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1111------ - VOL. XII N0.4 UNITED STATES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT 01\ ISIOS OF PU BU CATIONS COMMA'NOER J S TAYLOR, MEDICAL CORPS U S SA\Y IS CHARGE OCTOBER, 1918 ( QilARTERLY) W,\SHINGTON CO\'f:RNMENT PRINTING OFFICF. 1918 , VOL. XII no." UNITED ST A TES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PUBLICATIONS COMMANDER J. S. TAYLOR, MEDICAL CORPS, U.S. NAVY IN CHARGE OCTOBER, 1918 ( QlJARTERL Y) WASHINGTON GOVERNMENT PRINTING OFFICE 1918 NAVY DEPARTME:XT, Washington, March go, 1907. This UNITED STA'l'ES NAVAL MEDICAL BULLETIN is published bv direction of the department for the timely information of the Me<li- cal and Hospital Corps of the Navy. NOTE. TRUMAN H. NEWBERRY, Acting Secretary. Owing to the exhaustion of certain numbers of the BIJLLETIN and the frequent demands from libraries, etc., for copies to complete their flies, the return ot any of the following ls,ues will be greatly apprecintecl: Volume X, No. 1, January, 1916. Volume XI, No. 1, January, 1917. Volume XI, No. 3, July, 1917. Volume XI, No. 4, October, 1017. Volume XII, No. 1, January, 1918. SUBSCRIPTION PRICE OF TRF. B1JLJ.ETIN. Subscriptions should be sent to Superintendent of Documents, Government Printlng Office, Wnflhlngton, D. C. Yearly subiicrlption, beginning January 1, $1; for foreign suhscrlptlon nrld 25 cents for postage. Single numbers, clomN~tic 25 cents; foreign, 31 cent~. which inclul.lefl for· eign postage. Ex~han~e of publications will he extended to medical aml scientific orgnnlzn· tions, societies, laboratories, nncl journals. Communications on this «uhject should be addressed to the Sur~eon General, United States Navy, Wa,111~­ ton, D. 0. II TABLE OF CONTENTS. Page. PREF ACE............................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII FROXTISPIECE: A ward in the old Ilotel Dieu of Paris. SPECIAL ARTICLES: RBPORT ON BEA.RT MURMURS IN RECRUITS. By Lieutenant Commander F. J. B. CORDEIRO, Medical Corps, U. S. N. (Ret.) ••••• ••• ••••••••.•.•. •.••••••••••••••••••••.••••.••••• 577 PHYSICAL DIAGNOSIS, PREVENTIVE TREATMENT, AND RECONSTRUCTION lN RBLATION TO CARDIAC AND TUBERCULAR DISEASE. By II. s. AN1'ERS, A. M., M. D............ ............ ... .... ....... 584 ATHLEncs AND THEIR RELATION TO WAR. By Lieutenant D. F. LUBY, Medical Corps, U. S. N.. .. .... ....... .... 592 lliYORANDA FOR MEDICAL OFFICERS WHEN A amp IS CO:llMISSIONED AND SUBSEQUENTLY. By Captain A. FARENHOLT, Medical Corps, U.S. N. .•.......•.......• 601 E~'DOCRINE lUNIFESTATIONS. By Lieutenant S. G. STRAUSS, Medical Corps, U.S. N................. 609 CLL'iICAL STUDY OF ONE HUNDRED CASES OF DENGUE AT ST. THOMAS, V. I. By Lieutenant (J. G.) F. F. LANE, Medi cal Corps, U. S. N.......... 615 EPIDIDU{OTONY IN MILITARY SURGERY. By Lieutenant (J. G.) L . HERMAN, Medical Corps, U. S. N.......... 623 EPIDF.lUOLOGY OF CEREDRO·SPINAL FEVER AT NAVAL TRAINING STATION, GREAT LAKES, ILL. By Lieutenant J. T. SHORT, Medical Corps, U.S. N........... ... . . . . 627 SPINAL FLUID IN RELATION TO ACUTE INFECTIOUS DISEASES OP TIIE CE~RAL ~ERVOUS SYSl'EM. By Lieutenant D.R. IlIGBEE, Medical Corps, U . S. N.............. . . 646 HISTORICAL: T~ HOTEL DIEU OF PARIS........................................... . . 653 EDITORIAL: A C. ... REER.- FUNCTIONAL AND ORGANIC LESIONS.-WHERE THE PSYCIIIA- TRIST PAII.8................................ .......................... 693 CLIXICAJ, XOTES: DISLOCATION OP CARPAL SEMILUNAR BONE. By Commander R. E. IloYT, Medical Corps, U. S. N............ . . • . . 701 AJiEURYSl! AND RUPTURE OF THE LEFT POSTERIOR CEREBRAL ARTERY. By Lieutenant CommanderJ. J. A. MCMULLIN, Medical Corps, U.S. N. 702 REPORT OF A CASE OF CAVERNOUS HEMANOIOMA. By Lieutenant Commander C. W. SMITH, Medical Corps, U S. N..... 704 REPORT OP A CASE OF ACUTE BILATERAL DACRYOADENITIS. By Lieutenant (J. G.) J. V. CONNOLE, Medical Corps, U . S. N..... •. . 706 m IV TABLE OF CONTENTS. Vol. Xii, CLINICAL !\OTES-Continued. P.\RALYSIS OP JdUSCULOSPIRAL NERYE l'RO:.I PRESSURE OF RIFLE ~TR \P wWLE nm:rn. By Liculen:mt J. <'. ADAMS, Medical Corps, "C". S. N................. 70, CuT..L'\F.OUS DrPHTlffR!.\ OF TnE FOOT. By Lieutenant (J. G.) J .. J. KEEG.\N, Medical Corps, U. f;, X........ . 709 LAROE CALCCLUS R&MOVED FRO?ll CO;\J:.JON DUCT. By Lieutenant Commander R. G. LECONTE, Medical Corps, 1.J. S. X. 710 CIRCUMCISION IN THE PRESENCE Ol' CIIANCROID. By Lieutenant (J. G.) J. S. VAN Winkle, Medical Corps, U. ~. X..... il2 PERSISTENCJ' OF 'J'JlE 'l'l!YROOLOSSAL DUCT. Bv Lieull·nant B. n. P.\Rrsu, ~Iedical Corps, -C. S. :N.... ....... .... . il3 RUPTURE OF l'OPLTTF.\T, ANEURYS~I 'FOLLOWING THE ADMINIS'l'RATION OF SALVARSAN. By Lieuto11a1\t. F. J. DEVER, and Lieutenant R. S. BOLES, Medical Corps, U.S. N..................... .......... ... .......... ..... i15 PERICARPIAL lWJIUS!ON. By Lieutenant (J. G.) J. "I. PERRET. ~fedical Corps, TT. 8. X........ 717 REPORT OF A CASE OF SYlll:METRICAL ENLAROE:MENT OF TllE SALIVARY GLANDS. By Lieutenant. R. S. BOLES, l\redical Corps, U.S. :N................ 719 DE!H>RITIC CALCULI IN TUE KIDNEY. By Lieutenant G. G. Ross, Medical Corps, U. 8. N................. 7!!0 FOREIOX BODY IN BRONCHUS. By Lieutenant. E.W. GouLD, Medical Corps, t". S. N... ... . .. .. . .. . . 7!!1 A CASE OF MULTIPLE SEBACl:ous CYSTS. By Lieutenant G. A. GRAY, Medical Corps, U.S. N.......... .. . . .. . 7:?2 .A CASE OF U!l.'DULA NT FEVER. By Lieutenant Commandor J.C. PARHAM, Medical Corps, U.S. N... 723 PROGRESS IN MEDICAL i:::cIENCES: GENERAL MEDICINE.-Treatmcnt of malaria.-Diagnosis of thyroid dis- ordere.-The blood plasma. and the kidnoya.-Sensitized vaccines.- X-ray diagnosis of pulmonary tuberculosis.-Trcatment of epidemic cerebra-spinal meningitis.- Treatment of Graves' disease by corpus luteum.-Enlargcd cervical lymph nodes............................. 725 SunGERY.-Purgation before operation.-Painful amputation stumps. Abdominal solf-protcclion.-Typhus iever.-Tonsillectomyin tho tubcr- culous.-Prostbotic a11plinnces.-Surgical use of human fat.-Prophy· !axis of typhus.-Transfusion for typhus.-Treatment of itch.......... 742 HYGIENE AND SA)'llTATION.-Swi.m.ming pools ....•........ - ... - - . - - . . . . . ;5; PATHOLOGY, BACTERIOLOGY AND ANIMAL PARABITOLOGY.-Diphtheroid organisms.-Flora of male genitalin.................................. i59 MILITARY, LEGAL AND I\'.DUSTRIAL.-War and psychology.-Thc Jew in America.-Relalion of drink to work and health.-Damagc by the air hammcr.-Yencrcal prophylaxis.-Vital statistics of the Philippines.- Statistics of Japanese Navy.......................................... 76".! REPORTS: REPORT OF 140 CASES OF PNEUMONIA. By Lieutenant. Commander L. W. McGumE, Modiral Corps, U. S. N. 7i5 REPORT OF 100 CASES Ot' PNEUMONIA. By Lieutenant F. J. DEVER and Lieutenant R. S. BOLES, Medical Corps, U.S. N..... .............. . ....... ........................ 7i8 EMPYEMA CO:MPLICATING PNEUMONIA. By Liou tenant J. J. TOLAND, Medical Corps, U. S. N............... 783 ,:>o. .f. TABLE OF COXTEXTS. v REPORTS-Continu<'d. P~ TBEATllE-.;T OP E:\!PYE~A. By I.ieutenant (J. G.) n. c. °WILLIS, ~fcdical Corps, u. s. x...... .. .. 786 OPERAn-.;o U)llTS AT THE FRO)o!T. By Lieutenant Commander R. G. LECOXTE, Medical Corps, U.S. N .. 787 PI.AGUE Di C!IlXA AND THE FAR EAST. By Lieutenant H. M. STENHOUSE, Medical Corps, U. S. X.......... 789 REUEP WORK AT GUATEMALA CITY. By J,ieutcnant S. M. 'fAYLOR, Medical Corps, U.S. N............... 796 As EPIDEllIC OF 3-DAY FEVER. Dy Lieutenant D. FERGUSON, Medical Corps, U.S. N..... ... .. . . . .. WO A DE.HU FROM ANTHRAX. Dr LicutenantH. B. LEIOIBERO, Medical Corps, U.S. N....... .• . . 801 IlAL.·ISTIDIU'C COLI IN THE VIRGIN ISLANDS. By PhnrmacisL('l'.) II. RYDEEN, U.S. N....... ....... . .... .. ...... 802 TETA:-OUS INFECTION. Dy Lieutenant Commander J unsoN DALAN o, Medical Corps, U. S. X . 802 UNITED ST.ATES XAVAL ~fEDICAL SCHOOL LABORATORlE$: .J.nnmo:-is TO THE PATHOLOGICAL COLLECTION.......................... 805 BOOK XOTICES. ...... ..... ... ................... ................. ..... 805 AXXOl'XCE~fENTS.. .... ........................ .................. ...... 813 XOTICE TO SERVICE CO~TRIBUTORS. ... ............. ............. . 815 IXDEX.... .... .. ... . . .. ... .. ......... .. . . . .. ......... ... . .. ............. Sli PREFACE. 'fhe publicntion nnd issue of a quarterly bulletin by the Burenu of Medicine and Surgery contemplates the timely distribution 0£ such information as is deemed of value to the personnel of the Medical Depar1ment of the Navy in the performance of their duties, with the 11Jtirn:ite object that they may continue to advance in proficiency in rc::-pcct to all of their responsibilities. It is proposed that the NAVAL MEDICAL BULLETrn shall embody matters relating to hygiene, tropical and preventive medicine, pn- thology, laboratory suggestions, chemistry and pharmacy, advanced thcmpentics, surgery, dentistry, medical department organization for battle, and nil other matters of more or less professional interest ancl importance undei· the conditions peculiar to the service and pertain- ing to the physical welfare of the naval personnel. It is believed that the corps as a whole should profit, to the good of the ::crvice, out of the experience and ·observations of the indi\idual. There are many excellent special reports and notes beyond the scope of my annual report being sent in from stations and ships, and by communicating the information they contain (either in their entirety or in parts as extracts) throughout the service, not only will they be employed to some purpose ns merited, but all medical officers wiH thus be brought into closer professional intercourse and be offered a means to keep abreast of the times. Reviews of advances in medical sciences of special professional intcrc::it to the service, as published in foreign and home journals, will be given particular attention. While certain medical oilict'1~ will regularly contribute to this work, it is urged that all others cooperate by submitting such abstracts :from the literature as they may at any time deem appropriate. Information received from all sources will be used. and the bureau extends an invitation to all officers to prepare and forward. with a new to publication, contributions on subjects relating to the profes- sion in any of its allied branches. But it is to be understood that the bureau does not necessarily undertake to indorse all views and opinions expressed in these pages. w. (). BRAISTED, Surgeon General United States l'itary. VlJ > I NTERIOR VIEW OF A WARD IN THE HOTEL DIEU OF PARIS IN THE SIXTEENTH CENTURY. Facsimile of a picture at the head of indulgences sold by the Archlshop of Bourees (1521-1525) for the support of the H6tel Dleu of Paris. (Reproduced through the courtesy of H. Champion, 9, Quai Voltaire. Paris.) U.S. NAVAL ~IEDICAL BULLErrIN. Yot. XII OCTOBER, 1918. No. 4. SPECIAL ARTICLES. REPORT ON HEART MURMURS IN RECRUITS. By .T. F. B. Conm:rno, Lieutenant Commander. :\!. C., United Stales Navy (net.). Preliminary.-By the theory of probabilities it is proved ihal the incidence of any particular event in a sufficiently large number is a fixed quantity. Thus there is a center of American population geo- graphically fixed, an American height and weighl, etc., which do not Yary over long periods. It was Qnetelet, one of the founders of onr modern system of life insurance, who showed that in the constant French population the number of even unusual and rare forms or suicide remained constant. The average yearly temperature of any point upon the earth's surface is a constant quantity. This constancy depends upon the fact that the average conditions are the same from year to year. If, however, some average which has remained con- stant for a long while, begins to change, either rapicliy or gradually it must be from some deep-lying or general cause. Thus the incidence of consumption for the total population was some years ago prac- tically constant, while recently it has been showing a continual de- crease. This we lmow to be due to active modern methods for its prevention and cure. Likewise the incidence of heart disease for the total population is gradually increasing, but we clo not as yet lmow the reason. It has been known for a long time that lesions of the rnln~s of the heart are in the great majority of cases, due to the poisons of certain acute infectious diseases-rheumatic (micrococcus) fover, i::cnrlet feYer. typhoid feyer, mensles, diphtheria, etc.-and almost inYariably it is the left heart which is affeded-mitral and aortic lesions It has been the experience and opinion of the profession, until recently shared by the writer, that lesions of the right heart were compara- tfrely rare. Thus Satterthwaite states that l<>sions of the pulmonary rnlves are only one-tenth of all valve lesions. He says that his statis- tics are <leriYecl from his personal cases. private and hospital. Such Rtatist ics. however, are of little value in giving a clue as to the in- cidence among the population, since the cases going about their usual vocations and nnconscions of any heart affection greatly ontnnmber those tlrnt tH'e obliged to go to a hospital or to corn:;nlt a physician. In 188G, the writer was examining one hundred or more men a 577 578 CORDJ-:IRO-IIE.\.RT IIIUR;\lCRS D< m:CRUITS. Yul. XU. dny. just as he is doing now, and his experience then was thnt pul- monary murmurs were rather rare. It is not merely a matter of memory, since the statistics nre at hand. H~ made a compilation of :,ome ten thousand cases, of which possibly he examinecl a third. where the causes of rejection and the :aumber of such cases were care- fully tabulated. The valvular lesions were not sepo.rated but all in- cluded under the head of valve disease. The proportion of such cases was about the same ns that found for endocarditis (left-heurt disease) to-day. The inciclence of these acute infectious disea~es for the total population is the same to-day as it was then, and the pro- portion of heart complir:~ntions in these cases is practically constant. as it should be by the theory of probabilities. The probability is therefore strong that the proportion of pulmonary lesions nmong those tabulated was small. This examination of ten thousand cases was published in the report of the Surgeon General for 1887. In it, the growth curve, both for l1eig:1t and weight, was cnrefolly plotted. and it is with little doubt the normal growth curve for .A.mcricnn males between the ages of 14 and 30. It should be used in exmnina- tions and permissible deviations should be taken from this curYc-not from the present tables. 1-'ulMonary murmurs.-The writer has recently examined pcrson- ::i ~ly some thousands of app1icrmts for the Naval Reserve. It w.1s with some surpri$e therefore that he found that pulmonary mur- murs far outnumbered all other forms of murmurs-perhaps ten to one. When coming upon something out of the ordinary it is necec;- sary to go over the ground very carefully and especially to irnnrd against errors. The ordinary experience of mankind is something like the law of the Medes and Persians which altereth not. When examining aortic or pulmonic murmurs, careful examine.rs always uo so on full expiration. There are indivuuls (obese onei:;) in whom on full inspiration it is impossible to hear any heart sounds at all, and to listen to them it is necessary to require full ex- piration. Pulmonic and aortic murmurs are heard louder on expiration than on inspiration, while generally a m'itral murmur is heard be . ..;t at mid inspiration-neither extreme inspiration or expiration. It may hn.ppen therefore that an examiner may not hear a pulmonary mur- mur, but when requested to listen at full expiration, he always finds it very loud and distinct. After finding it he usually has no trouble in following it through the whole respirational cycle, though of course it is fainter at inspiration. The reason for this is that nt in- spiration the edges of tho lungs cover both the pulmonic anu nortic valves with a considerable thickness of lung tissue and air cells are poor conductors of sound. Further the" roots" of the lungs are not immobile, but on each inspiration the pulmonary artery with its :\O. 4. CORDEIRO-HEART )!UBMUBS IN RECRUITS. 579 ri!!ht and left branches. is drawn away slightl~· from the sternum. ,\hile on expiration it is pushed forward again. Tho pulmonary ntery i::: therefore appreciably nearer to the chc,;t wall and the stetho~copc on cxpir.ttion . . .:\s nu illustration of this cla:,S of pulmonary murmurs let us tnke the following actual case. An ordinary perfunctory exnminntion (tho once over) reYeals a distinct pulmonic direct murmur and nlso. though not so distinct, an aortic direct and a mitral regnr!!itant. Thi;; case is not typical becnuse in most of the cases of puhnonic direct. there arc no other murmurs. On expiration the p11lmonic murmur is very lond-rough a,ncl rasping. It sounds like a c:aw ruttin!? through n board. The man is asked, "Have you eYcr clone :my running?" 'Ihc question seems absurd, as any one who has done any athletics himself, or been among athletes, would recognize nt once his typical greyhound build. The man smiles as "ell a two frie.nds who have come with him. Ile proves to be a crack two-miler: well kno'rn among the sporting fraternity. There is marked h~ pl'r- trophy and some dilatation. This is not typical of these cu~e<:, since usunlly hypertrophy is not marked and dilatation may be difficult to detect. This is because the majority of these murmurs arc in the initial st:\gl'. These mnrmnrs are rough~ as direcl murmurs u::.nally nre: rcgurgitant murmurs are soft. Fifty sound hearts may pn,,s in re iew and thl'n another direct pulmonic. This time it is a cham- pion bicycle rider; distance 10 miles and upward. :Murmur v~'r.r muc i like the other, but not quite so lond; no other 'nlws inrnlYecl. Cnsc semns like a preYions stage of the former. To make sure thnt the:'e murmurs were facts and not a theory, I refcrrcll a. number of them to another ('Xamincr. He pronounced them all Yery 1011<1 and distinct. It is n :foct then that a very appreciable portion of our yonng men have pulmonic direct murmurs and that these mur- mur"' are perhaps Len tin\es ·as frequent as all oth ·r murmurs com- bined. The cause of rejection was always noted simply a~ heart murmur, not heart disease or valve disease. This "as because the murmur was a fact, while other things might be a matter of opinion. It happened in a few cases that applicants had already been ac- cepted by the medical examiners of the draft boanls and had souuht to ernde the draft by entering the "Na Yal Reser' c.5. They were Ye11· much perturbed and promptly brought certificates from their fam- ily physicians that their hearts were sound. These opinions were probably sincere and due to the fact that they had not taken the precuution to listen during expiration. There ''"ns one cn!'c, howeYer, where n heart specialist wrote to the draft board that his client ht1d heart disease nnc.1 when the board would not cxcus.! him, gave him a letter for the Kn ml Rcsenes, saying that his heart was sound. As a mutter of fnct he did hnve heart disease and wns rejected. 580 CORDEIRO-HEART MUR~iURS IX RECRUITS. The po!'sibility of the"'e murmur::. being functional wa~ l':ll'l'f111lv consi<lered. So-called functional murmurs are usually sof l and heard o..-cr the apex in connC'ction with such conditions as anemia ' chlorosis, acute loss of blood. etc. They are fngitfre and difficult of detection, two examiners o-f«in disagreeing as to their exi-.tence. The pulmonar~· direct murmurs were permanent, as was pro,·ed by subsequent examinations. Rejected candidates often insisted that thC're was nothing the matter with their hearts anrl sometimes were fortified by physicians' certificates. They insisted that the trouble found was beranse they were nervous or had been smoking or <ll"ink- ing exccssiYely. It may be remarked that no rejections wen' made for functional disturbances snch as palpitation, bra<l,Vcardia. et{'. Such casec; were i1wited to present themselves for reexamination as often as they wished nnd the murmur vrns always fonml mwhanged in character or loudness. Some o.f the petty officers in chan:re of substntions would Rend n man rejected for heart murmm· a !'el·ond time, evidently believing it to be something temporary or a fod on the part 0£ tho examiner. In eYery case the npplicirnt "·as identified more ensily and certain1y by his heart. murmur than ho wonld ha,·e been by a finger print. Cases examined three months afterwards were unchanged. In some inclfricluals it is possible that the pulmonary urte1·y may touch the surface of the sternum on extreme expiration. or e\en be pressed against it. The mechanical pressure wou1cl then explain the m11rmur. But the murmur could be heard throngh the c·o1uplcte respirational cycle, fainter of course, at inspirati011, and \\"hC'n the supposed pressure was removed the murmur should ha.Ye C"easecl. which was not the case. The pulmonary artery rises Yery superficially from the top of the ventricle and is onl.v 2 inches long. sometimes less. It bifurcate: into two branches, right and le.ft, which are almost at right :rn!!les to each other. In foetal life, when the lungs are solid, the clnctn.:; nrteriosus shunts the b1ood from the left pu]monar:v branch iu o the descending aorta. uch a thing as a persistent ductus a1·tcrio~us or a patent fommen ornle are inconsistent with prolonged r r and can not be considered in these cases. but conceivably the rem tin- of the duct might lea\·e n rough tubercle within the left pnli ion:n·y branch. The suclclen hifurcation o.f the blood ~tream and thC' remains of such a tubcrc]e might conceirnbly ruffie the current sum,·il'ntly to cause a murmur. This, howeYer, wonld not explain the 01 c111Tnnce of the m11rrnur so preponderatingly among athletes. The rongh rasping sonnd is caniecl both up ancl down from the valve and is not necessarily loudest over the Yalve. In ... omt' cases where the sound is heard only just OYer this YalYe, which i~ tlw rno.:;t superficial of all the YalveR. and is not Yery lon<l, I hnn• l'lllll'lnded l\O. f COHDI-:IRO-HEART ::UUR:iIURS JN RECRUlTS. 581 th:it it conic! be :tcl'onntcd for by the re:,btance to the current offered hv the corpo111 nrantii. buch cases are not rejected. The general irn- p;·t•:-sion ~nin<'d from the:,e ~ouuds i::> that thl',V are not due to any Je.-.ion of the ::;emilunar 'a1Yes them,,,eh·es, but rather to a con"triction of the , entriculo-ttrterial orifice ·which may extend lo some distance 011 both :-ide-. of the vah·e. The majority of the pulmouic mumrnrs occur among tlthletes and I b:we de-.i!?"llatetl them as athletic murmurs. They are found chiefly 8111011!! 1·unner:s, though they occur in all forms of a.thl<'tics where there j ... a steady, prolonged grind. If a heart be examined after a .Mnrallwn. it will be found lo be acutely dilated. Percn<:sion "'ill cu:-;ily ~ho'' that the borders of dnllness a.re markedly extended be- yoml the norm1tl area. The best way to demonstrate this is to mark ~ut the a 1·ea of cluDnes::; "7ith nitra.tc of siher before the race and dircrtl~· :iftt'r. It ''ill be found that it will take senral hour:; before the heart retracts to its old area. Thn strain of a race is thrown nlmo t wholly upon lhe right heart. The left heart participates to a much le::.-:. degree. The call is for bloocl nnd air in the ln11gs and the ri:?ht heart endeaYors to supply a double amount of the fonncr. The pain in the side is a symptom of this abnornrn.1 effort. ~\..nother snb- jccth·e :-ymptom is the agonized look on the face of a runner as he doc ... the last 75 yards' sprint after a. long race. The Greek word 'a·:wvl2 means both agony and an exhausti\'e contest. In the ancient Olympian gitmes a foot race or a wrestling bout was called ~.'·f(r)'lf.7.. It j, :,ignificnnt that no man ever wins a Marathon twice been.use his heart has been permanently injured. The first Marathoner is said to haYo dropped dead at the finish. It is likewise significant that the career of all runners is usually short. ... \.ft er maJ,ing their best m111·k,.. they rapidly decline and they nc1er " come back.'' For Yarious reasons nearly all of the athletes around Boslou, both profe. ... ,,,ional nnd nmateur, haw sought enlistment in the Xnrnl Re- scrre. Some said it was because of their great lon~ for the :-ea; others becau,.e they thought it safest. This undoubtedly accounts for the !!Teat nu111ber of pulmonary murmurs found. Profes-.ional coaches, of com~e. know nothing about the heart and medical athletic nch-i~ers nm not heart specialists and usually incapable of makin~ a 1liscrim- inating diagnosis. Otherwise the conditions of which I hn,-e written woul<l ha.Ye been discovered long ago and this report would not hnve been necessary. f>atlwloyy.-'fhe pathological history of thes~ cases :;eems to be n:-; follow:, : At first, after each abnormal dilation. the hen rt con- tract,.. t-0 its normal size, or nearly so. But n phy,;iological hyper- troph.v ~ ccompanies these efforts and the pulmonary orifice. instead of ·contra ting to its former dimensions, cYentually O\·ercontracts and heeomes slightly narrowed. This may be furthered by the de- 582 CORDEIRO-HEART ::'IIURMURS IX RECRUITS. velopmcnt of new muscular tissue about the orifice. In a whole series of cases it is possible to follow the process from beginning to en<l. The first sign is the development of a pulmonic direct murmur which~ as we have said, is probably due to the contraction of th~ orifice. This murmur may be slight, though rough, and hypertrophy and dilatation may be difficult to detect. Later the left heart i ... in- voh·ed mechanically and we hase mitral and aortic murmurc:, ns in the case of our crack 2-miler. In only two cases was a pnln1ouary regurgitation found associnted with the direct murmur. If veteri- narians were capable of ausculting a horse, which usually they are not, precisely similar conditions would be found in raco horses. lt is a frequent occurrence for horses to <lrop dead upon the truck, both while racing and practicing. Outside of the few cases of anenri..,m, these deaths are due to the " athletic heart." These murmurs, while occuning chiefly among runners, were alSo found in footballers, basket-ball players, boxers, wrestlers, and among rowing men. Baseball players seemed to be least affected. L\ hammer thrower was found to have a perfectly sound heart. Tho above were mostly adults, but it must be remembered that eYcry secondary school nowadays considers it necessary to have a complete athletic system of its own, exactly as in a college. If it doP.s nut have its track team, its rowing crew, its football team, its b·lc::cbnll team, and its professional coach it is not up to d<\te. But the con- tagion does not stop there; it spreads to all classes and conditions of boys, even to the slums. Many of these boys, undeveloped and im- perfectly developing, without proper food at home, and often with- out a middny meal; practice assiduously every afternoon on a field. While their anemic systems am struggling with the burtlen of the rapid growth after puberty, they subject their hearts to the a<ldcd strain of the track. Of late years it has been n common sight to see a group of half-naked. men and boys, mornings and evenings, making their painful way over the streets of our suburbs. Once every year a large part of the population of greater Boston distributes itself o\·er 26 miles of highway to watch the agonized faces of some hundred contestants while they are ruining their hearts. Lastly, we must speak of another class of pulmonary direct mur- murs, which, while indistinguishable clinically from athletic mur- murs, have been found lc!"s often, and present a picture of their own. It seems that these cases can be attributed to an incoorclinatecl de,·cl- opment of the great vessels relatively to other parts of the body. I have called them, tentatively, hypoplastic murmurs, though. of course, hypoplasia of the great vessels is a condition which can only be diagnosed upon the autopsy table. They occur only among tho poorer classes and seem to be clearly the result of insufficient nutri- CORDEIRO-HEART MURMURS IN RECRUITS. 583 tion. There is usually a weedy growth in which the nutrition ~ro:- to be expended 'vholly in increasing the length of the body while the other part~ remain stat.ionary-notably the great vessels. The rule in such cases, to which there are of course exceptions, is that the subjects are very much under weight for their hcight-20 to 40 pounds underweight. Their complexions nnd skins arc pasty and pimply, in marked contrast to the clear skin of health, in which specimens there are neYer heart murmurs. Here is a typical picture: Height, 6 feet; weight, 40 or 50 pounds below normal for height; skin, sodden; chest, narrow and barrel- shnpeu; face, dull and apathetic; intelligence, subnormal; reflexes, slow: thinks and answers slowly; very loud and distinct direct pul- monic murmur; very o:ften1 also, teeth and vision arc defecti ,.e. What us to prognosisi These runners usually ask if they haYe any- thing >cry serious. They are told that their condition is not serious unles-: there is marked hypertrophy or other valYcs arc implicated, but all are always advised to stop running and all gruelling contests. The affection is not considered a lesion of the semilunar Yah-es, which are probably in no way directly affected, but rather a de- formation of the orifice. But the murmur is not functional, as the term is usually understood, since it is permanent and probably rep- resc.:nts a definite anatomical (pathological) condition. Its direct influence on the duration of life is probably slight unless the causes which produced it are persisted in. But no surgeon, after hearing one of these loud murmurs, would be willing to anaesthetize the subject for an operation "de complaisance," or if he did so, it would be only with the greatest precautions. Where an operation was im- pcmtive, the patient would experience a danger which would be nonexistent i£ his heart were sound. ·The importance 0£ the ttbove discussion from a militnr~· point of view must be evident. "\Ve shall assume that all the points made have been established, but the fullest investigation is desirable and necessary so that all possible doubt and mistakes may be cleared up. Having examined recently a large number of athlete:;. professional and amateur, the question occurs to the writer whether they are not of distinctly less nlue from a military point of view thnn the n,·er- nge normal man. It seems that this must be answered affirmatively. It may be thnt one of the reforms springing out of this wnr will be-not the abolition of athletics. but a revision of our present insane athletic system. Physical exercise from a recreational and hygienic point of view is necessary, bnt bP.yoncl that point is a waste of time and may be injurious. Track athletics among boys is criminal, nnd among their cldel's is of no value to the participants or the commu- nity. but on the contrary tencls to spoil what would otherwise hnve been good military material. The Loxer who remains in a comatose 584 AXDERS-OARDJAC AXD TI;BERCULUl DISEASE. condition from .1 minutes to an hour. or who suffers a hrmorrhn!!e into the brain. does not improYc his body or his mind. but in l'cbut- tal it may he sairl that he usually has so little mind to start '' ith thnt any alteration is of slight importance. It may be that onr institu- tions of learning, instead of turning out half educated foot-ball hrroes will deYelop mental athletes, and it will be recognized thnt the mind is of much more imporhnce than the bod.v. Finally the writer would sny that he is nb,,olutely without pr<'juclicc in these matters. Ile is not against athletics per se, but only against those foolish and Yicious forms which can be clearly proved to be in JUrlOUS. PHYSICAL DIAGNOSIS, PREVENTIVE TREATMENT, AND RECONSTRUCTION IN RELATION TO CARDIAC AND TUBERCULAR DISEASE. By II. S. ANDERS, A. ~I., ~. 0., I.llt<! Professor of Physical Dlugnos!s, )led!co-Chlr11ri;lcal Collrge, Ph!ludr!pWa. We must recop:nize the fact. from recent clinical obscrrntion rnd statistical information, that pneumonia is the overwhelming ·cute disease of modern incidence and prevalence. The rapidity 0£ de- velopment 0£ the physical si~ns, however, renders its diagnosis com- paratively easy and confirmatory of its symptomatic onset. The in- herent difficulty and seriousness of the diagnosis of incipient ~igns of heart disease an<l pulmonary tuberculosis stand out essentially be- cause of the Yery uncertainty, insidiousness, variety, and obscurity of their earlier manifestations. The tuberculosis problem is stupendous; its persistence and per- vasiveness, like poverty, is ever with us with convex prominence. Of all the diseases o.f infection and chronicity it is the mo<.:t co- lossal burden both of civilized society and humanized science: ue- cordingly, the lifting of it may confer the most colossal benefits: or its loading down may result in the most colossal blunder in blight- ing and blemishing the contiguous races of humanity. It is a paradox, for it is at once simple and complex; simple in the known elements and principles of causation, propagation, mor- bid processes, recognition, and prevention; complicated imm" 1~ely in the multitude of facts and the matrix of actions, interactions. in- fluences, and correlations of subtle and inevitable forces; compll'X factors of heredity and environment, 0£ predisposition, and eom- municability, of pathology and differential diagnosis, of immnnity and climatology, of sociology ttnd therapeutics. Essentially, tuberculosis represents the pathologic panora111:1 of n tremendous battle, between the tender and tired body and the tu- bercle bacillus. AXDI-:RS-CARDL\.C AND TUBERCULAR DISEASE. 585 Tho problem is in course of solution. The great world wnr against pru58unhm1 nnd P:m-Germanism hns added but another phase which nrnY compel factoring and transposing anew; nu<l perforce elernting the contiugency to tho nth power. I suppose it will be granted freely and uniYersally that no two organ:; are so vitally important in tho sifting process of phybi.cnl esnrnination as tho heart and lungs. Already the cardio-rnscular and tuberculosis commissions have done a largo work in the classi- fication and estimation of data pertaiillng to these organs as ex- amined in registrants for the Army and Navy service. The principle of the detection of disease in its incipiency pre- supposes tho preparedness of diagnostic acumen and efficiency. This we all know and believe; it is the magnitude and meticulousness of the problem and modes of application that call for a decided em- phasis and renewed study in view of the naval and military, as weU as economic and industrial, situation and stress of the times. We look for the best fruits and largest benefits of prevcnti\'e medi- cine in tho preservation of health and vigor, the promotion of re~rve und endurance, and the prolongation of life by just this factor of the prompt and positive discovery of early morbidity; of the fullctional derangement before the organic degeneration and disaster; of predisposition, whether inherited or acquired, before implantation, aggra.rntion, and complication. While it must be admitted that in the broad approach to diag- nosis mrious aspects of morphology and symptoms must be tuken into c:1reful consideration, at the same time it must not be forgotten thnt no balanced judgment or sufficiency of precision can be attained without a skillful technique and rational interpretation of the phys- icnl signs. To quote from the preface of my textbook on Physical Diagnosis, we must constantly a.void doing that which medical stu- dents are particularly apt to drift into, namely: "To exhibit a super- ficial nn<l hasty zeal and endeavor to get at the physical signs some- how, but without methodical and patient procedure and practice; • • • jumping at conclusions from insufficient data and ineffi- cient correlation." If this article may be assumed to have any suggesfo·e value, it will most probably be in emphasizing therefore the more de- termining and discriminating physical signs rather than the re- viewing and repeating of merely symptomatic salients. In the first place, I should like to advocate the adoption of special examin- ing officer::; respectively for heart cases and tuberculosis suspects. The cardiopathies.-Recently we have had a renewal of a. -very serious discussion concerning the perplexing problems presentccl to tho medical examiners of prospective candidates for the Army and 700!!"- lS-~ 586 AXDERS-CARDIAC A:XD ITBERCULAR DISl::.\SE. \"vi. ~II. X:n y. ay.; the editor of The Journal of the American ~fedical Asso. c:atwn (.Feb. ::?~1 HHS) : c: What constitutes proof of disqualifyin!! cardiac conditions? Of course. in most instances, the answer is clear: e'en on closest scr1~liny. the heart is free from any sign or l"ymptom of clisea:-1~. or, on the other hand, the history and examination 1-e\eal unmistakable cYidencc of organic mischief in nh·e or nrnsde. The· more t_:w::;tionahle cases are those in which the rate, rhythm: or ,izc arc not according to the generally accepted standnr<l, or t1 O'il' in which an endocardial murmur arrests attention.'' Sympto i-- of heart inefficiency should neither be minimized or glossed o,·er nor. on the other hand, magnified to the point of needless and unjust re- jection. "Common sense, experience ancl a sizing up o:f conditions in their entirety may here reach the correct conclusion 1hat would he missed were one 1.o rely on 1.he presence or absence of mnrmnr. the pulse pressure, the rhythm, the rate before and after exertion. or the instrumental record." The recognition of the so-called hemic and accidental mnr nuG. such as the carclio-rcspiratory, need not preclude the acceptnn ·c of a registrant. other things being equal. We may also agree with Babcock and ~fockenzie thnl not a few clear cnscs of enclocardinl murmur of organic YalYular origin may be passed into service with- out any slack in efficiency or endurance. And again, ns Fisk hn<= ver~· properly pointed out, there hns heen such a large pcrcenturre of apparently acceptable life-insurance risks that hasc encle(l ,]j,_ nstrously, that the utmost caution and reserve of clinical j11<lf!•nent should be exercised in the estimation of so-called fnnctional lwnrt signs and se"mingly insignificant, single organic hcnrt m11r11111rs. In short, it is fl very easy job to cleteet even the earliest, manifesta- tion of liem•t fail1m:; it is a Yery delicate, difficult, and rcspo11~ihlc iob to discriminate n failing heart. Quoting ngnin from the sound editorial just referred to: ".\fter all has been snicl abont 1he relative meaninglessness of certain mur- murs and extrnsystoles and tachycardias. must we not nclmit that. giYen one of these departures from the normal, the burden of proof is with th<' one who claims their insignificance? Grant that the out- door life. the regnlar military drill may benefit a flabb~· myo<•ardium; grant that the mitral lrak ma;v he $light, the seronclary cha11ges not manifest eYen to cnrefnl examination: grant thnt. the heart is com- petent. to meet all ordinary demands of ('iYilian life; the question i : 'Vill it be able to stan<l np nn<ler the storm and stress of tit• Army? Can it meet the snd<l<'n emergencies, the exposures, the phYsii•nl und nervons shock that '"ill come? Mny it not break clown in a few venrs?" - Says Fisk. also: "It is well to know that organic impairment M<'cl not be rapidly progressive. It is equally important to kno'' thut. on J'lo. 4. A:XDERS--CA.RDJAC AXD TUBERCULAR DISEASE. 587 the u,·enH!C. it definitely shorten" life eYen in apparent}~· farnrahle t\'J'<'"· nn1l emphasizes the need for hygienic liYing among tho..;e show- i~i~ p<'rsbtl'llt heart irregularitic-. or murmurs. .. 'Ye mny well take heed le8t. there be turned bnck into ciYil life. after the war is m·cr: an unduly large number of damaged men. ~Ien "ho now :-how an extra mortality of from 50 to 100 per cent uncler ordinary life ~train are not likely to be improved under wnr ~train . eH'll though ilt the oubet the camp training is temporarily bene- ficial." Let nw add in thh; eonnection that perhaps the NaYy in the cnse of ib nctirn personnel is facing a peculiarly grinding strain in the mutter of heart and artery endurance. It is w.Jll known that emo- tional strain nmy be as pernicious in its effects as physical ~train. I llo not hesitnte lo aflirm that the requirements of sea duty command thl' C:\JWilClitlll'l' of more prolonged effort. l'XpO.'Ul'C, <'Ul""O!'ion o( elas- ticity, infiltration of Yitality, in stress of weather and gale, and cea::;ele,s Yigilance in scouting, ancl tension in fighting. Li fc uu it torpedo-boat destroyer might be likened to automobiliug on~r nn earthquaking country. A certain monotony of the sea wear~; there j,. Inck of scenic Ynriety and interest : quarters for exercise are lim- itecl: conditions nre artificial; confinement to cabin and limitation of deck ,pace are wearing. Hence the great need :for a steady and thorough application of the setting-up exercises, swimming ancl the like. which are now being practiced by NaYy men as tl comph•ment to land actiYities which are naturally, casually, and more or l<>.ss con- ::-tnntly indulged in while 've walk and work, run ancl climb, an<l play out of doors without even plan or purpose. A physical <>rn·irn11111l'nt whieh thus inherently discriminates against the Navy must be com- pen~ated for by a steady and efficient physical supplement, if the highe't degree of health, vigor, endurance, efficiency, and cheerful morale are to be developed and sustained. f'a1diac u·eaknc.ss.-Right here the objecfrve examinntion of the henrt b~· phy~ica 1 methods rules supremely. Whether n~·ociat1•d or not with incipient or distinct disorders in the periphrrnl 'ac:cnlnr ".Y•1em, eardiac weakne$~--<lifficulty and functional incapacity nt the pumpin~ station-is the primary manifestation to diugno c. The initial, innate. nnd practieal importance of the quautitnti,·e vitality of the left ventricle cnn not. be o,-enalue<l. Its power is e..;.,sentinl: ib performance must be sl<'tlclily rhythmical. But the ~tabilit:Y nud ex- p<'ctn ncy of li fc, other things being equal. are not alone llcpemlcnt on mere Yentricular power ancl Yigor, inherent. temper:111w11tal 01· ncquirecl. but (and here is the crnx of the matter) on :Hll•qnatl' inerc- 1J1ents anrl an ndhesi ve permanence of rescrYe force; stayi11~ power; a 'ital, reinforced concrete sort of endurance; a margin of ~a:fety 588 AXDERS-OAilDUC A'XD TUBERCULAR DISEASE. Vol. XU. again:,t the stress, strain, ancl speed of existence; a surplus as well as carcliac capital to forestall circulatory bankruptcy. Very often, before the anamnesis is taken, immediate attention to examination of the cardiac region is virtually solicited by the e'i- dcnt emotion of the subject, an irrepressible mark or manner of fear, anxiety, nenousness from introspective thoughts, morbid gar- rulousness concerning repetitions of palpitation, and general per- turbation of conduct. A mcclical history of infectious and toxic maladies should mnke one parliculnrly nlcrt to the discovery of possible injuries to the heart musc1c. Conversely, as a proper move in preventive mctlicinc. clear evidences of weakness of heart action should invite close in- quiry into past or present injurious influences of bacterial, a11to- toxemic or nervous origin. Here the tcchnic of the physical diagnostician. the methods nnd logical mind of a Sherlock Holmes in synthetic induC'tion must he dominantly and inexorably linked i£ accuracy and sound j udgmcnt are to be attained. Pari passu with the examination of the heart a close study of the pube quality anrl rhythm as well as freqnen ·y is of like esRcnce in the estimation. The Yaried and Yital factors of significance of tach)'Ctmlia and uradycardia can not be too often renewed and repeated in the memory while the mind is searchinu ior the pathologic resources tor deduction. Rapid heart action shouill at once suggest first of all a possible condition of bacterial or toxic causation, a strcploroccu'i or tnber- culous infection; even Graves' disease or a tonsillnr infiltration. On t.he other lrnn<l, a bradycartliu. indicates the possibility of chronic tobacco or lead poisoning; th<1 post-infections consequence of one or more attacks of influenza, pneumonia, or rheumatism; a heart block: premature coronary artery thickening: a neuralgia rc{fox; a flilatccl and acidulated stomach. By palpation and auscultation over the heart the various at least commoner forms of disturbed rhythm are next recognized. How- ever, it is by the study of the apex-beat mninly that cardiac weak- ness is most positively determined. Actual \Yenkness of the heart muscle as indicated by a feeble or absent apex-beat can only be inferred if dislocation of the beat (con- firmed by percussion) and such extraneous factors arc excluded as th<1 following: A rib in front of the beat, emphysema, pericardial or pleural effusion, pneumothorax, tumors, edema of the chest wall. Again, an exaggerated apex-beat may be a weak one, due lo n dilated, flabby heart muscle, as pro,·ecl by the synchronous pulrn con- d1tion. Also an uneurism behind the henrt, or a retracted lung oYer the heart may afford an exaggerated heart beat that mny nt the srune 6me be decidedly functionally weak. Finally, it should be ~o.4. ANDEBS-CA.RDIAC AND TUBERCULAR DISEASE. 589 borne in mind that a slowly lifting apex-beat is rather decided evi- dence of a hypertrophied rather than a failing left ventricle . .Auscultation supplies still more definite, confirmatory or corrective results in the investigation of the intensity of the heart sounds. Here again errors of relative exaggeration and dimunition by adja- cent conditions must be carefully measured and allowed for. Thus, dimunitions in the force of the apex beat go handi in hand with dimunitions of the loudness, especially of the first of the two heart sounds. Intensification of the sounds of a weak heart may never- theless coexist because of the juxtaposition to the heart of a consoli- dation or large cavity in the left lung. Pitch, as an attribute of sound is too often neglected in the exami- nation of the heart for abnormal physical signs. Obviously, this must be clearly differentiated :from mere loudness. An exaggerated heart action with evidences of hypertrophy is invariably accompanied with elevated pitch of the aortic second sound; whereas mere exag- geration (usually physiological) of heart action has intensification of sound without elevation of pitch. Again, the recognition of a pulmonary valve second sound with pitch as high or higher than that of the aortic second sound is practically always indicative of peripheral resistance in the respiratory organs; in fact, should al- ways awaken suspicion of incipient tuberculosis; or of some thick- ening of the lung from an incomplete resolution of some prior pneu- monitic condition. In my recent experience the sign of ventricular flutter, both pal- pable 1.md audible in the region of the apex beat and limited to the area bounded above by the third interspace and within by the left parasternal line, has opened a fresh and significant study of failing heart power peculiar, in my judgment, to an increasing proportion of the most strenuous of the world's workers and worriers, fighters, and players of present-day civilization. This :fibrillato!'Y disord~r of ven- tricular function is probably one of the best danger signals of a fail- ing heart, not so remote from a rather rapid decline to actual heart failure that postponement of radical measures can be allowed with- out the pain and pathos of an irreparable result. The physical examination of the heart must be not only static- with the patient at comparative rest-but likewise and even more critically, dynamic; that is, an objective functional test for capacity is essentially of value. In this connection, as Krehl has pointed out, a labile heart frequency under the influence of such test exercises as forced breathing, stair climbing, body bending and twisting, and flexion and extension of the raised arms, generally points to myo- cardial weakness (myasthenia cordis) or valvular ditliculty or in- adequacy. Simultaneous disturbances of rhythm and arterial ten- 5~0 AXDEBS-C,rnDIAC AXD TUBERCULAR DISEASE. sion are con·e::;pondin~ly noted in many instances, the latter hej11., generally diminished rather decidedly when the arm:s n.re rni-.l'd. - Physical eYiclences of cardiac weakness are not infrequently ex- plained by an antec<'d<.'nt or associated symptom-complex nlon~ leading lines which might be designated as tht> hig four A:;-;: Auto- intoxic:ation (including acidosis); athleticism; alcoholism; nnxiety. To these should be added as a very Jim and Yirull'nt cnu:se chronic streptococcus infection, howeYer minute and remote or obscure the focus may happen to be. A final word pertaining to middle-aged men, parlicularly ofi1ce1 of the Xayy, arnl our s1wt"ific responsibility in detecting incipient phy ... j. cal signs of the cardiac affections to which they arc peculiarly s11hjeet. Perhaps 110 lictll'r classification need be consic1ere<l than that of l.J(' Clercq (Paris Medical, Dec. 22, 1917). He recogniz;cs three heart syndromes, namely, t·nnlio-~c1erosis, cnrdiartcrit is, nnd canl iuthcr- oma. Till' lir;-;t condition occurs mostly in the :iO's, aml is 1 ue to dietetic errors, with alcohol as an adjunct, and abo lo acquired lll'patic disease. High blood pressurn and cardiac hypertrophy are rather typical oI this condition, which later terminates in myocarclial fail- ure. Becornll~:, the ~olc ctrnse of car<liartcritis is some infection, c. ~., la grippe, common measles, scarlatina, typhoid fen•r, but mainly rheumatism and s~'philis. Cardiac insufficiency de\'elops slowly an(l is recognizl'u particularly by the functional heart tests, along ' ith more or lc.;s intermittent periods of mitral insufliciency of myoc. li:il origin. The third group arises through slow intoxication, as b~ to- bacco, lead, or alcohol; Yery often from sluggish colonic action nnd intestinal putrefaction. Murmurs, both aortic ancl mitral, may be detected in these cases; and complications are less prominent, violent, and imminent before senility occurs. Herc ari~es the concomitant importance of diil'crentialing by phys;- cal signs between mitrnl insufficiency of direct, organic Yal\'ular cau- sation and the rclatfre mitral insulliciency of myocnrdial cau:-ation. Also a temporary milral evidence of insufficiency thnt may he <lue to an infectious myocanlitis or myocardial poisoning. elimination of which and reco,·ery from "·hich will be :signalized by the disappear- ance of mm·mm-. and therefore must not be confounded with myocur- dial insufficiency of more prolonged, constant, and profouncl 1111turc and origin. Given a history of habitual constipation, dietetic excesses, especially of meats and sweets, intestinal indigestion with colonic inflation. with or without disproportionate bulging and sogginess of the oml'ntnl structures, a careful and rigid study and test of the cardio-rnc:cnlur system is indicated. Slight irregularities in force, smoothne "· nn<l rhythm of the heart beat, yentriculur fibrillatory pulsation and flut- .\:\DERS-CARDI.\C AXD TUBERCULAR DISEASE. 591 ter arc not infrequent "'i!.."Ib of u :-ubtle un<lercurrent of 1\i:-intea:rntion of cardio-nwtor stability. .\ weakened fir:-t ~ounJ "ith murke1l in- Cl't'!l'e in mpi1lity on !;light museular ellort (tc:-ted) :-how:; likewi:-e tlimini-..hed ,·e11tric11lar capacitv an<l enJ11ra11c1•: the pul,;e i:. corre- ,1wndingly :;oft. !'mnll, and rnlatile. '\e uro now apprnachin:.r a sort of balance of attitude r<'lati,·e to the di fft't-ent ial effed:i and benefit or detriment of physical l'Ulture or health and phy:-:ical training for competith-e sport in :-pPcinl lines of pro\H•::-.-. and excl'llencc to which belong laml'ls, prize CUP"': being tiouize1l. puhlicity, or fl. share of the gate receipts with :-ecrcey and (h'mornlizat 'on. It b worthy of reminder that many a heart l111s literally been lH·okcn by athletic excesses, especially in those irregularly or "'e,·crely trnined who shonkl earlier ha Ye been ·weeded out. Thu::-. \\ c haH~ ~el'n many pn•p s('hool boys, raw, tender, immature in HLer :rnd innntc capacities of resiliency and reserve, aping their older urothn,- in coll~gc nn<l Jnying a sandy instead of rocky foundation of l'nrdinc ,fa);ng power and continuity of deYclopmentnl vigor. I lune yet to see a habitual or so-called moderate u:-;er of nkohol with a likely heart muscle and neuro-motor function. I menn mocl- crntion in the lny and insurance acceptation of the term, where the a\·erngc <laily consumption consists of two drinks of two ounces of whiskey. Often thi!'l is in the form of a cocktail before dinner or of one or two bottles of beer. Yisible intoxication is rare. 111e 1lamage is in the nagging depression and disorder oi funetion <l111~ lo tht• constant narcotization of cellular tissue and the annihilation of thorough or even intermittent elimination. The organs and tis- :-ues ne\'er get any rest from the alcoholic acceleration and excitation. The man who goes on a spree for a week once or twice a year :mJ. in whom tt systemic revulsion with complete reaction through dr:i.stic excretion ends the metabolic crisis, is better off than the so-called modC'rnte drinker who takes ince::isantly and im·eter.1tcly his quoti- dian .. ere-openers," "appetizers," "digester:.,'' and •. ni~ht-cap:-:,'' and often between times his ~ocinble ·'nip" and occasionnl treat,:; at bar or table, and yet "ho to the casual observer ne,·er seems to be the worse for it. JN CONCLUSION'. I wi:-h merely to indicate the salient symptomatic lines :i.long which tneipi<•nt tuberculosis usually insidiously de,·elop:-; nnrl likewisp. to point out the inherent suggestions toward a careful ancl precise physienl clin~nosis in relation thereto. In a special experience of more than 20 years in tuberculosis work the ~y111ptom complex and objective signs dominating the purpose 592 LUBY-ATHLETICS .U."D THEIR RELATION TO WAR. of pulmonary physical examination might be grouped as the fol- lowing: ( 1) Bronchitic. (2) Pleuritic. (3) Laryngitic. (4) Anemic. (:>) Auto-toxemic (metabolic). ( 6) Myasthenic. (7) Psychoneurotic. Occasionally, even in early cases of tuberculosis, the only promj. nent symptoms may have been either gastric or hemoptytic. ATHLETICS AND THEI R RELATI ON TO WAR. By D. F. LuBY, Lieutenant, ll. c .. United States Navy. The withering effect of the great war is felt all over the world. Like a huge plowshare it rips up the traditions of yesterday, turns oYer the moss and dust which :for years have been accumulating within the institutions that are most vitnl to us and disclose, fallacies and false prophets, bringing us face to fa.ce with the neces- sity for radical change in many departments of life. The American system of athletics may be regarded as one of our national institutions, nnd through its channels pours the 'igor of the Xation, but it is only at a critica.l time like the present that there can come a general appreciation of the sad fact that for year:-; atlt- "letics in America have existed only for the sake of contests and that these contests baYe been developed, not primarily to upbuild the splendid youth of the land, but rather to satisfy the appetite for pleasure of a volatile and somewhat hysterical public. Twenty-fiYe centuri<'s ago a great nation had come to realize the £n.11 Ynlue of training its youth and was rewarded with victories which gv.ve ln.'-t· ing benefits nnd led up to a high plane of civilization. For the first time in the history of America. we are taught by the pen >troting thrust of war the real meaning and the real \alue of athletics nnd we hn.\e a vision of what they might do for the thousands of boy:; enger to strengthen their bodies, that they mny giYc the ·best to their country. In spite of the time and the money devoted to athletics nnd the hu~e interest which this subject provokes now when physical strenath and endurance is suddenly needed, we realize that we arc not an athletic people, but a people o.f athletic specialisl'l. and. becnu!'c of the urgency of the situation, we see our armic>s attc>mptin!! a rnpid development covering a period of 6 months or a year when the period of development should have covered at least 20 years. .. The athletics that count. Free physical tralninii at Cornell Medical School for men rejected by Navy recruiting offices . 592 I ?\O. 4. LUllY-ATllLETICS AND TREIB RELATION TO WAR. 593 It is the purpose of this article to draw attention to the fallacies of our nthletic ~y:-tcm ns dcnloped up to the pre.."cnt time. to point out the u:;cles.;;,ness of the object sought, and to assert thnt there was 110 !!llill but rather !'eriou~ loss to those who partici1>ate<l in athleti~ in the pnst. The plea ic: for a radicnl change in our metl1od:; and om· objcctin'S in the athletics of the preparatory schooli the college. nnd the unh·ersity. In maintaining that our course has been at a tangent to the line of real athletic deYelopment it is necessary to look back over the pn~t 40 years in this country. In the early days there wcre no gymnasiums, no athletic fields inclosed by wall or fence, and the most !"trenuons athlete of that period would to-day look with amaze- ment nt the Harvard stadium or the Yale bowl, which are nothing but colossal monuments to the present commercialization of athletics. In those dn.ys athletics consisted largely of friendly contests in physical strength between one half of the student body with the other half. There was no preliminary training: there was no huge fumncial budget requiring an adept business manager. there were no uniforms, no spectacular features. At a certain hour of the after- noon, moved by a universal impulse, books were closccl. old clothes were donned, and there was a rush into tho open to wnlk, run, jump, to let the physical man h:.n·e his fling. With time came the develop- ment of teams and clubs, organized for the purpose or winning championships, both local and national. Schools and colleges be- gan to taste the sweets of rivalry and to vie with one another in bas~­ ball. football, feats of the track, etc. Yale locked horns ·with Har- vard nnd Princeton, Exeter fought with Andover, and everywhere college paired with college and school with school. The interest in athletics was not confined to the student body. The nlnmni nnd the gPneral public soon became equally keen on the subject. Ath- letic Hents gradually became one of the dominant featur<'s of col- lege lifo and many times a year the spectacle was presente<l of thou- sands nnd tens of thousands of people clamoring nt the gates of our great pln.ying fields, utterly regardless of the cost of ncl111ission or the time required and the distance to be tra\"eled in order to par- ticipate in these glnditorial engagements. "\Yise young mnnngers worked day nm.I night to commercialize sport ns winnin!! teams brought prestige and attracted to the college the ambitious and en- terprising youth of the land. Even towns and cities where there were no colleges became infected with the spirit of the times nnd, whern local talent did not suffice to guarantee victory, athletes were imported from abroad for the purpose. In every form of athletics the object was the same, "to win," regardless of cost. Professional- ism held our country in its grip and it required a crnsade on the part of the public and certain of our institutions of learning to purge 594 LUBY-ATHLETICS AXD THEm RELATIO~ TO W.A..B. Yot.xu. our l'clucational institutions of this taint. The restrictions illlposed at college an<l the fron-clad rule:; about, the participants in athletic e\ ent:s seemed to make competition more keen and. as a con~qucn~. 11ew plays of en~ry sort were deYclopc<l, new thrills crept into the games. athletic feats became more startling in charaC'lcr, and even· year sttW new records made and broken. By this time tlwrc ' as ~1 need and an insistent, demand for trainers and coaches. ~\..t .letic u:;sociations consulted with presidents, trustees, and faculty, m·lin- taining that, an alumnus or some incapacitatecl member of last year·g team was not good enough to sene as coach. If coaches anc.l trainPrs were to be used, they must be the best. Arguments were folm<l for this in last, y1•ar's defeats or the phenomenoJ ctu·eer of some rirnl colll•ge, more prompt to take adnmced ground along this line. .\1Hl so thel"e came to be a new profession, that of coach and trainer, and now training tables and southern trips an<l s11mmer camps for pre- liminary training an<l expensirn equipment, ancl long trips to rh-al institutions ancl whole squads of couches became a IH'Clssily. This all grew out of the determination to win, which would ha,·e bceu commendable enough had it not been accompanied by a feclin!! vf utter incliffcrence to those who fell by the wayside, or, in othet· word-.. to the thousands of boys and young men who could not be admitte,l to the arena, whose physical proficiency entitled them only to :-.Pat., on the bleachers as spectators. The athle>tc has now become the r<:'nl kine o1 the college world. All· t,hosc who lo\·c good sport watch him nnd follow his example. He feels him~clI an Pssential and int<:'gral part of the school nnd tmins fai Lh fnlly. p11nisbes his bocly, makes eYcry sacrifice, strive"' with sup<'rhuman strength to !lccomplish the nlloted task ancl r<:'tain for as long as possible the halo of respect and nrlmirntion which Yic- tory brings him. Ile is too young to realize what the career of col- lege champion involves in the way of disaster to his body. and per- haps "·ould care little for the tlu·eat of future disaster, so long ll!' he coul<l stroke lhe winning crew or. as pitcher of a winning nine. hear the delicious music of applau~e from a n1st i1ssemblage of tHlmirer~. Xor docs the conch care, nor the stuclent boLly, nor the college. So long as he is a-ood for a point or a. run or a goal, he i~ applallllc<l. 'Vhcn he fails. his m;efolness is o'°er, and he is cliscarc.led and for- gotten. One of the most serious faults of our prt'sent, athletic S)'Stcm. a vicious, pernicious system if ever there was one, is the neccssit~· for haste. Our trainers work feverishly and anxiously to cleYelop a win- nin~ team. They must develop such a team at all costs because fail- ure means the loss of a job. A certain Harvard coach has said that coaching a football team is simply a race against tim<:'. The coach whose team meets. for preliminary summer training, in Augu~t has stolen a march on him whose team does not assemble until September. ~o 4. I.GBY-ATHLETICS A:!\J> THEIR RELATIOX TO WAR. 595 The first reform fr1 athletics rt•lated to proft•,,,..ionali..:m; later there wa ... n Je. .... ,.. radical reformation. People bcgnn to :tl:ik if the college athlete did any ~tud~'ing and pa::>:>ed hi::. examin.ttiotl::>. _\. cJi.•po-.i- tion now appeare<l to :--horten long southern trip::i, to alJlm.i,·iate the prl•liminar~- training ::;eason, to rai::;e the stanclanl of ::>d1ola::-tic re- <jllil'l'ment~. In some l:icctions there was a reaction ag-ain:;t the coach nnd the trainer. aml e,·ery eYi I that had crept into nthlctic,, wa:- lnitl nt tht lloor of these lll<'n, when the real fault was within the college wnlls and could be laid nt the door of tho faculty and ti·n::-.tcc::; aucl :-tuclcnb themselves, for from all these clement~ the demand wn~ ron- i;i-.tcut antl unvaryin€!. All clarnore<l alike for a winning tt•an1. It is sm·ill won<lct· that onr athletie eoaches cli ... rC'gnr<lC'tl the gn'at mn."" o potential athletic power. ttllowin~ it to he idh· in the hlearhN~. :incl concentrated its efforb on the fc" "lw iran' promi .... e of 111111 nnl ace0111pli::;hmcnt. I haw• sern the lute Mjke l\lurph~· "ork for houn; with his star high jumper:-. cn<lru\·oring to perfect th<'ir ,,cissors-like form that the~· mi!!ht :t<ld a triflin:r frnctinn to their {j-foot 4-inch rer.or<l. How muf'h more profitahlc to the coun- try Imel this grcatc:;t of all trainers derelopecl iu::-tl•ad fi' e hund rt'.'<l or n tho11snncl ;vonng men of mo<leratc athlctie nlJi~ity to jump 1 feet 6 inchc;;;. I-fad he suceecclecl there wonlcl have been that many more men nmilnblc to go on•r the top and stand the awful -.train of battle after the~ got o,·er. I haYe seen ,Johnny ~fack C'oach his -.ix or M.'\Cll h11rc1lcrs ns they skimmed OYer the 3-foot. G-inch stick~. .\:ritin nrnl a!!:Hn would they pass in review before him in the effort to at- tain that perfect form without which they ('Oul1l not win. How m11d1 more n.clYantagcons to the country to-Jay if he Juul co:whctl six or sncn hundred Yale men to hurdle tho,,e timber-:, eren if they rlid not acquire the form which he -:o well imparts: ancl. o it is with the conching in all departments of our colh•gc a th let ic,... In the mad ru~h for victory the mass of the students j.., ne!!lccte•l for the "llke of dcnloping n specialist or group of speciali:>ts. The nniYer:>ity, like the preparatory school, rewards the effort::; of thc.<;t• fortunate men with all the honors at hand. and it is the least thttl can be ginn them in return £or the real sacrifices they makc. It i::> n. well-known fact that the body nccommoclntt-s it:self quickly to nil manner of changes, ancl this is perfect!:'-· true in tlic ca..:e of the boy who, looking forward to a uniYersity career. he~ins to specialize in :-ome lin<' of athletics while still in a high school or ~mmmar school. Thanks to this adaptability he is not conscious of the <lele- ft'rions effects of stmin and has no hint of the brewing trouble clm·- ing his whole scholastic career, nor when he lea.,.·cs the uniYersity dot•s he appreciate that he should continue to take exerci-.c and, as it were. rt>trace his steps, a.long the ronte already trod. h_v tnking acfo·e 596 LUBY-ATHLETICS AND TIIF.IR RELATION TO WAR. ,.Ill.XU, physical exercise in slowly diminishing amount for a peri0<l of at least fix-e years. Instead of this the bulk of our college graduates become engulfed in the business world and either spend their time at office desks or else enter on a life of luxury very different from their previous Spartan existence. Hence a gradually diminished blood supply to various importtmt organs and tissues, an excessive \ <k•elopment of connective tissue, associated with tho deposition of fat droplets in and about the muscle cells. Fat begins to gather in omentum, cloudy swelling, and la1er cicatricial change develops in the kidneys, and the hypertrophied muscles begin to degeneratt>. I could name more than one friend or acquaintance who, after n brilliant career as a star athlete, has succumbed to diseases which those with well-developed and well-balanced bodies should success- fully resist. I could mention by name more than one ex-champion who has died or broken down following the terrible \Vear and tear of an athletic career. I could mention more than one man, whose name was well lmown throughout the country, who is no longer with us because an athletic career left him in what we might call a burnecl- out condition, with marked lowering of body tone and without that reserYe force so necessary to resist bacterial invasion. Dr. R. E. Coughlin, as early as 1905, called the attention of the medical profession to the high death rate among athletes. He is corroborated by many other writers and students-men like Lee, of Columbia; Abbott, of the University of Pennsylvania; Darli11gton, of New York; Savage, of Pittsburgh, etc. Surgeon General Charles F. Stokes, United States Navy, in his annual report for 1912, spoke in no uncertain language of the disastrous effect of athleticism upon health. While the number of retirements and deaths for 580 non- athletes in a certain period amounted to 22, there were 21 casualties in about the same number of athletes, despite the fact that the latter arc supposed to come from better material. When, howcYer, that group of diseases only was considered to which we would think athletes peculiarly liable there were 6 deaths of athletes to one among the nonathletes. Dr. Stokes said in part: The immculate hazards of sport arc lnronsequentlnl as compared with the future effects of o,·ertrainlni? nml oycrstrnlninA' for brief periods, to be fol- loweil by rears of relative physical quietude. The records naturally fall to take Into account those whose ph~·sical disabilities are of such n character as not to cause theiL· admission to the sick list, yet whose efficiency has been impairerl by them. There are many such officers In the service who conRult me1li<'nl officers for cnrdlnc irregnluritles, obes!tr, or physical staleness-In other wor1ls, for conditions thnt it appears reasonabl~ to attribute to o,·er- training- and ovrr!:;trnininA' followcll by periods of physical quietude exnrtr1l by se1·vlce con<Utlons. These rnses clo not become matters of record 1rnleRs they are of such moment as to rnn<ler Ute officers wholly unfit for duty, yet sucll Influences in many instances materially affect the military efficiency or the in<llvldual and should be averte<l If possible. The athletics that count. Free physical training at Cornell Medical School for men reje;ted by Navy recruiting offices. 696-1 l\O. 4. LUBY-ATHLETICS AXD TlIEIR RELATIOX TO WAR. 597 l'l~, {• 1 trolnln= n111l nthlctlc.-. "ltoultl bP so temI)(>r<-tl ns to hr hrnefidnl to nil. Tl c~ should 1m1d11C<' n supple, n"lle, nll-nrou1111. well-de, el p<>d lndhlclunl. nor n mu,. le-ooun<l mn... of l.Jmwn. The mun who ,fep,; out of n bo t, c<mie off the football field. or Jen' C" U1c truck ... houltl feel exbilnrntcd by ltl ex• rcl;:e. J,oi 11 lof'.lcnl to i;UJ!P<l'-'t' th·1t the 111:111 who Ii:. lilted out of n 1 o. t, coll. p <1. or is cnrrlccl oft' n football llcld or truck in the :snruc c.inultlon '" not harmed th!.'rcb~ ? It 1, th refurc recommended that n tUletk:< in the ~a'~ be o re ulnt I 1 to :noid these 1leleterlous condition,: b~· th<' Jlrohil1ltion • f en lur nee c 1test" \\lie.rt• the nl>llity to win Is lnrgl'ly, lf not entire!~-. 1lrpemlent 1111• 11 brut force, nml tltnt t"t her tlle muxl11n1111 efrort he mnde to <1t•\·P\op 1 :--yJnmetrlcnl. norm 11 ph~ ... iqm' in the mnn~· Instead of a hlirhly :specinlizrtl hum:m mnchh1l' In 1 few. Dr. Harlow Brook.c;, from an experience of many yf!ars of a ocin- tion with athletes anc.1 in connection with enlistments for the Xntionnl Guard. believes thnt after 10 or 15 years of business life the health of former athletes is for below thnt of the aYerage man. Dr. C. R. Ba.rdicn, of the UniYersity of Wisc JP ~in. hui:: ctlllC<l nt- tention to the greater frequency of ncnte dilution of the henrt in member::: of athletic teams as compnred with the number of --tude11t" who do not participate in athletic<:. It ~eems to be gcner· lh- recognized nmon!! mcdicnl men nnd, to a cN1aii1 e:\.ient, among militnry men. n:-; well. that there is i::omething distinctly wrong with athletic ns now conducted in America. If we per.-i:-t in nllowing our Lio~'" to follow the pcrniciou:s com-cc which be!?ins in the grammar ::::ehool or preparatory school and ends only with the uni,·er!'ity, we must he prepared to see them pay the price a~ their prC'dcces.~ors ho.Ye done. The question j._ no longer n per:son·\l one. if it e'er was. Now, certainly it is manifo.stl~· n matter of na- tional importance. It. should be patent to nU that to neglect the 1110-.t careful athletic clc\ clopment of our million:; of boys i~ to S:l p the Hl'Y roots 01 c:freull'lh nml ntarty in the future matcrinl of the Auny and NaYy. and if, a,, some 0£ the lllOl'l' consl•rrntivc nn<l per- hap::: apprehensi,·e obscners declare, the war is to la::.t for five years longer, then the sccuri1y of the United States will llepen<l 111orc upon the lads who are now 1G nnd 17 years of age than on the rrrown men "ho are on!r there at pre:-;ent. 'Ve hear a good deal of talk jut now of univer:;al 111ilitc11y training for our boys. and. while it is !!enerally nclmittetl that such training has considerable inci1lent d ndvuuta!!'":i from the point of view of health, it would seem thnt the fir:,t thing to be considered is the nni,crsal physU>al training- of our hoy~. ln the past. unprepnreclncss has been onr boast and motto, and ch ilian experts on military affairs haYe been content to helieYc lhnt a few months sufiice to make good soldiers~ but. even if we gaw ~or a }'l'ar::; to military training and met every condition of military preparation from a technicnl stam1point, it must be remembered that t\ strong, symmetrical nn<l healthy body, capable of C'Xtrcmc endurance. is not the re ... ult of hothouse gl'owth and inten<:ive training. 598 LUilY-A1'HLETICS AND THEIR RELATION TO WAR. fol. XtL There is a rc•al dnnger lei:.t the effort to bring out· sol<lit•rs lo-<l.a\' up to n proper physical standard may lead lo the tHlopt ion ~f methods similar to those cmploye<l. by the trainer-. un<l t·oaches of rnl- lege ter1ms working ag:iinst time to be ready for a contest on a given day. This clanger is particularly rnen'lcin~ ju:>t 11ow wlwn the eall for men is loud in the land. I ham witne::;sed the intem,ire trnininrr adopted in Fonie of 0111· c·t1111ps and greatly fear that tlw <'nthnsia!:'~ of athletic in~trnctors will finish what milil ary le:ulers hn' e not quite accomplished. namely, the prodnction in mnny of tlw nH'll of a i-;tate of fag nncl staleness due to o•ertraining. " 7hile sen·ing on the U. S. S. P1•c1Sirl<'11f Lincoln I obsenecI t11011snnc.ls of soldiers at the moment of their embarkation and it was clisconrnging to note in what a, large nu1nbl'r of them were to be seen e' idcnccs of an o\·ertraine<l con<lition-e\'idenecs such as deep sunk, hollow eyes, <lnrk rings around the' eyrs. lnssitrnle, depression. lack of appetite. hag-gar<l looks. One can not help wondering what the opsonic irnlex of these men is an<l to what <>xtent their tissue::: are oyercbargecl with tnxil' fatigue substances lending to render them more susceptihh• to tmmnunicnble disea<:e. esp<>cin lly in dew o:f the mental depression preH•n( c1ue to new em·ironnH•11t, leaYing home: etc. Fatigue an(l resistnnce become matters of pl'imc imporlance to the soldier "·hen he is as,i~ned to the troop cornpartnwnt below <leeks on a huge transport. where air space js re(ltH:e<l to a minimum and oYercrowding is ine\'itnlilc aJHl where he mu!:lt be subjected to the danger of d1'0plet infedion, th<' danger of contracting pneumonia. meningitis. meai:.les. and other sel'ious ail- ments. For a crrtnin period the reports from Gen. Penihing's army showed that the highest mortality from communicable disease was in the National Army and the lowest in tlw Regular .\.rmy. Thus it has bcl'n calcnlnted that for a certain period dealhs p<'r thou- sand from pneumonia in the National ~\.rmy , the ~n,fionnl Guard, and the Regnlar Army were in the proportion of .i.Ci.i, 4.80, !.00. I bl'lieye thnt the ntriation in susceptibility can he as(•ribecl clirrctly to the Y:triation in the time of preparation aml clen'lopment which these different 1mits haYe enjoyed, the deYelopment of the National Army having brcn characterized by intensiYe tmining and high spee<l. I belit•n' that the nccnrnnlation of foligue s11hst1rncl•s from oYertrninin:r for lengthy periods without proper attcnt ion to the time elenwnt brought about. in the soldiers that I :;aw, a condition anal- ogous to what we S('(' in the stale athlete, ancl it is not to bl' wondered at that the oYertrained soldier should be particnlnrly liubk to pneu- monia, scndeL fo,·er, influenza, etc. In order to rnustrnte my con- tention I took a number of photographs of the men as they ('nmc over the gangw:ty when embarking for Europe, n1Hl I invite attc11- tion to the expt'l'Ssion of the men's faces in thrse pictures. ·when View on American transport. The men are thin and In some cases seem overtralned. 698-1 Views on American transport. The men are thin and in some cases seem overtralned. 598-2 ~o 4. LUBY-ATllLETICS AND TIIEJR RELATION TO W AB. 599 their features arc in repose the expres8ons arc hagganl nml nnxiou-.;, nnd tho::;e who arc laughing nrc thin and seem trained "too fine.:· i\fan\ hatl Jo::;t weight nnd others <leclarecl that they had been COl' · ,ciot;» of a distinct clrclinc of vigor during the last monlh or two of thefr trammg. Thef'c !>tatcments were particularly frequent nnd rmphittic among the nwn who came to the sick-bay with diffcrrnt zymotic cUseases. During three trips there deYelopcd on the Prcsi- ,;r.flf Linroln JO cases of pneumonia, 3± of scarlet feyer, 8;) o:f in- fluenza. 68 of measles, 3G of mumps. In view of '"hat lies ahea<l of our men in Europe one cnn not but ferl that they hnYe been brought along too fa.st ancl that thc.v arc stnle bdorc they haYe begun the game, and yet in the fa.cc of ihc> mgent ncecl for men how cnn the GoYernment do differently? The inrnliclism and the dc•a.ths in our ~\rmy that result from epitlrmic di!'eases may fairly be laid at the door of milita1·y nnpreparC'\hiC$'S and tllC' lack of a general, properly lhought out system of physical training for our young men, calculated to make them hnrdy and capable of increased resistunce to infect ions. The immediate irnlicnt ion is to impress upon physical clii•t•ctors, trainers, and athl<'tic manager:, in training camps the importance of <leliberation and mo1lerntion and of "·orking in lrn.1·mony with the medical officers. In a 11 011r training camp!'. ancl more partic·u la r1.v at our aYiation schoolc.:, a cart'fully regulntcd diet. plenty of sleep, nnd 1he :woidance of alcohol arc matters of prime importnnce. Ilowc"er imperatiYe it may be in lhi-> acute and trying situation to rc."'ort to short cuts ttncl tC'mporary expedients, the present nntionn 1 emC'rgC'nt·~· should serve not to confirm us in bad practices too long in vogu\>, hnt rather to dm w ns ont of 0111· stagnation and i ndiff erC'ncc to the re- form of every abuse. There is a sense in which, no matter how bril- liant the Yictories of our armies, this country will suffer rle>fcat unl<'ss self-quc>stioning and self-crif icism lea\l us to men<l our way.;; in l'<'gnnl to the many vitnl pnrticulnrs in which we are no'' at fanlt. 1\'ith th<' lesson of the honr hefor(.> us it c;eems heyoncl hC'l ief that the country shonlcl not nlreacl;v han taken steps to i~llJH'OVC tbr> phy"i- cal condition of the sons of this generation, who will be the men of the next and the future protectors of our cherished irn;t itution-:. Jt, .'CC'IllS to me that one has a right to demand GovC'rnmt•nt c.:npervision of some systematic progrnm for the physical clc,·elnpment of tlw hoy,:; of the countr~·· U "·care to haw athletics following in a general 'YllY thr. old li1ws then WC' should eliminate the now e-..spntial icka of win- ing games at n11y cost. The coaches at the Yarious schools mnst be forhiclden to conc\'nfrntc their attention on the fow 'ipC'cialists fo the disrcgnnl of thonsancls of students who now merely stancl upon the side-lines. There mnst be 20 football teams pla~ring on the fields GOO LUBY-ATHLETICS ~D THEIR RELATION TO WAB. \'al. :S:IJ. where now we :>ee but two. Instead of half a dozen men training to jump a broad jump of :!2 feet 11 inches we must ~ee GOO boy:' lenrnin<? to jump 11 feet G inchc::i. The length of races must be reduced nnd cross-count1·y runs must be reduced both in length and in runninf? time or thrown out altogether unless a :>low jog trot is enough. Th~ rowing race.s must bo cut down to the Henley distance us a maximum and then there must Le 20 or 30 crews practicing daily instead of 4 or 5. In a. word, nll branches of athletics must be reclns::.ified on the basis of their effects upon the heart and other Yitn.l organs~ and we must u.· c·u·J the old cla:;sification based upon popularity and com- mercial advantage. In the grammar school the form of athletics to which a boy could be assigned or in which he would be permitted to engage in would depend upon (1) his family hbtory; (2) hi~ personal history, having regard especially to pre,'ions illnesses en- dured; (!3 )his physical status; (4) his particular type, height, wei!!ht, etc., il,1 relation to age, etc. EYery class would hnYe its specially pre- scribed athletics, both physical and tactical, and under no cir~um­ stances would a lad be allo'Yed to engage in competitive sports n;;. signed to a cla~s abO\'e or below his own. .A physical examination wonltl mark his entry nnd exit from n class and he would be marked for development of body and for ability to perform the ''arious tac- tics. 'Yhil1• in the grammar school a chart would be begun for L;n "·hich "·ould nccompany him throughout his educational career. As the boy pu~c;c<l oH to the higher school there would he a recon- i-idcration of his individual record and his family history. A physi- cal examinn,tion would take place, and his chart and previous athletic work would be considered. There would be athletic clas:::f's and all members of a s~hoo l or college would pnrticipnte except when exempted for physical disability. The alert boy, t!1e natural nthletc. ould l1we to be held in check, just as the laggard nnd lethargic would have to be stimulated, in order to maintain for the cln::>s an average of efficiency. Outside competitions v-ith other schools would be reduced and the competith-e idea find its illn:-:tra- tion principally in interclass games. ·work in the gymnasium should accompany nncl parallel the work done in teams and athletic games. Where !"tudents show beyond all reasonable doubt a real and per- manent improvement in body and an increased ability to participate in nrious branches of sport they should receive credits at the hands of tho college authorities in the same way that credits nre given for scholarship. All athletics of the more strenuous type and all thos•· contests which inevitably induce even temporary exhaustion must be abolished. Mass competition, such as that in which n clnss would participate as a whole, is to be encouraged. :New :feats of prowe~ should be introduced. There should be walking contesbi, well-seal- No.4. F.A.RENHOLT--MEMOB.ANDA FOR .MEDICAL OFFICEBS. 601 in" conte::.ts. ob:,tacle raising. hurdling. shorter r('luy CYent~ with in- <'~secl pH--ounel. more "O;:ct•r football. ;.hot putting with n lighter !'hot. etc. The athletics of to-dn.y mn!-it be remolcled :m<l their objt>d clearly defined. .\thlctics cn.n surely ha,·e no better purpose than to de- velop n robust nntl healthy boy who, though he may not be nn inter- scholastic champion or sought after by the larger colleges n~ likely to inrrdt"<' th<'ir fnmc. will H<',·ertheless enter upon his I:fo work with 11 ~,·11 1ml•tricnl. fully dt>\"Plopetl ho<ly. (':tpnble of rc--istin2" cJi,ta,.-e and of ·endnrin~ ph)•.;ieal strain. For ~nch a young man the trainin~ ,.~1mp. tlw lmnspol't. and the trench will not contain the threat of cJt>ath front <liSl'!lSP hcfon• his grapple with lite <'IH'lll_\". ~!EMORANDA FOR MEDICAL OFFICERS WREN A SHIP IS COM.MISSIONED .urn SUBSEQUENTLY. 11> .\. V\llf''dl•ll T, ('Uptain. )I. C' .. l'ultrd 8tnll'" :->11v>. Thi:-, li:-.l of duties has been compiled primarily for the u~e of th0:>e i;!Oing- to sea for the first time, but may be of ~ervice to other:- :ts well. Whm the ship i>. fitting out the medical officer shall examine sick hay nn<l spaces under hi~ charge' in nccordancr with :11 ticle ~101-I . . \s soon as possible he shall examine the crew au<l ( 1) YCrify descriptive lists; (2) ascertain if all crew are properly vaccinated, if not vaccinate I.hose needing it when permitted by commanding officer; (3) ascertain if all crew fully qualified physically. (See article 2102 and 3-I; also 2101 to 2131-I, 2901 to 2flfl7 R. 1 !\O:\ I. 1351-I, 1357-I, 1504-I.) CLERICAL DUTIES. The following work should be started and these books commenced: 1. Filing cases established for all letters, indorscmcnts, bills. rnuchers, inYentories, invoices, copies of returns, and other sick bay work: all classes of paper work are numbered serially beginning with Xo. 1: July 1. 2. Property record book or file sheets or card index. :3. Book recording receipt of all health records, also forwarding of :-amt•: contains names alphabetically arranged and numbered with corresponding number in pencil on health record. This book may ad- rnntngeously contain also typhoid and smallpox vaccination do.ta. 4. Prescription book; numbers and dates. :l. Linen and laundry book. 6. Sick bay recorders book; this may also be the rough journal and \~ard book 'j('.09~-11'~'3 fi02 FARENHOT.T-MEMORA~"DA FOR MEDICAL OFFICERS. \'ot. XII. 7. Yenereal prophylaxis book, or binder for holding liberty lisb . . ~Iemoranda of interesting cases. 9. 13ook recording articles ·wanted and articles for which a sun·cv will later be nece&>ary; one side for wants and other for articles f~r survey. 10. Book recording operations or rough Form P kept. 11. .\ filing box or boxrs for rough Form F enrds. 12. Venereal lists made out: copies for exrcntiYe office and ili.. pensary and for man who has >enereal duty. 13. A foll supply of blank forms laid in and conveniently stowed. 14. Slips provided for report to commanding oflicrr "not in line of duty"; article 2902-1-R. complied with. OTHER REQUIREMENTS AND SUOOESTlONH. 1. A pigeon-hole locker having about 30 compartments and lock- ing arrangement for health records. 2. Instruction for Hospital Corps o;tartecl (ser 2Ci42-l- fi- I, Yic!e No. 83); Handy 13ook for Hospital Corps, 1917, United States Ka' y: Mason; lectures; dummy operations, paper work and forms; Hos- pital Corps drill regulations; optional; Instructions for Medical Officers, 26. 3. Arrangements made with paymaster for food for patients in sick ba.y; diet slips for commissary steward . .J.. Liquor, poison lockers examined carefully; also stowage of nil stores either in stores or on hand in sick bay and <iispensary, 2964- 2965-R. 5. Hospital Corps billeted and arranged in lwd~ aud lockers; ham- mocks and mattresses to master at arms. 6. Hospital Corps find their messing arrangements, also method of drawing clothing. small stores, and money, :naO-.J. 7. General station and duty bill ma.de out and posted: (1) Sick bay watches. (2) Stations at various drills. 1. General quarters, Ma.nun] Medical Department, Chap- ter X; 2109-I. 2. Fire, 2707-5-I. 3. Abandon ship. 4. Battalion drill. 5. Landing party, :Manual Medical Department, Chapter X, section !3. 6. Collision drill, Manual Medical Department, 982. ( 3) Cleaning stations. ( 4) Liberty lists and rotation for duty as sick bay recorder. (5) Routine for sick bay and medicine hours, poison antidote list. FAI:h~UOl.T -~U:MO RA~Da FOR MEDICAL on'H.'ERS • 60~ . Operating room inspected; sterilizer tested; instruments and oppli:rnces inspected and placed in order: haLitunlly kept coated with cocoa butter~ liquid paraffin, or other method to pnwent rust. Table. "·nter. lights satisfactory. This room must not Lie 11· eel for bac- teriological or other work. 9 .• \pplicntion should be made by letter for microscope and acces- ~orie.'- and upon its receipt preparaticns made for :-11 orclinnry work: 110 incubator may easily be improvi:;ed. HI. It i::i desirable if possible to obtain an ice box: "<'l'll, vaccines. n·rtain foods, etc. 11. )letul feeding and dre~ing trays may be improvised for use acroi-::o bunk bars; also same for cups and glasse:;. 1~- Do not send officers to hospital witlwut i:mn ey. i:t "'eekly inspection of holds, storerooms, :md lfring :;p:u:1•:- madP with first lieutenant and written up in hull book or letter to com- manding officer, 2701-4-2702-2-I, 2115-I. !·t Bill of health always secured before leaving port; unlei:;s ttag- .. hip directs otherwise, 2126-1-2-I. Also meet health officer at gang- way. Manual for Medical Department, chapter XY. i; •. bee that Hospital Corps are always in proprr uniform. rating marks applied, clothing regulation pattern. If possible ha.Ye all sick bay attendants wear white washable clothing. SC'e that uniform ig ,ufficient in amount and properly rnarkE'd accm·ding to Uniform Regulations 1913, 70-71-72. Iii. Keep smallpox Yaccine and such other vaccines and antitoxins a, may be necessary on hand. The flag::;hip somC'tirue::- ha!' i-uch stores. 1 i. Purchase as little extra food for use in sick bny as possi blC'. 18. Inspect bumboats con!'lrantly (if any); especial care about bottled wa.tcrs; mosquitoes in bnncht'-. of h:munas and in ~hore boats, 2113-2-I, 2618-2-I . . 19. Be prepared to examine water from shon for boilers or drink- ing, the latter is absolutely necessary, 2621-I. :20. t:3ubmit memorandum slip in each case in which admission to sick li:st is not in line of duty; 2902-1- R: Manual Medical Depart- ment, 22.>-!. :!1. $ee that all heads are clean; properly flushed; papers; live steam Ul'ed to clean if possible; basin to wash hands after using heads if :-urh can h<' arranged. :!:!. Carefully inspect prisoners; acute, feigned er cmnmunicnble discllse. 1431- R. Fracture of skuJl possible in tho,..1· 1h·:1d tlrnnk. '.!114-I. :2:1. ~ee that medical boat hoxes are. 0. K.; covered with canrns, marked with ship's name and medical department. .\!so metlical pa..J.;:c•t in regular boat boxes. 604 FABEXHOLT-MEMOBANDA FOR :MEDICAL OFFICEBS. Vol. XU. 2 L .\ rmngc butt le dr<':;sint! packcb for i~olu led po;,, it ion:>. lllrt-eb <fr., fo·p an<l <'nginl' rooms. :.t<·ru11 and mot OI' 11P:1 ts: t hl"C rnay he tii; boxPs or can ,·as-covered packa~cs. well mnrkl'<I. Resen·e dre. ... sin!! ... fol' 11~e after acti1•n should be proYi<lcd in tlw :-nme wa~-. :2.i. ;-;ce that stretchers are instantly rendy for U'-e. some l ·rmn- 1w11tl~· titted :tLout the deckl:i for ust' i11 accid<'nb. Sll<'h as at<' aliu~ .:-hip and handling of stores. ::!fi. Keep conbtanlly on hand drc•l:l,,ing~ ancl appliance~ fo1 1 "l' it1 case of accidents, such as burns from firProom or powder. fruc- t tll'es. r<>storing the apparently drowned. or thosCI owrcomc frn111 inhalation of poisonous gases. 27. Detcrmint> the best method of remoYing the wounded :fr0111 the fire ancl t'ngint' rooms. turrets. handling rooms. tops, and all inac- <·e ... sililc phtl't'S. :28. OLsenc regulations concerninµ: locking of btorerooms, clo ... ing of btureroom aml other doors al et•rtain ti111es-,,11n<lo\\'n at ~ : drilh-·k(•ys 11('\.<'I' to be taken out of the '>hip. Keys in hnnds of en- listed men, 2964-R., lil0-!--2-1. 29. Cotton or other car protectors fomisl1ecl it!! per:-;011.-< on hoar<l <lnring timt's of firing- of gr<>at guns. Carr nbo11t cars in swinunin!! in tropicnl waters. 30. IlnrbN· should be instrnricd in method of keeping his gear in sanitary condition. List furnished him (not posted) of all syphilitics. 31. Sec that food is 0. K. in quality, quantity, cooking. Dishe.., washed properly, disinfected if necessary. Syphilitics with open :::;ores have special gear. See that those who t'at al irregular hours ~Lre properly looked out for 2618-2-5, I. 32. Sec that wash rooms are in a sanitary condition and men do not urinate while under showers. 33. Prohibit use of tube in water breakers, notably in steam launch. See thnt scuttle butt is working in satisfactory manner and water cooled and aerated. 34-. ~ee that men are billeted properly and not in dangerous place" and exposed; no sleeping in storerooms or unat!thorized places. 35. H:we a landing party scheme always worked out and ready to be put into operation. Instructions fQr Medical Officers, chapter X: Inspected by flagship twice each year. Material to assemble: In- -..tr11mrnts. drugs. dressings, diagnosis tags, transportation. :rn. Prt'parc a schedule of routine and incident al returns in or<l~r to fncilitate snch work as per article 5222-5-I. !l 7. ~N' tbat ship's laundry is conducted jn lt sanit.ary manner; :1 ll infected sick-bay wash to be disinfected before leaving sick bay. :1."i. If ashore 8CC that a prop('}' place is selected. Inspect caref1 lly entire crew, stripped. at intervals, for curly. concealed, or unrecog- FARF.NHOL'.I.'--MEMOB.ANDA. FOR MEDICAL OFFICERS. 605 nized disease. especially in cases of men whose duties confine them below decks; especially look for T. B.: no cases of which may rc- mnin on ho:ml longer than can be help<>d. In port land them in hos- pital: at sen in tent on deck: in some places n tent on the Jx.ach. a9. Careful to rdain copies of <ill correspondence and paper work; cspccinlly irn·oice of medical outfit nnd all inrnices received ..:nb- ~qnently. JO. Keep commanding officer informed concerning dangerous or inft!ctious diseases, deaths, important happenings, sanitary condi- tion of port. 2952-3-4, R. .n. Report to officer deck, deaths, accidents, receipt of stores. uncl all ntfnirs which should h<' recorckd in the log. lSO'i- :3 (c)I. 42. See ';Ship and gun drill United States Navy, rno.r· for aid to wounded. page 17; casualties, 104:; general quarters: 276; medical department in battle, 279 (same as chnptrr X. Mnnunl for )INlical Department) . ~<'l' "Landing force and small-arm drill-1912" for first aid, a.~>- 12. e~p. 63; tent pitching, 75-83; sinks, i2 ; urinals. 73: kitchen pits. i3: water supply. 77, 69, JG: position hospital tents, i5; men:s equipment clothing; position ambulance party; packing knapsack haversack, 22; at battalion drill, 4H; officers' equipment, 1!); po- sition staff bnttnlion, 473; ambnltmce party, 17; position staff rcgi- mPntn l, 492. 4:3. Guard against disease brought by animals from ashorc.-c. f. plague by rats; also pets on board ship. 4-1. Recommend :mchorage away from shore in infected ports: flies, mosquitoes from bench, in bunches of bananas, sacking~ closed boat"': sweep out canopy cover 0£ stc.un la.unch; care about breed- ing plnc<:>s on boarcl for mosquito ·s. 45. Guard against lend poisouing, gas poisoning. (Sec circular letter M. & S. 12'1713, ~far. 23. 