly healed without scar tissue, except on the inner surfaces of the thighs. A small area on the inner surface of the right thigh did not heal after three weeks of treatment. There the granulations were exuberant. Silver nitrate was applied and healing promptly ensued. Too much enthusiasm should not be aroused by a single case, but it seems to me that in warm salt solution and impermeable dressings we may have an effective substitute for ambrine. A lllETHOD OF LOCATING BULLETS AND OTHER FOREIGN BODIES BY THE X-RAY. By Dr. SI~CLAIR 'l'Ot::SEL I ham made a careful study of the 57 methods of X-ray localiza- tion of bullets and other foreign bodies which the European war has brought forth. Such a large number of remedies naturally sug- ge ... ts the possibility that none of them is a specific. including 1me of , .. No. 4. TOUSEY-METHOD OF LOCATING BULLETS BY X-RAY. 545 my own published a number of years ago. I have therefore made a new attempt to solve the problem, with the following result: As with all other methods, facilities are required for placing the X-ray tube at a measured distance from the plane of the photo- graphic plate, and, after the first exposure, displacing the tube a measured distance in a plane parallel to the plane of the photographic plate and making a second exposure upon the same or another photo- graphic plate. The only special apparatus required for my new method is an 8 by 10-inch piece of galvanized-iron wire netting, one-eighth inch mesh and with the thickness of wire such that there are seven meshes to the linear inch. This is laid upon the photographic plate while the exposures are made, and the squares show unchanged in the finished picture. If the displacement of the tube is one-seventh of the distance from the anticathode to the plane of the photographic plate, then the number of squares that the image of the foreign body is dis- placed in the second picture will show the number of half inches that the foreign body is distant from the plane of the wire netting. For the thigh or any part of the trunk the distance from the anticathode to the plate might, for example, be 21 inches and the lateral displace- ment of the tube 3 inches; while for the leg or arm the distance might be 14 inches and the displacement 2 inches. Here again each (one- seventh inch) square over which the image of the foreign body is displaced in the second picture will represent a distance of one-half inch between the plate and the foreign body. In addition to the sheet of wire netting, a small lead marker of a uniform and distinctive character, like a small ring, for exmaple, should be fastened to the skin with adhesive plaster at a place where the skin will be in contact with about the middle of the wire netting when the exposure is made. Before this marker has a chance to hecome displaced its exact position should be indelibly marked upon the skin. A lead serial number should be laid upon the plate in- variably at its lower external corner. This is very important for identifying the picture and avoiding any uncertainty which might result from the plate being film side up or glass side up. The letters "R " and "L" (right and le!t) in connection with the serial number will be of occasional value, but the essential thing is to mark the number on the lower outer corner. The same serial number had better be indelibly marked upon the patient's skin. As a rule the two exposures had bette1' be upon the same plate and each exposure had better be of the duration and intensity which would be required if only one picture were to be made. If for any reason separate plates are used, a stereoscopic plate holder is an inexpensiYc and nonbulky apparatus. The lead marker near the middle of the wire netting, 8551-17--8 546 TOUSEY-METHOD OF LOCATING BULLETS BY X-RAY. Vol. XI. the serial number in the lower outer corner and the wire netting itself should not be displaced, ns they are to identify the position of the image of the foreign body upon both plates. Of course the patient's position is unchanged. The advantage of my new method lies in the small space required for the apparatus and especially in the absence of any mathematical calculations. It would be of great advantage for the X-ray operators to acquire practical experience beforehand with this method upon different parts of the human body employing the X-ray apparatus that they are to use in actual service, so that the pictures may be perfect from the start (of course this applies to any method). PROGRESS IN MEDICAL SCIENCE.5. REVIEWERS. Medical Inspector J. C. PRYOR, United States Navy. Surgeon C. N. FISKE, United States Navy. Surgeon C. FOX, United States Public Health Servl~e. Surgeon H. F. STRINE, United States Navy. GENERAL MEDICINE. HAI.DWIN, E. R. Latent tuberculosis: Its importance in military preparation. Cleveland Med. Jour., xvi, June, 1917, No. 6. The author defines latent tuberculosis as, first, "any and all old or recent tuberculous infections that are capable of producing clinical disease, bnt have never caused recognizable symptoms"; second. "cases whose symptoms were recognizable but nnnoticecl and tran- sient and now ceased." · Ho states that infection usually in the tracl1eu-l.mmchial lymph nodes occurs in from 75 to 90 per cent of ~'Olmg adults. These lymph nodes and mesenteric glands arc "storage places for the tubercle bacillus." The author reminds us that living tubercle bacilli have been found in the most calcareous remains of tubercle. The period of incubation of tuberculosis appears to be not longer than three months, during which time the organisms produce tubercles and remain encysted indefinitely or die. The author believes that no one is immune to primary tuberculosis infection if a sufficient number of virulent bacilli enter the body fre- quently and considers that the disease in the young adult!i usually is metastatic and the result of infection in childhood or youth. Physical, mental and occupational strains play their role in favor- ing the development of the disease. Mechanical factors tend to spread the disease from foci where living organisms have been en- cysted, "but do not act in causing fresh invasions from the· outside." The bearing of latent tuberculosis upon military preparedness is considered very important. The inability to recognize some cases, as well as failure to detect recognizable ones upon examination for enlistment, may result in the development of clinical tuberculosis in these latent cases, many of whom might almost be rejected upon his- tory alone. 547 548 GENERAL MEDICINE. Vol. Xl. The British and German reports concerning tuberculosis are stated to concur in the fact that little tuberculosis is acquired from infection in army service. " The germ enlists with the man " (Osler) and is merely reactivated. "\Vetting, cold, overstrain, trauma and hemorrhage are considered ('auses for the lighting up of latent infections. Chest wounds do not appear to predispose to any unusual degree. It is thought that care- ful, candid history and thorough examination of the chest and glandu- lar system would have excluded a large percentage of those who already have broken down in military service. The value of the various diagnostic methods in common use is discussed briefly and the author concludes that "the serum reaction with complement fixation" is of greater value than the tuberculin test. Those upon whom responsibility rests for sifting out the latent tuberculous at recruiting stations may gain a measure of comfort from the following pronouncement: "It is impossible for sanitorium physicians after prolonged observation to confirm or disprove a con- sidernble percentage of suspected cases." (J.C. P.) COLE, H. Suggestions concerning the prevention and cure of acute lobar pneu- monia. Am. J our. Pub. Ileultb, June 1917, Yii, No. 6. The author reports briefly some of the late observations and con- ceptions concerning prevention and cure of acute lobar pneumonia and includes a resume of some work done at the hospital of the Rockefeller Institute. He emphasize$ the fact that over half the cases of acute lobar pneu- monia occur between the ages of 20 and 50 years, " the period of greatest activity." Many laymen and physicians are prone to regard pneumonia as a disease of the very young and the aged. In discussing the recent observations concerning pneumococci, he calls attention to the several groups which until recently have been classified under the general term " pneumococci " and shows that acute lobar pneumonia may be caused by any one of several groups or types of organisms having definite immunological and less de.finite morphological differences. About 65 per cent of the cases of acute lobar pneumonia are caused by pneumococci of types I and II, types which are "immunologically quite distinct and have definite, specific characters." The mortality rate among cases infected by these or- ganisms is 25 to 35 per cent. The organisms constituting type III are those having very large capsules, forming sticky exudates, and are known as pneumococcus mucosus. This organism causes pneu- monia in only about 10 per cent of the cases, but of the cases caused No.4. GENERAL MEDICINE. 549 by type III the mortality rate is at least 50 per cent. Group IV em- braces different strains of pneumococci not falling in any of the aboYe-mentioned three groups. About 25 per cent of ca,,e.c; of acute lobar pneumonia are produced by this group~ and its rate of mortal- ity is low compared with the other groups, namely. 10 to 15 per cent. "Most of the pneumococci found in mouths during health belong to group IV." Of 942 normal individuals studied in the ho,-pital of the Rockefeller Institute, 450, 47 per cent, were found to harbor pneumococci, and group IV claimed 345 out of the total. Types I and II appeared in 56 instr.nces. In all but three of the case::. in which types I or II were isolated from normal incfo·iduab. the healthy individuals had been in close association with a per~on. sick of pneumonia caused by the same type of pneumococcus. In study- ing the length of time convalescents or healthy carrier::; might harbor organisms belonging to types I or II it was found that in mo.c;t cases the organisms belonging to these types die out in the mouths of con- valescents within a few weeks. The longest time in which any organ- isms have been observed in the mouth of a convalescent has been 83 days. The same facts hold good concerning the persistence of ty~,. I and II in the mouths of healthy carriers. Study of dust in houses where pneumonia was present and in houses where no known cases of pneumonia had occurred showed the following interesting results: From 175 specimens of dust from houses which had contained pneumonia due to type I or II. 73 spec:- mens showed pneumococci, and o:f this number 47 belonged to type.s I or II. In only two cases did the type of pneumococcus :found in the dust fail to correspond with the type isolated :from the patient. Sixty-two specimens of dust from houses where no cases of pneu- monia were known to have existed were studied. Of these specimens 18 showed pneumococcus and only 1 was o:f type I or II and in this case the "known carrier of the corresponding fixed type was found to be visiting at the time." Two small epidemics were inwstigated and it was shown that a fixed type organism was responsible, car- riers of the same type of organism were found and the same type of organism was found in the dust. This evidence all tends to indicate that infection occurs either directly or through healthy carriers. Concerning group IV the author remarks that the cases produced by this group, which is commonly carried in the normal mouth, may be autogenous, as all infections with pneumococcus originally were belieYed to be. Infections from type III, which causes the most severe pneumonill l\re somewhat baffiing in the effort to discover their source. In an examination o:f 450 healthy carriers group III appeared 8:J time5: "and in practically none of these persons could any association with cases of pneumonia due to the same type o:f organism be discovered.'t 650 GENERAL MEDICINE. \'ol. XL It has been proved that these healthy carriers may harbor group III organisms even for years, and as yet no difference of any character has been found between the type III organisms found in disease and those found in the mouths of healthy carriers. 'Vith reference to preventi•e inoculation the author appears to think that ··among troops pre,·cnti•e inoculation might be tried with considerable hope of success," although the results of its use in ci,·il population hitherto ha•e been disappointing. Concerning serum treatment the author notes the difficulties in determining the type of organism present before administration of the specific serum. He states that a diagnostic method has been devised which "is sufficiently simple to be carried out as a routine measure in any well-equipped laboratory," but does not describe the method. Against pneumococci of type I a serum of a high potency has been obtained; against type II a .serum of " considerably less power"; against type III a serum of very slight protective power. Since group IV is a group containing pneulnococci which can not yet be placed in fixed types according to present laboratory methods, it has been impossible to prepare specific protective sera. The serum treatment of acute lobar pneumonia appears to be most satisfac- tory in treating the diseases caused by pneumococci of type I. '' In the ho:opital of the Rockefeller Institute 103 cases of this type have now been treated with but 8 deaths." The New York City and State Health Departments are now determining the "type of pneu- mococci present in specimens of sputum sent to them for examina- tion." The author recommends: 1. That pneumonia be made a reportable disease. 2. That patients be isolated, sputum sterilized and that the rooms O<'cnpied by pneumonia patients be thoroughly cleansed " at least with soap and water" (if not disinfected). 3. That for statistical purposes health departments should deter- mine the type of pneumococci in pneumonia cases. 4. That utmost speed be exercised in indentification of the type of pneumococcus in a given case when it is intended to employ serum treatment, the greatest benefit being obtained by the earliest possible administration of the serum in appropriate cases. In cases treated with serum the author states 250 c. c. have been nece.'-sary in the average case. This large amount causes the manu- facture to be very expensi•e. No established standard of potency for this serum exists at present. Effort is being made to establish :mch. The author states that in his opinion a. thorough washin!? with soap and water is "Yery much more efficacious" than fumiga- tion in the matter of prophylaxis, and states that knowledge conceru- No.4. GENERAL MEDICINE. 551 ing per:::.istence of the organism in dust is insufficient. Type I dis- appears from the dust within three or four weeks. (J. C. P.) SJlITH, A. L. Perleche. Its bacteriology, symptoms, and treatment in 223 cases. Arch. Pediatrics, xxxiv, No. 4, April, 1917. "Perleche is an infection of the labial commissures, manifesting itself, first, by ii. maceration of the epithelium; secondly, by a desqua- mation of this tissue, and, thirdly, by a formation of shallow ulcers and cracks." While occurring chiefly among children the contagion is frequently conveyed to adults ( 16 cases, 7 being dispensary attendants). An anaerobic streptococcus was isolated from 135 cases, although other common pyogenic organisms may be present, and, in causing second- ary infection, starve out the anaerobe. Six times the author in- fected his own labial commissures with the anaerobe. Cold weather favors infection through chapping and fissures: buccal and nasopharyngeal conditions which favor increased ~aliva formation are secondary or contributing etiological factors. Treatment for this otherwise obstinate affection consists in relieY- ing conditions causing salivation, painting lesions with 50 per cent solution of silver nitrate and when dry the application of Lassar's zinc oxide paste. Spirits of camphor locally and tincture of bella- donna internally may be required. For secondary pus infections soaking crusts with 1-1,000 solution of bichloride of mercury fol- lowed by 5 per cent ammoniated mercury ointment will prove efficacious. (c. N. F.) CoPEMAX, A. l\1. The prevention and arrest of certain epidemic diseases in war time. Jour. State l\!ed., xxv, 1917, Vol. 4-5. In connection with cerebro-spinal meningitis the article states that in the early spring of 1916 it was decided, in Yiew of the possibility of wide extension of the disease, not only to isolate cases, but to segregate contacts and examine bacteriologically for carriers by swabbing the nasopharynx. Under this arrangement it wa:::. possible to release about 70 per cent of the contacts within 2-1 to -18 hours and the majority of the remainder within 2 to 4 days later. Those found to harbor the or.ganism were isolated until positive results were no long.er obtained. To perform the work a central cerebro-spinal laboratory was equipped and 37 district laboratories started or coopted for the purpose. 