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Volume XXXVI JANUARY 1938 Number 1 > 9 United States " Naval Medical Bulletin Published for the Information of Medical Department of the Navy ■ THE MISSION OF THE MEDICAL CORPS OF THE NAVY • TO KEEP AS MANY MEN AT AS MANY GUNS AS MANY DAYS AS POSSIBLE Issued Quarterly by the Bureau of Medicine and Surgery Washington, D. C. Vol. XXXVI JANUARY 1938 No. 1 UNITED STATES NAVAL MEDICAL BULLETIN Published Quarterly for the Information of the Medical Department of the Navy Issued by l^ j, DIVISION OP PUBLICATIONS THE BUREAU OF MEDICINE AND SURGERY A NAVY DEPARTMENT Compiled and published under the authority of Naval Appropriation Act for 1937-38, approved April 27, 1937 i UNITED STATES GOVERNMENT PRINTING OFFICE WASHINGTON : 1937 For sale by the Superintendent of Documents, Washington, D. C. See page 11for price Navy Department, Washington, March 20, 1907. This United States Naval Medical Bulletin is published by direction of the Department for the timely information of the Medi cal and Hospital Corps of the Navy. Truman H. Newberry, Acting Secretary. Owing to exhaustion of certain numbers of the Bulletin and the frequent demands from libraries, etc., for copies to complete their files, the return of any of the following issues will be greatly appreciated: Volume IX, 1915, No. 1. Volume X, 1916, No. 2. Volume XI, 1917, No. 3. Volume XII, 1918, Nos. 1 and 3. Volume XXIV, 1926, Nos. 1 and 4. Volume XXV, 1927, No. 1. Volume XXVII, 1929, Nos. 3 and 4. Volume XXVIII, 1930, No. 3. Volume XXXIV, 1936, Nos. 1, 2, and 4. Volume XXXV, 1937, No. 1. Subscription Price of the Bulletin Subscription should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. Yearly subscription, beginning July 1, $1; for foreign subscriptions add 35 cents for postage. Single numbers, domestic, 25 cents; foreign, 35 cents, which includes foreign postage. Exchange of publications will be extended to medical scientific organiza tions, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy, Washington, D.C. n TABLE OF CONTENTS Pig* PREFACE vn NOTICE TO SERVICE CONTRIBUTORS viu SPECIAL ARTICLES: Diabetes and Protamine Insulin. i By Elliott P. Joslin, M. D., Boston 1 J Compbessed-Air Illness. By Charles W. Shilling, Lieutenant, Medical Corps, United States Navy 9, Treatment or Hay Fever With Alum-Precipitated Pollen Extract. By Robert F. Sledge, Lieutenant Commander, Medical Corps, United States Navy 18 Malaria. By W. H. Michael, Commander, Medical Corps, United States Navy 29 Barbiturate Poisoning. By F. L. McDaniel, Commander, Medical Corps, United States Navy, and Robert A. Bell, Lieutenant, Medical Corps, United States Navy 32 Cahboxide Poisoning. By J. D. Blackwood, Jr., Lieutenant Commander, and E. B. Erskine, Lieutenant, Medical Corps, United States Navy 44 The Sulfanilamide Therapy op Gonorrhea. By R. H. Snowden, Commander, Medical Corps, United States Navy, and Robert A. Bell, Lieutenant Medical Corps, United States Navy 45 Sulfanilamide Treatment of Ludwig's Angina. By James E. Fulghum, Lieutenant, Medical Corps, United States Naval Reserve 68 Psychosis Precipitated by Sulfanilamide. By Bartholomew W. Hogan, Lieutenant, Medical Corps, United States Navy, and Philip J. McNamara, Lieutenant, junior grade, Medical Corps, United States Navy 60 Sulfanilamide Poisoning. By J. T. O'Connell, Lieutenant Commander, Medical Corps, United States Navy 61 Results of Sulfanilamide Therapy of Gonorrhea. By E. R. Hering, Lieutenant, Medical Corps, United States Navy 63 Chondrodystrophy Fetalis. By Willard S. Sargent, Lieutenant Commander, Medical Corps, United States Navy 67 The Cancer Problem in the United States Navy. By Otis B. Spalding, Lieutenant Commander, Medical Corps, United States Navy 74 m IV TABLE OF CONTENTS SPECIAL ARTICLES—Continued. Fig. Carcinoma op the Lung. By Irving J. Warmolts, Lieutenant, Medical Corps, United States Navy 79 Bronchogenic Carcinoma. By Irwin L. Norman, Lieutenant, Medical Corps, United States Navy, and William M. Sffliphant, Lieutenant, Medical Corps, United States Navy . - 89 CLINICAL NOTES: Krukenbergs Spindle. By Raymond W. Hege, Lieutenant, Medical Corps, United States Navy 95 Dental Neurosis. By V. A. LeGlair, Lieutenant, Dental Corps United States Navy. 97 Passive Algolagnia Masochism. By James E. Fulghum, Lieutenant, Medical Corps, United States Naval Reserve, Louieburg, N. C 99 Atypical Lobar Pneumonia. By A. J. Walter, Lieutenant, Medical Corps, United States Navy, and J. L. Holland, Lieutenant, Medical Corps, United States Navy 101 Atypical Meningococcic Infection. By W. H. Funk, Lieutenant Commander, Medical Corps, United States Navy 104 Tularemia. By Julian Love, Lieutenant, Medical Corps, United States Navy, and Alfred W. Eyer, Lieutenant, Medical Corps, United States Navy... 105 Neutropenia Following the Administration of Neoarsphen- amine. By Albert R. Behnke, Lieutenant, Medical Corps, United States Navy 108 NAVAL RESERVE: Symposium, Humphreys 111 NOTES AND COMMENTS: The Twelfth Surgeon General, United States Navy— The Fleet Hospital Ship-— Blunders of Plain Muscle —Treatment of Surgical Shock With Neo-Synephrin —The Common Cold —Cancer — Skin Irritation and Cancer in the U. S. Navy—Syphilis Prophylaxis — Articles on Professional Subjects —Articles of Special Merit, 1937— College of Physicians 115 BOOK NOTICES: The Practice of Medicine, Meakins —An Introduction to Medical Science, Boyd —Clinical Allergy, Manifestations, Diagnosis and Treatment, Rowc —Operative Surgery, Horsley and Bigger —Pre operative and Postoperative Treatment, Mason —Handbook of Orthopaedic Surgery, Shands and Raney —Injuries and Diseases of the Hip, Albee and Preston —Diseases of Infants and Children, Griffith and Mitchell—Medical Treatment of Cataract, Davis — The Ocular Fundus in Diagnosis and Treatment, Atkinson — Mi croscopical Technique, McClung— Flying Vistas, Jones —Dental Pharmacology and Therapeutics, Blayney — Essentials of Oral Surgery, Blair and Ivy 125 TABLE OF CONTENTS V PREVENTIVE MEDICINE: Pw Toxic Effects of Arsenical Compounds as Administered in the United States Navy, 1936. By C. S. Stephenson, Commander, Medical Corps, United States Navy, and E. H. Wingo, Chief Pharmacist's Mate, United States Navy 131 Anti-Tetanus Toxoid. By C. S. Stephenson, Commander, Medical Corps, United States Navy, and W. W. Hall, Commander, Medical Corps, United States Navy 150 Food Poisoning on Board the U. S. S. "Nevada" 162 STATISTICS: Health of the Navy 155 Injuries and Poisonings 158 Morbidity 159 Deaths 160 Mental and Physical Qualification of Recruits 161 PREFACE The United States Naval Medical Bulletin was first issued in April 1907 as a means for supplying medical officers of the United States Navy with information regarding the advances which are continually being made in the medical sciences, and as a medium for the publication of accounts of special researches, observations, or experiences of individual medical officers. It is the aim of the Bureau of Medicine and Surgery to furnish in each issue special articles relating to naval medicine, descriptions of suggested devices, clinical notes on interesting cases, editorial com ment on current medical literature of special professional interest to the naval medical officer, and reports from various sources, notes, and comments on topics of medical interest. The Bureau extends an invitation to all medical and dental officers to prepare and forward, with a view to publication, contributions on subjects of interest to naval medical officers. In order that each service contributor may receive due credit for his efforts in preparing matter for the Bulletin of distinct originality and special merit, the Surgeon General of the Navy will send a letter of commendation to authors of papers of outstanding merit. The Bureau does not necessarily undertake to endorse views or opinions which may be expressed in the pages of this publication. P. S. Rossiter, Surgeon General, United States Navy. vn NOTICE TO SERVICE CONTRIBUTORS Contributions to the Bulletin should be typewritten, double spaced, on plain paper, and should have wide margins. Fasteners which will not tear the paper when removed should be used. Nothing should be written in the manuscript which is not intended for publication. For example, addresses, dates, etc., not a part of the article, require deletion by the editor. The Bulletin endeavors to follow a uniform style in heading and captions, and the editor can be spared much time and trouble, and unnecessary changes in manuscript can be obviated if authors will follow in these particulars the practice of recent issues. The greatest accuracy and fullness should be employed in all citations, as it has sometimes been necessary to decline articles otherwise desirable because it was impossible for the editor to understand or verify references, quotations, etc. The frequency of gross errors in orthography in many contributions is conclusive evidence that authors often fail to read over their manuscripts after they have been typewritten. Contributions must be received at least 3 months prior to the date of the issue for which they are intended. The editor is not responsible for the safe return of manuscripts and pictures. All materials supplied for illustrations, if not original, should be accompanied by reference to the source and a statement as to whether or not reproduction has been authorized. The Bulletin intends to print only original articles, translations, in whole or in part, reviews, and reports and notices of Government or departmental activities, official announcements, etc. All original contributions are accepted on the assump tion that they have not appeared previously and are not to be reprinted elsewhere without an understanding to that effect and that editorial privilege is granted to this Bureau in preparing all material submitted for publication. Eben E. Smith, Editor, Commander, Medical Corps, United States Navy. vm U S. NAVAL MEDICAL BULLETIN Vol. XXXVI January 1938 No. 1 SPECIAL ARTICLES DIABETES AND PROTAMINE INSULIN » By Elliott P. Joslin, M. D., Boston Insulin was wonderful, spectacular, miraculous. Think of it, children as a result of insulin, instead of dying within the year of the onset of their disease, now have a life expectancy above 30 years. Coma, which used to carry off more than 60 percent of all the diabetics, today is acknowledged to be needless, and the mortality has dropped to about 10 percent, and in the better clinics even during an attack is almost as low. The age at death of diabetics as a whole has risen from 44 to 63 years. Truly, the metamorphosis of the disease diabetes is stupendous. A hint of what we may expect for diabetics in general has been furnished by the course of the disease in doctors during this same period. Some 300 of these have consulted me for diabetes and the comparison between the doctors and all patients for corresponding age groups shows that whereas the mortality between the ages of 25 and 39 years for doctors is 10 per 1,000, it is 45 per 1,000 for all diabetics. Even at later age periods doctors far exceed the average diabetic. A proper understanding of the disease should dispel coma and, as a matter of fact, but 3 percent of the doctors have succumbed to it in recent years, and there has not been a single death of a doctor in the group from diabetic coma since 1925. The average age at death for doctors generally, is 63 years, but for my diabetic doctors, 68 years. I shall never cease to be grateful to the Metropolitan Life Insurance Co. for the analyses by their statistical department of this group of doctors, because it indicates how much better the possibilities are for all diabetic patients and forces us to revise our measures of medical care. Furthermore, it should be remembered that these advances have been accomplished with regular insulin, dated from its first discovery when it was an unknown quantity, and do not depend on the more modern methods which have been introduced in the last 2 years. The factor which has accomplished so much for diabetics as a class is insulin, and for diabetic doctors in particular is insulin plus a knowl edge of the disease. That is the key to improvement in treatment. 'An Informal address delivered at the United States Naval Medical Center, Washington, D. C. Pub lished concurrently In the Military Surgeon. 1 2 JOSLIN —INSULIN THERAPY We must make the knowledge of diabetes more universal, so that in the first place patients who have it will be discovered more closely to the onset of the disease; second, that when they do acquire it they will be able to take advantage of all modern ways of alleviating it, and third, so that both public and patients will grasp the idea that there are simple measures which are now available for this purpose. Above all, however, stands insulin which more than anything else has brought this change about and therefore whatever will promote the use of insulin will improve the status of the diabetic. The greatest impetus to the extension of the use of insulin has been the discovery of protamine insulin by Dr. Hagedorn of Copenhagen. Already diabetics have caught the essential feature of this discovery, namely, that instead of injecting many doses of insulin each day, one injection will suffice. It is true this could not be accomplished at first with the protamine insulin as described by Doctor Hagedorn, but it is a fact today, because of the improvement in protamine insulin by combining it with zinc. The simplicity of treatment with prota mine zinc insulin as compared with regular insulin is obvious to all. Furthermore, it is safer because reactions on the average are less frequent and less severe, and as a rule are accompanied with a warning which the observant patient can recognize. The control of the diabetes with protamine insulin is far better than with regular insulin. Regular insulin acted for 8 hours or less and two doses would only protect the patient for two-thirds of the day. With protamine insulin the duration of action and consequently the protection are for 24 and more hours. The difference may seem slight at first thought, but when one considers the duration of life of the diabetic today which is certainly 12 years for all and for the average new case more likely 20 years, it is evident that for 4 to 7 years the diabetic treated with regular insulin would be out of control. And it is the uncontrolled diabetic with whom we know that complications are more frequent. Before the discovery of protamine insulin I almost shuddered at the thought of what might happen to the mass of diabetics who lived for years because of the complications they might develop, but now with protamine insulin this worry to a large extent can subside. The diabetic taking protamine insulin stores glycogen in his liver, his muscles, and skin, so that he resembles a normal individual. He begins his day with a normal blood sugar and without the handicap of a mild acidosis which took place to a greater or less extent during the night when his diabetes was uncontrolled with regular insulin. Indeed, being so closely like a healthy individual, when he exercises violently he is exposed to all the danger a marathon runner would undergo if he started his run fasting before breakfast. JOSLIN —INSULIN THERAPY 3 The original protamine insulin of Hagedorn acted for about 12 or 14 hours, so that most of us at first gave regular insulin before break fast and protamine insulin in the afternoon. The improvement through the addition of zinc has prolonged its action for a day or more so that little by little regular insulin has been rendered unnecessary. This advance in insulin therapy seems very simple but it dates back to Miescher's work in 1868 when he discovered protamines, and to Kossel's work in the final decade of the last century when he observed that a protamine was a protein precipitant. Still more recently it has depended upon a whole group of workers chiefly in the United States from Toronto to California. Protamine zinc insulin does not deteriorate as was first thought. I have tested specimens which worked perfectly well after 6 months. (Writing in July 1937, I can add that it will act much longer.) The potency of the insulin is in the precipitate and therefore great pains must be taken that the precipitate in the vial is carefully rotated so that the particles are uniformly diffused in the bottle before it is injected into the patient. It is wonderful to me how well the patients are able to do this, and it speaks much for the skill of the manufac turers, but I suspect it will not be long before even simpler prepara tions will appear. Incidentally I will add, we have tried protamine zinc insulin U80 and demonstrated that it works perfectly well. The technique of administration of protamine zinc insulin is simple providing one will bear in mind that its action is slow and persistent for 24 and more hours. One must remember that diet must be ad justed to this slow action. This means that much food should not be given at any one meal but rather spread out through the day with three meals and often three lunches, and second, that provision must be made for exercise. The diabetic patient taking protamine zinc insulin is so nearly normal that with exercise he bums up his carbo hydrate completely like a normal person, and therefore he must have carbohydrate to burn. One can lessen regular insulin by a few units if exercise is contemplated, but it does no good to lower protamine insulin by a few units because the effect of its reduction would not be manifest for many hours. Consequently, instead of lowering prota mine zinc insulin by a few units for adjustment to exercise, one gives extra carbohydrate. Exercise favors the combustion of carbohydrate with insulin, when either endogenous or exogenous insulin is available, and therefore this also must be borne in mind. I think that most of the reactions which I see from protamine insulin are due to the neglect of this feature. The patient is doing so well, is burning up his carbo hydrate so entirely that when he exercises and demands a little more glycogen there is none available and the blood sugar drops to an insulin reaction level. 4 JOSLIN —INSULIN THERAPY The dietitian has much more to do for the patient on protamine insulin than for the one on regular insulin. She can spread the meals throughout the 24 hours, an earlier breakfast and a later evening meal. She can see to it that the carbohydrate peaks at meals are reduced by- lunches between meals and upon retiring, thus averting night acidosis as well as reactions. Furthermore, by this spreading of the carbo hydrate throughout the day its utilization is improved. Protamine insulin is adaptable to any diet but on the whole we have adopted as an optimum about 150 grams, although there are frequent exceptions. In daily practice, protamine insulin is ideal for the fresh case of diabetes. In various publications I have reported a diabetic who was placed on protamine insulin taking 10 units the first day, 20 units the second day, 30 units the third day, and 40 units the fourth day, and have noted a quick response in lowering of his glycosuria and his blood sugar. Such patients, however, must be kept under close observation because from day to day the protamine accumulates and one must be alert to see when the dose required has been reached. Thus, one of our patients eventually took 50 units, but within 1 or 2 weeks, she dropped to 28 units, and several months later required but 12 units. Similarly, I have seen patients drop their peak from 60 units of prota mine insulin to 18 units and even less. With such early discovered patients, showing a high percentage of sugar in the urine, it is dramatic to have the sugar quantitated for the first 24 hours and show the patient exactly how much he voids. One of our patients reported having drunk 32 glasses of water before the diagnosis was made and I computed she was voiding 1 pound of sugar daily. When she saw its equivalent in a bottle and how day by day the quantity decreased to 0 you can imagine what an education in diabetes it was to her and what an example her case was to my diabetic class. There are certain elderly people who have taken regular insulin twice daily, 10-0-6 or even 10-0-10 units, and some of these patients can be changed over to the protamine zinc insulin with the dose of 20 units injected before breakfast. This is by no means always the case and never should one attempt to make a transfer from regular insulin to protamine insulin even when dealing with a mild diabetic unless he is under daily observation, even though not in the hospital. Cases like the two groups mentioned above, however, include the great mass of diabetics in the country and it is for them insulin should be used to the fullest extent, because if they will learn how to use it, certainly the danger of complications will drop. For patients who have taken insulin for years and have become expert in its use I hesitate to alter their course and change over to protamine zinc insulin as long as they are doing well. Otherwise I ask them to give us 1 or 2 weeks in the hospital and with the under JOSLIN —INSULIN THERAPY 5 standing that for a month or more after discharge they will cooper ate closely. Unless this is done, one is bound to get into difficulty and if one single case gets into difficulty it causes so much trouble and talk that the 90 and 9 patients who rejoice and are successful in their use of protamine insulin are forgotten. Please remember that these cases above described are often your best patients, the most reli able, and from whom you have learned much, and therefore have done so well that the chances for a betterment of their state are far less than for many others. Consider how much these patients have learned to adjust their daily life to three doses of regular insulin, often feeling free to lessen or raise the dose according to whether they plan to go to a dance or a dinner or both combined. They understand their reactions to regu lar insulin so well that they change it almost automatically according to their needs. Protamine insulin acts very differently, however, and it is not easy for these patients to learn how to adjust themselves to it and we doctors cannot tell them easily. In general when transferring from regular to protamine insulin the patient, who before the transfer might be taking regular insulin 24- 0-18, would continue the same morning dose of regular insulin, but would be given at the same time the remaining units of regular insulin employed during the day as protamine insulin. Dr. Priscilla White says that with the children she often doubles the balance of units for the day ; thus the above patient might be given a prescription of regular insulin, 24 units plus protamine insulin 36 units. Gradu ally thereafter, one attempts to lower the regular insulin and often to do so one must increase the protamine insulin to offset it. Fre quently one is gratified to find a patient who will react exceptionally well to the change and others in the course of months who will change from 10 units of regular insulin plus 40 units of protamine zinc insulin to 50 units of protamine zinc insulin. This of course makes treat ment very simple for the patient and will be still easier when U80 protamine zinc insulin is on the market. Our dependence upon the laboratory is even greater with prota mine zinc insulin than with regular insulin, but in a somewhat differ ent manner. Thus we use 24-hour specimens with the total glucose as guides of treatment much more than for the last few years. We have reverted to carbohydrate and glucose balances of the Naunyn and Allen eras. A patient might be taking 150 grams of carbohydrate and his urine is examined several times a day, some of the tests may have been yellow, or red, or orange with Benedict's solution. The patient gets discouraged, but if.it is demonstrated to him that these specimens represent a small fraction of the 24 hours, and the loss of glucose is very slight, he is reassured. The patient may void a single specimen of urine containing even 3 percent sugar but the aggregate 6 JOSLIN —INSULIN THERAPY glucose excreted very likely would not exceed 15 grams and if his diet contained 150 grams carbohydrate it would show that, as a matter of fact, he is 90 percent controlled. And this takes no account of glu cose formed from protein or fat. More and more I believe you will see that the 24-hour tests of urine for patients using protamine zinc insulin are valuable. The second specimen test is also most useful. For years we have utilized that in differentiating between coma and insulin reactions. The first specimen voided might be confusing, because during a reac tion the urine might show sugar, because hours might have inter vened since the bladder was emptied, yet a second specimen would be sugar-free. This is in contrast to diabetic coma, in which the second specimen invariably would contain sugar. Then, too, the second specimen is valuable for the patient on rising in the morning for the same reason. Repeatedly when we began with protamine zinc insulin we made mistakes and added regular insulin to the dosage with pro tamine insulin for the patient before breakfast, when if we simply had done a second test following the voiding of urine which collected during the night we would have found the patient sugar-free. Capillary blood sugars in contradistinction to venous blood sugars must be used far more extensively in this country than hitherto, not only for the sake of little children whose lives will be saved thereby, but because you can do more tests in one day with less annoyance to the patient. Furthermore, so often patients with protamine zinc insulin are sugar-free that one is in a quandary whether or not the dose should be changed, but with more frequent blood sugar tests one can act more rationally. The fasting capillary blood sugar is identical with that done upon venous blood. But after a meal one must make allowance for the capillary, blood to be higher. Arbi trarily we have put the difference at 0.03 (30 milligrams) percent, but of course this is not at all accurate. I cannot say enough for the necessity of a laboratory being avail able day and night and holidays for diabetics. In this way one can secure tests which are of the utmost help in treatment of coma. Presumably we have had at the New England Deaconess Hospital about as many diabetic comas to treat as anywhere and yet not one of my colleagues would forego the help which we receive from the tests of blood sugar, carbon dioxide combining power, salt, and nonprotein-nitrogen. We cannot help wondering how others (who have had less experience) can get along without these aids. We are as anxious to simplify treatment as anybody. We report every death of diabetic coma, even though he may not die for 3 or 4 months after treatment for the coma and from complications, because we want everyone to see that we lean over backwards in reporting deaths. We have had one death in 83 children we have treated for JOSLIN —INSULIN THERAPY 7 diabetic coma from 1923 to September 1936. One of our patients recovered from diabetic coma who was 75 years old, but the mortality for 338 cases has averaged 17.1 percent. One can practice guess medicine, but in general it is not justifiable. I make enough mistakes as it is without deliberately taking chances. Insulin reactions occur with protamine insulin but as a rule they come on more gradually and are less severe. They are distinctive because of two symptoms not met with in the course of reactions with regular insulin, namely, nausea and headache. It is particularly unfortunate that nausea is a symptom, because that is also a symp tom of diabetic coma and it makes the diagnosis between coma and a protamine insulin reaction more difficult and, at the same time, between these two and appendicitis. The nausea may persist for hours and greatly interferes with the taking of food. At such times one must place the patient on quite a free choice of liquids, but it is unlikely that he will take too much carbohydrate, because even if 500 cubic centimeters of orange juice or gingerale and 1 quart of milk are consumed during the greater part of the day, one is giving the patient only about 100 grams of carbohydrate. The headache is likewise disagreeable. Headaches are so uncommon in diabetes that this symptom is particularly annoying to the patients and interferes with a gain in health. Look out therefore not to overtreat the patient and thus make him as wretched as he made himself with under- treatment. Keactions from protamine insulin are more apt to occur in the mid- afternoon or during the night, and rarely just before breakfast. To avoid them, one takes 5 or 10 grams of carbohydrate between meals and also upon retiring. Sometimes patients take 5 or 10 grams of carbohydrate upon going to bed with 30 grams of cheese. Other patients take 30 grams of nuts, and still others, 180 grams of milk so that they will be afforded protection from an insulin reaction during the night. If regular insulin is given along with protamine insulin before breakfast one must look out that a reaction does not occur before the meal. Under such circumstances patients should take their regular insulin only 15 minutes before breakfast because the blood sugar is apt to be low at that time. Deaths from protamine insulin reactions certainly must be rare because I have seen but one in the literature, and none have occurred in our group of cases taking this form of insulin, although the present number certainly must reach 1,600 patients. Treatment of a reaction of any sort should be prompt and if re covery is delayed for more than one-half hour glucose should be given intravenously. If the reaction is really severe, glucose may be administered continuously in 5 percent salt solution during several 8 JOSLIN —INSULIN THERAPY hours. It is a fact that both with reactions due to regular insulin and to protamine insulin, recovery does not take place coincidently with a rise of the blood sugar to normal. The blood sugar may almost disappear during a reaction with either regular or protamine insulin, if one actually determines the fermentable blood sugar. Furthermore occasionally the blood sugar may fall to very low levels with children and sometimes with adults, and yet scarcely any symptoms may be noticeable. For a discussion of hypoglycemia, with literature, I would refer the reader to the sLxth edition of my monograph on diabetes. I think diabetes is a good disease for a great many reasons. First of all, one is dealing with facts. Carbohydrate in the diet can be calculated with reasonable accuracy and the excretion of sugar in the urine balanced against it. The blood sugar is normal or abnormal. The carbon dioxide combining power is normal, high, or low. If the patient does not do well there is a reason. Recently I had difficulty while transferring one patient to protamine insulin, and it turned out at this time catamenia came on and upset the program for several days. As you are aware diabetes is apt to be worse during menstruation and occasionally coma develops at such times. While struggling with this patient I had complaints from another that the protamine insulin was not working well, but before the day passed a telegram came and the patient apologized and said that she had made a mistake in measuring her insulin. A third instance of trouble developed and poor protamine insulin was blamed, but when the shingles broke out 2 days later the explanation of the difficulty was at hand. In the fourth instance, so soon as the site of the injection of insulin was changed so that absorption was more marked, the diabetes responded better to treatment. Finally a telegram was received that a patient had died of an insulin reaction. Persistence in following up this tragic telegram and sending a pathol ogist some 200 miles demonstrated to all that there was an absolute occlusion of the coronary artery showing the cause of death. There fore, when there is anything unusual in diabetes, I say there is a reason and we must always find out the reason because diabetes is a good disease. Prevention counts in diabetes. One cannot alter heredity but one can arrange for one's posterity. Two diabetics should not get married, because theoretically all their offspring would develop the disease. We should not say too much about this, because even if they did have 100 children only 44 of the hundred would live long enough to come down with the disease. The others would succumb to other causes before they reached the decade they were destined to show it. As you are aware, the onset of diabetes throughout the world appears quite uniformly in the same percentages per decade of life. If the SHILLING —COMPRESSED-AIR ILLNESS 9 heredity is less strong, of course, the percentage of those developing the disease would be correspondingly less. The inciting cause, moreover, in the hereditarily predisposed is well known. It is obesity which becomes increasingly manifest after the age of about 30 years. Be tween 60 and 70 years of age only one of my patients developed the disease who had been thin throughout his life. Statistics such as those collected by Dr. Matz of the Veterans' Bureau are ideal, because the follow-up of the patient is so perfect. A veteran acquires diabetes, and there is little doubt but he will draw a pension as long as he lives, and consequently there is no difficulty in tracing him. I think the work that Colonel Matz has done is most valuable along this line and that he has started something the importance of which none of us can foresee. Who would have thought that in his group of patients the duration of the disease would have already reached the average of 9 years? I look for great progress and advance in the treatment of diabetes from the studies which will be carried on in the Army and Navy. Of course, the number of cases will increase many, many times because two-thirds of all diabetes develop the disease above the age of 40 years, and as yet the veterans are only beginning to march past that landmark. Cooperation in diabetic treatment is just as important as coopera tion in the Army. Nothing can be accomplished of value without officer and private, doctor and patient, working hand in hand. But this principle extends further. A diabetic does not live to himself alone. If he lives safely he has health, but if he lives carelessly, he develops coma, hypoglycemia, or a multitude of complications. COMPRESSED-AIR ILLNESS i By Charles W. Shilling, Lieutenant, Medical Corps, United States Navy Introduction The purpose of this paper is to present an impartial review of all of the available literature on compressed-air illness. This material has been collected, translated, read, analyzed, and classified, and a brief review of its forms the basis of the paper. No new ideas, original studies, or unpublished researches are reported. The study has been divided into the following sections: History, cause, symptoms, treatment, prognosis, prophylaxis, and general bibliography. Immediately following the introduction there appears a list of those books and articles covering all phases of the subject i This work was made possible by the assistance given by N. J. Cahana, machinist mate, second class, U. S. Navy; Mr. Walter Oliver, Panama City; Mr. M. C. Roemer, Navy Yard, Washington, D. C.; and Mrs. C. W. Shilling in translating the various works, and by F. E. Lusk, first class pharmacist mate, U. S. Navy, in collecting the references. 24140—87 2 10 SHILLING COMPRESSED-AIR ILLNESS which are recommended for a general consideration of this entire field, although they do not, in every case, give the latest advances in all phases of this subject. Then, following each section there appears a double bibliography; the first being those references from which the ideas incorporated in this review have been taken, the second being references on the same phase of the subject but considered to be of secondary importance. At the conclusion of the paper, in order that the bibliography may be complete, there appears a list of references so general in their concept and treatment that they could not be included under any single heading, and which are considered to be valueless in a study of this nature. In order to focus our attention exclusively on compressed-air illness the articles covering the following commonly associated subjects have been excluded: 1. Accidents to divers other than compressed-air illness. —Under this heading are articles concerning asphyxia, blowing up, drowning, ex haustion, mechanical injuries and squeeze. 2. Oeneral articles on deep sea diving not primarily concerned with compressed-air illness. —This also includes all articles concerning diving suits, bells, caissons, diving ships, recompression chambers, salvage of sunken wrecks, and treasure hunts involving diving. 3. Ear conditions. —Although it is well recognized that increased air pressure affects the ears, inasmuch as this is not considered a part of compressed-air illness these studies have been excluded. 4. Oxygen poisoning. —These articles deal with poisoning caused by breathing high pressure oxygen, or with oxygen effects of high pressure air. 5. Normal physiology and pathology under increased air pressure. — Under this heading are the articles on the effects of increased air pressure on the pulse, blood pressure, blood volume, velocity of blood flow, vital capacity, metabolism, etc. Bibliography fob General Consideration. Bert, Paul. La Pression Barometrique; Recherches de Physiologie Experi- mentale. G. Masson, Paris, 1878. Bornstein, A. Erfahrungen uber pressluftkrankheit. Vrtljschr. f. gerichtl. med., Berlin, n. F. 44: 357-375; 1912. Bornstein, A. Physiologie und Pathologie des lebens in verctichteter luft. Bull. klin. Wchnschr., 51: 923-928; 1914. - Erdman, S. Aeropathy, or Compressed Air Illness among Tunnel Workers. J. A. M. A., 49: 1665-1670; 1907. Heller, R. Die caissonkrankheit (Eine Monographic). Schweiz. arztl. Mitt, a. Univ. Inst. Zurich., 357-419; 1912. Heller, R., Mager, W. and von Schrotter, H., Luftdruckerkrankungen met be- sonderer berucksichtegung der sogeannten Caisson krankheit. Wien 2 v. 8°, 1900. Hill, Leonard. Caisson sickness and the physiology of work in compressed air. Longmans, Green and Co., Neve York, 1912. SHILLING COMPRESSED-AIR ILLNESS 11 LeCaplain. Accidents de l'air comprime au cours des travaux de reconstruction •du viaduc d'Eauplet. Normandie med., Rouen, 30: 288-301; 1914. Keays, F. L. Compressed Air Illness. Ann. Labor Legist. Rev., N. Y., 2: 192-205; 1912. Kober and Hanson. Diseases of Occupational and Vocational Hygiene. Pub lished by Blakiston. , Martini, R. Delia Malattia dei Caisson. Med. d. lavoro., 24: 201-215; 1933. v] Oliver, T. Diseases due to Working in Caissons and Compressed Air. Diseases of Occupation, Chapt. I11. Pi y Lleonart, J. Paralisis de los buzos; el trabajo a altas presiones atmos- fericas. Bol. mens. d. Col. de med. de Gerona, 1-60; 1910. Waller, G. De ziekten der werklieden bij pneum, fundeeringen under boogeren luchtdruk (ook-caissonziekten genoemd), en baare voorbehoeding. 8° Amster dam. 1932. J Wright, W. and Brady, W. S. Compressed Air Illness or Caisson Disease. Forcheimer's Therapeutic of Internal Diseases. D. Appleton & Co., 35: 690-706; 1932. I. HlSTORY Classical historians record for us many stories of the employment of "naked" divers, even as early as 460 B. C. In the intervening cen turies men have continued to dive to great depths without aDy type of suit and even today in many parts of the world similar practices are employed by those engaged as pearl or sponge divers. From the days of Aristotle attempts were made to construct a satisfactory diving dress so that the divers could breathe under water. It was not until 1819, however, that a practical diving helmet was produced and not until 1837 that a satisfactory complete diving dress was made by Siebe of England. Diving bells were referred to as early as 360 B. C, but the first practical one was built by Taisner in the sixteenth century. In 1665 attempts, were made to recover portions of the Spanish Armada by the use of a diving bell. However, it was not until the introduction of compressed air by John Smeaton (1678) that the use of the diving bell became successful. The use of compressed air in the treatment of disease was proposed by Dr. H. Henshaw in 1664 but it was not until 1836 when Junod published his exhaustive study on the same subject that it became widely used. The pressure of the air used, however, was so low that compressed-air illness was impossible. Robert Boyle in 1670 was the first to observe gas bubbles in the blood as a result of sub jecting animals to suddenly decreased air pressure. ,* Compressed air was first used in a mining project by a French ongineer, M. Triger (1841), and he mentions symptoms experienced by the workers after their exposure to increased air pressure which were undoubtedly due to compressed-air illness. Similar symptoms were observed by the physicians Hamel (1820) and Colladon (1826) which they attributed to neuralgia. The first report of scientific value was published by two French doctors, Pol and Watelle (1845) who recog 12 SHILLING COMPRESSED-AIR ILLNESS nized clearly the nature of the illness and presented a complete dis cussion with many case histories. In addition to the well established use of compressed air in diving and mining, in 1850 it had its first use in pier building in England, and in 1879 in tunnel construction under the Hudson in the United States. With the increasing use of compressed air in construction there were many occurrences of this strange new illness, which was variously known as diver's palsy, diver's paralysis, caisson disease, aeropathy, "bends," and compressed-air illness. Among the workmen, accord ing to Aldrich (1904), the illness was known by various names, each usually significant of some prominent symptom. Thus we find "bends" for abdominal pain (loosely used for any attack), "chokers or chokes" for dyspnea or a choking feeling, "staggers" for vertigo, "itch," "prickles," or "lice" for pruritus of the skin, and "fits" for convulsions. Bibliography Aldrich, C. J. Compressed Air Illness, or Caisson Disease. Med. News, N. Y., 85: 1020-1024; 1904. Colladon, L. T. F. Relation d'une Descente en mer dans la cloche des Plongeurs Paris, 1826. Hamel. Bibliotheque de Genver. 1820. Pol, B. and Watelle, T. J. J. Memoire sur les Effets de la Compression de l'Air. Annal. d'Hyg. Publique et Med. Legale, Paris, 1: 241-279; 1854. Smeaton, John. Historical Report on Ramsgate Harbor, London, 70; 1791. Triger, M. Memoire sur un appareil a air comprime. Compte rendus Acad, des Sci. 13: 884; 1841. 11. Cause op Compbessed-Aib Illness From a study of the many theories advanced as to the cause of compressed-air illness it is evident that most of the authors were not familiar with the literature and so laboriously developed individual theories. The most unusual is that of Bouchard (1869) which has to do with the expansion of gas in the intestine causing rupture and fatal hemorrhage. Jaminent (1871) attributed the cause to exhaustion from excessive tissue-waste brought about by increased absorption of oxygen. MacMorran (1902) believed the cause to be due to hyper emia of the nerve centers from mechanical pressure and accumulated CO2 in the blood owing to imperfect interchange of gases in the lungs. Merget (1905) believes the condition to be due to air embolism from rupture of the alveoli upon rapid decompression. Abbamondi (1906) said that rapid compression caused tissue damage predisposing to compressed-air illness on final emergence. MacNaughton (1906) attributed the disease to frictional electricity encountered while exposed to compressed air. Conroy (1910) attributed the illness to "nothing else than a toxemia, due to excessive catabolism." SHILLING COMPRESSED-AIR ILLNESS 13 However, most of the theories as to cause fall under the following three classifications: 1, The theory of exhaustion and cold; 2, the theory of mechanical congestion with sequelae; and, 3, the gaseous emboli theory. « 1. The theory of exhaustion and cold has for its proponents Bouhy (1848), Barella (1868), Lampadarious (1891), and Woodward (1881). They said that when the pressure was reduced and the temperature of the air dropped there was produced a very marked exhaustion of the body system causing neuralgic and rheumatic symptoms. The spinal cord damage was the result of reflex action caused by "spon taneous refrigeration" of the whole system. 