1!)12, 3:.127-1 2, I. 40. Guard against infection by '>yphilis by band instruments. whistles (boatswain mates. officers' deck), all cooks and mess nt- temlants and dentists. 4i. "'atch for and detect presence of cocaine and other drug hnL't!'. ~s. Ilestrict liberty in ports havi11g much ::;iclrness; also rc::.trict Y<'ncreal cases. 4fl. Swabs and spitkids washed and disinfectants used. 50. Repair at once breaks in surface of linoleum covering of fron decks. ;;i. Air bedding and contents of ha.gs as often as po~siblc : a maximum of sunlight and fresh air. 52. Cubic capacity of the various spaces in the ship should be known ; or know how to determine, for use in case of disinfection. ti06 PARE.:-;uOI.T-MEl!ORAXDA FOR :\IEDICAL OFFICERS. \01.x11. 53. Before a target practice all qualified and acting gun pointer,, exnmiuc<l as to vist1al acuity; result entered in gunnery recorcl. ~;)01-3-I. !iJ. Surgem 's repol't :\t quarters should not be a perfunctory one, but he must haYe an actual report from the sick bay as to the rc:.lllt of the muster of Hospital Corps and sick. 55. Hospital Corps to have no matches other than of the safet\· pattern, ~607-1::>-I. • JG. Regulations concerning standing lights in sick bay and ;;paces must be obscn·ed, 2607-2-I. 57. Before going to sea secure sick bay for rolling and collision . .:>S. Use of harbor water, 2G21-I. In infected port~ . .:rn. Formulate scheme for coping with contagious disease; a few cases; many. 60. See that all spaces in ship are ventilated in bcRt possible manner. Gl. ~fonual for Medical Department, page 1!>3, suggests white clothing when thermometer 75 at 8 a. m. Bathing not allowed if water below 10. G2. See that proper awnings are spread in ship's boats and on deck. 63. ~Iu·l !<> be clM1ted from anchors nnd chains when in infocted ports. Cleaned on~rside, not on deck. Instructions )Iedical Officers, 80-12. G4. Mosquito nets for camping parties in Tropics. 65. Patients suffering from mosquito-borne diseases to be screened. G6. Disinfection of ship, see Manual for Medical Department, pn~e 206.· 67. Patients transferred to hospital require- 1. Hospital ticket. ) 2. Clinical card. . 3 H 1th d From med1cnJ department. . ea recor . ±. Clothing list made out. · 5. Efficiency report to .M:edi-} cine and Surgery. To Bureau of Medicine 6. Card, transfer of hospital and Surgery. corpsmen. 7. Conduct report. I 8. Senice recor<l. 9. Gunnery record. From Executive and Pay Office. 10. Pay accounts. 11. Receipt. GS. Chief pharmacist's mate to keep on hand rubber pillowcnse in which to place henlth records and other valuable official papers in times of danger, abandon ship, fire. ;.u. 4. J'ABEBHOL'.r-'MEMOBANDA FOR MEDICAL OFFICERS. 607 li!l. No smoki11g in ,,ick bay, 262.>-2-I. iO. Jn-.truct chief pharmacist':-; mntf' and other hospita 1 corpsmen ju~t whnt mr.dicin<'s they are allowed to gi•c nnd whnt not without order:- :from n medical dli<'er. ~ee that the,> nn<lerst:mcl fully the danger of cnrthartics or opiate::. in cases of beginning appendicitis or other abdominal trouble. See that they understand fulfillment of thn nlrious poison conditions and artificial respiration. il. See that wnter is not wasted in the sick bay. 12. Isolation ward always ready for sen·ice. i!l. Ilospilo.l Corps instructed as to the proper \\ ny to pack lmap- sack, haversack, blanket, and as to wearing equipment. 71. Designate proper place for stownge of cleaning gear. iii. )fcclh·al olTict'r should know if any nH\1\ tthoarcl lrns bet'n con- tiurd lo ship for period longer than 30 chys for 1·cnsons for which tlw nw<lieal department is cognizant. i:ickness. vcne1't'nl; this ques- tion n:-ked on ttchnirnl'8 inspection, limit 12 day:; by art. 3G70-R. iu. :.\farine's "gold medal" cots useful if extra beds are neces~ary. ii. )fottressas mny be dispensed with in isolation ward and parts of ::;ick bay; men using bunks supply their own mattresses and place them on canvas covers over spring bunk frame. iS. Preparations must be made :for the safety of insane patients. i!l. In case deserters are surrendered on board they must be physi- call~- examined and Form 21 made out and sent to executive officer. 80. When enlisted men are condemned by Board o:f Medical Sur- vey in the United States owing to causes not incident to service their transfer to another station or place for discharge e:hnll not be recom- ended, 3G6 R. 81. Health records should be written in ink. , 2. H medical officer is president of board of medical examiners he orders the new health record to be made out. 3257-1. 83. Regulations for instruction of officers, 2641-1-3: I; of .\mbu- lancc party, 2956-R.; of Hospital Corps. 2G42-I. (Vide ~o. 2.) 84-. Care concerning inflammable ~tores: ~707-1-:>. I. .i . Care tnkPn with Ycncreal prophylactic treatment; instruction concerning d:rnger; information circulars. lectures. circulars issued Ly bureau; posters on bulletin board; punishment for offenders adequate; educational and moral prophylaxis. li. Use whole (complete) name in official corre::.pondence relating to c.nlisted men. "'I. Keep vaccination of 1uen up until at lcnst three times; no prolnlbility of danger. Sec that all bands haYc typhoid mccinalion. 3 .• \. portable electric lump is useful in sick ba~· bed cases. also operating room, also store-rooms. An electric hnncl torch is useful in bt'd~idP work. 608 FARKXHOLT-:\f'E:\IORA~DA FO"ll )!ED~CAL OFFIC'F.RS. Yo(. XII. 89. Sec red cro~ in:,tructions, 3861-R., GeneYa. Conv<'ntion. Mnn. ual ::\fo<lfrnl Depart lllent, chaptet· 26; Hague Convention. ~Irunin) .Medical Department. chapter ~6. !lO. Paticnb transf~rred to other tlrnn united States X:ny Hos. pitab. :W62-l-.3. R. !)l. ~ick bay sw<'epings, clrt>&:ing::,. <'tc., taken in bundle::; to fire rooms and burned. X o boxe::; or anything thrown ovct·bonrd "ithout permission from officer of clack. :Nothing thrown out of ports 92. Ports not to lie opened w h<'n closed by proper authorit.v ( espec. ially at sea) without permission from officer of deck and medical officer. 93. Whenc,·cr nn ofl1cer lea Yes ship (detached) his room ~hould be carefully cleaned and pninted, if mattress is old it should b<' con- demned. 94 . .A high physical standard for applicants for the variou::; fire- room rates should be held. 95. Be prepared to embalm and bring into port bodies of dead. 96. Great care about "Linc of duty " in cases which ma~ pos" bly become pensionable; safeguard the Government. State all facts ery fully. 97 . ..Articles sun eyed and ordered to be destroyed should be so de- stroyeJ or cl<'nrly mnrkccl "not on charge." Metal objects mat ·ed by file; this to preYent confusion in inventory of articles on charge. 98. lnYestigat.e health conditions immediately on arrival in port: also keep post eel throughout the ship's stay, safe anchorage, etc. DD • .Arrange for the removal of infectious cases to hospitals ashore or tents on bench imlcss against the best interests of the patient. 100. If scuttle butt has not sanitary terminals keep cup immer"ccl in formn lclehyd sol.. 1-2500. 101. The United States Public Health Service recognizes as quar- antinable dist>ascs <'holera, incubation period. 5 days; yellow fever. 5-6 days: !'imallpox, H Clays; typhus fever. 12 days; plague. 7 days; leprosy, ( ?) days. State law~ impose additional restridions and quarantine, )fanuul for Medical Department, chapter XIV. 102. In a port where there is a Marine Hospital (United States Public Health Service and no naval hospital) patients may bt> sent to the former for lreatmcnt by application to authorities in charge; arrangements han> been made to that effect by Bureau of Medicine and Surgery, chargt• :30 cents per day, and at contract rate wlien hospital is not owned by the United States. 103. Dental work, especially if clone by other than com111i.ssioned dental surgeons to be carefully supervised, prices, kind of work. 10±. Spitting about the decks and ship must be prevented. 105. Visitors must not be permitted to interfere with the work ot the sick bay; loafing prevented. STRA"GSS-ENDOCRINE ~AXIFEST.\TIOXS. t>o9 101.i. The 1•xccntiw 's office must let medical officer know of all rhnn:re, of rating. Ac; i:oon as n m:tn is recefred on hoard his 11u111e niu't be ,ent to tlw me<lic~il officer; name ii: then l'lltf'r<'d in health t"t'1.:urd imk\. book with date of arrfr!\l: the henlth record it:-elf ma~­ come lakr. ~\.Jl personl:> tt·un:;ft•tTcd from the ship must he report1•u ro inediPal officer for same purpose. ENDOCRINE MANIFESTATIONS. Bys. IL l'!Tll\RS, T,l~utPDODt, M. c .. United Stlltl',; NRYr In this clay oi mechanical supremacy we are unfortunately t.oo prone to forget that the human body is not a machine. rnd('r the spell of surgical domination the clinician is all too upt to forget that pathologic events, both objective and subjective, are not ::itntic events. He is all too apt to forget that c.ver-chnnging flow which spells biologic life. Are we not all too smugly content to regard n. case of measle:;, for example, as a mere snccf':-sion of nasal catarrh, Koplic spot;: and an eruption which is characterized by this and that feature'( Ifogurd- ing the case of mea::,lcti as ::;omething definite, clear cut, static, do we often enough consider ">uch a case from the angle of the iJHliYid- uul so affected? Do "e often enough regard such n c•lSC of mea-.les as a particular case belonging to n particular individual? Is it not our habit, too, having become acquainted with definite dis- ea:;e pictures, to attach to those pictures in our practice the indi- Yiclunls who come to us as patients1 Do we often enough-do we e\·e:-consider that a particular individual prei:ents to us certain ::symptoms which in their entirety spc·ll ·wbate,·er our final cliagno is may be? In the cnse o:f measles we have become too accustomed to the state- ment" All children have measles at some time." Stop and u-.k a mo- ment "Do they1" 0£ cour::;e. the answer is n most emphatic "no." but why? It is going to be my attempt to at least show the need of recogniz- ing with mor~ clarity than has been our custom t:he individual's part in this pathologic world. ·we are confronted by the questions: "'\Yhat determines the indiYiduul's liability to certain pathologic states, and secondly, how are differences in the cour:-;e of such patho- logic states caused? Anatomy is not fixed and permanent, nor is physiology, nor en- Yiromnent, nor heredity, nor pathology. By the latter I mean states of illness. Surely every human being differs from his fellow exter- nally and so more surely differs in the forces that have gone to cause apparent di.fl'erenl!eS. It should be our attempt to find how in- 610 STRAUSS-E!iDOCRINE MANIFESTATIONS. cli\·iduals differ liO widely and in that answer lies tho answer to the question of the variation in cli:,easr states. If indiYiduals are so unlike physically and m1IDtally, surely their illnesses ure quite unlike in occurrence, in character-in nil that is bn~ic. How wrong it is of us to talk of n " case of measles." How much further our medical art would have come hr.cl we paid more attention to the distinguishing features of each individual who at some time presented the symptom-complex which we. for coin en- iencc sake, hn' c labeled " measles.'' \Yould we not now be better able to r<>cognize in measles more than a skin eruption, which falls within certain descriptive limits ·~ Woulcl we not now perhap..: be able to prophesy where reasonably we should find meac;le-.-tl) prophesy which individual is liable to measles~ Had we paid closer attention to individual differences-had we looked deeper into the reasons for these differences, would we not be better able now to understand the vast army of unlabeled clinical states which we each day in our practice meet, which we curse in our ignorance to-day, using a curse word all our own, "neurotic." Gradually there has crept into our medical teaching the dictum, "Study the patient" or" treat your patient." This is carried out in a mechanical way. The microscope, the .Roentgen ra.y, and the test tube arc king. We must believe but what is printed on the labora- tory slip and through these facts we are led to one conclusion-a pathologic an:itomic diagnosis-static-whereupon the individual. the patient, is forgotten and the organ treated in a static way. There is another path which we can follow. The picture that is presented by the cretin is too well known to warrant description here. Likewise, the pictures presented by fully developed cases of exophthalmic goiter and myxedema. We know that the remarkable psychic and physical phenomena manifested by these individuals are t11e result of a disturbed thyroid gland function. They are com- pleted pictures. Latterly, we are talking a lot of the" Forme Frustc." That is a step forward, but why not look further ahead. Study many cases-well developed-of thyroidal disbalance; note in exact detail the characteristic marks; determine which of these marks are con- stantly prominent in these cases and then remember them as thy- roidal marks, signs of a thyroidal disbalance; no matter where "!CD or how unexpectedly, for example, the dullness or glossiness of ·he hair, the dullness or brightness of the eye, the sluggishnes.c; or vivacity of the cardiovascular system. Do that in disturbances of all the glands of internal secretion and shortly you will have physical marks dependent on those endocrine glands, which I believe deter- mine to a very great extent the individual's physical marks. his mental marks, and so his life history. In such a way, study your patients. ~o.4. STRA USS--ENDOCRL'iE lIAN IFESTATIONS. till Reversely, study carefully the history of all your case::; with special regard to past infections and so determine the indi>iduars future liability or immunity to the infectious disea~es. To make my ideas more tangible. I will illustrate. I ghall present n case history ana- )>zed for subjective and objective endocrine factors. ).!any of the::;c. );ave no experimental proof but rest on a foundation of repeated clinic obserntion. Mr. L.: marded, nge 291 n Ru:::sian, manager of a large fa<'tory. presented himSl'lf for exanun tion on December 5, Hll i. complain- ing of ''indigestion, constipation, attacks of weakness and dy::;pnea.'' He further st!ltecl that the attack~ of weakness and clygp1wa c:unc e>ery four or five weeks, always following a meal, and that the first attack came in September, 191G. The indigestion consisted of 11 frequent sense of oppression in the epigastrium nssocinted with nausrn and tasteless eructations. The constipation. too: dates from f:eptcmber, 1916, being fixed, the bowels acting but once in three .Jays. and then the stool being small and hard. The first sif.mificant fact for me in this is the man's career; it means o. man of ,,ill, and courage, and untiring energy, for hnving come from Russia. n few years ago penniless, he is, at the nge of 29, the mo.nager of a .factory in New York City. A parallel fact is that feeding guinea pigs adre- nal extract makes them more pugnacious. One kno\"<'i:; that cour- age and will and the desire to fight are masculine tro.its, male sex characteristics in fact, and these male sex characteristics are under the domination of the adrenal system. Is it not fnir to assume. then, that the patient is one in whom the adrenal system is prominent? He p:ave the history of hnving been in an accident on l\Iay 30, 1916. He was caught between two street cars. thrown to the ground, sustnining a frn.C'ture of the left humerus. After his fall he was un- conscious for three hours. His convalescence ended Antnist. 1916. with n return to work in September. and shortly thereafter his pres- ent symptoms made their appearance. Of course, Crile has shown conclusively the direct damaging influence on the adrenal system which is possessed by mental o.nd physico.l shock. So we may fairly presume that. whatever other damage the accident sustained Ly the patient effected, it made it necessary for him to meet an ndrennl crisis. This was met snccegsfully for the time bt:::ci~. Three months later, upon resuming his work. which called for on incren~e of nenous and physical energy. such energy being nmde pos- sible by an evenly baln.nced o.drenal system. he deYeloped certain symptoms. These symptoms were at first diagnosed hy a general practitioner as "nervous indigestion," and after a period of 1111-.uc- <'C.'-sful treatment the po.tient was referred to a neurologist. The patient might have been tmnsferred to the attentions of a gitstro- enterologist had the usual custom been :followed, 'l>hich gentleman STRA USS--ENDOCRINE MANIFESTATIONS. Vol.XIL "onltl ha ''e l:lid special emphasis on stomach tube::>, gastric acidity, and la ,·a~t'. It hnppe1wd that I considered the case one of delayed adrenal in- sufficiency, the immediate symptoms being explained on the basis of <lishalancc•d splanchnic sympathetic tone. due lo a l'hange i11 the u,,uul adn'nul sy. tern coefllcient. Facts whic·h IC>nt weight to my hypothesis were bronght out by fmthcr cxnminntion. The patient stated that his father had died at the ag(• of 59 of apoplexy. I think there can be no doubt hut that individuals who show high blood pressures and the usually ll!l- sociated <l.egrec~ of arteriosclerotic ,.(•ssel changes muy br cm ,.,id- . ered as having adrenal systems of unusual activit.). So he n•c1·i e<I an adrenal heritage and through the male side, which emphasized the fault. In my physical examination a number of facts stood out as indicative to me of the patient's adrenal temperament. I warn the reader that there is no laboratory proof of this, but there is the strength of a continuous repetition behind them. Si:.rn" which in many other patients lrnYe come to possess an adrenal signifi- cance I made ont in this in:;tance. nnd I will point them out. The.patient was a heavy-set, dark-complexioned male. The fore- head was narrow and sloped sharply back from the bridge of the nose. I might state here that in most individuals exhibiting the pituitary temperament one usually finds a broad high forehead, due in part to the pituitary effect on bony growth, but I feel that the narrow retreating forehead of the adrenal individual is equally due to the reduced size of the anterior portion of the cerebrum. The hair of his head was block and coarse. It had a low implantation on his forehead in front of his ears and from the nape of his neck, nnd the hair line was not sharply marked. The eyebro,vs were heavy llnrt broad, and were joined o,·cr the root of the nose by a fairly wcll- markecl hair fringe. In spite of this profuse hair growth o' c1 the head that over the body was disproportionately scant and the pubic hair tended to the feminine type. 0Yer the sacrum grew a lot which may be considered n. poor prognostic sign. I consider the dispro- portion between the hen.cl hair growth and that on the bocl.v ' <'ry significant, poitning to an adrenal fault. It has been shown by guinea pig feeding that both skin pigment and hair growth can be to a degree controlled by adrenal extract. The patient's eyes were prominent, the pupils wide and slo\v in reacting to light. OI conrse it is known that the intru,Yenous in- jection of adrenalin into animals causes the same changes in the eye as follow the stimulation of th<' cervical sympathetic nC>n1e-that i<:, the retraction of the eyelids, protrusion of the eyeball, and the dilatation oi the pupil. ... SI'RAUSS-ENDOCRINE MANIFESTATIONS. Thc pntil'nt's ire:; were pigmcnt~<l dark urmn1 as was the skin of till' cntirt> hod_,., I have found thnt this pi~ent is an adrenal sign. 1'hc ph:uynx showed a slight congestion. The cars "·ere somewhat c\'nnos cl. nn1l the complexion. though sallow. was fln:.hecl, all facts 1;ointiug to a poorly :;tabilized rn:;omotor !"ystem, which i11 part i!- under the control 0f tlw a1lrenul organiz:ltion. The th~·t·oicl ~land ,bowed no enlargement. 1'hc ',,.,ornotor r<.>ae ion on the ::-kin. or. in other words, the cnpil- lan· rc.tdion to a nwclumical stimulus, was of very poor quulit~·. In thi"' co111wction I might Hay thnt this reaction is obtnined by rnpidl~· .Jr:1wing 1l blunt instl'umenl o,·er the skin's snrfocc, excrtin:,r slight pr<':-.. ... ure. In a normal reaction within the limit of fin• seconds a pink flush appenrs nlong the course of this stimulation, whic11 im- meclintel;v facles into white, carrying along its borders a fin<' pink halo. The factors which vary are the speed of the nppcamnce of this capillary dilatation nnd subsequent contraction. the duration of this ,-i::;ible reaction nnd finally the proportion between the contraction area CH' white part and the dilatation area or pink part. It h:\, been my experience to find in normally bnl:rnccd patients a fnirly rnpid rcnrtion within 5 seconds. the entire line fading within 20 seconds, the dilatation merging into contraction slowly with no disproportion between the white and pink parts. In sub- ject~ who arc extremely thyrodial this reaction appears too rapidly, fades too rapidly, and shows an exce.-;s of vasomotor dilatation or pink. In adrenal subjects the reaction is slower than normal. There ma~· be no initial dilatation along the course of the stimulant. but immediately one sees a line of contraction surrounded by a pink zone. the white portion, however, being disproportionately promi- nmt. In extreme cases ll. wheal forms along the course of the instru- ment used. In this connection it is interesting to recall the brilliant therapeutic resullc; which are obtained at times in cases of urticaria by the sub- cutaneous use of adrenalin. The patient showed a very poor vasomotor reaction, inasmuch as il.;; onset was slow and sho"·ed both poor Yasomotor contraetion and <1.ilatation. Fading look place too quickly. But. after an interrnl of nearly a minute the entire phenomenon wa:> repented but with nn en- tirely different character. This ~econclar.v reaction showetl a ,·ery prominPnt conlrn.ction zone slightly rai!'ed nbow the :-kin·s surfnce. bordc1wl with a fine dilnlation zone. I might c;n~· that this j..., the only time that I hwc !';een such n. delayed reaction. I here took it to mean an l'Xt l'e111ely pool' rPgnlatio1i of th<.> vasomotor nerve supply and on account of its final nclrenal character I placed the hlam" on thnt mem- ber. The pul"t' rntr was 60. the rh>·thm regular. the blood pre ... sure C)l4 grRAUSS--EXDOCRINE MANIFESTATIONS. Wtb 100 ") ... tolic. ::;O diastolic. This low hloou pre'-sure can easily. too, be attrib11te1l to some adrenal fouJt. The heart showed nothing un- ll"llal. nor <lid t hC' lung-:. The al.Jclomen was somewhat obese, rather glob11ln1· in hape. The reltcxc> were p~·c>-=ent an l equal. The abdomi- nal \mil "as held rather rigid. - • o n ·1 ... se::-. "ere made out. The liver and ~plccn 1licl not show any enlargl'ment. There was :;omc slight tendcrnc:;s in the epigastrinm. There . were no changes in the skin senc;ibilitic:; of the ahdomen. The extremities showed reflexes acti\'e within normnl limits, and equal on both sides. The hands and feet were somewhat con~ested, almost cyanotic, and were cold. This fault. t.oo. I took to mean <.Orne wcnknes.« in the nlsomotor regulation. ~nbjet'fo·ely, the patient presented nothing beyond what I huve already noted. His words were: Once In four or lh'c weeks after meals I find I can't catch my breath, and I ~et 1wak. I l.Jecomc nau<:eated but l1a\·e no 1·omiting. f:.ucb an nttack lash\ 'or about twq hou1·s. I think tbat it has in each instance been caused by the in~estlon of fried fntty food or shell foocl. I lm,·e no :wt uni JI:! In with It but feel a grenl p1·essure In the center of my abdomen. I have had three atmck.« in nil, but sl.nce my accident I have been constantly troubler! with much <'ruc- tation of 11 tnstele.«s ~ns, associated with abclom!nal distress after meals. Thi,. ilistrt'ss couws on immetlinteJ~· after meals and lasts appro>.1mntely an hour . . \s~chlll'U wllh this bus been a positive constipation, m~· bowels not mo,·lni: hut once In two or three dnys. Further questioning revealed no other subjective features. I analyzed my patient in the way outlined above. disregarding his :-ymptoms. EYerywhcre I found facts pointing to some disturbance in his adrenal balance, and, still disregarding his complaints, I set my:;eli the task of regulating his adrenal balance. which I felt sure wu~ at fault. The thernpeusis in this case consisted of feeding small quantities of :tdrcnoJ gland extrad l wice a day. The amount I used was one one-hundredth of a grain at each feeding, and on January 25 the patient reported to me that he was very much better. that he had hacl no spells of dizziness, that his appetite was excellent, that hi~ cpigastric pressure had gone, that his bowels moved each day, the stool being very well formed, that he felt stronger, that he had no more eructations of gas after meals, that he was sleeping excellently. and that he had gained 2 pounds in weight. The blood pre ... .;;me had gone up to 120 systolic, 100 diastolic. This was the extent of my therapy, and I feel that the result justifies its unusual character. ·working reversely, I have used adrenal· extracts. feeding them to patients who have presented the subjective and objective symptoms characteristic of all degrees of gastric hyperacidity, and have often been rewarded with success. This paper has been written simply as a plea. for a more accurate and thorough study of one's patients' characteristics; those charac- LANE-STUDY OF DENGUE· AT ST. THOMAS, V. I. 615 teristics which separate them from other individuals, which are bnsic for those individuals. It is a plea for an increase of regard for the factors which have gone to make a patient what he is, and, finally, :L plea for the recognition of the importance of correcting faults which tincture the entire organization of the patient. I feel sure• that in the correction of such defects we must eliminate the vast ma- jority of subjective symptoms, which in most cases do not depend on ~ny definite organic change. A CLINICAL STUDY OF 100 CASES OF DENGUE AT ST. THOMAS, V. I. By l•'. l~. LAI<~;. LIPulPnnnt (J. G.), M. C., Unite<l Statrs Nnvy. About the latter part of November, 1917, an epidemic of dengue fever suddenly made its appearance among the Americans who had been on this i~land three to eight months. White :rn<l black were affected alike. Up to the present time there have been over 200 cases. One hundred and forty-odd of these have been treated at the Naval Hospital. In looking oYer the literature of this disease it was found that there were some peculiarities manifested in this epidemic which it might be well to call attention to. One hundred records which had been carefully kept at the bedside were selected as a basis of this article. These represent rnry well the average run of tlie disease as seen during this period. · As far as statistics go, dengue has never been mueh in evidence on these islands. An occasional case was reported by the local health authorities each year, but it was of no moment. Ho,vever, dengue is probably quite a common disease, especially among the children, but the diagnosis is rarely made because; most likely, it is one of the very 11umerous :fevers which the nativP.s claim to be subject to, known by nany various names and usually ascribed to the evil influences of the night air and wind or to " obi," the evil genii of these paits. These patients would rarely come under the doctor's observation. Only an occasional sporadic case in an adult would be seen and diagnosed. The epidemiology is not very definite where it concerns the source of infection. The first cases appeared in the Marine Corps. At that time there were a number of natives working at the barracks, and it is .quite possible that one of them was the source of infection. The other possibility is that one of the enlisted men may have been in- fected elsewhere by one of the infant cases and thus brought the disease to the barracks. However, stress should be laid on one very important feature in the mode of spreading. The sanitation of this town is about nil up to the present time in spite of much effort nnd thought. When the trouble started not a uhi 1.A:XE-::;TUDY OF DENGUE AT ST. THOMAS, V. l. \'ol. XII, hou:-('. l'i!:iterll, or well hn<l l'\'er l11•p11 :-cl'l'l'llPd. " ·nll'l' 'to~.111 arn11ml in pool:;. The guttering of the roofs was i11 bail repair and wat('I· coll1•ctcd tlwrc. 11 was indeed a happy hunlin!! ground for the far-fumed and p<'stilent mo-.quito. .\llhough th<' ho::.pital hncl i'>L'<.'11 mad<' as mosquito proof as possible when it was put in com- mis.,ion. ~·et 011r neighbors raised enough mosquitoes to supply both thPmseln•. aml the institution. ·when tlP fir::.t few cases had been ad11:ittctl. tlw other patients, lhe members of the hospital corps. an1l doctors comnH'llCl'tl to ha\'e breaking bones and fo,·er. The spreatl was n~ry i·npid. It is generally under,.;lood that the m.osqnito 1s the infocting a~1·11t. About 99 per c ~ nt of all the mOhf(nitoes, both at the barrncln; :md the hospital, are Stegomyia oalopus. Very occasionally the ('Ult•x i!> St'l'll but no anopheles us yt->t. ft is ~v1w1·ally undpr,.,tood that tlw c·tdcx is th<' spl'eader of dengut•. In l'\'Pl'~ c·ust' th<' patient has bcc11 cxposNl t•ithC'r at the barracks or tlw hospital, and only thosl• that ha,.<' bt•Pn at one or the other of these two plncc,; li:n c bem attacked. Th<' conYerse is also true. Another point in fnstening 1 hP blamP on the proper carrier is the fact l hat dengue i~ a ,·ery rapid spl'eadl'l' among nonimmunes. The st gomyia bites by tlay n well as by night, so that no amount of mosquito bars could protect tho--e doing duty unless they were confined to bed. If the mos 111ito hacl been a night biter only, the rapid spread might have been cbeckcrl. All of the foregoing seems to put the blnme wholly on the J::ifr[;omyia calo7ms, a point which has never bcPn brought out Hry strongly. The possibility of the stegomyia as n. spreader of tht> dis- eas1> is mentioned by some but never considered sel'io11sly. ThC\ incid('nee of new cases <lepended very markedly on the rain- fall, 11s docs C\'erything else influencing the, health of t,his t·ommnnity. Within 36 to 48 hours after a rain tlH· mosquitoes would increase very rapidly and the new cases develop in almost direct proportion. During a dry spell there might he no new cases for clay$ M a timt> anrl the mosquitoes would be conspicuously lacking in proportion. The incubation period was rather difficult to ascertain. but in three cases it was Yery definitely placed at four to ~ix day'. _\II thr"e 1·011tracted dengue within this period after lhe arri,·nl from thr '3t.ates. The symptomatology, in general. was about the snmc as tlr~cribed elsewhere. The onset was sudden, beginning with the rnguc pains in the back and legs; headache; malaise; chilliness or an actual mild chill; perhaps constipation or maybe diarrhea; loss of appetite: fe•erishness and occasionally a flushing oi the skin o.f the face and tho neck. These wel'e ahont the usual findings the fit·st day. Tlw second clay found the primary flush of the face ,gone uncl the pn.tient wns quite sick. The temperature was between 102 and 105 degrees; the aches and pains in the back and extremities, the 11(\atl- ' CLINICAL CHART ONE ttUNDR'f.D CASf.5 Of DENGUE fE.VU ANALY.515 BY TYPE <o>~-~ . ~ . lf'l . . ~ .~. 3 FO>O>OO--C\lNIO ~ . ~ 2 Ol (]) 0 0 0 0 0 0 0 Q-o:;~ _ _. __ _. .......... 3 4 5 6 ' .._ 5 ~de le }) icl 7 I I I 1 vr e To al - ~deni 1s 52. % % % 0 0 0 2 16 8 2.0 16 8 6 e. 0 2 0 ANALY.51.S AS A WHOLE. Avera~e 100 cases Rash 63, % Adenitts 17. % 10. % Vomihno 8. % 3. % Di'a.rrhea. Ja.unc:l.Lc.e 1. % Heroes La..bialis 1. % l>LOOD WORK l a.verage) White l)Jood Cells 4300 -::i Polvs 59.5% A er kne 48 uses ~~ Lvmohocvtes 30.5% l-~1+-t.._:::i:=t~+-i--!--t±:--~µ,o~I O -~ ~ L~roe Monos 7.8% 2 _i:;;;;- o o ~0 Transilionals 1.7% 3 l.J"- 10 2 A Losinonhvles 0.5% 4 l7 32 JO J 10 4 W.B.C..s as low o.s eeoo 6 ,, 4 c Polvs as low o.s 38.% 7 2 4 Lvmoho as hioh as 8 0 0 To al - a! , 58 ~ 617-1 LA~!:.-:ffUDY OF DENGUE AT ST. rno:MAS, v. L 617 ache au<l the pain in the e.Yes were rnnch worse than the <lny I ·<!fore. Jlow·eyer, th<.>"<' symptom-. were not, and never became at nny time durin!! the disease. ns sHer<> us those usually described. especially the bone pains. The interesting feature at this time was the intense pain in the eye'. e:;pecially on voluntary motion. accompanied by n con!!'e::.tion of the conjuctirne and the watery condition so often -een in mea:;le::;. The pain on motion was elicite1l by havin!! the pndent k~ep the liea<l fixed anJ the eye follow the fin!!er of the ex- uminer :i:o far upward and to each side as possible. These eye -'\ mptmn:-;. the :-oudden ri::;e of the temperature. l\nd the anorexia were "~ charncteri:;tic .rn<l constant that a diagnosis conl<l be m:11lc defi- nitely without reference to the pre' ious day's hi,tory or the bone 5''tnPt"ms. which I remarked before were almost trivinl. Except f~r these <'ye pains the patient might ha>e had a sever\! nttack of intluenza "ithout nny bronchitis. The pnbe was quitt• .slow in com- pnri,on with the temperature, Sl!ld0111 rising abow 90 per minute, u::.milly 15 to 85, "ith the temperature at 104 F. or lO:i F. Tho~e cases that had a blood examination 111acle at this time showed a leucopeuia of from :;,ooo to 6,000, a slight decrease in the polymorphoneuclear Ieucoc~·t~ and u :slight increase in the lymphocyte.-;. In:stend of the in,omnia usually descril ed, all the patients seemed to sleep especially well throughout th<' <'ntire course of the disease. In fact. the concli- tion was quite the reYerse of insomnia, a sort of stupor for the fir.st four dnys ut least. The urine did not show any constant alteration from the normal. On the third day the temperature fell as suddenly as it rose, seldom, if ever, to normal, but to between 99 F . and 101 F. The mental and physical depression, while still pre::.ent, was much le:-s. th<' pains nnd nches better, nnd although i<till weak and tired the men nhno;;;t invari- ably staled that they were wl'll nnd wanted to get out. of bed. At this time the di::.case took on one of the two form,.; n;;nally dc.-;cribed: The ·· saddleback ., an l foe " nonsaddlelinck ·• type. ~\. careful study of the mnjority of the temperature chart:; would afre a fairly accurate progno,ticatiou. IL seemed that thos~· doomed for th1• '· !-iaddleback ·· or i:econd rise of fe\'<'l" would drop about a <le!!ree lower thnn tho<:c goiu6 011 to an uneYentful recoYery, the "nons:idcllebnck .. ( <:ce illnc;- trntion of tlw averuge chart). Some few (13 p!!r cent) would show the beginning of the secondary rash. The fourth day's chart found those of the "sncldleb:ick .. type with a rise in temperature of a fraction of a degree nnd tho,:;e of the '·non- satlcllebnck ,. type with n. fall of about the amc amount. In either cn-.c there was the bright rell or scarlet ra.-h like thnt of mea-:Jes. In the very typical cases this began on the palms of the hanlls, over the back of the thumb, and over the do1-c;al surface of the great toe, spread- IGOOS-18--4 618 1..AXH-:;;Tur>\ OF ugXGUl~ AT ST. THOMAS, v. T. Vol.Xii. ing rapidly 0' <>r tlw nrm:; a11tl leg--. :tbdomen. chest: ancl face. It wa most marked on the forettrms and lower legs: abdomen, and face. The itching was not a!' marked as it became some dn~·s later. This eruption was present on the fourth <lay of both type!-1 in 2G per cent of the cases. During the third or fourth day~, or the period of so called crisis, 10 per cent of the cm-es had epistaxi-; an<l 8 pN· cent vomiting. The epistaxis was quite senre when it OC<'lll'recl. lastin!! from 2-! to 7:! hour; ancl le:t' ing tlw patient somewhat t'Xs:m:r11in·1 ed in spite of ict•, packing, ab!-'olutt• resl, and the other usual form . .., of treating nosl'blN~cl. Dianhca was present in :t per cent, herpes labi- al is in 1 per cent. .A blood count late the third day or Ntrly the fourth day showed a. leucopenia of from :2,000 to 3,500, with a very consid- t>rable decrease in the polymorphoneuclear leucocytc:; as low as 38 per cent and an increasP in the lymphocytes ns high as 53 per cent. This fourth day was mo-;t important from our sta!l(lpoint, as it marked the beginning of a complication of which very little is ~nid in the literature on the subject; namely. the involvement of the lym- phatic glands, amounting to a general lymphadenitis ns n. rule. In 5 per cent of patients this started on the third clay, but in 25 per ('(!nt on the fourth day. The condition was brought very forceably to our attention in the third or fourth case. The man began to complain Yery severely of pain. tenderness, nnd swelling in the glands of both groins. ~xnmi­ nntion reveakd inflamed: swollen, tender. nnd painful glands in both inguinal regions. This was so very marked that although the man was known to be free of '"enereal disease (a hospital corpsm:i.n who had been with us for eight months) this possibility was carefully looked into and examinations made for the four or five succeedin_g days. Nothing of n Yenr1·r.nl nnture was found. The second day after the inguinal glands became involved, the epitrochlenr and an- terior and po terior cervical glands enlarged but were not painful. This case stal'led the careful notations of this series. All cases that had ~my history of venereal disea>'e, either active or of old standing. were thrown out as indefinite. In all, this venereal type amounted to about 25 per cent of the total number studied. The glands in all this number were found to be involved, but whether due to dengue or yenereal disease could not be determined. In the other 75, G2.'i per cent had lymph gland involvement to a greater or less degree. All were swollen. some were painful or tender, and in the Yery few cases that we were able to follow up they remained swollen and tender from four to six weeks. (See chart for incidence of aclenitis ard percentage developing each day of the disease.) The fifth dny invariably told the tale as to whether the case would be o:f the " snddlebnck" type or not. Of the cases studied, 52 hnd the secondary rise of temperature and the other 48 did not. On this f !..\XE· -STl.DY OF DEXGUE AT ST. THOMAS, V. I . 619 dar 1;, per cent. including both t~·pes, showed the th':"t signs of rash 110~1 10 per cent gnve the first signs of the ndenitis. Tho$C that hnd the rise went up one to two degrees and those that did not dropped to normal or a fraction above. Tho latter type immediately bcgnn to pick up strength, both mental and physical, and "ere m;unlly allowed 0ut of bed. On the ::ii:xth day, the "nonsadclle-back" had no fever and remained ~o. Tlw l'll!,:h appeared for the first time in 6 per cent n.nd the adcni- tis in 4 per cent of tho total number. The ':saddle-back'' type had a fall in tempernture to 99 F . or a fraction nbo' e. On thi~ 11ay one i·a:>e cleYelope<l jaun<licr. There were two other cnsei; tlutt had an icteroid appearance, but lhey had n history of ha\ing h;ul jaundice at some time previously, clue most likely to syphilis. and. therefore. they were not counted in tho statistics. )lost of the patients were out of bed on thr sewnth tlny. Thu;;e that bad had the remission of fe,·er ·were now either normal as to temperature or they had a fraction of a degree and were so restless that u longer stay in bed seemed to be useless. The other type hacl not had any fever for two days. Somo 2 per cent of all ca~ hau the beginning rush and 2 per cent the adenitis. At this time two \·ery interesting skin phenomena started. After being out of be(l ior a day or less 17 per cent, ttccording to the records that were made 'll the time (although I am sure that there were almost twice that number in whom the symptom was overlooked in the bcgiru1ing of the study and charting), commenced to have a very peculiar vaso- motor condition. The hands, arms, feet, and legs \\ erl' quite cyanotic, cold, and very damp. In a few instances this spread to th.! abdomen and the chest. Pressure on the skin would lun·e a white mark which very quickly became blue on rele:t!';e of prrc;snre. Hest in bed. elevation of the part, and heat did not seem to ha' c un,v effect in the relief of this condition. There were no ~ubjccti\·e symptom,.; except that the hands and feet felt cool without real <lbcomfort. The cyunosis gradually faded away in about three clays uncl did not reappear. It did not seem to have any definite relation to 1 ither typo of the disease. Secondly, there was n. very marked h~·per­ resthcsia. over the arms, chest, shoulders, and the upper back in three case!' The weight of the clothing was quite p;1inful aml if the part wns touch. cl the pain was intense. There was no local abnormality of the skin accompanying this. These cases did not ha Ye the cynnosi:; noted .1bove. · All cuses W<>re discharged by the end of the "ighth dav at the lntest. None had any fever n.t this time and all felt fairly strong nnd ambitious. About 1 per cent had the rash just starting, but no one hacl the lymph gland involvement beginning this late. About u2Q l.AYJ-:-STUDY 01'' DEXGT:E A'I ST. TII0lf:AS1 V. I. this l imc the desqu:unation of the skin c:ommeucetl. .\::; far ns l·oitld he learne1l practically enry one that had hatl the rash ··peeled." This proce-.<: -.tarted with a Yery fine furfuraceons scnle which !!radu nlly becnme (·oar,er ns time went on. In fact. wher<' the clesqu:nna. tion inYol,·cd the horny portions of the skin. such as the sole:; of the feet and the palms of the hands. the scales consisted of large pieces, In two or three instances there was almost a complete cast of tlie grrul toe. somr two or three weeks after the feyer ha.cl sub:-.iclCfl. In seYeral instances the clesqnamntion lnstetl for six ot· seYen ''eeks, ~radually becoming finer as time went on, until il fnclccl out com. pletely. Abont this time or a little earlier the appetite began to re- turn, but there wns a peculiar metallic taste to the food which almost cYery pntient complained of. ~othing much hns ever been said about the after effects of" Dand" feyer.'' ~\s far as c011lcl be learned. and in my own case pnrticulnrly, complete recoYery of strength was not attained until two or three weeks after the fever had subsided. It "·as about the same c nuli- tion as is experienced during the rccoYery from a very severe attack of tonsillitis or "quinsy." While lmcler ordinary circumstances the con-rnlec:cent felt fairly well and strong for the usnal tasks, enclur- nnce was 1ery low and any amount of exercise in excess was Ycry enervating. · Resene strength was entirely lacking. DIAGNOSIS. The absence of any throat, chest. or abdominnl symptoms or find- ings; the history of the sudden onset, in some cases beginning during the night with a chill; the sudden rise of temperature with a com- paratively slow pulse; the pains in the back, legs, and eyes, especially thl' pain on forced motion of the eyeballs; the watery, congested con- junctivre; chilliness and malaise; anorexia; the low leucocyte count ; the fall in the percentage of polys and the increase in the lympbocrtcs: and the absence of any abnormal findings in the urine woul.l bl' sufficient to give the diagnosis on the second day, the time nt which the great majority of the cases came under obc:er1nt ion. llG\i~ITY. In most cases there seems to be an immunity after one attack. Thl' epidemic begun suddenly among the newly arrived population. The American negroes, on duty in the Tropics for the first time, hnrl "breakbone" fever in even a higher percentage than the whites. The native negroes had no increase in the disease. There wcr" six or seven new cases reported by the civilian physicians, bnt these wcro among children of white pnrentage ranging in nge from 3 to G years. These circumstances only added credence to the assumption )lo. •. LANE- STUDY OF DENGUE AT ST. THOMAS, V. I. 621 that the natiV"es were immune, due most likely to the fact that they had all had the disease as infants or in early childhood. There were, however, at least 10 cases among the two hundred and odd in the town n:-; a. whole that had a recurrence within three to six weeks after a ivpical first attack. The second was always milder, but similar to tiie first. Five or six others had had dengue several years before, but had another attack at this time. There were two others who hn.d been through several epidemics without ever ]uwing contracted it and considered themselves to be immune. They both had a severe :ittack. It would seem. therefore, that one attack usually gives immunity, but about 5 to 8 per cent have a recurrence within a few weeks or within several years. Treatment.-The treatment of the condition as carried out was en- tirely symptomatic. The patient was given a bath and a purge and put to bed. The purge was usually a saline (mngnesium sulphate) and was sometimes repeated in two days. In those whose bowels were kept well opened there seemed to be a more rapid and complete relief of the symptoms. If the headache was very severe an ice cap w!\S in order. As a rule, 5-grain doses of nspiri11 I. i. (1. or q. cl. re- lieved the aches and pains and seemed to relieve thP sensation of fever by inducing a mild sweat, although in many cases the perspira- tion was spontaneous and profuse. The diet was usuaJly soft, unless, !lS rarely occurred, the patient retained his appetite. Water was ~iven freely. As a rule, the patient was allowed to do about as he pleased after the temperature had dropped to normal or thereabouts. He hnd whatever he wished to eat; he was nllowed to be in or out of bed according to his inclination, and it was found that none of them stayed up ior any length of time, for, although they felt quite strong before getting up, they were very glad to get bnck jnto b~d within 15 or 20 minutes, at least during the first day or two. This leniency seemed to act for the best in two ways-it satisfied the patient's mental and physical unrest at being laid up with a trifling disease, as he con- sidered it, and it also helped to get his mind off the aches and pains that still existed to some extent. There were no harmful effects ob- served from this method of treatment, and in fact we thought that it even improved the speed of recovery by hurrying the recuperatirn power for increased physical exercise. All cases were kept under mosquito bars during the infective stage, supposed to be five days. SummariJ.-There are some 10 or a dozen peculiarities of this epi- demic. Points that others have only touched lightly npon, or not at all, that I wish to call your attention to are: First. The immediate source of the infection was unknown and could only be guessed. The important feature, however, was the 622 l • .\~i:-STUD\" OF D1':XGUE AT ::>T. Ill0)I.\S1 Y. l. • \·01 Xll agt·nt cnrrying the infection. The Llame cnn lw pluced entirely Ulld -without hesitation on tl;<' SI f/Olll!fi.a cafo1111~. prnctically tlw onh· mo--1f11ito "l'<'ll and inhabitating the localitie::. where the tlif:ea!-oe w~s mo·.;t preYalcnt. :md the only place where the nwsrp1ito Lite seemed t•1 do any dam.age. I belie\·e thnt. the stegomyia family ha.>e been U-;- pccted before. but nothing definite has been written as fur as I ca11 finc.l in references to the subject. ~rcond. The mild character of the bone pains "as characteri-.tic. Third: The interesting and preYiously not detimtely reported in- Yoh·ement of the lymph glands. In many easel:> this was quite seYerl! and wns treated with ice. No breaking down nor suppura~ion sub- sequently has been noted. In all, 62.7 per cent 0£ the 75 free from Yenereal infection developed this. A rather high percentage. It was not one set of glands but all the large superficial glands throughout the body. Fourth. The epistaxis, although it only occurred in 10 per cent of the ca!;es, was •ery severe and difficult to control. Fifth. The pain on forced motion of the eycbalJs was the princi- pal cause of the symptoms described by the patient as" headache., or "pain in the eyes .. , Probably this was due to the muscular attach- ments rather than to the muscles themselves, for the pain was only elicited on extreme motion. Sixth. The very peculiar and sometimes startling symptom of hyperaesthesia, of a most intense 'ariety, was noted when the shoul- der was 1mconsciously touched by the examiner. Seventh. The vasomotor phenomena occurred from the sixth to the eighth day, causing a cyanosis and coldness of the arms, htmds, lower legs, and feet in about 17 per cent of cases. Eighth. The disappearance of the eruption was followeu in about 2-t hours by n quite severe and long-continued desquamntion, accom- panied by intense itching at times, a sensation as of swelling of the hands and feet, and a continual and profuse swt"?nting of these parts. Ninth. The blood work did not show on tlw average the very low leucocyte count and the discrepancy in the differential count usually acredited to dengue, yet these findings were sufficiently marked in a number of cases to accord perfectly with other description!;. It would seem from a general view that these blood findings depended largely on the severity of the attack. Tenth. A. very disturbing feature in the convalescence, from the patient'c; standpoint, was the inability to relish food due to the liad metallic taste that e•erything had, although the appetite was quite keen. J<:leventh . .All the ordinary work could be performed without an~· diffiC'ulty, but the least extra strain, such as inst walking or going up hill, brought on an intense weakness and fatigue which harl not !\II· 4. HERMAN-EPIDIDYMOTOMY IN MILITABY SURGERY. 623 been pr~sent before the fever and which it took some dnys nnd, in mnur c:i.-.e::;. week~ to overcome. Twelfth. The Ja,.i feature to which attention i,.- callt•<l is the quc-.- tion of imumnit\. In most cases this srems to hold after one attack, but nbout :; to S per cent hnd a recurrence three weeks to several vear:> ufter the original attack. · The epidemic gradually faded out. About the 1st of ~Inrch. 1!)18, with tlw tlrcrcase in rainfall it had almost dic:nppeared. Only un occnsiomd · 1<lividual who had just arrind "ould hecrnnc infodecl. J)uritl!:! thP 4lry seac:on when mosquitoes 11.,.cl'c n•r:v fow. dengue was praetica 11~ al.wt•nt. X ow the rainy season has i::tar!c<l :Ul<l in tlw ):i-.t H clay:-: seven cases ha,·e deYcloped. two hein!! recurrence!" from the ln-.t t.piclc•111ic·. The control of the mosquitoes nn<l their brC'cding pl:1ce-. h·1s impro,·C'd to 11 slight degree nrnl it is hopecl that then• will he fo" Pr of tlw pests. but the inabilit~· to obtain screening for ,Jw to" n. thl' lack of a properly trained corps of sn11it:u·~- in!:'pcctors. ·md thr difliculty in cclncating the people ( nnf i\'es) clocs not gin~ nnwh hope of freedom from dengue in the near future. EPIDIDYMOTOMY IN MILITARY SURGERY. fl~· r.. H1:111t.\~. t.h•nl1•nau1 (.T. (;.), :U. C .. l"nlti·d l:itntl'b :-;nvy. :-::11rg<o11s in <'i,·il prnctice haYl' no unanilllity of opinion ri'gard- in~ tlw tre:ttlllcnt of aeute gonorrheal epidi<lymitis. )fost :-nr!!eon,.; :tdYocat<' operation in n ~mall percentage of weJl-gl')cctl•d en~~:-:, a few employ it regularly, while the majority of authurittl•S ar opposed to . all 11pt•mti,·e forn1s of treatment and continue to rely c•ntirely upon the topical application of ointments 01· of val'ious otht•r i11t•clil'a- ments. Differences of opinion likewise cxi!'>t among tlw aJn1c:tte-. of routine opemtion as to the ue::;t technical procedure to l'IUplo~·. Some believe with Hngncr that the mo::;t satisfactory re~ults 'lre tc he out.a.ine<l by free exposure with splitting of the epididymis and rlrninuge; others mainfoin that a much simpler technique i!') in di l"l! .... pccts preferable in the \llSt majority of instances. In civil practice. it has been our rule to re,,,er,·e epi<lidymotomy for the hyperac11te <'a-.es and largely with tho idea of relieving the intense pain that chnmctPrize:-: them. In practice among out-patients in the clinics of large cities these cn--e:. nro tM •\lly nmbnlant. It has been our experience that while the com nlc ccnce time is materially shortened in this clnss of patients by opcrntion as fur as the subsidence of the intlnmmat ion is concerned, the total duration of the infection is not influenced by operation. This we now believe may be explained by the failure to confine thcsr patient~ to bed for a reasonable l<'ngth of time idter operntion. In 624 HF.R~fAN-EPIDJDY::>IOTO:MY IN MILITARY SURGERY. \'ol. XIJ. view of the foilnn' lo mntt>rially recluce the duration of the <li"c:lS{> ancl because of the probnuly greater percentage los" Gf function of the epididymis in operati,·e cnses.we had adopted epidi<lymotomy in only a small group of cases in ci,·il practice. The conditions that obtain in narnl surg~ry are in certain rP:-pect ditferent than those in civil practice. In time of war it is doubl~ important to return the patient to duty in the shortest time po:-... 1blo. and to return him in such condition that he will be no longer a men- ace to the health of hi~ i:;hipmates. It is <'qually important to mini- mize the probabilities of the reeunence of the disease. The prohlv11 ... are most satisfactorily sol n!d by th<' 01wra ti on of q>id idyn1oti·m~. We feel that in cases of unilateral epiclidymitis the small differences in the percentage retention of function gained hy the palliative .fo1·111 of treatment is far outweighed by the advantages of rapid relief from pain. rapid and more complete subsidence of the inf11tmmatory reaction, by the much shortened hospital residence of the patient through operation, nnd finally by minimizing the probabilities of re- current epididymitis so commonly seen in cases treated p11llint.ivc>l~·. Technique of operation.-The operation of epicliclymotomy l'ltl· ployed in Na\)' BasP IIospitaJ Xo. :> is a simple procedure. The tc>chnif(tH' about to ue described is npplicnble to I hat great majority < f C:l'ies of arute :N't>is!"eri:m epididymitis in which the major pnrt of the inflammator~· prores.:; is confin<'d to the globus minor of th• c•pi<lidymis. Infiltr:ition anesthesia. u~in:r a solution of cocnin U per c<-nt) is emplo;vc>d. and the operation can he performl'(l pnin- le~!"ly if care is taken in the localization of the injection. .\ line of infiltration 11 inches in length is mrrcle in thl' skin of 1he lowc•1· part of the scrotum, just to the side of and parallel with lhl' mplic and over the inflamed glohus minor. The scrotum is gently !!rnspecl at its bnse by nn :1ssistant who rotates it so that the field of opemtinn is brought conYeniently into position. The nssistant makes gentle pre;;;sure in order to render the skin taut. Unnece;:sary pressure nt this time w111 cause considerable pain to the patient and accomplish nothing more than will the gentlest handling of the inflnmecl pnrt~. An incision about 11 inches in length is now mncle through the nne,,-thetizecl !"kin and subjncent tissues down to but not through the fibrous sheath covering the epididymis. Care must be exercised in order to define the line of reflexion of the parietal layer of the tunica vaginalis from the point of its reflexion at the junction of th1 epiclidymis and body of testis. This differentiation is made by not- ing the differences in consistency of the tunica above nn<l the cpididy- mis below. The srrc of the tunica will be found to be more or less distended with inflammatory fluid constituting a hyclrocele whkh is flnctunnt arnl pninl<'si> to gc>ntl<' pr<'ssnre. 'T'he epidicl:vmis, on so .•. HHR~1A~-l':PrDiffD10TOMY rn ~OLITARY SURGERY. the c011trary. is induratcd und exqni:<itelY tender to prc::.snre. Cnre -honld be taken not to open the tunica. otherwi--e the patient's con- ,11Iescencc will in nll probably lie prolo11~l d through th<:' reforma- tion of n hyclrocele which hns little tendency to he :1hsorbcu und which will neccs.<>itnte either punctnr" or raclicnl operation. In c:M" in "hich l:n·ge 1·01lection-: of inflammatory fluid nre demon- trnhlc in the c:w of the t11niru at the time of operution we are in the hnbit of intl'oclucing n. ~m:i 11 aspirating needle nt u p•Jint as for re- 1110,·etl as po<:siblc from the epididymis, but through the opernth·c in- ci<;ion. nwl remo,·ing the finid. Small inflammatory hydm~el<'" mn~· he clisre!!:trclccl. Thu next step in the operation is to thoroughly atw<:thetiz~ the fibrous she!lth of the epididymis in the line of the oritrinal skin inci-ion. The shrath will usually be found to be mu<'h thic-kPne<l. 1" .. p('cinlly in cus('s of long standing. The sheath is tlwn inci!'e<l. the opening being npproximately one-half inch in I..m.gth: whereupon the epitliclymis proper. which ic; usually under considerable tension. will bulg-e throu~h the wountl. The incisiona1 edges in tho sheath nre then grn~1icd with forceps and if it is desired the opening mny be cnht!!ecl by exerting trnction on the forceps when the shenth will tenr in the line of the incision. It i<: highly importnnt to re1·ognize each nnntomicn1 structure in the various steps of the operation. This ! ... e~1,..ily 'lccomplished if the wound is kept free from blood. It i" now necessary to anrsthetize the tubule of the epididymis unu the fibrous tissues that connect ils rnrious com·olntions. This is the len ... t atisfactory step in the operation for lhe reason that im:rcn--ecl tension incident to lhc injection of the anesthetizing fluid cnns<'s pain: this is transitory, however. "\Vith a sharp knife, the <'11tlin~ edge. of which is directed a w::ty from the testis: a stab wound is madt• in the (•piuicl~mis. Not infrecp1ently nbsce.-s <'uYities nrc• <>J>t'lll'd in Jon!!- •tanflin_g case,_ ancl nccrosis of the epididymis is fournl. l 11 this latter e-roup we gently curette the walls of the necrotic nrcn. In the \'ery enrlie."t C:l"'CS of acute gonorrheal cpididymifi!'; we ... ometime ... substi- tute multiple needle punctures for incision of the epirlidymi<:. The relief of tension incident to depletion of the Ye..-;.-els promote_-. nhsorp- tio11 of the inflamnmtory exudate. Experience is necc. -ury. howc"\'"er, in the selection of cases suitable for this procedure. <:iJll'e in improp- erly :;elected cases it not only fails to relieYe the conditio11 but invites additional inflamma.tory reaction. In the small group of ca--c.s in which it is indicated it undoubtedly helps lo restore the patency of the seminnl duct and thus a.void sterility. Incision of the epicliclymis mu~t, it would seem, render the testicle functionless as fnr a,.; its ;permntogcnic function is concerned, although we hnYe no definite knowledge that. this does nctually occurc in <'Yer,\• in~tnnce. .\ small o:2G HERMAN-EPIDIDYMOTOMY IN MILITARY SUllOEBY. Vol. XII, quantity of Dichloramin-T is injected through the opening in the t>pidiclymis nn1l a piece of rubber tis;:ue rolled into the form of a ;croll is then anchored to the depth of the epididymal inci:-.ion. Thi ,,iep of the operation i ~ much facilitated hy using a ::;mall ~harp}~· CUl'H'1l 1wccllc and plain 00 c;llguf. In SOJll(' i11:sta11cc::. ulcrtling occur, from the inl'i:-ed t•pidid~·mi:s a11d thi . ., l'an lir~t Le contl'ollNl by tl1e in r•11 11H:ti1n uf 1l(lt'f> . ntm·t•,..,: 110 a,tunpt slicmld J,.._ m:ulc tu clamp nnd tie such bleeding vessels. Indeed, it i:'l unnecessary in any stage of the opemtiou lo C'mploy lipatun·.,;. alHl a rul.ber ti,,sne drnin is hro·1~ht out of the lower end of the incision. The latter is closed by mean,; of a few sutures of plain catgut so inserted as to include all areas of the scrotal wall. The application of a dry dressing completes the opc'r·t- tion. The scrotum is enveloped in a gauze bandage uppliC'd in e:x.1 t ly the ,.,a me manm: r as i!> a scu ltetus bandage of the head. A T-bandage may be used to advantage. Po;yt opc1·a#1·e f1'Mt1nent.-Tbe patient is confined to bed with de\ at ion of tlw H<'l'olmn until the ruhber tissue drain C< llll'S · wn~ ,.,ponln1wously. Tl1is occurs about the fifth da~· in the :\\~~·11,:,r,• c·usl'. The drainage is selclom profuse and rarely frankly purulent. 1 '1t• wound heals by primary union except in the rarest i11st:rnces. Rl.1 I- der irrigations with weak solutions of potassium perman:i•rnatP • n• begun after tlw drain has been removed but only in patients entirely free from acute urethral syrnptom:-.. Internal medication ma~· or mn) not be gh·en at the discretion of tho iucliYitlual surgeon. R esults.-The operation of epididymotomy immediately rclieq•..; the pain which is often severe, so that convalescence is pranic:tlly symptomless. In one case, terminal hematuria followed operation and persisted for 10 days. In the second case a small hydrocelC' necessitating aspiration, appeared after operation; this patient ho\\·- e-.er was clinically well and ready for duty 19 days after the cpididy- motomy. In a series of 40 consecutive cases, the average hospital re~idcnce of the patients operated upon was 25.3 days; in thC' 111 i lei case:; which were not operated upon, it has been 3G clays on the u.n:r- ag-e. The operated cases are not returned to duty until the wounds are completely healed, until the urine has entirely cleared and ha~ remained clear for 5 clays without trentment. nnd until the patients ha\e demonstrated their ability to do a full day's duty with the hospital working parties. We ha.Ye seen only one instance of recur- rence of epididymitis following operation in either ciYil or 111ilital'.' experience. The results of operative treatment are particularly striking in l'l'" I C'nrrcnt cases as is illustrated by the following case history : :_l\f. W. II .. senmnn first class, U. S. 8. ---, :idmlttecl to 1fav~· Ba-;e Hospital Xo. ;), KoYernbcr 7. 1918, for the treatment of bilateml gonorrheal cpididymitis of one month's duration. Under palliati\'e !'io. ~. SHORT-CEREBBO-SPINAL FEVER AT GREAT LAKES, ILL. 621 treatment the inflammation subsided but soon recurred on the left ,.ide. Repeated attacks of epiditlymitis on the left :;i(le n:;:-ociated with pcr.;i-.tt·nt Ul'l1thrit is confined this patieut to the ho:spital for a long period of time so that the question of medical snncy for incurable !!onorrhea was discussed. On February 10! the left epididymi wa"' <lrniucd: 21 days Inter he was returned to duty. He now rcporb to us two months after the operation that he bas had no furthf•r trouble . • \n especially satisfactory result in the operntiYe treatment of acute epididymitis is illustrated by the following cnse: J>. (' .• fireman first class, 1:. S. S. ---. wa,., a<lmittNl to tlw hospital on Februnry 8, 1918. with acute left sided epitlidymitis. Operntion was performed on the day after admission and nine> days 11tte1· he was returned to duty clinically cured. We foel justified in advocating epididymotomy in all acute cac:es of :;ronorrenl epididymitis with the possible exception of those case:: with a minimum of inflammatory reaction; in all recurrent ca ... es: in all chronic cases where marked thickening with the epididymis 11 ~ociatcd with tenderness is indicatile of the pre!"ence of pu~. In this latter group of patients. the> inflammation persi~ts for a long time unless drainage is provided and later gi'\"'es rise to neumlgia of the> testis often with profound sexual neurasthenia. EPIDEMIOLOGY OF CEREBRO-SPINAL FEVER AT UNITED STATES NAVAL TRAINING STATION, GREAT LAKES, ILL. Hy J. ·r. S11onT, Lleutcnnnt. '.\I. C., United St.ates N1wy. For many years epidemic ccrebro-spinal fever has been considered n communicable disease, which, in military life., appears upon the mobilization of young recruits, and uc:nally in connection with pre- disposing factors, such as bad weather, crowding. or fatigue. Mor<.' recently it hns been shown that the cauc:ative agent is the meningococ- cus. spread by direct contagion from the nnso-pharynx of n patient. a convalescent. or a presumably healthy indiviclual. The corollary which nt once suggests itself is that if the "carriers'~ of the menin- gococcus can be segregated the danger of an epidemic will be hrgely o,·ercome. In order to make clear many of the factors that wl'rc ope>rative in the recent epidemic of cerebro-spinal fever at this :.1ntion it is neces- sary tn desrribe briefly the genera] or!!nnization of the :::tation nml the se>vera.l phases of training throuµ-h which the an~rnge recruit ordinarily pnRses, as well as to outline the work on meningitis pre- cedint? the epidemic. On his arri va.1 the recruit is first place><l in an in<"oming <le>tention c· unp. "here he remains 21 days. Dnring this perio1l he is expected 628 SIIORT-CERERRO·SPINAJ. FEVER AT GREAT LAKEC:) ILL. \'uJ, ~II to make the transitio11 from ciYil to military life and to ndapt hin1· ~<'lf more or ll's.c: complct<'ly to his new envir011mcnt. to nb:mdon liis in<lh·i<lnnl idea~ and customs of dress. food. exerci==>e. and recrontio1 and conform to the manner of liYing that is prescl'ihed for the 11111, jorit~· of his fellows. Ho mu~t learn to sleep in n hammock. and u:>ually with more than his customary amount of fresh air. He must overcome his homrsiclme::-.s. mnke new acquaintances. and learn the l"Ucli.ments of military life unll cliscipline. )foanwhile physical ex- aminations, nec<'ss:uy dental work. nccinntion. and typhoicl prophy- laxis are completed. Following his detention period the rerrnit j., transfcrre>d lo one of the other camps, \Yhere general or special train- ing is continued for a vnriablc period. avernging three to six month.:. He may then be transferred to the outgoing detention camp. wh<'re he remains under observation and is giYen a number of medical ex- aminntions and inspections before leaving the station. In each en.mp ancl regiment a certain number of men are held for indelerminnte pl'riods to assist in administration, instruction. and the mnintenanr,• of public works. The "·ork of discon•ring and isolating meningococcns ci1rriers. n c·onformity to general practice. has been greatly facilititted here b,· taking acln.ntngc of the organization described aboYe. It has lieen the custom to make naso-pharyngeal cultures of all new men on the station as early as possible in their period of incoming detention. and to isolate those f ouncl to be hnrlJoring the meningococc11s. The m<.'n in outgoing detention ha,Ye been ~imilnrly examined. and the carriers detained and isolated . . ,,11enevcr a case of cerobro-spinal fever was diagnosed, the fol lowing procedure was carried out as a matter of routine. Tho com- pany of men nnd the banaeks from which the patient came Wel't' placed in quarantine and everyone cultured. AclditioMl cultures wN·e mnde on all possible contacts, such as hospital corpsmen ancl pat'ients in the regimental sick bay where the man with the disea:;<' may have been treated for a short time before transfer to the hos- pital. 1Jpon completion of a preliminary examination of the cul- tures. usually twenty-four hours, the men who had yielded organ- i~ms resembling the meningococcus in cultural characteristics, mor- phology and staining reaction were declared to be carrier suspects and were removed and placed in the isolation units or "cubicles," at the disposal of the regimental surgeon. The quarantine was then lifted and the remaining men discharged to duty. Suspects discovered in the detention camps were similnrly placed in cubicles. Accorcling- to the final laboratory report, based on agglutination reactions, tlw riated case. the> pof<'lltinl clnnµ-<'r "·011lcl be the samp rrom nll strain:- ?'o. 4. SllOI~l'-CEREBRO-SPINAL l'I~\'ER AT ORr:AT LAKE::>, lLL. 629 fcrrcd to the mcningococc?s carrier camp if po:-;itive. The types 1 of mcningococci were not determined in the routine work, and all men "ho~e organisms ga \·c po:>ifrrc agglutination reactions with FJe."(ncr·s polyn1lent .Sl'l'Ulll were isolated, under the n55umption that nltho11gh ull might not gi>e the type corresponding with the asso- ciated cn!'c, the potential danger would be the same from all strains thus shown to have been pathogenic. The i:.olateu cnrriers. from a.11 sources. hn\·c been cultured at in- t<'rnds of five <lays, and held until four succc.-=siw negnth·e cultures were obtained. For a time, all hospital patients rel uriwcl to lhc sta- tion were cultured in a. special camp and required to gi \·e two suc- ccssi rn nrgative cultures without treatment before discharge to duty, the discharged carriers a.lso going through this group. After th re· or four months, however, this was discontinued and the hospital (which is under separate management) secured the ueces~ary nega.- t ive cultures before discharge of patients, while the carriers were returned to duty directly from the carrier cnmp. In taking naso-pharyngeal cultures, the open-swab method has been used exclusively. The men to be cultured come forward in singk file, facing the light, and repeat assigned numbers (recorded serially) to the man who swabs. He in turn repeats each munb!>r as the S'\ ab is passed to me across a. table, and a blood-agar Petri dish: already numbered, is immediately touched wilh the swaL and streaked with a sterile wire. By elimination o.f all unnecessary move- mcntl:i nncl the assistance of one man on the lcit to number and dis- pose of plates and another on the right to flume wires (of which two arc used to allow time for cooling), entirely satisfactory cultures may readily be taken at the rate of nbout 300 men per hour. The, plates are kept w11.rm with hot-water bottle::. at all times except dur- ing accual inoculation. are transported to the laboratory by closed motor bus, and at once placed in an incubator. The methods in use by the ltlborator~· force are briefly a;; fol- lows: The inoculated peptone-blood-agar plates arc incubated ut 3i C. from 12 to 18 hours, or until a satisfaclory growth has taken place. Colonies with meningococcic characteristics are selected an<l if the organisms composing them show the morphology nnd ~laining reaction of meningococci, subcultures '1l'C made on Lloocl-ngnr slants and a preliminary positin report is giwn~ thu remaining plate" being regarded us negath-e. Saline suspensions are made from the ~ub­ cullures the following day and tubes nrc ::-et up for microscopic ag- glutiuation with Flexner's polyrnlent clin~no-tic sernm in dilutions . 1 Uordoo: Ilacterlologlcal Mcastll'<'S Adopted for Dealing With th<! ~lllltory Outl.Jr~ak In l'ebrua•r, lUH'i, nod ltllprovement Expected ns the nrsult ot lll'Searcll. ~pedal ll~1><>rt o• the lnd ted ltesearcb Committee on Bacterlologlcnl Stuillra In the l'atbology, I'ren.otlon. and Control of Ccrebro·sploal Fever Among till' lforce11 1"1rlng 191:> and llllU. London, 1, l.Js~. or t:nwlu, 1917, ()::lQ hllORT-t'EREBRO-SPlXAL FEVER AT GREAT LAKE~. ILL. uf l to ;;o. 1 to 100. and 1 to :WO, with cm~trols uf hor:;c ,erum 1 to 50. :mu phy:-iological ~nliue su~peru;ions of the orgnui,ms. The~e are in. cubated nt .->;; C. for 1 hours and the n•ading,., then mad£>. .Aggluti- nation uy I lie p0Jyn1lt•nt a11timt•ningut.:0Cd1; ,;cntlll in any of the :1bo,·c dilutions. with satisfac.tory control, has been regarded as in- dicati\C of the meningococcus. and th£> final report is made on thi' ba-,is. Typl' agglutinations with Flexner·s ~cr:t (for ''normal:· ··para;· '· irn•gul:u· normal:· aml .. irn•:,rular paramC'n1n~ococci'') have been done in a ~ew recultures. and will be reported upon com- plct ion of tho series. The practice of taking pharyngeal cultures for mmingococci was first begun at this station under the direction o:I' Medical Inspector C. ~!. DeYalin, Uniled States N"avy. in May, 11)17. This was near the close of a cerebro-spinal fever epidemic 0£ 9!> cases, distributed as follows: ,January (1917), 5 cases; February, 9; l\farch, 13: April. 25; May, 35; June, 11; July, 2. The mortality was 31 per cent. Xo further cases deYeloped until October, when three cases occurred. These were followed by 4 in No>ember and rn in December. Refer- ence to these latter cases will be made below. It is noteworthy that during the aboYe period the population of the station increased man~ times, reaching 1:>,000 in NoYember and 25,000 in December. The total number of cultures made nt. this station in 1!>17 are grouped below under se>ernl headings, with the percentages of car- rier::; foun<l in each instance. Number. I Percen~ 19, 039 ......... . 139 o. 7 14, 008 ......... . 234 l. 6 3, GCO ......... . 44 1.2 1, 4G3 ......... . 39 2.6 - - - - I Cul!urrs in incoming detention ............................... I Positive culturrs . ......................................... . l"ullures in out~oing detention ............................. . Positho culture!! .......................................... . Cult urcs of C"erehro-spinal fever contacts .................... . Po.<ith·e cultures .......................................... . Cul!~rcs of l1ospital comalescents ... : ........... . .......... ·I J'OSJfl\·e c·ulturcs .......................................... . 2, 716 ......... . 623 22.9 Cultures of meningococcus carriers .......................... . Posithe cultures .......................................... . 38, 770 ......... . 456 1. 2 61i9 •••••••••• Total culturc.<1 mad I', t>xclush-e of carriers .................... . Poe:ithe tultures, exclu~iYe of carriers ....................... . Cultures made, unda:;idfiecl .................•................ 42, ~55 .....•.... i. 294 , .•......•. Total C'ulturcs for 9fation lahorntory during l!Jl 7 .............. . . \dclitional cultures tal.en on the station for examination by oth~r laborntorics ......................... . .....•......... The epiclcmic.-Although 19 cases 0£ cerebro-spinal fovcr occurred ·at this station in December, 1917, the epidemic proper began in Janu- ary, 191 '3, with 8·1 cases. The incidence decreased <luring the last week, l\!lU February concluded the epidemic with 10, in the first three weeks. The mortality has been about 22 per cent, with a SIIORT-OEREBRO-SPINAL FEVER AT GR.EAT LAKES, ILL. 631 111:irkeJ d<'erensc since the middle of J unuary. The data obtained in the indi\'idtml cac;<'c;, more complete since January. is shown in tables rcfrrrl'<l lo belmv. The diagnoses of .January case::; No. 36 and No. 81 h,1 , ll lit:en changed. and reference to them as meningitis cm:es has twi·n 1•\'Pryw here omitted except in the J anuury tabk A alnncc tit the table of incidence by regiments and barracks, or at a :;pot map of the station, shows that the great majority of the men ih•rnlopt>d the disease in Camps Dewey and Perry, in the newest part .,f till :-.tation separated from the other camps by railroad tracks and 11 highwny. The seven regiments in these camps are made up mainly ot r<'<Tnits in thefr first period of training. It is sel'n further that of (he .Tnnuary incidence in these camps 30 per cent was in the second 1 •gin1ent, where there had been a previous epidemic of bronchitis, in1ltienr.a, nrnl mtmi:iles, and which was composed mainly of imper- f1'Ctly ~easoned recruits living under excessfre stress. as will be shown later. In contrast the incoming detention camps escaped with one h•olated case on .January 13 (Xo. ~.>). an<l a second fo·e weeks later February (:N"o. !>) . While this camp comprises the newest recruits it will be remembered that they are not yet doing routine work, their limitations are more generally recognized, and their mode of life is ycry carnfully superintended. In addition it has been shown that in 11is camp there is an allowance of approximately 50 square feet of tloor space per man, and indoors the men are segregated into groups of but 24, while in the camps mentioned above GO to 75 men were liY- ing in one room <luring this period instead of a proportional 40, thus reducing the floor space per man in some instances to almost half of thn.t mentioned above. In the rest of the station, made up of men in aclminbtralive or instruction details and thoc:e adrnnced in training, only a few isolated or sporadic cases orrurred. In looking for one or t"\\o barracks as foci in the dissemination (such as would be expected were a particularly menacing carrier passed unnoticed), the table of barracks incidence is di!-'appointing because of the inconstant results. Four cases occurred in barracks 521-S, and three in each of the following: 230-N, 231-S, 4.30-W: 431-W, 721-S. but most of the barracks had only one or two cases. While in a number of instances two men became sick on the same day or within two or three days of each other, the interval in as mn11y in- stances is found to be 22 days or n. month-as in barracks 521-S. Furthermore, in the barracks with several patients the percentage of cnrrie1·s was not excessive in comparison to that found in other bar- racks during that particular period. Almost exactly coincident with the epidemic in the latter part of December and January there was a long-continued period of cold weather. The mean daily temperature was below the freezing point from December 25, 1917, to February 5, 1918, with the minimum 632 8HORT-Cl::REBBO-SPINAL FEYER AT GREAT LAKES, lLL. \ol. XII mean temperature n•achiug --:I: F. on .Ju1111ary l~, aml I·\•bruary 4 • • \s shown by u weather chart there was a tendency. further, for fluctuations in the temperature to be accompanied by a variation in the incidence of cases, the greatest number of which occurred durino the coldest week, J unuary 12 to 18. ., Xotcs from various .Army camps during the winter show thut the cold weather also influenced the meningitis incidence in them. Camp Wheeler mentions on January 25,1 that the "cold rains" of the week ndded to their already high sick report, including mumps, pneumonia. and meningitis. ...\.tabulation o:f cases of meningitis reported in the .\rmy camps each week 2 shows that the disease was generall.\ mo t preYalent during Decem her and January with a decline during Feb- ruary, and by March 1 had almost disappeared. Exceptions art to be noted in Camps Bowie, Shelby and Funston, in which the epi- demics were a little earlier and Camp Hancock where it was Inter. Number or ca..<es or menlnltitls at Army camps for woon ending- ! ~ I _. ,.._· ,.._· ,.._· ...: oc_· ~-· ~ ~- -· "'-· "- Camp and lo<.-atlon. = a ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ = ~ g ~ = ~ ~ ~ = ~ ~ ~ 1 ~ · ~ ~ ~ - - - -- ~ ~o.; ' ~1~I ~o· A1g I .!i4c I .!i3' I ! I ..... 5g ~2~ ' ;;:o;; ~o~ I ;:1~ ~ lfrC'lellnn. 2!lth. \fahama ....... 2 0 Ilancock, 28th, Georpa .......... , 0 1 1 1 0 1 3 0 2 3 3 4 2 6 "l1eeler, 31st, Georgia ........... 2 3 1 1 1 2 I 0 1 4 0 1 1 0 0 Doniphan. 35th, Oklahoma ....... 1 2 6 110 12 0 110 0 4 3 2 1 0 1 0 Bo~c. 3Gth, Toxae.............. 8 15 9 2 3 2 I 0 0 0 2 3 1 3 2 Shelby, 38th, )fississippi. . . . . . . . 6 G 0 O 1 0 0 0 0 1 4 1 2 O Beauregard, 39th, Louisiana ..... 3 G 3 4 7 26 16 :13 9 8 6 5 O 2 Meade, 79th, Maryland ..... ...... 0 0 4 2 311 3 4 5 2 4 1 2 0 Jackson, 8lst, South Carolina . . . . 7 16 30 37 30 15 jl3 14 23 19 6 4 9 0 Gordon, 82d, Georjl'ia ......... ... 0 0 1 2 5 11 4 3 6 1 1 4 1 0 Sherman, 83d1,. Ohio.......... . ... 1 0 5 2 J O 2 3 0 1 1 3 0 0 O Taylor, S4th, J'-entucky .. . ...... 0 0 5 3 0 2 2 3 2 2 0 2 O 1 Custer. 85th, Michigan .......... 0 0 2 1 0 0 0 2 7 1 0 0 0 0 Pik!!, t-ith, .\rkanf'all . ............ 0 4 2 8 3 4 1 1 2 0 1 O 0 2 Fun.qfon. ')~i tb, Fort Riley, :Kims .. 12 9 6 3 1 5 4 11 2 5 3 3 2 2 3 Tran.-. 90th, Texas........ ....... 0 0 0 14 9 1 1 1 4 5 4 4 2 '.? O Lewis, tllst, Washington . . . . . . . . . . 5 5 I 1 _ 5 1 1 4 2 1 1 2 2 0 :... 2 In studying the inclh·iduals with the disease the well-known in- cidence among- new recruits is at once apparent. In the 9± case.:: during January nnd February, 71 men (75 per cent) had been on the station less than seYen weeks, or, in other words, hud finished their 21-tlay detention period less than a month preYiously. The cun·e showing this fact is equally striking in the abs~nce of cases beforE the latter part o.f the third week, which muy possibly be accounted 1 Jour. Am. :\It'd. Assn., F!'b. 2, 1018, p. 3!?2. • Jour. Am. Med. Assn., Dec. lo, 1017, to Mnr. 16, 1018. NO· 4 SHORT-CEREBRO-SPINAL F.E\'ER AT GREAT LAKEF"1 ILL. 633 for on the l>asis of the more careful housing clnring thnt period as pointed out ubo,·c.1 By talmlnting chronologically the Lhttes of arrirnl at the stntion of the men" Io clcnlopecl the disease duri...,g Jnnunry, it "as further fouml thnt :ii. or G7 per cent, of them had come to the station between December ~ and December 15. This is also trne of the fi.r:-,t case orcurrin!! i •1 February. These elates are significant in view of the situation on the station at that time. Owing to the ruling which pre- yentcd men of conscription age from Yolnntet>ring their sen·ice.s after December 13, 1917, recruiting oflices Wl're crowded nncl many men pnli,tcd in the Navy. In fact, from approximately 1:1.000 men on Dl•cembcr 1, the population of the stn.tion by December l:i had risen to :W.000, ·where it remained. At this time nnd snhl'equently 11 scrie:> of circumstances operated as strong predisposing or clctermin- in!! foctors in the incidence of disease among these young recruits, espl'ciully of cerebro-spinal fever. Owing to the limited capacity of the incoming detention camps it was nece~snry to hnrrieclly outfit a. Jnrgc number of the men and transfer them to an instruction camp within a r.JJCek, often within two or th1·ce rf a!fS. In spite of the skillful manner in which the situation was handled it wns ine,·itable tl1at many men should lose sleep and r est, while the hurried atmos- phere in "hich the~· were rushed from one place to another to secure Yarions examinations and new equipment made it exceedingly dif- ficult for them to adapt themse]Ycs to their new environment. In the routine tests of these men by the Psychiatric Unit it was found. further, that they were somewhat below the high a\'ernge in- telliircncc shown by the men enHsted before and after this period. From this it might be inferred that they would nclapt themsl'l"es to new conditions lrss rPnclily than the others. This won 1<1 show itself in "-llch things as failure to properly protect themsehes from ex- po~urc h~· the use of overshot>s and o>ercoats, or hy tho change of \'\'ct clothing. Jn the camps to which these men went, mainly the first four regi- ments in camps Dewey and Perry, an effort "·as made to coutinue their clet<'ntion: but it was somewhat less rigid than in the detention camp:::. Thel'c was aho co11siclernble crowding. as pointed out aboYe. which brought them into relation with a larger munber of people and in mnch closer contact. The question of proper nntilation. hO\\C\er, l'l'lY be ruled out, as throughout the station tlw regimental '-Urgeon::. make daily recommendations in this respect and earh night make in"pections to determine that they arc in force with satisfactory results. 1 Mink, O . • T.: Points Jn the Epidemiology of Meningitis, nl.>str., Jour. Am. lle<.I. A.,n., Feb. 23, 191~. p. i:i03. iGQns-lS--ri 634 ~HORT-CF.REP.RO-SPI!\AL FEVER AT GREAT LAKES, ILI.. \'ol. XU. Bt•fore lhes'C new men could much more than get their bcarin!!s they were overtaken with very sewre and continued cold weather which began about December 25, ns mentioned above. .\ &!\'Cr~ blizzard boon occurred \Vith snow from 3 to 6 feet deep, requirin!! strenuous effort to keep the roads open, and making any movement about the camps Ycry difficult. Then after a short rest, the p occ.'>S wo.s repeated by the appearance of a second blizzard, with som !whnt less snowfall, but more wiml and damp cold. Subsequently the hu!!e piles of snow had to be hauled away to avoid later floods. The consequence was that several other factors pr :clisposing to disease were introcluced and accentuated, namely, fatigue and exposure to the weather in unaccustomed clothing. The latter contributed to the production of many "colds," an epidemic of which was noted as hav- ing preceded the meningitis in the second regiment. A similar high incidence of other acute diseases among new recruits (72 per cent of the pneumonia; 57 per cent of the influenza) was also noted in charts prepared from cases during this period. The summation effect of all these factors is well shown in the comparative freedom from <lis 'lSe of seasoned men in other camps exposed to the same crowding o.nd weather conditions; of the escape of young recruits in the detention camp when tenderly cared for; but the development of meningitis by unw asonecl men when hastened to conditions of exposure. The typhoid prophylaxis and vaccination administered <luring- the detention period frequently caused considerable react ion, '"ith fe,·cr and malaise for one to three days. The role of this factor must be rehttfrcly small, however, since the interval between the proph~ la xi"' and the development of spinal fever was too long. Iii 79 cases tr•ms- fcrrcd lo the Na val Hospital during J anua,ry and Februar) in which the records of l.} phoid prophylaxis w0re availahlc, thC' time interrnl between the thircl injection and date of transf(•r was i11 on!' case three days, in two ca5es six dttys, and in three other inst ancc.s seven cla~·s. The intervals in all the others was lon~er. Schick's te had hccn performed on nine of the patients transferrcd during .T:mu- ary and February with frrn. positive and fonr negnti\·e rcaetion ·. With one exception all of these tests 1rn.d becn made more th:rn a month previously. Only one patient had receiYecl Behl'ing·s sprum, antl that was given three clays before hi!s transfer to the hospitnl. His rcaction to this sernm had not been noticeable. Among 80 men vaccinated agajnst smallpox. 62 or 77 per cent gun n positive J'(':lC- tion. The age incidence of the patients seems rclntively nnimpor1 mt sincC' the grcn.t majority o:f the men on the station arc ubout the ~nme ngc. Seventy-five per cent of the January and February patient-:. howcYer, were between 1D and 24. The oldest patient in this scrie:; J'(o.~· S!IOl!T-CEREDRO-SPIN.AL FEYER AT GREAT I-\l\.ES1 ILL. 1)35 wa"> :19. a;:: contru·-tecl "ith the English l'l'port 1 where thn•c men on~r 3G 1ir£' ment ione<l . • \lthou~h with the lifting of the '.:!l-cby period or dcte11tion the wung n~auit::; were giYcn liberty nnd le:ne, arhl frcqncntc<l crowded theater!> :mcl street curs in near-b~ toY us. the rnenim.dli in t he.<:e Jo<•alitie!'> nner assumed the proportions that it di<l on tho stution. nnd it ic; illogical to assume that they would be liable to contract the disease from these sources to the neglect of the much grl'atcr dan!!er nt home. It" as also shown (December table) that 'a,, llltllly of the t'ascs ou·nrred among men who had been on the 8tnlion contin11011 ... 1~· ~iuce their anintl, as n,mong those who had been known to .. go ashore:' Further, the section of the United States, or the town or citv from which the recruit came originally or which he Yh•itNl on le;,.<'. gaYe inconstant results in the few instnnccc: when· thi~ infor- mntion \YnS asai]able. Phnr~·ngeal cultures previous to the disease had been made of nearly nil of the patients, usually during the incoming detention period or as a contnct of a case, and som<.'time-. "'e' <.•ml <.·11lt1111' ... hn<l been taken. Eighteen men who developed meningiti..; during Dec1'111- ber, .Tnnuary, and February had giYen uegatin~ cultures l<'":> than a week before their transfer to the hospital, and 1;; of thc.-,c hnd gh·en ne1-,Pfttin cultures prior to that. (See cases 2, !>, 13. and rn in Drcem- her: 2. lG, '27, 3-1, 37, 38, 4!), 53, 57, GS, 71, 74, 78, in January:!) in Feb- ruary.) This is in accordance with the experienee of Fiklec: and Baker· who obtained negatiYe cultures :from 2G nH'n s110rtly h!'fnre they developed the disease. Dul'in!! December and January six men who had previou::ily been found carriers dc,relope<l cercliro-spinal forer. The results of their Yariou:; cultures are shown in a table. The fir:;{ man (.J. C. D.) had b<'en tlischnrgcd to duty 11 days before developing lhc lli:-ca-.c. The other" wne in ii=olation at the time. One carril'r had been fir:-t clis- con•rcd in incoming detention, two 11::; 110.,pital umvalc:oc:1•11ts. two in ont~oing detention. aml one ns a meningitis contnct. The Jn-.t m:m (I>. $. B.), who hntl been negative in incoming detention, wa,; cultumcl t wir<' as n contact. On the first f'CCasion two puti<'nb (.Jnn. Nos. 13 nnd 14) had been remoYed from the oppo..:itc end of the bar- racks from where he liYed, and he was founcl negatiYc. Ei!:!ht !fays later nnother case (Jan. No. 3G) <le, eloped in the. amc end of the harnick" hut the diagnosis wns later changed to hron<'hitis. .\t that. I ime he was positiYe and "·as shortly remoY<.'cl to n <.:arril'r harrncks 1 !"lack. )I.: fiPpnrt on C<>rchro-splnnl Fever In the f,ondon Tllsll"lrl, Tl<'<'l'ml.l<'r, l!ll:i- Jul7, 1:110 Spcclnl fil'JJOrt of the Jndlcnted Resenrch Comm!ttl'•' on B 1 tcrloloi:k11l ~tudl('S In the l'atholoi;y, Prevent Inn, noel Cont1·0! of Ccrebro-~plnal f~n:r among thtJ Forces during llltr. nnrl lilll\. London, 'I'. 1"!Hchrr Unwln. lnl7. 1 I"lldP1<, I'., nnd Bnk1•r, ~. T, •• J.nnc1•t, London. Oct. :!n. 1!ll7. 636 ::;HORT-CEREHEO·SPINAL FEYER AT GREAT LAKES, ILL. \ ol. XII '' hirh -.0011 became crowded, and where he developed the di~ea .. e tw0 wel•ks Inter. From the beginning of the work until the Ia--t of ,Jnn11• ary. "hen thi::. ca•e deYelopcd, 1.~~8 carrier:; had been di,.:co\e1-ed of whom only ti or 0.4 per cent clenloped the disea~e. Fikfo::. and Bnker1 report that among 485 carriers not one deYeloped c<'re>bro-spinnl le'\'er a111l they consi<ler it rare among carriers. Capt. Flttek 1 mentio~ fi, c carriers who cleYelopecl the disease while in holation, niitl con. sider:- that enry patient has been a carrier becalbe> the organif'm cnn .tlways be recm rred from the throat after U~e di:;ensc has made its nppearance. The important, icatures of the epidemic a.t this station as detailed <.thovo may be briefly summarized as follows : The great major1t y of the rnen afl'ccted were young unseasoned recruits who had been rup- iclly rushed through the regular incoming detention camp at a litne when the station was rapidly expanding, and sent to already crowded camps where 1hey were almost immediately exposed to severe cold, stormy weather and hard work. It is noteworthy thnt while with one exception (Feb. case Ko. fl). the ~·oung unf'easoned recruits did not uC\'elop the disease in the regular detention camp where they " ·ere more carefully cared for, they were unable to withstand the combination o.f circumstances and depressing influences met in the other camps, al! hough these same factors, operating on all ulike, did not materially influence the older men on the station. This same "hardening" process may also be seen in the incidence of meningitis among the several Army groups during this period. as indicated in tho following table derived from weekly reports ap- pearing in The Journal of the American Medical .A :;Hociation.~ Meningitis al Army camps. L nnunl :le per lhotL,and, week ending- . I I I ~ ~ ~ ~ ~ . ~ ~ ~ ~ ~ ~ ~ ~ ~ s ~ ~ ~ ~ § ~ § § ~ § s ~ lg ~ ~ ~ ~ ~1~ ~ •i • -1~ ~ ~ • I"- - C... "'" -. - - '='I - CIC. - N - ;;c;.·.·~ ... ---:...:.o-..: ,o ., l ~ c;; ~ E ; a a -z ~ I " ~ ~ - - -=--=-~ 0 ..:. , .... .., ...... ;.., _::: ... (· _ ...... Nationnl .o.\rmy, all ramps .... . .... 3. 2 4.1,6. 6 8. 3 7. 4 5. 7 4. 1 I. 9 7. 4 4. 5 4. 0 2. fl:?. !1 J.3 r\acional Guards. nil ramps ........ 3. 8 5. 4rt 2 2. 9 4.4 5. 4 4, 8 3. 2 4. 3 3. 3 3. 7 3. 2:!.'.?1. !I United States ,\rmy, Regulnrs ... . 1 • 2 0 0 . 411.11. 6 5. 413. 0 4.12. 9 4. 5.:u; :i. 51. 7 American E~pNlilionnry Forces ... ,3. 8 .. t .. 5. 5i5' 0 ... r 6,5. 7' ...... 1. GI .. ·(~ (j. 0 The rat" for 1916 among United States .Army Regulars was 0.:?9. H is seen that the hjghest incidence was in the National Army- thnt is, among the newest soldiers; and that in the X nt ional G 1·1 nl. 'Loe. cit. 1 our. Am. lllcd. Assn., Dec. 15, 1017, to Mar. l(l, lfllS, ~ o.4· SllOitT-CERF.BRO-;;;PJ:XAL FEY.ER AT GREAT LAKES1 ILL. 637 compo::;cc1 generally of older men who had some military experience, it was less thnn in the Xational Arm~·. but greater than among the seuo:oned Re!!nlars. Among the latter the incidence ro::;e when they inet the new conditions opcrnti ,.e in the u,·er,,e. s force-.. Carriers d111 'ng tM; cpidcmlc.-Tl1e incidence of meningococcu::; cnrriers among seYeral groups before, <luring, and after the epidemic Jin.:: been plotted against the incidence of case. .... n lso ... }wwin!.! the carrier index as derived from all sources. It will be ~~Nl from this cun·e (based on 32,::>DO cultures) that the epidemic of cnse:-:: coincides ";th remarkable closeness lo the cold weather, as indicated: while the increas<' of carriers does not beg-in with the cold weather or the ca~es (certainly docs not precede them), but starts about two weeks lntt'r. 'J'he percentage of carriers remains high for about thrf'l' weeks nftc1· the weather has b{)gun to moderate and the cases ha Ye almo:-.t ::;toppc<l. nnd then rapidly decreases with the achmt· of mild. fnir wenther. The incoming group. composed of the ne'w"t men. the best hon~<l. an1l the best protected, shows the lowest rate throughout. The con- tacts. Jiying under the same condition:; ns those 1leYeloping the di.::eases, and exposed to Oit>m, giYe the highe,t r:itc at all tim(» ... Out_!!oing detention. comprising oldt>r rncn frolll nlJ O\'er the stntion. gin's a. some·whnt lower percentage of C'lrriers. an1l is rather com- pnmble to the aYerage curve computC'cl from all cultures taken <lnr- in!! each week from all sources. Ilt'cause 0£ the very smnll number of men cultured on two occasions fi!!nrcs in two instances ha.Ye been discard xl as unrclinbJ .. in mnking this cur>e-week January lD-25, detention 2-1.4 per cent: week Feb- ruary 23-Mnrch 1, contacts 2G.7 per cent. During- the extremely cold weather a. charcoal foot warmer was use<l from .Tanuary ~O on to facilitate keeping the phttes warm. nlthongh hot-water bottles were usually found sufficient. On January 14, 1.i. rn. 21. 