A
VOL. XVII
NO. I
UNITED STATES NAVAL
MEDICAL BULLETIN
INFORMATION
OF THE MEDICAL
DEPARTMENT OF THE SERVICE
THE
BUREAU
OF MEDICINE
AND SURGERY
NAVY DEPARTMENT
DIVISION
OF INSTRUCTION
AND PUBLICATIONS
COMMANDER H. W. SMITH,
MEDICAL
CORPS, U. S. NAVY
IN CHARGE
EDITED
BY
LIEUTENANT
COMMANDER
W. M. KERR,
MEDICAL
CORPS, U. S. NAVY
Compiled
and published
under authority
of Naval Appropriation
Act
for 1922,approved July 12, 1921
PUBLISHED FOR THE
ISSUED BY
JULY,
1922
(MONTHLY)
WASHINGTON
GOVERNMENT
PRINTING
OFFICE
1922
VOL. XVII
NO. I
UNITED STATES NAVAL
MEDICAL BULLETIN
INFORMATION OF THE MEDICAL
DEPARTMENT
OF THE
SERVICE
ISSUED BY
THE
BUREAU
OF MEDICINE
AND SURGERY
NAVY DEPARTMENT
DIVISION
OF INSTRUCTION
AND PUBLICATIONS
COMMANDER
H. W. SMITH,
MEDICAL
CORPS,
U. S. NAVY
IN CHARGE
EDITED
BY
LIEUTENANT
COMMANDER W. M. KERR,
MEDICAL
CORPS, U. S. NAVY
Compiled
and published
under authority
of Naval
Appropriation
Act
for 1932, approved July 12, 1921
PUBLISHED FOR THE
1922
(MONTHLY)
WASHINGTON
GOVERNMENT
PRINTING
OFFICE
1922
Navy Department,
Washington, March 20, 1907.
This United
States Naval, Medical Bulletin
is published
by
direction of the department for the timely information of the Medi
cal and Hospital
Corps of the Navy. .
Truman H. Newberry,
Acting Secretary.
Owing
to the exhaustion
of certain
numbers
of
the Bulletin and the fre
quent demands from libraries, etc., for copies to complete their files, the return
of any of the following issues will be greatly
appreciated
:
Volume I, No.
1, April, 1907.
Volume II, No.
1, January,
1908.
Volume VII, No.
2, April,
1913.
Volume VIII, No.
1, January,
1914.
Volume VIII, No. 3, July,
1914.
Volume VIII, No. 4, October,
1914.
Volume X, No.
1, January,
1916.
Volume XI, No. 1, January,
1917.
Volume XI, No. 3, July, 1917.
Volume XI, No.
4, October,
1917.
Volume XII,
No.
1, January,
1918.
Volume XII, No. 3, July, 1918.
SUBSCRIPTION
PniCE
OF
THE
BULLETIN.
Subscriptions
should
be
sent to Superintendent
of Documents,
Government
Printing
Office,
Washington,
D. C.
Yearly subscription,
beginning January
1, $1.50 ; for foreign
subscription
add
$1.00 for postage.
Single
numbers,
domestic,
15 cents;
foreign,
24 cents,
which
includes foreign
postage.
Exchange
of publications
will be extended to medical
and scientific organiza
tions,
societies,
laboratories,
and journals.
Communications
on this subject
should
be
addressed
to the
Surgeon
General,
United
States
Navy,
Washing
ton, D. C.
ii
TABLE OF CONTENTS.
Page.
PREFACE
v
NOTICE TO SERVICE CONTRIBUTORS
vi
SPECIAL ARTICLES:
Sanitary inspector of the community.
By Capt. W. H. Bell, Medical
Corps, United
States Navy
1
Acid-base
equilibrium.
By
Lieut.
Commander
C. W.
O.
Bunker,
Medical
Corps,
United
States Navy
21
Aviation medicine in the United States Navy.
By Lieut. J. F. Neuberger,
Medical
Corps, United
States Navy
34
Personal hygiene of aviators.
By Col. C. M. Belli, Medical
Corps, Royal Italian Navy
39
Gas warfare:
Adoption,
methods
of use, protection of troops.
By Maj. W. R. Galwey,
Royal Army Medical
Corps
47
Functions and organization of Medical
Corps units serving with
the Marine
Corps in the field.
By S. N. Raynor,
major,
United
States Marine Corps
59
HISTORICAL:
Jonathan
Cowdery,
surgeon
in the United States Navy,
1767-1852,
Part I :
By Capt. F. L. Pleadweli and Lieut.
Commander
W.
M. Kerr,
Medical
Corps, United States Navy
63
EDITORIAL
:
On investigations
of the etiology of epidemic encephalitis. —A disser
tation
on
soup.— On acute
appendicitis. —Use of
iodine
as
a skin
disinfectant.—Removal
of foreign
bodies
from
the
eye. —On
kala
nzar
89
IN MEMORIAM:
Middleton
Semmes Guest, 1869-1922
105
REPORTS :
Report
of the hospitalization
of the veteran at Great Lakes.
By Lieut. Commander
R. G. Davis,
Medical
Corps, United
States
Navy
107
Report of the activities
of the Medical
Division
of the United
States
Naval Hospital,
San
Diego, Calif.
By
Lieut.
Commander
W.
D.
Owens,
Medical
Corps,
United
States Navy
111
NOTES AND COMMENTS
:
Revision of form K, Dental. —Gallery
at Wellcome Historical Medical
Museum
illustrating history of chemistry. —Public drinking
foun
tains.— Royal Air Medical
Service rules to improve
respiratory
and
circulatory
efficiency. —The
louse
as
a
menace
to
man. —Color
blindness in
seamen. —Immediate
surgery
with
the siege guns in
France. —Sources of vltamlnes. —Mollere. —Dr. William
Osier. —Erb
and Nissl.—Yellow fever in West Africa.—Aniliu
dyes
117
NURSE
CORPS
137
BOOK NOTICES
141
QUERIES
149
PREVENTIVE
MEDICINE
STATISTICS,
LETTERS,
ORDERS,
COM
MENTS
158
in
PREFACE.
The United States Naval Medical Bulletin was first issued in
April, 1907, as a means of supplying
medical
officers of the United
States
Navy
with information
regarding
the
advances
which
are
continually being made in the medical sciences, and as a medium for
the publication of
accounts
of special
researches,
observations,
or
experiences of individual medical
officers.
It is the aim of the Bureau of Medicine and Surgery to furnish in
each issue special
articles relating to naval medicine,
descriptions of
suggested
devices, clinical
notes on interesting
cases,
editorial
com
ments
on current medical
literature of special
professional
interest
to the naval
medical officer, reports from various sources, historical
esays, notes and comments on topics of medical
interest,
and reviews
or notices of the latest published medical books.
The bureau
extends
an invitation
to all medical
officers to prepare
and forward, with
a view to publication,
contributions
on subjects
of interest to naval medical
officers.
In order that each service contributor
may
receive
due credit for
his efforts in preparing matter for the Bulletin of distinct origi
nality and special merit, the Surgeon General of the Navy will recom
mend that a letter of commendation
be forwarded
to him upon the
acceptance
of his manuscript for publication,
and that a copy of this
letter be attached to his official record.
The bureau
does not necessarily
undertake to indorse
all views or
opinions which may be expressed in the pages of this publication.
E. R. Stitt,
Surgeon General United
States Navy.
NOTICE TO SERVICE CONTRIBUTORS.
When
contributions
are
typewritten,
double
spacing
and
wide
margins
are
desirable.
Fasteners
which
can not be removed without
tearing
the paper
are
an abomination.
A large proportion
of the articles
submitted
have an official
form,
such
as
letterheads,
numbered
paragraphs,
and
needless
spacing
be
tween paragraphs,
all of which
require
correction
before
going
to press.
The
Bulletin
endeavors
to follow
a
uniform
style
in headings
and
captions,
and
the editor
can
be spared
much
time
and
trouble
and
unnecessary
errors
can
be
obviated
if
authors
will
follow in
the
above
particulars the practice of
recent
issues.
This
is not
only
important
in
special
articles,
but still
more
so in reviews.
The greatest accuracy
and fullness
should
be employed In all citations,
as it
has sometimes been
necessary
to decline articles
otherwise
desirable
because it
was
impossible
for the editor
to
understand
or verify
references,
quotations,
etc.
The frequency
of
gross
errors
in
orthography
in
many
contributions Is
conclusive
evidence that authors
often fail
to read over their
manuscripts
after
they have been
typewritten.
Contributions
must be received two mouths prior to the date of the Issue
for
which
they are intended.
The editor
is not responsible for the safe return of manuscripts
and pictures.
All materials
supplied
for illustrations, if not original, should
be accompanied
by a reference
to the source and a statement
as to whether
or not reproduction
has
been
authorized.
The Bulletin intends
to print only original articles,
translations,
in whole
or in part,
reviews,
and reports
and notices
of
Government
or departmental
activities,
official
announcements,
etc.
All original contributions
are accepted
on the assumption
that
they
have not appeared
previously
and are not to
be
reprinted
elsewhere without an understanding
to that effect.
VI
U. S. NAVAL MEDICAL BULLETIN
Voi. XVII.
Jur.Y,
1922.
No.
1.
SPECIAL ARTICLES.
THE
SANITARY
INSPECTOR
OF THE
COMMUNITY.
By W. H. Bell, Captain,
Medical
Corps,
United
States
Navy.
" Without
responsibility
there can
be no
efficiency;
Without
efficiency
success
can only
be
accidental."
It may
be said without
fear of contradiction that one indication
of the spirit of the times is the mobilization of every form of science
in an effort to contribute to human
progress
and efficiency.
The
tendency
to reach into the
realms
of science for additional
facts or the discovery of new principles
has been stimulated by the
assurance
of their
speedy
application
to
the
solution
of
various
problems of everyday
life.
The
recent
war has
given
an impetus
to this spirit of investigation,
and by it alone
may
the world "ex
pect ultimately
to overcome the telling
advantages,
both in war and
peace, which Germany long enjoyed
because of the organization
and
development of her scientific
resources."
Every form of scientific
research
is important in building
the firm
foundation upon which enduring
advances depwid.
Thus, " Euclid,
working out problems
in pure mathematics
in Alexandria,
prepared
the way for the calculations of the engineer.
Galileo,
discovering
the satellites of Jupiter, convinced
the world of the truth of the Co-
pernican
theory,
broke
down absurd
medieval
conceptions
which
prevented
scientific
progress,
and
stimulated
exploration
and
ad
vance
in
every
field.
Pasteur,
studying
the optical properties of
certain
crystals, with no thought of practical result, was led to his
investigations
of bacteria
and his epoch-making discoveries
for the
benefit of mankind."
Not
only
are
scientific
bodies
organizing
their
educational
and
research resources in the interest
of efficiency, but teaching and
re
search institutions
are arranging
their facilities
along lines calcu
lated to foster progress
in
a precise
and
effective
fashion.
Every
where one notes the attempt
to overcome the sluggishness
with which
the public
receives
and
applies
scientific
information,
and
by the
word "public"
we
mean
the individuals
who
compose
military
as
l
2
BELL
SANITARY
INSPECTOR
OF THE COMMUNITY.
Vol.
XVII.
well
as civil
communities.
It has long been
noted that whatever
a
military organization
may
be considered
to gain
by virtue of
au
thority
is often lost in the persistence of a traditional
conservatism,
a conservatism
which is often expressed
as
a resistance
to reforms.
This resistance
is found in civil
as well as military communities
and
is the factor which prompts reformers to exaggerate
the conditions
which are under consideration in order to emphasize
the necessity
of reform.
It is difficult, however,
to exaggerate
the ill and far-reaching
con
sequences
of a disregard to the dictates of health.
Yet they are often
so subtle
and intangible to the average
citizen who can not readily
connect
an obscure
cause
with possibly an unseen effect, that efforts
to didactically
impress
the public with the necessity of precautions
regarding public health are often futile.
The mind is so constituted
that unfortunately
the value of experience
derived
from some public
disaster
is soon forgotten, and no matter
how good the intention may
be to continue
preventive
measures in the future, they often degen
erate into a routine and then pass into oblivion.
So discouraging
an outlook
does this
suggest
and
so
often
has
it been
the stumblingblock
to adequate
and timely preparation for
the prevention of public calamities,
that the development
of
a pre
ventable
disaster
is frequently
a needed object
lesson to arouse pub
lic interest in matters pertaining to public health.
It is particularly
in connection
with
matters
relating
to hygiene
and sanitation that cause
and effect are not apparent to the average
individual
who
at the present
time
has not been educated
up to
a
satisfactory
appreciation
of
the
value
of
public-health
measures.
His education
is a huge task, to be completed
by various means, one
of which forms the subject
of this paper,
namely,
the sanitary in
spector of the community.
It may
be interesting and helpful
at this point to outline briefly
the development of the science of sanitation from an educational
view
point and to review the facilities at present available to students who
aim to make public health their life work.
As early as 1865 the Medical College of the New York Infirmary
for Women and Children
made hygiene
and public sanitation a com
pulsory
part of its
curriculum.
Even
before
this
the Woman's
Medical
College of Pennsylvania
had taught hygiene
in connection
with
physiology.
The
University
of Michigan,
when
its medical
department
was founded in 1850, taught the principles of the analysis
of drinking water to its students,
and in the early seventies lectures
on hygiene
were
given
not only to medical
students
but to others,
including
those taking the classical
course.
Later, in
1876,
a course
of lectures
was established,
with the professor of hygiene
in charge.
In connection
with pathology or clinical
subjects,
as early as 1881,
No. 1.
BELL
SANITARY
INSPECTOR
OF THE COMMUNITY.
3
Western
Reserve,
in Cleveland, Ohio, taught
state, or
as it is now
termed, preventive
medicine
and hygiene.
At Harvard,
lectures
on
hygiene were instituted in
1876.
In
1892 the Institute of Hygiene
of the University of Pennsylvania
was established.
Foundations for
the financing of instruction in hygiene were likewise provided in other
medical
schools,
such
as the University
of California
and
Cooper
Medical
School, in San Francisco.
The
department
of hygiene in
the latter institution,
now Leland Stanford,
gave way to the depart
ment of bacteriology.
Not long ago Western Reserve
recognized
the
importance
of hygiene and appointed
a full-time
professor in this
branch.
A similar
change took place at Yale and at the University
of Chicago.
With all this, hygiene
as a major subject, with
a trained
scientist giving his entire
time to studying its problems
and teaching
its principles, until
recently existed
in
but
6 of the
38
reputable
medical schools in the United
States.
This was not a highly
creditable showing in comparison,
for ex
ample,
with
Germany,
where
all of
the
22
universities
teaching
medicine
had their hygiene
institutes, or with Great Britain, where
every graduate in medicine
must
have followed
a course
in public
health, and passed an examination in it.
This state of affairs in the
United
States was, perhaps, only a reflection
of the apathetic public
sentiment which
seemed
content
that its interests
in health
require
ments should
be
supervised
in
the
main
by so-called
" part-time "
health officers — often politicians, appointed without regard to fitness
for the office
they
were expected
to fill—and
with
such
inadequate
recompense as to inspire
a primary interest in their original gainful
occupation
as
a means
to livelihood.
This vicious
practice
is still
too prevalent; but better
things are coming to pass, though we are
a long way from realizing
practically
all that our scientific knowl
edge makes possible.
The methods of handling health conditions are
changing
and they began to change with marked strides even before
the World War gave such an impetus to the public-health movement.
Strong and able men and women
are behind this movement
and the
public is opening its eyes and its purse with the realization that there
are grave
facts to be faced with intelligence and
honesty,
and
that
there is much of an intangible nature and remote benefit that is worth
paying for in advance of delivery.
In preparation for the proper utilization
of this awakened
public
understanding
and
the
scientific
economic
disbursement
of
funds
allotted,
as a result of the growing confidence in public-health under
takings, the idea of developing personnel
to handle this tremendously
important work is taking practical form.
The study of disease and its prevention has always come within
the province
of
the
doctor of medicine,
but in this
new
field
of
endeavor—the
care of the health of
a community—there
is
room
4
BELL
SANITARY
INSPECTOR
OF THE COMMUNITY.
Vol. XVII
for other workers whose objective also is " the study of health
and
how to maintain it."
Much
is being
done
by various
powerful
agencies
such
as
the
United
States
Public Health
Service, the Medical
Departments of
the Army and Navy, health departments
of large cities,
and
educa
tional institutions
to lift our knowledge of preventive medicine out
of the realm of the casual and to make the use of it the general prac
tice of individuals
and communities, to educate
the public up to a
full understanding of its responsibility
regarding
preventive medi
cine,
and
to build
up
a body of public-health
workers,
men
and
women
whose efforts
are devoted
to the prevention of disease.
The requirements
of the health official
are to-day receiving most
careful
attention
by
such
men
as Sedgwich,
Reinhardt,
Whipple,
Rosenau,
and Overton, and out of a recognized
necessity
not only are
books
on the subject
being written
but special
schools with graded
courses are being established
for instruction in this subject.
In July,
1915, Rosenau
stated that "hygiene
is included as a major subject in
the curriculum of only three medical schools in this country, namely,
the University of Pennsylvania,
the University of Michigan,
and
Harvard."
On the other hand, Reinhardt
in February,
1913, with
regard to the division
between preparation for preventive and cura
tive medicine,
stated
: " The division
has evidently come to stay, be
cause it is recognized
and provided for in some of the best institu
tions of learning in our country;
in Harvard, in the Universities of
Pennsylvania,
Wisconsin,
and
Michigan
complete
and
separate
courses are given to students who attain the degree of M. D. (doctor
of medicine) and the degree of D. P. H. (doctor or diploma of pub
lic health).
Johns Hopkins University also has a school of hygiene
and public health.
Although
the University of California has
no
degree in public health, nor as yet any definite
course leading to the
degree in public health, it is rapidly working
to that end and
has
long supplied courses adequate for the need of general
students.
It
will perhaps be interesting, and in connection with
the development
of schools of public health it is pertinent, to note that " what is vir
tually a certificate
of public health (based upon methodical and ap
propriate courses)
was established
in Lyon, France,
as early as 1905,
and that, in 1919, 209 persons had received
the certificate,
135 having
been physicians or medical students
and
74 nonmedical men—phar
macists,
chemists,
architects, engineers,
etc."1
In the United
States
the school
for health officers conducted
by
Harvard University and
the Massachusetts
Institute of Technology
represents the greatest and most substantial step in this direction, and
' Rosenau,
Journal
A.
M.
A.,
Vol. LXV, No.
4,
p.
321 ; Reinhardt,
Journal
A. M.
A..
Vol. LX,
No.
6,
p.
427;
Sedgwich,
W. T.,
Am. Jour,
of Public
Health,
Vol. X,
No.
4,
P.
352.
Ko. 1.
BELL
SANITARY
INSPECTOR
OF THE COMMUNITY.
5
at present awards a certificate
of public health (C. P. H.).
A doc
torate of public health
(D. P. H.) is conferred in connection
with the
training at this school of Harvard University as one of its highest
degrees.
"The primary
object of the school for health
officers is to
provide the scientific groundwork
in the sanitary sciences which un
derlies efficient
health
administration,"2
for satisfactory
practical
work is done and economically done only " by those who have a secure
scientific foundation."
The school
recognizes,
it is understood,
four
general subdivisions of the field of public service for which it under
takes to train, viz, the teacher, the research scholar, the technical ex
pert, and the administrator.
The scope of the training for the tech
nical expert is perhaps comprehensive
enough to include what may be
termed
the sanitary agent and the district health inspector,
but the
requirements
for
admission
to,
and
the
required
period
of
study
within,
the school
exacted of candidates
for even its lowest
award,
the C. P. H., are such as to exclude the class from which are recruited
the grade of public health servant
at
present
so largely
depended
upon for the details of field inspection and work —the grade of public
health servant which constitutes
the sense bulb of the ultimate rami
fication of public health organizations.
I refer to the corps of field
workers
which
comes in daily contact
with the people
of a commu
nity as the representative
of health departments
in their effort to
secure
general recognition of health
dictates
and obedience to health
laws.
As above indicated, much has been
and is being done to develop
a
competent
personnel
in the upper stratas of health organizations
; but
it seems
that little well-directed or systematic
attention has been, or
is being, given to the question of creating a high-toned, efficient, and
dependable corps of sanitary inspectors,
or of making the remunera
tion sufficiently
attractive to assist such creation.
It has been esti
mated by Farrell3 that fully
7,000 sanitary
inspectors
are required
for work throughout the United
States on the basis of a conservative
minimum organization
of public health units per 20,000 of popula
tion.
This would
be
independent
of special
problems
and
under
takings.
Little or nothing has been written in this country touching
the peculiar requirements
as to fitness, training,
and service of those
who would fill this office. I have looked
almost
in vain, outside
of
English publications, for anything except the most superficial outline
of daily general
routine duties.4
■Rosenau, Journal
A. M. A., Vol. L.XIV, No.
10,
p. 795.
■Farrell, J. A., Jonrnal
A. M. A., Vol.
77, No. 7, Aug.
13,
1921,
p.
514.
'For example, Frank Stockman
says In the chapter
on "Duties
of sanitary
Inspectors
In London,"
in his Practical Guide for Sanitary Inspectors
:
1. Must
obey
and carry
out Instructions
and directions
of sanitary
authority.
2. Must
attend
meetings
as required
by
sanitary
authorities.
Should
report
at
these
meetings
all
matters
requiring
action,
etc.
(Footnote
continued
on p. 6.)
6
BELL
SANITARY
INSPECTOR
OF THE COMMUNITY.
Vol. XVII.
Yet these people
bear the same relation to the doctor of preventive
medicine
as does the nurse to the doctor of curative medicine
and are
quite as important in the scheme of things.
They represent
adminis
trative
assistance
reduced
to its lowest
possible
equation,
but which
is none the
less
indispensable
as a factor depended
upon for results
in the distal reaches of a health department's
daily
concerns.
A sanitary
inspector is anything
but a theorist.
His business
is
the observation of things as they are and the collection of information
which shall
reflect
facts.
The success of any
system of sanitation
or organization
in the interest of public health, assuming it is well
directed, will in the last analysis depend upon the type, training,
and
general
efficiency of subordinates,
the thoroughness
with which they
have
been indoctrinated
in
the
aims
of
the
institution
and
their
enthusiastic, persevering fidelity
to the objective.
The aim of all health organizations
is,
definitely and broadly,
the
physical
and
mental
improvement of
the
human
race—the
pro
gressive
recognition,
establishment,
and
observance
of
the
utmost
any given time in the interest of health, as
a
thing in itself, and
as
the basis of all that spells
the best in life.
Contributions
to civic
betterment
in any
and
every direction should be one of the aspira
tions in the breast of every
worthy
member
of society.
It
is
from
such
an element that we should seek
to recruit sanitary
inspectors.
Unfortunately
in the present state of our progress
and facilities these
are in the main without
special
training.
Dependence
for sanitary
aides in civil life, by virture of inadequate
compensation,
has
been
upon
a
class of citizens less self-respecting
and
less conscious
of
its responsibilities than
is
desirable.
This fact has suggested the very
attractive
proposition
that the
staff of visiting
nurses
which
is
a
part of every
properly
organized health establishment
be enlarged
and given the additional
duties of sanitary inspectors
5
or that sani-
(Continued
from
p.
5.)
3.
He Is to make systematic
and periodical
Inspections
of his district
to
keep
himself
Informed
as
to its sanitary
condition
and
especially
to
keep
sharp
lookont
for
those
nuisances
which
require
Immediate
attention
and abatement.
4.
On receiving
complaint
of nuisance
should
immediately
Inspect
the place
and
take
necessary
action
to remove the
cause.
u.
Should
report
to sanitary
authorities
any damage done to any waterworks
or other
works
belonging
to them.
Also any defects in water
supply
of any house.
6.
He is to make from
time
to
time inspections
of
slaughterhouses,
and of
shops,
and
markets
where
butchers'
meat, poultry,
fish,
vegetables,
In short,
all articles
of
food are
kept for sale
;
and In case any article appears
to be unfit for sale he shall
cause
It to be
seized
and dealt with
by
a Justice.
7. Shall procure
samples ol food, drink, or drugs for analysis
when
required
by
sani
tary
authority to
do
so.
8.
Should
report
overcrowding
In any
house
and
existence
of
any
nuisance
Injurious
or dangerous
to health.
9. Shall keep all books the sanitary authority requires
him
to keep.
10.
Shall carry
out instructions
of medical
officer of health
and give him all informa
tion In his
power, and produce
any
books relative
to his
duties
when
required
to do
so.
•
Overton
and
Denno,
The
Health
Officer,
1919,
express
themselves
as
of
opinion
that
the
public
health
nurse
may
also
do much
as a sanitary inspector.
" She Is
an
Inspector
and instructor of persons, while
the sanitary
inspector
deals with their environ
ment,"
but you can't, get away from
the one in dealing with the other.
No. 1.
BELL —SANITARY
INSPECTOB
OF THE COMMUNITY.
7
tary inspectors
be carefully
selected from
the female
citizens of
a
community.
In either case
the services of those who
by nature or
early training
are "housekeepers"
are
secured.
In
the
first
case
the advantage of fortifying the duty of exacting,
with the persuasive
influence of service, would be realized as an asset in getting results.
but whatever the source of personnel
for this service,
when
there
is combined
with the general
aspiration of good citizenship, an iden
tification with
a calling of vital moment
to the welfare of society in
one specific direction, nothing which will
add to the mental
equip
ment, fire enthusiasm,
and fix determination to devote the very best
efforts to the work in hand,
can
be neglected
by
the individual
in
office.
" He
must
be alive to conditions, awake
to discoveries,
and
conversant with the success or failure of methods in other localities ;
he can better afford to lag behind the science of which he
is an ex
ponent, but should be ambitious to hasten
its advancement;
this ho
can accomplish if he will dignify his least undertaking
as a definite
problem in research."
It is the small things that count in building
up big results just as the wonderful
creation
represented
by the liv
ing body is made up of billions of little cells.
Each sanitary inspec
tor may be likened to an individual
cell of an organ, and,
as in the
living body,
the well-being of the whole
depends
upon the perfec
tion with which the heart, liver, and kidneys perform their functions,
both individually
and in relation to one another,
so the effectiveness
of a given health department
depends upon the perfection with which
the corps of sanitary inspectors
does its particular work in coopera
tion with
other divisions of the
department
concerned.
It is
the
administrative
possibilities in the make-up
of
a sanitary
inspector
that count
so much
in
rating his
efficiency, for he
alone
comes in
daily contact with the individuals of a community.
Before taking up the several points I have in mind let us analyze
and give practical meaning
to the term " sanitary inspector."
In do
ing so I will take the last word first and change
its form from " in
spector " to " inspection."
" Inspector " is
a designation of office,
a
title; "inspection" represents
the execution —the function which
is
the realization of the office.
What does it mean ?
It means a routine
periodic
or
a special
investigation of
operations
or conditions
to
ascertain
whether or not the subject of the inspection is as the best
interests of all concerned
dictate that it should be.
And what is its
purpose?
Its purpose
is to obtain periodically
assurance that all is
right, or to learn definitely what is wrong, and, in the first case, to
commend
and
encourage
the
responsible
parties to continue
effort
and, in the second case, to guide and urge to better effort and to cor
8
BELL—SANITAKY IKSPECTOK
OF THE COMMUNITY.
Vol. XVII
rect the fault in one way or another, immediately if possible, but cer
tainly
by starting
the necessary corrective machinery.
The psychologic understanding with which the function of inspec
tion is entered upon, or the lack of
it,
and the spirit with which
it
is
carried out when human contacts are involved, spell success or failure.
What are apt to be the results if the inspection
is
undertaken in
a
spirit of gruff destructive
criticism with
a
crude
display
of au
thority?
In the first place
we note
resistance
which essentially is
opposed
to one's best
interests —opposed
to the work
in hand—to
one's reputation
as an official
of the sanitary
department.
Every
body within the field of the inspection will
assume the
defensive,
and
tenaciously
withhold
that information
or cooperation
so essen
tial
to success
in securing the desired
results.
And thereafter will
follow
a
long train of ill consequences
in comparison with
which
failure,
and the importance of
it
to one personally, fades into insig
nificance.
An insanitary
condition
and
the
spread
of preventable
disease entails far-reaching
damage
to the community.
The benefit
or damage,
as the case may be, to the community and to oneself
runs
parallel
and
is
effected by the same end result.
What,
on the other hand, are apt to be the results of the inspec
tion
if
undertaken in
a
spirit of kindly constructive criticism
and
helpfulness
with
tactful
firmness
based
on
precise
knowledge
as
the only show of force
?
In the first place, respect for and sympathy
with
the
aims of the
office
will
be noted.
The sanitary
inspector
comes in direct contact with the individuals
of his field of responsi
bility and must take their varying religious
and racial susceptibili
ties, customs of life, and
temperamental
and
habit tendencies
into
account.
He
is
the
one
who
must carry
the health propaganda
tcy
the home not only by word but by objective
teaching.
The secondary
rewards earned
by
a
proper spirit and bearing in carrying
out the
duty of inspection, and which
are
a
direct product of the respect
and sympathy thus won,
are the helpful
cooperation
of the individ
uals inspected,
and their open and frank response
to inquiry
in all
matters
of concern
to the inspector.
Many
inspectors
fail
because
they promptly kill the goose that lays the golden egg—their source
of information —by improper methods.
The
true
criterion
of efficient
general
sanitary
inspection
is
not
the number of reports of nuisances
or violations of the law that are
turned into headquarters,
but the health
of the district
a
given in
spector
may
be
assigned
to supervise
as shown by statistics from
month to
month,
or,
to
take for example
an inspection in which
special
training
and experience
is
necessary,
such
as the inspection
of
a
dairy farm, the criterion of efficient inspection
is
the maintenance
of the required standard of the dairy product as shown
by labora
tory
examination.
Of
course
reports
have
to
be
made,
and they
serve the important purpose of showing conditions as they exist, and
No. 1.
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
9
of bringing to one's assistance the power of higher authority, but I
want
to keep away from the idea that they
are more than a small
part of the full duty of the office. I want to avoid the possible
false
notion that the fulfillment
of the obligation of the office
is the sum
total of unfavorable criticism
and
the unearthing of some culpable
error or omission.
It is the part of administrative wisdom, rather, to>
loot for evidence of compliance with the sanitary code and general
sanitary
principles, taking careful
note the while of those features
in which
there
seems
opportunity
for improvement,
and
to
look
with surprise
upon failure
to render that measure
of
cooperation
which
is to
be
expected
from
those
possessed of intelligence
and
honest purpose.
Occasionally one will
be called upon to exercise all
the force resident
in the office
but, in general,
the aim should be to-
lead rather than
to drive.
When there
are adequate laws and
ade
quate
authority,
force is the shortest
road to
a desired
action,
but.
there are few laws perfect enough
to admit the elimination
of dis
cretion or that do not present some loop hole of escape—some defect
which
can
be
taken
advantage
of for
purposes
of evasion.
The
work of the inspector,
therefore, is in part a campaign of education,
to convert
a community to sanitary living and,
as in religion or pol
itics, it is impossible to convert
by force.
And now
as to the word " sanitary," which precedes the word " in
spector " and completes
the title : It stands for that condition of our
surroundings,
immediate
and remote,
which
conduces
to
physical
well being,
and brings contentment
and happiness,
not only as a re
flection of a state of health1 but by preserving unstained
and unmarred
the native beauty of Gtfd's gifts.
Furthermore,
the word " sanitary "
represents
a conditjio^ upon which is based the possibilities of progress-
and
accomplishme$i;,)in
all those enterprises
wherein human
energy
is a determining factor.
The title " sanitary inspector " is one of which to
be proud, and
it designates
an office which is growing in importance.
Indeed, it has
become
a specialty within a profession dignified by its identification
with the great undertakings in tropical latitudes during recent years.
Cuba would not be to-day the well-ordered, prosperous country that
it is if the work of the sanitary
inspector had been
faulty.
The
Panama
Canal would not be to-day accommodating
the ocean traffic
of the world if the sanitary inspector had
been
unequal
to the task
intrusted to him.
Each of the 25 districts into which the Canal Zone
was divided,
as far as general
sanitary work was concerned,
was in
charge of a sanitary inspector who had under his control a properly
trained
body of men, consisting of from 20 to 100 laborers,
with
as
sistants and foremen
as necessary.8
" No case of yellow fever, small
pox, or plague originated in or was brought to the Isthmus during the
• Gorgas,
W. C,
Sanitation
in Panama,
1915.
D. Appleton
k Co.,
" The
work of the
unitary
inspector,"
p.
182.
10
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
Vol. XVII
month."
This represented
the usual statement of the chief sanitary
officer in his monthly report upon health conditions during the con
struction of the canal and reflected the work of the sanitary inspector.
The
obvious
duties of the sanitary
inspector will vary
according
to locality,
season, and
peoples.
The difficulties in executing
these
duties will increase or decrease according
to the temper
of the com
munity collectively, and that of the individual
families composing
it
regardless
of the personality of the inspector.
In the Tropics,
foi
example,
the duties are concerned,
to a large extent, with the contro
of protozoal diseases, whereas in northern climates, except in malarin
districts,
the bacterial
diseases constitute
the
burden
of
concern
Urban
communities
present
quite
different requirements
from
thost
of rural settlements;
manufacturing
centers
present
sanitary
prob
lems distinct from
those of business or purely residential
districts
and
peoples of different races and religions
present
superstitions
01
habits or rites each of which, in its own
way, imposes
new and per
haps peculiar duties, or the exercise of ingenuity, to the end that thi
inherent violation of sanitary principles
may
be overcome
with
en
tire deference to religious or ritual considerations.7
As an example
of the general
outline of duties
which are formu
lated and issued for the guidance
of sanitary inspectors, I quote
th
prescription " by the local government
board for sanitary inspector
in the metropolis, in the sanitary officer's
(London)
order dated De
cember
8, 1891."
1. He
shall
perform,
either
under
the
speclaj! directions
of
the
sanitar;
authority,
or
so far as authorized
by the sanitary authority,
under
the
dire<
tions of the medical
officer of health,
or, in cases where no such directions
ai
required,
without such directions,
all the duties
specially
imposed upon
a san
tary inspector
by any
statute
or statutes,
or
by the oWers
issued
by
us,
s
far as the same
apply
to his office.
(>*•)''
2. He shall
attend all meetings of the sanitary authority when so required.
3. He
shall
by
Inspection
of
his
district,
both ■systematically
at
certal
periods,
and
at
Intervals
as
occasion
may
require,
keep
himself
informed
i
respect of the nuisances
existing
therein
that
require
abatement.
4. On receiving
notice of the existence of any nuisance within his district,
t
of the breach of any by-laws
or regulations
made by the sanitary authority
f<
the suppression of nuisances, of any by-laws
made by the London
County
Cou
cil which it is the duty of the sanitary authority to enforce,
he shall,
as ear
as practicable,
visit the spot and inquire
into
such alleged
nuisance
or breai
of by-laws
or regulations.
5. He shall
report
to
the sanitary authority any
noxious
or offensive
bus
nesses,
trades, or manufactories
established
within his district, and the
brea<
or nonobservance of any by-laws
or regulations
made in respect of the same.
1 1n this
connection
it Is Interesting
to note that in some
parts
of the Tropics
the ho
water
fonts
of
Roman
Catholic
Churches,
which
were
proline
breeding
places
for
t
yellow-fever
mosquito,
have
been
transformed
into
inclosed
receptacles,
the
preclc
water
being
obtained
by
the
devout
through
a
device similar
to
the liquid
soap
d
pensers in Pullman cars.
No.l.
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
11
6. He shall from time to time, and forthwith upon complaint, visit and Inspect
the shops and places in which
is exposed for sale, or in which
is deposited for
the purpose
of sale
or of preparation
for
sale,
any
animal,
or
any
article,
whether
solid
or liquid,
intended
for the food
of man, and examine
any such
animal or article which
may be therein.
If any such animal
or article appears
to him
to be diseased or unsound
or unwholesome
or unfit for the food of man,
he shall seize
and carry away
the same himself or
by
an
assistant,
in order
to
have
the same
dealt with by a justice
according
to the provisions
of section 47
of the public health
(London) act,
1891
: Provided,
That, In any
case of doubt
arising
under
this
clause,
he
shall
report
the matter
to the medical
officer of
health, with
the view of obtaining
his advice thereon.
7. He shall,
when
and
as
directed
by the
sanitary
authority,
procure
and
submit
samples
of
food,
drink, or
drugs
suspected
to
be
adulterated
to
be
analyzed
by the analyst
appointed
under
the sale of food
and drugs
act, 1875,
and upon receiving a certificate
stating
that the articles
of food, drink, or drugs
are adulterated,
cause a complaint
to be made,
and take the other proceedings
prescribed by
the act.
8. Whenever it appears to him that the Intervention
of the medical officer of
health Is necessary
in connection with any nuisance,
he shall forthwith inform
such
officer
thereof.
He shall
also, subject
to the directions
of the sanitary
authority,
attend
to
the
instructions
of
the
medical
officer
of
health
with
respect
to any
measures
which
can
be lawfully
taken
by
a sanitary
inspector
Tinder
the public health
(London)
act,
1891,
or
under
any
other
statute
or
statutes.
9. He shall
enter from day
to day, in a book to be provided
by the sanitary
authority, particulars of his inspections
and of the action
taken by him
in the
execution of his duties.
He shall
also keep
a book or books, to
be provided
by
the sanitary authority,
so arranged
as to form,
as far as possible,
a continuous
record
of the sanitary
condition
of each of the premises
in
respect of which
any action
has been taken under the public
health
(London)
net, 1891, or under
any other statute or statutes,
and shall
keep
any other systematic
records that
the sanitary
authority may require.
10. He shall at all reasonable times, when applied
to by the medical officer of
■health, produce to
htm
his
books
or
any
of
them,
and
render
to
him
such
Information
as he may
be able to furnish with respect to any matter
to which
the duties of a sanitary
inspector
relate.
11. He shall, if directed
by the sanitary
authority to
do
so, superintend
and
see
to the due execution
of all works
which may
be undertaken
under
their
direction for the suppression
or removal of nuisances within his district.
12. In matters
not specifically
provided for in this order
he shall observe and
execute
any instructions
issued
by
us,
and the lawful
orders
and directions
of
the sanitary authority,
applicable
to this office.
Another example of later date is given by Porter.*
These are prescribed
in the order of 1910, which details the duties
of the medical officer of health,
which, in some respects, they resem
ble.
He is required—
1. To perform
all duties
imposed upon
inspectors
by the public
health
act,
1875,
and other
statutes.
2. To attend meetings of the sanitary
authorities
when required.
' Porter,
Charles,
Sanitary
Law,
London,
1920.
Section
1,
" Sanitary
administra
tion,"
p.
4.
103390—22
2
12
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
Yoi. XVII
3. To Inspect this district and keep himself
informed
as to nuisances
calling
for abatement.
4. To
inquire
on the spot into
any complaint
as to nuisance
or breach of
by-laws or regulations
made for the suppression of nuisances.
5. To report
to sanitary
authority as to noxious
or offensive
businesses
and
breaches of by-laws or regulations
relating
thereto.
6. To report any damage done to water supply, works, or fittings
and any case
of waste or fouling of water.
7. To visit butcher's
and other
food
shops
and
inspect
the
meat,
etc.,
and
seize and deal with it if it is unsound ; in doubtful
cases
to consult the M. O. H.
(medical
officer of health).
8. To take samples under the sale of food and drugs act, submit
them to the
public analyst,
and if they are reported adulterated,
take proceedings.
9. To notify the M. O. H. of outbreaks of disease, and any cases of overcrowd
ing or nuisance injurious to health.
10. To attend
to the instructions
of the M.
O. H.
(so far
as
the sanitary
authorities
direct)
as to the taking
of measures which
an inspector
may
take
under the public health acts for the prevention of disease.
11. To keep
a daily journal and books recording
the action
taken
under
the
public health acts.
12. To produce his books to the M.
O. H. and furnish him with any informa
tion relating
to his work.
13. To superintend
work undertaken
by the sanitary
authority
for the
sup
pression
or removal
of nuisances.
14. To act, if required,
as officer under the diseases (animals) acts, and orders
and regulations
thereunder.
15. To obey
the orders
and directions
of the sanitary
authority and L. G. B.
(local
government board).
It makes
little
difference
from
where
the examples
are derived.
Such formulations of duties will vary according to the conception
of
the prescribing
authority.
It frequently
happens,
of course, that
sanitary inspectors
are assigned
to special
fields which
absorb their
whole
time,
at the expense of attention to the duties of the general
inspection above indicated, and in which the}' must become experts.
This brings me to the character and peculiar fitness requirements
of the
office,
and
as an introduction
to this section of my paper I
quote from The Sanitary
Inspector's Handbook,
by Albert Taylor
(London,
1914).
9
In general
terms,
a person
to be fully competent
to perform the
duties of a sanitary inspector should have the following qualifications
:
He should
be the owner of a good,
sound constitution
and
be able to follow
the rules laid down to preserve it, including
temperance.
He should
be able to write legibly,
spell correctly,
and have a fair knowledge
of
arithmetic.
» The
preface to the last
edition
Bays
that
this
book was compiled
with the desire
of
furnishing to the
sanitary
inspector
and
those seeking
to qualify for
such appointment
a useful
vade mecum
upon the subjects
pertaining
to the office.
The
book
aims
to supply
practical
Information
on the various
matters
which
come
dally
under
the
notice of the
sanitary
Inspector,
and not at being
an
exhaustive
work
of scientific
reference.
As it
la>
In
Its fifth edition,
it would
seem
that the
book
has
met a demand
and
filled
a useful
purpose.
No.1.
13
BELL—SANITAKY
INSPECTOR
OF THE COMMUNITY.
He
should
have
a
thorough
knowledge
of building
construction,
including
plumbing,
and
the
methods of water
supply
and
drainage;
also
the
proper
principles of ventilation
of rooms, and should
know
the best
and most suitable
sanitary appliances to use under varied
circumstances.
He should
have
an
observant
eye,
a quick
ear, and a sensitive
nose,
and
be
able to detect
any defective or faulty sanitary arrangements
of dwellings
and
other buildings.
He
should
be
thoroughly
acquainted
with
the
provisions
of
the
various
public health acts and model by-laws relative
to the duties of sanitary
inspectors.
He must
make himself
acquainted
with the various
kinds of infectious
dis
eases and
know
the best means to adopt for
preventing
the spread of such
diseases.
He should
acquire
a knowledge
of the different
kinds of disinfectants
in use
and know
those
best
fitted for safely
and effectually
disinfecting
bouses and
fever localities.
He should
have
a thorough
knowledge
as to the different
methods
adopted
for the collection and disposal
of house and other refuse.
'
He should
be of pleasing address, and in ids dealing with the public
he should
be calm and collected, learn
to restrain
his temper, and to endure hard
speeches.
He should
bear
himself
with
a
sympathetic
aspect
to
the
many
bereaved
widows,
mothers,
and
orphan
children
he
so
frequently
meets
in
the
per
formance
of his duties.
Civility
and kindness
must characterize
all his actions,
and rude behavior or supercilious
officialism
should find no place In his conduct.
He should at all times attend promptly
to any special complaints,
and frequent
inspections at irregular periods
are necessary
as
regards
slaughterhouses
and
other similar
businesses.
Sanitary
authorities
are
sometimes
disposed
to disregard
anonymous
com
plaints,
but it Is the duty
of the authority to investigate
every
specific
com
plaint made
to them without regard
to the means by which
it
comes
to
their
knowledge;
and, if satisfied,
upon Inquiry, that
such complaints
are justified,
they should
direct
that measures
be taken
to remove the ground
of complaint.
It is essential,
however,
to exercise
the greatest care when inquiring into
such
complaints, otherwise
the authority and its inspector
may be made the victim
of ill-will or spite.
Speaking from the Engish point of view again, and in
a rather
quaint vein, as indicating great expectations
and the extremely
large
order that some in authority were wont to impose upon the occupant
of a hitherto miserably compensated
office, it has been said, " That in
order to carry out the multifarious
duties of his office,
an inspector
should
be partially educated in the following
trades and professions,
viz, that of a plumber, in order to detect bad work
and
be able to
fill in his notices
how
the
bad
work
is to
be
rectified
; that of
a
butcher, in order to detect and intercept bad meat;
that of a veteri
nary surgeon, in order to observe animals that may be suffering under
the contagious
diseases
(animals)
act, and
also in connection
with
his visits to slaughterhouses
; that of a lawyer, in order that he may
he well cognizant with all the acts and regulations under which he
carries out his duties,
and to enable him to form
a judicial opinion
upon all statements of facts; that of an architect,
in order that he
•Day understand
plans, and, if necessary, make sketches of anything
14
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
Vol. XVII.
that comes under his notice in connection
-with his duties; that of a
clergyman, in order that he may
preach
the good tidings of sanita
tion, and may by his precept
and example
further the good work he
is engaged
upon, and also that he may
be able to patiently bear the
abuse which he may sometimes receive for what is called his
' prying
interference.'
Lastly,
he
must
try
to
educate
himself
in
common
sense —that most
valuable
commodity without which
book
learning
availeth not much."
Discussing the character
and temperament
of the sanitary inspec
tor, Taylor 10 says :
" To carry
out his duties
efficiently,
the sanitary inspector must
exercise great forbearance,
tact, and good temper
; sometimes technical
objections will
be raised
to his proceedings; vexations,
delays,
and
evasions will often occur in the fulfillment of his notices
; nuisances,
which
the
officer is anxious to suppress,
may
elude
his authority;
when
he would force
one person to refrain from tainting
the atmos
phere with the result that his tenants
were better housed than cattle,
he will often be reminded
of the rights of property and of an Eng
lishman's inviolable claim to do as he will with his own.
" With private affairs he should interfere only when they become
of public import,
and with private liberty
only when it becomes
a
public encroachment.
" Thus neither the personality nor the office should be magnified.
To do this is to court the contempt
of ordinary
men and women.
Officialdom is the curse of any administrative
body.
Therefore,
the
man
who
goes
about his duties
in
a way that compels
respect,
and
whose tactful
demeanor
impresses
others that the thing
he is asking
for can not be denied,
is the one who will win his way to the front
Owners and occupiers
are but human,
and they like to feel they
are
receiving the attention of a friend although an official."
And again,
on page 38 of his book, Taylor says under the heading
" Qualifications " :
" Sanitary
authorities do not and have not always sought to ap
point
the person
best fitted
for the
post of inspector.
They
have
too frequently appointed the man who could command
the greatest
influence
with its members without the slightest regard to his qualifi
cations.
The important
duties
which
sanitary
inspectors
are
now
called
upon
to
discharge,
and
the
large discretionary
power
that
must
be vested in them,
demand
that only qualified persons
should
receive these
appointments,
and experience
has undoubtedly rendered
it necessary
to establish
some mode of testing the competency
and
qualifications of persons offering themselves
as candidates
to fill such
appointments.
Some
assurance
should be given to the public
that
"Taylor, Albert,
Sanitary Inspector's
Handbook,
London,
1914,
p.
38.
No. 1.
15
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
the persons
entrusted
with
these
responsible
duties
are
properly
qualified.
" Evidence of special training
and of potential efficiency
as repre
sented
by character and temperament
ought to be regarded
as basic,
and when the question of qualifications has been thus determined
and
appointment has been made,
a fixity of tenure should obtain.
" Every sanitary inspector is entitled to security of office, for he it
is who is brought into personal conflict with property
owners
more
than any other officer appointed by the local authority."
The Secretary of Health
and Charities
in Cuba, speaking of his
local chief sanitary
officers, said: "They
can all feel perfectly
sure
that they will not be removed
from their offices while they
comply
with
their duties in
a satisfactory
manner,
because I sustain
the
view
that
the
employee
who fulfills
his
obligations
competently
should
be respected, defended,
and protected."
Needless to say, definite knowledge on a variety of subjects
is of
the
utmost
importance, but
the
best professional
equipment
may
be a total loss if its possessor lacks
a personality which is considered
essential
to the effective
application of such knowledge.
In seeking
to outline
the right personality I am conscious
of dealing with the
main
factor in
success.
Indeed,
so clearly is this the
case,
that if
something in one or the
other
qualifications
must
be sacrificed
in
the candidate
it had better
be in the direction of technical training.
Professional
shortcomings can be more easily corrected
than defects
in personality.
The difficulties
and
perplexities
which
beset
a
conscientious
in
spector
are rarely mentioned
or are insufficiently dwelt upon by the
instructors
in sanitary
science who are primarily interested
in the
technicalities
of this or that
particular
subject,
and
who may
be
merely preparing students for examination.
This fact the inspector
may be sure of, namely, that to frame requirements
is one thing, and
to see that they
are carried out is quite
another.
There is no doubt
many who, through luck of serious intention, through laziness,
men
tal or physical, or through sheer lack of ability
and perception,
skim
along lightly over things
and avoid annoyance
and
difficulties but
effect nothing.
Others fail for want of adequate training; for want
of a sanitary point of view, a sanitary interest and ambition, sanitary
ideal, and
a sufficient
acquaintance
with sanitary
problems
or satis
factory practical methods of solving them.
Ingenuity
and resource
fulness, which are so imperative, are to such a group total strangers.
But the vast majority
who find employment
as sanitary
inspectors,
and are appointed without regard to their qualifications, fail to do
more than to keep their own skirts clean —fail to realize
the reward
of perhaps an honest ambition and purpose
because they are not tem
peramentally
constituted
to be a telling figure in that field of work.
16
BELL
SANITARY
INSPECTOR
OF THE COMMUNITY.
Vol. XVII
What sort of personality fits the job and makes for its utmost possi
bilities ?
It is impossible to lay down any bard and fast rules or to
treat this phase of the subject
briefly.
It finds concentrated
expres
sion
in the thought that once an inspector succeeds in persuading
the people to accept him as a friend, working
as much in their inter
est individually as in the public welfare—even though a friend
who
tells home truths— the battle
is largely
won.
Difficulties
there will
always be under the
best of
circumstances,
difficulties which
may
have been increased
by want of wisdom or tact on the part of a prede
cessor, but
the gratification
of
a victory
in spite
of them
is great,
and
the
self-satisfying
consciousness
that
something
positive
is
really
being
accomplished —that
progress
is
being
made
through
one's personal
effects—is a large reward.
A number of contributors
to the literature of public-health
work
have
touched
upon the
element of personality
in
the
make-up of
sanitary
inspectors,
but the
one giving
most
systematic
and
sym
pathetic consideration to it is Edith L. Maynard
in her book entitled
" Women in the Public Health
Service."
It is written
from
the
English point of view, as is the case of most of the literature on the
subject,
but it is not the less applicable to either men or women in
field work anywhere,
and
so nearly expresses my own views tbat in
the following
paragraphs I have drawn largely upon it.
" It must
be borne
in mind that public-health
work of whatever
sort consists
mainly
in trying to make
people
do what, if left to
themselves, they would not do."
The bringing
about of a new order
of things, then, is the real crux of the task,
and it should appeal to
one's sporting
nature.
It is
a contest
as to which shall win —the
exponent of progress
or of the obsolete — and its very difficulties and
tenacity of purpose
is a characteristic of women
which men will do
well to imitate, and it is particularly
necessary
to the reformer
in
the guise of a sanitary inspector, for he can not afford to compromise
with principle.
He can do so only as a means to an end.
In other
words, if a thing can't
be done one way, it can be done in another
way, and it is the
inspector's
duty to be practical —to familiarize
himself with all the details involved in a given problem and to find
reasonable
means for meeting reasonable objections.
It is a matter of
managing people, of exerting and proving
oneself in the most inter
esting game imaginable, and " it is not everyone
who can deal satis
factorily
with others."
Owing to the variety of classes and racial peculiarities or habits and
shades of self-conscious
social caste that will be met in the course of
the day's
work, the background of the inspector, in other
than the
mere matter
of education,
is not an inconsiderable item in the total
making for potential efficiency.
The environment from which he is
No. 1.
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
17
drawn is important
and should be such
as to give
promise
that he
possesses that savoir faire which will make it possible for him to dis
cern both the nature of a situation and its opportunities or impedi
ments.
He should entertain
a sense of the importance of his work
and
assume
the
quiet dignity
and
full
measure
of responsibility
which properly
attaches
to his office, but he should be 'one who has
found himself, in a worldly-wise
sense,
and is not disposed
either to
take himself too seriously or to patronize those with whom
he comes
in contact.
There must
be
a nice appreciation
of ethical relation
ships
as shown in his bearings and
intercourse.
"But
this, obvi
ously, is not enough, for there are people of all classes who have the
(unhappy)
knack of rubbing others
up the wrong way, and such an
one is of no use in the Public Health
Service."
"To
whatever
class
the
public-health
officer
belongs,
he
must
possess
tact.
The tactful
official will quickly
ascertain
the frame of
mind of those whom
he visits, will know when to praise and when to
blame, when to be firm and when to use persuasion only.
Many
un
pleasant truths will have to be told if the work is to be effective, but
he will know how to take
the sting out of them.
He will
possess
that true sympathy which understands the greatest difficulties which
are in the way of those who would endeavor
to rise above their often
debasing
surroundings.
But weakness
is quite
another thing,
and
there is no place in public-health work for such
a characteristic.
It
is uphill work all the time, and the worker must possess the strength
of mind which will enable him to persevere in spite of the most dis
heartening results of his efforts."
Determination
and
patience
therefore
are also
essential.
In the
exercise
of these qualities
the
inspector should know
whereof
he
speaks:
he should be sure that the knowledge of his subject
is pre
cise.
Glittering generalities sound well, but they do not leave as deep
an impression
on those he seeks
to guide as do simple instructions
given
in a manner at once kindly and convincing, which
seems
to
invite rather than compel cooperation.
In this connection
too much
stress can not
be laid
upon the
importance of demonstration
and
memoranda.
Whenever possible,
resort should be made to object les
sons, and written instruction expressed in the simplest phrases should
be given, because, however
well intentioned, people will forget, and
the mere fact that they are being called upon to do something
strange
or unusual
fosters
that unfortunate
trick of
the
mind— forgetful-
ness.
The need of patient repetition will be realized when
the well-
nigh universal resistance
to any change from an old order of things
which has become the habit of life is taken into account.
People get
into
a groove
and
the older they
grow the
deeper that groove
be
comes and the harder it is to get them out of it.
Because
they have
18
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
Vol. XVIt
done
a particular
thing
a certain way for years
they rebel against
having a new way of doing that same thing imposed upon them.
For this and
other
reasons
the credulous person
will
not
accom
plish much.
Deception will be met with daily in almost every branch,
of the work, and the inspector must
be observant,
critical,
accurate,
and thorough.
Nor does the " cocksure,"
self-opinionated individual
usually go very far.
It is necessary for the inspector "to keep an
open mind as to the methods of work and to look out for opportuni
ties of learning from those engaged in the various branches of social
service
as well
as from
others
in his own profession.
A constant
effort will have to be made against becoming
stereotyped
in either
methods
or
ideas,
and
the
public-health
worker,
above
all others,
needs to remind himself frequently that the work of his department,
important
though it is, is only part of
a great endeavor
which
is:
being
made in many directions, by multifarious
agencies,
toward
social amelioration.
If, therefore, the inspector is to be saved from-
isolation and incompetency,
he must contrive to keep in touch with
other
agencies, learn their aims and methods,
and look out for every
opportunity
to cooperate."
Furthermore,
the inspector must
be self-controlled.
An " easy-go-
ing" person
will never
make
progress,
but a bad-tempered
person
will always be getting into difficulties and stultifying the effect of
work which
otherwise might
have
been
valuable.
There
i& ample
cause for annoyance
and
irritation.
Indeed,
"the
inspector
may
look for any sort of treatment —quiet patronage, insolent opposition^,
irritable
impatience
at disturbance,
a quiet acceptance of inspection
as one of the ills of life, or a marked anxiety to please."
His tem
per must be controlled throughout, and an endeavor
to see the point
of view
of the one responsible
for the condition or property under
inspection will make compliance
with this injunction
easier.
"It is:
by no means a pleasant thing to be inspected.
The interruption
alone
is a serious
annoyance
to a busy person
and the very fact of possess
ing the right of entry should make the official
all the more careful
to treat the occupier courteously and respectfully.
This is quite com
patible with
a quiet
dignity.
In
most
cases
the work
can
be car
ried out without friction if this is borne in mind.
It is not always-
easy for an employer to keep discipline among workers, and the dif
ficulty will
be increased if an inspector walks into a premises
as if'
it belonged
to him and speaks autocratically
to the occupier before
the workpeople.
It is always best to
act
as if it were
taken
for
granted
that everything would
be found in due order.
The major
ity of occupiers
err through ignorance, or carelessness, or press of
"
work, and are often quite
unable
to grasp the necessity of the legal-:
standard."
No. 1.
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
1$
Again, no one who is dependent
upon direct orders
as a basis for
his activities
will
ever "get through
more
than 'jog-trot'
routine
work."
Success in the office
demands
initiative
and
resourcefulness
for situations
constantly arise requiring
action without opportunity
for reference to higher authority, and the inspector can not afford to
appear
incompetent
in
emergencies.
Serious trouble can often
be
averted through quick decision
and rapid
action,
and failure in this
direction may also lower the service in the eyes of the public.
Not only are the
requirements
exacting
as regards
the tempera
mental make-up
of the individual,
but
the need " for
good
health
must
be emphatically emphasized.
The work is extremely
hard ; it
involves
a mental
as well
as
a physical strain
and makes
demands
upon the strongest."
Mere freedom
from organized disorder is not
enough.
Finally
the disposition of the inspector should be such as to teach
by example
as well
as precept.
The development
of
a health
con
science in the public is a progression hoped for as an asset to public-
health
organizations—to
the inspector in facilitating
his
work—
and every sanitary inspector should be a nucleus of enthusiasm
for
the health propaganda and spread an understanding of its principles
throughout
his district.
But in doing
so he
must
remember
that
acts speak louder and carry greater force and conviction than words.
His own personal appearance
and
the conduct
of his own life and
surroundings
must therefore
illustrate his advice.
As
regards
general
education
and
special
training,
others
have
spoken
and will
speak.
This phase of the question
of fitness was
not contemplated
in the discussion
planned for this paper other than
to touch upon the need, as has already been done, for
a wider insist
ence upon the degree of fitness represented by a certificate
or diploma
on sanitary
sciences.
It is perhaps
sufficient
to say here that, both in
general and technical education,
the highest is none too good if the
inspector
is to
be able to enter intelligently
into the wider
aspects
of his work and is to perform satisfactorily
the various duties that
may
be properly
imposed
upon him, to say nothing
about
the im
portance
of well-written
letters
and
reports,
an understanding of
statistics
and usefulness of a working knowledge of languages
other
than his own.
" It is certain also that every public-health worker will
be called
upon sooner or later to speak in public.
It may
be only to give
a
'friendly talk' to
a mothers'
meeting,
but even this is
no simple
matter if it is to
be given well, for simplicity
and conciseness
are
rarely combined with
a limited capacity."
It is incumbent
upon all sanitary
inspectors
to see to it that the
possibilities of their profession do not fail of realization
because
of
20
BELL—SANITARY
INSPECTOR
OF THE COMMUNITY.
Vol. XVII.
their neglect
to inform
themselves of the advances
made in sanita
tion..
They
must always do the best they can.
Well enough
is not
sufficient.
A mere show of enthusiasm
and
energy will not satisfy.
To have no deeper interest,
no higher ambition, than the accomplish
ment of that which suffices to save him from censure by his superiors,
exhibits an attitude of mind toward his profession which is bound to
be barren of anything worth while and which in the long run will
make his work a dull occupation.
It is a safeguard to his own per
sonal
contentment
and
essential
to his
success
that he thoroughly
acquaint
himself with both the theoretical and practical sides of his
job and discern all the possibilities in his field of work.
Probably
the large majority
of those
men
and
women
who
are
serving as sanitary
inspectors
in this country to-day have not had
a practical course in sanitary science, but that handicap is not, and
need not be, a serious
impediment to success, nor should it have
any
other effect than to inspire
a determination to learn by reading, ob
servation, and otherwise, anything
and everything that bears upon
the profession.
All those thus situated are in the same position
as
doctors
and lawyers who, in the early days
when
there
were
few if
any schools
and many students,
simply
read
medicine
or law under
the direction of
a preceptor.
At
a certain period of the
world's
progress
some of these men of the old order, so to speak,
had, of
course, to measure themselves
with the product of scientific schools,
and they did it creditably by just the process that is open to the sani
tary inspector
of the old order, or what is hoped will soon
become
an ohi order.
In other words, it is the urgent duty of the sanitary
inspector of this class to readjust his ideas to the fast-coming
new
order of things, and to place his services on the substantial basis of
scientific
knowledge.
The need that all persons occupying the posi
tion of sanitary inspector shall, by every available means and an un
flagging acquisitiveness,
improve their fitness for office
is,
of course,
imperative
;
but, on the reasoning that the process of rusting is more
reprehensible
than the failure
to develop,
the obligation to keep in
touch
with
progress which
rests upon
those who
are happy
pos
sessors of scientific training
as
a
background,
is
as vital
as self-
preservation.
As intimated above, in the last analysis the tell-tale of the efficiency
of the sanitary inspector
is
the health of his district.
By this
I
wish
to be understood
as referring
to the relation of his work to that of
the doctor.
The sanitary officer precedes in the field,
and
it
is
only
where
his failures crop out in relation
to preventable
diseases
that
the doctor steps into the breach.
The sanitary inspector should
be
and
is
coming to be,
more
and
more,
a
valuable accessory
for
the
dissemination of sanitary
gospel
and, in addition,
he stands ready
Xo. 1.
21
BUNKER
ACID-BASE EQUILIBRIUM.
to ameliorate
the situation
where
preventive efforts
have
failed,
but the sanitary inspector must
square
himself
with his conscience
and with the public
and with
his chief that he has honestly and
faithfully done everything that was humanly possible
in the circum
stances to prevent the demand for the doctor's
healing assistance.
ACID-BASE
EaiJILIBRITJM.
By C. W.
O. Bunkeu, Lieutenant
Commander,
Medical
Corps,
United
States
Navy.
Fourteen
years ago Ewing reviewed
the question of acidosis.
Since
that
time
our conceptions
have
undergone
profound
modifications,
and Haldane, Haggard,
Henderson,
and
Van
Slyke
have
figured
prominently in this development.
I have drawn largely upon their
writings
for this article.
At that
time
acidosis
meant
conditions
showing increased
amounts of acetone bodies
in the blood (ketosis)
or in the urine
(ketonuria),
usually
accompanied
by increased
ex
cretion
of
ammonia.
We now, however,
recognize
the
deeper
sig
nificance of this ketosis,
i.
e., that the body
is robbed of its
bases,
and extend the term
acidosis
to include conditions in which
other
factors produce
such a result.
Moreover,
we now realize that acidosis
is but
a particular
phase
of disturbance of the acid-base equilibrium of the body.
Van Slyke
restricts acidosis to
a condition
caused
by acid retention sufficient
to lower either the bicarbonate
or the pH of the blood
below normal
limits.
Work of the past five years
has demonstrated
the necessity
for
a broader
vision, and
we must
conceive
nine clinical
phases of
acid-base
equilibrium,
determined
by
high,
low, or normal
bicar
bonate
in the presence of
a high, low, or normal pH.
The pH of the blood may be considered
the danger signal—as long
as it is normal the acid-base equilibrium
is normal or compensated
;
otherwise, it is uncompensated
and life is seriously threatened.
The
normal pH of the blood
may
be given as 7.3 to 7.5, each individual,
however, having narrower limits.
That of blood
serum
is about
0.2
higher, and that of the other
body fluids (not the excretions)
prob
ably closely approximates and promptly
follows any change in that
of the blood
plasma.
Variations
to the acid
side may, for
a short
time at least, be as low as 7, although not much lower without fatal
results;
7 is considered
as the point where
coma occurs.
Variations
to the alkaline side {alkalosis) beyond
7.8 are accompanied
by symp
toms of tetany,
although one is not at present
justified in assuming
that all tetany
is either caused or accompanied
by alkalosis.
So the
extreme
range
of
reaction
compatible with life probably
lies
ap
proximately between pH of 7 and 7.8.
22
Vol. XVII.
BUNKER
ACID-BASE EQUILIBRIUM.
The hydrogen-ion
concentration (or its derivative, pH)
of
the
blood
varies
as
the ratio
between
the
concentrations
of
dissolved
carbonic acid
and bicarbonate
(generally
indicated by
rfflJQQ
1
in which B represents
the metal, such as Na, K, etc., in the bicarbon
ate), i. e., a relative increase in the H2C03 increases the hydrogen-ion
o
o
o
▼
n
t*
—
*03%sinmoA
concentration (CH+) and lowers the pH, and vice versa.
A full ap
preciation of the significance of this ratio is the basis of an intelli
gent comprehension
of acid-base
equilibrium.
The accompanying chart
(modified from Peters, Barr, and Rule,
and Van Slyke)
is a graphic representation
of essential facts in acid
No. 1.
23
BUNKER—ACID-BASE EQUILIBRIUM.
base equilibrium.
Ordinates represent total C02 (content, which com
prises that in simple solution and that as bicarbonate) of whole blood
in volumes per cent, and abscissae
the millimeters C02 tension in the
blood as withdrawn.
The line OT gives the proportion of total C02
present
in simple solution.
pH values
are shown by the lines OL,
OM. etc.
The extreme normals for carbon-dioxide-absorption
curves
are OP and OE.
These
curves
are obtained
by plotting
the total
C02 of whole blood
after being drawn
and equilibrated with dif
ferent
percentages
(tensions)
of C02.
The intersection of such
a
tune with
total C02 value of the blood as drawn would give the
C02 tension in the blood and also the pH.
The actual state of the acid-base balance can only be determined
by
the use of any two of a number of interdependent
variables, such
as
total C02, C02 tension, pH, H2C03 concentration, other buffers than
bicarbonate, plasma chloride, ratio of oxyhemoglobin to hemoglobin,
etc.
Findings that fall within -ABCD
and
at about
40 millimeters
tension
indicate
a normal equilibrium
for the resting individual
at
ordinary altitudes ; or, such
a normal would be a total C02 of about
49 (43-56)
volumes per cent for whole
blood, and 50-65 volumes
per
cent for plasma.
The normal for the individual
falls
within
nar
rower limits.
The C02 tension of alveolar air may
be the same or
vary as much
as 20 millimeters below, while that of venous blood will
be about 6 (0.8-10) millimeters higher than that of arterial
blood.
So, although
the C02 tension in alveolar air is usually approximately
that in arterial
blood,
it is not an accurate
measure
of the latter,
being dependent
upon
the
extent
to
which pathological
processes
may influence
ventilation
of alveoli
or alter their
walls
so
as
to
impair diffusion,
etc.
The "C02
capacity
(combining
power)"
of
plasma may
be as much
as 15 volumes
per cent more than the total
C02 of whole blood.
The ratio,
, is influenced
by many factors, of which the
following
is an analysis.
To increase or protect bicarbonate
:
1. Administration
of same.
2. Loss of gastric HC1 caused by obstructing
the pylorus,
and
regularly washing out the stomach for some days.
3. Processes
indicated by increased
excretion
via
the urine of
ammonia
(probably
diverted from
urea
formation)
and
titrable
acid
(including
buffer acids,
such
as acid
phos
phates)
.
4. Possibly
a shift of HC1 to the tissue
cells
from the
plasma
like that from the plasma
to blood
cells.
24
Vol. XVII
BUNKER
ACID-BASE
EQUILIBRIUM.
To decrease bicarbonate:
5. Acid substances.
(a)
Increased production.
(b)
Decreased elimination.
(<?)
Administration
of same.
6. Diuresis, and elimination via the urine.
7. Lack of factor
three
above.
8. The hyperpncea
of oxygen want.
To increase carbonic acid:
9. Administration
of same.
10. Impaired
diffusion in the alveoli of the lungs.
11. Slowing of respiration.
To decrease carbonic acid:
12. Hyperpnoea.
(a)
Voluntary.
(6)
Due to disease processes.
(c)
Due to low oxygen
content of air.
(d)
Emersion from warm water.
13. Low atmospheric
content of C02.
If either the H,CO, or bicarbonate
vary from normal values,
there
is apparently an effort on the part of the body to adjust the other so
as to maintain
at least
a normal pH
(compensation).
This is
ac
complished by respiration, or by diverting
alkali
from, or recalling
it to, the blood
stream.
In the chemical
complex
presented
by the
body fluids, the C02, or H2C03, is the easily
variable factor, at the
same time
activating
and
being
itself
regulattd
by the respiratory
center.
The latter is extraordinarily
sensitive
to the slightest altera
tion in the reaction of the blood toward the acid
side.
C
-f- is, so
to
speak,
the
hormone
of respiration.
Normally,
the
bicarbonate
(represented
in
the ratio
by BHCOs)
is maintained
at
a definite
level,
so much
so
as to
be
a physiological
constant
(more
so
than
temperature
or osmotic
pressure).
In case
the respiratory
control
of H2C03 is inadequate
to maintain
a normal pH, some bicarbonate
will disappear from the blood
stream if the [ILC03]
is diminished.
A
relative
increase
in
[H2C03]
recalls
bicarbonate
to
the
blood
stream, or an increase of the latter is effected by the hemoglobin as
noted below.
Such is the normal mechanism
by means of which the
constancy
of the ratio, and, consequently,
the pH, is preserved.
Another
powerful
factor, however,
also aids in the control of the
pH of the blood, i. e., the buffers.
Such substances in solution afford
a high
resistance
to change
in reaction —they
tend
to minimize the
effect of added
acid or alkali
so that the pH is but little
affected.
The body fluids contain a mixture of such chemical
substances
that
is probably
as satisfactory
as could
be devised,
being effective
in
colloidal
as well
as aqueous solution.
The important
blood buffers
No. 1.
25
BUNKER—ACID-BASE EQUILIBRIUM.
are
bicarbonates
in
plasma
and
cells,
proteins
(especially
hemo
globin), and phosphates
in the cells.
The hemoglobin,
in addition
to its general
buffer effect
as
a pro
tein, is especially
important since, by virtue of it and the reversible
reaction
H2C03+NaCl=HCl+NaHCOs,
the erythrocytes
not only control the [BHCO„]
but also transport
SO to 95 per cent
(sometimes
possibly all) of the C02 to the lungs.
The HC1 passes into the cell and is probably held by the hemoglobin,
although,
when .the latter is overburdened,
another buffer may
be
called into play, i. e.
HCl+Na.HPO^Nall.PO.+NaCl.
The relatively slight remainder of alkali
necessary for transporta
tion of the rest of the CG2 is supplied by the other
buffers,
i. e., cell
phosphates,
plasma
proteins,
and bicarbonate.
In the lungs, the C02
is excreted
and NaCl reformed.
The acid
phosphate
would
be ex
creted in the urine.
This ability of the hemoglobin
to form bicarbonate
is important,
inasmuch
as it not
only aids in
the
regulation
of the
[HX'O,]
:
[HHC03]
ratio, but
also because the corpuscles
can thus conceal
5
to
10 times
as much acid as the plasma
bicarbonate
can ordinarily
neutralize.
Moreover, by so controlling
the acid, H2C03, itself, the
hemoglobin
enables the cells to use their reserves of buffer alkali
to
maintain a constant
pH in the plasma.
The numbered
regions
of the chart
are
associated
with
various
clinical conditions, e. g., tetany from 1, 2, and
3 ; the acidosis of dia
betes mellitus.
nephritis, or infantile
marasmus
with
6 or 9;
pneu
monia, morphine
narcosis,
and
breathing of air containing
3 to
5
per cent C02 with
7 or 8; emphysema
with 4: some cardiac
cases
with 9; overdose of bicarbonate
with
1 or 4; fever with 2; as the re
sult of high altitudes,
2 or 3, or, when acclimated,
6: shock (handling
of the intestines), deep ether
anesthesia,
and
carbon-monoxide
as
phyxia with lowered
bicarbonate.
Relative to these areas, I will further brief a recent article by Van
Slyke,
and refer to the factors influencing the
[H2C03]
: [BHC03]
by their numbers in the analysis above.
Area
1 is uncompensated
alkali
excess.
Factors
1
(overdose)
and
2 will produce it. It will be accompanied
by compensatory
factors,
such
as
6
(may
excrete
several
grams
bicarbonate
per hour),
7
(titrable acid may become a negative quantity),
and
11.
Areas 3 (partial
compensation)
and 2 cover uncompensated
carbon-
dioxide deficit,
2 representing the first result of lowering the [H2C03]
in the blood
by a respiratory
stimulus other
than either the blood
hydrion
or the
[H2C03].
Genesis,
factors 12
a, c, or d.
Compen
26
Vol. XVII.
BUNKER
ACID-BASE
EQUILIBRIUM.
satory, factor
6 (only
a fraction of
a gram of bicarbonate
excreted
per hour) , and retention of acid metabolites
as shown
by factor 7.
Area
4 is
compensated
alkali
excess or
carbon-dioxide
excess.
Genesis
of former, factor
1
(the moderate
overdose orally
adminis
tered, which usually is not absorbed rapidly), and as entire
compen
sation
for area
1.
Genesis
of
compensated
carbon-dioxide
excess,
factors 10, possibly 4, and as entire compensation
for area 7.
Differ
ential
diagnosis,
compensated
carbon-dioxide
excess
is
associated
with cyanosis,
either permanent
or caused by slight exertion.
Area
5 is the normal for the resting individual in health at ordi
nary
altitudes.
May
be
final
compensatory
result from
adjacent
areas.
Area
6
is
compensated
alkali
deficit
or
carbon-dioxide
deficit.
Genesis of former, factors 5 a or b.
Compensatory for former, fac
tors 3 or 12 b.
Genesis of latter, factors 12, 13, and
as entire com
pensation for area 3.
Compensatory for compensated
carbon-dioxide
deficit, factor
8.
Areas 7 (partial compensation)
and 8 are uncompensated
carbon-
dioxide
excess.
Genesis,
factors
9 (air with
3 to
5 per cent CO,),
10, and
11.
Compensatory, factors 3, 12, and probably 4.
Area
9 is
the premortal
uncompensated
alkali
deficit.
Genesis,
from area 6.
Normal
metabolism
results
in the
constant
formation
of
acids
(H2C03,
H2S04,
H3P04,
etc.).
H2CO„
is probably
the
most
im
portant, being one of the chief end-products of catabolism
of
car
bohydrates, proteins, and
fats.
Fats and
amino
acids
give rise
to
fatty acids, the process normally terminating in butyric acid.
These
acids
react with the alkali
(fixed bases) of the tissues,
and
are ex
creted as salts of Na, K, Ca, Mg, etc.
The animal body furnishes the
curious
anomaly
of
alkaline
tissues
eliminating
acid
excretions
(principally C02 from the lungs and acid phosphates
from the kid
neys).
So beneath all metabolism
is a constant
diminution
of alkali,
notably blood bicarbonate.
Unless this depletion is repaired, acidosis
develops.
Normally, of course, the alkalis
are restored
by the food.
This, however, is not the entire story of the blood alkali.
Haggard
and Henderson call such a diminution,
i. e., as the result of acids, the
acidotic process.
They have also demonstrated
that the bicarbonate
may be varied in another
manner,
by the acapnial process.
In the
latter, variations in [H2C03]
automatically divert bicarbonate
from,
or recall it to, the blood stream,
as noted previously, in the apparent
attempt
to preserve
the [H2C03]
: [BHCO„]
ratio and thus a normal
pH.
" Various influences
and conditions excite the respiratory center
through agencies other than increase of hydrogen-ion
concentration.
This results in overbreathing and an excessive elimination of carbon
dioxide which leaves the blood abnormally alkaline.
A gradual com
No.1.
27
BUNKEK—ACID-BASE EQUILIBRIUM.
pensatory disappearance
of alkali from the blood follows."
Slowing
of respiration will tend to produce
an acidosis
by reason of retention
of HjC03, and alkali will be recalled.
So, an alkalosis may be a com
pensatory effort, just
as, under such conditions, an acidosis
may be
a restorative process.
The acidotic process above may
become accentuated
in disease by
reason of the presence of acid substances in increased
amount.
This
is due to increased
production (or ingestion) or to decreased elimina
tion.
Ketosis is the important example
of acidosis
due to abnormal
formation
of acid
substances,
while retention of acid phosphates
is
that of decreased elimination.
In both
cases,
the body is robbed of
its alkali.
As regards lactic acid, it is very ineffective
in the pro
duction of acidosis,
and
Haggard
and
Henderson
say, "It is im
probable that such
a condition
as 'lactic acid acidosis'
ever occurs
in life.
An increase of lactates in the blood or urine is probably an
indication,
not of
acidosis,
but of low ratio of H2C03
: NaHC03 ;
that
is,
alkalosis."
Fats normally are oxidized to butyric acid.
When, however,
there
is
a
deficiency
of, or lack of proper
tolerance
for,
carbohydrates
this
oxidation
is
incomplete
and
defective,
and
acetone
bodies
(acetone,
diacetic acid,
and
fi-hydroxybutyric
acid)
are formed in
increased
quantity.
Normally
there
is
a
slight but definite
produc
tion of acetone bodies.
To prevent ketosis,
one molecule
of carbo
hydrate must undergo combustion
for every three molecules of higher
fatty acids.
Acid
neutralization
normally
results in
the production
of acid
phosphates
(such
as NaH2POJ
from
basic
phosphates
(such
as
Na2HP04).
The former are then excreted by the kidney, and consti
tute about 90 per cent of the phosphates
in the urine.
Pathologically
and probably
as
the result of impaired
kidney
function
the
acid
phosphates are retained.
I
have indicated above the means by which the organism meets the
attack of acids upon its alkali, viz, respiratory control of C02, hemo
globin control of bicarbonate,
the
action
of buffer substances,
and
ingestion of
alkali
in
food.
The
average
total alkali of normal
human
blood available for the neutralization
of invading
acids
is
equivalent to 63 volume
per
cent of bicarbonate C02, of which
46
volume per cent belongs to bicarbonate alkali and 17 volume per cent
to the other
buffers
(mostly hemoglobin).
Buffers from the tissues
or other body fluids
also
become available in extreme
cases.
The
bicarbonate first meets
the onslaught, and
it
will maintain
a
normal
pH until reduced
to one-fourth
(perhaps even to one-eighth) of its
normal
value.
If, nevertheless,
the pH falls (and only then),
the
other buffers
are used;
and if
it
reaches
7
most of the remaining
bicarbonate
becomes available.
103390—22
3
28
Vol.
XVII
BUNKER
ACID-BASE
EQUILIBRIUM.
In connection
with
this
defensive
mechanism,
ammonia
must
be
mentioned.
Nash and Benedict present strong evidence to the effect
that there
is probably less NH3 in the blood than usually
believed,
and
also that
it,
as well
as the urinary
NH3,
is
the product of an
active
synthetic function of the kidneys themselves.
They
believe
that the " kidney, instead of excreting NHf from the blood, forms the
NH3 Avhich
it
excretes, while at the same
time
it
contributes a small
amount
of NH3 to the blood."
The source of the NH3 may be
the
blood
urea,
or, possibly, from
deamination of amino acids.
Such
NH3
is
available for the neutralization
of acid radicles only as they
are excreted,
and, in such neutralization, alkali
is
preserved
for
the
blood.
With impaired kidney function the result might
be
a
reten
tion
of
acid
radicles
or
defective
NH2
formation.
The
former
would deplete
the alkali
reserve;
the latter would permit excessive
loss of base during excretion of the acid.
The acid-base equilibrium of the body, then,
is
controlled by
a
mar-
velously sensitive
mechanism
that
constantly and
automatically
en
deavors
to preserve
a
normal alkali reserve and
a
normal pH.
Fail
ing in the former,
it
at least functions to maintain compensation
(a
normal pH).
if
possible.
In dealing with pH
values,
one usually
does
not appreciate
the extremely
small magnitudes in question.
It
might be well to place the extreme range of reaction compatible with
life (pH of
7
to
7.8) —not the lesser normal range
of 7.3 to 7.5—in
other terms.
Thus,
if
life
is
to be preserved,
the weight of hydrogen
ion per liter of blood
must not be more than one ten-millionth
of
a
gram, nor can
it
be so little
as one one-hundred-millionth
of
a
gram.
The appearance
of acidosis
in disease constitutes
a
serious compli
cation
demanding immediate
attention.
This
is
especially true for
females
and infants and children,
because their plasma
bicarbonate
is
normally lower than in men.
This difference
amounts
to about
8
volume
per
cent CO, with
women,
and
about
10 volume
per
cent
C02 with children.
I
have already called
attention to several
clinical conditions
asso
ciated with disturbance
of some phase of acid-base equilibrium.
The
acidosis
in the
cases
of carbon monoxide
asphyxia
and
deep ether
anesthesia
is
the result of acapnial processes.
We must also be pre
pared for acidosis
in terminal malignancy, starvation
(whether
the
result
of ulcer, malignancy, or otherwise), severe eclampisia, wood-
alcohol
poisoning,
salicylate
poisoning,
and
following
chloroform
anesthesia.
Acidosis
is
usually present
at time of death, and may be
its immediate
cause.
The surgeon
is
particularly
concerned
with
the influence of anes
thesia
upon
acid-base
equilibrium,
as well
as with
the detrimental
effect
of
acidosis
upon
convelescence.
Ether
causes
a
decrease
Xo. 1.
29
BUNKER—ACID-BASE EQUILIBRIUM.
of 4
to
17
volume
per
cent in
plasma
C02 capacity,
and
chloro
form
has an even more pronounced
effect.
In spinal or gas-oxygen
anesthesia,
the fall is but slight.
Hemorrhage and shock
accentuate
the danger.
The acidosis of diabetes mellitus is characterized by a ketosis, keto-
nuria
(as long as kidney function for acetone bodies is not markedly
impaired), and increased
ammonia
quotient
of the urine.
The blood
phosphates
are not increased.
Kidney function is commonly
impaired in nephritis, and then there
may
be decreased elimination of acid radicles,
and interference
with
the ammonia function.
This change in function
does not necessarily
parallel
that for chlorides or urea.
The acidosis
is largely
due to
retention of acid phosphates,
figures
as high
as 23 mg.
per
100 ml.
blood serum being obtained
for inorganic
phosphates.
There is also
probably an
increased
production
of
acid
radicles, although
there
is no ketosis nor material increase of lactic acid.
The NH3 quotient
is variable,
as one would expect, and is of little clinical
significance.
Generally there is not even a moderately
severe acidosis without con
siderable
nitrogen retention (a blood urea nitrogen of over
30 mg.
per 100 ml. demands examination for acidosis) . All fatal cases with
marked nitrogen retention show
severe acidosis,
sufficient
to be the
immediate
cause of death.
Acute nephritis
may show
a pronounced
acidosis
but no nitrogen
retention.
Acidosis
is usual with
a two-
hour phthalein test of under 30 per cent ; with over 30 per cent, how
ever, it is only found if there is severe toxemia,
such
as occurs
in
active parenchymatous types and in infections.
Infants and children are especially
susceptible
to acidosis by reason
of their normally
low level of C02 tension
and plasma
bicarbonate,
and,
with
them, it constitutes
a
very
fatal
complication.
It may
occur alone, or as the result of improper diet, or be a feature of other
dieases, especially alimentary tract disturbances
(diarrheas, cyclical
vomiting, etc.), and
pneumonia.
It is said
that infantile
diarrhea
with ileocolitis shows
a marked
ketosis.
but, lacking
the ileocolitis,
the ketosis is only moderate
and the acidosis
is then due to phosphate
retention.
The acidosis
resulting from
ether
is not only acapnial in origin
l>ut often shows
a ketosis.
Ketosis may also
occur in fever, malignancy,
psychoses,
and le
sions of the central nervous
system,
delayed
chloroform
poisoning,
liyperemesis
gravidarum, inanition, cachexia, starvation, etc.
Tiie symptomatology of disturbances
of the acid-base
equilibrium
is well known.
Alkalosis
accompanied
by tetany
may
be expected
to present
the symptoms
of the latter, including
carpopedal spasm,
Chvostek's
sign, Erb's sign. Trousseau's sign, etc.
The classic
evi
30
Vol. XVII
BUXKEH
ACID-BASE EQUILIBRIUM.
dence of acidosis
is Kusselmaul's air hunger—a respiratory
disturb
ance manifesting hyperpnoeic
dyspnoea without cyanosis, perhaps even
with
an abnormally
bright
color of the mucous
membranes.
This
hyperpncea
is the best of all the signs of acidosis
to be obtained
by
physical examination alone.
Such symptoms,
however,
occur
only
with the severer degrees of disturbance of the acid-base
equilibrium,
and earlier evidence
must
be sought
in the blood and secretions
by
laboratory
procedures if timely intervention is to
be secured.
Van
Slyke's
resume
above relative to different
areas of the chart indi
cates some points in diagnosis.
Dyspnoea
on exertion may
precede
the true hyperpncea.
Van Slyke
also calls attention to the fact that two variables
are
necessary for an exact
estimate
of the
status of acid-base
equilib
rium, as noted above.
But he furthermore states that the conditions
(diabetes
mellitus, nephritis, metabolic
disturbances of infants,
and
most
other pathological
as well
as normal
conditions)
most
com
monly examined
in this respect usually
present
a normal pH,
and,
when only one determination is made, either the carbon-dioxide
ten
sion or the carbon-dioxide combining power of whole blood
(pref
erably) or plasma will suffice.
With an abnormal pH, however, de
termination of only
one variable will
be
inadequate
to
accurately
define the condition.
Clinical methods
comprise
tests for whole blood or plasma
C02 or
bicarbonate,
alveolar CO, tension,
bicarbonate
(soda)
tolerance, pH
of blood or urine, Sellard's test, NH3 quotient of urine, or presence
of abnormal acids
(particularly acetone bodies)
in blood
or urine.
The first two methods
are the ones of choice, particularly
the first, as
by it one can estimate
the reserve of the very important blood buf
fer, bicarbonate,
and its result
closely
indicates
the
total
buffers.
Free H2C03 is present in the body fluids in such concentration that
it automatically
converts
into bicarbonate
all
bases
not
bound
by
other acids.
The bicarbonate, therefore, represents
the excess of base
which is left after all the nonvolatile
acids
have
been neutralized,
and it is available for the immediate
neutralization of further
acids.
In this sense, it constitutes
the alkali reserve of the body.
The en
trance
of free acids
reduces bicarbonate "to an extent
proportionate
to their amount.
The determination of plasma
bicarbonate
(C02 capacity, or C02
combining
power)
by either
the
gas or titration
method
of Van
Slyke
is not difficult.
It may
be considered
the standard method,
and the cooperation
of the patient is not needed.
Normal values for
men were given as 77 to
53 volume
per cent;
53 to 40 means mild
acidosis
without symptoms; 40 to 30,
a moderate
to severe acidosis,
possibly with symptoms;
less than 30, severe with symptoms;
20 is
osually fatal.
Xo. 1.
31
BUXKER—ACID-BASE EQUILJBKIUM.
The alveolar C02 tension
is a practical measure of the blood bicar
bonate, but the cooperation
of the patient is desirable.
The sample
of expired air obtained
at the end of a full expiration after a normal
inspiration should approximate the C02 tension in the arterial blood,
although,
as already noted, it may
be
on
occasion
as
much
as
20
millimeters
lower.
One obtained
by rebreathing is closer to that of
venous
blood.
Results
are
affected
by
manjT
conditions,
e.
g.,
pathological
processes,
especially
pulmonary
and
advanced
cardiac
disease, drugs, emotion,
atmospheric
conditions, position of the body,
digestion, etc.
The tensions in infants is 3 to 5 millimeters lower than
in adults.
For the latter, 40 to 45 millimeters is normal, 30 to 35 in
dicative of mild acidosis,
20 millimeters means imminent danger, and
8 to 10 may be observed in coma.
The tolerance
for bicarbonate
is
a very convenient
and practical
measure of acidosis,
and
means the
dose of sodium bicarbonate re
quired
to
produce
a
urine
alkaline
or
amphoteric
to
litmus.
A
normal finding is 5 to 10 grams ; 20 is required with a mild ; 30 to 40
with a more
severe ; and more than 40 grams with extreme
degrees
of acidosis.
In coma, it is usually impossible to produce
an alkaline
urine.
Kidney function
does not interfere with bicarbonate excre
tion, and tolerance
is the result of a need for fixed bases.
Determination of the pH is clinically
unsatisfactory, especially in
the
urine
where
it
is particularly
unreliable.
In
the
blood,
the
change is small and
late,
and
results
lack uniformity by reason
of
the technic.
Titration
does not measure
hydrion,
and
is unsatis
factory as the proteins interfere with
a clear end point.
Certain
changes in the urine are recognized
and acceptable
as indi
rect evidence of acidosis,
but they
are not
synonymous
and
are de
pendent upon renal integrity
and other factors for constancy.
These
comprise
acetone
bodies,
NH3
quotient, and
titrable
acidity.
The
last is of no real service clinically,
and it must be borne in mind that
acetone bodies are not necessarily
present in, nor is the NHS quotient
necessarily affected
by,
acidosis.
The
changes
neither parallel
the
severity
of
acidosis,
nor
measure
the
efficiency
of
compensatory
processes.
They
have
diagnostic
value,
but
are
not
safe
clinical
guides otherwise.
tennined
and upon
a mixed
diet,
is
normally
about
5
per
cent.
Values of 10 to 40 per cent occur in acidosis.
It may be increased
by
diet, disturbances
of protein metabolism,
ammoniacal
fermentation,
etc., and there
may
be no increase
in certain diseases with
acidosis.
It is said that the NH, parallels the acetone bodies,
and is
a better
measure of ketosis.
The ammonia
of urine, as usually de-
32
BUNKER
ACID-BASE
EQUILIBRIUM.
Vol. XVII
Acetone
and
diacetic
acid have
the
same
clinical
significance:
a
progressive
increase gives
a grave prognosis, and it is generally con
sidered
that
the presence of (3-hydroxybutyric
acid indicates
greater
severity.
It is well to bear in mind that the sodium
nitroprusside
tests for acetone are really
delicate
tests for diacetic
acid.
But
as
these
substances
have
the
same
significance,
it
is
wasted
effort
to
attempt
to clinically
differentiate them.
It is said that the kidneys
do not excrete acetone but do diacetic
acid, the latter changing into
the former in the urine, which, when freshly
passed, contains
about
10 times
as much diacetic
acid
as acetone.
More acetone forms as the
urine stands.
The qualitative
test for
acetone bodies in the breath
is sensitive,
and yields positive results earlier than Gerhardt's test on
urine.
Moreover, it is useful when
impaired kidney function
pre
vents excretion
of acetone bodies via the kidneys.
One might men
tion in passing that the sweetish odor in such a breath
is not due to
acetone, but to some
associated unidentified substance.
Intelligent
treatment
demands
a
recognition
of
the
etiological
factors involved.
With acidosis,
is it acapnial or acidotic in origin '(
In
general,
the
former
calls for administration
of
CO„. and the
latter for bicarbonate
; the use of the wrong one is dangerous.
The
former is employed
as a
6 to
10 per cent mixture in oxygen.
Mar
riott and Haessler call attention to a point that may have therapeutic
bearing.
With
phosphate
retention, the calcium in serum
may
be
decreased
to
1.5
mg.
per
100 mils.
Administration
of
phosphate
causes
an
increased
elimination
of calcium
via
the
feces, and the
converse
is
also
true.
Bicarbonate
(sodium
bicarbonate)
seems
especially
efficacious
in conditions
associated
with
phosphate
reten
tion.
It is now
about
a decade since Sellards obtained
his brilliant
results
in the acute nephritis of cholera,
and since Fischer advised
alkalinization
in similar conditions.
Bicarbonate is less effective in
the
presence
of
ketosis.
Glucose
is
indicated
in
conditions with
ketosis
due to carbohydrate deficiency,
providing
the organism can
assimilate it.
The administration of bicarbonate
is best controlled by estimations
of the
plasma
C02 capacity;
0.5 gram NaHCO.,
per
19 kilograms
body weight will raise it
1 volume
per cent.
Palmer,
Salvesen,
and
Jackson
recommend
its
oral
administration
(nausea
is
a
contra
indication)
in 100 mils of water every
30 minutes, using 2, 5, and
10
grams
as the dose in cases showing plasma C02 capacities
of over 50,
40 to 50, and less than 40 vplume
per cent, respectively.
For more
severe
acidosis
they
advise
administration
every
hour.
The effect
is determined
by
blood
examinations, the
frequency
of which they
lessen by following
the pH of the urine colorimetrically
before each
dose.
An increase of 0.3 to 0.4 in the pH calls for a determination
of
plasma
bicarbonate.
The more
usual
procedure,
however,
is to
No. 1.
33
BUNKER
ACID-BASE
EQUILIBRIUM.
stop the bicarbonate
when
the urine
is alkaline
or amphoteric to
litmus.
Methyl
red
is a better
indicator for the urine than litmus
in that, by ceasing administration
when the urine produces
a yellow
color with methyl red, one lessens the danger
of overdosage.
Relative
to the administration
of bicarbonate
in treatment,
there
is now
a decided
reaction
against
the
use of injudicious
amounts,
by reason of the danger of alkalosis.
There is a tendency
to employ
it only
in
decompensated
acidosis,
and
certainly
to control it by
estimations of the
plasma
C02
capacity.
It
is distinctly
contra-
indicated
in
conditions
with
a
low
plasma
C02
capacity
due
to
acapnial processes.
L. J. Henderson states that any attempt
to treat
a disease like nephritis by the indiscriminate administration
of large
amounts of alkali is malpractice.
Small amounts
over a long period
are justifiable and make
acidosis
impossible.
In most pathological
cases, the urine does not become more alkaline than the blood until
the plasma
bicarbonate
is above normal.
Therefore,
reliance
upon
a urine alkaline
to litmus may
involve the
use of unnecessary
and
possibly injurious
amounts of bicarbonate,
and erroneous
deductions
as regards the severity
of the acidosis.
In surgery, as noted above, evidence of even slight acidosis
should
be corrected prior to operation by the administration of bicarbonate.
Frank states that the patient is not in
the best possible
condition
to
undergo
any
surgical
procedure
when
he has
a blood pH of
below
7.35, an alveolar C02 tension
below
35 millimeters, or a soda
tolerance
test above 15 grams.
One should add a plasma
bicarbonate
under
53
volume
per
cent C02.
Women and children
should
be
especially considered
in view of their normally
low alkali
reserve.
For
the very depressed
condition following
prolonged etherization,
Haggard
and Henderson
recommend
the
use
of
the
C02 mixture
noted above,
as it induces
hyperpnoea,
helps
remove
the anesthetic,
and restores the plasma
C02 and bicarbonate.
Alkali is of only minor value in the acidosis
of diabetes mellitus
Its effect is temporary, being often lost in
a few hours,
and heroic
injections
are often required.
It is of definite
value
only in long
and
stubborn
acidosis,
or to
combat
coma in certain severe
cases.
Twenty-five grams in
5 per cent solution may
be used intravenously
for impending coma.
Death is not necessarily
caused by
the reac
tion of the
blood,
for
alkalinization
may
keep it normal, but the
patient may
die in coma with typical
ketosis.
The ketosis
is better
controlled
by other methods,
especially
periods of fasting alternating
with
periods
of properly
adjusted
diet,
combined
with
rest
and
warmth.
Fasting is more apt to be followed by acidosis
in
a normal
person
than in
a
diabetic.
The
ketosis
is not necessarily
due
to
lack of
carbohydrates,
but,
perhaps,
they
do
the
most
to control
it by insuring
proper oxidation
of
fats,
and
the
rates
of protein
34
NEUBERGER —AVIATION
MEDICINE IN TJ. S. NAVY.
Vol. XVH.
and
fat metabolism
must be lowered
to meet that of carbohydrate.
It must not be forgotten that proteins yield 48 to 80 per cent glucose
in metabolism,
depending upon the variety.
As with all methods of
treatment,
acidosis
is more
to
be
feared
than hyperglycemia,
but
especially with
the Allen method.
The
plasma
bicarbonate
should
be closely followed, and, with the Allen treatment,
a certain drop is
permissible before interruption
of the fast.
With an initial plasma
C02 capacity of 77 to 53 volume
per cent CO., a drop to 45 is allow
able : with
53 to 40, a further drop of 5 to 10 volume per cent ; with
40 to 31,
a drop of 2 to 3; with
less than 31, interrupt
the fast in
6 to 12 hours unless the value
rises by reason of the fast and
alka
linization.
Alkali is of real value in nephritis, especially in acute types.
Even
in the chronic or in the uremic cases, it affords at least much
symp
tomatic relief.
Sellards separates the frankly parenchymatous types
as having
a very low bicarbonate
tolerance,
small doses often pro
ducing an alkaline urine ; and one should be careful in any attempts
at alkalinization
in such
cases,
as they
may
react violently.
With
the other types, the effect of a course of bicarbonate
lasts for a com
paratively
long
time,
a normal
response
occurring
after
possibly
even weesk.
Acidosis itself is not infrequently
the immediate
cause
of death in the nephropathies.
As regards
infants and children, restortaion of bases may produce
a normal blood bicarbonate
and alleviate hyperpncea,
but the child
dies nevertheless.
Alkali
gives good results with older children, but
an acidosis
once established
in infants
may result in death
despite
it.
It
is,
therefore,
desirable
to begin alkalinization
even
before
acidosis
is
demonstrable.
Rapid action should
be sought,
and any
method
may
be used, although
a
4
per cent solution intravenously
is
considered
preferable
;
the alkali
is
administered until the usual urine
reaction
is
obtained,
and even 10 grams per 24 hours has been given
to an infant aged less than one year.
With
ketosis,
no glycuresis,
and
a
normal blood sugar, give glucose.
One should also administer
much
water.
AVIATION MEDICINE
IN THE
UNITED
STATES NAVY.
By J. F.
N'euberger,
Lieutenant,
Medical
Corps,
United
States
Nary.
HYGIENE
OF THE AVIATOR.
As has been repeatedly
stated, aviation medicine
has as
a
primary
function
the task of keeping the flier physically
and
mentally
fit.
When
the United
States
entered
the war medical
officers had had
little opportunity
to study the
effects of continuous flying
on
the
airman.
It was soon realized that the ordinary standards of fitness
Xo. 1.
NEUBERGER —AVIATION
MEDICINE IN U.
S. NAVY.
35
for the regular officers of the line and staff of the Army and Navy
were not applicable to the aviator.
The first aim of the leaders
in
aviation medicine was
to
determine
standards of
fitness
required
in air work and to find an explanation for the physical and
mental
deterioration
observed
among
aviators.
The Army early
recognized
the necessity
of keeping their fliers
in the pink of condition
and
physical directors were
provided
for
the various training fields of the air service.
These
physical direc
tors cooperated
with the flight surgeons not only in keeping the men
in the best condition
possible,
but also in teaching them how
to in
crease their natural strength
and endurance,
to sharpen
their powers
of alertness and to obtain quick, cool action, and muscular and mental
coordination.
These physical directors did wonderful
work during
the war and were in no small way responsible
for the excellent
work
of the air service in the armies of the Allies.
In the Army's publication, Aviation Medicine in the A. E. F., it
is stated that experience
has shown that in sports,
in which the sub
ject is undergoing great physical and nervous
strain, the period of
efficiency
is limited.
It is impossible to fix
the exact
duration
of
this period.
It depends upon the physical endowment
of the subject
and the care he gives his body.
However,
each athlete
has his day,
some lasting only a short period, some for months or even years.
The
strain
in aviation,
especially in war
times,
demands
more
of
the
human mechanism
than any other sport.
It also follows, therefrom,
that the period of efficiency
is limited.
The exact duration of this
period will depend
upon
the effort demanded
from
the subject,
the
condition under which flights are made, and above all, upon the mode
of life of the aviator.
The necessity for health comes from the fact
that the aviator has need of all his physical energy
and intelligence.
Flying is a question
of an active- well-balanced, decisive
mind, and
of quick
reflex
actions.
Not
a thing
can
be left to chance.
Every
flier must quickly recognize
the slightest difficulty with his machine.
His
senses
must
give him
accurate
information
of
changes
in the
rhythm of his motor, of the sing of the air across the wires of his
machine,
and
of his position in space.
He must be master
of his
impressions and
be ready
to make prompt decisions
in a calm,
cool
manner.
His correcting movements
should be made with precision
and without exaggeration.
It is clearly recognized
that the aviator's
reaction
to stimuli
are disturbed by disease, worry,
fatigue or after
excesses.
A delay of a second or a part of a second in correcting an
error in the air or in landing mean all the difference
between
a crash
and safety.
Excellent physical condition permits the body to react
with more adequate
compensation
to altitude
and
cold.
Hygienic
living is necessary to keep the body and mind in good condition.
36
NEUBERGER
AVIATION
MEDICINE IN U. S. NAVY.
Vol. XVII
Sleep
is
most
important.
Firm-nerved
men
become
vacillating
and irritable on account of lack of sleep, and are quick to take offense.
Troubles
that would
be laughed away by rested men are magnified
by sluggish brains.
Eight hours of sleep is a good average.
A few
men
seem
to
be able to do efficient
work with
seven hours or less.
Edison
is one of these.
It is said Napoleon was another.
But it is
known that Napoleon in his later years showed
a loss of energy
due
to accumulated
fatigue,
as
he often dropped asleep in the midst of
important matters.
To get the sleep one needs, often takes courage,
the courage
to refuse the invitations of pleasure.
It is believed
that
lack of sleep
is responsible
for
many
minor
illnesses,
because
it
lowers
the vitality or resistance of the body,
thereby
increasing
its
susceptibility
to infection.
Alcohol. —The
alcohol
problem,
despite
prohibition
and
many
opinions to the contrary, is still a grave
one.
The consequences
of
drinking are too well known to every one to even be discussed, except
to show that too much indulgence in alcohol has been the cause of
the
loss of many
a
good
flier
to the
service.
It
is often claimed,
however,
by aviators that a man can fly better
when
slightly
under
the influence of alcohol.
The writer's experience,
however,
does not
confirm
the
above
statement.
Excessive
alcohol will
remove
the
sense of fear so that the flier becomes reckless
and
careless and does
not use his best judgment in case of difficulty.
Major Dunlap
at the
research
laboratory, Mineola,
has shown by experience
that alcohol
produces
the same effect as high altitude or low oxygen.
It is very
easy for a pilot to lower his physical condition to the point of useless-
ness by the constant
use of alcohol.
He may be able to fly, but he is
not flying at his best.
Clouded brains prove
dangerous
and are not
fit to direct an air or sea plane.
Smoking.— Smoking
when
carried
on
to
such
an
extent
as
to
cause
nervousness,
palpitation
of the
heart,
faintness.
or impair
ment
of vision
must
be curtailed.
Most aviators smoke
too much,
and
in
talking
to
them
about
it
they
will
all
admit it.
yet
they
keep
on smoking.
Excessive smoking
makes
the flier turn out of
bed
heavy of head and this in turn, together with lowered vitality,
causes loss of enthusiasm
in his work
and has a tendency
to break
down his morale.
Underwood
and
Reeves,
in writing on " The ef
fects of smoking on the visual acuity,"
state that one of the great
est
difficulities
encountered
in
their
work
was
that
most
of
the
workers
are
habitual
smokers
and^are
never
free
from
any
such
effects
as smoking
may
have.
This
makes
a
control
test, in
the
strict
sense
of the word, almost
impossible.
Such clinical
disturb
ances, both
in
vision
and
of other bodily
functions,
as
have
been
ascribed
by medical
men to the use of tobacco
have
been
held to
be
the
result of long-continued
use.
Apart
from
the
graver
func
No. I.
NECBERGER —-AVIATION MEDICINE IN TJ. S. NAVY.
37
tional and anatomical disturbances
there
is a possibility
that func
tional depression,
short of anything that might
be held to threaten
permanent disability,
could result
from continued smoking and
be
come fatal to the flier by reason of the exacting requirements
of his
work.
Drugs. —Many
fliers
come
to the
hospital
and
ask for aspirin.
It gives
the medical officer
a
clue
to the fact that the flier
is not
feeling
well.
Drugs
do not render
one
fit, but only
temporarily
hide the symptoms
of fatigue and illness.
When the flier comes to
the sick bay and asks for medicine,
the medical
officer has to handle
him with
a great
deal of tact.
If the
medical
officer
uses his
au
thority and immediately places the flier on the sick list, the aviators
will not report to the sick bay. being afraid that the medical officer
will not allow them to fly.
I have always made it a point to enter
into
a personal conversation with
the flier
and
talk
his
case
over
with him and specifically ask him whether
he thinks himself capable
under his present
condition
to fly as well
as he
does
on other days
when
he
feels
normal.
He,
usually,
answers
" No."
By
talking
it over
with
him in this
manner,
he
feels
that
one
is only doing
what is best for him and
he himself usually suggests
a relief from
flying.
Overeating. —It is
a known
fact that work
in
the air
produces
a very keen
appetite
and there is a great tendency
to overeat.
Over
eating
produces
a
sense of fullness
and
general
sluggishness,
con
ditions
which are not desirable
in flying.
The effects of overeating
are particularly
manifect after lunch,
as
a great
deal
of flying
is
carried on in the afternoon.
The midday meal or lunch should con
sist of a very light repast,
sufficient,
however,
to supply the desired
amount of energy.
Eating between
meals,
as well
as the constant
or frequent
eating of confectionery
is not advisable.
Physical exercises. —In the Army's publication. Aviation Medicine
in the A. E. F., it is stated
that
physical
exercise,
judiciously
em
ployed will do much
to secure physical
fitness and
serves to arrest
the onset of staleness ; it will also put the body in condition
to sus
tain the compensations
needed when flying at high altitudes.
A man
in good physical condition is much more resistant
to altitude sickness
than
the physically
" soft " man.
The ability
to endure
high alti
tudes is dependent
upon adaptive changes in respiration, circulation,
and the blood
itself.
The untrained
individual
breathes
more
fre
quently
and
shallowly
than
the
trained
man
whose
breathing
is
low
and
deep.
Shallow
breathing
does
not
ventilate
the
lungs
effectively.
The habit of
deep breathing
can
be cultivated
by
ex
ercise, but not so satisfactorily
by voluntary effort.
It is also known
that
at high
altitudes, physical
exertion
makes
a greater demand
upon
the heart
than
the
same
amount
of work
does
at
sea
level.
38
NEUBEKGER
AVIATION
MEDICINE IN U.
S. NAVY.
Vol. XVII.
Men in good
physical condition
can
stand
the strain
on the heart
better than individuals
weakened
by dissipation
and fatigue.
Con
sistent physical
work
increases
the
percentage
of
hemoglobin
in
the blood.
Capt. William L. Culpepper,
United
States
Army,
has
shown that the hemoglobin and the red blood cells
are temporarily
increased
in the aviator during flight, which is very advantageous
at
high altitudes.
Exercises must necessarily
be arranged according to the tempera
ture and the weather.
Mass athletics are very much
desired,
as foot
ball, soccer, baseball, pushball, and basketball.
Tennis, handball, and
calisthenics are beneficial.
General hygienic principles. —The
general
h\7giene of the
airman
scarcely
differs from that of other sportsmen.
As in the case of all
other forms of exercise,
the younger he is the better he will be able
to adapt himself to it.
Training in flying after the age of 32 is not
recommended,
although some men above this age have developed
into
good flyers.
Airmen
need regular intervals of rest.
Some writers
recommend
three
weeks'
rest after four months' flying.
It is believed a better
method
would be to give
a rest after
so many hours of continuous
flying.
At most air stations it is necessary
for the pilots
to stand
officer of the day's duty.
This necessitates making frequent inspec
tions at night
and being subject
to call at all hours, and oftentimes
the flier does not obtain the necessary amount of sleep.
I can not too
strongly recommend
that any flying officer standing officer of the day's
duty should be excused not only from flying but from all other duties
the day following, in order to enable him to make up for the loss of
sleep, thereby
regaining his energy
and putting him back
to his nor
mal physical condition.
The writer knows of several
instances in
which crashes followed such
a tour of duty and could only attribute
them
to
a lack of
the proper
amount
of sleep.
The commanding
officers of air stations should
be made
to realize
the
above
facts.
After all, for the flier, the danger is personal.
His life is in his own
hands.
It is he who pays the penalty, irrespective of where the re
sponsibility
lies.
Another point of importance in connection
with the hygiene of the
aviator
is the attention to the
needs of nature.
It is desirable
to
move one's bowels
and void urine before going up in an airplane in
order to avoid, in case of fall, the rupture which may result from a
loaded
intestine or bladder.
The cold of high altitudes leads to an
increased
formation of urine, and this causes distress
unless relieved.
Certain
appliances for aviators have been designed
with this point
in view, which will be described
in a later article.
Clothing
worn while flying should not fit too tightly.
Clothing
next to the skin should be made of wool, as this material counteracts
No. 1.
39
BELLI—PERSONAL
HYGIENE
OF
AVIATORS.
most advantageously
the loss of heat.
A combination suit, fur lined,
and fur-lined
gloves
and boots are very satisfactory
as an outer cov
ering.
Frostbites, parching, and chapping of the skin, cracking of the lips,
and dryness of the nose are often the result of flying
in high alti
tudes.
These conditions can be prevented
by applying
an ointment
of petrolatum.
REFERENCES.
Aviation
Medicine
in
A.
E. F.
War
Department,
Document
No.
1004,
Office
of the Adjutant
General.
Underwood, H. L. and Reeves, P.
The effects of smoking
on the visual acuity.
Air Service
Information
Circular.
Washington,
D. C.
Vol. I, No.
3, March
15, 1920.
Culpepper,
W. L.
Blood
changes
in
the Aviator.
Mil.
Surg.,
Vol. XLVIII,,
page
180, February, 1921.
PERSONAL HYGIENE OP AVIATORS.
By Prof.
C.
M. Bnxi,
Colonel,
Medical
Corps,
Royal
Italian
Navy;
Director
Psycho
physiological
Division of Aviation, Royal
School
of
Naval
Military
Hygiene,
" A. Pas-
qnale," of Naples.
[Translated
and condensed by Capt. J. S. Taylor, Medical
Corps, United States
Navy.]
Aviation
is comparable to no other form
of
endeavor
and only
partially
resembles
mountain
climbing.
The
human organism
is
unlike that of birds and is not designed
by nature for flight.
Eagles
and vultures have been observed at altitudes of 7,000
meters.
Cigna,
over a century ago, reported a swallow that resisted for more than
half an hour
a pressure
of
229
milimeters,
which
is greater than
would
be endured
at
the summit of Mount
Everest —a height of
S.840 meters.
The high development
of the semicircular
canals in birds ; and the
air
spaces
in their
bones
and
feathers,
are
features which
enable
them to confront
the chemico-physical
conditions of flight.
Man's
state
is abnormal from
the moment
he leaves
the ground until his
return.
There is diminished oxygen and low temperature at high altitudes,
and
the aviator
experiences
a change
from
stable
to
unstable
equi
librium as soon as he leaves the ground.
He is aided by certain com
pensatory
actions
on
the
part of the
respiratory
and circulatory
organs.
The respiratory
rate
is reduced; breathing
is deeper
and
intermittent.
There is an increase
of blood pressure
and the cardiac
systole becomes more
frequent.
In no other form of human effort is the personal equation so strik
ing as in aviation.
The weak,
cachectic,
abnormal, those in
a state
of exhaustion
can not support
the variations
of external physical
agents
encountered
and
must
be prevented
from flying.
But even
individuals
who
are
sound
in
a psychic
and
physical
sense show
40
BELLI
PERSONAL
HYGIENE
OF AVIATORS.
Vol. XVII.
differences
of reaction during
flight : There
are all shades of dif
ference
between
the bird
man
and
the one who can not rise
a few
meters above the earth without experiencing all the torments
of hell.
Psychophysiological
examination
usually
helps to exclude
those
less fitted for aviation and liable to fatal accidents, but does not posi
tively
determine
the individual reaction.
A man's
behavior under
atmospheric rarefaction
is only forecast
by the pneumatic chamber.
Somewhat
as we judge our Alpine troops, the Americans
attempt
to classify aviators by the altitudes they can safely negotiate.
1. Those who can go to the highest altitudes.
2. Those who should not ascend above 5,000 meters.
3. Those who should not ascend above 2,500 meters.
Intolerance of aerial flight
presents
itself in two distinct
forms.
One
resembles
the picture of the disturbances
common
to going
to
sea and develops
at low levels —malaise,
vertigo, nausea,
and vomit
ing.
The second form, called altitude sickness, or aviator's sickness,
appears
at high altitudes, and the phenomena
are serious
and
com
plicated—headache,
vertigo,
cyanosis,
roaring
in
the
ears, impair
ment
of vision, respiratory
distress,
cardiac
palpitation,
syncope,
somnolence, and sleep.
The
most
pronounced
symptoms
concern
the
nervous
system.
The muscle
sense is obtunded
: muscular contractions are feeble
and
the
psychic control of muscular
movements
is
impaired.
Visual acuity is reduced: likewise
the peripheral
field of vision.
The
shape
and
distance
of objects
is imperfectly
perceived.
Con
centration of attention is reduced
; the will is enfeebled
and absolute
intellectual inertia develops.
This impairment of the psychic powers
acquires
special
significance
from the fact that the subjects
thereof
give no warning of the change from a physiological to a pathological
condition and go forth entirely unconscious
of it to meet the dangers
that threaten.
The type of symptoms
varies with the individual.
Altitude sickness
and mountain
sickness
differ in that the latter
appears
at lower altitudes, owing to increased
oxygen
requirements
following
muscular exertion.
The sense of equilibrium,
as in the case of sea goers, readily adapts
itself
after
a few flights
to
the
new
positions of the
body
with
reference
to the outside world and disturbances
of equilibrium grad
ually
cease
to develop.
But on the contrary
man
does
not
possess
the power to
become accustomed
to altitude
sickness
in
the
sense
of recognizing the symptoms,
though there is some
increase of toler
ation for them.
The
statistics of the World War
show
that
out of
100 milder
casualties
in the air, 2 were due to circumstances
of battle,
8 to de
fects of apparatus and motors.
90 to causes
inherent in man.
This
Xo. 1.
41
BELLI
PERSONAL
HYGIENE
OF
AVIATORS.
proves that the most important
factor in successful
flight
is a per
sonnel not only trained technically but, above all, physically
adapted
thereto.
Flight must
be
restricted
as far
as
possible
to
men
physically
perfect and
endowed
with the best psychic and physical qualities.
Every government requires
a severe test for the personnel
of avia
tion.
The
Italian
Navy
conducts
its
examinations
through
the
psychophysiological
bureau
attached
to
the
Royal
Naval
Medical
School, Naples.
Aviation,
like
athletics,
involves
great
expenditure of nervous
energy
and, as in the case of sports,
the capacity therefor is limited.
Aviators
after a continuous service of months
or years show signs of
incapacity
and
must temporarily
or permanently
be
excused
from
further
flight.
The
incapacity
shows
in
a technical way
by
less
able handling of the machine,
especially
in landings.
In a medical
way the incapacity is evidenced
by tremor of the hands
and eyelids,
•
insomnia, deficient
muscular control, increased
reflexes
and psychic
irritability.
Nervous
exhaustion is a not unusual cause of casualties,
many of
which
may
be
ascribed
to
the
fact that through
false pride
the
exhausted
ones have
insisted
in continuing
a flight
and paid dearly
for their imprudence.
Guynemer in his later period was
nervous
and irritable, in spite of which and
despite
advice
to the contrary,
he insisted on starting on that, last flight.
The individual's
constitution and his habits of life determine
full
capacity
for flight.
Incapacity' results
from loss of sleep, excessive
fatigue,
sickness,
and
abovfl'till from
nervous
exhaustion
following
excesses.
Such excesses —smoking, gambling, drink,
and
sexual
in
dulgence^—flow
in
part
from
a
certain
fatalism
imposed
by
the
.
aviator's very calling.
The authorities are not in a position to regu
late the minor details of an individual
aviator's private life.
Hence
the necessity that all concerned should appreciate
the scientific
basis
for rules of health bearing on flight
and the importance of
a maxi
mum of efficiency
and
a maximum of service.
For successful flight, apparatus and motors
must be in good order ;
on his side the aviator must have a maximum of physical and moral
energy.
The human machine
is fully
as complicated
and
requires
just
as minute care as the airplane.
HYGIENIC
RULES.
The function of preventive medicine
is not fully accomplished
by
the mere selection of the fit and the elimination
of the unfit ; but it
must include
preservation of forces.
The cardinal rule is : Modera
tion in all things.
42
BELLI —PERSONAL
HYGIENE
OF AVIATORS.
Vol. XVII.
FOOD.
Food
is important
both
as to quality
and
quantity.
Abnormal
digestion
and
constipation
weaken
both
the
physical
and
mental
powers
and
predispose
to
altitude
sickness.
Flight
sharpens
the
appetite
and
predisposes
the
aviator
to
eat heavily
which
is
in
jurious.
The hours for meals
are matters
of importance.
One should not
eat heavily just prior to flight.
(Less blood to brain; more to stom
ach, predisposition
to vomiting,
nausea,
etc.)
The
morning
meal
should be light and taken
about noon, after the morning
exercises.
These exercises should not be resumed
before 4 p. m.
The principal
meal of the day is best taken
at night, when the work of the day is
over.
During flight, hot drinks from
a thermos
bottle
(e. g., chocolate)
and sweets are
best.
Between flights
a sandwich, coffee, or
a light
' broth containing
a farinaceous ingredient
(noodles,
etc.)
are
bene
ficial.
REST
AND
SLEEP.
Flights should not
be
too prolonged
and
should alternate with
suitable periods of rest.
When the aviator returns to camp, showing
unusual fatigue, the rest period must
be correspondingly
prolonged,
eight hours being the minimum
period of sleep to restore him.
CLOTHING.
--•
Clothing
must
be warm to protect against the cold of high
alti
tudes
which
favors
discomfort
and
aggravates
symptoms
due
to
high altitude.
But garments
must not constrict the body.
Under
garments
next to the skin should be woolen
; outer garments
should
be fur lined throughout.
Fur-lined gloves for the hands and linen
shoes lined with fur for feet add to the aviator's comfort.
PERSONAL CLEANLINESS.
Personal
cleanliness
is of special
importance in the event of in
jury
so
as to lessen chances of infection.
A tepid shower
or tepid
bath is favored ; warm baths if prolonged and oft repeated
are
de
pressing to
the
nervous
system.
EXERCISE.
Physical
exercise of
a kind
agreeable
to the individual
and
not
entailing
unusual expenditure
of
nervous
and physical
energy
is
highly desirable.
Stunts, athletic meets, and the like are objection
able.
Mountain
climbing, sailing, swimming,
and polo are the best
pastimes.
JfeL
BELLI
PERSONAL
HYGIENE
OF
AVIATORS.
43
In
the United
States the training of aviators includes physical
drills calculated
to promote muscular coordination rather than mus
cular strength, 'and to develop
visual, acoustic,
and static control.
VISION.
Perfect vision is as important
to the aviator
as to the mountain
climber.
Aviation involves ocular strain and in bright
weather
the
ucess of solar
rays dazzles
the eyes and
reduces vision.
The high
velocity of flight causes a current of air which tends to dry the con
junctiva
and cornea
and all minute foreign
bodies impinge
on the
eye with force and favor trauma and infection.
The wearing of goggles
is imperative.
Usually, aviators dislike
wearing them.
Still the benefits of goggles
largely
compensate
for
some reduction of the field of vision and acuity of vision.
Mica lenses
have
been recommended,
through
dread of possible
injuries if crystal
lenses should be broken.
Mica is far less trans
parent than glass and the danger of injury to the globe from broken
eyeglasses is much
exaggerated.
Wilmer and Berens,
during
two
years on the American
front in France,
saw only
one
case of eye
injury
due
to broken
glasses,
but it was
accompanied
by general
lesions
serious
enough
to cause the death of the victim
on the day
following.
The best goggles are made of crystals having at least 2 millimeters
of thickness.
The surfaces are plain
and parallel.
A pure white
glass capable of transmitting
90 to
100 per cent of incident rays is
commonly
used, but it is better
to use glasses with a slight yellow-
2reen tint to
absorb
short-wave actinic
rays.
These do not
affect
color perception and
are
a comfort in traversing
snow
fields, large
bodies of water,
and cloud strata.
The
lenses should be round or
slightly ovoid,
set in
a metal frame,
and
retained by metal
rods.
They must be easily removable
during flight, and the aviator should
have spare lenses.
The spectacles
must be strongly
made and easily taken off, with
one hand only.
All metal parts must be sheathed in leather or cloth
to avoid frostbite.
In order to protect the eye from frostbites the goggles
must close
hermetically
over the orbits, even at the sides.
This results in con
densation of moisture and when temperature is below freezing a fine
frost collects on the glasses which interferes seriously with vision.
In some
models
the full protection
is obtained
by metal
gauze
at
the sides to favor the escape of water vapor.
It must be admitted
that, to date, all types leave much
to be desired
from this point of
view.
108390—22
4
44
BELLI —PERSONAL
HYGIENE
OF
AVIATORS.
Vol. XVII.
THE EAR.
Hearing
and equilibrium
are of the greatest
importance in flight.
The aviator must
be able to determine
by its rhythm
the regularity
of operation
and
the
number
of turns
of his propeller.
Also he
must be able to estimate his position relative to the medium
in which
he is immersed.
The care of the ear is therefore of immense importance.
Accumu
lations of wax must be prevented,
since they interfere with vibrations
of the tympanum.
Further, there
must
be
a balance
between the
outside
air
and
the contents
of the tympanum to prevent vertigo,
subjective
sounds,
and pain, occurring
when communication is inter
rupted.
The closure of the Eustachian tube becomes specially serious
in connection
with
the rapid
and powerful
disturbance of balance
between the inside and outside
air
as in hurried landings from high
altitudes.
Gradenigo,
the high
authority
serving
as consultant to
the psychophysiological bureau at Naples, insists on full and constant
patency of the Eustachian tube.
He advises frequent acts of degluti
tion during
recompression,
and
even the Valsalva
method
of deep
•expiration
with mouth
and nostrils closed.
RESPIRATION.
While respiration is automatic,
still, within limits, it can be modi-
tied by the will.
This
is not recommended.
Aviators should
be
required to breathe through the nose, with the mouth closed, in order
to moisten,
warm, and filter the inspired air and reduce the pressure
of the strong air current due to the velocity of the machine.
This is
also essential
because the teeth are sensitive
to cold.
Mouth
breath
ing under these conditions parches
the pharynx.
Agazzotti
advises
holding
a swallow of water in the mouth at frequent intervals.
The nostrils must
be kept clean.
Flights should
be forbidden if
the nasal passages are obstructed.
MENTAL STATE.
Intellectual
faculties and
special
senses
are under a great strain
during flight.
When the psychic state is in good balance, flying is a
source of pleasure.
With the nervous
system in perfect equilibrium,
resistance
to high altitudes is greatest;
the reverse holds when
the
aviator is dispirited, fatigued, etc.
Every sort of entanglement
caus
ing
mental
preoccupation and
worry
makes
for
casualties.
Three
seconds give time for irreparable disaster.
ALCOHOL.
Aviators
commonly
hold that
a moderate
dose of alcohol raises the
courage
in
the
face of danger.
Experience
and
physiology
teach
the very opposite
of this.
.Vo. 1.
45
BELLI—PERSONAL
HYGIENE
OF AVIATORS.
When alcohol is used, after a fleeting
period of excitation, there is
a paralyzing
effect
on
the
nervous
system
and
especially
on
the
higher
centers —in
the
psychic
faculties.
The
abuse
of
alcohol
suspends
inhibition; if persisted
in alcohol wholly
incapacitat«s
a
pilot for handling
his machine.
Casualties among
troops on high
mountains
during
the war showed
corresponding
disadvantages
of
alcohol.
According
to Mosso,
mountain troops should not go into
action on the day following holiday celebrations,
etc., and I consider
this still more important
in the matter of flying.
Italian aviators
are noted for their sobriety.
Neverthless
caution may
properly
be
enjoined
regarding
use of
alcohol
prior
to flight.
Of course
the
ordinary
wine with meals is not harmful.
TOBACCO.
Usually
aviators smoke
too much.
Tobacco
damages
the system
partly
through
the
action of pyridine
bases, partly through
the
tollidine,
carbon
monoxide,
and other substances formed during com
bustion
of cigars and
cigarettes.
Tobacco
has local action— irrita
tive
and
congestive —on
the
mucous
membranes
of
the
mouth,
pharynx, Eustachian
tubes, and even on the tympanic cavities—also
a general
toxic and depressing
effect on the central nervous
system,
nerves of special
sense,
and particularly
on the optic nerve.
During
the
war
numerous
casualties
were
attributed
to
tobacco,
hence
aviators should be most abstemious
in the matter of smoking.
DRUGS.
Aviators
very commonly
resort to drugs like aspirin,
phenacetin,
and
to secret
remedies
against
seasickness
to avoid discomforts
of
high altitudes.
This is a bad habit which only masks the real situa
tion and often leads
to casualties.
Narcotics
such
as cocaine, mor
phine, and opium are of course the most dangerous.
It is imprudent
to
fly
after generous
doses of quinine.
PREPARATION FOR FLIGHT.
The
aviator
who
feels
indisposed
and
is
lacking
in
confidence
should refrain from flight
and
consult
the doctor because ailments
that are negligible on the ground may seriously handicap the physi
cal and psychic side of the aviator and seriously reduce his capacity
for flight.
After sickness or accident
the aviator should always be
reexamined
by
a
physician.
According
to
Guilbert
the
old
precept
" head
cool,
feet
warm,
belly
clear "
is
as valuable in aviation
as in any
other
contingency
of
life.
The
intestinal
functions
should
be
carefully
regulated.
Symptoms of intoxication
may
arise from constipation and
destroy
46
BELLI
PERSONAL
HYGIENE
OF
AVIATORS.
Vol. XVII.
the fineness of perceptions.
Kidney functions
should
also
receive
attention.
Aviators
should always empty the bladder before climb
ing into the machine.
At high altitude ultra-violet
rays combined
with the cold lead to
erythemas
and
chilblains.
Mosso
has
shown experimentally
that
the best protection for the skin is to smear it with burnt cork.
This
method
has
never
become popular.
Instead
most
aviators
prefer
vaseline,
lanoline,
or
cold
cream.
These
agents
protect
the skin
from rapid evaporation, but not from the ultra-violet
rays.
PROPHYLAXIS
OF HIGH-ALTITUDE
SICKNESS.
The first symptoms,
confined
to the sphere of the vegetative
func
tions, are usually well tolerated by most men.
Very
few, however,
can withstand
the later
developments
involving
the neuro-psychic
feature.
Of these, sleepiness is the most constant
sign and indicates
depression
of
the
nervous
centers.
When it
develops
the
aviator
should come to the ground.
The primary
cause of these disturbances
is reduced
atmospheric
pressure.
This is not
the
place
to
discuss
the details of etiology
;
whether it is due to insufficient exchange
of oxygen
between the air
and the blood or to diminished tension of carbon dioxide in the blood.
Mosso
thought the administration
of oxygen
useless in mountain
sickness,
but admitted that it had some value
when
taken
at an ele
vation above
7,000
meters.
English
and
American
physicians
be
lieve that oxygen
saved the lives of many
aviators during
the war.
Oxygen
can not be employed
by the apparatus commonly used in
medicine.
Special apparatus is necessary for aviators.
It must be
easy
to
handle
and
not interfere
with
movement.
The
aviator's
hands
must
be free.
The inhalation
must
be by means of a mask
and entirely automatic,
that is to say, the oxygen feed must accom
modate
itself automatically
to the requirements
of changing
eleva
tions.
The apparatus devised by Colonel Dreyer has been used with
satisfaction in the American
Aviation
Corps.
Mosso insists that carbon dioxide should be distributed along with
the oxygen.
Agazzotti
has shown by
experiments
with
the pneu
matic
chamber that the proportion giving
the best results
is 15 to 20
parts carbon
dioxide
and
85 to
80 parts oxygen.
As the effects of
oxygen
persist for four to six minutes
after inhalation
has ceased,
the gas should be repeated
at intervals of not more than six minutes.
Administration
of oxygen
should
be
the rule, not
the exception,
when
the aviator
has reached
the height of
3.000
or
4.000
meters.
Oxygen may
be used to advantage
when
the aviator lands after
a
long flight to overcome
as quickly as possible his sensations of fatigue.
No. 1.
47
GALWEY —GAS WARFARE.
GAS WARFARE:
ADOPTION, METHOD
OF
USE,
PROTECTION
OF TROOPS.1
By Maj.
W.
R.
Galwey,
O.
B.
E.,
M. C,
Royal
Army
Medical
Corps.
The legitimacy of the employment
of noxious gas as a weapon of
warfare
has
recently
been
much
discussed
in
both
the public
and
scientific press.
At the meeting
of the British Association
in Edinburgh in Sep
tember, the president in his opening address,
called
upon the
asso
ciation
to
use
its
every
endeavor
to
persuade
scientists
to
cease
research
into chemical
methods
of destruction as derogatory to the
high call of
science.
Much might
be said regarding
the humanity of inflicting
casual
ties by gas rather than by high
explosive,
of the high
percentage
of permanent
recoveries
after
the former
as against the latter and
the low percentage of deaths, but it seems to me that two fundamental
facts are ignored by those who write
and
speak
against gas war
fare:
(1) That, in the highest sense, all weapons
in war are inhuman;
and
(2) That the
use of gas in warfare is an accomplished
fact.
It has proved a most effective
weapon,
so that any nation fighting
in the future for its existence
must
be prepared to combat it and
use it.
Research
into new compounds
capable of overcoming exist
ing methods of defense can be carried out in secrecy in the laboratory
without attracting
the attention of foreigners—many of the poison
ous compounds
are intimately
connected
with
the chemical
indus
tries.
Therefore it appears that so long as war remains
the ultimate
means of settlement
of international
strife, and until the League of
Nations can enforce
its mandates,
so long must each nation continue
to prepare for gas warfare.
Two facts are significant:
(1) During the inquiry into German methods
of making mustard
gas which
followed
the
armistice
one
of
the
respondents
asked:
"Why
are you worrying
about this, when
you know perfectly well
that this is not the gas we shall
use in the next war."
(2) Of the total American
casualties,
about
30 per cent were due
to gas, and of these
about
90 per cent were due to skin burns ; of the
gas casualties
3 to 4 per cent died and
about
95 per cent recovered
completely.
The Americans
have
laid
to heart the
lesson taught
by these figures and have established
a Chemical Warfare Service
on
a peace footing with
a personnel
numbering
about
1,600
and have
budgeted for an annual expenditure of $4,500,000
for research
into
this branch of warfare.
1Reprinted
from the Journal
of the Royal
Army
Medical
Corps, January,
1922.
48
GALWEY
GAS WARFARE.
Vol. XVII.
Adoption. —In
ancient
times
the Spartans
in the fourth
century
before Christ,
used
gas in
the
form of sulphur
and
pitch
fumes
against the Athenians.
Greek
fire,
which
is of
the
same
nature,
was
employed
by
the
Byzantine
(ireeks
against the
Saracens
and by the latter in turn
against
the Crusaders.
In modern times
the' first suggestion
to employ this
method
of
offense was made by Lord Dundonald.
It was seriousty
advocated
by the chemist, Lord Playfair,
at the time of the Crimean War, as
a humane
method of overpowering the enemy, and the use of sulphur
fumes was suggested
as an aid in the reduction of the Redan redoubt.
The
suggestion
was
considered
by
experts
and
dismissed
as
in
human.
Later The
Hague
Convention,
to which
German}'
was
a signa
tory, practically
forbade its use.
It was the treachery of Germany
in this case as much
as the nature of the weapon
she employed
which
raised
the storm of execration
against her in April, 1915.
At the end of the last century poisonous
gases were
investigated
in Germany by Lehmann and his pupils with the ostensible
purpose of
making
dangerous
trades
safe; but in England,
although many of
the
compounds
afterwards
used
had
been
met
with
in
chemical
research,
practically
nothing
was known of their
production
on
a
large scale or of their action on the human organism.
It is true,
however,
that useful work had been done prior to the war in South
Africa by medical officers to mines in investigating
cases of poison
ing from nitrous
fumes
given off after
the
discharge
of explosives
in blasting operations.
The first German gas attack was made against the French
and our
second
army
in
the Langemarcke
sector
on April
22,
1915.
The
surprise was absolute
and our line simply
ceased
to exist, since those
who did not retire were either killed or incapacitated.
The Germans
captured 60 guns
and
a large extent of territory.
A second
cloud
gas attack was delivered in the
same sector
on April
24.
and
was
chiefly directed
against the Canadians.
The Germans did not realize
the power of the new
weapon
and neither used it over
a sufficient
extent of front nor followed up their initial success.
Had they done
so the war might have ended in a German vic tory by the summer
of
1915.
The first attacks
were quickly
followed by others,
some of which
were on a large scale, during the months of April and May; all were
in the Ypres sector.
The
gas
used
in
the
early
attacks
appears
to
have
been
pure
chlorine, though later phosgene was combined
with it.
It was deliv
ered from steel cylinders, each of which contained
some 45 pounds
of compressed chlorine.
No. 1.
49
GALWEY
GAS WARFARE.
Gas attacks
followed
each other rapidly until May 24,
and
then
there was
a lull until
December.
1915.
The last cloud gas attack
was on August
8, 1916.
Various
statements
have
been
made
as to when
the Germans first
began
to use lethal gas in projectiles.
The earliest certain date is
July, 1916, when lethal gas shells
were used, and from that time the
enemy
developed
this mode of attack
more
and
more.
In all
he
used no less than
18 different gases against us and our Allies.
It is
unnecessary to detail these, and in my next paper I hope to put be
fore
my
readers
a classification of war
gases
according
to
their
pathological
effects.
It will suffice to say here that the three main
types of gas shell were known as green cross, blue cross, and yellow
cross.
The green
cross contained
phosgene
alone, or combined
with
such substances
as chlorpicrin
and chlorarsines.
Green cross 3 con
tained various
arsenic
compounds.
Blue
cross
contained
chlorar
sines,
cyanarsines,
and
N. ethyl
carbazol.
Yellow
cross
contained
dichlorethyl sulphide or mustard gas.
At first gas shells were fairly
easily distinguished from others, owing to the small bursting charge
they
contained,
but later they
were mixed with
bombardments
of
high explosives,
and the gas shells
themselves
contained
large quan
tities of high explosives;
so that it became difficult to say whether
a bombardment
was simple or mixed, and
a constant
outlook had to
be kept for gas.
Gas warfare
reached
its zenith in
1917
when
the Germans intro
duced mustard gas—a weapon,
which although of minor importance
from the point of view of death, causes a great number of casualties
from
its
insidiousness
and
persistence
and
which
can
be
used
to
render ground untenable
by troops for considerable
periods.
The last development
was the
use of large projectors which dis
charged by means of bombs
enormous
quantities of gas over small
areas,
so that concentrations were
arrived
at when
one breath
in
capacitated if it did not kill a man.
The projector attack was in
troduced
by the British in April, 1917, and adopted by the Germans
in December of the same year.
I may mention that toward the end of the war our use of gas far
surpassed
that of the Germans,
as our defense
was better;
so that
they were
very literally hoisted
with
their own petard, and
must
have bitterly regretted
their treachery in introducing this weapon.
Methods of use.—As the
science of gas warfare
was
developed,
three definite
purposes
emerged for which this weapon
is effective
:
(1) To inflict
casualties;
(2)
to
reduce
the
fighting
efficiency
of
troops by compelling them to wear respirators;
(3) to render
posi
tions temporarily untenable.
1. The best substance
to employ is that which
answers
the par
ticular purpose of the general
staff,
and the fact that
a substance
is
50
Vol. XVII.
GALWEY
GAS WARFARE.
lethal need not necessarily
give it preference
over
one whose
effects
are only temporary and do not permanently incapacitate, but which
quickly puts men out of action.
Thus
a lachrymator might in par
ticular circumstances
be more effective than phosgene.
The first
gas
attacks
caused
very
numerous
casualties
but it is
impossible to estimate
numbers
with
any great degree of accuracy
as
so many men
were killed outright
or died before
they
reached
medical
units.
But
as our defense
developed
the casualties
dimin
ished,
so that in the last cloud attacks
they
were confined
to units,
and
individuals,
where
gas
discipline
was
slack or
defensive
ap
paratus was not properly
cared for or adjusted.
With the advent of mustard gas the casualty list lengthened
until
the troops had again learned how to combat this new evil.
2. The
second
purpose
for which
gas is employed —to diminish
the fighting
efficiency
of troops—is more
difficult
to combat.
The
respirator is uncomfortable to wear, and if worn for any length of
time
the resistance
to breathing
and
general
discomfort
diminishes
the fighting and working power.
The greatest
sources of discomfort
are
the mouthpiece and
nose
clip, but,
so far, it has been impossible
to dispense
with them.
In
tercommunication
and
accuracy
in
handling
delicate
instruments
also suffer.
Two examples will illustrate how efficiency is impaired
:
(a) It was noted that if, when shelled by the enemy, our batteries
replied with gas shell, in 20 to 30 minutes the accuracy of the enemy's
shooting, as indicated by " qvers,"
" duds," etc., was greatly dimin
ished.
(b)
The French
experimented
to
see how
long men could wear
respirators.
An area was chosen in the rear,
where
men were made
to carry out light work or left at rest wearing respirators continu
ously and not even removing them for food or drink.
The men were
exposed
to a gas, nonlethal, but causing
intense
lachrymation with
the least
dose.
Forty-eight hours' leave was given to each man for
every two hours he could stick it over six hours, but though a certain
number of men managed
to accumulate
a considerable
spell of leave,
the best result that could be obtained
was that 70 per cent were
effi
cient at the end of 24 hours.
The French mask is more comfortable
than ours.
3. The third
purpose
for which
gas
is used
is to render posi
tions untenable.
Mustard gas has so far given the best results on ac
count of its persistence.
It is therefore imperative when occupying
a position which has been shelled
to make certain whether gas has
been
used and to warn troops against handling
objects which might
be contaminated,
and against drinking water contaminated
by gas.
Numerous casualties
were caused in France
by neglect of these pre
cautions.
No. 1.
51
GALWEY —GAS WARFARE.
Though the means by which an enemy attains his object in a gat
attack,
i.
e.,
gas
tactics,
is primarily
the
business
of the
general
staff and gas services,
it is important
that all troops, officers,
and
men
alike, should understand the general
idea in the use of gas.
Cloud gas is used to inflict casualties
and
as a preliminary
to an
infantry
attack.
The gases used must
have
the following
properties:
(1)
Must
be
heavier than air;
(2) must be easy to liquefy; (3) must
be lethal in
fairly low concentration.
Not
man}7 substances fulfill
these conditions, and for this reason
and
because
our
protective
measures
had
become
almost
perfect
against
it,
the Germans abandoned
the cloud attack.
Weather
conditions
must
be closely
considered
with all kinds of
gas warfare
but they
are particularly
important
in cloud attacks.
The best wind
is
a
steady
breeze from
4
to
9
miles
per hour, but
attacks have
been
made with winds from
2
to 20 miles per hour.
The effects of cloud attacks
has been felt as far back as 20 miles
from
the
point
of liberation,
but
the
usual
distances
for serious
casualties
is
5
to
6
miles.
Heavy
rain
is
unfavorable,
but slight
dampness
keeps
the
gas
low —fog gives
opportunity
for surprise.
Nighttime
is
most favorable both
on account of surprise and
be
cause cold currents coming downward keep the gas low.
The usual number of cylinders
employed
was
one per yard of
frontage and the front
attacked
was about
3,000 yards.
An attack can be recognized
by the hissing noise as the gas emerges
from the cylinders
and
by
the
greenish
color
(becoming white in
damp weather) of the cloud in the case of chlorine.
Gas shells are used both for surprise attacks
and to inflict casual
ties, and
also
to harass
communications and
prevent
arrival of re
inforcements.
The news of a cloud attack
can be quickly
passed to
the rear, but the gas shell
is
its own herald.
In the last stages of
the war
the only way of recognizing
gas shells
was
by
the
smell
of the compounds
they
contained.
The projector
attack
combines
the
advantage
of both
cloud and
shell and
is
more deadly
because of the enormous concentration which
it
can give.
The projector discharge
can be recognized
by: — (1) Noise on dis
charge— like
an ammunition
dump going up,
(2)
flash
along the
line,
(3)
whining
noise of the drums in flight,
(4) sight of drums
flying, (5) at night by the trail of sparks emitted from the drums.
For
a
big projector attack
as many as 1,500 drums, each containing
some
31 pounds of liquid,
were
used, one drum being sufficient
to
overcome the German respirator at the point of impact.
52
Vol. XVII.
GALWEY —GAS WARFARE.
It has been well said that " Gas warfare resolves itself into a con
test between offensive
materials and protectice
devices, and there
is
no finality
in regard to either;
so that the chemical
substances
em
ployed
must necessarily
vary from time to time,
as well as the tactics
adopted to using them."
Protection of troops. —Though the first attack found us totally un
prepared, efforts
were at once made to counteract
this new weapon.
On April 23, under telephone instructions from the Director General
Medical
Services,
General
Headquarters,
the
Director
of Medical
Services,
First Army, issued
a circular
recommending
the use of a
solution of bicarbonate
of soda, which should be kept in buckets, etc.,
and that men should
be instructed
to
use handkerchiefs
or cloths
dipped in the solution to cover the nose and mouth.
On the following
days various other appliances
were improvised :
for instance, on 27th and 29th, Professors Haldane and Baker visited
France, and the latter recommended
the use of cloths, etc., moistened
with urine, or of earth folded in cloth or inclosed
in
a bottle
from
which the base had been removed.
A German respirator captured at this time proved to be a pad of
cotton-waste
soaked
in
hyposulphite
solution
and
contained
in
a
gauze bag which was provided with tapes for tying over the face.
In the meantime
the War Office authorities at home had turned to
the Army
Medical
Service,
and
it
was
very
largely
due
to
the
scientific knowledge and unfailing resource
and energy
in organiza
tion of Col. Sir William Horrocks
and Colonel Lelan that the menace
to our troops was met and disaster
averted.
It was known that for the moment chlorine was the gas to be dealt
with, and the chemical
problem
was therefore simple, though the pro
vision of the appliances
for making pads within a few hours was far
otherwise.
However,
so nobly was the call met that within 60 hours 98,000
pads of cotton
waste in muslin
containers,
dipped in hyposulphite
solution and dried, were available at the front;
300.000
were avail
able in a week, and 2,000,000 within a month.
It was, of course, recognized
that this provision was at most a tem
porary expedient,
the life of the pads was short, and they
were not
effective in high concentrations
; if a heavier
charge of gas absorbent
were added the obstruction to breathing became serious.
Moreover,
they were only effective against chlorine gas, and, once gas warfare
had been established,
it was obvious that the enemy could and would
use higher concentrations
and different and more potent substances.
A research
laboratory
was therefore started
in the Royal Army
Medical
College.
The history of the evolution of our present
pro
tective apparatus records
a story of untiring zeal, energy, and dogged
pluck not surpassed
in the story of scientific
research.
GALWEY— GAS WARFARE.
53
At the same time a research
laboratory
was organized in France
and the closest liaison was maintained between workers at home and
abroad.
Every development in the use of gas was foreseen and pro
vided for, so that our gas defense in a short time equalled
and then
surpassed that of the enemy.
A brief
account of the various
types of protection evolved
will
serve
to illustrate the problems
which
must
be met
and
solved
in
chemical warfare.
The original cotton-waste
respirator was soon superseded
by those
of black veiling-cotton
waste impregnated with hyposulphite of soda
and glycerine.
Two problems
called for immediate
solution :
L To make the filtering
area greater
; and
2. To make
the absorbent
substance
such
as would withstand not
only chlorine
but other gases which, it was
recognized,
might
be
used.
The filtering
area
was
increased
by substituting
a helmet
for
a
pad. thus providing an area of 3£ to 4 square
feet through which the
air could enter
and reducing the resistance
to between
0.3
and
0.5
inch of water.
The air current was also slowed
so that the absorb
ent had more time to neutralize the noxious gas.
Suitable
materials
had
to
be found
and
in
sufficient
quantities.
After
a few days of testing on individuals
a manometric device was
devised for rapid testing at a definite standard pressure.
The color of materials used in making helmets was also important,
for if light colors were used men wearing the helmet's would furnish
an easy target for enemy fire.
The question of sight when wearing the helmet
was also a knotty
problem.
At first
mica
windows
were
used, but
these
proved too
brittle:
cellulose acetate and chromicized gelatine were
also
unsuc
cessfully tried.
Finally
nonsplintering
triplex
glass disks fixed
in
tin
rims
that
clamped
the textile of
the
helmet
firmly
by
being
screwed
into
flanged
collars
were
adopted
and
proved
most
suc
cessful.
Polyvalency
of the absorbent
was first secured by adding sodium
carbonate
to
the
thiosulphate of soda
and
glycerol.
This
helmet
could
be donned in four to six seconds, gave
10 times
as great
pro
tection
as the pad, while its effective life against chlorine at a con
centration
of
1 in
1,000 was five hours.
A new solution was made
necessary
by
the
fact
that
the
absorbent
afforded
no
protection
against phosgene
(carbonyl chloride)
or hydrocyanic
acid, and
sev
eral other gases.
An effective
absorbent
was, however,
found after
many trials in sodium
phenate,
but it was found that the solution
rotted
the
woolen fabric
of which
the
helmets
were
made.
This
difficulty
was met by adopting a cotton material which took up more
alkali, and for
a double
thickness
of cotton
gave
a resistance
of 0.2
54
Vol. XVII
GALWEY— GAS WARFARE.
to 0.3 inch of water,
as against 0.5 inch for a single thickness of wool.
The problem was further complicated by the discovery
that the CO>
given off in expiration neutralized the protective alkali, so that after
a time it ceased
to protect against HCN.
It therefore became neces
sary to provide
a valve through which the wearer could expire and
so get rid of his CO* outside
the helmet.
The simple and
effective
respiratory valve still in use
was the outcome
of this research.
One more addition to the absorbent
impregnating
the helmet
was
made
in January,
1916,
i.
e., hexamin—suggested
by Russia —this
substance
removed
the
remaining
phosgene
(carbonyl
chloride)
which had
escaped the sodium phenate.
With this final improvement the P. H.
helmet,
as it was
called,
removed
100 per cent of
1 in
1,000
phosgene
and HCN.
Of these
helmets, from the first issue in July, 1915, until the final withdrawal
in February,
1918, in favor of the box respirator
as the sole issue,
nearly
27,000,000
were
made —many were supplied
to our allies
as
well as to our own troops.
In addition
to protection against lethal
gases of the asphyxiant
type,
protection
had
to
be afforded against
a group of substances
known
as
lachrymators
whose
chief
action
is
on
the
eyes.
The
majority
act in minute proportions
so that
as small
a quantity
as
one part per million causes intense
lachrymation
which throws
the
victim
out of
action.
These
lachrymators
were
first
used against
us in the autumn of 1915,
and the first protection against them sent
to France
was
a goggle
of rubber with
glass
eyepieces
similar
to
motor goggles.
This failed in many
cases owing to the difficulty of
obtaining close adjustment over the bridge of the nose.
To obviate
that trouble
the
French
pattern
was
next adopted.
This
was
of
impervious cloth with
flannelette
lining and celluloid
eyepieces, the
fit over the bridge
of
the
nose being obtained
by malleable
wire
sewn into the lower edge of the fabric.
These were found service
able against low
concentrations,
but against higher concentrations
the
best fitting
results
were
obtained
with
rubber
sponge.
In
a
final pattern the
base was of stiff impervious
fabric
(gelatine for
malin impregnation)
lined with soft material to which were cemented
and sewn the two halves
of an oval sponge —holes being cut in the
sponge
and the base into which were fitted screwed metal and glass
(helmet)
eyepieces.
Elastics
were
provided for attachment.
The P. H. helmet was also fitted with rubber sponge round the eye
pieces and was issued as the P. H. G. helmet.
Goggles were finally withdrawn
after the issue of the box respira
tor, since they tempted
a man to put on his goggles
rather than his
respirator,
and
so continue to inhale small quantities of gas which
would have a cumulative effect.
No. 1.
GALWEY
GAS WARFARE.
55
No helmet could ever
be completely
polyvalent.
For
one thing it
is impossible
to impregnate
so thin
a layer of material with
both
oxidizing and reducing substances.
The realization of this fact led to
the research which culminated in the production of the present
box
respirator.
The object
was to produce
a container filled with strata
of different
absorbents,
through
which
air
could
be drawn —each
group of noxious gases being
removed
or neutralized in its appro
priate stratum.
The box respirator
was issued only one montli
be
fore the enemy attacked
with gases which the helmet could not have
withstood.
Very
extensive
and
exhaustive
trials
were
made
by Lieutenant
Colonel Harrison and his colleagues before
a granule was made which
was sufficiently
active,
and at the same time
hard enough
to with
stand the shaking and general rough usage which the respirator must
necessarily undergo and yet remain active.
The box respirator
was originally charged
with successive layers
of: Sodium
sulphite (reducing)
; soda lime manganate
(neutralizing
and oxidizing)
: animal charcoal
(absorbing and condensing)
; each
layer being separated
by plaques of cellulose.
This was found to be
completely polyvalent against every
gas which the enemy had then
used against
us, and to give very slight resistance
to respiration.
It
was
efficient
against
carbonyl
chloride
for
three
hours,
against
chlorine for eight hours,
and withstood
a sequence of six gases run
through it in succession,
each for one hour.
But it was found that
gas tended to pass up the smooth
interior
against
the side of the
box so that this channel
became ineffective,
whilst the remainder of
the box remained
effective.
This defect
was remedied
by corrugat
ing the sides of the box and so lengthening this route, leaving large
air spaces above and below
the absorbent
layers to equalize
the flow
and by arching the base of the lowest
absorbent
layer so as to divert
the flow from the sides.
Two valves
were necessary —an inspiratory
flap valve in the base of the box and an expiratory
valve, like that in
the helmet, between the mouthpiece
and the box, so as to prevent
ex
pired
COj, neutralizing
the soda-lime-alkali.
A closely
fitting
face
piece
with
eyeglasses
and
nose clips
was
added.
The
whole
ap
paratus could be adjusted in 25 seconds [since reduced to 10 seconds].
There
were
several
slight
modifications
of
the
box
respirator,
and the small box respirator
as at present in use replaced
all other
gas protection
appliances in February,
1918.
Work is still being carried out on it to make it more perfect and
to decrease its resistance
to the passage of air to the lowest
possible
amount.
The resistance of the present pattern is equivalent to about
3 inches of water.
56
Vol. XVIL
GALWEY —GAS WARFARE.
The
above
sketch of the evolution of the
methods
of individual
protection
against lethal
gases will
show
you the
essentials
to
be
aimed
at in devising such apparatus:
1. The apparatus must be capable of very rapid
adjustment.
2. It must be
able
to neutralize all forms of noxious gases and
clouds
and
vapors which
may
be
used against the troops wearing
it for a reasonable
length of time.
3. It must
offer
as little
resistance
to
breathing
as
possible
so
as to avoid diminution of the working
powers of troops.
4. It must
be strong and light.
The box respirator
has, so far, resisted
all gases used against us,
but it will be readily
understood
that constant research
in defensive
measures must proceed pari passu with new discoveries
of substances
which may be used in chemical
warfare.
The soldier must
be taught that if his respirator is kept in good
condition, and he has learned
to adjust it with the necessary
quick
ness, he can place complete reliance upon it.
Very
frequent inspection of respirators
is necessary
to
see that
they
are in good
condition.
Periodical
inspections are carried
out
by
the
antigas officer with
the
formation
concerned,
but it is the
duty of all
officers
commanding units or
sections
of units
to
see
that their men's gas equipment is thoroughly
effective.
The most serious causes of damage to the respirator are : (1) Water
entering the container and
damaging
the
chemicals,
(2) injury
to
the mask, (3) injury to one or both valves.
It is of the utmost
importance in reference
to (2)
and
(3)
to
see
that nothing
is carried in the satchel
but the respirator
and
anti-
dimming outfit for cleaning the eyepieces.
I hope to deal with the question of the disinfection of respirators
in my last paper.
The container,
as finally
issued,
should
be replaced
after it has
been
breathed
through
for
40
hours.
A record
card
is therefore
issued with
each container, and
on this should
be entered
the time
during which the apparatus has been worn during cloud gas attacks
or gas shell bombardments.
The number of hours during which the
respirator
has been breathed
through for training are entered in the
bottom
three rows under shell gas.
The date of issue is also stamped
on the card.
A fresh card is issued with each container.
I have dealt above with the apparatus supplied for the protection
of troops, and it is unnecessary
to do more than remind you that in
gas warfare
everything
depends
upon
the
quickness
and
efficiency
with which troops apply their protection.
It
is,
therefore, necessary
in preparation for war. to train all troops thoroughly
in gas drill,
i.
e., in systems
adopted
for spreading
gas
alarms,
in recognizing
conditions whether of weather or environment when gas may be used,
Xo. 1.
57
GALWEY
GAS WARFARE.
and in recognizing when gas shell is being used and the type,
and in
circulating information
to all who may come into a gassed area.
In
conclusion, therefore, I will
refer
briefly
to
the
secondary
means of protection against
gas attacks.
,1. When
cloud
gas
attacks
were
made,
various
methods
were
adopted
to disperse
the gas,
e. g., firing and throwing
bombs in the
gas; lighting fires in the trenches.
Fans were
also supplied for re
moving gas from dugouts
and trenches.
2. Solutions
of hyposulphite
and
hexamine
with
sprayers
were
also
issued
for spraying
the air in trenches,
dugouts,
etc.
3. With the development
of gas warfare
and the use of lethal gas
shells
these
methods
had
to
be
revised,
and
additional
measures
taken
for the protection of important
dugouts,
pill boxes,
and aid
posts.
It
was
recognized
that if
possible
the
dugout
should
be
evacuated
until
the
gas
had
dissipated,
but short of this it was
found that an effective
measure
was to light a fire in the middle of
a dugout after
a gas bombardment.
It was necessary
to take
care
that the ground
outside
the dugout was free from
gas before
the
fire
was
lighted,
otherwise the
fire
merely drew the
gas into
the
dugout.
In the case of dugouts which could not be evacuated —e. g., aid
posts,
advanced
dressing stations,
headquarters —a gas-proof curtain
was devised
as
a method
of protection.
One
method
of applying
this curtain
is
as follows:
A frame of
4 inches
by
1 inch timber
covered with blanket material is fixed
flush with the wall, sloping
outwards at an angle of 20°
from the vertical.
Antigas
material —
i. e., a special cloth to be treated with a solution of sodium
thiosul-
phate and sodium
carbonate
in water—is cut to the required size,
so that when
fastened
to the top of the frame it will close the en
trance completely and
leave about
9 inches
resting on the ground.
Three pairs of laths are nailed horizontally
to the curtain
to keep
it stretched.
The lath on the underside
must
be left shorter than
those in front
so
as to clear the
frame.
The
lowest of the laths
should
be
4 inches
from
the ground but must
not touch it.
Two
curtains should be provided, the upper as near the top of the stair
case as possible
(otherwise a pocket of gas may lodge
and be carried
into the dugout).
The frame for the inner curtain should, if pos
sible, slope inward.
A similar
contrivance was used to protect
pill
boxes.
When mustard gas came into
use it became necessary
to protect
men handling objects
contaminated
with it and to find some means
of removing it from clothing.
For men specially
liable
to
contamination—e.
g.,
gunners
and
stretcher bearers —in addition to their respirators special
gloves were
provided.
After trial of various substances
leather gloves
treated
58
Vol. XVII
GALWEY —GAS WARFARE.
with unboiled linseed oil were found efficient.
With them two pairs
of cotton
gloves
were issued to be worn over the leather.
Although
efficient in preventing
burns, these
gloves
were
large
and
clumsy
and hindered delicate manipulation.
To obviate
the hardening of the leather with
age the Americans
adopted:
(1)
Gloves of
a waterproof
material
coated
inside with
gelatine-glycerine- formalin
composition
and
protected
outside
by
another
waterproof
coating, and
(2)
gloves of a fabric
coated with
a softened
layer of cellulose
nitrate.
An effort was made
to provide clothing
which would
withstand
mustard gas.
We used cloth treated
with boiled linseed oil, and the
Americans cotton sheeting impregnated with boiled linseed oil, castor
oil, and paraffin wax.
These
proved efficient,
but difficulties of transport
and
of readi
ness when wanted were great obstacles to their use.
To destroy mustard
gas in clothing
three
methods
were
tried
:
(1) Treatment with steam or hot water;
(2) treatment
with chlorine
gas; (3) exposure
to fresh air.
As heavily contaminated or directly
splashed
clothing
can not be
effectively cleaned without damage to the cloth, it is considered
that
it should be buried.
Treatment with steam is the surest
method of degassing
contami
nated clothing,
and this can
be effectively
carried
out by means of
Colonel Lelean's sack disinfector or in a plant of any delousing sta
tion.
The Americans
found hot (not quite boiling)
soapy
water effica
cious.
The French used water at 90° C. containing mild alkalis to neutral
ize the acid formed by hydrolysis of mustard gas.
A solution of washing soda is safe, but it must be in correct
pro
portions;
too much
or too little retards destruction of the mustard
gas.
Keeping
men whose clothing has been contaminated in a chamber
containing
1 per cent chlorine for five minutes have been found effec
tive.
This treatment can
be carried out with cylinders of chlorine
gas in dugouts.
For slight contamination
exposure
of clothing in open air for 48
hours suffices, but if the contamination is heavy or the weather
cold,
a much longer time is necessary.
Dugouts may frequently be contaminated by infected mud brought
in- on boots.
Washing with a stiff brush and water and sprinkling
with chloride of lime have been recommended.
If dugouts are
contaminated,
it is well
to evacuate
and destroy
them.
If this
can not
be
done,
the contaminated soil
and
beams
should
be removed,
the walls and floor treated with chlorine, and the
No.
1.
59
RAYNOR
MEDICAL
CORPS
UNITS.
dugout shut
up for 24 hours.
After this period it should be well
ventilated by placing a lighted brazier in it and shifting the position
from time to time.
The atmosphere
may
be slightly
lachrymatory
for some time, the chlorine masking the smell of mustard.
Chloride of lime may also be used for this purpose
and for treat
ing shell holes.
In the latter
case the lime should be covered with
fresh earth,
the latter being employed
to prevent
chlorine masking
the smell of mustard and to render
the hole less conspicuous.
Two
pounds of chloride of lime per square foot of surface gives excellent
results, but this amount
is prohibitive.
One-half
to
1 pound
gives
fair results.
In
the
time
at our disposal it has only
been possible
to outline
the chief
points in measures
of
protection.
Everything
depends
upon
efficient preparation
and training and in the impressing upon
the troops that given these
they may have every confidence that they
will
escape
unscathed.
THE
FUNCTIONS
AND
ORGANIZATION
OF MEDICAL
CORPS
UNITS
SERV
ING WITH THE MARINE CORPS IN THE FIELD, i
By
S. N. Raynor, Major,
United
States Marine
Corpa.
THE ORGANIZATION OF THE BRIGADE.
[Introductory
Note. —The writer has undertaken
to prepare for the United
States Naval Medical Bulletin
a series of articles
dealing with the functions
and suggested
organization
of Medical Corps units serving with the Marine Corps
in the field.
Up to the present time there has been
no special organization
for
that service.
If the
necessity
for
such
special
organization
can
be
demon
strated, the quo animo of this series shall
have been attained.]
Before
taking
up
the
question
of
the
organization
of Medical
Corps
units for service
with the Marine
Corps in the field it seems
advisable
to devote some time to a consideration of the organization
of the military or fighting
units.
In general,
the function
of the
Medical Corps during
active operations is to provide sufficient
per
sonnel for first aid and part of the litter evacuation.
It is obvious,
therefore, that
the
organization
of the Medical
Corps
personnel
attached
to any fighting
unit
must
be
governed
primarily
by the
organization
and functions of that unit.
1In
the editorial section
of the January
issue of
the
United
States Natal Medical
Bulletin
reference
was made
to the establishment
of
a correspondence
course for
naval
medical officers
to be conducted
by Maj.
S. N. Raynor,
United
States
Marine
Corps.
It is
believed that
this
course
offers
many
advantages
to medical
officers, particularly
those
serving with
the Marine
Corps
in
the field.
The
Surgeon
General
is desirous
of having
all niedical
officers
who are available
for
duty
with
the marines
enroll
ifor
tills
course.
Applications
should
be forwarded
promptly
to MaJ.
Raynor
at the Marine
Corps
Schools,
Marine Barracks,
Quantico,
Va.
The
maps
used
in this course will
be supplied
by
the
Bnrean of Medicine
and Surgery.
103390—22
5
60
Vol. XVII.
RAYNOR —MEDICAL
CORPS
UNITS.
At the present
time the largest organization
in the Marine
Corps
is the brigade. In this article, therefore, we will take up the organi
zation of the brigade and of its component
parts.
As a result of the experience
gained in the World War, and after
a careful
and
exhaustive
study of innumerable reports and of the
conditions which presented
themselves
in various phases of the war,
the Army
Tables of
Organization
have
been
completely
revised.
The underlying principle in the revision of the tables was to provide
organizations that would meet all the requirements
for field service
under conditions of modern
warfare.
As the reasons for using the Army Tables of Organization
may
not be manifest to all, a brief explanation may not be inappropriate.
While
the
Marine
Corps
normally
functions
in conjunction
with
the Navy, Marine
Corps
forces
may
be, and, in recent
years,
fre
quently have been, detached for service with the Army.
Such being
the condition
which
must
be
met,
the Marine
Corps
organization
and that of any Medical Corps units serving with the marines, should
be such
as to fit in with,
and readily
function
with
and
as
a part
of the Army machine.
While
the Marine
Corps
organization
differs
in many
respects
from
that of
the Army,
due to the
nature
and
diversity
of
the
duties
which it is called
upon to perform, this dissimilarity
is one
of practical adoption to conditions of service rather than the result
of any
divergence
in the
fundamental
principles
underlying
their
respective
organizations.
By analyzing the Army organization, in so far as it concerns
this
problem,
we should get
a picture of
a machine
whose
efficacy
has
been proven, and
thus
enabled
to more
readily
determine
our
own
requirements.
In
the Army
an Infantry
division
is composed
of two brigades
of Infantry
and various auxiliary
troops and services.
A brigade,
as a part of a division,
is a purely tactical unit; i. e., it has no ad
ministrative
functions.
When
a brigade is
detached
from
the di
vision for independent
duties
it becomes
necessary
to provide
an
administrative
staff along
the
lines
prescribed
for that of
a
di
vision.
(StafF organization will
be the subject
of
a subsequent
ar
ticle.)
The new infantry brigade is organized as follows
: Brigade head
quarters
(10 officers)
; headquarters
company
(1
officer,
1 warrant
officer.
88 enlisted
men)
; 2 regiments
of Infantry
(each consisting
of 103 officers,
1 warrant
officer, and 2,950
enlisted
men).
Attached to each regiment
are
11 medical
officers,
87 enlisted
men
(Medical
Corps),
and
2 chaplains,
making
an
aggregate
for
the
brigade of 243
officers,
3 warrant
officers,
and
6.162
enlisted
men.
(See accompanying diagram).
No.l.
RAYNOR
MEDICAL
CORPS
UNITS.
h0
z
0
<
•<
u
as
o
o
as
fe
1
0 £
si
w '
2
E c w «
o
U
_ 9 ^ o
So
62
Vol.
XVII.
RAYNOR—MEDICAL
CORPS
UNITS.
It will
be noted that no provision
has been made for brigade sur
geon
and
the
necessary
personnel
to
assist
him.
As will
be
seen
later, this is because the regimental surgeons
function under the di
rection of the division
surgeon
when the division is intact.
When
a
brigade is acting independently
it is necessary
to assign
a
medical
officer to it for duty as brigade surgeon,
and
a quota
of officer
and
enlisted
personnel
from
the medical
regiment of the division
from
which
the
brigade
has
been
detached.
This
personnel,
when
so
assigned,
forms, for the Medical
Corps,
a brigade headquarters
de
tachment
which functions
as a part of the brigade staff.
HISTORICAL.
JONATHAN
COWDKBY,
SURGEON
IN
THE
UNITED
STATES
NAVY,
1767-1852.
PART
1.
By
Capt.
F.
L. PlbadwblI/,
Medical
Corps,
United
States
Navy,
and
Lieut.
Commander
W. M. Kerr, Medical
Corps,
United
States
Navy.
Jonathan
Cowdery,
the subject
of this biographical
sketch,
was
appointed
a surgeon's
mate in the Navy on January
1, 1800,
and he
lived to be the oldest officer in the service.
A review of his life is not
without
interest to the medical
officer of to-day for early in his naval
career he took part in the war with Tripoli, was taken prisoner on the
occasion of the loss of the U. S. frigate Philadelphia,
and held cap
tive by the Tripolitans for over a year and a half, during which time
he kept
a journal
which throws
much
light
on an historical
event
now almost forgotten.
He was a descendant
in the sixth generation
from AVilliam Cow
dery, who came to New England
in
1630 from Weymouth, England,
settling first at Lynn, Mass.,
and later at Heading in the same
State,
where he died in the year
1687.
Jonathan Cowdery
was
born
on April
22,
1767,
at Sandisfield,
Berkshire
County.
Mass.
His
father,
Jabez
Cowdery,
was
a
physician
who practiced
his profession for many years in Tunbridge,
Vt.
His mother was Ruth
Wickham,
bora
at Glastonbury,
Conn.
Where
Jonathan
received
his
medical
education
is not
definitely
known,
but
he
probably
served
a
quasi-apprenticeship
with
his
father, and he appears
to have attended
lectures for two winters at
Dartmouth in Hanover, N. H..
so it is not unlikely
that this school
was his alma
mater.
At any rate
we find that by the time
he had
reached
the age of 22 he felt himself qualified to support a wife, for
in 1789, at New Marlboro,
Mass..
he married Mary Bryant, daughter
of Col. Richard Bryant, of Revolutionary
fame.
At this period of his life.
Doctor
Cowdery
seems
to have
been
somewhat
of a rolling stone, for during the next six years
he and his
wife lived in
three
different localities
where
he practiced his pro
fession.
However,
he was happy,
as in each of these places
a child
came
to bless his home.
A son, Benjamin
Franklin,
was born in
1790,
at New Marlboro,
Mass.;
another,
Isaac
Newton,
was
born
in
1792,
at
Salisbury,
Conn.
In later
years
this child
became
a
63
64
JONATHAN
COWDEBY,
SURGEON IN
U.
S.
NAVY.
Vol. XVII.
musician, playing
the violin very skillfully.
He taught music
and
penmanship.
A daughter, Mary, was born in
1795,
at Livingston,
N. Y.
She died the same year, and during the following
year,
1796,
Mrs.
Cowdery
died.
After
his wife's
death
Doctor
Cowdery
returned
with
his two
sons to his father's home in Tunbridge.
Leaving
his children with
his mother,
he settled in the little town of Hudson, N. Y., where
he
was practicing
medicine
at the time
he received
an appointment
as
surgeon's
mate in the Navy of the United
States,
as the naval force
of the country
was called in its early
days.
His
commission
was
dated January
1, 1800, and
was signed
by John Adams, the second
President of the United
States.
His first cruise
was on the frigate
Philadelphia
commanded
by
the
elder
Commodore
Decatur,
in
operations in the West Indies against the French.
The first mention of him in official
correspondence
occurs in the
following letter signed by Robert Smith, then Secretary of the Navy :
Navy Department.
2S Oct.
1802.
Doctor
Jon.
Cowdeby,
Hampton,
Virg".
I have received your letter
of the 19th instant
and sincerely
regret,
as well
on your
own as on the public
account,
the occurrence
that
has deprived
us of
your services
on board the John Adams
the present cruise.
On receipt
hereof, you will consider
yourself
on
furlough
until again
called
into service and you will
be pleased to report yourself
to this department
when
you shall have recovered your
health
and are again
tit for duty.
It1
Smith.
On July
18th,
1803,
we find
Doctor
Cowdery
once
more sailing
as
one of
the junior
medical
officers
in
the
frigate
Philadelphia,
at
this
time
commanded
by
Capt.
William
Bainbridge,
United
States
Navy, for service
in the Mediterranean
against the Barbary
States.
The
senior
medical
officer
of
the
vessel
was
Surg. John
Ridgely, United
States Navy.
The
Barbary
States,
Morocco, Algeria, Tunis,
and
Tripoli,
lie
along the northern coast of Africa, between the Mediterranean
and
the Sahara, stretching from the Straits of Gibraltar to Egypt, a dis
tance of
2,000
miles.
The
Mohammedan population
of
this strip
of coast, consisting of Moors, Arabs, Berbers, and Turks, had long
been
engaged
in piracy, especially since
the
Conquest
of Granada
in 1492, which was followed by the exodus from Spain of thousands
of Moors who passed over to Africa carrying
with them
a hatred of
the Spanish
and
a thirst for vengeance
which early found vent in
piratical
raids on the commerce of Christian
nations trading
in the
Mediterranean.
These
pirates continued to infest
the Mediterran
ean until their extermination in the nineteenth
century.
The
captives taken
in
these raids
were
reduced
to slavery and
many of
the
pirates grew
immensely
and
rapidly rich
upon
the
No. 1.
JONATHAN
COWDERY,
SURGEON IN
U.
S. NAVY.
65
plunder
seized
and
the ransom
of their
captives.
The redemption
of slaves
was
procured
with
money
raised
by missions,
contribu
tions, and collections,
and
individuals
and
families
sometimes
im
poverished
themselves
to
ransom
friends
and
relatives.
William
Eaton,
United
States
consul
at Tunis,
writing of
the
corsairs in 1799, says : " Their mode of attack is uniformly boarding.
For this their vessels are peculiarly
constructed.
Their long, lateen
yards drop on board the enemy and afford a safe and easy conveyance
for the men
who
man
them
for this
purpose;
but being always
crowded with
men, they throw
them in from all points of the rig
ging and from all quarters
of the decks, having their sabers grasped
between
their teeth and their loaded
pistols in their belts, that they
may have
the free use of their hands in scaling the gunnels or net
ting of their enemy.
In this mode of attack they are very active and
very
desperate.
*
*
*
Proper defenses
against
them
are high
nettings, with
chains sufficiently
strong
to prevent
their being cut
away, buckshot plentifully administered from
muskets
or blunder
busses, and lances.
But it is always best to keep them at a distance,
that advantage
may be taken of their ignorance at maneuvering."
" The attitude of Europe toward the Barbary
States was cowardly
and
dishonorable
from
first
to
last.
The
action
of
the
stronger
powers
was prompted largely by policy.
In order to injure
their
enemies and
to crush
the
commercial
competition of their
weak
neighbors they were willing to bribe and subsidize the pirates, sub
mitting to the indignity and dishonor of being tributary
nations and
encouraging
a system of ruthless piracy
and slavery."1
Shortly after the Revolution
a new flag appeared
in the Mediter
ranean
which
the
pirates
soon
learned to
recognize
as that of
a
young, weak power in distant America, likely to fall an easy prey to
their
vessels.
Before
long
there
were
many
Americans
held
in
captivity in Barbary, who addressed letters
and petitions to the Pres
ident, to Congress,
to the ministers of various denominations,
and to
Col. David Humphreys, United States minister to Portugal,
who, in a
letter to the American
people,
suggested
a lottery
as the means of
raising
the necessary
funds for the ransom of their fellow country
men.
Various diplomats,
commissioners,
and agents were appointed to
the difficult
task of negotiating with
the Barbary
powers,
but their
efforts
met
with
indifferent
success.
The
rulers
of
the
Barbary
coast maintained that they were the sovereigns of the Mediterranean,
and that no nation could navigate that sea without
a treaty of peace
with them.
1Out Navy and the Barbary
Corsairs,
by
Gardner
W.
Allen.
Houghton,
Mifflin
A
Co..
Boston, 1905.
66
JONATHAN
COWDEBY,
SURGEON IN U.
S. NAVY.
Vol. XVII.
In
1792,
the
Senate
favored paying
$100,000
annually
for
peace
with Algiers, Tripoli, and Tunis, and $40,000
ransom
for the captives;
but many of the leaders of that time favored the early and energetic
employment of force against these piratical
States and through their
influence
three
ships were
built
and
launched in
1797,
the
United
States,
Constitution,
and
Constellation,
forming
the nucleus
of the
American Navy.
A treaty of peace and amity with Algiers was ratified by the Senate,
March
2,
1796,
and it cost
up
to January,
1797,
nearly
a million
dollars,
exclusive
of
an
annuity
in
naval
stores
valued
at
about
$25,000.
This treaty was not
so liberal
as one concluded
with Mo
rocco,
but it
was
the only
one which
stipulated
the
payment
of
tributes.
A treaty
was
also
concluded
with Tripoli and Tunis at
great expense.
Looking backward
to those
times it is easy to
see how
the
em
ployment of force
would have
saved time and money
and
won
re
spect for our infant nation, but, as Gardner W. Allen says, " to judge
the question
fairly it is necessary
to look
at it from
the point of
view of that time.
Most of those who favored following the
prec
edent of Europe
by paying tribute to barbarians, and who opposed
a navy, did what they thought was best for the country and many
of them
were
among
the
foremost public
men
of
the day."
The
money
received
only
enabled
the rulers of the
Barbary
States to
prepare
for further
depredations upon commerce
and
each waited
for a pretext and opportunity
to break peace with the United States.
The pasha of Tripoli
apparently did not make
as good
a bargain
in the conclusion of his treaty with
the United
States
as did some
of his fellow
pirates.
Accordingly
he became
dissatisfied.
Diffi
culties arose between
him and
the American
consul,
Mr. Cathcart,
and
finally
on May
10,
1801,
the
pasha
declared
war against
the
United
States.
Without delay
he sent out his corsairs in search
of
American
prizes but with little
success,
as his hostile act had
been
anticipated by the American Government and
a timely warning had
put American
merchantmen
on their guard.
About June 1, 1801, a squadron under the command of Commodore
Richard Dale, set sail from Hampton
Eoads for the purpose
of ob
serving the situation in the Mediterranean
and protecting American
commerce against the threatened
attacks
of Tripoli.
This squadron
consisted
of the frigates
President,,
44 guns,
flagship, Capt.
James
Barron; Philadelphia,
36 guns,
Capt.
Samuel
Barron; and Essex,
32
guns,
Capt. William
Bainbridge,
and
the
schooner
Enterprise.
12 guns, Lieut. Andrew Sterrett.
The squadron arrived at Gibraltar
July
1.
Here Commodore Dale found two Tripolitan cruisers which
had left Tripoli with
the intention of sailing
into the Atlantic
to
prey upon American merchantmen
off the straits, and by forestalling
No. 1.
JONATHAN
C'OWDERY,
SURGEON IN
U.
S. NAVY.
67
their
passage through
the
Straits
of Gibraltar
he
doubtless
pre
vented severe
losses to American
commerce.
The Philadelphia
was ordered
to cruise
in the straits and watch
the Tripolitans,
and the Essex was ordered
to collect
the American
merchantmen
in different ports and give them
convoy
through
the
straits.
The commodore
with the President
and Enterprise
cruised
along the Barbary
Coast where his appearance
produced a salutary
effect.
During this cruise
the Enterprise
fell in with
a Tripolitan
vessel of
14 guns
and
80 men.
The two vessels were
about
evenly
matched.
They at once engaged
at close range
and fought for three
hours.
Allen gives
the following
account
of the encounter
and its
results :
" By his superior skill in maneuvering, Sterrett was able to avoid
the enemy's attempts
to board,
and by choosing
his position, to rake
him
repeatedly.
Twice
the Tripolitan struck his colors,
and
when
he thought
he had
his adversary at
a disadvantage,
reopened
his
fire, hoisting his flag again.
The third time,
there being no longer
hope
of
making
up
for
his
poor
seamanship
and
gunnery
by
treachery or stratagem,
he threw his flag into the sea, and by suppli
cating
gestures
begged for quarter.
Porter
was
then
sent
aboard
the corsair to take
possession.
All her guns
and small arms,
with
everything
elese of value,
were thrown
overboard,
and she was sent
back to Tripoli
an empty
hidk.
Sterrett's report
to Commandore
Dale, dated
at sea August
G, 1801, is as follows: 'I have the honor
to inform you. that on the 1st August I fell in with a Tripolitan ship
of War, called
the Tripoli, mounting
fourteen
guns,
commanded
by
Reis
Mahomet
Sous.
An
action
immediately
commenced
within
pistol-shot, which continued three hours,
incessant
firing.
She then
struck her colors.
The carnage
on board
was dreadful,
she having
twenty
men killed
and thirty wounded;
among
the latter
was
the
captain
and first lieutenant.
Her mizzen-mast
went over
the side.
Agreeable to your
orders, I dismantled
her of everything
but
an
old sail and spar.
With heartfelt
pleasure I add, that the officers
and men throughout the vessel
behaved in the most spirited
and
de
termined
manner,
obeying every
command
with
promptitude
and
alertness.
We had
not
a man
wounded,
and
sustained
no material
damage in our hull or rigging.7
Sterrett received the thanks of Con
gress and a sword, and his officers and men a month's extra pay.
The
Tripoli crept slowly home,
and
on her arrival
the pasha
was filled
with
rage
and
chagrin.
The
unfortunate
Mahomet
Sous
was
mounted on a jackass,
paraded
through the streets, and bastinadoed.
The effect of this severity was that men were greatly
discouraged
from serving
in the corsairs then fitting
out.
For some time after
this, very few Tripolitan cruisers ventured
from port."
68
JONATHAN"
COWDERY,
SURGEON IN U.
S. NAVY.
Vol. XVII.
The
remainder of the year
1801,
was
devoted
to
a blockade
of
Tripoli,
which
was
effectual
in that it caused
a great scarcity of
food in the capital.
In
1802 the American
Government determined
to prosecute
the War against Tripoli with more vigor.
As the terms
of enlistment of Commodore
Dale's men had nearly expired, it be
came necessary
to send out
a new
squadron to
relieve
the
vessels
in the Mediterranean.
The
command
was given to Capt. Richard
V. Morris, who hoisted
his pennant on
the frigate
Chesapeake,
36
guns.
This
squadron
having
reached
the
Mediterranean,
the
Philadelphia, together with
some of the other vessels, returned to
the United
States.
Commodore Morris operated
in the Mediterranean until the fall
of 1803 when
he was relieved of his command
by Capt. John Rodgers
by order of the Navy
Department
because it was believed
that he
was not producing the results
desired.
When it was decided to recall
Morris, a new squadron was fitted
out, the command
of which
was
given to Commodore Edward Preble.
Commodore
Preble's instructions from the Secretary of the Navy,
Robert Smith, were dated July 13, 1803.
The vessels of the squadron
sailed as they became ready for sea in the following order : Nautilus,
12 guns,
Lieut.
Richard Somers,
June
30;
Philadelphia,
36
guns,
Capt. William
Bainbridge,
July 18;
Vixen,
12
guns,
Lieut.
John
Smith, August
3; Constitution,
4A guns,
Commodore Preble's
flag
ship, Lieut. Thomas Robinson, jr., acting captain, August
14; Siren,
16 guns, Lieut.
Charles Stewart, August
27; Argus,
16 guns, Lieut.
Stephen
Decatur,
September
8.
The
Enterprise,
12
guns,
Lieut.
Isaac Hull,
already in the Mediterranean,
was
to
remain
there
as
one of the new squadron,
but on the arrival of the Argus, which was
a larger
vessel than
the Enterprise,
Hull, being senior in rank to
Decatur, was to exchange
commands
with him.
The Philadelphia arrived
at Gibraltar August
24,
1803, in
the
vicinity of which place she cruised
in search of enemy vessels, until
on
the arrival
of Commodore
Preble,
she was
sent together with
the
Vixen
to establish
the
blockade
off Tripoli
before which
port
the
vessels appeared
on October
7.
Bainbridge
was informed
by
the captain of
a brig, coming out of Tripoli,
that two Tripolitan
vessels of war were out upon a cruise.
Thinking they were probably
to the westward, he sent the Vixen
to cruise
off Cape
Bon
where
these vessels would most likely be met if returning
from that direc
tion,
and
where it was safer for
the schooner
than
off Tripoli,
as
the
season for heavy
storms
was
approaching.
The Philadelphia
from
then on, maintained the blockade alone.
On the last day of October an event occurred
which, according
to
Allen, is narrated by Captain Bainbridge
in his report to the Secre
tary of the Navy, dated November 1, 1803,
as follows:
"Misfortune
No. I.
JONATHAN
COWDEBY,
SURGEON IN U.
S. NAVY.
69
necessitates
me to make a communication the most distressing of my
life; and it is with deep regcet that I inform
you of the loss of the
United
States
frigate Philadelphia,
under my
command,
by being
wrecked on rocks
between four and five miles to the eastward
of the
town
of Tripoli.
The
circumstances
relating
to this unfortunate
event are : At
9 A. M., being about
five leagues
to the eastward
of
Tripoli,
saw
a ship inshore of us standing
before
the wind
to the
westward.
We
immediately
gave
chase;
she
hoisted
Tripolitan
colors
and
continued
her
course
very
near
the
shore.
About
11
o'clock
had
approached
the
shore
to
seven
fathoms
water, com
menced firing at her, which we continued by running before the wind
until half past
11, being then in seven fathoms of water; .and finding
our fire ineffectual to prevent
her getting into Tripoli,
gave up the
pursuit and
was bearing off the land when
we ran on the rocks
in
twelve feet of water forward
and seventeen feet abaft.
Immediately
lowered down a boat from the stern, sounded
and found the greatest
depth of water astern.
Laid all sails aback,
loosed topgallant sails
and set
a heavy
press of sail-canvas on the ship, blowing
fresh, to
back her off.
Cast three
anchors
away
from
the bows,
started
the
water in the hold, hove overboard the guns
excepting
some abaft to
defend
the ship against the gunboats
which were then firing on us ;
found all this ineffectual.
Then made the last resort of lightening
her forward by cutting away the foremast,
which carried the main-
topgallant
mast with it.
But labor and enterprise were in vain, for
our fate was direfully fixed.
*
*
*
Striking on the rocks was an
accident
not possible
for me to guard against
by any intimation
of
charts, as no such shoals
were laid down in any on board, and every
careful precaution, by three leads kept heaving, was made use of on
approaching
the shore
to effect the capture
of a Tripolitan
cruiser.
And after the ship struck the rocks all possible
measures were taken
to get her off and the firm determination made not to give her up as
long
as
a possible
hope
rema:ned.
although
annoyed
by
gunboats
which took their position in such
a manner
that we could
not bring
our guns to bear on them, not even after cutting away part of the
stern to effect it.
When my officers and self had not
a hope left of
its being possible
to get her off the rocks,
and having withstood the
fire of the gunboats
for four hours, a reinforcement coming out from
Tripoli, without the smallest
chance of injuring them by resistance,
to save the lives of brave men left no alternative but the distressing
one of hauling our colors
down and submitting
to the enemy whom
chance had befriended.
In such
a dilemma the flag of the United
States was struck.
*
*
*
The gunboats
in attacking fired prin
cipally at our masts;
had
they
directed
their
shot at the hull,
no
doubt but they would have killed
many.
The ship was taken
pos
70
JONATHAN
COWDERY,
SURGEON IN
U.
B. NAVY.
Vol. XVII.
session of
a little
after
sunset
and
in
the
course
of
the
evening
myself and all the officers, with part af the crew,
were brought
on
shore."
Captain Bainbridge
was greatly
depressed in spirits over the loss
of his
vessel.
His
officers sympathized
deeply
with him, and
in
a
letter signed
by all of them, November
1,
1803. expressed their feel
ings in the following
words : " We, late officers of the United
States
frigate Philadelphia,
under your command,
wishing
to express
our
full approbation of your conduct
concerning the unfortunate
event
of yesterday,
do conceive that the charts and soundings justified
as
near an approach to the shore
as we made, and that after the ship
struck, every
exertion was
made
and
every
expedient
tried
to get
her off and to defend her. which either courage or abilities could have
dictated."
On November 2.
a heavy
wind
caused
the Philadelphia to float.
The Tripolitans succeeded in pulling her off the reef the next day and
brought here into the harbor, amid the rejoicing of the people and to
the great mortification of the Americans.
The officers and crew of the lost vessel had
a long bondage
before
them.
Doctor Cowdery kept
a journal
during
his captivity
which
gives
much
information
about
the
fortunes of
the
prisoners,
and
which will
form
the subject matter of the historical
essay in the
Bulletin next
month.
The officers
Avere
well treated
at first, and
were allowed some recreation on the roof of the house where they were
confined, but after three or four days this privilege was denied them
and soon they
were removed
to the prison where
the men were con
fined.
Doctor
Cowdery
attracted
the attention of the
pasha,
who
employed
him
as his physician,
and
he
was
allowed
more freedom
than any other
officer.
The
men
fared
much
worse
than
the
officers.
The
different
classes of mechanics
were put to work at their various trades, and the
others
were employed
at all sorts of hard labor, chiefly on the fortifi
cations.
They
were beaten
and
maltreated
by
many
of their task
masters,
and
sometimes
basinadoed.
When Commodore Preble heard of the Philadelphia's
situation
he
determined
to destroy
her and selected Lieutenant
Stephen
Decatur
for the task.
On the night of February
16. 1804. with the Siren and
the ketch Intrepid, Decatur entered the harbor of Tripoli and set fire
to the captured
vessel which, as Admiral Nelson
said, when he heard
of it, " was the most bold and daring
act of the age."
Without
a
doubt
the burning of the Philadelphia added much to the reputation
of the Navy both at home and abroad.
In July,
1804.
Commodore Preble
assembled his entire squadron
before Tripoli
and on August
3. he began a series ot bombardments
which lasted
a month
and which caused great destruction of the gun
No. 1.
JONATHAN
COWDERY,
SURGEON IN
U.
S. NAVY.
71
boats in the harbor, and much
damage to the city.
He was relieved
by Commodore
Barron,
who continued the blockade.
Two
letters
written
by Doctor
Cowdery
after
the bombardment
throw
some light
on
the
condition
of
the
American
captives
in
Tripoli
at this time.
One letter dated
November
7,
1804,
and
ad
dressed to his father. Dr. Jabez
Cowdery,
at Tunbridge,
Vt., is as
follows
:
My Dkar Father, No doubt you have often heard of the loss of the Frigate
Philadelphia,
and the capture
of its whole crew
(by the Barbarians).
Among
whom is your unfortunate
son.
We were
taken
on
the 31st of October,
1803,
and entirely
robbed of our property
even
the greatest part of the clothes on our
backs were taken
from
us.
Our seamen were
immediately
put
to hard
labor,
without mercy,
and have suffered
much for the necessities
of life.
Five have
paid their last debt to Nature,
and five have turned
Turk.
Myself and fellow
officers
were
permitted
to occupy
the house
where
our
Consul
Mr. Cathcart
resided, while in Tripoli.
On our first arrival, we signed a Parole of Honour,
but have not been allowed to enjoy it.
The Bashaw
(or the head of the regency)
compels
me to exercise
my profession
in his Palace,
and among his slaves;
to
relieve the distress
of the latter is
a pleasure
to me.
About
the first of Feb
ruary
we were
removed to the Castle
and placed In close confinement
under
a
powerful guard of Turks, who examined every paper and letter with the utmost
scrutiny,
to prevent
our having
any communication
with our
squadron
off the
town, which
they much feared.
What few letters
we received from
our friends
are opened
before
we get them ; no doubt
many
have
been
suppressed.
Mr.
Nissen,
the Danish Consul,
has done us many favours,
and is entitled
to our
utmost gratitude.
We live in hopes of being
liberated
in due time, and In a
manner that will do honour to our country
whose service we were in, and whose
wrongs we were avenging, when by a sad misfortune
we fell into the hands of
a Monstrous
foe, who divested us of liberty and property,
and plunged
us Into a
Prison,
from
thence we were removed to a more gloomy
one,
the dreary
cells
of a Castle, the gloomy walls of which bespeak the miseries
of Christian slaves
who erected
them under
the lash of Tyrants, the glimmering
light of which
Is
admitted
through
an Iron grating
in the top ; the doors
are secured by large
locks and bars
of iron,
and guarded
by
infamous
Turkish
soldiers,
who
are
ready to plunge their daggers into our hearts, at the nod of a tyrant,
who pre
serves us only for the ransom which
he expects from our country.
We
hope
and
expect
that
the Free
Sons of Columbia
will
soon
relieve
us,
their oppressed countrymen,
and restore
us to
our native
shore, that
we may
join
them
in the protection
of its rights,
and the enjoyments
of its blessings.
May the day soon arrive,
when we may have the pleasure of joining our Country
men hand in hand
to
erect dungeons for
vice
and
tfmples
for
virtue.
May
we teach
the haughty
tyrant,
and
the
barbarian
that
our
rights,
the common
rights
of man, are sacred, and not to be infringed,
that
we will establish
and
maintain
them in spite
of
the
enemies of
Mankind.
Ever since our
captivity
the Bashaw
has
been
possessed
in favour of me : I have had two fits of sick
ness,
one of the Dysentery
and the other Ophthalmia,
both very
severe
during
which
the
Bashaw
paid
me
every
attention
that
could
be
expected
from
a
Turkish foe.
On the 30th of July
lie took
me from
the prison
of my
brother
officers,
and gave me a pleasant
and well
furnished
apartment
in his palace; I
now
have
liberty
to walk about
the town
when I please, and to take
a short
ride into
the country
on a mule.
Occasionally
a Turk
who speaks
the English
language, is appointed
to walk and ride with me, to prevent
my
running
away,
72
JONATHAN
COWDERY,
SURGEON IN U.
S. NAVY.
Vol. XVII.
or meeting with insult, and to act as interpreter
; he is very
polite
and pays
me every
attention, I can
speak Arabic
(the
language of the place)
tolerably
well ; I
have
received
some
of the
books
which
were
taken
from
me
when
we ran
on
the rock,
them I make use of as my best companions, I
spend
the
best of my time in perusing
them and in attending
the sick slaves, particularly
my countrymen.
I
am
not allowed
to hold
any conversation
with our officers
(and
our
letters
to each other
are examined
with
the utmost
scrutiny)
who
are still in close confinement.
Our worthy
Captain
Bainbridge
has established
a credit with Dr. Davis,
our Consul
at Tunis, and with the French and Danish
Consuls
In this place so that we draw a little money when we are in want,
by
this our
seamen
are often supplied
with bread, or perhaps
they
would
perish
with hunger.
The harbor
is closely blockaded
by the American
Squadron
under
Commodore
Barron, who lately relieved
Commodore
Preble,
in consequence of
which
there
is great
scarcity
of provision
In this place, and I fear it will
be
worse
among
us before we get from
hence.
Our Squadron
made five vigorous
attacks
upon
this
place last summer,
in which much blood
was
shed.
Terms
of Peace have been offered, without effect.
The Bashaw
demands
$1,000,000
of
dollars.
Our Government
has offered through
Commodore
Preble
one
hundred
and twenty
thousand
dollars,
a very wide difference
; an additional amount
is
expected from
our country
in the spring, I suppose you know
more of this than
I do.
We expect warm work next summer.
I assure you It is not very pleasant
to
be
a
prisoner
in
a
besieged
city,
but
God
is
our
protector.
The
present
Bashaw
has
been
on
the
throne
about
eleven
years.
On
the
death
of
his
father,
the former Bashaw,
he usurped
the throne, by killing
one of his elder
brothers,
and driving
the other
out
of the dominion
Into
Egypt.
He is
very
cruel to his subjects,
when
he finds them guilty of crimes;
for murder,
treason
&c he beheads
them;
for
theft,
housebreaking
&c
he
takes
off the left
hand
and right foot, at the Joint and dips the stump Into boiling tar ; for less crimes
he gives them from
five hundred
to a thousand
bastinadoes
as the Turks
call
It; this is done by tricing up the feet with a rope and beating
upon the
soles
of the
feet with
a
large
stick;
they
often
perish
under
the
operation.
Yet
this
cruel
prince
is
remarkably
fond
of his
children,
and kind
to
the
poor.
He Is about
thirty-five
years of
age.
He has two
wives,
one
white and
one
black ; by the former
he has five and by the latter four children,
a plurality
of wives
Is allowed
in this country.
The Bashaw
is a white man of middling
age, rather portly,
and tolerably
handsome.
He has a bombproof
room, which
he occupies during the rattling of shells
and shot and the sounding
of Colum
bian
Thunder.
The laws of our country
allow us full pay and rations during
our captivity ; this is of some
consolation
to us In this savage land.
How long
we are to remain
here, God
only knows; I
am in hopes of
once
more
seeing
my Parents,
I wrote you a letter directly after our captivity.
I have an oppor
tunity of sending this letter
to the Island of Malta by a particular friend,
from
thence it will be sent to America,
by our
Consul
who resides
near
that
place,
it therefore will escape
the scrutiny of my new masters; I
am
in good health
and spirits,
thank
God,
and
hope for
better
times
soon.
My respects
to all
friends,
I am with the greatest
respect, Your affectionate
son,
Jon"
Cowdebt.
Dr. Jabez Cowdebt.
The
other letter, dated
24 November,
1804,
was
addressed
to
a
friend,
a Doctor Mitchell,
and it was published in the National In
telligencer at Washington, D. C, August
5, 1805.
Dear Sib: I hope you will excuse me for the liberty I take
in suggesting to
you
a
few
remarks
which
have
occurred
since
my
captivity.
The
Bashaw
No. 1.
JONATHAN
COWDERY,
SURGEON IN U.
S. NAVY.
73
has
taken
uie
from
the prison
where
my
fellow
officers
were
confined
ami
ordered
me to attend
his sick slaves who
are principally
Neapolitans,
negroes
and our
unfortunate
crew.
Some
of the
latter
I this morning
saw
chained
to
a
cart
loaded
with
stones
which
they
were
dragging
through
the
town
to repair
the fortifications.
They
complain
much of hunger,
cold, hard
labor
and the lash of the whip.
I confess I never
saw anything
that
wounded
my
feelings
equal
to
the
sight
of
those
poor
fellows.
I
have
liberty
to
walk
in
the town
but am attended
by a Turk
who is loaded with weapons of war.
1 am not allowed
to visit any of the fortifications nor any of the foreign
con
suls.
Capt.
Bainbridge's
endeavours
to
relieve
the
wants
of
his
crew
are
often countermanded
by our new masters.
Five of our countrymen
have turned
Turk,
and five have
paid their last
debt to nature.
Diarrhea and
Dysentery
have
often
appeared
among our crew, but
on
a free
use
of
carbonate
of soda
(Natron)
which
is found
in abundance
in this country
and often white wash
ing the walls of the prison with lime where they sleep, it soon
disappears.
Our
crew are not very
healthy.
During
the several
attacks
upon this town
by our squadron
under
command
of Commodore Preble,
many Turks
were killed
utid
wounded
and several
men
much burnt by the explosion
of their own powder.
I had an opportunity
of
seeing
their
method of curing
burns
in particular,
many of which
extended
over the whole
body.
The
Bashaw
has all his wounded
brought
to an apart
ment
in the castle
where
he
visits
them
and
makes
them
a
present
of
ten
dollars
each.
He
then
orders
his
surgeons
and
Mamelukes
to
dress
their
wounds;
he often
assists
with his
own
hands.
The Mamelukes
are his body
guards;
the Marabouts
are employed
to
expell
evil
spirits,
and
make Inter
cession
with
Mahomet
their
prophet,
for
their
recovery.
Those
that
were
burnt,
were first annotated with honey, carefully preserving
the skin as much
as possible
and
keeping
the parts
exposed
to
the air.
They
then
sprinkled
the ulcerated
parts, if any, with
a
fine powder
of white
lead
(Ceruse:)
this
they repeated at short Intervals until
a scab is formed,
that
is carefully pre
served until a cure Is accomplished,
which
is remarkably
soon.
I hope
and expect that
in due time my country
will honorably
and
to the
astonishment
of Barbarians and Tyrants liberate
us from
the chains of slavery
and restore us to our
native
land,
that
happy
land
the thoughts
of which
is
a healing balm to our souls in their
miserable
bondage."
Commodore
Barron
maintained the blockade
through
the winter
of 1804-5, but his health at last became
so impaired
as to make it
impossible for him to manage
the affairs of the squadron.
Accord
ingly,
on May
22,
1805,
he turned the
command
over
to Captain
Rodgers, the commanding officer of the Constitution.
On June 4, 1805, Captain Rodgers, together
with Col. Tobias Lear,
the American consular general
at Algiers,
who had been invested
by
the President with full power and authority
to negotiate
a treaty of
peace with the pasha of Tripoli,
effected an amicable
settlement
of
the differences between that country and the United
States.
Colonel
Lear in his report to the State Department, writing of the termina
tion of hostilities says:
" I went into the harbor in the Constitution's
barge, with the flag of the United
States displayed, and was received
at the landing
place by the American
officers, who
had
been in cap
tivity, with
a sensibility
more easily
to be conceived
than described.
74
JONATHAN
COWDERY,
SURGEON IN
U.
S. NAVY.
Vol. XVII.
An immense
concourse
of people
crowded the shore
and filled
the
streets, all signifying their pleasure
on the conclusion of the
peace.
*
*
*
On
the
4th
of June,
at
11
a.
m.,
the
flagstafl
was
raised on the American
house and the flag of the United
States dis
played, which was immediately saluted with
21 guns from the castle
and ports and was returned by the Constitution."
The American prisoners, after a captivity of over
19 months,
were
released
and
sent
aboard
the
ships.
On
June
21
the
American
vessels left Tripoli,
leaving behind as charge
d'affaires, Surg. John
Ridgely,
one of the late
captives
and
formerly
the senior medical
officer of the Philadelphia.
Doctor Cowdery, as we see by the following letter, reached home in
the fall of 1805.
*
. Tunbridqe, Vermont, Nov.
1,
1805.
I arrived
here yesterday
where I intend
staying
until
spring
if not
sooner
honoured with your command.
I have the honour
to be, Sir, with the greatest
respect,
Your Obt. Serv't,
Jon"
Cowdery.
Robert
Smith,
Esq.
After Doctor Cowdery's return to the United
States
his fortunes
are best followed by a perusal of letters which he wrote from time to
time to the Navy Department or to relatives or friends.
With him in captivity in Tripoli was a private of marines named
William Ray, who
also kept a journal.
In July, 1807, Doctor Cow-
dry, who evidently was on leave at his father's house in Tunbridge,
Vt., received
the following letter from Ray :
Dear Sir: My volume
is nearly
complete and will
be put
to press in a very
short time, but I should nevertheless
be very thankful to receive the remainder
of your journal, for I have already
taken
the liberty of extracting
from that
part of it which
was published
in the Hudson
Balance; and have made some
remarks
on the extracts,
which perhaps,
from
a
view
of the whole, I might
be induced
to alter, I should also be happy
to receive from you any interesting
remarks
you may be pleased
to make ; particularly information relative
to the
origin of the war.
I have received both from General
Eaton
and the Secretary
of the Navy,
all the information in their power ; but they arc not explicit,
as
respects the true rise
of hostilities between the United
States
and Tripoli.
I
wish,
likewise,
for a list of the United
States vessels of war which
were lying
at Gibraltar
when
we first arrived there.
What arrivals while we lay there,
and what
ships of war of the U.
S. were lost at that place, for I have but an
imperfect
recollection.
I enclose you
two subscriptions
which I would
thank
you
to circulate
and return
to Mr. John
Barber,
Printer in Albany,
within
a
couple of months, by which
time it is expected the work will be nearly printed.
As
the time
is short, I must
beg
you
to forward
the papers
which
you have
been
kind enough to promise
me, with all possible expedition,
to the Gentlemen
above mentioned.
I am,
sir,
very respectfully,
Your
obedient
Servant
Wm. Rat.
Dr. John Cowdert,
Tunbridge,
Vermont.
No. 1.
JONATHAN
COWDEEY,
SUBQEON IN U.
S. NAVY.
75
Evidently Dr. Jonathan only " circulated " one of the " subscrip
tions " as there is one folded in the letter.
The following ia a copy
:
" To Headers,
Who search for knowledge,
mental food of man,
" Roam the wide field, and gather all you can ;
" Sweet's the repast where reason guides the way,
" But ah how bitter if from her we stray";
" Here
taste the product
of that barb'rous
clime,
" Where truth is error—virtue is a crime.
" No venal motive has the writer shown,
" The Author's benefit is all your own ;
" Subscribe, persue the volume, and you'll find
" Both pain and pleasure thrill the pensive mind,
" Mark the strange thesis, count the loss and gain
"And
feast on pleasure at the expense of pain.
" Proposals.
" For Publishing by
Subscription,
A volume
entitled
" Horrors of Slavery
" or
" The American
Tars in Tripoli
;
" Containing
"An account of the loss and capture of the United
States Frigate Philadelphia,—
Treatment
and suffering
of the Prisoners,
Description
of the place, manners,
customs
&c of the Tripolitans, Public
transactions
of the United
States with
that Regency,
including Gen. Eaton's
expedition
; interspersed
with interesting
remarks, Anecdotes, and Poetry on various
subjects, —Written during upwards
of nineteen
months Imprisonment
and vassalage
among the Turks.
By William Ray "
" Specimen of the Work.
" Extract from
a Piece written by the Author In Tripoli,
1804.
" Published
in the Port Folio.
" Ye lurid domes ! whose tott'ring columns
stand
" Marks of the despot's desolating
hand ;
" Whose weed-grown
roofs and mould'ring
arches show
" The curse of Tyranny, a nations
woe ;
" In ev'ry ruin—ev'ry pile, I find
"A warning lesson to a thoughtful
mind ;
" Your dreary
cells expressive
silence break,
" Echo to groans, and eloquently
speaks ;
" ' The Christian's blood cements the stones he rears,
" ' This clay was moistened with a Christian's tears.
" ' Pale as these walls a pris'ner
oft has lain
" ' Felt the keen
scourge, and worn
the ruthless
chain,
" ' While scoffing foes
increasing
torture
pour,
" ' Till the poor victim feels, alas ! no more ! '
" Here thy brave tars America
are found
" Lock'd in foul prisons,
and in fetters
bound."
Conditions.
"Hub
volume will
be handsomely
printed
on
good
papers, with a fair
type.
It will contain
about 300 duodecimo pages,
and be afforded
to subscribers,
neatly
103390—22
6
76
JONATHAN
COWDERY,
SURGEON IN
U.
S. NAVY.
Vol. XVII.
bound and lettered, at One Dollar, payable on delivery
of books.
The work will
be put
to press as soon
as a sufficient
number of subscribers
appear
to defray
the expense of publication.
Albany,
Feb., 1807.
This book was to be published in Troy, New York, in 1808, but all
efforts
to find a copy have been in vain.
Among
letters
found
in " Officers
Letters,"
Navy
Department
Library,
are some which show
Doctor Cowdery's
resentment
at his
delayed promotion.
In a letter written July 22, 1807, at Tunbridge, Vt (near Chelsea,
Vt.),
he acknowledges
receipt
of orders to New York,
and
makes
request for the promotion, which the Secretary had assured him that
he should have, upon the occasion of their last meeting.2
In
another
letter, written
at New York
on August
7,
1807,
he
reports his arrival from Vermont,
and
states that he has
reported
for duty to Commodore Eodgers, who has assigned
him to duty
as
surgeon's
mate under Doctor Marshall.'
States that he expected
a
"higher station,"
as he has been for a long time
the
oldest
in the
list of surgeons'
mates.
Mentions that he has attended
the medical
lectures at Hanover
* the last two winters, and has been recommended
by Doctor Mitchell
6 and others
to the Secretary for promotion.
Doctor Mitchell
was a teacher of rare attainments and wide knowl
edge in both science and medicine.
His name appears in several
of
Doctor Cowdery's letters.
In this letter Doctor Cowdery
declares his fondness
for the Navy
and for the gentlemen
belonging to it and is anxious to be of service
to the country in " the present critical situation,"
° but protests
against
being continued
as
a surgeon's
mate,
when
younger men
are
pro
moted
over
him.
He
requests
the
rank
which
was
promised
him
when
he and Lieutenant Stuart waited upon
the Secretary- in Balti
more.
1This letter
as well
as those which follow are addressed
to the Secretary
of the
Navy,
R.
Smith.
• S.
R.
Marshall,
surgeon's
mate,
14
May,
1799;
Surgeon.
16
January,
1800;
died
20
May,
1828.
'Dartmouth
College
(at
Hanover,
N.
H.)
established
a
medical
department
In
1797.
• Probably
Dr. Samuel L. Mitchell of the Columbia
College and the College of rhyslclane
and Surgeons,
N. Y., who may have given lectures
at Hanover.
• The
Chesapeake-Leopard
affair had occurred
only
two
weeks previous.
On
June
22.
1807,
the frigate
Chesapeake,
Capt.
Charles
Gordon,
bearing
the broad
pennant
of Com
modore James
Barron,
got under
way
from
Hampton
Roads
bound to the Mediterranean.
A squadron
of British
ships
of
war
bad
been
at
anchor
in
Lynnhaven
Bay
for
several
months
watching
some
French
frigates
that
lay
at Annapolis.
As
the Chesapeake
stood
down
toward
Cape
Henry,
one
of
the British
vessels,
the
Leopard
got
up
anchor
and
preceded the American
frigate to sea
by several
miles.
When
both
vessels were
well
off
the land
the BriUsh frigate
approached
the Chesapeake
and
hailed
her, Informing
Com
modore Barron that
she
had
dispatches
for
him.
In
a
few
minutes
a boat
from
the
Leopard
came
alongside
the Chesapeake beating an order to search the vessel for deserters
from the British ships.
This Commodore
Barron
refused
to permit,
Btatlng
that
he knew
of no such deserters
on board.
The BriUsh officer
returned
to the Leopard,
and
almost
No. 1.
77
JONATHAN
COWDERY,
SURGEON IN
U.
S.
NAVY.
Navy
Yard. New
York,
August
17, 1801.
D'- Sib: On my return
from
captivity
in Tripoli I did myself
the honour of
calling upon you and in addition
to letters
of recommendation
sent
to you by
Dr. Mitchell,
and commanders
in the Navy,
whom I had the honour
of serving
under
as surgeon's
mate, I delivered
to you two letters of recommendation,
one
from Captain
Bainbridge
and one from
Dr. Ridgely.1 late Surgeon
of the Phila
delphia.
You read them with great satisfaction
and applauded
my conduct in
the Navy.
I then told you that I had served a number of years
as
surgeon's
mate and now hoped you would grant
me a higher
station.
Y'ou
replied
that
I
should
be promoted when I should again be called into service.
You have again
called
me into service, and I am on duty as surgeon's mate, which,
under
the
circumstances,
is very humiliating
to
me indeed, and I now
beg you will
send
me
a surgeon's
commission,
or, if you
deem
me
inadequate
to this, I
beg
you
will send
me a discharge
from the service.
Yours with
esteem.
Jo" Cowdery.
Hon. K. Smith,
Secretary
of the Navy.
Fortunately,
the "discharge from the service " was never sent, and
Doctor Cowdery was promoted
to the rank of surgeon in the Navy on
the 27th of November,
1807.
He
was ordered
from New York
to
Norfolk. Va.. where
he made his home until his death in 1852.
On
May
15.
1807,
he bought some
land of Israel
Chase,
in Tunbridge,
Orange
County, Vt.,
and
it
seems
that he had left his son Isaac
Newton
in
charge
of
his
brother. Elihu.
The
following
extracts
are from letters written to his brother Elihu
:
Norfolk, Va., Jan.
26, 1808.
Dear Brother.
I had the pleasure of receiving
two letters from you since be
ing on this Station,
one was dated
Dec.
3. and
the other Jan.
3, in which I am
pleased to find that you and our Family enjoy Health.
In your letter of Jan. 3d
you mention that you fear that I would receive your letters with reluctance
were
it not for the Business
you have in Charge for me. —This, my brother,
is a need-
legs fear.
You may rest
assured
that I
esteem
you
as I ought
to
do as
my
Brother, both by Nature and
by Art. our
former
trifling
disputes
ought
to be
without warning
the
vessel
fired an entire
broadside
at the Chesapeake,
wounding
Com
modore Barron and his aid, who stood In the gangway.
The gunfire was continued
from
15 to 18 minutes,
when Commodore
Barron
ordered
the
colors to be hauled
down.
The Chesapeake Immediately
sent a boat to the Leopard
to say that the ship waB at the
disposal
of
the English captain,
who
then
directed
his
officers
to
muster
the
American
crew.
Four
men, claimed
to
be deserters
from
British
vessels,
were
carried
away,
and
the Chesapeake returned
to Hampton
Roads.
The attack
on the Chesapeake
aroused
public
sentiment
in
the United
States
against
Ureat Britain and almost
led to an Immediate
declaration
of war. —Cooper, J. Fenimore:
The History
of the Navy
of the United
States of America,
1853,
Vol. II, p.
13.
'Dr. John
Ridgely.
Appointed
2 July,
1803.
He
was
surgeon
on the Philadelphia,
Jonathan
Cowdery
and
Nicholas
Harwood
being the
surgeons'
mates.
Dr.
Ridgely
was
appointed
charge
d'affaires
of the United
States
to the Regency of Tripoli
in June,
1805.
upon
the
recommendation
of Commodore
Rodgers.
He resigned in
1808
and
settled
In
Annapolis,
Md.
The
practice
of appointing
medical
officers
to
diplomatic
posts
In
the
Mediterranean was not unusual
in these days.
In addition
to Dr.
Rldgely's
appointment
to Tripoli, Commodore John Rodgers
appointed
Dr.
James
Dodge, surgeon of the Constitu
tion, to act as
charge1
d'affaires
at Tunis,
and
Commodore
Richard
V.
Morris,
in
1802,
appointed
Dr.
George Davis
to be consul
at Tunis.
78
JONATHAN
COWDEKY,
SURGEON IN
U.
S.
NAVY.
Vol. XVII.
forgotten,
they were of too trifling
a nature
to
even
remember.
I wish
ofteu
to receive your Letters
as from
a Friend and a Brother.
As for my horse I wish him to be used by a careful hand until he can be sold.
Sell
the saddle
and bridle,
Sell
my sow as
soon
as she will fetch
the highest
price.
As for my Friends who enquire for me and wish
me
to return
to exer
cise my
Profession
among
them,
tell
them of the
Esteem I have
for
them,
and
as I intend
marrying
in
their
vicinity if
*
*
*
I
intend
to
return
and
settle among
them
as soon as our
Navy
is layed
up,
which I
hope
and
expect will be soon.
If Newton
learns
fast and well and wishes to persist, I wish him to continue
in it, in a manner you may deem
the most advantageous
to him, and my circum
stances.
If he does
not learn
well, and is willing
to go to a Trade, I wish you
to consult Austin and put him to a Good Trade, if any, and under
a Good and
Severe Master.
I am in Health and am employed
the fore part of every
day
visiting and prescribing
for the sick
and Lame in the Hospital
Vessel
and in
the Navy Yard, etc.
My Mates and attendants
put up the Medicine
and
do the
other Duty of the Medical
Department,
the afternoon
and evenings I spend in
Reading, Writing
and among my new friends and acquaintances
in Norfolk
and
in Portsmouth.
They
are of both
sexes
and are very
Hospitable
to the officers of the Navy
and Army,
who are here In abundance.
We are invited
to all of their public
amusements,
etc.,
etc.
The British
officers of the Frigate
which
brought
Mr.
Rose
as a minister
to our Government,
come
on shore occasionally,
they
visit
but
little
except
at
the
British
Consular
House
(Col.
Hamilton).
We
all
treat
them
much
cooler
than
they
have
been
used
in
the American
Ports.
Lieut. John
Davis,
one
of
our
officers who
Commanded
Gun
Boat No.
1, put
an
end
to
his
existence
the
other
day,
by
discharging
a
pistol
through
his
Brains while lying in his Bed in the Cabin
of his Gun Boat.
He had been
disgraced
for bad conduct,
he was much given
to Dissipation,
he found
that
he was despised
and neglected by all his Brother Officers,
and
was much
in
debt,
which
is supposed caused an insanity and
was the
reason
of his
committing
the horrid
deed
of Suicide.
I was called
to him before
he
was
dead,
but
could
not
help
him.
*
*
*
The winter
is
very
Pleasant,
but the summer
is to be dreaded
by
us northern
people.
(Signed)
Jon° Cowdeey.
The winter
was indeed
very
pleasant
for him
as will
be seen by
the following
letter:
Norfolk,
Va.
Feb.
13,
1808.
Deah
Brothek
: I
this
evening
am
to
marry
a
Woman
whom I think
is
one of the best in Creation.
She is of Good character,
has
a handsome
prop
erty, is of Good Family,
is amiable
in her Disposition
and manner,
and
above
all
she
is
a woman I ardently
admire,
her name is Eliza
Reddick,
widow
of
the
late
Capt.
Thomas
Mill
Reddick,
who
for
many
years
commanded
and
sailed in different
ships out of this Port, and was lost
on his return
from
the
West
Indies the winter before
last.
I shall
immediately
quit
my quarters
on
board
the hospital
vessel
and live with
my wife in Norfolk, but shall continue
in the same duty
in
the Navy
in this Station
as before.
I intend
coming to
Tunbridge
as soon as my
services
in the Navy will
admit,
perhaps I shall
bring my companion
with
me to visit our
friends,
if not
to settle among
you.
[Here he gives
directions
about
selling
his
property
in
Tunbridge.]
My
re
spects to our
friends,
particularly
our
Parents,
and my dear
Son, tell
him
to
No. 1.
JONATHAN
COWDERY,
SURGEON
IN
U.
S. NAVY.
79
be a good son, to
be obedient to his Grandpa
and Grandma
and learn well his
book
and his father will not forget
him.
N. B. an extract
from
the Norfolk
Ledger.
" Married
on the evening of the 13th Dr. Jonathan Cowdery,
Surgeon
in the U.
S.
Navy
(one of our
late
sufferers
in Tripolitan
Captivity)
to the
much
esteemed
Mrs.
Eliza
Reddick,
of
this
place,
widow
of the
late
Capt.
Thomas
M. Reddick.
Feb.
15. 1808."
8
(Signed)
Jon" Cowdery.
As we see by the following
letters,
he was not permitted to enjoy
the comforts of his Norfolk home long.
New
Yobk, Nov.
26,
1808.
My Dear Brother : We are about getting
under
way for another
Cruise
off
Boston,
Portsmouth,
etc.
I beg
you or Austin, or both of you will write me
Immediately
at Boston
on board
the U. S. Brig Argus to the care of the Navy
Agent at that place.
We expect War with England
and France,
our
Country
is In
a
woful
condition,
I
wish
you
to
send
my
Great
Coat
and
my Blue
Straitbodyed
Coat
to
me
at
Boston
to
be left with
the Navy
Agent
of that
place until called
for, I wish
you
to put
them up in my leather
thing
that I
used to carry my Great
Coat in.
Seal them up and send
them by
a safe hand.
Inform
me what you have done with Newton.
I wish
you to send
the things
soon for we shall
have a cold cruise.
>
(Signed)
Jon* Cowdery.
New York Jan. £ 1809.
Dear Brother, I have the pleasure
of again
addressing
you ; we lately
re
turned
from
a
very
tedious
cruise
on
the
coast
of
New
England,
we
had
almost
constant
gales of wind with much Snow
and Rain.
Many
of our
Crew*
were much
frozen.
I had thirty
on
my list at one
time, who were frost bitten
in
a
greater
or
less
degree.
I have
saved all their
limbs
and
the
most of
them are again
on Duty
; We are now taking
in Provisions, Water,
&c for an
other
cruise to the northward
to enforce
the Embargo
Laws, and to prevent
Insurrection
in
the forests
of New
England.
The Embargo
is
an
oppressive
law, but as it is the choice of the majority
of our Country,
it is the duty of ua
all to Support
It, I have suffered
much in the cause of my country,
and I am
willing
yet to serve It at the hazard
of my Property,
my Health,
my Comfort
and if Necessary
my life.
But
in
Vermont I was
called
a Federal Tory
by
those
who
are
now
violating
the
Embargo
by
smuggling
into
Canada,
and
these very
men
voted for the Member
in Congress
from
Vermont
who voted in
Congress
for
the
passing
of
the
Embargo
Laws ;
but I
am
happy
to
se*
a change
in your
People.
I see that you in Vermont
as well
as in all the New
England
States
have
a
large
majority
of
Federal
Republicans
for
the
next
Congress.
I
hope
that
the liberty and Character
of our
Country
will
yet
be
saved.
I saw Brother Austin's
name in
the proceedings
of the Grand
Lodge
of Vermont,
in the newspapers
at Boston.
I wrote
him
that I wished
not to
meddle much with politics
while I was in the service of my Country,
but I now
feel in a tone for it.
I lately
applied
for a furlough
and got an answer
this
morning
that I
could
not
have
one,
but
must
go
another
cruise
among
my
Brother
Yankees,
etc.
I wrote
you when I was hoe before
to send
my
Great
■Five
children
were
born
of
this
union.
George
Washington,
born
Dec.
13,
1808;
Cami-lla Wickham,
born Jan.
22,
1811 ; Theodorin.
born
Dec.
15,
1812,
died Oct
13,
1813
:
Ann ElUa.
born June
30,
1814,
died 1894;
and Alexander
Augustus,
born
May
11,
1817.
died 1S99. who lived
for many years with
his sister.
Ann
Eliza,
in Philadelphia,
Pa.
80
JONATHAN
COWDERY,
SURGEON
IN
U.
S.
NAVY.
Vol. XVII
Coat and small coat to the care of the Navy Agent at Boston, which I presume
you have
done
before
this.
If you have not, you
need
not
send
it.
We
did
not stop at Boston
on
our return
owing
to bad weather,
but we expect
to be-
there within
a few days to Blockade
their
harbor,
when I expect
to
find
the
articles
requested, and a Letter
from
you. —I want
to hear from you all. and the
state of my affairs in Tunbrldge.
I also wish
to know the state of our Infant
Medical
Society
which
we
were
establishing
when I left
you.
Give
my re
spects
to such of the members as you are acquainted
with,
and tell
them
that
I wish
them to send
me a Sketch of their establishment
and the name of their
officers,
etc.
I wish
to
give
them
a
place
in
the
Medical
Repository." I
am
with
much esteem
Yor loving
Brother,
Jon*
Cowdebt.
His letters written during
the year
1809 indicate that the state of
his health was not the best.
One dated Norfolk. June 7, 1809, acknowledges
orders to the Xau-
tilus and expresses regret
for
a delay
until
his health
is sufficiently
recovered
to comply with it and join
the ship before
she
is ready
for sea, " during which time, if you may
deem
it proper and will be
pleased to command
me, I will attend to the procuring the necessary
medicines,
instruments,
etc.,
which
may
be
procured
at this
place
on very reasonable terms."
Another, dated Norfolk. July 14. 1809, and addressed to Hon. Paul
Hamilton,
Secretary of the Navy, acknowledges
orders
to the Ferret,
but
he reports
himself ill, though
better of the lameness
which
he
mentioned
to Mr. Goldsborough
10 when
last
in Washington.
He
has
a complaint in the breast which is no better and is much
emaci
ated
and
debilitated.
His infirmity
originated
from
sufferings
on
board
the Argua'the
previous
winter off the coast of New England,
when
he contracted
a violent cold, since which he has not enjoyed
a
well day.
" I have yet reason to hope it will not prove
to be a con
firmed decay.
I am now in a course of medicine
and diet under Drs.
Barraud
and
Hansford,
(both
very
eminent
in their
profession)
which I hope in a few weeks will relieve
nie sufficiently
to join Lieut.
Gadsden
on the Ferret.
At present
am not able to perform the duty
required of a physician or surgeon
on a vessel of war."
" The
first
medical
journal
published
tn
America
was
the
Medical
Repository,
a quar
terly,
under
the
editorship
of
Samuel
L. Mltchill,
Edward
Miller,
and
KHliu
Smith.
It
was founded in
1797
and
continued
until
1824.
10Charles
W.
Goldsborough
was
for
many
years
chief
clerk
of
the
Navy
Department
and the
author
of the uncompleted work,
the
United
States Naval
Chronicle.
One
volume
only
was published
In
1824.
Goldsborough's
connection
with
the Navy
Department
con
tinued
over a period of 44 years.
He was chief clerk
under
Secretaries
Stoddert.
Smith,
and
Hamilton
and
secretary
of
the
Navy
Board
of
Commissioners
until
the
separate
bureaus
were established,
when
he was appointed
Chief
of the Bureau
of
Provisions
and
Clothing,
being the first
chief of that
bureau.
(His portrait
hangs
in
the
Paymaster Uen-
eral's
office.)
No. L
JONATHAN
COWDEBY,
SUBGEON IN
U.
S. NAVY.
81
Dr. Cowdrey reported to Lieutenant Gadsden on August
3 as " sick
and
afflicted
with
cough,
spitting
of blood, and pain in my breast.
I have
not been out of my chambers
from the day I saw you.
It is
with much regret that I am not able to join the Ferret under your
command."
On August
12 Lieutenant
Gadsden reports to the Sec
retary that Doctor Horseley
11 has reported.
The
doctor writes from Norfolk, under date of October 4,
1809,
that he has spent
10 years in the Navy — 19 months of which he was
in
captivity
in Tripoli.
He
has
lost
considerable
property
as
a
result, and
also the vision of the right eye,12
and has suffered
much
impairment of health.
He states that he has a wife and three chil
dren to support, and
asks if he can have duty at the navy yard
at
Gosport when Doctor Heerman leaves, the latter being not averse to a
change of station.
In a letter written on board the frigate United States
on February
20, 1811, he reports joining this ship, in accordance
with orders,
and
reporting to Commodore
Decatur.
He expresses
the
hope that the
cruise will benefit his health, but requests permission to visit Wash
ington
on
the return of the ship to Norfolk
in order to settle his
accounts
at
the
Navy
Department
and
obtain
a furlough,
during
which he desires
to make arrangements
to provide for his family (a
wife and four small children).
In
several
letters written
in
1808-9
and
1810,
Doctor
Cowdery
speaks of having established
a drug store in Norfolk, Va., and
also
mentions
owning
the
Chase,
Newhall,
and
Stanley
places
in Tun-
bridge, Vt.
The settlement of his affairs in Tunbridge
seems to have
been
the cause of much
perplexity,
and
some misunderstanding
be
tween him and his brother, and his brother-in-law,
Samuel Austin.
After much correspondence
on the subject, Doctor Jonathan
writes to
his brother Elihu, on July
8, 1914.
" I have written Mr. Paine, the
attorney,
to settle with
you
and Austin on amicable
terms
and
not
to put you to any cost or inconvenience
if he possibly
can avoid
it.
I
had rather lose a thousand dollars than wrong either of you
one cent.
I
therefore desire you and Austin will come to
a
settle
ment with
him of everything
concerning
me.
I
deprecate
family
disputes.
I
therefore hope you will settle everything amicably.
I
am on duty in the Navy on this Station.
We have about
700 men in
the service,
and
I
have
had
the
good
fortune
not
to lose but one
man since
I
had the medical charge
of them,
which
is
a
year
last
spring.
We hope for Peace
soon, but
are under
apprehension that
"In
later
years
Horseley
became
surgeon
ou
the
Lawrence
with
Commodore
O.
H.
Perry, and was present In the Battle of Lake Erie on Sept.
10,
1813.
"Conjnnctlvitla
was very
prevalent
in Tripoli.
82
JONATHAN
COWDERY, SURGEON IN
U.
S. NAVY.
Vol. XVIL
the war will last many years.
England being left to contend with us
alone, I fear will take ground that our Government cannot with the
dignity
of an independent Nation,
submit to.
My particular
Love
to our
aged Parents.
I
beg you will not let them
suffer,
should
they be in want I am ready
and willing to contribute to their com
fort and support."
In
a letter written
on August,
1815, Dr. Cow-
dery appoints " My honored Father Jabez
Cowdery of Tunbridge,
Vermong, my true and lawful attorney."
Nothing
appears
in
the
files
of
the
Navy
Department's
corre
spondence concerning Doctor Cowdery until
11 years later, at which
time
we find him ordered
to sea and apparently
feeling the
weight
of his years and the disadvantages
of ill health.
In
a letter written at Norfolk, on April
16,
1823, in reply to the
Secretary's order of the 10th to join the Hornet,
he states that ill
health will prevent,
that he is 56 years old on the 22d day of this
month and in the Navy 23 years, and has made no complaints about
orders until now.
He asks to continue on the station and
have his
orders to
sea revoked.
He inclosed
a letter from
Surg.
George J.
Kernays
which
states, "that
Doctor
Cowdery
for
12 months
has
feared
that he was losing
use of one leg
and
thigh.
He requires
care to prevent a termination in a general
paralytic
affection of the
lower extremity."
Indorsement by the Secretary of the Navy.
" The order may be
revoked,
another must
be obtained."
From Norfolk, under date of January 9, 1824, he writes that he has
been with Commodore Porter in former
days
and in trying scenes,
but by reason of ill health he is not able now to render service
to
him
and
under his command
" in
the
contemplated
cruise
against
the
enemies, not only of our country
but of
the human family."
He wishes to have a position on the station
(i.
e. Norfolk)
and states
that he was " in all wars since the Revolution
to the end of the last
British war—out in the Argus and in the United States during the
greater part of the embargo.
In the Navy
24 years on the 1st of this
month and 58 years old next April and been in sea service
(I.believe)
more than any surgeon
in the Navy."
He suggests that he may be
useful
at
the
recruiting
service
attending
the
sick
and
disabled
officers and
seamen not accommodated
at the hospital
and explains
the he "
is
now attending some of this description and assisting the
younger
surgeons
in
making
out
their
requisitions,
etc.,
and
in
examining old or damaged
articles of the Medical
Department
be
longing
to vessels after
a
cruise,
and in attending sick seamen
on
Crany Island who may be quarantined, as
I
did the last two seasons."
No. 1.
JONATHAN
COWDERY,
SURGEON IN U.
S. NAVY.
83
This letter bears
the following indorsement
by the Secretary of
the Navy
:
" Countermand orders and
leave him
as he was before.
16 Jan. 24, Samuel L. Southard."
1S
A letter from the U. S. R. S. Alert, dated April 19, 1827, indicates
that Doctor Cowdery was still at Norfolk.
When
63
years
of
age, Doctor
Cowdery
was
ordered
to
sea
as
medical officer of the U. S. S. Warren and as he was to be the senior
medical officer in the Mediterranean Fleet he was exceedingly
anxious
to secure
the denomination as surgeon
of the fleet and accordingly
wrote the following letter to Andrew
Jackson,
the President of the
United
States:
Navy Yard, New York,
SO June
1829.
Sib: I hereby
take
the liberty of addressing
your Excellency
on
a
subject
which
to
me
is of vast
importance,
and for which I have
reason
to believe
you will have the goodness to excuse, and duly
appreciate.
I have belonged
to the Navy of the United States
as
a Medical
Officer nearly
thirty
years,
have
been
on
duty
at
sea
and
on
shore
stations
the whole
of
this
time,
excepting
about
two
years
after being
released
from
Tripoli
cap
tivity
and I flatter
myself
to believe
that I have performed
my duty
to the
satisfaction
of all whom I have the honor
to serve.
I lately
received
orders
from the Honb"
Secretary
of the Navy to proceed to New York
and report
to
Commodore
Chauncey
for a passage to the Mediterranean
and then report
to
Commodore
Crane
for duty
on
the U.
S. Ship
of War Warren.
I resolved
to
obey the orders
as far as was in my power, and did myself the honor of calling
on and taking leave of your
Excellency,
and also the Hon"*
Secretary
of the
Navy.
I then wanted
to confer
on the subject of my rank,
but found your excellency
so much engaged that I concluded
It would
be best
to write you
on
the sub
ject,
and not delay
the obedience of my
order.
The
Act of Congress
for the
organization
of
the Medical
Department
of the Navy
of the U.
S.
of 24th of
May
1828,
2nd
Section,
authorizes
the President of the U.
S.
to appoint
to
every
fleet or
squadron
of
the Navy
a surgeon
then
in
the naval
service
of
the U.
S. to be denominated
Surgeon
of the
Fleet.
Therefore
if I
am
to
be
the oldest
surgeon
on
the Mediterranean
Station I
do
most
respectfully
ask
your Excellency
to grant
me my rank.
It would
be humiliating to serve under
a younger
surgeon.
From
your
Excellency's
military
renown
and
kindness
of heart,
you
can
duly
appreciate
the feelings
of
an
officer
on
a subject
of
this
nature.
I
hope I may
not
be
allowed
to leave my country,
my friends,
my wife
and children,
with a heavy heart.
As for
my
naval,
or professional
character, I refer your excellency to Commodore Barron under whose command
I last had the honor of serving
on the Norfolk
Station.
"This letter
Indicates
that
Doctor
Cowdery
hud
been
ordered
to
Commodore
Porter's
squadron,
which
had
been
operating
in
the
West
Indies
against
pirates,
then
infesting
these waters.
Commodore
David
Porter
had
resigned
his
position
as Commissioner
of
the Navy to assume the command of this expedition.
He took his squadron
to
sea
on
the
Hth of February,
1823,
and after
successfully
suppressing
piracy
about
Cuba and Porto
Eico,
arrived
at
Thompsons
Island
(Key
West)
late
in
the
year.
Here
yellow
fever
broke out in several
ships and soon forced the sailing of the squadron
to the northward.
Porter's
action
during
thla campaign
in landing
an armed force at Fajardo,
on
the
island
of Porto
Rico,
in an attempt
to
force
an apology
for harsh
treatment
of
some
of the
officers and
men,
brought
about
his trial
by
court-martial
and
his
suspension
from
duty
for
six months.
84
JONATHAN
COWDERY,
SURGEON IN
U.
S. NAVY.
Vol. XVII
I
am
to take passage to the Mediterranean
in the U.
S.
Ship
Ontario;
she
is to sail from this port ; it is likely that
she will be detained
several
weeks for
want
of seamen, whom
are
slowly
procured,
therefore I hope to
be
honored
with a reply
to this communication
before leaving
this country.
I am respectfully,
Sir, Your Excellency's
Obedient
and very
humble
servant,
Jon"
Cowdebt,
Surgeon.
His
Excellency,
Andbew
Jackson,
President.
(Indorsed
by the President:)
"Referred
to
the Secretary
of the
Navy
for
answer.
A. J."
The
following letter,
which
was
written
to
his
son,
Benjamin
Franklin
Cowdery, then ir Geneva,
N. Y., gives
some insight
into
Dr. Cowdery's character.
New Yobk, Aug.
17,
1829.
My Deab Son. It is a considerable
time since I had the pleasure of hearing
from
you.
As this may be the last
time, I feel it a duty
now to address
you.
I am
about to leave my Dear Country,
family and friends,
on another
cruise
of perhaps
three years in the Mediterranean.
I was in hopes
that my former
services
and
age,
would
induce
the Government
to allow
me
a shore
station
the balance of my days.
On my receiving
orders for this service, while I was
on duty
as Surgeon
of the Naval Station
at Norfolk,
in Virginia,
and
where
my wife and four children
now
reside, I went
to the city of Washington
to
see
the President
of the United
States
and the Secretary
of the Navy on
the
subject
of my being ordered
to
sea in my old days, they both urged the neces
sity
of
my
complying
with the order
and said
that
my services
were particu
larly required
in the fleet as being an old and experienced
surgeon.
I concluded
that
it was
my duty
to
obey
the call
and again
go
on
foreign
service for my country.
I am to go out
a passenger
in the U.
S. Ship of War
Ontario;
she
is fitting out
on
this
station.
We
expect
to sail
within
two
or
three days for the Mediterranean
to join our
Squadron
at Port Mahon,
where
I expect
to
be put
on
duty
as fleet surgeon.
The Delaware
74,
Commander
Crane,
is to return
to the U.
S.
Commander
Riddle is to take command of the
Squadron.
A Mr. Lee,
Consul
General
of Algiers, two
or
three
Lieutenants,
two young Gents
who lately
graduated
at Yale College,
and
several
Midship
men
are going as passengers
in the ship.
I have left my
son
G.
W. Cowdery
in charge of my family in Norfolk.
He will be twenty
one
years of age next
December ; he is a moral,
steady, studious
and promising
youth.
I place great
confidence in him,
and hope he will become
a Christian
and an ornament
to
his fellow mortals.
My son,
before closing this epistle I will
say a few words
on
this
important
subject
of
Religion.
I for
several
years
have
been
under
serious
impression
on this subject.
I am convinced
of the truths
of Christian
ity, as it is set forth in the Holy Scriptures.
I hope that God has forgiven the
many
sins of my younger
days, I feel
a confidence
in him and
a thankfulness
for
his
many
and
continued
blessings
bestowed
on
me
and
mine.
I
am
a
member of his Holy Church. I read his Word and pray
for his Blessings and
Salvation.
What is this world without religion.
.Toys at best are but transi
tory, all checkered with afflictions,
even if we live
a hundred
years, life is but
a
phantom
in comparison
to eternity,
therefore
is it not best to strive
to serve
God, with the hope of
his
benediction
in this world,
and
the world to
come.
My love and best respects to your Dear Family, and that all of you may be con
stant
in serving
God and our fellow
mortals
is the prayer
of your
affectionate
father,
Jon*
Cowdebt.
No. 1.
JONATHAN
COWDEBY,
SURGEON IN U.
S. NAVY.
85
Fourteen
years
pass.
We
assume that Doctor
Cowdery
finished
his cruise
in the Mediterranean
and
returned to duty
at Norfolk,
but detailed
information
relating
to this period is lacking.
He
is
now well along in years,
but evidently
not willing to be superseded
by
a younger
man,
as
the following letter
to the Secretary of the
Navy indicates.
It is not in his usual
handwriting
and
the signature is that of a
hand tremulous with age
:
Naval
Rendezvous,
Norfolk, March SI,
1843.
Sn» : Dr. G. W. Codwise,
who has just arrived here from
the North, I am
in
formed either has, or Intends applying
for the situation,
which I have the honor
of filling, as the recruiting medical
officer at this place, I have, I believe, faith
fully gone
through
every
species of service,
incident
upon my profession,
and
after 40 years
servitude,
find myself
at the head of the list of Surgeons.
I am
now,
Sir,
76 years old, and
too
infirm
for the more active
and
rougher
duties
of my profession.
I believe the duties of the Rendezvous,
are, and can be still,
performed
by
me,
as well as any
one else,
and as I do not desire
to
be sup
planted, unless
the good of the service
requires
it, I most respectfully.
Sir. re
quest that I may not be detached from my present position.
I have the honor
to be,
Very respectfully
your
obt.
Servt.
etc.
,
Jo° Cowdeby.
Hon. A. P. Upshur,
Secretary
of the Navy.
[Indorsed
as follows:]
Dr. J. Cowdery
having
punctually
performed
all
the
duties of medical officer at the Rendezvous
to my entire satisfaction
I cheerfully
request for him
a full consideration
of his application.
Jno.
P. Young,
Coma. Naval Rendezvous,
Norfolk.
[Indorsed
by the Secretary:] This
removal
is not because of any deficiency
or neglect on his part
but
in
compliance
with
a rule
which
Is applied
to all
officers of the service that they shall
hold such places only three years.
Ansd 7 April
1843.
Def1. and waiting orders.
Apr. 7, 1843.
Apparently
his successor
did not like
the detail
at Norfolk
and
Doctor Cowdery, learning that he was desirous
of leaving, writes re
questing
the duty.
Norfolk,
Va., October
23,
1844.
Sir: As Doct' Codwise
is desirous
of leaving
the Rendezvous
of this
station
and
as my Infirmity of age
renders
me unfit for very
active
service,
and
as I
desire
to
render
some
benefit
to
the service.
I
hereby
respectfully
ask
to
be
ordered to attend
the Naval
recruiting
service
ax surgeon of the Rendezvous
on
this station.
Respectfully
Sir Your Obt. servt.
.Io° Cowdeby,
Surgeon.
U.
S.
Navy.
Hon"" John
Y. Mason,
Secretary
of the Navy.
86
JONATHAN
COWDERY,
SURGEON IN U,
S. NAVY.
Vol. XVII
[Indorsement
on letter:] Surgeon
Cowdery
is the oldest surgeon in
the Navy,
to whom this duty would
be particularly
acceptable,
on account of his age
and
incapacity
for active
service.
Should
the Department
see fit to grant
this
ap
plication,
it would
be an act of kindness
to him, very gratifying
to himself
and
friends.
Very
respectfully,
etc.
^ c
BoLTON
Ref to Bureau of Medicine
and Surgery
J. Y. M.
It is recommended
that this application
be granted,
that
the transfer occur
the 1st of November
and that
Dr.
Codwise
be relieved
and granted
3 months'
leave.
Respectfully,
Thos. Harris.
Done, 2 Nov. 1844.
A letter dated
November 6, 1844, acknowledges
the receipt of orders
of the 1st instant to attend
the naval rendezvous
at Norfolk, and in
dicates that Doctor Cowdery has reported to Commander Bolton and
Commander Armstrong.
A letter of July
14, 1845, gives some details of a report of survey
on
a midshipman,
" affected
with
bilious
pleurisy,
which
has
ter
minated in chronic hepatitis
and
pleuritis.
He
is
also
threatened
with Phthisis Pulmonalis.
We respectfully
recommend
change
of
residence,
as
we
consider
such
change
essential
to
his
recovery.
Jon. Cowdery, Surgeon, V. S. N.
Danl. Egbert,
Surgeon, U. S. N."
The following correspondence
indicates that his service at Norfolk
was once more interrupted
:
U. S. Naval
Rendezvous,
Norfolk, June
6,
1850.
Sir:
On
the
21st
of
May
last
Commodore
Sloat
ordered
me
to
take
the
place of Surgeon
Thomas
Williamson
at this Rendezvous,
the duty
of which
I continued
to perforin
from
the date of this order.
I now respectfully
desire
the Department
to be pleased
to confirm
the order.
Very respectfully
your obt.
servt.
. . „
Jo° Cowdery.
Surgeon
Thomas Harris,
Chief of the Bureau
of Medicine
and Surgery.
Referred
to Department
recommending
confirmation
of orders.
Thos. Harris.
[Indorsement
hy Secretary:] Is this (?) able to perform
this duty?
W. B. P.
[Indorsement
by
the
Chief
of
the
Bureau
of
Medicine
and
Surgery:!
Dr. Cowdery
is believed to be fully competent to the duty for which
he has been
above detailed.
Very
respectfully,
Thos. Harris.
Order him.
W. B. P.
Order
confirmed,
11 June
1850.
U. S. Naval
Rendezvous,
Norfolk,
Va. June
13,
1850.
Acknowledges
Secretary's
confirmation
of
orders
to
duty
at
Rendezvous
To : Hon. Wu, Ballard Preston.
Secretary
of the Navy.
No. 1.
JONATHAN
COWDERY,
SURGEON IN
U.
S.
NAVY.
87
Doctor
Cowdery's
death
occurred
on
November
20,
1852.
The
Norfolk Beacon
of that date in referring
to him said : " Few
men
have borne
a more unblemished
character or been held in such high
and
universal
esteem
for all the qualities of head
and
heart that
constitute
the efficient officer and worthy citizen."
He was buried in Cedar Grove Cemetery
in Norfolk, in a lot with
his wife Eliza, and his sons, Alexander, Augustus, and George Wash
ington.
His
remains
are in
a small vault resting
on the ground,
the sides of which are granite and the top marble.
One visiting his
grave to-day may read the following inscription
covering the marble
slab of the vault :
" In Memory of
Jonathan
Cowdery,
Surgeon of the Navy of the United
States
He was born April 22,
1767,
And died November 20, 1852.
Affectionate in his nature, faithful in the performance of his duty,
and pure in spirit, He has left,
as a patriotic
christian,
a character
without stain, and an example
worthy of emulation.
He was upwards of fifty-two
years in the service of his Country,
and at the time of his death held the oldest commission
in the Navy."
(The writers
of this article wish
to acknowledge
their indebtedness
to Dr.
Southgate
Leigh, of Norfolk,
Va., for much
material
relating
to
the personal
history
of Doctor Cowdery
and for assistance
in securing
the loan of the da-
guerrotype
from which
the portrait appearing
in this article was reproduced.
It so happened
that
when
one of us had decided
that
Doctor
Cowdery
had
probably
spent
his last
days
in Norfolk,
Doctor
Leigh
was
addressed
with
a
request
that
he indicate
some
one who
might
give
information of the place
of burial
of Doctor
Cowdery
and
supply
biographical
data
relating
to
him.
The selection of Doctor
Leigh
was entirely
accidental
but very fortunate
since
he proved to be a great grandson
of Dr. Jonathan Cowdery.)
(to be continued)
I
EDITORIAL
EDITORIAL
STAFF.
Capt.
M. F. Gates, Medical
Corps,
United
States
Navy.
Lieut.
Commander
W.
M.
Kkbb,
Medical
Corps,
United
States
Navy.
Lieut. J. H. Chaubkbs, Medical
Corpa,
United
States
Navy.
Lieut. Edwin
Pitebhon,
Medical
Corps,
United
States
Navy.
AN
INVESTIGATION
OF THE
ETIOLOGY
OF EPIDEMIC ENCEPHALITIS.
The
causative
agent of epidemic
encephalitis
(lethargic
enceph
alitis) has apparently
been demonstrated
by Strauss, Hirschfeld, and
Loewe, working
in the pathological laboratory of Mount Sinai Hos
pital,
New York
City.
Their work
has been confirmed
wholly
or
in part by others in France (1), England
(2), and the United
States
(3).
The investigation was exhaustive,
conclusive,
and all the steps
were well controlled.
The results
were published in a series of arti
cles entitled " Studies in epidemic
encephalitis," appearing in various
periodicals.
The first of this series (4) describes
results
obtained
by
subdural or intraperitoneal
inoculation of seven monkeys,
with ma
terial obtained
from human cases or from artificially infected mon
keys.
A saline emulsion of brain tissue from a fatal human
case pro
duced lesions
in
a monkey
similar
to those of human
cases.
Wash
ings from the nasopharynx of a human case
were passed through
a
Berkefeld
filter
and injected subdurally
and intraperitoneally
into
a monkey and
produced
a paresis of both hind legs and an increase
in the spinal fluid cells.
A similar
filtrate, from the mucous
mem
brane of the nasopharynx of a fatal cardiac case, produced no appar
ent lesions in the monkey
up to the date of the presentation of the
report.
The next report (5) describes experiments with
a group of rabbits
and the further
results
on the first seven monkeys
as well as several
additional ones.
Rabbits were injected intracranially
with
a Berke
feld filtrate of nasopharyngeal material
from
a patient suffering
from encephalitis,
and others with material from control
cases.
At
the
same
time,
others
were
injected
with
material
from
rabbits
dying
from
the
induced
infection.
By this
series
of
experiments
the
authors
demonstrated
that
a
filterable
virus
from
the
naso
pharynx
would
produce
lesions
in rabbits
and
monkeys
similar
to
those in the
human
brain,
and
that
this virus
could
be
recovered
89
90
Vol. XVII
EDITORIAL.
from
the
nasopharynx
of animals which
had
been previously
in
oculated
intracranially.
Approximately
50
per
cent
of
rabbits
seemed
to
have
a
natural
immunity.