2. The mechanical congestion theory states, in general, that when the body is exposed to air pressure the peripheral blood vessels are compressed or collapsed by the pressure on the skin surface and the blood is driven into the visceral organs and especially those organs — the brain and spinal cord —which are protected by bony cases from this external air pressure. The sequelae which are the specific cause •of the illness are: "Black blood," "evolution of gas," "hemorrhage," "acute revulsive anemia," or "comparative stasis." "Black blood," held to be the cause by Gueard (1854), Limousin (1863), and Bauer (1870), was the blood deprived of its oxygen which was held in the congested internal vessels and caused a "stupefying action" on the tissues. The sequela, "evolution of gas," advanced as the cause by Boucquoy (1861) came very close to the true theory, but he says that the gas liberation is due to internal congestion followed by sudden release of pressure, and that it is only liberated in the internal organs and tissues. "Hemorrhage" was the cause advanced by Babbington and Cuth- bert (1863), and Febvre (1879). It was due to rupture of the dis tended internal vessels by the pressure of the blood being forced in from the periphera. "Acute revulsive anemia," according to Moxon (1881) and Twynam, (1888) was due to the great rush of blood from the congested internal to the empty external vessels upon rapid reduction of the external air pressure, thus leaving the internal organs a prey to dangerous anemia. "Comparative stasis" was the causative sequela supported by Smith (1873, 1894), Nixon (1889), Knapp (1891), Edelheit (1896), Snell (1897), and Porter (1907). This theory holds that the gorged internal vessels have become paralyzed due to overdistention and are unable to regain their elasticity when the external air pressure is released and the peripheral blood flow reinaugurated ; thus there is a comparative stasis existing in the internal organs which leads to tissue damage. Van Rensselaer (1891) supports this theory and also gives & most complete review of the entire literature on the cause of the 14 SHILLING COMPRESSED-AIR ILLNESS illness. Meigs (1885) says the disease is due to a combination of the foregoing causes. 3. The gaseous emboli theory, in one form or another, has had the following advocates: Boyle (1670), Musschenbrock (1755), Hoppe (1857), Francois (1860), Bert (1873), Leyden (1879), Cassaet (1886), Catsaras (1888, 1889, 1890), Zuntz (1897), Greenwood (1908), Grim- bach (1909), Oudard (1911), Hill (1912), and Keyser (1916). All authors writing since 1916 have accepted this theory and of course all of the authors mentioned in the introduction to this paper were ardent advocates of the gaseous emboli theory. Experimental work was performed by Oliver (1906) and Quincke (1910) to demonstrate the truth of bubble formation. The gaseous emboli theory is based on the fact that as the individual breathes compressed air, whether it be in a diving suit, bell, caisson,, or tunnel, the blood circulating through the lungs is exposed to a partial pressure of nitrogen and oxygen proportional to the air pressure, and takes up an extra amount of nitrogen and oxygen proportional to this increased pressure. As the blood circulates through the body the extra oxygen is used by the tissues but the extra nitrogen is not used, and gradually saturates all of the tissues until they are charged with nitrogen at the partial pressure existing in the air breathed. It is evident at once that there are two factors involved in this saturation, namely, the depth or degree of pressure and the length of time exposed to this pressure. If the air pressure is lowered slowly (decompression) then the process - is reversed and the nitrogen is given off through the lungs and equilib rium again established with atmospheric air pressure. But if decom pression is too rapid, the blood and tissues, which are supersaturated with nitrogen, are left with an internal partial pressure far above the external atmospheric pressure. Under these conditions the nitrogen' tends to leave the blood and tissues in bubble form and produce local or general blockage of the circulation; or as pointed out by Brooks (1907, 1907-08) they may produce painful pressure or tearing of the tissues. - The symptoms of the illness vary according to the location of these bubbles and the local tissue damage produced. Thus we have three principal factors involved in the production of compressed-air illness: Degree of air pressure to which exposed, length of time exposed to this pressure, and the length of time taken to come out from this pressure to atmospheric pressure. In addition to these we have certain physical predispositions having a seondary bearing on the production of the illness which are: Age. —The ideal age for air-pressure workers is considered to be between 20 and 40 years, for during that period the cardio-vascular system is at its greatest efficiency and is best able to withstand thfr trauma of taking air pressure. SHILLING COMPRESSED-AIR ILLNESS Systemic disease. —Individuals with any weakness, abnormality, or disease of the heart, lungs, or kidneys, or other general disorders are subject to caisson disease and are to be ruled out at the first examination. Degree of fatness. —As pointed out by Vernon (1907) and Boycott and Damant (1908), fat at body temperature dissolves more than five times as much nitrogen as an equal volume of water or blood plasma. Thus a fat man would be a poor risk since his tissues would not only con tain more nitrogen but also give it up more slowly because of the poor blood supply to adipose tissue, and thus be more likely to bubble formation during decompression. Alcoholic consumption.— All authors agree that alcoholics should be excluded from increased air pressure work because of the changed cardio-vascular responses produced by consumption of alcohol. ^-Fatigue or general malaise. —No man should be exposed to increased air pressure who feels below par physically, for careful history taking has demonstrated a definite relation between a feeling of indisposition and the incidence of compressed-air illness. For the same reason acute upper respiratory disease or other acute disease should exclude the individual until recovery is complete. / Gallivan (1907) points out that lowered vitality of any part means lowered metabolism and circulation and thus slower elimination of the nitrogen stored in the tissues of that part. In this connection it should be noted that during decom pression if the person, who has been working hard under pressure and thus saturating rapidly, vceases to exercise or becomes chilled there may be such a drop in the metabolism, heart rate and volume output, and velocity of blood flow that the excess nitrogen is not eliminated and bubble formation ensues. In addition to these physical causes Thomson (1913), O'Donnell (1929), and many others have pointed out that excessive dampness and foul or vitiated air are contributing causes of compressed-air illness. All of these points will be considered in more detail in the section on prophylaxis. Primary Bibliography Abbamondi, L. Researches into the causes which tend to bring about serious accidents to divers. J. Ass. Mil. Surg., U. S. Carlisle, 18: 170-184; 1906. Babington, T. H. and Cuthbert. Paralysis caused by working under com pressed air in sinking the foundations of the Londonderry new bridge. Dublin Quart. J. of Med. Sci., 36: 312-318; 1863. Barella, H. Du travail dans 1'air comprime. Bull, de l'Acad. Roy. de med. de Belgique, 2: 593-647; 1868. Bauer, L. Pathological effects upon the brain and spinal cord of men exposed to the action of a highly increased atmospheric pressure. St. Louis Med. and Surg. J. 8: 234-245; 1870. Bert, Paul. Communication sur les effects de l'air comprime. Bull, de la Soc. Med. de l'Yonne, 8:48-55; 1873. Bouchard. Pathogenie des Hemorrhagiea. Paris, 1869. 16 SHILLING — COMPRESSED-AIB ILLNESS Boucquoy, E. Action de l'air comprime sur l'economie humaine. These de Strasbourg, 1861. Bouhy. Annales des travaux publics de Belgique, t. 7; 1848. Boycott, A. E., and Damant, G. C. C. Experiments on the influence of fatness on susceptibility to caisson disease. J. Hyg., Cambridge, 8: 445-456; 1908. Boyle. New pneumatical experiments about respiration. Philosophical Transactions, 5: 2011-2058; 1670. Brooks, H. Caisson disease. Long Island Med. J., 1: 149-158; 1907 (Part I) and 1: 196-208; 1907 (Part II). . Brooks, H. An experimental study of caisson disease. Proc. N. Y. Path. Soc, 7: 58-87; 1907-8. Cassaet, J. E. T. De la pathogenie des accidents de l'air comprime. Bor deaux, 4°, 1886. Catsaras, M. Recherches cliniques et experimentales sur les accidents sur- venenant par l'emploi des scaphandres. Arch, de neurol., 16: 145-194; 1888, 18: 80-109; 1889, and 19: 48-77; 1890. Conroy, P. Etiology of caisson disease. Maritime M. News, Halifax, 22: 330- 334; 1910. Edelheit, S. Physikalische Erklarung der Caisson-krankheit. Aertzl. Centr.- Anz., Wien., 8: 257; 1896. Febvre, Alphonse. Experiences comparatives sur la decompression brusque, et sur l'injection d'air dans les artères. Nancy, 77: 1-39; 1879. Francois. Des effect de l'air comprime sur les ouvriers. Ann. d'Hygiène. 14: 289-319; 1860. ^ Gallivan, J. V. The etiology of caisson disease. Long Island Med. J., 1: 181- 184; 1907. Greenwood, M. Physiological and pathological effects which follow exposure to compressed air. Brit. Med. J., 1: 914-918; 1908. Grimbach, R. Zur kasuistik der pneumatischen erkrankungen. Zentralbl. f. innere. Med., Leipz., 30: 1169-1176; 1909. Gucrard, A. Note sur les effects physiologiques et pathologiques de l'air com prime. Ann. d'Hygiène, 1: 279-304; 1854. Hill, L. An address on compressed air illness and experimental research. Brit. Med. J., 1: 348-353; 1912. Hoppe, F. Ueber den einfluss, welchen der wechsel des luftdruckes auf das blut ausubt. Arch. F. Anat. Phys. und Wissensch. Med., Leipz., 24: 63-73; 1857. Jaminent, A. Physical effects of compressed air. Monograph. St. Louis, 1871. Keyser, T. S. Compressed air disease with notes on a case and discussion of etiology from the standpoint of physical laws. Cleveland Med. J., 15: 250-255; 1916. Knapp, C. P. The caisson disease. LeHigh Valley Med. Mag., 3: 1-12; 1891. Lampadarios. Accidents arrivant aux pecheurs d'eponges. Cited from Van Rensselaer. Leyden, E. Ueber die durch plotzliche Verminderung des Barometerdrucka enstetehende Ruckenmarks-Affection. Arch f. Phychiato., Berlin, 9: 316-324; 1879. Limousin. Action de l'air comprime, apoplexie de la moelle epiniere. Union Med. de la Gironde, 1863. MacMorran, A. H. M. Observations on caisson disease and its prevention. Brit. Med. J., Lond., 1: 1018-1020; 1902. MacNaughton, G. W. F. Frictional electricity; a factor in caisson disease. Lancet, London, 2: 435-436; 1906. SHILLING COMPRESSED-AIR ILLNESS 17 Meigs, A. V. Caisson disease. Med. News, Phila., 47: 589-592; 1885. Merget, M. Death of a diver from air embolism. Lancet, 2: 1738; 1905. Moxon. Croonian Lectures. Brit. Med. J., 1: — ; 1881. Musschenbrock. Collection academique, 1755. Nixon, C. J. Drivers' paralysis. Dublin J. M. Sc., 87: 376-380; 1889. O'Donnell, F. J. Caisson disease as experienced in construction of Liffey tunnel. (1926-1928) Irish J. Med. Sc., 6: 618-622; 1929. Oliver, T. La maladie des caissons. Bull. Med., Paris, 20: 437-439; 1906. Oudard. Accidents de decompression, relation d'autopsie. Arch, de med. Nav., Paris, 96: 63-72; 1911. Porter, W. H. Compressed and rarefied air illness. Diet. & Hyg. Gaz., 23: 135-144; 1907. Quincke, H. Experimentelles zur Frage der Luftdruckerkrankungen. Ver- handl. d. deutsch. Kong. f. innere Med. Wiest., 27: 250-253; 1910. Quincke, H. Experinientalles uber Luftdruckerkrankungen. Arch. f. exp. Path. u. Pharm., Leipz., 62: 464-493; 1910. Van Rensselaer, H. The pathology of the caisson disease. Med. Record, N. Y., 40: 141-147; 1891 (Part I.), 40: 147-150; 1891 (Part 11.), 40: 178-182; 1891 (Part 11I.). Smith, A. H. The effects of high atmospheric pressure, including the caisson disease. N. Y. and Brooklyn Bridge Co., 8°, 1873. ,♦Smith, A. H. Caisson disease. Med. Record, N. Y., 45: 130-133; 1894. Snell, E. H. The Blackwall tunnel from a medical point of view. Hospital, London 22: 126- ; 1897. Thomson, T. K., An unsuspected cause of caisson disease. Tr. 15 Internat. Cong. Hyg. & Demog.. Wash., 3: 608-610; 1913. Twynam, G. E. A case of caisson disease. Brit. Med. J., 1: 190; 1888. Vernon, H. M. The solubility of air in fats, and its relation to caisson disease. Proc. Roy. Soc. Lond., 79: 366-371; 1907. Woodward, C. M. History of the St. Louis bridge. St. Louis, 1881. Zuntz, N. Zur pathogenese und therapie der durch rasche Luftdruckanderungen erzengten Krankheiten. Fortschr. d. Med., Berlin, 15: 632-639; 1897. Second Bibliography Altschul, A. Beitrag zur Kasinstik der Taucherkrankheiten. Wien med. Wchnschr. 45: 1977-2020; 1895. Citroen, S. Over het ontstaan van caissonziekte. Nederl. Tijdschr. v. Geneesk., Amst., 1: 1916-1924; 1908. DeVeaux, O. F. Observations on caisson disease. Maine Med. J., 21: 138- 141; 1930. Feilchenfeld, L. Zur Begriffsbestimmung des Unfalles. Arztl. Sachverstandi- genztg., 9: — ; 1907. Gruber, M. Zur Aetiologie der Caissonkrankheit. Oesterr. San.-Wes., Wein., 7: 111— ; 1895. Hepburn, M. L. Caisson disease. Brit. Med. J., Lond., 1: 1179; 1902. McWhorter, J. E. Etiological factors of compressed air illness. Am. J. Med. Sc., 139: 373-383; 1910. VonSchroetter. Zer pathogenese der sogenannten Taucherlahmung. Verhandl. d. deutsch. Path. Gesellsch, 8: 136-138; 1905. Sparr, R. Ein Beitrag zur Lehre von der Caisson-myelitis. Kiel, 8°, Alsfeld, 1910. 18 SLEDGE—HAY FEVER THERAPY TREATMENT OP HAY FEVER WITH ALUM-PRECIPITATED POLLEN EXTRACT By Robert F. Sledge, Lieutenant Commander, Medical Corps, United States Navy The history of hay fever begins with Botallus, who in his writings on the Duties of the Doctor, published in 1565, gives an account of the ill effects, headache, sneezing, and coryza, produced by smelling roses. Following Botallus, the next step forward did not occur until 1819, when John Bostock read a paper at a meeting of the Medical- Chirurgical Society of Boston giving a minute and accurate clinical description of his own case of hay fever. Bostock, in his second paper, read in 1828, referred to his malady as "summer catarrh" and thought that the condition was due to heat and sun rays. Also, in this second paper, the term "hay fever" appears for the first time in medical literature. Elliotson did not agree with Bostock as to the causation of hay fever, and in 1831 he gave a lecture at St. Thomas Hospital in which he referred to flowers and pollen as the cause. In 1870 Dr. George Moore claimed credit for the discovery of what he called the pathognomonic sign of the disease, i. e., excessive cold ness of the tip of the nose. About this time Von Helmholtz ad vanced the opinion from experiments on himself that the condition was due to "certain vibrio-like bodies (infusoria)", and thus the bacterial theory of the disease was born. Due to Von Helmholtz's standing in the scientific world, the microbic theory of the disease became very popular, thereby retarding the discovery of the real causation. Dr. Swett, an American, in 1852 gave an account of an "autumnal catarrh"; and as early as 1854 Morrill Wyman described the ailment in his clinical lectures at Harvard. Charles Harrison Blackley, a physician of Manchester, England, was the outstanding investigator of hay fever during the nineteenth century. By many experiments he proved that hay fever was due to the pollen of grasses. He produced hay fever by placing pollen in fhe nose of hay-fever subjects during the months when pollen was not usually present in the air. He rubbed pollen into the skin of the arm and leg and produced violent reactions. This is the first record of skin tests made with pollen. Blackley also made pollen counts and showed that pollen had their greatest concentration in rural sections. In 1881 Dale, of Pittsburgh, advanced the idea that hay fever was due to a pathological condition in the nose, that cer tain sensitive areas were responsible for its initiation, and that treat ment should be directed locally to the nose. It was not until 1903 that the controversy as to the etiology of hay fever was finally settled by the work of W. P. Dunbar and the germ and nasal theorists were converted. Dunbar extracted an albuminous substance from pollen capable of producing symptoms of hay fever in susceptible people which he SLEDGE—HAY FEVER THERAPY 19 thought was a toxin. He then attempted to elaborate an antitoxin by injecting horses and other animals with increasing doses of pollen, endeavoring to duplicate in hay fever the beneficial results of anti toxin in diphtheria. The serum was patented and marketed under the trade name Pollantin. Not long after this, "Weichardt introduced Graminol, a serum obtained from herbivorous animals that had not ))een intentionally immunized, the idea being that such animals would automatically "create the antitoxin" from eating the various grasses. Neither of these sera was of much value in treatment, although this method of therapy was the one of choice for many years. The cur rent method of therapy followed the work of Noon, who published -a paper in 1911 reporting the results obtained by subcutaneous injec tions of pollen extracts. The concepts of Noon and Freeman, as reported in this paper, led to the treatment of pollinosis on a scien tific and practical basis. Noon's work, interrupted by his death, was carried on by Freeman. Following a paper by Noon and Freeman, many other writers reported their experiences with polen-extract therapy. In 1934 Harrison (1) published the results of experiments on guinea pigs with alum-precipitated pollen extracts. Guinea pigs were sensitized by injecting an aqueous extract of giant ragweed pollen, and then attempts were made to desensitize them with alum- precipitated pollen extract. Harrison found that alum-precipitated pollen extract was a more certain sensitizer than was the aqueous 'extract. He further found that alum up to 0.3 percent did not in terfere with desensitization, but that alum in concentrations of 0.6 and 0.8 percent definitely retarded or prohibited desensitization. Caulfeild (2), in July 1936, published a report confirming that part of Harrison's experiment relating to alum-precipitated pollen extract being an efficient sensitizing agent. In the fall of 1934 Har rison suggested that we treat some of our hay-lever patients with alum-precipitated pollen extract and furnished the following formula for the manufacture of the extracts : To one volume of the pollen add three volumes of ether ; shake well, allow to settle, decant the supernatant ether, and discard. Repeat this operation three times. After the third extraction decant all ether possible and remove the remainder by evaporation in a warm (not hot) water bath. The pollen is now ready for extracting. Solution no. 1: Extracting fluid NaCl grams.. 2. 5 NaHCO. do 2. 7 Aqua dist. (qs) cubic centimeters.. 1,000.0 Solution no. 2: Solution no. 1 parts 55 Glycerin, C. P do 45 Solution no. 2 is designated the extracting fluid and is filtered through a Berkefeld filter and tested for sterility. 20 SLEDGE—HAY FEVER THERAPY Add two grams of pollen to every 100 cubic centimeters of extracting fluid. Allow this to stand for 10 to 14 days at room temperature with occa sional shaking. It Is now filtered, first through coarse filter paper to remove as much pollen debris as possible, then through a medium Berkefeld filter. The extract Is tested for sterility by aerobic and anaerobic cultural methods. We have been combining the various pollens from the spring grasses in one extract and the ragweed in another, as : Spring type Orchard grass- Sweet vernal grass June grass Timothy Red top English plantain Extracting fluid . 4.0 Cubic centimeter! 200.0 Fall type Oram 1. 00 Ragweed, common 2. 0 . 60 Ragweed, giant 2. 0 .50 . 2.00 .50 .50 5766 Cubic centimeter) Extracting fluid 250.00 The pollen of Bermuda grass, and, at times, any desired combina tion of other pollens, may be prepared as a separate extract for treatment of particular cases. This extract contains approximately 20,000 pollen units per cubic centimeter, the pollen unit in this in stance having been arbitrarily chosen as the equivalent of 0.001 mgm of pollen based upon the amount of nitrogen per cubic centimeter as determined by the Kjeldahl method. Assuming that the finished extract contains 20,000 pollen units per cubic centimeter, the dilu tions are made in the following manner : 10 cubic centimeters of 20,000 unit extract plus 10 cubic centimeters ex tracting fluid equals 10,000 units per cubic centimeter. 2 cubic centimeters of 20,000 unit extract plus 18 cubic centimeters extract ing fluid equals 1,000 units per cubic centimeter. 0.2 Cubic centimeter of 20,000 unit extract plus 19.8 cubic centimeters of extracting fluid equals 100 units per cubic centimeter. Prepare a 10-percent solution of potassium aluminum sulphate in distilled water. Filter through Berkefeld filter and test for sterility. This is added to the various dilutions of pollen extract so as to give 0.25 percent of alum. Schedule of doses of alum-precipitated pollen extract as used at the V. S. Naval Medical School Deso no. Vial, units per cc Amount in co Units Dose no. Vial, units per cc Amount in cc Units 100 100 100 1,000 1,000 1,000 1,000 0.05 . 10 .23 .035 .00 .10 .19 5 10 20 35 60 100 190 8 10,000 10.000 10,000 20,000 20,000 20,000 0.035 .07 . 135 .13 .25 .80 350 700 1,Sju 2,600 5,000 6,000 9. 8. 10 11 12 6 13 7 The schedule of doses, as listed above, was agreed upon by Harrison and Lt. Comdr. F. M. Rohow, Medical Corps, United States Navy. SLEDGE—HAY FEVER THERAPY 21 It is only a guide to treatment and must be varied according to the needs of the patient and whether or not reactions occur. The dose in cubic centimeters is very small so as to give a minimum amount of alum. The total amount of alum for a full course of spring and fall treatment is less than one-quarter gain, distributed over a period of several months so there is no danger of cumulative effects. We have not exceeded 2,600 units of the spring, and 6,000 units of the fall type, as a maximum dose, and have found this dosage sufficient to give complete relief in the majority of cases. In the District of Columbia we begin treatment for the spring type of hay fever about April 1. Treatments are given twice weekly until the maximum dose of 2,600 units is reached, after which treatment is given weekly until about the middle of June. In the case of fall hay fever, we start treatment about July 1 ; the injections are given biweekly until a dose of 6,000 units is reached, and thereafter treatment is given once a week until frost. Due to the slower rate of absorption of alum-precipitated pollen extract, we expected to accomplish the following beneficial results by its use: (1) An increase in therapeutic efficiency due to the constant and even rate of utilization by the patient ; (2) an abolition of con stitutional reactions, or at least a reduction in frequency and severity ; (3) a decrease in the number and frequency of treatments required. The first cases treated with alum-precipitated pollen extract received the initial treatment after the beginning of the hay-fever season in the fall of 1934 under the supervision of Rohow. There were only five of these cases, so the dosage, reactions, if any, and the results of the treatment will be given in detail. Case 1.—Mrs. C. J. M. Complaint : Hay fever yearly, beginning on or about August 15 and continuing until after frost. Skin test gave the following reac tion : Ragweed, common, 4 plus ; ragweed, giant, 3 plus ; and 4-plus reaction to the following grasses: Orchard, June, sweet vernal, timothy, and redtop. Patient denied having symptoms of hay fever in the spring and early summer. Treatment was begun with alum-precipitated ragweed pollen extract on August 10 and continued as follows: Data Unit of pollen per co 1 Amount in cc Unit dose Remarks Aug. 10, 1934 100 0.05 5 Headache and local reaction lasting 24 hours. Aug. 13, 1834 100 .15 15 No reaction. Aug. 16, 1934 1,000 .04 40 Local reaction lasting 24 hours. Aug. 20, 1934 1,000 . 10 100 Do. Aug. 23, 1934 1,000 .24 240 Do. Aug. 27, 1934 10,000 .05 500 Do. Aug. 30. 1934 10,000 .05 600 No reaction. Bept. 4, 1934 11).000 .05 500 Do. Sept. 8, 1934 10,000 .05 500 Do. 8ept. 10, 1934 10,000 .05 500 Do. Sept. 17, 1934 10,000 .06 500 Do. Oct. 1, 1934 10.000 .06 600 Do. Oct. 8, 1934 10.000 .05 500 Do. 11 unit equals 0.001 mgm of pollen. 22 SLEDGE —HAY FEVER THERAPY In this case not more than 500 pollen units were given as the maximum dose- because treatment was started after the beginning of the hay-fever season. Although this patient had an occasional attack of sneezing, the treatment from her standpoint was highly successful. Cast 2.—Miss G. Du V. The usual history of hay fever was obtained. Skin test gave a 4-plus reaction to common ragweed ; a 1-plus reaction to giant rag weed; 4 plus to redtop and timothy; and 3 plus to orchard grass. Treatment was started on August 11. Unit of pollen per CO. Amount in on. Unit Remarks Aug. 30, 1934.... Sept. 5, 1934 Sept. 8, 1934 Sept. 11, 1934... Sept. 15, 1934... Sept. 20, 1934... 100 100 1,000 1,000 1,000 10,000 1,000 1,000 1,000 1,000 1,000 1,000 0. 05 .15 .04 . 10 .24 .08 .24 . 24 .24 . 24 . 24 .24 15 40 100 240 500 210 210 240 240 240 240 Local reaction at site of injection lasting 24 hours. Local reaction; 36 hours. Do. Do. In addition to the local reaction patient devel oped hives which lasted about 3 hours. Mild constitutional symptoms with hives rapidly subsiding. No reaction. Do. Do. Do. Do. Do. Although this patient had a local reaction about the site of inoculation for the first six injections, and mild constitutional reactions with the fifth and sixth treatments, she obtained so much relief she desired to continue her treat ment. Also, this patient requested treatment in the fall of 1935 and 1936, and had no further reactions. It is believed that the mild constitutional reactions in this ease were the result of too rapid an increase in dosage or the time Intervals were spaced too close together. Case 8.—Mr. W. E. L. Gave a typical history of fall hay fever beginning about August 15. Skin tests gave 4-plus reactions to the common and the giant ragweed. There was no reaction to the spring grasses. Treatment with alum-precipitated pollen extra began on August 27, 1934. Date Unit of pol len per cc Amount in cc Unit dose Remarks Aug. 27, 1934 100 100 1,000 0.05 .15 .04 .10 .24 .05 .06 .05 .05 .05 5 15 40 100 240 500 500 500 500 500 No reaction. Do. Do. Do. Do. Do. Do. Do. Do. Do. Aug. 30, 1934 Sept. 4, 1934 Sept. 6, 1934 l.ooo Sept. 10, 1934 1,000 10,000 10.000 10,000 10,000 10,000 Sept. 13, 1934 Sept. 17, 1934 Sept. 20, 1934 Sept. 25, 1934 Sept. 27, 1934.. It will be noted that the season was well under way when treatment was begun and that the doses were administered at frequent intervals and with rapid increase in amount without reactions occurring. The patient experienced marked relief of symptoms. SLEDGE— HAY FEVER THERAPY 23 Case 4.—Mr. P. It. Appeared for treatment September 6, 1934, with all the symptoms of hay fever present Treatment with alum-precipitated ragweed extract was begun on day of reporting. Date Unit of pol len per so Amount in cc Unit dose Remarks Sept. 6, 1934 100 100 1,000 1,000 1,000 10,000 10,000 10,000 10,000 a 05 5 I5 40 100 240 500 500 600 600 No reaction. Do. Do. Do. Do. Do. Do. Do. Do. Sept. 9. 1934 .15 .04 .10 .24 .05 .05 .05 .05 Sept. 18, 1934. Sept. 21, 1934. Sept. 24, 1934 Sept. 28, 1934 Oct. 1, 1934 Oct. 8, 1934 Although this patient was suffering from hay fever before treatment was begun and had surpassed his threshold of tolerance from absorption from the mucous membranes, he gave no local or constitutional reactions even though the doses were increased rapidly and given at short intervals. The patient received marked relief from symptoms. Case 5.—Miss H. P. This case was very similar to case no. 4. The treatment was begun on September 6, 1934, and ended October 8, 1934. There were neither local nor constitutional reactions. There was marked relief from symptoms. This patient has been treated with alum-precipitated pollen extracts of the spring and fall groups for the years 1935 and 1936, with complete relief. As the results of treatment of these five cases were so satisfac tory, even though treatment was not started until late in the season, we decided to use this preparation in the treatment of all our cases, both spring and fall types, for the season of 1935. The same formula was used for 1936. Many of our cases received treatment for both the spring and the fall type of hay fever during the seasons 1935 and 1936. Table I shows the results of treatment with alum-precipitated pollen extract of some of our cases of the spring type and Table II the fall type. The treatment in a number of cases was not completed, due to trans fer, illness of some nature other than hay fever, etc., hence are not included in the report. Some of these patients were supplied with extract which was given at other hospitals or naval stations after they had left this locality. We have received some favorable individual reports from these patients, but no accurate follow-up data has been kept. In our series the following cases merit individual comment : Case 6.—Mr. W. D. B. Tolerated the increase in doses as in table of doses without trouble until reaching 2,600 units on May 6. Within 30 minutes follow ing the dose of 2,600 units the patient had a rather severe reaction characterized by lacrimation and itching of the conjunctivas, sneezing, rhinorrhea, and itching of the mucous membranes of the nose, tingling and Itching of the body surface, and a typical asthmatic attack. Treated with adrenalin, with rapid disappear ance of symptoms. Following the constitutional reaction, the next dose was reduced to 350 units and then gradually increased to 900 units and held at this dose for the remainder of the season. 24 SLEDGE —HAY FEVER THERAPY is w £7 5. s 1 2 tj I SI ' 3 D B £ M is I a ■ £s * — 4, a, c L. B MM siii u -til 5 a 3 3 I B B 3 aI c5 5= ~ § S°l, sill 2 » 5 ^ C ■C3 c . 11 J 0 Eg £«" e — si 8" o o .2 * ■ 1- * ^ 3 iI « £3?E IFI fill (rt of ss is E aj p o o OO O a s <i £ Bg p 3*3^8 oS E be c 3. i^.4i5 won B»q oa o E^E-JS1frO 5 » Et=E_ bS£ fi» «l2sE,'fe oagfi&sf ill* o o o O ' Srfl Co— O tb 20 uaits. iid not rc- •tion with \ B i i o O s,< itutional local reaction bi Constitutional i tion Apr. 2», 1'j iction May 8, 1»1 itutional reaction I 9 ■ * - a Si " 9 CTJI.2 sajlll d c all 3*1 S3 § §83 aoO t" ,o ©<tf 25 B{ -• - :' w - - j © oir^ corf o «'dc{ off I? 3 E£g K n '< H ifII sasg oooo r--,o r- t—r- II ej*3 8« i>3 o3 11 E£g li5 gg § gss 8 8g§ 82 28 | KR8 8 g WW <M ' ' OJ O "i >i M" Ci M 0i 3^ a — c4 CVC- 31 " 0 0(i f*:c-3co c»cs=i |« « " loI aCO>O a a U L L SLEDGE —HAY FEVER THERAPY v. 5 1 * = * * S3 - = S.2 ho 38 8 8 5 S 5 S jr.i - -~- -3.2 I S32-5 1 II >>Sj Jul 3 = "1"-* s sis a a sssss 8 24140—37- 26 SLEDGE— HAY FEVER THERAPY S 2 H 3 - e = 9 134 «alj ga BHI1 -it c5? E 5 £7 -a = c e B c * 3 = 5 §s fifiS Ii If J-Sfl •2 3 Q c ^<5 s § z SLEDGE —HAY FEVER THERAPY 27 Cu-xe 8.— Miss H. P. (same as rase 5 of 1!)34 series). Had a mild constitutional reaction on April 19 following a 2(i-unit dose. The 20-unit dose was repeated on April 23 without symptoms, after which the regular increases were given with out producing reactions. It is believed that the reaction in this case was due to the accidental injury to a blood vessel or lymph channel, causing a too rapid absorption of the pollen extract. Case 9. —Mrs. A. G. H. Suffered with "rose cold" every spring since a girl. Skin tests gave marked reactions to .lune grass, lamb's-quurters, orchard grass, plantain, redtop, sweet vernal grass, and timothy. Negative reactions were obtained to all the tree pollens and a moderate reaction to both ragweeds. Treat ment with pollen extract tnot alum-precipitated) on two previous occasions without benefit. Had ionization (or iontophoresis) of nasal mucosa in France, with slight improvement for the remainder of the season. This patient was markedly sensitive, as shown by violent skin reactions occurring within 2 minutes by the scratch method. Treatment was started with alum-precipitated pollen extract 20 days earlier than usual. This early start was made in order that a more gradual increase of dosage could be given, yet giving sufficient time to reach the maximum dose before the beginning of the hay-fever season. She tolerated the gradual increase without even a local reaction, and there was no reaction of any kind until May 29, when she had a mild constitutional reaction following the twenty-first dose. She reached the maximum of 2,t500 pollen units on May 4, after which date she received three doses of 2,t500 units without trouble, but on the fourth dose of 2,t500 units the reaction occurred. It is believed that this reaction was precipitated by overfatigue, for the patient had been very busy the week preceding superintending the storage of her household effects. The following doses were not reduced and were tolerated by the patient without ill effects. Case 10. —Mr. J. W. This patient was one of those extremely sensitive indi viduals, so the initial dose was 2.5 pollen units instead of the usual 5 units. The increases were more gradual than in the table of doses. Following the (50-unit dose the patient asked that he be given a certificate requesting that he be excused from gym classes, as the exercise made his arm quite red and painful. Thinking probably the symptoms were exaggerated, the request was not granted. Three days after the 60-unit dose he was given 100 units, and again he complained of a sore arm. The next dose, 190 units, produced a mild constitutional reaction, and it was realized that the patient was not exaggerat ing his sore arm. He was excused from gym class and treatment continued. On reaching 1.200 units, patient again complained of a red and painful arm, so this dose was repeated a second and third time, then the doses gradually increased. Case 14— Mrs. I). B. B. This patient suffered a local reaction with 350 pollen units. This dose was repeated, followed by a more gradual increase. Ou May 8 the patient received 1,200 units, and within 30 minutes had a mild constitu tional reaction. She next received 1.500 units, then 2,(300 units for the re mainder of the season without reactions. Case 27.—Mrs. I'. A very mild constitutional reaction with 5,000 units occurred on August S. The dose was then reduced to 4.0IH) units, given at weekly intervals, without further reaction. Case 33.—Mr. P. B. On August S there was a mild constitutional reaction with 2,000 pollen units. The dose of 2,000 iMillen units was repeated on August 11 without reaction. On August 18 the patient again had an extremely mild constitutional reaction, consisting of a tickling sensation in the nose and throat, 28 SLEDGE —HAY FEVER THERAPY with an increase of nasal secretions, with a dose of 4,000 units. The 4.000-uuit dose was repeated, then doses were increased by 500 units per dose until the maximum of 6,000 units was reached. Cage 37.—Miss B. S. Had a mild constitutional reaction with 1,000 units on August 14, consisting of a hacking cough and general itching of the body. The patient stated that the cough was due to a tickling sensation in the chest. Hives and urticaria were absent. Symptoms subsided within 1 hour without treatment. The dose of 1,000 units was repeated August 18, 21, and 25 without recurrence of symptoms. Following this, the dose was gradually increased and reached 2,000 units on September 8, at which time the patient again had the same type of reaction as described above, except that on this occasion hives appeared over chest and neck. No treatment was necessary. On Septem ber 11 she received 2,000 units and on September 15, 1,900 units; and eac* time a milder reaction occurred. Thereafter, 1.800 units were given without reaction. In this case the dose of aluui-precipitn led pollen extract plus the absorption from the mucous membranes surpassed the patient's tolerance, producing the reactions. Even though this patient received comparatively small doses of alum-precipitated pollen extract, she had only an occasional attack of tickling of the mucous membranes of the nose and throat followed by sneezing. She was highly pleased with the results of the treatment. While the treatment of hay fever with alum-precipitated pollen extract leaves much to be desired, it gives better results in our hands, in the short series of cases treated by this method, than with the non-alum-precipitated extracts. The patients rarely complain of pain or discomfort around the site of injection. Constitutional reactions are mild, as a rule, when they occur at all. In ouv series of 96 cases we have had only 2 severe reactions, both readily controlled by adrenalin. The patients have experienced greater freedom from symptoms; in fact, most of them were entirely relieved. Even those cases start ing treatment late in the season, after the appearance of symptoms, obtained almost complete relief. ,: SUMMARY 1. A method of treating hay fever by alum-precipitated pollen extract is described. 2. The rationale of this method and its probable results are dis cussed. 3. Case histories are reported. CONCLUSIONS 1. In our hands, this method of treatment has given decidedly better results, so far as the relief of symptoms is concerned, than has the non-alum-precipitated pollen extract. 2. Constitutional reactions were reduced in frequency and severity. 3. The number of treatments necessary to control symptoms were reduced in some cases but not in all. MICHAEL—MALARIA 29 References (1) Harrison, W. T.: Public Health Reports, U. S. Public Health Service, vol. 49, no. 14, Apr. 6, 1934, p. 462. (2) Caulfelld, A. H. W.: The Journal of Allergy, vol. 7, no. 5, July 1936, p. 451. MALARIA By W. H. Michael, Commander, Medical Corps, United States Navy Two fallacies are rooted in the minds of a majority of the population and of a considerable portion of the medical profession: first, that ma laria equals chills and fever; second, that the diagnosis of malaria is not difficult. Eight consecutive cases of malaria were sent to a naval hospital by naval medical officers, that is, by physicians who have more than the average experience with that disease. Five of these were diagnosed, catarrhal fever acute; one, migrane; one, fever, cause undetermined; and only one, diagnosis undetermined, malaria. Of course these diagnoses were made hurriedly in the course of large routine sick-calls. Confronted by acute symptoms, the doctors right fully considered hospitalization more important than diagnosis. However, this did occur in a district where malaria is known to be common. During the same period as the above admissions, two non-naval cases" came in who were treating themselves with chill tonic. Neither had malaria. One had syphilis and the other, who had taken chill tonic for 6 months, soon died with acute nephritis. Necropsy showed no malaria. More recently a case was sent in by a civilian physician with the positive diagnosis of malaria. The case had received intravenous quinine. Thick smears were negative and remained so. Pie proved to have an appendiceal abscess—hence his chills and fever. Failure in the diagnosis of malaria accurately is not limited to the present generation. The writer recalls spending two uncomfortable days in a Canal Zone hospital (1913) before his case was diagnosed by himself. Several thin smears had been reported negative. Malaria, like the gamut of diseases, is diagnosed by: history, sub jective symptoms, physical findings, and most conclusive of all, laboratory examination. History alone may clinch the diagnosis. In a patient exposed at night in a malarious district malaria must either be determined or excluded. Frequently, week-end camps, night bathing parties, or a stalled automobile will fix both the time and place of infection. In Port au Prince, Haiti, many cases among the white foreign population could be traced directly to open air dinner parties on a picturesque but badly infected hotel terrace which overhangs the bay. 30 MICHAEL MALARIA Subjective symptoms may be conclusive or misleading. The so- called typical cvery-other-day chill is not the rule, but when it occurs it makes the diagnosis. However, urinary chills are frequent and may simulate a double tertian infection, and a chill may be the first symptom in almost any of the acute infections from erysipelas to typhoid fever. The more important and constant subjective symptoms are: head ache, general malaise, nausea, and fever; and these usually occur without cough or other localized infections to account for them. But neither does another disease exclude .malaria, nor does malaria exclude another disease. The most beautiful malarial blood smear that the writer ever saw, was taken from a convalescent pneumonia ; and his most embarrassing moment was when his chief of service pulled down the bedclothes from a malaria patient and uncovered syphilitic leg ulcers. Physical findings indicating malaria are rather the exception in active military service. They are: a large spleen, anemia, and a subicteric tint. These can only be expected in chronic cases. One palpable spleen was found in the 15 cases which inspired these notes. He was a war veteran who had been treating himself intermittently for 6 months, incidently, with both quinine and atabrine. Beware of the supposed pneumonia with a comparatively low pulse rate and slow respiration, with a "central" lung envolvement, and low white count. Who among those who have practiced in the Tropics cannot recall acquaintances who have gone to the States on summer vacation and have not come back? Pneumonia is so often the official diagnosis. If questioned, sometimes a relative will answer: "No. his chest did not seem to hurt a great deal and he hardly coughed at all." Laboratory examination would save many of these. The examina tion of a thick smear of the patient's blood is the only sure way to diagnosis malaria. If he has acute symptoms due to malaria, the experienced eye will find parasites in two thick smears. If no para sites are found in two thick smears, there is no reason to treat the case for malaria. Experience has proved the thick smear 32 times more effective than the thin smear. The thin smear has the advantage of rapidity of preparation, but a negative is not conclusive. When the diagnosis of malaria, is made in a case, the most pressing thing is to find the mosquitoes that infected him and kill them if possible. If the history points to infection in his home or in military barracks, the mosquitoes are probably still in the building. Look for them under and behind the bed, in the closets, dark corners, and in the early morning inspect the screens. From this point the strategy of mosquito war would lead too far afield, and perhaps, divert too much attention from the next important procedure: Find the humans who infected the mosquitoes. They, MICHAEL MALARIA 31 too, are probably in the house. If that house is a military barrack, beware. If not in the house, they are close neighbors. Suspect particularly the colored neighbor. If white and truthful, the malaria carrier will give a history of headache, fever, or even chills. If colored, supplement the history with a search for a spleen. A thick smear will do the rest. One of the most astounding common breaches of hygiene on expeditionary duty in the Tropics, is the custom of enforc ing the use of mosquito nets by all camp personnel except the malaria infected native camp follower. Moreover, it is a waste of time to cure the patient and send him back to be infected again. When this small epidemic of malaria appeared, the writer was befuddled by a mass of contradictory propaganda. Further com plicating the situation was the recent death of a malaria patient treated writh atabrine. No autopsy was obtainable. Post hoc may not be propter hoc; nevertheless, the routine treatment adopted re served that drug for those cases who reacted badly to quinine. Ac cording to recent literature individuals sensitive to quinine are more common. None occurred in the present series and not a dozen have been observed in 7 years of tropical service. Ten grains of quinine sulphate were given three times a day for 7 days. No acid was given because it is unnecessary and increases the tendency to nausea. During the last 3 days of these 7 days, the patients received one-sixth grain of plasmochin three times a day in addition to the quinine. There were some exceptions to this routine: In a heavy malignant infection, the treatment was begun with 0.7 gram of quinine hydro- chlorosulphate and 100 grams of glucose in a liter of salt solution. Reaction was excellent. This case and another continued to receive quinine intravenously until they could tolerate it by mouth. The above routine of treatment was repeated after 4 days rest in one case, because parasites were still present after the regular course. One case relapsed. On his first admission he showed a mixed infection with many sexual forms of both P. falciparum and P. vivax. All, including the relapsed case, have been returned to duty for several months. After having undergone the old Canal Zone treatment (liquid quinine for 6 weeks) the writer confesses enthusiasm for the results in this very small series which was treated (with an exception) for only one-sixth of the time. The chances of blackwater fever or other complications should be greatly reduced by the adoption of the short course, while 1 relapse in 15 cases would be expected even after the Canal Zone treatment. 