24, and February 15 contacts were cultured nncl the plate:-: examined by medi- l·nl officers who ho.cl formerly been working on carriers alone. Their figures have been generally somewhat higher, hut tlrnt the new per- :-:onal equation introduced did not m:iterially affect the Clll'\'C uut rather confirmed it is shown by the fact that they took no culture:-. from January 24 to Febrna.ry 15, when the cune remnined at it;;; height; the figures from other sources rose correi:;pomlingly: an<l since February 18, when they have cultured all the contacts. tlw pC'r- centn~es obtained have fallen parallel- with tho;;e ltefore mentioned. The :-mall elcrntion in an the Ctll'\CS clnring the middle of Decemher "hows the cases and carrierl'.l to be synchronous. but on plotting tho <laily fignres the rise in carriers is seen to come a week later. all(l thus conesponds to the later curYe, and gi\c!'i ncl<litionn I weight to its outline. smre tl1e work during that perioil was wry 11nifonn in 63~ SllORT-Cirn:EBRO-SPIXli. FEVER AT GREAT LAKES, ILL. chnracter. Further corroboration of the real increase of carrier,, during this period is shown by the fact that without further Yaria- tion in technique the curYe came down and has remained down. From nll of these considerations it seems justifiable to conclude that the incidence of widely distributed carriers came after the appear- anco of cases and not before, and was the result of the epidemic rather than the cause since in the presence of the greatest nmnher of carrier::. the epidemic stopped. The comp<natiYe harmlessness of these carriers is further shown l>y the following circumstances. ..\fl er sending iww inen to the C!\r- riC'r ramp steadily for several months, somewlrnt in excess of the rate oJ discbarge, lhe quarters available Ior them hod become nearly filled. Toward the latter part of January the incidence of carrie;s ro:-;.' so rapidly that their usual accommodal ions wt>re completely fill<.'cl, including the iwailable mom in the naval hospital, where some of the more chronic carriers were sent. The carriers who were first isolated as suspects, could not be removed from the regiine11tnl cubicles, which became filled so that snsp cts could no longer be remoYed from quarantined barracks. Finally, a case of cer1.:bro- spinal feyer appeared among the crowded carriers (February. Xo. !>). About this time, January 28. when the case cune was falling nncl th<.' carrier cune still rising, n new procedure was introduced by Sur!!eon 0. ,J. Mink, United States Ni:n.r, the l-IC'nior medical oflicer of the station. of whose administration, criticisms, and sugge:;tions this report is largely the outcome. This procedurn, which affected the last 10 cases shown in the January table and those occurring sub- sequently, has been substantially as follows: The contacts have been qna.rantinecl in their barracks for five clays, cultures being taken from ever) body hut the carriers not remove<! nnd no one informed who the carriers might be. During this period, naso-pharyngeal spmys with Dobcll's solution haYe been giYen three times daily by the regimental surgeon, and at the end of fi\-C' clays the quarantin(! lifted and all men return<'cl to duty, although at this time public gatherings were interdicted and Y. )!. C. A. buildings: etc .. close<l. The carriers who had alrC'ady been isolnt<.'d haYe been handled as usual, and more recently haYe been formed into com- panies. with reguln.r duties on the station in working parties. They are now giYen one or two evenings liberty in the middle of the week. when the remainder of the m<1n arc kept on the station. Incoming- dcll•ntion carriers have beC'n umlistnrbed. Carriers found by routine cultures made in outgoing detention ha,·c bC'en withdrawn from the drafts and held on the station, but otherwise umcstricted. In spite of the more favorable wc:i.ther conditioll8 during this period. it <lppcars Rignificant that the <·a8e curce conti111wl to fall after tlrn rcst1·iction8 on can·iNs had been 11lm·o8t e11tirtly 1•t mo1•Nl. ~o. 4. SHORT-CEREBRO-SPINAL r'EY.EU AT GREAT LAKES, ILL. 639 Thr1t clo!;e relationship exists between the pnticnts ancl the car- riers. n:> reported b~- some ob::;e1Ters, hn:::. not been the experience at thi:- ~iation. nlthou~h in J:muary ca"'e Xo. ! there was nmplc oppor- tunity for carrier infection. The patient in thi-. in.--tance had hcen rn!!Ul!Nl in swabbing carriers ancl exnmining cultures for a month pre,·ion,Jy. during which time he was associated in the work with n. urnn who at the time of his illness giwe a positive meningococcus culture. In culturing many contacts, howcYer. the highest pcreent- n!!e of c·uTiers was frequently found nmon~ those len::;t closely a~--o­ ciuted with the patient, as in the opposite end of the barrack::. ::.epa- rntcd I~ a solid partition with no indoors communication. (See De- ccmhl'r cases No. 12, 14; January cases No. 12, 13, 14.) D. J.C. (De- ccmlwr cnse No. 14) had been isolated as a carrier, and yet when he rlrn•loped cercbro-spinal fever 11 clays after his return to duty and the whole company was cultured, 8 of the 10 carril.'rs found were Jh·ing in the opposite end of the barracks and ne'er came in contact with him indoors. When carriers were found in the s:1me end of the barracks, they were sometimes men who hacl been sleeping in the hamn11 ·k next the patient, but just as often in the second! thiru. or fourth hammock distant . • \ plot ma<le of the sleeping arrangement of two barracks ( 42G-E. 4'.! -'Y) showed carriers scattered about without any obvious relation to the patients. 640 SIIORT-CEBEBRO-SPINAL FEVER AT GREAT LAKES1 ILL. -- - - - -- R.'l.RIUCKS -4'.!G-\Y. EAST. - - F.)f. W. c .. \. K. F. W.Y. r.. P. :K. L.A. L. 0. E.T. C'. s. J,. W. E. ~f. R. S. T. 0. L. V. A. M.1 B. ll. V. I?. E. n. E. C. T. N.A. L. - -- -- IT. K. T. W.L.M. R.M.S. c. C'. u. w. II. R. 1 F . R. W. E. R. C.KW. --- G. J. R.I J.E. P. J. R.R. B. A. ~I. I .A. T. P. 1 E. P.' ~. G. S. I L. J.P. I 0. L. P. P. 0. C. J.P. J. R. J. ~LP. c. R. s. 1 ~!. 0. W.E.O. J. 0. N. J. c. 0. A. J. S. 0 . R. s. G.W. V. \\1. E. M. II. W. P. F. B. S. R.R. P. J. A. P. J. \\'. P. D.A. L. 1 J. R. S. R.KS. 0. R. L. L.A. S. ~. R. L. --- N. G. )f. \'. S. P. \\'. F. N. J.C. L. S. 11. L. - - WEST. 1 Carders found January 29, 1018. • Ja.nuary 28, cerebro-splnnl revc1". ~o.4 . SHOIIT-CEREBRO-SPLXAL :FEYER AT GREAT L\.Kl·:s, ILL. 641 Perhap:- the ~ucce-.s in tracing n•lation,.;hip of carriers reported by Cnpt. Finck 1 was due to the method of detcrminin!! that n man was in clo!-C rclationc:;hip before culturing him. "herea:-; in tl1c culturin~ dOJ'C here nll the men in the gener:il viciuit_,. of thc patient were rc- gnrdctl n contacb ttnd were cultured: while the 1kgrec of contact was cJi-.rcg:u·decl until the carriers hacl been fouutl. Furthel' discrepancies in the carrier propo ition were di ... covered in n fow instances in which a patient was tran,fcrrcu to the hospital with the diagnosis of cerebro-spinal fover ancl his c·ontact!- cultured, "hen tlH1 case finally proved to be some other di,ea:::e. In spite of the small number of cultures, the results were similar to tho~e obtained in hona fide cases of spinal fever. (J11rricr8 amony "co11foclx" of c•11gc·~ not <:1 r c f,ru·xpi11al fcnr. Il.lte. Number or I C'ar- I Per I cultures. rlers. ~~ ,- ::-.amo ofcnse. 191;. I 4. 0 I P. n. H. (main hril?) •. Dec. 19 50 2 Acute torudlliti~. l91S. I Jan. l 165 7 4.1 J . ..:\. C., 3 C. P. L .. . ·I ~fo~llbriti•, ;:treptococ· CIC. Jan. i 105 1 . 9 T. G. B., 32'.l.. ........ EpilP~Y· Jan. ll 129 2 1. 5 No c.u;e, 42;; ........... li ta ·en number. Jan. 21) 52 1 1. 9 E. R.H., 122-X ....... Xot 'Pinal. Feb. 4 57 7 12.5 C. W. :\L, 255 .......... Acutc> pbaryncith<. Feb. 4 GO 11 18.3 D. W. A., 2:n .......... Pneumonia. Ft•b. l!l Dr. C. 96 12 12.5 L. F. N., 12L ........ )[eru.le'. Ft!b. 3 50 9 18.0 E. II. H., 52!>-N ....... Influenza. Feb. 3 47 5 10.6 G. n. G., :m-X ....... Toll:!illitb. )far. 8 Dr. C. 55 1 1. 8 H. H. G., 330 ........... lnfiuen7..a. - ~- 'Yhen these .few instances are plotted by week,; the cune thnt re- sults conforms in a general way to the carrier index of the station for t bat period. (See chart.) ~ome" hat similar results were obtained when the occupants of n barracks were recultured. On January H,, case No. 39 was remoYed from Barracks 421-'V and case No . .13 was tnken from the same barracks three days later. There being no a"ailuhle space for caniers nil men were left in quarantine together without L-eatment while cul- tures were made on January JG, 18, and 2~, after which carriers were isolated. On February 15, all nYailnblc men ori1:?"innlly present were a!!nin sought out: wherever their location, and the culture:; repeated. This wns again done on March 4. All plnle::. were made and exam- i11e1l by the same technique. 1 Loe. cit. 642 SHORT- CEllE.HHO- SPJNAL FEV£ U A'l GHE.\1' 1..\KE:-)1 ILL. Repealed cullura in Barrarb 4JJ-1r. (Pm.-l'oUth·e by atclt:tin~Hon. o-~eZ3th-e (no c·h~m·ttristic co'o:tl•. or ll!?elt 1f .. a1lro nci:a I~ llla'lk Sn!'e• :'\o c~llnrem ;1,,_ •-li;?la•t'I aH-:.-ric.r )an. 2.; to h•b.11, l91S, a'l<I di'leh3ri;:ed a ler ~ nc.;J.tlre c ii aro. 1-Isohted Ja:i. 2.'i; po;ill.-.i c;iJtur11 'Fe:1. J, Ill~; s 1 i slill I l)l.\tc.l Fdl>. I~ IJl~ l .,,..... ~="I'·· .. ;.~,, I}~~~·~~ '.':: II. F. K.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pos. 0 Pcs. I * 0 I o E . .\.. K. - - . --. ----- --. --. --- ---------. -. 0 Po..~. I 0 * 0 fJ D.L. 1........................................ 0 0 Pos. * 0 o 1''.J.L ............................................... POEI. * 0 O J. E. L................................... 0 0 0 Pos. o II . .T. ~f.................................. O 0 Poe. 1 o o ~!}L~~:.·.·.·.·.·.::::::::::::::::::::::::::: Poso g ~:: * i g i:::::: L. F. )f................................... 0 0 Pos. * 0 o L. F. M ............... .......... .... ...... Poo. PoR. I 0 1 0 O D. D. P .................................. Poe. 0 Pos. 1 0 o "17. E. P.................................. Poe. O I 0 1 0 I o F. H. R................................... 0 Poe. 0 1 O o F.\V.R .... : ............... : ........... : 0 0 Pos. , * 0 O F. R.R .......... ... ........... ...... .... Poe. 0 0 1 O O F. W. R......................... . ...... .. Poe. Po~. 0 (2) o P.L.R .. . . ..... . ......... ........ ..... .. Poe. , 0 0 1 0 O F .. r. s.................................... o o Pos. j * o o D. E. S ...................... .. .. .. ........ Poe. 0 0 * 0 o T. E. S................................... 0 POI!. , 0 1 1 0 0 C.R.\\' .................................. Poe. O 0 1 o o R. F. 8...................... ............ 0 I 0 Pos. , * 0 I 0 E.J. W .................................. Poe. o O 1 Pos 0 . o R.P.\V ................. ................ Poe. I 0 01 1 0 c. W .••••••.......... •..••.•...••••.••.•. Poe. 0 0 * 0 I O Atlditionalmennegative..... . ............ 33 Q 33 ...... 2~ - 2i •_\carrier Dec. 7, 1917. Poo.; 4 succcsslve negatives; Dao. 29, 1917 to duty. ' ~'11rlough. Percent. Positive by agglutination Jan. 16, 1918........... . .................. ... . . . . . 22 Positive by agglutination Jan. 18, 1918 ............................. - ~ ....... 9 P0t;it.ive by agglutination Jan. 22, 1918 ...................................... l!l Pns:itiw hy agglutination in first thr<'e cultures of all men.................... 4:l P~itivc by agglutination Feb. 15, l\Jl8 ................... _ ............ _..... !U! P<ll'iti ve hy agglutination Mar. 4, 1918....... .... ........................... 0 It will be seen that during the first week while 22 per cent was the high<.'st percentage of positfre cultures found on any of the three occasions, that 43 per cent of nll men present were found to be car- riers once or twice " ·ithin that time. ~\. month later 3.8 per cent wc·re found positiYe, and two aud one-half weeks after that, when the car- rier 1111.fox of the station " ·as approaching the figures that precc:<led the epidemic. no carriers were found in I his group. X o new cn:::c~ had m('anwhilc developed in that barracks. After the occurrence of a case barracks were often cultured arnl -.:arrict·s removed, "·hen within a few days another case "ould 1r'lkc its appearance, both when tlw pcrC'l'lltUg<' of cn1Tiers had been lt'1gli (sec ,Jan11nt',V cases Ros. ±l, 50, ii5. 73, 75) and when they had bt·1·11 low or zero (sec .January cnf;es Nos. Cl, 10, 12, 29, 31, GO) . On the otl11!f ?lo. 4. S.HOR1"-CEBEHU0-~P1XAL FEVER AT GREAT LAKES, ILL. 643 hnncl, in numerous in:,tunn•:-: new ca~e:; foiled to <1Hl•lop not only "lwn carrier:- wcro remoYetl. but abo wlwn they were not remon~cl Tt'!!nrdlei'::-- of whether the perccnt:t!!c was Jo~· (see Fcliruary case:. ~o<:. ;;, i) or high (SL\ Janu try cases Xos. 3!>. 3. tili. Febrnar~· xo~. a. r., fl. nnd 10). In this connection may lie mcntionc1l abo the de- ,·elopment of cerebro-spinal fever in a draft for an Ea~tern port in ))<.'Cctnl r l!lli. All ha<l girnn negati,·e cultures three dny:; hl'fore ka \'in.!!. X cvertheless one man deYelopc<l the di.;;ease <'n route. The 1 nrL ~laring defects nncl failures of the c;11Tier !'C'~rr¥:ttion plnn at this stnti<m ma~· be brief!~· enmneratc<l as follow~: (1) 'I he nearly idcnl application of the system failed to prc,·ent or upprrciably affect an epidemic, which rnn its cour:-c and sub~idell with th<' colcl weather after gencrnl h~·giC'nic measure!' had been rn~t 1t ntc <l. The subsidence of the epiucmic was umtlfoctcd. 111orecffe1-. ln' the rrmontl of restrictions on carriers. \YLose incrra:-c wa,.. the ~-.ult rather than the cause of the epidemic. (!!) All of the real carriers present arc neYer cliscoYered nt any 011P time. c Yen with the most careful technique. This i:-s best l'hown in the ro111ine culture of chronic carriers, where, it is schlom po-:.;ihle to !!Ct mon• than 50 per cent of cultures positiYe. Furthcrmon~. dnrin!! the 24 to 'i2 hour:; covering the inYestigation, some of the men hel<l to be carriers may haYe lost the organism, and of those pas::-cd as nrgntin• a few may directly pick it np in n crowded barracks. Y. ~L C . .A., street car. or town (cf. table of repeated cultures in bar- racks 421-W). (3) Carriers can not be truced in relation to new case~. except in n very fow instances and they are not nlways closely associated with the old ones. In fact the greate:;t number of c11rl'ier:; has oftC'n lie<>n f onnd among those least associnti>d. Finally new cases occur or fail to occur without apparent reference to carrier:- who remain or are taken away. ( 4) It has been found in general by roost ob:>cner:-. with few ex- cept inns. that the segregation and treatment of carriers docs not !!i H' s:itjsfactory results in hastening the <lisappc.'lr:mcc oC the or~:mi,m. It does not seem logical to srgregatc men who h:tn• pil'kcd up the- or- ganism durin~ chance contact with presumably only a few carriers. and f'Xpcct that they will lose it while isolated in doser cunt<tct with mnny t •trriers. while to isolate caeh ca nil•r i11 a :,;in!!le room i:- usun lly impossible. (5) During the past nine months 1.363 currier:-; have heen found on this '-lation, and 120 cases of cerebro-spinal fever ha,·e clcn•lopecl. During one month only has the number of t':t"'cs l'XCCrtlcd ~O but from 200 to 400 men ha. ve been in isolation constantly. "·111•n th<' elli- C'iency of the general measure is not clearl,\' eddent it does not SC'em consist,<>nt with military economy to deprive the organization of 10 64·1 ::>IIOHT-CEREBRO-SPINAL FEVER AT GREAT :wurns, ILL. ,·01. xu. rncn continuou:-;Jy for c,·ery one whom it is hopc<l will be protected from a temporary disability. That the inclfcct iYcncss of this method is not t\ new cxperienc2 is :-l1own by the ab1>tmctecl report of ~!eyer, \Toltmnnn, Furst&. Griebcr1 which is here quoted: They fouwl l.i:> per c•pnt of meningococcu-1 carrier;; in O\'l'r 9,111 h1..>a lthy i;ollllers in the l\lunlcll gurrison nt u time when no <·crC'bro-splnnl fewr ,,·ns p1·e:;eur. 01w cxamlna tl011 wns mnde of each man. One thousand nine hunilrt-.1 111111 elcn~n h<>:i.lthy pe1·wns were examined mnn~·. runny times wlt!J tlH' re,ult thai. 2.·Hi 1w1· Nnt were founcl to be mcnlngococcus carriers. Of U10 totnl or 11.ll~'..? healtllr 11er>:om;, nhout 2 per cent cxnmilwtl contninctl the menlngo<·o i·u~ In tlwir thro:1ts. Isolation of the carriers hnd no ln1luence on the lnei<h•lil'E' of tht:: tllscn1<e, 1uHI cpid<'miologic•ally tlH'Y founcl only exccpllonnl 1·elntion .. hlp b<'tWC't'n the cnrrio'r;. and l!Jc i:;i('k. In one of tlie year;; <lurln~ this stu:ly nu. mcro11s clinical cns('s occunell; i11 another ~·e:n 11one, nl tho11~h the numher or carrierH n•mninf'<l lhr i-mrne both rears. The authors conchulc thnt cxtr~me palnstakln~ culluml detection of rueningococcus carriers Is unnecessary lo comhating the s11re:ul of cerebro-spinnl meningiti>1; that the tlrncticul benefits do not justify the care 111111 time necel'Sllry for such work. They bellcYe that the chipf foci, uslcle from factors not understood in the spr1'UU or this tlis- eas•', ~et'lll to he lhl' sic!;: nnd cs1JCcially mild cases. In order to summarize the various clinical types of meningococc 1:. ii~fcction that haYe bren described, a classification might be made lC· cording to the degree of inYasion by the mcningococcus. Pre- sumably the least degree of invasion -would amount to merely a con- tamination of nn indiYidual"i,; throat, a transient affair measured in hours. In increasing degree the following types would occur: Tem- porary carrier~, measured in days, and chronic or persistent cnr- riers measured in weeks or months; local infections of the pharyn::t, producing "sore throats; " 2 general infections. either of low grade and passing £or influenza, etcetera,8 • or ontspokC'n sepsis/ with a Ya.- riety of metastatic involvements including meningitis itself. In accounting for rnriations in the type of disease Thompson & "'Wulff• conclude that meningococci vary in virulence at differ ~'nt pe1·i0<ls. and that the virulence is enhanced by repeated passage through one naso-pharyn.-.: after another. They thus explain why chronic car- riers rarely take or give the disease, but point out that during an epidemic of '·colds," the organism is passed along, and becoming more virnlent produces mild cases to be followed, perhaps, by nn epidemic of the fulminating type. 1 )foyc1·, '\'oltmnnn, Furst & Grlcbcr, Munchen llfed. WchRchr., 1910, No. 30, .Tuly !!G, nbstrncled In "rrc\•cntlvc .Medicine & Ilyglene," by M. J. Rosenau. 'llledlnr, n. lll.: Epidemic cerel>ro-splnnl meningltl~, nt Cnmp :llcClellnn, Jour. Am. llf Pd. Assn., Feb. 10. 11118, p. 4GS. •Thompson, o.; Wulf!', I<'.: Menlngococcus infection nntl mcnlm:ltls. rrospltalstldende, Copcnbagcn, Dec. 0, l!l17, Jl. 1102; nl>stt·., Jom·. Am. Med. Assn., Feb. l!l, 1018, p. 40~ • llcnlck, "" W.: Elpldrmlc of ;\lcnlngltl8 at Cnmp .lnckson, Jour. Am. ;\led. A:wn .. Jan. 20, llll8, p. 227. l(o.4- SHORT--OEREBRO-SPINAL FEVER AT GBEAT LAKES, ILL. 645 Granting the wide distribution of the meningococcus and its dis- semination by carriers and patients as the basis of both propositions, tho alternative explanation of the variable incidence and type of disease would obvious1y be that of a variation in the susceptibility and immunity of individuals themselves, as by the factors already discussed. Since control of the carrier is so inexact, and of doubtful efficiency, while harboring of the organism is of itself insufficient to produce the disease, it appears wiser to concentrate attention on the roore general measures of proved value and easy application. In addition to lhe avoidance of haste, crowding, exposure, and ex- brmsti·on in training recruits, all considerations of the utmost im- portance, other hygienic and sanitary measures available to combat· epidemic meningitis may be briefly outlined as follows: The 'men who have been in indoor contact with a cerebro-spinal fever patient should b6 quarantined in as small groups as po5sible in commodious barracks with good ventilation and ready access of available sunshine. A. nasopharyngeal spray with an antiseptic solution should be given at regular intervals to combat the organisms in the throat if possible, bnt more especially to accompany those which leave the tlu·oat in ta1king, sneezing~ and coughing. Special attention and treatment should be given to men with "colds" and coughs, including instruc- tion in properly screening others from an unavoidable shower of saliva. Curtains or screens may be placed between the hammocks or beds at night, as has already been instituted at this station by Dr. Mink. Light exercise may be taken outdoors, with proper clothing and protection from the weather, the danger of carriers being prac- tically negligible in the open air. After a period of five days or a week, when the temporary carriers will probably have cleared up, and the chronic carriers become relatively harmless, the whole group may be discharged to duty. During an epidemic large and promis- cuous gatherings, as in Y. M. C. A..'s or tlwaters, should be pro- hibited. During a quarantine cultures may be taken and repeated at pleas- ure, with a preceding temporary suspension of antisepticsJ and as a midd1e course during an epidemic the chronic carriers might be seg- regated to the extent of preventing contact with other men indoors. It is unnecessary to call attention to the usual precautions in ' handling the patients, who should be iso]ated through illness and conva]escence, and the desirability of masks for the attendants.1 The recognition and prompt treatment of the mild and previously unrecognized cases will undoubtedly do much to prevent outbreaks. 1 Weaver. Cl. H. : The value or the face mask and other measures, Joor. A.m. Med. Assn., Jan. 12, 1918, p. 76. 646 HJGBFE-DISE.\SF.S OF CEXTR.\L XER\'OlrS SYSTEM. Vol. Xll ('()~ CT.l""10~ "'· 1. Epidemic cerehro-:::pinul feYcr is a dise:be cau--ed by the menin, !!Ococcus: which j,., E'preatl for the most part hy dirl·ct contagion from putil'llts ancl healthy inclivitluals. In military organizations the me11ingococc11s hn ... a predile<·tion :for young recruits, but is usually inert in the ab--ence of depressing or resistance-lowering factors. ~- The :11·guments for isolating meningococcus carriers to pre,·ent the disease are not conYincing, since consistent practice on that ba-:is has proved not only extravagant :rnd against military efficiency, but also impracticable and noneffective. 3. The search for meningococcus carriers ancl their disposition shoulcl not cause neglect of the more generally effective and easily controlled measures of hygiene, of which the following are of tl1e greatt'~t. importance: The pre,·ention of crowding among young re- cruits; the allowance of ample time for their " hardening " and "sea- soning;" protection from weather, o,·erwork, and fatigue; and the use of all measures that will promote the general health of the camp. The laboratory work reported here was done under Surgeon 0. J. Mink's direction by Assistant Surgeons C. W. Barrier, ·w. E. ~for!'•', R. M. Choisser, and D.R. Higbee, United States Xavy, and .Assistant Surgeon C. Koenigsberger, United States :Nanl.l Resen·e Force. Ynl- ual le data ""ere contributed by ~\ssistan.t Surgeon R. R. Spencer, Unite<l Stutes Public Health Service, while accuracy in tlw numhcr and dic:tribution of the cas<'s was promoted to a great <.leg-ree by the work of .Assistant Surgeon C. J . Robertson, United Stutes Narnl Reserve Force, in checking up transfers to the Na val Hospital an1l following the diagnoses established there. SPINAL FLUID IN RELATION TO ACUTE INFECTIOUS DISEASES OF THE CENTRAL NERVOUS SYSTEll. • By D. U. II1om:1:, Lleutcnnnt, :\I. C., United States Navy. So Yariable haYe become the manifestations of disease of the cen- tral nen·ous system that it ma~· almost be said as a clinicul axiom that no obscure c1se with nenons symptoms is completrly ~un·eycd without C'Xamination of the >;pinal fluid. Pre-vious to the year 1891 the cerebro-spinal fluid ha.cl been the subject of much specula.tion among physiologists, chemists, and pathologists. ~fony, inclPed, were the theories a<lrnnced as to its origin. its analysis, and its functional relation to the anatomy of the bruin and cord. In the year .1801 Heinrich Irenueuc;; Qu incke, n German physician, invented n trorar nnrl r.nnnnla for the pnrpo:;e :\O. 4. HIGBF.E-DlSF ... \.SF.S OF CEXTR.~L ~r.nvous SYSTE)f. G-l'i of puncturing- the spinal dura and obtaining fluid from the spinal cnun I. Since tlrnt time both normal nnd patholo~ically d1nnged ~pinal lluid:; hnve been snbjected to the study of cytologi;;h dmni'-b pnthologi:;ts, physiologists: and bacteriologists with n I"l''llltnnt ma,..- ,_j\e uccumulation of data which have been correlated with <liS(>ased c.tntcs. ,\s a result of the very exten:;ive exn.mination~ anll re:,:eard1es which h:n·e been cnrried out it is now po$$ible for the clinician and the technician to arrive at certain definite diagno .. cs nn1l probable prog-noses in diseases of the central nervonR system ancl also to re- t•eiYc indications :for certain methods of treatment. It is only by a complete laboratory examination of the Uuicl that 11 correct interpretation of the pathologic processes 1lcvcloping within tJie central nervous system may be revealed. The lack of coopera- tion between clinician and technician has too often led to gro:,;s error in din,!!nosis, treatment, and progno~i>;. Since the entrance or our forces into the war tlw n-;sembling of lnr~<' :rroups of men has kept U:3 on the alert for the early detection of nil contagious disca!;eS, particnlarly meningitis. .\s a re:;ult much thnt is new has been disclosed and much thnt was formerly consid- e1·ed of little significance has come into its proper recognition. This adrnncc has been made lnrgcly through the spirit of mutual help- fulness and cooperation which abounds in the military service. The Inbomtory worker has familiarized him!>clf with the clinical aspects of this disease and has even been permitted to take chn.r:rc of the wards \\here these cases are segregatecl. The clinician has abo profitetl by visiting tJ1e laboratory and obserYing th(' methods fol- low11(l for the detection of e.vidence of disease. For example a new meaning has been :rhen the term clca:r 'fluid. It hue; b~n shown that a water-c1<'nr fluid h~; artua1 count may <'On- tain an~· number up to 800 cells per c. mm. Consequeully we no longer wait for a fluid to be definitely cloudy or 11ndl'r marked pl'('C..;,Ure before we consider the cast one of mcnin!!'it i:- or administer th 0 rap utic scrum. Lumhar puncture as a procedure has in limes pa t he"n rc!!arded ns nltog('thcr too serious a manipulation, nnd I helie,·e in time>.:; pres- ent is much too lightly regarded. Ther<' r-houl<l be dt>finitc inclicn- tions for it when clone ancl it should ncver be 1wrf ormecl n::, n l>hort r·nt to 11 diagnostic end. By so cloing we clcprcciatc our power:, of o~. ernition ancl fail in conscientious phy--kal e.'l:nminntions. I pro- pose no"· to describe n detail in the technilJUc of tlw operation which i11a' Le of scr,•ice to those who work in the field whL·rc there i ... little op1;ortnnity to render the hands surgically clenn. Select the exact 648 Ji IGBEE-DISE.\8I~S OF CE~TUAL XERVOUS SYSTE~f. Yo!. XII spot" lwre it is proposed to insert the needle and touch this with the tip of an applicator immer-.;ed in iodine 10 per cent 5olution. Allow thi to clry and then with the broad surface of the npplicato1· paint the field of Opl'ratiou up to ancl including the etll!e., of the ::,mnll ::ite Fclectcd for punctme. This small area. will r('main sharply clcfined. The first two finp:c 1·s of one hand are widely spanned acrcss this area, stretching the skin and holding it firmly against the spinous proc- e"'scs lo JH'C\•ent motion. The palm of the hand should rest on the back of the patient. The neeclle is engaged ·with the other han<l only by the hilt nnd directed through the center o:f the small tu·ett sckl"tcd. In this technique no gloYes are required. and the operator's hnn<ls , need not be specially prepared. EYe1·y operation should be attended by the most cnreful considera- tion for tho patient. It is only a matter of decency a.ncl an obliga- tion that rests upon eYcry operator to render the procedure as pain- less as possible. This ca.n be easily and quickly clone by needling along lhe line of the proposed puncture and infiltrnting wilh any of the local anesthetics in 1 to 2 per cent sterile solution. Tho fluid is usually collected in two sterile test lubes, becau.::e it so frequently happens that the first .few c. c. are blood tinged. Thi:; first portion can bo used for a ·wassermann test after being cleared by centrifuging. For the cell count, the bacteriological culture: and the colloidal gold test, pure spinal fluid is required and the second portion is used. If the fluid is not blood tinged there is no difference to be noted and it may all be taken in one tube. Inasmuch as the determination to do a puncture on a giYen case is b:tsecl largely upon physical signs it is, of course, essential that the physician should acquaint himself with all the classical signs indica- tiYe of cerebral nnd spinal irrita.t.ion. Physical signs nrc so inti- ma.tely related to the anatomy of the parts that each sign elicited can generally be correlated with the localization of the process. For example, the Kernig sign when positiYe indicates an irritation of the lumbar region of the cord. 'Vhen the leg is st raig11tenecl out upon a flexed thigh the lumbar region of the cord and the plexus issuing upon it is put on a stretch and pa.in and inhibition by coutraction of the extensor muscfos will be elicited if there is irritation in the i·e- gion. :::lo nl:-o the Bruclzinski neck sign is, w·hen positi\'e, an ·indicn- tion of ltbnormal tenderness in the ccrviclll region. There is nn inhi- bition shown by spasticity of the muscles of the neck ancl an attempt to oYcrcome the :.trrtching of the cord by flexing the thighs. J •. sign "hich has hitherto been undescribcd nncl so for as I um able to lPal'll has neYer before been elicited will now be described. The nrm of the patient is placed at the side of th:.- body and a firm. steady pull is exerted at the wrist in the direction of the long axis of f\O. 4. HIGBEE-DISEASES Ol' CE:XTRAL :XER\'OUS SYSn:~I. 649 the nrm. This mny also be modified by placing a ~oft but re...,ii;tant roll in I he nxilla nnd finally pushing the abdu<'tecl nrm ngain:>t the side. The:- munipulntions stretch the large plexus issuin!! from the L-erdcal cord. Thi.' sign is posith e if the mu!'rle8 of the shoulder nnd fore:\rm inhibit the action and pain is procluC'ed in the back of the neck and head. Th11 fir:-t phl.'nomcnon generally noticed as evidence of an nbnormal condition within the spinal meninges is th:it of incrC'nsed prC'.:-;:;ure. The fluill is forced out in a stream and runs out in continuous flow. When under normal pressure the fluid comes out in a !':ucces.-;ion of clbtinct drops, and enough should always he withdrawn to reduce the pressure to this state whether or not scrum is to he introduced, cx~pt in those instances in which the patient's heart action or res- piration is seriously disturbed. Increased pressure usually accurs in nil disturbances and diseases of th!.' central nervous system. but is not of itRelf pathognomonic of any one condition. The next cYidence of an 'lbnormal flui<l is opacity. A normal fluid is wntC't' clear. The opacity is due to inflammntory products and cellulnr elements of the blood and endothelial lining of the canal. The opaC'ity is of variable degree. and is only an in<licntion of a ~l.'rio11s lesion within the central ner•ous system mmnlly an acute infect' ot1s process. But the fluid is not always turbid or en>n cloudy "hen !'llch n process is present. Typicn lly the fluid of tuherculous meningitis is water clear and under increased pressure. As c:tnted nbO\·e the term water clear is only n provisional description applied to th·1t physical characteristic of the fluid. There mny be as many ns 800 cells to the c. mm. before any degree of opacity is perceptible. ~o in the early staires of nny of the ncute infections which typically yielcl a cloudy fluid at a later period. the fluid nppNtrs ns perfectly c)(•:tr. A microscopical examinntion for the exnet cell count is the only reliable practicable way of determining whether n fluid has in- crea ... e<I ce11s or not. From time to time. usually following epidemics of certain infectious (li!'ease:; of the nerYous systems, articles haYe nppe:u·ed in our mecli- cnl journals detailing the results of a lnr~e serie<> of cell counts and in suli,..tanee t('nding to show that a differential clia!!nosis could he made bY f his ml'thocl. One such instance in pn rl icnlar followed in the wnke of the epidemic of poliomyelitis in Kew York City in HllG. The nuthor attempted to cliffC'renti'a.tc poliomrclifi~ from :-pinul menin- gitis on the basis of a cell count. Nothing in medicine is le.:is !'Cientific. Any one who has a knowledge oi the pro~re::-si,·c tencll'ncit•s of in- tla111mation. will rcndily appreciate tlrn.t a high or relatiYel.'· low cell count i,, a fairer inclex as to the stage and t1w ncntencs.' of the process than of iii> particular identity or etiology. This rule. of cour,,e, would iTifl.18-1 't---G 650 llIGllJ:E-DI:;E.\SES OF CE~TP .. Al ~RlffOUS S1f;TEnL \oL Xtt not embrace tllO"l' Yery \'irulcnt infection.;., "hich :ire culled fulminnnt aud proclucc death 1 efore a reaction can occur. Consi<lernhll' attention must Le gh-en to the morphology of the cell founcl. Thii:; i::s e!;pecially true in dealing" ith the ,.o-c.11lecl clear fluirlio. There is infinitely more of diagnostic \'aluc in the morpholo!!V of the ce]h; pre...:ent than in the number. It is perfectly couceh·nbl~ that a puncture may he performed at a. time when the number of cells would disclo~e no information whate-ver ancl be within the limits of the cell count of any one of the disease processes to which the ucr>ou system ii. c;ubject. l:f the cells are found to be mononuclear om· mind~ travel Yery difiercnt paths of thought than if they are polynuclcar. In the former instance we think of noninfectious irritations. tnucr- culous meningitis, syphilis of the central nervous system. In the lat- ter imtance we are concerned with the various infectious meningitides which run a relatively short and severe course. For the identification of bacteria cultural methods should be em- ployed. It frequently happens that a reasonably cc>rtain dia!!Ilo~is can be ma.de by centrifuging the fluid and making Efained "lllenr.:; from the sediment for microscopical examination. The sediment from a centrifuged steril" specimen should be he:n il~- inoculated into n rich slant medium. First only a small area about the fluid of condt>n:;ation is inoculated to instigate a goocl initial growth. Four hout':; I.1ter the entire :;lant is inoculatc(l. The culture may be exam- ined at 18 to 2-1 hours and subinoculations then performed with ,·ari- ous sugar media to determine its fermentation reactions nnd with whole blood agar plates to determine the nature of its reaction with the erythrocytes. The chemical analysis of the cerebro-spiirnl fluid is for all prac- tical i,urpo:;es l imilctl to the detection o.f incrcnsc<l nmonnts ot s11~1tr and prote111. Very complete chemical anal~rses have bt•cn made with so great n lack of uniform results that little Yalue ran nt pre~ent be attached to them. Furthermore the methods are complex and the amount of £111" d requi reel is excessin. There :Lrc scYeral Y~ry reliable tests for the detection of an incrensn in protein. The Pancly. Xoguchi. and Ro<:s-Jones melhou;; are nll sin.pie ancl arc preferred by the \Hiter. There is much to lie ~nid in favor of select in~ one method and adhering to it. The accumulation of experience with a method is not the least important phase of the deductions which may be made from its results. 'Ihe protein in the normal cerebra-spinal fluid is derived from the blood by filtration through the choroid plexns nnd from the cellular cxct·ction of the gl:mdulnr cells. Whatever influences the µrcatr r pE'rmcnl>ility of this plexus and stimulates sr.cretion will consec111P11lh· inci:ease the amount of protein. Such an incrPasc. then. m 111;{ :d wa ·,, ,·ot. ,:1:11. IIIGBEE-DJSEAGES O.F CEXTRAL XERYOUS SYSTt~:IT. G51 lw J'('~nrdl'd ns indicuti,·c of nbnormnl con<litiom;. The etiolo~y may IJe either trnumatic. infections, or toxic. The only deduction to IJe ni.ulc b thnt there is irritation prc;:;cnt. The nmouut of increase of the protein may be regarded ns a rough i1.dcx of the severity of the procr .... There is nalnrnlly a more marked reaction to an acnk infrc- tiou:; cli~easc with its toxic, irritating. uncl paralyzing powers and to nn injury so seYerc us to create gross anatomical lesions than to a 9owly 1 rogl'<'Shing chronic proC('SS. 'fhcrc is contninc<l in normal spinal fluid abo11t OA: to 0.G µram of dc-.:tro"e per 1,000 c. c. This is suffici<'nt quantity to gi w a positi,·e rP<lndion of copper in the solutions of Fehling or Be11cdiet. llene- Jirt":-- qnnlita.fo e solution is a little more sensitiYe than 1hnt of Pit her Fehling or Haynes and the quantitative solution is a reliable reagPnt to u:-• ior measurement of the -rolume. Tl1 bUgar content in the changed fluids of m('ningitis case:-- is reduc 'll. Severnl explanations of this phenomenon have been giYen. ~one of them are satisfactory. It has been c1uimed that the cellnlur t>lt>mr.nts increased in the fluid to so marked an exle 1t nhsorb the :ou!!tlJ', Tile theory has also been achunced that th<' bacteria pre:-cnt u:>e up 'l porlion of the sugar in their metabolism. Yery pertinent objections can be ndvnnccd against both of thrse statements. The C{'rebro-spinal fluid normally is not a satisfactory medium l'or the growth of organisms. It becomes much more nutriliYc nnJ fa- rnmhlc to gro"·th when the changed conditions which aro prc::;ent in infectious irritations prernil, ,·iz., increase of protein. If the l'cllular elements absorbed the sugar present, then lhe centrifuged macerated sediment should disclose this fact when the test for copper rC'll11c:t ion is mncle. I believe that the natural law of physics can be i,uccessfully in- rnlml for the corr<'ct <'Xplanation of this fact. Sugar is a clialyznble :ouh:;tance and normally penetrates the choroid plexus, hut in the con<lit · ons where increased pressure prevails the tension is :-igainst this t.lialysis. Consequently the sugar content of the flui<.l is lc.<:s than norm•\l. This explanation may be correlated satisfactorily with the disensecl conditions presented. The diseases which incite the greaft!.':t amount of increased pressure show the le:-ist sug-ur. often the total absence of sugar, e. g., cerebro-spin:il fr, ct· and pncumo- corcic alJ(i streptoroccic meningitis. The disenses ,~d1ich cause a }cc.:s mark!'d incr<.>ase of pressure show a lrss marked r('<l11ction of the ,-olumc of sugar, e. g., par('sis, tuberculosis meningitis, ccrcbro·spinal :;~·phil s. f.'urther e' iclcnce in favor of lhis explanation is re,·cakcl in the PX11111i11ation of spinal fluids in patients s1dfaing from systemic disease~ which clo not increase the p1'Cssure ~itbin the spinal canal. 652 HIGBEE-DISEASES OF CEXTRAL NERVOUS SYSTEM. \'ol. :\IJ In diabetes mellitus the sugar content of the spinal flui<l is grentlv increased an<l in rcnnl in-.ufficiency especially attended by hi~h blood pressure the snit content is abnormally high. "G-'DC.\RY. 4\ lumbar puncture should be done on every obscure ca,.e with :;ymptoms relating to the nerrnus system. This procedure should never be employed until a thorough physi. cnl cxnmination has been made. Every specimen of fluid should be subjected to a complete lahora. tory examinnJion. A clear fluid mny contain as many as 800 cells per c. mm. The number of cells present in the fluid depends upon the stnge of the di~eased process and its intensity. It is of no diagnostic vnlue. The differential cell count is of considerable diagnostic value. Ko single finding except the recoYery and recognition of a micro- organism is pathognomonic. A new physical sign to be elicited in cases of meningitis has been described. An explanation of the decreased sugar content of the spinal flui<l in meningitis is offered, based upon the physical law of vsmosis. The laboratory findings in the changed spinal fluid can be cor- related with the stages of disease in the acute infectious meningitide:;, PL&v .A VEVL DOI&EA.V DE iHosxEL DIEV:m.P..ABJS BIRO'S-EYE VIEW OF THE HOTEL DIEU, PARIS, IN THE SEVENTEENTH CENTURY. E. Lecroisnier and Babl!, Paris 6&:1·1 HISTORICAL. THE HOTEL DIEU OF PARIS. Rome possesses in the Santo Spirito Hospital 1 the lincnl s11cc·essor .if tho largest institution of its kind erected in the mi<ldle ages. As Wvlie 2 has suggested. thf? Ospeclnl Grande of Milan (founded :n °1456 A. D.) furnil•hed the model for onr older type of block ancl corridor hospital. Lyons owed to Childeric, son of CloYi", ancl t.o lJltrogothe, his wife, a hospital founded in 5-19 A. D .. which sur- ,·irnd up to the fifteenth century. It is generally conceded. howcYcr, that the Hotel Dieu of Paris is the oldest of the hospitals of Europe which have a history of unbroken service up to the present lime.3 Certainly no institution extant in Europe to-tlay has had a more rnried and checkered career or been more closely associated with the fortunes of the people who resorted to it in theh' indigence nnd dis- tress or patronized and supported it in their affiuence. Having its origin in the benevolent enterprises of the national church, being through many centuries under the dirC'ct control of the cathedral chapter of Notre Dame, and at the same time t.he spe- cial object of royal munificence and parliamentary legisl!ltion; be- cau~e its Joors were open to rich aml poor, .Jew nnd gentile, Chris- ti:i.n and heathen, bond or free, and its ministrations to no race or c•reed confined; bC'cau!:le its reso11rces were deriYed from all classes of :>uciety-nol>les of the court. wealthy burgher~. the Yery b"ggnrs on the streC't--and, finally. because it was so intimately connecte<l with the many Yicissitudes of religious and social life through which the cit.r passe(l. the H otel Dien of Paris is to-day an ohject of affpc•tion ancl ,-eneration to citizens of eYery type. It is common t.o regard the modern hospital as nn es~t·ntin lly Clil'is- tinn institution and as one which has its origin with the foundation of Christianity, but this iden. is not altogether accurate. There is 1 Thr ln ~ tltutl o n romprlses n hospltnl for every kind oC dl ~Pn•P, with l ,n;,n h1 ''' In ordlnnry times 1tncl doulJlc this capuclly nt need; a lunntic usylum with n 1·np11C'l1y or r.nn lnmntes; a fonndllni;: nsyhun through which soml' a.ooo f<luocllln:;d pn~ ... nnnunlly. 2 llo•pllnls, Their LJlslory, Organization, aU<l Constl'UCtlon, by W 0111 Wyllr, M. D., D. Appleton & Co., New York, 1877. a 1'hr Hospice ot !llont Cents (A. D. 82u) nnd the Ilospkc of St. Brl'Ilnrd (A. D. IJ80) w~r.· not ho~nltals In the orcllnnry ePnse. Bans, Hist. ot ~lc<llclu1•. 033 654 IIJ::iTORICAL. Yol. XH re.1son lo belieH' that lung Lefore the Chri ~tian em facilitic>S for caring for the sick existt•d in Eµypl and in Greec(• in connC'dion "ith certain temples ancl llw mctlirnl schools attached to them. Jn lndill hospitals wel'e nnmero11s nncl extcnsi'e :fully three centuries before Chri<:t 1 nncl it was not until the time of Constantine, three centuries after Christ. that the C1lri ~tians them.;;elve,; began to found in titu- tions of this cliarnctcr. :Xor is there any ground :for the clnim thnt Harun al Rashid aJHl his )Iohammeclan succes.-ors \H'll' t·onseiou,lv imitating t.hc ('hristinn t'Xnmplc when they started im;titutions <;f this kind in Arabia. On tho othcl' ha ml, ell•emo..;ynary enterprises ancl charitable i11-:t it11- tions, being typical of the Christian spirit, became more an<l 111orc genern,l with the spreacl of Christianity. The necessity for isol:ttm~ the lepers, of whom there "·ere many thousands in Europe, nn<l the fear ino;pirecl hy the contagious diseases brought back from .\,in :Minor by the cru 0:1dcrs caused lazarettos and hospitals to be con- structed in large numbers. The proclivity of members of the religious orders to ~tmly measures of relief :for sickness nnd wounds made monasteries ancl connnts centers o:f medical nicl and nursing, and the rules of hospitality which they practiced, the need for plnc '" of shelter at night when the prevailing disorder of the times renclere1l traYel dangerous mnde it natural :for the conduct oi hospitals nnd kindred e-,tab1i-.hnH•nt:> to fall to the lot of the church, which took up the task more and more readily as its own organization was pcr- £ected and it acquired the authority and the funds necessary for the prosecution of all kinds of business. And so while in many case.., hospitals "·ere founded by bishops and other clergy, the Hospital of the Holy Spirit in Home owes its origin in 1108 to no less a personnge than a pope, and to one of llie ablest that ever occupied l he chair of Saint Peter, Innocent III. It was this Innocent who completed the work of Gregory YII, who made himself protector of Itt1ly again<:t foreign aggression and thus consolidated the temporal po"·er of the church; who bitl nn interdict upon Eng1antl and threatened En!!- land's ltln~ with a t•ru~acle; who compelled a King of France to tnke back the wifo he ha<l ca::;t aside, and who interfered with the mar- riages of two King-, of Spain. To-clay "·e hn·ish money on marble, brass, tiling, nml cement to nm ke our hospital" firt'proof buildings, capable of being maintained in the highest degree of cleanliness. The ordinary cleanliness o( the housewife nml t.hc more minute cleanliness of the snrgcon are the principnl objrcts sought. Onr poor and our sick '"ho arc shel- tered by bare, nndt'eorrtt.ed, bnt sanitary walls are the objects of the su.m.c kind of love and charity which moved the people of the l\Ii<l- cllc ~\gcs, when nscpsis was unknown, to surronnd pn.lirnts with ob- jects of artistic beauty and to subject them to spiritual and religious ~o.4. HISTORICAL. 655 influence~ to lead them to Goel. Of hygiene, of bncteriology. of di--infcction. the people of the olclen lime knew 1ittlr· or nothing. but of whnt the~· hncl they g:l\"e fr ely. Thu~, in Pistoin in Tuscany. the 0-pedale tle1 Ceppo: built in the thirteenth century and rc- lllodcled in the fifteenth, has <'Xterior decorations of rare beauty in color :!fl term cotta and enamel. Abo>e the open arcade there is n seri ~·of group representing the SeYen Work~ of )forcy. the figures 1nnkina n frcize rich in color nnd light and shade eifocts. The Hall of the Sick in the hospital at Tonnerre is a beautiful ti111LPr-roofcd apartment dating from the thirteenth century, ancl now us(!{l ns a chnpl'l. :.'lfargaret of Burgundy, wifo of Charles of .Anjou. the fonndre'-'S of the hospital, and Louvois, war minister of Louis XIY. briug bmitcl in it. Ben,une, most widely known for its win<', Loal>iS a li1'~pitnl c::o well constructed that, though mainly of wood. it is ~iill in good pl'eserrntion ititer nen,rly five centuries of existence. Cts hi!!h-pitch<'tl roofs, dormer windows, and elabornte gable:;. its council chamber, its tapestries, and the mural paintings and altar piece!> musl have delighted the eyes of the beuuty-Jo,·ing people who went there to be cured n,t a time when our country was but one rnst Indinn territory. In the dn,ys gone by. pleasure was belien~d to con- tribute to convalescence, and pious patron, architect, and builder were trying to benefit the sick us well as to gratify their own in- stincts. when they enriched the hospital ward and the hospital chapel with cnrvingi:i and pictures. In Santo Spirito, Rome, the wards were frescoed with scenc>s from the life of Innocent III nnd of Sixtus IV. Plntina, the distinguished humanist, the papal biog- rapher. the custodian of the Vatican library under Sixtus IY. com- posed the insc:r:iptions for the pictures. The belfry of its church is one of the most beautiful and graceful towers produc ~ d by the early Reuaissance. Its nltnr boa!':ts one of the few works of PalhHlio extant in Rome. In the spring of 1014 I SJ>l'llt many a ple:umnt hour wnndl'ring about the streets of old Paris. but grie•ing to ob-.ene at c,·cry corner how fast old landmarks were disnppearinf!. for tl1e :-traig11tening of ~treet and the frenzy of sanitary reform in Paris did not entl with Bnron Hnussmnnn and the Second Empire. That part of the left bank of the Seine between the Petit Pont :•nJ the Pont nu Double hn::- n peculiar charm and interest for the sight-seer who is a <loctor. for not on ly did Paris' great hospital, the Hotel Dieu. occupy this l'ite ns ~ <'11 as part of the bri<lges jui::t nnmecl ancl :\ lnrge area of the · Inn<! known as Ile de ln Cite, but here was located tli • School of Medicine and this section of the town ''"as the hnliitat and re.;ort of me<lieal students and their teachers. Dnde in the tenth canto of his Paradis refers to the Rue du Founrre or Street of the Straw. "Te 656 HISTORICAL. see in this nnme a reference to the stra'Y on which slndent::; ,;at dur. ing lectur<>s at their near-by school. Here is a cougerie of queer old $frcet,-H11e Dante, Rue du Rat, Ilue des .Ani:rl::tis, Rue de la Bucherie. Hue dn Haut Pa>e, Rue de la JuiYerie1 Rue St. Sc!,·erin- many of which are doomed to disappear ns ha.Ye so many others al- ready. I searched in Yain nmid builders' l~igh wooden fences for the ruins of the wall of Philippe Augustus, looked in for n moinmit at the Church of Saint Julian the Poor, which Baedeker snys was once the chapel of the old Hotel Dien, and then sauntered down the street of lhe Hotel Colbert, a building in the shape of 1i rotnn<la. used as a lecture room by the faculty of llll'• I 1eine for a trifling matter of 300 years and then as a school of anatomy. It is not for to the ~Iedical School, with its museums and laboratories, and to the famous Hotel de Cluny, where Mary Tudor, the "·white Queen.'' enjoyed her merry sports and pastimes in that endless round of pleasure which brought her elderly hnsband, Louis XII, to the grave. The Hotel Dien of modern Paris stan<ls near but not on the pre- cise site it originally occupied, having been reerected between 1 5- and 1818 on the side of the great cathedral square opposite instead of adjacent to the small branch of the river. The buildings are thus lacking in those examples of mural decoration, of plastic art. of architeclural charm found in establishments of older construction, though much of the original structure erected by Eucles of l\Iontrcuil. builder for Louis IX, remained unchanged almost to our own time. Tho Hotel Dien of Paris was founded by Saint Landry, twenty- eighth bishop of lhe city, about the mi<lclle of the seventh century, when he assumed responsibility for the support oC many poor people who sought asylum in his palace. He disposed of many treasures of the Chnrch in order to meet these obligations and the year 660 has been assigned as the exact date of the selection of a special building for the case of the sick. It had been occupied prc,·iously h,v the 11111b who hacl charge of the treasures ancl linen of the Cntheclra l of X tre Dame, and from its connection with the chapel or thn.t name the h~­ pital was first known as the Hotel Saint Christophe. Erchinoalcl, Mayor of the Palace and styled Count of l'nris who died in Ci-11, bequeathetl land on which stood hi::; palace and chapcl for hospital purposes. (Felibien History of the C'ity of Paris, 1125, Yol. 1.) In 82!) this building was torn down nnd the first building in- tended specifically for the Hotel Dieu was erected. This is not nc- ceptecl by Chevalier,1 who believes that when the bones of ::faint Cliri.:;loplu>r were moved from Toledo, Spain, to Saint Denis, in 6-10. ' Alexis ChcvullN' In "L'IlOtcl Dleu de Paris et Les Soonrs Augustlu~a." II. Champion, l':ll'IS, lUOl. HISTORICAL. 657 they Wl'l'C dl'po:>itccl in a chapel name(l for him. and that when under the patrou:H!' of Bishop Landry n ho,-pital was founded here, the n•lll" from a ron\'ent near-by were per~uade<l to undertake the nur:::o- in~ of the "'kk therein. The in:::otitution was known ns Sniut Chris- topher's IIo:::pitul up to the eleventh century, though there b a mnnu- ,cript extunt. elated llG-!, which alludes to the kar1ng down of the hospital and its reconstruction on the north shore of the smaller n1·m of the ~l'inc. The original name of the institution was Domus Dei, or Hon:'l' of God, nnd its motto was" Medicus et Hospcs." or Ifonler and Host. The primith·e hospital consisted of four wards or hnll:-; capable of 21ccommc dating a total of eight or nine hundred patients. Of the«e, the St. Denis ward, to which were assigned tho ... e cle-..1wrately ill. wus erected through the munificence of Philippe Augu.::tu!'. The Jnfirml'rie, and the St. Thomas ward for conrnlc.-.;cent~ were equipp<'tl largely by the contributions of Queen Blanche. mother of Louis IX (1210 A. D.). The new ward was for women. The base- ment of the latter was for maternity cnses. The unfortunilte situa- tion of this ward rendered it dnmp nnd unhenlthy. but the women awnitii !! confinement hnd to stay there, excl'pt pHhaps the few lu<'ky inclividuals "ho might be detailed to help with sewing in the linen room. There was n feeling that pregnant women were un- si!!htly and so could be stowed away in an out-of-the-wny place with the utmo:;t propriety. 'I"hl' location on the river had advantages and disndvantages. The ::.trcarn certainly prevented other buildings from springing up in too close proximity to the hospital, thus reducing the li#?ht and the ci1·cu- lution of air in its vicinity, and it sened us a sewl'r. The water- clo ers Wl'l'C located directly OYer the rh·er llnU for a long time Wl'l'C ronne:ctcd with it by gravity alone.1 The jonrney thither from some parts of the hospital was considerable and inrnh·cd 110 little trouble for the patients and their nttendunts. " rhen a sick per:-;on passed the porter's lodtrt'. wns admitted ns n patient and assigned by the sister, "ho prl'sided nt the entrance. to the proper warcl. he confessed to a priest, surrendered his clothe,<; to n cnrctnker. who saw that they wern waslwd and clcnncd. nnd <':tt"C- fully stowed a,,·ny to be returned to him on rr.con•ry or ~old • t auc- tion in case of death. He was then put to bed nnkecl excl'pt for n. nightcnp, nnd it wns a rare and unusual thing for the newct nll'r to enjoy a hNl 1.o himself. Usually the patients lept two :md three in n b1 tl and in time of famine or p<'stilence. when the Wttrd,, were crowclr.d, iL was often necessary for six or l'ight per:-ons to sleep torretLPr. The beds were largo, four-poc:.tl'r beds, fitted out "ith one 1 In ti~ zumc wny In the llt1trl Dien nt Amlena aml In other houses or tLat city built on the Somme the wntcr-c!osets ovcl'hung the l'h'N' co1·bdwl r, 65 IIl::>TOBICAL. \II XII or two feather pillows. hu!!e bol::-ters and strnw mattrr::i,cs rc4in~ on cord:' in lieu of c:pring~. These mattrc::;scs w·cre made O\ er thrCG time::. a year. The ::.upply of linen wns plentiful, a thous:uHI sheet l>ei n!! the allov. an cc per week in v. t~rds, with a rcscne of a thou- ::.nud in the linen presses. ThPrc were gray quilts for use in cold winter wc:tlh<•r. They were lined with :fur from dog, cat, i,.heep, s iuirreJ, or fox, seYeral kinds to a quilt. The wurk of renorntiug the beds 'vns done by nuns. noYices, and convalescent patients anll the <.'omplet ion of this huge task was inrnriabJy celebrated by a hnnqnet. Crude as were many of' the pro,·isions for the sick. we must re- member that they were in harmony with the times and analogous to "·hat patients had been used to in their own homes. It was not till Yery late in the Middle Ages that a trtwcler could cxpecl a bed to himself at an inn,1 and certainly among the middle and lower clas--c:; any special nightdress was a thing undreamed of. If a person <licl not choose to sleep in his clothes he slept without them. It "ns, howeYer, a real hardship for the clelicnte and infirm to have to turn out at night and make long pilgrimages to the toilet, especiall~· in winter, and with their clothes locked up. Each ward, therefore, hacl a supply of cloaks or dressing gowns and slippers. and the oM records and chronicles contain frequent refer1::nce to the night nurses' specific duty of assisting the sick or the old on these expeditions. The fact that no diagnosis was urnde on entrance and that patients were sent where there was most room meant that a madman, a man with a broken limb, or a case of smallpox might find themselYes not only inmates of the same room, but actual bed:fellows. 'Cntil Franci I, in 1535, founded a special hospital for children there were always from fifty to a hundred in the Hotel Dieu, though there was no pro- vision for them. U::;unlly they were not sick, but accnmpnnied their sick mothers because they had no other place to go. While we can condone lack o:f ventilation and limited heating facilities, it is ter- rible to think of children occupying a bed with tlie syphilitic or the insane. Syphiliphobia became rampant during the last years o:f th<' fifteenth century. as the co11tngio11 hacl become Yery general in France nnd more particularly in Paris with the return o:f Charles YIII's army from its cl i.::a:-.t rous sojon1·11 in K aplPs. Yery strcnnous efforts wen! made in Paris to !wgn~gate the victims of the discac::e, special how• s being as<=ignrcl them. Onn of these was in close proximity to thl' dwelling oi the canons of Notre Dame, but these reverend gentlemen naturally took alarm and, follo,dng their vociferous rcprc~·t'nta­ tions. the patients were remoYcd from tha.t locality. Remarkable to relate, the general ~care nbout syphilis died down bcfort> n11ythin~ 1 A st::iio~d-glnss window lo the church nt Trkl, Canton of f'olssy, Department ot S~loe et Olse, shows three travelers lo bed together at an loo, looking comfortnlllc and lrn111 y. IIJSTORICAL. asn definitl' hnd been a<'c1 11 plishcd in c:uppre,,.,in!! the <li:-l':M~ and there bns continued to I e an~· number of ca:-,e, of syphilis in Paris from that <ln) to this. :-o that ouc <1oc::. not lune to go to X a pies to acquire it. 1t j.., cert::.iuly iuil•1csting lo note that the one cla ::: of 11nfort11- nnte,, against whom the portals of the II\itel Di<'U remained c,·er cl se<l was th, t of the lepe1s, the coimtry being libcrnlly providrcl with asylums for the111.1 J>rimiLivc a::. wcr0 the arrangements of the llotrl Dieu up to the br!!·nning of t.ho eightee11th century, it mnst hn.Yc accompli::.lwd an incrc-clihlc amount of good. Not only did it rrceiYe the ~kk but the roor and the destitutr resorted thither for free lodginl!, he!!~:tl':. sometimes receiYed alms there, and in time of war it slwlt1•rl'1 l a l'-'o refugee<> and soldiers. EYen when cured the poor patit•nt wa~ allowed to remain for another week, a well-meant regulation "hich unfortu- nately did not always bring good to the beneficiary. sim·c it wns quite common for convalescents to pick up some new discn ... e on the r<'r!!C of their departure. There was pro1?rcssiYe improvement in the installation an<l man- agement and inlernal discipline of the hospitnl up to the fourteenth rentury, and from this time dates the most flouri~hing period of its exi:,tence. Patients were regularly admitted from G a. m. to G p. m .. Lut in emergencies could gain admission at any time. During the tle>enth and twelfth centuries there appears to have been no surgeon or physician regularly attached to the hospital, attendance beini:r ginn by priests who had some notions of medicine or by sisters. The patients were fed twice a day-at 11 a. m. and at G p. m. Deshle each h<'d was a rack or table for the earthenware wine bowl, the drinking r11p, the wooden bowl, and ,...-ooden spoon provided each patient. There were three fa!':t days a wrrk for all hands. )futton was the commonest \'ariety of meat sened. Beef was rare. and veal, lamb, or pork was only to be had on special holidays nncl feast clay-,, pcrhap~ ten times a year in all. The dietary inclu<led soup.;, c•g;r'. fresh-water and !'alt-water fish, fig:;, grape.c::, sugar, oatmeal. cheese. and tn1i"'. 'Ther' was a definite allowance of milk for cnch w~1rd daily. The d l'tnry for fa!=:t days included cured and c:moke<l lwrrimrs nnd onions p1-cser,·ecl in oil, etc. Patients who were scriou ... ly ill rcceb·ed the best wine ancl fowl of all kinds-spring chicken,,, go::.linrrs. pigeon~, nnd en pone:. If they hntl no ~tomach for meat. hroth:- nntl jellie were prcpnrecl for them, but sometimes the;v could be made to l'at it "hen it "as en·Nl as a roast. For the mil<ler cac:e;-;. co<l and "hit in~ were good enough, bnt those who were very ill coultl h:nc pccial cli he:-; of 'In 12~\J Chc1·1• Wt'l'C nt lcnst 2,0110 lnznrrttos In l• ranc nn<l ten times tbnt number In F.urope tor the B<'l:l'eg11 tlon of h•p1•rs 11ml Inter !or the P• , r.Hlon of cholera nncl smallpox n s cluo to the crusnclcH. '.fh1• French leper homes were nboll hctl In th<> rd~n or Louis .-1v. B1llls, lll•tory or :lfodlclne. 660 HISTORICAL. \"ot :'\It .small. delicate fried fbh. Bread ''.tis lalkPd in the hu,.,pital four times a Wct'k. aml it wa-. of three grades--ordinnry brcu<l. fine wl ·te brend and brown bread. Other bread was bought outsido or s~nt in n'j ~ charity. It was customary for the master bakers of Paris to make an annual visit to the hospital, upon which occasion they were ex- pected to make a gift of six dozen lotl\°c~ ancl au equal weight of pastry. On holidays and fetes herbs and flowers were strewn everywhere ancl counterpanes of bright color and "storied carpets" w, re put on the beds. There was a special room for such hangings and draperhs and they were brought out but four or five times a year. :Meanwhile the altars in Notre Dame were decorated a.nd all the statues of altar or chapel were crowned with chaplets of roses. The holiday would end with a banquet, when there would be an extra allowance of wine and ample store of pigeons, goslings, and tarts. The fragments were carried to the poor, who were never forgotten. As it is a malter oi record that the brothers and sisters looked for- ward eagerly to such holidays, it may be inferred that the lion's share of the banquet 'vent to the worthy priests and pious sisters who ministered to the wants of the sick, and we cnn see no harm in this, :for the laborer is worthy of his hire, and surely it would h:1rn been killing them with kindness to line the lean paunches of dying beggars with fat capons. Whenever the corporntion of drapers assembled it was their custom to send to each patient in the Hotel Dien a measure of wine, a roll, and a piece of beef or pork, while each occupant of the lying-in ward receiYed a plateful of food. The master grocers, bakers, and spice merchants were equally kind. Members of certain trades, seeking promotion from apprentice to mastPr, WP.rA required to produce and exhibit before their judges a sample of their handiwork. Thus, the pastry cooks, when quali- fied, sent their masterpieces to the Hotel Dieu after they had been inspedNI by the judges. The greatest ~ indfall of the year was the annual banquet given by the rich guild of jewelers. It came at Easter. Each patient receiYed a bowl of soup, a roll, a measure of win?, two eggs, a portion oi roast veal, a crack:nel) and a generous purse of money. On leaving the hospital cured (or, as sometimes happened, merely disgusted) each patient got back his clothes, mended and cleaned, often with a shirt added and an extra penny or two in the pocket., and he was furnished with a ccrtificate that he hncl been n patient in the IIOtel Dien, which entitled him nt neecl to receive further aid from the Ilospitnl of the Holy Spirit of Paris (throughout tho mid- dle nges Holy Spirit was a favorite designation for hospitals}. But auctions of the effects of lhe decensPd were very frequent, ns the HISTORICA.I .. 661 mortality was high. The dead were buried in a common lrPnch of ,.n ... t proportions. which was dug once n year and filled in n little at a time ns S:ld occasion dem:mded. The still-born babies of the Irntel Dieu and \'icinity "l re disposed off in a peculiar way. Conn('ctecl wirh the hospital was a tower, called the Tower of Limbo, lun·ing n rrntral chamber filled with quicklime. One ::-.ister wns ::ipcrially designated as the custodian of the ke) to f his chamber. Iler,, wa.; the duty of throwing the little bodies into the lime ,;that the~· might be quickly consumed.,. Tht· munificence of some of the French monarchs did much to in- sure the permanence of the Hotel Dien, nnd in times of fina1wial dis- tres" or when the demands upon the institution called for u111bual cx- penditurcs an appeal to the king ahnt)s brot ght relief. Philippe Augustus, Louis IX, Queen Blanche, his mot her; Henry of X a \'nrre and hi~ son Louiv XIII, eYen Louises xn·, XY. nnd XYI. m~rc COll- spicuo1i::; for their interest and practical hC>lp. In 1209 a royal order assigned to the Hotel Dieu the straw of the ldn!!'F room and of his palace dnring the monarch's aust>nce from the city. Reference has already been mnde to the nrchitecturnl t·on- struction carried on unclc•r Philippe Augu~tus. Louis IX and hi:; motlll'r. to the generous contributions of Yario11s guikls. to thl· lc~a­ cies of the canons of the cnthedral. Saint Louis a:osigned a pcn1ion of the taxes to the Hotel Dieu and exempted it from pa~·ing tolb on proYisions brought to it by land or water. Under thi=-- ruler the custom of giving money and :food (grain and herring:::) to the poor of hospitals and laznrettos during the Lenten period was ~:rnc­ tione<l by law. These onlinanccs were duly confirmed by Philippe Ya 'lcl Charles IV. A definite amount of wood went anmrnlly to the lli1td Dicu from the roynl forests, and officHs n111l puncyol',., of tho royal household were prohibited from comman<lecring for tcmpo- rnry use, as was done in case of prirnte indiviclnals, the hor:..:t':o. oxrn. or cnrts belonging to the ho«pital. In return for the gift of wood the brothers and sisters of the hospital wPrc n•:..:pon:;ihh' fo1· ral'ry- ing the sacred relics of the Sainte Chapelle to where\cr tlw kin:r migl1t be when absent from the capital. p1·0Yided the clistnncc "·ns not ~cn!C'r than 34 leagues, nor could this c111ty ho irnpo~ed ofte11cr than four times a year. Philippe VI, founder of the House of Yaloi!': nntl whose claims to tl1e crown were conte<;te<l Ly Edward III of En:?lnnd. leading to tho llunclrcd Year:;' War, was a patron of the IH'itel Dieu. He> initinlt'cl the prnctice of letting the hospital send it:; henl of ho!!:; In :feed in thr royal :forests, mere})' limiting the l111mhC'r of nnimal-. to :!00 tl ~~ . It became the fnshion for the queen to 'isit the Hotel Dieu M'<·r~· Good Friday. and, of course, a Yisit nt !'melt a time mean! lihernl clona- 662 HIS I ORICA L. \ oL Xtl tion,; from member" of her court as well Ml from the monnrch. In time. too. the cw-lom sprang up of prc.c:cnting to the hospital ea.rh roynl crndle and of buying it back at a fonc~· price when needed, while on the death of a queen the furniture of her apartment wa,. !!i H?n to the hospital. Iu the twelfth century the cathedral chapter pn!ise1l an ordinance Ly which eYery canon was required to beqnNtth to the Hutd Dieu his feather bed and sheets. Likewise, e\ cry canon who recei>ecl a promotion had to make a similar offering. As we turn oYer the records of the hospital we come in the com'l>e of time to m •ntion of a lawsuit before the Court of Parliament of Paris. brong'ht by the Go,·crnment commissioners of the Hotel Dien against the h •1i.:, of a certain canon, the complaint being that saicl heirs had turned on~r to the Hotel Dieu the feather bed, bolster, and sheets belonging to the ckcea~ed, hut no covering. tester, or curtains. The lawyt'l' for the defense replied that the sister-; no longer tPncled the canons when they "ere sick and so did not cle~crve liberal alms and le~acies. The Procurator General. howeYer, com;iderecl thici countercharge irrcle\lmt., approYed the contention of the Ilol el Dieu, and or<le~ the deficiency to be supplied. The revenue from all these som·cps, ho'''e\'Cr, was relatively in- significant nncl not to be comparetl with that deri\"ed from the fines impo::;c1l and the confiscations made by civic officials of Pari!':. As the kings themselYcs often set the bad example of issuing a debased coinage, it was to be expected that the use of false weights and measures should be very general. "Whenever the fraud was detected the foods and storPs involYed became the property of the hospital, "·) ich was largely supplied with candles in this wny. During one period of 1he city's history the executioner was empowered to turn over to the hospital all stray hogs captured in the streets, and, though he only recch·ecl a few cents for each nnimnl apprehended, the annual gains from this bloodless duty were considerable. In 1418 Capeluche made quite a neat sum in this way. One gets a striking sidelight on the critic:1l sitmttion of Franc() ju~t before the mission of Joan of .\rk was accomplished and when two kings claimed the soYercignt~· and were nctun.lly aclmowle1lged by different factions, from the record of two gifts macle to the Hotel Dien. While the wife of Charles VII, the rightful ruler, sent 4 liucs. the Duchess of Bedford, whose husb:rncl represented Henry YI of F.nglancl. the riYal claimant, sent n matter of 80 livres. Henry of Navarre built two hospitals in the suburbs of Puri~ for syphilitic and contagions case.s, thus cnnying out plans made long before his clay. More than this, he rebuilt the Saint Thomas and Saint Denis wards, his architect, Clanclc Vellcfoux, substituting a :-o. "· HISTOI:ICAL. 668 i>inelc nrd1 for the p1-e,·ions douulc groin. a mo<litic-ntion which helped to emphasize the J>U"~ing of the Gothic :-I.\ le. Ycllefnux wa,, follo,,cd by his pupil, Gamard or G:unart. "llO cnn.;trncted the Pont nu Double and on this erected the Hosary Duildin!!. n t" o-.. tory :;tructur" opening on thl' Hnc de la Blichcrie. En!ll before comiug to the throne, while still engaged in the ll't'ril1le :.tru!!gl(' "·hich had r<'duced France lo poYerty anrl st:1rrntio l, Henry of XnYnrre had shown 1111 intere.<:t in the inmates of the JIOtel Dien. It is not hard to helioYe that genuine sympathy as well n.s shrcw1l polic,· prompted him to sencl relief to the unfortunate p:iticnts o this c:-tnhlishmcnt while he was actually besieging the city. We r<'ad tlrnl in 1;;oi. while occupying Chartres, called the granary of Paris, he dispatched Ji~rnl prm·isions of wine and wheat lo the Ilf>tel Dieu. It was by such acts as thjs that he prepared the way throurrh men's hearts to the throne, and many a Parisian burgher would h:\\'c \H'komccl him to it cYen before the hated heretic h:ul remoYed tl1e h:,t ob- :;tncle in his path by abjuring his faith. Throughout hi~ rd!!n the Yert Oalant showed himself n. l:n·ish patron of the hospital and his cxnmplc was, of cour~e. followed by the court. who!"C mcmbe1s Yied Fith each other in their display of generosity. It became the fashion to !!'iYc and to giYe liberally. During the declining years of Louis XIV the financial admini~trn­ tion of the H otel Dieu became heavily invohcd and royal sanction wn,., obtained for converting into cash n consjderable part of the real c~tntc owned by the institution. A huge lottery wns n],o organized in this reign, the king being one of the chief promoters of the scheme and buying n thou~and tickets. The tickets werC' on sale all over Frnnce, and the lottery netted a \Cry large sum to the hospital l"nder Louis XIV a statute was enacted. (hough 11ot enforced until the time of his grancl~on, Louis XY, by which a levy was made on nll money paid for admission to public ~hows !lncl C'lltertninments. Thus one-ninth of the price paid for ticket:-:; to O!JUU or comedy in Paris went to benefit the inmates of the U titcl Dien. Still "O <lire was the Jll'<'cl of increaced re,enue that the!':e measures did not ~uilic~ . au<l. in a<ldition to the collections taken in all the churches of Paris. a l1<J11-e to house Yisitalion \Yas unclcrtnk<>n to raise further sums n.nd r·lmritnble "·omen banded themselves together to contribute to the 1omfort and welfare of the patients. From its Ye1·y founda6on the hospital had d~rin.'ll. n Yery large 11:1 rt of its income from the legacies of cleYOnt or d1ttritable per~ons. TJ1e IHitcl Dicu 'vas beloved of Parisians trnd Fr<'nchmen an<l there arc• H·ores nnd $Cores of documents extant which ~h<1w how 11niYer~a1 \\:ts t lie pr:ictice of bequeathing to th<' ho:::pital l'lothing-. furniture: money. lands, antl houses. From the earlie t time-: it hnd been a 664 lliSTORICAL. \"ol. XII pious cu::,tom to mention lhc ho::pitul in one':,., will, nll(l if, with the decay of earnc:::.t religious belief, piou:; custom changed to society ·~ fashion the material gain of the Leneficiary wac: not reduced. E,·ery- body left something to the Hotel Dieu, from th-1 king to the hum. ble;:,t artisan in his dominion. 'Ihe Dukes and Duchesses of Berrv Brittany, Artois and Anjou, and the king's barber and his wife, th~ seller of parchment, the prosperous fish monger, the Captain of ti.le Bastile remembered the Hotel Dieu when they came to die. Out of 48 wills filed for probate before the Parliament or Paris in the reign of Charles VI, 40 contained clauses in favor of the great hos- pital. Cardinnl Mnzn.rin contributed huge sums to the H.otel Vieu and heartily desired to have a special hospital built for convalescents in connection with it. Ile arranged for the suppression of the ancient priory of Saint Julian the Poor, which was falling into ruins. All its rights, rentals, and privileges were to accrue to the Hotel Dien an<l the ground and buildings were to be assigned to connlr~cents. Cn- fortunately the great cardinal's wishes could not be executed and the plan fell through owing to legal complications connected with the transfer of the property, but the great bulk of the testators, unlike cardinals. left wife or child whose support had to be con~i<lcre<l: nnd "0 we find that a ycry large proportion of the legacies ga,·e a life interc:,;t in the transferretl property to wife, sister or cousin. It is interci:;ting to rrad the records of these transactions becnuse on each page we get a fresh glimmer of light on the history of Paris itself. Among Lhc earliest papers we find a brief and businesslike state- ment that Renancl Crest nnd Joan, his wife, on the point of starting for Jerusalem, relinquish in :favor of the Hotel Dieu their part of the inheritance of Agnes Battle, their aunt, in case they never return from the Crusade (February, 1225 A. D.) .1 Many legal docnml'nts are concerned with the rentnl of property deeded to the hospital. In 1190 the brothers of the Hotel Dieu of Paris rented a house for a stated ,.,um to one Bencelin and Sedilie, his wife: the Ilot<•l Dieu obli- gating itself furthermore to lend to Bencelin during his lifetime four rnattn•,ses nIHl ::-ome pillows. About the same time one Renaud <le Mello prc~entcd to the Hotel Dieu a house situated near St. Landry. It was doubtless to cnhuncc the rental Yalue of this building thnt Philippe ~\ugustns decreed that is occupants should be subject only to trial by the king exc<:>pt in cases of mmcler, homicide, theft, treason, nnd rnpe. It was the common prnctice also to assign to the Hotel Dieu a definite proportion oJ the yield of certain vineynn1s, wheat fields, forests, nnd form lnncls. One Simon, occupation not giren. 1 Archives de l'l'olcl D!cu dll l'nrls (1157-1300): Bry~lc, lmprlmcrlc Nnllounlc. l'nrls, 1804. tiut rtyktl rfr Xobili~ . pre 00l'llt~ tl11· Jlftel DiNt with n barn locatl'd 1 ot :far from wher<' the H ott>) de Chmy now stnn<lo:. .\.tlnm. form<'r J,ing·~ clerk. 1•rc>'-;<.'1 t ., to the Hi1t<'l Dieu n hou..:n in a c..'rtaiu street. another in a cN1:tin alley on condition that a portion of the rC'\'t.>1111c frotn the,..C' hou-=cs h:-ill l 1' emplo~·cd CH~r.\• year on the :umiwr,..ary of tl•e d"'nth of the givcl' to f. np p l~- tlw pntien1s at the H otel Dieu with "hnte,er thC'y mny cl1•mand to l'at. There was Perrmelle. who in her Jifetiml' £?;aw to the Hi\tel DiC'u n vineynr <l, exuding- iu t"<'lllrn for it one ho~head of the wine> m;Hle from it::; proclnct for her own u e. Amon~ the humble bcnefuctors of I he great :m u pop11lnr institution we flu' harness makers, saddlcrs, blacksmiths, tick 111nkers. wc~n·ers. ppwtct. rs. m11~ta n l rnakt•r:-;. Jm·k~n1it tis. lrn th-r~. barh<•r-.. clyPr". pa$try cook-=. ·ud old-clothes men. .\ little hig-}1er in tl1e <;ncin 1 "<'ale come" the ,..,•rgP::rnt of th· s\'hools of Pari'i, a ki111:(s cook. a 1 t>atlle. a \'hnrch TI"nrden, a knight, a librnrinn. an abbot, :t grand chamberlain. Th nanws of the -;fl'<'!'t:- rPfor1·<·d to i11 thP Yariou:; 1l('(>d, nre inter- esting. There was a rue des .\ nglais. des P eintre:>. de Jn .Tniverie. like the old Jewry of Lon<lo11. tlie ...,lll'N of tlw H arp. the Strl'<'t of the Fishing Cat, Straw 8treet. Butcher ~h op Street. :rnd other" which surviYe to our own time. In 12:W _\_ D. H erbert tl1e :3emp,ter. nt Brie, brought suit against the ITOlel Dieu bec:rnse from n housi> owned by it all sorts of things were constantly falling 0 n hi-: own house. He had to pay the cost!'! nnd was told that he could remedy the situation by acldinp: stories to his rec;iclence until it dominated the source of trouble. One broad-minded individual divided hi:-: <'state between the Hotel Dieu and four poor students of Paris to be selected annually by properly constiutNl nnt hority. Unremembered for face or figure, Alice.1 waioherwomnn to the Bishop of Paric;, hnc; her small niche in the hall of fame, because she L ·qurathed her arcnmulntcd savings to the gr<>:it hospital for the poor. During the middle nges a Yery large n n-enue was deri,·cd from the sale of pardons nnd indulgerw!'s or tlwir be,..townl 0 11 :renl·1·011:- hene- facti :-s of the hospital. Each year the m n~ter of the hosp itnl '-Olicited from the Pope the neccssar~· hull nnthorizing the pr:wtic1•. " Then it was r ceived the churches of the cit~· would be crowdecl n11d likC'w i~ the chapel and bnilding-s of th!' H titel Di <>u. On the 1lny of the por- don high mass was <;aid at N"otr<> D~me while the r-nthe1lml hells • ln turning ovl'r the nrchlvc" of tlH' ITM<>I Dleu, or Perl•. from 11;;1 to 1300 on ~ Ii< !trud;: by the llnll~tUll cb.1rncln or t h t> WOIJl('D 0S nnmP.S In \'Ot::ne durlni: that per1o<l. Few of the n1 mrs thnt follow nrP In us .. t1Hlay. nnd tl1r mRjorlt; nt them hn•I dlqappeere<I by thl' ~ Xt e<'Ulh <'l'll1\ll'y: Allx Douce Ameline Edeline Aefellne Ellend ~vole Erchenoud Anllne Ilulle l:r!'mhourg Eudcllne i GO'.lS-1<;-i l'um1u!' Gille I ltwole ll••r <endc 1 IN•><cllne :\tnhaut I.I lardl' l 'errrnelll' Ran!"e Rlcbcut San<"cllne l'rd llle T hcce Throphonle T lph11ln" 666 HIS TO BI CAL. Vol. :n1 pealed. Fifty prie::;ts were on hand in ~otrc Dame to henr the con. fcssions of strangers. Pardon!' were likewise publLhecl throughout the pro,·inc<'s! preachers selected for their eloquence Ul'ing dispatched to the proYinces to stimulate interest, and they were accompanied b_, brothers from the hospital who attended to the nct11al sale of the in- dulgences. Dy a decree of Parliament pasged in 1552 the care of nll found- lings had been assigned to the Bishop of Paris, and there existed i11 the Cite, hard by the cathedral and espiscopnl palace. n house known ns the Couche, where these unfortunate creatures '"ere ro. ceh·ell and cared for. In 1G34 lt widow woman nssiste<l by two i-en·. unts. under the suneillance o:f one of the directors of the Hotel Dicu ' di<l all the work necessary for the care of the foundlings. The pay of these women and the expenses of the Couche were defrayed bj alms received ut the porblls of Notre Dame. ;: There, under the porch, on the left-hand side. it was customary on holidays to set out a wooden trundle-bed in which were deposited n few foundlings to excite the people to contribute to their support. The nurses stood nenr. pointing them out to the passers-by nnd to tho~e going into the church and repenting this prayer: 'Do good to these poor children. worthy people.' ,. The nvailuble funds for thil" work were scnnt while the number of foundlings to be cared for steadily increasecl. ":Nearly all the;~ poor little creatures died.'" The !"Cl'\'ants took litlle care of them i administered narcotics to make them sleep; sold them to beg~ars, to bargel's, to persons who wanted to nse them in connection with mngic nnd necromancy. Fortunately M. Vincent de Paul got some of the Dames de Charita to inspect the place, and. as he> hncl anticipated, tbey came nwny horrifie<l, with the re!:>ult that u small nnmber were nt once adopted and removed from the Conche. and in a few years the entire care of the foundlings of the Hiitel Dit'U was a~snmecl by this worthy !'oriety. Thus the Hotel Dien participated in tlw ge!l<~rul improYement of c·onditions which characterize<l tlw rc>ign of Henry IY under the abl<' directorship of his prime minisl<'r, Sully. .As stated ahon~. the first Bourbon made it the fashion for one's ch:1rities to center around n 110:-;pital. It would appear that tlw l'llthnsinsm ancl Z"al 0£ some of the noLJe women who took to visitin~ the Hotl•l Dieu pa<;<;ed tlll.' hounds of moderation. for WP find the hospital nnthorities invitin~ them to come and watc·b tht• 1lif'lrihntio 1 uf food, to obscne the clet:1ilf.: of h'e<tlnwn!, nml :-ati:;;f_, tlH'msehP ns to tlw care the patients wen• rcceiviu<r. but while they \\'ere urgecl to require the si::;ters i-crupnlon:-;I_,. lo pe1form their du!iPs. the lady \'isiior~ were ear- nef;tl,V rN111estccl not to take any of tlH•m 11pon t hemsehes. Incliscreet f'O. 4 HI::;TORlCAL. 6G7 then ns now. tlw worthy dames and mbscs :-:0011 I'• quirl'd tho imposi- tion of still further re:::trict.ions. Thus in .\.pril. 1Gl2, tlw h~pitnl bonrd .. trictly forebade the sisters to rec iw !!ift of lJre'ld, wine. nnd inent. whkh bring morP discomfort t hnn profit to the pntients in the long run nn<l entnil "much confu:,io11." In 1 h • s.um ye tr '\":e find tJie authorities hrcomin~ aroused (perhnp:. throu~h· the n~ency of the Indy vi;:;itors) to the annoyance thnt might 1•ome to the occupant of 11 clouble hetl hy the inconsideratcnc!>:i of hi~ he1lfollow-ns in dying oYcrnight. It was. onlcred that CH'r~ -.·. nrcl hould li:n c n 1..'0t1ple of ~pare beds to which patient~ coul<l be rnovrcl tempornril~· when it bcl'nmC' eviclent, that those sleeping he.;;ide them \\ere ahom to <lie. The winter of 170!) wus long nnd rigorous. It \\a~ n hn<l time for France un<l especially for the poor and the sick. Louis XIV sent hb ~old plate to the mint und the Cartlinal <le Noailles. Archbishop of .Pari .... meltecl up his sih·er th~t thev mi!!hl de\·otl' the proceeds to the poor. There were 240 cases of Sf"lll'\'J nt one 1imr in the Irtel Dieu. P:ttienb lay four nn<l :::ix in n bed and on the floor .... nnd many hec.ls had been :;et up oul of <loor::. By :3eplember the deficien- cies in the hospital fund,; amounted to 319,000 liHcs and during th(' com ~e of tlw y(•:tr 4.;jOO patient::-. amon~ wlwrn GOO case'i of scurvy. hncl been tmnsfotTC'<l frnm thC' Hotel Dit•u to the Hi1pit: 1 Saint Louis. Dueling was ut this time a universal practice. On the mo~t frirn- lo~ pretext sworcls flashed from their scubbnrds t ... cl tlirou!!h the most line-spun notions of honor hundreds of noblemen lost their lives t>neh yt•ar. In 1609 Henry IV had promulgated :m cclict on the snh- jcct ~ nS!:iigning nll fines and confiscationc:, in connection with the sup- pre-·ion of duelin~, to the benefit of the Hiitel Diru. The periotl from the middle of the fourteenth to the end of the fifte nth crntury was apparently that of the HOtcl Dien's gre~'ltC'"I prosperity. .\l.Jsolute ckanlincss prcYnilcd in the wnrdc:. ln n ~ingl" y<'ftr n m·rny as 1,300 brooms were used in th<' buildin~:>. "Every 10oming llw floors WC'rc washed by ':"1lcts nnd there wn;; n ur:.md mmual scrnping and whitewashing before Easter. 1t is l'emarkable thnt about the l>c!!inning of this p<.>riocl running wnter wn nrnilable for u e in the wards, being piped to them from hu!.('e o,·et·hend tnnk,., <111 thC\ roof. Such an equipment n1t11r;1lly r~snlted in !!rent economy of time :md labor for the employees. Thon,gh the records of the Hlitcl Dien abound in interesting de- tails rcgi 1'fliug the architectural structure: intcrnnl arrnngf'ment. nnd ndmini. tmtion, and though there i:s a considt>mblc litc>rnture dealin:? with th<• :ulminist r:ttion of this great asylum fol' tlw -:nfferin!! nml need::;. thnu~h nll the different phases of it,., career n-. n chmch institu- tion whose purpose was to confer spiritunl blessings ns well ns relief llG HI:::T•)nH'AJ.. to bodily nilmcnt al'e hundc>d <lown to lb in cletn i!, the rPforences to the. pUl'l'ly medical foatnres are few nnd nrnngPr. ThcrP would per. hap,; linH' be n :1mpl~ time to rC'Cord the doing~ of th doctor.: and .:;11rgco11 hnd there Leen a feeling thnt sneh a reconl would hay. '•1l11c. hut apparently the professional men playcll I.mt a small pun hi the li1e of the IIotel Dien and there seems to ha n~ b2en no regu. Jar mC>dical ~taff co1lt1c>~tl'd with thl' ho-pita) b. forc the "bHmth or twelfth century. tlw priest::: and mms gi\'ing th·' rNpiirecl treatment n~ IJrst tlwy rnnld. St ill. there is some grnl ificntion an1l comfort in th~ siJCJl('l' 0 f hislOI')' l't'!!;arding the cloclOl'S, !'illC:<' 1101 a few Of the lHtll!ef: lllOSI com;picnonsly t•mblazonec.1 on tlw histo1y •lf th 1Ti\td Dieu ~re there held up to the obloquy of posterity. Witl th \i(·~inninµ: of the thirteenth ccnllll'_\ lhc> maslc1 f the Hotel Dieu made u. clefinjte agreement by which the sel'\'ices of t doc- tor and a surgeon were retained for the patients of that e~t hlish- 1111'nt. ln 1:?·.!l a certain Hubert a~1·ees lo gin~ hi~ profossioual ,.:('n-. i1•c · gratuitously It> the lto,;pital. To thi'i -.nuw t•pod1 I elon!!'; \~incl nt d<'"' Boi~'· who not only offoretl his sen ice:; free. bm mude 11 gift to till• ho:-pital of 40 ponmh pnrisis. In spite of these \\Orthy rlispositions the nffnirs of des Bois did not prospe1· and penury Ol'(!I'- took him iu old age. when the master, in recognition of past. serYice.;;, gmntecl him tL !"mall annnity from the funds of the hospital. From thr thirteenth century on the IIOtel Dicu \\:ts :rn integral part of medical instruction in Paris. and gradnalc;-; in 11u·tliti111· were required lo receiYe the master's robe either at the Hotel Dieu or at the Mathurins. By the fonrtcenth century the p rofos.o:;ionnJ scrvico at. the HOtd Dieu stood on still firmer basis. Jt was intrustecl to two snq .. 'l'Ons, who were r<·<ptircd to takl' a :-.olc11m oath at tlw ('hi1ll'lc>t before undertaking the ·'king's senice" nt the Hot.cl Dieu. During the :Middle Ages there was no pharmacy in the modern ::wnse at the Ilokl Dieu. T he master honghl :from the spic<'r,:; arnl grocers of the neighborhood the drugs and medicinal plants required. The concoction Of simple draughts and the prepara- tion of ointments fell to the lot of the nursing sisters, and it would "eem that the earlier physicians reliecl largely upon very simple remedies, baths, exercise. and modifications of diet. Special provision wns made for the bathing of patients. Stationary baths were not employed until Yery recent times, a::; il was found ~ulli- 1·ic•ml~· c>a~:v and conrt'nic•nl to use portable copper tubs. which ruuld liC' rolk1l into the ward and to the bedside as occasion demanded. The bnths were hot, of course, and the water for them was heated in h11g~ cn.nl<lrons intended for that specinl pnrpost'. The lying-in department was managed by a nursing sister, the specific services rn•ce~u ry being rendered by a midwife with one assistnnt. The oh- HISTORICAL. ~-tetricnl sen ica wn,., un important feature of the ho pita I and :il- ihou!!h from fl() t-0 100 l'hildren wen ... prr~ent there nt nll times, ~ome of whom hnd been abandoned on the :>tep::- of the building. \\ hile ol ht•"' hnd bec·11 brought t lwn~ hy :-ick n)l)tht'rs who had no pl.1c w leaH! them, but Oil<' Wt't 1mr"<' wa:- permnn<'ntly employed for II t•luldrc.'n at thc brf':1st. Tho snnitnry fr:itun•s of rhc hospital haw .1h·t>ady bN·n allmled to. liut it :-houl<l bc ·1id that tht'y rnried eou~clerahly in differmt pcriotl::; of the ho pita l's hi~tory . • \t one 'imr' we. :finl} it -.tnt('tl thnt thcr1: wl'rc hu~l' fireplncrs in each ward wht're fire" l'ould he lit in winter. and thnt in nr~ cold Wl'tttlH'r it wa" cu!'t<i111:1r.'' to clruw np and down through the wanl!'> iron wagons full of glowi11~ r•nal;:;, 011 the othl'r hnnd. WP find :i \\ortli.' p1·iorvs.,, 1·•1m!>l:1i11;ng of tie r--i1 on·f)lb adrnini fratio11 of affairs nn<l telling or ho\\' 11 .. hnd to h11r11 the ;trlt\\ from nrnttres~es in (ll'cler to ... :l\"<' pa1irnts from frE'E'Zin~. and UH'IC i .. n rt'corcl of a joint complni11t m:tde by patient i rl'gnrcl to the quality of llw food '"ern•cl and th" fln.perut ll'l' of th"' ·• ·d"'. It i impo. ihle to rend the history of the H tel I>ie11. full of thfl pet ,. ,.trifc of rival 1tspirant!' for c·1 ntml ,.f t I" ·n 1'tnti1 1, •ill • f tlw bickering..; of c1wious fadions a111011:..: th!." 11u11s. full of ilw bitter stnt!!!.!le bebwen the lay :rntho!'itit-s oi' th• < io, c· :rn1t•11l m cl ti ._,,..dc·- i,i:L-.ticul officeri;;, witho11t rea 1 izing how li tt Ito L1~111:m 11aturP ch~mg-cs from u!!'e to agl'. X ow. a-. in t lw pas(. tlw !-<id• patiently l'nuure pain. arr. the \'ictims of d11bio11-. lreat i:wnt :rnd t-:xtort ionah hills. nnrl t>ndurr. humiliatious of all sorts without a mu1·11111r. lint c·omplaiu bittPrly a ncl p1·0111pt I.\' of insuft1eient lwat ;\lld p.i11r foo· J. whether in nn <':Xpcnsi\",l' l'OOlll i11 n priY:tte infirnrnry 01· in !It .. frt•f' w trd" of n c•lmrity l1ospital J li~h 11p undrr the roof were windows wliic-11 hy n1cm1~ of cords uncl pulley!' could lw opened in s11111mrr t imc• to i111prm <' n•ntilntio11. In the :-e\'rntl'enth ccnti1ry a supply rd jnnipm· wo01l wu kept on hand. and u little of it was burned from time tu time in tlw ward ... tu drhe n"n~· bud i::mells. The glas"' was -;tainrcl -.o a-. lo ~often the li:rht. .\t night thr warcls \Y<'l'l' in darkill'"" e~cept for mi mule 1·11:-h li~hts hetw(•e11 the beds. It is noteworthy that within a !',paci.: of 10 yl·ars' tinw in the la her part of tlw Jifh'<·nth ('\•nt ury at lc:i-t two donations were made to the Hotel Dicu tu pro' ille li!!hti> for the toilet-. that o\·crhung the riYer and for li!!htin!! tlw npproadw., l<' them. Tl1c ::.itc of the hospital on both bunks llf thr "'lllnller Lrnnch of the rinr and on two bridges favored clnmpnc•""· Owing to its location in the basement. the lying-in ward w1"' pnrticularly b.1d in this re~pect. Worse still was the main wa!:'hrr om or ln11n1lry. wheru n numbrr of thC'. novices werl.' employed nil rlny in wac;;hing the ho"- 670 HISTORICAL. \ ot. iu1 pitnl lincn.1 When tho tiYcr was high the laundry wa::. often iloodco. and it wns considered a wise precaution to hnYe a boat moored the~ nncl pro,·ide the l>ontmnn with a bout hook so that he could sah-nrre laundress nnd linen if the tide threatened to benr them ofl'. "' The good nur::iing si!=tcr:> had a pa;;sion for linen. It was abundant and of fine quality. CJo,.;.-Ls, !=heh-cs, bureaus, wardrobes, clr ers. chest:; in hall nnd linen room. in ward and corridor were filled to oYerffowing. < Jncl' a month tho priore::i:; \\'Cnt lo market. Enrly in the morning a cart would be bitched up, and accompnnieJ bv n brother and Ollll 01· two sisters the prion~l's wolllcl :"tart for· t:. Denis, her chaplain following on horseback. She retumed I~ le in the evening und next day the new linen would go to the laundry, the dyer, or the f-ewing room. The itinerant linen merchants pa ing through Paris never :!niled to go to the Hotel Dieu to offer their wares, because they could often dispose of the entire lot then•. The Februnr~· and J nne fair~ were occnsions of great moment and many a. hnrd bargain 'ms dri' en at them. All tho year around four si-..ters were busy from morning till night repairing, sewing, hemming. or cutting up bedspread~, bolster cornrs, sheets, and pillowcases. The big laundry and the mall laundry between them occupied the '·hole time of nine sL.ter,.. nml six no>ices. The) worked near what we might cnll the traclc.Emcn's entr:mce, where boats made fast to u~liver the butcher's supplies and lhe prm·isions and stores from the furm~ belonging to tho Ilotc.l Dieu. It was here: too, that brothers em- barked when going to Yisit remote estates to inspect the crops, collect rc11ts. etc. \\'hen the clothes were all washed they were hung along the balconies to dry, but often so great was the quantity of linen there wus no plncc outside and much of it had to be brought in and hung in tho ward&. Patients often complained of the dumpne->s that resulted. ~Iention has !Jeen made of the syphilitic patients who swarmc1l in Paris nt the time of tho Italian wars and of the wholly inadequate measures for their segregation. It is equally terrible to road how the place wu~ o,·crrun during the prevalence of tho pestilence, 1llld that by putting the beds close together the~· could uccommo<lnte 12 to l:J in cuch; :rnd yeL. but a few yeurs before, the pap:1l legate. C•n:c.lin.tl Duprat. hnd gt•nerously e11deuvored to provide the addi- tional ucromrnotJat ion, ~o greatly needed by purchn.~ing l wo build- ings in the '"icinity for use until such time as another ward coulc.l be udcled. The building" i.n que-tion wcr<> known as the Chef St. Quent in uncl the Fishing Cut. When the IH'W W<trd wn"l finislied it wn" known as the Legate's 'Varc.1 und it held 11 hundred beds. , .. J,et us realize how mnny gh'ls there are at th!' Illlt~l rncu who all next winter will .tand l:i the wnttlrs or tlw ~kine, frozen u1> to their kn~e,, lu ord .. 