552 GENERAL MEDICINE. Vol. XL The culture material invariably employed was trypagar. The work of media preparation was performed in the central laboratory and supplied to the district laboratories as needed. For rapid trans- portation a motor laboratory was fitted up. Four specifically distinct types of the organism have been isolated from cerebro-spinal fluid, the serum prepared from one type being useless as a means of treatment in outbreaks associated with other types. Encouraging results have followed the use of a polyvalent serum. If the organism is isolated from the throat as well as the cerebro- spinal fluid, it will be of the same type. This also holds good for cultures from the nasopharynx of positive contacts of the case. This fact can be made use of in tracing possibly unsuspected carriers. The trend of opinion is that the disease is spread through contact with healthy carriers. As a prophylactic measure and in the treatment of carriers good results are claimed by nasal insuffiation of 0.5 to' l per cent of a solu- tion of chloramine or of 1 in 5,000 permanganate dissolved in normal saline. On a large scale promising, results have been obtained by requiring the men to remain for five minutes in an inhaling room the air of which is charged with steam and fine droplets of either a 1 per cent zinc sulphate solution in normal saline or, in the case of chronic carriers, 1 to 2 per cent of chloramine. Under beriberi mention is made of a "savory" tablet which is both antiberiberic and antiscorbutic. It is made up of a basis of steam-cooked pea flour with which are incorporated extracts of yeast and also of certain vegetables extracted at a low tempernture, to- gether with certain other flavoring constituents. These tablets are quite palatable and weigh one-half ounce, which is the prophylactic dose for one week, the two halves being taken at intervals of three days. (c. F.) AULD, A. G. New treatment for bronchial asthma. Brit. Med. Jour., l\fay 5, 1917. In a preliminary note the author refers to his belief, uttered in 1908, that a pure asthmatic attack is a reaction on the part of the lungs to a toxic substance, " either of distinctly pathological origin or else a product of normal metabolism which gradually accumulates in the blood." In the following year Auer and Lewis, of the Rockefeller Jnstitute, showed that the lung of the guinea pig in anaphylaxis presented conditions identical with those of bronchial asthma. They found the pulmonary distention to be due to imprisonment of the air in the alveoli from an intense bronchial construction which was No.~. SURGERY. 553 exclusi>ely of peripheral origin. The symptoms could be relieved or a>erted by atropine. The anaphylactic nature of bronchial asthma has since been expounded by Meltzer and many others. The author desired to use 'Vitte peptone in the treatment of selected cases of pure bronchial asthma with or without bronchial catarrh or t:mphysema. The '\Vitte peptone being unprocurable, .Armour's was u"ed. He began with one-third gram of peptone dissolved in about 5 c. c. distilled water at blood heat, injecting this (with due precau- tions) subcutaneously at an interval of three or four days during the fin;t week. The next week two injections of two-thirds gram were gi>en at similar intervals, and during the third week two injections of 1 gram in 7 to 10 c. c. water. This sufficed in !'Orne cases. In others 1-gmm injections weekly or biweekly were indicated for three weeks more. No apparent constitutional reaction followed. The author concludes: "In the limited number of cases tried the results have surpassed expectation. In several cases of moderate asthma the symptoms have become perfectly quiescent, while other:-: have greatly benefited. In one case three months have elapsed without recurrence. Sometimes the relief is very rapid, the patient experiencing relief after one injection. Where attacks of great severity occurred every two or three months, a few weeks' treatment beforehand has caused the attack to abort." (ED.) SUB.GERY. Huoo1::o;s, G. N. The surgery of amputation of stumps (an experience of 2,000 consecutive cases). Lancet, London, April 28, 1917. Until the outbreak of the war modern aseptic methods have meant a negligible number of amputa.tions in this generation. The experience of an earlier race of surgeons is not applicable to present circumstances, because they planned their operations for speed and the eventual use of peg limbs. The classical operations for the foot were devised before artificial joints had been introduced. Amputa- tions must now be done with the idea of ultimately employing a deli- cate and complicated artificial limb. Primary amputations are done to arrest infection, and ~o to save life. Further operation or radical treatment has commonly been necessary in England to prepare or improve the stump for the fitting of an artificial limb. The author aims to elucidate this secondary treatment and at the same time give the basis for action in the case of primary amputations. The cases seen at the Pavilion Hospital, Brighton, had experienced amputation at periods varying from two months to two years before coming under the writer's care. He makes this rough classification: (1) Good stumps not ready for arti- 554 SURGERY. Vol.XI. ficial limb; (2) stumps that have not healed after primary amputa- tion; ( 3) sequestrum formation : ( 4) sinus; ( 5) bad scars and ecze- mas; (6) pain or tenderness; and (7) joint contractures. Three months is the minimum time in which an amputation stump can be made ready for an artificial limb, and then only if a tight bandage has been worn and massage given daily. These measures accelerate the shrinking of the stump. Unhealed i::.tumps are usually the result of so-called guillotine amputations, or those in which the flaps have not been stitched up. These should be treated with continuous skin extension from the earliest possible moment until healed or operated on again; continu- ous extension for a few weeks will almost cover such a stump. Every infected stump, after healing is well advanced, suddenly shrinks and skin becomes loose. This is the time to refashion the stump. The time for this varies, but two or three months or longer are required for the thigh. It is sometimes possible to remove the scar and bring the skin edges together without shortening the bone. The importance of a few inches of bone can not be overestimated, and it is hardly ever neces::;ary to remove more lhan one-half to ll inches. Other rP-asons for waiting are the improvement in general health and the higher resistance to infection developed by the patient. Many bad results are due to operating on guillotine stumps in le:;::; than two months after the original amputation. Mmy of the cases of necrosis of bone occurred in guillotine 1 nless repeated attempts have failed. When silk is the cause of a sinus there are often several pieces. In one thigh stump 17 silk ligatures were discharged in three months. Four or fiye is a more usual number. ~luch harm is done to a stump by exploring for silk. ~ilk should neYer be used for ligatures on amputation stumps. It SURGERY. 555 caused 40 per cent of the sinuses treated by the author and prolongs and increases pain. X ecrosis and foreign matter are localized by the aid of X-rays and the remarks under;, Sequestrum" apply. The Jong septic track in scar tissue is hard to diagnose, and can only be demonstrated by exploration. "\\hen no foreign body is found, excise the skin around the sinus, remoYe deep portion of scar, sew up wound. Packing the wound and attempting to obtain healing from the bottom often leads to a bad puckered scar. Pain and tenderness of stump is due to: (1) :Xerves adherent to ='car; (2) bulbous nerves; (3) sequestrum in new bone; (4) spurs of new bone ; or, ( 5) chronic abscess . • \.dherent nerves (result of not shortening the nerves at time of amputation) always have to be removed. As bulbous nenes vd1ich no not adhere to the scar as a rule become painless in three or four months, wait that long before removing. On the other hand, bulbous nenes which are not tender or painful may become so after three or four months. Bulbous nerves may cause extensive symptoms such as large areas of hyperrosthesia. In one case it caused epileptiform fits. Spurs of new bone are common and every now and then cau~c pain and require removal. The large amount of new bone formation in stumps that have been infected is striking and it often takes ,;n fan- tastic shapes and follows muscular attachments and sinu&'s. It is important to be sure that pain apparently due to a spur is not caused by a bulbous nerve, as the spur alone does not often cause pain. Often where a diagnosis of bulbous nene is made a small abscPss will be found instead. It may be' around a ligature or han~ no ap- parent cause. Fic:lrs in stumps that have been infected are clue to insufficient coY- er:ing of bone or to too much co-\ering. If the scar is very large and liahle to ulcerate, in the case of insufficient covering, use skin exten- :':ion and then excise the scar. In the second group, if the edges are 'er.\' puckered or turned in~ the scar is liable to eczema, and after wearing an artificial limb is apt to break down through the softening induced by decomposition of sweat. In excising a scar refashion the deep parts as well as the skin, or the condition will relapse. The commoner contractures are: (1) Flexed knee. (2) flexed and nbducted hip, and (3) adducted shoulder. These deformities are ,•orrected by massage, splints, forced movements, plaster of Paris dressings and, if necessary, tenolomy. In shortening a stump the author uses only skin flaps and makes them shorter than usually recommended in the text books. Exces~ive :-kin flaps are never well nonrished. He does not nc:c mnsclc in the flaps. 556 SURGERY. >ol. XI. For foot amputations the writer finds that as a rule the stump of a Chopart becomes deformed ; a Pirogoff is too short to use as a peg and too long to take an artificial foot. He prefers the Syme ampu- tation with section of bone a quarter of an inch above joint surface of the tibia~ rounding off all bony projections. This stump is end hearing and short enough to fit an artificial ankle. For the leg amputation in the middle third at the lower end of the prominence of the calf, use a long anterior and a short posterior flap. Unless two fingers can be placed side by side on the inner side of the posterior surface of a leg stump when flexed, the stump is too short to use a below-knee artificial leg and a kneeling leg will have to be worn. It is unusual for enough skin to be available for a good amputa- tion through the knee, and if there is enough skin a short below- knee stump can as a rule be obtained. RemoYe the patella. The Lt>st amputation is through the top of the condyles, rounding off all hony projections. The Gritti-Stokes amputation is an unnecessary refine- ment unless the bone section has to be made above the cancellons p: rt of the femur, and then it should be used to make an end-bearing stump. EYery inch of the femur above the condylcs is of the utmost 'alue until the upper third is reached. In that situation, unless 2t inches of bone below the lesser trochanter can be saved, a thigh bucket can not be used. Therefore when this amount of bone is not available it is Lest to amputate through tho neck of the femur, thongh an equally satisfactory and less severe operation is to go through at the junction of the great trochanter and shaft. The artificial leg for a hip-joint amputation is a sound practical appliance and can be fitted to a subtrochanteric amputation. The conical stump is often satis- factory and must not be regarded as unnecessarily bad. For the wrist and forearm it may be said that one movable finger is better than any artificial device. Every inch of bone from the lower end of the ulna to within 3 inches of the upper end of the ulna is of value. Less than 3 inches can not be utilized, and in such a case amputate above the condyles, removing the supracondylar ridges. Every mch of humerqs above the condyles is useful. The shoulder joint can not be used unless 11 inches of bone can be saved below the anterior fold of the axilla. (ED.) BERNHEIM, B. M. The limits of bleeding considered from the clinical star.d- point. Am. Jour. Mecl. Sc., Ap1il, 1917. Bernheim believes that there has been a tendency to overemphasize the importance of blood transfusion methods when in reality there is greater need for fl more thorough understanding by the medical SURGERY. 557 profession at large of the indications for this procedure. It goes without saying, of coursei that to achieve the best results one must be prepared to use the method best suited to the case in hand: since no device answers equally well in every instance. The question to be determined is, 'Vhen has the limit of bleeding been reached 1 The author is convinced of the utter futility of having a specific rule by which to be governed, each case being a rule unto itself. Yet one must have some tentative plans by which to be guided, and there are, after all, certain fundamental features which are true to a degree in all cases. For instance, a sudden loss of blood is a more serious matter than a gradual depletion . .A rapidly falling blood pressure is always a warning of rnlue, although it must be remembered that nausea of the slightest degree will send the pressure down. In severe cases, it matters not what the cause, a good working rule is to transfuse if the blood pressure falls as low as 70 mm. of me1·cury, since life is hardly possible with anything below this level. Pallor, sweaty skin, the anxious counte- nance, are all danger signals that come to mind at once and air hnn~er when present is always of true diagnostic import. Curiously enough, the blood picture itself is of little avail in severe accidental hemorrhage. A patient apparently exsanguinated ma:y hnxe a hemoglobin estimate around 50 per cent, with a red-cell count of onr 2,000,000, figures well within the limits of safety. E-rnn in cases of actual air hunger blood counts alone do not indicate the dire need for fresh blood. In fact, so constantly has this state of affairs been found in cases of this sort that the nuthor now entirely ignores this feature. Terrific loss of blood apparently gives rise to the tighten- ing up at first of the vascular apparatus, a narrowing of the >essel lumen, thus causing a concentration of the blood remaining in the peripheral system, and at the same time preserving a blood pressure sufficient to sustain life. The true anemia does not become apparent until later on, when the vessels have relaxed and taken up a renewed supply of plasma with resultant blood dilution. In chronic bleedings and the anemias the hemoglobin is the safest guide. Drugs are of little aid in acute bleeding, morphin, judiciously giYen. excepted. It is human nature to try to help, but drug therapy in acute bleeding is misdirected aid. The author thjnks <' quartc>r of a grain of morphin seems to be indicated at the start of any hemor- rhage to quiet restlessness; after that the doses h~d better be smaller. because of the depressant effect of this dru!Y on re,.piration and the blood pressure. He believes in liquids of any and all sorts. bY mouth. per rectum, subcutaneous infusions, intravenously, coffee, tea. water: ice-any- thing at all that will quench the intolerable thirst and keep up the bulk of the circulating medium-nll within reason. Many patients 558 HYGIENE AXD SAXITATION. Yol. Xl. have been actually water-logged by overadministration of salt solu- tion-a heart can be overdistended and the blood can be made too dilute. If 1.000 c. c. or 1.500 c. c. of salt solution do no good, a greater amount will be equally rnlueless and may do harm. In case:::; of severe hemorrhage, if 1:200 c. c. do not steady a falling hlood pre.