One
infected
monkey
that
recovered
was found
to have
developed
an immunity.
Up
to this
time
attempts
at culture, using the
ordinary
aerobic
and
anaerobic
methods,
were unsuccessful.
Another
paper
(6)
describes
the
successful
cultivation
by
the
method
employed
by Noguchi
(7)
of
an
organism
resembling
in
appearance
of colonies, of growth, and of morphology the organism
described
by Flexner
and Noguchi
in poliomyelitis
(8).
Details of
the method of culturing
and of appearance
of the organism are given
more fully in
a separate
report
(9).
The media
used consisted
of
sterile kidney
fragments
covered
with
3 or 4 cubic
centimeters
of
sterile ascitic fluid in test tubes of 20 by 1.5 centimeters,
and which
was incubated for
48 hours.
Contaminated
tubes
were
discarded
when contamination
was detected by gross examination or by dark-
field illumination
of smears.
Better results
were obtained when an
old
ascitic
fluid
was
used.
This should
be bile-free
and of high
specific gravity; the presence of fibrin helps the growth
of the or
ganism.
The best material was that obtained from decompensating
cardiac cases.
The tubes were first inoculated and then ascitic fluid
was
added
to make
a column
10 centimeters
high.
Petrolatum
of
low melting point
was
added
to make
a layer of
1 centimeter in
thickness.
Alboline may
be
used, but with this
a
Novy
jar
is
necessary.
As control
tubes they
employed
combinations of ascitic
fluid
with
petrolatum;
inoculum,
ascitio
fluid,
and
petrolatum;
ascitic fluid, kidney tissue, and petrolatum.
As inoculum they
used
brain
fragments,
spinal
fluid,
blood,
and
nasopharyngeal
wash
ings.
The tubes were inoculated at 37° C.
' In
no
instance
did
the organism grow
on solid
media
from
in
fectious
material,
and only grew on solid media
on subculture.
A
successful
growth
appeared
by
the fifth
to
the
seventh
day
as
a
clouding of the media
about
the kidney
tissue.
The optimal solid
media was of gelatinous consistency,
made so by the addition of one
part of 2 per cent nutrient agar to four or five parts of ascitic fluid
with
kidney
tissue.
The
organism
appeared
in
solid
media
as
minute colonies,
more
numerous
near
the kidney
tissue.
All
con
trols
were
negative
in both
solid
and fluid
media.
The organisms
were fixed in methyl alcohol and stained
with
Giemsa's
or Loeffler's
alkaline-methylene
blue
for
one or two hours.
They
appeared
as
small globular
or spherical
bodies
stained
purple
or blue
and ar
ranged
singly, in pairs, chains or clumps.
The organism lived in
culture media for at least six weeks and in the older cultures showed
larger
degenerated
forms.
The
organism
was
nonmotile.
Gram
staining varied with age and with the culture media
; young cultures
No. 1.
91
EDITORIAL.
on solid media were mostly gram positive.
Morphologically,
it is like
the organism of poliomyelitis of Flexner
and Noguchi, but it differs
from the latter in its action
in animals, particularly
in the suscepti
bility of rabbits to this organism.
The virus was carried through
12
generations
on
culture
media,
and
the
seventh
and
eighth
were
still fatal for animals.
The organism was
obtained
from
the fol
lowing locations :
1. Berkefeld
nitrate of extract of nasal
mucosa,
7 of 10 cases.
2. From the washings of the nasopharynx,
15 of 23 cases
(66 per
cent of the human cases).
3. Spinal fluid in 12 of 24 cases
(8 negatives
from other diseases)'.
4. Babbit
nasal
mucosa
in
3 cases.1
5. Babbit brain, 36 of 56 positive,
(64 per cent).1
6. Monkey brain,
5 of 6 cases.1
7. Human brain, positive in a few rapidly fatal
cases observed.
8. Human
blood, positive in 2 cases tried.
Babbits
were
readily
inoculated
while
monkeys
were
relatively
refractive —the
reverse
of
poliomyelitis.
The
spinal
fluid
of
poliomyelitis
patients
is innocuous
to
rabbits
or
monkeys,
while
encephalitis is produced in animals by injection of spinal fluid from
positive
cases.
Successful
inoculations
of monkeys
and
rabbits
having
demon
strated
the
presence
of the
virus of epidemic encephalitis
in the
nasopharynx
and in the spinal fluid of patients
with
the
disease,
it was suggested
(10)
that this
be employed
as a means of making
a differential
diagnosis.
They used nasal washings or material ob
tained
on
a swab
from
the nasopharynx,
which
was
emulsified
in
saline,
passed
through
a
Berkefeld
filter
and
inoculated
intra-
cranially.
Spinal fluid
was
used for inoculation,
in quantities of
0.5
c.
c. or less.
An inoculation
with
Berkefeld
filtrates of naso
pharyngeal
material
produced
characteristic
lesions
of
epidemic
encephalitis in rabbits in 78 per cent of cases tested.
A small coccoid
body was recovered
from cultures of filtered nasopharyngeal wash
ings in
11 of the
17 cases
(64 per cent).
The spinal fluid from
12
of the 16 patients, or 75 per cent, when inoculated into rabbits intra-
cranially
produced characteristic
lesions.
Cultures
of spinal fluid
were
positive in
10 of the
20
cases
(50
per cent).
The
positive
results with spinal fluid sharply differentiate encephalitis lethargica
from
poliomyelitis.
Numerous controls
were
entirely
negative.
In France, Levaditi (1)
and Harvier
(11)
found
a virus fatal to
rabbits in four to six days in many cases of epidemic
encephalitis.
A Berkefeld filtrate of the virus from human cases
was nonpatho
genic
to
monkeys,
but
became
pathogenic
after
passing through
'These animals
were
Inoculated
cases.
103390—22
7
92
Vol. XVII
EDITORIAL.
several
rabbits.
It could also be preserved
in glycerine.
A crossed
immunity
between
poliomyelitis
and
epidemic
encephalitis
could
not be induced.
The serum of a convalescent
from one disease had
no effect on patients suffering with the other.
Their cultural experi
ments
were
negative,
but
they
did
not employ
the
technique
of
Noguchi.
In England,
Mcintosh
and Turnbull
(2) injected subdurally into
monkeys
an emulsion
of the central nervous
system from a patient
who died of lethargic
encephalitis,
as well
as
a Berkefeld
filtrate
of this emulsion;
both
animals showed
characteristic lesions of the
disease.
No attempts
were made to culture.
In
the United
States,
Thalhimer
(3)
has confirmed
the findings
of the Mount Sinai Hospital
Laboratory,
using material from four
cases of the disease—two of the fulminating
type, one with marked
myoclonus,
one
with
marked lethargy.
A Mandler
filtrate of the
central nervous
system of all four cases was used as a source of ma
terial
as well
as the spinal fluid of one fulminating
and
one con
valescent
lethargic
case,
with
fading
symptoms.
He
used about
two
hundred
rabbits,
giving
intracranial
injections
through
the
temporal plate, and found that they withstood the injection of 1 c c.
very well.
Infected
animals showed
varying
symptomatology.
A
few died of intracranial
hemorrhage.
Most of them
died
in from
2 to 4 weeks
and
some as late
as
10 weeks.
Material
in each in
stance
was inoculated into groups of from
three
to eight rabbits.
Some groups showed
100 per cent mortality,
while others
as low as
50 per cent.
Two strains of the virus have
been
passed through a
Mandler
filter
and
reinoculated into
six groups of
rabbits.
The
lesions in the nervous
system produced
by the disease are scattered,
and extensive study is necessary or they will be missed in many cases.
Several series of controls were negative.
In
the cultural
work, Thalhimer
(3)
used Noguchi's media and
method.
Spinal fluid was inoculated directly, while an emulsion of
central nervous
system was passed through
a Mandler filter and the
filtrate
inoculated.
Growth
appeared
in
5
to
10
days,
and was
similar
to that described by Loewc and Strauss.
Cultures were ob
tained
from the brains of the four cases
studied,
and from the two
spinal
fluids.
Some cultures were carried to their sixth successful
subculture.
Cultures were recovered
from about
84 per cent of the
brains of the animals successfully inoculated.
A positive culture
from
a rabbit's brain
from
the sixth
series or generation was ob
tained.
All subcultures
were made from a Mandler filtrate of posi
tive
cultures.
Original material
and
cultures inoculated
on ordi
nary media
and Rosenow's
ascitic fluid glucose
agar were all nega
tive except for occasional
contamination.
Control cultures from tlie
No. 1.
93
EDITORIAL,.
spinal
fluid
obtained
from
patients with
other
diseases
were
all
negative.
In summing up his work the author stated that infectious
agents
were apparently
constantly
associated
with
epidemic
encephalitis.
The infectious agent passed a Mandler filter and produced a disease
in rabbits very similar
to that in man.
The original
dose of virus
was passed
through
six animals, and if it were
not
a reproducing
virus it would
be
so well diluted that it could hardly
be held re
sponsible
for the
lesions
produced.
On Noguchi's
media
he culti
vated
an organism like that of Loewe and
Strauss.
The organism
was recovered
from 80 per cent of inoculated cases and from animals
inoculated
from cultures.
(Loewe and Strauss produced the disease
in animals with
the eleventh
generation of the organism.)
Loewe and Strauss diluted
a filtered virus through
six diluting
tubes, putting
0.2
cubic
centimeter
into
15
cubic
centimeters
of
ascitic fluid in each instance,
and
demonstrated
that the virus
was
so diluted
as to
be innocuous
in the sixth
tube,
thus
proving
that
the virus must proliferate
in animals in order to continue producing
the disease.
Amoss
(12)
confirmed
the absence of crossed
immunity
by con
trolled
experimental
inoculation
of
monkeys,
showing
that
serum
from epidemic encephalitis
cases
would
not
protect against polio
myelitis virus.
Other workers
have reported several
other organisms recovered
from the blood stream or the brain of cases of epidemic
encephalitis,
but all from limited groups of
cases.
The organisms varied as to
type,
source,
and pathogenicity for animals.
The latter investiga
tions were not
sufficiently
thorough
and
complete
to
be
conclusive
and may very well be disregarded, whereas
the work at Mount Sinai
Hospital was very thorough and conclusive.
Koch's
postulates
were
fulfilled
and
at the present
writing it would
seem
that we have
a
definite causative
organism for epidemic
encephalitis.
BIBLIOGRAPHY.
(1) LevaditI, C, Compte Rendus
des
Seances de la
Soc.
de Biologle,
83:354,
1920.
(2)
Mcintosh, J., and Turnbull, H. M., Experimental transmission
of Enceph
alitis Lethargica
to
a monkey.
Brit. Jour. Exper. Path.
1 : 89, April,
1920.
(3)
Thalhirner.
Willinm,
Cultural
and
experimental
studies
on
Epidemic
Encephalitis,
preliminary
communication.
Arch,
of
Neurol,
and
Psychlat,
5:114,
February,
1921.
<4) Strauss,
Israel, Hirschfeld,
Samuel
and Loewe,
Leo, Studies
in Enceph
alitis Lethargica.
New York
Med. Jour.
109 : 772,
1919.
(6)
Loewe,
Leo, Hirschfeld,
Samuel,
and
Strauss,
Israel,
Studies
In Epi
demic
Encephalitis.
Jour,
of Infect. Dis.,
25:378,
1919.
<6) Loewe.
Leo,
and
Strauss.
Israel.
Etiology
of Epidemic
Encephalitis.
Jour.
Am.
Med. Assn.,
73 : 1056, October
4,
1919.
94
Vol. XVII
EDITORIAL.
(7)
Noguchi,
Hideyo,
Cultural methods.
Jour,
of Exper.
Med., 14:99,
1911:
15 : 90,
1912 ;
16 : 199,
211,
1912.
(8)
Flexner,
Simon,
and
Noguchi,
Hideyo,
Poliomyelitis
cultures.
Jour.
Am. Med. Assn.,
CO : 362, February
1, 1913.
Jour, of Exper.
Med., 18 : 461,
1913.
(8)
Loewe,
Leo,
and
Strauss,
Israel,
Studies
In
Encephalitis
Lethargic*.
Jour.
Infect.
Dis.,
27 : 250, September,
1920.
(10)
Loewe,
Leo,
and
Strauss,
Israel,
Diagnosis
of Epidemic
Encephalitis.
Jour. Am. Med. Assn.,
74: 1373, May 15, 1920.
(11)
Harvier, P., Bull,
et mem.
Soc.
med. d. hOp. de Paris, 44: 179, February
6, 1920, and 44 : 583, May 7, 1920.
(12)
Amoss, H. L., Immunological
distinctions
of Encephalitis and Poliomye
litis.
Jour, of Exper.
Med., 33 : 187, February, 1921.
( j. h. c.)
A DISBEBTATION
ON
SOUP.
In an experience
of about
16 years of hospital service
(civil and
naval, ashore and afloat), the writer
has often been
impressed
with
the
fact
that,
except
as
concerns
patients
on
" special
diet,"
all
food is consumed during
a period of about
10} hours
in each day.
This is partly due to custom and partly
to practical considerations
relating
to employees,
but it does not seem
to
be the best
possible
arrangement as regards those who are being
fed.
Especially
is it
unsatisfactory
where it is desired
to build
up
men whose
physical
condition is impaired from any cause, and this includes
a large pro
portion
of all hospital patients—postoperative
cases,
and
convales
cents
from
acute
infections
of
whom
only
a fraction
are
usually
carried on the " special " list, for " 8 o'clock nourishment."
For about two months
an experiment
has been
tried at a certain
naval hospital, which
is felt
to have given such
successful
results
as to merit report and which it may
be desired
to try elsewhere.
Each day
a large kettle of soup
is prepared in the main kitchen.
After supper it is transferred to the ward kitchen, in charge
of the
ward supervisor,
and
during
the early evening is reheated
on the
gas range.
Later in the evening
the soup is served in Navy bowls,
with
bread
(no butter)
to all applicants—patients,
Hospital
Corps
men,
and
those employees
who
are subsisted
at the hospital.
The
only restriction
on its issue
is that the supervisor
on
watch
shall
see that a sufficient
quantity
is reserved
for the night force coming
on duty at 9 p. m., and it is allowed to be taken to the bedside or the
ward table or to be eaten in the ward kitchen.
The cooks are given wide latitude but are instructed to vary the
kind of soup as much as may be done conveniently.
The main points
to
be
observed
are that it shall
be nutritious,
ample
in quantity,
appetizing, and economical.
A " stock pot " is kept constantly in use
and receives all suitable
bones, meat trimmings,
and other proper ingredients.
If soup
has
No. 1.
95
EDITORIAL.
been served at dinner any residue
that may
be left is utilized.
All
available " odds and ends " and " left-overs " find their way into the
soup
kettle,
and
a very large proportion
of these would
otherwise
go to the garbage
can
as the quantity is not sufficient
to serve to
a
mess and it is not practicable to serve any article to
a few persons
only.
This utilizes any small surplus of materials remaining in the
ice box or in the serving dishes
such
as cold beans, peas, potatoes,
tomatoes,
macaroni,
bits
of
asparagus,
carrots,
turnips,
cabbage,
and oatmeal.
Occasionally
a plain
bean or pea soup
is served,
or
a regularly made " cream of celery " or potato
soup but, in general,
it is an " olla podrida " and
best liked
when
it has " lots of vege
tables."
I believe
that
the serving of soup
in this way not only utilizes
materials
which would otherwise
be wasted
but that the absorption
of calories
and
other food
values
contained in the
evening
issue
reduces
the amount
consumed
at other
meals by more than enough
to offset the cost of the bread
served
with it; therefore I think it
may be said that the cost is nothing, the satisfaction
immense.
One
evening,
an
ex-patient,
"who
was
visiting
a
friend
in
the
hospital, was asked, " Did you come up to have a bowl of soup with
us?" and his reply
was " No-o, I came to see X, but I surely will
mm that soup."
I feel that this serving of soup
and
bread
may
also
have
some
effect in the direction of reducing the desire
to "go ashore" in the
evening,
which makes for the men's good in other
ways besides
re
ducing their
expenditures
in
restaurants.
It
is
possible
that
in
larger hospitals difficulties would be encountered,
but it is also pos
sible that
they might
be surmounted.
If there
is
a "night cook"
regularly
on duty,
as was
the
case at one hospital under my
com
mand, the necessary service
and care of utensils is easily arranged.
Why should this idea not be given a try out, not only in other hos
pitals but at receiving ships and barracks and even on board cruising
ships?
A steaming
cauldron of soup, one man in the galley, a row
of serving
pots, each supplied with a ladle and kept filled,
a pile of
cut "chunks'7 of bread,
and
a bowl
and
spoon
for each man
who
wishes to come and "help himself" at any time from
8 o'clock to
taps," would not be impossible nor even difficult, and the soothing
sensation of repletion
following
a " night
cap " of
bread
and
hot
soup would
add luxury
to the swaying hammock
and prove
a real
asset of welfare, comfort, and contentment,
to be looked
forward
to
by tiie men as an agreeable break in the long evenings
on board ship.
I'erhaps even the officer of the deck would find not disagreeable
the
Performance
of his duty in " inspecting " this issue of food.
(m. f. o.)
96
Vol. XVII
EDITORIAL.
ON
ACUTE
APPENDICITIS.
In the Annual
Report of the Surgeon General of the Navy for the
fiscal year
1921, we find that 1,038 patients were admitted to the sick
list during
the
period covered
by this report with
a diagnosis of
acute appendicitis.
Of this number,
861 came to operation, and of these
16 died.
The causes of death were ascribed
in
1 case to carcinoma,
in
1 to ether poisoning, in
1 to pneumonia,
and in 13 to peritonitis —
truly
a satisfactory
showing for the naval operating surgeon; yet
might not the 13 deaths from peritonitis have been reduced in number
or avoided
altogether
by perhaps an earlier diagnosis or an operation
in the early stage of the disease?
The mortality
from
acute appendicitis
is practically
nil in cases
which are operated
upon early in the disease;
the mortality
is high
in
cases
operated
upon late.
After
the infection
has
invaded
the
peritoneum
and
resulted
in peritonitis,
either
localized or general,
the disease becomes a serious
affair.
If the diagnosis can be made
within
the first
12 hours after the onset of the symptoms,
a prompt
operation, with removal
of the appendix and closure of the incision
without
drainage, will
usually
result
in
a
prompt
recovery.
If,
however,
operation has been delayed until peritonitis
has set in, the
peritoneum
must
be drained, and the patient has not only to combat
the effect of the operation but must
also
overcome
the peritonitis.
Often
he is unable
to do this and
dies,
when
he might
have been
saved by earlier diagnosis or earlier operation.
Three
wrong principles
of so-called
medical treatment
of acute
appendicitis are partly
responsible
either for the errors in diagnosis
or the hastening of necrosis of the tissues of the inflamed
appendix.
The first is the administration
of morphine
to relieve
the initial
pain before any diagnosis has been made.
Before giving
any nar
cotic to
a patient with belly pains every
effort should be made to
establish
the diagnosis, for as soon as a patient is under the influence
of morphine the symptoms
are masked.
Spasm and rigidity, two
very
important
signs in appendicitis,
disappear;
the patient feels
better and when
seen later in the day it is often impossible
to make a
diagnosis.
The second error in the treatment of abdominal pain of unknown
origin
is the administration of cathartics, usually castor oil, calomel,
or salts.
Any one of these excites
a violent peristalsis and if ap
pendicitis is present,
not only tends to spread
the infection over the
adjacent
peritoneum, but often induces
a perforation.
The third
error
is the indiscriminate
use of the ice bag.
Capt.
A. M. Fauntleroy. Medical Corps, United
States Navy, writing in the
Medical Record of August
3. 1912, calls attention to a series of cases
of acute appendicitis coming to operation on the U. S. S. Solace.
In
No. 1.
97
EDITORIAL,.
60 per cent of these
cases the appendix was gangrenous,
about to per
forate or pus was present.
The health records of this series showed
that an ice bag had been applied in 50 per cent of the cases.
Fauntle-
roy observed that when
the ice bag was used there
was a noticeable
lack of effort on the part of nature to wall off from the rest of the ab
dominal cavity the appendix, which was frequently very much
con
gested, gangrenous,
or perforated.
Every medical officer knows the symptoms
of acute appendicitis,
yet when we stop to think of the seriousness of the disease, a review
of the symptoms
may not be out of order.
In
a typical
case of appendicitis
the symptoms are somewhat
as
follows : The onset of the disease is generally ushered in with severe
abdominal
pain which extends
over
the whole abdomen.
However,
the first pain
may
be referred to the epigastrium, or it may
be In
the appendix
region.
The pain is usually followed
by nausea
and
vomiting.
In a few hours the pain localizes in the right iliac
fossa
and the patient is exquisitely tender at McBurney's
point.
The tem
perature is usually elevated, but it may be normal.
The pulse is usually accelerated
and
there
is pronounced rigidity
or spasm
over
the
right
rectus
muscle.
Constipation
is usually
present,
but occasionally there
is diarrhea.
Symptoms referable to
the bladder may be present when the appendix is long and hangs over
the brim of the pelvis.
The
pain
and
tenderness
are usually
re
ferred to the left iliac fossa or they may
be referred high up on the
right side when the appendix is retro-cecal.
Examination of the blood at this time will usually show
a marked
leucocytosis and an increased
percentage of the polynuclear cells.
A
low leucocyte count may indicate a lack of reaction on the part of the
patient with
a consequent poor prognosis.
The severest types of appendictis may
present
the mildest symp
toms.
The writer has operated
on cases presenting few symptoms
in
which the appendix was found full of pus and ready to rupture.
In considering
a diagnosis
of acute appendicitis
one should not
neglect to examine
the patient's general
physical condition.
Often
the pain of a pneumonia
on the right side is referred to the region of
the appendix.
The symptoms
and signs of acute appendictis are usually clear and
onmistakable.
As soon as the diagnosis
is established,
the appendix
should be removed
at once.
The treatment
of acute appendicitis
is
surgical, not medical.
During the first
12 or 18 hours following the
onset of the disease, the abdomen can usually be closed without drain
age and the patient will make
a prompt recovery.
When the peri
toneum,
however,
becomes involved, drainage must be employed,
and
if the patient
recovers,
convalescence is prolonged and often stormy,
(w. M. k.)
98
Vol. XVII
EDITORIAL.
ON THE USE OF IODINE
AS
A SKIN
DISINFECTANT.
The use of tincture of iodine
as
a disinfectant for the skin, par
ticularly for
the field of operation,
and for
the
treatment
of in
juries, came prominently
before the medical profession
about
1905
and
has
been
used extensively
since that time.
It was found
that
a
3 or 3| per cent
alcoholic
solution
gave
the
best
results.
The
use
of
a solution of this strength
accomplished
sterilization
in
a
few minutes.
Furthermore,
it was found that if a healing
wound
was subjected
to slight irritation by iodine a much smaller scar would
be left than if it was allowed to heal normally.
An
excellent
resume of the
development
of the use of iodine up
to the latter part of 1910 by J. F. Wollheim
appeared
in the Ameri
can Journal
of
Surgery
for
November,
1910.
Little
or
nothing
has been written
on this subject since
1912 or 1914,
so to get
some
expression
of the present
uses of iodine, particularly
in industrial
work,
inquiries
were
sent
by Dr. F. L.
Rector,
who
writes
on
"Iodine
as a wound disinfectant,"
in the Nation's Health
for Jan
uary
15,
1922,
to
about
75
physicians
asking
what
preliminary
cleansing was done to wounds and what strength iodine was used.
Replies were received from
65 physicians, all of whom were doing
industrial
work or surgery closely
allied to industry.
Of this num
ber, 2 use 10 per cent solution, 18 use U. S. P. 7 per cent tincture, 21
use 3| per cent, 10 use 3 per cent, and 3 use 2 per cent solutions.
The
other 11 physicians reported use of solutions of 4 per cent to
5 per
cent strength.
It is thus seen that a majority
use a solution of 5 per
cent strength or less.
A few of the men said they
did not use
iodine.
One preferred
camphophenol, others used dichloramine-T,
chlorazene,
Dakin's
solu
tion, 7 per cent sodium oleate, picric acid, 5 per cent liquor cresolis
compositus,
10 per cent calendula for large lacerated
wounds, alcohol,
bichloride of mercury
1 : 2,000 in 95 per cent alcohol, to which
2 per
cent hydrochloric
acid has been added.
Several of the physicians
emphasized
the importance of having
the surface perfectly dry before iodine is applied.
A damp surface
interferes with
the
penetration of the
antiseptic.
Earlier
writers
laid
stress upon this point.
The
most satisfactory
method
of pre
paring the wound area for iodine is to use alcohol and ether as final
cleansing agents.
For the preliminary
treatment
of wounds gasoline
alone or in con
junction
with
benzine
or ether
was
used by
23 physicians.
With
4 men soap and water was the agent of choice with the addition
of
gasoline
or benzine if grease was present.
Tincture
of green
soap
was preferred by 6 men.
From the replies received by Doctor Rector it would seem that the
use of iodine as a skin and wound disinfectant still holds first place in
No. 1.
99
EDITORIAL.
surgical technic in the industrial
field, in spite
of the great popu
larity
attained by the chlorin
compounds in the treatment
of war
wounds.
Such objections
as
were
raised
were
against the
danger
of burns and the discomfort
iodine caused
rather than against its
efficiency
as
a sterilizing
agent.
The
Conference Board
of Physi
cians in Industry has
since
its organization
recommended
the
use
of a 3 to 3£ per cent solution of iodine, and in the light of present
experience
feels that this recommendation
is justified,
(w. m. k.)
ON THE REMOVAL
OF FOREIGN
BODIES FROM THE EYE.
In discussing the removal of foreign
bodies
from the eye, H. D.
Bruns, writing in the New Orleans Medical
and
Surgical
Journal
for February,
1922, points out the value of a good hand magnet, not
with the idea of extracting magnetizable foreign bodies from within
the eyeball, but for the purpose of pulling out those stuck in the con
junctiva.
There is probably no small operation more embarrassing than the
removal of a nonmagnetic splinter which has penetrated
the cornea.
If the point of such
a splinter
enters, or almost
enters
the anterior
chamber,
the
accepted
practice is to pass
a
keratome
through
the
margin of the cornea
while the
eyeball
is steadied
with
a fixation
forceps.
The point of the keratome
is held against the penetrating
end of the splinter
to prevent its being driven
in further
as
the
operator
grasps it with fine forceps.
If the splinter
has penetrated
the iris and lens
as well
as the
cornea
an incision
must
be made
embracing
the
point of entrance
of the
splinter.
With
a Graefe
knife the cornea
is transfixed a few millimeters from the wound, the
knife is passed
across
the anterior
chamber,
and brought
out at
a
point about the same distance
on the other side of the point of pene
tration.
By cutting outward the incision is completed.
The end of
the splinter
lies free
in the incision
and can
be grasped
and
the
object removed.
If prolapse of the iris occurs
iridectomy
is indi
cated.
Metallic
splinters
may
often
be removed
by
a
good
hand
magnet, especially if they have only penetrated
the superficial layers
of the cornea.
Foreign
bodies on the cornea which are not magnetizable
must
be
removed by some instrument under cocaine
anesthesia.
The writer
prefers
a
probe with a 4ittle cotton
tightly twisted
about
its end.
Standing
behind the patient, who sits facing the source of light, the
operator holds the lids with the thumbs and forefinger of one hand.
Having located
the foreign body, with a quick motion of the fingers
he makes the cotton-wrapped tip of the probe describe
a short curve
from above downward, which strikes the body at the height of its
convexity at the point where the curve is tangent to the cornea.
This
100
Vol. XVII.
EDITORIAL.
should be done lightly at first and then with more
force until he is
convinced
that the body can not be removed
in this way.
If one is
successful,
the foreign body should be found sticking to the cotton
on the probe or in the lower conjuctival
cul-de-sac
where it has been
knocked.
If the body is not removed by this manipulation,
one must
resort to the use of a dull-edged spud, flat on one side, rounded
on
the other
and with
no point, using it as he used the cotton-tipped
probe.
Failing in this, the end of the spud should be placed
above
and against
the foreign body,
and with
a quick downward
and out
ward flip an attempt
is made to turn it out of its bed. If this fails,
the point of an old Graefe knife or a flattened
discission needle in
serted behind the body may dislodge it.
Foreign bodies
either on
or in the conjunctiva are easily removed
after eversion of the lid.
In all manipulations
about the eye the greatest surgical cleanliness
is
necessary.
Instruments
and
dressings
should
be
sterile.
The
method
of cleaning an
eye in use in
a New Orleans clinic
consists
of repeated
instillations
of fresh
10 per cent solution of argyrol
as
repeatedly
washed
out with sterile normal salt solution or freshly
made
borax—boracic-camphor
water.
Fresh
argyrol,
in freshly
made solution of a strength not greater
than 15 per cent, used not
longer than two
weeks
at
a time, does not irritate the
eye.
The
diffusibility of argyrol
is pronounced; it penetrates
everywhere; it
dislodges
old
secretions
from
the
lachrymal
sac
and
thoroughly
cleans the conjunctival
sac.
After
a foreign body has been removed
and
the eye thoroughly
cleaned it should be occluded
by a sterile dressing,
which should be
renewed
every
day
after cleansing the
eye until all
abrasions
are
healed.
If the abrasion is small
and the patient cleanly and intel
ligent, argyrol solution may be instilled every hour until redness and
the
rough
sensation
on
winking
have
disappeared.
Bathing the
closed eye frequently with hot water favors this and gives comfort.
The
Berger
binocular
loup
and
its
accessory
condensing
lens,
together
with
the
5 per cent solution of fluorescine,
are very useful
in locating foreign bodies.
The binocular magnifier greatly increases
the information
we derive from the examination of any small lesion,
and
the fluorescine
solution, after it has been instilled for three or
four minutes
and then
washed
out,
reveals
the tiniest body by sur
rounding it with a bright green ring; or if the foreign body has been
swept away by the tears, the abrasion caused by it is shown by a small
spot of an intense green color.
If the search is not successful
in the daylight, it must be continued
in a dark room with the aid of artificial light.
Indeed the search for
a foreign
body
must never
be abandoned
until one has made use of
oblique artificial light in a dark room.
(w. m. k.)
No. J,
101
EDITORIAL.
ON
KALA
AZAB.
With the exception of the discovery of the specific action of tartar
emetic in the treatment of kala azar, Wenyon finds, in reviewing the
recent literature
on this
disease in Tropical
Diseases
Bulletin for
February,
1922, that very little has been added
during
the
last
10
years to our knowledge of this infection.
In addition
to the well-
known endemic centers in North China, India (particularly Assam),
the Caspian region, Mediterranean littoral, and the Anglo-Egyptian
Sudan, new foci have also been discovered
in Mesopotamia, Sumatra,
and Siam and in the districts around Lake Chad (Africa).
The role of animals in spreading kala azar has not been determined
;
in several
regions,
notably the Mediterranean littoral and
the Cas
pian
region,
canine
kala
azar
occurs
as
does the
human
disease,
whereas in other regions only one of the two has been demonstrated.
Even if it is admitted that the two types
are
caused
by
the
same
organism,
Wenyon
does not believe that the dog plays any essential
role in the spread of the human disease.
The diagnosis of kala azar depends upon the discovery of the para
site,
and
spleen
puncture still remains
the most reliable
and rapid
means of attaining this object.
The organism is frequently discovered by direct examination of the
peripheral
blood, where it generally appears in the mononuclear leuco
cytes, although it may
occur
in other cells.
Painstaking
search
is
often required before the parasite is found by this procedure.
Blood
culture on NNN medium
has yielded very good
results in the hands
of some
observers.
There
is
a certain disadvantage in
using this
method,
however,
because the number of parasites
inoculated in the
medium is so small that often two or three weeks must elapse before
flagellates are detectable.
It should always be done, however,
espe
cially in cases in which spleen puncture is contraindicated.
The prevalent
idea
that
the
Mediterranean
type
of the
disease
attacks
only children
and
the Indian type only adults must
be dis
carded
in view of more
recent
and
careful
observations.
Mackie,
Muir, and Knowles in India, Cochran and Wylie in China, and vari
ous
observers
in
the
Mediterranean
littoral
have
shown that
the
respective
" types " may attack all ages, thus removing the mark of
distinction
between the two forms.
The greatest
advance
has been made in the treatment
of the dis
ease.
Since Caspar Vianna in 1913 first treated American cutaneous
leishmaniasis with such remarkably
good
results,
the specific
action
of tartar emetic has been
confirmed
both in Italy
(Doctors Christina
and Caronia)
and
in India
(Bogers, Muir, Knowles,
etc.), in the
general infections occurring in these countries.
102
Vol. XVII
EDITORIAL
Attention
has been drawn several
times to the toxic effects of this
drug.
It was realized that great care had to be exercised
in admin
istering the drug, and that it was necessary
to commence with small
doses
and gradually
to increase
them.
Deaths have
been reported
in a few instances.
Long-continued
treatment
is essential
to bring
about
cure
and to prevent
relapses.
Muir
states
that
injections
should
be given every
second
day till fever has been absent for a
month and then once a week for two to four months.
Unless these
weekly injections
are continued
relapses
may
occur.
Knowles,
in
Shillong,
has
presented
some very interesting
facts regarding
the
effect of treatment.
The immediate
result is the rapid
disappearance
of the parasites
from
the
peripheral
blood, later followed
by
disappearance
from
the spleen
and finally by cessation of the
fever.
The body weight
increases,
while
the
spleen
decreases
in
size
and
a normal
blood
pressure
is restored.
Knowles
recommends
that the potassium salt
(the "heavy
powder" and not the "light powder")
be used.
He
employs
a
1 per cent solution in normal saline,
autoclaved
at 110° C.
for
10 minutes and kept in
a rubber-capped flask.
If there is the
least trace of deposit
or opalescence
in the solution it is discarded
as not being safe to«use.
The initial intravenous dose is 3 to 4 cubic
centimeters
for
an adult.
Injections
are given on
alternate days,
the dose being gradually
increased until 10 to 12 cubic centimeters
are
given toward the end of treatment.
The intervals between the doses
should be increased
as there is some evidence of accumulative
action.
The standard course at Shillong is
a course of 200 cubic centimeters
distributed over a period of two and
a half to three
months.
The
injections
should not
be given within
two hours of
a meal.
The
sudden
appearance
of
edema
should
be
a
danger
signal.
Other
antimony compounds
have been introduced for the treatment of kala
azar,
notably
stibacetin
and
colloid
antimony
sulphide.
Rogers
treated
10 cases with the latter preparation
and regards it as a dis
tinct improvement over
the soluble antimony tartrates in the treat
ment of kala azar.
The problem of transmission is still unsolved.
Attempts have been
made to inculpate many insects, especially the flea and bedbug.
As
yet, however,
no satisfactory
evidence
has been forthcoming
to sub
stantiate claims made.
In
a telegram published in the Indian Journal
of Medical
Re
search, January, 1922, Mrs. Adie states that she has found
a swarm
ing infection
of Leishman-Donovan
bodies
in the salivary
glands
and
ducts
of
Cimex rotundatus
caught in the
bed of
a suspected
kala azar
case,
and
that this discovery positively
proves
that
the
bedbug
is capable
of transmitting
the
disease through
biting.
In
No. 1.
103
EDITORIAL.
a letter
to the editor of the Lancet, published
February
25,
1922,
C. M. Wenyon
discusses
this announcement
of Mrs.
Adie's
and in
a well-arranged argument shows that in spite of her discovery con
vincing evidence is still needed to prove that the bedbug is the vector
of kala azar.
Some of Wenyon's
points
are: Numerous
previous
experiments
on
the bedbug,
apparently
successful,
have
been shown not to
be
conclusive
when
the results
have been critically analyzed.
In Mrs.
Adie's case it is evident
that the bug came from
a bed, not of a case
of kala azar but only
a suspected
case,
and
there is no proof that
the bug had
even fed
on this particular
individual.
Proof is also
needed that the parasites
found are Leishman-Donovan
bodies.
It
is possible
that the bedbug
may occasionally harbor
a flagellate of
its own, although this has never been shown before.
Prophylaxis
as carried
on in India
to-day
is
based
on
the
ap
parent fact that kala azar is a house and family
disease.
Segrega
tion of all families
having
the
disease is attempted,
especially in
Assam.
That the newly introduced treatment
by tartar emetic will
undoubtedly
play an important
role in facilitating the eradication
of this disease is pointed at by McCombie Young,
(e. p.)
IN MEMORIAM.
XXSDLSTOH
SEMMES
QUEST.
1869-1922.
Surg.
Middleton
Semmes
Guest,
United
States
Navy
(retired),
died at the United
States Naval Hospital,
Annapolis,
Mel., on Janu
ary
7,
1922,
following
a protracted illness.
Surviving him
are his
widow,
the daughter of Athanase Branchand, K. C, of Montreal,
and one daughter, Ann Branchand
Guest.
Doctor Guest was born on May
23,
1869, at the navy yard, Ports
mouth, N. H.
He
was the son of Commodore
John Guest,
United
States Navy, who died in 1878 while commandant of that yard, and
of Anna Josephine
Pleasonton, daughter of Gen. Augustus Pleason-
ton, of Philadelphia,
and
niece of Gen. Alfred
Pleasonton, United
States Army.
He chose
medicine
as his profession, graduated
from
the Uni
versity
of Pennsylvania
and,
drawn
by his
associations,
and
the
love for the service which remained
such
a prominent characteristic
throughout his life, he entered
the
Navy
as
assistant
surgeon
in
1891.
His professional
career
was marked by evidence of his conscien
tious devotion to the details of duty, and
a nice sense of discrimina
tion in estimating
the value of the rapidly succeeding
advances
in
the theory and practice of medicine.
Unfortunately,
Doctor Guest
was not given to writing for publication
and consequently
relatively
few realized the shrewd, sane judgment
he habitually
displayed in
matters of medical practice and administration.
He
exhibited
similar
reticence
in his personal intercourse, and
only intimates knew what
an
acutely observing mind
functioned
actively
beneath
his usually
reserved
exterior.
His
fund of remi
niscence
was
a source of unending enjoyment to his friends, light
ened
as it was
by
a wit that
was
keen
and
penetrating,
and
yet
always kindly.
As is common
with
men of
a retiring
disposition,
he found his
recreation in the active pursuits of fishing, gunning,
and the sailing
of small craft.
Of these amusements
he never
tired, and
on occa
sions when the actual sports were impossible he passed much of his
leisure in studying
the natural history of game birds and fish.
He
105
106
Vol. XVII.
MIDDLETON
SEMMES
GUEST.
took great pride in his strength and endurance,
so that the misfortune
of prolonged invalidism
was hard for him to understand and doubly
hard to bear.
Doctor Guest possessed an ardent love for the service, its customs,
traditions,
and even the minor features of a ship's routine.
This de
votion to the Navy was so absorbing that his retirement in 1910 came
to him as a' great shock, the separation from the service entailed quite
overshadowing
in
his mind
the
personal
significance of his
dis
ability
; and when the United
States
entered the recent war, against
the
advice
of those
near
him,
he earnestly requested
active
duty.
It was given him, but he could not carry on for long.
The disease
for which
he was
retired
became
active,
and it proved
necessary
again to place
him in an inactive status.
In reference
to this, he
wrote in a private letter, " This is a villainous
blow and upsets my
hopes and plans completely.
I hoped to have kept on until the close
of the war and at least to have released
some younger man for sea
duty
*
*
*, but it
seems
that
my
desire
was
greater than my
strength to perform
*
*
*."
Comment would add nothing to these characteristic phrases.
Liv
ing comfortably, his disease quiescent,
and urged by all his advisers
to remain inactive, he could not tolerate
the idea of taking
no part
in the struggle going on.
Although,
when the end was approaching,
he realized clearly that his war duty had activated
the disease,
he
had no regrets.
By no other course could he have remained at peace
with himself.
REPORTS.
A EEPOET
OF THE HOSPITALIZATION7
OF THE VETEEAN AT OEEAT
LAKES.
By H.
O. Datis,
Lieutenant
Commander,
Medical
Corps,
United
States
Nary.
The hospitalization
of the veteran
of the late war has become an
important function of our naval hospitals and we are constantly seek
ing the best method to efficiently
administer to his needs and expedite
the treatment
that will
make
possible
his
complete
vocational
re
habilitation.
The usual hospital
routine
in professional,
administrative,
and
clerical
procedures
becomes widely
varied
when
an
institution
is
handling and treating
a class of patients largely unacquainted with
naval customs.
The veterans admitted to the naval hospital at Great
Lakes,
111., differ greatly
in mentality,
temperament,
and in their
general attitude toward any form of treatment
due probably to their
experience in other hospitals or to seemingly
unsatisfactory
compen
sation adjustments.
The admission of ex-service
men began
in
a small way early in
1921,
when
50 beds were allotted to patients of the Bureau of War
Risk Insurance.
Those admitted were distributed
among
the Navy
patients
with
no
specific
supervision
other than
general
hospital
care, and as there were no very definite regulations for handling them
there soon arose petty disputes
over working details in general.
As
the Navy patients decreased more beds were assigned to the War Risk
patients, and it was deemed advisable
to establish
a special
office apart
from the main hospital
offices in which business in connection
with
these patients could be carried out.
A medical officer was placed in
charge of this office.
His specific duties are to admit all patients, ex
plain the plan of treatment
and something of the hospital, administra
tion.
He is concerned with all matters relative to ex-service
patients
during their stay in the hospital.
After the passage of the Sweet bill, September
9,
1921,
the Vet
erans' Bureau was established,
replacing the Bureaus of War Risk
and Vocational Rehabilitation.
By Executive
order that portion
of
the naval: hospital
at Great Lakes
known
as Camp Ross, was
turned
over
to
the
Veterans'
Bureau
for
the
care of
300
neuro-
103390—22
8
107
108
HOSPITALIZATION
OF THE
VETERAN
AT GREAT LAKES. Vol.
XVII.
psychiatric
cases under naval administration.
The bed capacity of
the main hospital was enlarged to 300 general
medical and surgical
cases, making a total of 600 beds available for the care of ex-service
men.
All patients for observation,
treatment,
and
final
diagnosis
are
received
through
the eighth district
office
in Chicago
representing
Illinois, Wisconsin, and Michigan.
A board of three medical officers
make
a recommendation
for the disposition of each case which,
ac
companied
by
a clearly stated word picture in the medical
history,
makes
possible
a proper compensation
adjustment when
the
case is
reviewed
by the rating
board.
A network of subdistrict
officers in
these States
keeps the central office in Chicago supplied with
cases
needing
hospitalization,
and after
a medical
examination, authority
for the admission
of each patient to enter
one of the various hos
pitals throughout
the district is issued.
From 10 to 30 patients are
admitted
daily at Great Lakes.
Each man is assigned
to the depart
ment especially fitted
to care for his particular
ailment.
On arrival
these
patients report to the special
office
representing the Veterans'
Bureau which is connected
with
the receiving ward.
A special in
patient report card, the Navy Form F card, and
an identification
card is made out, after which the medical officer takes a brief history
of the
case,
recording the dates of enlistment and
discharge from
the service, together with the chief points of the present
complaint.
After
a preliminary
examination, the patient signs
a receipt for
a copy of the hospital rules which also contains
excerpts
from Gen
eral Order 27-A issued by the Veterans' Bureau.
A short explana
tion of the plan of treatment is given to him
and
any questions
answered,
so that the patient is sent to his ward with
a clear under
standing of what is expected of him by the hospital authorities
re
garding his cooperation
in the treatment.
All patients pass through
a
general
routine of laboratory,
dental, and
X-ray
examinations.
A complete
urinalysis
is made,
also
a blood count and blood Was-
sermann
test.
There are repeated examinations of the sputum in all
suspicious cases,
examinations of the stools of all patients coming
from
southern Illinois,
where
hookworm
infection
is
prevalent.
A spinal Wassermann test is made on cerebrospinal suspects in ad
dition
to other observations
on the spinal fluid.
The
X-ray
department
radiographs
and
fluoroscopes
all suspi
cious
chests
and
makes
fluoroscopic
examinations
of all
gastro
intestinal
cases
which
are
referred
for
an
opinion.
The
dental
officers note all cases of infectious and carious teeth for treatment.
About
75 per cent
of
the
medical
cases
are
admitted
as
being
possibly tuberculous.
Special wards are set apart for these patients
and
a regular routine is followed.
Preceding
the first physical
ex
Xo.1.
HOSPITALIZATION
OF THE
VETERAN
AT GREAT LAKES.
109
amination. the following
three-day temperature,
pulse
and respira
tion chart is filled in and
the routine X-ray
examination
is made.
TEMPERATURE
PULSE
RESPIRATION
CHART.
First dav
(in bed.)
7 a. m.
9 a. m.
11 a. m.
1 p. m.
3 p. in.
5 p. m.
7 p. m.
9 p. m.
Second day.
7 a. m.
9 a. m., before
exercise.
9.30 a. m., after exercise.
10 a. m., after rest in bed.
1 p. m.
3.30 p. m., after J hour exercise.
4 p.m., after i hour rest in bed.
7 p. m.
9 p. m.
Third day.
7 a. m.
9 a. m.
11 a. m., after
2 hours exercise.
11.30 a. m., after J hour rest in bed.
2 p. m., before exercise.
4 p. m., after
2 hours exercise.
4.30 p. m., after J hour rest in bed.
7 p. m.
9 p. m.
The sputum of each suspicious case is examined
daily until five to
seven
negative
reports or three
positive findings
are obtained.
In
negative
cases
a
second
series
is
started
after
an interval
of one
week.
Physical examinations of the chest are made weekly. A large
number of the negative cases are found to be suffering from nose and
throat infections
which, when
removed,
result in
a cessation of the
symptoms simulating tuberculosis.
About
10 per cent of the cases are
really tuberculous and are promptly transferred by the district
office
to a suitable
sanitarium.
The negative
cases are discharged to take
up light work, vocational training, or dispensary treatment.
The 300 beds set apart for neuropsychiatry
cases
are generally
filled.
The
average
period of hospitalization
for this class of pa
tients is about 90 days.
The larger per cent
are neurasthenic
and
require protracted study by the various departments
of the hospital
in order to rule out organic
disease.
The following outline which
has been found very useful is employed
in recording the history of
each case of this type :
Name.
Organization.
Claim
No.
Date admitted.
Nativity.
Vge.
Education.
Occupation.
Religion.
Social
status.
Address.
Date of induction.
Date of discharge.
Status
on admission.
Family
history
:
Grandparents.
Parents.
Brothers
and sisters.
Collaterals.
Personal
history
:
Prenatal.
Birth.
Infancy and early
childhood.
Education
and school life.
Character
and home environment.
Industrial
history.
110
HOSPITALIZATION
OF THE VETERAN
AT GREAT LAKES.
Vol. XVII.
Disease of adult life and injuries:
Habits.
Sexual
life.
Venereal
history.
Crimes
and misdemeanors.
Marital
history.
Reflexes :
Deep.
Superficial.
Mental examination
:
General
attitude.
Psychomotor
state.
Emotional status.
Delusions.
Hallucinations.
Dreams.
Insight and judgment.
Orientation.
Disorders
of attention.
Intelligence
tests.
Special
senses:
Sensation.
Psychobiological
make-up.
Disposition.
Temperament.
Instinctive
demands.
Adaptability.
Military
or naval
history.
Present
illness:
Before discharge from service.
After discharge
from
service.
Physical examination
:
Cranial
nerves.
Sensori-motor-general
motility.
Special
tests and examinations
:
Spinal
fluid.
Nutrition of muscles.
Tone
of muscles.
Active movements.
Coordination
of movements.
Motor
irritation.
Approximately
TO
per
cent of the neuropsychiatric
cases
repre
sent the various
types
of psychoneurosis
and
20
per
cent
are suf
fering
from
mental
and
nervous
diseases.
Epileptics
are
trans
ferred
to their
home or to special
institutions,
and
the
insane
are
sent to the Cook County
Psychopathic
Hospital
for further com
mitment to a State institution.
The majority of the neuropsychiatric
patients possess little educa
tion
and fail to appreciate
the problems incurred
in settling their
claims.
The
present
economic
depression
has
resulted
in the hos
pitalization of many border-line
incompetents.
A reconstruction center
has been established
in Camp Ross with
an educational
director
in
charge,
to
give prevocational training
and to gauge the individual's
qualifications for a new vocation after
considering his educational qualifications,
intelligence, past experi
ence
and
present
handicap.
Courses
are
offered
in
elementary
academic
and
commercial
branches,
also
in
mechanical
drawing,
drafting,
automechanics,
machine-shop
practice,
electrical,
wood
and cabinet
work, printing,
shoe and watch
repairing, truck garden
ing, poultry raising,
bee husbandry, and in the arts
and crafts.
The local Red Cross chapter is rendering very valuable assistance
in obtaining
social
histories and furnishing financial
assistance
to
dependent
families
while
compensation
claims are being adjusted.
They are fully equipped
to file claims,
assist in obtaining the essen
tial
affidavits
and
to investigate
delays.
No. 1.
ACTIVITIES
OF
MEDICAL, DIVISION,
SAN
DIEGO,
CALIF. Ill
The general
morale of the ex-service
patients has been excellent,
and
serious
infractions
of discipline
have
been few.
Every effort
is made
to assist
each patient in straightening
out his difficulties
and to prevent
trivial complaints
and misunderstandings
from
as
suming any degree of seriousness.
The hospital
office
of
the Vet
erans' Bureau is constantly ironing
out these wrinkles
and keeping
an ear to the ground for any
echos of discontent.
It is significant
that only
two
disciplinary
boards
have
been convened
in the
past
seven months in handling nearly 1.500 nonnaval cases from all walks
of life.
Upon the recommendations
of medical
officers daily liberty
and periods of leave are granted.
Moving pictures and vaudeville
are furnished by the Morale Division
and various organizations give
parties and dances under the direction of the Red Cross hostess.
The Bed Cross distributes clothes,
shoes, and toilet articles when
requests
signed
by
medical
officers
are
presented.
The
Knights
of Columbus distribute cigarettes
and toilet articles weekly, and fre
quent concerts
are given
by the naval station band.
A well-stocked
library and several recreation
rooms add to the diversion of ward life.
BEPOBT
OF THE ACTIVITIES
OF THE MEDICAL DIVISION OF THE
UNITED STATES NAVAL HOSPITAL,
SAN DIEGO, CALIF,i
Br W. D. Owbsb,
Lieutenant
Commander,
Medical
Corps,
United
States
Navy.
The activities of the medical
division
during
the year have
been
directed
to the detailed
study of each case admitted and of series of
eases of the same disease.
This study has been conducted
in order
that the value of the latest methods of diagnosis and treatment
might
be determined
with the view of establishing a routine for the general
management of medical
cases.
The diseases which have been espe
cially studied include thyrotoxicosis, neurosyphilis, acute and chronic
nephritis,
diabetes mellitus, amebic dysentery,
cholangitis, the pneu
monias,
malarial
fever,
Vincent's
angina,
and
acute
and
chronic
rheumatism.
In each
instance
observations
have
been
directed
along
special
fields of interest, such
as basal
metabolism
estimations,
functional
kidney
tests,
blood
chemistry
and
Allen's
treatment for
diabetes,
intubation and visualization with the duodenal
tube, and the location
and elimination
of foci of infection.
Spinal
punctures,
performed
in some
95 of our
cases
have thrown light upon the
frequency
of
neurosyphilis
and
the
diagnostic value of this procedure.
Several
cases of atypical, ataxic gastric crisis, neurasthenia
and epilepsy in
which the blood Wassermann
was negative
have been determined
to
be syphilitic by means of the examination of the spinal fluid.
Blood
'From the Annual Sanitary
Report of the U.
S. Naval
Hospital,
San Diego, Calif.
112
ACTIVITIES OF
MEDICAL
DIVISION,
SAN DIEGO,
CALIF. Vol. XVII
Wassermann
reactions
have
been
determined
in
all
medical
cases
admitted.
Nine
cases of thyrotoxicosis
have
been
studied.
In this series of
cases
we determined
that, with
the exception
of basal
metabolism
estimations,
the various other
diagnostic tests, including
the Goetz
and Bram tests, are of little or no value and in some cases do actual
harm.
Basal metabolism
findings, however,
are of real value,
par
ticularly
in the differentiation of cases of thyrotoxicosis from "effort
syndrome
cases."
As the result of our studies
we have
abandoned
the other diagnostic tests and confine our efforts to basal metabolism
observations.
We have learned
to accept readings over +10 or +15
as
evidence of
a hyperthyroid
condition.
Of the various medical
treatments
for exophthalmic goiter we have had most success with
hydrobromide of quinine.
In our hands X-ray exposures
have been
of doubtful value.
Our plan has been to withhold surgery until all
medical efforts have failed.
In one case, however,
on which a partial
thyrodectomy was performed, the results have been satisfactory, but
only for a limited time.
In nephritis we have made certain observations
with the functional
kidney tests, and have studied
the " Fisher treatment."
We have not
been able to obtain the excellent
results claimed by Fisher and have
abandoned
its use in our nephritic
cases.
Of particular
interest
has been our work with the Einhorn tube.
Intubation and visualization of the duodenum "has an important field
of interest.
More than 100 intubations have been done, and our ob
servations show
that it is an excellent
adjunct in the treatment
of
acute cholangitis, and that its use shortens
the course of the disease.
It also has considerable
value in the treatment
of cases of atony of
the gall-bladder,
and
is useful in differentiating
between
duodenal
and gastric ulcers.
Visualization
with the X-ray of the tube passed
into the jejunum, affords an excellent
method of determining peri
cystic adhesions
and
assists in the differentiation
of cholelithiasis,
chronic appendicitis, gastric and duodenal
ulcer.
With
amebic
dysentery
gratifying results have
been
obtained by
the administration
of ipecac by means of the Einhorn
tube.
The
following
method
of administering
ipecac
by
the
duodenal
tube
has been adopted in our most recent cases
: The patient is put to bed
under the usual restrictions.
An Einhorn duodenal
tube is passed on
a fasting stomach early in the morning.
When the tube is well into
the duodenum,
1 ounce of syrup of ipecac, containing
40 grains of
the drug to the ounce, is passed through the tube by gravity.
This
is washed
out by
a pint of warm water and
the
tube withdrawn.
This treatment
is given every morning for 10 days and the course is
<sonsidered
complete.
The patients usually take the tube very readily
after
the first or second
time
and
retain the drug
well until the
Xo. I.
ACTIVITIES
OF MEDICAL, DIVISION,
SAN
DIEGO,
CALIF.
113
system becomes saturated.
Then a slight nausea may
be complained
of,
but will subside if the dose
is
reduced.
This has been tried on
two patients
here with
excellent
results.
One
case
had
symptoms
for two and one-half
years in spite of the usual
treatments.
The
first
examination
showed
the stool
loaded
with
amebse.
After
the
fourth
treatment
with the
tube
the
stools
were
reported negative.
After the seventh
treatment
the stools
were normal in number and
consistency.
The
case has been watched,
and after five months
has
shown
no
signs of
recurrence.
Eight
dysentery
cases
have
been
treated during the past eight months and of this number six have
been Veterans' Bureau patients
who contracted
the disease in France.
A
number of cases
of malarial
fever have been observed
in order
to
estimate
the
therapeutic
value,
if
any, of
a
combined
treat
ment consisting of neosalvarsan
administered in conjunction
with
Oschner's quinine treatment,
but the results have not been encouraging.
Salvarsan seems to have no place in the treatment
of malarial
fever.
Likewise in the
case of Vincent's angina, our studies
have been di
rected to
a
determinataion of the best method of employing salvarsan
in
this
disease
and
its therapeutic
and
prophylactic
value.
Un
doubtedly
salvarsan suspended in glycerin and applied locally
is
the
treatment of choice in this disease.
In the pneumonias we have established
the value of the early ad
ministration of digitalis,
the advantages
of proctoclysis to furnish
an
increased water intake and as
a
very satisfactory means of adminis
tering sodium bicarbonate in order to diminish
the possibilities of
acidosis.
In pneumonia we administer from 2,000 to 2,500
cubic centi
meters
of liquid
by mouth and
by proctoclysis, and
are
convinced
that this liberal
quantity of fluid slows
the heart action and
makes
the patient more restful.
It
is
no uncommon
occurrence
to see our
cases quietly sleeping during proctoclysis.
We have been impressed
with the value of daily blood-pressure estimations,
and have
estab
lished the custom of performing
venesection
when
the systolic blood
pressure
is
above 150 or 160, and especially in those cases in which the
pulse
pressure
is
increased
and
there
are
evidences
of impending
circulatory
failure.
The vast majority of pneumonias
which occur
at this hospital
are of
the broncho-pneumonic
form.
A study of
the clinical
manifestations of these
cases
discloses
certain clinical
features not usually
observed in this form of pneumonia.
A high
temperature terminating
by
a
sudden fall to normal,
is
not uncom
mon, and has occurred
in fully one-half of our cases.
A leucocyte
count from
16,000
to
20,000
occurs
more often than the low count,
and
in
typing our cases pneumococcus
type II has been encountered.
There have
been
12 cases of pneumonia treated
with no deaths.
In the treatment of diabetes mellitus, the Allen technic
has
been
found most satisfactory.
A patient now under treatment when
ad
114
ACTIVITIES
OF
MEDICAL
DIVISION,
SAN
DIEGO,
CALIF. Vol. XVII.
mitted gave
5 per cent sugar estimations,
and under Allen's
treat
ment has been sugar free for two months.
An endeavor
has been made
to develop
cooperation
and
interest
in our work amongst
the other departments
of the hospital in order
to encourage
the group study of medical
cases.
In no other condition
has the group study been so instructive and so highly
developed
as in
the study of foci of infection.
Every department in the hospital
has rendered
excellent
service in assisting us to detect and eliminate
foci of infection
occurring
in our
patients.
In practically
every
medical
case
we have
had
the
teeth,
nose, sinuses,
and
tonsils
ex
amined
to determine
the presence of foci of infection
; and
less fre
quently studies of the prostate,
the bladder, the
intestines,
the
ap
pendix, and
the gall-bladder
have been made.
Some of the results
following
removal of definite
sources
of infection
have
been
re
markable, and there
is no doubt that this factor, when intelligently
and honestly
studied,
has an important
place in the management
of
medical cases,
and especially so in thyrotoxicosis, nephritis, cardiac,
and rheumatic conditions.
As a result of the study of acute
and
chronic rheumatic cases the following conclusions have been reached
:
(a)
Acute
rheumatic fever—in
the majority
of cases —is due
to
infection of the tonsils.
A few cases
have shown numerous
apical
abscesses.
(b) Apical
abscesses
occur
in the majority
of
cases
of chronic
arthritis,
myositis, muscular rheumatism.
Heart
involvement, usu
ally uncomplicated mitral
lesions,
developed
in
60 per cent of our
cases.
The importance of a complete
history in a medical case is so well
recognized
that the medical officers of this hospital have
adopted
a
plan of procedure
which
has
been found
highly
satisfactory.
In
conjunction
with certain permanent
additions
to the clinical
chart
hereafter to
be indicated, the routine employed
is
as follows:
The
medical
officer taking
the history
records
the complaint, the family
history, previous history,
the present
illness,
and the physical find
ings.
In lung
cases
the picture is more
clearly
defined
by using
symbols
to
record
the
physical
findings
on
a
skeleton
diagram.
Standardized
symbols
taken
from Norris and Lander's
Diseases
of
the Chest are employed for this purpose.
Finally, the medical
officer,
as
a result of the
medical
history,
physical
examination,
and
the
laboratory
findings, determines
certain "impressions" —and from
a
study of these " impressions " the diagnosis is accomplished.
In order to utilize the advantages
to be derived from recording at
definite
intervals
the blood pressure,
basal
metabolism,
the weight,
intake of fluids, and the urinary output, additional
permanent
nota
tions have
been
made
on the clinical
chart, and
curves
indicating
these factors are recorded.
These
records
have
been
found particu
Sfcl.
ACTIVITIES
OF
MEDICAL
DIVISION,
SAN
DIEGO,
CALIF.
115
larly useful in such
conditions as thyrotoxicosis,
nephritis,
cardiac
infections,
and the
pneumonias.
When
indicated,
as in thyrotoxi
cosis, weekly basal
metabolism
readings
are
recorded,
and
on
the
same
day the blood
pressure
and weight are added.
Such
a set of
observations,
when
completed,
is of great
value
in
the
study of
exophthalmic
goiter.
We
have
been
particularly
interested
in
the
value
of frequent
blood-pressure
readings.
The blood pressure
of every
patient who
is admitted
to the medical section
is determined
and in acute
cases
additional
readings
are made every
week
as long
as there
are any
indications.
Probably the greatest
value of frequent blood-pressure
readings occurs in the treatment
of pneumonia.
Daily estimations
are recorded and, as already mentioned,
when under certain condi
tions the systolic pressure
is above
160, venesection
is indicated.
Two other routine
entries
are
made in every
case
paper;
these
are notes of tropical service
and
service
in France.
Knowledge
of
tropical service in the Navy is important,
while with the Veterans'
Bureau
patients, on account of the frequency of amebic
infections,
the information
that
a particular
patient
served
on
the
Argonne
front is of considerable value,
as amebic infection occurred frequently
in that sector.
NOTES AND COMMENTS.
Form K Dental has been revised
to the form of a simple statistical
report, thus obviating the necessity for sending to the bureau
each
month the names of patients
receiving dental
attention.
In order that permanent
records of dental
treatments
may
be pro
vided for, it is directed that the dental appointment books, furnished
by the supply depots,
be used for recording in ink the names, rates,
and operations
or treatments
received
by patients under the
date
of each appointment.
These appointment books or records
are to be
retained as part of the permanent
records of the ship or station, and
are to be forwarded to the bureau
when the ship or station is placed
out of commission.
In order to facilitate
a
search
for
the
treatments
rendered
an
individual, it is directed
that an index of the dental patients' names
be kept on the last pages of the dental
appointment book,
entered
under
the first letter of the surname
and followed
by the numbers
of the
pages
on
which
the
appointments, operations,
and
treat
ments for that patient have been recorded.
The form
as revised should not take much
time to prepare at the
end of each month if a systematic
record
is kept of each operation,
number of dental
charts
made, etc.
It is believed
that the following
method will prove of value in obtaining correct records
with a mini
mum expenditure of energy and time :
Cut the new Form K in the center from top to bottom
; this pro
vides two papers,
each containing the operations, etc., which it is
desired to record.
Paste a sheet of letter-size paper sufficiently over
the right edge of each
piece, leaving
the
" operations,"
" number
of persons,"
etc., uncovered.
Then with
a rule
continue
the lines
under each operation to the right edge of the sheet, which has been
pasted on.
Immediately
upon
the completion of the work upon a
patient after each appointment, make
a mark after the correspond
ing operation— thus
a totaling of the marks after
a given operation
will give the number performed during
the month.
The British
Medical
Journal
of January
28,
1922,
informs
its
readers that a gallery has been set apart at the Wellcome Historical
Medical
Museum
to illustrate
the
history of chemistry, from
the
most primitive
use of still and furnace to the exact
and
elaborate
117
118
NOTES
AND COMMENTS.
Vol. XVII
methods
of the present
day.
It has been arranged in such
a mail
ner as not merely to interest or even instruct
the casual visitor
but
to inspire
the
student,
and
to furnish,
so far
as this can
be done
by
pictures,
manuscripts,
and
models,
a
graphic
outline
of
the
progress
of chemistry through the ages, not forgetting
the cloud
of
magic and superstition out of which it emerged.
On the pillars and
frieze the student
is reminded of the epochs into which the history
of chemistry may
be divided,
the
names of its pioneers,
and
the
symbolism which has been employed
by ancients
and moderns.
At
one end of the gallery there is placarded the definition of chemistry
which
appears
in Johnson's
dictionary,
and
at the other the
defi
nition which appears in Murray's.
The objects in the collection in
clude
examples
of ancient glass apparatus employed
by the alchem
ists;
these include
matrasses,
cucurbits,
alembics,
and
the like.
A
model of the alchemist's
hearth, with its pewter and stoneware,
has
been installed,
as
well
as the
" aludel " of the
sixteenth
century,
used for subliming
sulphur
or mercury,
and, in curiously
shaped
bottles,
specimens
of the elements
and their
symbols
as they
were
known
at this
period.
A
most
interesting
section
illustrates
the
history
of
perfumes
and
aromatic
substances.
The
curator
has
gathered
together
many specimens of the little containers in which,
from
Roman
times
onward,
mixtures
of
substances
of
powerful
odor
have
been carried
in
the
hope
of
warding
off plague
and
other infections.
In another
cabinet
there
is
a collection of
the
chemical
substances
known
in
ancient
times,
together with
speci
mens of alkaloids, with the names of those who isolated them,
and
the
date of their
introduction
so far as these can
be
ascertained.
Other
articles, in original
or replica,
have
an interest on account
of a particular individual; these include appliances used by Dalton
and Faraday in their demonstrations, the pneumatic
trough used by
Priestley
for collecting gases, a porcelain retort which belonged to
Joseph Black, the discoverer
of carbonic acid, old books on chemistry
which
had
been in the
possession
of the Boyle
family,
and
docu
ments
in
the handwriting
of Caventou, one of the discoverers of
quinine,
and Labaraque,
whose
name
is associated
with
the manu
facture of sodium
carbonate.
On the walls of the gallery
are care
fully chosen pictures, in oil and water-color, representing personal
ities
and
episodes
of interest
to
chemists.
Such
primary
figures
are
depicted
as
the
Greek Hermes, the
Arabian
Rhazes,
and
the
German
Paracelsus,
who insisted that
the
function
of chemistry
was
not
to
make
gold
artificially,
but
to
prepare
medicines
and
substances
useful
to .the
arts.
The
various
alchemical
processes
used in
the
search
for the " philosopher's
stone "
are
depicted
on
long scrolls by
a fifteenth century draftsman,
and
there
are many
paintings of the Dutch and Italian schools, whose artists appreciated
-No.1.
119
NOTES AND COMMENTS.
the pictorial
value of
the
alchemist
in his laboratory,
lighted
by
lurid
flames
and
heaped
up with
strange
accessories,
though their
rendering may not always have
been quite faithful.
One
interest
ing portrait
is that of Mayow,
the father of pneumatic chemistry,
who was originally a physician
; the visitor
is reminded in the same
way of Lavoisier,
and of Scheele,
to whom we owe glycerin
and.
prussic
acid;
of Dalton,
Humphry Davy,
and
Liebig,
and
many
others.
The gallery is dominated by the statue of Joseph Priestley,
the discoverer
of oxygen
and nitric and nitrous oxide.
Public drinking fountains of the "bubble" variety in which
the
spurt of water is less than 2 inches
have been banned in Cleveland
by Health
Commissioner
H.
C.
Rockwood.
Fountains
with
in
sufficient pressure
to force the water 2 inches or more
are a serious
health
menace
and
assist in spreading
communicable
disease.
The Royal Air Medical Service Rules to improve respiratory
and
circulatory
efficiency
are formulated
by Wing Commander Martin
Flack, Royal Air Force Medical
Service, in the Milroy
lectures
re
cently
delivered before the
Royal
College of Physicians
of Lon
don, on " Respiratory
efficiency
in relation
to health
and
disease."
This
system
of
10 exercises
he has
elaborated
for the
purpose
of
producing
circulatory
and respiratory
fitness, the work being based
on physiological
principles
and
observations
made in
the training
of fliers.
In the performance of these exercises
Commander Flack
lays
stress
on
the great importance of the contraction of the dia
phragm at the initiation
of inspiration,
protruding
the " pit " of the
abdomen together with
a movement
of the lower ribs, full inspira
tion being obtained
by
a wave-like
movement
spreading
from
the
lower ribs to the upper part of the chest, and on no account should
the upper part of the
chest be expanded
first.
Expiration
is
ac
complished
by the contraction of the muscles of the abdomen
and
of the lower part of the chest.
The exercises are here given :
1. In
bed.
(a)
Lying
flat,
inhale
to
the fullest
extent,
at
the same time
raising
the
hands
above
the
head in
a
natural
"stretching"
motion.
(6)
Exhale
to
the
utmost
extent,
using
the abdominal
muscles forcibly
to
press
out
as much air
as possible
from
the lungs,
at
the
same
time
carrying the
arms to the sides.
Repeat five times.
2. Using
the weight
of the bed
clothes
turned
down
to the hips as a means
of
keeping
the
legs
down,
raise
the body
from
the
hips
and
bend forward
as
much
as possible,
at
the
same
time
breathing
out
forcibly
to
the fullest
extent,
then slowly
return
to
the
lying
posture,
inhaling
deeply
meanwhile.
Repeat
five times.
3. (a)
Using
the
bed
clothes
as
before,
from
the lying position
raise the
trunk, with
the hands by the sides, through
an angle of 45°,
then twist round
120
Vol. XVII.
NOTES AND COMMENTS.
the trunk
upon
the
hips,
keeping
the
legs
flat
and
endeavor
to
make
the
forehead
touch
the bed,
meanwhile
exhaling
forcibly
as far
as possible.
(&)
By a reverse movement assume the lying position,
inhaling deeply meanwhile.
Repeat five times to right and left sides.
4. (a)
From
the lying
position,
flat
on
the
bed,
with
the
hands
clasped
behind
the head, raise
the
legs
from
the hips, carrying them
as far over
the
head
as
possible
meanwhile,
(ft)
Lower
legs
slowly
to
the fullest
extent,
meanwhile
exhaling
deeply and forcibly.
Repeat
five times.
(5)
Out
of
bed.
(c)
By
a "stretching"
movement
raise
the
arms
slowly
and strongly
forward and upward,
then lower
them sideways
until they are in
line with the shoulders,
which
are well thrown back, meanwhile
inhaling to the
fullest
extent.
Brace up the muscles of the abdomen
and all
the accessory
muscles of inspiration.
(6)
Keeping
the body as upright as possible, carry
the
arms forward until they overlap
and hold
sides of trunk ; expire
meanwhile
to
the utmost extent, working specially
the lower
chest and abdominal
muscles.
When
in the position of full expiration brace up all muscles of lower
chest and
abdominal
wall.
Repeat five times.
6. (a)
With
the feet about
18 inches apart
(or
other
comfortable
distance,
which
may
be gradually decreased
as proficiency
is attained)
carry the arms
forward, upward
and backward,
inhaling meanwhile
to the fullest extent.
(6)
Bend trunk forward and full downward,
carrying the arms between the legs to
touch the ground with the fingers
as far as possible behind the feet, meanwhile
exhaling
to the fullest extent.
Repeat five times.
7. With
the feet about
18 inches
apart
(this distance
may
be decreased
as
proficiency
is attained)
and arms raised sideways
and in line with the shoulders,
bend the trunk to the left (right) until the left (right)
hand touches the ground,
keeping
legs straight,
meanwhile
breathing
naturally
or
holding
the breath.
Repeat
five times to each side.
8. (a)
With the feet as above, carry the arms forward, upward,
and bnckward,
inhaling meanwhile
to the fullest extent.
(6) Turn and at the same time bend
the trunk to the left (right),
and touch
the ground
on the outside of the left
(right)
fast, expiring meanwhile
to the fullest extent,
(c)
Stretch
trunk up
ward
to upright position,
inhaling meanwhile
to full
extent.
Repeat
five times
to
each
side.
9. Inhale as fully as possible,
then exhale
sharply
to the fullest extent, and,
with
the
chest
and
abdominal
muscles,
alternately
forcibly
contracting
and
relaxing.
Repeat
two or three
times.
10. Stationary
running; shadow boxing; shadow skipping; rhythmic
balancing
exercises ; jumping or any other form of exercise preferred
by the subject until
out of breath.
These
exercises
take
about
10 minutes
to perform
and
should be
followed by a tepid or cold bath and a brisk rub down.
They are par
ticularly useful for those engaged in sedentary
occupations
and will
enable them to engage in open-air exertions
without
undue fatigue.
They are to be especially recommended
as requiring no special appa
ratus.— (The
Nation's Health,
February,
1922.)
We learn from the British Medical Journal of January
28, 1922,
that Dr. James Waterston, in a short monograph on " The Louse
as
No. 1.
121
NOTES AND COMMENTS.
a Menace to Man," issued by the Natural History Department of the
British Museum, gives a straightforward
account of the life histories
of the three forms of lice which prey on man and describes
methods
for their
destruction.
He insists that
the
essential
factor
in
the
spread of lice is a person who is already infested by the parasites,
and, as a rule, transference
to a clean
person
is effected by contact
of a more of less direct kind.
Contact has long been recognized as
the determining condition of disseminataion in the
case of the crab
louse, but it is no less true of head and body lice, in regard to whose
spread
many misconceptions
are prevalent among
the lay popula
tion.
The importance of close association
between clean and infested
persons
in spreading
these pests
was
abundantly
demonstrated
in
the late war, when men were crowded for long periods in dugouts and
billets or herded
together
in prison camps.
The normal activity of
both head
and body lice is found to be greater
than was commonly
supposed,
and
this is responsible
for their
spread;
but in certain
circumstances —temperature
being the
decisive
condition —lice will
leave their host without
the stimulus afforded by contact
with
the
fresh victim.
Broadly speaking, says Doctor Waterston,
body lice
tend to leave
a host
whose
temperature
rises
above or falls below
the normal;
they are stirred
to activity
by violent
exercise
on the
part of their host, and in cases of fever will be found
moving
on
the upper blankets.
Similarly after
the
host's
death
lice
appear,
sometimes
in
enormous
numbers,
while
the
body is
cooling
and
migrate to surrounding
bodies.
Typhus
fever, relapsing fever, and
trench
fever are, of course, well known to be spread by lice, while
Bacillus pestis has also been found in lice feeding on plague patients.
There
is no evidence,
however, that lice are of importance in spread
ing this disease,
although, in Doctor Waterston's
opinion,
there
is
reason to believe
that they might on occasion
do
so.
In regard to
the destruction of lice, he recommends, for lice on the body, smearing
the skin thickly with undiluted paraffin
emulsion, followed by a hot
bath
and
clean
clothing.
In cleansing
the
head
he
recommends
paraffin oil
(preferably)
or its emulsion, rubbed
in thoroughly,
the
head being afterwards
swathed
in
a tightly wrapped towel for an
hour.
Mr. A. Bacot found wood-tar oils effective.
Mr. Burt Ham
ilton
recently,
however,
pointed out in our
columns
that
the
one
essential to safety in any mixture that is to be prescribed for home
use is noninflammability,
owing to the ingrained
carelessness of the
class for which such treatment
is usually required.
He considered
paraffin
effective for institutional
use, but refused to prescribe so
dangerous
a method for home use.
The question of a suitable mix
ture for this purpose, which should
be cheap, noninflammable, and
harmless to the skin and hair, is one which merits further
study.
122
Vol. XVII.
NOTES
AND COMMENTS.
Referring to tests for color blindness in seamen, an editorial writer
in the British Medical Journal of January 28, 1922, states that until
comparatively
recently
candidates
for
certificates
as
mates
and
masters in the mercantile marine, and men working
on the railways,
were examined
for color blindness by means of pigments of different
colors.
In the
sea service Holmgren's
wools were
employed,
in the
railway
service the men were asked to distinguish
between the colors
of dots on a white card.
The dot test was employed
until quite re
cently upon the Great Western Railway,
and may even now be in use.
The Northwestern
and other railways
have for some years given up
pigment tests and used an efficient lantern.
The Board of Trade not
only prescribed Holmgren's wool test for the examination of officers
in the marine, but they also laid down the rule that candidates
were
not to be asked to name colors, but were to match skeins of wool with
three
standard,
so-called
confusion
colors.
Doctor
Edridge-Green
and others
pointed out that these methods
of testing were
open
to
grave objection, in that many who were able to match the colors were
in reality dangerously defective
in color perception, while others who
failed were not color blind
at all, or at any rate not dangerously so.
Doctor Edridge-Green
also drew attention to the fact that by none of
these tests were men eliminated for whom the red end of the spectrum
was shortened.
Such men—and there is no doubt that they exist—
are unable
to perceive
a red light of low intensity which is plain to a
normal individual.
In other words, in a fog at sea they may fail to
appreciate a red light which is obvious
to the normal
sighted.
It
is only necessary
to allude to the fight, long and
fierce,
waged
by
Edridge-Green
and his supporters with the Board of Trade.
Step by
step, in face of bitter opposition from officials,
from physicists, and
from
some physiologists
and ophthalmologists who might have been
expected to know better, ground was gained, although the Board of
Trade were supported by the Royal Society, till eventually a committee
was formed to examine the whole question.
As a result of its report,
a lantern was used in the examination side by side with the now obso
lete wools.
The battle was all but won.
The final victory coincided
with
the appointment of Doctor
Edridge-Green
as adviser to the
Board of Trade on color vision and eyesight.
Doctor Edridge-Green
has just issued his report, which lies before
us.
It is agreed that any
one who can distinguish
between
red,
green,
and white lights at a
distance of a mile has sufficiently good color perception for naviga
tion.
Edridge-Green
states that 25 per cent of men have diminished
color perception, and that
5 per cent will fail to differentiate red,
green,
and
white lights, in
a properly
constructed
lantern, or the
actual
lights
themselves,
at
a distance
of
1 mile.
We gather that,
in the opinion of Edridge-Green,
men who fail with the lantern are
No. 1.
123
NOTES
AND COMMENTS.
to be held dangerous
at sea, and those who pass the lantern test are
safe, and this no matter what degree of abnormality
in color per
ception they may show with other tests.
He says definitely that the
possession of a sense of yellow is a sure indication of safe color vision.
There are many who will not agree with that portion of the report
which deals with the Edridge-Green
theory of color blindness.
In
the main it may
be true, but there
are
some
anomalous
cases which
the theory
fails
to explain.
As regards the tests we
are
on surer
ground.
The men have to name colors shown in
a ship's sidelights
or from shore lights.
It is not part of their duties
to match
wools.
Common
sense
demands
that if the men have to distinguish
lantern
colors they shall be examined
with a lantern.
This will in future
be
done.
The Board of Trade will come into line with the Royal Navy
and the more enlightened railway
companies,
and will test its can
didates
for the work
they
have to do, and
as far as possible
under
conditions similar to those which obtain at sea.
In the Journal of the Royal Naval Medical
Service
for January,
1922,
Surg.
Commander
G.
R.
McCowen
writes
on
" Immediate
surgery with the siege guns in France."
In the first portion of the
paper
the writer describes
the difficulties under which the
surgeon
at the front works, and he gives
a brief outline of the composition,
distribution, and work of the artillery with
which
he served,
and
comments
on the conditions under which officers and men lived.
As the batteries were stationary, the medical
organization
was very
much more simple when compared
to a mobile army unit, such as the
infantry or field artillery.
Fortunately,
only
6
miles
behind
the
most advanced
batteries,
was the Belgian hospital at La Panne which
was magnificently
equipped
and organized.
This hospital could be
reached
in 20 minutes
by motor ambulance
and it acted
as an ad
vanced dressing station, casualty
clearing station, and
base hospital
all combined
in one, caring for the
wounded
of the batteries
until
such time as they were fit to be evacuated farther back.
All preparations
to meet casualties
were
based
on
the
principle
that, in advanced
units, surgical intervention should be reduced to the
minimum
and should be restricted to dealing solely with complica
tions likely to prove fatal and to protecting wounds from contami
nation.
Therefore,
as a routine, only such operations as were abso
lutely necessary were performed.
Operations for hemorrhage
which
threatened
life and
those for removal
of hopelessly
smashed
limbs
were the only ones done.
Exactness of surgical technic
gave way to
speed in order that the
cases might
be gotten
away to the hospital
as soon as possible.
103390—22
9
124
Vol. XVII.
NOTES AND COMMENTS.
The
medical
personnel
of
the siege guns
consisted
of
3 medical
officers and
17 Hospital Corps men.
Their distribution
was as fol
lows : Two medical
officers were stationed
with the foremost
section,
i. e., the senior medical officer, who lived with the group commander
and his staff in a dugout central for the foremost batteries,
and an
other medical officer who lived in one of the battery positions.
Each
was responsible
for an equal
number
of batteries
as far as sickness
and hygiene
were concerned.
The third medical
officer was respon
sible for the casualties,
sickness, and hygiene
in the rear section.
Each
battery
had one Hospital Corps man with it, with
the
ex
ception of the antiaircraft
batteries, which, because of their isolation,
had two.
The Hospital Corps men were taught to be proficient in the
following
four things:
(1)
The first-aid treatment of wounds;
(2)
the control of hemorrhage
and treatment
of fractures;
(3) the treat
ment of shock; (4) the transportation of wounded.
Each battery had its own supply of medical
stores, and the Hos
pital Corps man
on duty with
the battery was
responsible
for re
plenishing it.
Surplus supplies were kept in the foremost batteries
with
the senior medical officer,
and
at the rear with
the medical
officer responsible
for that section.
" The following were the stores
kept in water-tight
boxes in each gun position, allowing
25 men
to
each, of which probably not more than
15 would be in action in the
gunpit
at the time,
the rest being in dugouts
close by.
Thus two
gunpits being close to one another constituting
the battery, enabled
double this amount
of stores to be available, and always one lot was
close by should the other
be destroyed
by gunfire.
Absorbent
wool
pounds—
3
Gauze, aseptic
tins —
8
Oils for burns
ounces. _
10
First
field dressings
10
Bandages
(various)
40
Antigas
ampules
boxes —
10
1(Kline
tincture
ounces —
6
Safety
pins
~
20
Splints,
leg (2 Thomas's
and
2 back with foot piece)
4
Tourniquets
6
Extra supply of blankets.
Cyanide
gauze
yards —
12
Bint (white)
pound —
1
Picric
acid
dressings
5
Shell
dressings
20
Bandages
(triangular)
6
Hydra rg.
perchlor.
(solution
pellets
8.75 gr.)
20
Scissors
pair__
1
Splints,
anrr
(2, Thomas's
and 2 Bowlby's)
4
Stretchers
3
Tow for splints
pounds
5
No.l.
125
NOTES AND COMMENTS.
Besides
the
above
there
were
also
the
following
utensils:
One
bowl,
one
basin,
soap,
and
buckets
of
water.
These
stores
were
found to be ample
and to contain everything
required,
even should
the maximum number of casualties
take place at one time, as they did
on
a few
occasions,
when
an
11 -inch
shell
in
each
case
came
in
through
the embrasure
of
one of the batteries
and either killed
or
wounded every one inside.
Kach medical
officer, in addition to the above, had his own haver
sack, which
he carried about with him, the contents varying
accord
ing to his taste.
From experience
the following
stores
were found
useful and adequate and a comfortable amount
to carry :
Absorbent
cotton-wool
pound
J
Antlgas
ampules
boxes —
2
Bandages, 3-inch
10
Bandages, triangular
2
•'arbolic
acid,
pure
ounce
1
Cyanide gauze
yards—
0
First field
dressings
3
Iodine
ampules
10
I'ocket case of instruments.
Picric acid
dressings
1
Scissors
-y
Pair—
1
■Spirits,
methylated
(for
occasionally
flushing
out hypodermic
syr
inge)
ounces
4
Safety pins
2."
shell dressings
:t
Hypodermic
syringes
(1 Wlldey's and
1 Down
metal glass)
2
Injection,
hypodermic
morphia
in
Wildey's
bottle, J gr.
in
each
5
min
ims
ounce
1
Sterilized
sutures
with needles :—
Horsehair
tubes
5
Silk
do
5
Catgut
do
5
Tourniquets
3
Pituitary extract, i cubic centimeter
capsules
10
A book of tallies for wounded.
" In
addition
to
the
gun
position
and
medical
officers'
stores,
each
ambulance
carrying
four
stretchers
had
a
cabinet
specially
made
for it containing
sufficient
stores,
instruments,
anaesthetics,
etc., to perform
a major operation, should one be required, but this
was found unnecessary
and from a practical point impossible
in any
advanced
position
near
the line.
Besides
the
impracticability
of
Informing
any elaborate
surgery, it was found
impossible
to get
amlmlances
up to advanced
positions during
the shelling, and only
'luring a lull were they able to approach near the positions, and then
only to collect the wounded
with the minimum amount of delay
and
convey
them to the hospital six miles in the rear."'
126
Vol. XVII.
NOTES AND COMMENTS.
Communication
was by means of telephones,
ground wires being
laid
to
exchanges,
so that all
batteries
were
able
to
communicate
with
each other.
Each medical officer was supplied with
a motor
cycle
which
greatly
facilitated
his
rounds.
Two
Sunbeam
am
bulances
and one light Ford ambulance
served
the unit.
The Ford
car was used to evacuate cases from certain advanced
batteries
where
the
heavier
Sunbeam
would
run
the risk of stalling
in
the
sand.
The immediate
treatment of casualties
encountered
is considered
by the writer under the following
headings: (A) General treatment,
(B) Local
treatment
with reference
to special
wounds.
The majority of the casualties
were caused by fragments of " high
explosive
shells"
which in the case of large shells
were apt to tear
off a limb or crush it to pulp.
The mere explosive force of the gases
of
a large shell exercise
great
power of destruction and
a few men
were
severely
injured
by
the
expansion
of
the
gases
alone.
The
wounds
caused by high-explosive shell
fragments are infinitely vari
ous, so that it is not possible to describe
a characteristic shell wound of
a type.
All shell fragments tear away parts of the clothing and carry
them into the depths of the wound.
The large
fragments tear large
masses
of skin and muscle
away
from the limbs and trunk,
so that
the whole of 'the calf or the front of the thigh, or the gluteal or deltoid
regions
may
be destroyed,
and the tissues from which they have been
avulsed
are themselves
so crushed
and lacerated
that all the vessels
are pulped and extensive
areas die.
In the neighboring tissues there
is widespread
contusion
and extravasation of blood,
and,
as a result
of these injuries,
the exposed muscle often
loses all its natural char
acteristic appearance
and looks like a mass of mud, and as it is quite
dead, it may
be cut away without causing pain or bleeding.
The condition of the
wounded
man himself
is greatly influenced
by the time that elapses before
assistance arrives, by the amount of
blood
lost, by exposure
to cold and wet, by want of food and drink,
and by exhaustion
from lack of sleep.
Most of the wounded were
found with some degree of shock.
Three factors in the general treatment of wounds which have to be
combated in their early stages, and which react on one another in a
marked degree are shock, hemorrhage,
and sepsis.
Shock was generally due to the combined
action
of several causes,
among which the most common
were hemorrhage; exposure
to cold,
wet, and hunger, and fatigue; pain and anxiety; the presence of mul
tiple injuries,
particularly
those complicated by compound
fracture
of the femur.
Next to the actual injury, unavoidable early handling;
and transport of the patient were found to be potent
factors in pro
ducing shock.
It was soon learned that the good
work of an ad
vanced unit rests on attention to the various causes of shock rather
than on the performance of surgical operations.
No. 1.
127
XOTES
AXD
COMMENTS.
The methods
employed
by the medical officers with the siege guns,
were the protection of the injured man against cold by the liberal use
of blankets, both under him and over him. the avoidance
of exposure
by unnecessary removal of clothing, the administration of morphia in
large
doses, the quenching of thirst
by
hot drinks,
and
finally
by
gentle handling.
The following method of folding blankets
in order that the maxi
mum advantage
may
be obtained
from them was used by practically
all army
units in France
and
is worthy
of
remembrance.
"Two
blankets
are laid on the stretcher,
each with a double fold correspond
ing with the width of the stretcher.
The breadth
of the blanket is
used,
as it is sufficient
to reach
from the foot to the pillow of the
stretcher.
Xo part of
the blanket
is
placed
under the pUlow,
as
here
its objective would
be
wasted.
If
they
ore
not
found
long
enough to reach well down
to the foot of the stretcher they need not
be made to exactly coincide,
but the upper one may be placed slightly
higher
on
the stretcher
than
the lower one.
When not in use, the
free portions of the two blankets
may
be rolled up and laid on the
stretcher.
When
required,
the
free
portions
are
opened
out,
the
patient is lifted onto
the two
double
folds, and
the free portion of
each blanket wrapped around him.
The ends of the blanket at the
foot of
the
stretcher are
tucked
in underneath
the
feet.
He
has
thus four
thicknesses
of blanket beneath
him and two on top.
In
rainy weather
a mackintosh sheet is added to protect
him from fur
ther wet. If a third blanket is available, it may
be folded along its
length and placed
over him, the lower end being
tucked
well in be
neath the feet and the two corners brought round and secured above
the legs by
a safety pin.
This third blanket is, of course,
applied
to
the
patient
before
the
free
portions
of
the two
blankets
are
wrapped
round him.
He has now four thicknesses
of blankets above
him
as well
as
below.
By this procedure
the maximum
benefit
is
obtained by using blankets
in this manner, and
also when
thus
ad
justed they do not work out of position as often happens
when other
methods are employed."
With the siege batteries
on the Flanders
coast,
where
casualties
were
generally
caused
by
high
explosive
shells
of
large
caliber
lacerating
the
tissues
and
pulping
the
vessels,
severe
hemorrhage
was not common; still one had alwa\rs
to be prepared
"for it.
" The
majority of external hemorrhages
can be controlled by firm pressure
with
a pad over the bleeding
point, at least until
a field
ambulance
fT hospital
is reached,
where it can be thoroughly
dealt with.
Such
i pad
can
be made
from
a first field
dressing,
or. if necessary,
two
held dressings,
one
on top of the
other.
The
unnecessary
use of
tourniquets
should
be
avoided,
as limbs
may
be
lost by the indis
criminate
use of them.
The application of a tourniquet to any
case
128
Vol. XVII.
NOTES AND COMMENTS.
of
hemorrhage
must
always
be
regarded
as
a
purely
temporary
means.
Every patient on whom a tourniquet has been placed should
have
the fact clearly
indicated
on
the tally,
and
be
evacuated
as
promptly
as possible.
With
regard
to tourniquets, the
use of the
round rubber one is strongly advocated in place of the web tape with
buckle,
as it is more easily applied
and more
effective.
If circum
stances permit, severe hemorrhage
should always be tried to be con
trolled by seeking
for the bleeding vessel and ligaturing
it,
and, if
necessary, enlarging
the wound to do so.
If this
is
impossible,
due
to circumstances,
or delay entailed,
or lack of surgical facilities, and
if packing fails in such
a
case
and
a
tourniquet
is
out of the ques
tion—such
as in
a
wound of the neck—the wound may, if possible,
be closed by sutures
embracing the skin, fascia, and muscle,
and so
converting
the
case into
one of diffuse traumatic
aneurysm,
in the
hope that the pressure
will
prevent
further
loss of blood.
"Any wound of
a
limb in which bleeding has had to be specially
controlled should
be splinted,
as sudden
movement
or jarring will
often restart bleeding that has only been temporarily
checked.
"A type of wound which, though possibly
it
may not appear to be
severe,
is
likely to give
rise to serious
results,
is
one in which there
is
a
slow, continuous oozing that
is
at no time sufficiently rapid to be
regarded
as severe hemorrhage,
but which in
a
long run may cause
more
loss to
a
patient than
a
brisker
hemorrhage
that has received
prompt treatment.
Such
a
case may not be in danger of death from
bleeding, but he will start his fight
against
sepsis
severely
handi
capped,
for hemorrhage,
shock,
and sepsis go hand in hand."
The sepsis
most to
be
feared
was
gas gangrene,
but fortunately
it
was not common with the siege batteries,
due to their location in
the sand dunes of Flanders, and to the fact that evacuation
was very
quickly
accomplished
and
the man
reached
the operating
table at
La
Panne
within
an hour
of being hit.
At this hospital
every
wounded
man was given
a
prophylactic
dose of
1,500 units of anti-
tetanic
serum
as soon as he was admitted.
With the siege guns, iodine was used for cleaning the surrounding
skin and outside of wounds,
but with the infantry
a
3
per cent solu
tion of picric acid in alcohol was used and,
it
was claimed,
with
bet
ter results.
In the majority of the cases
the only dressing was the
application
o'f
a
very large " shell-wound dressing."
All fractures were immediately immobilized in splints before re
moval of the patient.
The earlier
a
limb
is
immobilized the better
;
shock
is
diminished
and
the patient stands
a
better
chance for his
life.
For
fractures of
the
humerus,
the small Thomas's
arm splint.
Jones's extension
humerus
splint,
and the Depage
modified
humerus
splint were the most popular.
No. 1.
129
NOTES AND COMMENTS.
Fractures of the femur were the most important of all.
Early in
the war the mortality from this injury was 90 per cent, but with the
use of Thomas's splint it was reduced
to about
15 per cent.
These
splints were supplied to advanced
posts
and
were applied
without
removing either trousers or boots.
If no Thomas's or Listen's splint
was available the following im
provised means of temporary fixation in a case of fractured
femur
was
found
useful: "A
puttee
or
bandage
was
passed
under
the
perineum and round the handle of the stretcher opposite
the injured
side at the head of the patient, pulled tight and tied.
Another band
age
was then
passed
by means of
a clove-hitch
around
the
ankle
of the injured
leg, extension
applied,
and
the bandage
tied to the
handle
at the foot of the stretcher
on the same side
as the injured
thigh.
A couple
of splints
were then
fixed
to the broken thigh by
bandages
or tapes.
Finally, the toe of the boot of the injured
side
was connected
by a bandage or puttee to each handle at the foot of
the stretcher.
This kept the foot stationary and prevented
rocking
from side to side.
An additional
bandage
was generally put around
the hips and stretcher
to keep the pelvis firm against the latter."
The British Medical Journal of January
21,
1922, comments
edi
torially
on the sources of vitamines.
Though
the chemical
nature
of vitamines
is still unknown, recent researches have thrown light on
the conditions under which they are formed. It has generally been
assumed
that plants
can
synthesize
vitamines, but doubt has
been
cast upon this by various workers.
Bottomley
stated
in
1916 that
certain
plants
obtained
these
accessory
food
substances
from
the
growth of certain organisms in
the soil.
Recently Williams
and
other workers
have gone further
and
have claimed that vitamines,
and especially the water-soluble vitamine B, are necessary
for the
growth of yeast and other microorganisms.
These
statements
made
it very difficult to conceive
where
and how the vitamine supply
of
the world
was
produced.
Fortunately
recent
work
has cleared
up
this question.
Nelson, Fulmer,
and Cessna
(Journal of Biological
Chemistry,
77, xiv, 1921), grew yeast for a year on a medium com
posed of inorganic salts and, cane sugar ; they made subcultures every
other day,
and
calculated that the final solution only
contained
a
minute portion of the original constitutents of the medium
or yeast.
The yeast thus grown
on
a synthetic diet was found
to contain
a
normal
amount of
vitamine
B.
Harden
and
Zilwa
(Biochem,
Journ..
438, xv,
1921),
also
showed
that
yeast
grown
on
a
pure
synthetic
diet contained
almost
as much
vitamine B as yeast grown
under normal conditions.
130
Vol. XVII
NOTES AND COMMENTS.
These experiments
seem fully to establish
the contention that yeast
can grow freely without
any supply of vitamines, and
that it can
synthesize
vitamine B
from
a diet of inorganic
salts
and
sugar.
Yeast
does not synthesize
the fat-soluble vitamine A, but the origin
of this vitamine appears
to have been demonstrated
by recent experi
ments of Coward and Drummond.
(Biochem. Journ., 530, xv, 1921.)
These
observers
showed that dried seeds contained little vitamine A,
and that this amount
was not increased
by germination, but that as
soon
as
the
seeds
formed
green
leaves
a
considerable
amount of
vitamine A appeared.
Experiments
made with Tradescantia shoots
grown
on
Sach's
solution
also
showed
that
green
plants
could
synthesize
vitamine A
from
inorganic
salts.
The
production
of
vitamine A was shown to be dependent
upon the presence of chlo
rophyll
in plants, for etiolated
seedlings
contained
no vitamine A,
nor did white leaves from the interior
of cabbages.
In green
sea
weeds, containing chlorophyll,
vitamine A was present, but red sea-
Aveeds contained
none.
Mushrooms
were
found
to
be
almost
com
pletely deficient
in vitamine A.
It appears,
therefore, that the pres
ence of chlorophyll
is essential for the synthesis
of vitamine A, and
that chlorophyll-containing
plants can synthesize
vitamine A when
fed on
a pure synthetic diet.
The
chemical
nature of vitamine A
is still unknown.
Coward
and Drummond found that it could be extracted
by fat solvents from
green leaves and that it appeared
in that fraction of the fat which is
resistant to saponification.
Vitamine A was at one time believed
to
be one of the yellow plant
pigments.
These
plant carotinoids
are
the
source of the
lipochromes which
produce
the yellow
color of
animal fat, and,
as
a general
rule, those animal fats which contain
most
lipochrome
also contain
most
vitamine A.
Various
workers
have shown,
however,
that this association
is not constant
and that
the association
between lipochromes and vitamine A is probably
ac
cidental.
These
researches
give
a fairly
clear picture of
the vitamine ex
change in living organisms.
Vitamine B is synthesized
by all forms
of plant life, whilst vitamine A is only synthesized
by plants con
taining
chlorophyll.
Fishes
and
whales
obtain the rich supply of
vitamine A present in their oil either directly or indirectly
from the
chlorophyll-containing
algae
or
from
the
chlorophyll-containing
organisms which passively float in water.
Land animals derive their
vitamine A supply from the green vegetables.
The source of the vitamine A in milk has been shown very clearly
by Drummond,
Coward,
and
Watson.
(Biochem. Journ.,
540, xv,
1921.)
They
measured
the vitamine content of the milk of a herd
of
cows
from April
to July,
1921.
The
animals
were
stall
fed
until
the
end
of April,
and
in April
their
milk
contained little
No. L
131
XOTES
AXD
COMMENTS.
vitamine A : after
the
cows
had
been
a
week
at grass
their milk
Yielded
a high
content
of vitamine A, which persisted
during May
and June.
The drought last year spoiled the
pasture,
however,
so
that in July the
cows had to be fed on cake,
and
the vitamine A
content of the milk at once dropped.
A quantitative
study of the
vitamine
A
content
of butter
showed
that during
the
process
of
butter making a certain amount of vitamine A disappeared,
but that
butter could
be stored in tins for many
months
without
any marked
diminution
in vitamine content.
The conclusion
was drawn that the
vitamine A content
of butter was much
more
dependent
upon
the
reason at which the butter was made than upon the length of time
for which it has been
stored.
This conclusion
is obviously of great
practical
importance.
The
cow
can
only
secrete
in
its milk
the
vitamines which it receives in its food, and
the milk or butter of a
cow
fed
on
a vitamine-poor
diet will contain very little
vitamine.
Our knowledge
of the importance of vitamines has emphasized
the
necessity
for obtaining
fresh
milk
in which the vitamines have
not
been destroyed,
but
now it appears
that it is equally important
to
obtain milk from a cow receiving
a vitamine-rich
diet.
Drummond
and his fellow
workers have
examined
also the vitamine A content
cf the body fats of animals,
and in this
case
also they
found that
the fat of
a stall-fed
animal often
contained
very little
vitamine
A; whilst
on the other hand,
the fat in tinned beef
obtained
from
grass-fed animals was often rich in vitamines after
many
months'
storage.
These
conclusions
as
regards
the
vitamine
content
of
tinned
foods apply only to fats which have been stored under good
conditions,
and
are probably true only for the
case of vitamine A,
which is more stable than either vitamine B or C.
It is. of
course,
a matter
of
extreme
difficulty
to
preserve
vita
mine C;
the
only
substances
in which
this vitamine
is
preserved
for any length of time are the fruit juices, and even from them the
vitamine slowly disappears.
Harden and Robison (Biochem. Journ.,
521, xv,
1921)
found that when
dried
orange
juice
was
stored
in
a desiccator for
15 months it lost
50 per cent of its vitamine C con
tent,
and
dried
orange
juice
kept under ordinary
conditions
lost
s5 per cent of its activity.
The supply of vitamine A and vitamine
C therefore
appear to present two separate problems.
In the normal
adult there is really no problem,
for an adequate quantity of green
vegetables
in the diet provides a full supply of all three
vitamines.
In the case of bottle-fed babies, however,
the supply of vitamine A
appears to depend chiefly upon the diet on which the cows supplying
the milk
are
fed, while
the supply
of vitamine
C is determined
chiefly by the treatment
which
the milk undergoes
during
its pas
sage from the dairy to the infant.
The conclusions
of Coward
and
Drummond
certainly
suggest that during
the winter it is desirable
132
Vol. XVII
NOTES AND COMMENTS.
to add cod-liver oil, or some other rich source of vitamine A. to the
food of infants
on
a milk
diet.
The British Medical Journal of January
14,
1922,
makes
the fol
lowing comment
on Moliere
:
" Jean Baptiste Poquelin,
who when
he became author and dram
atist assumed
the nom
de
theatre
' Moliere.'
was horn in Paris
on
January
5, 1622— at least, his baptismal
certificate
bears that date.
His father, who was upholsterer to Louis XIII, came of a prosperous
bourgeois
family of Beauvais, and
there
was once
a tradition
that
some
remote
forbear
was
Scottish.
Of
medical
practice
in
his
day Moliere
was a bitter critic.
He first satirized physicians in his
farcical
comedy Le Medecin malgre lui, and returned to the attack
in L'Amour Medecin.
His last comedy
was Le Malade Imaginaire,
in which he himself
played the part of the sick man
when it was
produced
for
the
first
time
on
February
10,
1073.
During
its
preparation
and
rehearsal
he
had
been suffering
from
cough
and
haemoptysis,
and
before
the third representation,
on February
17,
he was so ill that he was advised
not to act.
He did act, however,
but during
the performance
a violent paroxysm of coughing
came
on and
he was carried
away
dj-ing from
the theater
to his house.
Fielding's version
of Le Medecine
malgre lui, bearing the title
of
' The Mock
Doctor,'
was first produced in
1732.
In
a later
play,
M.
de Pourceaugnac, Moliere gibed at the physicians, and there can
be little
doubt that lie suffered
much
at their hands
during his long
illness.
The physicians and
apothecaries
of the day could not for
give
Moliere
his
bludgeon blows;
but
in
exposing
humbug
and
formalism
he was a true friend of medicine,
and medicine
will join
with the other arts in celebrating the tercentenary
of the great French
dramatist."
The United
States
naval hospital
at Olongapo, P. 1., was placed
out of commission
on February
15, 1922.
There are comparatively few people- in or out of the medical pro
fession, who know how enchanting a writer was the late Dr. William
Osier, that great Canadian diagnostician and teacher
whose brilliant
and many-sided career came to an end just
a few hours before the
close of the year 1919.
Why is not Doctor Osier more widely
read
to-day?
Why are not those writings of his, covering a great range of
subjects
beside
those
pertaining
to
medicine
and
medical
history,
better known to the general public ?
There are several
reasons.
The chief of these is that his fame as
a physician
and
scientist completely overshadows
his fame in any
other direction,
and
as
a result
the
general
reading
public
shies
No. 1.
133
NOTES AND COMMENTS.
away from his books.
It is well nigh incomprehensible to the public
that a great scientist can write anything that is not of the dry-as-dust
category.
The public has a deep and abiding abhorrence of anything
too deep, and does not like to take chances on the product of a man
with the reputation
of
a profound
thinker.
He
is never
given the
credit of versatility
and moods.
The taint of superhigh-browism
is
on him and
he remains
a sealed book
to all and sundry
outside
the
inner circle.
Doctor
Osier made
the
mistake
(?) of becoming
too
renowned in his line of work.
He was
quoted
too
much
and
dis
cussed too much
in print— perhaps,
during
his life, more than any
other
physician
the
world
has
known.
The
fact
that
he
was
a
physician,
and a great one, was burned into the public mind on divers
occasions,
especially after the odd
circumstance
at Baltimore
which
brought into being the verb " to Oslerize."
It killed his chances, for
this generation, of becoming
a best seller
even in, that neglected
de
partment
of literature
in which
he
excels.
It
associated
him, for
the time being at least, in the mind of the average
man
as one of
those
intellectual
giants
whose
processes
are unintelligible
to
the
common
run of men.
He
has failed of popularity
as
a writer for
the same reason
that
an intellectual
drama
fails while
a girl-and-
music show next door succeeds.
He requires
too much
involuntary
concentration.
Men.
alas,
are slow in finding
the treasures
that lie close
about
them.
Perhaps
by the time the Osier centenary
is celebrated
things
will have changed.
The human mind and intellectual appreciation
will have
progressed
to the point
where
fame in one direction will
not hamper fame
in another.
Or perhaps Doctor
Osier's
fame
as
a physician will by that time
have
become
so dimmed,
outside his
profession, that the public will think of him first and last as a writer.
That sort of thing
has happened
frequently.
If it happens
in the
case of Doctor
Osier it will
be an approbation of his work that is
justly
deserved.
Doctor Osier's writings
are many and varied.
His bibliography,
covering
a period of
49
years,
comprises
no
less than
730
titles,
including
his
collected
essays
and
addresses,
according
to
Dr.
Harvey Cushing,
his biographer.
" His charm
as
a writer,"
says
Doctor Cushing, " had much to do with his great success as a teacher.
*
*
*
His Textbook of Medicine
(200,000 copies)
was translated
into French, German, Spanish, Chinese, and other languages.
*
*
*
It remains
the most used and most useful book in medicine to-day."
Doctor Osier was extremely fond of literature and of literary allu
sion.
He was an omniverous reader, and, having a retentive
memory,
his mind was stored with quotations and incidents.
It was
a quo
tation
that brought
about
the
famous
60-year
deadline story that
made him the talk of two continents.
In his farewell address at Bal
134
Vol. XVII.
NOTES
AND COMMENTS.
timore, where
he had been connected for 16 years with Johns Hop
kins University,
he quoted from The Fixed Period,
one of Anthony
Trollope's
rarer
novels,
in which
the theory
is
advanced
that
the
greatest work of man
is done before
he reaches 40 and that it would
benefit
society in general if chloroform
were administered to all on
their
reaching
60.
This
is how he happened
to
be misquoted
as
to chloroforming
all men
over
60.
In quoting Trollope he jested,
trusting
to his hearers,
as well he could, confidently enough
to un
derstand that he knew
as well
as they did that the utility of man
has no such limitation.
He was himself
55 years old at the time and
his remaining
15 years were years of great activitj* and his greatest
influence. — (New York Medical Journal, February
1, 1922.)
Possibly
the days of the "master"
and "disciples"
in medicine
are passing or have passed, and with wider dissemination of special
ist teaching the world over the delights of a continental Wunderjahr
will be less frequently sought; but no one who has sojourned in the
ancient
becastled
tow7n by the Neckar will forget Erb and Nissl, or
admit that stay
at homes can ever
sense
the fascination
of contact
with
master
minds of foreign
schools, under foreign
skies, in
days
when receptivity is at its maximum and when the chosen career
is at
its opening.
For this reason, if for no other, the death last month of
the veteran
neurologist of Heidelberg, Wilhelm Erb, can not be al
lowed
to pass unnoticed, though
a
new generation of neurologists
has arisen
to whom
he must
be little
more than a name.
It is true
that in Erb's birth
palsy
and in the Erb variety
of myopathy
we
have a means of perpetuating his memory,
but these serve but feebly
to indicate the prominent part he played over many laborious
years
in
the
development
of scientific neurology
and
in that
movement
which has led to its commanding position in medical
studies
to-day.
The student now entering on his curriculum
finds in nearly
every
hospital
a neurological department, or at least one teacher of medi
cine who devotes himself largely to neurology;
and he can have little
or no idea of the epoch when
the voice of the pioneer was
as of one
crying in the wilderness.
It was in 1865,
as assistant
to Friedreich,
that Erb
began his career
in neurology,
and
succeeding
years saw
him establishing, by exact clinical observation and equally important
classification,
the
foundation
of scientific neurology
in
Germany
;
myotonia,
myasthenia, muscular
dystrophy,
intermittent
claudica
tion, the syphilitic etiology of tabes dorsalis
and
of certain
para
plegias, were all differentiated
and
elaborated
and
erected
on
sure
foundations,
and this before
modern
methods
of investigation
came
into vogue.
Erb was, after Duchenne of Boulogne, one of the first
to employ electricity for purposes
of diagnosis
and treatment;
his
No. 1.
185
NOTES
AND COMMENTS.
" Elektrotherapie " appeared
in 1875, and his diagrams of the motor
points have since then reappeared
in textbooks
time without number,
until, indeed, one may suppose they are one of the few things which
will never
be
better
done.
From
a note
in
the Miinchener
medi-
zinische Wochenschrift
we learn that no fewer than 237 publications
stand to the credit of Professor Erb, that he had in the course of his
life's work
no less than
61
assistants,
and that it was said of them,
* Untersuchen
konnen
die Erbschen Schiiler alle."
From such data
we may
better
understand what Erb's school
meant
to neurology,
what stimulus to research, what inspiration
and enthusiasm; we may
compare
it,
indeed, in respect of scientific and clinical attainment, to
that of Charcot at the Salpetriere. — (The Lancet. January
7,
1922.)
It
was
formerly
taught that yellow
fever was
endemic
in West
Africa,
but
the
recent
commission
of
the
Rockefeller
Foundation
which traveled through West Africa from Senegal
to the Congo had
<rreat
difficulty
in finding
there
any
account
of
recent
epidemics,
such as have
occurred
in the Southern United
States
and in South
America.
The
commission —of which
General
Gorgas
was
presi
dent till he died,
when
his place
was taken
by General Noble who
had worked with him at Panama— had the advantage
of the cooper
ation of Dr. Juan Guiteras, of Havana,
whose life's work has been
with yellow fever.
At the present time yellow fever
is
found chiefly
in
South American ports where
temperature
is
higher than in West
Africa, where
there are more mosquitoes,
and where
there
are many
white
people.
Negroes
and their children
have
a
marked
immunity
to yellow fever, and
it
is
only where,
amongst
the blacks,
there
are
many
susceptible
white
people
that
a
considerable
epidemic
can
arise:
and
only
in
a
place
which
is
a
great center
of trade
and
visited
by many strangers can repeated
epidemics
occur.
Like sev
eral other communicable
diseases, yellow fever rather quickly infects
those susceptible
and
is
brought soon to an end by the raised
resist
ance of
the community,
unless
fresh
nonimmunes
are
continually
coming into
the
area.
The cleaning up of the American
endemic
areas with the destruction of mosquitoes,
and
the disappearance
of
the
sailing
ships
which
carried
infected
stegomyia
from
port
to
port are the chief agencies which have led to the disease dying out in
West Africa.
Prof.
W. H.
Hofmann,
of
Havana,
is
of
opinion
that the best proof that yellow fever
is
not longer endemic
in West
Africa
is
that no outbreaks
occurred
there during
the war, though
so many susceptible
white men
were
sent to the
region.
He men
tions that Doctor Guiteras, with his large experience,
does not sup
port Noguchi in claiming Leptospira
icteroides
to be the cause of the
fever.
Noguchi
has,
however,
recently claimed that the injection
136
Vol. XVII.
NOTES AND
COMMENTS.
of killed
cultures has definitely
protected
thousands
of susceptible
persons
in
Central
and
South
America,
while
the
immune horse
serum, if used before
the fourth
day,
has
a curative action. — (The
Lancet, January
7, 1922.)
Before the war the bacteriologist always obtained
his stains from
Germany.
That country
was supreme
in the field
of aniline
dyes.
While other countries were wasting their coal tar Germany was con
verting this valuable and unsightly
material into all sorts of drugs
and into dyes of all the shades of the rainbow.
One German, more
over, realizing
the laboratory
uses of the dyes, took it upon himself
to purify
and standardize those
dyes which the bacteriologist
and
biologist
particularly
needed.
It was
a very small
business
com
pared
to the textile dye industry,
but the whole
world
was his mar
ket and his business flourished.
When the war broke
out and the stock of these standardized and
reliable
German
stains
already
in
the
country
gradually
became
exhausted,
the
bacteriologist
had
a
hard
time
finding
what
he
needed for this important
work.
The
American
dye business
was
born
to meet the emergency;
but the
dyes
made in America
were
particularly
textile dyes and ordinarily were not suited
to the work
of the bacteriologist.
Finally,
one or two men in the business tried
adapting their
dyes to biological
purposes,
and very shortly
after
wards several other companies
started to do the same thing
so many
in fact that none of them made
a satisfactory profit and their prod
ucts differed so much
that no two samples of the same
stain could
be counted
on to give
the same result.
The
first
attempt
to
standardize
these stains
was
made
by the
Society of American
Bacteriologists.
With
the
assistance
of cer
tain dealers in biological stains they have been working
on the mat
ter for
about
a year and
find that American
manufacturers
have
already met the bacteriologist's needs in an admirable way.
A little
standardization
is all that is now needed.
The work that has to be
done in this way by the bacteriological society appeared
so important
that the National
Research
Council of Washington,
D. C, offered
to
take it over
so as to put it on a broader basis and place facilities
at
the
disposal
of
the
worker
which
were
not available
to
the
bac
teriological
society
alone.
Under
this
new
arrangement the work
has
been
organized
on
a broad basis,
with
the cooperation of the
Department of Agriculture and several of the large national scien
tific
socities
besides
the
Society of Bacteriologists.
The
hope of
the
committee
in
charge
of this work
is
not
only to standardize
the
stains
and
to secure
American
products
as
good
as Germany
can
produce,
but
to
secure
the
production
of biological
stains in
this country
decidedly
better
than those available
before
the
war.
NURSE CORPJ-.
WHAT IS PROFESSIONAL
ETHICS t
One of the questions
frequently
asked
the applicant for appoint
ment in the Naval Nursing; Service is " What is meant by professional
ethics?"
From
the
answers
received,
which
convey
such
varied
meanings, it would
seem
that the word " ethics " is losing some of
its fullness.
A protesting patient recently exclaimed
" What is this
■professional
ethics ' which
hampers
my
choice
of physician
and
nurse
and
which
further
hampers
me if I
desire
to
change
my
physician or nurse?"
The
general
definition
of
ethics
is probably
summed
up in
the
statement
that we mean those rules which govern
actions
relating to
the
duty
and
discipline
demanded
by
the
profession
or vocation
with which we are identified.
Since
the inception of a nurse body
there have been certain principles which are the ethics of our calling.
In teaching
the meaning of professional ethics,
we become aware of
confusion in the minds of those who have preceded
us produced by
a more or less successful
training
in social
ethics.
The term should
not be confined
to social
or professional
customs
which
have
been
established
by
the consensus
of opinion.
The history of our pro
fession, or vocation, points significantly
to the influence
exerted
by
religious bodies.
This is especially true of the nurse
standards in
Germany
and
England
from
which
countries
we
received
the
incentive
to
establish
our training
schools.
The
history
of
the
evolution of the hospital
shows
the recognition of the
necessity
of
religious teaching to develop
moral standards.
Here we find the ethical principle of authority with the responsive
obedience among those who took unto themselves
the care of the sick.
Religion formed the background and gave to us the rule that though
a cure could not be effected, the patient could be given care and com
fort in dying.
Without the religious background and the voluntary
service of the religious sisters trained from childhood by the church
in self-denial,
we of the present day have our background in teaching
in the homes and the training of schools and colleges.
It may
be safely
affirmed
that the resulting
development
of our
training attains a success in proportion to the strength and soundness
<>fthe foundation.
" Ethics."
therefore, if so well understood, as to
an intrinsic part of the nurse, is not learned from a definition, but
137
138
Vol. XVII.
NURSE
CORPS.
from an absorption of the idea that discipline
is necessary to develop
thoughts and actions in relation to others.
The result is respect for
teachers, thoughtfulness toward
associates,
and, in the struggle
for
mastery
in any line of endeavor,
mental
development,
and formation
of character.
When this home background is lacking the understanding of ethics
is
so slowly
absorbed
that
the professional
knowledge
is
obtained
before
the spiritual
nature has developed,
and the practical prepara
tion is accomplished
while the qualities of heart
and mind are absent
or unawakened.
Some vocations
demand
a greater
accountability than others.
In
the
profession
of
nursing
the
existence
and
development
of
the
ethical principle
is a fundamental necessity.
The conception
of the
ethics of nursing, therefore, is the development
to the point of un
conscious
possession of the characteristics which every nurse
should
possess,
to
spend
and
be
spent
for others:
Truthfulness,
not
the
studied
correctness,
but involuntary
truthfulness;
obedience
in
the
meaning of " dutif ulness ; " respect for those in authority, one of the
first lessons taught by Christ
; gentleness in speech and manner ; con
trol of
tongue,
abstaining
from
destructive
criticism.
" Thoughts
Unexpressed
may
sometimes fall
back
dead, but God himself
can't
kill them when they're
said."
When these characteristics have
been
acquired
there will
follow
self-respect,
dignity,
observation, judg
ment, and tact.
Where these characteristics have been
implanted in
the home life the correct
conception
of professional ethics
is innate.
The
defect
in the foundation
can only
be fortified
by efforts well
directed
on the part of those in authority
; and conscious
rebuilding
without
resentment
or animosity,
on
the
part
of
those who
have
chosen the profession of nursing for their field of work.
The incul
cation
and the willing conception
of right principles will innoculate
our profession with the knowledge
that ethics and ethical standards
rest in
a rooted
feeling that to realize
our greatest
ideal
we
must
toil and work for the development
of our lives in relation to others.
Nothing perfect is given to us ; each day we must take up the struggle
and live the highest that is given us to live; working, not despairing:
not rebellious, but having
a mind
open
to
every
new
and
worthy
experience.
The following citations were inadvertently
omitted from the list
of those receiving honors or distinctions
published in the January
issue of the Bulletin :
" Certificate of citation for exceptionally meritorious and conspicu
ous service at Navy Base Hospital
No. 1, bestowed upon Miss Frances
Van Ingen, chief nurse, United
States Navy.
I
Vol. XVII.
139
NURSE
CORPS.
"The Elizabeth
medal
of Belgium
presented
by the Queen of the
Belgians on the U. S. S. George
Washington to Miss Sophia V. Kiel,
chief nurse, United
States Navy, in appreciation of her work and also
of the work of the American nurses during the war.''
Recently
the Bureau of Medicine and Surgery
has been presented
with an historic flag which was used when the hospital of base No.
1
was commissioned
in Brest.
The flag hung in the office of the chief
nurse of the unit, Miss Frances Van Ingen, of New York, who was
also the chief nurse of the hospital,
and
has been presented
to the
bureau.
When
Brest
was
in
gala
array
on
the
occasion
of
the
armistice this flag was used in the decorations.
When
one opens
the door of the
office of the superintendent of
the Navy Nurse Corps this flag is the first object which
meets the
eye.
Just
beside this flag, which shows marks of service,
hangs
the
beautiful
banner
of the Navy
Nurse
Corps,
which
was
presented
by the Sixth Division, and which has been used in various official
parades where the Nurse Corps was represented.
After viewing the flag and the banner,
the eye travels around the
wall, resting on the various groups of members of the Navy Nurse
Corps on duty at many
of the hospitals in the United
States.
He
is a rare visitor who fails to notice
and make favorable comment
on
these photographs showing the nurses in their uniform of the Navy
Xurse Corps.
103390—22
10
BOOK
NOTICES.
Publishers submitting
books for review are
requested
to address
them
as follows:
The Editor,
L\ S. Naval Medical
Bulk-tin,
Bureau
of Medicine
and
Surgery.
Navy
Department,
Washington,
D. C.
(For
review.)
Books
received for review
will
l>e returned
in
the absence of directions
to
the contrary.
REVIEWER.
Lieut.
Commander
W.
M. Kerr,
Medical
Corps,
United
States
Navy.
"A little music,
a choice picture or tiro, and a shelf of good books
ritnrk a real home, for they distinguish
those ir-ho appreciate the finer
things in life from those who don't."
Medical
Service
in Modern
War, by Lieut. Coli. P. S. Bond
and C. F. Martin,
ilftlieal
Corps,
L". a. Army.
George
Banta
Publishing
Company,
Menasha,
Wis., 1920.
This is an admirably written pamphlet of 76 pages delineating the
functions
and
tactical
employment
of Army Medical
Department
formations
and units in a modern
campaign.
The
surgeon
with the combatant
forces
in modern
warfare
must
be more than a surgical operator.
He must be well versed in admin
istration.
He
must
be
forceful
and
able
to organize
and
direct.
Above all, he must
be a tactician with the ability
to foresee coming
events.
With this in view, the authors have described,
in a general
way. the functions of the medical
department of an army in the field
;
the medical equipment
of divisions, corps, and army ; the evacuation
and treatment
of sick and
wounded,
and
medical service
in
open
warfare.
When the United States entered the World War, the Army adopted
an organization which
was
a compromise
between
American
ideas
and those of our Allies.
This organization proved to be satisfactory,
although it was by no means perfect.
This treatise
is based upon it,
but since the war a number of changes have been agreed upon which
141
Ii2
Vol. xvir.
BOOK
NOTICES.
appear
to tend toward greater simplicity.
These, the authors make
clear to their readers.
In an appendix will he found some excellent diagrams which illus
trate the more
important
tactical functions
with
which all
officers
should be familiar.
The Surgeon General of the Army, in a short preface to this work,
says: "All officers will find in its perusal
a well-arranged
and
co
ordinated exposition of standard doctrine, which is the resultant of
the extensive
experience
of the Medical
Department of the United
States Army in the World War."
Naval
medical
officers who
are taking the Correspondence
Course
for Medical
Officers
now
being
conducted
by
the
Marine
Corps
Schools,
Quantico. Va., will find this pamphlet a valuable addition
to their working
library,
(w. sr. k.)
South America from
a Surgeon's
Point of View, by Franklin H. Martin, M. D..
F. A. C. S.
Fleming
H. Revell
Co..
New York, 1922.
This is a delightful
collection of notes gathered
during two visits to
South America during
1920 and
1921 in behalf of the American Col
lege of Surgeons,
the first visit being made
in
company
with Dr.
William J. Mayo,
then president of the college,
and
the second
in
company
with
Dr. Thomas J. Watkins
of Chicago.
The itinerary
of the first journey included Jamaica.
Panama, Peru, Chile, Argen
tina, and Uruguay: the second journey covered the same ground with
the addition of Brazil.
This book really is a report to the American
College of Surgeons;
in it are included
some observations
of Dr.
Francis
P. Corrigan
who,
at the time of the
second journey,
was
making
a survey
of the medical
conditions of Bolivia and Ecuador,
together
with
some
extracts
from
papers
written
by Dr. Martin's
traveling
companions.
The visits to South America were made with the object of securing
the affiliation of the surgeons of South America with the American
College of Surgeons.
Dr. Martin tells in a readable
manner of the
party's reception
and of the hospitality
afforded them by the Gov
ernments of the various countries
and by the members of the medical
profession in each city visited.
The conditions
encountered
made
a profound
impression
on the
visitors who regard the surgeons of South America in their hospitals
and operating rooms
as equals of any representative
group of oper
ators in the world.
The
book
contains descriptions of the
medical
schools
and
the
hospitals visited, especially in the cities of Lima, Santiago, Buenos
Aires, Montevideo, Sao Paulo,
and Rio de Janeiro, as well as much
interesting information
concerning the social
and
professional
con
ditions in South America.
So. 1.
14?
BOOK
NOTICES.
It is copiously illustrated with portraits
of eminent
surgeons
and
photographs of interesting buildings
and scenery.
The medical man of North America who contemplates
a visit to the
regions south of Panama will find this little
volume
of great
assist
ance,
(w. If. K.)
Abdominal Pain,
by Prof. Norbert
Ortner,
chief
of
the
second
medical clinic at
the
University
of
Vienna.
Translated
into English
from
the
second
anil
latest edition
by William A. Brams,
M. D., formerly
Lieutenant
Commander,
Medical Corps, United
States Navy.
Rebman
Co., New York. 1922.
Medical
men whose good fortune it was to study in Vienna in the
days before
the war have many
pleasant
recollections
of Professor
Ortner. and many of them will welcome
an American edition of his
book on Abdominal
Pain,
a work
which
is
the product of many
years of personal
experience
and observation.
In a short preface which Professor Ortner wrote for the American
edition, he remarks that he hopes the book will be well received, and
that
it will
be of help
in reestablishing friendly relations between
members of the medical profession of English-speaking
countries
and
of his own.
One can assure him that
the American
medical
profes
sion at least is willing to meet him more than half way in this recon
ciliation,
although
we fear that it will
be
some
years
before
the
clinics of Vienna attain the popularity
they formerly
enjoyed.
The work is a concise and competent
discussion
of abdominal pain
in all its phases.
In abdominal disease one is not often called
upon
to make
a diagnosis on the consideration of the pain alone.
There
soon
develop
other symptoms
which are of assistance, but the pain
often points out the direction one must follow in the objective
exami
nation in order to arrive at the proper diagnosis.
As the author re
marks
: " It
is
one of the early
symptoms
and
serves
as
a guide
through the maze of possibilities, and, therefore, it seems justifiable
*
*
*
to consider
the pain as the starting point in the differential
diagnosis."
This is not a book
to pick up in an idle moment,
but one to
be
read carefully, if one is to extract all
the
meat it contains.
The
author considers
abdominal pain in the various localities in which it
occurs.
Hence we find first
a discussion
of diffuse
abdominal pain ;
then a section on localized abdominal
pain.
This is followed by con
siderations
of epigastralgia
or stomach
cramps,
pain
in
the right
hypochondrium,
pain in the right ileocecal region, acute pain in the
left iliac region, pains in the lumbar region, flanks and lateral parts
of the
abdomen,
pain
in
the left
hypochondrium.
bilateral
hypo-
chondrial
pain, pain
in
the
region
of
the
navel
and
pain in
the
hypogastric
region.
In
an appendix
various
other
phases of
ab
dominal
pain are treated fully.
144
Vol. XVII.
BOOK NOTICES.
Each of these topics
is elaborated
extensively until every
variety
of abdominal pain together with associated symptoms
have been pre
sented to the reader in a systematic
manner.
Nothing
has been left
out, and the careful reader gains not only a comprehensive
knowledge
of the meaning of abdominal pain, but considerable
knowledge
of
the diagnosis of abdominal disease in general.
The book is written in the heavy style characteristic of the German
school of scientists, but in spite of this handicap it should prove to be
a useful volume to one concerned with abdominal disease,
(w. m. k.)
Diseases of the Skin and Eruptive
Fevers,
by Jay Frank
Schambrrg,
A. il.,
M. D., professor
of dermatology
and syphilis,
Oraduute
School of Medicine,
University
of
Pennsylvania.
Fourth Edition.
W. B.
Saunders
Co., Phila
delphia,
1921.
An admirable book which has been revised
and amplified in order
to bring it abreast of the recent advances in dermatology.
Whoever
attempts
to treat skin
diseases should
be skilled
in
the
diagnosis
not only of the ordinary
dermatoses, but of the rashes of the various
eruptive fevers.
These two classes of affections
frequently resemble
each other to such a degree as to present great difficulty in differenti
ation as is exemplified by the striking manner in which syphilis
may
simulate smallpox.
The
differentiation
of various
skin
lesions
requires
skill
which
is usually
acquired
only through
years
of
experience
with
many
patients.
Unfortunately
most of us do not have an opportunity
to
develop
the diagnostic acumen
so often noted in the skin specialist
to whom we have referred our puzzling
cases
and
we grope about
in the mazes of what seems
to us an intricate
subject.
Should
one
wish
to
acquire
a
good
working
knowledge of
dermatology,
or
merely
to obtain light on an obscure
case,
Schamberg has written
just the book to aid him.
Each skin disease is presented
in a brief
and practical
manner,
special
attention being devoted
to symptom
atology, diagnosis and treatment.
The exanthemata
are dealt with in a separate portion of the book
and, because of the importance attached
to their diagnosis, they are
given greater
space than is usually
accorded
them in textbooks.
The
text
is
supplemented
with
excellent
photographic
illustra
tions,
which
add greatly
to the
value of the
book
from
the view
point of the general
practitioner,
(w. m. k.)
Pneumonia, by Frederick T. Lord,
51. D.
Harvard Health Talks, No.
9, Har
vard
University
Press,
Cambridge,
Mass..
1922.
The Harvard University
Press has issued
from time to time
val
uable little books which form a series known
as the Harvard Health
Talks.
This series aims to provide in easily accessible form modern
No. I.
145
BOOK NOTICES.
and authoritative
information
on
medical
subjects
of general
im
portance.
So far these talks have been on the care of children, pre
servatives and other chemicals
in food, the care of the skin, the care
of the sick room,
the care of the teeth, adenoids
and tonsils, an ade
quate diet, and the avoidance of injection.
The last of the series to appear is a little book on pneumonia, the
text of which was originally delivered as a popular Sunday afternoon
lecture
at
the Harvard
Medical
School.
The
book
sets
forth
in
nontechnical
terms
our present
knowledge of pneumonia,
and
con
tains valuable suggestions
for the prevention and
treatment
of this
disease,
(w. m. kl.)
The Americanization
of Edward Bok.
The Autobiography of a Dutch Boy
Fifty Tears After.
Charles. Scribner's
Sons, New York, 1921.
" Sir, the biographical part of literature is what I like most," said
Dr.
Samuel Johnson;
and
many of us agree with
him, especially
when the biography
is so full of human interest
as is the American
ization of Edward Bok.
Here a strong, honest, upright
man has written
a book out of his
own rich personal experience,
relating in simple and convincing lan
guage what he has accomplished,
giving,
as it were, an account of his
stewardship
and of the intellect with which he was
endowed.
He
has written
the story of
a little Dutch
boy " unceremoniously set
down in America " in
1870,
unable
to make himself understood or
even to know what people
were saying, but
who "by
some
curious
decree of fate " was destined,
as editor of the Ladies Home Journal,
to write for 30 years to the largest body of readers ever addressed by
an American editor.
He lived
a busy life in his adopted
country.
At an early
age
a
hobby —that
of
collecting
autograph
letters —resulted
in
his
ac
quaintance
with
many of
the
notable
men
of
the early
eighties.
Although he
possessed enterprise and
energy,
the continuous
good
fortune which
followed him resulted
from
the friendships
he
had
made and the men with whom
his life had
come in close contact
at
its most formative period.
At the age of 21 he became associated with the Scribner publishing
house,
where
he received
a training
in magazine
management
which
fitted him for his life work.
Of course
he met obstacles — every suc
cessful man does —but obstacles to him " soon became merely difficul
ties to be overcome,
and
he trusted to his instinct to show him the
best way to overcome
them.
He soon learned
that the hardest
kind
of work
was
back of every
success;
that nothing in the world
of
business just happened,
but that everything was brought about, and
only in one way— by willingness
of spirit and
a determination
to
carry through.
He soon exploded
for himself
the misleading
and
146
Vol. XVII.
BOOK
NOTICES.
comfortable theory of luck; the only lucky
people,
he found,
were
those who worked hard.
To them luck came in the shape of what
they
earned.
There
were
exceptions
here
and
there,
as
there
are
to every rule, but the majority of these he soon found were more in
the seeming
than in the reality.
Generally speaking
a man got in
this world about what he worked for."
In 1889 Edward Bok became the editor of the Ladies*
Home Jour
nal and he was eminently successful,
for he possessed the faculty of
rightly gauging the psychology of his public.
He gave his readers
the subjects
they asked for, but always " on a slightly higher plane:
and
each year he
raised
the standard
a notch,"
and
each year the
circulation
of the magazine
increased.
No
one
can doubt the great
influence
which
the
Ladies'
Home
Journal
has had on American
life, for many of us have
noted
the
changes
for the
better
which
have
been brought
about
by its
en
deavor.
One of the
first
we
remember
was
the alteration
in
the
character of the American
small
house.
The
houses of the early
nineties were for the most part wretchedly planned, so Bok devoted
his attention
to
better
American
architecture,
gardening,
and in
terior
decoration,
with special
application
to the small house.
For 25 years he pursued the plans adopted
and in time his dream
of better
homes came true.
" Bok had
begun
with
the exterior of the small American
house
and made an impression upon it ; he had brought the love of flowers
into the hearts of thousands
of small householders
who had
never
thought
they
could
have
an
artistic
garden within
a small area;
he had changed
the lines of furniture and he had put better art on
the walls of these homes.
" It was
a peculiar satisfaction
to Bok
that Theodore
Roosevelt
once summed up this piece of work in these words : ' Bok is the only
man I ever heard of who changed
for the better
the architecture of
an entire nation, and did it so quickly and yet so effectively that we
didn't know it was begun before it was finished.
That was a mighty
big job for one man to have done.' "
Bok next turned his attention to certain civic questions —the im
provement
in the decorations
of the Pullman parlor car; the elimi
nation of billboard advertising and of untidy spots in prominent por
tions of various municipalities;
the improvement of rural
schools;
and the education
of women in civic matters, with equal
success.
The Ladies'
Home Journal,
under
Bok's direction,
was
the first
of America's magazines
to refuse
to accept advertisements
of patent
medicines.
The magazine
attacked
the patent -medicine
evil from all
sides.
It aroused
the public by showing the actual
contents of some
of their
pet medicines,
or the absolute
worthlessness
of them,
and
was instrumental in securing legislation which abated this traffic.
No. 1.
147
BOOK
NOTICES.
Then Bok
took
up the question of venereal
disease and
he had
a
lonely fight for a while.
But it was a question that had to be faced,
and he faced it with
a will.
There was much
opposition from his
readers
at first, which only proved
to Bok that he was right.
With
a series of well-selected
articles
he
presented
his
case
so ably that
soon women
began
to realize
that the Ladies' Home Journal
was
working for their best interests
and for those of their children.
In
the end he accomplished
what he had set out to do.
" He had taken
the question of natural life and stripped it of its false mystery in
the minds
of hundreds of thousands
of young people;
had
started
their inquiring minds ; had shown
parents
the way ; had made a for
bidden topic a debatable subject, discussed in open gatherings, by the
press, an increasing number of books, and in schools and colleges."
He next attacked
and
abolished
the public drinking cup;
insti
tuted the movement for a "safe
and sane" Fourth of July, and for
" better babies."
These are only some of Edward
Bok's achievements.
His story is
fascinating
to the very end.
It is full of lessons and encouragement
for all who are striving
to make the world
a better place in which to
live.
Perhaps
he was influenced
by
a sentiment
that was voiced
by
his Dutch
grandmother
on
sending
her
sons
out
into
the world
:
"Make you
the world
a bit more beautiful
and
better
because you
have been in it."
At any rate Bok believed
: " No man has a right to
leave the world no better than he found it.
He must add something
to
it;
either lie must make its people better
and happier or he must
make the face of the world fairer to look at, and the one really means
the other."
(w. m. k.)
QUERIES.
Medical officers are invited
to submit queries and to present
their
problems
to the Bulletin,
which,
being
in a position
to draw
on
varied and extensive sources of information
such as are not available
elsewhere, ioill use every means of securing authoritative opinion.
All queries will be answered
by mail; and the replies, if of sufficient
general interest, will also
be published in this column.
To the Ewtob : I was much interested
in reading
the discussion
of the toxic
effects
of picric
acid
as commonly
employed in the treatment
of burns
which
appeared In the January
number of the Bulletin
in reply
to Ambrine's
request.
Personally, I am confident
that, in spite of all theoretical
considerations
to the
contrary, picric acid is not good to use in burns.
I am inclosing
a series of com
munications
from different
sources regarding
the. treatment
of burns,
and from
them
you will
see
the point of view
of men who
are
probably
treating
more
emergency burns than anyone in the country.
I have no doubt
that you could
get a great
deal more data
by writing
to a large
number of industrial plants,
out believe this will show quite definitely
that picric
acid is considered
as some
what obsolete.
Akbustio.
The treatment of burns is an important subject
and one worthy of
consideration by the naval medical
officer,
as the Annual Report of
the Surgeon General of the Navy for the fiscal year 1921 shows
736
original admissions
to the sick list during
the year for this class of
injury.
The use of a 1 per cent solution of picric acid is quite routinely em
ployed in the treatment
of burns throughout
the Navy, but the use
of this preparation
is open to certain objections and,
as Ambustio's
letter indicates,
is not universally
popular.
It may
be that picric
acid,
by suspending skin respiration
and
exudation
in the areas on which it is applied, or by doing something
to a skin
area already elaborating
a toxic substance
as a, result of
the burn, or by further irritating a nervous
area already irritated
to
the point of inducing
shock,
may
produce
definite
injury, but such
actions
seem
never
to have
been demonstrated,
and
before
we can
learn much that is definite concerning such speculative effects, it will
be necessary
to learn more
about
the toxicology of burns, which
as
yet is very obscure.
Abstracts of the correspondence
referred to in Ambustio's
letter
are given in order that medical
officers may
be familiar with treat
149
150
Vol.
XVII.
QI/EKIES.
ment advocated
by the surgeons of several large industrial
establish
ments.
It will
be noted that these
men do not speak against picric
acid, but they do not recommend
its use.
Armour & Co., Chicago, III.: V. S. Cheney, M. D.—" We do not use
the picric-acid
treatment
on any of our burn cases.
" We have had considerable
experience
with the paraffin treatment,
and it has given very good
satisfaction
in
extensive
burns of
the
legs and arms
due to scalding water.
We have also tried the open-
air
treatment,
and in my opinion
the result has not
been
as satis
factory with that method
as it has with
the paraffin treatment.
In
a great many cases with the open-air treatment
we have had exuber
ant granulations,
with very pronounced
scars, resulting in contrac
tures; this, however,
was in very extensive
burns.
I believe that the
open-air treatment is
suitable
for superficial
burns
and
those
not
covering
a very large
area.
I believe
that the
paraffin
method
is
preferable in burns of the third degree
and
involving
most of
an
extremity."
Tennessee Coal, Iron
&■Railroad Co., Birmingham,
Ala.: L. No-
land, M. D.—" We have conducted
rather extensive
experiments for
a number of years, using
a number of different treatments; but for
the past four years we have used the so-called
' open treatment
' only,
and are satisfied that we are getting very much better results than we
ever did with any other type of treatment.
"As soon
as
cases
of burn are
received
in the hospital they are
placed on a sterile
bed under a bed tent, with electric
bulbs inside in
sufficient quantity to insure warmth.
" When
the burned surface begins
to dry
and
crust over,
com
presses freely moistened
with normal saline solution are applied each
morning for two or three hours, followed
by
the
easy removal of
crusts
and necrotic tissue with forceps.
If there
is a tendency
to
spreading infection,
moist hot dressings
of one-half of
1 per cent
carbolic acid are used for periods of from
12 to 24 hours, but other
wise the open treatment
with exposure
to light is constant.
" We are convinced
that this treatment
is giving us far better
re
sults than we have ever secured
any other way, with
a minimum of
pain and scar."
Bethlehem Steel Co., Bethlehem, Pa,:
Loyal A. Shoudy, M. D.—
" Before talking
about the direct treatment
of burns I should like to
call your attention to the care of the patient generally. I find that the
burn of itself is not the part which causes the trouble, but the " tox
emia " produced.
I am not sure that it is a toxemia,
but that is the
nearest I have been able to come to it.
Because of this, in all
cases
of extensive burns, the general care of the patient must be considered.
" For the so-called
minor burns, by this I mean those which do not
confine
to the hospital or bed. but those which come from the shops
No. 1.
151
QUKRIKS.
and can
Ik> cared for as ambulatory
cases,
we cleanse with benzine,
dry. and then apply dressing of ointment of the following
:
Parts.
Bismuth
subnitrate
6
" The paraffin
in this is sufficient
to hold the ointment above the
melting point of the body heat, and I believe this is the main point
in all the paraffin dressings.
In some
cases
we find it easier to heat
the ointment
and apply it directly to the burn
; but in most
cases we
spread it on lint or gauze.
"This you will find gives
a flexible
dressing and
enables
a man
to return to work in the case of hand or finger burns.
It is our expe
rience that the burns from the hot-metal departments — splashes,
and
mostly of the feet—are the ones hardest to ' get well.' partly
due to
the fact that they are mostly third-degree burns, and
also that they
are
in
the dependent
position.
These
we cleanse, dry,
remove
all
'cooked' skin, then apply
a wet dressing of chinosol and cover with
a dressing of the ointment.
Latter
used to keep
the
wet dressing
from sticking and to keep it moist.
If extensive
we use the paraffin
gauze for
a protection.
If extensive
and
' deep
' we
use
the
wet
dressing of chinosol and keep moist and elevated.
"Support
and protection are helps
in all
cases of burns.
If wet
dressings
are used, use paraffin gauze, which prevents
sticking.
The
so-called
bad
cases
must, from the start, be treated generally as well
as locally
and don't forget that if the man
is or has been
a user of
alcohol that it should be supplied now.
" These men we cleanse if not in a condition of shock.
If in shock,
a hypo of morphine sulphate is given and the patient is kept warm
until
recovery.
If
able
to
cleanse
do
so;
blisters
we
open
under
sterile conditions, but do not cut away the skin.
Cleanse,
dry. and
apply the ointment described.
Keep
clean daily with warm saline,
chinosol. and a little green soap.
Then keep well covered
with
the
ointment.
In the
' deep
' cases
use
the
wet dressing of chinosol or
saline.
" In general
measures
we have found that the
use of the Murphy
saline
drip
is good
measure for the
help
of elimination.
We
give
water freely and try in every way to keep the spirit of the man
' up.'
" We believe in fresh air and keep the body warm.
•' We have
almost
reached
the state where
we believe
that the so-
called
' general measures
' are of
as
much
value
as
the
particular
treatment used.
"Dakin's
solution is good, but sometimes
the men complain of the
continued stinging.
Pa raffin
Petrolatum
14
SO
152
Vol. XVII.
QUERIES.
"In burns of the skin around the eyes we
use
zinc oxide,
with
paraffin,
as we have learned
that it gives better results; why I do not
know.
" As to picric acid we have not used it for the past six years.
" Chinosol I
learned
from
Doctor
Murphy's
clinic
as
a
general
antiseptic."
Carnegie Steel Co., Clairton, Pa.: A. W. Colcord, M. D.—In 1910
Doctor Colcord said at a meeting of the Pennsylvania Railway Sur
geons' Association
: " For the
past
10 years I
have
been
using
an
ointment known
as Burn Ointment, old formula,
and
composed
of:
Carbolic
acid, thymol, menthol, camphor, of each
5 gains; ichthyol,
balsam
of Peru, of each
10 grains;
zinc oxide;
starch,
of each 1\
drams; petrolatum to make
1 ounce.
Mix well.
" It occurred to me that carbolic acid had some
good properties in
the treatment
of burns.
It is germicidal,
a deodorizer, and
a local
anesthetic,
but it is irritating and
poisonous.
For some years I ex
perimented
to find a combination which would retain the three good
qualities and
remove
the two bad
ones.
I believe
this mixture
has
accomplished
the result.
These four crystalline substances —carbolic
acid,
thymol,
menthol,
and
camphor—rubbed
together
produce
a
new
product,
which
has neither
the
physical,
chemical,
or
thera
peutic
properties of either drug
taken
alone.
It is a clear sirupy
liquid.
You
may
put your
tongue
into it
and
experience
only
a
slight burning.
Painted
on the unbroken skin, it produces
no
red
ness,
pain or gangrene,
only
a cooling
effect
followed
by
a slight
local anesthetic.
The
balsam
of Peru
and ichthyol,
advocated
by
Doctor Estes, are valuable aids in stimulating
granulation
and
epi
dermis
formation.
The oxide of zinc and starch incorporated
in a
petrolatum base make of it a protective dressing of about
the right
consistency.
After treating over 2,000
burns with this ointment, I
am convinced
that it has the following advantages:
"1. It is an efficient germicide and not only renders the surround
ing skin sterile, but also
keeps
the discharges
and
burned surface
free from germs
and, therefore, free from pus.
The only pus
cases
we get are:
" (a)
Those who
take off their
own
dressings
and
so infect
the
burn.
" (b)
Those who
come after several hours or days with burns al
ready
infected.
" (c) Burns near
the mouth, nose, or hair, or near
the buttocks
in babies.
" (d)
Possibly
some bad sloughing burns of the third degree, but
these are treated
as soon
as
a slough begins
to form with continu
ous wet dressing of Ochsner's
fluid, which prevents
bad odor or pus.
No. 1.
153
QUERIES.
"2. It is
a powerful
local anesthetic
and
soon
stops
pain,
espe
cially in burns of the first or second degree.
A badly burned baby,
screaming
with pain, will often go to sleep from the relief
afforded
before the bandages
are all on.
" 3. It is a deodorizer.
Our burns have no bad odor except badly
sloughing third degree ones, and
the odor is best controlled by the
wet dressing.
" 4. It is nonpoisonous.
I have never
seen
a case where I thought
absorption of the drugs produced any unpleasant symptoms.
" 5. It is with some exceptions,
to be mentioned
later, nonirritant.
"6. It is easily
and quickly
applied
and
convenient
to carry
in
the grip.
"7. With this, dressings
do not stick
as they
do with picric
acid
and many other applications.
Men with slight burns can, with this
dressing, work in comfort.
"8. It is especially adapted
to mill and
office
practice, where
we
do not have
the perfect cleanliness
of the hospital
and
where
the
open-air (Sneve)
dry
method
or the
continuous bath is impracti
cable.
It is the only method I have found that will keep a burn clean
in the dirty homes of some of the foreigners working
in the
steel
mills.
"9. The recovery is much
more rapid by this method,
because (1)
the
edema
and inflammation of the skin soon
subside,
(2)
there is
no pus, (3) granulation
and epidermis formation
are stimulated.
" 10. There is less scarring, because less destruction of tissue.
" Some years ago I treated
30 cases with picric acid, and there was
a general
demand from these patients
that we return to the ointment.
" Let us suppose we are called to treat a severe burn of the second
degree. . We find the patient suffering agonizing pain, with oncoming
shock and a chill.
We at once administer a hypodermic of one-fourth
to one-half
grain of morphia, one-fortieth to one-twentieth grain of
strychnia, and one one-hundredth to one-fiftieth grain of atropin
to
stop his pain and apprehension and combat
the shock.
We then
see
that the room is warm—80° to 85° —clear it of unnecessary
furniture
and bystanders
and
order hot-water
bottles
or hot bricks
gotten
ready.
The
bed should also
be prepared. If we have
a nurse
or
assistant
at hand we can order her to prepare the necessary
things
for a hypodermoclysis or a Murphy drip.
"We must
bear in mind that in every
bad burn three things
are
more important than the local treatment.
"1. Stop pain.
/
"2. Combat shock.
"3. Provide
for dilution
and elimination of the toxins, which
at
once are thrown into the blood.
154
Vol. XVII.
QUERIES.
" Having gotten
thus far with our work, we can proceed
to do the
local dressing.
The clothing
should
be carefully
cut
away —never
pulled off or dragged
over the burned
area.
We must remember that
a burn
is,
at first, sterile
and
we must try to keep
it
so.
Unless we
believe
that
it
has
become infected through dirty handling, dirty
clothing dragged
over
it,
or a dirty blanket laid on it,
it
is
best not
to wash the burn.
Estes washes the surrounding skin with
5
per cent
carbolic solution, protecting
the
burn with
pledgets
of
wet gauze.
With our burn ointment we have not found this necessary.
" Pieces of gauze of convenient
size are now
spread
thickly
with
the ointment and applied somewhat
beyond
the burned areas.
Over
this cotton
and over all
a
bandage
is
placed.
The patient
is
now put
to bed. and
if
shock
continues
the normal salt solution
is
repeated
every eight hours, giving plenty of water to drink.
Nourishment for
the first three days should be liquid
on account of the intense conges
tion of the alimentary tract;
then
we may gradually
feed according
to conditions.
" There should be the usual
care of the bowels, skin, kidneys, etc..
not forgetting,
in our zeal over the local treatment,
that we have on
our hands
a
sick man with blood
loaded with toxins, with meninges,
lungs,
stomach, kidneys, and other organs congested.
u We re-dress
our burns daily, gently wiping
away the discharges
of serum
and broken-down
cells, which
is
poisonous
and irritating,
with dry
gauze or cotton.
Blisters
are opened
and
pieces of loose
skin removed
with sterile scissors or forceps,
but all skin
is
left in
place as long as possible to protect the underlying, new-forming skin.
" Every
dressing should
be made with
aseptic
care, clean hands,
clean gauze, and clean instruments.
''As
the old epidermis
is
shed
we have
a
red, raw, irritable
sur
face,
and
we
must
reduce
our ointment
to one-half
or
even one-
fourth
strength.1
In an occasional
case
even this
is
too irritating,
and we change to oxide of zinc ointment, or. better, to strips of gutta
percha
tissue wet in normal salt solution.
When the islands of epi
dermis have coalesced, we can change to aristol or any dusting pow
der.
" Of course, the greater number of burns are not so extensive, have
no shock, and come to the office for daily dressing.
" In burns of the third
degree
the initial
stage of shock,
pain,
and
toxemia
is
treated
as in extensive
burns of the
second degree,
and
the ointment applied.
As soon
as the slough begins
to form,
if
there
is
much odor,
it
is
well to change
to
a
continuous wet dress
ing;
we prefer
Ochsner's
fluid
(or Dakin's
solution)
with
gauze.
'In
a
personnl
communication
Doctor
Colcord
states:
"We
now
use
on
practically-
all burns
an ointment
:
Burn Ointment —old formula,
one-sixth
;
5
per cent boric
acid In
white
vaseline,
flve sliths."
No. 1.
155
QUERIES.
cotton,
and bandage.
The patient or nurse
is given a bottle of the
fluid, which
is poured on every
three
hours without
removing the
bandage.
The burn is re-dressed daily, and sloughing masses are re
moved
when
ready.
We often see new epidermis forming
along the
edges
before
the slough has all come away from
the deeper parts.
The sloughing
area
is rapidly filled with
red granulations,
and if
kept clean, the epidermis from the edges starts to cover it.
During
this period we usually apply
the ointment daily, one-half strength,
using silver nitrate if granulations are too high at the edges.
Where
ulcers, following deep burns,
are sluggish with
a poor blood supply
at the base, balsam of Peru or bovinine is used daily.
" When
the area is large in a third-degree burn, skin should
be
grafted as soon as the slough is well away and the hole is filled with
granulations.
To wait until
the granulating
mass is old and high,
we not only invite failure of the grafts
to take, but we have
a mass
of scar tissue formed which will eventually contract, with resulting
deformity.
" Murphy says : ' In late grafting where
a heavy
mass of connec
tive tissue forms beneath granulations, I advise that this be dissected
out, down to the normal fascia, muscle, bone, or other tissue beneath,
before placing the graft.'
" We use mainly Reverdin or Thiersch grafts, covering with gutta
percha tissue strips and wet gauze dressing
of normal salt or borax
solution.
"' Young, of Glasgow, following
the method of Wolf, Krause, and
Matas, has obtained some excellent
results
by grafting the whole skin
with the subcutaneous
fat removed.
He claims much
more
perma
nent results than with the other methods, greater elasticity and better
appearances.
" Much of the ugly scarring and deformity
resulting from third-
degree burns is due to the neglect of skin grafting.
It is often done
too late or poorly done, and in many
cases not done at all.
"Reverdin grafting can
be performed without
an anesthetic
and
at the home of the patient.
No apparatus is needed but some gutta
percha
tissue,
a pair of sharp scissors,
mouse-toothed
forceps,
and
some sterile salt solution.
The wound surface and surrounding
skin
must be clean, the granulations firm and healthy, and there must
be
no bleeding.
If near
a joint, apply
a splint
to insure
perfect rest,
keep
the parts constantly wet with normal salt solution.
Leave the
strips of gutta-percha tissue in place three days, then change to clean
strips.
Put on grafts, one-half inch apart, in rows, both ways, so that
the strips may be crossed like basket work.
"First-degree
burns
are dressed
once or twice
with
the ointment
and discharged
cured.
Those
of
the face are
coveved
with sterile
103390—22
11
156
Vol.
XVII.
QUERIES.
vaseline
or zinc-oxide ointment,
or the Burn Ointment, and are left
without bandages.
They rapidly dry and heal without further
atten
tion.
" Burns of the eye are dressed with Lippincott's
Ointment
: Bichlo
ride of mercury.
1 grain; ammonium
chloride,
1 grain; sterile
vase
line.
5 ounces.
"This can bp put in the eye
where
the burn is on the eyeball
or
under the surface
of the lid. and gauge and bandage applied.
These
burns
also do well with
a wet dressing
of boric acid solution.
When
the cornea is burned,
atropin is used.''
In a recent communication Doctor Colcord
said : " In my address
before
the Pennsylvania
Railway
Surgeons' Association. I reported
the treatment
of
1,000 burns
with
no clinical
infection.
I can now
add
9.000 more to the list.
Nurses,
assistants,
and
patients
have
al
ways
been enthusiastic
about
the results
of this ointment.
As you
will note, I am now using it much weaker than
at first.
"Am just finishing the treatment
of a very deep third-degree elec
tric
(6,600 volt) burn, destroying skin, facia, and
a portion of mus
cles of ball of thumb.
Slough
was 2 by
3 inches
and three-fourths
inch
deep.
Ointment
used first four
days.
Then
a constant
wet
dressing of 10 per cent Dakin. mopping slough daily with pure Dakin
solution.
Skin
of
hand
was
protected
with
the Burn
Ointment.
Swelling
of hand
was
slight
and
soon
subsided.
There
was
the
usual
amount
of discharge
from
a rapidly dissolving
slough
but no
signs
at any
time of clinical
infection
about
the burned
area.
As
soon as slough
was complete I returned to the Burn Ointment
and
the cavity rapidly filled with healthy granulations covering in from
the edges with epithelium. I had told the patient that skin grafting
would be needed, but the new skin came so rapidly that I did not use
it.
Throughout
his treatment
he has
been
free from pain and has
worked in comfort.
There has been no perceptible odor.
I cite this
case as typical of our treatment
and its results.
" I treated
200
cases
with
paraffin
and
got
good
results,
but
not
nearly so good
as with the ointment.
The paraffin
does not prevent
infection, does not deodorize,
does not provide for the carrying
away
of the discharges,
does not tend to sterilize the surrounding skin,
but
on the other hand keeps the wound discharges
in close contact,
per
mitting
them to become infected
by the pus germs ever present
in oil
glands,
sweat glands, and hair follicles, and
so carrying
infection
to
the burn.
In about
25 per cent of cases I got pustules
or furuncles
around the burn.
Yet paraffin
has great
advantages
and
has
been
an advance
over the antiquated methods in vogue before
the war or
those used to-day by many otherwise
good surgeons.*'
From
a communication recently
received by the editor, the follow
ing is quoted
:
No. 1.
157
QUERIES.
" 1. For burns, either erythematous
or vesicular,
in which the epi
dermis
is not broken, I use picric
acid.
"2.
(a) For second or third
degree burns in which the epidermis
is removed. I use the open-air treatment,
with some
means for main
taining desiccation
of the surface.
"(b) If,
however,
infection
supervenes
and
the crusts
are inter
fering with drainage, I saturate
the individual
with citric
acid
in
ternally, and keep the parts wet with citrated solutions until the in
fection is overcome.
I then revert to the dry treatment
(2 a)
or the
pus
dressing
(3).
"3. The
tissues
in the neighborhood of
a burn always show,
as
you know, signs of damage from the heat, a condition similar
to that
produced
by
therapeutic
thermo-coagulation,
so
that
a
prolonged
period following the injury is occupied
in repair of damage
before
definite
healing processes start.
" When the healing process is well under way,
as shown by healthy
granulations
and
advance
epithelium, I use my old pus
dressing—
a
sheet of rubber
dam
covering
the
whole
granulated
area.
The
theory of this dressing is: (1) It protects
the granulations and tender
epidermis
from
mechanical
injury,
(2)
conserves
all
the
exudate,
which, in clean
wounds,
consists
of nutritive
and reparative
mate
rial, and (3) by the conservation
of this exudate,
the young, ' naked
'
cells and capillaries
are bathed
in fluid which
is not only nutritive
but ideally adapted
in chemical
constitution,
being far superior
to
any salt solution that we can concoct.
" I speak at length of the theory of the
' pus dressing,'
since
the
rationale of paraffin dressings
is,I
believe, identical.
Consequently,
I
regard the healing period as the indication for paraffin,
if
it
is
to be
used
at all."
The Bulletin
woidd
welcome
the
ideas
of individual
medical
officers
on the subject of the treatment
of burns in order that
it
may
present to its readers
treatments
which have
been found
to
be
effi
cient.
THE DIVISION OF PREVENTIVE MEDICINE.
Lieutenant
Commander
K. F. Jones,
Medical
Corps,
United
States
Navy,
in charge.
Notes
on Preventive Medicine for Medical Officers,
United
States
Navy.
INSTRUCTIONS
TO MEDICAL OFFICERS.
THE VENEHEAL DISEASE
PR0B1EH.
By Pail Richmond, Jr., Ueutenant.
Medical
Corps,
United
States
Navy.
The
problem
of combating
the
venereal
diseases
lias
not
been
Bolved either for the Navy or for civilian communities.
Comprehen
sive and well-defined plans are being carried out to reduce the harm
ful effects of other communicable
diseases but considerable
difference
of opinion
exists
as to the
best
method
of procedure
in directing
activities aimed at minimizing
the incidence of the venereal
diseases.
During the World War the liberal contributions of patriotic citizens
and popular enthusiasm
made it practical to carry out more extensive
measures
than had
previously
been possible.
Resulting
therefrom
there
was
a widespread suppression
of the old type
of " restricted
district"
which
has
changed
the outward
aspect of commercialized
prostitution.
Another
factor influencing
the problem has been the
advent of prohibition.
It is, therefore, difficult to compare
present
conditions with pre-war standards.
From 1910 until the beginning of the war there had
been
a gradual
reduction in the annual admission rates for venereal
disease in the
naval service.
By some, this diminution
has been attributed
to the
more general
use of medical
prophylactic
treatment,
whereas
other
medical
officers
claim
that
improved
conditions
in
seaport
cities
as well
as more
extensive
instruction
and warning
of the men were
the determining factors.
This
was
true especially in
those
cities
where
restricted
districts
and other resorts
of commercialized pros
titution
were
closed.
During
the two years of the war
the
rates suddenly fell to not
much more than half the pre-war rates.
Undoubtedly
this was due
to many influences
: the causes tabulated below
are listed in what
is
believed
to be the order of their importance :
1. Enlisted men of a higher type than in time of peace.
2. Improved social status of enlisted
men.
159
160
Vol. XVII.
THE VENEREA!,
DISEASE
PROBLEM.
3. Suppression of all forms of prostitution in the vicinity of naval
establishments
and in seaport
cities in the United
States.
4. Prohibition of alcoholic beverages for men in uniform.
5. Military
activities occupying
a
greater
portion
of
the
men's
time than normally.
6.
Improved facilities for recreation
and amusement.
7. More intensive
instruction
as to the nature
and dangers
of the
venereal
diseases.
8. Patriotism,
with
a desire to avoid sickness
during
war.
Since the war the rates have again reached almost
to the 1916 level
and
are about
where
they
would
have
been if the pre-war
rate of
decline
had
continued uninterruptedly.
Inasmuch
as the low war
rates were not destined
to be lasting in spite of
a continuance
of as
many
activities
aimed
at reduction
as
was
possible,
the
questions
have been repeatedly
asked: "What should be done in the future and
what permanent
policy should the Bureau of Medicine and Surgery
adopt
in
regard
to these diseases?"
and "Should
the propaganda
against
venereal
disease be abandoned
or should new lines of activi
ties
be sought?"
Before undertaking
to answer
such
questions
an
analysis of the possibilities of present
methods will
be attempted.
Inasmuch
as the type of the men enlisting in the naval service
in
time!- of peace
is more dependent
on conditions of industrial employ
ment
and
wages in civil communities
than on service
inducements,
it remains only for officers on recruiting
duty to select the best
men
who present themselves for enlistment.
Since this policy has always
been
carried out, it may
be
presumed
that the
best
types
of
men
available have
been
and will
in the
future be
obtained,
so that ef
forts from within
the service
can not
be expected
to make
any
par
ticular
improvement
in
this
factor.
Suppression of
prostitution
can
not be undertaken
by the naval
service.
However, such organizations
as the Interdepartmental
So
cial Hygiene
Board, the American Social Hygiene Association,
and
many local agencies are active in this field and have gone, far toward
eliminating
open prostitution
in
the United
States.
Women's
po
litical
clubs
are especially
interested
in this matter
and
are able
to
exert
so much
influence
on mayors
of cities,
city
and
State
boards
of health,
and police
officials
that
few cities will again
tolerate
open
prostitution.
As
a result of
these
activities,
prostitution
in
the
United States
is rapidly
assuming
a clandestine
form and,
as active
suppression
continues,
women
of this character will
be
more
and
more difficult for men in the naval service
to find.
This has already
been
reported
to
be an important
factor in reducing exposures
in
San Diego, Calif., where
strenuous
measures were employed
to sup
press prostitution.
On the other
hand,
medical
officers of ships re
No. 1.
161
THE VEXEREAL,
DISEASE PROBLEM.
port that the exposure
rate increases markedly when liberty
is given
in European or South American
ports where
prostitution
is unre
stricted.
The active
suppression
of prostitution
by municipal
po
lice authorities promises
more in the way of reducing the incidence
of venereal
disease
in
the naval
service
than
any other
available
measures.
The venereal
rate for military forces in the United
States-
should gradually
improve
as
the
practice of
prostitution
becomes
more precarious.
While
many
men will continue
to Hud prostitutes
in every large city, solicitation
by the women will cease to be a con
siderable factor.
However, many
men, especially those recently en
listed
and those whose sexual habits are irregular,
will often be dis
appointed
in their search.
Medical
officers may occasionally render
assistance
to
the local authorities
by
reporting
foci
of infection.
The commanding
officer by bringing
pressure
to bear on those in po
litical power can aid in improving conditions.
But, in the main,
the
Navy can not take an active part in solving this phase of the problem.
-Nation-wide prohibition
by reducing
the
amount
of drinking is
thought to have reduced the number of exposures
to venereal
disease.
Many men are restrained
while sober, but
when
intoxicated tend
to
seek
out
and
associate
with
prostitutes.
Medical
officers
on ships
visiting foreign
ports almost
invariably
mention
drunkenness
as
a
factor
in increasing the number
of venereal
infections.
Men under
the influence
of alcohol
are notably careless concerning exposure
and
prophylactic
treatment.
The facilities for amusement,
recreation,
and athletics are recog
nized as of great importance in reducing exposure
to venereal disease.
Inasmuch
as the Morale
Division
of the Bureau of Navigation
has
funds with which to aid
ships
and stations,
there is no reason why
every ship and station should not have adequate amusements, etc., for
>ts complement,
when
the officers take
an active
interest.
Medical
officers, in general,
encourage
athletics and other recreations
among
the men, as such activities have a beneficial
effect on the body and thus
diminishes all forms of physical disability.
Although
indirect this
K one of the best methods of reducing the incidence
of the venereal
diseases especially since the war, when the men have more spare time
and less engrossing duties.
Its preventive value
is believed
to be in
direct proportion to the character of the men, however, for some types
of individuals
will not be restrained
to any appreciable
extent.
In the matter of instructing
the men
as to the nature of venereal
disease
and
warning
them
as
to the
dangers
of
such
diseases, the
medical officer has definite obligations and should have
a broad
view
°f the problem
in order that he may not be discouraged
if his efforts
are often apparently futile.
It is important that those phases most
likely to have a lasting beneficial
effect, however small, be emphasized,
out fallacies
which lead to opinions which can not
be defended
and
162
Vol. XVII.
THE VENEREAL
DISEASE
PROBLEM.
are contrary to the policies of the Navy Department must be avoided.
The first consideration of educational measures aimed at the preven
tion of venereal disease is the prevention of promiscuous sexual
rela
tions.
The number of cases of venereal
disease will bear
a definite
ratio to the number
of exposures,
i. e., after all other factors have
reached
the best possible
efficiency.
From
a study of the Forms A
from
all ships and
stations
for
a period of
a year and
a half, it
appears
that many medical
officers
give
this phase of the problem
little or no consideration, but concentrate
their efforts on instructing
the men how
to use prophylaxis.
Those having tried to reduce the
number
of
exposures
by
instructing
and
warning
the
men of
the
dangers of venereal
disease are divided
as to whether any reduction
has resulted.
A few report that " much
good
was
accomplished,"
others state that " it is believed
that the pamphlets,
posters, and
lec
turers do good."
A great many more medical officers state that " the
men continue
to expose themselves in spite of intensive instruction
as
to the nature
and
danger
of the venereal
diseases, both by lectures
and the distribution of the literature provided."
Although
the actual restraining power of such propaganda can not
be measured, some men are known to be influenced
thereby.
Whether
such instruction will be of any avail is believed
to be entirely
due
to the individual
man's
moral viewpoint.
The group of men who
believe that promiscuous sexual
relations
is morally
wrong in
the
same way that theft, lying,
and other forms of dishonesty
are con
sidered
wrong can, it is believed,
be dissuaded,
in great
part, from
what they
consider
lapses of morality.
The number of exposures
for this class can thus be greatly reduced.
However, similar propa
ganda is of no avail for that group who regard promiscuous sexual
intercourse
as a matter for individual
choice, in the same way that
the use of alcohol is usually considered,
and who
do not attach
any
moral stigma to those practicing such irregular
sexual relations.
The
exposure
rate may, nevertheless,
be reduced
in this class by caution
ing the men to avoid intercourse with prostitut«s, who are practically
all diseased.
Opinions
on this subject
are usually
fixed
before
men
enter
the
service; consequently
the influences
of later environment and
teach
ings to change the viewpoint are of no avail, except in the occasional
instance.
The lack of success experienced
by medical officers who
have given the propaganda
a thorough trial is attributed mainly
to
the relatively small number of men in the first group, as well as to the
fact that such instruction may have been given at a time when oppor
tunities for sexual relations were especially numerous
and attractive.
For instance, this seemed
to be true on the U. S. S. Utah in Mediter
ranean waters
where the monthly exposure
rate exceeded the number
of the complement.
Certain variations in exposure
rates must be due
No. 1.
163
THE VENEREAL
DISEASE PROBLEM.
to other factors also.
For example, in case of the U. S. S. KUtery
and the U. 8. S. Gulf port, which regularly visit practically
the same
West Indian ports, each medical officer
states on Forms A that
he
instructs and warns the men of the dangers of venereal
disease.
For
the last quarter of 1921 the U. S. S. Gulf port, with an average
com
plement of 92, reported 2,746 exposures, whereas the U. S. S. Kittery,
with an average complement
of 121, reported only 191 exposures for
the same period.
Such variations in the exposure
rates, where other factors appear
to be the same, can possibly be attributed to the example
set by cer
tain
men
among
the crew
who, by their conversation and
conduct,
more than neutralize any beneficial
effect produced by educational
measures.
Such environmental influences
induce
many
men to seek
sexual gratification much more frequently than the}- would otherwise
be inclined
to do.
This may also be a factor on large ships and shore
stations
among
any particular
group of associated
men.
The writer
had occasion to observe such an example
among
a group of Hospital
Corps men. following the arrival of a pharmacist's mate whose sexual
habits were unusually irregular.
Although
transfer
of this man
to
other duty did not immediately reduce the rate of exposure
to aver
age,
a much
more salubrious character of conversation immediately
prevailed among
the
corps
men.
Unfortunately,
recruits
get most
of their
information
or
misinformation
from
conversation with
other enlisted
men
" between
decks."
For this
reason
is it to
be
wondered
that
an
occasional
talk
by
the
medical
officer,
however
forceful, can not displace the
effect of the continual
reiteration of
fallacious
statements?
Fear of disease
is rapidly dissipated when
an ''old timer" tells of his "career"
and
appears
none the
worse.
As these conditions can not easily
be changed,
those carrying
out ed
ucational
measures will have to be contented
with scant evidence
of
improved
rates for venereal disease.
Recently a case of syphilophobia
was reported to the Navy Department.
From this it can be seen that
our appeal to the fear of disease may do harm in some
instances.
Instruction as to the value and use of the new form of medical
pro
phylactic treatment must continue
to form
a part of the educational
program.
The percentage of infections following any form of pro
phylactic treatment
in a large group of cases
is a good index of the
relative value of such measures.
Tabulation
from Forms A of over
36.000 treatments
given within one hour after exposure
indicate that
i.'
per cent of infections may be considered
the average
rate of disease
following early treatments
by the methods
applied during
1921.
It
is
expected
that the
use of the prophylactic
packet
will reduce
the
ratio for all exposures
to this minimum.
Present
methods
are deemed both justifiable
and
adequate.
New
departures
are not to be looked
for. nor should existing measures
be
164
Vol. XVII.
THE VENEREAL
DISEASE PROBLEM.
despaired of.
The venereal diseases result from human conduct which
follows
age-long customs.
As social
conditions generally
improve
the venereal diseases must diminish.
In southeastern
Europe
a social
collapse
has produced
the inevitable increase of these infections.
In
asmuch
as the sexual impulse depends
on a primitive
instinct it can
not be expected that promiscuous sexual relations will diminish faster
than other forms of antisocial conduct.
ABSTRACTS FHOM THE ANNUAL SANITARY REPORT, FLEET SURGEON,
UNITED
STATES ATLANTIC
FLEET,
FOR THE
YEAR
1921.
A review
of the health statistics
of the fleet
for the year
1021 shows
rliat,
as
far as sickness
and injuries are concerned,
the
return
to peace-time conditions
lias been practically fulfilled.
By this it is meant that the admission
rates per
1,000 for diseases and injuries
now
approximate
those rates
that
were
in
ex
istence prior to the entry of the service into the World War.
The returns avail
able for examination
indicate
that there is improvement
in nearly
all classes of
diseases
and injury.
In
fact,
it can
be stated with
more optimism
than
for
many years that the health of the fleet during the year
1921 has been excellent.
The admission
rate for the entire
Navy
for the previous
year
was
07(3
per
1,000.
For the 5-year period immediately
preceding
the war
the mean
rate was
464 per 1,000.
Therefore,
the annual
rate of 398 per 1,000 for the year 1021 may
be considered
as reflecting
very satisfactory
health conditions
in the fleet.
Communicable
diseases.—About
22 per cent of the total admissions
to the sick
list belong to those ailments
classified
as communicable.
The kind
and number
of each of the communicable
diseases that occurred
in the tieet during the latter
half year are as follows
:
Diseases
and
number
of Admissions.
Tonsillitis
665
Influenza
'9
Cellulitis
71
Abscess
(all)
39
Pneumonia
(all)
25
German
measles
22
Fever,
unknown
cause
21
Furunculosis
18
Malaria
17
Chickenpox
16
Measles
13
Tuberculosis
(all)
11
Mumps
8
Rheumatism
(all)
6
Scarlet
fever
4
Erysipelas
2
Diphtheria
I
Dysentery
1
Total
1.019
There
were 605 admissions
for tonsillitis, which
amounts
to about two-thirds
of the total
number
of admissions
for
these
communicable
diseases.
Next in
importance
to tonsillitis is that
group made up of those diseases caused by the
pus-forming
organisms
;
that
is, cellulitis,
abscess,
and
furunculosis.
Tonsil
litis and the latter group have
a total of 803 admissions,
or about
80 per cent
of the entire
number of admissions
for the diseases of tins class.
It is singu
lar
that
miliaria,
measles,
mumps,
chickenpox,
and
other
similar
diseases
have such low admission
rates.
Unfortunately,
the two diseases most menac
ing
to
life,
pneumonia
and
tuberculosis,
are
represented
by
a
considerable
number
of
admissions.
No. 1.
165
THE VEXEREAL
DISEASE PROBLEM.
The above table
shows
that
tonsillitis
anil
diseases
of
the
pus-forming
or-
pmisnis
are the principal contributors
to
this
class
of communicable
diseases
and
that if
it
were
possible
to
control
these
contusions
a
relatively
large
amount
of sickness
would
be avoided.
An
explanation
as
to
the
reason for
the predominance of these two diseases can not readily
be offered.
It is prob
able that
a predominance
of tonsillitis
and diseases of the pus-forming
organ
isms is due to some
defect in ship sanitation.
Unfortunately, no definite
state
ment to this effect can
be made.
But whenever
the admission
rate for one
or
both of
these
diseases
is unusually
high,
experience
indicates
that
the condi
tion
of the
sculleries,
drinking
fountains,
and
other
similar
sanitary
factors
should
be carefully examined
with the view of finding
the probable
cause of
the increased
incidence.
Smallpox
and
typhoid
fever. —During the latter half of the year
there
was
no admission
for smallpox
or typhoid
fever.
Two
isolated
cases of modified
smallpox occurred
in the first half of the year.
These two cases were handled
with
a minimum
of inconvenience
to the fleet.
It is believed
that
the Atlantic
Fleet
is now fully
protected
against
typhoid
fever
and smallpox.
If either
of
thes»> diseases
appear,
it
is
quite
certain
to
be
in
a
mild
or
modified
form.
Therefore, it is improbable
that
the health
of any persons
in the fleet will
be
jeopardized
by
their
contracting
smallpox
or typhoid
fever,
or that
the move
ment of the
fleet,
or any ship of the fleet,
will
be restricted
on
account
of
the
appearance
of
either
of these diseases.
Fatalities. —A total of 29 deaths
occurred
among
the personnel
of the fleet .
during
the year.
Of
these,
8 were due
to
natural
causes and
21
to
external
violence.
Of those due
to disease.
3 were caused
by
pneumonia,
3
by
inflam
matory
brain
affections,
and
1 each
was due to acute peritonitis and dilatation
of the stomach.
The following is a summary
of the
21 fatal accidents:
Drowning
"
Fell overboard
tone unwitnessed)
3
Swimming
(one
unwitnessed)
3
Capsizing
of canoe (unwitnessed)
1
Suicide
(unwitnessed)
*
Fell
overboard
on watch
(unwitnessed)
1
Airplane
accidents
3
Crash
2
Caught
by revolving
propeller
1
Street
accidents
Trolley
car
1
Fell down
street stairs
1
Coaling,
drawn
into winch
*
Engine
room,
bursting
steam pipe
1
Asphyxiation, working in confined space
(unwitnessed)
1
Drug poisoning,
drug
addict
1
Homicide,
unwitnessed
Fall on board,
unwitnessed
Jumped
in front of train, suicide
1
21
It is seen
from
the above that drowning
as a cause of death leads all other
causes.
It is natural to expect that
the hazard
of drowning
is greatest In a
seagoing occupation.
Consequently,
there are many recognized precautious
that
are constantly
being
enforced.
But in spite of all
these,
drowning
accidents
166
Vol. XVII.
THE VENEREAL
DISEASE PROBLEM.
occur.
Accidents
resulting
from
swimming
and
men
falling overboard
account
for the greatest number of drownings
and these are difficult
to guard
against.
Of course,
no man
should
be
permitted
to enter
a
swimming
pool
when
no
other
person is present, and the breaking
of this
rule
seems
to have accounted
for one
death.
Each
year
a number
of deaths occur among swimming
parties.
The unnoticed
disappearance
of a member of such a party
is a frequent
occur
rence.
To prevent
this
a plan
has
been
suggested
by
which
the members
of
a swimming
party pair off before going into the water,
each one of a pair
to be
responsible for the safety of the other.
Under
such a plan the occurrence
of an
unnoticed
disappearance
of a man would
seem
quite improbable.
The
fleet regulations
require
that
care
be taken
for the safety
of the
lives
of the personnel,
in particular, when new activities
are being carried
on,
and.
also
when
conducting
activities
known
to
be hazardous.
Furthermore,
there
is
an
order
that
when
an
accident
resulting
in
a fatality
occurs
a
copy
of
the board of inquest
or investigation,
as
the
case
may
be, shall
be furnished
the commander
in
chief.
These
reports
are carefully considered
to
ascertain
if
blame
or
responsibility
for
injury
to
personnel
can
be
attached
to
any
person or persons, and also
to determine if it is possible
to institute
any
safe
guarding
or precautionary
measures
against
the recurrence
of the same or
a
similar accident.
Venereal
diseases. —According
to
incomplete
statistics
collected
within
the
fleet during the past year it appears
thnt
the venereal
situation
for
1921
will
. be relatively
good.
Calculations for the last half of 1921 give an annual
rate
of
102
per
1,000.
The rate for
the entire
Navy
for
the previous
year
was
126 per
1.000.
and for the year
before
that
111
per
1,000.
The
last half
of
the
present
year
does
not
include
the
period
during
which
the
fleet
is
at
Guantanamo,
when
a
comparatively
small
number
of
infections
occurs.
It
does
not
seem
improbable
that
when
a
complete
calculation
is
made
the
venereal admission
rate of the Atlantic Fleet for
1921 will
be found
to compare
favorably with the low rates of the war-time
years.
The last
annual
report
of the Surgeon
General
of the Navy
notes that " in
general
*
*
*
the
rates
for
the
venereal
diseases
were
lower
for
shore
stations
than
for
the entire
Navy."
It appears
that
the reverse
is true for
the Atlantic Fleet for
1921.1
The rate
of
102 per
1,000
is small
for a
force
afloat.
It would
be worth
while
in the interest
of further prevention
to deter
mine, if possible, the reason for this
reduced venereal
rate.
This year medical
prophylaxis
and
educational
propaganda
were
carried
out
with
about
the
same amount
of zeal as during
previous
years.
The presence of a less changing
personnel
might
be
assigned
as
a
cause
for
fewer
communicable
diseases,
but
this
condition
would
appear
to
be
practically without
effect
to
reduce
the
number
of
venereal
diseases.
It
is
probable
that
the
favorable
results
of 1921 followed
some
definite
cause or causes.
In
attempting
to
annlyze
the
venereal
situation
it
should
be
taken
into
consideration
that
the enlisted
personnel
nowadays,
in consequence of various
propaganda
that
have
been
forced
upon
it,
is
better
informed
concerning
venereal
matters
than
formerly.
Also,
vice conditions
on
shore have changed.
In the past
the sailor was
often
exploited
by commercialized
vice, which
Is
seldom
the
case
any
more.
When
the present-day
sailor
encounters
vice
on
shore it is probable
that
he
has
sought it instead
of the vice having
sought
him.
In
other
words,
the
sophistication
concerning
venereal
matters
which
1 Provisional statistics In
the
Bureau
of Medicine
and
Surgery
do not
bear out
this
statement.
The
admission
rate for venereal
diseases for
1921
for
shore stations
was
73
per 1,000 per annum.
No. 1.
167
THE VENEREAL
DISEASE
PROBLEM.
ihf enlisted
mau
now
possesses
has
resulted
more
in
his
avoiding
the conse
quences
of his
moral
transgressions
than
it
lias
in
bolstering
up
his
better
inclinations.
The
administering
of prophylactic
treatments
on
board
ship
has
many
ob
jectionable
features.
Among
them,
and not the least of them, is the attending
publicity,
which
tends
to dull the moral
sensibility
of
th>> applicant
for treat
ment.
The fact that the taking
of medical prophylaxis is considered
a require
ment after
an Illicit
exposure has resulted
in
a great many
untrue
statements
being made to the attendant in charge, and, consequently,
considerable
erroneous
data are now
entered in the prophylactic
records.
Many
men
are providing
themselves
with their own
methods of prevention.
If the method fails, or If
the individual believes it
to
have failed,
he takes
a
treatment
on
board
ship,
thereby having his name recorded and giving
any number that happens to come
into
his
mind
as the
number
of
hours
after exposure.
It
is
probable
that
this practice,
more than anything
else,
causes the high
percentages of failures
and, without
doubt, the erroneous
percentages
that
are now being obtained
on
Form A.
A summary
of the Forms A from
the fleet for six
months,
representing
an
average complement of 23,414,
is as follows :
Hour.
1
2
3
4
5
6
6 to 12 . .
Over 12.
Number of
treatments.
3, 952
4, 403
2,851
2,151
1,411
1,253
2,073
837
Diseases.
66
110
106
87
r,i
64
126
68
18, 931
088
Per cent.
L6
2.4
3. 7
4.0
4.3
5.1
6.0
8.1
3.6
It is
seen
in the above table that the percentages of failures for each
hour
after exposure
are
unusually
high.
The inference
is that
medical
prophylaxis
In the fleet has
been particularly
unsuccessful.
It
seems
inconsistent
to have
among the same personnel
a high rate of infection
following prophylaxis
and at
the same time the low rate of admission
of 102 per 1,000 per annum
previously
noted.
This phenomenon may be explained
by the suggestion already
advanced ;
that
Is, that the
enlisted
man,
through
greater
knowledge
of the
subject,
is
seeking
In his own
way
to avoid
venereal
disease.
Some
men
are
avoiding
disease by comparative
or absolute
continence,
while others
resort
to various
mechanical
or medicinal
means of prevention.
The result
is
that,
the ship's
prophylaxis is used to cover up errors or neglect, thereby causing
a considerable
distortion of the compiled results.
On the other
hand, there is a better appre
ciation
on the part of the crews at large of the dangers of illicit intercourse.
This is associated with a more intelligent
effort
to avoid
or prevent
infection,
which is apparently
the cause of the low rate per 1,000.
168
HEALTH
CONDITIONS
OF THE
NAVY.
Vol. XVII.
HEALTH CONDITIONS
07 THE
NAVY.
The
iinnual
admission rate for all
causes, entire Navy,
for
the
five-week
period ending June
10 was
488 per
1,000 per annum,
as
compared
with
a rate of 506 per
1,000
per annum
for the previous
four-week period ending: May
G.
The
progressive
average
rate for
the entire Navy
on June
10 was
624 per
1,000 per annum,
which is
considerably lower than it has been
at any time during
the year
or.
in fact, at a similar time for the past four years.
There has been a gradual decline
in the annual admission
rate for
diseases only since
about
the
1st of March; the admission
rate
for
the five-week
period ending June 10 was 422 per
1,000 per annum.
The morbidity rate for accidents
and injuries for the week ending
June
10 was higher
than
it has been at any
time
during
the
past
two
years,
the rate being
1)2
per
1,000
per annum.
The
average
rate for accidents and injuries for the five-week period ending June
10
was 66 per 1,000 per annum.
The
morbidity
rate
for
communicable
diseases
continues
to
be
very
low.
The
following table
shows
the
rates
for certain
com
municable
diseases for May,
1922,
as
compared
with
the
average
rate for this month for the previous four years:
Annual admution
rate*
per
1,000 for attain
rommunieabU
diseases,
current
month
of
May,
1922,
in comparison
with
the mtan
annual
admission
rates,
month of Map, for
the.four-year period
1918-1921,
inclusive.
March,
March,
191S-1B21. |
1922.
Cerebrospinal
fever
0.32
0
Diphtheria
,
s- 29
,
^20
German measles
■W
2. 44
Influenza
4 1 I
12. P0
Malaria
5.98
|
12.89
Measles
&■79
2.83
Mumps
15.76
1.27
Pneumonia
-.8.?
Scarlet fever
2.40
.20
Smallpox
■
Jjj
°
Tuberculosis
345
X*
Typhoid
fever
,
•0:5
0
It will
be
noted
that
the
morbidity
rates
for German
measles,
malaria,
and
tuberculosis are higher than usual.
German
measles
has
been
reported
from
several
battleships
of
the
fleet;
this, no
doubt,
accounts for the high rate for this disease.
Malaria has not
only
been
prevalent
among
marines
stationed
on
foreign
shore
service,
but
also
at Quantico,
where
there
were
31
cases
admitted
during the past month.
No. 1.
169
HEALTH
CONDITIONS
OF THE
NAVY.
The morbidity
rate for the venereal
diseases has continued to de
cline during the past five-week
period, the progressive
average
now
bein<r
108 per l.()00 per annum
as compared
with
112 per
1.000
per
annum for the four- week period ending May
6.
The mortality
rate
for
the entire Navy
is not only
much
lower
than for
a previous five-year norm, but
is also lower than for the
year
1921
;
the
progressive
average
rate
for
1922
now being
1.83
per 1.000 per annum, as compared
with 3.20 per 1,000 per annum
for
1921
and the five-year norm rate of 5.40 per 1,000 per
annum.
Health conditions
at training
stations
have
been
excellent,
few
cases of communicable
diseases having been reported.
DIPHTHERIA
IMMUNIZATION
IN ADULTS.
By J. r. Leake,
Surgeon,
L".
S. Public Ilenlth
Service,
in
charge
of
biologic
products,
Hygienic
Laboratory.
Questions
are frequently asked
as to the advisability
of immuniz
ing adults against diphtheria
by the use of toxin-antitoxin
mixture,
a procedure which gives
promise
of definite
reduction
in diphtheria
mortality
among
children.
The case in regard to adults is very different from the use of the
preventive
in the younger
age
groups.
For
one thing,
diphtheria
is not the serious
problem
which it is in children.
Among
males in
the registration area of the United
States for 1919, the last year for
which the mortality statistics are available, 60 per cent of the deaths
from diphtheria
and
croup were
before
the
age of 5.
88
per
cent
before the age of 10, 94 per cent before the age of 15, while only
5
per
cent occurred in the age group
15
to
44.
In the
ages
2 to
9.
which
are
those
chiefly
concerned
for
diphtheria
prophylaxis,
13
per cent of all deaths were due to diphtheria,
a proportion of
1 death
out of every
8, while at the ages of
15 to 29,
1 in every
300, and
at
the ages of 15 to 44, only
1 in every
600 was caused by diphtheria.
The diphtheria
death
rate
per
100,000
below
the
age of
15
was
45,
only 2 at 15 to 29 years, and
1 per 100,000
at 30 to 44 years.
The year
1919, for which the figures
are given above, was
not
a
year
of exceptionally
low diphtheria
incidence
in the
registration
area, and it is not to be expected that in the future the deaths
in the
Savy, for example,
will frequently
exceed
the high point of
14 per
100,000 reached
for the
year
1920.
For
the six
years
before
the
World War the death rate was continuously below
2.
There
is
no
considerable
evidence
as
to
the
permanency
of
diphtheria immunization
in
adults,
but it is reasonable
to suppose
that
persons who
have
reached
adult
years
without
being
able
to
170
Vol. XVII.
HEALTH
CONDITIONS
OF THE
NAVY.
maintain
the degree of immunity
which is usual at that time may
not only be difficult to immunize, requiring
more injections than do
children, but also
be uncertain in their hold on the immunity
thus
produced,
losing it more rapidly than normal individuals.
The
presence
of
a
larger
proportion
of
pseudoreactions
to the
Schick test in adults than in children corresponds to the observed fact
that the injections
of broth cause less discomfort in children than
in older persons.
For all these reasons — the slighter need, the more uncertain value,
and
the greater trouble to the persons
receiving the treatment—the
testing
and immunizing of adults against diphtheria
is on a different
footing
from the same procedure
in the case of children,
and
is to
be advised
as
a routine for adults, at present,
only in the
case of
individuals
who are likely to suffer a considerable
and prolonged ex
posure
to diphtheria.
FRESH-WATER FISH AS CONSUMERS OF MOSQUITOES.
The following was abstracted
from an article entitled, " Notes on
the
use
of
fresh-water
fish
as
consumers
of
mosquito
larvae
in
containers used in
the
home,"
by N. E. Connor,
published in the
American Journal of Public Health, March,
1922:
With
the exception
of metal
tanks, for which no satisfactory fish
has yet been discovered,
fish can be employed
as larva? destroyers in
all classes of reasonably large water-storing
receptacles.
The four
factors needed to insure their effectiveness
are—
1. That the fish
be in
a sound condition when placed in the con
tainer.
2. That the water in the container receive sufficient air to support
fish life.
3. That the container be protected
from the sun.
4. That there
be
placed
at the
bottom
of the container, against
the side,
a cave-like arrangement beneath
or behind which the fish
can
rest
or can hide when
frightened.
A condensed
milk can,
a
curved
piece of earthenware,
or an elevated
stone
device
made
by
resting a flat
stone on two other stones will
suffice.
As a general
rule, all fresh-water
fish that can adapt themselves
to the confines of containers will consume
mosquito
larvae.
Species
of top minnow, carp, pike,
mullet, and
perch,
and
also shrimp
and
small turtles, have been used with excellent
results.
Unfortunately,
some
species
of
fish
which
consume
great quantities of mosquito
larvae
are unable
to adjust
themselves
to the narrow
limits of the
average
container.
Larva-eating
fish
may
be roughly
divided into
" top
feeders "
and
" bottom
feeders.''
Top-feeding
fish
are
most
Xo. 1.
171
HEALTH
CONDITIONS
OF THE
NAVY.
effective where
there
is plenty of sunlight.
They
seem
unable
to
locate larvae in dark containers.
The bottom-feeding fish have, how
ever, given
the best
results.
One fish is enough
for a cistern,
barrel,
or well.
PROMOTION
OF BETTER HEALTH IN THE NAVY.
Dr. F.
G.
Barr.
medical
director,
National
Cash
Register
Co.,
Dayton, Ohio, in an article appearing in the National
Safety News,
June, 1922, states that—
"The selling of health
must begin
in the medical
department,
for
so long as the doctors,
nurses, dentists,
and clerks do not act as sales
men and saleswomen
meager results
must
be expected.
" The medical force at the National Cash Register factory at Day
ton consists
of three
doctors,
two dentists,
three
nurses, two treat
ment-room
men
(physiotherapy),
one
masseuse,
and
three
clerks.
To insure
success in the work among the employees,
we believe that
every member of the staff should have the following
qualifications
:
"1. A vision of the value of preventive medicine.
"2. Adaptability.
Patients
ranging
from
the
foundryman
or
trucker to the president of the company must
receive
medical
care
which will lead them to have confidence
in the medical department.
The president and other
executives
must
not feel that it is merely
a
department for the laborers,
nor must
the trucker or foundryman
feel that
the department is only
interested
in
the
executives
and
"white-collar
men."
" 3. Interest
in the employees'
troubles,
no matter
how trivial they
may seem from the medical
viewpoint.
A curt, ill-considered answer
to one of these trifling questions
is often enough
to make
the
em
ployee
a confirmed " knocker " so far
as the medical
department
is
concerned.
" 4. The ability to sell health as a factor in production.
" 'k Honesty.
There is no place in industry for the physician or
nurse
who
merely
asks
the
patient
a few
questions,
looks
at
his
tongue,
fills in
a report, and
sends him
back
to work.
A doctor
should
be discharged upon the second offense of this kind, for thor
oughness
is one of the first essentials of success
in industrial
hygiene.
"6. The medical department
employee
must have his heart in the
work."
Inasmuch
as the Navy, in many ways,
is very similar
to
a large
industrial organization, it seems that the qualifications which
have
been laid down by Doctor Barr for the staff of an industrial
concern,
might
be applicable to the personnel
of the Medical Department of
the Navy.
In this connection
it will be of interest
to know that the
103390—22
12
172
Vol. XVII.
HEALTH
CONDITIONS
OF THE
NAVY.
average
time lost by the employee of the National
Cash Eegister Co.
was 11.5 hours per year, whereas
the average time lost by all indus
trial workers in the United
States on account of sickness is variously
estimated
from six to nine days per year per employee.
In other
words, a saving of more than 75 per cent has been accomplished
as
a result of Doctor Barr's most excellent work with the National
Cash
Register Co., which, no doubt,
is largely
due to the efficiency of his
organization.
ABSTRACTS
FROM
THE
ANNUAL
SANITARY
REPORT.
DESTROYER
SQUADRONS,
U. S. ATLANTIC
FLEET.
FOR THE YEAR
1921.
The
most
Interesting
fenture of epidemiological
interest hns been the venereal
situation
and the influence thereon of our two buses.
For example, in February,
1921, representing
the middle
of the stay of the destroyer
squadron
at Charles
ton,
it was
reported
in
'• Notes
on
Preventive
Medicine
"
that
the mean
rate
for
venereal
disease
from
destroyers,
Atlantic
Fleet,
was
225
per
1,000
per
annum,
whereas
in August.
1921.
representing
the middle of the stay at
New
port, R. I., the mean
rate was 103 per 1.000 per annum.
That this is not merely
fortuitous is confirmed
by
the increased
rates
reported
in November
and
De
cember,
when vessels were again at Charleston,
S. C.
In the United
States Public Health Reports for December 16. 192L it is noted
that the physicians
of the State of South Carolina
reported
11,826 cases
of vene
real diseases, including
5,719 gonorrhea
and 5.508 syphilis,
between July
1.
1919.
and June 30. 1920.
The Rhode Island physicians
reported
1,224 total
cases, of
which
485 were gonorrhea
and 732 syphilis.
If the reported syphilis were used
ns au index, it would
npj>ear that
South Carolina,
with two and one-half
times
the population
of Rhode Island,
was reporting
about three times as much syphilis
per capita.
In
the
" Report
of the
Percentage
In
the
Second Million
of Drafted
Men
Found
Infected
with Venereal
Disease" (war statistics). South Carolina stood
fourth,
with
13.1 per cent,
and Rhode Island was thirty-fifth, with 2.8 per cent.
The average for the whole United
States was 5.7 per cent.
We expect, then, to record
a higher morbidity
rate for venereal diseases when
the destroyer
squadrons
are in Charleston
than
is recorded
at Newport.
This
is borne out by the actual
returns.
The
situation
in Charleston
and its
adverse
effect
on
the personnel
is com
mented upon in several of the Annual
Sanitary Reports
for 1921 submitted
by
the medical
officers attached to this force.
Charleston,
on
the
other
hand,
recognizing
the desirability
of
having
this
force make this
port
a permanent
base,
has begun
a clean-up
eompalgn.
The
first
step was taken
during
the summer
before
the destroyers
returned.
The
white
vice district
was closed.
The
local
follow-up
efforts
have not
been
as
energetic nor as effective
as the first
steps.
Prostitution is still rampant.
Real
improvement
of vice conditions
probably
will
be
slow
in becoming
manifest.
This
is
an
inherent
defect
in
our
present
political
conscience.
The
clean-up
idea
is merely dormant
now and may at some
future
date eventually
carry
Its
point.
Economic
pressure
has been
the factor
most
useful
In getting
results.
All
local effort
has been
entirely
on the initiative of the residents
themselves.
No. 1.
173
HEALTH
CONDITIONS
OF THE NAVY.
but the Navy lias cooperated fully in every measure tending
to improve
condi
tions.
The former practice of maintaining
a first-aid
and prophylactic
station
on the
Government
landings
at Charleston
and at Newport
has
been
continued.
ABSTRACTS FROM
THE ANNUAL SANITARY
RETORT, U. S. S. "PENN
SYLVANIA," FOR THE YEAR 1921.
During March,
1921. while
anchored
in Guantanamo
Bay,
Cuba,
an epidemic
of
acute
bronchitis
occurred
aboard
this
vessel.
There
were
approximately
100 cases.
In order
to
cope with the epidemic
about
50 per cent
of the cases
were
transferred
to the hospital
ship Relief for treatment.
The
cause of the
epidemic was undoubtedly
due
to
infection
with Pfeiffer
bacillus.
The
infec
tion
was
either
airborne
or
carried
through
the
agency
of
mess
gear.
The
symptomatology
common
to all of the cases
was
a nonproductive
cough, mild
fever,
tightness
and
constricted
sensation
of
chest,
headache,
and
moderate
prostration.
There were
seven
battleships
at Guantanamo
during the period
of tliis epidemic, but five of
them
had
no
cases.
A similar epidemic
occurred
at this time on the U. S. S. North
Dakota.
Acute follicular tonsillitis has been prevalent
during the year.
This disease
lias
not appeared
in epidemic form,
but has been
endemic, there being always
one or two
cases
of tonsillitis
reported
on
the morning
report
of sick.
The
cnuse of this disease is believed to be due in large part
to nonsterllization
of the
mess
gear.
The
condition
of
the
decks—worn-out
linoleum
with
residual
water beneath —has probably
been
a contributing
factor
at times when
repair
was delayed.
The etiology of these cases
has been carefully
studied, and certain
ones
have
been
found
to
closely
follow
exposure
to
wet
and
cold
weather.
Defects in the ventilating
system
may also contribute
to the etiology
of this
disease.
Throat infections
by Vincent's
organism
were common
while
this
vessel was
"n the Atlantic coast, but since a change of station
occurred
in September, 1921,
to the Pacific coast, Vincent's
angina
has rarely
occurred.
The influenza
cases
occurring
during
the latter part of 1921 have been
char
acterized
by marked
selective
action for
the nervous
system.
The
symptoms
were
mild
fever,
with
cough
or
pulmonary
symptoms;
mild
rhinitis;
severe
neuralgias,
usually
of head, face, or neck ; and prostration
disproportlonal
to the
mildness
of the
other
symptoms.
Recovery
from
attacks
has
been
compara
tively rapid.
The absence of certain diseases which were present in 1920 is noted with satis
faction.
There
has been
no case of cerebrospinal
fever, typhoid
fever, or lobar
pneumonia.
Three cases
of encephalitis
lethargtca
occurred
during
January,
1921.
Two of these cases
terminated
fatally on board the U. S. S. Relief.
Several
cases
of subtertian
malarial fever
occurred
among members of
the
marine expeditionary
force,
which
was aboard
this
ship
while
at
Panama
in
Anzust.
1921.
These
cases
attracted
interest,
as it was definitely
found
that
the infection
did
not occur in the Tropics.
The
cases
occurred
too
soon
after
arrival
at the Isthmus of Panama
to permit
of the belief that the infection
had
hec-n acquired
there.
As these
men
had been
stationed
at Quantico,
Va.. prior
to embarkation, and
as they had never lived
in the Tropics previously,
it is as
sumed
that they were infected
while
serving
at Quantico.
174
Vol. XVII.
health conditions
of the navy.
Preventive
measures against
epidemic
diseases have been
carried
out aboard
ship
in
routine
manner.
The sanitary drinking cups
are burned
out with
a
gasoline
torch
daily.
Linoleum
decks
have
been
washed
down
with
cresol
solution
each
morning.
Air-bedding
orders
have been
made to include
officers'
bedding.
Divisional officers and crew have been
instructed
by
medical
officers
regarding
venereal
diseases and the prophylaxis
and hygiene
relating
thereto.
Instructions
regarding
typhoid
prophylaxis
and
vaccination
against
smallpox
nave 'jeen carried
out scrupulously
and energetically.
The principles
of venereal
prophylaxis
have
been
rigidly enforced.
Disciplinary
measures for failure
to
take venereal prophylaxis
have been very
rarely
used.
Ventilation. —There
has
been
no
change
made
in
the structural details
of
the ship's
ventilating
system since certain
recommendations
were
made in the
sanitary
report
from
this
vessel
for
the
year
1920.
The
deficiencies
of
the
supply
system
reported,
upon
at
that
time
are
in
no
way
improved
and
are
found
to be worse on the third deck and in the storerooms
below.
Late in
1921 the main
air ducts leading
forward and aft
from
the forward
air-intake
vents were examined
and
the
following
conditions
found
: The walls
of the ducts were
entirely
covered with
impacted
black
soot
to
a thickness of
2
to
3 inches.
In other
words,
the lumen of the main
air ducts
was
reduced
from
2
to
3 inches
at the place of their largest
circumference
and their
air-
carrying
capacity
was proportionately
reduced and choked
by the accumulation
of dirt and soot on their
walls.
The insanitary
aspect of this
condition
is
most obvious.
So
much
soot
is
blown
through
the terminal
louvers
that
it becomes
necessary
in
many
com
partments
to
filter
the air
through
gauze veils
tied
over
the
louvers.
While
this plan acts to keep out dust and dirt, it also reacts
to diminish
the air supply.
The
presence of dirt at
each
end of a ventilating
system indicates
that
the
entire
system Is air choked and in consequence is incapable
of functioning
to
full
capacity.
It
Is
natural
that
the smaller
ducts
should
be
most
affected
by this condition,
and consequently
it is in the storerooms
that the air supply
is most deficient.
The
dangers
from
insufficiently
ventilated
storerooms
have
recently
been
made the subject
of
a special bulletin
sent out by the Bureau
of
Medicine
and Surgery.
Vcmrrnl
dixenxcx. —Preventive
measures
against
venereal
infections
have
been
carried
out through
the agency of warning posters,
venereal prophylaxis,
and instruction
to
the divisional officers and crew
by
the medical
officers.
On
such occasions emphasis
has been placed
on instructions
that eontinency
is the
sure preventive
against
venereal diseases.
Venereal
prophylaxis has
been
given
as
a
matter
of routine
to those men
who admit
having
risked
infection.
The
system employed
has been
efficacious
and
has
undoubtedly
served
to
prevent
many
cases
of
disease.
During
the
period
of February
1
to
4, while
at Callao,
Peru,
venereal
prophylactic
treat
ment was
given
to
737
men.
Diseases
resulting
from
these
exposures
were
confined
to
11
cases
of
gonococcus
infection
of
urethra
and
two' cases
of
chancroid.
During
the period
from
February
10.
1921,
to February
22.
1921,
while at Balboa,
Canal
Zone,
472 prophylactic
treatments
were given, with
no
venereal
diseases resulting
from
these exposures.
Conditions
on the Pacific
coast are found to be less favorable
for the effective
ness
of venereal
prophylaxis,
and
the admission
rate
has
been
high during
the time that the ship has been based at San Pedro. Calif.
No. 1.
175
HEALTH
CONDITIONS
OF THE
NAVY.
ABSTRACTS
FROM THK ANNUAL SANITARY
REPOR
T, UNITED STATES
SUBMARINE
BASE.
NAVAL
OPERATING
BASE,
HAMPTON
ROADS,
V.\.. FUR THE YEAR
1921.
Living
conditions
on
a
submarine
are
apparently
far
from
healthful.
In
ventilating
a
submarine
during
surface
runs
there
are
many
fluctuations
in
the atmospheric conditions
within
the
boat,
the
rapid
changes of air causing
drafts of cold air
to enter
a
warmed
space:
on
the other
hand,
during
sub
merged
runs or runs
in heavy weather,
when hatches are closed, there is com
plete stagnation of air in
an overcrowded
space.
The
older
type
submarine
is
poorly
heated
and when
lying
in
cool
water
the
temperature
within
the
boat
is always
cold and damp.
The air
is saturated
with
water,
and
as
a result
the bedding
and spare clothing
become
soggy,
cold, and
damp.
Facilities
for
bathing are much curtailed.
Men are living closely crowded
together
and
have
no opportunity
for exercise
other
than
what
their duties
in
this
small
space
provide.
It
would
seem
that
living under
conditions
of
this
kind
would
be
conducive to the development of respiratory
and rheumatic
affections of various
kinds,
but
experience
in this
division
of submarines
shows
that
men
serving
on submarines
are not more subject
to such diseases than
men
doing
duty at
Hie Hampton Roads
Base.
Most of the men are young, only
a few of the chief
l*tty
officers
being
in
the
neighborhood
of middle' age.
This
Is
undoubtedly
another example
of how young
men,
kept
in
good
physical
condition,
may
be
made to stand
adverse conditions
and
is no argument
whatever
for minimizing
'lie disadvantages nnd discomforts
of such living conditions.
ABSTRACTS
FROM
THE
ANNUAL
SANITARY
REPORT.
U.
S.
S.
" MONOCACY,"
FOR THE YEAR
1921.
The incidence
of venereal
disease for the year
was
very
high,
there
being
admitted
to the sick list
13
cases
of gonococcus
infection
of the urethra,
13
'•ases of chancroid, and 3 cases
of syphilis.
Thirteen
of these 29 cases
occurred
during
the month of June.
It is believed that
the entire
crew appreciates
the
seriousness
of
the venereal
diseases, for
they
have
been
given frequent
indi
vidual instruction
as to
consequences
of such diseases.
A prophylactic
station
lias
always
been
accessible, and
the
men
have
been
Instructed
in
the proper
method of taking prophylaxis.
After having been in the upper part of the Yangtze
River for the entire winter,
the Monocacy
returned
to Shanghai
in June, where
liberty
was given freely
to the men.
The
13 cases of venereal disease for that
month
does not prove that
the
men had failed
to receive the proper instructions
:!iid
warnings
against
the
dangers
of
venereal
disease,
but
rather
that
they
■iail disregarded
them.
Shanghai
is overrun
with houses of prostitution;
the
number of Chinese,
Japanese,
Russian,
and European
prostitutes
is very high
and no attempt is made
to cleanse the city of this terrible
vice.
The
" houses "
usually
frequented
by
sailors
are
along
the
water
fronts.
In
localities
where
filth
and
disease are prominent
and where
the
men
have free and
easy
access
lo an unlimited
quantity
of intoxicating
liquors.
The
latter, I believe, is in
a
large
measure
responsible
for
the high
incidence
of venereal
disease
on
the
Asiatic
Station.
Many
men
have told
me
that
when
they
went
ashore
they
"ere
determined
to abstain
from illicit
intercourse,
but that after having
con
sumed
" liquor " they did not realize
what
they were doing.
Under
the influ
ence of intoxicating liquors
they would
thus become
easy
victims
of this large
army of prostitutes.
176
Vol. XVII.
HEALTH
CONDITIONS
OF THE
NAVY.
In
the smaller
ports
up the Yangtze
River
there are fewer
prostitutes
and
no all-night liberty is granted,
and, as a result,
there Is a lower incidence
of
venereal disease.
All these facts will explain
why the venereal
report for June
was so very high.
I believe that the number of cases of venereal disease would
be greatly
diminished
if the Navy
Department
would
return
to its former cus
tom of allowing the men to furnish themselves with prophylactic
tubes such as
the Royal Navy issues to their sailors.
Certainly such a custom could not
do
any
harm, for
as
long
as houses of prostitution are
tolerated
and whisky
is
easily
obtained
men will
respond
to their sexual
desires.
The Yangtze
River
ports
lack
recreation
centers
and clubs; there
is no mental
diversion
for the
men
when
they
go
ashore,
and there is nothing
with which
they
can advan
tageously occupy themselves.
I am not attempting to uphold the men or offer any
apologies for their misconduct; I am merely
stating
facts —facts of which
all
medical
officers on this
station
are fully cognizant.
INSTRUCTIONS
TO MEDICAL OFFICERS.
Circular
letter.
Serial No. 186-1922.
WJCA : ESK 129733 ( 53 ) .
Washington,
D. C,
16 May,
1922.
To : All naval hospitals.
Subject:
Occupational
therapy for Veterans'
Bureau
patients
In United States
naval
hospitals;
quarterly
reports
concerning.
Reference:
(a)
Bureau's
circular
letter,
Serial No.
185-1922
of
6 May,
1922,
No. 129733(43).
1. On May
1,
1922, the Bureau
of Medicine
aud
Surgery,
Navy Department,
assumed
entire
charge of all personnel,
equipment,
and
material
used in con
nection
with
occupational
therapy
and
physiotherapy
for
Veterans'
Bureau
patients in United
States naval
hospitals.
2. In
the future no reports
or
other
information will
be furnished by
the
occupational
therapy
personnel.
These
employees
are
employed
by
the Navy
Department
and
have
no further
connection
with
the
Veterans'
Bureau.
All
reports,
etc.,
must
be forwarded by, and information furnished
by,
the
com
manding officers of the various
hospitals.
3. On June
30,
1922,
and
at the end of each quarter
thereafter,
command
ing officers will forward
to the Bureau
of Medicine
and
Surgery
reports
con
cerning occupational
therapy
for
Veterans'
Bureau
patients
in the form and
order
indicated
below and containing
the following information :
(a)
Name, rate
under civil service, date of appointment,
and salary of each
employee
connected with occupational
therapy
for Veterans'
Bureau
patients.
(6) List
of
courses
taught
Veterans'
Bureau
patients
giving
names
of
instructors
or teachers
in each course.
(c) Hours
spent
by instructors in
connection
with occupational
therapy.
(i) Hours
actually
occupied in teaching
and manner
in which
time is spent
when not actually
teaching.
(e) Number
of Veterans'
Bureau
patients
availing themselves of courses
In
occupational
therapy,
giving
number
of patients
and
hours
devoted
to
each
subject.
(0 Detailed
report
of duties performed
by educational
director.
is)
Report of duties performed
by clerks
and stenographers.
Note. —In making
reports,
time spent by Veterans'
Bureau patients
in study
outside
classroom shall not
be counted in with time actually under
Instruction.
A separate report of time devoted to study can. If practicable,
be made.
E. R. Stitt.
Circular
letter.
Serial
No.
187-1922.
H\VS:MFD
130402
(53).
Washington,
D. C.,
May 17, 1922.
To: All medical officers.
Subject
: Consultation
service in roentgenologic
interpretation.
Reference
: Manual for the
Medical
Department,
section
3221.
1. The
general
adoption
of
celluloid
films in roentgenology
has made prac
ticable
an extension
of the service rendered by the U. S. Naval Medical
School
for
many
years
in
the examination
of pathological
specimens.
177
178
Vol. XVII.
INSTRUCTIONS
TO
MEDICAL, OFFICERS.
2. Any
medical
officer desiring
to
consult
with
a
roentgenologist
regarding
tlie
appearances
in
an
X-ray
iilni
can
obtain
an
opinion
by forwarding
the
film
or
Alms
in
question
addressed
to the Commanding
Officer,
U.
S. Naval
Medical
School,
Washington,
D. C,
accompanied
by
a brief
abstract
of the
clinical
history
of
the
case,
and
the following
data
written
on
each
film :
(ft)
Name
and
rate
of patient;
(b)
name of hospital,
and
(c)
"right"
or
" left."
3. In
cases of injury
to
a joint, and
always
in any
affection
of the knee,
a
corresponding
plate
of
the unaffected
side
should
be
inclosed.
X
rays
of
fractures
should
be taken
in
two
directions,
as
nearly
perpendicular
to each
other
as
possible.
In
chest
cases,
take
stereograms
if
available
apparatus
permits
making
them.
4. In order
to comply with postal
regulations,
celluloid
films are to be mailed
in a metal container,
sealed, and labeled " Inflammable."
5. Medical
officers
de'siring
photomicrographs
of tissues,
blood,
or bacterial
preparations
or
photographs
of gross
specimens
for
use
as illustrations are
reminded
that
the school
is prepared
to undertake
such
work
on
request.
E. R. Stitt.
Circular letter.
Serial
No. 18S-1922.
W.ICA : ESK
129733 ( 52 ) .
Washing-ton. D.
O.,
IU May,
1922.
To: All naval
hospitals.
Subject
: He Transportation for Veterans'
Bureau
patients
upon
discharge
from
I". S. naval
hospitals.
References:
(a)
Telegram
from District Manager.
I". S. Veterans'
Bureau.
At
lanta.
Ga..
to
Commanding
Officer.
T".
S.
Naval
Hospital.
Pensacola,
April
IT.
1022.
<b)
Letter
from
Commanding
Officer.
IT.
S.
Naval
Hospital, Pen-
sacola. to District Manager,
IT. S. Veterans'
Bureau. Atlanta.
Ga.. April
29, 1922.
(c)
letter
from
Director,
V.
S.
Veterans'
Bureau,
MCG : ecr :
10
Hospital Section
to
the Surgeon
(ieneral
of the Navy.
May
13. 1922.
1. For your
Information
and guidance
the
((intents
of
the
above
reference's
are hereby
quoted :
(o)
" Rertrans
Edwards ('
eleven
fifteen five three naught
issue transporta
tion
to Cincinnati
Ohio."
(h)
"The above-named man was this date discharged
from further treatment
at
this hospital
and has
been
furnished
twenty-one
meal
and lodging
requests
in
lieu
of transportation
to
Cincinnati.
Ohio,
which
was
authorized
by your
telegram
reference
above."
The following statement
was signed by the man concerned: "I hereby waive
transportation
to Cincinnati. Ohio,
and accept
in lieu
thereof
meal
and hnlging
requests mentioned
above."
(r)
"There are inclosed herewith
copies of a telegram from
the district man
ager of the fifth district.
Atlanta,
Ga., to the Commanding
Officer. Naval
Hospi
tal. Pensacola, Fla.. and
a letter from
the commanding
officer.
It will
be noted
that
the commanding
officer,
presumably
upon
the
request of
the
claimant,
is
sued
in lieu of the transportation
to Cincinnati,
authorized
by the district man
ager's telegram.
21
meal
and
5 lodging
requests.
The
commanding
officer,
as
noted
above,
presumably
di'l this upon
the request of the claimant.
No. 1.
179
IXSTPiI'CTIOXS
TO
MKIHCAI,
OFFICERS.
"It will
he noted that
the claimant
waived
his transportation
to Cincinnati
and
accepted
in
lieu
thereof
the meals
and
lodging
request
noted.
This,
of
course, is contrary
to the practices
of the Veterans'
Bureau,
as it is felt that the
transportation
to the claimant's
home
is a privilege
baaed
on humanitarian
con
sideration
and is not
a
vested
right
which
the claimant
may
demand in cash
or
other valuable
consideration.
"It is therefore
requested
that
you
instruct
the commanding
officers of
the
different
naval
hospitals
caring
for Veterans'
Bureau
claimants
that
transpor
tation
requests are to
be issued only for legitimate
and actual
intended
travel
and can
not he exchanged either
for cash or for other
valuable
consideration."
E. R. Stitt.
Circular
letter.
Serial
No.
189-1922.
WJCA
: ESK 132687-0(54).
Washington.
D. C,
22 May.
1922.
To: All naval
hospitals.
Subject
: Occupational
therapy
for Veterans'
Bureau
patients
In United
States
naval hospitals. —Red
Cross personnel.
Reference:
(a)
Bureau
of
Medicine
and
Surgery
circular
letter
Serial
No.
184-1922-WRJ-THC 132687-0(51)
of May
2, 1922.
1. In order
to simplify administrative control
and
reduce overhead
expenses
in connection
with
occupational
therapy
in
naval
hospitals,
the
Bureau
of
Medicine and
Surgery
has
adopted
the following
policy
in
this
connection
:
2. Commanding
officers will
arrange
the
instruction
of
Veterans'
Bureau
patients
in
such
a manner
that all work in
connection
with
the former
term
of occupational
therapy
(i.
e.,
beadwork.
basketwork,
and
any
other
branch
which
may
have
been
included
under
the
old
terminology
of
occupational
therapy) will
be designated
(assigned)
to Red
Cross
personnel,
and all other
work
such
as that
formerly
Included
under
the
term
of prevocational
train
ing
(i.
e..
stenography,
typewriting,
English,
reading,
writing,
bookkeeping,
commercial
subjects,
agriculture,
etc.) will
be designated
to civilians employed
for that purpose.
3. In
this
way
all
naval
and
Veterans'
Bureau
patients
will
receive
their
instruction
in
branches
included
under
the
occupational
therapy
(old
term)
(par.
2)
from
the Red
Cross
personnel,
and
Veterans'
Bureau
patients
only
shall
receive
training
and
instruction
in
branches
formerly
included
under
prevocational
(old
term)
(pnr.
2)
from
the
civilian
personnel
supplied
by
this
bureau
for
this
particular
work.
It
Is
not
the
intention
of the bureau
to furnish
prevocational
training
to naval
personnel.
4. Red
Cross
personnel
will
request
all
necessary
material
and
equipment
necessary
in
connection
with
occupational
therapy
(old
term)
for
Veterans'
Bureau
patients
from
the
commanding
officers of
the
naval
hospitals,
who
will
furnish
the
material
and
equipment
in
accordance
with
reference
(a)
;
that necessary for naval
personnel
will
he obtained
in
the same manner
as is
now practiced
by the Red Cross.
5. All
articles
made
by
Veterans'
Bureau
patients
will
be
held
pending
legislation
regarding
their disposal,
and information concerning
this will
be
supplied
in a subsequent circular letter.
E. R. Stitt.
180
Vol. XVII.
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
Circular letter.
WJCA : ESK
129733
( 52 ) .
Serial No.
190-1922.
Washington.
D. C,
22 May,
1922.
To: All naval
hospitals.
Subject: The handling
of records
for patients
of the United
States
Veterans'
Bureau
in United
States
naval
hospitals.
Reference:
Letter from
the Director
United
States
Veterans'
Bureau
to
the
Surgeon General of the Navy, ML/EG:
6 of May 13, 1922.
1. For
your information there is quoted herewith
the contents of the above
reference :
" In order
to facilitate
the handling
of records
for
patients
of the United
States
Veterans'
Bureau,
it is desirable
to extend
to other
Government
insti
tutions
certain
procedure
now followed
in United
States
veterans'
and United
States
marine
hospitals.
You
are
therefore
respectfully
requested
to
Issue
orders
to
all
United
States
Navy
hospitals
treating
patients
of
the United
States
Veterans'
Bureau
as follows :
" THE ASSIGNMENT OF REGISTER
NUMBERS.
"a. Every
patient
of the United
States
Veterans*
Bureau
should
receive
a
register
number
upon
admission
to
the
hospital.
This
number
should
be
retained
by the patient until his discharge,
and it should
appear
on all records
of the patient during the period of hospitalization,
particularly
admission
ami
disposition
cards, Form 1971-F.
" 6. The
register
numbers
for
United
States
Veterans'
Bureau
patients
should
be assigned consecutively
from
one distinct
series for each
hospital.
" c.
Only
one
number
should
be
assigned
to
each
patient
during
one
con
tinuous
hospitalization.
"d. A
new
register
number
should
be
assigned
upon
readmission
of
the
patient
to the hospital.
" e. The series of register
numbers
for
United
States
Veterans'
Bureau
pa
tients
should
start with
1 and be carried
on
indefinitely
until further advised.
" In order to start this system of register
numbers all patients of the United
States
Veterans'
Bureau
remaining
in
the
hospital
on
June
1,
1922, will
be
numbered
from
1 up.
The
first new patient
admitted
on June
1,
1922, will be
assigned
the next
highest
number.
For
instance,
if
on June
1
there
are
SS
patients
in
the hospital,
numbers
1 to
88 will
be assigned
to
these patients.
Number
89 will
he assigned
to the first
new patient.
"A list of patients
in
the hospital
on
June
1,
1922.
giving
name, register
number,
date of admission,
and
diagnosis,
should
be sent
in
to
the Director
United
States
Veterans'
Bureau,
Washington,
D. C,
attention
Medical
Sta
tistics
Section.
"TRANSMISSION
OF
REPORT
CARDS.
FORM
1U71-F.
"Two copies of report
cards, Form
1971-F,
will
be executed upon admission
and
discharge
of each
patient
in
addition
to
copy
retained
at
the hospital.
One of the copies will
be forwarded
to the manager of the district where
the
hospital
is located and one direct
to the United
States Veterans'
Bureau.
Wash
ington,
D.
C.
Cards
to the Director United
States
Veterans'
Bureau,
will be
forwarded
as follows:
No. 1.
181
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
"a. A man i la envelope
of special
size
(6 by 8* indies),
a
supply
of which
may
be obtained by requisition,
should
always
be used.
" b. All
envelopes
bearing
the
name of
the
forwarding
station
should
be
numbered
consecutively,
beginning
with
1
and
marked
thus,
Cards
1971-F,
package
No. — .
" c. All envelopes are to be addressed
to
The Director,
Attention Medical
Statistics Section,
United States
Veterans'
Bureau,
Washington,
D. C
" Cards should never
be allowed
to accumulate
any length of time, but should
be forwarded as soon as possible after admission
or discharge
of patients.
"It is requested that two copies of above orders
to hospitals
be supplied
to
the
Director
United
States
Veterans'
Bureau,
attention
Medical
Statistics
Section."
K.
K. Stitt.
Circular letter.
Serial No.
191-1922.
HBS:DKG
132609-0(54).
Washington,
D. C,
25 May,
To: All medical
officers.
Subject : Surveys
on Medical Department
property.
1. The attention
of all medical
officers is called
to
the
necessity for greater
care in the preservation
of Medical
Department
property.
2. Surveys are daily reaching
the
bureau
which
show many costly
items
re-
wived within
the
past
year
or
two with
recommendation
from
the board
of
survey
that
they
be destroyed
as of no value,
deterioration
due to " use," etc.
In many
instances
the date of receipt
is given
as " unknown,"
original
cost
"Qnknown,"
or the word
"missing"
is
used
with the statement
"no
responsi
bility."
Again,
pocket
cases,
surgical
instruments,
or
other
cases
are
recom
mended
for return
to supply
depot, and upon arrival
at the depot it is found
that
they
have
been
looted of their contents
and only
the
bare cases returned.
3. The new
supply
table of the Medical
Department,
1922,
provides
Instru
ments
and spare parts
for cabinets,
cases,
and pouches;
therefore,
when
a few
of their
contents
are
deteriorated
or
broken
only
the
actual
instruments
so
affected
should
be
surveyed
and requisitions
submitted
to
supply
the missing
parts.
Medical
officers
and
Hospital
Corpsmen
should
carefully
study
the
new supply table of the Medical
Department.
4. Upon
receipt
of nonexpendable
medical
supplies
property
cards
must
at
once
be prepared
showing
date of receipt,
cost of each item, and number
and
fiscal
year of requisition.
The bureau
will
then
be able
to
determine
when
such property
is surveyed
If reasonable
service
has
been
obtained
therefrom.
Sursical
instruments
should,
with
reasonable
care,
last
for
a
number
of
years,
and
platinum
needles, which
are
so
frequently
surveyed
in
quantities
and are expensive, should
last indefinitely.
5. It is impracticable
to enumerate
in detail the many
expensive
items sur
veyed which appear to have rendered
but little service, but if the same
care is
given
hy medical officers and Hospital Corpsmen
to Government
property
that
is used
with
respect
to their personul
property
the bureau will be relieved of
considerable
embarrassment
from
needless expenditures,
which
is essential
in
these days of economy.
182
Vol. XVII.
INSTRUCTIONS
TO MEDICAL
OFFICERS.
C. The
Secretary
of the Navy,
in a recent letter
to all bureaus,
directed that
disciplinary action
he taken against
persons guilty
of neglectful
responsibility
in the care of Government
property.
Property
.surveys
will
therefore
receive
special attention
in future.
E.
It. Stitt.
Circular
letter.
Serial No.
192-1922.
HBS : DRG 132079(54) .
Washington,
D. C,
24
May, ldii.
To: Medical
officers on shore stations
in
the
United
States.
I. This
bureau's
reply
to
an
inquiry
made
by
Commanding
Officer.
Naval
Medical
Supply
Depot,
Brooklyn,
New
York,
is
published
for
information
of
officers concerned :
"To: Commanding
Officer. Naval
Medical
Supply
Depot. Brooklyn,
New York.
" Subject: Complement
of shore stations
relative
to quantities
of medical
de
partment
supplies
to be furnished.
"References:
(«)
Letter,
Commanding
Officer.
NMSD.,
Brooklyn.
M-2-2—
EKR: KG of
12 April.
1922.
{b)
U.
S.
Navy
Regulations,
1920, Article
1185 (l)-(7)-<9).
(c)
U.
S. Navy
Regulations.
Article
1575-1580."
1.
Replying
to question contained in reference (a), "Are expenditures
author
ized
under Medical
Department
of the Navy
appropriations
for double
Hie num
ber of civilian
attaches
to
the number
of
Navy
personnel
attached
to
a sta
tion."
It lias
been
decided that
on shore
stations
in the United
States
where
the treatment
of families
of officers anil enlisted
men and first-aid
treatment
fin-
civil
employees,
as provided
in reference I'/), is required,
medical and surgical
supplies shall
lie requ
sitioned
for on the basis of active Navy
and Marine
Corps
complement
allowance.
2.
Medical
supplies
over
the complement
allowance
will
be
furnished
such
stations
in such
quantities
as may be necessary for the treatment
of families of
officers and enlisted
men, and first-aid
treatment
of civil employees, as provided
in reference
(b), but the additional
supplies
required
for this purpose must be
made the subject of
a special letter
to the Bureau
to accompany
the requisition
in each
instance.
3. The
unlimited
expenditure
of Medical
Department
supplies
for
treatment
of civilians, not
authorized
by
reference
(«),
is not
approved,
and the medical
officers of shore stations
concerned will be so informed.
K. R. Stitt.
Circular
letter.
Serial
No.
193-1922.
\V.ICA:ESK
132li!S7-Oi
01 > .
Washington,
D. C.
.7 June, 19£i.
To : All naval
hospitals.
Subject
: Care
of Veterans'
Bureau
patients
in U.
S. naval
hospitals.
Reference:
Letter from
Director.
I'.
S. Veterans'
Bureau,
to
Surgeon General.
U. S. Navy,
dated May
29. 1922.
1. Arrangements
have been
made whereby,
during
the liscal
year
1923. the
Bureau
of Medicine
and Surgery.
Navy
Department,
will
designate
and main
tain
the following number of beds
in
the respective
naval
hospitals
mentioned
below for the use of U. S. Veterans'
Bureau
patients:
Xo. 1.
183
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
Chelsea.
.Mass
500
Great
Lakes,
111
650
League Island,
Pa
125
Newport,
H. I
50
New
York,
N. Y
400
Norfolk, Va
100
Pensaeola, Fla
25
Portsmouth,
N. H
50
Washington,
D.
C
250
2, 150
2. Should
the
necessity
arise
the Veterans'
Bureau
lias
been
authorized
to
utilize
from
time
to
time
a
certain
limited
number
of beds at
the following
naval
hospitnls
:
U.
S. Naval Hospital, Mare Island, Calif.
D.
S. Naval Hospital, San Diego, Calif.
U.
S. Naval
Hospital, Honolulu. Hawaii.
U.
S. Naval Hospital, Manila
(Canacao,
P. I.).
It
is
not
thought
that
the utilization of hospital
facilities
in
these
hospitals
will be of a sufficiently
continuous
or extensive
nature
to warrant any increase
of personnel
to care for Veterans'
Bureau
patients.
3. Commanding
officers of naval hospitals
other than those referred
to in para
graphs
1 and 2 are directed
to admit Veterans'
Bureau
patients
in emergencies
and
to
notify
the
Bureau
of Medicine
and
Surgery
of
all
such
admissions.
E. R. Stitt.
Circular
letter.
Serial
No.
194-1822.
HBS-DRG
125884(61).
Washington,
D. C,
~ June,
19tZ.
To: All medical
officers.
Subject
: Alcohol,
X-ray supplies,
laboratory
supplies,
and surgical
instruments,
requisitions
for.
References:
(a) Bureau
medicine
and
surgery
circular
letter,
No.
172-1922;
dated
28 March,
1922.
(6)
Supply
table of the Medical
Department,
U. S. Navy,
1922.
I.
ALCOHOL.
1. Alcohol
for use by
the Medical
Department
of the Navy
will
iu future be
obtained
on Form B or Form 4 requisitions
from
nearest
naval
medical
supply
depot :
quantities
required
will
correspond
with
complement
allowance
pre
scribed
on
page
9, supply
table of the Medical Department,
1922.
This product
is furnished
in
500
cc. bottles exclusively
is a cologne spirits,
and suitable
for
internal administration.
Naval
hospitals
are authorized
to procure
additional
alcohol
needed
for
nonmedical
use
from
supply
officers
on
stub
requisitions,
chargeable
to allotments
granted
by this bureau
for the purpose.
II.
X-BAY SUPPLIES.
2. Estimates
for laboratory
and X-ray
supplies
submitted
to
the bureau,
in
accordance
with
instructions
contained
in
reference
<n)
indicate
that
these
instructions
were in many instances
misinterpreted,
and numerous
Items were
included
in the estimates for laboratory
supplies
which
are listed in the supply
184
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
Vol. XVII.
table of the Medical
Department,
1922.
The following additional
instructions
relative
to proper procedure for obtaining
such supplies are therefore
issued:
(o) X-ray dental films and duplitized
films will
be furnished
by Naval Medi
cal Supply
Depot, Brooklyn.
X. Y.,
on letter request direct
to that depot.
These
requests will not exceed
estimates
submitted
to the bureau
In compliance
with
reference
(o).
Upon
receipt of such request by the commanding
officer Naval
Medical
Supply
Depot,
Brooklyn,
the contractor
will
be directed
to
forward
films direct to the activity requiring them.
The expenditure
will lie covered by
emergency issue slip in
the same
manner
as are biologicals
at present.
Upon
receipt of the films by the activity concerned the responsible
officer will
imme
diately
accomplish
the emergency
issue slip and
return
to
the supply
dei>ot.
This is important,
as authority
for payment for the films is contingent
upon the
receipt of these receipted slips.
The films supplied will be freshly
prepared
and
will bear
a date of expiration
of period of usefulness.
It is contemplated
that
requests will be promptly
filled, which will obviate the necessity for carrying o
large stock
Of films on hand and insure
fresh supplies
when
needed.
Sufficient
films for three months' supply only should
be required
at one lime.
(6) X-ray chemicals
(nonsupply
table)
will be obtained
on Form
4 requisition
from
Naval
Medical
Supply
Depot,
Brooklyn,
direct,
within the estimates
sub
mitted to the bureau.
These products will be supplied in the following standard
size packages :
Barium sulphate for X-ray diagnosis,
1-pound carton
or can.
Sodium
sulphite
in 5-pound bottles.
Chrome
alum in 1-pound-
bottles.
Sodium
hyposulphite
in 25-pound kegs.
X-ray powders
in size sufficient
to make one gallon of developing
fluid.
Potassium
ferrlcyanide in 1-pound bottles.
Other chemicals
required
are Form B items.
(c)
Requisitions for
dental
film
mounts,
X-ray
photographic
papers,
film-
filing jackets,
lantern
slides
and
accessories,
film
hangers,
developing
trays,
gloves,
X-ray
aprons,
X-ray
and
kidney
compressor
bags,
will
be
made
on
requisition
Form
4,
and
forwarded
direct
to Naval
Medical
Supply
Depot,
Brooklyn, if within the estimates
submitted
to the bureau.
(rf)
Requisitions
for X-ray Coolidge
tubes will
be made on
requisition
Form
4, submitted
direct
to the Naval
Medical
Supply
Depot, Brooklyn, if within the
estimates submitted
to the bureau.
In preparing
requisition
for Coolidge X-ray
tube,
radiator
type,
10
milllampere
capacity,
specify
the
make
of
machine
with which
tube is to be used.
(e)
Requisitions
for
cassettes
and
intensifying
screens
will
be
made
on
requisition
Form 4 direct
to Naval
Medical
Supply
Depot, Brooklyn, if within
the estimates
submitted
to the bureau.
Requisition for cassettes must specify
dimensions
of
cassette
required,
especially
the
thickness,
and
the
make
of
machine
with which
It is to be
used.
In preparing
requisition
for intensify
ing
screens,
specify
the size of cassette with which
they are
to
be used and
whether
the standard,
thin,
or both
standard
and
thin,
are
required.
These
two items will
not be carried
by supply
depot, but will
be purchased
upon re
ceipt of requisition
giving
specifications.
(f)
Requisitions
for any
other
X-ray
material
required
in
emergency will
be submitted
to the bureau for approval
together with explanatory
letter.
in.
LABORATORY
SUPPLIES.
3. Requisitions
for laboratory
supplies
will
be submitted
in accordance
with
instructions
in
the
supply
table
of
the
Medical
Department,
1922,
and
will
specify
items
listed
in
Parts I
and III
thereof
wherever
possible.
Special
No. 1.
185
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
attention
is called
to
contents of cabinet,
labosatory,
Navy
standard,
which
together
with
Form
B
chemicals,
includes
practically all
apparatus
and
re
agents required for usual
laboratory
examinations
in accordance
with modern
methods.
It will
not
be
necessary
to
requisition
for
reagents
of any
other
size
containers
than
those
specified
in
the
supply
table,
nor
to
require
a
multiplicity of sizes of items
such as test tubes, flasks,
bottles, pipettes,
etc.
(a)
Requisitions
for
laboratory
supplies
listed
in Part III of the
supply
table will be
prepared
on
requisition
Form
4 and
forwarded
direct to naval
medical supply depots.
(b)
Requisitions
for
items
not
listed
in Part III of the
supply
table will
be
made
on
separate
requisition
Form
4
and
forwarded
direct
to the Naval
Medical
Supply
Depot,
Brooklyn,
N.
Y., if within
the estimates
submitted
to
the bureau.
(c)
Requisitions
for laboratory
supplies
other
than
specified
above will
be
made on requisition
Form 4 and submitted
to the bureau for approval,
together
with explanatory
letter.
IV.
6UBGICAL
INSTRUMENTS.
4. All
" requisitions
for surgical
instruments
other
than
those listed
in Part
III of the supply
table will
be made
on requisition Form
4 and
submitted
to
the bureau for approval
together with explanatory
letter.
E. R. Stitt.
M-§.
#13267!) (43).
41822CO-SD.
U. S. Naval Medical Supply Depot,
Sands
and 1'eabl Street,
Brooklyn,
A".
V., April 18, 1922.
To: All medical
and dental
officers.
Subject:
Typographical
errors
in supply
table, Form B and Form B-Dental.
1. The above-mentioned
forms
contain
errors
which
should
be corrected
on
each copy, as follows :
supply table.
I "age
.1,
4th line,
change " Snick " to " Schick."
Page
10,
column
B,
strike
out "Less
than
T.*i men"
and
insert
"75
to 150
men."
I'age
21, strike out "Case, diagnostic,
electric
(recruiting)."
Page
27, items " Corks, bottle, Nos.
3,
4,
5
6,
7
(16)
.
.
.
dozen 10 10 20 30 40
"i<i 60
70
100 "
out
of
alphabetical
order.
Indicate by arrow
that
this item
should
follow
item "Cork presser."
(This
change necessary
to conform
with
Form
B.
I'age
36.
item " Illuminator,
bracket,
electric."
strike out " 110
volts "
and
insert reference number "(40)."
Page 36. Item " Illuminator, bracket, electric, lamp for," strike out " 110 volts "
and insert reference
number "(40)."
i'age
40, Item " Syringe,
conductive
anaesthesia,
etc.," change " 88 " to " 87."
Page
42, Item "Atomizer,
hand, etc.," change allowance "
3
" in eoulmn " Stand
ard equipment." to " 0."
Page
44,
items
"Argentum
eolloldale,"
change
reference
number
"(24)"
to "(42)."
186
Vol. XVII.
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
Pages
46 ami
47,
insert
reference
number
"(42)"
after the following Items:
"Apron,
operating,"
"Gown,
operating."
"Towel,
hand,"
"Toweling,
crash,"
" Book
blnnk,
small
quarto,"
" Envelope,
official
size,"
" Eraser,
rubber,"
" Ink
stand,"
" Pad. memorandum,"
" Paper
clip,"
" Paper
fastener,"
" Pencil,
lead,"
" Penholder."
" Pen, steel," " Rubber
band,"
and " Rule."
Page 60 item "Gauge
steel
(Handerson
)'* change to read "(Henderson)."
Page
88, item
" Water heater,
electric,"
strike out
the Hue
" Water heater
.
.
. number
1."
INDEX.
Page 90. " Bistoury, straight,"
strike out "84."
Pago 91, " Bone surette,"
strike
out "69."
Page 91, " Bucket,
agate." change " 29 " to " 30."
Page 92. "Card confusion
colors"
change "87"
to "88."
Page 92. "Case diagnostic
electric
(recruiting)"
strike out "2,1."
Page 93.
" Combination
syringe,"
strike out " 77."
Page 93, " Corkscrew
" insert
page
" 27."
Page 93. " Cotton,
absorbent,"
stroke
out " 65," " 66,"
" 86."
and " 87."
Page
93,
insert
after
" Cotton,
absorbent,"
" Cotton,
absorbent,
compressed
.
.
. pages 65,
66,
86, 87."
Page 93. " Curette,
bone," strike out " 69."
Page 94,
" Diagnostic
case,
electric
(recruiting),"
strike out "21."
Page 9."). " Diagnostic
tags " change to " Diagnosis
tags."
Page 97, " Hagedorn
needles " change " 24 "
to " 23."
Page
99.
after
" Laryngeal
mirror,
handle,"
insert
page
numbers
" 58 "
and "72."
Page
99. strike out "Matches, waterproof
.
.
. 65."
Page 99. strike out " Methyl violet
.
.
. 81."
Page 100, " Morphine
sulphate
hypo, tablet,"
insert page number " 65."
Page 100, " Needle, suture, Hagedorn,"
change page
" 24 " to " 23."
Page
103. " Reamer,
root,"
insert
page number
" 39."
Page
103, " Repair tools, bridge,"
change " 49 " to " 51."
Page 105, "Suture,
needle, Hagedorn,"
change " 24 " to " 23."
Page
107, " Urethroscope,"
insert
page " 63."
FOBM
B.
Page
13, strike out " Case, diagnostic
electric (recruiting)
(19)
.
.
. number."
FOBM
B—DENTAL.
Page
3,
Item
" Illuminator,
bracket,
electric,"
strike
out
" 110
volts " and
insert
reference
number "(40)."
Page 3, item " Illuminator, bracket,
electric,
lamp for," strike out "110 volts"
and insert
reference
number
"(40)."
Page
11.
the following items are not in alphabetical
order
according
to the
supply table : "Caryophylli, oleum," "Collodium flexile,"
and " Hydrargyrum."
Pages
13 and 14, insert
reference number "(42)"
after items:
"Apron, operat
ing,"
"Gown,
operating."
"Towel,
hand,"
"Toweling,
crash,
(38),"
"Book,
blank,
small
quarto,"
"Envelope,
official
size," "Eraser,
rubber,"
"Inkstand."
" Pad,
memorandum,"
" Paper
clip,"
" Paper
fastener,"
" Pencil,
lead,"
" Pen
holder,"
" Pen, steel,"
" Rubber
band,"
and " Ruler."
Xo. 1.
187
INSTRUCTIONS
TO MEDICAL OFFICERS.
VITAL STATISTICS.
In the future the " Monthly Health Index," which will be published
on the
fifteenth of each
month, will contain
statistical data for individual
ships
and
shore
stations.
The statistics appearing
in this bulletin are summaries
com
piled from those published in the "Monthly Health Index."
Annual
rates,
shown
in
the
succeeding
statistical
table,
are
obtained
as
follows :
The total number
of admissions
to the sick list or the number of deaths re
ported
during
the period
indicated
is multiplied
by JA4 or -V/ or 12, depending
upon whether the period Includes four or five weeks or a calendar
month.
The
product
Is then multiplied
by 1,000 and divided
by the average complement.
E. R. Stitt.
Table No.
1.—Monthly
report
of morbidity in United
States Navy and Marine
Corps for the nwnth
of Man,
1022.
Atlantic
stations
Pacific
stations
Entire
Navy.
Forces
afloat.
Atlantic
Fleet.
Pacific
Fleet.
Shore
stations.
in
United
States .i
in
United
States.
Marine
Corps.
ADcauses:
•122,870
■82,122
•32,652
•29,760
•40,748
•22,958
•6,104
21,612
Annuxl rate per 1,000
4 929
481.37
2,529
369.54
988
363.10
984
398.78
2,400
706.78
1,318
688.91
215
422.67
1,238
687.39
Di&t&»only:
4,237
415.74
2,179
318.40
867
318.63
870
350.80
2,078
611.95
1,075
596.S8
Annual rate per 1,000
Injuriesand poisons:
Number of admissions...
672
65.63
350
51. 14
131
4a 14
124
50.00
322
94.(3
103
90.50
Annual rate per 1,000....
Communicable
disease
ex
clusiveor venereal
disease:
Number of admissions.
. .
1,061
108.62
575
169.33
386
143.12
57
29.79
19
297
164.91
Annual rate per 1,000
37. 35
Venerealdisease:
170 !
38
88.86
74.70
Number of admissions...
1,088
106.25
677
98.92
365
134.14
212
85.48
411
263
146.03
Annual rate per 1,000
121.04
1Doesnot include
9th naval district.
1includes Navy and Marine Corps personnel.
Note.— Asiatic and unaligned
ships not reported.
103390—22
13
188
Vol. XVII.
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
Table No.
2.—Number of admissions
reported
by Form F cards for certain
dis
eases for the five-week period, April 29 to June
3, 1922, inclusive.
Forces afloat, Navy
and Marines
(com
plement),
82,122.
Forces ashore. Navy
and Marines
(com
plement),
40,748.
Total (comple-
plement),
125,870.
Number
of admis
sions.
Annual
Number
of admis
sions.
Annual
rate per
1,000.
Number [ Annual
of admis-
rate per
slons.
1,000.
2, 179
rate per
1,000.
3IX. 40
51. 14
2,078
322
611.95
94.83
4 257
41V 74
350
672
65.63
2,529
369.54
2,400
706.78
4,929
481.37
class nr.
a
6.28
1.02
3.65
34
11
10.01
3.24
5.01
.59
77
18
42
7.52
1.76
4.10
7
25
0
1
17
2
0
23
13
8
41
30
18
4
2
.20
10
19
.15
1.46
2.78
6.77
3.83
2.36
12.07
8.83
4. 71
1. 18
1
33
32
.10
3.22
3. 13
Gastritis, acute catarrhal
1
19
39
11
.15
2.78
5.70
1.81
9
60
69
27
.88
5.86
6.74
2.64
3
.44
7
.68
Clan VII.
Clou VIII.
178
26.01
199
58.60
377
36.82
11
1.61
15
4.42
26
2.54
1
0
21
7S
23
11
2
8
2
0
.15
2
2
4
.59
.59
3
2
25
129
29
13
12
17
2
1
:2
3.07
10.96
3.36
1.61
54
6
2
1.18
15.90
2.44
12.60
2.83
1.27
1.17
1.66
.20
.10
1.77
.59
Pneumonia,
broncho
.29
1.17
10
9
0
1
2.94
.29
2.65
.29
Clatt IX.
CUut X.
143
20.90
90
26.50
233
22.75
0
1
.29
1
. 10
Dengue
5
0
13
.73
12
2
119
3.53
.59
35.04
17
2
132
1.66
.20
12.89
Filariasis
1.90
CUut XI.
Clan XII.
18
2.i'.::
133
39.17
151
14.75
9
1.32
34
10.01
43
4.20
141
478
20.60
69.85
a 47
98
223
90
28.86
65.67
26.50
239
701
148
23.34
68.46
14.45
58
Clau XVIII.
677
98.92
411
121.04
1,088
100-25
111
1
9
18
19.00
.IS
1.32
2.63
95
6
7
18
119
27.98
1.77
2.06
5.30
225
7
16
36
Tonsilitis, acute follicular
249
36.38
35.04
368
Clasi XX.
407
36.38
245
72. 15
652
63.67
29
4.24
26
7.66
55
...
Xo. L
189
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
Table No. 3. —Summary
of annual
admission
rates for venereal disease reported
from ships for April and from rxirious
shore stations for the five-week period,
April 29 to June
3, 1922, inclusive.
All ship*
Battleship
and cruiser force:
Atlantic
Fleet
Pacific Fleet
Asiatic Fleet
Destrover
force:
Atlantic
Fleet
Pacific Fleet
Asiatic Fleet
Miscellaneous:
Atlantic
Fleet
Pacific Fleet
Asiatic Fleet
■
Unaligned, including ships on special duty
Annual rate per I,O00t April.
Average rate since Jan. I, 1922.
Mini
mum
rate.
Mean
rate.
Maxi
mum
rate.
Mini
mum
rate.
Mean
rate.
Maxi
mum
rate.
0
102.70
902.25
0
126.01
831.02
10.38
98.68
326.84
16.62
103.49
321.25
22.26
77. 21
106.09
68.61
98.82
142.01
112.50
212.07
393. 19
0
118.54
902.25
0
147.12
697.39
0
79.84
631.57
0
96.33
476.19
0
78.68
103.66
o
.
280.3S
831.02
0
105.12
666.6*
0
123.ST
403. 15
0
85.26
448.59
0
73.96
258.06
0
321.95
698.41
0
340.34
814.81
0
194.28
700.00
0
163.27
491.80
Annual rate per 1,000.Apr. 29-
June 8. 1922.
Average rate since Jan. 1, 1922.
Mini
mum
rate.