1· to wnFh lbe clotbu of the poor," so.Id Gerson, prenchlni; In the presence or Charles VL HISTORICAL. 671 At this time pro\•ision wa..: mnde for some 50 ndditionnl cape..., for the co1n-enicnce of patients who hnd to get out of bed. There hnYc hcen many gro<=<= exa:r~erations al out the number of patients lodged in the ho::pitul nt different time.". Up to the begin- nii g of the Bourbon d~·uast~· the maximum of the Hotel Dien wns 1 obabl~ bet" l en ~en~n ttJHl nine hundred jnmnte..:. with tI1rce or tour hundrc<l ns an :werngc number in time-. of pro perity nnd pe1cc. Jt is po ifo·c1y known th,1t on the 14th of~ pril. 141i. there \\ere> but VG patients in the institution. It speak~ we 11 for the hmm.nit,\· of the times that when the plnguc imadecl Pnri..: in l.Hfi nil infected prisoners from the Conciergerie were trnnsferred to the Jlr.trl Dien for trratmcnt. and it was f>trictly l'njoinr<l that they -.hould not be clischar~ed on recoYery without dm• notici> to th~ jailPr of the prison. It j ... not until the ~eventeeuth centmy that we obtain definite documentary eYidenee of measures instituted to in:-ure the aclcquntl! nrofcc.sio11:11 care of the pntients of the Htitel Dien. I•rom now on. in addition to the two phy!"icinn~ attnched to the ho'-'pital. there is n mn"t<'r ,..ur~eon with fiye apprentices. The minute,, of the mccting- uf the hospita 1 board on ,July 18. 1G2V, contnin th is en tr~·: The "'fll•I Millot. huvin.t: heen rcc~ived a,.: urnf'.h•1· "ur~C(m nt tlw bltl!l Ilr.tel D NI nnd hrln;? fed, pnltl. nncl lmls,red. ~bnll himself he on hand to exercl. e bhi 'uuctions '\\Ith g,·('nt nssiduity in prri:on nnd shall 0 h:wr under him th·e Pxpert enr.cd nncl l'fl! nhlc npprcntke l'Ur;::cons, also fed nt Uw charge;:; of the hm:pltul. Tt1r. flJ)Pl'l•ntic:e ::;urgcons Rhnll not absent themsehcs without the nuthorlty of their rnn ... ier, nor shull the~ go out except when ut lcnst two remnlu for con- tent senic·c In the wnrcls nn<l two ::-:hall sleep in the snhl Hi.tel Dleu-thnt Is to ny, mw i;hull ht' on hand to examine the sick who pr• ~em 1 ht>msehes 11 t the t•ntrullCfl nntl another to ~tnnd by in cn;;e of 111·ciclent!I. On April 22, 1UJ1, the medical. nnd sunricnl :--tnfT of thr. Hotel Dieu rPported that, within a. period of a few dnys three lithotomics hnd bE- ~ succe,.;sfully performed and stated thnt in order to obtain uniformly safo;fnctory results special facilitie . .; :-hould be nliorded th<'m for caring for this clnss of patient'. After clue drliberntion the go,·crno1·:-;, recognizing the justice of tlw demand. directed tl1nt the new ward. preYiously destined for the sick members of tlu· pl'rsounel of the in .. titution. ,,.honld ue assi~ed to tlw lithotomy cn-.c,.. From the1 on. in conjunction with thl' fncully of flw School of ~foclicinc of Paris. the IIiitel Dic>u gn\o marked attpntion to this operntion. During tho year 1602 operations for stone wen.• performed nt the ll•'itrl Dicu 10J: time::; with 18 deaths. a mortnlit) of 1 i.3 per ccnl. In re<'ognition of the !"ignnl success of the --urgeoth who hnd operated on and rnred for these cnse8 the maua!?:ctnenl of 1lw ho::.pitnl \Olt•rl them n ,.pccrnl honomrimn as a rcwarcl for what thl'y Jm<l done and u11 mcnm·a~~mcnt for further effort. The chief operator recei,·ed UISTORICAL. :!00 liYre:;. thl' i.ecoml operntor 1:10 Ii\ re". nntl the sm·g~on who lo kiiQ after dre: ,;ing thP cnses l.iO line~. During the ymr 170" opcrntion for lithotomy was perforrned ~I time.• in this ho~pitnl, ,,·ith ·1 1110 tality of 21.G3 per cent. The Hotel DiC'u hatl nlways been .t· !! 'l·at center for iuscruction 111 midwifer." and foreigners had been con~tant in their attendance, but in time this b<.'gan to be r<'garded as a nuisance ancl w::is mnde the .subject of a r<'port by the prioress. the sister in charge of the lying-in ward anu the heacl midwife, the women coming in pen;on to thc- managcment and stating that •:while forrnerly no surgeons from the outside were allowed in the lying-in ward and only within the past 10 years hnc.1 tho privilege' been accorded to a few in lhe hop tlrnt they would behaYo with great dignity and prndl'!IC<'; now, nm inly do the \Yonwn show t'Xll'<'llle repugn:rnce to being ch•li' c•red li,\ 1en; but it wns obsened with regret that ,:ome of th<' smgeons admitted to the lying-in war<l abuse this privilege nnd indulge in liccntiou:s converrntion nntl unseemly behayior, the mer<· dc!"C'ripti.on of \\hich is forbidden by modesty. so that much scandal has hC'en created nnd complaints nrose, followed by reprimands. which pro lurt'd nn effect. Furthermorr. innsmuch as it is indecc>nl for _men to h· l'lllplo.' "tl it delh·eries <'X<'t•pt in ca!'es of nna>oidable nec1.>::;sity, wh<'n the senior ~:urgeon of f liC' c·st:1bli..,Jrnwnt ong-hl fo hC' callrrl :ind. i11 lien of him. his senior assistant, the mnnngement is urged to grnnt no forlhl'r :ulmi,,sion to s! ranger::." Tlw l1ospitn l boa rel. on D1 cPmher :11. 17:.:'0, is.,;uecl nn order forbiclcling th<' entra11ch of :rn 011t,;itll'1' for :lllj rc11 son wJintt'\'l'l. but it \\'ll fo11111l t•asic>r fo <lelii>"l'ilil' :lllll lllHkP l't1les than to carry f hem ont. Exceptions were mad<· in fa \Or of ccrtnin English physicians, and they were permitted for three succes .. -.h·e years to attend the obstetric clinics of the> HOte>l Dicu. This wnc:; ap· pnrently done as an act of courtesy to the King of England. In 17:'25 the nttmdnnt of the Queen of Denmark wns allowed nccei::s to the sacred precincts of the lying-in room. '\Ye hnn ~h·cn above one of the two 1111h ron1 bk l'o111111(·11!s cxtunr upon the behnvior of medical men at the hospital. It is to be noted. on the other hand, that the doctors were not nlwnys satisfied with the con<luct of the> nur .. ing sisters, ancl in the sixte1•nth century period of demornlizntion, mark<'d by religion~ exrrcises nncl nt>glcct of work, the charge wns made that when the doctors gan~ onlt>rs for blisters, euppings, nncl bleedings, their directions were not nl ways carried out. As we sur,•ey the 13 centuries of the Hotel Dieu's existence the most prejudiced observer can not fail to testify to the devoted service and loving care bestowed by the nursing sisters upon their patients, and they were in the main generously hncke(l up by the peoplo of Paris and the civic functionaries and clergy of the city. There were HISTORICAL. frequent disturbnnces und occasionally bitter contests, due to ambi- tion nnd the stru~gle for control of the institution. Laymen were prompt to decry the .m~ngcment of the clergy, and the ~lergy w~ro often jenlou:. of outside influence, though always wclcornmg outsHle ll"sistnnce. Politics often had a disastrous elfect on the efforts to i.Inprovc the hospitnl service made by participants in ench ~ide of the ar;:!'ument: but while the petty wcnknes,.;es and Hil pn':.;ons of humnn nature often rhcckcd for a uioment they could not wholly arre!'t the progt"C'" of this noble institution nor check the lwttPI' impulses oi sclf-sncrific' nncl devotion of the bulk of the sisters. 'fhc following extract, a, sort of panegyric on the nursing si:>tcrs, ib from the Liue de Vie .Acti\C, a 111un11:-cript of thl' 'l<:o11tl ltalf of the fifteenth century, whose author, a canon of Xotrc Dnme. wns for ycnr:; one of the provi:;;curs or commissioners of tltc llote,I Dicu: t'onsh!l»·. oh 1h1111 11F 1l1 lil'nl•' .ip111 tit.·. whl\P hl'f111·" thi· ch1111, \\h,11 1111'l' lh •U lw ·1 for Ill~· llll'ill nt lilt! t:i ·tcr,;' lnhlP, CPIHli'g ""thou •lo I 11 m 1111 w. r Is 11f 11te 11;d> lnrlc>n with lilt• U1l<•r of pu111-. 11c>edy hm11n111ty. ll••W • 1h ~ N·ll-h rlesh 111 tl1t·lr rpfrctory wlwu lht·~ t·11UJI' "tr; i"ht frnt:1 1)1!' ~t k :.1111 tltl~ht!! tbC'm 1111 :1fu•1· 11:it11 c>'" h11111bl1•s1 f111u·ti1111,.:: <ltl:l'r,. h·l\I' i-•rnl h~. 1·.111llP In Mm1. to ::;IH! th" d~ In;.: r:o·lsJ.t'<'il. or ha\t' .in ,1:, ir lipi; .1 111 uf thrl':ltl It f from •\\"Ing UJ• :• sh1·011•I, 1111 1111• l pJI 1·n11i::: for hrl'akf111<I. r 111, th 111 ,,r cl.11 l!y ta tc". IO\\ c1mltll'>il thou ht• I 1111;:1·y ... .,111:11;: 1lin•.-1 rrolll tlw w1·.-.:c•1•'ll hi. \ h·• t llhl not cnt, hnl fot·•·Pd tl11w11 llll)l'•PIS wit hPnl appct ill"' 'l'ht• :,10,·in;; t'{'l"\ l•'l ~ uur l'bters rcllt!C'r hi orl' thl'\' ;1" c·nlll'ri tn n•fr1•U1111 and lhl' sCJ1·1·1m·s 11 f•\ hn\•' wlllll'l;.~<'d in llw wnrd nove tlwm nithPr tn pious ll"tr,.. thrlll 111 11!ra~:i1i1 hum.: ... \I tl11• oufbrt•ak of die Frt>nch Rcnilution the al!':tirs of 1lw Hotel lfo•u \\ere at a lo\\ ebb. Xot only b:ul all :;oJ't,.; of allll'-l!:" t•1·rpt into the ndministmfion, but the bnilding ~ had bc-conw the CClll! of clirt and \\ rei<'lwcl1ws:<. Dr. ,John .Tones. of N' t•w \ 01·1'. "ho ... 1• 111 bor, c1111- trib11terl lo tlw fo11mlation d the Xcw ) orh. Ilo-pital. "C'lll to Eun>Jh' in 1 ii~ to s! wl.v the s11bjr t of ho::,pitaJ ... and buy me.dic:il and ::urgieal apparatus under anthorily of lhe ~<•H•rnor..: of Ki11g·s Collr!!c (now Cohnnbia Unin!rsity. Nrw York). Ill' wrote: 'fhe llt"Hl'I ll!cu-a 1:1,;t bulllliu:; ~irna11•d in thl' mt.1<11,, uf till' l'lt;\·-n.'l'd\"e- :tboul :!"..!,(ll)(I ppr:.:ons 11111111:111~·. 1111<>-lirth of whom •lie l'\l'r~· ~.:·nr. It b lm- 1111~ lhl•• for a ma 11 of any humanity to walk thnmi:h the 1011::: wnrd,. of tl1b c·ro\\ll•~I ht1>')1ilal withuut fei>lin;: a rnixlllr,• of horror nntl 1'(.1111m!--erntlon :i.t the •11d ;;p1'l'la•·ll' whi"11 pri>s1•11ts it~l'lf. Tlw he.ls nr•• 1'hu::1'll In trl11lo r11w:.. \\ith fou1· :11111 six p:tlh.'11(:< Jn l'Hd1 bed. :m<I I 1111\·(' 111111·1• than Olll'l' lu the morning r•mntls round tlw de:ul l~·Jn.~ with tlw lhinz: for. n11t:wltltstanrll11g the ~C':lt :lSSidUil,\' and t1•1H!i•1·11ps;; uf tht• lllll'>'f'>', some 11f \\hum llrC W•lllll'll Of family ;mil tnk(• ti" vril arnl pinu-<ly 1lC\'11tc• 1lu•1usl'h<'s tu thnt offic,., It l-< 111!11n:;1 impo,.;sihl<'. frn111 1 lw VH>'t m1111lwr of patlPllt«, to he~ t o\\ timely n,.; ... i,t· :tit<'•' upon c:1<·h l11dil·ld1111l. 1 1 llospltals, Thell· fll~tory. 01 !lnlzntlon, ant.I <'onRtrnell"n. b)' W. <:Ill W)·llr, M n. l• Appleton & ~o .. Nt>w Yo1k, 1S77. 674 RISIORICAL. The pcoplP in uuthority during thi~ stormy pori0tl sought to re duce to a minimum the influmce of the religious order:;, but the sisters of the Hotel Dien were permitted to continun their noble function n~ nurseq, prO\·icle<l they worked only <b so mnny charitable and wc>ll-di:,1'0Sed incli\·idnals. no official recognition being ~inn to their relation to the chmch. Ily 1816 the Hotel Diem wa,, again iu t•xcclk•nt orclcr. if we mav trn::.t the report of a capable au<l critical English physician 1 of th~t <lny. "h<, after a tom of Continental hospitals, ~aid of it : I thoul!ht thn t Hw hospiUtl was much Detter kl'JH th:i 11 t It<' ;trcnte>r number o( prh all' holl1'l'S In .~rl'at l'ities on tiw ConUucnl. Tltl'l'C~ wcr1• ::o i:;p:11•Iom: wnrtl;i, some conta!niu~ as lTlnny ns 90 LlL>tls. 'l'hl! bnll<llnl!" \H•rf' "••I I YC11tilatcd: and :rn nc:1t mi coul1l Ile cxpcctccl. The bed- r!oth!'s nnll <·11rtnltw W<'l'I' C'lNin and white nncl. the be1li'I were ;::oo!l, though not mncle ol' Iron. 'l'lw prmlslono:: werP plenlifnl ancl wholesome, the kit«hen lu good orller, !Ill!! !ht• patients w<'re found to be quite 11!'; nPnl us the patients ot Loudon hos11ltals. The vi!'litlni; stnlI of tlte hospital con,.,istcll at this time o! 10 pbysldans nn!l 2 sur;::cons, with an ample number of assistant,:;. Almost from its foundation the Hotel Dieu exercised u pro- nounced and beneficial influence on the other hospitals of the conn. try, and wn find requests from out-of-town hospitals, such as the Uutel Dieu of Orleans, or Bourges or Blois, for the loan of a mns- ing sister to instruct in the methods employed in the great mother institution of the metropolis. Again, the provincial ho::;pitals were in the hubit of nsking permission to send their own nur::;es to J>nris to obsene the routine of the great Paris hospital. In Paris itself the nursing sisters of the Hotel Dieu were always in great clemnnd to nurse privnte cases in the homes of noble and affiuent families. This practice was the subject of endless debate between the sisters themseh-es nnd the supreme authorities, the lntter clniming that these outside undertakings detracted from the interest and the energy available for the legitimate work in the wnrcls of the Hotel Dieu; that jealousy was apt to be engendered; thnt the strict lis- cipline of the Augustinians was interfered with. The priores5, on the other hand: held herself to be the be::;t judge of hrw to utilize the services of the sisters under her control and w:.s loathe to abolish u custom which undoubtedly made for contentment amon~ the sistt>rs by giving them occasionally a reireshin~ change frcm the hard, unvarying monotony of the wards. Besides all this the outside nmsing did much to popularize the hospital nnd the order. thus bringing in lnrge returns for the benefit of the poor nnd mnny 'l\"elcome gifts to the sisters themselves. 'Cnrtcr, II. W., M. T>., 1r. R. 8. (Edlnburl\'hl. A Short Account or fiomc or the l'rlnrl- JIRI lloapltolH or !11·1111<'•'. Ttf1ly, Switzerland. and tlle Ncthcrluntl~. 'rhomaR nnd t'ndcr· ,..ood, London. l A1 !> IIJSTORICAL. 675 nut the nurses of the olden time were prone, like tho~c of to-<lny. to !!Ossip nnd tell tnlcs, nncl on nt lca:,;t one occn<:ion ~eriou;; trouble rc:;~ltcd. Pcri-enelle In Vertj use hnd gone to nurse the wife of the King's commissioner nt the Chntelet. Either during or nfter the course of her ministrations Perrcnelle indulged in rather scnndnlous tnlk nbout the commis~ioner's mother nnd n seriou. row followed. perrcnelle's punishment was to stay in the hospitnl for one year without going out and to eat her meals off the floor C\ er~r Fridn)· until the All S:linh' Day following the conuni~sion of her offense. 1n the year 136S n fierce cont<'-'it clcvelopcd bctw(•en the prioress. <ll'C Philippa du Bois. and Stephen Fouehict, the 1u.1stl'l'. on•r a que<:. tion of authority. Eubtachic de ProYin~, one of the nur,ing sii::l<'rs. }incl nskrd permission of the priort>>-s to lea Ye the IItitcl I>icu nn<l h"en refused. She romplainrd to the t1wster, who aulltorizecl her l<>:n·c of :ibs.,.nc<' in defiance of the pl'iorc~s'~ i·cfu:::.:d. • \ t a mretin!! of the c:ilhc>drnl ,chaph'l' on December 13, 136S, the prioress lod;ed n form:tl complaint. against the ma. ter, charging him with usm·pation of her authority and setting forth her case with great cle:.rne<;" nnd vigor. Thinking. cloubtles:s. to conclude her :irgumcnt by a telling blow. ~iEter Philippa clo::.ed her app:-al by a c;.mtic reference to the dnnge~ ri ing from un~· a ociution of tlw master wi.th the sister;; and cited the case of Marguerite de Chicle. a sister o~ the Hotel Dieu. who for 14 yenr:.: had been confined in tlw prison belonging to the cathedrnl chapter. in expiation of the crime of inf:mticide proYe<l again<rt her. The infl'rence from the prioress's attack wns that a former 111ai:.1er of the Hotel Dicu had been copartner with Marguerite in sin. Whether Philippa's arr;umentum ad homincm was m pired by the pitiful case of Mnrguerite. or by desire w l 'l ·e no :-tone untnrnecl to prejudice the chapter ngninst the ma<:t<'r in nnthority in her own chy, the do<'11- mcnts do not revenl, but one happy con:=:equcnre of the refer<'llC<' to the poor prisoner wns thnt she was forthwith UIJ<'rnted from her dungeon and re::;tored to duty in the ho5pitnl. though sutTcrin~ the degrndntion of being forbidden to wear the Yeil lik<' the other si"t<'r". being compelled to lose her old place at the table. nncl reduced to the humble;.t position in the esta.blishment. The main contention of the priores . ., ,.~.snot sustained, and she. herself. wns. by orck·r of the King, rcmoYerl from the Hotel Dien. This incident is memorable because it marks the be~inning of long und acrimonious rontroYersy between the sisters. r<>prc"ent<'d by the prior~ and other nuthoritv. usuallv that. YCSted in the master. It is interesting, too, been.us~ .it cont;ins one of the two, and only two. di ·tinct references to immoral conduct on the part of the si<:ters 1dTorded hy the docnmentnry history of more than a thousand yenr~. 676 HISTORICAL. The :-eco111l iucident i briefly referred to in the n1inutrs of Uie 1uceUn!.! of Ti'ebrunry .... 1400. in the follo" ing l:m!!unge: B~1rn-•• 1:1·11th1•1· .Joh11 I..----, 1u1'111ber .,r tl1e religious onlcr of the lIOteJ Dk•u, urn! Sl~tcr .Jane, of fhc uboYL'-nnmc<l Ill\tcl Dicu, were discovered In 6111 It Is or<l:iiuc,J tlt1ir t111• ;:aid sif;ter ~hall lean~ the II1ill'l Dit•11 for a Jl('rlO<} ot l\111 months. .\s to the hrother. lle is dl'pt·h·cd furew1· of 1111y 1lut~ In the HotPI I)lcu 1111<1 11hnll hp s••nt lo jail for a p<'riod of onp )·1•1r. Thou!.!h ignor:ml of the circumstances which attended the ·· in ,. ia question. this example of fifteenth century justice attract nttcn. ti on bN~ause. for once, the male sinner see111:> to h~t' <' bonw I he brunt o{ I he unpleasnnt consequences. "'hilt• the records of the medical scnice are :-:cant, Ill<' <111 1u1cnts rclnting· to llw organization and ndmi.nistrntion oi lll<\ ho .. ' nl, 3 a whol<'. :tre alrnmlllnt and interesting. From them we learn thnt the rcspon:-;ibility for the conduct of the institution pa::;sed from the bishops of Paris to the cathedral chapter when the IIUtcl Dieu lll<ffed to the north bank of the smaller arm of tlw 8l'inc nnd bcca111e a part of lhe group of ecclesiastical buildings which oc ·upied the hulk of the Tll' de la Cite. Two 1ncrnh•rs of the chapter werc.- sPll:'ctc<l lo net as O\'Cl'fleers or proviseurs aml exercisl' authority thronp:h the 111edi1t1H of a. master chosen frorn the .\ngu:.tininn Brotlwrs. It \\':lS the master's special function to Yictunl the hospital with the snpplics coming- fron the country an<l to at tend to the renl ~.::folte in the citr. He had charge of the farms nnd vineyard" belongin~ to the in-.titution, was responsible for the chapel ~enice . lh<' cellar, the b:lkery, the nlrns. the benefices, nncl acconntahility and rPt urns of thr gt'C>at establishment. The master and proviseurs together selected from the nnrsint! sister,.; a priorl~ss or mistress. Though lhe sisters wore suppo:;ed to ,·otc in 1he matlf'r and record and length of senjce might give n certain f>ister prior claims, the master and tho proviseurs were bound to ~1ppoint the person that they considered most capable and most "ort hr for the Illa intenance of charitable work and strict discipline. The mnlc members of the Augustinian order at tlw ITlitC>) Dir.ti were few in number and, in time, cea,,ec1 to function, bnL I lie i-i-.ter,.. ha Ye bce11 associated with the nnerable institution clown to our own timr'. The brothers, for the most part ln.ymcn, nc,·er exece<led 30. and rnrely reached that number, and by the sixteenth century hnd dropped to 6. The brothers and sisters lived as two separate c<:tnb- lishments under the monn!:'tic rules and rf'strictions as to <'' nduct which were common to all the religious orders. The si-.tcr,.; uum- bereu 25 at first and by the twelfth century had increased to JO. In the seventeenth century they numbered 120. They began their cn.rcer in the hospital serdce in a lay capacity untl were Htyled Filles Blanches, or ·white Daughters. in reference to their co~tnme, which HTST'ORICAL. 677 c0nsi,ied of t\ white gown. a white cape and veil. n whit<' ,urplil'e, :ind n guimpl'. In the'· nook of .\ctive Life:' nh·ea1ly referred to. '\\"e rend thut •·The dr<',- had ns little fit a' n bn!!. One might hnve snid it would fit one si.st<>r as \";"Cl! as another. and the fir,t one up in the morning could don nuy oue of tlw clrl'::i.-.e., nud '' l'llr it as C'Ont- fortnbly n'> nny of the re t.)' At one period of their bi:::.tory it "a proposed by the chapter to change the heuchlre::;s of :,i:,,ter:::. nncl 110,·icc~ in the ho:--pital. Tho cil"iiiau admini,,tralor,., objected. in vie'' of the fact thnt no 8pecial object would be gained by altering a style that hnd prcrnile<l from rcmott> l imPs and that hu<l nc\ er lwcn crit i<'izC',tl 0,. vo1mi:r or <Jhl before. "As for the headdre.,:-> of the "i"lt>r .... it is n~t· only well adapted to them but a necess\v. becau:ic1 as it b more or le"s clo'>t>ll in :rnd projcdecl in front of the foe\', it doc.:: them goo:] senicc when they communicate. as their profc,,,,ion require,,. with tho well nnd the s:ck. preventing the.-;e people from gettiu1!' too uenr :mcl really keC'ping them far away wlwn they talk together. Then. bcin~ 5.tarched nn<l fostPnccL the hea<ldre,,:::. keep" it. ,hnpe rn thnt the :-i:-· ter~ cnn haYe their he:Hls quickly <lre.~::ell aml 11mlre:::.::,Nl ancl the coverin:.. does not need to b~ la undried lmt ouce iu three month . for all of which reasons a grrnt deal of time is saH•d an~l madc uniilnbll\ for mort: useful occupations. As for the headcln•s,,c-. of the !!irk if they are not ornamental to the face they arc adapted to case in the performance of the ~erYice which they arc required to rcndPr the sick and to other dutit>s flowing therefrom, bceause they nrc tight fitting in front, the pad being placed well back so that nothint! i11tt•r- feres with working and mo,·ing freely, whatever they haw to do.'' Girls were eligible for the work of the 'Ylute Daughter:; between the ages of 12 and 20, a.nd after five or six years' service in this CRpncity could become full sisters, provided they scned nt lenst u year ac; novices prior to taking the rnws. . The drat b of a :;ic;ter cau"c<l a. Yacancy. which could be filled by the de<"tion of a novice. The sisters remained on duty for the period of their naturnl lifetime unless d1:-:abled through phy:.ical weakne:-s, in "liicli cnse they P-ould be cared for at the Hotel Dieu. It usunlly took from !\O to JO yea.rs to become a prioress. Their costume difieretl from thnt of the daughters in that they wore black surplice--. ;ape:;. and Ycik By the thirteenth century the hospital organization W;I" perfected. The bishops who met in council nt Paris in l:!l:! de111on:.tmte<l their wisclom nnd foresight by limiting the nur-:ing "tatf to the !'mnllest number of individuals compatible with a reasonably etlir.icnt . ~en·­ icc to the patients. They expressed themsel ,·es as unwilling to foster unduly the dcYelopment of a monastic in<-titut ion who:;c ~upport would Le derived from funds primarily inlcndecl for the hcm•lit of the poor nnd the sick. The precaution of not concentratin.!! too mauy members of !t religioU!'; order in a. single ho.~pital W:t'< often rol'!!Olte11 678 IIISTOHICAI.. rn the middle n!!c; and the history of the Hotel Dieu of Pari~ illu trntes how readily nbu,es ari:>e ''hen the main purpo~e of nn ins itu tion i-. ob.,cured. Tho worthy brother;:, nnd ::il~ters were nl" oys in danger of letting their religions piety and devotion drnw them nwny from prncticnl ministrations to the ::iick. It is remarkable thnt in 1G3G we find the hospital board compelled to remind them that. while it was a good thing to pray the principal function of uur~es wus to ~uccor tho neelly, :wd the novices and White Daughters were told that if they i:,tayed up until 11 o'clock at night for spiritual cxc.rci they would be too tired aml :;]cepy on the morrow to do goo l \\01k in the wards. A peril of an opposite nature. the decay of vital religious fcC'ling. wns likely to produce equally unfortunate l'C' ult to the pntie11t by destroying the sbtcrs' motive for enduring Lnnlcn E<omc nncl repulsive dntit>:; and by inclining them to seli-indulgencc. That these fears were not imaginary is shown by regulations p:t"!'ed in 1559 forbid<ling master, prioress, brothers, sister . or White Daughter:- from gadding about town without special permis- sion. ~\t the same time ::t1·:rngers were not to enter the building or to talk. eat, or drink with the sisters. Priests nncl chorif>ter::. we~ uot to talk with sisters :rnd White Dnnghters except about affairs con- nected with the p:1ticnts and then only m public places frcquen~d by all. Likewise it becnme necessary to forbid the employment of pri>nte serrnnts when their number had grndunlly increased to n hundred, and nll persons were forbidden to give or scnfl or 'ausc to be tnken out of the hospital buil<lings bread, wine, mGnPy. or 11nv other thing. Though tho prioress had specific charge of the nursing. yet i11 H'ii!5 it was establishecl t hnt the master must see to it that all sister., and daughters in the hospitul were thoroughly trained in" nll the nrt o{ caring for the sick." It was the prioress v>ho regnlated the cominn and going of sisters and daughters, who behind closed doors imparted corporal punishment to those who hr..d misbehuvccl, who cared for the liiwn room nnd the laundry, who looked io the general clcnnline of tl1c institution, und super\ iscd the sick and poor ~dtl1in its wnlls The brothers and sisters aro~c at 5 a. m. in suuu11cr ancl at G a. m. in winter, and aflel' their ablutions betook themSPlrns to ::;cr,·ica- in the hospital chapel while the prioress m~dc a rapid tonr of inspe tio11. This inspection was repented se-rcrnl times a duy and made at leuct once during the night. Ma.tins over, men und women hurried to their posts in Juundry. linen room, cellar. wards, etc. Night lij!ht.., were extingni .. heel nml preparations wen~ made for the work of the <lny. • \ s onr by one the patients woke up, the sisters appeared with basins nnd towels to wash faces nnd hands und clean finger 11nils. Patients who needecl refreshment rcceirnd something to drink. Then HISTORICAL. 679 the beds were made. Such of the sick as were nblc got up for u while, others being movecl for a chan:;e to unoccupied beds. At 11 o "clock the fir:-:t mc.'11 was se1Ted throughout the l}ospitol. 'Yhile some of rho :llt('nd:rnts remained to distribute food in the wnrds the re:-t tfOOped to the refectories, one for male. one for female workers. The two npnrtmcnts were identical. The mn.sler in one. the mistress in the other snt alone at one end. The subordinate.-; were ranged nlong the sides. Though the tables were sprend with linen cloths. the tnblewnrc wits of tin. A reader in each room rc.'lcl nloucl during meals from som<' book of devotion. Brid prnyp1·c: were snid in the chap,,] and then work was resumed. During tlw a ftcrnoon patients saw dsitors, nncl at G came snpper. ..t\.n hour later ill<' mnc:ter inspected his domain nncl cunsed nll doors to be lockNl. Th<'n th1• night. nurses rnn1c on duty. There were three so-culled dormitories: but in !'eality only the quarter ... of the White Daughters merite.cl the title of dormitory. for the rest each hnd ::t room to him or hl'r "<'If. simpl~· but commodiouc:Jy furnished. .\.11 the doors "ere locked by t11e same key. From 1!1:}7 on, the night nurses rcccin<l :m estrn mca m·c of wine. thnnk to the pro\'ision~ of the wi1l of a cc1 tnin thoughtful canon. Ende;:, of Sens, who surely mu!-'t haYe had some pcrc:on:il knowlcclrre of how hungry watchmen and night ll\ll':'es cap become. 8eYeral timec: durin~ the night the prioress could be ~cen mn kin!! her round, through th<' w:mls by tlw flickering light of n torch. At th1: time of the row between Philippa du Bois, prioress, and :-\tephe11 Fouchier, mnster, :feeling hnd rnn ~o high that t11c Pro,·ost of Puris :o:tllnrnoned the contestants before th<' tl'iblllrn lat the< 'hfttelet;. 11ncl finnlJ~r ('hnrlcs V, to qui<'t the unsr.cn1ly cli ... {11rba11ec, nppointe<l 11 pecinl committee of the canons to tnk<' cognizn1we <•f the nffuir and \\imJ it up. Tnlerual 1fo•-,1utiou" t·o11ti11m•(l to i11!C'l'f~rc ''ith the work of the hoi::pital, nnd <luring the reign of LDui« ,. • 1 ( 1461-1483) pnblie nttCl1tio11 wns ngain dr:iwn to the irrcgulnritic> that obtnincd th<'rc· The 'Yhite Dnughter..: bcl'ame rnutinon, "hen trnnc;ferred from the can• of one si:,l er to an<]ther. X 1111s <'n me und went a, the} 1,Je e<I nncl slept outside the hospitn 1 whe11 thl'y .. aw fit. They !jllnrrelcd \'iolently or becmne unduly intimnte with the prie,ts. nnd in 'nrioth ways a situation was produced with whi<"h the canons felt them ch-es unable to <'ope. They :1ppenlcd to the municipality. aud L<>ui<: XIT in 1:)01) appointed 12 notnhle bm·gl' .. c~ of the <'ity n, a hurenu of ndministrntion for the hospital. From thi.:; time dates the struggle for !'Ontrol o)f the Ilf•tt'l Die11 \\aged between the religious and ciYil 1rntl101·ities, which has contin- ued tlown to Olll' own time and thrown into the .;}mill' all le~·er di:-.- !-(>nsions. That these dissensions had been fur from i11signifiea11t. J10WC\'C'I'. i~ -hOWll uy tJip :lC'C01111t Of I hr t'H,'lli<: !'Ollll!'!'(PiJ ~with the 680 IIISTORICAJ •. career of one J ohn Ldcn-c, 11111~tcr of the llotC'l Dit>u i11 1 Wi.: gain whom :-uit Ll•forr the Parliament of Faris \\ n. Lroughc by the Ii(>:> l,itnl nuthoritil•s, charging him w-ith rnriou:s irn•gularities of n mini:otmtion. ln the cour-=c of tLe trial the :;i,.tcrs and lhu~hl joined b~· a few of th(', young<.'r brother,_, made an atta('k <lll ti e ror1 1 occupied by l•iwrC'ncc Lai!'ne: u priest who ha<l been appoint 'd lrnr:;ur, whotu they uC'licn•ll to be friendJy to Lefc"-rc•. Knn c nn I axt · v;er<' brni11Ji, Jwil. and crip .... of ·•.Tnda>'.:· ,; In• it or:· ·· rohlier : re ~ounclecl throug!1 the; lmilclin~. greatly to the terror ·uul <li ·0111fort of the ~ick. Poor Brother Lawrence was pro.;tratetl with tm1or n the door of his room foll to pieces under the shower of blo"·s. ·' " 7lmt. do you want~" he asked. "You will know soon enough," said one of the sisters, hruntli ·hin" "' nn ax over his head. There is no knowing whnt might have happened but for the re- sourcefulneS!> of a sister nicknamed "The Cake." who, feelin~ thot some crime would he committed, diverted the crowd from further violence by making Rrother Lawrence promise that he woul1l go and bring to tho l>pot lhe haled LefeYre. Lat.c>r in ll1l' da~ when the dean of the chapter and the proYiseur:s betock themselves to the hospital to remind the sisters of their duties to the sick, who were being -wholly neglcclecl-both male and female member;; of thl' order broke into open mutiny. They were joined by 20 or 30 of the patients, who jumped from their beds. and, in concert wit b the tlome;;tics of the im;tilulion, lwc:unc so ins111tiJ1g ancl tlm·alt·1 l ,!! to the canons that they hnd to withc1raw and only just succe"ded in escaping by the wicket gnte. The burenu of administration founded by King Louis was not a success. It held solemn assemblies and issued orders to which no one paid the least attention. T hen, appeals would be mn.do to the K ing, and ewr~·onc knm\'s that while merry monarchs mny Jw-.tow !'.tenerous swns in charity the~· ofttimes seem disinclint>d to worr~· their heads about the fine points of other people's concern~. For 1;, years John Lefevre had manngrd the hospitnl to suit himself nnd made no prett>nse of keeping nny accounts of his financial ac1mini trn- tion. EYerything wns in confusion and disorder. The hurgh<'r:- nat- llrally could not imn1edintely produce system out of chaos, and yet re :-nlts and accurate r<•po1-ts were wanted at once. The new commi~sion, charged with the reform of the entire service, showed itself dis:oatis- ficd with the condnct of religious affairs in the hospitnl and witb the cure given the sick by the brothers an<l si,:;ters: whom they dis- tmsted. They accordingly introduced from F landers the Gray Sisters in the hope that lhey would be an inspiration and cx:1111pl1• ior a renewal of energy and devotion in the wards of the Hotel Dien. This was a darin~ innovation and gent>r:11ly rcgarJcd n~ of HISTORICAL. 681 ~ye import. At fir5t they "ere but 11 m number nnd did not ~rry sufficient weight to make nny material changes or dominate tho hostility and malice of the older section. Later, they were in- crcn<=cd to 30. \uy ~eriou~ reform of morals~ however, wns forgotten or lnid . sick. owing to the l'onfinnc<l wrangling of the chapter of cnnons: the committee of the burghers, and the Paris Pnrliumcnt: who were nil nt crcsc-purposcs with each other und ne•·er P"Ot bcy01Hl mutual recri111inatio11. The crying neccl 'vns :for an ironclad system of ac- r.onntnbilit.v nncl legihlA hookkeeping. This !'itatc of .dTnirs ln.stcd for 10 y<'nn; or more'. i\fennwhile C'Omplaints were beii1g con:-;ta11lly n•gii::terccl by the p.itient . Th" sisters laid the blamt• for the cktc.i'iorati'll service on the !!11?11tl_\ lflCJ'l'llSC<l lltlllibcr of STCk and tlw Jack of fiCCOIOIOOdntion for them. fhcy c.l:limed that they hacl r-o chance to att.>11d to their tcg1timatt> work nml at the same time prosecute their spiritual duties. Thi~ \\ n::, offC"recl ns an excuse for the mcintcnance of owr :.!00 con- , 01escents to do the work of the \Yard.;;. These conYtil(·"cenb mis- npprapriat<•cl food by way of wages, nnd the nuns tht•msel\'cs were a cused of stenling s11gn1· frvrn the dispensary. The sisters ret,llintecl by accusing the pro,·iscur.-; nncl masters: blaming them for the lnck of heat in the wnrcls: nnd declaring that the patients stnn cd or iron. to death. Thcy "·ere directed co be more patient and more pains- tnkinrr 'vit h the sick. whilr t~1c master was reminded that it was his duty to OYersee the beb:n ior of the sisters nncl to proYiclc ccmpetcnt I ersons to instruct them in the art o:f n11rsing. Nothing came of thi..:. nnd in 152(i we fincl the personnel of the Hotel DiNt mnkin:! common c-nnse with the <·nthedral chapter against the Oon•rnment n<lminisfrntors. In min the doctors were directed to report the numher of discharged and conYalescent patients who remninc<l in the ho pital after they had pronounced them cnred. The conva- ll""-eeuts kept ont. of the way of the d(·ctors and coul<l uot be :foun<l. When the prioress \YO::; questioned on the mnttcr -.he stood on her dignity and as8ertecl that sl1e could not remember. Francis I found time in 153;) to occupy himself for a moment with the Hotel Dien, and appointed a committee to i1wcstigate nnd 1·cport. This committee recommended the discharge of the master, John Petit nn<l his confederate in peculation, Brother .Tuli:m Lueas. Ule! e worthies hn,•ing nppnrently li,·ed on the fat of the land, unbeknown to the chapter and contrary to their vows. This vigorous committco also rcmoYcd the prioress and her understudy and replact•cl them by other women. The decisions were badly recci,·ed by hoth Lrotlwr . .; nncl sisters, and one of the latter became so noisy in lll'r mnnifosta- lions of <lisnpproYal thnt it was n~cessnry to lock her up immedintlll_r. iro:JS-1~ 682 HlSTORICAL. Discouraged hy the t nnm1t nn<l by the general situation of the ho pitnl the chai1mnL of the committee. _\Tch<lcaeon Loui ... tlu Bellay rc:oig1w<l his pMition. :1n<l in consequence a new inwst i!!ation , a' ordered by the court of Pnrlinmcnt. The patients WC're enlled on nn<l they tcstifiC'Cl Jontlly ubout the lack of heat in the ward and the poor quality of the foocl. Sister Joan de Co!'tes, the a"sistunt prio recently :lppointed b,r the reformers. haYing been 14 ~· ea1·:=; a 1ne11 ·r of the nmsing order, testified that, moYed b~' the pit ial>l(' c·ondition of the patients, she often had been constrained to bn,\' \\'hiting nnfl ttounders to fry for the hungry in order to keep them :din•. aud that she luul h<'g-gccl mon<'y f< r the purpo.;;c from relati\'<'8 and others. She declared that during the two previous winters she hnd h<'Pn con. strained to burn tlw sfrn\\ from the rnattre;.:i::c.;; of the l>Nl!'i in nrder to be able to pro1wrly dry thr ~hPc•b intc11<lc•c1 for the :-;irk. Shr t< 11 how she complninecl onC' day to one of the gowrnor:;. when he· c:tm(• into the St. DC'nis ward, that the poor had bnt one small hcrriug n day to cat. To this he replied in thec;e words: .. ·whC'n I am olfored herring at the tnble I always take one of the smallest.'' Sister ,Tonn went on to relate how Oil(' da~· a poor to\\ -.man brought in I wo Il!:<h for his wifr aml a i:;ick woman 1.\'intr 1wxt 1 ' her. H:n-ing no fire "ith whiC'h to cook them she told thr poor mnu ~ . nnd he, wild with an!!er. rushr<l ont of the building hy tlw /,!ate opening nn Little Bridge. crying: .. Tho!'r bi~ rascnls. thr wom<'n t tho ho-,pital. kt thr poor di<' of hnngC'r. and if yon take in food for thl' pnt icnts tho,_,t; womC'n won't cook it e\'(~n.'' On the mor1·ow c;h · '' ent to the ofllce 0 f the governors 0 r tlw hos pita L and l'l'l:ltP<l t lw UO\ e happenings nn<l they snid in nnswpr: "Let. lhl'm go lo th<'ir 1101i-es nn<l ham their ;.:tufl' cooked. \\Tc al'e not required to do it hc-r '. • Apparently the earl~· ~'<.'<\l'S of the seYentC'enth c0nt111·y const'tuted a period of gren t tlC'trriomtion in t~w <'ha meter of the . ' i<X' re11dcred to pnlients. In 1H3-I- a ec1fain prioress. q t1 l'~tionc<l about her :tnthorit~'. i:;aid that she hncl the ;;ame powers as Her to comm:lt d h'ut was now no longer well obeyed. <l'i the dnnµhter-; and no\ ices nttached more impodance to thr direction~ recein•d from the si!-:>ter ll"S. ~11ed as their spir itual mother or ir11icle th:rn to the- priore..,s' orclc'I' ... for ~enice with thc patiC'nt". "These girl,-." she said. ''disdain to rnit on the sick becanse of th<.> spiritual exercises ''hich thr said mother lays upon them daily nnd which the)· find sweeter. They no lo 1ger care to occupy themselyes with wn!'ihing clothes, cleaning the poor. rutting their hnir, paring their nail:;, nnd doing other ncrc ... c:nry things, so th :tl as a r11le the hcacl nurses Jun<' to grt in women :from the outside to lwlp them." _\. lady, deeply inlerrsted in the sick of the Hot cl DiPu and "ho worked h ard in their bclrnlf during the trying prriod 0£ rivil tir; HISTORICAL. 1'83 bet"-ecn Henry Ill and Henry of X a ,·a1Te. "rote> in l\,:).i to the ;idminic;trators of the hospita 1. complaining of the -hm tugP of bed:> for the :,ick owing to the lar~c number of poor propil' who '' 1 re i11 the habit of !!Oing ea<'h y<.>.\r ro the Hotel Dit•n to pend t lw winkr. S}w a -ertccl that the fir::-t ward could rradily holll :!.J :Hldit:fon:il ~d,, :md tllat tlw i:arpenter and mates attni:hL•d to tlw in. litution could ensiJ~· proYi<l<' the..:c bed~ in G or 7 week,, by ,,·orkin~ !.teadily. 'J hi:- \\Orth~· inn• .... tigator found that oftt>n tlw night lamp., \\Pr,' "ithout oil. that t lw windo~v-panes wer1' broken. :mcl tl11• Lo\ 1·, in.de1p11tll'. On!) a fot·t11ight. before her co1uplui11t the clool' of the h ·n!!-ill "an! "·11s l<•i't oprn and :~soldiers t':ll11<.' iu .llld i.111m• l:11li1•'; ,~·ho h:1p1w11<'d to l>P nt tlw 111.LPl Dien Lalkt-<l 10 lllC'm. 1·011tr:1ry lo 11rdrr. IIad tl1t· door lm.•n close11 acconling to tlil' ordi11n11c·c· of he ;11:i1rn!!<'I"" s11d1 ii thing eonld not haY<' lrnp];l'll<'d, to tit•· !!rc· 11 "'·.111d.tl of UH· Ilitl'l Dil't1. It wn-. at thi~ 1wriod that the porters wen• tlirectt·d io stop the patient-. from going 0111 of the building for tl•e pnrpo-c of ac::kin_g aim nncl returning at meal hours or l edtin e. Likt•wi<-c, under penalty of a whippiug the doorkeepers were not 111 receive tipc:: from the patient:; as they 'came or went. The si~ter~ WC'rc. not al- lowed t< 1 <lraw tlwir rations of raw or cool~ecl me:tt :it the kitchen individually, us this mac.le it easier for them to 8Cll their rations und live otf the food assigued to patients. The custocli:rn oi the pa- tient:<' dothers was expressly forbidden to sell them ks! on their recovery the poor should have to go out 0£ the hospito.1 naked. It w:1s founcl ncc1•ssnry to put up in the laundry a !"Ort of woodt•n pas- sag1•way.,regnlnte<l by lock nnd key, to prevent clothes, lilll'n. or food from IJC'ing snrnµ-gled out of the hospital by this rout<'. 'YhPn n sisti>r wi>nf to nurse a case inn priYntP hothe notice was to be given by the mttf<ler to the baker, the cellnr mu<-t<.>r, :incl others, :-o that they mighl stop the issue of rations until hc•r return. It was likewise the duty of the master to know the h•ngth of her a~ence and the house to which she went, so thnt he could nscertain the exact amount of money she had earned for the in-titution. Another wise and businesslike measure was the order to determine how much wine there was in the cellar and then decide. by the num- ber of patients present, the amount to be is::.ued to end1 one. The orders for the wine ration were to be signe<i e\'l'l"Y day by tl;c ph~ ... j. <'inn:-) nnd surgeons of the hospital and st•nt1 to th·· ''(•liar rnn ... trr to ser. e ns '011ch<'rs in making up his acco1111t!"'.1 .Amid all these sordid details of human weakness till' history of the hospitnl is illnmined by the beautiful life and noble ch'l'~}c:: of a. 1 :\olf'I! Hur CJ Anclt'n rIOlcl Dlcu de Paris, by A. Rousselct. F'. Le•·ro,111l~r & Bah~. Paris, 1 88~. 684 IlISTORICAL. ' member of its nursing stuff. Gene>ieve Bouquet, the dnughter of a rich jeweler, wns £e11t to court nt un early uge und entered the service of Marguerite of Valois. It is to be hoped that her contact with th~ dissipated d::rnghter of Catherine de :.Medici and di Yorcecl '\ ife of Henry of Xarnrre di<l not occur until after the qnee~'s ~mppo5ed conversion to the pnths of rectitude, until the period when :-he wn under the worthy i11fl11enc<' of her almoner. the pious Vincent de Paul. At the age of 22 Genevihe enteretl the Hotel Dicu, n11d for 1:> years scrYecl as tt 'White Daughter before becoming a Lc.;ter. After a Yaricrl S<'nirc in the pharmacy, the lying-in wnrd, nnd th"' other wards she was elected prioress, and continued to be a model of piety and practicnl charity until her death at the nge of 74. The founding of the ::;ocicty of the Dames de ChnritC-. or Ladies of Charity, is commonly nscrib<'d to Vincent c1e Pnul. though ns a matter o.f fnct he actually opposed the scheme in the beg1 rniug. The idea originated with l\i)]e. Le Gns (Louise de Mnrillac), a n<l the ontline of the project was laid before M. Yincent by Genm;e'"e Goussault. nee Fayet, n rich '\lom::m of the better middle clnss in Anjou. widow of A. cle Sauvigny. president of the Court of Account~. Vincent de Paul, 'd10 was prudence and discretion itself, hesitnt~ to interfere, ancl put these worthy women off with the assurance thut the nble nnd wise persons, whose duty it wns to administer the hos- pital, would take nll the necessary measnres ancl n~eded no help from vithout; but Mme. Goussnult appreciated the benefit which would accrue not only to the patients but to the Indies themselves from nn uctive participation in hospital work. and did not allow hC'r •If to Lccome discourngecl by the reverend gentleman's rebuff. "'lwn she realized thnt her continued appeals to Vincent de Pn ul were n n she boldl,v turn<'cl to the 1U'chbishop o:f Pnris. Mgr. elf' Goncli, "·ho snw at once the exceeding merit of the proposition and :lssured Vincent de Pan] that he "·onltl be glad to have the undertaking carriecl out. Accordingly, the latter culled n. meeting of fh·e ladies known to be interested in the hospital, and they agreed to associate tht>m!'eln$ together for the purpose of visiting the Hotel Dieu. On the ~Iondny iollowing, n.fter communion. 10 people met to initiate the society, the noble mother of Fouquet. the rr hister of finance, bring 'nmont: the number. M. Vincent made n tactful speech, in which he explninetl thnt, as 'the visits of the ladies and their practical interest in the '' orkings of the ho~pital mi~ht be expected to mnke public some deficiencies in the administration of the Hotel Dien, they wo11h un- doubtedly pro,·oke sonw hostility. Accordingly. he urged his heare~ to be more than careful in their attitude toward the sisters. They appreciated the point nt once and displayed so mnch tact and grnco in their "·ork that they won the affection nnd esteem of th!:' priorc.;;s and those under her from the start. l:USIORICAL. In JG3-! the Associntion of the Ladies of Chnrity began its work. In trying to comfort the sick they di<l not limit themseln!S to words. '[hey decided to pro,ide for the patients a light meal between dinner and supper, and, accordingly, began their operations by hiring n room in the vicinity, where they prepared or stored provisions, fruits, di5he:::, lim•n, nn<l useful utl·n~il"'. .\bout :J p. m. each ,Jny bread, t;iscuits. jelly, preserves, fruits, either stewed or bnkecl, were given out to the patients, the members of another society, the Dnughters of Cbnrit.), founded by Mlle. Le Gras, nssisting in the distribution. In the course of time this elaborate menu wns somewhnt modified, owin~ to the necessity for economy. Each day four or fh·e women, simply garbed nnd wearing nprons, went from bed to bed through the \'fnrds carrying little gifts for the sick nnd the poor. It was their aim to minister to both physical and spiritual needs. They culti- ,·ntc>d nn humble bearing an1l tried to feel awl to :-how"-.) mpathy for the ills of mind and body. In accordance with the wise directions of Vincent de Paul, they forbore to talk about themseh-es an<l tried to 8,·oid the appearance of preaching. He urged upon thE' members of the two charitable societies the importance of wearing the simple t g:irb when employed on such n mission, so thnt, without uny pretense of po,•erty on their pa rt, at least they would not ~l'l'.111 ~o fnr rcmo\ cu from those they sought to succor, nnd would not sadden them by the conspi1 uous contrnst of their respective stations in the worlcl. It is not surprising that u1111er ...,uch wise guidance the Dnme..~ de Chnrit ·oon had a mcmbe>r,:;hip of n hundred women, one-fourth of whom were me111h1•r; of thP nobilit . .-. Two .rear,., aft<'t' iti;; organiz.1- tion it was rlee111Nl Pxpedic>nt to aivitl1• the work at the H1jtcl Dien in !'lll'h II \\ ny that '-Offil' of' the l:tcl ic:-; OCCUj>iNl thcmseJ VCS whoJI_v "ith rc11dc1 ing· ~p!rit11al aid vd.iilt' otlll'r cfo1·oted thcmselvc>.s to !'('lie' iug phy!:iirnl di<;fl"c:s~. Tht> pestilence of 1G3G fuuml both tho Oamc all<l tl11· Fillc-; <le Charile at their po ts, no1 did c.'<msidem- tion" of pel':-;onal :-.:1fcty intedl're with their good work until they \\l'l'l' 1N1uirctl '\ their !';pirit:ml director to stop, two of the olcfor women awl o 1t' of lhe yunn~er ones havin!r died from xposure to the cpid<'mic at thP Hotel Dien. In tllC 111iuulc>,, or tlw mC'eting of the board of dii·ectors of the Hotel Dien. 1111<11•1· the dntc of ,\n~nRt ::!G. li05. \\C Tend ihnt it wa..<:: \'otcd lo «Ontinne to J\foster Petit. -.nrgeon. his nnnunl nppoint- 1n<·nts. by way of testimonial and favor, so u · to reliPve tht· needs :mo infirm1til'" of hi <:: gl'en( '\gc. ,\nd in the deliluwnlinrL" of .\ngnst. :!:!. 170s. we rc>n<l : ~lllHl'r l 11•t It. fnl'llll'I" l"hief" >llll';.;"l'Ull or till· HMt>' l lf••u. ,, In~ siit·k lllll<J •'••:l[h, !mi: l'f'lll to petition th~ honrd that n1'tPr his dPc·:-: '"hi,.; J,.><ty n 111) lw lonriP<I 111 tho chll'·• Ii of t 11,. 1 ltit•'l PiP11, th•' \\·Jii<'h 1l"tlti11:i 11,; f1t•1•11 ;!1"8 ll•'tl In the u ,.,,.1.1hl) in co11slth•ratiu11 of ll!e servit'l'l' whkli lhl· ufort alll ~ln--ter Petlt hn r••wJer,•<I to thl' poor tluriu~ a ::;en·il't> of nicorl' than 1-:lJ .rear,.. HISTORICAL. \·o1. XU OthC'r ~trikin!! l'XampJc,. of lwroi"m and •le,·ot ion :t re furnL,hed by the rl'Clll'(l of thC' great fire "·hich on the ni~ht of Di!i.:ember ~9 171::!, dcdroyld a :rt·cat part of the I-fotel Dien. The fire oric:innted in the chancllcn oi the h< "nital. an<l in a fC'w mnmenls flame "-"<'re seen bursting from the windows of the Legate warcl, the Snin• _\.u~11,,ti11 ward. or Yellow wnnl, and Ra int ,J<'un warcl. .\.s the <leau of the chnptcr an cl ot lier functionaric" were h 1t1·ryi11g aero--~ tlie cnthechal C'!ose to r<'nc·h the «c·c•m• of tlw 1fo;a::,t 'I' tlwy bL>IH·ld l'O\llllfo women, lrn lf mHlres~ecl ancl weeping in I error. their.· natural 11ai·rn being heightened by the loud alarm 'vhich pealed forth high abore tl l'ir head· iro• 1 lh<' I Plls of Xotrl' Dame. ·Forthwith 1he clc or:, of the cathedral were thrown open, the nave was lighted 1tp, antl the refugees W<'l'<' dirrcte<l lo betake themsC'lves thither. The fire h:n·in1r ,., readrc<l Uw 1lormit orit>s of the no\·ic:os. lhey were ns8C'mbled :i.nrl counted, and when it was found that no one of them was mi-sinir they were sent in haste to the cathedral, nncl in less thnn nn hou; they had prepared beds there with mattresses, pillowc::, and feather beds for the accommodation of the sick and injured. l\Ieanwhill' Sl'nfriC'<. hnd beC'n stationed nt the portnb of tlw church to prevent the entrance of all nnnnthorized persons, and Yalorou,, efforts were macle to sa,·e ns much property as possible from the burning building-. From the chapel of the hospital the sn<:r<••l ve.;.,. sels. cross, chandeliers. and various ornn mentc:; and vestment" were remoYecl to lhe trc;1sm·e house of Xotre Dame, as well as thl' hirth registries and th<' recorcls of burials and funerals. .At thr first rumor of the fire the procurator ~eneral, the president of Pnrli:unent. the lieutenant general of police, the head of the criminn l <'Olll't. the kin~'s prosecutor, and other functionaries arriYed, one by onC'. The clooN of the hospital WC'l'C' ordered opened, biat nt that moment the chil•f night nurrn. who had th~ keys. was busy elsewhere rescuing the :-ick nnd could not be found. _\.n attempt was made to bre1tk lhe lock-. and so. when the keys were #inally broui:rhL they were of no usr. The doors hnd to be battered down. and owing to their great strength thi;, took a long time. Before the task was completed the firemen had arriYed, accompanied by city wat<'hmen nnd numerous fri9.r" oi Yarious orders. .\bout 3 o·clock 1n the mornin~ the archbishop arrived and, after ob::;ervin_g the flames. entC'red the cathecll'al anrl \'isited the ~ick. He immediately took steps to furnish broth anci wine for them. The clean of the chapter toward 7 o '('lock in the morning roceh·ecl as his guests the si>;ters ancl 110\ iC'es and nrr:inged ior them lo hn\'C' somethini:r to eat. At 8 o'clock mass wa'i !'aid as usmd an<l then the canons met to deliberate on whnt should be d 1>n<' to relieve the sitn1ttion. _\..11 dav the fire continued to burn and lh·el v fears were entertnined le"t the ·<lispen<>in-y. the wine cellar with its store of wine~ nn.i HISTORICAL. U87 liquors :rn<l barrels of oil should go up in flumes. The city otliciu b , howc,·er. b~· their promptness in irnlating thc:;e portions of the )ivspifnl und by covering the cellars ,\·ith fragment:-: of old plaster work :ind other 1:oncombu;,t ibk• material. ::;ucceetled in pren'nting further c_'\ten::oion of the flume-.. .\Jl this time it was nece.s~ary to operate the rump,, which wu:; clone with difficulty on account of the great cold. lh 4 o'clock on the afternoon of Thur,;day, December :H. the fire w~~ romplctcly t>xtinguished and patients w~re carded back .from the cuthNlral to such portions of the ho3pital a:; "ere !;till sta1Hling, us it wns anh•ntl,\ desired to clear the church au cl prepare it for the cn::otomar~ religious services tlppropriate to the new y<•ar. That evening after their dinner the sister::; to the n1unber of !10 und the no\icc.s, :Win number, pao;;::;ed from the large ll'lll of the arehui:-hop':i pnluce to his audience roo111, and, haYing thanked hi111 for hb hospi- tnlity. fell on their k11ees and i1woked his ble:.sing. During the two days that the patient:; of the Hotel Dieu were lodgell in the cathedral one woman gaYe birth to a child and 12 paticnh died. Owing lo the cold. numerou:. braziers Imel ix-en ;,Ct up in the mn c an<l lamps had been lighted all o,·cr the church in order to facilitate the work of the nurses in caring for the ~ick. .Many were the wild stories uflotlt in Paris about the occurren1 ·e:. at the fire. Of the 500 patients in the wards that burned, not one. said ru111or, e:;caped. Indeed, popular report claimed more deaths than tht~ enl ire nu111ber of patients in the institution. The facts renaleu by the legal investigation held on the spot establishNl clearly that only 12 bodies were found amid the ruins. while a fireman and one of the city's rniUtiamen were killed and 19 per:-,ons were wounded. One of the nurr.;ing !':isters, alone and unaided, rescued and carried to :;nfct~ 15 patients. The loss resulting from the fire was e:->tinrnled nt over a million livres. It was in the reign of Louis XYI, under the able <lircction of t3uron Necker. minister of finnnce, who was him;;clf inspired by the counsels of his wife, an indefatigable ho<.pitul worker. that the reco11,;truction of the Hotel Dieu was begun. When political in- trig-ue hud ctlllised the full of the great financier, the "ork went on without interruption acconling to the wise plnns formul:itecl hy him. By the t>igbteenth c:entury the profo~sional stnti' of the hospital uppcars to hn ve been organized on modern lines. It con,.i,;ted of :;e, ·n doctors, one of whmn was specially delegut<''l to treat the rwiPst<:. sisters, ·white DatLghters, and 110,·ices. The others \H'rc us- ~i1.?1wd to various wards, :,,cl'\'ing in turn for four mvntJ1, in l'ach. They mucle their rounds betwt>en q and 10 n. m. daily. Each wn:, itc- cornpanic<l by nn upothecnry or surgeon to take down in n book the pr1•.-.u·iptions ordered for the patients. These book::. were later taken to tlu 1lispema1ry. where the apothecurie.;; and surgeons came to con- 688 HISTORICAL. \"ot, XII. sult them for precise directions. The dispensary was in charge of a special sister, who gaYe out the necessary drugs and materials wherewith the apothecaries could make up sirups, pln.,ter-:. nint. ments, etc. The surgeons were of f'e,·eral classes. First, there was the chief surgeon, who was overseer of the surgery and surgeons of the H otel Dieu. He was lodged and subsisted and paid GOO lines in wages yearly. Under him wns n. .first associate surgeon, with a salary of 100 livres and boarcl and lodging in the Hotel Dicu. Twelrn otlicr associate surgeons were lodged and fed in the building, but received no salary. The 12 associate surgeons were assigned to various \Vartls and had under them externcs to bleed patients, blister them, and perform other operations of minor surgery. o.r these associate surgeons two were alway~ on duty, dny and night, to nttcn<l emergency c·ac:;es, both of the hospital and dispensary type, and they slept in whnl was called the guardroom, so that they could be notified readily by the night nurses when they were wanted. At this time there worn 21 ward~. with a capacity of 880 hedfl. · It is interesting to compare the salaries of the medical oillcer::; of the Hole] DiC'u with that of the head midwife of the institution at this time. Tn the yenr li37 we find Miss Langlois, head mhlwifo of the Hi\tel Dien. reporting to the board of <lireclors that sh" hn<l always considerC'<l it. a duty, during her long period of service, lo deYelop a ~uitnl>le understudy, capable of replacing her in need; that one Echnee Oonet, ha' ing &hown herself throughout a period of 12 yc.>nrs i11 e,·ery way capable: deYotrd, and entirely fit to ron<ltt<"t t he lying-in ward, is recommended to the place the present incumbC'nt 'mrn.;t soon \:neat!'! owing to nge and "·C'a rines~ from long service. The bourcl 1tccorclingly voted a salary of 200 lin·pc; 11 yea1· to the sni<l Edmrc Gouet. to be increasecl to 400 livrc•s nftcr the death of )fos Langlois. :Mennwhile tlH• sai<l Langlois was to be lodged ancl feel aud supplird with heat and light ancl laundry ser1ice and was lo receirn :WO lines annually as ~a]nry in view of th<' goocl scnicc which she hnd "0 long rPncl<'red to the poor. llwrr.by wrecking her lwnlth and strenirth. TherC1 are 110 !'tntisti('s showing the maternal a1Hl infant mortality in the l~·ing-in ward, bnt we know that the birth rate of the Hotrl Die11 ro,;e from 1,2() J in 1732 to J.:>08 births in 1757. About this time serious complaints began to gain circnln.tiun in regarcl to the professional ability and behavior of the doctors of 1ho hospital staff. It was reported that instead of coming nt 7 o'cloek in surnml'l' nncl nt 8 in \\'inter to mnk<> rounds 11111ong tlwi1· patient,., they ofl<>n dicl not come till 9, 10, or 11 o'clock in the forenoon, this to the great inter ference with the propc>r hospital care of flte patient,. Their rounds should Inst at least two honr!', but instead were often View of the H6tel Dleu of Paris and surroundings In 1734. Courtesy or 11 . Champion, 9, Qua.i Voltaire. Paril. 6811 I so . .f. lllSl'ORlCAL. 689 made in hnlf nn hour, n. quarter of nn hour. or less. This illlfoccnt precipitation was not clcemc<l compatible with a thorough study nnd tr('atment of their cases. Furthermore, it was alleged that the attend- ing 11n<l other phy~icinns constantly ab::ented themseh·es on unnnthor- ized und on un<luly protracted leave. )foladmini:.tration nnd waste of funds were charged in connection with the dispensary. nnd t.he apprentice surgeons wero believed to be engaged in petty pilf('rin~ of dnigs, etc. The minutes of the board's meeting of December 20, 171G, contain this horrifying entry: Three nssoclnte surgeons Introduced some girls 1nto the nl::;ht-<hll) room nnd spent the night with them, nnd, having become Intoxicated, rotmnlttcd nil sort.~ ot exce:-es. • • • Slmllnr <llsorclers nre hut too frequ<'nt. In"tcn<I o! sl<'('p- lng In the bospltnl, ns they nre require<] to do, the associate sur::;L"<>ns often ::et !'.Xterne" without experience or nl.Jlllty to tnke their places at nl::ht In tht> i::unrd room or night-duty room, these substitutes beln:; quite unfit to rc111ler the require<l ahl to the sick. These random notes on the history of the H1itcl Dieu \\ oulcl La incomplete without a brief reference to the l'fi'Ol t~ of the ,J ntM'lll"i~ to gnin p~sesc:ion of the institution. The well-kno\\ n ect of the .Tnnscni:-ts represented a struggle on the part of a portion of the Catholic Church lo return to more ernngelical stundnrds an<l to in,·e..,t worship and life "ith increased spirituality. It was in 110 ... en..,e a mo,·emcnt townrd Protec;tnntism, nnd ih founder toutly held tn the Roman Church. The hostility of the Jesuits and the C''entnnl condemnrtt ion of the movement by various popes, from Innocent X to Clement XI. and the determined nud f:mnticnl op- position of Lo11is XIV sealed its doom, though for n time the nd .. hereucl' of i11fluentinl men nnd 1\·omen at court, of prcbteg like tlw Cardinal de Noailles .. \rchbishop of Pnris. of thinking men lilm Blaise Pnsca 1, excited wide:'JlrNi.d attention and intere t in the 1110\ e- ment. which nniortunntely degenerated to something not unlik<' c:on e of tJ1e l't'Yivalist movements of our own time. The miruculous cur~ "'uppo:-ed to hnv(' been worked nt the tomb of one Fr:m~ois de Pnri:::. 11 .T:rnsenist of beautiful and holy life, led to the closir g of the ce nc tery by the Government. It wns this incident which occasioned the fnmons epigram: l>I' r11 r il' rot, dHensc ll. Dku ne fulre mlrncle en ce Heu: whi<'h we may translate as follows: No mlrnde or wonder raising thing ~fay Clod do here. By order of tbe King. While the Jnnseni.st doctrines were warmly chnmpionr<l by fh·e or six of the canons of the cathedral, who deluged the public with .Jansenist writings nucl song'° and <=atire-; again~t the pnpel bull, Uniqe11itu8, our interest here chiefly centers around the piquant 690 HISTORICAL. per:;onality of a young girl. :\Iarie Louise Claire <lcs Tournell daughter of William Charpentier. Lord of Lunaisi des Tuur11elle · and of Louist> .Marie cl'Anbonne. was born on the 2d of Februnn lGlfJ, grew up al lhe coun of the Duche"s of :Maine. and con:-,tnnu; attended the ball-.; ancl festirnls at the royal court of Lotti XIV until she wm; ~2 ycnrs of age. ·whether suddenly '· con,·crtcd · in true Jnnscnh;t style or acting on convictions gradually £om1ecl by the contra~t Let ween her inward thoughts and the worklly. licentious surroundings of cou rt life we do not know, bnt on a certain day we .find her getting up from her lmees after long nnd earnest pra~er in Notre Dame and hurrying into the presence of the prioress of th2 H otel Dieu to beg admission into the order of nursing sister,,.,. We can picture the scene and readily appreciate the astonishment, al111ost horror, of the prioress when this fashionably altirecl young lady made her sud<lm appearance within the sombre walli:; of the hospital. Her lip::; were rouged; on her cheeks were black patches; in lll'r hair aigrettes. The prioress expresses her surprise at a demaml so unusual from one decked out in all the livery of worldly vnnitic.'-. ~Ille. Drs Tomnelles appreciates the incongruity of the situation. but says: )lothcr, harken to we nod raise no objection to recelvln~ mt' u~ I a1n, for I assurP you tbut If you were once to let we out I ml~ht ncv('r comp linek to offer m~· services. Then the eager postnlant for admission begs that a message Le sent to M. Lenoir, canon of Notre Dame, who knows her and will vouch for her. This is done, and on the prelate's strong recotn- mendat.ion she is admitted to the Hotel Dieu to begin her appren- ticeship as a Fille de Charitc. On the 25th of .Tune, 1707, ~llle . d~·:. Tournelles took the vows. adopting the n1rn1P of Mother of Mercy. II et· relntion"li ip, lo l hc> Marchiorn'SS dl' l\1ontmorl'nc~· and thl' frc>quc>nt yj:;its and tommunjcations recci\'ed Ly her from member:- of thi, :rnd other noble familie!-; nnd her clo-.c alliancc> with Canon Lenoir :,ta ,.c lo ::\in rie Louise a position of considerable import tmt·e in the Hotel Dieu. nnd ns the year~ f!O b~· we find her using her in- creasin~ influc>nce to attempt a chang-e in the n~ry coni;t it ution of t!1e order. _\ ssoeintcd with her in the enterprisr were l\Iothc>r of ~ai11t Gertrude, who had been selected prioress~ though but 1.) out. of ~O ~isl er::; \'Oted for her for that po3ition. and otht'r mt'mbers of tl1e order, her de\C>tt'd friends and aclmirers. Fl'om thi::; re\·olutionary entc>rprise sprang ;1 long i1westigat.ion and n111rh diR<'orcl. Under tlw regime of lh<' Duke of Orleans, acting as regent during thc> minorir.' of Louis XV, n board of inquiry delil>cratecl at the Uf>tt'l Dieu anti called Lefort> il tho prioress, nnd then, after some discussion, tlw :i\fothrr of Mer<'.\ and her followii11.?. C'Ol1Risli11g of S0111(.; rn (lJ' :!fl HISTORICAL. de\ ot<'d nuns. There hatl been much di!<.:Orll bl'tWt•en the priol'l.!s~ :tnd the Ml-re de l:t 1iliH'ricorde, and it is doubtful if the bn•acli wa,.. eHr rrnlly l11.•;tlt•1l. but tlw Kiug:s commisf'ioncr succet~kd in mnkin!! thin:.."' <-mooth 011 t]H• finrf:u•e. and J:111::cni..:m i:1 the prr:;on of Lo11i"t' de:; Tournelks was thoroughly suppressed at the Hotl'l Dicu. Our anthorit~ !-:l1iffs at tlw temerity of )farie Luui ~c in livin~ and .ivili!!' ;1 ,Jamt•ni!"L antl quotr;-; from the horrific,l ncco1111l gi' en by L.;nnon Le Gernlrc, a mock I of orthodoxy. of what thl' rcfor111cr tl'ic<l to do in the U11tl'l Die11. Poor Marie J,ouise>, who had di;-;(.'ardcrl ro• ~c an<l blnck pntchcs antl fine feathers to embrace :t lifo of ~ncri­ ticl' :ind toil, must have hncl some prophetic vision of the organized charities, the hosp it n ls. the settlement work of I o-<lay, for, by the .:on~11tution whic11 she and the Mother of Saint Gcrtr11tle nd\'Ocatctl, " nun;-; would no longer ha.Ye been nuns at all but merely members of :u organization, leading an ordinary life, unfettered by rule.:;, ,. Jur tarily ussocinted together to care for the poor." EDITORIAL. • CABEEB- •'My clear Surgeon General." write.~ many a young me<licnl otlicer, "bile others who nc,·er come to the point of actually putting the words on paper plan night after night to do so as they lie awake in their norel and unaccustomed surroundings $pC'culating nnd wonder- in~, "I feel that I hn' e 11 special gift for s11rgery and desire more opportunity for pedecling myself in this branch than is afford<>cl me on this ship. I would like to be sent to our largest ho5pital nnd n1Jowed to specittlize in :;urgcry, for which I feel myself peculiarly fitted. I lun·e been very successful in surgC'ry prinr to joining the naval scr\'ice nnd fe1tr lhnt my talents would b<> wnstcd on this ship, ns tlwre have been uone but dispensary cases and 111eclicnl rast•s dur- iu~ the month I have been on it.'' Oh the glamour of surgery, the fascination of the title" surgeon:•_ whether narnt militar), or civilian! All that history, fiction, or a fc.n·id imagination has pictured flushes before the mind's eye :uul one is compelled to rrgard tlH':,c young enthusiasts with tender s_ylllpnthy. Who has riot thrilled nt the description of the surgeon working- im- perturbably~ swiftly, skillfully, nmid shot and shell, as Zoln has c.le- scribl'd him, as he is reportrd in the chronicles of the ~npolconic wnrs? We recall the brilliant operators of the French school nnd the marvelous manual dexterity with which they nmputatetl by trnns- fixion, we realize "·hnt our leading operators do to-clay ancl arc not surprised that the definite and conspicuous results of surge1·~· !'.'bould entrance the tyro and that h(} should feel the challenge of a calJing thnt offers dnily chances of brilliant success or dnmni11g failure. E,·en the grotesque figures drawn by Smollct and Mnrrynt do not disillusion or daunt the aspirant for renown who enters the medical service of the Navy. He argues thnt all the portraits wcrP dmwn on the same scale; that admirals, captains, and first lieutenants were portrnyecl in the snmc ludicrous guise as the medical men. nnd if the former "·ere heroes in spite of their foiblrs then the nmazing creatures who sailed with them as surgeons wern probably c.lc,·er handicraftsmen. Kor is it; a misnomer for the naval medical officer to be called a snr~eon. Surgcr.'· is an essential part oI his work. Xo medical officer while nvnilable for general service and on crui~ing hips enn nlljurc surgery ns cnn the medical practitioner ashore, who politrly refers cases to the surgical confrcrc on the next block. However, the young mnn who enters the senice "·ith the iclen thnt lie ·will find there u large fil'ld for 8pecializin,q iu ..,uqrery is lnhoriug 00:1 EDITORIAL. 11ncler a misapprrhr11sion and c1oomN1 to disappointnwnt 11nlr he can find irratification for his ambition along other Hnes. If he holds to his surgery. th<' ·oont'r he lea\'es the "l'ITicr the better it will b for all couc·erned. Tlw 01wrntor who tries to see how many hernia or app<'ntlicrs or p:nll blndcl1•rs he c:tn opemtc on between one c•ruise nnd another is simply depriYing- other men in the hospital with him of an oppo1 tnnity to acqn in• tlrn l reasonahh• 1·ompt•tenc·y whi<'h f1!l oflic ·rs should po:;:;ess in or<l<'r that he may speak of the hnnclrrds oi opern t ions he has done. :;urp:<'l'Y should not be hdd out as nn ind nccm nt lo <·:rnc1i1late; for tlw :\JediC"a] C'Mps, nor ~houlcl imJi,·i1l11al J•ref r. cnc•t•s for spel'ial typ<'-; of work be givt'n nnduc weight in as:-ii1-.'Tling to cl11ty young medir.al oJriet•rs still in a formn.ti\'e :;tagc with icli>as lik<'ly lo unclt•rgo '<'l'im1s moclifiC'ation as they :ulrnncr in k11owledge of men and things. There is no desire to 11rg11e all)'onc out of his ta<:les and prcdil ·c tions. but it is an in<li,,putable fact thnt if a man confines him eli to Slll'!!Pry and will con1lP'<"1·11d to <leploy his energy. talent, ancl inter est in no other lirn• of work, he will in the long nm be of infinitely le.: bC'nefit to thl' penonncl of the 'etTll't' than the good nll-:lronn J medical man, competent nt n pinch to 1lo a little emeqrcncy s11r!!ery. He will remo' e the occasional appemlix, Pnucleate the occasional C\}e. perform the occasional amputation, but the fenr cases. the pn<'U· monias. the contni6011s disease._, the \'cnereal ca-;es. the !wart. nnd kidn<'y cases call for a rnlume of work exceeding the ~urget)' :\ hun- dred to one. and medicine an<l surgery is not all. There is the l'\'er- broaclening field of sanitation, there is the mi litar:v side of Ii fr, tho pedagogic side, tho constnnt call for administrative and construct ho ability. IL is high Lime for the Hll'Vice coneeption of the medical ofiicer and for the popular conception of the Navy doctor to be recu:>t. 'Ve oursel...-es, after n sm·vey of the past and a consideration of tho future. must take account of stock un<l be prepared to adapt our- sehes to altered ct nditiom;, discarding what is worn out, holding fast to that which is p:ooll. In order that the public may under· stand our comprchen~iYe aims and the broad scope of onr work, the :Medical Corps, itself, must have :1 clear under::itanding of il'i opportunities and obligations. There can not be a reasonable degree of contentment among medical oflicers if on the one hand they ure ::-lruggling to" anl ends impossible of uchie' ement, and if, o:i the other hand. as capable nnd umbitiou:-; men, they fail to appreci1to the dh·er:;ifiecl and ample r:rnge open to intelligent effort. Because preconceived not ions of the mt ''al service must be modified or sur- rendered, it must not be assumed that the service is withont incentive to work or rewards for uccou1plishmc>ul. If the attraction of the senice resides in its militnry feature:; alone, then, it should be entered by but one door-the Na val Academy. ,o. 4. lWlTORl.\l.. fiH5 Jn the next plncc 110 111an ;:;lannl<l frrl that liy entering th<' Xn\·y Mctlica I Corps he i, gi \'ing t1 p the pro~pect of :--uccec:.;:fu l nch icve- mcnt nlong 1lefinite :lll<l ::;prcifi1· linr..: to hecome :1 jack-nf-nll-trnd<'s nntl ~oo<l at nonP. This Yil'w i~ c·ntel't:1inrc1 in "Ome quarter:;. It is a. Hr\" unfortunate ,-jpw and is c·aknl:l!l'd to do lu1rm to the S('t·ri1•t• :mil to the indi,·iclnnl. \\'hethcr th<• incliri1l11al i!" a patiP11t or n 1lodot'. The ~enicc will t<'lHl lo l'Xprd lr"s of illl'll ,:o n'gr•nh'cl. to trnc:t tlwm le:--<:, to honor tlw111 le::;-.. Pnd the in1li' itl11a I nH'cli"al oll'1·er who r•on- ,ents to be placed in this cla!>s is unconsciow;ly "'Calin~ hie: own doom by con~mtinp: to mediocrity and inertia. The linr oflicrr ronsiders his life wol'k n hip:hly sprc·ialized pro- fr.,.ion ~incl :ulverli8cs i ! n~ !-inch, and lie is right. He may lir kc.:s \H~ll informe1l about c·xplosi' rs thnn the chemist or rv1•n th1111 the intt>IJjgent fore111an of some lnrgt> powder plnnt. lmt he knowF th<' procticnl applicntion of explosiws for pul'poses of n:t\':ll wnrfnre. Ile 111ay not be as cll'eply YCI'SNl in the s11bjcct of en~inr~ as t lrn mun \\"IHI designs and huilds tlwrn ashm·t•. nnc1 in otlwr department-: of knuwclge he may haw less cxpcrt ability than many ciYilinns, but he will stand high in his profossion if hc succes3ful]y brings to lwar rxperi nee as orp:anizer nnrl disciplinarian with skill as n:l\·igator, 1'ngincer: and artilleryman on the training nnd dewlopment of man- of-\ntr's men ancl tlw upkN'P of battleship, submarine. or clt•"troycr n!..rnim:t the po,..sible tla \' of bottle. The fact that on the em of battle hdp mw he receiYccl from ciYilian chemist. engineer, elrctrical <'X- pert. inYentor. and scientist of eYcry kind does not rcdu<'c the merit or !!!or)· of the oflicer of the line whos(' ;reneral Imm\ h'd; .. 1·mhr:u~1·s the whole field of n:trnl cnllenvor, conpting. harmonizinp:. and hh·n<l. ing its various feature~ into a p:reat offensive and defensive ngcnry. It should he made d ear to t]1p yo1111~ mnn who conteniplatt•:; entc'r- mg the NaYy Meclicnl Corps that he, too. is selecting n <listin<'t arnl pemliar calling and on<> essentially different from that ofthe ciYilinn practitioner or oi any practitioner on shore. a real career cliffl·renl in ib nims and requirements imd essentially different in its r<>wnnls. He must not be allowed to think of himself as renouncing amhit ion, <'ompromising with fort11ne 01· ~:terificin~ hi~h pmvoi-e::, of nobll' en- deaYot· in exchnnge for guaranteed snb~istence :mil frretlom from nnxiety in the years of declining "igor. The physician who dons for life the naYal uniform ( nrnl there is no pos~ibility oi contentment and pence of mind 11nlcc;c: a mnn do<',., take it up as n life work. one to which he is committed for lietter or wor,..e) becomes part of an organization. liYing lar!!Ply.apnrt. pcc11lia1· to itself. little nnder:-;tood, a. highly specialized. diffcrt'11tinte<1 botly of men. Their physicnl s111To11nclings, tlwir phy"'i":d nc•<'d!". ancl the physi<'nl details of 1heil' eYcrycllly life. are romplicntcd and peculiar. Thi~ function of the medical officer is to study the physical conditions 696 EDITORIAI- Vol. xu and requiremenb of naval life, to amcliorn.te them, to mini. ter to thl'm. The variety of the subjects within his scope is only hinted at when we mention the proper illumination of an officer's room. the working ration of nn nviator. the mC'<lieal nspects of deep-sea dh·inrr the handling of an epidemic, emergency surgery, the training ot"'~ ho::ipital corps. the sanitation of a recruit camp. The benu ideal of :i medical officer not only knows well the subjects of medicine rur- gery, therapeutics, chemistry, ophthnhnology, genito-urinary dis- l'ases, dermatology, obstetrics. bacteriology. nncl hygime, but is ~.pe ciull.r good in 011e or more of the.::e brnnehes, and hns tlw power to set forth his 'icws clearly and convincingly uy tongue or pen. He is n man of wide reading and much general information. He has the tact and p1ttience and inlelligenee which ennl1le him h S<' cnre from supe1·iors finornble atlt>ntion fo1· liis 1·pcom111c1iclatfon.· nnd to win the confidence and affection of his j nniors. to commanrl the rPspect of nll in the close juxtaposition and the trying intimnU! relations imposed by the conditions of life nt sea. From the risin" of the snn till the going do'\ln of the same nnd into the silent ni!?ht wntches cYerything that hears on the life of n sniJor has an inte for him and furnishes him with food for thought ancl inYestigation. In a word. the NnYy surgeon is a specialist. nncl he has a ,·cry peculinr sperialt_v. One of its anomalies is the fact that few nppre- cinte the clistinctiYe tC'atures of his c!\lling. To a large number of people ashore a n:wnl surgeon is an agreeable fellow of some edncn- tion. pC'rhaps culture, with n. hearty, jolly manner. nncl plenty of time on his hands. The popular conception of the Nn'y line officer has 1mtil recenlly been eqnnJly inaccurate n ncl nnfnir. 'With 1 htl passing of the wooden ship ltav(' gone forever the dnys or elegant lei. nre. the long stays nt Villl"franche and Yokohama. The wnrship of hi" generntion is n workshop and all hands nre bnsy . • Just ns it would he wrong to compare n line officer with Eclison or )foxim. so it is wrong to meac;ure the nttainments of the KnT) doctor by those of nlC.'n C'tninent in a singlC'. limited fip]c] of profe3- sional work. Dr. Ride's opinion on some obscure disease of the ~kin may be worth $~0, but how many years have pnssC'd since he s<'t n. fracture or nttt>ncled n cat<c of pneumonia? Dr. Cutter's fame ns a sur~n has been !!"really enhanced of late by his wonderful success 1n re· moYing tumors of the brain. He would doubtless turn nsicle from his hobby nn1l rlo a. wry neat appendectomy for you for n mn.ltcr of n thousand clqllar~. ancl if yon talked poor ,,hen t11c• bill tam<> in he might knock off n couple of hundred, but would you trust to his jmlgmcnt in diagnosing some tropical mnlacly or conducting a cnm- pn.ign U/!a inst an cpi<l<'mic on shipuoarcl ~ The great Prof. Iris is known the world over for his cataract operation. but he has not EDITORIAJ .. fi97 uented 11 ra:<e of gonorrhea since he had it him~li ns n me«lical student. Thr.:;e men are inrnluable ashore because there 11re enough of them to i.uppl<.'ment each other and make up for indivi<lual deficiencic .... hut "°ould it not be truly a hardship for officer:-- and men starting on a Jong cr1Ji. .. c· if they were restricted co the profe!'.,ional mini ... tration ... and tender mercies of but a singk• one of this l!.•ame<l :t!->"Cllluln~e ~ The publie, most generously and sympathctirnlly di:,po ... <'«1 j11i-l now undi'r the stim11 l11s of wnr condition'-. probably holds that tlw e1111n- tr\ .. !-> braYC uefcndCl'fl al ::;ea, in Order to be adequately tn•atcd when ... i~k. ::-honld have "ith tht·m as many expert;i a~ tlH'l'; arc :<JWCinlUes in 111r<licin<'. Fortunatdy the Htilor knows that if the sil'k hay \H•re stoekcd with a complt>lC' outfit of tht•st• peopl(• the -.:hip wculd lit• dnn. l,!'l.'ron,f~· clown hy the lwad. I~ is impradical, richculou,- to think of pro1 icling n whole fncnlt~·. What can be fnrnishecl and is furnished i ... tho man of reasonable competence in a preponderanee nf the proL- Jem!'> which may arise. The rnn-al surgeon is not the equal of th£> mo::.t eminent operators ashore, I.mt he is superior to tlwm in medieal knowledge. He is not the equal of the distinguis1wd intcmi:-t a ... J1nr<'. but he i;-; r·apable of doing good emergency surgery, vdwreas hi-: .-.u- (>(lrior in internal medicine would undoubtedly fight shy of a bi:-.- toury. His kno" ledge of the eye, ear. and throat arc limited. but he npprecintes his limitations. It is his ambition and constant aim to l·e as good as he can along as many different lines as possible. This conception of the nantl medical officer may well stinrnlall' the nble:-.t, the best equipp<'d, the most ambitious man. To flw one with n leaning ·for sllJ'gery, a period of tPmpornry in:lcti,·ity alon!r thi<: line will but giYe opportunity for brnshing up on thr r~·(' or i-kin or nenons clisea~es. The man whose passion or clinrsion i::, bacteri- oloir~· ""ill· when sent. to recruiting duty, have n11 opportunity to come in contact again with men :rnd to reinforce his pre,·ious stmlie-, of human nature by fregh observation of its Yagnries. With a clne appreciation of the nature of his cnreer, of it:; oppor- tunitie.c:: antl dn6es clearly fixed in his mjnd. the ml'clicnl offic<.'r will be able constantly to rl'legatc petty wxntions nncl disappointment,; to the subordinate place where they belong. Ile will hnvc no time to brood over wounded sensibilitic>s and worthy moti,·e,; mi<:umlcr:-tmxi Dis..;;afr::faction because n. giYen suggestion wns not acted on will be brushed aside hy tho lively consciousness of the infinite number of 'thinl!" to he learned if n medical officer is to be up to cfote. well informed, ready with sound. expert adYice when it i~ cnllecl foi· ancl urgently needed. FU:SCTIO~AJ, AND OflOANlO LESIONS. A prolific source of mistakes in the ·examination of recruit-;, e~pe­ cinlly when conducted by civilian physicians or by young medical 7600~ -lS-!) 698 EDITORIAL. officers without practical experience of senice conditions, is the fnil. ure to distinguish between the candidate·s expectation of life and legitimate grounds for the expectation that he will be a useful mcm. her of the military body he ~eeks to enter. It is not eaough to be able to say that in all probability a candidate will live for 20 yenrs. The examiner mu:-.t have a reasonable assurance that the candidate will be able to giYo from 8 to 12 years of satisfactory sen-ice in re. turn for the GoYernmenl 's outlay in feeding, clothing. and training him. A candidate for enlistment '~·ill often say with perfect tr11tl1 of some disability \\hi ch the examining surgeon has disco\·erc<l: "It ne\·er bothe>rccl me:' The vital consideration then is, will thi., di . ability bother him under the peculiar conditions which wilt s11rro11nd him in the ~ervice , conditions entirely different from any he h·1 pre- >iou -;ly known. It not infrequently happens that a clisabili•y ar- countecl trifling by a man working in a store or factory assumes con- sideraule real or imagined importance after enlistment. \Yl en nn enlisted man hns to Le curried on the sick list for purpo~es of ob er- >ation, when frequent examinations and consultations nre nece ary in his case, when the defect which "neYer bothered him'' grn<lunlly leads to disinclination to work or di~satisfaction with the cl11ty as. signed him, such a man becomes a poor asset to the sen-ice, nntl, if he loutlly and per:-;istently points to his dt>fect nncl maintain-: thnt it docs bother him now, his ultimate discharge from the service is almost n matter of certainty. The time and energy dcYotecl to train- ing this man has been wasted jusL as truly as if he had been a sutferer from a physical defect which should have caused his i~ejection at the recruiting oflice. The expert civilian physician constantly n.ssures candidates for en- listment and their medical examiners that this or thnt pl1ysical defect is merely functional and so negligible, but medical officers of ex- perience know only too well how often these negligible defects utterly inYalidate a man·s eventual usefulness in the service of his country. En~ry medical officer who has serYed at sen cnn testify to the fre· quenc~' "ith which the medical suncy and discharge of a man lends to re-quest::. for discharge from a large number of other;;; from men who han: Lecome disgruntled or dissatisfied when the glamour of sailorirg has worn off. The effect of a medical survey and dis- charge is peculiarly clemoralizing when it is occasioned by some rle- fcct ''hich was a:-s11med to Le trifling at the time o.f cnli~tment. In the majority of cnses an experience of service conditions hnc: demonstrated that "hilc there is a rnst difference between fnnctionnl lll1U organic lesions (of tho heart for example), SO for as C'Ol1C('l'OS expectation o( life, thC' 1mdesfrability of a candidate for enlistment " EDITORIAL. 699 i:: about the same whether his lesion be organic or functionfll. The :::ubject of n. functional cardiac disorder is not apt to he a cheerful, indefntignble worker, and, whene•er he wishes to aYoid any arduous or di::ngreeable effort, his slight disability provides him with n way of e::cnpe. Such a man creates around himself an ntmo.:;phere of :;,'11lpath_y that will often seriously embarrass the ::::olit:iry medical ,;racer embarked with him, no longer backed up by the testimony of t•niinent specialists and open to criticism on many counts. \\"II l r. 'l"IJI: PSYClll.\TRI RT J/°AH.8. If the remarlrnblo and a:-:tounding ucti,Titics, th<' proj'o11ncl ngitn- tioi going on in mnny branches of business, if tho conntk•ss mter- prises recently undertaken in this country were all in one pince nml could be cxpres!'ed by word of mouth, thPre would be a pnn<l •monium of .::ound us disconc•·rting as the drum fire of the "·ar zone. Hap- pily. a great deal of the disturbance becomes relntiv<'ly harmless by bein!! committed to the written or printed page n.nd soon flows ~ilently to the wnstc-pnper basket. "\Y'ashington is the storm center of this feY<.'r of reform and change. Suggestions. requests, orders, tbrents: ultimatums~ hints. prayers. tears. pelt the GoYernment like hailston<'s. The trifling matter of reforming human nature and stopping il- licit sexual indulgence, the extermination of venereal disrasc, the liquor question, the tuberculosis problem, the matter of tobncco nncl drug addictions are but a few of the questions more or less connected . with medicine foi· which solntions have been found by W<'ll-meaning an<l even well-infornwd persons, willing, without profit or renown, to h •tnenth their idens to the Government. One of the earliest subjects to receiYe attention was the enlistment of the mentally unfit. The Medical Department of the K :n·y has been engaged on this problem for some years, and, e•en bcf ore our active participation in the present war, social and industrial work- ers philanthropists, psychopaths, and those educators particulal'ly concerned with juvenile defectives and delinquents beg-an to call :l.t- tention to the importance of keeping the mental defcctiYc.s out of the ranks of onr fighting forces. Din-steel of form and ceremony the offers of senice said in t'SSence: Girn me the tnsk of keeping out the unfit. I will select. n slntf of sssi::::tants from among those trained by me, conforming to my Yit•w", nn<l personally known to me. I will rid you of these pests with thl· thoron 'hncss of the eoelo-oaeh king who ,,·ill nd t1•ll what hi" rrm- 1·cl,\· i !Jut eornt>-. n boa rd and g:111u·anh•e3 to st a mp 011 t P 11·r~' form of n•noin. 700 EDITORIAL. \'ol. XII It was recognized that thet·e \vus grl•at danger of taking in unu- wnres weaklin~ unable to <'1111111·" th(• as1wl'ities of a rnmpaign aud that the nwnaee of the unfit wa:-. mon• to bl• dreaclecl than PH'r 11n•IPi· the emotional stres~ of wnr tillll'. .\1111 so an effort has- bel.'n made to supply our training camp:-. "ith a sufficient force of psychiatrists to <'Xamine the recrnits witl1 sy:-.ll•t11at i<' <',U'l'. The n•stilts ha Ye bt'l'H Hltisfnctory to the extent tlrnt a larg1• n11111bl'1' of men haYe lwen cli-.- chargl.'d who were prt>snmnbl,r 11ot pos-'t'SSl'd of the stabh• mental bal- am•e necessary ior ·war t•nd111·ancl\ nnd out of till' num1wr 1lisc0\et'l'd by om ;30 odd psychiatrists <loubtless a certain per cent would not ham been discoYered 80 early and therefore been remo,·ed so promptly from the serYice. This is good as far as it goe>!:'. but then' is a problem of wider scope whose solution »oulcl bring large returns to the GoYernment. \Yhethel' the solution has been seriously attempted ic: not known. but 110 answers haw been sent in as yet. :N" ow that the expert exnmincrs refl•ned to lrnn:• had a reasonable opportunity to beconw fnmiliar with the conditions of narnl life. it lllll"t he clear to them that tlwre i,., no permanent demand for any considerable number of ps~·chia­ trists in the ~foclical Department on n peace ·footing. This statement 1s no disparagement to tlwru, for. as n matter of fact. the recruiting- oflice ancl training station examinations for the cletel'tion of mPntal dt>foC'l ives hardly offer H'op1• for a Ii f<> work. \Yhi le tlw yonngcr specialists in this branch might be glad to put in a year or so em- ployed in such routine work. the ambitions and able alienist will in time find this field monotonous and restricted. When the war ends and the country releases these experts from the patriotic duty of sr1·vice with the colors, the :Medical Corps of the Navy should be in a position to continue the active protective efforts now employed. We ask, therefore, of the psychiatrists as.c:ociated with us the elahoration of a brief. comprehensive method of procedure capable of being u~erl h~· en•ry medical offic<.>r for detecting the defectives. That examin:i- tions conducted by the general praC'titio11el'S of the Xavy will be pro- clncti ,.e of resuJts as satisfactory ns those obtained by specialists we do not claim, but, once a proper routine method of testing is ai:rrced npou, our recruiting surgeons can certainly perfect themselYes in its u!"e, and the kno\Yleclge thry acquii·e in this way \\'ill haYe permnnent \·alue for them. If. on the otlwr hand. the psychiatrist should not he able to ;;t>tt le upon a practical method capablr o C snc·c:essfnl cmplo~ ment b~· some> one other than an expert, he fails to meet the clemnncl laid on him. The best things i11 science, in art, in medicine are for the 111any. 1md the practical helper has always saicl, "I will show you how to Clo this," which is considernbly hetler thnn i;ayi11g, a That is my !·wrn'L 1 'llU the only pt>rSOD who ('fill SllCCl'SSfu1Jy Operate the device." f 9. e n d I - llt' Fla. 1.-Dtslocatlon of left aemllunar bone and normal rlaht wrist. 701-1 CLINICAL NOTES. DISLOCATION OF CARPAL SEMILUNAR BONE. By Jt. El. IlOYT, Commander, M. C .• lJnlU>d Stnte~ ~nvy. CaS<'. J. G., private Marine. 58 year!; old, 22 years' senico in Ca v- nlr·y and Marine Corps, and famous for a prolonged alcoholic rec- ord. frll into an excavati<m while on liberty, striking on his face and ont..,tretch('ll left hand. which, according to tlw very hazy recollection of the pnlt'nt, was bent forcibly backward. On admission to the Unit('cl States Na \'ti I llospit al. Pnget Sound, lln• "rist was found considerably "'" ollcn. \'('l'}' tender to the touch, an<l 1•xct•e<1ingly painful on attempt('d motion, which was limited. FJ11oros<·opi<' examination, eonfinl'd ehiefl) to th<.' lower t'lllls of the racliu' and ulna. failed to show any fracture. Two days latc>r X-1':1), plates showing ;rntero-po~t<'rior and foteral 'i1•ws of the wri..,t were taken and from these. <'~P'-'Cially from the la tern I 'iew (fig. 1), the characteristic picture of dislocation of the i;emilunar bone '"as obtained. This cast> emphasizes the importance of \'c1·y cardnl X-ray cxa111i- nntion of nll lesions involving the wrist joint. Disregarding the common Colle's fracture. which, as a rule, is diagno~ed wit bout any special difficulty nncl tho rare condition of dislocation of the wrist as a whole, most of the less definite abnormalities about the wri&t fol- lowing injuries or falls, and having as their signs and i:;ymptoms, pain, swelling, and limitation of motion, are classed under the head of "sprains." The X-ray has been most rnluablt> in the."<' obscure caRes and has enabled us to correct the indefinite blanket diagnosis of "sprain" and to realize the comparnti•e frequency of carpal injuries. The three methods of treating a dislocated scmilunar are: Fir::.t, forcible reduction by manipulation under an nnresthetic; second, re- duction by manipulation through an anterior incision; third, in case these methods are unsuccessful, removal of the bone, through an an- terior incision. Owing to the swelling of surroundh1g tissues ancl en- croachment of the other carpal bones on the space formnlly occ11pi<'d by the semilunar, it becomes an exceedingly difficult matter to re- place the latter bone even after cutting down upon it. In cases of 701 702 McMULLEN-RUPTURE OF POSTERIOR CEREBRAL ARTERY. Vol. Xlt complete dislocation, such as shown in this case, the reposition is practically impossible without extensi>e injury to the wrist, which is not justifiable, considering the fact that a good functional result usually follows the removal of the bone. After unsuccessful attempts at reposition by the first two methods mentioned, the bone was removed through an anterior incision. Re. coYery was uneventful and a good functional 1·esult obtained. ~\ picture was taken several months after the patient had been restored to duty, and figure 2 shows the condition of the wrist at that time. ANEURYSM AND RUPTURE OF THE LEFT POSTERIOR CEREBRAL ARTERY. By J. J. A. Mcl\Iui.1.1:-:, T.l ~ut~nant Commander, lll. C., United States Navy. This case is reported bC'crwse i1 has point::; of medical, snrgical, and medico-legal interest. J. R. 0., a carpenter in the navy yard, CaYite, P. L 5-1 years of age. entered the hospital at 2.30 p. m., May 11, 1918, in a deeply comntose condition. According to the history the patient was much adclicled to natfre gin; had a remarkable tolerance for alcohol; was app:rr- ently neYer much ail'ected by his imbibitions. It was also learned that 12 hours prior to admission he stumbled to the floor while walking about in the dark, and that he strnck his head and imnwdiately be- came uncomicious. Ile wa:-; seen by u physician scn'ral hour.-;; latrr ancl pronounced under the influence of alcohol. P 1Lysico7 c.cam i11atio11. Large, well-<leYelope<l man, presenting marks of external violence about hcnd. The palpebral tissnes of both eyes swollen and ccchymotic; lips cut and swollen ; ecchymm;is, hcma- toma, ancl i:;wPlling in left parietal region. Lungs: Coarse bubbling ~·files throughout both lungs. No clnllrn•ss. Heart sounds : \\Teak; ohscured hy stertorous breathing nnd riilcs. Dloocl pressure: systolic, 125: d instolic, 83. Li,·er: :Xo enlargement Spleen: Palpable. Iloentgenogram of skull·clitl not show fracture. No motor paralysis could be maclc out. Patient moved arms and legs and there was no edclence of fncial paralysis. Pupils regular, equal, contracted. a.nd fixed. Biceps cremasteric and patellar reflexes absent. Babinski well marked on both sides. Lumbar punct nre showed fluid under pressure; 40 mils of homo- geneously bloody fluid were withdra.wn1 after which patient breathed more quietly and less frequently. Specimen of urine obtained by catheterization showed heavy trace of albumin, no casts, and mnny pus cells. Fli. 2.-Left wrist several months after operation. 702-1 • Ruptured left posterior cerebral artery. n~J-- · ff , ... .1 (',.LU,.,..~ />-f c·~~r, u. (i_·.....,_,.f~ 1 tu ,-.,, c ~ c.I. . 702-2 :;o. 4. McMULLEN-RUPTUBE OF POSTElUOR CEREBRAL ARTERY. 703 The question of diagnosis in this case was complicated, as it fre- quently is, by factors which pointed to alcholism, uremia, and intra- ,-r;inial pressure from fracture, rupture of a meningeal vessel, or ,·t"rebral hemorrhage. In this case there was a general suspicion of "foul play," and the marks of external violence about the head seemed to bear out the !>uspicion. Did the patient have a fracture of the skull? Did he h~we meningeal hemorrhage without fracture~ Did he htwe cerebral hrmorrhage 1 Or did he have none of these things and lhe coma result from uremia? The evidence in favor of intra-cranial hemorrhage led us to be- lie,·e that the signs and symptoms were due mainly to that cause. The probability of kidney damage in a gin <lrinkl'r 54 years old seemed great. But the absence of casts in the urine, the low blood pressure, the absence of urinous odor on the patient's breath, and the history of the onset of the attack inclined us to the opinion that the coma was complicated slightly, if at all, by uremia . .Although there were no localizing symptoms, a decompression op- eration seemed indicated, considering the evidence o:f external vio- lence nnd intra-cranial hemorrhage. The decompression ''as done in the left parietal region over the site of injury. No anrcsthetic was necessary. The skull was trephined with Hudson's drill and the opening enlarged with rongeur fore ps. The site of the hem- orrhnge could not be located. A cigarette drain was inserted and the patient returned to bed as rapidly as possible. The pulse gm.du- ally became -weaker nncl more rapid and respiration more shallow, and the patient quietly passed out six hours ln.t('r. Auto7isy finrllngs.