~­ sure or cause a slight rise. its introduction had better be discontinued. When the bleeding has been excessive a transfusion is indicated. be- cause it has been conclusively shown that blood alone can raise a pressure and sustain it. Salt solution has no sustaining power per se, and when the fall comes after a rise :from this means it usually por- tends the end, for added salt solution is useless. It never raises a pressure twice. (H.F. S.) HYGIENE AND SANITATION. DAKIN, II. D., and Duxu.nr. K K. Disinfection of drinking water. Hrit. Med. Jour., May 26, 1917. Sterilization 1 of drinking water by use of bleaching powder or Rimilar hypochlorite or chlorine preparation has been used with the greatest success for relatively large volumes of water when troops are practically stationary. The problem of sterilizing small indi- ,·idual quantities of water, such as are needed by cavalry or rapidl~ moving troops is much more difficult. For such purposes the insta- bility of small tnblets containing the minute quantity of active disinfectant required led the writers to make a number of experi- ments. which are summarized here. The first experiment was made with chloramine--T. It was un- satisfactory. If waters were heavily contaminated and hard and alkaline, the concentration required was too great, though this could be reduced by use of citric, tartaric and other organic acids. The next attempt was with preformed toluene-sulphondichlora- mines: and first results were encouraging, but when put up in tablet form too much time was required for solution to bring about prompt ~terilization. Greater solubility and stability were obtained with p-sulphondi- chloraminobenzoic acid. This can be prepared from cheap, readily available material. The formula is Cl2N.02S.C6H 4.COOH. The presence of the COOR group confers a slight but definite solubility in water, which is increased by dispensing it with alkaline salts, such as sodium carbonate, sodium bicarbonate, borax, etc. The writer:. propose for convenience that the designation "halazone" be used for this substance. 1 Halazone Is now on sale In the United States, con>enlently put up In ~mall vials of a hundred tablets each. One to two tablets sterilize a quart of water in 30 minutes. ~o.4. HYGIEXE AND SANITATION. 559 Tests of the efficacy of this .. halazone,:· both in powder and tablet form, were made. using tap water and B. coli: hard water and feces suspension; hard 'Tater and 10 per cent city sewage; tap water and 5 per cent city sewage; hard water and B. coli. The "halazone" was in Yarying degrees of concentration, as 1 : 250,000, 1 : 500.000. 1: 1,000,000. The ordinary routine was to take ,) or 10 drops of the treated water, place on agar to count surYiving organi:;rus and use suitable controls. The experiments appeared to show that in a concentration of 1: 300,000 an ordinarily heaYily contaminated water was sterilized in 30 minutes. This concentration could be relied on to remove coli, typhoid, or cholera organisms. The tablets were efficacious when acting on water in aluminum· containers, though if the tablets were allowed to remain undisturbed for a long time in contact with the metal a negligible action on the latter resulted. In the concentration prescribed the water acquires a o::light taste but is not unpalatable. The active chlorine is used up slowly, and the disin- fection continues for a longer time than when most hypochlorite preparations are used. The starting point in the preparation of "halazone ., is p-toluene- sulphonamide, which is readily obtained by the action of ammonia on p-toluenesulphonic chloride, a cheap waste product in the manu- facture of saccharine, and is available in relatively large quantities. It is now used in the manufacture of chloramine-T. Toluenesulphonamide is oxidized to p-sulphonamidobenzoic acid, and the latter substance on treatment with chlorine giYe" the desired dichloramino acid. A\.dcl 250 grams commercial sodium dichromate t.o a mixture of 200 c. c. concentrated sulphuric acid and 600 c. c. water contained in 2-liter round flask. Then add 100 grams crude toluene-p-sul- phonamide and heat on a sand bath with reflux condenser for one hour. using a small flame at first, as the reaction is vigorous. On cooling, wash separated crystals with cold water and dissoh·e them in hot dilute sodium hyroxide in slight excess. Filter hot and add excess of hydrochloric acid. When cold filter off precipitated acid und wash well with water and dry. Twenty grams of p-sulphona- midobenzoic acid thus obtained are dissolved in 200 c. c. normal ~odium hyroxide (2 vols), warming if necessary. Then add 200 grams crushed ice and saturate the mixture with a rapid current of chlorine. The reaction is best conducted in a wide-mouthed flask, which is shaken as the gas is introduced. More ice can be added if necessary. A white, chalky precipitate of the dichloramino acid is at once obtained. Filter off the acid by suction, wash in cold water, dry in vacuo on a porous plate. The dry substance is prac- tically pure, may be powdered and will apparently keep indefi- 560 HYGIENE AND SANITATION. Vol. Xl. nitely. It is spariugly soluble in water and in chloroform and in- soluble in petroleum. It readily dissolves in glacial acetic acid crystallizing in stout prisms, which melt at 213 C. When rapid!; heated on platinum foil it explodes feebly, but is remarkably stable when compared with most members of this group. The sulphondichloraminobenzoic acid behaves equally well whether made into a tablet with salt and either sodium carbonate, sodium bicarbonate, dry crystallized borax or sodium phosphate, but the crystallized salts are undesirable if the tablets are exposed to high temperatures. A convenient formula for tablets weighing 100 to 105 mg. is: Sulphondichloraminobenzoic acid, 4 per cent; sodium carbonate, 4 per cent (or dried borax, 8 per cent) ; pure sodium chloride 92 per cent. Grind the acid with the dry salt and then add the sodium carbonate. Pass mixture through a 40-mesh sieve. No lubricant or other addition is necessary. Tablets must be stored in small amber-colored bottles. One tablet prepared as above sterilizes one liter of moderately contaminated water. H contamination is excessive, use two tablets to liter or quart. Sufficient time has not yet elapsed for final reports on the stability of the tablets, but under ordinary conditions no decomposition was noted after two months. Bright sunlight acting on tablets in clear- glass bottles did cause decomposition. The estimated cost in England of disinfecting water by the use of halazone is 2 cents per 100 gallons water. (ED.) GUNN, J. A. Note on prevention of pediculosis. Brit. Med. Jour., May 5, 11>17. The writer gives very favorable reports on the use of thin under- shirts made of muslin (so cheap that the original intention wa~ to throw them away after using once) soaked in the following solu- tion: Naphthalene and sulphur, each, 1! ounces; benzol or gasoline, 1 gallon. :N'o inconvenience results from the use of undergarments so treated. The effect on pediculi is not immediate. The writer quotes from a letter from France, in which it was stated that 200 dead pediculi were counted on a shirt that had been treated with the above solution. The solution has been applied under a plaster cast without irritation to the skin. [ED.] BELLI, C. M. Food ration of the Italian Navy. Office Internatlon11l D'Hygil!ne Publique, Ix, No. 5. This is a resume of a brochure published in Naples giving the • results of a royal commission's inquiry into the subject of the navy ration. HYGIENE AND SANITATION. 561 Belli notes that the navy is recruited from a sober, thrifty ele- ment of the population, and that, thanks to the influence of German ideas in recent years, a ration has been constructed not only in excess of physiological requirements but unconformable to the' previous habits of the men. He quotes Chittenden and his school and the work of the Italian investigators in support of the postulate that man can live and work on less food, especially of proteid character, than has generally been considered necessary. Since 1912 Tenente-Generale Medico Rho, R. M. I., has contended for this idea. In 1915 he published his views and asserted that all so-called war rations were wrong, in that when more labor is re- quired the ration is supplemented by proteid increase instead of starch increase, which is better calculated to contribute to restora- tion of strength. No attention was paid to his researches and recom- mendations because of the unfavorable impression likely to be pro- duced by a reduction of the ration. During the past year the necessity for economy has triumphed over political considerations. One by one various reductions have been made in the Italian Navy ration. The following tables show the allowance for a period of a week, column I being the issue for men on duty ashore. column II for men at sea: I VinPgar -------------------------Centiliters__ 3 Coffee ______________________________ grams__ 105 Beef _________________________________ do ____ 1, 200 Beans--------------------------------do____ 235 Cheese _______________________________ do____ 335 Olive oil _________________________ centlliters__ 30 Bread ______________________________ grams __ 4,270 Farinaceous material (macaroni, etc.) __ ao____ 600 Rice _________________________________ do____ 380 Salt ---------------------------------do____ 78 Wine ---------------------------Centiliters__ 25 Sugar ------------------------------grams__ 140 Biscuit------------------------------~do____ 140 'runny preserved in oil ________________ do____ 140 The above yields per day : Proteids ____________________________ grams__ 99.8 Fats ---------------------------------do____ 15. 3 Carbohydrates ________________________ do____ 524.3 Or, expressed in calories-- Calories from proteld sources________________ 409. 1 Calories froni fats-------------------------- 142.2 Calories troni carbohydrates ________________ 2, 149. 2 II 3 105 1,650 340 190 50 3,360 640 4-.?() 96 175 140 700 50 106.7 18.9 545.3 437.5 174 8 2,224. 7 2,700.5 2,837.0 In actual practice the ration differs distinctly from that of the tables. In addition to the provisions indicated above the navy depart- ment allows a varying cash amount for purchase of fresh stores re- 8551-17-9 562 HYGIENE AND SANITATION. Vol.XI. quired for preparing and improving the ration. Furthermore, the commanding officer is authorized to substitute other articles for any or all of those enumerated. This privilege is taken advantage of to a considerable extent among the personnel on shore. The tables are therefore misleading, except where it can be ascertained that there has been no waste and no commuting. Belli, under orders of the minister of marine, examined 15,000 men, both in barracks ashore and on board ship. He has determined that the ration has a value of over 3,000 calories, which he considers in excess of physiological requirements and entaHing a tax on the digestive and assimilative organs of the body. The daily proteid consumption, though actually below that shown in the tables, is. he believes, greater than the bodily requirements, which he fixes at 90 grams per diem. While the fats furnished are low and derived wholly from oil, the cash allowance permits the purchase of other fats, principally lard, so that column I should actually read 22, and column II, 30 to 35. The average carbohydrate intake is, column I, 500 grams; column II, 540 grams. An interesting control test is furnished by a study of the not in- considerable number of groups who by reason of military necessity are not rationed by the Government but allowed cash for the pur- chase of an exact equivalent of the ration and permitted to consult their individual tastes and preferences. Two important points are to be noted-first, the money issue is proved to be liberal by the fact that a majority of the organizations thus subsisted are actually able to save on the allowance; secondly, much greater variety in diet is made possible. The energy obtained from the diet thus selected and bought is represented by 2,700 to 2,800 calories, which is approximately the yield of the Government ration. The average daily proteid ingestion is 90 grams, about what the official ration calls for, but the proportion derived from animal sources is much less. The fats selected yield 25 to 28 grams a day, but, on the other hand, carbohydrates in the diet of election reach 500 to 600 grams. In a word, where there is an option the diet tends to be principally vegetarian, thus conforming to the popular basis of sustenance in the Italian of the working classes. The ration seems to the writer to he adequate except for a lack of variety. His recommendation is to have but one column or table which shall be mandatory for pro' iding a total of 2,600 calories from the morning and midday meal. The remaining 200 calories required are to be obtained by the evening meal, which shall be largely vegetable in character, selected and pre- nared according to the wishes of the messes concerned. (ED.) REPORTS. A REPORT OF 112 CASES. OF CEREBB.0-SPINAL FEVER. By J. T. MILLER, l'assed Assistant Surgeon, United States Navy, and D. D. MARTIN, Assistant Surgeon, United States Nnvy. It is so seldom that medical officers of the Navy ha,·e the oppor- tunity of studying a series of 100 or more cases of cerebro-spinal fever that the following report is submitted, with the hope that it may assist others in caring for and treating this most trying and treach- erous disease. It is not our aim to attempt a scientific discussion of cerebro-spinal fever, but, rather, to bring to the attention of medical officers the more important facts as they presented themselYes to us during this epidemic. While the first case was admitted to this hospital in March: Hl17, it was not until April that the disease began to assume epidemic pro- portions. The fact that this first case was admitted before the first draft from the Chicago training station arrived throws some doubt upon the prevailing belief that that station was the original focus of the disease and that all subsequent cases can be traced to men coming from there or to contact with these men, but it must be ad- mitted that there is considerable evidence in support of this belief. Etiology.-It is, of course, universally accepted now that the causa- tive organism is Weichselbaum's meningococcus and in all of the cases in this report this diplococcus was found in the spinal fluid. Also cultures from the nasopharynx were positive for the menin- gococcus in practically all cases, and, as has been reported by Eng- lish army surgeons as well as others, in the few cases in which it has been possible to follow up this line of work the mcningococcus has" run true to type," i. e., the meningococcus found in the naso- pharynx of a. given case is always the same type as that found in the spinal fluid. Mode of transmission.-While Flcxner's experiments have proYed that the meningococcus may gain entrance through the nasal cavity~ Pizzini has recently incriminated the body louse and reports a series of 77 cases in which all cultures from the nasopharynx were ncgatiYe and enltnrcs from the blood of the patients positi•e in every case, remaining so (with occasional intervals of ll<'f!atiYc cnltttr<'s) ln.te fiG3 564 REPORTS. Yo!. XI. into conYalescence. The experience of the writers has also been that blood cultures (at least those taken early and during the Yery acute stage of the disease) have pro,·en positi,·e for the meningococcus, and it doe:; not seem reasonable to suppose. although we have no direct evidence to submit, that the disease may be transmitted by some parasite such as the body louse or bedbug. ~\..n interesting fact in support of the former mode of entrance is that the disease fre- quently complicates or follows measles. It, indeed, would seem that a person in normal health and with an uninf!amed nasal mucous membrane is naturally immune to the disease, otherwise jt is hard to explain the fact that, with the large number of Hospital Corpsmen, nurses and medical officers who have come in such very close contact with the cases now reported, not one has become infected. It mav also be noted that, so far as these cases are concerned, all vermin hav~ been excluded by daily inspection, sterilization of clothing, etc. Under this heading must be mentioned carriers, those who show no evidence of disease and yet who harbor the meningococcus in the nasopharynx. It probably is not generally known what a large per- centage of these exist. Research along this line shows a considerable percentage of noncontacts to be carriers. Pathology.-It is much to be regretted that no report of the path- ology of this disease can be made, as it was impossible to obtain a complete autopsy in any case. DiagMsis.