All naval districts In the United States
First naval district
Third naval district
Fourth naval district
Filth naval district
Sixth naval district
Seventh naval
district
Eighth naval district
Ninth naval district
Eleventh naval district
Twelfth
naval district
Thirteenth
naval district. . . .
0
13.92
0
0
0
35.93
0
0
24.12
41.60
61.57
0
Mean
rate.
76.26
11.80
72.00
91.43
107.52
73.71
0
85.80
24.12
53.15
122.87
0
Maxi
mum
rate.
287.71
14.47
119.81
89. 16
216.06
287.74
0
87.81
24. 12
51.61
167.60
Mini
mum
rate.
0
12 45
4.33
0
17.96
50.99
29.81
0
66.14
13.69
60.61
17.14
Mean
rate.
89.07
21.30
65.04
188.04
145.25
54.01
29.81
129.91
66.14
31. 78
111.11
37.84
Maxi
mum
rate.
253.24
32.30
127.48
225.24
253.24
171.42
29.81
87.81
66. 14
48.37
139.21
88.88
RATIO
OF
GONOCOCCUS
AND
SYPHILIS
INFECTION
TO
TOTAL
CASES
OF
VENEREAL DISEASE.
All ships
Battle-Slip and cruiser
force:
Atlantic Fleet
Pacific
Fleet
Asiatic Fleet
Destrover force:
Atlantic Fleet
Pacific
Fleet
Asiatic
Fleet
Miscellaneous:
Atlantic Fleet
Pacific
Fleet
Asiatic
Fleet
Unassjgned, including ships on special duty.
Per cent, April.
Percentsince Jan. 1,
1922.
Gono-
coccus.
Syphilis.
Gono-
coccus.
Syphilis,
66.05
10.8S
65.80
11.42
64.70
16.47
68. 49
82.52
61. 11
12.87
9.70
16.66
91.13
1.26
52. 17
81.35
100.00
14.78
60.95
77.00
45.65
8.83
7. 31
14. 13
6.77
0
44.73
10.52
6.38
0
59.94
13. 16
78.72
72.72
61.76
17.64
81.25
51.29
59.24
7.38
18.53
13.02
190
Vol. XVII.
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
Table No. 3.—Summary
of annual admission
rates for venereal disease reported
from ships for April and from various
shore stations for the five-iceek
period,
April
29 to June 3, 1922, inclusive —Continued.
RATIO
OF GONOCOCCrS
AND SYPHILIS
INFECTION TO TOTAL CASES
OF
VENEREAL DISEASE—Continued.
Per cent Apr. 29-
Per cent since
June 3, 1922.
Jan. 1, 1922.
72.59
15.00
67.87
16.96
S
n
66.56
2ft 83
72.22
16.66
65.16
24.71
90.47
9.53
80.68
4.82
65.71
16.19
62.45
15.77
So.71
14.28
78.00
3
0
100.00
0
42.85
57. 15
65.3,8
30.76
100.00
0
68.12
15.62
100.00
0
80.76
65.62
It
S3.33
13 33
0
0
84.61
15.37
.
Table
No.
4.—Number
of admissions
reported
by Form F cards
and
annual
rates
1.000,
entire
Navy,
for the five-week
period, April 29
to June
S,
19t£,
inclusive.
Navy
(complement),
101,258.
Num
ber of
admis
sions.
Annual
rate
per
1,000
Marine
Corps
(complement),
21,612.
Num-
Annual
ber of |
rate
admis-
per
sions.
I 1,000
Total
(complement),
122,870.
Num
ber of
admis
sions.
oral
and
Diseases of blood
Diseases of circulatory
system
Diseases of digestive
system.
Diseases of ductless glands ar
Diseases of ear
Diseases of eve and adncxa
Diseases of genlto-urinary
system (nonvenereal)
Communicable
diseases
transmissible
by
oral
nasal discharges
•- ••■
Communicable
diseases
transmissible
by intestinal
discharges
Communicable
diseases transmissible
by insects
and
other arthropods
Tuberculosis
(ail forms)
Venereal
diseases
Other diseases of infective
type
Diseases of lymphatic system
Diseases of mind
Diseases of motor system
Diseases of nervous
system
Diseases of respiratory
system
Diseases of skin, hair, and nails
Hernia
Miscellaneous
diseases
Parasites
(fungi and cert
Tumors
Diseases of women
Total
I
33
477
1
93
71
163
228
40
39
926
■_';t
62
15
76
29
793
89
50
62
105
9
1
560
19
0.12
3.91
56.52
.12
11.02
8.41
19.32
27.02
4, 176
4. 74
4.62
109.73
27.73
7.35
1.78
9.01
3.44
93.97
10.55
5.93
7.35
12.44
1.07
.12
66.36
2.25
494.S6
n
6
147
16
16
40
124
7
263
99
17
4
38
14
139
41
11
24
40
1
0
141
22
1,238
3.33
81.62
.56
8.88
ass
22.21
14.44
.56
68.85
3.89
146.03
54.97
9.44
2.22
21.10
7.77
77.18
22.76
6.11
13.33
22. 21
.56
78.29
12.22
••.ST.Ki
Ka.L
191
INSTRUCTIONS
TO
MEDICAL
OFFICERS.
Table N'o. 5—Deaths reported,
entire Navy, for the flve-tceek period, April
29 to
June
S,
1922,
inclusive.
Meningitis,cerebrospinal
Pneumonia, lobar
Tuberculosis,chronic, pulmonary
Tuberculosis, other forms
Dermatitisexfoliative,
general
(Twlocystitis.
Enterocolitis
Poliomvtiitis, chronic, anterior
fvpluBs
Utber diseases
Drowriinr
Otheracudents and injuries
" ' BOS
Total
J admission rates per 1,000, all causes. . .
1admission rates per
1,000, disease only
Navy
(comple
ment),
101,258.
Marine
Corps
(comple
ment),
21,612.
Total
(comple
ment),
122,870.
1
0
1
1
0
1
1
0
1
1
0
1
0
1
1
1
0
1
0
1
1
1
0
1
2
1
3
5
2
7
3
0
3
S
1
6
2
1
3
23
2.73
1.54
7
:«)
2.1)3
1.76
3.88
2.77
o
VOL. XVII
NO.
2
UNITED STATES NAVAL
MEDICAL BULLETIN
INFORMATION
OF THE MEDICAL
DEPARTMENT
OF THE
SERVICE
THE BUREAU OF MEDICINE
AND SURGERY
■
NAVY DEPARTMENT
DIVISION
OF INSTRUCTION
AND PUBLICATIONS
COMMANDER
H. W. SMITH,
MEDICAL
CORPS,
U.
S. NAVY
IN CHARGE
EDITED
BY
LIEUTENANT COMMANDER
W. M. KERR, MEDICAL
CORPS, U. S. NAVY
PUBLISHED
FOR THE
ISSUED BY
AUGUST, 1922
(MONTHLY)
Compiled and published
under
authority
of Naval Appropriation Act
for 1922, approved
12 July, 1921
WASHINGTON:
GOVERNMENT
PRINTING
OFFICE
1922
Navy
Department.
Washington, March
20, 1907.
This United
States
Naval
Medical, Bulletin
is published
by
direction of the department
for the timely information of the Medi
cal and Hospital
Corps of the Navy.
Truman H. Newberry,
Acting Secretary.
Owing
to the exhaustion
of certain
numbers of the Bulletin
and the frequent
demands
from libraries, etc.,
for copies to complete their tiles, the return
of
any of the following
issues will be greatly appreciated
:
Volume VII,
No.
2, April,
1913.
Volume VIII, No.
1, January.
1914.
Volume VIII, No. 3, July, 1914.
Volume VIII, No. 4, October,
1914.
Volume X, No.
1, January,
1916.
Volume XI, No.
1, January,
1917.
Volume XI, No. 3, July,
1917.
Volume XI, No. 4, October,
1917.
Volume XII, No.
1. January,
1918.
Volume XII, No. 3, July,
1918.
Subscription
Price or the Bulletin.
Subscriptions
should
be
sent
to
Superintendent
of Documents,
Government
Printing
Office,
Washington,
D. C.
Yearly subscription,
beginning January
1, $1.50;
for foreign
subscription
add
$1 for postage.
Single
numbers, domestic,
15 cents ; foreign,
21 cents,
which includes foreign
postage.
Exchange
of publications
will
be extended
to medical and scientific organiza
tions,
societies,
laboratories,
and
journals.
Communications
on this
subject
should
be addressed
to
the
Surgeon
General,
United
States Navy, Washington,
D. C.
n
TABLE OF CONTENTS.
Page.
PREFACE
v
NOTICE TO SERVICE CONTRIBUTORS
vi
SPECIAL
ARTICLES:
Fish poisoning in the Virgin
Islands.
By Lieut. F. D. Walker, Medical
Corps,
U.
S. X
193
Chemical analysis
of the dlood.
By Lieut Commander
C. W. O. Bunker, Medical
Corps, U.
S. N_
202
The Weil-Felix
keaction.
By Lieut. J. H. Chambers,
Medical
Corps, U.
S. N
211
Aviation
medicine
in the United
States
Navy.
By Lieut. J. F. Neuberger,
Medical
Corps, U. S. N
214
Functions
and organization
of Medical
Corps Units serving with
the Marine
Corps
in the field.
By MaJ.
S. N. Raynor, United
States Marine Corps
220
Gas warfare: Effects of poisonous
gases —Early
and late.
By Maj. W. R. Gahvey,
Royal Army Medical
Corps
230
HISTORICAL:
Jonathan
Cowdery,
surgeon
in the United
States
Navy,
1767-
1852, Part II.
By
Capt.
F. L. Pleadwell and
Lieut.
Commander
W.
M.
Kerr,
Medical Corps,
U.
S. N
243
EDITORIAL :
Sir Patrick Manson — Demand for trained
leadership
In sanitation —
Use of Schick
test, antitoxin, and toxin-antitoxin in prevention
of
diphtheria —Quinine
and malaria —Oral hygiene
as applied
to hos
pital
practice — Ischiorectal
abscess —Treatment
of high blood pres
sure—Neuropsychiatry
disabilities—Airplane
ambulances
269
CLINICAL. NOTES:
Notes on the orthopedic service,
U.
S. Naval
Hospital,
Chelsea,
Mass.
By
Lieut. J. W. White,
Medical
Corps.
U. S. N
287
Notes
from
the
of.nito-i'kinary
service,
U.
S.
Naval
Hospital,
Chelsea.
Mass.
By Lieut. P. O. Northington,
Medical
Corps. U.
S. N
293
MeBCCBOCHROME-220
AS
A GERMICIDE
IN 8PTHALMIA
NEONATORUM.
By Lieut. C. C. Croft*, Medical
Corps,
U. S. N
295
AN" VSl'Sl'AL
CASE OF FOREIGN
BODY
IN PHARYNX.
By Lieut.
S. B. Forbes,
Medical
Corps,
U.
S. N
296
NOTES AND
COMMENTS:
What
is
an
epidemic? —Gonorrhea — Immediate
surgery
with
the
Royal
Marine Artillery
Howitzer Brigade in
France,
1916-1918 —
Contraction
of tularaemia
by
laboratory
workers —Carbon
monox
ide poisoning —Thomas
Dover— Destruction
of vitamins
299
NURSE
CORPS
313
BOOK NOTICES
319
QUERIES
327
NOTES
ON
PREVENTIVE
MEDICINE.
PREVENTIVE
MEDICINE
STATISTICS, LETTERS, ORDERS,
AND COMMENT
331
m
PREFACE.
The United States Naval Medical Bulletin was first issued in
April,
1907,
as a means of supplying
medical
officers of the United
States
Navy with information
regarding
the
advances
which
are
continually
being made in the
medical
sciences,
and
as
a medium
for the publication
of accounts of special
researches,
observations,
or
experiences
of individual
medical officers.
It is the
aim of the Bureau of Medicine
and Surgery
to furnish
in each
issue
special
articles relating
to naval
medicine,
descrip
tions of
suggested
devices,
clinical
notes
on
interesting
cases,
ab
stracts of current medical literature of special
professional
interest
to the naval medical
officer, reports from various sources, historical
essays,
notes
and
comments
on
topics of
medical
interest,
and
reviews or notices of the latest published medical
books.
The bureau extends an invitation
to all medical
officers to prepare
and forward, with
a view to publication,
contributions
on subjects
of interest
to naval medical
officers.
In ord«r that each
service contributor
may
receive
due credit for
his efforts
in preparing matter for the Bulletin of distinct origi
nality
and
special
merit,
the
Surgeon General of
the
Navy
will
recommend
that a letter of commendation
be forwarded to him upon
the acceptance of his manuscript for publication, and that a copy of
this letter be attached to his official
record.
The bureau does not necessarily
undertake to indorse all views or
opinions which may be expressed
in the pages of this publication.
E. It. Stitt,
Surgeon General United States Navy.
NOTICE TO SERVICE
CONTRIBUTORS.
When
contributions
are typewritten,
double
spacing
nnd
wide
margins
are
desirable.
Fasteners
which
can
not
be
removed
without
tearing
the
paper
are
an
abomination.
A
large
proportion
of the
articles
submitted
have
an
official
form
such as letterheads,
numbered
paragraphs,
and
needless spacing
between
paragraphs,
all
of
which
require
correction
before
going
to
press.
The Bn.r.ETiN
endeavors
to follow
a uniform style
in
headings
and captions,
and the editor
can
be spared
much time
and
trouble
and unnecessary
errors
can
be obviated
if authors
will
follow
in
the
above
particulars
the
practice
of recent
issues.
This is not only
important
in special articles,
but still
more
so in reviews.
The greatest accuracy
and fullness
should
be employed in all citations,
as it
has sometimes been
necessary
to decline articles
otherwise
desirable
because
it
was
impossible
for the editor
to understand
or verify
references,
quotations,
etc.
The
frequency
of gross
errors
in
orthography
in
many
contributions
is
conclusive
evidence that authors
often fail
to read over their
manuscripts
after
they have been
typewritten.
Contributions
must be received two months prior to the d;ite of the issue for
which
they are Intended.
The editor
is not responsible for the safe return of manuscripts
and pictures.
All
materials
supplied
for illustrations, if not original, should
be accompanied
by a reference
to
the source and a statement
as to whether or not reproduction
has been authorized.
The Bulletin
intends
to print only original articles,
translations,
in whole
or in part,
revietrs,
ami
reports
and
notices
of Government
or
departmental
activities,
official
announcements,
etc.
All original contributions
are accepted
on
the
assumption
that
then
have not appeared
previously
and are not
to
bei
reprinted
elsewhere
without
an understanding
to that
effect.
VI
103
U. S. NAVAL MEDICAL BULLETIN
Vol. XVII.
AUGUST,
1922.
No.
2.
SPECIAL ARTICLES.
FISH POISONING IN THE VIEGIN ISLANDS.
By F.
D. Walker,
Lieutenant,
Medical
Corps,
United
States
Navy.
The records of the sanitation office,
St.- Thomas, Virgin Islands of
the United
States, show
that
each
year
there have
been
cases of fish
poisoning.
During the months
of August
and
September.
1918,
34
cases occurred, due to the fish known
as " carang " which had
been
caught in deep sea fish pots.
The greater
portion of carang caught
are seine fish, caught near the surface of the sea and considered
good
food, in contrast to the "yellow jack"
variety of carang which is
generally considered
poisonous
and never used for food.
On October
14, 1919,
11
cases
were reported
due also to the carang.
There were
no deaths,
and
the predominating
symptoms
were gastrointestinal.
In
1920 there
were only two
cases of fish poisoning, one each in the
months of July and August, both from eating carang latus (locally
called
horse-eyed
"jack''
or "yellow jack").
This fish
is seldom
eaten in the summer
months,
because
the natives
have learned
to fear
it.
However, poverty or indifference often leads to its being used and
poisoning generally follows.
In this year, fish poisoning was made
a
reportable
disease.
Although
only two cases
were reported,
inquiry
brings out the fact that
many
mild
cases
occurred
that did
not re
quire medical attention.
The first
case for 1921 was reported
in February,
and was due to
an "amber jack"
carang.
From
March
until June, there
were
no
more
cases.
June and July show
one
case each due to amber jack.
August
had no cases.
September
showed
14—
6
carang,
7
king-fish
{scomberomorus
cavalla),
1
barracuda.
In October there
were
10
cases,
8
from carang and
'2
from barracuda.
In November
there was
one case from carang.
In one of the cases of barracuda
poisoning, the
fish weighed
about
3
pounds,
and was handled
in the following
way:
The patient caught
it
in the early morning;
it
was out of the water
for about four
hours,
when
he cleaned
it,
split
it
up by long knife
cuts and packed
it
in salt over night.
The next day he cooked
it
and
193
194
Vol. XVII.
WALKER— FISH
POISONING.
ate at least a pound.
No other person ate any.
The other
case of bar
racuda poisoning resulted after a similar treatment of the meat.
Both
these patients caught
the fish
and handled it themselves:
both
were
aware that there was some danger of poisoning, and the salting pro
cess was to avoid the effects.
Both men had been poisoned
some years
ago from eating this fish without
salting.
They
declared
that the
fish weighed
about
3 pounds.
A small barracuda is not
considered
dangerous
and large ones are never eaten.
In the history given the
sanitary inspector,
the patient said that about three hours after eating
the fish he had " reeling in the head, and an hour later diarrhea
set
in, which kept him from sleeping at night "
; he states that " the bones
throughout his body became very weary and as well he had an itching
of the skin very bothersome."
The itching and weakness lasted two
weeks and his convalescence
was slow in view of his mild illness.
In 1918,
1919, and
1920 all cases reported were carang poisoning,
more especially the fish called " horse-eyed jack." " cavalla," or " yel
low jack"
{carang latus), and
these
were all taken in deep-sea pots.
However,
in
1921,
out
of
the
28
cases
reported,
18
were
carang.
7
king
fish,
and
3
barracuda.
The
cases
of
carang
poisoning
occurred
in eight different groups;
one group of
6 cases all in one
family;
one of
5 in
one family;
one of
2, and
the
others
singly.
Groups of five, two,
and one occurred
on the same date— October 9.
1921.
The group of six occurred on
September
19,
1921.
All of
these
fish
were
caught in
deep-sea
pots.
On investigation
it was
learned that many families which had eaten carang had mild illness
among
the members for which
they
had
had
no medical
attention
and therefore were not reported.
The after-effects
were weakness and
itching that lasted sometimes for three weeks in some degree.
Our
inference from this investigation was that a day or two of illness in
a family group that had
eaten carang, at a time
when
other cases
were being reported,
especially
when the illness consisted of gastro
intestinal symptoms,
syncope,
and weakness with subsequent itching,
was enough to make a diagnosis of poisoning from fish.
It is safe to
presume that with
18
cases of carang poisoning reported there must
have
occurred for
the
season
about
50.
No
cases
were
reported
among
any American
people or local whites.
These
people
eat fish
less frequently, and their cooks are very careful to get the best fish.
On the other hand, in the fishing villages of Honduras
and in the
locality known as Cha-Cha town, populated by French people whose
chief article of food is fish,
and where
every marketable variety of
fish is eaten, including
carang and small barracuda, no cases of fish
poisoning have been reported.
In connection
with carang poisoning in 1920, the following warn
ing was published in the daily
papers
of St. Thomas by Lieut. E.
104-1
19J-2
No. 2.
195
WALKER—FISH POISONING.
Peterson. Medical Corps, U. S. Army, then chief sanitation officer for
St. Thomas-St. John:
WARNING AGAINST POISONOUS
FISH.
CAKANOS
CAUGHT
IN
FISH
POTS APT
TO
CAUSE
FI8H
POISONING.
September 22, 1918, an epidemic
of fish poisoning
occurred
In St. Thomas.
Investigation
of the cases
revealed the fact that all the victims
had partaken
of earang,
caught
in
a
deep-sea
fish pot.
In all,
34
cases
of fish poisoning
occurred.
October
14,
1919, practically the identical
occurrence
was repeated.
Nine carangs
were
caught
in
a
deep-sea
fish pot, and of the
11 people who
ate this fish, all were taken sick with fish poisoning.
It may be stated
that
the carangs
caught
on
nliove occasions
were
identical
in appearance with the ordinary seine carnng,
a distinct
species as compared
with the well-known
poisonous
yellow-jack
cnrang.
The underlying
factors,
causing
fish poisoning,
are, in the majority of cases,
obscure.
In some fishes u well-defined
toxin has been isolated, whereas in others
no positive
findings
have
been
ascertained.
Willi regard
to the earang,
the consensus of opinion
on the subject
seems
to
be that
this
fish at certain
times
is very
prone
to spoliation
with
the forma
tion
of
poisonous
substances,
probably
in
connection
with
their
spawning
periods.
Due to the above facts
that fish poisoning
hns been
caused two years in suc
cession
by eating earang caught
in deep-sea
fish pots, around
the same
time of
the year, it is likely that carangs,
caught
in this manner,
between the months
of August
and November,
inclusive,
are poisonous.
Hence a warning Is hereby given against
eating
carnngs
caught
in fish pots
during
the nbovp period.
E.
Peteksox.
Chief Sanitation Officer.
The Carangidse,
or the Pompanos, are pictured
and
described
in
" Naval Hygiene,"
Gatewood,
and mention
is made of the fact that
the earang latus seems
to be poisonous
only at certain seasons and
under certain
conditions.
In the
waters
about
St. Thomas it
is
a
dangerous
fish always during
the hot months of summer,
especially
when caught
in deep-sea
pots,
and
is always dangerous
when
the
fish is large.
No deaths
have
ever been reported, and it never
has
seemed
necessary
to
forbid
the eating of the
fish,
since
so many
people
depend
upon it for
a cheap
food.
The naval personnel
of
this
station
rarely
ever
get
earang
as food.
The
principal
thing
for visiting
ships
to
remember
when
in
the
waters
of
the Virgin
Islands
is that it is
a safe
policy
to reject
all fish
of
the
earang
variety, commonly called by the natives " jack," " yellow jack." " am
ber jack," and " horse-eyed
cavalli."
Some species may not be harm
ful, but many other better
food fish
abound
that can
be
accepted
with little or no risk.
Whether or not
the poison is in the fish or
is due to rapid
decomposition
can not be settled because of the man
ner in which they are handled.
196
Vol. XVII.
WALKER—FISH
POISONING.
In spite of the fact that in 1921 the kingfish
{Scomberomorus
re-
galis, cavaJla)
was responsible
for a number of severe sicknesses,
it
is
considered
the
finest
food
fish
in
these
waters.
When
caught
around these
islands these fish weigh
about
12 pounds: some heavier
but few less than 8 pounds.
All cases of poisoning reported occurred in the month of Septem
ber.
There were four separate
poisonings, one involving
three
in
a
family
and
one
two.
The
fish
in
each
case
was
caught
in
deep
water early in the morning, probably about
5.30,
and cooked in the
late afternoon about
4.30.
The symptoms
as given
were loose stools,
vomiting,
" bad
feelings,"
griping,
prostration.
The
writer
saw
these cases
and
can testify
to the " bad feelings " and prostrations,
which were all out of proportion
to the quick recovery,
the patients
being
able
to
get
about
the
next
day.
However,
the
prostration
continued
in part for two weeks or more
and some of the patients
were
troubled for days
with
severe itching.
Authorities
call this
fish a mackerel, akin to the Spanish mackerel
(Scomberomorus macu-
latus),
a smaller fish abundant
here, and considered
a toothsome
and
entirely
safe
fish.
The
National
Geographic
Magazine.
January,
1922,
says: "The
kingfish
sometimes
attains
the
weight
of
100
pounds,
is an excellent food fish, and is. next to the Spanish mackerel,
the principal export fish from the Florida coast."
The
month
of September
when
this fish
is thought
poisonous'
is
a very hot
month,
and
no doubt
the poisonings that occur
are true
food
and
not
fish
poisonings.
The
manner
in
which
fish
is han
dled
by
the
fishermen
of St. Thomas,
while
the
best
possible
for
the average
month,
is a bit faulty for the hot season.
They
go out
about
4
a. m., get their catch
and return about
9
a. m.
The fish are
brought in without any cleaning or cooling.
The sale occurs
on th?
wharf or
in
close proximity
to it and
by
11
a.
m. all
have
been
sold.
As
a rule, the natives
carry their
fish
home personally
and
cook it
at
once.
The high price of
ice or cooling systems,
and the
impracticability
of making the fishermen,
who
are very poor,
pro
vide " live-well " boats, makes it possible
only to endeavor
to lessen
the length of time
between the catching and cooking of the fish.
In St. Thomas it is very important that nothing shall
be done to
increase
the price of food, unless
it
can
be shown
that an advan
tage in
health
is gained
thereby.
It is thought
Letter
to have
an
abundance
of cheap
food, and trust
to the general
warning
issued
by the health
department,
and more especially to the native ability
to know "good
fish." than
to attempt
more regulations and restric
tions.
A
king-fish
caught,
cleaned
thoroughly,
and
well
cooked
within two hours,
is probably not poisonous
in any season.
The fisherfolk of the American Virgin Islands
in general consider
the barracuda
(Sphyraena barracuda)
caught
in
these
waters
as an
No.
if.
197
WALKER
FISH POISONING.
unsafe food.
Some will eat
a
small
fish, about
3
pounds,
others will
not eat any.
Here again the facts
seem
to favor
a
food rather than
a
fish poisoning.
The
natives
who eat barracuda
are usually
those
who fish for their
families
and
do
not
sell.
They
have
on
many
occasions
eaten
the fish without
harm.
In the
cases
reported here,
the fisherman
had
attempted
to cure
the
fish
by
the
local
method
which
consists
of thoroughly
cleaning
it,
making
long, deep
cuts
in
its flesh, and then packing
the whole
in coarse salt.
The fish
is
allowed
to stay
12 hours,
then
cooked
and
eaten.
Two
fishermen
who
so
prepared
the
fish
said
that
once
they
were
poisoned
by
"uncured"
barracuda and that they had since often eaten small
fish
" uncured
and fish of over
3
pounds
" cured " by their method
and
had experienc ed no ill effects.
The efficacy of salt to prevent
poison
ing from
barracuda has
been
under discussion
for many
years.
As
early as
1829, Currier and Valenciennes quote
a French
naturalist,
M. 1'lee, who lived in the West Indies,
as saying that the inhabitants
of St. Croix never
ate the fish until
it
had
been
in salt for 24 hours.
A
French physician
in
1823
reported
a
case of poisoning in Marti
nique, the fish having been
so cured.
The symptoms
complained of in our
cases
came on
three
hours
after eating
a
good portion of the fish
and
were
extreme
dizziness
and diarrhea, followed
later by "aching"
bones and
extreme
itch
ing.
Prostration
was
marked
for three
days,
and
in one
case
the
writer saw the patient still incapacitated for work after three weeks.
T. L. E. Clarke, medical
officer in the British Virgin
Islands,
in
1918. reported that in his experience
barracuda of
a
good
size from
certain
fishing grounds were always poisonous,
and that the poison
was not
due to any decomposition
from poor handling.
However,
many other specimens of edible
fish from these same fishing grounds
proved
poisonous.
The different
theories
regarding
the
poisonous
qualities of this fish are interesting, but none
is
based on experiment.
The idea that the fish eat the fruit of the very poisonous
manchaneel
tree can not be proven.
About St. Thomas there are plenty of these
trees overhanging the water, but to connect them with the barracuda
seems trivial.
Very little fruit gets in the water:
fish food for the
barracuda
is
very plentiful,
and this fish shows
no particular
desire
for this highly irritating berry.
The theory
that the fish
feeds on
copper
banks and thereby
attains poisonous
qualities
is
also firmly
believed
here.
There
are
few
copper-bottomed
wrecks
in
this
vicinity now. and no copper banks
near the fishing grounds.
The idea that during the summer
months this fish eats
a
poisonous
moss
is
well
established
in
the native
mind,
but
has
never
been
proven.
One
thing,
however,
is
constant,
and
that
is
the
symp
tomatology.
As proof of this
constancy
can
be
quoted
a
French
author in
1829 and
a
native
St.
Thomas
sanitation
inspector
in
198
Vol. XVIL
WALKER
FISH
POISONING.
1921.
The
older
observer
says: "The signs of
poisoning
by
the
becune (barracuda)
are a general trembling, nausea, vomiting, sharp
pains, particularly
in the arms and hands."
The inspector,
quoting
the patient, says, " Three hours after eating the fish,
he took in with
a reeling in the head, and an hour after diarrhea set in, which kept
him from sleeping
at nights.
His bones throughout his entire body
became
somewhat
weary as well, and he had an itching all over his
skin."
In 1675
an observer
states : " The fish that are here are many of
them poysonous,
bringing
a great pain in their joints who eat them,
which continues
for some short time, and at last, with two or three
days' itching, the pain is rubbed
off."
The inspector reports : " The
fish
was caught and corned
for
about
three
weeks
before
it was
cooked
and
eaten,
and
about
two hours after eating they
took in
with
the reeling in their
heads,
vomiting,
and
bowels."
The fish
weighed
about
18 pounds.
The writer saw the patients to whom the
inspector referred;
one was incapacitated for a month and suffered,
for clays from extreme itching.
In the 28 cases reported in St. Thomas in
1921 and treated
at the
municipal hospital, reliable data
were available.
The most striking:
thing in the histories is the fact that regardless of whether the fish
was
barracuda, king-fish,
or carang. the
symptoms
were all alike,
namely,
that of acute food poisoning.
Vomiting and diarrhea were
always
present,
as
was
prostration
in
some
degree.
Many other
symptoms
were
noted
in
addition,
such
as
violent
gastric pains,
muscular weakness,
slow, feeble
pulse, flushing of the skin with ex
treme itching.
The symptoms
were so uniform that in family groups
often only one case was described in detail, the others being so similar.
Few of the patients had any after effects, and these only showed les
sened capacity for daily tasks and some uncomfortable itching of the
skin.
One of the
most
common
food fishes eaten in St. Thomas is the
Batistes vetula Linnaeus, locally called " old wife."
Gatewood says,
in " Naval
Hygiene,"
that the family
Balistidse or trigger
fish, of
which
he
says Batistes vetula, is
a suitable example,
should not
be
used as food, as the flesh in some localities is said to cause very marked
toxic symptoms.
W. R. Dunlop, writing in the West Indian Bulle
tin,
1917,
upholds this view and
quotes
other observers,
including
Evermann
and Marsh, who say " shore
fishes of the tropical
seas of
rather
large
size
are carnivorous
or partly
herbivorous;
they
are
rarely used as food, many of them being reputed
as poisonous."
In
another
issue of this periodical Clarke states that this fish is readily
purchased
in the British Virgin
Islands
and is undoubtedly whole
some for food.
He has. however,
seen two cases of poisoning from
this fish that he could not attribute
to ptomaine formation between
SOME
EDIBLE
FISH
FROM
ST.
THOMAS.
1. Sparisoma chrysopterum
(Bloch and
Schneider).
Brown
goutu.
2.
Scarus cceruleus
(Bloch).
Blue
goutu.
3. Balistes vetula
(Linnaeus).
Old wife.
EDIBLE
FISH
OF
ST.
THOMAS.
1. Epinephalus
odsensionis
(Osbeck).
Hind-fish.
2. Anisotremus surinamensis (Bloch).
Paugy-fish.
3.
Pomacanthus
arcuatus
(Linnaeus).
Flat-fish.
4. Sparisoma
abiidgaardi
(Bloch;.
Speck-tail gutu.
ms-2
No. 2.
199
WALKER —FISH
POISONING.
capture
and preparation.
The " old wife " as sold in St. Thomas is a
small fish weighing only
a few
pounds.
Like
a well-known
patent
medicine it is " unlike any other " and anyone who sees a picture of
it can readily pick it out of any group of fishes.
It is pictured well
in "Naval
Hygiene,
Gatewood."
Tradition
has it in St. Thomas
that this fish is sometimes
poisonous,
but since
1918 no case has been
reported.
A very large number is eaten in all seasons, and one of the
most common sights in the streets is the line of housewives going home
from the wharf carrying
a small string of fish with
the inevitable
"old wife."
The
dried skin is supposed
to have
some
virtue
as
a
scrub brush, and native women
use it on the floor in preference
to a
more modern brush.
Many other fish are used as food here and have no stigma
of poi
soning attached to them.
The red snapper is highly prized;
fish of
this
type
are
locally
called
rock
fish.
The
National
Geographic
Magazine
for January,
1922,
shows
a plate of a similar
fish called
mutton fish.
The groupers and grunts are palatable and
safe fish,
as are also the fish called
locally
the " Goutu,"
a blue fish of about
4 pounds weight with a flat nose like a dolphin.
Xo difficulty is ever experienced
in keeping the people from eating
such well-known poisonous
fish as the Puffers (Spheroides spengleri)
and similar ones equally dangerous.
No cases have ever
been
noted
by the writer
of poisoning from
the toxic
effects of handling
the
fish.
The
conclusions drawn from
the
cases
observed
point
to the
fact that at certain seasons some usually good market fish are harm
ful, either due to inherent poison
from whatever cause, or from bac
terial products
produced
by poor handling.
The absence
of mortal
ity
in these
cases lightens our responsibility
and permits us to allow
the most liberal
use of all fish that
a
Virgin Islander
sees fit to eat.
Visitors, especially in the months of August, September,
and October,
will profit best by listening to the advice of local fish savants,
even
though they can not prove the point at issue.
Dr. H. F. Taylor,
assistant, United States Bureau of Fisheries, has
published
certain notes concerning poisonous
fishes
and
a
selected
bibliography of references
to literature on the subject
which will be
found
exceedingly
valuable.
He states that
it
appears
to be true that poisonous
fishes are much
commoner in tropical than in temperate
waters,
and that fishes that
are harmless and
a
regular article of diet in the latter may
be regu
larly or
frequently
poisonous
in
the
former;
that
certain
species
are constantly and always poisonous,
and that others only occasion
ally cause sickness.
The members of the family Tetradontida? (puff
ers, swell
toads)
are looked upon generally
as poisonous
in tropical
waters, while several others are said to be occasionally poisonous.
In
200
Vol. XVII.
WALKER
FISH
POISONING.
the book by Ciatewood there is a list with illustrations, mentioning the
toxic characteristics of many
fishes.
The causes of poisoning by fishes are diverse
(no account
is taken
here of venomous fishes that inflict with their teeth or spines poison
ous wounds).
It appears
that some people exhibit idiosyncrasies
in
this respect ; in such
cases there appears
to be an inability
to digest
fish, due, it is said, to a deficiency
of hydrochloric
acid in the gastric
juice;
violent
digestive
disorders,
such
as
acute
indigestion,
may
follow
a meal composed of fish.
In other cases, the oil in the fish is
an obstacle to digestion.
Some
fishes,
not
themselves
poisonous,
may
transmit
poisons
through their food to persons eating them.
This is alleged
to be true
in the West Indies
where
fishes
eat
the
manchineel
fruits.
Other
foods, sometimes poisonous
to man, but apparently harmless to fishes,
include
molluscs,
zoophytes,
corals,
medusae,
holothurians,
and
protozoans.
Fishes
that live in putrid detritus
may
undoubtedly
convey some poison to man.
This case is unlikely,
however,
in open
sea
water.
The
deliberate
use of poisons
to capture fish,
such
as
fish
berries
{Cocculus
indicus),
may
cause poisoning in this
class,
though it is not known that persons have been actually poisoned
from
this illegal method of capture.
The
most important
cause of poisoning
by
fish
relates
to
cases
where the meat of the fish is in itself poisonous.
There are two im
portant subdivisions of this general
class ; first, inherently poisonous ;
second, and flesh which acquires
poisonous
quality after death of the
fish.
In the former subdivisions certain fishes (Tetradons)
undoubt
edly
belong.
The poisons
are called " leucomaines " or animal alka
loids that are normal and physiological in the fish, and represent no
derangement.
The
poisons
seem
to
be
concentrated
in the genital
organs,
viscera, and surrounding
tissues, especially
during the breed
ing seasons.
They are violent piosons causing death in a short time.
They
are also distributed
to
a lesser degree in the flesh of the fish.
It is possible
that other
chemical
poisons,
possibly cynates, exist in
other
fishes, especially
the liver, of certain selachians.
The other subdivision of this class of poisons
relates
to poisonous
quality developed
after death of the fish, and the opinion is general,
though not
unanimous,
that the poisoning
by
the barracuda
is of
such
a
nature.
It
appears
almost
certain that poisoning
by
Ca-
rangidae is of this kind.
Fish flesh may spoil very readily, especially
in tropical climates,
and when slightly
spoiled
contains
the so-called
" ptomaines. " or substances of a putrescent
origin.
The
degree
of
poisonous
quality
may vary from mild to very
great
virulency.
A
close examination of the methods of handling may reveal that the fish
are
not
properly
chilled, or are otherwise
improperly
handled,
so
that opportunity
arises
for this decomposition
to occur.
In tropi
EDIBLE
FISH
SOLD
IN
THE
MARKETS
AT
ST.
THOMAS.
1.
Epinephalus
morio
(Cuvier
and
Valenciennes).
Grouper.
2.
Teuthis
hepatus
(Linnaeus).
Doctor-fish.
3.
Haemulon
album
(Cuvier
and
Valenciennes).
Margot.
No. 2.
201
WALKER
FISH POISONING.
cal
waters
every effort should be made
to
ice
the
fish immediately
upon capture
and keep them at ice temperature
at all times, and also
to
shorten
the time
between
capture
and
consumption
as
much
as
possible.
The markets should
be rigidly
supervised
so that their
fish
are
never
exposed
to warmth
at any time.
One
method
that has
been
used
to
prevent
" ptomaine "
poisoning
consists
of dropping
the
freshly
caught fish into boiling
water,
thus cooking it.
It will then
keep under
moderate
precautions until
eaten, better than raw fish.
Poisoning
by fish
is called in
the
AVest
Indies
" Ciguatera "
; in
the Philippine Islands the name for the puffer " botete " has become
the general
name for poisoning by fish.
Poisoning
by inherent
fish
poisons is called " ichthyotoxism. "
During the frequent mortalities of fishes in the West Indies, many
fishes
are found afloat, recently dead, and apparently
good.
Cases
are known where such fishes have
been
eaten.
Needless
to say, this
practice
is extremely
dangerous,
for there
is no means of knowing
how long the fish have
been
dead, and the looks of
a dead fish af
ford no necessary
indication of its chemical
constitution.
Perhaps
such
dead fish may be taken intentionally
or unintentionally.
Every
effort should be made to prevent
their being taken
at all.
SELECTED
BIBLIOGRAPHY.
AX-BAHAKY, A. J.
Toxic fish with venemous milts.
Chemical
News, Vol. CVIII,
p.
188,
1914.
London.
Aj.HAHAHY, J. M.
Sur
quelques
poissons
toxiques
n
laitances
veneneuses.
Bulletin
de
la
Societe
Centrals
d'Aquieulture
et
de
Peche.
T.
XXIV,
p.
131-141.
Paris.
Ari stasiow,
Ueber
die Natur
des.
Fischglftes.
Therapeutisehe
Monntshefte,
1S92.
COCTIERS.
HENRr.
Poissons
venimeux
et Poissons
veueneux : venins, toxalbumins
du serum et
des
orpines,
toxiues
mlerohionnes
d'infection
et
de putrefaction.
Paris.
Georges Carre et C. Naud, Editeurs,
3 Rue Racine,
3, 1899.
DrMERiL,
A. H. A.
Des poissons veneneux.
Ann.
Soo. Linn. Depart.
Maine
et Loire,
Vol. VIII,
p.
1-17,
1866.
Same author:
1867
(translation of above).
Annals and
Magazine of Natural History, 3 ser., Vol. XX, p. 153-167.
Fischel. Friedrich,
uwl Carl Enoch.
Ein Beitrag du
<ler
Lehre
von
den
Fischgiften.
Fortschrltte der Medicin,
Bd. X, p. 277-290.
1892.
Gatewood. James Duncan.
Naval
Hygiene,
Chapter
V,
The
Navy's
Food.
(Poisoning
from
eating
fish,
cases
reported
and species responsible,
p.
."">36-5G9.)
Philadelphia,
19(19.
P. Blak'ston's ,Son
&
Co.
( Gives
descriptions
of many
species
alleged
to
be poisonous
and cites
many
cases
of
poisoning.
Makes
no
effort
to explain
the nature of
the poisoning.)
202
BUNKER
CHEMICAL
ANALYSIS
OF THE
BLOOD.
Vol. XVII.
Gudoeb, E. W.
(Sphyreana
barracuda)
: Its
morphology,
habits,
and
history.
Carnegie
Institute of Washington,
Publication No. 252, IV, p. 53-108
; Washington,
1018.
Use of barracuda
as
food
and poisoning
resulting
therefrom,
p.
83-03.
Cites numerous
accounts and discussions
in the literature,
includ
ing accounts of old voyages.
Fish-poisoning
diseases called " Ciguatera."
Considers
ptomaines
and poisons
in the food of fish derived
from
man-
chineel fruits and from
other
poisonous
fishes.
Extensive
bibliography.
Heiser, Victor G.
(Poison
fish)
subhead.
Annual
report
of
the
bureau
of
health
of
the
Philippine
Islands for
the year
ending
June
30,
1907.
Manila,
1907.
Short
statement and list of fishes prohibited
from
sale in the Philippine
Islands.
Robert,
.
Ueher Giftfische
und Fischgifte.
Stuttgart,
1905.
Mauriac, E.
Cases of poisoning
caused
by
spoiled
codfish
and
the
unnecessary
pro
hibition of the sale of reddened codfish.
Report
of the
United
States
Fish Commission
for 1886, p. 1027-1053
(translation).
Mowbray, L. L.
Fish poisoning.
(Ichthyotoxisnms.)
Bulletin of
the
New York Zoological
Society, Vol. XIX, p. 1422-1423.
1916.
Peixegrin, Jacques.
Les poissons veneneux.
121 p.,
16 figs.
Paris,
1900.
Augustin
Challamel.
Editeur, 17 Kue Jacob, Libralrie
Maratime
et Colonilo.
Reichard, C.
Animal poisons
(German
title).
Pharm.
Zentralhaile,
Vol. LIV,
p.
1099-
1108, 1914.
A review.
SCHREIBER,
.
Ueber Flschvergiftung.
Berliner klinische
Wochenschrift,
1884.
VON
SOBBE,
.
Ein bemerkenswerter
Falle von
Flschvergiftung.
Ebenda,
1884.
Stoll,
.
Mitteilung ueber
7 Falle von Flschvergiftung
an
der medizinischen
Polik-
llnik Zurich.
Korrespondenzblatt
fur Schweizer
Arzte.
1905.
CHEMICAL
ANALYSIS
OF THE
BLOOD.
By C. W.
O. Bunker,
Lieutenant
Commander.
Medical
Corps,
United
States
Navy.
The chemical
analysis of the blood
has attained
a clinical simplic
ity and
significance
that demands
recognition.
It provides points
of value in diagnosis,
prognosis, and treatment,
and is especially
use
ful in nephritis,
diabetes,
acidosis,
comatose conditions,
gout,
and
in questions of kidney function
and treatment,
especially
dietetic.
Few diseases have been
as j7et studied
thoroughly
in this respect,
but our fund of knowledge
is receiving constant additions.
The field
of tropical medicine
is practically
untouched,
and it is quite possible
that an investigation along this line might there yield facts of inter
est and value.
Some naval medical
officers have
access
to such ma
terial, and the time is ripe for the endeavor.
Numerous
articles relative to this subject have appeared in medical
literature during
the past few years.
Most, however,
have been in
So. 2.
BUNKER—CHEMICAL
ANALYSIS
OF THE
BLOOD.
203
journals to which
the
average
naval
medical
officer
does
not have
access.
So it is the intent of this brief
summary
to emphasize
the
clinical advantages
to
be obtained
by examinations along this line,
and to touch in a general
manner
upon
the significance of findings.
I have considered
acidosis
in a previous article, and will endeavor
to
do the same for kidney function
later.
No exhaustive
consideration
will
be attempted,
nor will matters of technique
be considered.
For
those who
desire
such elaboration or details, I would
suggest
two
hooks —" Practical Chemical
Analysis
of Blood,"
by V. C. Myers
(C. V. Mosby
Co.,
St. Louis,
1921),
and "Practical
Bacteriology,
Blood Work, and Parasitology,"
by E. R. Stitt (P. Blakiston's
Son
& Co., Philadelphia).
The
former
considers
the
question
of sig
nificance very satisfactorily,
and the two works supplement
one an
other very
nicely
as regards
methods.
Current
literature
must
be
consulted for advances.
One must
not anticipate
the solution of all
his difficulties when
the sample of blood is sent to the laboratory.
Very
few matters
are
entirely settled there.
Abnormal
findings relate
to the patient,
but
not necessarily
to
the
disease
under consideration.
The
malarial
parasite found in the blood
smear establishes
malaria, but does
not
eliminate other concurrent disease, perhaps
rheumatic fever.
Simi
larly,
a marked
nitrogen
retention
in the blood
would
be strongly
suggestive of uremia
in a case of coma, but would not exclude
cere
bral concussion as the cause.
It is for the clinician in charge of the
patient to consider the blood chemistry report just as he does that of
examination
of urine, feces, cerebrospinal fluid, etc., and
to
deter
mine its possible significance
in view of the other evidence
present.
And it is also well to bear in mind that nephritis
is a common
com
plication,
especially in chronic conditions, and will itself
affect
the
blood picture.
The
peculiar
advantage
of
examination
of
the
chemical
con
stituents of the blood
lies in the fact that we thus
pass behind the
barrier
of
the
kidneys.
Findings in
urine
are always
dependent
upon
the renal function.
The kidneys normally
excrete but traces
of certain
substances,
e.
g.,
cholesterin,
fats,
proteins,
sugar,
etc.
Others,
such
as urea, uric
acid, creatinine, chlorides, etc., are con
centrated
in the urine from the
blood
with
varying
facility.
The
kidney
is said
to have
a certain threshold
value
for
certain
sub
stances,
i. e., they
must
be present
in the blood
stream in
a certain
concentration
before
they
can
be excreted
in the urine either at all
or in abnormal
amounts.
Thus, for sugar,
there normally
must
be
more than
160 to
180 milligrams per 100 mils of blood
before
gly-
curesis occurs;
no chlorides are
excreted
unless
the
blood
plasma
108165—22
2
204
BUNKER—CHEMICAL ANALYSIS
OF THE
BLOOD.
Vol. XVII.
contains
562 milligrams
chlorides
per
100 mils.
Kidney function,
may
be impaired,
a situation in which there
is not necessarily
any
parallelism
between
the
effect upon the excretion
of different sub
stances.
The function for chlorides, for instance,
is independent
of
that for urea.
Such an impaired function could
cause our being led
widely
astray
by urine examination
alone.
It is not unusual for
diabetes mellitus with
a blood
sugar of treble
the normal to show
no glycuresis;
there is upon record
a patient who had
1,100 milli-
grames sugar per
100 mils blood
and only 0.5 per cent sugar in the
urine.
The
net result,
then, of our blood chemistry is
a more intimate
picture of metabolism.
We can study substances that are not avail
able in the urine.
Early metabolic
changes
are detected,
as well as
the first
disturbances
of renal function.
Abnormal
concentrations
of
constituents
may
arise
on
the
one hand from
overproduction,
defective
assimilation, or
retention,
or,
on
the
other hand, from
decreased production or depletion as the result of excessive excretion
or assimilation.
Consequently,
the findings in the urine are natu
rally complementary
to those in the blood,
and their joint considera
tion quickly
settles
the bearing of kidney
function
on
the latter.
Alone
the urine
is
a very unsafe
index of conditions beyond
the
genitourinary tract.
Our
chemical
examination
is
directed
toward
many
substances,
which are conveniently grouped as nitrogenous and nonnitrogenous.
Enzymes
are
also
studied,
especially
diastase.
The
following
list
includes
the
constituents
most
frequently
under consideration,
as
well as normal values for adults.
These
are expressed in the usual
terminology of milligrams
per 100 mils of whole
blood
unless other
wise
noted.
Values elsewhere
in this article will
also
follow
the
same system.
Normally,
total solids are
19-23
per cent, and total
nitrogen is 2.7-3.5 per cent
(0.6-1.1
per cent in plasma).
Nitrogenous
:
Proteins —
Hemoglobin
14 per cent by weight.
Serum albumin
4. 5 per cent.
Paraglobulin
3 per cent.
Fibrinogen
0. 4 per cent.
Nonproteins—
Urea
20-30
milligrams
per
100
mils
of
whole
blood (10-15 for urea nitrogen).
Uric
acid
2-3 milligrams
per 100 mils of whole blood.
Creatinine
1-2 milligrams
per 100 mils of whole blood.
Creatine
3-5 milligrams
per 100 mils of whole blood.
Amino
acids
6-8 milligrams
per 100 mils of whole blood
(constituent
nitrogen only).
Ammonia
about 0. 1 milligram per 100 mils of whole
blood.
Bile pigments.
No. 2.
205
BUNKER—CHEMICAL
ANALYSIS
OF THE
BLOOD.
Nonnltrogenous
:
Sugar
90-120 milligrams
per
100 mils
of
whole
blood.
Chlorides
450-500
milligrams
per 100 mils of whole
blood
(570-620 for plasma).
Bicarbonate
53-77 vol. per cent C02 (plasma).
Oxygen
18. 5 vol. per cent (oxygen capacity).
Carbon
dioxide
about 40 nun. tension in arterial blood.
Fat
about 600 (Bloor's fat method).
Cholesterin
170-250
milligrams per 100 mils of whole
blood (Bloor's method).
Lecithin
(Bloor's " lecithin ")__
3o milligrams per 100 mils of whole blood
122
for plasma).
Acetone
bodies
0-4 milligrams per 100 mils of whole blood.
Calcium
5. 3-6. 8 milligrams
per 100 mils of whole
blood
(7. 2-12.
1 for serum or plasma).
Magnesium
2. 3-4
milligrams
per
100
mils
of
whole
blood
(1. 6-3. 5 for serum).
Potassium
153-240
milligrams per
100 mils of whole
blood
( 18-21 for serum ) .
Sodium
170-225
milligrams per 100 mils
of whole
blood.
Phosphorus
(total,
as H«P04) —
about 120 milligrams
per 100 mils of whole
blood (35-40 for plasma).
Phosphorus
(of
inorganic
phos
phates)
:
1-3.5
(serum).
Sulphur (of sulphates)
0.5-1
milligrams
per
100
mils
of
whole
blood.
This rather lengthy list, however,
is of more theoretical than
prac
tical
interest
at present.
C linically,
we desire only that which helps
us in our problems.
The routine examination, then,
confines
itself
usually
to nonprotein nitrogen, urea nitrogen, uric acid, creatinine,
sugar, and chlorides of whole
blood,
and plasma
bicarbonate.
There
might
be added
cholesterin
and
oxygen
capacity, the latter being
a
measure of the hemoglobin.
Two technicians can complete
about six
such routine examinations in an ordinary
working
day.
And I wish
to reiterate that the technique
is not complicated,
usually being quite
simple
and within
the capacity of an intelligent
hospital corpsman.
Moreover, the new test case has been equipped
with these methods in
view.
Phosphorus
and
calcium
are receiving
considerable
attention
in
connection with pediatrics.
As time progresses
others on the list may
assume definite clinical importance and be generally useful, providing
a simple
technique for estimation
is available.
Whole blood, plasma,
corpuscles,
and serum have each been
studied,
as the list would indi
cate.
And I might mention
that
volume
relations are being scruti
nized —the effects of increased
or decreased blood
volume
upon
con
centrations of constituents,
as well as the relation of such concentra
206
BUNKER
CHEMICAL
ANALYSIS
OF THE
BLOOD.
Vol. XVII.
tions to variation in corpuscle
volume relative to the plasma.
In fact,
the antipyretic effect of such drugs as sodium salicylate, aspirin, anti-
pyrin, quinine, etc., is considered
to be the result of the mobilization
of sugar in the blood and the consequent general blood dilution.
I have
found that
the meaning
of " nonprotein nitrogen ''
is not
clear
to some.
It simply
signifies,
as the name would indicate, all
nitrogen except that from the proteins.
The nitrogen of the blood
is in the proteins (serum
albumin, hemoglobin,
corpuscles,
etc.)
and
also
as
a nonprotein portion.
The list
above shows
that
the
non
protein nitrogen would then be the nitrogen from the urea, uric acid,
creatinine, creatine,
amino
acids,
etc.
It amounts
to 25 to 30 milli
grams per 100 mils of whole
blood, while the total nitrogen is about
3,000.
The nonprotein nitrogen
is at present
especially
important
clinically,
and our chemical
examination
uses
it,
precipitating
and
discarding the protein portion.
It
is
well to bear in mind that urea
is
largely exogenous in origin,
and subject
to considerable
variation
as the result of food.
TTrie acid comes about equally from exogenous
and endogenous
sources;
a
high concentration
in the blood
is
usually
due to decreased elimination.
Creatinine
is
almost
entirely endoge
nous.
For the nonprotein nitrogen 30 to 35 milligrams
per
100 mils
of whole
blood
is
considered
a
slight,
35 to
50
a
considerable,
and
50 to 100
a
great increase, and uremia
may be expected with values
as
high as the last.
With advanced
retention
the urea nitrogen may
be
75 per cent of the nonprotein nitrogen.
The following
table (amplified from Myers)
is
a
concise summary
of normal findings and those encountered
in various clinical
condi
tions.
In general, the blank spaces indicate normal findings, although
in
a
few they
ma}' mean no data.
The diagnostic significance
is
evi
dent.
Some of the results are based upon the analysis of man}-
cases,
others
upon but
few.
The
values
are in the terms
already
noted
above,
except
those for diastatic
activity
(recorded
in Winslow's
empirical units)
and acidosis
(expressed
in terms of plasma
carbon-
dioxide combining power—volumes per cent carbon dioxide—follow
ing
Van
Slyke).
"Inc.'"
and "Dec."
signified
increased
and
de
creased, respectively.
No. 2.
BUNKER
CHEMICAL
ANALYSIS
OF THE
BLOOD.
207
HESUr.TS
OF CHEMICAL
EXAMINATION
OF IlUlOU.
Condition.
Non
pro
tein
nitro
gen.
Urea
nitro
gen.
t'ric
Creat-
acid.
inine.
Sugar.
Choles-
terin.
Chlor-
Dins
ides.
tase.
Plas
ma
CO'.
Normal
Exercise, short and violent
Exercise, long and fatiguing
Tropics
Aviation
Foruiiculosls
Dlalietes raellitus, mild
Diabetes mellitus.
severe
Pancreatic disease
Arteriosclerosis
, passive congestion
of. .
s, acute
s, Interstitial, early
Nephritis, interstitial, terminal.
, parenchymatous
(ne-
, dlifuse.
severe
ir. double
atic obstruction
25-30
10-15
2-3
Inc.
1-2
90-120
Inc.
167-255
450-500 I 8-64
53-77
30
100-
350
00-350
Inc.
conditions
.
Hyper, mesis gravidarum.
Eclampsia
Cholelithiasis
Acute yellow atrophv
of liver. . .
Intestinal obstruction,
acute
Fever, acute
Pneumonia, severe and late
Anemia, pernicious
Leukemia
Leukemia, myelogenous
Malignancy, late
Dementia precox, catatonic
Shock
Edema
I'll poisoning.
75-170
to 108
to 110
Inc.
Inc.
Alcoholism
Ether anesthesia..
Adrenalin
, antipyrin, quinine.
to 370
Inc.
4-10
inc.
2-4
Inc.
Inc.
Inc.
150-300
300-1200
Inc.
Inc.
201)-SHI
inc.
400
Inc.
Inc.
10-50
40-100
15-25
60-300
20-50
to 230
to 75
70-300
12-40
5-15
5-12
5-27
2-5
to 10
to 5
5-28
2-4
to 16
to 8
120-180
120-150
120-240
120-200
to 250
to 200
to 300
Inc.
Inc.
150-fiOO
450-600
MO 100
■<
«>-<;
in
Inc.
Dec.
Dec.
3 9
4-10
1.5-3.5
110-16.1
Inc.
60-90
10-25
45-120 ■
Inc.
to 53
to 75
to 20
Inc.
6-10
Inc.
to 300
Inc.
Inc.
Inc.
to IS
to 10
Inc.
to 7. 6
Inc.
Dec.
Inc.
to 4
to 3.5
to 3.1
to 180
to 300
to 15
Inc.
Inc.
inc.
to 33
Inc.
Inc.
120-200
Inc.
J no.
Inc.
to 500
Dec.
130-300 .
to 87
.
Dec.
Inc.
to 60
Dec.
Dec.
Dec.
to 600
Inc.
to 350
inc.
Inc.
Dec.
Inc.
20-45
i2^40
Dec.
43-58
Dec.
Doc.
Dec.
Dec'.
Dec.
The table gives definite
values, but it is worth while for the person
analyzing
a report to endeavor
to determine
how much any variation
from
normal
is due to such
factors
as food, increased
metabolism,
defective
assimilation,
retention
by
a
kidney
whose
function
is
impaired,
etc.
Nephritis
produces
blood
changes
essentially
by
reason
of
the
usual inability to properly excrete the waste products of metabolism.
Acidosis,
edema, or uremia
are the clinical
evidences of such reten
tion.
Interstitial nephritis is characterized by the retention of nitro
gen,
the first changes being noted in the uric acid.
Urea and non
protein
nitrogen
increase
later.
The
significance
of
albumin
in
traces and occasional
casts in urine has been
more
definitely estab
lished
by examination for
increase
of uric
acid
in
the
blood — an
increase arguing for an organic lesion.
On a high purine diet there
will be an accumulation of uric acid,
a result that does not occur in
208
BUNKER—CHEMICAL ANALYSIS
OF THE
BLOOD.
Vol. XVII.
normal persons.
Inasmuch
as the urea furnishes such
a large por
tion of the nonprotein nitrogen and varies
so markedly by reason of
diet,
a high nitrogen value
affords
definite
information
only if the
intake is known.
The nonprotein nitrogen has, however,
always
a
negative
value.
Associated
cardiac
decompensation
will
further
increase
the blood urea.
Values of over
4 for creatinine
do
not
occur without
great
impairment of renal function,
and findings of
more than 5 have practically
uniformly
foretold
a fatal termination
in less than six months, except in acute nephritis and mild bichloride-
of-mercury poisoning.
The creatinine is also the best guide
to the
status of renal function in terminal
cases.
Parenchymatous nephritis
shows
relatively
little
nitrogen
reten
tion, but does evidence
a decided tendency toward chloride retention.
Low urea values,
due to superpermeability of the kidney, are found
occasionally with
chronic
diffuse
nephritis
and
in
hypersensitive
cardio-vascular disease.
The
imminence
of uremia may
be judged by
the extent
of
the
nitrogen
retention.
We
have
an aid in the
differentiation
of the
uremia of nephritis accompanied
by a flagging heart from the passive
congestion
of cardiac decompensation,
especially
as to which
is the
secondary
condition,
and
thus therapeutic
indications
relative
to
mooted
questions of treatment,
such
as hot
packs, morphine, renal
stimulants, etc.
Unsuspected
cases
of nephritis
showing only gastric
symptoms
subjectively have been detected by blood chemistry.
Essential
hypertonia, with its normal
blood
chemistry,
is differ
entiated
from arteriosclerosis with its frequent nitrogen retention.
It is of interest
to note that experimental administration of choles-
terin has caused histologic changes in the aorta.
The
important
questions
of
acidosis
and
kidney
function,
as
already stated, will not be
considered
in this
paper,
although
the
former is an integral part of blood chemistry and
the latter is an
important
factor in determining
the blood
picture.
Their
discus
sion requires
considerable
space, and it is probably preferable to con
sider
them
separately,
while bearing in mind their relation to
the
chemistry of the blood.
The
surgeon
is especially
concerned
with
them if he desires the best results
and uneventful convalescence.
The
pediatrician should always
bear acidosis
in mind.
The blood
may indicate
a prediabetic state, and place the practi
tioner
upon
his
guard.
Nephritis
may
be
present
with
diabetes
mellitus, and usually is when the latter is severe, so one must be pre
pared
for the blood
picture of
the former.
The
blood
sugar
and
plasma C02 are usually considered
the only safe guides in the treat
ment of diabetes mellitus, and no extended medical or surgical inter
ference
should
ever be attempted
without their estimation.
Glyco
No. 2.
BVXKER
CHEMICAL ANALYSIS
OF THE
BLOOD.
209
suria
is a poor guide, especially in advanced
cases,
as is readily in
ferred from the remarks relative to renal function in the early part
of the paper.
A persistently low blood sugar is extremely
favorable.
A high
threshold for sugar in a mild
case on diet usually indicates
some complication,
such
as arterial hypertension.
A rising
or per
sistently high threshold for sugar despite
diet is serious.
Blood
fats
are considered
by some to be a better index of the patient's condition
than
the
blood
sugar,
but their estimation is by no
means
simple.
The cholesterin determination is not difficult, and this compound
is
said to parallel
and be an index of the fats.
Some
diagnostic significance
is
attached
to
the
sugar
tolerance
text.
There is some variation in methods for its application, and the
following
may
be considered
as good
as any.
After
an overnight
fast,
ingest
100
grams
glucose
dissolved
in
300
mils black
coffee.
Collect blood samples just before feeding and at 45 and
120 minutes
after same,
and
determine
the blood sugar in each sample.
If the
blood sugar has not by then returned to about normal, one may
test
further
samples
taken
at hourly
intervals.
The urine may
also
be
collected
and tested for sugar.
Under such conditions
a normal person
will
show
no glycuresis,
and his blood sugar will
be at its maximum
(about 150)
after
45
minutes,
and approximately normal at the end of 120 minutes.
The
usual abnormal variation
consists in increased
height, or, especially,
duration of curve before reaching normal, as much
as six hours being
not unusual.
Until
the significance of the test is more fully estab
lished, it will probably be better to interpret such an abnormal curve
as indicating
an impaired sugar tolerance
and
its degree.
Practi
cally
equivalent
results
are
obtained
in
such
diverse
conditions
as
diabetes
mellitus,
nephritis,
hyperendocrine
(thyroid
and
hypo
physeal)
conditions, tuberculosis, epithelioma,
pregnancy,
fatigue,
etc.
There
is a condition
but recently recognized
in which there
is
a
normal
blood sugar,
a persistent
glycuresis of usually less than
1 per
cent and independent
of carbohydrate intake,
occasionally polyuria,
but with no other
symptoms
of diabetes
mellitus.
It is known
as
renal
diabetes,
is
apparently
harmless,
probably
not
uncommon,
and
may
comprise
most of
those " diabetics
" who
can
disregard
diet with impunity.
Fumnculosis
often shows
an increased
blood sugar, and diabetic
restriction of sugar may
be of much aid in its treatment.
In comatose
conditions, nitrogen retention will
select the uremic
and hyperglycemia
the
diabetic
cases.
But acute nephritis
should
always
be borne in mind, as it may
have
a pronounced acidosis
but
no nitrogen retention.
210
BUNKER
CHEMICAL ANALYSIS
OF THE
BLOOD.
Vol. XVII.
The frequent
hyperglycemia of hyperthyroidism
is useful in dif
ferentiating
the irritable
heart.
The solitary increase of blood uric acid
(probably the result of re
tention) in gout aids in the differential diagnosis from simple rheu
matic fevers
and other
arthritides,
any uric acid retention in them
being
usually
accompanied
by retention of other nitrogenous
ele
ments.
It is
especially
useful in the diagnosis of gouty arthritis
without
tophi.
Of course this
increase of uric
acid
alone
is also
characteristic of early interstitial
nephritis, but, with the latter,
a
general nitrogen retention usually supervenes
and there is commonly
albuminuria
and cylinduria.
The amount of uric acid in the blood
bears no relation to the severity
or the chronicity of gout.
A purine-
free
diet
tends to lower
the uric
acid.
This
can
be
accomplished
more effectively,
however,
by drugs, such
as tolysin
(neocincophen)
or cincophen
(Acidum
phenylcinchoninicum).
These
increase
the
excretion
of uric acid, and will also reduce increased
blood urea or
chlorides.
They
act
as renal stimulants, and this excretory action
is rapidly secured
(that for tolysin
reaches its maximum in about
one day) and gradually lost.
They apparently are not toxic, and are
analgesic,
the latter effect being gradually
lost.
Ten grams of sodium
chloride by mouth in a glass of water is said
to decrease blood
chlorides if the gastric secretions
are normal.
If
the secretory
disturbances
are marked,
an increase in blood chlorides
may
be expec ted.
Pregnancy
is
accompanied
by
low
values
for
blood
urea,
and
cholesterin
is said
to increase beginning with the fourth
month
and
progressing to term.
An increase in blood uric acid is definitely as
sociated
with
the
toxemias
of
pregnancy,
and
should
place
the
obstetrician
upon his guard.
Diet is concerned
particularly
with
retention,
especially
of nitro
gen
and
chlorides, and
defective
assimilation,
especially
of
sugar.
The blood examination definitely settles such questions,
and it should
precede and then guide dietetic
treatment.
The efficacy of treatment
will, in general,
be shown by the degree of approach to normal blood
findings.
As a general
rule, it is preferable to determine
the chlo
rides of whole blood rather than of plasma.
Plasma, if used, should
quickly be separated
from the corpuscles.
It is appropriate to mention
here the ferment,
diastase.
This is an
amylolytic enzyme whose activity is considered
to be normally under
the inhibitory
control of the internal secretion of the pancreas,
and
whose function is concerned
with the production of the blood
sugar
from the glycogen
of the body.
It is found in the body fluids and
excretions.
An impaired kidney
function
may
cause its retention
in the blood,
and thus be the etiological factor in the hyperglycemia
of such cases.
Its diagnostic significance
is still debatable,
but very
No. 2.
211
CHAMBEKS
THE WEIL-FELIX
KEACTION.
high values, especially in the blood and with no evidence of impaired
kidney function, should be considered
confirmatory of impaired pan
creatic
function.
For a complete
examination
one should secure at least
10 mils of
blood,
and it is best taken
Z\ hours after
a meal,
preferably
be
fore breakfast.
The
values
obtained
from
the sample
taken
after
the shorter interval
are probably satisfactory for clinical
purposes.
Truer
values require the longer interval.
Hammett found no prac
tical difference
between samples secured after fasts of 14 or Si hours.
The sugar
was variable, while
the nonprotein
nitrogen,
urea,
and
uric acid were slightly lower after the longer interval.
Plasma sugar
concentration
is not
affected
by ingestion of water.
A rich
carbo
hydrate
meal
causes
a slight
increase
of sugar that may
last
for
several
hours.
. A protein meal causes a temporary increase of non
protein nitrogen and amino-acid nitrogen.
Fifty grams of protein,
eaten
by a normal person,
produces
an increase in urea nitrogen for
8 or more
hours, the
blood sugar being unaffected.
With
severe
diabetes
mellitus or nephritis
the increase
in urea nitrogen is more
marked and
sugar
is increased,
although
the latter
effect
may
be
overlooked in the presence of a marked hyperglycemia.
The values for many of the blood constituents
will
decrease
the
longer the sample
stands.
Twenty
hours at room
temperature
does
not change
the nitrogenous substances,
and
the sugar only slightly.
The sugar then
deteriorates
rapidly,
especially when
the sample
is
agitated.
The other ingredients show
but little
change for two or
three
day's,
especially if preserved
as blood filtrate
and in the re
frigerator.
THE WEIL-FELIX
REACTION.
By J. H. Chambers,
Lieutenant,
Medical
Corps,
United
States
Navy.
The
Weil-Felix
reaction
has
gradually
come
into
general
use
within
the
past
few
years
as
a laboratory
diagnostic
measure
in
typhus fever. It is an agglutination
reaction,
employing the patient's
serum
and a member of the Proteus group of microorganisms.
The
particular organism employed
is known as X19, and was isolated
by
Weil from the urine of a patient suffering from typhus fever.
From
experimental
evidence it is not
believed
that the Proteus organism
has
any
causative
relation
to
the
disease,
nor
is
it
apparently
a
secondary invader in the ordinary
sense.
It is, however,
very often
present
in
the
urine of tjTphus
patients,
particularly
in
the later
stages of the infection.
The strain
used in the test has
the usual
characteristics
of members of the Proteus group
that
ferment
glu
cose and saccharose, but do not ferment lactose, maltose,
or mannite.
Another
organism having
cultural
characteristics similar
to
those
212
Vol. XVII.
CHAMBERS —THE WEIL-FELIX
REACTION.
of Xl9 is known as X2 and is frequently used along with X19
as
a
confirmatory
test.
It has recently
become apparent that Xl9 gives
uniform
and consistent
results
and is now commonly
used alone.
Sufficient
work
has
been
done in typhus
centers
to demonstrate
conclusively that
a positive reaction occurs
only in serum obtained
from
typhus
patients
and
not
from
other
diseases.
Napier
(1)
reports results
on
a number of cases of typhus, including
40 with
mild attacks,
and all of these gave a positive reaction.
The highest
titer was
1 :20,000
on the eighth day, the lowest
1 :200 on the eighth
day, rising to
1 :10.000 on the sixteenth
day.
The average titer of the
40 cases was
1 :2,600, and was present
on the seventh to the thirtieth
day.
Eleven
cases
clinically
doubtful
at
the
onset
gave
positive
Weil-Felix
reactions.
The highest titer in this group was 1:20,000;
the lowest
1 :50 on the fifth day, rising
to
1 :800 on the seventh day.
Two groups of control . cases
were used, one of 50 refugees
with no
record
of
treatment
in the hospital,
and
the
other
of
24
patients
suffering
from febrile conditions incompatible with
a diagnosis of
typhus.
Of the first control group, one gave
a titer of
1 :100, four
1 :50.
Of the second group, two gave
a titer of
1 :100, eight
1 :50.
In the latter group, if cases of typhoid
were excluded,
none gave
a
titer of
1 :100, and only five of
1 :50.
He concludes
that eight per
t ent of normals give
a titer of 1 :50, and 25 per cent of febrile con
ditions, other than typhus or typhoid, give
a titer of
1 :50.
Hence a
positive Weil-Felix
reaction
must
show
a titer
greater
than
1 :50.
Of his 59 cases, only 12 failed to give
a titer above
1 :1,600, and none
below
1 :640.
Of the 77 control cases, none gave a titer above
1 :400,
and only one that high.
In Fairley's
report (2) of cases in Egypt,
63 of
65 showed
a positive reaction.
Of the
120
cases
other
than
typhus, none were positive in dilution of 1:20.
Felix and Weil (3)
reported
positive
reactions in 125 of their 126 cases.
Of 632 patients
not having typhus, including typhoid, meningitis, and relapsing fever,
12 per cent gave agglutination
as high as
1 :25, with the agglutination
incomplete
or delayed.
Sacquepee
and
Delavergne
(4)
report the
Weil-Felix reaction
constantly positive in typhus fever and negative
in 14 cases other than typhus.
Montefusco (5) reports reaction
posi
tive with
a titer of
1 :800 in all but one of 100 cases,
and constantly
negative
in
a
large
number
of
acute
diseases
other
than typhus,
except
one case of smallpox.
Compton
(6)
reports
47 tests on
14
cases in Syria, with all but one case positive.
Numerous other writers
have reported series of positive results in typhus, and negative results
in other diseases.
Kraus and
de la Barrera
(7)
reported positive
results
in all
cases of typhus
fever,
with
two positive
reactions
in
other
diseases.
One
of
the latter
was
a
case
of typhoid
(Widal,
1 :4,000, agglutination
X19
1 :10.000)
who had lived in Russia till
a
few years previously, and the other,
a case of measles, with
a history
No. 2.
213
CHAMBERS
THE WEIL-FELIX
REACTION.
of previous
residence
in an endemic
focus of typhus, whose
serum
gave
a titer of
1 :'20O.
The authors termed
these " anamestic
reac
tions."
The exact technique of the test varies with the individual.
Kesults
obtained
by using live or killed
suspensions
seemed
to
be equally
satisfactory:
and
inasmuch
as
killed
suspensions
are
more
con
venient,
they
were
used
in
the
majority
of
tests
reported
below.
Cultures
of X2
and Xl9
were
obtained
through
the
courtesy
of
Dr. G. W. McCoy
and Miss I. A. I5engtson. of the Hygienic
Labora
tory of the United
States Public Health
Service.
Twenty-four
hour
agar
cultures
were
washed
into
normal
salt
solution
containing
0.3 per cent formalin
and kept in the refrigerator
for four days, by
which time all organisms were killed.
This suspension
was stand
ardized
to make
a 0.1 per cent suspension
of each strain.
One cubic
centimeter
of this
suspension
was
added
to
an
equal
amount
of
diluted serum,
each serum
being
tested against both organisms and
each series of tests having the usual control of salt solution.
Living
cultures in broth were used in 20 tests and living organisms in salt
solution in 25.
The results
differed in no way from those obtained
with killed organisms.
Sera
for these
tests
were
obtained
from
patients
in
the
naval
hospital. Washington. D. C, on whom
complement
fixation tests for
syphilis were being
done.
About
14 per cent of these gave
a posi
tive complement fixation reaction
and the remainder included a wide
variety
of diagnoses.
The
serum,
which was kept
in
the refriger
ator, was always used within
24 hours after withdrawal.
Four dilu
tions, ranging from
1:16 to
1:128,
were
used for both
organisms.
After
thorough shaking
the
tubes
were
placed
in
an incubator
at
37° C. and readings made at the end of three
hours.
A final read
ing was
made
on
the following
morning,
and
in
no
instance
was
there any change
in the reaction.
Of 370
sera examined,
only one
showed
an agglutination
in any dilution.
In this case agglutination
was present in a dilution of
1 : 128.
In another
test on fresh
serum
of the same patient agglutination
was complete
up to
1 : 160, whereas
it was present
but incomplete
at 1:320
with X2 and Xl9.
This is
in accord
with results
obtained
elsewhere.
Much of the work hith
erto reported has been
done on individuals
coming from or residing
in
districts
where
typhus
is
endemic
and
epidemic,
whereas
the
majority of the patients
seen here had never
been exposed to typhus,
and this may well explain
the greater
frequency of agglutinations
in the low dilutions
reported
elsewhere.
The
one patient showing
agglutination
was
a native of Denmark,
had
been
in
the merchant
marine
for eight years, and in the United
States Navy for a number
of years,
so might very well show a mild form of the happily
termed
"anamnestic
reaction" of Kraus and
de la Barrera
(7).
214
Til. XVII.
NEL'BERGER
.AVIATION
MEDICINE.
This additional
evidence
is added to the already lengthy series of
tests showing
a negative
reaction with
diseases other than typhus.
All the patients examined
here had
received
vaccine
as prophylaxis
against typhoid
and
paratyphoid
within
the
past
five
years,
the
majority
within
three
years
and
a few
cases
very
recently.
The
immunity
thus
acquired
did
not
seem
to influence
the Weil-Felix
reaction
in any way.
As the titer of typhus serum is not very high
prior to the fifth or sixth day,
and
a diagnosis on clinical findings
alone
is
then
often
quite
definite,
the
test
is not
needed
in such
cases.
However, in the large group of atypical or doubtful
cases, it
is
of
much
practical
value,
particularly
in
the
diagnosis of the
early
cases of an epidemic.
Here, it is in the first
cases
that the
diagnosis is most often missed till late and it is then that the most
effective
preventive measures
may
be instituted.
Conclusions.— (1)
The reaction is negative
in diseases other than
typhus;
(2)
it is not
influenced
by
serum
showing positive
com
plement
fixation
test;
(3) it is not
influenced
by typhoid prophy
laxis.
BIBLIOGRAPHY.
1. Napier,
L.
E., Well-Felix
reaction
in
a
mild
epidemic
of typhus,
occurring
among a typhus- rid den
people.
Lancet,
2 : 863, November
15, 1919.
2. Fairley,
N.
H., Laboratory
diagnosis
of
typhus;
further
observations
on
value and significance
of Weil-Felix
reaction.
J. Hygiene,
18 : 203, August,
1919.
3. Bengtson,
I.
A.,
Weil-Felix
reaction
as
laboratory
test
in
diagnosis
of
typhus.
'Pub. Health Reports,
34:2446,
October
31, 1919.
4.
Saequepee,
E.
and
Delavergne,
P.,
Serodiagnosis
of typhus,
Bull,
et mcim.
Societe medicate des HGpitaux
de Paris, 43 : 151, February 21, 1919.
5.
Montcfusco,
A.,
Agglutination
test
in
diagnosis
of
typhus.
La
Riforma
Medica,
Naples,
35:782,
September
13,
1919.
6. Coinpton,
A., Weil-Felix
serological
test.
Lancet,
2 : 860, November
15, 1919.
T. Kraus,
R.,
and
de
lu
Barrera', J.
M.,
Typhus
in
South
America.
Semana
Medica,
Buenos Aires,
28 : 371, March
31,
1921.
AVIATION
MEDICINE
IN THE UNITED
STATES NAVY.
By J. P. Nki bkkuer,
Lieutenant,
Medical
Corps,
United
States
Navy.
THE FLIGHT SURGEON.
The British, French, and Italians,
all stated early in the war that
it was fortunate that the air forces of the United
States
were profit
ing by the mistakes of the allied flying forces,
and in recognizing at
the beginning the fact that the medical problem of aviation is a very
special
problem
and can not possibly be conducted
except by medical
officers specially trained for this sort of work (1).
The British were
the
first
to
recognize
the
advantage
of
medical
officers
specially
NO. 2.
215
NEUBERGER
AVIATION
MEDICINE.
trained for aviation.
During the first year of the war, 2 per cent
of air casualties
were caused by the Germans,
8 per cent
were
due
to defective
planes,
and
90 per cent were due to physical defects of
pilots.
As soon as they had established
an independent
air medical
service and specialized
in the care of the flier, statistics changed
im
mediately
and in the next year the
90 per
cent was
reduced
to 20
per cent and in the following year to 12 per cent.
When the United
States
entered
the war, it was decided
to follow
in the footsteps of our Allies and medical
officers with special qualifi
cations for aviation duty were selected.
At that time we knew
very
little
about
the medical
problems
of aviation, and in order to prop
erly investigate these problems
the United
States Army established
a research
laboratory in Mineola, Long Island,
N. Y.
The
labora
tory was subdivided into seven professional
departments,
and
each
department
studied
the problems
of aviation that concerned
its own
particular field.
These departments
were physiology, cardiovascular,
ophthalmology, otology, psychology, psychiatry,
and
physics.
This
laboratory
has produced
wonderful
results in this connection
and the
highest praise is due to the officers connected
with it.
A most
im
portant
phase of their researches
was the study of the effect of low
oxygen on the circulation,
respiration,
mental
reaction,
and the eye.
One of the early ingenious devices
developed
at the laboratory
was
a low-pressure
tank with which it was possible
to simulate air con
ditions
from
sea level
up to approximately
36,000
feet.
Later
a re-
breathing machine
was developed.
With this apparatus the subject
breathes the same air over and over again with the impurities elimi
nated.
The oxygen, of course,
is constantly diminished, and the re
sult is similar to that in the tank, for it was soon found that the im
portant
factor in altitude is the decrease in oxygen,
the decrease of
atmospheric
pre&sure and temperature
being of secondary
considera
tion.
The
primary
duties
of
the
medical
officer
assigned
to
aviation
duty can be described
under the headings
:
1. The
selection
of the flier.
2. The maintenance
of the fitness of the flier.
The most important factor in the selection of the flier is the physi
cal examination.
One
can not be
too careful
in this examination
and
should
always carry
the
old rule in mind— " when
in doubt,
reject."
This rule might work an injustice on an individual,
but it
will ultimately
benefit
the
service
as
a whole
and it certanly will
save the lives of many
men.
The maintenance
of the fitness of the flier is of equal
importance
to the physical examination.
The aviator
is subject
to certain con
ditions, which have
a tendency
to produce
mental
fatigue, which, if
not discovered in time, will cause
the aviator to deteriorate
and make
216
Vol. XVII.
NEUBERGER
AVIATION
MEDICINE.
him
useless
for further
service.
This condition
of
mental
fatigue
is commonly spoken
of as " staleness."
It is in reality
a functional
degeneration
of his mental and
nervous
system.
After
prolonged
flying without
a rest the aviator
begins
to do unusual things.
He
makes
a bad landing.
Perhaps
he has a crash, or he hesitates
to go
into
the
air.
He
may
completely
lose
his
nerve.
The
aviation
medical
officer should watch the flying
in order
to
see how
pilots
are withstanding
the effects of flying, to take steps to combat
at an
early stage the onset of flying stress and to prevent undue fatigue.
The
term
" Flight
surgeon " is used in the United
States Army
to designate
medical officers assigned
to aviation
activities.
While
this term
is not used officially in the Navy, it simplifies matters
to
employ it in
this
article,
as
referring
to
medical
officers of
the
United
States
Navy
assigned
to aviation duty.
The flight
surgeon
in the United States Army officially receives training
and instruction
in actual
flying in aircraft,
which is not the case in the Navy.
The
Navy
Department,
however,
has
never
voiced
any objections to
a
medical
officer taking flight, or instruction in actual flying, providing
he can find an instructor
at a station willing to give him flight in
structions.
The writer
has found that all pilots realize the impor
tance of the services of a medical
officer on aviation stations
and ap
preciate
the fact that he is looking
after their
health
and
safety.
They are always more than willing to assist him in any way possible.
The
question
should
a medical officer of the United
States
Navy
officially
receive
flight
training?
has
been
often
discussed.
The
Army surgeons claim that in order to understand the medical
prob
lems of aviation,
one must
be
a qualified flier.
From
the writer's
personal
experience,
he has come to the conclusion that training in
actual flying of aircraft is not essential,
although it might be desir
able, and that a medical
officer, not a qualified pilot, can perform his
duties just as well as though he had received
actual
training.
It
is,
however,
essential that he fly with the pilots as often as time and cir
cumstances permit, in order to obtain
first-hand knowledge
as to the
work the pilots have to perform, to experience
the different air con
ditions, to notice any changes in the human body in the air at high
altitudes and in general,
to have the same
experience
as
a
qualified
pilot.
It
is
believed that this experience
can be obtained
just as well
by accompanying
the
flier
as by
oneself
piloting
the plane.
The
writer
has taken
numerous
flights under all sorts of conditions and
at the end of each flight he has found, on discussing different occur
rences, that everyone
had practically
the same
sensations,
ideas, and
opinions about all that happened
while in the air.
It is. of course,
obvious that some men have keener powers of observation than others
and notice things which others do not.
The writer personally
is
not
So. 2.
217
NEUBERGER — .AVIATION
MEDICINE.
in favor of making a doctor a " flier."
He can not be expert in both.
If the medical
officer is a qualified aviator, it is necessary for him to
spend a good deal of his time in the air in order to keep in practice
and
he develops
the
same peculiarities,
attitude
and
symptoms
as
other pilots.
He can no longer observe them in any one else, as prac
tically all the symptoms of " staleness " are objective,
and his useful
ness as a flight surgeon
is therefore at an end.
He is just
as likely
to develop symptoms
of staleness as any other flier without realizing
it,
for many pilots showing objective signs of this condition, yet un
aware of
it,
protest most vigorously
if
the medical
officer recommends
a
temporary
" grounding,"
stating that they
are perfectly
all right
and capable of flying, despite
the fact that they show signs of com
plete mental
and
nervous
exhaustion.
It
is
honestly
believed
that
more can be accomplished
and greater
progress will be made in avia
tion medicine
if
the,
medical
officer assigned
to aviation duty
is
not
a
qualified
aviator provided he takes sufficient
interest
in aviation,
becomes engrossed in air problems,
sees and experiences
them himself
in
the air, either as an observer
or passenger.
"A medical
officer assigned
to aviation duty must have
a
thorough
knowledge of internal
medicine,
including
physiology
and psychol
ogy, and
he must
be able to
make thorough
eye
and
ear examina
tions.
It
is
believed
that every
flight
surgeon
should have
special
training
in eye, ear, nose, and throat work."
A medical
officer
as
signed
to aviation duty should be selected with
as much
care
as the
pilot.
With deep and interested
self-devotion to his work, he must
be unselfish,
approachable,
gentlemanly, at the same time
possessing
firmness,
and
must
have all other qualities
expected
of
a
medical
officer, and, above all, he must not be afraid
to fly.
He must
be "
a
pood mixer,"
and
must obtain the implicit confidence
of all pilots
and should
spend
as much
time
as possible
in informal
association
with them.
He should make
it
a
practice to be at the flight office
as
often as practicable and whenever
the pilots " take
the air."
Half
of the fliers are usually watching the others, and one can obtain
a
lot
of valuable
information
from their remarks and
general
conversa
tion.
The flight
surgeon
should
be
a
young man,
about
the
same
age or
a
little older than the fliers.
He must work in close cooper
ation with the instructors in order to gain
as much
information
as
possible about the student flier.
He must be on the station whenever
there
are machines
in the air, be
it
day or night, for when his serv
ices are required they are certainly very badly needed.
The flight surgeon must keep in touch with the flier's physical con
dition
and
become
acquainted
with
all
affairs
pertaining
to him.
He should spend as much time on the flying field as
is
possible, watch
ing for defects
in flying, such
as bad take-offs,
bad landings, uncer
218
Vol. XVII.
NEUBERGER —AVIATION
MEDICINE.
tainties of action,
and
he should make it a point of seeing each flier
every day, either on the fields,
at mess, or in the quarters.
At the United
States
naval air station on Rockaway
Beach
the
commanding officer issued an order for all officers to have the midday
meal at the bachelor
officers' mess.
This order at first brought forth
a storm of protest,
especially from
the
married
officers
who had
quarters on the station or in the vicinity,
as they preferred to have
lunch with
their families.
However,
they
soon
saw
the
benefit of
the order
and
adjusted themselves
to it.
This order brought
the
officers
together
at least once a day and gave
them
an opportunity
to know each other
better
and
to discuss
the different events of the
day ; they obtained
different viewpoints and oftentimes better under
standing of a happening whether it was a successful
maneuver
or
a
fatal crash.
The writer knows from personal experience
that argu
ments
and
scientific
discussions
during
this
meal
hour
resulted
in
many improvements,
increased
knowledge,
better understanding,
and
the greater efficiency
of all
the flying
personnel.
It is considered
an excellent
procedure
and
recommended
for all naval air stations.
One
of
the
most
important
duties
of
the flight
surgeon
is
the
repeated
physical and
mental
examination of the aviator
to
deter
mine his continued fitness for flying.
Its accomplishment
is not an
easy task,
as it inconveniences
the pilot.
The average pilot dislikes
frequent physical examinations, because he is afraid that something
may
be
found
which
would
ultimately
disqualify
him
physically
from flying.
It is quite hard for him to realize
that this examina
tion is carried on for his benefit and personal
safety.
The frequency
of these examinations depends
upon circumstances
and
the amount
of flying carried on.
It is believed,
however,
that this examination
should
be made
at least
once
a month and
an entry of the result
should
be made in the health record.
In making this examination
the possibility of staleness should always be borne in mind.
The flight surgeon
should always keep in intimate touch with the
flight commander
and the instructors, especially on stations
used for
training purposes.
He should
act in
an advisory
capacity
to
the
flight
commander,
and
by mutual cooperation many men
may
be
discovered
who a re for some reason not flying at their best.
It is the flight surgeon's
duty to see that all of the flying personnel
have
sufficient,
proper,
and suitable
exercise.
He
should
impress
upon the fliers that they should regard themselves
much in the light
of athletes,
and that they must bear in mind the rules for the train
ing of
athletes,
such
as temperance
in all things,
good
hours
and
plenty of sleep, good food and comfortable quarters,
and
the right
kind of recreation.
It is believed
that comfortable quarters for the
aviator are just
as necessary
as
a comfortable flying suit, as flying
is
accompanied
by
great
mental
and
physical
fatigue,
and
the
No. 2.
219
NET'BERGER
AVIATION
MEDICINE.
aviator should
have
a comfortable and
pleasant
place
to rest after
his work is done.
The flight surgeon should organize the medical
department
of the
air station so that all accidents may be handled quickly and efficiently.
He should investigate every
crash,
to determine
whether it was due
to a physical or mental defect of the pilot. If the defect is of a tem
porary nature,
grounding should be recommended,
but if the defect
is permanent,
the
pilot
should
be
disqualified
for further
flying.
When in doubt the pilot should be kept under
observation
until his
status is definitely determined.
The flight
surgeon
must
appreciate
his work.
There
is no duty
for the Navy medical
officer of to-day in which there is more chance
and opportunity for progressive
research than that of the flight sur
geon.
It is a known fact that marked reduction in fatalities
has
occurred where
efficient flight surgeons
have been placed.
While we
can not reduce the incidence of accidents
due to mechanical
or struc
tural defects, we certainly can reduce those due to the men themselves.
A recent publication
(2) of the United
States Army Air Service on
the subject of aviation states : " The value
of the flight
surgeon
has
been abundantly proved
in the training
schools of the United
States
and
France;
but
the signing
of
the
armistice
prevented
the full
realization
of the hope that flight surgeons
would
be placed
where
they
are of the greatest
value — at every
aerodrome
and balloon sta
tion at the front.
" It can readily
be seen that a skillful flight
surgeon
would have
been very valuable at the aerodrome
where Guynemer had his head
quarters.
That
marvelous
flier had
shown
increasing
nervousness
and physical unfitness
for
some
time.
In his delightful
book, Mr.
Driggs says: 'A new Guynemer revealed himself to his friends and
comrades.
He
became nervous,
sick,
and irritable.
His
comrades,
unable
to control their captain, telephoned
to Paris, informing
their
old commanding
officer, Brocard, that Guynemer was sick and in no
condition to fly, and imploring him to come back to the aerodrome
to
take their captain away for a much-needed
rest.
He arrived
about
half an hour after Guynemer had left on his last flight.' "
" Rickenbacker says: 'It is plainly imperative that one keeps one's
self always
fit and
clear
minded.
It is
a matter of life and
death
to every air fighter—this quick-thinking,
unburdened mind.'
His
words in speaking of the fatal accident of Lieutenant Kurtz are very
illuminating : ' I had
noticed
before starting that Lieutenant Kurtz
appeared
nervous,
but did not give the matter any great
considera
tion.
The explanation was given
by a brother officer who had come
with Lieutenant Kurtz to the squadron.
Before starting on his last
flight Lieutenant Kurtz had confided
to him that
he was subject; to
108165—22
3
220
Vol. XVII.
RAYNOR —MEDICAL
CORPS
UNITS.
fainting
spells
when
exposed
to high altitudes, and
the only thing
he was afraid
of was that he might
be seized with such
a fit while
in the air.
Alas, his fear had been only too well founded.
But what
a pity it was he had not confided in me. his flight commander.'
" After
a flight of over
15,000
feet, Lieutenant Kurtz was making
a turn
over
an adjoining
field,
when
his Xieuport
dropped into
a
vrille, crashed, and caught fire.
Experience has shown over and over
again that a flier will confide
in his flight surgeon
when
he will
be
silent with his commanding officer."
REFERENCES.
(1)
The Air Medical
Service
and
the Flight
Surgeon,
by Lieut. Col.
L.
H.
Bauer and Maj. W. McLake,
U. S. Army, Mil. Surgeon, January,
1920.
(2)
Aviation Medicine
in the A. E. F.
Offlce
of the Director of Air Service,
U.
S. Army,
February,
1920.
THE FUNCTIONS AND ORGANIZATION
OF MEDICAL
CORPS UNITS SERVING
WITH THE MARINE CORPS IN THE FIELD.i
By
S.
N.
Raynob,
Major, United
States
Marine
Corps.
ORGANIZATION OF THE DIVISION
STAFF.
In the preceding article we discussed
in brief
and
general
terms
the organization
of
a
brigade.
Because
the brigade, except
when
serving alone,
is not an administrative
unit, and,
because the regi
mental
medical
officers function directly under the division
surgeon
(when the brigade forms
a part of
a division)
and should, there
fore, have at least a working
knowledge of the duties
and functions
of the latter in order that they may intelligently
cooperate with him,
it is believed that the next logical step is a description of the organi-
1 There
has
been
established
at the field officers'
school, Marina Corps
schools,
Marine
Barracks,
Quantlco,
Va.,
a correspondence
course for medical
officers which
offers
many
advantages
to medical
officers of
the Navy,
particularly those
serving
with
the
Marine
Corps in the field.
The duties
required
of medical
officers on board naval
vessels and at shore stations
in
the United
States
are totally
different
from
those required
when serving
with
the Marine
Corps in the field, where, during
active operations,
aid stnUons,
dressing
stntions,
field and
base
hospitals
must
be established,
and problems
of evacuation
must
be solved.
The
staff
problems
connected with a military
force in
the field are complicated
ones —
much more so than
those presented on board ship,
and require
a high
degree of initiative
on
the part
of all staff
officers and in whom
must
be centered
a great
deal of
responsi
bility.
The
senior
medical
officer of any military organization
is
a technical
advisor
to
his
commanding
officer, and upon him
rests the responsibility
for the coordination
of all
the
medical
units
assigned
to
the command,
their disposition
to
most
effectively
serve
the
combatant
troops,
and
the
procurement
and
issue
of
medical
supplies
in
adequate
quantities.
To
perform
these duties most efficiently
requires
a more or less intimate
knowledge
of
the organization
of the combatant
units ; their
tactical
dispositions
under varying condi
tions ; familiarity
with the
organization
of
the
Medical
Corps units
best
calculated
to
meet
the demands
made
upon them ; and
a knowledge
of topography
and tactics.
In
time of
peace
the only
means
available
to
the
average
officer
for acquiring
this
knowledge
lies in the solution
of map problems.
The
general
purpose
of medico-military
map problems
is to invite
attention
to
the varying
conditions
and
factors
which
might
.No.
if.
221
BAYNOB — MEDICAL
CORPS
UNITS.
zation and functions of the division general
staff, and an outline of
the administrative and technical
services.
A
division
consists
of
approximately
20,000
officers
and
men.
Manifestly,
it
would
be
impossible
for one man
to control
such
a
great
number
of individuals.
For this reason
we find
these indi
viduals organ:zed
into
a
great
number
of subordinate
groups, each
having its own
commander
and varying
in size from
the squad of
seven men under
a
corporal to the brigade, which
is
the largest
sub
ordinate unit in the division.
It
is
by
means of this organization
that the commander,
by dealing with
a
very
few men,
is
enabled
to
exercise his authority over each individual
in his command.
This organization,
by means of which
a
commander
controls and
directs the movements of his troops,
is
called
the chain of command.
The number of subordinates
with which one man can deal effectively
varies
from five to nine,
and
it
is
upon this principle
that military
organization
is
largely based.
Let us assume that
a
division
has been directed
by
some higher
authority
to march from X and attack the enemy
at Y.
The first
task of the division commander
would be to draw up
a
plan for the
movement.
But before
a
plan
can
be
formulated
the
commander
must obtain as much information of the enemy
as possible.
The size
of the enemy's
force,
its composition, disposition, condition, morale,
probable
intentions, etc., will all have
a
material
influence
on his
plan.
So also will
it
be influenced
by the routes
available and
the
nature of the terrain.
In addition
to the foregoing,
he must study
the question of supply in relation to the movement.
He must deter
mine and decide how
much
food and ammunition will
be required,
the kind and quantity of clothing and equipment to be carried, and
innumerable
other things that
affect
the fighting
efficiency
of the
command.
influence
the management
of
the Medical
Corps
units
serving
with troops
in
the
field.
The
correctness
of the solutions
rendered
Is of
relatively
small
Importance.
Such
solu
tions
merely apply
to Individual
concrete
cases
;
but
the solution
of
a
sufficient
number
of problems
demonstrates
broad
general
principles
upon
which
the
efficient
solution
of
such problems
or
the handling
of actual
situations
liable
to
be encountered
in
the
field
must
depend.
The
practical
value
of
map
problems
lies
in
the stimulation
of
thought
along
lines ordinarily relatively
unfamiliar.
Medical
officers of the Navy are urged
to take advantage
of this
opportunity.
Further
information
regarding
the course may
be obtained
from MaJ. S. N. Raynor,
Marine
Corps
Schools,
Quantico,
Va.
Officers
enrolling
for
the course would
be required
to provide
themselves with the fol
lowing maps, which
may be purchased from the book
department,
General
Service
Schools,
Fort Leavenworth.
Kans.,
or which will
be supplied
free by
(he Bureau
of Medicine
and
Surgery,
upon request, to medical
officers enrolling
for this
course
:
General
map,
Gettysburg-Antietam
($0.10).
Gettysburg-Antletam,
3-inch
map,
12 quadrangles,
either
mounted
together
on muslin
'$3)
or mounted singly
($0.25)
each,
or single
unmounted
sheets
($0.05 each),
at their
option.
Geological
Survey
map
of
Gettysburg
and
vicinity,
1
:
62,500,
6
sheets,
mounted
together
on
muslin
($1.60).
222
Vol. XVII.
RAYXOR
MEDICAL
CORPS
UXITS.
Having gathered
together all the information
obtainable,
the com
mander is then ready
to draw up his plan, and after having done so
to communicate
it in the form of orders to his subordinates.
These
questions
all
relate
to strategy
and
tactics,
and
naturally
group themselves under the head of planning, directing, and coordi
nating.
In
addition
to
his
tactical
and
strategical
functions,
there
are
others of
a more technical and administrative
nature for which
he
is held
responsible.
Having decided that he will need so much
am
munition,
food, clothing,
equipage,
etc., he must
also take
the
nec
essary measures to procure it.
Such questions
as the kinds and pro
portions of the artillery ammunition to be carried must
be decided.
If the operation involves crossing
a river
where
the bridges have
been
destroyed
or are inadequate,
he must determine
and decide the
kind
and quantity of bridge material
to
be carried.
Questions of
signal
communication, hospitalization
and
evacuation
of men and
animals, disposition of prisoners of war, traffic
control, kinds and
quantities of various
materials for
the
construction of
command
posts,
shelters,
etc., must
also
be decided.
These functions
are all
closely
related,
and are therefore placed
in a group by themselves —
a technical and administrative group.
There are still other functions which group themselves into a purely
administrative
group.
These
functions,
such
as the
assignment
of
officers
and
men to subordinate units, records
of personnel,
awards
of merit, infractions
of discipline,
and
many
others
of a like and
routine matter, while they do not directly affect the tactical handling
of the division,
do affect its morale,
its discipline,
and its personnel,
for all of which the commander
is held
directly
responsible
by his
superiors in command.
It is quite obvious
that it would be beyond
the powers of any one
man to perform more than a very small proportion of the functions
enumerated.
He would
become
so involved in the mass of details
as to preclude
any possibility of his exercising his higher functions
of command,
viz., the study and consideration of questions
affecting
the tactical and strategical handling of his division, and upon which
depends the success of his command
as a combat unit.
Evidently, if the division
commander
is to successfully carry out
the tasks
assigned
his division,
he must have
competent
and trust
worthy
assistants
who are specialists in the various tasks
assigned
them.
These assistants constitute
the staff.
While the duties of these
staff
officers pertain to the functions of command,
they
do
not,
as
such,
exercise
command.
Where orders are
issued
they
are issued
in the name of the commander,
who alone
is responsible
for them
and to whom falls the lot and right of making a decision.
The staff
No. 2.
223
RAYNOR —MEDICAL
CORPS
UNITS.
z
z
F
1
8
G-2
00
O
5
d
n
tf
3
<!
M
h
C
k
s
T
5
c
5
0
■Ha
>-
•<sn
jopireuraioa
jajsBuuajJBnt)
itwtyo aammpjo
.tusdmoo Musnpio
uoo8jiig
j<K>nj3ua
J80UJO IBuSlg
XaodniOD pra8is
japuBtn
joiaao
aSsssojv
laoujo
jaUpnoH pas-o'W
■jpraoo'SuaVi
-
--f
Bp
•qsaow isoaojj
pns
jpiuoD
bH
■03 bH
1
Li
:
c
■
a
Si
i
2
a
I
e
o
224
Tol. XVII.
EAYNOR — .MEDICAL
CORPS
UNITS.
is charged
(1) with gathering
and furnishing the commander
with
the information
upon which he bases his decisions;
(2) with work
ing out
the
details
necessary
to complete
the
decisions
and
enable
the subordinates to carry
them out;
and
(3)
to see that the tasks
assigned
are carried out in accordance
with
the ideas of the
com
mander.
We have
seen that the functions of the division
commander
are
divided into three groups:
First, that pertaining
to command
and
called the planning, directing, and coordinating group;
second, that
pertaining
to the technical arms and services,
and called the techni
cal and administrative group;
and third,
those pertaining
to routine
functions, and called the administrative group.
This division of the functions forms the basis of staff organization.
Officers
assigned
to the first group constitute
the general staff ; those
assigned
to the second group the technical and administrative
staff ;
arid those to the third group, the administrative staff.
We will now consider
those three groups separately
and in more
or less detail in order that we may see the relationship that exists be
tween them and the commander,
with the troops, and between them
selves.
THE GENERAL STAFF.
The general
staff
is the connecting link between
the general
and
his command.
It relieves him of the mass of detail and leaves him
free
to
devote his attention
to the higher
functions of command;
it furnishes him with the information
necessary to reach
a clear and
correct
decision
; works out tentative plans and
the details thereof ;
and gives
expression
to his decisions
in the form of orders
and in
structions, and insures
their execution.
By referring
back
we will
see that this group naturally
divides
itself into four sections —one having to do with information
of the
enemy;
another with
questions
of supply
as affecting strategy and
tactics;
another with
administrative
questions;
and
still
another
section which having received
all the information
required from the
first two sections,
and
the commander
having drawn up a tentative
plan, works out the details of this plan and, when
a decision
has been
reached,
communicates
that decision
to the subordinate commanders
in the form of an order.
From this division
of
duties
has
evolved
the
four
sections
into
which the general
staff of the division is divided :
To the second sec
tion or G-2 appertains intelligence of the enemy ; to the fourth section
or G—1, questions of supply;
to the third section or G-3, the prepara
tion of plans of operation and their promulgation in the form of field
orders
so that they
may
be intelligently
executed;
and to the first
section or G-l , personnel
and routine matters.
In Armies and higher
No. 2.
225
RAYNOK
MEDICAL
CORPS
UNITS.
headquarters, the G-3 section is again divided into a G-3 section and a
G-5 section,
the former being confined
to operations and
the latter
responsible for questions of training.
The volume of work required from each of these sections is such as
to require
considerable
personnel,
varying with the size of the com
mand.
The work of this personnel
in each section is coordinated and
controlled
by the chief of that section.
Each chief of a section
is
officially designated
as assistant chief of staff G-l, G-2, G-3, or G^,
depending
upon the section to which assigned.
Jn order that all parts of the staff may function smoothly and that
all questions
of differences
of opinion
may
be settled,
and that all
may be coordinated into an efficient team, the four sections of the staff
are placed under the command of the chief of staff, who is the mouth
piece of the division
commander
and
the officer through whom he
communicates
his decisions
and
wishes,
and
through
whom
he re
ceives the information
and tentative plans upon
which he bases his
decisions.
It is not the purpose of this article to go into a detailed
description
of the organization,
functions, and operations of the four sections of
the general
staff.
Only
a very general
outline of their
functions
sufficient for a clear conception
of the staff organization
as an entity
will be given.
As a concrete
example
let us go back
to the division
which
was
ordered to march from X and attack the enemy at Y.
The operations
or G-3 section is the group which will plan and work out the details
for the movements
of the division.
The
commander
may, through
his chief of staff, submit
to this section
a general
outline of how he
wishes the movement to be carried out, or, he may simply transmit to
it the instructions he had received from higher authority and direct it
to draw up tentative plans for his approval.
The chief of this section,
before he can draw up any plan, must get in touch with the chief of
the intelligence section (G-2) in order that he may familiarize
him
self with any new information
concerning the enemy, for, as already
stated, the strength and disposition of the enemy will, very naturally
affect the formation of the division for the movement.
If the enemy
is near, the formation
must
be such
as to facilitate early and rapid
deployment.
This might
best
be
accomplished
by
an
advance
in
several columns over parallel roads.
On the other hand, the presence
of a hostile force
on one flank would necessitate
a flank guard.
The
strength and composition
of the advance
guard would also be influ
enced
by the strength and disposition
of the enemy.
It is evident,
therefore, that there must be the closest cooperation
between the G-2
and G-3 sections.
The
same sort of relationship
must
also
exist
between G-3
and
the supply (G-4)
section.
This latter section works out and plans
226
Vol. XVII.
RAYNOR
MEDICAL
CORPS
UNITS.
the operations of the
services.
If there
is not the
most
complete
coordination
between these two sections, confusion and the most
se
rious consequences are likely to result.
Ammunition
and
food
sup
plies,
without
which
an
army
is
helpless,
may
fail
at
a critical
moment.
For example,
G-3, in drawing
up his plans for the attack,
may wish to use smoke or gas on certain sections of the enemy's posi
tion, or he may
desire
to put over a long and heavy
bombardment.
He should first ascertain
from G-4 if this ammunition is procurable,
for otherwise he may find out, when it is too late, that his plans were
faulty because the ammunition
he desired
was not obtainable.
Likewise, G-4 must obtain from G-3 the latter's plans in order
that the field and administrative
orders will
not conflict with
one
another.
If
the division
is
to
be
deployed
for action G-4
must
know the relative position of the various organizations
before
he
can determine
and designate
the distributing
points for rations and
the distributing
stations for ammunition,
as well
as the
numerous
other details that go to make up the administrative order, and which
are dependent
on the field order.
(Note. —The administrative order
will be discussed in a subsequent article.)
THE TECHNICAL
AND ADMINISTRATIVE
STAFF.
It has
been
previously
stated that the administrative
(G-4)
sec
tion of the general
staff directs and controls the operations of the
technical
and
administrative
staff.
Before
we go into
the details
of this latter group,
let
us examine
for
a moment
the
reason
for
this group of the staff.
As a matter of principle
every staff should be
reduced
to the minimum consistent
with efficiency.
What are. the functions of the technical and administrative
staff?
Day after day
the
20,000
men of our division
must
be fed, which
means that rations must
be procured and
delivered.
Furthermore,
they
must
be properly
and
adequately
clothed
and
equipped
at all
times.
During combat they must have
a plentiful supply of ammu
nition, which must
be procured and distributed.
Every day
a large
number
of men are taken sick and
require
medical
attention.
Dur
ing combat
many
become casualties
through wounds or gas.
Arms
and equipment
are constantly being lost, destroyed,
or worn out, and
must
be replaced.
Animals,
like
men, become casualties,
and
some
must
receive
medical
attention, while others
must
be evacuated
and
replaced.
Constant
communication
must
be
maintained
withan
the
division
and
with
headquarters,
and
this requires the
supply
and
installation
of
signal
equipment,
such
as
telephones,
switch
boards, wire, radio apparatus, flags, panels, pyrotechnics, etc.
When
marches are undertaken the road may be in need of repair or bridges
may require strengthening or have to be replaced.
To distribute
the
supplies
we
must
have
both
horse
and
motor transportation,
and
KAYNOR— MEDICAL
CORPS
UNITS.
227
this transportation
must be so regulated
as not to cause congestion
on
the roads or interference
with the troops, otherwise the supplies may
fail to reach their destination in time to be of any value.
It is quite
evident
that
no one man
could perform
all of
these
multifarious
duties.
Moreover, many
are of a technical nature and
require
technical
knowledge and skill which
no one man
could
ex
pect to master.
This, then, is the reason for the technical and admin
istrative staff: the
officers who compose it being
specialists in the
bran, hes they direct.
These
officers are the technical
advisers of the
general and his general
staff, and while they ordinarily function un
der the direction and control of the G—4 section, nevertheless,
at times
and for some purposes
they may function under the direction of some
of the other sections of the general
staff.
Within
a division
the staff
officers forming
the technical and ad
ministrative staff, and functioning,
as a general
rule, under the G-4
section of the general
staff, are as follows
:
Field Artillery brigade commander.
Machine gun and howitzer officer.
Air service
commander.
Signal
officer.
Engineer
officer.
The surgeon.
Ordnance officer.
Quartermaster.
Tank commander.
Chemical officer.
With the exception
of the duties of the surgeon,
it is not believed
necessary to go into details regarding
the functions of these staff
officers.
The functions of the division
surgeon
will
be the subject
of the next article.
THE ADMINISTRATIVE
STAFF.
If, as has already been shown, it is beyond
the powers of one indi
vidual
to perform
all
the
duties
pertaining
to
the
administrative
and technical
staff, it is equally impossible for any
one individual
to dispose of the innumerable details of routine administration
which
fall within the province of the administrative staff.
These functions
divide themselves naturally
into certain classes which are clearly
de
fined
and pertain to the routine administration
of the division,
its
correspondence,
records,
statistics, finances,
questions
of personnel,
and others of a like
nature.
There are other functions which
con
cern
inspections,
questions
of morale,
discipline,
military justice,
and spiritual welfare.
228
Vol. XVIJ.
RAYNOE —MEDICAL
CORPS
UNITS.
These
duties, which constitute
the functions of the administrative
staff, are divided among the following staff officers :
The adjutant.
The inspector.
The judge advocate.
The chaplain.
The postal
officer.
The finance officer.
The headquarters
commandant
and provost marshal.
In the channel of staff control and coordination
these officers oper
ate under the G-l section of the general
staff.
RELATION
BETWEEN HIGHER
AND LOWER STAFFS.
In the foregoing discussion
the staff organization of a division has
been taken
as a model.
The staffs of all organizations
are, however,
organized
on the
same general
principles.
Although in principle
each staff functions under the authority
and in the name of its com
mander, it will
be found that in matters
of a purely routine nature
the
higher
and
lower
staffs
deal
more
or
less directly
with
each
other.
However, it should always be remembered
that a staff officer,
as such, can not exercise command
except in his own office
and over
his own assistants.
Before closing it seems
to be advisable to define and illustrate
the
words coordination, supervision, and control, which
are continually
being used in reference
to the general
staff.
Webster's Dictionary
defines coordination
as " The act of regulat
ing and
combining
so
as
to produce harmonious results."
Let us
apply
this
definition
to
an example
and
assume for this purpose
that
the division
which
was
to march
from X
to Y
reaches
the
vicinity of the latter place late in the afternoon, and that the com
mander
decides
to bivouac for the
night
and attack
the
enemy's
position early the next morning.
There are many questions of sup
ply and
administration
which will conflict
and
produce confusion
at this critical
time
unless
there
is some one in authority
to make
harmonious
adjustments
of these conflicting claims of the adminis
trative
and technical staff in the light of their bearing on the plan
of the commander
and which can not
be known to them.
There
is
the
quartermaster
who
is
responsible
for
feeding
the
troops;
the ordnance
officer who
must
see that all small-arms
am
munition
needed for the
battle
on
the
following
day reaches
the
troops in sufficient
quantity
and
on time;
the surgeon
must
make
plans for the evacuation
of the wounded
and
that necessitates
the
establishment
of collecting stations,
field hospitals, ambulance
routes,
etc. ; and the engineer
and signal officers who must get supplies to the
front.
Each of these officers is. quite
naturally,
interested
only
in
No. 2.
229
RAYNOB— MEDICAL
CORPS
UNITS.
his own particular
task.
If some one does not pass upon
and regu
late their conflicting
claims,
the evening
before
the battle will find
the road leading to the front
blocked
with traffic
and, instead of all
the supplies
reaching their respective
destination that night,
traffic
jams will probably prevent any of them from reaching their
desti
nations.
In addition
to
the
foregoing,
the
quartermaster
has
selected
a
point where
he wishes
to establish
a ration distributing
point, but
it appears that the ordnance
officer has selected that same
point for
establishing
his
ammunition
distributing
station;
or that
the sur
geon wishes
to establish
a collecting station there; or that the engi
neer officer would like to use that spot
as
a dump for engineer
ma
terial.
Not one of these officers is in a position to decide
as to who
shall have priority because not one of them is familiar with the gen
eral plans for the attack,
and, even though they did know, each one
would naturally
decide
in favor of his
own service.
There
must
be some one, other than
these technical staff officers, to make harmo
nious adjustment of these conflicting claims,
so that no one particu
lar class of supplies will reach its destination but that all of them
will reach their destinations on time
and
without
confusion.
The
officer
best qualified to coordinate
the activities of these officers of
the administrative and technical
staff,
and to produce
a harmonious
and smooth working
machine,
is one who can view
all of the func
tions from the viewpoint of the commander — in other words,
a mem
ber of the general
staff,
and in the
ease in question,
the assistant
chief of staff G-4.
Control is defined
as "To restrain, rule, govern,
manage, guide."
The assistant
chief of staff G-4, having coordinated the conflicting
claims of the technical and admisistrative
staff,
and having decided
on such other matters
of
a supply
and
administrative
nature
as
required direction and adjustment, governs,
manages,
or guides
the
operations of these services
by the issuance of administrative
orders
and instructions to the command
in the name of the division
com
mander.
The mere issuance of orders is not sufficient,
as we are all well
aware.
There must
be
a follow-up
to see that the instructions
and
orders of the commander
are carried out in accordance with his plans
and
wishes.
This overseeing,
inspection,
superintendence,
etc., con
stitutes the general staff supervision.
The accompanying chart
shows
graphically
the
organization
of
the general
staff of a division.
Note. —The subject
matter of this article has
been
compiled
from
War
De
partment publications
and pamphlets
used
In the courses of instruction
at
the
General
Service
Schools,
Port
Leavenworth,
Kans.,
and
the
Marine
Corps
8chools,
Quantico,
Va.
From
its
nature
much of it
has
been
copied
verba
230
Vol. XVII.
GALWEY
GAS WARFARE.
tim.
By quoting
or modifying
the text of those publications
and
pamphlets
where, for the purposes of this article,
such
modification
seemed
desirable,
the
writer
has
endeavored
to
present
a
clear
and
understandable
picture
of
the
general staff of a division,
but disclaims
any credit for originality except in the
method of presentation.
GAS WARFARE.
EFFECTS
OF POISONOUS
GASES—EARLY AND LATE.1
By Maj.
W. R. Galwbv,
O. B. E., M. C, Royal
Army
Medical
Corps.
Since the advent of chemical
warfare
a very large number of sub
stances have
been
examined
with
a view to determining their suita
bility
from
the points of view of production
in quantity,
use in
shells,
bombs, or projectors, and the physiological
effects on human
beings
and other animals exposed to them.
A detailed
list of these substances would serve no useful purpose,
and it will suffice
to show how thej' may be grouped into the follow
ing
classes according to their physiological
effects
and
to mention
one or two of the more important substances in each group.
(1)
Lachrymators.
(2)
Sensory
irritants
of
the
eyes,
nose,
and
upper respiratory
passages.
(3)
Vesicants.
(4)
Asphyxiants
or acute lung irritants.
(5)
Direct poisons of the nervous
system.
(6)
Gases which act by interference with the respiratory property
of the blood.
Compound.
Formula.
Boiling
point °C.
Characteristics.
Benzyl bromide..
.
C«H(CU5Br
198
Colorless
liquid
with pungent
smell.
Group
(1) Lachry
mators.
Xylyl bromide
CH^HsCHjBr...
CHjBrCOCH,
185
137
Brom.
acetone
Pale yellow liquid with pungent
smell.
(2) Sensory irritants of
the
eyes,
nose,
and
upper respiratory
passages.
Examples:
Di-phenyl.
chlor. arsine
(C6Hr,).,:
AsCl melt
ing point 43°
C. ; boiling
point 333°
C. ; faintly odorous,
yellowish
oil or as a solid; ethyl-di-chlor.
arsine,
C2HsAsCl2< boiling point 156°
C, faint ethereal
smell.
(3)
Vesicants.
Examples:
Di-chlor.
ethyl
sulphide
(mustard
/CH CH CI
gas)
S<^
c^CH^Cl^0^11^
P0^''
a
Pa*c
yeH°wisft
\
2
2
odor of garlic or mustard.
(4)
Asphyxiants
or
acute
lung
irritants.
Examples:
Chlorine
Cl2, boiling
point
33° C, greenish-yellow
gas,
smell
of bleaching
1
Reprinted
from
the Jour. Royal
Army
Med.
Corps,
London,
February,
1922.
No. 2.
231
GALWEY —GAS
WARFARE.
lime; phosgene (carbonyl-chloride)
COCL, boiling point 8° C. ; col
orless pas,
smells of musty
hay,
tobacco
gives
a characteristic
taste
after phosgene has been inhaled.
(o)
Direct
poisons
of
the
nervous
system.
Example:
Hydrocy
anic acid HON. boiling point 26.5° C, melting point 13.8° C; color
less mobile liquid with smell of bitter almonds.
(6)
Gases which act by interference with the respiratory proper
ties of the
blood.
Example
: Carbon-monoxide
; colorless,
odorless
gas, lighter than air.
This classification
is to some extent
artificial,
for in certain
in
stances
the groups merge into each other,
e. g., some lachrymators
are asphyxiant in high concentrations and
the
asphyxiants
cause
lachrymation.
Again,
the arsine
compounds
besides
being
sternu-
lators cause
lesions
in the lungs and possibly in the central nervous
system.
A8PHTXIANTS.
Confined
to the upper air passages these substances
may reflexly
inhibit breathing and
may
produce
anesthesia of the mucous
mem
brane with loss of taste and smell.
If they reach
the larynx
in quantity,
they
may
cause immediate
suffocation
through spasm of the glottis.
In the pulmonary
air passages they
may
cause intense bronchial
spasm,
also necrosis
and stripping
of the mucous
membrane
leading
to mechanical
blocking of the air
passages.
If they
reach
the air
cells in large quantities, they
may
penetrate
the epithelium
and the
capillary
walls
and directly
affect
the
blood,
and
so lead
to those
changes
which bring about
a blocking of the pulmonary circulation.
Immediate
death
has occurred
in laboratory
animals exposed
to
high concentrations
of phosgene.
When this happens,
intense
ven
ous and capillary
congestion
and subdural hemorrhages
in the brain
are found.
The lungs show practically
no edema.
The blood ves
sels in the lungs are much congested
and inundated with
a brownish
granular material.
The blood in the systematic
circulation
is nor
mal
to spectroscopic
examinations.
Death
is thus
accompanied
by
and probably
due
to
an immediate
pulmonary
vascular
stasis
re
sulting in acute asphyxia.
Cats
exposed
to chlorine
1.700
died
in less than
15
minutes,
the
blood being almost black, arterial pressure falling rapidly
and there
being no asphyxial rise, and practically
no lung edema.
Pulmonary changes appear to be a necessary stage in all the patho
logical
effects
of the irritant gases.
With doses of such
a strength
as to cause death
in two hours,
damage of the lung
seems
a
neces
sary factor.
232
Vol. XVII.
GALWEY —iGAS
WARFABK.
In smaller quantities
than
those giving
rise
to
effects
just
de
scribed,
the asphyxiants may injure in various degrees the bronchial
mucous
membrane
and the epithelium of the air sacs
and capillary
walls, without
actually
penetrating
into
the
capillary
vessels,
the
lesions giving rise to intense pulmonary edema.
Finally,
a secondary
bacterial infection
may
lead
to
pneumonia
and infective inflammation of the respiratory
passages.
The condition
brought
about
after
the injury
to
the capillaries
and air cells is one of want of oxygen,
and to this most of the serious
symptoms
and the sequelae of asphyxiant gas poisoning are due.
In
fact, there
is no
good
evidence
that with
moderate
concentrations
of gas, any
system of the body other than the respiratory
is pri
marily
damaged.
So far as the evidence
goes at present,
the lesions
found in the other organs
are a consequence of the interference with
the respiratory exchange of oxygen.
Of the typical asphyxiants chlorine affects the upper air passages
and
bronchial
tree
primarily;
while
the
action
of
phosgene
is
chiefly on the cells of the lung alveoli.
Chlorpicrin is intermediate
between the two.
Experimenting
with
dogs, Underhill
found
that chlorine
has
a
very strong irritative
action,
an animal gassed therewith
becoming
excited
and in evident distress.
With chlorpicrin
the character of
the reactions
is very similar
but less pronounced.
With
phosgene,
on
the
other hand, the
animals
appeared
to
be in no
immediate
distress.
To some extent this difference
of reaction
can be explained.
When
the substance
is introduced in the
atomized
condition, if the spray
is coarse it may be entirely held up in the upper respiratory passages.
A fine spray, on the other hand, may
reach the alveoli. If the
sub
stance is very soluble,
as ammonia,
the moisture of the surfaces of
the air passages would largely entrap it.
Possibly
also
a substance
may
be comparatively
innocuous
to
the
more
resistant epithelium
of the air passages,
and only
effective
on
the
more
delicate
lining
of the alveoli.
Or again, the vapor may
have
an affinity for some
tissues while it is relatively
indifferent
to others,
as in the case of
mustard gas, which
attacks
the epithelium of the air passages,
but
not that of alveoli.
In acute deaths from asphyxiant gas poisoning, i. e.. those occur
ring in about
24 hours,
the most striking changes
are found in the
lungs.
The following are the gross lesions
found in human beings :
On
opening
the
thorax
the
lungs
are
voluminous,
and
hardly
collapse
at all.
Distended lymphatics
and small subpleural hemor
rhages
are visible
on
the
surface.
Rarely the
hemorrhagic
areas
coalesce with stripping of the pleura.
Xo. 2.
233
GALWEY —
WARFARE.
<!AS
i
Air from damaged
lungs is visible as chains of bubbles
below
the
visceral pleura along the interlobular
fissures,
and occasionally pene
trating into the tissues of the mediastinum and into the subcutaneous
tissues.
The whole external surface of the lung shows
deep purple
areas
of collapse
or consolidation
slightly
depressed
below
the surface,
alternating
with
irregular
areas
of
acute
emphysema
of
a light
grayish color.
Emphysematous
patches
are
more
numerous
along
the margins
and
diaphragmatic
surface
of
the
lung
where
bullae
are sometimes found.
In the pleural cavities are found serous fluid in varying quantities
and some traces of blood.
The lungs, on removal,
weigh several
times their normal weight.
They
feel
wet,
and
on
section
drip frothy
fluid
and
blood.
The
irregular patches of collapse
and emphysema
extend throughout the
lung substance.
Occasionally definite infarcts
are found.
The fluid
collected
from
the lungs of animals dying
with
acute
pulmonary edema
is clear
straw-colored,
and
occasionally contains
a few red blood
corpuscles.
Underhill found that its chloride
con
tent
is essentially the same as that of a simultaneous
sample of blood
plasma.
This shows that there is complete
permeability of the pul
monary capillaries for salts.
The edema fluid and blood
plasma
are
in equilibrium
as regards their salt content.
The trachea
and bronchial
tubes are largely filled with thin, yel
lowish, highly albuminous fluid, which sometimes
escapes as a froth
from the mouth and nostrils after death.
The
degree of inflammatory
change
in the mucous
membrane
is
variable.
In severe cases the lining of larynx,
trachea,
and bronchi
is of a deep purple color, swollen and edematous.
The epiglottis
is
affected to a less extent than the trachea
and the edema of the larynx
is not sufficient
to endanger
life.
The
mucous
membrane
of the pharynx
is generally dry,
glossy,
and somewhat
congested.
Sometimes
only
the lower trachea
and bronchi
are
affected,
and
occasionally
(as in cases of pure phosgene poisoning)
they
are nor
mal save for frothy fluid.
It is stated that a false membrane
was rarely found in cases which
survived
to reach a medical
unit.
If death is delayed
to the second or third day the aeration of the
lung tissue is better; and if the patient survives till the fourth
day
areas of broncho-pneumonia and pleurisy may be found.
In examining lungs from animals killed
at various periods after
gassing
one is struck by the very small amount of sound lung tissue
with which the animal appears
to be able to carry on.
234
Vol. XVII.
GALWEY —GAS
WARFARE.
On
examination
of
the
circulatory
system
engorgement
of
the
large veins is found.
The right heart is generally but not invariably
distended,
and
sometimes
petechial
hemorrhages
are found in the
endocardium.
Sometimes
there is an increase in the pericardial fluid.
The blood clots rapidly and its concentration is above normal.
Abdominal
organs. —There
may
be
petechial
hemorrhages
and
slight ulceration in the stomach.
Large hemorrhages
in the stomach
cavity have been
described.
There is a general
engorgement
of viscera; enlargement
and nut
meg appearance
of the liver and enlargement
and congestion
of the
kidneys are found ; but frequently in experimental animals no abnor
mal appearances
are observed.
Central
nervous
system. —In early deaths
as
a general
rule only
engorgement
of vessels, both
meningeal
and cerebral,
is found;
but
when death follows after two or three
days of cyanosis
and uncon
sciousness
due to want of oxygen,
tiny
petechial
hemorrhages
are
seen surrounding
vessels throughout
the whole of the white matter.
Similar hemorrhages
have
been
found in the brain in deaths which
were ascribed
to shell shock, but as Sir F. Mott has pointed out, such
deaths may in reality have been due to poisoning by the carbon-mon
oxide generated by the shell explosion.
The punctiform
hemorrhages
occurring
in
the white matter
are
primarily
due
to
the
anatomical conditions
of
the
vessels in
the
cerebrum,
where they are terminal, each small artery having a sepa
rate capillary
system, as is also the case with the emerging
veins.
A
tendency
to stasis may
be brought about in these separate
vascular
systems by the failure of the heart as a force pump, also by respira
tory conditions which lead to right heart dilation
and interference
with return of blood
from the skull.
In those gas cases
where
the
hemoglobin
has been converted
into pigment the
hemorrhage
may
arise from occlusion
of the arteries.
Observations on animals have enabled
observers
to give a fairly
clear
account of the sequence of events which lead
up
to the post
mortem
appearances
desmbed above.
.Professor
Shaw Dunne made^
extensive
observations
at Porton
on goats gassed with phosgene, and
the following
account of the changes in the lungs is abstracted
from
his paper:
By
the
end
of half
an
hour
after
gassing
on
inspection
of
the lungs
red
areolae
are
observable
in
the centers
of
alveoli.
Fluid
accumulates
In
the
interlobular
planes, which
are seen as fissures and under
the pleura.
On
miscroscopic
examination
alveolar
edema
is
found.
Masses
of light
granular mnterial
are seen most commonly
in the openings of the infundibular
cavities
toward
the centers of the lobules.
This light edema is found all over
the lungs.
At this stage desquamated
pulmonary
epithelial
cells and red-blood
corpuscles can be seen in the edema
in small
numbers.
No. 2.
235
GALWEY
GAS
WARFARE.
The Interlobular planes of connective
tissue
show marked
edema,
the fibers
forming
them
widely
separated
by granular material
representing
fluid.
The lymphatic
vessels
in
these
planes
are
distended
us
are
those
In
the
bronchial
and arterial walls.
In the central
lobules there Is blocking of the capillary vessels in the alveolar
walls
by minute
thrombi.
This phenomenon
may be
seen
as early
as half an
hour after gassing,
but
is usually
well
advanced
by two
or
three
hours.
In
the earliest
recognizable
stage the damaged
vessels appear
collapsed
and
con
tain few red-blood
corpuscles
but many leucocytes.
The process Is confined
to
the rows of alveoli
nearest to the infundibular openings.
On the fringe of this
area the capillaries
are much engrossed with blood in contrast
with those situ
ated more peripherally.
The latter
are almost
empty as in a section of normal
lung.
The engorged state of the capillaries
points
to stasis of blood in them during
life.
At quite
an early
stage the musculature
of the bronchlolar termination
and
infundibuiu
is affected.
The fibers are swollen
and tend
to lose their
striation.
In some
cases these
muscles are
in
a condition
of spasm
so that
groups of
alveoli are distended with air which
can not escape.
This
condition
has been
found
to persist
as late as 12 hours after gassing.
As it affects the airways to
both edematous and nonedematous
areas it tends to prevent loss of function
in
the former
being compensated by the latter and so Increases the lack of oxygen
of the animal.
At this
stage the superficial
layer
of ciliated cells of the bronchi
also show
evidence
of damage.
During the Initial
period of three
to four hours
the amount
of fluid which
remains In the air spaces
is very small, though a great excess must escape
from
the capillaries which
have undergone
a less severe lesion
than those which
are
actually
thrombosed.
The edema
in the interlobular planes
indicates
this and
also shows how rapidly an abnormal
exudate can be got rid of from the alveoli.
After this initial
stage, naked-eye examination
shows extension
and intensifi
cation
of
the
edema
with
progressive
diminution
of the
normal
post-morten
collapse
of the lungs.
The reddening
In the center of lobules extends to whole
lobules
and
deepens in
tone.
The surface
of the
lung
is mottled
In varying
shades of red, as some lobules are more affected than others.
Later large areas
become entirely filled with fluid
to the exclusion
of air.
By the end of 48 hours the condition
of light profuse
and universal
edema
is
no longer
seen.
In the majority of the animals
observed
there
are greater
or
less
tracts
of solid
lung,
contrasting
with areas
in which
edema
is slight
or
absent and aeration
well
established.
Histological
examination
shows a further development of the changes observed
in the early stage.
The alveolar
edema
is more abundant
and more generally
distributed.
The solid
residue of the edema
is denser
in consistence.
It may
appear
as a reticulum
like fibrin or
a homogeneous
masslike
colloid.
Every
alveolus in a lobule and also the infundibular cavities
and terminal
bronchioles
may be full of It.
Even where there is a vacant
space
representing
air this may
be situated centrally so that it is away
from
the capillaries and alveolar walls.
If edema persists
for more than 24 hours
the alveolar
walls may show thicken
ing and many of their
epithelial
cells may be desquamated
and He in the edema
residue.
There may be a few polymorphonuclear
leucocytes in the exudate.
There is evidence of loss of tone in the elastic fibres in the alveolar
walls.
The smaller
bronchi
and
bronchioles
show
loss of superficial
ciliated
cells,
bnt rarely is the whole epithelial
coat destroyed.
108165—22
4
236
Vol. XVII.
GALWEY
GAS WARFARE.
In places bronchioles
are partially blocked.
Those which
lead to solid lobules
become
filled
by albuminous
material,
mucus and epithelial
debris.
Capillary thrombosis
undergoes very little extension
after the initial
period,
and
persists
practically
unchanged
for
36 to
48
hours.
It
<s always
accom
panied
by much engorgement
of the neighboring
capillaries.
The fluid
in
the
alveoli
diminishes
the lumina
of the capillaries since it subjects
their walls to
greater pressure than would
the normal
content of air.
Up
to
48
hours
after gassing,
then,
the outstanding
feature
is progressive
diminution of aerating
surface
by fluid accumulating
in the alveolar
spaces.
As
the distribution of the edema is not uniform,
a greater
or less extent of lung
may remain relatively free and may suffice
to keep
the arterial blood sufficiently
aerated till the edema
subsides.
There is experimental evidence
to show
that though
the circula
tion in the capillaries
is much
impeded
by intense
edema the total
blood flow is fairly well maintained, therefore
a greater
proportion
than
usual
must
pass through
the
less edematous
portions
where
some degree of oxygenation can be effected.
The accumulation of fluid seen in the interstitial
planes and under
the visceral pleura and
the exudation in the pleural
cavity
shows
how
the fluid
escaping
from
the alveolar capillaries
is being con
tinuously drained off.
The
amount
remaining in the alveoli shows
how far supply is in excess of disposal.
As a rule in animals gassed with phosgene,
death during
the first
48 hours is associated
with an extreme
degree of pulmonary
edema,
and as a result of fluid in these spaces the greater part of the respira
tory area is out of action.
Death is thus due to diminution
of the
supply of oxygen
to the blood,
and this conclusion is confirmed by
blood gas analysis.
In animals dying in first 24 hours the edema, though universally
distributed,
is not so intense.
Death in these
cases
may
be due
to
oxygen lack combined
with shock or lower resistance.
In animals dying
on third day it is found
that
the
pulmonary
lesions
are on the decline
; the alveoli could take in air if the neces
sary respiratory effort were forthcoming.
In such cases it is possible
that the earlier lack of oxygen
has brought
about
failure
of
the
heart and respiratory
center.
It is usual
for animals to die within the first two to three
days
after gassing
with phosgene
; deaths at a later period are frequently
due to secondary
infection.
In animals which have survived till the
third or fourth day and have then been killed for purposes of exami
nation there
is evidence
of the
decline of edema.
The only visible
edema is on the ventral aspects of the lungs, but the affected portions
are almost
entirely
solid.
The
lesions
may
be scattered
or occupy
large areas.
The main body of the lungs appears fully aerated.
The
aerated portions collapse
less completely
than normal.
No. 2.
GALWEY
GAS WARFARE.
237
t
The contrast
between
the solid
areas and
expanded
areas
is
ex
treme.
It is probably due to the edema in the greater portion of the
lungs being
insufficient
to interfere seriously with
aeration,
so that
expansion
and
contraction
is not checked.
The
movement
of
the
lung tissue and compression of air will aid drainage of fluid through
the lymphatics.
On the other hand, in solid lobules
no such help is
■riven
and air may not even enter choked bronchioles.
In
the worst
cases
amongst
goats
which
recovered,
Dunn
found
solid
edema in one-third
to half of each lung
and
edema in some
degree in the remaining portions.
By the fourth day there is definite evidence
of the absorption of
edema.
The lungs are less bulky and there
is obvious
shrinkage of
the solid areas.
The dorsal parts of
the lungs are fully
aerated.
The margins of the solid and aerated
areas are not sharply differen
tiated
; there is an intermediate zone where reexpansion
is proceeding
slowly.
By
the fifth day scattered
lobules
in
the solid
areas
are
aerated.
By the eighth day only small areas remain unexpanded.
In animals surviving
to
the fifth
and
sixth
week
the lung
has
resumed
its normal appearance.
Microscopic examination shows
how reparation is brought about.
The more lasting the edema in a lobule
the greater
is the amount
of
histological
change
developed.
The
maximum alteration
is in the
area
of
thrombosed
capillaries.
The
alveolar
walls
here
become
thickened, partly owing to edematous swelling of their connective
tis
sue
elements, partly
to increase
in the number
of their cells.
The
thrombi are disposed of by phagocytic action,
and the capillary
net
work
is ultimately
completely
reformed.
The thin pulmonary
epi
thelium is replaced
by closely
set cubical cells like those in the termi
nal bronchioles.
The reparative changes are therefore of a subacute
inflammatory
character.
The
albuminous material
shrinks
and
is
attacked
by
phagocytes
from
the
pulmonary
epithelium.
In
the
more peripheral portions of the lobule outside
the thrombosed
area
there is slight thickening of the alveolar epithelium which later dis
appears.
The signs
and symptoms
of asphyxiant
gas poisoning.—All
the
gases which
act as lung irritants
cause practically
the same type of
symptoms,
though the time of onset and the concentration
necessary
to cause symptoms
of the same severity differ with particular
gases.
The picture
also varies slightly according to whether the gas affects
primarily
the respiratory
passages of the alveoli of the lung.
Exposure
to an atmosphere
containing
one of
these
gases
causes
immediate
sensory irritation accompanied
by smarting and watering
of the eyes.
The irritation of the respiratory
passages causes catch
ing of the breath, coughing, and a sensation of tightness in the chest.
238
GALWEY
GAS WARFABIi.
Vol. XVII.
The intensity and duration of those early symptoms
depend upon the
concentration.
Even a very mild dose of phosgene may cause a feeling of lassitude
and general
discomfort for some
hours.
As a rule nausea, vomiting,
and retching are prominent features
in the early stages.
Inhalation
of phosgene
causes
a very characteristic change
in the
taste of tobacco.
The onset of edema of the lungs is signaled by deep cyanosis
or
leaden-colored
facies,
the
cough
and
frothy
expectoration, the
dis
tress
and
restlessness,
the
quickened
respiration
and
rapid
pulse
which
are characteristic of a serious
case of gas poisoning.
These
signs are usually well established
by the time a patient is admitted
to
a field ambulance
or casualty clearing
station.
In
the
case
of
phosgene poisoning there
is,
however,
sometimes,
considerable
delay
and
a
man apparently only slightly gassed may carry
on his duty
for several hours and then become seriously ill.
Headache,
pain behind the sternum
and in the epigastrium are asso
ciated
with
these signs
and
symptoms
in the majority
of patients.
As the case develops, want of oxygen becomes more serious and domi
nates the clinical
picture.
The serious
cases may
be divided into two groups
:
(1) Those which show
definite
signs of venous engorgement,
i.
e.,
congested
and
deeply
cyanosed
face,
blue
lips
and
tongue,
visible
distension
of the superficial
veins of the
face
and
neck,
increased
breathing
which
is
often
deeper
than
normal.
Cough
may
be
present
and accompanied
by abundant thin frothy fluid.
The pulse
is
full, of good tension,
and beats about
100 per minute.
(2) In the second group the deep cyanosis
is
replaced
by an ashen
pallor, the lips being pale and of the color of lead.
The patients are
collapsed,
respiration
is
rapid
and shallow, the pulse
is
rapid,
weak
and running up to 130 to 140 per minute.
There
is
often little cough
or expectoration.
This latter group predominates
in phosgene
poisoning.
Of these
serious
cases
in both groups, some exhibit
extreme
restlessness
and
anxiety;
others
a
semicoma
and muttering delirium.
Consciousness
may be maintained to the end.
Sometimes
a
case
in
the first
group will
gradually
assume
the
characteristics of the second group.
Four-fifths of the deaths occur in the first 24 hours and very few
after the third day.
This has also been observed
in animals gassed
for experimental purposes.
A case apparently slight during the first 24 hours may rapidly go
downhill
and die on the second day
;
but, generally speaking,
for the
less severe cases the danger
is
passed on the second day.
-No.2.
239
GALWEY
GAS
WARFARE.
Bacterial infection may lead to the characteristic signs
and symp
toms of broncho-pneumonia
developing on or after the fourth
day,
and
this complication
may rapidly kill the patient.
Deaths from
this cause are not so common
as might be expected.
As a rule by the end of a week
a patient is convalescent.
During
convalescence
there is often a temporary bradycardia.
Complete
recovery
may
take
a considerable
time,
and
a certain
percentage
of patients develop
symptoms
which
are very trouble
some and intractable to treatment.
These
cases fall into three main
groups
:
(1) Cardiac.
(2)
Spasmodic
dyspneic.
(3)
Combined
cardiac and dyspneic.
(1)
Cardiac.—These patients exhibit
the characteristic signs and
symptoms
of the effort syndrone or irritable
heart,
i. e., precordial
pain, dyspnea, exhaustion,
and persistent tachycardia after exercise.
The
patient
may
look "done"
after
walking
half
a mile in
10
minutes and may
be quite incapable of going upstairs quickly.
(2)
The
characteristic
symptom of
the
second
group
is
spas
modic attacks of dyspnea
at night.
They may occur every night or
at intervals of a week.
During an attack the patient sits up in bed,
his breathing
is rapid
and shallow, but not difficult, resembling the
dyspnea of uremia rather than that of asthma.
Slight cyanosis
may
be present.
The attack may last up to 30 minutes and several
may
occur during
the same night.
The
pulse
may
be slow and full or
rapid and thready.
Such a patient on exercise suffers
from intense
headache
and
giddiness.
The
pulse
rate
after
exercise
may
fall
rapidly, unlike
that of
the
cardiac group.
In
these patients
the
blood usually shows
a hemoglobin percentage
over 100.
(3) A third group combines
the symptoms
of the first two.
All these groups suffer from pain in the head, pain in the abdo
men, usually worse after food, and pain in the chest.
The above description
gives
a fairly typical
picture of the course
of a case of gas poisoning : there remain, however,
a few observations
made either clinically or by laboratory
examination of gassed ani
mals which are of importance.
(1) Respiratory
system. —The
percussion
note
may
remain
reso
nant
all over
the
chest,
notwithstanding
the
presence
of
marked
pulmonary
edema.
The
breath
sounds
are
weakened,
especially
behind.
Fine rales and rhonchi are heard.
Considering
the extreme
danger to the lungs the physical signs give little indication
of the
seriousness of the
case.
(2)
Circulatory
system. —In
the
early
stages
the
pulse
may
be
so rapid as to
be uncountable.
This may
be due to shock or to an
early
developing condition
of oxygen
want.
Another
early
sign
240
Vol. XVII.
GALWEY— GAS
WARFARE.
in some cases
is acute dilatation
of the right heart.
This
may
be
only temporary, disappearing during convalescence.
The
second cardiac sound
is accentuated;
this
is connected
with
raised
tension
in the pulmonary
artery.
In experimental animals
blood
pressure
falls early
and
the fall
is permanent.
The initial fall
may
be
preceded
by
a temporary
rise,
and this occurs
before there
are distinct signs of lung
edema
or
as asphyxial
state of the
blood.
This fall
may
be
due
to
the
development
of an early want of oxygen
reacting on the spinal and
medullary
centers, or to dilatation of the pulmonary
vessels leading
to stasis of blood in the lungs and its withdrawal
from the systemic
circulation.
(3) Changes in the blood. —Concentration of the blood is a marked
feature of cases of gas poisoning.
This is brought about primarily
by the
production
of pulmonary
edema,
but
is contributed
to
by
shock which leads to stagnation of the blood in the capillaries,
and
by partial
asphyxiation
of muscular and other tissues which brings
about increased
local production of lymph.
The
curve of the concentration of the blood follows
closely that
of the percentage of hemoglobin as measured by a hemoglobinometer,
and Hb. values
up to 140 per cent have
been
obtained.
This
means
that the concentration of red blood corpuscles
is really
40 per
cent
greater
than normal,
and
therefore
the
potential
oxygen-carrying
capacity is increased;
but on the other hand analysis of the
blood
gases shows that the actual oxygen
content
is seriously diminished,
and that the increase of corpuscles
does not compensate for this loss.
It should also be noted that the increase of red blood corpuscles
at
this stage is relative and not absolute.
Later
a true polycythemia
may
develop
in certain
cases
which
are
slow
in
convalescence;
it may
be regarded
as
a compensation
for chronic
oxygen
deficiency.
(4) Digestive
system.—Acute gastritis
occurs
in fatal
cases, and
chronic dyspepsia
is one of the commonest
sequela?
of gas poisoning.
(5)
Excretory
system. —The kidney
are congested,
as
a rule,
in
cases which come to the post-mortem
table.
Albuminuria is found
in poisoning with chlorpicrin.
In goats dying
as the result of gassing with this substance
and
with phosgene,
a condition of acute necrosis of the kidney was found.
This change
is probably
due
to
a circulatory
deficiency
and not to
the direct effect of the gases themselves.
Gases
which
interfere
with
the
respiratory
functions
of
the
blood —Carbon
monoxide. —This
gas, though not used directly
for
offensive
purposes,
was a cause of casualties,
being generated
when
camouflets
in mines
were
blown, when high-explosive
shells burst
in
a
confined
space,
and
from
the
discharge
of machine guns
in
No. 2.
241
GALWEY
GAS
WARFARE.
insufficiently
ventilated pill
boxes;
from
charcoal braziers in dug
outs, and from the exhaust
gases of motor engines in tanks.
Carbon
monoxide
combines
with the hemoglobin in the blood
as
does oxygen, but
has
about
240
times
the affinity for hemoglobin
that oxygen
has.
When
blood
is exposed
to
an
atmosphere
con
taining CO and 02, the hemoglobin divides itself between the gases
in proportion to their relative partial
pressures.
The gas acts as a poison
simply through
its exclusion of oxygen
from the red-blood corpuscles
so that want of oxygen develops —the
degree of want of oxygen
depending upon the amount of CO hemo
globin present
and upon the fact that when part of the hemoglobin
is combined
with
CO
the dissociation of oxygen in the
tissues
is
slower than normal.
The symptoms
of the poisoning depend
upon the degree of satura
tion of the blood with the gas, and vary from giddiness and headache
to loss of consciousness, respiratory and cardiac failure and death.
The treatment
is pure
oxygen
at once.
This is given not for the
purpose that oxygen
is given in asphyxiant
gas poisoning,
but
to
drive the CO
out of combination
with
the hemoglobin, since
the
amount
which
the
hemoglobin
combines
with
depends
upon
the
partial pressure of CO and of 02 in the blood.
Care should be taken
that
the patient does not
rebreathe
his own expirations.
As soon,
then, as the CO has been driven out the Oa may
be stopped,
though,
on account of the damage already caused by the lack of oxygen,
the
patient may not recover
consciousness
at once or, indeed,
may
not
recover at all.
All are, no doubt,
familiar with
the cherry-red
color which
the
Mood develops in the presence of CO.
The box respirator
does not protect against CO poisoning and
in
entering mines,
etc.,
when
it is present,
it is necessary
to wear
an
oxygen-breathing
apparatus.
Direct poisons
of the nervous
system. — Hydrocyanic
acid
is a di
rect tissue poison,
but the nervous
system is peculiarly
susceptible
to
its action.
Concentration
of the gas is of more importance than duration
on
exposure,
i. e., it has practically
no cumulative effect.
When
a cer
tain
concentration
is attained the
action
is very rapid,
but if the
concentration
is low it may be borne for a considerable
time without
ill
effects.
Syjnptom*
follow
each other
in rapid
succession —giddiness, con
fusion,
headache, indistinct sight, palpitation,
and pain in the chest
and over the heart,
labored
breathing, unconsciousness,
convulsions,
failure of respiration, and, finally, of the heart.
In large doses death
is almost immediate.
242
Vol. XVII.
GALWEY —GAS WARFARE.
The
respiratory
center
is rapidly
paralyzed — immediate
treat
ment,
therefore,
is
necessary.
The
patient
must
be brought
into
fresh air,
and if the respiration
is stopped
or gasping
and
weak
Schafer's
method
of artificial
respiration
must
be
resorted
to im
mediately.
This
is the essential
in treatment,
and
although other
well-known
methods
of resuscitation
may
be
applied
time
should
not be wasted
on them before artificial
respiration
is commenced.
6
243
LETTER
WRITTEN
BY
HAMET
CARAMALLI.
HISTORICAL.
JONATHAN COWDERT, SURGEON IN THE UNITED
STATES NAVY,
1767-1852.
PART II.
By
Capt
F.
L. Pleadwell,
Medical
Corps.
United
States
Navy,
and Lieut.
Commander
W. M. Kbrb, Medical
Corps,
United
States
Navy.
In
1806
there 'was printed
and sold by Belcher
& Armstrong
at
No. 79 State Street in Boston a small book with the title "American
Captives
in Tripoli
or Dr. Jonathan Cowdery's Journal
in Minia
ture."
Evidently Doctor
Cowdery
contemplated
a more
extensive
account of his experiences, for it is stated in the preface of this book
:
" He kept a regular journal
from the time of his capture to the day
of his release, in which he noted,
as minutely
as circumstances
would
admit,
everything novel or remarkable and he has in contemplation
to publish
a volume
to
be entitled 'American
Captives in Tripoli,'
containing
the particulars of the capture of the Philadelphia frigate ;
general description of Tripoli with its adjacent country, its curios
ities, etc., and
a sketch of the customs
and
manners
of its inhabi
tants;
to which will be added the journal
at full length kept during
his captivity,
and
an appendix containing
the treaties
and
general
relations between
the United
States
and
the Barbary Powers."
As far as we know, this contemplated
book
was never
published,
but
the
following
extracts
from
Doctor
Cowdery's
"Journal
in
Miniature " will tell the story of an interesting and romantic episode
in American
history.
It is printed
just
as it was written
over a
hundred
years
ago,
with
the
quaint
phraseology,
spelling,
and
punctuation
in vogue
at that time:
The particulars of the unfortunate
capture of the Philadelphia frigate,
by the
Tripolitans,
have already
been
before the publick.
She run
on
a bank
abreast
of tlie harbour
of Tripoli,
on the 31st
of October,
1803,
at
11,
A. M.
and kept
up
a brisk cannonade, with the pun
boats of that regency, until
4 P. M. ; when,
failing in their efforts to get her off, they surrendered
to supertour
force.
The
Philadelphia
mounted
44 guns, and had
350
men
;
she
was afterwards got off
by the Tripolitans,
and moored
in their harbour:
but
was destroyed
by Capt.
Stephen
Decatur,
jun. in
a schooner,
with
three
boats,
a part of our Mediter
ranean
squadron,
who boarded
and burnt
her up the night of the 18th
of Feb.
1804, four
months after her capture.
On the capture
of the Philadelphia, the
Tripolitans
demanded
one million
six
hundred
and
ninety
thousand
dollars,
for the release of our captured
brethren
! they, however,
have
been
very
glad
243
244
JONATHAN
COWDERY,
SURGEON IN
U.
S.
NAVY.
Vol. XVII.
to take 60,000 dollars
for their
release, and
to enter into new bonds for future
good
behaviour
!
This
much
promised,
we
now
proceed
to
Dr.
Cowdery's
Journal;
which
he commences immediately
after his
capture.
After
the flag of the Philadelphia
was
struck,
(says
the Doctor),
and
the
officers
and crew
were waiting the pleasure
of their
new masters,
the Tripoli-
tan
chiefs
collected
their
favourites,
and, with drawn
sabres,
fell
to
cutting
and slashing
their
own
men,
who were stripping
the Americans
and plundering
the
ship.
They
cut
off
the
hands
of
some
and
it
is
believed
several
were
killed.
After this battle amongst themselves, was a little over, we were ordered
in the boats to be carried
on shore.
One of their
officers, whom I had taken by
the hand,
and who promised
me
his
friendship,
came to
me,
took
me
by
the
arm, and told
me I must go.
I asked him
to let my boy go with me, which
he
refused.
I then took hold of my small trunk, which contained
my best clothes ;
he gave me to understand
that I could not take it, but should
have every thing
taken
care of and restored
to
me.
He took hold of my hand
and
hurried
me
over the side of ship, while his other hand was employed in rifling my pockets,
from
which
he
took
about
ten
dollars.
I
had
concealed
some
gold
in
my
clothes, which
he did not find.
I then went down into
one of their
boats, from
whence I was
to pass into the next, which
was almost full of our officers
and
men.
I
made
all
haste
to
get into it for I
observed
that
the Turks
in
the
boat
where I then
was,
were
stripping
my messmate, Dr.
Harwood,
and
the
carpenter,
Mr. Godby ; but I was
soon
stopped by three of the ruffians,
who
stood
over
me with drawn
sabres and cocked pistols,
and wrested
my surtout
from
under
my arm.
Whilst
they
were
picking
its
pockets,
and
quarrelling
with
each
other for the booty, I sprung
for the next boat, which
was \vaitlng
for
me.
In my way, I met a little fellow,
who seized me, and attempted
to take off my
coat ; but I hurled
him
into
the bottom of the boat, and jumped
into
the
one
which
was waiting amongst my fellow
officers, where I thought
the Turks
more
■civil.
They
then set off for the town, compelling
our
men
to row
the boat, and
standing with drawn
sabres over our heads.
When
we had got near the shore,
they ordered our
men
to stop rowing.
Two of them came
to me and gave me a
severe blow
on the side of the head.
They
then
searched
me. and took
a case
of
surgeon's
instruments
from
my
pocket.
They
took
my
pocket
book,
but
finding
it contained
nothing
but papers, they returned
it.
One took
my
silver
pencil,
and another the handkerchief
from
my
neck.
They
then began upon Mr.
Knight, sailing master, Mr. Osborne,
lieutenant
of marines,
and all the officers
in
the
boat,
plundered
their
pockets
and
took
the
handkerchiefs
from
their
necks.
They
then landed us at the foot of the Bashaw's
palace, where we were
received
by
a
guard,
who
conducted
us
into
the palace
before
the
Bashaw.
He
viewed
us
with
the
utmost
satisfaction,
and
had
us
conducted
into
an
apartment
where
we
found
the
captain
and
several
officers,
who
arrived
in
another
boat just before
us.
Here
was a table
set in the European
style.
The
servants
appeared
to be Maltese
and Neapolitan
slaves.
Here
we supped, after
which it was announced that another boat had arrived with our officers and men.
who were
before
the Bashaw.
Capt. Bainbridge requested
me
to
go
and
look
for Dr. Harwood,
whom it was feared
was killed.
I found
him
with the car
penter before the Bashaw,
stripped
of everything
but their shirts and trousers.
They afterwards informed
us, that they were stripped
in the boat where I lost
my surtout;
and
when
they
got
within
a
few
rods
of
the shore,
they
were
thrown
into
the
sea, and left either
to drown
or swim
ashore.
The Bashaw's
No. 2.
JONATHAN
COWDERY, SURGEON IN
V.
S.
NAVY.
245
servant
gave
tlieiu
dry
clothes,
and
we were
nil
again
conducted
before
the
Bashaw,1
and
formeti
into
a half circle.
He
was
seated
on
his little
throne,
which
was decorated
in the Turkish
order, and made
a handsome appearance.
He is a good looking
man,
aged about 35.
He counted us, viewed us with a smile,
and appeared highly
pleased with us.
We were then conducted
by the minister
of exteriour relations
and a guard,
to the house formerly
occupied by the Ameri
can consul— a very
good
house,
with
a large court, and roomy enough for our
convenience.
We
were
seated
here about
nine
o'clock
in
the
evening.
Capt.
Bainbridge got permission
from the Bashaw
to send for the Danish
consul, who
paid
us a visit and offered every assistance
in his power.
We slept upon mats
and blankets
spread upon the floor, which
was composed
of tiles.
November
1.—This morning
the
Danish
consul, Mr. Nissen,
paid
us another
visit.
Capt.
Bainbridge
engaged
him
to furnish
us
with
provisions
and such
other
necessaries
as we might
want.
Our
dwelling
was
furnished
In
a plain
style,
and
we
were
supplied
with
fresh
provisions
that
were
tolerably
good.
We were allowed
to go to the front door, and to walk on the terrace
or top of
the house,
which
commanded
a handsome prospect of the harbour,
the sea,
the
town, the palace, and the adjoining country.
Here we could
see our ship on
the
rocks, full of Turks, and surrounded
by their boats, and
a constant
stream of
boats going
to,
and bringing
off, the plunder
of the ship.
We
could
see
these
robbers
running
about
town,
with
our
uniform
conts
and
other
clothing
on.
The minister of exteriour
relations
promised
to be friendly,
and collect
as much
of our clothing and effects as he could, and return
them to us.
Nov.
S.—The Bashaw
sent for the carpenter
to go on board
the ship ; he went
and found six feet water
in the hold.
The carpenter's
crew and fifty
men
were
ordered
and carried
on board
to work at night.
A gale of wind
and heavy
sea
hove the ship off the rocks, and the carpenter
returned.
Nov.
4.—In the morning
lieutenants
Hunt
and
Osborne,
and
myself,
were at
the Danish consul's
observatory,
on
the top of his house,
upon
a plain with
and adjoining ours, which
together made
a large and handsome walk.
We were
looking at the ship with Mr.
Nissen's
glass, when our
dragoman
came
and in
formed
us that
the
Bashaw
had ordered
us not to walk upon the terrace
any
more.
We immediately
returned
to our
house.
'The reigning
Bashaw
(Pasha)
of Tripoli
at
this
time
was Yusuf
Caramalll,
who,
about the year
1792,
had
usurped
the
throne
by deposing
his
elder
brother
Hamet
(or
Ahmet)
Caramalli.
Yusuf
had
already
done
away
with
his
elder
brother
Hassan,
and
Hamet after
a wandering
life had taken
refuge
among the mamelukes
of
Egypt.
From
this latter situation
he was rescued
early
in
1805,
and, with
his
followers,
joined
the
expedition
under
Gen.
William
Eaton,
formerly
United
States
consul
to
Tunis.
This
expedition
was undertaken
for the purpose of bringing
pressure
to bear on the
de
facto
Bashaw,
Yusuf,
securing
recognition
of
our
rights,
and
reinstating
Harnet.
A
further
reference will be made
to this picturesque
exploit,
in which
the city of Derne was carried
by storm, an event commemorated
in Whittier's poem
Derne.
The letter
which
is reproduced
in
this article is written
by
Ahmet
Caramalll
In
more
or less incorrect Italian and apparently
contains
Arabic
terms.
The
following
is a rough
translation
of it* contents:
To the Very Honorable
Captain
Cheter,
Mi
veey
dear
Friknd
: I believed that
being far distant
from
the pleasant
surround
ings of Placenza
you
would
no
longer
bear
In
mind
our
friendship
of
long
duration.
Nevertheless I
send
you
my
letters
wherein
I
acquaint
you
of
my
good health,
hoping
that yours
is
the
same.
What
has
become
of your
notes
used
In
medical
work,
which
will
be my
salvation
(Sanita).
I
hope,
therefore,
that
you will
not
abandon
me
as I
have always been
your
sincere
friend.
I
remain,
therefore,
with
a
thousand
greetings,
and saluting
you
as
a son.
Your sincere friend,
Ahmet Caramalli
Bancian
(t)
SIracusa,
December
20,
1806.
246
JONATHAN
COWDERY,
SURGEON IN
U.
S.
NAVY.
Vol. XVII.
#01;. 5.—Our new masters
came and closed up the passage which
led to
the
top of the house;
and
a guard
was
set at the front door
to prevent our going
Into the street.
The minister
sent his chief
secretary
with a parole of honour,
written
in French,
which
we all signed.
Nov.
6.—We
found
that
we were not allowed
to go out, notwithstanding
our
signing
the parole of honour.
The minister
of exteriour relations
sent us word
that
he had got eight of our trunks,
which
we might
have for twelve
hundred
dollars.
We
did
not take them, nor
thank
him
for his
hospitality.
We pur
chased new blankets,
sent to us by the Danish
consul.
The English consul, Mr.
McDonald,
paid
us a visit and offered us every assistance
in his power.
Nov.
S.—The Jews purchased
some of our clothing
and offered
it to us at an
enormous
price ; but we purchased
little of it.
The Bashaw sent for Captain
Bainhridge
and
told
him
that
John
Wilson
had
informed
him
that Captain
Bainbridge,
before hauling down
the colours,
threw
overboard
nineteen
boxes
of dollars and
a
large
bag of gold.
Captain
Bainbridge assured
him
that it
was false, and gave him
his
word
of honor,
that
there was
no
money thrown
over to his knowledge
; but that the money in question was left at Malta.
In the
evening,
the Bashaw
not
being
satisfied,
sent for
the
captain's
servant,
and
ordered
him
to
be flogged if he
did
not tell the truth concerning
the money.
The boy denied having any knowledge of it.
After repeating
the threat
several
times,
and the boy insisting
that
he knew
nothing
about
the
money,
he
was
acquitted.
Wilson had turned
traitor, and given the enemy all the assistance
in his power.
He now acts as overseer over our men.
Nov.
9.— Our captain
established
a credit
with the Danish consul
who
sup
plied us with necessary provision,
and with cloth for mattresses.
A guard was
posted at our door, to prevent
our going out into the street, or purchasing
any
books
or
clothing.
Nov.
10.—Several
Turks
came
and
informed
Captain
Bainbridge
that
the
Bashaw
had
been
told that Captain
Rodgers
who commanded the IT.
S. frigate
John
Adams,
treated
the Tripolitan
prisoners
taken
last
summer,
very
badly,
and they feared
that we would
suffer for it.
We
have
plenty
of pomegranates,
dates,
and
oranges.
The
Danish
consul
visits
us every
day.
Nov.
IS.- —The minister of exteriour relations
sent his
dragoman
to Captain
Bainbridge and
informed
him.
that if he would
send an immediate
order
to
Commodore
Preble,
to deliver
up the Tripolitan
prisoners
captured
by Captain
Rodgers
last summer, amounting
to about eighty
in number,
we might
remain
where we were, but if lie did not comply,
we should
fare worse.
Captain
Bain
bridge
replied,
that
he
could
not command
Commodore
Preble,
and
therefore
could
not comply
with his
request.
At
9, in
the evening,
a Tripolitan
officer
came armed with two pistols
and a sabre, and said, To night
nothing; to-mor-
rou?
the
castle.
We accordingly
prepared for the castle.
Nov. lh—Breakfasted
early
to
be
ready
for
our
new
habitation.
At
9,
A. M.,
a guard
came and
ordered
us to the castle.
We
formed
agreeable
to
rank,
an:l marched
to the castle.
We were huddled
into the most gloomy
cell,
among our
men.
where there was hardly room for us to stand.
Here we spent
the day without
food, and were scoffed at by our foes until night,
when, to our
happy surprise,
we were conducted
back
to our old place of
abode.
The min
ister
of
exterior
relations
sent for
Captain
Bainbridge,
and
affected
great
surprise
at our going to the castle, saying that he knew nothing of the measure,
which
we all knew
to
be
false.
He told
Captain
Bainbridge that
we should
remain
where
we were until
he
heard
from
his
people,
the prisoners,
in
the
hands of the Americans.
No. 2.
JONATHAN
COWDERY,
SURGEON IX
U.
S.
NAVY.
247
A'oi?. IT.—Visited our sick, who
were quartered
in
a small
house without
a
floor, near the palnce. and about half a mile from
our lodgings.
(As this
was
Doctor
Cowdery's
daily
practice,
we shall
omit
the
repetition
of it.)
The
Danish
consul
supplied
the sick with fresh
provisions,
by the request of Cap
tain
Bainbridge.
Nov.
20.—Tlie minister
permitted
us
to
purchase our clothes.
We got but
a
few, and at a high rate.
One of our men,
by the name of Thomas
Prince,
turned
Turk, and was admitted
into the palace.
Nov.
21. —After visiting our sick, I was
permitted
to
go with our
dragoman
about
the town
to purchase
medicine ; we found
but a few articles.
A man of
116 years of age came to me to cure him of deafness.
Nov.
24- —The Bashaw
refused
to furnish
necessary
clothing
for the sick, or
anything for them
to eat, hut sour filthy bread.
Captain
Bainbridge contracted
with
the
Danish
consul
to supply
the sick with beef and
vegetables for soup
every day.
Nov.
27. —Our men
complained of their
hard
usage,
in being compelled
to lie
on the cold damp ground,
to eat bad bread, to work
hard, and to be bastinadoed
by their drivers.
Nov.
80.—One of our
men
in
a tit of despair
attempted
to kill himself;
but
was prevented
by the Turks, when in the act of cutting
his throat.
The wound
did not prove mortal.
I was permitted
by the minister
to call
on
the Spanish
physician
for medicine for Dr. Bidgley,
who was then
sick.
December
5. —The Bashaw sent for
me
to
prescribe
for
himself
and
two
officers of his body guard,
and ordered
me to get such medicine
as was
neces
sary of the minister,
who had a medicine chest.
Dec.
6.—Visited the sick
at the palace,
and
found
them all better.
I was
received
and treated
very politely.
The minister
sent for me to cure him of a
blindness
in the left
eye.
I prescribed
for him with very little
success.
Dec.
7.— Visited
the ambassador
of Constantinople,
who
was
affected with
the intermitting fever.
Pound
my patients
at the palace almost
well.
««»*»*»
Dec.
9.—Visited
the Turkish
ambassador
and
found
him
better.
He asked
many questions about America,
and treated
me with coffee.
Dec.
10.—Visited
the Turkish
officer, where I found
a captain
of one of the
grand
Seignor's
ships
of
war,
who
came
to Tripoli
to
carry
presents
to
the
Grand
Seignor.
The Tripolitan
captain
who took
the brig Philadelphia, Cap
tain Morris,
was also
there.
He
was
very
inquisitive
about
our
country
and
tur navy.
Dec.
12.—Was
called
on by the general of Marine to visit his principal
sec-
etary.
Before I was permitted
to give any
medicine
the Turks,
six in num
ber, with Hamet,
our dragoman,
surrounded
the sick
man.
and offered
a prayer
to Mahomet.
The sick man then told
me that if I would
cure him
he would
be
very thankful, and would
speak to the Bashaw in our favour.
Dec.
15.—The
Bashaw had
a
schooner
launched,
which
was
built
by
the
Spanish
carpenters.
She was tolerably
handsome, and was calculated
to carry
six
guns.
When
she
was launched,
three
guns were
fired
from
the batteries,
and the consuls all hoisted their
colours.
At sunset,
a firing from
the batteries
announced
the
commencement
of
the
Mahometan
Rhamadam.
continuing
a
lunar month, in which they neither
eat, drink nor smoke, while the sun is above
the
horizon,
but
feast
at
night.
In walking
through
the
town,
to visit
my
patients, I found
the mosque and principal houses illuminated,
and
the people
rejoicing.
Passing
the.
Coffee
house with
our
dragoman,
Lysle,
a
renegade
Scotchman,
who was now
the Tripolitan
admiral,
called
me in to drink coffee
with him and was very polite.
248
JONATHAN
COWDERY,
SURGEON IN V.
S.
NAVY.
Vol. XVII.
Dee. 16.—Visited
the Marine secretary,
and found him in a state of great de-
biiity.
Could
not prevail
on
him
to take
any
medicine,
or
the least
kind
of
nourishment.
He said
he
would
rather
die
than
offend
Mahomet
by
break
ing the Rhamadam ; but he would
take whatever I would
advise him at night.
Dec.
20.—The
market
was
so
poor
that
we
could
get
nothing
for dinner,
but
a shoulder
of poor dromedary.
January
1.— Was called
to visit
the
Bashaw's
child,
about
eleven
months
old.
The
Bashaw
seemed
much affected
on my pronouncing
the child
danger
ously ill ; and wished
me
to pay every attention
to it, saying
that anything
he
could afford
would
be at my service.
Jan.
2. —Found
the Bashaw's
child
better, at which
he expressed great
sat
isfaction,
and offered
me a horse and servants
to go to his gardens, about
two
miles from
town.
I preferred
walking,
and took our dragoman with me.
As I
passed out of the gates of the city. I saw
a man's
head sticking
on
a
pole.
On inquiry, I found that it was the head of one
of the Bedouins,
who, about
a
year before, killed a
son
in law of the Bashaw,
who commanded
the army,
in
collecting
the taxes
in the back
part
of h's dominion.
About
a quarter
of a
mile from
the gate,
the road passed through
a burying
ground full of graves.
After this I came into a well cultivated
country
which
was laid out in squares
of from
one to six or eight acres, each surrounded
with date trees,
interspersed
with orange, fig. olive, lemon and other trees.
On coming to Admiral Lysle's
garden
we found
him there, and he invited
me in.
It was very beautiful.
He loaded
me with its fruits,
and offered
me
access
to it whenever I
chose,
and
said I
was welcome to anything
growing
in it.
I concluded
to postpone going to
the
Bashaw's
garden, until
another
day.
Jan.
8.—Went
to the Bashaw's
garden,
where I
met the minister
and
the
prince,
the Bashaw's
oldest son.
They
politely
conducted
me through
the gar
den,
which
was
ornamented
with
a great
variety
of fruit trees,
loaded
with
fruit, particularly with oranges, lemons and limes.
John Hilliard
died in the
evening.
Jan.
h. —William
Anderson
died.
Jan.
12.—The Bashaw's
eldest daughter
was married
to Selim,
the Bashaw's
chief
Casteda
or Treasurer.
Wilson, who was one of our quartermasters,
and
lately
turned
traitor
and Turk,
received
500
bastinadoes
for quarreling with
the famous
Lysle.
Jan. Ik-—The minister
of foreign
affairs,
Sidi Mahomet
Dacize,
visited
our
prison.
The month's fasting
(Rhamadam)
ended
this day at the change of the
moon.
The Tripolitans
fired
a salute
from
our
ship
which
lay
moored in the
harbour,
within
sight of our
window.
Jan.
15.—The
feast
called
By ram
commenced.
Every
gun
in Tripoli
was
fired
in honour of the day.
Every
Turk
put on his best
suit, and there
was
a
general
rejoicing.
Jan. 16.—Oapt. Bainbridge
and lieutenant
Porter,
were invited and accordingly
visited
the Bashaw,
with all
the consuls.
Jan 17.—The Byram ended
this evening.
The
consuls, the ships in the har
bour, and the castle displayed
their colours
during
the three days.
The rejoic
ing was great, but neither
elegance
nor taste were discoverable.
Jan.
18.—By permission
visited
the triumphal arch
which
was built at
the
time the Romans
conquered this country.
It is dedicated
to Augustus
Caesar;
is very large, built of fine marble,
and Is full of engravings
and inscriptions In
tolerable
perfection.
It
stands
near
the
niarinery.
Jan 19.—The Bashaw's
agent sent us a present of tea,
coffee
and sugar, and a
lamb, probably
to induce us to buy a quantity
of old clothes taken from
us, for
which
they
asked
600
dollars.
JONATHAN
COWDERY,
SURGEON IN
U.
S.
NAVY.
249
Our diet at this time was two
eggs and
n piece of bread, with rain water for
breakfast
and supper ; poor beef or camel's
flesh,
bread,
and sometimes boiled
cabbage,
with rain water
for dinner.
February
3.—Was
conducted
to
the
castle
to
visit the Kashaw.
whom I
found after passing
several sentinels,
about fifty
fierce yelping
dogs, and threi>
heavy
doors
loaded with irons
and bolts, which
were
opened
for us by
armed
mamelukes.
Prescribed
for the Bashaw's
disorder.
Feb.
6.—The Bashaw
sent for
me
to
come
to his
room
in
the castle.
He
shook
hands with
me.
received
me with much politeness,
and
requested
me to
pay every attention
to his family ns a physician.
Feb.
10. —The Bashaw gave the officers permission
to walk out into
the town
and
country,
but
not
to visit
the
consuls
nor
the
batteries.
Our dragoman.
Haniet.
was ordered
to walk with
us and direct
us where to go.
We went out
six at a time.
,
Feb.
16.— Prescribed
for the Bashaw's
eldest daughter.
Her husband
offered
me
many civilities.
At
5 o'clock.
P. M. were informed
that
two English mer
chantmen
were
standing
in
for
the
harbour.
They
proved,
however,
to
be
two vessels under the command of Oapt. Decatur.
About
11, at night,
we were
alarmed
by a most hideous yelling and screaming
from
one end of the town
to
the
other,
and
the firing
of
a
cannon
from
the
castle.
On
getting
up
and
opening
the window
which
faced the harbour,
we saw the frigate Philadelphia
in flames.
Feb.
17. —The Turks appeared much disheartened
at the loss of their
frigate.
A strong guard
was
put at our
door,
and
we were forbid going
out.
I was
forbid visiting our sick.
It was reported
that an American
schooner and three
boats
set fire to the ship.
Two Turks
escaped
who told this news.
They
said
that eight Turks had charge of the ship, and they supposed the other six were
carried off by the Americans.
Our dragoman
informed
us that we were
to
be
removed from our present habitation
into the castle.
Feb. IS.—A guard of about twenty Turks was
at our door.
I asked permis
sion
to visit
our
sick
and
was
refused.
A
gloomy
aspect
continued
on
the
faces of the inhabitants
at the loss of the frigate.
Feb. 19.—Again asked permission
to visit our
sick,
and
was
again
refused.
Feb. 20.— Permitted
to visit the sick. —-Pound the town full of country militia
and our guard doubled.
Feb.
21.—Our prison
was
kept full
of Turks,
to
guard
us.
The Bashaw,
having got a little over his fright, consented to let us remain
where
we were.
Feb.
21.—We
were forbid
sending
letters
to our
friends,
without first
show
ing them to the Bashaw
or his
ministers.
The
last
letters
we received, were
broken
open
by the latter,
before
they were
delivered
to
us.
March
1.—We were conducted
to the castle.
March
2.— Found
our
habitation
very dark and smoky,
having
no
light
but
what
came through
a
grated
sky
light.
March
3.—Not allowed
to visit the sick, and our dragoman
was forbid carry
ing letters
to
use.
March
.}.
—Captain
Bainhridge
received
a
letter
from
the
ministers,
repri
manding him on account of three
men
who floated ashore
a
few days after the
burning
of the frigate.
The Turks
pretended
that
they were
murdered
after
they
were
made
prisoners
by
the Americans.
March
6.
—In close confinement.
Hamet.
our dragoman,
was taken
from
us
The Bashaw
suspected him of being too friendly
to
us.
March
7. —The Tripolitans
got the guns from
the remains of our frigate,
and
mounted
them
on their
batteries.
In trying them, several
of the gun carriages
250
JONATHAN
COWDERY,
SURGEON IN
U.
S.
NAVY.
Vol. XVII.
broke
down,
and
one
of
the
gun.-*
hurst
and
killed
one
Turk
and
wounded
four.
March
H. —The Turks
seemed
much alarmed,
and placed
a strong
guard
at
our door, for what
reason we knew
not.
March
16.—The Bashaw
sent word
that I should
have any thing I wanted,
free of
expense.
March
17.—Ordered
not to send
our clothes out to wash.
March 2/t. — I was taken out of prison
to visit a mameluke's
wife and
child.
The minister
of foreign
affairs paid
us a
visit",
and said many clever
things.
March 26.—A truce was held between Commodore
Preble
and the Bashaw.
From March the 28th to the 13th of April, I was violently
afflicted with
the
dysentery, during which
time the Bashaw
expressed
much anxiety,
and offered
me
every
assistance.
April
1").—We felt the Syroc wind,
which
was very oppressive.
April
2.1!.—John Morrison died,
in consequence of a hurt
he
received
a
few
days before
while
at work under
the directions
of his
new masters.
The Ba
shaw
permitted
me, with two of my fellow officers, to
go to his garden,
con
ducted by a guard of two Turks, armed with pistols
and sabres.
This
precau
tion, they pretended, was taken to prevent the wandering
Arabs and Moors from
robbing
us ; but it was probably
done to prevent
our escaping
to the squadron,
then cruising off the harbour,
in
sight.
May
11.—Our
squadron
appeared
off
the town.
The Turks
were
at their
quarters.
They
had twelve
gun boats, armed, manned, and moored out in the
harbour.
May
16. —Ten of our
officers took
a walk to the gardens
under
escort
of
a
guard.
They
returned
with a variety
of flowers
and ripe apricots.
May 20.—A party
of us,
under
escort of four Turks, walked
to
the
desert,
about four miles
from
our prison.
We ascended a large
bank of sand,
where
we had
an extensive
view
of
the country.
The deserts
have
a singular
and
grand
appearance.
They extend
to Mount Atlas, which
we could
see
at
the
distance
of two day's journey.
The
sand is in heaps,
like snow drifts
in our
country.
There
was not a house nor any other
object to be seen;
nor a thing
growing
to interrupt the sight ; but it appeared like an ocean of sand.
On our
return we visited
several gardens, where we got oranges, lemons, apricots,
and
a variety of flowers.
We were treated with sap of the date tree, which tasted
much like mead.
May 20.—A party
of us,
under escort
as before, took a walk into
the desert.
On
our
return
we dined
in
the Bashaw's
garden,
under
the shade of orange
trees.
The dinner
was prepared
in the Turkish
style and we ate with wooden
spoons—it was simple and good.
We visited
several gardens, and were treated
with as much respect as could
be expected or desired
from
a foe,
who held
us
as prisoners
of war.
On returning
to town
we saw two of our brigs
at anchor
off the harbour,
seeming to defy all the force of Tripoli.
June
-}.
—We are plentifully supplied with squashes and cucumbers.
The Bashaw's
eldest wife,
called
the queen,
was delivered
of her ninth child
on the 18th of June.
She was twenty
three years
of age.
The first child was
born
when
she was in her eleventh
year.
It is said
to be common to marry
at ten.
June
27.—Mr. Hodge,
our boatswain,
Mr. Douglass,
the sail-maker,
and Mr.
Fontaine,
the first
master's
mate, were taken
from
the prison
and set to work
by order of the Bashaw.
July
15.—The Bashaw,
his wives
and guards
removed
to their
country
seat
at his garden.
The season
was very warm and our close confinement continued.
We purchased
figs,
watermelons,
muskmelons
and cucumbers.
No.I.
JONATHAN
COWDEBY, SURGEON IN V.
S. NAVY.
251
July
28.—I was called
to visit the Bashaw's
eldest
son,
the Bey of Tripoli
(termed
the Prince of Wales of Tripoli,
by the English Consul)
at his
palace,
about three miles from town.
I found him in a lofty and airy apartment,
lying
on a mattrass and surrounded
by his attendants.
I prescribed
for him and was
highly entertained
in the Turkish
style.
July
29. —The Bey
was well
enough to return
to Tripoli.
He called
at the
door of our prison, which was unlocked and the bolts and bars unloosed.
I was
conducted
to him when
he expressed great satisfaction
at having
recovered his
health,
thanked
me for my attention,
and promised
to alleviate our misfortunes,
as far as was in his power.
I was then sent back
to prison.
The Bashaw
and
Bey
spend
a day alternately
in town, on account
of the expected attack
by the
Americans.
July 31.—I was carried
with, my trunk,
and bed, to the castle, where
a room
was provided for
me, and the Bashaw
informed
me I must attend
the Ameri
cans and his family as a physician.
August
S.— The
American
squadron,
under
the
command
of
Commodore
Preble, consisting
of one frigate (the Constitution), two brigs,
three schooners,
and seven
gunboats, at about 2 o'clock, P. M. commenced an attack
on the bat
teries and gunboats of Tripoli.
I stood on the top of the castle, where I had a
fair view of the engagement.
Three of the enemy's gunboats were captured
by
the Americans.
Two Turks
swam
to
the shore,
and
were
carried
before
the
Bashaw, who gave them a suit of clothes
and a few dollurs.
They said
that
many
were killed
on both sides.
Aug. 5.—The American
squadron
nnchored off Tripoli, I was ordered
to dress
a wound of a mameluke, who had his hand shattered
by the bursting
of a blun
derbuss.
I amputated all his fingers but one, with a dull knife, and dressed them
in a bungling
rannner, in hopes of losing
my credit
as a surgeon in this part of
the country, for I expected
to have my hands full of wounded Turks
in conse
quence of the exploits of my brave countryman.
Aug.
9. —At about
12 o'clock
the alarm
gun of Tripoli
was fired.
The Trl-
politans all took their stations,
and went
through
the Mahometan
prayer,
by
kneeling
and kissing
the ground several times, with their faces toward
the east,
all with
as much regularity
as the exercise in a well-disciplined
army.
Their
military
manoeuvring
was
a
scene
of the utmost
confusion.
I got permission
to go on the top of the castle,
where I had
a most extensive
view of the sea
and land,
and
saw
the American
squadron
approaching
the town.
At
about
1 o'clock the attack
commenced, and the battle
soon became vigorous,
with a
tremendous
cannonading
on both
sides.
I now
beheld
the melancholy
catas
trophe of the explosion
of
one of our gunboats.
I saw the mangled
bodies of
my countrymen precipitated
into the air.
For
a few moments a general silence
took place, when
the firing recommenced with
unabated
vigor.
I saw
shells
explode,
and set fire to the town
in many places ; but
the houses being prin
cipally
built of stone, mud and
mortar,
the fire did
but little
damage.
The
shells and shot, however,
battered
the town
very much,
and almost
destroyed
»me
of
the
houses.
The firing
ceased
at
4,
P.
M.
when
the
ship
John
Adams
joined
the
squadron.
The
Bashaw
has
a
bomb-proof
room
in
his
castle, where
he staid during the action.
On hearing
of the explosion
of our
gunboat,
he
ventured
out
to
take
a
peep,
with
the precaution
of
having
a
ilarubetct
or
priest,
to seal
a black
piece of paper
on
the top of his
head,
with
a Turkish or Mahometan
scrawl,
with assurances
that it would
entirely
secure him from all danger;
but
he
soon
returned
to his cell.
The Turks all
wear a paper of this kind, sewed up In a little velvet bag, with assurances
from
the itarabeu
t that it will protect them in the greatest danger.
The Marabewt
108165—22
5
252
JONATHAN
CO WDERY,
SURGEON IN U.
S.
NAVY.
Vol. XVII.
gets
a sum of money for these blessings.
If a Turk
gets
wounded
or killed, it
Is supposed the blessed paper was too old, or not placed in
a proper
manner.
In the time of action
the Marabeivt
gets upon some
secure place and
cries
to
Mahomet
in
the most
dismal
yells
to let
them
conquer
their
enemies;
and
beckons to the vessels to run on shore or be destroyed.
Such
of our
crew
as
were able, were put to work, and drove about like horses or mules.
Aug.
10.—Lewis
Heximer,
who
lately
turned
Turk,
went
by
order
of
th«
Bashaw,
and
told
Capt.
Bainbridge,
the particulars
of the two
late
actions.
The Bashaw
informed
me
that
the
late
commander
of
the
schooner
Vixen,
Lieut. Smith,
was commodore of the gunboats
in the late action, and was killed
by a musket
shot through
his head.
Our
men complained
of being drove and
beat about at an unmerciful rate, In consequence of which
they petitioned
the
Bashaw,
in the following terms:
" To his Excellency
the Grand Bashaw of Tripoli:
The petition
of the whole
of the American
prisoners,
most humbly
sheweth :—
" That your humble petitioners,
when doing their duty with all their power,
as they are commanded,
are most cruelly beaten by our
wardens,
stoned, In
sulted,
and
spit
upon by the soldiers
and others;
required
to carry burthens
impossible
for us to sustain,
and
chased
and bruised,
until
we are,
or
soon
shall
be, unable to labour at all.
" From
the many
acts of justice,
kindness,
and
generosity
we have
experi
enced
from your Excellency,
we cannot suppose that such conduct is authorized
by your commands ; or that we should
be punished for what is out of our power
to perform
; or for the actions of others, which we have no agency in, and which
we cannot prevent.
" Returning your
Excellency
our sincere and humble thanks
for your bounty
and privileges
heretofore
shewn,
and
relying
upon your goodness for protec
tion,
we
therefore
most
humbly
pray,
that
your
Excellency
would
interpose
your royal authority
and grant
us
a speedy relief.
And your petitioners,
as in
duty
bound, will remain
your
Excellency's
most humble, faithful
and obedient
servants."
On
the
petition
being
explained
to
the
Bashaw
by
Heximer,
(or
Hatnet
Anverikan, his new name) the Bashaw
forbid the Turks striking the prisoners.
Aug.
11.—The Bashaw
sent for
me,
and,
agreeably
to his
orders,. I took
a
seat by his side.
He began conversation
about
my
country,
and our
squadron,
which
was then in sight, and consisted of eighteen sail-
He said
that for two
dollars he could repair all the damages that the bombardment
did
to his town;
that but one man was hurt by the shells ; that what
he had been effered for the
American
prisoners
was but fifty dollars per man ; that
he would
make
them
earn that
sum
in two months.
He asked me what I thought
my country
would
give for me.
I told him I did not know.
He said
he would
not take
twenty
thousand
dollars for me;
to which I replied,
that I might
then expect
to re
main in slavery for life.
He patted
me on the shoulder
and said, I might
then
content
myself
to
stay
with
him.
I asked
to
go
and
see
our
men,
but
he
refused,
saying, that Moors
and Arabs would kill me if they could catch
me.
Aug.
12.—Our squadron
hoisted
a flag of truce, sent in a brig and schooner
and tired a gun.
The Bashaw did not, and swore
he would
not, answer it; and
said lie would
not treat witli commodore
Preble.
A truce
however
was
after
wards
held.
Consul
O'Brien wished
to come
on
shore, but was refused.
Aug.
13.—Another
truce
was held, when
the Bashaw
demanded
one
million
of dollars
for our
ransom.
One hundred
and
twenty
thousand
dollars were
offered and refused.
Aug.
17.—The
Bashaw
informed
me
that
fifteen
Americans
were
found
drifted ashore
at
the
westward
of the town,
and
that
one
of them
was
an
No. 2.
253
JONATHAN
COWDERY,
SURGEON IN U.
S.
NAVY.
officer
with an epaulet
on
the right shoulder.
We
supposed
they
were
men
destroyed
by
the explosion
of the gunboat, in the lute engagement.
I asked
permission
to go with two or three of our
men
and bury them, and the Bashaw
told
me I might go the next day.
Our squadron
lay at anchor
off the harbour.
The inhabitants
had chiefly
moved out of the town,
through
fear of another
bombardment ; and the Bashaw
ate,
drank
and
slept
in
his
bomb
proof
room.
Several
tribes
of the
back
country
inhabitants
had
lately
come
and offered
their services
to the Bashaw, —in all not more than
one
thousand
men.
Many
of them
had
muskets
without
locks,
but
had
a
sort
of match
to
put
fire
to
them.
They
were almost
naked, half starved,
and
without
discipline.
When
(hey
are
going
to
battle
or appear
before
the Bashaw,
they
run
to
and
fro,
shaking
their rusty
muskets over their
heads, all
crying
Holouet
Buoy
(I
am
my futher's
son.)
Every tribe has a priest, or what they call Marabeict,
whose
badge
is
a small
green flag, which
is carried
in his
hand
or
stuck
up at his
tent.
They
pretend
great
skill
in
prophecy,
in
which
the
people
put
the
utmost
faith.
They
prophecy
success
in
battle
;
and
for
a
small
sum
of
money,
ensure any one against
wounds
or death in fighting
a Christian.
They
often
go
on
eminences, and
beckon and
sing
to
the American
vessels
to run
on shore.
They
prophecied
that
another
American
vessel was
to
go
on
the
rocks, and the Bashaw
fully believed it.
Aug. IS.— Was
not permitted
to bury
our
dead.
Our
squadron
stood out
to
Bea.
At
evening
the Bashaw
went
to
his country
seat and
the Bey
came
in
to
keep
the throne
till
his
father's
return.
They
never both leave the castle
at
once.
When
the Bashaw
leaves
it, the gates are
shut till his
return,
for
fear of
incursions
upon the throne.
In
the evening,
th«
moon shining
very
brightly,
the prince
or
Bey
ordered
out
the band of music,
which
was
very
ordinary,
and
made Christians, Turks, Arabs and
Guinea
Negroes
dance
be
fore him,
according
to
the
mode
of
their
respective
countries,
at
which
he
seemed highly diverted.
Aug. 19.—Between
0 and 10 o'clock in the evening, Mr. Church,
a respectable
English
gentleman
was shot through
the head in the street, on his return
from
visiting
bis neighbours.
Aug.
2k-—In the morning,
between 2 o'clock
and daylight,
two of our
small
vessels- hove about thirty shells,
as was supposed for the round fort, but
they
all fell short of the mark.
Such
attempts
served rather
to encourage
than
to
intimidate
the Tripolitans ; and the Bashaw
was in high spirits on the occasion.
Aug. 26.—At about 4 o'clock P. M. the fellow
who murdered
Mr. Church,
was
executed
near the spot where the crime was committed.
It had theretofore
been
a custom in this country,
when
a person
had
committed
murder,
to
fly
to
a
tomb of a Marabewt
(or priest)
where they were protected
from
justice,
and a
fee to a Marabeict
would
procure
them absolution.
This fellow
fled to a place
of this
kind immediately
after killing
Mr. Church.
The English
consul,
Mr.
Langford.
on
being informed
of the murder,
addressed
the
Bashaw,
and
de
manded
justice.
The
Bashaw
then found
out
by
a boy, who accompanied
the
murderer when he committed
the crime,
the particulars of the affair ; and im
mediately sent a file of men
and ordered
them to prevent
any person carrying
food or drink
to the murderer.
They watched him until night when
the Bashaw
sent his Marabewt,
who coaxed him away, brought
him
to the castle and con
fined him in irons.
The next day the Bashaw
called his divan,
when it was de
cided that the prisoner
was guilty
of wilful
murder,
and ought to suffer death.
It appeared
by
the evidence
and confession
of the prisoner,
that Mr.
Church
had lent a sum of money
to a Spanish
carpenter in this place:-— that Mr. Church
had pressed
him for payment ; and that
the carpenter's
wife hired
the Turk
to
kill Mr. Church
for forty dollars.
The villain
took his watch
from
his pocket
254
JONATHAN
COWDERY,
SUKGEON IN U.
S.
NAVY.
Vol. XVII.
after he had shot him.
The boy who
accompanied
him and carried a lantern
was bastinadoed
with
five hundred
blows.
The
carpenter's
wife was
ordered
to leave Tripoli.
Aug.
27.—Our squadron
stood towards
the harbour.
Aug.
28.—About
4 o'clock in the morning, I was awoke by a heavy and inces
sant fire of cannon, and the whistling and rattling of shot nil around
me.
On
getting
up, I found
that our gun-boats
were close in, and were firing upon the
town
and batteries.
Every gun in Tripoli
that
could
be brought
to bear, was
returning the fire.
The Tripolitan
gun boats were close under
the castle
for
protection.
The firing continued
until
a few minutes
after sun-rise,
when
one
of the largest gun boats ventured
out, with an Intention
of boarding
the nearest
American
boat.
As soon
as she got within pistol shot, the American
discharged
their piece,
loaded with grape, and killed four and wounded
two of the enemy,
they then put about and retreated.
At the same
time, commodore Preble bore
down and gave the batteries
to the westward
of the town two broadsides.
The
squadron
then stood out and anchored off the harbour.
The damage done to the
town
was
considerable.
A large
vessel was
sunk
in
the harbour and
others
damaged.
Many men were killed and wounded.
Aug.
29.—The Bashaw sent me
to his palace in the country,
to see his eldest
son the Bey, whom I bled in the foot.
He requested me to spend the day
and
dine with him, which I did.
He endeavoured
to have the dinner
in the Christian
style.
It was
set
on
a table,
and consisted of a large
dish of boiled
rice
and
stewed fowls,
out of which
we both
ate,
he with a wooden spoon, and I with
a
silver one, without knife or fork.
The prince's
servant
stood by him, and pulled
the fowl in small
pieces with his fingers, for the prince
to eat.
I -made
use of
my fingers and teeth to get mine in
pieces.
Our dessert was dates and water
melons.
Our drink was lngby,
or the juice of the date
tree,
which
we drank
out of a large
gold
cup.
He shewed
me the garden,
and
took
great
pains
to
entertain
me.
Aug.
SO. —A truce was
held, I took
a ride upon
a mule about eight miles
to
the westward
of the town, in company with my guide, Hamet,
a Turkish officer,
and
several
footmen.
I
there
saw
a
boat,
which
drifted
on
shore,
with
a
dead man, and several
muskets
and swords
in it.
The man appeared
to have
been
shot
through
the body with
a cannon
ball,
which
hnd
also
pierced
the
bottom
of the boat.
The Turkish
officer
collected
about
twenty
Arabs, who
hauled
the boat upon the beach, dragged
the dead man out of it, stripped
him
entirely naked,
and left him
on
the beach.
I tried
in vain
to hire the Arabs
to bury the body ; they said it was contrary
to their religion
to bury
a Christian.
I asked permission
to
get
him
buried
by our
countrymen,
some
of my fellow
prisoners,
but was refused.
I found
that our
men,
who were destroyed
by
the
explosion
of the gun-boat,
on the 9th
inst.
lay
in
a state of putrefaction
on
the beach.
They were scattered
on the shore for miles, and were torn in pieces
by
dogs.
The Bashaw
had
frequently
promised
me
that
these men
should
be
buried
; but refused
to let me take some of our
men
to go and bury
them.
September
?..
— At about
4
P. M. our squadron
commenced another
attack on
the
town
in which
eight of our
gun boats drove
sixteen Tripolitan
gun boats
under
the battery
on the east side of the harbour; while the Commodore
bore
down
and
gave
the batteries
at the west end of the town,
several
broadsides.
Many
of his
shot
came
into
the
town,
and
castle.
Two
bomb-ketches
were
employed
In heaving
shells
into
the town,
which
did considerable
damage
to
several
houses, and entirely
destroyed
the house of the Spanish
carpenter,
the
Bashaw's
naval
constructor.
I
observed
the
utmost
confusion
and
random-
firing
among
the Tripolitnns.
It appeared
they
were
almost
out
of
powder.
Two of their
guns
bursted,
one of which
was
an eighteen
pounder
from the
No. 2.
JONATHAN
COWDERY,
SURGEON IN V.
S. NAVY.
255
late Philadelphia
frigate.
The men,
women and children
ran out of the town
in the utmost terror and distraction.
.Sep*.
3.—Had been to see the prince in the country,
and was returning
about
10 o'clock
in
the evening,
with
the Bashaw
and
suit,
when
we saw
a most
extraordinary
light or flash, and heard
a heavy report.
We all wheeled about,
and made for the place
we had left ; but
the Bashaw
soon
altered
his mind,
and proceeded
to town, while I went to the country
palace and staid all night
The explosion was a fire ship sent Into the harbour
by Commodore Preble, which
did but little damage.
Sept.
5.—The
Turks
found
ten dead
men near
the place
where
the vessel
blew up,
on the evening of the 3d instant.
The Bashaw
and his people had a
thanksgiving
to
Mahomet
on
the
occasion.
Their
ceremony
was
prayer
in
doleful tone,
and singing,
accompanied
with the sound of an instrument
made
by drawing a skin over a hoop.
Sept.
6.—More men were found,
three of which
appeared
to be officers.
By
permission,
I took our boatswain
and a gang of
men,
and buried
these bodies
a little east of the wall of the town.
All that I saw, who appeared to have been
killed
by the explosion,
amounted
to fourteen.
The Bashaw's
son-in-law
told
me that six more had been found drifted on the western shore ; but I could not
ascertain
the truth of it.
Sept.
7.—John
McDonah
died
of a consumption,
with
which
he
had
Ion?
been ill.
Sept.
9.—The
Bashaw
took
me with him,
and his suit to his
country
seat
where we spent the most of the day.
About
5 o'clock P. M. we went
to see the
great Marabetct,
or Mahometan
priest,
In
whom
the Bashaw
had great faith,
and thought he could foretell events.
It was said by the Turks, that
he fore
told
the stranding
and capture
of the Philadelphia ; that
he got offended with
the Bashaw and caused and foretold
her being burnt.
But I had beard nothing
of these mysteries
until a little previous
to this.
He now said
that
the com
modore's
ship,
the
Constitution,
would
never
return
to
America
;
that
she
would
either
be blown
up, or run on shore ; and that
the Bashaw
would
have
success in his warfare with America.
It appeared
that this great prophet
was
a sojourner;
and that
he only came to Tripoli
when the Bashaw
was in want
of a prophet.
He was encamped on the sandy desert, at a tomb of an ancient
Marabewt.
The tomb had a house over
it, with
several
rooms,
and was
en
circled
with
several
green trees.
It was about two miles back of the gardens.
We found this great
Marabewt
standing
on
a
large
mat,
which
was
spread
on
the sand under
the shade of a
large
mulberry
tree.
About
thirty
of his
attendants
stood back of him. paraded
in form of a crescent.
I was ordered
to pull
oft my hat; and all approached
him
from
the west;
the Bashaw,
with
«ome
of his most truly attendants
in
front.
When
we
came
near
to
him
we
all dismounted.
The Bashaw
run
to him,
kneeled before
him,
and kissed his
hand.
The
mamelukes
followed
his example.
The Marabewt
then sat down,
and was
followed
by
the Bashaw
and his suit,
forming a circle
on
the mat.
During this time, I stood
by my mule, about five rods from
the scene, with my
hat in hand.
I was
soon
called
and
ordered
by
the Bashaw
to take
off my
slides and
feel the Marabewt's
pulse.
I left my shoes
at the edge
of the mat,
or holy
ground,
and
stepped
on.
I laid
my
hat
on
the
edge
of
the mat in
Preference
to laying
it on the sand ; but it was immediately
taken
off.
I was
then
ordered
to
approach
his
holiness
and
kiss
his hand.
I felt his pulse;
but
before I had time
to prescribe
for him,
he put
his hand
against
me, and
gave
me
to
understand
that I
must
go
off
the
holy
ground.
Immediately
stepped
off; put on my shoes,
took my hat, and went to my mule.
The Bashaw
called me back, and asked what I would
do for the Marabewt.
I recommended
256
JONATHAN
COWDERY,
SURGEON IN V.
S.
NAVY.
Vol. XVII.
bleeding:
but the Marabewt,
shook his head and
gave
me
to understand
that
lie wanted
nothing
of the kelp
(the Dog).
I whs then told to withdraw, which
I did,
and
took
a walk
round
the tomb,
which I found
to
be
very
ancient.
The Bashaw
spent about half an
hour with the Marabewt,
when
he kissed
his
hand ; and
we all
returned
to
the country.
The Bashaw apologised
for
the
impoliteness
of the Marabewt,
and
said
that
they had
a foolish
antipathy
to
all but Mohometans.
October
—None of our cruisers
were
to
be seen
from the top of the castle.
The Tripolitau
gun boats were disarmed,
and the Bashaw's
gunners
were
em
ployed in drawing the charges
from
the cannon
on the battery.
Many
of the
guns now stood in the sand, as they did when Commodore
Preble
first attacked
the town.
On
being fired
two
or
three
times, they
recoiled
into
the
sand
so
deep
that
they could
not
be worked,
and
were
abandoned.
The Bashaw told
me that if he had three frigates,
he would blockade America.
He said he could
do it as easily as a frigate and schooner could blockade Tripoli
!
Oct.
26. —A great
scarcity
of grain.
Our crew
had
no bread for three days.
The Bashaw
gave orders
to all the market
people,
not
to sell grain to anybody
but his household.
There
was
no bread
to be had for money.
A dispute took
place
between
the Bashaw and
the renegado
Lysle,
about
the purchasing
of
some
barley.
Lysle
was
considerably
intoxicated,
and
insisted
on
his
right
to purchase
grain
in the market.
The Bashaw
was highly affronted,
and flew
at him with all his
might,
struck
him, and
ordered his mamelukes
to disarm
him
and
put
him
in prison,
which
they
strove
to
obey,
and
carried
him
off.
The Bashaw,
however,
soon
ordered him released, and then ordered his servant,
who was
supposed
to be the cause of the quarrel,
bastinadoed
with five hun
dred blows, which
was Immediately
put into execution.
November
9. —The
Bashaw had
an
epileptic
fit,
and his people thought
he
was
possessed
with the devil.
They
performed
many
ceremonies
to cast him
out, which
they
said
succeeded.
The Turks
said
they
saw
many
ghosts
the
night
before;
and
that
a Marabewt
drove
the devil
out of the Bashaw.
December
6.— Our men suffer for the want of provisions.
The
Bashaw
does
not allow them
either
victuals
or cash.—They
get
but
a
small
allowance
of
bread,
and that
on
the credit
of their own
country.
They
are
beat unmerci
fully and compelled to work hard every day.
Dec.
7. —I
was
informed,
that,
through
the
Influence
of
many
Turks,
the
Bashaw had given orders to Sarcey, our master, to treat the American
prisoners
with
the utmost
cruelty,
In' order
to
induce
the
United
States
the
sooner
to
make peace.
He was impatient
for his money.
Dec.
10. —Our men
all agreed not
to work unless
they were fed, and accord
ingly
when
the
wardens
went
to
the prison
and
ordered
them
out, they all
refused.
The
wardens
whipped
them until
they
were
tired,
and
then went
to Inform
the Bashaw,
who immediately
ordered
them bread and oil, and they
went
to work.
Dec.
21.—At evening,
the Bey.
the eldest
son
of the Bashaw,
was married
to
his
first cousin,
eldest
daughter
of
the Bashaw
who
was
driven
out
of
Tripoli
by
the
present
Bashaw.
The
bride
was
said
to
be
very
handsome,
and but twelve years old.
Our boatswain,
carpenter,
sail-maker,
and first
master's
mate, who
had the
liberty of the town for a few
months,
were put in close confinement with our
other
officers,
on
suspicion
of attempting
to raise
the crew
to take
the town.
Dec.
25. —The
Bashaw's
son-in-law,
Selira,
who
had
charge
of
the
stores,
was
detected
In selling
a quantity
of cordage
to
a Tunisian
merchant.
The
Bashaw ordered
him
five hundred
bastinadoes,
but
Selim
fled
to
a Marabeict
for protection,
and escaped
punishment.
No. 2.
JONATHAN
COWDERY,
SURGEON IN U.
S. NAVY.
257
January
24.—Renegade Wilson, who pretended
to
be
a great
engineer,
was
ordered
by the Bashaw
to fire hot shot at a mark,
but
succeeded
indifferently.
The
Bashaw,
however,
was
highly
pleased,
gave
Wilson
eight
dollars,
and
promised
to reward
hira
in proportion
to his exertions
in his future warfare.
Wilson engaged
to teach the Turks
how
to
throw
bombs, hot shot, and hand
grenades
; and to alter and improve the fortifications,
etc.
Jan.
25.—The
Bashaw
sent
me
to
visit
the wife
of Alia
Mameluke.
She
was once
a wife or concubine
to the Bashaw,
who gave her as a wife to his
favourite.
She was sister to a wife of the Emperor
of Morocco, about eighteen
and
very
handsome.
She was
in
child-bed
travail, attended
by
a number
of
Jewish
women.
She was delivered
of a
son,
her
first
child,
to
the great joy
of all the Turks in the castle, male and female.
It was proclaimed
by a loud
yelling,
with clapping
of hands
to and from
the mouth,
by the women of the
castle.
Jan.
28.—The Bashaw
was informed
by Wilson,
the renegade, that our crew
were all armed, and about to rise upon the town.
Search
was
made,
and the
report
found to be false.
But the Bashaw was much intimidated
and an addi
tional guard was placed over us.
February J.—George Griffiths,
one of our crew, having
informed
the Bashaw
that
he
could build an air
furnace,
and
cast
guns, shot,
etc.,
was
furnished
with a mason and nine of our crew, and set to work,
with a promise he should
have
a hundred
dollars for
the first
shot
he
should
cast.
After
expending
about
five hundred
dollars
in
the experiment,
Griffiths this day attempted
a
blast
in his furnace
; but with all the wood
and coal that
the Bashaw
could
furnish,
he could
not melt the iron, and the furnace
cracked in several
places.
It afterwards
appeared that
Griffiths
had no intention
to cast any shot.
Feb.
5.—While
a number of our
men were at work at
the north
corner
of
the castle,
a large body of the wall fell, and killed Jacob Dowdesher.
The only
consolation
we
received
from
the Turks,
was,
that
he was
amak
deric
and
sansafedah —that
is D
n his mother,
he has got no faith, Romo Kelfi —He
it a Christian dog.
March
1.—An American
frigate appeared
off the harbour.
The Turks
were
all at their quarters,
and were manning their gun boats.
The Bashaw
was preparing
an armament
to go against
some
of his refractory
tribes
on the borders of Egypt.
March
4-—Hassan
Bey,
the
Bashaw's
chief
raameluke,
was
appointed
to
command
the expedition
towards
Egypt,
on
the borders
of the dominions
of
Tripoli.
Hassan
and
his
officers
were
attended
by
the Bashaw
and
several
stand
of colours
to
a ilarabewt
about
three miles
from
town
to
receive
abso
lution
and assurances
of victory
in
the intended
expedition.
A great
part
of
our crew,
and many Turks and Jews were employed In packing
up ammunition,
etc., for the camp.
March
5.—Two frigates
and a brig,
supposed
to
be American,
appeared
oft
the harbour.
The
people of Tripoli
were
preparing
and moving
their
effects
Into the country,
expecting a siege
by the Americans.
March 12.— Swallows appeared.
Apple,
peach and plumb
trees were in blos
som, and peas in market.
March 17. —Walking by the house called the American
house, I perceived that
It was full of Turks, and a strong guard
was at the door.
On inquiry, I found
that
they
were
the sons and
nearest
relations
of the Bashaw's
officers,
who
had
gone in
the expedition
to
the frontiers.
The Bashaw
kept
these people
as hostages
for the fidelity
of his officers, whom it appears,
he was afraid to
inist, least
they might join in the rebellion
and
come
against
Tripoli.
It was
258
JONATHAN
COWDEEY,
SURGEON IN U.
B.
NAVY.
Vol. XVII.
said
that his highness
had
received
a letter,
stating
that
the Americans
were
making
great
preparations
to attack
Tripoli.
A tent was
pitched
on the bat
tery of the castle,
and orders
given
to keep watch
all night,
and every
night
afterwards.
Orders
were
also given
to
make every
preparation
to repel
the
Americans.
March
18.—The Bashaw sent his
son-in-law
into
the country
for
troops
to
protect Tripoli.
March
19.—It was
reported
and generally
believed
that
the Americans
had
been
to Alexandria' in
Egypt,
where
they
had
got the Ex-Bashaw * and four
thousand
Egyptians,
and
carried
them
to
Syracuse*
where
they
were
to
be
landed
to act in concert with the Americans
against Tripoli.
I perceived
many
private councils
and long faces amongst the Turks.
March 21.—A frigate and brig appeared
off the harbour.
The Bashaw told
me
he suspected commodore Barron was dead, as he had not heard from him
for a long time.
Not long before,
he told
me,
that
he had heard of the death
of his brother
the Ex-Bashaw.
He seemed
highly pleased at such news.
Sev
eral of the sons and dearest friends of his chiefs
In the country,
were brought
into the castle, as hostages for their fidelity
to the present Bashaw.
Symptoms
of dissatisfaction
appeared amongst the people.
March
22.—Two
negroes
were
hung
at
the
gate of the
city
for robbery.
The Bashaw's son-in-law
who had been
sent into the country
to collect troops
to protect
Tripoli,
returned
without
success.
The people refused
to fight for
the Bashaw,
because he had made unusual
demands for money, and even had
stripped
their wives
of their jewels.
For several
days it had
been
reported
that
ten
thousand
troops were to muster
on the beach near the town ; and his
highness
was to make a speech
to encourage
them to fight for him against
the
Americans
and his brother.
I prepared
myself
to see these troops;
but to
my
disappointment
not one of them appeared.
April
7.—One of
our
cruisers
appeared.
A large
gunboat
was
launched,
which
was built by the redegade West,
who was
one
of our
crew, and turned
Turk.
April IS.—The
Bashaw received
an
unfavourable
letter
from
his
agent
at
Malta,
concerning
the armament
of the Americans.
The Spanish
consul
pre
sented the Bashaw three hundred
stand of arms
and a number of pistols,
and,
it is said,
advised
him
to
keep
up the war,
and
force
the Americans
to
pay
his demand.
It was
concluded
that
the Bashaw's
women and children
should
stay at the castle during the summer.
They
said that if they must
be taken,
they would
rather fall into
the hands of the Americans
than
the Arabs.
April
IS.—The
Bashaw
declared,
that
If
the
Americans
drove
him
to
extremities,
or attacked
his town,
he
would
put
every
American
prisoner to
death.
April 19.—The Bashaw interrogated
me concerning
the force of my country ;
-he asked
me
how
many
marines
the United States
kept In pay.
My answer,
for
good
reasons, was, ten thousand
!
How many
troops?
he asked.—Eighty
thousand,
said
I,
are
in
readiness
to
march
to
defend
the
country,
at
any
moment;
and one million of militia
are also ready
to fight for the liberty and
rights of their countrymen
!
At this, his highness
assumed
a very serious
look,
and I returned
to my room.
• It has
been
mentioned
that
the ex-Bashaw,
Hamet
Caramelll,
after
falling
to
gain
any
advantages
in
his
brother's
forces,
had withdrawn from
Derne
early
in
1804,
and
gone to Egypt
■At this
time the United
States
utilized
the harbor
of Syracuse
as a
base
from
which
to operate
against
Tripoli.
A naval
hospital
had
also
been
established
at
Syracuse.
No. 2.
259
JONATHAN
COWDERY,
SUBGEOK IN U.
S.
NAVY.
April
27.—A very
oppressive
Syroc
wind.
Several
companies
of Arabs hail
arrived within a few days : about three hundred
horse and seven
hundred
foot.
'
May
3.— The Bashaw
and suit went
very
early
this morning
to the great
Marabeict, of whom
some particulars have been
before
mentioned.
He was to
continue
with the Bashaw
during the contention
with the Americans.
He now
nssured
the Bashaw that
the American
frigates
would
be destroyed
; and that
the gunpowder
of the whole
squadron
would
be
so damaged,
that
the Ameri
cans would
not be able to fire a gun.
He agreed to attend the Bashaw,
to keep
the balls and shells from hurting him.
He receives large sums of money from
the Bashaw.
May 1-J.—I received
a note from
capt. Bainbridge,
stating
the inconvenience
which
the officers laboured
under by being in close confinement
and by breath
ing
unwholesome
air.
I
spoke
to
the Bushaw
on
the
subject,
and
humbly
solicited
that
our
officers
might
be
removed
to
the
American
house.
The
Bashaw replied, that the war between him and my country
at first was about
money;
but
now
it was
whether
him
or his
brother
should
be
the Bashaw;
and that the Americans
had bound themselves to his brother
In such a manner
that it was not in their power
to make peace with him.
But that
his brother
and
the Americans
were
determined
to
take Tripoli
and
take
off
his
head.
He swore by the prophet of Mecca, that If the Americans
brought
his brother
against
him,
he would
burn
to death all the American
prisoners
except
me;
that my life should
be spared, because I saved the life of his child
when
very
sick.
He went off In a great passion, and mounted his horse.
His mamelukes
and guard,
to the number
of about forty, attended
him,
and they took
a ride
to
his
country
palace.
They
returned
about
sun
set,
and
the
minister
of
exteriour relations
and the Bashaw
were in private
conference.
May 19.—A spy employed by the Bashaw,
arrived
from Malta and Syracuse.
He brought
news that
the American
squadron
sailed for Alexandria in Egypt
about
twenty
days before;
that it consisted of 4 frigates,
3 brigs,
3 schrs.
24
gun boats, 6 bomb ketches, and several
transports
; that
they were
to take on
board
the former,
or Ex-Bashaw,
and
to proceed
along
the coast of Tripoli,
and take the principal towns; and then to attack
and take the town of Tripoli,
and put it in possession of the Ex-Bashaw.
The Bashaw
and his people seemed
much agitated
at this
news.'
'General
William
Baton
waa born in Woodstock,
Conn.,
on the 23d
of
February,
1764.
Ar a boy
he served for a short
time in the Continental
Army.
He graduated
from
Dart-
month
College
in
1790,
wag
cleric
of
the
lower
house
of
the
Vermont
legislature
in
1791-92,
and
then
reentered
the
Army
as
a
captain,
later
serving
against
the Indians
in Ohio and Georgia.
In
1797
be
was
appointed
consul
to Tunis,
where
he
arrived
in
February,
1799.
While
In Tunis
he
became
acquainted
with
Ha met
Caramalli, the rightful
pasha
of
Tripoli,
who
about
the year
1792
had
been
deposed
by
hlB
brother
Tusuf.
When,
In
1803, because
he
refused
to comply
with the extortionate
demands of the
bey
of Tunis,
Eaton was driven
from
tbat country,
he returned
to tie United
States
to urge American
intervention for the restoration
of Hamet
Caramalli to the throne
of Tripoli
on condi
tion of a permanent
peace
and no tribute,
arguing
that
this
would
impress
the Barbary
States
with
the power
of the
United
States.
On
reaching
Washington
he
succeeded
in
exciting
a
moderate
amount
of
interest
In
his
project
to
cooperate
with
Hamet
Cara
malli,
who in the
meanwhile
had
taken
up
arms
against
his
brother
Yusuf,
bad
been
defeated,
and had early
in
1804
withdrawn
to Egypt.
In May,
1804,
Eaton
was appointed
Navy
agent
and placed
under
the orders
of
Com
modore
Barron.
To the latter
the Secretary
of
the Navy
wrote,
June
6,
1804
: " With
respect
to the ex-pasha
of Tripoli,
we have no objections
to your availing yourself
of his
cooperation
with you against Trjpoli.
•
*
*
In such an event you will, It Is believed,
find Mr.
Eaton
extremely
useful
to you."
Commodore
Barron's
squadron
sailed
for
the
Mediterranean
in
June,
1804,
arriving
at Malta
in
September, and the .following
month Eaton was sent in the Argus to Egypt
260
JONATHAN
COWDERY.
SURGEON IN
TJ.
S. NAVY.
Vol. XVII.
May 21. —The Bashaw with his attendants
rode into
the counry.
According
"
to custom
he took
with
him
on
a
mule,
two
hoxes.
said
to contain
twenty
thousand
sequins,
(forty
thousand
dollars).
But I did
not
believe
they
con
tained
that
sum.
They
were
light.
I had
lifted them both ; and
they
were
carried
to and from the mule by one slave.
Another
mule was loaded with
the
At Cairo
he lenrned that
Unmet,
with
a fow of
his followers,
had Joined
the Mamelukes,
who
were
at
war
with
the
Ottoman
Government,
and
was
at
that
time
besieged
at
Mlnieh,
150
miles
or
more
up
the Nile
from
Cairo.
The
prospect
of
getting
into
com
munication
with him
seemed
doubtful.
En ton obtained
nn
audience with the Viceroy
of
Egypt
nnd frankly explained
the object of his visit.
The
Viceroy,
delighted
at an oppor
tunity
of
ridding
his
country
of
an
enemy,
promised
an
amesty
for
Hamet
and
his
followers
and
a
passport
through
the Turkish
lines.
In
the course of
time
Hamet
and
his followers
nppenred at an appointed
rendezvous.
Eaton's
plnn
had been
to embark with Hnmet
on the Argus and to proceed from
Alex
andria
to a point
near Derne
In Tripoli
where
they would
meet
Hamet's
troops
and
cap
ture
the city,
but it was thought
best
to
go
by
land,
chiefly
because
it was
feared
that
Hamet's
army
would
evaporate
In
his
absence.
He
therefore
formed
his
camp
some
distnnee
to
the
west
of
Alexnndrin.
Arrangements
were
made
for
the Argus
to
meet
the expedition
at
the Bay
of
Bomba
with
supplies
and reinforcements.
Eaton
entered into
a convention
with Hamet
in
which
it was
provided
that the
Gov
ernment
of the United
States
should
reestablish
him In
the possession of his sovereignty
of Tripoli
and that' the expense
Incurred
by the United
States
was to be repaid
by
Hamet
out of
the tribute
derived
from
certain
other
nations.
Eaton's
little nrmy was composed
of about a dozen
Americnns
from
the Argus,
including
Lieutenant
O'Bnnnon
of
the
marines
and
Midshipman
Peck ;
25
cannoniers
of
various
nationalities,
with
3 officers ; 38 Greeks, with 2 officers ; Hamet
nnd
his suite of 90
men
;
a
party
of
Arabian
Cavalry
under
Sheik
el
Tahib
and
another
chief ;
a
number
of
footmen
and camel drivers,
altogether
about
400 men,
and a caravan
of
107
camels
and
a
tew
asses.
This
expedition
to
Derne
is
of
Interest
because
It was
the
first
American
force
to
operate
on
foreign
soli.
The
story
of
the
expedition
Is
splendidly
told
in Gardner
W.
Allen's
" Our
Navy
and the Barbary
Corsairs,"
from
which
the following Is quoted :
" On March
8,
1805,
the march was begun across the Lyblan Desert to Derne,
a distance
of
between five and six
hundred
miles.
For
the greater
part of the way
the route
lay
within Right of the sea.
Wnter
was generally
obtained
from natural basins
worn
In
the
rocks
by
the streams
during
the wet
season, and
filled
with rain water
; but there
was
often
great scarcity
of water
and
suffering
for want
of it.
An advance
of
15 miles
was
made
the first
day,
and then
on
the
following
morning
the owners
and
drivers
of
the
camels
became
mutinous
and
demanded
advance
pay.
In this
they
were
encouraged
by
Sheik
el Tahib,
one
of the Arab
chiefs,
who made trouble during the whole
march.
This
difficulty
caused a delay of
a day and a half.
Hamet
was lrresolate
and
seemed
to have
no Influence
with the
Arabs.
At
last
Eaton,
finding
argument
fruitless,
assembled
the
Christians
' and
feinted
a
countermarch,
threatening
to
abandon
the
expedition.*
This
had
the
effect
of
checking
the mutiny,
and
the
march
was
resumed.
On
the
13th
a
courier
from
Derne
appeared
and announced
to Hamet
that
the Province
was preparing
to support
him.
This news caused rejoicing
and a discharge
of firearms,
which
alarmed
the
Arabs
in
the
renr.
who
thought
nn
attack
was
being
made.
They
thereupon
at
tempted to disarm
and massacre the Christians escorting
the caravan,
but were restrained
by
one
of their more prudent
chiefs.
" March
lfi and
17. there was a cold rainstorm,
and the Arabs
again
became
mutinous.
On the 18th, having
advanced about
150 miles, Eaton
learned
that
the caravan
had
been
freighted
by namet
for this
distance
only.
The
owner.8
finally
promised
to proceed
two
days farther,
upon being paid.
This took nearly
all the money Eaton
had, and when
they
had received it, all deserted, part the first
night
and part the second, setting
out on their
return
to
Egypt.
Sheik
el Tahib
nnd
other
chiefs
now
refused
to
proceed until
news
should
be brought
from Bomba that
the United
States vessels were there, and proposed
to
send
a runner
to ascertain
the fact.
Eaton
ordered
their rations
stopped.
These
com
plications
consumed
three
days.
The
Arabs
finally
yielded,
about hnlf the caravan
was
induced
to return,
and the march
was resumed.
" March
22, they arrived
at a great plain, bordering
upon the sea, inhabited
by thousands
of wild
Arabs
who
had
never
before
seen
Christians or
tasted
bread.
They
had
vast
herds
of
camels,
horses,
nnd
cattle,
and
countless
sheep
and
goats.
Hamet
was
here
reinforced
by
80 mounted
wnrrlora,
and
a caravan
of 90 camels was freighted: and later
another
force of Arabs, including 150 warriors, with their
families,
Joined
the expedition.
Xo. 2.
261
JONATHAN
COWDERY,
SURGEON IN
U.
S.
NAVY.
packages
of the
Bashaw's
clothing.
The
Bashaw
always
wont
thus
provided,
through
(far that he might
be served as he served his brother
the Ex-Bashaw,
who
was denied
to return
to the castle when the present Bashaw
usurped
the
throne.
During the absence of the Bashaw,
his
eldest
son,
the Bey,
had
his
amusement.
He ordered
two carpets
spread
on the south corner of the cnstle.
On the 2flth a courier
announced
that
a large force, sent
by Yusuf Pasha,
was marching
from Tripoli
to
Dome.
This
canned
another
panic,
Hamet
hesitated
and
wavered,
the
camel drivers
fled
with the caravan,
and
Sheik
el
Tahlb
deserted
with
pnrt
of
his
tribe
and a large number
of other
Arabs.
Hamet
begged
Eaton
to
offer inducements
for
the
Sheik
to return.
This
Eaton
refused
to
do
and was glad to be rid of him,
but
he
soon
came back
of his
own
accord.
On
the 28th
Hamet's
slender
stock
of
resolution
seemed
to have
oo»ed
away
completely,
and
he decided
to
abandon
the enterprise
and
return
to Egypt.
Eaton
kept or. with
the
baggage,
and in two hours
Hamet
followed
him.
That
evening all the Arabs
that had Joined
a few days before deserted, having
been
discouraged
by Shiek
el
Tahl!>.
An
officer
was
sent
back
after
them
and
returned
with
them
the
following afternoon.
"The
next
complication
was
a
quarrel
between
Sheik
el
Tahlb
and
another
Sheik,
which
ended
in the lntter's
deserting with many others
whom it was Important
to retain
on account
of their
influence
with
Arabs
near Derne.
Hamet
went back to induce
them,
If possible,
to return.
' From Alexandria
to this
place.'
wrote
Eaton,
' we
have
experi-
inced continual
altercations,
contentions
and delays among the Arabs.
They have no sense
<jf patriotism,
truth nor honor ; and no attachment
where
they have no prospect
ot gain,
except
to their religion,
to which
they are enthusiasts.
Poverty
makes them thieves
and
practice
renders them adroit in stealing.
The Instant
the eye of vigilance
is turned
from an
object on which
they have fixed a desire, it is no more to be found.
Arms, ammunition,
and
provisions
most
engage their furtive speculations,
but
sundry
of
our
people
have
been
robbed of their clothes and other articles.
With all their depravity
of morals
they possess
a savage independence of soul, an incorrigible
obstinacy
to discipline,
a sacred adherence to
the laws of hospitality and a scrupulous
pertinacity
to their religious
faith and ceremonies.'
After
an
absence
of
four
days,
Hamet
returned
with
the
Sheiks
who
lrad
deserted.
Meanwhile
there had
been
more trouble
with Sheik
el Tahib,
who demanded an increased
ration.
He
became
insolent,
and
Eaton
threatened
him
with
death If
he
attempted
to
incite
a mutiny.
He rode off with two other chiefs,
hut
a few hours
later
returned
very
penitent
and took an oath
to remain faithful
thereafter.
"On
the evening of April
2, Eaton
held
a meeting of Hamet
and all the Sheiks
in his
tent, and endeavored to impress upon them the Importance
of union
and perseverance,
and
they all ' gave
pledges of faith and honor.'
The
force now consisted
of
between
six and
seven hundred fighting
men,
who with camel
drivers
and camp followers,
including
women
and children, made a total of about
1,200.
The next morning
the march was resumed, hut
after advancing
only
10 miles the Arabs
positively
refused
to go farther
until
a caravan
bad been
sent
to an oasis five days' Journey
inland
for a supply
of dates.
Eaton
flnallj
agreed to this
on
condition
that
they
should
proceed the next day, being met at Bomba
by the detachment
sent after
the dates.
During the few days following there was much
suffering
for lack of water,
but a good
supply
was found on the 8th.
"On this
day,
also,
occurred
the most
serious
commotion
yet experienced.
Although
there was
only a six days' supply
of rice and no other food,
Hamet
Insisted
upon encamp
ing and sending
a courier
to Bomba
to look for the American
ships.
Eaton
stopped the
Arabs'
rations.
They
prevailed
upon
Unmet
to
return
to Ecypt
and
made
a
move
to
seize provisions.
Eaton
assembled
the Christians
and
formed
a
line
to
resist
this
at
tempt.
After facing
each other
for
an
hour
the Arabs
dispersed.
Supposing
the tumult
tranquilized,
Eaton ordered
the troops to pass
the manual
exercise according
to his dally
practice.
In
an
instant
the
Arabs
took
an
alarm,
remounted
and
exclaimed.
1The
'-hristlans
are preparing
to fire
on
us.'
The
Pasha
mounted
and put
hlmseelf
at their
bead, apparently
impressed with
the
same
apprehension.
A body of about
200
advanced
in full charge
upon
our
people,
who
stood
their
ground
motionless.
The
enemy
with
drew at
a small
distance,
singled
out the officers, and with deliberate
aim
cried,
' Fire.'
Some of the Pasha's
officers
exclaimed.
' For
God's
sake,
do
not
fire.
The
Christians
are onr friends.'
•
•
*
Eaton
advanced
toward
the Pnsha,
and cautioned
him against
giving
countenance to a desperate act.
At
once
a column
of muskets
were aimed at his
breast.
The Pasha
was distracted.
A universal
clamor drowned
Eaton's
voice.
He waved
his hand as a signal for attention.
At this critical moment some
of the Pasha's
officers and
sundry Arab chiefs
rode
"retweeu
the lines
with
drawn
sabers and repelled
(lie mutineers.
Hamet
repented
of
his
rashness,
ordered
the Arabs
to
disperse,
called
Eaton
his
friend
and protector,
and promised to take up
the march if rations
were issued.
This was done,
•nd the next morning
they
moved
forward.
262
JONATHAN
COWDERY,
SURGEON IN U.
S.
NAVY.
Vol. XVII.
On
one of the carpets,
the Bey
and his
attendants
seated themselves, with a
band of musiek,
consisting
of two
men
with tamborines,
and
one with
a
sort
of drum.
Murat, his uncle, and myself were seated on the other carpet.
Three
large
negroes
were
brought
and
ordered
to
perform
before
the
Bey.
The
musick
then struck
up and the three negroes commenced the negro dance, with
"By
April
10
there
was
'nothing
but
rice
and
water
for
subsistence
and
that
at
half rations'
for three days.
No news from
Bomba.
Hamet
was beginning
to entertain
the idea that
he was being
used
by
the Americans
merely
' for the purpose
of obtaining
a
peace
with
his
brother,'
a
suspicion
that
proved
to
be
not
wholly
unreasonable.
A
mutiny
was
organized
among
the
cannoneers,
of
which
Eaton
was
secretly
Informed
;
they
were
to
insist
on
a full
ration.
The
situation
seemed
critical,
and
Eaton
took
O'Bannon
into
his
confidence.
Early
In the evening,
however,
before
any
outbreak
took
place,
a courier
arrived
from
Bombn with news that
the ships
had
been
sighted.
Confi
dence
was now
restored,
and
nothing
more was
heard
of
the mutiny.
The
last
of the
rice
was
Issued
on the
12th.
The
next
day
Hamet
had
one
of
his
camels killed, and
exchanged
another
for
sheep
with the Arabs
; this
gave the troops
one full
ration.
For
the next two days they subsisted
on roots and herbs.
On the afternoon
of the 15th they
reached
Bomba,
but
found
there
no
trace
of
a
human
being
and
not
a
drop
of water :
moreover,
not
a
vessel
was
in
sight.
The
Arabs
now
became
mutinous
and
abusive.
Eaton
took the Christians upon a mountain,
where they built
fires and kept them burning
all
night.
" The
next morning
at 8 o'clock. Just as the Arabs
were preparing
to leave In disgust
a
sail
was
sighted,
which
proved
to
be
the Argus,
Isaac
Hull
in
command ;
she
had
seen
the smoke of
the fires.
Eaton
went
aboard
at
noon.
He
found
a letter
from
the
Commodore
dated
March
22,
1805,
informing him
that
stores
and
provisions
were
sent
and seven
thousand dollars
in specie, but that no marines
could be spared.
The camp was
moved around
the bay to a cistern
of water
which
had
been
found,
and in the afternoon
provisions
were sent
ashore.
Either
here
or
later,
at
Derne,
Midshipman
Mann
came
ashore
and rejoined
Eaton.
April
17, the Hornet arrived
with abundance
of provisions.
They
remained
in camp recuperating
until the 23d, when
they resumed the march with
■
sufficient
supply
of provisions
to carry
them to Derne,
a distance of about
60 miles.
The
next day another
courier
arrived,
with the news that
an army
from
Tripoli
was rapidly-
approaching
Derne
and
would
probably
reach
the
place
first.
The
Arabs
were
agniu
seized with alarm
and
became
mutinous.
Sheik
el
Tahib,
at
the head
of
the cavalry,
began
a retreat.
Hamet,
as usual,
was irresolute
and despondent.
After
much persua
sion and
a promise
of money, the sheiks
were Induced
to advance,
and on the afternoon
of the 25th they encamped on a height
overlooking
Derne.
" The
town
was
rcconnolti-red,
and Information was also
obtained
from
a number
of
shieks who came
out in the evening to meet
Hamet
and assured him that
two of the three
departments
into
which
the city
was divided
were loyal
to him.
The
third department,
situated
along
the water front and containing
a third of
the inhabitants,
was devoted to
the interest
of his
brother
1'usuf.
This department
was, however,
the strongest
in posi
tion
and
in its defense, which
consisted
of
a
water
battery
of eight
9-pounders
on the
northeast
breastworks,
and walls of old houses on the southeast,
and
a
10-lnch howitzer
on the terrace
of the bay's
palace ; the walls
of
the houses were also
pierced with loop
holes for musketry.
It was likewise
learned
that
the bey bad 800
fighting
men,
and that
the Trlpolitan
army
was near at hand.
On
the 20tb
Eaton
sent in
a flag of
truce with
a letter
to the
bey
offering
terms.
His reply
was :
' My
head or yours.'
Smoke signals
were
made,
and in
the afternoon
the Nautilus appeared:
The
next
morning
the Arf/u*
and
Hornet
hove
in
sight.
The
Nautilus
and
Hornet
came
close
in.
and
sent
a
boat
ashore with two
field
pieces.
One of
these
was landed,
but owing
to the great difilculty
and delay of hauling
it up the steep and rocky
precipice
that
bordered
the bay,
the other
was left
behind, as Eaton
was very
anxious
to attack
without
any loss of time.
" Eaton
at
once
set
about
making
his
dispositions,
and
the
attack
was
made
that
day, Apr.
27,
1805.
The
enemy
began
by
firing
on
the ships.
The
Hornet,
Lieutenant
Evans,
anchored
within
a
hundred
yards
of
the
water
battery
and
opened
fire.
The
Aryus,
Captain
Hull,
and
Nautilus,
Captain
Dent,
anchored
about
half
a
mile
from
shore, to the eastward
of the Hornet, and
opened
on the town
and battery.
The
breast
works
and a ravine
at
the southeast
part
of the town
waB
held by
a considerable
force
of
the
enemy,
and
opposite
this
point,
on
an
elevation,
were
posted
the
squad
of
marines,
24 cannoniers
with the fieldpiece,
and
36 Greeks, all under
the immediate
com
mand
of
Lieutenant
O'Bannon
;
also
a
few
Arabs
on
foot.
Hamet
occupied
an
old
castle
south-southwest
of
the
town,
with
the
Arabian
cavalry
drawn
up
in
his
rear.
By
2
o'clock
the
action
had
become
general,
and
45
minutes
later
the
battery
was
silenced
by
the fire from
the ships,
and most of the
enemy
In that
quarter
being driven
No. 2.
263
JONATHAN
COWDERY, SUBGEON IN U.
S. NAVY.
many ridiculous
airs,
whirling
around,
shaking
their heads
and roaring like
mad
bulls.
This
continued
about
hnlf
an
hour,
when
they
appeared
to
be
raving
mad.
They
ran about, as if to tear in pieces every body they met.
One
of them made a leap at -me. but was prevented
from reaching
me, by the Bey,
Murat and another Turk,
who jumped
between us.
Two other Turks
caught
nut
reinforced
the
party
opposed
to
the
Christian
land
forces.
At
this
point
the
enemy's
musketry
fire
was
very
hot.
In
the excitement
the
rammer
of
the
fleldpiece
was
shot
away
and
Its
Are In
consequence slackened.
Eaton
saw
that
his
little
force
of undisciplined
troops
was falling
Into
confusion,
and
as
the
only
hope
of
restoring
confidence,
he
ordered
a
charge.
The
enemy
fled
from
their
defenses, firing from
be
hind
trees
and
houses
as
they
retreated.
At
this
moment
Eaton
was
shot
through
the left wrist
by
a musket
ball.
O'Bannon
and
Mann,
with
the
marines,
Greeks,
and
as many
of
the
cannoniers
as could
be spared
from
the
fleldpiece,
pushed
on
toward
the battery
under
a
heavy fire from
the
houses.
The
way
was
cleared for them
along
the beach
by the
ships'
guns.
The
battery
was
soon
captured
and
the
American
flag
was planted
upon
its
walls.
The
guns,
which
were
found
rendy
loaded
and
primed,
were turned
on
the
town,
and with
the
help
of
the
ships'
Are
the
enemy
were
soon
dislodged
from
their
houses.
The
bey
fled
from
his
palace
and
sought
refuge
In
a
mosque,
and
Hamet
took
possession
of
the
deserted
residence.
The
Arabian
cavalry
flanked
the
flying
enemy,
and
a little
after
4 o'clock
the whole
town
was
In the
hands
of
the
assailants.
The
ships'
boats
were
sent
ashore
with
ammunition
for
the
bat
tery,
and
took off the wounded.
One marine
was killed
and two
wounded,
one of them
mortally;
11 others
were wounded.
Including
Eaton
and several
Greeks.
Practically
all
the fighting on this occasion was done by the Christians under Eaton's
command, assisted
by the ships' batteries.
"May 1 the Hornet
sailed with
dispatches
for
Commodore
Barron.
The
bey
of Derne
left
the
mosque,
where
he
had
taken
refuge,
and
Bought
asylum
in
the
harem
of
an
aged sheik,
who, although
a partisan
of Hamet,
could
not
be Induced
to break
the laws
of
hospitality
by
giving
him
up.
The
town
was
now
fortified
against
the Trlpolltan
Army,
which
was
approaching.
The
enemy advanced
slowly,
and
on
the
8th
occupied
the
ground
held
by
Eaton's
forces
before
the
capture.
They
spent
several
days
in
attempts
to corrupt
the inhabitants
of the town,
who
were vacillating between
the two
parties,
fearing
that If they adhered
to Hamet
they would
be slaughtered
In the
case
of
his defeat
The
late
bey
Intrigued
actively
from
his
sanctuary,
attempting
to Incite
a
counter
revolution
In the town.
At the
head
of
60
Christians,
Eaton
proposed
to enter
the house of the old sheik and
seise
the
bey.
This ccurse, however,
was offensive
to the
Arabs,
and Hamet
begged
that
action
be deferred until
the next
day.
That
night,
May
12, the bey
escaped
to the Trlpolltan
camp.
" Eaton believed that
the enemy before Denie
would
disperse,
but they displayed
more
resolution
than
he
gave them credit
for.
On
the
13th,
apparently
encouraged
by
the
bey's tales of disaffection
towards
Hamet,
they
mado
an
attack
on the town
which
fell
only a little short of being successful.
In the morning
they appeared
on the heights
back
of
the town
to the
number
of about
1.200,
Including
Trlpolltnns.
Arabs,
and
fugitives
from
Derne.
After
rcconnoitering,
they
attacked
an
outpost
about
a
mile
from
the
town,
(onsistlnir
of
100
of
Hamet's
Cavalry,
who
held
their
ground
firmly
until
over
come by numbers,
when
they were forceed to give way.
They
retreated
Into
the
town,
followed
by
the Tripolitans, who
pursued
as far
as
the
bey's
palace,
now
occupied
by
Hamet.
Although
exposed
to
the fire of the Argu»
and Kautilug,
as well
as of the bat
tery
and
small
arms
from
the houses,
they
made
a vigorous
attack
on
the palace, deter
mined, if possible,
to seize
the person of the pasha.
Their success seemed
imminent,
and
Eaton
began
to
fear
that
the
day
was
lost.
His
little
force
of Christians
was
too
weak
for
a sortie
from
the
battery,
and
he
torned
the guns
upon
the
town.
A
fortu
nate shot
from
n
9 pounder
killed
two
of the enemy's
mounted
men.
Immediately
the
undisciplined
rabble
beat
a
disorderly
retreat,
pursued
by
Hamet's
Cavalry
and
har
assed
by
the fire
from
the ships.
On
this
day
Hamet's
people
surprised
Enton
by
an
exhibition of courage
and
firmness
of which
their
previous
behavior
had
given
him
no
reason to believe them capable.
From
deserters
it was learned
that
the enemy had
lost
28
killed
and
50
wounded.
11
of
them
mortally.
Hamet
lost
12
or
14
killed
and
wounded.
"The Tripolitans fortified
their
camp,
abont 3 miles distant,
and made
preparations
for
another
attack,
but
their
leaders
could
not
Induce
the Arabs
to Join
In
It.
Eaton
had
the same
difficulty.
He wished
to attack
the enemy's camp, but
Hamet
and
his
people
could not be prevailed
upon to make
the attempt.
Eaton
was beginning
to feor
a dearth
«f provisions,
as the enemy cut off all
supplies
from
the country.
The
Xautilua
sailed
264
JONATHAN
COWDEBY,
SURGEON IN U.
S. NAVY.
Vol. XVII.
hold of the negro and held hlra, when I, by the advice of the Bey, went
to the
top of the
north
end
of
the castle,
where I could
see
the
sport
in
safety.
During the frolick. I saw
those negroes chase several Christians : and I was
told that they often tear all their clothes off, and hurt them much by biting,
etc.
May
22.— I
was
informed,
that,
in
u letter
which
the Bashaw
received
the
May
18 with dispatches,
leaving
the Argus alone before Derne.
Several
times
the euemy
seemed
about
to
attack,
but they
could
never
persuade
the
Arabs
to
expose
themselves
again
to the Are o£ the Christians ; artillery
they could not face.
Eaton
believed
that if
he
had
had
money
he
could
have
bought
a
wholesale
defection
of
these allies
of
the
Tripolitans.
' We want
nothing
but
cash
to
break
up our
enemy's
camp without firing
another
shot.'
On
the 28th
the
enemy
sent
a
detachment
of
50
or
00,
supported
by
cavalry,
on
a
foraging
expedition
;
they
descended
a
ravine
and
attacked
a
party
of
Arabs,
but
were
driven
back.
June
1, the Hornet returned
with
dispatches
from
the
commodore,
dated May
19, announcing
that
peace
negotiations
were about
to
be
entered
upon, and
that
Derne
must
probably
soon
be e"acuated.
June
10,
the
enemy,
who
had
been largely
reinforced
by Arabs,
made
another
attack
and were (irmly
resisted
by
Hamet's
■cavalry.
The engagement
which
ensued lasted four hours.
The
Argun
was occasionally
able to use
her long
Im pounders
when
the enemy
in their movements
emerged from
the
hills and ridges, and one of Eaton's
fieldpieces also gave some
assistance.
The Tripolitans
were
finally
repulsed
with
a
loss,
according
to
deserters,
of
40
or
50
kilted,
and
70
wounded.
Hamet
lost between
50 and
60 killed
and wounded.
O'Bannon
wished
to lead
out the Christians and take an active
part
in the fight,
but Eaton
was unwilling to leave
the defenses unmanned,
and, moreover,
doubted If offensive operations
would
be justifiable
in view of the peace
negotiations
supposed to be in progress.
" June
11,
the
Constellation,
Captain
Campbell,
arrived
with orders
from
Commodore
Kodgers,
dated June
5, to evacuate
Derne
immediately,
and announcing
that
peace had
been
concluded.
It now
became
necessary
to embark
on the Constellation
all the Chris
tians,
together
with
Hamet
and his
suite.
This
must
be
done
secretly,
moreover,
as it
was feared that
the populace and the Arabs,
enraged at being deserted, would
attempt
to
revenge themselves
by a massacre of those about to depart.
Eaton
was filled with disap
pointment
and mortification
at
this
ignominious
ending
of
the expedition
which
he
had
hoped would
result
in the capture
of Tripoli.
But he had now no choice but to yield
to
necessity.
To divert
the attention
of the people, preparations
for an attack
on the enemy
were
made
June
12.
In *he evening
patrols
of
marines
were placed
as
usual
to prevent
communication
between
the
town
and
the
battery.
The
Constellation's
boats
came
ashore
and first
took off the cannoniers
and Greeks, with the fieldpieces and
the 10-lnch
howltier
captured
April
27.
Then
Hamet
and
his
suite
were
embarked,
and
next
the
American
officers and marines.
Lastly, Eaton himself
put off in
a small
boat,
and
had
barely
got clear
' when the shore, our
camp, and the battery
were crowded with the dis
tracted
soldiery
and
populace,
some
calling on
the
pasha,
some
on
me,
some
uttering
shriekB,
some
execrations.
Finding
we
were out of
reach,
they fell
upon our
tents
and
horses, which
were left standing,
carried
them off, and prepared
themselves for Sight.'
" The
next morning
the Arabs
and many of the Inhabitants
of Derne
fled
to the moun
tains.
The
enemy had already
retired,
under
the impression
that
the Constellation,
had
brought
reinforcements
to
Eaton,
A Tripolltan
officer,
a messenger from
Yusuf Pasba,
who
had
come
from
Tripoli
in
the
Constellation,
went
on shore
under
a flag of
truce,
bearing
letters
of amnesty
from
the pasba
' to the people of Derne
on condition
of their
returning to allegiance
;'
but the people remaining
In
the town
had no faith in
Yusuf's
promises, and in despair
prepared to defend themselves to the last.
This abandonment
of
Hamet's
followers
to the tender mercies of his brother
was the most painful part of this
whole transaction,
but it is believed that no harm
came
to them and that Yusuf's
promises
in their
case
was fulfilled.
" The
Constellation
sailed directly
for Syracuse.
From this point
Eaton
sailed for the
United
States
In
(he brig Franklin
August
0, and arrived
at
Hampton
Roads
Nov.
10,
1805. "
The
situation
of
the unfortunate
Hamet
was
by
no means befitting
to
a
royal
exile.
In
a
letter
to
Eaton,
dated June
29,
1803,
he
acknowledges
that
everything
had
been
done for him
which
he
had any
reason
to expect, but
suggests " some
small
assistance
to enable
me
(o subsist myself and suite."
Accordingly,
by order of Commodore
Rodgers,
he
was allowed
.¥200
a
month
for the support
of
himself
and
his
12
or
15
dependents
in
Syracuse.
A
few
weeks
later
he
appealed
to the
President
and
to the
people
of
the
United
States
for
relief.
He
was
allowed
for
a
time
to
suffer
in
neglect.
In April,
1806,
Congress
appropriated
$2,400
for
his
benefit,
but
it
was
not
delivered
to
him
until
more
than
a
year
later.
'Hie
allowance
authorized
by
Commodore
Rodgers
was
then
stopped,
lu
the
meantime,
Feb.
18,
1S07,
he
had
addresed
a
memorial
to
Con
So. 2.
265
JONATHAN
COWDEBY,
SURGEON IN U.
S. NAVY.
evening
before, it was
stated
that
Hassan
Bey
and his array
were
taken
in
Derne,
by
the
Americans
and
Sadi
Haniet.
the Ex-Bashaw.
I
was
desired
not to mention it, because it was a great secret ; and the Bashaw did not wish
to let
his people
know
it.
I
was
also
informed
that
the Bashaw called
a
council
of his chiefs,
and proposed to put all the American
prisoners
to death,
but it was agreed to postpone this measure for that time.
May
23. —Twenty-five
of our
men
were sent with
u cart for timber
into
the
country.
The wind from
the desert was very heavy and hot.
The men
almost
perished
in the sand, which
flew and drifted like a snow storm in our country.
They
stopped
through
fatigue,
and
asked
their
driver,
who
was
a
Turk,
for liberty to drink
at a well which
was near
them.
The Turk
replied,
that
they were
Romo
kelps, Christian
dogs,
and
said
they
should
have
no
water.
He gave them all a severe beating with a large club, which
he always
carried
with him to drive them with,
and made them go on with the cart,
which
the
poor fellows had to drag, loaded with timber, through
the burning
sand.
They
returned towards
night
almost perished.
May
2$. —At night
the Bashaw dispatched
a boat with powder,
musket
balls
and money for his troops,
who were
collecting
to oppose the approach
of his
sress In
which
he
says : " I
will
not,
like
the
world,
reproach
the
representatives
of
the American
Nation
with
ingratitude.
I
rather
implore
their
commiseration
toward
me; at least so far as to restore
to me
my family and to grant
me
a competence."
In
May,
1807,
Dr.
George
Davis,
who
had
been
for
some
years
charge
d'affaires
of
the
United
States
at Tunis,
went
to Tripoli
as
consul,
and
one
of
his
first
acts
was
to
demand of the pasha
the fulfillment
of the third article of
the treaty
of June
4,
1805,
which
provided
for
the
restoration
to
Hamet
of
his
wife
and
children.
It was
now
learned that
Colonel
Lear had
agreed to
a
secret article of
that
treaty,
allowing
the
pasha four
years
to
comply
with
this
stipulation.
This
fact
had
never
been
commu
nicated
to the
State
Department
nor
to
Congress,
although
Eaton
had
stated
his
sus
picion of some
such secret agreement in
a letter
to the chairman
of the Senate committee
on Hamet's
application.
The
President,
in
his message of
Nov.
11,
1807,
expresses sur
prise at this
affair,
and says : " How
It has happened
that
the declaration
of June
6th
has never
before
come
to our
knowledge
can not
with
certainty
be
said.
But whether
there has
been
a miscarriage
of it or
a failure of the ordinary
attention
and correctness
of that
officer
in
making
his
communications,
I
have
thought
it due to
the
Senate,
as
well as to myself,
to explain
to them the circumstances
which
have withheld
from
their
knowledge,
as
they did from
my own,
a
modification
which,
bad It
been
placed
In
the
public
treaty,
would
have
been
relieved
from
the
objections
which
candor
and
good
faith
can
not
but
feel
in
its
present
form."
Doctor
Davis,
however,
prevailed
upon
the pasha
to
restore
his
brother's
family
without further
delay,
and this was
done in
October,
1807.