-H.eart : No gross lesions. Aortitis, calcareous plaqnes iu fin;t part of nrch of aorta. Lungs: Passive congestion. Li Yer: X o gross lesions. Kidneys: A ppnrently normal. Microscopic section showed cloudy swelling nnd passive congestion. Stomach and intestines: K othing except nclhesions between great omentum rind colon. Appendix showed e,·idenct' of past inflamma- tion with many adhesions. Spleen: Enlarged; e.'i:tended 3 inches below costal border. Bladder: Chronic inflammation. Contained 20 mils purulent urine, also three small calculi. Prostate: Not enlarged. Normal in a ppearancc. Brain: Showed evidence of extensive hemorrhage under arachnoid. Firm clot investing medulla and pons and extending over the surface of the cerebellum. Fluid in ventricles bloody. 704 SMITH--CAVERNOUS RAEMANGIOMA. The il'ft po!-tcrior cerebral artery showed a rupturl•<i ntiliary unt>ury .. 111 and do~ thereto an intact miliary aneurysm. These art !'iurn 11 in the accompanying illustration. Till' l'li111i11ation of uremia and alcoholism wn:- eo1Tt!CL and th clia:rnosis of intra-nanial hemorrhage was correct. Localizing "Ytnp~ tom~ !wing ab .. ent. the locntion of the bleeding Yesscl w:t:-- a matter of :-peculation, hut tlccomprC's"ion was ju~tifinble since we had E'Yidt>nce of lal•:ul injury and intra-cranial hemorrhage. ThC' 1·C'reliro-~pinnl fluid withdrawn bt>forC', but examined after death gan• a l'ompletely positi,·e Xogouchi rC'action. This ('OtuplN~d tlw picture of b.' philitic aorlitis, nrterio-sclerosis, nncl nn<:'urysm anti rnptltr<' of tlw posterior cerebral artery. Tlw injury to th<> head wa incidC'utal an<l prohnhly di<l not cansc the rupture of the artl•ry. hut 1':tU"l'S lending up to Uw head injury raisc><l the bloocl JH'l'S"llrl' 'ilfti- ci<'ntly to n1pturc the damaged wall of the ,·c::;sel. It is not likely that both eyes, upper and lowN' lips, and the ll·ft parietal 1·pgion would he injun.•d by a man stumbling nncl fallin!! to lhe floor. The chance's ar<> that the patient wac; engaged in au ntirny of some sort and that the history given was will:fully mislC'adi• I!· I~ this instunc'<' the nuthorities inclined to this opinion and 1t1Tl'Stccl a man with whom the patient was alleged to have fought. ~11b:-l'<111ent inYl'stigat ion sho\\ eel this ..,nrmise to lie corrl'C't. It is readily cOJH'eirnbll' that a conYiction for 111mdcr or 111:111 slaughter might be made in a. ca:-:e with circ11111stnncl's similar to thi:;. pro\'icled syphilis was not ~ou~ht for, a11d llw anc•m-y::;m n ncl ruptme of t lw artery owrlookl•cl. REPORT OF A CASE OF CAVERNOUS HAEMANGIOMA. II~- C'. W. i'lll ·u. f,l1•utt>11ant Comm:intl.-r, )l. C, l"nllt·d Stntcs .'\nvy. Yirchow ha<.; obsCl'\"C'd bnt onn pure caS(' of l'<l n>rnous hacmnnhriom:i. The foll cl\' i 11g t:asl' of caYcrnous haemangiomu u ( I he :-.u pr:tclu vicnlar region woulcl t hE'n'fol'e beem sufliciently interl'sling and unusual to be ma<le the snbjt'ct 01 a rt>port ancl placed ou record. ,J. R R.. ~C-!3. agl' ~3 years. enlisted in the United States Xa, .. y .May ~4, l!H i, and has licC'n a<lmittell as a m ·nin~ococens carrin ancl with mumps, but there is no record 0£ anyone luwmg obsened a well- markcu tumor m the left supracht ,·icnlar region. This young man fir:;!, en.mo under obsenation when lw appeared before the command- ing officer for discharge from I he :-;enicc1 at which time the com- muncl ing offic01· noticed a swelling in the neck nnd referred him to the medical officer for examination. Except for the ordinary dis- easeb o:f childhood he lias never been ill. Ilis family and pcrsonnl history are negatiYe. He state::; that in 1911 he received a slight in- jury in the region of the tumor and later in the same year was burned ,, c .. ~ ~ .. E 0 .. c .. E " s: "' ~ 0 E .. > .. u ,o. 4. :->M:ITH-CA\"1-:RNOUS IIAEM:ANGIOMA. . 705 in this region h,, the <li ... cJiarp:e of a Roman eandle. At about this time he fir:"t noticed a small, soft i;welling-, which hns intermiltently been t:u·ger alHl smalll-'I' up to tlw pl'escnt time, but he bclicYes that the ~"elling is C"On!<iclerably lal'gPr now than when he> fit·st notic('d it. He st11tcs that the wearing of u collar ea11,..l-'s him discomfort, ancl that wbt>n he rxercist·~ tlw tumor becomes tensr and cause,; him slight dis- <·omfol'l antl pain. :-\incl' lw hns been in thr N:ny hr hns pcl'formecl all thl' clulic>s of his rating- without any discomfort, <'X<"Ppt 11 ''tight" feeling nnd slight pain when reqnirc•d to mnkt' an_\ unusual ph)'sicn.l effort. Ex:uninut ion of the patit•111 re1 t•als a so ft, i rregulnrly '>h:qwd f um or. ll'hich. whl'n <listen<lc>d, t~xtt-ncls from the sl<'rnnl he:tcl of the i:Mrno- mat-itoid mus<"h1 lo n point lJ inehet; from thl' ant(•rior hor<lcr of tlic tl'apeziu~. and I 'I inches alio\'e the cla' icle. Tlw t uni or projl'cts in front of the sternomastoid m11sclc> and abo comes to tlw ;;11dace be- t\\een the claYicnlur and l;t<•mal hends of th.! muscle. (Sec> fig. 1.) \\'hen the pnti<•nt i,.; 1·el11xcd and sitting quietly at re-;t the lumor is har<ll~· Yisibh'. U''<'l' fil!. 2.) On palpation thl'n• art' irregular pro- jl'ctions similar in nat11re to laqrc Yaricot-iitil's, but no p11lsat ions can he sren or felt. 011 1wrc11 -sicm a liar note is elicit<'d. .\ 11sc11ltaLion re- ll'<ils 110 brnit or lm•n(h ~011111bL Th<' oYerlying skin is not discolorl'd and not atlhrn•ut to tliP <ll·<·p ~·1· ti~sll<''· The most slr ikin~ symptom "ns the enormou"' incn·a~e in size procluec1l when the d1cst an<l neck muscles were contl'iwi<'cl and t·xpiratory effort ma<ll' after foll i11-;pil'a- tion with the mouth nn1l no-.c closed. in contrnst with nhnost com- plete clisapp<•n1·a1•e1• of lhl' tunh>r while tlw p;ttient \\':IS sitting qtii<>tly at rest. (See figs. 1 and 2.) Tlw clingnosi., of inl<'l'lllllsc11h1r c.tn•rnous haem11ngioma wa-; con- firmed by Sm·gpon .r. Chalmers DaCostn, rnifc·d ~~tulPs Xn\~ll Hv- sene Force, who mntll' n <:ardnl examination of this CllH'. Ile "t:ltnl that in his opion tlw tumor probably <•xtendt><l ;nto tlw "''IJ)('rior nH•di- astinum and Hs re111oval there.fore wonl<l involn· gn•nt surgical risk. Ile belieYcs thul the only irnlications for opemtiou woul11 be i11m1i- nent rupture ot· se' ero pressure symptoms. Dr. Frnneis T. ~frwart. ,Jefferson l\Iedical Collegl', Philadelphia. agnt'd vrith SnrgP<>n Da- Co,;la as to the cl iagno~is nnd suqpcnl prognosis. Racliogrnpliic examination was made by Pns.-,ctl .\ :-;sistant :)urgeou U. :h-f. ~eubcrger. United ~tate-: Xayal Hr~cn<• Force. Lt•agttP Island Naval Ilospit11l, Philadelphia, ancl his interpl'l•tation of the mdiograph is here quoted: ''Dense shadow in left aprx cXll'ncling down lower border first rib. lI<.>arl unnsually lnl'ge and displnc<.>cl into right chrst." These findings wonld tend to eonfit·n1 the opinion that the growth l'Xlen<ls within the chest cavity. Cavernous hromnngioma is a vascular tumor consbling of lttrgl' intcrromm11nicating blood spaces lined with endothelium. Connect- 706 CO~NOLE-AOUTE BILATERAL DAORYOADENITIS. \"oL XII ing tissue framework rnries in quantity and in this case there seeins to be >ery little. Blood circulates through the tumor and is supplied in most cases by the venous system. The tumor occurs in the skin subcutaneous tissues, intermuscular tissues, bones. and viscera. It i~ most commonly found in the lh·er. The etiology iti obscurl'. :Some authorities claim thut trauma has un importa!1t be:1riug. othe1 thnt the condition is almost ahrnys congenital and that the tumor inav en1argc later in life. Cavernous ha~mnngioma oi tho neck -.houlit b.e distinguished from the following conditions; .\crocclc, hernia or the lung. vascular goiter, fi.broma, lipoma, cold ah~ccss: :mcl an~urysiu. In this case the flat note on percussion. lhe absent(' of breath sounds or bruit, the rapitl distension antl relaxation of the tumor. and the sensation imparted on palpation as of an accumulation of ihtid under slight tension, made the diagno"is clear. Sutter states drnt there arc on record 51 cases of cavernous and telangicctatic angio- muta. and only 11 of these arc of the pure c:wernons type. Their distribution in the body is as :follows: Lower extremity: 19: upper ext remit~·. 1=>: back and neck. 12; :lbdomen. 3: brcnst, 1: head. 1. J. B. Carnett reports two c:tses of cenicnl :;ubcutnneous cavcrnOlL'> hremnngiomn. He states that these tumors wer~ rather c·1c:-ily re- moved after n long dissection with no unusual loss of blood ns they were situated high in the neck nnd surgical approach was compnra- tinly easy. The dial!Jlosis in these cases was confirmed by laboratory examination. m:n:ru:='iCES. (1) Cnrnett, .J. B., 'l'ruusuctlons of the rhllndelphlu Academr Of Sur::ery. 1910 (Yol. XII). (~l KnOcw~ki, W . .\., Chicn~o Clinic, lSOS (Yol. XI). (:I) Reltlener, :\l.. MUnchen, 1010. ( 4) Binni>, .\ .. Kiel 1003. (;l) Suttl!r, hi.. Dcut:;che 7.eltsehrtft fiir Chlrurgie, 1!103. (G) Petit nntl l'a~non, Purls, lOOG. R:EPORT OF A CASE OF ACUTE BILATERAL DACRYOADENITIS. By J \ 0 , l'O::'iSOI c, f,leutcn:int (.J. G.), M. C~ Cnllcd l'lntes :'\n..-y. Dacryoaclcnitis, or juflammation of the lncrim:tl gland. may be acute or chronic: unilateral or bilntcral: suppuruti ve or nonsnppu- rntive. Weeks, in considering all forr •s f'i dacryon<lenitis, :-tates that it occurs once in ten thousand eye cases. Acute bilateral inflamma- tion of the lacrimal gland is very rare and has for its chief symptom the disfigurement of the face, occasioned by the swelling of the lids. Resolution usually occurs after a short mild course and the function of the glands is not altered. Rider, in 18'72, reported a case of acute bilateral inflammation of the lacrimal glands, occurring in epidemic pn,rotithi. in whiC'h mctn:-;- Bilateral dacryoadenitis. 70'/- l ·--------------~- CONNOLE--.A.CU'.IE BILATERAL DACRYOADENITIS. 707 tn:;is to the testicle took place as the parotid swelling disappeared. The swelling of the lacrimal glands was observed as the testicular Sn-elling subsided. A similar case has been obserYecl by V. 5chroeder.2 Gordon Norrie,' iI1 1889, observed in a girl of 11 years a bilateral "°elling of the lacrimal glands which was followed two days later by epidemic parotitis. Sendral • reports a similar case. In 1800, Jlirschberg 5 described two cases of bilateral subacute. nonsuppura- ti'l"e dacryoadenitis, which he called "m'umps of the lacrimal ~lands" on account of its analogy to bilateral parotitis. Giani,6 in 1007, de- ,cribed a case of acute bilateral dacryoadenitis occurring during the rourse of acute urethritis . • T. G. R.. S-2, was admitted to the United States N axal Ilospital, League Isln.nd, Pa., complaining that for the past three days he bad had dull, pounding headache, though not suffering enough to prevent sleep. Anorexin, and pains in limbs and trunk were present . . \bout two days ago, the eyelids began to swell and become red until the appearance was that shown in accompanying illustration. Family 11ncl personal history have no bearing on the case. No history of ex- posure to any acute infection or mumps. Venereal infection denied. Physical examination as follows: Well-nourished white mtlle of 23 years. IIend nnd neck negatiYe except for the condition of eyes. Heart and lungs negative. Ab- clomen presents scar of appendectomy in lower right qna<lrnnt. Upper and lower limbs negative. Genitals negatiYe and present no <Wi<knre of venereal di.sense. Glandular system negrttirn except the bilateral swelling of lacrimrtl glands. Examination of eyes: Vision right eye 18/20; vision left eye lG/20, upper and lower li<ls of each si<ic markedly swo11<'n rtncl slightly reel; mech:rnicrtl pt osis to the extent of covering upper half of each pupil. Palpation of temporal siclc• of each upper lid reYeals enlarged lacrimal glancls. which are not tender. Lacrimal secretion not increased; conjunctin1 of fornices ~light l:r injected; ch<'mosis of temporal quarter of b11llinr conjunc- ti' re of each side. Examination of anterior segments. media. and <-ye g:rouncls of both eyes negati>'e. Temperature on :ulmi.ssion 100.G F .. which g1:aclunlly i-nhsillecl until uormnl was reached in four days. The. swelling of the lids and :rluncls and the redness of lids gradually disappeared in five clnys. F1mction of the glancls is not altered. Blood examination, including Wa"Sermann negati.Yc. Urine examination n<>gntive. Slllears from eyes showed fow Grnm positi,·e cliplococci. Cultures showed scanty growth of pneumococci. The features of interest i.n this case are the unnsnal occurrence of the condition and the question of etiology. In vie'' of the fact that although no history 0£ exposure was ob- tain<><l. cp1<1emic parotit i~ was preYalent in this locality n t the time 708 ADAMS-PARALYSIS O~' MUSCULOSPIRAL NEB.VE. Yo! l\!f and since the literature has sho,vn that acute bilateral infl1u11matio of the lo.crimal glands occurs as the complication of mumps or p~~ ceding the Rwclling of the parotids. there is a. possibility that th caui-ativc agent of tlw latter may be the etiologic factor in thi:-. ra:. On the other hand. the finding of pneumococci presents the l•os sihility of its being the cause. This is given additional '''eig11t b'" the fact Iha I seYernl cases of pnenmococcic conj uncti vi tis we~ treated at about this time at this hospital. Treatment was eliminntiYc.combined with the employment of watlli applications of normal 1:;alt solution. 1. Rider. Two ('l\l<CS of lnflurnmntion or tile l.H('l'flllUl <llnncls in :\l11m1is (Tran~nctions of ::'\C'w York 8tate :IIedir•nl ~o<'lety, 1872.) 2. V. 8chrot><lt•r. Eln li'1dl von Tl;H•ryondenltls a<•uta hC'i Parotitis E'J1l1h•111lc'll (Klin. :Monntsbl. f. Au~<'llhcllk., 1891.) 3. Gonion Nnrri<>. :!\lump~ cle '.rhriiuen-drilseu. (('e11tr11lhlntt filr prnkti~ct1~ Augenheilkunde, 1890.) 4. Sendra I. De::; Oreillons m·ulah <'S. ( HPcueil t.l'Ophtl11du10logle, J!lOl.l :>. Hirio:rhlwr,t?. :'.\lumps llt>r Thriilll'lHlrii~n. (Centrnlhlntt fl11· prnktI.<t hµ Aul!'enhellkunclC'. 1890.) G. (;Jnnl. nilnternl .\ !'UtP Tl:u·ryollllf'nitis Co111J)lil'llfi nl! .\1·ute l'r<'thrlt Q IOnhthalmo-o.;t•ope, April. 1007.) PARALYSIS OF MUSCULOSPIRAL NERVE FROM PRESSURE OF RIFLE STRAP WHILE FIRING. Uy .J. C AoAMF.1, Lieutenant, M. C., United States Navy. '\\nile t.nuunatic paralysis of the nrn!"cnlospirnl ncne is Ii,\ 110 means an nncommon condition, y<'t the following cnse is report Pd because of lh<' nnnsunl ~ay in. which it was caused nnd th<' ea"<' with which a condition of this kiml might occur ngain 111Hlc•r tlw salll<.' circumstances. L-, J. R., private, United States :Marine Corps, age 21, was admitted to the sick list June 5. 1918, compluining of loss of sensa· tion nnd function of the Jcft forearm. ~\.ccorcling to hi:; own state· ment. disability commencecl while firing a. course on the range the previous afternoon nnd eventually .forced him to cease firing. Ex:uni· nation of the arm showed a complete loss of senso.tion over the area supplied by the superficial branch (Radial N.) , while wrist drop. inability to extend the wrist and fairly complete paralysis of the extensors of the hand showed the involvement of the muscular or deep branch (Posterior Interosseous N.). By the use of massage. strychnine and mild counterirritation the patient was returned to duty in four days. Showl ng position of rifle strap on the arm. 708-1 ..-o ... KE}:OAN-OUTANEOUS DIPHTHERIA OF THE FOOT. 709 'fhe picture~ :-.how fair!.'· \\Cll the ritlc strap in the lirina position nd the manner in which till' greater pnrt of the pre.-..surc from the ~tr:lP i~ cxP1ted nYcr th<' 11111sc·ulor!'piral nerve as it c11nc·~ round the hu111er11s. CUTANEOUS DIPHTHERIA OF THE FOOT. By J. J, Kr.i:o.\s, Lkutt>nnnt (J. n.) . :II r.., Cnlted ~tat~ :-.-11,-y • • \n unusual case of cutnncons diphtheria w·t" n'Cl'llt ly ob-.l'ned at ihe Cmtrcl Stales NaYal Ilospilu.1, Chelsen, Mass. The patiPnl wus rcceiH 1 for tren I ment of a gangrenous ulcer. 12 cent imet<'l's long nnd i erntinwtl'l'S wide, oc·enrring onr thC' external mallPolus of till' ri~ht foot. Th .. 11ke>ralNl !'nrfat't' "as CO\ C'red with a §?I H,\ ish-" hilt• 111em- br:1111 :rnd smTotmclc<l by an elen1terl incllll"1t1 ti lionkr. The p1.-tcrior and lateral ~urfacP of lhC' leg. exte>ntli11~ a-; hi!!h a:- the knre. :-ho,Yed rnnrlwcl indurnlion. l'l'<lne::i:-i. and tenderm•-.s. :-:mr:ll'!'> matl<' from tlw t'OY<'ring rnembr:ine or C'Xudate ho\\ C'd pre- d0111innting numbers of !!l':llll po!'iti\'C~ b:i.cilli with typic1tl morplwlo~!Y nud -.taininf! qualities of cliphllwria bacilli with methylene Llue tt1JCI ~eiS,.:;er's stains. ThC'l'l' were also COil!'>iderable number., of nmm po-.itiw coC'ci nnd diplococci. which proYcd on culture to h<' ..;taphylo- rocd nnd "t reptococci. CulturC's on Loeffier's blood serum :?:t \'t' a w1·y positiw ~rowth of diphtheria bacilli of typical morpholog,,· and staining qualities. A slight huskine,.;s of the pn.lienL's voice was noted. although no -.pecial !-on•npsc:: of the throat was complained of. The tonsils and po-.te>rior pharyngeal wa JI \VC're dark reel and rather rough. Thue wa-. uo nembrnne on:•r th<' ton!'ils but n. few areas of l.!l':l,\'i"h-whitc 6Lrinons exudate \\ore noted on the po~terior pharyngl•nl wull. ( ul- turrs :fro111 t h e~e on Loelllcr's blood scrum gaYc a pmv :!l'owt h of diphtheria bacilli. Th<> prcaclmission history of the case record-: a small pres•:urc ~ore from a tight shoe, nbout seven dnys ngo, which spreaJ n~ry rapidly. a-, a lnrge bleb and was op"necl three da.ys before a<lmis .... ion nnd found to contain n largP. nmount of r:ither thick grnyi~h-yellow pu!>. This ''as treated with sterile dressings, but resultC'Cl in a large h1l· perficinl slough. increase in size of the ulcer, and marked inflam- matory ext nsion into the surrounding tissue. The p:1tient t!ave no hb•tory of ~pecial throat, symptoms. The huskiness of the rnic·e hnd been present two clays Lefore admission. The clinical history was negative. The temperature was about 99° and the pulse 80 to 90 for a few clnys. The nlc'r was treated first with a dressing moistened with cliphtherin. antitoxin ancl !l.000 710 LECOXTE--OALCULUS BEMOVED FROM COMMON DUCT. Yo!, XU units of diphtherin antitoxin were injected intramuscularly. Be f scrum dressings were applied daily thereafter. The surroundi: inflammation subsided rapidly and healthy granulation tissue fiUe~ the floor of the ulcer. Twenty-one days after admission the ulce had reduced in size from 12 ems. by 7 ems. to 8 ems. by 5 crU: Throat cultures were positiYe for diphtheria bacilli nine days after admission and ulcer cultures positiYe only two days. The literature records many instances of cutaneous infection with the diphtheria bacillus, which, however, are rure when the ~reat number of cases of diphtheria are considered. These are chiefly cases of extension from the oral mucosa to the face, to the surface of wouncls, or to the female genitals. Authentic cases of cutane u diphthel'ia without evidence of clinical diphtheria are very rnrc. It is ncccs..<;ary to pron~ these cases by guinea-pig inoculation of cul- tnn~s of the organism to tlemonstrnte its Yirulcncc and iclcntitv 11 a trne di pht hcritt bacillus. ' · The present case is int rpreted as a probable prima1·~· pharyngeal infection with the diphtheria bacillus, with mild symptou1s: nnd the tram;mission oi this to the skin abrasion on the foot, resulting fa cxtensiYe alJsce~:; :mu ulcer. There was undoubLelllY a sccondnn streptococcus infection of the ulcerated surface, ca;1sing in large pnrt the '"ide surrounding erysipelatous in!lamrnation. 'l'lH' cl!R"!-1 slmilur 10 the present rei10rted cnst', with abscess, r,nngreuous ul cerntiou, nml ::;m'l'un1Hllug eryslpelatous iuflum11111tlo11, nre not numerou<;. W11- lilllns (.Jour. :\led. Hes., 1002, viii, 83) and Ahcl (Chit. f. Bukt., 18!).t, n~ 45G), Isolated vin1lcnt diphtheria bacilli from n lesion on n finger of a patlei:t wltb clinit'nl clit)lltherta. 'l'otld (The Lancet, London, 1808, l, 458) briefly records the finding of tliphtheria bacilli in two pustulC'S or the foot, compll eating cases of diphtheria. Ueelis (Brit. l\Iecl. Jour., I, 5:30) cllscovm·ccl ,-lru- lenr t1l111llht!ria b.1cllll In two cnscs of ulceration of Ula foot. thought to ~ 1luc to chllblnlns. Ll'llr~· (C\Iell. Snrg. Rep., Boston Cl1~· Hosp., l8DG, 129) found a pure cultun' of Yirulent diphtheria hacllll In nn nbsccRs which de- Y<.>loped about a lmlr follicle two dayi; after nn 1111to11sr on 11 case of dlphtl1crla. The ah:-;n'i<;; rr·mnlnc<l lo<'al. LARGE CALCULUS REMOVED FROM COMMON DUCT. By R. G. Li:Co:o.TE, Lieutenant Commander. ).f. C., 'Cnlh•d Slates l'invy. R. n. L., Filipino. cabin steward, age 2G }'NU'S: ndmitted Murch 20. l!HS, to the medical scnice. When he entered the 110spital. ho <'Omplaine<l of right-sided abdominnl pain which, act'ording to his statement, hncl hC"gun four day" preYiously, or on Mnrch 22. His pain was knifclikC' and, nt times, radiated to back nnd right shoulder nnd his ahclomcn showed the scar of a l'<'Ctns incision bC'ginnin!! in :'\O. 4. LECO~TE-CALCULUS REMOVED FROM COMMON DUCT. 711 the right hypochonclrinm. cholecystostomy hn viug been performed pi-c' iou ~ly. On March 28. fluoroscopic aud skiagraphic exnminntions showccl a •. projection below margin of liYcr at micltllc anterior <'<lgc." On the snme day a gastric analysis showed that there wa..:: n£tcr u .. fn"ting 8tomach, small quantity of subacid content. Xo obstruc- tion. :-;ixty-minnte c1ige~1ing ~tomach, subaci\l cat:1rrhnl ~:-tritis. 1nuc11s greatly increased, but no bleeding.'' l\Iunh 20, patient hacl definite gall-stone colic: juunriicc of sclcrru nnd 10.:3.iO kucocytl' count. l\Iarch :10, h·ucot~1:l' count wn 10,000. On March 31 two trifnceted gall stones were rceonrctl in the f'tool. On ,\pril 2 two more faceted stones wpre SC'Cn in focrR . • \ conferenrr '1ai'\ held and, although surgical interference wa" clecidc<l upon, it wns deemed advisable to wait for quiesc<'nre of ncutc inllammnlory s.' mptoms. Tr:msfrrrccl to surgknl scr' ire. On ~\pril n. at 9.30 a. m. the patient was operated 11pon under chloroiorm-ethcr anrcsthrsin. Incision ju. t to right of metli:m line, ;, inches long, abo\"e umbilicus. ~\J its lower cml incision was pro- longed trunsYer..,ely ncross "·hole body of rcctus. Omcntal adhcs.iuns surrounded gall blri.clcler :Ind lower i-urfacc of liYcr. Omcntnm n.<l- hcl'ent to anterior abdominal wall. These adhesions were broken up ncl the omental hemorrhage controlled I y c:\tgut ligature>=. An- tetior wnll o:f stomach nenr "pylorus also nclherrnt in mas-,. \Vhile ~eparating t hcce adhrsions the gall bladder "as torn from anterior nhd 11in11l wnll. It was large, thick-walled, nncl fillecl wit11 currant- jell~ clot without visible bile. The head of the p:mcrcns wa:::. har<l und common cluct greatly dilated; on opening the httkr it wu-; found filled with currant jelly clot. ~\ large faceted fitonC', iwrha1Js 11 incite:-, in its diameter. was remo>ed from the common duct. together "it h sc\"eral smaller stones. The am pull:~ of Yater wa:::. fr('e from stones. The hepatic duct. although greatly dilatl'd, .cC'mctl cmilty. After emptying the gall bladder and common duct of "lob. a thick. altere<l bile with sandy flakes appeared. _\ large drainage tube wns fnstrne<l in rnmmon clnct with a <'atgnt !'llture anti gall blnclder dminecl in n sirnilnr way. Peritoneal ca' i ty <lrnined witlt cfrrar<'tte Jrnin :mrl n. split rubber tube. Heturnr.d from operation at 10.45 n. m. in good condition. Pa- tient 1·erlrcssc(l at -! p. m. "·hen gull blaclclcr nnd common duct w~rc conncc!rcl "·ith two bottles by means of rubhC'r tube.... Patient drnined 120 c. c. of bile during first 1~ homs nnd thereufter quite freely. On _\ pril 11 , rubber tube rcmo-recl from p ritoncn I c!lvit~-. ·.April 1~, cigarette drain removed. Rubber tubes, <lrninin!! g-nll hlnclller and common duct, removed April 1-!. 712 \"AX WIXKU:-CIRCUMCI::ilOX IX PRESEXCE OF CllAXCROlDS. Vol. XII CIRCUllCISION IN THE PRESENCE OF CHANCB.OIDS, ~urgicnl opemtion 011 the pe.11i, in the prt.'"''lll'l' of ch:mcroi<lul ul- ct•:-:ttiou i-. gPlll't':tll~· conc·l•ded to be in1Hh·i-,able. Opcrati,·e trent- nwnt in the--c ~l'l'' hn:-. ueen limited t•ither to ._jmph• ca.utc·riz:it;c.11. to the inci:-iounl t't'licf of u c·omplicatll1g p:traphimosi-:. or to <lor:.al !-plittin~ ctf the prcpm•e i11 cnc:e-: of phimo~is for the purpose of ex- posin~ and treating conceule<l lc!'ion-:. C'ircmncisicm. as a primnt·y operalin~ proc<>d11re in chancroidal case,,;. ha:-: usutllly r<>s11Hed i11 g1•11• ernlizecl infection of the line of incision with sp reatlh1~ ulet'rntion and prolonged ronvalc•st•c1ice, and oftrn with urnrk<>d Hltimatt' de- formity of the> penis. In llw less Yirulent cases of penik ch:rncroirl,.. wit ht ut l'Olllpl ica t ions, local treatmE>nt Hhoulcl be• adhered to since in tlw ... c mild t'n•c-: th<' op<'mtion of <'ircnmC'ision n ·i!lwr ha:-; •11...: tl1e •'tll'c nor contribute!; to the patieuf~ ~afpty or l'Olllf'nrt. Jn the\ int- lent etbC::l with serpip;eno11:-; fornh of 11lcPmtion. t•ftt•n c·ornpl:c·de,t .,,. mm·kl'll etlcma of the prepncc and phimoc;i~ •. "t• han• lately -ubstf tnted rrimnry eircnm<+.,ion fo!' thE' u:-;11nJ pr< Ct"l1tn• of clor ·1} or lateral :-plits. 'Ve ban: fo1mcl that prinmry l'irtunwi:--inn 1·a11 ~ performP<l \\ith i:afcty in the.._,. c:tH'"' and "ith thl' fnll.t>X()('C'lntion of primary union of tlw wound in prac·tically all in..;tant·<':-- l•XC<'pt wlwre the line of i1wisioa nctu:dly tr:t\l':·:-:1•:- thl• 1d1"!':tk1l arpn,,_ E\l•n in this latter group there is ·1 11rnrk"cl 1·pd11dion in the c·o11- Yah••cenr<' time over the old metl1ods of trentment if the tl'rhnique clei:criu<'<l bl'low is rigidly followed. T1ch11i111<'.-Cond11ction :mestlll'sia is protluct•d in f ht• clors.11 H<'l'Yc>s of tlu• penis by injections of rorni1w solution C: pt>r ernt) .. \ 1·irc11ln1· <kin incision is thrn made just haC'k of the coronal linr. a11r! the pn'putil\l skin flap tlrns outlined is diH~<'ded forward until the rrflected mucosa] layer covrring the gl:m~ of tlw prnis i:-- '':l•ll .. x. po~ed. Thus far the dissection ha~ been made throu~h healthy t.!-::-;11c. hut in order to pr<> vent :futur<> conb mi nn ti on the denuded :n·Pa i ... !<fll'll,Yctl with (lichlornmin-T ~o1ntion (7 per cent). A smnll Y1~rtiral .::lit is now made in the reflected hwr of the p,repuce nenr th•• corona! ni:n·gin. nnd throutrh this opening the prepntial sa.:! is thoroughly ir- ri::r:1tecl with lhe dichlornmin solution. With n pair of cur,·•·11 sd<=- ""rs intr0tluced through the smnll slit in the mucosa, the latter 1:; e~­ ci!'e<l in the usual manner, thus permitting the remornl en bloc 0f the prepuce from behind forward. This dissection is made entirely ->nt- siclc of the ulcerated area except in caBCs where the coronal sulcus i;; inrnh·ed in the destrnctiYc process. The same technique is followed in tho latter gr011p 0£ cas<>s with the addition 0£ thorough cnutcriza- tin1 of thE' remaining areas 0£ ulceration. r Persistence of the thyroglossal duct. 7l:l-1 J>o.4. PARISH-PERSISTENCE OF THE THYROOLOSSAL DUCT. 713 Besults.-We hnve followed this technique since January 1, 1918, in 28 cases. O.f these, 24 (86 per cent) healed primarily; delayed primary healing occu1Ted in 3 cases (10 per cent), while complete !•reaking down of the wound occurred in only 1 case (less than 4 per cent). PERSISTENCE OP THE THYROGLOSSAL DUCT. By B. D. PAit!SII, Lieutenant, 1>1. C., United Stutes Nnvy. Congenital cervical fistulre require radical treatment when they !!ive rise to much inflammation or to cystic tumors or for cosmetic ;,ffect. Cervical fistulre may be lateral or median; when lateral they qre known us branchial fistulro due to failure of closure of one of the branchial clefts; when median the fistula is the result of the non- ' obliteration of the thyroglossal duct. Congenital fistulre do not always cause symptoms ancl may not lie discovered until adult life or until some distention and irritation bv mucuous-hyaline or muco-purulent discharge has called attention t~ them. The term "duct" is rather misleading as the thyroglossal dnct has no such function, being merely the unobliterntecl canal · lined with npithelium through which the thyroid sinks from ihe base of the tongue to its final resting place in embryo. From the dissections of Moragni, and later Minot, it appears that the thyroid sinks from its original position on the dor::;um of the tongue, normally obliterating its tract. In some mammals, "\Voelfler, .Memon and Van Demmclen found that the thyroid sometimes snnk nc: low as the arch of the aorta, but never below the top of the sternum. Unoblilcmted portions of the descending canal with tt lining of epithelium form congenital thyroglossal tract~. This congenital malformation is better upprccintccl if the manner of <len~lopment of the tll}'roid gland is clearly understood. In t>arly <'mbryonic lifo: the gland consists of three parts, two of which arc ~it­ uatt'd }att>ralJy and deriYCcl from endodermic linings ( f the fourth 'isccral furrows on <'ach side, while the third one, which forms the central portion of the gland1 is an outgrowth from lhe ycntral wall of the phnrynx, about the position of the second visceral arch. which out- growth. known as the thyroglossal duct, or canal of His. grows down- ward through the hyoid bone and joins the Intern! portions. Xor- mnlly this outgrowth of glandular tissue should lose its connection with the pharynx, and the connecting band become obliterated by the eighth week of fetal life, its origin being representecl in the normal individual by the fornmen caecum at the lmsr of the tonguP. 70008- 18- 10 714 PARISII-PERRJSTENCE OP THF. TlIYROOLOSSAL DUCT. Yol. :\II If glandular ti!isne persi~s.in tl~e whole or any portion of the U1tct course: we ha>e in the rcmammg tissue a nucleus for the development of a pathological condition which may assume one of scvernl fornb Thc.c;e forms are solid tumors of thyroid tissue at the base of th; tongue (1), cysts or solid tumors of thyroid tissue in tlw hyoi1l bonl'. or betWC'C'n it and the tongue (2), or below the. hyoitl bone, between it nncl the tb~Toicl gland. ~ometinws the whole duct persif-t..; as n canal lined with <:'pithelinm, although it is said usna ll ~, to b\• inter. rnpted at the th yro-hyoi<l ligament (3). . The following case is interesting b<:'cause of lhe misleading history of the p resence of a foreign body and the rnth er rare condition of ~l p<:'rsistent thyroglos::;al duct. . . W . C. ,J., seaman , second class, age 18 years, was n.dm1Uecl to thP ;\aval Hospital. Lt•ag1w Island, Pu., NoYrmber 28. 1H17, with thl' following history : For about one year he had pain and n. discharging '<inus just above the snprasternal notch in the midline of tlw Mck. II<:' was of the opinion that there mu-;t still be a foreign body :-ome- whcrc in his ne<'k. a" about three year::; ago a piece of metal about the size of u p in was P'\pres::;ed from the neck at the opening of the sinu". " •ith this history it was thought be;;t to study the c~lse first bv mean, of thl' X-ray. 'fh~1->e plates were taken by P·assecl Assistant Sm~e<m X\•Uhcr:rer. united ~tatc,., X:t\al Reserve FOi'('(', 01\(• to d<:'tern1im the pn•:-elll'c of a fon•ii,,'11 h>dy. one with a st-gmentetl opnqur pl'Obe in- set·ll•tl. and one after injection with Li:-muth pa'<te. Xo Ion•ign boch being found. the duct was then dis::,<'Ctecl out nnd<:'r ether ana~sthesi~. It exten<led from jnst about the suprnslernnl notch to the hyoid hone. al ong the anterior surface of the trachea, where it eudecl in a hroacl fan-like aponeurosi~. X o extension abo\·p the hyoid cottltl be ionn<l or outlet at the base oi the tongue. The 1\ouml was closed by metal clamps, and heuletl by first intention. No recurrence of the condition has been reported up to the present time. It would appear that the hi~tory of a pin being extracted was true. the probability being that it was placed in the duct during childhood and forgotten till it expelled itself. A.ny swelling or sinus of more than transient duration situated in the median line of the neck, or in the floor of the mouth or at. the ba!"e of the tongue should be carefully examined to exclude the presence of a thyroglo::;sal duct. l. 11. L. \\"illi11u1". l 1 11tholo~it-al ~ot-. l'hll11. T runsuctlons. \·01. II, 189. :!. .T. TI. C .. JOp!iOll, Annnls of Ciynecolo~y Hild l'edlalry. \'ol. JO,. :l. nr. H1e>111rn11, A nwrl1•11n ~1edi c ine, June, 190 1. Persistence of the thyroglossal duct. 714.-1 DEVER-RUPruRE OF POPL.ITEAL ANEURYSM. 715 J1JPTURE OF :POPLI1'EAL ANEUllYSH FOLLOWING TRE ADKINISTRATIOl'l OF SALVARSAN. 81 F. J . Osna, Lieutenant, M. C., and ~· S. Bou:s, Lieutenant, :\f. C., C:nlted .'tate..i ~ary. The following case is reportell in order to illnstrntc the harmful n':-nlt that may follow the administration of the arsphenamins in ... rphili:- of the cnrdio-vasculur system. · H. JI. A .. firl'mnn second class. 47 years old, wns utlmitled to the rnill•d States ~aval Hospital, League Island, Pit .. Non~mher ~o. Ifll'i. Ile complainl'd of n small mass of four \\CCk!S' duration in till' ri!!ht popliteal space, causing li.l tle discomfort aside from oc- t•:i•iorml aching following unusual exertion. From the time it was first noticed it. did not increase in size to any appreciable. extent. The patient believed the mass resulted from riding a sli('e uar. He has be<·n a fireman for four months, prior to which time lw was a. bookkeeper. While a fireman he almost constantly rode the !Slice b:ir. The patient states he had a chancre 2:5 years ago. Ile wns nntll'l· 1re:itment for same for two and a half years, receiving mercury an1l iCldi<les. Secondary symptoms were ncYer observed. Fnmily history was negatiYe. Ile is unmnrriecl and hns ne\'er inclnl~Nl <'Xcessin~ly in n1eobol or tobacco. 011 admission physical examination reYealed normal station and !!11il. t·xcept for slight limping of right leg. Pu pi ls "ere cqnnl and n•!!nlnr and ren('ted lo light and accommodal ion. Xo thyroid t•n- lnr!!t•111t•nt. P11ls1• of in('rca::;etl tension; rhythm rPgnhu·; normal mil>. YPssl'ls hnrtlenecl. The area of cnr<linc dnllnl'ss was Hormal. Tlwr,. was slight ncct>ntuation of the aortic scconcl :-ound and no uudil It> nH1rm11r:;. Lungs were negatin>. Liver an<l sp1e •n were not 1 ulargcd. Knet• jerks normal. Xo :1hn0t'maliti<'s detet·lc<l in upper <'Xlrcniit it1s. Th»n• wns a tender, pulsating, expansik• nrn"s nhont tlw sizl• of :1 hC'n'-; egg in the right pop1iienl space n.ncl OYcr this ma's could he hen rd :t distinct hrnit. A pulse of eqnn 1 vol um<' wa" felt 0\ e1· either do1·:-:di1; pedis. There wns an appreciable cliffercnl'e in tlw .size of the 1 ·· o legs. tlw right calf measuring 1 inch lnr~"f'r than the left. The right £oot was slightly swollen. Tho circumference of the left knee> was 14.l inches nnd of the right lmee 15i inche,,. There wa~ no difference in the surface temperature of the two legs. Blood examination reYcnled -t:+ 1'Tnsscrmann and normal coagula- tion tirnt>. Systolic blood pressure was 140 mm., and diastolic ;} mm. Urine was negative. The patient wns confined to bed. 'fen grains of potnssium iodide were administered t. i. d. and mercnrial treatment by inunction was ~·h-en in the usual manner C'ontinnom; digital prec;sure was ex- 716 DEVER~RUPTUBE OF POPLITEAL ANEURYSM. erted over the right femoral nrtery for 48 hours, at the encl of which time the pulsation over the aneurysm was distinctly less Yiolent, al. though the size remained unchanged. Ten days after ndmission o.4 gm. salvarsan in 100 cc. solution was given intravenously. The drug was properly dissolved and neutralized and the solution was free from sediment. Following the injection the systolic blood pres. sure was 5 mm. higher and the diastolic blood pressure 5 mm. lower than immediately before. There was no constitutional reaction fol. lowing the administration of the drug. Within 48 hours after the injection, the patient co mph' necl of seYcre pain over the aneurysm which became so intense at the C'lld of !)6 hours that morphine was required. The mass was observed to be distinctly larger, pntcl icnlly filling the popliteal space. Dnrin" the next 10 days the mas!': became progressively larger and 111or~ painful and extended about 4 inches down the calf of tho le:?". The eJge was not clearly defined. The circumference of the right knee at this time "as 17t inches and the left knee Ht inches. Becau.;e of the rapid extension of the mass and the great increase of pain with total disability, the leg was amputated at the junction of the upper and middle thirds of the thigh. This was followed by an un<'wntfnl con>alescence. Dissection of the leg following amputation revealed a rupturl'cl saccular aneurysm of the poplileal artery occupying the entire pop- liteal space. The skin over the aneurysm showed conaidernble JH ·. sure atrophy and discoloration. The wall of the aneurysm "·as YC'r~ thin, softened and inflamed and had ruptured lhrongh its lo" er aspect. As a result, the onUine of the aneurysm merged incl<.'finitely with an extravasntion of blood into the subcutaneous tissue cxtentlin!! about 4 inches clown the 1cg. The aneurysm itself contn ined a "Oft 1oose clot. In our opinion. the rupture of the aneury!'m may be nttrilmted di- rectly to the action of the sah·arsan on the wall of the sac:. Sub · qnent to the injection of snlrnrsan in a case of tertiary s~·philis pre- senting large, inclol('nt incrustecl ulcers, there resulted act in~ jn. flammation and softening of the ulcers. Their edges bel'ame markedly swollen ancl they were surrounded with a distinct nn•a of redness. It is very probable that the same sequence of eYents took place in the affected tissue of the aneurysmal sac, sufficient softenin~ occurring to cause the rupture. It was most unlikely that the rnp· turo was due to the flnicl injected, as the solution was injected slowly a.ncl caused a rise of bnt 5 mm. in blood pressure. Furthermore, the rupture did not occur until at least 48 hours after the injection. In view of tho results obtufoed in this case, it is important to t'm· phasize the danger of the administration of lhe arsphcnnmins in syphilis of the cardio-vnscular system. Mm. ~ co ~ I I I Hg. ~ co ~ ~ 130 I I I - ..... ..... 120 110 100 - / .,,,,, -. 90 ,.....,.. " 80 70 60 50 BLOOD PRE55URE CHART fig. c ~ ~ ~ ~ ~ ~ dJ - I I I I I I I 0 ~ I"') co I') LI) -D co I I I I I I I ..... - C\l .... ~ ~ ~ "" -~ I \ / "v \ !'\.. - / r----./" 'w""' ~ c:o cO ~ - - I I I I g - N C1) I I I I ~ ~ '<t' ~ - - / v - - / "' "'--·· - Upper ILne represenb lhe systolic, lower one the diasloli.c pressure. 717-1 PEBRE~PERICABDJAL EFFUSION. 717 PERICARDIAL EFFUSION.' By J. :u. PEBllET, I.leul<'Dant (J. G.), ll. C., L"nlted Stntes !\"avy. Pericardinl effusion is n. comparatively rare disen~e; thus in the nnnual report of the Surgeon General, United States X:n·y, for the ,·rur 191G, in which are tabulated 39,0!>4: cases of diseases, there was ~nl~· one case of pericnrditis. In the same report we find 4,0!)2 CllSCS of acute follicufor tonsillitis. 81 of chronic tonsillitis, :HV of b,rpertrophiecl tonsils, 212 of ucnll' rheumatism, and I~ of subncnte rhcunrntic fever. 0:-let fonnd U p~r cent of his cases of acute rheu- matic fornr to he rcmplicnted with pericarditis. The rarity of pericarclit is in the X a ,.y is striking, when we con- ~idcr the large nnmhcr of cnscs of tonsillitis and rhcumati m. "·c do not yet fully realize the rnlne of the :X-rnys in helpin!! ll" IO follow the progress of diseased conditions. "\Ve are too prone to b~ content with a single rndiogrnphic examination. A s •rie~ of X·r:ty pictures would often giye us \cry Yaluable information. ""hat would we think of the clinician who would lay nside his stetho~cope after his fast examination of n henrt or lung c:1se? Let us use the .X. .rays more often to stud~· the pro~·c-.s of our ctl:-;t•s . ..... G. ,\., age 31, was admitted to the hospital on January 1, ~ · : '-. complaining oi painful joint!'. Past history is irrelevant ex- cept that in February nnd August, 1917, he had Yery miltl atlacks of tonsillitis, without any complications. Pre-.ent illness (.latcs back to six <lay:; previous to admission. The oru::ct was gradual, with pain aml swelling of both ankl '!". Se,·erul dnys later the left knee became invohed. He had slight feyer. Physica.l examination ·was negath·e except thnt both ankles and left knee joint were painful, red: hot. and swollen. The hip jointct were also painful. Temperature 100 F. Laboratory findings: White count, 18,000; Neutrophils, S5 per cmt: pro-.tatic smen. ll,!-'~ativc; urine. negative. The fever was moclernte and ranged between !lV0 and 100 F .. until .January I. when it took n sudden j imp to 104 F. This marked the on-.et of :1 pn£>11111ococcic lobnr pr ·umonia, which affected the left lower loLe and terminated by cri~is on the seHuth day. Durin!! the pneumonia the jointc; were normal. A week after recowring from hhi puht?onary complication the patient began to complnin of a feelini;r of fullness under the upper part of his sternum. A pl •uro- pericnrclinl rnurmnr was then beard m left mammary space, just nt. the edge of the heart. Ten clays later the tempcratme ro"e to 100 F. 'Cnsc report frnrn tbe tinlted Stn1cs Naval IJospitnl, cn~aroln. Fin. 718 PERRE~PERICABDJAL EFFUSION. Physical examination now revealed a bulging of prectirdium. '!'ht" apex beat could neither be seen nor felt. There was dullness 011 both sides of the sternum in first and second intercostal spares, nii increase of C'~lrcliac dullness to the left. and a well-marked ohtu~ cardio-hepatic angle>. (Rotch's sign.) The heart sounds coul<l not be heard at the mitrnl nnd tricuspicl areas and were 'er~ faint nt the base. The breathing was labored. The pulse was ,·cry weak. 130, irregular. The diagnosis of pericardia] eff nsion was ohvion-. Skiagraph made on 1-28-18 showed the extent of the etfu:-;ion. The blood-pressure chart, figure 2, shows that clm'ing the 1wriod of greatest cffuc;ion lhere was hardly any pulse pressure. Treatment wns simple. The fluids were restricted and the bowels kept open with salines. ~\.n ice cap was kept over prccnrdimn. Sodiuru sa.licylatr and sodium bicarbonate Wl're given. Sti.mula11Lq in the shape of tr. of <ligitalis :rnd strychnine sulphn.te were aclmin istcrecl by hypodermic. .\t the suggestion of :\Iedica I Dirrctor Smith a fly blister was applied to precardium. Present condition of patient: It is now nine weeks since signs of pericardiol effusion were dtt.ected. Symptomatically pntient is well The pulse is just a trifle fast, but is regular and of good rnlume and does not get abnormally fast after exertion. The apex beat i<> still invisibfo and can not hr felt. The cardiac dullness is approi1chi11!! normal. The patient was surYcyed out of the service because it was not deemed likely that his heart could stand th:i arduous work of a ~en· faring life. If he can secure employment in civil life which will not demand too much muscular exertion, his prospects of gcU in;.: along seem fairly good. It is well lo recall the old paradox: "Prr sons rarely die of the disease with which they suffer." Table of heart measurements from skiagraphs showing transverse diameters of heflrl. !jig. 8 First intercostal space ....................................... . Second inlercostal space .......................... . .......... . Third intercostal space ........................ . .......... . . . Fourth rib .............. .. . ..................... . . .. ....... . Fi£th intercostal space ...................................... . I Ja: 28, ':Feb. IR, I "pr.6, 1918. 191fi. 1·•1'. - ---- cm. 10.6 15 18 18.7 17.6 cm. 8.7 11.8 16.2 16.8 15 cm. 7.6 10.6 15 15 15 Symmetrical enlargement of salivary glands. 718-1 Symmetrical enlargement of salivary glands. 718- 2 ~o. 4. BOLES-ENLARGEMENT OF SALIVARY GLANDS. 719 J:&PO:R.T OF A CASE OF SYMMETRICAL ENLARGEMENT OF THE SALI- VARY GLANDS. Hy H. :::. llm.i;s, Lli·ull•nant, .\I. C., Lnltecl St11t1'< :\11vy. ~y111mctrical enlargement of the saliYary and lacrimal glands ''as !ir,,L clcscribc>d by Yon l\likulicz in 1888.1 Since that time the l'ondi- uon has been lmown as .Mikulicz's cliseaRe. .\.ccorcling to H.il'-.111an.~ it is n ''chronic inflammation affecting tlw lacrimnl and saliqH·y !!lands, but there• are casl'S, eYidcntly of thl' same nn.turc. in which the ~.diu1ry glands alone n.re affected.'' Some authoritit>s lwfa•n' the cnlnrgcment of the salirnry glands is due chiefly to a diffuse lym- phoid hyperplasia and not to the hypertrophy of the parcnchyma proper. The etiology of the disea~e is unkno'\\ n. Hiesman l'iassifics the cases into two main groups, namely, tho:-(' with and those without blood changes. Among those without blood changl'"· there is a group prescn tin~ symmetrical cnla1·gement of the :-,a]irnry !!lands alone. Filipino, age 27 years. wardroom :itcward, admit led to the United States Xa ml Hospital: League Island, Pu .. with chief com- plaint !hat for thn•e and a half years he had been troublell with a swelling below i\nd in front of either ear. Ifo states that the s"·ell- ings fir:=:.t nppcarccl in ~oYember. 19H. without any apparent cause. They quickly became the size of a lemon and ha Ye so n•mn inNl. They occa;.ioned no pain or discomfort. The~· appea1·erl i-imnlt.111rously aml enlarged symmetrically and synchronously. His general health hns been unimpaired. Ile believes that he hnd mumps n1 7 years of age, but no swelling was ever observed after this. Ile has ncYcr !:>Ufferetl from any distnrbnnee of the saliYiu·y en· lucrinml secretions. The family history is negatiYe a!> regn.rch; tu- L<'rculosis nnd syphilis and no other member of tlw family has e'er bren known to suffer from a condition similar to Ins. The patient has been in the Navy three years and eleven months and taught ~chool in the Philippine Islands prior to this. He doc::> not recollect ernr having had any parasitic infection or tropical disease nnd is not nddicted to alcohol or tobacco. The physical examination is as follows: The patient apparently enjoys good health. His station and gait are normal. The pupils rPact to ljght and accommodation. There is no enlargement of the Iacrimal glands. The salivary and lacrimal secretions are normal. The pulse is regular and of normal tension. The epitrochlear and nxillary glands are normal. The teeth are in good condition. The tonsils arc not diseased. Both parotid glands arc soft. of the same consistency and swollen symmetrically to the size of a lemon. They lll'Cl not '-ender, not adherent to the skin and nonfluctuating. They do not interfere with the movements of the jaw. The lnngs arc nor- mal on physical examination and this is confirmed 1.:,y :X-rny exami- 720 ROS&-DENTRITIO CALCULI IN THE DODY. Vol Xll. nation. Cardiac examination reveals a faint systolic murmur at the apex, following exercise. The lmee jerks are 11. trifle exaggerated. The liver and spleen ure not enlarged. The systolic blood pressure is 144mm. and diastolic 72 mm. The urine is negative. \Vasscrma 1,11 tl'st negative. Hookworm ova were discoYered in feces. W.th appropriate treatment subsequent examinations were negative. The blood count was as follows : Hemo;:rlohln ----- ---------------------------Per cent {Suh II)__ l)Q Heel l.Jloo<I cell!!- --- -- --- --- G, 300, 000 'Vh!te blood CCII!'! ---------------------------------------------- G, 000 Differential count: Pob·111oq1ho1111clt'!lr leukocytes___________________ per cent__ 51 Large 1~· u1phocytcs __ . ------· -------------------· _ .clo __ 1:? Small lymphoc~tei:L ---------------------------------clo --- 23 Emd11011hiles _ --------------------------- ·--------· __ clo____ 13 The etiology of the case is obscure. S~'philis can be eliminated as a result of the \Vassermann te~t and the history elicited. Aside from the eosinophilin which can be attributed to the pre . .;en<'e of the hook- worm, there i!; no eYidence of leukemia, pseu<lolcukl'mia, or other blood disease. The case is therefore not one of n leukemic or pseudo- leukemic origin. The case is absolutely noninflammatory, is of too long duration, and is not associated with a te . .;ticular clistlll'bance. which eliminates the question of mumps. As X-ray examinalion and physical examination of the lungs is negatiYe and there is no evidence of tuberculosis elsewhere, it is fair to deduce that this is not an etio- logical factor. The chronicity of the swellings a.nd their symmetrical distribution eliminales both benign and malignant tumors in the clifi'crent,ial diag- nosis. The disease per sc is not fatal. Treatment, except possibly by the X-rny, is unavnilin~. REFERENCES. 1. l\Iiinchen Mell. '\'och. lSSS, p. 750. Heit. z. lfe,;;tschrift f. Blllroth. Stutt- gart. lS!l:.!, p. GlO. 2. :\Iocl. :\!NlkhH', Osler & :U<·Crne, Yo!. nr, pp. 73 ll!l(] 7.J. DENDRirIC CALCULI IN THE KIDNEY. n.r Cl. G. 1:1 ss. Ueutcnnnt, M. C., l;nltcd Stntcs Navy. F. F. McG., fireman second cla!'s, age ~.>, aclmittccl February 10. HHS, from U. S. S. ill onar;lwn. Upon cxamina.tion, he complainecl of pain in npper right abdomen and right loin ancl of what he termed "stomach trouble." Ile had never been sick in bed in his life, but for the preceding five or six years had experienced at intervals a Dendrltic calculi of rl11ht kidney. 720-1 Early picture of foreign body In bronchus. 720-2 GOULD--FOREION BODY IN BRONCHUS • 721 • ('li.sation of fullness and heaviness in the epigastric region. There ~:is tlistinct tenderness in the right bypochond1·ium, not only over nnll blatl<lcr but extending outward to anterior axillary line. After ~rt:rnl carefully studied gastric analyses had been made and treat- 111, nt instituted, the patient's gastro-intestinal symptoms persisted. !!: X-rtty examination February 28 re\ealed denclrilic calculi in ri. 1t kidney. Cy:.toscopic examination on February 28 showed nor- u;l function of both kidneys although four out of fhe urinalyses, iutmetli<ltl'ly preceding this cystoscopic examination, sho,Yetl bloocl . ..\ l'Ulturc of the catheterized specimen of urine from right ki<lncy was l:>terile. On llfarch 2 patient '"as transferrecl tv surgical sen ice. ()11 March 6 the patient wm; operated upon. An Israel incision ,rn::; ma.de in the righL lumbar region. As the kidney was adllCrent Loth at upper pole and posteriorly, it wa::; dclivcrctl with some dif- ficulty. 'l hrough kidney cortex. se>eral large calculi could be pal- pated. .\. small incision was made into the conYcx surface of the kid1wy lo cnaule the operator to Yerify the presence of the stones ancl 10 en:1ble hi111 to decicle whether or not rcmo,al of the :.e,·eral calculi co•tkl be accomplished without complete destruction of the kidney ~ubstancc; or whether or not nephrectomy wou lcl be the logical surgi- cnl procedure to be followed. As the calculi were \'cry large and ir- regular in outline, filling up all the calices, they could be remo\'ed neither via pelvis nor via cortex without complete dt·struction of kid- ney substance and dangerous hemorrhage. Nephrcctomy therefore ~as pcrformccl. There was no pus. Muscles sutmecl in series with catgut. Hubbcr tube drainage. Dichlorami.·1-T was nsed to control n•t infection at lower angle of wound. Otherwise there was un- complicntcd recovery. The removed kidney, when sectioned, showed brgc <lcndritic calculi in its calices. FOREIGN BODY IN BRONCHUS. By E. w. (;II LO. Lleut~nnnt, :u. c .. Cnlted StnlC9 X<l\'Y· EleYcn year::; ago in Pro,·idence, R. I., before i;he began her train- mg as nurse, the patient inhaled a "beauty-pin,. with fi,·e pearls. This accident occurred 'rhile she was lying <lown on her back at night) and was using the open pin to remoYe a temporary filling from lier tooth. 8he dropped the pin into her month and at the same time took a deep breath. This accident caused so little il'l'ilalion at the time that she was not sure that it had gone. down her lar~1 nx ancl carched the bed clo~ely to locate the pin if possiulc. She llill not :ncntion that fact to others until the next day when she had n slight harp pnin in the right anterior chest about tl1e level 0£ tho fourth or fifth rib. 722 GRAY-MULTIPLE SEBACEOUS CYSTS. Bronchoscopy was dmw four llays later al Pt·o,·idcncl', R l ., bt a physician who was able to locate the pin, but was not able to re1n0,· it, because the point had h(>C'Ome emhedclccl in tlw 11111c·ous mc•111hruiu~ She was then taken to Philaclclphia, Pa .. wh(>re X-rny exami11atio~ showecl the pin to he in one of the small bronchi in th<' lmwr ri~ht lobe not far from its present position. During the succPeding years there haw been very few syn1pt1. 111, She has had occasional slight cough with mueous expectoration an i occasional attacks o[ slight pain in Lhe right anterior chrst ca"\~ more frequently by J if! i ng: or vigorous elm ngP of position than by deep inspiration. Sht' nen~r spat up bloocl 1111til l'nrly in ~ltn, 1918, when she had an hem.optysis of abo11t 1 01mc<' of fre~h blood, which was not preceded by severe cough. She has had a , e11 !>light cough since that time. bnt no blood has bern seen in the smnii amount of expectoral ion. The general health i" ,·pry good ancl th. !'I ight pains which she sometimes experiences in her right ant<'rior chest do not in any "ay interfere with her duties. No signs of th~ pr<'sence of this pin can be made out by physical examination. 'fhe accompanying X-ray picture would seem to indicate that there had hecn >cry little irritation of the lungs surrounding the pin. Com- parison with the X-ray picture taken 11 years ago shows that the pin is in practically the same position but that it has rotated on its long axis about 90°. A CASE OF MULTIPLE SEBACEOUS CYSTS. Oy 0. A. GllAY, Lieutenant, M. C., United States Navy. The .following condition was noticed on a recruit reporting for draft, and Wl).S thought to be of sufficient interest on account of it~ rarity to be photographed and reported for record. PrivatP II. G. M., United States ~farine Corps, agt• 2.'i }'Pars. first noticC'd the nppearnnce of a t·~·st on hi~ srrotum nhonl 10 y<'a1·s ago. The lC'sion started as a small yellowish-reel ~welling near tlrn top oJ his serotum and increased slowly in ~iir.e. Before the fi~ c.\·st had bet'ome Yery large others dc,·eloped, and at the end of the fir:::.t year of the condition there were sev<'n tumors on the right ~ide of his scrotmn and eight on the left. Since that time other growths have mncle their appearance in no definite sequence, until at the pre~· ent writing 114 cysts are noted, varying in size fron1 that of s marble to thnt of a small bird shot. The lesions arc usually symp- tomh•ss but at times one or more break down with a typical cli-- churge. Eighteen years ago he had a small cyst the size of a pea oYer the k•ft malnr region; 10 yenrs ago one the size of n hazel nnt on hi• Later picture of rorelitn body 1n bronchus. SetJaceous cysts of scrotum. PARUAM-CASE OF UNDULANT FEVER. 723 Jdt elbow; eight years ago a slightly smaller one in the right. maiHlib- u::u· region. These were removed as they occurred . . \. t tlu> XaYal Hospital. l\Iarine Barracks, Paris Isl:lntl. S. C .• one nf thl' crotal tumors was 1·emovecl and 1lingnoH•d as being a selm- 1-eims c)·::'l. This diagnosis was con.firmed after 1·emoY ing four of the nmiors. The H<'Companying pictures pre"ent the subject graphically. A CASE OF UNDULANT FEVER. i:y .I. l' l'.\tlft.\ 'I. Li<'Ut!'nitnt ('ommnnd1·1-. .\I. C .• Unlll'd S"tul1·s Nu,·~-. (Tnclulant fever is almost a total -;trangt'r to the Na, . .\ rrturi1:-. of "irk lmt upon learning that the destination of 111)' ship would be in 11 ione where it is endemi<' I rc,·iewt•<l I lw litPrnt 111·• of thi-; <list·ase in order that I might not overlook auy casrs tlrnt mig-ht confront me. Om• ca:-e has occurred on thi:; ship and the histol')' ih interesting. Ensign H. G. IC., N. 'N". V .. had been losing weight slowly for ~p\C•ral lllOll!h:-.. rpon his annua] physical C'-'X:tlllinntion which took pl11C'e the latter part of January. a :-.uspicious lesion was located in his right pulmonary apex. Therl' was slig-htly increased Yocal an<l tactile fremit11s and har:;h breathing ,yjth some prnlongation or the Pxpiratc.ry murmur. :No adYentitious sounds could be heard. Ile \lllS closPly ohsened thereafter and a temperature c.1rn11: i-;tartecl. Jie gaYC' a histor~· of malaise, and frequent headaches in the supra- orbittll rPgion. SeYeral weeks earlier hC' hacl tle,·elopecl an otitis nwclia which had yielded readily to trealmrnt. His temperature chart showed a daily eJcyation to DD 01· 99.:>° F. There was no family history of llote or personal history that pointed to tubercu- lo,,is. There were no night sweats or coughs und hrnce no sputum. Ile• eomplained of constipation of receni origin. SC'Yera1 days later 1;ppornnity for consultation presented itself and another medical ofli«cr c>xaminC'd him. He was told the history of the case but was not informed as to my physical findinp:s. Ile reporle<l the ::;nme :-.,nnptoms and the. f:lllll(' signs that I had found in the area p;iYen nbove. The pnticnCs condition did not imprc)\'e; tl'mpP.ratnre showetl an i11crensing daily rise and he was surveyed as with ''diagnosis un· cletermined" and transferred to tlw Roynl ~fond IIospital, Ply- mouth. England. on February 8. l!H8, for diai:rnosis and treatment. His t(>mperntnrC' by this time wa~ be:,rinning to show a typical 1ypl10icl ascent and a Wiclal showe(] ngglutinntion in 1- 12;), T he meclic:al officer in charge of the case did not confirm the chest findings nnd indinet.1 to a diagnosis of typhoid or para.typhoicl. Patient ha,d l11Hl typhoid prophylactic in Jun<', 1917. The "\Tidal reaction was 724 PABHAM--CASE OF UNDULANT FEVEB. Vol. XIJ, negati>e for paratyphoid, ~\. and B. Cultures of blood, feces, and urine were negati,·e for B. typhosus and paratyphoid, A and B. Diagnostic tuberculin could not be gi>en on account of bis tem. perature and by an unfortunate coincidence an X-ray of the lun~ was impossible at the time. · Close questioning by the medical officer in charge, who had seen service in the Mediterranean. deYeloped the fact that while a~hore on patrol duty in Gibraltar some weeks previously, this officer hnd had tea diluted with goat's milk. An agglutination test was posifrre in 1-400 dilution for M. melitensis. In this case the fintli ngs in the lungs which were corroborated hy an. other metlicul officer; the foct that the pa.tient had had typhoid fever in 191.:> nnd the prophylactic less than '1 year previously; tlrn foct that no milk is allowed on board when in Gibraltar and that all milk imported from Spain is required to be sterilized before being offered for sale, all served to lead to the conclusion that the case wns one of incipient tuberculosis instead of Malta fever. The latest :.wnilablo Annual Sanitary Report for Gibraltar, lOlG, shows that during this year six cases were reported, the year pretl. ous two cases, and during 1914: three cases occurred. Investigation showed that five of the cnses reported in 1916 originated in milk import\!d frum Spain nnd that there was reason to believe that the milk hacl hc>en sol<l unboiled. Such is believed to have been the origin of this case. PROGRESS IN MEDICAL SCIENCES. REVIEWERS. Surgeon II. S. Cu1n11NO, United States Public Health Serrlr<'. , Lll'utcnnnt Commnndrr l•'. U. BOGAN, III. C., Unltl'd Stntr~ ::\a..-y. Lieutenant Commnndcr G. B. TRIBLE, M. C .• United Stairs ::\nvy. Lieutenant Commnndc1· D. G. SU'l'"l'ON, M. C., Unltrd l;tates ::\n\·y. Lieutenant Commnnder G. F. CLAllK, !Ir. C., United Statl'S ::\n'l'y. Lieutenant Commnnd<'r W. A. BLOEDORN, M. C., United 8ta.t.•s Na.v:r. GENERAL MEDI CINE. STEPnPs, J. W. W., YonKE, W., BL.\CJ~LOcK, B., )lAcFn:, .T. W. S., CQ.•Prn. C. F., aml C.\RTER, II. F. Studies in the treatment of malaria. Ann. Trop. Me<l. aml Para sit.. Mny 11, 101 ~. The authors ha,·e conducted a series of extensive im·estigations into the results obtain<>d by the oral administration of quinine sul- phate in simpl<> t<>rtian malaria ancl their conclusion should be of grl'at interest. In the ob~er' ations recorded all the cases were a<lnlt males in- fected in Macedonia at least 6 months previously, and all had lrn.d more or less quinine during t11is prriod. Tn c\·ery instance a diagnosis of simple tertian malaria was made by microscopical examination. In the vast majority para:-itcs were preEent in the ulood on the day treatment commenced. . Quinino sulphate in solution was gi,en daily in two or more 10 or 15 grain doses. The oases are grouped a~cordi11g to the t'°t:il daily dose gfreri. The continuous daily administration of quinine sulphate was tried. giving one series of cases 20 grains daily. another series !lO grains daily and a third series 45 grains daily. This treat 111cnt was con- tinued for eight weeks. The authors endea.Yore<l to obsene all C.'\Ee.s for GO days after cessation of treatment. The results were based on the percentage of relnpH~s both during the treatment and following cessation of treatment. Practically all of the cases were able to take a daily <lo.;e of' grains 20-.30 f'or eight weeks or more. ·when. howcYer, the daily dose ri>.'lched grains 45 it was found that only seHn out of nineteen cases 7!!5 726 GE~LR.\L MEDICINE. wer(' able to complete the full eight weeks' treatment. Iu the •e- maining twl'h'e the treatment. had to be stopped pn'mnt111·<.>Jy owj 11,. to tremors and vomiting. ~ The author:; conclude that the superiority of thl' grains 4;-, treat- ment is clenr. as the maximum percentage of relapses possible iu nn 01.t~errn.tion pHiod of 60 clays is less than the obS<:'r\'e<l minimulll rnlues in any of the other series. Inh•rrupted treatment. i. <.> .. treatment on one or more chtys at in. lernils, inst<'a<l of Jaily, OYer a girnn period was triNl. The treatments were given on two consecuti Ye days en ch we"k and were extend<'cl ornr a period of eight weeks or more. Tho cases woro divided into a 10-grain series, u 15-gniin scrie:-, u 30-gmin seri<.>S' llnd a 45-grain series, and the results obtained wert> considered from l1. palliative point of view and a curntive point of view the same as in the series of cases in which quinine was give.11 continuously. In comparing tho results of the various forms of prolonged inter- rupted treatment the authors found it necessary to give two l'el;; o:f figures as some of the cases could not be observed for the full period of 60 days after treatment; (1) minimum figure, i. c., the>. pcrcenta!!e nctnnlly obsened to have relapsed: (2) maximum figure. i. e .. one based on the assumption that ull cac:es not obsl'ned for a p<'ri• 1 of 60 <lays rdnpsed before the expiration of that periotl. The authors conclude that of the various forms of interrupted treatml'nt Wit•tl, l11t' superiority of grains 4:i trent11H 11t i-; t'l •111·. n-.. the maxi111um iwre<.>nt:1ge of relap:-<'s possibll' in an olist'I \:1tic>11 period of GO clays is Jes-; than the ob';l'l'\'Pd rni11i11111111 \11)11<·~ 111 tlw grains 10 series. The curative value of grains 45 on (,wo consecutive days weekly for a period of 8 weeks-no relapse in an obsern1tion period of 60 days being the criterion of cure-lies be>tw<'cn 71 4 and 61.9 pe.r cent. .\11 the patients were able to take without di1ficully the Iare:est dose of quinine employed, namely, grain" 4:) (tlll'<.'l' do.:<':-; of J.i /.?;rain::) on two consecutive days weekly. Comparing the results of the interrupted and continuous treut ment tho authors conclude that interrupted treatment with quinir.e grains 30 or 41> twice weekly is preferable to continuouc; trl'ntmcnt with quinine grains 30 or 4.3 seven times weekly. Grains 4.i twice weekly is better than grains 80 t~ice weekl.\ ot· thnn grnins :rn tlail.L both as a palliative und as a curative treatment. The interrupted treatment requires over any gi rpn period only two-sevenths o.f the quantity of quinine required for tho correspond- ing continuous treatment. I w. \. n.] . ~ lil-:XERAL MEDICINE . 727 tiot:T"Cll. E. Newer methods in the diagnosis of thyroid disorders: pathologi- cal alld clinical. ~1·w York l'tatl• .Junr. ~lt-.1. .. July. 1~11 . The author from thC' study of nlllllt'l'Oll' cases of thyroicl tlis- 11Jer.- has clr.Yi"lNl n<'W<'l' rn<>tho<ls in tlw dia!!no,is of tlwse affN·tion:< '!fhich .... houltl U<' of grent int<'rcst. Ht· cJj,·idcs his pl'esent pap<'r into two parts: (A) Functional acti' ity of thyroid :tdt•nomata. as indicated by the> cellular content of mitochondria. (B) .Adr<'nalin hyperBCnsitin'n<"•s in elinfra) •1.itt'" of hypcrthyroitlis111. l'nder th<' fil'st hcacling the author outlines the diffie11lties whid1 1.:xh .. t at present in <.'stablishing Hn associatio11 bC'tW<'l.'11 tlini1·al symp- 10111;; nn<l histological stl'llct m·e in cases of adt•nomnta. t 111' onlinary gros .. er pictures of colloid hypertrophy n.nd exopht hal111i1· hypt•1·- pla::-ia foiling absolutely to indicate glandular i11l\cti\'it~· on the cml' b:1111l or :.:ccretory ov('ractiYity on the othPr. Then• is an obYious neerssity thereforr of obtaining if po:.:sihle a hi~tolo!!ical mrthod which is capable of clcmonstrat ing within the <>Ji ~11·11rt111·e~ which are clo::-ely a;.soeint<•tl with its functional ac- 1hi1~-. This is not a cliflicult matter to rct'ogni:w in glandul:u· organ;; ~ucl1 as the p:uwrras. whosp H'Cretory actiYity is <.'Yiclenre<l by thf' ap- pe:irtllH'l' of 7.ymo~en granules. In the thyroid. ag in most of the drn ti ('~,., glands. tlw l'Xif't('nc·p of such definitC' arnnnlc•s i:-; still p1·ob- le111a I ira I. Thrn• a!'(', howc,·e1', other i 11tnte<'ll1tlar stru('tlll'<'S whit'h h·1 ,.!' hl•t•JI k110\\'ll to <•xist in all li,·ina t'<'lls, whrtlH•r plant or nnimal. whi<'h are <'lO'l'l:V nssoc•iatcd in number and f:izc with drnngt•s i11 the nt·t i,·i- tir" of tlw cell. ThPS<' structur<•s are kno\\ n as lllitoC'honddn. Th('~ oceur in the c·ytoplas111 of all Jj, ing cells wlwtl1C'r plant Ol' animal. In tlw higlwr po\H'I' 111agnification the mitol'honclria appear as !!r:m- 1 le" 01· ·:g straight or cun·cd filaments or rot!~ of rnryinµ length:-; up to four ir fh<' mierous. Tlwy are mo:st abundnnt in the net iH' sta;rc>s of tl1l' lifl' of the c·Plls and climini!-'h prog1·e~sivPly i11 nmulwr 11:- tlw rcll:- l ·<'OlllC senile. Tl11 01wnniw material of about :200 ca::;es of th~ J"Oitl di;.ea .... e W:l" x•u11i1 cd Iot· tlw occn1Tencp of mitochondria in thC' gl:ua!-. :rn1l l'm11t• interc-.ting and Ycry constant results were obtained. Thuti in the \\ell-r1'l'ognizNl 1·11:-;es of colloid goiter unas.~or.iatrcl with ... ymptom::; of h~-p· 1 ,hyroicli::;m very few or practically none of tht•~l' :-;tl'llcture~ \1e1-e found in the thyroid cells. In <'very cnst• of l'Xophthulmic goitl'r examined !he mitochondria were found to he prl':::ent in enor- nu111s 1111111bers. Thus tlwir occurrence in '-'lllall or lnrge numut'rs, lls an in<lcx of functional activity of the th:vroid c<•ll. corr<>.-;pontl~ 1c1·~ rlo::.ely to our conception of ftmctional Ltrtivity of eolloid and exophthalmic goiter. 728 OE?-."ERAL MEDICINE. As further C\'idence of iucrea!;ed secretory acfo·ity of thn .d ndenomata the author describes the <:'hypersensitiYeness to adren~J:., test. which is carried out as follows: The patient having been in bed thoroughly at r<>sl n day or more previou::.ly and having become acquainted with the attenclin!! physi. cinn who is to do the test, is assured that the examination i~ it; no way painful and is in no way associated with any danger. Two readings are taken, at 5-minute intervals, of the blOOd pressure systolic and diastolic, pulse rate, and respiration. .\ nott is made of the subjective and objective condition of the. putient This includes the state of the subjective nervous manife:::.tations, the throbbing, heat and cold sensations, asthenia, and the objcdi,·e signs such as pallor or flushing of the hands and face, the size of I he pupils, throbbing of the neck vessels and precorclium, tremor. tt•mperature of the hands nnd feet, perspiration, and any other characteristic signs or symptoms. These signs are all noted previous to the injec. tion of the adrenalin so that comparison may be made after the in. jection. A hypodermic syringe armed with n fine needle "'hfrh, when in. serted, causes little discomfort, is then used to inject 0.5 cc. (i.5 minims) of tho commercial 1-1,000 solution of adrenalin chloride into the deltoid r<>gion, subcutaneously. Intramuscular and intravenoru injections were not giYen. Readings are then made eYery ~l minut for 10 minutes, then eYery 5 minutes up to 1 honr, a11d 11 n e\·erv 10 minutes for half an hour longer. At the end of H ho r . som~­ timcs earlier, the reaction has usun.lly entirely pas:;ed otI The re- peated early readings arc made in order not to miss certai1 reactions on the part of the pulse and blood pressure that may com<> on in lt'.~ than 5 minutes after the injection is made. This is partic11l11rly true of cases of aclh e hyperthyroidism. In a so-called positive reaction there is usually an early ri~o in blood pressure and pulse of oYer 10 points at least; there mny be a rise of as much ns 30 points or eYen more. In the course of 30 to 45 minutes there is n moderate fall, then a slight secondary rise, then :1 second fall to the normal in about 1! hours. Along with these one secs an ex:1qgcrntion of the clinical picture of Grnxe's disease or hypcrtbyroidi~m brought out, especially the nervous nmnifrstntions. The particular symptoms of which the patient has complained are usually increased, and in addition there nre brought out m:11 y symp- toms which ha Ye bcon latent. Thus it is not uncommon to hwe extrn systoles bron~ht out, aft~r the injection of the adrenalin. The pa· tient is usnnlly aware of them and mny tell one that she has felt this samo thing a year or two previously, n.t which time the !'.ymptoms of the disease were more active. ,io. t . GE~TERAL MEDICTh"'E. 729 The following mny nll or in part be found: Increased tremor. np- 11rchension. throuuing. nsthenia, and in fact nn increase of nny of the symptoms of which the pntient may ha'"'e complained. Yaso- Jtlotor changes may be present, namely; and early palor of the face, lips. nnd fingers, due to rnsoconstriction, to be followed in 1.3 to 30 Jtlinutcs by rt. stage of vasodilation "ith flushing and sweating. There may be a slight rise of temperature and n slight diuresis. In order to interpret a test ns positirn it is regarded nc: necessary to ham n. majority of these signs and symptoms definitl'ly brou~bt 0ut or increased. A normal perwn shows no signs nnd symptoms, no reaction whnt- C''<'I' on the pnrt of the blood pressure or pulse, when 7 minims or 0.5 cc. of 1-1,000 nclrenalin solution is injected. The test hns been of great rnlue and help in the cliagno~is of that J:trgc group of borderline cnscs resembling in some re~pects true byper1 hyroiclism, but without definite recognizable si::?ns on the part of the patient genemlly or in the findings of the thyroid gland. which may 11ot be palpnbl.v enlarged. In summarizing, then, the following conclusions are drnwn: Thyroid ac.lenomnta nre responsible of themseh·cs for hyperthy- roicli~rn . They are .often multiple and should be rernoYed whcneYer it is possible to make lho cli~gnosis. The '\"'cry common belief nmong mnny physicinns that they nrc innocuous nncl need no surgical treat- meut except "·hen they produce mechanicl\l pressure is incorrect. In n smnll pcrcentnge of cases, 2 per cent in this series, mnli!!nant drgeneralion OC'curred. Symptoms of hyperthyroidism disappear wh"n an aclc.>noma formerly acti vc degenerates, only to Le followed by n Ec .oncl wnYe of hyperthyroidism when a mw health~· nclenoma arises. •lS i!:i !:iO frcqnentl.Y t.hc case. Almost e\'Cry form of c11?~enern­ tion ncognizecl by the pathologist can ocenr in these ndenomntn.. The 1I1yrohl glancl itself a~socinted with an nctiYe nclcnomn presents n simple'colloicl nppeurancc, contains :few or almost no mitochonclria, and is relntively inncth·e. The abundance of mitochondria in the thyroid cell forms a good index for judging of the nctidty of the tissue under consiclerntion, "\Vhether this tissue be from nctin~ colloid goiter. cxophtha lmic goiter, or from an nclenomn; the grentc:r the number of mitochondria. in the thyroid cell the grenter the functional ncth·ity of the latter. In f'tates of hyperthyroidism there is a hypersensith·eness to acl- r:rnalin whether administered hypoclermically or intmdermicnlly, which hypcrsensiti\·encss is proportional in n. remarkable way to tho degree of hypc1·thyroidism present. 'iGOJS-18-- 11 730 GESEBAL MEDICISE. The rcnction to nclrcnnlin should be of considerable Ynlue in tbt din~rnosis of obscure l>ordcrline cnse.s of ncrrnus <listurb:mces Whici may or may not b:we their origin in true hyperthyroidism. [w. A. n.] ll.\C.\LLUll', A. H. The ancient factors in the relations between the bloat plasma and the kidneys. A..tuer. Jour. Mc<l. Sc., July, lfllS. The nnthor hns tlrnwn some >ery interesting conclusions from , longs ries of exn111inntions of the inorganic composition of the s ra of certain Yertebrntes, the function which the kidney exercises in regulating this inorganic composition and the ancient f:tclor which appears to goyern the concentration of the inorgn.nic Fn lts in the blood plasma. Among all lho organs with their yaried history as to structure ancl function, the kidney function in one particular respect has not changed from the time it first began to evoh·e in the very fn1· past. This function is the regulation of the inorganic composition of the intcrnd medium of the body, known as the blood plasma. The renal orgnn in the embryological history of the nrtcbrnte is ns :mcient us the neural canal nncl appears to unteclatc the clo3Ure of this canal. The salts of tho blood plasma rnngc between O.iS nn<l O.SS per cent of the weight of lhe plnsmn, nnd they consist of the chloridl'S, phosphates, cnrbonntcs, nnd sulphates of sodium, potnssinm, cal- cium, uncl mngncsinm. The salts of sodium arc by for the most nbunclant, after which come those of potassium, calcium, nnd mng- nr!';inm in thl' order mentioned. T he salts of sodium, chiefly the chloride, amount lo more than DO per cent of the total inorgnnic solids of the plasma. The following tnblc shows the clements nn-angcd in Ynlucs pro- portional to the most abundant one, sodium, which is mncle to e1ual 100, nntl shows a surprising resemblance in the values obtained from plasmas of nll the mammals: Na. K. Ca. 14 Do!!Cish (Ancanthias vulguris) ............... 100 4.61 2. 7l 2.41 Cod (C1aclus callnrias) ..•.. . .......•...••.. 100 9.!iOG 3.!13 1.41 Pollock (Pollnchius vireos) ............ .•.. 100 4.33 3. 10 1.41 Do~ .........•....•.............. .... •. ... 100 6.!'G 2.52 o. 1 Mammal (averazo) .....•........... .. . . ..• 100 6.69 2.liB O.f.O ~fan ~C . Schmidt) .......... . .........•. . . 100 9.22 3.37 1. 71 Mao A. J3. ~L) ....•• .•. . ....•............ 100 G. 11 2.71 0. 81 T he pnrnllclism in the ra.tios of these clements in tho highest as well as in the lowest vertebrates is a cs.rdinnl fact nncl suggests that 8 1 8 1 0 8 5 s t GEXERAL MEDICl:XE. 731 it j .. an endowment rccch·cd from the common ance,tor of both, the prot<>,'·eii.el~rate .which must have exbted in thl' early Cambrinn or pre·lnmbna~ times. . . . . '.fhe followmg table shows the strikmg parallel cx1stm~ between the inor!!anic constituents of ocean water ::tnd the inorganic composi- tion of the common jelly fish, Aurelia. fb.vidula: --- ~~~~~~~~~~~~- Occ:m w:i.tcr (Dittmar) ................... . Aurelia ll:i.vi<lulo. Pio.callum) .............. . Na. I K. 100 I 3. 63 ioo _ _ u.1s I Co. 3. 91 4.13 l'.!.10 11.43 'The above table shows tlrnt the fluid in the tissues of ~\urelia is bnt slightly modified ocean water und of the sun e concentration ns the latter. When the ratios for sett vrnter were compared with the ratios of the blood plasma of n mammal. as. for example, the clog, there nppe:trs to be no doubt of their oceanic origin. 'fhe hori;eshoe crnb, Limnlus polyphemns, which has had its habitat in the ocean since its origin in the Pa1aeozoic age, has a plasm:t in "hich the parallelism between it and ocean water is incontro,·ertihle. Tn I ot h tl}c lob-ter nncl Ow crab the concentration of the inoq~anic ,nJts of the plasma appt>ar:; lo rnr~· with the concentration of the oce:rn water of their habitat, nncl in brackish water it folls to that o.f the I. ttcr. The re is then a profound cliffcrencc between the Lloo 1 plasmn of >ertcbrntes an<l that of invertebrates. That of the latter rnries more or less readily wilh nn immetli:i.tc change in the medium of the- habi- tot. while that of the former is nffectecl, antl then but npprccial.ily, only after mill ions of yt>:u-...;. The parallelism ulrca<ly referred to in the ratios of the clements in the different forms of vertebrates and im·ertehrates appears to indicate that the Llood plasma. of Yertebrates '\Tas also ori!?innlly ::.en water, not the sen. water of the present age, but of n. fnr past when the concentration of its salts was less than one-third of what it is IlQW. The kidney has maintained this concentration nnd the3o ratios, practically unchanged, through long ages of vcrtcbmtc history. It i this organ that hns made a fundamental difference hl'tWel'n the vertebrate and the inrnrtebrn.te, not only in the c:trn!!!!'le for existence but il:-:o in the capacity to eYolve higher forms of animal life. The anim: 1 form that must accommodate its intcrnnl mcclium to that of its habttat hns nn enormous handicap when it changes it· cm·iron- ment. 732 GEXERAL 'MEDICIXE. \·ol XU The author conclndcs from his examination of the plnsrnn in Drighfs disease that the Yery first change from tl.e normal to the definitely established primary condition in some of tha fmms of Bright's disease is a loss of tha power of the kidney to maintain the Palaeo-oceanic ratios. The !ilructure in the kidney invoked in mnin. taining these ratios consists of the proximal convoluted tubules, which arc also concernecl in reclucing the H-ion concentration of the bloocl plasma. The author regards the hloocl plasma, so far as its inorgirnic snits nre concerned, as but a reproduction of tha remotely ancient ocean, the original home of all life on the globe. [w. A. n.] CECIL, TI. J,. Sensitized vnccines in the prophylaxis and treatment of illfec. tions. Amer . .Tour. ~let.I. Sc., June, 1018. The author clescribes the de,·elopment. of the urn of sensitized vac- cines with the results obtained by their use and rrports a series of cases in which he used such rnccines both as a prophylactic and ns n curati ,-e measure. A sensitized rnccine is defined as a suspension of bacteria "·hieh has been pre,·iously treated with an homologous rnrnm. The bac- teria arc wa!=hcd before injcclion so that whateYer antibcdy ·~ pres- ent in the Yuccine is firmly nttnched to the bacteria. ancl wh 1te,·er Yal•:e sensitization of a Ynccine possesses probabl.v inheres frq n the direct influence of the nntibo<ly on the bacteria to which it is nttnch~d. Sensitized rnccine nppears lo have been more frequently employed ns a prophylactic and therapeutic agent in typhoid :fever than in nny other infection, althongh Shign use<l a sensitized Yaccine fo1· im- munizing against plague aml uysentery and Calm<>tte and (1ucrin for protection against boYine tuberculosis in cattle. Sensitized gonococcus Yaccine hns been extensively cmplo)'('d ns n therapeutic measure with apparently gratifying results. Sensitized streptococcus, stnphylococcus and pneumococcu<: vac- cincs hn,·e beC'n employccl ns well as sensitized tuLerculin with re-· suits which appear to justify further work nlong these lines. llesrccllrn. emplo~·ed sensitized plague and typhoid bacilli in 1002 and fo11nd that the sem;ilizcd hacilli. 'both subcutaneously and in· trapcritoncally, were consiclerably less toxic thn.n tho nonscnsitized bacilli; furthermore, thal injections of sensitized bacilli were fol· lowed by nn almost immediate increase in immunity, in contrnst to the nonsensitizecl bacteria which excited first a so-called "ncgntirc phnsr." The anthor has employed sensitized vaccines of typhoid bacillus, gonococcus, streptococcus and staphylococcus nureus nncl tubercle bacillus. GE~""ERAL ~DICIXE . 733 111c typhoid Yuccine was employe<l in :!O case~. in which it wns used for prophylaxis. The do::.agc employ<'<l wus the -.:ame us thnt usunlly emplo.vccl with or<linury lyphoid ,-uccine, namely. 500 mil- lion for the first inoculation and l billion each for the second nnd third. In 8 cases t he vaccine wus giYen at i-day intervals; in th(I remaining 12 cnscs it was :ulminislcrcd en1·y other dny. Tuo )utter metbod caused no unpleasant symptoms. The local reaction produced by the sensitizeu vaccine was nlwnys mil<l nncl appeared to be less scYere than thut which usually follows an injection of ordinary typhoid Yn.ccine. The le::.scr toxicity of the sensitized vaccine und its possibly superior immunizin~ power are sufficient rC>usons for giYing it a trial. "ensitizc>c.~ gonococcus Y:tccine wns employed in lG cnse of gono- coccus infection, chiefly gonorrhoeal Yaginitis uncomplicated and complicated with cnclomctrit.is, salpingitis. nncl arthritic;. 'Jhe inocu- lations were gi ren at inlervn ls of 5 to 10 days, the do nge varying from 100 million to 2 billion. The renctions were u~ually miltl. there Leing u~ually. howeYer, n shnrp local reaction followin~ tho first inoculation. Six of these cases recoYcrcd complctcl~·. und nH bul 2 showed improwment. 'fh<' author employc<l sensitized tuberculin in 4: cases of tubt'rcu- 1011-. ndentis, 3 of whom showed improvement uncl in ~ cases 1ho f!lun<ls disappeared. The author arri\·es at the following conclu- sions: It has been shown by numerous im·estigators that a Yaceine 5l'n- sitizcd with an h omologous serum produces lcc;s locnl and consliln- tionnl disturbance when injected subcutaneously. llinn cloc: :i 11011- sensitized ni.ccine. E-ven living virulent orguni"ms when properly sensitized can bo injected subcutaneously witlinut serious conse- quences. ~cnsitized rnccines haYe been extensi,ely m:ecl ior prophylnrtic an<l therapeutic purposes. The sensitized typhoid Yaccine produces u. somcwhnt miltll'r reac- tion thnn ordinnry typhoid vaccine, and probably giYe jthi ns hi~h an immunity. At the present time, ho"evcr, the evidC'ncc for its suprriority is not sufficient to justify the subc:titution of sen~itizr.cl for ordinary Ynccine in practice. In the vnrious infections treated with :scn,dt i7.cd 'accines tho re,,uJts were, as n rnle. no better thnn woul<l haw been <'Xpcctcd with ordinary n1ccinc. It hnppened thnt in n few instances reco,·cry fol- lowcu the ndministration of sensitized vaccine after treatment with ordin.ay ,·accinc hnd fa ilcd. This may ha' c Imm dnc lo the fact that larger cloPes conlcl be employed without nntownrcl ~ymptomc:. Thr chief objection to the genera.I use of sensitizeu ,·accincs is the tncreac:e<l. labor nn<l time necessary for their preparation. 734 GEXERAL MEDICIXE. _\t the prcscut time it would seem desirable to limit their use to the treatment of infections in which there is hypersensitiveness to ordinary vaccines or in which the latter have proved inefficacious, [ w . .\. n.] IIu.o, I. W .. null noi::mm. J. X-ray diagnosis of pulmonary tuberculosis. In. terstnte )lerl. Jour., Yolume 2u, Number 4. Everyone who bas occasion to take or interpret X-ray plates of the chest should read nnd assimilate this article. It is seldom that so much of rcnl value is found in such small space. Starting out with an exposit ion of the relative values and special uses of fluoroo scopy and radiography, it is pointed out that neither is of any value in the diagnosis of tuberculosis unless proper focnsing is u~ccl. Aa a result of poor focusing, shadO"\YS which stimulate disease are •{!en, In fluoroscoping a patient in the dorso-ventral position, with the tube at a level of the third or fourth dorsal vertebrn, normal apices will appear shadowed. In the normal lung both apices are not of equal dimensions and equally bdght. The right ap '.'x, because of stronger musculature of the shoulder in right-handed people, throws a darker shadow than the left. The r .. •versc is true in left-handed people. The least curva- ture of the spine darkens the apical shadow. Normal plurU! and glands throw i10 shadow. The primary focus (initial lesion) is in the lymphoid tis~ucs of the hilus, n. region inaccessible to any other method of diagnosis but tho X-rny. The apices are no"'. considered to be the primary focus in about 5 per cent of lung invoh-emcnt. The cliITerencc in appearance between healed nnd active lesions of the hilus arc emphasized. The former is clmructorizcd by a dense elongated, quadrangular shadow, mostly on one side, which extends from the second to about the fourth rib along the outer border of the pericardium. The butterfly appearance is still maintained. From the hilns small strands project upward to the second rib and below to the base. Calcified glands varying in size from g to 10 mm. arc seen mostly at the hilns. Acute processes originating nt the hilus are genernlly lmilateral, the shadow is denser thtm in hC'Ulcd lesions, the butterfly shape is obliterated, the area is circumscribed, and there may be evidence that several foci have coalesced. Yascu- larization ·is marked. Ringlike shadows of '\'t\rious sizes indicate diluted bronchi. The fluoroscope is indispensable in the study of the apices. The first fluoroscopic impression as to the difference in the shadow of the two apiccs is of paramount importance. The somewhat darker shadow of one apex, o!ten brightening up after prolonged fluoroscopy, GE~"'"ERAL MEDICIXE. 735 j~ of great diagnostic vnlne. The cough phenomenon of Krentzfuchs, l\"hich menns the clenring up of the shadow hy coughing nn<l in pir:t- tion, shoul1l be obsen·ed. Early apical tuberculosis ~houlcl he sus- pected if the shadow dot's not clear or if it clears less on one side thnn the other. Further eT"idence of <?arly apical tubcrculo ·is c.'\n be Eho\Tn by study of the :X-ray pl:.tte. An infiltrated apes is narrower tbnn a healthy one, the prest'nce of small glands b abo posith·e ed- dcnct'. The calcification of the cartilage of the fir::t riu an<l the SIJlall heart, once famous ns diagnostic features, nre now discredited. Certain anatomical con1litions and lesions of a nontubercular vnture may cause the npiees to be shadowed. Xu~al obstruction re- tnrding entrance of air into the lungs, or pressure on the larynx, troche~, bronchi, or pulmonary tissue by thymu<:, rnlarg<'cl glan<ls, tumors. etc .. cnuse collapse, inclurntion and showi11~ of the npiccs. The chssification of pulmonary tuberculosis by Gerhard. Turban, ond others, depending on the amount of pathological iiwoh·cmcnt, is now heing <lisrega.rded, and Peterson's method of classification and prognosis, depending upon the symptoms and !?encrnl condition of tho patient, ncceptecl. This has been made possible by means of the X-ray. Peterson has emphasized certain clinical facts heretofore ol"erlookcd-i. c., that a person presenting but fe,l" ph~·sical si~ns in the lungs ma~· succumb because tubercles erode :t large hlooll re cl nncl produce falul hemorrhage, or mny cause meningitis or miliar,v tuberculosis, while patients with caxities may fo·e for ycar3 in compnrntiYe comfort. For the clingnosis of tuberculosis of the hi1us, tul:crcnlo~is com- plicating chronic cmphysemn, for the indications and rcc:ults of n. therapeutic artificial pnewnothorux, the :X-ray supcr~edcs nll other methods of diagnosis. (P • .M. 11.] Il1:J1n1cx, W. ,Y. Intravenous serum treatment of epidemic ccrebro-splnal meningitis. Ar1·b. Int. Me.1., .\1J1·il, lnlS. The author's article is n report of obserYntions on 20 cnc:cs of ccrehro·spinal meningitis at the Ilase Hospital. Camp ,Jnck on, ~ . C. The foJlo,Ying conclusions were renched: 1. "The disease is in most, probably in all, inc:tnnccs a primary meningococcus sepsis with usual, but not ncccss:.1rily uni,·crsal, sec- ondary mcni ngi tis. 2. "The clin~nos1s can be made in at least :JO per cent of the cnscs in the premcningitic stage of sepsis. 3. •· Tre·1tmcnt by large amounts of antin1cni11~ococcus . crum in- traYt'nou~ly , combined "·ith actirn spinal <lrninngc and intrnspinal scrum administration, has reduced the duration of the cliscasc! the number nnd ~eyerity of complications and the mortnlit~·.P 736 GEXERAL 1\fEDICIXE. )!.tj. Herrick is of the opinion thnt the nnme of the disease," cero. bro-spinal meningitis." nnd of the ctrn"ntivc :lJcnt Las led to n single manife:-tntion of the <fo:cns<\ the mcni1:gitis nEpc:.'t: usmping 'Uch n. prominent place in the commonly accepted ideas of the nature of the disease thnt important facts haYe been kept in the bn.ckgrouncl nnd that the premeningitic stage of tho meningococcus sepsis hus for practical purpcs::-s been disrrganlcd. It is his view that in a rcrognition of thi:; prim:n-y stage of sepsis lies the key to early diagnosis and more cffccfo·e tn•atment. .\ppre. ciation of this fact resulted in the recognition by l\fnj. llcrrick and his coworkers of primary mcningococcus sepsis in almost half of the cases before the ch:Hacteri:;t ic selective action on the meninges hucl Leen exerted; the recognition of abortive cases or of ether types of meningococcus sepsis not showing menin~itis, the cstablish111eut of intravenous serum therapy, notable reduction d mortality nnd, further, the development of clinical uncl laboratory methccls of vnlue. Emphasis is laid on the fact that cerebro-spinal foyer is a medi l emerg2ncy, on the prompt recognition of ''"hich, and Yigorous action, the life or future well-being of the -Yictim depwds more than in almost any other acute disease. To insure early dingncsis instruc- tions were issued to regimental surgeons to refer at once to the Bnso Hospital all men complaining of headache, feyer, Ycmiting, or other suggestiYc symptoms. This procedure afforded an exccptionnl op- portunity for study of the curly stages of cerebro-spinal menin~ilis and other acute diseases. )foningitis was preceded hy n stage of genernli:1,ccl infection whith lasted from n few hours to three clays, averaging about 4:8 hours, nnd n. few cases, usually lhe abortive or fu lminating, rarely those with prolonged course, ncYer de,·elopecl meningitis. Ilcccgnition of llic prcmeningcal stage of sepsis depended upon clinical ancl bacteriological cdclence. Clinical eviclenee of the in- cipient discnse is fairly uefinilc for the practiced ob"erver, althounb for certainty laboratory confirmation is usually necessary. Tenderness of the eycbaJJs, dilnta.tion of the pupils nncl in n fow cases slight retinal edema with faint obscuration of the disk mnr· gins and fullness of the retinal wins were among the less common symptoms. In n large proportion of the cams there was an upper respiratory tract infection, coryza, pharyngitis, tonsillitis, laryngitis, rnrcly bronchitis, in four Ca!=es of pneumonia. The skin manifestations are con5idered the most importn.nt; of these, mottling giYing n lea.cl-colored appearance appears early. Tncho c,crcbrale is constant but not of dingnostic vnlue. A few cnses harn shown a puzzling mncular rash. 'The predominant skin sign is tho petechial rash which n.ppcurs with astonishing rnpiclity in crops GE~EUAL M:EDICnm. 737 abeut tllC shouluer or pch·ic girdle. less frequently over the tnmk, estremities. face, oral mucosa, ancl conjunctivne. The petcchine vnry in size up to 1 cm., clo not disappear on pressure, nnd lust alout threo day:-. Ie:n·ing n pigmented stain. In the presence of nn epidemic this rt1~h i~ considered dingncstic. A purpurn is a fenture of the fulrninnt- in!! cnscs; it develops with the greatest rapidity, nnd within n iew Ji;ll'S considerable portions of the body may be covered. Maj. Herrid, considers that next to the rush nn unequal enhancement of thr deep reflexes is the most valuable early e>idence of the disease. While nn increase in reflex irritnbility is not uncommon in a. ,-ariely of in fcctions the incrense is uniform on both sides, while in cerebro- spiunl fever it is unequal. Hendnche of the "pressure" or "bursting., frontnl or Hrtical, 1~~ often occipital, type occurred early in about S3 per cent of the cn~cs. nnd chills were common. Rigid neck, Kernig's sign, and llrutl- zin Id's were nlmo,..t always ab.Qent during this :,tage. The clinicnl su~picion aroused by any combination of two or more of the signs or "ymptoms enumerated demnncl lumbar puncture. During the stage of sepsis the spinal fluid is usually clear. In GO per cent of his cases there was slight increase in press.ure, a normal number of cells, the fluid reduced Fehling's solution and in somo instances showed n trace of globulin. After long centrifuging nn<l ernporation of scyeral cubic centimC'ters 0£ the !luicl on n. slide 3 few extra ccllnlur polymorphous meningococci mny be found. Repe- tition of the puncture often results in finding organisms. Capt. F. ,V. Ilaei:;lnck, chief of the hospital laboratory, has found meningococci by blood culture in this curly stage in 3G per cent of cases so cxnminetl. (Jonr. Am. Mecl. A~sn., 1!>18, 70, G84.) Tho manifold complications of the epidemic constitute a strong armmwnt in :farnr o:f the Yiew that the disease is primnrily a sepsis. The rapidity of invasion of the eye, for instance, points townrd hemu.- togenous infection. Prompt enucleu.tion of the eye n.s n focus is ur!!