-This is not difficult in a fully developed typical cage, when we find stupor or delirium, stiff neck muscles with retraction of the head: positive Kernig's sign, etc., but in the very early stages all of the symptoms mentioned may be absent. However, there are se,·_ eral symptoms that will invariably be present even in the >ery early stage before there is any turbidity of the spinal fluid. These are elevation of temperature, perhaps of only 100 F. or 101 F.: head- ache, generally occipital in type but perhaps described as'· all OYer 1'; increased leucocyte count. This latter has been found to be over 30,000 per cm. when there was no backache, no stiffness of neck muscles, negative Kernig, and perfectly clear spinal fluid. Finally the lumbar puncture determines the presence or absence of the disease. It is particularly difficult to diagnose cerebro-spinal fever from other forms of cerebro-spinal meningitis; for instance, that of streptococcic origin, and this can be done only from the bacteriology of the spinal fluid. During an epidemic one must be on his guard not to be de- ceived by hysteria. The following interesting case was recently seen. The patient was in attendance on cases of cerebro-spinal fever, and, when seen by one of the writers, fear and dread of meningitis was most marked; this is practically never seen in a true case and is a good diagnostic point. Kemig's sign was positive in both legs; intense headaches (occipital) and pain in the lumbar spine were Vol. XI. has also been t hut fog the Yery acute he meningococcus. iough we have no be transmitted bv t\n interesting fa;t at the disease fre- d, "\\ould seem that med nasal mucous erwise it is hn,rd to Iospital Corpsmen, i very close contact ~ infected. It may ed, all vermin haYe clothing, etc. those who show no mingococcus in the n what a large per- hows a considerable report of the path- possible to obtain a ·eloped typical case, ~s with retraction of very early stages all ivever, there are sev- en in the very early al fluid. These are F. or 101 F.; head- :ribed as " all oYer "; .n found to be OYer no stiffness of neck pinal fluid. Finally bsence of the disease. ·inal feyer from other that of streptococcic riology of the spinal guard not to be de- !l.Se was recently seen. >ro-spinal fever, anro-apinai meningitis. case. Rate. Dato or Mlmfs. alon. Via hosplt.al ship. Name or ship. -1 I I 1--- 1017. Trafnlng camp. Followed other dl8ca8ca. 1 A. S ............ May 1 I Solace ... Arizona ........ . 2 A. B.. ...... .. .. May O .. . .. . .. . . Montgomery . •.• 3 A. S ............ May 13 Solll('e ... Baltimore ....... 1 .................................... . 4 F., 2d cl.. ...... May 6 1 ... do .... Rownu . .. ........................ ! Measles .•....•. • 5 A. S ............ May 10 ... do.... Florida . . ....... Great Lakes ••.. 8 A. S ............ May 12 .......... .................. Norlolk .... .... . 7 A. S ......... ... Apr. 24 .......... Delaware ....... Great Lakes ........... .. 8 A. S ......... ... Apr. 27 Solace .•. Arizona .... .......... do . ....... .. ~ n:++ ~ii: ~ -:1r-::::n:::0: :::-~:: +: H Sea., 2d cl. .. .. . May 6 • • • • • • • • • . Prometheus ..................... .. 15 F., 3d cl.. ...... May o Soloce ... Vestal.. ... .............. ......... . 16 A. S ............ May 4 . .. do .. .. Now York .. .... Great Lakes . . •. 17 A. S ..... ...... . May 1 ... do .. . . Connertlcut . ..................... . 18 A. 8 ............ Apr. 23 .......... New York ....................... . 10 A. 8 ............ Apr. 15 . . ...... .. Great Lakes Groat Lakes ... . dralt. 20 Sea., 2d cl. ..... May 6 Solace .. Seattle .......... Newport ....... . 21 A. 8 ........... . May 13 ............................ Norlolk ... .... .. 22 Sea., 2d cl. ..... Apr. 27 SoJBce •. Michigan ........................................... . 23 Sea., 2d cl.. ...... . do ....... do .... Wvomlng ....... Great Lakes ... ··1 ................. . 24 Sea., 2d cl. ........ do .... . .. do . ... C'onnectlcut ........................................ . 25 Soo., 2d cl. ..... . \pr. 21 ... do .•.. New York ..... . ................................... . 26 A. 8 ............ llay 1 ... do ......... do .......... Great Lakes ..................... . 27 A. 8 ............ Apr. 23 ... do ••.• Connecticut ... ....... do . . ........ Measles ....... .. 2R A. 8 ............ Apr. 21 ... do ...... ... do ............................ ;··--............. . 20 PYt ............ May 13 ... do .... Ut.ah ............ Great Lekes .... Measles ........ . ~ ~~l:·.~.~~:::: ~:;: ~ :::::::~:: :~~'t:,;a:::::::: ::::::::::::::::::::::::::::::::::::: 32 A. 8 ............ May 6 ............................ Norlolk ......... ' :Measles ........ . 33 Sea., 2d cl...... May 1 Solace.. . • .. .. . .. . . .. .. .. .. Greet Lakes ....• 34 Sea., 2d cl ...... Apr. 17 ... do ........................... do ......... . 36 A. 8 ............ May 10 ... do.... Delaware ............ do .. ....... . 36 Sea;; 2d cl...... May 21 ... do.... Florida .............. do ••.•.•.... 37 A.:; ............ Moy 16 ............................ Norlolk ....... .. 38 Sea;; 2d cl...... May 4 8016<'8... Baltimore ........................ . 30 A.:; ............ Apr. 27 .•• do •... Connecticut ...................... . 40 A. S ............ May 16 ............................ Norfolk .•.•••... · ................. . llrat c. c. bar given Date of I No. I Lum· 1 Senim puno- with· puno- In tore. drawn. tures. c. o. 1017. Apr. 28 May 11 May 8 May 6 May 6 May 12 Apr. 21 Apr. 24 May 7 Apr. 27 May 8 Apr. 23 Apr. 17 May 6 May O May 4 Apr. 27 Apr. 23 Apr. 16 May 4 May 16 Apr. 24 Apr. 23 Apr. 25 Apr. 18 Apr. 28 Apr. 23 Apr. 21 Kay 12 Mar. 26 May 1 May 6 Apr. 28 Apr. 17 May 6 May 12 May 16 1 May 2 Apr. 25 May 16 245 60 56 105 ~ 240 110 70 246 640 125 220 lQO 160 205 106 136 260 250 116 05 236 253 170 270 320 300 350 :m 245 308 309 356 210 370 300 225 110 125 176 8 1 21 6 10 5 3 3 6 20 4 6 6 4 6 6 5 6 7 4 3 7 8 4 7 7 7 16 6 7 7 8 8 6 7 8 6 3 4 4 125 30 115 60 165 60 60 20 90 300 76 100 140 30 60 90 75 35 105 110 40 110 110 85 120 175 95 90 70 110 00 70 1115 00 120 185 flO 76 70 30 Complications. Died (day orl Re. dis- co very. cue). 8 2 6 13 6 6 Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. · .Aitiiiiii;::::::::::::: :· · · · · · · · · Yes. Yes. Yes. Orchltls . ..•....•••.... , ........ Yes. ·p-n,;·oi>iii&1iDiiiS::::::: :::::::: ~=: .. ...... Yes. .. ...... Yes. ........ Yes. . ....... Yes. . ............................... Yes. ................................ Yes. .. .............................. Yes. ................................ Yes. Malaria....... ........ •• . • . . • . Yes. ................................ Yes. Mea~les ....................... Yes. Mumps ...................... . Yes. ................................ Yee. Otltls media .................. Yes. .................. .............. Yes. .................. .............. Yes. Ery!lpelas ............ 1 ........ Yes. ................................ Yes. ~ f" ~ 0 ~ fll C1l 0) c.o Analysts of 11! cases of ccrebro-spinal mc11i1igftiR-Contlnued. Rate. Date or admU. slon. Via hospital ship. Name or ship. Training camp. Followed other dlseaaea. --- 1 I 1----1 1- - ----- 1917. 41 Soo.:1 2d cl...... May 6 . . • . . . . . . . . . . . . . . . . . . . . . . . . . Norro!k ......••• 42 A."'· ........... Apr. 27 Solace ... Arkansas •....... Great Lakes .•... 43 Sea,,., 2d cl..... . Apr. 24 • • •• • . • • •• Mlchlgnn ...•.•..... .......•.•..••. 44 A. "'·........... Mny 19 . . • . . . . . . . Connecticut . ........ .........•.•• ·1 ·. -........ ·. -... . 45 A. S . ........... Mar. 16 ...•.................•...... Norfolk ......•.. Maasles .. ..•...• 46 A. S .. ..••...... Apr. 23 ..•....... 47 A. S ...........•... do.... Solace ... 48 A. S............ lilly 4 ... do •..• 49 A.$ .......... .. Apr. 30 oo ~-A., 3d cl.... May 6 51 A. S ....•....... May 9 52 Sea., 2d cl.. . . . . A pr. 24 53 Sea., 2d cl. . . . . . May 1 54 Sea., 2d cl...... Apr. 27 6/i A. S ...........• Mny 20 M Sea., 2d cl.. .... May 16 67 II. A., 2d cl..... May 6 68 A.S .......... . . Mny 26 69 A. S ..••...•..•• May 1 00 A. S ............ Mny 21 . . . . . . . • . • Prometheus ..... Solace .. Nebrnska •..•... .......... Montana .•..............••.•.. .••• ..•.....•.•.•..•............ Norfolk •.. .....•.................. Solace... Arkansas..... ... . . . • . . . • . . . . . . . .. . Mumps .•.... ... Solace ...•.... do...... .... . Groot Lakes..... Measles •........ Alabama • . •.•.. .•... do ..... ...................... . 61 A. S .........•.• Apr. 28 62 A. S ...•...•...• ?.fay 6 63 1:1ea, 2d cl....... May 281 Solace .•. 64 F, 2d cl.. ....... June 1 ... do . .. . Delaware .•.•..•.•... do ...•...•.. Mumps •......•. W~onsin ............•....•....•.. .•.•......... ..... Michigan ........ Newport ............•............. 6S A. S ............ May 29 66 A. S ............ lfoy 9 67 A. S...... ...... May 29 OS A. S. ........ . .. June 14 69 A. S .•.........• 70 A.S ........... . 71 A.$ ........... . 72 A.$ ....•....... 73 A.$ ........... . June 16 June 4 Mny 28 May 1 June 3 Norfolk ....•.•.• Mumps ••••.•... ..... do ..••....•............•...... . .•. . do .••.....•• Measles ........ . ..... do .•••...... Lobar p nou· monla. Orchitls ..•.... . Measles ....•...• 74 A. S .••.• ••....• 75 A. S ....... •. . .• ~~ ~ns~~~~::::::: 78 A. S ........... . 79 ~Sea ,2d cl.. .... . June I Solace .•. Seattle .......... Newport ....... . ~~~ ~, - - --- -i- May 29 ............................ Norfolk ......••. June 6 1 •••••••••• Kentucky •...••• ! ..... do •...••.•.•••••.•••.••.••....• May 26 ••••••••••••••••••••••••••••••••• do ••.•..•••• Dato or llrst punc- ture. 1917. May 6 Apr. 26 Apr. 24 May 18 Mar. 16 Apr. 23 No. I Lum-1 Berum c. c. bar gt von with· unc- In drawn. f urcs. o. o. <'ompllcatlons. Died (day orj Ro- dis- covery. onse). 120 4 301························1········1 Yes. 135 4 80 Orchltls............... . . • . . . . • Yes. 115 3 .•......•.....•••...•..••..•..••••.•..•• Yes. 120 8 76 Pleur. ac. fib........ . . . . . . . . . . Yes. ········ ········ -···-·· 60 1 30 ······-· ········ 60 1 30 110 8 100 ··-· ········ ........ ························ 2 .... ········ ····-··· ························ 8 .... ............... ............ ..... ........................ 10 iii)" . i.i~iciici .. ac". .• "(s;;pp:. 1 Apr. 13 5 76 ········ Yes. arth.) May 21 423 12 160 .......................... ........ YM. May 9 310 6 100 Mumps .... ...•.•..... ........ Yes. May 6 325 8 40 .......................... Yes. May 26 330 7 60 ························ ........ Yes. May 1 290 6 95 .................... ~ ...... ........... Yes. May 26 258 8 30 ......................... ········ Yes. ~r. 28 3:0 9 2.'.i Bronchitis Ill' ••••• ••• •• ........ Yes. ay 13 269 9 00 .............................. ........ Yes. May 25 496 12 123 ························ ......... Yes. May 29 596 14 155 . .... ....................... .......... Yes. May 27 411 13 .......... ........................... . ....... Yes. May 9 900 30 200 .......................... ......... Yes. June 9 380 9 140 .......................... ......... Yes . June 14 255 5 110 ........................... ········ Yes . June 16 160 3 60 ························ ········ Yes. June-13 300 7 200 D . pan opthalmltls .... ········ Yes. May 2ll 376 10 45 ........................ Yes. Apr. 28 610 17 2[,Q Mumps .. ....•....•... ········ Yes. June 3 435 11 105 ......................... Yes. June 1 327 11 85 · ii8i&;1;1:::: :.: : : : : : : : : : ····t·· Yes. May 24 40~ 12 0 Yes. May 28 1 416 10 135 ......................... ........ Yes. May 29 210 7 0 ············· ··•········ . .......... Yes. May 26 435 10 136 . .............................. ........... Yes. 1une 6 480 11 100 ••••••••• •••••• •• ••••••• . ........ Yes. C11 -l 0 ~ ~ ~ ~ r.l !le6, 2d cl ••••••• May 21 Solace •.• :-lortb Dakota •.. Great Lakee . •. •• ••.• ••••.•.•.•••. . May 17 81 See ••••••••••••• June 1 . • • •• • •••• Florida .••.•..•....•....••.••.•••• Measles •...••••• June 2 112 A. S ..••..•••.. . May 6 Solace •••. \rkansas ••••.••. Great Lake., .••.•....••• ...•.. ••.•. May 6 83 A. 8 .••.••••• •. • June 4 . •••••.••. . . ... . ..••.•••.. Norfolk .. .•••• .•.••. . ••• .•.• .••... June 4 84 F, 3d cl.. . . ..... June 18 Solace .•. Mkhlgan .••..... ...•....••••.•... . Mumps •..•..•.• June 24 86 Sea. 2d cl. ..•... June 26 . •. do • ••• Arizona .•••••... . ..•.•. .•.••••...• ••••••••• . •.••••.• 1une 16 86 A. s ............ July 1 .....•..........•...•...•.. Norrolk ....••. · ..•........ ..•..•... July 1 87 Sea, 2d cl.. ..... June 30 .••• •• . ••. Rhode Island .•. Newport . .•.• ••. Mumps ••....... June 30 88 Soo, 2d cl....... June 26 Sollll'e... 'ifornda......... • . . • . . . . . • . • . . . . . . • • • . . • . • . • . • • • . . . . June 21 89 Sea, 2d cl.. ........ do ....... do ••.. Michigan ........ Newport .......•.•.•.....•........ June 7 00 W. '!' •.•.....•.••.. do •... .•• do .•.. Wvomlng ......• Nortolk . . •....•................. . • June 14 01 Sea, 2d cl.. . . ... June 15 .......... Utah .•...................•...•......•........•...... June 16 02 Soo, 2d cl. ...... June 26 Solace ..• Vosl111..... .. .•.. Groat Lakes .•..................... June 4 ~~ l:~~- 0 !::::::::: ·j;S~·-5· :::~~:.-.:: -~~~:::::::::::: -~~~~~~::::::::: :::::::::::::::::: ·i;;~·T 95 y_,3dcL . ...... June 14 Solace .•. Nevada ..•..•... Utah ..•••.•...•. Mea,les •...•.... June 23 96 lll.. M., 2d cl. ••. July 4 •• •••••.••.. ••• do •..•..•... Norfolk ....... .• Mumps •........ July 4 725 140 895 400 030 6.'15 3-'lO 500 425 476 470 170 195 405 2:IO 566 240 17 7 21 12 19 19 g 12 12 10 10 7 7 10 8 20 7 ra \::::::::::::::::::::::::·:::::::: 156 ••••••••••••· •· ••••••··. ••• ••• •• 2ro ··•···•·•·••·•·•·•·••••· ·••••·•• ml:::::::::::::::::::::::::::::::: 160 .• ·• ··· ·•·•••· •·•· ..•..• ····••·• 140 ••·•••••••·••·••••••·••· ·••• ••·· 30 •••·•••••··•••·••··••••· ·••••••• 195 60 00 00 00 285 100 26 4 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 Sea, 2d cl.. ..... June 26 .•........ :Y:lcblgan .....•.. Newport •.•. ..••.•... .•........... June 26 670 I 12 136 . . . . . . . .. •. .. .. • . ..••... 11 F,3dcl.. .. ..... July 6 ............................ Norrolk ......... Mumps ••.•••••. July 11 140 6 100 . . .............•....• . ..•...... 1~ I~~~~~~~~~~~~ .~L~. ~~~~~~~~~ ~ ~~~:;~~~~ ~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~ t~~~?: ::::~~: :::::~~: ::::~~: ~~~~~~~~~~~~~~~~~~~~~~~~ if ~. 3 ~c1·~i::::::: ·i;~~-2i· :::::::::: .~:.~~~~::::::: ·:Norrouc::::::::: :::::::::::::::::: ·iw;ti·2i· ····295· ······5· · ·· ··so · : :::::: :::: :: :::::: : : :: :··-- -~~- ......... . . . . . . . . May 21 . • . • . . . . . . Minnc.,ota....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 :f !~~······· ~ ~ ·l~j::: ·~········ :~~f •••• •ti~!••·······~~·~:'.····~·,•····~· ····~·1•~;,;~~UJl:·:::·.: ::::::: N. B ... Jn case.<1 where data is missing, death had occurred and all papers heen !orwnrdod to bureau before the writers assumed charge. YGll. Yes. Yes. Yes. Y8s. Yes. Ye~. Yes. Yes. Yllll. Yes. Yllll. Ye.,. Yes. Yes. Ye.,. Yos. Ye.1. Yes. '.I. ? !'" ~ 0 ~ 01 ~ '""' 572 REPORTS. Vol XI. SPINAL IRRIGATIONS IN EPIDEMIC MENINGITIS. By J. J. O'liALLEY, PaRRed Assistant Surgeon, United States Navy. In treating patients with meningitis during the recent epidemic in the fleet the idea of irrigating the spinal canal with normal salt solution was suggested by the rngue which irrigations of pm; caYities ha,·e reached in the present European war, and from an ac- quaintance with the original observation of Flexner 1 that salt solu- tion is toxic to the meningococcus. Experiments by Shearer 2 showed that the action of sodium chloride is most toxic when the conce'ntration of the salt is not much below 0.85 per cent or above 0.9 per cent and that freshly isolated menin- gococci were more yulnerable than older cultures, the former sel. •Shearer: Lancet, London, Noyemt>er, 1916. !\o. 4. REPORTS. 573 Lumbar puncture is made low down between the fourth and fifth lumbar vetebrre, with the idea of using the lower part of the canal as a reservoir. The head of the bed is elernted and the canal drained of all fluid that will return. ~.\s the fluid is generally under pressure, the quantity obtained can not Le used as an index for the amount of salt solution in irrigating or the quantity of serum to be injected afterwards. In one of our cases we obtained 96 mils of fluid and could use only 56 mils of salt solution in irrigating, and in only a few instances could we irrigate with a quantity equal to that ob- tained in drainage. The irrigating fluid or the serum should never be put into the canal in quantities to cause pressure symptoms. For complete drainage and proper irrigations the position of the patient is very important and provisions should be made for lower- ing the upper part of the body while fluid is going in and elevating it while draining. Dlocks inserted under the legs of the bed will answer this purpose very well. When primary drainage of spinal fluid is complete the burette is filled and the nozzle inserted into the needle, the burette being held on a plane slightly higher than the needle and from 15 to 20 mils of salt solution are allowed to flow in slowly. The solution is immediately allowed to return, measuring it with the graduate to insure a full return of the solution. The irrigations are repeated at least three times to clean out the lower portions of the canal, or, as sometimes happens, the spinal fluid is quite thick with pus cells arnl flows very slowly through the needle, and a few prelimi- nary irrigations will tend to dilute this and allow it to drain more freely. Then "·ith the hips elernted the solution is allo,Yed to flow in until the capacity of the canal is reached. The nozzle is detached, the stylet in~rted into the needle, and the solution allowed to re- main in the canal for 20 minutes to allow for diffusion of the liquid and for its toxic effect npon the organism. The irrigations are repeated until the return flow has become clear or until it is much clearer than the fluid obtained from the puncture. The capacity of the canal is judged by the pressure symptoms dem- onstrated by the patient, and these are always referred to the sacral region, hips and lower extremities. 