Dec.
18,
1807,
a
committee
of
the
House
of
Representatives
recom
mended further
pecuniary
aid for
Hamet.
In
1808
provision
was
made
by the pasha for
his brother's residence
in
Morocco,
with
a
pension ; and
in
the following year,
through
the influence
of
Consul
Davis,
Hamet
was
appointed
by
the
pasba
to
the
government
of
Derne.
Two
years
later
he
was
again
expelled
by
bis
brother
and
fled with
his
family
to Egypt,
where he died.
Upon
his return
to America,
Eaton was
received with
marked
distinction.
The
Leg
islature
of
Massachusetts
made
him
a
grant
of
10,000
acres
of
land
in
Maine.
But
he could
never
get over
his
chagrin
and
disappointment
at
the
inglorious
termination
of his expedition,
which
he had hoped
and believed would
end with the capture of Tripoli,
the restoration
of
Hamet,
a brilliant
victory
for
the
United
States
forces
afloat
and
ashore,
and
an
honorable
peace.
The
remainder
of
his
life
was
embittered.
Toward
those who,
he
believed,
had in
any
degree thwarted
his
plans,
Lear especially,
he was
nnsparing
of
his reprobation.
He therefore
not unnaturally
made
enemies,
and
a
reso
lution
to present him
a medal was
defeated
In
Congress
by
a small
majority.
He
was
embarrassed
by
long
delay
in
settling
bis
claims
nnnlnst
the Government.
Finally,
in
February,
1807,
a bill passed in Congress authorizing the State
Department
to settle
the
accounts
according
to equity.
Many
years later
his
heirs
applied
to Congress for relief.
The
total
expense
of the Derne
expedition
was
a little
less
than
$40,000 ; Eaton
would
accept
for
his
own
services
during
this
campaign
only
enough
to
cover
his
personal
expenses.
His relations
with
Hnmet
continued
cordial,
and for some
years they kept up a
friendly
correspondence.
Eaton died in
1811
at the age
of 47.
266
JONATHAN
COWDERY,
SURGEON IN U.
S. NAVY.
Vol. XVII.
brother
Hauiet,
the Ex-Bashaw.
The eldest son of Hamet,
was confined in the
castle
by order
of the present Bashaw.
The Bashaw
was
so much agitated
at
the news of the approach
of his brother,
that
he this day declared,
that if it
was
in his power
now to make
peace
and give up the American
prisoners,
he
would
gladly
do
it, without the consideration
of money.
His
funds
were
so
low, that his steward
ran in debt for the supply of the kitchen.
He gave his
mamelukes
and domesticks,
and myself, but one meal per day.—The rich Turks
in town took turns
in supplying
his few troops.
He heartily repented for not
accepting the terms of peace
last offered by our country.
May
26.—Three
frigates
in
sight.
At
about
11,
A.
M.
the
smallest
came
near in, and hoisted the banners of peace.
The Bashaw asked his head men of
the town,
who were with him
in his gallery,
whether
it was best
to hoist
his
white
flag.
All
except
one,
the
charge
de
affairs for Algiers,
declared
in
favour of it, and of making
peace if possible.
They
expressed great
contempt
towards
the Algerlne
consul
for
his
advice,
and
said
that
whoever
would
advise the Bashaw not to hoist the white flag at such a critical moment must be
his foe and not his friend.
The Algerlne soon
disappeared
and left the castle.
The Spanish
consul
soon after came to the castle;
and the Bashaw sent him
in one of his handsome boats, with Shous Hammad
to the frigate.
They returned
at evening with the joyful
news of
a prospect of peace.
There was
a visible
change, from
gloominess
to joy, in the countenance
of all the Turks.
May 27.— Both Turks and Christians were all anxiously
looking
out for the
frigates.
It
was
said
that
Col.
Lear
had
promised
to
come
on
shore
this
morning
and that the Spanish
consul was preparing
a dinner for the gentlemen
who
were
expected
to
come
with
him.
We
were all
agitated
alternately
by
hope and despair.
The terraces
and every eminence in town, were covered with
people of all
classes
and
ages,
who
were
looking
for
the
wished
for
peace
maker.
But Dot
a frigate nor
a sail
hove in sight
during
the day.
May 28.—All looking
out again for our
squadron.
A brig
hove in sight in
the morning,
which
we all at first thought
was the flag ship.
On discovering
it
was
a
brig,
a gloominess
again
appeared
on
every
countenance.
The Turks
began to think that
the frigate had
gone
to
fetch
the whole
fleet,
which
they
heard
consisted
of sixty
sail of different
sizes.
They
thought
that
the flag
of
truce
was only
a plan of the Americans,
to find out the force of Tripoli,
eta
But at sun
set
three frigates
and
a brig
appeared,
which
revived
our
hopes.
The Bashaw
showed
the greatest
anxiety
for peace.
He was
sensible of
the
danger
he
was in from
the lowness
of his funds
and
the
disaffection
of
his
people.
May 29.—Three
frigates
and a brig bore down upon the town
and displayed
the ensigns
and signals
of peace,
which
were
immediately
answered
from the
castle.
The
Spanish
consul, Fafah the Jew and several Turks
went on board,
and did not return until late at night,
when it was
reported
that
negotiations
for peace
were going on rapidly.
Miiy 31.—The
Spanish
consul and
Shous Hammad
went
on board
to
see the
Commodore,
and
returned
at night.
The Bashaw sent
me
to inform
Captain
Bainbridge,
that
peace
was
agreed
on,
which I did
to
the great joy
of, the
officers.
June
1.—The truce continued.
Our men
were still drove
to hard labour,
and
our officers kept confined.
June
2.—I received
a letter
from
Captain
Bainbridge
stating
that
the terms
of peace
were agreed
on.
and that
we should
soon
go
on board
the squadron.
I immediately
read this letter
to our
crew, who were
so overjoyed
that
many
of them shed tears.
They
were still
drove
to hard
work,
and
many of
them
Hogged.
No. 2.
JONATHAN
COWDEBY,
SUBGEON IN U.
S.
NAVY.
267
June
3.— The articles of
peace
were
signed,
and
salutes
fired
from
the
frigates and batteries.
June
6.—I bid the Bashaw
a final adieu, at which
he seemed
much affected.
James Fenimore
Cooper writing of the war with Tripoli,
in his
"History of the Navy of the United
States of America,"
makes the
following comments upon this naval campaign and its results
:
"It is not easy to express approbation of the terms of this peace.
America
had been contending for the usages of civilization,
and the
rights of nations, and the ransom
was a direct abandonment
of both.
When
we
remember
the
force
that
was
about
to
assemble before
Tripoli,
the season of the year,
the fact that Derne was occupied
by
Hamet Caramalli,
and the disposition that so generally prevailed in
the squadron
to renew
the attacks
on the enemy, we find it difficult
to believe that
better
terms
might not have
been obtained.
How
far the course of the negotiator was compelled
by his instructions,
we have no means of saying, but the treaty was approved and rati
fied.
While many condemned
it
as
unwise,
all,
however,
rejoiced
that it was the means of restoring so many
brave men to their coun
try.
It is no more
than liberal, moreover,
to believe that the situa
tion of these unfortunate
officers and
men, had a deep influence
in
inducing
the Government to forego abstract
considerations, with
a*
view to their relief.
" Thus terminated the war with Tripoli, after an existence of four
years.
It is probable that the United
States
would
have
retained
in service some officers, and would have kept up a small force, had
not this contest occurred,
but its influence
on the fortunes and char
acter of the Navy
is incalculable.
It saved the first, in a degree at
least, and it may be said to have formed the last.
Perhaps no serv
ice, either in the way of ships or officers, ever had so large a propor
tion of what was excellent
in
it,
and
so small
a
proportion
of that
which was defective,
as the Navy of the United
States, the day peace
was signed with Tripoli.
A stern discipline,
a
high moral tone, rare
models in seamanship,
active warfare, the means of comparison,
and
a
spirit of emulation that
is
certain to carry the national character
to the highest level, whenever
the national energies
can be permitted
to exhibit
themselves,
had conspired to produce
this end.
The petu
lant and always questionable
proofs of private rencontres,
which are
so apt to sully
the renown of infant
services,
had
disappeared
in
a
chivalry that seemed
to have forgotten all but the country and her
honor.
Not
a
duel was fought during
the command
of Preble;
the
brave
men
assembled
under
his
orders,
regarded
each
other
as
brothers,
and the honor of one appeared
to be
connected
with
the
honor of all.
An admirable esprit de corps was created, and the but
ton, which
bore the emblem of the common
profession, was deemed
a
signal of the presence of
a
friend.
Men had
stood by each other
108165—22
6
268
JONATHAN
COWDEBY,
SURGEON IN V.
S.
NAVY.
Vol. XVII.
in moments of severe trial, and even the body of the Nation, which
is
so little addicted
to
the
sentimental, or
the
abstract,
began
to
regard
the flag with open
pride.
In
a word, the
tone, discipline,
pride, emulation, and spirit, that the Navy derived from this remote
and, in one sense,
unimportant
war, prepared it for another
and
a
severer
trial that
was
at hand.
The
impression produced in the
Mediterranean
was
also
favorable,
and
the
head
of
the Romish
church is said to have publicly
declared, that America had done more
for
Christendom,
against
the
barbarians,
than all
the
powers
of
Europe united."
EDITORIAL.
EDITORIAL STAFF.
Lieut. Commander
Lucius
W.
Johnson,
Medical
Corps,
United
States
Navy.
Lieut. Commander J. G. Ziegler.
Medical
Corps.
United
States
Navy.
Lieut. Commander
W. M. Kerr, Medical
Corps,
United
States
Navy.
Lieut.
Commander J. J. O'Mallcy,
Medical
Corps,
United
States
Navy.
Lieutenant
L. J.
Roberts,
Medical
Corps,
United
States
Navy.
Lieutenant
J. D. Benjamin,
Medical
Corps,
United
States
Navy.
Lieutenant
E.
Peterson,
Medical
Corps,
United
States
Navy.
SIB PATRICK MANSON.
The death of Sir Patrick Manson, the distinguished parasitologist
and teacher of tropical medicine,
occurred
on Sunday, April 9, 1922,
at his house in London.
The Lancet and the British Medical Jour
nal for April
15 contain glowing
tributes to his memory.
He was
born
in
Aberdeenshire
on October
3,
1844,
and
was
educated
at
Edinburgh and at the University
of Aberdeen, where
he graduated
in medicine in 18G5.
He spent the early part of his professional life
in the East.
In
1866
he went
to Formosa to act
as medical
officer
to a group
of merchants and missionaries.
Here he encountered
diseases, espe
cially
beriberi
and
elephantiasis,
which
for
the
most
part
were
unstudied
in
the
medical
schools
of
Great
Britain,
while
their
etiology was unknown to the entire
scientific
world.
After practic
ing in Formosa
for
five years
he
went
to Amoy,
in China,
where
he acted
as medical
officer to the Chinese
maritime customs
and was
in charge of a large native
hospital.
In Amoy
he saw many
forms
of elephantiasis, but could at first find no satisfactory solution of the
problem
it presented.
During
a visit
to London
in
1874
he
heard
for the first time of the discovery
made by Timothy
Lewis
in
1872
that in the blood of a proportion
of the inhabitants of certain dis
tricts of India was to be found an organism which Lewis called
the
Viler' a sanguinis
hominis.
These
parasites
Lewis
has
encountered
in association
with
elephantiasis.
On his return
to China
in
1876
Manson
discovered
that
these
parasites
were
present
in many
dis
tricts in
a high
percentage
of the population.
He spent
the
next
two years in working
out the life history of filaria.
As the parasite
showed
no evidence of growth
while in
the blood
or any
features
warranting the supposition that it was capable of reproducing itself,
the inference
was that it was an immature form.
After much search
L'G9
270
EDITORIAL.
Vol. XVII.
Manson found that this was
the
case,
although
the discovery had
been anticipated
by Bancroft
as well
as by Lewis.
Turning
his
attention to the manner
in which this organism entered
the body it
occurred
to Manson that, as it was never found in any of the natural
discharges,
it could not escape
spontaneously
so as to pass from man
to man without the aid of an agent capable of penetrating the skin
and withdrawing
blood.
The mosquito
appeared
to him to
be
the
most likely agent in the dissemination of falaria.
To determine
the
frequency
with
which
that parasite
was
present
he examined
the
blood of a thousand
natives
with
the help of two
Chinese
medical
students.
These
assistants
were employed
in the hospital, one work
ing in the daytime, the other at night.
The one who worked at night
brought Manson many
specimens,
the other seldom
found
a filaria.
Investigating
this point
he found
that in
ordinary
conditions
of
health, this filaria came into the peripheral blood stream
about
sun
set, increasing in numbers
toward midnight,
but
decreasing
toward
morning.
This filaria
periodicity
suggested
an adaptation of
the
habits of the parasite
to the nocturnal habits of the mosquito.
The
next step was to determine
whether the filaria was ingested with the
blood which the mosquito
imbibed and, if so, what changes occurred.
An examination of the abdominal contents of mosquitoes
which had
fed at night upon a patient having filaria
in his blood, showed
the
presence of the organism and its stimulation
by the digestive
juices
to certain structural changes;
its inclosing sack had been broken and
discarded,
while considerable
growth
had
taken
place, accompanied
by
the
development
of
a
mouth
and
alimentary
canal.
In later
years,
after
months
of research,
it was
demonstrated
by Dr. G. C.
Low,
one of Manson's
pupils
in
the London
School
of Tropical
Medicine, that the filaria in its modified form leaves the stomach
of
the mosquito,
reaches the thoracic muscles
and finally
the proboscis,
in which locality it is ready to infect man.
It was thus proved that
certain kinds of mosquitos
are carriers of this filaria and are agents
in transmitting
the diseases to which this parasite gives
rise.
In
1883
Manson returned to England where
he worked for
the
first time with an oil immersion lens then recently
perfected.
While
at home lie published a small book on filariasis. and in 1884 returned
to China, where he confirmed
his previous work with the better appa
ratus
now
at his disposal
and
made
his original
researches
into
sprue.
The years
1885 to
1889
were spent
at Hongkong
in general
practice, where
he founded
a medical
college
for the Chinese.
In 1890 he returned to England,
and with his unrivaled personal
knowledge of tropical
medicine
began
practice
as
a consultant
in
London.
He became physician to the Seamen's
Hospital
Society in
1894,
and
in
1897
was
appointed
medical
advisor
to
the colonial
office.
In 1898 he delivered
at St. George's Hospital
a lecture on the
No. 2.
271
EDITORIAL.
need of the special study of tropical
diseases, which resulted
in the
establishment
of the London
School of Tropical Medicine.
Manson's
knowledge
of the life history of filaria
was of value
in
clearing up the mystery
surrounding
the malaria parasite
which had
been
discovered
by Laveran
in Algiers in
1880.
Manson
reasoned
that this parasite
like the filaria, to pass from man to man, must re
quire the intervention of some blood-sucking insect
as the mosquito.
It had already been noticed
that the malaria organism underwent
certain changes, becoming flagellated when removed from the human
body,
and
Manson concluded
that these flagellated bodies
were
an
early form of the extra-corporeal phase of the parasite.
At Manson's
suggestion the life history of the malarial
parasite
was worked out
in India by Sir Konald Ross to the satisfaction of the scientific world,
and two well known experiments
conducted
in Italy and
in London
demonstrated to the world at large the means of preventing malarial
infection.
The first of these experiments
Avas
the sending out
to
the most malarious port of Italy two observers, Dr. Louis
Sambon
and Dr. G. C. Low,
who were
to live
among
the malaria-stricken
population,
exposing themselves
all
day
to
the ordinary
environ
ment, but who were to retire for the night before sunset into houses
specially
protected
from
invasion
by
mosquitoes.
These
men
re
mained health}', while the inhabitants of the district were ill and often
dying of malaria.
The
second experiment
consisted
of subjecting
healthy subjects
in London
to the bites of infected mosquitoes
col
lected
in the malarious
parts of Italy.
These
men
suffered
from
malaria fever two
weeks after they
were bitten, the parasites
being
found in their blood.
" Sir Patrick Manson
retired from
active
practice in
1913," we
are informed by the Lancet, " and for a time traveled in Ceylon and
South Africa
noting hygienic
problems.
On his return
he contin
ued to take
a deep interest
in the conduct
of the London
School of
Tropical Medicine and the progress of his special branches of science.
He exercised
great influence
upon
all who worked with
him, for
which
nothing
was too big or too smali for him
to consider;
his
clinical
acumen
was
sound,
so that
he made
few
mistakes.
His
habit of thought may
be summarized in his own words written
in
1909 to his son-in-law
: ' Never refuse to see what you do not want to
see or which might
go against
your
own
cherished
hypothesis or
against the views of authorities.
These
are just the clues to follow
up. as is also and emphatically
so the thing you have never
seen or
heard of before.
The thing you can not get a pigeonhole
for is the
finger point showing the
wa}- to discovery.'
His own scientific hy
potheses had a knack of turning
out right —for example,
his fore
cast of the life history of Schistosoma haematobium
in the fourth
272
Vol. XVII.
EDITORIAL.
edition of his manual of Tropical Diseases in 1907 ; also his sugges
tion in 1903 of the two species of schistosoma
proved true by Leiper
in 1915.
Younger men who came under Manson's influence remarked
always that in outlook and in knowledge he remained
eager and en
thusiastic to the end.
His interest in his work never flagged.
Only
14 days before
his death
he visited the London
School of Tropical
Medicine
and critically examined
some microscopical preparations,
showing his usual
perspicacity in picking
out
the important
points
in each specimen
and emphasizing the lessons they taught.
Almost
the last words he uttered
expressed
his hopes for the future of this
school for which he anticipated
a still wider field of work in coop
eration with
the Rockefeller
scheme for the new Institute
of Hy
giene.
" He married, in 1876, Henrietta
Isabella, daughter of Capt. J. P.
Thurburn,
R. N.. by whom he had two sons and three daughters, one
of whom is the wife of Doctor Manson-Bahr,
the editor of the last
edition of Sir Patrick Manson's famous
Treatise
on Tropical Dis
eases."
We learn from the British Medical Journal
that " Manson was a
devoted
disciple of Izaak Walton and
at one time
used to fish in
Scotland
every
year.
In recent
years
he deserted
the rivers of his
native land for Ireland and took a place at Clonbur, County Galway,
where
he indulged his sport to his heart's
content.
After his retire
ment from practice he retained
his interest
in the London
School of
Tropical Medicine
and usually spent part of the winter in London.
For many
years he had
been crippled by gout and rheumatism, but
his mind remained
vigorous."
(w. m. k.)
THE DEMAND
FOK TRAINED
LEADERSHIP
IN SANITATION.
On reading Capt. W. H. Bell's article on the Sanitary
Inspector
of
the
Community,
which
appeared
in
the July
number
of
the
Bulletin, we recall to mind the new types of technically expert in
dividuals
demanded
by the expanding conception
of health.
It has
been estimated
that in the next
10 years
the number of persons
en
gaged
in public-health
work
in civil
communities
in this country
must be doubled.
The same ratio of
increase will undoubtedly
be
noted
in regard to naval sanitarians.
In discussing the demand
for
trained leadership in public-health
work
George
E. Vincent,
presi
dent of the
Rockefeller
Foundation,
said
: " Only in the last
few
years
have
opportunities
for
special
public-health
training
been
available in the United
States.
With exceptions
almost negligible in
number, American health officers have had no other formal training
than that of doctors
of curative medicine.
They
have gained what
No. 2.
273
EDITORIAL.
special competence
they may
possess in the hard, wasteful, and one
sided
'school of experience.'
That
a few have
attained the
level
of ' sanitary statesmen ' is an evidence of exceptional
ability and char
acter,
not
a vindication
of rule-of-thumb,
trial-and-error
methods.
The
future
of preventive
medicine
depends
upon
drawing
first-
class men and women
into the profession and giving
them
efficient,
modern,
specialized
training
and supervised practical
experience."
(w. M. K.)
ON
THE
USE
OF
THE
SCHICK
TEST,
ANTITOXIN,
AND
TOXIN-ANTITOXIN
IN
THE
PREVENTION
OF DIPHTHERIA
IN THE
NAVY.
The Schick
test and the active
immunization
of individuals
sus
ceptible to diphtheria
are procedures
rapidly
coming into more fre
quent
use.
Important
work in this direction
has been carried
out
on a large scale among
school children and those in orphanages
and
similar institutions.
Particularly notable
was the work of Park and
Zingher,
who
administered
immunizing
doses of toxin-antitoxin
mixtures
to more
than
52,000
nonimmune school
children
in New
York
City.
The conclusion reached
as the result of this work
is
that all children
between
the
ages of
6 months
and
5 years should
receive immunizing
doses of toxin-antitoxin,
and that all children of
school
age found by the Schick test to be susceptible
should be im
munized by the same
method.
The conclusions
in regard to the im
munization
of adults are less definite.
In view of the fact that so
large a proportion
of adults have severe reactions
following the im
munization
treatment.
Doctor Park
does not
even urge
nurses
to
submit to it.
This work brings us face to face with the problem of
diphtheria
prevention in the Navy.
To what extent, if at all, are
we to make
use of the Schick test, antitoxin,
and toxin-antitoxin
in
the prevention
of the occurrence
and spread of diphtheria
?
The Schick test and its purpose
are well known.
Descriptions of
the usual method of immunization by toxin-antitoxin
have appeared
in previous
publications
of the Bureau
of Medicine
and
Surgery,
and it is unnecessary
to give more than an outline of it here.
Briefly,
it consists of three
subcutaneous
injections,
at seven-day
intervals,
of a
1 c. c. mixture of diphtheria toxin and antitoxin.
If it should
be thought
desirable
to immunize the personnel
of the Navy it would
lie advisable to do a preliminary
Schick
test on all individuals
and
immunize only
those who are, by this procedure,
found
to
be sus
ceptible to diphtheria.
It would also be necessary to apply the Schick
test three to six months
after the course of injections to determin"
whether the individual
had been rendered
immune.
Active immunity
develops slowly, often requiring 8 to 12 weeks.
In his follow-up work
in New York City. Park found that three injections of toxin-antitoxin
274
Vol. XVII.
EDITORIAL.
mixture had produced an immunity in about 90 per cent of those who
had
been previously
nonimmune.
During the 11-year period ending December
31,
1920, the average
aninual admission
rate per thousand for diphtheria
in the Navy was
2.22.
The death rate for the same disease was 5.77 per 100,000,
and
the
case
fatality
rate 2.6 per cent.
The
death
rate for the United
States in 1917 was 16.5 per 100,000.
In Massachusetts
in 1919 it was
15.4 per 100,000.
These are representative
figures.
There are a number of reasons for the lower death rate from diph
theria in the Navy as compared with the population at large.
In the
first place, the naval personnel
is an adult population, and, as so con
clusively shown by Park and others, most adults are immune
to diph
theria.
The figures for New York
and other city populations show
about
12 per cent of adults susceptible
as against 50 per cent of chil
dren under 5.
In rural communities the percentage of nonimmunes is
somewhat
greater, but in a mixed adult population the average figure
would probably
be not far from 20 per cent.
Park believes that the
repeated exposure of one living in the congested districts to the diph
theria bacillus, resulting in slight, unrecognized, mild infections of
the mucous membranes,
leads to sufficient
development
of antitoxin
to
produce
an immunity —the
so-called
natural
or contact
immunity.
Living conditions in the Navy approximate fairly closely,
as regards
crowding,
the
densely
populated
quarters of our
cities,
and it
is
probable that after
a few months of Navy life the number of non
immunes should approach the city figure of 12 per cent.
Another
reason
for the
lower
death
rate for diphtheria
in
the
Navy is the fact that the personnel
is under constant
medical super
vision.
Wherever
numbers
of men are grouped together
a medical
officer
is readily
available.
Moreover,
line
officers
cooperate
with
the medical officers
during
epidemics
in seeing to it that
the
men
report to the sick bay when
the first symptoms
develop.
Control
of
the epidemic is thus facilitated,
and
in the
case
of diphtheria
the
early administration of antitoxin is made almost universal.
As a result of the high degree of immunity of the naval personnel
and the prompt steps taken to prevent diphtheria spread
when
a case
develops
diphtheria
should not
be
a menace in the Navy.
Rarely
do more than a few cases develop on board ship in any so-called epi
demic.
In view of these facts the need of general immunization meas
ures in the Navy is not as great as is the case among
the population
at large, and any method
which introduces any seriously objection
able features
would scarcely
be justified.
That there
are objections
to the general
administration
of toxin-
antitoxin in the Navy
is indicated in the reports of medical
officers
who have
used it extensively
among
the naval
personnel.
At the
Naval Training Station, Great Lakes, 111., toxin-antitoxin
immuniza
No. 2.
275
EDITORIAL.
tion against diphtheria
was Carried
out on a large scale.
The work
ers there found, as Park has found in New York, that the percentage
of very sore arms
and the constitutional
reactions
necessitating
bed
treatment is very great in adults as compared
with the lack of reac
tion in infants.
A large proportion
of those inoculated had
to
be
admitted
to the sick list for at least
one day.
Many
others
were
inconvenienced to a greater or lesser degree.
Aside from the damage
to the Navy in " sick days," there is the added objection that any pro
cedure which
causes such
inconvenience
is bound to
be unpopular
and
lessen
the
confidence
of the naval
personnel
in immunization
measures
in general.
This, of course, would
be a great misfortune.
There
is another very important
reason why most naval medical
officers who have
to do with
the use of toxin-antitoxin
on
a large
scale are not as enthusiastic over it as they were at the outset of their
work.
They have reached
the conclusion that immunity,
at least
as
revealed
by Schick test interpretations in the Navy, is not constant.
Large numbers
of men who had given negative
Schick tests on one
occasion
were
tested
several
months
later
and
a considerable
per
centage of them
found
to
be Schick
positive,
i.
e., susceptible
to
diphtheria.
This could not
be explained entirely
by
the personal
factor on the part of those reading the tests, because the same medi
cal officer made all the readings on both
occasions,
and any error,
therefore, would tend to be constant.
This observation was made at
Great Lakes by Hughens
and
at Annapolis
by Houghton.
At An
napolis, in
the
fall of
1918,
all
susceptible
individuals
were
im
munized by the injection of a toxin-antitoxin
mixture furnished
by
the New York Department of Health.
In the following spring
an
epidemic of diphtheria
developed
in this same group.
The entire
personnel
was Schicked again, and of the
1,147
who had received
toxin-antitoxin
22 per
cent gave positive tests.
One very striking
example
of
the
temporary
quality
of
even
active
immunity
was
demonstrated by one individual
who had
a definite
attack of diph
theria in the spring of
1918,
gave
a positive Schick
and
received
toxin-antitoxin in November,
1918,
and
developed
diphtheria
again
in March,
1919.
These
facts brought out by medical
officers in the
Navy
are of particular
interest
to the service,
and
although
there
may
be certain
instances
where
immunization
by
means
of toxin-
antitoxin
among
certain given
groups is advisable
its general
use is
probably not justified.
In the control of a diphtheria
epidemic,
which actually exists,
we
have,
of
course,
an
entirely
different
problem.
Toxin-antitoxin
would be of no avail here because of the length of time necessary for
the
establishing
of
active
immunity.
Along with
the
usual
pre
ventive
measures, many
have advocated
performing
the Schick
test
on all contacts and the administration
of prophylactic
closes of anti
276
Vol. XVII.
EDITORIAL.
toxin to those who are found to be susceptible.
The question
of the
phophylactic
use of antitoxin in the Navy
can not be
answered
by
a sweeping
statement, and it must be settled by the individual
medical
officer as the occasion arises.
But, in order to avoid the false sense of
security which
such
a
method
so often carries with
it,
its short
comings
should
be realized.
The immunity
produced would
be of
very brief duration, quite possibly not outlasting the epidemic.
The
possibility
of
serum
sickness
must
also
be
considered.
Although
serum sickness
is
seldom
serious, its effect on the morale of the crew
and their possible
loss of confidence
in such
a
sovereign
remedy
as
diphtheria antitoxin,
is
not to be overlooked.
In case
it
is
not considered
advisable
to use antitoxin in epidemics,
there
is
still the question
as to whether those among the contacts who
are
immune,
should
be
identified
by the
Schick
test.
It
is
con
tended
that,
if
the
medical
officer knows which
men
are immune,
these
immune
individuals
can
be
disregarded in
the
attempt
at
early identification
of clinical
cases of diphtheria.
Under
certain
conditions, and where the medical
officer feels confident of his ability
to interpret
the Schick
test, this procedure
may
be advantageous.
Before the crew
can be tested and
readings
made, however,
two or
three
days or perhaps more
have
elapsed.
After all, the strict ob
servance of the usual preventive measures
is
the procedure
of prime
importance in the Navy.
The application of the Schick test can only
be an accessory.
These
observations
are made with
the idea of presenting some of
the new problems
in the prevention of diphtheria
with which naval
medical
officers
have
to
deal.
The
questions
involved
can not be
decided
now.
Much work and careful compilation of data
is
neces
sary and
it
would
be
regrettable
if the investigations
along these
lines should not be continued.
In the meantime,
we should realize
the
limitations
of these
procedures
as
applied
to
the
Navy,
and
recognize
that
with
us
they
are
still
in
the
experimental
stage.
(l. j. r.)
ON
QUININE
AND MALARIA
:
EFFECTS
AND
MODES OF ADMINISTRATION.
Quinine
is
still the drug par excellence in the treatment
of malaria,
although occasional
reports
of wonderful
cures by other methods are
sometimes
seen,
notably
by
the intravenous injection of arsphena-
mine.
As in the
case of many
other
so-called
specifics,
the limita
tions of quinine are being
more and more appreciated.
Lane in his
critical
review
of
recent
malaria
literature
in Tropical
Diseases
Bulletin
for February,
1922, brings out some very
interesting find
ings.
It lias been long known that relapses in the malignant tertian
type are less apt to occur than in the benign forms.
Acton and his
No. 2.
277
EDITORIAL.
coworkers
in
Dagshai
have
also
demonstrated
this
fact, showing
that quinine
cured
the malignant
cases
but that
the
benign
ones
were
wont
to
relapse.
Wayne
and
Wenyon
have
independently
shown that this selective action of quinine, so to speak, applies only
to the asexual
phase of the
parasite.
With
regard
to the
game-
tocytes
the
opposite
seems
to hold
true.
The quinine
apparently
has a specific action
on the gametocyte
of the benign tertian whereby
its
subsequent
development
in
the
mosquito
is
prevented,
whereas
the gametocytes of the malignant
type do not suffer during quinine
administration but
retain their
faculty
of developing in
the
mos
quito.
Hence even if benign infection is difficult to cure with quinine,
the
danger
of spreading
the
disease
is practically
nil
while
the
patient
is under treatment.
The patient suffering from the malig
nant type, however,
is always a danger in this regard until complete
cure has been established
(i.
e., as long as the gametocytes
persist).
With regard to the modes of administration
the modern
tendency
is
to give the drug by mouth
to the exclusion of the intramuscular
and intravenous routes.
The latter method
is
indicated only when
marked gastric disturbance
is
present or when other conditions
(es
pecially
pernicious typos of the disease)
render oral administration
impossible
or
impracticable.
The
intravenous
injection
is
con
demned
as
a
routine
measure
on
account
of the inherent
dangers
of such a procedure.
In order to minimize
as far as possible
the dangers
from the in
travenous
introduction
of the drug,
it
is
well to bear in mind that
the
procedure
should be carried on with
aseptic
technic; the drug
should be given
in marked dilution
and very slowly.
The size of the
dose should
never
exceed
15 grains and
it
is
better
to start with
a
smaller
dose
(5
to 10 grains).
The dilutions
should
be
\
grain of
the drug to
1
c.
c. of solution and the injection
should be given
at
the rate of
1
c.
c. per minute.
The injection should be discontinued at once
if
there
is
any
sign
of the solution not entering the vein properly.
In
case of circula
tory collapse,
adrenalin will be found of great
value.
After
the
indications
for intravenous
injections
have
subsided,
oral administration should be started.
The intramuscular
route
has
no
advantages
over
the
oral
one.
McLay in Macedonia (J. Roy. Army Med. Corps. February,
1922)
obtained evidence that the malarial parasite disappeared
more rapidly
from the blood by oral than
by muscular administration of quinine.
The intense reaction,
sometimes amounting to abscess
formation, and
the marked
discomfort which
it
produces
in the patient are too im
portant
disadvantages
to make this method
of administration
even
tolerable.
278
/ol. XVII.
EDITORIAL.
With regard to the oral administration of quinine, the method,
em
bodied in the Standard Treatment of this country so ably advocated
by Bass, probably is as good
as any.
According
to this method
30
grains of quinine
are given daily
during
the period of symptoms
and then
10 grains a clay for a period of at least
8 weeks.
This method of administration
is based on the fact that a marked
difference
exists
between
the clinical
cure of the
disease
and
the
thorough disinfestation
of the patient.
Experience
has shown that
the latter is a fractional
process
and that even
the daily
adminis
tration of 10 grains of quinine for
8 weeks is not always effective.
A certain number of patients subjected
to this method
of treatment
will continue to have
relapses.
But with
each course of treatment
the number of relapses grows smaller and smaller.
The point to bear
in mind, however,
is that no person with malarial
parasites
should
have less than 8 weeks of standard treatment,
(e. p.)
ON
OBAL HYGIENE
AS
APPLIED
TO HOSPITAL PRACTTCK.
In conjunction with the Forsyth
Dental Infirmary at Boston, the
Massachusetts
Homeopathic Hospital
has taken
up the work of oral
hygiene
and prophylactic
treatment
of the
mouth
in all
cases
ad
mitted.
The work
as it is at
present
conducted
consists
in
having
the
house officers list cases
they wish treated,
these cases
then being ex
amined
and
treated
by dental hygienists from
the Forsyth
Dental
Infirmary.
These hygienists clean the teeth, give toothbrush drills,
and
massage
gums,
and
then report
the condition
of the patient's
mouth,
suggesting any
necessary
further
treatment.
The results aimed
at are several
: During pregnancy the teeth are
often neglected
and allowed to decay.
This, of course,
can
be pre
vented by dental care.
This factor of the care of the teeth during
pregnancy is a very important
one from the educational standpoint.
If women
in the obstetrical wards can
be shown that it is desirable
to care for the teeth during pregnancy, the loss of teeth will be pre
vented
and
many
diseased conditions which result from poor teeth
and mouths infected with pyorrhea will be prevented.
Another result is the instruction of children in the care of the teeth,
in order that they may be started
in the proper way.
Faulty dental
conditions are often at the bottom
of digestive
disturbances
in chil
dren.
Another result is the prevention of bronchitis
and pneumonia
which sometimes occurs from the inhalation of septic material about
faulty
teeth during
the course of ether
administration.
As
a pre
ventive
measure it is highly desirable
to have
the mouth and
teeth
So. 2.
279
EDITORIAL.
in the
best possible
condition prior to anesthesia.
This is particu
larly
so in nose and throat work, in which it is most important that
the oral cavity
be as clean
as possible
before operative measures
are
undertaken.
Focal infection of the mouth plays an important part in orthopedic
conditions.
Many
cases of infectious arthritis clear up under dental
prophylaxis and
treatment.
In medical
cast's
also
the care of the
mouth
and
prophylactic
dental
treatments
are
valuable.
A
clean
mouth may have a tendency
to prevent
communicable
diseases of the
respiratory
tract.
Many of the vaguely indefinite
digestive
symp
toms in adults may be alleviated by oral hygiene,
because if the teeth
are put in good
conditions,
they
are
more
capable
of functioning
properly, thus rendering food in better form for digestion.
Viewed from the standpoint of education,
oral prophylaxis
is ex
tremely
valuable
because by means of such treatment
the attention of
the patient is called to the fact that teeth do need care, and if he is
shown how to care for them himself after he leaves the hospital
he
is likely to carry on the work started
there,
(w. m. k.)
ON
ISCHIOKKCTAL
AIISCESS.
A recent careful review of 90 cases
shows but a scant
25 per cent
of complete
cures, with
a large number of unsatisfactory
results.
In
order
to incite bacterial
suppuration
within
the
ischiorectal
fossa
the organisms must be provided with
a means of entry.
This
does not exist under normal conditions.
Any mechanical
factor that
produces
a tear or puncture of the mucuous
membrane
of the anal
canal
opens
the pathway of infection.
This
break
in
the
mucous
membrane makes
a short path for the organisms to the ischiorectal
fat.
This fat is of a very
loose nature,
subject
to frequent trauma
and low in resistance
to bacterial infection.
The relation of tuberculosis to ischiorectal
abscess
and fistula in
ano has long been
a debated question.
G.
S. Dudley writing in the
American Journal
of Surgery
on ischiorectal
abscess
quotes
many
statistics
to show that this association
is rare and that not more than
2 per cent of anal abscesses
and fistulas are due to that cause.
The operation must
be approached
on the scale of a major proce
dure.
In preparation, castor oil catharsis
is indispensable,
since it not
only
empties
the intestinal
tract thoroughly
but also
there
follows
a period of two or three
days during which defecation
is not likely
to occur.
General anesthesia
is the rule, since thorough manual
dila
tation of the sphincter is essential.
This should
be done gradually
and
gently.
The
anal
mucous
membrane
is
then
inspected
and
palpated
to locate the point of entrance of the infection. If no such
280
Vol. XVII.
EDITORIAL.
point can be found, the abscess
is opened by an ample radial incision
and
a further
search made for the point of entrance.
The opening
of the
abscess
is completed
by
a clean
transverse
incision through
the external sphincter continuous with
the radial
skin incision.
A
single transverse
division of this muscle
is seldom
followed by per
manent
loss of power.
The wound is packed
lightly with petrola
tum gauze and a dry dressing applied.
The first dressing is done after the first bowel
movement,
usually
on the third day of convalesence,
the gauze is removed
and the wound
irrigated,
then repacked,
(uw. j.)
ON THE TREATMENT
OF HIGH
BLOOD
PRESSURE.
The control of hypertension
has been attempted
in many
ways.
None of them
have
been completely successful; some of them rest
upon hearsay
and
tradition
rather than upon clinical
observation.
For many years protein foods were considered
to
be at the root of
the "blood-pressure
evil."
The dietary
prescription
of meat once
a day or less and as few eggs as possible
has been advocated until the
meatless diet has become a popular slogan.
There is no doubt about
the
fact that many of our citizens through
an overindulgence in
starchy foods are becoming
obese
and favoring
the development
of
" high blood pressure " and " hardening of the arteries " by the very
diet that is supposed
to preA-ent
these maladies.
The feeding of pro
tein, as meats or otherwise, will not tend to increase
the blood pres
sure of a hypertensive individual.
The former idea that the retention
of the end products of protein
digestion act
as irritants
that stimulate the heart and
the arteries
to increased
activity
and
raise
the blood pressure
can not be con
sidered
to
be
correct.
Many of these
cases
do have
a high blood
pressure, but its cause must be sought in another direction.
Dietetic
therapy
in these instances
demands
a lowered protein
intake, but
while ordering it we must
be clear in our minds that we are doing
it to relieve
the kidney of its burden and not to diminish
the hyper
tension.
Enough
protein
food should
be allowed to maintain the
body in an efficient condition, and nothing is to be gained by the rou
tine restriction of meat, fish, or eggs.
The starches
have always been considered
the most
innocuous
of
foods; their final digestive
products are carbon
dioxide and water,
which put no strain on any of the eliminative
functions.
The one
drawback
to
an excessive
carbohydrate diet is that it is prone to
engender
obesity in the individual.
Many persons
may become obese
and exhibit
no
increase
in their arterial
tension
; others
are not so
fortunate. If the combination of obesity
and increased
blood pres
No. 2.
281
EDITORIAL.
sure
does exist,
a restriction of the starchy foods may bring relief.
In individuals who are overweight, a control of the starchy food may
be of distinct importance in regulating the blood pressure.
What has been said in regard to the relation of starches to obesity
and hypertension
may
be
repeated
for the
fatty
foods.
The 'fats
in themselves
appear to have no other specific
effect upon the level
of the blood pressure.
The effect of fluid intake upon blood pressure
is practically
nega
tive when only such quantities of liquids
are ingested
as supply the
normal
needs of the body.
When huge
amounts of fluids are taken
the arterial tension may be increased, but the normal allowance
shows
no changes, and it is not worth while to trouble patients in restricting
the fluids with any idea of controlling
the blood
pressure.
The only procedure
that has been at all satisfactory in yielding
a
drop in blood pressure
that may
be regarded as a definite
effect of
therapeutic
interference
has
been
nervous
relaxation
obtained
by
longer or shorter periods of rest.
It can not be said without reserva
tion that rest and
removal
of nervous
strain will lower pressure
in
every instance, but it is vital to regulate the business and family cares
of hypertensive
patients to eliminate nervous strain, and this requires
an unusual
amount of tact, cooperation,
and forbearance on the part
of all concerned.
Drugs
have failed
to furnish
us with the means of permanently
reducing
hypertension.
This
is
the
consensus
of
opinion
at
the
present time of the best minds,
and drugs are not being extensively
used for this purpose to-day.
H. O. Morsenthal, writing in the Medical Clinics of North America
for January, 1922, on the treatment
of high blood pressure,
remarks
that it is worth remembering
that essential hypertension is a disease
that occurs commonly
and
is,
in its early stages, not associated
with
kidney
involvement;
that
as the
increased
blood
pressure
persists
certain
secondary
changes
occur.
These,
in
their
order of vital
importance
to the patient, are
:
Cardiac
hypertrophy,
dilation
and
failure,
apoplexy, and nephritis
and uremia.
One of the most im
portant elements in the treatment
of hypertension
is
the prevention
of these
sequelae.
Aside from symptomatic therapy, there
is
in the
majority of instances
no specific
effect to be expected from any form
of treatment.
Belief
from
nervous
strain
and
rest for shorter or
longer periods offers the best means of reducing the blood pressure
and
lessens
the strain upon the heart
and
arteries,
for
a
time
at
least.
Diet
as
a
whole or its various
constituents,
proteins, fats,
carbohydrates, fluids, or salt have no direct effect upon the degree of
arterial
tension:
indirectly
the
regulation
of
the
various
dietary
factors
so
as to reduce
weight, diminish
the
number
of red blood
cells, or bring about undernourishment may lower the blood pressure.
282
Vol. XVII.
EDITORIAL.
A careful
general
survey of the patient will
indicate what other
measures
should
be
taken
in
regard
to
the
teeth,
gastrointestinal
canal, genito-urinary
tract, etc., which in some instances
may be pro
ductive
of
far-reaching
results.
The
above
represents
the
facts
concerning
the
treatment
of
essential
hypertension
as
we
possess
them
to-day;
there
is much in the routine therapy of this disease
that is traditional
and that demands
investigation
before it can
be
successfully or conscientiously applied,
(j. j. o'm.)
ON NEUROPSYCHIATRY DISABILITIES.
For purposes
of description,
neuropsychiatric
cases
may
be di
vided into four groups which differ from one another
in the require
ments of treatment.
These
are :
1. Injury or disease of nerve tissue.
2. The psychoneuroses
(or neuroses).
3. The psychoses
(or insanities).
4. Certain constitutional
nervous
deficiencies.
Group
1 is comparatively small in size and relatively simple in its
requirements.
It includes such cases
as gunshot and other accidental
injuries to nerves and the damage produced by diseases of the nerv
ous s}Tstem, such
as meningitis, " strokes " of paralysis,
etc.
Uncom
plicated disabilities of this kind can be adequately
treated in 'general
hospitals or relief stations.
Group
2, the psychoneuroses,
is by far the largest, but for hospi
talization it should
be extremely small.
It includes the
great ma
jority of those conditions which
were
loosely
and
erroneously de
scribed
as
" shell
shock "
during
the
war—the
" nervous
break
downs," hysteria, neurasthenia,
anxiety neurosis,
psychasthenia.
and
the
so-called
functional
diseases of the heart, stomach,
and other
organs.
In
essence,
the neurosis
is a " way out " of some intolerable con
flict or difficulty.
The feelings of stress, apprehension, and worry
that belong to the conflict are interpreted by the patient as evidences
of disease or injury, the origin of which
is referred
back
to some
accident
or illness—gassing,
influenza, overwork,
etc., of the more
or less recent
past.
The suffering is genuine
and none the less real
because the symptoms
are ascribed
to disease or injury.
The treat
ment of such
cases
must
consist
of discovering the conflict or diffi
culty, convincing the patient of the real facts, and then helping him
to find
some
more satisfactory
method
of dealing with it which
is
within
his capacity.
To place such a patient in a hospital is to con
firm his belief in the existence of serious
disease or damage.
Fur
thermore,
it very effectually brings
a cessation of the responsibilities
No. 2.
283
EDITORIAL.
and needs for
adjustment that brought
about
the disorder.
It is
often
extremely difficult
to discharge such
patients; it
is
a much
simpler problem to keep them out of a hospital.
Douglas
and
Singer,
writing
in
Mental
Hygiene
for January.
1922,
on
the
care of neurpsychiatric
disabilities
among
ex-service
men, are very strongly of the opinion that special
hospitals for the
treatment
of psychoneuroses
will eventually
be found
unnecessary,
provided adequately
staffed out-patient clinics are established.
Group
3, the
psychoses,
in
the
great
majority,
must
be
treated,
often for long periods,
in a hospital.
The fourth
group of constitutional
nervous
deficiencies
comprise
(a)
the
feeble-minded,
(b)
the psychopathic personality
(constitu
tional inferiority),
and
(<?)
the epileptic.
The feeble-minded
man who was accepted in the service is in prac
tically all cases among the higher grades of defective.
He is capable
of placement
in
some
activity,
though the effort to carry
this out
may have to be repeated
many
times
before
a finally
successful
ad
justment
is secured.
In attempting this placement
and
vocational
training, it is essential that the capabilities of the man be very care
fully studied.
An
unwise
selection
may result not only in the dis
couragement
of the patient, but
also in greater
disability
than was
present
at first.
Selection of vocation
and environment should
be
made by an expert, with all the advice
he can get from the physician
who has really studied the patient.
The
psychopathic
personality. — The
psychopathic
personalities
present some of the most difficult problems
of all.
Such persons may
show comparatively low intelligence, but they
may
also grade
even
above
the average
upon
test.
The
essence
of the defect
lies in the
personality.
Often
such
persons
are
plausible
and
superficially
shrewd,
but they
seem
to
be
incapable
of steady
application
and
soon tire of any
task.
No State
has yet succeeded in dealing with
this group satisfactorily.
The epileptic.—The epileptic in very many
instances
can get along
in
the community, especially where
compensation
and
supervision
through
an out-patient clinic
arc
possible.
In a certain proportion
of cases,
when
the fits
are frequent
or the
patient
has difficulty in
adjustment
due
to
personality,
segregation
from
ordinary
society
is advisable.
The character of the institution
to which
he
is sent
should be that of a model community with its own industries, amuse
ments, etc., rather than a hospital.
In the opinion
of Douglas
and
Singer
the
greatest
need of the
service at the
present
moment
is for trained
personnel.
It is
an
unfortunate
fact that neuropsychiatric
medical
officers, nurses,
and
social workers exist only in limited
numbers,
in no way commensu
rate with the demands.
To supplement
the available supply
and to
108165—22
7
284
Vol. XVII.
EDITORIAL.
prepare
for the increased
demand
that will come with
the opening
of new hospitals and out-patient clinics, the establishment
of a train
ing
center for medical
personnel
is highly
desirable.
This center
must
be accessible
to university
instruction
and
also to field facili
ties.
Any of the existing psychopathic institutes, if provided with
out-patient clinic facilities,
would
be suitable
and
doubtless
would
be willing to cooperate.
St. Elizabeths
Hospital
in Washington
is
being
used for the purpose of training naval medical
officers in this
special
line of work.
Douglas and Singer, in their article draw attention to the frequent
misconception
existing with
regard to the relation of occupational
therapy and vocational training.
Occupational therapy is not in any
sense an effort " to make some
thing."
The purpose
with
which it is employed
is quite
variable,
as the following classification will indicate.
It may
be prescribed
(a)
as
a diversion;
(b)
because it brings into play certain muscles
or joints which are functionally
damaged;
(o)
to produce
sedation
or stimulation;
(d)
as an education in habits of application.
The
product
of
occupational
therapy
is
the
effect
it
has
upon
the
patient.
The articles produced in the process are. like the copy books
of the child in the primary
school grades, of no importance.
Vocational training,
on the other hand, is a training of the patient
to carry out some technical operation and thus to give him a means of
earning
a livelihood.
The product
is,
therefore, the patient placed
in industry.
Articles
produced in this process must
have
a
market
value, and there
is
absolutely no place for the merely beautiful but
fancy products, the value of which
is
personal
and largely artificial,
(j. g. z.)
On Airplane Ambulances.
Strange as
it
may seem
a
stretch of seacoast extending almost from
Cape
Henry,
Va.,
to Wilmington,
N. C, having
a
population of
nearly 3.000,
is
quite
devoid
of medical
attendance.
One looking at
a
map of this region will note
a
series of sounds —Albemarle. Curri
tuck, and
Pamlico —extending along the coast
and
separated
from
the Atlantic by low-lying
sandy
islands.
In places
these stretches
of
sand
are fairly
wide
and
high,
and
have
become
sufficiently
fertile
to permit
the
growth
of
a
few
trees
and
underbrush;
in
other parts, for mile after mile, one encounters
nothing
but barren
l
eaches of sand.
The storms of winter deal severely with this stretch of coast which
mariners regard
as treacherous
as any
seacoast in the world, often
preventing communication with the mainland for days.
The inhabitants of these desolate
sand
bars
are mainly seafaring
rolk connected either with the Coast Guard, the Navy radio stations,
or the fishing industry.
Among
them
up
to the
year
1918 there
No. 2.
285
EDITORIAL.
labored
a physician who dwelt in the little village of Hatteras, but
the influenza epidemic
of that year cut short his career and no other
physician
has found these sand
reaches sufficiently enticing to take
his place.
In the towns on the mainland there
are doctors, but they are busy
men.
and
a trip across the sound
to the sand
reaches, 5, 10, perhaps
20 miles away, can be made only in a great
emergency.
So it came
about one day last winter when
the young wife of a Coast Guard man
had
been
in labor for
72 hours
and
required
the
services
of
an
obstetrician,
some
one conceived
the idea of asking the commandant
of the fifth naval district by radio to send assistance to the suffering
woman by airplane.
In an hour a Navy seaplane with
a naval sur
geon
and
an obstetrical outfit
was on its way to the lonely
Coast
Guard station near
Cape Hatteras
and
both mother and child
were
saved.
A few weeks later a Coast Guard man with pneumonia and
a man
with
acute appendicitis
were
transported comfortably
through
the
air to the hospital
at Norfolk.
Since then
many people
living in
this
isolated
region
have
received
medical
attendance
brought
by
airplane from the naval operating base at Hampton
Koads.
The average airplane is not suited
for ambulance
work because of
its construction,
and
as the Coast
Guard
and
the personnel
of the
Navy radio stations
on duty along this coast are entitled to medical
attendance, it is hoped that before long specially constructed
air am
bulances will be avilable for this service.
The air ambulance
has passed the experimental stage and
is now
in daily
use in many parts of the world.
Airplane ambulances
hnve
been
used in the Air Service of the United
States Army since early
in
1918,
and it is very
evident from
the following
news
item
ab
stracted
from the Figaro, Paris, December
5, 1921, that the French
Army is using airplane ambulances
to an increasingly greater extent
:
" It
appears
that the
ambulance
airplanes of the Levant
and
in
Morocco are growing rapidly in their emulation of each other, which
is both admirable and profitable.
Every
day
a new record
is made
by one or the other.
'"A few weeks ago in Morocco they
made
a remarkable
record
by
transporting
18 wounded
men 80 kilometers ; now we hear that in the
Levant they have just evacuated
44 wounded
a distance of 100 kilo
meters over the desert of Syria between Deir-t z-Zor. on the Euphrates
at the southern border of our mandate,
and Aleppo.
This last opera
tion is a record for transporting
wounded
by airplane.
Moreover, the
conditions under which it was done and the advantages
gained
merit
attention.
"After the victorious battles of the 24th and 26th of October, fought
in the region of Deir-ez-Zor
by Colonel Debieuvre
against
the war
286
Vol. XVII.
EDITORIAL.
like tribe of Ogueidats, who fought all the more fiercely against
our
troops because they had given a severe setback to the British in 1920,
General Gouraud, high commissioner
in Syria,
gave orders on Octo
ber 26 to Medical Inspector Emily, chief surgeon of the Army of the
Levant, and to Major Denain, commanding the Air Service,
to pre
pare
for
the
evacuation
as rapidly
as
possible
to
Aleppo
of
the
wounded
we had during
the course of these glorious combats.
This
work was
rendered
particularly
difficult
and
dangerous,
due to the
fact that the 400 kilometers which
separate
these two places
is an
inhospitable
desert,
without
landing
places,
occupied
by
hostile
Bedouin tribes, with atmospheric
conditions impossible to have a gas
station at Deir-ez-Zor, which is 20 days from Aleppo by camel convoy.
"A detachment,
composed of all the ambulance
airplanes in service
with the Army of the Levant, was immediately organized at Aleppo
under the command
of Lieutenant-Pilot
Vindreau
and of the chief
surgeon of the Air Service in the Levant, Doctor Liegeois.
On Octo
ber 25 a military surgeon, Doctor Chevalier, went to Deir by airplane
to render
the urgent surgical assistance
needed.
The same day five
airplanes brought back
10 wounded,
covering in a few hours
the 800
kilometers for the round trip from Aleppo to Deir-ez-Zor
and return,
a
very
remarkable
performance
when
the
difficulties
enumerated
above are considered.
" Evacuation continued the following
days, and soon all the trans
portable wounded —44 in all—were transported by air to the military
hospital in Aleppo, making in three hours and a half and under very
satisfactory conditions, as far as comfort was concerned,
a trip which
requires
at least a week by motor ambulance,
and by camel or cacolet
(form
of saddle
for horse
or male,
carrying
two men in
a sitting
position)
more than three weeks over heavy roads.
This would have
been very trying on the wounded men.
"Thanks
to
the
airplane, Principal
Surgeon
Chartres. division
surgeon of the second division, was able to go to Deir to superintend
the evacuation
and care of the wounded.
Doctor Liegeois, who fol
lowed
and directed
the operations from the medical
standpoint, esti
mates that, without
counting
the suffering
that was avoided,
five
wounded
men owe their lives to this method of evacuation.
"The results
are a great honor to the air service of the army of
the Levant and especially to the pilots who, not satisfied
with being
courageous
war pilots,
have
on this occasion
given proof
of their
skill,
endurane,
and
training
by
bringing
safely into
port all
the
wounded
confided
to them, in spite of the difficulties of such
a long
flight.
'• It should be noted that in all the time that this means has been
used for evacuation
in the Levant, not a single wounded
or sick man
has been the victim of an airplane accident."
(j. d. b.)
CLINICAL NOTES.
NOTES ON THE ORTHOPEDIC
SERVICE,
V.
S. NAVAL
HOSPITAL,
CHELSEA,
MASS.i
By J.
W. White,
Lieutenant,
Medical
Corps,
United
States
Navy.
With the advent of the Veterans' Bureau patient, the orthopedic
service
at this hospital increased
in activity
so that now it handles
well over twice as many patients as it did a year ago.
A great many
of the patients referred by the Veterans' Bureau
are reconstruction
problems following old war injuries
and comprise
such
cases
as
re
section
of painful
scars,
reamputation
for
painful
stumps,
and
osteotomy
to
correct deformities.
Many
of
these
patients
suffer
from
some
form of arthritis
aggravated
usually
by
some
postural
strain or some chronic condition existing previous to discharge
and
needing operative
treatment,
such
as internal
derangement
of the
knee joint, hallux
valgus,
free
bodies in joints,
and
exostoses
asso
ciated
with old fractures, etc.
Inasmuch
as physiotherapy,
in some
form, is indicated in the post-operative treatment of most of the sur
gical cases, particularly
where
the operation is on or closely
associ
ated with joints, these cases are transferred to the Parker Hill Hos
pital,
a near-by Public Health
hospital, which
is equipped
with
a
complete
physiotherapy
department,
as soon as they have sufficiently
recovered
from their operation.
They return from time to time for
observation and further directions as regards treatment.
A complete
physiotherapy
department
is to be supplied
to this hospital in the
near
future
and
the
post-operative
treatment
can
be
better
con
trolled.
The naval
patients,
to
a large
extent,
are
admitted for
recent
traumatic
conditions,
while it
is
seldom
that
a Veterans' Bureau
patient is admitted with anything of recent origin.
Men in training
are the only
ones strictly
entitled
to
treatment
for conditions not
associated
with previous service.
In spite of the fact that routine treatments
often are ill advised,
we have devised some routine measures for conditions such as chronic
back strain and foot strain, which we have found are the most diffi
cult
cases to treat satisfactorily.
For
the patients suffering
from
back pain, after satisfactory X-rny examinations of the entire
spine
■From
the Annual
Sanitary
Heport,
U.
S. Naval
Hospital,
Chelsea, Mass.
287
288
Vol. XVII.
CLINICAL
NOTES.
have
been
taken
to rule out organic disease, and physical examina
tion is otherwise negative,
hyper-extension in bed is employed until
the patient is relieved from pain and muscular spasm.
A snug fit
ting plaster jacket is then applied and kept on for varying lengths
of time.
In
the
case of Veterans' Bureau
patients, they
are dis
charged
from the hospital
wearing this jacket and
the
rest of the
treatment
is carried on at the Veterans' Bureau dispensary, where,
upon removal
of the jacket, the patient is supplied with
a back brace
to maintain the corrected
posture for a longer period.
Exercises are
started
to regain the normal mobility of the spine at this time as well.
While this treatment
is by no means satisfactory, we have by consid
erable
experience
decided
it is the most rational for this group of
cases.
Of course, where there is any indication of arthritis present,
a thorough search for surgical foci is carried out and the indicated
eradications are performed if practicable.
As a rule, teeth have been
found to be the main offenders.
These
patients all are on an anti-
arthritic
diet which
is
a balanced
diet with
as low
a carbohydrate
content
as possible,
as advised
by Pemberton of Philadelphia.
Patients with pes planus sufficiently
severe to require hospitaliza
tion usually show
acute foot strain.
A routine type of treatment
is
applied
to these cases
that do
not
require manipulation
under an
anesthetic.
If full correction can not be obtained
on admission be
cause of muscular spasm,
they
are manipulated
to a position of ex
treme varus and are held
in plaster for three or more weelcs.
This is
usually sufficient
to correct
the worst
cases.
There
have
been some
cases where
there was extreme bony deformity
produced usually by
the inward and upward deviation of the neck of the astragalus which
were
at the
time
treated
conservatively
but
which
will ultimately
come to operation such
as an astragaloscaphoid arthrodesis or some
similar
procedure.
The routine
treatment
consists
of absolute
rest
in bed, light massage and contrast baths.
This is kept up until all
evidence
of foot strain
has
disappeared.
The patient
is continued
in bed
a few days longer, during
which
time
exercises
are started
which he is to continue after being allowed on his feet, a few hours at
first and then gradually increasing the time until he is up the normal
time.
These
cases
are all carried
on our antiarthritic
diet
as
de
scribed
above.
When the patient is allowed up his feet are strapped
in
as extreme
varus
as possible
and
the contrast baths
are discon
tinued.
This
strapping
is
renewed
frequently
to
retain
the cor
rected
position.
The
exercises
followed
are
those
which
tend
to
strengthen
the muscles upon which the normal arch depends, for it is
muscles and not ligaments that maintain
correct
posture
not only in
the
feet but throughout
the
body.
Symptoms
are produced when
any constant strain is put upon ligaments whose function essentially
is to prevent abnormal extremes
of motion.
The form of support
No. 2.
289
CLINICAL
NOTES.
used most frequently
is the one devised by Whitman, of New York,
which is corrective,
almost forcing
the patient to walk properly
and
yet preventing
the ligamentous strain-causing
symptoms.
In
feet
where the deformity
is extreme,
this type of plate
can not be
em
ployed and frequently the usual
type of plate is used in the way of
palliative treatment.
In general,
the use of plates of all sorts is dis
couraged and relief from symptoms
is hoped for as a result of muscle
training, proper shoeing,
and correct
walking.
While under treat
ment
at the hospital
these
cases
are made
to walk
slightly
" ding-
toed."
In the case of naval patients with
definite
evidence of acute flat
feet, which, on examination show that there will be a predisposition
toward
recurrence,
the policy
of
recommending
them
for medical
survey is followed with few exceptions.
These men can temporarily
be relieved
of symptoms,
but with
as little cooperation in following
exercises
and
adhering
to proper
methods
of walking
as
one gets
in most flat-foot cases, they will soon be appearing at sick call again,
particularly if they
are put on some detail distasteful to them.
A
congenital
flat foot is always predisposed
to acute foot strain,
and
it is only by the patient's efforts that he can keep free from symptoms.
By
flat
foot is meant
everted
foot
and
not
the
anatomically
flat
foot
without
eversion,
which
rarely
causes
symptoms.
In
naval
patients
that do show
cooperation and
are otherwise well
adapted
for the service, an attempt is made to return them to duty.
They are
retained at the hospital until they
understand the proper exercises,
continue to be free from foot strain and if
thought advisable,
par
ticularly in the case of petty
officers, are given Whitman
plates to be
worn to prevent
the recurrence of their foot strain.
Among the more interesting
cases treated during the year
may
be
mentioned a case of hematomyelia
causing an almost
complete
trans
verse myelitis at the level of the fifth cervical segment, following a
fracture of that vertebra
and with practically
complete
recovery
in
five months
without operation;
a case of multiple
bone cysts which
ultimately
proved to be Von Recklingshausen's
disease;
and
a suc
cessful repair of a ruptured anterior crucial ligament of the knee.
An interesting series of four fractures of the femur has been ob
served,
two supracondylar
and two of the shaft.
Malunion
consist
ing of outward anterior bowing occurred in the latter group, both
due undoubtedly to premature weight bearing.
In fractures of the
shaft,
it has
been
my
experience
that unsupported weight bearing
short of six months is hazardous.
In both of these cases, an osteotomy
was performed at the point of malunion with the result that in one
case the shortening was reduced
from
an inch and
a half to three-
eighths of
an inch with
practically
perfect
function
of
the
knee,
which latter element
is always a serious
problem to face after such
290
Vol. XVII.
CLINICAL
NOTES.
long immobilization.
The other case is still in his Thomas ring splint
through which, via calipers in his shoe, his weight is supported, be
ing now on his sixth month.
His knee is receiving the usual baking,
massage, and manipulation,
and already there is about
30° of motion
in it.
This patient originally had the same shortening that was pres
ent in the first case, but as the angulation
was not so great and
as
there was more overriding
he still has five-eighths of an inch shorten
ing.
His convalescence was considerably complicated by a hemolytic-
streptococcic
septicemia,
originating
in all probability
from an old
extensive
war wound on his other thigh.
Four days following the
operation his left subdeltoid bursa was opened and several
ounces of
pus was removed,
from which a pure culture of the above-named
or
ganism
was obtained.
Several days later a large phlegmon on the
anterior aspect of his thigh containing
5 or 6 ounces of the same sort
of pus discharged through
the lower end of the operation incision
well away from the site of the operation, which has never given any
indication of becoming
septic.
For about three
weeks following the
operation his old war wound on his other thigh
gave him consider
able discomfort, and it was expected that
it,
too, would break down.
It never progressed
further than getting red objectively and subsided
spontaneously.
The patient, needless to say, was very sick, and the
fact that he lost so much weight rather jeopardized the position of the
fragments in the cast.
The return of his strength has been slow and
he did not get about
as much during his fourth month in his cast as
is
usual in such cases.
It
is
confidently expected that he will be returned
to duty.
The mechanical
treatment
of these cases
is
as follows,
and may be
said to be divided in three periods
:
The first period immediately fol
lowing operation, at which time
a
plaster spica
from well above the
costal border extending down to the toes with the leg held in as cor
rect position
as
is
thought possible,
consists of rest in bed for two
months.
X-rays are taken through the plaster to determine the posi
tion
a
few days following the operation. If accurate alignment has
not been obtained,
the deformity
continuing
to exist
is
corrected
by
cutting
a
wedge out of the plaster at the appropriate point and of the
calculated
size and then approximating
the edges of this wedge, leav
ing
a
corresponding open wedge on the other side of the cast.
More
plaster bandages
are then employed
to hold this corrected
position.
This plaster
is
allowed to remain on for two months.
It
is
then re
moved
and the leg
is
examined
to see if there
is
union.
X-rays are
taken
before another heavier plaster of the same extent
is
applied.
After this plaster has thoroughly
dried the patient
is
gradually
got
up on his feet. It
is
surprising
to see how well one can get about with
such an extensive
cast.
Activity
is
urged until this cast
is
removed
at the expiration of the fourth
month which
completes
the
second
No. 2.
291
CLINICAL
NOTES.
period.
The patient is then put into a Thomas ring caliper brace ex
tending down and
inserted
into the heel of sufficient
length to take
practically
all the weight from
the operated
leg.
Strenuous treat
ment is then instituted to mobilize the knee which has been absolutely
immobilized
during the previous four months.
Little difficulty is ex
perienced
with the ankle or hip.
This brace is discontinued at the
end of the sixth month, which completes the third period.
One of the supracondylar fractures of the femur was a fresh case
and I had him practically from the first.
There was the usual marked
posterior
rotation of the lower fragment.
Skin traction
with
ad
hesive in
a Thomas splint
was
employed
with only
increase
in the
deformity.
This is what may usually be expected because of the loca
tion of the points of origin of the gastrocnemius.
Skelatile traction
by the use of " ice tongs " applied to the femoral condyles
reduced the
malposition
without
difficulty in spite of the fact that there
was an
intercondyllar fracture
as well.
Unfortunately
the tongs
were only
allowed on for three
weeks, and after removal the inner fragment
rotated
slightly.
This case was returned to duty four months later
with a perfectly stable knee and over 90° of painless
motion.
The other supracondylar
fracture
was three
years'
duration with
the usual unreduced
lower fragment allowing
30° hyperextension at
the knee
and with If shortening when
the knee is in full
extension
and
3 inches
when
fully
hyperextended.
His
symptoms
were
due
for the most part
to knee strain,
as might
be expected.
An
oste
otomy
was performed
at the
point of malunion.
Correction
was
maintained
by the
use of bone
wedges
taken
from
the tibia.
The
convalescence
of this
case
was
complicated by an attack of renal
colic for which he underwent operation for the removal of a ureteral
calculus.
He has satisfactorily
convalesced
from the operation.
At
the present
time
he still
has an inch shortening, but there
is only
the normal amount of hyperextension at the knee.
These two
cases
demonstrate
the
importance of using
skelatile
traction
in
these supracondylar
fractures.
Very little
discomfort
was experienced
from the tongs,
and there was less discomfort than
with skin
traction.
A small
amount
of osteomyelitis
persisted
on
one side for about
four
weeks before
the sinus
healed.
At no time
was it painful and did not interfere in any way with his convales
cence.
Two cases of recurrent dislocation of the shoulder have been
oper
ated upon,
and
the revived Clairemont-Ehrlich operation
has been
adhered
to.
This consists
in passing a good-sized
muscle
flap
from
the
posterior
portion
of the
deletoid.
being careful
to preserve
its
enervation
and
blood supply,
from
behind anteriorly
through
the
quadrilateral
space and attaching it to the coracoid process of the
292
Vol. XVH.
CLINICAL
NOTES.
scapula.
This forms,
as can
be readily
understood,
a sling which
prevents
any tendency toward a downward or forward dislocation of
the shoulder.
This is the only t}rpe that has any tendency
to recur.
One
was
a chief
boatswain's
mate
and
was returned to duty four
months
ago and
so far has had
no recurrence.
The other
case was
a Veterans' Bureau patient and
was only
discharged
a month
ago
and is too early to report (no recurrence
has occurred four months
after the above observation).
He states, however,
that he can abduct
his arm with a perfect feeling of security and has little limitation in
motion.
We have
at the present
time
a case of generalized
ostitis fibrosa
under observation.
A multiojulated
cyst was removed from the right
tibia
five
months
ago
bacause
the
patient
was
experiencing local
symptoms.
He has a similar
lesion
in a corresponding point of his
other tibia which causes no symptoms.
Other lesions
are present in
the head of his left humerus
and
a large fusiform
swelling in the
mid shaft of his right
numerous
involves
the
entire
shaft.
This
proved
on exploratory
operation to be fibrous replacement
of bone
typical of this condition.
X-rays
have been taken
of all his long;
bones and there is very little of the cortex of the pipe bones that is
normal.
In appearance,
it resembles
cancellous
bone with
the tra
becular running
longitudinally.
He is being fed
on
a high calcium
diet at the present time in the hopes that this might have some effect
on his apparently
deranged
calcium
metabolism.
There
is
some
question
whether the conditions variously
known
as adult rickets,
osteomalacia,
Paget's
disease,
Von
Keckingshausen's
disease, and
ostitis fibrosa
are not all different manifestations of the same entity
with
which calcium metabolism
is in
some
way
associated.
It is
feared
that if we operate
on this patient at the present
time there
may
be some difficulty in getting
a graft
to take properly.
AVe have
had
various types of Pott's
disease of the spine, from
the very earliest to the extreme
case
with
emaciation
and double
draining
psoas
abscess.
Absolute
recumbency
usually
in
a plaster
shell or some similar retentive
apparatus and heliotherapy comprise
the essentials of the treatment.
No cases
have been operated upon,
as in our group
there
appeared
to
be insufficient
indication.
It is
our experience
and the consensus of opinion
seems
to be that oper
ative treatment
should be confined
to a very limited number of cases
where the disease has obtained
little
headway.
In one of our cases,
which incidentally
is doing very well, there
are three
distinct foci
of tubercular infection.
There has been only one other case of bone
or joint tuberculosis.
This was
an ankle in
a case that physically
was going down hill.
Amputation
was performed
at the point of
election,
with
improvement in
general
condition
immediately fol
lowing the operation.
No. 2.
293
CLINICAL
NOTES.
One of the most interesting fractures we have had was one involv
ing both bones of the forearm, in which the fracture of the radius
was located between the insertion of the pronators and suppinators.
As is usual
in fractures of both
bones of the forearm, it was put
up in mid-pronation
and supination,
as it is in this position that the
bones
are separated
the widest.
After union had taken
place, how
ever, only a few degrees of pronation
and supination
was possible.
The fracture
was cut
down
upon and
it was noted
that the union
was
immediately proximal
to
the insertion of
the pronator
radii
teres.
This explained the poor result.
The upper fragment, to which
the supinators are attached,
was rotated into full supination, while
the lower or distal fragment was rotated
in just the other way,
be
cause
both
unopposed
pronators
acted
upon
it.
An osteotomy
was
performed
six weeks after the original
break and the forearm put up
in full
supination.
The
end
result warranted
this
procedure,
as
the patient was returned
to duty and
has almost
normal motion at
the present time.
I0TES
FROM
THE
GENITO-URINARY
SERVICE,
TJ.
S. NAVAI
HOSPITAL,
CHELSEA,
MASS.i
By P.
O. Nohthi.voton,
Lieutenant,
Medical
Corps,
United
States
Navy.
The majority of the patients
treated
in the genito-urinary
depart
ment during
the past year
have suffered
from
gonococcus
infection
of the urethra and its complications.
In the treatment
of acute ure
thritis, mercurochrome
was used sufficiently diluted so as not to cause
irritation.
The strength varied from one-half of
1 per cent to 1£ per
cent.
The results obtained
from the use of mercurochrome
in the acute
cases have been consistently better than the results
obtained
in simi
lar
cases
with silver
preparations.
Posterior
urethritis
has
been
treated with diuretics, urinary
sedatives
and mild antiseptic irriga
tions until the acute symptoms
subsided
; then silver nitrate instilla
tions and
prostatic massage
were begun.
In
the chronic
case,
the
urethra
was dilated and prostatic massage given
twice
weekly,
and if
the case did not respond
to this method of treatment, a urethroscopic
examination
was made to determine,
if possible,
any
demonstrable
focus or cause for the persistence of the infection.
Epididymitis has
responded to palliative treatment,
and the Hagner operation has been
abandoned
as we believe that it does not materially
lessen the course
of the infection and it increases the possibility of producing sterility.
A large number of cases give a negative
smear in a very short time
after beginning treatment.
However,
an injection
of silver nitrate
solution will
frequently
increase
the
discharge
and
the
gonococcus
then can be found in the smears.
When there is no discharge and the
urine is clear for a week the patient is discharged to duty.
' From the Annual
Sanitary
Report,
U.
S. Naval
Hospital,
Chelsea, Mass.
294
Vol. XVII.
CLINICAL
NOTKS.
The intensive course of treatment
given
to
the syphilitic cases,
provided there
are no contraindications,
consists of six intravenous
injections of arsphenamine
and six intramuscular injections in doses
of 0.1 gram mercury salicylate.
Arsphenamine
0.3 gram is given for
the initial dose and 0.6 gram in each subsequent
treatment.
Follow
ing the sixth treatment
a blood
Wassermann is done
and
a spinal
fluid
examination
made.
Arsphenamine
is given
by
the gravity
method.
The number of reactions
both local and constitutional
have
been lessened, since we abandoned
the syringe method.
We attribute
this to the fact that in giving
the solution with
a syringe it was ad
ministered too fast and many
cases of extravisation occurred
with un
necessary hardening of the veins.
At lea t
";0 per cent of our cases
show some reaction,
the most constant
symptoms
being nausea, vomit
ing, watery diarrhea, and malaise which usually clears
up within 12
hours.
Our patients
lose weight under treatment and some as much
as 10 pounds during the period of a course.
There has been one fatal
ity following
the administration
of arsphenamine.
This patient was admitted with
secondary
syphilis
May
9, 1921,
Wassermann four
plus.
Administration
of arsphenamine
0.3 gram
on May
17, no reaction.
Urinalysis on May
22 showed
nothing ab
normal.
Arsphenamine
0.6 gram on May 24.
A few hours later the
patient complained of nausea, vomiting, and diarrhea.
The following
day he was markedly shocked
and purpuric
but reacted favorably to
stimulants.
Two days later jaundice and bleeding from mucous mem
branes of nasal cavities and gastrointestinal tract developed.
Urin-
i.lysis revealed marked destruction of the kidneys.
Patient died June
8,'l921.
It is believed
that, though probably
arsphenamine
is more active
therapeutically
than
neoarsphenamine,
its contraindications
are not
always found out on examination and it is administered with a greater
risk to the patient.
Spinal fluid examinations have been made routinely in the follow
ing instances
:
(a) In all cases at the end of an intensive course of arsphenamine
and mercury therapy, irrespective of the blood Wassermann reaction.
(b) In cases of early syphilis showing symptoms
of central nerv
ous system
involvement.
(c) In all cases showing mental or nervous
symptoms,
irrespective
of the blood Wassermann reaction.
Many
cases showing early involvement of the central nervous
sys
tem,
clinically,
and
with
characteristic
spinal
fluid
changes,
will
respond
to intravenous therapy, hence intraspinous
treatment
is not
given unless there are persistent
symptoms
or signs after a course of
intravenous therapy.
No. 2.
295
CLINICAL
NOTES.
Neurosyphilis
requires
more
intensive
treatment
than
syphilis
■which
does not affect the nervous
system.
The following
method
advocated
by Fordyce has been
used in all
intraspinous
treatments.
The
blood
having
been
removed
from
a vein
is centrifugalized,
serum pipetted
off, and centrifugalized
again to insure complete
re
moval of any red cells.
To 10 c. c. of this serum fa to
1£ milligram
of arsphenamine, according to indications,
is added.
This mixture
is incubated at 37° F. for 40 minutes
and inactivated to 56° F. for
one-half hour, and
is then
administered.
The
advantages
of this
method
over
the
use
of autosalvarsanized serum
according to the
Swift-Ellis
method
are the administration
of a definite
quantity of
arsphenamine,
the addition of a definite
amount
of the drug in
a
small quantity of serum,
and the convenience
of preparing
several
doses with
the serum
from
one patient.
There have been no reac
tions following this method
of treatment
save an occasional
head
ache which was attributed to the puncture.
This can usually be pre
vented by keeping the patient in a recumbent position for 24 hours.
MEB.CUR0CHH0ME-220
AS A GEBMICIDE
IN OPHTHALMIA
NEONATORUM.
By C. C. Gboff,
Lieutenant,
Medical
Corps,
United
States
Navy.
The
following
cases of ophthalmia
neonatorum
are reported be
cause
at
the time of treatment,
1920,
mercurochrome-220
had
not
been used in the service,
so far as I am aware, in this condition.
This
remedy
seemed
to shorten
the duration of this disease,
but
has
the disadvantage
of staining
the lids
and
face deeply,
yet not
permanently.
The
fact that it seemed
to shorten
the duration
of
the
disease may commend its use to eye men in the service.
Case
1.—B. W.,
white, male,
age
11
days,
was
seen February
2,
1920,
two
days
after
the
discharge
first
appeared.
Examination
revealed
acute purulent
ophthalmia
neonatorum
with
edena of the
lids
and
much
pus
in
the
right
eye.
The
cornea
was
clear.
A
smear
showed
pus cells with gram
negative
intracellular
diplococci.
The child was delivered
by
a country
physician
who
neglected
to
instill silver nitrate into the
eyes.
After
cleansing
with boric acid
solution, a 2 per cent solution of mercurochrome
was ordered
every
two hours.
A small quantity of boric
acid
ointment was
smeared
around the margin of the lids after the instillation
of the mercuro-
chrome.
This seemed to make for a longer retention
of the solution
in the eye.
To be absolutely
sure of preventing infection
1 drop of
2 per cent mercurochrome
was used in the normal
eye
three
times
a day and a shield applied.
February
5 : The right conjunctival
sac
was
almost
entirely
free
from pus.
The edema was much
less
and the gonococci
were
much
fewer in number.
'296
Vol. XVII.
CLINICAL
NOTES.
Treatment was ordered to be continued for a week longer.
February
12 : There
was
a slight
serous
discharge
but no
cocci
were found.
Boric acid instillations
were
ordered.
February
27: Eye apparently normal.
Case £.— Gr. E. F., colored,
female,
age 13 days, was seen January
14, 1920, four days after discharge first appeared.
The mother
stated
l"the
accoucher
dropped something in
the
babies
eyes but its
eyes
were red and inflammed
looking
about one week after it was born."
Examination
revealed acute purulent ophthalmia neonatorum
of right
eye with left
eye. weeping
copiously.
The lids of the right eye
and
conjunctival
sac
were markedly swollen, sclera
injected
and
cornea
beginning
to look dull.
A smear
showed
numerous
pus cells
with
gram negative
intracellular
diplococci.
The eyes were cleansed with
boric acid, saturated
solution, and
a 2 per cent mercurochrome
solu
tion was ordered
every half hour for six applications.
This seemed to
be slightly irritant, and
a saturated
solution of boric acid was then
alternated
every half hour with the mercurochrome
solution during
the night.
January
15 : Twenty-four
hours later the cornea
was beginning
to
lose its dull
appearance
and the march
of infection
seemed
to have-
been
halted.
Instillations were now
ordered
every
two
hours.
The
left
eye
was
receiving instillations
of
mercurochrome
every
three
hours
from the first examination.
January 19: The
free pus in the conjunctival
sac of the right
eye
had
almost
disappeared
and
the left
eye
was
apparently
normal.
Boric
acid ointment was now applied to the edges of the eyelids of
the right eye. after instillation
of mercurochrome
to insure retention
of solution.
The left was still
receiving instillations
of mercuro
chrome three times
a day to prevent reinfection.
January 24: The edema was now
much
less
and
a smear showed
the gonococci
to be much fewer in number.
January
31 : There were no gonococci
present
but
a slight serous
discharge
was
present.
Instillations of
mercurochrome
were
con
tinued and
saturated
boric acid, camphor water and
zinc sulphate
were instilled every three hours alternating with the mercurochrome.
February
12: Eye apparently normal.
Because of frequent
instil
lations of mercurochrome
a condition similar
to argyria
was looked
for. but no permanent
staining resulted.
AN UNUSUAL CASE
OF FOREIGN
BODY IN PHARYNX.
By
S. B. Fordes, Lieutenant,
Medical
Corps,
V/nittd
States
Navy.
The following unusual
case of foreign
body
in
the
pharynx
is
reported,
as it serves to exemplify
the difficulties sometimes encoun-
FOREIGN
BODY
REMOVED
FROM
THE
LARYNX.
No. 2.
297
CLINICAL
NOTES.
tered in arriving at the etiological factor in patients
admitted to
a
hospital in a comatose condition.
The patient
was a white male, age 35 years, unconscious
on admis
sion ; no history was obtainable.
Physical
examination.—Temperature
was
subnormal,
pulse
was
126
and of fair
volume.
Respirations
were
12
and
very
labored,
with great inspiratory
and expiratory
dyspnea.
There
was an ex
treme
degree of cyanosis.
His skin was cold
and covered with
per
spiration.
The
odor of
alcohol
could
be
detected
on
the
breath.
The pupils
were equal in size but dilated, and did not react to light.
The
patient's
condition
was
rapidly
becoming
worse
and
he
was
practically in
a moribund state.
Examination
of the upper respiratory
passages revealed
a foreign
body in the oropharynx
extending from
the level of the tip of the
uvula
clown to the epiglottis.
The lower portion
rested directly
on
the anterior surface of the epiglottis, forcing it down over the upper
laryngeal
orifice.
Kemoval
of the
foreign
body
was
effected
with
some difficulty
owing to its tremendous
size.
It was found to be
a piece of roasted
meat weighing
37 grams.
The dimensions were
as follows:
Length
10.2 cm., width
3.2 cm., and
thickness
3.8 cm.
The illustration
will
give some idea of the size and shape of the foreign body.
A distinct
odor of alcohol could now
be
detected
on the
breath,
therefore
gastric lavage
was
done with
a warm solution of sodium
bicarbonate.
Several particles of undigested
food
were
recovered.
An excess of solution was allowed to remain in the stomach
and the
patient was returned to the ward.
Clinical
course. —The
dyspnea
and
cyanosis
rapidly
disappeared
and
the patient returned
to full
consciousness
within
15
minutes
from the time of removal
of the foreign body.
He had no recollec
tion of any of the circumstances
surrounding
the attempted
inges
tion of this large bolus of food.
His condition was perfectly normal
the next morning.
Later a history
was obtained
from
a relative who stated that the
patient
while partaking
of the evening
meal suddenly fell over
un
conscious.
He volunteered
the information
that they
had
imbibed
several drinks during
a period of three hours prior to dinner time.
A
physician
was called and
he
pronounced
the
case
one of
acute
alcoholism.
This
case well emphasizes
the fact that the diagnosis of acute alco
holic
toxemia should not be arrived
at too rapidly
and that
a thor
ough
physical
examination should be made, thereby
eliminating
all
possible
etiological factors, before
attributing
the comatose
state to
alcohol
alone.
NOTES AND COMMENTS.
The following editorial
comment
on
the question
" What is
an
epidemic ? " appeared
in the issue of the New York Medical Journal
for March
1, 1922 :
" ' The disease is epidemic'
' The disease is not epidemic'
' The
disease is epidemic'
Year after year we hear these statements from
health officials,
uttered
not in
succeeding
breaths,
perhaps,
but in
breaths of succeeding
days.
They remind one of the harlequin who
rushed upon
the
stage with
a bundle of
papers
under each
arm.
When asked what was in one bundle,
he replied, ' Orders ! ' and when
asked
about
the
other,
answered,
' Counterorders
! '
What
is
an
epidemic, or when
is an epidemic? If health officials
do not know,
who does know ?
"An epidemic disease is not different in nature from the same dis
ease when not called
epidemic.
Scarlet fever is scarlet
fever and
influenza
is influenza.
If there
is any difference
in the infectious
agent, it is only
a matter of more
or less of its native qualities.
There is nothing
new
about it. If there is any difference
in those
infected, it is again only a matter of more or less
resistance.
There
is again nothing
new or original
in their state.
There is an altered
relationship between
host and parasite, but there
are all degrees of
alteration.
In other words, the law of relativity
holds in infectious
diseases
as elsewhere.
What is now an epidemic
of smallpox
was
a normal
state of affairs a century ago.
" There is no drawing
the line between epidemic
and nonepidemic
disease, and there would be a more rapid
advance in health matters
if we were
to do away with the words ' epidemic
' and
' endemic,'
or
use the word
' epidemic
' for all communicable
diseases.
We
seem
perfectly
content,
at least the public does, when a disease is not pro
nounced epidemic, but when that name is applied by official
author
ity
or,
more
often, by popular
decision,
there
is suddenly
much
alarm and much
precaution taken
to avoid the disease
and
to pre
vent its spread.
And yet, in its ordinary
every day, every year run,
the communicable
disease carries off some fourteen times
as many
lives as in the briefer days or years when it is pronounced epidemic.
The disease,
then, in nonepidemic form, whatever that may mean,
is fourteen
times as much to be dxeaded as when it is called epidemic,
whatever that may mean.
108165—22
S
299
300
Vol. XVII.
NOTES
AND COMMENTS.
" It is high
time for health officials
to cease quibbling
about the
existence
of epidemics
and
turn
their attention to
the stimulation
of greater interest
in the ordinary
incidence
of communicable
dis
eases.
Let the public
consider any number of
cases
an epidemic.
We
should
be
thankful
if
their
public
health
consciousness
has
reached
such
a developed
state that they
are readily alarmed."
The
Division
of Venereal
Disease
of
the
United
States
Public
Health
Service contributes the following on gonorrhea.
A review of
1921 literature:
" Syirvptomatology.
—Sagot
has
collected
the reports of
45
cases
of gonococcal
endocarditis, including
one observed
by himself
and
Halle.
He concludes
that gonococcal
endocarditis may
be benign
or
vegetative
; that the benign
form is more
common
than is generally
supposed,
and is a probable cause of chronic cardiac disease ; that the
vegatative
or ulcerative form has the character of an acute septicemia
with
cardiac
symptoms
and
is usually
fatal ; that
the
danger of
septicemia
increases
with
extension
of
the
disease
to
the
deeper
genito-urinary
organs,
but bears no definite
relation to the severity
of the primary infection.
" Kivaz
describes
a
case of the
rare
complication
of gonorrhea
keratodermia blenorrhagica.
The patient was treated with perman
ganate irrigations
and
a polyvalent vaccine.
The condition cleared
up about two months after its first appearance.
" Citron reports a case of gonococcal
septicemia
which was
cured
by subcutaneous
injection of 50
c.
c. of meningococcal
serum.
He
refers to cases reported by other observers
which benefited by men
ingococcal
serum — acute gonorrheal affections of the internal genital
organs in women
by Le Masson, and gonorrheal arthritis
by Barlee.
and concludes
that this serum is indicated in all severe cases of gen
eral gonococcal
infection.
Weill
and Colaneri report another case of gonococcal
septicemia.
Symptoms of septicemia
developed in a man during the acute stage of
gonorrheal
urethritis.
Treatment
by
intramuscular
injections
of
electrargol and afterwards by antimeningococcic serum and an auto-
vaccine has no effect.
Patient died a month after symptoms of septi
cemia commenced.
Valentin remarks on the frequency
of relapses in gonorrheal vul
vovaginitis in children.
In his 161 cases the chief source of relapse
was found to be the rectum.
" Diagnosis. —Norris and Mickelberg
give
an analysis of 794
ex
aminations of films (Gram's)
from
women
presenting clinical
evi
dences
of
gonorrhea.
They
believe
that
clinical
evidence
is of
No. 2.
301
NOTES AND
COMMENTS.
greater
value in diagnosis
than staining methods.
Minor details of
technique
are given.
" Prophylaxis. —Schumacher
prefers alburgin
to protargol,
hego-
non, or other silver preparations, as it contains a high percentage of
silver,
and can, therefore, be used in weaker solution.
A 1 per cent
solution is considered
a sufficient prophylactic against
the gonococcus.
As in the case of mercury, solutions of silver salts must contain silver
ions in order to be effective.
Schumacher
points out that perchloride
of mercury
acts as a prophylactic against both the spirochete
and the
gonococcus,
and
can
hence
be
used alone.
The chief objection .to
general
use
is its poisonous
property.
He
therefore
suggests
the
use of 10 per cent solution of albargin as a general prophylactic,
and
holds that the silver ions have also
a bactericidal action
against
the
spirochete.
" Treatment—Phelip claims
good results
from silver ionization in
the early stages of gonorrheal urethritis.
He gives method of treat
ment used.
" Haxthausen quotes the investigation of Eizenberg
and Okolska
(Zentralbl. f. Bakt.N 1st Abt. Orig.,
1913,
69. 312)
as having shown
that the action
of certain disinfectants can
be greatly
increased
by
the addition of even small quantities of alcohol.
He compares
the
results of his 100 cases of acute uncomplicated
and mild complicated
gonorrhea
treated
with
a solution of protargol
(0.5 per cent)
and
alcohol
(5 per cent) with Jersild's (Ugesk. f. Laeger., 1913, 961) re
port on 116 cases treated with a watery solution of protargol followed
by a watery solution of silver nitrate later in
the
disease.
Hax
thausen
finds
this comparison
favorable
to his treatment.
" In
a
subsequent
paper, Jersild,
who
has
treated
14
cases
of
gonorrhea of the urethra in women and of vulvovaginitis
in children
with alcoholic solutions of protargol
and
has compared
the effects
with those obtained
in 20 other cases treated with
a watery solution
of protargol, has nothing good to say of the former method.
'"Mann
advocates
acriflavin
for
the irrigation of
gonorrhea.
"Oettinger and Deguingand report on eight cases of gonorrheal
arthritis treated with antigonococcal
serum.
The results obtained
by
intra-articular
injection
were
much
more
rapid
and
effective
than
when the serum was injected subcutaneously.
" Scherliess claims good results with hot-water irrigation in gonor
rhea in soldiers.
He gives his treatment
used in 200 cases with only
three failures.
" Lindblad has tested the value of milk injections in gonorrheal
diseases of the eyes by a statistical comparison
of the results obtained
at the Sabbatsberg Hospital
before and after the introduction
of this
treatment, which for the past year and nine months had been adopted
in every
case of gonorrhea of the eyes.
Author concludes
that this
302
Tol. XVI r.
NOTES AND COMMENTS.
treatment
is beneficial
in some cases but it does not deserve extrava
gant
praise.
" Terrien,
Debre, and Paraf have studied the effect of antigonococ-
cal serum by experiments
on the rabbit.
From the results obtained
the authors are of the opinion that antigonococcal
serum, to be effec
tive, should be injected into the actual
focus of disease.
This, how
ever,
does
not apply
absolutely
to the effects of serotherapy
in the
human
subject.
"Sagot
regards
subcutaneous
or
intravenous
injection
of
anti
gonococcal
serum as the most promising form of treatment
in cases of
gonococcal
septicemia.
He mentions
the experiments
of Debre
and
Paraf with. this serum in animals.
" Reenstierna
reports
favorable
results
from
the
treatment
of
gonorrheal complications by a combination of antigonococcus
serum
and a temperature-rising
agent.
" Sezary discusses
the variable results of antigonococcal
vaccino
therapy.
In conclusion
he
remarks that
we
must
not expect too
much from vaccinotherapy.
Its role is to stimulate and reenforce the
reaction
of immunity,
but
this
reaction
may
be slow
and
insuf
ficient.
" Boyd
has investigated
the value of vaccines in acute gonorrhea.
Comparing
270
cases
treated
with
vaccines
with
200 control cases
treated without them, it was found that the vaccine had no effect on
the course of acute gonorrhea.
" Demonchy
advocates
the
use
of
vaccines
in
acute
gonorrheal
urethritis.
From his
experience
he
concludes
that intravenous in
jections of antityphoid
vaccine give the best results.
He thinks that
the specificity of the
vaccine
plays only
a secondary
part in the
treatment of the complications of gonorrhea
and that the therapeutic
results
are not proportional
to the
dose
injected.
He advises small
doses repeated not later than five or six days.
" Weill reports favorable results
from the subcutaneous
injection
of hydrocele
fluid in
cases
of gonococcal
epididymitis
complicated
with hydrocele.
Three cases
are reported, in the first of which two
injections of 10 c. c. were given, in the second one of 5 c. c, and in
the third one of
3 c. c.
The first case improved most rapidly, and
Weill
considers
that
the therapeutic
effect is proportional
to the
quantity of liquid injected.
Weill also obtained
improvement in two
other
cases
of gonorrheal
epididymitis
by injections of hydrocele
fluid from the first case —hetero-plasmo-therapy.
" Cumming
and Glenn
recommend
vas puncture and injection of
collargol
in
cases of acute
and
chronic
seminal
vesiculitis.
Their
method of treatment
is given.
As the result of an experience with
55
cases
the
authors
conclude
that this
is
an effectual
method
of
treatment
of gonorrheal
infection
of
the
seminal
vesicles;
that it
No. 2.
303
NOTES AND COMMENTS.
should be combined
with
the usual
treatment
for
associated
condi
tions of urethritis
and prostatitis;
that vas puncture is contraindi-
cated in
cases
with acute anterior urethritis
or acute epididymitis;
that while not
a certain
cure, it leads to improvement
in most cases,
and to cure in some.
" Tests for cure
of
gonorrhea. —Fraser
warns
against
overtreat-
ment and overinstrumentation.
He concludes
that there
is no abso
lutely certain test for cure,
but gives
a scheme which
he
considers
practical
and
sufficient.
With
regard
to
the
complement
fixation
test, he thinks that more knowledge of the different types of gono-
eocci and
a more
sensitive
antigen are required before
the test can
be rendered reliable.
" Volarelli, who has investigated the tests for cure of
gonorrhea
from the results of 172 cases, considers
that the best
test consists
in
provocative
injections of gonococcal
vaccine,
together
with bacterio
logical and cytological examination of the secretion.
" Herrold
has attempted
to establish
a more
definite
standard of
cure in gonorrheal infections in the male
by improved methods
for
cultivation of the gonococcus,
and by study of the value of provoca
tive
and serological
tests.
He
concludes
that cultures of prostatic
and seminal
secretions
and the first urine sediment
furnish
the most
reliable means of determining whether
a gonorrhea is cured."
Surg.
Commander E. L.
Atkinson,
R.
N., writing
on
" Imme
diate Surgery with the Royal Marine Artillery Howitzer
Brigade in
France, 1916-1918,'' in the Journal of the Royal Naval Medical Serv
ice
for January,
1922,
reviews
his
experiences
during
a period of
service in France from May,
1910, to June, 1918, during which time
between
three
and four
thousand
wounded
came
under
observation
and treatment.
He describes in detail the dressing
station
used dur
ing
the Somme
offensive
in
1916.
It
was
a small dugout, located
roughly,
3,600 yards from the front line, and provided room for five
stretcher
cases
and
a wooden
table for dressings
and
examinations.
Lighting was by means of a small acetylene lamp, supplemented
when
necessary by oil lamps
and candles.
Heating
was secured by an im
provised
stove made from a l()-gallon gasoline drum, with
a stovepipe
made of biscuit tins.
The entrance
to this dressing
station, to pre
vent the entrance of gas, was fitted with double
curtains of blankets
soaked
in
a saturated
solution of hyposulphite
of soda.
A goodly
supply of shell-wound
dressings,
splints, and stimulating
food was
kept on hand.
Two-gallon
primus stoves were used for the steriliza
tion
of instruments.
Instruments for immediate
use
were
kept
in
trays containing
1-20 phenol.
Hypodermic
and seruni syringes and
a supply of morphine in solution were kept sterilized.
Iodine, was
304
Vol. XVII.
NOTES AND COMMENTS.
kept prepared for application.
A large supply of ammonia
ampules
were provided for cases of gas poisoning.
There
was
constant
de
mand for agate urinals.
This station proved satisfactory, but in the Battles of Arras and
Ypres and in the retreat
in 1918 any available shelter
was occupied.
In an advance or retreat
one had to rely entirely upon shell and field
dressings
and upon
what field equipment
could be carried.
Ambu
lance
patients forwarded
from
an advanced
dressing station
were
tagged
with
a description of the injury, identification,
treatment,
morphia, and antitetanic serum given.
Fragments of high-explosive
shells
and shrapnel bullets were
re
sponsible
for the majority
of the injuries
received.
Shock varied in
degree and in time of onset according to the temperament
of the in
jured man, to the severity of the injury, and the duration of previous
exposure.
In men lightly or moderately severely
wounded
the first
symptoms
are
a feeling of chilliness
and
a desire
for warmth, fol
lowed by drowsiness.
In the more severe cases —independent
of
th<
degree
of
the
wounds — the
onset
is
almost
immediate.
There
in
pallor,
sweating of the
face
and
hands,
the
heart
beating rapidlj,
and the breathing labored.
Cases of mild degree respond
to any appropriate stimulant, such
as
aromatic spirits of ammonia,
hot drinks,
and warmth.
The sitting
position, with the arms pressing the knees firmly
against the abdo
men, was found
beneficial.
In moderate
cases
the horizontal
posi
tion, with
10 minims of ether
hypodermically
and
a large 4-inch
flannel
bandage
compressing
the
abdomen,
produced
good
results.
Hot drinks in small quantities were given when the symptoms
began
to subside.
Ether
hypodermically
acts quickly
and
efficiently.
No
benefit was derived from the use of strychnine.
Hemorrhage from shell wounds varied with the character of the
projectiles.
These
wounds were
generally punctured or lacerated,
and bleeding from them in most cases was controlled by packing with
lint soaked
in sterile saline
and
a firm pad and bandage.
Morphia,
one-half grain hypodermically.
assisted
in the control of bleeding.
No attempt
was made at the advanced
dressing
station to tie bleeding
vessels;
a tourniquet was applied and the patient evacuated
as Boon
as possible to a casualty
clearing station.
In cases where
a tourniquet
was required
a special
note was attached
at the time of application
and the ambulance
orderly told to report on arrival
at the clearing
station.
In the early treatment
of wounds the clothing was first cut away
and the wound itself was covered
with
gauze soaked
in hypertonic
saline
(4 per cent).
The skin immediately around was cleansed with
swabs
soaked in gasoline.
The
gasoline
having
been removed
with
clean
swabs,
the
surrounding
skin
was
painted
with
tincture
of
No. 1.
305
NOTES AND COMMENTS.
iodine or with picric
acid.
If the iodine or picric acid gets into the
wound
great
pain
results.
After
the
removal
of fragments
and
dirt the wound was cleansed with
1-2,000 bichloride of mercury
so
lution,
washed
out with
saline solution,
and
packed, if necessary,
with saline
gauze.
The
results of this method
were very satisfac
tory.
Cranial
wounds were generally in a very dirty condition, the pa
tient in collapse
and bleeding severely
from the scalp.
When suf
fering from embarrassed
respiration
efforts
were made to clean
out
the fauces, draw
forward
the
tongue,
and, if
necessary,
secure it
with
a stitch fixed
by
adhesive
plaster to the cheek.
The
injured
man
was placed
in
a sitting
position and, if shock
was
profound,
ether was given hypodermically.
The scalp
was shaved and painted
with iodine.
The wound was then examined,
any obvious
bone frag
ments
removed,
and saline gauze,
wool,
and protective applied.
In thoracic
wounds a sudden, large intra-pleural
hemorrhage
pro
duces profound
shock
and
embarrassment
to respiration,
which is
complicated
by coughing.
Such large hemorrhages,
however,
were
rare.
The immediate
indication
was absolute
rest in
a sitting
pos
ture and cessation of movement,
which is generally impossible in the
field.
Aspiration of
a hemothorax
was
adopted
in cases
where
the
fluid reached
a level causing embarrassment.
In
the writer's
experience,
abdominal wounds produce
less shock
than
in other regional wounds.
Bullet
wounds of the abdomen
do
not cause protrusion of gut.
They
are best cleaned
and left
alone,
morphia
administered, and the patient evacuated
as soon as possible.
Wounds of the abdomen
caused by shell fragments usually
cause
more laceration,
and necessarily
more protrusion of gut.
When there
was protrusion
without
obvious injury
to
the
gut, morphine
was
given and the wound cleaned and the gut replaced
under chloroform
anesthesia.
If the gut was injured
an
attempt
was made
to
pack
off the wounded gut from the peritoneal cavity.
In wounds
involving
joints
the
best practice in the
field
is
the
removal of any visible foreign body, but not to explore for the frag
ment causing
the wound.
Rupture
of the membrane
tympani was exceedingly
common
from
the near explosion of large shells.
All
six
of
the
laboratory
workers of
the United
States
Public
Health
Service
who have
been studying tularemia,
a disabling sick
ness of man which has been known, particularly
in Utah, for the last
five years, have contracted
the disease, two of them being infected in
the laboratory
in Utah and the other four in the Hygienic Laboratory
in Washington.
Such
a record of morbidity
among investigators of
a disease is probably unique in the history of experimental medicine.
306
Vol. XVII.
NOTES AND COMMENTS.
Two of these workers are physicians, one is a highly trained scien
tist, and
the others
are experienced
laboratory
assistants.
One of
them contracted
the disease twice, once in the laboratory in Utah and
again,
two years
and
five months
later, in the laboratory in Wash
ington.
In these workers the disease began with
a high fever, lasting about
three weeks, and was followed by two months of convalescence.
The
disease
has few fatalities,
its chief
interest
arising
from
the
long
period of illness which
it causes in midsummer,
when
the
farmer?
of Utah are busily engaged in cutting alfalfa and plowing sugar beets.
The studies into the cause and transmission of the disease show it
to be due to a germ, Bacterium tvlarense,
which is conveyed by six dif
ferent insects
: The blood-sucking fly, Chrygops distalu; the stable fly,
Stomyox calcitrans; the bedbug, Cimex lectularius;
the squirrel
flea.
Ceratophyllus acutus: the rabbit louse, Haemodipsus ventricogus ; and
the mouse louse, PolypJax serratus.
Only the first four of these are
known
to bite
man.
It
appears
possible
that the
germ
may
also
enter through unbroken skin ; for instance, that of the hands.
Carbon monoxide
poisoning is one of the most widely distributed
and most frequent of industrial accidents, says the United States Pub
lic Health
Service.
The gas
is without color, odor,
or taste.
It is
an ever-present
danger about blast and coke furnaces
and foundries.
It may be found in a building
having a leaky furnace or chimney
or
a gas stove without flue connection,
such
as
a tenement, tailor shop,
or boarding house.
The exhaust
gases of gasoline
automobiles
con
tain from 4 to 12 per cent of carbon
monoxide,
and in closed garages
men are not infrequently found dead beside a running motor.
A simi
lar danger
may arise from gasoline
engines in launches.
The gas is
formed also in stokerooins,
in gun turrets on battleships, in petroleum
refineries,
and in the Leblanc soda process in cement and brick plants.
In underground
work
it
may
appear
as
the result of
shot
firing,
mine explosions,
or mine fires ; or in tunnels from automobile
exhausts
or from coal or oil burning locomotives.
Carbon monoxide
exerts its extremely
dangerous
action on the body
by displacing
oxygen
from
its combination
with
hemoglobin,
the
coloring
matter
of the blood,
which normally
absorbs
oxygen
from
the air in the lungs and delivers
it to the different tissues of the body.
Oxygen will
replace
monoxide
in combination
with
hemoglobin
whenever
the proportion of oxygen
in the lungs is overwhelmingly
greater.
Therefore —
1. Administer
oxygen
as quickly
as possible
and in as pure
form
as is obtainable,
preferably
from
a cylinder of oxygen
through
an
inhaler mask.
NOTES AND COMMENTS.
307
2. Remove patient from atmosphere containing carbon monoxide.
3. If breathing is feeble, at once start artificial
respiration by the
prone-posture method.
4. Keep the victim flat, quiet, and warm.
5. Afterwards
give plenty of rest.
Among
the
members
of our profession who have
had
a life of
adventure
few
names
are
more familiar, says
the British
Medical
Journal for February
18,
1922, than that of Thomas Dover
(1660-
1742), who took his B. A. at St. Mary's hall, Oxford, and the M. B.
from Caius College, Cambridge,
and
became
a captain in a bucca
neering expedition, in which capacity he in 1710 rescued Alexander
Selkirk, whom Defoe made immortal
as Eobinson
Crusoe.
Eventu
ally Dover
began
the practice of medicine
in London,
where
he be
came known
as " the quicksilver doctor " on account of his cure for
asthma and many other ills—namely,
" an ounce of quicksilver daily,
to be taken at what hour the patient pleases, and
a spoonful of the
gas of sulphur in a large draft of spring water at 6 o'clock
in the
afternoon
and
at bedtime."
In
his well-known
collection of bio
graphical essays, An Alabama Student
(1908),
the late Sir William
Osier
gave an attractive account of this " physician
and buccaneer."
with many details about his popular work, The Ancient
Physician's
Legacy to His Country,
" designed
for the
use of all private fami
lies."
To
the
February
number of The
Bookman's
Journal
and
Print
Collector, which we are given
to understand is the only peri
odical
in the world
devoted
exclusively
to the collecting
of books
and prints, Dr. Philip Gosse,
the
son and
grandson of
leaders
in
literature and
zoology, respectively,
contributes
a brightly written
sketch of Dover's adventures
as a pirate, based mainly
on a rather
rare book, A Cruising Voyage Bound
the World.
This book was
begun in
1708,
and, according to the title-page, contains
" Remark
able transactions
as the taking of Puna and Guayaquil, of the Aca-
pulco ship and other prizes ; an account of Alexander Selkirk's living
alone four years and four months
on one island, etc., 1721," by Capfr.
Woods
Rogers, who commanded
the expedition of two
ships—the
Duke
and the Duchess —fitted
out by the merchant
adventurers
of
Bristol at the instance of William Dampier, the famous circumnavi
gator,
freebooter,
naturalist,
and hydrographer.
Dampier.
then
56
years of age, went
as pilot, and Dover, who was practicing in Bristol,
was chosen
as second in command,
not
because he had
any knowl
edge
whatever of the sea or ships, but,
strange
as it may
seem,
on
account of his bad temper
; for it was shrewdly
argued
by the mer
chant
adventurers
who
were financially
interested
in the expedition
that
Dover's
vile temper
would
render him
so unpopular
that
he
308
Vol. XVII.
NOTES AND COMMENTS.
would not have any followers should he attempt
to break away from
the main party—a danger that had
led
to the failure
of previous
expeditions in which
a popular
second in command
had
been per
suaded
by
a discontented
party
to go off on a separate
cruise.
As
may
be imagined, the voyage
was not free from quarrels over
the
distribution
of
the
spoils.
After
sacking Guayaquil
the
English
sailors stored their plunder in the churches
and spent the night there
to guard
it,
but their
sleep
was
much
disturbed by
the smell of
corpses
recently
buried
as
the result of
an epidemic
of " plague."
Next day they returned to the ships, but within 48 hours 180 of the
crew of one ship
were down with
the plague;
here Dover stepped
in
and
ordered
the ships'
surgeons
to bleed
every
sick
man
to
a
hundred ounces, and
to give large drafts of dilute sulphuric
acid
;
it
is
recorded
that this drastic treatment
was justified by the recov
ery of all but eight patients.
The editor of
the British Medical
Journal
makes
the following
comment
on "the
destruction of
vitamins"
in
the
issue
of that
periodical for February
11, 1922
:
" The two facts of greatest
practical
importance about vitamins
are, first, that
a
certain minute supply of these substances
is
essential
for animal life, and,
secondly,
that they
are very easily destroyed.
It
is
most necessary
to bear this second characteristic in mind, for
the
actual
existence
of vitamins
can only
be
demonstrated
by the
disastrous effects
produced
by their
absence
from
the diet
or their
presence in
it
in insufficient
quantities;
indeed,
since vitamins occur
naturally
in nearly
all
fresh
foodstuffs,
it
is
probable
that their
existence
would never
have
been
suspected had they
not
been such
unstable
bodies.
"An
abundant supply of vitamins
exists
in all fresh vegetable
foods,
and
considerable
quantities occur
in milk and in meat, pro
vided that the latter are obtained
from animals fed on fresh foods.
A normal adult living on an ordinary
diet containing
a
reasonable
proportion
of fresh vegetables
is, therefore, certain of obtaining
a
plentiful
supply
of
vitamins.
Unfortunately
these
indispensable
food
constituents
are,
as
has
been
said,
very
readily
destroyed.
All three vitamins are rapidly destroyed
by heating in the presence
of air or oxygen.
Hopkins showed
that the fat-soluble vitamin A
in butter was completely
destroyed
by heating the butter to 120° C.
for four hours
if
oxygen
was bubbled
through the butter, although
practically
no destruction occurred
if
the butter was heated without
aeration.
The experiment
established
the important
fact that this
vitamin,
though fairly
resistant
to
heat,
is
readily
destroyed
by
oxidation.
Zilva
found that
the antiscorbutic vitamin
C
was com
No. 2.
309
NOTES AND COMMENTS.
pletely
destroyed by boiling for an hour in the presence of oxygen,
but that no destruction occurred
when it was boiled for two hours
in an atmosphere
of
carbon
dioxide.
The
destruction of vitamins
depends largely upon the length of time for which they
are heated
in the presence
of air.
Hess, for instance,
showed that little destruc
tion of vitamin
C occurred
when
tomatoes
were
heated
to
100°
C.
for
15 minutes,
but that four-fifths
of the vitamin
was
destroyed
when
the tomatoes' were heated to
100°
C. for an hour.
Similarly,
it has been shown that a greater destruction of the vitamin C present
in fresh milk occurs when it is heated to 60° C. for half an hour than
when it is boiled for a minute.
The reaction of the fluid containing
the
vitamin
is
also
of
importance, for
vitamins
are
much
more
readily destroyed
in
an alkaline
than in
an acid fluid.
The
fluid
ne^d only be feebly acid.
The antineuritic, water-soluble vitamin B
is more resistant
than vitamin C, but it also is readily destroyed
by
boiling in an alkaline fluid in presence of air.
"A fair proportion of all three vitamins in fresh vegetables appears
to survive all ordinary cooking ; but prolonged boiling, such as occurs
in making stews, destroys
nearly the whole of vitamin
C and prob
ably
most of vitamins A and B.
The vitamins in milk
are unfor
tunately
very unstable; ordinary
pasteurization destroys
practically
the whole of vitamin C and a considerable
amount
of vitamin A.
" The extraordinary
difficulty of retaining vitamins in preserved
foods
is in large measure
due to the fact that vitamins slowly oxi
dize on keeping.
Vitamin A is the easiest to preserve, for it appears
to be fairly stable when
dissolved
in oil, and it can be kept in cod-
liver oil for
months
and
probably
for years; it
also survives for
many
months
in tinned meat.
Vitamin B can
be preserved
in the
dry state, and whole-meal
flour and unpolished rice retain their con
tent of this vitamin for long periods.
The preservation of vitamin
C, the antiscorbutic vitamin,
is by far the
most
difficult
problem.
This is well known ; efforts
have been
made for the last hundred and
fifty years to find some satisfactory way of obtaining
a concentrated,
portable,
and stable preparation of the antiscorbutic element in fresh
fruits or vegetables.
The
problem
is of the greatest importance to
the
Navy
and
to explorers;
in special
circumstances
it may
be of
first-rate importance to
the Army
also.
A
stable
preparation
of
vitamin C is essential for the prevention of scurvy when
fresh
vege
tables
and fruits are not
obtainable.
Lemon-juice
was introduced
as an antiscorbutic in the eighteenth
century, and its use reduced
the
mortality
in
the
Navy
enormously.
Lemon juice
is very rich
in
vitamin C, and the acids present help to preserve
the vitamin.
Un
fortunately, in the nineteenth
century lemon juice was discarded
for
lime juice, which
has only
one-quarter
the vitamin
content
of the
former.
Lemon juice, however,
is not
a really satisfactory
vehicle
310
Vol. XVII.
NOTES
AND COMMENTS.
for the preservation of vitamin.
C. Bassett-Smith
found that com
mercial lemon juice lost all its vitamin
content rapidly; he showed,
on
the
other
hand,
that
dried
lemon-juice
tablets
retained
their
vitamin for at least
a year.
Harden
and Robison found that dried
lemon
juice kept in
a desiccator
for
15 months
at room
tempera
ture only lost 50 per cent of its activity.
Hess ascertained
that tinned
tomatoes
retained
their vitamin
C content
with little
loss for three
years.
He
also found that if perfectly
fresh milk was dried by
a
suitable
process and stored in sealed tins its vitamin C content
was
preserved
for many
months.
The
simplest
way of transporting
vitamin
C is by the
use of dried
peas;
they
contain little of the
vitamin
when
dry. but
produce
large quantities
when
allowed to
germinate.
By the use of germinating
peas an abundant supply of
vitamins can be obtained
by explorers or troops in sterile countries.
It is important
to realize
that although dozens of different methods
of food preservation
are known,
yet
the few examples
mentioned
above are practically
the only methods
by which vitamin
C can
be
preserved for any length of time.
" Individuals living
under
normal
conditions
may
suffer
from
vitamin
lack, owing
to
an improper
diet
from
which
all vitamin-
containing
foods
have been eliminated.
All that is needed
in such
cases is the addition of such foods to the diet.
The following foods
are particularly
rich in A'itamins:
Cod-liver
oil contains
about
240
times
as much
vitamin A
as butter, yeast
is the
richest
source of
vitamin B, and fruit juices contain
a large
amount
of vitamin
C
(ierminating
seeds contain large amounts of both vitamin B and C.
while green
vegetables
and
tomatoes
contain large quantities of all
three vitamins.
An abundant
supply of all the vitamins can there
fore he obtained
simply by the addition to the diet of cod-liver oil
and the fresh
vegetables
mentioned.
" Certain
workers claim
to have
produced concentrated
prepara
tions of vitamin
B,
but
no
methods
are
known
by
which
eithei
vitamin A or vitamin C can be obtained
in concentrated
form.
Any
attempt
at chemical
treatment
produces
a rapid
destruction
of the
vitamins.
As already pointed out, it is a matter
of great
difficulty
to
devise
any
means
by which
vitamin
C can
even
be
preserved,
and
its concentration is at present
impossible.
It is extremely
easy
to obtain
an abundant supply of vitamin
C
by
the
use
of
fresh
foods,
but it is very difficult to retain more than a fraction
of this
vitamin
in
any
form
of
preserved
food.
Xo
substance
is
known
which contains
more vitamin A than cod-liver oil. and,
as has been
said, it is only in the case of vitamin B that any success has attended
the repeated
efforts
that
have
been
made
to purify
or to concen
trate vitamins.
No. 2.
311
NOTES AND COMMENTS.
" In spite of the fact that ordinary
fresh foods are the simplest,
cheapest,
and
richest
sources
of
vitamins,
the
public
apparently
demands to
be supplied
with
vitamins
in
the
form
of
medicinal
products.
A large number of preparations are on the market
which
claim
to contain vitamins.
Some of these
preparations
are
so
far
satisfactory
that
the
prepared article
has
been
proved
to contain
vitamins,
although even in these cases
a few
ounces of green
vege
tables would probably contain more vitamins than large quantities
of the preparation.
In the case of certain manufactured
products,
however, it is simply stated that the preparation
is made from sub
stances very rich in vitamins.
This statement
means nothing,
for.
from
the facts mentioned
in this article, it is obvious
that even if a
preparation
is made from
a raw material rich in vitamins, it
does
not follow that the finished
article will contain any vitamin
at all
when it reaches the patient.
" We
have
endeavored
to
state
the
known
facts
as plainly
and
directly
as possible,
and invite manufacturers to take note of them.
They may be unwelcome,
but they
are, we believe, incontrovertible.*'
NURSE CORPS.
DREAMS.
By
an Old
Dreamer.
Much has been written on the subject of dreams, and some of these
writings have been pernicious nonsense even though emanating from
high
authority.
But why
let
the voice
of authority
dominate
our
reason without giving it the " once over " on our own account j
The imagination, literally the making of pictures, is a faculty of
the mind,
and
a very entertaining
faculty
at that, which
goes on
alike
whether we are awake
or asleep,
and
the pictures which
are
made
are for our delectation.
The normal physiological
exercise of
any bodily function gives
a pleasurable sensation
; thus while we are
asleep
with
consciousness
partially suspended
or disassociated,
but
never completely obliterated, the reins of imagination
are loosened.
Without
the restraining influence of other faculties of the mind, such
as the logical, the moral, the cautious,
the imagination literally plays
and paints its fantastic pictures for the amusement
or consternation
of the latent consciousness.
The instinct of play, while universal, is strongest
in youth.
Sleep
rejuvenates,
not only in a physical
sense,
but also
gives
to- one the
mind of a child by submerging the barriers of sophistication.
Sometimes
dreams terrify rather than amuse, in which
case
the
latent
consciousness
generally
says : " See here, young
person, I'll
not stand for that, you know,"
and
emerges
from
the too
violent
shock.
In such
cases it usually happens
that consciousness
proceeds
to reflect upon this picture too vividly painted.
Wide awake, it re
members
with
horror
the
vision of the
executioner
wearing
that
curious red mask, standing just under the scaffold.
How black his
beard looked showing below the mask
!
Why did he not wear a black
mask, then his beard
would be
red, like Uncle
George's —why it is
" Uncle George "—and lo, one is asleep again, and " Uncle George "
this time puts the noose around one's neck and gives it a tug—and
again consciousness
emerges and the painting
is suspended.
It is a
characteristic
of the dream
to recur to the same subject
and present
it in many different aspects, and this specimen
dream
is related
to
indicate
the transition
between sleep and wakefulness, also to show
that the imagination may continue
to follow
the same figment unin
313
314
Vol. XVII.
NURSE
CORPS.
terruptedly
in both
states, back
and forth, repeatedly playing with
the image
and changing it in color and form, though retaining the
motive which in this case gave the consciousness
a shock of horror.
Sleep,
as a part of life, is curiously undervalued by most of us, if
one may judge from popular habits and daily routine of the general
pleasure
seeker.
All that the young realize about sleep is that it is a
part of the daily life to be postponed
as long
as possible,
although
usually prolonged at the further end.
To the young and healthy sleep
is " lost time," and they would discredit the fact that it is supposed to
be a pleasurable part of one's existence.
And yet children are adept
dreamers;
the imagination
paints rare pictures for the young both
waking
and
sleeping.
Thankful
we may
be that the sophisticated
theorist can not impute to the age of innocence
his idea of the sub
ject matter of dreams.
And the child is no martyr of repressed
de
sires, or I know not the child
!
To those of us who have
experienced
the sensations
of life and
have realized the numbing effects of sophistication,
then
is the re
sponse deeper than recognition of the poetic
beauty of the lines :
"Above
thy
deep
and
dreamless
sleep,
The silent
stars
go by."
Such
a degree of disassociation of the conscious
mind
as expressed
by " deep and
dreamless
sleep " is perhaps the fullest
pleasure
the
cup of life contains.
Sleep
may be dreamless.
Just as in the case of the Cape Cod cap
tain, while
we are awake " we sometimes
sit and think and
some
times we jest sit": so, while we are asleep the imagination, may rest,
or, as high authority
declares but can not
prove,
the disassociation
is
so
great
that memory
does
not register.
Various
physiological
states account
for this—such
as the amount
of blood in the brain
and
the degree of fatigue or excitement
which
preceded
sleep.
A
high pillow will tilt the head forward
and
lessen the blood supply,
and this has been found to lessen the number of dreams.
The influ
ence
of the digestive
functions
upon
dreams
is too well known to
require
comment.
From
such
stimuli of the body
arise
the hints
which start the imagination
on its wild
excursions.
After allowing
for all such causes, however,
it certainly leaves a vast horde of ideas
unaccounted
for.
Transitions
are instantaneous
and without appar
ent connection
; nor can acts or thoughts of the wakeful hours give
the clue to the flash
of memory
which revives
something
long for
gotten.
A creative
faculty is sometimes manifest;
one may compose verse,
devise an invention, or plot a story.
Not infrequently
do we hear of
individuals
who have writing materials at the bedside
so that ideas
which sleep creates may not be lost
to waking
consciousness.
This
No. 2
315
NURSE
CORPS.
power of innovation is strong evidence that all dreams
are not sug
gested by external
stimuli.
The cause of such unsuggested
dreams
is the well-recognized but entirely mysterious power of the imagina
tion of making spontaneous
mental
combinations.
When such com
binations are the most varied they result in inventions, and the indi
vidual
is called
a genius.
In dreams
also genius
is at work.
All this is subject
matter of common
observation,
and it requires
no elaborate theory to elucidate.
If perchance
one dreams that it is
thirty degrees below
zero, and that it changes to sixty degrees below,
and some
one knocks at the door
and
asks if one is going skating,
it requires no great mental
feat to perceive that one dreamed
because
one was cold.
A psychoanalysis may explain that the dream of zero
weather
means the repressed
desire for another blanket ; but the de
sire does not remain repressed after one has sufficiently come to con
sciousness to make
even
a reflex
movement
toward
the foot of the
bed where the extra coverings
hang ; yet it is the repressed desires of
the awakened existence
which this theory would
have
as the cause
of our dreams.
Surely there is no place for that explanation in the
case of a sensation
of the body occurring while we are asleep.
It would be absurd
to deny that to a certain number of dreams this
psychoanalytical
explanation
is applicable, but can not this be over-
advertised?
Is there
not
a Zurich
school
of analysis
as well
as
a
Viennese?
As a matter of fact, what are these desires which we so
persistently
repress
in our waking hours
as to afford material for
our
nightly
volume
of
dreams?
The
majority
of
us
adults
are
under the impression that the human animal
is not given over
to
practicing self-control,
and one can not credit him with much in the
way of
repression.
" Lead
us not into temptation, for if you
do,
assuredly
we shall
yield."
would
seem
an
honest
prayer
for
the
majority of the human
adults.
That the general
color of our dreams
may
be influenced
by the
general
color of our lives is not denied,
but
a closer relationship of
cause and
effect between
the acts and thoughts of the day
and our
dreams
at night
other
than that of the
broad
general
emotions,
anxiety,
sorrow, pain, and their
opposites,
does not always occur.
A
patient
suffering from
a chronic
ailment
may
have
depressing
dreams of death or of varied calamities.
His thoughts during
the
day may not have embraced
a single one of the specific
elements of
his dream, but (shall we say subconsciously) they determine
the field
in which his imagination rambles
at night.
And so the study of our dreams
may give
a hint to the character
of our lives, whether
we are placid or morbid, spiritual
or sensuous.
But in spite of "high authority" may not we who
are merely
plod
ders on the road of life state that we do not think that they can give
108165—22
9
316
Vol. XVII.
NURSE
CORPS.
more
exact or explicit
information?
Certainly
knowledge of our
selves
so obtained
is not in
the
least
comparable
in
value
to that
afforded
by
a study of our waking hours, and. also, one would hate
to acknowledge
that the stuff one's dreams
were made of were made
in Austria.
THE
ROLE
OF THE
NURSE
TN CURE AND PREVENTION.
Speaking of the role of the nurse
in the cure
and prevention of
disease George E. Vincent, president of the Rockefeller
Foundation,
in his review of the foundation's activities in 1921
sa37s :
" The modern
hospital
and
doctors
and
surgeons
are largely
de
pendent upon the trained woman
nurse, who has made an invaluable
contribution
to
curative
medicine.
Public
health
administrators
are recognizing the visiting or health nurse
as equally indispensable
to the
success
of public
and personal hygiene.
Already
maternity
and
child
welfare
nurses,
school
nurses,
tuberculosis
nurses,
and
several
other specialized
types
have
taken
their
places
in private
health
systems
and
in
Government
departments.
One
State
has
announced
as its goal
the appointment of
a health
nurse for every
2.000 of the population
; another
has fixed the ratio at
1 to 3.000.
" Questions
as to the exact function of the bedside
nurse, the kind
and length of training
she should receive,
have
been
under discus
sion for some
time.
The
advent of the health nurse
raises similar
problems.
How far should her education
coincide
with that of the
hospital nurse?
In what should consist
her special
training?
How
much
time should the entire course occupy
?
Should there
be differ
ent grades of both bedside
and health nurses
?
Is there
a place and
function for a lay worker or a health
visitor?
In
1919 the founda
tion, invited
a group of persons
who
are most familiar with nurs
ing problems
to
a conference
which
nominated
a survey
committee
under whose
auspices
a competent
expert
has been making
a study
of the subject in all its phases.
A report is promised in the summer
of 1922.
The expenses of the survey
have been met by the founda
tion.
"During 1921 the International
Health Board contributed toward
short courses for New York State nurse training.
Four nurse train
ing centers in France
were
aided not only to train visiteuses
<Phy-
giene but to improve in certain hospitals standards of ward nursing
and administration.
The Cavell-Depage Memorial
School of Nurs
ing in Brussels will be an integral part of the reorganized hospital
8nd medical
school
to which
the foundation
is contributing
a large
sum.
The International
Health
Board is cooperating with the new
Government hospital in Rio de Janeiro in establishing good
stand
ards of nursing under the leadership of American
trained
nurses.
No. 2.
317
NURSE
CORPS.
The foundation supports a nurse training
school in connection
with
the Peking
Union
Medical
College.
A survey of nurse
training
in
Great Britain and on the Continent, to be begun early in 1922, has
been
authorized."
NOISE.
A recent publication
has stated that scientific investigations have
shown
that "there
are few
more
active
robbers of our energy
and
strength
than
noise.
Whistling,
whether
it
be
the
effort of the
passing
boy, the shriek of the railway
engine,
or the blare of the
police alarm, is only
a type of the many noises with which
the in
habitants of all towns are cursed.
These
noises are really
a serious
menace to the health and happiness of all communities.
Those of
us who live in cities believe that we become accustomed
to the din,
but this
is
not
entirely
correct.
What we think
is
a
process of
becoming
accustomed to noise is in fact a state of active resistance
to
it.
We ignore by refusing to hear, but this can not be done without
expending more energy than we can afford."
This
nerve
energy
which
transmits outside
sounds
to
the brain
may
be likened to the electric energy
which
operates
a
telegraph
system
or the familiar house
electric
bell.
In all
these
cases
the
striding of the message, be it the noise from ear to brain, the code
from operator to tape, or the push button to bell, uses up
a given
quantity of nerve or electric
energy, tending to ultimate exhaustion
of
the
nerve
centers
or batteries.
Our nerves of hearing
expend
some of their energy
transmitting
sounds
to our brains;
when
we
make an effort to refuse to hear an unnecessary
waste of nerve energy
goes on.
It is claimed
the amount of this waste is measurable.
The
intense
effort required for not hearing is accompanied
by a rise in
the pressure of the blood
stream on the walls of the arteries,
and an
ingenious mechanism
attached
to the pulse
measures this increased
pressure of a column of mercury.
It is thus our total available stock
of energy is reduced
and we have not enough left to bring our " not
hearing " faculty into play and noise becomes a torture.
One of the most persistent
criticisms made of our naval hospitals
is the
amount of noise the sick are forced to endure.
Heavy boots,
slamming
doors,
rattle of dishes,
loud talking,
scraping of metal
furniture—all
these have
been
enumerated.
To
the query, "Why
do you not report these
disturbances
? " there
is but one answer, " I
have tried, but I am regarded
as
a crank."
Outside the hospitals
city authorities
have tried
to help in the
suppression
of noise
by
notices of " Zone of quiet," but few could assert that these
signs have
restrained any motorist from blasting his horn or any motorcyclist
from cutting out his muffler.
The
boat
proceeding
up
the
Sound
318
Vol. XVII.
NURSE
CORPS.
passes
a hospital
at the waters
edge;
the wall
bears
a 3-foot sign,
" Quiet— Xo
unnecessary
noise,"
but
at
this
particular
point
the
boat sends forth
a siren whistle.
Employers of labor now recognize that time and energy are wasted
from the fatigue engendered
by the noise of machinery and manual
operations,
and it is believed
that more active measures will be taken
to control unnecessary
and preventable
noises.
When one is very ill,
one fully realizes
how great
must be the stock of energy required to
intercept noise.
It is not work that kills but the continuous drain of nervous energy
entailed
by our efforts not to hear distracting
din.
Even if
one
does
not entirely
agree
to this statement,
one can not gainsay
the
retarding effect of noise in cases of sickness, and such united and per
sistent
efforts
as can be made to promote
quietude
in our hospitals
will result in greater good to the patients and increased
efficiency
on
the part of the personnel.
BOOK NOTICES.
Publishers
submitting
books for review
are
requested
to address
them
as follows:
The Editor,
U.
S. Naval Medical
Bulletin,
Bureau of Medicine
and Surgery,
Navy
Department,
Washington, D. C.
(For
review.)
Books
received
for review
will
be returned
in
the
absence
of directions
to
tbe contrary.
KCV1HWERK.
Lieut.
Commander
W. M. Kbrk. Medical
Corps,
United
States
Navy.
Lieut.
John
Harper,
Medical
Corps,
United
States
Navy.
Lieut.
L. J. Koberts,
Medical
Corps,
United
States
Navy.
Still am I busy books assemblynge,
For to have plentie it is a pleasant
thynge
In my conceyt, and to have them in hande,
But what they mene
do I not understande.
(Medieval
book collector.)
Pboteji* Therapy
and Nonspecific
Resistance, by William F. Petersen,
M. D.,
associate in pathology,
University of Illinois,
College of Medicine,
Chicago, III.
The MacMillan
Co., New York, 1922.
A book on this subject is timely.
For the past six or seven years
clinical
data has been
accumulating which indicates that it is neces
sary for us to broaden our views in relation to biologic therapy.
For
the past
30 years
the
idea of specific
immunity
has so dominated
medical thought that it is difficult for us to think in terms of non
specific
protein therapy.
The fact of the existence of
a nonspecific
reaction,
however,
has been established,
and
its application
in the
treatment of disease is becoming
more and more widespread.
There
fore, because of the opportunity it offers of keeping us abreast of the
times, it is very fortunate that the author has made available such
a
complete
and judicious resume of the subject.
The
book
is divided
into
three
sections,
the
first
dealing
with
" The method," the second with " Theories," and the third with " The
clinical
results."
In the first
section
the author
gives
a sketch of
the
early
history
of
nonspecific
protein
therapy,
followed
by
an
enumeration and brief discussion
of the various nonspecific
agents
319
320
Vol. XVII
BOOK
NOTICES.
which have
been
used.
He then
describes
the so-called
nonspecific
reaction,
taking
up
in detail
the
rather
marked
effect
which
the
intravenous injection of 25 to 50 million
dead typhoid bacilli
has on
the
physiological
balance
of
the
body.
The
last chapter of this
section
deals
with
the
focal
reaction
in
response
to
nonspecific
protein
injections.
In
the
section
on " Theories " the
author dis
cusses briefly
those
advanced
by
various
writers
to explain
the
mechanism
of
the
nonspecific
reaction.
This
is
followed
by
a
rather extensive
discussion
of his own views
on the subject.
He has
formulated
what appears
to be
a very plausible theory explaining
the probable
mechanism
of the reaction.
In considering the clinical
results of nonspecific
protein therapy the application of this form of
treatment
to various diseases is taken up.
The methods of procedure
are merely outlined
and
dosages
either not
mentioned
or merely
suggested.
We
are
given
a brief summary of the
forms of non
specific therapy used and the results obtained
in the diseases in which
it has attained
any application worthy of note.
The final chapter on
indications
and contraindications
contains information
with which
everyone
should familiarize
himself
before
attempting
to
use this
form of therapy.
One of the most valuable features
of the book is
the
extensive
bibliography
which
it
contains.
There
has
been
published
a
surprisingly
large
mass
of
literature
on
nonspecific
protein therapy
and allied
subjects,
and
the author has
gone to
a
great
deal of trouble in compiling
this bibliography
for the benefit
of those who may wish to refer to the original
sources.
The
volume
under
discussion
will
undoubtedly disappoint
those
who have
been
looking
for
a ready
reference
book
to which
they
might
turn
for
definite
well-developed
methods
of
treatment
by
means of nonspecific
agents.
Nonspecific protein therapy, however,
can
not
at present
be carried
on by rule of thumb, and this book
serves an entirely different purpose
than that of an outline of treat
ment.
As the author says in his preface
: " The summarizing of our
present knowledge in this particular
field has
seemed
of some
pos
sible
value,
not with
the
idea of popularizing
a
new
therapeutic
measure but rather in stimulating
interest
in a direction that seems
to offer
decided
possibilities
of advance.
I have therefore merely
indicated some of the methods
at present
employed
in nonspecific
therapy
without
effort
to
define
precise
modes of application
or
indications for therapeutic use.
On the other hand I have endeavored
to present
the
possible
theoretical basis
and
some of the collateral
fields of application
as fully as our present knowledge will permit."
With an understanding of the author's point of view in the presenta
tion of this subject
one can more readily read the book with appre
ciation.
In dealing with
so new
a subject
it has been necessary
to
No. 2.
321
BOOK
NOTICES.
include reference to, and in some cases relatively lengthy discussions
of, methods and theories which may later have to be discarded.
The
average
reader will be inclined
at times to be skeptical of the value
.of
some of the material
used.
But if we bear
in mind that
the
author's purpose
is to present
a subject in which he wishes to stimu
late further investigation this material is seen to be essential.
It must not be thought, however,
that this book
is not written for
the practicing
physician.
As the author states: "It was
the clinic
that directed that attention to this form of therapy."
It is a method
of treatment, and, therefore, must of necessity
be handled by those
caring for patients.
The
use of protein therapy is outlined in the
case of some of the diseases with
enough
definitenoss
to enable one
proceeding
cautiously
and with judgment
to carry
out with safety
in certain
selected
cases
some
of the methods
described.
The final
paragraph
indicates
the spirit of caution and yet the enthusiasm
with
which
the author has attempted
to present
his subject.
He says:
" Needless
to say, nonspecific
therapy does require judgment, careful
attention,
and bedside study on the part of the physician perhaps
in
greater
measure
than any other therapeutic
procedure.
It should
never be
a routine ; to be useful it must be an individualized
therapy,
with
dosage
and preparation
and
time of application
varied to the
disease,
its intensity, its duration,
and the resistance
of the patient,
So used, nonspecific
therapy should prove
to be one of our most
use
ful measures
both in acute infectious diseases and chronic inflamma
tory lesions."
The
enthusiasm
embodied
in this last
sentence
may
be
unwar
ranted.
But
even though
some
may
not
be willing
to
accept
all
that the author claims
for nonspecific
protein therapy, this book
is
undoubtedly
a distinct contribution
to medical
literature,
(l. ,t.r.)
A Textbook of General
Bacteriology,
by Edwin
O. Jordan, Ph. D., professor
of
bacteriology
in
the University of
Chicago
and in Hush
Medical
College.
Seventh edition.
W. B. Saunders
& Co., Philadelphia, 1922.
In the new seventh edition of this well-known work the author has
made a thorough revision with
the addition of 52 pages of subject
material.
The
chapters
on
the
methods
of studying
bacteria,
the
hemophilic
bacteria,
and spore-forming
anerobes have been rewritten
and
enlarged.
Extensive
revision
has
been made
in
the
chapters
dealing
with
the
streptococcus
and
pneumococcus.
Typhus
fever
has
been
revised
and
placed
in
the
appendix
under
the
chapter
dealing
with
infectious
diseases
of
doubtful
origin
or
unknown
causation.
The spirochaetal
diseases have been brought
up to date
and grouped under
a separate
heading.
A commendable
feature of this edition is the effort on the part of
the author to get away from
the present
loose
and
unsatisfactory
bacteriological
nomenclature
by
using,
so
far
as
practicable,
the
322
Vol. XVII.
BOOK NOTICES.
nomenclature
proposed
by the committee
of the Society of American
Bacteriologists.
Objections to adopting new names for old ones will
be heard mainly on the ground of confusion, but it is a well-known
fact that wherever
confusion has reigned,
the establishment
of order
always results in temporary greater
confusion,
(j. h.)
Bacteriology,
General,
Pathological,
and Intestinal,
by Arthur
Isaac
Ken
dall,
B. S., Ph.
D.. Dr.
P. H., professor
of
bacteriology
in the Northwestern
Medical
School,
Chicago,
III.
Second
edition.
Lea
and
Febiger,
Philadel
phia
and
New
York.
1921.
The author is to be congratulated upon
the appearance
of an edi
tion that has been thoroughly
revised
and, where
needed, rewritten.
This edition, similar
to the first, is divided into
5 section
and
32
chapters: Section I—General bacteriology;
Section II—Pathogenic
bacteria;
Section III—Higher
bacteria,
molds,
yeast,
filterable
viruses,
and
diseases of unknown etiology;
Section IV—Gastro- in
testinal bacteriology;
Section V—Applied bacteriology.
In nearly every chapter extensive
changes and additions have been
made, in accordance
with the advance in the science of bacteriology
in recent years, prominent
among
which is the chapter on anerobic
bacteria.
The subheadings,
spacing, and print are excellent.
Illustrations
are few but good.
References
are extensive, and the revision has been
accomplished
with practically slight increase in size—30 pages.
The
reviewer believes that this newer edition will prove even more popu
lar than the preceding one.
(j. h.)
A Textrook of Bacteriology,
by Hans Zinnscr.
M. /)., professor
of bacteriology.
College of Physicians and
Surgeons,
Columbia
University,
New
York City;
with
a
section
on
Pathogenic
Protozoa,
by
Frederick
F.
Russell,
colonel,
Medical
Corps,
V.
S. Army.
Fifth edition.
D. Appleton
and Co., New York
City, 1922.
This work is a new edition in every
sense of the term,
as it brings
all
the
subject
matter up to date.
Consistent
without
advancing
knowledge of certain pathogenic organisms,
the
chapters
dealing
with the pneumococcus,
streptococcus,
meningococcus,
influenza, and
anerobic
bacilli
have
been
extensively revised
or rewritten.
Those
familiar with the extensive
literature concerning these subjects
will
appreciate
the brief,
yet complete,
manner in which the author has
summarized
the results of the numerous
investigations.
The same applies to the chapters
dealing with spirochetal infec
tions,
diseases caused
by filterable virus,
and
diseases of uncertain
etiology in which yellow fever, Rocky Mountain
fever, typhus fever,
etc., have
been
revised in accordance
with our present
knowledge of
these diseases.
The section on pathogenic protozoa by Russell has been completely
revised,
is thoroughly up to date, and contains many
excellent
illus
trations.
No. 2.
323
BOOK
NOTICES.
A commendable
and outstanding
feature
of the work which will
be
appreciated
by
the
laboratorian,
clinician,
and
public-health
worker alike, is the
successful
effort on the part of the authors to
correlate
laboratory knowledge with clinical
and preventive medicine
by
the inclusion of
a wealth of clinical
and epidemiological
data.
(J.H.)
Modern Italian Surgery and Old Universities
of Italy,
by Paolo De Yecchi,
M. D., F. A. C. S.
Paul B. Hoeber, New York, 1921.
Before the war American
students of the medical sciences went to
France, to Germany, or to Austria to visit the great clinical
centers
which
existed
in
those
countries,
but they
never
went to Italy
to
visit the hospitals or to learn from Italy's medical
teachers.
The
achievements
of Italy in medicine
and surgery during
the war have
been so great and
the country is so interesting that the American
medical man, with an inclination for a trip abroad, might well profit
by a visit to her sunny shores.
It is with the idea of familiarizing
American
surgeons
with the Italian School of Surgery
in the hope
that they will visit Italy "not
only
as
a pleasure
resort or
as
a
center of antiquities, but as a new country and
a new seat of educa
tion " that Doctor De Vecchi has written this readable
book.
In spite of the antiquity
of the Italian
peninsula, Italy,
as we
know her to-day, is a new country.
Only 62 years have passed since
Giuseppe
Garibaldi,
with
1,000
volunteers,
landed in Sicily
and
started
a revolution
which
ended
the domination of the Bourbons
and resulted in the unification of Italy.
Yet during that short time
the Italian
people
have
learned
to rely on their own capacities
and
to depend on their national unity, in which lies their strength, power,
and ability to develop their own resources to their utmost
extent.
Among
the surgeons
of modern
Italy who have
achieved
promi
nence
may
be mentioned
Edoardo
Bassini, of Padua,
who devised
the well-known
operation for the cure of inguinal hernia ; Francesco
Rizzoli
and
Alessandro
Codivilla, of Bologna,
who
are
noted
for
their work on orthopedics ; Enrico Bottini, of Pavia,
who has made
valuable contributions to the surgery of the prostate gland ; Edoardo
Porro,
of Milan, whose
name is associated
with his special
uterine
operation;
Antonio
Carle, of Turin,
and G. F. Novara, of Genoa,
who
have
contributed to the surgery of
the
intestines;
Francesco
Durante, of Rome, who has
devised
an
iodine treatment of bone
tuberculosis
; Raffaele Bastianelli,
also of Rome, who has extensively
contributed
to the surgery of the thorax and kidneys; Davide Gior
dano, who has contributed to the surgery of the kidneys:
Giuliano
Vanghetti who experimentally devised
a successful
method of utiliz
ing the muscles of a stump to actuate
artificial
limbs ; and Antonio
Ceci. of Pisa,
who,
applying
the principles
of this method
to the
human
subject,
attained
a much
more
satisfactory
prosthesis
than
324
Vol. XVII.
BOOK NOTICES.
ever before achieved.
There are a host of other men who, while per
haps not quite so prominent, have
attained
distinct
renown.
These
men Doctor De Vecchi introduces to his readers
as he conducts
them,
in the pages of this book, through the Italian universities.
In the book will be found
an excellent
review of Italy's medical
and surgical achievements
during the war, an account of the work of
reconstruction and of orthopedic surgery in Italy.
The latter half
of the book
is devoted
to an account of the Italian universities
and
their relation to modern
Italian surgery.
" There are at present
17
universities in Italy all under the control of the Government, with
a complete
course of medicine
and surgery of six years'
duration.
Each
is administered by the
same standard
and
regulations,
and
provided with a staff of professors and instructors elected by a special
board after public examinations, or by the exhibition of some special
scientific studies
or contributions which would entitle the candidate
to the responsible
position of teacher."
The number of universities in Italy far exceeds the needs of the
country.
Before
the unification
of Italy,
when
the land
was di
vided into small kingdoms and principalities,
the existence of a uni
versity for each State was justified, especially for political
reasons.
It is unfortunate
that some of these centers of learning
have
not
been consolidated,
as such
a concentration would strengthen the uni
versities
retained
and
would
provide
large clinics,
promote
more
uniformity of work, and would undoubtedly attract more attention
from
the
outside
world.
Educational
centers
in
Turin,
Rome,
Naples, and Palermo
might well supply
the
demand,
but certainly
such
a consolidation would deprive the visitor to Italy of the charm
of the universities in the smaller cities of Bologna, Modena. Parma.
Padua, Pavia,
Genoa,
Pisa,
and
Siena, which Dr. De Vecchi
de
scribes.
(W. M. K.)
Ephraim
McDowell,
Father
of
Ovariotomy
and
Founder
of
Abdominal
Surgery,
by
August
Sclmchner,
M.
D., F.
A.
G.
S.
J.
B. Llppincott
Co..
Philadelphia, Pa.,
1921.
This
is
a remarkable book,
the biography
of
a surgeon
who in
the early years of the last century laid
the foundation
of modern
abdominal surgery.
Biographies
of men who have achieved
success
in any line are always fascinating.
A natural curiosity
exists
con
cerning such persons.
We like to read of their everyday life, their
habit of thought, and of their accomplishments.
A certain lapse of
time must follow the death of one more or less entitled to fame
be
fore the story of his life can properly
be written, because his contem
poraries are so close to him that they can not view the details of his
life with
the proper perspective,
and if they
do write of him they
are apt to set down merely a series of facts, some of which are rela
tively unimportant.
So. 2.
325
BOOK
NOTICES.
The
contemporaries
of
Ephraim
McDowell
could
not
possibly
realize
the intricate
and marvelous
development
of abdominal sur
gery which
was the logical outcome of his discovery that the peri
toneal
cavity
could
be successfully invaded under proper
precau
tions;
nor
could
they
have
understood
the
factors
which
forced
him to explore fields which surgeons practicing
in the great medical
centers of that time dared not enter.
Ephraim
McDowell
practiced in Danville,
Ky.,
when
it was
a
small frontier
town.
His practice
extended for miles around.
This
was before
the days of roads or stage coaches, and his visits to his
patients were made on horseback
at times through trackless
regions.
Some of these calls meant
absence from home for a week or more,
especially
when
a surgical operation was involved.
Doctor Schach-
ner
gives
a delightful
review of the frontier
life in Virginia
and
Kentucky, and indicates
its influence
upon McDowell
and his surgi
cal work.
On December
13,
1809,
McDowell
was
asked
to
see
a Mrs. Jane
Todd
Crawford,
who
lived in
the wilderness some
60
miles
from
Danville.
He found her to be suffering from a large ovarian tumor,
a condition
which up to that time
had
been considered
inoperable.
Realizing the possibility
of relief only through surgery he induced
Mrs. Crawford
to make
the journey
to Danville,
where
he
success
fully removed
the diseased organ.
When
we realize that this was
the first time
this operation had
been
performed
and
the fact that it was
done without
the aid of
anesthetics,
antiseptics,
trained
help, or
any
operative accessories,
save the simplest domestic
utensils,
wre can understand the dramatic
possibilities
of the occasion.
To Doctor McDowell
apparently this operation was but an inci
dent in his daily life and it is possible
that he did not realize its
full significance,
as seven years
passed before his friends could pre
vail
upon him to publish
an account of three
such
cases
which
he
had successfully
operated
upon.
When
he .did publish his modest
account of the first ovariotomy it exposed him to the ridicule
and
sarcasm
of
some
of
the
foremost
surgeons
in
England.
Doctor
Schachner ably reviews
the entire controversy and defends McDowell
from those who attempted
to dispossess him of his justly earned and
richly deserved
honors.
Ephraim
McDowell
came more or less in contact
with many im
portant
personages of his day and Doctor Schachner has woven into
his tale delightful
sketches of such men as John Bell, of Edinburgh,
and Philip Syng Physick, of Philadelphia.
He concludes the volume
with
a very readable
sketch of Mrs. Jane Todd Crawford,
whom
he
aptly styles the heroine of the first ovariotomy,
(w. m. k.)
QUERIES.
Medical
officers are invited to submit queries
and
to present
their
problems
to the Bulletin,
which, being in a position
to draw
on
varied and extensive sources of information
such as are not available
elsewhere, will use every means of securing
authoritative opinion.
All queries will be answered
by mail; and the replies, if of sufficient
general interest, vrill also be published in this column.
To
the Editor: Please
publish
in
the Query
section
of
the Bulletin
some
good methods for the destruction
of lice on the body.
Lieutenant,
Medical
Corps,
U. S. X.
The following outline found in " Sanitary Entomology,"
by W. D.
Pierce, will be found useful:
Control of lice on body.
A. Crab louse.— (1) Kerosene emulsion soap: The soap is made by
boiling
1 part of soap chips in 4 parts of water and then adding
2
parts of kerosene oil, or 4 parts of gasoline.
This jellies when cold,
and
1 part
of this soap jelly is added
to 4 parts of warm water,
making
a good liquid soap at very small cost.
This is followed by vermin jelly:
Texas fuel oil.
sp. grav.
0.86
b.
p. 250
to
350°
C
-._
50 parts.
Crude
vaseline
20 parts.
Soft
soap
30 parts.
The cutting or shaving of pubic or axillary hairs is to be avoided
because of the discomfort
caused.
Powders
such
as N. C. I., etc.,
should not be used in the pubic regions.
B. Head
louse.—Wash
head
with equal
parts of
kerosene
and
vinegar
or 25
per
cent
acetic
acid for one-half
hour,
keeping
the
head
covered
with
a towel.
The vinegar
separates
the eggs from
the hairs, while
the kerosene kills them.
Use
a fine-toothed
comb
to remove the eggs and lice.
Wash the head with warm water and
soap containing
kerosene (Xuttall).
C. Body louse.— (1)
Bathe, using liquid
kerosene
soap emulsion;
(2) disinfect
and disinseet clothing, possessions,
etc.
328
Vol. XVII.
QUERIES.
In absence of facilities for the above—insecticidal powder (Moore)
-
Superior
to N. I. C.
Fumigation: Entomologists prefer cyanide.
In " Investigation of the Louse Problem," by W. Moore and A. D.
Hirschfelder,
the authors give the following summary of the problem
:
1. Lice
and their eggs are destroyed
by the ordinary
laundering
processes used in the washing of cotton and khaki goods ; for woolens
slight alterations in the methods of washing are necessary.
2. Chlorpicrin may
be used for fumigation
of garments,
accom
plishing
the desired
results
in
a short period of time, with
a small
quantity of the chemical,
without the use of high temperatures.
3. The
sachet
method
of controlling
lice
is
ineffective
or very
expensive.
4. Louse powders
may
be used with
success
but, being
a wasteful
method of applying
an insecticide,
are not recommended.
5. Impregnation
of the underwear is the most promising method
of
louse* control
between
lousings.
Active
chemicals
of
very low
volatility are necessary
to prove
effective for the longest
period of
time.
Halogenated phenols,
such as dibrommetacresol,
dichlormono-
brommetacresol,
and
their
sodium
salts,
dibromcarvacrol,
and di-
bromxylenol were found to be the most promising
under laboratory
conditions.
To the Editor: I was interested
in reading
the
communications
regarding tlie
treatment
of burns
which
"Ambustio
"
submitted
for
publication
in
the last
number of the Buixktin as evidence to support
his contention
that
picric acid
is not a proper agent to use in the treatment
of burns.
I believe the reaction
against
the use of picric
acid set in because it was feared
this chemical might
be
a
factor
in
the
production
of
shock.
In
this
connection
the following
extract
from
an" editorial
which
appeared
in
the Journal
of
the American
Medical
Association,
February 25, 1922. is offered
as a commentary
on the fact
that shock may be produced
in burns by other agents than picric acid, which I
have found
to be an extremely
useful agent in certain
types of burns.
" Cannon 1 has
recently
summarized
the
best-known
features of
wound shock
as characterized
by
a low venous
pressure;
a low or
falling arterial pressure
; a rapid, thready pulse ; a diminished blood
volume
; a normal or increased erythrocyte count and hemoglobin per
centage in peripheral blood
; a leukocytosis ; an increased
blood nitro
gen;
a reduced
blood
alkali
content;
a lowered
metabolism;
a sub-
Creosote
Sulphur-
Talc
1 c. c.
i gr-
20 gr.
Commander.
1 Cannon,
W.
B. : Studies
in
Experimental
Traumatic
Shock,
IV,
Evidence
of
a Toxic
Factor
In Wound
Shock, Arch.
Surg.
4 : 1 (Jai.),
19^2.
No. 2.
329
QUERIES.
normal
temperature
; a cold skin, moist with sweat ; a pallid or gray
ish or slightly
cyanotic appearance
; thirst
; rapid respiration
; often
vomiting and restlessness;
and anxiety, changing to mental
dullness
and
lessened sensitivity.
Many
of
these
features,
he
adds,
may
appear
at once or
as soon after the reception
of the wound
as the
observations can be made, or they may
develop
only after the lapse
of several hours.
At one time it was urged that the widespread
effect
in the organism induced by severe trauma might
be due to nervous
impulses.
Numerous
investigations,
however,
have
made
such
a
theory
untenable.
It matters
little for the outcome
of the trauma
whether the injured parts are denervated
or not; in truth, there is no
clearly
demonstrable
essential
relation
between
the
production
of
shock and an
excessive
stimulation of the central nervous
system.
Equally true is the now-recognized fact that the low blood pressure
initiated by severe injury is not primarily due to a loss of vasomotor
tone or any comparable
sort of exhaustion.
As Cannon
has
con
vincingly
pointed out anew, if the low blood pressure
resulting from
local trauma is not due to loss of blood
into the injured
region, or
to reflex vasodilation,
or to
depression
or exhaustion of the
vaso
constrictor
center,
or to fat
emboli,
or to
acapnia,
the
connection
between
the local damage
and
the general
bodily
state may
reason
ably
be looked for in the remaining
great
connecting
system—the
circulation.
"In harmony with this conclusion
there
has arisen
a theory of
a
toxemic cause of wound shock,
based on evidence
for the existence
of a toxic factor liberated in the injured
tissues.
Striking analogies
between
the physiologic
effects of certain occasional
tissue
compo
nents
and
the phenomena
of surgical shock
have
been
presented
by
Dale 2 and his associates in England.
Poisonous protein derivatives,
products of partial digestion, of bacterial action,
and tissue manipu
lation readily produce
a fall of blood pressure
attended with a series
of changes
in
which
' dilation
of
the
capillaries
and
pooling
of
blood within them, poisoning of their endothelial walls
so that they
are
abnormally
permeable,
escape
of
plasma
through
these
walls
into the tissue spaces, and consequent
concentration
of the corpuscles
are the main features.'
Championing
the importance of these fea
tures characteristic
also of traumatic
shock,
Cannon
has presented
a convincing review of clinical as well as purely experimental evidence
for traumatic
toxemia,
citing
in
particular
the
notable
contribu
tions of the French
surgeon
Quenu.3
They
show,
among
other
in-
* Dale
and
Laldlaw : Memorandum
upon
Surgical
Shock
and
Some Allied
Conditions.
English,
Medical
Research
Committee,
February.
1017.
Dale,
Laidlaw,
and
Richards:
Traumatic
Toxemia,
English Medical
Research
Committee,
Report
Series
26, March,
l'JIO,
P. 9.
'Quenu
: Rev.
dc ehlr. 56: 204,
1918.
330
Vol. XVII.
QUERIES.
teresting observations,
that anything which delays or checks absorp
tion from
the injured
region delays
the development
of shock:
but
if there is a sudden removal of the check serious results follows.
" If shock
is actually
the outcome
of an intoxication,
presumably
by protein derivatives set free from areas of tissue destruction, some
of the manifestations of severe burns
become more easy of interpre
tation.
As Cannon concludes,
in harmony with other experts in this
field,
the
present
conception
seems
to
be that
not only
the
shock
following burns,
but also
the
delayed
shock
consequent
on
severe
trauma, is properly
placed
in the same category
with
some forms
of general
depression
of bodily functions
and
defective
circulation
due to the setting free of toxic material in the body."
To
the Editor:
Is there any way of rejuvenating
dried-out
adhesive plaster?
I.IErTKNANT.
Unroll the plaster, and, without stripping off the muslin covering,
wipe over with a gauze sponge wrung out of cottonseed oil.
Warm
over a radiator or in a sterilizer for an hour and the result will be all
that could be desired.
THE DIVISION OF PREVENTIVE
MEDICINE.
Lieut.
Commander
R.
F. Jones,
Medical
Corps,
United
States
Navy,
In charge.
Notes on Preventive Medicine for Medical Officers,
United
States Navy.
INSTRUCTIONS
TO MEDICAL OFFICERS.
STUDIES
ON VENTILATION
OF
CLOSED
COMPARTMENTS.
Conducted
in
the laboratories
of
the Naval
Medical
School,
by
Lieut.
Commander
R.
F.
Jones,
Medical Corps,
V.
S. Navy,
and Lieut. J. E. Henry,
Medical
Corps,
U.
S. Navy.
BRIEF DISCI SSION
OX MODERN
VIEWS
OF VENTILATION.
The problem of supplying air in sufficient
quantity and of proper
quality
to
an
occupied
space
must
take
into
consideration,
first,
physical properties—temperature,
humidity,
and
air
movement —
which
control
the cooling power of the air upon the surface of the
body:
second,
chemical
constituents; and third,
the variability
from
time to time of the physical properties already mentioned.
Inasmuch
as the cooling
or heating power of the atmosphere
surrounding
the
body governs
to
a large extent
the physiological
function of heat
elimination, the physical properties of air should be given first con
sideration.
The chemical
purity
of the air is also an essential; but,
contrary to the former belief of sanitarians, the physical properties
are of far greater
importance than the chemical.
The importance of
the third factor—viz. the proper range of variability in the physical
properties
of air supplied for human
consumption—has not perhaps
been fully realized.
Yet a variation in these properties undoubtedly
stimulates
the human
mechanism,
giving
tone to the vasomotor
sys
tem, exciting muscular activity,
and thus assisting the proper func
tioning of glandular, respiratory,
digestive,
and vascular organs.
I. Cooling power of the air.—The comparison of the human body
to
a furnace
is, in many
ways,
an apt
one.
However, the ordinary
furnace
is kept at no particular temperature and
a variation of many
degrees
is unsually unimportant, whereas the human
body is .a special
furnace that must constantly be kept at a temperature
of about
98.6°
F. and a variation of so little
as li° from that temperature
will cause
108165—22
10
331
332
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
discomfort.
Through
centuries
of hardships in the past the human
body has been admirably trained to resist cold but it has been shown
that only to a limited extent can it resist heat.
Therefore, one of the
biggest
problems
in ventilation
is to avoid overheating, which
in
reality
is more
injurious
than the reverse — unless it be in the
case
of the very young, the very old, or invalids.
Through
various physiological
processes the body
is continuously
eliminating
heat to maintain itself at a standard temperature
of ap
proximately
98.6° F.
Some of the more important of these processes
are the dilation of the cutaneous capillaries to allow the exposure
of
a larger volume of blood to the cooling air about
the body surface,
the accelerated heart action to increase the rapidity
of flow and con
sequently
the amount
of blood that can get to the surface in a given
time, and the secretion of perspiration
and its evaporation.
On the
other hand,
the
body,
when
necessary,
may
check
to
a degree
the
amount of heat that it will give off.
It can also provide extra heat
when elimination
from outside
causes is great
by increasing its fuel
consumption.
In addition, in our civilization,
man successfully pro
vides against too much loss of
body
heat by warm clothes
and by
artificially heating the air of his living apartments.
In fact, since this
is so often overdone,
we have to deal with overheating in our ventila
tion systems more than with underheating.
In general then the prob
lem of ventilation is to surround the body with air of such physical
properties that the heat loss will be just sufficient
to maintain body
temperature
at 98.6° F. without having to call too much on those auto
matic devices by which a person can increase or decrease his heat elim
ination.
If the physical conditions of the surrounding
air take
the heat
away from the body too rapidly or too slowly the body protects it
self against heat loss or heat gain by those means with which nature
has provided.
If it does not readily succeed these mechanisms
have
a heavier and heavier strain put upon them, and if they finally fail
the body suffers the consequences of a decreasing
or increasing body
temperature
(98.6°
being
the standard).
The
oppressive
feeling,
the drowsiness,
and other discomforts associated with
a warm, close
room
are the results of too little cooling power of the air (physical
property)
and not to an increase
in the C02 in the air (chemical
property).
This was proved some years
ago by Flugge.
He placed
men in a
closed
cabinet
and
allowed them
to
breathe
and
rebreathe
the air
contained
therein until they
were very uncomfortable.
He then in
troduced
fresh air to them through tubes without changing the con
dition of the air that surrounded their bodies.
They got no relief
at all, although they
were getting air which contained
little carbon
dioxid and about
21 per cent of oxygen.
He then allowed men out
,N'c.2.
333
DIVISION
OF PREVENTIVE MEDICINE.
side of the cabinet
to breathe the air from within the cabinet through
tubes while their bodies were surrounded by fresh outside air.
They
experienced
no discomfort, although they were breathing the foul air
of the cabinet which contained
an excess of carbon
dioxid
and other
expired
impurities,
as well
as
a decreased
amount
of oxygen.
The
excessive heat
and humidity
that were
generated
in the cabinet
by
the bodies of the men were the
causes of the discomfort
(physical
changes)
and not an increase of carbon
dioxid and other impurities
(chemical
changes)
.
As the heat and humidity in the compartment
rose the cooling power of the air, of course, grew
less and
less until
the body could no longer eliminate enough heat to keep itself at 98.6°
F.
As a consequence
the body
temperature
began
to rise, and
as it
rose the discomfort
became more
and
more
marked.
Men
outside
not in contact with this heat and humidity did not have a consequent
rise
in their body temperatures
and
were,
therefore, entirely
com
fortable,
although they breathed the cabinet air.
The cooling power of the air upon the body
is dependent
on :
(1) Radiation. —This
is
dependent
on
the
difference
between
the temperature of the body (98.6°)
and that of the surrounding air.
The colder the air the greater
the radiation.
Hence,
the importance
of the temperature
regulation of the air.
(2)
Convection and conduction. —Air movement
and temperature
of the air are both
involved.
Currents
of air
(which
need not be
drafts)
replace
frequently
the aerial blankets of warmed
air about
the body with cooler air.
The frequency
of replacement
(air move
ment)
as well as temperature
of the replacing air, then
measure the
amount of heat that is taken
away
from
the
body
by convection.
High humidity at a temperature
of 65° F. and under favors heat loss
by convection
and conduction,
whereas
at
70°
or over
it prevents
heat loss by hindering evaporation of perspiration.
(3)
Evaporation. —This
depends
on
three
things —temperature,
air movement, and water-vapor
tension
of the air.
The higher the
temperature
of air the more
moisture
it will hold
and
the greater
will
be its capacity
to evaporate
the
perspiration
that covers
the
skin.
In stagnant air evaporation of perspiration
would soon cause
the body to be surrounded by an aerial blanket of almost
completely
saturated air, and
as a result no more evaporation could take place.
Air movement
would
remedy
this
and would
replace
this blanket
surrounding
the
body
with air not
so nearly saturated
with
water
vapor,
and,
therefore,
capable
of
permitting
evaporation.
The
drier
the
air
or the
lower
its water-vapor
tension
the
greater
its
evaporation
capacity.
334
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
To
summarize,
the cooling
power
of air
upon
the
hody
is
de
pendent
on :
(1)
Radiation,
affected by—
(a)
Temperature of surrounding
air.
(2)
Convection and conduction, affected by—
(a) Air movement.
(b) Temperature of surrounding air.
(c) High humidity
at less than
65 ° F.
(3) Evaporation,
affected by—
(a) Air movement.
(5)
Temperature.
(r)
Water-vapor
tension
(determining
the
amount
of mois
ture which the
atmosphere
is still capable
of absorbing).
To attain, then,
the proper
air
movement,
water-vapor
tension,
and
temperature
and
to have proper variations
in them
is the
aim
of the modern
ventilation engineer.
It is better in our ventilation work to think of humidity
in terms
of water-vapor
tension
or
as grains of moisture
contained
in each
cubic
foot of air rather than
as relative humidity.
For example,
air of 25 per cent relative humidity
at a temperature
of 55° F. dries
the skin
and
mucous
membranes
in an unpleasant
manner:
but if
the same air is maintained at 25 per
cent relative humidity
and
is
raised
to 85° F.. it has an agreeable
effect upon the skin and mucous
membranes.
The explantion of this is that at 55° F. air can hold
only
5
grains of
moisture
per
cubic
foot
when
fully
saturated.
Twenty-five
per cent relative humidity,
then, gives only
1} grains of
moisture
per cubic
foot of air, which
is too dry for the skin
and
mucous membranes.
The vapor tension
of such air is about
2.8 mm.
of mercury.
At 85° F. the capacity of the air is about
12.5 grains
per cubic foot and with 25 per cent relative humidity
it would con
tain over 3.1 grains per cubic foot and have a vapor tention of about
7.9
mm. of mercury
as compared
with
1.25 grains and
2.8 mm. of
mercury for the same relative humidity
(25 per cent)
at 55° F.
It is readily
apparent that if all these factors contribute to the
cooling power of the air. and if this is of such prime importance in
ventilation,
an instrument that could
register cooling power would
be of immense value.
It would, indeed, indicate the effects of many
causes— some of which, such
as air movement,
are not readily meas
ured-—in ow.
figure.
Such an instrument
has been devised
and
is
known as the katathermometer.
A description of it follows.
Many
hundreds of observations
with it have convinced
the authors of
its
great
value,
practicability,
and
accuracy.
Its
inventor
has intro
duced
another
instrument for the same purpose,
but adapted
more
particularly
for popular
use.
This he calls the comfimeter.
A de
No. 2.
335
DIVISION
OF
PREVENTIVE
MEDICINE.
scription of it
also
follows.
Many
observations
have
been
made
with the comfimeter
by us, but judgment on it is reserved until it has
been more completely
studied.
The
katathermometer.
—The
katathermometer
is
an
instrument
devised
by Leonard Hill to measure the cooling power of the atmos
phere exerted
on its surface
at body
temperature
(36.5° C).
It is in reality an alcohol thermometer
with a relatively long cylin
drical
bulb 4 cm. long by
2 cm.
in diameter and
a stem
20 cm. in
length, graduated between 95° and 100° F.
To use the instrument, it is immersed
in water at a temperature
not over
80° C, until
the column of alcohol (colored red) is raised
above
100° F. and overflows into and half fills the overflow reservoir.
The thermometer
is then taken from the water and suspended
in the
air.
A stop
watch
records
the number of seconds required for the
column to fall from 100° F. to 95° F.
Each
instrument
has
a factor
determined
for it at the
factory,
which,
when divided by the number of seconds consumed
in falling
from
100° F. to 95° F., will give
the cooling power of the air in
mi He-calories
per square centimeter
per second exerted on its surface
■At 98.5° F.
Two readings are commonly taken,
a wet and
a dry.
To get the
wet
kata reading, the bulb is covered
with
a knitted cot, immersed
in hot water
and held in the air.
The cooling effect of evaporation
enters into this reading.
The dry
kata
observation
is obtained
by
immersing
the
bare
instrument,
drying
it.
and
holding
it in
the
air.
The
rate of cooling of the
surface
of thi* instrument
(and
by
analogy, of the surface
of the human
body) depends
on convection,
evaporation,
and
radiation.
The dry
kata
cooling power depends
almost entirely on convection
and radiation,
since the surface
of the
instrument
is not covered
with
a wet cover and
is purposely wiped
dry.
The wet kata reading depends
on all three factors;
the differ
ence between the wet and dry gives the cooling power from evapora
tion
alone.
It should
be remembered
that this instrument measures the power
o* the atmosphere
to cool its own
surface
when
the temperature
of
that surface is 98.5° F.
If the
atmosphere
has
a certain cooling
power on objects
at this temperature
the rate of cooling of the sur
face
of such
objects
will
depend
on their character
as .well
as the
cooling power of the atmosphere.
In the
case of the skin, the rate
would depend on such things as the amount of clothing, the amount
of moisture produced
by the body,
and the structure of the skin and
tissues
under
it,
as well as the cooling power of the air around
the
body.
336
Vol. xvn.
DIVISION
OF
PREVENTIVE
MEDICINE.
The experiments
performed by the authors seemed
to indicate that
the cooling power of air should not be less than
15
wet kata and
6
dry kata for sedentary
occupations.
The instrument appears
to accurately measure
the cooling power
of air, and, since the comfort of man depends
so much on the control
of his heat elimination, it is very important
to know just how much
heat
a surrounding
medium
can take from him.
This is probably
the most important
single factor in the
realm of ventilation.
The
katathermometer,
or some
modification of
it,
has probably
come to
stay.
The
comfimeter. —Comfimeter
observations
in
these
experiment-)
are
recorded
for what they are worth.
No opinion
has yet been
formed as to the value of this instrument, but data
is
being gathered
for this purpose.
Leonard Hill
is
the inventor of this instrument
also,
and in
a
letter he makes
the following preliminary
remarks.
He has informed us that he will soon publish
a
paper on this subject.
In order
to
keep
comfortable
conditions
in rooms by determining
the cooling
power
by
convection
or
radiation —convection
depending
on
the
temperature
and
movement
of
the air—
I
have
designed wl
instrument,
which
I
call
a
" Comfimeter."
This
takes
the
place
of
the
katathermometer
for
ordinary
civilian
use.
The katathermometer
requires
to
be
heated in water,
and
the
cooling
rote measures as the meniscus
drops from
100°
to 95° F.
The warm
ing of the katathermometer
and the time measurements
are against its popular
use.
The comfimeter
is an instrument
which
can be read at any time just
as
the ordinary dry bulb
thermometer;
it
consists
of
a
cylindrical
metal
box
18
cm. high and 10 cm. in diameter,
in which
is inserted
an
8
candlepower
carbon
filament
lamp,
the
lower
part
of
the box
being
removable
for this purpose.
On the top of the box is fixed
a
metal
cone,
which
in its turn forms
a union
with
a
chimney
25
cm.
long
and 2J
cm.
in
diameter.
There
are
some
holes
in the lower
and upper part of the box for the purpose of ventilation.
An ordi
nary
dry
bulb
thermometer
is introduced
into
the chimney
so
that
the bulb
hangs within
it
to
a
depth of
9
cm.
The thermometer
rests
on the top of
a
chimney
by
means of wire
which
is
twisted
around
its stem in a suitable
fashion.
There
are two
disks
of gauze through
which
the
stem
of the ther
mometer passes to give it
a
central
position
within the chimney.
The candle-
power lamp acts as
a
constant
source of heat and the box and the chimney
are
cooled
by
radiation
and
convection.
Under
satisfactory
conditions
in ideal
summer days, with the windows
open,
the comfimeter
standing
on
the table
in
my room indicated
a
temperature
of
about 30° C.
In
a
close room, heated, with
hot-water
coils
on and the windows
shut, the comfimeter
indicated
a temperature
of
40°
C.
If the comfimeter
be
sheltered
from
wind
by
a
screen
of cotton
material
placed
around
it.
it
will
Indicate
in place of, say, 30° C, u temperature
of about W C, while the dry
bulb
thermometer
standing
within
the
same
screen will
only
vary
a
degree
or
two
as
the
result
of
screening.
These
figures
show
how
sensitive
the
comfimeter
is
to the cooling
power
of the wind.
It must,
of course,
be given
time to get in equilibrium
with
the environmental
conditions.
When
the
comfimeter
indicated
30°
C.
the
dry
katathermometer
gives
a
cooling
power
of about
7
mille-calories
per square
centimeter
per second.
So
long
as schools
and
factories
are
kept with
the
comfimeter
indicating
some
where about 30° C. fresh conditions
suitable for work will
be obtained.
No.
2.
337
DIVISION
OF PREVENTIVE
MEDICINE.
In another letter of January 22, 1922, he states:
We have been
investigating
the behavior
of the " Comf."
against
that of the
" Kata "
recently.
We
use
the "Comf."
as
made by
Siebe
Gorman
(Ltd.),
187
Westminster
Bridge
Road,
London,
with
measurements,
blackened
sur
face,
orifices,
and
thermometer
arranged
according
to
instructions
given
to
this
firm.
The lamps
we
use are
8 British
candlepower
carbon
filament
ones
supplied
to us by
Edieswan
& Co., Queen Victoria
Street,
London
E. C.
This
firm picks out lamps for us which
take the same
number of watts.
It does
not matter
whether
the current
be, say,
100 or 200 volts, but it does
matter
that
the voltage
should
be steady.
It
does
not matter if the voltage
swings
up and down
a little
as leads
come
on
and off, and average, say,
100,
but it matters
considerably
if the voltage
Is 95 or
105 in place of being
100.
Given
the right
lamp and voltage, the " Comf."
in air of rooms with no sensible
draft gives readings
which
can
be graduated
against
the
" Kata " quite
well.
The
" Comf."
is not
meant
to
be
used
in
sensible
drafts.
The paper
dealing
with it we are now preparing
for the press, and when ready we shall
probably
send
it to the American
Journal of Industrial Hygiene.
II. Purity of air.—In the past, physiologists
and sanitarians
be
lieved
that the bad effects of close, ill-ventilated
rooms
were due to
increased
carbon-dioxid
content
and decreased
oxygen.
This was
a
plausible theory.
Acting on
it,
sanitarians set
a
standard of so many
parts of carbon
dioxid
per
10,000
as a maximum, which should not
be exceeded, and required sufficient air turnover to keep
it
at or below
that figure.
By doing this they overcame the discomforts due to poor
ventilation, for they were getting rid of other conditions at the same
time they removed
the carbon
dioxid.
The experiments
of Flugge and others
definitely proved
that the
harmful
effects had not
been
due to the carbon
dioxid or other im,
purities
but to the physical effects of air on the surface of the body.
Many clung to the idea that emanations
from the body were respon
sible for some of the ill effects, but no acceptable
proof of this has
ever
been
offered.
Of
course,
in
submarines
and
other
occupied
closed
compartments,
carbon
dioxid will soon reach
dangerous
con
centrations and the oxygen will be reduced
very rapidly unless pro
vision
is
made
for purifying
the
air.
Body
odors —for
esthetic
reasons, if for no others —are not tolerated in
any
good
system of
ventilation.
But ordinarily,
if
air be obtained
from
a
good
source
and is free of gases,
smoke and dust, we do not have to concern our
selves with its chemical
composition.
If pure at the source, the turn
over necessary
to take care of the physical properties prevents
any
serious vitiation.
In fact, long before
any such acquired
impurities
could have any effect conditions would have become intolerable from
other causes.
III.
KaNOE
OF VARIABILITY
IN THE
PROPERTIES
OF THE AIR.—When
all
has
been said
and
done
about
ventilation,
nothing
is
better
or
healthier than window
ventilation
properly
handled.
This
system
permits of the best range of variability.
A hothouse plant, constantly
338
Vol. XT11.
DIVISION
OF PREVENTIVE MEDICINE.
subject
to the monotony of unnatural
and unvarying
warmth
and
humidity,
is fragile
and
delicate,
full of sap
and lacking
in fiber.
Yet, if the temperature,
humidity,
and air movements
are given
con
stant variation without going to foolish extremes
a much more hearty
and virile plant can be raised
even in
a hothouse.
Monotony
tends
to
stagnation
and
disintegration,
whereas
variety
stimulates
and
freshens.
By widening
the
range
of variability
we stimulate
and
keep
active
all
the
functions— the circulation
is
quickened,
waste
products
burned
and
removed,
muscular activity
is
increased
and
every gland and organ in the body is made more healthy and active.
Variety
is literally the spice of life.
EXPERIMENTS.
The studies submitted
herewith deal mainly with the physical con
ditions of air in closed occupied
compartments.
In some of the ex
periments the chemical
aspects werfe^also considered.
The
conditions
dealt
with
are
unVsual,
such
as might
exist
in
submarines
or compartments
into which and from which no air can
be taken.
The conclusions
are. therefore, applicable to such problems
only and would probably be of little value in ordinary ventilation.
From
the evidence
obtained
it would
seem
that relief
from
the
acute
distress
resulting
from extreme
physical
and
chemical
condi
tions in such
compartments
is entirely
feasible
and
that men
may
be made comfortable
in such
places
by reconditioning
the air for
short periods without
injurious
effects.
Whether
long confinement
in them would be possible without danger is another
question.
P^xperiment I
was performed
to show,
first, the
rise
of carbon-
dioxid
and fall in oxygen
within
supposedly
safe limits
in
a closed
occupied
compartment; second, how
temperature
and humidity
may
lie satisfactorily
controlled
at the same time
by means of cold coils
and
fans.
The experiment
was done three
times
in order to give a
good check on the work.
Experiments II to VII were performed to show
the effects of air
motion (electric fan)
and cold running
water
in coils on air condi
tions in a closed occupied
compartment.
The chamber
used was a double- walled cabinet of special
construc
tion and
so insulated as to allow
a minimum
escape of heat, gases,
or sound.
The dimensions
were
7 by
7 by
5.83
feet.
After proper
deductions
for furniture
and other contents,
there was a net capacity
of 278.8 cubic feet.
There wore 44 lengths
of water coils, each 33.5 inches
b,y
1 inch in
diameter
(outside
measurement).
The inside
diameter of the piping
was j inch.
The fan was
a 16-inch
Westinghouse.
It was always run at first
speed.
No. 2.
339
DIVISION
OF PREVENTIVE MEDICINE.
f
g
I
J-
=
£
•v
2
c
—
I
1
s
s
1
s
s
a.-^^
s=.c'.;
=rE
« c ©
S '- -c
Z O
* C °-
« c
HI
3>3
C.I-
OC — —(C
at
—ci
8
!
s
?£g
ii,-:,-:'
—.—,{N
:
C r-
ss£ sr..
.ti 5
^re—o
E t e J Q.C.6.
* p£I?
csci co
CO
•4-
C
o
<
I
a
•—I
H
O
x
o
To
show
rise
of
C03
and fall
in
03
within
supposedly
safe
limits
in
a
closed
occupied
compartment,
etc — Continued.
EXPERIMENT
I
(C).
Per cent
of O,.
20.9
19.3
18.6
17.3
16.9
16.2
Per cent
of CO,.
0.04
1.7
2.5
3.51
3.8
4.4
Comfi-
meter
reading.
39.8
40.6
35.1
35.3
31.2
28.3
27
Dry kata
cooling
power.
1.9
1.5
2.9
1.8
5.9
7.4
7.6
Wet kata
9.9
10.2
18.5
25.1
cooling
power.
7
8
23
Dry kata
tune
(seconds).
275
347
183
291
90
71
69
Wet kata
time
(seconds).
53
75
52
66
29
23
21
Grains
of
moisture
per cubic
foot of
Bir.
7.13
10.67
12.21
15.04
9.57
6.84
6.08
Relative
humid-
ity.
57
79
86
94
87
72
64
Dry
bulb.
84
87
88.5
92.6
80.5
75.5
76
Wet
bulb.
72
81.5
85
91
77.
5
oas
67
Time.
1
1.30
2
2.30
3
3.30
4
Remarks.
Warm,
men
perspiring;
respiration
18.2; no
fan; no
cooling coils.
Hot, men perspiring
freely;
respiration
19.2.
Fan
on at 1.52.
Afforded
some
relief; close, heavy;
heavy
perspiring;
respiration
22.
Hot,
uncomfortable:
respiration
23.2.
Three
men
complained
of headache.
Water
on
at
2.46.
Relief
felt
in
a
few
minutes;
respiration
22.4.
Matches
would
not
burn.
Respiration
23.1.
Quite
cool; headache relieved.
Cold, chilly;
suggestions to turn fan oil; respiration
25.
OUTSIDE
CONDITIONS.
3.21
3.96
30
36
79.5
80
00
62
1 4
35
37
im
in-.
15.
1
14.3
3.4
3.2
(1) Five
men were used, entering at
1
p. m., emerging at
4
p. m.
(2) Net
capacity of cabinet
278.8 less space occupied
by men themselves.
(3) Water
passed through coils at rate of 40 liters
per minute.
(4)
Temperature
of water as
It
entered and left the coils:
Time.
2.51 p. m.
3.16 p. ra.
3.36 p. m.
3.56 p. m.
Inlet.
6.3° C.
4.1° C.
4.0° C.
4.1° C.
Outlet.
6.9° C.
5.1° C.
4.8° C.
4.6° C.
Notes.
Comfort
fair.
Do.
No. 2.
341
DIVISION
OF
PREVENTIVE
MEDICINE.
21
1
1
—
BINET
J*
3
-
u.e
i
.
m
I
"
4
M
!
o
az
<
PERCENT
OF
CO,
■
at
«
1
i
1
■
S
5
8
e
8
om
eo
■am
N
i
X
V
EXPERIMENT
1(e)
SHOWING
PERCENTAGES
OF CO,
AND
0a IN
ATMOSPHERE
OF
A
CABINET
OF
26S CUBIC
FEET
CAPACITY
WHEN
OCCUPIED
BY
S
MEN
FOR
3
HOURS.
N
Conclusions, Experiment
I.
1.
Five men
in 265
cubic
feet of air raised
the carbon
dioxid
to
4.5 per cent in about three hours.
They lowered the oxygen
to about
15 or 16 per cent in the same time.
2.
These limits for that length of time
caused no distress
to men
not engaged in manual work, when humidity and heat were controlled.
3.
Before
the
carbon
dioxid
reached
4.5
per
cent
and
oxygen
16
per cent, when
the heat and humidity
were not controlled, the com
342
VoL XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
partment became oppressive if not unbearable
as a result of the heat
and humidity emanating from the bodies of the men.
4. Carbon dioxid
and oxygen
conditions and body odor conditions
to some
extent are susceptible
of control by method practiced in sub-
EXPERIMENT
1(c).
EFFECT
OF
COOLING
COILS
AND
AIR
MOTION
(COMBINED)
ON
UNFAVORABLE
TEMPERATURE
AND
HUMIDITY
CONDITIONS
WITH
FIVE
MEN CONFINED
IN
AIR-TIGHT
CABINET
OF
265
CU.
FT.
CAPACITY
FOR
3
HOURS.
marines.
Heat and humidity in submarines
are probably taken care
of by cold water on the skin of the ship and precipitation of moisture
on the inside.
.r>. Since
no
such
escape of
heat
and
moisture
from
air within
closed
compartments
in the center
of
a large ship
is possible,
un
No. 2.
343
DIVISION
OF
PREVENTIVE
MEDICINE.
doubtedly
some consideration will have to be given to these
factors
in caring for air conditions under such circumstances.
6. This experiment showed that fans up to a certain limit will give
great relief;
this limit being approximately
the
body
temperature
(98.5° F.) and very high relative humidity.
The effects of convec
tion and evaporation from a fan would then
cease to operate.
7. When the above limits
had
been approximated
in the experi
ments,
cold
water
was run through coils, thus giving
a cooling unit
as well as a surface for precipitation of moisture.
The fan was left
on and rapidly passed the moist, hot air over the cold coils.
8. complete relief was obtained in this way.
344
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
P c
t c
- 3
If
12
■5 "
No.
2.
DIVISION
OF PREVENTIVE
MEDICINE.
i
S3
Comfl-
meter
reading.
Remarks.
Uncomfortable,
but
easily bearable.
Fn
Moisture
on colls at 2,35.
More comforts
Small
drops on coils at 2.55.
Still
uncomfortable
but bearable.
No
dripping.
Some (tripping.
.
Still
uncomfortable.
Almost
com/ortable.
Hi
?<£>oe*<e«cr^ac
l-ieieiNficici
lit
wcooooooon
ssiasjJssJs
Wetkata
time
(seconds).
53333333
Grains
of
moisture
per cubic
foot of
air.
8SS388SS
-
ftp
.
Jlift.'lb
8SgS8833
#.
?-
• #
•
■
•
>
*
Ui
•
^
>
*
. ■
•
*
s
e
SS3S3S51
1
ouoouoo
3
u. t. t* t, u. u.
f^c c o e «
o
c
jSBBaSE
.£~g.«PS|;Sg38S
Oui>^
oi c«e*5eo
co
346
vol. xvn.
DIVISION
OF PREVENTIVE MEDICINE.
Conclusions, Experiment III.
In
1 hour and 45 minutes
there were marked improvements.
These
were mainly
due to
(a)
lowering
of temperature
(7°
in
wet
bulb
and
19.5° in dry bulb temperature), and (b) improved dry kata
con
ditions, as seen in columns
2. 3, and 9.
2. Readings of the comfimeter
decreased very slowly.
3. Wet kata conditions did not change greatly.
No. 2.
347
DIVISION
OF PREVENTIVE
MEDICINE.
348
DIVISION
OF
PREVENTIVE
MEDICINE.
Vol. XVII
x
-o
2
mzH
in
u
■•
<o n
5
o
M
»
m
oo
x
F
O
X
X
o
I
HILLECALORIES
PER SO.C.M.PER
SECOND
GRAINS
H20 PER
CU.FT.
OF
AIR.
s owo><oroG!S£i!
2
3
8 8!*
w
I'M
•
\
\
11401
■
I
ne
Ml
KID
*M
):4<
i
s
o
«
o
I
m
S•
■
n
■
A
S
5
O
1
■>
r4*f
»
sX
_
I
c
■
S:5B,
\
p
4:10
o
••>
«d
i3
;8
i
k
a
!s
a
i*
8
■
1
■
X
t
t:m
3a
?J
>
*
i
w
It II
i *
|S
P c
Conclusions, Experiment IV.
1. In
30 minutes,
from
1.48 to 2.18
p. m., better
conditions
were
obtained
than was obtained
in Experiment III with
cold running
water in coils in
1 hour and 45 minutes, from 2.25 to 4.10.
In other
words, with high temperature
and low relative humidity,
air motion
and cold coils together
were over three and one-half times as effective
No. 2;
DIVISION
OF PKEVENTIVE
MEDICINE.
as cold
coils alone.
The
added
efficiency
obtained
from
a fan
de
pends, of course, on its size, speed, and position with relation to the
amount of air passing directly over the coils.
2. Although air motion itself does not take out heat and humidity
(Experiment II (b)), it does force the air over the coils many times
more rapidly than it would naturally
pass over them, thereby getting
much more rapid action from the coils.
09
i
O
To
show
the effect
of
air
motion
(electric
fan)
on
high
temperature
and
high
relative
humidity.
EXPERIMENT
V.
[Observations
made with
fan off.]
Remarks.
Very uncomfortable.
Uncomfortable.
Comfi-
mcter
reading.
43
41.5
Dry kata
cooling
power.
.95
1.7
Wot kata
cooling
power.
4.4
7.5
Dry kata
time
(seconds).
555
310
Wet kata
time
(seconds).
121
70
Grains
of
moisture
per cubic
foot of
air.
13.34
11.74
Relative
humid
ity.
85
87
bulb.
92
87
Dry
Wet
bulb.
87.5
83.5
Time.
2
Notes.
(1) Observer
entered cabinet
at 1.45 p. m. and left
it
at
'2
p. m and entered
again at
I
p. m.
Allowance,
therefore, should
lie made
for increase
of humidity
and
temperature
due lo his presence for 30 minulcs.
Allowan'-e
also should
be made for some dilution
of air when he left and reentered the cabinet
during the experiment.
(2) When
observer entered at
4
p. m. the comfimeter
registered 33.2 (fan had been on).
In
15minutes
it
registered 41.5° (fan off).
('onc/iHiorti,
Kiptriinrnt
V.— (1) With
a
high temperature
and
high relative
humlditv
actual
physical
conditions
were little
changed
by brisk
air motion.
(2) With
high relative
humidity
a
fan can do little
for comfort
by evaporation
since the air
is
almost
saturated.
With
high temperature
it
can do little
by convection,
because
removal
of the warm
aerial blanket
about the
body and its replacement
by air almost
as warm
as the
body helps very little.
(3)
Comparison
of (a) and
(b),
Experiment
II, shows that comfort
conditions
were much
improved
with
high temperature
and
low
humidity
when the fan was on, due
prin
cipally to possibilities
of evaporation.
No. 2.
351
DIVISION
OF PREVENTIVE MEDICINE.
w
able.
M
Water
turned
on.
Soon more comfort
Uncomfortable,
but
slight
improvemei
Do.
Do.
Do.
Do.
|
Do.
it.
1
|
Almost
comfortable.
Do.
Comfi-
metcr
reading.
42.5
41.9
41.2
40
40
39.5
39.2
39.1
39.
1
1||
■^tiO».-H—« 'f5
<©
St.-
at>C00
"3CO»C'OO
lis
.-i o>ci o -~o
r4cs
o
5
o
(seconds).
Dry kata
time
if
Is
uns of
isture
cubic
ot of
lir.
Relative
humid-
ity.
iOiOiO
bulb.
Dry
Wot
bulb.
S7
77.5
74
70.5
69.5
87.5
06.5
65
84.5
Time.
i
en-~
1
g
GciddddddtJ
§
.
8
§
%
1
^^^^
I
°Sg3|
«l3ogt
. BB6ESESE |".|n«s
ci
re
:c -* HvS^c^k
4>o»ol
352
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
To show the combined effect of air motion
(electric
fan) and cold running water
in coils
on high
temperature
and
high
relative
humidity.
EXPERIMENT
VII.
Remarks.
Soon very
comfortable.
Mois
ture
on colls
at 10.22.
Felt
improvement
almost at once.
Drops on oolls at 10.28;dripping
from
coils at 10.30;very com
fortable at 10.38.
Notkb.
1. Water running Bt rate of 40 liters per minute.
,
2. Temoeratures
of water:
Time, 10.25a. m.;
ingoing,
8.0° C; outgoing,
6.3" C.
3. Observer
remained
in cabinet
throughout
the experiment.
Time.
Wet
bulb.
A.
M.
10.21
82
10.3»
63
Dry
bulb.
Bt
Ti
Rela
tive hu
midity
68
Grains;
of
mois
ture
per
cubic
foot
of air.
10.9
5.04
Wet
kata
time
(sec
onds).
75
23
Dry
kata
time
(sec
onds).
65
coollngjcoollng
Wet
kata
power.
24
Dry
kata
power.
1.2
Comfl-j
meter ]
read
ing.
44
27.8
Xo. 2.
353
DIVISION
OF PREVENTIVE MEDICINE.
Conclusions, Experiment VII.
The following
table shows that in 15 minutes
(10.21 a. m. to 10.36
a. m.), with
worse
initial conditions,
better
results were
obtained
with both fan and cold-water coils than were gotten
in 105 minutes
(2.15 p. m. to 4 p. m.) in Experiment VI with cold water alone.
Time.
Wet
bulb.
Dry
bulb.
Relative
humid
ity.
time,
(seconds).
Wet
kata
time,
(seconds).
Dry
kata
Wet
kata
cooling
power.
Dry
kata
cooling
power.
Com-
flmeter
reading.
Experiment VII:
10.21 a.m
82
89
75
75
451
7
1.2
44
15 minutes later..
63
73
58
22
65
24
8
27.8
Experiment VI:
2.15 p. m
77.5
85
72
55
212
9.6
2.5
41.*
105 minutes later.
64.5
74.5
59
42
147
12.6
3.6
39.1
The combination of water and fan as run accomplished
the same
work
as the water alone in less than one-seventh
the time.
HEALTH CONDITIONS OF THE NAVY.
Health conditions of the Navy
are better than they have been at
any time during the past five years.
The annual admission
rate for
all causes from January
1 to July 8 being
589 per 1,000 per annum,
as compared with
776.27
for
1918,
676.02
for 1919,
778.99
for
1920,
and
625.65 for 1921.
The morbidity
rate for all causes for the four-
week period ending July 8 was 385 per 1,000 per annum
; for diseases
only, 340 per 1,000 per annum; and for injuries
and poisons,
45 per
1,000 per annum.
With
the
exception
of malaria,
there
have
been very few
com
municable
diseases reported during
the past four weeks.
The fol
lowing
table
compares
the admission rates for certain diseases for
June, 1922, with the average
admission
rates for that month for the
previous
four years.
Annual admission
rates
per
1,000 for certain
communicable
diseases, current
month of June,
1922, in comparison
icith the mean annual
admission
rates,
month of June, for the four-year
period
1918-1911,
inclusive.
Disease.
June,
1918-1921.
June,
1922.
Cerebros
inal fever
0.13
2.37
2.53
21.70
24.30
4.21
11.07
4.34
2.29
.15
4.02
.19
0
Diphtheria
0.88
1.68
6.81
14.31
1.28
.99
2.27
.30
3:H
.10
354
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
It will
be noted that the morbidity
rates for measles and mumps
are exceptionally low; this is no
doubt due
to
the
fact that
few
recruits
have
been
inducted
into
the
Navy
during
the ;past
few
months.
Although
the admission rate for malaria
is lower than the
average, it is believed that this rate should be further lowered.
Very
few admissions
for malaria
are being reported from stations
in the
United
States, except Quantico, or from ships serving in and around
United
States
ports;
the
vast majority
of the
cases
were
reported
from San Domingo and Haiti.
The
annual
admission
rate
for
venereal
disease
for
the
four-
week period ending July
8 was
96 per
1,000, which
is considerably
lower than the annual admission rate for
1919,
1920, or 1921.
The
progressive
average
rate for venereal
disease for 1922 is now
107 per
1,000 per annum.
PREVENTIVE MEDICINE EDUCATIONAL
MATERIAL.
The Bureau of Medicine
and Surgery
has forwarded
to all ships
and
stations within the
past month
a
set
of
posters
dealing with
general,
personal,
and social hygiene.
It is requested
that medical
officers inform
the Bureau of Medicine
and Surgery if the material
now being supplied
to ships and
stations
is of sufficient
value to
continue
such
an
educational
campaign.
If
such
posters
are
re
ceived
favorably
by
the
commanding
officers
and
medical
officers
of ships
and
stations,
new
sets
of posters
dealing
with
the
pre
vention of
diseases
and
accidents
will
be forwarded
to ships and
stations from
time
to time.
In order to
keep
a constant
flow of
material
it will
be
necessary
for medical
officers
to
furnish
the
Bureau of Medicine
and
Surgery
with
sample
posters
and, if pos
sible,
with
actual photographs of conditions existing
at
sea or at
naval stations.
If each medical officer of a ship would forward
to
the burean one such
poster
a month or, in fact, even one
a year,
ample
material
would
always
be
available
to
provide
a
steady
flow of posters.
Many
accidents
and
diseases occur in the Navy
each year which
could
be prevented.
It is not so easy to obtain photographs showing
how disease occurred and how it may be prevented,
but it is a very
simple matter to obtain photographs of the
place
of the
accidents
and
consequences therefrom.
Such photographs
when
placed
upon
posters
attract attention and lead men to read the lessons contained
thereon.
The
next
set of posters
to be forwarded
to ships were
obtained
from the National
Safety Council.
Many of these are excellent,
but
No. 2.
DIVISION
OF PREVENTIVE
MEDICINE.
355
unfortunately
they
do not depict the life and environment of the
bluejacket.
It is considered
that it would be far better if the Navy
Department could make their own posters
instead of having to call
on civilian organizations.
Such posters,
however,
will demonstrate
to the medical
officers
the extent
to which civilian
manufacturing
establishments
are progressing along these lines.
In addition to posters, the Bureau of Medicine and Surgery is hav
ing made a series of lantern slides which may
be used at the regular
motion-picture
shows
while
reels
are
being
changed.
Such slides
will be self-explanatory
and will not require a lecture by the medical
officer in conjunction
with
them.
If the medical officers
so desire
another set of slides will be made for lecture purposes.
Here, also,
it will be necessary for the medical
officers throughout
the Navy
to
furnish
the Bureau of Medicine
and
Surgery
with
new
ideas
and
necessary
material for producing such slides.
"Within
the
next
month
a
12-reel
motion-picture
film,
entitled
" The Science of Life," will be forwarded to the commander
in chief
of the Atlantic Fleet, the commander
in chief of the Pacific
Fleet,
and
to the naval training stations,
Hampton
Boads, Va.,
and
San
Francisco,
Calif.
Later, such
a film will be forwarded
to the com
mander in chief of the Asiatic Fleet.
Medical
officers afloat who
desire to show this film may obtain it by forwarding
a letter to the
commander in chief of their
respective
fleets.
This film
has been
produced by the Bray Productions
(Inc.)*,
New York, N. Y., in co
operation with the United
States Public Health
Service, the United
States Army, and the United
States
Navy.
The first four or five
reels may require some explanation,
inasmuch as these
reels
were
produced
largely for high-school
students,
but the remaining
reels
are self-explanatory.
The following
subjects
are
covered
in this
motion picture :
General
biology.
Protoplasm,
the beginning
of life.
Reproduction
in lower
forms of life.
Interdependence
of living
things.
Reproduction
in higher
forms.
Communicable
diseases.
Reel
5
Parasitism.
Plants
and
animals
that
live
at
the
expense of
other
plants
and animals.
Heel
6
How disease is spread.
Reel
7
How
to
prevent
disease.
Reel
8
How the mosquito
spreads
disease.
Reel
9
The
fly as a disease carrier.
Reel
1
Reel
2
Reel
3
Reel
4
356
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
Personal hygiene.
Reel
10 (M)
Personal
hygiene for young men:
(a)
Importance
of understand
ing
reproductive
function
in
man.
(6)
Avoidance
of
venereal
dis
ease,
(c)
Consequences of venereal
disease.
ACCIDENTS
AND INJURIES
AMONG
CIVIL EMPLOYEES
AT NAVAL
ESTAB
LISHMENTS
DURING
1921.
An endeavor
has been made to analyze
the accidents
and injuries
occurring
among civil employees
at naval stations,
reported in the
annual sanitary reports for the year
1921.
As the basic
data from
several navy yards and stations were obviously incorrect in many in
stances
and
the
totals for
"location
of injury"
and
"cause
of
accidents"
did not balance,
no
accurate
conclusions can
be drawn
from such an analysis.
However, it is believed
the medical officers
acting in the capacity of industrial
physicians
may
obtain useful
information
from the following tables
:
Table I compares
the number and
type of injuries
occurring
at
certain navy yards and shore stations
:
Reel
11.
Reel
12.
(Personal
hygiene.)
General
hygiene for men
and women.
No. 2.
357
DIVISION
OF
PREVENTIVE
MEDICINE.
3
O
ISO) joqmn \
"3KG
en
duiu
■—o
©~ir-
iv. >Ijejuni \
-«
©~ ©
OOGjgi-id
•aniri
J90| jaqmn.v
~i6
«s
©
O o- ~«coO
eo~©
~© 0
5
«o-*^j^O
*©T£~
~S
o
o
o o
•©©©
O
O
O
OOOflOO
O
©
06 |HHO
PO"■•"5"
©
o a> o
~
Fg
o
n jo
O
0030 o
o©
©
©
©"^
©~ ~«
©~
O
M
0UIT1
ISO] jaqnin\
©7||
o
ST"
■amp
ISO] j,H!imi\-
2
s=
C4
—C
2
5
oo
■o»n =i ™3
©
-m—©
ae-
1
"
3g
38
1 S
0DJ11
O S
©~ o»
■-Hill!
S3SBD[«*>X
J*
|
*sastt>imox
- ©
- -i c
cr:-
"~55 (6
©~ oo
as
o
©
© 2°
°
USI
•euiri
j.kiumik;
■suni
lsoi ia<)mn\
r--
tg
O
OO
■~ "5N
^
—
8
S3 °
S°a"sffi-'
—.
o
~o" oo
•«©©
© noVnx ©
o'us^
o B
PT"
8
8
N
oo ;gno
s=cg-
3
3 "
="238-
SSfg"
~M 5
o
o O
©
"(5
SS
31?
Is!
own
8
O m O
358
Vol. XVII-
DIVISION
OF PREVENTIVE
MEDICINE.
It will be noted that the naval station, Mare Island,
Calif., had
an average of 7,411 civil employees;
the navy yard, Philadelphia,
Pa., 7,775;
and the navy yard, Washington,
D. C, 6,388,
and that
the
total
number of injuries
for the
naval
station, Mare Island,
was 6,062; the navy yard, Philadelphia,
6,134;
and
the navy yard,.
Washington,
3,331.
More
than likely,
the
reason
the
navy yard,
Washington,
had fewer injuries
than either Mare Island or Phila
delphia, all of
which
are
comparable
as
they
employed
approxi
mately the same number of men, was due to the fact that this was
the only navy yard or station which employed
a safety engineer.
Table II shows the frequency of various types of injury, the parts
of the body
injured,
and
the cause of the
accident
as well
as the
total number of injuries
for civil employees,
the number of men
who lost time,
the
average
number of
days
absent
of
cases
that
lost time,
and the average
days
absent of the total number of cases
for various types of injuries.
No. 2.
359
DIVISION
OF
PREVENTIVE
MEDICINE.
| piloi jo tuasqv
8
£
SBS=SS3SSSS
JSOl )BI()
S^BpaSBJOAV
|
I
1
>.
3
>>
*o
eo
I
MM VB%oj,
■("319'sanmj
'sprou)
sagag
pire
ppnbtq
8
s iggiHIPF
•' ■
:
: Ffg
:
: :«
:
•
.
• * •
la
.
.
.
'•Mummi
pub ssaj^
M X iO<0SO00©
;2
sj t; —s
saunpem
auipuug
N r; «
X K
.
•sau^qoBiaguidBqg
•sipa
jnomdmba
n.»u,i
•pBojjmi jo saptuj,
'(POOA pm |991S)
SJSAIIS
PUB
i ' \
•sjoox
•s[jbi pan sdijS
1BIOX
■)ooi
PUBH
•smjv
g
ES8ȣS2"
—
o r- x r- « ——
—
—
"
2
?Sg2S--gS'-°'-2
8
S eIP*SSS9§
O
r- 04N
n e*—I
M
■uouropqv
j
Jo50.©.
~g
c*
n «5«
O'd
~5
Nt^eo
;
i
91
« if
ffi
— a
360
DIVISION
OF
PREVENTIVE
MEDICINE.
Vol. XVII.
It is fully realized that there
are many
apparent inaccuracies
in
Table II, particularly
when it is compared
with Table I, most
of
which are due to the fact that the report from the navy yard, Ports
mouth, N. H., is included in this table, whereas it was not considered
in Table I.
There
are also a few inaccuracies due to faulty
basic
data.
However,
this table
does show
the injuries
most
frequently
encountered
in navy yards and
stations,
the parts of the body most
frequently injured, and the principal
causes of accidents
among civil
employees.
Since the instructions
relative to the preparation of statistics of
accidents
and injuries
among civil employees did not reach the medi
cal officers concerned until the latter part of the year, they could not
be expected to have the necessary
basic data with which to prepare
the form in the annual sanitary
report.
For the year
1922
every
medical
officer should have the necessary
basic data
and tables
from
stations should be correct.
If so, the tables published by the Bureau
of Medicine
and Surgery
next year will be of immense
value not
only to the medical officers in the field but to various civil industrial
concerns.
MENTAL
HYGIENE AND DELINQUENCY.1
By WiLLiiM Healy,
M. D., Judge Baker
Foundation.
At present
mental
hygienists are endeavoring to get before legis
lators, people in charge of institutions, judges, probation officers, and
others
who handle delinquents an understanding that an important
proportion of delinquency is directly
related
to abnormal function
ing of the mind.
But it was not many years ago that the reverse was
true ; we can read case histories of 10 years ago and find reformatory
heads insisting to psychiatrists that certain individuals
were insane,
although
as the result of some professional
examination they had
been declared
sound
mentally.
We could give many instances of
this, showing a point of view that differs widely from that taken by
modern
psychiatry.
A very striking though
short
paper
appeared
in the "British
Medical Journal" in 1906, written by a certain Justice Rhodes, who
plumped the question
at the medical profession concerning whether
the crime situation in England was not one for prime consideration
by that part of the medical
profession which had to do with mental
diseases rather than one to be decided merely through legal methods.
He very pertinently
asked what could be the meaning
of the fact,
for instance,
that of
186,000
convictions in
1906, upward of
10,000
' Reprinted
from
The
Commonwealth,
Massachusetts
Department
of Public Health,
by
permission
of Eugene
B. Kelley,
H. D., commissioner
of health.
No. 2.
361
DIVISION
OF
PKEVENT1VK
MEDICINE.
of those convicted had been sentenced more than twenty times before.
In all common
6ense, was this more likely to be a matter that could
be remedied
by continuation of these same legal methods,
or was it
a matter
for the
deeper
understandings that might
come through
medico-psychological studies of these individuals?
And
concerning recidivism
itself,
the
repetition of offense,
one
may recognize
at once that this is one of the cardinal
points of the
problem
of
delinquency.
The
individual
who, taken
in
hand
by
the
law,
does not profit
by
his
experience,
even
by
punishment
meted
out to him, what can
be his mental make-up?
The figures
of recidivism for this country can not
be given, because as yet we
have
developed
no sort of general
or nation-wide
study, not even
statistical,
of our most expensive
problem of delinquency and crime.
But if one looks up the
facts of any of our metropolitan
institu
tions for criminals,
one finds that they readily approach the figures
found in the " Blue Book of Crime and Statistics " in Great Britain,
or the carefully
worked-up statistics that are available from other
countries.
The
implications
of
recidivism,
or
the
failure
of
the
law to successfully cope with
a repeated
offender,
are of vast sig
nificance for us in America.
Twenty
or thirty years
ago almost the only explanation
offered
for the career of the delinquent or criminal
was
comprised
in the
term "degeneracy."
The
criminal
man
was
the
degenerate
man;
and under the influence of the positivist school, volume
after volume
was
produced
descriptively
setting forth the characteristics of the
delinquent
man,
woman,
and child,
as if one were dealing with
a
certain
species or subspecies
of human beings.
But in the really
remarkable
developments
of the last two decades all this has been
changed.
Much
more
has
been
learned
of
the
nature of mental
disease, and vastly more, particularly
through psychological studies,
of the nature of mental
defect.
And these two principal
divisions
of mental abnormality,
mental
disease and mental defect,
are being
studied every
day more
and
more
in their relation to delinquency
and crime.
Now
there
is no
need
whatever for exaggerating
the extent of
the
correlation
between
mental
abnormality
and
delinquency.
It
must be confessed at once that enthusiasts
have indulged in rash and
ridiculous
statements
in connection
with their earliest studies,
par
ticularly with the first introduction of the use of mental
tests.
And
there
have
been people,
including
lawyers, who
have
been willing
to state that " crime is
a disease " and
ergo
the criminal
is
a dis
eased man.
But all such sweeping generalizations are worth little.
Judging
by the most careful and consistently undertaken studies,
the fact regarding mental
defect
and its relation to delinquency and
crime seems to be that among young delinquents there are very many
DIVISION
OF
PREVENTIVE
MEDICINE.
Vol. XVII.
more
times
the number of
mental
defectives
than is to
be
found
among the general
population.
The definite percentage
varies
for
different
places, of course,
and naturally
is greater in institutions,
when, under probation, the brighter
ones are selected as offering the
most
promise of doing
better
outside
of institutional
walls.
But
under
any
circumstances,
taking
cases
just
as
they
come in
any
one of the large juvenile
courts,
it will be found that
at least
10
per cent of the delinquents are mentally defective.
We have made
very careful
studies
of several
thousand youthful
offenders
in Chi
cago
and Boston, and our conservative
estimate
is that at least
25
per cent of these must
be regarded as abnormal mentally.
Of this
25 per cent, by far the largest number are to be classified
as mental
defectives.
It
is
unnecessary
to
more
than
mention
the
classic
studies of family
groups in this country where
mental
abnormality
and
delinquency
were
closely
related —the Jukes family,
with
the
recent restudy of this family,
the story of the tribe of Ishmael —
an Indiana family,
and the Kallikaks
as studied by Goddard.
The size and importance of the problem is clearly apparent from
all this.
The percentage of delinquents
or criminals who are suffering from
definite
psychoses
varies widely.
Figures
as published
are unfor
tunately
particularly
dependent
upon
the
inclination
of
the
ob
server toward some given theory, but in situations where judgments
are conservative
we still
see that there
is a very considerable
rela
tionship
betwen
actual
mental
disease
and
the
commission
of
an
antisocial
offense.
Statistics might
be quoted
that range from
the
2 to
5 per
cent of mental
disease, which
we ourselves
have found
among young offenders,
to the large percentage
of even some special
mental
disease which
some observers
claim to
have found
in par
ticular court or institutional
groups of older criminals.
A much
wider viewpoint
has recently
been taken —and very cor
rectly
taken, I believe —by
the
exponents
of
the modern
ideas
of
mental
hygiene.
It is not only the frank psychoses, the " real cases "
of mental
disease, and the plain
cases of mental
defect that are im
portant
for
the
students
of
mental
health, but
also
many
other
matters
that are to be properly
classified
as unhealthy
functioning
of the mental
life,
and
matters
that pertain to peculiarities of the
structural
make-up of the mental
powers in a given individual,
even
though there
be no feeble-mindedness.
By studies in this field we come across the facts of, as well as the
causes for,
intense
dissatisfaction,
grudge formations,
impulsations
and even obessions, mental
conflicts,
jealousies,
emotional outbreaks,
urgent desires,
and
other affairs of the
mental
life
as originating
from within or from without, any of which directly cause or directly
underlie
tendencies
toward delinquency.
Surely
these are
matters
No. 2.
363
DIVISION
OF
PREVENTIVE
MEDICINE.
of the highest importance for therapeutic endeavor
under the head
ing of mental
hygiene.
They
are matters
of the greatest
social
as
well
as personal concern.
They require study which
is only
com
petently undertaken by persons
with
a wide range of knowledge of
what is available in psychology, normal and abnormal, and of what
bears on the given situation in medicine.
We have many instances of minor abnormal mental
manifestations
such
as occur
during
the course of disease,
as in chorea,
or during
a period of life, as in adolescence.
School dissatisfactions
leading
to
delinquency—" the
kindergarten
of
crime "—are
based
upon
special disabilities for learning and many other factors in the whole
school situation.
We
have
the
production
of unfortunate
mental
states
as the result of reactions
to irritating conditions in home or
school life or in employment.
And in connection
with
recreations,
or even with reading, we sometimes
find the development
of a most
unhealthy
type of ideation.
In many ways undesirable mental habits
are formed
as the result of experiences
or inner tendencies.
Some
of the very deepest emotional upsets
are to be observed
in normal
or even unusually
intelligent
individuals
as the result of untoward
happenings
experienced
at particularly
susceptible
periods of their
fives.
Any and all of these, we know from the study of many
cases,
are conditioning elements at the foundation of careers of delinquency
and crime.
Observation also shows
the immensely
fruitful
field that there is
in all this for the therapeutic approach that the term mental
hygiene
implies.
It is a work for trained specialists with open minds, who
know not only the phenomena
of mental disease as such, but who are
also
students
of personality, characteristics, and
trends,
of psycho
logical capacities and incapacities that are quite beyond
the implica
tions of " an intelligence quotient," who are students of all that goes
to make the individual
(always through
the mental life itself)
ex
hibit unfortunate antisocial tendencies.
There are adjustments that can be made with the greatest
hope of
success in ways that are not at all contemplated
by the alienist
as
implied in his dictum " insane or not insane," " feeble-minded or not
feeble-minded" (which
amounts
to institutional
care or not institu
tional care), or by the work of the modern
psychiatrist,
though he
deals more carefully
than ever with definite psychoses.
There may
be much more to it for professional work as our science develops.
AVe
hope for much more, whether it be by glandular therapy, or by study
of toxins affecting brain cells, or through other investigations from
a physiological or psychological standpoint.
But, even
as it stands
now, the direct, proper, and main avenue of approach to the prob
lems of delinquency and crime is through the field which has come to
be designated mental hygiene.
108165—22
12
364
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
ASPECTS
OF
MENTAL
HYGIENE
RELATED
TO
ALCOHOLISM
AND
DRUG ADDICTION.
Any
one who
has even half studied human inebriety
must
have
reached
the conclusion that many alcoholics are defective
or insane.
And one may
hold this opinion without
being in the least
an ex
tremist.
Neff well writes : " It has quite often been said that all in
ebriates
are more or less insane
or mentally defective,
but it is our
opinion that when all inebriates of all social grades are classed
to
gether it will generally
be found that the majority
are neither de
fective nor insane."
This
statement
is merely preliminary
to
the
recognition of a very practical
fact for treatment,
namely,
that a
considerable
proportion
of drunkards
are by virtue of mental
ab
normality not responsive
to treatment.
Taking cases of habitual and periodic drinkers who have been re
peatedly
arrested,
Anderson found in his court work that 56 out of
100 had a decidedly inferior level of mentality.
He considered
37
of them clearly feeble-minded,
7 were insane, 7 were epileptic, and
32
of them
showed
evidences
of an innate psychopathic
constitution.
This is probably
a fair sampling of the chronic offenders in a metro
politan court where many arrests
are made for drunkenness.
No other statement
is needed to show
the relationship
of mental
health problems to the social scourge of alcoholism.
That another
feature is added in very many of these cases through alcoholic mental
degeneration,
the result of definitive poisoning of brain
cells,
goes
without saying.
Drug addiction is an issue before
the country at present
as never
before.
In connection
with the problem of drug
addiction,
prob
ably
the
student
of
mental
hygiene
is more
concerned
with
the
results
of the drug
itself
upon
the
mental
powers than with
the
original
constitutional
weakness
of those
who become drug
users,
in this
respect being
a variation
from
the problem of alcoholism.
The
fact that
some
observers
working
in courts have
found
evi
dences of
a considerable
proportion
of mental abnormality,
either
defect
or
psychotic
tendencies,
is
not
so
significant
as
in
cases
of inebriety, because nearly all of these drug users
as they appear
in court are delinquent individuals
involved in other antisocial
be
havior than the use of drugs.
They are either innately so abnormal
mentally or have become so deteriorated that they
place
themselves
in situations
where
they
readily
come under
the
ban of the
law.
Comparatively
few of their
arrests
are for breaking the drug law.
As a matter of fact a vast number
of drug habitues
never
come in
contact with the law because, of course, their use of the drug does not
entail such socially offensive
behavior as does drunkenness.
The problems of mental
hygiene, however,
are involved in prac
tically
every
case of habitual drug using even if there
is no drug
No. 2.
365
DIVISION
OF PREVENTIVE MEDICINE.
psychosis
or any innately
defective
mental
constitution.
This main
fact
constitutes
one
of
the
great
points of
attack
in
treatment.
Mental dissatisfaction itself, for example,
whether through ill health
or other stress, is one of the prime
reasons for entering into
and
continuing
the
drug
habit.
Anyone
who
would
merely
attempt
to get
an
understanding
of
why
human
beings
respond
to
such
artificial
stimuli
or satisfaction
must take into account
the facts
of
mental life.
As in the case of the relationship of mental
hygiene
to delinquency,
we see here again the fact that mental health means much more than
freedom
from
a definite psychosis,
just
the
same
as bodily
health
means much more than freedom
from specific
and well-known
dis
eases.
The student of health must take into account
the functioning
of the organisms upon
levels of efficiency,
adaptation, and satisfac
tion
to
the individual —facts that are not usually dwelled upon
in
textbooks of pathology, either of mind or body.
MENTAL
HYGIENE
AND
PROSTITUTION.
The studies and reports,
some of them very extensive, of the earlier
vice commissions
which, 10 or 12 years ago. first undertook the diffi
cult task of public enlightenment concerning prostitution
had
very
little to say concerning the mental
personality of publicly
immoral
women.
The
swing
from
the
nonrecognition
of
the problems of
mentality involved
to the
most
exaggerated
statements
concerning
the
amount of
feeble-minded
and
psychopathic
conditions
to
be
found among these women was the natural swing of the pendulum.
The real situation seems
to be about
as follows
: Of course, no one
who knows the facts would presume
to argue that such immorality
entered into by women
as a gainful occupation
is highly correlated
with mental incapacities of any kind.
The only studies of mentality
that have
been made
are of those women
who have
been
so foolish
that they did not avoid the notice of the police or other preventive
agencies, or, more
rarely, of some groups of those who have been
openly and notoriously plying their trade
and have been willing
to
be studied.
Even the superficial investigations of vice commissions
show that a vast amount of prostitution is engaged in by women
who
are sharp enough
to keep out of public notice
and to avoid showing
any
evidences of law breaking.
There is no reason
to believe
that
these women
differ in mentality from the average run of the popu
lation.
But through
the study of women
who are easily accessible,
be
cause of open
immorality
or being under arrest,
we get
a picture
that demonstrates
clearly
a very
considerable
correlation
between
mental abnormality
and
such " caught offenders."
In
the opinion
of
the
Massachusetts
Vice
Commission,
about
half of
the
women
3G6
DIVISION
OF PREVENTIVE
MEDICINE.
Vol. XVII.
seen
were
to
be
considered
as mentally
defective.
It is of
local
interest
that Anderson,
taking
100
women
who
were
seen
in
his
laboratory in the Boston municipal court, found that about half of
them
represented
pathological
mental
types,
among
which
feeble
mindedness
ranked
highest.
But here again we have the fact that
many of them evidently
came to attention
as violators of the law
because
they
were
alcoholics or drug
habitues.
Indeed,
some
of
them
had already begun
to show deterioration
from
these poisons.
The point of the whole matter is that no individual
or general
social
therapeutic
or preventive
treatment
of
prostitution
can
be
considered,
even in
terms of common
sense,
without
reckoning
on
the highly
practical
human factors of mental conditions
as
they
most
necessarily
affect prognosis.
The problems
of illegitimacy
are to some extent the same as those
of prostitution.
Here again it is clear that the brighter individuals
take
care of themselves
and
of their
offspring
in ways to
avoid
public
notice.
But
a study of cases of illegitimacy
as they
come
to public agencies
reveals
a very considerable
percentage
of mental
abnormality
among
the mothers.
Probably
the
best source of in
formation
for
readers
of this
bulletin
is
Kammerer's
" The Un
married Mother."
MENTAL
HYGIENE
AS RELATED
TO VAGRANCY AND
DEPENDENCY.
It is easy to understand
that the vagrant or tramp very frequently
indeed is a psychopath.
The fact of his lack of success or of find
ing satisfaction under ordinary
conditions, when,
as is usually
the
case,
he has
a fairly
good
physique,
is evidence
of something
ab
normal in his personality.
Of course
there
are economic
reasons,
fairly
clear
at different periods,
which must
be
taken
into account
in
estimation of the
causes of wandering
or vagrancy.
But
the
study of the ordinary
or habitual tramp in this country
as well
as
in Europe,
where
an important literature
has developed
concerning
the
subject,
reveals
a
considerable
list of mental
troubles in
the
background of the tendency
toward
a vagrant life.
One
mental
disease
in
particular
has
received
considerable
at
tention
as
relates
to
vagabondage,
and
from observation of indi
vidual
cases
we have no doubt that this disease
(dementia
praecox)
plays an unusually large part in the situation.
In the fellowship
of tramps—and it sometimes
exists
to the
ex
tent that there
are tramp
colonies —degenerate
practices are very
frequently
carried
on which
may
well
develop
a tendency
toward
deterioration, toward living at a lower level than the innate mental
constitution of these men would warrant.
Apropos of social
prevention of the ills that such irregular living
implies, it
is
most
interesting
to
note that in
communities
where
No. 2.
367
DIVISION
OF
PREVENTIVE
MEDICINE.
feeble-minded
youths and
cases
of mild
psychoses
have
been taken
care of early in greater
proportion,
there
is very much
less evidence
of vagrancy or tramp life.
The
problem
can be solved —it is solved
to
a greater
extent
in
Massachusetts,
through
better
cure of
the
mentally abnormal, than in most
States
in this country.
Much can be done by early attention to the real needs of the. feeble
minded,
the
mentally
diseased,
the epileptic
who
lias
mental
dis
turbances,
and
the
psychopathic
inferiors.
We
can
find
evidence
of it in the better
control
in
certain
localities of tramp
life,
pros
titution
and
delinquency.
Constructive
measure!-:
undertaken
arc
related
not only to the welfare of these
individuals
themselves,
but
also to their
progeny, for, of course,
dependency
results
from
the
nonsupport and the desertions
that are connoted
by alcoholism, pros
titution,
and vagrancy.
And
much
more
is involved (ban
the
eco
nomic situation resulting in State
care and placing
out of children;
we have
only too frequently
the matters
of actual
disease
in
these
children, physical and mental,
which are most costly
to our civiliza
tion.
There
is thus every
argument for
assailing
in
the
most
direct
way
those
burdens
of our social
life which
come under the
head
of
delinquency,
alcoholism,
drug
addiction,
prostitution,
illegiti
macy, vagrancy, and dependency through an approach
to them which
can only
be
gained
by knowing
their
intimate relationship
to the
facts of mental hygiene —through understanding what each of these
means
in terms of departure from mental health.
NOTES FBOM THE NAVAL BASE, HAMPTON
EOADS,
VA.
Newly
eidisted
recruits
began
to
arrive
at
the
naval
training
station
on the 20th.
As has been
the custom
for
the
past
year or
more, all of these men have been very thoroughly
reexamined
physi
cally by a medical
officer;
including
an examination of urine, which
is not customary, I think, at other training
stations.
This procedure
has brought
to light more than a dozen
men, having albumin
per
sistently
present
in their
urine.
These
men, of
course,
have
been
held up, transferred
to sick quarters and
placed
under observation.
The functional
efficiency of their kidneys will
be
determined,
and,
if found necessary, they will be surveyed.
Other defects, principally
heart
disease,
have
been found in various recruits.
Surveys
have
already
been
held
upon
those
who
are not physically
fit for
the
service.
We
are proceeding on
the
assumption
that
the Navy
re
quires
only
men
as nearly
perfect
physically
as it
is
possible
to
obtain.
368
Vol. XVII.
DIVISION*
OF PREVENTIVE
MEDICINE.
SANITATION
DIVISION.
The work of mosquito
prevention has been vigorously
carried on
during
the month,
and all breeding places, both on the naval oper
ating
base
and
the Virginia
Terminal
property,
have
been
kept
thoroughly
covered
with
larvaecide.
The
prevailing
heavy
rains
have made the work of mosquito
prevention quite
an undertaking:
but by directing
most of the time
and attention of the division
to
ward this particular
work, the situation has been kept well in hand.
Instead of the routine inspections that have been carried out liere-
tofore, inspections have been made to determine
the probable
breed
ing places of mosquitoes
and
flies.
All places that were, or could
possibly become, breeding
places for these
pests have
been covered
with larvsecide.
NOTES FROM THE
UNITED
STATES NAVAL
TRAINING STATION,
SAN
FRANCISCO, CALIF.
The
general
admission rate for the month of May
was
634
per
1,000
per
annum
as
compared
with
899 per
1,000
per annum
for
April.
There were
but two admissions
for communicable
diseases:
one with diphtheria
and one with tuberculosis.
About
20 per cent of all hospital
corpsmen
are found to
be car
riers of
the
organisms of Vincent's
angina, usually
with
minute
lesions of the gums.
The same condition applies to the personnel of
the Hospital
Corps
training
school.
Active
treatment
of lesions,
disinfection
and in appropriate
cases isolation is practiced.
NOTES FROM THE NAVY MINE DEPOT, Y0RKT0WN, VA.
During the month
of May
a bacteriological
examination of
the
water supplied to this station was made and it was found to contain
B. coll.
No chlorine was being used at this time,
as the supply bad
been exhausted.
Upon investigation of the watershed
it'was
found
-
that a number of laborers were working around the group of springs
supplying
the water mains,
and that there
was
a small amount of
pollution
of
the hillsides
around
the
springs.
Rigid
regulations
were instituted
at once to prevent further
contamination,
a supply
of chlorine was secured from
a neighboring Army camp,
and every
one concerned
was
advised
by
a station
notice
to boil
the water
before using it for drinking purposes.
No. 2.
369
DIVISION
OF
PREVENTIVE
MEDICINE.
INSTRUCTIONS
TO MEDICAL
OFFICERS.
Circular letter.
FEMcC-EFL
124842(103).
Serial No. 195-1922.
Washington,
D. C, June IS, 1922.
To: All
naval
hospitals.
Subject
: Report of board for consideration
of standardized
forms.
Reference:
(a)
Bureau's
letter No. 124842(103) of February 14, 1922.
Enclosure:
Report of board. No. 124842(103), June
6,
1922.
*
1. The
recommendation
of the
board
contained
in
the
attached
report
Is
approved.
2. The new forms will be put Into effect when the stock of old forms
at the
supply depot have been
exhausted.
F. Li. Pleadwell, Acting.
FEMcC-EFL
124842(103).
Washington,
D. C, June
6, 1922.
From : Board for consideration
of standardized
forms.
To : Chief of Bureau
of Medicine
and Surgery.
Subject
: Report of board.
Reference:
(a)
Bureau's
letter No. 124842(103) of Nov. 30, 1921.
(6)
Bureau's
letter No. 132-1921,
of Oct. 16, 1921.
(c)
Board's
report of Jan. 30, 1922.
(d)
Bureau's
letter No. 124842(103) of Feb. 14, 1922.
1. In
response
to
reference
(rf)
seventeen
reports
were
returned
from
the
commands
to which
reference
(c)
was referred.
Nine
of the reports
received
expressed
concurrence with the hoard's
recommendations.
2. The following
is
an
abstract
of the criticism received
and grouped
under
each form considered
:
(a)
N. M. S. Form No. 10.—" Recommended
that the following be added Im
mediately
after
absentee report
(reverse
side)
:
Mast
report.
Name :
rate :
offense :
date,
etc. :
Remarks.
This
gives the commanding
officer daily information
as to all mast reports,
awaiting-actiou cases,
etc.
(I'earl Harbor.)
"Daily personnel report, which
should contain
more than twenty-one wards"
(Great Lakes).
" This form as submitted
is incomplete
in that summary
does not show num-
Ikt of patients died, deserted, in confinement,
on leave,
or absent without
leave.
Summary
should
also show
number
of hospital
corpsmen
on duty,
in
confine
ment,
on leave,
or absent without leave."-
(Norfolk.)
" It is recommended
that
' Changes
in staff ' be made
a seperate
report
in
stead of being printed
on the back of the ' Personnel
report.'
The data for the
changes
in staff and the absentee report
is, at a large
hospital,
more efficiently
handled
at a desk other than the one handling
the personnel
report, and. due to
the delay
often
occasioned
by definitely
determining
the
absence
of
an
indi
vidual,
the distribution
of
the personnel
reimrt
would
be
unnecessarily
de-
•
layed."
(New York.)
(6)
N. M. S. hospital
Form No. 3.—"Horizontal
lines
are not practicable
in
that
copies
seldom
agree with original
when
inserted
on
typewriter,
due
to
faulty
printing.
An
unruled
page,
allowing
names
to
be
typewritten
single
spaced, will
permit
listing of twenty
or more nnmes instead
of ten as on
sug
gested
form,
an
item of interest
to large
hospitals.
Space allotted
to listing
of
service
records,
health
records,
and pay
accounts
should
be
reduced,
thus
permitting long names to be written in full followed
by service number.
Num
bering of lines
is not necessary."
(Norfolk.)
(c)
lia-ggage cheek. — " In order
to render
this check more difficult
to change
or counterfeit in the case of loss, more important
as a means of identification
370
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
to
the owner
and to better
serve Its purpose
as a
baggage
check, it is
recom
mended that both the tag and its stub be numbered consecutively
in conspicuous
type."
(Newport.)
" Recommended
•that
first
action
section
of stub
have
space
for patient
to
sign ns receipt.
Stub to be filed by baggage man for future reference in case
a
claim
is made for baggage
or missing
clothing
after patient
has left hospital.
" U.
S. Naval Hospital
" All personal
property
received this date
" Witness
:
" Bagroom
keeper."
(Pearl Harbor.)
" The advantages of this
form
believed
to
be of a doubtful nature.
Experi
ence at this hospital
has demonstrated
that only
constant
watchfulness
on the
part
of the corpsman
detailed
in
baggage room will
prevent
thieving,
and
it
appears
that the loss of baggage check and consequent finding
of it by another
person
would
tend
to
give the finder
access
to
baggage not his own
were
he
inclined
to be dishonest.
The above
remarks
are based on the assumption
that
the possession of the detached part of the tag will gain
access
to baggage indi
cated on the check.
It is suggested that the service number or some
other form
of a check
appear
on
the original check
(not
on
the duplicate)
that
can
be
furnished
only by the bona fide owner of the baggage."
(Charleston.)
(d)
Change
of
diagnosis. —"This
office
recommends
adoption
of
attached
standardized
forms with alteration
of " Notice
of change of diagnosis " to read
as follows,
due to the fact that patient
might
be carried
with a diagnosis
other
than the one with which
admitted
to hospital
:
Diagnosis
changed j
^^'.m
'
(Annapolis.)
" Recommended
space
be provided
for approval
by executive officer in smaller
hospitals,
or
by
supervisors
of
medicine
or surgery
in
the larger hospitals.
Eliminates
mistakes
(technical
or otherwise)
by junior
inexperienced
medical
officers and keeps immediate
superiors
familiar
with status of patients
under
their
supervision.
Authorizes
personnel
office
to
make
necessary
record
changes."
(Pearl Harbor.)
"A
similar
scheme
in
the
form
of
a
memorandum
has
been
tried
out
in
this hospital
and has not
met with
success.
A book kept in the record
office
and
accessible
to
medical
officers
is
believed
to
give
results
and
such book
is now being used as an experiment
in this
hospital.
Too often the card fails
to
reach the record
office
and only
a constant
check of health
records
insures
the
form
' F '
card
being
closed
out
and
a
new
one
for
the new
diagnosis
opened.
The book is believed
to provide
a more stable record."
(Charleston.)
(e)
Operations
scheduled. —" It is believed
that if space were
provided
on
this
form
to show the ward
to which
patients
to
be operated
on
are assigned,
it
would
aid
in
proper
distribution
of
the
several
copies
where
more
than
one
ward
is concerned."
(Charleston.)
" Suggested that
the word
' anesthetist
' be added
to the heading
anesthetic.
In most
hospitals
where
there
are
several
anesthetists,
the above additional
information
assures
equal distributiofi of this duty
and
gives
necessary
pre
paratory
information."
(Pearl Harbor.)
" Operations
scheduled "
should
contain
several
more
spaces
for
names."
(Great
Lakes.)
"That all new forms
recommended
in paragraph
7
be adopted
except
(b).
It
is
believed
that
the
' Operations
scheduled ' in its present
form
could
be
omitted
or modified for the following reasons:
" First.
Emergency
cases
could not be planned
in advance.
" Second. Operating
surgeons
must
be allowed
leeway
as to what
anesthetic
is to be used,
as the case
comes
to operation.
" Third. With
a
senior
operator
and
several
assistants,
it
is impossible
to
tell in advance
which
assistant
would
be given the opportunity
to do routine
work as the
need
for post-operative
watching
of
a patient,
and
other
condi
tions will modify
the schedule.
" Fourth.
Under
present
conditions
most
operating
surgeons
are
men
of
sufficient
experience
to be trusted with the details of the work they are doing,
and I believe all hospitals
now
have in effect
some
form
of official
approval
of work planned, but not in such detail
as indicated.
No. 2.
371
DIVISION
OF PBEVENTIVE
MEDICINE.
•' Fifth. A
schedule
such
as
proposed
would
be
constantly
changed,
either
by additions
or omissions,
depending
upon changed condition
of patients.
It
would
soon,
of necessity,
degenerate
into
a
perfunctory,
useless formality.
" Sixth.
Many
times
the
' Professional
assistant
to
the
executive
officer '
or the executive officer has followed
a case more carefully than
the command
ing
officer,
and the determination
to operate, or not to operate, can be better
decided
by
him
than
by
the
commanding
officer.
As
a
matter
of
fact,
a
majority
of
' approvals
' are
in
the nature
of taking the recommendation
of
the ' Professional
assistant
to the executive
' or the operating
surgeon.
" Seventh. In
most
cases
it
would
be
as
important
for
the
commanding
officer to give his
approval
for instituting radical treatment
in medical
cases
as in
the ordinary
run
of surgical
eases.
The
question
of venesection,
the
use of
oxygen,
and
the
more powerful
forms
of
medication,
are
not
ordi
narily
referred
to
the commanding
officer for approval
in
advance,
nor
do I
believe
the average
run
of
surgical
cases
need
approval."
(San
Diego.)
The following are the views of the board
regarding
the above
comments :
(a)
N. M. S. hospital Form No. 10.— Inasmuch
as the regulations
require
that
a special
report
book
be kept, which
report
book contains
entries
of all disci
plinary
refractions,
further
entries
regarding
this subject
are
deemed
out of
place on this form.
In order that more space for wards
be allowed
without
increasing
the size of
the form, it is
recommended that
the horizontal
lines
be eliminated
from
the
form
as originally
proposed.
This will
permit
any probable
number
of wards
to be enumerated.
The present
form, if correctly
made out, would
show
the disposition
of all
personnel
in the
body
or'
the
report.
It
is, therefore,
recommended
that
no
addition
be made to the " summary of patients,"
since the aggregate of change
in personnel
of the day is believed
to be sufficient
for requirements.
A com
plete dally
summary
for hospital
corpsmen
is
believed
to
be unnecessary,
as
daily
changes are infrequent
and a weekly
report
is already
in existence.
The recommendation
of the New York
hospital
as
to dally changes in staff
would necessitate
a new form, which
Is not recommended.
(b) N. M. S. hospital
Form No. 3.—The board
concurs
In this recommenda
tion and recommends
its adoption.
(c)
Baggage
check.— The
proposed
form
provides
for a storage
number.
Receipt
of patient
for baggage
is covered
by Form " G " when his signature
Is obtained
on discharge
or transfer,
Form " G " should
be filed in his jacket,
thereby being
made available
for any future correspondence
covering
the sub
ject.
The board
believes that the duplicate
checks should
be in the custody of the
ward nurse
and not carried
by the man concerned
on account of possibility of
loss.
The nurse Is in a better position
to identify the man than the bag room
keeper.
(d)
Change
of
diagnosis. —The
recommendation
of
Annapolis
Hospital
is
concurred in.
If a hospital demands that this report
be signed
by the executive
officer or
supervisor
o>f a department,
this
may be accomplished
by having
the proposed
report initialled
by the officer concerned.
It is the apinion of the board that while several hospitals
are now using this
form (which
is believed to be adequate and its adoption
recommended for this
reason),
nevertheless
it
would
appear
that
the
best procedure
would
be
to
return
the health record at the time the change is made to the record
office
so
that it may be checked by officers concerned and the record office.
A book for this purpose is not recommended.
(e)
Operations
scheduled. —The form
as proposed is for the official
notifica
tion and
approval of an
operation
by
the
commanding
officer
and
does
not
abridge any of the prerogatives
of the operating
surgeon with respect
to pro
fessional judgment.
Other suggestions
not concurred
in.
4. Copies of all forms
recommended are appended.
F. E. McCuix-otjgh,
Captain (M. C),
17. S. N
H.
W. Smith,
Commander
(U.C.),
U.
8.
A".
H. L. Gail,
Chief Pharmacist,
U. S. X.
372
Vol. XVII.
DIVISION
OF PREVENTIVE
MEDICINE.
Circular
letter.
WJCA:ESK
129733(04).
Serial No.
196-1922.
Washington,
D. C, June 29, 1922.
To: All naval
hospitals.
Subject
: Occupational
therapy
work for
Veterans'
Bureau
beneficiaries
;
re
port of.
Reference:
Letter from
Assistant
Director,
U.
S. Veterans'
Bureau
#BWC:
HW : It : lO.Hosp.
Sec.
1. In
order
that
the United
States
Veterans'
Bureau
may
have
a
complete
record of all occupational
therapy
work done by U.
S. Veterans'
Bureau
bene
ficiaries
in U.
S.
naval
hospitals,
you
are requested
to forward,
on
the first
of each month,
a report
covering
this work for the past month.
2. It
is understood
that
the committee
composed
of
representatives
of the
Ann}-,
Navy,
Public Health
Service,
Soldier's
Home,
and the U.
S. Veterans'
Bureau
have
adopted
a
new
form for reports
on
this
type of work.
United
States
Veterans'
Bureau
form
Med.
1870 will
be used until
such time as the
newly
adopted forms
are received.
3. All of these reports
shall
be forwarded
(in duplicate)
by the commanding
officers to the Director,
U.
S.
Veterans'
Bureau,
via
the Bureau
of Medicine
and Surgery.
F. L. Pleadwell,
Acting.
Circular
letter.
WSG/T
132586,
132641.
Serial No. 197-1922.
Washington, July 12, 1922.
■To: All naval
hospitals,
U.
S.
naval
medical
supply
depots, and
U.
S. Naval
Medical
School.
.Subject:
(a)
An act
to readjust
the pay and allowances
of the commissioned
and enlisted personnel of the Army,
Navy, Marine Corps, Coast
Guard,
Coast and Geodetic
Survey,
and Public Health Service,
approved June
10, ]922.
(6)
An act making
appropriations
for the naval
service for the fiscal
year
ending June
30,
1923.
and for other
purposes,
appro ved
July
1, 1922.
References
:
{a) ALNAV TWENTY-EIGHT,
4230-1230
of June
30, 1922.
Enclosures:
(A)
Copy of above (a)
(H. R. 10972).
(B)
Copy of above (6)
(H. R. 11228).
1. The
bureau
encloses herewith
copies of the
two
acts
above mentioned,
and directs
that they be made available
for all members of the staff, including
hospital
corpsmen
engaged
on
office
work ; the acts
are
supplemental
to one
another,
and should
be considered
together.
2.
An accurate knowledge of appropriational
matters is essential
to the proper
allocation
of
charges;
that
this
knowledge
is
not
so
widespread
throughout
the Medical Department
as it should
be is evidenced by the large
number
of
invoices
received in the Bureau
of Supplies
and Accounts
on which
the wrong
appropriations
of the Bureau
of Medicine
and Surgery
are debited.
3. The
strictly bureau
appropriations
are found
on
pages
19 and
20 of the
naval
act.
4.
The
appropriation
" Care
of hospital
patients " will
continue
under
the
immediate
and
direct
control
of
the
bureau,
but
wider
no
circumstances
will any charges be placed against
it, except directly
by this bureau.
5. Legislation
relating
to
"Passenger-carrying
automobiles"
will
be found
on pages
20 and
21 of the naval act.
6. The
value
of commuted
rations
stopped
on
account
of sick
in hospitals
is fixed
by the naval
act for the
fiscal
year
1923
at
seventy -five
(75)
cents
(page 17):
this rate for
three
meals will
govern
the charges
made against
the pay of civilian employees for subsistence;
it will also be the rate of charge
in
the duty
officer's mess;
the charge
for less than
three
meals in all cases
will be twenty -five (25) cents per meal.
7. The
pay
and
allowances
of members of the Nurse
Corps
are
defined
in
sections
5,
6, and
13, of the " Act to readjust
the pay and allowances."
exce-m
that the naval act (End. B), page
17. provides for "subsistence
in kind at hos
pitals
and on
board
ship
in
lieu of subsistence
allowance
of
female
nurses'" ;
No. 2.
373
DIVISION
OF
PREVENTIVE
MEDICINE.
the Assistant
Secretary
of the
Navy
in Alnav
twenty -eight
(ref.
a)
directs
that at hospitals
and aboard
ship
nurses
••shall
be subsisted
in kind
as here
tofore."
E. It. Stitt.
Circular letter.
HWS :MFD
125221 (71).
Serial No.
198-1922.
Washington,
D. C, July
13, 1922.
To : All medical
officers.
Subject : Training of flight
surgeons.
1. A large
number of medical
officers will be needed
for training in aviation
medicine and subsequent duty
as flight
surgeons.
2. The training
period
will
consist
of
a course
of
instruction
of approxi
mately
four
months' duration
either
at Washington,
D. C, or at Mineola,
L. I.
3. Any medical
officer wtio may desire to identify himself
with the specialty
of aviation medicine
is requested
to make early
application
to the bureau,
en-
<dosing a report of a physical
examination
such as is prescribed for pilots.
E. K. Stitt.
VITAL STATISTICS.
The "Monthly Health
Index,"
which
is published
on
the
15th
of each month, contains the statistical data for individual ships and
shore stations.
The statistics appearing in this Bulletin are sum
maries
compiled
from
those
published
in
the
" Monthly
Health
Index."
Annual
rates,
shown in
the
succeeding
statistical
table,
are
ob
tained as follows
:
The total number
of admissions
to the sick list or the number of
deaths
reported
during
the
period
indicated
is multiplied
by
Zfg-
or
-3S<^ or
12, depending upon whether the period includes four or
five weeks or a calendar month.
The product is then multiplied
by
1,000 and divided by the average
complement.
E. R. Stitt.
Table No.
1.—monthly
report
of morbidity in
United
States Navy and Marine
Corps for the month
of June,
1922.
Average complement
All causes:
Number
of admissions
Annual rate per 1,000
Diseases only:
N umber of admissions
Annual rate per 1,000
Injuries and poisons:
Number
of admissions
Annual rate per 1,000
Communicable
diseases exclusive
of
venereal disease:
Number
of admissions
Annual rate per 1,000
Venereal disease:
Number
of admissions
Annual rate per 1,000
Entire
Navy.
121,590
4,709
464.73
I,"
402.95
628
01.78
373
37.01
Forces
afloat.
81,224
2,331
344.36
2,004
aw. ta
4X.31
142
20.>J>
1,024 ;
6X5
101.06
101.20
Atlan
tic
Fleet.
258
109.39
Pacific
Fleet.
28,301
29,920
359^98
S49
3SS.23
968
320.98
757
336.09
838
39.01
92
52. 14
130
AU
shore
sta
tions.
Atlan
tic
stations
in
United
Slates
>
Pacific
stations
United
States.
191
76.60
2,378
700.91
2,079
618.02
299
SS. 8S
231
58.67
339
100.77.
1,034
495.57
49
23.48
135
64.70
6,004
185
366.09
S
20
39.58
Marine
Corps.
21,480
852
475.97
714
415.64
108
60.33
134
74.86
160
89.38
1Does not include ninth naval district.
Note.— Asiatic and unassigned
ships not reported.
374
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
Table No. 2.— Number
of admissions
reported
by Form F cards
fiyr certain
dis
eases
and
annual
rates
per
1,000
for
the
month
of June,
1922.
Diseases
Injuries and poisons. .
Total.
Class III.
Appendicitis, acute
Autointoxication, intestinal.
Cholangitis, acute
Cholecystitis,
acute
Colitis, acute
Constipation
Enteritis, acute
Gastritis, acute catarrhal
Gastroenteritis
Hemorrhoids
Pharyngitis, acute
Ulcer of duodenum
Ulcer o( stomach
Forces afloat,
Navy and Marines
(complement),
81,224.
Number
ofadmis-
sions.
Total.
Class VII.
Varicocele..
Class VIII.
Chicken
pox
Diphtheria
German
measles
Influenza
Measles
Mumps
Pnoumonia
, broncho
Pneumonia, lobar
Scarlet
fever
Smallpox
Whooping cough
Total.
Class IX.
Dysentery,
bacillary.
Dysentery,
cntamebic
Typhoid fever
Total.
Total.
Class XI.
Tuberculosis
(all forms)
Class XII.
Chancroid
Gonococcus
infection
Syphilis
Tjtal
2,004
327
2,331
Annual
rate per
1.IKKI.
296.05
48.31
Forces ashore,
Navy and Marines
(complement),
40,366.
Number
of adrais-
Annua 1
rate per
1,000.
Total (complement),
121,590.
Number
of admis
sions.
,079
299
. 603. 16 i
88.88
4,083
626
Annual
rate per
1,000.
402.95
61.78
464.73
as
3.84
46
13.67
72
7.11
u
1.63
20
5.95
28
2.76
32
3.25
22
6.54
44
4.34
7
1.03
4
1.19
11
1.09
2
.30
5
1.49
7
.69
7
1.03
19
5.65
26
2.57
11
1.63
15
4.46
26
2.57
6
.89
7
2.08
13
1.28
21
3.10
49
14.57
70
6.91
31
4.58
24
7.13
55
5.43
9
1.33
18
5.35
27
2.66
1
.15
4
1.19
5
.49
1
.15
n
1
.10
22.90
230
68.37
?.<,
38.00
17
2.51
16
4.76
33
3.26
4
.59
I
.30
5
.49
1
. 15
7
2.08
8
.89
16
2.36
1
.30
17
1.68
41
6.06
28
8.32
69
6.81
11
1.53
2
.59
13
1.28
7
1.03
3
.89
10
.99
1
.15
6
1.78
7
.69
11
1.63
5
1.49
16
1.58
2
.30
1
.30
3
.30
0
3
.89
3
.30
1
.15
0
1
.10
95
14.03
57
16.94
152
15.00
1
.15
0
1
.10
1
.15
2
.58
3
.30
0
1
.30
1
.10
2
.30
3
.89
5
.49
19
2.81
18
5.35
37
3.65
0
1
.30
1
.10
19 |
2.81
126
37.46
145
14.31
38
5.61
145
43. 10
183
18.01
7
1.03
26
7.73
33
3.26
67
9.90
50
14.86
117
11.55
579
85..54
235
67.86
814
80.33
39
5.76
54
16.05
93
9.18
339 |
-
685
101.20
100.77
—
1,024
101.06
No. 2.
375
DIVISION
OF
PREVENTIVE
MEDICINE.