32 McDANIEL AND BELL BARBITURATE POISONING BARBITURATE POISONING A Review with Report of Two Cases 1 By F. L. McDaniel, Commander, Medical Corps, United States Navy, and Robert A. Bell, Lieutenant, Medical Corps, United States Navy In preparing this paper the temptation has been great to wander afield and discuss allied topics. In selecting and discarding from the mass of literature it has been a problem to decide what to accept and what to discard. We have tried not to commit the error, as the Brit ish say, of throwing out the baby with the bath. The most common hypnotics of today belong to the barbituric acid group. Introduced about 30 years ago by Fisher and Von Mering (1), who established that barbituric acid, a derivative of urea and malonic acid, while physiologically relatively inactive in itself, could, by replacement of two hydrogen atoms with ethyl radicals, be made into a powerful hypnotic for both animals and man. The use of these derivatives therapeutically dates a little over 20 years ago. The first one extensively used was veronal. There is now a long list of preparations put out under different trade names and sold directly to the public. Their use is becoming more and more popular with the laity. If some check is not instituted these drugs may run a close race with aspirin as a popular form of self-medication. In the field of mental study the patient is questioned very closely about drug habits and it is astonishing to learn how widespread the use of the barbituric acid derivaties is becoming. It is the favorite medication of the restless and emotionally unstable, of the worried, the weary, and the jaded, and of chronic drunks to temper the natural physiological reactions of the morning after. As a rule the fatal dose of the barbiturates averages about 15 to 30 times the therapeutic dose. Clinically and experimentally this ratio has been found to vary greatly. As pointed out by Weiss (3), pain, sympathetic excitement, worry, and fever act antagonistically to the effect of the barbiturates; whereas anemia (4) and cerebral depression are synergistic, making the patient more susceptible to their depressant effect. Since the liver detoxifies the unsaturated barbiturates and the kidneys excrete the saturated series, disease of these organs accentuates and prolongs the effect of any given dose. Inactivation or elimination of the drug requires an efficient circula tion; hence in cardiac failure, shock or collapse, narcosis is usually prolonged. An idiosyncrasy to the drug may cause toxic manifes tations as confusion, psychotic or dermal reactions, although such symptoms are usually seen only after excessive dosage. The most popular of the barbiturates, both with the profession and the laity, is the amytal group. It shows the largest interval >This paper was presented at staff conference, U. S. Naval Medical Center, April 2, 1937,by the senior author. McDANIEL AND BELL—BARBITURATE POISONING 33 between the lethal and the effective dose in animal tests. Sodium amytal, the sodium salt of iso-amyl-ethyl barbituric acid was pre pared and used in animals experimentally in 1926 (2). Its intra venous use in 350 psychotic patients has been reported by Lorenz, Reese, and Washburne (5), who found that an average dose of 9% grains was required to obtain complete narcosis. The functional group required somewhat more than the organic group. You will see later that one of our patients took 13 times this amount with recovery. The anesthetic dose of the drug is about 50 to 70 percent of the so-called fatal dose and 23 to 37 percent of the fatal dose (3) is required to produce sleep, moderate muscular relaxation, and partial anesthesia. Instances of fatalities from very moderate doses are recorded. In one case reported (6) a patient being prepared for thy roid operation was given 7}i grains of nembutal in divided doses, 1% grains at night and 6 grains in the morning; fatal poisoning resulted. Hyperthyroidism, renal or hepatic deficiency make the patient very susceptible. This same article reports a patient who took 475 grains of assorted barbiturates and the fact was not discovered for 14 hours, so that the drug had become well absorbed. He recovered, alter very vigorous treatment, with apparently no serious after effects. This patient developed numerous urticurial blisters around the arms, wrists, and chest 12 or 14 hours after the drug was taken. In our case (R. O.) a marked urticurial reaction with blister formation and ulceration appeared in the right auricle. A point not given the attention it deserves and of special interest from the medico-legal aspect and in the Navy is the question of deciding upon misconduct and line of duty. Weiss (7) warns of this and Dr. Richards, lecturer on forensic medicine in the University of Aberdeen, Scotland, records several cases which have come to his attention and which he labels "barbituric acid automatism." It occurs among habitual users of barbital derivatives who usually keep a supply at their bedside. Apparently after one or two tablets a normal narcosis develops and while still unconscious they auto matically continue to take additional tablets. Should the patient take a fatal dose in this manner the obvious conclusion upon finding the body would be suicide. The general action of these hypnotics is to produce a descending depression of the central nervous system beginning with the cortex. It has been found that individual compounds act at slightly different levels and some exhibit earlier subcortical action than others. As the dosage is increased the depression deepens and gradually the action on the medullary or vital centers supervenes. This is usually first manifested by respiratory center depression. Some authorities say that cardiac depression is paramount but apparently paralysis of respiration is the most prominent symptom. In overdosage with 34 M.DANJEL AND BELL BARBITURATE POISONING other hypnotics, as chloral hydrate and paraldehyde, circulatory collapse may occur initially and the onset may be sudden and dramatic. Experimental work in pharmacology indicates that we may divide the barbiturates into three classifications. 1. In order of increasing toxicity. —Barbital, dional, dial, amytal, pheno-barbital, allonal. 2. In order of increasing efficiency. — Barbital, pheno-barbital, dional, dial, amytal, allonal. 3. In order of increasing margin of safety. —Phenol-barbital, barbital, allonal, amytal, dial, dional. Most of these compounds are produced by varying the alkyl group of radicals. It has been found that by lengthening the chain of alkyl groups the toxicity is decreased. The toxic effects from the use of the barbiturates are most often the result of taking an overdose with suicidal intent or from the indiscriminate administration for the induction of anesthesia. Adequate warning has been sounded against the latter (8) (9), and while the former is increasing in popu larity it still ranks rather low in the list of drug suicidal agents, being about eighth in the list for the United Kingdom (9a). The barbiturates taken orally are absorbed in from 15 to 60 min utes. Toxic manifestations may be delayed since nausea may induce pyloric spasm and slow absorption. Early hypnosis is attended by a feeling of extreme well-being and serenity, a sense of warmth and genial friendship towards the world in general. Fears and apprehensions vanish. Hallucinations do not seem to occur. There is no dream state. Pain is absent. As absorption increases the depression deep ens, coma supervenes, and consciousness is lost in about 15 to 20 minutes. The pupils become constricted, contrary to the com monly held idea that in poisoning with this drug the pupils are dilated, and that it can thus be readily differentiated from opium poisoning. In the cases wc have seen the pupils are always moderately con tracted, some very much so, and light reaction is absent. The respiration becomes slow and shallow, the pulse feeble but not espe cially rapid, and there is a pronounced fall in the blood pressure and body temperature, though the latter may be elevated (10). Fre quently there is suppression of the urine and retention may occur. Occasionally convulsive seizures occur, probably due to cerebral edema. The rellexes are usually absent in the deep stages. The fall in blood pressure is not as striking in narcosis with sodium amytal as with chloral hydrate or paraldehyde, but when it occurs the sys tolic falls more in proportion than the diastolic. There is increased capillary permeability with swelling of the eyelids, lips, cheeks, and ears, erythema, urticaria, blebs and other exudative and even ulcer ative skin lesions. Localized areas of edema may develop and edema of the lungs is an expected complication which predisposes McDANIEL AND BELL—BARBITURATE POISONING 35 to convalescent bronchopneumonia. The blood chemistry shows no change of blood sugar; there is a fall in calcium content and an increase in the C02 tension. The hydrogen ion concentration is ncreased. Renal function shows a diminution of output without impairment of glomerular activity as shown by the phenosulphophthalein excre tion. Liver function shows little change. Few observations have been made on the gastrointestinal tract. There appears to be no decrease in the tonus or amplitude of contraction of the small intestines. Neurologically, we have mentioned the disturbances of the pupillary reflex. Just before narcosis sets in the patient may show evidence of vertigo, a staggering gait, and diplopia. Individuals picked up on the street by the police may present a typical picture of inebriation. In the case of one patient who had been taking veronal, and was admitted to this hospital, a vigorous but unsuccessful effort was made to get a positive Bogan's reaction. The speech is thick and as narcosis proceeds there is a very decided tendency for the tongue to fall back into the pharnyx. This was a particularly troublesome factor in the cases reported below. It is a grave development which must be relieved, and ranks in seriousness with loss of the pharyngeal reflex. The pathological findings have been determined chiefly through experimental pharmacology. There is congestion of the brain, con siderable perivascular edema, and small scattered hemorrhages. Histologic changes are present in the cortex especially in the deeper cell layers. The Nissl bodies tend to disappear. The cortical cells show degeneration of the cell membranes and nuclei. The entire brain shows degenerative changes with cellular damage which seems to be due to the direct action of the drug rather than secondary to a disturbed circulation. The lungs are always congested and many authorities feel that there is a direct toxic action of the drug on the lung tissue itself. Bronchopneumonia and pulmonary edema de pendent upon prolonged coma, increased capillary permeability, and circulatory collapse, are frequent complications often responsible for death. In the kidney most of the damage is seen in the convoluted tubules, less in the glomeruli. In the liver we observe fatty degener ation, especially of the central portion of the lobules. In diagnosis Weiss (4) states, "The differences in behavior of patients intoxicated with various types of hypnotics are inadequate for the clinical diagnosis of the nature of the poisoning." He says that the diagnosis should always be determined through circumstantial evidence and the finding of the barbiturate in the excretion of the patient. We now have a very prompt and reliable method 1 for detec- »H. Oettel, Arch. Pharra. 1:10, 1936. 36 McDANIEL AND BULL BARBITURATE POISONING tion of the barbiturates and this should be made use of in all cases of suspected poisoning with hypnotic drugs. In the treatment of the acute poisoning with the barbiturates, we recognize two stages, that of coma and that of reaction. Energetic therapy is essential in early coma. The method of attack can be reduced to three fundamental procedures. Firstly: Attempt to elim inate the drug from the body either before or after absorption. Sec ondly: To combat the action of the drug, which has already been absorbed, by antagonistic drugs and supportive therapy. Thirdly: To prevent the onset of complications and combat any untoward after effects. Unfortunately most of these cases are first discovered after the drug has been absorbed from the alimentary canal. It is, however, always well to do a gastric lavage and after the stomach has been thoroughly washed to introduce 60 cubic centimeters of a saturated solution of magnesium sulphate. Do not remove the tube but allow it to remain for continuous drainage because gastric juice as secreted is saturated with the barbiturate and drainage constitutes an easy method of drug removal. Patient may be fed through the tube and aspiration of vomitus is prevented by its use. The barbiturates not detoxified by the liver are principally excreted through the kidneys (4) and in smaller percentages in the following order according to Koppanyi, Murphy, and Krop (11): Dial, neonal, phenobarbital, pernocton, and amytal. They report on the excretion of barbital in dogs and were able to confirm previously reported work by recovering in the urine from 42 to 91 percent of the dose administered. In the lowest output, that of 42 percent, it was revealed at autopsy that the animal had infarcts of the kidneys. These investigators found, also, that recovery from experimental barbital poisoning closely paralleled the amount excreted in the urine, and that the rate and percentage of total excretion did not vary with the size of the dose. They further found that recovery was not influenced by increasing diuresis with dextrose and conclude that maintainance of normal kidney functions, and not diuretic mensures, are necessary for shortening time of re covery from coma due to those barbiturates eliminated primarily by- urinary excretion. Previously reported work (12) (13) (14) (15) has emphasized the value of diuretic measures, especially with saline solu tion intravenously. Diuresis should be adequate and continuous with out overtaxing cardiac or renal function. Moderate prolonged stimu lation of renal function should be a chief aim of therapy in acute barbiturate poisoning. Diuresis may be aided by repeated phleboc- lysis using glucose and saline solutions to add calories and replace the chloride lost through gastric aspiration and perspiration. Damaging the kidneys or removing one kidney increases the toxic effect of the drug. It is reported (11) that amytal is recovered from the urine in only small amounts. Neither amytal nor neonal are excreted as such McDANIEL AND BELL—BARBITURATE POISONING 37 in the urine (16) and (20a). We recovered from the urine considerable quantities of a substance giving a positive test for the barbiturates (case 2, amytal poisoning). We may also recover barbiturates from gastric contents, saliva, sweat, cerebrospinal fluid and from most of the organs and body tissues. It has been found that the concentra tion of barbital in the cerebrospinal fluid and the saliva is about the same as in the blood plasma. The concentration of barbital in the blood during the first 2 hours shows a sharp decline and then a very slow drop. The first is due to fixation by the organs, and the second to renal elimination. In bilaterally nephrectomized dogs the second • decline does not take place. Spinal fluid drainage is recommended (17) (18). We found no case reports in which forced spinal fluid drain age had been given. Since the concentration of drug in the cerebro spinal fluid is about the same as in blood plasma (19) and low in com parison with that in the urine, this procedure would not seem especially indicated. There are no chemical antidotes for acute poisoning with barbi turates. Pharmacodynamically antagonistic drugs are used and should be given in large doses. Since the barbiturates act upon the subcortical centers in the mid-brain, drugs which simulate these areas are employed. Among these used are caffeine, strychnine, coramine, brucine, cocaine, physostigmine, ephedrine, calcium gluconate, pictro- tosdn, benzedrine, and insulin. All of these have been used with reported favorable results, in many cases the reasoning was post .hoc ergo propter hoc. The motor depressant, antispasmodic and peripheral action of physostigmine seem to render it unessential and probably harmful. Since amytal in anesthetic dosage inhibits the action of the vagus (20) atropine is contraindicated. The use of cocaine appears to add insult to injury and calcium gluconate is not essential. There is no definite indication for using insulin. The use of brucine, less active than strychnine, has no advantage over the latter, used experimentally (21) to save animals given three times the fatal dose of phenobarbital, sodium. Strychnine excites the ventral horn cells of the spinal cord lowering the threshold for stimuli ; and in view of this site of action its use has been condemned (22). A definite and therapeutically valuable antagonism does exist as demonstrated by its use in the case (23) of a young woman who ingested 17 grams of barital (veronal) and 10 hours later was given strychnine in does of 10 milligrams every hour or two to a total of 0.39 gram in the following 60 hours. The smallest lethal dose of strychnine for a normal person is 30 milligrams. It has been used successfully by Weiss (4) in dosage of 10 milligrams hourly, and by others (24). The use of ephedrine which stimulates the respiratory center (32) and counteracts sleep by stimulation of subcortical centers, appears 38 McDANIEL AND BELL BARBITURATE POISONING sound and is beneficial experimentally (26) and therapeutically (26b). Use of benzedrine, which has greater central and less peripheral action is also indicated. Ephedrine should be particularly valuable in these cases with vasomotor collapse, rapid pulse, low blood pressure and urinary suppression. It is in these cases that camphor and caffeine are especially useful; for while they fail to improve cases profoundly hypnotic they do have a beneficial effect on the circulation. The hypnotic antagonist pyridine, beta-carbonic acid diethylamide, synthesized by Hartman, studied pharmacologically by Faust and Uhlm»»o, and introduced in therapeutics by Thannhauser and Naunen- bruck over 12 years ago, is known under the trade name of coramin. It has been studied extensively on the Continent, more recently in this country. Its use was initiated in 1892 by Koppen while studying the relatively new drug coramyrtin. Its action, pharmacological not chemical, effects the medulla and diencephalon, stimulating the respiratory, motor, coughing and vomiting centers. It causes yawning, salivation, and bronchial relaxation with increased secretion and expectoration. Respiration is particularly stimulated both in rate and depth. The cardiac excursions and blood flow are increased. Toxicity is low, cumulative effects absent, and action evanescent (26). The depth and duration of sleep are diminished and the drug is capable of improving respiration when the depression is so deep as not to respond to carbon dioxide. Once improvement occurs the center will then respond to carbon dioxide. It is less useful in amytal hypnosis (26). The usual dosage is 5 cubic centimeters intravenously every 5 or 10 minutes. Untoward effects are hiccough, vomiting, and flushing of the skin but tbey are not alarming. It has recently been reported upon favorably (27) in a large series of cases. In action cardiazol resembles and is considered superior to coramin by continental workers (28) (29) but it causes convulsions in larger doses (26a). The respiratory effect of alpha-lobelin is brief. It is a cardiac depressant. Its emetic, respiratory and vasomotor effects are similar to those of nicotine. Even in Europe, where it was used extensively, it is giving way to inhalational treatment which is safer and more efficient (30). The respiratory depression in barbiturate narcosis is so refractory to the normal stimulus, carbon dioxide, that doubt has arisen whether it really plays a major role in the regulation of respiration. Its antidotal effect is minimal. Oxygen exchange and cellular metabolism are at a low ebb. Breathing continues mainly under the influence of anoxia. The administration of oxygen, by removing this stimulus, may induce fatal apnea (39). The oxygen is needed, however, and should be supplied in a carbon dioxide-oxygen mixture. MrDANIEL AND BELL BARBITURATE POISONING 39 There is frequent failure of therapeusis in employment of all these analeptics. This is explainable by the observation (31) that in increasing narcosis the analeptic effects of epinephrine, caffeine, strychnine, cardiozol (mitrazol), coramine and strophanthin diminish, and finally cease; and in deep narcosis they impair the circulation and respiration in the rabbit. In the neutral poisonous principle of the fish berry, Cocculus indicus, discovered by Boulay in 1812, we have a medullary and autonomic center stimulant apparently superior to those mentioned above. This drug is very poisonous in large doses causing clonic convulsions. Its favorable effect on barbiturate narcosis in rabbits and dogs (33) (34) and in humans (26b) (35), led Lilly & Co. to market it in ampoules containing 1/100 grain each. It can be administered orally, subcutaneously, intramuscularly or intravenously. If the narcosis be from a quickly absorbed barbiturate as pentobarbital, pernocton, amytal, alurate or evipal, a single large dose, 1 or 2 cubic centimeters of the Iilly preparation, may be given intravenously in a person weighing 150 pounds. If there are no toxic symptoms such as twitching of the arms, unduly increased respiratory rate, or rise in blood pressure, the dose should be repeated in 20 minutes. As the patient improves the drug can be given orally in 3-milligram doses as needed. It is useful in chronic poisoning to detoxicate the patient. In view of the incomplete knowledge and poisonous nature of this drug it has been withdrawn from the market (36). However the Council on Pharmacy and Chemistry of the A. M. A.1 (37) and others (38) have recently reemphasized the value and limitations of picrotoxin. The untoward effects of the prolonged barbiturate narcosis are frequently responsible for the fatality. The indications for therapy are definite. The respiratory failure, as noted above, being character istically refractory to carbon dioxide-oxygen, some other medullary stimulant is essential. The patient must be kept warm and adequate fluids administered. Continuous gastric suction and suction removal of secretions which collect in the pharynx, prevent aspiration pneu monia and interference with free respiration. The tongue must be prevented from falling back and thereby strangling the patient. The body tonus as a whole is lowered; and in conjunction with the central vasomotor depression, favors the development of broncho pneumonia and circulatory collapse. It is here that ephedrine, through its central stimulative effect and peripheral circulatory support, and strychnine, by increasing general body tonus, find their chief indica tion and usefulness. Camphor and caffeine are likewise useful, caffeine as coffee introduced into the stomach, or caffeine sodio- benzoate, 7.5 grains subcutaneously, may be repeated at 30-minute intervals. It is such measures, aided by frequent changes in position ' The Council on Pharmacy and Chemistry while recognizing its prohable value, felt the drug should not yet be distributed to the general practitioner. 40 McDANIEL AND BELJ>— BARBITURATE POISONING which increase body tonus, which ward off or minimize circulatory collapse, cause full inflation of the lungs and which prevent pulmonary oedema, atelectasis and bronchopneumonia. Catheterization when necessary and protective ointment to eyes, lips and mouth are obvious indications. With this review in mind two recently followed cases are presented. Case 1.— W. K. K., storekeeper second class, U. S. S. Relief. (Seen by F. L. McD.). This patient had caused no previous suspicion as to his mental condition or any drug habit. He was on duty on the vessel and one afternoon was found asleep in his bunk by a shipmate. He did not turn to at the usual hour next morning but was apparently in a state of coma with stertorous breathing, labored in type, and was thought to be drunk. As he slept in a small compartment with one or two other shipmates who were his friends, they decided to "cover him up" and allow him to "sleep it off" thinking to arouse him later in the day. When they attempted to arouse him for noon mess he was more comatose and was immediately taken to the medical ward. An abstract of the medical history follows: Diag nosis: Poisoning acute, barbital, classification A. 1. Within command. 2. Not work. 3. Due to own negligence or misconduct. 4. Used barbital (veronal) in excess, self-administered. Admitted at 11:30 a. m., from his bunk. An ordinary tablet bottle was found on his person and he is reported to have purchased veronal tablets a few days ago. Dose estimated at 2 dozen 5-grain tablets or 120 grains. Physical examination. — Patient comatose. The face is flushed or slightly cyanotic. The breathing noisy and the flaccid tongue tends to obstruct the passage. (This is mentioned in the literature as a very common symptom of barbiturate poisoning.) Pupils equal, 3 millimeters in diameter, react slowly to light. Eye grounds — no gross abnormality. No evidence of corrosive poisoning in the mouth or odor of alcoholic liquors on the breath. Blood pressure, 105/75; pulse, 90 to 100. No abnormal sounds noted. Some moist rales heard over the bronchi. Abdomen negative except Madder distended, 900 cubic centimeters of clear urine obtained by catheter. The deep reflexes of arms were sluggish and the right knee jerk very sluggish. The superficial reflexes not elicited. Impression. — Barbital poisoning. Treatment. — Gastric lavage, 2 ounces of magnesium sulphate left in stomach. I do not recall that strychnine was given in this case. Caffeine-sodium-benzoate and coramin were given freely. The respiration became more shallow and super ficial, cyanosis appeared, and he was placed in an oxygen tent. Pulse became more rapid, 110 to 120, and the patient died at 11:50 p. m. Laboratory findings. — Urine positive for barbiturates. Autopsy findings. — Edema and congestion with stasis of the lungs. Conges tion and venous stasis in the solid viscera with acute degeneration due to the chemical (barbital). Moderate dilatation of right heart, mainly the auricle. Petechial punctiform hemorrhage in the serous cavities. Cause of death —. poisoning, acute, barbital. The diagnosis was considered substantiated by the history, the physical findings, the clinical course, the presence of a barbituric acid derivative in the urine, and the autopsy findings. COMMENT This patient took an undetermined amount of veronal —approxi mately twenty-four 5-grain tablets. (About the same amount as that (amytal) taken by our second case). Treatment was started about 18 to 20 hours after taking drug. When seen he was in fairly good condition except for evidence of failing respiration. He did not respond to any McDANIEL AND BELL—BARBITURATE POISONING 41 treatment, including gastric lavage with injection of magnesium sul phate, coramine and caffeine-sodium- benzoate by hypo, and oxygen inhalations. The urine was positive for barbiturates. Death occurred approximately 30 hours after taking the drug. Case 2.—R. O., a young naval medical officer. Diagnosis: Psychoneurosis, reactive depression. For several days prior to this episode patient had appeared brighter and more cheerful. At 8 a. m.( on the 18th of January he could not be aroused for breakfast. The officer of the day was notified and patient was promptly seen. Coramine, 5 cubic centimeters given intravenously, because the respiration was shallow and irregular. There was apparently no response to the intravenous coramine. Within 5 minutes a large urticarial wheel was noted on the right face and auricle. He was given 0.5 cubic centimeter of adrenalin intramuscularly. Gastric lavage done and 2 ounces of magnesium sulphate with 10 milligrams of benzedrine and 300 cubic centimeters of black coffee were left in stomach. We saw the patient at 8:30 a. m., respiration was shallow and ster torous and the tongue continued to fall back in throat; 3.75 grains of caffeine- sodium-benzoate were given subcutaneously. Three hundred cubic centimeters of urine, obtained by catheterization, contained 40 milligrams percent barbiturates. Given intravenous injection of 500 cubic centimeters dextrose in normal saline and hypodermoclysis of 1,000 cubic centimeters in thighs. Shortly after 11a. m., the patient stopped breathing and artificial respiration by the Shaeffer method was carried on for 30 minutes before a shallow respiratory rate was resumed. At tin's time strychnine, grains 1/32, was given and followed in 30 minutes by picrotoxin, grains 1/100. The blood pressure reading was 92/56. Within 20 minutes after using picrotoxin blood pressure was 110/70. Patient began to breathe well and deeply, 95 percent oxygen and 5 percent carbon dioxide was administered. Blood pressure continued elevated. Catheterized specimen at 2 p. m., yielded only 200 cubic centimeters of urine, showing 20 milligrams percent of barbiturates. Strych nine grains 1/32 and picrotoxin grains 1/100 were given each hour alternately for two doses of each. Patient placed under oxygen tent about 3 p. m. The pupils began to react fairly well to light but general flaccidity and collapse continued. At 10 p. m., he was breathing well, color good, face flushed, respiration and cardiac function continued to improve. Blood pressure continued up during the night. At 4 a. m., January 19, patient tried to move hands and legs, yawned and at tempted to move head. This was the first evidence of voluntary movement ex hibited since his discovery almost 24 hours previously. At 7 a. m., 500 cubic centimeters of normal saline with 50 cubic centimeters of 50 percent glucose were given intravenously. Catheterized specimen urine at 8:30 a. in., of 500 cubic centimeters, showed 20 milligrams percent barbiturates. During the morning the patient became more restless, opened his eyes, and there was occasional mum bling response to loud questioning. He received 1,200 cubic centimeters of normal saline and glucose intravenously at 11:30 a. m. During late afternoon the oxygen tent was removed. The temperature was 100.6 by axilla; pulse, 96; respirations, 20. At 4:30 p. m., patient asked to speak to medical officer. He was confused but appeared to be recovering consciousness. During evening he was able to take liquid nourishment by mouth. Voided voluntarily for first time at 6:15 p. m. 250 cubic centimeters. This specimen contained 15 milligrams percent barbitu rates. He was visited by his wife at 10:30 p. m., and although there was consider able clouding of consciousness, he recognized her and could respond in a fairly rational manner. During the third day, January 20, patient was confused, showed moderate clouding of consciousness and was disoriented as to time, thought he 24140—37- 42 McDANIEL AND HELL BARBITURATE POISONING had only been asleep one night. Said he felt dizzy and light headed and ached in all of his joints. Specimen of urine through the third and fourth days continued to contain from 15 milligrams percent to a trace of barbiturates. On the fourth day the patient had made an excellent recovery with exception of persistent feeling of dizziness and the complaint that he could still taste barbital, especially when he smoked cigarettes. He admitted taking forty 3-grain capsules of sodium amytal at 8 p. m. January 17. SUMMARY We have attempted to review the symptomatology, pathology and diagnosis of acute poisoning with barbiturates. The problem of treat ment and prognosis has not yet been standardized. The use of thera peutic agents is reviewed in some detail. The histories of two rep resentative cases are presented. It is seen that prognosis depends upon the type and quantity of drug taken, the time that elapses before therapy is instituted , the condition of the patient, and the adminis tration of antagonistic drugs in heavy dosage, as guided by the depth of respiratory depression and degree of vascular collapse. CONCLUSION It is our opinion that patients may recover from enormous doses of the barbiturates but that they will do so only after prompt, energetic, and persistent treatment has been carried out. Bibliography 1. Fischer, E., and Von Mering, J.: Therap. d. Gegenw. 5: 97, 1903. 2. Page and Corrylen: Am. J. Pharmacolo. and Exp. Ther., 1926. 3. Weiss, S.: Am. J. Med. Sc., 188: 731, 1934. 4. Weiss, S.: The Clinical use and Dangers of Hypnotics, J. A. M. A. 107: 2106, 1936. 5. Lorenz, W. F., Reese, H. H., and Washburne, A. C.: Am. J. of Psychiatry 13: 1205, 1934. 6. Purves-Stewart, James: Lancet 1: 6, 1934. 7. Ref. 4, p. 210S. 8. Weiss, S.: Am. J. Med. Sc. 178: 390, 1929. 9. Report of Council on Pharmacy and Chemistry, J. A. M. A. 101: 208, 1933. 9. (a) Gillespie, R. D.: Lancet 1: 337-345, 1934. 10. Chang, D. K., and Tainter, M. L.: Case of Barbital poisoning. J. A. M. A. 106: 1386, 1936. 11. Koppanyi, T., Murphy, W. S., and Krop, S.: Arch, internat. de Phanna- codyn. et de therap., 46: 76, 1933. 12. Gower, Walter E., and Tatum, Arthur L.: J. Phann. and Exp. Therap. 37: 481, 1929. 13. Johnson, Luckhardt and Lighthill: J. A. M. A. 95: 576, 1930. 14. Sanderson: J. A. M. A. 96: 642, 1931. 15. Gower, Walter E., and Van de Erve: J. Pharm. and Exp. Therap. 48: 141, 1933. McDANIEL AND BELL— BARBITURATE POISONING 43 16. Herwich: J. Pharm. and Exp. Therap. 39: 267, 1930. 17. Purves-Stewart, James, and Willcox, William: Cisternal drainage in coma from barbitone poisoning, Lancet 1: 500, 1934. 18. Ref. 4, p. 2109. 19. Ref. 11, p. 90. 20. Lieb, C. C., and Mulinos, M. G.: Proc. Soc. Exp. Biol, and Med. 26: 709, 1928-1929. 20. (a) Shonle, H. A., Keltch, A. K., Kemp, G. F., and Swanson, E. E.: Ibid., 49: 393, 1933. 21. Haggard, H. W., and Greenberg, L. A.: J. A. M. A. 98: 1133, 1932. 22. de Barenne, J.: Physiol. Rev. 13: 325, 1933. 23. Bertrand-Fontaine, and Claass, A.: Bull, et Mem. Soc. Med. d. hop. de Paris 49: 1177, 1933. (Reported editorial Brit. M. J. Dec. 16, 1933). 24. Quoted by Weiss (Ref. 4). Denechau, D., and Bonhomme, R.: Ibid., 49: 1587, 1933. Laigncl-Lavastine, and Bidun, S.: Ibid., 49: 1624, 1933. Brule, M.: Ibid., 49: 1328, 1933. Flandin, C., and Bernard, J.: Ibid., 49: 1550, 1933. Ber nard, E., and I-eroux-Robert: Ibid., 49: 1418, 1933. 25. Raginsky, B. B., and Bourne, W.: J. Pharm. and Exp. Ther. 43: 209, 1931. 26. (a) Killian, Hans: The use of coramin for combating poisoning from nar cotics and hypnotics, Anesth. and Analg. 14: 23, 1935. (b) Arnett, John H.: Ephedrine and Picrotoxin Used Successfully in Amytal poisoning, J. A. M. A. 100: 1593, 1933. (c) Chen, K. K., and Schmidt, C. F.: Ephedrine and related substances, Medicine 9: 1, 1930. (d) Airila, Y.: Ueber die Einwirkung Verschildener Erregungs mittel der Grosshinrinde auf den Chloral hydratschlaff, Arch, internat. de. pharinacodyn. et de therap. 23: 453, 1913. 27. Shube, P. G.: New Eng. J. Med. 214: 926, 1936. 28. Steininger, H., and Gaubatz, E.: Klin. Wchnschr. 14: 159, 1935. 29. Weiss, O. L.: Munchen. Med. Wchnschr. 82: 748, 1935. 30. Norris, V. H., and Weiss, Soma: The Pharmacological and Therapeutic Properties of Alpha-Lobcline, J. Pharmacol. & Exper. Therap. 31: 43, 1927. 31. Von Brandis: Arch. F. klin. Chir. 177: 17, 1933, quoted by Council on Phar macy and Chemistry, Amer. Med. Assoc.: J. A. M. A. 108: 1173, 1937. 32. Schmidt, C. F.: J. Pharmacol. & Exper. Therap. 35: 297, 1929. 33. Maloney, A. H., Fitch, R. H., and Tatum, A. L.: Picrotoxin as an antidote in acute poisoning by the Shorter Acting Barbiturates, J. Pharmacol, and Exper. Therap. 41: 465, 1931. 34. Maloney, A. H.,: A Comparative Study of the Antidotal Action of Picro toxin, Strychnine, and Cocaine in Acute Intoxication by the Barbiturates, J. Pharmacol, and Exper. Thereap. 49: 133, 1933. 35. Maloney, A. H.: Acute Barbiturate Poisoning with Picrotoxin, J. Nat. M. A., May 1933. 36. (a) Council on Pharmacy and Chemistry: Report on Picrotoxin, J. A. M. A. 107: 354, 1936. (b) Personal communication from Eli Lilly and Co., to F. L. McD. 37. Council on Pharmacy and Chemistry: Evipal Soluable, J. A. M. A. 108: 1172, 1937. 38. Grabfield, G. P.: The use of Hypnotics, J. A. M. A., 107: 1381, 1936. Bar low: J. Pharmacol, and Exper. Therap. 55: 1, 1935. 39. Marshal, E. K., Jr., and Rosenfeld, Morris: Depression of respiration by oxygen, J. Pharmacol, and Exper. Therap. 57: 437, 1936. 44 BLACKWOOD AND ERSKINE— CARBOXIDE POISONING CARBOXIDE POISONING By J. D. Blacewood, Jr., Lieutenant Commander, and E. B. Ebseike, Lieutenant, Medical Corps, United States Navy Since the use of carboxide gas (ethylene oxide 1 part and carbon dioxide 10 parts) has been adopted by the Navy for fumigation pur poses, it is of interest to note the effect on personnel who have been subjected to its fumes, of unknown concentration, for a period of 2 to 3 hours. A search of the available literature failed to reveal any reference to any toxic effects due to carboxide. The toxicity of ethylene oxide has been determined experimentally on the guinea pig and Barber (1) cites the records of five fatal human cases of poisoning due to di-ethylene di-oxide in which the characteristic findings were a central necrosis of the liver without fatty degeneration or jaundice and terminating in about a week with a hemorrhagic nephritis and uremia. As the articles published in the Naval Medical Bulletin also did not describe any toxic effect on human beings, the following report is made. On May 21, 1936, the ship's company of the U. S. S. S-36 at the Navy Yard, Cavite, P. I., fumigated all spaces forward of the engine room (15,000 cubic feet), using six 60-pound cylinders of carboxide at 725 pounds pressure per square inch at 70° F. Fumigation was begun at 6:15 p. m. and was stopped at 9:15 p. m. The watertight door in the forward bulkhead of the engine room was dogged. There was a vent in the flapper valves from the torpedo room to the after-motor room in which six men had been working since 4 p. m. At about 9:30 p. m., these men appeared at the yard dispensary complaining of headache, nausea, and vomiting. These symptoms continued for the next 2)i hours after which they were discharged to their homes. As no other cause for their condition could be found, it was decided that there was a leakage of the carboxide through the vent into the compartment where they were working. As the toxic substance was inhaled in the form of a gas, the resulting vomiting was considered as of central origin. It was therefore decided to examine die respiratory tract, the heart, the blood, and the urine of the patients for evidence of any resulting ill effects. The respiratory tract was examined physically and by X-ray, the heart by physical examination and blood pressure, the blood by blood chemistry and blood counts, and the urine by routine examinations. These examinations were con ducted the following day and failed to show any ill effects resulting from the inhalation of the gas. SUMMARY 1. After exposure for about 2}{ to 3 hours to inhalation of a weak concentration of carboxide fumes, the toxic effects consisted of head ache, nausea, weakness, and vomiting. SNOWDEN AND BELL—SULFANILAMIDE THERAPY 45 2. The symptoms lasted for about 2 % hours. 3. The treatment consisted of gastric lavage. 4. No permanent ill effects were noted in examination of the respira tory and circulatory systems, blood, or urine. 5. Precautions should be taken to confine the fumes to the parts of the ship being fumigated. 6. Men should not be allowed to work where there is any possibility of even a weak concentration of the fumes to reach them. Our thanks are due to Lt. Comdr. W. H. Whitmore (M. C), United States Navy, for the X-ray reports and to Lt. (Jr. Gr.) F. W. Farrar (M. C), United States Navy, for the reports on the blood chemistry. BlBLIOGRAPHT 1. Barber, H. Hemorrhagic nephritis and necrosis of the liver from dioxan poisoning. Guy's Hospital Reports, London, 84: 257-386, 1934. THE SULFANILAMIDE THERAPY OF GONORRHEA By R. H. Snowden, Commander, Medical Corps, United States Navy, and Robert A. Beu, Lieutenant, Medical Corps, United States Navy ' In recent decades rapid progress has been recorded in preventive and curative treatment of many diseases. There have been several groups including streptococci, genococci, and virus diseases remaining resist ant to therapeutic efforts. The original work of Domagk (1) on the azo-dye derivative Prontosil has developed a promising line of attack (2) (3) on at least the first two of this hitherto resistant group. The therapeutic effect of the azo-dyes apparently resides in the reduction derivative para-amino-benzene-sulfonamide (4) (6f) (7) (13b) called sulfanilamide (5) from which they are formed. This reduction occurs both in vitro and in vivo. The use of this drug is not yet on a scien tific basis. The mode of action is not understood. Solutions of sulfanilamide 1 : 13,000 and 1 : 18,000 in defibrinated human and monkey blood or serum were found free from implanted cultures of beta- hemolytic streptococci in 2 days (11) (13a). In controls there was an increase of organisms. Frequent repetition of the experiment using different strains of streptococci and different bloods gave similar results. With the blood of rats, mice, and guinea pigs results were less favorable. Sulfanilamide inhibits growth and causes death of pneumococci in 24 to 48 hours in solutions of 1:10,000 or stronger. It is effective in less marked degree in 1:100,000 dilutions (12). No effect was demonstrable on virulent hemolytic streptococci in 1:1,000 dilutions, or on staphlococcus albus or E. coli. However, larger doses of streptococci wore used than by others (11) (14b) who obtained inhibition of organisms. i We are indebted to W. L. Ainsworth, Commander, U. S. Navy, executive officer, U. 8. S. Mistlstippi lor the supply of sulfanilamide used in this study. The authors wish to express appreciation to 11unh Li- Smith, pharmacist mate, third-class, for his thorough technical assistance. 