'Then the solution starts to flow in there will be tingling sensations about the thighs and legs or there may be complaints of warmth at the site of injection. Twitch- ing of the superficial muscles about the buttocks and thighs may be seen, and as the canal fills there will be sensation of fullness in the bladder and rectum, with pains about the hips and thighs and usually shooting pains down the legs. \Then these pains become quite severe the flow is stopped and a few mils are allowed to return to avoid any pressure. The quantity used is noted, and this will be 574 REPORTS. Yol. XI. the guide for the next irrigation and also for the amount of serum that can be injected. Experience with irrigations will quickly acquaint one with the amount of solution to be used, and neither the salt solution nor the serum should be allowed to remain in the canal under such pressure us to cause discomfort. The capacity of the canal will rnry in different indh-iduals. The largest quantity we used was 56 mils; the least 26 mils. The average capacity in 15 patients who were irrigated a total of 78 times was 32 mils. If the fluid obtained from the puncture is very cloudy, it is quite impossible to get it to return entirely clear, even with a number of irrigations; but if it contains only a moderat{I amount of pus, then persistence in irrigation will produce a clear return flow. In two patients the spinal fluid was so thick that the flow wa:; Yery slow through the needle and in each case a second puncture was made between the second and third vertebrre. The salt solution was allowed to flow in slowly through the lower needle and, by diluting the fluid, the drainage was much faster through the upper needle. As drainage is the slow process in irrigation, the use of two needles is a timesaver. The principal objection is the fact that it requires two punctures in patients who in the early stages of the disease are hypersensitive and complain very ~t.rongly oI a procedure that involves any pain; and as they have to be punctured seYeral times during their illness and have considerable tenderness in the tissues surrounding the puncture, it is hardly justifiable in every case to make two punctures at each operation just to save time. There were 51 patients in our series, and before they were trans- ferred to the base hospital ashore lumbar puncture was performed 211 times, and in each case the canal was drained of all the fluid that would return. Of the 51 patients the last 15 were irrigated and completely drained 78 times, and in not one instance in the entire series was there an untoward symptom associated with the drainage or the irrigation. Following up the patients to the termination of their illness, it was found that in the 36 cases of the series who were treated by drainage and injection of serum there were 12 deaths, a mortality rate of 33 per cent. In the 15 patients who were drained, irrigated and injected with serum there were 2 deaths, a mortality of 13 per cent. Besides this marked decrease in the death rate, the irrigated cases were more comfortable, rested better and suffered less from headache and other symptoms of the disease. No. 4. REPORTS. 575 SANITARY WORK AT CAPE HAITIEN, HAITI. By R. B. IIBXBY, Passed Assistant Surgeon, United States Navy. On the arrival of the United States forces in Haiti in August, 1915, the country was found in a. most deplorable condition. The city of Cape Haitien, on the north coast of the Republic, a place of about 30,000 inhabitants, was typical of the other towns through- out the country. Abounding in ill-smelling filth, its streets littered with decomposing refuse and the broken-down gutters widening at intervals into little pools covered with a green scum and swimming with mosquito larvre and water bugs, the town was an object lesson in the futility of negro management. Passed Assistant Surgeon J. R. Phelps, of the U.S. S. Connecticut, was detailed as sanitary or public health officer on September 1, 1915, and given full charge of all matters pertaining to this position. His first work was to organize a much-needed street-cleaning force and, securing the services of a foreman of the long-defunct street-cleaning department as native manager, an English-speaking negro boy as interpreter and a native clerk as timekeeper, together with a force of about 60 laborers, divided into half a dozen gangs under subfore- men, he started out to clean the city. A few carts with mules were obtained, and before long a marked change in the appearance of the streets took place. The writer relieved Dr. Phelps on October 1, continuing, in addition, the duties of regimental surgeon and Dr. Phelps returned to his ship after having accomplished much in the short space of one month. It soon became evident that the street-cleaning force required con- siderable augmentation in order to bring the town to anything like an American standard of cleanliness. Eventually the main body consisted of 8 street gangs, each with 1 foreman, 12 sweepers, and 3 shovel men with wheelbarrows. In addition, there was a mule-cart gang equipped with 8 carts and with brooms and shovels, who carted to various dumps the refuse collected by the street gangs. Part of this was burned in an incinerator which had been constructed by Dr. Phelps. A dozen men with machetes and rakes were placed in a number of public squares or small parks to keep these places in order. Most of the streets were paved with large cobblestones, which would catch all sorts of dirt in the interspaces, making them par- ticularly difficult to clean; and as the people live largely on fruit and sugar cane, the skins and leavings from these foods would be thrown about everywhere and, falling between the stones, would soon rot in the heat, attracting great swarms of flies, the sugar cane being espe- cially attractive to them. To meet this difficulty 120 boxes 3 by 2 576 REPORTS. Vol.XI. by 2 feet, with handles for carrying like a sedan chair, were placed in convenient places about the city and two dozen men were employed emptying these as they were filled up. Another gang was kept busy in cleaning about 20 concrete canals which emptied into the bay and drained nearly all the gutters of the city. Vacant lots scattered about the town had been used as dump- ing grounds for refuse from the neighborhood, and these were cleaned up and, in some instances, fenced in and wooden refuse boxes placed close by. Special sanitary guards had to be stationed at a. number of the largest of these places to prevent their immediately being used for the same purpose. A difficulty encountered at first was in the distribution of street areas to be cleaned daily by the various gangs. In the beginning the chief foreman laid out the work and the names of the streets cleaned each day were reported to the public health officer the follow- ing morning, but this system did not work well. Mitny of the streets were infrequently cleaned and the men were evidently shirking. A competitive system was then tried. a bonus being paid to the foremen whose gangs cleaned not less than a selected minimum of blocks each day during the whole week and, while this was an improvement over the older arrangement, the plan was still not satisfactory. Con- stant watching was required to prevent foremen from claiming they had cleaned more blocks than was really the case. The next arrange- ment tried proved entirely satisfactory and solved the problem. The city was divided into sections and each gang given a section and required to clean from end to end every street in that section running north and south on one day and every one running east and west on the following day, thus insuring that all the streets and the whole city were cleaned each two days. The main street, a long and wide thor- oughfare, was given to one gang and cleaned throughout its length e•ery day. An extra gang, called the" utility gang," was maintained to handle special jobs coming up all the time. The streets in Cape Haitien ha•e long and cumbersome names, such as Rue des Trois Chandeliers, Rue de la Marmousette, and the like, sometimes changing their names once or twice as they come to different sections of the town. This caused difficulty and delay in giving instructions as to localities, and so the streets were given new designations, those paralleling the water front being lettered, and those at right angles to the lettered streets numbered. The letters and numbers were painted . on all eight walls of houses on every corner in the city and, as the place is laid out with great regularity, matters were much simplified. Instead of saying, "The corner of Rue de la Providence and Rue du Petit Diable," one simply said, "p 21." No.L REPORTS. 577 The condition of the paving in different portions of the city had become so bad from years of neglect that to prevent the continuance of stagnant mosquito-breeding pools in the principal streets it became necessary to rebuild many portions of the latter. At first this was done by simply relaying the cobblestone paving, retaining the central gutter characteristic of the place (instead of two side gutters as with us), but later the paving was replaced by crowned streets of a sort of macadam ha "ring cemented side gutter:-:. Street, road and culvert construction was gradually taken up in different parts of the city and later extended into the outlying country for 8 or 10 miles. The work outside the city limits was carried on directly by Captain W.W. Low, United States Marine Corps, public works officer, until relieved by the writer in May, 1916. The engineering features were supervised by Mr. Charles Martin, a Haitian engineer in the employ of the department of public works. The street work in the city was for several months carried on by the department of public health but, as fund requirements demanded its transfer to that of public works, the public health officer was appointed assistant public works officer (and subsequently public works officer) and the work continued under public works without change of organization or personnel. There is no sewerage system in Cape Haitien and only the better classes have privies, the poorer people passing their evacuations on the water front, in vacant lots, in the near-by ravine and especially in spaces overgrown with vegetation and affording some measure of privacy, though this is by no means deemed essential. The result was that many foul-smelling places likely to become sources of dis- ease existed close to inhabited districts. The vegetation in these places was cut down and burned and the grounds cleaned and, in order to provide for the wants of the population, several wooden privies with corrugated iron roofs were built over the water and two in the town over concrete vaults. At first these were provided with seats after the customary fashion, but these were soon in such con- dition that no one would sit on them and they were replaced by little compartments, 3 by 3 feet, in which the central plank had been re- moved from the floor, leaving an opening 1 by 3 feet, over which the occupant squatted after the manner of the Japanese. The arrange- ment worked very well. The water supply of Cape Haitien is maintained by means of an excellent hydraulic system built by the French in the eighteenth cen- tury. This was thoroughly overhauled and put in first-class condi- tion by Captain Low and the daily supply of water, which is pure and wholesome, much increased thereby. The general health conditions about the town were excellent except for malaria and filariasis which 8551-17-10 578 BEl'ORTS. Vol. XI. flourished extensively on account of the swarms of mosquitoes. The breeding places of these pests were numerous and in a house-to-house inspection of premises many were found and destroyed. Great num- bers of large iron bowls 4 or 5 feet in diameter at the top, relics of ancient sugar mills, were standing in different places about the city generally filled with stagnant water containing larvre. These were turned bottom up by a sanitary squad sent around for the purpose. Handbills, in French, were printed and circulated, instructing the population with regard to steps necessary to maintain sanitary con- ditions, including the destruction of mosquito and fly breeding places. Close to the north end of the town was a space on the water front, about two city squares in extent, which was covered by a jungle of cactus and other vegetation. Pools alive with mosquito larvro were scattered about in different situations and cleared areas inside were used by the natives to pass th~ir discharges. Owing to its proximity to habitations, this locality was a distinct menace to the neighborhood, so a gang was put to work to cut down all vegetation; the ground was then graded, the pools filled in or drained and the land subse- quently raked and put in order. An ancient stone rampart several hundred yards in length was cleared out in this space and stone steps were built at the ends. Iron settees were procured from the United States and placed on the top and the whole area, which :formerly was very generally shunned, has since become a kind of public recreation ground where persons of all classes gather in the evening to walk about and enjoy the breeze and sunset. The main source of mosquitoes was a large pond situated on low- lying ground about a quarter of a mile north of the town in a dis- trict known as the Carenage. In order to abate this nuisance the public health department secured a mile or so of portable track and six steel dump cars and set about to fill the pond up, hauling dirt from different available hillsides during the process. The work re- quired about three months to complete and several thousand car· loads of dirt were thrown in the fill, successfully completing the ob- ject sought. In this job and the one mentioned immediately before it was necessary to employ some sort of drainage and for this pur- pose a number of trenches 2 to 3 feet deep were dug and filled with i:.tones, the surface being covered with small stones and pebbles. The plan worked satisfactorily, the trenches carrying off the water as it accumulated. Much of the land near the water front was infested with land crabs and, their holes becoming filled with water, they were prolific causes of mosquitoes. Various methods of combating them were tried but none with much success. There is a fairly large hospital, the Hospice J ustinien, run by French Catholic sisters, but there was no regular medical staff and ... Tullidge-War Injuries. I SHRAPNEL WOUND, FEMUR. T etanus developed. 30,000 units used. Recovered from tetanus. Amputation and recovery. (Russian prisoner.) 678-1 f '• 2,. , \ Tullidge-War Injuries. SH RAPNEL WOUND. ( Cl I 0: Compound comminuted fracture both bones leg, followed by infection of joint. (Russian front.) 678-2 ' Tullidge- War Injuries. GAS GANGRENE IN SHRAPNEL WOUND, ELBOW. 578-3 Tullidge-War Injuries. COMPOUND COMMINUTED FRACTURE OF TIBIA AND FIBULA, SHOWING SHRAPNEL I N TlSSUES. Recovery after removal of loose bone splinters and foreign bodies. (Russo-Austrian front.) 678-4 Tullidge-War Injuries. / FRACTURE OF LEFT PARIETAL BONE BY BULLET. (1895 RUSSIAN SHARP-POINTED AMMUNITION.) Extensive fracture. 678·6 SHRAPNEL WOUND. Two operations (trephlning). Survived 8 days. ments of bone driven into brain. Infection. Fine frag- Tullldge-W ar I njuries. SHRAPNEL WOUND. Fracture of last two lumbar vertebra;,. Paralysis of both lower limbs. Incontinence of fmces and urine. Ana;,sthesia. Wound cleaned of foreign bodies and bony spicules removed. When last seen was up and about, being taught to wal k again after two months dorsal decubitus In plaster. 578-6 !\o. 4. REPORTS. 