Table No. 2.—Number of admsisions
reported
by Form F cards for certain
dis
eases and annual rates per 1,000 for the month of June, 1922—Continued.
Forces
afloat,
Navy and Marines
(complement),
81,224.
Forces ashore,
Navy and Marines
(complement),
40,366.
Total (Complement)
121,590.
Number
of admis
sions .
Annual
rate per
1,000.
Number
of admis
sions.
Annual
rate per
1,000.
Number
of admis
sions .
Annual
ra
temper,
Class X VIII.
94
2
3
6
186
13.89
.30
.44
.89
58
4
4
16.65
1. 19
1.19
2.08
150
6
7
13
14.80
.59
.69
1.28
Pleurisy, acute fibrinous
7
109
Tonsillitis,
acute follicular
27.48
32.40
295
29.11
291
42.99
180
53. 51
471
46.48
Class XX.
31
4.S8
25
7.43
56
5.53
Table No.
3.— Summary
of annual
admission
rates for venereal disease reported
from
ships and shore stations.
Annual rate per 1,000,May.
Average
rate since Jan. 1,1922.
Mini
mum
rate.
Mean
rate.
Maxi
mum
rate.
Mini
mum
rate.
Mean
rate.
Maxi
mum
rate.
Battleship and cruiser force:
0
107.04
888.88
0
124.46
746.41
27.27
107.25
346.15
44.47
104.17
237.25
21.60
69.67
129.79
62.36
93. 10
121.36
Destroyer
force:
112.85
136.17
181.81
39.56
187.50
277.39
0
148.77
827.58
0
147.39
594.05
0
79.74
888.88
0
92.87
373.54
Miscellaneous:
0
136.96
594 05
0
243.50
555.74
0
130.43
750.00
0
124.55
347.36
0
90.04
470.58
0
77.00
220.58
0
219.06
375.00
0
316.68
746.41
Unassigned.lncludingships
on specialduty
0
126.03
413.79
0
155.95
432.43
Annual rate per 1,000, June
4 to July 1, 1922.
Average
rate since
1922.
June 1,
All naval districts in the United States. . . .
0
61.64
116.51
3.56
84.51
232.00
0
27.50
70.94
18.00
33.04
82.76
0
63.19
109.03
3.56
63. 98
123.01
41.93
71.99
79.10
6.25
147.22
113.31
0
69.84
111.51
26.53
111.01
178.43
(I
73. 10
116.51
44.06
56.18
73.50
0
0
0
24.16
24.16
24.16
0
52.57
61.97
87.37
116.02
232.00
101.67
101.67
101.67
70.03
70.03
70.03
Eleventh
naval district
11.81
19.32
34.07
11.07
29.80
43.47
Twelfth naval district
54.66
80.15
104.55
60.60
111.21
128.74
0
0
0
13.86
31.81
70.90
376
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
Ratio of gonococcus
and
syphilis
infection
to
total
cases
of venereal
disease.
Per cent, May.
Per cent since
Jan. 1, 1922.
cfocS.
Syphilis.
AU ships
Battleship and cruiser force:
Atlantic Fleet
Pacific Fleet
Asiatic
Fleet
Destroyer
force:
Atlantic Fleet
Pacific Fleet
Asiatic Fleet
Miscellaneous:
Atlantic Fleet
Pacific Fleet
Asiatic Fleet
Unasstgned,
including ships on special dut y.
All naval districts
In the United States
First naval district
Third naval district
Fourth naval district
Fifth naval district
Sixth naval district
Seventh naval district
Eighth naval district
Ninth naval district
Eleventh naval district
Twelfth naval
district
Thirteenth naval district
7.69
66.78
11.06
73.90
S3.09
75.00
71.92
S6.66
63.88
72.94
64.00
55. 55
67.44
6.02
11.26
0
7.89
1.66
5.55
I
4.70
22.00
22.22
2.32
Per cent June 4-
July 1, 1922.
72.67
57. 14
53.33
73.07
75.86
75.00
0
75. 00
85.71
66.66
77.77
0
12.67
0
20.00
15.38
10.34
8.33
0
25.00
14.28
33.33
11.11
0
69.86
82.60
64.28
62.79
78.67
50.00
62.44
77.43
51.85
60.63
11.60
9.93
12.24
8.67
6.34
13.05
11.53
10.61
20.20
11.34
Per cent sine©
Jan. 1, 1922.
68.87
67.64
63.46
79.53
62.08
77.41
100.00
67.07
79.48
85.25
68.05
84.61
16.26
14.70
24.03
6.43
15.20-
14.51
0
30.30
15.38
8.82'
25.00
15.33
Table
No.
4.-— Number
of admissions
reported
by
Form
F
cards
and annual
rates
per
1,000,
entire
Navy,
for
the
four-week
period, June
4
to July
1,
1922, inclusive.
Navy (comple
ment),
100,110.
Number
of ad-
Annual
rate per
1,000.
Marine
Corps (com
plement),
21,480.
Number
of ad
missions.
Annual
rate per
1,000.
Total (comple
ment),
121,590.
Number
of ad
missions.
rate
>
1,00(
Diseases of blood
Diseases of circulatory
system
Diseases of digestive
system
Diseases of ductless glands and spleen
Diseases of ear
Diseases of oye and adnexa
Diseases
of genito-urinary
system
(non-
venereal)
Communicable
diseases transmissible
by
oral and nasal discharges
Communicable
diseases transmissible
by
intestinal discharges
•
Communicable
diseases transmissible
by
insects and othor arthropods
Tuberculosis
(all forms)
Venereal
diseases
■
Other diseases of infective
type
Diseases of lymphatic system
Diseases of mind
■
Diseases of motor system
Diseases of nervous system
Diseases of respiratory
system
Diseases of skin, hair, and nails
Hernia
■
Miscellaneous
diseases and conditions
Parasites
(fungi
and
certain animal para
sites)
'
Tumors
Diseases of women
Injuries
Poisons
Total
3
36
395
4
79
7ii
150
111
3
62
27
59
12
63
30
515
71
46
66
107
12
1
430
18
0.36
4.31
47.34
.48
9.47
9.11
17.98
13.30
7.43
3.24
91.45
27.33
7.07
1.44
7.55
3.60
61.73
8.51
5.51
7.91
12.83
1.44
.12
51.54
2.28
0
8
120
2
19
13
24
20
108
3
160
67
12
3
23
9
84
24
4
13
24
1
0
101
7
4. 47
67.04
1. 12
10.61
7.26
13.41
11.17
1.68
60.33
1.68
37.43
6.70
1.68
12.85
5.03
46.93
13.41
2.23
7.26
13.41
.56
56.42
3.91
3
44
515
6
98
89
174
131
170
30
923
295
71'
15
86
39
599
95
50
89
131
13
1
531
25
0.30-
4.34
50.83
.59-
9.67
8.78
17.17
12.93
.50
16.78
2.96
91.09
29. 11
7.01
1.48
8.49
3.85
59.12
9.38
4.93
8.78
12.93
1.28
.10
52.40
2.47
No. 2.
377
DIVISION
OF PREVENTIVE MEDICINE.
Table
No.
5.—Deaths
reported,
entire
Navy,
for the four-week
period, June
4
to July J,
1922,
inclusive.
Ml
Pneumonia, lobar
Pachymeninptis, cerebral
Paraxon imiasis
Malaria
Mahfmant
(rrowths
Other diseases
Drowning.
Accidents
and injuries
Total
Annual death rate per 1,000,all causes
Annual death
rate
per 1,000, diseases only
Navy
(comple
ment),
100,110.
Marine
Corps
(comple
ment),
21,480.
2
0
2
1
0
1
1
0
1
0
1
1
1
0
1
2
0
2
3
0
3
6
3
1
16
4
20
1.92
2.23
1.97
.81
.56
.79
o
VOL. XVII
NO. 3
UNITED STATES NAVAL
MEDICAL BULLETIN
PUBLISHED
FOR THE
INFORMATION OF THE MEDICAL
DEPARTMENT
OF THE SERVICE
ISSUED
BY
THE
BUREAU
OF
MEDICINE
AND SURGERY
NAVY DEPARTMENT
DIVISION
OF INSTRUCTION
AND PUBLICATIONS
COMMANDER
H. W
SMITH,
MEDICAL
CORPS, U. S. NAVY
IN CHARGE
EDITED
BY
LIEUTENANT
COMMANDER
W. M. KERR
MEDICAL
CORPS,
U.
S. NAVY
SEPTEMBER,
1922
(MONTHLY)
Compiled and published under authority of Naval Appropriation
Act for 1923,approved July
I, 1922
WASHINGTON
GOVERNMENT
PRINTING
OFFICE
1922
<r
1
Navy Department,
Washington, March 20, 1907.
This United States Naval Medical Bulletin is published by di
rection of the department for the timely information
of the Medical
and Hospital Corps of the Navy.
Truman H. Newberry,
Acting Secretary.
Owing
to the exhaustion
of certain
numbers
of the Bulletin
and
the
fre
quent demands from
libraries,
etc., for copies to complete their files, the return
of any of the following issues will
be greatly
appreciated
:
Volume VII, No.
2, April,
1913.
Volume VIII,
No.
1, January,
1914.
Volume VIII, No. 8, July, 1914.
Volume
VIII,
No.
4,
October,
1914.
A'olume X, No.
1, January,
1916.
Volume XI, No.
1, January,
1917.
Volume
XI,
No.
3, July,
1917.
Volume XI,
No.
4, October,
1917.
Volume XII,
No.
1, January.
1918.
Volume XII,
No.
2, April,
1918.
Volume XII,
No.
3, July,
1918.
Subscription
Price of the Bulletin.
Subscriptions
should
be
sent to Superintendent
of Documents,
Government
Printing
Office,
Washington,
D. 0.
Yearly subscription,
beginning January
1, $1.50; for foreign
subscriptions add
$1 for postage.
Single
numbers, domestic,
15 cents;
foreign,
21 cents, which
includes
foreign
postage.
Exchange
of publications
will
be extended to medical
and scientific organiza
tions,
societies,
laboratories,
and
journals.
Communications
on
this
subject
should
be addressed
to the Surgeon
General,
United
States Navy, Washington.
D.
C.
n
TABLE OF CONTENTS.
Hugo
PREFACE
v
NOTICE TO SERVICE CONTRIBUTORS
vi
SPECIAL
ARTICLES:
WOUNDS
OF
THE
KNEE
JOINT:
THEIR
SURGICAL
IMPORTANCE
AND
TREATMENT.
By Commander
C. M. Oman, Medical
Corps, United
States Navy,
and Lieut.
E. J. Cummlngs,
Medical
Corps, United
States Navy_
379
Pl.AC.UE,
SOME
FEATURES
OF.
By
Surgeon
George
VV.
McCoy,
United
States
Public
Health
Service
386
Functions
and organization
of Medical Corps units serving
with
the Marine
Corps
in the Field.
By Maj.
S. N. Raynor,
United
States Marine Corps
394
Transillumination
and electric
vitality
tests.
By
Lieut.
Commander
H.
E.
Harvey,
Dental
Corps,
United
States
Navy
403
Gas warfare.
The treatment
of gas casualties —early
and late.
By Maj. W. R. Gahvey, Royal Army Medical
Corps
408
HISTORICAL:
Usheb Parsons,
1788-1868.
surgeon.
United States Navy.
By Capt. F. L. Pleadwell,
Medical
Corps. United
States Navy...
423
EDITORIAL :
On the
treatment
of
syphilis
with
bismuth
salts. —On
the
CHANCES
FOR
SUCCESS. —On
THE ELIMINATION
OF DIPHTHERIA. —On
systemic
infections
due
to
oral
sepsis. —hand
injuries.
Systolic mitral murmurs. — Recent studies in the bionomics
ok
the
hookworm.—on
the
choice
of
operation
in
inguinal
HERNIA
461
IN MEMORIAM:
Francis
M. Gunnel,
1827-1922.—John Cropper
AYise.
1848-1922
481
CLINICAL NOTES
:
Report of a case of sarcoma
of the orbit.
By Lieut.
O. D. Davis.
Medical
Corps,
United
States Navy
485
Report of a case of acute retrobulbar
neuritis.
By Lieut. L. G. Jordan. Medical
Corps,
United
States Navy
486
A CASE
OF
CEREBELLAR
TUMOR.
By
Lieut.
Commander
H.
Butts.
Medical
Corps.
United
States
491
Navy
Death from embolism following the administration
of salicylate
of mercury
by intramuscular
injection.
By Lieut.
S. R. Mills. Medical
Corps. United
States Navy
495
Epidemic encephalitis
490
Specific
treatment
of pulp gangrene
and its sequel.*:.
By Lieut. F.
S. Tiehy,
Dental
Corps,
United
States
Navy
498
Catheterization
of Wharton's
duct.
By Lieut. T. L. Sampsell,
Dental
Corps, United
States Navy
500
in
rv
TABLE
OF
CONTENTS.
NOTES
AND
COMMENTS.
Death
of
Charles
Louis
Alfonse
Levaran. —Celebration
of
the
seventh
centenary
of the University of Padua. —Gen. William
C.
Gorgas. —Transmission of plague by rats. — Treponema
pallidum. —
High
incidence
and
early
onset of neurosyphilis. —Treatment
of
empyema.—Mistake
in diagnosis
503
NURSE
CORPS
.
515
BOOK
NOTICES
1
519
QUERIES
525
PREVENTIVE
MEDICINE
STATISTICS, LETTERS,
COMMENTS
529
PREFACE.
The United States Naval Medical Bulletin was first issued in
April,
1907,
as a means of supplying
medical
officers of the United
States
Navy
with
information
regarding
the
advances
which
are
continually
being
made in
the medical sciences,
and
as
a medium
for the
publication
of
accounts
of
special
researches,
observations,
or experiences
of individual
medical
officers.
It is the aim of the Bureau of Medicine
and Surgery
to furnish
in each issue special
articles relating to naval medicine, descriptions
of suggested
devices, clinical notes on interesting
cases, reports from
various
sources,
historical
essays, notes
and
comments
on topics of
medical interest, and reviews or notices of the latest published medical
books.
The bureau extends
an invitation
to all medical
officers to prepare
and forward, with
a view to publication,
contributions
on
subjects
of interest to naval medical
officers.
In order that each service contributor
may
receive
due credit for
his efforts in preparing
matter
for the Bulletin of distinct origi
nality
and
special
merit,
the
Surgeon
General of
the
Navy
will
recommend
that a letter of commendation
be forwarded to him upon
the acceptance
of his manuscript for publication,
and that a copy of
this letter be attached to his official record.
The bureau does not necessarily
undertake to indorse all views
or
opinions
which
may
be expressed
in the
pages of this publication.
E. R. Stitt,
Surgeon General United States Navy.
v
NOTICE TO SERVICE CONTRIBUTORS.
When
contributions
are
typewritten,
double
spacing
ami
wide
margins
arc
desirable.
Fasteners
which
can
not
be
removed
without
tearing
the
paper
are
an
abomination.
A
large
proportion
of
the
articles
submitted
have
aa
official
form,
such as letterheads,
numbered
paragraphs,
and
needless spacing
between
paragraphs,
all
of
which
require
correction
before
going
to
press.
The Bulletin
endeavors
to follow
a
uniform
style
in headings
and captions,
and
the editor
can
be spared
much
time
and
trouble
and
unnecessary
errors
can be obviated if authors
will follow in the above
particulars the practice
of
recent
issues.
This
Is not
only
important
in special
articles,
but
still
more
so in reviews.
The greatest accuracy
and fullness
should
be employed in all citations,
as
it
has sometimes
been
necessary
to decline
articles
otherwise
desirable
because it
was
impossible
for the editor
to
understand
or verify references,
quotations,
etc.
The
frequency
of gross
errors
in
orthography
in
many
contributions
is
conclusive
evidence that authors
often fail
to read over their
manuscripts
after
they have
been
typewritten.
Contributions
must
be received two months prior to the date of the issue for
which
they are intended.
The editor
is not responsible for the safe return
of manuscripts
and pictures.
All materials
supplied
for illustrations, if not original,
should
be accompanied
by a reference to the source and
a statement as to whether
or not reproduction
has
been
authorized.
Only
the names of actual
reviewers
for a current
number
appear.
The Bulletin
intends
to print only original articles,
translations,
in whole
or in part,
reviews,
and
reports
and notices
of
Government
or departmental
activities,
official
announcements,
etc.
All original contributions
are
accepted
on
the assumption
that
they have not appeared
previously
and
are not
to
he
reprinted
elsewhere without
an understanding
to that
effect.
n
U. S. NAVAL MEDICAL BULLETIN
Vol. XVII.
SEPTEMBER,
1022.
>"o. 3.
SPECIAL
ARTICLES.
WOUNDS
OF
THE
KNEE
JOINT:
THEIR
SURGICAL
IMPORTANCE
AND
TREATMENT, WITH SPECIAL
REFERENCE
TO THE
METHODS DEVISED
AS A RESULT
OP THE
GREAT
WAR
FOR THE TREATMENT
OF SEPTIC
KNEE JOINTS.
By C. M. Oman, Commander,
Medical
Corps,
United
States
Nary, and E. J. Cumjtikgs,
Lieutenant,
Medical
Corps,
United
Stales
Navy.
This article was prompted by a case of knee-joint injury followed
by severe
infection that came under our care
several
months past.
Happily
the outcome
has been good, and the patient is now well and
walking with
a good functional
result.
The surgical importance of
injuries of the knee joint has
been
impressed
upon us by the cases
which
have
occurred
in our practice as one of special
concern
and
interest to the naval surgeon.
It is necessary for us to draw freely from literature, giving a short
epitome of the management
and
treatment
of wounds of the
knee
joint
as developed
and outlined by men of large surgical experience
and skill who have specially treated
and studied these types of cases.
It is our purpose
to present to the surgeon,
in a simple way, the best
methods
that have
been devised
in the
treatment
of these injuries
and their attendant complications.
In order to present
the subject
as a basis for our application of these methods in peace-time military
surgery or civil surgery we will have
to refer to the contributions
made
as a result of the war on the surgery of the knee joint.
The
wounds of the knee joint in military surgery in times of peace
and
in civil surgery will vary in several
respects from those of war sur
gery,
but
the
fundamentals of surgical
circumspection
and
treat
ment remain
the same.
Surgery of the knee joint has always been
a difficult and hazardous
problem,
due largely
to the great
size of the joint and
its peculiar
anatomical conformation.
Infection
of
the
knee
joint
is
doubly
hazardous
and vexing on account of the recesses
and pouches within
the joint that act as reservoirs
for the collection of pools of pus, pro
hibiting the accomplishment
of proper surgical drainage and threat
ening the patient as to life and limb.
It is the consensus of opinion
379
380
OMAN
AND CUMMINGS—WOUNDS
OF THE KNEE JOINT. Vol. XVII.
among
all surgeons,
American
and
European,
who handled
large
groups of gunshot wounds of the knee joint, that these injuries are
very serious.
If the joint becomes infected
as
a result of injury,
the outlook for the patient becomes serious,
first, as to life;
second,
as to limb; and, third, as to function.
It can be readily
seen
from
these few facts that the surgeon
who is confronted with any injury
of the knee joint has a formidable situation to handle.
In the various studies
made
by different surgeons
on the groups
of
these
injuries
some very interesting
and
instructive
data
have
been
collected
and
some
good
deductions
and
lessons
have
been
drawn.
Kellogg
Speed
published
an article in which
he gives
an
interesting
general
collection
of
knee injuries
as
made
by H.
G.
Barling, in the Rouen Hospital district,
from June
to December,
1916.
Barling discovered
that the statistics clearly revealed
a high
proportion
of patients
whose
wounds required early excision,
re
moval of the
damaged
bone
and
any retained foreign
body,
joint
irrigation and closure
by suture,
and which later followed
a course
of satisfactory
healing requiring
no
further
surgical
interference.
The findings in
845
knee joints
operated
on in the Kouen district
are presented,
as follows:
■
Results
of
845 operations
on the knee joint.
Classification
of wounds.
1. Total number cases of injury to knee
operated
on
2. With bone injury
3. Without
bone injury
4. Wound excised and closed
5.
Cases under (4) requiring further operation 1
6. Wound excised and packed
7.
Cases under (6) requiring
further operation 1
8. Excision of knee
9. Arthrectomy,
partial or complete
10.
Excisions
or arthrectomies amputated
11.
Deaths after excision or arthrectomy
12.
Amputation
without excision
13. Deaths under class
12
14.
Total amputations
15.
Total mortality
Number of
Percent
age.
845
438
407
322
82
336
128
42
15
13
13
151
48
164
72
25.2
38.4
22.8
22.8
32.4
19.4
8.5
Mine hospital
with a large number
of cases was unable
to separate
the cases under items 4 and 6.
It will
be noted in this group that of the
322 wounds that were
excised
and
closed
82, or 25.5
per
cent, required further
operation,
indicating
that 74.5 per cent got well without
further
surgical pro
cedure.
Of the 336 wounds, however,
that were excised
and packed
38.4 per cent required further
operation, only
61.6 per cent getting
well without further
surgical procedure.
This shows
clearly better
results
following
excision
and closure.
The total amputations num
bered
164, about
20 per cent of the cases, or one-fifth of the number,
No. 3.
OMAN AND CUMMINGS—WOUNDS
OF THE KNEE JOINT.
381
a rather high percentage,
as later improvements and different treat
ment in the management
of these cases shows.
The mortality of 8.5
per cent is rather high, but we must
bear in mind the serious
char
acter of
the
injuries
and
the lack of any uniform
or
conclusive
method of handling or treating these cases at that time.
Kellogg Speed
in
a series of
85
cases
had but 2 deaths,
1 death
not as a direct cause of knee injury but from
a gas infection of the
arm.
The amputations numbered
9, or approximately
10 per cent,
a much lower ratio than that of Barling.
Out of the 85 cases 65 were
treated
as nearly as possible
by wound excision
and joint closure,
leading to 55 fair to excellent
results,
which again shows the advan
tages of early excision and closure.
Of the 65, 6 suffered amputation,
2 died,
and
47 wounds healed
cleanly, demanding no surgical
in
terference.
The general
results of the series of 85 cases
were excel
lent in
25
instances,
good in
36, fair in
13, loss of limb
in
9, and
death
in
2.
He
makes
an
observation that
is
noteworthy:
We
might
believe
that the result
depends
not
so much on whether
a
wound is penetrating or through
and through
as it does on other
factors, namely, early surgical excision
and the presence or absence
of concomitant
bone injury.
His operative
technique
is given
as
follows: First comes careful
skin
shaving
and
disinfection.
The
leg should be held
up off the table by an overhead
swing.
Second,
the track of the missile is completely, carefully,
and slowly
excised
with a sharp scalpel, but no scissors.
The sliding of the tissues over
each other is avoided and
the
contused
edges are
removed
in one
piece.
Sufficient skin opening is made to permit
access to the for
eign body on the joint surface.
Fresh towels and instruments
are
then procured.
No fingers or instruments are inserted through
the
wound into the joint, since not only may infection
be carried in but
the foreign body may be pushed into an inaccessible
area.
The com
minuted
bone
and
foreign
bodies
are removed.
The
synovial sur
face should not be sponged
or irritated
or exposed for any longer
time than necessary.
It matters
little
about the length of the skin
incision, but the amount of skin removed should be sparing to avoid
'.indue tension in the closure.
Skin plastics may
be performed.
If
the foreign body is buried in bone, it its removed
and with it the
surrounding damaged
bone.
Third, the joint may be irrigated with
physiologic
sodium chloride solution.
Various
operators use ether,
flavine. proflavine, or eusol.
As far as we can tell, the solution used
makes little
difference.
Mechanical cleansing without joint trauma
is desired.
Fourth, the wound is closed in layers.
The synovia is
closed by stitching
to bring only smooth
surfaces
in contact
and the
skin
and superficial
tissues
are closed snugly, unless
there
is great
edema
and
contusion.
In
that
case
a
small
drain
may
be
put
down to the closed synovial surface,
not into the joint.
If the synovia
382
OMAN
AND CUMMINGS—WOUNDS
OF THE KNEE JOINT. Vol. XVIL
can not be closed,
a gauze pack is placed
down to its surface.
In
jection of formaldehyde solution, glycerine, ether, or other irritants
into the closed joint is of doubtful
value.
Fifth, a Buck's extension
is attached
to a Thomas splint on the leg, and flannel bandages
cover
all.
For comfort and steadiness
the application of the splint should
be
exact,
requiring
skilled
attention.
Most patients should be re
tained from
24
to
48 hours before
transportation.
Dressings
and
splints
are not disturbed
unless
there
is pain, fever, or
looseness.
We introduce this for your study that you may compare it with the
technique
of Willems,
as given later.
It might
be
well
to
state
with
reference
to
after
treatment
that
when
Speed
finds
aseptic
healing is in progress
and the joint is not painful slight passive
mo
tions may be started in the second week.
In an article on knee-joint war injuries, McWilliams
and Hetzel
state that Willems
(a Belgian surgeon) gives the following statistics
in regard to the final outcome of 100 of his consecutive
knee cases,
18 of which were accompanied
by a purulent synovitis of a virulent
type, chiefly streptococcus.
In the
100
cases
there
were
no
deaths
and no amputations.
There was one resection
and
two
stiff joints.
These
are very striking results
and
stand
in profound
contrast
to
the reports we have just studied of Barling and Speed.
The following are the general principles of Willems's treatment as
given in the article of McWilliams and Hetzel : Preliminary Roentgen
ray examination of the joint with the object of determining the degree
of fracture, if any ; also the marking out on the surface of the posi
tion of the foreign body beneath.
At the operation careful debride
ment of all the
damaged
tissues
surrounding
the wound, external
to the opening in the synovial membrane,
and the removal of all the
hemorrhages
in the fascial
planes
about
the wound.
Changing
of
the instruments, or resterilization
before
entering the wound.
Re
moval of the contused
edges of the synovial wound with its enlarge
ment up and down sufficiently to do the necessary
subsequent
work.
The joint should be kept open just as short a time
as possible in order
that the synovial
membrane
may
dry
as little
as
possible,
since
a
dry synovial membrane
seems
to predispose
to ankylosis.
Removal
of the foreign body, all clothing, and loose detached bone fragments.
Smoothing off of all rough bone edges. If the foreign body is buried
in the bone, it is chiseled away, following the tract to its end and re
moving all the devitalized bone surrounding
the tract.
If possible,
all the
procedures
should be performed without
the gloved hands
being introduced into the joint, or without touching
any contacting
part of the instrument to be introduced.
At this stage, one will de
termine whether there is sufficient
undamaged
articular cartilage left
to make possible
the hope of subsequent
restoration of function
by
immediate,
post-operative, mobilizing
movements.
The joint is then
Ko.3.
OMAN
AND CUMMINGS—WOUNDS
OF THE KNEE JOINT.
383
thoroughly
washed
out with
any nonirritating,
bland solution, such
as Dakin's
or normal salt solution, followed,
finally,
by
a flushing
with pure ether, and then the capsular opening edges are completely
closed with
a plain
continuous catgut
suture
either
through
and
through,
or, as some prefer, so passed that no suture
appears
inside
the
joint.
Unless
the
effusion
into
the joint
is frank
pus,
as in
neglected cases, the synovial membrane is completely closed, disregard
ing the length of time that the injury has existed prior to the opera
tion.
The
tissues
external to
the closed
capsular wound
need not
be closed,
however,
and had
better not be, if the injury
has existed
over 12 hours.
The external open wound may be loosely packed with
gauze, wet in Dakin's
solution, or Carrel's
tubes
may
be
placed
in
position
in the wound for subsequent
treatments
with
Dakin's
solu
tion.
The important point to be emphasized
is that the entire open
ing in the synovial membrane
must be completely closed.
A bandage is so loosely
passed about the dressing as not to impede
subsequent
movements.
At the time the joint is open,
a culture is taken of its contents
to
subsequently determine
the presence or absence of hemolytic
strep
tococci,
which, when found,
requires
speedy
drainage of the joint.
No splint to be applied, and this is all-important.
After treatment. —Just as soon
as the patient is out of the
anaes
thetic he is made to actively (never passively)
move the articidation
in bed.
Passive motions are painful and
set
up
an inflammatory
reaction,
and
later on an extra-articular
abscess
may
be
caused
to
rupture into the joint.
The patient's hands grasp the sides of the
thigh, which is lifted from the bed by muscular contractions, his heel
remaining resting on the mattress.
At first there
is excessive fear
of trying
these motions, but
as the pain
is felt
to
be very slight,
courage
is soon
established.
The
sooner
motions are
begun
after
the operation,
the less is the pain, because
the periarticular
struc
tures
do not
have
time
to
become
infiltrated
with
exudate.
The
nurse sees that this is done every
two
hours,
night
and
day, to the
greatest
extent
possible
short of actual pain.
To the faithfulness,
consequently, of the nurse in following these instructions will be due
the subsequent restoration of function.
There is astonishingly little
pain when active motions are started immediately after the operation,
providing
no bony fragments
are
displaced, in which
case
move
ments are not indicated.
Patients
say
that if painful
sensations
appear during
repose
the best means of making
them
disappear
is
to repeat the movements.
Willems's
treatment of a wound of the knee joint may
be briefly
outlined as follows: (This summary was taken
from the article by
Burton James Lee.)
1. Accurate
foreign body localization.
384
OMAN
AND CUMM1NGS
WOUNDS
OF THE KNEE JOINT. Vol. XVII.
2. Careful
debridement
of all soiled and
devitalized
soft
tissues
and soiled bone.
3. Removal of all loose bone fragments and foreign bodies.
4. Irrigation of the joint with saline.
5. Filling of the joint with ether.
6. Primary
closure
of the joint by suture,
usually
including
the
skin.
With considerable
injury to knee or muscle, it is wiser to close
the joint capsule,
but leave the skin and muscle unsutured.
7. Early and frequent repeated active motion of the knee, no splint
being applied, save with massive
bone injury.
This mobilization
is
begun
upon the second
day, and is continued at two or three
hour
intervals.
The patient is up about
the ward, with
crutch support,
on the fourth day, and is encouraged
to walk without
any support
by the tenth day.
We have not had
access
to the original
article of Willems,
but his
methods
have been so thoroughly
described
and
presented
by other
experienced
surgeons
that
we
feel
that
reference
to
the
original
article is hardly
required.
In connection
with the
progress
of the
case following closure, it
should be noted that effusion
into the joint sometimes
occurs.
Effu
sion into the joint at once puts a stop to the movements,
and as soon
as
the liquid is withdrawn
by
puncture, mobilization
instantly
is
reestablished,
which means that it is not the wound which abolishes
the function
but
the articular
distention.
Should
the joint become
distended,
should temperature rise and
sepsis
seem
to
be starting,
an aspiration may
be performed to decide the character of the intra
articular
fluid and
to obtain a culture.
Staphylococcus infection
is
less to
be
feared
than streptococcus.
Objections
to
aspiration
are
found in the wounding of the synovial surface and
leakage
of the
infected joint contents through the puncture hole into poorly
resist
ing
periarticular
tissues,
resulting
in
a rapidly spreading
sepsis.
The joint surface has more resistance
than the periarticular
tissues.
In the
cases of septic
knee joints, Willems
manages
them
in the
following manner
: As soon
as frank pus is evident,
either by signs
of inflammation
or bacteriological
examination, thorough
drainage
must
be
at
once
established
by vertical
external
and
internal
ex
cisions.
The joint is washed
out thoroughly
with
Dakiivs
solution
at the
time of the operation.
Tubes had
preferably
better
not
be
used at first, but may
be later if drainage is found to be insufficient.
When they are used, the internal ends should project just inside t\vt
synovial membrane
and no farther.
The after treatment
is conducted
exactly as in the case of noninfected joints, by active
(not passive)
motions carried
out to the point of pain.
These
are begun
imme
diately
after
the
anaesthetic
has worn
off and
are
repeated
every
No. 3.
OMAN
AXD
CUM MINGS— WOUNDS
OK THE KNEE JOINT.
385
two hours thereafter, day and night.
Even
a day's delay will preju
dice the final
functional
result.
Walking is important
because the
muscular contractions
compress
the joint
and
cause
a marked in
crease in the expulsion of pus.
The
patient
is made
to
walk
the
next day after the operation without
crutches.
It is surprising
how
much pus will exude from the incisions after each walk.
It is very
important
that sufficient
drainage openings
be made to allow for an
adequate
escape of the pus.
These
openings should be sutured
just
as soon
as the discharge becomes serous.
If the active
motions
are
performed
often enough
and vigorously
enough,
these secretions
are
expelled through the drainage openings as they are formed.
Drain
age seems
to be more thoroughly
accomplished
by this method
than
by any other, thus limiting the infection
to the synovial membrane,
and tending
to prevent its spread
to the cartilage
and
bones.
In civil injuries
the results of operations with
debridement,
joint
closure
and immediate
subsequent
mobilization
should be much
bet
ter than in war injuries,
because ordinarily the patient is operated
upon more quickly, the infection is not so virulent, there is no trans
fer
to
another
hospital ; and,
finally,
the
after
nursing
should
be
more effectually done.
This method
of treatment
is in absolute
contrast with
the
usual
teachings regarding infected joints where immobilization
for a long
period has been the rule.
However, the distinct advantages
derived
from active mobilization
of septic joints
prove
its value
as a sound
form of treatment.
By mobilization,
efficient drainage of the joint
is established,
the time
consumed
in recovery
is much
shorter, and
the percentage of good functional
results
is much higher.
Mayo Robson and Kellogg Speed
devised
a form of drainage for
septic
knee
joints
known
as subcrural
pouch
drainage
and
inver
sion treatment.
This method
consisted
in opening the joint in the
subcrural
pouch
through
a small
incision
through
the quadriceps
extensor
muscle
in the midline of the thigh.
A tube
is introduced
through this opening into
the joint
and
the
leg firmly
held in
a
Thomas
splint.
In order to effect drainage, the patient was turned
over on his
face for several
hours
several
times
a
day,
thus
per
mitting the exudate
to run out of the small opening, which, in this
way. became
the most
dependent
point of the joint.
The limb may
be also held
in the vertical position
at right angles
to the body in
the
Thomas
splint,
supported
by
fixing
it
to
an
overhead
bar.
This position
also favors drainage but not
as effectively
as in the
prone position.
Speed
suggests
this
treatment
for the first
stage
of knee-joint
infection
and
even for those that threaten
to become
severe.
In reviewing the methods
and reports concerning the management
of knee-joint injuries,
with
their
attendant complications,
it
ap
386
McCOY
SOME FEATURES
OF PLAGUE.
Vol. XVII.
pears
that
the technique
adopted
by Willems,
followed
by immedi
ate
active
mobilization,
is the standard
to follow.
Many
able
sur
geons practiced the principles of wound
excision
and joint closure,
but
to Willems
belongs
the distinction
of
having
practiced
with
marked
success
the principles of active
mobilization
in noninfected
and infected knee joints.
The splendid functional
results following
the conduct
of this principle
insures
its adoption in the prescribed
treatment.
We have purposely refrained from introducing
into the
article
a discussion
of knee-joint injuries
complicated
by severe
bon»?
injuries.
The subject
is too
vast
to enter
all
its
phases,
hence
we
have confined ourselves
to a discussion of the early treatment
shortly
following
injury and when complicated
by sepsis.
BIBLIOGRAPHY.
A. W. Mayo
Robson, British Medical
Journal,
2:4.">0,
1917.
H.
S. Barling, Br tlsh Med cnl Journal.
2:277,
1917.
Kellogg
Speed, J. A. M. A.. 70: 918, March
30. 1918.
Eugene
H.
Pool
and
Jt>lm
H.
Jopson,
Annuls
of
Surgery,
70:'_'GG.
Septeml»er,
1919.
Clarence
A. McWllllams
and William
B.
Hetzel.
Annals of
Surgery,
70: 207,
September,
1919.
Vernon
C. David, Annals of Surgery,
70 : 290, September,
1919.
Burton Junies Lee, Annals
of Surgery,
70:464,
October.
1919
Carleton
R. Metcalf,
Annals of Surgery,
09:318, March.
1919.
SOME
FEATURES
OF FLAGTJE.'
By
Surgeon
(,'eok«k W. McCoy,
United
States Public Health
Service.
INTRODUCTION.
As there
are excellent
treatises
on plague I shall not
attempt tc
cover the Avhole
subject,
leaving out of consideration in general
the
history, clinical manifestations, and pathology, which can be found
without difficulty, and
devote myself more particularly
to features
which are not usually stressed or which are not so readily accessible.
There are two
main
clinical
and epidemiological
types of plague
in man, but so far as we know but one type occurs
as a natural infec
tion in rodents.
The two
types
in man are the pneumonic
and bu
bonic,
and ordinarily
these breed true, i. e., pneumonic
plague gives
rise
to pneumonic
plague,
is not associated
with this disease in ro
dents, and for practical
purposes
may
be said
never
to give rise to
cases of the bubonic type.
Primary bubonic plague
frequently pre
sents secondary
pulmonary manifestations, but, with rare exceptions,
never gives rise to cases of the pneumonic
type.
■A lecture
delivered at the Vnlted
States
Naval
Medical
School,
Washington.
D. C
Xo. 3.
387
McCOY-
SOME FEATURES
OF
PLAGUE.
A third
class
is sometimes
recognized,
the septicemic
type,
but
careful
post-mortem
examination will usually
show
deep buboes
in
these cases.
In general,
pneumonic plague
is a disease of cold countries,
and
the little
we know about
it is derived chiefly from Manchurian
ex
perience;
while
the bubonic type
is
a disease of warm climates
or
warm weather
in temperate
climates.
In this connection
it may
be
noted that, while the. lung type prevails almost exclusively in north
ern China, in southern
China it is almost
unknown,
and
the more
usual
bubonic type
is quite
common.
Inasmuch
as the
pneumonic
type does not appear to have special significance for us in the United
States, my remarks will principally be with reference
to the bubonic
type.
The present-day
importance of plague
is indicated by data
taken
from the Bulletin of the International
Office of Public Hygiene
at
Paris, which catalogues
plague for 1921 at the following
places:
In Africa:
Eastern
English
possessions,
Algiers,
Angola,
Cape
Verde Islands,
many provinces in Egypt, Anglo-Egyptian
Sudan,
Lybia, Madagascar, Senegal, Tunis, the Union of South Africa.
In America
two
cases of human
plague
of squirrel origin
were re
ported
from California, and, though they are not reported, it should
be stated that a number
of cases of rodent plague
have occurred
in
Gulf coast cities and in three States in Mexico.
In South America
the list includes Argentine
Republic,
Brazil,
Chile. Ecuador, Peru, Paraguay.
In the West Indies, Porto Rico infestation
is shown
in six locali
ties.
In Asia
: Ceylon, China (including
Hongkong),
British India, East
Indies, French
Indo-China,
Asiatic Russia,
Siam,
the Straits
Set
tlements, Turkey in Asia.
From Europe,
infection
was
reported during
the year at three
points
in Greece,
five
points in Italy,
in Portugal,
in
the Azores
(Portuguese
possessions),
in Russia, in the new State of the Serbs,
Croats, and Slovenes, and in Turkey.
In 1920 an outbreak of some
thing like 100 cases occurred in Paris and there were infections in at
least one of the French seaports in that year.
From the Pacific islands, Australia and Hawaii reported
cases.
GENERAL CONSIDERATIONS.
While the list of places in which plague
has prevailed within
the
last year may give the suggestion
that in these modern times it is a
serious menace, yet we must class it with the other diseases which are
yielding to the advance of civilization
and
to progress in sanitary
science.
To justify this statement
one has but to read the history of
plague in England,
where for a period of about 600 years ending with
388
McCOr
SOME FEATURES
OF
PLAGUE.
VoL XVII.
about
the beginning of the eighteenth
century, plague was
present
and existed
as a serious menace, and to compare this with the occasional
trifling outbreaks
which have occurred in the British Islands in the
last 20 years.
In the earlier centuries,
the deaths from this
disease
for many
years
were
numbered
by the tens of thousands,
while
in
more recent years these cases may be counted by the dozen only.
In its spread
from country to country plague,
like other diseases,
follows
the line of trade;
and
because
trade
between
countries
is
chiefly in ships, plague is usually
a ship- borne disease.
Even where
facilities for land transportation
would at first sight seem
to be su
perior
to those for water transportation,
plague appears
to
prefer
water-borne commerce
as the medium by which it shall be carried. I
think it is more than a coincidence
that the only communities in the
United
States
which
have
ever
suffered
from plague are those
en
joying
a
considerable
water
commerce,
notably
San
Francisco,
Seattle,
New Orleans, Pensacola, Galveston, and Beaumont.
Many interior
communities,
with easy and direct railway
commu
nication to the places I have named, have escaped infection
; although
it can scarcely
be said that the measures taken to prevent the spread
of the disease were such as would have guaranteed
against its exten
sion.
While we may
take effective
measures
as soon
as the disease
is found among people, there is every reason to believe that, ordinarily,
human
cases occur only after rat infection has gained
much headway,
and during
the period prior to the occurrence
of human cases
there
is ample opportunity
for spread
to other communities.
BACTERIOLOGY.
Before considering the other
aspects of our subject,
a few words
may
be said about the recognition of the plague bacillus.
There are
few
pathogenic
organisms
more
readily
recognized
or
more
cer
tainly
identified than is this organism.
For all practical
purposes
but
four culture media
are necessary,
viz, agar slants,
on which
it
grows as a tenacious,
sticky, grayish streak; "salt agar" slants,
con
taining
about
2 per cent sodium chloride, on which, within one or
two
days,
most
pronounced
changes
in
morphology
occur;
broth
tubes,
which
present
a
delicate
surface
growth,
with
dependent
fringes:
and
litmus
milk,
which
is
rendered
slightly
acid
by the
organism.
These
features,
together
with its ability
to induce
char
acteristic
lesions
in laboratory
animals, suffice for the exclusion
of
other organisms with which, conceivably, it might be confused.
Pro
tective tests, using the Yersin antiplague serum, may be made
as the
final diagnostic procedure
in an exceptionally important test.
Punc
ture of
a gland with
a hypodermic syringe will practically
always
result, in the securing of fluid for morphological, cultural, and inocu
lation investigation.
No. 3.
McCOY—SOME FEATURES
OF
PLAGUE.
389
This is an appropriate
place to say a few words about plague-like
diseases.
It should
be
understood,
first, that
these
occur
only
in
rodents; for practical
purposes
we may say that there
is no plague
like disease of man.
Of the plague-like diseases of rodents, two may
be given
brief consideration : Pfeiffer's pseudo-tuberculosis rodent-
ium organism
produces
lesions
in guinea
pigs which
are very diffi
cult to distinguish
from plague;
however,
this organism
is practi
cally without effect on rats and
is never
found naturally
in rats or
in man.
In the
work of the Public Health
Service
we have
not
encountered
any
pest-like
organism
save Pfeiffer's
pseudo-tuber
culosis
bacillus
already
mentioned,
which
is closely
related to
the
plague bacillus— indeed,
some workers have
regarded
them
as iden
tical.
This
particular
organism
confers
immunity
to
subsequent
infections of plague.
A plague-like
disease is found
as a natural
infection
in ground
squirrels
and rabbits and is caused by a remarkable organism, Bac
terium
tularense.
In squirrels
and
in guinea pigs, it gives gross
appearances
which defy the most experienced
; however,
cultures on
the media used for the plague
bacillus are always negative
and
the
infectivity for rats is relatively low, so that if one is on the lookout
for it no confusion occurs.
This organism seems to be highly patho
genic for man but without producing plague-like lesions.
It seems to require but a slender basis on which to report an organ
ism as " plague-like."
For instance,
there
has recently come to our
attention
a report of a " plague-like " organism which
is described
as motile, flagellated, giving a greenish-yellow growth on agar, pro
ducing gas in sugar media,
and rendering milk acid and clotting it.
It also failed
to infect animals when rubbed
on the shaven
skin of
the belly.
It is difficult to conceive of any organism much further
from the plague bacillus than this.
PATHOLOGY.
With respect
to the post-mortem diagnosis of plague,
it should be
emphasized
that the gross lesions
are as characteristic as those in any
diseases in which we are accustomed
to rely on post-mortem
findings
for diagnosis.
I know of no infectious
disease,
with
the
possible
exception
of
lobar
pneumonia, which
gives equally
characteristic
appearance
after
death
as
does
bubonic
plague.
This
point
is
stressed
because
we
are
accustomed
to
receive
requests
for smears
and cultures
to enable laboratory
workers to become familiar with
plague.
While
cultural
investigation
may
be
necessary
to
clinch
the diagnosis with evidence which would convince
the most skeptical,
for practical purposes
the gross pathological
appearances
are path
ognomonic.
646—22
2
390
Vol. XVII.
McCOY—SOME FEATURES
OF
PLAGUE.
The tumors in the region of the lymph glands, the bloody
gela
tinous exudate
beneath
the skin, the pronounced hemorrhagic
ap
pearance
around
the
lymph
node,' the
enormously
enlarged
and
softened
bloody gland, all
combine
to give
a picture which
is
not
duplicated by anything
else.
The examination of smear
prepara
tions,
the making of cultures,
and the inoculation
of animals may.
and perhaps in many cases should be done, but such appearances
as I
have indicated leave no one with experience
in doubt.
In laboratory
animals, and
indeed in the wild rodents
where the
infection
has
been studied, the
lesions
are
almost
equally charac
teristic, although it is not necessary to discuss them in detail.
ANATOMICAL PECULIARITIES IN RODENTS.
There is
a remarkable difference
between
the
lesions
of bubonic
plague in
certain
rodents.
Perhaps
the
best
contrast
is
between
guinea pigs and rats.
While each species presents a bubo, the visceral
lesions differ markedly.
In acute plague in the guinea pig the spleen
is always full of whitish-yellow
necrotic
foci; in the rat these
are
not found, but
the organ is enlarged and purple
in color;
on
the
other hand, in the rat the liver is usually liberally
sprinkled
with
necrotic foci, while
in
the
guinea
pig the corresponding
organ
is
generally
free
from
lesions.
In
the rat
there
is often
a marked,
dusky red
subcutaneous
injection
that is most striking,
but this is
not seen in the guinea
pig, and, finally, in the rat we have often a
marked serous effusion
which is wanting in the guinea pig.
Indeed,
the bubo
is the only lesion
found in both
species of rodents
which
are commonly used as test animals.
Chronic plague in rats has been thought to be the means whereby
plague was carried over from season to season, although the evidence
is not very strong.
Among
rodents,
susceptibility
to plague extends
through
many
groups.
It is mentioned
here in order that an exception
to the rule
may be noted.
In our experiments
with the rodents found in the far
West, no example
of immunity
to plague was found in any
species
save the pocket
gopher.
This little animal, which
is very common
in California, was, to our surprise, found to be highly resistant
to
the
infection,
surviving
with
regularity
doses of highly virulent
cultures
which
were
uniformly
fatal
to
other
rodents.
Perhaps
there is a suggestion
in this fact for immunity
studies.
Plague is a disease affecting primarily the rats of cities; but. from
the point of view of control,
the
more
obstinate
infection
among
rural rodents is not so well known.
Let me refer to several examples
:
In our own Pacific coast region there is, in the State of California, a
squirrel
plague focus
covering an area of several
thousand
square
So. 3.
391
McCOY— SOME FEATURES
OF PLAGUE.
miles.
It is perhaps 50 miles wide by
150 in length.
Since its dis
covery
some
10 years ago it has been the theater of persistent,
intel
ligent attempts
at eradication, but the results have not been satisfac
tory.
To suppress squirrels effectively
would require an enormous ex
penditure
on the part of a control agency
; that
is,
the State or ths
General Government, or the practically
simultaneous expenditure of
larger or smaller sums by individual
landowners.
Neither condition
up to the present time has been brought about
;
indeed, after enjoying
opportunities
of familiarity with the work from the beginning,
I
am
driven to the conclusion that the eradication of this focus
is
impossible
with present resources.
Indeed,
it
may well be questioned whether we
would
be warranted
in spending
on this work
the large
sum that
would be required to do the job thoroughly.
Human plague of squir
rel origin
is
relatively
a
rare disease, only one or two cases occurring
in
a
year, and, of course, this
is
insignificant in comparison with many
other diseases.
What
we. must do
is
to watch
the rodents of adjacent
cities and endeavor
to prevent
their infection from squirrels
;
this
is
readily done by the creation of squirrel-free zones around large com
munities.
On one of the islands of the Hawaiian
group we have
a
focus of
plague
of over
20 years'
standing
among
rats, chiefly
among
the
species Mux rattus living in the sugar-cane
fields.
In spite of eradica-
tive measures, which on the whole have
been
as consistently and ef
fectively carried out as
is
believed
to be possible with any reasonable
expenditure of money, this focus persists
and gives rise to
a
few cases
of plague, usually two or three
each year,
sometimes
with intervals
of two or three years between cases.
An examination on the ground
is
necessary to enable
one to appreciate
the—for all practical pur
poses — almost
insuperable difficulties attending on attempts
to wipe
out the infection.
Here, as in California, the most we are able to do
is
to prevent
infection of villages and towns,
and we must
pay
the
toll of an occasional
human case.
Within
the last few months,
a
new focus of infection has been found
in
South Africa, where two rodents,
a
gerbill
(similar to
a
brush rat)
and
a
multimammate mouse
(similar
to
a
house mouse),
have been
found infected in nature,
the discovery having been
consequent upon
the occurrence
of cases of human plague
in isolated
parts of Cape
Colony.
The area known to
be infected in South Africa
is
at least
5,000
square miles,
and from the point of view of eradication, presents
a
problem
similar to our squirrel plague infection on the Pacific
coast.
The evidence all indicates that this particular
focus among
rural-
•Iwelling
rodents
is
of many years' standing.
The oldest of the infections among wild rodents
probably
is
that
of
Siberia
and Manchuria,
and
it
is
the one about which we know
the
392
Vol. XVII.
McCOY—SOME FEATURES
OF
PLAGUE.
least.
Very recently, for the first time,
we have reports of animal
plague infection
among
the
marmots
of Manchuria,
although
the
evidence
has long pointed to these rodents
as almost
unquestionably
the source of the outbreaks of the pneumonic
type of the disease which
according to available reports have occurred
almost yearly for a long
time,
and probably
have
a longer history
than is indicated by
evi
dence so far obtained.
Zoologically the marmot is closely related
to our ground squirrel of
the Pacific coast, and we have every reason to believe that the prob
lems are somewhat
similar,
although,
as I have stated, trustworthy
evidence
is meager.
These foci of plague among rodents of rural regions are all marked
by the following
features;
(1)
They
are exceedingly widespread.
(2)
They present more serious
difficulties in eradication, if indeed
this be possible.
(3) They may give rise directly to only
a few human cases.
This
holds for all except the Manchurian
focus.
Human
plague of squirrel origin
has several points of divergence
from that of rat origin; briefly stated, these are:
In
the
first
place,
the
location of the
primary
bubo
in
all,
or
nearly all, of the cases
is in the axilla
when squirrels are the source
of the infection, while in the majority of the cases of rat origin
the
primary
evidence
of infection
is to be found in the groin, usually
in the region of the femoral glands.
The infection
from squirrels
comes from fleas that get on the hands when squirrels are picked up,
while rat fleas do not come directly from the natural
hast, but from
the ground or from the floor.
In the second
place, there is
a smaller mortality
in the
cases
of
human
plague of squirrel origin, only about
50 per cent of the cases
proving
fatal, while a much higher rate ordinarily obtains in infec
tions of rat origin.
The only hopeful
thing
with
respect
to
the squirrel
situation
is
the fact that bringing
the land under intensive cultivation
drives
out
these rodents.
It is uncultivated
and
largely
pasture
land
in
which the ground squirrels thrive in California, and it is among
the
squirrels of these lands that we find plague prevailing.
Among
the most difficult things to explain in plague epidemics
is
the long intervals between the finding of infected rodents.
In some
of our southern cities
several
months
pass during
which
many
rats
are taken
without
detecting
infections;
then
a plague rat will be
taken,
and again a long interval, with many
negative
examinations.
In Hawaii the interval is often a year or more.
The early English workers laid considerable
stress on a particidar
species of flea. Loemopsylla
cheopus,
as the
essential
agent in the
No. 3.
393
McCOY—SOME FEATURES
OF
PLAGUE.
transfer of the disease from rat to man.
Further work
and
accu
mulated
experience,
particularly
that in the United
States,
clearly
indicates
that other fleas
may,
and
probably
do, serve equally ef
fectively
as vectors;
possibly one exception
to this should be made;
the blind
flea of the mouse, Ctenopsylla
-musculi,
frequently
found
on rats, appears not to bite man.
Some of the work done at our plague
laboratory
in
San Francisco
with
this
flea
gave
negative
results,
while positive results
were obtained
with all other fleas with which
we worked.
Somewhat later Professor
Martin
and
Doctor
Chick
got, working
in England,
practically
identical results.
IMMUNITY
OF RODENTS.
While rats undoubtedly serve as the chief agents in the transmis
sion of the bubonic
type of the disease, they are themselves far from
uniformly
susceptible.
It has long been
known that rats in infected regions show rather
high resistance
to infection ; thus,
as much
as 20 per cent of the San
Francisco
rats
were
resistant
after
plague
had
prevailed
for
a
very considerable time.
Only recently,
however,
we have been able
to show that rats from communities in which plague never
has pre
vailed
show
a similar
degree of resistance.
In work
at our plague
laboratory
in
Pensacola,
Doctor
Spencer found
that
rats
shipped
from Mobile,
Ala.,
where
plague has
never
existed,
showed
a
per
centage of immunity
comparable
to those in infected regions.
With
respect
to ground squirrels,
an interesting
state
of affairs
exists
in California.
The
ground
squirrels
in
the
sections
where
plague
has
never
prevailed
show
an
exceedingly
high
degree
of
susceptibility,
dying promptly
with definite
manifestations of acute
plague,
while those secured from regions
where plague
has prevailed
for many
years
show
a considerable
degree of immunity.
The dif
ference is so striking
that it leads one to believe that those
rodents
of this species which have long been exposed to plague have a heredi
tary immunity, and perhaps it affords some ground for the hope that
in due time the disease may become extinct by reason of the increased
percentage
of nonsusceptible
squirrels.
SUPPRESSIVE MEASURES.
In each community local conditions will
dictate,
to some extent,
the measures to be taken.
The experience
gained on the Pacific coast
with gray rats and ground squirrels was of little avail when dealing
with the black rat of Hawaii, which is found both in buildings
and
in sugar-cane
fields.
Similarly, the ratproofing
much
used in this
country
is economically out of the question
in India.
Cyanide fumi
gation,
much
used
in southern
mills
and dwellings,
is inapplicable
RAYNOR
MEDICAL
COBPS
UNITS.
Vol. XVII.
in India
on
account
of
the
loose roof
construction
which
readily
permits the escape of gas.
In the East Indies, for example,
where
bamboo is extensively used for building
purposes,
one of the impor
tant measures
is to find
a substitute
for this material which
offers
excellent
rat harborage.
Workers
in India who have recently
made many observations
on
rat poisons,
conclude
that barium
carbonate
is the
best
; and
when
it becomes necessary to vary this, or when it is not available, arsenous
acid
is to be chosen.
The effective
dose of the former is
grains
and of the latter one-half grain.
These observers
found great variation in the readiness
with which
various baits
were eaten, spiked millet being preferred, rice coming
next, and wheat coming low in the list.
(Indian Jour.
Med. Res..
Jan., 1921, p. 44G. vol. 8, No. 3.)
In India
attempts
at rat extermination
have not been very suc
cessful,
but
the
account
of the
efforts
leads
one to agree with
the
authors that the fault lies in
inadequate
means of rat destruction.
Ratproofing
seems
out of the
question.
(Indian Jour.
Med.
Res..
Jan., 1921, vol.
8, No. 3, p. 409.)
A few words
about
vaccines
and serums: Disposing
first of
the
serum, I majr say that there
is no very satisfactory
evidence
that
it
is of value.
Controlled
tests of its therapeutic usefulness
have
not
been particularly
satisfactory, although isolated series generally leave
the users with the impression that it has done some good.
fluffkine's
antiplague vaccine
has been used for many years; here,
too,
the
evidence
is not particularly
satisfactory.
On
the
whole,
perhaps, it is fair to say that biologic products have, from the public
health point of view, no place in dealing with outbreaks
of plague.
FUNCTIONS
AND
ORGANIZATION
OP
MEDICAL
CORPS
UNITS
SERVING
WITH THE MARINE
CORPS IN THE FIELD.
By
S.
N*. Rainob, Major, United
States
Marine
Corps.
THE DIVISION
SURGEON
AND THE MEDICAL
STAFF.
In this article
an attempt will
be
made to give an outline
and
general
discussion
of the duties
and
functions of the division
sur
geon
and
some of
his
assistants
of
the medical staff ; their
rela
tions
to
the
general
staff ; their
sources
of information
;
channels
of communication:
stations and division
of duties;
and
method
of
management of the medical
troops and units.
The duties
and functions of the surgeon of a brigrade acting inde
pendently would differ from those of the surgeon of a division only
as limited by the special
functions and actions or movements
of the
So. 3.
RAYNOR —MEDICAL,
CORPS
UNITS.
organizations composing the brigade, the number of medical
troops
attached thereto,
and
consequent
restrictions of medical functions.
RELATIONS
AND DUTIES
OF THE
MEDICAL
DEPARTMENT
AND
SURGEON.
The medical
department is a supply
and technical service
of the
organization
to which attached.
Its principal function is the pres
ervation of man power throughout the organization and maintenance
of activities for prevention of disease, early restoration of the dis
abled to duty, and the elimination of the physically unfit.
The division surgeon
is the chief of this service,
and
as such is a
member
of the
supply
and technical staff of the
headquarters
of
the organization to which
he is attached.
The medical department
as a service, and the surgeon
as a chief of service,
are not independ
ent entities but only part of the whole military machine,
with definite
functions of an auxiliary
nature.
As these functions are not included
in the primary
role of the organization of which they
form
a part,
they as well
as the necessities of this service
must conform
to those
of
the organization
of which
the
medical
department
forms
an
integral
part.
Supervision,
cooperation,
and
coordination
by
the
organization commander
through his staff are essential.
The medical
service,
however,
is technical and complex,
and such control of it as
is assumed by the division
commander
or his representatives
should
he limited
to
that
necessary
for
the
preservation
of
discipline,
efficiency, and
cooperation, and
should not enter into its intracor-
poreal structure
or
technical
activities
so long
as
the
foregoing
desiderata
are not affected.
DUTIES
OF THE
DIVISION
SURGEON.
In general the duties of the division surgeon
are the administration
and technical supply of the medical
service of the division,
and the
care of the troops.
In detail the duties of the division
surgeon
are as follows
:
1. Commanding officer of the medical regiment and medical
troops
of the division for medical
department technical service.
(Coordi
nated
by G-4.)
2. Sanitary inspection
and
prevention of disease.
(Coordinated
byG-1.)
3. Collection and transportation
of the sick and wounded.
(Co
ordinated
by G-4.)
4. Care and
hospitalization
of the sick and
wounded.
(Coordi
nated by G-4.)
-
•
5. Procurement
and issue of medical, dental, and veterinary sup
plies.
(Coordinated
by G-4.)
396
Vol. XVII.
RAYNOR —MEDICAL
CORPS
UNITS.
6. Replacement
of medical
department
personnel.
(Coordinated
by 0-1.)
7. Movements
and
stations
of medical
units.
(Coordinated
bv
G-4 and G-3.)
8. Records of sick, wounded,
and dead.
(Coordinated
by G-l.)
9. Training of medical troops.
(Coordinated
by G-3.)
10. Plans of evacuation.
(Coordinated
by G-4.)
11. Action to secure publication of memoranda,
orders,
and parts
of orders through appropriate
general
staff sections, i. e., G-l, G-3.
or G-4.
CHANNELS OP COMMUNICATION, DIVISION
SURGEON.
The channels
of communication used by the division surgeon
are
as follows:
1. Through
G-4: All matter not relating
to training,
sanitation,
and health, purely technical and intramedical
department subjects,
and excepted
subjects.
2. Through G-3 : All matters
relating to training.
3. Through
medical
department channels.
Strictly medical
and
technical subjects.
4. Through
other
staff
departments.
Excepted
subjects.
(See
diagram at end of article.)
AGENCIES
FOR PERFORMING
THESE
DUTIES.
According
to diagram at end of article.
SOURCES
OF INFORMATION
OF DIVISION
SURGEON.
1.
Conferences
with commanding general,
with
heads of general
staff sections;
and
with
surgeon
of corps,
army,
and
neighboring
divisions.
2. Personal reconnaisance
and inspection.
3. Reports
and
conferences
with sanitary
inspector,
assistants,
dental
and veterinary
surgeons,
second in command
of the medical
regiment,
battalion commanders
(medical supply
officer, regimental
and battalion surgeons.
(See diagram at end of article.)
DIVISION
SURGEON'S
OFFICE.
The location of the division
surgeon's
office
during
campaign
is
at the headquarters
of the medical
regiment.
In a permanent
camp
it
is usually
located
at division
headquarters.
For the
organiza
tion of the division surgeon's
office,
see diagram at end of article.
Under
the situations given below
the division
surgeon
will
take
measures, either directly
or through
the proper staff officers
(indi
cated in the right-hand
column),
to act or secure
the
measures
or
action
indicated.
Xo. 3.
397
RAYNOR —MEDICAL,
CORPS
UNITS.
THE DIVISION IN MOBILIZATION
AND TRAINING
(MEDICAL
DEPARTMENT).
(a) Organization and assignment of personnel
as given in diagram
and tables of organization.
(Coordinated
by G-l, G-4.)
(6)
Selection of positions of regimental
and battalion
dispensa
ries, medical
regiment, and station hospital.
(Coordinated
by G-4.)
(c)
Secure publication of annex
to administrative
order covering
reports
and returns to be rendered
and general routine of the medical
service of the camp or cantonment.
(Coordinated
by G^4.)
(d)
Secure publication of annex to administrative
order covering
sanitation of camp
and cantonment.
(Coordinated
by G-l.)
(e)
Secure inclusion of training
program for the medical troops
in
G-3 training
order.
(Coordinated
by G-3.)
(/) Make arrangements with
local civil
authorities
for mutual
sanitary cooperation.
(Coordinated
by G-l.)
(g) Take necessary action to secure medical
department,
ordnance,
and quartermaster
supplies.
(Coordinated
by G-4.)
MOVEMENT
OF THE DIVISION
BY RAIL OR WATER
(MEDICAL
DEPARTMENT).
(COORDINATED BY G-3.)
A. Warning
message.
Secure
inclusion of sanitary
inspector in
division quartering party.
(G-l, G-3, G-4.)
B.
Field order.
(G-3.)
(a)
Secure inclusion of the division
surgeon
in movement
of first
echelon.
(G-4.)
(b)
Secure inclusion of one sanitary company,
one ambulance
com
pany,
and one hospital
company
in first troop
movement.
(G-3,
G-4.)
(e) Secure inclusion of the headquarters
of the medical
regiment
and the main bodies of the sanitary, ambulance,
and hospital battal
ions, the service company
and veterinary company
in the troop move
ment of the main body of the division.
(G-3, G-4.)
{d)
Secure inclusion of one sanitary company,
one ambulance
com
pany,
and one
hospital
company in
last
troop
movement.
(G-3,
G-4.)
(e) If wagon
transportation
moves overland, move animal-drawn
units of the medical
regiment with animal-drawn
unit train.
(G-3,
G-4.)
(/)
Detail assistant
division
surgeon
to remain with
representa
tive of G-A at old
headquarters
until
move
is
completed.
(G-4.)
C.
Administrative
order.
(G^.)
(a) Plan for evacuation
of casualties.
(G-4.)
(&) Location of salvage
dump
for medical
department supplies.
(6-4.)
398
Vol. XVII.
BAYNOR —MEDICAL
CORPS
UNITS.
A MARCH IN CONCENTRATION TO BIVOUAC.
OR TO BATTLE
(MEDI
CAL DEPARTMENT).
A. Field order.
(G-3.)
(a)
Assignment
of
a sanitary
company
and
an ambulance
com
pany (or detachments
thereof)
to the advance guard or other cover
ing force.
(Usually the animal-drawn
ambulance
company.)
(Co
ordinated by G-3, G-4.)
(b)
Designation of the order of march of the medical units in the
column.
(Coordinated
by G-3, G-4.)
B. Administrative
order.
(G^.)
(a)
Assignment
of sanitary
and
ambulance
companies
to cover
march casualty collection.
(If an ordinary
march,
without possibil
ity of contact
with
the enemy,
animal-drawn
ambulances
are dis
tributed
to
regiments.)
(Coordinated
by G-4, G-3.)
(If contact
with
the
enemy
is possible
the animal-drawn
ambulance
company
will be with the advance
guard and motor
companies
must
be used.
In this
case march collecting stations must
be designated
approxi
mately 3 miles apart along the route of advance.)
C. Field order for the halt.
(G-3.)
Designation of the site of bivouac for the medical
regiment.
(Co
ordinated by G-3, G-4.)
D. Administrative
order for the halt.
(G-4.)
(a)
Inclusion
of sanitary inspector in division
quartering party.
(Coordinated by G-4.)
'
(b)
Designate
method
of collection and evacuation
of casualties,
and medical
supply surgeon
prepares
field order which, on approval,
becomes annexed
to administration
order.
(Coordinated
by G—4.)
PREPARATION
FOR AN ATTACK (MEDICAL DEPARTMENT).
(a) G-4 informs surgeon of approximate date and plan of ^attack.
Consultation
as to roads available for ambulances,
condition of roads,
etc.
(Coordinated
by G-4.)
(b)
Surgeon
(in consultation with
corps
or army surgeon
when
practicable)
arranges plan of evacuation
from division.
(Coordi
nated by G-4.)
(c)
Surgeon requires medical supply
officer
to
accumulate
addi
tional supplies.
(Coordinated
by G-4.)
(d)
Surgeon requires and
inspects
for completion of equipment
of all medical
troops.
(Coordinated
by G-4.)
(e)
Surgeon requires
and arranges for evacuation
of all sick.
DEVELOPMENT
FOR PREPARED
ATTACK
(MEDICAL
DEPARTMENT).
A. Field order (G-3).
Location of collection station to be stated in paragraph
4 of field
order.
(Coordinated
by G-3, G-4.)
(Taken
from plan of evacu
ation.)
No. a.
399
KAYNOR —MKDXCAL
CORPS
UNITS.
B. Administrative
order (G-4.)
((«)
Plan of evacuation.
(Coordinated
by G^.)
(b)
Assignment of sanitary inspector to supervise
police
of bat
tlefield.
(Coordinated
by G-4.)
ATTACK
IN OPEN
WARFARE
SITUATION
(MEDICAL
DEPARTMENT).
A. Field order (G-3).
In paragraph
4, designation of sites for collecting stations.
(Co
ordinated
by G-3, G-4.)
B. Administrative
order (G-4).
Plan of evacuation
(field order of medical
regiment).
(Coordi
nated
by G-4.)
C. Reconnaissance.
(a)
By division
surgeon
and
division
veterinarian
for plan
of
evacuation.
(b) By sanitary
inspector
for police
of the battlefield.
(c)
By
second
in
command
and
battalion
commanders
of
the
medical regiment
for collection and evacuation.
PURSUIT
(MEDICAL
DEPARTMENT).
A. Field order (G-3),
(or administrative
order, if issued, G-4).
(a) Inclusion
of reserve
sanitary,
ambulance,
and hospital
com
panies in pursuing force.
(Coordinated
by G-3, G-4.)
Note.—If pursuit is by an unengaged
division,
the medical regi
ment is divided between pursuing columns
according to their relative
strength
and mission,
keeping reserve units with main body.
Note.—If pursuit
is not to extend
over
6 or
8 miles,
all hospital
companies
are left to police
the battlefield and
cover pursuit
from
last battle position.
(b)
Arrangements
for police of the battlefield.
(Coordinated
bv
G-4.)
A RETREAT
(MEDICAL
DEPARTMENT).
A. Field order (G-3).
(a)
Order of relief, movement,
and march of the elements of the
medical regiment.
(Coordinated by G-3, G-4.)
(b)
Attachment of sanitary and ambulance
companies
to the rear
guard.
(Coordinated by G-3, G-4.)
B. Administrative
order (G-4).
(a)
Designation of evacuation
points.
(Coordinated
by G-4.)
(b)
Assignment of additional
transportation
to assist in evacua
tion.
(Coordinated
by G-4.)
RELIEF
OF A DIVISION
HOLDING A DEFENSIVE
SECTOR
(MEDICAL
DEPARTMENT).
A. Warning message (G-3).
(a) Preliminary reconnaissance.
(Coordinated by G-3, G-4.)
By
the surgeon, sanitary inspector, division veterinarian,
executive
ofti
400
Vol. XVII.
RAYNOR
MEDICAL
CORPS
UNITS.
cer, and battalion commanders
of the medical
regiment, and medical
supply
officer,
each
as to his own
special
function.
Call
on
the
surgeon of the occupying division, securing sector maps and guides
to stations of officers of similar
duties.
(6)
Examination
of
establishments
in
sector
and subdivisions
as to shelter,
day and
night
routes,
distribution
of medical
trench
stores, water supply, medical history of sector,
plan of evacuation,
fire habits of the enemy, method
and site of burial, sanitation, bath
ing, delousing,
billets, etc.
(Coordinated
by G-l, G—4.)
(c)
Location
of
battalion
and
stations,
regimental
aid
stations,
bearer
stations,
collecting
stations,
ambulance
roads
(day
and
night), ambulance
stations,
hospital stations,
evacuation
and supply
points.
(Coordinated
by G-3, G-4.)
(d)
Preliminary reconnaissance
by the sanitary,
ambulance,
hos
pital,
and
veterinary
company
commanders
as
to local
conditions.
(Coordinated
by G-4.)
(e) Preliminary reconnaissance
by regimental surgeons
with regi
mental
commanders
as to local conditions and stations, local aid posts,
battalion and stations,
bearer relay posts, regimental aid stations,
and
routes.
General situations.
(Coordinated
by G-3, G-4.)
(/)
Arrangements for details of relief between division
surgeons,
taking
over
time, plan of occupation, and
evacuation,
retention
for
24 hours of one officer of each
medical
unit
relieved,
and
transfer
of property
by local commanders
of medical
units.
(Coordinated
by G-3, G-4.)
B. Field order (G-3).
To include point,
time,
and route of re
lieving medical
units.
(Coordinated
by G-3, G-4.)
C. Administrative
order
(G-4).
(a)
Inclusion
of
the
division
medical
staff in advance
parties.
(Coordinated
by G-3, G—4.)
(b) Plan of evacuation,
battle position.
(Field order of the medi
cal regiment.)
(Coordinated
by G-4.)
1. Collection.
•2. Hospitalization.
3. Supply.
4.
Routes
and destinations of casualties,
u. Classification.
6. Method of evacuation.
(c)
Same plan of evacuation,
intermediate
position.
(Coordinated
by G-4.)
RELIEF OF A DIVISION
FROM THE LINES
(MEDICAL
DEPARTMENT).
(a) Time of relief of medical
units, routes of movement,
detach
ment
of officers
remaining
temporarily
with
new organizations
as
arranged between the division surgeons.
(Coordinated by G-3, G-4.)
(h)
Designation
of sanitary,
ambulance,
and
hospital
companies
and detachments
of veterinary companies
to cover
march
collection.
No. 3.
401
RAYNOR —-MEDICAL
CORPS
UNITS.
and hospitalization
in staging area or new
area.
(Coordinated
by
G-4.)
(c) Billet or cantonment
of medical
regiment
in staging area or
new area.
(Coordinated
by G-l.)
((f) Include sanitary inspector in division quartering party.
(Co
ordinated
by G-l', G-4.)
(e)
Division
surgeon
and
staff turn over to like
officers plan of
collection,
hospitalization,
supply,
routes,
and evacuation,
and maps
of sector;
arrange for transfer of material, log hooks, time of relief,
guides and
officers
to
remain
with
incoming
units.
(Coordinated
by G-4.)
SPECIAL TRAINING
FOU
AN OFFENSIVE
(MEDICAL
DEPARTMENT).
(a) Training and instruction of attached
medical
troops in duties
of battalion and regimental medical
troops,
first aid, dressing,
col
lection, evacuation, effects of fire and gas, use of cover, construction
of shelter,
physical
training
in littering
and
marching.
(Coordi
nated by G-3.)
(b)
Training
and
instruction
of medical
regiment units in
col
lection, dressing, and evacuation,
use of cover, effects of fire and gas.
construction
of
shelter,
management
of
transportation,
physical
training in littering and marching.
(Coordinated
by G-3.)
(c) Training of all medical
troops in general
medical
plan of the
offensive.
(Coordinated
by G-3.)
HANDLING
OF REPLACEMENT.
(a)
Physical
examination
prior
to
distribution.
(Coordinated
by G-l.)
(b)
Segregation of defectives
and contagious suspects.
(Coordi
nated by G-l, G-4.)
WELFARE
IN THE DIVISION.
(a)
Physical
examination prior to acceptance of entrants in phys
ical competitions.
(Coordinated
by G-l.)
(b)
Sanitary
inspection
of
huts,
kitchens,
and
food
supplies.
(Coordinated by G-l.)
(c)
Promotion
of all personal
relations, amusement,
educational,
supply,
and physical training activities in medical
department estab
lishments.
(Coordinated
by G-l.)
Note. —The subject
matter
of this
article
has
been
compiled
from
War De
partment publications
and pamphlets
used
In the courses of Instruction
at the
general
service schools, Fort Leavenworth,
Kans.,
and the Marine
Corps schools,
Quantieo,
Va.
From its very nature
much of it has been copied verbatim.
By
quotinp
or modifying the
text of those publications
and pamphlets
where, for
the purposes of this article,
such modification
seemed
desirable,
the writer has
endeavored
to present
a clear
and understandable
picture
of the dlvis'on sur
geon
and the medical
staff,
but disclaims
any credit
for originality
except
in
the method
of presentation.
RAYNOR
MEDICAL
CORPS
UNITS.
Vol. XVII.
Diagram.— DUTIES
OF THE DIVISION
SURGEON.
COM M A N DIN O GENER A I. .
Corp* SuriKO.
Chief of Staff.
Chief Surnroa Army.
]CliielSunreon Flrfd Force
1 a*
Replacements,
Medical Department-
<;2
Information of enemy I
activities.
as
7T
Train ioc Medical
Department Troop*.
Casualty Record*.
Area and Troop San
itation and Health.
I Hospitalisation m
and Animals.
Medical Department
Supply.
DIVISION
SURGEON
COLONEL MEDICAL
CORPS.
Division
Dental
Surf <ry—
Major Den
tal Corps.
I
Division
Dental
Service.
Dental
Surgeons
attached to
all units of
Divisions.
Assistant
Division
i
Surgeon,
Captain
Medical
Corp*.
General
Administra
tion and
Records.
Division
Surgeon'■
Office.
I Tlospitaliin-
,
tion,
I Evacuation. 1
Casualty,
and Supply
1
Records.
. _T~_7.J
Clerks and
|
Orderlies:
I
Warrant
Officer.
1
Master
Sergeant.
1Staff Ser
geant.
2Sergeants.
: 1 Chauffeur
General
Administra
tion, Super
vision, and
Control,
Medical
Service of
Division,
I_ .
Plans and
Movement
of Medical
Units and
Division Veterinarian.
Major Veterinary Corps.
Division Veterinary
Service.
1 Corporal. M. D.. Clerk.
1 Private, M
D .Orderly.
Medical troops
attached to units
other than modioli!.
Sanitary Battalion.
Collection—Hanitation.j
■iSanitary Cotnpaniee.
Service Company.
■Supplyand labora
tory Service.
Health, Mudk
') Profess
Ambulance Battalion.
Attached Veterinary
Troops.
Collection —Evacua
tion.
t:
Hospital Battalion.
Hospitalization.
1 Is Hospital Companies.
3 Amhulanee Com
panies.
Veterinary Co*
nies.
J
> j-
Veterinary Service. I
A —Channels and Subject of Communication, Information. Supervi*
—
General Channels.
Technical Channels.
B— Organization of the Division Surgeon's Office.
C— Agencies available for Maintenance of the Medical Service.
irgical .Service, .
■sultants^
j
, and Coordination.
HARVEY
VITALITY
TESTS.
403
TRANSILLUMINATION
AND ELECTRIC VITALITY
TESTS.
By H. E. Harvey, Lieutenant
Commander,
Dental
Corps, United
States
Navy.
With the modern conception
of the
value
of dental
diagnosis, it
would seem of vital importance that the
dental
officer should have
at his immediate disposal methods for the determination of the vitality
of the pulps of the teeth, not only for patients referred in cases sus
pected of oral sepsis, but for use in connection
with conscientious
rou
tine dental examinations.
Doctor Mayo has said that the next great
step in advance
in the prevention of disease rests largely upon the
shoulders of the dental profession.
In this connection,
it would seem
that methods for determining
the vitality of the pulps of teeth
are
pertinent
and should be utilized to the extent of their reliability.
If
prevention
means anything it means the determination in advance of
the factors which may cause disease and their elimination if possible.
Routine dental examinations should therefore be conducted
systemati
cally in such
a manner that with the minimum expenditure of time
teeth which are vital can be so noted and thus practically
eliminated
from further vitality consideration, while those which are not normal
can be checked for further examination.
As it is a well-recognized
fact that
pathological
conditions
are not to
be expected
about
the
apices of vital teeth, a reliable vitality test would at once place in the
safe class
those teeth
which offer the normal
response,
while
con
versely it would direct attention to the teeth not so responding.
Un
fortunately,
the dental profession has not at its command
a vitality
test which offers unerring accuracy
combined
with absence of destruc
tion of tooth substance.
Several methods
are in use, depending upon
the facilities at the disposal of the operator and the thoroughness
with
which
the examination is conducted.
The Navy, for instance,
does
not furnish
as equipment
dental
cauteries,
and thus the application
of the heat test resolves
itself into the laborious process
of heating
an instrument in the ever elusive
alcohol flame, at intervals testing
its temperature
by its charring action on paper, until the proper tem
perature is reached, upon which the instrument is placed against the
tooth.
This test is a valuable one in its place, but an effort to test an
entire
set of teeth is a disheartening procedure for several
reasons,
aside
from
the
time
factor.
Placing
a piece of hot gutta-percha
against
a tooth has
been recommended;
this likewise
has its good
points, but presents difficulties similar to those encountered
with the
use of a heated instrument when an attempt is made to test more than
a limited
number of teeth.
The application of cold to an individual
tooth, either as ice, ice water, or ethyl chloride spray, presents difficul
ties at once appreciated by the dental
practitioner.
As is well known to the dental profession, the X-ray or dental film
does not offer evidence
upon
which
a diagnosis of pulp vitality can
404
Vol. XVII.
HARVEY
VITALITY
TESTS.
be made, other than in those cases
where
the pathological
condition
lias
progressed
to such
an extent
in the
immediate
area of and in
connection
with
the
affected
tooth
as to cause
a difference
in
the
density of certain
shadows
portrayed
on the film.
Diagnosis
by
reading
dental
films should
never
be
undertaken
without
clinical
examination
and history;
the fact should particularly
be borne in
mind that only one plane of tissue is portrayed and an area of tissue
rarifaction
may overlie or underlie
a tooth apparently
involved
in
it,
when in reality
the tooth in question
may be vital.
It
is
hardly
necessary
to call attention to the fact that
a radioluccnt
area
does
not necessarily
mean
a
nonvital tooth,
and
it
is
a
source of satisfac
tion to have at hand methods which will help us to speedily determine
the actual
condition of the tooth by other means.
Again,
a
radio-
lucent
area may exist in
a
position not connected with the source of
origin, and therefore
if
X-ray evidence
is
the sole dependence for the
determination of the condition of the offending tooth
a
vital tooth
might easily
be sacrificed
to no avail.
Probably
the most reliable methods of testing the vitality of the
pulps of teeth
are
the electric vitality
test
and
transillumination
used
in conjunction with each other.
The former
is
essentially that
of the comparative determination of the amount
of electric current
necessary
to apply to
a
sound portion of
a
tooth to obtain
a
definite
response, while
the latter method,
transillumination,
which will
be
described
below more particularly,
is
based on
a
comparison of the
translucency of tissues enjoying normal circulation
with the opaque
ness displayed by tissues with impaired circulation.
A recent revision of the dental supply table will fortunately
place
at the disposal of the naval dental officer
a
very valuable appliance for
use in transillumination
tests.
This
is
a
modification of the straight
Cameron light, and might be described
as an all-glass tubular dental
mouth lamp, the last inch or so of which
is
curved
at right angles to
the main stem of the lamp.
This results in the light rays being pro
jected
at right
angles
to
the
long
axis
of the
lamp
stem.
This
feature permits of the control of the direction of the light rays in
the mouth,
and they
may
be directed onto the surface
of
a
tooth or
the alveolar process,
the manner and
degree in which
the light
is
transmitted through to the opposite
side of the tooth or process gives
to this method
its name of transillumination.
A normal vital tooth
will transmit
a
more or less clear pink glow, while
a
nonvital tooth
presents,
under
the
same conditions,
a
decidedly
opaque
or
dull
appearance.
The appearance
of an individual
tooth may, of course,
be modified by the
presence of
a
large filling.
Not only may the
translucency of the various teeth be compared,
but by placing the lamp
above the teeth
on the alveolus in the vicinity of the apices of the
teeth darkened
areas caused by poor light transmission may
be seen
No. 3
405
HARVEY —VITALITY
TESTS.
on the opposite side of the alveolus
about the roots of teeth which are
surrounded
by abnormal tissue.
It is claimed
that the destruction
of hard tissue is not necessary to obtain this differentation between the
appearance of normal and abnormal tissue, as the shadow
cast by the
latter is caused by the increased
amount
and condition of the hemo
globin found in conditions of retarded circulation
or blood stasis
which accompany
pathological conditions.
The composition of these
lamps has been perfected
to such an extent that they may be sterilized
by boiling.
In 1916 the writer
had the pleasure of witnessing a clinic by Dr.
Howard
R. Raper, demonstrating the
use of electricity for the
de
termination
of pulp vitality.
The simplicity
of the apparatus and
method of procedure
made an appeal, particularly
as the logic of the
method
was apparent.
Parenthetically
it may
be stated that experi
ence has somewhat
modified the original impression of the simplicity
of procedure,
as so often the results of the test are particularly
desired
on teeth the condition of which present difficulties to its application.
After thinking over the theory of pulp response
to the electric cur
rent, the writer in 1916 pressed into service
a cheap 1-cell " shocking
machine," improvising
an insulated electrode
by drawing
over
the
broach holder used as the electrode
a piece of rubber tubing, which
had the advantage
of being renewable
after the disintegration
inci
dental to repeated boilings.
It is gratifying to learn that Doctor Raper has recently published
a volume entitled " Electro-radiographic
Diagnosis," wherein he gives
the results of his extensive
experience
which is of particular
value
to the dental diagnostician,
as Doctor Raper in the practice of his
specialty,
radiography,
has had unlimited
opportunity
to compare
directly the results of the electric vitality test with radiographic find
ings, and also to reverse the operation by using the test to substanti
ate or elucidate radiographic showings.
Although
Doctor Raper ad
vises against placing reliance on this test for determining any factors
except the vitality or nonvitality
of the pulp, it has proven in the
hands of the writer of value in localizing
the cause of pains of ob
scure dental origin.
The hypersensitiveness
of a certain tooth to the
amount of current necessary to obtain a normal response in the other
teeth of similar class in the patient's mouth,
indicating
with
a mini
mum expenditure of time the one which should be viewed
with sus
picion and subjected
to a thorough examination.
The crude shocking machine
of early use has been replaced
by a
rheostat made
for
the purpose
of electrodental
diagnosis and
con
nected with the
110-volt lighting circuit.
This apparatus is nicely
graduated
as to the amount
of resistance
cut out and permits of a
gradual
increase
in the strength of the current, but nevertheless
is
646—22
3
406
Vol. XVII.
HARVEY
VITALITY
TESTS.
open to the major objection applicable to any apparatus which con
veys current from any electric main to a patient—that of the possi
bility of a short circuit.
In using an apparatus of this kind it might
seem
an
advisable precaution
before
using
each
time
to
test
the
reliability
of the insulation
and
rheostat
by setting the
indicator
above
zero, holding
an
electrode
in contact
with
each thumb
and
placing one hand on a metal portion of the chair.
The writer is indebted
for his limited knowledge of the procedure
of electric vitality pulp
testing to Doctor
Raper.
and
those
inter
ested in the technical details he would refer to the interesting text
book
on
the subject
recently
published.
Xo originality
regarding
the procedure
is claimed
by the writer
of this little
article,
but
it
may
be of benefit to some
to learn of the utility of this method,
its
limitations
and
value.
First
we
shall
consider it
in
relation
to
routine dental
examinations.
Dental
examinations
are
an important
part of
a dental officer's
service
and
are of value
only in
so far as they
let no guilty tooth
escape.
The following
is outlined
as a method of procedure
for the
examination of patients not having constitutional
symptoms: First,
a careful clinical
examination of the teeth, gums,
and mouth, with
charting:
second,
an examination
of
the
translucency
of
the
indi
vidual
teeth
by
transillumination;
third,
transillumination
of
the
alveolar processes;
fourth,
electric
vitality test for teeth which
ap
pear
abnormal
under
the
transillumination
test
or
are
otherwise
suspicious: fifth. X rays of crowns,
bridges,
nonvital
and doubtful
teeth.
The above is modified
when
the patient has been referred or
is exhibiting
constitutional
symptoms
of disease by testing the vi
tality
of all
teeth
and
radiographing
areas
from
which
teeth
are
missing, and, if the
case
requires,
radiographing
all the remaining
teeth.
Efficient dental service should result in the identification
of
nonvital
teetli
in
the
absence of local
manifestations
before
the
patient is aware of their lack of vitality.
In connection
with the
use of the electric
vitality test, its limita
tions should be borne in mind.
For example,
a recent clinical
exami
nation revealed on the distal aspect of an upper molar a large pyor
rhea
pocket
extending well into the bifurcation
of the roots;
the
electric
vitality
test was normal, but the tooth
was recommended
for
extraction.
The
principle
illustrated
is that destruction
of
tissue
from pyorrhea alveolaris
do.es
no interfere with
the test, unless
the
pulp
is involved.
The condition is sometimes
met
where, with
more
than
one canal,
one may
be
septic
with vitality remaining
in
the
other canal or canals.
In such
cases
a normal response to electricity
may
be obtained;
but transillumination
is usually
negative,
and in
a case with conflicting indications we at once bring to our aid all the
facilities
at our command
for the diagnosis.
No. 3.
407
HARVEY —VITALITY
TESTS.
Doctor Kaper brings out very clearly the value of his test in cases
in which
radiographs show
the apparent involvement of the apices
of several teeth.
A few minutes usually suffices to determine
which
teeth are vital
and which are actually involved.
Also the value
in
the not
uncommon
cases
where
the
dental
film
shows
the roots of
the bicuspids or molars confluent
with the floor of the antrum.
Not
least
is
the ability
to
determine
which
tooth
is nonvital
in
cases
where the area of degeneration
apparently involves a tooth which in
reality is vital, the cause of the trouble being a tooth
near by which
may present
no evidence of being the offending member.
This test
would also
seem
to offer
an easily
applied one in the very difficult
diagnosis of teeth which are adjacent
to nonvital
teeth, particularly
those which are classed as suspicious
from radiographic
findings.
One of the unfortunate limitations
is that crowned
teeth can not
be tested without
removal
of the crowns.
The electrode
used in the test should
be insulated except
at the
point, and it should be applied only to sound enamel, as enamel which
is undermined
with decay or covers a metallic filling gives
a response
which
is not
a true
index
for diagnostic
purposes.
Large
fillings
should
not
be touched
with
the electrode,
as they
may
convey
the
current
with
a disconcerting
intensity
either
to
the
pulp,
to
the
giims,
or adjacent fillings.
Allowance
should
be
made in elderly
persons for the resistance
offered by secondary
dentine,
and in doubt
ful cases it is sometimes necessary to make
a pit through the enamel
and introduce into this the electrode.
For use on nervous individuals, Doctor Raper suggests the moisture
contact,
which
is the water bridge formed from an excess
of water
or salt solution on the cotton wrapped electrode
and the tooth surface
placed in close proximity.
The recording
of the electric
vitality test is made
by using suit
able slips previously
numbered,
each slip with the figures
from
1 to
32.
After
the number indicating
the tooth being tested,
place
the
minimum
amount
of current necessary
to obtain a definite
response
from
that
tooth, and
a comparison of the
figures
following;
the
bicuspids,
for
instance,
should
give an approximate
index of the
normal
test for teeth of that class in that individual.
Best and Waldron,
in an article on " Oral diagnosis and treatment,"
say : " Vitality
tests of the pulps of the teeth
are essential
in order
that a well-balanced diagnosis may
be formulated.
There are many
intances
of the death of pulps that are not revealed
in roentgeno
grams.
The tendency for the tooth pulp to undergo degeneration
is
more pronounced
as
the
patient
approaches
middle life.
This is
not
a new
observation,
but
a fact that has been known for years.
The vitality of each
tooth
is determined
by testing the individual
408
Vol. XVII.
GALWEY
GAS WARFARE.
tooth with the faradic current.
This test is of great importance and
in no case should be omitted."
Machat, on " Pulp Vitality: Modern Means of Determining It (A
Process by Exclusion) ," says : "Four years ago, when I first presented
my method of diagnosis, I made the forecast
that electro-diagnosis
would be found indispensable.
Now, we feel that a differential diag
nosis of the internal conditions of teeth is not conclusive until checked
up with the electric current.
By electro-diagnosis of a tooth, I mean
the reaction of a tooth to a weak current of electricity
as compared
with a previously fixed index.
An index is taken by making contact
with the mesial or distal electrode
upon the labial surfaces of mani
festly normal incisor
teeth;
the saturation or tolerant point
is
the
guide or index for that individual.
The normal index can
be
as
certained
by the practitioner in accordance
with the instrument to be
used for testing.
" Finally
it should
be
realized that electro-diagnosis
is not
in
fallible.
Like the radiogram, it is not an oracle for every diagnostic
perplexity.
It is limited
in value for those who are unwilling to
study its intricacies
and
wide range
of usefulness.
On
the
other
hand, when mastered, it is a trustworthy
friend.
In the last analysis,
however, it is only part of a system of diagnosis."
GAS
WARFARE— THE
TREATMENT
OF
GAS
CASUALTIES,
EARLY
AND
LATE.1
By MaJ.
W. E. Galwby,
O. B. B., M. C, Royal
Army
Medical
Corps.
Before
the
foundations
for
a
rational
treatment of
cases
of
asphyxiant
gas poisoning
can
be laid
a clear idea must
be formed
of
the
causes which
are operative in threatening
the life of
the
patient.
It is agreed that the seriousness of the case varies with the degree
of want of oxygen
which
is present,
and
treatment
must
therefore
be directed
to prevent the development
of this condition or to relieve
it when
established,
and
so give the patient time to mobilize
his
reserves to fight and defeat it.
Recent
research
into
the
physiology
of normal
respiration
has
thrown
much light on the causation of and
symptoms
produced by
oxygen want, and in addition has explained such well-known
clinical
phenomena
as periodic or Cheyne-Stokes breathing
and
orthopncea.
It is necessary to refer briefly to the factors which regulate normal
breathing
to understand the
sequence of events
in asphyxiant
gas
poisoning.
1 Reprinted
from
the Jour.
Roy. Army
Med. Corps,
March,
1022.
No. 3.
409
GALWEY— GAS WARFARE.
When,
on inspiration,
the lungs expand to a certain point, expira
tion is initiated
; similarly,
on collapse
to a certain point inspiration
begins.
The nervous impulses
concerned
are carried by the
vagus
nerves, but the reflex itself is controlled by the action of the carbon
dioxide in the blood on the respiratory
center.
A certain
percentage
of C02 in the blood is necessary
to fire off
this reflex, and if too much C02 is washed out of the blood—as, for
instance, in
forced
breathing —the
subject
goes
into
apnoea
until
sufficient C02 again accumulates
to fire off the reflex.
On the other hand, a very small increase
in the pressure
of C02
in the blood —0.2 per cent—will
double
the respiratory
ventilation,
increasing
both
the depth
and
rate of breathing.
Anything, there
fore, which
interferes with
the normal
discharge
of C02 from the
lungs will bring about
hyperpncea.
What
the respiratory
center really
responds
to when it reacts to
increase of C02 is the balance of the hydrogen ion concentration in
the blood.
To any alteration in this balance
the respiratory
center
is extremely
sensitive,
and
the increased
breathing
in the presence
of increased
C02 is an effort of the body
to reduce the hydrogen ion
concentration by washing out the carbon dioxide.
In spite of the fact that different parts of the lung are unequally
ventilated,
it has been
shown that the percentage
of C02 in an aver
age sample of alveolar air from
a normal individual
is relatively
constant.
Though
a definite
percentage of C02 is normally
necessary
to fire
off the respiratory
reflex, it has been proved that it responds
to
a
lower percentage
in the presence
of lack of oxygen.
The first
re
sponse
to this condition
is therefore an increased
depth
and
rate in
breathing
owing to the lowered " threshold value "—as it is called—
of CO,.
As the condition
of
oxygen
lack
develops
the
next
response
is
periodic
breathing
unless
the want of
02
is considerable,
when
a
condition of rapid shallow breathing is established.
When the blood
comes in contact with the air in the lungs it takes
up oxygen and gives off C02.
C02 is much
more readily diffusible
than 02 and much
more can be stored in the body, which has a rela
tively small capacity for storing 02.
When, therefore, there
is interference with
respiratory
exchange
the main" effect is on the 02 intake rather than the C02 output unless
there
is considerable
blocking
of air passages
which
prevents
air
leaving large numbers
of alveoli.
To turn now to the tissues.
The blood gives up its oxygen in them
more rapidly
and effectively in the
presence of C02: if. therefore,
from any cause, as by increased
ventilation,
the C02 is washed
out
of the blood, it will then part
less readily
with
its oxygen.
If. in
410
Vol. K\'U.
GALWEY —GAS
WARFARE.
addition, the supply of oxygen itself is diminished, the tissues quickly
suffer from
the
lack
and
their
functions
are disturbed.
A
slight
diminution
of oxygen is
more
quickly
felt
and
has
more
serious
effects
on such
organs
as the brain,
particularly
the
vital
centers,
such as the respiratoy, and on the heart.
A vicious circle is thus
set
up; the lesion
in the lungs interferes with the respiratory
exchange,
this in its turn reacts on the vital centers with a resulting diminution
in the efficiency of the ventilation of the lungs and the circulation of
blood
through the body.
The circulation itself is regulated
in the main by the rate at which
the tissues allow blood to return to the heart, rather than by the heart
itself, which simply pumps
at increased
pressure
the blood
delivered
to it.
The rate of delivery from the tissues is regulated by—
(1)
The degree of saturation of the blood with oxygen
; and
(2)
The degree of saturation with C02 and consequently
its reac
tion in the capillaries.
The capillaries do not merely
react passively to blood
pressure
bu.
actively contract and dilate.
We have now, I think, sufficient
data to understand what happens
in asphyxiant gas poisoning and why the serious
cases fall into two
main groups:
(1) Those with
purple-colored
cyanosis,
distended
veins,
hyper-
pnoea,
and evident
distress; and
(2) The gray
cases,
with pallid lips, shallow breathing,
but
no
distension
of the veins and little respiratory
distress.
The latter being the more serious.
Remember
the
anatomical
conditions
which
occur —the
acutely
inflamed
condition
of
the air
passages,
particularly
in
poisoning
by
chlorine;
the
damage
to
the
alveolar
epithelium,
particularly
with
phosgene,
the engorgement
and thrombosis of capillaries
with
flooding of the lung by
cedema.
These
bring
about
a condition
in
which both the pulmonary circulation
and the respiratory
exchange
are interfered with.
Owing
to the swelling
and exudation, oxygen
can not get through quickly enough
to the blood to saturate it during
its passage through the pulmonary vessels.
The damage to the capil
laries causes leakage of fluid, and, in consequence, the blood is more
concentrated
and its volume
is reduced below
the danger point.
As
the heart fails, there is cardiac inhibition
and loss of vasomotor
tone.
The
hyperoxaluria
of concentration does not compensate
for
the
anoxaemia
due
to unsaturation,
but
does
make
for stagnation
by
throwing
more work on the heart.
A combination of the types of want of oxygen —anoxajmia —which
Professor Barcroft describes
as the most serious
consequences of gas
poisoning, are thus brought about: (1) The anoxic type in which
the
No. 3.
411
GAL.WEY-
'
GAS
WARFARE.
oxygen pressure
in the blood is too low, the haemoglobin
is not sat
urated and
the
blood is dark;
and
(2)
the
stagnant type
where,
though the blood is normal, it is supplied in insufficient quantity.
Besides
the lack of saturation of the blood with oxygen,
the dis
charge of C02 from the lungs is also interfered with, and this is the
main cause of the hyperpnoea.
The lack of oxygen
causes failure of
the right heart, which is then unable to cope with the increased
work
of pumping
blood through the oedematous lung.
As the right heart
fails, the superficial veins become distended,
and if there is retention
of CO, the capillaries will also dilate.
The causes, then, underlying
the symptoms
of the first group of
cases—those
with
plum-colored
cyanosis —are
(1)
lack of oxygen,
(2)
retention
of CO,, and
(3) failure of the right
heart.
So long as the heart is not losing much ground and the lack of 02
is not extreme the cyanosis will remain plum colored.
Owing to bronchitis,
emphysema,
and
areas of relative
collapse
in
cases
of chlorine
poisoning,
there
is probably
more
C02
in the
alveoli
which
are still
permeable,
whereas
in
phosgene
poisoning
the injury
to the air passages
being
less there
is less
likelihood
of
retention
of CO,, but the lack of oxygen
is greater since the alveoli
are more
damaged.
There
is,
therefore, in
phosgene
poisoning
a
greater likelihood
of the second
type of
cases —the gray type.
In
these the lack of oxygen
is
more profound
and the breathing there
fore becomes
rapid and shallow.
There
is
practically
no hyperpnoea,
because the increase of breathing washes out the C02 from the blood.
For the same reason there
is
little distension of capillaries.
But the lack of CO, causes the blood to part less readily with its
02
to the tissues.
If there
is
less CO, in the alveoli the blood takes
up
02
more readily
and the arterial blood will be redder, but since
there
is
less CO, in the capillaries
the blood parts with
its 02 less
readily
and the want of oxygen
becomes more serious.
With
an
equal
degree of deoxygenation of the
oxyhemoglobin
there
is
less free 02 in the blood when little CO,
is
present or when
blood
is
a little more alkaline than when more C02
is
present or the
blood
is
a
little less alkaline.
There has been a considerable
amount
of controversy on the ques
tion of acidosis in cases of irritant gas poisoning.
Professor Haldane points out that the increase of circulation
and
respiration
caused
by
the
want of oxygen
diminishes
the CO,
in
the tissues
and
brings
about
a
condition
of alkalosis,
as indicated
by
the urine becoming
less acid or alkaline
and
the NH, formation
in
the body sinking
to
a
minimum.
The alkali
reserve of the body
gradually diminishes;
that
is
to say, the amount
of soda available
for combination
with C02.
412
Vol. XVII.
GALWEY-—GAS WARFARE.
On the other hand lack of oxygen does produce
acidosis,
and Pro
fessor
Barcroft found
evidence
of acids
other than carbonic
acid
in the blood.
How, then,
does the subject
combat
these conditions?
In three
ways
:
.
( 1 ) By increasing his ventilation.
(2) By increasing his circulation.
(3) By the consolidation
or shutting
off of the injured
area of
lung.
(1) By increased
ventilation. —As soon as the oxygen want begins
to develop
the subject breathes
more
quickly,
partly
owing
to
the
fact that C02 has a lower threshold value in the presence of a slight
lack of oxygen
and partly owing
to the stimulus of oxygen want
itself.
The
increased
ventilation
raises
the
pressure
of 02 in the
lungs
and
reduces
the
lack of oxygen
and
tends
to
stave
off its
more
serious
development.
(2)
The circulation
rate is increased,
and if a blood gas analysis
is made in a patient who is maintaining
his position it will be found
that the venous
blood
contains more
02 than normal.
This is not
because the
tissues
are using less oxygen,
but because the blood is
being propelled around the body more quickly.
(3)
So long as the respiratory
center
and the heart can withstand
the strain
involved until
the third line of defense
is
established,
the patient will make good.
This third line of defense is the shut
ting off of the damaged
area of lung.
As I described
in my last
lecture,
the alveoli most affected
become consolidated
and the blood
practically
ceases
to flow through
them.
Others
less
affected
clear
up
and
the
patient
carries
on with
less available lung
substance
until the oedema
is absorbed
and
the lung becomes practically
nor
mal, as it does in the majority of gassed cases which recover,
though
some may have scar tissue and emphysematous
areas.
We can now
formulate
a rational
line of treatment
for cases of
asphyxiant
gas poisoning,
and modify
it according to the
need of
individuals.
(1)
The first point in treatment
should be to diminish the patient's
need of oxygen by every possible
means—by keeping him at rest and
by warmth.
To keep him at rest necessitates
a special organization
for evacuation
of gas casualties
when these occur in numbers,
and I
shall hope to refer to this again in my last lecture.
Warmth
can
be
given by means of hot water bottles or by preparing
a stretcher with
folded blankets
and applying
warmth by means of a Primus stove
as
was
done in
cases of surgical
shock.
If circumstances
permit,
patients should not be evacuated
to the lines of communication until
all serious
symptoms
have disappeared.
No. 3.
413
GALWEY
GAS WARFARE.
(2)
The next and
most important
point is the administration
of
oxygen.
But on service,
oxygen
is difficult to obtain in large quan
tities and also difficult to transport.
What then should be the indi
cations for administration of oxygen?
If
a patient
has
no
cyanosis —whether of
the
plum-colored
or
pallid variety—oxygen
is not necessary.
If he has cyanosis,
oxygen
is necessary and should be given at the earliest possible
moment
to
prevent the vicious circle initiated by even slight anoxaemia.
This is most easily and economically given by the portable appa
ratus
devised
by Professor
Haldane,
and with comparatively little
trouble
an installation
can be arranged so that two or three orderlies
can attend to a number of patients.
The administration
should be begun
early
and should
be
perse
vered with,
even though apparently
there
is little
improvement in
the patient.
Remember
that lack of oxygen may have already done
damage to important structures and organs and that it will take the
patient time to recover from this even though oxygen administration
may prevent further
damage.
Usually
a delivery
rate of 2 to 3 liters per minute is a sufficient
dose, the mask being withdrawn
for five minutes every half hour.
In very bad
cases up to 5 liters per minute have been given with ex
cellent results.
Once the patient regains his color and his pulse improves and the
improvement
is maintained, oxygen
may
be stoped; but any return
of the symptom indicates resumption of the administration.
Oxygen
is itself irritating
to the
lungs in large quantities
and
should not therefore be pushed further than necessary.
Before leaving this treatment it is only fair to say that in a series
of experiments
carried out on
dogs
exposed
to standard
doses of
gas by Underhill, the American
observer,
he found that administra
tion of oxygen neither delayed
the time of death nor increased
the
percentage of recoveries.
Clinical
experience
in France,
however,
proved
beyond
doubt the value of this treatment.
Again and again
apparently
hopeless cases recovered
when oxygen was given efficiently
and over long periods.
Venesection. —Clinical experience in France was in favor of bleed
ing in irritant-gas
poisoning, but not as a routine treatment
in all
cases.
It is certainly justifiable
in cases with
venous
congestion
to
relieve
an overburdened
right heart.
The quantity
removed
should
amount to 20 ounces
(550 cubic centimeters)
and the bleeding should
be done slowly —about
20 minutes for the quantity
mentioned.
In the pallid
cases
the
treatment
was not considered
justifiable.
On the other hand, the work of Underhill in the treatment of gassed
dogs brings forward
very strong evidence in favor of early bleeding
and still stronger
evidence
in favor
of bleeding
and
injection
of
414
Vol. XVII.
GALWEY
GAS WARFARE.
saline.
In phosgene
poisoning
he found that in many cases early
bleeding was sufficient
to save the animal, whereas
in chlorine bleed
ing
plus
infusion
was
indicated.
The
reason
he
gives
for
this
difference
is that in phosgene
poisoning there is in the early stages
a preliminary
dilution of the blood—the fluid being probably with
drawn from the tissues —before
the stage of blood concentration and
stagnation sets in.
Early bleeding to 0.5 per cent of the body weight
of
the
animal
relieved
the
distension of
the
heart,
and
in
many
cases this treatment
sufficed.
In some cases, however,
the condition of
dilution
recurred,
and
was
always
accompanied
by a rise of tem
perature.
When this happened
he bled
the animal again, and
even
repeated
the
procedure
a third time until blood to
1.5 per
cent of
the body weight had been withdrawn.
If after this
the
stage of
concentration occurred
he infused or injected intraperitoneally
nor
mal saline.
In chlorine poisoning he did not find this stage of early dilution
occur.
The blood immediately
began
to
concentrate,
and
for
this
reason he bled the animal
and infused
a quantity of normal saline
equal to the amount of blood withdrawn.
There
are obvious objections to adopting this
as
a routine
treat
ment in the
case of human
patients.
To begin
with, the personnel
required
would
be very large when
gas
cases
were
numerous.
Nor
does experience
in France go to show that bleeding was necessary
in
all cases.
One thing
is,
however,
fairly certain,
i.
e., that in the early stages
of blood concentration and stagnation bleeding does no harm, and
that bleeding
and
infusion
with
saline will
probably
do
good
by
increasing the volume of circulating
blood.
The experimental evidence
goes to show that normal saline
is
the
best diluting fluid to employ.
Drugs. —The inhalation
of ammonia vapor often
gives
relief
in
the early stages of chlorine poisoning.
It probably
acts more
as
a
stimulent than in
any
other way.
It should
not
be
given
in
too
strong
a
concentration, and
if
it
increases
the cough
or dyspnoea
it
should be withdrawn.
Atropine
was tried
as
a
means of relieving
the bronchial
spasm
which
sometimes
occurs,
but
little
benefit
appears
to
have
been
gained by its use.
Cardiac stimulants.—Brandy has proved very effective.
Pituitrin
0.5 cubic centimeter
hypodermically,
at intervals
of
not
less than
three
hours;
hypodermic
injections
of camphor,
or
caffeine
have
been well
spoken
of.
Neither
strychnine
nor digitalis
proved
of
much value.
Morphia
should only be given in cases of extreme
restlessness, and
then the dose should be small.
No. 3.
415
GALWEY-— OAS WARFARE.
Expectorants
should
be given
with caution.
Their use in the first
two days is contraindicated
for fear of increasing
the
damage
to
the lung by coughing.
,
Aspirin
and
phenacetin
should not
be
used
to
relieve
the
head
ache which occurs.
Such
methods
as emetics, tickling the throat,
and
posture
to aid
the drainage of fluids from the lungs have been
used with success.
Food should only
be given
in
fluid
form
and
sparingly
in
the
acute
stage, and
the diet should
be light
till
convalescence
is well
established.
There
seems
to
be little
to
be gained
by
an}'
form of treatment
specially
designated
to correct
the
accumulation
of carbonic
acio
or other acids in the blood.
TREATMENT
OF THE LATE
EFFECTS
OF
GAS
POISONING.
Apart from the treatment of the neurasthenic
symptoms
and func
tional disturbances
which appear in certain patients during
conva
lescence,
and which I shall refer to when dealing with the treatment
of mustard-gas poisoning, there is evidence to show that the cases of
cardiac disturbance and spasmodic
dyspnoea are due to chronic lack
of oxygen.
Observations
on these patients have shown
that their breathing is
much shallower than that of normal persons,
and shallow breathing
is a cause as it is also a result of lack of oxygen.
It may be that during the acute stage the respiratory
center
has
been so damaged that the reflex controlling inspiration and expiration
becomes
abnormally
sensitive
and
fires
off before the normal
dis
tension or collapse of the lung has been reached.
The lack of oxygen
is not due to the anatomical condition of the
lung itself, for in the great majority of cases, if the patient survives,
the lung quickly returns to normal and very little permanent damage
remains.
The shallow
breathing
is accentuated
by
the lying posture,
and
this explains the dyspnceic
attacks
at night.
The condition is markedly
relieved
and in many
cases
was cured
by administration
of oxygen
either by means of a Haldane apparatus
or by making the patient sleep in
a special
chamber
in which
the
atmosphere was enriched
by oxygen.
Moreover,
experiments
on
an
ergometer
showed
that
patients
suffering from the effort syndrome
could perform more work without
dyspnrea if given inhalations of 02.
VESICANTS.
Mustard gas poisoning. —The time at our disposal does not permit
of more than an outline of the lesions and associated signs and symp
416
Vol. XVII.
GALWEY
GAS WARFARE.
toms
due to poisoning with mustard gas, but to those who wish
to
study the subject
further, I would recommend
an article by Drs.
C.
M. Wilson and J. M. Mackintosh
in the Quarterly Journal of Medi
cine, volume xiii, No. 50, January, 1920.
At the time of exposure to this gas. nothing is noticed save the faint
smell usually likened to garlic or mustard.
After a lapse of two or three hours symptoms
begin to make their
appearance
and the intensity and duration
depend upon the concen
tration of the gas.
The eyes usually
are the first to show
signs of the mischief —an
acute conjunctivitis,
which develops rapidly.
There is extreme
lach-
rymation
accompanied
by
headache.
Blepharospasm
is marked.
From the second day the discharge is mucopurulent, and the injury
may go on to corneal ulceration, but this complication is not common.
Later, photophobia of functional
origin
develops
in
a considerable
number of cases.
Coinciding
with
the development
of eye symptoms
there
is nasal
catarrh, and sneezing
is frequent.
Nausea,
retching, and vomiting,
with epigastric pain, are common
at the same period.
During the next few hours other signs and symptoms
make their
appearance.
The throat
feels
dry
and
burning,
the
voice
becomes
hoarse
and
a brassy cough
develops.
A red erythema
appears
on the skin of the face and neck, and other
parts of the body (particularly
where the skin is moist) are similarly
affected.
Small
blisters and
blebs
appear later in these areas.
In
the early stages the condition resembles the rash of scarlet
fever.
During the second 24 hours the vesicles develop into large blisters,
while the scrotum
and penis, if affected, become cedematous and pain
ful.
Eespiratory
signs now appear with the onset of bronchitis,
and in
the mucopurulent
sputum
large sloughs
from the inflamed tracheal
lining may be found.
Secondary infections of the respiratory tract, varying
from puru
lent bronchitis
through
broncho-pneumonia
to
bronchiectasis
and
even gangrene
of the lungs, supervene
and cause death.
The temperature,
pulse,
and respiration
rates vary in accordance
with the character and severity of these affections.
Post-mortem. —The
most
important
changes
are
found
in
the
respiratory
tract.
Throughout
its entire length it is acutely
inflamed
and covered with a yellowish-white
false membrane,
representing the
disintegrated and desquamated
epithelial lining mixed with
a fibrin
ous exudate.
On removal of this membrane
a red granulating
sur
face is exposed, sometimes pitted by small ulcers.
The lumen of the
trachea is filled with
a thin pus, and
pus can
be squeezed from the
bronchioles when the lung is cut.
No. 3.
417
GALWEY
GAS WARFARE.
The lungs are voluminous, but they
do not exhibit
the
massive
oedema characteristic of the asphyxiant gas cases.
In early
deaths
small hemorrhages
may
be found
and
scattered
areas of emphysematous
and collapsed alveol.
As a secondary
lung infection extends, the appearance
are those of
typical broncho-pneumonia, going on in some cases
to small abscess
formation.
The alimentary
tract. —Although vomiting
and retching are early
signs of mustard-gas poisoning they do not as a rule persist after the
first 24 hours.
According to English observations
a true gastritis
is rare, though
it does occur.
French writers, on the other hand, state that in their
view the digestive system
frequently participates in the syndrome;
gastric
pain
and
discomfort
and
diarrhea,
often
bloody,
help
to
weaken the patient, and when there is a general
affection
of the skin
produced
by mustard gas, and not a purely local one, the digestive
apparatus is always involved.
In their view the lesions
in the di
gestive tube
are sufficiently marked to
account
for the
symptoms.
The gastric mucosa has lost its sheen and is dark in color ; ecchymotic
areas and sometimes true ulcers
are found.
German
observations
do not support this view.
In this connec
tion one may say that apart from
the mustard gas, which
may
be
actually
swallowed
with
saliva,
there
is experimental
evidence
to
show that dichlorethyl
sulphide
when
injected
subcutaneously
ap
pears to be obsorbed
and excreted
by the mucosa.
The Americans claim to have obtained systemic
effects which are
quite characteristic and unmistakable on the heart, alimentary tract,
and central
nervous
system.
They
state that these effects are pro
duced by hydrolysis —the mustard gas being broken up into hydro
chloric
acid
and
a body which
can
be recognized
by converting it
back
again into mustard.
And that the products of hydrolysis
are
found in the urine.
The time taken for a solution of mustard gas
to hydrolyze
in vitro corresponds
with the time taken for symptoms
to appear after exposure
to the vapor.
The experiments
are not yet
conclusive,
but the Americans hold that the evidence already to hand
strongly supports their view.
Urinary
system. —Albuminuria is present
in serious
cases
as
an
early symptom,
and if persistent
is a sign of grave import.
Acute hsemorrhagic
nephritis
has been described.
Circulatory
system. —The
heart is unaffected
at first,
except
by
changes
associated
with
the
pulmonary
complications.
Later,
in
convalescence,
symptoms
of D. A. H. and the effort syndrome are
observed in
a considerable
number of cases.
Observers are agreed
418
Vol. XVII.
GALWEY
GAS WARFARE.
that these symptoms
are of nervous
origin,
and
depend
largely
on
the methods of treatment
adopted in the early stages.
Blood changes. —The leucocyte count is of importance in mustard-
gas poisoning.
In the early stages, from the first to third day, occasionally later,
there
is a great
leucocytosis
which may
rise
as high
as 35,000.
The
increase
is due to the polymorpho-neutrophiles,
which number about
98 per cent of the total.
Even
when
the total count is not
raised,
there
is a relative in
crease in these cells.
The lymphocytes are
reduced
in numbers; eosinophile and
baso-
phile
cells
practically
disappear.
The large
mononuclears
remain
either normal or are reduced.
In serious
cases
a fall in the leucocyte
count beginning
about
the
third or fourth
day is
a sign of bad
omen, unless
there
is marked
improvement in the patient's condition;
and
a leucopsenia
occurs just
before death.
There is no change of note in the red blood
corpuscles.
But the
coagulation time of the blood is said to be markedly diminished.
TREATMENT
OF CASUALTIES
FROM
MUSTARD GAS.
Immediately
on arrival
at the gas casualty
center, or. if practical,
at the aid post or advanced
dressing station, steps should be taken
to get rid of all traces of mustard gas from the patient, his clothing,
and equipment.
I have alread\? dealt with the methods
of disinfection of clothing,
and need only add that when
clothing
is taken from
the patient it
should at once be disposed
of in a safe place where it can not injure
others by continuing to give off gas.
The patient should then
be washed from head to foot with warm
soapy water to which bicarbonate
of soda 20 parts per 1,000, or lime
water
1 part per 1,000, has been
added.
Particular attention should
be paid to his hands, which
may
be infected, lest by scratching
he
convey
the poison to other parts of the skin.
He is then dried and put to bed in clean clothes.
Care should also be taken to prevent injury to the personnel
attend
ing to the patient.
The
conjunctivae
should then
be
washed
well with
a
2 per cent
solution
of
bicarbonate
of soda or warm boric lotion,
and
liquid
paraffin
instilled.
This
treatment
should
be
frequently
repeated,
particular
attention being paid to the cornel's
and the eyelids being
everted, if possible.
If liquid
paraffin is not available, castor oil may
be used, but is more irritating.
If the cornea is affected.
1 per cent sterile atropine ointment should
be used instead of paraffin,
and repeated sufficiently often to keep the
No. 3.
419
GALWEY — GAS WARFARE.
pupils dilated.
Cocaine
should
not
be
employed.
Washing
with
potassium
permanganate
1 in
4,000,
or the application of an oint
ment, containing
potassium
permanganate
or
methylene
blue
are
recommended.
If
the
discharge
becomes mucopurulent,
2
per
cent solution of
argyrol or protargol should be applied once a day.
The eyes should never
be bandaged.
Dark glasses or shades may
be given for the first two or three days, but should be dispensed
with
as early as possible.
The photophobia which follows the affection of
the eyes is nearly always functional,
the patients are in a very sug
gestible condition, and unless a firm attitude is adopted
and an atmos
phere of cure
established
at once by impressing
on them
that the
injury will not be permanent
a neurasthenic
condition develops which
is very intractable and prolongs convalescence
indefinitely.
Plung
ing the head
into cold
water with
the eyes
open often cures these
functional
symptoms.
The nose and naso-pharynx should be washed out with warm alka
line solution three times a day.
This should be poured in, not snuffed
up.
Relief to the condition of the larynx
may
be obtained
by inhala
tion of steam from boiling water to which an ounce of tincture ben
zoin
co.
and
10 grains of menthol have
been added.
The French
recommend
a laryngeal injection of gonienol
oil
1 to 2 cubic
centi
meters daily.
The. laryngitis
usually
clears
up in
a fortnight,
but a functional
aphonia may develop
which is best treated
by strict methods.
Tracheitis may
be eased and
the risk of secondary
infection
less
ened by the use of
a perforated metal mask moistened
with drops of
an antiseptic
solution, such as :
Menthol
grains—
20
Tinet.
iodi
mininis__
30
Oil of eucalyptus
do
30
Creosote
dram__
1
Chloretone
do
1
Alcohol
to
ounce. _
1
When secondary
infections
such
as broncho-pneumonia occur
the
appropriate treatment
should be given.
Venesection
or oxygen
may
he used if cyanosis
develops, but these measures are never called
for
in the early stages of mustard-gas poisoning.
The vomiting
and other symptoms
arising
from infection of the
alimentary tract may
be
relieved
by warm drafts
of
a solution of
bicarbonate
of soda.
The diet in the early stages should be mild
and light.
Indeed,
inflammation of the posterior pharyngeal wall
may
make swallow
ing a matter of difficulty.
420
Vol. XVII.
GALWEY
GAS WARFARE.
Skin
lesions. —After
the initial
washing
with soapy water
and
bicarbonate
solution, a dusting powder of boracic acid, chalk, starch,
and zinc oxide or calamine
lotion should be applied to relieve irrita
tion.
Fatty ointments give no protection against the poison.
Small burns heal well under Lassar's paste with 2 per cent salicylic
acid.
Washing with 4 per cent solution of potassium
permanganate
and
applications of ambrine have also been
recommended,
but before
the
latter is applied care should be taken to render the skin aseptic.
Large
excoriations or
areas
with
pyogenic
infections
should
be
treateJ
by soaking with boracic lotion for
a short perio,d
and
then
applying
zinc ointment with ammoniated
mercury.
Functional symptoms. —Mustard
gas
cases
are very liable
to de
velop
during
convalescence
hysterical
symptoms,
such
as vomiting,
photophobia, aphonia, or D. A. H., and it is of the greatest
impor
tance to remember
this and frame the early treatment so that what
the French describe as " benign contagion "—an atmosphere of cure —
is established
at once.
Unless this is done, not only may
the patient remain in hospital
but he may become a confirmed neurasthenic.
In France it was found that by adopting a strict and hopeful atti
tude
a very large majority
of the
cases
of mustard gas poisoning
were fit for discharge from hospital
within
four to six weeks.
In
England,
on the other hand, many cases
were still unfit
at the end
of twice or three times that period.
Allowing for the fact that the
most serious
cases went to England, this period is too long, and inves
tigation proved that
a great number were suffering from neuroses.
How far these neuroses
are the result of gas or of general war
strain is a matter of doubt.
In any case, the neurotic element should
never be forgotten in gas poisoning.
Being
a new weapon it was naturally
very terrifying, and the fact
that unless
in large concentrations the smell
was
almost
impercep
tible, kept men in a state of expectant
strain.
Many men thought
they were
gassed when they were not, and toward
the
end of the
war it became necessary
to send
men
to the gas centers
diagnosed
N. Y. D. gas or query gas, just as they were sent to the neurological
centers diagnosed
N. Y. D. nervous.
In such cases it only required
a little injudicious
sympathy to bring about
a nervous breakdown
■
with all kinds of symptoms
which were
merely
manifestations of a
conversion
hysteria.
I have mentioned
D. A. H. as one of the neurasthenic manifesta
tions in the late stages of mustard-gas poisoning.
As far as can be judged this syndrome did not arise from the same
cause as the D. A. H. of eases of irritant gas poisoning.
In the latter
it appears to have been consequent on the lack of oxygen in the early
stages which having upset the nervous
reflexes
gave rise
to chronic
No. 3.
421
GALWEY —GAS WARFARE.
shallow
breathing.
' In the cases of mustard gas, on the other hand, it
appears
to
be
a symptom
of the general
neurasthenic
condition of
the patient.
It is well then whilst adopting energetic
treatment
of actual lesions
to restrain
oversympathy with the patient and to impress
upon him
that he will in all probability
shortly
be quite fit to return to duty.
C hlorarsines. —When the blue cross shell
was first introduced the
effects were limited to irritation of the eyes,
nose, and throat and
a
burning
pain in the
chest.
These
symptoms
were
transitory
and
did not produce
serious casualties.
Later, however,
definite symptoms of poisoning by these compounds
were observed
and were probably due to the introduction of ethyldi-
chlorarsine
or to drinking of water
contaminated
by the blue
cross
shells.
These symptoms
were as follows
: Burning pain in the nose, mouth,
and throat;
smarting of the face;
aching pain in the eyes with in
tense
lachrymation
and mild
conjunctivitis;
frontal
headache
and
copious watery discharge
from the nose; burning pain in the chest:
salivation; pain in the stomach, nausea and vomiting.
In some cases sensations
of pins and needles were experienced,
or
temporary
numbness and loss of power in the limbs without the sen
sation of pins and needles giving
place to aching pain, but with no
tenderness of the main nerve trunks.
A curious
symptom
is
the
extreme
degree of mental
misery to
which
exposure
to this compound
gives rise.
These symptoms
are in the main transitory
and in many cases were
not
sufficient
to cause evacuation
of the patient;
or,
at the
worst,
cleared up in a few days, except in those patients who developed
neu
rasthenic
symptoms
which
were rather attributable
to general
war
strain and weariness than to the action of the gas.
In
a certain proportion
of
cases
alterations of sensation
and of
reflexes
appear
in
the
late
stages, but authorities
are
agreed
that
the lesions
can not be attributed to a definite arsenical
neuritis, and
that they are probably functional in origin.
Such
is the clinical picture of the casualties
inflicted by the enemy
use of the arsine compounds; but there is definite
experimental evi
dence
to show that these compounds
can cause much
more
serious
symptoms,
and may
be lethal.
Pathological
examinations of animals which succumbed
to the ef
fects of these compounds
show that lesions
occur in the respiratory
tract which are sufficient
to cause death.
Pulmonary
cedema
is com
mon and frequently
severe, but the chief feature is serious
damage
in the upper air passages.
Frequent exposure apparently increases susceptibility to their effects.
646—22
1
Usher Parsons, Surgeon,
United
States Navy.
V
HISTORICAL.
USHER
PARSONS
(1788-1868),
SURGEON,
UNITED
STATES NAVY.'
By F. L. Pleadwell,,
Captain,
Medical
Corps,
United
States
Navy.
Usher Parsons was born in the town of Alfred, York County, Me.,
when Maine was still a district of the State of Massachusetts,
so that
both
States may
rightfully
count him
among
their
distinguished
sons.
The date of his birth was August
18, 1788.
He was the young
est of the nine children of William and Abigail Frost (Blunt) Par
sons.
William
Parsons
was
descended from
Joseph
Parsons,
who
came to this country from England
in
1635, settling first at Spring
field, later
at Northampton,
Mass.
His
oldest
son, Joseph,
became
a prominent
citizen
and trader in Northampton
and
died
there in
1729.
Joseph's
oldest
son,
also
named
Joseph,
graduated at Har
vard College in 1697,
and was a pupil of the Rev. Increase Mather.
He became
a clergyman at Lebanon, Conn., afterwards at Salisbury,
Mass., where he died in 1740.
His oldest son, in whom
was still per
petuated the name of Joseph,
was
a clergyman at Bradford, Mass.,
from
1726 to his death in 1765.
This Joseph, who married Frances,
daughter
of John
Usher,
lieutenant governor of New Hampshire,
was Usher Parsons's grandfather.
Joseph
and Frances Parsons had
six
sons,
and of these
three
graduated at Harvard
and
were,
re
spectively,
clergyman, physician, and lawyer.
The remaining three
children became mechanics
or traders.
It is noteworthy that of the
two groups of children
those who went
to college
survived only to
an average
age of 36 years, while those who
remained
at home and
followed
the trades
reached
an average
age of 76 years.
The fifth
son, William,
was Usher's father.
He was born in Bradford, Mass.,
in 1743, and followed, by turns, the calling of trader, farmer, manu
facturer of potash, lumber merchant
; he was also a town officer.
William Parsons left Bradford and settled first in South Berwick,
Me.,
then in Alfred,
where
he died
in
1826.
He married Abigail
Frost
Blunt, daughter of Rev. John
Blunt,
of
Newcastle,
N. H.,
whose wife was
a daughter of Hon. John
Frost.
The mother of
John Frost was
a
sister of the celebrated
Sir William Pepperrell,
who captured Louisburg
in 1745.
•
1 For much
of the material
appearing
in this article
the writer is Indebted
to the article
on
Usher
Parsons
in Kelly
and
Barrage's
" American
Medical
Biographies
"
and
to a
•■Memoir of Usher Parsons,
M. D.,"
by
his son, Charles
W. Parsons.
423
424
Vol. XVII.
PLEADWELL
USHER
PARSONS.
The
family
connections
mentioned
in this review
of Usher Par-
sons's ancestry will explain not only the origin of his Christian
name,
but also his interest in writing in 1855 a life of Sir William Pepper-
rell, who
possessed
the distinction
of being the only native of
New-
England
who was created
a baronet
during
its connection
with
the
mother country.2
Usher Parsons's boyhood
was spent in Alfred, where
he attended
the
village
school
in winter
and
worked
on his father's
farm
in
summer.
He
was
11
years of age
when
General Washington
died
and
often
recalled
wearing
crape
and
taking
part in
a mourning
procession of school children on the occasion of this sad event.
When
12 years of age he was sent to school
at the Berwick
Academy, but
only remained
there
a year,
a period far too limited for him to ac
quire more
than
the
bare
rudiments of
a preliminary
education.
After leaving school
he worked as a clerk in several
retail stores in
Portland
and
AVells
(now
Kennebunk).
Me.
His
service
in
the
latter town terminated on March
29,
1807.
As an indication
of its
very satisfactory character
the following
certificate
of his employer
is quoted
:
This
may
certify
that
I.
the
subscriber,
of
Wells,
have
employed
Usher
Parsons
as
a clerk
to assist
me in my store for upwards
of eight months: and
have found
him to
he a capable Lad,
posses-st
of steady habits,
and well
calcu
lated for book-keeping.
Wells.
August
16th.
1800.
Daniel
Little.'
On May
6, 1807,
when
not
quite
19
years of age, Usher
Parsons
began
his life
work
by entering
the
office
of Dr. Abiel Hall,
of
Alfred,
as
a
student
in
medicine.
His
industry
as
a clerk
had
enabled
him to accumulate
a little money,
and
these
savings
were
drawn
Upon
now
for board,
lodging,
books,
and later for
a course
of anatomical
lectures
which he attended
at Fryeburg,
Me.
These
lectures
were
delivered
by the well-known
Dr. Alexander
Ramsay,
an eccentric
but gifted
Scotchman,
who had
come to this
country
from
Edinburgh
in
1802
to
offer
his services
at
the
time of
the
yellow-fever epidemic
in New York.
Usher Parsons's lifelong inter
est in anatomy
had
its origin
in the teachings
of Doctor
Ramsay,
who was himself
an enthusiast
in this branch of medical
science.
During his apprenticeship
with
Doctor Hall he studied
anatomy,
saw a little of the practice of medicine,
read Dr. William
Cullen's
First Lines of the Practice of Physic
(1776-1794),
and studied
the
works of Erasmus
Darwin4
and
the
celebrated
Dr.
John
Brown."'
•Life
of Sir William
Pepperrell,
Bart.,
Cambridge,
Mass.,
1865.
" Father of the tote Charles
C. Little, of the firm of Little, Brown
& Co.,
Boston.
« Erasmus
Darwffi
(1731-1802),
whose Loves of the Plants (1789)
and Zoonomla
(1794)
emphasised the gradual
evolution
of complex organisms
from
simple primordial forms,
the
struggle
for existence in animals
and plants,
sexual selection,
protective
mimicry,
and
the
Indirect
Influence
of environment
in
producing
transformations
which
may
modify
spe
cies."
(Garrison.)
"John
Brown
(1735-1788).
"The disputatious
and
disreputable
Brown,"
as Allbutt
styles
him,
was
a coarse
man of
low
habits
whom
Cullen
had
taken
up and
launched.
N«.3.
PLEADWELL— X'SHER PARSONS.
425
His medical
studies
were
often interrupted
by visits
home,
where
he worked on his father's farm, and by periods of teaching school in
Alfred
and
neighboring
towns,
in order
to
add
something to his
slender
funds.
While still at Kennebunk, Parsons printed his first
literary production, in the shape of some verses entitled "A Petti
fogger's
Soliloquy,"
which
appeared
in
the
Freeman's
Friend,
a
newspaper published in Saco, Me.
Of the incidents of his daily life at this period, and of his efforts
at self-improvement,
both in general education
and in medical
work,
and of the difficulties
met
with
and
overcome
in prosecuting
his
studies,
we may learn most satisfactorily
from the following
extract,
which is taken from an account which he wrote himself in later years :
Rein? disappointed
of a remittance
from my father of some
money
to enable
me to attend
a
second course of lectures
in Portland,
by
Doctor
Kaluga;, I
walked
about 15 miles
in the night, nearly
to Saco, slept
a few hours
on some
hay in a barn, and I reached Kennebunk
the following noon, and Alfred in the
evening.
During my moonlight
walk, I meditated
on
the past and
the future
c-nnrse of my life.
I thought of the misspent
time of my past years, of my low
alms in the
medical
profession,
until within
the last
few
weeks, and asked if
it would
be possible,
at this my 21st
year, to begin
a new course, that
should
redeem the
time, and elevate
me to
a
respectable
rank
in
the medical
profes
sion.
I was
now
wanting
in preparatory
education,
unable
to parse the most
simple sentence
in Latin, and hardly
able
to write a
common
letter
in Knglish
grammatically.
I
had
no means of educating
myself
but
by school
keeping.
How
many years
am I willing, I asked, to devote to this and to hard
study for
tie attainment
of
a
rank
in
the profession
that,
with
my
present
ambitious
views, I shall
be satisfied with?
I concluded
that
10 years
would
be required,
and determined that all my energies should be employed for that length of time.
lot
who. like
Colombo,
Borelll, and other
ingrutes
of
medicine,
turned
against
his
quiet
teacher with
the
pleblan's
usual
tactics
of
reviling his
Intellectual
betters
In
order
to
Halt himself.
Yet the Brunonlan
theory,
as It was called,
actually
held the attention
of
Europe for
a quarter
century,
and
as
late
as
1802
a
rlxa,
or
students'
brawl,
between
Brunonlnns
and non-Brunonlans
at the University of GBttlngen
lasted
two whole days and
had finally to be put down
by a troop of Hanoverian
horse.
As far as It went,
the theory
*as absolutely
consistent
and complete In
all Its parts.
Brown
regarded living tissues as
?icitable,"
in lieu
of the Hallerian "Irritability."
and life Itself
as
nonexistent,
except
as a resuttiint
of the action
of external
stimuli
upon
an
organized
body.
Diseases
are
Hen " sthenic "
or
" asthenic,"
according
as
the
vital
condition
of
" excitement "
Is
Increased
or
diminished.
The
essentials
of
diagnosis
are
simply
whether
a
disease Is
institutional
or
local,
sthenic
or asthenic,
and In what
degree,
and the treatment
con-
•ists in either
stimulating or depressing
the given
condition.
To
this
end,
opium
and,
of course,
alcohol
were Brown's
favorite
agents.
Hippocrates
said that no knowledge
of
'he brain
can
tell us how
wine will
act upon
any particular Individual, and Brown pro-
'wded
to apply
this experimental
Idea In
propria
persona
to elucidate
his
theory,
using
successive doses
of five glasses at
a time.
Abuse of opium
and alcohol
eventually
killed
him.
His method
gained^ little support
in
France
and England,
but
Rush
took it up In
America,
Rasorl,
Moscati,
Brera,
and others
In Italy,
and In
Germany,
after
Chrlstopb
'ilrtanner's
plagiarisms
of
1790
had
been
exposed
and the " Elementa
medlcinne,"
trans
lated by M. A. Welkard,
Brown
came
Into his own.
The
book
hypnotized
even
Peter Frank
at»l RSschlaub. and was greeted
by
a
flood
of pamphlets
and salvos of praise.
Although
Ms errors were pointed
out by Humboldt
and Hufeland,
Brown
had the unique distinction
"f polarizing the German
profession.
His therapeutic
ideas, Unas asserts, destroyed
more
people than the French
Revolution
and
the Nnpoleonle
wars
combined ; nor will
we dis
pute the
same
historian's
pronouncement
that
he
wob
" morally
deserving
of the severest
'imdemnation."
(Garrison.)
426
Vol. XVU.
PLEAD WELL
USHER
PARSONS.
and to be satisfied could I arrive at eminence in respect to knowledge,
nlthougn
the tenth year should find me as penniless
as at this hour.
My resolution
was
now
fixed
and
my plans
matured
this night,
and in
the
main were not deviated from during
that length of time. I determined
to obtain
the degree of A. M. and M. D., and to become
a teacher of anatomy.
On arriv
ing at Alfred, I packed
up my Latin
books, and went
to Sanford,
4
miles
off.
and
placed
myself
in
the family of Parson
Sweat.
I began with
the
Latin
grammar,
and by the last of November
had gone over it several times and read
two
books
in Virgil,
and
was
able
to read
the
Greek
Testament
a
little,
l
then taught school two months in Elliot ; then returned
to Parson Sweat's a few
months;
then went
in May to
keep
school three months half
a mile from
Ber
wick Academy
; then attended
the academy
one quarter,
and read two or three
of the Evangelists
(in Greek), and four orations
against
Catiline;
then
kept
school at Alfred three months, and during evenings read Virgil
nearly
through,
finished
the Evangelists
and the book of Romans.
I now felt that to go through
college in this tedious
way would
be likely
to consume tlie
10 years.
I there
fore concluded
to return
to medicine;
to read a few months with Doctor
Hall,
at Alfred,
and
then study
with
some
very
eminent
person six months,
which
would complete my three years,
to attend
a course of lectures,
und then
com
mence
practice,
or be ready
to commence whenever
a vacancy
offered,
and
en
deavor
to
go
through
the
college
studies
whilst
trying
to
get
into
practice.
Accordingly
I went to Doctor Kittredge, of Andover,
but found
him from home.
I then went
to Boston
and entered
the office
of Doctor
John Warren, for six
months.
It was with much difficulty
that I got through
with the expense of
lectures
and board,
although
assisted
to $50 by my father.
Following
the
plan
mentioned
above,
Usher
Parsons
went
t«
Boston in July,
1811,
and
succeeded
in establishing himself
under
the preceptorship of the eminent
surgeon, Dr. John Warren,
brother
of Doctor Joseph Warren,
who fell at Bunker Hill.
While in Bos
ton he boarded
at the Market Tavern in company
with his brother-
in-law,
Gen.
Samuel Leighton,
then
representative
to the
General
Court
from Elliot.
In February,
1812,
he underwent
a successful
examination before the censors of the Massachusetts
Medical
Society,
and was duly licensed
as a " practitioner of medicine." 6
■ISeal]
Commonwealth
of Massachusetts.
We the subscribers,
Censors
of
the Massachusetts
Medical
Society
duly
appointed
and
authorised
have examined
Usher
Parsons
of Alfred in the County
of York a candidate
for
tbe practice
of
Physiek
and
Surgery
; and
having
found
him
qualified
do
approve
and
license
him
as a Practitioner In Medicine,
agreeably
to the
law
in
that
case
made
and
provided.
Dated
at
Boston
this
7th day" of
February
A.
D. One Thousand
Eight
Hundred
and
twelve.
Lemuel Haywabd. MD.
Thomas Welsh, MD.
"Aaros
Dexter,
MD.
Josiah Bautlett,
MD.
William
Spooneb,
MD.
By virtue
of the power
rested
in
me,
I
bave hereunto
affixed
the Seal of_the
Massa
chusetts
Medical
Society.
,
John
Wabebn,
MD.
Attest:
, .
John
C. Warken, Recording
Secretary.
A true copy of the original.
Attest
:
J.
Wheeler,
Dover, X. II., May
V,, mt.
/ „
//
/
,
/ 1
/
-
j/t irf /.i >'/
■
•''.>.'•</'
,i/,:t<*
"
r: i
.< * .
,, . /. . .
'■•■I
■.
/
/
Letter recommending
Usher Parsons for appointment
in the Navy.
All
PLEADWELL
USHER
PARSONS.
427
After passing his examination
before
the censors,
he returned to
his home in Alfred, but as war with Great Britain now seemed
immi
nent,' and openings
for beginning practice in civil life not encourag
ing, he made an attempt to get an appointment as surgeon's
mate in
either the Army or Navy.
At first his efforts met with
no success,
but enlisting the support of his Congressman,
Dr. Josiah Bartlett, of
New Hampshire,
he was shortly commissioned
as a surgeon's
mate in
the Navy.
His commission
bore the date of July 6, 1812.8
The following copy of the credentials
mentioned
in Doctor Bart-
lett's letter has been found, and is believed
to be worthy of reproduc
tion here
:
Boston, January
the 20th 1812.
Tills certifies
that
Doctor
Usher
Parsons
has been
three full years
a student
of I'hysiek
under
Physicians of
approved
and
established
reputation
during
which
he
diligently
applied
himself
to
the various branches
of
his
Profes
sion;
attending
lectures in Anatomy
and
Surgery,
the Theory and Practice of
Medicine.
Chemistry
and Materia Medica
and Midwifery— That his proficiency
in these respectively
has been
such as deservedly
to acquire
the approbation
of
all
the gentlemen
under
whom
he
has
received
his
education,
and
that
his
moral character
has been
immaculate.
I therefore
recommend him accordingly.
John Warren.
A true copy of the original, attest :
J. Wheeler.
Dover, N. H., May 2k,
1812.
His experiences
at this time are best revealed by quoting again from
the sketch of his early life :
After
an
unsuccessful
attempt
to
get
a
school,
to repair
my
wardrobe, I
vent
to Exeter to get a place as physician,
but was soon discouraged.
I then
went
to
Dover
for
a
few
months,
but
received
no
encouragement,
and
the
expenses here added
to my debts and poverty.
There was now
a prospect
of
war, and I tried
hard
for
a place of surgeon's
mate in the Army,
but
failed.
At length an invitation was forwarded
me by the surgeon of the John
Adams
to Join
him
as mate,
assuring
me
he
would
try
to get my
appointment
of
mate
confirmed
by
a commission,
but
adding
that I must
be in Boston
in
60
hours.
I made all dispatch, but did not reach there till 64 hours, and then found
the ship
had
sailed.
I was
now
left
with
$\,
but I
succeeded
in borrowing
mother
and returned.
At Salem I tried
for
a berth
on board
a privateer.
I
'War
was declared on June
18,
1812.
'To tbe honorable
Paul Hamilton,
Esquire,
Secretary
of the Navy
Department
of the United
States:
The Undersigned
a citizen
of
New
Hampshire
begs
leave
to give
the name of
Usher
Parsons now
of Dover
In said
State
as a suitable
candidate
for an appointment
in
the
medical
part of the Navy.
It is not now
recollected
that
any citizen
of
New
Hampshire
is either a surgeon or surgeon's mate In the Navy
and from
the credentials,
copy of which
is enclosed,
the subscriber
believes that
said Parsons
would
be useful
in that
department
if a vacancy
will admit
his
Introduction.
,
I have the honor
to be your
humble
servant,
Josiah
Bartlett.
N. B. Hia preceptors
in
medicine
were Dr.
Hall
of Alfred, district
of
Maine
and
Dr.
John Warren of
Boston,
Massachusetts,
Professor
of
Anatomy
and
Surgery
in
the Har
vard
University,
Oamde.
428
Vol. XVII.
PLEADWELL—VSHEE PARSONS.
reached
Dover
discouraged,
indeed,
and
not
a little
mortified.
A few
weeks
previous
to this I
had
applied
for
a
mate's
commission
In
the
Navy,
but
despaired of success,
and I had now no hope left but that
a chance might offer
in
a privateer.
In about four days
from
my return from Boston I was told
there was a package In the office for me.
I went and found It to be a commis
sion of surgeon's mate in
the Navy,
my pay to commence from that day.
No
one can imagine
my joy ; it was ecstatic, frantic.
In spite of his failure
to catch the John Adams at Boston he was
destined
to go to this ship finally, for orders
issued from the Navy
Department under date of August
15, 1812. directed him to report on
board that
vessel in New York.
The period of Doctor
Parsons's
service
on the John Adams
appears
to have
been
very brief, for in
September
he as well as other officers and men of the ship volunteered
for an expedition being fitted out under Commodore Isaac Chauncey
for service
on the Great Lakes.
There
was at the time
very little
exact information
about
the proposed
expedition, nor is there
now
any written record of orders for Doctor Parsons to join it.
On the
contrary, there is evidence
that he was directed
to go to St. Marys,
Ga.,
but
these orders he never
received,
and
he asserted
an
entire
ignorance of them in correspondence
with the department later.
It
was
by
a narrow
margin,
therefore, that
fate decreed
him
to
go
where his services
in battle
a year later were to bring him the well-
earned
renown,
which even now,
more than
a century later,
makes
him deserving of " perpetual rediscovery by the medical profession
of the United States." 9
The
force
of men composing
the expedition which Parsons
now
joined left the Brooklyn Navy Yard for Albany on September 24,
1812, traveling first by boat to that point, and thence to Buffalo by
wagons
and on foot.
It required only 5 days to reach Albany (from
Sew York), but
18 days
passed
before
the expedition
arrived
at
Buffalo.
During the succeeding winter and spring. 1812-13. Doctor Parsons
was in charge of the sick and wounded
at Black Bock, near Buffalo.
At this time
an epidemic of pleuro-pneumonia
prevailed here and
in other parts of the country.
His observations on the treatment
of this disease formed the basis of his first medical publication.10'
11
This small paper, written in the form of an open letter to a Doctor
Ross, and published in a local newspaper,
gives us an idea of Doctor
•Am.
Med.
Biogs.,
1020,
p,
800.
10On
Pleuro-Pneumonia.
Addressed
to
Dr.
John
Boss.
The
Buffalo
Gazette
(circa
Jan.
10,
1813).
11This
epidemic
was
the
so-called
" cold
plague " of William
Steward,
D.
D.,
author
of
the
pamphlet
" The
Healing
Art,"
1812.
A
detailed
account
of
the
disease
as it
prevailed
in the United
States
Army
was written by
Dr. James
Mann,
a hospital surgeon,
in his Medical
Sketches of the Campaign
of 1812.
1813,
and
1814,
Dedham,
1816.
A very
complete
review of this epidemic, with bibliography,
has recently
appeared
in
the
Lancet
under the title "The Cold Plaugue
of the War of 1812-14,"
by
the Hon. William
Renwick
Klddell.
LL. D.
(Lancet,
Mar.
11,
1022,
p. 512).
•No.3.
429
PLEAD WELL
USHER
PARSONS.
Parsons's
professional
acumen,
and
reveals
his controversial
tend
ency, of which evidence will appear again somewhat
later.
This article indicates a decided
predilection for copious
bleeding
in the affection under discussion,
and
gives his experience
with this
treatment,
which had been criticized
by Doctor Ross.
Doctor Par
sons's
contention
about
the
seat of
the
disease
(as being in
the
thorax)
and not in the " right hypochondrium,"
as claimed by Doctor
Ross, is fully supported by a number of postmortem
examinations of
victims
of the
disease.
In closing his letter,
he states that
he is
"actuated
principally by
a desire to remove from the minds of my
patients any undue prejudice against the use of the lancet, which the
publication of your sentiment
may occasion."
An attack
on one of the enemy's
batteries
on the Canadian
side
of the Niagara River, which was made in November,
1812,
resulted
in casualties which gave Doctor Parsons
a number of surgical
cases,
as did also the attack
on Fort George
on May 27,
1813.
When, on
May
28, the British
blew
up their
magazines
at Fort Erie,
and
retreated, Doctor
Parsons with
a Doctor Purcell and
some 20 citi
zens crossed
the river, took 2 prisoners, and marched
to the fort.
On
arriving near the fort 2 men met them with a flag of truce
and sur
rendered.
The party then walked to the fort and were received
most
hospitably.
Doctor
Purcell
was
sent
back
with
information
of
this occurrence,
and in the evening
the colonel
in command
crossed
with a regiment
and took possession.
This incident was the basis for
his story of receiving the surrender of Fort Erie, told
by him
on
many occasions in later years.
Some two months
previous to the events just related
Capt. Oliver
Hazard Perry had arrived
at Erie
(Presque Isle), Pa., from New
port, B. I.
At this point the fleet was being built which was to meet
the British
force
later in the year.
It was in June that Captain
Perry came
to Black
Rock for the purpose of taking
back
to Erie
several
small vessels intended
to
be
fitted
as men of war.
Doctor
Parsons
appears
to
have
been
assigned
to this force
and
accom
panied Perry on June
14 when
they
sailed for Erie.
Apparently
many
men were ill at this time with fever, the so-called
lake fever,
and Doctor Parsons
was actively engaged
in caring for them in a
large unfinished courthouse,
fitted
as a hospital.
This duty at Erie
continued until some time in August.
In this interval Doctor Par
sons,
with
other
officers,
entered
into
the
social
life of the
com
munity
and formed many pleasant
acquaintances
among
the people
of the town.
On August
12, the little squadron under Perry sailed
from Erie to the head of the Lakes.
Doctor Parsons
was assigned
as the junior surgeon's
mate on the flagship Lawren-cc
On the 19th
the squadron
was
visited
by
Gen.
William
Henry Harrison
and
Col. Lewis
Cass, and
on the
26th it arrived
at the
mouth
of the
430
Vol. XVII.
PLEADWELL
USHER
PARSONS.
Detroit Kiver, sailed
thence
to Sandusky,
and
then
to Put-in-Bay,
where
the force
anchored.
Sickness
was
rife.
Commodore
Perry
and fully half the officers
and
many
of
the men
were
down with
bilious
remittent
fever.
Doctor
Parsons
himself
did
not
escape,
nor did
his
medical
associates,
Doctor
Barton
on the Niagara,
or
Doctor Horseley,
his
immediate
senior on
the Lawrence,
but for
tunately for Doctor Parsons, on the date of the battle,
he was suffi
ciently recovered
to be fit for duty, while
the other
surgeons
were
still too ill to be of service.
In speaking of his illness he states. " T did not
escape
an attack
myself, which confined
me
two
or three
days,
and during
this time
more than
100 lay sick without
any medical
aid."
On September
3
he adds, " I never was so much emaciated."
And now we come to the
narrative of the Battle of Lake Erie :
In this weakened condition, with only one doctor in the squadron
to attend
the
sick and take charge of the wounded of n battle, we met the enemy
(September
10, 1813).
The
action was
soon
very severely felt
on board
the Lawrence,
the
two largest vessels of the enemy
engaging her at short distance for nearly
two
hours.
The Lawrence
being shallow
built, and affording
no cock-pit. or place of
security for the wounded, they were received on the ward-room
floor, which wis
nearly level with the surface of the water.
Heing only ten or twelve feet square,
this floor was soon
covered, which
made it necessary
to pass them out into
an
other apartment,
as fast as the bleeding could
be staunched.
Several,
however,
were wounded
n second
time before this could be done.
Midshipman
haul)
was
moving from me with
a tourniquet
on his arm, when a cannon ball struck
him in
the breast;
and
a seaman brought
down with both arms
fractured
was struck
by a cannon ball in both legs.
An hour and a half had so far swept the deck that
new appeals for surgical
aid were less frequent.
This change was rendered
the
more
desirable
at this time, from
the circumstance
that the repeated request of
the commodore
to spare him another
man had taken from
me the last one sta
tioned
to assist
in moving the wounded ; in fact,
many of the wounded
them
selves took the deck at this critical moment.
Having sole charge of the wounded of the whole
fleet,
and the wounded being
passed down to me for aid faster
than I could attend
to
them
in a proper
man
ner, I aimed only
to
save life during the action
by
tying
arteries
or applying
tourniquets
to prevent fatal hemorrhage,
and sometimes applying
splints
ns
a
temporary
support
to shattered
limbs,
etc.
In this state the patients
remained
until the following morning,
under
the free
use of cordials
and anodynes.
At
sunrise
(the 11th), I began
amputations,
and in the course of the whole day and
evening was able to finish
all operations
and dress at least once
or twice, and
to do justice
to them all.
On the following day, I visited
the other vessels and
brought
all
the
wounded
on
board
the Lawrence
and
treated
them
In
like
manner.
In another
account of the battle which Doctor Parsons wrote addi
tional incidents are recorded:
Put-in-Bay,
Friday, September
10.
At five o'clock,
A. M., discovered
the enemy's squadron
bearing
North
West,
wind South West.
At seven could see all the vessels,
viz :— two ships, two brigs,
one
schooner, and one
sloop.
At
ten called nil hands to quarters.
At quarter
~$
•
jb.
cite.
7/n
ict
eu
I
a-
<//>
Perry's
letter to the Secretary of the Navy announcing the victory on Lake Erie.
430
No. 3.
431
PLEADWELL
USHER
PARSONS.
hofore meridian
the enemy
commenced
the action at one mile distance.
In half
an hour we came
within musket shot of the enemy's new ship Detroit.
At this
time
they
opened
a most destructive
fire
on
the Lairrcncc
from
their
whole
squadron.
At half past
one,
so entirely
disabled
we could work
the brig
no
longer.
At two P. M., most of the guns were dismounted,
breechings
gone,
or
carriages
knocked to pieces.
At half past two, when not another
gun could
be
worked or fired
from
the Lawrence,
Captain
Perry
hauled
down
the fighting
flag,
which
bore
this
motto,
Don't
give
vp
the ship,
repaired
on
board
the
Niagara, and there raised it again.
In ten minutes after we struck
to the enemy
Captain Perry made all sail with the Niagara,
which
hitherto
had kept out of
the action,
and in fifteen minutes passed in among the British
squadron,
having
the Detroit,
Queen Charlotte,
and Lady Prevoxt
on the starboard
side.'and
the
Hunter on the larboard
side,
and silenced them all, and ten minutes before three
they hauled down their colors.
Two small
vessels attempted
to escape,
but be
ing overhauled struck
a few minutes after
three.
Killed
on
board
the
Lawrence
(one
lieutenant,
eighteen
midshipmen,
and
three others;
sixty-three
wounded).
Slept but little, and
dressed
about
one-third,
and secured with
tourniquets
such as bled copiously.
During the action I cut off six legs in the cockpit, which
were nearly divided
by cannon balls.
Still further details of the action
appear
in the following
extract
from a letter to his father :
Near the Hkad of Lake Erie,
On Boabd the tJ. S.
Sr.oop Lawrence,
September
22, 1813.
Before the arrival
of this
an
account of our victorious
engagement with
the
British squadron
on this Lake will reach you. I can only add a few particulars.
Most
of the action
was supported
by this vessel, as you will suppose when in
formed
that out of one hundred
and fifty men
(our ship's crew), thirty-one
of
whom were sick previous to the action, we had rising eighty killed and wounded,
among
whom
were
nearly
all our
officers save the
intrepid
Commodore.
On
board
all the others
were about thirty killed and
wounded.
This vessel was
engaged with the enemy's two ships on one side and a brig astern
raking
us for
two hours,
all within musket-shot, during which
we rendered
the ships unman-
aseable, and when this vessel could not discharge
another
gun, the Commander
repaired
on
board
the Niagara;
and within
fifteen
minutes
after
he arrived
within
close
action with them, the enemy's three vessels struck.
Unfortunately
for
the
wounded,
the
two
surgeons
had
been
confined
for
several days with fever,
and could
render
them
but little
assistance.
It has
however operated
in my favor,
as I have had all Ihe amputations
to perform;
and it affords
me the greatest pleasure
to reflect that
in
no
case
have I failed
of the
best
success.
This
has
inclined
the Commodore's
opinion
so
much
In
niy favor that I have no doubt
he will render
me assistance
towards
obtaining
a better situation.
He is the first warm friend I have met with in the service
capable
of assisting
me.
I am now on my way
in the Lawrence
for Erie, hav
ing all the sick
and wounded of the squadron
on board,
and shall
continue
in
the hospital with them till they in a measure recover, and will
then direct
my
course
toward -Cape Home.
General Harrison
w-as' on hoard the Laiortwe
this morning,
and his army
was
on an island within half a mile of the vessel.
It is supposed
to consist
of at
'east
eight
hundred
regulars,
militia
and
Indians.
To-morrow
they cross
to
Maiden,
a distance
of about
eighteen miles.
Since
the capture
of the British
432
Vol. XVII.
PLEADWELL
USHER
PARSONS
squadron,
the Indians have evacuated Detroit,
after burning
the place, and (as
is reported)
massacring
the inhabitants.
The enemy's squadron
mounted
more
guns
than
ours,
and
carried
more
men
by
at
least
one-fourth.
I
had
some
narrow
escapes
for my life during the action.
Five cannon balls passed through
the room in which
I was attending
to
the wounded.
Two of the
men I had
dressed and laid
aside in the commencement of the action
were killed,
before
it closed,
by other shots.
I have had very poor health all the cruise,
am
reduced to a skeleton, but am
recovering.
Never will I cruise
again
on this lake
or any
other.
The action
was fought within about ten miles of Maiden.
The
enemy
came
out over night
for the purpose of attacking
us, and in the morning
were within about fourteen
miles of us, the wind
in their favor.
We made sail
to meet
them,
and the wind
changed in our favor,
which
gave us an advantage
over
them.
They
had
more
killed
and wounded
than
we.
It was a unique
and almost unparalleled experience
for a surgeon
to have
such
a burden
of casualties
thrust upon
him in so
short
a
period of action, and
the
results
speak
well
for
Doctor
Parsons's
skill.
Twenty-two
officers
and
men
were killed
on
the Lawrence,
and several others with shattered
limbs died shortly afterward.
The
wounded
on the Lawrence numbered
61 ; in the whole
squadron
96.
Except for
a consultation with two British surgeons
on September
13, and assistance
rendered
by a surgeon
sent him on the 14th from
General Harrison's
army.
Doctor Parsons handled
all the wounded
himself.
In referring
to his work.
Commodore
Perry, in
a letter
to the Secretary of the Navy stated :
Of Dr. Usher Parsons,
surgeon's mate, I cannot say too much.
In consequence
of
the disability of both
the
other
surgeons.
Prs.
Horscly
and
Barton,
the
whole duty of operating,
dressing
and attending
nearly
an
hundred
wounded,
and
as
many sick,
devolved
entirely
on him: and it must
bp pleasing
to you,
sir,
to reflect that, of the whole number wounded, only three died.
I can only
say that, in the event of ray having another commnnd, I should consider myself
particularly fortunate
in having
him with
me as
a surgeon.
Doctor
Parsons
attributed
his
success
in
the
treatment
of
the
wounded
to several factors.
From the 12th to the 2'2d of September
they were lodged in the open air on the upper deck of the Lawrence,
sheltered
by an awning.
In addition they had
a plentiful
supply of
cordials,
fresh
vegetables,
and
provisions,
and
finally
they
were
buoyed
up by the cheering
influence
of victory.
On September
23
the Lawrence reached Erie, and the sick, wounded,
and prisoners were
landed
and
placed
in the hospital
there.
For nine
months
Doctor
Parsons continued
in charge of this hospital
at Erie, during which
time he made many friends and formed many endearing associations
there, which were a great source of pleasure
to him in later years.
Congress
voted medals commemorative
of the Lake Erie victory to
all participants and Doctor Parsons received one of them in common
with other
officers.
He also received
a share of prize money, which
was
used to pay
off the balance
of
debt incurred
in obtaining
his
No. 3.
433
PLEADWELL —USHER
PARSONS.
medical education.
Not the least of the rewards which came to him
as a result of his service on the Lakes was the surgical experience
and
Commodore
Perry's
friendship.
During the period from January
1 to February
5, 1814, he appears
to have had service
with
the land forces
at Erie, being assigned
as
surgeon of the Twelfth Regiment, Pennsylvania
Militia,
by orders
from Maj.
Gen. David
Mead.
On April 15, 1814, Doctor Parsons received
his promotion to sur
geon, and on the 19th he sailed
with the fleet from Erie for Detroit
and Lake Huron.
Troops
were embarked
at Detroit,
and the com
bined land and sea forces then proceeded through Lakes St. Clair and
Huron, and attacked Fort Mackinac.
The attempt
to reduce the fort
was unsuccessful,
and several
officers
and men wore
lost.
The fleet
returned, and Doctor Parsons was back at Erie on September
21.
The incidents of Doctor
Parsons's
career
from this
time
on
are
best described
by quoting directly from
the " Memoir of Dr. Usher
Parsons " by his son.
Except for a few minor changes in phraseology
the text
of this work has been followed strictly
:
Perry had returned
to the seaboard, and been appointed
to command the new
frigate Java, building at Baltimore,
and was allowed
to select his own officers.
He chose several
of his companions
in lake service, among others,
Or. Parsons,
who on the second of December, 1814, received orders
to report to Perry at Bal
timore.
He was attached to the Java, under Perry, through
the years 1815 and
1816.
He
appears
to have
now
revisited
his
native
village.
It
was
at
this
period
that
he
first
came to Providence,
traveling
by stage with his
comrade,
Thomas Breese.
They
lodged at the house since known
ns the " Manufacturers
Hotel."
He passed the year
1815 mostly with the frigate,
at Baltimore,
Nor
folk, New York, and other ports.
War witli England
had ceased,
and the frigate
was ordered to the
Mediterranean,
to look after American
interests,
especially
in connection
with the Barbary States, and the threatening
attitude
of Algiers.
He sailed from Newport
as surgeon of the Java, January
22, 1816, and reached
the Straits of Gibraltar, February 12.
On February 7, in a severe storm, several
men were thrown
from
the masts and yards
; some
were killed,
and others
re
quired surgical
operations.
In assisting
to
move
them,
Dr. Parsons was thrown
between
decks,
breaking
his
right knee-pan.
For this,
he
many
years
after
wards received a pension.
His diary during this voyage of the Java, contained
an account of his daily occupations,
with full description
of local
customs and
interesting
places.
He visited
Gibraltar, Malaga,
Port Muhon
on the island
of
Minorca, Algiers,
Tunis, and the ruins of Carthage,
Tripoli,
Messina.
Palermo,
and
Naples.
Perry
gave his
officers
every
proper
facility
for excursions
on
shore, which
were often made by several
of them In company.
On arriving
at
Algiers,
April
1,
they
found
the British
fleet,
under
Lord
Exmouth, which
had gone there to secure the liberation of Christian slaves, and
prevent
future enslavement
of captured
citizens.
The barbarous
customs
of
piracy and the reduction
of captives to servitude,
and of demanding
tribute
from
commercial
nations,
were beginning
to call on that
State the vengeance of the
great Christian
powers.
In
1815,
Decatur
had
secured
by
force
of arms
a
treaty which relinquished
claims
to tribute from
the United States, and released
all American captives.
Lord Exmouth now visited Algiers for a similar purpose.
He obtained the release by
a large
ransom, of several
hundred
Christian
slaves
434
Vol. XVII.
PLEADWELL
USHER PARSONS.
mostly
belonging
to nations of Southern
Europe.
Dr. Parsons
writes,
April
7 :
" The British fleet departed for Tunis with Christian prisoners.
They paid from
five hundred
to one thousand
dollars per head for them, except
a very few be
longing
to the British,
which
were not ransomed.
Misunderstanding
arose
between
the
Dey
and
Commodore
Perry,
and
a
fight
was
expected.
Dr.
Parsons
writes.
April
8 : " Volunteered
my
services
to go in Captain
Perry's boat, and prepared
both for fighting
or doctoring. "
In May,
he
set
out
from
Messina
to visit Mount
Etna.
The excursion
oc
cupied four days.
He was aceompained
by Dr. Hoffman,
of the United
States
Navy.
His diary describes
the villages
and ancient
ruins that
they passed, —
the three regions,
torrid, temperate
and frigid. — the exhausting
ascent of the
great
cone,
and the grand
view
from
its summit,
the sea,
the flaming
islands
of Imparl,
the varied
landscape of Sicily, and the slopes of the mountain
itself,
its successive
zones,
its many
villages,
and its black
rivers
of solidified
lava.
From the village
of Nieolist,
which
is half-way up the mountain,
he
was
ac
eompained
by
a local
magistrate,
who had never before visited
the crater; and
who,
reading
in
an
old French
Gazeteer
that
Lima
was
in
South
American
inquired
whether
the United
States were near that.
While at Naples,
be examined
repeatedly
the remains
of Pompeii
and Her-
culaneum.
His
journal
of this
voyage
ends abruptly,
at
Naples.
July
21.
The Java
revisited
several
ports
on
the
Mediterranean,
Tripoli.
Algiers,
Malaga
and
Gibraltar,
and sailed in January,
1817, for the United
States,
bearing
a
new
treaty
with Algiers.
The
crew
suffered with the small
pox on the homeward
voyage.
On the occurrence
of the first case,
the
men
were
mustered,
and
it
was found
that
eighteen of them had never had either
small
pox or kine po«.
They
were vaccinated,
but with matter
brought
from
the United
States
a year
previously,
and the vaccination
failed.
Dr. Parsons thereupon
inoculated
them
with
small
pox
virus,
and all had
the disease
mildly.
Some continued
sick
when
the Java arrived
in Newport,
and the town authorities gave permission
to " land a number of persons from
on board the said ship, with the small pox,
at Coaster's
Harbor island. "
A more
detailed
report of the
circumstances
attending
this epi
demic was made by both Commodore Perry and Dr. Parsons,
as will
appear from the following letters
:
U. S. Ship Java,
Newport,
March S,
1817.
Sra : The Java having
arrived
in the United
States with several cases of the
small pox on board ; it becomes
a duty which I owe to myself
to account
to you
.
for a circumstance,
which
may appear
to shew a want
of that attention
in
me,
so essential
on the part of a Commander
toward
the health of his crew.
The Invalids of the Squadron
together with
a number of men
whose term of
service had expired
were sent on board
the Java
a few days before
ray depart
ure
from
Port
Mahon,
and
exchanged
for
an
equal
number
of
her
crew.
Shortly
after sailing
a
case
of the Small
Pox was discovered,
and an attempt
was made to vaccinate
those who were in danger of taking
the infection;
but
unfortunately the
matter
proved
bad.
It
therefore
became
necessary
to
in-
noculate
them for the Small
Pox,
and to my surprize,
on inquiry it was
found
necessary
to
perform
this
operation
upon
eighteen
of those
who
had
lately
been
received
on board.
The same
number. I regret
to add, have since taken
it in the natural
way. four of whom have died.
I had taken the precaution
to
have the Java's
Crew
vaccinated
prior
to
my
leaving
the I".
States.
PLEAD WELL
USHER
PARSONS.
435
Permit
me Sir, to suggest for your
consideration
the propriety
of making
it
tie duty
(by a special order)
of the Commander
and Surgeon of a public
ves
sel and of Surgeons
attending
Rendezvous,
immediately
on
a man's being ship
ped or received on
board,
who has not been
vaccinated,
to
cause the same to
be performed
on
him,
and
that
the former
be
directed
to report
to the
De
partment before sailing on
a Cruise,
their
performance
of this duty; and that
the Surgeons
be directed
to
keep
constantly
on
hand
a
sufficient
quantity
of
the vaccine
matter.
For your further Information
Sir, I have the honor
to enclose a report
to me
from
the Surgeon, Dr. Parsons.
I am Sir, With great respect,
Your
Obt. Servt.
O. H. Perry.
The Honorable B. W. Crowinshikld,
Secretary
of the Navy.
•
U. S. Frigate Java,
March 3,
1817.
Sis: Agreeable
to your request I here state the particulars of the commence-
meut and consequence of the smallpox
in this ship.
The day following our
departure
from Gibraltar,
and eleven days after our
separation
from
the
Squadron
at
Mahon,
a
seaman
was
attacked
with
this
disease
in its most malignant
form.
This
man was
among those whose
term
of service had expired
and who were transferred
to this
ship to be discharged
on their arrival
in the U.
States.
On mustering
the others,
eighteen
reported
themselves to have
never
had
either
the small
or kine
pox.
By your
order
they
were
immediately
vaccinated,
but with matter
that I had
brought
from
the D. States a year previous,
and its age had rendered it inert.
As soon as it
was ascertained
that
the vaccination
would
fail, I innoculated
them
and
by
the use of medicine with strict attention
to diet and regimen, they all underwent
the small pox in its most benign form,
none of them being confined
more than
two or three days.
Unfortunately
for others,
who failed to report
themselves
for
innoculation,
eighteen men
were attacked
with
the
disease the natural way.
F'our of them
died,
and the recovery of many of the other was long dispaired
of.
I am,
how
ever,
happy
to inform you, that only six now remain
on
the list, all of whom
are convalescing.
Altho'
the distress
and loss of lives
occasioned
by
this
disease
are much
to
be lamented,
it must be a pleasing reflection to you, Sir, that you have prevented ."
its spreading
among
our
own
crew
by
ordering
their
vaccination
before
we
left
the
U.
States.
By
a similar precaution
on
board
the other
ships
in
the
Mediterranean,
the
serious
calamity
we
have
witnessed
might
have
been
prevented.
Besides
those who died on our passage with the small pox, we have lost three
with pulmonary
consumption,
making
in all
seven
deaths ; an
unusual
loss
to
be seen for one ship, but considering
Sir, that in addition
to our own sick, we
had
to take home all the incurable
patients
of
the Squadron
and
hospital
to
the number of forty or fifty,
and with a long winter passage, the number
of
deaths will seem
as moderate as could have been expected.
I have
the honor
to be, Sir,
Tour mo*
ob'
(Signed)
Usher Parsons. Surgeon.
0. H. Perry, Esq.
436
Vol. XVII.
PLEADWELL
USHER
PARSONS.
The Java arrived at Newport on March
3, 1817.
On May
13, 1817,
Doctor
Parsons
addressed
a letter to the department which
reads
as follows
:
Boston, May 13,
181"!.
Sir: By the order of Commodore
Bainbridge I hereby
report
myself
to the
Navy
Department.
If consistent
with the good
of the service,
1 would wish for orders
to remain
attached
to the Java,
or if this indulgence
cannot
be granted, I would
like
to
be continued
on
this
station
in some other
situation.
My object
in this
is
to
avail
myself
of the
advantages
which
the
town
of Boston
affords
for
pro
fessional
improvement.
It will
appear in the following narrative,
which
is taken
from
the " Memoir," that his wish to remain in Boston was gratified,
and
as
a result he was
enabled
to complete
his medical
education
and
receive his degree :
In July Doctor Parsons came to Providence, bringing introductions
from Commodore
Perry and other naval friends, and contemplating
a settlement
there in civil practice.
He resided
there four months,
boarding at the house of Major McClellan.12
In November,
he went to attend
lectures
at the medical school
in
Boston;
and,
in March,
1818,
he received
the
degree of doctor of
medicine from Harvard University.
His dissertation in graduating
was on " The epidemic
pneumonia of 1812-13,
as it appeared about
Lake Erie."
In that year, he published, in the New England Journal
of Medicine
and
Surgery,
a " Surgical
account
of the naval
battle
on Lake Erie," and
a report of two cases of gunshot wounds of the
thorax.
He joined the Massachusetts
Medical
Society at that time.
His mother died
at Alfred, on the 4th of July.
In July,
1818,
he sailed from Boston
as surgeon
of the frigate
Guerriere, Capt. Thomas Macdonough, for St. Petersburg, carrying
out Mr. George
W. Campbell, minister
to Russia.
He spent
about
. 10 days in St. Petersburg and wrote very full accounts of remarkable
objects
in that
city
and
of peculiar
customs.
The
frigate
sailed
thence
to the Mediterranean.
He was
at Copenhagen
October
14:
off Cape Trafalgar November 4; reached
Syracuse
in December
and
spent several
weeks at and near Messina.
In April, 1819, the Guer-
riere left Messina for Palermo,
and
afterwards
sailed for
Naples.
Detailed knowledge of this
cruise
is best obtained
from
letters
to
his correspondents
in the United
States.
These show
that he took
an active
and inquiring interest in a great variety of subjects.
" MaJ.
Samuel
McClellan,
a
native
of
Woodstock,
Conn.,
and
a
pensioner
of
the
Revolutionary
War,
died
in
Providence,
February
7,
1850,
aged
90
years.
Ills
house
was for miny
years
a resort
of
the
most
prominent
lawyers,
judges,
and politicians
of
Rhode
Island,
and
was
a
scene of
much original
and
entertaining
talk.
It
stood
on
Benefit
Street,
opposite
the present rectory
of St John's Church.
PLEADWELL
USHEB PAKSOXS.
437
The
following
letter
was
addressed
to Dr. Jacob
Bigelow,13
of
Boston, then professor of materia medica
in Harvard University
:
Palermo, May
8, 1SI9.
A few
days
since, I was
favored
with an introduction
to
the Professor of
Botany
and
Materia
Medica,
and Director of
the Royal Botanical Garden
of
Palermo.
He took
nie
through
the college and
botanical
garden,
and favored
me with
a particular
description
of everything
pertaining
to them.
The col
lege is
a superb
edifice,
enclosed within the walls of
the garden,
and
is fur
nished
with books, prints,
herbariums,
etc. in abundance.
In short,
everything
about
this, as well
as the garden,
bears the impress
of royal
munificence.
On
entering the library,
he handed
me a book and asked
me if I knew
the author,
it was the Flora Bostoniensis
(written
by Dr. Bigelow).
He was much grati
fied with
my reply,
as well
as with
one
of
your
papers
on
the comparative
forwardness
of the seasons,
which I hail taken care
to have in my pocket.
He
observed
that
he had hitherto
been
obliged
to depend on the botanical
gardens
of England for all
his
American
plants,
but
was
now
desirous
of
obtaining
them direct
from
America,
and asked if I would
name his
wishes
to you.
For the last six weeks our squadron
has been
in the harbor
of Messina
about
one hundred
miles
from
this.
My
opportunity
for
acquiring
information of
this
sea has therefore
been very limited.
I have seen the other medical
school
of Sicily, at Catania,
which
is about
as large
and well
conducted
as the
one
at Palermo, there being about eighty
students
in
each.
We sail
to-morrow
for
Naples,
from which I shall
visit Home and Florence,
and return
home through
France and England.
At Palermo, he saw the telescope with which the first of the plan
etoids,
Ceres, was discovered
by Piazzi,14
on the first day of the cen
tury.
He remained
at Naples a few weeks, and writes from there
a
long letter to Mr. John
Pickering,15
of Salem.
Mass.,
in regard to
books he had bought for his correspondent.
He says :
A word respecting
Pompeii,
which I have visited
four times, with increasing
interest each
time.
Excavations are still carried
on, and of all the disclosures
of the city, about one-eighth have been made since I saw it in 1816.
Then there
had been three large excavations,
each something
more than
an
acre in extent,
ranging
in
a direction
obliquely
across
the city,
and distant
from
each other
"Jacob
Bigelow
(1787-1879),
of Massachusetts,
wan one of
the greatest
of
American
botanist*,
the three volumes of his American
Medical
Botany
(1817-1820),
Illustrated with
60 plates and 6.000 colored engravings,
technically
devised by himself,
being
a work of in
ternational
reputation,
and, in America,
approached
only
by
the writings of Barton,
Rat-
nnesqne. Porcher,
and
Asa
Gray.
Bigelow
was visiting
physician
to
the Massachusetts
General
Hospital,
professor
of materia
medica at
Harvard,
and a great
medical
reformer.
Daring
the cholera
epidemic
of
1832
his
wise
sanitary
rulings
limited
the
mortality
in
Boston to
100,
as against
3,000 in New York
City.
His discourse
On Self-limited
Diseases
(1835)
exerted
a powerful
influence
upon medical
practice
in the United
States,
and,
in
tlie words of Doctor
Holmes, did " more than any other work
or essay in our own language
to rescue
the practice
of medicine
from
the
slavery
to
the drugging
system
which
was
a part
of the
inheritance
of the profession."
In
1855
Bigelow
published
an anonymous
volume of clever
poetical
travesties
entitled
" Eolopoesis."
(Garrison.)
"Giuseppe
Plazzl
(1746-1826),
an
Italian
astronomer.
He
became
professor
of
astronomy
and mathematics
at
Palermo
In
1781,
director
of the
new
observatory
there
in
1791. and director of
the
observatory
at
Naples
In
1817.
He
discovered
Ceres
in
January 1, 1801,
and published
star
catalogues
in
1803
and
1814.
"Pickering,
John
(1777-1840).
An
American
philologist,
son of Timothy
Pickering.
He published "Vocabulary
of
Americanisms"
(1816),
a
Greek-English
lexicon
(1826),
and " Remarks
on the Indian
Languages
of North
America,"
1836.
646—22
5
438
Vol. XVII.
PLEADWELL—USHER
PARSONS.
about ten or twelve
rods.
Since that year, streets leading
from
one
excavation
to the other
have
been
cleared
out, with the houses on each side of
them,
so
that you can now walk through
the ancient city and suburbs
a distance
of three-
quarters
of a mile,
on
the same
pavements that
the inhabitants
did two thou
sands years
since.
From Naples, the cruise
was continued along the Barbary
coast
to
Gibraltar,
arriving there in the middle of June.
He there
received
permission from
Commodore
Charles Stewart, dated United
States
ship Franklin,
Gibraltar,
July
15,
1819,
to leave the Guerriere,
on
account of ill health, and " return to America, or make
a trial of the
air of the north of Europe."
He thus writes:
My
reasons
for
leaving
the
squadron
are,
that
the Mediterranean
climate
disagrees with my health,
on account of the heat and confined air of a
berth-
deck ; and secondly, because I am very desirous of making
the tour of Europe
for the purpose
of professional
improvement,
and
do
not expect to meet with
another
opportunity
so
favorable
as
the present;
lastly, I am so exceedingly
tired of the monotonous
scenery of a mnn-o'-war, of the perpetual
jarrings
that
occur,
and
of
the
restrictions
that
nre
imposed
on
'officers,
that
a
change
seemed
desirable
for the health of the mind
as well
as body.
He left Gibraltar July 20, and went
as passenger
to Leghorn.
He
then visited Pisa, in company
with Captain Macdonough.
He jour
neyed
thence
to Lucca
and
Florence.
He
examined
the
medical
institution
in
the
University
of Pisa,
and
took
great
delight
in
anatomical
preparations
in wax
at Florence.
He thence
went
by
carriage to Rome,
and there passed some days, visiting the hospitals
as well
as the
objects
of
general
interest.16
From
Rome
he
em
barked,
September
6, in a small schooner for Leghorn, having
only
"the hard
deck for a feather bed
and
without
any covering;
nor
would any other have been of service,
on account of the millions of
fleas in the vessel."
The
voyage
along the Tuscan
shore
was very
uncomfortable.
At
a small
unnamed
port, "was
called
on to
see
an
aged
female
afflicted
with
partial
blindness,
and
another
with
fever.
A jolly old bacchanalian is physician to about twenty soldiers
who are stationed
here,
and
to the few inhabitants.
He professed
great
veneration
for
the
Brunonian
system of
medicine,
and
his
bloated
face indicated the sincerity of his faith, though his apparel
gave him
the
appearance
of
a
Shakspeare's
apothecary."
He
ar
rived in Leghorn
September
10.
He then journeyed through Genoa, Nice, Aix, Avignon, and Lyons
to Paris, arriving there September
29.
He thus writes to Dr. Lyman
Spalding:
17
" Little
of interest
appears in his
notes written
at Rome, except the following : " The
present season a steamboat, with appropriate
machinery,
was ploughing
up the
bed of the
Tiber,
but I did not learn
that anything
was found."
" Spalding,
Lyman
(1775-1821).
Originator of the U.
S. Pharmacopoeia.
So. 3.
439
PLEADWELL
USHER
PARSONS.
Paris,
November
29.
Having
been
pretty
busily
engaged for
two
or
three
months
!n
attending
hospitals and medical
schools. I have thought it probable you might
feel
some
curiosity
to know
how I have found
them.
These
establishments
are
so nu
merous
and employ
so many
lecturers
and professors
that
a stranger
at first
sizht would
believe the attention
of the whole city
is directed
toward
them.
I
have attended
the lectures
of some
whose names are familiar
to you. particu
larly Dubois. Boyer.
Dupuytren,
'Kicherand,
Alibert and Larrey
on
surgery, —
Vaaquelin,
Chaptal,
Gay Lussac,
Tnenard
and Abb6 Hauy on chemistry.
It is
difficult to determine
which
surgeon
to rank first,
Dubois, Boyer or Dupuytren.
The two first are older and consequently
more experienced,
but Dupuytren
has
h*en at the head of Hotel
Dieu for several years, and during
the time has per
formed
more operations
than all the other surgeons in Paris.
I am willing to
acknowledge
him
the
best
operator
I
have
yet
seen,
although
I think
very
highly of the other
two
and of Larrey.
•
«
*
Larrey
is
surgeon
of
the
hospital of the king's
guards,
which
is but
a small
establishment.
An opinion
prejudicial
to
him
prevails,
that
he is too fond of cutting —that
he
has fre
quently
amputated
where
it was
not necessary.
Medical
gentlemen
are
per
mitted
to
see his patients
every Thursday, when
he gives
a particular
history
of every case,
and performs
some operations.
The last time I was there, I took
the liberty of introducing
myself
to him, which
he gave me
no reason to regret
doing;
he
inquired
about
hospitals
in
the
United
States.
I
have
found
the
people here very ignorant
of the state of medical science with us, and yet very
Asirous to be better
informed.
This circumstance
has induced
me
to
supply
one of the journals with a short description
of our contemplated
Dispensatory.
I have had the honor of becoming acquainted
with Drs.
Swediaur,
Pinel and
Cuvier.
The two former are very advanced in life, and the latter
is now turning
politician.
In another
place he writes :
Cnvler
has exchanged natural history
for politics;
he has lately
been erected
a peer, and is a leading ultra royalist,
as well
as a noisy one.
The liberals
have
enrolled
his name in the list of political
weathercocks,
or among those who have
turned
at every
change of government
In France.
Cuvier
still holds
a profes
sorship,
and
continues
his
residence
In
the
Garden
of Plants,
and
gives
a
weekly
levee
in
imitation
of Sir
Joseph
Banks,
to
which
all
strangers
are
invited.
Sir Humphrey
Davy
passed
through
here
not
long
since,
on
his
way
to
Naples,
to unroll
the Herculaneum
manuscripts.
While here he examined
the
chemical
laboratory, with other
things
connected with his
scientific
pursuits
;
hut Englishmnnlike.
as
the French
say,
he
turned
up his
nose
at
everything.
Every
object they
offered for his inspection,
he considered
as unimportant,
or
said it was borrowed
from England.
The following; are extracts
from his notebook,
entitled, " Surgical
notes and observations
made in different cities in Europe, particularly
in Paris and London,"
in which he gives short accounts of hospitals
and medical
schools
in Palermo,
Messina.
Xaples,
Florence.
Pisa,
Genoa and Nice :
U Charite
(Paris;
October 13).
Went
through
the wards
with Boyer,
his
"on-in-law,
Itoux,
and about thirty students.
Saw
nothing
hut bad ulcers and
those badly
managed.
The
French
surgeons-
are
neither
neat,
scientific
nor
440
Vol. XVII.
PLEADWELL
USHER PARSONS.
successful
in their treatment
of ulcers,
wounds,
etc.
They
rarely
attempt
to
heal
by the first intention
; even
in amputations
below the knee,
the first
sur
geons
are In the habit of stuffing
the stump with lint to prevent its closing
by
the approximation
of the skin of
the
sides.
This
practice
is condemned
in
England
and
must ere long
be In France.
In regard
to inhumanity
and
dis
regard
of life, and
the practice
of poulticing
inflamed
limbs,
he also
severely
criticises
the hospital
surgeons of Paris.
Larrey's
manner
of operating
Is pleasing.
He uses the knife adroitly
and
gracefully,
and is neat in his dressings.
He is humane and solacing
in his
be
havior
to
the patients,
differing in this respect
very
much
from
Dupuytren,
whose behavior
to
them is savage.
This
is the more
remarkable
when it is
considered
that
D.
has always
been in civil
life,
while L. has always
been In
military practice
where sympathy
and fine sensibilities
are less known.
Their
stature
is much alike,
both being very
stout
and very
stately
in their
appear
ance.
I,arrey is very ready and pertinent
in his remarks.
November
11.
Went
early
to the hospital
Salpetriere
to attend
the physician
in
his
rounds.
Enquired for M. Pinel, who
is physician-in-chief
and at
the
head of the institution, and sent in to him
my address, with a request that I
might accompany
him through
the hospital.
He invited me into his study,
and
after some enquiries
about American
hospitals,
etc. we made a tour first through
three large
wards
full of women
past sixty years of
age,
and
who
were ill.
After
prescribing
for
these,
we
visited
the lunatic apartments
in which
are
women
in
every
state of mental
disorder,
from slight melancholy
to furious
mania.
Those of the latter description
were many of them chained, and others
shut up in prisons.
*
*
*
• I found
in this instance,
that
introducing
myself
to the professor
had as good If not better effect than a letter would
have had.
He bought many medical books and instruments in Paris.
Among
these was Laennec's
treatise on auscultation, with a stethoscope of the
original
pattern, now a curiosity of medical history,
and
certified
to have been " examined
and used by Laennec"
Among other acquaintances
formed in Paris was that of a genial
and accomplished
Englishman,
Mr. William Clift, a pupil and con
nection
of the great British physiologist
and surgeon, John Hunter.
This acquaintance,
renewed in London, ripened into a lifelong friend
ship with Mr. Clift and his family,
including
his son-in-law.
Prof.
Eichard Owen, the eminent
comparative anatomist.
These
friends
corresponded
with Doctor Parsons for many
years,
and their kind
ness was continued to his relatives and
to visitors whom he
some
times introduced to them by letter.
He
went
from Paris to London, arriving there
December
4, and
remaining till Christmas.
In those three weeks he became acquainted
with many of the most eminent
surgeons
and savants of London — Sir
Astley
Cooper, Abernethy,
and
others.
He
attended
the levee
of
Sir
Joseph
Banks.
He
breakfasted with Sir Astley
Cooper, but
found him pressed with business.
He gave considerable
attention
to
the Hunterian
Museum at the college of surgeons
and contemplated
the formation of a museum of anatomy
founded on a principle sug
gested to him there, viz, that of bringing
together specimens
of cor
responding organs
and
sets of organs from
as many
as possible of
So. 3.
441
PLEADWELL
USHER
PARSONS.
the different classes and orders of the animal kingdom.
He attended
two meetings of the Royal
Society.
Besides
the usual
sightseeing,
he saw Kean play Hamlet at Drury Lane and heard
a debate in the
House of Lords,
by Russell, Castlereagh, and others,
on the subject
of " rotten boroughs " and
the expediency
of admitting
representa
tion
from
large manufacturing
towns
in
the House of Commons.
The following
extracts are from his diary in London
:
December
9. Examined
the Museum
of the College of Surgeons.
This collec
tion is calculated
for physiological
purjioses
alone.
Every organ of the animal
.machine
Is exhibited
in
as
great
a variety
of animals
as
they
have hitherto
been
able
to
collect.
The
separate
organs
are
preserved
in
spirit
and
are
arranged
from
those of the most simple
to
those of the most complex
struc
ture.
The
museum
begins
with
the simple
muscular
fibre,
rectilinear
;
then
follow single and double penniform
muscles, sphincters,
etc.
Then
the organs
of digestion
and assimilation,
beginning
with the stomachs of all sorts
of ani
mals; then the various
organs of mastication,
etc.
etc.
20. Went to St. Bartholomew's,
and heard Mr. Abernethy
lecture
on organic
diseases
of the heart
to about three hundred
pupils,
the most interesting
lecture
1 almost
ever
heard.
His
manner
is
peculiar,
and
the
most
engaging
and
amusing as well as impressive I ever heard.
Dr. Mason, of New York, makes
somewhat such
a figure
in the pulpit
as Mr. Abernethy
does
here.
He
is full
ot illustrative
anecdotes which
he tells
with
such a qunintness
as to make
one
laugh.
He is about fifty
years
old, of middle
stature,
head powdered,
dressed
in black.
He sailed from Liverpool
December
28, in
a merchant
vessel, and
reached Boston early in
1820.
He was
ordered
in May to service
ut
the Marine
Barracks
in Charlestown.
While holding
this
ap
pointment,
he
resided
much
of
the
time
at
Cambridge,
enjoying
opportunities
of study
and mingling
in the learned
society of that
place.
It was at this time, and through the influence of acquaintances
pained
in Cambridge, that he realized
his youthful
dream of being
appointed
teacher of anatomy,
which he appears
never to have given
up since
the year 1809.
In August,
1820,
he
was chosen professor
of anatomy
and
surgery in Dartmouth
College.
He
wrote
at
the
time: "Dr. Parsons's
motive
for engaging in lecturing
is
a desire
to establish
a museum of anatomy,
human
and comparative, on the
plan
of
the
late
John
Hunter's."
He
contributed
a
number of
preparations,
some of them in wax. which he had bought in his last
visit to Europe.
But he lectured
there only one year.18
1SMarine
Barracks,
Charleston,
Mass.,
October
9th,
into.
Sir:
In reply to the enquiry
whether
It
be my determination
to resign
my
commission
&£surgeon
in ttie Navy,
in consequence of having
received an appointment
as professor
in
Dartmouth
College, I have to observe;
that
said appointment
has
not yet been
accepted,
»nd that it
is
my
purjtose
(the
department
being
willing)
to
continue
in
duty
in
my
present situation
another
year, or till
one uttempt
more shall
have been
made
in Congress
to Improve tie Condition
of Navy
Surgeons.
I have the honor
to be.
Very respect.'
Tour
obed' servant,
I'sheb
Parsons.
Hon.« Seceetabt
of the Navy.
442
Vol. XVII.
PLEADWELL
USHER
PARSONS.
At this time,
he published at Cambridge the Sailors Physician,
a
medical
guide for
use
on merchant
vessels.
This
was
extensively
sold;
changed
its name to that of Physician
for Ships, and passed
through
five
editions, undergoing
various
revisions
and
improve
ments.
The
four
subsequent
editions appeared
in
the years
1824.
1842,
1851,
and
1867.19
In December,
1820,
he left Boston to visit the medical
schools
of
New York, Philadelphia,
and Baltimore.
He heard
lectures
from
Doctors Hosack, Post, Francis, and Mott in New York, and Physick,
Chapman,
and
others
in Philadelphia.
A fragment of diary
still
preserved
shows
his views
of
these
eminent
professors.
He intro
duced himself
to them
as surgeon
in the Navy.
His
observations
show that he was intent on preparing himself for anatomical teach
ing.
The following
extract may be worth presenting:
December
31.
Breakfasted
with
Dr.
Hosack.
Examined
his
anatomical
museum, which
is small.
His study is an octagon with a dome of light,
and
is
filled
With
n choice and very
large
collection
of books.
He
has
a very
small
private
study
for the
reception
of patients.
In
this
he
has
a
small
library.
On
one of the shelves is an elegant volume of Thomas's
Practice,
dedicated
to
Hosack,
which I had
heard ho always
took pleasure
in showing;
and to gratify
his humor,
1 anticipated
his putting
it into
my hands
by
taking
it down
and
asking
what work
it was.
I at once
saw what I had often heard,
that he took
a heartfelt
satisfaction
in perching
upon tins book to crow.
In April,
1822. Doctor Parsons began his long residence in Provi
dence.
He
was for
a while partner
in
medical
practice
with Dr.
Levi
Wheaton.
He married, September
23, Mary Jackson
Holme",
daughter of Rev. Abiel Holmes. D. D., of Cambridge. Mass., author
of The Annals
of America.
She
died June
14,
182">.
leaving
one
son.
In April.
1823, he resigned
his commission
in the Navy.
• A plan of giving
lectures
in Brown University,
which had failed
in 1817. was resumed in 1822.
A medical
school then existed
at this
institution, and Doctor Parsons was appointed professor of anatomy
and surgery.2"
Beside
lecturing
to the medical
students,
he gave
a
">Two
editions
of
this
work
have
been
found
In
the
Naval
Medical
School
Library,
with
titles
as follows
:
Parsons,
Usher,
M.
D.
Fellow
of
the
Massachusetts
and
Rhode
Island
Medical
So
cieties, and formerly
Surgeon of
the
U.
S. Navy.
The
Sailor's
Physician,
containing
Advice
for
Seamen
and
Other
Persons
at
Sea,
on
the Treatment
of Disease and
on the Preservation
of Health
in Sickly
Climates.
Second
Edition.
Providence:
Printed
by
Barnum
Field
& Co.
1824.
Parsons,
Usher,
M.
D.
Late
Surgeon
in
the U.
S.
Navy,
and
President
of
I he
Khode
Island
Medical
Society ; Honorary
member
of the Massachusetts,
New Jersey,
Philadelphia
and
South
Carolina
Medical
Societies.
Physician
for
Ships,
containing
medical
advice for
seamen
and
Other
Persons
at
Sea.
on the Treatment
of Diseases,
and
on the Preservation
of Health
in Sickly
Climates,
and
also in California.
Boston
: Printed by Damrell
& Moor,
No.
16 Devonshire
St.,
1851.
10His
associates were Drs. Levi Wheaton, professor of theory and practice
of physic
and
obstetrics;
John
De
Wolf,
professor
of chemistry;
Solomon
Drowne,
professor
of materia
medka
and botany.
Wheaton
was a pioneer physician
of Providence,
horn there
in
1761.
No. 3.
443
PLEADWELL—USHER PARSONS.
short
annual
course
to
the
higher
classes of undergraduates.
In
1826 he published an introductory
lecture on anatomy
and physiology
as branches of general
education.
The policy of President Wayland
*
requiring
the officers of instruction
to be also
officers of discipline
and
give their
whole time to collegiate duties
necessarily
severed
his connection
with the university.
His special
interest in anatomy,
awakened
in his youth by the lectures
of Doctor Ramsay, continued
through his whole
active life.
In 1831 he published at Philadelphia
a
volume,
mostly
compiled,
on
the
Art
of
Making
Anatomical
Preparations.
From
the
time of the
death of his wife until the year
1831
he
boarded at McClellan's.
In
1832
he built a one-story
office
of three
rooms on
President,
now Waterman
Street.
This
he
afterwards
enlarged
and
occupied
until
hi9 death.
Until the marriage of his
son in
1853
he had
no
home
establishment,
but took his meals
at
hotels
or boarding houses, and generally slept in his office.
He liked
the freedom of this way of living.
During the last
15 years of his
life he had
a home with his son.
He rose gradually
to
a very prominent
rank
in his profession.
Besides his varied opportunities,
which brought
him to the
begin
ning of civil practice with more than usual experience
and resources,
he had many qualities of body
and mind that fitted him for medical
life.
He was
robust,
with
uncommon
powers of endurance,
and
a
frame
strengthened
by
labor
in early
life.
He
was
industrious,
persevering, ambitious, and social
; faithful in attendance,
and
con
siderate in his charges.
His
early training in naval
service,
and
the predominance
of the reflective
powers,
fitted him rather for the
office of consulting physician, and for cases of exceptional difficulty,
than for the ordinary
run of daily
medical practice.
He had
not
that easy tact, that quickness
of thought and
command
of language
and features
which were conspicuous
in some of his contemporaries.
Yet in many families of refinement
and education his acquirements
were
appreciated
and
his ready sympathies
and
sound
judgment
made
him
a trusted adviser
and
friend.
As consulting
physican
and surgeon he was very widely known in Rhode Island and in neigh
boring parts of other States.
For many years
a large part of his
practice
was out of Providence.
He was
a fast driver; and,
before
the railroads were multiplied, his sulky was well known on the roads
leading
from Providence in all directions.
He served
as
a surgeon of
a
privateer
In
1782,
and
being
captured
by the British
was
detained a prisoner
in New York, where
he was put in charge of the prison
ship Falmouth.
When the Brown
University Medical
School
was orRantzed
in
1812,
Doctor
Wheaton
be
came professor of medicine
in
that institution.
He
was
a sound
practical
physician,
a
Oneclassical scholar,
and a writer of ability.
He died In Providence
in the year
1851.
444
Vol. XVII.
PLEADWELL
USHER
PARSONS.
His naval experience
had turned his attention particularly
to sur
gery.
In European
hospitals he
appears
to have
observed
surgical
* cases
almost
exclusively.
As an operator
he was more marked
for
caution
than
dexterity,
and
was
particularly
methodical
in
the
preparation
and
arrangement
of
instruments
and
dressings.
He
used to point out
a house in Smithfield
where
he first operated for
strangulated hernia in 1823.
Being little acquainted
with
the oper
ation, he studied it up, perhaps,
in Scarpa's treatise,
which he had
bought
in Paris, while
the
messenger
was
conveying
him
to
the
house.
In the American Journal of Medical
Sciences,
1848,
he pub
lished
a summary of his large surgical
operations.
He reports
15
cases of herniotomy, with
11 recoveries.
He performed lithotomy only
once and successfully on a patient in Apponaug,
aged 74 years.
He
tied the common
carotid artery for a supposed
tumor in the brain,
producing
intense headache
and total blindness ; the symptoms were
relieved,
but returned and ended in death.
He extirpated the eye
ball, with
the lachrymal
gland
and
much
of the other textures
in
the orbit,
as was then
the common
practice,
instead
of
the milder
process of enucleation.
He
operated
frequently
for cataract.
He
was at one time
much
interested
in the surgical
treatment of
de
formities
and performed
tenotomy
often.
He contrived and
used
with fair success an apparatus for securing a union in cases of cleft
palate.
It was only in the latter part of his professional career
that
he
enjoyed
the advantages of etherization in surgery.
He never became
so fully at home with it as the later generation
of surgeons.
In the
greater part of his operations the only anaesthetics at his command
were
such
as laudanum
and
brandy
and
words of
encouragement
and
sympathy.
While in
active
practice
he
gave
a great
deal of
attention to private
pupils
in
medicine,
having often
several
at
a
time and more than 50 in all.
He very commonly
had private
dis
secting
classes in the winter.
After
becoming
well established
in practice,
Doctor Parsons
al
lowed himself
more liberty
in regard to
absence from Providence
than is usual with equally busy physicians.
In the autumn
of 1843
he visited Europe
for the third time,
contemplating
a journey
to
Egypt, but going no farther than Paris,
where his son was studying
medicine.
He spent some days in London
on his outward journey,
renewing his acquaintance
with Mr. Clift and attending
a meeting
of
the Geological
Society, where
he
saw Doctor
Buckland,
whose
Bridgewater
Treatise he had read with great
interest.
In Paris he
frequented
the hospitals and took copious
notes of surgical
cases,
as
he had done 24 years earlier.
A few
extracts
from his diary show
the character of his observations
:
There
is to my
mind
an unaccountable
aversion
on the part
of French
sur
geons
to attempt uniting wounds
after
operations,
by the first
intention.
To
No. 3.
445
PLEADWELL
USHER
PARSONS.
clay,
the flaps made
in the amputation
might
have
been
brought
together,
a
depending opening left, and the whole
or nearly
all the wound
closed- ; instead
>f which
the
old
system in vogue
twenty -three
years
ago Is
continued,
of
itufling
the wound with charpie
or lint.
There is in French surgeons an indifference
to life that seems
inhuman.
They
operate when they
should not; when they
must
know
that the advantages
to
be gained are not to be compared with 'the risk of life, and the certain
amount
of severe pain that must be suffered from
the operation.
He bought
several
valuable instruments and anatomical prepara
tions in Paris.
He
also
bought
a copy
of Josephus,
printed
by
Schussler
at Augsburg,
1470 ; " and the Annals of the World's His
tory, printed by Walch at Venice, 1479, and adorned with woodcuts
representing
the Tower of Babel, Nineveh, Solomon's Temple,
etc.
He
was
in Paris from November
19,
1843, till February
19,
1844,
when he set out for London.
He there received polite attentions from
Mr. Richard
Owen, Bransby
Cooper, Mr. South, Dr. John
Forbes,
and
other
distinguished
surgeons
and
men of science;
visited
the
largest hospitals, and attended
a meeting
of the Royal Society.
He
left London March
8 for Liverpool,
Glasgow, and Edinburgh.
Re
turning
to Liverpool he there
passed several
days in the agreeable
society of some old American friends and sailed April 4, bearing dis
patches from the minister, Mr. Everett.
He arrived in Providence
April 22, 1844.
Doctor Parsons joined the Rhode Island Medical Society in 1823.
In 1837 he was elected president of the society for three years, with
out having passed through the usual
stages of vice presidency.
He
was
a constant
attendant at its meetings,
and contributed
several
papers
to its transactions.
These
were mostly on strictly
medical
subjects.
One had a semihistorical character.
In 1859 a committee
was appointed to prepare sketches of eminent
deceased physicians
of Rhode
Island;
and
Doctor
Parsons,
as its chairman, compiled
from various sources a pamphlet on this subject.
It contains notices
of nearly
40 physicians
who lived
on the island of Rhode Island,
mostly in Newport;
of the Bowens and
others
in Providence,
and
the north part of the State
; and longer articles,
contributed by other
writers to the chairman, on Doctors Levi Wheaton, Solomon Drowne,
Peter
and William Turner,
Charles Eldredge, Edmund T. Waring,
find David King, all deceased.
His latest printed- communication to this society
was
a " Letter on
some points of military surgery," read December
19, 1860; and
re
citing some of his experience
on the Great Lakes.
This paper would
appear to have been suggested by anticipation of the Civil War.
"Beloe,
William:
Anecdotes
of Literature
and
Scarce
Books,
1810,
Vol.
IV.
p.
109.
"This is a very
rare and very curious
book
•
•
*
in Gothic
characters
•
•
•
the
first printed
by
Schussler.
(P. L. P.)
446
Vol. XVII.
PLEADWELL— USHEE PARSONS.
When the American Medical Association
was organized in Phila
delphia in 1847, Doctor Parsons was present
as delegate, and took an
active
part.
In writing of the receptions
then
held,
he says: "It
was gratifying to me
to find whenever I introduced myself to any
stranger,—which I did
a
dozen
times
this
evening, —as Dr. Par
sons of Ehode
Island,
they all called
me at once by my christian
name, having
read
of my
writings
through
journals."
For
many
years
he attended
the annual
meetings
of this
association,
succes
sively in Baltimore, Boston, Cincinnati,
Charleston, Richmond,
.New
York, St. Louis, and Philadelphia.
In 1848 he was appointed chair
man of a committee
on adulterated drugs ; and, in 1849, chairman of
the committee
on medical sciences.
His report on this last subject
contains a summary of the " progress
of American
medicine
during
the year."
In 1853, at New York, he was elected first vice president.
In 1854, at St. Louis, he acted in the place of president at the early
part of the meeting,
and
as such delivered
the opening address; the
president,
Dr.
Jonathan
Knight, of New Haven,
being unable
to
attend.
He was honorary
member
of the medical
societies of Massachu
setts, Connecticut, New Jersey, and South Carolina.
Doctor
Parsons
was
an industrious
writer
on professional
sub
jects.
He wrote frequently for the premiums instituted
by Ward
N. Boylston,
Esq., of Massachusetts,
and awarded by
a committee
appointed by the corporation of Harvard University
for
disserta
tions on " medical,
anatomical, physiological,
and chymical subjects."
Four of these prizes were awarded to him, viz, for dissertations on
periostitis, 1827; on eneuresis irritata, 1828; on "The connection
be
tween
cutaneous
diseases which are not contagious
and
the internal
organs," 1830 ; and on cancer of the breast,
1835.
The other subject
proposed
for the year 1830 was the comparative
influence of animal and vegetable
decomposition
in producing
fever.
The premium for the best dissertation on this subject
was awarded
to Dr. Charles Caldwell, of Kentucky; but Doctor Parsons's
essay
on the subject
was highly praised by the committee,
with
a wish that
it might be published and its author's name made known.
He also
received
the Fiske Fund premium in Rhode Island in
1842 for an
essay
on
spinal
diseases.
These
six
papers
were
published
in
a
volume.
He
contributed
numerous
articles
to
different
medical
journals.
In 1831 he was appointed professor of obstetrics
in Jefferson Medi
cal College, Philadelphia,
and
lectured
there
the following winter.
Some valuable models for illustrating these lectures
were lost at sea,
on their way to Philadelphia.
The subject
was one for which his
experience
had not particularly
qualified him.
He did
not after
No. 3.
447
PLEADWKLL- —TJSHEK
PARSONS.
ward
accept any appointment which
would
require him
to
reside
away from Providence.
Doctor Parsons had long been impressed
with the need of a gen
eral hospital
in Providence and he played a prominent part in secur
ing a State charter for this institution
and in obtaining bequests for
its support.
When the Khode Island Hospital was organized he gave $1,000
to
it.
He followed the progress
of the undertaking with great interest,
though
he had then
withdrawn
from
medical practice.
He
gave
about 300 volumes
to its library and bequeathed
it
$100 by will.
He
was at first appointed at the head of its consulting staff.
Doctor
Parsons
had
too
active
a
mind to
rest
satisfied
with
the
knowledge required for everyday
medical
practice.
He investigated
many subjects
more or less connected
with his professional
studies.
When the doctrine called phrenology was presented in Boston, graced
by
the zeal and eloquence of Spurzheim, Doctor Parsons gave much
attention to it.
Dr. Jonathan
Barber gave
a
course of phrenological
lectures in Providence
;
and Doctor Parsons followed him in a short
course, illustrat«d by many
crania and models, describing the anat
omy of the brain
and concurring in the general
principles of phre
nology, but opposing the extravagant claims of the so-called
science.
In 1837 he obtained
a
charter for the Rhode Island
Natural His
tory Society, of which he was chosen the first president.
It held sev
eral meetings and made some collections,
but never attained the posi
tion of
a
working scientific society.
He kept up the practice of col
lecting
specimens.
He purchased
and read
the geological works of
Buckland,
Hitchcock,
and others.
He had some knowledge of field
botany,
and occasionally gave private
courses of botanical lectures
to classes of young ladies.
In
1831
he prepared
an
address
on
temperance,
which
he
de
livered
in Providence
and
other
places,
and which
was afterwards
published.
In
1840
he lectured
before
the American
Institute
of
Instruction,
at
its
meeting
in Providence,
on
the
connection
and
reciprocal influence
of the brain
and
stomach.
In this
as in other
addresses
partaking
of
a
physiological
character,
he dwelt
much
on the doctrines
of Bichat, whose treatise,
" Sur la Vie et la Mort,"
had made
a
great
impression
on his mind, and
was habitually
rec
ommended by him to his medical
pupils.
His reading on subjects
not
connected
with physical
science was
mostly
in works of history
and travel.
He took little
interest
in
purely
imaginative literature.
He read
few of the classical
novels.
A
special interest in the
remains
of Pompeii,
which
he had care
fully examined
when cruising on the Mediterranean, led him to buy
and
read Bulwer's Last Days of Pompeii.
In poetry, his favorites
were Thomson and Young.
He often read through the " Seasons "
448
Vol. XVII.
PLEADWELL
USHER PARSONS.
as
the
seasons
came
around,
and
was
equally
familiar
with
the
" Night Thoughts."
He selected the opening lines of this poem for
his son
to speak
at
a school
declamation
when
less than
10 years
old ; and it will
be readily
believed
that they
were
not very intelli
gently or impressively
uttered.
He was
also
a regular
reader
of
the
Bible.
Besides
frequent
recurrence
to
certain
favorite
parts,
especially in the Psalms, he read
through the Bible, with
probably
some omissions,
four times in the last 30 years of his life.
He thus
wrote in his notebook
November, 1837 :
I have this day
finished
the
Old
Testament,
which I began
in
June
1837.
I cannot
but think that
the Christian
religion
would
gain
by excluding
some
of the books.
Two-thirds of what
follows the first
chapter
of Jeremiah
might
be omitted,
and all of Solomon's
Song.
These writings of the Prophets
might
be
transferred
to
the Apocrypha,
or
incorporated
into
a
separate
division
of
the
Bible,
and
considered
as elegies
on
the
woes prepared
by
Divine
Power
to bring upon this ill-fated people the Jews.
The Bible,
after such an exclu
sion,
would
be
read
more
generally,
intelligibly
and
thoroughly,
than
It
Is
while encumbered with such a mass of matter
so irrelevant to subsequent
ages
of the world.
As
a rule of life, and
a history of God's
government
and
the
plan of salvation,
an abridged
volume
might
be formed for general
circulation,
which
would
embrace
all
that
is
essential.
I shall
now
commence
reading
Tyndall's New Testament with notes.
His ecclesiastical
relations were peculiar.
He was brought up in
congregational worship
and the faith of the Puritans.22
Soon after
his marriage he was admitted
to the Episcopal
communion at
St.
John's Church.
In later years he had
a seat in one place of worship
after
another—St. John's,
the First Baptist,
St.
Stephen's
(now
Church of the Saviour),
and
the Central
Congregational
Church.
For the last
12 years
of his life the latter was his usual
place
of
attendance
on Sundays
and
the only
one
where
he owned
a
pew,
though he frequently
partook
of the communion of the Episcopal
Church.
He often went to other churches,
especially the Unitarian,
under the ministry of Dr. Edward B. Hall, whose preaching he much
admired.
After hearing him on Thanksgiving
Day, 1853, he wrote in
his notebook
: " I wish he and other Unitarians
would follow after
St. Paul's
example
and
preach
a little more
about Christ and Him
crucified.
At the
same time, I wish orthodox would
preach
more
practical
sermons
and
not
be forever
harping
on
particular
doc
trines of the Calvinistic order."
In his busiest
years of practice he
was remarkably regular in attending church once or twice on Sunday.
He seldom took an active part in politics.
He voted with the Whig
Party in its day.
The nomination of General Harrison for President
awakened
a special
interest in him on account of the general's
con-
" His grandfather,
the minister
of Bradford, was suspected of Armlnlanlsm.
Whether
any traditionary
influence
Inherited
from
him
softened
the rigor of Calrlnistlc
belief
In
the family of his
son William
is
not known.
So. 3.
PLEADWELL
USHER
PARSONS.
449
nection with Commodore Perry and the service on Lake Erie.
Doctor
Parsons wrote several newspaper articles in favor of Harrison which
were widely reprinted and spoke on the same subject in the old town
hohse October
19,
1840.
He was appointed messenger
to carry
the
electoral vote of Rhode Island to Washington and handed the package
of votes to Vice President Richard M. Johnson.
When the suffrage
troubles arose in Rhode Island he did not share in the attachment
felt
by many
natives of this State to the charter of
1663,
and his sym
pathies were with the movement for enlarged
suffrage.
Mr. Thomas
W. Dorr23 was his intimate friend.
But when
the affair took on
a
revolutionary character he rallied
to the support of the existing gov
ernment.
He acted
as volunteer surgeon
of
the marine artillery.
The subsequent imprisonment of Mr. Dorr was exceedingly
distasteful
to him.
He exerted himself to procure his release by circulating
peti
tions,
etc. ; but his course did not suit the uncompromising
views of
Mr. Dorr, and was unavailing.
Immediately after the passage of the
act of liberation he visited Mr. Dorr as physician and friend.
On
the outbreak of Civil
War.
in
1861, he offered
his services
as
surgeon, in
a letter to Governor
Sprague.
He
was
commissioned,
in June. 1861, surgeon of the Providence Horse Guards.
He followed
the various fortunes of the conflict with intense interest.
At the time
of the presidential election
in 1868, his last illness had begun; he had
been confined
to the house
16 days, and walked with difficulty.
The
warden
came down from the wardroom,
and met him in the lower
entry, where a chair had
been arranged, and he gave his last vote for
Grunt and Colfax.
From
an early age he was interested
in tracing
the history
and
genealogy
of his family.
Till the year 1834 he did not correctly fol
low up the line beyond his great-grandfather.
Rev. Joseph Parsons,
of Salisbury.
In that year, he carried on a lively correspondence
with
the eminent
antiquary of Northampton,
Sylvester Judd, Esq.
Mr.
Judd's
valuable letters
helped
him
to
connect
Joseph
Parsons, of
Salisbury, with the first Joseph, of Springfield,
and the second Joseph,
of Northampton.
He explored old graveyards, old records,
and all
written sources of genealogical lore.
He visited the towns where his
ancestors had lived, talked with
the old men of those
places,
and
treasured up the knowledge he had learned from their trembling lips.
A manuscript
book
is still preserved,
in which he wrote out the his
tory of the families of Parsons. Frost, Usher, etc., with
sketches of
the
lives of individuals,
and
preserved
autographs of
many.
In
1838. he printed on a sheet an outline of the " Genealogy
of the fam
ily
of Joseph Parsons."
"The leader of the so-called
Dorr's
rebellion,
in
the year
1842,
450
Vol. XVII.
PLEADWELL
USHER
PARSONS.
In 1849, he prepared a somewhat
elaborate memoir of Maj. Charles
Frost,
his great-great-grandfather,
who
was
a
man
of
some
im
portance
in civil and military affairs, and was killed by the Indians
in Kittery, now Elliot, July 4, 1697.
This was published in the New
England
Historical and Genealogical Kegister, July,
1849.
It was
founded on materials drawn from old manuscripts obtained in Maine,
especially the voluminous
papers
left
by
Frost's
son-in-law,
Capt.
John Hill, who commanded
Fort Mary, at Saco, from
1693 to
1700.
It contains,
from the original in his possession, the account of Major
Frost's
death,
written
to Captain Hill by Joseph
Storer,
who
was
another
son-in-law
of Major
Frost.
Doctor
Parsons
afterwards
prepared a genealogy
of the Frost family,
and
an account of " the
descendants of Peter Hill, of York County. Maine, with some inci
dents relating to the French and Indian wars," founded on the same
Hill papers.
His
most
important
literary
undertaking,
the
" Life
of
Sir
William Pepperrell,"
sprang originally out of his genealogical
stud
ies.
He
began
to prepare
for this
task
in the year
1846.
but sus
pended
it on
learning
that Pepperrell's
life would
be written
by
others.
The principal
exploit of Pepperrell.
in heading
the attack
on the French fortified town of Louisburg,
in 1745,
and reducing it
after
a siege of 48 days,
had
been fully
described
by Belknap
and
other
historians.
But
no extended
memoir of Pepperrell
had
been
published.
Rev. Dr. Charles Burroughs, of Portsmouth, N. H., and
Hon.
Lorenzo
Sabine, of Framingham,
Mass.,
had
both
prepared
sketches of his life.
A connection
of the family.
Col. George
Spar-
hawk, of Kittery, where Pepperrell's
mansion still stood, had talked
of writing his biography,
and
was known to have
a great many of
his papers,
which had lain
neglected
in a shed or fish house on the
estate, till Colonel Sparhawk
selected and arranged the more valu
able documents.
It was after correspondence
with
these gentlemen
and
many
others
that Doctor Parsons
determined
to carry out the
undertaking.
He
read
the State
and local histories bearing on his
subject,
examined
the papers in the Massachusetts
Historical Society
and other public
places
of
deposit,
and
procured documents
from
all available sources.
The Sparhawk
papers, after some negotiation,
reached his hands in January,
1851, through the kind
offices of Mr.
John Blunt, of New York.
For four years after that he gave much
of his leisure
to this work.
Not satisfied
with studying the details of Pepperrell's
career in its
written and printed records,
Doctor Parsons visited the harbor and
ruins of Louisburg
in August,
1852, in company
with his nephew,
Edwin Parsons, Esq., of New York.
They took the English steamer
from
Boston
to Halifax,
and
then
a small
steamboat
to
Sidney,
Xo. 3.
451
PLEADWRLL
USHER
PARSONS.
driving thence
to Louisburg.
An account of his observations
there
is given in the Life of Pepperrell.
At the beginning of the year
1855, his book
was essentially com
pleted, and had
been submitted
to the friendly
criticism of several
historical
scholars,
especially
Hon. Mr.
Sabine,
before
mentioned,
and J. Wingate Thornton, Esq., of Boston.
It was published in May.
It was very favorably
received
by students of colonial history, both
in America
and
England,
and was kindly
noticed
and
sompwhat
copiously
analyzed in the leading newspapers
and magazines
of this
country, and in the London
Athenseum.
The
subject
being,
ante-
revolutionary,
was
interesting
both
in
the mother country,
where
several
descendants
of Pepperrell
still lived,
and
in America.
It
was republished
in London in 1856.
Most of the reviews
of this book consist mainly of an analysis of
its contents, and are hardly fitted for mention
here.
The following
few sentences
from
a discourse
delivered before
the Rhode Island
Historical
Society, by
its
president,
Hon.
Samuel
G. Arnold, the
author
of the History of Rhode Island,
give
one a very good
idea
of contemporary
opinion
on this work :
This
work
is
a
very
important
contribution
to
our
colonial
history.
The
conqueror
of Louisburg was
one
of
the
foremost
men
that
America
has pro
duced.
A merchant
of vast
wealth,
whose landed
possessions
alone extended
thirty miles from
the Piscataqua
to Saco, acquired
by his own skill and indus
try; a soldier
whose genius was attested by success in capturing
the stronghold
of France
from
its
powerful
defenders;
a civilian
whose talents
were
every
where admitted
to be of the highest
order.
Sir William
Pepperrell
was
the
only
native of New
England
who
was
created
a baronet
during our
colonial
period.
The
eclat of the war of
Independence,
has dimmed
the fame of the
great
names
of ante-revolutionary
days,
and whoever
aids
to
rescue from
ob
livion the achievements
and the characters
of the mighty
men of the past, con
fers a favor upon humanity,
and adds an enduring
page to the volume of history.
This Dr. Parsons
has done
in
the
memoir of his illustrious ancestor.
*
*
•
To revive
the memory of these
school-days of the republic,
and to bring
before
us the men who
led in that era of our national
pupilage,
and who formed
the
mind
and
trained
the muscle of
the
growing
state, is
a pious
duty
which
Dr.
Parsons
has well
performed.
He left in manuscript a history of his native town of Alfred.
When
a celebration of the hundredth anniversary of the settlement of that
town was contemplated,
in 1860, he was asked to prepare
a historical
discourse, but declined
on account of impaired health.
For many
years,
he
interested
himself
in studying
the
remains,
language,
and customs of the aborigines of this part of our country.
The first record
of his meeting
with Indians
is in the diary of his
march from Albany
to Buffalo, in 1812.
He there writes.
October
7,
being on the route between Vernon and Whitestown
:
Passed
by
the
Oneida
tribe
of Indians,
consisting
of
about
two
thousand
.
souls.
The warriors have volunteered
their services to assist in prosecuting
the
war
against
Canada.
Their dress is
a shirt which
does
not extend the length
452
Vol. XVII.
PLEADWELL
USHEB
PABSONS.
of the trunk,
a cloth
pinned
around
the waist,
and
extending
over perhaps
a
fourth part
of the lower
extremities,
a pair of broadcloth
leggins,
moceasons,
and a blanket
thrown
over the body.
Their
huts
are
one
room, in which
are
one
bench,
kettle,
pail,
dish
and samp-mortar.
The tribe
have two schools at
tended by all the children,
and
a church.
The conversation
of the warriors
I
could
understand,
but not of the squaws.
This difference
may
be
imputed
to
the
circumstance
that
the
warriors
have
more
intercourse
with
the
white
people.
In Iii s rides extending many miles around Providence, he examined
the Indian burying grounds, and gradually made a collection of bones,
and various utensils,
such as hatchets, arrowheads, pots of soapstone,
etc.
He recorded
the Indian names of localities, with the meanings
that had been assigned
them by tradition
or by guess.
In
1840,
he
furnished
a barrel ful of skulls,
from
an aboriginal
burying
place
in Washington
County,
to Dr. Samuel
G. Morton,
of Philadelphia,
author of Crania Americana.
After his principal
historical
work
was published,
and
when
he
was
about
70 years
old, he began
to collate
and
arrange his notes
on Indian localities in Rhode Island.
He made
new
researches
on
this subject,
and by examination of various maps, of historical works
relating to Rhode Island, and old records, collected
many new names,
with supposed explanations of some.
At length, in 1861 he published
a pamphlet of 32 pages, entitled " Indian Names of Places in Rhode
Island." It contains
more than 300 titles ; but some of the names
are
repeated in different applications
; thus, the name Pettaquamscot
re
curs
as given to a river, a tract of land, and a rock.
There are
a few
repetitions
from
inadvertence,
sometimes
concealed
by
an
unim
portant variation in spelling.
In a preface
he says :
No attempt is herein
made, by the author,
to examine Indian names of places
as a philologist,
or grammarian,
but merely
to gather such as were in existence
when civilization commenced within the State of Khode Island, according
to its
present
boundary
; and, in a few instances,
give the meaning
or derivation
of
the word
used.
I was led to this enterprise,
partly for the amusement it might
afford
in my leisure
hours,
but more for the purpose of rescuing
from oblivion
names of places in use
among the aborigines,
and for the convenience of those
who
may
hereafter
wish
to
apply
them
to
their
country
villas,
factories,
or
institutions,
as has often been done in this and other states.
As early as the year 1841 he visited the Indian burying ground and
old fort in Charlestown, R. I., and made some examination of Indian
graves.
He went
there
several
times in subsequent
years, procured
various Indian relics,
wrote
out descriptions of the places, and took
part in some
attempts
at disinterment.
In 1860,
and again
in
1861,
he made these entries in his diary
:
Saw
the old Indian burying-ground
and fort,
and the articles
lately
dug
up
from Indian graves, as coins, wampum-peag,
kitchen
utensils,
chains,
iron
and
silver.
*
*
*
Six of us went to the place and worked with spade till near midnight.
Took
up a well preserved skeleton,
eight feet deep.
.No.3.
453
PLEADWELL—USHEB
PAKSONS.
When
some Indian graves were
afterwards
opened
by another
party, Doctor Parsons bought many of the bones and articles found
with them, and
retained some in his possession
at his death.
He
prepared
a paper on this subject,
which he read, exhibiting
many
of
the relics, before the historical
societies
of Rhode Island and New
York.
This paper was published in the Historical Magazine, Feb
ruary,
1863.
It describes
the customs
of the Indians in regard to
burial,
sketches
the history of the Narragansett
Tribes,
and
their
intercourse
with the
Dutch,
and
particularly
of
Sachem
Ninigret
and his descendants,
and
gives
a minute account
of the discoveries
made in the ancient Indian burying
ground, believed
to have
been
the sachem's cemetery.
He states
the
reasons
for supposing that
the grave in which the most curious articles were found was that of
Sachem Ninigret's
daughter;
and that the adjoining
grave was that
of the sachem himself, who was living when the country he inhabited
was first settled by the English.
Doctor Parson's various labors were recognized by his election
to
many literary and historical societies.
He was a corresponding mem
ber of the historical
societies of Maine,
Massachusetts,
New York,
New Jersey, Georgia, and Wisconsin,
the American Antiquarian
So
ciety, The Academy of Natural
Sciences,
etc.
He was an active mem
ber of the New England Historical Genealogical Society and was its
vice president for Rhode Island from September,
1864, till his death.
He joined the Rhode Island Historical Society in 1825 and was a use
ful member
of
it,
making many contributions
to its collections and
reading several
papers at its meetings.
It
is
well known that
a
controversy
arose
between
Commodores
Oliver H. Perry and Jesse D. Elliott in relation to the conduct of the
latter in the naval battle
of September
10, 1813, and that long after
Perry's early death
the credit of victory
was claimed for Elliott by
himself
and his friends.
Doctor
Parsons
took a warm
and
active
interest in this dispute.
He was strongly attached
to Perry and con
vinced that Elliott's conduct was disgraceful.
In conversation, by
newspaper
articles, by contributions to writings
published by others,
and lastly in a public historical
address
he vindicated the claims of
Perry and the truth of history
as he understood
it,
often in terms
reflecting
severely
on Elliott and his defenders.
In January,
1836,
Tristam
Burges
read
a
discourse
before
the
Rhode Island Historical Society in which he gave
a
vigorous account
of
the battle.
In 1839 this was published with copious
notes and dia
grams of the battle in different positions.
Some of these notes were
furnished by Doctor
Parsons.
The "extract from
the log book of
the Lawrence"
was
taken
from
his diary.
He contributed
many
notes to the " Life of Commodore Perry," published in 1840 by Alex
ander Slidell
Mackenzie.
646—22
6
PLEADWELL— USHER
PARSONS.
Vol. XVII.
In 1852, having been invited to deliver the stated annual discourse
before the Rhode Island Historical Society, he chose for his subject
" The
history
of
the
battle
of Lake
Erie."
" I
have
made
this
choice,"
he says, " first, because this battle is a part of Rhode Island
history, and therefore appropriate
to the occasion
; secondly,
because
I could speak
of it from personal knowledge;
and thirdly, because
a very inaccurate and perverted account of it has been written
and
imposed
upon
the public by the late J. Fenimore
Cooper, esquire,"
He narrates the circumstances
which led to the formation of a fleet
on Lake Erie, the difficulties under which it was
created
and
got
afloat,
and
the
reasons
why it is regarded
as belonging
to
Rhode
Island history.
He relates the incidents of the battle quite fully and
then
attacks Elliott
and
Cooper in
a style of indignant
sarcasm.
In the words of Mr. Arnold, " He has done this in a style that leaves
nothing
to be said upon the points in dispute.
His own testimony
is direct and incontrovertible.
His reply to the
assaults
of Cooper
is comprehensive
and complete.
A certain irony
pervades
this por
tion of the address,
which
is the appropriate
weapon
wherewith to
treat mendacity of statement
when brought to the support of cow
ardice of conduct and infamy
of character."
Doctor
Parsons
had
always
a
fondness
for written
controversy
and
could handle
the
caustic
pen as well as the scalpel or saw.
In his more
advanced
life he became well known in the growing
cities along the southern shore of Lake Erie.
He often visited
that
region after his retirement from active practice.
Those cities appre
ciated
more
and more
the importance of Perry's victory,
and com
memorated
its anniversary
by yearly
gatherings,
and
occasionally
by special
observations
and various plans for the erection of monu
ments.
Doctor Parsons
was the only surviving
officer of the
battle
who
had
cultivated
historical
tastes
and
possessed
the
powers
of
writing and oratory.
In
1858,
the anniversary
was
celebrated
at Put in Bay Island,
near
Sandusky,
where Perry's fleet had
anchored
the night before
the
battle.
There
was
a
very large
assemblage,
and
a brilliant
display of yachts and steamers.
Hon. Salmon P. Chase presided
at
the ceremonies
on the island.
Eloquent
addresses
were
made,
and
three surviving
officers appeared
on the platform,
Captains Champ-
lin
and
Brownell
speaking briefly,
while
Doctor
Parsons
read
an
elaborate
narrative
discourse.
This was received with a great
deal
of interest by the large audience,
and was afterwards
printed in all
the principal newspapers
of Buffalo, Erie, Sandusky, Cleveland,
etc.
He afterwards wrote in his notebook,
" this anniversary
was
among
the most delightful
of my life, as well as most interesting."
Two years
later the forty-seventh
anniversary
was
celebrated
at
Cleveland.
That
city
alone
successfully
carried
out
the plan
of
No. 3.
455
PLEADWKLL
USHER
PARSONS.
erecting
a monument
to Perry, which on that day was dedicated.
It
stands in the park at Cleveland, and consists
of a statue of Perry,
and of other appropriate sculptures.
The dedication, September
10,
1860, was very largely
attended.
The governor of Khode
Island,
with many of her civil and military
officers, were present
by special
invitation.
The two most important
features
of the literary
exer
cises on that day were the oration by Hon.
George
Bancroft
and
a
historical address by Doctor Parsons.
These
three discourses
relating to the battle of Lake Erie all give
the story in essentially the same way,
and
show
some unavoidable
repetition.
The two delivered at Put in Bay
and
Cleveland
were
not. however, controversial.
In his later journeys
along Lake Erie, Doctor
Parsons
was
re
garded
as a guest of the public, and was passed and entertained
as
such
on
the
steamboats
and railroads.
These
various acknowledg
ments of his early services,
and the kind
reception
of his historical
discourses, after he had passed
the age of 70, gave him the keenest
pleasure.
^ome
other
published
writings,
less known
than
those
before
mentioned,
attest his permanent
interest in his naval reminiscences.
In
1836 he contributed to the Naval Lyceum, New York,
an article
on quarantine.
In
1840
he published in the Knickerbocker
Maga
zine, a story. " The Avenger of Blood," founded on an incident that
occurred
on board
the Guerriere in
1818. In
1850 he helped
to agi
tate the question
of the abolition of flogging in the Navy, and wrote
a pungent
article
on the
subject
for
a New York newspaper.
In
1862 he contributed to the New England Historical and Genealogical
Register " Brief
Sketches of the Officers
who
were in the Battle of
Lake Erie."
A sketch of Doctor Parsons's career would
be very incomplete
if
it did not allude to the tenacity with which he clung to early attach
ments, and
the pleasure
he took, during
his mature
and
declining
years, in revisiting
the
scenes
of his boyhood
and
youth.
Almost
every summer,
after he had gained
an established
position in Provi
dence,
he went to his native place and the neighboring
towns,
where
lie had struggled with poverty and youthful
ambition.
No recrea
tion
gave
him greater pleasure.
He kept up intimate
intercourse
and correspondence
with the relatives who still lived the.re.
He
also
reverted
with
the
deepest
interest
to
the region
about
Lake
Erie, where
he
had
laid the foundations
of
success.
He
re
visited
this
region
several
times,
beside
the
occasions
already
re
ferred to. when
he delivered
historical
discourses.
In 1835
he made
u tour
to Lake Erie, in company
with
Capt. Daniel
Turner,
who
commanded
the Caledonia in the battle of September
10, 1813.
They
went from New York to Albany
by steamboat,
and thence to Black
456
Vol. XVII.
PLEADWELL
USHER
PARSOXi
Rock by canal.
The journey by canal occupied
three days.
Doctor
Parsons minutely describes, in his diary, the localities at Black
Rock,
and
enumerates
the houses that were standing
there
in
1812,
most
of which were
destroyed
by fire in December,
1813.
He could
not
determine
the
exact
location
of
the
barracks
where
he
had
been
lodged
in 1812.
He was joined at Buffalo by Capt. Stephen Chanip-
lin, who
commanded
the
Scorpion
in the
Battle
of Lake
Erie.24
They visited the Queen Charlotte, captured from the British
in that
battle,
and afterwards sunk in the lake.
"A company of merchants
lately bought the ships,
and have raised
the Queen
and
refitted
her.
The captain
received
us politely,
and
gave
us some pieces of
oak
from
her to make walking
canes.
Captains Turner and
Champlin
and myself made out an inscription
to be put on a gilded cannon
ball
that is to be slung in her cabin.
Said ball was taken from among her
timbers ; and, as we stated, was fired by the Tigris.'''
In 1836 Doctor Parsons went to the West in behalf of the " Smith-
field
Emigrating Land Company."
He thus writes,
September
4.
1836: "About three weeks since, I caught the western land-fever
for
speculation, which has ever since occupied
my thoughts.
Two weeks
yesterday I
attended
a meeting
at Scott's pond, and
bought
four
shares.
I was chosen member of the purchasing committee,
to have
my expenses paid."
He
was
absent about
seven weeks, went from
Buffalo
to Detroit,
thence
to Toledo,
where
he bought
a horse
for
$60,
a saddle,
bridle, and blanket for $12.
He then traveled
horse
back
to Fort Wayne, Laporte, Chicago, Danville,
and Indianapolis.
His
expenses
on
this
journey,
as
charged
to
the
company,
were
$311.25,
including
the purchase of horse and outfit, which were
sold
for $41.
He then
and
subsequently
bought land at different
points
in Western States
; and some of these investments,
after entailing
a
long-continued burden of taxation and other expenses, became profit
able many
years later.
In 1838 he revisited Erie, after an absence of nearly 24 years.
In
his diary he mentions
Cayuga Lake
as almost the only place on his
route
to Buffalo
which
he recognized
as having
seen
on his early
march.
He arrived in Erie late in the evening of July 5.
" Friday.
6th, visited the court house at seven o'clock.
Here I received
nay
wounded
of the fleet about the 20th (24th) of September
1813."
He
called on many persons with whom he had been very well acquainted
for two years; only
one recognized
him without
aid, though
many
expressed
great joy
in
meeting
him.
In
the
burying
ground
he
» Capt.
Daniel
Turner,
born at Staten
Island,
N. T., Aug.
8, 1792,
died In Philadelphia,
Feb.
4,
1850.
Capt.
Stephen
Champlin,
born
in
South
Kingstown,
R. I., Not.
17,
1789.
a cousin of Commodore
Perry,
died nt his residence in Buffalo
Feb.
20,
1870.
No.3.
457
PLEADWEIX
USHER
PARSONS.
looked for the graves of Claxton, who died of a wound received
in
battle, and of other naval comrades.
He writes :
I called
on
Captain
Dobbins,
who
was
a
sailing-master
in
the war,
now
commander
of the revenue
cutter.
I went with
him
to
the Peninsula,
(Erie
was formerly called Presqu'isle,
) and trod once more the deck of the Latcrence,
now a hulk
resting
about
east
a quarter
of a
mile
from
the old
blockhouse.
H*r deck
is in
a sound state ; but the water
conies nearly
up
to
it.
so that I
could
not
see
her
hold.
In this vessel I
sailed
in
1813,
and
was
in
battle.
She was
repaired
the following
year,
and I
went
in her
to
Mackinac
with
troops
under
Colonel
Croghan.
She
was
sunk
and
remained
no till
within
the last two or three years,
when
she
was
raised
and
proved
to
be perfectly
suond.
Took some pieces from her to make canes of.
The following
day he visited James Miles, whose arm he had am
putated
the day after the battle on Lake Erie.
" He did not recol
lect me, but
on learning who I was shed
tears of joy."
His diary
concludes thus :
This visit
to Erie
gave
me
indescribable
pleasure.
The thousand
associa
tions
of
pleasure
and of pain ; the
fresh
recollections
of events,
as if they
transpired but yesterday,
which
a thousand
objects served to call up, and many
of which would but for this visit never have been revived
; the pleasure
afforded
in taking old friends by the hand, after a separation
of twenty-four
years ; the
changes
in looks ; the changes in worldly condition
for better
and for worse ;
the grave-yard
where lie the bodies of great
numbers
of
early
friends ; the
changes
and vast
improvements
about
the city, —elegant houses and churches
where
there were
then but a few humble
dwellings, —all, all tended to render
my stay here one
of the most Intense interest,
on many occasions
so powerful
as to take from
me the power of speech.
Hut what
shall
1 say of the protecting
mercy
of Him who through
dangers
seen
and unseen, perils
by land perils
in
the deep,
lias
surrounded
my
path, and preserved
me
to the present
moment?
May the remainder of my days be more devoted to His Service.
In
1854, after
attending
the meeting of the American
Medical
Association
at St. Louis,
he journeyed
to Chicago
and
St. Paul,
visited the Falls of St. Anthony,
and returned by the way of Buffalo,
-Montreal,
and
Quebec.
The next year he went to Lake
Superior
with his nephew,
Edwin.
On his way he rehearsed
on the spot his
adventure
in the capture of Fort Erie in 1813.
He stopped
at Macki
nac and Sault
Ste. Marie,
and
examined
and
described
the copper
mines at Lake Superior.
For several
years
before
his
death
Doctor
Parsons
was
almost
wholly withdrawn
from active practice, though he sometimes visited
in consultation
and even performed some surgical operations.
His
last amputation
was of the
forearm, performed
when
he was
74
years
old
in
Rehoboth.
His
sturdy
health
of
body
and
mind
gradually
failed,
but with
very little suffering,
and
with
many
circumstances fitted
to make old age happy.
An increasing forget-
fulness in regard to business
matters,
and
hesitancy
in speech and
uncertainty in locomotion
showed that his powerful brain was yield
458
Vol. XVII.
PLEADWELL — USHER
PARSONS.
ing to the natural changes in its texture; but he still enjoyed
reading,
frequented
the
Athenaeum,
called
at
the
houses of
a few familiar
friends, kept up a rather extensive
correspondence,
visited his near
relatives in Maine
and
New York City, and
interested
himself in
watching the progress of the Rhode Island Hospital.
The exercises
at the opening of this hospital took place October 1, 1868.
He was
conducted
to a seat on the platform,
and was kindly referred
to in
Professor
Gammell's
eloquent
discourse.
This
compliment,
the
last he was ever to receive on any public occasion, gratified him
very
much.
He wrote in his diary the next
day with
a trembling
hand,
" I feel very happy for yesterday's
doings."
He was present
at the
first important surgical operation performed there October 10.
On the evening of October
17, after
exposure
to
cold,
he had
a
severe, acute attack, involving
the brain, and followed by persistent
nausea,
headache,
and confusion of mind.
He first left
the
house
after this, November 3, when
he voted
at the presidential
election.
He continued to go
out
almost
every
day for
a month more,
but
with feeble and uncertain steps and a degree of mental
disorder
that
gave
his family
great anxiety.
From
December
4
he was
again
confined
to the house,
and mostly to his chamber,
and
died on
the
morning of December
19,
1868,
aged
80 years
and
4 months.
He
was very faithfully
attended
on the last sickness
by his friend
Dr.
Stephen
S. Keene.
An autopsy
showed
chronic degeneration
in the
arteries and
membranes
of the brain
and
acute inflammatory
dis
ease in the cerebellum.
This last probably
dated
from the
17th
of
October, and
was
the immediate
cause of death.
His funeral
was
kindly attended by Rev. J. G. Vose, of the Beneficent
Congregational
Church.
He was buried in Swan Point Cemetery.
On
the
1st of
June, 1869, Hon.
Samuel
G. Arnold, President of the Rhode Island
Historical Society, read before that body, in accordance
with
pre
vious appointment,
a
discourse
"On
the
services
of three
distin
guished
members
of
the
society
who
died
during the year
1868,"
Albert Gorton
Greene, William
Read Staples, and Usher
Parsons.
The portion of it referring
to Doctor Parsons
closes with the
fol
lowing sentences :
Probably
no
man
now
living
has
so
complete
a knowledge
of
Indian traditions
and history
or is so competent
to interpret
their
meaning as was Dr. Parsons.
In his later years he retired from prac
tice
and
devoted
his time
to these favorite
pursuits, often making
long journeys, even beyond
the Mississippi
River,
always returning
with some new discovery in Indian lore and some vivid impressions
of the growing
greatness of our country.
He was
a man in whom
the love of country
was strongly marked and
whose fidelity
to the
flag never faltered in the darkest hour.
His was
a genial tempera
ment
and
a kindly heart,
with much of the jovial spirit of the seas
in his hours of relaxation.
We miss his familiar form in these seats
Xo. 3.
459
PLEADWELL
tTSHER PARSONS.
at our stated
meeting,
and
we
miss
his cordial
greeting
and
his
honest smile in the daily intercourse of life, for there
are few fam
ilies in this city where he was not a welcome
guest and where during
his long residence of nearly half a century among
us his name had
not become
as a household
word.
Loved in life and honored in death,
his memory will
be revered
by
all who value
those high qualities
of manhood which were united in his character.
BIBLIOGRAPHY
OF DR. USHER PARSONS'
PUBLICATIONS.
1. Pettifogger's
soliloquy,
in verse;
Freeman's
Friend, Saco,
1809.
2. Book of Chronicles,
2 chapters
; Boston
Scourge.
1811.
3. On pleuropneumonia,
addressed
to Dr. John Ross; Buffalo Gazette.
1813.
4. Gunshot
wounds
through
the "thorax;
New
England
Journal
of Medicine
and
Surgery.
1818.
5. Surgical
account of the naval
battle
on Lake Erie; New
England
Journal
of Medicine
and Surgery-
1818.
6. Letter to Hon. John Holmes,
from Isle of Wight ; Eastern
Argus,
1819.
7. Sailor's
physician,
1 vol. 8vo. ; Cambridge.
1820.
8. Physician
for ships, a 2d edition of the above,
with additions
(2,000
copies).
1824.
9. Poison of rattle-snake
cured
by
whiskey
; Philadelphia
Medical Recorder.
1824.
10. Epilepsy
cured
by
galvanism
;
New
England
Journal
of
Medicine
and
Surgery.
1826.
11. Introductory
lecture
on
anatomy
and physiology
; Brown University.
1826.
12. Boylston
prize
dissertation
on
periostitis.
1827.
13. On introduction
of medicines
into the veins ; Philadelphia Medical
Recorder.
1827.
14. Review of Allen's mechanics ; American
Journal of Science.
1829.
15. Boylston
prize
dissertation
on
eneuresis
irritata
;
Boston
Medical
and
Surgical
Journal.
1829.
16. Case
of poisoning
by
tartar-emetic
; Boston
Medical
and Surgical Journal.
3829.
17. Boylston
prize
dissertation
on
cutaneous
diseases,
etc. ;
Boston
Medical
and Surgical Journal.
1830.
18. On animal
and vegetable decomposition
as a cause of fever.
Ib.
1830.
19. Discussion
on the above,
with Dr. James Jackson, of Boston.
Ib.
1830.
20. Address
on
temperance,
Providence.
1831.
21. Art of making
anatomical
preparations
:
1 vol.
8vo. ; Philadelphia.
1831.
22. Review of Allen's "Practical
Tourist;"
American
Journal of Science.
1832.
23. Remarks
on
phrenology
; Literary
Journal,
Providence.
1833.
24. Biography
of Dr. Solomon
Drowne
; Literary Journal,
Providence.
1834.
25. Boylston
prize
dissertation
on cancer
of the
breast;
Boston
Medical
and
Surgical
Journal.
1835.
26. On quarantines
; United
States Naval Lyceum.
1836.
27. Genealogy
of the family of Joseph
Parsons.
1838.
28. Boylston
prize
dissertation,
1 vol.
8vo. ; with
a history
of the fund
and
a
notice of its founder.
1839.
29. Brief account
of early
physicians
and
Medical
Society
of
Rhode
Island ;
American
Quarterly
Register.
1840.
30. Lecture on connection
and reciprocal
influence
between bruin
and stomach.
before
American
Institute of Instruction, Providence.
1840.
31. The avenger of blood ; Knickerbocker Magazine.
1840.
460
Vol. XVII.
PLEADWELL
USHER
PARSONS.
32. Notice
of Dr. Jeremiah Williams;
Boston
Medical
and
Surgical
Journal.
1842.
33. Flake Fund prize dissertation
on spinal
diseases..
1842.
34. Physician for sliips,
3d edition, with new notes,
etc.
1842.
35. Notice
of Dr.
Niles
Manchester;
Boston
Medical
and
Surgical
Journal.
1843.
36.
Statistics
of
large
surgical
operations;
American
Journal
of
Medical
Sciences.
1848.
37. Memoir
of Charles
Frost ; New
England
Historical
and
Genealogical
Reg
ister.
1849.
38. Report
of committee
on
adulteration
of drugs ; Transactions
of American
Medical
Association.
1849.
39. Report
of committee
on medical
sciences;
Transactions of American
Medi
cal Association.
1850.
40. Article
on
prohibition
of (logging
in
the
Navy
;
Sunday
Dispatch.
1850.
41. Physician for ships;
4th edition.
1851.
42.
Report
of
case
of
removal
of
uterus
by
ligature
;
Boston
Medical
and
Surgical
Journal.
1851.
43. Discourse
on
the Battle of Lake Erie,
delivered
before
the Rhode
Island
Historical
Society.
1852.
44. Genealogy of the Frost family, of York County,
Maine.
1853.
45. Address
before American
Medical
Association,
at St. Ixmis.
1854.
46. Life of Sir William Pepperrell,
Bart., the only native of New England who
was
created
a baronet
during its connection
with the mother
country:
Boston
(London,
1856).
1855.
47. Address
on the Battle of Lake Erie; delivered
at Put-in-Bay Island.
1858.
48. Notice of descendants of Peter Hill, of York County,
Maine
; New England
Historical and Genealogical
Register.
1858.
49.
Sketches of Rhode
Island
physicians
deceased
prior
to
1S50,
etc. ; Trans
actions
of Rhode Island Medical
Society.
1859.
50. Notices
of
Dr.
Walter
V.
Wheaton
and
Judge
Haliburron ;
Providence
Journal.
1860.
51. Address
on Battle of Lake Erie ; delivered
at Cleveland,
Ohio.
1860.
52. On the importance of culture
of flax; Transactions
of Rhode Island Society
for Encouragement
of Domestic
Industry.
1860.
53. Indian names of places in Rhode Island.
1861.
54.
Letter on
some
points of military
surgery
; Transactions
of
Rhode
Island
Medical
Society.
1861.
55. Brief
sketches of the officers who
were in the battle
of Lake Erie;
New
England
Historical
and Genealogical
Register.
1862.
56. Lecture
on Indian relics; Historical
Magazine.
1863.
57. Letter to Mr.
George
Livermore,
on
services
rendered
by negroes in
the
war of 1812;
Proceedings
of Massachusetts
Historical
Society.
1863.
58. Physician
for ships ; 5th edition.
1867.
EDITORIAL.
EDITORIAL
STAFF.
Commander
C. M.
Oman,
Medical
Corps,
United
States
XRvy.
Lieut. Commander
Lucius
W. Johnson,
Medical
Corps,
United
States
Navy.
Lieut. Commander
W.
M. Kerb,
Medical
Corps,
United
States
Navy.
Lieut Commander
H. B. Habtet,
Dental
Corps,
United
States Navy.
Lieut. Edwin
Peterson,
Medical
Corps,
United
Statos
Navy.
OX THE
TREATMENT
OF
SYPHILIS
WITH
BISMUTH
SALTS.
Sazerac
and Levaditi,
of the Pasteur Institut. Paris, have recently
proposed the use of tartrobismuthate of potassium
and sodium,
con
taining approximately
50 per cent of bismuth, for the treatment
of
syphilis.
In
their
preliminary
work
on
rabbits
(infected
with
Spirochaeta pallida and S. cwmculi)
they
found that the only safe
and efficient method
of administration
was by the subcutaneous
or
intramuscular
route.
Intravenous
injections were shown to be dan
gerous on account of the markedly toxic action of the drug.
In order
to decrease this danger as far as possible
they substituted a suspen
sion in oil of the drug for the watery solution.