46 SNOWDEN AND BELL—SULFANILAMIDE THERAPY In vivo experiments (11) (14) (confirmed (15) and (13b) including pneumococci types I and II and certain Neisseriae) show good therapeutic results with sulfanilamide in mice infected with hemolytic streptococci of high virulence. Little effect was observed with strains of low virulence. Favorable results have been obtained (16) with strains of medium virulence by using from 1-10 minimum lethal doses. Animals experimentally infected intraperitoneally with pneumococci exhibit prolonged life incident to sulfanilamide therapy. While they show peritonitis with a purulent exudate at autopsy (12) the infection is more markedly localized than in controls which present intense bacteriemia. Xo bacteriostatic effect was noted (13b) on staphlococcus aureus, E. coli,. E. typhi and certain other gram negative organisms. The sulfanilamide therapy of guinea pigs infected intradermally with hemolytic streptococci has shown (16) less dissemination, greater localization, and more rapid healing as compared to untreated controls. The drug possesses marked bacteriostatic and bactericidal action in vitro. If this is the mode of action in vivo it is unproven. Diaz- otization and aeetylation of sulfanilamide destroys its activity in vitro and in vivo indicating a similar mode of action (12). The results of in vitro experiments cannot however be applied directly to those in vivo. This is apparent (12) for sulfanilamide in the test tube is more than 100 times as bacteriostatic and bactericidal against pneumococci as compared with streptococci whereas in mice it is more effective against streptococci. This action in vitro is adequate to explain the chemotherapeutic effect against pneumococci in animals if dosage of 1 gram per kilo is given. The concentration thus obtained in the body is comparable to that in the test tube. However it has been shown (1) that against streptococci in mice, from one-tenth to one-fiftieth of the tolerated dose gives a distinct effect if treatment is continued for 3 to 5 days. To explain the variance of action between test-tube and animal experiments enhanced bactericidal action of the blood, supplemented by that of the tissues of the whole animal, has been supposed (11). However, Meyer (19), injecting streptococci intraperitoneally in guinea pigs, concluded that prontosil does not prevent the growth of bacteria, for in treated pigs, killed after a time, billions of organisms were found. The treatment promoted phagocytosis and seemed to diminish virulence and inhibit toxin formation. It is believed (13b) the stimulation of granulocytic and monocytic phagocytosis is favored by injury to the organisms rendering them more susceptible; or that capsular produc tion by streptococci may be interfered with (17) and a neutralizing effect upon the leucocidins and hemolysins of streptococci in vitro is shown. However, in an excellent study (16) of the effects of sulfan ilamide upon hemolytic streptococcus infections ("Stoddard" and SNOWDEN AND BELL— SULFANILAMIDE THERAPY 47 "Pion" strains) in mice and guinea pigs no qualitative differences in histologic response were noted in treated and untreated animals. There was little or no evidence of increased phagocytic activity h\ either granulocytic or reticuloendothelial cells. The presence of masses of organisms in both treated and untreated animals does not favor the suggestion that the bactericidal activity of the blood, supplemented by that of the tissues as a whole, can account for the favorable effect of sulfanilamide. There was no evidence that phago cytosis was a factor in obtaining favorable therapeutic results. Possibly some of these variable results can be explained by exper imental results rc"nntly reported by Finklestone-Sayliss and asso ciates. (18) These investigators report that the bacteriostatic action of sulfanilamide on streptococci seeded into fibrinated serum varies markedly depending upon the age of the culture. Using an 8- hour strain the action during the first 4 hours is that of a marked growth stimulation. During the next 4 hours the growth, curve presents an even more precipitous fall. Older cultures are propor tionately less responsive. These investigators noted that sulfanil amide is far more soluble in the fatty envelope of the streptococci than it is in aqueous solution, and that, the fatty envelope decreases with age. They are of the opinion that the chemical acts first as a stimulant and later as a depressant. This stimulatory action was also demonstrated in animal experimentation. They could demon strate neither stimulation nor depression of phagocitic activity, and confirmed Colebrook's findings that the bactericidal action of sulfan ilamide does not require the presence of leucocytes. Sulfanilamide was found to have a definite stimulatory action on the granulocyte production in that crises would occur when the total white cell count might reach 30,000. They report that the chemical's action on the bone marrow has little effect on hemopoietic function although showers of abnormal nucleated red cells may occur during the crises. There was apparently no stimulation of the reticulo-endothelial system, although the phagocytic activity of these cells was definitely increased. Animals that died under treatment had petechial hemorrhages in the gastric mucosa, muscles, and connective tissue. Certain conclusions are apparent: 1. Sulfanilamide is bacteriostatic and bactericidal in vitro. 2. Results relative to destruction of organisms in the peritonea! cavity are contradictory. 3. A diffuse peritonitis does follow the intraperitoneal injection of organisms in spite of therapy. 4. Sulfanilamide therapy none the less does preserve life despite the multipli cation of organisms. 5. It results in less dissemination, greater localization, and more rapid healing of the infection. 48 SNOWDEN AND BELL SULFANILAMIDE THERAPY 6. The evidence suggests its action in vivo is antitoxic, possibly also antibac terial. 7. That phagocytosis is an important factor is questionable. A colorimetric method has been devised (24) for deternuning the concentration of sulfanilamide in the body fluids. The human ex cretes the drug in unchanged and conjugated form. The latter is mainly para-acetylamino-benzene sulphonamide. Their relative importance in effecting a clinical cure remains conjectural. The conjugated derivative is nearly inactive (24). Acetylation and diazotization of sulfanilamide destroys its activity (12). The urine of patients excreting sulfanilamide has no bactericidal activity against beta-hemolytic streptococci (20) but it has been found capable of destroying the bacteria usually causative of urinary infections (21). Experimental results (6), (13b), (16) indicate that the maximal curative result is exerted by maintaining a high concentration of this substance in blood and tissues for several days. A blood level of sul fanilamide of 10 milligram percent is therapeutically satisfactory (6f). The optimum dosage for this attainment varies. It lies near 15 or 20 grains four times daily. This is much less than the 1 gram per kilo dosage commonly used in animal experiments. It compares favorably with the results obtained in streptococcus infections in mice (1) using one-tenth to one-fiftieth of the tolerated dose. Differences in absorp tion rate exist in humans (24). Absorption is nearly complete in 4 hours. For this reason divided doses are preferable. Equilibrium between intake and output is established in 2 to 3 days and then nearly 100 percent of the intake may be recovered from the urine. The toxic effects of this drug are frequent but usually not alarming. They soon subside after withdrawal. Large amounts of fluid act as an antidote. Apparently few fatalities have occurred (36). The toxicity is low. The minimal lethal mouse dose following single sub cutaneous injections in olive oil is 6 grams per kilo of body weight. Two grains or more per kilo produces spasticity of the extremities, excitability, and incoordination. They tolerate 1 grain per kilo in definitely. Similar symptoms have been noted in humans (26) including toxic optic neuritis (27), mental dullness, confusion, lassi tude, giddiness, and sleepiness are common. These toxic effects are usually mild, appear early during drug ingestion, and either disappear or are well tolerated after 48 hours even if treatment is continued. Cyanosis occurs in up to 75 percent (6f) of cases. It is best ob served by slaty nail beds and bluing of the lips of varying intensity. It may be associated with methemoglobinemia, an aniline effect, not unexpected, since sulfonanilamide is an aniline derivative. It also contains a sulfamido group. Sulfhemoglobinemia occurs (6f), (15), (21), (22), and the administration of sulfates is thought to be pre disposing. The sulfhemoglobin is slowly removed from the blood SNOWDEN ASD BELL SULFANILAMIDE THERAPY 49 having been observed 6 weeks after drug ingestion ceased (21). Methemoglobin disappears in 24 hours. Spectroscopic examination of the blood is a more delicate means of detecting sulfhemoglobinemia than is clinical observation of cyanosis (21), (24). A fall in the blood COi combining power is frequent (6f) having been found in 15 consecutive cases (23). A febrile reaction was noted in 15.6 percent of cases (33), and must be differentiated from a bacterial effect. It may develop during the first day or two of drug ingestion but occurs more frequently following prolonged therapy. Various subjective symptoms of toxicity ac company the fever and other objective findings are commonly present. A dermatitis was noted in 9 of 21 cases (33). Cutaneous eruptions are frequent (28), (29), (30), (32), (34), (35) and vary from a maculo- papular erythema to purpuric areas (29), (33) with intense pruritis often present. These eruptions usually occur on exposed areas and are attributed to exposure to sunlight (30), (34), (35) due to a photo sensitizing property of the drug. Both dermatitis and febrile reaction may appear after reduction in dosage or even after the drug is dis continued. They may disappear even though treatment is continued and rapidly subside after drug withdrawal. The administration of small doses of the drug has been noted to induce toxic recurrences (29), (30), (31), (32) and positive patch tests are reported. However, this evidence of cellular sensitizing properties is not universally found for negative intradermal and patch tests, absence of precipitins in the blood serum and passive senistization tests in humans and guinea pigs have yielded negative results (33). A depression of hepatic function is revealed by the bromsulphalein test (37) and jaundice may develop (13a) (33). This subsides upon drug withdrawal. In one case (13a) the subsequent administration of large doses of sulfanilamide failed to provoke a recurrence. Renal irritation does not occur (6f) but the drug is excreted slowly by damaged kidneys. In such patients cessation of therapy is indi cated when blood levels reach 15-20 milligram percent. The drug may exert a profound effect upon the hematopoetic system. Since it contains a benzene ring this is not unexpected. Apparently certain persons are more susceptible, i. e., have a sulfanilamide idio syncrasy. Granulocytic maturation may be inhibited and one death has been attributed (36) to agranulocytosis. However, many case reports indicate that granulocytic stimulation also occurs and leuko cyte counts up to 83,000 have been reported. The relative importance of the underlying infection must be assessed but some cases show an increase of immature granulocytic cells after institution of therapy. A moderate eosinophilia is not uncommon. The red blood cells are also attacked, producing acute hemolytic anemia, 5 cases (38), 5 cases (37), and 1 case (31). Skin testing and repetition of therapy after .-)() SNOWDEN AND HELL — SULFANILAMIDE THERAPY recovery has failed (37) to provoke a recurrence. The anemia is associated with the appearance of nucleated red blood cells, poly- chromatophilia, anisocytosis, and poikilocytosis. The serum bili rubin is increased and urobilinuria occurs. The drug sulfanilamide has been accepted for New and Nonofficial Remedies (3) as a therapeutic agent for the treatment of infections by hemolytic streptococci of Lancefield's serologic group A. This includes most of the hemolytic streptococci causative of acute severe infections in man. It has been used successfully in mouse protection experiments with meningococcus infections (6a, b, d, e) and in similar infections in humans (6c, f). Another compound (disulfanilamide) possesses a better therapeutic index in streptococcus and menin gococcus infections if given subcutaneously (6d). The effectiveness of sulfanilamide in meningococcus infections suggested its use in those due to the gonococcus which is closely related biologically. A series of 47 cases of various types of gonococcic infection of the genito-urinary tract has been reported (9). In 36 cases the gonococci and the urethral discharge disappeared in less than 5 days. In five cases the subjective symptoms disappeared completely; there was a marked diminution in the urethral discharge, but the gonococci were still present. Three cases showed no response to the drug. Three other cases showed prompt response, but treat ment was discontinued and the infection recurred. In two of these cases it disappeared following a second course of treatment. In no instance was there a progression of the infection. The possibility of late recurrences was recognized. The prompt subsidence of burning and frequency was noted. Alcohol and sexual excitement were pro hibited. Another report (10) of 100 sulfanilamide treated cases (40 grains daily) included 40 new infection cases with 3 treatment failures and 60 old infection cases with 7 treatment failures. The average length of time for clinical recovery was 5 days. The criterion for cure was the disappearance of microscopic pus from the urine, absence of pus from the prostate gland, loss of all symptoms and the failure of recurrence. In a third report of 31 cases of gonorrhea (25) 4 were classed as failures. Two failures were males with symptoms after a week of therapy. Two were women with positive cultures at the conclusion of treatment. One case of arthritis responded nicely. In these cases once clinical cure was established a daily dose of 20 gi ains was continued for 10 to 14 days. The clinical observations reported present unusual optimism. There is need for reporting of clinical controls. A survey of sul fanilamide treated cases is presented. The diagnosis of gonococcic infection was made on the demonstration of gram negative intra cellular diplococci of typical morphology and distribution in the stained smear of yellowish urethral discharge which appeared in from SNOWDEN AND BELL SULFANILAMIDE THERAPY 51 3 to 10 days following sexual exposure. All cases were restricted to the ship thus restricting alcohol and sexual exposure. No local, oral or dietary measures were instituted. These patients continued ambulant and performed their routine duties. The only treatment given during the period covered by this report was sulfanilamide orally. The dosage varied slightly in certain cases but approximated 4 grams daily for 2 days, then 2 grams daily for G days and 3 grams daily for 6 more days. Each case was observed daily. At least every other day the amount of urethral discharge was noted and gram stained and the two-glass urine test recorded. Each case was charted but due to lack of space only one representative chart is presented for each group. CASE REPORTS The 15 cases studied are subdivided as follows: Recent infection cases reacting favorably, 5 Case 1.—J. F. M., seaman second class. Exposed July 1, 1037; initial symptoms July 3, 1937. Presented with profuse purulent urethral discharge. Meatus acutely inflamed. Two-glass test, cloudy— clear. July 6, 1937: Sulfanilamide started. July 14. 1937: White blood cells 6,650, hands 5, segs. 60, lymphs. 32, monos. 2, eoains. 1. July 16, 1937: Two-glass test, clear— clear. Discharge— none. Smear of urethral scraping positive. July 20, 1937: Smear of urethral scraping positive. July 23, 1937: Smear of urethral scraping positive. July 25, 1937: Sulfanilamide discontinued. July 30, 1937: Smear of urethral scraping negative. Prostate normal to pal pation. Secretion contains 1-2 leukocytes per high-dry field. No organisms. August 5, 1937: Prostate normal. Smear negative. Cane 2. —J. Y. M., seaman first class. Exposed July 12, 1937. Presented July 17, 1937 with a slight urethral discharge. Meatus not inflamed. Two-glass test, cloudy —clear. Sulfanilamide started. July 21, 1937: Smear positive. July 22, 1937: Smear negative and continued so through August 5, 1937. August 1, 1937: No discharge. Two-glass test, clear— clear. August 4, 1037: Prostate normal. Expressed secretion shows many leukocytes, no organisms. Sulfanilamide discontinued. Cafe ?..—A. D. H., ship's cook third class. Exposed June 22, 1937. Presented June 29, 1937 with slight purulent urethral discharge. Meatus not inflamed. Two-glass test, shred— clear. Sulfanilamide started. July 12, 1937: No discharge; two-glass test, clear— clear. Smear negative. Sulfanilamide discontinued. July 21, 1937: Smears continue negative. Prostate slightly enlarged, not indurated. Expressed secretion contains 1 2 leukocytes per high-dry field. No organisms. Toxic symptoms- slight dullness. Case 4-—U. S. S. Mississippi, 11. R. B., seaman first class, Division C. Exposed July 12, 1937. Initial sympton July 14. 1937. Reported for treatment July 16, 1937. Present symptoms: Slight yellowish urethral discharge. Burning upon 52 SNOW'DEN AND BELL SULFANILAMIDE THERAPY urination. Meatus not acutely inflamed. Laboratory report shows many intra and extracellular gram negative diplocoeci. Many pus cells. Chart I No. dais infected 1| s, r, 9,111s16|1719,212s 262729 ,s1,sss0,s7,s;'1143M 47496115sbl 6759 2 Class test |[J | 1 1 1 1 1 1 . 1 1 J 1 1 Cloud ill .od .? " 1 1 1 1 1 1 1 , 1 1 Cloud Cloud 1 i 1 1 1 i 1 1 1 1 1 1 I Cloud Haxe lei 1 1 1 1 1 1 1 [ i i i i 1 1 Hue Haze 1 | 111 i 1 C1..U.1 Clear ivl 1 | 1 1 1 1 1 | Hate Omj > 1 1 | 1 Shred Clear 1 1 1 1 ' 1 1 1 1 1 Clear Clear _i | : 1 1 1 1 gl... 2 01Hss i > 1 a 34 1 1 I'rofose Purulent > 1 1 1 Slirtt 1vl 1 1 1 1 1 1 1 1 1 > 1 1 1 1 Intermittent Kl I 1 1 1 1 1 1 1 1 1 1 1 1 A. M. Tear 1 1 1"V : 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 None I11 Ml 1 1 1 1 1 1 1 1 1 Sulfainlamide 16| 1 i i i i i i i i i i i i 1 1 1 drams daily «_ 1 1 1 1 1 1 1 1 i i 1 1 1 1s1 1 t-i i i ii i i 1 1 1 1 1 1" 1 1 i i I i . - L 1 1 1 111 1 1 1 1 1 1 1 i i i i i i i 1 1 1 i 1 GcDocoeel. Laboratory report ooel. Many ~T" gram nt-K intra or extra cellular diplo.^or * jeLLL i i IX1' 1. July 22, 1937: W. B. C. 6,350. Hgb. 85 percent. Differential: Bands 8, seg. 66, lymph. 24, mono. 2. 2. July 28, 1937: W. B. C. 7,800. Hgb. 85 percent, R. B. C. 4,580,000. Differ ential: Bands 5, seg. 64, lymph. 27, mono. 3, baso. 1. 3. August 1, 1937: Prostate normal. Expressed secretion normal. 4. August 3, 1937: Prostate normal. Expressed secretion normal. Cast' o.—J. C. F., seaman second class. Exposed July 25, 1937. Presented July 28, 1937 with scanty urethral discharge. Two-glass test, haze— clear. Sul fanilamide started. July 31, 1937: No discharge. Two-glass test, clear— clear. Smear of urethral scrapings negative. August 6, 1937: Sulfanilamide discontinued. August 12, 1937: Prostate enlarged, not indurated. Expressed secretion con tains many leukocytes, no organisms. Smears of urethral scrap ngs have re mained negative. Recent infection cases reading unfavorably, 6 Case 6.—J. K. K., ship's cook second class. Exposed June 12, 1937. Presented June 23, 1937 with a profuse purulent urethral discharge, meatus acutely inflamed. Two-glass test, cloudy —clear. Sulfanilamide started. July 1, 1937: White blood cells 7,100, bands 8, seg. 62, lymphs. 26, monos. 4. July 21, 1937: White blood cells 7,500, bands 10, segs. 60, lymphs. 23, monos. 4, eosins. 1, baso. 2. Two-glass test, haze — haze. Discharge— morning tear. Smear positive. July 27, 1937: Differential white blood cells: Bands 2, segs. 68, lymphs. 18, monos. 3, eosins. 9. Two-glass test, haze—haze. Discharge consists of morning tear. Sulfanilamide continued. August 5, 1937: Morning tear positive for gram negative intracellular dip locoeci. Prostate slightly indurated and nodular. Secretion contains many leukocytes, no organisms. SNOWDEN AND BELL SULFANILAMIDE THERAPY 53 Cafe 7.—E. E. C., seaman first class. Exposed June 8, 1937. Presented June 11, 1937 with a profuse purulent urethral discharge, itching and burning on urination, meatus acutely inflamed. Two-glass test, cloudy — cloudy. Sulfanila mide started. June 30, 1937: Epididymitis, acute right — in bed 4 days. July 22, 1937: White blood cells 7,450, bands 8, segs. 65, lymphs. 25, monos. 2. August 9, 1937: Prostate slightly enlarged, irregular, not tender. Expressed secretion contains many leukocytes and gonococci. Two-glass test, haze —haze. Discharge slight and positive for gonococci. Sulfanilamide discontinued. Case ft.—T. N. J., seaman first class. Exposed July 4, 1937. Presented July 7, 1937, with a purulent urethral discharge and acutely inflamed meatus. Two- glass test, shred—clear. Sulfanilamide started. July 11, 1937: Two-glass test, cloud —haze. July 15, 1937: Two-glass test, shred— clear. Discharge had decreased to morning tear. July 19, 1937: Discharge profuse and purulent. July 27, 1937: White blood cells 7,000, bands 2, segs. 43, lymphs. 50, monos. 2, eosins. 2, basos. 1. July 31, 1937: Discharge profuse, positive for gonococci. Prostatic infection present. August 6, 1937: No change. Sulfanilamide discontinued. Case 9.—H. G. M., seaman first class. Exposed June 27, 1937. Presented July 4, 1937, with a scanty yellowish urethral discharge. Two-glass test, cloudy — clear. Sulfanilamide started. July 21, 1937: White blood cells 4,700, bands 10, segs. 70, lymphs. 16, monos. 4. July 29, 1937: Urethral discharge intermittent and positive for gonococci. Two-glass test, haze —clear. Sulfanilamide discontinued. Case 10.—U. S. S. Mississippi, H. E. L., fireman first class, division B. Ex posed June 20, 1937. Initial symptom June 22, 1937. Reported for treatment June 23, 1937. Present symptoms: Profuse purulent urethral discharge. Meatus inflamed. Laboratory report shows many leukocytes, many gram negative intra- and extra-cellular diplococci. See chart II. Chart 11 i 1335 .7J 1!14s4 . 17rj 5153.74575'J No. days 113: 5| 7 11113IS :T 19|212s 25-2729 31 2 Glass teat 1 1 1 1 1 1 1 1 M i 1 Cloud Blood -ft!- 1 1 1 1 1 1 1 1 1 1 1 1 1 l 1 1 Cloud Cloud Cloud Haw 'n /\ 1 1 1 1 1 1 i 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Ii Sua Haze r4. 1 i 1 1 1 1 , 1 1 1 i 1 1 M 1 1 1 i 1 1 Cloud Clear I l 1 i i i 1 1 1 1 l 1 i Hale Clear i i i i l l 1 i l i l ll 1 1 1 1 1 1 1 1 1 1 1 Shred Clear 1 1 1 1 1 1 I1 1 1 1 1 || 1 1 i 1 1 l 1 I 1 1 Clear Om l 1 l l . i ; i i 1 l 1 Mill 1 gla» 2 C.1.M 1 i il 2 1 i ,3 i 1 . 111 i Discharge Purulent □ i l l ll l i 1 | —ShJEht— ill! • 1 ill; ; i i i i i i i i i i 1 1 i i i i 1 Sulfanilamide 61 1 Ml 1 1 M 1 1 1 M 1 1 1 1 1 Grams dally 4- 1 i i l i i i i i i 1 1 1 1 1 1 1 1 i ' 1 ' 1 ' 'i 1 i r* — i — i — 1 —i—1— -t- 1 1 1 1 1 1 1 1 1 1 i ' 1 l l l i l l i i i i l l 1 i i i i l ll 1 1 M 1 1 1 1 1 1 1 1 1 1 1 1 1 ' 1 1 Laboratory report , ny Laboratory re; Gonooocei. jjg Moderate . □ 1X1 1 1 1 1 M 1 3d X 1 Gram neK intra or extracellular diplo. •or * 1XJX XX J X1 X ! 3 1X1 1 1 1 1 1 1 1 1 1 1 1 1 I 1 1 KXX X 1X1 □ 1 1 1 5-1 SNOWDEN AND BELL SULFANILAMIDE THERAPY 1. July 1, 1937: White blood cells 8,100. Differential: Bands 8, segs. 68, lymphs. 18, monos. 5, cosin. 1. 2. July 15, 1937: White blood cells 6,500. Differential: Bands 5, segs. 47, lymphs. 35, monos. 6, eosins. 5, basos. 2. 3. July 31, 1937: Prostate increased in size, nodular and indurated. Expressed secretion shows many leukocytes and scattered groups of gram negative diplococci. 4. August 12, 1937: Prostate is indurated and nodular. Expressed secretion shows a few gonococci. Case It.—S. N. L., seaman first class. Exposed June 22, 1937. Presented June 29, 1937, with a profuse urethral discharge and an acutely inflamed meatus. Two-glass test, cloudy — clear. Sulfanilamide started. July 15, 1937: Discharge profuse. Two-glass test, cloudy — cloudy. White blood cells 7,300, bands 8, segs. 50, lymphs. 26, monos. 5, eosins. 10, baso. 1. July 23, 1937: Complication — acute inflammation of distal tendinous insertion right rectus femoris. July 29, 1937: Discharge slight but positive for gonococci. Two-glass test, cloudy —cloudy. Sulfanilamide discontinued. Old infection cases reacting favorably, 2 Case 12 — T. M. G., private. Exposed April 2, 1937. Treated by local injections until June 6, 1937. at which time he presented a purulent urethral dis charge with an acutely inflamed meatus. Positive for gonococci. Two-glass test, shred— clear. There was a subacute prostatitis and he was recovering from a right epididymitis. Sulfanilamide started. June 11, 1937: No discharge. Two-glass test, clear— clear. Smear of urethral scraping positive for gonococci. June 17, 1937: Has continued to show no discharge. Two-glass test, clear— clear. Urethral scraping negative for gonococci, for past 5 days. Prostate is normal in size, shape, and consistency. Expressed secretion contains clumps of gram negative diplococci. June 25, 1937: Three prostatic examinations negative. Sulfanilamide discon tinued. June 29, 1937: White blood cells 9,300, bands 8, segs. 43, lymphs. 43, monos. 4, eosins. 2. Case 13. — C. G. H., seaman first class. Exposed April 15, 1937. Treated by local injections until June 7, 1937, at which time he presented a slight, purulent, G. C. positive, urethral discharge, inflamed meatus, a large, boggy, regular, slightly tender prostate and a two-glass test, cloudy —clear. Sulfanilamide started. June 15, 1937: No discharge. Two-glass test, clear—clear. June 23, 1937: Prostate normal in size and consistency. Expressed secretion loaded with leukocytes. No organisms. June 27, 1937: Prostate same. Expressed secretion contains 10-12 leukocytes per high dry field. June 29, 1937: White blood cells 6,000, bands 5, segs. 55, lymphs. 28, monos 7, eosin. 1, basos. 4. Sulfanilamide discontinued. July 1, 1937: Prostate normal. Old infection cases reacting unfavorably, ? Case l.'i. —1. N. R., seamen first class. Exposed May 28. 1937. Treated with local injections until June 19, 1937 at which time he presented a profuse, purulent. G. C. positive urethral discharge and an acutely inflamed meatus. Two-glass test, dourly — cloudy. Sulfanilamide started. SNOWDEN AND BELL SULFANILAMIDE THERAPY 55 June 29, 1937: No discharge, urethral scrapings G. C. positive. White blood cells 8,100, bands 6. segs. 45, lymphs. 38, monos. 5, eosins. 3. basos. 3. July 21, 1937: Discharge — purulent morning tear, G. C. positive. Two-glass test, haze —clear. White blood cells 9,300, bands 8, segs. 42, lymphs. 44, monos. 3, eosins. 3. Sulfanilamide discontinued. Cane 15.— E. L. R., seamen second class. Exposed May 1. 1937. Turned in May 31, 1937 because of an acute vasitis, right. Presented a scanty, yellowish, purulent, G. C. positive urethral discharge. Two-glass test, cloudy — cloudy. Prostatitis, acute. Seminal vesiculitis, acute. Sulfanilamide started. June 7, 1937: Epididymitis, right, acute—9 sick days. Discharge consists of morning tear, G. C. positive. June 22, 1937: Discharge same. Prostatitis still present. July 1, 1937: Prostate normal in size and consistency, not tender. Expressed secretion contains many leukocytes, no organisms. Vesicles not palpable. Right epididymis presents slight residual induration of globus major and minor. July 30, 1937: Discharge of morning tear, G. C. positive Prostate normal. Expressed secretion normal. White blood cells 6,100, bands 8, segs. 42, lymphs. 40, monos. 6, eosin. 1, basos. 3. Sulfanilamide discontinued. SUMMARY Of the 15 cases studied 4 were old cases in that their infection had been treated locally prior to the use of sulfanilamide. Eleven of the cases were recent infections. Of the old infection cases 2 reacted favorably, 2 unfavorably. Of the new infection cases 5 reacted favorably, 6 unfavorably. A patient's reaction was considered favor able if all symptoms and signs (including negative gram stain of the urethral scrapings) disappeared and there was no recurrence. The favorably reacting recent cases were definitely mild infections. They did not present profuse urethral discharge or the acutely inflamed, pouting urethral orifice so commonly noted. The two chronic cases wliich reacted favorably had been under treatment for some time. They were improving at the time this therapy was instituted. No severe toxic manifestations were noted. All patients complained of one or more of the symptoms: Lassitude, giddiness, confusion, or sleepiness. These were particularly noticeable during the first few days of therapy and tended to become less troublesome. One patient reported with an acute vasitis, right, and went on to develop an acute right epididymitis in 7 days in spite of sulfanilamide treatment. His course was unsatisfactory throughout. The epididymitis, however, proved quite mild and pain was not preeminent. Another case developed an acute teno-myositis which cleared up in 4 days. White blood cell and differential counts were done on 12 of the 15 cases. Four cases presented eosinophilia of 3 to 10 percent. No case developed jaundice, dermatitis, neuritis, or hemolytic anemia. The examination of many smears of the urethral discharge did not reveal any increase of phagocytosis of gonococci. 56 SNOWDEN AKD BELL SULFANILAMIDE THERAPY CONCLUSIONS In cases of gonorrhea sulfanilamide therapy causes: 1 . Prompt disappearance of urethral discharge in some cases. 2. Gonococci persist in urethral scrapings for several days after the subsidence of the urethral discharge. 3. Prompt subsidence of symptoms of burning and frequency in all cases. 4. Metastatic extension of the infection does occur. 5. Disabling complications which have occurred have run a short course, subsided quickly, and were attended by less fever, less pain, and less discomfort than usual. 6. No evidence of increased phagocytosis of gonoccoci was observed. 7. The rapid subsidence of discharge, symptoms, and urethral inflammation in favorably reacting cases suggests control of gonotoxin (19). 8. If a case does not react favorably within 2 weeks it is not likely to do so. Bibliography (1) Domagk, G. : Kin Beitrag Zur Chemotherapie der bakteriellen Infektionen. Deutsche Med. Wchnschr., 61: 250-3, 1935; Domagk, G.: Chemotherapie der bakteriellen Infektionen. Angew. Chem., 48: 657-67, 1935. (2) Chemotherapy in Streptococcic Infections, editorial, J. A. M. A. 108: 48 1937; Treatment of Streptococcic Infections with Sulfanilamide, ibid.; p. 976. (3) Council on Pharmacy and Chemistry, A. M. A.: Sulfanilamide and Related Compounds, J. A. M. A. 108: 1888, 1937. (4a) Trefouel, J. et Mme. J., Nitti, F., et Bovet, D. : Activity der P-amino- Phenylsulfamide sur les Infections Streptococciques experimentales de la souris et du lapin, Compt. rend. soc. biol., 120: 756-8, 1935. (4b) Nitti, F., and Bovet, D. : Les Septicemics Streptococciques Experimentales et leur traitement par le p-amino-phenylsulfamide. Compt. rend., 202: 1221-3, 1936. (5) Council on Pharmacy and Chemistry: "Sulfanilamide" (the Council name for Para-amino-benzene-Sulfonamide), J. A. M. A. 108: 1340, 1937. (6a) Buttle, G. A. H., Gray, W. H., and Stephenson, D.: Protection of Mice Against Streptococci and Other Infections by P-amino-benzene-sulfonamide and Related Substances. Lancet, 1: 1286-90, 1936. (6b) Proom, H : The Therapeutic Action of Para-Amino-beuzenesulfonamide In Meningococcal Infections of Mice, Lancet 1: 16, 1937. (6c) Schwentker, F. F., Gelman, S., and Long, P. H.: The Treatment of Menin gococci Meningitis with Sulfanilamide, J. A. M. A. 108: 1407, 1937. (6d) Rosenthal, S. M., Bauer, H., and Branham, S. E. : Comparative Studies of Sulphonamide Compounds in Experimental Pneumococcus, Streptococcus, and Meningococcus Infections, Pub. Health Rep., 52: 662, 1937. (6e) Branham, S. E., and Rosenthal, S. M.: Sulphanilamide, Serum, and Com bined Drug and Serum Therapy in Experimental Meningococcus and Pneumo coccus Infections in Mice, Pub. Health Rep., 52: 685, 1937. (6f) Long, P. H., and Bliss, E. A., Sc. D. : The Use of Para-Amino-benzenesul- fonamide or Its Derivatives in the Treatment of Infections due to Beta-Hemolytic Streptococci. Pneumococci and Meningococci, Southern Med. J., May 1937. SNOWDEN AND BELL—SULFANILAMIDE THERAPY 57 (7) Fuller, A. T.: Lancet, 1: 194, 1937. (8) Gley and Girard: Presse med. 44: 1775, 1936. (9) Dees, J. E., and Colston, J. A. C.: The Use of Sulfanilamide in Gonococcio Infections, J. A. M. A. 108: 1855, 1937. (10) Reuter, F. A.: The Use of Sulfanilamide in Treatment of Gonorrhea, Med. Annals of District of Columbia, Washington, 6: 117-152, 1937. (11) Colebrook, Leonard, Buttle, G. A. H., and O'Meara, R.: Lancet 2: 1323, 1936. (12) Rosenthal, S. M.: The Effect of P-amino-benzene-sulphonamide on Pneu- mococci in Vitro, Pub. Health Rep., 52: 192, 1937. (13a) Long, P. H., and Bliss, E. A.: Para-Amino-Benzene-Sulfonamide and Its Derivatives, Archives of Surgery, Feb. 1937. (13b) Long, P. H., and Bliss, E. A.: Para-Amino-Benzene-Sulfonamide and Its Deiivatives, J. A. M. A. 108: 32, 1937. (14) NItti, F., and Bovet, D.: Compt. rend. Soc. de biol. 119: 1277, 1935. (15) Colebrook, L., and Kenny, Meave: Treatment of Human Puerperal Infec tions and Experimental Infections in Mice with Ptontosil, Lancet 1: 1279, 1936. (16) Mellon, R. R., Gross, Paul, and Cooper, Frank B.: Experimental Studies with Sulfanilamide and with Prontosil, J. A. M. A. 108: 1858, 1937. (17) Levaditi, C., and Vaisman, A.: Compt. rend. Acad. d. sc. 200: 1694, 1935: Compt. rend. Soc. de biol. 119: 946, 1935 (quoted by (14) and 120: 1077 (1935) quoted by (12)). (18) H. Finklestone-Sayliss, C. G. Paine, and L. B. Patrick: The Bacteriostatic Action of p-Aminobenzenesulphonamide upon Haemolytic Streptococci, Lancet 2: 792-795, 1937. (19) Meyer, F.: Quart. Bull. Sea View Hosp., 2: 148, 1937. (20) Hill, Justina H.: Personal communication to authors of article (9). (21) Paton, J. P. J., and Eaton, J. C: Sulphemoglobinemia and Methemo globinemia Following Administration of P-Amino-benzenesulfonamide. Lancet, 1: 1159, 1937. (22) Discombe, G. : Sulphemoglobinemia Following Sulfanilamide Treatment, Lancet, 1: 626, 1937. (23) Southworth, H.: Proc. Soc. Exper. Biol. & Med., 36: 58, 1937. (24) Marshal, E. K., Jr., Emerson, Kendall, Jr., and Cutting, W. C.: Para- aminobenzenesulfonamide, J. A. M. A. 108: 953, 1937. (25) Buchtel, H. A., and Cook, E. N. : The use of Sulfanilamide in Treatment of Urinary Infections. Proc. Staff Meetings of The Mayo Clinic, 12: 444, 1937. (26) Whitby, L. : An Experimental Assessment of the Therapeutic Efficacy of Amino Compounds with Special Reference to P-Benzylamino-benzenesulfpnamide; Lancet 1: 1517-1519, 1937. (27) Bucy, Paul B. : Toxic Optic Neuritis Resulting from Sulfanilamide, J. A. M. A. 109: 1007, 1937. (28) Salvin, Monte: Hypersensitivity to Sulfanilamide, J. A. M. A. 109: 1038, 1937. (29) Goodman, M. H., and Levy, C. S.: The Development of a Cutaneous Eruption 1Toxicodermatosis), J. A. M. A., 109: 1009, 1937. (30) Frank, L. J.: Dermatitis From Sulfanilamide, J. A. M. A. 109: 1011, 193/. (31) Kohn, S. E.: Acute Hemolytic Anemia During Treatment With Sulfanil amide, J. A. M. A. 109: 1005, 1937. (32) Schonberg, I. L.: Purpuric and Scarlatiniform Eruption Following Sul fanilamide, J. A. M. A. 109: 1035, 1937. (33) Hageman, P. O., and Blake, F. G.: A Specific Febrile Reaction to Sul fanilamide, J. A. M. A. 109: 642, 1937. 24140—37 5 58 FIJLGHUM —SULFANILAMIDE THERAPY ANGINA (34) Menville, J. G., and Archinard, J. J.: Skin Eruption in Patients Receiving Sulfanilamide, J. A. M. A. 109: 1008, 1937. (35) Newman, B. A., and Sharlit, H. : Sulfanilamide: A Photosensitizing Agent of the Skin, J. A. M. A. 109: 1036, 1937. (36) Borst, J.: Death from Agranulocytosis After Treatment with Prontosil Flavum, Lancet 1: 1519-1520, 1937. (37) Harvey, A. M., and Janeway, C. A. : The Development of Acute Hemolytic Anemia (during the administration of Sulfanilamide), J. A. M. A. 109: 12, 1937. (38) Long (6f) quoted by (31). SULFANILAMIDE TREATMENT OF LUDWIG'S ANGINA By James E. Fulghum, Lieutenant, Medical Corps, United States Naval Reserve Ludwig's Angina is a diffuse cellulitis of submaxillary region and floor of the mouth which may eventuate in gangrene of the skin or mucous membrane. The swelling usually progresses rapidby, spreading toward the neck and upwards into the floor ot the mouth. The swelling is board-like resembling that seen in carcinoma of the neck. The floor of the mouth and tongue are elevated with the latter pushed toward the affected side. Sepsis is marked. In unchecked cases, the mor tality rate is high. The condition is usually secondary to extraction of teeth or infections of throat or tonsds and the invading organism is usually the streptococcus. The treatment heretofore has been early and adequate incision with drainage and hot fomentations. Streptococcus serum has been used. CASE REPORT This is a case report of a white female child, age 3 years, who had always been healthy with no history of any illness before the onset of present infection. Present illness. —Parents give a history of a fall 1 week prior to infection in which a small area of skin was abraded from the anterior surface of the chin. This was given first-aid care by the mother who applied mercurochrome. On August 22, 1937, during the late morning, the parents noted that the child was drowsy, ill, and fretful, had anorexia and some temperature. She refused food during the day of the 22d. She was put to bed on the same evening. During that night, she was extremely restless, cried out, and complained of pain in the sub maxillary region. The mother noticed a firm swelling in this region but thought that it was glandular. By early morning, the swelling had increased alarmingly fast and was then the size of an egg. The temperature rose steadily and by early morning was quite high. She could not eat or drink anything after 5 a. m. on the morning of the 23d. Physical examination. —I saw her at my office at 6 a. m., August 23, 1937. The swelling of the submaxillary region was about the size of a lemon and felt like carcinoma of the neck. It was quite tender and not movable. The tongue was pushed up into the roof of the mouth and the mouth could not be opened except FULGHUM —SULFANILAMIDE THERAPY ANGINA 59 enough to insert a tongue depressor between the teeth. The temperature was 102.5° and the child was acutety ill. There was a scab on the chin which was lifted off and a small amount of pus was obtained for a microscopic study. Smear showed short-chain streptococci. Gentian violet was painted on the abraded area. Blood: White blood cells, 16,300; red blood cells, 4,496,000; polys, 85 per cent; lymphs, 15 percent; haemoglobin, 80 percent. Urine: Reaction, acid; sp. gr., 1.020; albumin, negative; glucose, negative; micro, negative; color, red. Treatment. —I decided to use sulfanilamide as treatment since other diseases of streptococcic etiology have yielded to this preparation. Accordingly, 5 cubic centimeters of 25 percent sulfanilamide was given intramuscularly each 4 hours for 4 doses. The swelling did not increase any in size during the day of the 23d. The only sign of improvement was the fact that the child asked for water about 4:30 p. m. and drank freely. On August 24th, the child was seen again at 6 a. m. She was much brighter, temperature was 99.6°, and she was able to take liquid diet and fluids freely. By 12 noon, she was able to eat solid food in small quan tities. The swelling was decreasing in size slowly and the board-like hardness was not quite as evident. Blood: White blood cells, 18,050; polys, 94 percent; lymphs, 6 percent. During that day, three doses, 3.5 cubic centimeters each, of 2.5 percent sulfanilamide were given. The morning of the 25th, the child had improved rapidly, was playful, tempera ture was normal, and the swelling was still regressing. She was able to eat and food was asked for. Blood: White blood cells, 16,500; polys, 68 percent; lymphs, 26 percent; endothelial, 1 percent; eosinophils, 5 percent. On the 26th, the child was given 2 injections of 2 cubic centimeters each of 2.5 percent sulfanilamide. She was feeling well except for a mild acute bronchitis. She had a temperature of 99.5° which l thought probably due to the bronchitis. Blood: White blood cells, 11,000; polys, 64 percent; lymphs, 34 percent; eosin ophils, 2 percent. On the 27th, she was given one injection, 2 cubic centimeters of 2.5 percent sulfanilamide. The child appeared normal except for a small swelling of about the size of a small marble in the submaxillary region. This was not hard, neither did it fluxate. It seemed to be resolving without pus formation. Blood: White blood cells, 10,600; polys, 60 percent; lymphs, 38 percent; eosinophils, 2 percent. Patient was seen again on the morning of the 28th. Temperature was still normal and the child appeared to be well. Further rapid regression had occurred in the swelling, and still no pus formation. Sulfanilamide was given in 1.5 cubic centimeters dose and the patient discharged to return again in 3 days for further examination. Blood: White blood cells, 9,200; polys, 61 percent; lymphs, 38 percent; eosin, 1 percent. SUMMARY Ludwig's Angina in a 3-year-old child due to streptococci entering from lesion on chin, treated with sulfanilamide intramuscularly, with an arrest of the progress of the disease, and gradual regression of swelling without pus formation and rapid return to normal as compared to the usual surgical treatment. Although I am reporting only one case, I feel that we have a valuable medical treatment for Ludwig's Angina due to streptococci, and that by its use, the mortality rate of this dreaded condition will be greatly decreased. 60 HOGAN AND McKAMARA SULFANILAMIDE PSYCHOSIS PSYCHOSIS PRECIPITATED BY SULFANILAMIDE By Bartholomew W.Hooan, Lieutenant, Medical Corps, United States Navy, and Philip J. McNamara, Lieutenant, junior grade, Medical Corps, United States Navy This is a preliminary report of one of the cases of a series now being studied under the direction of the urological service, United States Naval Hospital, Washington, D. C. The object of the series is to aid in the determination of the role of sulfanilamide in the treatment of gonococcus infections. Complete results of this series will appear at a later date. CASE REPORT ' A. C, private, United States Marine Corps; age, 21; was admitted to this hospital August 27, 1937, from the marine detachment on duty at this ho-pital. Chief complaint. —Urethral discharge, frequency, burning and stinging on urination, and rattier constant severe pain in the perineum of 1 week's duration. Family history and past history. —Noncontributory as regards this illness. Present illness. — May be considered to date back to December 1935, at which time he had his first diagnosis of gonococcal infection of urethra. A concurrent prostatitis complicated his condition, but he was finally considered apparently well after extensive treatment ending June 1936. He entered the United States Naval Hospital, Washington, D. C, October 17, 1936, with diagnosis of gonococcus infection of prostate. He received treatment and was returned to duty December 28, 1936, with instructions to continue treatment as an ambulatory patient. About July 1. 