579 only a meager surgicn1 equipment. A native physician was ap- pointed city physician under the department and his duties em- braced attendance at the hospice as well as on employees of the city injured in the course of their work. He was also employed by the gendarmerie and the prison, under their respective heads. A sum sufficient to purchase a general operating set, with a metal and glass case, was allotted for this institution and the articles were obtained from New York. Among other work handled by the public health department was the maintenance of the market, including scraping, red leading and painting the market building, an iron structure imported from France and covering four blocks. A minor work, but not without value, was that of repairing and painting the city band stand and cleaning out the surrounding square which had become oYergrown till the weeds stood about 'l feet high. Flowers and shrubs which were contributed by the sisters and other public-spirited persons were planted within. The port quarantine was under the public health officer, who ex- ercised a general supervision in the matter by authority of the dis- trict commander, Colonel Cole, United States Marine Corps. The ordinary routine business was handled by a native physician, Dr. Doucet, holding a Haitian Government appointment as port phy- sician. The Haitian quarantine regulations are excellent and ample. In July, 1916, there was a definite separation of the activities car- ried on under public health and public work, respectively, Dr. E. U. Reed, surgeon of the Second Regiment, taking the former, and Captain F. B. Garrett, United States Marine Corps, the latter. X-RAY PICTURES OF WAR INJURIES. By E. K. TULLIDGE, Assistant Surgeon, United States Navy. When the war broke out I was a postgraduate student in Vienna, and offered my services for the relief of the sick and wounded of the Austrian Army. During the short but interesting period of my connection with that org,anization I obtained many souvenirs of my service. The accompanying illustrations are of interest as show- ing the severe traumatism caused by shrapnel on the Russo-Austrian front and also as demonstrating the character of the work accom- plished with the portable field X-ray machine used in the Austrian service. The apparatus is transported on a horse-drawn vehicle and can be set up at the dressing station. 580 REPORTS. Vol. XI. CIVIL HOSPITALS AND OTHER AIDS TO THE 11.ECll.UITING SURGEON. By w. G. FARWELL, Surgeon, United States Navy, and E. W. GOt:Ln, Assistant Surgeon, United States Naval Re~erve Force. In the four months following the declaration of war recruiting was extremely acti,·e, 10,848 men h3ving been examined at the New York recruiting office, and the class of applicants was far abo•e the average in quality as well as in numbers. Intensive recruiting neces- sitated a larger staff and the department assigned to duty at this station several members of the Medical Reserve Corps and Reserve Force. Fortunately these men were residents of New York and in close touch with many of the hospitals, dispensaries and research institutions of the city and one was a member of the mayor's com- mittee on national defense. It was realized that problems of diagnosis and treatment were constantly arising in connection with the examination of the recruits which made it advisable to have the expert opinions of specialists in order to pass more intelligently upon the physical and mental eligibility of applicants. Furthermore, many of these volunteers who were desirable except for minor defects such as hernia, vari- cocele, varicose veins, etc., welcomed opportunities to submit to oper- ation and thus make themselves acceptable. An appeal to the civilian hospitals and dispensaries met with a most enthusiastic response and unusual facilities for diagnosis and treatment were at once placed at our disposal. The Cornell Uni- versity :\fedical College and the New York Eye and Ear Infirmary and the University and Bellevue Medical College placed their dis- pensaries at the service of the recruiting station. They arranged to have all men sent by the Navy surgeons examined promptly and without charge and on request sent back sealed opinions as to diag- nosis and prognosis. They have been of great help in the diagnosis and treatment of mild disabilities of the ears and throat, of suspected trachoma and other diseases of the eye, of skin diseases and gonor- rhea and the medical clinic at Cornell has made a careful study with X-ray plates of all tuberculous suspects. Most valuable information and advice was derived from consulta- tion hours held at our statio1~ by the eminent specialists, Dr. Col- man W'. Cutler, oculist, and Dr. Bryson Delavan, laryngologist. Dr. A. S. Knight, the medical director of the Metropolitan Insurance Co., offered all the facilities of his excellent laboratory situated directly across the street from us. During the past four months Dr. Knight and his assistants have removed impacted cerumen from over 200 cases, thus allowing us to complete an examination almo!d immediately which would otherwise be impossible, as neither the time nor the facilities for doing this work were present at this sta- No.erestimated as a means of raising the standard of cardiac examinations. It is always a matter of keen interest to see if one can in a necessarily hasty examination grasp the essential features of the case. The New York, Harlem and Bellevue Hospitals have received and, without charge, operated upon many of our applicants who have since been accepted and enlisted. St. Luke's Hospital generously opened a ward of 30 beds and placed it entirely at the disposal of the recruit- ing surgeons. Since May 21 they have operated upon 72 cases and 582 REPORTS. Vol.XI. of these 35 have since been accepted and 22 have already enlisted. The United States army and British recruiting surgeons are now l also sendi.ng many defective cases to this military ward. The con- -valescence of these operative cases frequently becomes a difficult social problem, but most valuable assistance has been received from the Burke Foundation, a convalescent home located in the suburbs, where many of these men were most comfortably housed, fed and entertained for periods of two or three weeks. In order that we might have a convenient and accurate record of these cases which have been referred to various hospitals, a card catalogue system has been instituted and is being maintained by the mayor's committee on national defense, who have kindly fur- 11ished the services of a competent civilian clerk. A cross index under the heading of the defect or cause of rejection serves as a ready refer- ence. Entries are made on the name cards whenever the applicant 1·eturns to report or is accepted or enlisted. It was intended, further- more that, by means of these records, a" follow-up" system could be instituted by which we could, by civilian help, keep in personal touch with the recruits at the hospitals and during their convalescence. Their final return for acceptance and enlistment would thus be more easily insured. In this card catalogue were filed under proper head- ings the records of cases which were, after complete examination, found desirable except for defects which might later be remedied, such as underweight, undeveloped, underage, defective teeth and thus a list of excellent volunteer material exists from which we might later draw should the occasion arise. The custom of having all surgeons working together in the same quiet room has proved to be of great mutual advantage for, instead of causing interference and confusion, each surgeon ha~ benefited by frequent consultations with others and has thus personally ob- served the salient and interesting points noted in more than 6,000 cases. In all this work where the applicant is referred to civilian doctors the final decision in all cases rests with the Navy surgeon. Civilians can not understand service conditions, though their help is often invaluable. Whenever an applicant is sent out for treatment he is given a note made out on a special form and he is required to sign a statement releasing the Government from any financial or moral responsibility. Copies of these special forms and a picture of the military ward at St. Luke's Hospital are shown. 682 ...: en 0 Ct: < 3:: >- 0: < f- -' LL 0 I 0.. < Ct: 0 0 f- 0 I 0.. 11 No.!. REPORTS. I have been rejected for enlistment in the U. S. Navy on account of ----------------------------• und have been asings shoultl begin with the pupil nurse, who at the start has little Idea of the cost of supplies or the economies of their preparation. It is therefore nece."'sary, first, to present to the pupil nurse a frank statement as to the cost of gauze, cotton, and other accessories that enter into common surgical dressings. The pupil !lhould learn that all waste ends and cuttings in the manufacture of dressings • 588 FOR THE HOSPITAL CORPS. have a vnlue. even though that value be represented by clean white mg,;, which are a marketable commodity. The next general prindple to be taught is to the effect that the cutting ot gauze for dressings, cornpre,,ses, sponges, etc., should be arrau~ed on definite geometrlcnl lines so as to fully a•old waste. The pupil should learn that fanciful dres,,ings and surgeons' hobbies In supplies should be dl!':coura~ed and that compresses, sponges, bandages and all dressing units should be fuily standardized and approved by the entire surgical staff. • • • It should be stated that the majority of these surgical units can be systematically washed and used again. It is the practice of this hospital to wash all gauze dressings and bandages and utilize the washed gauze after proper sterilization and culture for secondary dressings in the surgical depart- ment. ·This has been carried out here for 10 years and in many other large hospitals for a like period. It has been demonstrated that washed dressings ure softer in texture and more desirable for redressing wounds than unwashed mill gauze. The adoption of certain standard types of surgical dressings for ships and hospitals of the Navy is already under way. This will not preclude the employment by surgeons of dressings of special patterns preferred by them, but will greatly simplify the work of preparing dressings for routine cases and, as diagram and specifica- tions can be prepared so as to get the maximum yield from rolls of cotton and gauze of standard size, a marked saving should result. Here is a simple practical suggestion for the sick bay of a ship: Ha•e a muslin bag hanging near the dressing table and collect in it all the fairly clean odds and ends of cotton and gauze from the outer layers of dressings as they are removed from the patients. When the bag is full the contents can be sorted, some becoming available for resterilization, while the rest can be used for cleaning purposes and thrown away after use, for wiping up a drop of blood from the clean deck, for drying the leakage around steam pipes, etc. The usual practice is to use a towel, and when this article is em- ployed in the dispensary to wipe up the prescription counter it soon becomes unsightly with stains of silver nitrate, picric acid, etc. The Supply Depot is now prepared to furnish on requisition a sort of rough dish toweling to be used for such purposes in the dispensary instead of the regular high-grade, expensive towel. It will be issued in bolts, to be cut up into proper lengths and hemmed aboard ship. (ED.] CONSERVATION OF LINEN AND BLANKETS IN NAVAL HOSPITALS. By SARA B. MYllR, Chief Nurse, United States Navy. Recent experience in naval hospitals has shown that in order to prevent as far as possible wasteful destruction of linen, one person. preferably a member of the Nurse Corps (who by reason of possess- ing the woman's instinct for the careful use of household supplies. inherited from generations of housekeepers, is naturally better fitted No. 4. FOR THE HOSPITAL CORPS. 589 than a man for this duty), should have entire responsibility for all linen from the time it is received on requisition until it is con- demned and turned over to her to be torn up and issued for cleaning rags. She should have charge of the linen storeroom, keep an inventory, receive and store the new linen. Being familiar with the stock, she should recommend the items for each requisition in order that the hospital shall not run short of pillowcases, for instance, while dozens of extra spreads and nightshirts lie on the shelves year after year, being carelessly added to with each requisition, only to go to pieces from old age when finally issued for use. She should receive and pass upon all linen turned in for survey, list and store it for the board, mark and issue new in exchange. She should have full supervision of the laundry to insure that no destructive methods are in use there. In the laundry she will be able to observe the condition of linen from different parts of the hospital and run down various careless habits of destruction, i. e., articles put to uses never intended, wet linen stuffed into hampers and allowed to mildew instead of being dried, nightshirt sleeves cut instead of being slipped off, patients allowed to write on their beds and upset ink bottles, etc. She will also see that worn linen returning from the laundry is sent to the mending room and that the badly worn is turned in for survey instead of being used for rags and appearing minus at inventory time. She should keep the ward inventory books and count the linen in use at regular intervals. She will be able by word and example to teach those using linen the value of its conservation, and through constant care and interest the life of each article will be greatly prolonged. The provision of suitably constructed places for keeping soiled linen before sending to laundry, preferably a porch furnished with a wire hamper, also a drying cupboard for wet towels and sheets, which could be used as well to dry cleaning rags and swabs in bad weather, would fill a long-felt want and prevent much deterioration and waste. It is a question worthy of consideration whether the custom in naval hospitals of using condemned linen and blankets for cleaning rags does not off er too great a temptation to the willing cleaner (on occasions when rags may happen to be scarce and" inspection" very near) to tear up partly worn or even perfectly good articles. H it were possible to exchange the rags for a cheap substitute to be issued for cleaning, it might be found to eliminate one source of needless destruction.1 •Rough toweling for cleaning purposes is now procurable by r equisition on navnl medical supply depots. 590 FOR THE HOSPITAL CORPS. NEW ISSUES BY SUPPLY DEPOTS. In order t-0 avoid the possibility of error in interpreting the value of the various preparations which may be issued, it has been deemed advisable to adopt the following general (class) designations, which will appear on the labels of respecth'e containers in addition to the commercial or registered title: " Colloidal silyer "-to co,-er a elm<~ of preparation containing al>out 20 per cent silver. with chewlcal, bactericidal and clinical properties equlrnlent to those of argyrol. "Protein silYer "-to cover a class of preparation containing about 8 per rent silver. with chemicnl, bactericidal and clinical properties equil ale11t to tho,.:e of protargol. " Sulphonated oil "-to cover a class of organic sulphur compounds with a sul11hur combination and properties similar to Jchthyol. N"otwithstanding the relatively lower silver content (8 per cent) of protein silver, protein silver can not be used in solutions anywhere approximating the strength of those in which colloidal silver can be employed. This is readily understood when it is remembered that argyrol, which is of the colloidal silver type, is often employed in 25 per cent to 50 per cent solutions, while protargol, which is of the protein silver type, is probably seldom employed in solutions exceed- ing 3 per cent strength. Therefore any preparation issued by naval medical supply depots bearing a colloidal silver label is to be used in solutions of the same percentage strength as argyrol, likewise any preparation bearing a protein silver label is to be used in the same percentage strength solutions as protargol. Rough toweling for cleaning purposes, etc., will be issued in bolts. It will be torn into proper lengths and hemmed aboard ship. THE ROUGH FORM F CARD. By J. R. PHELPS, Passed Assistant Surgeon, United States Navy. Form F cards contain an important part of the data upon which vital statistics of the :N" avy are based. It is necessary that every itcn. called for on the face of the card be furnished as accurately as pos- sible. Each and every item is essential, but nothing should be entered on the face of the card except the information demanded by the in- structions for numbered lines, which instructions are printed in red on the back of the detachable card designated "Original." Upon disposal of the case, as soon as the proper indicator has been entered after "Disposition," on line 7, the card should be forwarded to the bureau at once. As a rule, it is practicable for all stations and ships in United States ports to forward cards the day they are released. ]S'o.4. FOR THE HOSPITAL CORPS. 