This was found to
be the method of choice in the treatment of human cases on account
of increased tolerance
and less local reaction.
Fournier and
Guenot have
tested the
value of this treatment of
syphilis on a comparatively large scale and report the results of the
treatment in about
200 cases.
In cases of primary
sores
the
treponema
disappeared
as
a rule
after
the second injection;
in some cases
even after the first.
The
small erosive chancres
healed completely in a few days ; the medium-
sized chancres in one to two weeks.
The large or ulcerative chancres
persisted about three weeks, but they lost rapidly their specific char
acters
and
soon
appeared
as ordinary
lesions,
the
time of healing
depending
on the size of the individual
ulcer.
The local
induration
and
the
adenopathy
were
influenced
more
rapidly by bismuth than by
any
other treatment
and
disappeared
often completely
within a few weeks.
In no
cases
where
the treat
ment
was regular did secondaries
appear.
The Wassermann
reac
tion became
negative
and remained
so for the period of observation.
461
462
Vol. XVII.
EDITORIAL.
In
cases
of secondary
syphilis
the
mucous
patches
disappeared
after the first or second injection.
The hypertrophic
patches dried
up in a few days, faded and were resorbed in 10 to 25 days, according
to the amount of new tissue formation.
If the treatment
was com
menced during the appearance
of the roseolar
rash this was arrested
in its
development,
sometimes
after
an
exacerbation
of
24
hours.
Herxheimer's
reaction
might
also appear near
the papular
syphi-
lides.
The simple roseolar rash usually disappeared
in 5 to 10 days ;
the papules
took a little longer to be absorbed.
The authors have
seen a generalized
miliary eruption and palmar syphilides, manifesta
tions which as is well known are rebellious to specific treatment,
dis
appear in two weeks.
The
general
secondary
manifestations — headache,
bone
pains,
etc. —always yielded to the first injection.
The authors mention eight cases which had not yielded to arsenical
and mercurial treatment,
but which readily responded
to the bismuth
treatment.
They also had
a case of acute syphilitic
meningitis
with
all the characteristic
symptoms.
After
four injections
the clinical
improvement was complete.
After two weeks of treatment
the lym
phocytes in the spinal fluid had been reduced from 400 to 7 per cubic
millimeter.
Lesions of tertiary syphilis,
gummata,
osteoperiostitis,
and
ulcers
yielded,
as
a rule, very rapidly to treatment.
In cases of visceral
and nervous
lesions the time allotted to treatment
has been too short
to enable the authors to express an opinion.
In their discussion
of the effect of the bismuth treatment
on
the
Wassermann
reaction,
Fournier and Guenot show
that the clinical
improvement of the cases is accompanied
by a marked change in the
serological test.
Seventeen
primary
cases
received their first
injec
tion while the Wassermann was still only partially positive.
In
10
of these cases the Wassermann became actually negative; in the oth
ers it weakened markedly.
In
18 other
primary
cases with frankly
positive Wassermann, 6 became completely
negative, while the others
were weakened.
The authors found it to be rare for the Wassermann
to become negative
after the first series of injections;
as
a rule it
gradually grew weaker
and finally
became negative
from the second
to the fourth month.
Fournier and Guenot used a 10 per cent suspension
in olive oil of
the tartrobismuthate of sodium
and potassium.
As the subcutaneous
method
was found to be painful, they always administered the drug
intramuscularly.
Due to the tendency
of the drug to produce
stomatitis when
large
doses were given, the authors
recommend
that
a single
dose
never
exceed 0.30 gram, and in aged and debilitated patients
not over 0.10
to 0.20 gram.
No. 3.
463
EDITORIAL.
After the first two or three injections of 0.20 gram, a biweekly in
jection of 0.30 gram seems
to be good practice.
Two to three grams
should
be injected during
a month.
After the first series of injections the treatment
could be contin
ued with a single weekly injection of 0.20
to 0.30 gram, or be sus
pended for a month to be recommenced
again in the same manner as
described above.
One should follow
the progress
of the treatment
by repeated
ex
aminations of
the
blood
and
check
up
every
case
at
subsequent
regular
intervals.
With regard
to untoward
effects of this
treatment
the
authors
state that they have given over
1,500 injections without having expe
rienced any really important mishap.
In cases of grave
visceral lesions,
and especially where
the renal
function is impaired,
one should
proceed
with
caution.
A slight
elevation
of the temperature
was
seen in some cases
the
day
after
injection, accompanied
with pain in the back, but no general
reac
tion was observed.
After the first four injections
a moderate
poly
uria occurred
in a few instances.
The only two manifestations that
might cause
some
trouble
are
local
reactions
and
the
stomatitis.
The former were seen in a few patients who walked too much
imme
diately after the treatment.
The tendency
to stomatitis can be very
well controlled by hygienic measures of the mouth.
In a few cases
dark spots of bismuth impregnation
were
seen on the mucous
mem
brane of the mouth.
The bismuth has been recovered
from the blood and cerebrospinal
fluid and has been shown to be eliminated through
the saliva, bile,
feces, sweat, and urine.
The authors state that bismuth undoubtedly is
a most
energetic
antisyphilitic agent, having particularly
marked effect not only
on
the infectious
manifestations of the disease but also on the Wasser-
raann reaction.
They
conclude,
however, that
time
only will tell
if this drug will prove
to be of value in the radioed cure of syphilis.
(EP.)
ON
THE
CHANCES
FOB
SUCCESS.
Edward Bok, who for
30 years
so ably edited
the Ladies
Home
Journal,
is a man with a keen insight into human nature.
The suc
cess he attained in life was not achieved without hard work, and what
he has to say on a young man's chances for success is worth reading.
As a young man, so he states in his autobiography, which was pub
lished last year under the title of " The Americanization
of Jidward
Bok," he was possessed of the idea, as are so many young men enter
ing business,
that the path which
led to success was very difficult;
464
Vol. XVII.
EDITORIAL.
that it was overfilled with
a jostling, bustling, panting crowd, each
eager to reach the goal;
and all ready
to dispute every
step that a
young man should take ; and that favoritism
only could bring one to
the top.
After Bok had been in the world of affairs, he wondered
where
were these choked avenues, these struggling
masses, these competitors
for every inch of vantage.
Then he gradually
discovered
that they
did not exist.
In the first place,
he found
every
avenue leading to success wide
open
and
certainly
not
overpeopled.
He was
surprised
how
few
there were who really stood in a young man's
way.
He found that
favoritism
was not the factor that he had been led to suppose.
He
realized it existed in a few isolated cases, but to these everyone
had
pointed and about these everyone had talked until, in the public mind,
they had multiplied
in number and
assumed
a proportion
that
the
facts did not bear out.
Here and there
a relative " played a favorite,"
but even with the
push
and
influence
behind him "the lucky
one,"
as he was termed,
did not seem to make progress,
unless he had merit.
It was not long
before Bok discovered
that the possession of sheer merit was the only
real factor that actually counted
in any of the places where
he had
been employed
or in others which he had watched
; that business
was
so constructed
and conducted
that nothing
else, in the face of com
petition, could act as current coin.
And the amazing part of it all
to Bok was how little merit there was.
Nothing
astonished
him more
than the low average ability of those with whom
he worked or came
into contact.
He looked at the top, and instead
of finding it overcrowded,
he
was surprised at the few who had reached there ; the top fairly begged
for more to climb its heights.
For every young man, earnest,
eager to serve, willing to do more
than he was paid for, he found ten trying to solve the problem of how
little they could actually do for the pay received.
It interested
Bok to listen to the talk of his fellow workers dur
ing luncheon
hours and
at all other times
outside
of office hours.
When the talk did turn on the business
with which
they
were con
cerned, it consisted
almost entirely of wages;
and he soon found that
with scarcely
an exception,
every young man was terribly underpaid,
and that his employer absolutely
failed to appreciate his work. It was
interesting, later, when Bok happened
to get the
angle
of the
em
ployer, to discover that invariably
these same lamenting young men
were
those
who, from
the
employer's
point
of
view,
were
either
greatly overpaid or so entirely worthless
as to be marked for early
decapitation.
Xo. 3.
465
EDITORIAL.
Bok felt that this constant thought of the wages earned or deserved
was putting the cart before
the horse ; he had schooled
himself into
the belief that if he did his work well, and accomplished
more than
was expected of him, the question of wages would take care of itself.
But according to the talk on every side, it was he who had the cart be
fore the horse.
Bok had not only tried always to fill the particular
job set for him, but had made it a rule at the same time to study the
position
just ahead, to see what it was like, what it demanded
; and
then, as the opportunity
presented itself, do a part of that job in ad
dition
to his own.
As a stenographer, he tried always to clear off the
day's work before
he closed his desk.
This was not always possible,
but he kept it
before
him
as
a
rule
to
be followed
rather
than
violated.
One morning Bok's employer happened
to come to the office earlier
than usual, to find the letters he had dictated
late in the afternoon
before lying on his desk ready to be signed.
" These are the letters I gave you late yesterday
afternoon, are they
not? " asked the employer.
" Yes, sir."
" Must have started early this morning, didn't you ? "
" No, sir," answered Bok.
" I wrote them out last evening before I
left."
" Like to get your notes written out before they get stale ? "
"Yes, sir."
"Good idea," said
the employer.
" Yes, sir," answered
Bok, " and I think it is even a better
idea to
get a day's work off before I take my apron off."
"Well said,"
answered
the employer, and
the following pay day
Bok found an increase in his weekly envelope.
It is only fair, however,
to
add
here, parenthetically,
that it
is
neither just nor considerate
to
a conscientious
stenographer for
an
employer
to delay
his
dictation
until
the
end of the
day's work,
when, merely
by judicious
management
of his affairs
and
time,
he
can
give
his
dictation
directly
after
opening
his
morning
mail.
There
are two sides to every question
; but sometimes
the side of the
stenographer is not kept in mind by the employer.
Bok
found it
a uniform
rule
among
his fellow
workers
to
do
exactly
the opposite
to his own idea; there was an astonishing una
nimity
in
working
by
the
clock;
where
the
hour of closing
was
•r»
o'clock
the preparations
began
five
minutes
before,
with
the hat
and overcoat over the back of the chair ready
for the stroke of the
hour.
This concert of action was curiously universal, no " overtime "
was ever to be thought of, and,
as occasionally happened
when
the
work did go over the hour,
it
was not, to use the mildest term, done
with care,
neatness,
or accuracy;
it
was,
to use
a
current
phrase,
466
Vol. XVII.
EDITORIAL.
" slammed off."
Every moment beyond
5 o'clock in which the worker
was asked to do anything
was by just so much
an imposition
on the
part of the employer, and so far as it could be safely shown, this
impression was gotten over to him.
There
was
an entire unwillingness
to let business
interfere with
any anticipated pleasure or personal engagement.
The office was all
right between
9 and
5.
One had to
be there
to earn
a living;
but
after
5 it was not to be thought of for one moment.
The elevators
which ran on the stroke of
5 were
never
large enough
to hold the
throng which besieged them.
The talk during lunch hour rarely, if
ever, turned toward
business,
except
as said
before,
when it dealt
with underpaid services. In the spring and summer it was invariably
of baseball,
and scores of young men knew the batting
averages
of
the different players and the standing of the clubs with far greater
accuracy
than they
knew
the standing or the discounts
of the cus
tomers of their employers.
In the winter
the talk was all of danc
ing, boxing, or plays.
It soon became evident to Bok why scarcely
five out of every hun
dred of the young men whom
he knew made any business progress.
They were not interested
; it was a case of a day's work
and a day's
pay ; it was not a question of how much
one could do but how little
one could get away with.
The thought of how well one might do
a
given thing never
seemed
to occur to the average mind.
" Oh, what do you care? " was the favorite expression.
" The boss
won't notice it if you break your back
over his work ; you won't get
any more pay."
And
there
the subject
was
dismissed,
and
thoroughly
dismissed,
too.
Eventually,
then, Bok learned that the path that led to success was
wide open; the competition was negligible.
There
was no jostling.
In fact, travel on it was just
a trifle lonely.
One's
fellow travelers
were
excellent
company,
but they
were few.
It was one of Edward
Bok's
greatest
surprises, but it was also
one of his greatest
stimu
lants.
To go where
others could not go or were loath to go, where,
at least, they were not. had a tang that savored of the freshest kind
of adventure.
And the way was so simple,
so much simpler, in fact,
than
its
avoidance,
which
called for
so
much
argument, explana
tion, and discussion.
One had merely to do all that one could do. a
little
more than one was asked or expected
to do, and immediately
one's head rose above the crowd and one was in an employer's eye.
where
it is always so satisfying
for an employee
to be.
And as so
few
heads lifted
themselves
above
the
many,
there
was
never
any
danger
that they would not be
seen.
Of course, Edward Bok had to prove to himself that his concep
tion of conditions was right.
He felt instinctively
that it was, how
EDITORIAL.
467
ever, and with this stimulus he bucked
the line hard.
When others
played,
he worked, fully
convinced
that his playtime
would
come
later.
Where others shirked, he assumed.
Where others
lagged,
he
accelerated his pace.
Where others were indifferent to things around
them,
he observed
and
put away the results for possible
use later.
He did not make of himself
a pack horse ; what he undertook he did
from interest in
it,
and that made
it
a
pleasure
to him when to others
it
was
a
burden.
He instinctively
reasoned
it
out that an unpleasant
task
is
never accomplished by stepping
aside from
it,
but that, un
erringly,
it
will return later to be met and done.
Obstacles,
to Edward Bok,
soon
became merely difficulties
to be
overcome, and
he trusted to his instinct
to show
him the best way
to
overcome
them.
He soon learned that the hardest kind of work
was back of every success; that nothing in the world of business just
happened, but that everything
was brought
about,
and only in one
way—by
a
willingness of spirit and
a
determination to carry through.
He soon exploded for himself the misleading and comfortable theory
of
luck;
the only lucky
people,
he found,
were
those who worked
hard.
To them
luck
came in the
shape of what they
had earned.
There
were exceptions
here
and
there,
as there
are
to
every
rule;
but the majority of these, he soon found, were more in the seeming
than in the reality.
GeneraUy speaking—-and, of course, to this rule
there
are likewise exceptions,
or as the Frenchman said, " All gener-
alizations are
false,
including
this one" —
a
man got in this world
about what he worked for.
And that
became, for himself,
the
rule of Edward Bok's
life.
(W. M. K.)
ON THE ELIMINATION
OF DIPHTHERIA.
During the year 1921 in the Navy
there
were
372 original
admis
sions to the sick list for diphtheria
which, combined
with
18 cases
remaining under treatment
from the previous year, resulted
in 11,669
sick days and 20 deaths.
These figures probably represent
the aver
age morbidity for this disease in the Navy,
as
it
was not present in
epidemic
form during
the
year.
The
case mortality
of
5
per
cent
compares favorably with the average
death
rate of
8
per cent exist
ing among civil
communities.
However,
the diphtheria
morbidity
and mortality should
be lower,
as the medical profession probably
knows
more about this disease than
almost
any other infection, and
yet no great inroads have been made either on the morbidity or mor
tality beyond what occurred
after the introduction
of antitoxin.
We have
seen yellow fever and, typhoid
fever cease
to be
a
mor
bidity
and mortality
factor in the vital statistics of the Navy,
and
when the Schick test and
the toxin antitoxin
immunization
became
468
Vol. XVII.
EDITORIAL.
available we had
hopes of the eradication of diphtheria.
Unfortu
nately, up to the present
time,
the use of toxin-antitoxin
in produc
ing active immunity in recruits in the Navy is attended with consid
erable
difficulties
and
has not been
considered
practicable,
princi
pally because of the severe reaction
which the toxin-antitoxin
injec
tion produces
in adults.
So naval medical
officers still have to
de
pend on early diagnosis, prompt isolation, and the detection
of car
riers to keep down the incidence of this disease.
However,
we have not given up hope of the eradication of diph
theria.
We may not live to see
it,
but we believe that the day will
come when diphtheria will be under control.
Much has been written
recently
about
the value of the Schick test
and
the
active
immunization
against diphtheria
by
means of the
toxin-antitoxin
mixture.
Julius Blum, writing in the American Journal of Diseases of Chil
dren
(1920, 20, p. 22), reports the results obtained
by immunizing
children,
and
demonstrates
the fact that
it
is
possible
to render
a
child-caring
institution diphtheria
free.
This has been accomplished
for
a
period of seven years
at the Home for Hebrew Infants, New
York,
as well
as in other institutions,
by injecting
all susceptibles
with toxin-antitoxin
mixtures.
Abraham Zingher, who has devoted much study to the problem of
active
immunization,
believes
that all children
from
6
months to
5
years should be injected with the toxin-antitoxin,
and he believes that
the Schick test can be omitted in this age group, as most of the chil
dren give
a
positive
reaction.
He believes
that to place
the diph
theria preventive work on
a
practical basis,
it
is
advisable at present
to simplify
it
for the school physician by omitting
the Schick test
in
younger children
and by immunizing
all children
on their entrance
into school.
Schick testing and immunization
on
a
fairly large scale has been
carried out in the schools of New York City, and the results of this
work are being watched
with interest.
During this procedure some
interesting observations
were made.
It was noted that children from
the homes of the more well-to-do have
a
much higher percentage
of
positive Schick reactions than those from
the homes of the poorer
classes
who
live
in
closely
crowded neighborhoods.
The
highest
number of positive reactions found
was
67 per cent, and the per
centage
decreased until
it
was found that in the schools of densely
congested
districts
the number of positive reactions was
as low
a=
16 per cent, and in one instance
13.6 per cent.
Repeated
exposures to the diphtheria bacillus in the congested
sec
tions of the city probably produce mild infections in the membranes
which
are not recognized
as diphtheria
but which may lead
to the
development
of an antitoxic immunity.
No. 3.
469
EDITORIAL.
Compared
with these figures are those of two private schools.
In
one, 79 per cent of the pupils gave positive reactions,
and in a second,
85 per cent, showing that segregation
of the children either in rural
or well-to-do
and sparsely settled
sections
plays an important
part
in the nondevelopment
of natural
immunity
to diphtheria.
This
fact has an important bearing in the Navy
as the majority
of our
recruits come from rural communities.
Standardization
of the diphtheria
toxin for the Schick
test and
of heated diphtheria
toxin for the control test is being advocated.
Improvements in the method of immunization
are possible, according
to Zingher,
and further
work is being carried out at present
to see
especially whether two doses of toxin-antitoxin
will
give,
in
a con
siderable number of children, results
as good
as those obtained
with
the three
doses used at present.
This would simplify
the process
and make it very convenient
for general
use, and it is not at all im
probable that
a means of preventing the severe reactions
in adults
will be attained.
The problem
to-day is one for the civil community rather than
for
the Navy.
Zingher
intimates
that
the
active
immunization
against
diphtheria
should
be carried out first of all by the private
physicians
in
the
different
homes
where
the
majority
of
young
children can be reached.
In large cities
the milk stations,
day nur
series,
children's
dispensary, infant
and
orphan
asylums furnish
large groups of children suitable for immunization.
The children of
preschool
age found in kindergartens and those of school
age should
be actively
immunized.
The
success of such
a procedure
depends
upon the development
of a public health conscience in the people of
the country.
Zingher1 believes that the diphtheria problem seems nearer a solu
tion by the thorough application of these newer
diagnostic and im
munizing
procedures
which
should
be
encouraged
by the
various
departments of health.
On the other
hand, J. G. Cumming, writing on the question, " Is
the control
of diphtheria leading to eradication?"
in the Journal of
the American Medical Association for March
4, 1922, states that the
present
procedures
for the control of diphtheria
do not
seem
to be
leading
toward
the
complete
eradication of the
disease,
since
the
case
rate
is approximately
the same
as that of 30 years
ago.
By
eradication he means such perfect
control of the factors concerned
in
diphtheria that epidemic
spread of the disease becomes impossible.
The factors underlying
present-day
procedures
for the control of
diphtheria
are:
(1) Early clinical
and laboratory
diagnosis of the
disease
and the isolation of the patient;
(2)
laboratory
identifica-
1Collected
Studies
from
the
Bureau of Laboratories,
City of New York,
vol.
9.
640—22
7
470
Vol. XVII.
EDITOKIAL.
tion of the healthy carrier and his isolation;
(3) the Schick test and
immunization
; and (4) the use of antitoxin
as a curative measure.
Only the first two of these factors are useful in the prevention
of
infection distribution
; the other two are of value in the reduction
of
mortality.
The correct diagnosis, followed by quarantine of the patient and
of the carrier, has for about
a quarter of a century been the accepted
procedure
for the prevention of distribution,
yet we still have
epi
demics,
and
the
few
deaths
in
each
endemic
and
epidemic
focus
throughout the United
States amount
to an annual toll of more than
15,000
lives.
So Doctor
Cumming
asks the
questions
: " Is not
the
gradual
accumulation
during
the
interepidemic
times of
unrecog
nized carriers associated with oncoming susceptibles
responsible
for
our periodic
epidemics?
Can
such
interepidemic
carriers
be
pre
vented by the activities of health departments,
or is it a question
of
educating the people
relative to the major
avenues of disease dis
tribution?"
There
seems
to be no argument as to the value of the Schick
test
and immunization
for morbidity
and mortality
reduction, but. asks
Doctor Cumming, " Is it useful in the control of distribution
? "
The
injection of the antitoxin for the cure of the disease does not relieve
the patient from the carrier state, and presumably the immunization
by the injection of toxin-antitoxin
mixture has no effect on the car
rier state. If this immunization neither eliminates nor prevents
the
carrier
state, and
at the same time
removes
the danger
signal
(the
manifestation of symptoms
in those who
have
become infected as
a
result of transmission),
there is developed
a false
sense of security—
security against immediate
mortality,
but not against an increasing
healthy carrier rate.
If the control of diphtheria
through
the Schick
test alone
is to
become as perfect in the prevention of diphtheria
mortality
as has
the procedure
for the prevention of typhoid fever, it will be necessary
that 31,000,000
children now living be immunized and that 2,000,000
born each successive year be immunized.
" Presumably,"
says Doc
tor Cumming, " the accomplishment
of this is not possible,
and if it
were, since there is neither elimination nor a reduction of carriers, is
it worth while ? "
As the four factors mentioned
above have not proven adequate to
eliminate diphtheria, resource must be made to a fifth factor —that of
transmission prevention.
The case rate can only be reduced by the blocking of transmission
from the mild, unrecognized
case and from the unidentified carrier.
A reduction in the endemic carrier index seems to be the end desired.
The epidemiologists must determine
the avenues of distribution
and
devise
practical
methods
for blocking
them.
"Only
when
these
No. 3.
471
EDITORIAL.
methods are inculcated into the habits and customs of the people will
there
appear
a reduction in the
endemic
index, and
the successful
control of diphtheria leading to eradication."
In
a paper
on the "Application of bacteriological
studies
to the
prevention of diphtheria,"
read at a meeting of the Society of Medical
Officers
of
Health
held in
London
on • February
17,
1922,
Sir
Frederick W. Andrews considered
the means at the disposal of public
health officials
in combating
the disease.
To him mere sanitation
appeared to offer no solution to the diphtheria problem, the propor
tion of immunes
being actually least in those individuals
higher in
the social scale.
At present the means at our disposal
are inadequate
for the discovery
of virulent carriers in the community as
a whole,
for their isolation, and for the cure of the condition in all cases.
It
seemed
to him that
the problem
of the undiagnosed
case
called
for
better education
both of the public and the doctor.
"From
the point of view
of prevention by immunization
rather
than by the prevention of the spread
of infection
we
now
have an
effective method,
so far as concerned
the individual,
in the injection
of toxin-antitoxin.
Up to the level of the institution
the problem of
the prevention of diphtheria
was solved if we chose
to use the means
at our command,
but this
was
not
true
in dealing with
the
com
munity
as
a whole.
Prevention
by the
removal
of infection
only
might defeat
itself
by
the production
of
a population
having
no
resistance
to diphtheria.
The method of active immunization would
involve the Schick
testing of young children
and injection of the
positives.
The immunity conferred is found to be fairly lasting and
probably persisted
after antitoxin
had
disappeared
from the blood,
the earliest
stimulus of
a
commencing
infection
reawakening
the
dormant machinery of antitoxin."
Sir Frederick
set forth
an inter
esting
speculation
" whether,
if
the
whole
community
were
made
immune,
the bacillus, condemned
to an existence of helpless
sapro-
phytism,
might
not
degenerate
into
a
relatively7
harmless
atoxic
form."
Writing
on
"Active
immunization
with
diphtheria
toxin-anti
toxic " in the Journal of the American Medical Association for March
11, 1922, Dr. Jacob Meyer, of Chicago, states that in 108 children the
duration of immunity
conferred by
injection
of diphtheria
toxin-
antitoxin
mixture
as determined
by the Schick
test extended
for a
period of 44 months in 94.4 per cent of the cases.
In Chicago the incidence
of diphtheria
has decidedly
diminished
since injection of diphtheria
toxin-antitoxin
was adopted
as a rou
tine
measure.
This
coincides
with
the
experience
in
New York,
where the efforts of the department
of health to immunize the school
children
have
been
so successful
as to prompt
the
State
board of
health
to immunize children throughout the State,
cw. m. k.)
472
Vol. XVII.
EDITORIAL.
ON SYSTEMIC INFECTION DUE TO ORAL SEPSIS.
It Avas as recently
as 1911 that Dr. William Hunter, of London, first
brought to international attention in such a forcible manner his com-
demnation of certain methods of dentistry,
as then practiced, which
observation and investigation
had
convinced
him
so frequently
re
sulted in pathology of the oral tissues or oral sepsis.
While Doctor
Hunter's observations
lead to an awakening of the medical and dental
professions, his work, as well as that of many
others,
was not based
upon scientific evidence.
Dr. C. E. Bentley, writing in the Illinois
Medical Journal for February,
1922,
on systemic
infections
due
to
oral
sepsis
says : " The
work
of Doctor Hunter
and
many
others
could
be summed up by saying that clinically
they noted the improve
ment which followed
the extraction of teeth in hundreds of cases."
Incidentally
it also might be stated that hundreds of cases showed no
clinical improvements
as the result of extraction of teeth.
That serious
systemic
infections occur as a result of suppurations
in the mouth is a view which, starting
as a small wave of progress,
has increased to overwhelming dimensions
as is shown by many nota
ble papers
and laboratory experiments
in recent years.
Bentley cites the laboratory
experiments
of Bosenow, demonstrat
ing the
selective
affinity of organisms,
and
of which
he remarks:
" These experiments
seem to have established
beyond question
the im
portance of the blood stream as a carrier of infection and also the very
peculiar and as yet unexplained tendency
for the organisms to have
what might be termed
a selective affinity for the same tissues in ani
mals
as in the individuals
from whom cultures were obtained."
Ex
periments
in animal inoculations have opened new fields of investiga
tion, the exploration of which
are becoming
of particular
value
in
reference
to
diagnosis.
Chronic
arthritis,
endocarditis,
nephritis,
cholecystitis, ulcers of the stomach,
and appendicitis are given as the
most
frequent
definite
secondary
effects
to
oral
foci of infection,
" while
general
impairment
of health
and
vigor, with
or without
recognizable
lesions,
is common."
In regard to arthritis, attention is invited to the fact that in young
persons, say up to 20 years of age, the condition is due to secondary
infection of the tonsils, adenoid
tissue, or infections of the paranasal
sinuses
and not
to oral infection,
but
in middle and later life
very
few cases are due to these causes ; arthritis then being largely due to
periapical infections of the teeth.
Early dental diagnosis is desirable
and imperative if preventive medicine
is the aim,
as the progress
of
the disease tends to metastatic
infection of the joints, manifestly
a
much
more
difficult situation
to
meet than
the eradication of
the
primary periapical infections of the teeth.
Endocarditis,
like
arthritis,
is
due
to
infection,
and
its
most
dangerous
symptoms
are
shown
in
the old patient and
not
in
the
No. 3.
473
EDITORIAL.
young.
Doctor Barker, of Johns Hopkins,
says : " It is not at all
uncommon
to have viridans endocarditis arising from infected teeth.
I have personally observed over 20 cases, and every one of the patients
is dead."
It was
possible
for Doctor
Barker
to
demonstrate,
in
several of these patients,
the presence of Streptococcus virklam in
granulomata
in the mouth.
To quote Doctor
Barker
further, "The
method
of procedure
at
Johns Hopkins Hospital
is to study the mouth in all cases of arterio
sclerosis
and of arterial
hypertension
in order to detect
there
any
source of infection that may signify
danger.
They do that not only
in the
cases
here
mentioned,
but
in
every
patient who comes for
diagnostic study.
Suspicious gums are carefully examined
and every
pulpless tooth is X-rayed.
A report from an expert
dental diagnos
tician
is considered,
with
other
accumulated
data,
before
the final
diagnosis is made."
Due to the natural vigorous resistance of the oral tissues, the pres
ence of chronic
foci
does not indicate by
any
means
that
an in
dividual
is suffering from systemic
effects, but it does indicate a con
stantly lurking danger.
A most important point in this connection
is that the development of definite
lesions from these foci is so gradual
that they are generally not recognized
by the patient, consequently
a
physician
is not consulted
until the disease has made such progress
as to offer obstinate
resistance
to treatment
and in many
cases to be
incurable.
The opportunity
for the dental
profession exists, first, of course,
in periodical
dental
prophylaxis
as a preventive
to the development
of oral pathological conditions and, second, in the early recognition
of dental foci of infection before the patient is aware of the existing
conditions,
or the appearance
of symptoms
indicative of secondary
lesions.
In viewing foci of infection the all-important
fact must not be over
looked
that
these
embrace many sources from which similar
infec
tions and results may come, prominent among
these being the tonsils,
paranasal sinuses, gall duct, intestines, Fallopian tubes in the female,
prostate gland in the male: in short, wherever
in the body the condi
tions
are favorable for the growth
and distribution
of
pathogenic
organisms.
The practice of extracting all nonvital teeth, recommended
by some
physicians, is in the light of results
obtained
by skillful conservative
dentists
being
abandoned
by
the leaders
in both
professions.
The
conservative
dentist
pleads for the retention of
inadequately
filled
pulp chambers about which no rarefied
areas are shown by the X ray,
but always with the reservation
that they
be constantly watched for
untoward symptoms.
474
Vol. XVII.
EDITORIAL.
In connection
with accessory foramina
remaining unfilled
by vir
tue of size and inaccessibility, Bentley, in common
with others in
vestigating
this condition,
believes
that
they
should
be given
the
benefit of the doubt in view of the evidence tending to the conclusion
that their
contents,
under favorable conditions,
become
organized
and their openings finally
covered with omentum,
thereby
prevent
ing infection
at
these points.
Dental
diagnosis should always
be
based upon clinical
examination,
as well
as X-ray findings,
and in
general the
internist,
the
dentist,
and
radiographer
should
be
in
consultation.
To Dr. Frank Billings
we are indebted
for the following
state
ment: "To investigate and manage
these
patients requires the team
work
of the clinical
and
laboratory
workers.
The clinician
must
carefully
examine
the patient, exhausting every
detail in
personal
history.
The skill of the dentist,
the nose and throat specialist,
the
gynecologist, the genito-urinary
expert,
and
others
may
be
neces
sary to locate the foci of infection.
Each focus must
be destroyed."
Bentley agrees in principle with many
when he states in his paper:
" It can not be too strongly said that
a tooth which can not be made
healthy should be extracted,
but all of us who have looked into this
matter know that many
teeth to-day are being cast out
when
they
could
be
made
things
of
use
and
beauty
by
modern
methods
of
treatment."
In reference
to the subject of systemic
infection due to oral sepsis,
it might
be of interest
to quote Doctor Gardner, of the Mayo clinic :
"We
have
come
to
the
conclusion
some
time
ago
that all
teeth
showing definite
pathology should be sacrificed," which is a positive
statement
from
a recognized
medical center and indicates the value
placed
upon dental
diagnosis,
(h. e. h.)
HAND
INJURIES.
During
the calendar year
1920 injuries
of the
hand
and
fingers
caused
27.G89
sick days
in the
Navy,
and
18 men
were
invalided
from the service in consequence of such injuries.
Proper
management
of
these
cases
is
one
of
the
most
difficult
problems that the naval medical officer is called
upon
to solve.
The
responsibility
is great,
not only to the patient, because good func
tion
is necessary
to enable him to
earn
his living, but
also
to
the
Government, because sick days with full pay and lifelong compen
sation for disability
are tremendously expensive.
The first treatment
is most important
and is never
to be slighted
for minor injuries
may develop
into severe infections, tenosynovitis,
or ankylosis if they
are not properly
treated.
Tetanus is a danger
No. 8.
475
EDITORIAL.
that must be always in mind, especially in the motorcycle
accidents
which are now so prevalent.
Conservation of all
possible
tissue
is
an excellent rule, for one is frequently surprised by the recuperative
ability of tissues apparently without circulation.
Accurate
adjustment
of
fractures
is
essential
because thus
the
smallest
amount of callus is produced.
Excessive callus
leads
to
involvement of the tendons
and
their sheaths,
with
ankylosis
as
a
result.
To avoid ankylosis early massage and manipulation
are im
portant.
Manipulation
begun
too early produces
nonunion; if de
layed
too long ankylosis
results.
Experience
and
frequent X-ray
examinations are necessary to determine
when to start manipulation.
If infection occurs
the first incision should be radical in order to
avoid the necessity
of repeating it later.
There
is no place
where
the Carrell-Dakin
technique
produces
more strikingly beneficial
re
sults than in the infections of the hand or fingers.
Proper
prepara
tion of the wound so as to allow access of the solution to every part
is essential.
Willems
has taught us the importance of open treat
ment and frequent motion
in
infected
joints,
and
these
principles
are of equal importance when
the tendons of the hand are the seat
of infection.
Reconstructive
surgery of the hand is one of the most
difficult,
delicate,
and uncertain branches
of the surgical art.
The
necessity
for it will
be
lessened
by
proper
care of injuries
in their
early
stages.
Careful
checking
of
the
diagnoses
made
by
experienced
men against
the X-ray picture shows
almost
50 per cent of failure
in diagnosis
of fractures of the bones of the hand without
the
use
of the X ray.
This difficulty of diagnosis and the serious
results of
failure
to make
the proper diagnosis make
the serious
injuries
of
the hand or fingers essentially hospital cases.
<l. w. j.)
SYSTOLIC
MITRAL
MURMURS.
Examination of recruits and
men prior to discharge
often brings
to light systolic mitral
murmurs about
which there
is always some
uncertainty
regarding
their
significance.
Much
has
been written
recently about
these findings, and the conclusions
of the writers seem
to be that a systolic murmur by itself is no evidence of heart disease.
In the Journal of the Royal Army Medical Corps for March,
1922,
Dr. K. R. Smith
discusses
cases of disordered action
of the heart
whose usual symptom
is distress upon exertion, which subsides slowly
and is accompanied
by an increase in the pulse and respiration
rate.
These
evidences of distress
on exertion have
become known
to ex
aminers as the effort syndrome
and they indicate an incapacity but
not necessarily
a disease of the heart.
The patient usually complains
of shortness
of breath, pain in the precordia, fatigue, and sometimes
476
Vol. XVII.
EDITORIAL.
of dizziness.
These
symptoms
generally disappear following
grad
uated exercises.
From a military point of view, men exhibiting
the
effort syndrome
should
be considered
unfit for the service if their
attacks
are
accompanied
or have
followed
acute
rheumatic
fever,
and
present
precordial
pain, with
tachycardia
over
120 when re
cumbent,
and
severe
dyspnoea
on
exertion.
Systolic
mitral mur
murs are of little account.
Men, according to Doctor Smith, if in
valided from
the
service
for systolic murmurs, per
se, are
subse
quently nearly always found fit for active
service,
and it is
a well-
known fact that during the war such men stood the severest strains
of active
service
without
accident.
If the mitral
systolic murmur
is accompanied
by cardiac hypertrophy,
however,
the man should be
pronounced
unfit for military service.
In the Military Surgeon for March, 1922, Lieut. Col. Koger Brooke,
Medical
Corps, United States Army, discusses
2,400
recorded
cases
of
men
who
were
drafted
into
the
service
with
cardio-vascular
symptoms.
When
they
were examined
on
discharge
it was
found
that of 459 men accepted with functional
systolic murmur, and 687
with mitral
regurgitation
without hypertrophy,
9 were discharged
as with valvular
disease of the heart, and it has been noted that of
these
9 men only
3 have applied
to the Veterans' Bureau for
dis
ability compensation.
Of the 2,400 men enlisted,
90 were discharged,
but Colonel Brooke
believes
that
60 were discharged through
lack
of appreciation of the effort syndrome.
He, like other writers
on
this subject, is of the opinion that a mitral systolic murmur is func
tional
unless it is associated
with cardiac hypertrophy,
with
acute
rheumatic fever, or diseased
tonsils, and with
an accentuated
pul
monic second sound or with the effort syndrome.
(w. m. k.)
RECENT
STUDIES
IN THE
BIONOMICS
OF THE
HOOKWORM.
The investigations of the control
of hook worm
disease carried
on by Cort
and his coworkers in Trinidad
under the
auspices
of
the
International
Health
Board
and
Johns Hopkins University,
have
added
a large
amount
of
information
to our knowledge
of
this problem.
The control of hookworm disease centers around two
main
points:
Prevention
and
cure.
In
these
investigations
par
ticular
attention
was paid
to the preventive
phase,
and with
this
end
in
view
the investigators
concentrated
their
attention
on
the
biological
aspect of
the
problem.
The
commission
studied
hook
worm eggs and young larva?, the distribution
of the eggs over
the
soil by man, other
animals, and physical agencies, conditions
neces
sary for the
development
of the hookworm in the soil, the
length
of life of
the infective
larvse, conditions
necessary
for
their
life,
active migrations
and passive spread
of the larva?.
No. 3.
477
EDITORIAL.
The one thing that made the investigation of these various phases
of hookworm
life possible
was the recent introduction
of the " isola
tion apparatus " by Baermann in Sumatra, which was slightly modi
fied for use in Trinidad.
A description
of the apparatus and
the
technic of using it follows
:
"The apparatus for the isolation of hookworm
larva?
from
the
soil, works by bringing
the
lower
surface of
a soil
sample
into
contact
with
water of
a considerably higher
temperature.
Under
these conditions
a large proportion
of the nematodes
in the sample
will pass into
the water
and
can
be collected
and
counted.
This
isolating
apparatus
consists
of
a
glass
funnel
almost
filled
with
water,
which
has
the outlet closed
by
a
clamped
piece of rubber
tubing.
The soil sample
is placed
in
a sieve, which is then
fitted
down into the funnel
so that the
level
of the water is above
the
lower
surface
of the soil.
For
the examination of soil samples
of
half a pint or more there
were used large glass funnels
8 inches
in
diameter
and
specially
prepared brass
sieves
7 inches
in diameter
and 3 inches in height, with
a
1 -millimeter
mesh.
To prevent
small
particles of soil from sifting through
into
the
funnels,
the
sieves
were lined
with one or two
thicknesses
of cloth.
Tightly
fitting
rubber
tubes
closed
with
Hoffman
clamps
are
placed
on
the
stem
of the funnels.
*
*
*
It is possible
to substitute
for the sieve
a piece of wire screen covered with cloth, of such
a size that it can
be fitted down into
the funnel.
The
sieves have
the
advantage
of
being more easily handled in the transfer of soil."
In using
the apparatus this sieve is lined with one or two thick
nesses of cloth.
The soil is broken up thoroughly
before placed
in
sieve.
Water
heated
to
115° F. is
placed
in funnel
to within
1£
inches of rim.
The sieve is now put in place, care being taken that
no contact
occurs
between
water
and
bottom
of sieve.
Water
of
above temperature
is now
added until level
is
1 inch above bottom
of sieve.
The
apparatus should
be
set up during
the
day,
to
be
examined
the following day, at which time the clamp on the rubber
tube is slightly
opened, the water run into a centrifuge tube, centri-
fuged, and the supernatant water withdrawn.
The residue
is spread
on a 2 by 3 inch slide for microscopical examination.
The identification of mature
hookworm
larvae is somewhat
diffi
cult at first, but if practiced for some time the difficulties will soon
disappear.
The
authors recommend
that the structure
and
move
ments of cultured
larvae
be
studied
until their
characteristics
are
familiar.
In this connection
the authors recommend
a new
method
of culturing human faeces to secure hookworm
larvae.
The animal
charcoal method of Loos was deemed not to be quite satisfactory, and
Ackert developed
another method
that the commission
found to
be
superior.
The following points are of importance :
478
Vol. XVII.
EDITORIAL.
(1) If possible
faeces from individuals
heavily infested with hook
worms is obtained.
(2)
The culture medium
consists of ordinary
soil first heated to
150°
F.
to insure killing of all
nematodes.
This soil is placed
2
inches
deep in shallow tin pans,
11 inches
in diameter,
with
holes
punched
in their bottom
to permit drainage.
(3)
One-fourth inch layer of stool is spread
on surface of soil.
(4)
Cover with
1 millimeter
of wood or charcoal ashes to inhibit
growth of mold and prevent formation of hard crust.
(5)
Keep culture in screened place from rats and other animals.
(6)
Keep cultures well moistened.
The isolation apparatus has a large range of use in investigations
and
hookworm
control work,
such
as examination of soil
samples
from various situations in areas where
hookworm
disease is preva
lent to determine
the exact
sources of infestation of the people,
to
follow
the reduction of soil infectivity after the elimination of soil
pollution,
to study
the
extent
of migrations
of larvae in different
situations.
Experiments
designed
to standardize the isolating
appa
ratus
showed
that to isolate
a satisfactory
percentage
of the
larvae
the water must
be at least
10° warmer than the soil, that a slightly
higher
percentage
of larvae can
be
isolated
from moist than
satu
rated soil, that in soil with
very finely
divided particles
the
per
centage of larvae which can be isolated is less than in coarser
soils,
and that while most of the larvae escape from the soil into the water
in
the first six hours, an appreciable number come
out
after
this
time.
Up to the present time the conception
has been prevalent that the
hookworm larvae during their free existence
were surrounded by the
detached skin of the second larval stage, which acted as a protective
covering and was thrown off in the normal course of events when the
worms pass into a suitable host.
Cort and his coworkers found that
in a series of soil samples
examined
from places polluted by people
infested with hookworms
a large proportion
of the
mature
larvte
were
without
a sheath,
suggesting that it is
a common
thing for
mature larvae to lose their sheaths
and continue to live in soil.
The
fact that mature
hookworm
larvae lose their
sheaths
under certain
conditions has been
noted by previous investigators, but the general
opinion
has always prevailed
that they live normally
inclosed in
sheaths.
With regard
to the relation of the
domestic
chicken and pig to
hookworm dissemination, Ackert
and F. K. Payne, members of the
commission,
have contributed some valuable information.
The for
mer showed that hookworm eggs swallowed by chickens
produce in
fective hookworm larvae when the fowl
faeces are mixed with animal
charcoal or with soil, but that the majority
of eggs failed
to do
so,
this failure being attributed in part to breaking of eggs in the giz
Xo. 3.
479
EDITORIAL.
zard, injury from urine in the faeces, and to malnutrition
of the larvae
in the excrement.
Ackert
concluded
that chickens
are
more
bene
ficial than harm fid in the control of hookworm
disease, at least in
Trinidad.
Ackert
and F. K. Payne
consider
the free-range pig
as
an important factor in the dissemination of human
hookworm eggs,
having
shown that eggs swallowed by this animal produce
infective
larvae in five days.
They also found
a new species of hookworm, iterator
suUlus,
to be
of common occurrence
in the domestic pigs in Trinidad.
Cort
and
G.
C.
Payne
studied
the
effect of hookworm
control
measures on soil pollution
and infestation on a sugar establishment
and found the same conditions that Baermann had found in Sumatra.
The hookworm
larvae in the soil were
not
diffused
over
wide
areas
but
were
concentrated
in the areas where soil pollution
took
place,
in this instance in certain
places in the cane field where many of the
people were in the habit of visiting for purpose
of defecation.
After building
an adequate number of latrines and the carrying on
of an educational
campaign, coupled
with treatment
of the people of
the
area,
the soil pollution
was reduced
to
a minimum.
A subse
quent examination of soil samples
taken at intervals showed
a rapid
dying out of the infective hookworm larvae, so that in about six weeks
soil infestation
was
practically
eliminated.
Practically
the
same
findings were noted after proper treatment
of a cacao estate.
Baermann's
isolating
apparatus
enabled
Augustine
to carry
out
Home
definite
experiments
with
regard
to
the migration
of hook
worm
larvae.
The field studies of Baermann in Sumatra and those
of the commission
in Trinidad
were verified.
Experiments
showed
that infective hookworm larvae placed on moist soils did not migrate
during periods of observation
from
15 hours to 42
days, but that
hookworm
larvae may
be carried
out
from
centers
of soil infesta
tion by surface water and thus establish
themselves in new locations.
They were not found
to migrate
to more favorable situation
when
their original
environments became unfavorable.
The
larvae
under
optimum conditions of moisture
and temperature
were found to re
main on and within the upper surface of the soil.
The
conception
has been prevalent that the infective
larvae can
remain alive for one to two years in their natural environment.
This
has been
based on observations
made in the laboratorv
where
some
investigators kept the larvae alive for 18 months.
The commission
showed,
however,
at least
so far as conditions in
Trinidad went, that the life of the larvae in nature
is limited to about
six weeks.
Augustine found that the loss of sheath under favorable
conditions did not tend to shorten their lives, but rendered
them more
susceptible
when
in unfavorable environment.
He believes that the
conclusion
can
be
drawn
that
environmental
conditions,
such
as
tropical
temperatures
which
tend
to
increase
the
activity
of
the
480
Vol. XVII.
EDITORIAL.
mature
hookworm larvae, will shorten
their lives by the more
rapid
using up of stored food material,
(e. p.)
ON
THE
CHOICE
OF OPERATION
IN INGUINAL
HERNIA.
Most authorities agree that in infancy high ligation
alone
suffices,
little or no deliberate
effort at reconstruction being made, and prac
tically all agree that in adults not only must high ligation
be
done
but the canal
must
be reconstructed
with care to form
a strong bul
wark against recurrence.
The type of sac is a determining factor as to whether the posterior
wall
need
be reconstructed.
The
stalked
sac,
when
long,
narrow
thin, nonadherent,
and representing an unobliterated funicular proc
ess, such
as is encountered
in early life, adolescence, or in
a recent
hernia in well-muscled adults, calls for high ligation
without
recon
struction of the posterior wall, the internal
oblique muscle
usually
being well developed
and capable of withstanding
strain.
The
ses
sile sac, on the other hand, such as is found in direct hernia, need not
be
ligated,
merely
turned
in,
but
reconstruction of
the
defective
posterior wall
is the essential
factor in this type.
In old. indirect
hernia? the canal musculature has been overstretched
and
weakened
by long-continued drag of the sac with its heavy
contents.
The
sac,
though still stalked,
approaches
the sessile type, must be ligated high,
and the posterior wall must
be carefully
and stoutly
reconstructed.
A " pantaloon " sac must not be overlooked
in any hernia operation.
The essential
features of the operation practiced by P. G. Skillern,
jr., as described
in
a recent number of Surgery,
Gynecology,
and
Obstetrics,
are
free
exposure
and
thorough
cleaning of Poupart's
ligament,
Gimbernat's
ligament,
the
triangular
fascia,
the
pubic
head of the rectus
inclosed
in the linea semilunaris, the linea
semi
lunaris itself, and the aponeurosis
extending laterally
from it; firm
reconstruction
obtained
by developing
a fingerlike
cylinder of
the
musculo-aponeurotic tissue just mesial
to and above the thinned-out
conjoined
tendon
and
internal
oblique muscle
fibers,
suturing
this
cylinder
to Gimbernat's
and
Poupart's
ligaments
from
the
pubic-
bone to beyond
the internal ring, fastening the lower flap of external
oblique
aponeurosis
down
upon
the
cylinder
and
the
upper
flap
down upon
the lower, thus imbricating
the two flaps and taking the
•strain
away from
the first row of sutures; bringing
the
cord
out
somewhat
lateral to the internal ring, preventing constriction of it.
and transposing it to the surface
of the imbricated external oblique
flaps; and finally obliteration of dead spaces by suturing the edges of
the fibrous deep layer of the superficial fascia to each other and down
upon
the
imbricated
external
oblique
aponeurosis.
The
postural
method
advocated
by Lyle, which
relieves
tension
both
during
and
after the operation, should be practiced,
(c. m. o.)
IN MEMORIAM.
REAR ADMIRAL
FRANCIS
M. GUNNELL, MEDICAL
COEPS,
UNITED
STATES
NAVY, RETIRED,
1827-1932.
Rear Admiral Francis
M. Gunnell,
Medical
Corps, United
States
Navy, retired,
died at his residence
in Washington,
D. C, on June
10,
1922.
He
was in his ninety-fifth
year,
and
at the time of his
death was, with one exception,
the oldest
commissioned
officer of the
Navy.
He was born in Washington
on the 27th of November,
1827,
and except for nearly
17 years spent at sea, passed his entire life in
that city.
Graduating
from
the
medical
department
of
Columbian
Uni
versity, which in later years
became the
George
Washington
Uni
versity, he entered
the Navy
in
1849
as an
assistant
surgeon,
and
was promoted
through all the grades
to medical
director, in which
grade
he
was
serving when he
was
placed
on
the retired list for
age
on November 27,
1889.
He served
as Surgeon General of the
Navy, with the relative rank of commodore,
from April
1,
1884.
to
April
1,
1888.
After his retirement
he maintained
an
active
interest
in Wash
ington affairs and on several
occasions
served on special
duty at the
Bureau of Medicine
and Surgery.
Admiral Gunnell's first duty was on board the U. S. S. Falmouth
on which
vessel and on the store ship Supply,
he served in the Pa
cific from April, 1849, to January, 1852.
On his return home he was
stationed
at the navy yard, Washington,
and in September,
1854,
he
was detailed
to the U.'S. S. Independence,
on which he again served
in
the Pacific
until
1857.
In August,
1857,
an attempt
was made
to lay
a
cable
across
the
Atlantic
by the American
frigate
Niagara
and
the British ship of
war Agamemnon, but about
300 miles from the Irish coast the cable
parted, owing to
a
strain caused by a sudden dip of the sea bottom.
Admiral Gunnell
was attached
to the Niagara
in
1858, in which year
the same two ships, each with half the cable
on board, steamed
to
a
point
in
the
Atlantic
midway
between
Valencia,
Ireland,
and
Hearts Content, Trinity
Bay, Newfoundland,
spliced the cable, and
481
482
Vol. XVII.
IN
MKMORIAM.
steering
in
oppositie
directions,
safely
landed
the
ends
at
their
destination on August
5.
After
a short tour of duty at the receiving ship at New York
he
joined
the U.
S.
8. Fulton, and
was medical
officer of that
vessel
when
she
was wrecked
in
1859.
During the Civil War he was
at
tached
to
the U.
S.
S. Pawnee
and
participated
in
many
naval
activities.
From
January,
1863,
until
October,
1865,
Doctor
Gunnell
was
attached
to the naval hospital at Washington.
His next tour of sea
duty
took
him
to
the
European
station,
where
he
served
on
the
U. S. S. Ticonderoga, from
1865 to 1868.
At the end of this cruise
he returned to the naval hospital, Washington,
where
he
remained
until
1872.
After
a short period of service
on the U. S.
S. Frolic
he served
as fleet surgeon
of the North Atlantic Fleet on board the
Franklin
and
Wabash.
In
1875
he
was
a member of the Medical
Examining
Board
in
Washington,
and
served
once
more
in
the
naval
hospital
at
Washington
until
1879.
In that
year
he
was
ordered
to the U.
S.
S. Richmond
as
fleet surgeon
of the Asiatic
Fleet.
Returning
to Washington
in
1881,
he served
as
a member of the
retiring board until
he was appointed Surgeon General and Chief of
the Bureau of Medicine
and Surgery.
His
last duty on the
active
list
was
as
president
of
the
Medical
Examining
Board,
which
service
was terminated, as has been mentioned,
by his retirement on
November 27, 1889.
Professionally.
Admiral Gunnell
was very active.
He repeatedly
represented
the Medical
Department of
the Navy
at the
meetings
of
the American
Medical
Association,
and
was
a
delegate
to
the
International
Medical
Congress
in
1876.
Connected
more
or
less
intimately
with
St.
Elizabeths
Hospital
for
43
years,
he
was
a
member
of its board of visitors for a quarter of a century and its
chairman for
a decade.
Admiral Gunnell
was
a courtly
gentleman
of the old school
and
will
be remembered
by the older medical
officers of the service
as
a
man of pleasing personality, punctilious
in the performance
of hin
duties,
and
immaculate
in
dress.
It
is interesting to note that
he
was the last surgeon
general
to employ quill
pens when signing his
correspondence.
After his retirement,
he married Mrs. Harriet Chew Barnes, the
widow of a former surgeon
general of the Army, who, with her two
children,
Lieut.
Col. Joseph
T. Barnes, United
States
Army,
and
Mrs. Mark Brooke, survive him.
Admiral Gunnell
was buried
in
the National
Cemetery
at Arlington.
No. 3.
483
IN
MEMORIAM.
COMMODORE
JOHN
CROPPER
WISE,
MEDICAL
CORPS,
UNITED
STATES
NAVY, RETIRED, 1848-1922.
Medical
Director John
Cropper
Wise, United
States
Navy, died
at the United
States Naval Hospital, Washington, D. C, on June 12,
1922.
Born in Virginia, October 7,
1848,
he was commissioned
an
assistant
surgeon
in
the
Navy
April
28,
1870.
During
his
first
cruise he served on the Savannah, Guerriere, New Hampshire, Talla
poosa, and
Gettyslmrg .
He
was
promoted
to the grade
of
passed
assistant
surgeon
June
8,
1874, while
he was on duty at the naval
hospital,
Philadelphia.
During his second cruise
he was attached
to the U. S. S. Despatch
from May,
1875,
to July,
1878.
After
a short tour of duty at the
navy yard, Norfolk, he returned to the naval hospital, Philadelphia,
where
he
remained
until
March,
1881.
He
was
attached
to
the
U. S. S. New Hampshire
from August,
1881, till April, 1884, during
which
time
he
was
commissioned
as
surgeon.
From
September,
1884, until May, 1887, he was medical officer of the U. S. S. Jamestown.
On leaving this vessel he was ordered
to the torpedo station, New
port. R. I., where
he served until September,
1890.
He then
went
to sea on the U. S. S. Alliance,
on which vessel he served until April,
1893.
Various
duties
in Washington
occupied
his attention until
June.
1897,
when
he went
to
sea for the last
time.
During this
cruise he was attached to the U. S. S. Philadelphia and to the U. S. S.
Baltimore
until March,
1899.
He was promoted
to the grade of medical inspector March 20, 1896,
and to that of medical director February
7, 1900.
After
his last cruise
he returned to Washington
and
served
on
various boards until August,
1905, when he was ordered
to the com
mand
of the United
States
Naval
Medical
School in Washington,
in which capacity he served until September,
1908.
He was a mem
ber of the Naval Retiring Board
and of the Naval Examining and
Naval Medical
Examining
Boards until September,
1910.
He
was
placed
on the retired list at the age of 62, on October 7, 1910.
Doctor Wise was noted for his professional attainments.
During
the later years of his active
service
he represented
the Medical
De
partment of the Navy
at many conventions of medical and
scien
tific men.
He was
a delegate
to the Tuberculosis
Congress
held in
Baltimore
during
January,
1904,
and to the meeting
of the Asso
ciation of Military
Surgeons held at St. Louis, Mo., in October of
the same year.
He was a delegate to the International
Medical Con
gress which met in Lisbon, Portugal,
in April, 1906,
and to the Red
Cross Conference
which was held in London in June, 1907.
484
Vol. XVII.
IN MEMORIAM.
Doctor Wise took an active interest in the Association of Military
Surgeons of the United
States,
and was president of that organiza
tion during
the years
1903
and
1904.
For years
he was
an active
contributor
to
its work
and
literature.
A fluent
and
interesting
writer,
his contributions
to medical
literature
embraced
essays on a
wide range of subjects.
Doctor
Wise
was of distinguished
appearance,
sympathetic and
broad
minded.
He will be held in affectionate
memory
, by his asso
ciates.
Sarcoma
of the orbit.
485
CLINICAL NOTES.
EEPOET OF A CASE
OF SAECOMA OF THE
OEBIT.
By 0. Davis, Lieutenant,
Medical
Corps,
United
States
Navy.
A boy (T. F.), aged
5 years,
was admitted to the municipal
hos
pital, St. Thomas, Virgin Islands, with a tumor of considerable
size
protruding from his left orbital cavity.
The history as secured from
the mother was indefinite, she stating that the tumor had appeared
overnight about two weeks previous to admission to the hospital, had
not increased in size during the intervening time, and had not caused
pain
nor
any other
symptom.
No
subjective
symptoms
could
be
obtained from the patient.
On admission, temperature, 100 ; pulse,
88.
Physical
examination
negative,
except for a mass protruding
from left orbit.
The eyelids
were edematous, their ciliary margins covered with pus, and protrud
ing between
them
was
a red
edematous
mass of conjunctiva.
On
separating the eyelids farther the globe of the eye was found to be of
normal size, but pushed into the upper inner quadrant of the orbit by
a rather
firm
mass, occupying approximately
three-fourths
of the
orbital cavity.
Pupillary
reflexes
were absent
and
no vision could
be demonstrated.
The
mass was not adherent
to the orbit and no
fluctuation
was present.
Laboratory
findings : Urine and feces negative.
W. B. C, 8,000.
Wassermann
(Nogouchi),
negative.
In view of the rapid growth of the mass, loss of function of the
eye, and open exposure of the conjunctiva to infection, it was decided
to operate.
At operation the mass was found to be
a rather firm
white
tumor,
poorly
vascularized,
and
not firmly
attached
to
the
globe of the eye nor the orbital
walls, but growing
from the
apex
of the orbit
and completely filling the orbital
cavity.
The tumor
tissue was rather firmly attached to the periosteum
at the sphenoidal
fissure, its origin
as far as could be determined.
The periosteum
at
this point was cleaned from the bone, and the orbit cleaned of all tis
sues, leaving only the periosteum
of the orbital
walls, packed
with
gauze,
and
the
conjunctiva
closed
with
openings
for
drainage.
Sloughing followed,
with
foul-smelling
discharge,
and within six
weeks after operation the tumor had again filled the orbital cavity
646—22
8
485
486
Vol. XVII.
CLINICAL
NOTES.
and
was
protruding
between
the eyelids as
a raw bleeding
mass.
Pathological
examination of the tumor at the naval medical school
showed
a round
cell
sarcoma
with
numerous
mitotic
figures.
No
further
operative procedures
were
attempted,
and
at the, parent's
request
the patient was sent home, where
he died
three
days after
leaving the hospital.
No autopsy
could be obtained.
REPORT
OF A CASE
OF ACUTE RETROBULLAR
NEURITIS.
By L. G. Jobdan, Lieutenant,
Medical
Corps, United
States Navy.
The patient, aged 29, first appeared
at the clinic late in the after
noon of August
9.
His history was negative
for any previous oph-
thalmologieal trouble.
He stated that in the morning of August
7
he first noticed
a coryza associated with considerable
congestion
of
the nasal mucous
membranes,
headache,
and lachrymation.
Though
feeling unwell, he attended
to his duties that day.
The following day in the morning
he commenced
to experience
pain behind the right eye of a dull constant
character, but of only
moderate
severity.
The
headache
and nasal congestion
had abated
considerably.
During the afternoon
he noticed
a slight haziness of
vision in the right
eye,
while
the pain
behind
the
eye
increased
somewhat
and
movement
of the
globe
itself
became painful.
The
loss of vision was more marked on August
9, and had increased
pro
gressively to such an extent that the man became alarmed and came
to the hospital for treatment.
There
was
no
evidence
of venereal
disease, alcoholism, or other
poison.
The teeth were in good condition.
Examination
of the af
fected eye showed
the following conditions : Right eye : There
was
a
slight congestion
of the conjunctiva.
The pupil was of the same size
as that of the left eye; it reacted
to light and accommodation (?),
possibly
a little sluggishly.
The outline was regular.
Vision
was
20/200.
(Snellen test type) , and that only by peripheral vision, i. e.,
when
the visual axis was directed
to a point on the wall below the
chart.
The mobility
of the globe
was of normal amplitude
in all
directions.
Ophthalmoscopic examination of the fundus showed all
media
clear,
the only appreciable pathology being a slight
disten
sion of the veins of the retina.
Left eye: Normal
in every respect;
vision 20/20.
Muscle balance
was not obtainable.
When the patient was tested -with lenses it was impossible to im
prove
the vision of the right
eye.
The left
accepted
a sphere,
plus
.75 (20/20).
A nasal
examination
disclosed
a marked deviation of the
nasal
septum
to the right,
superiorl}',
and
a heavy
ridge of the vomer
to
the left inferiorly.
The right
middle turbinate
was hypertrophied
No. 3.
487
CLINICAL
NOTES.
and undergoing
cystic
degeneration.
A small
amount
of purulent
discharge
was seeping clown between the septum and the right middle
turbinate.
August JO.—The X-ray examination
showed
that the right
eth
moidal cells and
the right
sphenoidal
sinus
were
slightly
clouded.
The dental
officer
reported
that the teeth
were
negative.
The
pa
tient
was symptomatically
and objectively
about
the same.
Vision
right 10/200 indirect: left 20/20.
Ophthalmoscopic;
no change noted.
'tee
Chart of field of vision
showing
a large central
scotoma, the central
portion
of which was
absolute,
the outer
edge
being
only
partial,
for
although
the
colors
were
obliterated,
there was
some
perception
of movement.
Perimeter examination was made
(fig.
Xo. 3.).
There was
a large
central
scotoma, the central portion of which was absolute,
the outer
edge
being
only
partial,
for although
the
colors
were
obliterated,
there was some perception
of the moving object.
The green field and
also
the
red
was
lost,
except
in
one
direction
as
indicated.
The
blue, white,
and form fields
at the periphery
were unaffected.
This
syndrome
is indicative of disease of the optic nerve.
Under
local
anaesthesia,
a
submucous
resection,
a
right
middle
turbinectomy,
and
a partial
exenteration
of the posterior right
eth
moidal
cells were done.
Profuse
hemorrhage
prevented
further
op
488
CLINICAL
NOTES.
Vol. XVII.
erative
procedure.
The nares were packed.
The turbinate removed
was hypertrophied. cystic,
and filled with polypoid granulations and
pus.
August
11.—The eyes were somewhat
suffused
and the right eye a
little painful.
His vision was not tested.
The ophthalmoscopic pic
ture was unchanged.
The Wassermann reaction
was reported
nega
tive.
Chart
of field of vision
showing
a loss of the border
zone of relative
scotoma, diminished
size of
the absolute
scotoma,
and
a partial
recovery
of
the
color
fields
for
red
and
green.
August
12.—The
nasal
packing
was
removed,
but due
to sharp
hemorrhage,
it
was
necessary
to
reintroduce
the
packing
on
the
right
side.
Both
eyes
were quite
injected.
The patient claimed his
sight was unchanged,
and that pain behind the right eye
was still
present.
August
13.—The packing was again
removed,
but profuse bleed
ing a second time necessitated reinsertion on the right side.
Ophthal
moscopic examination disclosed
a hyperemia of the right nerve head,
a slight blurring of its margin, and some slight increase in the venous
engorgement.
The level of the disk was apparently
normal.
The
conjunctiva
of both
eyes were
quite
injected.
Vision
10/200
(in
direct).
T. P. R. normal.
No.
3.
489
CLINICAL
NOTES.
August IS.—The
packing
was
removed;
there
was
no bleeding.
The subjective
relief
was considerable.
By afternoon the conjunc
tiva] conjjestion
and pain behind right eye had markedly diminished.
The fundi showed
no change.
August
17.—Externally
both
eyes
were
normal.
The
vision
of
the right eye
had improved to 20/200.
The hyperemia
of the right
disk
had
disappeared
and
the
venous
enlargement
subsided
some
what.
The margins were still slightly
hazy.
The level was normal.
The mucous membranes of the nose were in good condition and there
Chart
of field of vision showing
that the central
scotoma has almost
disappeared
and that
the color fields are being restored.
was only a small amount
purulent discharge
from the operative
site
and
the
cells
in that vicinity,
even
when
the
Sonderman suction
apparatus was used.
August
18.—Vision
20/200.
A
second
perimetric
examination
(fig.
No. 4)
showed:
(a) A loss of border zone of relative scotoma;
(6) diminished size of absolute
scotoma;
(c)
a partial
recovery
in a
somewhat
irregular
manner
of
the color fields
for
green
and
red.
The right fundus was normal except for the persisting haziness
of
the disk margins.
The nasal
mucous
membranes
were healing rap
idly, with practically
no discharge
observed
from the operative
site.
490
Vol. XVII.
CLINICAL
NOTES.
August
20. —Vision
20/100.
X-ray
of
ethmoids
and
sphenoids
reported negative.
August
Vision
20/50.
%
August
24. — Vision
20/30
plus.
Another
perimeter
examination
(fig. No.
7)
showed that the central
scotoma
had disappeared
with
the following exceptions:
(a)
Slight
enlargement
of
the "blind
spot"; (b) two small areas one in the nasal and the other in the infra
orbital
fields.
The
color
fields
were
restored,
except
that at one
position the field for red was much smaller than the field for green.
9 £-2/
the "iteyrowitt"
'» * B. u.vr.*,n..or<
Normal
chart
of
Held
of vision
with form
and
color
fields
In
their
proper
relationship
and extent.
Nasal examination showed that the mucous
membranes
had covered
the denuded
operative
site, and there
was no further
discharge ob
servable.
Ophthalmoscopic examination of the fundi
disclosed
both
to be apparently normal, with the exception
that the margins of the
right disk were slightly
blurred.
September
6.—Vision
20/20.
The
nose
had
thoroughly
healed.
A perimeter examination
(fig. No.
8)
showed
a perfectly
normal
chart with form and color fields in their proper relationship
and cx-
n of a pin-point
scotoma in the nasal field and
CLINICAL
NOTES.
491
a slight enlargement of
the
" blind
spot."
Ophthalmoscopic
ex
amination
revealed the following findings : The disk outlines were not
sharply
defined,
but the
level
and
color
were
apparently
normal;
the vessels were normal ; the balance of the fundus did not show
any
apparent pathological
variations.
All media
were clear.
The case was kept under observation
for a period of three months,
and the end examination showed
no variation from that noted under
the date of September
6, when
he was sent to duty on the hospital
reservation.
The
vision of the affected
eye
was
20/20.
The small
central scotoma
is apparently
permanent.
While it does not annoy
him in his ordinary
pursuits, it renders
him unable
to sight
a rifle,
his last scores
on the rifle range
being conclusive
evidence
of this
fact.
Because of this defect it was necessary
to recommend
his dis
charge from the service.
A CASE
OF CEREBELLAR TUMOR.
By H. Bdtts, Lieutenant
Commander,
Medical
Corps,
United
States
Navy.
The following
case is deemed of interest, not because of its rarity,
but because
it emphasizes
the importance of complete
and careful
physical and
neurological
examinations, including
an examination
of the eye grounds, of patients who present
no apparent neurologi
cal symptoms in general, before operative procedures are undertaken.
It goes to show that the apparent cause of symptoms
is not always
the real one, and that if sufficient
search is made one will often arrive
at a very different diagnostic conclusion from the seemingly obvious
explanation of symptoms.
The patient, Mrs. D. S., 31 years old, was the wife of a chief petty
officer.
Admitted to St. Joseph's Hospital,
San Diego, Calif., Novem
ber
10,
1921. she complained of very severe headache
in the suboc
cipital region.
She stated that she had suffered with headaches, " off
and on," localized at the base of the brain, since childhood, but they
had been much
worse
during
the last four
years,
and for the
two
months prior to her admission
to hospital she had suffered with head
aches
constantly.
They
were
said
to be
worse
before,
during,
and
just after menstruation.
She also complained of severe sacral back
ache and profuse leucorrhcea.
Physical
examination
showed
the
uterus
to
be retroverted
and
immovable,
and
the right ovary
large
and
hard.
The
following
laboratory data were obtained : Blood examination : 4,390,000
erythro
cytes; leucocytes,
10,200; large and small lymphocytes,
12 per cent;
polymorphonuclears,
88
per
cent.
Urinalysis:
Specific
gravity
1.011;
heavy
trace of albumin
present,
sugar
absent,
few
urates,
492
Vol. XVII.
CLINICAL
NOTES.
large amount of mucus,
and few bacteria present.
Blood
pressure:
Systolic, 100; diastolic, 70.
Blood
serum
and two spinal fluid Was-
sermann
tests were all negative.
On November 28 the uterus
was curetted,
suspended
by the round
ligament, and
a cyst of the left Fallopian tube, as well as the appen
dix,
removed.
The
uterus
was
enlarged
and
retroflexed,
and
the
appendix was enlarged,
kinked, and acutely
inflamed.
During opera
tion the patient showed
a decided
hemorrhagic tendency.
The
patient
made
an
uneventful
recovery
from
the
abdominal
operation, but continued to complain of headache, "sour stomach,"
and occasional
emesis, which had no relation to the taking of food,
and which afforded
no relief of headache.
On December
11 she complained of difficulty in. remembering,
de
fective vision, and of arms feeling numb.
Temperature, pulse,
and
respiration
were
normal
at
this
time.
The
next day
she
talked
irrationally, had difficulty in voiding urine, and complained of pain
in the back of her neck.
Two days later she had a fairly comfortable
day, and on December
17 she left the hospital.
On December
30 she was readmitted to the hospital in an ambu
lance, screaming with severe pain in her head, which morphine
re
lieved
to some extent.
The next day she was nauseated
at times and
pain in head continued,
somewhat
relieved
by morphine.
She would
cry out while sleeping and would awaken
as the result of the pain.
At this
time
the
case
was
referred
to
me, after
a diagnosis of
" brain tumor " had
been made,
and I was requested
to attempt
to
localize the tumor with a view to operation.
On January
4, 1922, 1
made a complete neurological and mental examination of the patient.
Her mentality was unimpaired,
and she lent as good
cooperation
in
her neurological examination as I could desire.
She stated that her
head
had
not been entirely
free from pain for the past four years,
and
upon closely
questioning her husband I learned that
he
had
noticed
when
she walked with him she tended to bear to the left and
would sometimes
crowd him off the left side of the sidewalk.
She
could give no explanation for this peculiarity,
and her husband
did
not attach any significance to it and would not have mentioned
it to
me had I not specifically asked him about it.
Her neurological
examination
revealed
the following:
She
could
not read or tell
time
from
a clock, but could count fingers.
Both
eyes contained markedly
choked
disks,
the left one more
than
the
right.
Nystagmus
was
present
in all directions, but coarser
when
her eyes were turned to the left.
There was no paralysis of the
eye
muscles.
The
pupils
reacted
very sluggishly
to light and
accom
modation ; they
were round in outline, and the left one was slightly
more dilated than the right.
Diplopia was present.
The position of
the eyeballs
was normal.
When questioned,
she complained
of sco
No. 3.
493
CLINICAL
NOTES.
tomata,
tinnitus,
and
vertigo.
In smiling
the left labial
fold
was
less distinct
than the right.
She
could whistle, wrinkle
forehead,
and expose
her
teeth well.
Her hearing
(watch)
was
6 inches for
right ear and 2 inches for the left ear.
Speech showed
no defect,
and
her senses of taste and smell were apparently normal.
Her muscular
apparatus
showed
diminished
tonus of muscles,
but no atrophy
or
hypertrophy of same.
Hand grips were equal and strong.
Stereog-
nosis was normal.
Adiadokokinesis
was
absent.
Her deep reflexes
were all plus.
Finger-nose and finger-finger
tests were poorly
done
with the left hand ; well done with the right.
Localization
of touch
and pain sensations
was well done, and thermo-anesthesia
was absent,
except
on
the anterior
surface of the right side of her
abdomen,
where she apparently
could not distinguish
heat from
cold.
Rom
berg's sign was present,
and she showed
an inclination
to fall to the
right.
She had a somewhat
ataxic gait, and would invariably
bear to
the left in attempting to walk on a straight line.
Oppenheim's, Gor
don's, and Babinski's
signs were absent.
A clonus of both feet was
present, but the clonus was not sustained.
The point of maximum pain was suboccipital, and more marked on
the left side.
Moderate pressure
on this point elicited pain.
Cranial
percussion
was not attempted.
In view of the history obtained and
the above neurological
find
ings, I made a diagnosis of cerebellar
tumor, located in the left half
of the cerebellum,
and
advised
operation.
Before
preparation
for
operation
had
been completed
the patient suddenly died January
6,
1922.
The following
post-mortem
notes
on
the
brain
were
made
at
autopsy :
"The
calvarium
is normal.
The
dura
mater
over the
vertex
is
normal.
The external appearance
of the cerebellum
shows indenta
tions and impressions from
the
parts having
been
under pressure
against
the brain and tentorium.
The left lobe of the cerebellum
is
largest,
and in the upper inner segment of the left cerebellum
there
is what
appears
to
be blood extravasation,
extending
over
to
the
upper aspect.
Part of the substance of the central lobe of the cere
bellum
has been forced into the foramen magnum by excessive pres
sure, and there
is an imprint of the edge of the foramen magnum.
There
is an annular-shaped
depression
surrounding
this dislocated
portion of the central lobe of the cerebellum.
The convolutions of
the cerebellum
have been obliterated by the excessive pressure
under
which
the organ has been ante mortem.
" The cause of sudden
death
was probably
due to pressure
on the
vital centers of the medulla from the dislocation of the middle lobe
ind downward pressure.
494
Vol. XVII.
CLINICAL
NOTES.
The left
lobe of the cerebellum
is softer than the right, and
has
fluctuation,
indicating
the
presence of fluid
in the
interior
of
the
same lobe.
The floor of the fourth
ventricle
showed
indentations
from the pressure exerted by contiguous parts.
The left
lobe of the
cerebellum
was practically
excavated
by
an
encapsulated
cyst containing
straw-colored fluid, in quantity
about
an ounce
(estimated).
The
cyst wall
was thick,
and
composed
of
white scar formation.
What
appears
to be a sarcomatous
mass about the size of a hazel
nut is found at the upper part of the left lobe at the site of the extra
vasation
previously referred to.
In the outer aspect of the right lobe
is found
a tumor formation
exactly similar
in gross
appearance
to
that in the upper part of the opposite
lobe.
This one is about the size
of a grain of barley.
A similar formation is found in the roof of the
cyst about the size of a grain of barley.
There were adhesions
between the under surface of the dislocated
portion of the middle
lobe of the cerebrum
and
the
cerebellar
pe
duncles.
Microscopical examination of the tumors showed them to be benign
haemangiomas,
and the cyst had no definite limiting membrane.
Comment. —It is believed
that
these tumors
were
operable,
and
that 'if an operation had been
done earlier
death
might
have
been
averted,
and partial, if not
complete,
relief of symptoms
obtained.
During the last few days of the patient's life her vision was rapidly
growing worse, and head pains more severe and frequent.
It is common
practice in cases
presented
to the surgeon
suffering
with headaches, constipation, and disorders resulting from malposi
tion of the uterus
to proceed with the operation, with little consid
eration of possible
neurological findings.
This, I believe,
is a mis
take.
An examination of the eye grounds, which, in this case, would
probably have cleared up the entire condition in the beginning, would
have excluded
the gynecological operation.
Spinal
puncture is not without its dangers,
and great
care should
be exercised,
not only in the selection of appropriate
cases,
but also
in the method of doing the puncture.
Where an examination of the
eye grounds reveals
a choked disk, spinal puncture should be under
taken with
great
caution, if done at all.
According
to Lewandow-
sky, without continuous measuring of the pressure
during
the with
drawal of the fluid, spinal puncture is a dangerous
procedure
in cases
of suspected intracranial
neoplasm,
as death may occur by the lower
ing of the blood pressure
so that the brain
is to
a certain extent
drawn
down,
and
the
cerebellum
and
the
medulla
oblongata
are
pressed against the foramen magnum.
Though spinal puncture
was
done twice in this case, in view of the post-mortem
findings it is be
.No.3.
495
CLINICAL
NOTES.
lieved that the life of the patient was greatly jeopardized each time
it was done, and these punctures
may have hastened
her death.
BEPORT
OF
A
CASE
OF
DEATH
FROM
EMBOLISM
FOLLOWING
THE
ADMINISTRATION
OF SALICYLATE
OF MERCURY
BY INTRAMUSCULAR
INJECTION.
By S. R. Mills, Lieutenant,
Medical
Corps,
Tnited
States Navy.
The following
case is reported on account of its unusual
features
:
S. F., corporal, U. S. M. C, age
34, reported
to the sick bay, First
Air Squadron, Santo Domingo City, Dominican
Republic, complain
ing of general pains without apparent cause.
He had had what was
considered
a venereal wart on the penis
some
three months
previous
and presented general
adenopathy.
Denied intercourse
within the
last six months.
The day following
there appeared
a maculo-papular
eruption, copper colored, over the chest and characteristically
specific
in appearance.
The Wassermann
test was strongly
positive
and
the patient was
transferred to the
base hospital
at Santo Domingo
City,
where
he
received three intravenous injections of neoarsphenamine
0.9 gram,
at weekly intervals, returning
to his station for further
treatment.
On arrival at the First Air Squadron he received, on Friday, Janu
ary 27,
1922, neoarsphenamine,
followed on January
30,
1922, by an
intramuscular
injection of mercury salicylate,
1 grain, which
were
repeated
on February
3 and February
6, respectively.
There was no
reaction
following
the
arsenic,
but
there
was slight
headache
and
diarrhoea following
the mercury on January 30.
No report was made
of this by the patient until after his second injection of mercury on
February 6.
Several hours
after this injection
he returned to the
sick bay
on account
of chilliness, headache,
and painful, sensitive,
bilateral,
and
symmetrical swelling
under
the
jaw.
Examination
showed
the submaxillary
and
sublingual
salivary
glands,
on
both
sides, to be enlarged
and very painful.
The
teeth
were very sensi
tive, slightly
loosened,
and
the gums
showed
the typical
lesions
of
mercurial
stomatitis with
ptyalism.
The patient was readmitted
to the base hospital February
8, 1922, at
10.30 a. m., with diagnosis
of poison, mercurial, acute, with the symp
toms mentioned
above;
the salivary
glands were markedly swollen
and painful;
gastrointestinal
symptoms
were
absent.
The
urine
showed
a slight trace of albumin without casts or blood.
February
9, 1922 : The patient felt no discomfort
except for pain
>n glands
and teeth, but that evening
he had a sudden sharp pain in
the great toe of the left foot, which he said he had " stubbed " a few
days previously.
Examination
showed
only
slight
blackish
dis
496
Vol. XVII.
CLINICAL
NOTES.
coloration of the nail.
An hour later the pain in the
toe was ex
cruciating
and the discoloration
was found to extend up in a wedge-
shaped
area over the
dorsum
of foot to the
ankle.
This
area was
mottled
red,
involving
almost
the entire
dorsum
of
the
foot
and
great toe.
Hot fomentations furnished some relief.
Early
the next morning
the patient had
a sudden
severe pain
in
the chest (substernal) without
cough, but accompanied
by dyspnoea,
marked cyanosis,
and very feeble rapid
pulse.
The
area of discol
oration,
as
above
noted,
was
found
to
be sharply
defined,
wedge-
shaped,
apex upward
at ankle,
and blue-black in appearance.
The
lungs
showed
beginning
edema,
which
accumulated
rapidly,
with
death resulting
at 9.05
a. m., the patient remaining conscious
to the
end.
Autopsy
showed
embolism
of the
anterior tibial artery
at
left
ankle,
pericardial
exudate,
thrombus filling entire right
ventricle,
and
edema of the lungs.
The gall bladder
was markedly
dilated.
The liver, kidneys, spleen, stomach,
and intestines
showed
no macro
scopic
lesions.
Owing to the lack of facilities,
no pathologic
sec
tions were made.
The mercurial
injection
consisted
of
1 grain of the salicylate in
oil
injected
deeply
into
the buttock.
The
medical
officer
reported
that on both occasions
the syringe
was
removed
from
the
needle
and the latter inspected
for bleeding.
There was no sign of a vessel
having been punctured in either case.
No incision was made
at the
site to determine
the amount of absorption.
It is interesting to note that the deceased was one of several
who
received
mercury
on
the
respective
days.
He was
second of
four
on
the
first
occasion,
and third of four
on
the
second
and
last.
None of the others
so injected
had reactions of any sort.
A CASE
OF EPIDEMIC ENCEPHALITIS.'
Patient
: L. C. U., seaman, United
States Navy. —Encephalitis,
epi
demic
(lethargic).
Previous history.—Patient
20 years old ; had been in naval service
since February,
1917.
His family history is negative,
his father be
ing a coal miner and the patient himself having worked at times in
the
coal
mines.
On
December
19,
1919.
patient had lobar
pneu
monia in lower left lobe.
He was sick at that time until July
15.
1920, the pneumonia
being very slow in resolving.
Tuberculosis was
strongly suspected, but no definite signs of this could be found.
His
sputum
was examined
nearly every day from February to July, 1920,
1 From
the Annual Sanitary Report
of the United
States
Naval
Hospital,
Portsmouth,
N. H.
No. 3.
497
CLINICAL
NOTES.
and
no tubercle
bacilli
were
found.
On July
15,
1920,
he left
the
hospital after a month's sick leave in apparently good condition.
On
December 27, 1920, he was readmitted with bronchitis,
acute, and on
January
14, 1921, tubercle
bacilli
were found in the sputum and the
diagnosis
changed
to tuberculosis, chronic
pulmonary.
From that
time on tubercle bacilli
have
been found in his sputum at frequent
intervals.
X rays of his chest
show
areas of consolidation
in his
left lower lobe.
Subsequent illness.—Patient
was admitted to this hospital
Decem
ber 27,
1920, with
a diagnosis of bronchitis
acute, this proving
on
January
14, 1921, to be tuberculosis, chronic pulmonary.
On admis
sion
patient
had
temperature
of
101°
and
complained of
double
vision, which he states he had
had for previous week.
Blood count
at that time
was
86,000
whites
and
59 per cent polynuclears,
haemo
globin
82 per cent.
His temperature varied between
100°
and
102°
on December
28 and
between
99° and
100.4°
on December
28,
1920.
On December
30 he had an evening rise to 99° ; on December
31 it
was normal all day; and on January
1, 1921, an evening
rise to 99.5°
occurred.
From that time on his temperature
was normal until Jan
uary
18,
1921, when
he had
a midday rise to 100.8°.
From then
on
the temperature
stayed between 98° and
100° until January 28, from
which time his temperature
was normal.
On
December
31,
1920,
it
was
noticed
that
his left
pupil
was
smaller than his right, both being rather small and reacting poorly to
light.
On this day
he complained of
a slight frontal
headache for
the first time.
A complete
examination of his reflexes showed
both
knee jerks marked
but
equal,
no ankle
clonus
and
no
Ehomberg.
Blood examination
showed
10,800
whites
and
67
per
cent
poly
nuclears,
5.100,000
reds and
90 per cent haemoglobin.
At this time
the patient began to develop
a marked apathy, which daily increased.
He would lie for hours without speaking and with
closed
eyes,
but
he was
not sleeping,
and
upon
being spoken
to would answer.
By
January
18,
1921, this apathy had
increased
to such an extent
that
the patient
was reported
dangerously ill.
This day also for the first
time weakness of his facial muscles was definitely noticed, this being
especially shown in his inability to show his teeth or smile or frown.
He could, however,
wrinkle
his forehead.
Wassermann, of January
13, was reported negative.
On January
19
a spinal
puncture was
made
and 15 cubic centimeters
of perfectly clear fluid, flowing at the
rate of two drops per second, was obtained.
The laboratory reported
that this fluid contained
37 cells per cubic
millimeter,
was positive
for globulin, that no tubercle
bacilli
were found,
and that the col
loidal gold
curve
was
1-5-5-5-5-5-5.
On January
23 blood had
5,800 whites, with 60 per cent polynuclears, 34 per cent mononuclears,
and 16 per cent lymphocytes, 4,650,000
reds, and
80 per cent haemo
498
Vol. XVII.
CLINICAL
NOTES.
globin.
The apathy, which
reached
its height on January
18. con
tinued unchanged
until this date, the patient having incontinence
of
both
urine
and
faeces,
and
never
making
the
slightest
movement
unless urged.
He was fed by a spoon by a hospital corpsman,
liquid
diet only being taken.
On January 30 patient was observed
to be
a
little brighter mentally.
On February
3 he had improved sufficiently
to answer
questions,
and said that his double vision had
gone.
His
facial muscles
also showed
marked
improvement, and
he was able to
show his teeth and smile.
He improved rapidly
from this time on
and was up in a wheel chair for 20 minutes on February
19, and by
February
25 he was up for 3 hours
a day.
In view of the fact that
this patient had chronic pulmonary tuberculosis the diagnosis of en
cephalitis, epidemic,
was not
made until all nervous symptoms had
entirely disappeared, because of the danger of mistaking
a possible
tubercular meningitis for encephalitis, epidemic.
He was seen by the
entire
staff from the first, and
the opinion of all was that it was
a
case of encephalitis lethargica as early as January 30. but because of
the presence of the tuberculosis in his illness the
definite
diagnosis
was not made until March
22,
1921.
The patient continued
under
treatment
for chronic pulmonary tuberculosis and was transferred
to
the United
States
Naval Hospital,
Fort Lyon,
Colo., May
28,
1921,
for further
treatment.
SPECIFIC
TREATMENT
OF PULP
GANGRENE
AND
ITS SEQUELS.
By F.
S. Ticiiv, Lieutenant,
Dental
Corps.
United
Stutes
Navy.
When Dr. John
Buckley
gave the
dental
profession his " formo-
cresol " (cresolis
et liquoris formaldehydi,
equal parts) for the treat
ment of pulp gangrene
and
its sequelse,
he gave
a treatment
which,
from
a rational therapeutic standpoint,
is
a specific.
In fact, it
is
as much
a specific
for pulp
gangrene
as Ehrlich's salvarsan
is for
syphilis, or quinine is for malarial
fevers.
But
alas,
there
often
comes
a
patient
who
desires
immediate
relief
from
pain
which
is
the
result of
a
gangrenous
pulp.
We
try to relieve
the pain by opening into the pulp chamber
and releas
ing the pressure,
but some of the liquids
and
gases of putrefaction
have
already
been
forced
through
the apical
openings,
setting up
an acute
septic
pericementitis.
It is then
that
a great number
of
us find ourselves
in a dilemma.
We try anodynes,
local and general,
anything
to relieve congestion; saline cathartics, hot foot baths, ami
what not, possibly the seemingly
inevitable extraction and curettage.
We know that if it were not for the irritating property of formo-
cresol we would not hesitate
a second to seal it in the most
trouble
some tooth, because we know the physiologic action
of cresol — it acts
So. 3.
499
CLINICAL
NOTES.
as
an
analgesic
locally; it is
a
good
disinfectant
and
cauterant.
The other constituent of formo-cresol is liquor
formaldehyde —a 37
per cent
aqueous
solution
of formaldehyde
gas—a
powerful
and
highly irritating
gas,
which will readily
combine
with
the
fetid
passes of putrefaction,
and
these form nonodorous compounds.
It
is a gas which one would hesitate
to confine
near a tissue which is
already hyperemic.
Doctor Buckley claims that the irritating effects
of formaldehyde
can be controlled by mixing it with cresol.
This is
true, but, on the other hand, I have found that the cresol-formalin
combination
as recommended
by Doctor Buckley, very often proves
to be highly irritating.
As I have stated before, cresol acts as an anodyne,
disinfectant, and
cauterant.
The
ratio of each of these properties
differ
consider
ably, and I take it that the disinfectant
property exceeds by far the
other two.
We have an irritation set up by all disinfectants
; hence
the pain set up by the disinfectant property of cresol is not offset by
its anodyne
property,
and
the result
is that
we have
produced to
some
extent
an irritation by the application
of cresol.
I will not
discuss the formalin
of the combination because its irritating prop
erty is acknowledged by all.
I agree with Doctor Buckley
when
he
says that the irritating effects of formalin
can be controlled by mix
ing it with
cresol.
In
my study of the
two constituents of
Buckley's
treatment,
I
have found both to be irritants.
The irritating effect of one (forma
lin)
is controlled by the other (cresol), but formalin
has not a coun-
tereffect
upon the irritating property of cresol.
To overcome
this
irritation I
have
used
liquor
cresolis
compositus
instead
of
the
cresol. I have found that this compound
solution of cresol
has not
the irritating property of cresol alone, and its action, when combined
with
formalin,
in
proportion
of
3
to
1,
is
most
admirable
when
sealed in the root canals of teeth with
dead pulps.
I believe that its action upon the ptomaines,
fats, and fatty acids of
pulp decomposition is not so violent,
since
the
cresol of the
com
pound is predigested
(if you please)
by the potassium
hydroxide of
the compound.
It is not
so antagonistic
(the cresol
compound)
in
its neutralizing action,
but still the action
is there.
So then we have
the deodorizing and neutralizing effect of the formalin upon the gases,
and its irritating property reduced
to a minimum by the cresol of the
compound,
and
the irritating property of cresol
controlled
by
the
potassium hydroxide of the compound
solution of cresol.
Along with
the linseed
oil of the
compound
plus the fats, fatty
acids, and potassium
hydroxide, we have an ideal cleansing solution —
soft soap.
The
liquor
cresolis
compositus
et liquor
formaldehydi
combination
is an ideal remedy
for
cases
in the naval service,
be
cause
we have to treat not only patients that can present
themselves
500
Vol. XVII.
CLINICAL
NOTES.
for two or more
sittings, but patients who are
able to report for
treatment only
once.
Then,
too, I
have
experienced
considerable
trouble in having
an ordinary
combination of formalin
and
cresol
made
up at the dispensary
(cresol will not mix with the
aqueous
formalin
solution),
whereas not so with the liquor cresol
compound
and formalin
combination, since the latter two mix well and form
a
clear solution.
The following is a good example
of many similar
cases, in all of
which the action of the cresol compound and formalin
combination
proved to be superior to that of plain formo-cresol or modified formo-
cresol
:
Patient,
male,
age about
42; physical condition
good.
Case
pre
sented
two
weeks
ago.
Suffered
greatly
from
pain
and
lack of
sleep.
A
considerable
swelling
in the apical
area of right central
incisor.
Treatment
(impossible to get radiograph)
: Made opening
through internal
surface of crown of tooth, generous
flow of thick
greenish
pus.
Canal washed out and formo-cresol dressing inserted.
Patient instructed to take
a good " dose of salts."
Boric
acid solu
tion compress to mouth and lip.
Patient
returned in
a couple of hours suffering from
acute septic
pericementitis ; dressing removed
and formo-cresol dressing replaced
by combination of cresol
compound and
formalin.
Next morning
patient returned, very grateful, relieved of all pain; changed
dress
ing.
After the sixth treatment the tooth had become firm in socket,
canal
clean
and
dry;
followed
treatment
with
strong
root
canal
germicide, and filled with chloropercha plus thymol
and root canal
points.
CATHETERIZATION
OF WHARTON'S
DUCT.
By T. L. Sampsell,
Lieutenant,
Dental
Corps,
United
States
Navy.
Although
cysts in the floor of the mouth and
ranulae of one kind
or another are not frequently
encountered
in the practice of
den
tistry,
yet, now
and
then,
one is encountered
when
least
expected
and,
unless promptly
recognized
and successfully treated,
gives rise
to disturbances
of a severe character.
Inspection of the literature
on the subject shows that this ground
has been fairly well covered,
and its repetition would be superfluous
here but for the fact that no authority
which I have
been
able
to
consult thus far mentions
that method
of treatment
which,
in
my
opinion, is the simplest and
most satisfactory for these
conditions,
i. e., the simple catheterization of the duct.
To avoid encroaching upon that which
has already been written,
this report is confined
to the actual treatment of three cases which
No. S.
501
CLINICAL
NOTES.
occurred
in my own practice,
the
last
quite
recently,
all of which
were clinically
the same and treated alike.
Upon examination in each case the caruncula sublingualis
was seen
to be engorged
and pointing upward toward the elevated
tongue
in
stead of lying parallel
to it and flush with the floor of the mouth.
The submaxillary
gland
was distended
but did not pit on pressure
and was slightly tender to the touch.
The ducts of Stenson
were
occluded
with
cotton
rolls to prevent
their discharge of saliva during
the examination,
and
the floor of
the mouth
was evacuated
with
the saliva ejector.
The floor of the
mouth was then swabbed dry, the tongue
elevated,
and the action of
Wharton's ducts observed for several minutes.
The duct on the unaffected
side continued to discharge its saliva
normally, while the floor of the mouth on the affected
side remained
dry.
A strand of ligature
wire, thin
gauge,
was
bent
double,
leaving
a very small loop at the end which would distend
but not injure
the
duct.
The loop was then
passed through
the meatus
into the duct
and gently
maneuvered
backward into the gland, the fingers of the
left hand manipulating
the floor of the mouth from outside
and
be
low, thus assisting in overcoming the duct curvatures.
The gland in each instance
began to empty itself immediately, and
numerous
small bits of caseous material could be observed in the dis
charged
saliva.
In two or three
minutes the duct appeared
to
be
functioning
normally,
and the wire was withdrawn.
The patient was then instructed
to massage the gland from time
to time,
chew
gum,
and exercise
the neck muscles periodically
until
the condition had completely
subsided.
This usually occurs in a few
days, but the patient should be observed
for a week or two longer
for a recurrence
of'the obstruction.
The writer firmly
believes
that this method
of catheterizing
the
duct
is the specific
treatment for all simple duct obstructions
and,
in all cases, should precede any decision
to intervene
surgically.
No
especial
skill
is required in
catheterizing
the
duct,
though
great care should be taken not to injure the walls.
646—22
9
NOTES AND COMMENTS.
The death of Charles Louis Alfonse
Laveran
at
the
age of
76,
on May 18, following
so closely that of Sir Patrick Manson. removes
another of the great pioneers
of tropical medicine.
Laveran
was the
actual
discoverer
of the malarial
parasite of man, and both
he and
Manson conjectured
that the mosquito
would be found to play a part
in its transmission,
a theory which
obtained
final proof
from
the
researches of Ross in India, and Grassi, Bignami,
and Bastianelli
in
Italy.
Laveran's
researches
covered
a wide field in the
realms
of
parasitology.
He was an indefatigable
writer,
and
a complete
list
of his publications would cover many pages.
The following sketch of his life appeared
in the Lancet for May
27,1922:
Alfonse
Laveran
was
born
on June
18,
1845.
He commenced
his
medical
studies
at the civil hospital
in Strasburg,
where he graduated
doctor of medicine
in 1867, with
a thesis entitled
" Recherehes
experimentales
sur la regeneration
des nerfs."
In
1874
he was appointed
to
the staff of Val-de-Grace
School
of
Military Medicine
in Paris.
He served in north Africa
from
1878 to 1883, and
there conducted the researches
on malaria which
have made his name famous.
Returning
to France in
1884
he occupied
the chairs of military
hygiene
and
clinical medicine
at Val-de-Grfl.ce
for 10 years.
For
a short
period
after this
he held the post of medecin chef of the HOpital
Militaire
at Lille and director
of the Service
de Sante at Nantes,
and during this period his brilliant observa
tions on the parasite of malaria
received confirmation
at the hands of Italian
workers.
Honors commenced
to shower upon him.
He became
a member of the
Academie de MMecine in 1893,
and
member of the Academle
des
Sciences In
1895, while various other medical and scientific
bodies felt it an honor to include
him on their roll of fellows.
He was elected an honorary
Fellow of the Imperial
Military
Academy
of Medicine
of St. Petersburg,
a foreign
member of the Royal
Society
of London,
a Fellow of the Medical
and Chirurglcal
Society,
and hon
orary Fellow of the Royal Society of Tropical Medicine
and Hygiene.
In 1889
the Academle des Sciences awarded
him
the Breaut prize
and
the Cothenius
gold medal.
In 1905 he was awarded the Mary Kingsley medal by the Liverpool
School of Tropical
Medicine.
He became a " meclectn
principal " of the army,
an officer of the Legion of Honor,
and was universally recognized as the highest
authority
on military hygiene and sanitation.
There was opening
up before
him
a public
career of such brilliance that it
would
have
attracted
many a man of high
scientific
attainments.
But not
so
Laveran.
His
early
experience
of microscopic
investigation
had
so fascinated
him that he longed for the quiet
and seclusion of a laboratory
where he could
pursue
his
studies
without
interruption.
Accordingly,
in
1897,
he
suddenly
603
504
Vol. XVII.
NOTES AND COMMENTS.
abandoned his public career and retired
to the Pasteur
Institute of Paris,
where
lie became
professor, and. finding the atmosphere congenial,
remained
constantly
for the next 25 years.
His interest
in malaria
was first
aroused
in
1878 by
the
characteristic malarial pigment in the liver and brain of fatal cases.
This pig
ment, of course, had been
previously
noticed, bur it was Laveran
who observed
the same granules of pigment in the blood inclosed
In crescent-shaped
bodies
or
In
spherical
structures
which
exhibited
amoeboid
movements.
He
regarded
these bodies
as parasites,
but was not absolutely
convinced till
1880.
when
at
Constantine
he observed for
the first
time the striking
phenomenon
known
as
flagellation
of the crescents.
His
views
were
received
with
doubt
in
many
quarters,
but with that
doggedness and determination
which
characterized
all
his subsequent work
he remained
true
to his beliefs,
which
were finally
recog
nized in
1889
by the Aead&mie des
Sciences, and
in
1907
by
the award
of
111•■
Nobel prize for medicine, which
lie devoted to the establishment
of laboratories
of protozoology
at the Pasteur
Institute.
In the same year he was elected
firs
president of the Soeietf-
Pathologie
Exotique
of Paris.
At the Pasteur Institute Laveran
devoted himself
to the study
of protozoal
parasites,
especially
those forms
which
occur in the blood and are pathogenic
to man and animals.
The discoveries
of trypanosomes
as the cause of nagiina
by Bruce
and his coworkers
in Zululand in 1890, and by Dutton
in man in
the
Gambia
in 1902, attracted
his
attention,
with the result
that
he undertook
the
study of these organisms
chiefly in collaboration
with his colleague.
Professor
Mesnil.
He carried
out
a
long
series
of most
intricate
researches
into
the
behavior of these organisms
in experimental
animals, in the hope of discovering
a remedy for the dreaded sleeping sickness of Africa.
With
the
discovery
of
leishmania
as
a
cause of disease
in
man,
Laveran
undertook
the study of these organisms,
and has published
the most
complete
account of the diseases they produce
that
has yet appeared.
Laveran was
an
acute
observer
and
had
absolute
confidence
in
his
own
observations
anil
opinions,
to which
he adhered with almost
stubborn
persistence.
For
example,
most authorities
now believe that
there are three species of malarial parasite
producing
disease in man, but Laveran adhered
to his original
view
that the
variations
observed
were
an
indication
of
the
polymorphism
of
the
single
species.
Again,
he devised an immunity
test for the separation of trypanosomes,
and concluded
that any trypanosome
which
could
be inoculated
into
a goat or
other animal
which
had acquired
an immunity
to another
trypanosome
was a
distinct species.
Though
the criterion is not generally
accepted,
Laveran main
tained
his opinion
that it afforded
a reliable
means for distinguishing
species
Since the views
to which
he clung
so tenaciously
were no mere dogmatic
asser
tions,
but
were
the
outcome of
personal
observations,
extending
over
many
years,
one could not but admire his refusal
to relinquish
them
readily.
Those
who have had the privilege
of knowing
Professor Laveran
personally
can
well
understand
the admiration
and
respect
with
which
this great
man
was regarded.
Those who did not know
him would
find it hard to realize
how
complete was his absorption
in his work.
Prom
8 a. m. till 8
p.
m.. with
only
the usual
break for dejeuner,
he was to be found
in his laboratory on six
days
in the week.
Sunday
afternoon
alone was spent in recreation,
which consisted
frequently
in reading at home or planning
future
researches.
Laveran objected
to interruptions in his work,
not because of any harshness
of tempera men t, but
because he was reluctant
to lose a moment of time.
He was, however,
always
ready to listen
to anyone who had serious matters
to discuss, though
he
found
it
irksome
to
converse
except
in
French.
He
found
time
to
publish
many
comprehensive
treatises.
While in 1867 he wrote on the regeneration
of nerves,
in
1873
he published
a treatise
on
tuberculosis.
In
1875 appeared
the
Traite
No. 3.
505
NOTES AND COMMENTS.
des Maladies et fcpidemies
ties Armies, while in 1880
he published
in the Pro
ceedings
of the Academy
of
Science
his
famous
paper
entitled
" Note
sur
un
Xouveau Parasite Trouvl dans le Sang de Plusieurs Malades Atteints de Fievre
I'alustre."
His observations
on malaria
appeared in book form
in
1884 as the
TraitC de Fievres
Palustres,
in 1891 as Du
Taludlsme
et
de son
Hfmntozoaire.
and in
1898
as his Traite
de Paludisme,
a new edition
of which
was issued in
1907.
In
1894,
in
collaboration
with
Teissier,
he published
a
book
entitled
"Xouveau
Elements
de
Pathologie
Medicale,"
and
in
1904
appeared
the well-
known Trypanosonies
et
Trypanosomiases,
written
in
collaboration
with Pro
fessor
Mesnil.
A
new
edition
of
this
book,
which
had
been
translated
into
English,
appeared
in
1912,
while
in
1917
he
reviewed
the
whole
subject
of
kala-azar,
oriental
sore,
and
allied
diseases
in
his
work
entitled
" Leish
maniases."
These form but
a small
part of the numerous
papers
issued
by this remark
able worker,
and almost
everything
he
wrote
was
a practical
record
of facts
observed
by himself.
Herein lies
the immense value
of his
work.
He
was
a
man
of
iron
constitution,
stupendous
energy,
and
quite
unusual
powers
of
mental
application.
Combined
with
these
characteristics
he
had
the
true
scientific mind, which
entitles
him to be remembered as one of the great leaders
of scientific research.
We learn from the British Medical Journal for May 27, 1922, that
(he seventh
centenary
of
the University
of Padua
was
celebrated
on May
14 to 17 in fortunate circumstances.
The weather
was fine,
Imt not too hot, and
over
200 foreign
delegates
attended,
about
50
coming
from
the United
States
of America,
about
30 from Great
Britain,
Ireland,
and
the Dominions,
and
a large number from the
universities of Italy.
On Sunday, May
14, the delegates met in the
grand hall of the university
at 2 p. m., under the presidency
of the
rettore magnifico, Prof. Luigi Lucatello;
this preliminary
ceremony
was followed by a discussion
on " Scientific synthesis
and speculative
science,
the methods
and aims of these researches,
and their relation
to philosophy."
During
the day the
students
organized
a pictur
esque carnival
and paraded the streets,
as they did on the following
Tuesday;
in
the evening
there
was
a
reception
at
the Casino Pe-
drocchi.
Monday, May 15, was the chief day of the centenary,
as the
King of Italy
arrived
and presided at the solemn
ceremony
in the
Sala Ragione, where,
before
an audience
of 5,000
people,
addresses
were delivered by the rettore magnifico. the sindaco.
and Prof. Nino
Tamassia, and
the students
sang
verses by Giovanni
Bektacchi, set
to music
by Riccardo
Zandonai.
The foreign
delegates
and
those
from other universities and bodies in Italy handed in their congratu
latory addresses,
and
short
speeches were
delivered by
one repre
sentative of each of the nations.
The British representative
was Sir
Archibald
Garrod,
an appropriate
choice, for not only is he regius
professor
of medicine
in Oxford— the oldest British university — but
in that capacity a prominent figure in the subject
matter
of one of
506
Vol. XVII.
NOTES AND COMMENTS.
the chief faculties of the University
of Padua, with which the hon
ored names of Linacre,
Caius, and Harvey
are so closely
connected.
In
the
evening
there
was
a gala performance
of Arrigo
Boito's
Mefistofele, which was attended by the King of Italy.
On Tuesday
morning Prof. Augusto Bonome delivered
-an oration on Morgagni.
and a large number of honorary degrees were conferred on the repre
sentatives
of foreign
universities,
including
those of this
country,
who
were well represented
in the list and
most cordially
received.
This was followed by
a visit to the Collegio Sacra, where
more ad
dresses
were
delivered:
the
company
then
made
a
special
train
journey to an open-air lunch in the beautiful grounds of the Istitnto
Idrotechnico
(Villa
Keale)
; in the evening
a banquet
was given
to
the' delegates by the municipality
of Padua.
Wednesday. May
17,
the
last
day of
the
celebration,
was
occupied
by
an excursion
to
Venice.
The
town of Padua
was
en
fete
and
provided
much
of
interest for the visitors, who
were able to study the stemma of Wil
liam Harvey in the court of the university.
Admiral Braisted, writing in The Nation's Health
on the Gorgas
Memorial Institute to be established
at Panama, pays, indeed,
a glow
ing tribute
to the late
master of tropical
sanitation.
Gen.
William
C. Gorgas, United States Army.
" Formerly
men memorialized their
heroes in stone, with the result that the monuments
of the world
are
for
the
most
part
retrospective,
representing
some
peak
of
past
achievement,
but exerting no vital force of inspiration
or restraint
except
as they are reinterpreted by successive generations.
And yet.
if civilization
is to carry on, it is through uninterrupted
cumulative
achievement;
and
the
most enduring
memorial to
any
man
is the
provision of the means by which to perpetuate
his work.
Especially
when
a humanitarian
achievement
has been made
possible
by
the
unusual skill or the clear vision of one man does such perpetuation
seem
desirable.
As this applies to the work of General Gorgas,
he
may well be considered
as the personification of the public
health
era
and
the plant of the Gorgas Memorial
Institute
in
Panama
a
truly representative
enterprise.
Established in a country unhappily
known as the pesthole of the Tropics, which, by his efforts, was trans
formed into one of the healthiest places on the face of the globe,
the
institute will afford opportunities complete in every detail for trained
research men a*nd scientists
from all over the world to work together
upon
the common problem of how best to prevent and eradicate dis
ease.
" Anyone who has seen the old Panama at the time of the abandon
ment of the work of the first canal, involving
so much wasted energy,
life, and money, with its abandoned
equipment
and the evidences
of
No. 3.
507
NOTES AND COMMENTS.
unsuccessful
labor, and the thousands of unknown
and unnumbered
graves of its workers, can not help but be struck with
the present
aspect of Panama, its splendid sanitation, its beautiful
cities, its fine
hospitals,
and
the magnificent accomplishment of the completion of
the work of the canal, making it one of the most beautiful and salu
brious spots in the world.
" The accomplishment of this great work and the sanitary regenera
tion of Panama are due to the efforts of the late William C. Gorgas,
United States Army.
To his efforts
more than to any other agency
the success of this work must be accredited.
His earlier work in the
Southern States and
the West Indies,
particularly
Cuba, his later
efforts in Ecuador
and Peru,
and his projected work in Africa, give
one an idea of the vast field of splendid endeavor
which
he accom
plished
and would have continued had his life been prolonged.
His
reputation
has gone forth to all the world,
and he is loved
and
re
vered in every household.
Perhaps no single life has ever made pos
sible so much for the good and wellbeing of humanity
as has that of
General Gorgas.
"Many types of memorials were
considered
to do honor
to this
great man, but I feel sure that the establishment
of this memorial, the
Institute
for Research
in Tropical Diseases
and
the Study of Pre
ventive
Medicine, carrying with it not only
a permanent monument
to his memory,
but one that will continue his work and be of greatest
value to the welfare of the entire world, will be considered
the ideal
commemorative effort.
Panama, situated in the heart of the Tropics
and in the midst of the Central
and South American
States,
which
offer a splendid field of work of this kind, would seem to be the ideal
location, furnishing a wealth of material for the institution
which is
brought
into existence."
Prof. J. J. Van Loghem, director of the department of tropical
hygiene at the
Colonial
Institute,
Amsterdam,
delivered
a
lecture
to London recently, on the "Transmission
of plague by rats."
We
learn from the British Medical Journal that in the lecture he dealt
with the
plague
question
as it
affected
Europe
past
and
present.
He
confined
himself
to
bubonic
plague,
which
he regarded
as
being the plague of all the great historical
epidemics,
and his argu
ment was that in the time of old Europe
the domestic
architecture,
the habits of the people,
and the sanitary conditions generally were
such as to encourage
the breeding of rats in much
closer proximity
to man than was the case anywhere in western
Europe
to-day.
At
the time of the plague outbreaks in London
and Amsterdam in the
seventeenth
century the rat probably lived as near to the occupiers
of
dwelling
houses
as it did at the present
time in the plague-stricken
areas of the Tropics
and sub-Tropics.
In this connection
he spoke
508
Vol. XVII.
NOTES AND COMMENTS.
of his recent investigations in Java, where he found the house rat—
Mm rattus—making
its nest inside the bamboo
poles
used for the
beams of the houses and the supports of the beds.
Plague infection,
in his view, depended
upon the distance
between rat and man being
sufficiently short to permit of the rat flea conveying the disease to
man.
The influence
of climate and season upon the rat flea carrying
the plague parasite accounted for the climatic and seasonal variations
of rat-borne plague.
He showed
diagrams illustrating
the
fluctua
tions of the plague in London
and in certain Dutch
towns in
the
seventeenth
century.
In all these cases the highest point was reached
in August
and
September,
after which
there
was
a sharp
decline.
He quoted Daniel
Defoe's Journal
to prove that in the winter
and
spring preceding the plague of 1665 in London isolated
cases appeared
within
a few weeks of each other and traceable
to the same neighbor
hood —Long Acre —although it was not until
the summer
that any
epidemic
arose.
There was no difficulty in explaining
these sporadic
cases
in the light of modern
knowledge if it
was
remembered
that
the
propagation
of
the
plague
depended
not
on
contact
between
human beings but on the activity of the rat flea, for the supposition
was
that
all
through
this
epidemic-free
period
there
was
plague
among the rats, and only when the seasonal conditions favored insect
activity
did
the
epidemic
arise
among
human
beings.
His pupil.
Doctor
Dykstra,
of
Amsterdam,
had
made
some
interesting
re
searches on the plague which occurred in that city is 1617. by study
ing the lists of the Carthusian
burial ground.
They gave full
par
ticulars of the persons
interred, including
their places of residence,
and he found that for six weeks in the early summer
the plague
was
strictly localized to two or three streets ; later it spread
over a large
quarter of the town, but its spread
was topographical,
from
house
to house and street to street.
There was no other explanation of such
a picture than localized rat plague.
The animal concerned
was not the
brown or gray rat now familiar, but
the black house rat. the "big
mouse."
which was rarely
seen in Europe to-day.
Even in the time
of Cuvier
the black rat, though still common,
was being ousted by
the brown, but it was a rat of the same species as this former domes
ticated
habitant
of
Europe
which
caused
the
recent
outbreak
of
plague in Java.
That the brown rat can carry plague in the
same
way
is,
of course, evident
;
it
was the brown rat which was responsible
for the small epidemic
in Paris in 1920, when most of the 150 victims
were rag dealers, who were compelled
by their trade to live near
to
the haunts of the rats; but the point
is
that the brown rat
is
not
a
domesticated
animal like its predecessor,
and to that extent
is
less
dangerous.
In the old days, with
dark house interiors, straw beds,
and abundance
of food and other stores kept in dwellings, the black
rat had
a
fertile breeding ground.
Xo. 3.
509
NOTES AND COMMENTS.
We
learn
from
the division
of
venereal
diseases
of
the United
States Public Health
Service that G. Stura
offers
a modification of
Fontana's
method
for
the
demonstration of
Treponema pallidum.
The modification
concerns
the staining
stage of Fontana's
method
and should
be carried out
as follows:
(1)
Smears
fixed
by heat are
kept for a few minutes
in a solution consisting of formalin
50 cubic
centimeters, acetic acid
2 cubic
centimeters,
distilled water 150 cubic
centimeters.
(2) After
washing with
distilled
water pour
on the
slide a few drops of a mixture of 5 grains of tannic acid,
3 grains of
carbolic acid,
and
100 cubic
centimeters
of distilled
water.
Warm
on
a flame up to boiling point.
(3)
Wash repeatedly.
Pour on the
slide
pure
ammonia; after
a
few
seconds pour it off and. without
washing, allow
a 0.5 per cent solution of AgNO,
to pass from
one
side of the slide over the smear.
As soon as this has become brown
the staining is finished and there only remains
washing the prepara
tion and drying it over a flame.
Recent
medical
literature
contains
many
expressions
of opinion
by syphilographers
of this and
other
countries regarding
the high
incidence and earl}' onset of neurosyphilis.
Another condition cited
by them
is that an increasing number
of patients in the infectious
second stage
are being
observed
in the clinics.
Many of the writers
claim
that too rapid sterilization
and
inadequate
treatment
are re
garded
as important
contributory
factors.
Because of the serious
ness of the problem and the diversity of opinion regarding the cause,
the United
States Public Health
Service
recently
addressed
a com
munication
to a few of the leading syphilographers of this country
asking for an expression
of opinion on this important
subject.
The
general opinion of the men written to is expressed
as follows
:
While
a certain
amount
of the apparent
Increase of neurosyphilis
is due to
the increasing
use
of spinal
fluid
examinations
and
other
modern
diagnosis
methods,
I think
there
is
no
question
that
the
ineffective
use
of
arsenicals
plays
a very important
part
in this
most undesirable
tendency
*
*
*
the
physician
or health
officer
who
is
unable
or unwilling
to follow
a
syphilitic
patient
through
a period
of years, if not for life,
should
not attempt
to
treat
the disease.
Relapse
is certainly
the great
outstanding
fact
of syphilis,
and
the so-called
modern
treatment
has certainly not entirely
done away
with it.
In particular,
relapse
in
the
nervous
system
and
infectious
involvement
of
the mucous
membranes and genitalia
are so alarmingly
frequent
under
the in
adequate
use of arsphenamine
that
every
agency which
employs
this
drug
in
the treatment
of syphilis
should
be
thoroughly
on
the alert
and equipped
to
detect the earliest
manifestations
of relapse.
(Stokes.)
It appears
to us that
among the factors
mentioned
as
probable
causes two
are of paramount
importance,
viz,
(1)
the tendency
to undertreat;
(2)
the fail
ure to interpret
pathologic
findings
in the light of the clinical picture.
(Fraser
510
Vol. XVII.
NOTES AND COMMENTS.
and Duncan,
British
Journal
of Dermatology
and
Syphilis,
July, August,
and
September,
1921.)
To
these
we would
add
another
of
almost
equal
impor
tance— the tendency to interrupt treatment
by periods of rest.
To our minds
the treatment of all syphilis ought logically
to be continuous
rather
than inter
mittent.
Early
neurosyphilis
In
the
form
of
neurorecurrences
would
be
re
duced
to nil if this were
done.
Late clinical
neurosyphilis
might
be equally
easily
avoided
by the early
routine
use of spinal
puncture
and by adjustment
of treatment
to the pathological
findings.
We
agree that
the "sterilization"
treatment
of syphilis,
as
exemplified
by Pollitzer's
method,
is distinctly
dan
gerous from
the point of view of neurosyphilis,
and that
treatment
should
be
directed
toward
building
up
the
patient's
own
resistance
to
the
disease.
Stokes's discussion
of this problem
in his paper, " The application
and limita
tion
of
the
arsphenamine
in
therapeutics"
(Archives
of
Dermatology
and
Syphilology,
September,
1920;
see Venereal
Disease Division Abstracts,
March,
1921)
deserves wider circulation than it has as yet obtained.
The most crying
present
need
of syphilotherapy
is
a standard
treatment,
sufficiently
elastic
to
be adapted to all types of cases
and sufficiently
simple
to be used by the aver
age
physician
«
*
*
unless
a
physician
feels
himself
competent
to
carry
out all the necessary procedures
in the treatment
of any given
case,
he should
not attempt
to treat
it at all.
Though
many
cases
can
be successfully
dealt
with
by the general practitioner,
he should
realize
that
the appearance
of any
complicating
features
is sufficient
to warrant
the transfer
of
the patient to
a
competent syphilologist.
(Keidel and Moore.)
Syphilis of
the
nervous
system
probably
begins
in
the
first
year
of
the
infection.
The number
of cases
corresponds
roughly
with the total
number
of
cases
of so-called
late neurosyphilis.
These
statements
are based on the
fol
lowing
observations
:
(a)
The number of early
cases
showing
positive
findings
in the spinal
fluid;
(b)
l'nmilial
types of neurosyphilis;
(e)
biologic
evidence of
a
neurotropic
strain of the treponema ; (d) persistence of the Infection
in loco,
as in aortitis,
interstitial
keratitis,
etc.;
(e)
observation
of patients
who developed
signs
of
early syphilis of the nervous
system and who after many years died of paresis
or other
late
degenerations
; (/)
no serologic
evidence
as
yet
exists
showing
normal
spinal fluid
in the early stage and its infection
at a later period.
Early
neurosyphilis
may
manifest
itself
by obtrusive
symptoms,
by
slight
objective
signs, or be asymptomatic.
Unless
they are properly
and thoroughly
treated
these early
infections
may persist
and cause late
neurosyphilis.
Every
case of early
syphilis
should
be treated
intensively
with arsphenamine
and mercury
given
systematically
in courses
consisting
of not less than
eight
injections
of arsphenamine
or its equivalent,
neoarsphenamine
or silver arsphe
namine,
and 15 injections
of mercury;
a minimum
of two courses
of the for
mer and three of the latter should
be administered.
The treatment
should
be
controlled
by frequent
Wassermann
tests
and
a lumbar
puncture
made about
six
months
after
infection
or
earlier
if
indications
should
exist.
Complete
neurological
examination
should
be made in order
to detect early
involvement
of the nervous system and as a control
for future examinations.
The treatment
outlined
is not an
insurance
against
the occurrence
of neuro
syphilis,
which
not infrequently
takes place during
the active administration
of
the drugs.
In such cases
intraspinal medication
administered
by one
familiar
with the proper
technic
may be a necessary adjunct.
It is only by controlling
early
neurosyphilis
that we can hope to prevent the later degenerations.
(John
A. Fordyce.)
No. 3.
511
NOTES AND COMMENTS.
In commenting
on these opinions Asst. Surg.
Gen.
C. C. Pierce.
United States Public Health
Service,
says :
" It is of extreme
importance, therefore, that physicians
engaged
in the treatment
of syphilis carefully
consider these statements
and
direct treatment
toward the avoidance
of the dangers
outlined.
"In inviting your attention to this matter the service is not un
mindful that many clinicians
are engaged in the control of venereal
disease merely
from the standpoint of health officers and that avail
able funds do not admit of intensive
or long-continued treatment
and
are often used for sterilization
purposes for public health protection.
That there is danger to the public health in dismissing patients from
treatment
too
early
is
seen
in
the
claims of
some observers
who
state
that
as
larger
numbers
of
infected
individuals
are
brought
under surveillance opportunity
is afforded
to
observe
an increased
number of patients in the infectious
second
stage, which condition
they believe to be due to inadequate
treatment.
" In the light of present knowledge regarding the subsequent
dan
ger to both
the individual
and community by ineffective
and
inade
quate
treatment
the
service
urges
that great care
be exercised
in
recording
case histories ; in referring patients for intensive treatment
to health centers or competent
physicians to continue treatment when
the clinic is unable to do so; and keeping cases of positive syphilis
under proper observation until the period of danger for both the
individual and the community has passed."
Writing on the principles in the treatment of empyema in Surgery,
Gynecology,
and Obstetrics for March,
1922, Dr. Carl A. Hedblom
says :
"The aim of all forms of treatment
of nontuberculous empyema
is to evacuate the pus, combat
sepsis, and restore
the structures and
functions
to
as nearly normal
as possible,
all without
undue risk.
Difficulties
in accomplishing
drainage
may
be
due
to interference
with respiration resulting from
a partial
collapse
of the lungs inci
dent to opening
the pleural
cavity or there
may
be secondary
en
capsulated
pockets.
The
virulence
and
metastatic
nature of
the
infective
organism
may
be
beyond
our powers to
combat.
In
a
chronic case
structural
changes
in the lung
and in the wall of the
chest may be beyond repair.
"The
data
with
regard
to the
treatment
of empyema
constitute
one of the most interesting chapters
in the history
of medicine.
It
is a remarkable fact that while
the condition
was
recognized
and
treated
by
the
ancients
and
spasmodically
treated
throughout
the
centuries it is only 60 years since Walter,
an American, first excised
a segment of normal rib in order to establish
drainage.
512
Vol. XVII.
NOTES AND COMMENTS.
"Although numerous
intercostal drainage devices continued to be
rediscovered
and reintroduced periodically,
rib resection
came to be
the standard operation with or without one or another of the numer
ous valve-drainage
devices.
Most
cases
were of the frankly puru
lent type at operation,
and
the mortality,
though
on
the
average
high, was considered
unavoidably
so.
Then came the great pandemic
of streptococcus
pneumonia
and
empyema.
The
forbidding
mor
tality resulting from simple rib resection
and drainage in these
cases
and the prompt
and great reduction in mortality
following
the in
stitution
of
' closed
drainage
'
with
irrigation
seemed
to
indicate
that the last word in the treatment of acute empyema
after all had
not been spoken.
Physicians
were
forced
to recognize
the danger
of pneumothorax in these
cases.
It was
also
discovered
that
it
is
possible
to employ
suction
rather than gravity
for the drainage of
pus
and that irrigation,
particularly
with Dakin's
solution,
was of
distinct benefit.
" The assumption
seems
rational
that the closed
method
is indi
cated in very ill patients with
acute empyema of any
type, particu
larly with pulmonary
involvement.
A to-and-fro
suction
sound
is
often heard
following opening of the pleural cavity in these cases,
indicating
a partial
collapse
of
both
lungs.
In
a patient
already
critically ill this
added
insult
may
be
the
last straw.
Air-tight
aspiration, on the other hand, tends to increase respiratory
capacity
by expanding
the lung
an amount equal
in volume
to
the pus as
pirated, which
may
mean full expansion of the lung
from
almost
complete
collapse.
" In
combating
sepsis
the
most
important
consideration
is
the
thorough
evacuation
of the
pus.
This can
be
accomplished
prob
ably more thoroughly
by aspiration
and flushing of the cavity with
a
cleansing solution
than by rib
resection
and
gravity
drainage
alone.
The relative superiority
of the hypochlorite solution is prob
ably due not only to its germicidal properties, which are considerable
when it is used copiously, but also to its characteristic property
of
separating all necrotic material and pus from the living tissue.
Fill
ing the cavity through one air-tight tube, besides being simpler
and
easier than rib resection,
followed by an attempt to place
a number
of Carrel
tubes,
would
seem
to insure better contact
between
the
fluid and all parts of the cavity.
Such procedure also tends to dis
solve the shelving partitions.
It is probably important
to use large
amounts
of fluid
at frequent intervals during
the first days
to pre
vent walling off of any part of the cavity.
"The communication of bronchial
fistulse with
empyema
cavities
may often
be proved by injecting
methylene
blue
into
the
cavity.
Dakin's
solution, generally speaking, is contraindicated in the pres
ence of large fistula?, but normal saline solution may be used.
No. 3.
513
NOTES
AND
COMMENTS.
"In
a
large
proportion
of
cases of chronic
nontuberculous
em
pyema,
very material reduction or complete obliteration of the cavi
ties may
be secured by irrigation
with
hypochlorite
solution.
An
extensive
plastic operation, besides
the hazard it involves, is dis
abling,
as pointed out by Graham, because
of the marked reduction
it may produce in vital capacity."
The department
of health, city of New York, has called attention
to the fact that of three
cases
of smallpox
discovered
in that city
recently, which were of common origin,
one was treated for several
days as syphilis.
Such a mistake
is especially apt to occur in those
cases of mild
clinical
symptoms
nowadays
so
common,
and
when
the opportunity for extended examination of an individual
is limited.
i
NAVY NURSE CORPS.
MARIA ROBERTA:
A TRIBUTE.
By D. V. Kwioht, Chief Nurse,
Untted
States Navy.
Somewhere,
sometime, I hope to see published, where all the world
may read,
a fitting tribute
to the Medical Department of the Navy
for what it has done for the natives
of Guam.
The medical
officers
who were ordered to Guam immediately after this island became
a
possession
of the United
States found
the natives
in great need of
medical
and nursing
care.
Overcoming
what
seemed
to
be almost
insurmountable
difficulties,
they
established
a hospital,
and
native
women
were instructed in the nursing
care of the sick women
and
children.
First among
the women
who received this instruction
was
Maria
Roberta.
Maria Roberta was born on the island of Guam about 45 years ago.
The world to Maria is the small island upon which she lives ; and she
being of a practical nature, I doubt whether she has ever strayed from
this island, even in fancy.
She has not had the advantage of a school
education, but as a beautiful flower will sometimes
be found growing
in the most unexpected
places amid the most unfavorable surround
ings, so Maria Roberta grew, if not in physical beauty
(though her
tall, well-built,
graceful form could be so considered), in beauty
of
character.
'Her keen mind, well-developed
sense
of honor, all
the
gentleness and lovableness
of the native, with
a great desire
to do
for others,
have made
her an outstanding
and
valuable person
on
the island.
When I reported for duty in Guam August
27,
1914, I found that
the principal
duty of the chief
nurse of the Navy
Nurse Corps
at
this station
was
the
instruction
of and
the
responsibility
for the
native
nurses.
In a short time
it became evident that in order to
give the
necessary
nursing
care to the native women
and children
who
were patients in the hospital
and
to provide
a nurse
for the
dressing stations
at villages distant from the hospital
more native
nurses were needed.
It seemed impossible to supply this need with
desirable material.
Upon inquiry, I learned that many of the better
class
of native girls
were willing,
even anxious, to
do this work,
but there was an objection on the part of the parents.
Guam having
been
a
Spanish
possession,
some of the Spanish
conventions
were
515
516
Vol. XVII.
NURSE
CORPS.
still
adhered
to by
the better
class natives,
and parents would
not
allow their daughters
to leave the confines of their homes unchaper-
oned.
Not being
able to, nor having
a desire
to, change
these
con
ventions,
it became clear to me that to provide for what I knew to be
a great
need it would be necessary
to first obtain
a chaperon
for the
native nurses.
Having heard much
about Maria Roberta from
the
nurses,
there was no doubt in my mind that she was just the person
for this place. I sent for Maria.
She came to see me at the hospital
and told me that she could
not accept my offer as she had an adopted
child to care for and the pay was not sufficient.
(She had left the
hospital some years previous to make
a home for this orphan child
which she had adopted.)
After discussing the matter
with the com
manding officer, he decided that out of the fund for the care of sick
natives
Maria was to be paid
a sufficient
amount
for her needs
and
the needs of the child.
Maria being well known
on the island and
the fact that she was engaged
as "official
chaperon"
for the native
nurses
removed
the objection of the parents to the extent that it be
came possible
to get the required
number
of pupil nurses.
Maria
lived with
the nurses; was with
them constantly while in the hos
pital,
and
when
they
were
off duty
and
wanted
to
go
home
she
accompanied
them
to their
homes,
where
she
was
relieved of
her
responsibility
by their
parents,
who returned them
to the
hospital
not later than 10 p. m.
This constant
supervision was accepted
very
gracefully
by these girls,
as they
were
accustomed
to it and
were
very fond of Maria.
They
also knew that nothing
stood
between
Maria and her duty.
One evening
just as we were sitting down to dinner I heard foot
steps on the walk
at the entrance
to the dining
room,
and looking
out I saw Maria Eoberta
with
two shrinking forms of
men,
one
gripped firmly
in each hand.
One was a native policeman in full
uniform, club " 'n everything " except his shoes, which he was carry
ing in the hand not held by Maria.
She, with her keen sense of duty
predominating,
gave the policeman
a shove into
the dining
room,
then
she gave the other man
a shove, placing
them before me,
and
told me that she had found these two men just outside of the hospital
wards talking
to two of the native nurses,
giving
the names of the
nurses.
She realized that she
had caught these two Romeos
" red-
handed "
in
a
most
glaring
offense.
I
informed
Maria
that
we
would take them
to the police station.
The policeman very meekly
asked permission to put on his shoes.
This permission was granted,
after which Maria and I proceeded
with
the two frightened,
non-
resisting offenders
to the police station, where
they
were
locked up
for the night, and the next day they were tried and found gulity on
a charge of trespassing.
But in this South Sea island, with its balmy
climate
and
its tropical
beauty
making
it
a
veritable
fairyland.
No. 3.
517
NURSE
CORPS.
which seems to exude romance,
and when the girl is young and beau
tiful, who can blame mere (native)
man for trying to sidkjtep even
a Spanish convention?
Oh, yes; it takes
a Maria Roberta's sense of
duty to hold this convention intact,
as not only
the
men but the
girls also are willing to do a bit of side-stepping on the matter of
conventions.
When little Francesca, who in appearance
was like a
bronze doll, was admonished
for flirting,
she responded
with
: " But,
Miss Knight, it is my custom."
If any doubt as to Maria's authority
existed in the minds of the people prior to the above-mentioned
epi
sode, no doubt remained
following
it.
Maria's field of usefulness
is not limited
to being
"official
chap
eron" to the native nurses.
Her ability
to understand and
speak
English
makes her services
as interpreter in the instruction
of the
nurses
and in transmitting
orders most
valuable.
The instruction
of the
nurses
is
adapted
to their mentality
and
the
needs of the
people.
A large part of their work is obstetrical nursing, in which
Maria is most efficient;
and, knowing
the customs
and living condi
tions of the people,
she
was most helpful
in adjusting
the work
to
their needs.
The training of Maria Roberta and other native women,
who became quite
efficient
in
the
care of obstetrical
cases,
was
a
great help to the medical
officers in dealing with the question of the
midwives of the island.
When
the commanding officer of the hos
pital ordered
that all midwives pass an annual examination in order
to keep
their
licenses
to practice, there
was
much
protest
on
the
part of those who
could
not meet the requirements
of the examina
tion, which was entirely practical.
This action
on the part of the
commanding
officer resulted
in a great decrease in infant mortality
and blindness.
Again Maria Roberta's
usefulness
became evident,
in that she knew
personally all the midwives, where
they practiced,
how
they did their work, whether they
were
meeting
the require
ments set by the medical
officers—and to Maria these requirements
were unconditional.
She had
a way of appearing just at a time
to
get first-hand information,
and well the midwives knew that—nothing
stood
between Maria and her duty.
Knowing
this,
they
respected
her.
Not least
among
Maria's
characteristics
is her marked maternal
instinct, which
was demonstrated
in her adoption of a child.
This
child has been the source of much
happiness
to Maria and is to her
the one source of diversion from the routine duties of the hospital.
As the years
go by this child
gives
great promise of repaying
her
for her devotion and sacrifice.
Other children
have been fortunate
enough to be the
recipients of Maria's
great
generosity.
Among
them
is Benadino.
When I reported for duty in Guam, Benadino
was nearly
3 years old and had been
a patient in the hospital about
646—22
10
518
Vol. XVII.
NURSE
CORPS.
two years, or so long that if he ever had any people who were inter
ested in him no evidence of this interest remained.
He apparently
belonged
to the hospital and
was considered
the hospital " mascot."
He was a bright, cheery
little fellow,
a bit vain, and had the Cha-
morro
love
for bright colors.
He
objected
to wearing
the
plain
gowns provided by the hospital for other children and always found
some
one
to
encourage
his
vanity.
On special
occasions
Maria
Roberta could always produce Benadino in gala attire, and it would
be difficult
to say whether Benadino
or Maria derived the
greater
happiness
from the effect.
Service
conditions make frequent changes in the Navy
personnel
at Guam. It is Maria Roberta who remains and who holds together
the fabric of the work built up by the Navy nurses.
BOOK NOTICES.
Publishers
submitting
books for review are requested
to address
them
as follows :
/
The Editor,
r. S. Naval
Medical
Bulletin.
Bureau of Medicine
and Surgery.
Navy
Department,
Washington,
D. C.
For review.
Books
received for review
will
be
returned
in
the
absence
of directions
to
the contrary.
REVIEWERS.
Lieut.
Commander
W. M. Kerr, Medical
Corps,
United
States Navy.
Lieut.
L. J. Roberts,
Medical
Corps,
United
States
Navy.
Lieut. E. J. Cchminqs,
Medical
Corps,
United
States
Navy.
" Thou
fool ! to
seek
companions
in
a
crowd !
Into thy room and there upon thy
knees,
Before
thy
book
shelves humbly
thank
thy God.
That
thou
hast
friends
like
these ! "
Management
of the
Sick
Infant,
by
hangley
I'orter,
M.
/).,
professor
of
clinical
pediatrics,
University of California
Medical
School; and William
E.
Carter,
M.
D.,
assistant
in pediatrics
and
chief
of
outpatient
department,
University
of California
Medical
School.
C. V.
Mosby
Co., St.
Louis,
Mo.,
1922.
When sickness
overtakes
a baby,
the management
of its
case
de
mands many departures
from those methods of treatment
which are
quite appropriate
when
we,
as physicians, have to deal with older
people.
Many good books have been written on the diseases of chil
dren, but, so far as the reviewer is aware, until the appearance of this
volume there existed
no book in the English language
which dealt
with the peculiarities of disease as it occurs in infants, that is, dur
ing the first two years of life.
This fact alone should give the book
a
place in medical
literature.
A perusal
of the text reveals
the fact
that the book contains
much of real value to the general practitioner,
and it would appear
to be of great
use to the young physician whose
professional
reputation
often
is founded upon his successful
man
agement of the sick baby.
In this book
the
whole
subject
of
the
management
of the sick
infant is ably
and
concisely
treated
in three
sections:
the first of
519
520
Vol. XVII.
BOOK
NOTICES.
which
deals
with
the
predominate
symptom
noted
in
an
infant's
illness, such
as vomiting,
diarrhoea,
constipation, nutrition,
hemor
rhage,
pain
and
tenderness,
convulsions
and
syncope,
fever
and
cough.
In the second part, the authors discuss
the various
disease
entities
which
are met during infancy; and in the third, they
con
sider some very practical
methods
of
treatment
which
have
been
found to have stood the test of time in their practice in San Fran
cisco.
Each method
is given in detail.
Of special
convenience
are
the chapters
on formulas
andx recipes for infant's
food, and on the
employment
of drugs in pediatric
practice.
The
text
covers
642
pages and is amply illustrated.
Although
the naval
medical
officer
at
sea
is rarely
called
upon
to treat sick infants, pediatrics forms a considerable
portion of one's
practice
at large naval
stations,
Marine
Corps
posts,
and
foreign
shore
stations,
hence this book
is recommended
to medical
officers
serving in those situations, and especially
to surgeons
of transports,
who will
find in it the solution of many of
the difficulties
which
the management
of the sick infant presents
at a time when
pediatric
specialists
are not available for consultation,
(w. m. k.)
The Thyboid Gland.
Clinics
of George
W. Crile
and Associates.
Edited
by Amy F. Rowland.
W. B. Saunders
Co., Philadelphia,
Pa.,
1922.
The number
of cases of endemic
goiter and hyperthyroidism
en
countered
among recruits coming from the region of the Great Lakes
and from the Northwest makes this volume
on the thyroid gland of
special
interest
to the naval medical
officer.
It is not a textbook on
the subject,
but rather
a presentation
of the Crile clinic
at work,
and aims to present in a series of papers
the theoretic and practical
viewpoints of Doctor Crile and his associates to-day.
Much
new knowledge has been developed
in the Crile clinic
con
cerning the thyroid
gland, and
the discussions
which
comprise
the
text center about
a number of important points.
Endemic or simple
goiter has been found
to
be
a geologic
deficiency
disease due to
a
lack of iodine in the organism, and by the proper administration
of
iodine to the pregnant mother
and to the child, up to and through
the period of adolescence, endemic
goiter may
be prevented.
These
facts are brought out in a well-written
paper on the " Prevention of
simple goiter
in man," by Dr.
O. P. Kimball,
dealing
with
the
prophylactic work carried out by him in the public schools of Akron.
Ohio.
The practical
application
of the principle
of the
prevention
of
simple or endemic goiter is now on such a firm basis that a few gen
erations hence will
see the end of this condition, as well as of cretin
ism in every civilized nation.
Xo. 3.
521
BOOK
NOTICES.
In the clinic
it has
been found that after
the twenty-fifth
year
of age iodine exerts little or no beneficial
effect on goiters ; also that
by the improper
use of iodine or thyroid
products many
cases
of
quiescent goiter, especially of the adenomatous
type,
are converted
into exophthalmic goiter or hyperthyroidism,
and that this induced
hyperthyroidism
is
essentially
identical
with
spontaneous
hyper
thyroidism.
A practical point dealing with
a paper by Dr. Allen Graham
on
the " Diseases
and pathology of the thyroid
gland," is the fact that
about 90 per cent of all malignant
tumors of the thyroid
arise
in
the fetal
adenomata.
Therefore,
iodine given the pregnant mother
may prevent
fetal
adenomata,
hence
cancer
of the thyroid
in
the
offspring.
The relations between diseases of the thyroid gland and laryngeal
function
are
discussed
by
Dr. J. M. Waugh,
and
the differential
diagnosis of diseases of the thyroid gland by Dr. John Phillips.
In a short paper Dr. R. S. Dinsmore brings to our attention
the
advantages of the adrenalin
sensitization
test for hyperthyroidism
which was first used by Goetsch
to establish
a differential
diagnosis
between
hyperthyroidism
and
early
tuberculosis
in
patients
pre
senting the syndrome
of loss of weight and strength, fatigue,
and
slight elevation
of the temperature,
in whom
the physical signs
and
X-ray findings for tuberculosis were negative.
The role played by
the radiologist
in the diagnosis of goiter
is
discussed
by Dr. B. H. Nichols,
and the value of basal
metabolism
studies in exophthalmic goiter by Dr. C. D. Christie.
Basal metabolism
estimations
provide a valuable, but not
a specific,
test for the presence of hyperthyroidism.
They
are of value in the
differential
diagnosis of border-line
cases, but are of little
value
in
the determination
of the operability or prognosis of cases of hj'per-
thyroidism.
Any case of hyperthyroidism
is operable, or may be made operable
by a short period of active
treatment
involving
a planned regimen
of rest and diet ; and in view of the surgical results
obtained,
Crile
advises surgical treatment
for all cases without regard to the degree
of hyperthyroidism.
Heretofore, the only valid objection to surgical
treatment
has
been
the mortality;
but with
modern
methods
the
mortality is practically
eliminated;
much
time
is saved and
a more
certain
cure
is achieved
thftn with
the X-ray
treatment
or any of
the
medical
treatments
advocated.
About one-third of the volume
is devoted
to the consideration of
the
preoperative;
the operative,
and
the postoperative
management
of exophthalmic goiter.
Apparently
this
book
is the first of
a series of clinical
volumes
which will present various subjects
as handled
at the Crile clinic in
522
Vol. XVII.
BOOK
NOTICES.
Cleveland.
The series promises
to be so valuable that we trust
the
next volume will soon make its appearance.
The first volume
of the series is recommended
to any one wishing
the latest information
concerning the thyroid gland,
(w. m. k.)
Collected
Papers of the Mayo Clinic.
Rochester,
Mtxn.,
Volume
XIII,
1921.
Edited
by Mrs. M. H. Mellish.
W. B. Saunders
Co., Philadelphia, 1922.
To those of us who are unable
to visit the Mayo clinic the appear
ance of the collection of 118 scientific papers contributed by 76 of the
physicians and surgeons
connected with the clinic during
1921 will be
most welcome.
The papers
cover
a wide range of subjects,
and
each
may be read with
profit.
Of these papers,
23
relate
to
conditions
affecting the alimentary tract ; 19 to the urogenital organs ; 7 to the
ductless glands;
8 to the blood;
6 to the skin and syphilis; 19 to the
head, trunk, and extremities ; 8 to the brain, spinal cord, and nerves ;
4 to technic; and 24 to general
subjects,
(w. M. k.)
Surgical
and Mechanical
Treatment of Peripheral Nerves,
by Upton Utookev,
A. M., M. D., associate
in neurology,
Columbia
University.
W. B.
Saunders
Co., 1922.
This book is a most practical, modern,
and especially scientific pre
sentation
of this subject.
Throughout
the
book
the author
shows
evidence
of exhaustive
study
and
careful
analysis, with
extensive
reference
to
the writings
of
eminent
scientists
whose
works
have
fallen within the scope of his subject.
The book
is systematically
arranged;
the
opening chapter dealing with
the
anatomy
of the
spinal
nerves,
the second chapter with
nerve
degeneration
and
re
generation; two very
important
preliminary
sections
in preparation
for a proper comprehension
of the following chapters
which follow in
very logical sequence.
While it would seem that the author
devotes-
considerable
attention in his chapter on " Methods of Nerve Repair."
to the standardization of terms with reference
to these methods, this
is,
indeed,
essential
in order that the terminology
may properly
ex
press the type of operation.
This chapter describes
in
a
very
clear
manner various methods of nerve repair.
The operative technique
is
very well described with its contiguous perplexities, and the drawings
are sufficiently descriptive to get
a
good
mental
picture of the pro
cedures.
The
chapters dealing
with
the
mechanical and surgical
treatment of special
nerves
is
excellent.
The anatomy
is
accurately
presented,
both
descriptively
and by splendid
cuts,
as well
as sur
face projection
pictures showing the relative position of the nerves
to surface anatomy.
The discussion
of cervical ribs, in the chapter
on the brachial
plexus,
is
noteworthy
and
completes
an
excellent
chapter.
The nerves of the arm, so frequently
subjected
to injury,
receive
their
proper
apportionment
of discussion
and
space, with
sufficient
attention
devoted
to
the
mechanical
side,
as well
as
the
No. 3.
523
BOOK
NOTICES.
surgical side of the
treatment.
The closing
chapters
of the
book
deal
with
nerve
tumors,
causalgia,
and
amputation
neuroma.
(E. J. O.)
Clinical
Tuberculosis,
by Francis
Marion
Pottenger,
A.
M.,
M.
D., LL.
D.
medical director,
Pottenger
Sanatorium
for D-iseases
of the Lungs
and Throat,
Monrovia,
Calif.
With
a chapter
on laboratory methods,
by
Joseph
Elbert
Pottenger, A. B., M. D.
In two
volumes.
Second edition.
C. V. Mosby
Co.
St. Ixmls,
1922.
The consideration of the subject of clinical
tuberculosis as found
in these two volumes
is complete
and thoroughgoing.
As a work of
reference
the
treatise
fills
a very definite and
important
place
in
medical literature.
Practically every phase of the disease is discussed
in considerable
detail, the author's wide knowledge of the subject
and
his pleasing style combining to give a production which one is glad
to sit down and read at length.
The illustrations,
which are numer
ous, are a distinct addition
to the work.
The author has taken ad
vantage of the opportunity
offered
in
a work of this scope to give
the reasons, as they appear to him, for many of the signs and symp
toms of the disease.
His classification of symptoms
according to their
causation
and his discussion
of the part which
the
nervous
system
plays in bringing
about
the clinical
manifestations of tuberculosis
are very instructive.
The greatest
value of the work, however,
lies
in its more practical
considerations.
The author is more peculiarly
fitted because of his experience to discuss the diagnosis and especially
the treatment of the disease, and this he has done in
a very clear,
comprehensive, and foiweful fashion,
(l. j. h.)
QUERIES.
Medical officers are invited
to submit queries
and
to present
their
problems
to the Bulletin, which
being in a position
to draw
on
varied and extensive
sources of information
such as are not available
elsewhere, will use every means of securing authoritative
opinion.
AU queries will be answered
by mail; and the replies, if of sufficient
general interest, will also be published in this column.
To the Editor
: Twice during
my
tour
of duty
as medical
officer of this sta
tion recruits
have
been
invalided
from
the service
because of mental
inferior
ity.
These
cases
have impressed
me with the unnecessary
expense they
have
meant
to
the Government.
In both
cases
the applicants
falsified
as
to
their
education
; and without
facilities for carrying out a standard
test to determine
their mental
age
the mistake
was made of considering
their knowledge
as an
accurate
index of their
intelligence.
The action of the Board of Medical
Sur
vey
in these cases
is based on
the results
obtained
by the Stearns
group
test
and the Stanford
revision
of the Binet-Simon
test.
The value of these tests can not be overestimated,
not only from
the point of
view of detecting
applicants
who are totally unfitted
for the naval
service, but
in determining
the adaptability
of the recruit to any special duties
which might
be assigned him during his naval
career.
For this
reason I have felt the need
of
facilities
for
making
some
test
which
could
be
considered
standard
and
which would
make it possible
to grade
our
applicants
in
standard
terms.
In
other words, is it practicable
to advance
the place for making
these tests from
the boards of medical survey at training stations
to the recruiting stations?
Lieutenant,
Medical
Corps.
The question
asked in this letter is similar to others that have been
received
by the bureau
at intervals in the past.
During January of
this year a set of three or four simple psychometric tests were submit
ted, with the suggestion
that they
be used as
a standard test at re
cruiting stations.
After careful consideration of the subject
at that
time by a board appointed for that purpose,
the opinion of the board
was that the adoption of such tests was impracticable.1
The Stanford
revision of the Binet-Simon
test is possibly the most
reliable and most generally used of the numerous
psychometric tests.
In
a sense
it is an intelligence
test.
"While the intelligence
tests
are important,
and while taking
them in
a routine manner one can
get
a good
deal of information
from the patient
(applicant),
often
1 U.
S. Naval Medical
Bulletin,
June,
1922.
525
526
Vol. XVII.
QUERIES.
information
of matters
that lie deeper than mere
questions
of
in
telligence,
still they
are by no means all-sufficient.
*
*
*
These
tests are valuable
in skilled
hands for the more pronounced degrees
of defect,
but
as
development
proceeds
they
become
progressively
more
unreliable
in proportion
to
the
increased
psychic
mass,
the
impossibility
of
standardization
because
of
the
wide
individual
differences,
and the greater probability
of distortion
from unknown
emotional
sources."
2
Psychological
tests are of value only when conscientiously carried
out and their findings correctly interpreted.
Their impracticability
with
respect
to their
general
adoption
by the recruiting
service
of
the Navy
lies in the fact of the
time
required in each individual
case, and in that their
correct
interpretation
requires an examiner
who is either a trained psychologist or psychiatrist,
and preferably
both.
The Army conducted
some very exhaustive
tests* with regard
to these matters,
but in order to do
so they
developed
an entirely
separate
corps of specially trained psychologists who were
assigned
to the recruit depot.
Opinion
was divided as to the ultimate result;
and,
as a matter of fact, we are in frequent contact
with
men who
have successfully passed the Army tests and
adapted
themselves
to
their environment while
in
the Army, but
who on
subsequent
en
listment in
the Navy
do not adapt themselves
and
eventually
are
surveyed
because of mental
deficiency
or constitutional psychopathic
tendencies.
White says, " Xo set of tests can be applied in a purely automatic
way nor will such tests in any way take the place of knowledge and
experience
on the part of the examiner.
In the most skilled
hands
the
results,
expressed
in terms of psychological
age, are but rough
approximations.
It has
been
well
said
that
the only
way to tell
whether
a person
is feeble-minded or not is to live with
him for
six months.
Reactions to life situations
are immensely
more valu
able and illuminating
than reactions
to psychological tests."4
For
the
present it would
seem
that the best way of eliminating
undesirables at the recruiting
stations
would be—
(a) By assigning to recruiting duty only such officers who have had
sufficient
experience
in
a cruising
vessel to
appreciate
the type of
recruit best suited for naval duty.
(b) By brief study of the personality of each applicant
through
a series of questions
selected for the purpose of determining his pre
vious
activities,
in
an effort
to elicit
any abnormal,
unstable,
or
asocial
tendencies.
* Diseases of the Nervous
System, Jelllffe
and White,
2d edition.
* Memoirs
of the National Academy
of Sciences, vol.
15.
4 Outlines
of
Psychiatry,
White.
No. 3.
527
QUERIES.
(e) By continued observance of each recruit during a period of pro
bationary detention at a training station with its ideal of eliminating
promptly
such individuals
as appear incapable of making
a satisfac-
.
tory adaptation and adjustment to the naval service required of them.
Home publications dealing with the subject of psychometrical tests
are:
Memoirs
of the National
Academy of Sciences,
vol.
15.
Terman,
Lewis
M. : The Measurements
of Intelligence.
Whipple, G. M. : Manual of Mental and Physical
Tests.
To the Editor
: Kindly
let
me know
the value of sodium
fluoride
as an ex
terminator of cockroaches,
the method of application,
and any precautions
that
should
be employed
when
this
chemical
is distributed
about
a
ship.
Phyllodromia.
Sodium fluoride
is considered
one of the most
efficient
roach
ex
terminators.
It is best used mixed with an equal part of powdered
sugar.
After
thoroughly
cleaning
the
locality
which
harbors
the
roach,
the sodium fluoride mixture is liberally
sprinkled
or blown
by means of a powder blower into corners,
drawers, closets, behind
pantry drain boards,
and into other places of concealment.
It must
be distributed in such a way that it will not be swept up or removed.
It should
be allowed to remain and act for weeks at a time.
It can
be sprinkled
along the back parts of shelves and
out of the way in
the recesses
of drawers
and in filing
cases.
This
substance
is not
injurious to books or other materials nor to the crew.
It forms the
basis of most roach powders now on the market.
The use of sodium fluoride seems to be too slow a process of eradi
cation when large numbers of roaches
are in evidence, in which case
a 5 per cent mixture of cresol in kerosene is very effective.
The mix
ture should be sprayed freely by means of
a powerful
mechanical
sprayer
into any place
harboring
roaches.
The
process
should be
repeated
once each week for several
weeks,
when
very few roaches
will be found.
This mixture
does not stain, although
its odor is
offensive to some.
In the eradication of cockroaches,
one must keep in mind the neces
sity of keeping all pantries and storerooms
free from crumbs or other
food remnants
which attract roaches.
-
All Ihe apparatus
required
for use aboard
ship
packed
in 2 cubic feet of space.
THE DIVISION
OF PREVENTIVE MEDICINE.
Lieut.
Commander
R.
F. Jones,
Medical
Corps,
United
States
Navy,
In charge.
Notes
on Preventive Medicine for Medical Officers,
United
States Navy.
INSTRUCTIONS
TO MEDICAL OFFICERS.
A SIMPLE
TYPE OF PORTABLE
STEAM BISHTFECTOR.
Bj R. F.
Jones,
Lieutenant
Commanaer,
and
P. Richmond,
Lieutenant,
Medical
Corps.
United
States
Navy.
During
the
World
War,
ships,
particularly
transports,
were
equipped
with large steam sterilizers for the disinfection of clothing
and bedding.
Such sterilizers occupied
considerable
space and there
fore were usually placed
on " topside."
Moreover, they
were costly
to install and operate, and when exposed to the weather
required con
stant attention.
Since it is still necessary
to sterilize clothing
and
bedding
occasionally,
a
suitable
disinfecting
apparatus
should
be
provided, preferably
one which could be stored in a small space and
easily transported.
Such
a portable disinfector
could also
be used
by landing parties and marines on shore duty.
The " sack " steam disinfector, invented by Col. P. S. Lelian, R. A.
M. C, professor of hygiene,
Royal Army Medical College, seems
to
meet these specifications.
The British Army is said to have used the
M sack " steam disinfector with success during the World War.
A
series of experiments
were
carried out at the Naval
Medical
School,
Washington,
D. C, to determine
the efficiency of this
dis
infector.
Before describing the results of the experiments
it might be
well
to give the reader
an idea of the
appearance
and
method
of
operation
of the "sack"
steam disinfector.
CONSTRUCTION AND WORKING PRINCIPLES.
The construction of the apparatus is very simple.
It consists of
a canvas bag, somewhat
similar
to the ordinary
Navy hammock
bag,
529
530
Vol. XVII.
DIVISION
OF PKEVENTIVE MEDICINE.
4 feet long and
2 feet in diameter,
with
a circular
wooden
bottom
and
a draw string to close the top.
The canvas of which the bag is made is impregnated with
a heat
and
waterproof
paint
to
make it impervious
to steam.
A 1-inch
rubber
hose
is attached
to the sack near its
base.
Steam
may
be
obtained
from a steam line or from
a copper boiler by making
the
necessary
connections.
The copper
boiler, with heating appliances,
is part of the equipment.
A metal disk from which coats, suits, or
other clothing may
be loosely hung to avoid creasing
and rumpling
is also provided.
This is not used when
clothes
are tightly packed
in the bag.
Clothing,
bedding, etc., may
be
packed
tightly
into the
sack
or
hung loosely
to avoid rumpling.
In
the first
instance
the sack is
packed
as would
be
done with
a
sea bag; it is then
inverted
and
suspended
from
a suitable
support.
When
suits
or other
clothing
are to be sterilized, the sack is first suspended
in an inverted
posi
tion and then
the clothing hanging from the disk is pulled up into
it by means of pulleys.
In either case the outlet of the sack is partially
closed by means of
a purse string.
Steam
obtained
in one of the ways
described
above
is now allowed to flow into the sack through the rubber hose.
As
steam enters its base an equal volume of air is expelled
from its down-
turned mouth, which has been partially closed.
Gravity
forces each
entering volume
of steam to spread
horizontally
across the sack,
dis
placing the heavier air downward
from the interstices of the cloth
ing.
This stratum of steam immediately condenses
and, by the in
tense latent heat thus liberated, heats to
a high
degree every fiber
with which it comes in contact.
A fresh wave of steam then
enters
the resultant partial
vacuum,
fills it, heats
its contents
to the con
densation
point, and
sweeps onward to repeat
the cycle
in another
layer of clothing immediately below.
Heating of the contents
thus
progresses,
layer by layer, until there is free escape of steam
from
the mouth of the sack, indicating that air has been entirely displaced
from the sack and the contents
heated throughout.
However,
com
plete sterilization
is not effected until steam is allowed to flow from
the mouth of the sack for from
15 to 30 minutes,
depending on the
volume
of
steam
entering
the
sack.
But
in
this
connection
it
should be stated
that
insects
and
nonspore-bearing
organisms
are
killed in a much shorter time.
EXPERIMENTS
TO TEST EFFICIENCY OF
SACK.
The sack was tested under varying conditions.
The first tests
con
sisted of packing bedding and clothing tightly into the sack
and
ob
No. 3.
531
DIVISION
OF PREVENTIVE MEDICINE.
tabling steam from
a copper boiler which was heated by
a pressure
kerosene
stove.
The accompanying diagram illustrates the locality of thermometer,
culture
media,
eggs, or animal parasites which were
used to deter
mine
the efficiency of the sack
as a sterilizing
agent.
The numbers
shown
thereon
were
used
constantly
throughout
all
experiments.
In
every
instance
the thermometer,
culture
media,
eggs, or animal
parasites
were
placed
in the center of tightly wrapped
bundles
of
clothing.
The following table shows the results obtained
:
532
Vol. XVII
DIVISION
OF PREVENTIVE MEDICINE.
O o 3
.tj
3 S S S-g 8
§55-1
£.3
CO
ago
.gS.3
(*XI
If
iff!!
5
£ £ o o
- e o a
3 -£^.2
1 =3-
m
Is
1 g
■a
itijj twi
Effect
i
cente
mark
Position
No.
Tempera
ture as re
corded
on
thermome
ter in center
of bundle
at point
No.
0
as
i
marked
on
;
diagram,
i
—
^2
CO
O
CO
80
98-100
100
• c.
Time
dur
ing which
steam
llowed
freely from
mouth
of sack.
i
N
!2
§5
^'
The
apparatus
in operation
with
steam
supplied
from a copper
boiler heated
by a kerosene
burner.
The sack inverted
and ready
for operation.
Disk for suspending clothing hung alongside
532—1
Complete
outfit for field use being transported in motor-cycle side car.
No. 3.
533
DIVISION
OF PREVENTIVE MEDICINE.
DISCUSSION
OF THE FIRST
SERIES
OF
EXPERIMENTS.
From an examination of the above table it will
be noted that all
material
packed
in the sack was not sterilized after steam had
been,
allowed to flow from the mouth of the sack for 2 minutes,
although
the manufacturer of the apparatus in his descriptive pamphlet claims
that complete sterilization
should be obtained
within
2 minutes after
steam
commenced
to
flow
from
the
sack.
This
experiment
was
repeated
several times and invariably
the same results
were obtained.
Bedbugs, which are killed
at a temperature
of approximately
76° C,
were not killed when
placed
at position No.
6 for this time.
Here
it might be stated that it required approximately
20 minutes to get
a full flow of steam through the mouth of the sack.
All nonspore-bearing
organisms
and
bedbugs
were
killed
when
steam was allowed to flow from
the sack for
15 minutes,
although
spore-bearing
organisms
were
not
killed
in this
time.
Therefore,
this length of exposure
is not deemed sufficient
to sterilize.
However,
it would
be perfectly safe to use the sack under similar circumstances
to destroy
vermin.
When steam was allowed to flow
from the mouth
of the sack for
30 minutes all organisms and
parasites
were killed.
In our opin
ion, when
steam is obtained from an improvised boiler or the boiler
furnished
with the apparatus, it would be safer to lengthen
the time
of operation to 30 minutes in order to be definitely certain of good
results.
In an endeavor
to simulate conditions under which the sack is to
be used
aboard
ship, steam
was
obtained
from
a steam line by in
troducing
a reducing
valve
between
the
sack
and
the
steam line
having a pressure of 75 pounds.
The pressure of the steam entering
the sack was approximately
5 pounds per square inch.
The follow
ing table shows the results obtained
:
646—22
11
534
Vol. XVII.
DIVISION
OF PREVENTIVE
MEDICINE.
!
mm
T3
o o
5?
-3
5
3X
it
"J
d
d
d
d d
•OT3
■•■it
IS* tail
«
5 ec« a) d
3
"3
r33
"o
-g-g
£ jj = 3 3.2
^" - _
— -
—«- C L.-3 <3S3
E8SSS.SS,
S
8
8
8
8
88
si
3-
53
s * I s >>=
o
©
i—\
No. 3.
535
DIVISION
OF
PREVENTIVE
MEDICINE.
DISCUSSION OF TABLE
II.
By reference
to Table II it will be seen that the sack is effective
as
a sterilizer for all organisms when the steam is allowd to flow freely
out of the mouth for
15 minutes,
but that only nonspore-bearing or
ganisms will be killed after 2 minutes.
The results
were apparently
the
same
whether the bag
was
packed tightly or the
clothes
hung
loosely in the sack.
It is obvious,
from
a comparison of the two
tables, that it is desirable
to have the steam entering the sack under
slight
pressure
and in considerable
volume.
It may
be possible
to
obtain some pressure
and
a considerable
volume
of steam with
the
heating appliance furnished with the apparatus, but we were unable
to do so in a series of some
15 tests.
It was never
possible
to get a
flow of steam in any way comparable
with
the flow when
the sack
was connected
with
the
steam
line.
Not only
does steam sterilize
more rapidly when
under pressure,
but there is also
less
condensa
tion, which is evidenced
by the drier condition of the clothing
when
removed.
Furthermore,
steam obtained
from a steam line penetrated
the clothing more rapidly.
PRACTICAL
USES
OF
THE
SACK DISINFECTOR.
The compactness
and simplicity
of this apparatus makes it espe
cially
suitable for use aboard ship
where
connection
between
the
sack and a steam line can
be easily made by interposing
a reducing
valve to reduce
the pressure
below
25 pounds.
Whenever steriliza
tion of clothing, bedding, or mattresses
is required the "sack"
can
be rigged in a few minutes
and can be safely used to disinfect cloth
ing and bedding contaminated
by bacteria
and parasites.
When not
in use it can
be stowed in approximately
2 cubic feet of space.
The
sterilizing power is approximately
equal to that of an Arnold steam
sterilizer,
and in the event of the autoclave
being out of order, large
quantities of surgical
dressings,
especially bulky
packages
of shell-
wound
dressings,
towels,
gowns,
etc.,
can
be
safely
subjected
to
fractional sterilization with this apparatus.
An outfit with
all the necessary
appliances for use where
boiler
steam is not available will pack
in about 4 cubic
feet of space and
does not weigh more than 60 pounds.
Such an outfit could be used
to advantage
on expeditionary
duty, particularly
by marines, who
can not readily transport heavier appliances.
If necessary, supplies
of surgical dressings for a temporary field hospital could be sterilized.
By utilizing the same principles
aboard ship a small compartment
capable of being made practically
air-tight could
be converted
into
a sterilizing chamber.
Satisfactory
results
from
such
an arrange
ment
are reported in
the
annual sanitary
report of the U.
S.
S.
Wyoming.
The only alterations required would
be the installation
536
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
of two pipes, controlled by valves
; one located
above, and
connected
with
a steam line, and
the other below
for exhausting the chamber
of air or steam.
As soon as steam flows freely from the lower pipe,
the
valve
controlling
this should
be
closed
and
steam
allowed to
flow
into the
room
until
there
is slight
bulging
of the
bulkheads,
indicating
that sufficient
pressure
has been
obtained
to permit thor
ough penetration.
The efficiency of such
a procedure
can be tested
by
placing
hens'
eggs
at various
parts of
the
room.
Live
steam
should be allowed to flow into the room for about 30 minutes.
Under
ordinary circumstances
the eggs would be " hard boiled " in this time.
CONCLUSIONS.
1. The "sack"
disinfector
is particularly
useful for the military
services on account of its compactness
and portability,
and the writers
are of the opinion that it should
be adopted
as permanent
equipment
of the Navy and Marine Corps.
2. When steam is obtained
from an improvised boiler, sterilization
should continue
for
30 minutes
after
steam flows freely
from
the
mouth of the sack:
when
connected with
a steam line this time may
be reduced
to
15 minutes.
3. Bedbugs and other such insects may be destroyed
in a third the
time required for complete
sterilization.
4. The
time
required for sterilization
is the
same
when
clothing
is packed in the sack tightly
as when hung loosely.
HEALTH CONDITIONS
OF THE
NAVY.
Health
conditions of the Navy for the four-week period
ending
August
5 were not quite, so good
as for the previous month.
The
annual admission
rate for all causes for the four-week period ending
August
5 was
540
per
1.000
per
annum
as compared
with
385
per
1,000 per annum for the four- week period ending July 8.
However,
the health
conditions were better than they were at a similar
period
last year.
The morbidity
rate for diseases only was 471 per
1.000 per annum
and for accidents
and injuries,
69 per
1.000 per annum.
The admission rate for the
communicable
diseases,
exclusive
of
influenza and the venereal
diseases, for the four-week period ending
August
5. was
37 per
1,000
per annum.
It will be seen
in the fol
lowing
table that malaria
caused approximately
half of the admis
sions for the communicable
diseases :
Xo. 3.
537
DIVISION
OF PREVENTIVE
MEDICINE.
Annual
admission
rates
per
1,000 for certain
communicable
diseases,
current
month
of
July.
1922, in comparison
with
the mean annual admission
rates,
month
of July, for
thefour-year
period 1918-1921,
inclusive.
Disease
Cerebrospinal
fever.
Diphtheria
German
measles
Influenza
Malaria
Measles
Mumps
Pneumonia
Scarlet fever
Smallpox
Tuberculosis
Typhoid
fever
0. 15
0
L 98
0.75
1. 30
L40
23. 79
10. 01
12. 97
17. 10
3. 83
.97
12. 92
.75
4. 48
2. 26
L 54
. 11
.09
0
4.59
.65
.05
.22
There
has been little
change
in the morbidity
rates for the vene
real
diseases
in
the
past
three
or
four
months.
The
progressive
average
rate for venereal
disease for the year is now
108 per
1,000
per annum.
Although
a considerable
number
of recruits
have
been received
at training
stations
since
about June
1, there
have
been few
com
municable
diseases reported from
any of the training
stations.
Health
conditions of the
forces
afloat
are
excellent.
Few
com
municable diseases have
been
reported
during
the past
month.
NOTES FROlIt THE NAVAL TRAINING STATION, HAMPTON
ROADS,
VA.
During
the
month
of June
there
was
a
great
deal
of rainfall,
resulting
in many pools of water being present
under houses
and
bungalows,
and
a
consequent
increase
in
the
prevalence
of
mos
quitoes.
Oiling of all surface
water has been continued, but
inas
much
as it is difficult to use an oil spray in the confined
space under
buildings,
no
doubt,
many
pools
of water were
missed.
Toward
the end of the month
the weather
cleared
and became dry, and the
decrease in number of mosquitoes
was quite noticeable
to those who
have
occasion
to
be in the open in the early morning
and evening.
Flies have apparently
decreased in numbers,
and can not be said
to
be
present
in undue
proportion.
Parts of the training
station
have been inspected
every
day,
and it is believed
that there
are no
breeding places for flies in this territory.
There have been no diseases contracted
on the station during
the
month
of June attributable
to either mosquitoes
or flies.
Cases of
malaria
have
come
up
from
the Tropics,
and
some of them
have
had
acute
exacerbations
while
here, but
no
secondary
cases
have
538
Vol. XVIi.
DIVISION
OF
PREVENTIVE
MEDICINE.
arisen.
Until recently, no anopheles
mosquitoes
were found at this
place,
but
they
are
here
now;
therefore,
all
men
who
have
had
malarial
fever in the past
are now required to sleep under nets.
The water supply of the station is obtained
from the water mains
of the city of Norfolk, from which it is pumped
into a distributing
reservoir
oh
the
base.
This
has
been
the
cause of
considerable
concern during the month because our laboratory reports have shown
that
the
colon
bacillus
has been persistently
present
in the
water.
Keports
from
the health department of the city of Norfolk
early
in June
showed
that
the water
was infected with
that
organism.
The city water supply
is chlorinated
by
the Wallace
and Tiernan
apparatus,
using
compressed
chlorine
gas.
The
amount
of
gas
used
was
promptly
increased
by
the
city,
and
for
a time it
was
found
that
the
water received
into the reservoir at the
base
was
apparently
free from harmful
bacteria.
However, toward the end
of the month colon bacilli
again appeared
in the
water.
As
soon
as it was found that the
organism
was
present
in the
water, the
chlorinating
apparatus installed
at the
power house
at
the
naval
operating
base
was
put in operation
and,
on June
10,
we
began
using
2 pounds
of chlorine
to the
2,000,000
gallons of water
used
each 24 hours.
This is in the proportion of 0.26 part per
1,000,000.
Our apparatus injects the chlorine into the water between the power
house
and
the reservoir.
The quantity of chlorine
was gradually
increased
until the 16th, when
5 pounds
of chlorine, corresponding
to 0.3 part per 1,000,000,
was used.
Cultures were made every other
day.
On June 22, 6 pounds of chlorine, corresponding to 0.36 part
per 1,000,000,
were used in 24 hours, and the last report, dated June
23,
showed
an
improvement;
it being impossible
to
isolate
colon
bacilli
in less than 10 c. c. of water.
It was known that the station
reservoir
had
an accumulation of dirt on the
bottom,
since it had
not
been cleaned
for more
than two
years.
Although
it
was
be
lieved that this reservoir did not form,
at that time,
a real menace
to the
personnel
of the station, yet
recommendation
was
made
to
the
public-works
officer that the reservoir
be thoroughly
cleaned.
Health conditions.—The total number of admissions to
the
sick
list for the month of June was 206 ; this is against 87 for the month
of May.
This, however,
does not indicate the actual amount
of ill
ness occurring among
the personnel,
inasmuch
as the 206 admissions
includes
54 recruits
admitted for survey,
65 recruits in whom
in
testinal parasites
were found, and 20 men, admitted with no disease,
and
placed
under
observation
as
measles
contacts —total of
139,
which leaves but
67 cases of routine illness to be compared
with
87
cases
that occurred in May.
From this it would appear that
the
health of the command
has been excellent.
No. 3.
539
DIVISION
OF PREVENTIVE MEDICINE.
Recruits. —From
the time
recruiting
started,
in May, to June 30,
inclusive,
1,036
men
were
received
at this station.
Of these it was
found necessary
to hold out
70, or 6.75
per cent, because of various
disqualifying disabilities,
as listed below:
Nephritis,
chronic (interstitial
and parenchymatous)
Color blindness
Otitis media,
chronic
Valvular
disease,
chronic cardiac
Hypermetropia
Union of fracture, faulty
Astigmatism
Atrophy
of muscle
Myopia
ritis, chronic
ysis of nerv e
litis maxillary
Total surveyed
Attention
is invited
to
the
large
number of
cases
of chronic
nephritis,
34, or 3.21 per cent of all recruits.
It is our custom,
at
this station,
to examine
the urine of every recruit and when albumin
is found
to be present
the urine is examined
chemically
and
mi
croscopically
every
day until it is determined whether the recruit
has
a transitory
albuminuria
or Bright's disease.
Of the
34 men
who were discharged, as reported above, all were shown conclusively,
after repeated examinations, to have chronic Bright's disease.
Aside
from the 34 positive cases,
'29 other men showed albumin on the first
examination, followed by two or three negative tests.
In practically
all of these latter
men there
was
a history of their having
drunk
corn whisky or other " bootleg " liquor within
a day or so prior to
their examination.
It is also interesting
to find that all of these
men, in
whom
albumin
was
persistently
found,
denied
absolutely
that they had
been drinking liquor of any sort.
Many of them pre
sented
a
blood
pressure
in
excess of normal
for
their
age
and
physique, and most of them gave
a history of some acute infection.
Aside from the 34 men who were finally
discharged,
17 others
were
under observation as nephritis
suspects for a period of several
days,
but were eventually outfitted and sent on through the training course.
In the recruit-examining
room
the hospital
corpsman,
assigned
to
make the examination
of urine of all these men,
was
on duty for
six months in the naval hospital in Charleston,
S. O, where
a por
tion of his daily work was the routine urinalysis of all urine samples
of patients
in
the hospital.
His work
was
checked
personally
by
the medical officer of the examining room, and the findings were later
540
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
substantiated
at
the
base
laboratory.
This
eorpsman
states that,
in his
experience,
the percentage
of albuminurias
in
these
recruits
was much higher than in routine hospital patients.
This experience
raises the question
whether
it is not advisable
for the medical
officer
in
each
recruiting
station throughout
the country
to make
a uri
nalysis of every man he is inclined to accept and throw out those who
show albumin.
The
11
cases of color blindness that were discharged by medical
survey were
examined
first with
the
Jennings
test
and
then
the
Holmgren
skeins.
The
examination
was
repeated
several
times,
and
the board of
survey,
as well
as the senior medical officer, - is
thoroughly
satisfied
that
there
was
no question
in the diagnosis of
their condition.
Sick quarters. —The
month
of June
completes
the first year of
our organization in which sick quarters has played such an important
part.
The plan originally made
has
been
followed
with very few
modifications,
and
has
been
found
to work
most
admirably.
All
activities of the
base
have
cooperated
to the fullest
extent; there
has been
no friction,
and it is believed
that all activities will agree
that the presence of the facilities
offered by sick quarters
have given
them a sense of security they could not possibly have felt had the old
base hospital
gone out of commission,
leaving nothing in its place.
During the year
3,209
cases
have passed through sick quarters,
898
of which were transferred to the naval hospital at Norfolk for treat
ment.
Of the total
(3.209)
2,625
were
admitted
from the training
station, 355 from
the receiving ship.
195 from
the air station, and
34 from miscellaneous
sources,
such
as submarine
base,
ships in the
harbor, etc.
In addition
to the original
plan of work, one medical
officer
has
been
assigned
to the
care of the families of Navy
per
sonnel, and this activity has grown to such
an extent that during the
month of June this officer covered
1.041 miles attending to his duties.
PARIS
GREEN
AS A LARVICIDE FOR ANOPHELINE
LARV-ffi.
The
following
is
an extract
from
an
article
appearing
in the
United
States Public Health
Service Report
of
December
9,
1921.
entitled "Arsenic
as
a larvicide
for
anopheline
larvse,"
by M. A.
Barber, special
expert,
and T. B. Hayne. technical assistant,
United
States Public Health Service:
QUANTITY
AND
METHOD
OF USE OF PARIS
GREEN.
" Baris green in antianopheline work should be diluted with a large
proportion
of inert
dust.
Only
very small
doses
are necessary
to
poison
larva?,
and
the dilution
enables
one
to
spread
a relatively
No. 3.
541
DIVISION
OF
PREVENTIVE
MEDICINE.
small quantity of the poison over a large surface.
Further, any risk
of poisoning
the operator or the water treated
is minimized by the
use of the diluted
dust.
As
a diluent
we
have
successfully
used
fine sand, rotton-wood
dust,
and road dust.
Road
dust, preferably
mixed with some fine clay, seems to be as effective
as any.
The addi
tion of weight in the form of some coarser sand is helpful in enabling
one to direct the dispersal of the lighter
dust.
Some of the diluting
dust sinks on contact
with the water, but most of the arsenic
is left
on the surface.
Flowers of sulphur
has not proved a suitable dilut
ing dust, possibly because so large a proportion
of it remains float
ing that it is ingested
with the Paris green, which latter is then too
much diluted.
A dilution
of about
1 part of the poison to 100 parts
of the inert dust seems to be a favorable mixture.
"The quantity of Paris green
to be used must depend
somewhat
on the character of the breeding place.
Where there is much high
trass, reeds, and the like, one would use somewhat
greater quantities
of the poison
than where the surface of the water is clear or covered
by low surface vegetation
only.
Since the poison is relatively
in
expensive,
and
the danger of poisoning
the water of the breeding
place is small, quantities somewhat
larger than those given in the
protocol would seem to be advisable,
possibly about
10 c. c. (approxi
mately
12 grams, 0.43
ounces avoirdupois,
0.6 cubic inches,
or two
level teaspoonfuls) to 90 square meters
(1,000 square feet).
''A slowly settling cloud of
dust
carried
along by
a light wind
is apparently the best agent for the distribution
of the dust, and the
main thing
is to start this cloud in the right place
and
direction.
A single cloud may destroy
larvso over a wide area and at a consid
erable distance
from the operator.
We have tried certain mechani
cal means for distributing
the dust, such
as the dust-guns used in
dusting arsenic
on cotton plants, but thus far we have succeeded best
by simply throwing
the dust into the air by hand.
The
cloud
can
thus be formed high or low, to the right or to the left, depending on
the
force
and
direction
of the wind.
The
pole and
bag method,
sometimes
used for dusting plants, has been found useful in treating
a breeding place at the bottom of a deep ditch.
TIME OF DAY FOK THE USE OF THE POWDER.
''The
best results are to
be
expected
on
a sunny day
when
the
powder
is spread
after the sun is well up and
the
dew has disap
peared from any vegetation
covering the breeding place.
FREQUENCY
OF TREATMENT.
" The frequency of
treatment
of
a breeding place
must
depend
largely on
the
temperature
of
the water.
In
a
recent experiment
542
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
anopheline larvae
were thoroughly
destroyed
over
a given area.
The
place
was kept under observation
from
day
to
day,
and
frequent
collections of larvae were made.
Eleven
days after treatment
fully
grown larvae and
a few pupae
were found.
In this breeding place,
then, it would have been necessary to repeat the treatment
within ten
days.
The weather was warm, and the temperature
of the water very
high, and it is probable that in this pond the growth of the
larvae
(larvae of A. quadriniaculatus)
was nearly at its maximum rate.
COST.
" Paris green
was recently quoted
at 22 cents per pound, f. o.
b.
New York City, packed in 300-pound
barrels.
Small quantities may
be purchased
in drug
stores
for
$1 per pound.
At
25
cents
per
pound the amount sufficient
for at least
1,000
square
feet,
10
c. c,
would cost about seven-tenths of a cent.
The calcium arsenate in com
mon use for dusting cotton plants may
be purchased
for about 15 to
20 cents per pound.
The
use of a powder instead of a liquid should
greatly lower the cost of transportation.
Usually
a dust suitable for
dilution
can be found in the neighborhood of the breeding place, so
that one has to transport only
a pound or so of Paris green for the
treatment
of a large area.
DANGER OF POISONING THE OPERATOR OR THE WATER TREATED.
" The danger to persons
engaged
in distributing
arsenic-contain
ing dusts as larvicides would seem to be mainly through the possibility
of inhalation of the poison or its absorption through the skin rather
than through ingestion.
In our search for information
regarding the
possible
harm to men or domestic
animals engaged
in distributing
arsenical
dusts as insecticides,
we sent letters of inquiry
to 17 United
States
or
State
agricultural
experiment stations in
the
cotton or
tobacco growing
States, in the hope that information
might
be ob
tained from those who have had much practical experience with these
dusts
and
their
possible
harmful
effects.
In
some
States
these
arsenical dusts, calcium arsenate in particular,
have been used by the
ton in combating the boll weevil.
Of the 16 stations replying to our
inquiry
14 of the correspondents
had
had
experience
in the use of
arsenical
dusts.
Of
these
14
about
half
had
knowledge of
some
injury to man or domestic animals through the use of these arsenical
dusts.
The lesions
reported
were chiefly of the acute type
and of a
minor degree, such
as sores on exposed
parts of the body, irritation
of the bronchial
tubes,
and
sometimes
intestinal
disorders—lesions
which usually healed promptly.
Some more serious
cases of chronic
poisoning were reported
to us by Mr. B. R. Coad, in charge of the
Delta Laboratory, United
States Bureau of Entomology,
at Tallulah,
La.,
who kindly
wrote
us
a full
description of these
cases.
The
No. 3.
543
DIVISION
OF
PREVENTIVE
MEDICINE.
cases
were of the cumulative type of poisoning,
and
occurred
ex
clusively
among
persons
who
had worked with
the
dusts
in
close
quarters
for several
years.
They occurred
as the result of exposure
to calcium arsenate
as well as to other kinds of arsenical
dusts.
' The
chronic types of poisoning
are practically
always accompanied
by
some dermatic
disorder, the injury of which varies widely with the
individual,
. and
is
somewhat
recurrent.
Furthermore,
in
extreme
cases we find neuritis and occasionally some fairly pronounced heart
symptoms.
It has proved
a very obnoxious ailment, and,
further
more,
a very stubborn
one.
Apparently
it is brought
about by
a
saturation of the system with arsenic, and the victim is nearly always
hypersensitive
to arsenic
exposure.
In the case of constant
exposure
the mucous membranes of the nose and throat reach such a condition
that they are exceedingly
sensitive
to mechanical irritation by any
form of dust, and a slight exposure
to dust brings on an attack which
very closely
resembles hay fever.'
"It is to be remembered
that these chronic
cases followed
a long
and intimate exposure
to arsenic
dusts.
Mr. Coad was of the opin
ion that
the
amount
of
exposure
incident
to
the
antianopheline
work we have
described
would probably not lead to any particular
danger.
It is significant
that
so little trouble
is reported
by
e±-
periment-station
workers
and
by
other
persons
who
have
used
arsenic
dusts extensively for some years.
Possibly
their immunity
has
been
due
in
part
to
the
fact
that
they
use principally
the
slightly water-soluble calcium arsenate,
and that cotton-plant
dust
ing extends
over
a comparatively
short period
each
year.
How
ever, in antianopheline work
where
such small quantities of highly
diluted Paris green
are used, and
where
the work
is wholly
out of
doors,
simple
precautions
should
suffice
to
protect
the
user,
nor
would
a health officer anticipate
any
strenuous
objections from
the
people of a community
to the
use of
a substance
so commonly
em
ployed
as an insecticide.
"In our experiments
we have
used no precautions other than to
stand to the windward of the dust cloud—the place where one would
naturally
stand
in distributing
the dust— and
we have
experienced
no harmful
results
whatever.
However, even with the small quan
tities used in larvicide work, it is well to remember that one is work
ing with
a poison and
that
some precautions should
be
taken
at
least until
the matter is further
investigated.
It is probably
suffi
cient to keep to the windward
of the dust
clouds
and
to avoid in
haling the dust as far as possible.
In case
a great deal of exposure
is necessary,
one
should
use
some
precaution
to
keep
any
large
amount of Paris green from entering the clothing or accumulating
anywhere
on the skin.
544
DIVISION
OF
PREVENTIVE
MEDICINE.
Vol. XVII.
" As regards the danger of poisoning the water treated, it should
be emphasized
that only a minute quantity of Paris green is dusted
over
a very large surface, and of that compound
only
a very small
fraction
is water-soluble.
We
have
never
observed
any
effect of
the
poison
on culicine larva; or on
any
aquatic
insect
or animal,
however
delicate,
other than the surface-feeding
anopheline
larvae.
In particular,
we have
never
observed
any indication
of harm to
top-feeding minnows or to any other natural enemy of larva?.
The
danger to
domestic
animals through drinking treated
water
seems
very remote.
In order to meet any objections on
the part of
the
owner of
a breeding
place,
one might
arrange
to
have
the
stock
removed
from
the breeding place
for
a day
or
so, but the owner
will hardly
insist
on this precaution
when it
is- explained to him
that the powder is the
same
as that commonly
used against insects
and that only
a very small quantity of it is to be used on a large
body of water.
" In
sum,
the
possible
advantages
of arsenic dust used
against
anopheline larvae are its cheapness,
portability,
ease of distribution
by
means of the wind,
and
the possibility
of using it over
areas
difficult
of
treatment
by
methods
now
in
use.
The
chief
disad
vantage
is that
its
use
is
limited
to
anopheline
larvae—ova
and
pupae
of all
kinds,
and
culicine
larvae
are
apparently
unaffected.
It is believed,
however,
that this method will have
a place in anti
malarial work, especially in places not easily
drained and so covered
by vegetation
or other obstacles
as
to
render
them
inaccessible
to
natural
enemies of larvae, or to other methods
of treatment."
CHLOROPICRIN
AS SHIP
FUMIGANT.
The following is an extract from The Nation's Health of July 15,
1922 :
" Sulphur
dioxid
is the aeon-old standby in ship fumigation.
It
is
a fairly
good
agent of deratization;
accidents
to human beings
very
seldom
follow
its use;
it is relatively
cheap; it requires very
little apparatus to use; highly skilled labor is not absolutely neces
sary in its application.
On the other
hand, its diffusibility is not
good; its weight
sometimes
makes
post
fumigation
aeration
some
what
slow; it is destructive
to colors
and tarnishes or even corrodes
certain metals.
"Carbon monoxid is of considerable
value; it is fairly
efficacious
for killing small mammals; it is fairly cheap;
it is not
destructive;
there
is no danger from fire during its use,
as with sulphur
dioxid:
it is light and
aeration
is easy following its use.
A special
appa
ratus and skilled operatives
are required for its use; it diffusibility
No. 3.
DIVISION
OF
PREVENTIVE
MEDICINE.
545
is not uniform
and is uncertain; in the presence of a humid atmos
phere it is apt to cause sweating of painted surfaces
; it is ordorless,
tasteless,
nonirritant,
and
invisible,
and
has
therefore
the
great
hazard that someone may walk into it and be killed.
"Hydrocyanic
acid
gas is an extremely valuable fumigant;
it is
highly lethal for mammals,
many insects, and all birds; it is highly
diffusible,
relatively
cheap,
and
not
destructive.
Skilled
and
de
pendable
labor is required for its use ; aeration must be perfect before
the
fumigated
compartments
may
be
entered.
It
is
a useful
but
highly dangerous
weapon
in the armentarium of the sanitarian.
"An attempt
was made by Seguy F. (Arch,
de Med. et de Pharm.,
Nav..
1921. HI, No. 6, p.
509 et seq.)
to utilize chloropicrin
in the
proportion of
5
c.
c. per cubic
meter
as
a deratizing
fumigant
for
ships.
The
chemical
formula
of chloropicrin
is
CC13N02
and
is
made by the action of calcium hypochlorite
on calcium picrate.
It
boils at 111.9° C, freezes at —0.602° C, and has a density of 1.648
at 25°
C.
It is an intense
lachrymant.
For a ship of 4,000
cubic
meters capacity (about 1,500 registry tons)
20 liters, at a total cost
of 280
francs
(about
$50 gold), were
required.
The agent
killed
all rats and bugs, but 24 hours' aeration was necessary.
The difficulty
of removal of the gas by ordinary
ventilation
methods
interposes
an
almost insuperable obstacle by reason of the time element involved.
This gas is relatively
safe, however,
because no one will walk very
far into it."
INSTRUCTIONS
TO MEDICAL OFFICERS.
Circular
letter,
serial
No.
198—1922.
HWS: MFD.
125221
(71).
department of the navy,
Bureau
of Medicine and
Surgery,
Washington,
D. C, July IS. mi.
To : All
medical
officers.
Subject
: Training
of flight surgeons.
1. A large number of medical
officers will
be needed
for training in aviation
medicine and subsequent duty as flight surgeons.
2. The training period will consist of a course of instruction
of approximately
four months' duration
either
at Washington,
D. C, or at Mineola,
Long Island.
3. Any medical
officer who may desire to identify
himself
with the specialty
of
aviation
medicine
is
requested
to
make
early
application
to
the
bureau,
inclosing
a report of a physical
examination
such as is prescribed
for pilots.
E. K. Stitt.
Circular letter,
serial
No. 199—1922.
SDS.
HWM:HCM.
124842
( 73).
Department of the Navy,
Bureau
of Medicine and
Surgery,
Washington,
D.
£?., July
18,
1922.
To: All medical
officers.
Subject
: Forms
N. M. S. " F." and N. M. S. " K.," revision
of.
Inclosure:
1.
1. Form F
has
been
revised
to
include
all information necessary
for
the
morbidity
and mortality
statistical
purposes of the Bureau of Medicine
and
Surgery.
Form K will therefore
be abolished
when the present supply of either
Form F or Form K is exhausted.
2. Naval medical
supply
depots will
not Issue the new form while
requests
can be filled
from the old stock on hand.
3.
Ships
and stations
will continue
to
use
the present
forms until
the
stock
of such
is
used
up and until
such time
as the revised
Form F is furnished
by the depots.
4.
Copy
of the new Form F Is attached
for Information ; supply
of which
can
be secured
when
needed
from
the nearest
naval
medical
supply
depot
in
the usual
manner
(Form O).
E. R. Stitt.
Circular
letter,
serial
No.
200—1922.
WSG/T.
125949
( 54).
Department
of the
Navy,
Bureau of Medicine and
Subgeey,
Washington,
D. C, July 17,
1922.
To: All
naval
hospitals,
V.
S.
S.
Mercy
and Relief,
sick
quarters,
marine
barracks,
Quantico,
Va.
546
No. 3.
547
DIVISION
OF PREVENTIVE
MEDICINE.
Subject:
Subsistence
of
enlisted
personnel
of
the
Navy
and
Marine
Corps
( Regular and Reserve)
during period
granted
leave from
treatment
in hos
pital.
Inclosure:
(A)
Bureau's
attached
1st
ind.,
No.
125949
(34),
June
3,
1922.
1. The Bureau
of Navigation
in forwarding
this
bureau's
first indorsement
(inclosure)
in
its
second
indorsement
No.
57309-140
of June
9,
1922,
made
recommendation,
as
follows
:
"1. Forwarded.
This
bureau
concurs
In the opinions
expressed
in
the let
ter of
the Bureau
of Supplies
and Accounts
and the first
indorsement
of the
Bureau
of
Medicine
and
Surgery,
and
recommends
that
reference
(6)
be
rescinded
to
take
effect June
30.
1922.
(Signed)
Thos.
Washington."
2. The department
by its letter
No. 9047-1219-4 of July
12.
1922, decided as
follows
:
"1. Authority
contained
in
decision
of
the
department
of
May
14,
1919>
(9047-1219).
to pay
enlisted
personnel
a
subsistence
allowance
while
absent
on
leave
granted
while
patient
in
hospital,
etc.,
is
revoked,
effective
imme
diately.
(Signed)
R. E. Coontz,
acting."
3. In
accordance
with
the
direction
of
the
department
as
quoted
in the
foregoing
paragraph,
no further
" so-called
sick
leave "
as
mentioned
in this
correspondence
will
be
grunted
at
naval
hospitals
on
and
after
the date of
the receipt
of this letter;
such
leaves
already
granted
will
not
be extended;
but
such
leaves
already
in
force
when
this
letter
shall
he
received
may
be
completed.
E. R. Stitt.
[1st
indorsement
]
WSG/T.
125949
( 54).
Department
of the Navy,
Bureau of Medicine and Surgery,
Washington,
D. C, June
S, 1022.
To: Secretary of the Navy.
Via : Bureau
of Navigation.
Subject : Subsistence
of
enlisted
personnel
of
the
Navy
and
Marine
Corps
(Regular
and Reserve)
during period
granted
leave from
treatment
in hos
pital.
Reference:
(a)
Opinion
of Judge Advocate
General,
No.
9047-1219,
May
14,
1919;
(b)
letter of Acting Secretary,
No. 9047-1219,
May 14, 1919;
(c) letter
of Secretary,
No. 9047-1219-2. June
26. 1919;
(d)
Acting
Secretary's
letter
to Navigation,
No. 26254-2SS3
:
2, October
30, 1919;
(e)
this bureau's
letter
to all naval
hospitals,
No.
125949
( 63), June
25, 1919;
(f)
Supplies
and Ac
counts preceding
indorsement
No. 82-5-E, May 31, 1922.
1. The
granting
of
so-called
" sick
leave "
referred
to
in
the
attached
papers
and in
the
several
references
was
primarily
for
the
convenience
of
the Government
while
the Navy,
including
the Marine Corps,
was
expanded
much beyond the available
naval hospital
facilities.
By sending selected cases
to their homes for the period
of convalescence, the bureau
was able
to release
beds for more serious
cases,
and
to avoid
rental
of beds
in civilian hospitals
;
it was also granted,
secondarily,
for
the purpose
of
hastening
convalescence
through
change of environment.
2. The
scope
of
this
authority
was
further
extended
to
include
the sick
attached
to naval
vessels by the department's
letter
to the Bureau
of Naviga
tion (ref. d) of October
30, 1919.
3. This bureau
concurs
with
the Bureau
of
Supplies
and
Accounts
in the
opinion
that
the practice
in question
should
be terminated,
but
suggests that
646—22
12
548
vol. xvir.
DIVISION
OF
PREVENTIVE
MEDICINE.
instructions
to
that
effect
be made effective
on June
30,
1922,
in
order that
the new fiscal
year may not
be involved.
4. To
avoid
complications,
directions
should
be
given
that
no
further
so-
called
sick leaves, as mentioned,
may
be granted
; that
leaves already
granted
may
not
be extended ; but that
leaves now
in
force
may
be completed.
5. If
authorized
by
the
department,
the bureau
will
issue
instructions
to
the above effect to all naval
hospitals,
only.
E. R. Stitt.
Circular
letter, serial No. 201—1922.
YVJCA:ESK.
132687-0(73).
Depabtment
of the Navy,
Bureau or Medicine
and
Surgery,
Washington,
D. C, July 21,
1922.
To: All naval
hospitals.
Subject: Modification
of circular letter,
Serial
189— 1922.
Reference:
(a)
Bureau
of Medicine
and
Surgery
circular
letter
W.TCA:ESK,
132687-0(54),
serial
No.
189—1922,
of May
22,
1922.
1. You are directed
to change paragraph
5, reference
(«), to read as follows:
" 5. All articles made by Veterans'
Bureau
patients
from
material
supplied
by the Bureau
of Medicine
and Surgery
will be held pending
legislation
regard
ing
their
disposal,
and
information
concerning
this
will
be
supplied
in
a
subsequent
circular
letter."
(This
paragraph
in
no
way
applies
to
articles
made by Veterans'
Bureau
patients
from
supplies
and
materials
furnished
by
the
Red
Cross
Society.)
And to add paragraph
6 as follows :
" 6. The Bureau
of
Medicine
and
Surgery
has
no
objection
to
Veterans'
Bureau
patients
receiving
occupational
therapy
training
from
the
American
Red
Cross
personnel
at
naval
hospitals,
under
the' same
conditions
as
now
apply
to
naval
personnel."
E.
R. Stitt.
Circular
letter, serial
No. 202—1922.
HBS/MPS.
132679
(81).
Department of the Navy,
Bureau
of Medicine
and
Surgery,
Washington,
D. C, August
3,
1923.
To: All medical
officers.
Subject
: Bottles
issued
to
the Naval
Service
labeled
sodium
bicarbonate
but
found
to contain
monohydrated
sodium
carbonate.
1.
Purchase
of
a
quantity
of
sodium
bicarbonate
from
the
McKesson
&
Hobbins
Co.,
New
York,
during June,
1919,
was
made
by
the
commanding
officer,
naval
medical
supply
depot,
Brooklyn,
N.
Y.
This
particular
con
signment,
lot
No. 2694-dA,
has
been
found
to
contain
inonohydrated
sodium
carbonate.
Medical
officers
are
therefore
directed
to
examine
carefully
all
sucli
bottles
before
issue.
Monohydrated
sodium
carbonate
may
be
distin
guished
from
sodium
bicarbonate
as a free-flowing
granular crystalline sub
stance
instead of a nontlowing
palpable
powder.
2. So
far
as
can
be
determined,
the
above-mentioned
lot
was
issued
to
the service
during
the summer and fall of
1921.
F. L. Pleadwei.l,
Acting.
No. 3.
549
DIVISION
OF
PREVENTIVE
MEDICINE.
Circular letter, serial
No. 203—15)92.
WSG/T.
132097-0
(81).
Department of the Navy,
Bureau of Medicine and
Surgery,
Washington,
D. C, August
3,
1922.
To: All naval
hospitals.
Subject : Bed capacity
; Veterans* Bureau
and Navy.
Reference:
(a)
Veterans'
Bureau
letter
(ADH-Fac-6-MSS),
July
14,
1922
(No.
129733-63)
; (b) this bureau's
letter
No.
132G87-0
(72), July
12.
1922,
to
the nine
naval
hospitals
involved
only;
(c)
this bureau's
circular letter
No. 132687-0
( 61). June
5, 1922 (serial No. 193—1922).
1. In
the bureau's
above-mentioned
letters,
statements
were
made of
the
number
of beds
to be reserved during
the fiscal year
1923 for Veterans'
Bureau
patients and (ref.
b)
the number
to be reserved for naval
personnel.
2. By
a more recent
arrangement
with
the Veterans'
Bureau
(ref. a) of a
reduced
number
of reserved
beds
(1,650
instead
of 2.150)
and because of the
reduction
in
the enlisted
force of the Navy
to 80,000
men,
it
is directed
that
lit the hospitals
mentioned
beds
be reserved as follows :
*4 In
Hospital.
Veterans'
Bureau
patients.
Navy
patterns.
Total.
50
100
150
350
200
550
SO
300
350
400
4*8
888
125
480
591
150
150
300
100
7lH)
800
25
124
350
100
450
Portsmouth, N. H.
Chelsea,Mass
Newport, R. I
New York, N . Y . . .
LeagueIsland, Pa.
Washington, D. C.
Norfolk, Va
Pens&cola,Fla
GreatLakes, 111
i
I
3. To
economically
administer
these
hospitals,
it
is
directed
that
beds in
excess of the number shown in the column
" Total " above
shall be considered,
and re|K>rtetl
as beds
" Out of commission
but available
for emergency
expan
sion;"
all
temporary
buildings
not
required
in
maintaining
the
numbers
of
beds
above
mentioned
will
be
dismantled,
so
far
as
necessary,
and
closed,
but will
be so left
as to permit
of being placed
in service
on short
notice;
the
supply of water,
steam, and
electricity
will
be disconnected
where
and
when
practicable,
due
consideration
being
given
to
the
fire
hazard,
and
no other
repairs will be made than tiiose absolutely
necessary for the preservation
of the
buildings.
•
i. As the arrangement
with the Veterans'
Bureau
(ref.
a)
contemplates
"50
bods which may
be utilized
from
time to time in naval
hospitals
where
a defi
nite quota
of beds has not been
established,"
naval
hospitals,
other
than
those
mentioned in paragraph
2 above,
are directed
to admit Veterans'
Bureau
patients
in emergencies,
and to notify this bureau of all such admissions.
F. L. Pleadwell,
Acting.
550
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
N65-JFL-BL.
31847-29.
Navy Department,
Bureau of Navigation,
Washington,
D. C, July U,
1922.
BUREAU
MANUAL
CIRCULAR
NO.
5.
From : Bureau
of Navigation.
To: All ships and stations.
Subject
: Injury or
death
of
persons
in
the Naval
Service,
information
con
cerning.
1. The following changes in Bureau
of Navigation
manual are approved
and
directed
to be made
upon receipt of this letter
:
Add
the following articles
:
" B-84I3. Information
concerning
injury
or
death
of persons
in the Naval
Serriec. —The
bureau
is in
receipt of numerous
letters
from
relatives
of
de
ceased
or injured iiersons requesting
detailed
information
concerning
the death
or injury of the individuals concerned.
" D-8414. In all
cases
of
death
and
in
eases
of accident
involving
serious
injury
to any person in the Naval
Service, commanding
officers will, as soon as
possible, acquaint
the next of kin with all the circumstances
connected therewith,
so fur as definitely
known.
The communication
(telegram
or letter)
should
be
in such detail
and in such language
as to show personal
consideration
for
the
next of kin, an accomplishment
which
can not but react favorably
to the Naval
Establishment.
(See Art. D-8411 for reports
to department.)
" D-S415.
Care shall
be exercised
to see that the information
given is not at
variance
with the findings of any court or board which
may have been convened
in the premises."
R, H. Leigh, Acting.
VITAL STATISTICS.
In the future
the " Monthly
Health Index," which
will
be published
on
the
fifteenth
of each
mouth, will
contain
statistical
data for individual ships and
shore
stations.
The
statistics
appearing
in this
bulletin
are summaries
com
piled from those published
in the
" Monthly
Health Index."
Annual
rates,
shown
in
the
succeeding
statistical
table,
are
obtained
ai
follows :
The
total number of admissions
to the
sick list or the number of deaths
re
ported during
the period
indicated
is multiplied
by
or t££
or
12,
depending
upon whether
the period includes four or five weeks or a calendar
month.
The
product
is then
multiplied
by 1,000 and divided
by the average complement.
E. R. Stitt.
No.
:s.
551
DIVISION
OF PREVENTIVE MEDICINE.
Table No.
1.—Monthly report
of morbidity
in
United
States Navy find Marine
Corps for
the
month of July,
1022.
Average complement
All causes:
Number
of admissions....
Annual
rate per 1,000
Diseases only:
Number
of admissions...
Annual
rate per 1,000
Injuries and poisons:
Number of admissions
Annual
rate per 1,000
Communicable
disease, exclu
sive of venereal disease:
Number of admissions
Annual rate per 1,000
Venereal
disease:
Number of admissions
Annual rate per 1,000
Entire
Navy.
5 120.803
.5.062
502.S3
4.41S
438.86
614
63.97
376
37.3-.
1.339
133.01
Forces
afloat.
- 82. 919
2, 535
401.85
2,196
355.91
339
51.94
137
22.20
889
144.08
Atlantic
Pacific
Fleet.
Shore
stations.
1 leet.
31, 250
I 19,950
'37,884
650
2:5.76
505
202.35
2.527
'
800.38
555
213.12
433
172.30
2.222
703.77
85
32.64
72
288.50
305
96.60
239
75.70
175
67.20
142
450
112.53
56.90
Atlantic
stations
in
United
States.'
1,197
604.08
49
21.73
175
88.32
Pacific
stations
In
United
States.
' 6, 179
227
440.83
5
9.71
142
275.76
1 Does not include ninth naval district.
1 Includes Navy and Marine Corps personnel.
Note. — Asiatic and unassigned
ships not reported.
Table
No.
2.- -Number
of
admissions
reported
by
Form F
cards
for
certain
diseases for the month
of July,
1922.
Diseases
Injuries and poisons..
Total admissions.
class
ra.
ucitts,
acute
ntoxication, intestinal.
Cholangitis, acute
Cholectystitis, acute
Cholelithiasis
Colitis, acute
Constipation
Enteritis,
acute
Gastritis, acute, catarrhal
Gastroenteritis
,
Hemorrhoids
Pharyngitis,
acute
,
Ulcer of duodenum
Ulcer of stomach
Total admissions.
Varicocele..
Chicken pox
Diphtheria
German
meaMes.
Forces
Navy
rineji
ment,
afloat,
and
ma-
(comple-
S2,919).
Forces
ashore,
Navy
and
ma
rines*
(comple
ment,
37,884).
Total (complement,
120,803).
Number
of admis
sions.
Annual
rate per
1,000.
Number
of admls-
Annual
rate per
1,000.
Number
of admis
sions.
Annual
rate per
1,000.
2,196
339
317.76
49.05
2,222
305
703.71
96.59
4,418
644
475.38
69.29
2,535
366.81
2, 527
800.30
5,062
544.67
34
4.91
.
1.44
3.47
.43
39
12
13
0
12.35
3.80
4.11
73JJ
37
...
10
24
2.36
3.98
.32
3
3
0
1
.31
1
. 11
3
10
20
.43
1.44
2.89
3
16
15
10
51
34
19
1
0
.95
5.06
4.75
3. 16
16. 15
10.76
6.01
.31
6
26
35
14
84
66
35
2
1
.64
2.79
3.76
1.50
9.03
7.10
3.76
.22
.11
4
33
32
18
.57
4.77
4.63
2.31
1
.14
1
.14
191
27.63
214
67.77
405
43.57
18
2.60
10
3.16
30
3.2 2
5
0
.72
2
.a
7
7
.75
.75
7
2.21
12
1.73
9.69
1.15
.86
.43
1
.31
8.23
.63
.31
.9S
13
93
9
7
1.4 0
67
26
2
1
3
10.01
.97
.75
.64
I
3
6
552
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
Table No. 2. —Number of admissions
revolted
by Form F cards, etc. — Continued
Pneumonia,
lobar.
Scarlet fever
Total admissions.
class IX.
Dysentery,
lwiltarv
,
Dysentery,
entamebic
Typhoid fever
Total admissions.
. .
class x.
Den cue. . .
Filariasis..
Malaria. . .
Total admission1-'.
CLASS XI.
Tuberculous
(all forms)
cuss xn.
Chancroid
Gonococcus infections
Syphilis
Total admissions
class xvm.
Bronchitis,
acute
Larymriti*.
acute
Pleurisy,
a:ute fibrinous. .
RhinitR acute
,
Tonillitis,
acute follicular
.
Hernia.
Total admissions
CLASS xx.
Forres
afloat,
Forces
ashore,
Navy
and
ma-
Navy
and
ma-
Total K omnlement,
rines
(comple-
rines
(<omple-
120,803).
ment, 82,919).
ment.
17,884).
Number
Annual
Number
Annual
Number
Annual
of admis
rate per
of admis
rate per
of admis
rate per
sions.
1,001).
sions.
1.000.
sions.
1,000.
8
0 11
8
2.21
15
1.01
0
1
.31
1
.11
108
15.02
50
15.S3
158
17.00
0
1
.31
1
.11
0
2
.C3
3
.22
2
.2S
0
2
.22
2
.2S
3
.9.5
5
.53
3
.43
22
6.90
25
2.60
0
2
.63
2
.22
19
2.74
140
44 33
159
17.10
22
3. IK
104
51.93
Is;
20.01
5
7''
20
0.33
2.5
2.69
232
34.4')
127
40.22
379
40.78
554
SO.10
L'.'l
70.94
S3.71
83'1
12.01
99
31.35
182
19.58
8S9
128.H3
450
142.51
1,339
144.07
100
14.47
78
24.70
17s
19.15
1
. 14
3
.95
4
.43
8
1. IS
!
;ii
'.i
.<)?
34
1
4.91
13
4.11
47
5.06
I
SO
!
21.04
.
98
31.03
i
27s
29.91
323
40.73
US
01.12
|
■">
!'>
55.52
32
4.03
30
9.50
|
f.2
6.67
Table No.
3.
—Summary
of annual
admission
rates for venereal disease reported
from snips for June, and from various
shore stations for the four-n cek period,
July
2
to July
29, 1922, inclusive.
Annual rato per 1,000,June.
Average
rate since Jan.
1,
1922.
All ships
Battleship and cruiser force:
Atlantic
Fleet
Pacific
Fleet
Asiatic Fleet
Destroyer
force:
Atlantic Fleet
Pacific
Fleet
Asiatic Fleet
Miscellaneous:
Atlantic Fleet
Pacific
Fleet
Asiatic Fleet
-
CnassiKnod,
including
ships
on
special
duty
Mean
rate.
Maxi
mum
rate.
142.53
1,
283.71
130.90
98..50
384.98
428.57
104.21
545.45
139.26
I
1,153.84
70.87
1
720.00
549.22
|
1.250.00
144.01
112.28
378.01
757.89
406.77
1,285.71
148.52
480.00
Minimum
Moan
rate.
I
rate.
Maxi
mum
rate.
48.82
,
68.45
1
32.81
0!
0
;
18.43
0
129.00
l
108.48
93.96
232.59
147.04
S9.09
290.48
I
127.12
82.33
317.39
154.62
SO0.0O
225.30
119.80
295.70
640.00
371.51
597.36
429.47
220.85
SO0.0O
250.40
No. 3.
553
DIVISION
OF
PREVENTIVE
MEDICINE.
Table
No. 3.—Summary
of annual
admission
rate* for venereal disease reported
from ships for Jung, etc. —Continued.
All naval districts
in the United States.
.
First naval district
Third
naval district
Fourth naval district
Fifth naval district
Sixth naval district
Seventh
naval district
Eichth
naval district
Ninth
naval district
,
Eleventh naval district
Twelfth naval district
Thirteenth naval district
Annual rate per 1,000,July 2-
July 29, 1922.
Minimum
Mean
rate.
rate.
0
9.72
0
0
0
28.06
o !
o
98.76
28.33
17.56
0
101.14
89. 12
113.27
316.39
75.97
37. 51
0
90. IS
98.76
37.97
115.50
34.07
Maxi
mum
rate.
355.98
324.M)
307.22
355.98
333.77
115.04
0
105.93
98.76
60. 88
196.72
99.99
Average
rate since Jan. 1, 1922.
Minimumi
rate.
5.43
16.99
3.08
5.43
27. 13
38.31
20.61
85.60
73.69
15.76
54.82
10.98
Mean
rate.
87.57
40.31
69.36
171.40
104.28
53.31
20.61
111.16
73.69
30.58
110.41
31.76
Maxi
mum
rate.
210.23
142.85
114.94
149.77
210.23
143.18
20.61
192.00
73.60
42.80
128.21
68.57
RATIO OF GONOCOCCTS
AND SYPHILIS INFECTION
TO TOTAL
CASES
OF VENEREAL
DISEASE.
Per cent, June.
Gonococ-
cus.
Syphilis.
Per cent since Jan.
1, 1922.
Gonococ-
Syphilis.
All ships
Battleship
and cruiser force:
Atlantic
Fleet
Pacific
Fleet
Asiatic
Fleet
Destrover
force:
Atlantic
Fleet
Pacific Fleet
Asiatic Fleet
aneous:
Atlantic
Fleet
Pacific
Fleet
Asiatic
Fleet
Cnassigned, including ships on special duty
70.75
73. 14
82.47
23.40
80.89
83.69
55.66
75.00
85.24
57.69
68.18
v.'T
12.03
5. 15
14.89
12.35
5.45
.94
3.26
14.75
11.53
11.36
67.24
70. 50
82.58
49. 72
65. 12
79.35
52.02
64.60
79.in
54.27
61.48
10.57
11.69
». 13
14.91
9. 13
6.21
9.09
10.11
11.48
17.64
11.31
All naval
districts
in the United States
First naval district
Third naval
district
Fourth naval district
Fifth naval district
.Sixth naval
district
Seventh
naval district
Eighth naval
district
Ninth
naval
district
Eleventh naval district
Twelfth naval district
Thirteenth naval district
Per
cent, July
2-
July 29, 1922.
Per cent since Jan.
1, 1922.
Gonococ-
cus.
76. 76
77.27
it
85.29
64.70
50.00
0
85.71
100.00
83.32
82.75
100.00
Syphilis'00"^" | Syphilis.
7. 88
9.09
7.69
2.94
8.83
16.66
0
0
0
16.66
17.24
0
70.04
72.67
65.39
81.17
64.00
75.00
100.00
68.26
79. 16
80.00
70.52
86.66
14.94
11.95
20.76
5.43
14.48
14.70
0
26.98
13.04
14.28
23. 12
13.33
554
Vol. XVII.
DIVISION
OF PREVENTIVE
MEDICINE.
Table
No.
4. —Number
of
admissions
reported
by
Form F cards
and
annual
rates per 1,000, entire Nary, for the four-week
period, July
2 to July
29, 1922,
inclusive.
'
Classes.
Diseases of blood
Diseases of circulatory
system
Diseases of digestive
system
Diseases of ductless glands and spleen
Diseases of ear
Diseases of eye and adnexa
Diseases
of genito-urinary
system
(non-
venereal)
Communicable
diseases transmissible
by
oral and nasal discharges
Communicable
diseases transmissible
by
intestinal discharges
.,
Communicable
diseases transmissible
by
insects and other arthropods
Tuberculosis
<all forms)
Venereal
diseases
Other diseases of infective
type
Diseases of lymphatic system
Diseases of mind
Diseases of motor system
Diseases of nervous system
Diseases of respiratory
system
Diseases of skin,
hair, and nails
Hernia
Miscellaneous
diseases and conditions
Parasites
(fungi
and certain
animal
para
sites)
Tumors
Injuries
Poisons
Navy (comple
ment, 99,207).
Number
of ad
missions.
1
36
426
2
89
61
151
131
4
51
23
1,005
221
39
20
81
23
680
90
tf
82
109
10
437
20
Total
[
3,724
Annual
rato per
1,000.
0. 13
4.71
55.80
.26
11.65
7.99
19.78
17.16
.52
6.68
3. 01
131.65
28.95
5. 10
2.62
7.99
3.01
76.76
11.79
6.02
10.74
14.27
1.31
57.24
2.62
Marine
Corps (com- ;
plement,
21,596).
Total (comple
ment,
120,803).
I
I
I
Number | Annual
Number
, Annual
of ad-
rate per
'
of ad-
! rate per
missions.
1
1,000.
|missions. |
1,000.
487.84
0
14
130
0
17
11
24
12
131
1
JS I
59
21
10
28
7
109
32
6
18
19
2
128
11
1,054
8.42
S3.66
10.23
6.62
7.22
.60
78.84
.60
152.88
35.51
12.63
6.01
16.85
4.21
65.60
is. 26
3.61
10.83
11.43
1.20
77.04
6.62
631.44
1
50
565
2
106
72
182
24
1,259
280
60
30
89
30
695
122
52
loo
128
12
565
31
4,778
0. 10
5.38
60.79
.21
11.40
7.74
18.83
15.38
19.58
2.58
135.46
3a 12
6.45
3.22
9.57
3.22
74.78
13.12
5.59
10.76
13.77
l.»
60.79
3.33
514.11
Table
No.
5. —Deaths
reported,
entire
Navy,
for
the
four-week
period, July
2
to July 29, 1922, inclusive.
Causes.
Malaria
Pneumonia,
lobar
Tuberculosis,
chronic
pulmonary
Syphilis
Dyscnlcrv (unclassified)
Myelitis.'.
Malignant
growths
Other diseases
Drowning
Other accidents and injuries
Total
Annual death rates per 1,000,all causes. . .
Annual death rates per 1,000,disease only
Navv
I M,arine
99,207). ! gjgfc
1
2
1
0
1
1
5
19
5
35
4.58
1.44
2. 1
1.8
Total
(comple
ment.
120,803).
1
1
2
1
1I
1
6
19
e
. IS
.50
T
VOL. XVII
NO.
UNITED STATES NAVAL
MEDICAL BULLETIN
PUBLISHED FOR THE
INFORMATION OF THE MEDICAL
DEPARTMENT
OF THE
SERVICE
ISSUED BY
THE BUREAU
OF MEDICINE AND SURGERY
NAVY DEPARTMENT
DIVISION
OF INSTRUCTION
AND PUBLICATIONS
COMMANDER
H. W. SMITH,
MEDICAL
CORPS, U. S. NAVY
IN CHARGE
EDITED
BY
LIEUTENANT COMMANDER
W. M. KERR,
MEDICAL
CORPS, U. S. NAVY
OCTOBER,
1922
(MONTHLY)
Compiled
and published
under authority
of Naval
Appropriation
Act
for 1923, approved July 1, 1922
WASHINGTON
GOVERNMENT
PRINTING
OFFICE
1922
Navy
Department,
Washington, March 20, 1907.
This United
States
Naval, Medical Bulletin
is published
by
direction of the department
for the timely information
of the Medi
cal and Hospital
Corps of the Navy.
Tkuman H. Newberry,
Acting Secretary.
Owing
to the exhaustion
of certain
numbers
of the Bulletin
and
the fre
quent demands from
libraries,
etc., for copies to complete their
flies, the return
of any of the following issues will be greatly
appreciated
:
Volume VII, No. 2, April, 1913.
Volume VIII, No. 1, January,
1914.
Volume VIII, No.
3, July,
1914.
Volume VIII, No. 4, October, 1914.
Volume
X, No. 1, January, 1916.
Volume XI, No. 1, January, 1917.
Volume XI, No. 3, July,
1917.
Volume XI, No. 4, October, 1917.
Volume XII, No. 1, January,
1918.
Volume XII, No. 3, July,
1918.
Subscription
Pkice of the Bulletin.
Subscriptions
should
be sent to
Superintendent
of Documents,
Government
Printing
Office,
Washington,
D. C.
Yearly subscription,
beginning January
1, $1.50 ; for foreign subscription
add
$1.00 for postage.
Single numbers, domestic,
15 cents ; foreign,
24 cents,
which includes
foreign
postage.
Exchange
of publications
will
be extended to medical
and scientific organiza
tions,
societies,
laboratories,
and
journals.
Communications
on
this
subject
should
be
addressed
to
the
Surgeon
General,
United
States Navy,
Washing
ton. D. C.
n
TABLE OF CONTENTS.
Page.
PREFACE
V
NOTICE
TO SERVICE CONTRIBUTORS
VI
SPECIAL ARTICLES
:
Yellow
feveb in St. Thomas, with special reference to its sponta
neous ELIMINATION.
By Lieut. E. Peterson,
Medical
Corps, United States Navy
555
Kidney
function.
By Lieut.
Commander
C. W. O. Bunker,
Medical
Corps, United
States
Navy
570
Functions and organization
of Medical Corps units serving with
«
the Marine
Corps in the field.
By Maj. S. N. Raynor, United
States Marine Corps
578
Hygiene
of sitkmersibles.
(Part
1.)
By Capt. C. M. Belli, Royal Italian
Navy
589
Gas warfare
: Organization in peace and war.
By Maj. W. R. Gnlwey,
Royal Army Medical
Corps
611
HISTORICAL:
Benjamin
Henry
Latkobe,
1764-1820.
By Lieut. Commander
W. M. Kerr, Medical
Corps, United
States
Navy
1
615
EDITORIAL
:
Yellow
fever
in
retreat —Bubonic
plague — On
faults
in
writing —
Painful
back and feet—Ori" prevention
of cardiac
diseases—Immu
nity against measles—On filariasis
637
CLINICAL
NOTES
:
Bronchial
asthma in a child apparently
cured
by intramuscular
injections of peptone solution.
By Lieut.
Commander
R. H. Laning, Medical
Corps, United
States
Navy
655
Case of abscess of the lung.
By Lieut.
AV. H. Funk. Medical
Corps, United
States Navy
658
Unusual location
ov an extragenital
chancre.
By Lieut. W. T. Brown, Medical
Corps, United
States Navy
659
Benign tumors of the male breast.
By Lieuts. J. D. Benjamin
and T. C. Quirk, Medical
Corps, United
States Navy
660
A DENTAL
HINT.
By Lieut.
Commander
Emory A. Bryant,
Dental
Corps.
United
States Navy
601
Some interesting
dental
cases.
By Lieut.
G. C. Fowler, Dental Corps. United
States Navy
662
Additional assurance for the fit of a Davis crown.
By Lieut. C. T. Lynes.
Dental
Corps, United
States Navy
663
in
IY
CONTENTS.
REPORTS :
REPORT
ON THE NARCOTIC
CONTROL
ASSOCIATION
OF CALIFORNIA.
Page.
By
Lieut.
Commander
W. 6.
Farwell,
Medical
Corps,
United
States
Navy
665
NOTES
AND COMMENTS
:
" Montaigne
and
Medicine
"—Chronic effects
of
suffocating
gases —
Strict
compliance
with
article
1139
of the
United
States
Naval
Regulations —White
race
in
the
Tropics—Work
of
medical
offi
cers^—Rare
works
on
use
and
abuse
of
tobacco—Lower
back
pain —Easy
method of finding
tubercle bacilli in the sputum
66!)
NURSE CORPS
..
070
DIGEST OP DECISIONS
Cs7
BOOK NOTICES
601
PREVENTIVE
MEDICINE
STATISTICS,
LETTERS,
ORDERS,
COM
MENTS
701
PREFACE.
The United States Naval Medical Bulletin was first issued in
April, 1907,
as
a means of supplying
medical officers of the United
States
Navy
with
information
regarding
the
advances
which
are
continually
being made in the medical sciences, and as a medium
for
the publication
of
accounts
of special researches,
observations,
or
experiences
of individual medical officers.
It is the aim of the Bureau of Medicine and Surgery to furnish
in
each
issue special
articles relating to naval medicine,
descriptions of
suggested
devices, clinical
notes on interesting
cases,
editorial
com
ments
on current medical literature
of special
professional
interest
to the naval medical
officer, reports from various sources, historical
essays, notes and comments
on topics of medical
interest,
and reviews
or notices of the latest published medical books.
The bureau
extends
an invitation
to all medical officers to prepare
and forward, with
a view to publication,
contributions
on subjects
of interest to naval medical officers.
In order that each service contributor
may
receive
due credit for
his efforts in preparing
matter for the Bulletin of distinct origi
nality
and
special
merit,
the
Surgeon
General
of
the
Navy
will
recommend that a letter of commendation
be forwarded
to him upon
the
acceptance
of his manuscript for publication,
and that
a copy
of this letter be attached
to his official
record.
The bureau
does not necessarily
undertake
to indorse
all views or
opinions
which may
be expressed
in the pages of this publication.
E. R. Stitt,
Surgeon General United States Navy.
T
NOTICE TO SERVICE CONTRIBUTORS.
When
contributions
are
typewritten,
double
spacing
and
wide
margins
are
desirable.
Fasteners
which
can
not
be removed without tearing
the paper
are
an abomination.
A large
proportion
of the articles
submitted
have an official
form
such as letterheads,
numbered
paragraphs,
and needless spacing
between
paragraphs,
all
of
which
require
correction
before
going
to
press.
The
Bulletin endeavors
to follow a uniform style
in
headings
and
captions,
and
the editor can be spared much time and trouble
and unnecessary
errors can
be
obviated if authors
will follow in the above
particulars the practice of recent
Issues.
The
greatest
accuracy
and
fullness
should
be
employed
in
all
citations,
as it has sometimes
been
necessary
to decline
articles
otherwise
desirable
be
cause it was
Impossible
for the editor
to understand
or verify references,
quo
tations,
etc.
The frequency
of gross errors in orthography
in many
contribu
tions
is conclusive
evidence
that
authors
often
fail
to read
over their manu
scripts
after they have
been
typewritten.
Contributions must
be
received
two
months prior
to the
date of the
issue
for which
they are intended.
The editor
is not responsible for the safe return of manuscripts
and pictures.
All materials
supplied
for illustrations, if not original,
should
be accompanied
by a reference
to the source and a statement as to whether
or not reproduction
has been
authorized.
Only the names of actual
reviewers for a current
number appear.
The Bulletin
intends
to print only
original article!, translations,
in
whole
or in part,
reviews,
and
reports
and
notices
of
Government
or
departmental
activities,
official
announcements,
etc.
All original contributions
are
accepted
on the assumption
that
then
have not appeared
previously
and
are
not
to
be
reprinted
elsewhere
without
an understanding
to that
effect.
VI
U. S. NAVAL MEDICAL BULLETIN
Vol. XVII.
October,
1922.
No.
4.
SPECIAL
ARTICLES.
YELLOW FEVER IN ST. THOMAS,
WITH SPECIAL
REFERENCE
TO ITS
SPONTANEOUS ELIMINATION.
By
E. Peterson,
Lieutenant,
Medical
Corps,
United
States
Navy.
Forty
years
ago
August
Hirsch
said in his Handbook
of Geo-
grapical
and Historical Pathology, "The earliest history of yellow
fever along the shores
of the Gulf of Mexico, including
the West
Indies, is enveloped
in an obscurity which we can not now enlighten.
In particular,
there
is no way of getting an answer
to the question
whether the disease was prevalent there,
and, if so, to what extent,
before the arrival of European
colonists; or to the question,
when
and
under what
circumstances
it first
appeared
among
the
new
comers.
It is not only
the
defectiveness
of the
records
from these
earliest times of our intercourse with
the Western Hemisphere that
renders all historical
research
on the subject illusory;
a still more
serious impediment, and one that has continued in force down to the
most
recent times,
is the Irequent confounding of yellow fever with
bilious
remittent malarial
fevers,
especially
with Febrls
remittans
haemorr7uigica."
(1)
According to this writer, the first reliable accounts of yellow fever
date from the middle of the seventeenth century.
From this period
on we find discussions
of the importation of the disease from place to
place,
from island to island.
The chroniclers of that time further
remark on the circumstance
that it was especially the new arrivals
that were visited by the sickness,
and that not only the settlers
but
also the crews of merchant
ships and ships of war at anchor in the
ports of the
West Indies
were
menaced
to
a great extent
by the
disease.
According to Gorgas, Carter, and Lyster, " there
seems
good
rea
son to believe that the Gulf coast of Mexico
was probably the orig
inal cradle of this disease in man,
and that it may
also be its last
resting
place.
Just how far back
the history of the disease may
be
traced
depends
upon interpretations
of early writings
of Spanish
explorers
from
the time
of Columbus
to the middle of the
seven
teenth century.
We
know
that
epidemics
of unknown
character
did occur among
the Mayans in Yucatan
as far back
as the
first,
century of the
Christian
era.
We know that these people
moved
>
555
556
Vol. XVII
PETERSON — YELLOW
FEVER.
from Guatemala
to their
present
homes
in Yucatan
for
some
un
known
cause.
An
explanation
has
been
offered
by
Morley,
the
well-known
anthropologist, to the effect that this migration
was due
to the exhaustion of the soil around their cities and villages so that
corn could not
be
raised.
While
this
seems
the
most
reasonable
explanation, it
does not
prove
that
diseases in the
area
may
not
have
been
a
contributing
cause.
However
this
may
be,
we
feel
pretty
sure „that
Columbus
found
the
disease waiting
for him
on
his arrival,
and it is believed
that the disease was first introduced
among white men in Santo Domingo."
(2)
Hirsch
(1)
credits the
accounts
of Dutertre
("Hist,
gener.
des
Antilles Franc,"
Paris,
1667)
as describing the first authentic epi
demic
of
yellow
fever,
occurring
in
Guadeloupe
in
1635.
This
epidemic
lasted off and on until the year
1649; it did not reappear
again until
1699.
According
to Ligon
(3)
(History of Barbadoes,
London,
1657)
the disease occurred
in epidemic form in Barbadoes
in
1647.
He states that the inhabitants of the island
and shipping
too
were
so grievously
visited with
the
plague
(or
as "killing
a
disease"),
that
before
a month
had
expired
after
his arrival
the
living
were
hardly
able
to bury
the
dead.
The
disease then dis
appeared
for 43 years,
and
when it recurred in
1690 it was at first
not recognized
as being the same disease which devastated
the island
of 1647.
(4)
Through his chronological
survey of the epidemics
of yellow fever
in the West Indies, North America, Central America,
and the Mexi
can Gulf coast of South America, Hirsch shows how the disease was
imported
from
place
to
place
and
how
it disappeared in certain
islands
to
recur again after
a
few years,
until
nearly
the
entire
Caribbean littoral could be included in the endemic
area of the dis
ease.
Various
seaports
on the Atlantic coast of the United
States
were visited at frequent intervals.
According
to Hirsch, only two epidemics
that may
be designated
with certainty
as yellow fever had been observed
on South Ameri
can soil up to the year 1850.
Both of these happened
at Guayaquil,
the first in
1740,
concerning which
an importation
of the
disease
from outside
is expressly mentioned
; and the second in 1842, which
can in like manner be proved to have been introduced by strangers
who had come from New Orleans by way of Panama.
Paraja
(5),
apparently
unaware of Hirsch's
reference
to the epidemic
in
1740,
states
that
not even
a tradition exists
to
cause the
disease to
be
suspected.
According
to him the epidemic of
1842 caused " a mor
tality
more or less unbelievable
if one relies
upon lay historians."
The
general
outbreak of yellow
fever in Brazil
dates from the
end of
1849,
when
the disease appeared
in Bahia, having
been im
ported either fram New Orleans or Habana.
(1)
No. 4.
557
PETERSON
YELLOW
FETOR.
ST. THOMAS.
Dr. John Bard of New York gives the first available record of the
existence
of a possible epidemic in St. Thomas.
He had heard from
the " ancient
inhabitants " of
New York that
so
long
ago
as
the
year 1702 a malignant fever, little inferior to plague,
was imported,
which from its extreme mortality
was distinguished
by the name of
"the
great
sickness."
Doctor
Bard
adds:
"The
formidable
dis
ease, if tradition
says true,
was brought here (New York) from St.
Thomas in a single bale of cotton."
(3)
The first authentic report of yellow fever in St. Thomas dates back
to 1793.
This epidemic
lasted
to 1795.
The disease then reappeared
again in 1816-1818,
1825,
1833, and 1852-53.
During the latter two
years the disease became very prevalent throughout the Antilles, and
St. Thomas has the questionable
distinction of having been
the start
ing point of this epidemic.
(1)
From
1852 on. there
are certain records
available in St. Thomas
which give us
a distinct idea how devastating the disease was, espe
cially
to the shipping
and to the military garrison.
The records
are
those
kept
by
the
cemetery
authorities
and
consist
of
two
large
volumes in which the
name of every
person
buried in St. Thomas
appears;
age, sex, birthplace,
cause of death,
and
plot in cemetery
where
buried
are also given.
A striking
fact in reviewing
these
records
is that nearly
every
person who died from yellow fever was attached
to a ship lying in
the harbor or was
a member of the military garrison.
Apparently
every country on the globe has some mother's
son buried on this rocky
peak in the Caribbean.
The following tables
show
the number of persons
that died
from
yellow fever and were buried in St. Thomas from
1852 to 1902, when
the last death from this disease occurred
:
DEATHS
FROM
YELLOW
FEVER
IN
ST. THOMAS.
Table I.—1852-1861.
Year.
1852
1853
1854
1855
1856
1857
1858
1859
I860
1861
Total.
0
29
1
14
11
4
4
4
22
0
89
February
1
5
0
12
13
2
15
1
6
0
55
March
0
3
1
15
21
2
2
0
6
0
50
May1:::.:::::::::::
0
13
0
14
12
10
17
0
0
0
66
0
37
0
54
32
49
17
0
0
0
189
o
68
0
65
15
93
3
0
0
0
244
July
0
29
0
22
4
22
1
0
0
0
78
August
17
4
0
6
3
12
0
2
0
0
44
September
21
0
0
0
1
0
0
0
0
1
23
October
41
0
2
0
1
0
0
33
0
3
80
63
1
1
4
2
3
11
32
0
2
119
112
0
8
3
0
3
7
23
0
3
159
Total
255
189
13
209
115
200
77
95
34
9
1,196
558
PETERSON —YELLOW
FEVER.
Vol. XVII
DEATHS
FROM
YELLOW
FEVER
IN
ST. THOMAS—Continued.
Table II.—1862-1871.
Year.
1862
1363
1864
1865
1866
1867
1888
1869
1870
1871
Total.
January
0
0
0
7
4
31
25
3
8
0
78
February
0
0
0
4
1
19
20
0
1
0
I
45
March
0
0
0
1
0
14
12
0
0
0
27
0
0
1
7
1
5
0
0
o
o
14
May
0
0
2
2
2
8
2
0
0
0
i
16
0
0
4
1
5
2
0
0
0
0
12
July
0
0
5
2
4
5
0
2
0
0
18
August
0
0
5
6
7
2
2
8
0
0
j
30
September
0
0
5
0
12
10
0
6
0
0
1
33
0
0
3
1
44
44
0
8
0
2
102
November
0
3
5
0
65
43
0
21
0
o
137
0
1
26
2
90
55
0
6
1
0
1
181
Total
0
4
56
33
235
238
61
54
10
2
693
Table III.— 1872-1881.
Year.
1872
1873
1874
1875
1876
1877
1878
1879
1880
1881
Total.
January
1
0
0
0
o
o
0
0
0
0
1
February
0
0
0
0
o
0
0
0
0
0
o
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
July
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3
3
September
0
0
0
0
0
0
2
0
0
0
2
October
0
0
0
0
0
0
11
0
0
1
12
November
0
0
0
0
0
0
0
0
2
0
2
0
0
0
0
0
0
0
0
1
0
1
Total
1
0
0
0
0
0
13
0
3
4
21
Table IV.— 1882-1891.
Year.
1882 i 1883
1S84
1885
1886
1887
1888
1889
1890
1891
Total.
0
0
0
1
0
0
0
0
0
0
1
0
0
0
3
0
o
0
0
0
0
3
March
0
0
0
6
0
o
0
0
0
0
6
April
0
0
0
1
0
0
0
0
0
0
1
May
0
0
0
4
0
0
0
0
0
0
4
0
0
0
0
0
0
0
0
1
0
1
July
1
0
o
0
0
o
0
0
1
0
2
August
0
0
1
2
0
0
0
0
1
1
5
0
0
0
0
0
0
0
0
4
0
4
0
0
0
0
0
0
0
0
2
0
2
0
0
1
0
0
0
0
0
1
0
a
December
0
0
2
2
0
2
0
0
0
0
6
Total
1
o
4
19
0
2
~1
10
No. 4.
PETERSON —YELLOW FEVER.
559
DEATHS
FROM
YELLOW
FEVER
IN ST. THOMAS—Continued.
Table
V.— 1892-1901.
Year.
1802
1893
1894
1895
1896
1897
1898
1899
1900
1901
Total.
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
March
0
0
0
0
0
0
0
0
0
0
0
April
0
0
0
0
0
0
0
0
0
0
0
May
0
0
0
0
0
0
0
0
0
o
0
0
0
0
0
0
0
0
0
0
0
0
July
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
2
September
0
0
0
0
0
0
0
0
0
o
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
December
0
0
0
0
0
0
0
0
0
0
0
Total
0
0
0
0
2
0
0
0
0
0
2
Table
V.—1902-1911.
Year.
1902
1903
1904
1905
1J06
1907
1908
1909
1910
1911
Total.
0
o ~
0 T
0
0
0
0
0
0
February
0
0
0
0
o
o
0
0
0
0
0
March..'
0
0
0
0
0
0
0
0
0
o
0
0
0
0
0
0
0
0
o
0
o
0
Mav
0
0
0
0
0
0
0
0
0
0
°
0
0
0
0
0
0
0
0
0
0
0
July
1
0
0
0
0
0
0
0
0
0
1
August
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
o
o
0
0
0
0
0
0
0
0
0
0
0
0
0
November
0
0
0
0
0
0
0
0
0
0
0
December..
0
0
0
0
0
0
0
0
0
0
0
Total
1
0
0
0
0
0
0
0
0
0
1
Table VI.—NUMBER OF TOTAL CASES OF YELLOW FEVER
FOR
EACH
MONTH
FROM
1852-1902.
Jan.
Feb.
Mar.
Apr.
Hay.
June.
July.
Aug.
Sept.
Oct.
Nov.
Dec.
Total.
169
103
83
81
209
257
99
84
62
196
260
347
1,950
As
stated
above, Hirsch
gives
credence
to
the opinion
that
the
epidemic
of yellow
fever that
raged
over
the Antilles in
1852-53
started
in St. Thomas.
As seen
from Table I, the epidemic com
menced in August when
17 people died from yellow fever.
Of these,
7 were soldiers from the Danish garrison,
3 European
residents,
and
560
Tol. XVII
PETERSON —YELLOW
FEVER.
the balance sailors from European
and American
ships lying in the
harbor.
The first deaths
recorded
during
the month occurred
in the gar
rison.
The
death
that occurred in February
was that of
a sailor
from
the American
brig Lady Maxwell.
Of the
255
persons
who
died
from
yellow
fever during
1852,
19 were
Danish
soldiers,
15
European
residents
(including
the American
consul),
and
221 Eu
ropean and American sailors.
This represents
the typical
toll from this disease.
White sailors
were
the
common
victims.
In January,
1853,
a
Chinese
also
died
from the disease.
From the nature of the disease it seems
reasonable
to suppose that
St. Thomas
was
an
endemic
center
for yellow
fever for the
two
decades
between
1852
and
1872.
The
break
that
occurred
during
1861,
1862,
and
1863
may
represent
years
when
the
disease
was
actually absent from St. Thomas, but amongst
the
9 cases that died
in
1861,
at least
1 was
a European
resident
of the island.
The
4
cases in 1863 were all sailors from ships in the harbor that may have
been infected at other ports.
,But amongst
the first cases that died
in 1864 some were residents
and members of the garrison.
Hence it
seems that the above break is only apparent and that the disease was
actually present.
From
1870
yellow
fever suddenly
ceased
to play
the
important
role it had held for the last
20 years in the health conditions of St.
Thomas.
The death from yellow fever that occurred
in 1872 was in a sailor
who might
have
contracted
the disease in another port.
With
re
gard to the epidemic
in
1878, the " Sanitary
report of the Kingdom
of Denmark" (6) of that year states:
"This disease
(yellow
fever), which previously
had
been
present
in
the
island
for
a
number of
years,
has
not shown itself
since
March,
1870; hence for a period of nine
years, in spite
of the
fact
that
the island
is in
steady
communication
with
two of the
most
important
foci of the
disease, Rio
de Janeiro
and
Habana.
The
disease was introduced into St. Thomas from Habana in July,
1878,
and
spread
during
the
balance
of the year amongst
the ships
in
the harbor and in the garrison;
40 cases
in all with
30 deaths.
At
the same
time
a continued fever of other than the usual
type
spread
all
over
the
island,
with
sudden
onset
resembling that of yellow
fever,
a short continuous fever-attack followed
by
a contracted
con
valescence.
The
landsphysicus
considered
this
an
abortive
form
of yellow fever."
In Table III we find that the year
1878 is credited
with
13 deaths
from
this
disease,
whereas
the sanitary
report of Denmark
notes
N». 4.
561
PETERSON—YELLOW
FEVER.
30 deaths,
with
40
cases
in all, illustrating the
inaccuracy of
the
statistics
during
these years.
What is of particular
interest
in the
above
report
is
the
appearance
of
an unusual
type
of fever that
spread over the entire island.
From the description
given one
is
forced
to think of dengue
fever.
In the sanitary report for 1880 it is stated
(6) that the epidemic
started
in October
and
ended
December
30
and
that
25
cases
oc
curred,
with
9 deaths, another discrepancy
as compared
with Table
III.
With
the
exception
of 2 children
all the
attacked
were
sea
men or people
recently arrived.
From the report for 1881
(6)
we
find that 23 cases of yellow fever occurred and that nearly all were
imported.
The deaths from yellow fever occurring in 1882 and
1884 were all
amongst
European
sailors.
The
epidemic
of
1885
was
confined
to
the garrison,
and
all who died
were soldiers;
the same holds true
of those cases that died in 1887.
From the year 1884 the records
from the cemetery
files can be sup
plemented
with
special
reports from
the King's
physician
and his
assistants,
the
communal
physicians.
Thus
we
find
a
report
by
Doctor Wissing for the years
1884-85 covering the yellow fever out
break during these years.
Doctor Wissing shows how the
case that
died
in August
was
imported
from
La
Guayra,
Venezuela.
The
patient passed quarantine inspection, but became ill six hours later.
•He remained
for three
days in
a hotel
in town before
his case
was
brought to the attention of the health authorities.
A diagnosis of
yellow fever was then made,
and
the patient
was
removed
to the
municipal
hospital,
where
he died.
Doctor Wissing states that no
other case developed
from this one.
The epidemic that occurred
in the latter part of 1884 and during
the first half of
1885
was
undoubtedly
caused by the importation
of
a
case
on
a French
steamer.
This
case
was
a stowaway
and
escaped quarantine inspection.
A few hours after landing he became
very sick and
was removed
to the marine hospital.
The following
morning
he presented
the typical symptoms
of yellow fever, includ
ing black vomit.
Investigation
showed
that
he had undoubtedly
received
his infection in Habana.
Seventeen
days later a Dane con
nected
with
the
harbor
master's
office
contracted
the
disease
and
died.
In December
2 cases occurred on a sailing
vessel lying in the
harbor.
The
2 were removed
to the hospital, where
they both
died.
During this month another case occurred
in town who gave history
of having just returned from Habana.
In January, 1885. the local epidemic started
in earnest.
The first
case occurred
in the Government house and was soon followed by a
number
of cases
in the barracks.
In this latter place
26
cases
oc
562
Vol. XVII
PETERSON —YELLOW
FEVER.
curred during
the year, with
15 deaths.
In August
and
December
4 more deaths occurred amongst
newly arrived Europeans.
During
1885, 32 cases in all were reported, with 19 deaths.
At the proposal of the King's physician, Doctor Magens, a yellow
fever commission
was
appointed by the
Government
to
study
the
yellow fever situation
at the barracks.
This commission
found that
the shore
bed to the east of the barracks, where
all kinds of debris,
both
from town and barracks, were gathered,
undoubtedly
was the
cause of
the
epidemic.
The
commission
recommended
"that
the
shore
line
be filled
up with
good
material."
In the
meantime
the
soldiers were
removed
to the country and the barracks thoroughly
disinfected.
Doctor Wissing,
one of the communal
physicians in St. Thomas at
this time, enters into discussion with other physicians of the Danish
Islands
with
regard
to the
spontaneous
occurrence
of the
disease.
Doctor
Wissing
is of the opinion
that yellow
fever
can not occur
spontaneously
after it has been absent for
a number
of years,
but
that its reoccurrence
is due to importation.
Doctor Br0nsted, of St.
Croix,
declared
that yellow fever could occur spontaneously
in the
West
Indies
in
general,
but that
St.
Thomas
was
an
exception.
Wissing rightly
calls
attention
to
the
falsity
of
such
argument.
"That a disease can occur
spontaneously
in one place
and
must
be
imported in order to occur at another is on the
face of it without
meaning."
Magens, of St. Thomas, believed that yellow fever might
occur spontaneously
in the harbor, although importation
might play
some role.
Wissing
states : " It is a fact that a fatal
case of yellow
fever was imported here in the latter part of 1884
and that
a small
epidemic
started
right after; until the mentioned
importation
there
had not been yellow fever in St. Thomas for a number of years, and
I consider it a powerful
and solid argument for its not being endemic
that it does not occur at all for a number of years and then suddenly
occurs after a known importation."
Doctor Calmer, however,
from his study of yellow fever statistics
in St. Croix, concluded
one should be careful in drawing conclusions
from the apparent long intervals of freedom
from }rellow fever that,
as is well known, occurred in nearly all of the West Indian Islands.
Wissing
did not believe that Calmer's statistics were very
conclusive
on account of the uncertainty of the diagnosis.
On the other hand.
Wissing
states that in
an endemic
area,
epidemics
could occur
at
times and mild sporadic cases in the intervals.
But where the disease
occurs only with long free intervals there it is not endemic,
but due
to importation.
" But," Wissing
asks, " what does it mean that after the epidemic
has ceased, sporadic cases may appear for several months with quite
long intervals between each case?"
He compares this with
a measles
No. 4.
563
PETERSON
YELLOW FEVER.
epidemic in Copenhagen.
" The epidemic
starts, it grows until the
culmination
has been reached, it subsides week after week ; fewer and
fewer
cases occur until
a few sporadic
cases
spring
up
here
and
there, when the epidemic is finally stopped."
Yellow fever reappeared
in St. Croix in 1885, after that island had
been free from the disease for six years.
Wissing
can not agree with
the opinion expressed
that
the
disease
appeared
spontaneously
on
that island
when it was in direct communication with St. Thomas
where yellow fever was known to exist during
1885.
During 1886 no case of yellow fever was officially reported.
In
1887
we
find
an
argument
between
the
communal and
the
quarantine
physicians
as
to
the
presence
of
yellow
fever.
The
quarantine
officer reported 2 cases of the disease in two soldiers that
had been placed
as guards on board two ships that had arrived from
smallpox-infected
ports.
The first one was feeling somewhat
indis
posed
before
he went on this duty,
and
two days
later
was taken
seriously ill with
symptoms
of remittent
fever.
He was
placed
in
the hospital,
where
he developed
symptoms
of high
fever,
bloody
vomit,
albuminuria,
and yellow discoloration
of the skin
and later
died.
The second
case
was taken
sick four days after having
been
placed
on
guard
on
another
ship.
This
patient
also
died
with
typical symptoms of yellow fever.
A third case also developed
under
similar
circumstances.
He recovered,
however.
He developed
the
same symptoms as the others except black vomiting.
The communal
physician considered
these cases
as bilious remittent fever.
From a
study of the symptoms
it seems,
however,
that the quarantine officer
was right.
No cases of yellow fever were officially reported during
1888
and
1889.
In
1890 we find a new landsphysicus in St. Thomas.
In his
annual report for that year he says in part : " During the summer
7
cases of yellow fever occurred.
The first case occurred in the early
part of June, the second in the latter part of July, the third and
fourth in the first part of September,
and 3 in the first part of Octo
ber.
In order not to harm
the
islands without
sufficient
cause—
through possible
isolation and quarantine—these cases
were officially
reported as pernicious remittent fever.
This was considered
to be so
much more permissible as the cases were more or less sporadic and the
disease did not appear as an epidemic.
Any importation of the dis
ease could not be proven, and it is also commonly considered
that this
disease can occur anywhere in the West Indies spontaneously.
" Six cases
were in young European
adults who had been only
a
short
time
in the West Indies.
These all
died.
The
seventh
case
occurred in
an 8-year-old
boy
who had been born in
St. Thomas
but who had recently returned from a long visit to Denmark.
This
boy recovered.
564
Vol. XVII
PETERSON
YELLOW
FEVEE.
"Any
connection
between
the
above
cases
could not
be
shown;
the
disease
attacked
young Europeans
of different nationalities
in
different
positions
and
residing
in different
places.
A long
time,
sometimes
over
a month,
passed
between
the
development
of
the
various cases."
In addition
to
the
above
cases,
three
deaths
from yellow
fever
occurred amongst
the soldiers at the barracks.
This epidemic
is of
peculiar interest
from many standpoints.
The landsphysicus failed
to find any proof that the disease was imported.
The mortality
was
extremely
high.
Cases
occurred
in
the
barracks,
and
in
widely
separated
localities.
Two explanations
can
be given.
The
disease
was still endemic
in St. Thomas in spite of the fact that no
cases
were officially
recognized
during
1888
and
1889.
This explanation
finds some support when
we recall the argumentation over the cases
in
1887,
and is, of course,
also supported by the fact that importa
tion could
not be shown.
The other explanation is that importation
of the disease had taken
place without
the authorities being
able to
demonstrate
it.
From
1891
on, no
case
was officially
recognized
as yellow
fever.