~d in coses of pnnophthnlmitis. The myocnrdium seems lo suffer little; one case of cnclocarditis, six of dry fibrinous, and two cases of pericarditis with effusion were noted. Otitis media was common but no case required mastoid opera- tion. The accessory sinuses of the nose were frequently fouu<l filled with pus. Three cases showed orchitis or epidicl_nnitis which wns nonsup- purati ve and soon subsided. Arthritis wns n marked feature of the epidemic. bnt the pro~osis is I?' ocl and permanent disability rare. The recognition thnt cercbro-spinal fover often occurs during tho COUI"f of ether acute disease is n mnttcr of highc.st importance. Tho organism thrives in n soil prepared by any conditions wbid1 lower 738 GE~"'ERAL MEDICI~E. resistance; hence change in environment, fatigue of travel, or of un. nccustomccl drill, and homesickness act in a manner similar to stich acute diseases as mcnslcs, tonsillitis, or other respiratory infections. The most marked constant finding in the 31 nccropsics performed was n remarkable dryness of the body, muscles, and internal or~nns. No evidence of suppuration about the cribriforrn plate of the eth. moid or macroscopic appearances were found to suggest extension of the infection from that point. The intravenous treatment has been based on the conceptirn thnt the disease is, in its early stages, a generalized mcningococcns ;sepsis which can be recognized before meningitis or other local complica- tions occur. Instead of attacking a metastatic focus in the meninges endeavor has bC'en made lo reach th~ organism during the stage of sy:;temic invasion by intravenous serum therapy. The method finally adopted when a patient presented early symp- toms was as follows: If the fluid obtained from lumbar puncture was clear, no injection wns made; if cloudy, enough was removed to reduce prcs:;urc to nor- mal and a less amount of :-ermli allmved to run into the canal. The fluid remoYed was transferred in a thermos bottle to the laboratory nnd meanwhile n small dose of serum was giYen to <lcLcrmine . ensi- tiveness. One hour later 50 to 120 c. c. of sernm were given by the veins from a large glass syringe. In a case of ordinary severity the intravenous dose was repeated e>ery 12 hours until the temperature became normal or until six or eight injections had been given. In severe cases the serum was repeated every 8 hours until the <lcsiml results were obtained. In fact, the size and frequency of intra\ ·nmrs Eerum doses \Vas like those prescribed by workers in RockefcllC'r In- stitute in lobal pneumonia. No ill effects from large closes wen' oh served aml sterilization of the blood was attempted by massive dose~. especially in the early stages when a positiYe blood culture and n clinical picture indicated general hematogenous infection. "·hen meningitis was rstnblished this treatment was supplemented by spinal drainage about half an hour after intrnxenons injection. Suf- ficient scrum was introduced into the canal to relieve headache. "With large intravenous injections meningococci as a rule disap- pear from the fluid within 24 to 48 honrs. Some prolongecl cases in which the scrum apparcnlly acts as an irritant, causing delirium and heaclache, do better without scrum. Second in import:ln<'e to serum is morphine, which should be gi,·en freely, especially in early stages. The total mortality in the entire series 0£ 208 cases was 26 per cent. In the 120 cases treated by intruspinal methods alone or with intravenous doses of only 10 to 45 c. c. it was 31.7 per cent; in 7l> GENERAL MEDICINE. 73~ tre:tt'ed with large amounts of serum intravenously and average or gn:1Uer amounts intrathecally, 16.4 per cent. lfild cases do well under either treatment; it is in the most severe tl'pes that intravenous methods give the most striking results. · Mnj. Herrick clafrns that the value of the treatment is found in the shortened course, diminished number of complications, prompt dis- nppcarance .of meningococci from the spinal fluid, and decreased 111ortn.lity. In cases showing signs of a blocking of the foramina Lieut. Cobb devised a method of starting the flow of spinal fluid. Chloroform is given to relax the neck muscles and the head is manipulated to break up adhesions that tnay be forming about the foramen magnum 11nd fourth vcnticle. Liberal drainage and tho use of this method is advised by Maj. Herrick when drainage is slight and symptoms persist. [n. s o.] UoPPE, H. II. Tbe Medical Treatment of Graves' disease with special refer- ence to the use of corpus luteum extract. Jour. Nerv. and Ment. Dis., April, 1918. The author discusses the origin, structure, and physiology of the corpus luteum. He shows the results of various investigators who conclude that the corpus luteum is epithelial in character and is derived from the epithelial cells of the membrnna grnnulosa of the Graafinn follicles. There are two kinds of specific cells in the corpus luteum, namely, the lilteum cells and the pnraluteum cells. The corpus luteum is therefore regarded as a ductless gland, pouring its secretion directly into the Llood vessels and having a most important function in regu- lating the sexual life of woman. Being one of the ductless glands, the ovnry, perhnps through the corpus luteum, stands in relation to all the other ductless glands nnd is the avenue througµ '\\hich all the other ductless glands in· fluence the function of the female generative organs. Falta divides the ductless glands into two groups, the accelerntory group and lhe retardative group, in so far as they produce nccelera- tory or retarding hormones. These groups through their hormones exort an antagonistic effect on the metabolic process of the body. Thus, the hormone of the thyroid gland is regarded as acceleratory. It quickens metabolism and increases excitability, as is evidenced in Graves' disease, ,,·hereas the absence of this hormone which we see in myxedema, causes an arrest of growth or an inhibition of meta- bolism. Opposed to this action is the group of glands with retarda- tion, nnabolistic, or nssimilutory hormones. The author regards the secretion of the corpus luteum ns having this function. 740 GENER.AL MEDTCIXE. ~\s the result of his clinicnl experi<'nce in the treatment of Graves's disease. he Hl!!!!C'Sts that the internal secretion of the corpus luteurn has an inhibitory effect on tho thyroid :;ecretion~ and that hyperthy. roidism i:- au C..'\:pression of a <ly:-;fu11ction of the corpus luteum in the female nud of the iuter::.litial glantb of the testicle in the male. The most serious objection to thi::. theory is that typic<tl Gra'"es18 disease rarely follows remo\·al or the O\'aries and te:sticlcs, Ilo1we,·er them i.:, a marked incrC'use in the size of the pituitary after castratio~ in Loth male and female ancl thi~ may mean a physiological c 1mpcn. sation of function. TLe author hacl treated about 20 cases of Graves's disease in the past. three years in which the ordinnry Forchheimer treatment wns attended with only inclifi'erent success. The combination. howC\er, of the quinine hydrobrornate, extract of belladonnn "·ith the extra of corpus lutenm, 'ms found to he rapidly beneficial in nearly all tho cases and the improvement was usually so rapid and so marked, in n few clays to a week, ns to be nccotmted for only on the ground thnt tho corpus luteun was the active therapeutic agent. These cases were all clinically cases of Graves's 'lisease. no doubtful cases being in. clucled. The most notable and prompt improvement is in the canlio- n1scular symptom<:. The pulse rate <lrops very quickly .md tlio disugreeuble symptoms caused by the disturbance of circulation quickly subside. Then the general nen ous irritability dimin- ishes nnd the patients return to more or less normal condition. They show n. tPndency to relapse. however. if they stop the extract of corpus luteum. The author regards the Grnv<'s' symptom complex us a re.o;ult of n defective or deficient secretion of the corpus lutcum which when replaced by giving the extract of corpus luteum continuously results in improYemC'nt and a fairly normal state. [w . .A. n.1 IlAl~Es. n. ~. The dit!erential diagnosis of enlargements of the cervical lymph nodes. .\rcb. l'ecliat., April, 1!!18. 'Ihe author divides enlargement of the cervical lymph nodc'i into three clas"es n.s follows: (a) inflammations-simple or tuberculous, (b) hyperplusias, and (c) neoplasms. The commonest forms o{ enlargement of t.hese lymph nodes nrc the infections or enlargements secondary to bacterial invasion of stn1c· tures of the hen.cl and thront whoc:-c lymphatic drainage terminates in one or other of the group:; of lymph nodes situated in the superficial or deep structures of the neck. ll):perplasias of the lymph nodes occur typically with the in- fectious rli,;eases: pnrticu1nrly lhe cxanthematu, scarlet fc'"'er= men.sics, )10.4° GENERAL :M:EDICINE. 741 German meac;le;-. and diphtheria: or in syphilis and, more rarely, gen- rralizecl tuberculosis; in leukemia, Hodgkin's disease, and the glan- dular fc>er of Pfeiffer. Scoplasms are the least common of the enlargements and ns types · arc mentioned lymphaclenoma, lymphosarcoma a~ primary diseases and carcinoma nc; a f'econdnry process. Enl:ugement of the cerYical lymph nodes, other than that clue to infections, is usually nccompanied by signs of disease elsewhere 11 hich serve to estnblish a diagnosis e,·en if the enlnrgements them- .;eb·es can not be diff ercntiated. The glandular swellings accompany- ing the exanthemata arc acute and the symptoms and physical signs of the primary disease are present. Those of scarlet feyer nre typically of the deep ccnical glands, both anterior and posterior, and may progress to intense infiltration and to suppuration. The enlarged lymph nodes of diphtheria are nlso acute and o>er- shadowed by the symptoms of the primary disease so that the diag- nosis is reasonably certain. In measle3 the enlargement is apt to occur days or weeks after the original disease. In mumps the S\\elling of snli\'ary glands may be confused with corresponding gl'Oups of supcrficinl lymph nodes. Particulnrly is there likely to be confusion between submaxillary mumps and en- largement of the submnxillary nodes; the latter are situated above the sn.liYnry gland, often on the horizontal ramus of the mandible. A bilateral swelling in this region senes to establish mumps as the diagnosis. The acute glandular fc,·er of Pfeiffer runs a characteristic conrso of feyer, constitutionnl symptoms, nncl enlargement, usually uilntcral, of the deep cer,·ical lymph nodes. The nodes may become the size of walnuts, but nre discrete, hn1'Cl, Ycry .sensitive, do not suppurate, and subside after a week or two. The enlargement of cervical nodes which occurs in syphilis is part of a general :ulenopathy. The posterior cervical group is likely to be im·oh·ed. The nodes are di"crete, without signs of inflammation, and not adherent to adjacent structures. The ·wassermnnn reaction and the luetin Rkin te:;t will clear up the diagnosis. Hodgkin's disensc shows constant progression of enlnrgamcnt with- out coalescing or suppumtion, the invol\'ement of other groups of nodes, particularly within the thorax and abdomen, the splenic en- largement: n.nd progressive anemia. Lymphosnrcoma ma.} resemble Hodgkin's disease at fir~t hut thcro is a tendency for the capsule of the node to rupture ancl the nodes to become adherent to each other and the surrounding ti ~snes . .A.cut~ lymphntic leukemia presents enlargement or noclcs up to walnut size, discrete nncl with little or no redness or tenclcrncss. Tlrn diagnosis is made by blootl exa.mination. Anemia with 1 to 3 mil- 742 SURGERY. \•01. ~ 11. lion red blood cells, hemoglobin of ~O to 30 per ccnti nnd leucocytc:s of 50.000 to 150.000, of which !JO to !JS per cent nre lymphocytes complete the picture. ' Enlargement of the occipital, ma,,,toid. preauriculnr, nnJ parotid nodes may ha due to n tuberculous infection such ns lnplls but moro probably is due to n pyogenic infection such as results from cczemn pediculosis, furunculosis, fissures, and cracks about tho nostrils 0 ; corners of the mouth. Enlargement of the submental and submaxillary grollps may be due to pyogcnic infection of tho teeth and gums. Differentiation between simple and tuberculous infections mny be very difficult. In pyogenic infection there is likelihoocl of c, idence of inflammation in mouth, throat, or nasopharynx. Usually the swelling is larger, comprises more lymph nodes, has mor\\ pcrinodu- lar swelling, is tender, rcdclenecl, hot, and elastic, all the tissues being bound up in the swelling. Examinntion of tho blood will sh°'v a polynucleosis in pyogcnic and a lymphocstosis in tuberculous enlargements. Tho tu\Jerculin test, the complement fixation test, or the von Pirquet reaction are valuable aids in diagnosis. · In some cases excision of the gland itself may be necessary for n positive diagnosis. [w. A. n.l SURGERY. ALVAREZ, W. U. Is the purgation of patients before operation just !lable1 Sur;;., Gyncc., nml Obst., June, 1018. The :rnthor's Yiews nrc startling and would. perhaps, be, more con- vincing if he '\Yere less rnclicnl, but it is rare for crnsaders to occupy middle ground. There is probably no single detail of surgical pro- cedure upoi1 which there has been such 'rnrldwide agreement ns the rule to erncuate the bowels of n patient about to undergo opcmtion under n general anesthetic. It is no easy matter to renounce tho habits of years, and the more fixed and uniYersal n practice has be- come the more likely it is to outlast its usefulness. W11cn the pro- priety of such a measure is questioned in :i. dispassionate and scien- tific way we should listen to the arguments without prejmlicc. Dr. Alrnrez clnims (1) that the administration of the anesthetic is not rencleretl. more safe or easy or agrecabJe by preliminary purbrn- tion; (2) tlrnt preliminary purgation does not lessen 010 dttnger of autointoxication, gns pains, or peritonitis, but, if anything, ti-nus to induce these conditions through disturbance 0£ the normal mesentcric circulation. ~o. 4. SURGERY. 743 The author states that the 'idea of preparation preliminary to operation is partly ascribable to the patient's desire for some such thin[! and must be a " relic of medical practice 2,000 ancl more years 11go." He connects it with the humoral theory of disease. Experiments on rabbits demonstrated that purgation induced npathy and appearance of sickness. The bowels were found injected, full of gas, sometimes atonic and flabby, often irritable here and there, and inclined to contract down into hard white cords. In many rnLbits the mesenteric vessels nncl intestinal walls were engorged. The author's summary of reasons for avoidinp: pnrgat ives before operations are in part as follows: Pmgatives "bring about patho- logical conditions by interfering with intestinal absorption and upsetting the balance of salts. The body is WC'akened and not strengthened." "There is an increased gro"'Yth of bacteria." "There is a tendency to flatulence and distention." "Purgation makes the bowel react poorly to drugs." "The purge must be responsible for some of the post-operatiYe nausea and vomiting." ''1iile not agreeing with the contention of the author, the reviewer hopes that the article in question will be widely read and believes that it will do good because there is undouLteclly a great deal of thoug-ht- less prescribing and there are not a few in the ranks of our profession who believe thnt if n thing is good the more of it the Letter. 'Ve habitually speak o.f seYerc or mild purgatives and dictionaries classify them as drastic, simple, saline, laxative, etc.; therefore the term "purgation" does not imply the production of excessive al vine dis- charges. To induce violet cntC'ric activity and copious loss of fluid does seem irrational and. of course, in certain cases eYen the mildest purgative will be harmful, as in cases of appendicitis, intussusception, Yolntlus, etc. Aharez says: If n patient's bowels move normally eYery clay and particularly if th£>y move on the momln~ of the 011erutlon. ns they probably will <lo If breakfast Is ullowed, no enema should be giveu. Enemns need be given only to those who are defi- nitely constipated. This view of the situation seems optimistic in the extreme. A con- siderable proportion of surgical patients are "omen, and women as a class are notoriously constipated. While they may have established a very considerable degree of tolerance for the presence in the body of 1 or 2 pounds of excrC'rnentitious matter, most men are apt to be rather miserable when the bowels are inactive. Patients ha.Ye a right to expect that these details will be considered by the medical attend- ant before and not after the operation with its ineYitablc discomfort and possible suffering. It is our obscrnttion that the change of habits incident to becoming a hospital patient tends to constipation nn<l thnt a. satisfactory stool on the morning of operation, breakfast or no breakfast, is rarely to be expected. 744 SURGERY. Vol XIJ, Wo sincerely hope that the third-<lay purgati"e will continue in rngue in obstretric practice, because we h:H'c >iYid recollection of the increased comfort and well-being that came to the women of the lying-in ward when they were rclieYed of their faecal accumuln- tions. Experienced matrons often begged for the "C. 0. nnd G.'' on the second clny, nnd there were few "·ho did not ndmil n.ftcrwnrds thnt the relief secured amply made up for the horrid tnstc. The third-dny purgnth·e constantly brought down slightly elcn1tcd tC!m. pern.tures or seemed to do so. If not related as en.use and result, still the two c>ents wero constantly related in point of time. The trouble with purgation before operation is that it is part of a routine pl·occdure, uncl routine procedures. though beneficial in 1nn0,. ways, haYe huge disadvantages as well. Had Dr. Alvarez contended that the routine administration of drastic cathartics prior to opern- tion was wrong there would be no disfient. Routine procedures mnke hospitals run smoothly nnd are good. but in the long run that sur- geon will ha>e the most lasting success who. besi<les manual dex. terity and diagnostic acumen, po£spsc:es an insight into tempernment nnd can spare the time to inquire about the individual habits and needs of his patients. The patients 0£ such a surgeon will have nde- quatc preparation for operation. but it will probably not be the same in two cases. For one a cheerful smile or a reassuring word about the children at heme will suffice, an<l for another a 1·cry liberal ~tinrn­ lution of the emunctories mny not lead to drnstic catharsis. As to the unsatisfactory n.nd disagreeable action of snits. we arc in hearty ngr<'cment with tlia nnlhor and reC'ommend as n. substitute n fluid preparation or casc:ira, castor oil given in a, sirup of rhubn.rh, or the pn.lntable n.nd thorough compound licorice powder. COR:'\'rn, E. M. The surgery of painful amputation stumps. l'ror. Uoy. Sc:. Iccl., !II:ir, 1018. As shown by l\fnrinesco, the chief factor causing pnin in stumps to be fitted with artificial limbs is inflammatory chnnge within tho ner>es, and it has been found n.s ln.te as 38 months after the amputn· tion ir a healed stump. Amputations were rather neglected b--fore the war and in large hospilnls used to be handed o>er by the surgeon to his house officer. Painful ner"es in stumps were not unknown be- fore the war, but painful !"cars and bulbous nerYc endings were un· common. In 1!)13 there were no such cases among 529 applicants for artificial limbs to the Royal Surgical Aid Society. In 1915 1 egnn the work at Roehnmpton House, nnd here, out of the first !)3 r,ase.s sent to be fitted with artificial limbs, 38 were found to be 1111re:uly. However, now, improvement in the technique of amputations is progressive. S'lJRGERY. 745 The encl of n ncne in healing hus to go through three stngcs, which may be brief but can not be obvinted. They are: Fir:::t, the stage of repair inflammation: secondly. the E.tn!!e of compres.<;ion: thirdly nnd finnlly. the stago of regeneration. To reduce the first stage it is necessary to close t!ie end of crery :,tructure left open by the cutting nncl sawing of the amputation. There mu!'t be no infection. so that the "·oun<l can Le closed "ithout drainage and without the discltar!!e of serum from open ends. ~\..mputation surgery is complicated by nn 11d<litional difficulty of n threefold charncter-namcly. tho com- pression, inflammation, and regeneration of nen·e endings. ActiYe inflammation is kept aliYe by the irritaton of unnbsorbnble li!!atures. It is curious that with the changes in the nen·c endin!!s the pro1l11ctc: of irritation from ligatures should he carried to the nen-c lymphatics. The condition reminds one of tetanus, in which the poisons arc con- 'l'eycd by the neural lymphatics to the nenous ~yf'tem. The rescm- bl:rnce is increased by the spasmodic cramplike pain. Compression acts in hundreds of ways. It is mainly brought nbont by the contraction of the fibrous tissue on to the expanding, growing tissue of the cut nene end. "The contracting cap of fibrous tiss1 o O\er the nerve end is derived from the endoneurium. perineu- rinm, and cpincurium coats of the nerYe. Through tho meshes in them tho unprotected regenerated fibers ha"l'e to pass. This is tho ma· n place at which the strangulation of the nerYes takes plac<'. If o.ny of the nerve sheaths can be uninjured in the division of the ne1 rn, so much less the strangulation of the new nen·e fibers to be formecl by regeneration. This is shown by tho different shapes of the nerve endings if the epineurium is preserved or not. If no epincurium is retained the nene ending is truly bullion!'. If the epincurjum is retained the nen·e ending- becomes p~ncil shaped. Uet\Yeen these two extremes there are any numher of varintions in the shape of ncrYe endings, such as those obtained Ly my 'swinf!ing- door method' of dividing nenes.'' The distal dh·ision is made with ll ~harp instrument hy two oblique snips meetin~ centrally al nn ncute nngle. A\s the nern~, which has been pulled down and ouliquely di,·id.tl by two cuts, one from each side, retract~. the cut surfaces become coapted. In order to produce a painless stump the inflammatory stage nntl the contracting of scar tissue must be over before the nen·c fibers push their "·ay out of the nerrn bulb and through the mesh of the ''internal" scar. The following paragraphs are quoted literally from the author's pa1er: Kormally, more or less of this takes place, but in these war cases regeneration begins very early after nerve injury antl its processes IGODS-18--1!:! 746 SUilGEUY. proceed rapidly, this perhnps being due to the increased vn::;culnrity brought nbout U)' the inOammntion nnd the irritation of the sepsit Thus the nerYe fibers begin to regenernte in n few days, according to Ita Jinn authorities, nn<l they branch and branch ngnin; one ori ..... innl fiber becoming represented by many fibers, each of which is '>a potential source of trouble-it may encounter un inflammatory notlule_ or b~come compressed. Thus, possibilities of future trouble arc manifold; the early regeneration enables the yonng fibers to become long enough to be strangulated before the scar tis ue hns ceased to contract, nncl the greater number of brunches of new fibers make the occurrence of trouble still more probable. After the wowing fibers of nerve regeneration hn ,.o escn peel from the nene bulb and the zones of certain uncl poc;sible compression I thl'y follow the direction of the scaffolding of connectiYe tissue and make their appearances in strange places, completely foreign to tho course of a ne1Te. For instance, in one example regeneration hnd taken place :from the sciatic nerve and reached the popliteal artery, where pnrt of the ncl rnncing regeneration fibers followed the nrtl'ry through the adductor magnus and appeared on t.he front of the thigh, forming a. tender lump. In other cases the progress of thn regeneration fibers is like the course of a river. nnd where nn ob- struction is met the flow pools up until the obf'trnction is owroome. Thus regeneration neuromatn. are .formed and mark the site ns 11. regcnaration "pool." No less than three neuromnta were present, attached to the long snphenous nerrn in the case of Thomas nnd tho small sciatic nene in the case of .Anstey. So far ns I know at pres· ent these regeneration ncuromata seldom possess foci of in'lnmmn· tion, but they may be somces of pain, not of spontaneous pnin but they ca11se pa.in ''"hen pressed upon. In inilnmmutiou uud compression, two forms of the causation of pain are in evidence. The inflammation does not remain in tho nerve bulb and only extl'ncled peripherally, but it also progresses up the nerve as an ascending nl'uritis. Clinically there may be distingnished at least £he types of pnin in amputation stumps, the first of which is universal and the Inst un· common. Fir~t. Early pain. coming on immediately after the amputnlion, dependent on an enclonenritis set up by the injuries inflicted on thn nerves at that operation. ·when alone present this accession of pain dies nway in a. few days or weeks. Secondly. Compression pain, coming on about two months after the intennl nnd sonietimes steadily increasing. Thirdly. J nfinmmntory pain. The early pain neYcr passes off, or it may become paroxysmn.1 and seYere, or it may even be still moro dearly <lefinetl, as in a man recently under my care. ~o. 4. SURGERY, 747 Clinically these cases may be grouped in a series; pa in imme- diately after the operation is due to the trauma. of that operation :ind the inflammation of the repairing tissues; u Ii ttle later, after from 2 to 10 months, the pain is due to the compression of the ncrYe fibers by the contraction of scar tiss11e; later still~ pain is due to :ictirn inflammntory changes in the nene ends. The fourth clinical type is produced by the regeneration of nerve fibers. It is characterized clinically by more continuous pain and illusions as to the presence of the missing part; for instance, the amputated foot. The pnin is acnte, ancl first appears \vithin a. few days of the nmputntion. At first it is not great. but increases in seYerity. The fourth type has clinical features of both the second n.nd the thircl type. The fifth type is only recognized clinically by the process of elimi- nation; neITe trunk after nen-e trunk is removecl by opemtion nnd their consideration eliminated by trustworthy surgcry. Still the pain :incl tenderness persist, and are not of neurotic origin. The pain may originate from the irritation and inflammation round n silk ligature or other foreign body. Or the skiagram mny show thnt it is due to lisense in the bone; terminal rarefaction of the bone is due to the injuries of operation ancl the healing of tho wound. but when the bony changes are fnrther afield they are partly due to nel'\ ons irrita- tion-dystrophy. Such cases exhibit the usual signs of bone pain, night pain, and pain in wet weather, and are Yery persistent. They are frequently called neurotic patients, but the fault is nol theirs but ours-we hnYe not found out the cause of the patient's, pain. \Ve shoulcl bear the reproach. The stumps of patients of thii; Lype fre- quently twitch and twitter. It would appear then that them nre many cnusrs for nonnrrvo- trunk pain in amputation stumps, and these may he clussificcl accord- ing to theil' source o.f origin-hone pain, muscle pain. ligature pain, nncl joint pains. This class of case is one of the 111ost interesting to study. In the exploitation and unraveling of these cases one speeclily becomes n.wnre of the fact that this infcctiYe inflammatory wouncl callus has the greatest tendency to spread along Ye.:-:sels nncl t•asily enyelops the nerves which may accompany them. tllHl. further. that this condition is made worse by the presenc<' of 1111absorhnble liga- tures. il'ritution produced by which maintains the inflammation. One of the most successful nmputntions of the whole wnr is a suprnmalleolnr amputation of the foot, a Syme's amputation. With it the patient can wulk as well as he ever did and follow his orclinary nvocation. Unfortunately the Sime stumps are sometimes tl'n<ler. The stump is ideal to look at. The explanation of the painful stump 1s almost always the same--the posterior tibial nerve is strangulated 748 SUilGEBY. by the largo internal scnr. The anterior tibial nene has either b~n retracted or cut short. The posterior tibial nerve is not :-o easily found and is rarely cut short. Some 01 these posterior tibial ncncs become str.Lngub.tcd; the mnjority ec::•ape. Dy the contraction of tlrn fibrous tissue they may be tied to the posterior surface of the tibia or pulled under the newly fastened down tendo Achillis. The swollen and redcmntous stranguln.ted encl of the nerve is easily demoustratecl. In fact, for the demonstration of ner\e ~trnn~u­ l:ition I know of nq better stump. The nerve lies in the heel flap which was brought O'\"er the encl of the amputated limb, coYerin~ it er.tircly, n long flap cnnyiug n ner•e. The retraction after the divi. sion of the nerve tmnk is \Yell shown, hut I have never found trouh]e with this nenc ns it lay in the flap, but higher, about the lcn~l of the external skin scar. Theoretically these nerves shonlrl he 1li' idcd nt tho level of the skin incision, but practically, a<:: teachers of opera. tin' surgery known well, the nerve is redivided higher up in the freeing of the heel flap. So it escapes lower down as it lies in tlte heel flap. The anterior tibinl nerve always escapes as its end retrncts nnd i-i not exposed to the irritation of the healing wounds; and t11e in- cision is so situated that the nerve end is wholly abo•e the nmputn- tion. The anterior tibial nen·e always escapes and the posterior tibial nerrn always gets str::rnguluted. Ilut why is there such n high percentage of painful nerve bulbs in the amputation stumps of the upper nrm 1 The nerves and muscles here nre included in one big cicatrix whose lower encl is at the ampu- tation, forming n nenro-vascular bundle. This formation is only found here, not elsewhere. It is peculiar to this part principally. I belicv<>, for two reasons: First, on the inner sicle of the upp ~r arm there is n hngc lymphatic and blood course, enabling the l <• pi<l nntl ~tensiYe formation, and subsequently contraction, of scar; scconclly. in this situation the nerve endings are only covered by n thin smsitive skin. Ilony formations here arc unusual, whilst they are plentiful nnd n distincth·e feature on the posterior and inner part. of the thigh. Almo;;t nll the amputationc: through the nrm have been <lone by means of the circular method. In ·dew of the formation of so lnrge a scar, in•olving so many nenes, it is better to convert the circulnr nmpnt:ttion into n racquet incision, and, through the incision rcprc- scntin~ the hnncllc of the racquet lying over the Yessels nncl on the inner sitle of the arm, the nen-e can be remoYecl. A great lc'1!!th of nerve can be removed, as the nerYes which become painful an<l bulb· ous ha•e no bmnchcs of import:rn~e in the arm. The mcclinn nenc, the ulnar nerYe, and the internal cut:rncous nerve cnn be removed up ~o. •· SURGERY. 749 to the axilla; and the musculo-spiral nerYc can' be remoYed as far as its junction ·with the circumflex nerYe. Forearm stumps, bearing Yery little pressure, are Yery nm1sti:1lly painful. In the neighborhood of the wrist the median and 11lnu.r nerrns would seem to be seldom nipped or inflamed, but they regcn- crnte into infoclhe fibrous tissue nncl into adherent tendon", the regeneration here, as ebewhere, being a. new formation, and invading structures like malignant disease. The pull of the tendons or the infiamma.tion nncl cicatrizntion of the scar tissue sometimes makes their excision ncce!;Sl\ry. The mass of tissue might be compared to a. fruit and the nen-e to the stalk. Sometimes these are very trouble- some cases. ( 1) Tender nerYe bulbs should be excised together with a. long piece of nen'e so us to get aboYe any perineuritis or ascending neu- ritis there. (2) The best method of remoYing a nerve is by means of the epi- neural slee,·e. (3) Drainage should always be employed. A good-sized tube is used. Its nonuse leads to hemorrhage. . (-!) All ligatures nucl buried sutures should be of absorbable ma- terial to minimize sources of irritation. ( 5) Injtctio.i,:; of alcohol, quinine, and urea, etc .. should not be used, as about three or :four fifths of an injection flows out of the nen·e into the surrounding connecti,·e tissue, carn::ing lnter a lnrge formation of scnr tis~ue round the nerve and its suLsequent str:mg11lu.- tion. (6) Fixation abscesses ure <.'asily produced by tucking gauze ot· part of a. swab into a rcc<.'ss of the wonnd and leaving it there. They seem to attract a ccrtnin nmonnt of the infection to the nhsrcss, which, when the gauze is rcmo\·ecl, allows that sepsis to drain away. Perhaps these fixation abscesses are more frequently mnde 1mintrn- tionally than intentionally, antl are at times most beneficial. The gauze may be left there as long as three or four weeks. They ce1•- tainly seem to relieve the pain in some cases-infective cases for in- startce-and are a goocl counterirritant . ..l.nother method for reJie,·ing pain is the use of nn old-fashioned scton of gauze put through the skin of the stump n little abo,·e the amputation. The recommendations that I would make to tho2e surgeons doing the amputations are: (1) Let technique be as surgically clean as possible. Much harm results from" lighting n fire" in a wound. (2) Use only nbsorbable sutures. (3) Cut all nerves as short as possible, using the ''~wing-door method " to close their mouths. 750 SUBGEBY. Yol, XII (4) Cut nil ''e£Scls short, ns they form the great~:-t channel for the spread of infect ion. ny cutting them :-hort "the door is closed." (U) Drnin tempornrily nll amputation wounds, ming a large tube, nntl at least one. (C,) Start the Cnrrel-Dakin treatment at the time of operation in dirty cases. (i) In clean cases close the deep '•ound with a few catgut ~fochcs. WrLLE"S, C. Abdominal self-protection in war surgery. Ilclglan ~Ie•llca l Ard.1lrcs, 1!>17. Among the few symptoms that may be considered pathognumonic in surgery is rigidity of the abdominal wall. Thi~ symptom or sign should be sought in eYery case of injury to the belly or where chest, loins, or pelvis are iiwoh·ed. The examination is made with tho patient on his back, the head low, the thighs flexed, the knees npart, tl1e mouth open. The patient is told to relax the abdominal musdrs ns much as possible. The hand is placed flat on the belly, slow gradual pressure is made. Gentle, steady pressure may cauc::e pain, Lnt if rigidity is not present the abdominal contents may he com- pressed by this manem·(!r. If rigidity is present the muscles become hard and bonrcllike and ofkr stubborn resistance to pressure. In its most conspicnons form nbdomin:il rigidity is general but there may be loculizecl rigidity only. General rigidity indicates a perforation of the peritoneum, but <loC's net prove a ruptu reel viscus. Large hemorrhnge excites general rigidity. Less severe hemorrhnge would excite less rigidity. G cnernl rig:clity Ynries in character. It is seen best in <'fl<;£'); of perforation of the gut. Here it nppears early, extends o' e1· tho whole belly. nncl passes away before septic pcritoniti~ is fully d~ ,·eloped. Perforation of the bowel usually shows general rigidity prior to the de,·elopmcnt of peritonitis. Rigidity is less when it is cnuscd by hemorrhnge. \Vounds of the liYer, if not excessh'e, may show results nlmost iclentic:ll ·with tho'>e due to a perforated gut. Injnries to the kidney may cause localized rigidity which migl1t be a mii::lea<ling symptom. D.i.NIELOPoULu, !J. Typhus !ever. .Archi 1·es of henrt discusc, 1018. The red bloocl connt is normn1 unless there is cyanosis with coltl extremities. Then the blood is Llackish in color anrl shows a pol.v- cythaemiu of 7,;:;00,000. In the great majority of cases the; Jcucocyte J'(o.4. SUBGERY. 751 count is raised. Sometimes there is nn initial retlnction, but this r:irely lasts. In mild or moclerate cases the leucocyte count mny rench 20.000. In grave nnd fatal cas!.'s the leucocytes mny reach townrd the entl as high ns 128,000. In the differential leucocyte count in typhus Danielopoulu nrrives at conclusions rather different from those of previous observers. He finds that a mononuclear increase, due to the large nnd medium sized cells, is the predominant feature, and he has followed fatal cases with a. mononuclear percentnge of 50, G3, GS, 'il, and e,·en 7G. The polymorphonuclear leucocytes nncl the large mononnclears often show dcgeneratin~ vacuolation of their protoplnsm. Granular nen- trophil myelocytes are Yel'J rare and 11ucleated red blood cells even more so. The blcocl nlmost constnntly shows the presence of mono- nuclears with highly bnsophil protoplasm ,~dthout grnmiles and with nn eccentrically phtced nucleus; these cells Yary in size; some are quite small and the hugest measure 20 µ.; they are oval or more rarely round. DEXNls, F. I... Tonsillectomy i:i the tuberculous. arya~oscop, St. I.oul!!, No- vewller, 1017. Difficulty was encountered in estimating the direct results of ton- siliectomy in these cases-first, some cases were 'vell on toward rccoYery, nt time of operation, and continued to improYe, which probably would have occurred without operntion; second, there was lack of definite information regarding the condition before opemtion, :mtl inability to follow case afterwards; third, it was impossible to judge exactly what e[ects the operation has had on the tubercular process. In general, certain conditions must be observed; a time should be chosen when the lungs are relath·ely quiescent, ether is coolrnindi- cated; local anesthesia if possible. After operation. the author advises the application of tincture of iodine to the wound. In general, his experience has been favorable. (G.D. T.] Reprints nnd extrnrtii from tlle Medical Supplement to the Daily Review of the Fol'eign Press. l~suecl hy the General Staff, War Otnc:P, Lomhm. Volume 1, No. G (June 1, 11)18), contains an illustrated article on prosthetic appliances, in which the history of artificial arms and lrnntls is given jn clctnil, beginning with the artificial arm used by Gotz von Berlichingen in 1500 "·hich is presened ir, Nuremberg. In this the fingers were not capable of actiYe movements but "·ere ad- justable. It permiltecl great grasping power. All the finger joints 752 SURGERY. \'ol. xu. were moYable and the fingers were held in exten:;ion by flat springs. When forcibly flexed the fingers remained in that position until re- leased by pressure on a projected button at the wri~t. _\. Berlin den- tist named Peter Baliff produced a mechanical hand in 1818. In this the normal position of the fingers was flexion. which was maintained by special springs and extension through catgut cords worked by the action of the sound shoulder with straps around the chest. Tho weak point in this device \Vas the weakness of grasp. The principlo was deYeloped by Karoline Eichler, but in the hand made by her the fingers are in extension, maintained by spiral springs. Flexion is brought about by means of catgut cords worked by the sound shoulder. The Keller hand for forearm amputations has been extr •mcly popular in Germany. It has three stiff metal claws and is used in conjunction with a strap. The arm of Lange is an interchangeable work and Sunday arm. This is attached to a leather cap, closely modeled on the shoulder girdle, or, in upper arm cases, a leather ring around the shoulders with steel strips attached to it. The important points in an upper arm prothesis are: _'\ccurate adjustment and fixation to the trunk; (2) great simplicity of con- struction; (3) solid material is required. Tl:te Carnes hand has been used by Dr. Max Cohn even for oper- ating. Lange describes two kinds of hands, one for finger-tip grip, the other for the broad or palmar grip. Adequate arm prothesis is mnch more difficult of attainment than the production of a suitable artificial lower limb. This absence of cu- taneous sensation in the hand may be atoned for in a measure by the deYelopment of the muscular sense of the stump muscles. The arti- ficial hand to be useful should form a fist for grasping purposes; the hand should utilize the sense of touch, or at least the muscle sense. The artificial arm should be wholly independent of the function of the muscles of the sound limb. No artificial arn1 has any great value unless it ptrmits a man to pursue his daily life and work. Among the signs of a good artificial arm are the following: (1) Power of flexion and extension at the elbow; (2) rotation around the long axis of the upper arm; (3) pronation und supination. flexion, and ex- tension at the wrist. For an arm to be useful there must be free movements of the shoulder. Maintenance of the free movements of the shoulder is asine qua non of a useful arm. Of the short muscles all except the opponens pollieis can be sacri- ficed. !\O. 4. SURGERY. 753 In musculo spiral palsy the fist can not be closed while the wrist is flexed. '' For hard work it has been ''"ell sai<l. · The stump is the best pro- thcsi.:;.' The mechani~m of the hand is wonderful. but skill in its use depends more on the cerebral cortex. The stump has sensation, which plays an enormously important rtile in the mechanism of the hand. Sot only is there cutaneous sensibility. bnt muscular se11se and pres- sure sense. Sensibility can be dcYeloped in use and touch cor- puscles incrrasecl in number, so that after a year or two the stump nu y be as sensitiYe as the finger-tips, but this will happen only if the sh mp is continually uncovered and exposed to fresh air. so that it is not coddled, but hardened and strongly vascularized." The follo-wing directions u re given for making :Martin's "\Yater- proof Gluc: Diraolrn in a water bath (or the ordinary gluepot) 1 kilogram (35 ounces) of the best glue in 1 liter (ll pints) of water. When the !'Olution is homogeneous precipitate it by adding the following so- lution of tannic acid: Acid tnnnic. 2,500 grams, say, 5 pounds; acid carbolic, 500 ~rams, say, 1 pound; watc-r, 50,000 grams, say. 10 gallons. Add this solution to the glue until it becomes a milh.-y white throughout. Let it cool down to 35 C. (D5 F.). Collect the precipitate then produced and wash it thoroughly in tepid running water at about 30 C. (86 F.) until the washing water is only very slightly discolored by the addition of a dram or two of an aqueous solution of sulphate of iron of a strength of 10 per cent. ' The stringy precipitate should be leathery nnd of a pale mauve color. It becomes rather brittle when cold. Take this precipitate nnd make it soft again in the water bath. Dissolrn it at a temperature of SO" to DO C. (176° to 19-! F.) in dilute alcohol (alcohol as used for burning or ethyl alcohol of 90°, 1 part to 3 parts of distilled water). Dilute till it has a sirup-like consistence 'vhen cold; it coagulates while becoming paler in tint. Before using the solution bring it to the boil. which occurs at aLont 80 C. (176 F.). This glue is used hot, and it should remain of a constant con- sist<mcy. As soon as it becomes in the air the color of dark-brown caramel, and remains so, it must be restored to the proper tint by the addi- tion of a certain quantity of dilute alcohol. 754 SURGERY. Yo!. X:ll Dr. Martin uses a tnble or trough kept nt n constant tempu-nturo by a current of hot water. The Ycsscls containing the glue in use arc stood in this running water. The glue is applied with n bru h nnd the adherence oi the strips of wood is s2cured by pressure with n hot copper roller. Cramer stntes that bony spurs, either from periostium or meclulla ' ure rnre in the upper pnrt of the tibia but they are ;ilmost the rule in the femur. The nrch of the sound foot must receive close ut. tention in cnse of amputation of the lower extremity, because of the o.dditional strnin put upon it after long confinement to bccl. The effects may be disguised but the disposition of the patient to throw tho weight on the outer side of the foot, raise the border and so in. advertently conceal a flat foot. The following are the stumps thnt need operatiYe interference: (1) stumps with sinuses, which usually go down to <lend or nn infected. ligature; (2) stumps with abnndnnt skin; (3) stumps with little or no skin covering; ( 4) stumps which can not benr pressure because skin over them is too tender. Preliminary to renmputation there must be weight extension ap- plied. to the skin during n period of nearly 3 weeks but neYer for longer. In doing reamputntion it is essential to leave no bleeding points untied. The most difficult stumps to h::mdlc are the short ones with pro- jecting point ends. One has to try to coYer them, sometimes by snc- rificing more bone, sometimes by using pedicled flaps. Stnmps of the upper arm are easier to close OYer than those of the thigh. In Yolume l, Ko. 7 (July 1, JOH!) lllerP ls a reY!ew of WEDEBIIAKE, The surgl· cal use of human fat. Berl. kiln. Wcbuscbr .. 1!>18, u5, 47. Wederhake reports on tho surgical uses of human fnt, which he nhrnys obtained from the living hocly, either from the omentum or from li pomata. .Aiter clue prcparu t ion and sterilization it is in n liquid state. Before use it is heated to body temperature. The author employed it with ach·nntnge in the following groups of cases: (1) By way 0£ hypodermic injections to raise depressed and de· tach adherent scars. (2) In connection with suture oi tendons. (3) By injection into the she1tthc; in case of tendovaginitis crcpi· tans. ( 4) By · njcction into lhe sheaths of the flexors in Dupnytrcn·s contraction. The author claims that no other mode of treatment brings about reliable results in so short a time. SURGERY. 755 (5) In traumatic oedema, the moc:t important field for the use of bum:m fat, since here it shows in a preeminent degreo its striking r:ipncity for dissolvinrr scar tissue. (G) In dealing with the after effects 0£ phlegmonous tendovngi- nitis. (7) For patlclin~ the skin over bony prominences. Thus it proved 0seful in a cnsc in which the plantar fat 0£ the he~l hacl completel.v uisappearcd from trophic lesion. (S) For filling vein grafts used for bridging defects in the con- tinuity of n nerve. (D) Ily hypoclermic injection in pruritus ani et vulvro. (10) For detaching nerve adhesions. (11) As a dressing for wounds. I3ut it does not supply an oint- ment base. Its chie£ 'alne, however, lies in the £act that it dissolves cicatricia1 material, chiefly in conection with the sheaths of tenclons. It is superior in this respect to thiosinamin, fibrolysin, nnd cholin; but its effects arc purely local. MARnNI, E. ~Illncllen. l\Icd. Wcbnschr., WlS, G5, 40!, recommends the use of the following epiln.tory powde~ in tho prophy- laxis 0£ typhus; Two parts of strontium sulphate and one part ench of zinc oxide and talc. The powder is made into a paste with water nnd applied to the hniry pnrts of the trunk and limbs; the crust is '."CIDOYcd in about 10 minutes. The patient is then wa~hed nll OYer, nnd the skin, especi1llly of the scrotum u.ncl n.nul region, grensecl with oil or vaseline. The pnstc is not applied to the face or hend, the hair 0£ which is rnrc>fully shnved. The patient's clothes arc in the meamYhilc deloused in another room. This epllntory method is ap- plied to nll typhus pntients, to those suspected to haYc the disease, nnd to those known to hnve been exposed to infection. Durin~ the last 18 months this rout inc has been in •oguc at the "'locl:nYck feyer hospital nncl none of the stnff. the male and £cmafo nurses. or the washerwomen haYe contracted typhus. Trnnsfuslon with the blood obtained from com·nlescent patients lf1 <lcscrlbed by KA.DELEK, J. Wien. klin. Wchnscllr., 1018, 31, 47-l:iO. ns very simplo and not necessitating centrifngnlization or delay to allow the bloocl to clot. Whole blood is employecl ancl it is consillered that this is more likely to be sterile than the ser11m. It is doubtful if the red cells nncl the platelets exert any specinlly benefi<'inl influ- ence, but the leucocytes certainly do. The technique is free from 756 SU1!GEI:Y. complicated steps; the syringe is washed throuah with a 4 per solution of sodium citrate in normal saline, ancl nn amount eq11nl to one-tenth of the blood to be withdrawn is re~ainccl. for example, 2 cc. when ~O cc. of Lloocl, the smallest quantity of uloocl that has nny ctfoct, arc to be taken. The blood is then withdrawn from tha vein nt the elbow of the connlescent patient, mixed with the citrntt i:;olution nlrcacly in the syringe, and injected into the febrile patienL The earlier in the course of the disease the transfusio~ was giYen the better the resnlts. If ginn before the rash appeared, a. prompt nnd permanent fall of temperature resulted; when administered later the recovery was not so ra pi cl, but the course of the cl isease is short~ encd nnd the symptoms alleviated. No bad results were obsen·cd. Daily Review of Foreign Press, July, 1!>18, points out thnt psoriasis is now Jess severe in type in Germany, owing to the reduc. tion of meat and the increase of milk and Yegetnbles in the genern} diet. Scnbies is a serious scourge among French troops, as under war conditions vexatious complications arc numerous nnd common. These are persistent ulcers, boils, superficial phlebitis. MILIAN, G., In Paris Mc;licale, recommends the use of an insoluble sulphur preparation whereby the treatment is simplified and abbreYiated. The ointment is macle by mixing nscline and lnnoline, 250 grnnrn of cnch, to which is ndcled first n ~olntion of sulphide of potassium in 2.10 grams of water, nucl then oxicle of zinc (5 grnms) in 200 grams of liquicl 'a~· lirn>. ~\.fler a Lt-th or wash with soap and water this ointment is applied all OYer the body. ancl the patient puts on his clolhc..:;: the next cln.y the process is repeated. and on thr followiug <lny a bath with soaping is given to remove entirely the slightly irritating oint- ment. Scahit•s with impetigo nnd boils can thus be treated, and the need for disinfection of the clothes is clone nway with. Two fnrther points, howc,·er, ~honlcl be mentioned. In the first place, the ob- jectiYe signs of scabies often 1ccome moro prominent for three or four dnys after the ointment has been applied, thus burrow;'; pre· Yionsly invisible become evident: nnd, in the second place, persons with su~ceptible skins or those who btffe not been thoroughly washed with sonp after the second npplicntion of the ointment ma~· hnve n more or less widespread acute nonsuppurathe iolliculitis which np· pears, in about 2 per cent of the cases, four or five days after the 11se of the o"ntmcnt, and lasts :for fi,·e or six days. These red papules, due to the irritation of the remains of the ointment. must not be ml"· taken for a relapse of the scabies. IIYGIBN'E. 757 HYGIENE. Sll!Tll, C. E., nnd SCHODEKU, II. M. Sanitation of swimming pools. Am. Jour. r ub. Ilenltb, Juue, 1018. The diseases likely to bo acquired by bathing in polluted water fall into three groups: Intestinal diseases, those of eye nn<l ear, nnd rcneren l. Typhoid feyer and dysentery ha>e been contracted through the ingestion of polluted rh·cr water by bathers. Trachoma 11ncl ear infections ha.Ye been reported following the use of swimming pcols. Cases of gonol'rhen nncl infections of the Yaginn. by the bacillus procligiosus following use of public baths have been re- ported. The greatest menace to health i~ represented by the B. coli communis and tho B. 1yphosus. · 11! anagement of tlie watrr.-There is no direct relationship be- tween number of weekly fillings and sanitary condition oi the water in a swimming pool. Dilution is expensi>e and efficient. Rcfiltni- tion improves general :tppearance of the water, lowers bncterinl con- tent of swimming-pool 'rater, and reduces cost of maintenance. Chemical disinfection.-Copper sulphate destroys bncteriu and nlgro. From 0.04 parts of copper sulphate per million of water used each dny to 0.5 pnrts per million is reccmmencled. The effects of bluo vitriol taken internally in small doses frequently repented hns not been determined, but in concentrated form it is poisonous, hence tho need of great care in its employment for purposes of disinfection. Cnlcimn hypochlorite is an effectiYe germicide through the liberation of chlorine. Tully recommends 0 .. ) parts hvpochlorilc of calcium (30 p. c. available chlorine) per million. Others believe tlrnl us much as 3 parts per million nre necessary. This subject is still nn<lel' in-vestigntion. The amoun! of bleach required depends in pnrt on the lrnr<lness of the water. At this "-riling the chemical is costly, nnd it may be cheaper to use liquid chlorine. Chlorine being irritnting to mucous membranes is unpopular with the patrons of swimming pools. Adminbtrntion hns much to do with keeping the bacterial count low. Bathers shoul<l lie instructed in swimming-pool sanitation nncl should be inspected before entering the water. They shoul<l hnve a cleansing with soap and hot water preliminary to entering the pool. General conclusions.-Swimming pools should. be :::o well lighted that a submerged per!'on can always be readily seen. Ec<lnomy therefore suggests locating the pool at the top of n building. Tho waste water from the pool can then be used for flushing of closets, urinals, etc., in the building. The sides of tank should be smooth. Four sides of the pool should be available for use 'vith lifo rails all around. Overflow gutters nre necessary, and there s11011ld be a trip basin 12 inches below the ma.in platform. When the tank is emptied 758 llYCIENE. the :-.i<les should be scraped. £crubbcd. and flushed, then steamed nirecl. :mcl dried. \Yrenths of sediment on the floor !'houlcl be ~ mo' ed nncl pumps on the general plan of a rncuum clC'uncr nre rec. omme.ndcd. Rdiltra1 ion and constant agitation of the water should pre,·ent formation of wreaths. The water selected for the Pool should be the cleanest nrniluble and not th11t ''hose source is siin. ply the most accessible. Con:;tant refiltrntion makes it possible to uso n giver filling n greater length of time. This is an important item in cost of main. tenance nncl will more than compensate for the initial co::;t of the equipment. The tendency toward installing a plant of too small capacity should be nvoidcd. It should be possible to refiJLer all the water in the tank in one day (eight-hour clays nre in vogue}. Usual frequent attention $hould be given to reYersal of filters, washing, and steaming. Dilution should be practic<>d sufficiently to make up tho Joss by splashing~ etc. No definite amount can be stated. This shoulc.l de- pend on the number of bathers. frequency of refilling. etc. .As a rough ·working rule it is suggested that the dilution be suflicient to amount to one filling between re.fillings. Refillings should be determined by the number of bathers. size of pool, nnd bactcrin 1 content, as there is no direct relationship between the number of weekly refillings and the sanitnry condition of water. The general appearnnce of the water counts for nothing. Ohemiral disinfection is impemtive.-Doth calcium hypochlorito and copper sulphule have advantages-the latter probably being tho favorite. Either should be used in strengths increasing from 0.5 parts to the million of water, depending on the Rize of the pooJ, num· ber of lmtherR, lhe hardness of the wat~-. and the bacterrnl rednc- tion obtained. Blt>uch must be tested frequently for nrnilnblo chlorine. It quirkJy di$appears from the pool. Superl'ision of 7Hrthers.- Full shower bath wilh soup should be demanded of nll bathers. To make this possible the shower nppa· ratus mu~t be inspected very frequently. Instruction should be gi,·en bathers in the purpose of the bath. Especial attention should be given the perinea! region. When water strikes n pcl':"on's body the nat urn] tendency is to urinate. This should occur in lhe shower, not in the pool. The floor should be taken care of to prevent trnck· ing the dirt, bacteria, etc., which have been washed off by the ::.bower, onto the deck about the pool. On the pool pltitform inspcc· tion of eYcry entrant should be performed. Dnthers shoulcl ' car no clothes. If this be impracticable the auLhoritics of the pool should furnish lhe snits· one-piece, undyed, scanty-and sec that they nre properl) sterilized nnd dried between usings. PATIIOLOGY A.:\D BACTERIOLOGY. 759 PATHOLOGY, BACTERIOLOGY AND ANDrlAI. PABASITOI.OGY. £I:J:B~OX, F. A b3cteriological r.tudy of the dlphtheroid organisms, with special reference to Hodgkin's disease. .Toni'. Infect. DI-<., Jul.r, 1!:11 . The "-riter h:ls given an excellent historical rCYiew of the diphthc- roicls. He states the difficulties in cln5sification nnd ::,ui?gei:.ts that they be placed in nine groups, under the term '· Corynebncterin.'' He realizes thnt his classification is far from being complete . .Agglutination and complement fixation tests were carried out to determine the idenlity of strains isolated from Ho lgkin's cliscnc:c. Scrn from four patients hnving Hodgkin's disease fa~!cd to cnuso ng_!!lutination of elenm strains of bacteria, eight of which had been bolatcd from glands in cases of Ilo<lgkin's disease aml three from (1) n case of leukemia, (2) ascitic !lnid in cirrhosis, and (3) blood. Complement fixation tests led to the conclusion that the cnu:se of Hodgkin's disease is not the organism described by numerou:s wo1 k- ei • :lnd that cultural characteristics did not sen(' to <lifl'ercntiale tho supposed cause of Hodgkin's disease from numerous saprophyl io di phtlwroids. The following table has lwcn prepared from his ttmtati' c clas:;ifir:i- tion: ~ ngeon ne~ L I. . Navy c. "' f 0 l l 2 2 2 3 3 3 3 3 4 4 4 4 5 5 5 5 5 G Diphlhtroida (Ebmon), Gram positive, nonapore forming, no11motile, no liqutfaction of gelatin (txeept C. Putidum). NlllDO or org:lllbm. C. Diphtherh ....•...•..... C. Pseudodiphtherfae sp. nov. C. Pseudodiphthcriticum ... c. Ccruminis ............... c. Dclicitum sp. nov .. ..... c. Xcrosia ................. c. Epid<'rmidiq ~p. nov . .... C. fluppurntum sp. nov ..... A. Auns ............ . ...... c. Cerebral is sp. nov . .. ..... c. Nodosum ................ e. Acid um sp. uov .......... u. ~1scitcs sp. nov .......... c. Flocculcns sp. nov ....... c. IIO'.igii .•.......••.•...•.. c. Aumnt.iacum sp. nov ..... c. Glandulae sp. nov ....... c. Stri:l.tum ....••.......... c. Sc"'mnntl)Sum nom.110~ .. c. Putitlum sp. nov •.•••... d I . 1 lsolatcd rrom- Romar la. ~-; g.~ g ~ ~ ~ ~ Q ::a '° Q ..:I• ::ii t=: --: < ~ ! !.~ ~ ~ ~11 ~ - -- ---i-- - - -- -----··------------!·--------- + + + ........ .... A······+ + + + ............ .\ . . . • . . . . . . . . . . . . . . . . . . . . . . . . Polar lm<lics, toxin products. Tonsils. ..................... No toxin produced. ± + + + + + + + + + + + + + + . . .......................... Short and thick; broth cloudy. A ••.••• '.:: . . . . . . . . . . . . A Nonna! car ................. . ± . . . . . . . . . . . . . . . . AN Ascitic fluid b.Jood cult. ... . + + - ............ A · •···· .•.. Eye ................. .. . . . . + . . . . . . . . . . . . . . . . . . . . A AN - I Skin pu~ pockots .. .. . .. . ... . + ± . . . . . . . . . . . . . . . . A .. . ..• - Pus pockets, abscesses .. . .. . f ·:· :~: :~: :::: :::: :::: :::::: ± B~L~:::·:·:-_.·_.-_:.:.~:::::::::::: + + + + + A . • • • . . Uriut> . ..........•......... .. + + ,+I - + .... ' .... ······ - , Asciticf)~d ............... . ~ + + + - ........ · · · · · · . . . . .\ppendix .................. . I+ ............ ····,···· .......... ···························· Ilrolh clear with ~cdiment. Small and dolicato. Dclicnte gro11 th. Small, ovoid. Ilca.vy; glistening growth. Lou~; scanty growth. Ovoid, coccoid. White growth on agar. Do. 1\Iuny club-eh!!pcd fonns. No cloud; Nci.sser'11 brrrumles; fiocculcnt sediment. Abundant 1J11t imperfect ttrannlcs, Sllmon-c·olorcd m scrwn. + 1 • •••• • ••••••••••••• .' A AN ................................ Coccoid; orange J>igmcnt. + + ± ......... ... ' .............. Hodgkin's disease ........... Ovoid and coccoid; col. dry and heaped up. + - ... -i-......................... 1 X11S1! mucus............... L~W~~k 1 :~rs~lar granules; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - .•... do..................... Polar hodtt'B. - I ,\ I A:-: •••• Ascitic lluicl ••••••.••••••••• , o~ilii~ivo odor; li<1uclies gel- 7 Cl. Typb.Ml'DDthC!matfct •••• + + 1···· ..... ... ... . .... . . .. A'N + 'J'7pbut-..•.... ...... , A&l \1\ \nu\tA .all 11l1•omorphk. 7 1·. Ar11r1. ........ . ... .. ... + + -+ ........ I + ± A AN + Pmtule11 (dt>op) ............ , Acid in inulin. R I <'. P11P11doh1b1•rr11lotris •.• •.. + + ........ .......................... .Anirnnle .....•.....•.•..... ·\ To:i~~(.mlfhlC'Ptl l(0\111•1\ pig· 8 0. Pyogcncs ................ - .... ,. . . . . . . . . . . . . . . . . . . . .\ AN ± ............................ , H<'moglobinophilir. 8 C. Yaccinnc .................................. --1·... . . . . _\ AN .... Vaccine P-ustulcl! in calves .. Yellow pi!!m•·nt 9 ' l'. Lymphopbilus ........... + ... +... .. .. .. . . . .. . . . . . .. .. AN : - llodgkin s discn11e ..... ..... . ~ lrndt>r; plN1rnorphic-. [o. '· o.1 • 762 'MILITARY 1 LEGAL AND INDUSTIUAL. \"01.~,I. Xooucm, II. The spirochetal 1lora ot the normal male genitalia. .Tour. l::i;. per. :\f<>cl .. June I, 1!)18. On account of the reports by Mnrtin, Knnki,·ell ancl Sundell. und by Patterson of the presence of spirochaetes in urine in case:s of trench fever or" P. G. 0.'' (Pyrexin of unknown origin), Xoguchi hns studied the spirochetul Hora of the normal mule genitulin. His discus:;ion and summary is as follows: 'l'he nirletiPs of splruchl'll'" enumerated nnd photomltro~raplw1! rorn t e male smcgmn llol'll n•111·t•sp11{ Lll'Utlically t'Yer~· l'orm hllh<>rto 1lPsc·ril>ctl liy Xnn. klvell and Sundell and l>y Patterson in the specim1•n!-l of urlne from treu<.'b- fever cas('s. TIH' Ul'l'I hrnl !lorn, ns stmlied l>y Stotlclarll, se<'m to cont1. n more vurieti<'f:, hut, f'X<'ept lllosc of his more detalle>d morphological 1le>sc·ription, every form obKl'l'Ye1l by hirn Is umon~ lhost' founcl ill thP srneirma. ~ O(lilurd i;aw c1•rl11in forms with hnokf.'tl L"ll!lS su~c:e!'>liv!.' of the Lc>ptos11lrn ktt>roha<'m ?· rhairic·tl of inf<'<'tiY<• jauntli<'l', hut llw l'<'SClllhlnnce encls with t)li,.: nil(' fenture, and differenti:ttlon shoulcl nl\\ 11~·::; he ims,..il>Jp under the durJ,-lield micro OOJ!e. by uwanf: of whir.II the lc[1tos11ira rc•\"l'ttls it'I highly (•)\11rac!t>1·islic m nute el mentar~ >;piruls. lJl'eH1•11ting- fhl' nppeantlll'l' or 11 c·hnin nf 1lot:< ....•.••• Of all tht• :-:piro<·lwh"'. 1um1• 1111-; "'1 c·Jo,..ely s1•t :<pimls us ll1•• .Jannell~ )1>pto'. spira, the dist 'll<'I' lwt \\l'\>ll t\Yll :;pint!:< bdn~ 0111~· o.:; ml<-rons. Ynrit '" IDl.'tb- o(]i;, includi11~ 1"011lt1111t'N, Bennins·s, the mortlant gentian viole>t staln, or Burrl'a india-lnk 111f'tlt<1tl, ar,• lnudt'f(unte to <lifferPntinte the 1€.'ptospln\ frN other "Pirochl'tes. Why H 110!-lililP s11il«WhPtf' li11cling with llw Ulm:< from tlw urethra an1! tlt1> spt-ciuien:< Clf 111·f11c was 11ot obtuine1l is llift1cuh to ('XJll:tln, escept on the ~-rounds of llH' paucll) of spt>dmpns P'l::tmined. .\t nil e\·e111 s, I he l'!'crnl nc:,.'llthe rc- i;ults l'<'lJOl"tt'<l hy l1'iessl11ircr with Frt•nc·h ,:0!1111.'l'S n1ul lnvn 11111:1 nft!.'r rleani;inl( of the urethra unrl :.tlitni; ~l'<'lll lo be in ham1011y with 111y n•sulti;. Tn 1·otwl11sion It n1ay he stated that Spirnn1•nm l'!·frl~enH, T1·e1101w:.11 <'Dill· ~yrum, 1111tl T1·pp01w11111 111inutum 1·epr<';.;1'nl 111·nc·f ientls 1111 till' KplroC'hetal ·forms ohsen·<'ll In the mnle sme~nm flora. .\ le[ltm;pirn hni,: ne,·er hPen «onclush·f.ly shown to be prel'<'Dl in the sprcimen~ o( normal 11ri11e or su1egma. F•ir the ~ntisfac tor~· rnlcros<'OPlc lll'llHlltNtrntion of a lpptospil'lt 11 fl11 rk-fiel<l llluminntor Is indlRpem;abl<'. f O. F- c. J MILITARY, LEGAL AND INDUSTRIAL. ~11LLH, <..:. K. Notes on the influence of wars and the phychology of the times. Am. Jom·. lnRnnity. Yol. 'ii. Xo. -l. _\Jwil. 1!ll<;. Since the beginning of the pre:-.t·nt w:tr and e5pet·iully "'in<;c• tins <'Ountry ha!', become inYoh·ecl in tlw conflict. c\·cry c•nc\ of rour,..<'. h been inlcn"·;ted in arriving nt the truth relalin• to its definite ca1M· ti\'e faC'tors. To al'l'irn at a conclusion on tlrnt pomt it is ne<·e~,..nr) for 11,; to go bn.ck and study the factors involwd in other wnrs. th~ eft'c<·t of those wa 1·:; on the times, antl to folly understand the nn tional, :tH well as the iuternn.tional, psychology of th<• present. These t hinl!S the nnthor presents to us in a Ycr.v inst l'LlC'tfr,, and inlere:-.ling way and for that rC'nson the article is well worlh careful 1wru~nl. 'Ve arC' remin<le>cl that in times of peace• people nre \'<'l'Y linlilc to lose MlLITAlt\' 1 LEGAL Al\J) INDUS'.IBIAL. 763 I sight of the higher ideals, become self-centered. ·ind indulge in n.x- c~ses of all kinds. In times of war the heroic q11:1:1ties of the people sre de'"eloped; they become as a rule. ~lf---acri licing. nml hu\'ing n de~ire to bb of some assistance to their relatiYe.-, who nrc on either. ::.ide they do all manner of things, inYoh-ing manual labol'. It is not un- common in times of war to see imlivi<luab actiYcl_v engaged in all forms of war work, who had formerly lived what might he termed para~itic existences. \Vars may be traced to the influcnl'c of former wars. The emotions and sentiments of the peopl,• at 011c period of conflict become more or less crystalized in their p~yel1ology. and Inter. under the influence of u variety of solwnt:; they an• :,rt freo 11uain lo become active. This can be well illustrated by the ~trifo e ' which began in England in 1G4~ against the tyranny of thl' King-. Tht'se efforts passed down to the American and French resolutions . . \t. the beginning of this war Germany belieYed thnt defeat wn" im- possible, but now there are evidences that the p,..ycholog_v of thnt country is changing nnd the people are. beginning to 1'<'nli7.e thnt her foe ... may be 11ncon<1ucmblc. Engl:mtl wa::: m<ll'l' ~ df -comp1acC'nt. rather than self-i<lolatrons. her energies luning hccn l'Xpended nlon!; the lines of commerce an<l social clen~lop111ent. The .\mericnn '\\flb apparently entirely intcrC'stc<l in accumulating great wealth, nnd in :,;o doing he lost sil!ht of many of the <le~irable ich•nls and bl'lien!d, for ..;omc reaRon, that t11e po;.;sibili.ty of this country being invr lvcd in the war wns velJ' remote, becnnse of the fact that 3,000 mih•s :>CJl!l- rntC'd it from EuropC'. A poor under,,tanding of ;11ternnt ion al p::;y- chology resulted in the unpreparedness in England, ns well as in .\mericn, and so the pr<'sent conflict is being prolongNl n1:rny years. If thP ulliccl 1rntions ha<l bern folly prrpnrecl then' is 110 qlll'. t ion that th" war wonl<l prohnhly h:l\'P hPPn over hy thi:-: tinw. Tn eonC'lusion, thP anthor refrrs lo the po~sibilit~· of intern 11tional pl':ll'<• hy :t:.!l'N'- ment. ancl is of the opinion tl1at there will he 110 ~nch thing unl<',,., nll parties to the agrecm<'nt are inclixicluall~· ~tronf! l'l\Oll!!h to :-11pport what they consi<l<'r to he tlwir rip:ht$ h~~ forC't'. f u. n. "· 1 Hn111 .. \ .. \. The adjustment of the Jew to the American environment. MPn- tnl llyZif'nr. \·ui. :!. '\o. :!. April, l!llS. Since the entrance of tlw United States into tho world coufiict, nnd the accompanying increase in the Army nn<l ~ • n \'.)'. it has liecn notec1 that there hns been n propor.tionate increa~e in the i1widencc of nwntal disorders of functional type. A w1·y hi~h prrcC'ntage of th"'" C'~tsrs have been in indiYidua]s of Jc>,>ish extriwtion. the patif'nts as n rnl<' recovering when lhc service ronditionR of :-,Ire's and diH- c·iplinP ha.ve bt'en l'<'movecl. To be of assistanee to I h<•s(• pat iP11(s it. is. of <'Onrse, desirabk to Jun'<' an insight illto tlw d1:trnl'lt>J' anti 1•mo- tionnl 111·1ke-1q> of th<' race. its normal conflict-; ancl its reactions. "'> 764 MILIIARY1 LEGAL .U."D Th"'DUSIRUL. Vol. :tlt that uny illness dc,eloping in a mnn mny be discovered in its in- cipiency nnd possibly kept from actually assuming the o.spects of a definite psychosis. The general features, as outlined above, o.re won. derflllly expressed by the o.uthor of the article, and it is rerommend!l(} for careful study by nil medical officers of the Navy. Aside frona the professional vo.lue of the article it is interesting from the psv. cholcgicnl standpoint and contains valuable information which e\·ery American in an executive position should be :fnmiliar with. The physicians specializing in mental conditions have realized for years that the Jews, as n ruce, usually evidence functional mental derange. ments, almost to the exclusion of organic brain lesions and the senile conditions found in the non-Jew. Ileco.use of conflicts through which the Jewish race has gone in the past centuries, as o. result of the treatment of other peoples o.nd nations, the Jew, o.s o.n individual, is now realized to be oversensitive and inclined to repress the t?reater number of his difficulties. As a result, when repression is not success. ful, a psychosis develops usually of functional type. There hare been two definite psychological factors involved in the emotional make-up of the Jew that we see to-day. The first is a reaction which has come as n. result of religious conditions which ha ''e made il nccos- sary for him to develop along very narrow lines. It is therefore difficult for him to adjust to outside life, be is a poor competitor for existence, aside from financial and business matters, is usually cod. dled and spoiled, self-willed and egotistical. Ileen.use of the action,. of the non-Jews with whom he comes into conU\ct, he, as a rule. re- presses his emotions and becomes an isolated individual. His feel· ings, bis desires, and his ideals are not understood by those with whom he is thrown, and because of bis inability to meet the difficult problems in an outward manner he apparently prefers to remain by himself. The second factor is said to be the family situation. where all of the patient's love, affection, and interest is centered in the home. He is not allowed to select his own mate; he is suspicioll:: and fearful of outsiders, is a poor mixer, and as a result when he gets into a difficult situation, given added responsibility> and r!l- quired to use initiative, he, as a rule, develops !t paranoid reaction. It is not uncommon to see this reaction in officers of the NaYnl Re- serve Corps who are pushed into difficult situations, having left a home of ease where their every want had been supplied by the parents. They usually develop ideas of reference, feel that the people about them are not showing proper respect, and a little lnte1 on, if this tendency is al1owed to develop, they will feel that ~me definite action is being taken against them by their associates. [o. o. s.l so 4. MII..lTAllY, LEGAL AND INDUSTRIAL. 7uf> AKll ~RO:\ll-.lo=-- cs. ll. Notes on drink and its regulation in rein ti on to work. and health of Great Britain. .\m .. lour. In,.anlty. \",11, 'i4, ::\n. l. .\J)rll. 11ns The question of prohibitin11 and allier! s11g~e~tions h:n·c b<.'en con- ,.1untly before the pubhc in thi;:; country in a politic:tl mhl social wny for n nuwber of yl':n·s, but 110 effort had been made for a GoYernment l'l'g:ulntion of liquor traffic until the onset of tlw pre:scnt wnr. Since thnt tinw there has lw~n a l'egulation by the .\rmy and Xnvy. in the ,·icinity of cantonments, mt Yal base:>. etc .. in t lw form of nh:solutc pro· ltibition. nrcat Britain det·i<lecl to arrive at tlw :-:une destination by rr~rulation of liquor through a bonrd of t.entral contrnl. "hit•h wns i1Hitutcd hy an act of Parliament in ,June, Hll:i. Thi~ l1ounl wn:; ant 10riz<'d to nol on]~, regulate liquor control. uut lo maintain the rtfic11 nc~ · of the workers in \'nrious areas. .\JI of lirent Britnin \\US 1ncl11de<l, with the PXception of Ireland, which ha,. )p:-,, tha11 c>m·- tWl'ntieth of lhe populatioll of lhe whole. In 111o::;l c a :'CS thi~ board 0 wm><I and co11trollecl the licensed premise.-:. (•stnhlishecl canfeC'ni'. eatin:! houses, regulate<l lhe hours the nnious <':-tahlisluneuts \\\'re> to lie kr pt open, l<•galizcd the sale of spirit::. u11d bct·r of a Jo" l'r :-t1 cngth than formerly mncle, and made Yery definite efforts to lei\\ <'I' incidents of drunkenness, especially at week ends. It also abolisheLl the -.ale of intoxicating liquors in bottles from grocers and other places, so thut the 'ntoxicant could not be co1weniently carric>rl away for conswup- tion later. The canteens and eating houses were tastefully decorat t•ll, the pro- prietors of these establishments were paid on n commission IJa.:;is, the l:irp:c•r rate of commission being allowed on ecliblcs and n011e on in- toxic>nting liquors. As a result the efficiency of ilie workmeu, soldiers, snilon;, etc., was raised to a great degree, there wns less drnnkenncsc;, 8DU llt the SUJllO lime the laboring class apparent)y made llO objection to the procedure~ llS outlined. The success of tho board's efforts was apparently very mnrke<l mid the medical profession nf Gr1•:1t Tiritain i<= Hl':V much elnt<>d over the outcome. fn. '·· ""·1· Hum.rol\, .\. Effect of the air hammer on_the hands of stonecutters. Monthly Re,·IPw. l'. S. Um'. Lah. ~tntlstks. A1>ril, WlS. Dr. Alice Hamilton has investigated a curious condition in th~ hands of stonecutlers which seems to follow the use of the air ham- mer m cutting and carving stone, and which is fonn<l nmong the lime~1one workers of Indiana, the granite cutter:-; of :.'\fo.:;sachusctts irnd Vermont. the mnrble workers of Long I sland <~it~" :ind tho workers ii1 thi> sandstone mills of northern Ohio. The pneumalic hammer employed consists of a handle l'Ontnining the lrnmmer. which is driven by compressed air nnd ic; sni<l to <leliver 766 l\ULITARY, LEGAL AND INDUSTIUAL. Vol. X1t from 3,000 to 3,500 "trokes per mii;ute. T here are various ways or holding the handle in the.right hand while the chisel is held by the left hand against the hammer with the cutting edge pressed nirain , the stone. ' Vith the exception of the workers in the marble sho11 in Long Island City all the workmen seen by Dr. Hamilton wei·e without any acleqnatc mC'ans of conveniently warming their hand~ in the winter. A description of om• or two of the more marked cases of anemia In the fingers will !'how Ju"t what this conclltion is. The first one ls a llme,.,to n~ <:utter whom I saw early In the morning when the temperature W:t!i about 14 F. He hncl been oul of door:; for 01·er lrnlf 1111 hour, nncl in or!let• to Lt· nble to show' me hlH bnncls in il typical conclitlon he hacl rl.'frnlnecl fro111 r ubbing lhem violently nn<I. Rwlnging his a rms a bout, as he woulcl ordinarily <lo to restore the circulation. The cliscomfort, howeveL', hucl grown Ro in ten~ •• In his fingers thnl he couhl not bear it any longer nncl almost at once after I arrivecl he began rubbing nm\ kneading and shaking h is huncls. The four finsers of his left hnn1l were a dencl greenish white and were shrunken, !JUltt· Uke the bond of n co1·pse. The whiteness Involved nil the little finge1· to the knuckle, but In the other fingers it stopped midway between knuckle a n1\ second joint. As he rubbed his hand the contrnst between fingers and han<I lncreasecl and at on<' singe It was very strikinl!', th e cr imson and Aligh t\ ~ swollPn hnncl meetlnl!' tlle white, Rlu·unken finge~ abruptly, without nny in termedh:te zone. On thC' 1mlmnr side the condition was not so cllstlnrt, for the skin wns too thic:lc 1uul cnlloused to allow the color to show well. The ril!'hl hantl was 1111l('h ll'I'-" nITec:tl'cl. the little flnj!'et· escnpl'll altogether, the thrE'L' otl1prs WPl"I' wlilt1•. hut not dead whilP. 11:; fnr aR lhe ><C<'Otlll jolntll, and there wa-. a ring or while aruun<l the se1·0111I phnlnnx of the thumb. .\fter vigorous mnssa;..rc n11d h1•nt illl! of hi,.; arm" 1Jn1·k n111l forth o\·er his chmit th!' blood l!l':ul11:.1lly flll1•d thP flngpr,.; am! the :t)lpcurm1c1• then wns fuh·ly normnl, i;howi111! onl_,. a motl1·rttll.'l.r pu1·plish-1·e1l color, and no swelling. ThcRe :;Lonei·utlc>rs 11rP t>X<'l'Jllioually go0tl 1m1terinl for ,.;ul'h a Htufl~', for they arc lntelligC'nt nwn. usun ll.v of ;.:ooc\ P<lurutlon. an<l nhle to note 111111 clcscrih<' their !':Ylll))l0111!'> 1·h•11rls. 'l'h1•t'l' is 1111111ng some of them 11 tt>ndl.'11<')' t<> 1lwell, perhnps too mul'11. 1111 tlw 1ic1·,·ou:; tliRorclerR whi!·h the)' believe nrl.' cnusccl by tbe tiring \'ihrations of th!' hnmmer·, and whirh gh·p them a ;?OOcl cleul of worry. Of ni>arJy•u]) of the Hll'll. howc\·er, this is not true. '.\Inn~· of thC'lll ha\'e no romplaint at nil, exc1•pt of lhl' tt<.:tual conclition In tile hand!!-. hut others Huffer from more• or [pss 1lls1 l'l"-Nill~ ,.;ym1>toms which thc•y thin];: arc mu Heel b~· the vibra1ing h:rnnnel'. 'l'hc> 111ost 1·ommo11 s~·rnptom !:; covered by lhnt \'a;:?uc term "nerrnusness." 'l'h<'Y say thnt lh<'Y fc<'l jump~· n111l irritable, UJISCt by n slam. min~ tloor. unublP to sl•ttlP tlown after a full clay',:: work with th1• tool. Their sleep Is 11ist11rhe1l 11ml r1•sth•,:,.;, nrnl thl.')' hllY<' hnzzin:! or ritH!ill!!' In tlw <':11'!1. The numbness In the hilllll?-\ ls Inconvenient, for they can not holcl a 1:ewspaper or a book for nny h'll~th of tllll<' without !Jein;:? forc1•d to put it tlnwn 111111 ruh aucl k11Pa1l their ha11<ls ~oml'tlmt-,.; they ha\·p to sl!'l'JI with the l!'ft arn1 hnng· Ing down from I hr ht>d, or lhl' nnmhne"s \\;l11 walwn lh<'m, aml then they must gPt up anti Hwing lh1• arms nhont or bathe lhe hamls in hot water. Some of them nre not trouhlt•<l nt nll In sun11ner. others get uumh ftn!l;l't'!I on <'hilly , days, or if tlwy put t1wt1· ha t\fls in c:oltl wnter. A few men compll\lll of t1·ouble with lht• left foot, which Is c·ohler than the right. There UL'!' 8l'Y~1·1il n'n"ons why the l<>ft haml ii:! more uffectecl than l\Je rii;:ht. In the fir!'t pln1·c• n !!t'1•nt1'r dfort must be ma1ll.' hy tlle lrft hnn!l In gro.spln~ MILITARY, LEGAL AND INDUSTRIAL. 767 we tool. hulo.li11:: one end :1::ul11:;t the hammer, allll ::uhlln:: nncl prc,-.lng the other eurt along the surfn<'<' 11f th<' .:tone. 'rlw fini;<'r" ofh'n cJn-,11 the tool l<() tJghtl~ th:it tlu• I.l<><ttl is 1lrln•11 fro111 th<'tn. :11111 thl-... t••:!:<'llll·r with lh•• vlhrn· t1o11 of the tool from the hlo\\,. of tlH• bnmmer 111111 the infinencc of the cold, i;ecm.: to i;d llJ> :I l'U!Hlltl1111 ill llW h1UOI\ \'I'"<:(•),- Which lend' to 'lm~rundlc t.'On· trill'rl•ms :mo.l tlw 1·N<111tln~ hl:111<·hPtl am! "hrunk<·n n>11tlitl1111. The ri~ht hnnd c:nn bolt! tht· lar)!er ha1111111·r rnor • loo' •lr :•nu can ..;lJiCt il In dlff<'r<'nt wny" cturlng work. ancl tlw 1·ibrationi< :ll'l' 11ot !<•It so """'l'l'I~· as i11 the left hnml. ~(IIJH' mc•11 1•011tin11i> tn hp llnhlC> to atrn<'kH of white flll!!l'l"' even nfter tlw~ 1::nc i..<ivt'n up ><tonp1·11ttin;! for scn~rnl )·car:;. There were alto~l'lher 1~:l wu1·kmt•n In the thr1.,-c br;rnche" uf -<oft stunt•. m;lr!Jlc, nn!l ~runitc• work whom I 1•xu111i111•d, nnll I fom1cl 0111.1· 17 ''ho 111111 not hall the so-c11IIC'cl "tlc·atl Hn:::Pri<." IC \\'l' omit. tho~e who ,-ou:::ltt me out In or!I· r to show me thPir lnllHls and who mlg-ht be l\><lkr<l np1111 :tl' plcke•I 111sc~s. tb1•r1• rcmuin 10:! whom J suw in lhC' mill!'! :in<l wl1n \\'1'1"1' not -..plt•<·tt·rl nt nil, bot •.;tkl'n :t~ llH'Y 1·n111C'. 0111~· l(j of these• were quite frPe from tllP n·ouhle. Dr. Hamilton descrilil's the condition as a spastic anemia depend- ent on three factors, (1) long continn<'d muscnhr rontrnction of the fin!!ers. {2) mechanical Yibrations of lhe tool. (3) the cold. HOOKER, E. H. Criticism of venereal prophylaxis. :Social Hn;iellll, .\prll, l(}Jo,;, The writer takes an article by Medical Inspector Charles E. ni~~::-, United States XaYy, which appeared in Social Hygiene for .Tuly. l!Hi. and was only an elaboration of the article which appeared in the !\.n·AL MEDICAL BULLE'IT'\ for ,January, 191'7, as a text for an nttnc1• on venereal prophylnxis. The author's contentions seem to l>P that prophylaxis is not sufficiently effecti \'C an<l can not be owing to the inherent difficulties attending prompt administration: that the <ioY- nnment nttitud0 tow;u·d conf'itwncc, vcncrenl diseases. etc., is uot ,,;hnt it should he; that repression of prostitution depend'> nltimall'ly for its success 11pon the r·nopp1·ation of men in the :,;pr,·ic<>; t hnt •1 continence should be ronsiclercd by the practical man. not c1n the grotind of moral~" lmt lwcause reJ!nl:ition h~-; £ni1ec1. The e::,Snyi-:t ~iws as her final argnmc1~t against prophylaxis: ·· It is an cllort on the part of the Go"\"ernment to make it safe for n,en to satic:fy their !-=exnnl pa-.s ons without reganl lo the primary purpo:::e of sex:· In the beginning 0£ her paper the essayist seems to concede that the ·· practical impossibility ·• of a rnca;.ure make;; it of ·· nt Jea~t deLntable vnlue,'' and we rather think that this thought ;;houl<l han~ con,-iderable weight before it is e~q)ected of an 0YerworkP1l parental Go· errunent that 1t !':hall forcibl~ pm a stop to fornication. Wt may be wrong, bnt we infl'r' lhttt the 'uiter for ;:-:;ocinl Ily- gic · expects the GoYcrmnent to penalize the men "Uy lnck of puy or refusal 0£ leave for hining hn<l lllicit i11tl'rcom-:-e... ::-:he arlmits indirectly that a goo<l many men woulcl e:scnpe pnnish111cnt by not confcs.;ing to their sin, but makes no :suggestion as to how the otfen<l- 768 MILITARY, LEGAL AND I:KDUSTBIAL. ers could be dcteetl'd. U11e is l'l'lllintled of the fable of the lllll:e "i~hing to bell the .:at. :i phm cxl'cllcut in theory but characterized hy ··practical impo ssihilit~· ., of execution. One recalls: too. lhe chn ity l>elts of the mid<llc agl!s and a more extended historical l'l'h·o~P<'ct suggests that punishment has newr yet proved efficacious ns a me ns of prernnting sin. It seems to the reviewer unfair to charge the Go' eriunent \'itth "connivance" at male incontinence, to accuse the Government of officially tolerating male prostitution, and to say that the men infer ·'from this attitude on the part of Government thnt promi;;cuous intercourse is permissible" and direct their conduct nccor<ling y. "Government" is n term of sufficient vagueness to permit of all sorts of attacks and much vilification with impunity lo the critic, but this same vagueness makes it rather difficult to speak accurately of the "Government's attitude." If by the "Government's attitude'' the essayist is speaking of the Army policy, that is one thing; tlie attitude of the N:wy Department may be somewhat different; Con- gre.s,:; mn.v have nn attitude n.ll its own. It seems to at lea::.t one reader of E. H. Hooker's nrticle as though the author held th t in some w<1y or other Bachmann and Riggs nncl the Gowrnment and Xapoleon and physicians generally are banded togethet· in J hy. pocritical sort o{ way to condone incontinence in men. While not prepared to take up the cudgels for GoYcrnment, we can not admit thilt when Congress passed a law which mulcted men of the \nny and N:.wy of their pa)- while cnrriecl on the sick lisi for •en ,ronl disease characterized ns due to their "own misconduct," it was con- doning incontinence. The law now in force recognizes the. medical fact that venereal disease may be innocently acquired, and the vie· tims of venereal disease so acquired are not punished. There · s no escape, therefore, from the conclusion that the intention was not to punish the victim of venereal disease but the person guilty of illicit sexual intercourse, whose sin is disclosed by his physical aft1iction. In practice the lnw amounts to a punishment for contracting venr.rcnl disease, but it was doubtless intended to punish illicit intercom· ·e, or at any rate it is the nearest approach to doing so. At least it was propos.:d not to spend public funds on pay to men disqualified from performing their duty by nets of misconduct on their part. We ha,·e seen the innocent child blind from birth owing to gon- orrhea of the mother. "\Ve have seen the beloved mother ancl <le- •otccl wife suffering an n.mputation of the le~ for supposed tul r- culosis when the real disease was congenital syphilis acquired thr011gh the sin o{ a pnrent. We have seen the young bride of n week writhe in pain from an acute vaginitis nnd proctitis acquire1l from her husband, nnd we have no sympathy with the dispassionate moralist who can stand coldly aside and permit child. mothPr >r xo. 4. MlLlTABY, LEGAL AND INDUSTRIAL. 169 bride to be he ma.de the unwitting victim of a clisease that can in in:tn.\' cascs--nlas, not in all-be pre'\"entecl by physical means; who refuses such physical prcrention of suffering because a :far better, 11 more irlea1. a worthier prevention would he thnt due to mornl 11~encies. -If men are hardly preYented from improper conduct by a full kflowle<lge of the punishment which nature herself imposes and n kflowledge of the punishment superadded by the authorities, we are nt a loss to know what puniti,·e measures are still within the power of the authorities. One doubts if the cssnyist is really familiar l\"ith the history of prophylaxis in the United States Navy and of the attitude of the " authorities" which "go>crn" it. As E. II. £looker is not 11.Jo1w in her ignorance on this snhject, it is hriefiy rehearsed here. Prophylaxis in the Navy began to be employed on a considerable £cnle some lG years ago and wns first conspicuous on the China sta- tion, whel'C:, 0\\ ing to couditions ashore, tlw prevalence of 't>nerea1 disease in the personnel of our ships reached a startling magnitude. It began as n. purely medical and sanitary measure, mid the results to health promptly recommended it to the military authorities. Prophylaxis then became more or less general throughout the ~avy, but its nclministratiou has always Yaried widely according to the 'iews of indiddual commanding officers of ships and fleets. In home 'raters the moml aspect of prophylaxis soon obtruded itself into the problem nrnl moral and ethicnl <'onsidcrations soon made it. "prac- rically impossible" to administer prophylaxis in a thoront:rhgoing manner. Meanwhile changes in the internal economy of ships and stabons nloo contributed to the decline of prophylaxis. As periods of liberty and furlough were increased and lengthened the possihil i t:v of prompt and efficient prophylaxis was much reduced. Coincidently with these changes and the frank failUTe o.f prophylaxis in many cases, due largely to indifference on the part of the men, in spite of court- martials and fines for fnilnr<' to take prophylaxis, a large proportion of the medical officers of the Nin-y realized the necessity for enlarg- ing the scope of prophylaxis so as to include more instruction on reneral disease, and on the importUIH'l' and Ylllue of contin<'OC<'. It is hard to realize that any portion of the Americnn public is still unaware of t1w Yery pronotmced and outspoken attitude of the present head of the. Navy Department on this ~nbject. The Hon- orable Secretary of the Navy has more than once givC'n pnblic <'X- pre8.<;ion to his convictions and no officer or man in th<' service to-da.v ran be in the full possession of his mental faculties if he claims that the go,'ernment of the N nvy sympathizes with, rondones. or ron- nives at sexual impurity. 770 MILITARY, LEGAL AND INDUSTRIAL. Prophylaxi,- in the X1Hy to-thy is a good dea] more thnn th aclrninistrntion after coitu:-. of an injection or ::mlve. There hns bee~ for ~ome time !\ concentrated and strenuom; effort on the pn1t of thn medical oflicer~ of the :N"avy to impart to officers and men of the ~en·icc :-uch information regarding health and disease and such cone N~ption" of life. worthy effort and true .success us shall build up in the mun n power of inhibition far superior as a deterrent from sin, to the fear of punishment. I n the instruction gi"Ven to-d:i) thl' physical agents like calnmel ointment. and solutiou:, of the siln~r salts are mentioned as the last resort in the attempt to main- tain efliciency, nncl the subject is so hunclled that it is as 11nfuir to ~peak of medicnl preventives o:f Yenereal disease ns incentives to immorality us it wonlcl be to pronounce the Snvior's nton<'mrnt anc\ s:wing grace :i "·arrant for sin. The author has gracefully conceded to Dr. Riggs a "fine sincerity .. and the possible ahility to "give fair consideration to a point of Yi~w opposite his own.'~ The point of view is everything. For one per- son the point of view may be the quiet study room. with ,.ugge...,lions of refinement and culture in books, paintings, ancl furniture. The world is Yiewed through mullioned windows. The glance i,- to the fur horizon and the clear dawn o:f a better era. There arc othl!r!;, ':intelligent medical men~'i for instance. '"ho haYe neither the time nor the type of mentality for casuistry. ncnclemir discus.-.ion-- nncl fine theoretical distinctions. In the heat and burden of the clny the\• fincl thC'msches jostled and pllsbcd about by the struggling. ~went­ ing mass of hnmanity that goes faltering and staggering nlong the rough rond of life, now fainting, now falling, by the wayside. To those thus plunged amid their fellow men, knowing them. pitying them, sympnthiziug with them, one form o:f duty app<'als with special force. It is tbe duty to bind up wounds and to heal bruL"l!Si to reduce by every means in their power the sum total of humnn suffering and sorrow. To the glory of the medical prof('~ion be it said that its members haxe D<n"er stood aside like the Phari~ee or U1P Puritan speculating on the moral quality of the needy or demnndinc• rnnchers of respectability from those in pain. For the hone.<:t and upright physician of to-day who is well in- formed about the rarnges of Yenereal disease and the toll they tnke from innocent women and chiklreu. there is but one 1·onr:-e open. Ile must warn and exhort. e''ery mnn that he has any chnnce of in- fluencing; he must do eYerything in his power to deter that man from vice., but when his books, his tructs, his speeches, his iwh·ntl' tulk . hie; illustrated lecture!':, his· posters, his moving picture_c;, his plead- ings, and his prayc·rs have all failed to deter him :from \'ic • nn1l . cohabitation with a harlot. it remains lhe doctor's dnt.r to try I> pre\'ent the de\'clopmcnt of syphilis nnd of gonorrhea in thnt mnn, l\11LITARY1 I.RGAl. AND I:XDUSTRTAL. 771 befnuse every ca:::c of Yenereal cli!,easc is a potential fr1fector of in- nocent women and children: because from one Cll$e of gonorrhea lll:tY come indirectly hundreds of othei; cases and cases of peritonitis and :4erility and an intel'll1inable list of ills: because n ~in!!le case of syphilis may dir<'ctly or in<lirC'ctly lt·u<l to hnndre<is of other C!lses. to locomotor ataxia: to dementia prrecox: and :m interminnble lkt of ills. Wt take so cold and 1w1I crial n \'iew of life and its facts through 8~-..ociation with men and women of all types, clean and unclcnn. that lfe bdieve e\'il pructic('S and physicnl tlisabilitie,.; form n dcious circle. Immornlil y indnccs venereal disease, and Yenercnl disease indirectly causes immorality, because gonorrhea nnd syphilis menn Jo3s of time, loss of pay, hunger, discouragement, the crnving for liquor, or drugs to dispel that discouragement. Children born of alcoholic or starYing parents, of those addicted to drug::-, of the un- roployed. the syphilitic, etc., are not only candidates for the reform sthool, the prison, and the nsylnm but help to populate the din~ and brothel. It is the custom in America to consider that e\·ery fallen woman, 11"hethcr a profe~ional prostitute or an amateur dabbler in sin, was originally the victim of so~c one man's lust but, as many more lfomen arc tempted or attacked than fall, it is fair to suppo:;e that those who do succnmb to man's passion haYe some weakness or ab- normality which predisposes them to sexua1 indulgence. In a lnrge proportion of cases low wages, loneliness, and all the other <'Xplu- natio11s which hnve hcen aclducecl are insufficient to nccounl for lack of resi~tance. Recent investigations in this country nml abroa<l show fhnt clislinct lll('nlal or ph~·sical abnormnlity. ne11 if no tllOl'P than ·'neurotic taint," is common among profc~sional prostitute.", and it ... eems highly probnblc that while one man may he thr exciting cause of wrongdoing, F;Ome man of a preYiou~ gen°rat ion est:1 bl i~herl the predisposing cause when he bequeathed to hi:s off~prin::r the heritage from a diseased bod~'. a weakened mind, and u dehnse<l nncl penerted moral natu1·e. If the prevention of Yenereal di ca~t' means le.;;-.ening some of the factors pr. judicial to phy:>icul inte~rity. com- fort. and happiness, and if the lack of phy:;icnl iutP!!rity nml well- being contributes in any way to immorality, proph~·lnxi~ ha~ a ri!!ht to be carried on. I· seems tmreasonable to a~k that a parental government he re- quirl'cl to replace the nursery governess, the father nnd mot hl•r. the school and the church in the life of the soldier :rnd ;ailor and yet be refused the prerogatives of a big-hearted phy::,ici:rn. Xow, in spill' of her attacks ngninst the Government's uttitndc.'. ,urely the writer in Social Hygiene must know something of the ,·nst and 772 MlLlTAB'.l, LEGAL AXD INDUSTBIA.L. comprchensiYe effort for good represented by the Commi"sion on Training Camp Acti,·ities, the a&;ist::mce of which commission •aa not forced upon the GoYernmept but cheerfully and eagerly accepted The moment government accepts~ fosters, and enlarges the sen·ices oi an ageut, those services may reasonably be considered part of "ov emmcnt effort. It is only £air, therefore, to concede that the Gov. erument is exerting itself directly to promote mornlity in it milit.nry forces if all the inlluences exerted by the Commission on Training Camp A.ctiYities and otheF authorized workers for the Government are really on the side of morality. It is of interest lo rompnre the attitude of the American Government with the aLtitudcs of <liffrrent Gm·ernmcuts abroa<l. Some, thou~h perhaps entertaining eonccrn over the impairment o.f military efficiency due to venereal diseue, are doing little or nothing, others are in great agitation hnt "ide diversity of opinion among the people halts action. In other case. fairly successful r<.