1937, he was again considered apparently well but advised to have a periodic check-up on his prostate. On August 27, 1937, he was admitted again to thN hospital with the chief complaint mentioned above. Further information showed that he had occasional recent sexual exposures. Physical examination on admission was essentially negative except for a profuse purulent urethral discharge and a moderately enlarged, tender and indurated prostate. A smear of the urethral discharge was positive for gram negative intracellular diplococci. Blood studies were all normal. Kahn and Wasserman reaction were negative. Urinalysis was negative except for 3 to 6 white blood cells per high-power field. His diagnosis was considered to be gonococcus infection of prostate. Clinical course. —In the hospital consisted of bed rest and general supportive measures until August 30, 1937, 3 days after admission, at which time it was decided to start him on a course of sulfanilamide. He received 80 grains of sul fanilamide daily for 2 days; 60 grains daily for 9 days; and 40 grains daily for 6 days. On September 16, 1937, sulfanilamide was stopped because of disappear ance of complaints. Total dosage, 940 grains. On September 21, 1937, his pro static secretion was found to contain gram negative intracellular diplococci and a morning tear had returned. He was again started on sulfanilamide September 21, 1937, 80 grains daily for 2 days; 60 grains daily for 2 days. On September 24, 1937, he presented himself to the ward medical officer requesting something be done about "conditions in general", and in particular "the attitude" of his fellow patients and the hospital corpsmen. He was of the opinion that a con spiracy was on foot to bring about his discharge from the Marine Corps and he threatened to jump ship if action on his behalf wa.s not immediately obtained. He wondered if he was "slipping mentally and wanted to check up on this before things went too far." Further administration of sulfanilamide uas discontinued i Submitted for publication Oct. 25, 1937. O'CONNELL —SULFANILAMIDE FATALITY 61 this date and patient was transferred to the neuropsychiatrie service for observa tion and treatment. Total dosage sulfanilamide, second course, 280 grains. Up to this time his reactions had been normal and his conduct in the ward had been satisfactory. Complete blood studies, including quantitative blood sulfanilamide determinations had been done biweekly. Temperature, pulse, and respiration were charted daily. He remained under constant medical supervision and was restricted to the urological ward. He seemed to be tolerating the drug very well as far as could be determined by physical signs and laboratory date. The highest blood sulfanilamide concentration was 7.7 milligrams per 100 cubic centimeters. The lowest red blood count was 4,240,000 per cubic millimeter, with a hemoglobin of 81 percent. The lowest COj combining power was 52 volumes percent. Quantitative urine sulfanilamide determination showed good elimination. Eisumi of psychiatric findings. —Patient's past history shows him to have been somewhat unstable, a behavior problem, making a poor adjustment in his home and school life. He gave no history of previous nervous or mental illness. His father is a practicing physician. No family history of mental illness. While on active duty with the marine detachment at this station and for 3 weeks follow ing admission to the sick list he exhibited normal behavior. His psychotic picture was characterized first by mild paranoid feelings with apprehension and restlessness. He became acutely psychotic, entertaining audi tory and visual hallucinations with a fairly clear sensorium. He stated that he saw, his relatives around the hospital and that his mother was talking from the floor above. The picture continued to resemble a toxic delirium, dreamlike fancies and bewilderment. Because of his desire to escape to locate his mother, he was transferred to St. Elizabeths Hospital, where he has made and maintained a gradual improvement at this writing (Oct. 25, 1937). SUMMARY 1. A case of gonococcus infection of prostate was treated over a period of 3 weeks with sulfanilamide. 2. An acute onset of a psychotic condition was apparently precipi tated by the administration of sulfanilamide. 3. The psychotic picture resembled that usually seen in toxic psychoses. 4. One month later, following the withdrawal of the drug, there is a definite improvement in the mental state. SULFANILAMIDE POISONING Report op Fatal Case By I. T. O'Connell, Lieutenant Commander, Medical Corps, United States Navy R. S. C., seaman, first class, was admitted to the United States naval hospital, San Diego, Calif., September 25, 1937. Chief complaint. —Sore throat and fever. Family history.— Father died of influenza at 35. Mother died of influenza at 30. No brothers or sisters. Denies familial diseases. *tr#tp*i&S »^f'*t«**|(i Past history.—Born in Texas. Had the usual childhood diseases. Enlisted October 1934, and has had continuous service since. Operations: appendectomy, 1936. Illness, gonorrhea, 1935-37. Denies syphilis. 62 OCONNELL SULFANILAMIDE FATALITY Present illness. —Last night patient had a severe chill followed by fever, and he reported to the sick bay. This morning his throat became sore and he was transferred to this hospital. Temperature on arrival, 104.4; pulse, 126; respira tion, 28. Patient's health record shows that he had been under treatment for chronic gonorrhea treated with sulfanilamide as follows: September 1, 1937, 70 grains. September 2, 1937, 70 grains. September 3, 1937, 55 grains. September 4, 1937, 55 grains. September 5, 1937, 55 grains. September 6, 1937, 30 grains. September 7, 1937, 30 grains. During this course of treatment blood counts were made and no change was noted. On the sixth day of treatment he had white blood cells, 5,650; 75 percent polys; red blood cells and hemoglobin normal. Treatment was discontinued after the seventh day because he developed acute catarrhal fever. ln a couple of days he was feeling well and the urethral discharge had stopped. When he reported to the sick bay on his ship last night he had a mild sore throat and was given routine "cold" treatment. His temperature was 102.0. This morn ing his temperature was 104.4; pulse, 130; respiration, 34. White blood cells, 3,500; polys, 0 percent; lymphs, 99 percent; monocytes, 1 percent; red blood cells, 3,910,000; hemoglobin, 80 percent. He was transferred with a diagnosis of agranulocytosis. Physical examination. —Well-developed and well-nourished young white male of 22 lying in bed and appearing acutely ill, but rational and clear mentally. Head: Eyes: Pupils equal, regular, and react normally. Conjunctivae icteric. Nose and ears: Negative. Mouth: Tongue negative. Teeth in good repair and hygiene. Throat red dened and inflamed. No ulcerations. Tonsils inflamed but not mark edly. Neck: Anterior cervical glands palpable. Chest: Lungs: Negative to percussion and auscultation. Heart: Normal position. Rate and rhythm regular and very rapid. No murmurs. Blood pressure, 110/60. Abdomen: Rounded and soft. Appendectomy scar, right rectus incision. Genitals: Negative. No urethral discharge. Extremities: Reflexes normal. Rhomberg negative. Treatment and clinical course. —September 25, he received 1,000 cubic centime ters of saline solution intravenously. At 9:30 p. m. he received 10 cubic centi meters of pentnucleotide. September 26. He was made a strictly bed patient with forced fluids and liquid diet and pneumonia jacket. White blood count, 650; lymphs, 100 percent; urine, 20 milligrams albumin. He received 10 cubic centimeters of pentnucleo tide at 9:30 a. m., 2 p. m., 6 p. m., and 10 p. m.; deep X-ray therapy, long bones; and morphine p. r. n. At 4 p. m. his temperature was 105.0; pulse, 140; respira tion, 32. September 27. Twenty-four-hour fluid intake, 2,905 cubic centimeters, output 1,690 cubic centimeters. Red blood cells, 3,110,000; hemoglobin, 90 percent. Patient had considerable edema of the throat for which an ice collar was used. HERING SULFANILAMIDE THERAPY GONORRHEA 63 He received 5 cubic centimeters of ieucocytic extract intramuscularly at 11 a. m., 4:30 p. m., and 10:30 p. m. He was given 325 cubic centimeters of blood by indirect method at noon, and 1,000 cubic centimeters of normal saline by hypodermoclysis at 4:30 p. m., and a similar amount with 5 percent glucose intravenously at 10:30 p. m. September 28. Swelling of the neck increased; patient became semicomatose and was placed on the critical list. Oxygen tent was applied at 5:20 a. m. Temperature, 102.0; pulse, 142 and weak; respiration, 33. Red blood cells, 3,240,000; white blood cells, 500; lymphs, 100 percent. At 1:40 p. m. his blood pressure was 84/58 and white blood cells, 650; lymphs, 100 percent. Urine, specific gravity, 1.015; albumin, 30 milligrams; positive for red blood cells and occult blood with a few granular casts. Kahn, negative. Patient received morphine one-fourth grain at 0040 a. m. and 9:45 p. m.; leucocytic extract, 5 cubic centimeters at 10:30 a. m. and 10 cubic centimeters at 6:10 p. m. intramuscularly; blood transfusion, 200 cubic centimeters of citrated blood at 11:45 a. m.; normal saline 1,000 cubic centimeters by hypodermoclysis at 5:00 p. m. and 1,000 cubic centimeters normal saline with 5 percent glucose intravenously at 10:00 p. m. At 10:50 p. m. patient became cyanotic, and an airway device was inserted for relief. He failed to respond to coramine at 11:15 p. m. and died at 11:34 p. m. September 28, 1937. Autopsy findings. — 1. Agranulocytosis. 2. Edema of the glottis. SUMMARY This patient was hospitalized because of a sore throat and fever of overnight duration. The blood picture showed a total absence of granulocytes, confirming the diagnosis under which he was admitted. There was a history of taking 365 grains of sulfanilamide over a period of 7 days 3 weeks ago. The patient was critically ill with ulceration and swelling of the throat. The hemopoietic system failed to respond to X-ray therapy to long bones, "Pentnucleotide" Ieucocytic extract, or two blood transfusions. The leucopenia with agranulocytosis persisted and the patient died after 3 days' illness. A 100-tablet bottle of Prontylin (Winthrop) containing 22 5-grain tablets was found in the patient's effects. This finding would suggest that he may have taken an unknown amount of sulfanilamide in addition to that prescribed. RESULTS OF SULFANILAMIDE THERAPY OF GONORRHEA By E. R. Hering, Lieutenant, Medical Corps, United States Navy The use of sulfanilamide in the treatment of gonococcus infections was instituted at the United States Marine Corps Base, San Diego, Calif., on June 9, 1937. The observations noted in this paper cover the period from that time until August 28, 1937. The data reported in this paper covers the observations on 46 cases of gonorrheal infec 64 HERING SULFANILAMIDE THERAPY GONORRHEA tion and a group of 15 cases of post-gonorrheal involvement where no positive smears could be obtained, streptococci infection of the throat, and cellulitis of various parts of the body. These 15 cases are included to show the percentage of reactions occurring in a total of 61 individuals treated with sulfanilamide. NEW CASES This group comprised 29 cases which were seen within the first 2 days of beginning of symptoms, and which had had no other type of treatment. Table I shows the results obtained in these 29 cases. Classification A, table I, includes those cases which were symptom free within 5 days and which, after observation of from 1 week to 2 months, have remained so. Two-glass tests and smears on these cases have all been negative, and they have been considered as cures. Classification B, table I, includes those cases which were cleared up within 30 days. Most of these cases showed negative smears after 15 days, and the infection ran a very mild course. In some of these cases silvol, 5 percent, was given by urethral injection and served to dry up the mucous discharge after smears were negative. Classi fication C, table I, includes those cases which still showed positive smears after 30 days' treatment with sulfanilamide and were considered as failures, although the sulfanilamide was considered of possible value in preventing complications. Table I Cases Percent 12 7 10 a Classification B 34 34 Classification C CHRONIC CASES This group comprised 17 cases which had had more or less con tinuous urethral discharge for a period of from 2 months to 2 years. All of these cases had positive smears when treatment with sulfanila mide was started. Table II shows results obtained in this group. Classification A, table II, includes those cases in which discharge was completely stopped and smears were negative after 6 to 8 days' treatment. It is not presumed that all these cases in classification A were completely cured. However, most of these cases were ones that reported to the sick bay as soon as they learned that sulfanilamide was being used {2){ months ago), and have since that time shown no clinical evidence of gonorrheal infection. Classification B, table II, includes those cases that showed no clinical response to sulfanilamide within 30 days. This group is especially interesting because of the complete and rapid amelioration of symptoms after various other HERING SULFANILAMIDE THERAPY GONORRHEA 65 forms of treatment over a period of from 2 months to 2 years had failed. Table 11 Cases Percent I5 88 12 Cassiflcation B 2 Total 17 MISCELLANEOUS CASES This is a group of 15 cases including streptococcic infection of the throat, cellulitis of various parts of the body, and nonspecific ure thritis and prostatitis. They were not of a sufficient number to form a basis for any definite conclusions, but are included in order to com pile the percentage of reactions in the total of 61 cases which were given sulfanilamide. DOSAGE When the drug was first used, it was customary to give 30 to 45 grains daily for the first 2 days and then raise the dosage to 60 grains daily for the next 3 days, depending on how the case was progressing. As we became more familiar with the drug, we started with 80 grains daily for the first 2 days followed by 60 grains daily for the next 3 days, and then gradually decreasing the dose until 10 days' treatment had been given. No better results appeared to have been achieved by this method, and we now give the drug in the following manner: Grains daily 3 days * 60 3 duys 45 3 days 30 3 days.- 15 Total, 12 days 450 The tablets are given three times daily, after meals. REACTIONS Reactions from sulfanilamide were divided roughly into three main types, viz., skin, constitutional, and renal reactions. Some of the cases showed a combination of the skin and constitutional types, but they are listed under the classification of their most predominant symptoms. Skin reactions. —These reactions varied from a slight papular rash on the hands, arms, face, and neck to a severe involvement of the same areas with marked edema and weeping eczematoid lesions. These reactions occurred from the second to the eighth day of treatment and lasted from 2 to 5 days, depending on their severity, following discon tinuance of the drug. Figure 1 illustrates a severe form of this skin reaction. 66 HERING —SULFANILAMIDE THERAPY GONORRHEA In all there were 12 skin reactions in the group of 61 cases. How ever, there were only three which could be classified as severe, the other nine being of very little consequence. It is interesting to note that the manifestations appeared on the surfaces of the body exposed to the weather, and the three severe cases had been exposed to the direct rays of the sun during the whole day previous to the occurrence of the eruption. Constitutional reactions. —This group consisted of four cases which gave symptoms of general malaise, headache, nausea, and some ver tigo. They were very mild, showing no rise in temperature, or pulse. Practically half of the cases in the entire series, on questioning, stated that they experienced some drowsiness, but these four were the only ones that had sufficient subjective symptoms to complain of volun tarily. The symptoms disappeared within 24 hours after discon tinuance of the drug. Renal complications. —This group consisted of four cases which developed what is believed to have been, for want of a better term, an irritative or chemical pyelitis. They showed a rise in temperature to 100°-103° F., and the urine showed a heavy concentration of pus cells. No casts or erythrocytes were found in the urine. All four of these cases developed their symptoms after the gonorrheal symptoms had disappeared, within 6 to 8 days after starting the treatment. Constitutional symptoms disappeared and the urine promptly became free of pus cells within 2 days after discontinuance of the drug. Classification of these four cases under the heading of renal complica tions may be misleading, but the fact that these four were the only ones of the entire series that showed a concentration of pus cells in the urine along with constitutional symptoms seems to point to some irritation of the kidney in this group. All of the Gl cases were given a complete blood count at least once during the course of treatment. At no time was there found any decrease in the blood elements. In fact, in most of the cases which had reactions, the leukocyte count showed a rise of from 3 to 5 thou sand with very little shift to the left. TREATMENT OF REACITONS The only treatment of reactions consisted of rest in bed, forcing fluids to aid in elimination of the drug, and large doses of sodium bicarbonate. During the latter part of this series, sodium bicarbonate, from 60 to 90 grains, was given daily in conjunction with the treatment as a prophylactic measure, but it is impossible to state at this time whether or not it was of much value. CONCLUSIONS 1. Sulfanilamide appears to have a specific effect on gonorrheal infection in a great majority of the cases. Figure 11 —Chondrodystrophy Fetalis. SARGENT—CHONDRODYSTROPHY FETALIS 67 2. It is most efficacious when used at the earliest possible moment, and its most striking effects take place within the first 5 days. 3. Sulfanilamide is especially efficacious in producing clinical cures in long-standing cases of gonorrhea. 4. Sulfanilamide appears to eliminate complications and lessen^the severity of the infection, even in those cases which do not respond immediately to the drug. 5. Sulfanilamide is capable of causing severe reactions, and should only be given under the strict supervision of a medical officer. 6. Direct exposure to intense sunlight appears to have some effect in increasing the severity of skin reactions. CHONDRODYSTROPHY FETALIS By Willabd S. Sargent, Lieutenant Commander, Medical Corps, United States Navy. This condition is also called achondroplasia or microlelia. It is more of a cartilage dystrophy than achondroplasia, therefore chon drodystrophy is probably a better term. It is a congenital affection in which the stature is small and at birth the legs and arms are proportionately smaller than the trunk; the latter may be of nearly normal size. ETIOLOGY The real cause is entirely problematic and unknown. Some say heredity plays a part in this disease and some say it does not. Both sexes are affected and it has been said that males transmit the disease. It has been attributed to placental changes or to intrauterine infection with consequent epiphyseal changes or destruction, which changes probably occur in the first half of intrauterine existence. Some, as might be supposed, blame the internal secretions and others have suggested a toxic basis. It has been present in as many as three successive generations of males. A person with the condition may have normal or abnormal children. PATHOLOGY It is essentially a dystrophy of the epiphyseal cartilages of the long bones — a disturbance of normal ossification. The cartilage atrophies and ossification occurs early, causing the bones to become distorted, the joints limited and growth retarded, and since it begins in utero, the earlier it starts the more marked the deformity. The cartilaginous skeleton essentially suffers and it rarely involves the membranous bones. The bones of the arms and legs are the ones mostly affected, but the tribasilar bone in the floor of the skull may be involved and ossify 68 SARGENT CHONDRODYSTROPHY FETALIS early, causing disproportion of the vault. The long bones become bowed and shortened and as the periosteum continues its usual func tion of bone formation the bones enlarge in diameter and the connec tive tissue from the periosteum invades the epiphysis, which unites prematurely with the diaphysis, stopping growth. The growth makes the arms and legs stumpy, while the head and trunk are apt to be normal. The epiphyses are frequently enlarged. The ossa innominata and ribs also frequently suffer. The glands of internal secretion are rarely involved, and a few cases may have precocious sexual develop ment, but this is not an essential of the disease and other evidences of pituitary affection are not present. The genitalia are apt to be normal. It is a malformation of bone and the enchondral matrix may be defective in its development. The nasal bone depression is due to lack of development in which it differs from lues which is due to diseased bone. SYMPTOMS The fetus may be aborted, it may be still-born, it may die while an infant, or may live a few years and then die. If it lives beyond child hood it is likely to grow to adult life and die at any age from other causes; being usually robust and well muscled, but dwarfed. As a child it walks late and, while it is usually somewhat disabled, the muscles are apt to be well-developed later even though in some cases movements are painful. The number reaching adult life are few; they have average intelligence ; the head is of normal size or larger. As the person grows from childhood to adult life the condition gradually becomes more marked as the limbs and deficient cartilage areas do not keep pace with the parts of the body unaffected. The vault of the cranium is prominent at the parietal and frontal areas and the nose being depressed makes the forehead seem still more prominent. The trunk appears long but is actually shortened, the back is flat, lordosis is present and the scapulae short. The buttocks are enlarged and prominent. The belly is usually prominent due to the marked exag geration of the lumbar curve. The hand has fingers of short length and the so-called trident hand is caused by a separation of the second and third fingers at the second phalangeal joint. The arms are short, the humerus is especially affected, the radius is longer than the ulna, which is usually deformed and shortened, and the hands are thick. The legs arc short, and the femur is proportionately shorter than the bones of the leg. The fibula is longer than the tibia, and the limbs may be considerably bent or bowed . The bones are very thick at points of muscular attachment. The relative shortening of the ulna and tibia tends to produce bowing of the arms and legs. The joints are promi nent, hyperostoses may form about the epiphyseal line, and joint disability may occur. SARGE N T CHOS DRODYSTHOPH Y FETALIS 69 French describes the body as of the dachshund type. The normal curves are exaggerated which may make caesarean section necessary in pregnant women. The vertebrae often are effected, producing spinal deformity. The ribs may show deformity suggestive of the "rosary." The fontanelles often close late in childhood and there may be a mild internal hydrocephalus. The eyelids and lips are apt to be thick. DIAGNOSIS The history, the age of appearance of symptoms, the size, the X-ray, and the facies help to rule out acromegaly, leontiasis ossium, gout, arthritis, fragilitis ossium, osteomalacia, osteitis deformans, multiple exostosis, and osteogenesis imperfecta. Oxycephaly has an enlarged head, impaired vision and exophthalmos. Progressive facial hemia trophy is not congenital, it shows discoloration of the skin, wrinkled and furrowed cheeks, the skin glands are functionless, and the teeth and eyebrows may fall out. This leaves cretinism, rickets, syphilis, and yaws to be differen tiated. Rickets is usually, though not always postnatal. The bones are soft, fracture easily, and the suture lines are insecure. There is no pug nose, and the spleen is apt to be enlarged. The limbs are not necessarily shorter than normal, and the stature may be little affected. Some have thought that achondroplasia is fetal rickets, but it is essentially different; at birth it simulates a case of severe grade of rickets which has run its course. In true achondroplasia the bones remain distorted, the joints are limited in range of motion, general body growth is retarded, and only the milder cases may reach adult life. The X-ray shows greater enlargement of the epiphyses in rickets. In chondrodystrophy the enlargement of the epiphyses may be slight or absent and the lesions are in the cartilage, but exo stosis may form at this region or at muscular attachments on the bone. The lesions are complete at birth and the later deformity is the result of the early lesions. The X-ray further shows the curved and short bones in the chondrodystrophy. The latter has the disproportion between the trunk and extremities and the more striking deformities. Most cases of rickets appear after the sixth month; excess cartilage is produced, the periosteum fails to lay down bone, bone is absorbed from the canal, and ossification is irregular. The muscles in rickets show lack of tone, the lymph glands may be enlarged, the liver is often enlarged, and the patient is subject to complications. Deformities are more frequent in the lower than the upper extremity because of weight bearing. The humerus is rarely deformed, the wrists are broad, the knees and ankles are large, and 70 .SARGENT CHONDRODYSTROPHY FETALIS bowlegs or knock-knees are apt to develop. Necrosis never occurs in rickets. Cretinism has the so-called myxedematous cachexia and defective growth of the bony skeleton. The patients are mentally slow, have a peculiar blank facies, enlarged tongue, small stature, old-looking appearance, and are benefited by thyroid therapy. The hair is scanty and coarse, while in achondroplasia it is abundant and soft. The thyroid is apt to be absent, atrophied, or goitrous. The skull bones are thick, the sutures remain open, and the fontanelles close late. Symptoms are not usually noted till 1 year of age or more. The skin is dry, coarse, thick, and does not pit on pressure. The extrem ities are apt to be short and stubby but lack the characteristic deform ity of chrondrodystrophv. Tho affection is general and not selective. Syphilis and yaws are the same disease or else very similar. It is lesions of the nasal bones in these that give the depression and not lack of development as in chondrodystrophy. Necrosis occurs in lues but not in chondrodystrophy. In congenital lues tlie long bones, especially the tibia, are most frequently affected, particularly near the epiphysis, which causes a broadening. Proliferating changes occur in the periosteum, with periostitis. The tibiae often have nodules or show roughening. Gumma are rare, although pain at night often occurs in lues of bones and the Kahn test is usually positive. Yaws as seen in the tropics with such extensive bone involvement would probably involve the nose, throat, and face and produce gan- gosa. PROGNOSIS The condition is present at birth and becomes accentuated as age progresses. Abortion may occur before the fetus is developed or it may be still-born. It may die soon after or in the first few years of life. The prognosis as to life is not good till after the first year or so of existence but after this the prognosis as to life is good, but as to altering or curing the condition it is hopeless. TREATMENT No treatment is of any avail. CASE REPORTS Cane 1.— M. J. M. Male. Age 69. Height, o7 inches; weight, 164 pounds. No history of yaws. Kahn negative. Father and one uncle, who are now dead, had the same affliction and he is very sure he was born with this condition. He is the father of cases 2, 3, 4, and 5. See illustration, figure 2. His skull measures 23 inches around. His arms and legs, including the bones, are short, curved, and deformed and he has a tilt to the body. The bones by measurement show the right ulna to be ti inches and the right radius 7 inches long, while the left ulna is 7 and the left radius 8 inches long. This together with a shorter humerus on the right side gives a right arm 2 inches shorter than the left. An osteophyte appears SARGENT— CHONDRODYSTROPHY FETALIS 71 at the insertion of the right deltoid. The distal end of both ulnse taper and give narrow wrists. Case 2.— M. J. M. Age 27. Height, 65 inches; weight, 135 pounds. The right side of his face is smaller than his left. His skull is 20 inches in circumference. The right half is 9^2 and the left 10% inches. There is no discoloration of the skin, no wrinkled or furrowed cheek, no falling out of the teeth or eyebrows, and no lack of function of the skin glands as there is in facial hemiatrophy. I was unsuccessful in trying to get a picture of the tribasilar bone of the skull. Case 3.— M. A. M. Age 23. Male. As seen by the picture he is a marked case of tuberculosis. Since I got the picture he had died. I did an autopsy; the lung infection was marked but nothing else abnormal was found except these numerous or multiple exostoses. He is not a dwarf but he shows these exostoses in the neighborhood of epiphyses, so I put him in the picture since he shows cartilage dystrophy. It goes without saying that he is not a case of chrondro- dystrophy fetalis but being a cartilage abnormality, I thought it might give a small point of suggestion of heredity here. He had these exostoses all his life. Case 4-— M. M. M. Female. Age 22. Height, 5 feet; weight, 115 pounds. The circumference of the skull is 21 inches, the face is normal, and the mentality is normal. The right humerus is shorter than her left humerus. Her family are very sure she was born this way since her father took notice at birth of all children, because of his own affection. The right humerus is 10 inches and the left is 11% inches long. As shown by the picture her left wrist is narrow. There are exostoses in the center of the right humerus at the insertion of the coracobrachialis and deltoid. The chest cage is normal. The second and third right toes are shorter and of equal length. The lower end of each ulna is tapered. There is no sign of yaws or gangosa and her Kahn is negative. Case S.—M. J. M. Age 25. Single. Male. There is no history or evidence of yaws or gangosa, and his Kahn is negative. The right side of his body is smaller than his left but it is not an hemiatrophy or hemihypertrophy because both sides of his body are affected. His condition was present at birth but has become more evident as he grew older. His mentality is normal and there is no internal glandular affection. His head measures 21J4 inches around, the right half being 10 and the left half IIJ2 inches. The right side of his face is smaller; the X-ray of his skull also shows this. All his teeth are present including the wisdom teeth. The hair on the head is soft and abundant. The bridge of the nose is sunken in. His eyelids and lips are thick. The right arm is 22 and the left 26 inches long, the right humerus being 10 and the left 1CJ4 inches. The two prominences on the outer side of the right forearm are bone ends; the upper is the radius projecting beyond the joint, and the lower is the short distal end of the ulna. The right radius is T/2 and the right ulna is 5 inches long, while the left radius is 7'4 and the left ulna is 6% inches long. The left radius is prominent distally yet both wrists are narrow and the metacarpals are short. The right index finger is shorter than the others and both hands show the trident effect. Lordosis is present, the genitals are normal, the inguinal crease and the gluteal fold are lower on the right side, and the trunk is 25 inches from the first dorsal spine to the end of the coccyx. The left leg is 1 inch longer than the right and the right kneecap is lower than the left while the right tibia projects at the upper and inner end. The left femur is 13!$ inches while the right is 1 inch shorter. The left tibia is 13 and the fibula ll1-! inches but the right is U inch shorter in each bone. The first metatar sals arc only 2 inches long and the toes are all short; the second and third right toes are of the same length and relatively shorter. The bones throughout are distorted somewhat and show thickening at muscular attachments with hyperostoses in many places. 72 SARGENT CHONDRODYSTROPHY FETALIS Case 6.—Female. Age 22. Height 57 inches; weight 90 pounds. The circumference of her head is 20}i inches. Her family were all normal, but her father's father had a similar condition. There is no history of yaws but her Kahn is 4 plus; this case is the only one in the entire group I am reporting that has a positive Kahn test. Her mentality is normal or above average. Her legs and arms are short and her trunk is proportionately longer than the limbs. The legs are not grossly deformed but the bones are shorter than normal, and a few exostoses are present. The ribs are normal and the pelvis is contracted and small. The buttocks are large and prominent, some lordosis is present and the abdomen is large on side view. Her right arm is longer than her left by 1% inches. The fingers are short, especially the right thumb, index finger, and little finger. The arms and forearms are short and the wrists are narrow, especially the right. The right humerus is 10 and the left humerus 9H inches long. The right ulna is 5 and the right radius is 6H inches long. The left ulna is 5 and the left radius is 6 inches long. In both forearms the ulna is larger above and very small and pointed below. The radius in each case is bent and the head of each bone projects beyond the joint and is forward. Case 7.—J. R. S. Female. Single. Age 34. Sister to cases 8 and 9. She is 54 inches tall and weighs 108 pounds and has normal mentality. Her father is dead; he had a similar affection. There is no history of yaws in the family or herself, and her Kahn is negative. Both legs and arms arc short and the body relatively long with a small pelvis. The left humerus and forearm are much shorter than the right. The wrists are narrow and the fingers are short. The right hand shows the trident effect. There is a small projection on left elbow which is the head of the radius covered only by skin. The right humerus is 10% and the left 10 inches long. The right radius is 8 and the ulna S'A inches long; the radius is bowed, and lower ulna tapers and. is deformed slightly. The left ulna tapers, is small distally, has no styloid process, is deeply placed at the wrist region, hardly extends to the wrist, and is 6 inches long. The left radius is curved, large distally, projects beyond the joint, and is seen projecting at the elbow. The circumference of the head is 21 inches. All the toes are short, the left second and third markedly so. Case 8. —J. R. S. Male. Age 36. Married. This case is 57K inches tall and weighs 102 pounds. Brother to case 7. The Kahn is negative. He has good intelligence. The skull measures inches. He has short arms and legs and his body is proportionately longer. The hands, especially the left, show the trident effect. The wrists are narrow and the fingers are short. The meta carpals are short. There are osteophytes on several bones. Both bones in both forearms are deformed and short, and the ulnar bones are small distally so that the ulnar prominence is lacking. The right ulna is 6 and the right radius 7 inches long. The left ulna is 6 and the left radius 7}$ inches long. The humeri are short and are each 10J£ inches long. The right second and third toes are shorter than the others. Case 9.—J. R. S. Male. Single. Age 30. Brother to cases 7 and 8. This case is 61 inches tall, or a few inches taller than the others. The skull measures 22J4 inches. Kahn, negative. No past history of yaws. He has tuberculosis. He has the trident right hand. This case has short metacarpals, the peculiar distal ulnar deformity, exostosis around some epiphyses, but he is not typically short. His humeri are about 11 inches. His ulna and radius of each arm are about 8H inches long. His left second and third toes are shorter than normal, compared to the others. Case 10— G. J. G. Male. Single. Age 26. Height 56 inches; weight 112 pounds. Kahn, negative. There is no family history of yaws, gangosa, or this SARGENT CHONDRODYSTROPHY FETALIS 73 affection. He has no past history of yaws. His skull measures 23 inches in circumference. His arms and legs are short; his body is actually short, but relatively long. His left arm is shorter than right. His chest cage is normal, but his lungs show tuberculosis. The femur and humeri are short and also his lower legs and forearms. The fingers and toes are short, but the trident hand is not definite. The third and fourth toes of the left foot are shorter than the others. There are exostoses about the epiphyses of several of the bones; a large one springing from the right upper epiphysis of the humerus presses against the chest wall and deforms the upper ribs. The metatarsals and metacarpals are short. The right humerus is 10J4 inches long and the left is 10. The right radius is 6}i and the ulna 6 inches long. The left radius is 6 and the ulna 5 inches long. SUMMARY AND COMMENT ON THESE CASES As only few cases reach adult life, we would not expect to find the worst cases in adults and we might say that only the milder cases reach even puberty. Some of the cases may only have partial affec tions. I have not been able to find any children with this dystrophy and at autopsy on children no cases have been noted. The children of those in the group, except those of case 1, are normal. There are marked variations in the type and appearance of different cases. To illustrate this point I would refer the reader to pictures in the books of French, Graham, Bradford and Lovett, Spear and Coplin. The condition is said to be transmitted by males, which has been verified in these cases. Cases 1 to 5 are one family, Cases 7, 8, and 9 are a family in which the father (now dead) was affected. The grand father of case 6 was affected. No relation with case 10 could be established. We must not overlook the fact that illegitimacy might fill in an otherwise unexplainable gap. Case 5 is the most typical of all. Cases 2 and 4 show changes less marked. Case 3 was put in to lend weight to an hereditary tendency. The faces of cases 2 and 5 are not hemiatrophy for reasons already explained. Case 6, the only one with a positive Kahn, has characteristics of the affection. Cases 7, 8, and 10 are types of it. Case 9 has only a few of the characteristics. A superstitition held by some of the natives is that some tune back some son struck his father and his punishment was handed down. There being no signs of internal glandular affection, no thyroid was thought necessary as a therapeutic test. The mentality, in all cases, was normal, and other signs of cretinism were absent, and all these cases were congenitally affected. In lues, necrosis occurs, the X-ray looks different, and a positive Kahn with some other evidence ought to be present. No case or relative has had a history of disease or treatment. Yaws is apt to involve the nose in late neglected cases. In rickets a broad wrist is usual and the humerus is rarely deformed. In this condition a narrow wrist is present and the humerus is de- 24140—37- 74 SPALDING — CANCER formed frequently; and the hair is abundant and soft in all cases reported, while in rickets it is apt to be scanty and coarse. A point noted in the literature is the frequency of bone thickening at muscular attachments and the exostoses at epiphyses, both of which were noted frequently in these cases. In these cases we note the frequency of a long radius with the head projecting beyond the joint at the elbow, and a deformed short ulna with the ulnar distal prominence missing and a narrow wrist thereby being produced. The head in circumference is large for the rest of the body in all the group. THE CANCER PROBLEM IN THE UNITED STATES NAVY By Otis 13.Spalding, Lieutenant Commander, Medical Corps, United States Navy The cancer problem in the Navy must be viewed from three differ ent aspects, as regards the active personnel; the military, the social, and the economic. From a military standpoint the Navy is the fleet, and the great problem of the naval medical officer is largely one of preventive medi cine. With thousands of officers and enlisted men afloat in the Battle Fleet, which for the past 5 years has based in the San Pedro- San Diego area, and with additional thousands afloat and ashore in our widely scattered naval stations and ships in the far distant ports of Samoa, Guam, the Philippines, China, and Hawaii, and our impor tant shore stations along the Pacific coast, the management and con trol of malignancy naturally depend on the early recognition and prompt transfer of all such cases to the nearest naval hospital for treatment and final disposition. Prior to July 1, 103G, it was the custom to send all inoperable cases that could be safely moved, to the United States Naval Hospital, Brooklyn, N. Y., for further treatment at the Memorial Hospital, New York. But here the social and economic feature affecting these unfortunate patients complicates the problem. Transfer of these cases from stations and hospitals on the Pacific coast, either by transport or train to New York, meant in many cases the breaking up of families, with the inevitable lowering of the patient's morale, which we all know to be of such vital importance in the treatment of such cases. The financial aspect was a serious problem to the families that follow patients to the east coast, and there is also the transpor tation cost to the Government of the patient and his attendants. Taking these varied factors into consideration, the Bureau of Medi cine and Surgery issued orders designating the Naval Hospital, Brooklyn, N. Y., as the cancer center of the east coast, including the Great Lakes-Chicago area; and the Naval Hospital, San Diego, SPALDING CAN CER 75 as the cancer center for the west coast and insular possessions. In compliance with this order the commanding officer of the Naval Hos pital, San Diego, appointed a permanent cancer board on July 1, 1936, this board to consist of the following members: Chief of Medi cine, president of the board ; members, Chief of Surgery, Dermatology, Bacteriology and Pathology, Dental Surgery, and Radiology. Since its inception the board has met at regular intervals in the auditorium of the Red Cross Building. All medical officers and visit ing and local physicians have been welcomed and encouraged to enter into discussion of the cases. All suspicious skin lesions and new growths admitted to the hos pital or referred by medical or dental officers, afloat or ashore, are reviewed by the board at these meetings, and a decision made in each case as to probable diagnosis, and necessary treatment. All cases requiring surgery, or combined surgery and radiation, are treated by the staff. Biopsy is made in all operative cases, immediate frozen sections in all doubtful cases. Since the cancer board at the San Diego Naval Hospital was offi cially organized, July 1, 1936, a total of 463 cases have been treated, requiring 2,322 treatments. Of these 463 cases, 356 cases were benign lesions or infections; 107 cases were malignant, proven by operation or biopsy. Of these 107 malignancies, 20 percent of all cases were basal cell epitheliomas, 8 percent epidermoid carcinomas. 15 percent adenocarcinomas, and 10 percent sarcomas. There are 32 titles in the Navy nomenclature in the class of tumors covering malignant and benign neoplasms. Most of the admissions included in this class are recorded under such titles as simple retention cyst or wens, or other cystic growths. A review of the annual reports of the Surgeon General of the United States Navy for the 5-year period 1931 to 1935, inclusive, reveals that there were 1,960 original admissions for all types of tumor. Of these 1,566 were benign conditions and 394 were malignant or of malignant tendency. In the benign group there were 2 deaths, 1 with benign mixed tumor and 1 with lymphangioma, and 15 were invalided from the service. Of the 394 malignant cases there were 65 deaths and 43 were invalided from the service. The more common malignant tumors were represented as follows: Tumor Admissions Deaths Carcinoma. - 70 48 IS 18 13 8 36 0 Epithelioma Sarcoma .... ; 10 5 4 5 Tumor, malignant, mixed 76 SPALDING CANCER The admission rate per 100,000 for all tumors was as follows: Admissions Deaths 1931. 