We find, however,
that during
1896 two cases were imported through
the
shipping.
These
cases
died.
During
1897
the
landsphysicus
states, in his annual report, that intermittent
and remittent
fevers
increased
and
that
the remittent
type of malignant
character was
not
so rare.
He
states,
however,
that no
case
of yellow
fever oc
curred during this year.
In the report for the year 1901 we find that
no distinct
case of yellow fever occurred
but that "the Stegomyia
mosquito,
which lately has been pointed out by American
and Cuban
physicians to be the vector of yellow fever contagion, is very com
mon in St. Thomas
as well as in the other West Indian Islands."
In the report for the year
1902,
the landsphysicus, Dr. P. Mor-
tensen, pays a glowing
tribute
to the work of the American
physi
cians in the West Indies.
He says in part : " The Americans
have
had
wonderful
success in fighting
smallpox
in Porto Rico.
But
still more credit is due them on account
of the excellent
manner
in
which
they
are fighting
yellow
fever in Porto Rico
as well
as in
Cuba.
During the reign of Spain
over
these islands they were
a
continuous source of danger to the whole
West Indies
; yellow
fever
was always present,
and every so often it occurred in severe epidemic
form, especially in Habana.
The United
States
has certainly
done
an
herculean job
in
cleaning
out
this Augean
stable,
but it has
been done, and the United
States
can refer with pride to the results
that have been accomplished.
.
.
.
" The
Americans
have
succeeded
in
a
few
years
in
practically
stamping out yellow fever both
in Porto
Rico
and in Cuba.
This
has also
been
a great help to the Danish Islands,
and
St. Thomas
No. 4.
565
PETERSON —YELLOW
FEVER.
has learned
a lot from this work.
There
are still
some sources of
yellow
fever in Mexico
and
Colombia,
but they are farther
away
and are not so dangerous
to St. Thomas as were those of Porto Rico
and Cuba in Spanish times."
In
the
above
report it is
also
stated
that
no
distinct
case
of
yellow fever occurred in St. Thomas during
1902, although
a young
Danish
officer
attached
to
the
local barracks
succumbed
to
a dis
ease very
much
resembling yellow
fever.
The
landsphysicus
was
of the opinion that it was a typical
case of yellow fever.
(7)
During
this year
we
also
find
that
three
cases
of " pernicious
malaria,"
resulting
in death,
were
imported through
the shipping.
From
1903
on it is very difficult to show
that any yellow
fever
occurred
in St. Thomas.
From this time the deatli
rate from inter
mittent and remittent fevers also rapidly declined,
and the formidable
figures which
represented
these diseases in the death
tables
became
overshadowed
by
those
representing
deaths
from
gastrointestinal
infections.
The
deaths
from
such
conditions
as
intermittent
and
remittent
fevers
undoubtedly
were
closely associated
with
the
yellow
fever
situation.
We find, however,
that these fevers
grow less and less in
number
as the sanitation of the city improves.
The
Danes
built a
complete
system
of surface
drainage
in
the
city
proper,
and
the
influence
of this improvement is readily
seen in the marked reduc
tion of deaths from malarial
fevers.
The latter condition
ceased to
be an urban factor and became a rural one, still, however,
affecting
the suburbs of the town.
SPONTANEOUS
ELIMINATION
OF YELLOW FEVER.
The one fact that stands out clearly is that yellow fever has
dis
appeared
from St. Thomas without
any attempt
on the part of the
island to eradicate
its mosquitoes.
As a matter of fact, the disease
had practically
disappeared from St. Thomas before Finley's
theory
of mosquito transmission had been proven.
History tells us that many of the West Indian ports were
free
from yellow fever for long periods of time.
Epidemics occurred and
died
out,
and
years
later recurred.
There
is no doubt
about
the
fact that the recurrence
of the disease after these years of freedom
was due to reinfection of the community from without.
H. R. Car
ter (8), that master in tropical sanitation, has given us a mechanism
of the spontaneous
elimination
of yellow
fever from
endemic
cen
ters, which not only gives the reason for this elimination,
but also
shows that the conception of
a world
free from yellow
fever is a
practical
one and needs only
a few helping
strokes
from
the sani
tarian before it is an accomplished
fact.
4530—22
2
566
Vol. XVII
PETERSON —YELLOW FEVER.
Let us follow Carter in his logical argumentations and deductions.
" In endemic
centers it is not necessary to exterminate Stegomyia
to
eliminate yellow
fever.
If the number of mosquitoes
be brought
below
the
' critical
number ' for yellow fever,
at that place
the dis
ease will die out.
Note, too, that this critical number for any place
will vary directly
as the proportion
of men immune
to yellow
fever
is to the total population.
" Thus, if with 100
cases of yellow
fever introduced into
a com
munity
in which
all
were
susceptible
to yellow
fever, the number
of Stegomyia
were
such
that
exactly
100
men
would
be
infected
from
them,
the
disease
would
neither
die
out
nor
increase.
This
would be the critical
number of Stegomyia for that place
and time.
With fewer mosquitoes than this, less than 100 men would be infected
and
the
fever would
die
out.
If more,
it would
increase.
Now,
if one-quarter of the .inhabitants are immune
to yellow
fever,
obvi
ously
the
same
number
of
mosquitoes
which
infected
100
men
before would now infect only
75—one-quarter of their
bites
going
to immunes
and hence wasted —and the disease would die out.
The
number of mosquitoes
required to infect
100 more men,
and
hence
perpetuate
the fever, would have to be increased
by one-third
above
the first number.
" Obviously,
then,
this critical
number,
below
which
the
Stego
myia
must
be brought
to eliminate fever, is less in
a town
as the
proportion
of susceptible
people
increases,
and more intensive work
is required
to
eliminate it from
such
a community,
other things
being
equal,
than
from
one in which
a
large proportion
of the
population
is immune."
We know that yellow fever has disappeared from such
places
as
Georgetown, Demarara, Port
au
Prince,
Santo Domingo,
and
St.
Thomas
without
any effort
on
the
part
of
these communities to
lower the mosquito
index.
But, as Carter
states, nonreport of yel
low fever does not of itself imply its nonexistence.
If a number
of nonimmunes
are introduced into
a supposedly yellow-fever
free
city
and
the
disease develops
amongst
them,
this is positive proof
that yellow
fever
existed
there.
On
the
other hand, if intimate
contact
was kept up between these nonimmunes and the natives for
a long time and no yellow fever developed, it may be deduced from
our present
knowledge of the
disease that it did not at the time
exist there.
This practical
test
has
been applied
to nearly all of
the
above towns.
Let
us now
consider
Carter's
mechanism
of spontaneous
elimi
nation of yellow fever in a little more detail.
It is
assumed
that
one
attack of yellow
fever usually
gives,
a
permanent immunity.
The endemicity of yellow fever in a certain
Xo. 4.
567
PETERSON —YELLOW
FEVER.
area depends on three factors for its continued existence
: Parasites
(in mosquitoes
and men),
active
mosquitoes
(Aedes calopus),
and
susceptible men.
These
factors should all
be
present
at the
same
time
and
the
insects
have
access
to
both
infected
and
susceptible
people.
If for any
reason
any
one of these factors
disappears
or
ceases to function, yellow fever can no longer exist.
According to our present
knowledge of the disease, the parasites
of yellow fever exist only in the infected mosquitoes
and in infected
people.
The life of
a mosquito
in nature is compartively
short—
hence also the life of the harbored parasites.
Man
serves
as a res
ervoir only for a short time. If the third factor, susceptible
men, is
not
present
at the
same time
and
place
as
the infected mosquito,
yellow fever will have no chance to spread,
but will disappear.
Susceptible
people
may
be supplied
in two ways:
Immigration
(shipping)
and births.
" Both
classes effect continuance
of yellow
fever,
and theoretically
either one may
be sufficient
to continue
it.
Yet
the proportional
effect of
the
introduction
of
an
adult
and
the birth
of
a baby
in keeping up the infection
is very different.
That of an adult immigrant
is very much
the
greater,
so that
to
supply the
people
necessary
to keep up yellow
fever, it requires
a
very much larger number of babies
to
be born than of susceptible
adult immigrants.
In proportion
to their number
then, adult immi
grants are of far more importance in thus keeping up yellow fever
than babies, and
a town receiving no susceptible
immigration
needs
to be much larger to be a permanent
focus of yellow fever than if it
did
receive
such
immigration.
Indeed Gorgas, in
1916,
expressed
himself
as
believing
that
immigration
of
susceptible
adults
was
necessary
to continue
yellow fever
.
.
. that it could not
be kept up
by the births alone."
In St. Thomas the influx of susceptible
adults through
shipping
grew
gradually
less and
less and
the
new
born
showed
themselves
incapable of keeping the endemic
alive.
Hence, in Carter's words : " If one attack of yellow fever produces
in general
a permanent
immunity,
a community will
have in time
no people susceptible
to yellow fever left.
Unless there is an intro
duction of such people, yellow fever would then disappear;
and
as
soon
as
the infected
mosquitoes
died
off,
the parasites would
dis
appear and
the community be
free from infection.
Indeed, yellow
fever would
doubtless
disappear before
there
were
1 no people
sus
ceptible to yellow fever left,' because, under the doctrine of chances,
there would be no susceptible
people left, fulfilling the conditions of
time and
place
mentioned
above, before there
were absolutely none
at all —possibly long before."
Carter calls this mechanism
the " fail
ure of the
human
host."
568
Vol. XVII
PETERSON —YELLOW
FEVER.
REINFECTION
OF A COMMUNITY.
Once a community has freed itself of yellow fever by failure of the
human host, it will remain free forever, unless the same three
factors
for conveyance
are again brought together.
Because
the mosquitoes
are
a constant
factor — always breeding
to the limit—the next
ap
pearance
of the
disease would
depend
on the influx of susceptible
people
and the introduction of parasites.
A community which for some reason or other has lost its impor
tance
as a shipping
center and whose immigration
is practically
nil
will not become susceptible
to a yellow-fever
epidemic
until the new
born have increased
in number and grown
up to become one of the
deciding factors.
The number must
be large enough
in order that
the conditions of time
and
place
be fulfilled when
the parasite
is
finally
introduced.
In order to keep the disease out, isolation
from
infected places is necessary.
" The community that has eliminated yellow fever through the con
trol of the insect
host
does not need to isolate
itself
from
infected
places
as long as this control continues
to be efficient,
because, with
control of the insect host, yellow fever is not communicable,
and such
parasites
as are brought in by infected men or infected mosquitoes
would, at the most, establish
a very temporary focus of infection.
If
the control were complete, infected men would transmit no parasites.
It is to be noted, however,
that the reduction of Stegomyia sufficient
to eliminate yellow fever from
a town in the Tropics
would nearly
always
be
less than that required
some years
later to prevent its
spread,
because there will then
be a larger proportion of susceptible
people than at first.
Hence the mosquito
control must be more in
tensive."
(8)
Carter
gives
the following factors
as responsible for the
great
diminution of yellow fever which has been going on since the decline
of the tropical sugar industry
and which is still in progress.
"(1)
Diminished
immigration
to
the
Caribbean
littoral
due
to
diminished trade and commercial
importance of this area.
"(2)
The substitution of steam for sailing
vessels has enormously
lessened the number of infections carried between ports, thus
lessen
ing the reinfection of such ports which had cleared
themselves of
yellow fever.
Sailing vessels—
Frequently
carried
stegomyia
as
well
as infected
men.
Longer
in port.
Larger crews per unit of carrying
capacity.
Laxer
discipline.
Iron steam vessels—
Rarely carry stegomyia.
Less long in port.
Smaller crews.
More strict discipline.
No. 4.
569
PETERSON
YELLOW
FEVER.
"(3)
Diminished
strategic importance of the Caribbean
Sea
and
the
practical
withdrawal
of
European
fleets
and
garrisons,
thus
lessening the number of susceptible
people.
"(4) The
extinction
of
the
great
permanent
foci
at
Habana,
Panama,
and Rio.
"This enabled
such
ports on
the Caribbean
especially
as
could
spontaneously
free
themselves
of yellow
fever to remain
free—be
ing no longer exposed to reinfection, or rather much less so exposed.
"(5) The European
war has both restricted foreign immigration
and caused commercial depression."
In surveying
the
death
tables
from yellow
fever in St. Thomas
we find epidemic
outbreaks of
the
disease nearly
every
year
from
1852
to
1871.
From
1872
to
1891
we
find
many
years
without
deaths,
some
years
with
a
few
deaths
amongst
sailors
(Imported
cases) , and a few years with small epidemics.
The general
tendency
of the disease to disappear is clearly
seen.
Between
1892
and
1901
only
two
deaths
occurred, and
these
were
imported
cases,
apparently
not
followed
by
any
secondary
ones.
It is difficult
to believe
that the
death
from yellow
fever recorded
in
1902
actually
was
a
case
of
this
disease.
From
our
present
knowledge
of the epidemiological
features
of yellow fever it seems
that
a
case
occurring
in
a
member of the garrison
would
be fol
lowed by other cases,
as we have here a number
of susceptible
people
concentrated
in one building
(the mosquito always being present).
From 1902 on not even a suspicion of the disease being present in
St. Thomas has been noted.
In analyzing
the factors having bearing on this spontaneous
elim
ination
of
the
disease from
St. Thomas
we find that it occurred
before
the
method
of transmission of the
disease
was
known
and
hence
could not
have
been
influenced
by any sanitary
measures.1
Due
to
the marked
decline
in shipping
and
lessened
immigration
the number of susceptible
people
was brought
below
the "critical
number"
and hence by " failure of the human host" the disease dis
appeared.
By elimination
of the
disease from
Habana
and
other
ports
through
control of the
insect
vector,
chances for reinfection
of St. Thomas were rendered
more remote.
The
importance of clearing up great permanent
foci of infection
and its influence
on the smaller foci was realized by the Gorgas com
mission of the International
Health
Board
when
they,
in
a world
survey for endemic
yellow
fever centers,
reported that this disease
could
be "eradicated
from
the
west
coast
of
South
America
by
'Acdes
calopus
(Meigen)
has
been
a constant
factor
In
St.
Thomas — breeding
to
the
limit.
Mosquito
eradication
was
not attempted
until
a
few
years
ago
when
the
United
States
took
over the islands.
Since
that
time
the progress
of mosquito
eradication
has
steadily,
although
slowly,
gone
forward
step by
step.
570
BUNKER—KIDNEY
FUNCTION.
Vol. XVII
*
eradicating
it
at Guayaquil,
Ecuador."
The
truth
of this
state
ment has practically
been realized.
The soundness of Carter's view with regard to the mechanism
of
spontaneous
elimination of yellow fever
is further
seen
on the west
coast of Africa.
The yellow fever commission,
headed by General Gorgas and after
his
untimely
death
by General
Noble,
which
was
sent under
the
auspices of the International
Health Board to study the yellow fever
situation
on the west coast of Africa,
found
no trace of
a yellow
fever epidemic
in spite of the fact that Aedes
calopus
was present all
over.
The
old
idea
that
an extended
area of
endemic
pestilence
must
exist
or that the whole area of West Africa
must
represent
such
a pestilence
district
must
be discarded in the face of the find
ings of the commission.
The same reasons may be given for this dis-
nppearance
as have been given
above— lessened shipping, substitution
of steam for sail, clearing up of West Indian foci, and, finally,
the
" failure of the human host."
The proof that yellow
fever
has disappeared from this coast was
furnished during the World War, when large bodies of white troops
were introduced without
the occurrence of any epidemic.
REFERENCES.
(1)
August
Hirsch.
Handbook
of
geographical
and
historical
pathology.
1883, London,
The New
Sydenham
Society.
(Translated from the second Ger
man edition.)
(2)
Gorgas,
W. C, Carter,
H. R., and Lyster,
T. C.
Yellow fever:
its dis
tribution
and control
in
1920.
Southern
Medical
Journal.
1920, XII : 873.
(3)
Quoted from
R. Roche.
Yellow fever, considered
in its historical, patho
logical,
etiological,
and therapeutical
relations.
Philadelphia, 1855.
(4)
Shipley,
A. E.
The carrier of yellow
fever.
Brit.
Med.
Journal,
Lou
don, 1915,
1 : 921.
(5)
Pareja, W.
A brief account of yellow
fever in Guayaquil.
New Orleans
Medical-Surgical
Journal,
1919-20,
72:271.
(6)
Medicinalberetning
for Kongeriket Denmark
for aaren
1878,
1880,
1881,
1884.
1885.
Kjobenhavn.
(7)
Personal
communication
to writer.
(9)
Carter,
H. R.
The mechanism of the spontaneous elimination of yellow
fever
from
endemic
centers.
New
Orleans
Medical
and
Surgical
Journal,
1919-20
; 72 : 347.
KIDNEY FUNCTION.
By
C.
W.
O. Bcnker,
Meutenant
Commander,
Medical
Corps,
United
States
Navy.
Kidney
function
deals
with
the ability
of the kidney
to
excrete
substances from the blood stream —a process usually accompanied
by
concentration, especially in the case of what we consider to be waste
products
(urea, uric acid, etc.).
Concentration
here means that the
No. 4.
BUNKER
KIDNEY
FUNCTION.
571
I
percentage
strength of the substance
is greater
in the urine than in
the
blood.
It would
appear
that, in addition
to the
secretory
(or
excretory)
function, the kidneys have also an active synthetic func
tion.
Nash and Benedict have presented strong evidence to the effect
that the ammonia
in blood
and urine is the result of the latter.
The
efficiency
of
the
kidneys
is
frequently
affected
by
disease,
especially such
as disturbs the kidney, and is also usually diminished
after the age of 50 years
as the result of senile
changes.
It can not
he too strongly emphasized,
however,
that disease of the kidney does
not necessarily
imply
an inability
(either partial
or complete)
to
eliminate substances —anatomical need not parallel functional
lesion.
Function
may be normal, with organic changes
present, especially if
they are focal in nature.
So, disease of the kidneys is not synony
mous with
impaired
kidney
function.
Even
less definitely
is
the
latter condition
established
by the finding
of albuminuria
with
or
without cylinduria.
Renal
insufficiency
does
not affect the excretion
of all compounds
to the
same
extent.
It is well known that the functions for chlo
rides and for urea are independent
of each other.
Uric acid may
be
retained
in the blood
while the excretion of other nitrogenous sub
stances is apparently normal.
In any urine examination, then, one
should
bear
in mind
the
possible
effect of an impaired
excretory
power relative
only to the substance under consideration.
From ex
perience, we may estimate the probable effect upon excretion of other
substances,
but as yet no hard and fast comparisons can be drawn.
To advancing
uric-acid retention is usually added that of urea,
and
later of creatinine.
But in gout (where the increase of blood uric
acid is believed
to be the result of retention)
the uric acid
alone
is
retained,
even when it may exceed by far that which would be accom-
'
panied by retention of other substances in nephritis.
And our ex
perience
also leads us to expect, with
a marked general
retention of
nitrogenous
compounds,
that
certain
other
substances
(sugar,
cholesterin, diastase, etc.) will be retained.
As the preceding would suggest,
the usual
result of impaired kid
ney function
is
retention
in
the blood
stream
of material
that
is
normally
secreted into the urine.
The other side of the- picture is a
diminution
of such material in the urine
unless
the kidneys work
overtime.
This they will do, but
a continued effort of such nature
aggravates
the condition and, sooner or later, exhaustion
will resvdt.
Such
is the
sequence of events in uremia, in which
one finds the
amounts
of
nonprotein
nitrogenous
compounds
increased
in
the
blood and
decreased
in the urine.
It
is well
to bear
in mind this
complementary
nature
of urine and blood examinations.
The
functional
variation
from
normal
may,
however,
be
evi
denced
by
an
increased
permeability
of
the
kidneys.
In
such
a
572
BUNKER—KIDNEY
FUNCTION.
•
Vol. XVII
case,
depletion
would
be
the
result,
as
happens
occasionally
in
chronic diffuse nephritis
when
one finds low
values
for the
blood
urea.
And, finally,
the alteration that disease may
produce
in
the
ammonia
function
noted above must
not
be overlooked, as it has an
important
protective
duty
in
the
acidosis
of
certain
diseases.
I
have
considered
this more fully in
a separate
article
on
acid-base
equilibrium.
In this
connection,
we
speak
of the
kidney
" threshold " for
a
substance,
i. e., the concentration required in the blood stream before
the kidney will excrete
it,
at least in abnormal amount.
For chlo
rides, this
is
quite definite
at
562 milligrams
per
100 mils of blood
plasma; for sugar,
it
lies at about
160-180 milligrams
per 100 mils
of whole blood,
and
if
such concentration be passed, then glycuresis
occurs until the blood
sugar
is
normal.
The threshold
is
not neces
sarily
absolute,
but
simply
indicates that, with
less sugar, for in
stance, only the normal traces are passed.
Chloride excretion begins
only
when
their
concentration
passes the threshold
value,
and the
rate of their
elimination
depends
upon
their
excess.
Other
com
pounds,
such
as urea, for example,
may
have
no definite threshold
value.
Disease
may
affect
the
value,
either
by
raising
it
and
causing
abnormal retention, or by lowering
it
and giving rise to depletion.
The threshold for sugar rises with advancing age
;
up to
a
value of
200 milligrams
of sugar per 100 mils of blood, diuresis will lower it.
In diabetes
mellitus,
the sugar threshold may rise to 200 per cent
or more of the normal.
Some consider that renal diabetes
is
the re
sult of
a
lowered threshold for sugar.
The thoughtful
practitioner
of medicine
is
interested
in kidney
function
for several
reasons.
It
is
frequently
affected
in
disease,
and
the
timely
recognition
of
impairment
enables
one
to
guard
against serious
consequences,
such
as uremia.
Chemical analysis of
the blood indicates the metabolic substances
affected, and guides in
the adjustment and regulation of diet, habits, etc.
We have
men
tioned the connection
with acidosis.
The status
of kidney function
having
been
established,
one
can
more
intelligently
interpret
the
results of urine examination.
And, before
accepting
a
normal find
ing,
one should
be
satisfied
that
one kidney
has
not taken
upon
itself the work of
a
badly crippled partner.
Lastly, remember
that
a
normal function
does not exclude
a
diseased kidney.
Renal function
and
acidosis
enter
prominently
into the
question
of operative
risk.
The
former
is
especially
material
in
genito
urinary surgery, notably in the average prostatectomy.
A few days'
drainage of the bladder may
alleviate
a
renal insufficiency due
to
obstruction or infective
processes in the lower genito-urinary
tract.
Failing so to do, the patient
is
not
a
good surgical risk,
as then the
No. 4.
573
BUNKER—KIDNEY
FUNCTION.
impairment is probably due to the kidney itself.
Frank states that,
from a standpoint of renal function,
a patient is not in the best pos
sible condition to undergo any surgical procedure if he has a phenol-
sulphonephthalein excretion of less than 40 per
cent
(unless
due to
disease of other organs,
especially the liver), an Ambard
coefficient
of more than
0.1,
and,
as^ regards the urine, but little variation
in
quantity from day to day, fluctuations in specific gravity of less than
0.007
regardless of
diet,
and
a
nocturnal
polyuria.
Others
have
added a nonprotein nitrogen of the blood of more than 50 milligrams
per 100 mils, and, with the phenolsulphonephthalein
test, an appear
ance time of more than 25 minutes,
or less than 20 per cent excretion
during the first hour.
Many
methods
are employed
for the estimation of renal function,
and, in general,
they
are based upon four principles
of procedure.
1. The determination of the
degree of retention in the blood of
various metabolic
products.
Here
enters
chemical
analysis of the
blood,
in the
course of which
examination
is
made
especially for
urea, uric acid, creatinine, nonprotein nitrogen, and chlorides.
2. The determination of the rate of excretion via the urine of
a
chemical
substance
that
has
been
injected
or
ingested
in
known
amount.
Such as phenolsulphonephthalein,
methylene
blue, indigo-
carmine,
rosaniline, sodium chloride, potassium
iodide, salicylic
acid,
lactose,
urea,
etc.
3. The comparison in a patient on
a known diet between
the in
gestion
and
excretion of, as well
as the ability
of the
kidneys
to
concentrate,
a group of substances
involved in normal
metabolism,
viz,
water,
nitrogen,
and
sodium
chloride.
This
is
Mosenthal's
method.
4. The
determination of the ratio
between
the concentration of
various metabolic
products, especially urea,
in the blood and their
excretion
in the urine, the result being
expressed
as
a ratio of ex
cretion, or as a coefficient.
This includes the Ambard
coefficient,
the
McLean index, the Austin,
Stillman,
and Van Slyke formula,
etc.
The relative value of the different methods is debatable.
Probably
those least open to criticism
are chemical
analysis of the blood, the
phenolsulphonephthalein
test,
and
Mosenthal's
method.
The for
mulae have many warm advocates
as well as severe critics.
A rough
clinical
comparison of the two kidneys may
be obtained
by
deter
mining
the
urea in specimens of urine simultaneously
collected
by
means of the uretheral catheter.
Blood chemistry, now that its value
has been established,
is gen
erally given preference
and allowed greater weight in
case of dis
agreement with other tests If treatment
brings
a high blood
urea
to normal while the Ambard coefficient remains high, kidney function
is probably not impaired.
It measures excretory function for normal
574
Vol. XVII
BUNKER—KIDNEY
FUNCTION.
metabolic
products, and has the additional
value of an aid in prog
nosis, especially if the creatinine is increased,
in diagnosis, and
as a
guide to treatment,
especially dietetic.
It has the disadvantage
of
a possibly unfamiliar technique,
and does not afford a comparison of
the two kidneys.
The substances usually considered
are the nitrogenous compounds
(nonprotein nitrogen, urea nitrogen, uric acid, and creatinine),
but
retention of others
(sugar, cholesterin,
chlorides, diastase)
are
also
of significance in this connection.
Of the nitrogenous constituents,
the kidney excretes creatinine most readily, urea next, and uric acid
with
the most difficulty.
It normally
concentrates
creatinine about
a hundred, urea about eighty, and uric acid only about twenty times.
As
a
consequence,
an impairment
of function
results first in
the
retention of uric acid, then urea,
and, finally, creatinine is also
re
tained.
Owing to
the relatively
small
amounts
of uric
acid
and
creatinine present, the nonprotein nitrogen, which includes
the nitro
gen in
them
as
well
as
in
other
compounds,
is
not
appreciably
affected except by the urea increase.
This is the basis of an intelli
gent interpretation of the findings.
The
urea
(and therefore the nonprotein nitrogen)
are
so mark
edly
affected
by
diet,
especially
among
nephritics,
that judgment
must
be used when
they
are employed
as indices of renal function.
This fact was not properly
appreciated
until recently, and probably
accounts
for much
of the discredit cast upon chemical
analysis of
the
blood
in this connection.
The uric
acid,
being less exogenous
in origin, is perhaps the most delicate
and the safest index.
The in
crease appears
early, and
3.5 milligrams
per
100 mils blood may be
considered
the
high
normal
value.
An
increase
during
a high-
purine diet is especially significant,
as it does not occur
in normal
persons.
We have found the uric acid determination of much assist
ance in judging
the significance of occasional
casts
and
traces of
albumin in urine—an increase speaking for an organic kidney lesion.
On the usual restricted hospital diet, over 20 milligrams
urea nitro
gen per 100 mils blood should be considered
suggestive
of impaired
renal function;
over
75 speaks decisively for renal involvement and
probable uremia.
Values around 50 demand judgment and a scrutiny
of the
diet
as well
as search
for other possible
causes of unusual
protein metabolism.
Results of change of diet are usually apparent
only
after
several
days.
Values
for creatinine of
over
4 milli
grams
per
100 mils of blood
do not occur without
great impairment
of renal
function
and probability
of uremia.
Phenolmlphonephthdilevn
(phtkalein,
or red)
test. —This was de
veloped
by Kowntree and Geraghty, and its simplicity
makes it very
useful, especially to the isolated
practitioner with limited laboratory
facilities.
It estimates only function for a foreign substance, is not
No. 4.
575
BUNKER—KIDNEY
FUNCTION.
considered
quite
as reliable as chemical
analysis of the blood,
and, of
course, does not give the additional information
that the latter sup
plies.
It is, however,
of much
value,
has no contraindications,
and
does
compare
the kidneys when
combined
with ureteral cathetriza-
tion or the use of a separator.
The technique of the test can be found in any work that considers
clinical laboratory methods.
t
Impairment of renal function, of course, increases appearance
time
and lessens the excretion,
serious
cases not unusually excreting less
than
1
per cent
during
two hours.
Positive
results
are of more
significance
than negative,
and the excretion
of the dye is less affected
by glomerular than by tubular changes.
Values of more than 75 per
cent for two hours may
be accompanied
by diuresis, and Frank con
siders such a finding suggestive
of renal disturbance with irritation if
there is any other corroborative evidence.
MosenthaPs
test is a refinement
of previous work that endeavored
to estimate
renal function by measuring the ability of the kidneys to
concentrate
and excrete substances that occur normally
in the blood
stream
(water, chlorides, and nitrogen).
As originally promulgated,
it involved
the
use of
a
definite
diet that
he now describes
as the
" high-protein "
diet.
A " low-protein " diet and
the diet normal
for the patient were later tested, and he finds that the essential
facts
held
with all.
The
result
has
been
a simplification
of technique
that
enables
wider
application,
and
its use for ambulant
cases
in
ordinary
private
practice.
It was
claimed
that earlier evidence of
renal insufficiency was obtained by this method than by the phthalein
test, the Ambard index, or by determination of the blood urea.
At 8 a. m., void and discard urine, and eat breakfast.
Void and
collect urine only at 10 a. m., 12 noon.
2, 4, 7, and
10 p. m., and at 8
a. m. on the following morning, this last sample being the night urine.
Eat lunch at
1 p. m. and dinner at 7 p.
m.
(three
hours before last
evening collection
of
urine).
The
meals
are
those
to
which
the
patient is accustomed,
and
a record of everything consumed
is kept
in round
figures
in order that a basis for criticism
of the diet
may
be at hand.
No food or drink is to be taken except at meals.
*
Determine volume
and specific gravity of each sample,
and the 24-
hour excretion of chlorides
(as NaCl)
and nitrogen.
He avails him
self of
the inaccuracy of
the ordinary
hypobromite
estimation of
urea,
and
estimates
that the
results
obtained by dividing the urea
value
thus
obtained by
2.14
(the nitrogen
factor)
is
a sufficiently
accurate
expression
of the total nitrogen
value for the
purposes
of
the test-
As normals, he gives
1.020
(1.018 with
tfie "high-protein diet")
or over in any specimen
as a maximal specific
gravity,
the extreme
values of the different samples
to show
a variation of 0.000 or more.
576
Vol. XVII
BUNKER
FUNCTION.
KIDNEY
:
and
a night
sample
of
750 mils or less.
By "fixation of specific
gravity " is meant
a variation
between extremes of less than 0.009.
A normal maximal
specific
gravity
indicates that the kidney
can
concentrate
the urine satisfactorily,
providing
the 24-hour amount
is
adequate.
A high specific gravity
with oliguria
occurs only in pas
sive
congestion
of the kidney,
and
in
acute,
subacute,
or
chronic
nephritis,
conditions
that
also
show
a markedly
diminished
NaCl
excretion, together
with considerable
albuminuria
and edema.
Long
life is often possible
providing
a low specific gravity is compensated
by polyuria,
as in
diabetes
insipidus
and
a few
cases of chronic
nephritis.
A high fixed
specific
gravity
(about 1.020)
may occur in normal
individuals
as the result of insufficient fluid intake, or may be the re
sult of diseases characterized by edema and oliguria, especially myo
cardial
insufficiency
and
acute or chronic
nephritis.
A low
fixed
specific gravity is a danger signal and is found in many widely vary
ing conditions
(diabetes insipidus, chronic nephritis, marked anemia,
the elimination
of edema, cystitis, pyelitis, polycystic kidney,
pros
tatic hypertrophy,
urethral
stricture, paralysis of the bladder as in
tabes dorsalis or tumor of the cord, etc.), which may do well as long
as there is a compensatory
polyuria.
A nocturnal
polyuria
indicates
an overworked
kidney,
and
this
may result in functional
damage.
Over
400 mils should be consid
ered somewhat suspicious of renal insufficiency.
In nephritis, it may
be improved by curtailing the food intake.
Edema, hypertrophied
prostate,
and
diabetes mellitus
should be excluded.
It is a graver
sign of functional impairment when on a low protein diet, as it may be
largely compensatory
during a high one.
NaCl is being ingested
in unnecessary
amount if the 24-hour ex
cretion exceeds 5 grams.
A very low excretion, together with edema,
indicates an inadequate
elimination, and is then not a criterion of the
diet.
If
5 or 6 grams of nitrogen are eliminated in the urine every
24
hours there
is sufficient
protein in the food to maintain
the indi
vidual's health and strength, provided
the diet contains a consider
able amount of starch,
and restriction of proteins should be guided
by the nature of the disease.
The test then supplies information
useful in diagnosis and prog
nosis, an early index of renal function, and a guide to diet.
Chemi
cal analysis of the blood, especially as to the nitrogenous constituents,
will furnish further details
as to the manner in which
the intake
of nitrogenous foods and sodium chloride
should
be varied.
Con
clusions should preferably
be based upon more than
a single test.
The
underlying
idea
in the
use of formula?
is to eliminate
any
confusion
that might
arise
as the result of
changes
in
the
blood
No. 4.
577
BUNKER—KIDNEY
FUNCTION.
concentration
of urea due to the level of the general
protein metabo
lism.
They
are usually
based upon the urea function,
but may be
derived
for
other
and
urinary
constituents
such
as
chlorides
or
sugar.
They are criticized mostly because of the use of exact mathe
matical
formulae
for the
expression
of life
processes,
and
because
of disagreement
as to what does constitute
the law of urea function.
Again, it is inconvenient to accurately collect the urine excreted dur
ing short periods.
In arteriosclerotic
conditions
and
those of car
diac
decompensation,
they
are occasionally
at fault,
and should
be
checked
by other methods,
especially blood chemistry.
It is doubt
ful if they give information
that is not supplied by blood chemistry
alone.
The Ambard
coefficient
changes
before
the nonprotein nitro
gen of the
blood,
but
they
agree
closely
in later stages.
The
co
efficient
has also possibly
a greater
prognostic significance than the
phthalein
test.
While Ambard
has also developed
a formula based on the chloride
function,
the following one relative to the urea function
is the more
familiar.
K is known
as Ambard's
coefficient;
U is grams
urea
per liter of
blood ; C is grams urea per liter urine ; D is grams urea per 24 hours :
and Wt is the weight of the individual
in kilograms.
The normal
value is about 0.08
(0.06-0.09)
, and indicates either no disease or com
pensation.
K rises
as kidney function
is impaired,
more than
0.2
indicating
severe, and
more than 0.3 maximal impairment.
A rise
is graver with vascular than with chronic diffuse nephritis.
Depres
sion of the coefficient means increased renal activity
due to irritation.
The coefficient
is said to have a peculiar diagnostic significance with
tuberculosis of the kidney, a normal value indicating that only one is
affected,
while an increased
coefficient
means that both
are affected
or that there is a toxic nephritis of the opposed
kidney.
McLean's index is :
The
symbols
have
the same significance as with
the Ambard
coef
ficient.
A normal value is 80 to 100.
It is lowered in renal insuf
ficiency.
Values
below
50
mean
impairment;
below
10,
marked
impairment.
The index may be
1 in terminal states.
Austin, Stillman,
and Van Slyke have corrected
what they believe
to be erroneous
assumptions in Ambard's
formula,
and suggest,
as
giving more consistent
results,
the following:
2T=
r
WtX U*
D
578
Vol. XVU
RAYNOR —MEDICAL,
CORPS
UNITS.
1) is grams urea in 24-hour urine specimen ; B equals grams urea per
liter of blood; V is liters of urine per 24 hours; and W is weight of
individual
in kilograms.
The
normal
value
is
7.5±3,
and
renal
insufficiency
produces lower values.
We can establish
the status of renal function in any given
case,
and are then in a position to intelligently
prescribe dietetic and other
treatment.
The
substances
affected
by a retention are determined,
and our aim should then be to adjust diet, etc., in such a manner
that
the kidneys are able to excrete materials brought to them.
Regulate
the regimen by the excretory powers of the kidneys, but do not over
look the nutritive
needs of the body.
THE FUNCTIONS AND ORGANIZATION
OF MEDICAL
CORPS UNITS SERVING
WITH THE MARINE
CORPS IN THE FIELD.
By
8.
N.
Ratnor,
Major,
United
States
Marine Corps.
THE MEDICAL
REGIMENT,
INFANTRY
DIVISION
(WAR STRENGTH).
Like every other branch of the Army, the Medical Department has
been completely reorganized since the World War.
Old units have
been discarded or radically
modified
and new names adopted,
so that
modern
sanitary tactics
presents many phases of a new subject.
The general
scheme of the new Medical Department field organiza
tion
is
best exemplified
in the
recently
established
" medical regi
ment."
The prescribed methods
of this unit in the collection, treat
ment, and evacuation
of the wounded
are followed, with appropriate
modifications in every organization of the Army, from the battalion
to the base.
A study of its workings
at this time will greatly facili
tate the study of the medical service of the brigade, which will
be
considered
in the next article.
The medical regiment is primarily a divisional organization.
All
of the medical
services of the division
have
been brought together
into one unit.
The old hospital companies
have been assembled
as a
battalion of the medical
regiment; the former ambulance
companies
now
constitute
the
ambulance
battalion,
and
a
new
organization
called the " sanitary battalion " has been added.
In addition to these
battalions, the medical regiment includes
a headquarters,
a service
company,
a medical supply section,
a medical
laboratory section,
and
a veterinary company.
The medical regiment
is commanded
by the
division surgeon.
The medical
regiment,
as a divisional unit, occupies an intermediate
position between the infantry regiments
and the larger medical
units
in the rear.
It transports the wounded
to the nearest ambulance
sta
tion by litter,
and from there
to the hospital station by ambulance.
The hospital station is equipped
with beds, operating equipment,
and
No. 4.
579
RAYNOR —MEDICAL
COHPS
UNITS.
arrangements
for treating gassed
cases.
Facilities
are available for
fairly
extensive
medical and surgical
treatment,
but as
a rule only
emergency work is performed,
as the hospital
must
not
be allowed
to become
overcrowded, and
the interests
of the patients are better
conserved by transporting
them
as speedily as possible
to the better
equipped hospitals in the quiet sectors.
On# medical
regiment
is
assigned
to each division,
one
to
each
corps,
and
four
to
an
army.
The
two
latter
organizations
have
hospital
and transportation
facilities in addition to the medical regi
ment,
but the division does not under normal conditions.
A brigade acting
alone
might
have
attached
to it one sanitary
company,
one ambulance
company,
one hospital' company,
and addi
tional medical
personnel
from the medical regiment.
An outline of the organization
of the medical
regiment
is given
below :
ORGANIZATION OF THE MEDICAL
REGIMENT.
(WAR STRENGTH.)
Headquarters (division
surgeon's
office)
:
1
colonel
(division
surgeon).
1 lieutenant colonel
(executive
officer).
G majors—
1 sanitary
inspector.
1 orthopedist.
1 urologist.
1 neuro-psychiatrist.
1
dentist.
1 veterinarian.
3 captains or lieutenants (including
1 attached
chaplain).
1 warrant
officer.
12 enlisted
men
(attached
from service company).
Service company:
2 captains or lieutenants.
40 enlisted
men.
Sanitary battalion :
1 major.
12 captains or lieutenants.
306 enlisted
men.
Ambulance
battalion:
1 major.
7 captains or lieutenants.
177 enlisted men.
Hospital battalion :
4 majors.
22 captains or lieutenants
(6 dental).
247 enlisted
men.
580
Vol. XVII
RAYNOR —MEDICAL
CORPS
UNITS.
Medical
supply section:
2 captains or lieutenants.
13 enlisted
men.
Medical laboratory section:
1 major.
1 captain.
7 enlisted
men.
'
i
Veterinary company :
4 captains
(1 meat inspector).
70 enlisted
men.
Making
a total for the regiment of 60 officers,
1 warrant
officer,
and
860 enlisted
men.
HEADQUARTERS.
The
headquarters
of
the medical regiment
is divided
into
two
sections,
one constituting
the
office of the division
surgeon
and the
other the headquarters
of the regiment.
As stated in the previous article, the division
surgeon
is a member
of the staff of the division
commander
and is also in command
of
the medical
regiment.
As senior medical officer he has supervision
over
all
matters
pertaining
to the public health and
as
a member
of the staff and as commander of the medical
regiment he is in charge
of the sanitary tactics of the medical troops.
A lieutenant colonel
is executive
officer of the medical regiment.
Attached
to the division
surgeon's
office are six specialists having
the rank of major,
as indicated in the outline of the organization.
These officers are the chief advisers of the division surgeon, and each
has supervision of the divisional
work
pertaining
to his specialty.
THE SANITARY
BATTALION.
The sanitary battalion is essentially a battalion of litter bearers.
The
designation "sanitary"
is not suitable
and
probably will be
changed.
During combat it collects
the wounded
from the aid sta
tions and from the field and carries them by litter to the ambulances
in the rear.
In camp or cantonment
it operates
sanitary apparatus
and is employed in improving
the sanitation of the area.
The battalion
consists of
13 officers
and
306 enlisted
men.
It is
divided into a headquarters
and 3 sanitary companies.
The headquarters
consists
of
1 major in command,
1 technical
or
first sergeant,
1 staff sergeant,
1 sergeant,
and
3 privates who act as
chauffeur, messenger,
and orderly, respectively.
Its equipment con
sists of a tent and
a field desk borrowed from one of the companies.
It has
no
fixed location, but would
probably
be most
frequently
placed
at a collecting station.
No. 4.
581
RAYNOR — MEDICAL
CORPS
UNITS.
THE SANITARY
COMPANY.
The sanitary
company
is organized
as follows:
Captains
or lieutenants
4
Sergeants
8
Technical
sergeants
1
Corporals
4
Staff sergeants
5
Privates,
first class, and privates.
82
The personnel
is divided into two sections —a litter-bearer
section
and
a collecting-station
section.
The
number
of men
assigned
to
each section can not
be definitely fixed,
as it varies greatly with the
needs
of
the
situation.
It frequently
happens
that
no collecting
station
is needed, or it may
happen
that the route of evacuation
is
long
and
the
ambulances
are
unable
to
get
up
close.
Under
the
latter
condition
the
collecting
station
becomes
a
very
important
reinforcement of
the
aid
station
and
will
require
many
men
to
handle
it.
The organization
must, therefore, be very elastic.
Per
sonnel
can
be assigned
at will to duty with either the litter-bearer
section or the collecting station, as the situation may require.
The
table of equipment
for the medical
regiment has not as yet
been
completed
by
the War Department.
The
table
given herein
is an extract from
a tentative list prepared by the Surgeon Gen
eral's Office.
It is expected that it will be adopted
without material
change
and may
be accepted, for all practical purposes,
as standard.
In order that each company
may act independently when occasion
requires,
the tables
have
been
prepared with the company
and
not
the
battalion
as
the
basic
organization.
The
equipment
of
the
litter
bearers
is such
as can
be carried
on the
person
and
consists
of a litter and
a belt.
The belt contains pockets for first-aid
dress
ings.
It is not improbable that the belt will be finally
adandoned
and
a pouch
slung from shoulder substituted.
The collecting
sta
tion is the rendezvous
for the wounded
of a brigade, and its equip
ment is intermediate between that of an aid station of an infantry
battalion and
a hospital station of the medical
regiment.
It
is,
for
the most part, easily packed in boxes and bundles
and
is
transported
upon
trucks.
Each
company
is
allowed
four
three-quarter
ton
trucks.
The materiel
is
divided into seven sets,
as follows
:
One
set drugs, chemicals,
and reagents.
One
set surgical
instruments.
One
set surgical
dressings
and
appliances.
One set hospital furniture
and supplies.
One
set field-equipment supplies.
One set food supplies.
,
One
set miscellaneous
supplies and
equipment.
4539—22
3
582
Vol. XVII
RAYNOB —MEDICAL
COUPS
UNITS.
The drugs and chemicals
are relatively few in number and consist
of such
as
are commonly used
for
emergency
treatment and
the
relief of minor ailments.
The
surgical equipment is
designed
for emergency
surgery
and
consists of small cases of instruments, needles, simple surgical
appa
ratus,
and splints.
The surgical dressings
are abundant and complete for their purpose,
consisting of large numbers
of bandages,
rolls
of cotton,
adhesive
plaster, first-aid packets,
etc.
The hospital furniture
and equipment
is of the simplest character.
It
consists
of such
articles
as hot-water
bags,
basins,
instrument
boilers, etc.
No cots are provided, but litters
are available for re
cumbent
cases.
Fifty litters are assigned each company.
The field supplies include blankets, carriers
(field)
for litters,
a
folding
operating
table,
a
venereal
prophylactic
unit,
notebooks,
buckets, lanterns, etc.
The food supplies consist of cans of milk, soup, coffee, and sugar.
The miscellaneous
supplies consist of such articles as rope,
axes,
flash lights, nails, twine, etc.
Each station is provided with 2 ward tents.
The
transportation
for each company
consists
of 4 bicycles,
10
riding horses,
1 kitchen trailer,
1 trailer
tank
(180 gallons)
and 4
trucks (three-fourth
ton).
The battalion headquarters
has, in addition,
1 motor cycle with side
car,
1 bicycle,
and
3 riding horses.
The
litter-bearer
section
works
between
the
ambulance
station
and the front, for the most part, transporting
wounded
from aid sta
tions to collecting stations and from
there
to ambulances.
It will
work in front of the aid stations of the infantry battalions only when
the regimental medical detachment
is insufficient for this duty.
The collecting station should be situated at a convenient place be
tween the ambulance
station and the aid station of the infantry bat
talion.
The exact location would, of course, vary with the nature of
the terrain and the character of the combat.
Sometimes it might not
be used at all ; at others, used at the ambulance
station as an adjunct,
or it might be placed immediately behind the battalion aid stations.
In order to give a schematic
location for the collecting station,
a
point may
be selected along the line of evacuation about
1,000 yards
in front of the ambulance
station, which would make it about
2,500
to 3,000 yards from the front.
It must
be borne in mind, however,
that this location is purely schematic
and would be varied
as local
conditions required.
In
combat,
the
duty
of
the
sanitary
company
is
to
transport
wounded by litter under conditions which prevent the use of wheeled
transportation.
Such
work
necessarily
lies
in
the
front
areas.
No. i.
583
RAYNOR —MEDICAL
CORPS
UNITS.
Normally
the wounded will be evacuated by litter to the aid stations
by aid station personnel,
and from the aid stations to the ambulances
by the personnel of the sanitary companies.
The organization should fill a long- felt want.
There is no part of
the evacuation
of the wounded
more difficult or more important than
that which
takes place in the front line.
No other means of trans
portation
is possible.
When transportation is lacking in the rear, the
wounded may
be housed in tents
and buildings,
and their
injuries
cared for in the interval of waiting
; but on the field the wounded
are
constantly
subjected
to additional dangers,
and their injuries
are be
coming progressively more serious and complicated.
The prompt re
moval of the injured
from the field
is the first duty of the medical
department in combat.
The litter bearers from the sanitary company
are expected to cover the whole field from front to ambulance
station,
when
necessary,
although
their
prescribed
position
is the
area
be
tween the aid stations and the ambulance
stations.
One collecting
station
is established
by
each sanitary
company,
or one for each infantry brigade.
They provide temporary shelter
for the
wounded awaiting
transportation
by
ambulance
and
are
means of affording
the wounded
more thorough threatment before
evacuation
than can be furnished
at the crowded
aid station.
As previously
stated,
the sanitary
battalion
is employed
in
time
of peace,
and in camps
and cantonments
at all times, in improving
the sanitary conditions of the garrison.
THE
AMBULANCE
BATTALION.
This unit provides wheeled
transportation
for the wounded
from
the battle
field
to
the hospital.
It proceeds
as near
to
the front
as conditions will permit, and
there
receives
the wounded collected
by the sanitary battalion
and conveys
them directly
to the hospital
station.
The
ambulance
battalion
consists
of
a
headquarters
and
three
ambulance companies.
The headquarters
is established
at an " ambu
lance station."
Two of the ambulance
companies
are motorized and
one is equipped
with
animal-drawn
vehicles.
Twenty
ambulances
are assigned to each company.
The ambulance
station is the center of the activities of the ambu
lance battalion.
From here the ambulances
are dispatched
to places
where they
can
be
loaded
with
the
wounded.
The
headquarters
section consists of a major (in command),
a captain, three sergeants,
and three privates.
There
is no prescribed
office
equipment.
Such
few
articles
as
are
needed
are borrowed
from
the
companies.
Its
transportation
consists of a motor car, a motor cycle with side car,
and a bicycle.
584
Vol. XVII
RAYNOR—MEDICAL
CORPS
UNITS.
Like other units of the medical regiment the location of the am
bulance station varies with local conditions.
The following general
requirements
must
be satisfied:
(1) It must be
accessible
by
road
from
front
to rear;
(2)
it must
be near enough
to
the
hospital
to keep in easy touch with it and must be connected
to it by a pass
able road;
(3) it must be as near as possible to the aid stations
and
collecting stations in order to prevent unnecessarily
long
carriage
by litter and must have
access
over
a good
road to these stations;
and
(4) it must
be in a position
reasonably
well protected
against
fire.
When it is possible
to do so the wounded
should be evacuated
by a different road than that congested with supply wagons
of other
services.
For the
purpose
of giving
it a schematic
position, it might
be
placed
in the forward
divisional
zone
about
equidistant
from
the
separate
ambulance
companies
and
on
the
road
to
the
hospital
station.
The
reserve
ambulance
company could
also
be
stationed
here.
This
would
(place
the
ambulance
station
a little
over
2
miles
from the front line.
From this point
ambulances,
of course,
work forward
as far as conditions permit.
THE AMBULANCE COMPANY.
The
two motorized
companies
and
one
animal-drawn
company
of the ambulance
battalion
are organized and
equipped
very much
alike, except for differences
due to the different types of transporta
tion provided.
There has been a pronounced
tendency
in recent years
to increase
the number of motor ambulances
at the expense of the animal-drawn,
but it has been
determined
that the animal-drawn
vehicle
can travel
over
torn-up
roads
and
plowed
fields
much
better
than
can
the
motorized ambulances,
and
that horses
can pull
loads where
auto
mobiles
can not go.
In view of these facts, we can not
as yet dis
pense with the animal-drawn
ambulance.
Excepting
that
6 more privates are assigned
to the animal-drawn
companies,
the prescribed
personnel
for the two kinds of companies
is the
same.
The table of organization
is
as follows:
Captains
or first
lieutenants
2
Privates,
first
class,
and
privates
Technical
sergeants
or
first
ser-
(for animal-drawn)
53
geants
1
Privates,
first
class,
and
privates
Sergeants
4
(for motorized)
4"
Corporals
3
The transportation
for the two
types of companies
is radically
different.
The motorized
ambulance
companies
are each
provided
with
20 ambulances,
1 trailer kitchen,
1 trailer
tank
(300 gallons),
No. 4.
585
RAYNOR —MEDICAL,
CORPS
UNITS*
1 trailer
spare
parts,
5 trucks
(three-fourths
ton),
1
motor
car,
1 motor
cycle with side car, and
1 bicycle.
The animal-drawn
am
bulance
company
has
20
ambulances,
2
escort
wagons,
1
spring
wagon,
1 motor cycle with side car, and
1 bicycle.
Each
ambulance
is provided
with
1 driver
and
1 orderly.
This
leaves 8 noncommissioned
officers and
7 or
13 privates for adminis
trative and
company
duty.
The
additional
6 privates
assigned
to
the animal-drawn
company
are charged with the care of the animals.
The equipment,
other than transportation,
supplied
the company
is of two classes : The first consists of the " ambulance
kit," and the
second of the " ambulance
company sets."
The "ambulance kit"
comprises
appliances and
dressings
which
are carried on each ambulance.
They are neither numerous nor bulky.
The principal
items are 4 litters, 8 woolen blankets, 1 rubber blanket,
flash lights, a bottle of aromatic spirits of ammonia,
bandages, splints,
cotton, adhesive plaster, and first-aid
packets.
The * sets " furnished the ambulance
company
consists of supplies
which
will
supplement
and
replace
the
articles
provided
in
the
"kits."
They
comprise
40 litters,
80
woolen
blankets,
20
rubber
blankets, an assortment of splints, a prophylactic unit, and
a number
of small articles, such
as emergency
medical packs,
notebooks,
and
pins.
The duty of the ambulance
battalion
is,
as its name implies, to con
vey wounded from the field in ambulances.
Like the sanitary
battalion, this organization
must
be
scattered
over
a
wide territory and
considerable independence
of action
al
lowed each element.
In combat
it
will
be operated
more
often
as
three
separate
companies
than
as
a
whole.
When
attached
to
a
division of
two
brigades
one
company
will
be
assigned
to
each
brigade and one will be held in reserve.
The action of separate com
panies will be coordinated through the battalion headquarters
at the
ambulance station.
This headquarters
station takes the place of the
old
" ambulance
control
station."
The
designation
" ambulance
head" has been discontinued.
The activities of ambulances
are reg
ulated from the ambulance
station.
On the march, ambulances
will
be detached
from the parent or
ganization
and assigned
to follow
the foot troops, one, two, or more
per regiment,
as conditions require and facilities permit.
In widely
scattered
cantonments
it
is
usually convenient
to attach an ambulance
or two to different billeting towns.
In no case, however,
should am
bulances
pass from the supervision and control of the officer in com
mand of the ambulance battalion.
This officer should take such steps
as may be necessary to insure the speedy assembling
of all the ambu
lances in his battalion
when conditions render
it
necessary.
586
Vol. XVII
BAYNOR —MEDICAL
CORPS
UNITS.
At no time, in peace or war, must the ambulance
be used for any
other purpose
than the transportation
of the sick and wounded,
and
the hospital personnel
and equipment.
THE HOSPITAL BATTALION.
So far, we have considered
only such units as are chiefly concerned
with
evacuation.
The hospital
battalion
affords the
wounded
the
first opportunity
to have their injuries
dressed, free from the hurry
incident to getting them beyond the range of fire.
The hospital battalion consists of a headquarters and three hospi
tal companies.
The entire battalion is normally
operated
as one unit
at the hospital station.
Each hospital has a capacity of 150 recumbent
cases without crowd
ing.
An additional
100
can
be cared for in an
emergency.
This
brings
the maximum capacity of the hospital
to
250.
About
150
Gold Medal cots and 100 litters are provided for beds.
The headquarters
consists of
1 major (in command),
1 captain or
first lieutenant,
1 technical or first sergeant,
1 staff sergeant,
1 ser
geant, and 4 privates first class, and privates.
The organization of each company
is as follows
:
Majors
1
Sergeants
7
Captains
or first lieutenants
7
Corporals
3
Technical
sergeants
1
Privates first class and privates
65
Start sergeants
4
The transportation provided for headquarters
consists of one motor
car and one bicycle.
Each company
is provided with
20 trucks
(1£
to 2 ton),
1 kitchen trailer.
2 motor cars, and
1 bicycle.
As in the sanitary
and hospital battalions, the equipment
is pro
vided on the basis of the company's
requirements
and not those of
the
battalion.
The
equipment
per
company
is
approximately
as
follows
:
One set drugs, chemicals,
and reagents.
One set surgical dressings.
One set surgical instruments and appliances.
'[
One set dental laboratory.
;
One set dental, operating.
One set hospital furniture
and supplies.
<
One set field equipment
and supplies.
One chest food supplies.
One set miscellaneous
supplies and equipment.
The
set of drugs, chemicals,
and reagents is a well-chosen
assort
ment sufficient for the needs of medical
cases and including
a liberal
supply of antiseptics and disinfectants.
The whole set can be packed
within
a few boxes the size of a steamer trunk.
No. i.
587
BAYNOR —MEDICAL
CORPS
UNITS.
The set of surgical dressings
consists
almost
entirely of bandages
and dressing packets.
It is similar to and about twice as large as the
set furnished the collecting station.
The set of surgical instruments and appliances contains a liberal
supply
of the instruments
best adapted
for
general
use in major
surgery,
and
an
assortment
of
special
instruments
for
eye,
ear,
nose
and
throat,
and
genito-urinary
surgery.
This supply
of in
struments is sufficient for two or three operating teams working at the
same time.
The hospital
furniture
and
equipment
consists
of
a long list of
small
articles,
such
as
basins,
brushes,
crutches,
irrigators,
litters
(100), pillows (150), towels, hospital clothing,
etc.
The field equipment
and supplies consists
of 500 woolen
blankets,
100 rubber blankets,
6 carriers for litters,
a
medical
and
surgery
chest,
a mess chest,
150 Gold
Medal
cots,
2 field operating
tables,
and a number of additional small articles.
The dental
set contains sufficient supplies for routine dental treat
ment and enough
laboratory
equipment
to permit of making splints
and other apparatus for treating injuries
to the mouth and jaws.
The
chest of food supplies
contains
canned
soup,
canned
milk,
coffee,
and sugar.
The
miscellaneous
supplies
and
equipment
consists
of
kitchen
utensils,
axes,
spades,
lanterns,
etc.
Especially
important
items
under this heading are
20 ward tents,
4 large and
4 small paulins,
and
150 mattresses.
From
the foregoing it will
be
seen that the hospital battalion
is
well equipped
to render
the necessary
immediate
treatment
required
for the sick and wounded of the division.
As it is essentially a mobile
field unit, it is not expected
to provide prolonged treatment
which
can be better given in the permanent and semi-permanent
hospitals
in the rear area.
THE
MEDICAL
SUPPLY
SECTION.
This
corresponds
to
the
supply
section
of the
infantry,
except
that is concerns
itself chiefly with the procurement
and distribution
of medical
supplies.
Its personnel
consists of 2 officers,
3 noncom
missioned officers, and 4 privates.
THE MEDICAL
LABORATORY
SECTION.
This
section
consists
of
2
officers,
1
staff sergeant,
2
sergeants,
and 4 privates.
It is provided with complete
field laboratory
equip
ment, packed in 12 chests, each about the size of the regulation trunk
locker.
The equipment
consists of microscopes,
an incubator, glass
ware, stains, reagents,
and other necessary laboratory supplies.
The
588
vol. mi
RAYNOR —MEDICAL
CORPS
UNITS.
function of the laboratory
section
is twofold: First, it assists the
sanitary
inspector by examining
food
and
water supplies
and
in
determining,
by laboratory
tests,
the
presence
or
absence of
con
tagious diseases in suspected individuals:
and. second, it assists the
hospital by examining blood, sputum, and other specimens.
These are the routine duties of the unit.
In addition to this it will
render aid in
every
possible
manner by laboratory
investigation,
in the detection of diseases, and in the treatment
of the sick.
THE DENTAL SECTION.
A
dental
clinic will
be
a department
of each hospital
and will
consist
of
7 officers
and
6 enlisted
men.
In addition
to rendering
emergency
dental
treatment,
this section will give advice
and
assist
ance in treating wounds of the mouth and jaws.
THE SERVICE COMPANY.
This organization
corresponds
very
nearly
to
the
headquarters
company
of
the
infantry
regiment.
It
consists
of
2
officers,
14
noncommissioned
officers, and 26 privates.
THE VETERINARY
COMPANY.
The veterinary service comes under the general supervision of the
medical department,
both for purpose
of administration
and supply ;
but its evacuation
service
is necessarily
separated
from that of the
medical department
proper and touches it at few points.
The veterinary
service
consists
of
5
officers
and
14 noncommis
sioned
officers.
It has
a special equipment of drugs, surgical in
struments
and appliances, surgical dressings,
and hospital furniture.
It is supplied with 16 horses (draft) and
17 horses (riding),
2 trucks
(2-ton),
2 wagons,
and
1 bicycle.
It establishes
a collecting station
for wounded
animals
and
evacuates
chiefly by halter
and
leading
rope.
THE HOSPITAL
STATION.
The location of the hospital unit is designated
" hospital station.*'
conforming
to the usual nomenclature
of
field
medical
formations
as illustrated by " aid stations," " collecting station," and " ambulance
station."
The hospital station is usually located near the rear of the division
zone.
It should
be
accessible
by wagon road from
the
front
and
rear.
If conditions permit, it should be about opposite
the center of
the division front.
The
arrangements
of the hospital
would
vary with the
special
needs of
the
station.
It would
consist
of
seven
departments,
as
follows
:
No. 4.
589
BELLI —HYGIENE
OF
SUBMERSIBLES.
1. Sorting hospital.
>
2. Sick and gassed hospital.
3. Surgical
hospital.
4. Hospital
for transportable wounded.
5. Laboratory
section.
6. Supply
section.
7.
Reserve
hospital section.
The sorting hospital is the receiving and dispatching unit.
It cor
responds
to the " triage " of the French Army.
Here the wounded
are classified,
recorded,
and distributed
to appropriate
departments.
From
here they are returned to the front or evacuated
to the rear.
The headquarters and
office
are usually
located
at or near this hos
pital.
The sick and gassed hospital may or may not be operated
as one,
depending upon the amount of gas which
has been encountered
in
action.
The surgical hospital contains
the operating pavilion
and beds for
dressing serious surgical cases.
The hospital for transportable wounded is provided for the slightly
wounded.
Many of
these will not require
beds, . as
they
may
be
speedily evacuated.
The laboratory section, supply section, and reserve hospital section
perform
the functions implied by their names.
The duty of the hos
pital battalion
is to provide the sick and wounded with immediate
definitive
treatment,
which
must be provided
before they
can
be
transported to the stationary hospitals in back
areas.
Units of the corps and army evacuate
the patients from the hos
pital station.
At times
the corps will take over the entire hospital
and provide the division with a new unit.
Note.—The subject
matter of this article has been
compiled from pamphlets
used In courses of instruction at the infantry school, Camp Benning,
Ga.
The
writer disclaims any credit
for originality.
HYGIENE
OF SUBMERSIBLES.1
PART
I.
By Capt. C. M. Belli, Medical
Corps,
Royal
Italian Navy.
CONSTRUCTION.
The introduction
of submarines
and
submersibles
has opened
up
a totally
new
and very interesting
chapter in naval
hygiene.
On
these
vessels
the
conditions
of
existence
are
so
different
that
the
rules of hygiene
for ordinary
vessels are inapplicable,
and
further
hygienic
research
becomes
necessary,
as,
in
the World War, these
1 From AunaU di Medlcina
Navale
e Colonlale,
Rome, February,
1922.
590
Vol. XVII
BELLI—HYGIENE
OF
SUBMERSIBLES.
new
instruments
demonstrated
an
extreme
offensive
power,
and
presumably
their
construction will
undergo
an extraordinary
de
velopment.
The literature
on the hygiene of these vessels is limited
to a very few original
works exclusively by Italian authors.*
The
reason for this scarcity of publications
lies in the difficulty of un
dertaking experimental studies
on the subject and in the
necessity
for maintaining
secrecy Vith regard
to
the internal
arrangements
of the vessel.3
Until the beginning of the war the architecture of the submarine
was shrouded
in an atmosphere of mystery.
After the seizure of the
Austro-German
submarines by the Entente and, reciprocally that of
the allied submarines
by the enemy,
the motive for this reserve,
at
least concerning past methods
of construction, ceased,
and
at this
time it is possible, without violating any military secrets, to base our
naval hygienic considerations upon a knowledge of the internal
ar
rangements
and instruments on board these vessels.
To-day the true submarine
has been abandoned,
and there is being
constructed
only
the
submersible
torpedo boat, known
as the
sub
mersible; that is, a boat which ordinarily travels on the surface of
the water,
and which, in order to attack the enemy or to retreat, can
submerge to such a depth
as to render it invisible and invulnerable.
From the nautical point of view the two types of boats are distinct,
because the submarine has a reserve buoyancy less than
10 per cent
of the displacement,
while that of the submersible
is greater.
In the
latter, with
a considerably increased
bulk, the conditions of life are
more favorable;
a large portion is above water, and the entire ma
neuvering station remains
at a convenient height above
sea level,
so
that the crew, when the submersible
is navigating
at the surface, can
take the air on deck.
The large submersibles
have a displacement
of from
1,500 to 2,000
tons, the more
recent
ones reaching even
5,000 tons; their length is
70 meters or more, and they have two screws.
They attain
a speed
1 Belli :
Hygienische
Betrachtungen
fiber
unterseelsche
Schlffe,
"Arch.
f.
Scblffi
u.
Trop.
Hyg.."
1905.
Belli
e Trocello
: Vlzlamente
e rlnnovamcnto
dell'arla
nel sottomarlni,
" Ann.
dl
Med.
Nav.."
1908.
Belli
e OHvi : L'arla nel sommerglblli
lmmersl, " Ann. dl Med. NaT.,"
1912.
Belli
e OHvi : II rlcamblo
material?
nel sommergtbili
immersi,"
" Ann.
di Med.
Nav.."
1912.
Belli
e OHvi : Crasl
tanguisna,
respirazlone
e circolazlone
nei
sommerglblle
immersi,
" Ann.
di Med. Nav.,"
1913.
Marantonio
: Meccanlaml
di
ventilazione
e di
rlcamblo
dell'arla
respirabile
sulla
nave
aomergible Balllla,
"Ann.
di Med. Nav.,"
1917.
3 To
give an
idea
of
the jealous
care with which
construction
secrets
are
guarded. I
will relate an incident
within my experience.
In
1905,
having
published
an article
on the
hygiene
of submersibles
based
on
a German
review, I was
accused of divulging military
secrets.
Naturally
the inquiry
brought
to light
that
the
State
defense
had
suffered
no danger
through
the incriminating article.
For the successive
publications
I
obtained
the licet
of the general
staff.
Public authorization
has
been
given for issuing
the data
of the present work.
No. 4.
591
BELLI—HYGIENE
OF
SUBMERSIBLES.
of 25 miles on the surface
and
15 miles immersed,
and can submerge
to a depth of from 30 to 40 meters.
The large tonnage
permits the quartering of a crew of 40 or more
men under sufficiently
comfortable conditions, the carrying of enough
fuel for a radius of action of more than 6,000 kilometers, and every
thing else necessary
for navigation,
so as to be able to remain away
from the base 30 or 40 days.
These
vessels
are
divided
into
two
classes:
Those with
single,
spindle-shaped
hull, Holland type
(English),
and
those which
are
double,
with an inner, pressure-proof hull, the exterior being in the
form of an ordinary ship— the Laurenti
type (Italian), Krupp (Ger
man), Laubeuf (French), Lake (American).
The difference
between the types consists essentially in the method of
immersion,
the interior
arrangement
being approximately
identical.
In the type with double hull, the inner one represents
the true hull.
The intervening
space is subdivided into water-tight
compartments
which are either empty or else form tanks for water ballast or liquid
fuel.
The walls separating the compartments
are water-tight
and
permit the boat to maintain
a certain degree of floatability
in case of
leaks involving
the two hulls and flooding one compartment.
The
doors between compartments
are likewise water-tight.
The submersible
can navigate at various depths,
such as :
(a)
On the surface of the water.
(b) In the awash state, more or less emerged (with only the peri
scope showing or with the whole tower out of water) .
(c)
Completely submerged.
Submerging
is accomplished
by automatically
filling the proper
compartments
with
sea
water,
which enters
by
an aperture in the
outer hull furnished with valves.
A return to the surface is accom
plished by
expelling
the
sea water from
the
compartments,
using
turbine
exhaust
pumps run by electric motors.
Under
exceptional
circumstances
compressed
air
is introduced into the compartments,
but this is regarded
as a means in reserve.
The transition from the
one
method of navigation
to the other is accomplished
in two or
three minutes.
Submersion can last
more than 24 hours.
With
complete
submersion
the conditions of visibility
are anal
ogous to those which prevail on a steamer enveloped
in a thick fog,
vision through the mass of water not being possible
beyond
a few
meters.
With partial
immersion, visual perception is accomplished
by means of the periscope,
a sort of telescope formed with
a cylin
drical tube which may
be raised
to the surface of the water (nor
mally it is held
at about
80 centimeters)
or lowered,
and which by
means of combinations of lenses and prisms furnishes
a means for
discerning
objects
almost
as with the naked
eye.
In the reflector
of
the periscope
is seen only an eighth part of the horizon, which, how
592
Vol. XVII
BELLI —HYGIENE
OF
SUBMERSIBLES.
ever, may
be entirely scrutinized
by turning the instrument
so
as
to- change the field of vision.
Underwater
navigation
is silent because the electric motors while
running
make no noise.
The silence is broken only by the sound of
the screws of near-by vessels, which is detected by means of acoustic
receivers
adjusted for purposes
of offense and
defense.
INTERNAL
STRUCTURE.
In
submersibles
of
a single hull,
three
planes
are
considered:
Deck, main corridor,
and hold.
In submersibles
with
a double hull
there is a fourth
plane, constituting
the double
bottom.
Deck
plane. —The
deck
has
a form like that of
a torpedo boat,
but the central portion is narrower
and the ship's sides slope to the
sea with an incline much
more accentuated.
In
the central part
rises
the conning
tower,
with
its two
peri
scopes.
Hatches,
the
ventilation
tubes,
and
the
passages
for
the
guns
and
torpedoes
open
forward
and aft of the conning
tower;
above appear
the radio
antennae
and the periscope
tubes.
The
conning
tower
has
a
superstructure
around
the
walls
of
which
are arranged port
holes for
use
when
the
boat
is emerged;
hatches
open from the roof giving
access
to a companionway
lead
ing to the rooms
below.
It is superimposed
upon the control room
and contains the governing apparatus.
Only when
in port
does the hull stay
open; exceptionally
it is
open
when
navigating
at the surface, with
the
sea perfectly
calm.
Under
these conditions
the
personnel
may
come upon deck,
which
with ordinary
navigation
remains
clear.
Corridor plane. —This is constructed
so that the inside -walls of
the hull form
those of the corridor,
the flooring
beneath
being
of
metal strips.
All the surrounding
chambers
are intercommunicating
by means of apertures fore and aft.
On the Laurenti
type of sub
mersibles
there
is
a
second
passage
across
the
intervening
space
between
the two hulls,
which
makes it possible
to pass
from
bow
to stern without going through the accumulator rooms.
Such a pas
sage is arranged for the safety of the personnel
in case of accident.
When the tubing is damaged,
or through
some other cause the
sea
water penetrates
the accumulator boxes
and
comes in contact
with
sulphuric-acid
gas, there is a strong development
of chlorine
which
renders
the air unbreathable.
Under
these circumstances
this
pas
sage offers
a safe exit for the personnel.
The number of compartments
into which the hull is divided
bears
a direct relation to the dimensions
of the boat.
With the exception
of the two extremities,
which remain empty,
these compartments
are
used as living quarters, control room, torpedo launching rooms, motor
(heat and electric)
rooms,
and for electric accumulators.
The quar
No. 4.
593
BELLI —HYGIENE
OF
SUBMERSIBLES.
ters for the
crew
and
officers
are
located
in the central compart
ments.
On
account
of the small amount
of space
and
its arrangement,
living conditions were very unsatisfactory in the first submersibles.
The
crew, in carrying
out maneuvers
and
while
resting,
occupied
very
uncomfortable
positions.
With
increased
size of
the
boe.ts.
their underwater characteristics changed and more nearly approached
the conditions
which
obtain
on ordinary
vessels.
The
crew
now
enjoy relative comfort
and
can carry
on their regular
occupations
without
any difficulty.
On
the large submersibles
there
is
a spa
cious
dormitory
for
the crew;
but also
on
the smaller
ones
every
man has a hammock or a small camp bed.
The officers are lodged in
one or more small rooms with
a bunk for each officer and they have
a small wardroom.
In the same central part of the
boat
there
is
a stove, cook's galley, steward's room,
and two toilets.
The stove is
electric;
a coal stove can not be used, because fire consumes
oxygen
which is very necessary for respiration.
One of the most difficult
problems
to solve has been the installa
tion of toilets.
At first, provision
was made for the removal of ex
crement
through deodorizing
boxes.
Recently
a convenient
system
of toilet cabinets
has been devised, having an arrangement of double
valves and
a pump, such
as are used for torpedo boats, but with the
difference
that the material is ejected from the ship by a stream of
compressed
air.
The capacity of the compartments,
both
absolute
and relative to
the number of persons,
varies
essentially according to
the
size of
the ship.
Nevertheless,
bearing in mind the serious
causes for viti
ation of
the
atmosphere,
in order
to give to each individual
the
greatest
possible
quantity of surrounding
air,
the
number
of men
is restricted, and
as a consequence each person
has a larger amount
of work to perform than on ordinary
vessels.
From
the data
published by Marantonio
upon the German sub
mersible seized during
the war by the Italian Navy, and rebaptized
Balilla, I have calculated the amount of surrounding air per person
and per space.
Amount of
Inclosed
space.
Cubic
capacity
(meters).
Number of
atmosphere
per person
(cubic
persons.
meters).
92
14
6.5
31
2
15.5
79
3
26.0
101
5
20.0
43
5
8.5
131
3
43.0
81
4
20.0
Total
558
36
594
Vol. XVII
BEIXI—HYGIENE
OF SUBMERSIBLES.
On this submersible,
with
a total air capacity of 558 cubic meters
and a crew of 36 persons, the average surrounding air per individual
is
15.5 cubic
meters, with
a great
difference
between
one place
and
another,
varying from a minimum of 6.5 to a maximum of 43.0 cubic
meters.
In an absolute
sense
the proportion
can not be considered
small, being greater than that for the majority
of ordinary ships; in
a relative sense, when submerged, it is sufficient to insure respiration
to those on board for but a few hours.
The average is attained
when
all the spaces freely communicate
; but
the amount
varies
with the
opening and shutting of the various doors communicating with the
different compartments.
Torpedo-launching
rooms. —These
contain the torpedo-launching
tubes and
the torpedoes
kept in reserve; if the boat
is of average
tonnage,
the spare space is utilized
as
a dormitory for the crew.
Control room. —This is located beneath the conning tower ; here are
assembled
the
two
periscope
tubes,
the
telephones,
the
speaking
tubes, and the radio apparatus.
Engine
rooms. —The propulsive motors
are of two varieties
: Heat
engines for navigation at the surface,
and electric
motors for under
water navigation.
The heat engines
are generally of the type
designed
for oil com
bustion
(gasoline and similar
products)
; however,
the more recent
French
and English types
use the steam-turbine
variety.
The heat engines
propel the vessel when
at the surface or when
partially submerged,
as long as it is possible
to keep open the tubes
surrounding
the periscopes
through which
passes
the air needed for
combustion.
They are arranged in pairs, two on each side,
respec
tively.
The products of combustion
are expelled
through two large
tubes, one on each side, corresponding to the smokestacks of ordinary
vessels.
The tubes pass through the double
bottom
on each side and
expel their contents above the water line.
From the hygienic point of view in this class of ships, the com
bustion motors present two advantages:
They
heat the surrounding
atmosphere
less, sufficient
coolness
being maintained
by means of
water circulation,
and, by introducing
the air necessary for running
the motor,
ventilation
is aided.
With
turbine
motors
cooling
can
not
be
effected
by
means of
water circulation,
and
in this
type of motor,
notwithstanding
the
covering of the hottest
pieces with insulating
material, there
is ex
cessive
heat
radiation
into the surrounding
atmosphere.
Such an
inconvenience
may
be remedied,
up to a certain point, hy separating
the
engine
room
from
the
other
compartments
by
walls
with
a
water circulation
and by systematic
forced ventilation.
The primary function of combustion
motors
is to furnish
mechani
cal
energy
for
navigation
at
the
surface;
but
these
motors
can.
No. 4.
595
BELLI—HYGIENE
OF
SUBMERSIBLES.
through
the
working
of the dynamo, charge
the
storage
batteries
which supply
the energy
to the electric motors
for partial
or com
plete underwater navigation.
In the vicinity of the heat motors
are the pumps for exhausting
water
and the air compressors;
all this apparatus causes excessive
crowding
of the
compartment, leaving
only
a very narrow
space
in the center.
In the same compartment in
a small boat, in a special one in the
larger types,
are installed
the electric motors
with continuous cur
rent,
which,
while
the
vessel
is
running
submerged
or partially
submerged,
take
the place of the combustion
motors.
The
motors,
by virtue of their reversibility,
are at the same time the regenerators
of the electric current
(dynamo),
and
when
the boat
emerges serve
to charge
the batteries,
which also are charged
at the shops on shore
or by mother ships.
Battery
compartment. —The
batteries
which
furnish
electric
en
ergy to the motors
for navigating
submerged
are located
in one or
two compartments
on the plane of the central passage ; in some boats
on the plane of the hull.
These
batteries
are of the sulphuric-acid
or liquid
type.
The ordinary
batteries
preferred
in the European
submarines
are
composed
of impermeable
boxes of ebonite,
closed
by covers provided with
holes for the passage of the poles.
They
are fastened
perfectly water and air tight
in order to prevent the
creeping
of the electrolyte
and
the
escape of
gases generated
by
the
development
of
the electric fluid.
Inside
the
boxes
the
lead
plates are arranged in series, separated
one from the other by strips
of rubber and immersed
in dilute sulphuric
acid.
The Edison
alkaline batteries
employed
in American
submersibles
are made of steel and nickle
and contain
a solution of potassium.
As compared
with
the ordinary
type, they
present
the following
notable hygienic
advantages:
By doing
away
with
sulphuric
acid,
they
remove
the possibility
of the
generation
of
gases
(sulphuric
anhydride
and
chlorine)
which
render
the
atmosphere
unfit
to
breathe,
thus
affording
a great
improvement in the matter of res
piration
and avoiding
the possibility
of serious
accidents;
they
oc
cupy
an appreciably
smaller
space
and
require
less
attention;
on
the other hand, from the technical point of view, they
are inferior
to the ordinary sulphuric-acid
types.
Plane
of the hold. —This portion of the boat
is set apart for the
storing of ammunition,
fuel, compressed
air, water,
and
the other
requirements for navigation.
Liquid
fuel is stowed
in perfectly
closed tanks, from which it is
conveyed to the motors by pumps.
The air under
a compression
of
150
to
180
atmospheres
is con
served in steel tanks arranged
as far as possible
beneath
the floor
596
Vol. XVII
BELLI —HYGIENE
OF
SUBMEKSIBLES.
ing of the engine
room.
The amount provided is in proportion
to
the
dimensions
of the
boat,
attaining
quantities of
10 and
more
cubic
meters to every
2 tons of weight.
The replacement
of the air
consumed
or lost through
the tubing is effected
by means of
force
pumps
which
operate
when the
vessel
is
completely
emerged.
A
system of piping leads from the tanks to a tap provided with
valves
in each compartment.
In one of the compartments
is located
the fresh-water tank
of
a
form
and construction similar
to that in ordinary
ships.
In the deepest part of the inner hull is the bilge, which is almost
inaccessible
when
all the apparatus and appliances are in place.
Double
bottom,. —The
double
bottom
for
the
water
ballast
ex
tends the whole length of the hull in the Krupp
and Laubeuf
types,
is limited
to the central part of the boat in the Holland and Lake
types
; likewise to the center but shorter in the Laurenti.
In certain
types
some of the
compartments
with
a
double
bottom
are
filled
with
a material which expands
on contact
with
sea water thus clos
ing any possible
leaks.
The
double
bottom
being ordinarily closed,
without
communica
tion with
the surrounding
portions of the ship, has no importance
as
regards
hygiene,
except
when
entered
for cleaning
and
repair
work.
INTERNAL
ATMOSPHERE.
Submersibles when
navigating
on the surface of the water, both
from
the nautical
as
well
as
the hygienic
point of view, do
not
present
notable
differences
over ordinary
torpedo boats, and within
certain limits
the same principles
imposed
by naval hygiene on the
latter can also be applied to them.
The submersible
is characterized
by the ability
to navigate beneath
the surface, in which condition
it
constitutes
an hermetically
closed
space,
circumscribed
by
imper
meable walls, entirely surrounded by a thick stratum of water,
and
absolutely separated
from the atmosphere.
This being the case, the following questions
arise : First. What are
the causes of the changes which the air undergoes
inside the vessel?
Second. In what proportion
do they occur
and which of them
pre
dominates?
Third. What index
may
be
adopted
as
the
limiting
factor of these changes?
1.
Causes of the deterioration of the air.—In ordinary
ships the
causes which produce the vitiation of the air are chiefly the function
ing of the vital organs of man and the various and complex activities
in which he engages.
In submersibles
the causes of the vitiation of
the air are similarly
complex,
but have different effects owing to the
fact of the space being hermetically inclosed.
No. 4.
597
BELLI —HYGIENE
OF
SUBMERSIBLES.
Man
renders
the
air
impure
through
his
biological
functions.
Respiration
and cutaneous perspiration
produce
chemical
and physi
cal changes in the air.
An adult man, working
moderately,
subtracts
every hour from the surrounding
air by his respiration 42 grams of
oxygen
and gives off 47 grams of carbon dioxide, as well
as a small
and variable quantity of ammonia,
sulphureted hydrogen, and heavy
volatile
acid.
At the
same
time,
man
emits
every
hour
with
his
pulmonary respiration
and cutaneous perspiration
50 to 60 grams of
water.
Furthermore,
man vitiates the air by the. radiation
of heat.
Engaged in moderate work, man emits every hour by radiation about
100
calories.
The
thermic capacity
of
the air
is
0.35
calory
per
cubic meter, whence through this single source of heat, if no absorp
tion of heat by the water surrounding
the boat takes place, the tem
perature of the air inside the latter will be noticeably increased.
Man
also vitiates the air with tobacco
smoke.
Lastly man
causes a final
vitiation of the air by carrying
on board in his clothing and various
objects the finely pulverized dust of the outside
atmosphere.
Another important cause of the chemical
and physical vitiation of
the atmosphere
lies in the heat and electric motors.
The heat motors
produce
chemical changes
with
their
products of
combustion
and
with the gases thrown off into the atmosphere
by the fuel carried on
board.
The fuel employed
for the heat motors
is composed of the residues
of the distillation of petroleum,
the principal
products of combustion
of which are carbonic anhydrid
and water vapor, while the secondary
products
are
oxide of azote
(which
is subsequently
converted
into
hypoazotite),
nitrous or nitric acid, methane,
acetylene,
and various
other substances.
The gasoline
tanks are closed hermetically, hence
theoretically
no loss from
them should take
place.
In actual prac
tice, however, small quantities of gas escape from joints of the tubes
and valves and
become mixed with
the inside air.
When
the sub
mersible
is in confmunication
with
the
external
air,
the
gasoline
vapors
escaping
from the tanks and the products of combustion
are
quickly expelled
outboard by the exhaust ventilators,
so that the air
is completely changed
at frequent intervals;
but if submersion
fol
lows
immediately
upon
the
stopping
of
the
engines,
there
is
no
time
for
completely
renewing
the
air,
which
therefore
remains
vitiated.
Electric motors
vitiate the air by the functioning
of the accumu-
.
lators.
The reaction of sulphuric
acid on the metal
develops hydro
gen, which in part reduces the sulphuric
acid, with
the production
of sulphureted hydrogen and sulphurous anhydrid,
and is in part set
free.
The
storage
batteries
are inclosed
within impermeable
boxes
from which
the
gases
are carried
directly
outboard by means of
4539—22—4
598
BELLI —HYGIENE
OF
SUBMERSIBLES.
Vol. XVII
proper ventilators ; consequently,
except in case of damage or break
age, these gases can not be given off into the surrounding air except
in a minimum quantity.
Finally,
a chemical
vitiation of the air is produced by the lubri
cation of the machinery, which is accomplished
with heavy
mineral
oils introduced into the parts in motion to diminish
wear
and
for
the purpose
of saving motive
force which would otherwise
be
lost.
These
oils distill at a temperature
above 200° C.
They
constantly
contain, however,
a greater
or less quantity
of light oils having
a
lower boiling
temperature,
which
in
contact
with
the
superheated
parts of
the
engine
become
gaseous
and
mix with the
surround
ing air.
The physical change in the air produced by the functioning
of the
heat and electric motors consists in the elevation of the temperature.
The
consumption
of
gasoline varies with
the
speed;
its calorific
power is very high, namely, 1,136
calories,
so that at cruising
speed
several
hundred
thousand
calories
are
developed
per
hour.
The
greater
part
of
the
heat
energy
is
transformed
into
mechanical
work, but
a portion
is given off into the surrounding
space.
The
same thing happens with the electric motors.
The mechanical
energy
furnished by the electric motors does not correspond to the
energy
consumed.
A portion of the latter, about
0.17 of
1 per cent, is trans
lated into the development
of heat, which increases
the temperature
of the inclosed spaces in question.
In
a submersible
of large
dis
placement
there are developed jn this way more
than 10,000 calories
per hour.
Ordinarily
the storage
batteries
are charged
at the elec
trical stations on shore and are placed
on board already in a charged
state, so that the development
of heat in discharging is a minimum,
and
the surrounding
temperature is therefore not
increased
in this
way.
This is not the
case
when the
storage
batteries
are charged
on board,
because in performing
this operation the temperature of
the jars is increased
and heat is given off into thf surrounding
air.
The ventilators carrying
off hot air lower the temperature unless
submersion
takes
place
immediately after stopping the motor.
Secondary
causes of
physical
and
clinical
changes
in
the
air
reside
in artificial
illumination,
the varnish
of surfaces,
the
escape
of compressed
air, and ventilation.
Illumination
is accomplished
by
means of
incandescent
electric
lamps,
which entail
a slight
increase
in the temperature of the air
by the radiation
of heat.
In fact,
a 16-candlepower
lamp
radiates
40 calories per hour, so that supposing there
were
50 lamps giving
out radiation
there would
be about
2,000
calories per hour.
The
sheet
metal
is
coated
with
lead
and
covered
with
enamel
varnish
which
is likely to become oxidized,
thus drawing
oxygen
from the air.
No. 4.
599
BELU —HYGIENE
OF
SUBMERSIBL.ES.
During
the
maneuver
of emersion,
while
ballast water
is being
exhausted
by
compressed
air,
an
amount
of air
escapes
which,
though slight, is still sufficient
to cause an increase of the pressure
of the inner atmosphere.
Immersion
is regulated by means of
a compensating tank located
beneath
the floor of the control room.
Two air exits are provided
from the tank, and
during
immersion
the air exhausted
from
the
intervening
space
is replaced
by
an
equal
volume
of
water.
If
the tank
is allowed to remain empty
for
a period of time
the air
is vitiated
by the gases arising
from putrefaction
of the
sea water
remaining
on
the
floor, and
the introduction
of this air into the
interior of the boat causes chemical changes in the atmosphere
and
increases
the barometric pressure.
Finally,
ventilation
by means of the
outside
air introduces into
the submersible the fine dust held in suspension
in the atmosphere.
The process of deterioration of the air is not continuous ; the chem
ical
changes
depending upon the biological
functions of man
are
constant;
on the other hand, those proceeding from the running of
the engines are produced in proportion
to the amount
of the latter,
considered in terms of the duration of functioning
and the tempera
ture attained by the parts of the machinery.
Therefore,
in every
operation
of the
submersible
three
periods must
be distinguished:
In the first period navigation takes place
at the surface, and there
fore the changes in the air are caused by the heat of the motors
; in
the second
period the submersible
navigates beneath
the surface of
the water where the changes in the air are caused by the heat motors
and batteries ; finally, in the third period, in resuming ordinary navi
gation, we return to the first condition.
Therefore, not only are the
changes
different in the three periods, but in the second the changes
of the first persist in part, to which
are added
those proper to the
second
period ; the same
is true of the third period with
respect
to
the two preceding ones.
Kind of changes in the air and their value. —The changes caused by
man
are
based
on
physiological
data
and
can
be calculated with
sufficient approximation.
On the contrary, the physical
and chem
ical modifications derived from motors and other above-mentioned
causes are variable inside of wide limits and may
be ascertained
only
through
direct investigation.
Complete researches
were effected by
Belli
in
a series of collaborations
with Trocello,
and
again with
Olivi, in which the results obtained were very nearly coordinate.
Organoleptic
properties.—The air in
a submersible
after
several
hours of immersion develops
a special odor, differing from the musty
odor of an inclosed compartment on land
in that it irritates
the
mucous
membrane
because of the presence of sulphureted anhydrid
600
Vol. XVII
BELLI —HYGIENE
OF
SUBMERSIBLES.
developed
by the batteries
and hydrocarbonates escaping
from the
motors by explosion.
Physical characteristics.—The
physical
changes
of the air
have
on the whole a limited importance.
Temperature.—The
temperature
upon first
immerging
is raised
from 2° to 3° C. above the external temperature,
but tends afterwards
to a thermic equilibrium with the various surroundings
and with the
water round about.
The reason for this fact is found in the physical
conditions of the submersible
with
respect to its external surround
ings.
The hull is of steel, one of the best of heat conductors,
and is
surrounded on all sides (during immersion) by a liquid medium that
possesses
a great capacity for heat; therefore from the walls there will
be a strong caloric dispersion into the surrounding
water.
The ini
tial increase
is due to the heat from the gasoline
motors; but with
the hull closed and immersed,
notwithstanding
the great radiation of
heat from the several
sources
(machinery
and men), the dispersion
of heat is such that the temperature
of the air is principally domi
nated by that of the sea water,
with which the internal atmosphere
tends to put itself in thermic equilibrium.
Immersions are made
to
a depth
of from
20 to 40 meters, where
the temperature of the sea
water is influenced
by the seasons.
In Italian
seas the temperature of the water near by and round
about
is slightly
higher than the air above;
this explains why
the
temperature
of the submersible
is higher than that of the external air
measured
before
immersion.
The
temperature,
then,
is maintained within limits
tolerable
to
the human organism.
In temperate
seas,
during
immersion in the
cold season, the air in a submersible
is rather cold ; but keeping warm
is not difficult with
suitable
clothing
and through
artificial
electric
heating.
In the summer
season the temperature does not often go
higher than 30° C. and, being accompanied
by a high degree of at
mospheric
humidity,
causes great discomfort,
as in places oppressed
with
a hot-humid
atmosphere.
The air in proximity
to combustion
motors
is hotter than in other portions of the vessel and ventilation
tends to spread this heated air, at least when immersion follows imme
diately upon the stopping of the motor.
Humidity.— The relative humidity
increases up to 90 per cent and
over, reaching at some
points saturation,
as is demonstrated
by the
tiny drops of moisture condensed
on the walls.
The increase
is not
so great
as it should be when based on the water vapor calculated
to
be normally thrown
off by man.
The reason for this, however, has
not been
determined.
Every opening which
would permit
the
entrance
of outside air
is closed,
hence the water vapor,
a product of the various
degrees
of humidity
on board, accumulates
in the internal
atmosphere.
No. 4.
601
BELLI—HYGIENE
OF
SUBMERSIBLES.
The
interior
of
the
submersible
being
restricted,
the
air
can
absorb only
a limited
quantity of water vapor.
For this
reason,
in the cold season, the temperature
of the air being low, saturation
is
accompanied
by
a relatively
low
degree of water vapor.
The
increase, however,
when the immersions are of brief
duration
and
in
the winter
has but slight
effect upon the organism.
When
the
immersions
are made
in the summer
season, with
the temperature
higher than 30° C, the excessive humidity
of the air causes a feel
ing of annoyance
when
the stay below water is protracted beyond
a
certain period.
Barometric
pressure. —The
atmospheric
pressure
increases
with
respect
to its environment from
10 to 30 millimeters, but the varia
tions are less regular and constant
than those of temperature.
The
increase of
pressure
may
be
attributed
in
part
to
the
escape of
hydrogen
and other
gases from the electric storage
batteries,
but it
is principally
derived from
the escape of compressed
air from the
air tubes and
valves.
At the moment
of emersion,
before opening
the small doors, the air valves are opened, which gradually
places in
equilibrium the internal and external
pressure, thus avoiding sudden
pressure changes.
Chemical composition of the air.—The chemical
changes
are much
more important
than the physical
ones.
The
chemical
composition
of the atmospheric air undergoes
quantitative
modifications
in its
normal
components,
and
qualitative
ones through
the
addition of
gaseous impurities.
The variation
of these components
is represented
by the diminu
tion of the oxygen
and an increase of the carbon dioxide.
Oxygen. —The percentage
of oxygen in the air undergoes
a dimi
nution greater than the consumption of oxygen
by the processes of
organic combustion through the men of the crew,
because a portion
of the gas serves for other
oxidations,
especially
for
those of the
hydrocarbons
of the motors.
The diminution
is proportional
with
the duration of immersion, and
a minimum
percentage
of
18 was
noted in an experiment of Belli and Olivi after 6 hours of immersion.
With the successive renewals of air (always in the position of immer
sion) the percentage
increased
to about
19 and fluctuated
around this
figure for the rest of the experiment; that is to say, for the next
18
hours.
It may then
be maintained that with normal immersions the
quantity of oxygen remains
sufficient for respiration, it being ascer
tained
in physiology
that asphyxiation
occurs
only
when
the pro
portion of oxygen in the air falls below
3.5 per 100, which can only
happen in case of mischance.
Carbon
dioxide.—The
proportion
of
carbon
dioxide
varies
ac
cording to whether the men work or remain in repose.
With
the
diminution of oxygen,
the increase of carbon dioxide is greater than
602
Vol. XVII
BELLI —HYGIENE
OF
SUBMERSIBLES.
that dispersed
in the air through the process of respiration,
because
there exist other causes than that of animal respiration.
In the ex
periments of Belli
and his collaborators the increase
was
gradual
and reached
the proportion of 31 per 1,000 after the first 6 hours
of
immersion.
The experiment was protracted for 24 hours; but after
6 hours the
physical-chemical
state of the air became
almost
in
tolerable (because it was the month of July)
and the air was renewed
about
every
5 hours.
After every renewal the proportion
was
low
ered between
13 and
17 per cent, rising promptly
to its first figure
and reaching at the end of the experiment, after
24 hours, 37.2 per
1,000.
The
increase
was without
doubt
significant;
however,
no
alarm
ing
toxic
phenomena
were
observed.
This
knowledge
assumes
a
special
importance even for general
hygiene, inasmuch
as it demon
strates
that with
a proportion
of carbon dioxide
of
37 per
1,000
man can live and attend to a certain amount of work.
Gaseous impurities. —The gaseous impurities,
represented
by gases
extraneous
to atmospheric
air, are as follows
:
Indifferent: Hydrogen.
%
Unbreathable
: Sulphurous
anhydrid.
Poisonous : Hydrogen
sulphid, chlorine, hydrocarbonates, car
bonic
oxide,
ammonia,
nitrous and nitric anhydrid,
arseni-
ureted
hydrogen,
organic
gaseous
substances
of
an
inde
terminate nature.
Hydrogen. —The
presence of hydrogen may
be presumed
because
of the functioning
of the electric storage
batteries,
since hydrogen
is derived
from
the same chemical
reaction from which
originates
sulphurous
anhydrid
and
sulphureted
hydrogen,
as
demonstrated
by the
researches of Belli
and his collaborators.
Hydrogen
is in
different
to
the
human
organism
and
produces
no harm through
inhalation, but it is dangerous
because in certain proportions
(from
9 to
66
pet- cent)
it forms with
the air an
explosive
mixture.
Sulphurous
anhydrid. —Sulphurous
anhydrid
produces
a
very
powerful
effect
on
the
organism, especially
when
combined
with
air to
be breathed.
In air which contains 0.05 of
1 per cent of
it,
animals can not breathe
without suffering, and with
a
dose of 0.24
of
1
per cent
a
rabbit
is
killed
in about
4
hours.
In the researches
cited
above,
a
maximum of 0.314 gram per cubic
meter of air was
demonstrated
after
20 hours,
a
small quantity, but sufficient
to
ex
plain,
in combination
with
the
other
poisonous
gases, that
slight
feeling of suffocation which gives warning
during
a
prolonged
im
mersion.
Sulphureted
hydrogen.—Sulphureted
hydrogen
is
also
a
most
poisonous
gas, killing
a
dog in an atmosphere
containing
0.125 of
No. 4.
603
BELLI —HYGIENE
OF
SUBMERSIBLES.
1 per cent of it.
In submersibles
it has been found in the proportion
of 0.00049
gram per cubic
meter
of air,
a quantity
which
can not
affect the health.
Chlorine. —Ordinarily
chlorine
is completely absent; in
case
of
accident
it is produced
by the penetration of sea water inside the
electric storage
batteries.
The escape of chlorine is very dangerous,
as it is highly noxious in the proportion of
1 to 10,000.
Hydrocarbonates. —Hydrocarbonates
collect in quantities of 0.1449
gram
per cubic meter
of air.
This quantity
is already
found
at
the beginning of immersion, and neither increases or decreases when
immersion is prolonged— a sign that it is produced mainly through
the gasification of gasoline in motors
as well
as from the lubricat
ing oils.
The chemical composition of the derivatives of petroleum is varied
and their toxic power is in correspondence
therewith.
The poison
ous effect depends upon the dose and upon the duration of inhalation.
The quantity found was so small as to produce
but slight effect even
if it were of the most poisonous quality.
Carbon monoxide, ammonia, nitrous and nitric anhydrid. —These
have been absent in all researches.
Arseniureted
hydrogen.—Arseniureted
hydrogen
may
be
present
because of abnormal reactions from the batteries.
It is a toxic gas
in the proportion of 1 to 100,000.
Giordano
has
observed
two
almost
simultaneous
instances
of
poisoning from
arseniureted hydrogen
on board two submersibles.
They were
equipped with
storage
batteries, which
were
not only
unprovided with air-tight tin covers,
but also
the ventilating
hole
on the inside of the box was in direct communication with
the sur
rounding air.
The lead
plates
were enveloped
by asbestos sacks, in
order to prevent, under the action of the movement
of the
vessel,
the crystals of lead oxide, which particularly
form in positive plates,
from
falling
to
the
bottom
of the
box.
A chemical examination
demonstrated
the
presence
of arsenic in the asbestos and traces of
arseniureted
hydrogen
in
the
air
during
the
functioning
of
the
storage batteries.
The presence of arsenic
in asbestos which is of
recent manufacture and used for the first time might cause a throw
ing off of arseniureted hydrogen
as well as hydrogen
alone.
With
the successive
charges
and discharges of the storage batteries
the
greater part of the arsenic
is eliminated and, as has been proved on
experimenting
with
animals, the small portion
which still escapes
does no harm.
Similar
cases of acute poisoning from arseniureted hydrogen have
been
observed
on
a French
submersible
after
two consecutive
im
mersions, each of 18 hours.
An examination of the air of the sub
604
Vol. XVII
BELLI —HYGIENE
OF
SUBMERSIBLES.
mersible
revealed
the presence of arseniureted
hydrogen
developed
from the batteries
of the accumulators.
Other cases have been noted upon English submersibles,
caused
by
the use of lead plates or of sulphuric acid containing
arsenic.
The
development
of toxic gases takes
place particularly during
the charging of batteries.
To avoid the development
of arseniureted
hydrogen
it
is
necessary
to
employ
lead
free
from
arsenic,
and
sulphuric
acid which contains not more
than
0.0008
part of it by
weight.
In all
cases
it
is necessary
to thoroughly
ventilate
the
battery an hour before the charging of the accumulators and while
in
use.
Atmospheric
dust. —This is made
up of those mineral,
vegetable,
and animal particles which in small quantities impregnate the atmos
phere, causing no special
effect. It is of minimum quantity.
Organic substances of indeterminate nature having a toxic effect. —
An individual
who remains in a hermetically inclosed
space admitting
no outside atmosphere
suffers disturbances which grow from a simple
feeling of discomfort to the gravest
symptoms
of asphyxiation.
The cause of symptoms produced in confined
air is not definitely
known, and various hypotheses
have arisen in explanation.
Sanarelli,
Biffi,
Hermans,
and
several
others
are
of
the
opinion
that
the
poisons
found
may
be due to processes of putrefaction
thrown
off
by
the skin,
from intestinal
fermentation,
from
disease conditions
(ozena,
fetid
breath,
dental
caries,
etc.).
Other
authorities, while
admitting
the
formation
in
the stagnant air of malodorous
com
pounds,
deny
that
they
may
have
any toxic
effect
and
that their
quantity
is such
as
to
cause
symptoms.
Wolpert
. holds that
the
phenomena
are
due
to
the
diminution
of
the
quantity
of carbon
dioxide
eliminated
from
the
crowded
compartments.
.
Weichardt
attributes the disturbances
found in the inclosed
spaces to the waste
products analogous
to the colorless,
odorless toxic gases formed under
fatigue.
Fliigge
excludes
the
presence
of toxic
products
and
at
tributes the cause of the symptoms to physical
factors in the sur
roundings, such
as increase of heat, humidity,
and immobility
of the
air.
.
,
On Italian submersibles
no serious disturbances have been observed.
The men confined
for long hours inside the boat
experienced
only
cephalgia
and
mental
torpidity,
occasionally assuming
the form of
complete
lethargy.
In
the
confined
atmosphere
of
a
completely
submerged
submersible
a considerable
quantity of carbon dioxid
is
accumulated; and sulphurous anhydrid,
sulphureted hydrogen, and
hydrocarbonates are present.
There
are likewise
present
in a con
siderable
degree the physical
factors mentioned
by Fliigge (immo
bility of the air and its high thermic and hygrometric quality).
This
to me seems
sufficient
to explain the symptoms.
No. 4.
605
BELLI—HYGIENE
OF
SUBMERSIBLES.
Predominance of the various air changes in different localities.—
The
physical-chemical
state of the air differs in various locations,
according to the number of men and the kind of machinery and ap
paratus on
board.
In the torpedo and control
rooms
the
changes
of the air are principally due to the presence of persons.
In the
combustion
and electric-motor rooms they are to be attributed to the
combustible
and lubricating
oils for the engines, and in the accumu
lator space to the chemical
reactions
of the accumulators.
However,
the differences
between the communicating rooms
tend to disappear,
because inside a closed boat the air becomes rapidly
mixed
through
the
law
of the diffusion of gases
and
by
means of differences
in
temperature.
The difference
is maintained, in particular
localities,
because of the different densities of gases,
hence carbon dioxid, which
is heavier than air, collects in the lowest parts of the rooms.
3. Index of the limiting factor of the changes. —The changes of the
air during immersions
of brief
duration
have
no injurious
results
and in no way threaten
life;
however,
when
the time
is prolonged
it may reach
such
a point
as to bring
serious
danger.
A criterion
which
might warn
the crew of the approach of danger would
be,
however,
of the highest utility.
The quantitative modifications of oxygen
and of carbon dioxid are
not constant,
and still less constant
are the gaseous impurities thrown
off into the atmosphere
of submersibles.
We can not therefore fix
basically the physiological
data nor the experimental results
of the
maximum
duration of immersion.
In dwellings the sense of smell
gives warning that the impurities
of the air have reached
the limit of tolerance
of the human
organ
ism ; but this sense,
although very keen, is dulled when
exposure
is
protracted
for any length of time and especially in' an atmosphere
containing
gases which
have different effects,
so men who are
con
fined in submersibles
do not receive this physical warning of immi
nent peril.
In
default
of olfactory
warning,
small,
warm-blooded
animals
may
be
employed,
such
as
rats,
guinea
pigs,
and
pigeons.
Upon
the first submersibles
it was customary
to carry small rats in cages,
,
as their
death
gave warning of the beginning of danger for man,
who would then have a chance to escape.
As a matter of fact, rats
are very sensitive
to toxic gases (especially carbonic oxide)
and die
in
10
minutes
in
an
atmosphere
where
a man
may
live
an hour.
In
the
experiments
of
the authors quoted
above
the
rats
did
not
give
any sign of suffering,
so that this physiological
check proved
the result of the chemical
research
as to the absence
of carbonic oxide
from the air.
The indication
given by the
death of the
rats
may
be late in manifestation, hence this method
often fails
in its aims.
On
the other hand, on recent
boats,
the danger of carbonic oxide
being eliminated, the need of animal proof is obviated.
606
Vol. XVII
BELLI—HYGIENE
OF
SUBMERSIBLES.
The proof of
a lighted
candle
going
put
in this
atmosphere
is
valueless,
because in
an
atmosphere
harmful
to man
there
is still
enough oxygen to feed the flame.
On shore our only index of impure air is the presence of carbon
dioxide in dwellings,
and
the maximum limit is fixed as
1 part to
1,000.
May not the same index be adopted for submersibles
?
If we consider only the carbon dioxide thrown off by the respira
tion of man, in a little over a half an hour in a submersible
of average
size the limit is attained.
The net air capacity of a submersible
for
maintaining
life would permit of immersion of less than an hour.
In actual practice, however,
it happens
otherwise.
Kespiration
in
side
a submersible
during immersion is not as agreeable
as when
in
a balmy wood, but experience
demonstrates
that it is possible
to live
and work there for several hours without appreciable suffering.
The
reason for this apparent contradiction
is not hard to trace.
The
maximum quantity of 1 to 1,000 of carbonic dioxide admitted by the
hygienists does not represent
the limit of tolerance
for this gas, but
it has been assumed
as the easiest appreciable exponent
for the com
plex changes which the air undergoes
in the confined surroundings of
dwellings on shore.
The vitiated air within a confined
space may
become harmful in
two ways: By slow and
continuous action in the form of chronic
poisoning, or by the rapid action of acute poisoning.
In the first in
stance there will be a lowering of hematosis, of nutrition in general,
and of all vital
powers of the organism.
In the second
case, acute
asphyxiation
is brought on, as in the tragedy of the Black Hole of
Calcutta, in which out of
146 prisoners after
8 hours' confinement,
there
came out alive only
22;
and
that of the boat
Londonderry,
where, out of a crew of 200, 72 died.
The measure of carbon dioxide was proposed
by Pettenkofer
as an
expression
of the degree of purity of the air in dwellings for a pro
longed
and continuous sojourn;
on the contrary, the limit of toler
ance of carbon dioxide for a brief sojourn is very much higher
as
demonstrated
in
the personal example
of Pettenkofer,
who stayed
several hours in an atmosphehre
of 10 to 1,000 of carbon dioxide with
out discomfort, and that classic incident of the chemistry hall of the
Sorbonne with
a proportion of carbon dioxide of 10 to 1,000, and, to
remain in the field of naval hygiene,
that of Belli and Trocello in the
dormitories of the torpedo chasers,
11 to 1,000, without apparent dis
turbance
to the crew.
In dwellings
on land the content of carbon dioxide
has been
se
lected as an index of the corruption of the air, because of the suppo
sition that the substances constituting the true changes, and especially
the
supposed
volatile
toxins
emitted
with respiration,
proceed
co
No. 4.
607
BELLI —HYGIENE
OF
SUBMERSIBLES.
equally with the quantity of carbon
dioxide ; but the parallelism
be
tween the carbon
dioxide and the other gaseous impurities
does not
exist,
and
the contrary
is, moreover,
the
case.
In submersibles
the
factors which change the composition of the air, whether with regard
to the modifications which occur or from the point of view of the loss
of purity, are not the same as with dwellings on land, for the reason
that the proportion of carbon dioxid as an index of the contamination
of the air can not be fixed on a scientific basis.
At all events, wishing
to accept this criterion, we must raise the limiting factor at least to
15 to 1,000, which corresponds
to about half the maximum quantity
encountered
in the experiments
above cited,
as also half the amount
endured by divers (30 to 1,000).
The criterion for determining the amount of oxygen
needed during
immersion has also no scientific basis, inasmuch as when
the air has
become quite
heavily
charged
with
carbon
dioxide the quantity of
oxygen which remains is amply sufficient
to maintain life.
On
which
account
the apparatus for the
extemporaneous
deter
mination of the oxygen
and the carbon
dioxide of the air introduced
in the submersibles
merits little
confidence,
and furthermore, being
founded on colorimetric
reactions,
gives
results
which
are not very
exact.
In my opinion it is possible to determine
when it is time to renew
the air without employing any instrument.
In
the
experiments
on submersibles
it has
been
proven that the
crew begins to feel discomfort from the confined
atmosphere
when
the proportion
of carbon
dioxide
reaches
20
to
1,000.
To remain
after
that
time
within
physiological
limits,
it
is
proper
to
put
in operation
the
means of renovation,
when
the gas which
serves
as an index shall have reached
15 to 1,000.
Calculating
upon physi
ological data, the quantity of carbon
dioxide given off in breathing
by a crew in relation to the atmosphere of the submersible,
the above
proportion of
15
to
1,000
is reached
on an average
in from
6 to
8
hours,
after which
a renewal
of the air
becomes necessary.
A criterion
of greater approximation
may
be
had
by making
a
calculation for every individual
boat.
A man, working
moderately,
as on board a submersible,
gives off into the air 23 litters of carbon
dioxide
per hour.
Thus we may establish
after x number of hours,
that the air contains
the aforesaid quota of 0.015, through the follow
ing formula, in which v is the number of persons
embarked,
c is the
cubic contents of the submersible
:
23Xn:tf=0.015:a?;
0.015 Xc
hen0ea?=-23xF
608
Vol. XVII
BELLI
HYGIENE
OF
SUBMERSIBLES.
Example
: Given a submersible
of 500 cubic meters
(500,000 liters)
of air, with 36 persons in the crew
:
0.015 X 500,000
_
x= -
—o
23X36
that
is,
we should take steps to renew the air after
8
hours of immer
sion or better,
9
hours from the last complete
renewal of inside air.
VENTILATION.
X.
METHODS
OF VENTILATION.
The greatest obstacle to underwater navigation, from the personnel
point of view,
is
the difficulty of remaining inside the boat when
it
is
in
a
state of immersion.
Thus the hygiene
of submersibles
con
sists, above all, in the study of the factors of habitability
under all
of its
aspects.
Among
these
factors
the
predominant
one
is
the
renewal of respirable air.
Submersibles make use of two methods of ventilation, natural
and
mechanical.
Those
used
in navigating
above water
are
the
same
as
the
methods
employed
in the ordinary
torpedo -boat;
those
for
navigation
beneath
the water are proper to the submersible.
The
means of admitting
air,
analogous
in all
the types
of sub
mersibles,
are the following
:
(a)
The hatchway.—This
is
a
means of entrance
to the inside of
the boat,
and at the same time
gives
ventilation
and
illumination.
One of circular
form opens on the conning tower, between the two
periscopes,
and
gives
entrance
to
the
engine
room.
Others,
ordi
narily three in number,
open on the upper bridge, the first and the
last into the fore and after torpedo-launching
rooms,
respectively,
the middle one into the electric motor room.
The hatchway of the conning tower may remain open when
navi
gating above water,
and the others ordinarily must
be kept closed.
(b)
Ventilation
tubes.—Several of these, varying
in number, are
assigned
to the ventilation of the
combustion
motors and
are
com
parable
to
the
various
pumping
or
exhaust
artificial
methods.
Among these tubes, two rise
3
meters above the upper bridge and are
near the periscope
tubes; therefore, to distinguish
them,
it
is
useful
to
indicate
them
by the
term " para "
periscope
tubes
(paraperi-
scopici).
During complete
immersion they
are closed by means of
a
sliding valve;
but the part which
remains above this fills
with
water which, on returning
to the surface,
is
ejected by means of
a
jet of compressed
air.
Two or
more
serve for the
extraction
of
pases emitted
from the accumulators.
Other
apertures
are made in the hull for discharging
torpedoes,
for the telephonic buoy,
for the siren, for radiotelegraphic
cables,
for periscopic tubes, for the expulsion of gases from thermal motors,
No. 4.
609
BELLI
HYGIENE
OF
SUBMERSIBLES.
but they have no hygienic purpose
and do not serve for ventilation
or
as passageways.
Mechanical
ventilating
devices
are
operated
by electric motors.
As
on
ordinary
boats,
the driving out and
drawing
in of air is
necessary,
both for respiratory
functions
and
for promoting
the
combustion of thermic
motors,
so that
the
crew
benefits
by
both
these factors.
In addition
to the above-mentioned
devices, there is
a special one having
the hygienic function of carrying
off gaseous
substances
escaping
from
the accumulators.
The provision of air for navigation on board submersibles
in some
cases is by
a detached
system, in others
a system of centralization,
and in still others with two systems operating at one time.
The detached
system is used exclusively for the exchange of inside
air for outside
air, and
hence it is employed
when
the boat
is in
communication
with
the
atmosphere.
The
centralized
system,
in
addition
to the foregoing, performs
a second function, i. e., provid
ing for the circulation of air inside the closed boat.
The detached
system,
analogous
to that employed
on the ordinary
torpedo boat,
employs exhaust
and intake ventilators
placed
in each single com
partment,
without
any
intercommunication
one
with
the
other.
The
number of these ventilators, their length, and
the location of
their
outlets is arranged according
to regular navy criterion.
In
any event
an exhaust
ventilator
is necessary
in the toilet rooms.
The system of central ventilation
consists of tubing which leads to
all the inhabited compartments
and has two openings for each room,
one on one side for the introduction of air, the. other on the opposite
side for its extraction.
At the two extremities the tubing
is con
nected with two ventilators,
the pulsator
at the
bow,
the
exhaust
at the stern.
When
the hatchways are open,
putting
in operation
both ventilators at once, the pulsator sucks in the air from the nearest
hatchway, and sends it to all the compartments
; the exhaust ventila
tor, located
at the opposite
extremity, carries the air out through
the adjacent hatchway.
When the hatchways are closed the ventila
tors act merely as agitators, putting
the air inside the boat into cir
culation.
The
louvers of
the
pressure
ventilators
and the
intakes of the
suction ventilators open in the upper part of the rooms, contrary to
the rule of placing the louvers of the pulsators in the lower part and
the intakes for the exhausts
in the upper part.
The systematization
of the openings
of the upper part is convenient
when the centralized
system of ventilation is in operation with the boat immerged,
because
the movement of air remaining confined
to the upper strata, the car
bon dioxide
accumulated
below
is not disturbed.
On the contrary,
with the hatchways open, the scope of the ventilation is to completely
renew the atmosphere,
driving out the carbon dioxide and other im
610
Vol. XVII
BELLI —HYGIENE
OF SUBMERSIBLES.
pure gases.
The location of the intakes of the aspirating
ventilator
in the upper part of the room
is unsuitable, for the reason
that it
leaves in the lower part zones of stagnant air.
Under
these circum
stances, in order to also renew
the air in the lower part and remote
from
the
intakes of
the
fixed
tubing,
there
are installed
flexible
sleeves which will enlarge the field of aspiration
of the ventilators.
As in the
engine
rooms
of ordinary
vessels,
a special
system of
1
ventilation
is installed in submersibles
to further the combustion of
the gasoline for the operation of the thermic motors in which
a large
volume
of fresh air, of great
benefit
to the
men, is introduced
by
electrically driven apparatus : pulsators which introduce the air into
the compartment,
exhausts
which draw the air from the rooms
and
expel it outside.
The quantity of pulsator ventilators is much greater
than that of the exhausters,
because
a large quantity
of air is em
ployed to drive
the products of combustion through
the
tubes in
tended to carry them off.
Electric motors
are
operated
in underwater
navigation;
that
is,
with the hull completely immerged,
and in partial
immersion when
the " para " periscopic tubes, although out of water, for reasons of
safety must be kept closed.
Consequently during the operation of the
electric motors there
is
no introduction of air from the outside.
It
is
an essential condition therefore that such motors may go on operating
in closed surroundings
without prejudice to the health of the crew.
From these motors when they are working,
there
is
developed
a
con
siderable quantity of heat, which raises the temperature
of the atmos
phere.
With the motors running while the submersible
is
immersed,
it
is
not possible
to utilize
ventilation
to lower the temperature
of
the atmosphere,
as on ordinary
ships.
Instead, three different meth
ods are
employed
for this purpose
:
One,
cooling by means of sea
water, another the intermixture
of the air of all the compartments,
and the third the employment of refrigerating
machines.
The cooling of the air by means of sea water
is
accomplished
by
using
a
ventilator
which sucks the air from the accumulator rooms
and
conveys
it
through
a
tube
across
the space between
the hulls.
Here the air gives off its heat and
is
cooled by the sea water, return
ing to the accumulator rooms at
a
lower temperature.
The cooling of the air by circulation
is
attained by
a
mixture of the
entire atmosphere
of the boat, brought
about
through
a
system
of
central ventilation
which
places in circulation
the air from all the
compartments in such
a
way that the hottest air of the electric-motor
rooms gives off heat to the cooler air of the other compartments
until
a
thermic equilibrium
is
reached.
The third method,
cooling by the refrigerating
machines,
was
at
first introduced to cool the batteries of the accumulators and finally
was extended
to the living places.
The air, by means of suction
ap
No. 4.
611
GALWEY
GAS WARFARE.
paratus.
is made to pass through the refrigerating
room, where it is
cooled and separated
from its water vapor, which is deposited
in the
form of brine.
In the refrigerating
room the air passes into circula
tion conductors, by means of which it circulates through all the com
partments.
The plant may also be operating when the boat lies on
the surface of the sea with the air from the outside
atmosphere
pass
ing through the refrigerating
room.
In large submersibles
there are
two plants, one for compartments
forward
and
the other for com
partments
aft.
This arrangement is very useful hygienically, inasmuch as it lowers
the temperature and the humidity of the air and does away with the
principal cause of disturbances
in confined
atmosphere.
A special system of exhaust
ventilation
has been devised
for the
electric
accumulators,
which
when
charging
cause the development
of toxic gases,
which develop,
too, although in an appreciably lesser
degree, when the accumulators are discharged.
The batteries are closed hermetically with air-tight
covers to pre
vent the gases from entering the atmosphere.
For greater safety, the
ventilating
system draws off the gases that are
set
free
and
expels
them outward.
GAS WARFARE— ORGANIZATION IN PEACE
AND
WAR.1
By MaJ. W. R. Gal wit, 0. B.
E.,
M. C, R. A.
M.
C.
Gas warfare
organization
in the British Army at the beginning
of the
use of this arm
was in much
the same status
as it was in
the other allied
armies.
Responsibilities
were divided
and policies
were
constantly
changing.
Offense
measures
were
first
under
a
branch
of the War
Office.
Defense
appliances
and
troop
protec
tion fell to the Army Medical Department, in which
a new section
was
created
for
the
purpose.
The
offense
had,
as
an
advisory
group,
the chemical
committee
of the Royal
Society, composed
of
eminent
scientists,
and
the
antigas
committee,
also
numbering
among its members
prominent
specialists,
functioned .in
a similar
capacity for the defense.
In May,
1915,
the Ministry of Munitions
was formed
and took
over
chemical
warfare
problems
of
research
and
supply,
but
the
antigas department was not transferred from the War Office to the
Ministry of Munitions
to become a section of the chemical
warfare
department until October,
1917.
At this time
a new advisory com
mittee —the
chemical
warfare
committee —was
appointed.
It
con
sisted of practically
the same persons
who had
been on the former
committee.
1Reprinted
from
the Jonr.
Roy. Army
Med.
Corps,
April,
1922.
Abstracted
by
Lieut.
G. H. Maokin,
Medical
Corps,
United
States
Navy.
612
Vol. XVII
GALWEY —GAS WARFARE.
In
1916
the experimental station at Porton
was placed in
com
mission.
Here were carried on the large-scale
field experiments and
applied
research
into both
offensive
and defensive
measures.
Here
were studied the
physiological
effects of gas poisoning
as well
as
the pathology
and
the
methods
of treatment.
Abundant
proof
of the
wisdom of the
transfer
of
the
antigas
department
to
the
chemical
warfare
department has
accumulated
since
the time that it first became evident that any divorce of de
fensive
from
offensive
research
was
fatal
to
rapid
action
and
efficiency.
At the time of the signing of the armistice the chemical
warfare
department consisted of the following sections
:
(1)
Administrative
headquarters
in
London,
with
the
chemical
warfare
and chemical
designs
committees
attached
to it.
(2) An antigas section
at University College, responsible
for re
search
on
defensive
measures
and
the manufacture
and supply
of
all antigas equipment.
(3)
The Porton Experimental
Station for field work and applied
research on a large scale.
(4) A small-scale
experimental station at Wembley.
(5)
Research
for special
problems
at universities and other places
throughout the country.
Consequent
upon
the
demobilization,
the
organization
went
through
various times of stress, but was finally
reconstituted in its
present
form.
The chemical
warfare
department is now under
the
master-general
of ordnance
and
forms
a branch of the directorate
of artillery.
It is
a joint organization,
serving
the
needs of
the
three services —Navy, Army, and Air Force.
It is advised
on tech
nical matters by the chemical
warfare committee.
Many of the problems
of defense
are in the fields of hygiene and
physiology, but it must
be remembered
that gas-defense
administra
tion is not one of medical administration.
The following constitutes
the author's personal view of the mini
mum
medical organization
required
in
peace
time if
the British
Army is to be prepared for a future war.
The directorate of pathology in the War
Office
deals
more
par
ticularly with the medical aspects of gas warfare and keeps in touch
with its representatives
in districts at home and abroad.
The assist
ant directors of pathology and deputy assistant
directors of pathol
ogy are charged with keeping in intimate contact with all new work
in physiology, pathology,
and treatment
which will aid in bringing
about the most effective
care of gas casualties.
Similarly, the direc
torate of hygiene keeps its representatives,
the assistant
and deputy
assistant
directors of hygiene,
informed
of work
on
problems of
respiration
and physical efficiency
which bear upon the wearing of
No. 4.
613
GALWEY— GAS WARFARE.
defensive
appliances.
The
officers
mentioned
above,
in
connection
with the directorates,
should be required to pass on all information
*
in their
respective
fields
to
all medical
officers
and Royal
Army
Medical
Corps personnel.
He
feels
that
every
medical
officer
should
be required
to
go
through
the Army antigas school
or through
the experimental sta
tion at Porton.
As a distinctly
medical
problem, is mentioned
the matter of dis
infection of respirators.
It is pointed out that there is a real danger
of infection of this equipment
with
a variety of disease-producing
germs.
It is recommended
that either 1 per cent Izal solution or 2£
per cent cresol solution
be used asHhe disinfecting
fluid.
•
.
Another
matter of first importance
is the training of stretcher
bearers in first aid to gas casualties
and the instruction
of hospital
corpsmen in the treatment
of these cases, particularly in the adminis
tration
of oxygen
by the Haldane
method
to
a large
number of
patients simultaneously.
A diagram
giving
the
desirable
antigas
organization
for
war,
which seems to lend itself to reduction to moderate simplicity,
makes
provision
for the following:
At general
headquarters,
the director
of gas services
:
(1)
Offensive, Assistant
director of gas services
(with Special
Brigade
R. E.).
(2)
Defensive,
Assistant director
of gas services.
(3)
Central
laboratory.
At army
headquarters:
Chemical
adviser.
Assistant
chemical
adviser.
Army
gas
school
(two-day
course
for
staff
officers
niul
senior
regimental
officers).
At corps headquarters
:
Chemical
adviser.
Corps
gas
school for officers and
noncommissioned
officers.
At division headquarters
:
Division
gas
officer.
At headquarters,
line
of communication,
under
the direction
of the assist
ant director
of gas services
(defense)
:
Chemical
adviser.
Assistant chemical
adviser.
Base
gas schools.
The
medical
organization
consisted,
broadly,
of
one
or
more
casualty
clearing stations
for each army area,
a gas center
in each
division,
and
of certain
base
hospitals
set
apart for the
reception
and
treatment
of gas
casualties.
It was
designed
that
treatment
should
be supervised
by a consultant, specially conversant
with these
cases, at the base, and one or more consultants in the forward
areas.
There was liaison between
the medical
and
gas directorates at gen-
4539—22
5
614
Vol. XVII
GALWEY
GAS WARFARE.
eral
headquarters,
and
the central laboratory
for defense
research
- had a physiologist
on its staff.
The
author
suggests
that
both
casualty
clearing
stations
and
base
hospitals
should
have
special
arrangements
for
disinfection
of
clothing
and
for
the
administration
of
oxygen.
He
indicates
the
necessity
for the gas-proofing of motor
ambulances
as well
as
aid
posts
and
dressing
stations in the next war, and that, further,
this
new
form of warfare
is bristling with
new problems for
the
medical department whether on the side of protection or treatment.
He gives
a diagram of
a so-called
gas center
in
a field hospital.
It consists,
in the main, of three
long temporary buildings
placed
parallel
to one another and connected
by a walkway.
Two of these
buildings
were fitted up as wards, one for serious
cases
and contain
ing fittings
for
oxygen
administration,
the
other
for slight
cases
without
oxygen
installation.
The
third
building
contained
the
receiving, bathing, and dressing rooms.
The ward for serious
cases
was situated
between
the other two buildings.
The buildings
pre
sent
no particularly
new
features
with regard
to their interior ar
rangement and require no special description here.
Benjamin
Henry Latrobe,
HISTORICAL.
BENJAMIN HENRY LATROBE.
1764-1820.
THE DESIGNER
OF THE FIRST NAVAL HOSPITAL.
By
W.
M. Knits,
Lieutenant
Commander.
Medical
Corps,
United
States
Navy.
We pay
so little
attention in general to what
is going forward
on the
scene on which
we ourselves
are
actors
that when nov) and
then
a real story, unadorned
by fiction, is presented
to us in the
succession
of its circumstances,
we
are apt to fancy
it too full of
incident
and contrivance
to
have
passed
on
the tlieater of actual
life. I have mare than once made this observation in reading
my
old journals of trivial transactions, which had very little but truth
to recommend tliem.
In this respect
we are like actors of dramatic
scenes, who are
so engaged
with
their own parts that they
hardly
ever study
the performance of others.
We wait till our own act
comes, and then go on, as we have accustomed
ourselves
to do.
I have often intended
to
make
the recital
of some of my own
adventures an
amusement
of my leisure, but
whenever I have at
tempted
it
the
appearance
of
fiction
has
accompanied
many
of
the most positive facts.
Indeed, the general rage for novels, which
most frequently
recite very common
occurrences
but which we know
to
be invented, throws a false reflection upon every relation which
at all steps out of the common road.
The practice of keeping
a regular journal
was recommended
to
me very early in life by my father, merely
for the sake of irriting
down my
ideas
with
ease and correctness,
for
he
recommended
at
the same
time
that I should at
the close of every
year extract all
the generally
useful
facts and burn
the
remainder.
I
have
fol
lowed his advice
at intervals ever since I was a boy, both in writing
and burning
my journals.
Since my arrival in America I have in
a great
measure
altered my plan of a diary
into
a collection of
observations and a record of facts in which my personal interest and
actions were not immediately concerned?-
B. H. L.
1 Foreword of the Journal
of Latrobe.
615
616
Vol. XVII
BENJAMIN
HENRY
LATROBE.
Benjamin Henry Lutrobe was the youngest
son of the Rev. Benja-
mine Latrobe, a clergyman of the Moravian
faith, and Ann Margaret
Nutis, the daughter of a gentleman
of Pennsylvania.
The Latrobes
were of old French stock, having emigrated to England from France
during
the persecution
of the Huguenots.
Miss Nutis had
been
sent
from Pennsylvania
by her
parents,
who
were Moravians,
to be edu
cated
in Germany
and
meeting
the Rev. Benjamin
Latrobe
while
there, they were married about the year 1755.
The childhood of Benjamin Henry Latrobe which, until
11 years
of age, was spent chiefly at school in Yorkshire, was marked for his
fondness for drawing, and he early attained
a correctness
of percep
tion
and
a force
and
facility
of
delineation
which
are
generally
acquired
onty after years of practice.
When he was
12, he was sent
to Saxony, to a Moravian
seminary, where
he remained
until he was
prepared to enter the University of Leipsic
where
he remained
nearly
three years.
During this time
he was a diligent
student
and devoted
himself to the acquisition of that knowledge which he believed
would
be useful to him in later years.
In
1785,
when
in his eighteenth
year,
he left Leipsic
and
spent
some months
in traveling
through
Germany.
The
following
year
he returned to England
and established
a residence
in London.
He
adopted
architecture and civil engineering as a profession, and
con
centrated
all his energies upon the acquisition of practical informa
tion concerning these sciences.
His father's friends in London
were
influential,
and he gained ready
access to the best society of England,
forming
friendships
and acquaintances
with the distinguished scien
tific men of his day.
He became intimate with the celebrated
Smea-
ton,2 who, although retired from the active practice of his profession,
gave him the benefit of his advice
and vast experience.
3 John
Smeatoo,
an English civil
engineer,
was
born
at
Austhrope,
near
Leeds.
York
shire,
June
8,
1724,
and
died
there,
October
28,
1792.
At an
early
age
he
showed so
Inclination
toward
mechanical
contrivances
and
when
16
he
became
apprentice
to
a
philosophical
instrument
maker,
and in
1700
set
up In
business
on
his
own
account.
The
following
year
he
began
a
course of
experiments
on
a
machine
of
his
own
In
vention
to measure
a ship's
way at
sea.
In
1753
he was elected
a Fallow of the Royal
Society.
In
1755
the Eddystonc
Lighthouse
was burned down, and Smeaton was Intrusted
with
the task of rebuilding
it.
Operations
were begun
in
August,
1756,
and
completed
in October,
1759.
This
lighthouse
remained
in
use
until
1882,
when it
was
replaced
by a new
structure.
Besides
improving
various
mathematical
instruments
used
in
navi
gation
and
astronomy,
he
carried
on
experiments
in
regard
to other
mechanical
appli
ances,
among
thorn
investigations
of
wind
and
water
mills for
which
he
received
the
Copley
medal of the Royal
Society in
1759.
After this,
Smeaton
was employed
on many
works
of
great
public
utility,
tie
made
the
River
Calder
(In
Yorkshire)
navigable;
planned
and executed
the Forth
and
Clyde
Canal
in
Scotland,
constituting
a
waterway
for traffic
passing
between the Atlantic
and
the North
Sea.
He
improved
various
har
bors :
designed
and
erected
several
bridges.
He
built
a
steam
engine
at
Austhrope.
and
made
experiments
with it
to ascertain
the
power
of
Newcomen's
engine,
which
he
brought
to
a greater
degree
of perfection,
both in
Its
construction
and power.
Snieston
spent much of his leisure
in
the study of astronomy,
for which
purpose
he
fitted
up an
observatory
in his
bouse.
No. 4.
BENJAMIN
HENRY LATBOBE.
617
In
1788 Latrobe
entered
the
office
of Mr.
Cockerell,8
one of the
leading
architects of London,
where
his classic education, his skill
with
the pencil, his profound
mathematical knowledge, and his ac
quaintance
with the architectural
features
of the great buildings
of
Germany
and France
gave him a decided
advantage
over
the other
young men employed
there.
In this office he soon acquired a prac
tical knowledge of drafting and architectural
calculation,
and,
be
lieving himself
competent
to commence
the practice of his profes
sion, he opened an office of his own.
He met with immediate
success
and was soon appointed surveyor of the public
offices
in London.
In 1790 Latrobe
was married
to Miss Lydia Sellon.
As a result
of this marriage two children
were born, a son and
a daughter:
In
1793
Mrs.
Latrobe
died.
Her death
affected
him profoundly;
and
although
he was at a period in his life when
his professional rela
tions in London
offered him every inducement
to remain in that city,
he determined
to leave England.
He had taken
a great interest
in
the new doctrines of government which were then being widely dis
cussed.
Taking the side of liberal principles,
he was among
those
who looked
to America
as
the
scene
of that great experiment in
government
which has since
been
so successfully accomplished; and
as his mother had been born in America
where
her relatives still
resided, he determined
to cross the Atlantic and to practice his pro
fession in the United States.
He completed
his business in England,
declined the office of surveyor to the Crown, with
a salary of £1,000
per annum, disposed
of his property, and on the 25th of November,
1795,
he left England.
On the 20th of March,
1796, after a passage of nearly four months,
Latrobe
landed
at Norfolk,
Va.4
After remaining several
months
at Norfolk, he went to Richmond,
where
he was employed
to superintend the erection
of a penitentiary
which he had designed
and which the legislature had determined
to
build.
He designed
many dwellings
which
were
erected
in Rich-
"Cockerell,
Samuel
Pepys
( 1754-1S27),
architect.
His
mother
was
a
daughter
of
John Jackson, the nephew and
heir
of Samuel
Pepys,
and through
her Cockerell
became
the representative,
and Inherited
many
interesting
relics,
of
the
great
diarist.
Cockerel]
soon
rose
to
eminence
in his
profession,
and
in
1796-1798
he
rebuilt
the church
of
St.
Martin,
Outwich,
London,
his most important
work.
He also
designed
several
large
and
handsome
residences.
One
of
his
sons,
Charles
Robert
Cockerell
(17S8— 186:!)
became
a far more distinguished
architect
than
his
father.
* In those days
the world
moved
slowly.
No change had yet
been
made
in methods
of
transportation
and
communication.
It
took
as
long
to
travel
from
London
to
Rome
as it did in the
time of Julius Caesar.
It Is interesting
to note In
this
connection
that
the nineteenth
century
was destined
to be the period of the world's
greatest
progress,
due
to
the
development
of
rapid
transportation
and
communicHWon
accomplished
by
steam
and electricity,
in which
some
of the sons of B. H.
Latrobe
took an active
part.
B.
H.
Latrobe,
Jr.,
was
for
years
the civil
engineer
of
the
Baltimore
&
Ohio
Railroad,
and
another
son,
John
Hazlehurst
Boneval
Latrobe,
was
the
head
of
that
organization's
legal department.
618
Vol. XVII
BENJAMIN
HENRY
LATROBE.
mond, Norfolk, and Petersburg.
He was employed
to examine
and
report upon the feasibility of the construction of the Dismal
Swamp
Canal
and
the improvement of navigation of the Appomattox
and
the James Rivers.
His services
as a geologist and mineralogist
were
frequently in demand,
and he devoted
some time
to a study of the
geological features
of Virginia.
He traveled much throughout
the
State.
His acquaintances
were numerous,
his talent
appreciated,
his
society
sought;
ample
occupation was
afforded
him, and he had no
reason to regret the loss of the prospects
which he could have enjoyed
had he continued to reside in England.
On one of his many excur
sions through Virginia
he visited President
Washington,
at Mount
Vernon, an account of which will be found in his journal.5
He was a great admirer of beauty,
and his tribute to Miss Custis,
the grandchild
of Martha
Washington,
who
had
been adopted
by
Washington,
shows his high appreciation of that lady's good
looks.
He writes
as follows
: " Miss Eleanor Custis has more perfection of
form, of expression,
of color, of softness,
and of firmness
of mind
than I have ever seen before or conceived
consistent
with mortality.
She is everything that the chisel of Phidias aimed
at but could not
reach."
In 1798 Latrobe removed to Philadelphia, where he designed
a new
building
for the Bank of Pennsylvania.
This building
is the work
which
permanently
established
his professional
reputation
in this
country, and his performance is all the more remarkable in that he
did not have
access
to a single book on architecture from which to
obtain the proportions
of the type
to which
the building belongs.
The
vessel in which his library had been shipped to America
had
been taken by
a French privateer,
so that for several
years he was
without
a single architectural
authority
and
was
obliged
to
rely
solely upon his memory and his taste.
In Philadelphia
he met
the
lady
who became his second
wife,
Mary Elizabeth
Hazlehurst,
daughter of Isaac Hazlehurst,
who was
the
business
partner of Robert
Morris,
the great financier
of
the
American
Revolution.
His marriage was a happy one and resulted
in the birth of two sons, B. H. Latrobe, jr., and J. H. B. Latrobe.
Latrobe's
next
professional
undertaking
was
the construction of
the first waterworks for supplying
the city of Philadelphia with the
water of the Schuylkill by means of a steam engine, which pumped
the
water
into
reservoirs,
from
whence
it
could
be
distributed
through
the streets of the city.
It was the first time that
such
an
enterprise had been attempted
in America,
and Latrobe
was looked
upon as a visionary
when
he proposed the scheme.
Unfortunately,
2 The Journal
of Latrobe.
D. Appleton
and
Co.,
New York,
1905.
No. 4.
619
BENJAMIN
HENRY
LATROBE.
Major L'Enfant,4
a French engineer,
the designer
of the plan of the
city of Washington,
had
disappointed
the
people
of Philadelphia
in the home which he undertook to build for Robert Morris, and in
the city
assembly
rooms, for which
a large sum of money
had
been
raised by popular subscription
and squandered.
The
house, for Mr.
Morris
was
never
finished,
the incomplete
structure eventually
be
ing torn down, and the assembly
rooms never rose above the founda
tions.
L'Enfant
had
scarcely
left
the city when
Latrobe
made it
his
home
and
attained
public
notic«
by
the two works that
he
at
once
commenced— the Bank
of Pennsylvania
and
the
city
water
works.
The bank building
was easily understood
by the inhabitants,
but
the
city
waiter supply
was
at first
incomprehensible,
ranking
with the schemes of L'Enfant, and they believed
they were justified
in transferring at once to Latrobe,
because of his profession
and
French
name, all
the unpopularity
of L'Enfant.
People were not
satisfied
with
treating
him
and
his
designs
with
contempt.
Per
sonal
abuse was heaped upon him.
Difficulties
were thrown
in the
'On the 16th of July,
1790,
nn
act was passed
by
Congress
authorising
the President
to appoint
commissioners
to survey,
under
his
direction,
a district of
territory,
not
ex
ceeding
10 miles
square, at
some
place on the River Potomac,
between
the mouth
of the
Eastern
Branch and Conococheague.
The
President,
" with
that
consummate
Judgment
which
distinguished
his
career, fixed upon just the one
spot
in the entire
range of terri
tory
prescribed
by
Congress
which
commanded
the
threefold
advantages
of
unfailing
tide-water
navigation,
convenient
access
to Baltimore
and
other
large
cities,
and
superb
natural
sites alike for public
buildings
and the varied
wants
of a populous
city."
To
prepare
the plan
of
the future
city,
the
commissioners
appointed
Charles
Pierre
L'Enfant
to
be their
engineer.
He
had
come
to
America
as
an
officer
in
the
French
line
in
1777,
was wounded
in the assault
of Savannah
by
D'Estaing,
was taken
prisoner,
was exchanged In
1782,
became;
major
of engineers
in
the American
Army
In
1783,
was
sent
to France
by the Society
of the Cincinnati
to arrange
for
the engraving
of its
gold
badge,
and,
being accomplished
In many
ways,
on
his
return
he
was employed,
in
1789,
to prepare
the Old City Hall in Wall
Street,
New York, for
occupation
by
Congress after
the adoption
of the Constitution.
Brought
into notice
in
this
way, L'Enfant
seemed
to
be the proper
person
to prepare
the plan for the new city ; and at once
proceeded,
with
the assistance
of Andrew
Elllcott
and
others,
to
execute
the
work.
It
was
Elllcott
who
established
the
meridian
of
Washington,
the intersection
of which
by an east and west line Is marked by the Capitol.
L'Enfant
appears
to have had carte blanche In the matter
of planning
the future
city ;
nor
had
Peter
the Great
more control
In this
regard,
when
he
laid
out, on the marches
of
the
Neva,
the
grand
avenues
of
the
Russian
capital,
than
the
French
major
of
engineers— who
in
some
respects
Imitated
him — when
he
traced,
on
the swampy
ground
of
the Tiber,
a small
stream
long
ago
diverted
into
the city's
sewers,
the plan
of
a city,
which
in the stately
magnificence
of its
public
buildings
has long
surpassed
the city
of
the former
Czars.
When
the map of the future Washington
was finished
and the public
sales were
to
be
effected
L'Enfant
refused
to submit
his
work
to public
inspection
; his
excuse
being
that
certain
neighborhoods
would
be
seized
by
speculators,
and
shanties
rnn
up
where
he designed
palaces
to
be constructed.
Such
not being
General
Washing
ton's view of the matter,
the commissioners
took
possession of the
maps,
and L'Enfaut's
further
services
were
dispensed
with.
In
1812,
he
was
employed
by
Mr.
Madison
to
plan
a
fort
on
the
Potomac
below
Washington,
and
later
Mr.
Monroe
offered
him
a
professorship
at West Point, which
he did not accept.
As an old man he wandered
about
the
streets of
Washington
in
peculiar
dress.
He died
In
1825,
taking
his
place
In the
ranks of the vast host of forgotten
bene
meritos.
He was burled
on
the farm
of William
Dudley Digges at Green Hill,
Prince
Georges County,
Md.,
where his declining
years were
spent as a
guest,
but his
remains
were removed
84 years
later
(Apr.
28.
190!))
to
a site
in Arlington
Cemetery In front
of the Lee Mansion.
620
Vol. XVII
BENJAMIN HENRY
LATROBE.
way of his procuring
laborers.
Injuries were done to the buildings
by
unknown
persons.
No argument could convince
the
public of
his good intentions.
Popular dislike of Latrobe
advanced
with
the
progress of the work until,
when
the pipes were laid in the streets
and the steam engine finished, affairs became so strained that he was
threatened
with
violence.
In
fact,
the
situation
became
quite
melodramatic.
On the afternoon of the day when
the steam engine
was in readi
ness, by Latrobe's orders the hydrants were left open.
In the middle
of the night, with three friends and one of his workmen, he went
to
the waterworks, kindled a fire under the boiler, and set the pump in
motion.
Everything worked as he anticipated,
and the inhabitants
of Philadelphia
awoke
to
see
the
streets of their
city
flooded
by
water from the gushing hydrants.
The successful
operation of the waterworks established
his reputa
tion firmly in Philadelphia.
With a wife and
a growing
family
to
support,
he endeavored
to
increase
his professional
activities.
He
was engaged to survey a route for a canal to connect the Chesapeake
and Delaware Bays, and shortly after the commencement
of the sur
vey he became interested
in the construction of the Capitol in Wash
ington, to which city he had made frequent visits.
As shown by his correspondence,
he was thrown with the leaders of
society in Washington, and the following extracts from letters written
by him throw light upon the customs of the times.
Washington,
Nov. 24, 180Z.
Having employed my morning
in
my
business I went
to dine with the Presi
dent.
His two daughters,
Mr. and Mrs. Madison,
Mr. Lincoln
(Attorney
Gen
eral), Dr. Thornton,
a Mrs. Carter from Va.,
and Captain
Lewis,
(the Presi
dent's
Secretary)
were in the party.
The dinner
was excellent,
cooked
rather
in the French style,
(larded
venison),
the dessert
was profuse
and
extremely
elegant, and the knic-knacs,
after withdrawing the cloths, profuse
and number
less.
Wine was served In great variety,
from sherry
to champagne,
and
a few
decanters of rare
Spanish
wine.
The conversation
of which
Mr. Madison
was
the principal leader, was incomparably
pleasant,
and though Mr. Jefferson said
little at dinner besides attending
to the filling of plates, which he did with great
ease
and
grace for a philosopher,
he
became
very
talkative
as
soon as
the
cloth was removed.
The ladies stayed till five,
and half an hour afterward the
gentlemen followed
them to the tea table, where
a most agreeable
and spirited
conversation
was kept up until
seven,
when everybody
withdrew.
It is
a long
time since I have
been
present
at
so elegant
a mental
treat.
Literature,
wit,
and a little business, with a great deal of miscellaneous
remarks
on agriculture
and building,
filled
every'
minute.
There
Is a
degree
of ease in Mr. Jefferson's
company
that
everyone
seems
to
feel and to enjoy.
At dinner
Mrs.
Randolph
was
asked
by Mr. Carter to drink
a glass of wine with him
and did
so.
Mr.
Jefferson told her she was acting against the health
law.
She said
she was not
acquainted
with it, that it must
have passed during her
absence.
He
replied
that
three
laws
governed
his
table —no
healths,
no
politics,
no
restraint
I
enjoyed the benefit of the law. and drank for the first
time at such a party
only
No. 4.
621
BENJAMIN
HENEY
LATROBE.
one glass of wine, and, though I sat by the President,
he did not invite me to
drink
another.'
' Practically
all
the letters
written
by
Latrobe
are
In
tlie
possession
of
his
descend
ants.
An
explanation
of this
remarkable
fact
is to
be found
in
the following quotation
from an address
on " the Capitol
and Washington
at
the beginning
of
the present
cen
tury."
delivered
by John
H.
B.
Latrobe
before
the
American
Institute
of
Architects
in
Washington,
D. C,
Nov.
16,
1881.
" The
materials
from
which
much
of
the foregoing
has
been
prepared
have
been
fur
nished by the letter
books and portfolios
already
mentioned.
That I
should
have letter
books
from
a date that
knew not pnss, copybooks, or manifold
writers,
needs
an explana
tion that
might
be put
Into
n footnote
were it not
connected
with
one who,
if
not
an
architect,
was an artist,
a mechanician,
and
a scientist,
and
in
this
way
near of kin
to
the profession
whose members are before me.
I refer to Charles
Wilson
Peale.
About
the
year 1802
he
invented
what
he
called
' a polygraph,'
the essential
parts
of
which
were
a light
horizontal
rod, with jointed
sockets at each
end
to hold common quill
pens.
This
was
connected
with
parallel
motions
;
one
traveling
on
the upper
part
of
the
Inclined
desk,
while
the other
was
suspended
from
a
frame
above it—the
two
permitting
the
pen rod
to move
the width
and length
of
a
sheet
of paper.
Two of such sheets of paper
were
held
flat
by
spring
bars
at
their
upper
edges.
The
movement
of
the
two
pens
being
thus
made
identical,
while
the left-hand
one,
held
by
the writer,
wrote
the letter,
the right-hand one
wrote a duplicate
original,
which
was placed in the desk drawer,
until
a sufficient
number
bad accumulated
to be bound and Indexed.
Of these originals I
have
IS volumes,
covering
the period
from
1803
to
1810,
inclusive.
Unfortunately,
they form
but
one
side
of
the
correspondence
which
embraces
all
conceivable
subjects.
In
my
father's
frequent
changes
9f
residence
the other
side has
been
lost.
I do not
know if
there is
a
polygraph
still
in
existence.
If
not,
this
notice
will,
at
any
rate,
make
a
matter
of recerd of a most ingenious
device, the Invention
of one
whose name is insepa
rably
connected
with the history of art in America."
In
a letter
to
Mr.
Jefferson
dated
Oct.
2,
1803,
Latrobe,
speaking
of
the polygraph,
says : " I
am
not
yet entirely
master
of the motion
so as to write
exactly
the same
hand which
a single
pen
produces ; but in
an hour's practice I learned
to write with the same
ease
and rapidity as with a common
pen.
I
doubt
not you
have
heard
of the machine,
and perhaps
you
possess
one
of them.
What I
have written
on
the other
side Is a specimen of the truth with
which
a copy is
made."
That
Jefferson
owned
a
polygraph
is
Indicated
by
the
following
news
Item
which
appeared
iu the Washington
Post of May
28,
1922.
" The
polygraph,
with
which
Thomas
Jefferson
wrote
his
letters
and manuscripts,
has just
been
restored
to
a
working
condi
tion
in
the workshop
of
the Rouss
physical
laboratory
at
the University of Virginia
by
the mechanical
ingenuity
of A, J. Weed.
"This
instrument
was
presented
to
the
University
of
Virginia
in
1875
by
Col.
Thomas
Randolph.
In
his
letter
of
presentation
he
states
that
Jefferson
used
this
polygraph
during
the last
20 years of his
life.
" Careful measurements
were
made
of all broken parts
and new
pieces
were substituted
in
their places,
but all of the original parts
which
could
be
used
were
cleaned
and
re-
finished.
" When
closed the polygraph
presents
the appearance
of
a substantial
mahogany
box.
10
by
17
inches
in
size
and
5
inches
high.
On
opening
the
cover
a
push
pin
is
dis
closed,
by
pressing
which
the central
portion
of the
case
can
be loosened
from
the
bot
tom
on one side and
stood in an upright
position
with the bottom
and
top
of
the
case
resting
flat
on
the table.
"Upon
withdrawing
a
sliding
bolt
the writing
mechanism
can
be
brought
forward.
This consists
of two
penholders
of silver
mounted
on a wood bar In such
a manner
that
while
they
are
free
to
be
moved
in
any
direction
the
motions
of
both
are
identical.
This
is
made
possible
by
two
pantographs,
one
end of each
being
attached
to
the
bar
carrying the two
pens.
One pantograph
controls
the horizontal
motion
of the pens and
the
other
controls
their
vertical
movements.
When
one
pen
is
dipped
into
nn
ink
bottle
the other
pen
makes a corresponding
movement
in a duplicate
bottle.
"The preservation
of so many
of Jefferson's
papers and
letters
is due to the fact
that
he used this
instrument
and therefore
wrote them in duplicate."
In
1798 Latrobe had met in Washington
Dr. William
Thornton,
a man of great genius, but not an architect, who had drawn the plan
of design of the Capitol
which had
been selected by General Wash
ington
as the one to
be followed
in its erection.
Thornton
was of
622
Vol. XVII
BENJAMIN HENRY
LATEOBE.
English descent, born in the West Indies.
He became the first super
intendent of the Patent
Office.
He invented
a paddle-wheel steam
boat,
and in later years
accused Fulton of having wrongfully de
prived him of it.
When Latrobe met him he was one of the commis
sioners appointed
to superintend
the
construction
of
the
Capitol.
Latrobe makes the following remarks concerning this meeting
in his
journal
: " I spent
the afternoon with
the doctor.
One of the first
subjects
introduced was the plan of the Capitol, of which he had
a
ground
plan
and
east
elevation.
.
.
.
With
freedom,
but
without
giving offense, I objected
to
both
plan
and
elevation,
and
offered
to give
the doctor a drawing
in perspective
of his design
which I
trusted
would
convince
him
of his errors.
But he never
sent
me
the necessary materials."
In 1803 President Jefferson invited Latrobe, then in Philadelphia,
to undertake
the supervision of the construction of the Capitol,
and
he accepted the appointment to the office of Surveyor of Public Build
ings mentioned
in the following letter :
Washington]
D. C, March
6,
1803.
Sib—Congress
has appropriated
a sum of $50,000
to
be applied
to the Public
Buildings
under
my
direction.
This
falls,
of
course,
under
the
immediate
business of the Superintendent,
Mr. Munroe.
whose office Is substituted
for that
of the Board of Commissioners.
The former
post of Surveyor
of the Public
Buildings, which
Mr. Hoban
held until the dissolution
of the Board (at $1,700
a year)
will
be revived.
If you choose to
accept
it you will
be appointed
to It and would
be expected
to
come
on
by the first of April ; Indeed if you could
make
a flying trip here
to
set
contractors
at
work
immediately,
in raising freestone,
it
would
be
ex
tremely
important,
because it is now
late
to have to
engage
laborers
and
the
quantity
of free stone which
can be raised,
delivered
and cut in the season Is
the only thing that will limit the extent of our operations
this year.
I shall
set out tomorrow
for Monticello
and shall be absent 3 weeks, but shall
be glad to receive there your answer
to this.
Accept my friendly salutations
and regards.
Th. Jefferson.
Latrobe's first step on receiving his appointment was to examine
the work that had
been
done and
to see how far the plans yet un
finished could be carried into execution.
In his journal
he says:
" I called for drawings to guide my opera
tions.
The President
gave
me
a plan, and Dr. Thornton
gave
me
another.
They
were
copies
of each other and
both
perfectly
use
less;
neither of them
agreed
with
the work
as founded or carried
up,
and
there
were
no details
whatever.
In
the superintendent's
office
no drawings
existed.
To speak
plainly,
the
design
was
evi
dently
the
production
of
a
man
wholly
ignorant
of
architecture,
having brilliant
ideas, but possessing
neither the knowledge
neces
sary for the execution
nor the capacity to methodize
and
combine
the various parts of
a public work.
In
some
respects
the plan, as
No. 4.
623
BENJAMIN
HENRY LATROBE.
far
as it indicated what was
intended,
was
impracticable,
and
in
all respects it was
so inconvenient and often useless in its arrange
ments that I despaired
of correcting it.
However, I gave it several
days of severe study, and then stated to the President that I could
not undertake
its execution.
He consented
to alterations. I pro
posed consulting Dr. Thornton.
The President said it was unneces
sary and would
be
useless.
Having in the course of a week, how
ever,
formed
and
reduced
to drawing
all
my
proposed
alterations,
I called
on the doctor,
to whom I believed
much
to be
due on the
score of
delicacy.
I procured an interview,
at which, after much
argument and heat, he at last consented
to admit my ideas into the
plan.
But the next day he called
on me, and, with much irritation
and
using
language
offensive
and
uncivil,
he
recanted."
8
Latrobe
not
only
encountered
opposition
on
the part of Doctor
Thornton,
but all who
hud
been
engaged
in the work
opposed
him.
Even- effort was made to injure
his reputation.
If he suggested
an
alteration in the plans, if he pointed out
a defect, if he showed
the
impracticability of executing a part of the
design,
he
was sure
to
bring upon
himself
a host of assailants.
Congress
especially was
opposed
to
any
change
in
the
plans
that
had
been
approved
by
General
Washington.
Several
times
Latrobe
was
on the point of
resigning from his
office,
and was only prevented
from doing so by
the firm
and unwavering support that on all occasions
he
received
from the President.
Shortly after his appointment Latrobe
commenced
the
construc
tion of the south wing of the Capitol,
of which the foundation
had
been already
laid.
The whole
design of the interior
of this wing is
his work,
the exterior, of course,
was built in conformity
with
the
design of the north wing, which
was built
under
the direction of
Doctor Thornton
and which was so far completed
by the year
1800
that Congress
moved to Washington
and occupied
it.
At the time
of his appointment
to the
office
of Surveyor
of the
Public
Buildings,
the design
and supervision of the construction of
the buildings at the navy yard in Washington
was put into Latrobe's
hands
at an extra compensation
of $1,000
per
annum.
He designed
the workshops
and supervised
all the improvements
within or in con
nection with
the yard during
his
residence
in Washington.
"The
result
of I-atrobe's
visit
to Doctor
Thornton
Is
best
explained
by
the
following
letter,
dated
Feb.
27,
1804
:
TO THB PRESrDBNT OF THE U.
S.
Dear Sib :— I judged
very ill In going
to Dr.
Thornton.
In a few
peremptory
words,
he in
fact
told
me
that
no
difficulties
existed
in
his
plan
but
such
as
were
made
by
those who
were
too
Ignorant
to
remove
them:
and
though
these
were
not
exactly
his
words,
his
expressions.
Ills
tones,
Ills
manner
and
bis
absolute
refusal
to
discuss
the
subject, spoke
his meaning more strongly
and offensively
than I have expressed.
In Mr. Jefferson's
reply,
dated
the
following day,
he
says :
" De.ik
Sie :
I
am
very
sorry
the explanations
attempted
between
Dr.
Thornton
and
Jourself
over the manner
of finishing
the House
of Representatives
have not succeeded."
624
Vol. XVII
BENJAMIN
HENRY LATKOBE.
The navy yard
gate," which
was long admired
for
its excellent
taste and the beauty of its proportion,
is an example of his art. It
was by reason of this appointment as civil engineer of the Navy De
partment that Latrobe was requested
a few years later, to design the
plans for the first naval hospital.
Latrobe
moved
his
family
from Philadelphia
to Washington
in
1807
and
established
a residence in what was known
as the "Navy
Yard House," where
they
resided
until the spring of
1812.
From
notes
left
by
one of his sons, John H. B. Latrobe.
we
quote the
following
: 10
" My earliest
recollection of my father and mother dates from the
Navy Yard House.
The occasion
was their appearance
when dressed
for a
' Drawing Room ' to which they
were going at the President's.
I remember well a tall striking-looking
person.
6 feet, 2 inches high
in fact, in black, wearing knee breeches and silk stockings with silver
buckles
in his shoes, erect
as a soldier, and without being handsome
in the
face, of
a distinguished
carriage.
My
mother
was
as dis
tinguished in her
appearance
as my father was in his.
She was
a
very tall woman,
five feet,
8 inches
and had always been
celebrated
for the beauty of her figure.
Her face was in no ways
remarkable.
She had
been
a leading belle in Philadelphia,
and had the air of a
woman
of fashion of that day.
On this occasion
she was dressed in
white satin with
a long train, and wore
a turban of spangled muslin
with
a gold crescent, fastening a heron's upright
plume.
They must
have been regarded
as a verv noble looking pair.
" In
addition
to
my
father's
other
accomplishments
he
was
an
excellent
musician,
and
my
mother
was
celebrated
for her voice,
cultivated
when
she
was
a girl, under the instruction
of the
best
masters in Philadelphia
of that day.
" The Navy Yard House was an attractive one for the society of
Washington
in
1808
or thereabouts.
Mr. Madison
was
a frequent
visitor, Chief Justice Marshall. Mr. Foster, the British Minister, Mr.
Serruvier,
the French
Minister,
Madam
Dushkoff,
the wife of the
Russian Minister,
Robert
Fulton,
Doctor
Mitchell.
Gilbert
Stuart,
the painter.
" Another visitor was the dearest little woman in the whole world,
my
mother's
bosom
friend,
Mrs.
Juliana
Miller,
one
of
the
most
diminutive of her sex, but one of the best and truest.
" Both my father
and
mother
were fond of
society.
My
father
was a man of great conversational powers
and rare accomplishments.
My mother
was a brilliant talker and a wit."
A
description
of Latrobe
is
contained
in
the
following
letter
written
by John H. B. Latrobe
to his cousin John Frederick
Bate-
man.
• " The
entrance
to the navy
yard
Is
through
a
spacious
gateway
of
hewn
stone "—
October
2,
1809.
Recollections
of Samuel
Breck,
edited
by H. E.
Scndder,
Porter,
and
Coates,
PhUadelpbia,
1877.
10John H. B. Latrobe
and His Time — 1803
to 1891.
By John E.
Sommes.
No. 4.
625
BENJAMIN
HENRY
LATROBE.
Baltimork,
Maryland,
S June,
1370.
My dear Oocsin : I Imve forwarded
to your
London
address
a copy which I
made
of Reinhurt real's
[Rembrant
IVale
'.']
very
poor portrait of
my
father,
the only merit of my work being that
it
is pretty
nearly
a facsimile.
My father
was six feet, two inches in height, of erect and military carriage.
In repose
his
face was almost
dull.
In conversation
it was all animated
and
his listeners
thought
him
handsome.
His hair was
very
dark,
with
a
slight
wavy
curl.
He spoke most living languages,
German,
French,
Spanish,
Portu
guese and Italian
with
fluency
and
understood
most
dead
ones,
Greek
and
Latin
thoroughly,
and knew
a
good
deal of Hebrew; was
n
clever
poet
and an
accomplished musician.
In 1811 the south wing of the Capitol
was completed
and the fur
ther progress
of
the
public
buildings
was
suspended
for want of
appropriations to carry
them
on, the approaching
war with
Great
Britain being alleged
as the reason for curtailment in the expendi
tures for this particular
object.
The work
at the navy yard, how
ever, was carried on upon
a
larger scale than ever.
From the following
extract of
a
letter written by Mrs. Latrobe to
her friend, Mrs. Juliana Miller, 185 Walnut Street, Philadelphia,
we
learn that in the spring of 1812 the Latrobes moved from
the Navy
Yard House to
a
residence on Pennsylvania Avenue.
Washington,
February
17,
1812.
. .
. We
were
last
week at
a
dance given
by the officers of the Enterprise
[subsequently celebrated for her engagement with and capture of the
'
Boxer
'
in 1813] in the great sail loft of the Navy Yard;
the
insufferable
smell of tar
gave me
a
headache or
I
should
have spent
a
pleasant
evening.
We
are about
to
remove from
our
present
habitation
to
a larger
house
on
Pennsylvania
Avenue.
We
shall
be
very
near
the Hauiiltons "
and
not
far
from
the
President's
and
what
is
equally
agreeable,
we
shall
be
near
the
market
and
can
offer
you,
my
dear
Juliana,
a
much
better
accommodation
than when you were last here.
J.
H. B. Latrobe,
commenting on this period, cites his personal
recollection of the city as
it
was in 1812
:
Pennsylvania
Avenue
was little
better
than
a
common
country
road.
On
either
side
were
two
rows
of
Lombardy
poplars,
between
which
was
a
ditch
often
filled
with
stagnant
water,
with
crossings
places
at
the
intersecting streets.
Outside
of the poplars
was
a
narrow
footway,
on which
carriages
often
intruded
to deposit
their
occupants
at
the brick
pavements
on which the few houses scattered
along the Avenue
abutted.
In dry weather
the Avenue was all dust
;
in wet weather,
all mud
;
and along
it
" The Royal
George"
an
old-fashioned,
longbodied
four
horse
stage—either
rattled
with
members of Congress
from
Georgetown
in
a
halo
of dust,
or pitched,
like
a
ship in
a
sea
way,
among the holes
and
ruts
of
the
national
highway.
The
Capitol
itself stood
on
a
steep declivity,
clothed
with
old
oaks
and
seamed
with
numerous
gullies.
Between
it and
the Navy
Yard
were
few
buildings,
here
and
there
over
an arid
common;
following
the
amphitheater
of
hills
from the southeast
around
to the heights
of Georgetown,
houses few
and far
uPaul
Hamilton.
Secretary
of the Navy.
626
Vol. XVII
BENJAMIN HENRY
LATROBE.
between,
Indicated
the
beginning
of
the
present
city.
The
Patent
and
Post
Office,
in one iiugh
un-ornamental,
barn-like brick
edifice, occupied
the
place
of their marble
successors ; and at
the other
end of the avenue, the
' White
House
' had become
a conspicuous
object with the adjacent
public
offices.
Still
following
the
amphitheater
around
the
eye
caught
a
glimpse
of
Alexandria
and rested upon the brond expanse of water
where
the Eastern Branch joined
the
Potomac,
with
Greenleafs
Point
between
the
two,
on
which
the
great
tribe
of the Shawnees
once lit its council
fires
and had its fishing
ground.
Additional extracts
from two other letters written to Mrs. Juliana
Miller by Mrs. Latrobe throw
some light upon
those times
:
Washington,
June
27,
1812.
The
theater
is
nearly
opposite
to
our
present
residence.
They
have
full
houses.
Many
of
the
members
of
Congress,
never
(I
suppose)
having
seen
a piny, avail themselves of it.
There
was
a terrible riot last evening,
owing
to the musicians
refusing
to play
" Hail
Columbia."
One of them called
out
" Play
Foster's
March,''
upon
which
Sam
Ringgold
threw
a bisket
at
him,
and
another
gentleman,
Mr. Howard of the Senate,
caught
him
by
the collar
and dragged
him over the railing.
A terrible battle ensued which
ended
in an
apology
from
Warner nnd an order
to
start
up " Hail
Columbia
", which
was
played
so long
a time that
most probably
none of the audience will ever wish
to hear it again.
Washington,
December
14,
1812.
On Tuesday
a very splendid ball was given to the Navy
Officers —Hull, Morris,
Stewart,
etc.
My husband
could
not
be
absent as
he
holds
an
office
in
the
Navy
Department,
and I was not sorry
we went,
as it is not likely that I shall
ever
witness
such
another
scene.
At
about
five
in
the evening
my husband
came home
and informed
me that
we
must
immediately
illuminate our
house,
as the account of
a
victory
gained
by Commodore
Decatur
had just arrived.
My
house in ten minutes
was
prepared
for lighting
up,
and
we prepared
for
the ball.
The avenue was
very brilliant
on
our way
to the Capitol Hill,
and
the company
assembling,
the crowd
was
immense.
Mrs.
Madison
was
there,
but not the President.
The evening went on with crowded dancing
and treading
as usual
upon the toes and trains of
those
who
did
not
dance;
when
about
ten o'clock
a loud huzza
announced
the arrival
of young Archibald
Hamilton,
who had that
moment appeared with the colors
of the Macedonian.™
He was
" Commodore
Decatur
cruising
in
the
United
States,
a
44
gun
vessel,
on
Sunday.
October
25,
1812,
In lat.
29°
N., long.
29°
30' W.,
sighted
a large sail
to
the southward
and eastward.
The
stranger
was
running
down
a little
free,
while
the
American
ship
was on a wind,
standing
towards
the chase, which
was soon ascertained
to
be an enemy.
The
latter
having
come
within
a
league,
hauled
up,
and
passed
to
windward,
when
each
party
was
enabled
to
see
that
they
had
a frigate to
oppose.
The
stranger
now
wore and came round
on the same
tack with the United
States,
keeping
away
sufficiently
to get within
reach of her long
guns, when
she
hauled
up
on
an
easy
bowline,
with
her
mizen-top-sail
aback.
At
this
moment
the
distance
between
the
two
ships
a
little
exceeded
a
mile
when
the
Englishman
opened
his
Are.
Finding
the
enemy
on
his
weather
quarter,
Commodore
Decatur
delivered
his
larboard
broadside,
wore
round,
and came up to
the wind
on
the other
tack,
heading
northerly.
It was
observed
that
all the carronade
shot fell short,
the enemy
doing
very little injury
by
his
Are.
Having
passed her antagonist,
the United
States
delivered
her starboard
broadside,
and
wore
again,
bringing
her
head
once
more
to
the
southward,
or
on
the
same
tack
as
the
enemy,
both
ships
steering
rap
full
[with
every
sail
drawing],
with
their
miien
topsails
aback, and keeping up a heuvy cannonade.
In this manner
the action
continued
about
an
hour,
the
English
vessol
suffering
heavily,
while
her
own
fire
inflicted
very
little
injury
on
hpr
antagonist.
At
length
the
stranger's
mlzen-mast
came
down
over
his
lee
quarter,
having
been
shot
away
about
ten feet above the deck.
He
then fell off.
and
let
his
foresail
drop,
apparently
with
a
wish
to
close.
As
the
ships
got
new
No. 4.
627
BENJAMIN
HENRY LATROBE.
borne
into the room by many
officers.
Good little Mrs. Hamilton, his mother,
stood
by me, and was so much agitated
at the sight
of her son that she
must
have fallen,
had I not stepped forward
and offered
her
my arm.
The
young
man sprang into
her arms, his sisters
threw
their
arms around
him,
and the
scene was quite
affecting.
The
colors were then held up by several gentlemen
over
tlie heads of Hull,
Morris,
and
Stewnrt,
and
" Hail
Columbia
"
played
and there
were huzzas until my head swayed.
The aforesaid
colors were then
laid at the feet of Mrs. Madison.
Oh tempora !
Oh mores !
This was rather
overdoing
the affair.
together,
the
shot
of
the
American
vessel
did
fearful
execution,
the
forecourse
being
soon
In
ribands,
the fore
and main-topmasts
over
the
side,
the
main-yard
cut
away
in
the slings, and
the foremast
tottering.
The
United
States
now
filled
her mizon-topsail,
gathered
fresh
way,
and
tacked.
As
the stranger
was drifting down,
nearly
before
the
wind,
and was
almost
unmanageable,
Commodore
Decatur
had
no difficulty
In
heading
up high enough
to cross
his
wake,
which
he
handsomely
effected,
with
his
people still
manning
the larboard
guns.
At
the time
the
United
States
filled
her mlzen-topsail,
In
preparation
for stays,
it
is said
that
the enemy,
under
the
impression
she
was
about
to run
away,
gave
three
cheers,
and
sot
a
union
jack
in his main
rigging,
all
his
other
flags
having
come
down
with
the
several
spars.
When,
however,
the
American
ship
was seen luffing
up
to close, the jack was lowered,
and resistance
ceased.
As
the
United
Slates
crossed
the stern
of
the English
ship,
the firing having
ceased
on
both
sides,
she
hailed
and demanded
the
name of her
antagonist,
and
whether
she
had
submitted.
To
the
first
interrogatory.
Commodore
Decatur
was
answered
that
the ship
was the Macedonian
38. Captain
Carden,
and to the
second,
that
the vessel
had
struck.
On
taking
possession,
the
enemy
was
found
fearfully
cut
to
pieces,
having
received
no
li'BS
than
a hundred
round
shot
in
his
hull alone.
Of
three
hundred
men
on board
him, thirty-six were killed,
and sixty-eight
wounded.
The
Macedonian
was
a
very
fine
ship
of
her
class,
mounting,
as
usual,
49
guns,
<ighteens
on her
gun
deck, and thirty-two
pound
carronades
above.
She
was
smaller,
of lighter
armament,
and had fewer
men
than
her opponent,
of
course,
but
the dispro
portion
between
the
force
of
the
two
vessels,
was
much
less
than
that
between
the
execution.
In
this
action,
the
advantage
of
position
was with
the British
ship
until
she was crippled,
and the combat was little more than
a
plain
cannonade,
at
a distance
that
rendered
grape
or
musketry
of little
or no
use,
for
the
greater
part
of
the
time.
The
fire of the United
States
took effect so heavily
in the waist
of her antagonist,
that
it is
said
that
marines
of
the latter
were removed
to the batteries,
which
circumstance
Increased
the efficiency of the ship,
by enabling
new crews to be placed at guns that
had
been once
cleared
of their
men.
On
the other
hand,
the
marines
of
the
United
States
remained
drawn
up
In
the waist
of
that
ship,
most
of
the
time
quite
useless,
though
they
are
understood
to have shown
the utmost
steadiness
and
good
conduct
under
the
example
of
their
gallant
commander,
the
weight
of
the
enemy's
fire
passing
a
short
distance
above their heads.
The United
States
suffered surprisingly
little, considering
the length
of the cannonade,
and
her
equal
exposure.
She
lost
one of
her
top-gallant
masts,
received
some
wounds
in the spars,
had
a
good
deal of
rigging
out. and was otherwise
injured
aloft,
but
was
hulled
a very
few
times.
Of her officers
and people
5 were killed
and
7
wounded.
Of
the latter,
two
died, one of whom
was Mr. John
Musser
Funk, the junior
lieutenant
of
the ship.
No other
officer was hurt.
.
On
taking
possession
of
his
prize,
Commodore
Decatur
found
her
in
a
state
that
admitted
of
her
being
taken
into
port.
Her
two
principal
masts
were
secured,
and
a jury
mizen-mast
was
rigged
by Mr.
Allen,
the first
lieutenant
of
the
United
States,
who was put
in
charge
of her, with great
ingenuity,
so
as
to convert
the vessel
Into
a
bark.
When
the necessary
repairs
were completed,
the two ships
made
the best
of their
way
to America ; Commodore
Decatur
discontinuing
his
cruise,
in
order
to
convoy
his
prize
into
port.
The
United
States
arrived
off
New
London
on
the
4th
of
December,
and
about the same time the Macedonian
got into Newport.
Shortly
after,
both ships reached
New York by
the Hell Gate passage.
The
order
and
style
with
which
the
Jh*ucedonian
was
taken,
added
materially
to
the
high reputation
that
Commodore
Decatur
already
eujoyed.
His
services
were acknowl
edged In
the
usual
manner,
and
he
was
soon
after
directed
to
cruise
in
the
United
States, with the Macedonian,
Captain
Jones,
in company.
Mr. Allen,
the first lieutenant
of the
United
States,
was
promoted
to the
rank
of
a
master-commandant,
and
he
re
ceived due
credit
for
the
steady
discipline
that
the
ship's
company
had
displayed. —
J. Fenimore Cooper's History of the Navy
of the United
States.
628
Vol. XVII
BENJAMIN HENEY
LATEOBE.
In the month of August,
1814,
the British captured Washington
and on August
24 the Capitol
and White House were burned.
The
British intended the complete
destruction of these buildings.
Hap
pily their
efforts
were only partially successful.
The
greater
part
of the exterior
and
the principal
divisions of the interior
resisted
their
efforts.
The
soldiers
piled
the
interior
of
the
Senate
and
House Chambers as well as the wooden
corridor
between
the wings
with inflammable material
and made
a great blaze.
All the wood
work and
some
of the stone and brick work were damaged.
Latrobe
gives
the
following
graphic
description of the
effect of
the fire: '"In the Hall of Representatives the devastation has been
dreadful.
There
was
no want of materials for the
conflagration,
for when
the number of members
of
Congress
was
increased,
the
old platform
was left in its place and another
raised
over
it,
giving
an
additional
quantity
of
dry
loose
timber.
All
the
stages
and
seats in the galleries were of timber and yellow pine.
The
mahog
any desks, tables
and chairs were in their
places.
At first, rockets
were fired through
the roof, but they
did not set fire to it.
They
sent
men
on
it
but
it
was
covered
with
sheet iron.
At last they
made
a
great
pile in the center
of the room of the furniture,
and
retiring,
set fire
to
a
quantity of rocket stuff in the middle.
The
whole
was
soon in
a
blaze,
and
so
intense
was
the
flame that
the
glass
of
the lights
was
melted,
and
I
have
now lumps
weighing
many
pounds,
run into
a
mass.
The
stone
is, like
most
freestone,
unable
to resist
the force of flame, and
I
believe
no material would
have
been
able to resist
so sudden
and intense
a
heat.
The exterior
of the columns
and entablature scaled off and not
a
vestige of sculp
ture or fluting remained."
As early as
1809, Mr. Latrobe
had been asked by Governor Clai
borne,
of
Louisiana,
to
ascertain
whether
it
was
practicable
to
supply New Orleans with water by the
same means that had
been
so successful
in Philadelphia.
In
1810 he became convinced
of the
feasibility
of the
undertaking,
and
having
been promised
an
ex
clusive concession
of the water privilege,
he sent his eldest
son by
his first
Wife, Henry S. Latrobe,
who had been for some time
in
his office, to New Orleans to negotiate
for the concession.
In
1811
the Legislature
of Louisiana
granted to him the exclusive privilege
for 20 years from May,
1813, the time intervening
between this date
and the date of the grant being considered
as sufficient
for the erec
tion of the necessary
buildings
and machinery.
He commenced
the
preparation
in Washington
of those
parts of
the building which
could be made cheaper
than at New Orleans, sending them by
sea
to his son who was in that city
engaged
in erecting the
works.
The
war with Great Britain
in
1813
broke up Latrobe's
plans.
The
engines
for the waterworks
had not yet
been built nor could
No. i.
629
BENJAMIN
HENRY
LATROBE.
they
be built at New Orleans,
and if built,
as
was originally in
tended, in Washington,
they could not be sent around by sea without
the risk of
capture
and
a
great
loss
of
time.
As
work
on
the
public
buildings
and
his salary
had
been
suspended
by
the
war.
he determined
to remove to Pittsburgh,
and there to superintend the
engines for the New Orleans waterworks, sending them
when
com
pleted down the Mississippi.
While making
arrangements
to carry
this plan
into effect
he heard
that Robert Fulton, with
whom
he
had
long
been intimate,
contemplated
removing his engine
works
to Pittsburgh
and obtaining for his steamboats
the same monopoly
on
the
Mississippi
and
tributary
rivers
that
he
enjoyed
on
the
Hudson.
He wrote to Fulton; the result was a combination of inter
ests,
and
Latrobe
in
the fall
of
1813,
as
the
agent
of the
Ohio
Steamboat
Co., moved
his family to Pittsburgh,
and
began
there
the construction of a steamboat which was the fourth to be launched
upon those waters.
When
the boat
was finished
it was his idea to
build
the engines for which his son was waiting
at New Orleans.
The journey
to Pittsburgh
was made by the family in
a
vehicle
which,
says J. H. B. Latrobe. " had
been built after
a design of my
father's and its color was a dark olive preen.
It had the usual
seats
for four persons vis-a-vis, and the driver's
seat
was under the same
roof.
But instead of giving him the entire width of the seat
a semi
circular space in the center was surrounded with
a back, elbow high,
on either side of which were nooks which we children called
' nests
*
and which we occupied with our backs to the horses and our feet over
the front seat.
This gave us a capital chance to talk with David, the
coachman, a jet black little fellow who drove for my father
as long
as the latter had horses to drive.
To alleviate the possibility of one
of
us
children
falling
out of
the
usual
side
door,
while
leaning
against it to look out, my father put the door behind, making
it
necessary
to scramble
over
the hind
seat to get into
the carriage.
The
curtains
were
of
leather
and
were
so contrived
that
by
an
ingenious arrangement of pulleys they could be drawn into the roof
instead
of being fastened
at the
edges in the
usual
way.
In
the
bottom
of the
vehicle
was
a well,
a good
sized
box
that could
be
lifted out. its cover forming
part of the floor.
It was waterproof,
as it needed to be when the carriage was crossing fordable streams.
Our journeys from
Washington
to Philadelphia
to
see my
grand
father were made in this carriage, as was the long, weary journey to
Pittsburgh."
In
his
undertaking
in
Pittsburgh
Latrobe
was
disappointed.
Fulton
had
based his estimates
upon
prices
current in New York,
and the high
cost of labor and
materials in Pittsburgh
exhausted
the money Fulton
had allotted for the project before
the work was
4539—22
6
630
Vol. XVII
BENJAMIN HENRY
LATBOBE.
completed.
The result was
a breach,
destructive alike to the inter
ests of both
men.
As all hopes of being able to build
the
engines
for his New Orleans works vanished,
he was greatly
discouraged;
but as the war had ended, he was fortunate in being reappointed
to
his former office
as surveyor of the public buildings in Washington.
While at Pittsburgh
Latrobe
designed
several
private
dwellings
that were
erected
there
or in the neighboring
State
of Kentucky.
Among the latter were the residences of Henry Clay,
at Lexington,
and of Governor Taylor, at Newport.
Upon
receiving
his appointment,
Latrobe
immediately
went
to
Washington
to examine
the condition of the public buildings.
In
the summer of 1815 he returned for his family, and soon afterwards
found himself once more
at the seat of government.
His reception
here was of the most gratifying kind, and letters of congratulation
came to him from all those with whom his profession had at any time
connected him.
For nearly three years Latrobe
devoted himself assiduously to the
restoration of the public buildings
at Washington
and made
those
alterations in the interior
arrangements
of the south wing and north
wing which
the
destructive
fire
started
by
the
British
soldiers
necessitated.
The Hall of Representatives was altered
from an oval into a semi
circle, and the design as it is now
executed
is the work of Latrobe.
The columns of Potomac marble are due exclusively to him.
During
his rambles in Virginia he observed the great quantities of this mate
rial that projected
above
ground
in many localities,
and, having
ascertained
that it was susceptible
of high polish, he proposed
that
it should be used in place of freestone
for the columns of the Senate
and House of Representatives.
Certain of his designs
display
distinct originality.
In the small
vestibule
at the east entrance
to the north wing of the Capitol
the
vaulted roof
is
supported
by
columns
representing
the
stalk
of
Indian corn with its fruit.
The shaft of the column is composed of
stalks of the corn
bound
together by
a cord
at the bottom,
of suf
ficient size to form the molding of the base, and with
a smaller cord
at the top so as to form a proper fillet below the capital.
The capital
is composed of the ears of the corn with the husk or outer covering
sufficiently open to show
the grain within.
The proportions
of the
columns
are perfect and the effect is singularly
striking.13
"The design
of
these columns
Is commonly
attributed
to Jefferson,
but
the
following
extract
of
a letter
written
by
Latrobe
to Jefferson,
who
was at
Monticello.
leaves
little
doubt
as
to
the
author
of
the
design,
for
Latrobe
would
never
have
written
such
a
letter
to Mr.
Jefferson
had the latter been
the originator of
the design :
" Dear Sib :—I have packed up and sent
to
Richmond,
to
be forwarded
to
Monticello,
a box containing
the model
of the capital
of the columns
of
the lower
vestibule
of tie
senatorial
department
of
the north
wing
of
the Capitol,
which
is
composed
of
''nrs
of
maize,
on
a short
frustum,
raising
it
about
four
feet
from
the ground.
It
may
serw
Basement
vestibule, north
wing
of the Capitol, showing Indian corn design.
030-1
The handwriting of Benjamin Henry Latrobe
630-2
No. 4.
631
BENJAMIN
HENRY
LATBOBE.
The
Supreme
Court
room
and
the Senate Chamber vestibule
are
of his design,
and in the capitals of the columns of the latter the leaf
iind flower of the tobacco plant are used as were the ears of corn in
the capitals of the columns of the small vestibule of the east entrance
of the north wing.
In addition
to his work on the public buildings,
Latrobe
is said
to have designed St. John's Church on Lafayette
Square.
In
1817 Latrobe
received
news of the
death of his eldest
son in
New Orleans.
He had made that city his permanent
abode and was
rapidly advancing in his profession.1*
On the 26th day of February,
1811, a bill was passed in Congress
establishing marine hospitals in the United
States.
This bill pro
vided that the money accruing from the execution of an act for the
relief of sick and disabled
seamen should be paid to the Secretary
of the Navy,
the Secretary of the Treasury,
and
the Secretary of
War, who were by this bill appointed a board of commissioners,
to
be known
as the " Commissioners of Navy Hospitals."
This money,
together with the sum of $50,000,
appropriated by the same bill out
of the unexpended
balance
of the marine hospital
fund,
was to be
lor
a dial
stand ; and
should
you appropriate
It
to
that
use, I
will
forward
to you
a
horizontal
dial
In
Pennsylvania
marble
of
the proper
size.
These
capitals
during
the
summer
session
obtained
me more applause
from
the members of Congress,
than all the
works
of magnitude
or difficulty
that
surround
them.
They
christened
them the " corn
cob capitals "—whether for the sake of alliteration I cannot
tell,
but certainly
not very
appropriately."
" " On
October
6.
1817,
Latrobe
wrote
to
Thomas
Jefferson,
then
at
Montlcello,
a
letter
from
which
the
following
Is extracted
: " I
have
lost
my
eldest
son
after
three
days' illness,
by
the yellow
fever
at
New
Orleans.
He
was
the pride
and
hope of my
family.
Upon
him,
in
case
of my own denth, my younger
children
could
have depended
for support
and education.
What
he
was to
us
all,
and
what
be
promised
to
be
to
his
country,
may
be faintly
gathered
from
a sketch of his short
life In the National
Intelli
gencer of the 2nd or 3rd of this
month."
The
sketch referred
to In the letter
is the following
:
Hied
at
New
Orleans
of
the
prevailing
fever,
after
an
illness
of
only
Ave
days.
Mr. Henry
Sellon
Boneval
Latrobe
eldest
son
of B. Henry
Latrobe.
Esq., of this city.
From
his
Infancy
he
had
given
promise
of
eminent
usefulness.
An
ardent
desire
of knowledge
and
an
almost
intuitive
faculty
of
acquiring
whatever
he
attempted
to
learn,
distinguished
him
always
from
the
majority
of Ills school-fellows.
To
the bril
liancy
of genius he added a presence of mind,
a civil courage, and a discretion
beyond his
years. ...
At
12 years of age
he entered the college of St. Mary at Baltimore. ...
At
14 circumstances
detained
him
at
Philadelphia
when
he
attended
the
lectures
of
the
University,
and
was chosen
by
the late
Dr.
Woodhouse
from
the class
as
his
assistant.
Returning to St. Mary's
he graduated
at
16, and
by his valedictory
oration
on
the Edu
cation
of
American
citizens. ...
he
merited
singular
applause.
His irresistible
propensity
to follow
his
father's
profession,
of which
he
had studied
both
the civil
and military
theory,
under
Mr.
Godefroi.
prevailed
to
place
him
In
his
father's
office,
where
In
a short
time
he
gained
so much
experience
In
the great
public
works
then
executing
in
Washington,
and
acquired
so
much
influence
among
the
per
sons employed
that
he was appointed
Clerk
of the Works
at the Capitol
by Mr.
Madison,
•ad at the
same
time
performed
all
the practical
duties
of
Engineer
to
the canal
and
to public
roads of the District of Columbia.
In
1811
the
supply
of
New
Orleans
with
water
called
him
to
that
city
where
he
commenced
the
works
with
a spirit
and
intelligence
that
would
soon
havt> completed
them hnd not the war
interrupted
them.
After
the
declaration
of
war
he
was
encaged
In
the
works
required
by
the
U.
S.
In the neighborhood of that
city,
and when the British invaded
Louisiana,
he was among
the first to offer his
services
to General
Jackson,
who appointed
him
assistant
engineer
632
Vol. XVII
BENJAMIN
HENRY LATHOBE.
paid to these commissioners
and was to constitute a fund for Navy-
hospitals.
This fund
was to be augmented
by all the fines
imposed
on naval officers, seamen, and marines.
The commissioners
were, moreover,
authorized by this bill to pro
cure
a suitable place, or places, proper for naval hospitals, and, if
the necessary buildings could not be obtained
with the site, they were
empowered
to have
such
erected, " with
a due regard to economy,
giving
preference
to such plans as with
most convenience
and least
cost would admit of such
subsequent
additions
as the funds would
allow and circumstances
require."
In
a report 15 dated February
2,
1813,
submitted
to the honorable
William Jones, Secretary of the Navy, on work directed
to be under
taken since
1803, is the following,
which indicates that Latrobe
pre
pared
the plans for the first naval hospital which it was
proposed
should be erected in Washington.
I have
been
ordered
by
the Department
to
report
a plan
of the
proposed
naval
hospital
and having
devoted to the subject
very
close attention. I sub
mitted
a design, report
and estimates,
which
are, I presume, with the Commis
sioners
appointed
by law.
I also
attended
the late
Secretary
to the site
ap
proved by him in this city for the erection of the buildings.
As to the Report
and
Plans, I have copies should
the originals
be mislaid.
This
service
was
considered
to
be
a
duty
not
necessarily
belonging
to
my
engagement with
the Navy
Department.
All which
is respectfully
submitted.
B. Henry Latkobe,
Civil Engineer,
Navy
Department.
In a Treatise on Marine Hospitals,
by Surgeon W. P. C. Barton,
United
States
Navy, published in 1814,
the author tells of the out
come of the endeavor
to establish
naval hospitals.
to Major Laearrlere
Latour.
Major Latour in his
works
mentions
him
In
the
following
words :—
"That
very
morning,
(December
28,
1813),
the
engineer
Henry
S.
Boneval
Latrobe
had
established,
under
the
Are
of
the
enemy's
artillery,
and
a
cloud
of
rockets,
a
24
pounder
on
the left of
the
battery
No.
1
on
the
line.
This
gun
dismounted
one
of the field pieces which
the enemy
had placed in the battery
on the road."
The
principal
engineer.
Major Latour,
being
engaged
on
the
first
and principal
line
of defense, Gen. Jackson
ordered
Capt.
Latrobe
to
construct
a second line,
between
the
first and
the city
to which
to
retreat
in
case
of
defeat.
The
manner
in which
he per
formed
this duty
gained him the entire
confidence of the General.
. .
.
He had his
share
in
the labors
and
glory
of
the 8th
of January,
and
on
the
retreat
of the British
to their
ships,
he
was ordered
to erect such
works
in advance
as
should
render
their
return
with
reinforcements
impracticable.
He
was
not
then
22
years
of
age.
Peace restored
him
to
his civil occupations,
and
he projected
works
and
buildings
at
New
Orleans
which
soon
gave
him
the
lead
In
his
profession.
In
1815
he
wu
appointed
by
the
U.
S.
Government
a
commissioner
with
Com.
Patterson
and
Mr.
Dn-
plessis,
the collector,
to select
a site for
a lighthouse,
so essentia] to the safe
navigation
of
the river.
His design
and
report
on that work .... will
give to
professional
men
a full idea of bis early
talents
and taste.
.
.
.
It is
remarkable
that, till
his
last
illness,
his
temperance
and activity
had
secured
him
from
all
sickness
in
the
dangerous
climate
of
New
Orleans
; and
on
the
24th
of
August
he
wrote
to
assure
his
family
that
there
need
be
no
apprehension
on
hit
account.
A few days afterwards
he fell
a victim,
perhaps
to his security.
.
.
.
Henry
S. Latrobe
was 24 years old on the 19th of July last.
» Miscellaneous
Letters.
Navy
Department
Library,
vol.
1,
1813,
No.
78.
No. 4.
633
BENJAMIN
HENRY LATROBE.
Though
*wo yftars
hnve elapsed
since
the passing
of
this
law
[the bill
to
establish
naval
hospitals],
the
end it
was
intended
to
effect
has
never
yet
been
accomplished.
The
talents
of
that
able
engineer,
Mr.
Lntrobe,
were
employed
by the
Secretary
of the Navy
(Mr. Paul Hamilton)
for the design
ing of aa .architectural
plan of the
buildings
to
be
erected.
This
plan
was
admirably
calculated
for the erection of permanent
and convenient
edifices, to
which,
from
time
to time,
as exigencies
might
require,
or
the
hospital
fund
admit, additions might
be
made,
so that
when
the
whole
was
completed
it
would
present
one entire
and
perfect
building.
In
this
plan
he
had
exceed
ingly
well «ombtned
the
requisite
economy,
so
far
as
compatible
with
the
ultimate
object
of the
law,
with
that
simplicity,
elegance,
and
convenience,
which
characterize
all
the
works
of this
master
architect
This
plan
met
with the "warmest
approbation
of the secretary
of the navy,
but was objected
to
by
the
other
two commissioners,
for
those
qualifications
which
ought
to
have entitled
it to their favorable
opinion,
viz., its permanency
and stability.
The business
therefore
fell through,
and
the whole
plan
proved
abortive.
The great need of establishing
naval hospitals
at this time
was
emphasized
by
Surgeon
Barton,
who,
in his
Treatise
on
Marine
Hospitals, says:
The
time
has arrived,
when
we must
view
the establishment
of extensive
navy
hospitals,
as an event by no means remote or improbable,
but in fact
as
necessarily
connected
With
the augmentation
of the
navy,
and
the preserva
tion of the health
and lives of the officers and seamen
who compose it.
An
extensive
and
energetlck
naval
establishment,
cannot
possibly
be
con
ducted
without
the institution of publick
marine
hospitals
for sick
and hurt
officers,
seamen, and marines
; and asylums
connected with them, for superan
nuated
or decrepit
pensioners of the service.
We have no such institutions at
this
time, in any
part
of the United
States.
The very
Inconsiderable
estab
lishments
in
some
of
our
seaport
towns,
limited
in
extent,
and unsystematl-
cally
organized,
deserve
not
the
appellation
of
hospitals.
In
some
of
these
there are medical
officers, whose ability and experience
would certainly enable
them to superintend
and govern
very
extensive
establishments,
if the appro
priations
by
Congress
for
the building of
such
hospitals,
were
adequate
to
defray
the
expense of them.
The spirit of exertion
and
enterprise
then of
these surgeons,
would, if unrestrained
by
the necessity of such circumscribed
expenditure
in their operations
redound
very much to the interest
and welfare
of the service.
Every
naval
station
in
the
United
States,
presents
a
noble
site
for
the
erection
of marine
hospitals.
Those of St. Marys and Norfolk, on the southern
coast ; the
central
ones of Philadelphia
and
New
Tork ;
and
those
of
New
London,
Newport,
and
Boston,
on
the
northern
coast,
are
peculiarly
well
adapted
for hospital
establishments.
The liberality
and munificence of a gov
ernment
cannot
find
more
worthy
objects of their favour,
than
that
class of
its citizens
who voluntarily expose their
lives
and fortunes
to the most
immi
nent
perils
and
afflicting
accidents —for
the
safeguard,
the
protection,
and
defence,
of
the
honour
and prosperity
of
our
country.
And
when
we
view
the present want
of extensive
institutions for the care of sick sailors,
we
can
not but hope,
that
the Imperious
necessity for their
establishment,
will, before
long,
elicit
the
attention
of
Congress;
particularly
when
we
advert
to
the
known
impolicy
of
such
deficiencies.
They
are
impolitick,
because
it
is
natural to suppose,
that men will be deterred
from entering
a service, in which
no sufficient
provision
is
made for
alleviating
the distresses
it
is
liable
to
produce.
634
Vol. XVII
BENJAMIN HENRY
LATROBE.
Nothing
causes
seumen
to
discover
alacrity, promptitude,
and
faithfulness,
in
the performance
of their severe
and
arduous
duties,
or
contributes
more
to reconcile
them
to the comfortlessness,
the hazardous
chances and accidents,
to which
they
are constantly
liable
in
the service — than
a certainty
of
being
attended
humanely
and ably,
by the superintendents
of
a medical
department
replete with every
comfort
and convenience for the sick
and afflicted.
Every
one
who has had
an opportunity
of mixing
with
seamen
on
ship-board,
must
be aware
of this fact.
While,
on
the other
hand,
the neglects,
irregularities,
or inability, of the
medical
ollicers.
never fail
to create
discontentment
and
disgust.
In
the
petition
to
the lords
commissioners
of the admiralty,
made
by the delegates of the English fleet at Spithead, in the ever memorable
mutiny
that
prevailed
in
his
Britanick
majesty's
navy
in
the
year
1797,
when
the
command
of the
whole
fleet
was
usurped
by
the
seamen,
in
consequence of
what
they deemed
their grievances, one of the principal articles
referred
to the
neglect of their sick
on
board
the ships,
and the embezzlement
of such
neces
saries and comforts
as were allotted
by government
to their use.
This alarming
mutiny
could
not
be quelled,
until these grievances
were
absolutely
relieved;
and it was
deemed
prudent
and
expedient
to
issue
new orders
and
instruc
tions
from
the
office
of sick
and wounded
seamen,
respecting
the
medical
de
partment,
the strict observance of which
was required
of the surgeons.
Indeed,
I have myself
seen,
among
a number
of sick
seamen
with
whom I was
left
in
charge
at
the
navy
yard
of
this
place
[Philadelphia],
where
they
were
necessarily
huddled
into
a miserable
house, scarce large
enough
to
accommo
date
the
eighth
part of their
number —a
spirit
of
impatience,
and
even
of
revolt,
in
those who were
able
to discover
it, that
was
calculated
to contrive
the
most
serious
injury
for the service.
So
wretched
was
the hovel,
and so
destitute
of every necessary
comfort
for sick persons, in the charge of which
I was left witli thirty
patients,
(although
a
surgeon
had
been
between
five
and six years
on this station)
that every man who gathered
sufficient
strength,
and
was
successful
in getting
an opportunity
to effect his
escape,
absconded
Immediately.
The
replies
of these
men,
when I addressed
them
respecting
the
desertion
of their
comrades, were strongly
expressive
of their wearisomeness
and
impa
tience of such
disgraceful
accommodations;
and
their
disgust
and
sense
of
grievance
were uttered
in terms, that convinced
me the intention
to desert was
not confined to
a few of them.
Undoubtedly
Surgeon Barton's remarks had
some effect on those
in authority, for in the following
letter we see that the Secretary of
the Navy, the honorable Benjamin W. Crowninshield,
evidently
de
sired to expedite
the building of the hospitals.
Washington,
January
1st,
1815.
The Hon""" the Secretary of the Navy.
Sib : The designs of the Navy
Hospital,
are now within a few hours of being
finished,
and will
be presented
to you tomorrow
morning
about
one o'clock-
Having delivered
the only perfect copies in my possession to Mr. Hamilton, when
Secretary
of the Navy, I have been
obliged to make out a new set of drawings
from
my first sketches, and have devoted all my leisure since my late very pain
ful illness
to their
completion.
Mr. Dallns requested
me
the day
before
yesterday
to ask of you
the favor
to
meet
me
at his
office
in
the Treasury.
If
tomorrow
(Friday)
this
favor
could be granted to me. I shall
be much obliged.
No. 4.
635
BENJAMIN HENRY
LATROBE.
The designs
of that part of the Marine hospital
which
is proposed to be first
built, I have
seen in possession of the Commissioners
of the Navy
within a few
months.
1 am very respectfully,
Yr.
Obed.
Servt.
B. H. Latrobe.
No evidence exists that Latrobe's design
was ever used.
The first
naval hospital at Washington
was established
in a building rented for
that purpose near the navy yard.
This was succeeded by one estab
lished
at the navy yard, which
was discontinued in
1843,
when
the
sick were transferred to marine headquarters.
The Civil War caused
these accommodations
to be insufficient,
and a temporary hospital was
established
in the grounds of the " Government Hospital for the In
sane." and
used until October
1.
1866,
when
the naval hospital
on
Pennsylvania
Avenue near the navy yard was completed.18
From November, 1815, until Latrobe
severed his connections
with
the Capitol,
the records
show many protests
from
the commission
ers against
the slow progress
of the work
and against him giving
too much attention to private matters, for Latrobe
had many private
interests
and enterprises which he was endeavoring to manage
con
temporaneously with his work on the Capitol.
Both he and the com
missioners were fretting, he, because he felt under too much restraint,
and they, because he gave, according to their
ideas,
too little time
and attention to the public work.
April 24,
1816, Congress abolished
the commission of three who
had
been
put in
charge
of Government buildings
and
authorized
the appointment of
a single commissioner at a salary of $2,000
per
annum,
Samuel Lane, of Virginia, being appointed to fill this posi
tion.
On
October
31,
1817,
Mr.
Lane
made
Capt.
Peter
Lenox,
clerk of works at the Capitol
against the protest of Latrobe.
This
appointment
was
the
cause of Latrobe
sending in his resignation
to President Madison, who does not
seem
to have raised
any
objec
tion to this
action, but referred
it
to
the
commissioner,
through
whom it should have come.
The commissioner answered
as follows
:
November
24,
1817.
B. H. Latrobe.
Sib: Having seen your letter
to the President
of the United
States
resigning
the appointment
of Architect of the Capitol, I have
to inform you that
your
resignation is accepted and to request that
you will deliver
to Captain
Lenox
all
the
books,
plans,
instruments,
etc.,
belonging
to
the
public
in
your
pos
session.
Yours.
Samuel
Lane,
. Commissioner
of Public Buildings.
"Notes
on
Naval
Hospitals,
Medical
Schools,
and
Training
Schools
for
Nurses,
by
J. P. Ontewnod.
passed
assistant
surgeon. I'nlted States
Navy,
1893.
636
Vol. XVII
BENJAMIN
HENRY
LATROBE.
After
the
acceptance
of
his
resignation,
Latrobe
removed
his
family
to Baltimore.
There he was engaged
to build the Exchange
on Gay Street and
to supervise
the construction of the
cathedral,
which
had
been
started
in
1805.
The
building
of
the
Exchange
was commenced
in
1817 from
a design
made by Mr. Latrobe
while
he was in Washington.
The cathedral, in point of size and solidity
of execution,
is his greatest
work.
The Bank of Pennsylvania
was
long considered
as the most beautiful
; but
while it
does
not yield
to the cathedral in taste or execution,
it is of course inferior in size.
After
his removal to Baltimore,
Mr.
Latrobe
decided
to
go
to
New Orleans with
a view to completing the waterworks there which
had been commenced
by his son and in which so much of his fortune
had
been invested.
Leaving
his family
in Baltimore,
he
went
to
New Orleans by sea in 1819 and began assembling
the engines
which
he had
had built in Baltimore.
In
1820
he
retnoved
his family
to
New Orleans, with
the intention of making that city his
residence
until
the
waterworks
were
completed
and
their
success
certain.
His
work
progressed
rapidly.
The
engine
and
pumps
were
in
stalled
and
in two
weeks
the entire work
would
have
been
done
and water flowing through
the streets, but on the very day
that
he
was
engaged
in superintending
the laying
down
of
the
pipe
con
necting the pumps with the Mississippi
he was stricken with yellow
fever and in
a few days he was dead.
He was buried beside his son
in one of those cemeteries
in New Orleans which he had
described
so vividly in his journal.
EDITORIAL.
EDITORIAL STAFF.
Lieutenant
Commander
W. M. Kerb, Medical
Corps, United
States Navy.
Lieutenant
J. W. White,
Medical
Corps,
United
States
Navy.
Lieutenant
E. Pbt»hson, Medical
Corps,
United
States
Navy.
YELLOW
FEVER IN RETREAT.
In connection
with
the article on " Yellow fever in St. Thomas
with
special
reference
to
its
spontaneous
elimination,"
by Lieut.
E. Peterson, Medical Corps. United
States
Navy, which
appears
in
this number of the Bulletin, it seems proper to recall the remarks
concerning
yellow fever made
by George
E. Vincent,
president of
the Rockefeller
Foundation,
in his review
of the activities
of the
Foundation in 1921.
President Vincent
summarized as follows
the
salient facts about yellow fever
:
" Probably prevalent in Aztec times in Mexico and Central Amer
ica; for last two centuries
a dreaded
scourge
in Mexico, the West
Indies, Central and South America, frequently invading North Amer
ican ports and causing thousands
of deaths in the lower Mississippi
Valley; fact of transmission of bite of female
Stegomyia mosquito
established by American Army Medical Commission under Reed in
Cuba, 1900-1901;
Habana
and
Cuba freed from
fever
by Gorgas,
who organized antimosquito measures
1901-2;
example
followed
in
Rio
de Janeiro
and
Vera
Cruz,
1903-1909;
Panama
Canal
Zone
successfully
protected
by same methods,
1904^1906;
fear that canal
traffic might carry disease to Far East and the confidence of Gorgas
that fever could be eliminated led to appointment in 1916 by Inter
national Health
Board of special
commission
to survey seed
beds of
infection
; Gorgas, head of commission,
recommended
a campaign of
extermination; during delay
caused by war, Noguchi, of Rockefeller
Institute of Medical
Research,
visited Ecuador, Peru,
and Yucatan,
isolated germ believed
to be inciting
cause of yellow fever,
and pre
pared
vaccine
and
serum,
1918-1920;
yellow
fever
commissions
or
ganized in Central American countries, Colombia, Venezuela,
Ecua
dor, and Peru; intensive
campaign, 1918-1919, under Connor elimi
nated
disease from Guayaquil,
the chief endemic
center;
1920, com
mission sent to West Coast of Africa to investigate suspected
areas;
with occasional
outbreaks,
most of them traceable
to places in south
637
638
Vol. XVII
EDITORIAL.
em Mexico, the fever gradually
gave ground ; late in 1920 Mexican
Government organized commission
and invited cooperation of Inter
national Health Board.
" Up to the beginning of 1921 experience with Noguchi's vaccine and
serum indicated that the former when properly administered affords
a
marked
protection
against
attacks
of yellow
fever,
and
that
the
latter if it is used on or before
the third
day of the onset of
the
disease reduces the mortality in
a striking
way.
Data reported dur
ing last year confirm these
conclusions.
In Peru, of
a group of
50
nonimmune
soldiers who
were being sent into
an infected district.
25 were
vaccinated
and
25
were left
unvaccinated.
Twenty
of the
latter group
contracted
yellow
fever,
while
no
case
of the
disease
occurred
among members of the former.
Of 12 yellow-fever
patients
in Belize, Honduras,
who
were treated
with serum
on or before
the
third day of the attack,
11 recovered.
Until yellow fever is eradi
cated at its sources, the vaccine
and serum
promise
to be most valu
able means of prevention and cure.
" With the entrance of the Mexican Government early in 1921 into
the
yellow-fever
campaign
the
prospects
of
successful
advance
brightened.
The chief remaining sources of infection were attacked.
During
1921 Ecuador,
Honduras,
Nicaragua,
and
Costa Rica were
not invaded by the disease.
Guatemala reported no case after Febru
ary 2; Salvador's last case
was recorded
February
15; by July
16
Peru was free, as was British Honduras
in November.
From north
ern Brazil cases were reported,
but the situation was being dealt with
by the Government. It was gratifying to the Foundation
to be able
to advance
money
for continuing
the campaign in Peru
at
a time
when Government funds were not quickly available.
The advantages
of having
resources
which
could
be immediately
mobilized
in
an
emergency
were strikingly demonstrated.
It
was another example
of the efficiency
of a unified plan of cooperation.
The outlook
is
encouraging; it is too early to proclaim
a complete
victory, but the
purpose
to push
the fight against yellow fever remains
steadfast."
(W. M. K.)
BUBONIC
PLAGUE.
In connection
with Surgeon McCoy's excellent
lecture on some fea
tures of plague which was printed in the last number of the Bciae-tin.
it is interesting
to read
some
remarks on plague by Dr. M. Neveu-
Lemaire, which appeared
in La Presse Medicate of May 31,
1922.
After describing the primary
and secondary
endemic
foci of the
disease and the manner in which it has affected the colonies of France
in the past, the writer continues
his discussion,
in part,
as follows:
Since the most remote times, it has been noted that epidemics
of
plague
were always preceded by a considerable
mortality
among the
No.
-t.
639
EDITORIAL.
rats of the locality.
Rats are not, however,
the only animals capable
of harboring the bacilli of plague.
Mammals which are capable of
spreading the infection are sufficiently
numerous.
They are particu
larly the rodents—mice, marmots,
and the spermophiles.
Mammals
belonging to other classes, such as the dog, the cat, monkeys,
sheep,
the hog, and the donkey
may convey the disease.
However, the great
disseminators
of bubonic
plague
are two species of rat, found in all
parts of the world, the sewer rat and the black rat.
The sewer rat, Epimys norvegicus (mus decuvum.ua)
,
is
also known
by
the name of gray rat, city rat, or brown rat.
It
is
longer than the
black rat
;
its coat
is
fallow gray on the back, grayish on the belly
;
its ears are the length of one-third of the head
;
its tail thick at the
base,
is
a little shorter than the trunk.
An interdigital
membrane
unites the claws at their
base.
This rat, more
common
than
the
other, originates from the Orient
and,
about two centuries
ago, in
vaded the Occident following the great famines which raged in the
Asiatic regions.
It
is
very prolific
and resisting, chasing the black
rat before him
;
it
lives particularly
in the country and in the interior
towns, inhabiting
especially
the sewers, cellars, and
the subsoil.
It
is
important
as
a
propagator of an epidemic,
because
it
emigrates
readily, swims easily,
and
can disseminate
the malady through
the
country from village to village and from city to city.
There exists
a
brown
or black variety Epimys norvegicus maurus,
which
must
not be confused
with the following
species.
The
black
rat, Epimys
rattw
(Mus
rattus).
is
known
as
the
domestic
rat or garret rat.
Smaller than the preceding variety,
it
is
distinguished
by its black coat on the top, gray underneath
:
by
its ears, longer than half its head;
by its tail, slim at the base and
a
little longer than the trunk; and, lastly, by the absence of an inter-
digital
membrane.
Probably
of Asiatic origin,
it
has
existed
in
Europe
since
the Middle
Ages, lives chiefly in the upper stories of
houses, but also
on ships and
on docks
where
foodstuffs
are kept.
Equally as prolific,
it
emigrates
less than the preceding species, and
swims
less easily.
A variety of this species, Epimys rattus alexan-
drinus, which
resembles
in color E. jwrvegicva, although
it
has
a
blacker back and
a
whiter stomach,
is
found in certain warm regions,
such as Italy and Egypt.
Plague
is
transmitted from the rat to man by means of the flea.
The role which this insect plays was established
in 1898 by
a
French
physician, P. L. Simond.
Fleas
are
temporary
parasites,
and
each
species
is
generally
adapted
to
a
particular
host, but the specificity of this parasitism
is
not absolute,
and the majority
of fleas can pass from one animal
species to another, which explains the transmission of the malady
from rat to man.
In an investigation by A. W. Bacot. 34 different
640
Vol. XVII
EDITORIAL.
species of fleas were found on various rats, but these rats were not
the normal hosts of the majority of the species of flea.
Ordinarily
about
a dozen species of flea are found on rats.
Among
them, two
species play an important role in the transmission of plague—Cera-
tophyllus fasciatus and Xenopsylla
cheopsis.
A flea commonly
found
on man, but rarely on the rat, Pulex irritans,
can play a role in the
transmission of plague from man to man.
"6'eratophyllus fasciatus is distinguished from the other two
spe
cies by the presence,
back of the prothorax, of a dark
denticulated
cape, called the thoracic comb.
This flea normally
lives on the rats
in Europe, in India, and in Egypt; it transmits plague from rat to
rat
and
can
remain infected
45
days,
according to Gauthier
and
Eaybaud,
and 67 days, according to Bacot.
It seldom
attacks
man :
therefore is not especially dangerous.
" Xenopsylla
cheopis
possesses
no comb ; it resembles
a great
deal
the flea of man, even though its color is a little clearer ; the presence
of a bristle which is inserted
before
the eye is the point which dif
ferentiates
it from the latter.
This flea is a normal parasite of the
rat in all warm regions, but it can also live and be reproduced in the
temperate
countries.
H. Violle has observed it in great proportion
in Paris on the sewer rat, even during
the cold season.
While it is
the
habitual
parasite of the
rat, it readily
bites
man
and
passes
readily
from
one
host
to
another.
This
species
is the
principal
propagating
agent of bubonic
plague from rat to man.
It remains
infectious from
36 to 43 days,
and
the plague bacilli
live in much
greater
number in its organism than in that of CeratophyUus
fasci
atus or of Pulex irritans.
" Pulex irritans
is man's own parasite,
which can, nevertheless,
be.
exceptionally found
on various domestic
animals and
even on rats;
it is a cosmopolitan species, abundant during the hot season in the
temperate
climates
Its
role
in
the transmission
of
plague
from
man
to man
is certain, although
the bacilli
are less numerous
and
live a shorter time in the flea's stomach
than in that of Xenopsylla
ckeopis.
Zirolia
and Verjbitsky have
observed
plague bacilli
in
the
dog
flea, Ctenocephalus
canis, and they have succeeded in experimentally
transmitting
the malady with the aid of this insect.
Verjbitsky
has
obtained
analogous
results
with
the
cat
flea,
Ctenocephalus
felis,
but on the contrary,
experiments
made
by the English
commission
to India with this same species have
been negative.
A rat flea of
Asia,
CeratophyUus
anisus,
is able to transmit
plague from rat to
rat, but it will
not
bite
man.
Lastly, the
mouse
flea, Leptopsyfla
musculi, can harbor plague bacilli;
and by means of it Verjbitsky
has succeeded in transmitting
the malady from rat to rat.
No. 4.
641
EDITORIAL.
Experiments
have also been made with bedbugs. Cimex lectularius,
which is easily infected by the plague bacilli, but a large quantity of
the bedbugs so infected die.
In the
case of the surviving
ones, the
bacilli multiply
and the intestinal contents of the insect remain viru
lent at the end of 48 days.
Cimex rotundatus acts in the same man
ner, according
to the experiments
made by Cornwall and Menon in
India
in
1917,
and this species remains infected
as long as 38 days
after the bite.
However, in the case of bedbugs, the development
of
the plague bacilli
is a great deal slower than in the case of fleas and
their role in the transmission of the plague must
be very slight, if it
exists at all.
As it is known that certain rats
are the reservoirs of the plague
bacilli, and that the fleas which they lodge, more particularly
Xenop-
sylla ckeopis,
are the transmitting
agents,
it is quite
simple to
ex
plain the evolution of the epizootic among
rats
and of human epi
demics.
When
a rat dies of the
plague,
the
fleas which it lodged
leave its corpse
and attach
themselves
to other rats,
as soon as they
find them,
which
they
contaminate.
Thus
the malady
among
rats
is spread.
In
the
regions where
plague
is endemic,
in India for
example, the fleas have the opportunity,
when
rats diminish
follow
ing an increase
in their mortality,
to bite the
natives,
thus trans
mitting the malady to them, so that the human
plague is always asso
ciated with an epizootic in rats.
According
to Violle,
1 cubic centimeter
of plague blood contains
100,000,000
bacilli,
so that one flea which
bites
a sick rat can
accu
mulate
probably
5.000
germs
in its stomach
cavity.
But by what
mechanism
does the
flea transmit
those bacilli when
it afterwards
bites an animal or individual?
By analogy with what occurs in ma
laria, it was at first believed that the plague bacilli could
be found in
the salivary
glands of the
flea and that they
were thus inoculated
with
the
saliva,
but
this
hypothesis had
to
be
abandoned
as un
true.
It was
determined
that after
a flea
had
bitten
an infected
animal no plague bacilli is found in that portion
of the digestive
tube
between
the
mouth and the
proventricule,
but
they
are
nu
merous in the stomach,
and the fact that they are so numerous
proves
that they have multiplied,
but the valve formed by the proventricule
prevents
them normally
from leaving the stomach
and being inocu
lated
through
the medium of
the
buccal
portions
of
the
flea.
It
has been noted that the flea, while it bites, drops from time to time
its excrement on the skin, and this excrement,
containing
numerous
plague bacilli, is infectious.
This is not, however,
the most common
manner of transmission.
In 1914 Bacot and Martin, experimenting
with Xenopsylla cheopis
and Ceratophyllus
fasciatus, observed
that
a certain number
of these insects suffered
from an obstruction of the
alimentary
canal.
Later investigations
demonstrated
that in these
642
Vol. XVII
EDITORIAL.
cases
the plague bacilli
had
been
multiplied
to
such
an
extent
in
the
proventricule
and
in
the
stomach
that
they
had
formed
a
compact
mass, incapable
of being
evacuated.
Fleas
so infected
are
more
famished than
normal
fleas.
When
they
are
placed
on
a
host
they
suck
with
vigor,
but the
aspirated blood can
not
pass
through
the stomach.
Therefore,
when
the effort ceases,
the blood,
which has been
aspirated and has come in contact
with the plague
bacilli,
is contaminated,
and
as it is regurgitated
into
the
wound
by
force
infection
occurs.
Regurgitation
being
produced
many
times
in
succession,
the
result
is
that
the
number
of
inoculated
bacilli
is augmented.
In the
case
of bedbugs,
the anatomical dis
position of the
digestive
tube
not permitting
the blockage which
has just beeen mentioned,
the excrements
only are infectious.
Some
authors admit that several bites are necessary to transmit the plague,
but Swellengrebel
has
succeeded
in
infecting
43
guinea
pigs
out
of 45 by one bite of Xenopsylla
cheopis.
How can the appearance
of an epidemic
far away
from the orig
inal home of the malady be explained?
Let us suppose that a ves
sel, having
been
contaminated
in
an oriental
country,
arrives
at
an European. African, or American
port.
Black rats infected with
plague
have
slipped
aboard
with
the
cargo;
a
great
number of
them
have
died during
the voyage
and their bodies
have
remained
at the bottom of the hold ; those which have survived may have left
the vessel
upon its unloading and may have gone to die in the market
places
near
the
docks
and
the
warehouses,
where
native rats
are
usually
found in
abundance.
The latter
are
contaminated
by
in
fected
fleas which have left the imported plague-infected
rats,
and
a veritable epizootic is started
among
them.
The majority,
fright
ened
by
the
mortality
among
them,
emigrate
and
take
refuge in
dwellings, or they in turn contaminate,
through the medium of their
parasites,
the
domestic
rats living in garrets and under
the roofs
of houses.
Fleas leave the latter, and finding
no other rats to bite,
the
greater
part of
them
having
died
and
the
survivors
having
emigrated,
fall
upon
man,
whom
they
contaminate.
Thus
have
started
a great
number of epidemics
of plague
which have raged
at
different epochs in diverse
regions of the globe.
The prophylaxis
of plague,
as that of yellow fever, can
be effica
cious,
when
the knowledge of the etiology which has been
acquired
is applied.
In order to prevent
plague
from being
spread a
great
distance,
it is first necessary
to refer to certain international
meas
ures.
Each country must take the precautions
necessary
to prevent
the scourge
from spreading, and this general
prophylaxis
must con
sist,
above all, in the destruction of animal carriers of virus
and
of the vectors of the pathogenic
germ
: that is to say, of the rats and
the fleas.
The means of deratization
are many; they
consist,
either
No. 4.
643
EDITORIAL.
of destroying
the rodents
by means of virus, of traps, or of toxic
substances,
or by causing them
to perish in depriving
them of all
that
can
serve
as
food or
shelter.
The
destruction
of
fleas
and
bedbugs
is
also
obtained
by
different
processes;
the
insecticides
most commonly used are carbon disulphide and oily substances, such
as petroleum, naphtha, etc.
When
an epidemic
has been discovered,
in spite of tbe precautions
which
have
been carefully
taken, the individual
must
then
protect
himself.
This individual
prophylaxis
is especially
necessary for per
sons called upon
to administer to the sick.
Besides
the precautions
used
for all contagious
maladies,
one must
be
protected,
moreover,
from the bites of fleas by wearing a one-piece garment,
fitting closely
at the neck, at the wrists, and at the ankle, similar to the contrivances
which are used by mechanics or aviators.
The ■wearing of a mask is
recognized
as being the only means of efficacious
protection against
the pneumonic
plague,
and certain types of masks,
used against gas
during the war and conveniently modified, could be utilized
to that
effect.
Finally, preventive vaccinations, the technique of which need
not be dwelt upon here, should
be administered not only to the hos
pital personnel
and
to men engaged in deratization, but to all the
inhabitants of an infested
locality,
(w. m. k.)
ON FAULTS
IN WRITING.
Not long ago, Dr. George
H.
Simmons,
editor of the Journal
of
the American Medical Association,
was called upon to give an ad
dress as president
of the Chicago Institute of Medicine.
He selected
as his subject " Medical periodical literature.'1
upon which he is well
qualified to speak, because of an acquaintance
of nearly 30 years with
medical journalism.
He began by reviewing the growth of the medi
cal periodical in the United
States.
When Oliver Wendell Holmes
was chairman of a committee of the American Medical Association on
medical
literature, in 1848, only 20 medical
journals
were published
in this country.
The number had risen to 230 in 1903. but it has since
declined
to
120.
Doctor
Simmons notes " a distinct
change
in the
type of papers appearing in medical
journals
to-day
as compared
with 20 years
ago.
The therapeutic article of the past, replete with
favorite prescriptions, often proprietary
in character,
has given way
to scientific contributions on therapeutic methods, on pharmacology, on
pathology,
on etiology, on methods
of diagnosis, on prophylaxis."
Although
the number of medical journals has decreased in late years,
the volume of writing for publication has not undergone
any dimuni-
tion. for the Journal of the American
Medical
Association
is now
receiving
about 1.500 manuscripts a year, exclusive of the papers sub
mitted to the sections of the annual meeting.
It
seems
that about
644
Vol. XVII
EDITOKIAL.
three-fifths of the manuscripts voluntarily
offered
are returned, and
Doctor Simmons devoted the greater part of his address to a consider
ation of the reasons for the rejection of the majority
of the papers
submitted for publication.
One reason for rejection is lack of space.
Some of the
papers
received
are excellent
both in the matter treated
and in the manner
of presentation,
and
there
is
no
doubt
about
their
acceptability.
Many papers
are too long, but one that is informative, that presents
new
facts or practical
information,
is not returned if fairly
well
written, though it may
be necessary,
with the author's help or ap
proval, to shorten or revise it.
The question of the proper length of
a paper, like Einstein's
theory as to space and time,
is a matter
of
relativity.
A paper of 500 words may be long; one of 5,000 may be
short.
Undue length is a common
fault, and Doctor Simmons finds
three chief reasons for it.
The first is " rambling," due to the absence
of a plan, so that the author repeats himself and meanders
to reach
a given point.
As a remedy,
cross headings are recommended,
not
only because in a paper of any length they
are of assistance
to the
reader, but because the task of introducing
them reveals to the writer
defects
in the logical arrangement of his matter.
If the proper
be
ginning is not apparent, Doctor
Simmons
recommends
the
author
to "go right to the
subject
without
preliminaries;
to begin in the
middle if necessary
; when the end is reached the difficulty of the be
ginning will often have disappeared.
The second
cause of undue
length is verbosity, which
is to
be
remedied
by revision.
When revising
a manuscript
one ordinarily
finds many words, phrases,
clauses,
sentences, and occasionally
even
paragraphs that can be struck out without detriment to the meaning.
Such deletions
not only save space but improve the
style
and help
the reader.
The third fault is the tedious discussion
of nonessential
details.
In an extreme
form this fault is displayed by papers in which
the
author, who has a new fact or observation to make, buries it under
a mass of material which often takes the form of a long historical
introduction.
The real remedy
for the defects
which
Doctor
Simmons
sees in
paper after paper received at the editorial
office of the Journal- of the
American Medical Association
is,
in his opinion,
a
more careful study
of the art of writing and
a
thorough revision of all papers
submitted
for publication.
In support of this he quotes Sir Clifford Allbutt's
method,
as described
in his book, Notes on the Composition of Scien
tific
Papers.
The
plan of this well-known
medical writer
is
first
to put down ideas and facts on slips of paper and sort them
under
headings; then to make
a
first draft and revise it; then
a
second and
No. 4.
645
EDITORIAL.
revise it; then
a third and revise it; and then to put the whole
away
for at least a week " in order that the final reading may he done with
refreshed
attention."
It may
be noted
that this
method
was
also
employed by Lafcadio
Hearn in all his writings.
Sir William Osier
wrote in much
the same
way.
During an inspection of some
of the
manuscripts
in the Osier library,
Doctor Simmons was able to trace
one article through its various stages: First there were notes on odd
bits of paper,
evidently written
at odd
moments:
then
there
was
a
rough outline on the paper in long hand; then
the first typewritten
copy,
with
interlineations,
transpositions,
and deletions;
next
the
second typewritten copy, which had been considerably modified ; and,
finally,
the
third
typewritten
copy,
which
had
been
sent
to
the
printer.
"If." Doctor
Simmons
asks, "this
is
the method
of the
masters, what about the rest of us? "
(w. m. k.)
PAI.NFIT.
HACK
AND FEKT.
A symptom
which is most difficult to treat is pain in the back and
in the
feet.
It is
a
symptom
commonly
encountered
at sick
call,
especially if some distasteful duty such as coaling ship is impending,
and is a condition prone to be exaggerated.
Where objective
symp
toms, such as involuntary
protective
muscular spasm and periarticu
lar swelling, are absent, advice regarding proper methods of walking
and standing is all that is indicated in the way of treatment.
For
a patient without objective
symptoms
who complains that he can not
perform his duties,
a routine back or foot treatment
which keeps him
either flat on his back in bed or occupied
with
an intensive course
of corrective
exercises
should
be
prescribed.
The
malingerer,
or
rather the exaggerator,
as most of them are. tends either to progress
rapidly toward a cure or to a request for return to duty.
In a case
of this sort, if the condition proves
to be more serious
than at first
it was believed
to be. no harm has been done by this treatment
: and
if the patient be a malingerer, it will serve
as a warning
to others
appearing at sick call with similar motives.
Pain in the back and in the feet comprises
the principal
complaint
of a large majority
of patients
seen in orthopedic consultation and
often occurs in both localities in the same patient, which in itself
suggests some associated
etiological
factor.
If organic disease can
he ruled out and there is no history or evidence
of definite
trauma,
the condition
may
be due to faulty
posture
resulting
from lack of
muscular
tone,
actual
muscular weakness,
overweight, or habit— as
walking with
the
toes turned
out.
A healthy
adult
instinctively
stands correctly if there
is nothing to prevent
him doing
so.
The
aborigines
never
were instructed in the proper methods of walking
or standing, yet the posture
was such that we can profitably
study
4539—22—7
646
Vol. XVII
EDITORIAL.
it and learn much
therefrom concerning correct
bodily
mechanics.
Faulty posture
is often the price paid for civilization.
Where muscles
are inefficient,
either from misuse, lack of tone, or
weakness,
the
erect
posture
is partially maintained
by
ligaments
primarily
intended
for
another
purpose.
Pain, which
is
nature's
warning
that something
is at fault,
is the result. If this warning
be
disregarded, nature calls into play
a protective
spasm
of
the
muscles
about the affected part which stiffens
the joint and enforces
rest.
It is the primary function of ligaments to maintain the struc
ture and relation of the elements constituting the joint in opposition,
and to limit the extremes of motion ; therefore, when the erect posi
tion is maintained without
the proper
use of the muscles,
the indi
vidual must employ the ligaments to
a certain extent
for this pur
pose.
This explains the abnormally acute curve in the lumbar spine
and the everted
foot often seen
in individuals
complaining
of pain
in the lumbar region and in the feet.
In the erect posture,
the lower portion of the spine
and the tarsus
are most affected by gravity
when
there
is a general
lack of tone to
the muscular system.
Less weight is carried above the lumbar spine,
and what is carried is supported at a better advantage,
as the spinal
column is more vertical.
The other
joints entering into the main
tenance of the erect posture
are the hips and knees, both of which
have
a greater
excursion
of motion in locomotion, thus, temporarily
at least, relieving the strain from the ligaments which on standing
or sitting
are not held
at their extremes of motion.
This explains
the frequency of symptoms
in the spine and tarsus.
In the
treatment
of these conditions
the cause of the
muscular
relaxation
must first
be investigated.
Frequently
the lack of mus
cular
tone is only
a manifestation
of
a general
atonic condition.
The patient is often one who is not making a success
in life, is some
what overweight, has possibly
a transient glycosuria, and is not par
ticularly active.
When the cause of the atonic condition
has
been
determined,
one should endeavor
to relieve
the affected
parts from
strain by the prevention of weight bearing, after which nature
can
be
assisted
in her repair of the damage
done by such
an agent as
physiotherapy.
When
all
evidence
of strain
has
disappeared,
exercises
without
weight bearing
should
be
begun
in order to mobilize the affected
joints
as much
as possible.
Instruction
in the proper
mechanical
use of the body should
be
given
the patient at this time
in order
that, after all symptoms
of strain
have
subsided
and
the
stiffened
joints have
been mobilized, he may know how to hold himself erect
and walk properly
when weight bearing is finally permitted.
Exercises
with
weight
bearing
are
then
to
be taken
up
in
an
attempt
to strengthen
the weak muscles.
These
should not be con
No. 4.
647
EDITORIAL.
fined
solely to the muscles
affected,
although most attention should!
be directed toward them, for, if the tone of the general
musculature
can
be improved,
the delinquent
muscles
will
be
more
apt
to
re
spond.
The
use of such apparatus
as back
braces
and foot braces
should
be discouraged in these purely postural
cases
except
as
an
aid to maintain
the proper
posture
until
the patient can retain it
himself,
(j. w. w.)
ON
THE
PREVENTION
OF
CARDIAC
DISEASES.
In late years
much
effort has been devoted
to the prevention of
tuberculosis
and
infant
mortality,
and now
the prevention of dis
eases of
the
heart and
of
the
circulatory
system
is beginning
to
claim its share of attention.
Statisticians
have disagreed
as to whether or not
diseases of the
heart and of the circulatory
system
have increased
during
the past
several
decades, but there are in the United
States
a great multitude
of
persons
in various
age groups
afflicted
with
such
disease.
It
has been stated that if it were possible
to bring together
every per
son in the United
States in whom cardiac disease had been definitely
diagnosed, we would assemble sufficient cardiacs to equal or possibly
outnumber
the population
of the city of Chicago.
If we were
to
add
to
this number the
persons
in this country
who suffer from
arteriosclerosis or from chronic renal disease, we might have a cardio-
nephritic population larger in size than that of the city of New York,
which
is now
estimated
at 5,753,151.
An average of 2 per cent of
the
persons
examined
by life-insurance
companies
are rejected
each
year
because of
a variety of organic heart defects.
In connection
with the examination of men who were drafted into military serv
ice in the recent war, it was reported that of 2,400,000
examined
5
per cent showed organic cardiac defects.
The role which heart diseases have played in causing poverty and
adversely affecting the lives of entire families
because of the crip
pling of the wage earners
is difficult to estimate, but it no doubt con
stitutes
a very substantial and serious
factor in the social lives
not
only
of the
several
million
suffers
from
these
diseases but among
their
dependents
as well.
The studies
of various men recently pub
lished indicate the necessity of more intensive
study of a number of
occupational
groups
which
are
particularly
subject
to
industrial
hazards.
Dr. Louis I. Harris, who
has contributed
to the Nation's
Health
recently
several
articles
dealing
with
the
prevention
of
cardiac disease, believes that such special occupational studies
would
reveal
a very much higher percentage of cardiac defects in a number
of industries than was found to prevail
among
insurance applicants
or men drafted
into military service.
There
is fairly
definite
evi
648
Vol. XVII
EDITORIAL.
denoe
that
in men employed
in the iron
and
steel
mills,
especially
when their work brings them in close proximity
to the various types
of furnaces
or processes which subject
them for comparatively
long
periods to high
temperatures,
the
incidence
of myocarditis
is
con
siderable.
It would be of great
value to learn more about the preva
lence of organic disease among stationary and marine firemen,
as well
as to determine
from among the great mass who are commonly desig
nated
as " laborers " the relation of physical strain or exposure
to
excessive
heat and other factors present
in
the various occupations
of the laborer, to the development
of organic cardiac disease.
Un
fortunately for science, the Navy can throw little light on this point
because
of the comparatively
short
time
a fireman
remains
at this
arduous
work—promotion soon separates
him from the coal
shovel
and slice bar— but the point is worth keeping in mind.
It is definitely known that heart
diseases result from focal infec
tions,
also from the various infectious diseases, as well as from per
verted
functioning
of various organs possessing
internal
secretions.
Cardiac and arterial diseases are most intimately related
to syphilitic
infection.
Among the commoner
causes of organic heart
disease one
finds
a variety of toxic agents
incident to faulty
metabolism
or
to
lack of
care
as to
personal
hygiene
and
toxic
agents
arising
as
a
result of
various
diseases
as well
as those that occur
in
industries.
Long-continued physical strain
is an important factor.
In an indirect way, mental
and nervous strains, excesses of various
kinds, as well as other factors in the home or industry which induce
fatigue may act as indirect causes of cardiac disease.
Preventive
medicine
is particularly
concerned
in the early
recog
nition of cases in which any
one of the numerous
causes may
have
operated
to
produce
damage
upon
any
part of
the
heart
or
the
vascular system,
so that such
persons
may
be shielded
from
these
causes
and those preventive
measures applied which are appropriate
to meet the problem
of reducing the incidence
of cardiac diseases
at
the various
stages of life.
In instituting
preventive
measures,
education
of the
masses
must
be conducted
with energy
and consistency,
and it must
be education
of a character
that shows in terms of dollars and cents that it pays
to safeguard the human
machine.
A great deal will be accomplished
when
people
can be persuaded
to submit to periodic medical
exami
nation.
Special study must be given to the question of the protection
of adolescents,
as it is during this period that vital changes
are being
effected
in
the human
organism.
Special attention must
be
given
those recovering from infections or other diseases which
predispose
to cardiac disease, and to those who are recovering from acute cardiac
disease or cardiac breakdown.
No. 4.
649
EDITORIAL.
Encouragement
should
be
given
to
the
establishment
of
work
shops for cardiacs
so that work of a suitable character,
done under
proper
medical supervision,
could
be performed
by
those
having
cardiac
defects
who
are
under compulsion
to
be
self-supporting.
There
is need of factory medical inspection of the most thorough
kind which will appraise the harmfulness of the various industrial
factors in their effects upon
the heart.
The short work
day should
be encouraged
wherever
severe mus
cular
exertion
or
other
factors
producing
marked
fatigue
may
be. found in the industrial
environment.
It is extremely
important
to warn
those with
a tendency
toward
the development
of diseases
of the heart and of the circulatory
system
against
the reaction
of
mental
strain,
worry,
rush
and
bustle,
unrestrained
zeal
and
am
bition, and of the far-reaching
effects which they
produce
directly
or indirectly
upon
the vascular system and upon
the heart.
Last but not least, provision
must
be made for the control of car
diac disease during childhood.
The foregoing constitutes
more or less an epitome of the tentative
program of the Department
of Health
of
the City of New York
for the prevention of cardiac diseases, which program
promises
in
time to reduce the rate of prevalence
of organic heart disease in that
city just
as tuberculosis and
infant
mortalit}'
have
been
reduced.
(w. M. K.)
IMMUNITY
AGAINST
MEASLES.
Although
in the year
1921 there occurred only
26 deaths
among
1.694
patients originally admitted to the sick list in the Navy for
measles,
the
death
rate
in civilian
communities,
especially
among
children
under
6 years of age, is high; in fact statistics show
that
it equals the death rate from smallpox before vaccination was intro
duced.
The introduction
of vaccination by Jenner
in
1796
was an
epoch-making
event in the history of preventive
medicine
and, as we
all know, the
practice
has brought
about
a diminution
in the in
cidence of smallpox.
According
to the Latwet for March
25.
1922,
it seems that we may
be on the
eve of
a similar
turning
point in
the prevention of measles, as Dr. Rudolf Degkwitz
(Deutsche
medi-
zmviche
IVochemcrift, January 5, 1922)
has found it possible
to con
fer immunity by the injection of serum
from a patient convalescent
from
measles.
Doctor
Degkwitz's
observation,
however,
is not
new, for Nicolle
and Conseil (Bull de U Soe. Med. d. hop.
de Park, April
12, 1918)
used
serum
from
a child,
the first
case
of
measles
in
a family
of
four children.
Two of the other children
were not
treated,
but a
child
2 years of age
was given serum
from
the first
case
taken
on
the
seventh
day
of
convalescence
and
10
days
after
the
first
650
Vol. XVII
EDITORIAL.
symptoms.
The other two children
developed
measles in three or
four
days,
but the 2-year-old
escaped
infection,
although
exposed
to the first child
and later to his two brothel's
who
had developed
the
disease.
Richardson
and
Connor
{Journal American
Medical
Association, April
12, 1919)
also report experiments in passive
im
munity on six children who were protected
against measles by intra
muscular
injections
of the
serum
of
a
patient
convalescent
from
measles.
In the March
number of Medical Science, Dr. J. D. Rolleston re
views
the literature
on this subject
up
to Degkwitz's
latest
article
in
which
he
gives
his
conclusions
based upon
the
inoculation
of
more than 1,700 children.
As we all know, the prodromal
stage of
measles,
before
the initial
rise
of
temperature
and
malaise
make
their appearance,
is highly
infectious, and it is impossible
to detect
and isolate
infected
cases early enough
to prevent
the spread of the
disease.
By the time
the
diagnosis
is made, all nonimmunes
who
have
been
in
contact
with
the
patient
may
have
been
infected.
Degkwitz
has
proved
that
by
inoculation
of
a small quantity
of
serum
derived from
a convalescent
patient, all the contacts
can
be
protected
completely
or to such
an
extent
that
they
only
develop
the disease in its mildest form.
The
success
of
the
inoculation
depends
upon
the
time
in
the
prodromal stage when it is given and the amount
of serum injected.
The
earlier
in
the
incubation
period
the child
is inoculated,
the
smaller will
be the
dose
necessary
to protect
him, and
vice
versa,
until
a stage
is reached
when if the inoculation
is
postponed
too
long no amount
of serum will produce
immunization.
Up to four
days from the date of infection,
2.5 cubic
centimeters
of the serum
is sufficient
to
protect
a child
under 4 years of age
from
measles.
This
dose
Degkwitz
calls the unit of protection.
On
the fifth
to
sixth day,
5 to
6 cubic
centimeters,
or two units, will
be necessary.
On the seventh
day
much
larger doses will not afford certain pro
tection,
and
on the eighth day
inoculation is useless,
as even large
doses, 30 cubic
centimeters,
neither prevent
the onset nor influence
the course of the disease.
According
to Degkwitz
the usual
period
of incubation
is four days; and applying
the
data given above,
he
advises the following
routine:
If in a case of measles the rash is just appearing, all children
who
have
been in contact
with the patient should be immediately inocu
lated
with
2.5
cubic
centimeters
of
serum
from
a
convalescent
patient and they will
be protected.
If the rash
is already 24 to 48
hours old,
5
to
6
cubic
centimeters
must
be
used
to
protect
the
other
children.
In
both
cases
the immunized children
may safely
be allowed in the room with the patient.
If the rash
is 72 hours old,
No. 4.
651
EDITORIAL.
8 to
10 cubic
centimeters
of serum should be given,
and in all prob
ability about two-thirds
of the contacts will
be protected.
No ill effects of inoculation
have been observed by Degkwitz,
who
is always careful
to exclude
syphilis
or tuberculosis in the donors.
His results have been uniformly pood within
the limits stated.
The
question of the duration of the immunity
is still uncertain;
33 days
is the shortest
observed,
but more
than
a year has been reached
in
other cases.
Degkwitz's
work
opens
a
field
for
experimentation.
Immune
human
serum
is difficult
to obtain on
a large scale;
therefore it is
highly
desirable
that an immune
animal serum
be developed,
which
might
be
produced
in any quantity
required,
and it would
be of
value to extend
these experiments
to adults with
a view to reducing
the incidence
of measles among
them.
(w. m. k.)
O.N FILAKIASIS.
It is well known that white people
may live for long periods of
time in tropical countries where
filariasis
is quite common
without
apparently contracting
the disease.
This in contrast
to other mos
quito-borne diseases, such
as malaria, yellow fever, and
dengue,
to
which the white man
is so susceptible.
Francis,
of United
States
Public Health
Service,
has presented
a few concrete
facts that pri
marily explain how mosquito transmission is accomplished
with much
less
degree of certainty
and
promptness
in filariasis
than in yellow
fever and malaria.
1. The microfilaria
does not multiply in the mosquito.
2. Only
a small number
of microfilariae
are imbibed
by the mos
quito when sucking blood, and a still smaller number
finally reach the
proboscis.
3. Multiplication of the filarial
parasite takes place in the lymph
gland of man and must be deferred until a male
and
a female
find
lodgment
within the same gland and there grow and develop
their
genital organs preparatory
to bringing about
a
fecundated
adult
female parent worm, permanently located in that lymph gland.
4. Maximum
opportunity
of infecting
mosquitoes
with filarise
is
limited to a few hours around midnight.
5. The microfilaria
is not injected by the mosquito
into the blood
stream of man, but deposited
on the skin, which the larva must pene
trate to find its way to the nearest lymph gland.
6. A comparatively small number of larvae find their way to the
proboscis of the mosquito;
a certain number pass into the hind gut
and are lost; and of those that pierce
the stomach
wall and lodge in
the thoracic muscles
where
the necessary
larval
changes
must
take
place, only
a small number finally find their way to the
proboscis.
652
vol. xvii
EDITORIAL.
The life of an infected mosquito
is probably shortened
by reason
of
harboring
the worms.
From above
facts it is readily
seen that a large number
of
mos
quito
bites
are
necessary
to bring
about
the
favorable
conditions
needed for propagation of the worms in men with subsequent
appear
ance of microfilariae
in the blood.
Culex quinquefasciatus
(syn.
fatigans)
has
been
proven to
be the
most successful
vector of this disease.
She is a night
mosquito
and
hence bites
at
a time
that is most
favorable for infestation.
This
factor
undoubtedly
has
some
bearing
on
the epidemiology
of
the
disease, in that the contact
between
the filaria-infested
native popu
lation
and
the white
residents
at this
time
is the
least,
the
latter
usually residing
in separate
sections
of the city or colony.
This
is
vitiated,
however,
to
a certain
degree
by the fact that C.
qttinque-
faseiatus is
a strong flier.
With regard
to the
role of
other
mos
quitoes
as
possible
transmitters,
both
Steyomyia
pseudosmtellaru
and S. Scutellaria
are proved
vectors.
Flu. of Batavia
(Dutch
East
Indies), recently
succeeded
in
infesting
two
anophelins, Myzomyia
htdlotci and M.
rossi Giles.
A large number of
larvae
perished
in
these mosquitoes,
however.
Aedes
col opus has never
been
proven
an
efficient
host of Filaria bancrofti.
Francis
found that Microfilaria
bancrofti
taken
into the mosquito's
stomach
did pierce
the
stomach
wall in limited numbers
and lodge
in the thoracic muscles, but there
they
died
as microfilaria? without
development
into the larval
stage.
In
discussing
the
various
accepted
factors
having
bearing
on
the spread
of filariasis. Flu points out that Batavia
is
a most suit
able place for such
a spread,
but that some
other factor or factors
undoubtedly
must
be responsible
for the rather small
incidence
of
infestation
in Batavia
(from
2.3
to
15
per
cent, according
to
the
location of the. various districts)
when compared
with that of other
countries where
the
incidence
varies
from
10 to
90 per cent.
Flu
believes that the relatively low figures
obtained
at Batavia
are due
to the transient character
of the population.
These transients serve
as traps for the filaria, absorbing
a large portion of the larva? from
the
infected
mosquitoes,
thus
reducing
the
chances
of
infection
among the settled population.
Maxwell
has
recently
published
a
rather
exhaustive
study
of
filariasis
in China.
In the infected areas of that country this dis
ease
plays
a
large
part
in diminishing
the working
capacity of a
considerable
number
of the manual workers and in rendering
many
of theni
altogether incapable
of work.
The geographical
distribu
tion of the disease in China is. according to Maxwell,
rather sharply
defined,
forming
a belt along the
coast
15 to 25 miles broad,
from
the Yangtse River to the Tonquin border, with
a tendency to extend
up along the various river valleys.
The infective index in this area
No. 4.
653
EDITORIAL.
is about 25 per cent.
Most of the islands off the coast are infected,
but not heavily.
The author finds that the causative
agent is nearly
exclusively Filaria bancroftl.
He
gives
a large array of clinical
manifestations,
which do not differ, however,
to any marked extent,
from those of other countries
where such heavy infestation is present.
Of particular interest
is what Maxwell
describes
as filarial
hemop
tysis—hemorrhage from the lungs occurring in patients
with filarial
infection,
correlated
in time
with
an attack
of filarial
fever,
with
or without manifest evidence of lymphangitis.
In some of the cases
the author found the microfilariae
in the expectorated
blood; tuber
culosis was excluded
as far as was humanly possible.
Another
rare
complication
of filarial
infection was gangrene
of the scrotum.
The
author
has
seen
eight
such
cases
and
finds that
the
condition
is
ushered
in by
a sharp attack
of fever,
accompanied
by redness
and
swelling of the lower half of the scrotum.
In a few days the lower
half of the scrotum
became black and comparatively dry, and if left
to itself gradually
sloughed
off.
(e. p.)
CLINICAL NOTES.
BRONCHIAL
ASTHMA IN
A CHILD
APPARENTLY
CURED BY INTRAMUS
CULAR INJECTION
OF PEPTONE
SOLUTION.
By R. H. Laninc,
Lieutenant
Commander,
Medical
Corps, United States
Navy.
There was
noted
in the Year Book of General Medicine,
1921,
an abstract of an article by A. G. Auld, of London, England, relating
to the curative results obtained
in
cases of bronchial
asthma,
par
ticularly with children, by the injection of peptone solution.
At the
time, being interested
in a case of severe bronchial asthma in a 9-year-
old boy, I suggested
to his mother that she allow
me to give him
this treatment,
in
as much
as thorough tests performed by an emi
nent Boston authority
had failed to reveal any anaphlyactogen sen
sitization which could have caused the condition.
The abstract
above mentioned
is as follows
:
This article presents extended results of the treatment
of asthma
by the use
of peptone,
by A. C. Auld. of London,
England.
These results
are based on
a fairly
large
number
of patients,
all of whom
received
treatment
for more than
a year previous
to the time this article was
written.
The method of Immunizing
depends on the type of case ; no reaction
appreciable to the patient
should
follow the injection
(intravenous), and
the
latter
should
be made slowly.
The treatment
has been
instructive
in respect to the grouping
of asthmatic
cases.
Two
main
groups
occur,
which
show
no tendency
to pass
into
each
other.
One group comprises such patients
as quickly respond to the treatment,
and in whom the effect is more or less lasting,
the recurrences
being infrequent
and milder
in
character.
The other
group
is
resistant,
and
is
subdivisible
into such patients
as are totally resistant
and those in whom by careful immu
nization the disease may be largely
overcome.
,
The
first
group
presents,
as
a
rule,
most of
the" following characteristics:
General
good
health,
little family predisposition,
limited
duration
of the dis
ease though
a variable
factor,
regularity in the recurrence
of attacks,
freedom
from bronchitis,
and emphysema.
Brief records of two patients
in this group are cited.
The first was
a man
22 years
old,
who
had
suffered
for four
years.
After
seven
injections
the
attacks
began
to yield, and ceased
entirely after
the tenth.
The second patient
was
a woman 37 years old.
She had suffered
from asthma for four and a half
years.
After eleven injections she remained
quite
free for five months,
when
the disease returned
in a milder form.
Another
short course of treatment
was
given,
and during the next year she had only three slight attacks.
The author
states that
no one responds better to the treatment
than children.