>gulntion is practiced, and, if we may L ·lie\c well authenticated reports, includes the establishment of ca ref t; lly super- vised brothels at the front. The most striking contrnst is furnished by those Governments which, by means of force furnish tlwir armies with meam; to gratify lust, urge one-night marriages aml ,<.>e \-irtue in '·capsule impregnations." The term "own misconduct" includes alcoholic cxccsse:<. drug ad- diction, etc. Just bow far would Hooker"s stnuda.rd com pd us to go if we graded the Govcrmnent's liability to medical aid by the ethical aspect of the genesis of disease? Shall we decline to rnc:cinate a man against smallpox because be was exposed to the disease. while absent without leave, through bis own misconduct~ Shall Wl· refuse to gin> an1itetanic serum to a man who cut his foot on broken glaa or rusty nail becuu1>e the accident occurred us he wns rlimhing a back-yard fence the night the police were raiding the "joint .. , ls the doctor to give tonics, sedatives, soporifics,.food to th<' drunkard verging on the horrors of delirium tremens ~ These are all illus- trations of preventive men!'iurcs against the consequences of <''·ii prac· tices, and since the wrath of God is directed against the sin nnd not against tho sinner, we think that man. and even sinless woman. may incline to mercy. r rnrrou. J Vital Statistics of the l'hilippines. The followln:r fa.c•t,. anti fl:.mr(',; are <le1·ived from the report ur 811rg1"111 J. D. LoNo, U. R Puhlic Jlenlth Service, Director of Public Hrnlth. to the 8<'CTt?tal7 of Publlr lnRll'll<'tion, for thr fourth qunrter of 1!l17. Births.-I:n. Manila alone, 2.241. or 33.32 per thousrrnd of inhahit- ants. ~ULITAllY1 LEGAL A.ND J~"DUSTRIAL. 77:-l jV(l"rriage.s.- Therc were 543 mnrrin!!e'=. n mnrringl' rntc of ltl.15 pl'r thousand. /Jeaths.-There wrrn U>26 deaths in ~Ianih. gi~ i ng u. ru.tc of :! ~.G4 per thousand inhabitants. 0£ these~ 56 were due to typhoid fever: t25 to dysentcr.v; ;38 to tetanus: 130 to beriberi: 3GO to tuherculosis. There were no deaths from cholera in the last quarter of UH I in the dt' of Manila. Deaths from cholt!ra in the Provinces W<.'rt' 1.80.). Bubonic plaguc.-There wer<.' no ca::;es and no dealhs from thi..; disease in Maniln during the last quarter of 1917. A total of 30.112 rats were cnught Ly means of fr(lps or poison in tht> city. All wert1 negative for bubonic plague. Regregation of le7Je1·a.-During the quu.rter, or rather during the month of November, a leper-collecting trip was made to rnrious Pro¥inces of the Archipelago, 194 lepers being gathered, 1!>2 of whom '!fere remo\·erl to ('11Jion leper colony and 2 brought to Snn Lnzuro Hflspital. Military Statistics. fbtract from ,\noull.I Rr110rt of tbc Japanetie Navy Departmtnt for tbe J~r 191~16. J . Comparing the number of sick cases and the number of sic~ dsys in the Imperial Japanese Navy in 1915 with those of the preceding year, the sick rate nnd the rate of number invnlided both increased, but the den th rnte clecrcitsed; und comparing with the n.vernge; of the last 18 years, the> sick rate and death rate both decreased, but tho rate of number invnJided increased. The number of death per 1.000 of sick cases decreased, but the rate of the invalided increased. Peraonnel.- The nverage day number of petty officers and men in 1915 is 51A39, showing nu incrPa~ of -!,.H!i o\·er the ~imilm· numlwr of the prececling yeut·, 46,963. Owing to the war, part of the reserve." were cullt>d w nctivt> 5en ice, the term of those in nctive '-t·rvil'e wns lengthened, and tt larger number of volnntc<.'rs nnd con-:cripb were raised; hence the increase. !f umbers in rnrious branches are as follows: Cadets ----------- Petty officel"!i : Senmnn brunch_ ------------------------------ ---------- - - 5. !l'iU Engineer bl'nnch ------------------------------ ------------ - S, 425 Other brunches - ----- - --------------------------------------- l , r.ii:; Men: Seumnn hrnnch --------------------------------------- - --- ::!:!, 43~• Engineer brnncll- ---------- ------------------------------------ 1:1, 616 Other hrnnchcs ----· ·-· ·- - ---------------------------------- 3, 00.i Civil officlnls nnd employees---------------------- - --------------- Mi In '(lrlson - - - -- ---- --· --------------------------- - ------------ 121 Totnl ---------- -------------------------------------- ----- r.t , 439 774 MILITARY, LEGAL AND I~DUSTRUL. . 'ol. X1t Sick cases ... ...... ............. -. -.. -. --.. Died ................................... ··· Invnlidcd from service ..................... . l - I ... , ... ,, ..... ".::- Tot.:11 1 I number. I Atl! I 191.i tQl4 1as& 40,555 40,579 198 208 836 842 788.40 788.88 3.85 4.04 16.25 16.35 'Yt:lrl 755. 70 I ws. is 762. 75 • ·•··•• 3. 58 5 ij !l.24 . 13.71 ... . i5:0:? 13. 71 ........ . ln Lhc abon' titble, in columns "1914" and "1D15" th<' lower figt1l'l'S inrhtclC' the number wounded or killed in the wttr. Numbl'r of cases of the principal contagious disea~C's and of •· knklw '' nrc as follows: ~lenf' l es __ Scarlet fever-------------------------------------------------------- :? Typhoid I e,·er -----------------------------------------------__ -------- 106 Paratyphoid, type A-------------------------- ------------- -------- Gll Pan1tnihoid, type B----------------------------------------------- 80 Dysentcr~· -----------------------------~--------- --------------- 185 l\Ial:u·la--------------------------------------------------------------- 19;; .Mcnin;;'lt!:> cerchro-spfnnlls epidemicus--------------------------------- 2 Intluenzn ------------------------------------------------------------- 183 K:akkC----------------· ----------------------------------------------- 108 Tullt-rculoi;;i1> ot lun~s-- ·-- -------------------------------------------- ;.r_>g REPORTS. JtEPOB.T OF 140 CASES OF PNEUMONIA, UNITED STATES NAVAL HOS- PITAL, CHELSEA, MASS. By L. W. llfc(lurnc, Lieutenant Commander, M. C., United Stat~~ Na~y. Of the HO cases of pneumonia occurring at this hospital betwee11 October ancl Mnrch, bolh inclusive, 98 were typed and 42 were not typed; 14. were type 1, 15 were type 2, 2 were type 3, G7 were type 1. The type 4: includes the cases due to the streptococcu". which wns an important. factor in this series. It was not found prncticahle to separate the pneumococcus type 4 from the streptococcus in nll ra,::es, both being present in some, but in many the streptococcus only w;ts found. .\ s the streptococcus nnd not the pncumol'Ot·cus was found in the pleural exudate which so commonly occu,.recl it can be .;afely stated that a large percentage of type 4 was n streptococcic inftction. These men, when admitted, were seriousir ill, very toxi1·, and mpidly de,·eloped'serious complications, the moist common being empyema. which developed in 50 per cent of this group. In other words, of G7 ca:ses of t.ypc 4 and ~lreptococcic pnpumonia, 3:3 clevclope<l 1'mpyema. For a time it seemed almost the rule for the pneumonias to 1iaYe fluid .in the pleural cavity, necesituting aspiration, nnd this fluid rapidly becoming purulent. The streptococcus "\Vtl!-; the com- mon organism preseul in the pleural exndare. In t" o cases the streptococcus hremolyticus was prest'nt. This outbreak of pne11mo11ia was of an wmsu:tl form as to the etiology, its severity, and it<> complications. Clinicnlly it was dif- fkult and oflt•n impossible to difforentiate between the lohar nnd bronchial types, as there was often present a large involn~ment with Aui<l. !mt mnny were )mown to be broncho-pneumoniac:. which wonl1l indicate a secondary infeclion. ...\ s there were mnny ... treptococcic ~ore thronts being ndmitte<l nnd al~o many infections of the maxil- lary sinus, middle enr and mastoid, and :m occasional cage of strep- tococcic sepiicromiu alHl thrombosis of the can.~rnons -.inus, it would ·• "m that there was a widespread streptocoecic infE>1·tion pre...,eni in certain localiii<'s in this district, the pneumonia, being nn incident in its activities. It is interesting lo note the stations in which tlll':-.c 1nw11monias tl•'H'loped. If we exdude the ships. lOCi l'a~e:-; dl'\'C'lop<>cl in thi:-. ' cmity, sn of which c1une from two stations, Commonwealth Pi<'r and tlw Ra1lio Srhool. li'rom the Commonwl':llth Pil'r came Hi, 7i:i 776 REPORTS. \•oL XII and from the Haclio ~chool -1~. From the enlira n:n·y yurcl onlv fonr cuc:es ilenloped in this period: the remainJer were isolated c.ases from different istation::.. Of these 89 cases from the Ratlio School and Commonwealth Pier: 58 were typed. Of the :18 type<l, 38 were type 4. which is 65 per c<>nt. - I Avorago Ind<knc. complll- of Ptieu- ment.s. mania l"1 lhollWld - Commonwoalth Pier •.......................... · .... ······ .. ·· .j Radio School. ................................................. 1 . Navy yard ............... : .................................. . 3,670 12.~ 3,208 13.4 1,525 2.8 Measles has been mentioned in some of the Army cantonments a the probable origin of many of their streptococcic pneumonias, CS· pecially of the broncho-pneumonias. While there has been a cer- tain amount of measles present in this district, there was no epi. demic nor anything approaching one. Very few of these pne11• monins followed measles (2 cases), and it does not seem to hn,·e played an important part. Many of these men gn.ve a history of a previous infection of the upper respiratory. tract before becoming ill with pneumonia. Influenza also was prevalent. Considering the places in which the great majority developed, it would seem to be a question of housing It large number of men together in close contact, ns happened on Commonwealth Pier and at the radio school. resulting in the spread of acute infections of the upp~t· respiratory tract, many of which end in pneumonia. The enlisted personnel of the navy yard, which' includes many women as yeomen, lives for the most part at home and was not subjected to overcrowding or that intimate contact, which probably accounts for the small number of pneumonias in compn.rison with the radio school and Common- wealth Pier. JI ortality.-Of the HO cases, 41 died, a mortality of 29.2 per cent. Types. CMes. J Deaths. I Per cent. , m~~~~ ~~:: L:::::::: : : : : : : : : : : : : : : : : : : : : : : : : : : I ~t ~ : 4b: ~ ~~ '.};~~ !: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : I 6~ 2~ I· ... 32.· 8. t~ N'ot typed................................. 42 10 23. 3 I. ....... . -~---~--1- As I have stated, complications were common, especially empyem!l. Purulent pericnrditis. c•ndocarditis, and myocarditis developed in a limited number. Empyemtt "us present in 49 of the 140, or 35 per cent. Of the 40 empyemns, 33 developed in the type 4 group. Of the 49 which devel· REPORTS. 777 oped empycmn. 20 dit'<l. 14 of the denths being in the type 4. It is evident thnt the type . which i ordinarily the mildest type of pncu- monin. hn,·ing n mort lit) of Ii per cent in thi:> ~ries. wru- the most rirulent. due to the presence of streptococcu~. The!. men dcnlopcd fluid early: they wen' commonly nclmitted \\"ith fluid and often with pu in the pleural an·it~·. This pus was u~nlly n thin. "'light!~ colored fluid. which. on l'Xnminntion. showed abundant slr~plol'orci and brokcn-do\rn cell • nncl not tltc tl1ick yc.1- Jow pus common],\• scPn followinz :t loh:ir pncumonin. It wn ... the prncticc to open th!' pleural caYity. resect n rib nncl <lrniu early in this claES of r.n!-:C.S, but many, if not most of them. died in from one to three tlu~·s. It w11s cvidt>nt thnl it "·:is not tlw propt'r procedure. Thi::: was dihcontimwcl und repeated aspiration cmTied out with fn.r better rcc::nlts. .\ftc•r aspiration there wns usnnll~· 1empornry im- provem1>11t. Tlw pus wouhl re-collect nnd wns nc::pirntcd ns often ns neccssnr~-. which wn~ sufficient to tide mnny of them m·er tlteir pneu- monia; they "oulcl appan·ntly cle,·elop a resistance. !!nin :-trength nnd weight. un1l become !!ood surgical ric:ks instt'acl of 11 desperate operation. Xone of our cnses were curecl of nn 1•mpyemn by nspira- tion :tlone. ..e' crnl r:m a ilnt temperature for from tw11 dnys to a week between nspirations clurinp; their convnl~cencc and we.re nppnr- ently well of their cmpyl'mn. but all eventunlly Juul to haw the pleural cnvity drnined and with most excellent results. erum trcatmcnt.-.\ll of the type 1 cases recei,·ccl serum nlthough some were sensitiYe lo horse serum, which intcrfl'rcd with :;?i,·ing lnrgc amounts. Tlic 1n·crnge cn.se receh·ed about 400 c. c.1 it being gi,·en intravenously in 100 c. c. doses. In i;e,·ernl cnses nfter admin- istering the type 1 serum the patient had a Jrop of temperature. with n correspond in~ jmprovement of the other symptoms. As one patient remarked, .. I enmc lo the hospital yester<lny sick with pneumonia: they !!n\·o me nn injection in the arm and to-cby I nm we]J.l' This _ rum has n specific nction comparnble to the results obtnined with diphtl1crin :mtitc1:"Ci11 in diphtheria. The ouly reo-r<'t jc:; thnt o few of our cnscs \\r•rc of typl' 1. _\~ our mortality in thi-. type 1 wn::; 'i.~ per cl!nt. lhe ~~rum trc>ntmem spe..-iks for iLelf. 111 the type 2 part or our cases t'C'cciverl -.erum. some with nppnrent benefit, but on tl1c whol<' the rc<:11lts were not !?:rntifyiu!!. Il is belie' eel thnt better 1·c·snlts may be obtninccl by using larger amounts of the scrum. In t~·pes 3 nn<l 4 i::<'rnm i~ not used. CONCLUSIOJ>S. l. ThCl'I.! was present :i severe grnde of pncumoniu., in lnr~c p:lrt due to the strcptocoC'cus. "ith n ~igh mortality. 7009S--18-14 778 REPORTS. \"01 XII. 2. The outurcak had no con11ectio11 with mN1~l C':<. h111 1licl follow acute infections of the upper rc-.piratory tract. 3. The bulk of the ca~es occlllTC'<l where large numl et°l'i of men "ere thrown toge her. often rc:o ilting in overcrowding. 4:. Serum treatment JS of th<' utmost imporrnnce in type l. and has a promising field in type 2. 5. WhcreYer pneumonias are treated. laborutory facilities to deter mine the type should be nvailabk. 6. Repeated nspir:ttions in empyema, especially of the strepto coccio type, followed by drnining the plN1rnI cavity. oifor the hest chance for recoYPry. REPORT OF 106 CASES OF PNEUl\IONIA AT THE NAVAL HOSPITAL, LEAGUE ISLAND, PA. By F. J. Ot: l'llll, l,fl•utennnt. ~r. c .. und R. s. BOLE!!, Ll<'Ul~nant, l'J. c .. Onltl'd States ;o.;1wy . In a comprehensive survey of the pneumonia situation in the mili- to.ry camps of the United States, during the past winter, ,,everal features were prominent. Probably the most significant nrnl dis- tinct was the large percentage of cases of empyema which deYelop"d. most of them following broncho-pneumonin ~ccon<lal'y to mPa~le~. The infectious agent was u. hemolytic streptococcus. These particu- lar cases were most severe and occurred very early in the course of the pneumonia, and the mortalily rate reported from some camps was as high as 50 per cent. The mortality rate from pneumonia itself, as reported from various camps, varied from 5 to 40 per cent, the great variation undoubted!~· being due to the typc.> of infocting organism. The pneumonia. at. this hospital was of the usual clinical vnriety, and in no cn.se secondary to measles. The diagnosis of pneumonia was made only in those cases presenting definite physical signs and symptoms and in which examination of sputum reYealed one of the varieties of pneumococci. The total number of cases observed was 100, of which 90, or 84.9 per cent, were of the lobar variety and lG. or 15.1 per cent, 0£ the bronchial variety. In this series deaths from all causes (as shown in Table I) totaled 27, yielding a mortality rate of 25.4 per cent. Deaths which could be actually attributed to lobar pneumonia numberecl 15, giving a mortality rate of H.l per cent. "° 4. REPORTS. TABLE I. Empyem:i ............••...........•........•...... -.........• -.. F.ropyem:i a.1!-d dip~th'i!r!a .•...•.•.............•.................• pocnrnorocc1c mamn:.p.tis ..•.....•.............................. ~b:;~o~~~~~r::~ ... ·. ~::::::::::::::::::::::::::::::::::::::::: 779 1.;;-caLhs. Mortnlltf (per cenL). 5 :i 2 2 15 4.71 2.83 1. 88 l. 88 14. lfi With the cooperation of Passed Assistant Surgeon E. A. Case, United States Naval Reserve Force, an attempt was made to study the type determination in all cases, but owing to the scarcity of white mice, this was possible in but GS cases. The result of this study 1-. shown in Table II. T . ...nr. ~: U- Typc 1h;lrrminntion in 68 cases. TY!l-0· !~IL:•••·•••• :• :: ••:•.••• •:·•· Streptococcus ..•. . .............................. Cases Per rent 11 16. l with 2 dealh!I. 4 5. ~with 1 denth. fl 13. 2 with :i deutb~ 3fl 57. :3 with 10 death!! 5 7. :i with l denlh The sputum was collected in sterile Petri dishes aml s(\nt to the laboratory immediately. The greatest number of cases foll in the Type IV group. We observe thnt the type itself is no criterion of the sev<'rity of the Lnfection, inasmuch us many of our Type IV i11 fec•tions were ex- tremely severe and rapidly fatal. It must be borne in mind that the group of organisms classified under Type IV is heterogeneous. Xo satisfactory distinction of the organisms of this group can be made. TABLE III. -Death• due to t.11pea. T~'ll<'· Type I. ........... .................. .......................... . ... ... . !fE!L.:.• .. •••••••·•••: :: ·:•: :••• :•::•: ••• •: .:: •••· •• :•:· :: : ::·: :· Per rent mortality. lR. 18 25 33.33 25.64 20 The study of Tnble Th shows Type III to be the most virulent of the pneumococci. Another interesting fact revealed is the viru- lency of some of th<' orgnnisms classified under Type IV. In pr:tc- 780 REPORTS. \"01. xu tically all the ~tatistics publishc(l prior to the use of .the serurn specific for Type I, a mortalit:v rate is shown muc} higher than that found in Type IV group. In our present series of cases Type I pre<:ents the lowest mortality rate. This is attributed to the u e of specific ::erum which was administered intravenously. The initial dose varied from 30 to 100 c. c., depending on the severity of the infection. "Te were also surprised to find that in pneumonin <lue to streptococci the mortality rutc wns less than that of Type JV. In 80 case=- tht' disem;P "·as initiated wi.th a chill and in 2G cn<ie:; the onset was frraclna l. TADLE I V. Cases. P~r ce:a. Onset with chill: Due to Type I infection ................................... . Due to Type II infect ion .............. .' ................... . Due to Type Ilf infection ......................... . ....... . Due to Typo IV infection ................................. . Due to streptococci infC'ction ..................... . ...•.... Onset without chill: 10 12.li 4 6 1 l. ! 35 4:l. 71i 3 3. 71i Due to Type I infection ................................... . Due to T)l>C III infection •................................. Dur to Typ<' IVinfoction ......................... . ... . ... . Due to streptococci infection ... . . . ....................... . 2 7.68 3 11. 11 4 15.38 2 7. GS Contrary to the usnal expectation, a large percentage of Type III cases de,·elopPd graclunlly. All Type II infections began su<luenly w:itb a chill. TAnr,i; V.-DiBtribiition of the disease. CllSCS. I_ Pct CODI. Lrft lower involved ............•............................... 47 52.22 Rii:ht lower involved ................... . .................... . Left upper 1nv11lvcd ........................... . . . ........... . Right upprr in vol vcd ............. . .......................... . Right middle involved ....•.................................... Right nud left lower ......................................... . Massive (both sides) ....•...................................... 25 27. 77 4 4.44 6 G.G6 3 3.33 1 1.11 4 4.44 The stud~ of the distribution of the disease re,·eals nothing n ·w. As shown in most tnliles preYionsly reported, the lower lobe of the left lung is involn~d in the greatest number of case!'. It was of interest to note that the majority of men ndmittcd witl1 pneumonia. came from the western part of the Unilrd States (:l0.4 per C('nt). Tho South furnished 29 per cent, the East 23.2 per C('nt, and the North 17.4 per cent. It was also •distinctly noticeable thnt the men from the western and southern parts o.f the United States were more :\cutely ill and succumbed in a. greater proportion than those from the northern part. Vol. XII to the u"e of the sernm )wn much higher than that mt series of cases Type I is attributed to the use of intra•enously. The initial ing on the ~verity of the nd that in pneumonin due ~ss than that of Type IY. •ith a chill and in 2fi cases - ----,- Cases. I Per cent. - - - --:\ .................. 12.ii ..... .. .... . ....... . 4 5 ............... .. ..... 1 1. ~ ................... 35 43. 75 .......... . ... .. .. .. 3 3. 75 ...... .. ..... .. ....... 2 7. 68 ................. .. .. 3 11. 11 ................ ........ 4 15. 38 .... .. .. .. ........ .. ... 2 7. CS trge percentage of Type III I infections began suddenly ' the disease. Cases. Per cont. ........... .. ...... .. 47 52.22 ..... .. ......... ... ..... 25 27. 77 ......................... 4 4. 44 ........................ . 6 6.66 ...... .. ................ 3 3.33 ....................... 1 l. 11 ! ••••••••••• •• • 4 4.44 disease reveals nothing new. >orted, the lower lobe of the nber of cases . . jority of men o.dmitted with t of the United States (~0.4 · cent, the East 23.2 per cent, .lso 'distinctly noticeable that n parts of the United Stnte:-; in a greater proportion than REPORTS. 781 TABLE VI.-Dislribution of casu a& to ratiM of men. Cao;es I Per cent i;earoan ........................... ...... .. . . .. ... ............ . Fircm:in .......... . ...... . ........... .. . ..... ............... . Private. \!arine Corps ..... . .. •..•.............................. £lect~i<;ia!1 .......... . .................... . ........ . ......... . )laclumst s mate ....... . .. . ... . .. . ............ . .. ....... . ... . Water tender ................. . ............. . ...... .. .... ... . . . Hospital apprentice . ......................... . ..... . .. . . ..... . . Coxswain ................................................ .... . Oiler ............. . ........... . ...... . ................... ... . Carpenter's mate ............................................•. C'hief boatswain's mate ..... .............. . .................... . Quartermaster ........................ . .... . .. ................• ~~~~~~< ·:.~.: :-::: : : :.::: ::: :- :-:; Pharmaci~t's mate ................. . .......................... I rz I 31.13 20.iG 15 14.15 9 S.49 G 5.liG 3 2.S3 2 1. 89 2 l. B9 3 2. S3 2 1.S9 2 1. !;!) 1 . !l4 I .!l4 1 • 9-1 1 .94 1 .94 1 .94 i I .94 - --- In Table VI it is observed that the greatest number of case~ occurred in the seaman branch. In accord with the experience of the )foclical Department in nll other camps and hospitals we had an unusually large number of cases of empyema1 ull of them following lobar pneumonia. The mortality rate was low chiefly because the pneumococcus nnd not thn streptococcus was tho infecting organism in the large majority of cases. It is also likely that the mortality rate was kept down by the prompt recognition of the onset of empyema. It was our rule to make exploratory aspiration in all cases of pnemnonin in which the crisis did not occur by the eleventh clay of the discnst•. Inuuediately upon the discovery of turbid fluid in the pleural cin ity n rib resec- tion or thoracotomy was performed. By this method the ,cw<'l·e • toxemia, which is so common in cases where pu" is retained in tho vkural cavity for a. considerable length of time. was nYoicled. W1• believe, contrary to the recominendation of certain authors. that thorough surgical drainage should be instituted immediat!.'ly ntl<>n the discovery of turbid fluid instead of resorting to repented aspira- tions until tbirk pn" develops. 'l'AnLE VII.-Complicatiom. Empyerna; 27 cases, all followin!? Johar pneumonia: Type 1 infection . . ..... .... ...................... . Type HT infection ....................................... . Type IV infection ................................... . . ... . ~treptococciciu£cction ................................ . . TypP IT inft>ction.... . ................................ . ~o typ<! <letonninatiou shown .. ........................... . Coses Per cent .1 2 I) 2 0 14 11.11 7. 4 22.22 7.4 0 782 REPORTS. \"ol. XII Table VII shows the incidence of empyema. in various types of pneumococcic pneumonia. The largest number occurred in Type IY in~ections. as was to be expected. TABLE YIII. I I -- Cases. Per t"Cnt or I total mu11• ~ .. I -- Serofihrinous pleurisy ........... ...... . ...................... . Pneumococcic meningitis ..................................... . Cholecystitis with jaundice .................................... . Ac. parenchymatous nephritis ................................ . Pericarditis and serofib. pleur ................................. . Mental confusion ............................................ . Rheumatic fever ............................................ . Otitis merlia ................................................. . Diphtheria ................................................... . Pericarditis with effusion ..................................... . Enteritis ..................................................... . Jaundice. otitis medfa and erysipelas combined ........•....... Erysipelas and serofibrinous pleurisy combined ................ . Furunculosis ................................................. . Acute endocarditis) Erysipelas........ . · Multiple neuritis .. combllled · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · · Otitia media ..... . 4 3. 76 2 1.1<8 2 L&r 2 1.88 1 .94 1 . 94 1 .94 2 1.88 1 l.88 1 . !}4 1 !\4 1 . l).t 1 .94 1 94 l .94 The complications met with were numerous and various. Otitis media was not as common in our series as it was in the ::;e. ries reported from the various camps in which the streptococcic type of infection prevailed. Pneumococcus invaded the meninges in two cases, both of which died. As a rule when jaundice occurs during the course of pneumonia, it terminates fatally. This was not true in the two cases of jaundice in our series. In one patient, as shown in Table YIII, a series of complications occurred, all of them in themselves rather serious, namely. otiti-< media. multiple neuritis, erysipelas, and. finally acute endocarditi:;. This patient recovered. The treatment instituted was largely symptomatic. We endeavored to medicate as little as possible. Stimulation was not used unless indicated by the character of the second pulmonic sound and the quality of the muscular element of the first sound of Lhe heart. When necessary, strychnine was used hypodermatically. Stress shoulrl be laid upon the Yalue of open air in the treatment of lobar pneumonia. This was adhered to rigidly in all our cases with, we believe. excel- lent results. Our cases of broncho-pneumonia wer0 treated 'ndoon. because in our opinion these cases are harmed by open-air tre 1tment. particularly cold air. The use of vaccines we know to be un~at isfac tory .. and in some instances even dangerous. "\Ve are of the opinion ;-\0. 4 . that the use that its adm · "hich mean. rnunizing hex of a speci fie beneficial an siw immunit mune bodies The questi throughout desire for f poached eggs Th()S(', who h 1. In a se1• the disease w death rate in 2. The ou age of empy merous and . 3. Vaccine with the spe :EHPY R During th a. .~ries of 1 2!1.2 per cen that the.\· w strt'ptococcu The diagn in that the to the stati. throughout t The early in early tre wa~ discoYe tion. the ca~ whereupon upon. Thoracotor and frrr rib IBIS. \"()(. .\11 of empyema in various types of 1rgest number occurred in Type l. nn. I C:N •s. Per~ntof lot.al nt1111- ber. --- - -- 4 3. 76 :l l.1\8 2 L 88· 2 l. 88 1 • 1)4 1 • 94 1 .94 2 1.88 1 L. 88 1 !l4 1 !l4 1 • \)4 1 .94 i~~d················ ................. ined ........................ 1 94 l .94 ~ numerous und various. l in our series as it was in the se- ps in_ which the streptococcic type ccus mYaded the meninges in two luring the course of pneumoma. it . h , rue m t e two ciu::e.c:: of jaundice in ile YIII. a series of complications ves rather serious, namely. otiti" • is, and. finally acute enclocarditis .. gely symptomatic. We endea,ored Stimulation was not used unless · second pulmonic sound and the the first sound of the heart. When podermatically. Stress should be the treatment of lobar pneumonia. our cases with, we believe. excel- 1-pneumonia were treated indoor~. ire harmed by open-air tre·1tment. rnccines we know to be unsatisfac .angerous. 'Ve are of the opinion so.~ . REPORTS. 783 that the use of vaccine in pneumonia j,.: unscientific for the reason thnt its administration is supposed to produce an acth·e immunitv \\"hich mean;; that tlll' patient himself must manufacture the i~­ rnunizing bodies. On the other hand. we are co1wincecl that the use of a specific serum: such as the :;;;erum for Group I pneumonias, is beneficial and scientifically justified. because in this instance, n pas- si\"e immunity is conferred by the introduction into the blood of im- mune bodies preformed in the serum of the horse. The question of diet is important. It was our practice to be guided throughout by the appetite of the patient. Any patient who had a desire for food was given such articles of diet as soft-boiled or poached eggs, toast, rice, junket, etc .. regardless of degree of fever . Those who had no inclination for food were ft'd on broths and milk. $U?ID!ARY. 1. In a series of 106 cases of pneumonia the nctual death nite in the disease was 14.l per cent, which was much lower than the avern~e death rate in civilian hospitals. 2. The outstanding feature of the epidemic was the high percent- age of empyema cases (25 per cent). Other complications wen> nu- mero\ls and severe. 3. Vaccine treatment of pneumonia was futile. but the treatment with the specific scrum in Group I cases is to be strongly advised. EMPYEMA AS A COMPLICATION OF LOBAR l'NEUMONIA. By J. J. TOLAND, Lleuteuant, M. C., United States Navy. During the past winter at the Naval Hospital, League I sland, in a ,;eries of 107 cases of lobar pneumonia, 27 cases of empyema, or 2ii.2 per cent. developed. The cases were of particular interest in that the,\' were all clue to the pneumococcus and none dne to the streptococcus hemolyticus. The diagnosis and treatment of the cases were of marked interest in that the percentage of empyema was very small in comparison to the statistics of hospitals in Yarious camps and cantonments throughout the country. The early diagnosis of empyema is indeed a most potent factor in early treatment bein~ instituted. In our series, as soon ns it was discovered that the serum was becoming cloudy upon aspira- tion, the cases were turned over to the surgical staff for treatment, whereupon the ~hoice of thoracotomy or rib resection was decided upon. Thorncotomy pro\•ec.1 to be by no means us satisfactory as curly and :fre<> rib resection. The resection of a portion of the sixth rib 784 REPORTS. Yotxu. in the mid-axillary line proved to be the most satisfactory due to the fact that the flnid or pus is not evacuated by gravity to :my great degree. but by lung expansion. Since this is the point on the thoracic wall that the expanding lung touches last an~· fluid rP- maining is more likely to be forced out. The anesthesia chosen depended upon the condition of the patient. Of the three anesthetics used nitrous oxide and oxy~en proYecl to be the most satisfactory from the standpoint of the patient's best interests. This anesthesia relieved the patient of any pulmonary complication that might have arisen from ether or chloroform and so added insult to injury. Local anesthesia was not used on account of the seriousness of the condition of each patient. They all had gone through the siege of a most severe pneumonia and by no means were able to tolerate any added physical or mental perturbation. Opuative tcchnique.-Patients were prepared by thorough bath and purge and at the time of operation the chest wall of the af- fected side was painted with iodine and then cleansed with alcohol. The anesthetic, :was then administered and as soon as the point of anesthesia was reached, aspiration was performed, follm>cd b~ either thoracotomy or rapid partial rib resection, the latter pre- ferred. Tlie drainage tubes were then placed in situ and dres!"ing,, applied. Patients were conscious before they were removed from the operating table. In our early cases, the usual fetid odor that accompanies empyemn prevailed throughout the wards and not only impeded recovery of patients by making them feel repugnance for food, but also caused the attendants to feel disgusted when they had to entC'r war<ls to ca.J:e for these patients. After having gone along a month with the old. routine post operative treatment of empyema, the modifiC'<l method of usmg Dakin solution was instituted. The pleural ·cavity was thoroughly cleansed by inserting a catheter and aspirating the pus by aid of a glass syringe. This was done nntil the caYity wns empty. The amount of fluid pus and fibrin removed was noted nnd then an C'qual amount of Dakin solution was slowly forced into the cavity and then withdrawn; this was repeated until thC' solution re- turned clear: The cavity was then filled (not to distension) with Dakin solution which was allowed to remain therein two hours. Th(' same treatment was resumed eYery t"'o hours thereafter. Daily rcC)r<l was made of the decrease of pus, which in every case was rapid. Dnring this treatment, free use of the Wolfe bottles wns Pmployed Each morning between 8 and 8.30 a. m .. a few minutes prior to treat ment, the patients each blew their 1Volfe bottles and expelled as much pus as possible. !(o. 4. Coincident odor about of intercurre one of septic n1ultilocular therefore. to from time to the only po,, nbscesse::.. T but also is a and the cxten Our recovQ duties of thci Durin~ th pleuritic l·pil nomenon oc cavity; ::;econ toms cameo cases. after symptoms w scapula; sec with profon recovered in The dang may occur a third, too r:1 ity: fifth, h1 The comp~ .. horax and t the Dakins tient. The tutecl. Th<' ment. The folio lobar pneum bly UCCOllil lowC'd hy p frcl'. p<'rsist of th<' X-ra 'S. Vol, XU, the most satisfactory due to th cuated by graYity to any grcn~ ince this is the point on tho ung touches last any fluid re- t. upon the condition of the iscd nitrous oxide and oxyf!en r from the standpoint of the esia relieved the patient of any lt have arisen from ether or jury. i account of the serions1 C':oS of · all had gone through the sic!!o no means were able to tolerate bation. ere prepared by thorough bath ation the chest wall of the nf- and then cleansed with alcohol. tered and as soon n · the point )ll was per formed. followwl bv 11 rib resection, the latter p~ ien placed in situ and dressin!! .. )efore they were removed from odor that accompanies empyema :l not only impeclccl recoven of ~nance :for food, hut also ca scd :i.en they had to Pnt<'r wards to ng gone nlong a month with the .ent of em pyema, the mod· fiecl s instituted. The pleural ·cavity lg a catheter and aspirating the ls was done nnt il the ca Yity wa" 1d fibrin removed was noted and ution was slowly forced into the !lS repeated until the solution re- 1 filled (not to distension) with i to remain therein two hours. cry two hours thereafter. Daily >£ pus, which in every case was ! the Wolfe bottles was t•mployed. . m" a few minutes prior to treat r Wolfe bottles and expelled as !(O. 4. REPORTS. 785 Coincident with the modified method of using Dakin ~olution, the odor about the wards al>solutcly disappeared. The patients' appe- tites improYe<l and each <'a~e gained rapidly in weight. In our ~cries of :3'i l'a:::es. u ended fatally, two ca~~ having: died 0£ intercurrent diphtheria. two of multilocular abscesses of the lung, one of septic endocarditis and one of hemorrhage of the lung. Tho 01ultilocular abscesses were disco>ered post-mortem leadinO' us , "' ' therefore, to make a thorough and most Yaluab]e study of our cases from time to time by the use of the X-ray, the X-ray finding:> being the only po::;sible method of confirming the presence of multilocnlar nbscesses. The X-ray not only reveals the presence of the abscesses, bnt also is an indicator of the lung expansion, the nmonnt of pus, and the extent of the diaphragmatic moYements. Our recoveries were such as to •Yarrant patient:-; returning to the duties of their ratingi;. During the treatment of these ca,,es, the intere"ting phenom<'non~ pleuritic epilepsy, occurred in four cases. In case Xo. 1 the phe- nomenon occurred upon the introduction of the catheter into tho ca• ity; second. upon emptying the pus from the caYity. The symp- toms came on as the amount ceai;ed to flow : in our third nnd fo01 th cases, after the cavity had been filled with Dakin solution. The symptoms were llS follows: First, severe pain ut the angle of the scapula; second, feeling of faintness; third, loss of consciou!'ncs::. with profound shock; fourth, convulsions. In each case the patient recovered in about 10 minutes without any special treatment. The dangers of this treatment arc: First, pleuritie cpilep:;y~ which mnv occur as above noted; second, too great pressur<' from the fluid; th' :I, too rapid injC'ction of the fluid; fourth, distention of the c:lY- ity: fifth, hemorrhage :from the injudicious u,;e of the cathet<>r. The eomplications of the cmpyemas were tv•o ca!;eS of pyopncumo- .hor. x and two of atelectasi;;:. In our two cases of pyopneumothorax. the Dakin f:olution, in fact :rny solution, was not tolerated b~- the pa- tient. The cases are remaining and other trentm<>nt hns been insti- tuted. Tlw two cas<>s of atelectasis arc impro\'inir under this treat- ment. SU:IDIARY. The following points arc emphasized: First. all ca~cs follo" e11 lobar pneumonitt and were of pneumococcic origin. 'This fact prob- ably n.cconnts for our low mortality. Second. early diag110--is fol- low<>d hy prompt surgical intervention and treatment; third, the free, persistent, conscientious use of Dakin solution: fourth. frc•P nsc of the X-ra.y from the diagnostic standpoint . 786 REPORTS, Vol, Xlt THE CYSTOSCOPE AS AN AID IN THE CARREL-DAKIN TREATXENT EMPYEMA. Op By B. C. Wu.l.1~, Lkutenunt (.J. G.), )1. C., United Stutes Navy The nccurate placing of Carrel tubes so that e\·erv port1.on I · • nu, pocket of the \Yountl may be reached, is only second to the thoron l opening :ii1d i·emoval of all devitalized and necrotic tissue. In tt; treatm~nt of empyema we .ha\·e no devitalized and necrotic tissue to dea~ with, so the problem is one of thoroughly dakinizing the entire cavity accurately so that fresh Dakin's Solution may come in con- tact with the entire infected surface. In the United States ~ll\ al Hospital, Newport, H. 1.. there have come to my attention 36 ~\be::. and several of them still dischal'ged pns after most prrsist<'nt <'ffom: had been made to clear them up, the Carrel tubes having b<>cn push<id into the chest crtvities with no definite idea of the extent of porkelc; or cavities. Jt was thought that if the tnbes could he acrnratch placed by sight after careful determination of the extent of the ca,:_ ity we might more reasonably expect a cure. Being familiar with the direct vision Braasch Oystoscope I could see no reason "·hy thi;; in strument might not. be u~ed for the purpose of thoro11ghl,v i~specting pleural cavities before placing the tubes, and further. to aid in accu- rately placing Carrel tubes in all pockets and over surface of lar"c cavities. "While this is by no means an ideal instrnml>nt it is a pa~-t of the armamentarium of nearly every hospital. The small ~p1·cu­ lmus of one-half inch caliber, electrically lighted might be mon· <IP- sirable. To facilitate plenroscopic cxaminatious of the chest, at op- erations, which consist of the usual rib resection at the lowrst point of the cavity, we make the incision a little longer, remove au inch and a half of rib and stitch the skin margins down to plenrn. of re- specth-e edge. This allows ll wider angle of Yiew in the plcuml caYity, which is gr'eatly limited if the wound edges are approximnted in the usual manner. A sterile cystoscope is introduced through the opening into cavity, thorough inspection of the caYity is mnde. u~in!! air as a medium, and the points for the location of the tubes aro l-'6- lected. A new Carrel tube, stiffened with No. 23 silnr wire is then passed through the cystoscope to the depth clesired nnd the latter is removed while feeding the tnbe through cystoscope, :'O ns not to pull it back out of position. The number o:f holes to the tube is to be judged by the depth of the cavity to be treated. We have had the 11pex of a pleural cavity under view repeatedly. Eight cases have been treated in this m::nmcr during the past 10 dn.ys with very satis- factory improvement in the amount and consistency of the discharge. Owing to the caliber of the cystoscope being so ne~r that of the new Canel tubing we are considering a new instrument with greater lumen and of a shorter cuned beak. This preliminar~' report is macle in the hope that others will try the method and report their result.;. l!.EPOI!. By R G Li;Co. On June 8, six Corps reported to i;igned to duty wit} 11t Neuilly, where The commanding be added to our te ported at Neuilly numbered 16 perso The German off from Rheims to Chateau-Thierry a come through a d · French, assisted b The casualties wer in the invaded di created back of th at the American h mary field dressin procedure except t transportation ca namely, massive i trench warfare, an and the proximity Before this off e and contained 30 quickly to onr LO maximum o:f udm · (all Americans), maximum number admitted in less t cent. This sudde exhausted the me ing for more tha1 operating rooms, a ing our first two more than 20 per nting tables simnl 1 The commandln<; o Curl, Unlt~J State!! N ~enlor operat ing surgeo men was or the very h ~i>eratln:; sen1< to ti Sargery his 1,r .. tttudr f 'IS. Vol. Xll E CARREL-DAKIN TREATXENT OP :MA. ;. ), :\!. C., Coiled States :Savy. tubes. so that eYery portion aud ·cl, is only second to the thorough lized and necrotic tissu('. In the <levitalized and necrotic tissue to thoroughly dakinizing the entire 1kin's Solution may come in con- lCe. In the United States ~a,al .ve come to my 11ttention 36 case:,. d pns after most p('rsistcnt rfl'orts .e Carrel tubes having bt>en pushed inite jdea of the extent of pockets . if the tnbes c011lrl hl' accurnteh ·mination of the extent of the cm:. ~ct a cure. Being familiar with the I could see no reason why th.~ in- c purpose of thoroughl.v i~1spectin!! ! tubes, and further. to aid in accu- pockets and over surface of large ms an ideal instrnml•nt it is a part every hospital. The smn.11 f'lwcu- ctrically lighted might br more de ic cxnminatioHs of the chest, at op- ml rib resection at the lowrst point ;ion ~L little 1ougcr, remove an inch skin margins down to plenrn of re- ~ider angle of Yiew in the pleuml f the wound edges are approximated :ystoscope is introduced through the spection of the cavity is mnde. nsinir for the location of the tubrs are .;;,e- ·ened with No. 23 silY('r wire is then o the depth Llesirecl and the lutter ·-- through cystoscope, ::-o ns not to pull .umber of holes to the tube is to be ity to be treated. 'Ve luive had the view repeatedly. Eight cases have ·ing the past 10 chys with very snti~­ rnnt aJ1.cl consistency of the dischaq~e. toscope being so near that of the new :ing a new instrument with greater eak. This preliminary report is made r the method and report their results. REPORTS. 787 REl'ORT OF Ol'ERATING UNITS AT THE FRONT.' Uy U. G L1.Co:-;n~. Llcnteoaot Comwand"r, :\1. C .• rolkd States Nav). On J~ne 8, six medi~al offi~ers and four members of the Ho!>pital ~rps reported t.o me in Pans. On the follo'\Ving day we were as- blgn;d ~o duty with the Americ~n Red Cross Military Ho:;pital :So. 1 at Nemlly, wh~re we were detailed to work in the operating rooms. The commandrng officer requested that 4 nurses and an anesthetist be added to our teams from Ilrest, and this additional per::.onnel re· ported at N euilly at 8 a. m., June 10. Our Navy continO'ent theu numbered lG ~ersons. " The Ge~man offensive started May 25 on the Chemin de Dam~ from Rheims to Soissons. Ily May 30 the Germans had taken Chateau-Thierry ~nd were in force on the river :Marne. They had come through a distance of about 40 miles on a 50-mile front. The French, assisted by American troops, stopped their further advance. ~he cas.ualties we~·e l~eavy. A large number of French hospital beds i.n the mvaded district had been lost and new hospitals had to be created back of the present line. Large numbers of wounded arrived at the American. hospitals .in Paris from 1 to 3 days after their pri· mary field dressrng, and, m many instances, without any operative procedure ~xcept the injection of antitetanic serum. This delay of transportat10n caused a repetition of the surgical conditions of 1915 namely, massive infections and gas gangrene. The narrow limits of trench warfa~e, .and, incident thereto, the prompt care of the wounded and the proximity to the battle front, had all disappeared. Before t.his offensive, the hospital at Neuilly was about ht1lf tull and contamed 300 French wounded. Its capacity wah increased quickly to over 1,000 beds, but there wa,; no increa;;e in the staff. The maximum ~f admissions to the hospital in one chy wa~ f1Hl patient...; (all Amen cans), the maximum of evacuations wn.s ~9g, and the max~mum.number of patients, 1.061. More than :2,.iOO pati('nt-.. were admitted :n less than a month and the mortality was about 1.3 per cent. This sudden and enormous increase in the ho:opital activitie;,; exhausted the medical and nursing staffs. manY of whom were work- ing for more than 20 hours a day. Our tea;n~ took charge of the ?perating rooms, .allowing their versonnel a much IH'l'dcd rl'~t. Dur- mg our first two days we operated on about 1()0 ''ounch•cl. of whom more than 20 per cent had multiple wound:". \Y' e nurnned fhe oper- nting tables simultaneously. About 70 per Cl'llt of tlHhl' operated 1 The commanding o!llcer of the Navy Base Hospital, Bre.-t. ~frdlcal lnsJl('ctor II. C. Curl, UnltcJ States Navy, In forwarding this report, 8nys: "I wns 1ntorme1! by tht> ••Dior operntlng surgeon of the A1ncrlcno ambulance at ::'\cullly that the work ~f our men was of the very lllo/lcst cl1aractcr; that be bnd practkally turned O\"tr th• entlrP ~pcratln::; sen·lcc to them. Ile nsked me to cxpr~• to th• nurc:w of ~!rrllcln" nn<l Snr::;1·ry his i:rntltude for tbe help rendered." 78i REPORTS. Vol. XII upon were mariuc;:,. Tho operative work then grallually decrca d and. "hen not occupied with it. we helped in the wartb where th~ dre::.sing:; wcro extremely he~n·y. For pa1t of the time, owin~ to the exhaustion of the sl'niol' "'lll'l!con. \H• had charge uf hi,; w.1rd:.. about 3SO patient". Our stay at Xeuilly "a" ~1 Jny:-'. \Yl' left Pari,... .Tunl.' 30, arriYing at Ilrest the same eYening. The work of our nurses and hospital corpsmen was of the best and was universally appreciated by all who came in contact with them. T'rn incidents desene special mention. ~"'- marine requiring a shoul- der-joint amputalion, and a. machine gunner requiring a thigh am. putation, each suffering from secondary hemorrhage and gas gan. grene, rcqnired also an immediate transfusion of 1Jlood. There was no one in the hospital prepared to act as donor. All of om· t:O''J>Smen rnluntccrcd, and Charles L. Steele, Pharmacist's mate, third cla ....... United :Stale" :Naval Rcscne Forcl'. and ~IcWhite Ilarnsberge1, Phnrmacisfs mate, third clnss, United States Xavy, Wl'l'e chosen}~. ·cause their brood reaction was similar to those of the pal icnt'-. This donation of blood contributed more than any other fnctor in th" Sa\'- ing of the;;e t"·o patients: lives. · From this three weeks' duty the follo"'ing conclusions mny be drawn: That the nrnssive infections and gas gangrenes of 1915 were due primarily to delny in operations, and not to a lack of surgical lmowl- l dge. 'While the science of war surgery has vastly impro,·ed in three years, given the same conditions of delay as existed in 1!>15. the ~nme rna::.~ive infections would be. encountered on the operating tablr to-day. Therefore, the statements made last winter by a num- ber of accomplished military surgeons, namely. that an aseptic technique "ith the excision of the damaged tissne ( dehrid()mr.nt) had done away with lhe us:• of antiseptics, can apply only to cnses operated upon within a few hours of the receipt of the injury. In trench warfare this condition exists, but in a war of movement it docs uot exist, and therefore an antiseptic which will retard or pre- vent ma<:siYe infection should be used at the primary dressing. A study .:.hould be made to provide the best antiseptic for this purpose. Patient:-' that Wl're im1mdi::ttely evacuated ,ifter operation, in "'hom the wounds were exei:'ed and then closed or partially closed and drained, did badly and required a complete reopening of the wonnd. Uy c]o::,urc or partial closure the infection spread far be· yonil thP limits of the wound. It therefore again emphasizrs the fact that dcbridement with closure of the wound ran not be done on patil•11b that mnst be C\ iwuated. Excision of the damaged struc- ture's should be clone, but the wound must be left wide open, loosely packed "ith gauze. and ,-ome :rntisC'ptic n~rcl to r1'tn.rd infection. Vol. XII ork then gradually decreased 1elped in the wnnl:, where th~ part of the time, O\\ ing to the 1ad charge of hi-.. war<h about .... ~l ,foy:-. "" e left Pnri:- ,June ~· 1 corp;;men was of the be:;t and ho came in contact with them. i. .\. marine requiring a shoul- gunner requirinll a thigh am. Lary hemorrhage and gas gan- rnsfusion of blood. There was as donor. All of onr co•·psmen Pharmacisfs mate, thirll cln''· e. arnl ~le \Yl ite Harnsberger. ·d States X n. vy, were cho~eu he- r to thos:• of the pat icnts. Thie: hnn any other factor in th~ sa'\"- following conclusions may be ~as gangrenes of 1915 were due . not to a In.ck of surgica.1 lmowl- urgery has vastly improved in ons of delay as existed in 1915. oc. encountered on the operating mts made last winter by •t num- ~eons, m1mcly, that an aseptic damaged tissue ( dCbriclement) iseptics. can apply only to case.., of the receipt of the injury. In s, but in a war of monment it .iseptic which will retard or pre- . ed at the primary dressing. A e best antiseptic tor this purpose. evacuated after operation, in d then closed or partially closed t'ed a complete reopening of the sure the infection spread far be· ~ therefore again emphasizes the B of the wonnd can not be done . Excision of the damaged struc- d must be left "Wide open, loo$ely SPptic n;;rd to r.-tar<l infe<'tion. 789-1 ., • . , c. 0 c " § " 0 .c .. c c ~ .c E z i-o 4 In severely wounded js more harmful to the ing, warmth, and co1nfo o:umcd in feeding and re Janee trip, much more tl ns the patient arriYes at dition for operation. When the bed capacit. 11ctivities increased tcnfo is useless to admit 400 c the personnel is 200 op~ the number of patients :J no small degree to the Li operating table . PLAGUE INC~ By IT. l1. STr' 11011 The epidemic of pne out in the annals of me and unselfish devotion o all in an e:ff ort to check brilliant example of the with serious problerns. Inside of three month whereas the spread of t1 far as China was concer The epidemic swept six days, in a great coun most primitive nature," Press dispatches pu attitude of the Chinese ease appeared inside the People are reported dyln Ing rapidly. Deaths In on wool carters coming from tering infection eu route. trnffic. Two days later the fo Drs. Lewis, Jom·elet, Ee by the police, invaded thel 1 These notes on the plagu reports published during th<' •·trect It might have on the ht• i:ronnd i~ at present the Ynut. alow and unrertaln. But w1· and thus be brought inlo t·l \pr. 13, 1918.) i;o. 4 REPORTS. 789 In severely woun<le<l cases a long continuous amlmlance journey 1s more harmful to the patient tha.n one broken by rest with feed- ing, warmth, a.ml comfort. The dela.y of six or eight hours, con- sumed in feeding ancl resting the wounded on a. 40 or 50 mile ambu- lance trip, much more than compensates for the delay in operation, ns the patient arrives at the end of his journe)' in a far hc>ltcr ron- dition for operation. . When the bed capacity of a hospital is sucldcnly doubled, and its activities increased tenfold, the personnel must a.lso be increased. It :s useless to admit 400 cases rPquiring operation when the limit of the personnel is 200 operations a. day. This discrepancy between the number of patients and the personnel at Neuilly contributccl in no small degree to the lateness of the arrival of the wounclcd on the operating table. PLAGUE IN CHINA AND THE FAR EAST IN 1918.' By R. M. STESllOl'SE, I.lcuten•rnt, :II. C .. rnlted f\tntl'S Navy The epidemic of pneumonic plague of 1918 in China will stand out in the annals of medical history as giving proof of the courage and unselfish devotion of doctors and missionaries who riskecl their all in an effort to check the ravagPs of this dread disease, and as a brilliant example of the romplete inefficiency of Chinp..;e in dealing with serious problems. Inside of three months a.\ area of 160,000 square miles was infected, whereas the spread of the disease might readily ha.ve been limited, as far as China was concerned, to the territory north of the Great 'Vall. The epidemic swept rapidly along, at the rate of "300 miles in six days, in a great country where means of communication are of the most primitive nnturc," nnd later by rail in less time. Press dispatches published early in the epidemic illustrate the attitude of the Chinese officials. For example, five days after the dis- ease appeared inside the Great.Wall- People are reported dying by the roadside and in the inns. Disea~e :spread· Ing rapidly. Deaths In one village numbered 32 in three days. Ilun<lre1ls of wool carters coming from infected centers daily toward the railway nnd scat- tering infection en route. Nothing being done by local authorities to !\top traffic. Two days later the following appeared: Drs. Lewis, Jouvclet, Eckfelt, and Wu Lien Teh report that a moh, assisted by the police, lnvadetl their quarters after investigating n case of plague. 1 These notes on the plague situation In China have beeu mnlle a!kr a "tmly ot rePQrtM published during the <'Pldemlc. Our original ohJrct Wll~ to u~c·!'rtntn what rll'ect It ml;;ht have on the health of officers and men of the U. S. S. PaluR. Our <·rnl,lng ~Tound l~ at vrc~ent the Ynngt1c above the Gorg<'"• where trnvl'I nntl C'o111111uuic'ntlon nre slow and uncrrtaln. But we 10oy, aftPr the river ri"''~. he ortlPrP<i to tl11• low<'r Ynn~tz 4 and thus I.Jc l.Jrou2bt Into closer proximity to the dangrr 7.llll<'. (Wanh-lf'n. China, \pr. 13, l!llS.) 790 REPORTS. Yo!, l>:il The doctors were held prisoners, being refused transportation hack to Peking. rp to this time -.imply clo::;ing the gates of the Great Wall to all traffil' wnuhl huYe rnnfined the epidemic north of the wall an1l the control of that limited :Hl':t would haYe been a co111paratin~ly easy task. But all wtn·nin!?> 11::; to the Jrravity of the c;ituation were either ignored or but half-lwartedly ob:;ened. The actual condi- tion-.. were ma::;ke<l h~· the ·· hopt'ful optimism·· of the olficinls. nnd in the fal·c of assume1l precautions. a soldier carrying a siek child cnuled the quarantine, tr:wcled from an infecte1l place hy rail and quickl)' ~JH'l·a<l the 1lil'ea;..c f>OO miles from his point of emharkation. Dr .. \rth11r Stnnlc>y, health officer of Rh:rnghai. obSl'l'\'ecl that: 1t is tlw 'l'ie1.tsin·l'ukm\ Hnilwa~· which ha-; suhjeet .. •l the lO\\l'I" !'1111 of the Y:lll!!Zlt• \':1111';. lo \<'I'~· t·o,1sil!Pl':1hh• dai11:1gl'. Tl>'s lnt h:l-< for so111e time p:tst Jw1.•11 1wtoriou-; :is :1 f;oldit>l'·ilifrnctl ro:Hl. .\ leak.t;.:<' i11 thf" norttwrn qunranti11c oc·cmTPcl. .\ per>'<•ll from tlw infede•l an':I in not'tllf"rt111w..:t Shnn<tl 1!1t•nhnting 1111eum011i1• pl:i~llP pa.-~ecl lh1·011;;h F1•1wlwn nn<l throm:h Knl:r.in nn a 1·rrtifit·all' of 111t•1lit-al in><pectlon only, without the ah~lutely C""<'t1tlnl tkff'11tit•t1 1111cll't' 01tst•n:11in11 !lnriu!! a quarantine Jl<•:'i<1tl ut l\YC' chy-. nt tht> "hnt'tt"•t. • + • Thi" inf1"t·tPol JJL't'so11 is t'cpot'tPrl as havin;.: t<tkl'n th<· 11·:1!11 at Pekh1!! \\hen already In the initial sta~e ot the actual <lise:l'-'e. ~he stnrtC'<I coui:hln~ on the train, hccnuu• \\Ol''l'. u11ol die.! ''"m after rt>achin:! ht•r h11rne at Fem:~ynn::. Anhui. whi1·h i» nhout 100 mile,; north of Pukow (~ankin~). Thi-; ense in· f~tP<I per-..ons :1111011;.: her i1ruue1lintr family nrnl ne;"hlnt'..;, who all clle.l of rmeu1111>nic plague hc>tween Fc>hru:iry 6 nnti 9. Then• is probably no place in the worhl "hen• !"iher an1l gold fail to nffrct the liYes and habits of the people. Ilut China is so literall~· living from hnnd to mouth that money is the enr-prest>nt nspiration of ewryonc. .\ nd money will purchac;e anything. Tf it j,, a q11c>stion of hn.Ying to stop trains or to decimate the popu- lation th<' latter is doomed to die unless more money is to be made by stopping th<' railways. The governor of Suiyuan "refus<'d to belieYe that plague eYen existed." Evidently the gowmor'.;; rca,on for disbeli<'f wa!'i the reYem1c deriYed from the wool carter-<. which amount"' to $.iOO daily, passing through his hands. It wa;; not until tlw .: group banks" came through "ith a loan of $240.000 llnd a promi~e of sl.~00.000 that action was really taken toward pro- tcctinz the lines of communication. And as shown, the practical effectiveness of this protection was nullifi~d h~- fear of a" truculent" roldier. PRO<lHESS Ot' THE EPIDE~IIC . Tb<.:. following ii, n. b1·ief chronicle of the epidemic: XowmbN' 15, 1917: Origin at Patsobolong, Mongolia . • January .3, 1918: Cases appear outside and to north of Great 'Vall. January 17, l!H8: Three cases south of Yenmen Pass (Great Pl ~ = Plo.~1Le. Inf ed ~-R"ilwo.ys ,...--"-Tro.ils f] I } i Epide.mtc slarl golian Trade Ro lher<} il spread norlh and south cause prevenh deo.Hls were r one halJ month without rapid lr 700- 1 tTS. Yol. XII :>eing refused transportation back e gates of the Great Wnll to all clemic north of the wnll and the h:we been a comparatiYely easy e gravity of the situation we~ lly ob,...en eel. Thl' actual condi- 11 optimis1 1 •• of the otllcials. and i::. a soldier carrying a sick child om an infech'<l plact• hy rail and es from hi~ point of embarkation. >r of Shanghai. obserYe<l that: 1•h ha-< .11hje••te1,I the lo\\ Pr e111l of t he an:i;.:t·. Th!:-: llnl' hn" for 'ome tiine tc1l r1~\•l. .\ le:1k.1::c in till' norllwrn e in fe ·ti'• I :1 n•a I 11 norrlwrrmin"t ~hnn~t .hr1111!!h l'••n ·hl'n :11ul through Knlzan only, without tbC' ahs(llutcly e..:.;entlal q11:1rantim• pC'ri11rl of fh1• d:t~" nt tht' H1\"i11:..: tttkt»i chi 1 ·aln Hl Pekin;.:: \\hen tunl fl\<:e:i<.:r. ~h<' <1tnrtMl rout?hlni:: on 1 aftE>1· rt>ad i1 ;.:: h1•r h11me at Fen~· nnl?. h of Pnkow (~fankln;:). Thi-. rn~ in· family :tnrl nei!!hhor..:. who :111 1lle<l of :mil !>. the \\Oriel· whPrt' sih er an1l gold s of the people. Ilut Chinn is ~ uth that money is the ever-present .oney will purcha~e anything. 1f •p trains or to decimate the popu- e unless more money is to be made governor of Suiyuan " refus<'d to ." Evident]~· the go,·ernor·, rea-on riYed from the wool rnrter--. which ; through his hands. It was not ri.rough with a loan of $2-10.000 and tion was really taken toward pro- cion. And as shown. the practical as nullifi~d hv fear of a " truculent " THE EPIOE)BC. iicle of the epidemic: P atsobolong, Mongolia. · outside and to north of Great Wall. ses south of Yenmen P ass (Great PNEUMONIC PLAGUt JN NORTl1 CHINA 1918 EpLde.mtc slarled al Patsebolon~ Nov. 15, 1917 ll spread alon~ Mon- gollan Trade Route. Jo.n 5, 1918 al 5opmsfu 6 cases oc.c.urred. from lher~ Ll spread rapidly reach mg fengyan~ Feb. c8 , 1918 . The area norlh and south of lhe Great Wall wo.s heavlly infec.h.d. lar~ely be- cause prevenhon wo.s anla~o11i3ed by off ic.io.ls. Ma.rc.h 1, 1918 four deaths were reported Jrom N ins~iafu (Kanslll. Withm lhree and one ha.lJ months infec.hon spread. over .1500 miles, lo.r~ely tn resions without rapLd. lramil. 700 - 1 ~o 4. \fall). Two death other passes closed . • January h. HH four day::- north tkhrd at Kal!!an a \\'a.VS runnmg: as th January 20. 191 .January 21. rn1 5ituation. Brcin 11 deaths to elate. be interceptecl east ,jx days'. Suiyunn Tohsicn. ~prcadi11g .T anuary 22. l!ll tal deaths there t 13 deaths between January ~:~. 1 fll t>ight li distant. S not stopped. F<'a .fonuary 2+. 1fll nuder a physicia Domiliciary in:-,pe teriologicall~-. Ga ct•ipt of adrnnee o{ of ~1.200.000 to h to establish prope Ts'ung; 17 clraths rapidly. Xorth o deaths incrra!'ing. ,January -2i. Hll 11f 34: deaths to <la :di village ... infrctr ing west,.,·ard. cian prie..;t clie,: !3 February 1. Hll ing :;outh. ~1ini. districts. ~UXISTRY I First. Suiynan power." (Area o ritory. Second. Charha Third. From T Y enmen Pass. :><>· 4. REPORT:;>. \full). T"o death~ nt Sinchow. R<'ported present nt Tnichow. All other passes clo$ed. January 1 . l!)l, : DC'aths n•ported ulong road south of Taichow. lfour da)::-. north Taiyu:mfu by cart). PreYention stations estab- \ishNl at Kal!!an and Knu!!chuan. Peking :::itill untouched. All rnil- "·ays running as usual except Peking-Kalgnn road. January 20. l!HS: Increasing at P.aratsi. January 21. 1!)18: Peking officials hegin to rralizc seriousne"" of situation. Begin lo train plague preYention police. .\t Fengchen 11 deaths to elate. Situation serious at Paotowchen. Traffic to be intercepted eastward. _\ll traYelers to be placed in quarantine six days·. Sniyuan go' ernor decides to allow preYenti,·e nwasnres. Tohsien. spreading rapidly. Saratsi, 1.000 tlenths in fin• day:-, . .T anuary 22, Hl18: 'l'wo soldiers die of plague at FengrllC'n. To- tal deaths there to do.le 27. Kweihachen. 100 <lraths. H!-:inchow. 13 deaths betv1een 16th and 22nd of January . • T anua.ry 23, 1918: Tatungfu without plague. Four cases de,·elop t•ight Zi distant. Saratsi. conditions bad. Traffic down Yellow Rh·er not stopped. Fear spread south through Shan!"i . . fonuary 2-1. l!l18: Tatnngfu; city di,·ided into four ::-t•<·tors each under 11 physician (Drs. P.myly, Chen .• Tou,·elet. and Kosuge). Domiliciary inspections inc;tituted. Two deaths. one proven hnc- teriologica Uy. Gate" do<<e~1l at Paotowchen. Peking annoum·es re- ct>ipt of aclrnnce of $:240.000 by group banks tD comhnt plague. Total of $1.200.000 to be loaned for that purpose. GoYernmmt con .... ents to establish properly equipped quarantine station at Xnnkou. Sun Ts~ung; 17 deaths to da.te. Taichow; 35 deaths; disea"t' spreading rapidly. Xorth of the Great Wall 1.000 deaths in :> days. Saratsi, deaths incr<'n"ing. Gates 1•losed. Dr. Young working at Taiyuo.nfu . • January 2i. 1918: .\t Fmgchen, 4 deaths among c;oldiers. Total of 34 deaths to dnte. Taiyuanfu; 233 deaths to dak Sarn.tsi. 1warly all village" infected. .\.11 infected die. Kansu r<•ports plague spread- ing westward. Hae: reached Santaoho, north of Xingsiafu. Bel- gian priest die::-: 3 others infe<"ted. February 1, HHS: Peking hopeful of keeping plague from com- ing :::outh. "Ministry of Interior diYide.c; infected area into fonr districts. :l[JSISTRY DWIOE!' I:s'YF.CT'ED AREA J~TO FOUR l>ISTitlCTS. First. Suiynan area under Dr. Chuan Shao·tsing ·'with full power." (Area of 10,QOO square miles.) Most heavil~· infected ter- ritory. Second. Charhar under Dr. Ho Show Yin. Third. From Tatung north to Provincial Boundary and south to Yenmcn Pass. Under Tuchun of Shansi with Dr. S. P. Chen as 792 Iµ:PORTS. Vot XII medical director of quarantine stations at Kalgan and N:mkou to keep Kingsui Railway open. (Area of 35,000 square miles.) Fourth. From Yenmen Pass southward along the Great Wall under Tuchun of Shansi. Boundaries of Chihli, Charhar, and Shansi to be strictly "Watched by troops under Tuchun of Ch; hli. Gen. Chiang is responsible ior preventive and suppressive measures generally. (Area of 75,000 square miles.) February 3, 1918: Sinlo reported infected. Shansi south of Wall · 35 deaths in two days. Fcngchen; total deaths, 70. ' February 5, 1918: Inside "Tall near Yellow River is a newlv-in- fected area. It is announced that the road on both sides of the 'y cl- low River should be watched as well as the river itself when opm to boats. Translations being made of plague literature. No new cases for a week in Taichow district. Feburary 15, 1918: Tingchow; no further ·cases. Chentinfu; sat isfactory. Huts to the number of 200 shipped to Fengchen for ad- vance quarantine station. Pekin announces: "Spread of plague now under control." February 18, 1918: Suiyuan district, 1,500 dead; more in outlyin!? regions. Shansi; 116 dead in past two days. February 23, 1918: Four suspicious deaths in Pekin. Average of 60 deaths a day in Shansi admitted officially. February 28, 1918 : Fengyang, Anhui; 8 deaths :from bubonir plague; Pengpu; 1 death. March 1, 1018: Tsinanfu, 4 cases. March 15, 1018: Nanking, 25 cases. Table of reported cases. ------P-fo.oo_. \. ~~~IE~t:::::: .:.:.:. :. : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :1 Kwei Wha Chen .......... . ............................ . Tsinfau ............................................. -... . Pengpu .......... _ . _ . _ . _ .. _ ... _ .... _ . _ . _ . _ . __ . _ . _ .. _ ... . S tn tao ho .... _ ...... ....... _ .... _ . _ .. _ ... -... -. -- --.. -... - S.ira!Bi ............... . ........ . ..... _ ....... _. ____ .. _. _ .. ~~;~~~:::::::::::::::::::::::::::::::::::::::::::::::: I Sniyna.n .. _ .. __ ............ _ .... _. _ ........... __ .. ___ . _ .. Run Ts'ung .... -.. . _ ....... ___ ......... -... -... -... . ... . Ta.ichow . . . . . . . . . __ . ..... _ .. ... . . .. -. -... .......... . Ta.iyua.n Fu ....... _ .................................. ' .. . Tatnn Fu .... - . . . : ............. - _ .... -.... - . -......... . Taihsien ....... ............. -..... -......... -........... . Cases. Date roportod. 8 Feb. 28, 1 !ll 76 Feb. 3, l!ll 13 Jan. 16 to:?!?, 1918. 100 Jan. 22, l!ll 4 \Jar. 1, l!l\S 1 Ft>b. 23, 1918 4 Jan. 2:1, 191 1, 000 Jan. lG to 21, 1918. 157 Feb. :l, l!ll 2 Jan. 17, J!JIS 1, 500 Feb. 18, l!lJf; 17 Jan. :!1, l!ll 38 Nono Pince Feb. I, 1!118 233 Jan. 27, WIS 6 Jan. 24. ms 17 I Jan. 21, l'.118 702-1 ---·lllllllllllllfl J'IS. VoL :\O:IJ tions at Kalgan nnd N ankou to :a of 35,000 square miles.) 1uthward along the Great Wall daries of Chihli, Charhar, and troops under Tuchun of Chihli. ventive and suppressive measures e miles.) . infected. Shansi south of Wall; . ; total deaths, 70. near Yellow River is a newly-111 the road on both sides of the Yel- ;rell as the river itself when op ·n le of plague literature. No new :t. no further cases. Chentinfu ; sat- 200 shipped to Fengchen for ad- nnounces: "Spread of plague now :rict, 1,500 dead; more in outlying two days. ious deaths in Pekin. Average of ed officially. 1 Anhui; 8 deaths from bubonic '" ;es. ported cases. -.--1· ................. , ....................... .................... 1::::::::::::::::: Cases. Date reported. 8 Feb. 28, 191" 76 Feb. 3, Hll" 13 Jan. 16to22, l!Jl8. 100 I Jan. 22, 191~ 4 \lar. 1, HHS 1 Feb. 23, 1!J18 4 Jan. 2:l, l'llS 1, 000 Jan. 16to21, 1918. 157 Feb. 3, um 2 Jan. 17, 1'l18 1, 500 Feb. 18, l'll!\ 17 Jan. 24, uns 38 Nono einre Feb. 1, l!\11' 233 Jan. 27, l!\lli 6 Jan. 24. l!llo 17 \ Jan. 21, 1!)]8 792-1 c ., Vi -"' c .. ?; .; .g ... c "E- :;; <.> .!':? 0 0 u , ( 7U2-2 The figures above are n •11ch thing as a registrati .,orts. The only informa t .; that from Yolunteer wo 11·onld at first imagine fr They should only be con iemic. Only 2,952 deaths i.000 deaths were occurri The alteration in the t, ·onic at Fengyang, Anhui 1nitted by human fleas or the disease in a rat. Tingsiang in Shansi :,; . ,fficials than most of th~ .~1rgely through early de with the advice of physic! '.'l'flects credit on all cone 5 of interest : Ju comhatinl{ the pneumon •I\\' vei·y clol'ely the methods 1»t place there is no hmq1it1 ·be second plaC'e there are 111 u:w on the sonth. Finnll. urn! rathl'r than urhan. In n boi=<pilals, with th!' railwa~· :irge cities. In view of tlw" -ervice has been de,·elupeil ·hat giving wicle publicity to e of great service to the Ch 11mbat this or similar eplde Tlngi'iang is 11 small distrl lty if> practically the gCO!!:l'll -ampaign an attempt was rea in detention stations at ·rlct city. Within a day or ro correct this ·• travelers ' ut were promptly interned -uch as temples." When plague appeared in . \\"!thin th!' village it!'<elf th!'r nd contacts. l~ollowing this ·• more dra ·lo~erl to all persons exct>i>t •llil'e. All the villa!!:es in th "illn ge heing strictly forbid Looking toward the 1anger to China, especi. 7G0!)8-18--15 so. 4. REPORTS. 793 The figures above are not to be regarded as statistics. There is no .uch thing as a registration area in China oubicle the larger treaty ports. The only information to be had from the infected territory ·s that from Yolunteer workers. The situation is ±ar worse than one 1rould at first imagine from a cursory glance at the figures alone. They should only be considered in tracing the progress of the epi- ,!emic. Only 2,952 deaths are there represented. As a matter of fact L.000 deaths were occurring in a few days in some neighborhoods. The alteration in the type of the disease from pneumonic to bn- oonic at Fengyang, Anhui, is noteworthy. This may ha Ye been trans- mitted by human fleas or it may have resulted after deYclopment of the disease in a rat. Tingsiang in Shansi seems to haYe fared better at the hands of officials than most of the plague regions. Herc it 'vas no doubt largely through early devastation that the people fiO readily fell in with the advice of physicians. The plan worked cut in thi:; diHtrict reflects credit on all concerned. The following plan of organization is of interest: Tu combating the pneumonic vlugue in Shnni;;i it bas not been possible to fol- low very cloi;;ely the methods employed in lllnnc:hurin seven years ngo. In the 1ir~t plnee lht•1·e iH no lWHpital in nil llH' north of 8ham:i ahove Talyunnfu. In tile ~ecoml plnee there ure no railwnys hetween Tntung on the north and Tni- ruan on the ~outb. Finally tbC' tcrritor~· at'fectC'd ltn~ hcen predominantly l'lll'lll rnthC't' than urhan. In :Manchuria seYen ~·ears ago il was possible to work in ho;.pitals, with th<> railwa~·s as hases, and 1n·11cticall~· all the work was done in lnrge cities. In 1·iew of tht>~c 1lift'erent (·omlitiom; 11 11ew type of puhllc health ;en· Ice has Ileen tlernlopecl i11 the pre:.:(•nt cnmpa if!n, nnd the 1\Ti ter bclie1·e~ that giving wide publicity lo the methods employed, especially In villages, will be of great service to the Chinese people and to all who may be called upon to 1·ombnt this or similar epidemics in the future. Tlng:.:lang i;. n small district, having a total of hut 9G villages. The llistrict city is practicnlly tbe geographic center of the district. At the beginning of the 1·ampaign an attempt was made to hold all travelers returning from infected area in detention stations at the pnsses, or In the detention ;.tation at the dis- trict city. Within a day or two, howeYer, thc!'le detention stations were filled. To correct this ·• tn11·elers were permitted to return lo their nntive villages, but were p1·ornptly Interned either In their own courts or in public building;:; ~uch as temples." \\'hen plague appeared in n village thnt village was promptly Isolated. • * * Within tbC' villagC' itself there wa>:, or comse, the isolation of the plague patients ·ind contacts. Following this " more drastic measures were adopted. The cit~· gates were rloserl to all persons except tbm•e holding special permits from the nntlplngue iffice. All the Yillag-es in the district wc1·e isolated. Intercourse from village to rlllnge helng strictly forbidden." Looking toward the future we mnst consider another source of ilan~er to China. especially to the Upper Yangtze, from the bubonic 7GODS-1S-l5 794 REPOBTS. plague in India, Siam, and French Inc.lo-China. Thi:s region is · fact nearer than the )fongolian epidemic was. And there is r~!: communication within 100 mih•:s of Szechuan which come:-; throu!!~ Tonkin. one of the infected areas of Indo-China. Furthermore, th main road southwanl out of Chungking passes through Yunnan~ ( tlw French railway terminus). directly to the borders of Burnia tlwnee to the British railway terminus. which runs from :\landala,: almost to the border of Yunnan. ~\lmost all of India i~ infected "ith bubonic epidemics, the Madras PresidC'llC)' being probabh the most heavily infected part. · Stitt in 1914 said: Till' plague epideuiit with whil'!1 nil pnrt>' of th\' \\"l>rld an• now '"' <'Oil (.'erned is supposed to !tan• 01·iµ:i11;1tpd i11 <'hi1111. in the J'roYin<·t' of Y1mni11i. The proximity of Ynnnan to India is significant, and the near11c:,, of Yunnan to Szechuan is equally important. It suggests the po~­ :-.ibility of this interior China being a huge reserrnir of infection. During the past year it is estimated that 100,000 Ynnnan and Kweichow soldiers have entered Szechuan. They ha ,-e taken <ffer the entire ProYince and ha Ye carried on military operations n•11uirin!! the transportation of supplies and munitions from the southern coun- try to the area of conquest. All of this has been done by coolie-.. It will be seen that the actual number of men toming from qne-.,tionable <li~tricts is probably at least t wire I 00.000. probably 400.000 or ~>00,000. This military migration continues and is utterly mid of any sanitary or hygienic organization or arrangement. Reference to the following table;, and to the map will show morP clearly the danger from this direction. ·when 1rn realize that i;;,ooo junks ply between Ichang and Chungking the year round. and that steamers run between these two cities in the summer and lielow Ichang to Hankow the entire ~rear. '"e can appreciate what i,., in store for China if plague begins to take root in Szechuan. To account for the absence of cases here we can not plead too :strongly for the theory of isolation, although the map shows cer· tain natural barriers. Rivers are more or less an obstruction to rodents. But rivers which are crossed by boats reduce the obstruc- tion, and human cases naturally could be carried across riYer:> dur· ing the incubation period. Mountains arc natural barriers to rodents if they are high enough and afforcl scant vegetation or other food. High altitudes operate against invalid migration. Distance increase• the protection. It seems unlikely that these natuml barriers are wholly respon· sible for Szechuan's freedom from infection. There must be other -----...... -., t~5T TUPJ(.tSTAM I "- Bubonic Type. is pr~valenl soulh of Clunq in Mon~olia and North China. ln India lh1 soldiers have come lo .S3echuan from Yol. XI! ma. This region is in as. _And there is rail 1 wlnch comes throu") . F ~1 ma. ~ urthermore, 1 Ii .ses through Y unnanfu the borders of Bunu a. h runs from .;\fantlal:" tll of India is infert"d idenc~r being probaLI~ lip \\ n1·1t1 a 1·p no\\ so <"on t lit• l'rm·in<·t' of Ym1t1m1. ificant, and the nearrn·ss 1t. It ::;uggests the pos. eservoir of infection. at 100,000 Yunnan and They have taken ov1·r ary operations rec]l1iri11., from the southern com;~ Jeen done by coolies. It oming from questionable )0. probably ±00,000 or s and is utterly void of rrangement. the map will show mor1• When we realize that mgking the year round. :ities in the summer and we can appreciate what e root in Szechuan. L'e we can not plead too ugh the map shows cer- >r less an obstruction to boats reduce the obstruc- arried across rivers clur- atural barriers to rodent" vegetation or other food. ation. Distance increase~ Tiers are wholly respon- n. There must be other Bubonic Type is prevalenl soulh of Ch ma and al fengyans. The Pneumomc. Epidemtc. is in Monsolia and NorH\ China. In India lherc. were 17,000 cases in 14 days 100,000 soldiers have c.ome lo .S3ec.huan from Yunanf u and Kweichow in lhe pasl year 794-1 City wall, Quay Fu, Yangtze Valley. 791-2 Ju nk on upper Yangtz e. No. 4. factors oper:~ or existence c Sectional natural barr n .Prev10us c~ Periodical to learn, tho~ zation fro1n ~ of the Phili1, th!l Philippi1j like intervals that idea witi then director ings haYe bet It may he 1 terval of yea immunity de' to succeeding "Dr. KitaSi A. D., when i were reporte~ the beginnin vanced, was ~ outbreak somi At any ra! Szechuan if would mean rrtts arr. rtr<'P this region. few which w Apr. 15-June 30, July 1-0ct. 20, 1 Oct. 21-0ct. 27, \ No. 4. HFl'UB'I ~ 79f) factors operative, such as sectional immunity or perioclic immunity; or existence of the disrnsr in mild endemic form. Sectional immunity may be due to t"o causes in addition to natural barriers: ( 1) To uctin~ immunization after tl 1 " ra rnges of a previous epidemic; (2) climatic conditions. 0Periodical immunit,\' i!> ~omcthing about "·hich we have still much to learn, though it probably depends to some extent on the immuni- zation from predons epidemics. It was suggestPll by Dr. Clements of the Philippine health service during an epidemic of cholera in the Philippines in 1916. Ile belieYed that cholera returned in waYe- like intervals of lt certain number of years, and he was working on that idea with Dr. Long of the United States Public Health Service, then director of the Philippine health service. No Joubt their find- ings have been published. though we do not have access to them. It may be that plague exhibits this tendency to recur after an in- terval of years, perhaps depending upon the persistence of active immunity dcYelopecl in a previous outbreak and transmitted weakly to succeeding generations. "Dr. Kitasato, in a lecture, traced the plague as far back as 200 A. D., when it found its way to Egypt and Europe. TJH' visittttions were reported until between the end of the thirteenth century and the beginning of the fourteenth. Europe, as medical science ad- vanced, was able to drive out the pest except for an inconsequential outbreak some 11 years ago." At any rate, there is nothing to prevent plague spreading in Szechuan if introduced unless it can be explained as above. It would mean periodical rat immunity as well as human immunity, for rats are accepted on equal social terms with the average resident of this region. Rat .fleas are not conspicuous by their absence if the few which we have examined are to be taken as examples. Statistical table. L'WIA. _ D~tc. - - - - I Apr. 15-June 30, 1917 ........................................ . July 1-0ct. 20, 1917 ............................ ... ........... . Oct. 21-0ct. 27, 1917 ......................................... 1 Cases. 43,992 45,657 13,571 Deaths. 30, 1U7 34,074 9, 390 796 REPORTS. Yo!. XI! stoli.~tico/ 111/111'.-( '011lint1Ptl. DISTRifll"TlON. PlaC<'. Dale. Coses. J,a.st r~port. I Ca~~s. -- Bassein ........ _ .\pr. 1-June 30 ... . . 54 July 1- 0ct. 13. l 917. Bombay ............. Apr. 22-June 30 .... :;!)7 July 1-0ct. 20, 1917. Calcutta .......... _ .. Apr. 29-June 2 ..... 38 July I- July 21, 19I7. Ileuzada ........... Apr. I-June 30 ..... 35 Aug. 12-Sept. l5, l!Jl7. Karachi. ........... .\pr. 22-J u ne 30 .... 468 July 1- 0ct. 20, 19I7. Madras Presidency .. A pr. 22-J une 30 .... 250 July I-Oct. 20, I9f7. Mandalay ........... Apr. 8-May 12 . .... !l July 29-0ct. 10, I9I 7 Moulmein ........... Apr. I-June 30 ..... 74 July 1- 0ct. 10, 19I7. MyingyJ.n ......... . . Afar. l-Afu1" 7 ...... I None ............... I'egu ............... .r. ay 27- une 2 ..... 2 July 29-Sept. 22, 19I7. R1tagoo11 ........... . Apr. 15-June 30 .... l83 July I-Oct. 20, I9I7. Toung:>o ....... ..... Apr. 8-Apr. 14 ..... 2 July 29-Sept. l, I917 INDO-CIIIi\A. Dale. Cases. ----------- --- Feb. I-June 30, 19I7 ...... . ................................. . July I-Aug. 3I, I9I7 ........... ........ _ .................... . 730 119 DISTRIBUTION. Place. Dato. Coses. -, ~ Last report. 2!l 432 4 7 4!l 5,490 (j(j 39 ···-····· 2 605 12 Dea tits. 491 89 Cases. Anam ........ ....... Feb. I-June 30 . . . . Cambodia .......... Feb. I-June 30 . .. . 232 132 219 Aug. l-31..... . ... 7 Cochin China ....... _ Feb. I-June 30 ... . Aug. 1-31. . . . . . . . . 26 Kwarg Chow Wan ... May I-June 30 .... . Aug. I-31. . __ ..... 16 Tonkin .............. Feb. I- June 30 ... . 34 113 -------······----- -· ········· Aug. I-31. ....... . SIAM. Place. Date. Cases. Deaths. -- Bangkok ........•... . ..... ...... _ ........ Apr. 22-June 30 ... _ I3 12 July 3-0ct. 27 ...... 31 29 RELIEF WORK AT GUATEMALA CITY. After the earthquakes of December, 1917, and January, 1918. By S. M. TAYLOR, Lieutenant, M. C., United States Navy. Having received orders from the Navy Department to visit the city of Guatemala and report on conditions and render what aid we 796-1 \·nl. XI ( 'olltillUPtl. x. :;es. 54 ;197 38 35 468 250 9 74 1 2 183 2 \. 'I. ~s. 232 132 219 34 113 La.st r~port. I Cn~~•. Julyl- Oct.13, l!ll7.1--~ Julyl-Oct.20,1917. 432 July I July21 , 1917. 4 Aug. 12- Sept. 15, 7 1917. July 1-0ct. 20, l!ll7. ·Hl July 1-0ct. 20, 1917. 5, 400 July29-0ct.10, 1917 (i(i Julyl- Oct.10,1917. 3!l None ....................... . July 29-Sept. 22, 2 1917. July 1-0ct. 20, 1917. 605 July 29-Sept. 1, 1917 12 Cases. D~n tlti. Last report. 730 119 4!ll S!l Cases. ·1--------1---- Aug. l-31. . . . . . . . . 7 Aug. l-31. . . . . . . . . 2() Aug. 1-31. . . . . . . . . 16 ---················· ········ · Aug. 1-31. ....... . Date. Cases. Deaths. 22-June 30.... 13 12 3-0ct. 27..... . 31 29 EMALA CITY. l917, and January, 1918 . . , United States Nnvy. tvy Department to visit the ions and render what aid we 796-1 !'o. 4. could. Capt. Brumby an one hospital appre1~tice. the morning by ,.pecial o·clock in the aft{'rnoon. ber of buildings along t earthquake. Dr. ~\.. M. at the train. and he and went to the first-ai<l ,.t equipment, and patien wounds dressed. " ' e .\merican L egation to r Capt. Brumby. Ensig of refugees, and my,;el American L egation, sk hospital corpsmen ,.1ee1 the veranda when the 10.30 p. m. ". e all im it was with difficult~· t to be rolling in waYes. one. The disturbance lasted 10 second,.. and f ation of earthquake..;. i n~ the night. The ne legation without ~omc ately to the first-aid great many more bni People were waiting h and the hospital corp ing the wounded. ". the injured that had : The follmving is a. eral capacities before Hospital General----- - llospital i\iilitar_ --- - Hospital De Yenereas - Hospital Amerie:rno - -- Hospital De Epldemins_ Hospital De Leprosos -- Asilo de Dementes---- Asilo de Maternidnd --- Asilo de Convaledentes Asilo de Mendi~·os----­ Hospital de Los Carne\ Hospital antirnbicO---- Hospital de vacuna ___ _ All the patients o after the quake on ?;o. 4. REPORTS. 7H7 could. Capt. Brumby and two other officer,_. two pharmacist\; mates.' one ho,,;pital apprentice. ,.,(•cond cla:,;~. and myself. left ~an Jo~e in the morning by ::.pecial train. and arrived at Guatemala City at -1 o·clock in the aft{'rnoon. Before arri,·ing at the city we saw a mun- ber of buildings along the railroad that had been de&troyed by the earthquake. Dr . .A. M. Struse. of the Rockefeller Jn .... titute, met us at the train, and he antl_I and the pharmacist·s mate:' with equipment. went to the first-aid ::.tation e::.tablished by him. Here I found no equipment, and patients were waiting by the score to 1uwe their wounds dressed. ·w c worked till nightfall, when I went to the American Legation to report the conditions to Capt. Brumby. Capt. Brumby, Ensign Purdy. the staff of the legation, a number 0£ refugees, and myself spent the night in the court ~quare of the American Legation, sleeping on mattresses-the other officer and the hospital corpsmen sleeping in a stable near by. "WC' were sitting on the \eranda when the most terri b]e e:irthqua ke came; this was at 10.30 p. m. vVe all immediately ru::,hecl out in the court ::;qwtrC'. an<l it was with difficulty that we could keep our feet. The earth i:;el'med to be rolling in waves, not a to-and-fro motion, but an up and down one. The disturbance seemed to be directly under tt::;. The :::hock lasted 10 seconds, and from then on till daybreak there wat; a continu- ation of earthquakes. Ensign Purely and I counted 240 quake:, dur- ing the night. The next morning, as soon as we could get out of the legation without some of the walls falling in on us. I went immedi- ately to the first-aid station. On the way down I noticed that a great many more buildings had been destroyed during the nifrht. People were wai6ng by the hundreds to haYe their woun<ls Jressed. and the hospital corpsmen and Dr. Strnsc were already busy dres,.;- ing the wounded. vVe worked till 12 o'clock and had dresSC'd all of ,the injured tlrnt hatl applied :for assistance. The following is a list of the hospitals in the city and their sev. eral capacities before the earthquake on December 2:): B~d~. Hospital General ------------------------------------------------------ 800 Hospital ~Iilitar ------------------------------------------------------- 300 Hospital De Yenereas ------------------------------------------------- 100 Hospital Americano --------------------------------------------------- 2;; Hospital De Epidemias------------------------------------------------- 100 Hospital De Leprosos -------------------------------------------------- 100 Asilo de Dementes------------ ---------------------------------------- 3(10 Asilo de Maternidad -----~-----------·---------------------------------- 201) Asilo de Convaleclentes------------------------------------------------ 200 Asilo de Mendiyos----------------------------------------------------- 100 Hospital de Los CaraeJy _______________________________________________ 200 Hospital antirabico ________________________________________ , ___________ 100 Hospital de vacunU---------------------------------------------------- 25 All the patients of the above hospitals were removed to the open after the quake on December 25, as every one of the hospitals was 798 REPORTS. \·01. XII praetically destroyed. Many of the instruments and practically all of the medicines and dressings were lost, owing to the fact that the heavy walls buried them. Fortunately not many of the patic•nt..; wrre killed. but no one could giYe a correct idea as to how ID'.lnv had been killed. After the quake on January 3, 1918, every hospit-ii. and such parts of them as were left standing were totally destroyed, ancl any patients that were not removed far enough away in the open were killed. The .American legation was the only building 10ft standing in the city after the shock on January 3, 1918, and it "·as considered Yery unsafe, as the walls had large cracks in tht>m. The sewage dispornl was only fair before the earthquake, the dis- charge emptying into a creek below the city. After the quake all. or pracitically all, of the pipes burst, and their contents were emp- tied into the streets. Before the quake there were two water ~up­ plics, one coming from a large spring, and the other from a ri' er. The one coming from the river was considered bad. This condition had been reported to the Government, but no effort was made to rem- ed:v it. After the quake there was no water to be had in the city, and it was a common occurrence to see the people drinking the water from the sewers. There were 70 native doctors in the city before the quake, but I am sorry to say that 40 of them left imediately after the first quake. There were 50 drug stores that were completely destroyed and prac- tically nothing could be saved. Great credit must be given tho~ native doctors who did stay and gave all their efforts to help relieve the dreadful situation. BULLETIN NO. 1 OF THE BOARD OF I-IEAT,TII OF THE ROCKEFELLER FOUNDATION. With the idea of preventing typhoid fever, dysentery, and other intestlDal Infections the following measures should be tnkcn: 1. Each family will endeavor to build provisional toilets. In order that these f::hould fulfill tlieir full object, they should be a yard in depth. 2. The water for drinking should be used boiled, filtered, or mixed with an- otlicr chemical substnnce, among the most practical are the hypochlorite of lime and the tincture of iodine. In order to use the hypochlorite of lime. take one gmm of it and mix with one liter of water, shake it and use It 15 minut~ after. The tincture of iodine should be used in the following manner-to s liter of water add two drops, shake and wait 15 minutes before using. 3. In order to llrcYcnt smallpox It is necessary that one be vncclnatell. This office has reque,.ted of the home office in New York a sufficient quant ty of the vnccine to vaccinate a;minst smallpox, t~·phoid fever. etc. As soon as it arrives it will be distributed grntultously. This board estahlishcd an emerg('nr~- hospital on the second avenue south, opposite the Escuela Practica Senoritas. GUATEMALA, Decembc,. 31, 191"'1. Among the most prevalent diseases were typhoid; typhus (in out- skirts of the city) : malaria; smailpox; tuberculosis common, especi- :\O· 4. ally grandular; goiter comm amebic and bacillary (high in{ preYa.lent: hook-worm. 22 to :! 111eningitjs. mostly amon~ th ~till worse the officials try to The medical authoritie..;; w thing. They would recomme irrnored. They coulcl not get first-aid station, ancl "·hen t that the naliYe sol<lier..; shot fl "ecmecl that the>· would not first-aid stations properly. Among the most se,·ere in of all kinds; fractures. c;imp n~rc lacerations of an kincls. to haw, nothing physically " fering from shock. whirh wa :md vomiting. During the month of De earthquakes. but the people The first powerful earthqual ing, the second at 10.·!:i. and shocks practically de..;troyed ing the night. On Saturdt~. the next large shock. Tln native physician. The nex Year's night. The last and 10.30 on the eYening of .J American Legation. This f'evcrc. This last sho<'k cm ception as stated before of t Fortunately the food con had established stations wh supplies, the condition~ w nothing left. It is eshma and 800 wounded. In the cemetery at leas irra ves by the force of the burned in oil. . Great credit is due Chie Pharmacist's Mate (Thircl _ tice (Second Class) \Y. \\ peatecl1y expose~ t?em~<>h to bring out the m1ured. \·01. Xlt practically a l1 e fact that the >f the patient~ ; to ho" many every hospital. tally destroved . ' ;h away in the ~ only building 3, 1918, and it cracks in them. 1quake, the dis- r the quake all, tents were emp~ two water sup- ar from a river. This condition >as made to rem- had in the city inking the wate; the quake, but I :r the first quake. troyed and prac- .t be given those ts to help relieve ~LJ,ER FOUNDATTON. and other intestinal In order that these 1th. 'I, or mixed with an- tbe bypochlorite of :blorite of lime. tal>e nd use It 15 minutes ,owing manner-to a before using. ; one he vaccinated. n. sufficient quantity :r • etc. As soon as it second avenue south, .d; typhus (in out- ;is common, especi- 799 REPORTS. tillY grandular; goiter common, especia Uy among men; dysentery ;in1ebic and bacillary (high infant mortality) ; venereal diseases, very prevalent ' hook· wonn. 22 to 25 per cent; and epidemic cerebro-spinal 111eningit,i.:;. mostly among the nati Ye sohllers. To make matters still worse the officials try to conN.'al the contagious diseases. so. 4, The medical authorities were practically powerless to do any- • thin~. They would recommend sanitary measures only to have them ignored. They could not get the people to c:ury the wounded to the first-aid station. and when told to work they refused. It is true that the native soldiers shot a great many people :for looting, but it seemed that they would not help to guard the hospitals and the first-aid stations properly. Among the most seYere injuries were tl1e :following: Contusions of all kinds; fractures, c;iroplc and compound; peritonitis; and se- vere lacerations of all kinds. A great many of the 'people seemed to havo nothing physically wrong with them, but seemed to be suf· fering from shock, whic11 was characterized by extreme nerYousness and vomiting. During the month of December there had been a great many earthquakes. but the people dicl not pay much attention to them. The first powerful earthquake occurred at 10.30 on Christmas even- ing. the second st 10.45, and the third about 11 p. m. These three shocks practically destroyed the city. Smaller shocks occurred dur- ing the night. On Saturday. at 2 o'clock in the afternoon, occurred the next large shock. Thi.s shock killed Dr. Volla, a prominent native physician. The next large shock came at 12 o'clock New Year's night. The last and most terrible of all the shocks came at 10.30 on the eYening of ,January ;~ \Vhi1e we were there in the American Legation. This shor.k was considered by all the most severe. This last shock completely deslroyed the city with the ex- ception as stated before o-f the American Legation. Fortunately the :food conditions were good, and the Government had established stations where food was given out. A.s to medical supplies, the conditions were ve<"J bad, as there was practically nothing left. It is estimated that about 350 persons were killed and 800 wounded. In the cemetery at least 10,000 bodies were thrown out of the graves by the force of the shocks. These bodies were immediately burned in oil. Great credit is clue Chief Pharmacist's Mate William Schofield, . Pharmacist's Mate (Third Class) C. A. Ray, and Hospital Appren- tice (Second Class) W. W. Methven, United States Navy, who re- peatedly exposed themselves to (\anger in falling buildings in order to bring out the injured. 