1932. 1933. 1934 1035. 2r$ 291 462 419 400 S 12 20 IS 9 From the above survey it will be seen that the admission rate for the active list of the Navy per 100,000 is certainly no higher than the average rate for the same age group in civil life. The selection by the Bureau of Medicine and Surgery of the San Diego Naval Hospital as the cancer center of the west was the logical result of not only its favorable location with regard to the fleet, but also due to the fact that it is a large and well-equipped hospital with a bed capacity of 1,070 and with an ultimate capacity when the new wing now under construction is completed of 1,270 beds. The X-ray department has recently been completely modernized with the installation of an oil-immersed shock proof deep therapy unit, acti vated by a special moisture-proof transformer of 300,000-volt capacity, 8 hours continuous operation at 20 m. a. This modernization was in line with the Bureau's policy to maintain all departments in naval hospitals at the highest point of efficiency, by purchasing the latest and best scientific apparatus for all departments. From 1932 to 1936 the standard technique employed in our therapy clinic for the treatment of deep seated lesions was 200 KVP, 25 ma. at 50 cm. distance, with 0.5 mm. cu. and 1.0 mm. aluminum, an equiva lent of 35.4 (r) units per minute, measured in air, and an estimated tumor dose at 10 cm. depth of 10 percent of the threshold erythema. Quimby (1) of the physics department of the Memorial Hospital, New York, has found that: —the threshold erythema with 200 KVP, 100 sq. cm. field, 50 cm. distance (T. S. D.) and 0.5 mm. copper plus 2.5 mm. aluminium is 500 to 525 roentgens. The therapeutic erythema, on the other hand, varies from 600 to 1,000 roentgens, depending on the skin type. Failla (2) of the physics department of Memorial Hospital, whose work on the effective wave length of radiation is internationally known, has found that the relative depth doses at 10 cm. depth, obtained under comparable conditions with 200 KVP, 700 KVP, and Gamma rays are respectively 29 percent, 41.2 percent and 56.7 percent. However, the advantage in percent depth dose in favor of radium is not realized in clinical practice because it is not practical to apply radium at the focal dis tances used in roentgen therapy. Articles by Quimby (1), Failla (2), Coutard (3), Pack (4), Ruggles (5), and Merritt and Rathbone (6), during the past year, inspired us SPALDING CANCER 77 with the desire to obtain a greater effective tumor dosage compatible with skin safety. Most observers who have had an opportunity to compare skin reactions and results obtained with 0.5 mm. copper and 2.0 mm. of copper filtration, are convinced of the latter's superiority. Merritt and Rathbone (7) state: Following the work of Thoraeus (8) we have been using at the Warwick Clinic a filter composed of 1.25 mm. tin, 0.25 mm. copper, and 1.0 mm. aluminum. This filter has been used at 220 KVP, 20 ma., 50 cm. distance with an intensity of 10 r. per minute, measured in air. This filter has a maximum wave length of 0.21 A, which is the same maximum wave length as 5 mm. of copper. Copper absorption curves show that this filter has a half layer value of 2.9 mm. copper at 220 KVP, which is the same as 5 mm. copper at this voltage. This tin filter is very transparent to hard roentgen rays generated at 220 KVP, and gives an intensity 35 percent greater than 5 mm. of copper. With this filter we have found the intensity of 10 r. per minute at 50 cm. distance to be practical and economical in the treat ment of selected deep seated malignancies. With these facts in mind and with the desire to secure the greatest tumor dosage possible in a given case, using the maximum power at our disposal, we have now standardized our technique at 220 KVP and 20 ma., using Thoraeus filters equivalent to from 2 to 5 mm. of copper, at 50 cm. distance, thus increasing the actual tumor dose at 10 cm. depth from 10 percent of the threshold dose to approximately 45 percent, and furthermore, as a result of skin protection resulting from such heavy filtration, it is now possible to deliver from 4 to 10 erythema doses to the tumor, in effect, a dose sufficient to sterilize the growth without permanently damaging the skin and adjacent tissues. The skin reaction may, in the average case be described as a second degree burn, which gradually fades out, with the skin completely restored in from 6 to 8 weeks. In view of the fact that 28 percent of our series of 107 malignant neoplasms were skin cancers, we have attempted to standardize our method of treatment with due regard to the essential features of each individual case. Results obtained by surgery, surgery followed by radiation, cautery excision, preceded by or followed by irradiation, or radium, over a period of 4 years, were all considered. Now, due to the brilliant results reported by Dr. Lyell Kinney and Dr. Ray Lounsberry of San Diego, in their private practice, and at the San Diego County Cancer Clinic, we have adopted their method of cautery excision followed by unfiltered radiation, in basal cell lesions, and cautery excision followed by copper filtered radiation in epidermoid carcinomas, with excellent clinical results in every case. Impressed by the results obtained in the treatment of leukemias, Hodgkin's disease, lymphosarcoma, and multiple myeloma, by continuous irradiation, at the Memorial Hospital, New York, we have modified Heublein's technique to fit our equipment, so that we are able 78 SPALDING CANCER to spray our patients at a distance of 115 cm., using 200 KVP, 0.5 mm. cu. and 1.0 al. filter, with an intensity of 5 r. per minute, measured in air. Heublein cites as possible advantages of his method: (1) The nearly uniform distribution of the rays throughout the body, in treating generalized neoplasms. (2) The possibility that great protraction of treatment would make possible the irradiation of all the tumor cells during their period of mitosis, when they are most sensitive. (3) The assumption that despite the protraction of treatment, the intensity of radiation affecting any given cell would nevertheless remain sufficient to sterilize it. In the small series of cases that we have treated so far, we are in clined to believe that this method is superior to any heretofore attained in the treatment of chronic lymphatic leukemia. Favorable results have also been obtained in the treatment of Hodgkin's disease. RADIUM All cases that the cancer board decides should be treated by either contact or interstitial radium, due to the location or character of the lesion, are so treated. Having obtained the necessary authority from the Bureau of Medicine and Surgery to defray the necessary expense, the case is referred to a civilian radium therapist for treat ment. This method, in use during the past year, has proved entirely satisfactory to the board, and the results obtained have been excellent. CONCLUSION A review of the Surgeon General's report covering the 5-year period from 1931-35, and of the San Diego Naval Hospital Cancer Clinic from 1936-37, would tend to show that the incidence of malig nant neoplasms in the fleet per 100,000 has remained relatively the same, and compares favorably with the rate per 100,000 in the same age groups in civil life. The present method of disposition and treatment of cases has proven to be eminently satisfactory, both to the patients and to the service. By the use of filtration equivalent to from 2 to 5 millimeters of copper, at 220 KVP it is believed that with such filtration inoperable intra-abdominal tumors can be brought into the field of radiotherapy. A permanent cancer board, with full power of function, is of vital importance in the successful treatment of malignancy. Bibliography (1) Quimby, E. H., and Marinclli, L. D. The Influence of Filtration on Sur face and Depth Intensities of 200 KV X-rays. Radiology, 21: 21-39, 1933. (2) Failla, G., et al. The Relative Effects producted by 200 KV Roentgen Rays, 700 KV Roentgen Rays and Gamma Rays. Am. Jour. Roentgenol. & Rad. Therapy, 29: 203-366, 1933. WARMOLTS —CARCINOMA LUNG 79 i'3) Coutard, H. Roentgen Therapy of Epithelioma of the Tonsillar Region, Hypopharynx and Larynx from 1920 to 1926. Am. Jour. Roentgenol. & Rad. Therapy, 28: 313-331, 1932. Roentgen Therapy of the Pelvis in the treatment of Carcinoma of the Cervix. Am. Jour. Roentgenol. & Rad. Therapy, 36: 003- 609, 1936. (4) Park, G. T. Principles governing Radiation Therapy of Cancer, Geo. T. Peck Memorial Hosp., N. Y. Am. Jour. Roentgenol. & Rad. Therapy, 36: 233- 244, 1936. (5) Ruggles, H. E. A Year's Experience with 800 KV Roentgen Rays. Am. Jour. Roentgenol. & Rad. Therapy, 36: 366-367, 1936. (6) Merritt, E. A., and Rath hone, R. R. The Treatment of Epithelioma in volving Cartilage, using 220 VKP and heavy filtration. Radiology, 24: 701-707, 1935. (7) Merritt. E. A., and Ralhbone, R. R. The Roentgen Treatment of Malig nancy using filtration Equivalent to '5 mm. copper. Am. Jour. Roentgenol. & Rad. Therapy, 35: 334- 343, 1936. (8) Thoraeus, R. Study of Ionization Method for Measuring Intensity and Absorption of Roentgen Rays and of Efficiency of different filters used in therapy. Acta. Radiol. Suppl., 15: 1-88, 1932. CARCINOMA OF THE LUNG By Irving J. Warmolts, Lieutenant, Medical Corps, United States Navy The startling increase in incidence of carcinoma of the lung en countered in the past 3 years has prompted this attempt to summarize the outstanding features of this serious disease, with emphasis on the roentgenologic diagnostic features. In contrast to the relative rarity of the condition a decade ago, when it was an uncommon autopsy finding and diagnosed antemortem in only about 5 percent of cases, lung carcinoma now comprises from 6 to 8 percent of all carcinomata and stands next in frequency to malignancy of the gastro-intestinal tract. At the Philadelphia General Hospital, which admits both sexes and all ages in about proportionate numbers, it is now the most frequently encountered malignancy. At the United States Naval Hospital, Philadelphia, in 218 autopsies performed in the past 2 years there were 52 cases of malignancy of which 10 were carcinoma of the lung, an incidence of 19 percent of all malignancies and 4.5 percent of all autopsies. These figures, of course, are not representa tive of the general population because of the large admission rate of veterans in the cancer age, but it serves to emphasize the incidence of the condition in males of this age group and proves its importance to the naval medical service. ETIOLOGY The etiology at present is largely a matter of conjecture. The great preponderance of males to females may be significant, being approximately the ratio of 10 to 1. Negroes appear to be less suscep tible than whites. Approximately 75 percent of cases occur between 80 WARMOLTS —CARCINOMA LUNG the ages of 41 and 60, altho, cases between 20 and 30 are not uncom mon. The hazard appears to be increased in industries involving inhalations of irritating dusts and fumes. It does not appear however, to be an especially frequent sequel of pneumoconiosis. In the cases reported in the literature there does not appear to be a convincing relationslup to the smoking of tobacco. The continuous irritation of the respiratory mucous membranes by exhaust and industrial fumes in our modern life appears a plausible cause. PATHOLOGY Practically all primary carcinoma of the lung is bronchogenic in origin, arising in the main bronchi, their branches, or in the terminal bronchioles. Both lungs are about equally involved and the upper lobe bronchi about as frequently as the lower. The primary lesion may be pedunculted, sessile, or ulcerative. Classified according to malignancy, grades 3 and 4, Broder's, greatly predominate. Histo logically the squamous cell type predominates; the undifferentiated type, including the spindle, round, and "oat" cell types, are almost as frequent, and adenocarcinoma comprises a small percentage. Exten- tion of the growth takes place by direct contiguity, by retrograde lymphatic permeation, by lymphatic metastasis to the peribronchial and thence to the hilar periaortic and abdomuial lymph nodes, and by the blood stream to all parts of the body. Peripheral growths reaching the pleura rapidly involve the serous surfaces, studding the parietal pleura, especially with fiat nodular secondary implantations. Contralateral pleural involvement is common. Subserous metastases to the abdomen may involve extensively the peritoneal surfaces. Hematogenous metastases involve especially the brain, bone, and the heart. The bone lesions are osteolytic. Pulmonary suppuration is the outstanding pathologic feature in many cases. Obstruction of the bronchi results in stasis of secretions beyond the stenosis with secondary infection, giving the picture of bronchiectasis or multiple abscesses. Abscess formation is also fre quently due to central necrosis of the tumor mass with secondary infection. Death occurs as a result of cachexia, long-continued second ary pulmonary suppuration, hemorrhage, or from metastatic lesions to brain or heart. SYMPTOMS Symptoms due to the primary lung lesion are quite constant and rather suggestive. The onset is insidious, the symptoms existing usually 4 to 8 months before becoming so severe as to lead to a thorough physical examination. Many cases present the symptoms of an acute respiratory infection at the start, from which recovery does not take place normally, or intermittent periods of apparent well-being WARMOLTS —CARCINOMA LUNG 81 may take place for some time. Many cases are diagnosed unresolved pneumonia, abscess or bronchiectasis due to failure of a supposed infection to resolve normally. Cough, either productive or dry and brassy, is present in over 80 percent of cases. Pain, in the chest, or referred to back or shoulder, occurs in over 60 percent, may be dull, aching and constant, or severe and paroxysmal. Pain may be in creased on percussion over the involved portion of the chest, a sug gestive sign. About one-half of the cases complain of dyspnea and it is most marked in cases with massive pleural effusion or with tracheal compression from gross glandular metastases. Hemoptysis occurs in 40 to 50 percent; it may consist only of blood streaking of the sputum or of gross or even fatal hemorrhage. The temperature is elevated in approximately 30 percent, which, along with misleading physical signs, frequently leads to be erroneous or incomplete diagnosis of chronic pneumonia, abscess, or tuberculosis. Night sweats and hoarseness are not uncommon. Clubbing of the fingers is reported in about 15 percent of cases. In addition there later occurs the usual findings of malignancy, weight loss in 50 to 70 percent, loss of strength, pallor, secondary anemia, etc. Frequently, however, the primary lesion causes few early symptoms and the first symptoms are due to metastatic lesions elsewhere in the body. The primary site may be entirely overlooked for long periods or may be first detected by routine chest roentgenograms. In the absence of pleural involvement or of gross bronchial obstruction the primary lesion may grow to considerable size without prominent symptoms. A pathologic fracture may cause the first suspicion of a malignancy. Metastatic brain lesions occur in 24 percent and the lungs should be considered as a primary source in this type of case. Gastro-intestinal symptoms from metastatic lesions may simulate the symptoms of peptic ulcer or primary gastric malignancy. Jaundice may occur from liver involvement and dysphagia from erosion into the oesophagus. PHYSICAL FINDINGS The physical findings are exceedingly variable depending on the location of the tumor. In general, most cases may be grouped into three types: The lobar type, the hilar and the nodular. In the lobar type a large bronchus becomes obstructed by the growth with resulting atelectasis of a whole or part of a lobe. Malignant invasion tends to occur more rapidly into the collapsed lung with progressive replace ment by tumor tissue. There is dullness on percussion over the atelectatic and infiltrated lung; breath sounds arc absent as a rule. Voice sounds and fremitus arc usually decreased or absent. Rales may be noted. In the lrilar type the growth may attain considerable size without entirely blocking a* bronchus, tbe growth breaking through the 82 WARMOLTS —CARCINOMA LUNG bronchial wall and infiltrating widely into the surrounding tissue. Atelectasis tends to occur later. The physical signs may be dis proportionately slight compared with the extent of involvement. The partial obstruction may cause asthmatoid wheezes; rales are frequent. The para-vertebral dullness may be perceptibly widened on percussion. However, the remainder of the lung may be normally resonant and voice sounds very little impaired. At times emphysema may be present for a while on the involved side due to partial obstruc tion, especially in the expiratory phase. The nodular type is a more or less circumscribed type toward the lung periphery and when involving only a small bronchus or bron chiole may cause but slight atelectasis and, when normal lung is present between chest wall and the tumor, auscultation and percussion may fail to reveal any evidence of the lesion. Most carcinomata of the lungs eventually involve the pleura, either by extension or metastisis. The findings of pleural effusion are then present. The fluid on tapping is usually sero-sanguinous and tumor cells may be discovered upon microscopic examination. Metastasis to the mediastinal nodes leads to progressive dyspnea, frequently causes venous congestion due to pressure on the vena cava, and oftentimes dysphagia due to pressure on the oesophagus. The paravertebral dullness tends to be widened. Evidence of pulmonary suppuration commonly develops due to stasis of secretion in the traeheo-bronchial tree peripheral to the stenosis followed by bronchiectasis and abscess formation. Fre quently central necrosis of the tumor mass occurs with expectoration of large amounts of fetid pus and blood. Evidence of cavitation may be elicited. Fragments of tumor tissue may bo detected by micro scopic examination of the sputum. Rupture of a large vessel may result in rapidly fatal hemoptysis. Supraclavicular nodes may be enlarged due to metastasis. Dia phragmatic palsy due to involvement of the phrenic nerve in medi astinal metastasis is common, as is also laryngeal paralysis due to involvement of the recurrent laryngeal nerve. Horner's syndrome may bo observed when the sympathetic system is involved. The roentgen findings are bizarre in their variability and in appear ance. In the lobar type there is progressive atelectasis of a part or whole of a lobe. The opacity diminishes toward the periphery and at the apex and is densest about the hihirn. A hard film may demon strate two superimposed densities, the inner due to tumor mass with usually a ragged irregular outline, the outer lesser density being cast by the surrounding atelectatic lung. The heart, trachea and medi astinum are displaced toward the side of the lesion; the diaphragm tends to be elevated and the interspaces usually narrowed. I have however seen a number of advanced cases with displacement of the WARMOLTS —CARCINOMA LUNG 83 mediastinum toward the lesion while the interspaces were widened. I have seen this in no other lesion and consider it diagnostic. A marked pleural effusion with displacement of the mediastinum toward that side is also peculiar to the condition. It may be due to fixation of the mediastinum by infiltration after the mediastinum has migrated following atelectasis. Progressive growth or massive effusion following this fixation of the mediastinum may cause widen ing of the interspaces or even intercostal bulging. In the hilar type a dense mass is present in the hilus, usually roughly semicircular in shape with sometimes a rather regular, sharply defined outline, but more commonly ragged and irregular, poorly defined with strands of infiltration into the surrounding lung. A variant of this type occurs when the primary mass is small and obscure but extensive lymphatic permeation has occurred throughout the lung fields causing a generalized coarse reticulation resembling pulmonary fibrosis or bronchopneumonia. A beading at the points of inter section may simulate miliary tuberculosis. Relatively large lesions near the bifurcation of the trachea may be entirely obscured by the heart and mediastinum and no charges may be evident on the film until gross glandular enlargement or atelectasis takes place. The nodular type usually forms fairly distinct, rounded or triangular shadows at the apex or toward the periphery of the lung. There is little or no surrounding atelectasis and the shadows have no surrounding zone of pneumonitis which helps to differentiate them from tuberculosis lesions and abscess. The outlines may be regular and sharply defined or ragged, irregular, and indistinct. Upper lobe lesions are usually free of complicating pleural effusion until late in the coarse and are the easiest to demonstrate. Glandular enlargement at the hilus and mediastinum may occur early with little evidence of the primary lesion and carcinoma must be considered in the differential diagnosis of mediastinal gland involve ment in the cancer age. The opposite hilus may also be prominent and nodular due to glandular metastasis. Metastasis to the heart and pericardium is frequent and may cause a marked irregularity or nodular appearance of the cardiac silhouette. Pleural effusion is a frequent and annoying development and by masking the lung fields makes the diagnosis difficult and at times impossible. Bronchogenic carcinoma should be considered in the differential diagnosis in every case of pleural effusion in an adult. The fluid reforms extremely rapidly after withdrawal, but, when replaced by air, a roentgenogram taken immediately may reveal the underlying pathology and is of great aid in diagnosis. Effusion occurs much less commonly with upper lobe lesions. In these cases, however, pneumothorax may also give aid in delineating the outline of the tumor mass and also demonstrate the presence or absence of 84 WARMOLTS —CARCINOMA LUNG pleural adhesions and probable chest wall involvement, an important factor in prognosis. Bronchography by intratracheal instillation of lipiodol may show the exact site of broncheal obstruction or may only show failure to enter a certain portion of the lung. I have repeatedly seen the latter phenomenon in early pulmonary abscess before it communicates with a bronchus and I have not been able to distinguish the appearance between the two conditions except where a definite bronchial block can be demonstrated. At times this blockage is sharply defined and definite and the margins of the intrabronchial defect can be made out. Abscess due to central necrosis of lung carcinoma usually is rather characteristic with a dense surrounding zone of infiltration with ragged, irregular outer margin of the mass. There is lacking the soft shadow of surrounding pneumonitis seen in simple abscess. Except where complicated by a coexisting tuberculosis the fibrotic or exudative infiltrations of that disease are lacking. The cavity usually presents a fluid level, tending to differentiate it from a tuberculous cavity. A differential point of value is that displacement of mediastinum and trachea seldom occurs with simple abscess, frequently with carcinoma. Abscesses secondary to obstruction occur especially in the lower lobes and are frequently multiple. There is nothing characteristic about their appearance but a tumor mass may be demonstrable between the abscesses and the lulus or bronchography may reveal blockage of the bronchus to the involved area At other times a typical picture of bronchiectasis may be obtained. Serial observa tions reveal an abnormally rapid progression of the lesion, however, and should suggest the cause. Obstruction due to foreign body aspiration produces effects in distinguishable by the roentgenogram but the history of abrupt onset, coughing and choking, is usually obvious and broncboscopic examina tion reveals the cause. Associated roentgen findings frequently found are diaphragmatic palsy due to involvement of the phrenic nerve, evidence of osteolytic metastatic lesions of bone, compression of the oesophagus by the mass or enlarged glands demonstrated by swallowing of barium, and at times erosion of the ribs adjacent to the involved lung. DIAGNOSlS An antemortem diagnosis was made 10 years ago in only about 5 percent of cases. Today as high as 50 to 75 percent are correctly diagnosed. The percentage of cases so diagnosed will depend upon the index of suspicion and the degree of cooperation between clinician, roentgenologist, pathologist and bronchoscopist, all of whom con tribute by their peculiar approach to the problem. Bronchogenic carcinoma should be suspected in any adult, especially over the age WARMOLTS —CARCINOMA LUNG 85 of 45, with progressive cough, pain in the chest and hemoptysis. Pleural effusion should be suspected when other cause is not obvious and the lung should be considered as a primary locus in metastatic malignant lesions, especially of the brain and mediastinum. The greatest responsibility lies with the radiologist, who may detect an unsuspected or asymptomatic primary lesion on routine chest exam ination. All suspicious appearing chests should be subjected to bronchoscopy. Biopsy by this means clinches the diagnosis in the majority of cases except those near the lung periphery. Roentgen findings of particular significance are atelactasis with displacement of the mediastinum heart, and trachea to the side of the lesion. Farrell (6) goes so far as to state: Whenever evidence of pulmonary collapse is detected in an adult, one should consider it as due to bronchial occulsion of neoplastic origin until the presence of neoplasm has been excluded. A progressive bronchiectasis should also be regarded with suspicion. Serial roentgenograms should be taken in all suspicious cases. A dense, thick-walled single cavity without frank evidence of tuber culous origin should always be considered neoplastic until proven otherwise. Microscopic examination of all hemorrhagic pleural exudates will reveal neoplastic cells in a large percentage. Lung puncture for diagnostic material has not been so successful. Biopsy of enlarged supraclavicular nodes when found gives a high frequency of involve ment and aids in diagnosis. The differential . diagnosis is concerned primarily with metastatic malignancy of the lung from a primary lesion elsewhere in the body, infectious processes of the lung and pleura, and neoplasms arising primarily in the mediastinum and involving the lung secondarily. The most frequently encountered mediastinal lesion which is difficult to differentiate is Hodgkins disease. Primarily the lesions are dis tinctly nodular, confined to the glandular structure with fairly well- defined, tabulated widening of the mediastinum. However at times it breaks from the confines of the glandular structures, assumes a distinctly invasive character into the hilar structures and at times radiating into the lung via the lymphatics, making differentiation very difficult. Biopsy of involved peripheral glands allows a micro scopic diagnosis when these are enlarged, but many cases are confined, at least for awhile, to the mediastinum. Moreover metastatic lesions to bone may be impossible to differentiate by X-ray although biopsy of the bone will reveal its true nature. Intrathoracic thyroid adenoma may resemble neoplasm at first appearance but there is usually thy roid enlargement in the neck; the intrathoracic mass moves upward upon swallowing or grunting when seen under the fluoroscope. I have recently seen a case diagnosed as carcinoma of lung due to 8G WARMOLTS CAKCINOMA LUNG parenchymal neoplastic involvement of the lung which upon necropsy showed a small primary lesion in the thyroid. This type of involve ment in the chest is rare. Tuberculous adenitis of the mediastinum may at times cause a dense shadow at the hilus simulating neoplasm and in a case recently seen caused atelectasis of the lower lobe due to compression and occlusion of the lower lobe bronchus and an erro neous diagnosis of bronchogenic carcinoma was made. Broncho- scopic examination in such a case will reveal the obstruction as due to extrinsic pressure and the true nature may be surmised. Thymomas arising from the mediastinum may protrude into the lung fields but are circular in outline, sharply defined, and are homoge nous and much less dense than carcinoma. They are characterized by extreme sensitivity to X-ray irradiation. Reticulum-cell sarcoma may invade the lung, tends early to produce pleural effusion and may be diagnosed only by biopsy. It is also relatively insensitive to irradiation. Advanced cardiospasm with dilatation of the oesophagus produces a bulge of the mediastinal shadow to the right but this has a rather smooth outline and barium meal shows the shadow to be due to a greatly diluted oesophagus. Carcinoma of the oesophagus with ulceration into the left bronchus or trachea produces a mottling at the bases due to aspiration and at times may obstruct the bronchus. The primary complaint of dysphagia and the demonstration of com munication of the oesophagus and tracheo-bronchial tree by the fluorscopic ingestion of barium reveals the true nature of the lesion. Diaphragmatic hernia produces a nonhomogenous opacity at the left base and at times upward almost to the apex. There is also often evidence of fluid at the base. The barium meal shows the opacity as due to herniated bowel in the thorax. Metastatic malignancy of the lung is usually multiple. The lesions tend to be rounded and more or less circumscribed. There is no sur rounding atelectasis and usually no symptoms referable to the chest until late. The hilar glands are not enlarged. The primary lesion may be discovered, usually in the kidney, testes, or thyroid. At times extension of a breast carcinoma through the chest wall may invade the lung parenchyma simulating primary carcinoma due to its invasive character. The history and physical examination how ever will prevent error in these cases. Among the infectious processes, pulmonary tuberculosis is the most frequently encountered and can usually be easily differentiated by the history, physical, and laboratory findings and the character of the infiltration. Lung abscess usually has a more abrupt onset with acute febrile course. The roentgen film shows a small abscess cavity with surrounding zone of soft exudative reaction while malignancy is of longer duration with signs of suppuration only later in the course. WARMOLTS —CARCINOMA LUNG 87 « However, it must be remembered suppuration is a most frequent sequel of carcinoma of the lung and evidence of it does not aid in excluding malignancy. Abscesses due to advanced Friedlander's pneumonia may present thick walls resembling neoplastic abscesses but are usually multiple and tend to involve both lungs, while culture of the secretion reveals the causative bacillus. Progressive bronchi- ectatic lesions should always be regarded with suspicion and bron choscopy resorted to in all cases to rule out a causative malignancy. Chronic pneumonia and the progressive fibroid pneumonias are rather rare and many so diagnosed are found at autopsy to be due to carci nomatous involvement of the lung. Primary neoplasms of the lung, other than bronchogenic carcinoma are rare. Chondroma appears as a sharply rounded opacity with densely calcified center. Primary sarcoma was formerly more fre quently diagnosed but reconsideration of many of the cases in the light of what is now known of bronchogenic carcinoma has led in many of these cases to a revision of the diagnosis. Neurofibromata appear as soft shadows usually obviously arising from the vertebral margin, are quite distinctly outlined, and not invasive. Diagnostic pneumothorax shows them to be extra pleural and outside of the lung as the latter collapses. Hydatid cyst appears as a sharply outlined circular shadow usually of distinctly less density and calcification in concentric layers is demonstrated at the periphery. Dermoid cysts are usually seen to arise from the mediastinum, are rounded or oval, sharply defined and thin walled. Layering of the fluid contents can often be demonstrated roentgengraphically. PROGNOSIS Surgery appears the best hope of survival at the present time. However, the operative mortality approaches 50 percent and, of those surviving, late evidence of recurrence in the mediastinal glands or of hematogenous metastasis supervenes to a discouraging extent. How ever, cases free of disease for as long as 7 years after operation have been reported. As in malignancy elsewhere in the body, all efforts must be made to attempt earlier diagnosis and with our increasing knowledge of its characteristics such will undoubtedly be possible in a larger percentage of cases. Death in untreated cases occurs in from 2 months to 7 years. The condition as a rule is slowly progressing and the average case lives about 8 months after the diagnosis is made. The prognosis appears to be somewhat better in lesions involving the primary bronchi where the cartilage appears to have some restraining effect and the cell type tends to be somewhat more differentiated. However, the localized parenchymal lesion before it has involved the pleura tends to involve the hilar glands late and if removed before blood stream metastases take place appears the best surgical risk. 88 WARMOLTS CARCINOMA LUNG TREATMENT Lobectomy has been successful in eradicating small localized growths toward the periphery. In larger growths and in all those involving the hilar glands total pneumectomy is required. The shock of opera tion is less than one would expect. The third interspace is the usual avenue of approach. Ligation of the pulmonary vessels and of the bronchial stump offers some difficulty and effective removal of the glands considerably more. Adherent pleura due to invasion is re moved ; these cases offer little hope of permanent cure. Later thoraco plasty is frequently necessary to obliterate the cavity. In children and young adults considerable migration of the heart and opposite lung takes place after pneumectomy and may entirely fill the space. Preliminary pneumothorax is induced before operation to determine the presence of adhesions and the involvement of the chest wall and pleura, to more accurately delineate the outlines of the tumor and also to stabilize intrathoracic pressure and thus decrease operative shock. After operation the chest wall is tightly closed and pneumo thorax reinduced with slight positive pressure to prevent mediastinal fluctuation and also exert pressure on the bronchial stump and ligated vessels. This tends to decrease postoperative hemorrhage and decreases the postoperative pleural exudate which invariably follows operation. This must be removed by aspiration if too extensive; if infection follows siphon drainage must be instituted. Preliminary irradiation of the chest is of doubtful value and appears not to warrant the loss of time involved. Roentgen irradiation has been very disappointing up to the present. However the cases have almost all been advanced and possibly if earlier lesions are treated by the Coutard technic better results may be obtained in the future. Bronchoscopic implantation of radon tubes has been successful in removing the primary growths in small especially pedunculated lesions which protrude into the bronchial lumen, and offer a method of approach combined with irradiation where operation is not feasible. In inoperable cases little can be done except nursing care and opiates. Bronchoscopic drainage is advised when suppuration supervenes, especially if irradiation is given. Bibliography (1) 1 Arkin, A. and Wagner, D. H. Primary Carcinoma of the Lung. Journal A. M. A. 106: 587-591, 1936. (2) Edwards, A. Tumor. Malignant Disease of the Lung. The Journal of Thoracic Surgery. 4: 107-124, 1934. (3) Eggers, C. Lobectomy for Carcinoma of the Lung. J. Thor. Surg. 4: 211-217, 1934. (4) 1 Ehrlich, D. E. and Hauptman. H. A. Primary Carcinoma of the Lung. Radiology, 26: 563-573, 1936. 1These references furnished the essential source material for this article. NORMAN AND STTJ.TPHANT —BRONCHOGENIC CARCINOMA 89 (5) Ewing, James. Neoplastic Diseases, 3d. Ed. pp. 851-859. (6) 1 Farrell, J. T., Jr. Diagnosis of Bronchogenic Carcinoma. Rad., 26: 261-269, 1936. (7) Flich, J. B. and Gibbon, J. H., Jr. Total Removal of the Left Lung for Carcinoma. Annals Surg. 103: 130-134, 1936. (8) Graham, E. A. Carcinoma of Lung. Ann. Surg. 103: 130-134, 1936. (9) Herley, Peter. Recent Advances in Radiology, pp. 158-165. (10) Jackson, C. L., and Konzclmann, F. W. Bronchogenic Carcinoma. J. Thr. Surg. 4: 165-186, 1934. (11) Lyle, H. H. M. Carcinoma of Right Lung; Pneumonectomy in One Stage. Ann. Surg., 103: 124-129, 1936. (12) Miller, J. K. Bronchogenic Carcinoma, case report, Am. Rev. Tuberc, 34: 433-436, 1936. (13) Overholt, R. The Total Removal of the Right Lung for Carcinoma. J. Thr. Surg. 4: 196-210. 1934. (14) 1 Pancost, H. R., Pendergrass, E. D., and Tucker, G. Bronchogenic Carcinoma of the Lungs. A. J. Roentg. and Rad. Ther. 27: 357, 1932. (15) Rabin, C. B., and Neuhoff, H. A. Topographic Classification of Primary Carcinoma of the Lung. J. Thor. Surg. 4: 147-164. 1934. (16) Roberts, S. R., and Gray, J. D. Primary Cancer of Lung and Difficulty in Early Diagnosis; case. J. M. A. Georgia, 25: 275-278, 1936. (17) 1 Tuttle, W. Mac, and Womach, N. A. Bronchogenic Carcinoma; a Classification in Relation to Treatment and Prognosis. J. Thor. Surg., 4: 125-146, 1934. (18) 1 Vinson, P. P. Primary Malignant Disease of Trachea-bronchial Tree. J. A. M. A. 107: 258-261, 1936. BRONCHOGENIC CARCINOMA WITH METASTASES TO HEART AND PITUITARY CASE REPORT By Ikwin L. Norman, Lieutenant, Medical Corps, United States Navy, and William M. Silliphant, Lieutenant, Medical Corps, United States Navy A generation ago carcinoma of the bronchus was considered a rarity. At that time most of the malignancies of the lung were considered to be metastatic from a primary growth in some other organ. Today it is estimated that about 5 percent of all carcinomas arise primarily in a bronchus (1). Metastasis from this primary site may occur to any organ in the body. In a study of 374 cases of bronchogenic carcinoma, Adler (2) found the metastases were dis tributed as follows: Bronchial lymph nodes, 117; liver, 103; kidney, 58 ; bones, 57 (in the order of ribs, spine, skull, and sternum) ; brain, 53 ; pleura, 52; pericardium, 39; adrenals, 38; heart, 30; tracheal lymph nodes, 26 ; cervical lymph nodes, 23 ; retroperitoneal lymph nodes, 23 ; spleen, 18; and voluntary muscles, 9. Other organs found less fre quently involved by metastases were skin, nasal septum, eye, urinary i These references furnished the essential source material for this article. 24140—37 7 90 NORMAN AND SHJJPHANT —BRONCHOGENIC CARCINOMA bladder, fallopian tubes, ovary, uterus, pancreas, thyroid, spinal cord, and pituitary gland. Metastases were absent in 33 cases. The following case of bronchogenic carcinoma is reported because metastasis occurred to two of the organs less frequently involved — to the heart and to the pituitary gland. As is usual in cases of metas tasis to the pituitary gland (3) there was an associated diabetus insipidus. CASE REPORT The patient, a white male aged 41, was admitted to the United States naval hospital, Chelsea, Mass., on July 31, 1936, for treatment of what he stated was a lung abscess that had been present for 1 year. The chief complaints on admission were cough with purulent expectoration, excessive thirst with the passage of much urine, and pain in the back of the neck in the region of the fifth cervical vertebra. The patient gave a history of having had pneumonia in 1934 with complete re covery, and dated the onset of the present cough and expectoration to a mild respiratory infection that had occurred in May 1935. Cervical pain had been present for 3 months and excessive thirst and the passage of large amounts of urine for 1 month prior to admission. There had been a weight loss of about 15 pounds the past year. Physical examination revealed a pale middle-aged man acutely ill. There was dullness to percussion over the lower left lobe of the lung with diminished breath sounds and occasional moist rales. The blood pressure was 100/64. The heart was not enlarged, there were no murmurs, and the rhythm was normal. On pal pation, the liver was found to be enlarged to the level of the umbilicus and was definitely nodular. There was marked tenderness over the lower cervical vertebra and the neck was held rigidly. The reflexes were normal. The Kahn blood tost was negative, and urinalysis was negative aside from a low specific gravity varying in different specimens from 1.001 to 1.004. The white blood count was 21,700, with polys, 87 percent; lymphs, 6 percent; large monos, 5 percent; and eosins, 2 percent. The red blood cell count was 3,350,000 with a hemoglobin of 70 percent (Tallquist). The sputum showed no tubercle bacilli, but at times contained elastic fibers. The sedimentation index was 31 millimeters in 1 hour. X-ray of the chest showed an indefinite shadow at the left base partially obscured by the heart. X-ray of the cervical spine showed complete destruction of the fifth cervical vertebra by what appeared to be a metastatic tumor. Stere oscopic plates of the skull showed an enlarged sella turcica with destruction of both the anterior and posterior clinoid processes on the right side. The patient went down hill rapidly, running a septic temperature from 99° to 104°. There was excessive thirst and polyuria which was relieved by pitressin given hypodermically in 1 cubic centimeter doses several times daily. Several days after admission there was noted a drooping of the right eyelid and dilation of the right pupil. Neurological examination revealed no other pathological findings referable to the central nervous system. Examination of the eye showed no contraction of the visual fields and the fundi were normal. The patient became comatose and died August 23, 1936, 23 days after admission. Although a bronchoscopic examination was not performed, the diagnosis based on clinical and laboratory findings was bronchogenic carcinoma, with metastases to the liver, fifth cervical vertebra, and to the brain in the region of the pituitary gland. Autopsy performed by W. M. S. showed the following findings: Left lung.—Was densely adherent to the diaphragm. There was a mass about the size of a large walnut near the hilum in the upper part of the lower lobe. On NORMAN AND SILUPHANT —BRONCHOGENIC CARCINOMA 91 section a constricting new growth was found, having its origin in the left descend ing bronchus, 0.5 inch from the bifurcation, and which had all but closed the lumen. The tumor mass was confined to this area, no other masses being found in either lung. The lung parenchyma, peripheral to the tumor, was atelectatic and gangrenous, and contained small multiple abscesses which exuded thick foul-smelling pus. Microscopical examination of the primary lesion showed a tumor arising from the bronchial mucous membrane, practically closing the lumen, and extending through the wall into the lung parenchyma. The cellular structure was that of a fairly well-differentiated squamous cell with large irregularly shaped hyper- chromatic and vesicular nuclei and abundant pink staining cytoplasm. Actual intercellular bridging could be observed. The cells were arranged in sheets of varying sizes separated by a fibrous stroma containing lymphocytes. Fairly well-developed epithelial pearls were present. Mitosis was not a prominent feature. The lung parenchyma beyond showed a severe degree of secondary infection, there being many areas of abscess formation, and most of the bronchioles were filled with pus cells. Lymph glands.