591 It is remarkable that in spite of clear and definite instructions many cards are received with errors or omissions and in many cases with both. The name of the patient must be entered, surname first, with the Christian name in full. Frequently, where enlistment rec- ords or health records have not been available at the time, cards have been sent in with the line for the date and place of birth blank. Those items are particularly necessary for statistical purposes and, inasmuch as the man himself has furnished the information in the first place, it is suggested that it be obtained from him when the card is filled out instead of waiting for his health record. In filling line 5, "Diagnosis," the official nomenclature must be adhered to strictly. That is very generally realized and yet it is surprising to note the number of cards in which the diagnosis is misspelled and in which other terms have been used. A key letter must be given in the case of each and every injury. When the term "Diagnosis undeter- mined " is used in the case of an injury, the proper key letter should be given anyway. Frequently line 8 is overlooked. Whenever a patient is transferred as a patient, even though the diagnosis may be "No disease," there should be entered on line 8 the name of the hos- pital, dispensary, place, or ship to which he has been transferred. Line 9 is the continuation of line 8, and is to be used only when there is not sufficient space on line 8. It is not to be used as a convenience for the filing of notes at the place where the card is prepared, al- though there is no objection to making such notes," Typhoid prophy- laxis completed,"" Contagious influences," etc., separately on the re- tained duplicate copy after the original has been detached. If line 10 is not filled in properly it is difficult to trace the card. Several hundred cards are received each day and in order to file them it is necessary that each shall plainly indicate the ship, station, or hospital in which the card was prepared. In the bureau the cards are sorted and all of the data they contain is taken from them on separate punching-machine cards. The latter are sorted and tabulated by an accounting machine under the various classifications required for the preparation of the Surgeon General's report and for the compilation of various special statistical reports from time to time. Form F cards are also used each day as notifica- tion cards for communicable diseases. When a case of measles, for instance, is admitted to the sick list at a station or on board a vessel and is transferred to hospital the same day, if it happens to be on the Atlantic coast, in the ordinary course of events the card reaches the bureau the fol1owing day, and by means of an appropriately colored spotting pin on a map kept for the purpose the case is imme- diately recorded as being in the hospital to which it was transferred. For the purpose of keeping track of infective areas the case is also 592 FOB THE HOSPITAL CORPS. Vol. XI. charged to the vessel or station where admission to the sick list occurred. As a notice of communicable disease, the card is deficient in only one respect. A certain percentage of acute cases are sent to hospital with the diagnosis undetermined or with the diagnosis in error, as with German measles, when later it may be clear that the correct diagnosis is measles. When the diagnosis is changed by the hospital there is no line on the face of the card for a statement of the new diagnosis. In order to facilitate the work of the bureau, in all cases when the diagnosis is changed it is requested that a memorandum be made on the back of the card, typewriting across the red printed instructions, giving the new diagnosis and stating whether the change was made on account of error, complication, or intercurrent disease. For example, "Changed to measles on account of error." At the same time, because the new card will indicate the patient as received from the hospital or place where the diagnosis was changed, a memo- randum should be made on the back of the new card giving the former diagnosis and stating the name of the ship or station in which the infection was acquired, as taken from line 4 of the old card, so that eventually when the new card is received in the bureau both can be filed together without trouble. l J~DEX TO U~ITED STATES :L\AVAL MEDICAL BCLLETIN, VOLCME Xl. 1:-IDEX TO SUBJECTS. [.\ r tlclcs not appearing In full in the BULLETIN are marked (ab).] A Page. Abdomen, gunshot wounds of_ ____________________________ (ab) __ 3()5, 307, 400 Absce;,-s of liver, nmclJie __ ------- - -·-------------------------- (ab) __ 25U Abscess of lung _______________________________________________ (ab )__ 255 Absorbent cotton, tests for___________________________________________ 435 Abstract, syphilitic record____________________________________________ 358 Acicl, lactic, in treatment of corneal ulcer _______________________ (nh >-- 103 Aci;is _____ --· ------------------------------- ------------------ - 99 Addiction to Argyrol and Wrigbt"s solution in gonorrhea____________________________ 170 Arseniuretteth >- - 74 Asphyxiation, gas_··---------------- ---- ----------- ------------- (ah) __ 388 Asthma, treatment of ____________________________________ _ ____ (ah)__ 5ii2 Atmospheric comlition:,:-effect upon res11iratory lrnct_ ___________ (ab)__ 8-! Kata-thermometer in ______________________________ ------ ___ (ab ) _ 85 Aviation, naval _____ --------------------- - - ------------------------- 273 B Bacilli- diphthel'ia, annph~·J actic skin reaction to ________________ (ah) __ 97 Tubercle, isolation of, from discharging ear _________________ (ab)__ 104 Bacteria-adaptation of, to tensions of oxygen __________________ (alJ) __ 04 In etiology of cholecystitis _________________________________ ( nh) __ 71 In milk destruction of. hy electricity ______________________ (ah) __ 255 Bacterial infection of fresh eggs _______________________________ (ab)__ 256 Bacteriology-general. pathological. and intei;tinaL ______________ (ab) __ 04 Of pemphip;us nconatorum __________________________________ (ab)__ 263 Of swimrninp; pools in 1\Ianila ______________________________ (ab )__ 83 Of the bubble fountain _____________________________________ (ab) __ 82 R eviews of literature on ------- ------ ---- -------------------- 94, 260, 410 Balilla, ventilation on________________________________________________ 156 Burinm-f ormn l i 11 -- :!4U Bichlorid of mercur~· poisonin~------------------------------ --------- 226 Bile nnd cholera----------------------------------------------------- 411 Bleeding, limits oL-------------------------------------------------- 556 Bone tli:sense~. Hoent;.:en diac:no:-- :!57 B ronchosroplt• trNllment -------- ------- ------------. --· _ __ (ah)__ '.2i0 Bubble fountuin, bncteriology oL------------------------------- (ab)__ 82 Building,; for Tropic;; ----------------------------------------------- - 425 Bullets, locutln~ by X r·tY-------------------------------------------- r).14 Burn!;, treatment of---------------------------------- - -------------- 338 Impermc:ihll' dre.,sings for________________________________________ ;-144 c. Canacno. improvements aL ------------------ ------------------------- 426 Cape Haitlcn, sanitary work aL-- - --------------------------- -------- 575 Cardiovnsculur renal problems---------------------------------------- 430 Cnrrell-Dukin, treatment-------- -------------------- ------ -- ----- __ &:iS Carrell method of wound sterilization _______________ ------- -----(ab)__ 253 Ca tu met. t•xtrnction oL------- - --------------------- ----------(ah)__ 266 Cati:ut, iodized______________________________________________________ 210 C<>rebro-s11Inal fever, pre,ent status oL________________________________ 504 C<>rehro-,;pinal fever. report of treatment of (112 ca~e.-;) _________________ :;r.3 Cerehro;minnl meulnc:itb; _____________________________________ (ab) __ 3G;>. 3Si Epidl'mle;;; of, in w111·--------------------------------------------- :i:il S\pinal lrri~tion;; in_____________________________________________ 572 Chemistry, reviews of literature on___________________________________ 99 Chloricls In body tluids-----------------------------------------(ab)__ 100 Chol eeystceto1n~·, indications and contraindications fpr ___________ (ab)__ !!:l~ Cholecystlti~, etiolo~· oL--------------------------------------< nh) __ 71 Cholera culture ancl hile _______________________________________ (ah l __ 411 Chol em, gnll-hlm\1ler infections in ______________________________ (ab)__ 261 Civil hospitals :ts aids to re1.:ruiting___________________________________ 580 Clinical notes ------------------------------------- ------------ :!:!3, 373, 58:> Clinicul thennomf'ters, cultures from ____________________________ ( :1b) __ 90 Co]() nml infl'ction -------------------------------------------- (ab)__ 410 Colon, i;iurirery of, in Intestinal stm:is---------------- ----------- (ah)__ 80 Color bllndnes'<, Jennings's tcsL----------------------------------- --- 334 Complcmcut-flxntion reaction on board ship___________________ ____ _ __ 15 Com11lement-1lxntion test for s~·philis------------------------ --- ------- 17;') Conclensc-- 10~ Cornrol ulcer treated with lactic acid ___________________________ (ab) __ 103 Cruz, Oswaldo-------------------------- - - --------------------------- ;:;~1 Cnltn, hookworm infedion in_____________________________________ ___ 00 Cyst, multllocular --------------------------------------------------- 54~ D. Deafness nnd 111M1l Infection><----------------- - ----------------< nb) _ :!69 Dl'tlcctcd Imllets, wounds from_______________________________________ 541 Dementla--eplll'plic - - -----------------------------------------(ab) __ 1.J In dementln paralytlcn ------------------------------------(ab)__ 73 01'. cerebral arteriosclerosis _________________________________ ( nb) __ 7 4 Pn rn lytlcu ________________________________________________ (ab)__ 75 Precox, i;tuclies ____________________________________________ (ah) __ ~41 Schlzophr1>nic__________________________________________ (ah)__ 76 Dental pntlents. "r"tem in lrnndlin~ oL________________________________ :i1;; Dermatitis 11n1l eczema _______________________________________ ( nh) __ 2.'H. ~3;1 Dermntltls from rnatche.~-------------------------------- ---- --- ---- :.40 De,1ecs, suggested------------------------------------------ r,1;, 2Hl, 371, ;:;33 SUBJECT INDEX. 595 Page. Diet and metabolism ___________________________________________ (ab)__ 388 Digestibility of Yery young veaL _______________________________ (ab>-- 89 Diphtheria bacilli, anaphylactic skin reaction to _________________ (ab)__ 97 Diphtheria toxiu in Schick tesL-------------------------------- (ab)__ 96 Disease, ear, in the service___________________________________________ 53 Disease---nasal sinus------------------------------------------(ab)__ 105 Weil's, in army in Flanders ________________________________ (ab)__ 93 Diseases incident to submarine dutY---------------------------------- 44 Mental and nervous, reviews of literature on __________________ 73, 241, 300 Diseases, ;enereal, prevention of______________________________________ 1 Disinfection-barium-formalin __________________________ r------------ 519 Of drinking water_ ________________________________________ (ab)__ 558 Of swimming pools---------------------------------------- (ab)__ 258 Dressings, surgical, economy in use of_________________________________ 585 Drug addiction------------------------------------------------------ 305 Drum membrane, trephining of _________________________________ (ab)__ 103 Duodenal indigestion in children ________________________________ (ab)__ 240 Duodenal ulcer, Sippy treatment of _____________________________ (ab)__ 236 Dysentery, gall-bladder infections in ____________________________ (ab)__ 261 Ear-disease in the service___________________________________________ 53 Reviews of literature on ____________________________________ 102, 266, 415 Eczema and dermatitis--------------------------------------- (ab) __ 234, 235 Eggs, bacterial infection oL-----------------------------------(ab) __ 256 Ehler's method in treatment of scabies __________________________ (ab)__ 233 Empyema, encapsulated ________________________________________ (ab)__ 255 Enucleation of tonsils, bloodless method oL _____________________ (ab)__ 104 Epidemic jaunuice in Europe----------------------------------------- 364 Epidemics in war, prevention of_ _______________________________ (ab)__ 551 Epidemiology of lobar pneumonia ______________________________ (ab)__ 231 Epidemiology of pertussis-------------------------------------- (ab)__ 69 Epileptic dementia-------------------------------------------- (ab)__ 75 Eustachian tube, obstruction of ________________________________ (ab)__ 267 Explosion of 6-pounder ________________________ :______________________ 224 Experimental surgical studies---------------------------------- (ab)__ 402 Exposure to cold anc1 infection _________________________________ (ab)__ 410 Eye---reviews of literature on ___________________________________ 10~, 266, 415 Testing case, simplified------------------------------------------ 533 Testing device--------------------------------------------------- 533 Femur, fractures of ___________________________________________ (ab)__ 78 Fcver-llemoglobinuric, quiniu in_____________________________________ 135 Trench ___________________________________________________ (nb)__ 02 Field hospital, Port au Prince, HaitL ____ .:_____________________________ 107 Field-operating theater, motor________________________________________ 535 Filtration planL----------------------------------------------------- 422 Fixation of thorax-------------------------------------------------- 220 Formalclehy-- 78 France, surgical observations in ______________ ·---------------- (ab)__ 393 Froin and ::\onne. ~vina l fluid syndromes 0L _____________________ (~1h >-- 243 Fumigation, formaldehyd-------------------------------------- (ab)__ 89 Functional neuroses------------------------------------------- (ab)__ 241 G. Gall hlad)__ 05 Gastric ulcP-r, Sippy treatment of _______________________________ (ab)__ 236 Gastric ulcer, treatment oL----------------------------------------- 58 Gastroenterostomy, mechanics of stomach after _________________ (ab)__ 251 SUBJECT INDEX. ~~1:~!: ~~dT~~~~~o================================:=========~====== ~Ialaria, quinin in __________________________________________________ _ Malal'ia, tnrtar emetic in ______________________________________ (ah) __ Malingering, psycholog~· oL ____________________________________ (ab) __ :Mare I sland, Yenereal conditions aL------------------------------- --- 1\Iarines in Santo Domingo __________________________________________ _ l\Iarines wounded in Santo Domingo _________________________________ _ ~latches causing dermatitis------------------------------------------- :'llaxillnr~· sinus _______________________________________________ (ab) __ liedical department at occupation of Santiago, Santo Domingo _________ _ liedical science,;, progre,:s in- 597 Page. 150 421 135 2GO 241 128 117 2!) 5-10 415 114 Chemistry ancl pharmaCY----------------------------------------- !)!) Eye, ear, nose, and throat_ _________________________________ 102, 2GG, 415 General medicine -------------------------------------- GO, 231. 385, 547 Hygien<> and sanitation _________________________________ 82, 255, 403, 038 Mental and nervous diseases _________________________________ 73, 241, 390 Pathology, bacteriology, and animal parasitology ______________ 94, 2GO, 410 Surgery ________________________________________________ 7G, 2·16, 393, 533 Tropical medicine ______________________________________________ 01, 259 ::\Iedicine-gcneml, reviews of literature on ___________________ GO, 231. 385, 547 Tropical, reviews of literature on ________________________________ !)l, 259 Megacolon, a ease oL------------------------------------------------ 223 l\Ielnnoma -------- ------------------------------------------ (ab)__ 411 Membrana t~·mpani, trephining oL _____________________________ (ab)__ 103 l\Ieningitls, acute syphilitic------------------------------------ (ab)__ 239 Mental diseases, reviews of literature on _________________________ 73, 241, 390 :'I font al h~·p:iene, un-- 255 :'IIortalit)' of 011r pnhlic men ___________________________________ ( nb) __ 87 l\Iotor-operating fiel35 N. Nails in joint surfaces _________________________________________ (nh) __ 78 Narcotic adh·ing ship New York _________________________ ---- _ 130 U. ~- S. HnnnibaL______________________________________ 274 IT. S. S. Ne\Y York-------------------------------------- 133 U. S. S. Saratoga________________________________________ 125 On- Liberia ------------------------------------------------- 429 Ti1e west coast of Mexico________________________________ 430 598 SUBJECT INDEX. o. Pan. Oc·ul:1r ::rnaph)·luxi:< ----------------------------------------- __ (ab)__ 266 Operating theater field motor_________________________________________ 53.) Omentum. i::tudies and U!='es oL ______________________________ -------- 402 Operations In HaitL------------------------------------------------- 374 Organizntion-111C11ical, !