In them
he makes
the injection
into
the
spinal
muscles,
basing
the practice
655
656
Vol. XVII
CLINICAL
NOTES.
on an observation
by
Meltzer,
that
the venous arrangements
in these
muscles
are such as to cause the absorrtion of the medicament
to approximate
more to
an intravenous
injection.
Witte's peptone must not
be
used,
Auld
says,
as it
may cause a severe
local reaction.
Most
other
varieties,
however,
are innocu
ous in
this
respect.
The
same
dose
as
that
used
intravenously
for
an
adult
should
be given,
but in double
concentration.
Bronchitis complicating
asthma in a child
is not the bar
to treatment
which
it
presents
in
an
adult.
None
of
the
children
hitherto
treated
has
been
refractory.
In discussing
Group
2 a few observations
are given regarding
cases
which
re
sist
the treatment.
They
include
nearly
all
those
individuals
with
chronic
bronchitis
and
developed
emphysema,
and
cases
presenting
any
degree
of
cyanosis,
even without
bronchitis; also those in whom, apart
from the asthmatic
puroxyms,
a more or
loss
oppressed
condition
of the respiration
is practically
never
absent.
As
a
rule,
the
affection
has
lasted
many
years,
dating
from
childhood,
or
from
the
age
of puberty,
and
a family
history
of asthma
can
nearly
always
be elicited
; sometimes
hay fever
is also found.
Often
the only
effect that
can
be produced
in
such
cases
by
means of peptone—and
it
has
very important
bearing — is
the complete suppression
of the attacks
for a short
period
by
a
mildly
toxic
dose.
For
two
or
three
weeks the patient
for
the
first
time
experiences
complete relief and thinks
a cure
has
at last
been
at
tained, only to be sadly disappointed.
The dose
of peptone necessary
to affect
this
desensitization
must
be carefully considered
in
relation
to the Individual
case,
and should
produce, in from
one
to two hours, headache, malaise,
shiver
ing, slight
rise
of temperature,
sickness,
with
pain
in
the abdomen
and
diar
rhea.
Sometimes
a
herpetic
eruption
occurs
about the mouth or is even
more
widespread.
In regard
to Immunization
in difficult
cases,
there are two. if not three,
neces
sary considerations
presented :
The first
is the rate of injection
of peptone and its dilution ; the second
is
the peptone to
be
used,
and
the indication
afforded
by the
dermal
reactions
as the case
proceeds.
If the patient
takes
the peptone well,
larger
doses
may
succeed,
given by very slow injection
to avoid
reaction.
If the patient
Is sensi
tive to ]>eptone. however, great care is required,
as the larger
dose
given in this
way may precipitate
an attack
of asthma.
Rarely this occurs
very quickly —
in a few
minutes —with concomitant
flushing
of the face, especially
if Witte's
peptone
is
used,
which
seems
to
contain
a
toxic
ingredient
not
present
in
muscle peptone.
Again,
a
mixture
of peptones sometimes
succeed
best.
The
dermal
reaction
(which
may
be prolonged
by
a
Von
Piquet
borer)
is
not of
much
value
at
the beginning,
as
nonasthmatical
subjects
may
give it, and it
varies
considerably
in different
persons, but as immunization
proceeds it ought
to lessen, and finally
disappear
; that
is. show
no distinction
from
the control
made with the solution
in which
the peptone
is dissolved.
Experience
proves
that
the
immunizing
injection
should
never
reach
the critical point:
it
only
injures the immunity
mechanism.
As
a general
rule,
also,
there ought
to
be
three clear days between each
injection.
In the large
number
of
cases
of
asthma
treated
by
the author
during
the
past
three years
the patient's
diet
hns
been
largely
a
negligible
factor.
The
diet
must,
of
course,
be
regulated,
but
the
cutting
out
of
certain
articles
rarely
produces
any
marked
or lasting
effect.
No
doubt
there
are cases,
but
they form
a small
class, in which
idiosyncrasy
exists
in
respect
to some par
ticular
food
(which
may
be
entirely
carbohydrate).
The
same
applies
to
asthmas
caused
by
animal
or
vegetable
emanations.
Again,
the
dyspne'e
No. 4.
657
CLINICAL
NOTES.
attacks
in bronchitis
may
be due to the products
of bacteria
locally.
But in
the
great
majority
of
genuine
asthmatics
the
explanation
is
rather
to
be
sought
in
a defect in the hydrolysis,
or metamorphosis
of foreign
protein
resid
ing in
the digestive
organs or in tile lymph or the body cells.
To this
protein
poison
the
asthmatic
individual
is sensitive,
and the bronchial
muscles
con
tain
the dominant
receptors
for it.
This
sensitiveness
may
be either
heredi
tary or acquired,
and
is influenced
by
climatic
and other
environmental
con
ditions.
This leads
one
to consider
the likelihood
of other
organs
or
tissues
behaving
in
a similar
manner,
and causing
recurrent
fulminant disorders
in
which
no local
gross
lesion
is discoverable.
The
fact
that
in
animal
experi
ments
the protein
poison
or
a foreign
protein
selects different
organs
in
rela
tion to the species may be of some
significance
in this connection.
The family history of the boy is somewhat
significant in that his
father and
paternal grandmother
have
been more
or
less
constant
sufferers
from " catarrh,"
and
in that one maternal aunt
and
one
maternal
uncle have been sufferers
from asthma.
Most of the deaths
in the family
appear
to have been
from pneumonia.
Outside of chicken pox and influenza
at the age of 5 years, the boy
has
been healthy,
except
for bronchial
asthma
and
its
attendant
emphysema.
The story of his
asthma,
according to bis mother,
is
as follows : When the child
was
7 weeks old. he developed
a condi
tion diagnosed
at the time
as bronchitis, which diagnosis was later
changed
at
the
age
of
4 months
to bronchial
asthma.
The
asth
matic
attacks
appear
to
have
had
no
relation
to food or
to
the
seasons
and
used to come on approximately
every
two months
or
so.
The attacks
might
be mild or frightfully
severe, lasting three
or four
days,
and
were
typical
in
character.
As
time
went
on
these attacks
tended
to become more
and
more
severe and to occur
at shorter and shorter intervals, until, finally, in the summer of 1921,
they were recurring
every
10 days or so, giving
the child no chance
to recuperate
between
attacks.
At the
age
of
(i years
he had
had
his tonsils
removed,
and had been given a thorough physical exami
nation, including
laboratory
and X-ray
procedures
and
skin
tests
with
numerous
foreign
proteins,
both
pollens
and
food, with
no
results,
except that after the tonsillectomy there was
a short period
of freedom from the asthmatic
attacks.
The
peptone
treatment
as
described
in
the
above
abstract
was
started
the latter part of August,
19*21, and prior
to it
a thorough
physical, laboratory, and X-ray examination was given
the boy with
no abnormal
findings except
that he
possessed
a markedly
emphy
sematous
chest, a mildly cyanotic appearance
of the face,
and
was
somewhat
below
normal
weight.
Nine
injections
of
Fairehild's
peptone
were given three
days
apart into the muscles of the back
in the following
manner : £ c. c.
5 per cent peptone
; | c. c.
10 per
rent peptone ;
1 c. c.
10 per cent peptone
;
lf_
c. c. 10 per cent peptone
:
2
c. c. 10 per cent peptone:
2£ c. c. 10 per cent peptone;
3
c.
c.
10 per
658
Vol. XVII
CLINICAL
NOTES.
cent peptone
; 3^ e. c. 10 per cent peptone
; 4 c. c. 10 per cent peptone.
The peptone solution was made up fresh each time,
autoclaved
and
filtered
through
cotton
under
aseptic
conditions.
After
the
first
four or five injections, there was marked tenderness
and pain at the
site of injection, starting three or four hours after the injection and
continuing for six or seven hours altogether, with slight
fever
and
increase
in the
chest rales:
the
symptoms
following the last three
injections were very mild.
Eight months have now elapsed since the
treatment
was given and
to date there
have been no signs of asth
matic recurrence
except for one attack
12 hours after
the last in
jection.
The boy's mode of life and surroundings,
as far as can
be
ascertained,
have been the same since the treatment as before
it.
He
has lost the mildly cyanotic hue which he used to possess, and has
put on considerable
weight.
He still, however,
displays the signs and
symptoms
of emphysema,
but there has been
a remarkable improve
ment in his facial
and physical
appearance
from that of a delicate
child to that of a robust
one.
A CASE
OF ABSCESS
OF THE
LUNG.
By
W.
H. Funk,
Lieutenant,
Medical
Corps,
United
States
Navy.
H. W. F., C. B. M., U. S. N., age 32, on the sixth day of his illness,
was
received
at the Shanghai
General Hospital.
Shanghai,
China,
with a broncho-pneumonia, following a severe attack of influenza of
two
days'
duration.
Physical
examination
showed
extensive
in
volvement
of the right
middle
and lower lobes, and slight
involve
ment of the
left
lower
lobe.
Maximum
temperature
varied from
103° to 101° F. with an evening rise of 2£° to 3°.
By the thirteenth
day of the disease, the left lung had entirely
cleared
up, while
the
right lower showed patchy areas of consolidation.
The
patient
be
gan
to have severe drenching sweats
and
septic
temperature
on the
twentieth day.
Needling of an area close to the spine
showing
in
creased dullness,
faint
tubular breathing, and diminished
transmis
sion
of
voice sounds, resulted in a dry tap.
The eough,which previous
to this time had
been loose with slight muco-purulent expectoration,
had become paroxysmal in type and nonproductive.
Eight days after there
was
a spontaneous
expectoration of about
200 cubic centimeters
of purulent
foul-smelling
fluid of
a greenish
tinge.
Improvement,
both
subjectively
and
objectively,
was
very
marked for a few days following.
However, by the thirty-first
day
the
temperature
had
again
become
septic,
reaching
103°
F. in
the
afternoon.
During this time the lung signs
were clearing up except
for the area close to the spine
which previously
had
been
needled.
Exploratory
thoracentesis
in this
region
again yielded
a
dry
tap.
No. 4.
659
CLINICAL
NOTES.
After four days of septic temperature
there was another
spontaneous
expectoration
of
a large
amount
of purulent
foul-smelling
fluid.
Relief was not so marked as that following the previous emptying.
On the forty-second day there was the third and last spontaneous
ex
pectoration of 200 cubic centimeters
of a sero-purulent foul-smelling
fluid.
Three
days
after, temperature dropped
to
normal
and
re
mained
so.
A
slight
mucoid
expectoration
quickly
disappeared.
The patient made a very rapid convalesence
and was discharged from
the hospital to his home on the fifty-fourth day of his illness.
Several X rays showed
a uniform
increase in density over the en
tire right lung.
Sputum examination
was
repeatedly
negative
for
tuberculosis, with staphylococci, streptococci,
and diplococci always
in
abundance.
The white-blood
count
gradually
rose, reaching its
highest mark, 37,800,
a few days before the second expectoration and
fell to 8,000 four days after the last expectoration.
The diagnosis of abscess
of the lung was made on the spontaneous
expectoration of large amounts
of pus on three different occasions.
In
no
case
did this immediately
follow
a coughing
spell.
In
the
patient's
own words, " It just
started
flowing
out of my
mouth."
This second expectoration was brought about by the patient lying in
bed,
so
as to give considerable
gravity
effect.
Operation
was
con
sidered, but deemed inadvisable after consultation because of the lack
of exact localization.
Open-air stimulative treatment
was employed
throughout
the latter half of the illness.
Therapeutic lying over the
side of the bed gave no results.
Although
the patient had a markedly
septic temperature,
with frequent drenching sweats, he retained his
strength in a surprising
manner.
Convalesence
was rapid.
Examination
on discharge from the hospital showed slightly rough
ened
breathing
and diminished
transmission of breath
and
voice
sounds over the right lower lung in back, close to the spine.
UNUSUAL LOCATION
OF AN EXTRAGENITAL
CHANCRE.
By
W.
T. Brown,
Lieutenant,
Medical
Corps,
United
States
Navy.
While extragenital
chancre
is not an uncommon
finding,
the
oc
currence of one
located
on the eyelid is possibly infrequent
enough
to warrant
a report of the case.
H. M., private, United
States Marine
Corps, was admitted to the
Shanghai
General Hospital
with
a diagnosis of blepharitis
of the
right eye, which condition
had existed for about six weeks and had
gradually
progressed
in spite of careful treatment.
Inspection
revealed
a slight
erosion
of
both
lids
at
the
inner
canthus,
extending over
the caruncle,
with an area of swelling
and
redness
of
the surrounding
skin
about,
the
size
of
a
dime.
The
660
Vol. XVII
CLINICAL
NOTES.
conjunctiva
was
slightly
congested.
The
patient
experienced
no
discomfort except from the troublesome
epiphora which was present.
The medical
officer transferring
the case
suggested
that the ulcer
might be a chancre,
and this diagnosis was confirmed
by finding the
Spirochaeta pallida
in the scrapings from the ulcer.
The day after
admission
a well-marked
enlargement of
the lymph
nodes
on
the
affected side, along the mandible and neck, was noted and
a general
ized macular rash
appeared.
The blood Wassermann was four plus.
The primary
lesion
healed
quickly
during
the
subsequent
treat
ment, with no deformity
remaining.
BENIGN
TUMORS OF THE
MALE
BREAST.
By J.
D. Benjamin
and T.
C. Quirk,
Lieutenants,
Medical
Corps,
United
States
Navy.
Three
cases
of tumor of the male
breast
have
appeared
on
this
station during the past year.
Two of these cases have been
operated
upon
and
the
third
is
now
under
observation.
A
diagnosis
of
adeno-fibroma
was
made from
specimens
sent to the laboratory
of
the United
States Naval Medical School in each case.
J. V. D., aviation machinist's mate, was admitted
to the sick list
on June
1,
1921, with
a tumor of the breast.
This mass
was
com
pletely excised
under
procaine.
No
reoccurrence
of this
mass
lias
been
noted.
D.
H.,
aviation
metalsmith,
was
admitted
to
the
sick
list
on
January
9,
1922, with
a small mass in the
breast.
This
mass
was
apparently
completely
excised
under
procaine
on
that
date.
On
March
31,
1922.
this
man
appeared
at
the
dispensary
with
a
re
occurrence
of
the
same
mass.
It
was
again
excised,
a
mass
the
size of an orange
being
removed.
Examination
of this
mass
again
revealed
it to be fibro-adenoma.
B. P. B., aviation
carpenter's
mate, was admitted to
the sick list
with
a tumor of
the
breast
on April
14,
1922,
and
is now
under
observation.
These
cases
are
reported
because, although
tumors of the
male
breast
are not rare, it seems unusual for a tumor of the male breast
when apparently entirely excised
and reported
as benign
to reoccur
twice as large
in
as short
a period
as three
months
and
the
second
laboratory
report
to
again
show
a
benign
tumor.
The
masses
were
not
adherent
but
were hard,
fibrous,
nodular,
nonvascular.
There was no lymphatic involvement, no capsule, nor
any retraction of nipple.
They were superficial and freely movable-
HOI
No. 4.
661
CLINICAL
NOTES.
A DENTAL
HINT.
By Kmory A. Bryant,
Lieutenant
Commander,
Dental
Corps,
United
States
Navy.
It sometimes
happens that a patient presents himself for treatment
with a bridge in which
the abutment
tooth
at one
end has decayed
inside
the crown owing to disintegration of the cement, allowing
the
crown to become loose and
the tooth
structure to decay
to such
an
extent that only the roots of the crowned
tooth are left in the alveolar
process.
Usually
these roots are in such
bad condition that extrac
tion is necessary.
Such
a condition leaves the bridge with only one
abutment
to assist in mastication.
This soon
becomes
loose, owing
to the loss of the sustaining structure of its accompanying abutment,
and the denture
becomes a menace to the health of the patient
as well
as a source of great pain and discomfort.
This condition
is usually
found
in lower
bridges,
and
the usual
abutment
affected
is the posterior one, due, as a rule,
to inability
to
keep
the abutment
tooth
dry while
cementing
the bridge in place.
The cement soon washes out. and if the bridge is not at once removed,
repaired,
and
recemented,
the
tooth
structure
dissolves,
the bridge
loosens, and soon becomes painful.
The
methods I have devised
to meet this condition vary with
the
case in hand,
but for illustration I will consider
a bridge from
the
lower
bicuspids
extending
back
to
the
twelfth-year
molar or
the
wisdom
tooth inclusive, with the tooth structure dissolved,
the roots
only remaining under the abutment
crown of the posterior abutment
tooth. If the roots
nre solid in their socket
and have
been filled to
the apex, previous to original
crowning, all that
is necessary
to do
is to open through
the cusp of the crown, cutting out nearly all of
the gold cusp, to enable
removal
of all the softened
structure down
to
u solid base
on the remaining roots, insert in the root
canals
one
or two of the screw
posts of the smaller sizes and screw tight, take
a piece of plate gutta-percha, soften
and
press down over the screw
heads in such
a manner that they project above the gutta-percha for
at
lea>t an eighth of an inch;
then fill in the crown with amalgam,
forming the cusp anew and carving to suit the case.
When the filling
is hard, finish up all projecting gutta-percha or amalgam
at the gum
margin, and the denture will again
be as useful as the original
struc
ture.
This case is one of the more ordinary
kind
remedied
by
a simple
method.
In some
cases not only the structure of the abutment
tooth
is
destroyed,
but
the
roots
are
loose
in
their
socket
and
usually
abscessed.
The
procedure
in
this
variety
is the
same
as
in
the
other until all
the debris
is removed.
The next step
is to extract
the diseased
roots from under the crown, taking them out laterally
so
as not
to disturb
the bridge from
its original
position.
After
4539—22
8
662
Vol. XVII
CLINICAL
NOTES.
the bleeding has been stopped,
swab out the wound with
phenol
on
cotton,
followed
by iodin
used freely.
Remove,
by bur
or curet,
the septum
of bone usually
between
the roots
of
a lower molar
in
such
a manner
as
to
leave
a
depression
or
socket
at this point;
again
swab
out
as
before
and
press
down through
the
opening
at the top of the crown cusp,
a cone-shaped
piece of gutta-percha,
packing
it
as far down in the wound from which
the roots have
been extracted
as it will
go without
bulging
around the gingival
margin of the crown and continuing
to pack in gutta-percha until
the crown is filled flush with the top and forming
the cusp.
Local
application
of
a counterirritant
around the
gum
margin
is
made
and
the patient is told to return in two or three
days.
When
he
returns,
the
inflammation
has
usually
disappeared.
The
case
is
now ready for the permanent operation, which consists of replacing
the gutta-percha cone with
a reproduction of it made from
a por
celain tooth, cusp downward, into the depression
and held in place
by amalgam
filling inserted
around
the part projecting up into
the
crown and forming
the cusp.
The placing
as well as the formation
of the porcelain
base
of the
abutment
is rarely
the only
difficult
part of the operation, but it is not a complicated procedure.
The
case illustrated
from
X-ray
radiographs
before
extraction
of the roots
and
after
insertion
of
the porcelain
base
is
one of
several
cases which I have handled by this method.
Figure
1 is a
view of the bridge with
the roots
incased
by the
abutment
crown
as presented
before
extraction of the worthless roots
and
showing
considerable
loss of bone.
Figure 2 presents
the anterior abutment
of the same bridge, which shows that but half of this root had any
surrounding
bone structure.
Figure
3 shows
the porcelain
base
in
place
two weeks
after
the extraction of the
roots.
Figure
4 pre
sents the same view after the period of one month.
Attention
is in
vited to the area of bone replacement
shown in Figures
3 and 4.
The patient informed
me that after the first week he felt no in
convenience
whatever
when
using
the bridge for mastication;
in
fact, he said it did service
as well as the original bridge.
SOME INTERESTING
DENTAL
CASES.
By
G.
C. Fowler, Lieutenant,
Dental
Corps,
United
States
Navy.
Osteoma
of superior maxilla. — Patient,
male,
aged
23 year.
Ex
amination
revealed
a large hard bony
mass of tissue
on the
outer
border of the alveolar process of the upper right maxilla.
X ray
showed
this mass of tissue
to extend
from
the first bicuspid
pos
terior
to the mesial
border of the third molar, and
slightly
below
the normal gum margin to the attachment
of the buccinator muscle,
No. 4.
663
CLINICAL
NOTES.
protruding half
an
inch outward
or laterally,
and
extending in
ward toward the median
line, practically
filling the right
antrum,
and projecting into the nasal
cavity-
No enlargement
of the hard
palate
was
noticeable.
The
dark
field illumination
showed
dense
tissues
on the right
side.
The left
side was normal.
There was slight
retraction
of
the lip
on
the right side,
which
was
very
prominent
on smiling.
There
was
no pain
to
pressure.
The hard tumor mass was
rounded
and
immovable,
and had never
caused any discomfort.
It was first noticed
by the patient about two
years
ago, but being painless
and not
uncomfortable
no attention
was paid to it by him.
The family history was negative
to growths
of any kind.
The
first
molar
was
missing,
and
there
was
a
loose,
ill-fitting
bridge
on the
second molar extending to the
second bicuspid
and
pressing slightly,
about
one-eighth
of an inch, into the gum.
Both
teeth
were
vital, with
a slight
thickening
of the peridental
mem
brane
at the apices.
Conservative
treatment
was deemed advisable
and operative pro
cedures
were
postponed
for the
present.
It
was
decided
to wait
until
the
tissues
healed
after
the irritating
bridge
and
teeth
had
been removed
and to watch for future developments.
The treatment
consisted of removing
the
bridge
and
teeth
involved,
under local
anesthesia, and taking
an impression of the maxilla,
including
the
tumor and surrounding tissues, as a control for future impressions.
The tissues
healed
without
difficulty.
One
month
later another
impression
was taken and by careful measurement
it was shown that
the tumor had decreased in size.
The patient was sent to duty and
informed
that he shoidd observe the growth and report when practi
cal
to
have
impressions
taken,
in
order that
careful
observation
might be made of the condition.
Diseased
teeth
as possible
cause
of rheumatism;
removal of un
usual impacted molars. —Patient,
male,
age
28 years, suffering from
rheumatism,
was referred by ward doctor for possible
focus
of in
fection.
Eadiographs
taken of all teeth showed several rarefied
areas
and
the
impaction of the upper
molars.
Under
conductive anes
thesia
all teeth that showed
rarefied
areas were removed;
also the
impacted
molars.
The rheumatism cleared
up
so that the patient
was able to do light duty in about
three
weeks after the teeth had
been
removed.
Prior to removal of the teeth lie had been unable
to
move about without
the aid of crutches
for three
months.
Considerable
space existed
between the upper left second bicuspid
and third molar.
The first molar was
lost when
the patient
was
about
10 years old.
He stated that he was about
17 years old before
he erupted
the third molar.
The
third
molar
extended
buccally,
giving considerable
curve
to the roots,
forcing
the lower molar to
664
Vol. XVII
CLINICAL
NOTES.
strike on its lingual surface of the crown, causing considerable
pain
at times.
Under
conductive
anesthesia
the third
molar
was extracted,
and
on examination of the socket the crown of the second molar was dis
covered,
and it was also extracted
through the opening made by the
previous extraction.
The socket was cleansed daily and in due time
healed without difficulty.
Strange to state, the impacted
molar did
not penetrate
the antrum of Highmore.
ADDITIONAL
ASSURANCE
FOR THE FIT
OF A DAVIS
CROWN.
By
0. T. Lvnes, Lieutenant,
Dental
Corps,
I nited
States
Navy.
In
the fitting
of
a Davis
crown, it has appeared
to
me that
to
grind
a crown and
root
so that they
are perfectly
adapted
to
one
another
is an impossibility.
If you
carefully
observe
the ground
surfaces of both
under
a powerful
glass I think that you will
agree
with me that it simply can't be done.
There
are
several
methods
of overcoming this point, mainly
by
cast base construction, but even with this method
the line of union
between the crown and the root is not minutely perfect.
That the following
method
is lasting
is evidenced
by the fact that
the first Davis crown that I
set
by the
use of this method
is still
intact
after
10 years
service.
1. Grind
root
and
crown
and
fit
post
according
to
the
usual
method.
2. Cement
the post into the crown.
3. Apply
a bit of base-plate
gutta
percha,
cut to the shape of the
root,
over
the pin.
(The
hole
for
the pin to slip through
can
be
readily
made with
the rubber dam
punch.)
4. Heat
the
crown
and
post,
with
gutta-percha
in
place,
over
an alcohol
lamp.
Place the pin in the root and
press to as near the
proper position
as possible.
Remove
the whole appliance from
the
root,
trim
the surplus
srutta-pereha
from
the edges of the crown,
reheat, and again apply to the root.
Repeat
this until the crown at
tains its proper position and
a perfect union is accomplished.
Seal
the edges of the gutta-percha to the crown.
5.
Cement
the finished
product to place.
This method
not only produces
a perfect union between crown and
root,
but
it
also
establishes
a
base
that
acts
as
a cushion for
the
crown, thus prolonging
the life of the root.
The numberless
cases of fractured
teeth, where
the line of frac
ture
extends
above the alveolar process, can also
be treated
by this
method,
the gutta-percha being
trimmed
so that no irritating sur
faces result.
REPORTS.
A REPORT
ON THE
NARCOTIC
CONTROL ASSOCIATION
OF
CALIFORNIA.
By
W. G. Farwbli,,
Lieutenant
Commander,
Medical
Corps,
United
States
Navy.
The first State-wide narcotic conference
in the United
States
was
held on October 27,
1921,
when
the Narcotic Control Association of
California was organized in San Francisco.
More than 1.000 promi
nent Californians interested
in the control of drug addiction
were
present at this meeting, which was opened by Mayor Rolph
; addresses
were
made
by
doctors,
lawyers, Federal,
State
and
municipal
of
ficials, civic
and
religious
workers—all of whom
appeared
to
be
impressed
by the growing but insidious evil of drug addiction and the
necessity for stamping it out.
James A. Johnston,
warden
of San Quentin
Prison,
was
elected
president
of
the
association,
and
the
following
resolutions
were
adopted
:
(1)
The organization of a central State
body
and provisions for
the formation of county organizations throughout California to work
in conjunction
with the State association.
(2)
Provision
for
the
memorializing
of
the
President
of
the
United
States,
the National
Congress,
and the Department of State,
whereby the provisions of the International
Opium Congress
at The
Hague may be better enforced
and the unlawful
importation of crude
opium
and
coca leaves
be prevented,
as well
as the stoppage
of the
unlawful
sale
and
distribution
of
narcotic
drugs
throughout
the
tforld.
(3)
Provision
for the amendment
of the Harrison Narcotic
Act,
whereby a minimum penalty of not less than six months'
imprison
ment nor less than a $500 fine shall
be imposed
upon first offenders,
and
whereby immediate
deportation,
upon
completion of sentence,
shall
be made of all alien violators of the Harrison Act.
(4)
Provision
for strict Federal suiveillance
of all manufacture,
sale, and
distribution
of narcotics.
(5)
Provision
for more
drastic legislation
in California against
the drug peddler.
The writer
was
detailed
as the naval representative
at this con
ference and gave
a brief
address
upon
drug addiction in the Navy,
which
may be summarized
as follows
: While there has been
a general
increase
in
drug
addiction
in
recent
years,
the
fact
was
brought
665
666
vol. xv :i
REPORTS.
out that this habit is not
as prevalent in the service
as in civil life
because of the following conditions:
(a)
Recruits
are given
a thorough
physical
examination
at
re
cruiting
stations
and later at training stations,
which often elimi
nates advanced
cases of drug addiction.
(b)
The close associations
and the military discipline
required
in
the Navy tend to expose a drug addict sooner or later.
(c)
The fact that naval vessels move from port to port takes the
addict away from his source of supply,
and
frequently
results
in
HOHE-MADE
HYPODERMIC JYRINGE
LevtVier Comb
Cii.sc-
Cont-wner For 5yrino^
desertion,
or occasionally in his coming to the medical officer,
con
fessing,
and begging for a " shot."
However, as drug addiction has unquestionably increased of recent
years, particularly
in large cities, and as the majority
of recruits are
obtained
from this source, every effort is being made to discover
and
eradicate
these
characters
from
the
Navy,
where
they
have
in
creased proportionately of late.
When drug addicts are found in the
service
they
are promptly
court-martialed
and
receive
a "bad
con
duct" discharge.
During the
past
year, of the
ten thousand
and
odd men that passed through the naval training station at San Fran
cisco
only
11
drug
addicts
were
found.
These
cases
were
dis
charged
and turned over
to the police in San Francisco,
who ini
No. 4.
667
REPORTS.
mediately freed them,
as there
were no civil charges
against them.
This is a situation that requires
better cooperation between the civil
and naval authorities, not only in San Francisco, but in other coast
wise
cities,
as
these
addicts,
when
released
from
the
Navy,
con
gregate in the large towns where narcotics are easily obtainable
and
swell the constantly increasing number of dope fiends in these com
munities.
If the
police
control of drug
addicts
was
made
more
stringent,
and suspected
cases could be kept under surveillance until definitely
diagnosed, when these cases appear
at recruiting
stations
they could
be turned
over
to the police,
instead
of being
merely
turned away
from
the recruiting
stations
to become foci for the further
spread
of this dread habit, as is the case at present.
While it may appear
at first glance
to be a cruel and inhuman act
to discharge drug addicts
from the Army and Navy without trying
to cure them, it must be remembered that the military
service is in no
sense
a reformatory,
and exists only for the military protection of
the citizens of the country ; any condition that would lower the fight
ing value of a military organization must
be promptly
eradicated.
In order to show the extent
to which drug habitues
will go to get
their " dope," the following incident was mentioned
: A Navy enlisted
man was recently
arrested
in San Francisco for some minor offense,
not connected with drug addiction, and lodged in one of the city jails
that contained
a number
of drug
habitues.
One of the " dopes "
became friendly with
the sailor
and
persuaded
him
to write
to
a
certain address in the city requesting
that a shirt
be sent to him.
In
due course of time an ordinary
woolen
shirt arrived at the jail and,
after being carefully
examined
by the warden, was delivered to the
sailor, who unsuspectingly turned it over to the drug addict.
Soon
after,
the jail authorities
noticed
that many of the prisoners were
under the influence of a narcotic ; investigation showed that the shirt
had
been soaked
in
a saturated
solution of
cocaine,
and
after its
arrival
in
the jail cut
up
in small
pieces, distributed
among
the
addicts and soaked in water to remove
the cocaine,
with
the result
that
as one of them told the warden, " They
didn't care
how long
they stayed in jail !"
Another
instance
of the ingenuity
shown
in obtaining
narcotics
was the recent case of an enlisted
man in the destroyer
flotilla of the
Pacific
Fleet
who
was
discovered
receiving
cocaine
concealed
be
neath the stamps of letters addressed
to him.
The homemade hypodermic syringe shown in accompanying illus
tration, which was found in the possession of a drug addict at the
naval hospital, Great Lakes, 111., was then demonstrated
to the mem
bers of the association.
NOTES AND COMMENTS.
Headers of the Bulletin who have enjoyed
the essays on subjects
pertaining-
to the history
of medicine
contributed
to its pages
by
('apt. J.
S. Taylor,
Medical
Corps,
United
States
Navy,
will
be
pleased to learn that his essays on " Montaigne and Medicine," which
appeared
recently
in serial form in the Annals of Medical History,
have been issued in book form by Mr. Faul B. Hoeber, of New York.
The book
which bears
the title " Montaigne
and
Medicine " con
tains
Montaigne's
comments
on
the physic
and
physicians of his
day; his thoughts
on many
material
matters
relating
to life
and
death;
an account of his bodily ailments and peculiarities and of his
travels in search of health, all written
in Doctor Taylor's
charming
style.
It is dedicated
to Dr. Hiram Itittenhouse Loux.
of Philadelphia,
" who
ministers
with
consummate
skill
to
forms of suffering
for
which there
was no relief in Montaigne's day."
During four trying years Doctor Taylor, as editor of the Bulletin,
labored in
the
interest
of the
officers of the Medical Corps of the
United
States Navy, and
we feel certain that each of them will wish
him all success in his latest literary
venture.
One of
the
most
enlightening
papers
on
the
chronic
effects of
suffocating
gases which has come to our notice
appeared
in the May
issue of the Journal of the Royal Army Medical Corps.
Its author
is
Capt.
Alexander
Mearns.
Royal
Army
Medical
Corps.
Lieut.
G. H. Mankin,
Medical
Corps. United
States
Navy,
has prepared
the following
abstract
of this paper for readers of the Bulletin :
Chronic effects of the inhalation
of suffocating gases may
be
ex
hibited for a variable length of time after convalescence in those who
have been subjected
to a so-called severe gassing in the field or else
where,
and
also in those who, though
never having
undergone an
acute gassing
necessitating
treatment,
yet have
been subjected
to
a
slight intoxication
or an absorption of noxious fumes
more 6r less
continuously for some time,
as occurs
among
those working
in in
dustrial plants.
The gases responsible
for the effects studied by the
author are those of tfie suffocative
series—chlorine, phosgene,
chlor-
picrin,
and
trichlormethylchloroformate.
670
Vol. XVII
NOTES
AND COMMENTS.
The
cases
were
divided
into two main
classes— first,
those
with
physical
signs and
symptoms
indicative
of organic
changes,
and,
second, those in whom
no such changes
are found and are described
as functional.
As might
be expected,
the respiratory
system
shows
the
greatest
degree of change.
This change,
in general,
results
in three
types,
each with its separate symptomatology and pathology.
(a) Fibrotic type. —This condition
is often seen
as a sequel to an
acute gassing,
but much more frequently among workers in industrial
plants with only
a history of continual light absorption of gas, and
seems chronic from the outset.
Usually the onset has been insidious,
and only after the symptoms
become well established
could the physi
cal signs indicate the exact condition of the lungs, which was revealed
as
a fibrosis at the hilum of the lung, spreading along the bronchi
and vessels.
Symptoms.— Shortness
of the breath on exertion is the first symp
tom in cases unaccompanied
by bronchial catarrh, while in others the
symptoms
resemble
those of a chronic catarrh.
The
peri-bronchial
fibrosis once having
been established,
the main symptom
is a dry,
unproductive cough, often paroxysmal, worse in the morning, the ex
pectoration
varying
with
the
associated
catarrh.
Due
to
minute
varicosities in the capillaries of the bronchial wall^ there is frequently
blood-stained
sputum,
or
even
small
hemorrhages.
Shortness
of
breath, orthopnoea at night, faintness
on exertion, general deteriora
tion in health,
loss of weight, and
associated
digestive disturbances
are noted in greater or less degree.
Occasionally cardiac symptoms,
such as palpitation, retrosternal pain, and tachycardia occur,
and are
usually accompanied
by sweating, irritability,
and vague
feelings
of
depression.
There is an increased
susceptibility
to acute colds
and
influenza.
Night sweats are uncommon.
Physical
signs. —The
most
constant
sign
is the shallow
type
of
breathing,
which
becomes
dyspneic
on
exertion.
On
percussion,
areas of impaired
resonance,
often
amounting
to
almost
absolute
dullness,
are found over the hilum of the lung, particularly on the
right side.
These
areas vary
with
the
extent
of the
fibrosis
and
spread in the direction of the bronchial
tubes.
Vocal fremitus
and
resonance are increased over these areas, and the type of breathinsr
is
bronch- vesicular, with slightly prolonged expiration.
There
is
im
paired ventilation,
loss of elasticity of the chest wall, and
a restric
tion of the
movements
of the diaphragm.
The
restriction
of
the
movement of the diaphragm is not functional, but probably defensive,
as the taking of a deep breath
gives rise to pain and cough.
X-ray
examination shows
areas of shadow
which correspond to the thick
ened
areas
revealed
clinically.
These
thickened
areas
spread
out
No. 4.
671
NOTES
AND COMMENTS.
from
the hilum into the lung like a fan and coincide with the distri
bution of the bronchi, bronchioles, and blood vessels.
As far as could
be learned the previous history of the cases recently
examined
contained
nothing
which
would obviously
predispose
to
lung disease.
With
regard to
the
changes
that actually
occur,
there
is a pro
gressive
peri-bronchial
fibrosis extending from the hilum of the lung
outward, in advanced
cases,
to the ultimate distribution
of the bron
chioles, with or without associated bronchitis and emphysema.
There
is also a loss of elasticity in the whole of the respiratory tract, due to
a loss or destruction of the elastic fibers throughout the lung.
Evidence of anoxemia
in several of the recent cases has been proven
by the beneficial
effects of
a sojourn in the high oxygen chamber,
though
the effects soon passed
off, and
also by the effort syndrome .
symptoms frequently associated, which have been shown to be largely
due
to
oxygen
want.
Considering
the
large
number of workers
who do not develop
this condition, it is evident
that the inhalation
of the
gases is only one element
in the production of fibrosis, that
individual susceptibility
must function in its occurrence
and
a low-
grade bacterial infection
institute or continue its development.
(&)
Emphysematous
type. —The
existence
of
emphysema
after
gassing in cases with no history of previous lung disease is usually
associated
with or is a sequel
to the other two types —fibrotic
and
bronchitic.
The
respiratory
and
cardiac
symptoms,
the
physical
signs in the lungs and
heart,
in no way differ from those observed
in cases of emphysema
from other causes, except in the rapidity of
onset.
(c)
Bronchitic type. —Most of the
cases
of supposed
tuberculosis
following
gas
inhalation
are of this
group.
The
symptoms
and
signs
are so suggestive
of tuberculosis that diagnosis
can only
be
made after careful examination.
Symptoms. —These
are,
in
the
main, similar
to
those
of bron
chitis—cough,
expectoration with
or without
hemorrhages,
marked
loss of weight, transient fever, shortness
of breath, and general
de
terioration of health.
Examination
of the chest reveals
bronchitis
rales generalized or localized to certain areas, harsh vesicular breath
ing, and impaired resonance
on percussion.
Physiological
examina
tion in these cases
shows
a permanent
lowering
of the respiratory
exchange
and
consequent
deficiency
in respiratory
functions.
The
symptoms
described
resemble
so closely
those occurring
in chronic
and subacute tuberculosis of the lung that the relation of gas poison
ing to this disease
has
been considered,
especially
in
view of the
apprehension originally entertained.
Several thousands
of gas cases
have
been
examined
for
the
frequency
of
tuberculosis
by
many
clinicians,
whose
reports
are of
especial
interest.
The
conclusion
672
Vol. XYlt
NOTES
AND COMMENTS.
that presents
itself after
the study of these papers
is that the in
halation of gas has an extremely
small influence
on the
occurrence
of tuberculosis,
but
that in
a few
cases
it may
light
up
a
focus
of infection previously latent.
The other possibility,
namely,
whether acute gas poisoning
creates
a condition in the lung predisposing or favorable to the development
of tubercle,
finds
a tentative answer,
at least, in the work of Achard
upon guinea
pigs.
Among
the
cases
recently examined
no
tuber
cular disease was discovered.
Digestive
system. —Digestive
troubles
traceable
directly
to
the
action of gas are extremely
few, though various symptoms
indicative
of
atonic
dyspepsia
are
to
be
observed
upon
occasion,
but
these
gradually
disappear after
a period of a few months.
Where
they
do persist, two factors in their
causation
are
evident,
the
general
weakness and malnutrition
consequent
on want of oxygen
and, prob
ably
more
important,
the
absence of
the
massaging
effect
of
the
diaphragm due to its restricted movement.
Cardiac system. —No organic lesions have ever been traced directly
to
gas poisoning, though
changes
in
the
heart, hypertrophy,
and
dilatation
naturally
follow
on the lesions
of the
respiratory
tract
described.
Sequellce xrith no organic lesions. —Especially
among
the " lightly
gassed " we find a group of cases wherein little can be noted clinically
to account for the symptoms.
The anoxemia
and symptoms
that are
present,
and which may last for a considerable
length of time,
yield
to the treatment of a sojourn in the high oxygen
chamber, thus show
ing that they are not due to any gross physical change, but constitute
a definite
gas neurosis.
The severity
depends upon the " instability
"
of the individual,
and
is probably largely
preventable.
The
use of
oxygen
is considered
to be the proper
form of treatment
for this
type of cases.
In conclusion the author states that " it has been shown that there
are two types of sequellse
to inhalation
of asphyxiation
gases,
(a)
A
type
affecting primarily
the
respiratory
system
with
definite
progressive
organic changes of the nature of a peribronchial
fibrosis,
emphysema,
and
pseudotuberculosis,
(b) A type of gas
neurosis,
having the signs
and
symptoms
allied
to those of effort syndrome,
without demonstrable
organic changes."
Recently
a letter
was
received
by
the
Bureau
of Medicine
and
Surgery
from
a medical
officer who
desired
to know if the bureau
wished
a strict
compliance
with
article
1139
of the United
States
Naval
Regulations
which states that " the medical
officer shall
not
give
an unofficial
certificate
of ill health
or of inability
to perform
any duty."
No. 4.
673
NOTES
AND COMMENTS.
It appears
that this officer, who is on duty at the dispensary of
a large navy yard,
frequently
receives
requests
for certificates
of
disability
from
injured
yard
employees
in order that they
might
receive
compensation
from various lodges,
benevolent
societies,
and
relief associations,
and that the refusal of these certificates,
in
ac
cordance
with the regulations, at times, submitted
an injured
work
man
to an
injustice,
inasmuch
as his medical
attendant
was
pro
hibited
from
giving
him the certificate
necessary
in adjusting
his
claim for compensation.
The bureau
forwarded
the correspondence
to the Judge Advocate
General for
a
decision
as
to
whether
article
1139,
United
States
Naval Regulations.
1920. applies to employees of a navy yard.
The decision of the Judge Advocate General may be gleaned
from
the following
extract of
a
letter
from
the .Judge
Advocate of the
Navy to the Chief of the Bureau of Medicine and
Surgery:
"Article
1139 of the United
States
Navy Regulations,
1920, pro
hibits medical
officers from giving
unofficial
certificates
of ill health
or of inability
to perform any duty.
It is the opinion of this office,
however,
that this article of the regulations merely
defines the rela
tion of a naval medical
officer to other individuals
in the naval serv
ice and does not apply to the relation of
a naval medical
officer to
civilians
employed
in navy
yards or naval
stations
under the juris
diction of the Navy Department.
"This
office
is. therefore,
of the opinion that requests for certifi
cates from, the civilian employees of navy yards or station*
to enable
them to receive compensations
from lodges,
benevolent
societies,
and
the yard relief
association
may
be properly
unofficially
granted."
The impression is quite general that the white race, does not thrive
in the Tropics.
Not long ago an article appeared
in a London
paper
advocating
restricted admission of the colored
races to tropical Australia
on the
ground that whites can not live and labor in the Tropics.
About
the time it was published
an article appeared
in the Medical Journal
of Australia
describing what has happened
to whites who have re
sided for several
generations
in the Dutch
East Indies.
It is not
generally
known,
says
the Living
Aye,
that families
of Teutonic
blood
have been actually living for five or six generations
in Hol
land's tropical
possessions.
Some of these
have retained
their white
blood pure: others
have mingled with
the natives.
The
author of the
article.
Doctor Elkington, of
the
Common
wealth Health Department, describes
the history of nine families of
Dutch
ancestry
sprung from settlers
who took
up their abode upon
the island
of Kisar
in
1767.
After
the
Dutch
garrison
withdrew
674
Vol. XVII
NOTES AND COMMENTS.
from the island, these families remained
behind, intermarrying
with
the natives,
relapsing into heathenism,
and losing all memory
of the
Dutch language.
During the eighties
the Government became aware
of the existence of these people and tried to help them, with the result
that they
have
been rechristianized
and
won back
to civilization.
Doctor Elkington
reaches
the conclusion, by studying
these white
or part white
denizens
of the Tropics,
that they have maintained
their mental and physical traits substantially
unchanged
after five
or six generations.
These
characteristics
have
survived
in
spite
of
environmental
conditions and associations
lasting over
60 years, from
1819 onward,
and probably for some 70 years
or more, which
are generally sup
posed to be totally unsuitable for persons of European stock.
These
conditions have included native standards of food and food supply,
endemic
malaria,
the psychological
effect of what must
have
been
for the earlier generations
an acute
sense of abandonment
by their
own race, life under the rule of native chiefs, constant
association
with
a native race of low mentality, loss of European language and
European
religion,
interbreeding
to
a high
degree,
and
constant
exposure
to a tropical
climate.
There is nothing in the available history of these people
to show
that
a tropical
climate per se has tended
to
produce
degenerative
effects on them or to limit fertility.
Whatever
evidence
they
may
have shown of lowered physical or
mental
activity
in the
past
can
be fully explained by the environ
mental
conditions
of
food
supply,
malaria,
and
particularly of
native associations,
aided possibly by the accentuation
of stock weak
nesses
arising
from interbreeding
over
several
generations.
It is always
a source of pleasure
to note the success of medical
officers with
whose
work
we are familiar, even though they serve
under another
flag.
In the British
Medical Journal
for May
27,
1922,
we read that the gold medal
founded by the late Sir Gilbert
Blane
has
been
awarded
by the Director-General
of the Medical
Department of the Navy
and
the
presidents
of the Royal College
of Physicians
and the Royal
College of Surgeons to Surgeon-Com
mander Sidney W. Grimwade,
Mho
obtained
a first-class certificate
at the examination held in February,
1922, for promotion to the rank
of surgeon-commander.
Three
Blane
medals
which
remained
un-
adjudged owing
to the absence of promotion
examinations during
the
war
have
been
awarded
to
Surgeon-Comander
Reginald
St.
G. S. Bond, Surgeon-Commander Robert W. B. Hall, and Surgeon-
Commander Sheldon F. Dudley, for distinguished professional zeal
and
ability
displayed throughout
their
service
career.
No. 4.
675
NOTES AND COMMENTS.
Readers
of the
abstracts
which
have
appeared
in the Bulletin
in late years will recall the researches of these men in their respec
tive specialties.
From the Lancet for May
27,
1922, we learn that out of some 360
titles of rare works
on old
medicine,
advertised
for
sale by
the
International
Antiquariaat
of Amsterdam,
more
than
50
relate
to
the
use
and
abuse of tobacco.
This large proportion
of books
de
scriptive
of a particular kind of intoxication
might lead us to infer
that old Dutch
medicine
was
chiefly
concerned
with the
evils of
smoking,
but the works
in question
are rarely
Dutch
and
mostly
modern, and,
as a matter of fact, smoking has had from the earliest
times a bad name.
The priests or councils of the American Indian
tribes seem to have been the first known smokers,
and probably used
tobacco as an intoxicant.
They inhaled smoke by way of the mouth
or nostrils when treating of war—the " pipe of peace " it was called
euphemistically—or
when
proceeding
to
utter
prophecy.
When
introduced
into Europe, smoking was still held by many to have
a
mystic significance,
and it became necessary
for Pope Urban VIII
to excommunicate
certain priests who took tobacco while officiating
at the mass.
This was in 1624, some 20 years after James I had for
bidden the use of tobacco in his realms.
A curious work, No. 241 in the catalogue,
is the Commentary of
Paullus, " De Abusu
Tabaci
Americanorum
ipsissima
est
Chamae-
leaguos
Dodonaei."
This very rare book was published
at Stras
bourg in
1665.
Other interesting works are : Tobacco, injurious
to
the Constitution
and
its Use Scripturally Wrong.
Dialogues
be
tween
a Doctor
and
a Miner, by a Surgeon, London,
1840 ; Murray
on Snuff-taking
: Its Utility in Preventing
Bronchitis,
Consump
tion, etc.,
1870;
Lowy
on
Raucherparanoia
;
Jamet
on L'Art
de
Fumer,
Metz,
1845;
Heward's
St.
Nicotine,
1909;
and
Bragge's
Bibliotheca
Nicotiana, Birmingham,
1880.
The last-mentioned work
is the bibliography
of tobacco, and is to that subject
what Lowndes
and Brunet are to literature in general.
Among
rare works
offered
for
sale
in
this
catalogue,
but
not
necessarily dealing with nicotine and tobacco, special
mention
should
be made of the Isagoge-Magico-Medica,
of Aug.
Etzler, published
at Argentoratum
(Strasbourg)
in
1631.
This deals with the whole
subject
of signaturism.
Bidloo's
superb
volume
with wide margins
known
as
Ontleding
(Anatomy)
des menschelijken
Lichaams,
is
here offered for 75 florins.
The plates
illustrative
of human
anat
omy, by the celebrated
artist G. de Lairesse, are those which Cowper
embodied
without acknowledgment
in his famous " Myotomia."
His
theft was not suspected till the discover}7,
by an assistant
librarian
in
the Royal College of Surgeons in England,
that the name of Bidloo
676
Vol. XVII
NOTES
AND COMMENTS.
had been covered with
a neat circular
label
on Cowper's title-page,
the same process having been gone through in other similar
volumes.
One
is sorry
to take
away
the reputation
for literary
honesty
of
so good
a surgeon
as Cowper, whom,
indeed, Lowndes
defends in a
note.
Here also is offered for 65 florins Gautier Dagoty's extremely
fine
atlas of
the
Anatomy
of
the
Generative
Parts
of
Man
and
Woman.
The book is one of great rarity, and is especially interesting
in that
the
plates,
which
closely
follow
nature,
are
perhaps the
earliest
known instances
of color-printing
in three
colors,
an inven
tion usually
considered
to be of quite recent
date.
Gautier
Dagoty
published his great
folio
in Paris as long ago as
1773.
J. R. Kuth, writing in the Journal of Bone awl Joint Surgery
for
April,
1922,
informs
his
readers
that
from
a
study of
208
cases
of lower back
pain, any injury or disease affecting the lower back
structures
(muscular,
ligamentous, bursal,
osseous, or joint)
may
give
rise
to
a similar
symptom
complex
in
cases
of chronic
low
back pains.
Unfavorable
static conditions in the lower back or ex
tremities
resulting
from
abnormalities
in
the
lower
extremities,
postural or occupational strains, or from fatigue or weakness,
fre
quently exist in these cases
and operate
as a cause in the production
of symptoms
either alone or in conjunction
with other causes.
In
all
cases
of low back
pain, the possibility
of
a progressive
disease
of the spine or of the spinal cord should be kept in mind.
The
best
results
from treatment
were obtained
in cases in which static abnor
malities
were
corrected,
in which lower
back
structures were pro
tected or put at rest, and in which such structures, if shortened,
were
stretched.
Graduated
systematic
exercises
are
an
important
ad
junct
in
the treatment
of many of these cases.
The so-called
concentration method
for tubercle
bacilli
in expecto
ration in cases
where
they
are
present
in scanty
numbers
has been
for some time past- effected by forming
an emulsion
with antiformin,
which
dissolves
the cellular
and
mucous
elements
and
allows
the
bacilli
to fall to the bottom of the liquid.
By this method,
however,
many
bacilli of recent
development
may
be dissolved
entirely,
and
others
damaged
to such
an extent
as to
lose their
special
staining
peculiarities.
The
concentration, therefore, consists
merely
in
the
collecting
at the
bottom
of the
liquid
of
those
bacilli
which
have
survived
the
process
with
a
respective
diminution
in
their
total
number.
Tuberculous sputum
to which the process of so-called
con
centration may
be most usefully applied is that from patients
in the
early stages of the disease in which the bacilli
are scanty,
and there-
No. 4.
677
NOTES AND
COMMENTS.
fore difficult to demonstrate
with
the ordinary
methods of staining.
From
a negative
result
the patient feels himself justified in neglect
ing any kind of precaution, and in such
a case it is indispensable
that
a result should be arrived at which is as near
as possible
abso
lutely true.
The Lancet for May 27,
1922, calls attention to the fact
that Prof. N. Pane, of the Bacteriological
Institute
at the University
of Xaples, has just published a new method in which a concentration
of existing bacilli
is obtained
without any diminution
in their num
ber.
The suspected sputum
is placed in a sterile glass receptacle
and
four
times
its volume
of physiological
salt solution
added;
this is
then incubated
at 37°
C. for 24 hours.
During this time the mucus
and cells
are liquefied
by
the proteolytic
enzymes
produced
by the
accessory
microorganisms
which
are more
or less abundant in all
sputum.
The
centrifugalization
of the
bacteria
is
by this
means
rendered easy by the elimination from the liquid of the organic sub
stances which spoil the clearness of the preparations, and the tubercle
bacilli are readily shown by the Ziehl-Neelsen method.
In some
cases
investigation
by this method
has shown
only occasional
groups of
agglutinated
tubercle
bacilli.
Professor Pane considers
this to indi
cate a slight immunizing
defense in the organism.
4639—22
9
NURSE
CORPS.
REPORT
OF THE COMMITTEE
ON NURSING PROBLEMS FINANCED
BY THE
ROCKEFELLER FOUNDATION.
The conference
of persons
interested
in the development
of nurs
ing, which met in New York
at the invitation
of
the Rockefeller
Foundation in March,
1919, has submitted
a report after practically
two years of investigation.
The original
committee
was invited
to
consider
the
development
of public health nursing,
and
was
made
up of well-known
members of the medical
and nursing professions
and several lay members whose work has been along the lines of in
dustrial
hygiene
and public welfare. The completed
committee
placed
the actual conduct of the investigation in the hands of Miss Josephine
Goldmark, whose work in social
research
and
studies
on industrial
hygiene fitted her for such a task.
The committee
has made special
mention of its appreciation of her study of the difficult and complex
problems and
believes that the detailed report will prove
of funda
mental value
in the development
of nursing
and of nursing
educa
tion in the future.
In February,
1920,
a second
conference
was called, also
at
the
invitation of the Rockefeller
Foundation,
and at this conference
the
discussion
centered
on
the
proper
training
of nurses
within
hos
pitals and on private duty ; in fact, the entire trend of nursing educa
tion was considered.
The result of this conference
was the widen
ing of scope of the former committee,
which was increased
in June,
1920, by six members, including
superintendents
of hospitals and of
nursing schools,
a clinician,
and
a representative
of mental
hygiene.
A brief resume of the report and the conclusions
of the committee
will be of interest
to our readers.
In an endeavor
to secure disinterested
and impartial
opinions on
controversial
subjects,
both
nurse
and
lay
investigators
were
em
ployed
in
the field work.
The
study of hospital
training
schools
was carried on
by Miss Elizabeth
G. Burgess, R.
N., inspector of
training
schools
of the New York
State
Department of Education;
Mrs. J.
B.
Piggott,
R.
N., Maryland
State
inspector of
training
schools; Miss Carolyn E. Gray,
head of the department
of nursing
education. Western
Reserve
University
; Miss
A. H.
Turner,
pro
fessor of physiology.
Mount
Holyoke
College;
Miss
F. G.
Gates.
679
680
NURSE
CORPS.
Vol. XVII
formerly
dean of the Women's
College, University
of the
State
of
Illinois.
Miss Turner
also
made
a study of
postgraduate
courses
for teachers and administrators in schools of nursing.
In compiling
data
for the chapter on hospital
training
schools,
assistance
was rendered
by Miss Edith R. Hall, Mrs. M. P. GatTney,
and Miss P. K. Angell.
For the study of public health
agencies, the field work was carried
on by Miss Grace R. Bolen, Miss Christina
C. Miller, Miss Elsa M.
Butler,
who were not nurses
but experienced
in public health work,
and Miss Helen Ross,
experienced
in industrial
investigation;
Mrs.
B. A. Haasis, R. N., and Miss Janet R.
Geister, R. N., secretaries
of the National
Organization
for Public Health
Nursing,
and Mrs.
A. M. Staebler,
R. N., secretary
of the Massachusetts
Committee
on
Health
in Industry.
In the study of private duty nursing
the field work was
carried
on by
Mrs. J. David
Thompson
and
Miss Adda Eldridge, R. N.,
with
the special
assistance of Miss
Sara E. Parsons, R. N.
The first part of the report considers
the role of the nurse in public-
health work, and gives an outline of the major health problems of the
present
day, such as the control of infant mortality
and tuberculosis.
It is stated
that education
is the only means of accomplishing
the
changes
in daily habits of people which alone can solve these prob
lems.
The objection of the health administrator
may
be approached
to a limited extent by mass methods, but direct personal contact
with
the conditions of the individual life is essential to success in a matter
so trmy
personal
as hygiene.
After enlarging
upon this fact, the
committee
stated
that
all public health authorities appear to agree
that the need for nurses
is the largest outstanding problem before
the health
administrator of the present
day.
This need has led
the
authorities
to consider
the possibility of finding
a short way out of
the difficulty by the employment
of women
who have
been given
a
course in public-health work less involved than that required for the
education
of a registered
nurse.
The problem of the necessary
and
desirable
equipment
of
these
teachers
of
hygiene
was
carefully
studied, and
the various types of public-health
nursing
were
noted
and
investigated.
The hotly
debated
question
whether the
public-
health
nurse should or should not render bedside care was reviewed.
The function of other
messengers in the field of public health were
noted and their work was pronounced
correlated to that of the health
instructor which, combined
with bedside care, is a function
possible
only to the fully trained
nurse.
The
committee
is convinced that
the teacher of hygiene
in the home should
possess, in the first place,
the fundamental education
of the nurse and that this should be sup-
Mo. 4.
681
NURSE
CORPS.
plemented by
a graduate course in the special
problems of public
health.
The conclusions
of section
1 are as follows
:
That,
since
constructive
health
work
and
health
teaching
, in
families is
best
dime
by persons
capable
of
giving^ general
health
instruction,
as distinguished
from instruction
in any
one specialty,
and
capable
of rendering
bedside
care
at
need,
those
agents
re
sponsible for such constructive health work and health
teaching
in
families should have completed
the nurses'1 training.
There will, of
coxtrse,
be need for the employment,
in addition
to the public-health
nurse,
of other types
of
experts
such
as nutrition
workers, social
workers,
occupational therapists,
and tlie like.
That as soon as may
be practicable all agencies, public or private,
employing
public-health
nurses
should
require
as
a prerequisite
for
employment
the
basic
hospital
training,
followed
by
a post-
graduate
course, including both class work and field work, in public-
health nursing.
The committee
next investigated
the modern hospital and the mod
ern
dispensary,
which
represents
social
forces
of
enormous
and
growing possibilities.
The
need
for women of fundamental train
ing
and
high
qualifications
is
as manifest
here
as in
the field of
public-health
nursing;
in fact it may
be
regarded
as of first
im
portance in this field of work.
Defective preparation
and
a lack of
proper
qualifications in many
instructors in schools of nursing were
noted.
The appointment of full-time
instructors
is
a recent
devel
opment in schools and is not yet general
; but it is a marked
advance
as the results
noted
shows.
The committee
is of the opinion:
That the career open to young women-
of high capacity, in public-
health nursing or in hospital supervision and nursing
education,
is
one of the most attractive fields now open, in its promise
of profes
sional success
and of rewarding public service; and that every effort
should
be made to attract such women into this field.
The
next
problem
considered
by the
committee
was
the
funda
mental one of providing
nursing care for the sick of the community.
The shortage
of nurses which had existed
during
the war has
been
overcome
to an appreciable extent
during
the last three
years,
the
census reports showing an increase of 83 per cent;
149,128 is the num
ber of trained registered
nurses reported in
1920.
Of these,
11,000
are employed
as public-health
nurses
and the same number
in hos
pitals and
other
institutions.
The remaining
120,000
available for
private-duty
nursing are not all in active practice.
In the cities
the
supply of trained nurses
appears
to be adequate,
and the failure
to
receive nursing care is to be sought in economic factors rather than in
shortage of nurses.
682
Vo'. XV i I
NURSE
CORPS.
Discussion of
the
subject
of the quality
of the nursing
service
brought out radical differences of opinion.
Some private physician
consider
the graduate
" overtrained " and
believe
a woman
with
a
very brief training in bedside routine would be as satisfactory.
As a
result of this feeling, there have been persistent
efforts to break down
the standards of nursing education
which have been laboriously built
up during
the past years.
Others believe
that the removal
of
the
safeguards
which
guarantee
the
quality
of
service
necessary
for
safety constitutes
a real danger to the cause of public
health.
The
committee
records its conviction as follows :
That for the care of persons suffering from, serious and acute dis
ease
the
safety
of
the patient and, the responsibility
of the
medical
and nursing professions demand
the maintenance
of the standards
of
('durational attainment now generally accepted by the best sentiment
of both professions and embodied
in the legislation of the more pro
gressive States; and that any attempt
to lower the standards would
be fraught
with real danger to the public.
The committee
found that many
physicians
demand
nurses
of a
higher
type
than
those
who
are
now
in
the
field.
While
others
desire merely " hands for the physician." with
a minimum of educa
tion.
Eeviewing the facts, it seemed that high natural qualifications
and
sound
education
are needed for the care of
acute and
serious
illness and for public health work:
but for the care of mild
and
chronic illness and for convalescence,
a different type of capacity
and training
could
be utilized.
The distinction,
the committee
believed,
should
be according
to
the type
of
illness involved
and
not
based
on
economic
grounds.
The survey
does
not indicate that the
income
of
the private
duty
nurse
is
especially
large.
The
solution
of
the
economic
problem
which confronts
the
family
of low
income
must
be sought
along
lines of cost distribution
through community organization, or along
lines of group insurance.
The problem
of subsidiary nursing is not new.
In 1920 the num
ber of nurses,
male
and
female,
in the United
States
was
300.0(H).
and of these more
than half were
below
the standard required of
the graduate nurse.
There are grave
dangers
in the existence
of a
loosely
defined,
unregulated
group
of
partially
trained
workers,
and
serious
complications
arise
when
this group
functions
in
the
same
field with
a more highly
educated
type of workers.
A funda
mental
duty to the public has been
discharged
by the nursing
pro
fession
in
stimulating
the
development
of
laws which
define
the
practices of the profession and protect
the community against fraud.
The lower grades of nursing should
also
be defined
and
registered.
The committee
recognized
the difficulty of selecting
a proper
name
No. 4.
683
NURSE
CORPS.
for this subsidiary group, but believe that " nursing aid" or "nurs
ing attendant " best
meets
the need for clear differentiation
while
providing a suitable name.
That committee
recommended
:
That steps should be taken through State legislation for the defi
nition and licensure
of a subsidiary
grade
of nursing
service,
the
subsidiary
type of worker
to serve under practising
physicians in
the care of mild and chronic illness, and convalescence,
and possibly
to assist under the direction of the trained nurse in certain phases
of hospital and visiting nursing.
(To
be continued.)
THE PAST PLAYED
BY A NURSE IN A HOSPITAL
PROGRAM.1
By Miss Ldcy Minnbobrode,
Superintendent
of Nurses,
United
States
Public
Health
Service.
Ordinarily,
well
regulated hospitals
may
be
divided
into
three
distinct
departments —medical,
nursing, administrative.
These
de
partments are coordinated under the superintendent of the hospital,
preferably
a physician with executive ability, able to understand and
appreciate the psychology of the heads of his services, to coordinate
the work of all units and branches of units in order to make a perfect
whole.
We will take it for granted that we are dealing with
a hospital in
which
the ideal service to the patient and the welfare of the patient
are of paramount interest.
Next to the medical service in importance must be placed the nurs
ing service, and if the medical service is to be effective
the physicians
should
be able to place implicit confidence
in the efficiency
and loy
alty of the nursing
service.
The superintendent of nurses and directress of the training school,
if there is a training
school in connection
with the hospital, must
be
in sympathy with
the hospital administration,
loyal to the superin
tendent of the hospital, to the medical
staff, and to the ideals
estab
lished by the nursing
profession.
She should
be
in
charge
of all
personnel
whose
duties
are
concerned
with
the
care of the
sick,
under the superintendent of the hospital.
All matters
relating to
this class of personnel
should be conducted
through
her,
and in all
questions
of policy affecting her people
she should have a voice and
a vote.
In disciplinary
matters
she should be sustained
unless there
is reason to doubt her justice, in which case she should
be removed.
The practice of exploitation of the student
nurse for the benefit of
the hospital is as old as nursing, and has resulted
finally
in bringing
1Read
before
the Catholic
Conference
in Washington,
D.
C.
684
Vol. XVII
NURSE
CORPS.
about
a situation
which
has
placed
many
hospitals
in
a
difficult
position at the present
time,
since there
has been
a pronounced
de
crease in the student
applicants for nurse
training
at a time
when
there is a very pronounced demand for a greater number of qualified
nurses.
The
ratio of student
nurse
to
hospital
beds
should
be
1
to
5, in order that proper time
may
be allowed for study and rec
reation,
and
for
every
6
students
in
a
hospital
there
should
be
1
graduate.
This
schedule
may
be
modified
to
some
extent
by
the construction
and
equipment
of the hospital
and
may
have to
be increased
for the same reasons.
The practice prevalent in many
hospitals
of keeping
student
nurses
on
special
duty
with
private
patients for which
the hospital
is paid should
be abandoned.
Six
weeks of
special
duty is sufficient
for any student
nurse,
and
the
constant
placing of student
nurses
on special
duty for the
purpose
of
earning
money
for
the
hospitals
is
but
another
form
of
ex
ploitation of the student
nurse for the benefit of the hospital to the
detriment of the student.
A happy and contented
nursing personnel
makes for a happy and
contented
patient, since the nurse
is in more
constant
contact
with
the patient than any other hospital personnel.
The patient, too,
is
dependent
upon the nurse for care and comfort, and the attitude of
the
nurse
toward
the
hospital
and
its administrators
will
be
in
evitably
reflected
in the patient.
Therefore,
as
a matter of policy,
if not of justice, the nurse should be considered
as an integral,
im
portant element in the success of the hospital.
It is worth while
to
make her contented
and happy in her work and loyal to the hospital
by providing
proper living conditions
and quarters, adequate
time
for both
recreation
and study and
ample
educational opportunities
and
advantages,
and
to
acquire
a realization
that
to
the
student
nurse as well as to the interne and medical student,
the hospital is her
workshop, study, and laboratory.
How can the hospital authorities reconcile
a proper recognition of
their responsibilities
to the nursing service with the necessity,
pres
ent in most hospitals, for rigid economy
in order to meet necessary
expenses ?
First. —It is essential
that the nurses
receive
a proper education.
This is as much
a matter of vital
interest
to the medical staff as to
the nurse herself, and nothing should be allowed to interfere
with
the course of instruction as established
by the hospital and approved
by the State board of registration for nurses.
Second. —Proper quarters
and
recreational
facilities
should
be
provided, with
adequate supervision of play as well
as of work.
Third.—Nurses
may
be
of
greater
service
to
the
hospital
and
increase their value to the public
as well by receiving instruction in
the various therapies which
have now become an integral
part of
\0. *.
685
NURSE
CORPS.
all our first-class
hospitals.
In all branches of physio-therapy nurses
can be used.
The advantage
of this is obvious,
since because of the
nurse's medical knowledge she can be made more valuable.
The elimi
nation of many different classes of personnel
means the elimination of
friction.
There is no desire
to infringe upon the rights
and privi
leges of the physio-therapists
in making
this suggestion,
but it is
understood
that in the United
States
Navy
this practice has
been
followed
with great success.
Fourth.—In occupational therapy
and social service
also,
nurses
should receive
some training,
and the heads of these various depart
ments who would
be experts
in their specialty should be considered
as a part of the teaching staff for student nurses.
Fifth.—The
same is true of the
dietetic
department.
The chief
dietition
is also
a part of the teaching staff,
and
nurses should
be
of
use
to
her
in
her
department
and
should
receive
a thorough
grounding
in dietetics,
at least to the extent that they would be able
to follow
intelligently
instructions
in the
preparation
of diabetic
and salt- free or other special
dietaries.
The
fundamental
essential, if successful
administration
is to
be
obtained, is cooperation among
the heads of the various departments
and
with
the administrative
head of the hospital
who coordinates
the interests and activities of all these units.
Through
a close
co
operation,
unnecessary
expense can be avoided,
greater care given to
the preservation
of equipment,
and to the elimination
of waste,
and
the strict economy
necessary
in order to make
ends meet financially
can be more surely established
than by a reduction in the essential
comforts for the personnel.
A loyal and efficient nurse
body will
be
interested in making the program of the hospital
a success.
Therefore, let us remember that only through the close cooperation
of the various services can the true mission of the hospital be fulfilled,
and
that mission is the
adequate,
efficient,
and
interested
care of
patients.
At
the
recent
convention held in
Seattle,
it
was
recommended,
voted upon, and carried that the superintendents of the Federal nurs
ing services be members
of the
advisory
council of the American
Nurses Association.
DIGEST OF DECISIONS.
The Comptroller
General has decided that the stoppage
of the pay
of an officer absent without
leave or because
of misconduct
includes
the stoppage of his rental and subsistence allowance.
He has further
decided that an officer not having dependents,
or an officer traveling
with his dependents
on
a commercial steamer
or transport
at Gov
ernment expense, is not entitled to a rental allowance.
The following
correspondence
is of interest
in relation to the ques
tion of origin not in the line of duty :
Department
of the
Navy,
offrce of the
.tvdoe
advocate
general,
Washington,
July 22, 1922.
From: The Judge Advocate
General.
To: The Chief of the Bureau
of Medicine
and Surgery.
Subject : Starnes,
Charlie Joe,
Ex-Sea-2c,
U.
S. Navy,
re origin
of disability.
1. Forwarded:
all papers returned.
2. It appears
from
the matter
contained
in attached
papers that
the above-
named
man first
enlisted
in the United
States
Navy
May
29.
1915. and served
until November
14.
1916.
upon
which
date
lie
was discharged.
It further
ap
pears
that
he
reenlisted
in
the service
January
8.
1918,
and
served until
on
or about June
19.
1918,
on
which
date
he was
discharged
by medical
survey
on
account of "constitutional
psychopathic
state."
origin
not
in
the line
of
duty, not due to his own misconduct.
3. From
an
examination
of
the
matter
presented
in
attached
papers
this
office
is of the opinion
that if there existed any disability which
warranted
the
discharge of this
man
from
the naval
service
by virtue of
a
medical
survey,
said
disability
must
be held to have originated
in the line
of duty.
The
fore-
Koing conclusion
is based upon the case of Vincent
Badolato,
ship's cook, second
class.
United
States
Navy,
May
19,
1921
(File
No.
7657-390:40),
who
was
discltarged
from
the naval
service
on
account
of
" dementia
prtecox,"
not
in
the
line
of
duty,
due
to
a
" predisposition
existing
prior
to
enlistment."
In
that case it
was
held that
the naval
service
was
estopped
from
asserting
that
Badolato
was
suffering
from
a
predisposition
toward
dementia
prwcox
before
entering
the service
owing
to
the fact
that
he
had
served
through
a
duration of
the war
enlistment,
received
a
discharge,
and
subsequently
re-
enlisted,
no evidence of said condition
having
been found prior to his enlistment.
4. The
case
of Vincent
Badolato,
above
referred
to,
has
been
consistently
followed
by
this
department
in all similar
cases
since
its
approval.
For
ex
ample, it was held in
the
case
of Rodney
G. Clark, apprentice
seaman, United
States
Navy,
approved
September
13,
1921
(File No. 29372-3)
that
before
a
687
688
Vol. XVII
DIGEST
OF
DECISIONS.
finding
of " not in line of duty " based
upon
a presumption
that
the disability
complained
of existed
prior to the claimant's
enlistment
in
the naval
service
is
warranted,
it
must
be
shown
by
definite
facts
that
said
individual
was
actually
suffering
from
the said
disability
prior
to his enlistment.
In
other
words,
quoting
decision,
" The facts
which
must
be shown
in a
case
such
as
the
one
under
consideration
before
a finding
of
' not in line of duty ' is war
ranted,
in
the absence
of fraud,
are
facts
established
by proof of their
exist
ence prior
to enlistment;
for example,
if it is shown
from
the
records
of a
creditable
institution
or
the
testimony
of
a
reputable
physician
attending
the
complainant
prior
to his enlistment
that
he
was
suffering
from
tuber
culosis,
chronic,
pulmonary,
at
that
time ; or if
a
statement
of the claimant
describing
certain
physical
conditions
which
he
had
noticed
prior
to his
en
listment
is submitted,
and this statement" could have no other plausible
explana
tion
than
that
he was
suffering
from
tuberculosis
in
some
form
at that
time,
i.
e., prior
to his
enlistment,
a finding
of
' not in
the line of duty
' would
be
warranted,
but under
no other
condition
except where
fraud is shown."
5. Likewise in
the case
of Hansel
Arcebole,
approved
October
4,
1921
(File
No.
29372-2),
it
was
held
that
in
view
of the
facts
that
there
was
no evi
dence
of epileptic
seizures
prior
to his
enlistment
in
the Marine Corps
since
early
childhood,
the disability
complained
of
must
be
held
to
have
been
in
curred
in the line of duty
for the reason
that
a history
of epileptic
seizures
during early
childhood
is not
deemed
sufficient
to warrant
a holding
of " not
in the line
of duty,"
in
the absence of facts
showing
that
the claimant
had
suffered
such
seizures
within
a reasonable
time prior to his
receiving
a
blow
on
the head of sufficient
force
to
knock
him
down,
which
blow
was
received
while in the naval
service
arid may in
fact
have brought
on
these
seizures.
6. In the case of Walter Reinold
Moline,
fireman, third class. United
States
Navy,
approved
December
10.
1921
(File No.
29372-4),
it was likewise
held
that in the absence of definite
facts showing
that
the claimant
in each case did
in fact have the disability complained
of prior to his acceptance into
the naval
service
a
strong
presumption
that
said disability
had
its origin prior
to his
entry
into
the naval
service is not sufficient
to warrant
a conclusion
that
said
disability
was
so incurred,
but,
on
the contrary,
it
should
be
considered
as
having
had its origin
subsequent
to the entrance
of the claimant
in the
naval
service.
In the case of Moline the facts showed that he had apparently
suffered
from
eye
trouble
for many
years prior to his enlistment
in the naval
service,
but there were no facts
showing
that
he had the disability complained
of prior
to his entrance
therein,
and in the absence of facts showing
that the particular
disability
complained
of actually
existed
prior
to his entrance
into
the
naval
service, it was held, in the absence of fraud and facts showing
that it was
due
to his own misconduct,
that it originated
in the line of duty.
7.
Reference
to attached
papers
discloses
not only
an absence of affirmative
facts
showing
that
the disability
complained
of existed
prior
to
the entrance
of the claimant
in the naval
service,
but it is shown
by sworn
statements
of
individuals who have known
the claimant
for a number of years prior thereto
that
his
" condition
of health
prior and
up to the date of his enlistment
was
good."
8. In
the case of Badolato,
above referred
to.
this
office
held that
" concern
ing so much of the diagnosis
of this case as states that the patient
is suffering
from
' dementia
prseeox
' this
office
has
no
recommendation
to
offer
for
the
reason that it considers that the determination
of the disease is a matter timing
wholly within
the
jurisdiction
of
the
Medical
Corps.
This
office,
however,
is unable
to concur in
so much of the diagnosis
in this
case
as states that
the
No. 4.
689
DIGEST
OF
DECISIONS.
' dementia
precox ' did not occur
in the line of duty,
the same
being
a matter
to be determined under the law and the facts."
9. Applying
the above rule
to the
case
under
consideration,
this
office
has
no recommendation
to offer concerning
so much of
the diagnosis
of this
case
as
states
that
the claimant
was
suffering
from
" constitutional
psychopathic
state." but
in
regard
to
the matter
of the reasons
assigned
this
office
finds
itself
in
disagreement.
For
example,
it
is
stated
by
the
board
of
medical
survey that
the patient
was
turned
over
to
the psychiatric division
because
he
had
been
telling girls
in
Norfolk,
who
were
wearing
a part
of the naval
uniform,
that they were doing
so Illegally
and would
be arrested.
"He had no
authority
to do this."
Reference
to section
125 of the national
defense
act,
approved June
3,
1916. which
was in
force
at
the time
when
the conduct
of
the claimant
complained
of took
place,
discloses
that it was unlawful for any
person not
nn
officer or enlisted
man of the United
States
Navy,
to wear
the
duly prescribed uniform of the Navy,
or any distinctive
part
of such uniform,
or a
uniform
any
part
of which
is similar
to
a distinctive
part of
the
duly-
prescribed
uniform
of the United
States
Army.
Navy,
or Marine
Corps,
the
penalty
prescribed
being
a
fine of
not
exceeding
$300
or
imprisonment
not
exceeding six months
or both such fine and imprisonment.
The further state
ment
that claimant
had
no authority
to
do this is likewise in error for the
reason
that being
a citizen
of the United
States,
as well
as an enlisted
man in
the naval
service,
he was peculiarly
authorized
to advise
individuals
against
the
wearing
of any
distinctive
part
of the Navy
uniform
or
a
uniform
any
part of which
was similar to a distinctive
part of the Navy
uniform.
10. After
a full
and
complete consideration
of all
the matter
presented
in
attached papers, and the opinions of the Attorney
General,
and decisions of the
court
relative
to the question
of line of duty, this office
is of the opinion
that
whatever disability
the claimant
may have
been
suffering
at
the time of his
discharge by medical
survey
must
be held
to have
been
Incurred
In
the
line
of duty, and you are advised accordingly.
/s/
A. Stanton,
Acting.
Approved,
22 July, 1922.
/s/
T. llOOSEVELT,
Acting Secretary
of
the Nary.
BOOK NOTICES.
Publishers
submitting
books for review
are requested
to address
them as follows
:
The Editor,
U.
S. Naval Medical
Bulletin,
Bureau
of Medicine
and Surgery,
Navy
Department,
Washington,
D. C.
(For
review.)
Books
received
for
review
will
be returned
in
the
absence
of directions
to
the contrary.
«BVI*W*I»8.
Commander
C. M. Oman, Medical
Corps,
United
States Navy.
Lieutenant
Commander
W. M. Kekb.
Medical
Corps,
United
States Navy.
" No book can be so good as to be profitable
when negligently
read."''
Reptiles of the Would, by Raymond L. Ditmars, curator of reptiles
and asistant curator of mammals in the New York Zoological Park.
The Macmillan
Co., New York,
1922.
Here is a rare book giving
a general
survey
of the reptiles of botli
hemispheres
and written in a popular
vein
by one who has made
a
life study of the subject.
The large collection of living reptiles to
be seen in the New York Zoological Park was created by the author
of this most readable
book, and it is doubtful if anyone knows more
of habits of the reptiles of the New World than he does.
The
reptiles
found
upon the earth to-day comprise mainly
the
tortoises, turtles and terrapins, the crocodiles
and alligators, the liz-
Rrds, and the snakes.
The author necessarily
has treated
this large
class of animal life
by limiting his descriptions
to
representative
groups
and
saying little
of individual
species.
Interwoven
with
the
descriptions of
the
anatomical
characteristics
of
the
various
groups of reptiles are anecdotes of the author's search for specimens
and of the methods
employed
in capturing
them.
Throughout
the
foxt is scattered
much interesting information
concerning the habits
and the feeding, general
care, and treatment
of reptiles in captivity.
Fact and fictjon has been
carefully
separated,
and the story of the
691
692
Vo.. XVIi
book: notices.
reptiles is
so well told that it should be interesting
to the
general
reader.
A notable feature of the book is over 200 photographic illustrations.
These apparently
are from the author's camera,
and each is a study
of reptilian
life.
They
have
been
so carefully
prepared
that
the
distinguishing
characteristics of
each
creature
photographed
are
easily noted.
Many
persons
are
interested
in turtles
and tortoises:
a
smaller
number
have
a liking for lizards
and small crocodilians,
but
few
people care to be associated with snakes.
However, the snakes seem
to have
been
the subject of the author's favorite study, and
he
has
devoted
the latter half of the book to them.
He realizes
that many
of his readers will encounter
the story of the ophidians
with aver
sion, but it
is his hope that ere the book
is finally
closed " a
per
sistently reigning and unjust prejudice may
be completely
shattered
by
the explosion of
a long train
of erroneous
theories,
when
the
snakes
have
been
described
as they truly are, and the clean,
grace
ful, and wonderful
phases of their varied structure have
been
faith
fully portrayed by the camera."
The snakes are of great
economic
importance,
destroying rats and
mice,
and
the
prevalence
of many snakes
about
the buildings
on
a farm
comes from the
presence of these rodents
in
them.
Many
snakes are surprisingly
gentle in their attitude toward man. making
beautiful
and
interesting
pets.
Many
are hardy,
not
at
all
par
ticular
as to the .character
of their
food—eating dead
animals
or
strips
of
raw
beef
covered
with
well-beaten
eggs—and
live
for
years
in captivity.
Healthy
and
well-nourished
snakes
shed
their
skin
at intervals
of
about
two
months,
or
sometimes
at
shorter
periods.
The
snakes
either lay
eggs or produce
their young
alive.
The
common garter snake is viviparous
and sometimes produces
as many
as 75 young in a litter.
This explains why this variety is so numer
ous in our country in spite of the fact that the farmer
boy
kills
every
one
he
encounters.
The young of
the
poisonous
snakes
are
provided
at birth
with
perfectly
formed venom-conducting
fangs
and glands;
they
are just
as dangerous
in proportion
to their
size
as
their
parent.
All young
snakes
at
once
shift
for
themselves
after birth
or hatching.
" Though
poisonous
snakes
are
common
enough
in many parts of the world,
the danger
from
them
is
not
nearly
so great
as imagined.
In India, where
a large
part of the
population
goes barelegged,
the
estimated
number
of
human
lives
lost each year
is about
20,000.
Conditions
are very different in the
United
States,
though the various species of rattlesnakes,
the
cop
perhead
snake,
and
the formidable
water
moccasin
teem
over
vast
No. 4.
693
BOOK NOTICES.
area.
Records
of snake
bites
are
exceedingly
rare
in
North
America."
In the pages of this book one who has served in the Navy a reason
able number of years will encounter
the descriptions of many of the
reptiles whom
he has probably met in various parts of the world.
Among
the
chelonians
we find
several
friends
of
our boyhood
days—the snapping turtle, " a bold and aggressive animal, not hesitat
ing to attack waterfowl, which it drags beneath the surface to drown,
when it tears up the prey by means of the combined
efforts of strong
mandibles and forefeet."
This is the fellow who occasionally " takes
the bait of
a fisherman,
when
its prodigious struggle
to free itself
from the hook leads
the
excited
sportsman
to
believe
that he has
made
a finny capture
beyond all power of imagination."
The little
yellow-spotted
turtles that bask along the banks of pools;
and
the
little terrapins which "may be seen sunning
themselves
in rows
on
derelict timber, from which they
tumble
clumsily
when
frightened.
Once
in the water their broadly
webbed
feet
take
hold
and
they
scurry
to the
bottom,
where
they
hide in the
aquatic
vegetation.
When they again approach the surface, it is with the greatest caution.
Only the snout and eyes are thrust above the water.
In this position
they paddle about
inspecting the outlook until thoroughly
satisfied
that all danger
has gone, when,
one after another,
they
clamber
on
their favorite roosts for another
sun bath."
In wardroom
tales of days long gone, one often hears
mentioned
a dish of which the diamond-back terrapin formed the principal
in
gredient.
This
creature
used
to
be plentiful in
the salt
marshes
along the coasts of North and South Carolina.
They were compara
tively
cheap, but the market demand
threatens
their extinction, and
a dozen 8-inch
" diamond-backs " are worth to-day, according to the
author, about
$75.
The tortoises
are strictly
terrestrial
species of the Chelonia, and
older officers may recall the giant tortoise,
specimens of which were
to be found on the Galapagos Islands until
a few years ago, when
a
scientific expedition secured what its members believed
to be the last
survivors
of
the
tortoise
colony.
The
author
describes
the
love
making of these
immense
creatures,
of which
specimens
weighing
over
300
pounds
exist in his collection.
Many of
us
are familiar
with
the
sea
turtles,
which
have
an
extensive
distribution
throughout
the tropical and semitropical seas.
They are the giants of the aquatic
chelonians
and never leave the sea
except to deposit
eggs on sand beaches.
One of the sea turtles—the
green
turtle—is of world-wide
renown
as an article of food;
an
other — the hawk's bill turtle —furnishes the valuable " tortoise shell "
which we always buy when
in Japan.
4539—22
10
694
Vol. XVII
BOOK
NOTICES.
In the
section
on
the
crocodilians
the
author
answers
the
oft-
asked question
: " What is the difference
between an alligator
and a
crocodile?"
In reality the question
is not a very important
one, as
among
the 21 species of crocodilians
there are but 2 members of the
genus Alligator,
one inhabiting
North
America
and
the
other
the
Yangtze
River in China.
There
is,
however,
a
great difference
in
the temper
and activity
of alligators
and
crocodiles.
"An enraged
alligator
will throw
its head
from
side to side, bang the jaws to
gether sonorously,
and
violently
swish
the
tail,
but
a
man
with
steady nerves may approach within
a
few feet of the animal, throw
a
noose over the head, tie the jaws together,
push
a
pole toward the
body,
then by successive
nooses pulled backward over the head
and
forward
over the tail, splint
the animal to the pole
so
it
is
entirely
powerless.
.
.
. Such proceedings
would be abruptly
terminated
by
a
crocodile."
The
author
describes
his first
meeting with
a
big
fellow from Florida
:
" Driven
out of the crate, the crocodile looked
the picture of good
nature.
Standing
away
from what he thought
to be the reach of his tail, the writer
prodded the apparently
slug
gish brute with
a
stick to start
it
for the tank.
Several things hap
pened in quick order.
With
a
crescentic
twist of the body
utterly
beyond
the power of an alligator,
the brute dashed
its tail at the
writer, landing
him such
a
powerful
blow that he was lifted com
pletely from the ground.
As he left terra firma, an almost involun
tary inclination
caused him to hurl his body away from
a
pair
of
widely gaping, tooth-studded jaws swinging perilously near.
Land
ing
with
a thud
on
one
shoulder, though
otherwise
unhurt,
the
writer threw
himself
over
and
over,
rolling
from
the
dangerous
brute that was actually pursuing
him on the run, body raised
high
from the ground.
.
.
.
Such
is
the average crocodile— an active,
vi
cious,
and,
above all, treacherous
brute."
The author explodes
the popular supposition that an alligator
re
quires
a
long period of time to acquire
maturity.
That such
is
not
the
case
has
been
demonstrated
by
a
number of young
alligators
under his charge.
" These outgrew one tank after another within
a
few years.
It only takes four years for an alligator,
from
the time
of
hatching,
to grow
fully large
enough
to
have
a
commercially
valuable hide."
Among the lizards we find manj' acquaintances,
especially familiar
to most of us being the little geckos
wTith their thick-set body, broad,
flattened
head, stumpy tail, and the round disk or " sucker " on each
toe, which dart about the ceilings of tropical quarters after the lamps
are lit in search of insects attracted by the light,
and
whose
small
white eggs the children
often find in crevices
about
the
house
and
place in
a
tumbler wrhere the hatching process may be watched.
No. 4.
695
BOOK NOTICES.
Probably next
best
known
are the
iguanas,
of which
there
seem
to be many species and which are so plentiful in tropical
forests.
It
appears
that fine specimens of the common
iguana may
be purchased
from dealers in the United
States for $3 or $4 each ; but the rhinoc
eros iguana,
a far more showy creature,
costs about
$25.
As it is
found only in Haiti and Porto Rico, I record this bit of commercial
information for the
benefit
of any member of the marine expedi
tionary
force
on duty in the " Black
Republics " who
may wish to
turn it to account.
Rhinoceros iguanas might
prove
a better
ven
ture than parrots or monkeys.
The chameleons
of course
receive their share of attention
in the
discussion,
and
the
author
records
several
interesting
facts
about
them.
Many lizards, especially those from
desert
regions,
require
great
heat in captivity,
and
the author tells
us that
he
has
seen
certain
specimens
" dashing about [their cage]
with
a great show of anima
tion when
a Fahrenheit
thermometer
registered
110°."
Many captive desert lizards live but a short time.
They die from
a lack of water.
It was quite by accident
that the author discovered
how such specimens may be saved, for they will seldom drink from a
pan or lap the dewlike drops of water from
the
vegetation
in the
cage.
His specimens
stubbornly
refused
water, became emaciated,
and were slowly dying.
One day when certain
cacti in the cage were
being watered
a remedy for the trouble was discovered.
A few drops
of water
were accidentally
scattered
over
the lizards'
backs,
where
they were instantly
absorbed.
Taking this as a valuable hint, the
author had all the lizards thoroughly
sprayed
with
a " mist " nozzle.
A change was soon noted.
After
a few days spraying
the reptiles
took on plumper outlines, feeding with more energy.
It is possible
that in their
desert
homes the quick change of temperature,
influ
enced by day and night, may produce
a certain condensation
of mois
ture, like a dew, thus enabling the thirsty skin of these little animals
to absorb the needed fluid.
From the decks of small gunboats,
cruising leisurely off the west
coast of Mexico
and Central America, one may often see a sea snake
somewhat under
a yard in length, jet black or rich brown above—on
the upper half of the body—while the lower half is bright
yellow.
This, according to the author, is the yellow-bellied
sea snake, Hydras
platunix, and it occurs only in these waters.
Reptiles of the World is a book which should
be in the library of
every naval vessel where
it would
be accessible
for reference
to all
those interested
in identifying
and studying the reptiles encountered
in travels
about
the
globe.
It
is highly
recommended
to all who
might wish to make the study of the reptiles a hobby,
as some
medi
cal officers have done.
(w. m. k.)
696
Vo'. XVII
BOOK
NOTICES.
The Pbactice of Medicine,
by A. A. Stevens, A. M., il. D., professor
of applied
therapeutics
in
the University of Pennsylvania.
W. B.
Saunders,
Philadel
phia,
1922.
The writer of this volume
on practice is peculiarly
fitted
to pre
pare
a work
worthy
of careful
consideration
by
the
medical
pro
fession of the English-speaking
countries by reason of his teaching ex
perience
in
the University of Pennsylvania,
and
his
vast
clinical
experience
derived from his connections
with the great hospitals of
Philadelphia.
In the preparation of the book,
Doctor
Stevens
de
sired
to present
descriptions of the various internal
diseases which
should accord
with
the present
state of our knowledge, and
which,
though concise, should give to the student
and the practicing
physi
cian
the most
necessary
points in pathology,
diagnosis, and
treat
ment, and he has succeeded in his wish to a remarkable degree.
In
looking
at
a
work
of this
size—the
volume
contains
1.106
pages—one does not often think of the labor involved in its produc
tion.
The manuscript must be written
and sent off to the publisher,
in whose establishment
it is made ready for the press —the copy is
set up in type, galley proofs are struck off, and, after these are cor
rected, page proofs, which are submitted
to the author for final cor
rection, are printed.
After all errors have been eliminated from
the
text and the index and illustrations
have been prepared, the pages
are
printed
and
sent
to the bindery,
from which
the finished
product
issues.
These various processes take time, yet in spite of the months
required for preparation,
this volume
is singularly
up to
date.
A
glance through the pages reveals
mention of many of the very
latest
advances in the practice of medicine.
The
work
is intensely practical,
a prominent
feature
being
the
excellent
outline of treatment
which concludes
the discussion
of each
disease, and it gives promise of being a successful
rival of the master
piece of Osier, whose pupil Doctor
Stevens
once was and
to whom
his book is dedicated,
(w. m. k.)
Symptoms
of Visceral
Disease,
A Study of the Vegetative Nervous System
in its Relationship to Clinical Medicine,
by F. M. Pottenger,
A.
31., M. fl..
LL. D., F. A.
C. P.
Second edition.
C. V. Mosby
Co.,
St. Louis, 1922.
The
one outstanding
need of modern
medicine,
according to the
author of this important
contribution
to medical literature,
is accu
rate clinical
observation and interpretation;
and
the clinician
who
must
weigh
the value of clinical
data gathered
from all sources
and
give the final opinion of the case, should not only
be familiar
with
iaboratory
methods
and
be able to properly
interpret
the
findings,
but he should cultivate the habit of accuracy
in the observation
of
his patient
and
be
able
to understand
the
meaning of
symptoms
which point to departure from the normal functioning
of the
body.
No. 4.
697
BOOK NOTICES.
In this book the author has attempted
to interpret,
so far as may
be
possible
in terms of visceral neurology, symptoms
which
are found
in the everyday clinical
observation
of visceral disease, and to show
how pathologic changes in an organ affect other organs and the body
as a whole through the medium
of the visceral nerves.
It might well
be called a study in pathologic physiology.
As the author remarks
in the preface, the work
is largely
a discussion
of " viscerogenic
"
reflexes;
and, as such, prompts the reader
to consider
carefully
the
problems
connected
with
the
vegetative
nervous
system
and
im
presses upon him the importance of careful clinical
observation
and
analysis.
" While the importance of the vegetative
nervous
system has long
been known to physiologists, clinicians generally have ignored it and
failed to see its intimate relationship
to clinical
medicine; but it is
the key which unlocks the door to many of the secrets of visceral ac
tivity.
An understanding of the vegetative
nervous
system and the
activities of the endocrine
glands will explain
to the clinician
most
of the physical
acts
connected
with
visceral function
and
furnish
the bridge
between the pathologic changes
in tissues and the expres
sion of the disease in altered
organic function.
In other words, the
vegetative
nerves
and
the products of the endocrine
glands are the
mediums
through
which visceral symptoms
are expressed."
Although the study of the vegetative
nervous
system is briefly pre
sented by the author, it is sufficiently complete
to furnish " the essen
tial facts which one should have in order to understand the manner
in which body activities,
both
physiologic
and
pathologic,
express
themselves
through
it."
The volume
is arranged in three
parts,
the first dealing with the
relationship
between
the vegetative
nervous
system
and
the
symp
toms of visceral disease : the second, with the innervation of impor
tant viscera and
a study of the more common
viscerogenic
reflexes;
the third, with the anatomy
and physiology of the vegetative
nervous
system.
The book should be read
in conjunction with Mackenzie's Symp
toms
and Their
Interpretation,
to
which
the
author
refers
fre
quently.
(W.
M. K.)
The Sumical Treatment
of Non malignant Affections of the Stomach,
by
f'htiric*
(irecn
Cumston,
M. /)., and Georges Patry,
M. n.
J.
B. Llpplncott
Co., Philadelphia,
1922.
This is a very
readable
and instructive book.
The writers
show
familiarity with the subject
at hand and in the first chapter
give us
a very
good and brief
resume of the various stages of development
698
Vol. XVII
BOOK
NOTICES.
of the
most commonly used operative procedures
on the
intestinal
tract.
The
subject
matter
is generally
well
handled,
and
the
student
gets a very
good idea of both sides of. the question
under discussion,
while the authors don't hesitate
to give
us their opinions in detail.
There are still a great many points in regard to gastric ulcer and its
many
divergencies
which
are
not
settled
by
any means,
and
any
book
written
by
surgeons
of ability
and
unquestioned
reputation
will
be eagerly
welcomed,
(c.
m. o.)
The Writing of Medical
Papers,
by
Maud
H. Hellish,
editor
of
the
Mayo,
Clinic
Publications.
W. B. Saunders
Co..
Philadelphia,
1922.
Mrs. Mellish
says in her introduction
to this valuable little
hook:
" Many
men and
women
who, unfortunately,
do not
possess
the art
of writing and have not acquired
its usable
substitute,
the craft of
writing,
have chosen medicine
as
a life work,
for success in which
they should
be able to write well for the medical
profession.
They
desire, therefore, to acquire
the craft of writing with the least
pos
sible effort or delay.
For these there
is a need, not for new manuals,
but for
a handbook adapted
especially to their profession
and
in
cluding
the essential
points to be found
in general
textbooks."
So
in order to assist those
who
are struggling
in their
attempts
to ex
press their
thoughts on paper with brevity, accuracy,
clearness,
and
in accordance
with the accepted
forms of the present
day.
she has
prepared
a small
volume
which
is crowded
with
useful
knowledge
pertaining
to the craft of writing.
The
book contains short discussions
of the
misuse of terms
and
words,
tin
advantage
of the acquisition of
a large vocabulary, the
use
of
italics
and
abbreviations.
The
chapter
on
punctuation
is
especially helpful
when
one is in doubt
as
to what marks
to
use
and
when to use them.
In a chapter on miscellaneous
grammatical
notes and pitfalls in diction, the writer points out some errors which
are the result of our careless habits of thinking and
forgetfulness
of the common
rules of grammar.
The latter half of the
volume
is devoted
to
a
discussion
of
the
technic
of the preparation of a satisfactory
paper,
in which subject
matter,
length, arrangement,
construction of the paper as a whole
as well as that of the paragraph
and sentence, the use of references,
the
revision of
the
manuscript,
proofreading,
the
use
of
quoted
material
and
respect
for
copyrighted
matter
are
helpfully
com
mented upon.
The
volume
closes with
a list of the standard abbreviations for
the titles of medical journals
which should always
be
used
when
No. 4.
BOOK NOTICES.
699
quoting references
to the work of other
writers appearing in these
journals.
Mrs. Mellish
has gone to great pains to tell her reader just what
to do in order to prepare
a readable
paper, but, better yet. all through
the volume she has been careful
to tell him what not to do, which
fact adds greatly to the value of her book.
This little
volume
will be helpful
to the naval medical
officer not
only in preparing
articles for publication,
but in the preparation
of his official
correspondence,
with which one can not be too careful.
(w. M. K.)
Applied
Chemistry,
an
Elementary
Textbook for
Secondary
Schools,
by
F. N. Peters,
Ph. D., instructor in chemistry
in Central High School, Kansas
City, Mo.
C. V. Mosby
Co., St. Louis, 1922.
This is a superb
volume for the student of elementary chemistry,
thanks to the author's direct, clear style
and the completeness
with
which the subject
is handled and owing also to the excellence of the
many illustrations,
the good type, and other features
of the book
man's
craft.
It is a most
readable
book,
and in it the author has
presented the chemical
facts of everyday life in
a concise
and
in
teresting
manner.
It is especially recommended
as
a textbook for
hospital
corpsmen.
(w. sr. k.)
New
Growths
and
Cancer
by
S.
B.
Wolbach,
M.
D.
Harvard
University
Press, Cambridge,
Mass.,
1922.
This tiny volume contains the
substance
of
a public lecture de
livered
at
the
Medical
School of Harvard University
and
forms
the tenth book of a series which aims to provide, in easily accessible
form,
modern
and
authoritative
information
on
medical
subjects
of general importance,
(w. if. k.)
mm
THE DIVISION OF PREVENTIVE MEDICINE.
Lieutenant
Commander
R. F. Jones,
Medical
Corps,
United
States Navy,
In charge.
Notes on Preventive Medicine for Medical Officers,
United States
Navy.
INSTRUCTIONS
TO MEDICAL OFFICERS.
REMAEKS
ON DEEP-SEA
DIVING.
By G. B, W. Frknch,
Lieutenant
Commander,
Medical
Corp*,
United
States Navy.
One of the important
duties of the medical
officer is the physical
examination of
men
selected
for
deep-sea
diving.
In
selecting
divers, only men of high physical standard should be chosen,
i. e.,
men free from
diseases of the ears, heart,
lungs, blood vessels, and
kidneys,
and men of good muscular development.
Two other
fac
tors are to be considered
in the physical qualifications of a deep-sea
diver:
(a)
Degree of fatness; (b)
age.
Moderately stout men and
middle-aged
men are more
disposed
to caisson
disease than young,
slim, small, or wiry men.
The
degree of fatness
is the more
im
portant
factor.
Nitrogen
is several
times more
soluble
in fat than
in the ordinary
body tissues, and on decompression
the fat gives off
its
nitrogen
more
slowly.
Hence
a stout person
is more
liable to
caisson
disease.
Men of middle age are more inclined to fatness
and
therefore
more
predisposed
to caisson
disease.
The respiratory
ex
change
in middle-aged men
is slower,
and in moderately fat men
the blood, instead of being one-twentieth the body weight, is nearer
one-thirtieth,
and hence elimination of nitrogen in solution of body
tissues would be slower than in the small, slim man.
Arteriosclerosis
is
a dangerous
factor, and
men with
even mod
erate or slight arteriosclerosis should not be chosen.
Ear
disease
is
a bar to diving.
This
is especially
true
of
any
trouble that interferes with the patulousness
of the Eustachian tubes.
Frequently
men with even a slight cold, owing to congestion
of these
tubes, are unable
to clear their ears; i. e., equalize
pressure
on both
sides of the ear drums.
Pain from unequal
pressure
on the drums
is severe.
If, despite
the warning
of ear pains, the diver is unable
to clear his ears and persists
in descending,
a rupture of the ear drum
is possible.
701
702
Vol. XVII
DIVISION
OF PREVENTIVE
MEDICINE.
Air pressures
exceeding
three or four
atmospheres
(66 to
99
feet
sea water) have an irritant effect on the lungs.
Hence, it is evident
the lungs must
be sound
and
the individual
free from
tuberculous
tendencies.
The best type for diving work is the young (20 to 30 years of age),
small, thin, wiry man of phlegmatic temperament.
The circulation
of blood is faster in his case, he desaturates
more quickly, and is less
inclined to caisson disease.
PHYSICAL
EXAMINATION.
The medical
officer should
examine
all candidates
for the course
of instruction at the diving school.
They must come up to the physi
cal requirements
before they are considered
eligible for instruction.
Qualified divers should
be examined
at frequent
intervals, and
a
special
physical examination should
be made in the
case of all
men
prior to each diving operation, especially if the depth
of the water
is over
40
feet.
Under
ordinary
conditions divers
over
40
years
should
not be permitted to dive in water over
15 fathoms in depth.
AIR SUPPLY
TO DIVERS.
The medical
officer should assure himself that a sufficient
amount
of air of proper quality is furnished the diver for helmet ventilation.
The minimum air supply
in
cubic
feet
per
minute
for any
given
depth may be computed
by the following
formula
:
£==1.5(1+F(0.0303)),
in which S is the required air supply in cubic
feet, measured
at the
surface, and F is the number of feet the diver is below
the surface.
To enable the diver to perform hard work, arrangements
should be
made for supplying three times this quantity of air, if practicable.
AIR SUPPLY
FROM
MANUALLY
OPERATED PUMPS.
Under
usual
service conditions the air supplied
to divers is fur
nished by two-cylinder, double-acting, manually operated
air pumps.
The latest type of pump is the Mark III, which has a capacity of 405
cubic inches per revolution when
100 per cent efficient.
Other types
of pumps
in service
are Mark I ; Mark I, model
1 : Mark I, model
2; the Mark II;
and
the Mark II,
model
1.
The capacity of
the
Mark I is 277.7 cubic inches per revolution, when 100 per cent efficient.
The
capacity
of the Mark U models
1
and
2.
and Mark II.
and
Mark II. model
1, is 296.3 cubic
inches per revolution when
100 per
cent efficient.
The efficiency of the service of manually operated diving air pumps
will
be found
to vary greatly.
The
greater
the depth
or
pressure ,
against which pumps
have to be worked,
the greater will be the loss
No. 4.
703
DIVISION
OF
PREVENTIVE
MEDICINE.
of efficiency.
The efficiency of
a pump will
depend
largely
on the
care and upkeep
the pump has received.
Tests on various service
pumps
against
pressure
as low
as
20
pounds
per
square
inch has
shown
efficiency
of pumps
varying
from
30 to
90 per
cent, and
at
higher
pressures —75 pounds
per square
inch —efficiency
has been as
low
as
5
per
cent.
It is essential
that the efficiency
of
the pumps
used should
be known in determining
the
amount
of air supplied
to the diver.
Inefficient pumps should not be used until
properly
repaired.
As every
foot
depth
of
sea water exerts
a pressure
of
0.445 pound per square inch, and
as loss of efficiency
increases
with
pressure, it is necessary that pump efficiency
be properly determined
in all diving operations in water in which the depth
is greater
than
30 feet, and
especially
so if the pump has been in service
for
any
considerable
time.
DETERMINATION
OF PUMP EFFICIENCY.
The percentage
efficiency of a diving air pump can be practically
and approximately
determined
by pumping
air into
a reservoir or
air tank of known capacity, noting
the number
of revolutions
re
quired for the different pressures,
and then making
a mathematical
comparison
of the results
thus obtained
with the theoretical capacity
of the pump at test pressures.
When
T= theoretical capacity of pump in cubic
inches
per revo
lution ;
Potest pressure
in pounds
per square
inch by gauge;
r=capacity of test tank, air hose, and air space in pump
connections
;
14.7 = pressure
in pounds per
square
inch of
1 atmosphere;
^"^theoretical
number
of
revolutions
required
to
charge
test tank to P;
A'=The number of revolutions actually
required
to charge
test tank to P—
L CP-R
T
2. 10o5=per
cent efficiency.
3.
100 minus per cent efficiency equals loss efficiency.
The theoretical
capacity of the various two-cylinder,
double-act
ing air pumps in service are as follows:
Mark I
(8J-inch
diameter
cylinders, 6-inch stroke)
is
277.7
cubic inches.
Mark I, model
1 (4-inch diameter
cylinders, C-inch
stroke)
is
296.3 cubic
inches.
Mark I, model
2 (4-inch diameter
cylinders. C-inch stroke)
is
296.3 cubic
inches.
704
Vol. XVII
DIVISION
OF PREVENTIVE
MEDICINE.
Mark II
(4-inch
diameter
cylinders, 6-inch stroke)
is
296.3
cubic inches.
Mark II, model
1
(4-inch diameter
cylinders, 6-inch
stroge)
is 296.3 cubic inches.
Mark III
(4^-inch
diameter
cylinders, 74,-inch
stroke)
is
405
cubic inches.
The
capacities
of
air
spaces
contained
in
the air
connections
(capacity of branch
pipes, air reservoirs,
gauge
pipes,
etc.) of the
Mark I ; Mark I, model
1 ; Mark I, model 2 ; and the Mark III diving
air pumps
are approximately
83 cubic
inches
each.
Those
for
the
Mark II and the Mark II, model
1, are approximately 43 cubic inches
in each.
The capacity
of a 50-foot length of standard diving air hose
(one-
half inch internal diameter)
is 117 cubic inches.
For proving
the
efficiency
of diving
air
pumps
in
accordance
with
the foregoing method,
a test tank of
1 cubic
foot capacity
is
furnished with all new diving apparatus.
In using the test tank as a reservoir for measuring the volume
of
air furnished
by
a diving
pump,
the capacity of the air-hose
con
nection
between the tank and the pump must be taken into considera
tion when computing the capacity of the testing reservoir.
For convenient
reference
the following
table
has
been
compiled.
This
table
shows
the
percentage
of
loss of efficiency of the two-
cylinder, double-acting, diving air pumps
at various revolutions when
tested to
100 pounds
pressure
per square
inch,
in the manner
pre
scribed,
using
a
test
tank
of
1
cubic foot capacity
and
a 50-foot
length of air hose between the tank and
a pump:
Revolution?.
Mark I.
model 1:
Mark I,
model 2.
Mark II:
Mark II,
model 1.
eflleiency.
Per cent
loss of
Mark I.
Mark III
47.2
49. 7
52.4
55.5
59. (I
62.9
67.4
72.6
78.7
85.8
44.6
46.9
49. 6
52. 5
55.8
59. 5
63. 7
68.6
74.3
81.
1
89.2
99. 1
111. 5
127.4
148.7
43. 7
46.0
48.6
51.4
54.6
58.3
62. 4
67. 2
72.8
79. 5
87.4
97. 1
109.3
124.9
145. 7
32.4
34. 1
36.0
38. 1
40. 5
43. 2
46.3
49.9
54.0
58.9
64.8
72.0
81.0
92.6
108.0
10
15
20
25
30
35
40
45
50
|
(I
5
!
118.0
134.9
157.3
55
I
No. 4.
DIVISION
OF PREVENTIVE MEDICINE.
705
■
!
i
i
When
testing air
pumps
for efficiency
according to this method,
using
a test tank of
1 cubic
foot capacity, errors are easily
made in
recording
the exact number of revolutions required for a given pres
sure ; therefore, each test should be repeated two or three times, and
the average
results
thus obtained
should be taken
as the true result.
On account of the heat generated
when compressing
air, and the con
sequent
increase in volume due to expansion
on account of heat, cool
ing water should always be used in the water cistern
of diving
air
pumps when they are being operated
against
pressure.
The specifications
for diving air pumps require that prior to accept
ance
they
shall
prove
at least
80
per
cent
efficient
when
tested
in
accordance
with the foregoing method, immediately after having been
tested for endurance
against a pressure of 100 pounds by gauge for a
period of one hour.
DETERMINATION
OF PUMP'S REVOLUTIONS TO FURNISH NECESSARY
AIR SUPPLY TO DIVERS.
Knowing
the
capacity
and
efficiency
of
the
diving
pump,
the
r.umber of revolutions per minute
necessary
to operate
the pump
to
furnish the proper air supply to a diver can be determined
as follows
:
When
Z)=depth of sea water, in feet, to which dive is made;
Ar=number of cubic inches of air the pump will furnish
per
revolution, measured at atmospheric
pressure;
/?=number
of revolutions per minute required of pump to
furnish
1.5 cubic
feet
(2,592 cubic
inches)
of air per
minute,
measured at atmospheric
pressure;
X=number of revolutions per minute required of pump tc
furnish minimum allowable air supply (1.5 cubic feet)
(2,592 cubic inches)
per minute at D—
2592
_
-y— *•
R(l + £(0.0303)) = AT.
If the efficiency of a diving air pump is less than 100 per cent, and
its actual per cent efficiency at the equivalent absolute
pressure
at D
is represented
by a symbol
as E, then :
1005(1+ D(0.0303))_v
E
As the value of N for the various types
of two-cylinder,
double-
acting, diving
air pumps,
previously referred to when
100 per cent
efficient,
is 277.7 cubic inches, 296.3 cubic inches, and 405 cubic inches,
then R must equal 9.33, 8.75, and 6.4 revolutions, respectively.
Multiplying
these respective
values
by
the
coefficient
0.0303,
the
following results are obtained
: 0.283,
0.265,
and 0.194.
Hence,
to determine
any number of revolutions
per minute, it is
necessary
to run any of these pumps
to furnish
the minimum allow-
706
Vol. XVII
DIVISION
OF
PREVENTIVE
MEDICINE.
able air supply (1.5 cubic feet per minute) for one diver at any depth,
proceed
as follows
:
Diving air pump, Mark I.—Divide
100 per cent by tbe actual per
cent efficiency of the pump at the equivalent pressure
to which
the
dive is made, and multiply the quotient thus obtained
by the sum of
the product of the number of feet depth of sea water and the constant.
0.0283,
added to 9.33
(number of revolutions required
to deliver
1.5
cubic feet of air at atmospheric
pressure).
Diving air pumps, Mark I, model 1; Mark I, model 2; Mark II:
Mark II, model
1.—Divide
100 per cent by the actual
per
cent
effi
ciency of the pump at the equivalent pressure
to which
the dive
is
made,
and multiply the quotient thus obtained
by the
sum of the
product of the number of feet depth of sea water and the constant.
0.265,
added
to
8.75
(number of revolutions required to deliver 1.5
cubic feet of air at atmospheric
pressure).
Diving air pumps, Mark III.—Divide
100 per cent by the
actual
per cent efficiency of the pump at the equivalent
pressure
to which
the
dive
is made,
and multiply the quotient thus
obtained
by
the
sum of the product of the number of feet depth of sea water and the
constant,
0.194,
added
to
6.4
(number of revolutions
required
to
deliver 1.5 cubic feet of air at atmospheric
pressure).
For example
: Diving air pump, Mark III, 80 per cent efficiency ;
depth
of
sea
water,
66
feet.
How
many
revolutions
per
minute
should the pump be run to furnish
the minimum allowable air sup
ply
(1.5 cubic
feet of air
per minute)
to
a diver working
at that
depth?
100-^80X (66X0.194-f6.4) =24 revolutions
per
minute.
The maximum rate of pumping that it is possible
to maintain by
a pumping crew over a practical period of time is about 30 revolutions
per
minute,
and
as the depth
or equivalent pressure
increases
this
becomes
less
and
less.
Therefore, if the
revolutions
required
are
in excess of the number it is possible
to maintain the work should
be
divided between two or more pumps.
What
arrangements
may
be
made
for supplying
the
requisite
amount
of air
to one diver working
at
a depth
of
168
feet
when
diving air pumps, Mark III, each 80 per cent efficient, are used?
(100-^80) X (168X0.194+6.4) =48.7,
or practically
49 revolutions per minute to furnish
1.5 cubic
feet of
air to one diver with
one pump,
or 24.5 revolutions per minute
with
two pumps.1
1At
this
writing
practically
the
only
diving
pumps
in
service
In
the
Navy
are
the
Mark III.
However,
in remote stations
and
older
ships
some
of the older
service putnps,
Murk I and II,
may
be encountered.
yp
•
No. 4.
707
DIVISION
OF
PREVENTIVE
MEDICINE.
When utilizing manually
operated
diving
air
pumps
to furnish
air for divers, the following conditions should
be observed
:
(a)
Arrangements should be made to furnish
at
least
the mini
mum allowable air supply
(1.5 cubic
feet per minute,
measured
at
the absolute
pressure to which the dive is to be made)
to each diver,
and, if practicable, a reserve air supply.
(b)
Arrangements
should
be
made
to
insure
the
dispatch of
a
relief diver.
(c)
Except
in shallow depths
and
where
there
is
no
danger
of
divers
becoming
foul of obstructions
on the bottom,
more than
one
diver should not be permitted to dive when using air from the same
diving air pumps or group of diving air pumps.
(d)
The rate of pumping should be regular.
(e) If the air being supplied to
a diver is uncomfortably warm,
cold water should be placed in the water cistern of diving air pumps,
and kept cold by the addition of ice, if necessai v.
AIR
SUPPLY
PROM
POWER
COMPRESSORS
AND
STORED
COM
PRESSED AIR.
For safety, ease of operation, and economy,
a power compressor
or stored
compressed air is
used
to furnish
air for helmet
ventila
tion when the diver reaches deep depths.
By the use of tliis appara
tus great depths
are attainable
over long periods
of time.
In the
hands of the unskilled this is a dangerous
procedure,
and those who
have
not been specially instructed in the
practice
and
use of the
power
compressor
or stored
compressed
air for
diving
should not
be allowed to utilize this method.
In using power compressors
or stored
compressed
air in diving,
the air supply in
cubic
feet per
minute,
measured
at surface,
for
any given depth
is calculated
at 4.5 (l-\-F (0.0303),
in which F is
the number
of feet the diver is below
the surface.
The
technic
of
the air supply
is
as follows:
Air
is supplied
to
the
diver
from
a tank
(from
1 to
5
cubic
feet capacity)
in which
the air
pressure
is maintained constantly
at
25
to
50
pounds
per
square
inch
above
the
greatest
pres
sure
necessary
for
the
greatest
depth
at
which
the
diver
is
to descend.
The diver
controls
the
flow of
compressed
air from
this tank
by
means
of
an
air
control
valve
which
is
interposed
in the diving hose, 3 feet from the helmet, and fastened to his breast
plate.
The
pressure
in the tank is kept constant
by low-pressure
(100
pounds
per square
inch),
automatically
controlled,
large-ca
pacity, power-driven air compressors,
or by high- pressure
compres
sors, 2,000 to 3,000 pounds
per square inch, of sufficient
capacity, or
high-pressure
(2,000 to
3,000 pounds per square
;nch)
stored
com
708
Vol. XVII
DIVISION
OF
PBEVENTIVE
MEDICINE.
pressed
air
(torpedo air
flasks)
; in which
case,
a
hand-operated
(not automatic)
reducing valve and
by-pass
are
interposed
on
the
line to the tank from which the diver takes his air.
AIR SUPPLY
FROM
HIGH-PRESSURE
ACCUMULATORS.
High-pressure
accumulators, such
as the air
accumulators
of
the
torpedo installation
on board vessels, may
be used in diving
opera
tions.
When connections
are made with accumulators,
diving
opera
tions are to be conducted
directly from or in the immediate
vicinity
of the diving
vessel, thus obviating
the necessity
for the
use of
a
long length of air hose and its accompanying dangers.
When
the
accumulators
are of
sufficient
capacity,
the
air
necessary
for
the
diver should
be taken
from accumulators already fully
charged
to
maximum capacity.
When
the capacity of the accumulators
is in
sufficient for the depth to be accomplished,
the air compressor
shall
be in operation when necessary, and care taken to see that the water-
cooling system
is intact in order to insure
a cool air supply.
The
capacity of the air compressor
and the accumulators must be known
and
taken
into consideration
when
calculating
the air supplied
to
the diver.
Under no circumstances
should the diver be permitted
to
dive to the limit of his air supply, no matter what the method
is in
use at the time.
Sufficient air must always be held in reserve to enable
a relief
diver to go to the assistance
of the
man under water.
To
increase the capacity of the air accumulators on board ship, the tor
pedo air flasks
can readily
be utilized
by connecting them
up
to
the air line with stop valves opened.
AIR SUPPLY
FROM TORPEDO FLASKS.
Torpedo air flasks
may
be utilized
to furnish
air to divers when
deep-diving operations are to
be conducted
at a distance
from
the
diving vessel.
In the use of this method,
at least three or more
flasks
must
be connected
to the manifold
ready for use, and one flask
held
in reserve, to be used only in case of special
exigency,
as in the case
of a fouled diver.
Not more than two divers shall
be permitted
to
dive
from
the
same boat.
The
pressure
in the working
flasks,
as
indicated on the high-pressure gauge, shall not
be permitted to fall
below
220
pounds
per square
inch in
excess
of pressure
at
which
the divers are working
while
on the bottom.
After they are clear
of the bottom
and safely on their way to the surface the third flask
may
be opened.
In case it should be found impossible
to obey
these
instructions the reserve flask may
be opened.
However, at the same
time
a reserve supply of air in another boat must be immediately
brought up and connected
to the manifold.
Under these conditions
the duration of air supply
from
one flask is calculated as follows:
Xo. 4.
709
DIVISION
OF
PREVENTIVE
MEDICINE.
6'=capacity of one air flask in cubic feet.
A= atmospheric
excess pressure in air flask.
D= number of divers.
#=number
of atmospheres'
excess pressure
to which
dive
is
made.
Allowing
1 air
flask
atmosphere
for charging
testing tank,
air
e,
and
helmet
to E;
4.5
cubic
feet
to
each
diver
per
minute
measured
at absolute
pressure, or El atmospheres;
and reserve pres
sure of
220
pounds
per
square
inch, or
about
15
atmospheres,
to
remain in the air flask in excess of that in
which
the divers
are
working while on bottom, or E, the calculation of time of air supply
is
as follows:
g D(E-\-t)^
" equal duration of supply in minutes.
AIR SUPPLY
FROM LOW-PRESSURE
ACCUMULATORS.
The method of supplying air to divers from low-pressure
accumu
lators is applicable to vessels or stations
equipped with
gas-ejector
systems —diving
vessels, navy yards, and
so forth.
In this method
the
arrangement
is practically
the
same
as
for
diving
with
air
from
high-pressure
accumulators.
The
air
pressure
in
the
ac
cumulators
is
maintained
steadily
by
large-capacity,
low-pres
sure,
steam,
or
electrically
driven,
automatically
controlled
air
compressors.
The
capacity of the
compressors
is
such
that
there
is never a question
of shortage
of air supply,
the maximum depths
to which
divers will
be able to descend will depend
upon the pres
sure of the air.
There
is no accurate
method
of determining
the
exact
amount
of
air
passing through
the
diver's
helmet
in
this
method of diving,
and the only means of knowing whether adequate
ventilation
is being maintained is by the diver's physical well-being,
and the percentage
of C02 in the air of the helmet.
When utilizing air from air accumulators or air flasks
the follow
ing conditions are essential:
(a)
The temperature
of air must
be such
as not to cause discom
fort to the diver.
(b)
The air in the accumulator must be free from noxious fumes
and
as near standard purity
as possible,
i. e., contains as near
0.04
of
1 per cent C02
as practicable.
In utilizing air from high-pres
sure accumulators
it must
be remembered
that the air in the cylin
ders of the compressors
is greatly
heated
in charging
the
accumu
lators,
and
oil with
a high
flash
point
must
be used,
castor
oil if
possible,
so that no flashing in the cylinders will
take
place,
pro-
4539—22
11
710
DIVISION
OF PREVENTIVE
MEDICINE.
Vol. XVII
ducing CO and C02.
As little oil as practicable should be used in
the cylinders of a diving pump.
(c) Thirty
to fifty pounds pressure
per square inch in the testing
tank above water pressure
(at the depth of the dive) must be main
tained
to insure proper ventilation of the helmet.
(d)
The
reserve air supply
must
always
be maintained
in
case
of accident
to compressors,
and
so forth,
to
insure
a proper
stage
decompression
for the diver.
TIME UNDER WATER AND ASCENT OF THE DIVER.
The medical officer should recommend
the time the diver shall spend
under water ; and if working at any considerable
depth,
he should as
sure himself that the decompression,
i. e., the ascent of the diver, is
properly
managed.
In deep wa^er, time under pressure should be made as short as prac
ticable,
as the greater
the length
of stay the longer will be the
time
spent in the ascent.
The cardinal essential point in connection
with the ascent of a diver
is a proper and efficient decompression,
so managed
as to eliminate
the
possibility of caisson disease.
For diving, the most efficient practical
method of decompression
is that known as stage decompression.
The following tables are constructed
on this theory
and have been
proved safe.
While they are not guaranteed
to protect
a diver from a
moderate
attack
of "bends,"
a diver
so decompressed
in accordance
with them will be spared from any serious attack of caisson disease.
In all diving
operations,
decompression,
i. e., ascent in accordance
with these tables, should be strictly
followed
and, except
in special
exigency,
no diver should be brought to the surface
faster than the
time specified.
No. 4.
711
DIVISION
OF PREVENTIVE
MEDICINE.
Decompression
Table No.
1. —Ordinary time limits in deep vater
and stoppages
to be
made during ascent.
I
Depth.
Feel.
0-36
36-42
42-48
48-54
54-00
00-00
66-72
72-78
78-84
84-90
90-96
96-108
|
108-120
I
120-132
132-144
144-1.56
i
150-108
\
108-180
180-192
192-204
204-225
225-250
Time under water, I. E., from
surface to beginning
of ascent.
90
I
80
feet.
feet.
stoppages at different
depths.
70
.
60
I
50
40
30
20
Xo limit
Up to 3 hours
Over 3 hours
Up to 1 hour
1 to 3 hours
Over 3 hours
Up to $ hour
A to 1* hours
\\ to 3 hours
Over 3 hours
Up to 20 minutes
20 minutes to J hour.
} hour to H houre
1J to 3 hours
Over 3 hours
Up to 15 minutes
i to * hour
i to 1 hour
1 to 2 hours
2 to 3 hours
Up to 15 minutes
i to i hour
* to 1 hour
1 to 2 hours.
Up to 20 minutes
20 to 45 minutes
I to 1J hours
Up to 20 mimites
20 to 45 minutes
} to 1} hours
Up to 20 minutes
20 to 40 minutes
40 to 00 minutes
Up to 20 minutes
20 to 35 minutes
35 to 55 minutes
Up to 15 minutes
15 to 30 minutes
30 to 40 minutes
Up to 15 minutes
15 to 25 minutes
25 to 35 minutes
Up to 15 minutes
15 to 30 minutes
Up to 12 minutes
12 to 25 minutes
Up to 10 minutes
10 to 20 minutes
Up to
10 minutes
10 to
10 minutes
Up to 9 minutes
9 to
14 minutes
Up to 13 minutes
Up to 12 minutes
Up to 10 minutes
Up to 10 minutes
Total
time
feet. | feet.
feet, i feet,
feet ' feet.
feet.
as™"<-
\fmutes.
i
0-1
1-1A
r>
H
64
I M
10
:;
5
10
10
::
:;
10
L0
in
.">
in
3
5
10
3
5
II)
3
10
:;
5
10
5
III
5
in
5
H
5
III
lo
1(1
20
Hi
ID
15
20
5
10
15
20
>>
5
12
20
5
15
20
5
15
20
5
15
15
5
15
15
5
III
15
8
10
15
7
I
15
5
12
5
10
5
10
5
10
10
10
15
15
I
12
22
12
22
32
15
22
32
4
10
19
32
22
:i2
32
III
22
30
II
22
32
1
1
23
33
1
5
23
33
17
10
32
10
31
18
30
18
30
30
32
IS
73
712
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
Decompression-
Table
No. 2. —Stoppages
to
be made during ascent
after
exceeding
'h
ordinary
limits of time on the bottom.
Time from
Depth,
leaving
surface to beginning
of ascent.
Fret.
66
72
78
84
90
96
108
120
132
144
156
168
180
192
204
225
250
Over 3 hours
2 to 3 hours
Over 3 hours
11 to 2J hours
Over 2J hours
\\ to 2 hours
2 to 3 hours
Over 3 hours
1 to 11 hours
1J to 21 hours
Over 2J hours
55 minutes to H hours
li to 21 hours
Over 21 hours
40 minutes to 1 hour..
1 to 2 hours
Over 2 hours
35 minutes to 1 hour. .
1 to 2 hours
Over 2 hours
1 to i hour
| to 11 hours
Over
11 hours
25 minutes to 1 hour. . .
} to 11 hours
Over 11 hours
20 to 35 minutes
35 minutes to 1 hour. . .
Over
1 hour
16 to 30 minutes
30 minutes to 1 hour. . .
Over 1 hour
14 to 20 minutes
20 to 30 minutes
30 minutes to 1 hour
Over 1 hour
13 to 20 minutes
20 to 30 minutes
30 minutes to 1 hour.
Over
1 hour
12 to 20 minutes
20 to 30 minutes
30 minutes to 1 hour.
Over 1 hour
10 to 20 minutes
20 to 30 minutes
30 minutes to 1 hour.
Over 1 hour
10 to 20 minutes
20 to 30 minutes
30 minutes to
1 hour.
Over 1 hour
Stoppages
at different
depths
(in minutes).
100
feet.
90
SO
feet.
feet.
70
SO
feet.
50
(eel
20
6
15
3
10
30
3
7
25
3
10
25
3
2
7
M
3
3
in
SO
3
3
10
30
7
10
15
36
10
15
20
30
I 30
35
40
feet.
30
Total
time
for
feet.
feet.
5
15
5
10
30
5
10
30
5
10
30
5
10
30
5
10
30
3
3
10
30
3
6
12
30
5
5
15
30
10
15
20
30
10
15
so
10
30
10
30
20
30
;
20
30
30
30
15 J
30
I
30
30
30
35
|
15
| 25
1
5
10
5
5
30
30
20
6
10
to
10
15
30
10
20
35
10
20
35
10
20
as
35
35
30
35
35
35
40
25
15
80
30
15
25
35
15
30
I 35
35
40
15
20
30
30
40
40
15
i 25
30
35
40
40
10
I 20
I 20
15
! 30
30
40
20
30
10
to
us
35
| 40
10
I
15
16
35
7
10
20
H
7
10
20
35
7
10
20
35
15
20
25
35
15
25
BO
(0
10
15
, 15
15
25
SO
40
10
20
30
10
20
25
30
35
Min-
42
42
52
52
62
47
67
77
47
67
92
52
102
48
83
122
57
97
142
53
98
163
61
108
178
61
95
193
56
101
203
41
60
111
218
46
64
118
228
51
67
124
238
95
121
164
249
106
146
209
289
No. 4.
713
DIVISION
OF PREVENTIVE
MEDICINE.
In selecting
the
decompression
table
for
a certain dive
(depth
and time of exposure), the
time
of exposure
shall include time
of
descent
and
time
on
bottom,
and
preference
should
be
given the
longer table.
PRECAUTIONS AFTER
A SECOND
DESCENT.
If a diver makes a second descent in deep water
with
an interval
of less than three hours between the two dives his body will be more
highly saturated
with nitrogen
at the end of the second
dive,
and
extra care will be needed in bringing him to the surface.
A safe rule
is to take the combined
time of the two dives and use a table for that
exposure
at
the
pressure
at
which
the
diver
was
working.
The
extra time is, however,
only needed for the second half of the stops
indicated in the tables.
EMERGENCY ASCENTS.
In case of accident
or special
exigency
it may
be essential
to get
a diver to the surface as rapidly
as possible,
even if an attack of
caisson
disease is threatened.
Under these conditions the speed of
the ascent will depend on :
(a)
Nature of the accident or emergency.
(b)
Depth
and
length
of
exposure
at
which
diver
has
been
working.
(c)
Whether or not means for treating or preventing an attack of
caisson
disease can
be resorted
to by sending the diver down again
immediately or whether there
is a recompression
chamber
ready for
immediate use.
In any
case where
a diver fails
to answer
his telephone
or signal
that diver should
be
started
toward
the surface immediately.
A
pause should
be
made
at the first
stage of decompression
and
an
attempt
made at communication;
then,
depending
on the nature of
the
accident
or
emergency,
the remainder of
the
ascent
must
be
according to the judgment of the officer in charge.
The emergency
may be serious enough to warrant
immediate
ascent.
If there
is
reason
to
suppose
that
the diver
can
be
sent
down
"gain immediately
or if a recompression
chamber
is ready for imme
diate
use. a chance should be taken
on a fairly rapid
ascent for the
'emaining distance.
In case of very deep diving,
when
a
recompression
chamber
is
available
and
a rapid
ascent
becomes imperative, bring
the diver
'it
once to half the absolute
pressure,
keep him there for
a
period
"f
20 minutes, if possible, or, if this
is
not possible,
as long as prac
ticable, then haul him to the surface,
remove
the helmet, life line,
and air hose (cut them
off the diver),
place him in the recompres
714
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
sion chamber,
then proceed
as directed
under " Treatment of caisson
disease," removing the diver's dress and equipment in the chamber.
ACCIDENT
TO DIVERS— PREVENTION
AND MANAGEMENT.
The medical
officer's services
are often required for treatment
of
divers' injuries.
Deep diving is an extremely
hazardous occupation.
Accidents
are constantly occurring,
and such accidents
occurring in
deep water are usually
serious.
Constant vigilance
on the part of
all
concerned
should
be
exercised.
It is essential
that
the
diving
apparatus should be complete,
in good condition,
and in good work
ing
order,
and
that
divers
and
"tenders"
be
specially
qualified.
Except under unusual conditions, no diving operations in deep water
should be carried out without
a proper recompression
chamber.
The
accidents
usually
encountered
in diving operations
are
as
follows
:
(a)
Asphyxia.
(b)
Squeeze.
(e)
Caisson disease.
(d)
Accidental blowing up.
(e)
Fouling.
(/) Ear pains (bleeding from the ears).
(ff)
Bleeding from nose and lungs.
(h)
Mechanical injuries from external violence.
(») Exhaustion.
(j)
Drowning.
(k)
Oxygen poisoning.
In all accidents
occurring
in
deep water it must be remembered
that the diver
can
not,
as
a rule, be brought
immediately
to
the
surface on
account
of the
danger of
a quick
and
fatal
attack
of
caisson
disease, but may
be brought
immediately
to the first stop
or stage of decompression.
On this account
coolness
and judgment
are essential,
as the effects of caisson
disease may prove worse than
the accident.
If the recompression
chamber
is near and
ready
for
immediate use, the diver may be hauled to the surface with
a cer
tain
degree
of
rapidity,
quickly
placed
in
the
chamber
with
an
attendant, preferably
a medical officer, and pressure
applied to
at
least half
the
absolute
pressure
at which
the diver
was working.
First aid or other treatment can then be given the diver within
the
chamber.
The record for apparent safe ascents, with a recompression
chamber
ready for immediate
use,
was from
150
feet after
a 30-minute
ex
posure.
Men were brought to the surface
immediately
as
a routine
after
an
exposure
of
30
minutes
at
150
feet, quickly
placed
in
a
recompression
chamber,
pressure
applied corresponding
to the pres
No. 4.
715
DIVISION
OF PREVENTIVE
MEDICINE.
sure of water at
150 feet,
and
then
decompressed
according to the
tables without ill effects.
ASPHYXIA.
Asphyxia
is probably
the most common
accident
occurring
when
(living under present
service
conditions, and most of the deaths
oc
curring
as
a
result of diving
are
from
this
cause.
Asphyxia
is
usually the result of a deficient
air supply, but may result from sup
plying air containing
a large per cent of C02, resulting from flash
ing of the lubricating
oil in the cylinders of air
compressors.
It
may result from the diving
dress
not being properly
inflated, thus
interfering with
the diver's respiration.
Its occurrence
would
be
indicated by the diver ceasing to answer his telephone or signal after
calling for more air.
In case of insufficient
or bad air supply the diver should remain
perfectly
quiet,
operate
his regulating
escape
valve,
inflate his suit,
and be prepared to ascend.
Asphyxiation,
except in case of a squeeze,
is the result of C02 accumulation in the helmet.
The diver is always warned of the excess of CO, by his increased
respiration —i. e., panting, an uncomfortable feeling of warmth and
sweating, headache, and clouding of the helmet windows from excess
moisture from his breath.
Fortunately
a diver
is cognizant of increasing C02
long before
dangerous amounts
are present,
and it is of value
to note that un
consciousness occurs
from it long before
death.
Attendants should
always be warned of a deficient circulation of air through the helmet
b>'-'
(a)
Decrease in the amount of air bubbles rising to the surface.
(b)
The
decrease of the noise
(caused
by air escaping
from
the
helmet
through
the regulating
escape
valve)
audible over
the tele
phone.
This
is an excellent
guide,
telephone
attendants
becoming
so efficient that by this method
they
are able to estimate
the amount
of air a diver is using.
With these two guides
alone, in conjunction with the diver's own
sensations, except in case of accident,
asphyxia from insufficient
air
supply is inexcusable.
The danger of supplying
air
contaminated
with
C02
from
flashing of oil in
the cylinders
is
very
unlikely,
especially if any precautions at all are observed
in using a good oil
of high-flashing point in lubricating
the compressors
and the water-
cooling system is working
efficiently.
Asphyxia
from
a slight
squeeze,
i.
e., improper
inflation
of the
dress, will only occur,
as
a rule, in
case of an inexperienced diver.
Divers learn to remedy
this defect
themselves
long before they
are
allowed to attempt diving at any appreciable depth.
716
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
In cases
where asphyxia is suspected, with the diver under
water,
he should be started immediately toward the surface.
A pause should
be
made
at the
first
decompression
period,
and
another
attempt
should be made at communication. If there is no response from the
diver he should be brought to the surface.
Once at the surface, in case of asphyxia, fresh air should be given
the diver as quickly
as possible, by getting the face plate open, or by
cutting the diving dress.
In mild
cases of asphyxia,
where
a man is still breathing,
a few
breaths
of fresh air immediately relieves
the condition.
In a case
where the man is apparently dead or unconscious,
with feeble respira
tion, artificial
respiration
should
be started immediately.
Do
not
wait to remove the helmet
and dress but get an ingress of fresh air
into the helmet
and start artificial
respiration.
Squeeze. —Squeeze is usually the result of an accidental fall.
If,
through
carelessness or culpable negligence,
a diver should be per
mitted to fall an appreciable distance
under water, there would
be
a sudden
increase of air pressure
; the helmet
escape valve would be
seated ; the air within the dress would be forced from it and into the
noncompressible
helmet
; the volume of air within the helmet dimin
ishing with the increased
pressure
(Boyles's law). If this volume of
air does not fill the helmet and
equal
the pressure
of water at the
depth to
which
the
diver's
body
has
fallen,
the
excess
pressure
exerted
on
the diver's body will tend
to drive it into the
helmet.
The result is most apt to be a serious injury or immediate
death for
the diver.
Falls from shallow to deeper depths are the most serious,
as the relative
difference
in pressures
is greater.
For instance, if
a diver at the surface, 14.7 pounds pressure to the square inch (abso
lute), should fall 33 feet under water, every
square inch of his body
would
have
an additional
pressure
of 14.7 pounds, or 29.4
pounds
absolute
pressure,
suddenly applied to
it,
a
proportion of
2
to
1
over
the pressure
in the helmet.
As the body has an area of about
2,000
square
inches,
the total
pressure
exerted
on the
diver's
body
and
tending to drive him into the rigid helmet
would
be
several
tons
(14.7).
If, under the same conditions, the diver should have fallen
from the surface to
a
depth of 66 feet under water, the increase in
absolute
pressure would have been trebled instead of merely doubled.
So from
the foregoing
it
is
clear that
a
long fall from
a
shallow
depth would
result in
a fatal
squeeze for the
diver.
Falls from
moderate
depths to deeper depths
under water are not apt to be
so
serious
as falls from shallow depths
;
that
is,
in
a
fall from the sur
face to 33 feet the relative difference
in pressure
is
as
1
to
2,
while
in a fall from
168 feet to 201 feet the relative difference
in pressure
is
as
6
to
7.
In the first case the column of air
is
reduced
one-half
and in the latter
case only one-seventh.
The effect of a fall under
!fo. 4.
717
DIVISION
OF PREVENTIVE MEDICINE.
water is known as a squeeze.
A squeeze may occur from other causes,
however
:
(a)
A diver descending
ahead of his air supply, i- e., descending
before the pressure
within
the dress is equal
to the water pressure
without.
(6)
Ruptured
hose
and a leaky safety valve.
(c)
Ruptured
cuff of the dress and the diver raising
hia arm,
as
when trying
to reach
the
escape valve
(squeeze in this
case
being
slight,
but enough
to interfere with respiration).
In cases of slight squeeze,
as caused by the regulating
escape
valve
being wide open
and
a minimum air supply,
extra
pressure
is ex
erted
on the chest
(suit flat).
The air within
the air passages
is at
a lower pressure
than the pressure
without, and the diver
is forced
to breathe against
this extra pressure.
Respiratory
embarrassment
results in a short while, and often
a diver struggling
up his descend
ing line (buoyancy negative) under these conditions may bleed con
siderably
from
the lungs
and
nose.
Hemorrhage
in
this
case
is
usually due to the rupture of small lung capillaries.
The injury from
squeeze
can
cause
an
almost
immediate
death.
Any injury from
squeeze
is usually
serious
and
as
such
demands
immediate
treatment.
Get
the diver to the surface
as soon
as it is
deemed
safe and remove
the apparatus
as gently
as possible.
The
patient will usually be unconscious
and bleeding profusely from the
nose
and
mouth.
Extreme
cases
have
been
known where
the diver
has been molded
into his helmet,
so that it was practically
impos
sible to remove it.
Treat
as for any internal injury, with shock.
On
account
of
the seriousness
of this
accident
" tenders "
must
always observe the utmost caution to protect
the diver from falling.
The life line and air hose should never
be permitted to skip through
the hands by
the run. If for any
reason
the diver
finds
himself
in danger of falling he should signal for more air, or open wide
his
air-control
valve
and
signal
to
the
surface
to
" Hold
on.'"
The
moment
the
danger
is over,
again
regulate
the air
to
prevent
the
counter
accident
of " blowing up."
Although
the effects of squeeze
are much more serious
than those of " blowing up," both should be
avoided
; but if it is a matter
of two evils, choose the latter.
CAISSON
DISEASE
OR COMPRESSED AIR ILLNESS.
In all deep-water
diving with adequate air supply caisson
disease
is the commonest
accident
that
the medical
officer is called
upon
to
treat.
Caisson disease is the result of improper decompression;
i. e.,
in the case of divers it is due to ascending
too rapidly
to the surface.
The
disease has many
symptoms,
at times manifesting
itself in at
tacks of dyspnea
and unconsciousness,
which may
result in death
in
718
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
a few minutes or hours;
at times
with paralysis of the motor
and
sensory
nervous systems,
involving
as
a rule the lower extremities
and
bladder.
Mild
attacks
are
more
frequent, consisting of pain
in the extremities and
various parts of the
body,
vertigo,
and
so
forth.
The
disease
rarely
occurs
unless
the
pressure
exceeds
20
pounds
excess pressure
(45 feet sea water).
The greater the pressure
and length of exposure
the
more
frequent
and
severe will
be
the
attacks
of
the
disease,
unless
proper
decompression
has
l>een
re
sorted to.
The
accepted
theory
as
to
the
cause of
caisson
disease
is that
bubbles of nitrogen are liberated in the various body
tissues, includ
ing the blood,
upon
a decrease in pressure.
In the anaylsis of over 3,500
cases of caisson
disease the following
classification
was
made :
Per cent.
1. Cases showing
pain in various
parts of the body
88. 78
2. Cases with pain, also having
local manifestations
.26
3. Cases with pain and prostration
1. 26
4. Cases showing
symptoms
referable
to the central
nervous
system :
(1)
brain
.11
(2)
spinal
cord—
(a)
Sensory
disturbances
( 6 ) Motor
disturbances
2. 16
(c)
Sensory
and motor disturbances
5. Cases
showing
vertigo
(staggers)
5.33
6. Cases showing
dyspnrea and sense of constriction
in the chest
1. 62
7. Cases showing
partial or complete unconsciousness
. 46
The
fatal
cases, of which
there
were
20
in
number,
occurred
in
those cases showing symptoms
under 3, 4, and
7.
Pain in abdomen,
vomiting,
subcutaneous
hemorrhage, and girdle
pains in the trunk
are considered
dangerous
symptoms.
With
immediate
recompression,
and
a
gradual
decompression,
properly
conducted,
even in severe cases,
the
outcome
is,
as
a
rule,
complete
recovery.
Without decompression,
the number of recoveries
is
remarkable even in
a
very
short while for low
pressures,
up to
50 pounds.
Insufficient
data
are available on extreme
pressures.
PREVENTION
OF CAISSON
DISEASE.
The prevention of caisson
disease consists of—
(a) Limiting
time of exposure
to high pressure.
(b) Proper
stage decompression.
(c) Proper physical standard in the selection
of divers.
An attack of caisson
disease may
be delayed
as long
as
15 hours
after the ascent.
For this reason divers should always remain
about
the
place
where
recompression
can
be
applied
until
dismissed
by
the officer in charge.
Symptoms vary from
a
slight
attack
of the
"bends" to complete
respiratory paralysis and death.
If any unto
ward symptoms
are noted,
as pains in the joints, cramps, staggers,
No. i.
719
DIVISION
OF
PREVENTIVE
MEDICINE.
weakness,
or paralysis of the arms or legs, inability
to talk, asphyxia,
or difficult respiration,
the diver should
be given immediate
treat
ment.
In all deep-diving operations
a compression
chamber
of some sort
is essential,
as there
is no efficient
means of treating caisson
disease
without
one.
Immediate
recompression
usually
alleviates
all symp
toms.
A submarine boat fitted
with
a diving
compartment
may
be
used to advantage
for this purpose.
In case
a recompression
cham
ber is not obtainable,
the only recourse
left to the officer in charge
is to cause
the diver to
be
recompressed
as quickly
as possible
by
sending
him down again to
at least half the
absolute
pressure
at
which he had
been working.
If recompression,
with
a proper decompression,
does not result in
recovery, the
case
resolves itself into treating conditions that arise,
remembering
in
all
cases
of
paralysis
there
is practically
always
bladder
involvement.
THE MANAGEMENT
OF THE MEDICAL AIR LOCK.
For the prevention
and
treatment
of caisson
disease
a portable
recompression
chamber
might
be had upon application.
No diving
operations
in
deep water should
be carried
out
without
a recom
pression chamber of some sort
except in case of special
exigency.
The maximum safe working
pressure of the portable chamber
at
the diving
school
is
120
pounds
per
square
inch, but it is rarely
necessary
to subject
a patient to a pressure
greater
than
60 pounds.
It
is desirable
that
a medical
officer, or at least
somebody
with
experience in the prevention and treatment
of caisson disease, should
go into
the chamber
with
the patient.
It is of the utmost
impor
tance that there
should
be
no delay
in getting
the patient under
pressure.
For this reason the attendants
should be trained to take
pressure, quickly.
Dry clothing,
blankets,
medicines,
etc., shall
be
kept in the chamber.
In case of stoppered
bottles,
small openings
through the corks should be made, so that
pressure
within
and with
out the bottles may be equalized,
and thus prevent
them from break
ing
as
the result of
unequal
pressures.
No volatile
or
dangerous
liquids shall be stored in the chamber.
An
air
lock
is provided
through
which
small
articles
may
be
passed in and out of the chamber.
In
case
a diver
has
made
a rapid
ascent
from
deep water, but
shows no symptoms
of caisson
disease, he must
be hurried
into the
chamber
as soon as possible
and pressure
raised
to 60 pounds
or less,
this pressure being at least half the absolute
pressure
at which
the
diver has been working.
He must
be kept at this pressure
for at
least five minutes,
after which, if no symptoms
have
developed,
he
can
be decompressed
according
to the tables,
corresponding
to the
720
Vol. XVII.
DIVISION
OF PBEVENTIVE
MEDICINE.
time and depth of the dive, with an extra live minutes
added
to the
total diving time for time in selecting
the table.
If symptoms
of
caisson
disease
develop,
the
patient
should
be
taken immediately into the recompression
chamber
and pressure run
up to 45 pounds
with
as little delay
as possible.
In most
cases this
will
be sufficient
to revive
him.
If, however,
the patient
does not
show
marked
improvement,
the
pressure
must
be
increased
to
60 pounds.
In one instance
75 pounds
was necessary after
a 300-foot
dive.
The patient must be kept at this pressure until any symptoms
of circulatory
embarrassment
or dyspnoea have
disappeared.
Such
symptoms
disappear
almost
immediately;
and if
no other serious
symptoms
are present,
decompression
may
be begun
at once.
If paralysis
is present
and
does
not
pass off in two hours,
it
is
useless to wait longer
at high
pressures.
It
must
be
remembered
that exposure
in the chamber
exceeding
30 ppunds
is likely
to delay
decompression
very much.
Decompression
should be started
as soon as the patient is relieved,
pressure being allowed to fall at the following
rate:
When
prcwure
in the chamber
is—
Above
60 pounds
Between 60 and 45 pounds
Between 45 and 30 pounds
Between 30 and 15 pounds
Below
15 pounds
No hard and fast rule can be laid down for a decompression
rate,
which will depend on the condition of the patient, how he stands the
decompression,
and also the pressure
at which he was saturated.
If
the patient becomes ill again while
the pressure
is falling,
decom
pression
must be stopped,
and, if necessary, the pressure
raised
; when
the patient is better,
pressure
may
be allowed to fall again but
at
a slower
rate.
If after
decompression
the patient again
develops
symptoms,
the process of recompression
and
subsequent
decompres
sion must
be repeated.
ACCIDENTAL
" BLOWING UP."
Accidental "blowing up" may
be injurious
in various
ways, as:
(a) From deep depths,
an attack of caisson disease may result.
(b) From any depth, mechanical
injury may result from striking
some
object,
as the ship's side, etc.
(c) from the possible
fall back into deep water, with
resulting
" squeeze."
Pressure ma}' be allowed
to fall at
a rate not faster than—
Rapidly.
1 pound in 1 minute.
1 pound in 3 minutes.
1 pound in 5 minutes.
! 1 pound in 10 minutes.
No. 4.
721
DIVISION
OF
PBEVENTIVE
MEDICINE.
Blowing up is caused by overinflation of the dress, or by the drag
of the tide on the diver's lines, etc., sweeping
the diver to the surface.
In case of blowing up from depths beyond safety limits, the diver's
valves should be regulated for him, as he will be unable
to regulate
them himself, and he should be sent down again as rapidly
as pos
sible
(without
subjecting him to a squeeze)
to his first stage of de
compression,
at least.
Decompression
should
then
be commenced in
accordance
with
the
tables.
A diver
who
has
been " blown
up "
should
never exhaust air from his helmet or dress until
he is certain
that the attendants
have secured hold of his lines.
FOULING.
Fouling is caused by the diver's lines and hose becoming
entangled
with
some obstruction under
water,
a situation which prevents
him
from
ascending.
It usually
requires
the services
of
another
diver
to clear
the one fouled.
Divers should be
warned
of the dangers
from
fouling.
When
a
diver
has
become fouled and
unable
to ascend,
death
has
resulted
from
shock
and
exhaustion.
Also,
prolonged
exposure
at
deep
depths may
be followed by a fatal attack of pneumonia.
EAR PAINS.
Ear pains are due to inequalities of pressure
on either side of the
ear drum.
They are experienced
while descending
under water, and
are usually
the result
of
inexperience,
the diver
not knowing
how
to clear his ears, i. e., equalizing the pressure in the Eustachian tubes
and the outer side of the ear
drums.
Where
the
pressure
on
the
outyr side has been sufficient
to rupture the drum, bleeding
from the
ear and nose usually occurs.
BLEEDING
FROM THE NOSE AND
LUNGS.
These conditions
are caused by the effects of a squeeze,
but may
result from
great
respiratory
efforts
when
the
dress
is unusually
flat or the air supply deficient.
Treat
as for "squeeze."
MECHANICAL INJURIES FROM
EXTERNAL
VIOLENCE.
There
are
many
varieties of injuries
which
call for no
special
comment.
The diver should be brought to the surface
as soon as it
is deemed
safe and necessary treatment
given.
DROWNING.
There
are two cases on record
of drowning in the diving
dress in
which
the helmet
became detached from the breastplate.
This acci
722
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
dent can not
happen
if the safety
catch
at the back of a helmet
is
properly
turned down.
It is
a common
superstition
among
divers
that if the dress is ruptured drowning will result.
Such is not the
case.
Diving with helmets only has been
accomplished
in depths
up
to
140 feet as readily
as with the complete
apparatus, but the practice
is deemed unsafe.
As long as the air pressure
within
the helmet
is
maintained
and
the diver
remains
in the erect
position,
water
can
not enter the helmet
and the diver will not drown.
By simply clos
ing
the
escape
valve,
air
is
forced
down into
the
dress
and
will
escape at the side of the vent.
In case the dress becomes too full of
water, it may
be
necessary
to slip
the
weighted
belt
to
facilitate
ascent.
OXYGEN POISONING.
Air composed of 20 per cent oxygen
exerts one-fifth of an atmos
pheric oxygen
pressure.
At
10 atmospheres,
the oxygen
being one-
fifth,
would
exert
2 atmospheres
of oxygen
pressure.
Hence
2,
3.
and 4 atmospheres of oxygen
would equal
10, 15, and 20 atmospheres
of air.
Exposure
of animals to
a pressure
of
170
to
180 per
cent of
an
atmosphere
of
oxygen
caused
in
a short
time
diminution
in
the
power of
the
lungs
to
absorb
oxygen.
The
tissues
of
the
lungs
showed
intense
congestion
and
an exudate
into the alveolar
spaces.
High partial
pressure of oxygen
produces
a marked irritant
effect
on
the
lungs,
producing,
first,
congestion,
and
shortly
afterwards
hemorrhagic exudation and consolidation, i. e..
a typical
pneumonia.
The pneumonia
is patchy if quickly developed,
and general if slowly
developed.
,
It requires
about
24 hours' exposure
to plus 7 atmospheres
of air,
or
168
per
cent
atmospheres
of oxygen,
to produce
marked symp
toms of pulmonary congestion.
Experiments
on monkeys
showed
no lung troubles in sequent ex
posures
every day for four or five hours
at a time at this pressure.
With exposures
to oxygen
pressure of 300 to 400 per cent, symp
toms of oxygen
poisoning quickly intervened
and, in addition
to the
lung irritation,
convulsions,
tetanic
in character,
are likely
to occur.
There
is but
one
case of oxygen
poisoning known
in
the
Navy,
and this may have
been
a complication of caisson
disease which re
sulted
after
a long exposure
to high air pressure —three hours of it
at 120 pounds
excess
pressure.
The diver developed
a double broncho
pneumonia.
The prevention
consists in limiting time of exposure
at deep depths.
Treatment
is that of an ordinary
pneumonia.
HEALTH
CONDITIONS
OF THE NAVY.
There has been little change in the health
conditions of the Navy
during the past
month.
The annual admission
rate for all causes,
entire Navy, for the five-week
period ending September
9 was
576
per 1,000,
as compared
with
540 per 1,000 per annum
for the four-
week period ending August
5.
The morbidity
rate for diseases only
during the same period was
510 per 1,000
per annum
and for acci
dents
and injuries
66 per 1,000 per annum.
The communicable
diseases were slightly
more
prevalent during
the past five weeks than at any
time during
the past four months;
the annual admission
rate
for
communicable
diseases, exclusive
of
influenza
and the venereal
diseases, for the five-week
period ending
September
9
was
47 per
1,000
per
annum.
Of
the communicable
diseases
malaria
continues
to
cause
the greatest
damage;
the mor
bidity rate for this disease for the five-week
period ending September
9 was 39 per 1,000 per annum.
The
following
table
gives
the
annual admission
rate
per
1,000
for certain communicable
diseases for the current month of August,
1922, in comparison with the mean annual admission
rates, month of
August, for the four-year period 1918-1921, inclusive:
Disease.
[
August—
11918-1921I
1922
trebrosplnal fever.
Diphthoria
German measles.
Influenja
Malaria
Measles
Mumps
Pneumonia
Scarletfever
Smallpox
Tuberculosis
Typhoid fever
i). II
l.tW
.80
20.19
10.58
3.02
11.31
:i,90
. no
.0*
I. Ml
.18
(). in
.SO
H.36
25.79
.50
.91
I. II
2. 32
Although
the
Navy
has
commenced
an
active
campaign of
re
cruiting
and
there
are now
more
recruits
at
the training
stations
than
there
have
been
at any
time
during
the
past
six months,
it
will
be seen
from
the above table that the admission
rates for the
common
communicable
diseases, such
as measles, mumps,
etc.,
have
not risen
to any appreciable
extent.
This
may
be
better
seen
by
comparing
the
table
of
communicable
diseases
for
August
with
the tables published in previous
issues of the Bulletin.
724
Vol. XVII
DIVISION
OF PREVENTIVE MEDICINE.
During the past
five
weeks
there
has been
a decided
rise in the
morbidity
rates
for
the
venereal
diseases,
the
admission
rate
for
this period
being
142 per
1,000
per
annum
as
compared
with
an
average
rate for the year
of
114 per
1,000 per annum.
The mortality
rate for all causes, entire Navy, for the five-week
period ending
September
2
was
3.23
per
1,000
per
annum.
The
annual
death
rate
per
1,000
for
diseases only
was
1.83,
for
acci
dents
and injuries,
other than drawning,
0.61
per
1,000
per
annum,
and for drowning,
0.79 per
1,000 per annum.
VENEREAL
PROPHYLAXIS
IN EUROPEAN
WATERS.
By W. E. Bradbury,
lieutenant.
Medical
Corps,
United
States
Navy.
Several
articles have appeared
during
the past few months
on the
venereal-disease
problem,
and it is believed
that the accompanying
chart
gives
a very
good
picture of
the
subject,
the result of
one
year's
work under the most adverse conditions.
The figures
are taken
from the activities of 1,051
men composing
the crew of the U.
S. S. Utah
during
one year,
practically
all of
which time has been spent in ports of Europe
and northern Africa,
where
there
is very little if any
attempt
made
by local authorities
to institute any proceedings
tending to combat the venereal
problem.
The men are nearly all under
25 years of
age,
the majority
much
younger.
Prostitution has
been
unrestricted in all ports with
the
exception of two, alcoholic beverages comparatively cheap,
and
both
available as soon as the men stepped
ashore.
Opportunity
for wholesome
recreation
of any kind was not avail
able to any extent.
Athletics
could
not be
indulged
in, owing
to
the lack of
time in
ports,
lack of suitable
grounds, and lack of
competition.
Moving pictures or other shows
were
not patronized,
because
of
unfamiliarity
with
the
language,
except
in
English
ports.
Sight-seeing
was the principal
amusement,
but the novelty
of that soon wore off, except for a small minority,
and that minority
are not in need of prophylaxis
of any kind,
as they
do not expose
themselves;
for
the
vast
majority
there
remained
only
the
cafe
and
dance
hall.
Every method
available
was
used to
combat
the problem.
The
men have been given frequent talks on the subject.
Literature
on
the subject
has been liberally
distributed.
Sight-seeing trips
have
been arranged
in
nearly
every
port,
athletics
whenever
possible,
moving pictures on board ship when available, and medical
prophy
laxis was provided.
No. 4.
725
DIVISION
OF PREVENTIVE
MEDICINE.
Naturally
the medical
prophylaxis
has
been
the most important,
as under the existing conditions
there
have
been
a large
number
of exposures.
In practically
every port
a prophylactic
station
has
been
established
ashore,
located
as accessible
as possible.
The hos
pital
corpsmen
go ashore
with
the first patrol,
and
the
station
is
open until
liberty
has expired.
Each
patrol
is able
to instruct
anybody
the nearest
way to the
station.
These stations are not utilized
as often as they should be;
nevertheless
a great
many
men take the trouble to go to them,
and
it is believed their establishment
is a very desirable
procedure.
The prophylactic
station on board ship is the most popular,
as it
is easier and the man can get his name on the book with
the least
amount of inconvenience
to himself.
This station is open at all hours
when men are returning from liberty.
It is believed that nearly all
treatments
after six
hours
are
taken
for
record
only,
as the
men
who have developed
disease and
have not
a record
of having taken
prophylaxis are severely
punished.
Convenient
packets of calomel ointment have been available at all
times, which are given
to the men free.
They have
been
placed
at
the
gangway
without
supervision,
have
been
distributed
to
each
liberty party by
a hospital corpsman
and left in
a convenient
place
in the sick bay.
and every effort has been used to educate
the men
as
to
their
use.
However,
they
are
not
used
as
much
as
they
should be.
The last six
months
of the year
was not
as bad
as the first; part
of this, I believe, is due to the men themselves.
Drunkenness is de
creasing, and the men in general
are better behaved.
This was made
more noticeable
by a new draft of about
a hundred men who recently
came from the United States who immediately got into trouble from
overindulgence
in alcoholic liquors.
There
have
also
been
a large
number infected with venereal
disease.
There are now about
00 men
under
treatment
for
syphilis,
and
their
propaganda
among
the
crew must have
some
good
effect
on the
rest, at least through
the
element of fear.
It
is not
believed
that, while
the number
of prophylactic
treat
ments is very high, it even approximates the truth
as to the /number
of exposures.
In conclusion,
it is believed
that under
any
condition,
compara
tively good or bad, one must
use every available method
to combat
the problem,
and that by constant
effort we have
reduced
the inci
dence of disease by from
15 to 20 per cent under the existing condi
tions
from what it would have
been
had
we been indifferent to the
4539—22
12
726
Vol. XT1L
DIVISION
OF PREVENTIVE MEDICINE.
question
or ignored it entirely.
The following table represents
the
venereal statistics for the year :
Month.
July....
August..
September
.
Ootober
November.
December.
.
January. .
February .
March
April..
May.
June.
Total
Number
of
liberties.
5,673
6,325
5,287
5,858
5,875
6,200
4,700
5,250
12,400
6,100
5,419
6,076
Number i Number
of
prophy
lactic
treat
ments.
634
1,285
774
1,560
1,520
1,761
921
691
834
597
172
of ad
missions
for
gon. Inf.
urethra.
Number
of ad
missions
for
chan
croid.
75,162
11,557
221
13
fill
Number
of ad
missions
for
syphilis.
Ports visited
and
number
of d»ys In
each port.
Boston,
Mass
J
Lisbon, Portugal
'
Cherbourg,
France
?
Cov.es. Isle of Wight
Cherbourg,
France
Gravesend,
England
Lo Havre. France
Gravesend,
England
Copenhagen,
Denmark
Danzig,
Free City
Cherbourg.
France
(Cherbourg,
France
.Gibraltar
'Tangiers.
Morocco
Constantinople.
Turkey
Constantinople,
Turkey
Pola, Italy
Spalato,
Oravosa, and Cattaro, Jugo
slavia
Naples, Italy
Malta
Hiierta. Tunis
Tunis. Tunis
Sfax, Tunis1
/Malta
Villefranche,
France
Villefranche.
France
Toulon, France
Toulon, France
Salinas de Hyers,
France
Algiers,
Algeria
Gibraltar
Oibralta
Cherbourg,
France
Portsmouth. England.
Portsmouth.
En
Gravesend.
En
n
1 Target
practice,
at sea.
Average
complement for year
Percentage
of infection
Number
of days
in port
Number
of days
at sea
1,051
29.59
77
USE
OF FISH FOR
CONTROL
OF MOSQUITOES
IN NORTHERN
FRESH WATERS
OF THE UNITED
STATES.
The following is quoted
from
the United
States
Public
Health
Engineering
Abstracts
from
an article entitled "Use of fishes for
control of mosquitoes in northern fresh waters of the United
States."
by J. Percy Moore, professor of biology, University of Pennsylvania,
temporary investigator, United
States Bureau of Fisheries:
The author discusses
the value
as agents for mosquito control
of
the
roach
or
golden
shiner
(Abramis
crysolencas)
,
the
goldfish
{Carassius
auratus),
the mud minnow
(Umbra
pygmaea), the com
DIVISION
OF
PREVENTIVE
MEDICINE.
727
mon
killifish
(Fundulus
herteroclitus) ,
the
translucent
killifish
(Fundulus diaphamus) , the common top minnow of the South (Gam-
busia
affinia),
the
blue
spotted
sunfishes
(Enneacanthus
glorioms
and E. obesus),
the long-eared sunfish
(Lepomis
auritus),
and
the
common
sunfish (Eupomotis
gibboms).
The geographical distribu
tion of the species discussed
is given in the report, and it is shown
that
all of them
occur,
either generally
or in
some parts of
the
malarious
districts
of the South.
The
results
of the investigation,
therefore, are probably in part applicable also in the South.
Methods of investigation. —The investigations were carried on dur
ing the three summers,
1918,
1919, and
1920, principally in Philadel
phia
and
Delaware
Counties, Pa.,
and
Palisades
Interstate
Park,
N. Y., but observations
and minor experiments
were also conducted
at other
points in Pennsylvania
and New York and
in Maryland,
Delaware,
and New Jersey.
The plan of procedure
consisted in pre
liminary examinations of many ponds,
swamps,
and
streams,
dur
ing which
collections of the fauna
and
flora
and
ecological
data
were
made.
Thereafter
certain
waters,
chiefly small
ponds,
were
selected for detailed
study.
These waters,
as far as possible,
were
visited
at weekly or fortnightly intervals,
and
usually
during
the
visits fish and other organisms were collected.
The fish taken were
at once dropped into 4 per
cent formaldehyde
to stop
digestion of
foods in their stomachs.
The density of mosquito
breeding was de
termined in the usual way,
i.
e., by taking
water samples
with
a
dipper
and
counting
immature mosquitoes
and
egg
boats.
Adult
mosquitoes
also
were
collected.
Numerous experiments
were
tried
by modifying
conditions in such
a manner that fish were admitted
to places from which they had been absent previously and vice versa,
and the actual transplanting
of certain species to small ponds
and
pools was practiced to a limited extent.
The conclusions
arrived
at
concerning the various species studied were based upon their obser
vations
and experiments and
upon
examinations made of stomachs
of fishes preserved
during the inspections of the waters.
Conclusions. —The conclusions with respect to each species studied
are as follows
:
(a) The roach or golden
shiner does not
push
its way into
the
"very shallow plant-grown
waters where mosquitoes
breed."
and the
investigations,
although
not
conclusive,
indicate that this
fish
has
been much overrated as a mosquito
destroyer.
(&) The goldfish has a very restricted value and is useful only in
containers
or small waters
where
foods
other than wiggle tails
are
scarce.
(c)
The
mud
minnow
consumes
mosquito
larva?,
but
its
chief
deficiency
appears
to the author to be
in
numbers,
i.
e.,
it
usually
does not appear to become numerous
enough
to furnish
complete
con
728
DIVISION
OF PREVENTIVE MEDICINE.
Vol. XVII.
trol, but since
the fish is very hardy he recommends
experiments
in
the direction of artificially propagating
this fish.
Of 50 stomachs
examined,
22
were
found
to contain
mosquito
larvae,
constituting
about 4 per cent of the total contents.
(d)
Concerning the common killifish, the author says, " The value
of this species in limiting the numbers
of the salt-marsh mosquitoes
is thoroughly
established
and
attested
by
scores of
antimosquito'
workers in New Jersey, New York, and Connecticut."
(e)
The translucent killifish was found to feed to some extent on
mosquito
larvse, and the author recommends
it in preference
to the
common killifish for muddy ponds and sluggish streams.
(/)
Gambusia, although
not occurring
naturally
in
the
area in
which the experiments were conducted,
was introduced.
It did not
survive the winter in ponds in the vicinity of Philadelphia where it
was planted, but it was found that this minnow can be used to a lim
ited extent by carrying
a brood stock through the winter in a green
house or other suitable place for release the following spring.
These
fish, under favorable conditions, increase with " astounding rapidity,"
and
mosquito
breeding may
be controlled by this method
in
small
ponds.
(g)
" Enough
is known of the blue-spotted
sunfishes to recommend
placing
them
on the list of species for stocking plant-grown
ponds
and streams,"
is the author's conclusion concerning these handsome
fish.
(h)
Insufficient detailed attention was given to the long-eared sun-
fish to determine
its exact
value, but the author thinks it probable
that the young, at least, may be of value.
(i)
The common
sunfish
was found to be the most valuable of all
the sunfishes,
the young being particularly
effective
because they
are
the ones that visit the extreme margins of the ponds.
Stomachs
of
224 examples, the majority under 80 millimeters in length were exam
ined and
" mosquitoes
in all
stages " constituted
9 per cent of
the
food present.
The author says that it is undoubtedly
an important
antimosquito
agent,
and
he believes
it to
be very nearly
equal
to
Gambusia.
In my own work in the South I have not found it any
thing like
equal
to Gambusia, and
numerous
times I have
found
it
necessary
to introduce Gambusia into ponds
already populated
by
this sunfish
and by the bream or blue-gill
sunfish.
As a general conclusion the author makes the following statement :
" The relatively small number of mosquitoes
produced
by such waters
(ponds, lakes, and sluggish streams under natural conditions)
result
from this influence.
Indeed, it may safely be said that were
these
fish suddenly wiped out mosquitoes would immediately and generally
become
intolerable
nuisance."
This
is in entire
accord
with
the
statement
made by me in a number of public lectures
and
elsewhere.
No. 4.
729
DIVISION
OF PREVENTIVE
MEDICINE.
viz, that several
large, prosperous
cities
in the South never
would
have been built had it not been for the check on mosquito
production
prov ided by fish, chiefly top minnows.
NOTES
FROM THE MARINE BARRACKS,
QUANTICO,
VA.
The health
of the command
has
been
excellent,
notwithstanding
the severe strain to which the men were subjected during the Gettys
burg maneuvers.
Malaria was more prevalent in July than during
the previous
month,
but this
can
be
accounted
for to some extent
because of the fact that the personnel
was rapidly
increased in prep
aration for the maneuvers;
men being drawn from various posts and
from detachments arriving from the Tropics
to fill up the organiza
tions
going
on
the
maneuvers.
The
majority
of
these
cases
of
malaria were of tropical origin.
Venereal disease, especially
gonococcus
infection,
showed
a slight
increase over last month.
This probably was due to the opportunity
of exposure
of the men who went on the hike to Gettysburg.
.1/ osquitoes. —A great many
more mosquitoes
are present this year
than in previous years.
This is due to the fact that practically
the
entire command
was in preparation and on the maneuvers
to Gettys
burg
during
the latter part of June
and
the early part of July,
leaving
no labor available for mosquito-prevention work, and
as
a
result the work stopped entirely.
Brush was allowed to grow up in
the ravines, the drainage ditches
which had all been
gone over
and
put in condition earlier in the season were filled up, and the water
was blocked
off in most of the laterals.
Culicinse larvse were found
to be breeding in great
numbers
in all of them.
The
personnel
of
the
medical
battalion
was
immediately
set
to
work
cutting
down
brush, opening and oiling the ditches
in
the
confines
of the camp
and in adjacent
territory.
The larger
creeks,
Quantico,
Little
Creek,
and
Chappawamsic
were
given
two
treatments
of arsenic
and
dust,
1 part to
100, but
it is too early as yet to determine
the efficacy of this process.
HOTES
FROM
THE UNITED
STATES
NAVAL AIR STATION,
PENSACOLA,
FLA.
During the latter part of July an epidemic
of gingivitis
occurred,
which was first discovered
by the dental
officer, among
the marines.
The marine command
was examined
and about 20 per cent of the per
sonnel were found infected.
A large
fusiform
bacillus and
a deli
cate
spirillum,
similar
to
those
found
in
Vincent's
angina,
were
found to be the cause of the epidemic.
No amo-ha1 have
been found
in the p3rorrheal
cases.
730
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
The
rather
prevalent
use
of
common
drinking
cups
evidently
favors
the
spread
of gingivitis.
The
medical
officer
again
recom
mends
that drinking fountains of the bubbling spring
type
be in
stalled
in
buildings
where
a
considerable
number
of
men
are
quartered;
this
is
also very desirable
for
the buildings
where
the
civilian
employees
work.
NOTES
FROM THE UNITED
STATES NAVAL
ACADEMY, ANNAPOLIS.
MD.
The sanitary condition of the Reina Mercedes
and the Cumberland
was excellent
during the month of July.
A special
antivenereal
campaign, including
lectures
on morale and
venereal prophylaxis,
distribution
of literature, and instruction
con
cerning the
use of the new collapsible
venereal
prophylactic
tubes,
was
conducted
among
the
mess
attendants
attached
to
these
two
ships.
It is interesting
to note that
among
the men who
used
64
prophylactic
tubes within
six hours after
the time of exposure
no
cases of venereal
disease
occurred,
whereas
among
the
9 men
who
took silvol prophylactic
treatments
six hours or more after exposure
3 developed gonorrhoea, 1 chancroid, and 2 syphilis.
INSTRUCTIONS
TO JVIEDICAL OFFICERS.
Circular letter, serial
No. 204-1922.
RFJ-LMT
SD 132687-0(81).
Department of the Navy,
Bureau of Medicine and Surgery,
Washington,
D. C, August
7, 1922.
To : Commanding
officer, U. S. S.
.
Subject
: Educational
material
dealing
with
the
prevention
and
control
of
accidents
and disease.
1. There are forwarded
herewith
a set of posters dealing with the prevention
and
control
of accidents
and
disease
which
have
been
approved
by the
com
manders
in chief of the Atlantic and Pacific Fleets.
It is requested that
these
posters
be
displayed
on bulletin boards
in
such
manner
as the
commanding
officer
sees fit.
Additional posters will be forwarded
to your
ship at approxi
mately
monthly
intervals.
In
accordance
with
the
suggestion
of
the
com
mander in chief
of the Pacific Fleet it is thought
best that
the posters dealing
with the control
of venereal
disease
be displayed
in such places that they will
not be conspicuous
to visitors coming aboard
ship.
2.
The Bureau
of Medicine
and Surgery
Is forwarding to the commanders
in
chief
of the Atlantic
and Pacific Fleets a 12-reel motion-picture
film entitled
" The Science of Life,"
which
may
be obtained
by individual
ships from their
respective
commander
in
chief.
Copies
of this motion
picture
have also been
forwarded
to
the
commanding
officer,
United
States
naval
training station.
Hampton
Roads,
and
the
commanding
officer,
United
States
naval
training
station,
San
Francisco.
As soon as possible
this motion
picture
will
be for
warded
to the commander
in chief of the Asiatic Station.
No. 4.
731
DIVISION
OF PREVENTIVE MEDICINE.
3. The Bureau
of Medicine
and Surgery
has had made lantern slides dealing
with the prevention
and control of accidents and disease which will be furnished
to any ship
or station
making
request for the
same.
Samples
of the lantern
slides have
been
furnished
the commanders
in chief of the fleets.
4. Comment
or criticism of the posters
now being forwarded
by the Bureau
of Medicine
and
Surgery
to ships
and
stations
is desired;
and if the officers
or men of the ships or stations
can suggest types of posters for use throughout
the service in the prevention
and control
of accidents
and disease,
the bureau
will
have such material
printed
and distributed.
E. R. Stitt.
Circular
letter,
serial
No.
206-1922.
WRJ:THC
124716(82).
Department
of the
Navy,
Bueeau of Medicine and
Suboeby,
Washington,
D. C, August
11, 1922.
To: All
naval
hospitals
and
hospital
ships.
Subject : Ration
memoranda —Hospital
Form
No.
36.
References:
(a) Hospital Form No.
52, Nurse
Corps
subsistence
report.
(6)
Hospital Form
No.
53, Hospital
Corps
subsistence
report,
(c)
Bureau's
circular
letter
No.
129733(54),
serial
No.
47-1920,
of July
20,
1920.
{d)
Bureau's
circular
letter
No.
129733(54),
serial
No.
63-1920,
of October
22,
1920.
(e)
Bureau's
circular
letter
No.
132685,
serial
No.
129-1921,
of
October
11,
1921.
(/)
Bureau's
circular
letter
No.
125884(22),
serial No.
163-1922,
of
February
11,
1922.
Inclosures:
(1) Ration memoranda —Hospital Form No. 36.
1. Hospital
Forms
Nos.
52
and
53,
statements
of
subsistence
of
Nurse
Corps
and
Hospital
Corps,
respectively — (refs.
(a)
and
(6)) —will
be
dis
continued,
and
these
numbers
will
be
given
to
other
forms
about
to
be in
stituted.
2. Instructions
contained
in
paragraph
6 of
reference
(c)
and
paragraph
5 of reference
(d)
are
hereby
revoked
and quarterly
report
required
under
said letters
discontinued.
3. In lieu of the tabular statement
required
by
paragraph
5,
reference
{d),
a report will
be
made
on
the " report
of expenditure
card " and
paragraph
15 of
reference
(f)
will
be
amplified
by
adding,
as
subparagraph
(ft),
the
following :
"(ft)
'Report
of expenditure
cards'
covering
expenditures
for care of the
dead
will
show,
in
the
case
of Veterans'
Bureau
patients,
the
name
of
the
deceased, date of death,
place of burial, and Itemized
cost."
4. Reports submitted
under
reference
(e), "Care of supernumerary
patients
during
fiscal
year,"
will
be
discontinued.
5. In lieu of the reports
required
by
reference
(a),
"Nurse
Corps
subsist
ence
report,"
(6)
"Hospital
Corps
subsistence
report,"
(c)
"Report
of
Veterans'
Bureau
patients,"
and
(e)
"Care
of supernumerary
patients,"
It is
directed
that,
beginning
with the month of July,
1922,
each hospital
and hos
pital
ship submit
Form
No.
36, " Ration
memoranda,"
prepared
in
the
man
ner outlined on inclosure.
6. Hospital
ships
will
report
only
the
personnel
subsisted
by " naval
hos
pital fund."
F. L. Pleadweix,
Acting.
732
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
Circular
letter,
serial
No. 206-1922.
WJCA : ESK
129733(74).
Department of the Navy.
Bureau of Medicine and
Surgery,
.
Washington,
D. C, August
7, 1922.
To : All naval
hospitals.
Subject: Monthly
report
of
United
States
Veterans'
Bureau
beneficiaries
in
United
States naval
hospitals.
Reference:
(a) Letter to the Surgeon
General.
United
States
Navy,
from
the
Assistant Director,
United
States
Veterans'
Bureau
No. ADH-fac-6-MSS
of
28 July, 1922.
1. For
your
information
there
is
quoted
herewith
the
tirst
paragraph
of
reference
(a) -
"In
order
that
the
United
States
Veterans'
Bureau
may
be kept
more
ade
quately
informed
in regard
to the current
hospital
situation
in naval
hospitals,
it is respectfully
requested that there
be prepared
each month and transmitted
to
this bureau,
attention
medical
statistical
section,
a
report
by
individual
hospitals
of the number of admissions
of United
States Veterans'
Bureau
bene
ficiaries
classified
by
tuberculosis,
neuropsychiatry, and
general
diseases :
the
total
number
of discharges,
unclassified
as
to
type of disease,
but
separating
deaths
from
discharges
;
and
the total
number
of patient
days
of treatment
rendered at each hospital,
unclassified."
2. You are directed
to forward
on
the first of each
month,
on
forms
similar
to the accompanying
form, original report
direct
to the United
States
Veterans"
Bureau,
attention
medical
statistical section, and
a duplicate
report
direct
to
the
Bureau
of
Medicine
and
Surgery.
The copy
forwarded
to
this
Bureau
should
be marked
" Copy for the Bureau
of Medicine
and Surgery'-"
3. These
forms
will not
be furnished by the bureau
and should
be prepared
by
the
hospitals.
Reports
covering
the
month
of
July,
1922,
shall
be
sub
mitted
immediately.
F. L.
Pijjadweix,
Acting.
Circular
letter,
serial
No. 207-1922.
HBS/DRG
132609-0 (72).
Department of the Navy.
Bureau of Medicine and Surgery,
Washington,
D. C. August
IK.
1922.
To: All
medical
officers.
Subject: Surveyed
medical
department
property
recommended
by survey
board
for disposition
by " fl. S. K."
(supply
officer).
1. When
a survey
of property
of the Medical
Department
which
recommends
certain
items
to " G.
S. K."
(supply
officer)
"for
final
disposition."
has
been
approved
by this
bureau
and copy returned
to activity concerned;
a
separate
list of
items
thereon
recommended
for disposition
by
supply
officer will
he
prepared
by the survey
hoard
on Form On-1
sheets,
with
the following signed
note appended :
"Above
items Nos. xxxx
recommended
to
be turned
over to supply
officer
for
sale to highest
bidder.
"(Signed)
"
2. The
commanding
officer
will
forward
above
list
to
supply
officer,
to
gether
with
instructions
that
the
recommendation
of
the
survey
board,
as
approved
by
the bureau,
be complied
with.
B. R. Stitt.
No. 4.
733
DIVISION
OF PREVENTIVE
MEDICINE.
Circular
Letter,
serial
No.
208-1922.
FLP-DRG
124920-0(83).
Department of the Navy,
Bureau
of Medicine and
Suboeby,
Washington.
D. C,
August
17,
1922.
To: All medical officers.
Subject:
Arsphenamine;
administration
of, on board
ship
forbidden
and stock
on hand
to
l>e turned
in.
Reference:
(a)
Bu. M.
& S. circular letter No. 44-1920 of July
10,
1920.
1. Attention is called
to reference
(«)
(quoted
below),
which
has not been
rescinded or modified :
To: All medical
officers.
Subject: Arsphenainine
and neoaispheuamine.
1. The following
letter
of
Hear
Admiral
E.
K.
Stitt,
Medical
Corps,
I'nited
States
Navy,
is
approved
by
the
bureau
and
published
for
the
information of the medical officers of the United
States naval
service:
"July
7,
1920.
"To:
Bureau
of Medicine
and Surgery.
" Subject
: Recommendation
that
neoarsphenamine
be
substituted
for
arsphenamine
in connection
with
use
on
board
ships
and
at certain
sta
tions
of the Navy.
" 1. I would
recommend thai
the
use
of
;irsphcnamine
be discontinued
on board ships of the Navy and in its place to substitute
neoarsphenamine.
This
same
recommendation
would
apply
to stations
and smaller
hospitals.
"2. Iu the
larger
hospitals,
where
facilities
for
the administration of
arsphenainine
are
satisfactory,
the
choice
between
arsphenamine
and
neoarsphenamine
should
be
left
to
the
discretion
of
the
commanding
officer.
"3. This recommendation
is made
for the following reasons:
"(a) In discussing
fully
this
matter
with
the director
of the hygienic
laboratory
he
is of the opinion
that
most of the accidents
attending
the
use of arsphenamine
linve
been
connected with errors
in technic.
In view
of the simplicity
of technic
when using neoarsphenamine,
many untoward
results
would
be eliminated.
"(b) In the clinic of the Brady Institute, neoarsphenamine
is
used
ex
clusively,
and
Doctor
Young
and his associates
are
unable
to note any
lessened
therapeutic
efficiency
with
this drug
than
when
arsphenamine
is used.
" E. R. Stitt."
2.
The
commanding
officers of the United
States
naval
medical
supply
depots will
be instructed
to include
neoarsphenamine
on
the supply
table
and requisitions
on Form
4 will
be filled
at the supply
depots.
3.
Requisitions
from
the larger
hospitals
will
be
approved
for
either
arsphenamine
or neoarsphenamine
as
the commanding
officers prefer,
but
it is recommended that commanding
officers of the larger
hospitals
continue
to requisition
arsphenamine
until the present
supply
is exhausted.
W. C. Braisted.
2. In connection
with the bureau's
circular
letter
quoted
above,
it appears
that
the
medical
departments
of
some
ships
are still
carrying
both
arsphe
namine
and
neoarsphenamine.
It
has
come
to
the
attention
of
the
bureau
recently
that an instance of the accidental
use of arsphenamine
occurred
under
an impression on the part of the medical officer that
he was using neoarsphena
mine,
with
serious
results.
This
confusion
of
one
variety
of
arsphenamine
with
the other
has in some
instances
been enhanced
by the similarity of labels
734
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
on the containers,
but steps have been
taken
by the manufacturers
to differenti
ate more carefully the two varieties
by distinctive labels.
3.
Since the instructions
contained
in the bureau's circular letter
No. 44-1920
contemplated
that
only
one
variety
of
arsphenamine
should
be
maintained
in stock
on ships, stations,
and smaller
hospitals
in order
to avoid
the
difficul
ties
referred
to in paragraph
2,
it is directed
that
all arsphenamine
now
in
stock
in
the
medical
stores
of all
ships,
stations,
and
smaller
hospitals
be
immediately
returned
to the nearest naval
medical
supply
depot.
It is further
directed
that
in
medical
departments
of
hospitals
where
both
varieties
of
arsphenamine
are retained
in stock
care
be taken
to differentiate
sufficiently
the two varieties
so that
no confusion
can
result
in
selecting
the appropriate
technic for the variety
intended
to be used.
4. No.
31, volume
37, Public Health Reports,
dated August
4,
1922, contains
" standard
instructions
for the preparation
and intravenous
administration
of
arsphenamine
and neoarsphenamine
for use by the Medical
Departments
of the
Army,
of the
Navy,
and of the Veterans'
Bureau,
and
by
the Public Health
Service."
These instructions
should
be followed.
E.
R. Stitt.
Circular
letter,
serial
No. 209-1922.
DCC: SMS
128586(84).
Department of the Navy,
Bureau
of Medicine and
Surgery,
Washington,
D. C., August
21,
1922.
To: All naval
hospitals.
Subject
: Retention
of patients
in naval
hospitals.
References:
(a)
Section
22, Veterans'
Bureau
act of August
9,
1921
(42
Stat.
155).
(6)
Circular letter
109-1921,
July 11, 1921, 128586(72).
1. Reference
(b)
is hereby canceled.
2. Reference
(a)
states:
"Sec.
315. That
no
person admitted
into
the mili
tary or naval
forces of the United
States after six
months
from
the passage
of this
amendatory
act
shall
be
entitled
to
the
compensation
or
any
other
benefits
or privileges
provided
under
the provisions
of Article III of the war
risk insurance
act, as amended."
The Judge
Advocate
General
(26510-1481)
commenting
on
this
provision
states: "In view of the foregoing,
you are advised
that as the law now
stands
enlisted
men
entering
the service
either
in
a
first enlistment
or
through
a
reenlistment
since February
9,
1922,
do
not
come
within
the purview
of
the
Veterans'
Bureau act or within the provisions
of the pension laws
unless their
rights
under said pension laws accrued prior to October
6, 1917."
3. In view of the above-quoted law and decision of the Judge Advocate
Gen
eral, this bureau
feels that it is incumbent
upon it to retain for
a
reasonable
period
those members of the
personnel
who
enlisted
after February
9,
1922.
especially
until Congress
passes
some
measures
for their
relief.
This
applies
particularly
to cases of tuberculosis
and other
diseases where
the patient
will
require institutional treatment if he were discharged.
4. It
is
requested
that
persons
so
retained
be
surveyed
after
each
three
months
and
that
the board
of
medical
survey
state
the necessity
for
their
retention.
If the person
surveyed
desires
to
be discharged
from the
service,
lie should
be informed
of his status
and that fact
stated on the medical
survey
form
recommending
his
discharge
from
the
service.
In
the case of persons
l-eenlisting
after February
9.
1922,
who are
surveyed for disease
or disability
No. 4.
735
DIVISION
OF
PREVENTIVE
MEDICINE.
occurring
after their
reenlistment,
the
survey
board
should
state the relation,
if any.
between the present disability and their service
subsequent
to October
6, 1917.
5. The bureau
does
not desire
the retention
of persons
whose disability
is
discovered
soon after enlistment, if " not in line of duty,"
and who are able to
care for themselves if discharged.
6. Patients
who
enlisted
prior
to
February
9,
1922,
should
be
surveyed,
recommended for discharge
from
the service, and retnlneri
as supernumeraries
until taken up by the Veterans'
Bureau.
F.
L. Pleadweix,
Acting.
Circular
letter, serinl No. 210-1922.
DCC:SMS
128586(84).
Department of the Navy,
Bureau
of Medicine and Surgery.
Washington,
D. C, August
22,
1922.
To: All naval hospitals.
Subject:
Tuberculosis
patients
who
have
enlisted
subsequent
to
February
9,
1922.
Reference:
(a)
Circular
letter
127-1921
(128586)
(101)
of
October
10,
1921.
1. Reference
(a)
is hereby canceled.
2. In
order
to
prevent
the transfer
of
tuberculosis
patients
to
the
Fitz-
simons
General
Hospital,
Denver,
Colo.,
who
will
not
be
benefited
by
the
treatment
there, it is requested that the following instructions
be observed :
(a)
Only
patients
who
have
a
positive
sputum
diagnosis
will
be
trans
ferred
to the Fitzsimons General
Hospital. Denver,
Colo.
(b)
Of
those mentioned
in
paragraph
(a)
only
those
who
in
the opinion
of the board
of medical
survey will
be benefited
by
the high,
dry
atmosphere
of Colorado.
(c)
Those
patients
whose
sputum
is
negative
for
tubercle
bacilli
will
be
retained for treatment.
3. The
bureau
expects
the
cooperation
of
the commanding
officers
of
the
various
naval
hospitals
in observing
the above instructions,
as it appears
to
be
the opinion of many specialists
in the treatment
of tuberculosis
that tubercular
patients
can
be satisfactorily treated In a general
hospital.
4. Paragraphs
4,
5, and 6 of circular letter
serial
No.
209-1922,
128586(84),
August
21,
1922. apply
to
cases
of tuberculosis.
F.
L. Pleadweix.
Acting.
Circular letter,
serial
No. 211-1922.
WRJ : THC 124842(84).
Department of the Navy,
Bureau
of Medicine and
Surgery,
Washington,
D. C, August
2J,,
1922-
Tn : All medical
officers.
Subject:
Blank
forms.
1. Hereafter
blank
forms
will
be
issued
to
the service
at a cost
value
and
will
be accounted
for on the " report of expenditures
" in the same manner
as
are other
supplies
issued from
the naval
medical
supply
depot.
2. Requests
for blank
forms,
Forms "O"
and "41." will
be
prepared
and
submitted
in
duplicate.
The
duplicate
copy
will
be
priced
by
the
medical
736
Vol. XVII
DIVISION
OF PREVENTIVE MEDICINE.
supply
depot
and
returned,
with
the
forms
supplied,
for the
information
of
the activity.
3. It has
been
brought
to
the attention
of the bureau
that blank
forms
are
requested
by the various
activities in quantities
far in excess of actual require
ments, sometimes in such amounts
as to require
rail shipments.
It Is directed
that
care
be
exercised
in
preparing
such
requests
and
forms
requested
in
quantities
only as may be shipped by mail.
F. L. Pleadweij,.
Acting.
Circular letter, serial No. 212-1922.
WHM-HCM SDS 124842(91).
Department of the Navy,
bureau
of medicine
and
surgery,
Washington,
n. C, September
1, 192i.
To: All medical
officers.
Subject: Re
the
reporting
of
disabilities
occurring
among
naval
personnel
attached
to and actually
serving
on
submarines.
1. It Is directed
that
in the future when personnel
attached
to and actually
serving
on board submarines
are admitted
to the sick
list, all submarine
bases,
tenders,
and other
stations
to which
submarines
are attached
will,
on line
10
of Form F. card, add after the name of the particular
base,
tender, or
station
the name
of
the submarine
in
parentheses,
e.
g..
Submarine
base
(U.
S.
S.
Ortolan), San Pedro, Calif.
(U. S. S., L-6).
2. The cases will, however,
be reported
in the usual
manner
on Forms F and
K. the above designation
appearing
only
on Form F cards.
F. L. PtEADWELL,
Acting,
Circular
letter, serial
No. 213-1S>2Z
WSG : ESK 125884(84).
Department of the Navy,
Bureau of Medicine and Surgery,
Washington,
D. C, September
7,
192Z.
To: All naval
hospitals.
Subject
: Navy
property
not
to
be loaned.
Reference
:
S. & A. " Memoranda,"
No. 239, July
1, 1922, page C454.
1. The following letter
from
the Acting Secretary
of the Navy
to
the Chief
of the Bureau
of Supplies
and Accounts,
dated June 28. 1922, is quoted for the
information
and guidance of all concerned:
" Confirming
oral
instructions.
Government
property
in
the custody
of
the
Navy
shall
not be lent
to anyone or any organization,
public
or private,
except
by express authority of the Secretary
of the Navy transmitted
through
the Pay
master General.
" Such Items of material
as the Secretary
of the Navy
considers
legal to Issue
to governmental,
humanitarian,
and
boy
scout
organizations,
or
organizations
of a corresponding
philanthropic nature,
shall
not be issued
as loans, but shall
be sold to such organizations
at a price fixed by the Paymaster
General,
subject
to the approval
of the Secretary
of the Navy.
In the case
of special
articles,
such as boats, engines, and ordnance
materiel,
the Paymaster
General will refer
the matter
to the bureau concerned before presenting
his recommendation
to the
Secretary
of the Navy."
No. 4.
737
DIVISION
OF PREVENTIVE
MEDICINE.
2. Especial
attention
is
invited
to the above order
and to the fact that
no
loans of Government
property
may he made " except by express authority of the
Secretary of the Navy."
3. The alleged
loan of Medical
Department
tentage has recently
been
unoffi
cially
brought
to the bureau's
attention.
B. R. Stitt.
Circular letter,
serial
No.-40-22.
N-14-RRME-KVS
55399-79
Navy
Department,
Bureau
of
Navigation,
Washington,
I). C,
August
2.'/.
1922.
To: All ships
and stations.
Subject : Activities
of
the
American
Red
Cross
for
the
benefit
of
Navy
personnel.*
Inclosures:
Two.
1. There
are
attached
inclosures
(2),
two
papers
which
indicate
clearly
the work
The
American
lied
Cross
is
constantly
iierformtng
for the benefit
of the
i>ersonnel
of the Navy.
2. It is directed
that
these
inclosures
be brought
to the attention
of the per
sonnel,
in
order
that
they
may
know
and appreciate
the very
large
amount
the work
The
American
Red
Cross
is
constantly
performing
for
the
benefit
form for the benefit of themselves anil their families.
Thomas Washington.
[Inclosure
1.]
Red Cross Activities
for United
States
Naval
Personnel.
July
25.
1922.
The national
headquarters
American
Red Cross
maintains
in their organiza
tion a department
called
the bureau of naval
affairs,
to which
a medical
officer
of the Navy is regularly assigned and detailed.
Through
this
office
all corre
spondence
from
the Red
Cross
chapters
concerning
naval
personnel,
ex-Navy
men and families
of naval
men.
is routed.
Through
this office
matters
pertain
ing
to emergencies arising in
families,
financial
affairs,
etc.,
can
be taken
up
.immediately with
the proper authorities
in the Navy
Department
and informa
tion furnished
the locnl chapters.
The Red Cross activities
in naval
hospitals
are as follows:
(fl) Providing
supplemental
entertainment
for
patients.
(This
consists
of
motion
pictures,
vaudeville
shows, dances, etc.)
(6) Regular visiting
(under
commanding
officer's direction).
(c) Stimulating in adjacent
community
welfare
activities
which
can be bene
ficial
to the patients.
During
the World War and subsequent demobilization
the Red Cross
activi
ties
at
naval
stations
and
bases
were
very
helpful
to
the
Navy 'and
were
greatly
appreciated.
At the present time Red Cross personnel
under
the direc
tion of
a field director
is maintained
at
eacli naval
station
and large
marine
post where
valuable
services,
especially
in
connnection
with the home service
conditions
and
contact
between
an
enlisted
man
and
his
family,
etc.,
are
rendered.
The
social
service
department
of
the
Red
Cross
in
relation
to
Veterans'
Bureau patients
in naval
hospitals
has to do with—
<<*) Securing
social
histories
and
other
significant
data
for
use of
tuber
culosis
specialists
and psychiatrists.
738
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
(b)
Securing
reports
on
home conditions
for help of physicians
in deciding
whether
or not to discharge
a patient
to his
home.
(c)
Correspondence
with
home
communities
to
adjust
home
situations,
thereby making
it possible for patients
to remain
in hospitals.
This
sometimes
involves
financial
aid
to families.
(d)
Arranging through
local
communities
for men
who return
home to have
proper
care and
assistance
in adjusting themselves
to civilian life.
(e)
The
Red
Cross
maintains
an
information
service
which
deals
with—
(1)
Communicating
with
family
doctors
and
others
to
assist
in
securing
affidavits
necessary
to substantiate
Government
claims.
(2)
Information
to families regarding
patients'
personal
and family affairs
when advised
to
do so by the commanding
officer.
(3)
Furnishing
information
to
patients
regarding
Government
legislation.
(4)
Furnishing
information
regarding
Government
insurance.
(f)
The
Red
Cross
also
assists
in
the
matter
of following
up
Veterans'
Bureau
patients
who leave the hospitals
A. W. O. L. or against
advice
to
see
that they return,
or if leaving
against
advice that they are placed under
proper
supervision
in a home community.
The Red Cross maintains
Red Cross convalescent
houses at each of the large
naval
hospitals
where
patients
may
avail
themselves
of
the
opportunity
to
read, play
such games as their physical
conditions
permit,
write letters,
etc.
The Red Cross
has accomplished
a great deal in filing with the proper
offices
information and data
necessary for Veterans'
Bureau
patients
to receive
com
pensation
from
the bureau.
There
are at present nearly
800 Veterans'
Bureau
patients
in naval
hospitals,
a large
number of whose claims
for compensation
have not
been
settled.
Through the investigations
by the Red
Cross
and
data
furnished
settlement of these claims
is greatly
expedited.
The Red
Cross
Society
maintains
in practically all of the large
naval hos
pitals personnel
to instruct the
patients
in
occupational
therapy.
This
con
sists
of bead work,
basketry,
weaving,
metal
work,
toy making,
etc.
(These
departments
are
practically
self-supporting.)
One of the
most
commendable
works
of
the Red
Cross
for naval,
marine,
and Veterans'
Bureau
patients
in naval
hospitals
is to keep their families ad
vised as to their
condition,
and to help, often financially,
to make arrangements
for parents
to visit their sons whose conditions
are critical.
[ Inclosure
2.]
REPORT
OF
SEBVICE
RENDERED BY
AMERICAN
KED
CROSS
FOB
MEN
OF THE
NAVY
AND
MARINE
CORPS,
INCLUDING
VETERANS'
BUREAU
PATIENTS
IN
NAVAL
HOSPITALS.
DURING THE MONTH
OF JUNE,
1922.
I. Men in camps and stations
lust day of month :
(a)
Number
of stations
covered
26
Co)
Approximate
number of able-bodied
men
served
75,565
(c)
Approximate
number
of service
patients
served
3,635
(d)
Approximate
number
of
Veterans'
Bureau
patients
served
1.9*5
II.
Record
cases
: •
1. Brought forward
from
preceding
month
3, 135
2. New record
cases
2. 1SS
3.
Reopened
record
cases
"S9
4. Total
open
during month
6, 112
5. Cases
acted
on during month
3. 864
6.
Closed
during month
3, 274
7. Remaining
open
at end
of month
2. 83S
No. 4.
DIVISION
OF PREVENTIVE MEDICINE.
739
III. Analysis
of new and reopened record
cases
:
1. Soldier
and sailor claims
(allotment,
allowance,
insurance,
compensation,
etc. )
945
2. Other
difficulties
regarding
Government's
program
250
3. Investigations —
(a)
Discharge
137
(6) Furlough
61
(c)
A. W.
O. L. or A.
O. L
64
(d)
Medical,
social
322
(e)
Other, social
374
4. Requests
for family service —
(a)
Relief
118
(6)
Social
173
5. Connections
with relatives
reestablished
115
6. Men's
other personal
problems
(preparing
affidavits,
obtain
ing
needed
clothing;
miscellaneous
friendly
aid;
legal;
business
problems,
etc.)
659
7. Number
men
given
loans during month
149
IV. Nonrecord
(individual
Information
cases
involving
elements
listed
in
Group III)
5,852
V. Hospital
recreation
and
entertainment
conducted
or
produced
by
the American
Red Cross for patients
in Navy
hospitals
:
1. Motion
picture
shows
28
Approximate
attendance
'.
4, 050
2. Vaudeville
and
plays
14
Approximate
attendance
3, 950
4.
Speaking
and musicals
15
Approximate
attendance
1, 125
4. Athletic
events
16
Approximate
attendance
450
5.
Miscellaneous
(dances, outings,
card
parties,
etc.)
28
Approximate
attendance
3, 198
VI.
Services
to patients
(not
elsewhere
specified)
:
1. Friendly visits to patients
8, 519
2. Number of instances of definite
services rendered patients.-
2, 728
3. Letters written by hospital
worker—
(a)
Communication
service
669
(6)
Personal
339
VII.
Supplies
distributed
for
comfort
nnd
welfare
of
patients
in
hospitals
, includes
a
variety
of items.
A
few
of
those articles
distributed
generally
throughout
all divisions
are listed
below:
Brushes,
tooth
170
Cards,
playing
76
Cigarettes
35,400
Cream,
shaving
tubes—
90
.
Envelopes
11, 240
Matches
books
650
Matches
cartons.-
6
Paper,
writing
16,950
Socks
pair—
112
Sweaters
L
104
Tooth
paste
tubes.-
141
740
Vol. XVII.
DIVISION
OF
PREVENTIVE
MEDICINE.
VITAL
STATISTICS.
In the future the " Monthly
Health Index," which
will
be published
on
the
fifteenth
of each
month, will
contain
statistical data for individual
ships and
shore
stations.
The statistics
appearing
in this bulletin
are
summaries
com
piled from
those published
in the " Monthly Health Index."
Annual
rates,
shown
in
the
succeeding
statistical
table,
are
obtained
as
follows :
The total
number of admissions
to the sick list or the number of deaths
re
ported during
the period Indicated
is multiplied
by W
or W
<jr 12< depending
upon whether
the period
includes four or five weeks or a calendar
month.
The
product
Is then multiplied
by 1,000 and divided
by the average complement.
E. R. Stttt.
Table No.
1.—Monthly report
of morbidity in the United
States
Navy
and
Marine Corps for the month
of August,
1922.
Entire
Navy.
5,418
545.81
Average
complement
t' 119,118
All causes:
N umber of admissions . . .
Annual rate per 1,000
Disease only:
Number of admissions.
. .
Annual rate per 1,000
Injuries and poisons:
Number of admissions.
. .
Annual rate per 1,000
Communicable
diseases,
ex
clusive of venereal diseaso:
Number of admissions.
. .
Annual rate per 1,000
Venereal
disease:
Number of admissions.
. .
A nnual rate per 1,000....
4,748
478.31
1,455
140.58
112.23
' Does not Include ninth naval district.
1 Includes
Navy and Marine Corps personnel.
Note.— Asiatic and unassigned
snips not reported.
Table No.
2. —Number of admissions
reported
by Form F cards
for certain
diseases for the month of August,
1922.
Forces
afloat,
Navy
and
Ma
rines
(comple
ment,
75,388). v
Forces
ashore,
Navy
and
Ma
rines (comple
ment,
43,726).
Total (comple
ment,
119,118).
Numbcr
of admis
sions.
Annual
rale per
1,000.
Number
Annual
ofadmis-
rate per
sions.
1,000.
Number
of admis
sions.
Annual
rate per
1,000.
2,282
374
363.23
59.53
2,466
676.74
296
81.23
4,748
670
478.31
67.50
2,656
422.76
2,762
757.98
5,418
545.SI
CLASS III.
39
17
17
6.21
2.71
2.71
.16
47
12.90
7
1.92
86
24
34
8
1
8.66
2.42
3.43
I
17
4.67
7
1.92
1
.27
.a
Cholelithiasis
.10
No. 4.
741
DIVISION
OF PREVENTIVE MEDICINE.
Table
No.
2. —Number
of
admission*
reported
by Form V
cards
for certain
diseases for the irumth
of
August,
1922— Continued.
Forces
afloat,
Navy
and
Ma
rines
(comple
ment,
75,388).
Forces
ashore,
Navy
and
Ma
rines
(comple
ment,
43,726).
Total (comple
ment,
119,118).
Number
of admis
sions.
Annual
rate per
1,000.
Number
of admis
sions.
Annual
rate per
1,000.
Number
of admis
sions.
Annual
1,000.
2
0.32
2.71
3.98
.32
5.41
4.62
1.11
2
20
17
22
67
30
11
0.55
5.49
4.67
4
0.40
3.73
4.23
2.43
10.17
5.94
1.81
.10
25
2
34
29
7
0
b.m
37
42
24
101
58
18
1
1
18.39
8.23
3 01
.27
2
.32
1
.27
3
.30
192
30.56
250
68. 61
442
44.53
13
2.07
19
5.21
32
3.22
3
.48
0
3
.30
0
.27
.10
5
.80
0
5
.50
46
4
4
6
7.32
.64
.64
.96
37
1
5
5
1015
.27
1.37
1.37
83
5
9
8.36
.50
.81
11
1. 11
68
.0.82
49
13.45
117
11.79
0
1
.27
1
. 10
1
.16
6
1.66
.71
1
. 16
7
1.92
8
.81
9
23
1.43
3.66
60
16.47
63.94
69
256
6.95
25.79
233
32
5.08
283
80.41
325
32.74
7
1.11
16
4.39
23
2.32
256
693
69
40.75
110.30
10.98
85
279
73
23.33
76.57
20.03
341
972
142
34.35
97.92
14.31
1,018
162.04
437
119.93
1,455
146.58
100
4
15.92
.64
105
28.82
205
4
20.65
.40
1.0
0
5
17
158
.80
2.71
25.31
5
20
88
1.37
5.48
24.15
10
22?
3.73
24.88
M
45.36
218
68.83
503
5a 67
21
3.34
21
6.59
45
4.53
Colitis,
acute
Constipation
Enteritis, acute
Gastritis,
acute catarrhal
Gastroenteritis
Hemorrhoids
Pharyngitis, acute
ricer of duodenum
Ulcer
of stomach
Total admissions
class
vn.
Varicocele
class vm.
Chicken
pox
Diphtheria
German
measles
Influents
Measles
,
lobar
Total admissions
CLASS IX.
nttry, bacillary
ntery, entamebic
Total admissions
CLASS X.
Dengue
Malaria
Total admissions
class XI.
Tuberculosis
(all forms)
CLASS XII.
Chancroid
C.onococcus infections
Syphilis
Total admissions
class xvm.
Bronchitis,
acute
Laryngitis,
acute
Pleurisy,
acute fibrinous
Rhitiitfs,
acute
Tonsillitis, acute follicular
Total admissions
class xx.
742
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
Tabu:
No.
3.—Summary
of
annual
admission
rates
for
venereal
diseases re
ported
from ships for July and from
various
shore stations
for the
/tt>e-tceeJe
period, July
SO to September
2, J9Z2, inclusive.
Annual rate per 1,000, Jul y.
Average rate since Jan. 1, 1922.
Mini
mum
rate.
Mean
rate.
Maxi
mum
rate.
Mini
mum
rate.
Mean
rate.
Maxi
mum
rate.
Battleship and cruiser force—
Destrover
foroe—
Miscellaneous —
0
173.89
1,633.36
0
136.82
840.33
35.08
71.57
130.43
160.58
144.01
381.45
484.47
229.50
871.97
47.02
69.41
32.81
115.82
101.02
24a 71
235.09
129.70
377.58
69.76
65.48
831.68
207.22
139.24
831.68
1,636.36
521.73
831.68
17.49
17.04
18.43
152.42
95.57
318.86
575.12
292.68
625.00
Unassigned,
including
ships on special
32.43
0
0
126.34
139.61
352.94
1,200.00
352.94
1,411.78
28.91
0
0
127.02
88.80
321.40
769.2J
221.05
84a 33
50.00
399.3S
1,100.91
24.39
185.05
313.13
Annual rate per 1,000,
July 30-September,
1922.
Average
rate since July 1, 1922.
Mini
mum
rate.
Mean
rate.
Maxi
mum
rate.
Mini
mum
rate.
Mean
rate.
Maxi
mum
rate.
All naval districts
In the United States
0
96.28
415.53
0
88.75
319.34
0
65.25
415.53
12.57
78.71
279.72
Third naval district
20.39
105.20
146.03
11.32
112.51
171.47
0
265.95
301.63
5.43
299.22
335.52
16.37
74.61
361.43
18.46
77.51
349.84
Sixth naval district
38.11
50.98
156.98
35.44
47.71
144.00
0
0
0
0
0
0
0
105.58
124.55
0
102.30
11132
96.16
96.16
96.16
99.85
99.85
99.55
21.66
39.97
83.75
20.00
40.25
65-12
73.91
131.22
172.71
49.99
231.29
198.73
Thirteenth naval district
0
27.44
167.74
0
31.55
97.56
EATIO OF QONOCOCCTJS AND SYPHILIS TO TOTAL CASES OF VENEREAL DISEASE.
Per cent July,
1922.
Per cent since
Jan. 1, 1922.
Gono-
coccus.
Syphilis.
Oono-
coccus.
Syphilis.
All ships
7tt 78
6.29
67.38
9.S3
Battleship and cruiser force-
Atlantic Fleet
58.51
6.66
6a 16
10.70
86.30
9.58
83.33
9.12
Asiatic Fleet
41.66
16.66
49.03
15.33
Destroyer
force—
85.18
4.62
67.63
8.JO
80.80
7.07
79.64
6.38
Miscellaneous
force—
0
0
6L87
7.79
Atlantic
Fleet
61.53
5.12
64.21
9.(1
79.03
3.22
79.08
10.M
53.84
3.84
53.84
16.26
58.71
3.66
60.38
9.05
Wo. 4.
DIVISION
OF
PREVENTIVE
MEDICINE.
748
Table
No.
3. —Summary
of annual
admission
rates
for
venereal
diseases re
ported
from ships for July and from various
shore stations,
etc. —Continued.
RATIO
OF
GONOCOCCDS
AND SYPHILIS
TO TOTAL CASES
OF VENEREAL
DIS
EASE: —Continued.
Per cent July 30-
Sept. 2, 1922.
Per cent since
July 1, 1922.
Gono-
coccus.
Syphilis.
Gono-
Syphilis.
coccus.
79.93
78.19
81.48
88.05
74.07
83.33
0
7.26
9.53
11.11
4.48
4.93
0
0
0
0
0
68.49
76.74
77.35
86.66
69.79
72.23
0
7.64
9.30
9.43
Fourth naval
district
3.70
Fifth naval
district
6.71
Sixth naval
district
.
5.55
Seventh
naval
district
0
Eighth naval district
90.00
100.00
100.00
88.22
100.00
92.30
75.00
100.00
0
Ninth naval
district
0
Eleventh naval district
7.69
16.66
0
Twelfth naval district
7a 90
100.00
16.36
0
Table No. 4. —Number of admissions
reported by Form F cards and annual
rates
per 1,000, entire Navy, for the flve-iceck period, July
80 to September
2, 1922,
inclusive.
Navy (comple
ment, 97,062).
Marine
Corps
(complement,
Total (comple
ment,
119,118).
Number
Annual
Number
Annual
Number
Annual
of ad
rate per
of ad
rate per
of ad
rate per
missions.
1,000.
missions.
1,000.
missions.
1,000.
2
0.21
1
0.47
3
0.26
26
2.79
9
4.24
35
3.06
578
61.93
171
80.63
749
65.39
4
.43
1
.47
5
.44
113
12.11
21
11.32
137
11.96
Diseases
ol
geni to-urinary
system
(non-
92
9.86
23
10.84
115
10.04
Communicable
diseases transmissible
by
133
14.25
38
17.92
171
14.93
Communicable
diseases transmissible
by
135
14.46
10
4.72
145
12.66
Communicable
diseases transmissible
by
7
.75
3
1.41
10
.87
96
10.29
252
118.82
348
30.38
25
2.68
2
.94
27
2.36
1,327
142.17
238
112.22
1,565
136.62
280
30.00
85
40.08
365
31.86
72
7.71
29
13.67
101
8.82
23
2.46
4
1.89
27
2.36
71
7.61
27
12.73
98
8.56
31
3.32
11
5.19
42
3.67
673
72.11
122
57.53
795
69.40
105
11.25
41
19.33
146
12.75
Hernia
50
5.36
9
4.24
59
5.15
Miscellaneous
diseases and conditions
65
6.96
29
13.67
94
8.21
Parasites
(fungi
and certain
animal
para-
194
20.79
16
7.54
210
18.33
12
1.29
3
1.41
15
L31
532
57.00
145
68.37
677
59.10
Poisons
61
6.54
8
3.77
69
6.02
4,707
504.31
1,301
613.45
6,008
524.50
744
Vol. XVII.
DIVISION
OF PREVENTIVE MEDICINE.
Table No. 5.—Deaths
reported,
entire Navy,
for the five-week period, July
SO to
September
2, 1922, inclusive.
Na'
iin-i n ,
97,062).
Marine
Corps
(comple
ment,
22,056).
Malaria
Pneumonia, broncho
Scarlet fever
Tuberculosis,
chronic pulmonary.
Tuberculosis,
acute pneumonic.
. .
Tuberculosis
of liver
Tuberculosis,
other forms
Syphilis
Malignant growths
Other diseases
Drowning
,
Accidents
and Injuries
,
Total.
rate per 1,000,all causes
rate per 1,000, disease only .
30
3.21
1.82
3.30
3.23
1.80
1.83
O
A*.a,.--V
I
v.
VOL XVII
NO.
5
UNITED STATES NAVAL
MEDICAL BULLETIN
INFORMATION
OF THE MEDICAL
-
DEPARTMENT
OF THE
SERVICE
ISSUED BY
THE BUREAU
OF MEDICINE
AND SURGERY
NAVY DEPARTMENT
DIVISION
OF INSTRUCTION
AND PUBLICATIONS
COMMANDER
H. W. SMITH,
MEDICAL
CORPS, U. S. NAVY
IN CHARGE
EDITED
BY
LIEUTENANT
COMMANDER
W. M. KERR, MEDICAL
CORPS, U. S. NAVY
PUBLISHED
FOR THE
NOVEMBER, 1922
(MONTHLY)
Conplled and published uoder authority of Nayal Appropriation Act
for 1923, approTod July 1, 1922
WASHINGTON:
GOVERNMENT
PRINTING
OFFICE
1922
Unite
.'ta"-
fa Uf. t-ririecLt
Navt Department,
Washington, March
W, 1907.
This United
States Naval Medical Bulletin is published by
direction of the department for the timely information of the Medi
cal and Hospital Corps of the Navy.
Truman H. Newberry,
Acting Secretary.
Owing to the exhaustion
of certain
numbers
of the Bulletin
and
the
fre
quent demands from libraries, etc., for copies to complete their flies, the return
of any of the following issues wi'l
be greatly
appreciated:
Volume VII, No. 2, April,
1913.
Volume VIII, No.
1, January,
1914.
Volume VIII, No.
3, July, 1914.
Volume VIII,
No. 4. October,
1914.
Volume X, No.
1, January,
1916.
Volume XI, No. 1, January,
1917.
Volume XI, No. 3, July, 1917.
Volume XI. No. 4, October,
1917.
Volume XII, No.
1, January,
1918.
Volume XII,
No.
3, July. 1918.
SriiscMPTioN Price
ov the Bulletin.
Subscriptions
should
be
sent
to
Superintendent
of
Documents,
<Jovermiieiit
Printing
Office.
Washington,
D. C.
Yearly subscription,
beginning January
1, $1,150:
for foreign
subscription
add
$1.00 for
postage.
Single
numbers,
domestic
15 cents:
foreign,
24
cents,
which
includes
forfiw
postage.
Exchange
of publications
will be extended
to medical
ami scientific
organiza
tions,
societies,
laboratories,
and
journnls.
Communications
on
this
subject
should
be addressed
to
the
Surgeon
General,
United
States Navy,
WashingtoD.
D. C.
n
TABLE OF CONTENTS.
Pne«-
PREFACE
-.
V
NOTICE TO SERVICE CONTRIBUTORS
vi
SPECIAL ARTICLES:
History of the United States naval hospitau
Fort Lyon, Colo.
By Captnin
F. W. F. Wieber,
Medical
Corps.
U. S. Navy
745
KOLMER
MODIFICATION
OK THE WASSERMANN
TEST.
By Lieutenant
J. Harper, Medical
Corps,
U.
S. Navy,
and Phar
macist's Mute L. F. Curtis, TJ. S. Navy
757
A MEDICINAL
GARDEN.
By Lieutenant
Commander
G. W. Calver,
Medical
Corps,
U.
8.
Navy
763
Functions and organization
ok Medical Corps units serving with
the Marine
Corps in the Field.
By Major
S. N. Rayuer,
United
States Marine Corps
771
Hygiene of bubmkrsibi.es
(part ii).
By Captain
C. M. Belli, Royal
Italian
Navy
-
785
Bone tumors, classification, diagnosis,
and treatment
of.
By Lieutenant
J. W. White.
Medical
Corps. U. S. Navy
802
Sterilization of glass syringes.
By
Lieutenant
Commander
H.
E.
Harvey.
Dental
Corps,
V.
S.
Navy
810
EDITORIAL :
Place of specialism
in the Navy — Yellow fever —Diagnosis
of lesions
within
the peritoneum
from
those of the urinary tract—Are her
nias
ever
acquired? —Hookworm
disease
in
Brazil — Vaccination
against
Asiatic cholera
SIS
IN MEMORIAM
:
James
Spottlswoode
Taylor,
1870-15)22
SXi
NOTES AND COMMENTS
:
Hygiene
of submers:bles — Medicinal
gardens —Filariasis
in the West
ern
Pacific —Centenary
of Bretonueau-
-Venereal
diseases—Exami
nation
of
commercial
arsphenamin
and
neoarsphennmln —Safe
methods of administering
arsphenamin
and neonrsphenamin
835
NURSE CORPS
859
BOOK
NOTICES
...
809
QUERIES
870
PREVENTIVE MEDICINE
STATISTICS,
LETTERS.
ORDERS.
COM
MENTS
P8H
INDEX
l
in
PREFACE.
The United States Naval Medical Bulletin was first issued in
April, 1907,
as a means of supplying
medical officers of the United
States
Navy
with
information
regarding
the
advances
which
are
continually
being made in the medical
sciences, and as a medium
for
the publication
of
accounts
of special
researches,
observations,
or
experiences of individual
medical
officers.
It is the aim of the Bureau of Medicine and Surgery to furnish in
each
issue special
articles relating to naval medicine,
descriptions of
suggested
devices, clinical
notes on interesting
cases,
editorial
com
ments
on current medical
literature of special
professional interest
to the naval medical
officer, reports from various- sources, historical
essays, notes and comments on topics of medical interest,
and reviews
or notices of the latest published medical
books.
The bureau
extends
an invitation
to all medical
officers to prepare
and forward,
with
a view to publication,
contributions
on subjects
of interest to naval medical
officers.
In order that each service contributor
may
receive
due credit for
his efforts in preparing
matter for the Bulletin of distinct origi
nality and special merit, the Surgeon General of the Navy will recom
mend
that
a letter of commendation
be forwarded
to him upon
the
acceptance
of his manuscript for publication, and that
a copy of this
letter be attached to his official
record.
The bureau
does not necessarily
undertake
to indorse
all views or
opinions which may be expressed in the pages of this public ation.
E. K. Stitt,
Surgeon General United States Navy.
T
NOTICE TO SERVICE
CONTRIBUTORS.
When
contributions
are
typewritten,
double spacing
and
wide
margins
are
desirable.
Fasteners
which
can not be removed without
tearing
the paper
are
an abomination.
A large
proportion
of the articles
submitted
have an
official
form
such
as
letterheads,
numbered
paragraphs,
and
needless
spacing
be
tween paragraphs,
all of which
require
correction
before
going
to press.
The
Bulletin
endeavors
to follow
a
uniform
style
in
headings
and
captions,
and
the editor
can
be spared
much
time and
trouble
and
unnecessary
errors
can
be
obviated
if
authors
will
follow
In
the
above
particulars
the
practice
of
recent issues.
The greatest accuracy
and fullness
should
be employed
in all citations,
as it
has
sometimes
been
necessary
to
decline articles otherwise
desirable
because
it was Impossible for the editor
to understand
or verify references,
quotations,
etc.
Tlie
frequency
of gross errors in
orthography
In
many contributions
1?
conclusive
evidence that authors
often
Tail
to read over their
manuscripts
after
they have been typewritten.
Contributions must he received two months prior to the date of the issue for
which
they are intended.
The editor
is not responsible for the safe return of manuscripts
and
pictures.
All
material
suppl ed for illustrations, if not original, should
be accompanied
by a reference
to the sonree and a statement as to whether
or not
reproduction
has been authorized.
Only the names of actual
reviewers
for a current
number appear.
The Bulletin
Intends
to print only original articles,
translations,
in trhok
or in part,
reviews,
and reports
and
notices
of
Government
or departmental
activities,
official
announcements,
etc.
All original contribution))
arc
accepted
on
the assumption
that
they have not appeared
previously
and are
not
to
ht
reprinted
elseichere
unthout
an
understanding
to
that
effect.
VI
J
U. S. NAVAL MEDICAL BULLETIN
Vol. XVII.
November,
1922.
No.
5.
SPECIAL
ARTICLES.
THE HISTORY
OP THE
UNITED
STATES
NAVAL
HOSPITAL,
POET
LYON,
COLO.,
AND THE ACTIVITIES
OP THE NAVAL
MEDICAL
COEPS IN THE
DEVELOPMENT
OF THE HOSPITAL
POE SANATORIUM
PURPOSES.
By
F. W. F. Wieber,
Captain,
Medical
Corps.
United
States
Navy.
HISTORY
OP THK NAVAL HOSPITAL, FORT LYON.
Fort Lyon, also known
as New Fort Lyon,
was built by the Army
in 1867 following the abandonment
of what was known as Fort Wise
and later as Old Fort Lyon, which was located
about
8 miles west of
Lamar and
22 miles east of New Fort Lyon, on low land close to the
Arkansas
River.
A flood of the Arkansas River at that time caused
such destruction of the original Fort Lyon that it was
abandoned
and a new site on a higher bluff westward was chosen.
This post was
a comparatively large one (the entire reservation covering an area of
a little over 9 square miles),
as it was the only other permanent
fort
besides
Fort
Massachusetts,
which
has
been
erected
at
an earlier
period farther westward in the mountains.
The new fort formed one
of the most important frontier
posts and commanded
the entire ter
ritory of western
Kansas, eastern
Colorado,
and
western
Oklahoma
(then the Indian Territory).
Of the original buildings
put up by
the Army quite
a number are still standing and in use, among
these
being ths entire officers' row on C Street ; the Kit Carson house ; the
west subsistence
building,
which was formerly
used as barracks;
the
stable,
the
south
storehouse,
the
administration
building;
and
one
part
of
the
men's
infirmary,
which
was
even
then
used
as
a
hospital.
Two
barracks
buildings
to
the
east of
the
present
parade
grounds
were
torn
down
when
the
Navy
took
possession
and
were
replaced
by
lean-tos for
the
accommodation
of
ambu
latory
patients.
The
following
description
of
the
quarters
at
the fort, picturing
the conditions that existed during Army days, is
quoted from the book entitled " Kit Carson Days," which may serve as
a comparison to the condition of these same quarters as they now ap
pear and are available for duty-officer personnel.
"New Fort Lyon was at this time (Kit Carson time)
one of the
rudest
and
dreariest of
frontier
posts.
It
was
uninclosed
after
plains fashion of Army days,
its buildings
being grouped about
the
sun-baked
parade
grounds.
The
officers'
row
was
composed
of
745
746
WIEBER
NAVAL
HOSPITAL,
FORT LYON.
Vol. XVII.
small
four-room
houses,
some
occupied
by
two
families,
built of
rough stone, chinked with mud, the floors of unfinished lumber,
the
wood partitions
being in many instances
only
8 or 9 feet high, with
the remaining space to the rafters filled in with flour sacking.
There
were no ceilings.
The roofs were of long boards
in the rough
and
untrimuied, so that their ends projected irregularly as eaves."
The Kit Carson house, spoken
of as one of the original
buildings,
might give the impression that Kit Carson himself
was on duty
at
this fort.
This is not correct.
The so-called Kit Carson house
was
the
residence
of the surgeon
of the fort, Doctor Tilton, who took
Kit Carson
to his
home
from
his ranch
at
Boggsville,
near
Las
Animas, during the last few days of his life, where he died
about
10
days later from ruptured aneurism of the aorta.
The establishment of the Army post of Fort Lyon at its new
site
resulted
in the founding of the town of Las Animas
on the opposite
side of the river.
The town was connected
with the fort by
a toll
bridge, and it is stated that it soon possessed a livery
stable,
hotel,
restaurant, and several
saloons.
Between
the cowboys of the plains,
the hunters,
travelers, and soldiers, a typical
western
frontier town
arose that rivaled many of the western towns for trouble and blood
shed.
The town was finally
abandoned
in 1876 on the coming of the
railroad,
and the present city of Las Animas
was built
some 4 miles
farther
west.
In
1889
the need for the upkeep
of
a military establishment had
disappeared and Fort Lyon was abandoned
by the Army and placed
in the hands of a caretaker until 1906, when it was taken over by the
Navy for sanatorium purposes.
CONDITIONS FOUND AT
Vt >KT LYON
AND NECESSARY WORK UNDER
TAKEN
TO FIT IT
FOR
MODKUN
SANATORIUM
PURPOSES
FROM
1906 TO
1922.
The first Navy
detachment
ordered
to Fort Lyon
arrived
there
on November 17,
1906,
and
was composed of Surg. T. A. BerryhiU,
Surg. James G. Field, Civil Engineer A. L. Parsons, and Pharmacist
Phillips.
When this party arrived they were confronted with a sorry
sight.
The buildings
were dilapidated
and falling to pieces.
There
was not a sound roof nor even a part of the old buildings which
could
safely be used for a temporary shelter.
A great deal of the
damage
was the result of natural deterioration,
but
the Colorado
blizzards,
Band, and rainstorms had been assisted
in their work of destruction
by human
agencies.
The buildings
had
been
systematically
looted
and gutted.
Doors, windows, and even structural
timbers had
been
carried away, and it is said that this material
may still
be found
in many of the old ranch buildings in the vicinity.
Cattle and horses
roamed
about freely on the grounds and in the houses, rattlesnakes
No. a.
WIEBEB —NAVAL
HOSPITAL,
FORT LYON.
were
encountered
not
infrequently,
and
signs
of destruction
were
everywhere.
,
In view of these conditions, temporary
office
rooms
were secured
in the courthouse
of Las Animas.
On November
20 the naval party
was joined by Civil Engineer W. R. Murphy and two assistants,
both
civilians, and Paymaster Ammen, U. S. Navy.
In January, 1907, Surg. B. L. Wright arrived
as the first patient.
He was immediately placed
on
a duty status.
At the fort, naturally,
the first work started
was the establishment
of a temporary
tent
camp
with
sanitary
facilities.
Then
a
large
labor force
was employed
for the clearing away of rubbish and for
making
temporary
repairs
to dangerous
roofs
and
walls of build
ings; others
were employed
in the construction of a more permanent
camp of rubberoid sheds and in the erection of tent quarters
for duty
personnel
and
patients.
The
first
plan
of
the
reservation
was
completed
in December,
1906, and
is still
on file in the public works
office.
The duty personnel
moved to the fort into tents during the middle
of February,
1907.
On February
25,
30
bundles
of hospital
tents
were received for the accommodation
of patients, who,
however,
it
seems, did not arrive in any large numbers until
about
September
16,
1907,
at which date 24 arrived from Fort Bayard.
Of the
24 buildings
found on the reservation
about
10 were torn
down,
among
these
being the
barracks
at
the
east
of the
parade
ground
and
a number
of buildings north of the officers'
row.
The
others were
repaired.
These
included
the administration
building,
two
west
wards
(formerly
used
as barracks),
the barn, the
south
storehouse,
the
officers'
quarters,
ward C, the operating
section
of
the men's infirmary,
and the " Kit Carson house."
which
is used at
present as a schoolhouse.
The reservation
was devoid of trees and was covered
with weeds;
roads did
not exist;
tumbleweed
predominated
everywhere.
The
water supply was derived
from shallow- wells.
The work of remodeling the buildings
and of const ru: ting sewers,
digging wells, constructing
a heating system and
a power plant was
mostly accomplished
by contract
from plans prepared
at the hospi
tal and at the Bureau of Yards and
Docks.
While
this work was
progressing, plans were prepared for new
necessary
buildings,
viz :
Leantos
4,
5, 6, 7; east subsistence
building: bakery:
pharmacists'
quarters 304 to 309; civilian
quarters
321,
322,
323,
324,
and
370;
bowling
alley;
west
subsistence
building
(center
wing);
laundry:
north storehouse,
officers' infirmary
and
cottages;
wards E. F, and
G of the men's infirmary;
commissary
store; disinfecting
building:
pump
house;
and
reservoir
at
the main
gate.
A
100.000-gallon
fresh-water
pressure
tank was completed
in June,
1908.
Until that
748
Vol. XVII.
WIEBER —NAVAL
HOSPITAL,
FORI
LYON.
time the water was supplied to the houses
in barrels.
The building
period for these .structures,
which were also erected by contract,
ex
tended over several
years.
Simultaneously
with the above
construc
tion a number of small farm sheds, shops, and storehouses
were built;
in addition,
roads
and
walks
were
laid, many trees
were
planted,
lawns were established,
and farm
and irrigation systems were devel
oped and put in operation.
By 1911 the hospital
was a well-organized
institution of approximately
200-bed capacity.
Civil Engineer
Par
sons was then
detached
and no public works officer was attached
to
the fort until the summer
of
1919.
Between
1911
and
1917
there
were no public
works activities, no new construction,
and
few
im
portant changes
were authorized.
As a result of the lack of avail
able funds the buildings
and grounds began to appear ill kept
and
shabby.
Beginning
about
1917 new construction again became active.
The
commanding officer was authorized to purchase
a dairy herd,
which
required a dairy barn and sheds.
These,
as well as four s los and a
house
for
the
dairymen,
were
contructed
by
station
labor.
The
area of the reservation, which when turned over to the Navy consisted
of only about
500 acres of land, was more than doubled
by the pur
chase of the West Farm, and work was begun there on sheds, corrals,
and also on the irrigation systems.
As the year advanced
a great in-
flux of patients—in consequence of the great expansion of the naval
l'orces—took place, and th s demanded
increased
accommodations
for
patients and duty personnel.
Wards A, B, D, H, I, J and Lean-tos
1, 2, 3, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and
18 were built by station
labor.
The construction of a nurses'
home was also authorized;
36
ready-cut cottages
were
obtained
for speedy
erection.
Increase
of
quarters for attendants,
mess halls, and storehouses
were needed; the
heating, lighting,
and power-plant
utilities
soon
became
overtaxed
and
demanded
expansion.
By
1919
the hospital
was buzzing
with
construction
activity,
the
work
being
accomplished
by
the
sta
tion
force.
At about
this
time
the
need of technical
supervision
for coordination
and
organization
of this work
became
apparent;
the old buildings had become dilapidated;
grounds and roads needed
attention.
During the summer
of 1919 the Bureau of Med cine and
Surgery took cognizance
of these conditions, reorganized the admin
istrative personnel,
and ordered
a public-works
officer to Fort Lyon
to assist the commanding officer in his work.
Assistant Civil
En
gineer Andrew
S. Bisset was detailed for this work.
A public-works
organization
of draftsmen,
inspectors,
and
engi
neers was established
and surveys
and inspections were begun.
Much
of the work done between
1917 and
1919 had
been
done, as a result
of the lack of proper technical supervision, in a haphazard sort of a
way.
and
water,
heat,
and light service
had
been extended
without
Xo. 5.
749
WIEBER
NAVAL
HOSPITAL,
FORT LYON.
plan record.
This made a complete resurvey of the reservation
neces
sary
before
revision and coordination
could
t>e attempted.
In
the
meanwhile
a definite
program of overhaul and repair to the build
ings was started.
This work included new slate roofs on the princi
pal buildings, new floors, new electric lighting,
plumbing, plastering,
and painting.
The mess halls and kitchens
of the subsistence build
ings were improved with tile wainscot
and floors, and new equipment
was installed.
The buildings
which
were under construction
were
completed with certain changes,
a number of others which had been
completed
were altered
to improve the fire protection, lighting,
and
utility.
Extensive new construction and additions, to round out the hospi
tal as a 700-bed unit, were then undertaken.
This work was done by
contract and station labor, in accordance
with plans prepared
by the
public- works officer and approved by the Bureau of Yards and Docks.
The projects included power-plant improvements,
new sewers, exten
sion and revision of water mains,
new water-storage
tank of 400,000-
gallon capacity and
a 200,000-gallon
pressure
tank, revision and
ex
tension of light
and power lines, concrete
pavements
and sidewalks,
and new heating mains.
Among the new structures are the pharma
cists' quarters 310 and 311, four
sets of quarters for medical
officers,
the nurses' infirmary,
the main gate and guardhouse,
a new Ward K
for the men's infirmary, the marine barracks, and
a number of civil
ian quarters
on the northeast
road
and at the West
Farm.
A Red
Cross house
was
built
and
paid for by
the American
Red
Cross.
Additions were constructed
to the east subsistence
building,
bakery,
laundry,
cold-storage
building,
garage,
and
to
18
sets of quarters.
Eleven ready-cut cottages
were moved from around the administra
tion building
to the northeast
road- and converted
into quarters for
chief petty
officers and for patients.
The farm buildings,
particu
larly
the dairy
barn, were greatly improved, and
the piggery
was
moved
from
the vicinity *f the hospital
to the West Farm.
The
refrigerating capacity was enlarged
from the original
8 tons refrig
eration and 2 tons ice-making capacity in 24 hours
to a refrigerating
capacity of 55 tons and
an ice-making capacity of 19 to 20 tons
(in
24 hours)
.
The
boiler power
was
increased
from
a capacity of
400
horse
power to one of
930 horsepower.
This is furnished
by six boilers.
The original
electric
plant consisted of two 20-kilowatt generators:
this was gradually
increased
to one of a total of 318 kilowatts.
An abundance of surface
water for flushing, fire protection, irri
gation, and sprinkling purposes
is supplied by four electrically
op
erated
pumps.
The water
is taken
from
a swamp
at the northeast
of the station.
A pumping test in 1917, kept up for 40 days, which
drew
1,500 gallons per minute,
did not appreciably affect this sup
750
WIKBKR
XAVAL
HOSPITAL,
FORT LYON.
Vol. XVII.
ply.
To this was added
a new steam-driven pump having a capacity
of 750 gallons per minute.
This supplies the flushing
system.
The
drinking water is supplied
by three artesian wells from
a depth of
about
300
feet
and
by
five other wells from
a
depth
of
about
100
feet.
These
furnish
about
300,000
gallons in
24 hours.
The
water
is potable; it has a slightly alkaline taste, but is not injurious in any
way.
The fresh-water
storage
capacity
is 700,000
gallons.
For fire protection there exist nine fire-alarm
boxes, with sufficient
hydrants to protect
the entire reservation.
Of all this repair or expansion work in connection
with the power
house, only the 400,000-gallon
storage
tank, the 200.000-galIon
pres
sure
tank, and
the
power-house
chimney
(having
a height of
155
feet)
were erected
by contract work: everything
else was
done
by
station labor.
The
last
large, project
(which
is now
Hearing completion)
is the
new
steam
and
heat distributing system
for the
northern
part of
the reservation buildings.
This supplies
heat
to
28
new
buildings
and revises
the heat supply
to 21 additional
buildings.
There
are about
180 buildings
on the reservation ; the
population
during Navy days numbered
about 1,000 persons,
including
patients.
The cost of the work accomplished under the direction of the pub
lic works' officers from
1907
to
1911
is approximately
$565,000: of
that completed
from
1917 to 1922, is $1,850,000.
The approximate
valuation of the hospital property
is as follows
(September 28,
1921) :
Buildings
and
structures
$2, 200. 000
Land
120.000
Pavements,
roads,
walks,
lawn,
sewers, pipe lines
outside of build
ings
-
580,000'
Power-plant
equipment
and
mechanical
equipment,
pipaig
in build
ings and shops, tools..
3-10,000
Ambulances
and garage equipment
-
50.000
Farm Implements, live stork,
tools, etc
«.
40.001'
Stores
and building material
on hand
30,000
Hospital equipment,
linen, furniture,
instruments,
etc
445,000
Mess fear,
foods, eul'nnO'
supplies.
5.">.000
3. 860.000
PRKSKNT HOSPITAL
ACCOMMODATIONS.
With the enlargement of the station, naturally
the equipment
for
the accommodation,
care, and treatment
of patients kept
pace.
All
wards have covered
porches,
which are 'used
by all but the very
sick
or terminal
cases: the wards themselves
are heated
so that
patients
during inclement
weather
could
move their
beds indoors:
at
least,
they
could
dress
themselves
indoors.
Toilets,
with
shower
baths
supplying
cold and hot water, are installed everywhere.
So. a.
751
WIEBER —NAVAL
HOSPITAL,
FORT LYON.
There
are
now
five
separate
mess halls,
with
complete
modern
kitchen
and dish-washing
equipment,
viz :
One
for infirmary
patients.
One for ambulatory
cases.
One for duty personnel.
One for sick officers.
One for sick nurses.
There
exists
an operating room
fully equipped
and always ready
for use;
a fully
equipped
dental
department, with
two chairs;
a
dark
room
for eye, ear,
nose, and
throat
cases;
a fully
equipped
laboratory;
an X-ray
department,
consisting of
a
waiting
room,
an operating room,
a filing and study room,
and
a developing room.
The X-ray
operating
room contains,
in addition
to
the
table,
all
the apparatus and equipment
necessary
for the making of pictures
and for fluoroscopic work.
This room is entirely in black.
The
de
veloping
room
is also
finished
in black
and
is equipped
for
the
development of large numbers
of plates or films of any size.
It is
also provided with
an exhaust
system of ventilation,
which aids in
the drying out of plates
and
films.
It contains lead-lined
negative
boxes, with running water conveniently arranged, and suitable sinks
for the making of developer,
fixing solution, and washing chamber.
As regards the equipment of the main part of this laboratory, the
apparatus consists of a Scheidel Western 8-kilowatt
220-volt
60-cycle
alternating-current
machine
of the standard rotary converter type.
This primary plant derives its power from the regular power supply
of the station
and
insures
sufficient
power and penetration for all
routine
work,
and
with
the Coolidge
system,
which
is exclusively
used here,
has been fairly satisfactory.
The low-tension or heating system of the Goolidge tube is obtained
by
a step-down transformer deriving
its energy
also from the main
current
supply.
In addition
to this last-mentioned
system
there
is
provided
a battery system for the heating of the Coolidge filament,
which
has
been of great
use at such
times
when
the fluctuations in
the main current supply
resulted
in difficulty
in maintaining
a con
stant temperature of the tube filament.
The table used in the laboratory
is the standard Victor universal
type.
In addition to being
provided for the taking of stereoscopic
pictures,
it
is also
provided
with
a
10-microampere
self-rectifying
radiator Coolidge tube for fluoroscopic work, and may be operated
in
any position from the horizontal
to the vertical position.
The high-
tension wiring system
is of
the overhead
cable arrangement
and
is
placed
12 feet above the table.
Duplitized
films
are
used
exclusively for the work in
chest
and
gastrointestinal
exposures,
and this is reinforced
by the
use of the
752
Vol. Wll
W1KBKH— NAVAL
HOSPITAL.
FORT LYON.
double-intensifying
screen.
For this part of the work the laboratory-
is provided with six Patterson double-intensifying
screens.
Since
90 per cent of the work
done in
the. laboratory
is that of
chest examination
it has given rise
to a technique
which
has
been
found of the most practical application
to the roentgenologist
and to
the
patient.
Ordinarily
the chest examinations are
made
standing
and,
to
facilitate
this
part
of
the
work,
special
arrangement
as
regards
a plate holder or stand
has been provided, which permits of
the exposure
with only one adjustment for the tube.
This has been
a
great
saving
in
time
to operator,
and
saves
weak
patients
the
trouble of climbing upon the table.
ROUTINE
AND
SPECIFIC
METHODS OF TREATMENT.
Fort Lyon must be considered
as an ideal spot for sanatorium pur
poses
in the care of tuberculous diseases.
It has an elevation
of
a
little
less
than
4,000
feet, is about
7 miles
distant from the nearest
town, the relative humidity
is very low. the rainfall
very slight, the
sky is generally clear, the number of sunshiny days is very great, and
the nights are cool and bracing.
Through
its dairy herd, which it is still developing, it furnishes
now
the greater portion of the milk supply
needed for its patients.
By its farm products almost
all the
feed
necessary for its herd
is
supplied.
The waste from the mess halls is in part used for the feed
ing of about
300 pigs, which furnish
a not inconsiderable part of the
pork used in the commissary
department.
One drawback to Fort Lyon, which, however, it shares with manv
other sanatoria in the Kocky Mountain
Plateau
region, is the prev
alence of dust
storms
in late
winter
and
early spring,
before
the
vegetation
has started.
These
sometimes
last for a whole day : gen
erally, however,
they
are of short duration. I have
seen the air
so
thick with dust that it was impossible to see across the parade
ground.
Such
storms, while they
last,
are of positive harm to patients,
inas
much
as they
seem to have
a depressing
effect on them
and
increase
their cough.
The treatment
of the patients
is based on modern
ideas
and
con
sists mainly of good rich food, out-of-door
life, observation of
rest
hours,
and heliotherapy.
The routine methods
followed
at Fort Lyon
are
a- follows: All
patients
admitted
are placed
in
bed
in
a receiving ward
in the in
Hrmary and
kept
in
bed continuously for about
two
weeks.
While
there accurate
temperature
and pulse observations
are taken
and
re
corded.
A careful physical examination of the chest is made and re
corded graphically
on chest charts.
The urine, feces, and blood are
examined
; X-ray plates of the chest are made in every
cas« ; an eye.
ear. nose, and throat examination;
and, finally,
a dental examination
•No.8.
758
WIBBER
NAVAL
HOSPITAL,
FORT
LYON.
4
is made.
The blood examination includes a Wassermann and
a tu
bercle bacillus complement
fixation
test.
The sputum is examined
daily until
10 negative
findings are recorded,
or until one test turns
out
to
be
positive.
The
receiving
ward
is
generally
under
the
charge of one of the older and more experienced
and trustworthy
as
sistants.
After all the examinations required on admission have
been
made
and a diagnosis
has been arrived at, the case is disposed of by being
sent either
to
a lean-to where
ambulatory
cases
are
treated,
or, if
further infirmary treatment is considered
necessary, to one of the re
maining 10 wards.
This includes cases requiring further
observation
for the establishment
of a diagnosis.
Cases
considered
negative
for tuberculosis or any other disease,
after a month's observation, before
final action,
would
be examined
by a permanent
board of survey for final disposition.
All febrile
cases
are assigned
to an infirmary
ward:
likewise all
those with marked activity.
Rest periods are enforced as follows:
Forenoon from
9 to
11 for
all definitely
tubercular active
cases; afternoon from
1 to 3.
These
two periods are subject to modification by the medical
officer in charge
of the ward.
Only nonfebrile.
quiescent,
or arrested
cases
may
be detailed
for
work alM)iit the ward.
All cases of tuberculosis sleep out of doors on covered
porches,
ex
cept during very severe weather.
The wards proper are well heated :
likewise the toilets and bath stalls.
For the heliotherapy
treatment
the graduated system
of Rollie-r
has been adopted.
This line of treatment
was started
in a systematic-
manner during the summer of 1921, and the patients
took to it very
well.
It
was
begun
by
a
5 minutes' exposure
of both
feet to
the
direct rays of the sun.
On the second day
5 minutes
were added to
the exposure
of the feet
and
o minutes exposure
of legs up
to the
knees was begun.
The third day 5 minutes' exposure
from knees to
hips, 10 minutes from knees to ankles,
and
15 minutes for
feet
was
required,
etc.
After the front had
been
thus gradually
exposed
to
the sun.
the
back
was similarly
treated.
The
head
was
protected
during the exposure
by any sort of device
produced
by the patient's
ingenuity.
The object sought
was to bring about
intense pigmentation of the
body without
ac tual sunburn and any sign of reaction,
such
as fever
or exhaustion.
The slightest sign of such
a symptom
should cause
suspension of the treatment
and resumption only after disappearance-
of all abnormal
reaction.
In
a febrile
case
no heliotherapy
treatment
was instituted.
The
patients
were
required
to
wear bathing trunks and stretched
them
754
Vol. XVII
WIKBEK
NAVA1,
HOSIMTAL,
FORT LYON.
selves out on canvas
cots which were
placed
on concrete
aprons in
the infirmary
courts
or on the south
side of the lean-tos.
The cob
were only
received
during
the middle of the
past
summer
and
the
treatment
was in use only for about
two
months,
consequently
no
expression
of opinion
as to results can be given.
Other forms of specific treatment of tuberculosis formerly used but
discontinued were the following two :
The treatment
by hypodermic
injection of sodium morrhuate. which had been first recommended
by
Sir Leonard
Rogers,
lieutenant colonel, I. M. S.
When this treat
ment first become known, a number of the patients
at Fort Lyon
sent
to England
to procure the drug
and
requested
that it
be
used
on
them.
This
led
to
its
general
use
in our patients, and
at
first
it
seemed
to give promising
results.
It was given in a <$per cent
solu
tion in gradually increasing doses, beginning with one- fourth
to one-
half cubic
centimeter
of the
3 per cent solution subcutaneous! v. and
increasing
by
2 to A minims
at each injection
two to three
times
a week until
a reaction
occurred;
then after the interval of
a week
a
dose smaller than the one which
had
produced
the reaction
was
again given.
After the subcutaneous
dose of 2 cubic centimeters
had
been reached, intravenous doses, beginning with one-half cubic centi
meter, were given and gradually
increased
as before.
In some
cases
doses up to 4 cubic centimeters
were given.
In febrile cases the dose-
were smaller and
increased
more
gradually.
A
reaction
consisted
in a rise of temperature; occasionally
a slight hemoptysis occurred
No harm seemed to follow such reaction.
The patients were very en
thusiastic and reported daily improvements.
Clinically there seemed
to be improvement.
In some cases there was an increase of weight:
in many cases gastric symptoms
subsided
; some febrile cases
becanit
afebrile.
Many
reported
an
increase
in expectoration during
the
first weeks, followed by a decrease of cough
and expectoration.
After following up these cases for months
to a year, the consensu*
of opinion
was that the improvement of symptoms
was not
actually
due to improvement in physical signs, for the area of activity showed
no sign of improvement.
No ill effects, on the other hand,
followed
the use of the drug.
The effect of the treatment
observed
seemed
t<>
be more psychic than actual.
The
patient felt that something
wa-
actually done for him and he felt encouraged.
The treatment
by medicated
sprays was likewise tried for
a
period
and
abandoned.
The use of calcium chloride in the symptomatic treatment of vari
ous complications
of tuberculosis
met with
partial
success