—There were many enlarged mediastinal and mesenteric lymph glands, some as large as golf balls. The structure of these glands was destroyed by tumor growth. Heart. —An oval shaped firm tumor mass was found in the posterior lateral wall of the right ventricle, the upper edge of which encroached upon the right coronary artery about 2 centimeters from its orifice. It was 4 centimeters in greatest diameter and occupied practically the whole thickness of the ventricular wall. It could readily be seen from the endocardial surface as whitish in color. Mi croscopical section revealed a cellular structure resembling the primary tumor. That portion of the coronary artery adjacent to the neoplastic growth was com pletely occluded by tumor tissue. Liver.—Was three times normal size and was studded with innumerable tumor masses of all sizes up to that of a walnut. The right lobe was practically one solid tumor mass. Microscopical examination revealed widespread metastasis to the extent that it was difficult to recognize the tissue as liver. Pituitary gland.—This organ was enlarged to about three times average size, the right side showing more enlargement than the left. It had eroded into the sphenoidal sinus. There was also erosion of both anterior and posterior clinoid processes. Microscopical examination showed little normal pituitary tissue remaining, the gland being largely replaced by sheets and masses of metastatic cells. Fifth cervical vertebra. —The body of the fifth cervical vertebra consisted of soft boneless tissue, which when removed, left only a thin shell of bone along the upper posterior margin connecting the two lateral processes. Microscopical examination revealed tissue resembling the primary tumor. DISCUSSION This case is of interest clinically because it illustrates how a lung abscess occurring secondarily to a carcinoma of the bronchus may obscure the primary lesion. When this patient presented himself for diagnosis the carcinoma had occluded the bronchus to such an extent that there was atelectasis of the area supplied by the bronchus with secondary pyogenic infection resulting in multiple abscess 92 NORMAN AND SILLIPHANT —BRONCHOGENIC CARCINOMA formation. There was not complete occlusion as there was a moderate amount of purulent sputum which on microscopic examination showed the presence of elastic fibers. This secondary purulent infection had been present for at least a year and had given rise to a diagnosis of lung abscess. In the presence of chronic purulent pulmonary disease the presence of carcinoma of a bronchus must always be suspected (4, 5). Vinson (4, 5) states that neither the history, physical ex amination, nor X-ray appearance are sufficient to distinguish car cinoma of the bronchus from chronic pulmonary disease. He makes the interesting observation that distant breath sounds over the affected lung area is the most important physical finding of carcinoma «of a bronchus and states: This finding is noted rarely in other pulmonary diseases without involvement of the pleura and when it is observed without corresponding impairment of the percussion note over the area involved, carcinoma should be suspected at once. This case is also of interest because of the unusual metastases. The sympton of diabetus insipidus was readily explained when at autopsy the pituitary was found to be greatly enlarged by a metastatic growth which completely replaced the normal gland structure. Metastatic lesions of the pituitary are not extremely rare (6). When metastasis occurs in the posterior lobe of the pituitary it usually gives rise to the clinical signs of diabetus insipidus (3). Indeed Fink (3) goes so far as to state that when diabetus insipidus develops in a case of malignancy it is an almost pathognomonic sign of metastasis to the posterior lobe of the pituitary gland. This author in a review of the literature in 1928 was able to find reports of 107 cases of diabetus insipidus in which necropsies had been performed; of this number 16 were due to metastatic lesions of the pituitary. In reviewing the literature since 1928, we have found the following authors who have reported cases of malignancy with metastasis to the pituitary gland: Grossman (7), Benhamon, Montpellier, and Curtillet (8), Johnson (9), Amstein (10), and Macchioro (11). These matastatic tumors may arise from any organ, but from a survey of the literature seem to arise with greatest frequency from primary growths of the breast and bronchus. The finding in this case of a metastatic nodule in the wall of the myocardium was unexpected, as there had been no history of cardiac pain or symptoms referable to the heart. The nodule was 4 centi meters in greatest diameter and had completely occluded the right coronary artery. The occlusion had apparently taken place gradually with development of collateral circulation from branches of the left coronary artery and from those of the right above the site of occlusion, as there were no signs of cardiac infarction. It is unfortunate that an 'electrocardiograph had not been taken to compare the electrocardio graphic findings with this interesting anatomical lesion. Metastatic tumors of the heart occur with greater frequency than is ordinarily believed. Blumensohn (12), in a review of 1,078 cases of NORMAN AND SILLIPHANT —BRONCHOGENIC CARCINOMA 93 carcinoma in general, found cardiac metastasis in 34, or 3.17 percent, while of 160 cases of sarcoma, 12, or 7.5 percent, showed metastasis to this organ. These metastatic lesions arise with greatest frequency from primary or secondary intrathoracic neoplasms (13) viz lung, pleura and mediastinal lymph nodes, and are probably best explained by retrograde extensions to the heart from the tracheobronchial nodes which also drain the lungs and pleura and in the case of the pericardium by direct implantation (14). Cardiac metastasis even though involving large areas of the myo cardium may occur without clinical symptoms (15) as in this case. This illustrates the great functional reserve of the myocardium. When symptoms do occur the prevalent symptoms are cardiac pain and cyanosis associated with frequent recurrent hemorrhagic peri cardial effusion (16). SUMMARY A case of bronchogenic carcinoma is reported with metastasis to the pituitary gland giving clinical symptoms of diabetus insipidus and metastasis to the myocardium with complete occlusion of the right coronary artery without the production of cardiac symptoms. Bibliography (1) Fried, B. M. Primary Carcinoma of the Lung. Williams & Williams Co., Baltimore, Md., 1932. (2) Adler, quoted by J. Ewing in Neoplastic Diseases. W. B. Saunders Co., Philadelphia, Pa., 1931. (3) Fink, E. B. Diabetus Insipidus. A Clinical Review and Analysis of Necropsy Reports. Arch, of Path. 6: 102, 1928. (4) Vinson, P. P. Discussion of Significant Signs in Early Carcinoma of the Bronchus. Proceedings of the Staff Meetings of the Mayo Clinic 11: 353, 1936. (5) Vinson, P. P. Primary Malignant Disease of the Tracheobronchial Tree. Report of 140 cases. J. A. M. A., 107: 258, 1936. (6) Simonds, J. P. Metastatic Tumors of the Hypophysis. Endocrinology and Metabolism. D. Appleton & Co., New York, 1922. (7) Grossman, W. Diabetus Insipidus bei Tumor Metastasen in der Hypo- physe. Frankfort Ztch f. Path. 42: 384, 1931. (8) Benhamon, E., Montpellier J., and Curtillet, E. Cancer du corps do pancreas avec metastases vertebroles, cutanees et hypophysaires. Bull, et Mem. Soc. Med. d hop de Paris, 54: 1516, 1930. (9) Johnson, G. Metastatic Carcinoma of Pituitary Gland; report of case. J. Ner. & Men. Dis., 70: 285, 1929. (10) Arnstein, A. Diabetus Insipidus bei Metastatischer Karzinose der Hypophyse, Namentlich de Hinterlappens bei primaren Bronchus und Mama- karizonom. Med. Klin., 29: 1679, 1933. (11) Macchioro, G. Su un caso di diabete insipido da tumore metastatico della regione ipofisario. Minerva Med., 1: 668, 1935. (12) Blumensohn, quoted by H. Le B. Peters and L. S. Milne. Secondary Tumors of the Heart. N. Y. M. J., 94: 383, 1911. 94 NORMAN AND SILLIPHANT —BRONCHOGENIC CARCINOMA (13) Morris, L. M. Metastasis to the Heart from Malignant Tumors. Am. H. Journal, 3: 219, 1927. (14) Peters, H. LeB., and Milne, S. Secondary Tumors of the Heart. N. Y. M. J., 94: 383, 1911. (15) Link, quoted by Averbach, O., Epsteen, H. and Gold, H. Metastatic Carcinoma of the Heart. Am. H. Journal, 12: 467, 1936. (16) Mead, C. H. Metastatic Carcinoma of the Heart Secondary to Primary Carcinoma of the Lung. J. of Thoracic Surg., 2: 87, 1922. CLINICAL NOTES KEUKENBERG'S SPINDLE By Raymond W. Heoe, Lieutenant, Medical Corps, United States Navy In 1898 Krukenberg made a report of cases of an anomalous pig mentation of the cornea. The special characteristics of the cases reported were as follows: An oval-shaped brownish pigment deposit on the posterior layer of cornea of both eyes, arranged in a vertical direction. His patients were myopes, females, and over 45 years of age. He believed that the pigmentation was the result of a fusion of the pupillary membrane with the cornea in fetal life. Edgerton in 1829 made an extensive search of the literature and his report discloses 37 such cases with slight variations from the originals reported by Krukenberg. The variations included cases, in hyperopes, in males, with one eye involved, in which the pigmented spindle was in the horizontal position, and in patients as young as 22 years of age. However, these variations were in the minority. Edger- ton's review of the literature included reports made by 22 authors. The greatest number of cases reported by any one author was six, made by Augstein in 1912. His 6 cases were seen among 12,000 patients examined. A further search of the literature after Edgerton's report discloses the following cases reported: Srinivasan, in the British Journal of Opthalmology, November 1930, reported one case. Ardwell in Jan uary 1930 presented a case report at the Royal Society of Medicine of London, and Doggart reported a case to the same society, March 1930. Several theories as to the origin of the condition have been pro pounded. Some authors accepted the pupillary membrane fusion theory of Krukenberg. Stock thought the cells of the posterior layer of the cornea possessed some anomalous pigment developing power. Koby in 1927 reported observing the development of typical spindles in a patient with iritis 4 months after an infection and a second which developed from a few dots of pigment into a complete spindle in a period of 18 months. He believed that the spindle-shaped pigmentation was due to breaking down of the pigment of the iris, facilitated by such condition as myopia, senility, and chronic inflam mation, and he believed convection currents resulting from tempera 05 96 HEGE KRUKENBERGS SPINDLE ture changes carried the pigment to the cornea, where it was deposited. In cases with existing inflammatory condition the pigment was depos ited rapidly, hut if the inflammatory condition was absent the deposition was slow and dependent upon scratching of the cornea by the granules of pigment carried by the convection currents. Other theories have been proposed to explain the origin of this rare condition and are referred to in Edgerton's report. REPORT OF A CASE Patient LWF, fireman third class, United States Navy, age 28, male, was admitted to United States naval hospital, Washington, D. C., March 4, 1936, with diagnosis Dementia praecox. The original diagnosis was made August 13, 1935, when admitted to Mare Island Hospital, California. History disclosed that patient had worn glasses for past 2 years at intervals for double vision. There was no history of eye disease. Glasses did not improve vision and he discarded them recently. Vision 20/20 either eye on entry into the naval service. No history of eye diseases in family. General physical examination was negative except for psychological and neurological findings and marked gingivitis and pyorrhea, alveolaris. Weight 130 pounds, and height 68 inches. An examination of the eyes revealed the following: No evidence of acute or chronic inflammatory disease. The color of iris is brown. VOD 20/20, VOS 20/30. Color vision normal. Visual and color fields, right eye normal; in left there was concentric contraction of visual and color fields and interlacing of colors. Under homatropine VOD 20/15, VOS 20/15. During the retinoscopic examination, bilaterally, a vertical elongated shadow was noted which did not move with the retinal shadow. The opthalmo- scope showed this to be a brownish pigmentation of the cornea extending in the vertical direction, opposite the pupillary opening. This pigmentation was about 5 millimeters in length and 2 millimeters in width, each eye, and appeared tapered toward each end. The opthalmoscopic examination was otherwise negative. Neutralization of the patient's glasses showed them to be OD 0, OS 3D prism, base down. An examination by the phorometer revealed at 6 meters esophoria 0, exophoria 0, left hyperphoria .2D and at 33 centimeters, 8D exophoria. An examination with the slit lamp disclosed the pigment to be in the posterior layer of the cornea. The pigment had a brownish appearance identical to that seen among the muscle bundles of the iris. The pigmentation was more extensive than it appeared to be on examination with the opthalmoscope, for scattered particles were seen over the greater part of the cornea. On the lower and mesial aspects of the cornea it extended as far as the limbus. These deposits were more numerous toward the center where they were sufficiently dense to show macroscopically as described above. No pupillary membrane or other anomalies were noted. Laboratory tests: Kahn and Wassermann negative. Urine negative. White blood cells 14,000, neutrophiles 69 percent, lymphocytes 22 percent, eosinophiles 3 percent, monocytes 6 percent. Sedimentation time, 8 millimeters in 60 minutes. SUMMARY 1. Krukenberg made the first report of cases of this condition in 1898, reporting three cases in that year. Since that time 26 authors have reported 41 cases of this condition. 2. Several theories as to the origin of the pigmentation have been propounded. LeCLAIR— DENTAL NEUROSIS 97 3. A typical case is reported with the following characteristics: (a) Vision slightly impaired. (b) There is a brown, oval-shaped pigmentation of the cornea, both eyes, vertical in direction and central in position, seen macroscopically. (c) Examination by means of the slit lamp shows the pigmentation to be in the posterior layer of the cornea, involving the greater part of the cornea. Below and to the nasal side the pigmentation extends as far as the limbus. The pigment is more concentrated as the center is approached, where the spindle or deep pigmentation appears macroscopically. (d) On refraction the eyes are emmetropic. Bibliography Illustrated Guide to the Slit Lamp, T. Harrison Butler, page 47. Archives of Ophthalmology, 1: 591-593; 3: 380, 496, 599-619; 4: 151; 5: 808, 996; 6: 771. American Journal of Ophthalmology, 13: 326, 334, 534, 654, 722, 1930. DENTAL NEUROSIS By V. A. LsClaib, Lieutenant, Dental Corps, United States Navy Impacted teeth cause subjective neuralgic symptoms, in many cases, where a lobical explanation of these symptoms cannot be given. It is problematical if all the conditions existing that are apparently caused by the teeth can be directly traced to the teeth. The following is a report of two cases that fall in this category: Case 1.—D. H. C., seaman, second class, age 25 years, married, white male. Chief complaint: Pain in the ear and "cold in the eye." Noticed eye would not close. Shipmates accused him of being a "wise guy" by talking out of the left corner of his mouth. Past history: Scarlet fever and diphtheria at the age of 8 and measles at 10. Uses alcohol sparingly. History of present illness: Three days prior to reporting to sick bay he started to talk out of the corner of his mouth. The night before he reported he felt pain for the first time in his ear and attributed the pain to a "blackhead" in the ear. The day after the pain appeared the eye commenced to water freely. Three days before onset of illness the patient drove about 240 miles round trip in a roadster with windbreakers. These trips were weekly events prior to this period. Two days after this trip he developed accentuated talking out of the side of his mouth, lacrymation right eye and slight pain in the ear, and reported to the sick bay where he was treated by the duty corpsman for a cold in the eye. The following day, April 18, he was admitted to the sick list with a diagnosis of Bell's palsy. Physical examination: A well developed white adult male. Rhomberg negative, no conscious stiffness of the face, pupils equal, react to light and accommodation. Ear normal, taste normal. All muscles of expression on right side of the median line of the face completely paralyzed. Phlegmatic, all muscles supplied by the facial nerve on right side involved. The wrinkles of the forehead and nasolabical fold, on the right side, flattened out. Deviation of the nose to the left. Inability 9S LeCLAIR—dental neurosis to whistle, bare the teeth, or close the eye. Cannot elevate the right eyebrow, cannot drink water without drooling. No pain on deep pressure in the styloid region or behind the ramus of the jaw. Oral cavity normal. Treatment: Patient remained on the sick list for 2 weeks with no apparent improvement. X-ray examination of the oral cavity disclosed the upper right wisdom tooth horizontally impacted, with the occlusal surface flush with the crest of the alveolus. No clinical, radiographical, or palpable signs of pathological involvement. May 1, the upper wisdom tooth was removed under local anes thetic, taking care to cause minimum of trauma. The following day, the right eyebrow showed evidence of movement. Four days later the patient could whistle and bare his teeth. One week from the date of operation the patient was apparently normal and has remained so to date. Case 2.— C. R. E., Lieutenant, U. S. N. age 31 years, married, white male, medium size and build. Chief complaint: Aggravating pain behind ear with an inability to raise voice above normal tone without loss of sound. Family history: Father died at the age of 67, mother living and well. Three sisters all living and in good health. Past history: Chickenpox at 8 and scarlet fever at the age of 10. Appendec tomy and herniotomy in 1925. Health record in Navy negative. About January 1932 he first noticed a slight aggravating pain on the left side of the face in the region of the submaxillary gland. These symptoms came on intermittently thereafter. The symptoms were aggravated and intensified when subjected to a draft as driving a closed car with the driver's window open. These symptoms subsided completely for a considerable time following the first attacks. Present illness: About a month before reporting for treatment the above symp toms reappeared and progressively became worse, being aggravated by exposure to drafts. September 15, the patient reported to sick bay with pain centered in the ear; bothersome but not clearly defined as to location, with swelling of the submaxillary region on the left side, and complaining of complete loss of voice when speaking in a forceful manner. Combination of intense pain with a sensa tion it was impossible to talk, comparable to someone grabbing hold of the vocal cords. No soreness of the submaxillary gland. "Like the sensation of a con traction of a throat muscle; when I stopped to clear my throat the impediment would disappear." The speech impediment has been steadily becoming worse. These symptoms are practically constant at the present time. Physical examination: Mouth normal, excellent oral hygiene. No evidence of clinically demonstratable pathology of the hard or soft tissues. Apices radio- graphically negative. Considerable swelling of the left submaxillary gland region with tenderness posterior to the ramus of the mandible, anterior to the external auditory meatus. Radiographic examination revealed tooth No. 16 in slight lingual version below the line of occlusion with a super impacted supernumerary third molar lying distally and above the roots of tooth No. 16 in close proximity to the maxillary sinus. No clinical, radiographic, or palpable signs of infection in the area could be demonstrated. Treatment: On September 16, the normal third molar was removed under local anesthetic. Forty-eight hours after the removal of the tooth symptoms disap peared with no recurrence to date. It is not assumed that the above cases were definitely caused by the existing dental condition; coincidence must always be considered, however, in view of the complete cures immediately following treatment —they strongly point to a dental origin. Dental literature is full of case reports of widely divergent subjective symptoms of dental origin. FULGHUM —MASOCHISM 99 COMMENT The etiology and nature of the pain caused by impactions is not known. In my opinion, the chain of symptoms is caused by an over stimulation of the vital structures supplying the tooth germ as the roots grow downward into the bone structure. The teeth are found in crypts in the bone, and when they begin to erupt the roof of the crypt is removed by absorption, making room for the crown to pass. The tooth germ remains relatively stationary during the entire growth of the normal tooth. If in the normal growth the tooth be comes impacted, the growth takes place in the opposite direction, causing a disturbance of the physiological balance of that surrounding structure. The capillary and nerve plexes of the tooth germ and the future dental pulps become impinged between the developing tooth and the bone of the maxillae. This disarrangement of the vital structures supplying the tooth causes an overstimulation of these structures producing a conscious recognizable chain of symptoms, or the irritation may be tolerated by the patient. All impacted teeth produce this overstimulation whether subjective symptoms are present or absent. The degree of tolerance to irritation varies in different individuals ; irritation always exists where impactions are present. The reflex nervous conditions of dental etiology oftentimes present no local symptoms and as a result the dental aspect is not considered until all other lines of treatment are exhausted. In the words of Dr. E. Roy Bier, D. D. S.: The presence of local or referred pains in or about the head of the patient in the following regions: Temple, back of head or neck, top of head, ears, dull pain around the eyes; or should even a general neurasthenic condition exist, the diagnostician is justified in ordering the removal of any impacted teeth, whether they show infection or not. PASSIVE ALGOLAGNIA MASOCHISM By jAMea E. Fulohum, Lieutenant, Medical Corps, United States Naval Reserve, Lonlsburg, N. 0. This report is made because of the rarity of this type of case outside of the cosmopolitan districts, the rarity of the passive algolagnia in the male, and the unusual type of lesion produced by a patient upon himself. Algolagnia is divided into two classes, active and passive. Active algolagnia or sadism is the gratification of the sex urge by infliction or sight of pain real or simulated. This abnormality is found most frequently in the male. Passive algolagnia or masochism is the gratification of the sexual feeling by suffering pain either real or simulated. This is found most frequently in the female. Many 100 FULGHUM —MASOCHISM sadists and masochists are potent only when they are subjected to suitable stimuli. In some instances, sadism and masochism coexist in the same indi vidual; however, one usually overshadows the other. Krafft-Ebling has defined sadism as "an association of cruelty and violence with lust." The condition obtained its name from the notorious Marquis de Sade whose obscene novels treated extensively of lust and cruelty. Masochism obtained its appellation from the writer, Saches-Masoch, who wrote at great length of this form of perversion.1 REPORT OF CASE L. A., a barber, age 25, unmarried, called me to his room in the early morning and asked me to take him to my office. He was standing in his room fully un dressed except for a towel which was closely pressed to the genitalia. There were many towels soaked with blood upon the floor which showed evidence of consid erable hemorrhage. Upon questioning him, he admitted that he cut his scrotum with the scissors "for the purpose of seeing what his testicle looked like." Imme diately, he was taken to the office where a more thorough examination was made. There was an incision about 2 inches long on the left anterio-lateral side of the scrotum through the skin, subcutaneous tissue, tunica vaginalis, and into the testicle. The incision in the skin had been closed by the patient with a needle and cotton thread. These stitches were taken out and a large blood clot removed. The hemorrhage was found to be coming from a severed vein in the tunica vagi nalis. Under aseptic conditions the wound was closed in three layers; 1st, testicle, 2d, tunica vaginalis, 3d, skin and subcutaneous tissue, without anesthesia. I explained to him that I could novocainize the wound and he would suffer no pain but he desired to be sutured without anesthesia. There was not the slightest flinching or other outward evidence of pain experienced by the patient. The wound healed by primary intention without complications, the sutures being removed on the sixth day. Upon close examination, four identical healed scars and numerous pinpoint scars were seen on the scrotum. These former experiences will be discussed in the personal history. Personal history.—He is the third child born of unrelated parents. His birth was normal and occurred in a small eastern North Carolina town. He has three brothers and five sisters. His preschool days were void of any unusual circum stances except that he never liked to play with other children. He loved his mother better than his father. His school life was normal. He was an average student. His education is limited to the eighth grade and training in a barber college. He took no part in the school social life. He bad measles, mumps, whooping cough during childhood but since then, he has had no serious injuries or operations. He does not use alcohol, tobacco, or drugs in any form. His work is satisfactory but he does not enjoy it particularly. He has no recreation except the theater. He has no hobbies nor does he enjoy or play any form of athletics or sports. He has no religious affiliation or interests. He has no friends and when not working he likes to be alone in his room. He does not care for books, music, or current events. He admits that he likes to read sordid and obscene magazines. He was reared in a small town and lived there all of his life except 2 years when he was in school in Baltimore. His sex life has been abnormal. He began the practice of masturbation at the age of 14. He has attempted normal coitus on 2 occasions but could not attain an erection. Erections can be secured 1 Patten, C. A. "Psychopathic Personality," Cyolopedla of Medicine, vol. X, F. A. Davis Co., 1934. WALTER AND HOLLAND—PNEUMONIA 101 In his room under suitable stimuli such as pinching himself or sticking himself with pins. The first scrotal operation was done 4 years ago. The others have been done at intervals of several months. One of these done in 1935 was followed by an abscess which had to be opened by his family physician to evacuate the pusv He used no form of antiseptic in these operations. He stated reluctantly that he- derived sexual pleasure and gratification from the operations which he had done- and that they had been accompanied by erection and ejaculation. He has never seen the same thing done by other people but began to do so because of the pleasure derived at first from pinching the scrotum and later by perforating the scrotum with pins. Girls are disgusting and repulsive to him and make him nervous. Mental examination. — Negative. Physical examination. —Well-developed and well-nourished white adult male who shows no abnormal findings except the scrotal wound. COMMENT This patient is greatly concerned about himself. He says that he knows that he should not do these things but feels compelled at time* to indulge. The fact that he is impotent has increased his worry. He expresses a desire that I help him to overcome these abnormalities,, and he has confidence that he can overcome them with the proper help. A supplementary report of the outcome will be made at a later date. ATYPICAL LOBAR PNEUMONIA By A. J. Walter, Lieutenant, Medical Corps, United States Navy, and J. L. Holland, Lieutenant, United States Navy This case is reported as it is believed to be of interest due to the following: (1) The unusual prodromal signs and symptoms. (2) The remarkable reaction following the administration of anti- pneumococcic serum with subsequent rapid disappearance of chest findings. (3) The clinical course and laboratory findings. REPORT OF A CASE Case of J. "T" B.—Patient reported to sick call at 8:30 a. m. complaining of a cold in head and chest of 4 days' duration, also severe occipital headache, stiff ness of neck, and general malaise. He stated that 2 days ago he had shore patrol on a cold rainy night from 10 p. m. until 2 a. m., and at 4 a. m. he began his duties in the galley. He stated that the night before admission while at home, he had a severe chill, was nauseated, vomited twice, and had a severe occipital headache which was not relieved by 10 grains of aspirin. The patient's physical appearance was that of a well developed and well nourished white male of about 26 years of age. He had a distressed look, marked pallor, and appeared quite toxic. The physical findings were not compatible with the above appearance. Temperature and respiration were normal, pulse 90. Examination of eyes, ears, nose, and throat was negative except for a moderate 102 WALTER AND HOLLAND PNEUMONIA nasopharyngitis. There was no stiffness of the neck. Heart normal,, blood pressure 100/66. The lungs disclosed a few scattered mucous rales, and abdomen was negative. Extremities and reflexes were normal except for slight pain in hip joints on flexion of thighs on abdomen. Skin negative. White blood cells 11,050. The patient was admitted to sick bay as an absolute bed patient under close observation. Symptomatic treatment was instituted. At 10:30 a. m. he had a moderately severe chill, and the occipital headache increased in severity. The temperature rose to 101. 6°, pulse 100, and respiration 21. One hour later a slight erythema was noted on his arms and chest. Temperature was 102.6°; pulse, 112; respiration, 22. He was immediately transferred to the Hankow International Hospital, Han kow, China. While en route he perspired profusely and on arrival 20 minutes later his temperature was 101.6°; pulse, 87; respiration, 20. Spinal puncture revealed clear fluid under normal pressure with five cells per cubic millimeter. The headache disappeared after spinal puncture. There was no evidence of the rash or erythema. The patient minimized his condition and felt very comforta ble. The white blood cells was 11,400; myelocytes, 1 percent; bands, 39 percent; segments, 35 percent; lymphs, 14 percent; and large monos, 1 1 percent. Repeated examination for malarial parasites were negative. Five o'clock in the afternoon he had a severe chill which was followed by a temperature 105.2°; pulse, 140; respiration, 30. The headache returned and the heretofore mild cough became quite harsh and deep. His breath had a strong fetid odor not noted before. Chest examination elicited marked congestion, and slight dullness over right middle and lower, and left upper lobes. There were loud mucous rales, with fine crepitant rales at the end of inspiration. The expiratory sound was prolonged. Sputum examination revealed many gram positive diplococci in almost pure culture. As there were no typing facilities and after sensitivity test which was negative, 10,000 units of Mulford's poly valent serum type I and II were given at 8:40 p. m. One hour later he had a terrific chill, pulse 150 and very thready. He had Cheyne-Stokes respiration. One cubic centimeter of adrenalin chloride was given hypodermatically which increased the strength of the pulse and accelerated the rate to 180. Axillary temperature was 108° and respiration 40. The patient became irrational and had to be restrained. One-half grain of morphine sulphate administered. After patient's condition subsided a second spinal puncture revealed clear fluid under moderately increased pressure. There were 11 cells per cubic millimeter and subsequent spinal fluid cultures were negative and Kahn was negative. He perspired most profusely and by midnight his temperature was 100.4°; pulse, 112; respiration, 14. He was also rational. At 2.30 a. m. his temperature was 95°; pulse, 80; respiration, 12. He had no complaints. By 9 a. m. his temperature was 97.6°; pulse, 80; respiration, 20. Examination at this time revealed the patient resting comfortably, the cough was only slight, and most remarkable was the absence of the physical signs of congestion noted the evening before. There were a few scattered mucous rales throughout the chest; white blood cells, 9,800; myelocytes, 1 percent; meta-myelocytes, 1 percent; bands, 42 percent; segments, 33 percent; lymphs, 15 percent; large monos, 8 percent. There was an afternoon rise in temperature to 105°; pulse, 140; respiration, 28. He then perspired profusely necessitating frequent changes of bed clothing during the night. Nine o'clock the following morning, which was the third day of his illness, the temperature was 97.6°; pulse, 80; and respiration, 20. During the day the temperature, pulse, and respiration gradually increased until at 5 p. m. the temperature was 104.8°; pulse, 140; and respiration, 28. The patient was looking quite toxic by the fourth day. At nine a. m. tempera ture was 100°; pulse, 96, and respiration, 24. The white blood cells had dropped WALTER AND HOLLAND PNEUMONIA 103 sharply to 6,800, with also a marked shift to the left. There was one basophils; myelocytes, 2 percent, meta-myelocytes, 3 percent, bands, 35 percent, segments, 21 percent, lymphs, 23 percent, and large monos, 16 percent. At 7 p. m. 250 cubic centimeters of blood were given by the multiple syringe method, which was followed by a chill with temperature rise to 105.2°, pulse, 104, and respiration, 27. This reaction was followed by a subnormal temperature of 95°, pulse, 60, and respiration, 18. His general condition on the morning of the fifth day showed slight improvement, with an increase in white blood cells to 8,200, basophiles, 1 percent, myelocytes, 1 percent, meta-myelocytes, 1 percent, bands, 32 percent, segments, 35 percent, lymphs, 22 percent, and large monos, 8 percent. The above slight gain shown in blood picture and clinical findings were only transi tory, and by the sixth day he was looking quite toxic, with his blood picture showing granulocytic shift to the left. The white blood cells had decreased to 7,800, myelocytes, 1 percent, meta-myelocytes, 1 percent, bands, 35 percent, segments, 30 percent, lymphs, 22 percent, large monos, 11 percent. A second transfusion of 450 cubic centimeters of blood and 100 cubic centimeters of normal saline solution was given. There was no chill following this transfusion and his' temperature only rose to 103.6°, pulse, 110, and respiration, 26. On the following day the patient showed decided improvement, he felt much better and his afternoon temperature was 103.8°. The white blood cells were 9,200; myelocytes, 1 percent; meta-myelocytes, 2 percent; bands, 39 percent; segments, 31 percent; lymphs, 15 percent; large monos, 12 percent. Examination of chest revealed only a few scattered mucous rales. From the seventh to the tenth day of his illness there was a gradual decline in the afternoon rise in tem perature, steady marked improvement in his general condition, and no marked change in blood picture until this date. However, on the morning of the tenth day his white blood cells were 13,400; myelocytes, 1 percent; meta-myelocytes, 1 percent; bands, 20 percent; segments, 56 percent; lymphs, 17 percent; large monos, 5 percent. The first X-ray of chest was taken this date as patient's condition was such that it was not advisable to move him to the X-ray room before this time. The lungs were essentially negative except for a moderate increase in infiltration of bronchi extending toward periphery. The heart showed marked dilation of the left ventricle. Next morning the patient com plained of a severe pain in right chest. Examination revealed a loud friction rub. The pain was much relieved by immobilization of chest with adhesive plaster. The white blood cells showed an increase to 17,200 with granulocytic shift to the left. On the thirteenth day examination revealed decrease in sound of friction rub, but an area of dullness was noted along costal margin, mid-axillary line. The temperature, pulse, and respiration gradually subsided to normal by the seventeenth day. The pain had disappeared, no dullness could be elicited, and the patient's general condition showed marked improvement. The blood picture was compatible with the clinical course and on this date the white blood cells were 8,600; eosins, 1 percent; meta-myelocytes, 1 percent; bands, 12 percent; segments, 52 percent; lymphs, 27 percent; large monos, 7 percent. The tempera ture continued to remain normal, no other complication developed, and the patient made an uneventful recovery. DISCUSSION The diagnosis in this case was very confusing because the charac teristic clinical findings and blood picture were lacking. No diagnosis was made until after sputum examination, the afternoon chill, and rise in temperature to 105°, with the accompanying chest findings 104 FUNK —MENINGOCOCCI INFECTION confirmed it. Patient's past history was negative except for malaria and repeated careful examinations were made of the red blood cells to rule out this condition. Repeated blood cultures were negative for pneumococci. Meningitis was ruled out after repeated spinal punctures, spinal fluid examinations, and cultures of spinal fluid, as being a complication. One of the most interesting laboratory find ings was the fact that proteus X 2 was positive in 1 to 250 dilution while proteus X 19 was negative. Another examination with new stock of proteus X 2 and ONX 19 were positive 1 to 100 dilution, but proteus X 19 was negative. A local doctor had four cases which agglutinated proteus X 2, 1 to 100, but not proteus X 19 or ONX 19. It was noted that of this group, this case had the highest tempera ture and perhaps there may be some relation between the temperature and the agglutinating power of his serum to cause precipitation in both proteus X 2 and proteus ONX 19 up to 1 to 100 dilutions. ATYPICAL MENINGOCOCCI INFECTION By W. H. Funk, Lieutenant Commander, Medical Corps, United States Navy H. J. A.—C. C. C. white, age 21, entered the United States Naval Hospital, Great Lakes, 111., on January 9, 1936, for treatment of a left inguinal hernia. On his way to the hospital, he caught cold and his complaint on admission was head ache, cold in his head and on his chest. On physical examination at entrance there was noted on his extremities a papular eruption, with breaking down and scab formation at the center and surrounded by a zone of erythema. During his stay at the hospital he had febrile rises to 102 or 103 about every third day, pre ceded by chilly sensations but not by a definite chill, with a new crop of skin lesions typical of erythema multiforme. Even with febrile accessions his pulse was low, never going over 100. With the later febrile episodes there was definite joint involvement, redness, tenderness, and pain similar to acute rheumatic fever. Repeated blood cultures were negative. Repeated blood smears were negative for malaria and a thera peutic test was tried with quinine. Because of the joint manifestations, salicylates were given over a long period of time with no improvement. There were no signs suggesting meningeal involvement until February 27, when a spinal tap was done because of rigidity of the neck and a positive Kernig. No organisms were seen on smear or culture and because of the low chlorides, T. B. meningitis was suspected. On the next tap a Gram negative extra-cellular diplo- coccu8 was seen on smear but did not grow on ordinary media. The Abbott laboratories very kindly took some of the fluid and on specially enriched media, were able to get a culture which gave an agglutination with antimeningitis serum. Intra-spinal therapy with antimeningitic serum was started on the 8th of March and convalescence was uneventful after 5 days of this therapy. It is believed that this was a case of atypical meningococcus septice mia giving an irregular temperature chart with erythema multiforme and arthritic manifestations for about 7 weeks and constituted a diag nostic puzzle during this period. After localization in the meninges, the organism could only be grown on specially enriched media, but responded to serum. LOVE AND EVER—TULAREMIA 105 TULAREMIA Report of Two Cases Occurring Among Active Naval Personnel By Julian Love, Lieutenant, Medical Corps, United States Navy and AIMED W. Era, Lieutenant, Medical Corps, United States Navy i Tularemia as a disease entity was established by Francis (1) in 1921. It appeared in the United States Navy Nomenclature of Diseases in the 1923 revision. An excellent discussion of the disease was presented by Simpson (2) in the United States Naval Medical Bulletin in October 1928, and in that same issue four cases were re ported by Bunkley and Smith (3). One of these cases occurred in a retired medical officer and two others apparently in nonnaval per sonnel in the United States Naval Hospital, Washington, D. C. The fourth case was a mild attack in the nephew of the first individual. It is probable that other cases have occurred among our naval es tablishments, but to date no report of the disease occurring in the active list of the Navy has been recorded in the "Surgeon General's Annual Report of Disease and Injuries in the Navy for the Calendar Years 1918-35," inclusive. Therefore, the appearance of this entity in two enlisted men on active service is considered sufficiently unusual to warrant its presentation. Case 1.-— R. J., seaman first class, United States Navy. White male, age 21. This sailor reported on April 19, 1936, to the dispensary, United States Naval Air Station, San Diego, Calif., complaining of "painful and tender lumps in the left armpit." He first noted the lump on April 15 accompanied by general malaise, headache, stiffness of neck, chills, fever, sweating, and a moderate degree of weak ness. These symptoms became progressively worse and the axillary kernels larger until he reported to the sick bay. In company with R. N. D. (case 2) and a civilian this man went on a week-end hunting trip near Bakersfield, Calif. They shot five wild rabbits, three of which were skinned by this patient while two were skinned by his companion. They had been warned by local residents to examine rabbits carefully for "boils" or "ulcers", and not to handle or eat animals so afflicted. No lesions were so noted on these rabbits, and the meat was thoroughly cooked. There was nothing in the family history, habits, or past illnesses which had any bearing on the case. Venereal diseases were denied. On physical examination a young white male with feverish appearance was noted. His temperature was 99.4° F; pulse, 80; and respiration, 18. Positive findings were injected conjunctivae, three very painful, freely movable pea to marble size lymph nodes in the left axilla, and a slight reddish mark about twice pinhead size on ring finger left hand, dorsal surface at junction of proximal and middle phalanges. There were no other abnormal physical findings, and there were no other enlargements of other lymphatic chains. Laboratory findings on April 19 were as follows: White blood count, 8,900; differential count, segments, 35 percent; bands, 3; lymphs, 54; monos, 5; and 1Our appreciation is expressed for the cooperation and assistance of Lt.