='ixth nnval dbtrict________________________ ___ 4!>7 ~Illita~·-tuherculosil' nnd -------------------------- _ __ _____ 43!) Otltls me-!. 260. 410 Patlwlo;:ical <'Ollcction. Xaval ~Iedical SchooL ________________________ 65, 437 Patholo;r)·-of nar<"otir addiction _____________________________________ G4. 305 ReYlew:s of literature on ____________________________________ 04. 260, 410 Patients-f'n>hilitic duty to_______________________________________ ___ 3:i5 Trnn,;fcr of------ ----------------------------------------------- 3G2 Pedkulosls, pre,·ention oL-------··--------~------------------- (ab)__ 560 Pemphi~'Us neonatorum, bacteriology oL ________________________ (ab)__ 263 Perli!cbe ------------------------------------------------------ (ab)__ 551 Person::lit~·-unemplo~·ment nnd ------------------------------- ( nh) __ 302 Pertussis. epi-- 548 Polsonin:!-hy hkblorl1l of mercury----------------------------------- :.!:.!() .\rsenluretted hydro~en ------------------------------------------ 342 Poliomyelitis, acute epitlemic. etiology oL ______________________ (ah)__ 263 Pool«, swlnunin~. 11islnfection oL_ ·----------------------------- (ab)__ 25.S Port nu PrlnC'e. llnitl. fiel1l hospital at________________________________ 107 Prevention of venereal di<:enses______________________________________ 1 l'roditis, gonorrheal_----------------------------------------------- 22S Pro;!I'cs,.; In medical srience!='. (See ~fedical sciences.) Prophylactic sern In Turki,;:h Army___________________________________ 271 Protein for maintenance _______________________________________ ( nh) __ 4-0S Prilritus nni, treatment of ______________________________________ (ab)__ 237 P,.;ycholo:..')· of malln~ering _____________________________________ (ah)__ 241 PsyclV>P:l thic lnhor:itory of the ~Iunicipal Court of Cbicn~o ______ t ah)__ 244 Public men. mortality of our ___________________________________ (:ib) __ 87 Q. Quinin and ninlnria__________________________________________________ 1'50 Qulnin in mnlarln and hemoglobinuric fever___________________________ 135 R. Ration. Italian XaYY------------------------------------------ (ab)__ 560 Rations, box, used hy French troops ____________________________ ( nh) __ 2;-13 Heaction-the complement fixation on board shiP---------------------- U Recelvlni:: ship Xew York, sanitary notes from____________________ ____ 130 Recor,5G3 Re,.;plratory t1:nct. atmospheric influences on ____________________ ( nh) __ 84 Reviews of lit<'rature. (See :\Iedicnl sciences; Sanitation.) noentg-en dln~noses in bone diseases _____________ --------- ____ (ab) __ 249 SUBJECT INDEX. s. Sanatorium. naval, Las Animas, ('oJo _________________________ _ Sanitary notes- From- Receiving ship New York-----------------------~------_ U. S. S. HannibaL __________________________________________ _ U. S. S. New York _____________________________________ . U. S. S. Saratoga ______________________________________ _ On- 599 Page. 120 130 274 133 125 Liberia ----------------------------------------------- _ __ _ 429 The west coast of l\lexico______________________________ __ _ 430 Sanitary work, Cape Hatien _____________________________________ ----- !i75 Sanitation, reviews of literature on __________________________ 8~. 2r>5, ·l05, 558 Santo Domingo, marines wounded in drive on_________________________ 29 Santiago, Santo Domingo, occupation oL______________________ ___ 114 Santo Domingo, with marines in__________________ _ ________ --· __ __ 117 Scabies cured by Ehler's method------------------------------- (ab)__ 233 Schick test, diptberia toxin in ________________ ---------------- (ah) _ 96 Schizophrenic dementia --------------------------------------- (all)__ 76 Screws in joint surfaces _________________________ ------------- (ah) ·- 78 S!'ra, Pl'OJlhylactic, in Turkish ArmY--------------------------·--------- 271 Serum, use of, in tetanus _____________________________________ (ab) _ 385 In cPrebro-spinnl menin.~itis ________________________________ (ab)--. 387 S<'rum therapy, locaL----------------------------------------- (ab)__ 232 Shark bite, Canacao BaY-------------------------------------------- !i39 Shell shock, etiolO!!:Y oL _______________________________________ (ab)__ 2-!2 Ship, rccei\•iug, :New York, sanitary notes from_______________________ 130 Shock, shell, etiology oL-------------------------------------- (ab)__ 242 Sippy treatment of gastric and duodenal ulcer __________________ (nh) __ 236 Six-pounder explosion -------------------------------------------··--- 224 Skin lesions, X-ray treatment oL------------------------------------ 373 Slop chute for battleships____________________________________________ 67 Soda, p;yuocardate of, in leprosy _______________________________ (ah)__ 91 Sphenoid sinus ________________________________________________ (ah)__ 417 Spinal anesthesia____________________________________________________ 34 Spinal fluid syndromes of Nonne and Froin ____________________ (ab)__ 243 Spirocheta ictero-hemorrha.~ica in rats-------------------------- (ah)__ 410 Spirochetosis ictero-hemonhagica ------------------------------(ab)__ 93 Staling of hread _______________________________________________ (ah)__ 257 Stasis, Intestinal, surgery of colon in ___________________________ (ab>-- 80 Station, naval, Norfolk, venereal diseases at__________________________ 1 Stomach, mechanics of after p;astroeuterostomy _________________ (ab)__ 251 Stovaln and stryclmin in spinul anesthesia___________________________ 34 Streptococci-in water supplies-------------------------------- (ab)__ 86 Specificity of---------·------------------------------------ (ab)__ 98 Streptococcus-dassification -----------------------------------(ab)__ 414 Lesions, study of ----------------------------------------- (ab)__ 265 Stl"ychnin-stovain spinal anesthesia__________________________________ 34 Submucous resection followed by ·septic arthritis ________________ (ab)__ 416 Submarines, poisoning on ·board of___________________________________ 342 Ventilation on___________________________________________________ 156 Submarine duty, diseases incident to_________________________________ 44 Sugar in urine------------------------------------------------(nb) __ 101 Suggested devices------------------------------------------ 66, 219, 371, 533 Supernumerary bones of foot---------------------------------- (ab>-- 404 Supply tlepot, Navy MeclicaL_________________________________________ 337 Supply depots, new issues bY----------------------------------------- 500 Surgery, reviews of literature on ____________________________ 76, 246. 393, 553 Surgical dressings, economy in_______________________________________ f>85 Surgical observations in France------------------------------- (ab)__ 393 Surgical studies, experimentaL _________________________________ (ab)__ 402 Sm;pcmdon laryngoSCOPY--------------------------------------- (ab)__ 269 Swimming pools-bacteriology oL------------------------------ (ab>-- 83 Disinfection of------------------------------------------- (ab)__ 258 Syphilis, complement-fixation test for_________________________________ 175 Syphills record----------------------------------------------------- 15.358 600 SlIBJECT INDEX. Page Syphilitks-(lut~· to-------------------------------·-------------- :r;;; Abstract --------------------------------------------------- --- 3~8 RN·ord of____________________________________ ---------- -- 3::;s Syphilitic meningitis, acute__________________________________ (:.h) __ :!:\!) T. Tampico, malaria in--------------------------------------------- 4::!1 Tartar emetic in malaria ______________________________________ (ab)__ 260 Test-complement-fixation. for srphifo;________________________________ 115 Schick, diphtheria toxin in --------------------- ---------- (ab)__ 96 \Vassermnnn, more general ·u"'c oL_____________________________ __ 177 Tests for absorbent cotton _____________________________ ----- --------- 435 Testing-vision ----------------------------------------------------- 53:: Devices for ------------------------------------------------- ---- ;;:~3 Tetanus :rn. ·------------------------------------------ ( :ih) __ 414 "C". Ulc!'r-<:orneal, treated with lactic acid____________________ _ • (ah) __ rn:i Gastric. tre:1 tment oL___________________________________________ 58 • _Ga~~ri<' and -- 86 Weil's disease in l<'landen;_ ___________________________________ (ab) __ 93 West coast of Mexico, sanitary notes on_______________________________ 430 Widal's reaction for typhoid ___________________________________ (ab) __ 260 Wounded mar ines during the drive on Santiago, Santo Domingo________ 29 Wound sterilization. Cnrrel method oL __________________________ (ab)__ 253 Wounds-gunshot, iodin vapors in treatment oL _________________ (ab)__ 247 Magnesium sulphate in t reatment of_ _______________________ (ab) __ 248 Wright's solu tion in gonorrhea________________________________________ 179 X, Y, Z. X -ruy for f'kin k•i.,H:< - ------- -------- ---------------- ------------- 373 Locating bullets br- - - --------------- ---------- ----- --------- - - - - 544 X-rays of war in.iurics- - - --- --- ----- --------------------------------- 679 INDEX TO AUTHORS. (Articles not appearing in run in the Bt:LLETIX are marked (ab).] :\(lier, H. )I_ ___________ (ah) _ Alfred. A. R _________________ _ .\lien. D. G------------------- Andrewi::. C. F __________ (ah) __ Ai::hurst, .\.. P. C ________ (11hL_ Auld, A. a _____________ (ah) __ l'nge. :m2 426 4:.':l 40::? 2:t:i ;);)2 Pase. Copeman, A. )L ________ (ab)__ 551 Cords. R ---------------(ab)__ 102 Cottle, G. F ------------------ 21, 273 Cowie, D. :\L ___________ (ab)-- 96 Craiir. C. B _____________ (ab)__ 73 Crandall, R. p ______________ 337, 519 Bal<. R H------------ (ah)__ 240 Eaton. W. E------------------ 540 Bonnema, A. ,L _________ (ah)__ 102 Espach, W. 0----------------- 421 Bowman, F. H___________ __ _ __ 141 Este;:. W. L ____________ (ab>-- 78 Dram;:. W. ,\._ ________________ :>s, 220 Falls. P. H _____________ (nb >-- 263 Bro1i;:tein. B ____________ f ah)__ :!30 Farenholt. A------------------ 318 nrmrn. E. W -------- 90, 3 :i, 400-410 : Farrar, C. B ____________ (ab)__ 76 Brown, )I. A ___________ (ah)__ 2:l0 I Farwell. W. G ___________ 346, 580, 584 Rntler, C. S------------------- 46:) Fi!:her, !_ ______________ (ab)__ 87 Caldwell. D. W--------- (nb) __ 2:>6 Fiske, C. X _____________ 128, 447, 551 Cal Yer, G. W ------------------ 407 Foote. J ________________ (ab>-- 240 Camerer, C. B _____________ _ 221. 430 Fox, 0---------------------- 547, 552 Campbell, C. )L ________ (ab)__ 7:t Fraser. J_ ______________ (ab)__ 397 Campbell, H. c __________ (ab)__ 400 Gabel, C. E _____________ (ab)__ 83 Carpenter, D. N _____________ 421, 475 Garrison, P. E---------------- 583 Cecil. R. L ______________ ( nb) __ 265 Gatewood, J. D---------------- 183 Chantemesse, • .\.. ________ (ab)__ 261 Giorcl:mo. :\I------------------ 342 Chnrle,;, S. F. A ________ (ah)__ 305 Godclnrd, H. H________________ 283 Chm-- 103 Conklin, F. L_________________ '343 HucllPy. P. B ____________ (ab)__ 256 003 604 AUTHOR INDEX. Ilnlrnnssou. E. G-------------- IIanes, F. l\L ___________ (ab)-- Ilnre, H. A-------------------- Hnrgra ve, "\V. W -------------- Hnselberg, A ____________ (ab) __ Haskins, H. D __________ (ab) __ Heimann, W. J _________ (ab) __ Hemici, A. T ___________ (ab) __ Page. 465 243 459 274 103 101 235 98 Pai:e. :\Iartin. D. D. _____ ------------ ;;03 :\lather>:, G _____________ (ab)__ ~63 :\Ian rel, E ______________ (ab)__ 23S :\kDowell, R W --------------- 44 :\IcFle, R. B ____________ (ab)__ 3!l:; :\IcKimitry, W. H _______ (ab)__ 413 :\IcLean, A. D_________________ 13:; :\IcLean, F. a ___________ (ab)__ 100 Henry, R. B ________________ 533, 575 "\lcl\1ullin, J. J. A ___ 181, 380, 540, 544 Herrman _______________ (ab)__ 103 :Melhorn, K. Q_________________ 117 Hetherington, R. R____________ 402 l\Ien-- 74 ~\Iiller, J. F------------------- 563 Ilolmes, A. D ___________ (ab)-- 89 :\!orison, A. E ___________ (ab)__ 248 Ilolmes, B ______________ (ab) __ 241 :\loshage, E. L __________ (ab)__ 97 Huff, E. p _______________ 34, 224, 271 l\Iurphy, J. B ___________ (ab)__ 412 Huggins, G. N __________ (ab)__ 553 :\Iurpby, J. T ___________ (ab)__ 251 Ilurst, A. F ------------(ab)__ 92 :\lj·er, S. B __________________ 175, 588 Ide, C. E--------------- (ab)__ 267 ~ngasaki, S ------------ (ab)__ 101 Imperatori, C. J ________ (ab)__ 416 Natale, ]] _______________ (ab)__ 232 Ionnescu, T------------------- 34 ~ichols , H. J -----------(ab)__ 261 ,Jacobson, J. IL ________ (ab) __ .J um;en, R ____________________ _ Johnnesco, T _________________ _ 2f:il 479 34 .Johnson, L. W ----------------- 223 .Tolles, A ________________ ( nb) __ 100 .Judd, c. c. w __________ (ab)__ 411 Kutz, J. R ______________ (nb) __ 257 K<>ndall, A. !_ __________ (ah)__ 94 Kennedy. C. :\L _________ (ab)__ 395 Kleh>;, A. 0-------------------- 439 Klien berg, S------------ (ab) __ 404 Knapp, A -------------- (ab)__ 266 Knowles, F. Q __________ (ab) __ 234 Kolmer, J. A __________ (ab)__ 97, 264 K~·Ie. J. J ______________ (ah) _ 103 Lnng, R. :\L ____________ (nh) _ 99 L:mg,Yorthy, C. F ------- (nb) __ 89 Laning, R. II---- 94, 385, 411, 412, 413 Leishman, W. B ________ (ab) -- 385 J.ewis, F. Q _____________ (ab)__ 255 Lockwood, A. L _________ (ab)__ 395 Low. G. Q ______________ (ab)__ 259 Lowenstein, ]] __________ (ab) -- 103 Lumsden, T ------------ (ab)__ 241 Luttinger, P ------------(ab)__ 69 Lynch, R. Q ____________ (nb) __ 269 l\IacCurdy, J. T _________ (ab)__ 75 l\Innheimer, W. A _______ (ab)-- 258 :\1ann, A. J_ ____________ (ab)__ 78 Mann, W. L----------------- 425. 543 l\1a rantonio, R_________________ 156 ~oble, W. Q ____________ (ab)__ 410 Noguchi, H _____________ (ab)__ 410 ~Oland, L ______________ (ab)__ 253 Ochsner, A. J ___________ (ab)__ 80 Oliver, W. W ___________ (ab)__ 94 Osborne, T. B ___________ (ab)__ 408 Olitsky, P. K ___________ (ab)__ 414 O'l\!alley, J. J _________________ 57!! Pnrk, W. H _____________ (ab)__ 406 Peck, A. E-------------------- 410 Penfold, E. A ___________ (ab)__ 246 Pettibone, D. F -------- (ab) __ 82, 406 Phelps, J. R___________________ 590 Prioleau, P. F ----------------- 539 Pryor, J. Q ______________ 547, 548, 551 Pugh, W. S------------------- 470 Rnlziss, G. D ___________ (ab)-- 264 Ramsey, W. B __________ (ab)__ 90 Randall, J. A --------------- 385, 390 Read, w. J _____________ (ab)__ 8G Richnrtls. T. W---------------- 130 Ridpath. R. F ----------(ab)__ 270 Riggs, C. E-- ----------------- 1 Risley, E. H ____________ (ab)__ 253 Robb, A. Q _____________ (ab)__ 387 Rollinson, l\f. M_______________ 219 RogerR, L ______________ (ab) __ 91, 260 Rosenbloom, J __________ (ab)__ GO Rosenow, E. Q __________ (ab)__ 71 Ruge, 0. G-------------------- 99 Hothholz, A. S __________ (ab)-- AUTHOR INDEX. 60& p~ ft~ Ryder, C. E___________________ 422 Syme, W. S------ -------(ab)__ 269 Ryle, J. A ______________ (ab) __ 93 Tallman, l\f. H __________ (ab) - - 252 Savage, W. Q ___________ (ab) __ 86 Tanganelli, E ___________ (ab)__ 233 Scharnberg, J. F ________ (at/)-- 264 Taylor , IJ'. E ____________ (ab)__ 413 Schier, A. R___________________ 325 Taylor, H. D ___________ (ab)__ 412 Schoberg, H. M _________ (ab)__ 90 Ta~·Jor, J. s _________________ . 156, 371 ScbObl, 0 ______________ (ab) __ 411 Taylor, K ______________ (ab)__ 95 Schroeder, M. c ________ (ab) __ 406 Thomas, W. s_________________ 533 Shi1tert, H. Q_________________ 133 Torrance, R. A________________ 141 Skillern, R. H __________ (ab) __ 417 Tousey, S-- ------------------- 544 Smallman, H. B ________ (ab)__ 385 Trible. G. B___________________ 53, Smith, A. L _____________ (ab)__ 551 102, 266, 334, 385, 415, 416, 417, 418 Smith. E. T _____________ (ab) __ 104 Tullidge, E. K ______________ 535, 579 Soiland, A------------- --- ---- 373 Tulloch, w. J ___________ (ab) __ 248 Solomon, H. Q __________ (ab)__ 390 Vnn Slyke. D. D ________ (ab)__ 100 Southard, E. E __________ (ab) __ 300 Vickery, E. A----------------- 540 Spear, R______________________ 50 Watkins, S. S __________ (ab) __ 268 Speed, K _______________ (ab)__ 393 Weinstein, J ____________ (ab)__ 416 Sterzi, L _______________ (ab) __ 247 Wells, W. 0---- --------------- 521 Stillman, E . Q __________ (ab) __ 231 Whel'ry, W. B __________ (ab)__ 94• Stitt, E. R-------------------- 259 White, W. A ____________ (ab)__ 391 Stokes, A _______________ (ab) __ 93 Whittington, T. H ______ (ab)__ 262 Stokes, C. F ---------- --- - ---- 64 Wieber, F. W. F -------------- 226 Stone, H. B ____________ (ab) __ 237 Wiltshire, H ____________ (ab)__ 242 Strine, H. F ______ 29, 385, 405, '547, 558 Williams, R. B ______________ 107, 374 Strouse, S-------------- (ab) -- 236 Winslow, 0 .-E. A ________ (ab)__ 85 Sullivan, J. J, jr ________ (ab) __ 415 Woods, A. a ____________ (ab)__ 266 Rutton, D. Q ____________ 385, 391, 392 ! Zalesky, \V. J_________________ 125 0 ,