800 REP0.HTS. Vol. :\ 11 REPORT OF AN EPIDEMIC OF 3-DAY FEVER AT THE UNITED STATES NAVAL AIR STATION, -- FRANCE. Hr IJ F1:n1;i·so:-;, LIPnt••nnnt. '.\I. C' .• United Stat"" Xa\'J". An epidemic res<'mbling influenza, which has been sweeping through Europe\ reached the United States Nan1l Air Station at ---,France, on June 24, 1918. The French authorities reported an epidemic in Algiers. in the eastern :\Iediterranean States, and th!' eastern Adriatic liUoral during the spring and summer of 191 i, and according to information received by medical officers of the United States Army considered these epidemics as dengue and pappataci :fever. It is now thought that these epidemics were Lhf' beginning of the one now prevailing. Etiology.-Vp to May 27, 1918, the exciting organism was not definitely identified. Since then, in eight cultures made on cases in the --- Regiment, United States Army, American Expeditionary Force, at Base Laboratory, Base Section No. 1, five cultures were positive for an influenza-like organism, described as a small gram negative bacillus in symbiosis with the pneumonias. It grows only on blood medium and presents the characteristic dew-drop colonies. It is very difficult to grow alone and to transplant. l\forphologically it is indistinguishable from Pfeiffer's organism, but, due to the dif- ficulties attending research, it has been impossible as yet to de- termine accurately its biological characteristics. Cultures ar<' non- toxic for rabbits. In a series of 20 blood cultures all were negative, 1hough every- thing pointed to a general infection. A series of 20 pharyngeal cultures were made at Base Hospital No. 8, American Expeditionary Force, and the results will be avail- able for our study on the return of the Lacteriologist from detached duty at the front. The final opinions of the laboratory men of the American Expeditionary Force as to the identity of the organism will be forwarded as soon as they become available. No immunizing work has been attempted as yet. White and colored races are equally susceptible. Symptoms.-Sudden onset of fever, varying from 90° to 105°, more commonly 102°, with jntense headache, backache, and general pains throughout the body. The degree of prostration varies greatly in different cases. Pain in the chest, made worse by deep inspira- tjon, and some cough without corresponding physical signs were cha1·acteristic of the majority of cases. Physical signs.-Tbe majority of cases were negative on physical examjnation except for infection of the pharynx and infection o:f the conjunctiva, the latter givjng the appearance of" pjnk eye." ~o . .J. Clinic((l 1·011 hours. falls ra hours. ~\. ppC't i usually got·~ to Comp! icafir11 ity, and the onl a case of front T1·ecttme11t is P1·eventio11. <litionary For· acter or the cl. ting are prHe there ·was a r' ·uarterecl in ba - Epidendoloy Force show th were affected. was usually at ported. The incubati ease is importa sudden noneff e The patient, native of_ Calif admitted to th January 27. 1 night of J anu macule on the 1 The scratching pronounced s" their appearan of 103°, with minute. The When first see a temperature right cheek sho with a center !! the incision thE Vol. XII 'ER AT THE UNITED STATES - FRANCE. United Smt<>s Navy. which has been sweepin ~tates Naval Air Station a~ . F~ench authorities reported . ed1terranean States, and the ng.and summer o:f 1917, and .ed1cal officers of the United :s as dengue and pappatac· .d . i n em1cs were the beginning exciting organism was not ht cultures made on cases in ny, American Expeditionary Jn No. 1, five cultures were , described as a small. gram pneu?1~nias. It grows only acter1st1c dew-drop colonies. :ran~plant. Morphologically ·gamsm, but, due to the dif- m impossible as yet to de- teristics. Cultures are non- .-ere negative, though every- vere m~de at Base Hospital :md the results will be avail- bacteriologist from detached >:f the laboratory men o:f the he identity of the organism e available. No immunizing and colored races are equally varying from 90° to 1050 lache, backache, and generai of prostration varies greatly nad~ worse by deep inspira- ondmg physical signs were es were negative on physical pharynx and infection of the ·ance of " pink eye." No . ..J. REPORTS. 801 . Clinical cou1•se.-The fever attains the highest point within 36 hours. falls rapidly, and is generally normal at the end of 48 or 72 hours. Appetite returns with the fall of the fever and the patient usually goes to duty after 3 days in the sick bay. Complications.- In the 163 cases treated here there was no mortal- ity, and the only serious complications were a case of otitis media an<l a case o:f frontal sinusitis . Treatment is purely symptomatic. P1·e·vention.-The surgeon of Base Section No. 1, American Expe- ditionary Force, is of the opinion that, in view of the benign char- acter of the disease and its rapid spread, the isolation of affected units and organizations would not be justified. The daily airing of bedding and quarters and the discouragement of promiscuous spit- ting are preventive measures recommended. It has been noted that there was a relatively higher proportion o:f cases among the men .~uartered in barracks than among the officers quartered in billets. Epidemiology.- The statistics o:f the American Expeditionary Force show that from 12 to 80 per cent o:f the men in different units were affected. An epidemic lasts from 10 to 20 days. The epidemic was usually at its highest within a week after the first case was re- ported. The incubation period appears to be from 2 to 3 days, and the dis- ease is important from a military standpoint solely on account of the sudden noneffectiveness of nearly hal:f the personnel exposed . REPORT OF A :QEATH FROM ANTHRAX. By H. B. LEH ~lllE llO, Lieutenant, M. C., United States Na vy. The patient, a fireman, second class, age 27 years and 7 months, a native o:f_California, 5 feet 8 inches high, weighing 151 pounds, was admitted to the United States Naval Hospital, Honolulu, Hawaii, on January 27, 1918. The patient had been in good health until the night of January 24, when he scratched with his finger nails a small macule on the dght cheek, which he ascribed to the bite of a mosquito. The scratching was soon followed by inflammation of the area and pronounced swelling of the cheek. Constitutional symptoms made their appearance promptly and the patient developed a temperature of 103°, with a pulse of 118 and ·a respiratory rate of 22 to the minute. The swelling was incised and ·wright's dressing applied. When first seen by the medical officer in the hospital the patient had a temperature o:f 103.6° ; pulse rate, 124; respiratory rate, 22'. The right cheek showed a small pustule about 1.5 centimeters in diameter, with a center slightly depressed and brownish in color. Owing to the incision that had been xpade the pustule was not typical in ap- 802 llliPORTS. \'ol .. \11. pearance, but anthrax was suspected and smears were made. These smears were negative for anthrax bacilli but positfre for strept 0 • cocci. Dakin's solution was used for a local treatment, while tine. ture of chlorid of iron and ipecac were administered internally. On January 28 smears were again negatfre for anthrax bacilli and ~ 0 was the blood. Cultures were made. There was no improvement in the patient's condition. On January 30 the cultures made on January 28 showed the presence of a few anthrax bacilli, but the infection ha;! become so generalized that the excision of the pustule was thought not advisable. On January 31 the temperature dropped to 101°, the pulse to 72 per minute. The patient became delirious, vomited. and developed other symptoms of cerebral irritation. A spinal puncture was made and an examination of the fluid showed it to be loaded with anthrax bacilli. The patient died at 6.45 p. m., January 31. 1918. PRESENCE OF BALANTIDIUM COLI IN THE VIRGIN ISLANDS OF THE UNITED STATES. By H. RYDEE\', I'hn1·maclst (T.), United States Navy. The patient, a girl 11 years of age, who has never been away from St. Thomas, complained of getting "dizzy" and of frequent loose bowel moYements. On examination of feces ova of Ascaris lumbricoides, Trichiuris trichiura, Necator americanus. and motile Balantidinm coli Wt'n• found. Examination of feces following medication with santonin ancl betanaphthol showed only encysted forms of Balantidium coli. Sub. sequent examinations five and SAven days later showed them us tlu.•:v were first seen. This is believed to be the first ease of Balantidium coli reported from these islands. It has been noticed that it is rather difficult to distinguish this or- ganism in solid or even semisolid feces, but this can be overcome by emulsifying a small quantity of ·feces in water at a temperature of 37° to 38 C. Encysted forms can best be seen by using the metho 1 recommended by Rear Admiral E. R. Stitt, l\I. C., United States NavT, of mixing feces with iodine solution (Lugol's). REPORT ON TETANUS INFECTION. ~Y JUDSON DAT.AND, Lieutenant Commander, M. C., United States Navy. Some time ago I met an American physician whom I have known for some years and who has spent about 10 years in Germany, when• he remained until March, 1917. Ile sen'ecl in a hospital in Berlin I '\o. 4. :1nd told me that :-o cperated upon sub:; dectomy, for exnmp, pears that tetanus rime of the original became acth-e in con operation. It is no )'UCh patients, befor of the antitetanus of tetanus. I believe that th ~hould be transmitt md smear::> were made. These cilli but positfre for strepto- a local treatment, while tinc- e administered internally. On i>e for anthrax bacilli and ~o There was no improYement in 0 the cultures made on J anuarv tx bacilli, but the infection ha~l )n of the pustule was thought nperature dropped to 101°, the became delirious, vomited. and irritation. A spinal puncture a fluid showed it to be loaded ied at 6.45 p. m., January 31, THE VIRGIN ISLANDS OF THE I.TES. ), United States Navy. who has never been a way from ' dizzy " and of frequent loose .scaris lumbricoicles, Trichiuris motile Balantidium coli Wl'r<' nedication with santonin and >rms of Balanticlium coli. Sub- :lays later showed them as thev •e the first case of Balantidim~ ~ difficult to distinguish this or- es, but this can be overcome by s in water at a temperature of st be seen by using the method R. Stitt, M. C., United States lution (Lugol's). JS INFECTION. nder, M. C., United Stales Navy. physician whom I have Im.own out 10 years in Germany, wherl' ' served in a hospital in Berli11 REPORTS. 803 : 1nd told me that, soldiers who had rccei-.;·ed wounds at the front. when operated upon subsequently for any rea'-on what$OCYer. as an appPn- dectomy. for example. frequently clewloped tetanus and died. It ap- pears that tetanus bacilli were introduced into the patients _at the time of the original wounds and remained latent or local until they became active in consequence of a lowered resi:oJance due to the second operation. It is now the rule in the hospitab in Germany that all 5nch patients, before a second operation, receiYe an immunizing <lo~c of the antitetanus serum which absolutely prevents the occurrence of tetanus. I believe that this information is of great pmctical Yalue and ;;hould be transmitted to the medical officers of the Army and :N"avy. UNITED STA .ttltlition.q to .\cres· ion Tissue. So. 1398 Dlood smears ......... . 1109 .•••. do ......... ......•. 1400 Feces .. ••.•.• ••...••••. 1401 Dlood smears ......... . 1402 1403 PRACTICAL BAC'J"ERIOT.OOY, BT. A. B., Ph. G., M. D. Fitt Pa., 1918. All the good feature retained, and the new v of its predecessors, con possible by the use of i print. Rear Admiral S of rflitr admiral as an o cal Department of the course of the last 29 yea Rear Admiral Stitt' the laboratory of the X his association with Georgetown Uni\ersity made him peculiarly w and lucid style. A :MANUAL OF CLINICAI. DIA DENTS, HOSPJT.\L PBYSI B. A., M. D. Xinth E11l 1918. In general this book fact that a ninth editi UNITED STA TES NAVAL MEDICAL SCHOOL LABORATORIES . . lll!lition.~ to the 1mlho/of!iC·a/ <"1//1!'/ir111. C11ilcd ,<.;fate_. Yarn/ Jfetli1·a/ •°"<'hoof, .f111111ur11 ./1111c. Ifll Q.. ,\cres· sion No. Tissue. Collected by or receh-c<I from- 1398 Blood smears .......... ncni~'ll terUnnmnlnrin ............ Commander C. St. J. llutler, M. C. n99 ..... do................. n. leprrl'.......................... no. 1400 Feces.................. Variou~ ova parn~ite•. . . . . . . . . . . . . Do. 1401 Blood smears .......... Quartanmalnria; estivo-autumual Lieutenant Comdr. F. X. Koltes, malaria. M. C. 1402 ..... do ................•..........•.......................•. Lieutenant T. T. Gatelv, M. C. 1403 ..... do •...•••..•.•...•. Benign tertian malaria •••.••.....• Lieutenant E. Doci..-ry;M. C. BOOK NOTICES. PRACTICAL B.\C'IERIOT,OOY, BLOOD WORK, AND ANill{.\L PARASITOLOGY, b~· E. R. Stitt, A. B., Ph. G., M. D. Fifth Edition. P. Blakiston's Son & Co., Ph!laclelphia. Pa., 1918. All the good features of other editions of this book have been retained, and the new volume, without noticeably exceeding the bulk of its predecessors, contains much new material. This was made possible by the use of interpolations in smaller but perfectly legible print. Rear Admiral Stitt has recently been promoted to the rank of rear admiral as an official recognition of his services to the Medi- cal DPpartment of the Navy and to the scientific world during the course of the last 29 years. Rear Admiral Stitt's many years' experience as a teacher in the laboratory of the Naval Medical School. Washington, D. C .. ancl his association with students at the Jefferson ~!edical College, Georgetown University, and George Washington UniYersity ha>e made him peculiarly well qualified to impart instruction in a simple and lucid style. A MANUAL OF CLINICAL DIAGNOSIS, BY 11!EANS OF LABORATORY Mt-:THOOS. l"OR STl'- DENTS, HOSPITAL PHYSICIANS, AND PRACTITIONERS, by Cl1nrlc.~ E. Si111011. B. A., M. D. Ninth Edition. J,eu & Febiger, Philndelphi:t nnd :'\ew York. 1918. In general this book attains a high standard of usefulnel'S. and thl• fact that a ninth edition has been called for is no small tribute to so;:; BOOK XOIICES. \'ol, XII. the >alue of the book. It would be ungenerous to allude to minor defects but for the fact that by mentioning oversights or inaccuracie~ these may be corrected in a possible tenth edition. Four types of pneumococci are mentioned, but the methods of determining and differentiating them are not given. No mention is made of the dif- ferent types of meningococci nor of the Dryer technique for de- termining typhoid and paratyphoid infections. In <liscussing th<' "\vassermann test on cerebro-spinal fluid the author does not ~tate whether he inactivates the fluid or not. In the description of the preparation of amboceptor the injection of animals is described, but it is not stated whether the injection is given intravenously, intra- peritoneally, or subcutaneously. The term typhoid serum is used when presumably antityphoid serum is meant. The author has not always followed the \,l.Sually accepted authorities in the matter of nomenclature; thus he speaks of Plasmodium immacnlatum instead of Plasmodium falciparum, and of Uncinaria americana instead of Necator americanus. In the study of gastric contents no mention is made of the "fractional method." The duodenal contents are not considered. THE 'l'REATMLJ\'T OF W.\R WOUNDS. By Ir. 1T. J(cen, Jl. D., LL.D. Second ajj. tion. \Y. B. Saunders Co., Philadelphia, Pa., 1918. The book has been considerably enlarged and improved since the appearance of the first edition last year. It now forms a compact. practical handbook reYiewing the principal features of modern war surgery. THE s~;nroUSNESH 01• \'lcNJmEAL lll S.l!:ASE. By Spmgue Charleton, M. D., F. A. a. s. Paul B. Roeber, New York, 1018. This small but beautifully prepared volume is a reprint of a lim- ited ellition arranged by the author as a gift for Base Hospital Xo. -18. It contains 26 pictures of syphilitic manifestations, each accom- pained by a :few words of text. At the end are instructions to men ha ,-ing gouorrhca and syphilis. ~\.s a sample of the bookmaker's art this little "Volume is admirable. Considered, however, as a contri bu- tion to the campaign against Yenereal disease, its value is question- able. Th<' object of all instruction and education should be towar<.l the cultiYation of purity. continence. and self-control. vYithout these restraints, fear of the consequences acts only during the ab- sence of serious temptation or leads to irregular methods of sexual gratification in which risk to health is supposed to be less. On the other hand, the wisdom of giving this book to a patient having a ,-enereal disease may be questioned because so many of them haw an exaggerated horror of their predicament. " ), 4. THE :MEDIC .. \L JtEl'OUT ( JI. D .. an<1 R . .. t. I.11 ,·ard Uni'l·er,..it~'. (' _\.n intere::-tiuf! a study of phy,..ieal the Rio X cgro nrnl water in thl' Hio ~ ricd out. Tlw rc Speaking of the It Certain of tlw cu" woman gives hirth to hammock and rN·eiv The ntlley of the.\ on earth. * • * * "' Apart 'from * '' * There is a ~ hard-workin~ popnln cities is extraor<linn try has :tttrad('(l in1 fall into the I anfls o is in the hands of th is chiefly cornhu·t•'<I h Tn addition to ruh sugar, cacao, 111:11Hli amonp; them rnany sarsaparilla. The p; lies in the timher, a 1Stroyed. There are the chief of th!'se h • value as timber. hu <·oukl not be ll"<'<l f< pulp. Doubtll'""· ho her, \\'ith the rnpi•I this seem i ng!~- ilwxl :. Much of the The unproYokcd constrictor. thou poisonous reptil jacaraca. ~Ienti chiefly in the for and sometime~ lle ing ants '' the 111 carries sections prepared by che which constitute! in the earth. ''it Vol, XU. :1nerous to allude to mino . h . l' ~ overs1g ts or maccuracie h d. . s ~ e it10n. Four types of thods of determining and iention is made of the dif- ~ Dryer technique for de- ictions. In discussing the the author does not state In the description of the >f animals is described but . . ' g1 ,·en mtra venously, intra- rm typhoid serum is used ieant. The author has not 1thorities in the matter of iium immac:ilatum instead naria a111ericana instead of ;tric contents no mention is duodenal contents are not ~cen, U. D., LL .D. Second edi- 1918. ~ed and improved since the It now forms a compact, )al features of modern war :{Jue Charleton, M. D., Ji'. A. O. S. )}ume is a reprint of a lim- gift for Base Hospital No. manifestations, each accom- end are instructions to men nple of the bookmaker's art red, however, as a contribu- sease, its value is qucstion- education should be toward and self-control. Without s acts only during the ab- rregular methods of sexual upposed to' be less. On the book to a patient having a use so many of them have ent. No. 4. BOOK NOTICES. 807 '.rHE MEDICAL HEPORT OF THE RICE EXPEDITlON TO BRAZIL. 'By IV. 'I'. Councilman, .1f. D., and R. A. l~ambert, M. D. Fl'om the School of Tl'opical Medicine, Har· val'd Univel'Sity. Cambridge. H:uYarcl Univer sity P ress, 1918. . .\n interesting account of an expedition primarily undertaken for a study of physical geog1·nphy, especially that of the region between the Rio Negro and the 01:inoco RiYer. Owing to the extremely low water in the Rio Negro the original intention could not be fnlly car- ried out. ThP report contains a chapter on the Amazon Valley. ~peaking of the Indium; of the Rio Negro, the report says: Certain of the customs a re also to the advantage of 1hc male, as when a woman giYeS birth to a child the father goes through a pcriocl of rest in his lrnmmock and receives delicacies and congratulations. The valley of the Amazon is the 1uost unchange<l a111l unchanging great region 011 earth. * * * 'l'he population is on the highway of the watercourses. * * " Apa rt from the Indians the population is a heterogeneous mixture. * " * Thel'e is a steady immigration of Portuguese, who form an industrious. hal'll-working population, anti do most of the work. T he population in the cities is extraor<lina rily rnried, for the wealth coming from the rubber indus- try has attracted immigrants from l he entire world. " * " Cel'tain trades fall into the hancls of diffet·ent nationalities ; the snle of dry goods by peddling is in the hands of t he Armenia ns, a11<1 the very extended t rade of prostitution is chiefly conducted by the Poles. I n addition to rnbher the 1·egion prorluf'es gutta-percha, snrsnparillu, tobacco, sug111', cacao, mandi o'ca, piassaba fihe1', nut·s, nnd a variety of forest products, a mong 1'11em mnny vnlunbh~ clrugs. 'l'he chief expo1·ts are n1bber, nuts, and sarsaparilla . The great wealth of the region, which has har<lly been touched, lies in the timber, and as a source of natural wealth this cnn hardly be de· stroyed. There are many difficulties which li e in the way oE its exploitation, the chief of these being the great variety of the growth. All of the wood has value as timber, but the charncter diffet·s so greatly that the unsorted lumber Muld not bt> nsed for n common purpose, not eYen for t he production of wood pulp. Doubtless, howeYe1', the time is approaching when t he demand fur lum· her, "·itlt the rapidly decreasing suppl~', will compel the world to drnw upon rhis seemingly inexhaustible source. " Much of the life is inimical or certainly unfriendly to man." The unprovoked attack on a man by the jaguar is unusual. The boa constrictor, though rare, has been known to attack man. Among poisonous reptiles are the rattlesnake, the coral snake, and the jacaraca. Mention is made of an ant an inch or more in length, found chiefly in the forests, whose sting produces great pain and prostration and sometimes death. ·This is the Tucandera or conga. Of the " forag- ing ants" the most interesting is the Saliba or leaf-cutting ant, which carries sections of leaves to its nest. After the material has been prepared by chewing, it provides a soil for the growth of a fungus, which constitutes the ant's favorite food. It excavates long tunnels in the earth, with communications extending hundreds of feet, and . os BOOK XOIICES. VoL XU. throw!-, up mounch; of earth seYeral feet high. Xests an' fot'llwd 111 the trees. Some species are winged. The region is characterized by a small biting fly, 2 to 3 mm. in length and 1 mm. in breadth. Protection from the bite can he ob. tained only by close-meshed head nets and gloYes. This fly is know11 as the pium and to it are ascribed the ulcers so common in this regio11. A more tormenting insect than the pium is the larrnl form of a "pecies of Trombicliclea. It has a soft body, with 6 legs pro,·ic\t>il with claws and a powerful h~' J)()stoma, which it clrins into tlw skin. It is so small as to b<' barel,Y ,·isible lo the naked eye ancl is ln·i ~h t orange in color. Tht' sting pro(111c<'s no irritation at tlw mon1P11t hut later an indmated wheal se,·eral centimeters in ([inmetPr fo1·111". The small towns of the upper Amazon are usually situated on high ground and appear comparaliYely healthy. the ~nalaria hc>i11g milder than that seen on the lower Rio Negro. . In discussing malaria on the Rio Negro, 3 general typt>s of in fc('- t1on are recognized: ( 1) An infection characterized by the pr<'sern•t• of numerous parasites in the blood with little or no disturbance i11 health, especially in children under 10 years; (2) a chronic infection showing moderate anemia, weakness with considerable splenic en- largement. There is an absence or scar city of organisms in the cir- culating blood. This corresponds to the so-called "malarial ca- chexia " of many writers. It is a predominating type in the Amazon r~gion; ( 3) the ordinary type of infection as we see it in suscep- tible people from the temperate zone who visit the Tropics. Chronic malaria is extremely prevalent in the Amazon Valley. ~\cute and malignant malaria was not observed by the Rice Expedi- tion, but it is said to exist. Of the cases examined, only 7.2 per cent showed organisms in the circulating blood. No quartan forms were found. Leprosy is widespread. No cases of yaws or filariasis were seen. Ulcers are extremely common and haw recently acquired greater in- terest through the discovery in them of Leishmania. The accepted mode of treatment consists of intrannous use of tartar emetic. ( ' J.I:\'IC.\J, ll1AGl'\OS1S. .\ llfANUAL OF LABORATORY METHODS, by Jame.~ Campbell Todd, Ph. B., JI. D. Fourth IDdition. W. B. f;nunders Co., Philaclelphi:i, Pa .. 1918. .A work of oYer 600 pages filled with illustrations of 11nus11a l merit. DISI:ASES OF TTU: :\LA L~; UlU~TlillA, INCLUDI:\G Hil'O'n::\CE .\ND STEIU1'1'l'Y, h~· J. /:). I\.oll, B. S .. M. D .. /1'. A. C. S. Illustrated. W. B. Saunders Co., Philndelphlu, Pa., 1918. The type, paper. and illustrations are of the high order which characterizes Saunclers's publications. Besides many new c1rawin~s, ~o. 4 . illustrative of the te trate the reYelations confusion has arisen on pages 80 and ol an The chapters on no rhea, and on tumors rial not commonlv fo The author claims from 5 to 10 days~ p the discharge has be in 20 days, he is clo known. He puts his patien drink 15 to 25 glasse ~1£ bicarbonate of so albargin are made th istered as a 1 per ce base, with glycerin a 15 minutes, and then this material should If the patient can no take injections of pr strength and twice treatment includes water. If the germ treatment has failed necesarily, a proof o germs are found aft several times a day aminations have bee " preferably a glass followed the alcohol the penis. an anterio Next morning exa has been effected. form a fa>orable o sketchiness and lack fied and unconYinccd advice, regarding pr he has to off er in co and without a guide. ence to surgical trea 76098-18--Hi ES. Vol.XU. high. Nests are formed in all biting fly, 2 to 3 mm. in ion from the bite can be ob- nd gloves. This fly is known Jers so common in this region. um is the lal'\'al form of a body, with 6 legs provided \\·hich it drives into the skin. the naked eye and is hright 10 irritation at tlw moment ntimrters in <liameter fortn8. lZOn are usually situated on r healthy, the malaria being egro. ~ro, 3 general types of infec- haracterized by the presence h little or no disturbance in ears; (2) a chronic infection ith considerable splenic en- city of organisms in the cir- the so-called "malarial ca- ninating type in the Amazon ~tion as we see it in suscep- ho visit the Tropics. lent in the Amazon Valley. bserved by the Rice Expedi- ' examined, only 7.2 per cent od. No quartan forms were yaws or filariasis were seen. recently acquired greater in- ! L eishmania. The accepted lS use of tartar emetic. w METHous, by James Camp/Jen B. i"atmdC'rf< Go., Philndelphin, ith illustrations of nnusua l [POH:NCE ANU STEIULlTY, h~- /. f.; • .'. B. Saunc!C'l·s Co., Philadelphia, ·e of the high order which ~esides many new drawings, No. 4. BOOK NOTICES. 809 illustrative of the text, there are numerous colored. plates to illus- trate the revelations of the endoscope. It is unfortunate that some confusion has arisen as to the nomenclature of the instruments shown on pages 80 and 81 and ref erred to on pages 80 and 86 . The chapters on nongonorrhcal urethritis, on the history of gonor- r~ea, and on tumors of the urethra are interesting and include mate- rial not commonly found in other works. The author claims to cure 60 per cent of his gonorrhea patients in from 5 to 10 days, provided he can see them within 24 hours after the discharge has begun. If he can cure 30 per cent of his patients in 20 days, he is doing well and his methods dPserve to be made known. He puts his patient to bed for 48 to 72 hours and directs him to drink 15 to 25 glasses of water in 24 hours, and teaspoonful doses ~1f bicarbonate of soda are given for ardor urirne. Instillations of albargin are made three or fonr times a day. The albargin, admin- istered as a 1 per cent ointment, with gelatin and tmgacanth as a base, with glycerin added for hygroscopic effect, should be retained 15 minutes, and then a swab made with a toothpick and coated with this material should be placed within the urethra for 15 minutes. If the patient can not endure the smarting of the albargin he should take injections of protargol solution twice a day, using ~ per cent strength and twice nsing a strength of 1 to 1 per ceij.t. The treatment includes frequent immersion of the penis in very hot water. If the germs of gonorrhea are found after 24 hours this treatment has fail~d, but if the germs are not found this is not necesarily, a proof of success, since they may appear later. If no germs are found after 24 to 36 hours, stop the injections, but look several times a day for gonococci. When the bacteriological ex- aminations have been negative for 24 hours give the alcohol test, "preferably a glass of beer or ale." No disastrous results having followed the alcohol -test, wait a couple of days and then massage the penis, an anterior sound having been passed. Next morning examine the secretion, and if it is nega6ve a cure has been effected. No one reading Dr. Koll's book could fail to form a favorable opinion of the author's ability, but there is a sketchiness and lack of detail throughout which leaves one dissatis- fied and unconvinced. · The author concentrates into 52 lines all the advice, regarding preparation, operation, and after treatment, which he has to offer in connection with external urethrotomy, both with and without a guide. It would have been better to omit all refer- ence to surgical treatment than to give only such a bare outline as 70098-18-lG 810 BOOK ~OTICES. Vol. Xll. ""ould scarce suffice to direct the beginner and yet would be super. fl.nous for the expert. APPLn:o ,\:'\ATOMY. TIIE CONSTRUCTIOC' OF THE HUMAN BODY CO:<ISIDEBED IN RF.L\TIOX TO ITS }<;'.NCTIONS, DISEASES, AND INJ"URIES, by (hoilym G. Davir JI. D., LL. D. Fifth Edition. J. B. Lippincott Co., Phlladelphla, Pn., 1ms'. A beautiful volume "-hose author has been more successful than is common in attempts to combine the teaching of anatomy and sur- gery. The drawings which illustrate surface anatomy are particu- larly instructive. A man may know his anatomy, both by the book and by the subject, and yet sometimes be confused, unable to tell his way about amid the muscles and bones, baffied by their cutaneous coYering. NAVAL HYGIENE, by James Gharnbers Pryor, A. M., !f. D. P. Blnklston's Son & Co., Phllndelphln, Pa., 1918. The author is to be congratulated upon having accomplished the object which he set for himself, namely, to produce a "student's manual of elementary character." Few of the so-called manuals with which the book market is overstocked to-day can rival Com- mander Pryor's book, which is eminently clear, concise, and to the point and yet singularly complete and satisfying for a book of its !'ize. It is only the author's modesty which characterizes as "ele- mentary " the material presented. It would be hard to suggest any line for comprelwnsive alteration or improvement. Among the special features of the book may be mentioned (1) the appendix. which gives the principal instructions to be observed in recruiting, in preparing health records, descriptive lists, finger prints, etc.; (2) a glossary of nautical terms employed; ( 3) the ready methods of calculating percentages and averages and rates of sickness for offi- cial statistical returns; ( 4) a complete index covering 34 pages. Of special interest, also, are the chapters on aviation, submarines. and diYing. The book is eminently practical. It gives just enough and not too mnch for the medical officer who has to face the daily problems of life on board ship. While it will be a boon to the young medical officer making his first cruise: there is a vast amount of valuable information, culled from many sources, as well as from the varied experiences of the writer, which will have great interest for every member of the profession. The numerous illustrations not only sub- ~erve the intended purpose to elucidate the text but throw interesting and vb·id sidelights on life afloat under the flag. (Medical officers may obtain this book by requisition on the Naval Medical Supply Depot, Brooklyn, N. Y.) No. 4. ,\ TE."XTHCOK o Keefer. -1. phin, ra., 1 A nontecn this work ft ical officers ficers and m strictly m<'d that should cellent judg guage empl does not se all officers i peated les~o slow to gra the succes:,; the clay is as many m those in co sideral le p through p them to lo. i.n trench. TROPIC.\L !'i 1''. A. C . • Louis, )[o The ant priate titl of i.nte ·e" exhaust in place in tl TIIE SUBYA Si11tl!1 I. Co., l'hil This is time of D ten in as· space is d experienc ICES. Vol. XI!. ~nner and yet would be super, 1'' THI!: HUMAN BODY CONSIDERED IN ~ND IN.nmms, by Gwilym a. Davit, ppincott Co., Philudelphlu, Pu., 1018. has been more successful than is ~ teaching of anatomy. and sur- te surface anatomy are particu- • his anatomy, both by the hook mes be confused, unable to tell bones, baffied by their cutaneous 101', A. M., M. D. P. Blaklston's Son :l upon having accomplished the 1amely, to produce a " student's Few of the so-called manuals ~rstocked to-day can rival Com- .nently clear, concise, and to the and satiSfying for a book of its :sty which characterizes as "ele- It would be hard to. suggest any . or improvement. Among the be mentioned (1) the appendix, ons to be observed in recruiting, ptive lists, finger prints, etc.; (2) oycd; (3) the ready methods of ?;es and rates of sickness for offi- nplcte index covering 34 pages. ~hapters on aviation, submarines, 1. It gives just enough and not ho has to face the daily problems 11 be a boon to the young medical re is a vast amount of valuable mrces, as well as from the varied will have great interest for every merous illustrations not only sub- clate the text but throw interesting· under the flag. (Medical officers on on the Naval Medical Supply No. 4. BOOK NOTICES. 811 A TEXTBOOK OF EU;MENTAf<Y .\llLITARY liYGIENC: .\ND ISAXITATlOX , by }1'ra1il.; R. K eef er, .1. M., ll. n. 1'C<·nu<l Eilition, HPst>t. "'. B. ~a u111l en; Co .. Pllilatlel- phiu, Pu., 1918. A nontechnical presentation of the topic has long been needed and this work fully meets the requirements. Being intended not for med- ical officers or members of the Hospital Corps but primarily for of- ficers and men of other branches of the military establishments, the strictly medical topics have been lightly touched upon, while matters that should be generally known are discussed in greater detail. Ex- cellent judgment has been shown in making this distinction in the lan- guage employed, in the illustrations, and in the size of the book. It does not seem unreasonable to require the mastery of its contents by all officers intrusted with the command of troops. In spite of the re- peated lessons from previous campaigns, military and naval men are slow to grasp the extreme importance of hygiene and sanitation for the successful issue of their enterprises. Though it may be far off, the day is undoubtedly coming when the loss of from 5 to 20 times as many men from disease as from wounds will be as discreditable to those in command as a fault in strategy; when to permit any con- siderable proportion of one's available force to be made unavailable, through preventable sickness, will be held as criminal as to permit them to lose their lives through failure to afford adequate protection in trench, bomb-proof, and turret. TROPICAL SUl!OERY AND DISH.SE& o :i,- THE F ,\U EAST, by J. R. ill cDill, M. D., I•'. A. 0. S., Major, Jlerlica/ Reserce Corps, U. S. A. C. V. l\fosby Co., St. Louis, Mo., 1918. The author has collected and, undrr a misleading and inappro- priate title, presents to the reader in a most attractive way many facts of interest regarding tropical clisetl.ses. His personal observations and suggestions are valuable. The illustrations are profuse and de- rived either from the author's collections or periodical literature. Without having much to say nbout surgery and without in any sense exhausting the topic of tropical diseases, the book still deserves a place in the library of a doctor going to the Far East. Trrn SUBMARINE IN WAR AND PEACE. ITS DEVELOPMENTS AND ITS POSSIDILITIES, by Si11101i Lake, M. I. N. A. With 71 illustrations and u chart. J . B. pppincott Co., l'lliladelpllia and London, 1918. This is the history of the development of the submarine from the time of David Bushnell's quasi achievement to the present time, writ- ten in a singularly interesting style, free from technicalities. Ample space is devoted to the achievements of Mr. Hollan<l.. The author's experiences when endeavoring to get an audience with a former Sec- 812 "BOOK NOTICES. Vol. Xll. retary of the Navy are amusingly set forth. The concluding chapters deal with the future of the submarine. Mr. Lake pleads the cause of the inventors and inveighs against the f.kepticism and indifference of the world, though he magn:mimoush- alludes to the professional handicaps which prevent tho naval oflice~ from taking up new inventions with proper avidity, but this narra- tive is itself the best justification of the hesitation felt by the gen- eral public about backing an innntor. The failures, the narrow c."- capes, the forgotten essentials that mark the progress of some great acl1ieYement, from its conception as an idea to its birth and later de- velopment into a device of commercial value. may well give the financier' pause. The utter unreliability of the inventor has been appreciated by every form of government. The bold imaginative and creative powers ·of the inventor are the very antithesis of the nicely calculated and meticulous operations of ordinary businPs-:. For a military man, who, to justify his control of men and his leadership, must be regarded as eminently practical antl reliable, the espousing of so doubtful a proposition as a new invention, is to put in jeopardy the most valuable asset of his professional reputa- tion. .Mr. Herbe rector of the has asked the the work oft scientific wor If there is suitable read Library War ton,D. C.: Same and ud Kind of cam How mnny n How mnny n Where will r Who should Will he arr• t;>ntire camp (o There has the America third Street, S"OTICES. vo1. xn. set forth. The concluding chapters .rine. ! inventors and inYeiglu; against the • world, though he magnanimously ap<; which prevent the nan.1 oflicer •ith proper avidity, but this narra- 1 of the hesitation felt by the gen- mtor. The failures, the narrow es- tt mark the progress of some great as an idea to its birth and later de- 1mercial value, mtty well give the ~liability of the inventor has been ermnent. The bold imaginative and II' arc the very antithesis of the .s operations of ordinary businPS". ustify his control o:f men and his s eminently practical and reliable, roposition as a: new invention, is t-0 )le asset of his professional reputa- ANNOUNCEMENTS. Mr. Herbert Putnam, the Librarian of Congress, ancl General Di- rector of the Library War Service, American Library Association, has asked the Bulletin to give publicity to the following facts about the work of the Library War Service. In a period of 7 months 1,271,800 books have been shipped to 39 large camps, where there are trained librarians and 36 library buildings; 185,000 books to 211 small camps; 130,000 books to 111 naval stations; 30,000 books to 111 vessels; 20,000 books among 81 hospitals-Army and Navy; 200,000 books for use on transports and overseas. Thus 2,000,000 gift books have been sent out through 600 agencies. In addition to all this, 350,000 new books, mainly technical, have been pur- chased and put to use. The subjects covered range from fiction. poetry, history 11.1 technical aml scientific works. I:f there is any ship, camp, hospital or station withouL a supply of suitable reading matter for the men, send the following data to the Library War Service Headquarters, Library of Congress, 'Vashing- ton, D. C.: Same and address of camp (or vessel) ; Kind of cnmp (or vessel) ; Approximate number of men in camp (or on board) ; What agencies are supplying reading matter and to what extent; What local library, if any, is cooperating; How many and what kind of books are needed; How many magazines are needed; Where will reading matter be housed; Who should be notified wben books and magazines are shipped; Will he arrange for the circulation of this reading matter throughout the mtire camp (or vessel). There is no red tape about getting the books; men in charge will be asked to keep simple records, instructions for which are furnished with each library. There has recently been organized in X ew York a c:ociPt~· en lle<l the American Defense Society, with headquarters at 44 East. Twenty- third Street, New York, which counts among its officers an ex-Presi- 813 814 ANNOUNCEMENTS, Yol. XII, <lent of the Vnited States, an ex-Attorney Gener.ii. an ex-Secrl'lan· of the Treasury, an ex-ambassador to Germany. an ex-ambas~tHlor t~ France, and other nofables. 'l he specific purpose of this organization is to replace in the ~\merican market all articles manufactured in Germany by articles manufactured in America or elsewhere. The following is the pledge of membership, which we consider a comprehensive arraignment of Germany for its high crimes and misdemeanors: That I may uot directly contribute financial aid to the German military policy with !ls disregHrd of international law, its attn<"ks on unfortified towns, its massacres of the innocent anu the helpless, its ensla ,·ement of peoples, its use of poison gas ancl flame$, its ignoring the Red Cross badge, its bombing 11o><pitals, and its torpedoing defenseless merchant ships. I ple<lge m~·self never to buy any article made In Germany. ~\. ne\Y magazine has recently made its appearance abroad. The first number of the BE¥UE INTERAJ.Lll:E POUR L'ZrUDE DES QUESTIONS INTERESSANT LES :MUTILES DE LA GUERRE bears the date of April, 1918. It is the official organ of the Perma- nent Interallied Committee for collection, classification, and dissemi- nation of information relative to the rehabilitation of the wounded. Dr. Bourrillon is president of this committee. The editor of the re- view is Dr. J. Camus, 102 Rue du Bae, Paris. With Ales Hrdlicka as editor, and apparently under the auspices of the Smithsonian Institution, thP. first number of the AMERICAN JOURNAL OF PHYSICAL AN'l'HUOi>OLOGY has recently made its appearance. The preface is an attempt to justify the "establishment of a new scientific journal. * * * at this critical period." The other articles are: Hrdlicka, Ales: "Physical anthropology : Its scope and aims." :Miller, G. S., jr.: "The piltdown jaw." Hooton, E. A.: " On certain Eskimoid characters in Icelandic skulls." Holmes, W. H.: "Organization of the Committee on Anthropol- ogy of the National Research Council, and its activities for year 1917." When contributl desirable. Fasten an abomination. • form such as Iette paragraphs. nil of LETIN endeavors t•> editor can be spnr viated if autho~ , sues. This is not views. For l'X:11UJ of the Gai;seriun c; By fl .. \I If a reYi<>w ls su F. R. C. S. (En;:.). of Texas, <>ntitlE'<l Anatomical and P and Obstetrics, Yol conform to the usa Thompson. J. E. :\1 October, 1917. The author's in! familia r with the Surgeon General's Association Pres-:, The grcatc .. t ace . ms sometimes hei' i.: was impossible f: etc. The frequen conclusive evidenc they have been t:n Contributions w to the date of the l Only the names The BULLETI;'; p and reYiews ancl n they have not appa. 01tt an m1dl'l"sta11rlit iTS. Vol XU. 1H'Y l cner.l I. an ex:-:::)cl·n·tary ennany. an cx:-umb::t!' .... ador to ization is to replace in the :ured in Germany by article:; The following is the pledge omprehensive arraignment of emeanors: H.:inl aid to the German military Y, its athwl;:s on unfortified towns, 'lSS, its enslavement of peoples, iti; the Red Cross badge, its bombing ·chnnt ships. article made ln Germany. o its appearance abroad. The UONS INT:l!:RESSANT LES :MUTIL:f:S DE E . he official organ of the Perma- tion, classification, and dissemi- rehabililation of the wounded. .mmi.ttee. The editor of the re- ,c, Paris. l apparen'tly under the auspices irst number of the YSICAL ANTHROl'OUJGY The preface is an attempt to r scientific journal. * * * at icles are: 1pology: Its scope and aims." L jaw." skimoid characters in Icelandic of the Committee on Anthropol- uncil, and its activities for year NOTICE TO SERVICE CONTRIBUTORS. When contributions nre typewritten, double spacing nnd wide m1ugin ure desirable. Fasteners which can not be removed without tearing the paper are an abomination. A large proportion of the articles submitted hun• nn otl1clal form such as letterheads, numbered paragraphs, and needless spacing between paragraphs. all of which rcquir0s correction before going to pres"<. The Bur.- r.ETI=" endeavors to follow n uniform style in headings, aml caption'.><, uml the editor can be spared much time and trouble and unnecessary l.'rrors can be ob- viated if authors will follow in the above particulars the practice of recent is- sues. This is not only important in special articles but still more so in re- news. For example, un article by P . • \. Sur:; G. Alen, U. S. ~ .• on Removal of the Gasserian Ganglion, should be headed as follows: Removal of the Gasserian Ganglion . By G. Alen, Passed .\ssistant Surgeon, United Stntes Navy. If a revi<'w h: submitted of an urticle by J.E. Thompson, M. B., B. S. (Lonu.), F. R. C. S. (Eng.), F. A. C. S., Galveston, Tex., Professor of Surgery, Univer!!lty of Texas, entitled "A Study of Modern Operations in Hypospaulas from an Anatornicnl and Functional Standpoint," appearing in Surger.y, Gynecology, and Obstetrics, Yolume XXV, No. 4, October, 1917, the following heading wouhl conform to the u:-;age of the BcLJ,ETIN in recent years: Thompson, J. E. Modern Operations for Hypospadlas. ~urg., Gynec .. and Ohst. October, 1917. The author's initials are important, not so his titles. If the reviewer is not familiar with the exact abbreviation employed by the lnuex-Catalo~e of the Surgeon General's Library and the style adopted by the American ~Iedlcal Af>sociatlon Press, it Is best to write the name of the perio1\i<-nl In full. The greatest accurc1cy antl f11llncs11 should. be emploucd in all citations, as it . ias sometimNl b<.'ell necessary to decline articles otherwHe <\c..;lrahle because h: was impossible for the editor to understand or verif~- references, quotations, etc. The frequency of gross errors in orthography in many contributions Is conclusive evidence that authors often fail to read over their munul:'crlpts after they have been typewritten. Contributions wblch require lilustrntlon must be received two months prior to the date of the Issue for which they are intended. Only the names of actual reviewers for a current number appear. The BULLETIN prints only original articles, translations, In whole or in part, and reviews and all original contributions are accepted on the assumption that they have not appca1·ea previously and. are n-0t to be reprinted. elscichcrc wit• out an 1111dcrstanding to that ctJect. 815 I1DEX TO U~l'1 [Articles not a Abdomen, wounds oL_ Abdominal draina~e-- Abdominal pain _____ _ Abdominal self-protecti Abscess of metliastlnu Abscess, mastoid ____ _ Abscesses after tonsil! Accidents, aeroplane _ Accommodation, spasm Aeroplane accidents, Air chambers for the ~ Alcohol, cetylic ------ Altitude for the tuber1 American Defense SOC! Amputation stumps _ Anaerobes --------- Anaphylaxis, acute _ Anemia, splenic ----- Aneurysm after salYa Aneurysm and ruptur Animal parasitoloi:y, r Anthrax ----------- Anthropology, Amer! Anthropology, pb~-sica Antityphoid in<X·nlati Antityphoid vaccine, Appendicitis, surgery Athletics and their r Aviation candidates Aviators: Examination of - Standards for -- Bacteriology, reviews Balantidium coll --- Bandages, cr~pe ---- ll\DEX TO UNITED STATES ~AVAL MEDICAL BULLETnl, VOLUME XII. INDEX TO SUBJECTS. [ArticleR not appearing In full In the BULLETIN ar~ marked (nb).l A. Pap. Abdomen, wounds oL-----------------------------w---- -------- (al>)__ 89 Abdominal drainage ___________________________________________ (ab)__ 91 .Abdominal pain------------------------------------------------------ 385 Abdominal self-protection ____________________________ ----·-----(ab)__ 750 .Abscess of mediastlnum ________________ ··----------------------------- 449 Abscess, mastoid-------------------------·---------------------------- 478 Abscesses after tonsillectomy ___________________________________ (ab)__ 10:5 Accidents, aeroplane ------------------------------------------(ab)__ 809 .Accommodatlon, spasm oL------------------------------------- (ab)__ 10:; Aeroplane accidents, medical aspects of ________________________ (ab)__ 309 .Air chambers for the Navy stretcher__________________________________ 441 .Alcohol, cetylic -----------------------------------------------(ab)__ 295 Altitude for the tubercular ____________________________________ (ab)__ 277 .American Defense Society ------------------------------------------- 813 Amputation stumps ------------------------------------------(ab)__ 744 .Anaerobes ---------------------------------------------------(ab)__ 494 Anaphylaxl~. acute ------------------------------------------------- 447 Anemia, splenic ----------------------------------------------------- 13 .Aneury;;m after salvarsan____________________________________________ 715 .Aneurysm and rupture of left posterior cerebral artery________________ 702 Animal parasitology, review·s of literature on __________________ 99. 293, 494, 75!l .Anthrax ----------------------------------------------------------- 801 .Anthropology, .American Journal of----------------------------------- 814 Anthropology, physical ----------------------------------------------- 814 Antltypboid inocnlntion in Italian Nary ________________________ (al>)__ 93 .Antltyphoid vaccine, the dangers of Intravenous injection oL__________ 1 .Appendicitis, surgery of--------------------------------------------- 393 Athletics and their relation to war---------------------------------- 592 Aviation candidates ----------------··-------------------------<ab)__ 504 .Aviators: Examination of ------------------------------------------------- 80 Standards for -------------------------------------------------- 155 B. Bacteriology, reviews of literature on ________________________ 99, 293, 494, 759 Balantidium coli ---------------------------------------------------- 802 Bandages, cr~pe ----------------------------------------------------- 572 Sli INDEX TO VOLU)IE xn. "'\ol. XJJ Pan, Baths ---------------------------------------------------- ---<ab) __ 292 Bedside screen ------------------------------------------------------ i5 Illindness, pretended ------------------------------------------<ab) -- 405 Blood and the kidneys----------------------------------------- {ab)__ 730 Bone, spurs of ________________________________________________ (ab)__ iiH Book notices-------------------------------------------------- a42, 57:1. ~:; Boycott of Germnn trade_____________________________________________ s1 :1 Bronchus, foreign body in_------------------------------------------- 7:.!l nu llet in I ung ____________________________________________________ --- 4:lii c. Calculi in kidney____________________________________________________ 7:.!0 Calcnlus rcmowd fl'om common dnct________________________________ 'ilO Camp sanitary notes------------------------------------------------- 327 C·1 mps, portable urinals for__________________________________________ iS Cardiac and tubercular clisease, physical diagnosis, preventive treatment and reconstruction in relation to ______ -------------- -------- ---- ;;s4 Ca rrel l<'Chnique for infectC'cl wound8. Dnkin'H solution ancl thC' _ 1:; CarriC'rS-tnPningococcus___________________________________________ 195, 20;; Diphtheria ------------------------------------------------------ 212 Cerebral artery, aneurysm and rupture of the left posterior____________ 702 Cerebro-splnal feYer-at No.val Training Station, Great Lakes, JIL______ G27 Atlantic Fleet---------------------- ------------------------------ l:.!1 Cnrrier problC'mS in ______________________________________ _ (ab)__ 271 Suhdural hemorrhage In----------------------------------- - ----- 84 T1·eatment of---------------------------------------------------- 474 (\•rPhrn-spl nnl meningitis-at Naval Training Camp, San Diego. Cnl____ 131 At Boston, ~fuss_____ _______________ ____________ __ ____________ __ _ 140 Treatm1mt of epidemic-------------------------------------{ o.b) __ 73ii Cen-ico.l lymph nodes------------------------··---------------- {ab) -- 740 Chemistry, reviews of literature on _________________________________ 103, 295 Chlorine poisoning-------------------------------------------- ( nb) __ 307 Chancroid, circumcision in the presence of---------------------------- 712 Circumcision in the presence of chancruitL- _ ·----------------------- 712 Clinical notes----------------------------------------------- 79,257,447,701 Colloidal gold --------------------------~-- ------------------------- 220 Commissary work at naval hospitals__________________________________ 217 Common duct, calculus of-------------------------------------------- 710 Conjunctiva, emphysema of------------------------------------------- 473 Contagious cases, the care of, and their importo.nce to the Navy_______ 17 Contagious diseases, the hospito.I ca1·e of_____________________________ 27 Contagious hospitals------------------------------------------------- 21 Corpus luteum in Graves' disease _______________________________ (ab)__ 730 Crepe bandages------------------------------------------------------ 572 D. Dacryoadenitls, bilateral_____________________________________________ 706 Dakin's fluid in treatment of chancroid_______________________________ 85 Dakin's solution, preparntion of____________________________________ 41 Dnkin's solution nnd the Carrel technique for infected wounds__________ 45 Deafness, pretended----- -------------------------------------- (ab l-- 495 Delinquents, juvenile------------------------------------------ {ab)__ 505 Dengue rt St. Thomas, V. I. ---------------------------------------- 6t:i .'.':o. 4. Destroyeris in D evice.«, sui::i:: Diabetes insip Dia~noHi!':, ph tlon to card Diphtheria bu Diphtheria, c Disabled sold! Disabled isoldi Drainage, a Drilling, axi, Drink, relatio Drinking cup, Ear-war in Dbem'e" Ile>lews Editorials __ _ Emphy~ema Empyemn Streptoco Treutmen Endocrine m Entries ot " Epidemic ot Epidhlymoto Erythema bu Er~·thrma no Examination Eye-dis 'l~e. ne,·iews Face. wound. Fever, three U~IE XII. Paee. ______________________ (ab)__ 292 75 ______________________ (ab)__ 405 ______________________ (ab)__ 730 ______________________ (ab)__ 7:;4 ----------------------- 342,57~.so~ ·----------------------------- ----------------------------··- diagnosis, preventive treatment 720 710 327 78 ·--------------- ------------ ~S4 lkin's solution nrnl lh<' l:i 195,20~ f the left posterior ___________ _ Station, Great L akes, IIL _____ _ ________________________ (abl -- 212 702 627 1:.!l 271 84 474 lning Camp, San Diego. CaL___ 131 ·------------------------------ 140 ________________________ (ab)-- 735 ------------------------(ab)__ 740 ----------------------------- 103,295 ______________ (ab)-- 307 of--- ------------------ ------- 712 i<J __ 712 ---------------------- 79,257,447, 701 --~--------------------------- 220 217 710 ---------------------~-------- · Importance to the Navy ______ _ of ____________________________ _ _________________________ (ab)-- ·------------------------------- •• ·------------------------------- [ ______________________________ _ ·------------------------------- ue for infected woundS---------- _________________________ ( nb) -- _________________________ (ab)-- 473 17 27 21 739 572 706 85 41 45 495 505 615 Xo.4. INDEX TO VOLUME XII. 8Hl Pap. Destroyers in I.he war zone----------------------------------------- 403 Devices, RUl!'i:tested--------------- ----------------------- -------- 75, 251, 441 Diabetes inslpidus --------------------------------------------------- 471 Diagnosis, physical, preventive treatment, and r econstruction in rela- tion to cardiac and tubercular disease------------------------------- :i'>4 Diphtheria bucllll, virulence of------------------------------- -- (ab)-- 100 Diphtheria, cutaneous------------------------------------------------ 70!l Disabled soldier, future oL------------------------------------ (uh l-- :-JOG Disabled soldiers and sailors. what France is doing !or __________ (ub )-- 112 Diseases, mental and nervous, reviews of literature on--------- ------ 279, 4S3 Dislocation of carpal semilunar bone---------------------------------- 701 Drainage, abdominal ------------------------------------------ (ab)__ 91 Drilling, axiuL-----------------------------.------------------ (ah l -- !l:.! Drink, relation of to work and health-------------------·-----<ab)-- 765 Drinking cup, sterilizer for------------------------------------------ 253 E. Ear-war injuries of----------------------------------------------- 501 Diseases nncl injuri<>s oL __________________________________ (nb l-- 502 Reviews of literature on---------------------------- ------- 10~. !:!f!S. 4!);-, Editorials----------------------------------- --------------- 65, 243, 433, 6'.J3 Emphysema of conjunct! 'I'll------------------------------------------- 473 Empyema--compllcatlng pneumonia----------------------------------- 783 Streptococcal____________________________________________________ 453 Treatlllent of---------------------------------------------------- 786 Endocrine Illanlfestations -------------------------------------- ------ 609 Entries of vaccinations on cover of health record-------------------- 76 Epidemic of three-day fever---- ------------------------------------ -- 800 Epidldymotony in military surgerY--------- -------------------------- 623 Erythemn bullosum-------------------------------------------------- 464 Er~·thPma nodosum -------------------------------------------------- 467 Examination of tnintors, The---------------------------------------- 30 Eye--<li'lea><e><, <l<>ntal Infection in__________________ ---------- ( nb l-- 50:~ Reviews of literature on---------- --- ---------------------- 105, 2!l8, 4!l5 F. Face. wound::; of ------------- __________________________ (ah) __ Fever, three-day, epi<lemlc oL----- ------ ---------------------------- Flies, prevention of nui<:nnces from _____________________ ------- (ub l-- F ood In war time------------------------------ ---------------(ab) _ Foreign body In brondJU!L---------- -------- ---- -------------------- Fracture-hundllng of at sell-------------------- --------------------- 90 800 28G 4<::9 721 257 478 477 267 Of mandible----------------------------------------------------- Of nasal bones-------------------------------------------------- Of os cnlclS-------------- --------------------------------------- Fractures-of the thigh, treatment of by the Gas!'<ette npparatu"------ 3 Suppurat!ng _______________________________________________ (ab) -- 282 G. Garbage bin for use on naval transports------------------------------- 2:J6 Gases, poison---------------------- ---------------------------------- 173 Gassett apparatus, treatment of fractures of the thigh bY------------ 3 General medicine, reviews of literature on-------------------- f'.7, 271. 481. 725 Genitalia, fl.or a of--------------------------------------------- (ab)-- 762 ~20 INDEX TO VOLUME XII. Vol. Xll Gold. colloiUaJ _________________ -------------------------------------- <lrafci ng, skin ______________________________________________________ _ Graves' disease, treatment of-----------------------------------(ab) __ «uatemala City, medical work during earthquake at_ _________________ _ H. Pan. 2:!0 fiGS 739 iOO H ewau:;iorna, cavernous----- -- - ---------------------- -- ------------- i01 !Ialifax di;.nster----------------------------------------------------- 341 Ham01er, air, da01age bY---------------------------------------(ab) __ i65 Ha01mock, substitute for--------------------------------------------- 251 Hayfever-----------------------------------------------------Cab)__ 2i5 Health record, enti-ies of vaccinations on cover of_____________________ i6 Hearin~. normal------------------------------------------------- 366 lieart block _________________________________________________________ 452 Heart disease, hydrotherapy oL ________________________________ (ab) __ 481 Heart murmurs in recruits, report on_________________________________ 577 Historical notes--------------------------------------------- 59, 225, 419, 053 !Io;.pital Corps l)Onch __________________________________ :______________ 443 Ho-<pitul shiP--------- -- --------------------------------------------- 347 Hospital units, 01·ganization and equipment of_________________________ 184 Ilospltnls. contagious------------------------------------------------ 21 ilospital cure of contagious diseases, The----------------~ -------- -- :.!7 Hotel Dieu of Paris-------------------------------------------------- t.1:! l lu111n11 fnt, uses oL ___________________________________________ (ab)__ 754 Hydrotheraphy of heart disease ________________________________ (ab)__ 481 Hnl'iene, reviews of literature on _________________________ ___ 93, 286, 489, 7fii I. Identification tags--------------------------------------------------- 44:! Ileus, paralytic------------------------------------------------------ 560 Industrial topics, reviews of literature on ___________________ 108, 300, 1)()4, 762 Intmvenous injection of antityphoid vaccine___________________________ 1 Italo-Austrinn campaign, statistics oL __________________________ (ab)__ 108 lt<'h. trca tment of - - --- ------------- -------------------------(ab)__ 756 .J. .f apa uese .:'.l.'avy, statistics oL ____________________________ ·-----(ab)__ 773 .Jew in America----------------------------------------- ·-----(ab)__ i6a K. K~her, Theodor----------------------------------------------------- 59 L. Lnborntories, Naval Medical SchooL---------------------------------- 805 Laborator~·. mobile-------------------------------------------------- 331 Lanolin, substitute for ________________________________________ (ab)__ 295 Laparotomy, exploratory --------------------------------------<ab)__ 284 Law. rpviews of literature on _______________________________ 108, 300, 504, 762 Library war service _____ --------------- ---------------------------- 813 Limhs. supernumerary ---------------------------------------- -face__ 86 I .oll:!'l'Vity _ --------- ---------------------- -----------------(ab) __ 317 Lung: Bullet in ______ ----- --------- ----------------------------------- 45!'> S_vphil is of _ -------- - - ----------------------------- - ------------- 200 !110. 4. INDEX Malaria: Chronic--------------------- Histology of---------------- Prevention oL _____________ _ Treatment of--------------- Mandible, fractured _____________ _ :\Iastoid abscess ________________ _ ~Ieat, condemned, use of_ _______ _ )fediastinum, abscess oL _______ _ l!edical school, Salem o _________ _ :Uedical sciences, progress in : Chemistry and 11hnrmac:y ___ _ Eye, ear, nose, and throat_ __ General medicine ------------ Hygiene and :;anitution ______ _ Mental ancl nervous diseases Military, legal <.nd imlustria Pathology, bacteriology and Surgery ___________________ _ Tro1)ieal medicine --------- Medical service, Italian _________ _ l\Ie<lieal School, Naval, laboratorl Medicine: General, reviews of literature Tropical, reviews of literatur Memoranda for medical officers w quentlY----------------------- )leningococcus strains, isolation o Mental diseases, reviews or lltera llllltary topics, reviews of llterat J\lortalitY---------------------- Mosquitoes, extermination oL __ _ Musculospiral nerve, paralysis or Musings during n cruil;e to the w Mutlles de la Guerre, Revue lut Nasal bones, fracture oL _______ _ Naval prison, psychiatric 01ateria :N'e1·vous diseases, reviews of liter Neuroses: Newer concepts or _________ _ "\Var ______________________ _ Nose, reviews of literature on __ Notes: ClinicaL __________________ _ ::>anitary, from a marine trai Operating units at Neuilly ____ _ Ophthalmolo~y and oto-laryn:;ol Os calcis, fracture or_ ________ _ E XII. Vol. XII., ------------~-----(ab) __ ake at __________________ _ __________________ (ab) __ ·------------------ (ab) __ r of ____________________ _ Pare. 220 568 739 796 704 341 765 251 275 76 366 ------------ --- ---- ------ 452 __________________ (ab)__ 481 577 ---------------- 59,225,419,653 443 --------------,---------- 347 184 21 27 653 ---- -- ------------- (ab) __ 754 ·------------------(ab)__ 481 ------ - - -------- 93,286,489,757 442 560 --------------- 108,300,504,762 ------------ - ----------- - 1 __________________ (ab)__ 108 __________________ (ab) __ 756 _____ _____________ (ab)__ 773 --------- --- ______ (ab)__ 763 59 805 331 __________________ (ab)__ 295 __________________ {ab)__ 284 ·-------------- 108,300,504,762 ·------------------------ 813 ___________________ face__ 86 __________________ (ab)__ 317 455 266 No. 4. INDEX TO VOLUME XII. 821 M. Malaria : Paite. Chronic------------ ------------.. ·-------------------------------- 457 Histology of-------------------··-------------------------- (ab)__ 87 Prevention oL-----------------··-------~------------------ (ab)__ 279 Treatment of ---------------------------------------~-----(ab)__ 725 Mandible, fractured__________________________________________________ 478 Mastoid abscess------------------------------------------------------ 473 Meat, condemned, use oL--------------------------------------- lab)__ 490 ~fediastinum, abscess of______________________________________________ 449 Medical school, Salerno_______________________________________________ 225 Medical sciences, progress in : Chemistry and pharmacy _______________________________________ 103, 295 Eye, ear, nose, and throaL--------------------------------- 105, 298, 495 General medicine---------- - - --------------------------- 87, 271, 481, 725 Hygiene and sanitation __ :._ _______________________________ 93, 286, 489, 757 Mental and nervous diseases----------------------------------- 279, 483 Military, legal and industrial_ _________________________ 108, 300, 504, 762 Pathology, bacteriology and animal parasitology ________ 99, W3, 494, 759 SurgerY---------------------------------------------------- 89,282,742 Tropical 1uedicine --- ------ - ------------------------------------- 95 Medical service, Italian---:--------------------------------------(ab)__ 492 l\Ie<lical .School, Na val, laboratories----------------------------------- 805 Medicine: General, reviews of liternture on _________________________ 87, 271, 481, 725 Tropical, reviews of literature on--------------------------------- 95 Memoranda for medical officers when a ship ls commissioned and subse- quentlY------------------------------------------------------------ 601 Meningococcus strains, isolation oL __________ :_________________________ 551 Mental diseases, reviews of literature on ____________________________ 279, 483 :Military topics, reviews of literature on _____________________ 108, 300, 504, 762 Aiortality ________________________________________ ~------------(ab)__ 322 Mosquitoes, extermination oL-------------------'--------------------- - 144 ~luscu lospiral nerve, paralysis of------------------------------------- 708 Musings during a cruise to the war zone_____________________________ 53 Mutlies de la Guerre, Revue lnteralll~e--- ---------------------------- 814 N, Nasal bones, fracture of______________________________________________ 477 Naval prison, psychiatric material in__________________________________ 406 Nervous diseases, reviews of literature on ___________________________ 279, 483 . Neuroses: Newer concepts of _________________________________________ (ab)__ 281 'Var ______________________________________________________ (ab)__ 483 Nose, reviews of literature on __________________________________ 105, 208, 495 Notes : ClinicaL _______________________________________________ 70, 257, 447, 701 :Sanitary, from a marine training camp____________________________ 327 0. Operating units at NeuillY-------------------- ---------------------- 787 Ophthalmology and oto-laryngology ____________________________ (ab) __ 107 Os calcis, fracture of________________________________________________ 267 INDEX TO VOLUME XII. Vol. XU. P. Page. Pain, abdoininal----------------------------------------------------- 385 Pnncreatitls, chron ic--------------~--- ------------------------------- 79 Pn nil~· sis of musculospiral nerve______________________________________ iOS Pnrasitology, aniinal, reviews of literature on ________________ 99, 293, 494, 75~ Paris, Hotel Dieu of------------------------------------------------- W3 Pathology, reviews of literature on ___________________________ 00, 293, 4!>4, 75!l Penis, tuberculosis oL ________________________________ --------- (ab) -- 4S.~ Pericardia! effusion__________________________________________________ 717 Pbarinacy-war and------------------------·----·--------------- (ub l-- 103 Reviews of literature on __________________________ -------------- 103. ~:; Plague !u China, spread of------------------------------------------ 789 Pneuinococcus-growth of ______________________________________ (ab) -- 101 Research OD------------------·-------------·- -- --- ---------------- 150 Pneumonia-Empyemu coinpiicating ______________ ---------- ----------- 783 Report of cases------------------------------------------------ 775, 77s Serum in ______________________________________ ------------------ 102 Sy01ptoins------------------------------------------------------- 447 Pneumothorax, spontnneous ---------------- ----------·---------------- 451 Polson gases--------------------------------··------------------------ 173 Poisoning, chlorine ____________ -------------- ----- -----·-------- (nb l-- 307 Pouch, llospitul Corps ___________________________ --- ------------------- 44:~ Progress in medical sciences. (See Medical scl-en.:es.) Prophylaxis, venereuL _____________________ ___ ------ ----·------(ab) -- 767 Prosthetic nppllances ----------------------------------------(ab)__ 751 Psychiatric material in Portsmouth prison____________________________ 406 Psychin try, Wassermann test in ________________________________ ( n b) -- 279 Purgation before operation ____________________ -- -----------------(nb) __ 742 Purpura hemorrhaglca _____ ---~------------- ------------- ------------ 5."i~ Putrefactions---------------------------------·---------------- (ab l-- 2SG Supernumerary-limbs------- ------------------------------- ---fnce__ 86 Tooth __________________________________ : ________________________ 270 R. Recruiting ----------------------------------·------. ··---------------- GG2 Recruits, report on heart murmurs iD-----------··----~---------------- 577 Reports------------------------------------------·--------- 121, 327, 527, 77:1 Daily sanitary ________________________ : _______________ ------------- 2'23 Repression of war experience __________________________________ (ab)__ 485 Retina, cletuchment of-----------------------------------------(ab)__ 2!>8 Revue, Interallice --------------------------------------------------- 814 s. Salerno, medical school of------------------------------------------ 225 Salivary glands---------------------------------------------------- 71!> Salva rs:i 11---------------------------------------------------------- 4-18 Deu th from---------------------------------------------------- 262 l\fanufacture oL------------------------------------------------- 1:12 Ruptured nneurysm after--------------------------------------- 715 Sanitary notes, marine training camP--------------------------------- 327 Sanitary report on Vladirn!'ltok------------------------------------- 146 San! ta tlon-enmp and trench --------------------------------- (ab) -- 300 Reviews of literature on ________________________________ 93, 286, 4S!l, 757 Scnbles, treatment of ---------------------------------------(ab) -- 2SV, 756 :'.\o. 4 i:;(;!er:t, re'-eet ion of Screen, bedside ___ _ Sebaceous cysts __ _ Semllunar bone, ca Ship, hospital ___ _ Sing Sing, ndmissl Skin grufting ----- Solar-ruy tl1erupy_ Soy bean --------- -"IJleni c· a 1emla __ Splnnl fluid in rein system -------- !'.'ta tis tics, ceusus S tutu re ---------- Sterilizer for drln Stethoscope bell, o. Stretcher, air cha St. Thomas, Yirgi Student medicnl o Substitute for ha Surgeon, naval, w Surgery, reviews Surgical judgment Surgical notes __ _ Swimming 1.ools, Syphilis-cerebral Ear, in ____ _ In IlaltL __ _ Legal ennctm Of lung ____ _ Of nervous s Tags, iuentific-ntio Teeth- Dead ______ _ Septic ____ _ Tetanus ------ In Haiti_ __ _ Thi~h fractures Thorax, tlf:.wa~es Throat, reYicws 1 Thyroglos::;al due Thyroid cllsortlet Tonsil, Jin~nL __ Tonslllectomy In Tooth, supNnun Troplct.l di-eu-:es Tropkal lllL'(licin Tropical ukers. Tubercle liacilli rn XII. Vol. XU . Pace. 385 ------ - - ----- ------------- 79 ----------------------- --- 70~ } ________________ 99,293,494, 759 --- - ----- -------- --------- 6;)3 ----------------- 99, 293, 494, 75n ----------- --------- (ab)__ 4S.l ____________________ (ab) __ 717 103 ------------------------ 103,2fl~ --- --- - -------------- - ---- 789 _____________________ (ob) __ 101 mo 783 - ---- ------ ------------- 775,77~ ---- ---· ------------------ 102 ---------------------- - --- 447 __ __________________ (ab) __ scl~nces.) --------- __________ (ab) __ ____________________ (ob) __ --------------------(ab) __ ---- __________ ______ (ab) __ --------------------(Rb) __ ____________________ face __ 451 173 307 44:l 767 751 406 279 742 53S 2S6 86 270 5G2 577 - - ---------- ----- 121, 327, 527, 77() - - - - --------- - ------------ 225 ____________________ (ab)__ 485 ____________________ (ab ) __ 298 814 225 719 448 262 152 -------- ----------------- 715 -------------- ------- ----- 827 146 -------------------- (ab) __ 800 ----------------- 03, 2S6, 4S0,757 ________________ (ab) __ 28!>,756 :So. -1. INDEX T O VOLU M E XII. Stlera, re-.ertion of_ ___________________________________________ (ab) __ Screen, bedslde-- - - --- - ---------- - - -------------------------------- Sebaceous cysts--------- - - --------------------------------------- Semllunar bone, carpal, dislocation of ________________________________ _ Ship, hospital ______________________________________________________ _ Sing Sing, a<lmisslons to ----------------------------------- (ab) __ Skin grafting -------------------------------------------------- - ---- Solar-ray theraPY-------------------------------------------------- Soy bean----------------------------------------------------- Cab) __ ::.;p ll'~bC anemia __________________________________________________ _ Spinal fluid in relation to acute Infectious diseases of the central nervous system---------------------------------------------------------- 8tatistics, census 1!)16--,--------------------------------- ------(ab) __ Stnture-- ---- ------------- ------------------------------------ Cab) __ Sterillzer for drinking CUP------------------------------------------- Stethoscope bell, n smnll------------------------------------- ---- ---- Stretcher, air chamber s for--- ---------------------------------------- St. Thomas, Virgin I slan<ls, uengue aL----- - ------------------------ Stndent medical officers, course tor---------------------- --- ----- - ---- Substitute for hammock----------------------------------- ------- ---- 823 Pap. !?OS 75 722 101 347 524 5G8 555 290 rn 6-JG 3•>-) 317 2::l3 75 441 ti15 ]41 2::ll Suggested devices------------------------------------------ 75, 2;:;1, 441 Surgeon, naval, what he shoul<l know_________________________________ Sl)4 Surgery, reviews of literature on _______________________________ SO, 282, 74:! Surgical judgment-------------------------------------------- - --- 38.> Surgical notes- -------------------------------------------- - - - - 527,530 s"·imruing pools, snnltn ti on of _________________________________ (nb) __ 7:;7 Syphilis-cerebral ____________________________________ _:____________ 469 Ear, In ---------- --- -------- ------------ --------------- (ab)__ l 00 In Ilaltl------------------------------------- ------------------ 300 Legal enactments agalnsL---------------------------- - - - - ( ub) __ 315 Of lung--- ---------------------------------- ------- ------------- 266 Of nen ·ous system ------------ --------------------------- (ab>-- 2S2 T. T ags, iclentification _________________ -------- - - ------------------ --- --- 412 T eeth- Dead ____________________________________________________ (ah)__ 2S5 Septic ----------------------------------------------------<ab)_ _ :!&I Tetanus ----------------------------------------------~---------- SO'.? In IIaiti------------------------- ------------------------ -------- SO Thi;?;h fractures ------------------- ---------------------------------- 3 T horax, disrasrs oL ____ --------------------------------------< nh) __ SS Throat, reviews of literature on _________________________________ 105, 298, 495 Tl 1~·roglossa l ducL------------------ ---------- - --------------------- - 713 Thyroid disor<lerS--------------------------- - -----------------(ab>-- 727 Tonsil, linguaL---------------------------------- -------------- (ab) -- ~ Tonsillectomy tu tuberculosis ----------------------------------------- 751 Tooth, supel'llumerarY-------------- - - - - - ------- - ---- - --------------- 270 Tropical d i ~ca~es ___ ----------------- --------- -------- _______ (ah l-- n;:; Tropical medicine, reviews of litrrature on____________________________ 95 Tropical ulcers, new mclho<l of treating_______________________________ 80 T ubercle bacilli in blood _______________________ . _______________ (ub >-- 293 INDEX TO VOLUME Xll. Vol. XU. 824 Tubercular conditiuns ________________________________________ (ab) __ Tuberculosis- Altitude in------------------------------------------------ (ab) __ Of penis __________________________________________________ (ab)-- Renal ---------------------------------- ------------------(ab)-- Tonsillectomy in------------------------------------------------- X-ray diagnosis oL--------------------------------------- (ab)-- Typhoid bacilli in urine ________________ ________________________ (ab) __ Typhus ----------------------------------- -------------------(ab) __ Prophylaxis oL------------------------------------------- (ab) __ Transfusion for-------------------------------------------(ab) __ u. liltra-violet therapy----------------------------------- ------------ Undesirable candidates, detection oL---------------------------------- .Undulant fever------------------------------------------------------ t;rlnals for camps, portable--------------------------------------- --- v. Vaccines, seu.sitir.e<L------------------------------------------ (ab) __ Yiri;in Islands- l)engue at St. ThoIDaB------------------------------------------- Balantidi um coli in ______ ---------------------------------------- Yi tamin, paucreatlC------------------------------------------- (ab) __ Ylallivostok, sanitary report on--------------------------------------- w. Wnr and pbarmo.cf-------------------------------------------(ab )-- War time, food ill--------------------------------------------- (ab) __ \Var and psychologY----------------------~--------------------(ab)-- War ;i:one- l)estroyers Ml---------------------------------------------------- ~Iusings during o. cruise tO--------------------------------------- Wasserroann- Test in psychiatrY-----------------------------------------(0.b) -- Reaction with diabetic sern--------------------'------------- (ab) __ Wounds- 4S3 27G 1u1 734 !)9 7UO 7;-,a i55 732 G15 802 94 HG 10:; 489 7G2 403 53 279 294 In civil practice-------------------------------------------------- 0! abdomen-----------------------------------------------Cab)-- Face -----------------------------------------------------Cab)-- 33G 89 ()() x. X-ray diagnosis -------- --------------------- ----------- ______ (ab)-- 734 Y. Young, Thomas------------------------------------------------------ 419 [Articles not appen A. .\<l:nns, .J. u ____________ _ Ainslie, C. A ____________ _ Alhrccht, A--- ·----------- Alrlcn, P _______________ (a .\lcxander, l). J __________ _ .\lrnrE'z, ·w. Q __________ (a _\tHll'n:, H. s ____________ _ .\ ntlerson, H. G--------- (a Armstrong-Jones, n.___ (a .\\"eQ·. O. T ____________ (a .\xelrad, S -------------la B. Hachmnnu, R .• \.. _______ _ Baird. G. W - -------- f Halc~tra, l) ------------ ( Barber, J. R----------- llarrier, C. \V ----------- nassct t-~mith, P. w ____ t mack lock, B. __________ ( rnackwcll, E. )! -------- Hloedorn. W. A---------- 271, 279, 2S!l, 723, 727' 730. lluaz;, F ------------· __ _ flo;:(an, P . )[_ __ ----- Doles, R . S__ ___ ----- BoniIDe, E ----------- Bouquet, H __________ _ Brill, A. A------------- Bruce, J ----------- __ _ Brunet, \\. )[ __ Bryant, \V. S __ -------- Bull, L. L ------------- Burrows, H __ _ Butler, L .. \. ----------- c. C'allaway, E_ C':uncrer, C. B --- ----- ( •antlie. J_____ ____ __ C'Hl'l', C. \Y ------------ 7GOflS -JS--- 11 dE xn. Vol. XU. Pap. ____________________ (ab)__ 299 ____________________ (ab)-- ____________________ (ab)-- ____________________ (ab) __ ·-------------------------- ____________________ (ab) __ ____________________ (ab) __ ____________________ (ab) __ ____________________ (ab) __ ____________________ (ab) __ _____________________ (ab)-- ·--------------------------- _____________________ (ab) __ ·--------------------------- ______________________ (ab) __ ______________________ (ab) __ ~---------- - ---------(ab) __ ______________________ (ab) __ --------~-------------(ab) __ ______________________ (ab)-- ______________________ (ab) - - ______________________ (ab) __ 277 483 276 751 734 99 750 755 755 555 413 800 78 732 615 802 94 146 103 489 762 403 53 279 294 336 89 90 734 419 l~DEX TO A"CTHORS. [A1·ticlcs not appearing In full in the Ilt:LLE'ril\ arc marked (ab).] A. Page. A1lnmR, .T. C------ - ----------- 708 Ainslie, C. A__________________ 469 Alhrecht, .A____________________ 396 Alden, P --------------- (ab)__ 112 A lexande1·, D. J _______________ 478 Alrnl'ez, W. c __________ (ab)__ 742 Anders, H. S- ----------------- 584 Ande1·son, ll. G- - - ------ (ab) 309, 504 Armstrong-Jones, R----- (ab>-- 765 A\-cry, 0. T ____________ (ab) 101, 102 Axelrad, S _____________ (ab)-- 293 B. Bachmann, R. A -------------- 30, 262 Ba ird. G. W ____________ face__ 8G Balestra, D ----------- - (ab)__ 108 Barber, .T. R ________________ 271, 286 Barrier, C. W ----------------- 20i:i Bassett-Smith, P. \V ____ (nb) __ 271 Blacklock, B_ ___________ (nb >-- 725 Blnckwell, E. 1\L______________ 347 rnoedorn. w. A________________ 85. 271,279,289,292,481,48~ 725,727,730, 732,739,740 Boaz. F ________________ (ab)__ 317 Page. Carter, C. F ---------------- 457, 471 Carter, H. F ____________ (ab)-- 725 Castellani, A ___________ (ab> - - 95 Cauch, ·w. A__________________ 270 Carn llini, E ____________ (ab)__ 279 Cecil, R L _____________ (ab)-- 732 Chickering, H. T ________ (ab)-- 102 Choisser, R. M________________ 205 Clark, G. F- ------------~---- 87, 100, 101, 271,294,331,481,495,759,762 Clark, N. H___________________ 452 Cla rkc, c _______________ (ab>-- 87 Clough, i\f. c ___________ (ab)__ 293 Cohen, H. B__________________ 299 Cole, R. C-------------- (ab)__ 102 Collie, ,}_ ______________ (ab)__ 483 Connole, J. V ----------------- 706 Cooper, C. F ------ - ----- (ab)__ 725 Conleiro, F. J. B______________ 577 Corner, E. M ___________ (ab)__ 744 Crnndon, L. R. G______________ 393 Cl'eSS, C. C-------------------- 257 C1·ow, G. B _____________ 271, 276, 277 Cumming, H. s _________ 271, 275, 735 Cul'I, II. C------------- ------- 394 D. Bo~an, I<'. ~r_ ___________ 87, 89, 94, 734 Dalanil. .J_____________________ 802 Boles, R. S ______________ 71;:;, 719, 778 Dnnielopoulu, D _________ (ab) __ 750 Bonime, E ------------- (ab) -- 27G Da Yid son, A. B_______________ 266 Bouquet, fl ____________ (ab)__ 3Vi Dennis, F. L ____________ (ab) __ 751 Brill, A. A------------- (ab) -- 763 De Yer, F. J __ ~---------- 455, 715, 778 Bruce, J --------------- (ab) -- Brunet, vV. 1\L-----------,---- Bryant, W. S------------ (ab) __ Bull, L.· L ------------------- - B urrows, H ____________ (ab) __ Butler, L. A -------------- ---- c. Callawny, E _________________ _ Camerer, C. B---------------- Cnntlie, .J ___________ . ___ (:ih) - - Carr, C. \V - - ----------------- 76098-JS--l 7 289 Do!'.bez, A. n ___________ (ab) 101, 102 33G DO\\'JH'Y, .J. W., j1· _______ (ab> - - 106 502 nu Roi;:, B. F ----------------- 75 551 Du1Jgpon, L. s __________ (ab)__ 87 90 . null'. ,L______________________ 568 27 E. Eatn11, "" ].] ___________ .. _____ _ '.WI\ Eber~on, !•' __ _________ _:_(ab} __ 146 Etldy, W. IL ___________ (ab)-- 2!)2 I E spach , W. C----------------- 447 Ewart, W -------------- (ab) __ ~ 25 443 759 94 457 88 8~6 l~DEX TO A"GTHORS. Yol.Xll. F. J. Page. Fnrenholt, _\_ _______________ 131, GOl Joslin. TI. I\:_________________ :!t rell. E. "°---- --------(ah) __ :!I!) Jacob~-. A. L------------------ 40(1 Ft'rguson, D------- ------------ 800 Ft>rry, X. S----------- (ah) 21;:; K. Fi;;ke, C. ::\" _________ ·-· _ :i:J, 87, 1]!) Knhelek, J ______________ (ab) 1~.;; F•1reman, F. ".---------(ah) __ 287 F t•X, Q __ ______ -------- --- - 87. 103 -rank, L-- - ---- -------- (nb) __ JO:i ""rac;er, J --------------- (ah)__ :iOl n·aser, J. s __________ (:th)-- 501 . G. t,,, tes, )I. F------------------- c,;ueck, B _____________ (ah) _ c 1et.sch, }·; ____________ (a Ii ) Golden. \Y. E----------------- 17,75 52-t 727 474 7:!1 G •Ulll. E. \Y _ G··aham-Smith, G. s ____ (ab) _ 2SG ( ray, G. A------------------ 467, 722 Ci·eenough, R. n __ ----------- 141 ( uillot, )f ______ (ah) _ 2.'l2 H. Ha~er, B ... \. ------------------ 79 Hale, G. D----· --------------- 1 H;1lpin . .T. _\ __ --------------- 80 H.1milton . .-\. ___________ (abl -- 765 Hartman, F. W --· ------ 1, 13, 70. 46 ~ Ha~·nes, H. g ___________ (ab l-- 7'10 Hebblethw:1ite, A. S---- (ab) __ 307 Ht.>ltl, I. W _____ .------ (ab) __ 734 Henry, H _____________ (ab)-- 49-t Hen r~·. R. R------------------ 76 ff •rmun, L -· _____ --------- 623 He:-rick. \Y. W __________ (ab)-- 735 H: . .!!iee, n. l~ --- --------- <HG Kazanjian, Y. II ________ (ab)__ !lO Keegan, .J. J________________ _ lll!l Keiper, G. F - ---- ------ (ab) __ .. HJ;; Kenni~ou, S ------------------ 1 :;o Kern, R. A---- ------------- 271. :lol Kinclleberger, C. P - --------- J :!1 , :!'.l 1 Knorr, E. _\___________________ .Jll Koltes, F. X ------------------ ::!hi Kriz, H. E____________________ :;:;:; Kmitn, T---------- __ (:1\l) _ 4'-'.i L. L nne, F. F-------------------- til;:i Le Conte, R. G--·-------- 3:!7, 710. l'-1 Lehmberg:. H. H _______ ------- 1-'tll .llil~ • .1. ll .. _______ (ah\ 7i:! Luo~· . D. F--------------· -· _ :;;;o, ;;:1:! 1 .usk. G ________________ (ab) .J'-'!l '.~·n<'h, G. R------------ ( :1 h) _ :!il 1-·· ... :!11 :\lacullmn .. \.IL------- (ah) _ :.1acfie, J. \\'. 8---- ·---· (.tb) _ :\faekenzic, G. !'L-------· ·---· _ l\ Iangham, S------------ ( nb) _ :'\[:\nn, ,V. I.1-------------- 78. 2:>3, :t:!'i :\Iartini. E ______________ (ah) 1-.1 :\kDonell, \Y. X __________ --- .J;", .• IcDowell, R. \\' __ 87,n~.:.:71,:lBl,~l)l ~,fcG uire, L. W ____ ·-· 140. jj:", :.\kMullin, J. J . .\_. ______ ----- i'll:l Ri'l. n _______________ (nb)-- 91 Holbrook. Jt. \Y ________ ·------ 447 H •nker, 1':. II. __________ (ab)-- 767 \11-Xierney. F. B--------------- -HS :\IC'llllel, L. B __________ (tlh) __ ~f\\.l Hnp])l'. Ii. TI ____________ (ab)-- 73!) Ht1tel Dien of Pari..;, history oL 65!~ Hough, P. \\'_____ __ --· __ 144 fl<'nghton, .T. E _______ 87, 101 , 271, 205 Honzel. G ---------· ----- ___ 3 H .. yt, R. E - ----------------- 701 Hn~hes, F . . \ Hutt. c. \\' -----·-· ·----- -- ---- ( nh) __ J. 473 506 :·.Iii inn. IJ __ ------------ ( :1h) __ i';Jli :1[ills, C . K- ____ (nh)__ l(.i:! i\linuker, .\. ,J_ _________ -- ----- 1 !l:"> l\looa~-. E. E --------------- .J:ii'. lil i\iorishimn, K ---------- (ab)__ !l!I )fnrphy, l'. J__ :~s~. ?"'. :;\onchi, lL ·--· .. (:th) :'\oYitzky, .T ____________ (ab)-- 473 :!\"o~·es, B. H _____ ------· _____ _ .rsrael, .T. p __ _ .JI :\o. 4. 0. Oshorne, '.f. n P. Parham. J. c; _______ _ Parish. B. [> _______ _ l'nrke;;;, C. JI P :1r,:on~. ll. P ------ l':lton. L ______ _ l \•net. :r. M _______ _ l'l'tl ei·son, H. (' ___ _ l'llllllll1l'l', l:. \\' ___ _ R. Hau. Y ___________ _ Hho. p ____ _ l: ic·hnn1>'. T. \\' ___ _ Hivers, \\'. II. H Hoerner, J ------- Hoper .. J. C Hos,.;. G. G ________ _ Hossiter, l'. ::-; __ l t.1·<1l'Cll. Il ________ _ s. f-i< holler;;. II. ;\[ S('hoonmnkl•r, IL __ l"<·lnrnh, S. L S hor! . .T. T __ ----- !'-'in<:l:t :r . .T . ... \. H Rllll'Ptou. )I. .\ __ _ Smirh. <'. E_. 8111i1h. t'. ,,. __ _ Rmith. .1. \\' _ f-ip<>i<lel. F . <: ---- SpPhn. <;. " Stauffer. :\. l __ S team;;. _\. \\' __ _ Skinlnt;!lo't'. \\'. \'' 81l•nhou~e. H. )L_ St Pplwns .. l. \\'. \Y Rt itt. l'i. R -· RtonP. E. IL _ S 1 01· ~-. <;. n AUTHORS. Vol.XII. J. . 1, R. K _________________ _ )y, .\. r. _________________ _ K. Paite. 21 406 lek, J ______________ (ab)__ 7;:;3 njian, Y. H ________ (ab) __ 90 an, J. J __________________ 709 ~r, G. F - ----- - ----(ab) __ 495 dson, S ------------------ J 50 , R .. ~--- -------------- 271,307 lebcrger, C. P ---------- 12], 251 r, R . .\___________________ ,177 ~s, F. X ------------------ 39G H. E-------------------- 53i\ ta, T ______________ (:tl>) __ ..JS:1 L. ~ F. F-------------------- Gl3 !onte, R G ___________ 527, 710. 787 .lbPr~. II. B _______ - - ----- 801 .1. ii _____________ (ah)__ 772 ·. D. F __________________ 330, 392 . G-------~-------- (nb) __ 489 ·h, G. R ____________ ( :t b) __ 271 ]\[. lllum. A. B _________ ( uu) -- 1e, .J. \\'. s _________ (ab) -- 730 12:; {CH%iC, G. i\l______________ 173 glrnm, s ____________ (ob l-- 271 n, W. L ______________ 78, 2G3, 3'.?i :ini. E ______________ (nh) __ 7:Ji\ ·onell, "._ ~ -----~--------- 4:; ·owcll, R. W ___ 87, 9~ . ~71, 284, 2fl0 uire, L. ""-----------··-- HO. 77:> lnllin, .T . .T. ,\_______________ 702 ·iern e~· . F. B _______________ 448 llel, L. B ___________ (ub) _ 290 ;111. G _______________ ( 11h) __ 7;:>G s, C. K _____________ (nh) __ 7G2 iker, .\. J _________________ 1n;-, dy, E. E ________________ ..J:l~471 ishimn, K ---------- ( nh) __ 9!) phy, P . J _________ _________ ~S;:;. d1i, r-1_ ______ ________ (:1u) 702 itzk~·, .T ____________ (:tl.J)__ 28:i es, R H___________________ .JI. No. 4. lNDEX TO AUTHORS. 827 0. Page . ·Osl.Jorne, 'l'. B ___________ (ab)__ 290 P. Parlrnm, J. Q ______________ 87, 92, 723 Parish. B. D __________________ 713 P :1 rkcs, C. H ___________ (ab)__ 28-! Parsons. R. P _________________ 155 l 'aton. L _______________ (ub) __ 103 l'enet. .T. l\L_________________ 717 Pt•ttcrson, IL Q_______________ 341 l'llllllllH.'l', H. 'V --------------- 2fi5 R. Rau. '°----------------------- 27 It ho, F - - ------- - - - - - - -- (al>)__ 93 Itich:t nl~. '.I'. w --------------- 18-! fliYers, "\\-. I-I. R ________ (ab)__ 485 Ht1t>111er. J_ _____________ (ab)__ 734 novt·r . .T. Q _____________ (ab)__ !)-! Hoss. G. G____________________ 72() Ho!"siter , P. S---------------·-- lfl:l H~·tlt>en. H -------------------- 802 s. .Pap. Strnuss, S. G________________ 609 St1·ine, H. F -------------- 87, ~. 572 Stnnrt, M. A________________ '442 Sund, A. G ________________ 449,451 Sutton, D. G ___________ 271, 286, 281., 282,481,485,525,762, 763,7.65 Swift, H. F _____________ (.ab~ -- 282 T. 'J'n~·Ior, J. s _________ 3,61,65,67,225, 243, 246, 419, 43H, 4;~7, 653, G9a, 767 'L'aylor, S. lVL_________________ 79G 'l'engnc, Q ______________ (ab,__ 99 'l'olirn<l, J. J ___________________ 183 'l'orok, E _______________ (ab' __ 298 TrilJl.Jle. G. B _________________ 87, 105 lOG,107,108,271,299,j00,3GG, 481,501,502,503, 504, 505, 'ijl 'L'wic\tell. D. a __________ (ab)__ 277 v . \':111 Sn1111. A. r_ ________ (ab)__ :294 \":111 \Yi11klc, J. s______________ :112 w. Sc·holwrg. II. ]\I_ _ _______ (ab) __ 757 Wal1:1cc, C _____________ (ab~_._ '89 SC:hoo111naker, H ________ (ab) __ 481 \\"enYer. R. ]<]_________________ '217 Sc·ll\nth, ~- L __________ (ab) __ 28] \\"pbh. U. R__________________ 84 ~horl. .T. '£ ___________________ _ 627 \\"ctlPrhnke _____________ (ab, __ 754 ~iIH:la ir , J. A. R ____________ 441, GG2 S111L•eto11. :\L ,\ ________ __ (ab)__ 100 S 111it h. 0. E ____________ (ub) __ 757 Smith, C. W ------------------ 704 Smith . .T. w ________________ 212, 220 ~pei<lel. F. G- ----------------- 220 Spnl1n. (~. "\\" ___________ (nh)__ 107 Rtaulfer. ~- p __________ (ab) ,__ 2!)() :';t('a rns, A. "\\" __ ---- --------- -I 13 !':h'inlrng-it'I', W. C ----- (nh) _ fi03 ~ll'11h ou se, H. l\I_______________ 789 S1 ephl•ns, .J. "\\". W ______ (ab)__ 725 Rtitt. I~. IL ____________ 87, SS.!}(). :33 l Stone. E. H ____________ (ah)__ 50:i Rtor~·. G. H------------------·- :iG2 Whiteside, G. B ______________ "267 \Vhitmo1·e. G. B_______________ :212 \\"iekl's:. G. L 1'l6 \\"Ude~·. A. Q ____________ (ab~ -- :92 Willems, Q ______________ (ab) __ 750 William;:;, L. H--- ------------- 463 Willis, B. 0------------------- "78G Wimmer, C. p __________ (ab) __ 103 Woimant, H ____________ (ab) __ ~82 \VoOllwa ru, J. S- ------------ O:'iS. 5G() Wynne, S. \V ___________ (:ab~ __ ~17 Y. Yorke. \V _______________ (ab~ __ 725 Yo1111ie, A. E______________ 453 0