-Comdr. F. C. Hill (M. C.), U. S. Navy, and Lt. E. P. Madden (M. CO, U. 8. Navy, of the U. S. Naval Hospital, San Diego, Calif., during the hospitalization period of these patients, and, also, to Commander L. L. Adamkiewicz (M. O.) U. S. Navy, for the biopsy and laboratory studies involved. 24140—3" 8 106 LOVE AND EYEB—TULAREMIA eosins, 3. The urinalysis showed a faint trace of albumin, a few leucocytes, and and occasional erythrocyte. On April 20 the white blood count was 6,000; dif ferential count, segments, 21 percent; bands, 16; lymphs, 50; monos, 10; eosins, 1; Turck cells, 1; and Rieder's cells, 1. The urinalysis showed a faint trace of albumin, a few granular casts, and a few leucocytes. On April 19 his temperature rose to 101° F., and pulse to 90, and on April 20 he was transferred to the United States Naval Hospital, San Diego, Calif. On April 21 a small denuded area appeared over the reddened mark previously noted accompanied by swelling and tenderness of the proximal and middle pha langes. From April 23 until May 7 his temperature showed an afternoon rise from 102° to 103° F. with a corresponding increase in pulse. Headache, extreme weakness, some chills and sweats were also noted. One axillary gland continued to enlarge and on May 1 began to soften but was not incised until June 2 when 10 cubic centimeters of pus were evacuated. His temperature began to recede by lysis on May 7 and after May 16 he was afebrile. His weakness persisted even after discharge on July 21, 1936. The laboratory studies at the naval hospital were as follows: April 21: Red blood count, 4.46 million; hemoglobin, 85 percent. White blood count, 8,750; segments, 30 percent; bands, 27; juveniles, 5; lymphs, 37; eosins, 3; and monos, 4. Urinalysis showed only a few leucocytes. April 22: White blood count, 7,450; segments, 35 percent; bands, 38; juveniles, 1; lymphs, 12; eosins, 2; and monos, 12. The Kahn test was negative. The serum showed no agglutination for Pasteurella tularense or Brucella group organisms. The serum was submitted to the Scripps Metabolic Institute and California State Public Health in addition to the local hospit 1 laboratory. May 4: Cultures of ulcer on finger were positive for staphylococci. May 5: A guinea pig was innoeulated with serum aspirated fiom the ulcer on the finger; 1 cubic centimeter of the suspension, intraperitoneally, and 0.5 cubic centimeter, subcutaneously. On May 11 the pig died. Autopsy report: "The pig appeared to be losing weight. The liver revealed numerous nodules and discolored ulcerated areas. The lungs appeared congested. Cultures made from liver and lungs were negative for Pasteurella tularense." June 2: Serum agglutination positive for Pasteurella tularense in dilution 1 to 640. Highest agglutination with Brucella group organisms, 1 to 80; positive for tularemia. Bunnell test was negative. Guinea pig innoeulated with pus from axillary abscess. One cubic centimeter was given intraperitoneally and 0.5 cubic centi meter subcutaneously. June 9 : Smear from axillary abscess was negative. Culture of the same material revealed no growth. June 23: The guinea pig was killed. Autopsy report: "The pig was apparently healthy and fat. It shows no apparent pathology. The internal organs were of normal appearance. No nodules were present. The lymph glands were normal." On July 21 the patient was returned to duty with scanty drainage left axilla. He complained of slight asthenia. Case 2.—R. N. D., seaman, first class, United States Navy. White male, age 18. This sailor reported to the dispensary on April 19 accompanying R. J. (case 1). His complaints were similar except that his "lumps" and tender ness were in the right axilla. Physical findings were essentially negative except for enlarged lymph nodes about the size of a large marble in the right axilla. No external abrasions were noted on right hand, wrist, or forearm. His white blood count was 7,400; the differential count, segments, 45 percent; bands, 4; lymphs, 37; monos, 8; eosins, 5; and basos, 1. The urinalysis showed only a LOVE AND EYER —TULAREMIA 107 few leucocytes and squamous epithelial cells. By evening his temperature rose to 101.6° F. accompanied by sweating and on April 20 he was transferred to the United States Naval Hospital, San Diego, Calif. From April 21 until May 1 his temperature rose daily to 103° F. His main complaint was weakness with chills and sweats. From May 1 until May 16 his temperature declined to normal, and he remained afebrile until July 21, the date of discharge. The right axillary lymph node increased in size and induration, and became immovable and quite tender. On May 7 it began to soften, and on May 22 10 cubic centimeters of creamy pus were aspirated from the abscess. On June 22 the fluctuant area was widely incised for drainage. There was gradual improvement until he was returned to duty. Laboratory studies while in the hospital were as follows: April 21: Red blood count, 4.46 million; hemoglobin 85 percent, white blood count, 7,650; segments, 32 percent; bands 32 percent; juveniles, 2 percent; lymphs, 24 percent; eosins, 6 percent; and monos, 4 percent. The urinalysis revealed some mucus and leucocytes. April 22: White blood count, 6,050; segments, 50 percent; bands, 15 percent; lymphs, 29 percent; and monos, 6 percent. The Kahn was negative. May 22: No agglutination for Pasteurella tularense or Brucella group organ isms was noted. Serum reported by the three laboratories was negative. A guinea pig was innoculated with pus from the right axilla, 1 cubic centimeter intraperitoneally, and 0.5 cubic centimeter subcutaneousiy. May 29: The Bunnell test was negative. June 2: Serum agglutination for Pasteurella tularense antigen was positive in dilution of 1 to 2560. Highest dilution for Brucella group organisms was 1 to 80. June 23: The guinea pig was killed. Autopsy report: "The pig was normal and healthy in appearance. The internal organs were surrounded by fat. No nodules or discoloration were present. The lymph nodes were normal. The pus inoculated May 22 was apparently sterile." The patient returned to duty well July 21 1936. DISCUSSION Tularemia may affect an individual in one of four ways; namely, ulceroglandular, oculoglandular, glandular, or typhoidal. Case 1 would be classified as ulceroglandular though actually it appeared to be "glandulo-ulceral." Case 2 represents the rarest clinical variety which is the glandular. Case 1 is a right-handed individual and held the rabbit in his left hand while skinning with his right, while case 2 is left-handed and so held the rabbit with his right hand. This may account for the presence of the adenitis in the left axilla of the former, and in the right axilla of the latter. The civilian who accompanied the sailors on the hunting trip must have handled the rabbits, too, since he was affected with the ulcero glandular type of the disease. He was treated by a physician in Bakersfield who incised the axillary abscess while under the impres sion it was one of nonspecific suppuration. It was not until the cases reported above wrote the true diagnosis to their civilian friend that he received specific therapy which consisted of injections of Foshay's antiserum. These injections were reported to have been ineffective 108 BKHNKE —NEUTROPENIA as they were probably given too late. Foshay (4) states that for the- serum to be efficacious it must be used before the twelfth day of tho disease. The above cases illustrate very clearly that the organisms can penetrate the unbroken skin, the incubation period of about 4 days, and the delay in formation of specific antibodies (agglutinins) until after the tenth day of the disease. In these cases positive agglu tinations were not obtained until after the third week of the disease. The diagnosis was readily made in these two cases, because the medical officer who first saw the patients had the disease in mind and questioned them about contact with rabbits. A suspicion of this disease should always be aroused by the presence of unexplained axillary or femoral adenitis. Bakersfield, Calif., is in Kern county, 350 miles from San Diego, and only 25 miles from Tulare County where Chapin and McCoy first isolated Pasteurella tularense in 1912 and so named it for the county in which it was discovered. CONCLUSION 1. Two cases of tularemia occurring in active Naval personnel are reported. These apparently are the first to appear among the active list of the Navy. Bibliography 1. Francis, E. The Occurrence of Tularemia in Nature as a Disease of Man. Pub. Health Rep. 36: 1731, 1921. 2. Simpson, Walter M. Tularemia (Francis Disease). U. S. Nav. Med. Bull. 26; 825, 1928. 3. Bunkley, W. 0. and Smith, E. E. Tularemia. U. S. Nav. Med. Bull. 26: 901, 1928. 4. Foshay, Lee. An Antiserum for the Treatment of Tularemia. J. A. M. A. 101:1447, 1933. NEUTROPENIA FOLLOWING THE ADMINISTRATION OF NEOARSPHENAMINE By Albert R. Behnke, Lieutenant, Medical Corps, United States Navy. This clinical report describes an uncomplicated neutropenia indica tive either of an early involvement of the leucopoietic function of the bone marrow or of a destruction of granulocytes in the peripheral circulation following neosalvarsan administration. While the blood platelets, and on one occasion the lymphocytes, were decreased in number, the primary involvement was characterized by a decrease in granulocytes. The interesting features of this report are the specific neutropenia with little involvement of the red blood cells, the freedom of the BEHJfKE NEUTBOPENIA 109 patient from upper respiratory tract infection, the absence of other serious manifestations of neoarsphenamine toxicity, including purpura, jaundice, and skin ractions, and the rapid, spontaneous recovery. From a partial survey of medical literature it is evident that the arsphenamines may depress the function of any or all of the cells formed by the bone marrow. This comparatively rare reaction com plicating the administration of the arsphenamines is probably caused by the action of the double benzol ring present in these compounds since inorganic arsenic does not depress bone marrow function. Kob- erts (1) quotes Farley (2) who considers it likely that, in certain per sons, there is a disintegration, in vivo, of the arsphenamine molecule setting free the benzol radicle so that a benzol-like action takes place. The action of neoarsphenamine on the peripheral cells and blood platelets rather than on the bone marrow should also be considered in view of the rapid and spontaneous recovery (3). The excellent papers and case reports on blood dyscrasias following the use of arsphenamine compounds appearing in previous issues of the Naval Medical Bulletin render further discussion unnecessary. CASE HISTORY D. W., electrician's mate, first class, age 37, was first admitted to the submarine base dispensary, Pearl Harbor, on December 11, 1935, with multiple ulcers on the prepuce; dark field examination was positive for treponema, the blood Kahn was negative. Nine hours after the first injection of neosalvarsan (0.3 gram) and thiobismol (0.2 gram) the patient developed fever and malaise. White blood cells 6,050 with neutrophils 56 percent; lymphocytes 42 percent; and eosinophils 2 percent. Recovery was rapid and uneventful. The following antiluetic treat ment was then administered over a period of a year: 25 injections of neoarsphena mine (14.1 grams) and 29 injections of bismuth salicylate (4.4 grams). On December 26, 1936, the patient complained of intermittent nausea and pain in the upper abdomen of about 3 weeks' duration. All treatment was discon tinued until February 20, 1937, when the patient felt well and appeared to be in good condition. From February 20, 1937, to March 13, 1937, four injections of iodobismitol, total 8 cubic centimeters, were given. Following these injections the patient complained of soreness over the hypothenar and metacarpal areas of the left hand. Iodobismitol was discontinued and neoarsphenamine was ad ministered in the following manner: February 20, 0.3 gram; March 27, 0.6 gram (patient was nauseated following this injection); April 3, 0.15 gram; April 10, 0.3 gram. Present illness.—On April 13, 1937, the patient complained of chilliness, head ache, abdominal soreness, and malaise. He stated that the chills began on the previous day or about 48 hours after the last injection of neosalvarsan. The physical examination was negative except for a fever of 100.4° F. The symptoms rapidly subsided with bed rest and a high caloric diet. On April 17 the patient was up and about, and in good condition except for a slight evening rise in tem perature. Urine analyses were repeatedly negative, icterus index was 6, and the 110 BEHNKE —NEUTROPENIA blood sedimentation time was within normal limits. The blood picture was as- follows: nb. Red blood cells Plate lets White blood cells Seg. Band Mono. Lymph;. April 14 85 4,240,000 3,500 3,650 2,200 3,950 4,650 4, 750 5,300 5,400 980 1,022 1,012 1,619 2,511 2,375 3,233 2,430 140 146 132 158 186 142 212 324 280 401 44 2,100 2,080 990 2,054 1,767 1,995 1,590 2,376 April 15 84,800 April 16 April 17 79 186 190 106 216 April 19 90 95 4,640,000 4, 980,000 4,900,000 5,030,000 279,000 179,000 215,000 285,040 April 22 April 23 May 14 95 On April 24, 1937, the cerebrospinal fluid was negative for syphilitic involve ment, and 2 days later the patient was discharged to duty in good condition with the recommendation that arsenical therapy be permanently discontinued. Bibliography (1) Roberts, L. J. Aplastic Anemia Following Arsphenamine Therapy. U. 8. Nav. Med. Bull. 29: 441, 1931. (2) Farley, D. L. Depressed Bone Marrow Function from Arsphenamines, Including Type of So-called Agranulocytosis. Am. J. Med. Soc. 179: 214, 1930. (3) McCarthy, F. P., and Wilson, R., Jr. The Blood Dyscrasias Following the Arsphenamines. J. A. M. A. 99: 1557, 1932. (4) Mink, O. J., and Campbell, H. D. Toxic Effects of Arsenical Compounds Employed in the Treatment of Syphilis in the United States Navy, 1931. U. S. Nav. Med. Bull. 31: 177, 1933; Toxic Effects of Arsenical Compounds Employed in the Treatment of Disease in the U. S. Navy, 1932. U. S. Nav. Med. Bull. 31: 383, 1933. (5) Cook, S. S., and Campbell, H. D. Toxic Effects of Arsenical Compounds Employed in the Treatment of Disease in the U. S. Navy, 1934. U. S. Nav. Med. Bull. 34: 97, 1936. NAVAL RESERVE PROMOTIONS, THIRD QUARTER, 1937 James Dominic Viecelli, 450 Sutter Street, San Francisco, Calif., promoted to lieutenant commander, MC-V (G), U. S. N. R., September 27, 1937. Edward Lee Alexander, Medical Arts Building, Newport News, Va., promoted to lieutenant, MC-F, U. S. N. B., September 7, 1937. Herman Maurice Garnett, 3019 Thirty-fifth Street, Long Island Citv, N. Y., promoted to lieutenant, MC-F, U. 8. N. R., September 14, 1937. Albert Hanly Held, 415 Jackson Street, Huntingburg, Ind., promoted ta lieutenant, MC-V (G), U. S. N. R., September 27, 1937. John Claude Hull, 4011 South Presa Street, San Antonio. Tex., promoted to lieutenant, MC-V (G), U. S. N. R., September 30, 1937. William Chunn ParsoDS, 420 Woodward Building, Birmingham, Ala., promoted to lieutenant, MC-F, U. S. N. R., September 24, 1937. Keitt Hane Smith, 206 East North Street, Greenville, S. C., promoted ta lieutenant, MC-F, U. S. N. R., July 30, 1937. RESIGNATIONS, THIRD QUARTER, 1937 Lawrence P. Engel, 1228 Professional Building, Kansas City, Mo., lieutenant, MC-V (S), U. S. N. R., resignation accepted August 19, 1937. Hal Elson Freeman, the University Hospitals (Lakeside), Cleveland, Ohio, lieutenant, junior grade, MC-V (G), U. S. N. R., resignation accepted August 19, 1937. Walter E. Hennerich, 4030 Chouteau Avenue, St. Louis, Mo., lieutenant com mander, MC-F, U. S. N. R., resignation accepted August 2, 1937. Willard H. Kinney, 315 South Seventeenth Street, Philadelphia, Pa., lieutenant commander, MC-V (S), U. S. N. R., resignation accepted August 26, 1937. Charles F. McCaffrey, 44 Summer Street, Somerville, Mass., lieutenant, junior grade, MC-V (G), U. S. N. R., resignation accepted August 29, 1937, in order that he might accept appointment as lieutenant, junior grade, Medical Corps, United States Navy, effective August 30, 1937. John S. McKee, c/o Western State Hospital, Morgantown, N. C., lieutenant, junior grade, MC-V (G), U. S. N. R., resignation accepted September 15, 1937. Thomas T. Sheppard, 530-532 Medical Arts Building, 3700 Fifth Avenue, Pittsburgh, Pa., lieutenant commander, MC-V (S), U. S. N. R., resignation accepted September 22, 1937. Wallace B. Smith, 490 Post Street, San Francisco, Calif., lieutenant commander, MC-V (S), U. S. N. R., resignation accepted August 2, 1937. HONORABLE DISCHARGES, THIRD QUARTER, 1937 Lloyd W. Bishop, 698 Congress Street, Portland, Maine, lieutenant, junior grade, MC-V (G), U. S. N. R., honorably discharged August 19, 1937. Ill 112 THE NINTH ANNUAL MEDICO-MILITARY SYMPOSIUM Henry A. Cromwell, 30 East Seventy-sixth Street, New York City, N. Y.. lieutenant, junior grade, MC-V (G), U. S. N. R., honorably discharged August 26, 1937. DEATHS, THIRD QUARTER, 1937 Guy D. Conover, 225 Santa Monica Boulevard, Santa Monica, Calif., lieutenant, MC-V (S), U. S. N. R., died May 1, 1937. THE NINTH ANNUAL MEDICO-MILITARY SYMPOSIUM By Lincoln Huuphbkys, Lieutenant Commander, Medical Corps, United States Navy The 1937 course of military, naval, and scientific training conducted at the Mayo Foundation, Rochester, Minn., for medical and dental officers of the Army and Navy Reserve, occupied the period from October 3 to 17, 1937. This, the ninth annual training course, the fifth in which the Navy has participated, was attended by medical and dental officers of the Naval Reserve from widely distant portions of the United States, including representatives from California, the District of Columbia, Illinois, Indiana, Iowa, Massachusetts, Mich igan, Minnesota, Missouri, Montana, Nebraska, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Texas, Virginia, and Wisconsin. The Navy and Navy Reserve attendance was 42 but this figure does not include the 15 members of the Naval Reserve specialists units normally attached to the Mayo Foundation on the staff of that institution, who attended and contributed to the success of the meet ing by scientific papers and clinical demonstrations. Distinguished guest speakers included the Surgeon General of the Navy; Maj. Gen. Charles R. Reynolds, Medical Corps, United States Army; Surgeon General of the Army; Maj. Gen. Stanley H. Ford, United States Army ; the Commanding General of the Seventh Corps Area, with headquarters at Omaha, Nebr. ; and Dr. S. L. Christian, Assistant Surgeon General of the United States Public Health Service. Instructors for the Army were Col. Kent Nelson, Medical Corps, United States Army, surgeon Seventh Corps Area, and Lt. Col. John R. Hall, Medical Corps, United States Army, Medical Inspec tor, Seventh Corps Area. Instructors for the Navy were Capt. Ausey H. Robnett, Medical Corps, United States Navy, district medical officer, ninth naval district, and the author who also col laborated on program preparation with the Seventh Corps Area surgeon and medical inspector, and represented the Bureau of Medi cine and Surgery in allocation of Navy medical participation. The Navy Department was most generous this year in ordering medical officers of high rank to represent the Navy Medical Department. As during previous years, Lt. Fred L. Smith, Medical Reserve Corps, United States Army, a member of the Mayo Foundation staff, served as plans and training officer. Through the collaboration of THE NINTH ANNUAL MEDICO-MILITARY SYMPOSIUM 113- this efficient officer with the Army and Navy representatives a well balanced program was prepared and published prior to the beginning of the course. This course like those previously reported, was con ducted as a joint training course for the medical and dental officers of the Army and Navy Reserve, with the surgeon of the Seventh Corps Area as the administrative head, and with whom the author worked as the Navy representative. A new plan was effected this year in arranging the morning session. A reservist could witness a surgical operation, then proceed to Plum- mer Hall and receive instruction in the allied specialties by leading members of the Mayo clinic staff. Naval reservists who lectured at these morning sessions were: Lt. Comdr. W. McK. Craig, Lt. Comdr. C. H. Watkins, and Lt. Comdr. H. M. Weber, all members of the staff of the Mayo Foundation, and Lt. Comdrs. E. H. Bruening and Milton J. Waas. The Navy received a generous allocation of instruction periods on the program. A well balanced schedule of instruction was presented and included a number of outstanding Navy speakers. The papers presented by these naval participants on the program were well received. The civilian physicians in attendance were enthusiastic over the medico-military discussions and many questions resulted from the lectures on naval subjects. There were also inquiries made about steps necessary to join the Navy Reserve, Medical Specialists units. This, it is believed emphasizes the importance of this type of joint Army and Navy training course, given in conjunction with clinical conferences at well established medical institutions. Through cooperation of the civilian medical institutions reserve medical and dental officers are enabled to attend the medical, surgical and other special clinics and to avail themselves of the advantages of scientific discussions by leading civilian medical specialists. A summary of medical officers of the Navy and Navy Reserve who presented papers during the afternoon and evening sessions is as follows: Rear Admiral P. S. Rossiter, Surgeon General of the Navy, and Chief of the Bureau of Medicine and Surgery, Subject: Logistics, Interrelation Aboard Ship and Tactics. Capt. A. H. Robnett, district medical officer, ninth naval district. Subject: Some Problems of the Naval Medical Officer. Capt. G. W. Calver, Physician to Congress. Subject: Administration of a Naval Hospital. Captain Calver also showed moving pictures of Spain and Shanghai before and after bombing which made an indelible impression upon all those present. Capt. E. W. Brown, Naval Medical center, Washington, D. C. Subject: Naval Medical Aspects of Chemical Warfare. Commander Joel J. White, Chief of the Medical Service, Naval Hospital, Philadelphia. Subject: Present Status of Artificial Fever Therapy in Medico- Military practice. 114 THE NINTH ANNUAL. MEDICO-MILITARY SYMPOSIUM Commander Kemp C. Christian, District Headquarters, Great Lakes, Illinois. Subject: Navigation. Lt. Comdr. Lincoln Humphreys, Assistant Instructor. Subject: The United States Fleet. Lt. Cmdr. W. McK. Craig, Mayo Foundation Staff. Subject: Relief of Intractable Pain. Lt. Cmdr. Frederick A. Jostes, President of the St. Louis Clinical Society. Subject: Backache and its Treatment. Lt. Cmdr. U. S. Widman, New Albany, Ind. Subject: European Cruise of the U. S. S. Charleston. Lt. Cmdr. E. H. Bruening, Professor of Dental Anatomy, Creighton Dental School, Omaha, Nebr. Subject: Governmental Public Health Relations. Lt. R. B. Phillips, Fellow of the Mayo Foundation. Subject: Medical Advertising of the Civil War Period. Lt. R. B. Phillips, MC-V (S) United States Naval Reserve, a fellow of the Mayo Foundation, served in the capacity of adjutant and aided greatly in securing pictoral and editorial publicity for the meeting. He arranged a luncheon at the Hotel Arthur at which the Naval Reservists honored the Surgeon General of the Navy, and attended not only by the Naval Reservists from out of the city but also by the majority of the members of the two specialists units of the Mayo Foundation. This was quite an accomplishment consider ing that the latter are busy specialists and their spare time is greatly limited. At this time the Reservists were given the opportunity to meet Rear Admiral Rossiter, and to hear from him his personal and official interest in these training courses. The Admiral expressed hearty approval of the course as presented at Rochester, and it was with regret that he was unable to remain, due to the fact that he had to proceed to Los Angeles, Calif., to deliver the presidential address before the Association of Military Surgeons. His tribute of gratitude to the Mayo Foundation for extending the clinic facilities so gener ously was the general sentiment of those in attendance. NOTES AND COMMENTS WILLIAM KNICKERBOCKER VAN RE7FEN By Louis H. Boddis, Commander, Medical Corps, United States Navy The twelfth Surgeon General, U. S. Navy, and the sixteenth Chief of the Bureau of Medicine and Surgery, was born in New Jersey in 1840, and was appointed from that State as an assistant surgeon on Christmas Day, December 25, 1861. After a short period of duty at the naval hospital, New York, he served on the steam frigate St. Lawrence in the East Gulf Blockading Squadron and so saw active war service at sea in the blockade of the southern ports. He was pro moted passed assistant surgeon in May 1865, and surgeon in May 1868. His service included duty at the naval hospital, Chelsea, Mass., Norfolk, Va., Annapolis, Md., and New York. His sea duty included both the European Squadron and the Asiatic Station. He was promoted to medical inspector in August 1887, and medical director just 6 years later, in August 1893. He was appointed Surgeon Gen eral by President McKinley on October 23, 1897, to succeed Surgeon General Newton L. Bates, who died in office after serving but 18 days. Van Reypen served until January 25, 1902, and was thus Surgeon General during the Spanish-American War and under two Presidents, McKinley and Theodore Roosevelt. He was an excellent economist. His regime was marked by many important measures affecting the Medical Department. A hospital ship, a separate Hospital Corps, and increased rank for medical officers had been strongly urged by Surgeon General Tryon, and Congress now passed legislation providing for all three of these measures. The steamer Creole of the Cromwell line was purchased and named the U. S. S. Solace. This vessel was selected, purchased, and fitted out for service as a hospital at the beginning of the Spanish-American War in just 16 days. It was the first of our naval vessels to fly the Red Cross flag. It was of the greatest service to the fleet in Cuban waters, and remained in active commission until 1920. In 1899 the Surgeon General was given the rank of rear admiral, though the pay and allowances were still those of a commodore. The following naval hospitals were commissioned during Van Reypen's term of office: Naval hospital, Newport, 1897; Sitka, Alaska, 1898; Port Royal, S. C, 1898; Cavite, P. L, 1898. 115 116 NOTES AND COMMENTS After retirement, Admiral Van Keypen lived in Washington, where he died in 1920. THE FLEET HOSPITAL SHIP The characteristics of a hospital ship should be based upon its- objective. No one type of craft would be equally suitable to function as a fleet hospital ship, hospital transport, hospital ship for advanced base, or rescue ship. Furthermore the problem arises of meeting the peak load of wartime demand without creating a top-heavy peace time organization. Of these various types of hospital ships, Johnson 1 discusses in detail the fleet hospital ship. This author has written extensively on subjects of interest to the naval medical officer and this article summarizes his recent and mature experience on a fleet hospital ship. In -his opinion this type of vessel should be about 10,000 tons in size, have a speed somewhat in excess of the train, be designed for fleet hospital-ship duty, that is, accommodate patients satisfactorily while conforming to fleet operating conditions such as darken ship. This vessel should operate with the fleet in peace and in war, provid ing hospital and specialty service. The author comments at length on the extent to which this vessel should conform with Hague Con vention provisions to gain immunity to hostile attack. Based both on its intimate function with the fleet and the World War experience, particularly of the British, he definitely recommends that this type vessel waive its immunity and accept the hazards common to the fleet. Other type hospital ships should continue to conform to Hague Convention provisions. BLUNDERS OF PLAIN MUSCLE "The frustrated subconscious uses the autonomic system as ita secret avenger, and spasm is commonly its sword." Thus does Eve 2 call attention to the vegetative nervous system which induces a smooth muscle hypertonus, particularly during anxiety state in the sensitive intellectual, ambitious, and idealistic temperament. The maiden's blush and the diarrhoea of the nervous examinee may result from different stimuli but they are actuated by the same mech anism. This muscle spasm may be more accurately described as an inability to relax with sympathetic tonus dominating the antagonistic vagus. A wide variety of intestinal, vascular, and genito-urinary svmptoms result. No age is immune. The newborn infant may have pyloro- spasm. In . males it is always associated with phimosis. It may accompany the anxiety of a nervous mother. In adults the mani- i Johnson, L. W., Captain (M. C), U. 8. Navy. The Fleet Hospital Ship, XT. S. Naval Institute Pro. eeedings, S3: 1225-1235,1937. > Eve, Frank C. Blunders of Plain Muscle Due to Allergy or Anxiety States, Linnet Z13:M0. 1837. NOTES AND COMMENTS 117 festations are many and usually multiple. If there is hunger pain due to pylorospasm, look for palpable, cordlike tender colon, urinary frequency, cold extremities, and spastic dysmenorrhea. The cause is probably exhaustion, chill, worrry, or alcohol. If coronary spasm is suspected, look for intermittent claudication and "dead fingers." Raynaud's disease and probably migraine result from angiospasm. If migraine occurs in early life look for intestinal or cardiovascular spasticity in later life. Asthma is one of the conspicuous blunders. Allergy must be considered as a possible factor in causation of smooth muscle spasticity. Allergy may be considered as a stormy immune reaction in a subject of sensitive temperament to various chemical stimuli so great that marked clinical symptoms result. It is associated with histamine production and is relieved by adren aline, in contrast with anxiety states which are associated with pro duction of choline and relieved by atropine or ergotamine. The author postulates the suggestion that individuals of sensitive temperament respond most successfully to the demands of civilization and that the price of this sensitivity is neurosis and allergy. TREATMENT OF SURGICAL SHOCK WITH NEOSYNEPHRIN Loss of vascular tone with consequent vasodilatation is one of the more or less conspicuous etiological factors causing the hypotension of surgical shock. Its prominence may be roughly estimated as proportional to the nervous trauma experienced. Rational treat ment of surgical shock would, therefore, indicate the use of vasocon strictor drugs for the vasogenic phase of hypotension. Adrenaline, epinephrine, and ephedrine are effective and have been employed to increase vascular tone. Unfortunately each has objectionable effects. In the search for a more effective drug Johnson 3 has used neo- synephrin hydrochloride for shock due to trauma and hemorrhage. This drug is very closely related to epinephrine hydrochloride. It is preferable to the other vasoconstrictors in that (1) its action is more prolonged, lasting 1 to 2 hours, (2) it has no ill effect on cardiac rhythm, (3) in shock cases the heart rate is not affected —in the normal individual it is slowed, (4) it does not cause nervousness or palpitation, and (5) it has a much greater margin of safety. It is employed in a dosage of 1 cubic centimeter of a 10-percent solution subcutaneously, from 1 to 23 doses being administered to patients in the author's series. It was employed in surgical, traumatic, and spinal anesthesia cases. In the latter group it was used both to restore normal blood pressure and as a preliminary prophylactic measure to prevent the usual >Carl A. Johnson. Surgery, Gynecology and Obstetrics, 66: 463-463, 1937. 118 NOTES AND COMMENTS resultant hypotension.** It is interesting to note that the drug was- useless in combating the hypotension resulting from foreign protein anaphylactic shock. There is general agreement that shock is due to loss of effective blood volume. Opposed theories attribute this loss to stagnation in the vascular system and to actual loss from the vascular system. Action of this drug would tend to support the stagnation theory in Johnson's opinion. THE COMMON COLD The common cold continues as a major cause of physical disability. At best it is an embarrassing condition and not infrequently it is the forerunner of complications that endanger life. Evidence is becoming more conclusive that this infection is due to a filterable virus and that this virus activates pathogens present in the upper respiratory tract. It has been the subject of extensive investigation and the resultant findings are still far from consistent and conclusive. There is like wise no unanimity of opinion as to proper treatment. Medication is largely empirical, if taken at all, and much of this is self-supervised. A well-balanced diet with liberal vitamin content and hygienic mode of living may be safely recommended. Beyond this, treatment may be regarded as conjectural and controversial. Unfortunately, whether treated or untreated, the victim is usually ambulant and his activity constitutes a menace to his health and a public-health hazard to his associates. This condition is usually ushered in by a feeling of chilliness, sneez ing, and a dryness in the nasopharynx. In the normal individual exposed to cold there is a temporary blanching of the nasal mucosa which is transient. In the susceptible individual, made susceptible presumably by presence of a filtrable virus to which for various reasons the individual has a low grade of immunity, this blanching persists for an extended period. As a result there is a loss of mucous secretion with a sense of dryness and a loss of ciliary action with a correspond ing stagnation in the normal flow of nasopharyngeal secretion. It is a fair presumption that this stagnation of nasopharyngeal and sinus drainage is at least a factor in promoting the propagation of naso pharyngeal pathogens. The normal sequence of events is for the ischemic state to progress to an hyperemia with more or less nasal and sinus obstruction. Rational treatment would suggest combating the ischemia and ciliary paralysis in the early stage, and combating the hyperemia with its associated obstruction and hypersecretion later. Rest in bed and heat to the lower extremities are particularly effective for the initial eschemia, and should be continued until the patient responds normally to chilling effect. NOTES AND COMMENTS 119 There seems to be little rhyme or reason for the local medication applied in either stage. It varies from heroic measures to no treat ment due to the patient's indifference or fatalistic resignation. Various investigators have reported on the action of normal cilla, and on ciliary response to various drugs. Water and water solutions such as the silver proteinates inhibit ciliary activity. Oil and the various oily preparations prevent ciliary action mechanically. Silver nitrate destroys the cilla. Atropine, adrenalin, and cocaine paralyze ciliary action. The aromatic oils, particularly thymol are depressing. Methiolate and mercurochrome are also depressant. Codeine, morphine, and the barbiturates cause little if any depression of ciliary action. Normal saline has a favorable effect on ciliary action, and used alone can be recommended and may be combined with about 1 percent ephedrine for local use. The saline solution is best applied with a medicine dropper in head-low posture. Vaccines of various types and administered by various routes — subcutaneous, oral, and nasal —have had advocates for years, par ticularly among grateful patients. The use of vaccines has some scientific justification on the basis that they have a favorable effect on control of the pathogens activated by the virus. This action helps explain the results noted in their use. The estimate equation of prophylactic value of vaccines includes variables from allergy to zeal. Obviously in such a poorly controlled group much dependence must be placed on the patient's subjective reaction and reports whether favorable or unfavorable should be evaluated accordingly. Bristol,4 health director for the American Telephone & Telegraph Co., of New York, reports interesting studies on an industrial group to whom vaccine was made available. He states that an industrial group can be roughly classed as follows: (1) The cold-proof who seem to never have colds, (2) the person of average susceptibility having one or two minor colds a year, and (3) the cold-prone who have several colds a year often with complications and disability. This third class constitutes about 25 percent of the entire group. It serves as a year-round reservoir for the common cold and presents a public-health problem both from the standpoint of absenteeism of the individual and as a source of infection for associates. The treat ment results reported by Bristol were not limited to this class of patient. However, it is a fair presumption that vaccinated individuals from this group were materially in excess of 25 percent. Bristol summarizes the results obtained in six different companies. The material used consisted of commercial standard stock vaccine or sero-bacterins administered by local practicing physicians to employees requesting treatment. Each company reported treatment * Bristol, Leverett D. Vaccines Against the Common Cold, American Jour, of Public Health, and the Nation's Health, 27: 987-990, 1937. 120 NOTES AND COMMENTS of more than 1,000 employees over a period of several years. One company reported treatment of about 13,000 over a period of 17 years. All reports were favorable, none were enthusiastic. There was little evidence that vaccination had reduced the incidence of common colds. There was an apparent reduction in the severity, duration, and complications of acute respiratory diseases in the treated. Recently an oral vaccine has been introduced in a naval dispensary service. As noted above, there is difficulty in obtaining an accurate estimate of prophylactic value from the patients' statements. How ever, the popularity of this oral vaccine in this dispensary would indicate that it has sufficient merit to continue its use on trial. CANCER The physician and layman are both becoming more cancer con scious. This tendency has already improved the prognostic outlook for the patient. Recent developments have been particularly encour aging. The United States Public Health Service has obtained funds and site for a Cancer Institute at Washington, which will soon be functioning. This will permit a long awaited concerted attack on the vexing problem of malignancy. Past progress has largely been the product of individual effort. Much has been accomplished with a surprisingly meager outlay. A patiently scientific, coordinated attack, comparable to that used so effectively in industrial research may now be anticipated. However, investigation has already proven the problem to be so intricate that a conservative attitude should be assumed on prospect of solution of the etiology and treatment of malignancy at an early date. Cancer is not a major problem in the active service from the stand point of sick days or retirements and surveys involved. However, it is of sufficient importance that cancer clinics have been established on each coast. The October issue of Annals of Surgery presents an excellent sym posium on cancer. Various authorities comment on the latest develop ments in the etiology and treatment of malignancy. It can be highly recommended to those interested in cancer. SKIN IRRITATION AND CANCER IN THE UNITED STATES NAVY 6 This is a statistical review of morbidity and mortality statistics of the United States Navy covering the 8-year period from 1929 to 1936. It involves 875,000 person years of active service and 469 cases of cancer. It is known that in rural districts epitheliomata of the skin and lip are more frequent than in the cities. Animal experiments have dem- » Siglsmund Pellet and Charles S. Stephenson. American Journal of The Medical Sciences, 1W: 3 26-333. 1037. NOTES AND COMMENTS 121 onstrated that ultraviolet rays play a part in the genesis of skin cancer. Therefore, the present study was undertaken to ascertain, first, whether a group of adults between 16 and 45 or 50 years of age, ex posed intensively to open air, to sun rays, and to salt water suffer from skin and Up cancer more than the average; second, whether or not this group shows the same probability of dying from cancer of the inner organs as does the general population; third, whether or not young men cured of a skin or lip cancer are later as much disposed to cancer of the internal organs and of the surface as men of the same age group. In this review it was found that the incidence of cancer of the skin and lips was eight times and the mortality was three times the normal expectancy of the average population of like age group, with melanoma predominating. In answer to the second question it was found that morbidity and mortality from all other cancers was greatly diminished in this group. In answer to the third question, the investigators found three cases of fatal cancer of internal organs in cases cured of skin epithelioma. One had squamous cell carcinoma of the nasal septum and the second died of carcinoma of the aesophagus. Their third case was a carcinoma of lung which they regard as probably being synchronous with the skin lesion rather than metachronous. The three cases were over 50 years old. Also they noted that of all the cases of cancer of the internal organs in patients from 30 to 50 years of age none gave a previous history of cured skin or lip cancer. These statistics would imply that these skin lesions confer a certain protection against the more malignant cancer of internal organs in later years. The authors propose that this phase of the investigation needs study on a larger scale. SYPHILIS PROPHYLAXIS Syphilis has become a popular issue and it behoves the profession to keep well-grounded on scientific fact in educating the public on this dread disease. The initial lesion is of prime importance if subsequent sequellae and prolonged treatment would be avoided. Much of the knowledge of the initial lesion has been based on the experimental work of Metch- nikoff and Kolle. On the basis of this work the former developed a very effective calomel ointment prophylaxis. Kolle, later, demon strated the rather spectacular rapidity with which the syphilis spiro- chaeta penetrates the tissues of the experimental animal where an abrasion is present. He applied the virus to a scarified area and re covered the organisms 5 minutes later from the lymphatic glands 8 centimeters away. 24140—37 9 122 NOTES AND COMMENTS On the basis of several years experimental work Surgeon J. A. Mahoney, United States Public Health Service, reports on tissue in vasion by the spirochaeta. They deposited the syphilis organism upon the intact genatile mucosa of the male rabbit. One hour later the organisms were found upon the surface of the mucous membrane and occupying a more or less protected position in the crypts and folds of the integument. After 2 hours, there was evidence of penetration of the deeper tissues. At the end of 3 hours the organisms had pene trated to a depth which would have rendered them immune to the direct influence of any agent applied to the surface. In contrast with this penetration of uninjured genatile mucous mem brane this investigator reports that they were never able to demonstrate penetration of stratified squamous epithelium by the spirochaeta. Data on prophylaxis are consistant with these findings. This in vestigator demonstrated that mechanical cleansing with soap and water gave very effective protection for exposures not exceeding 1% hours and beyond 2 hours was completely ineffective. After 3 hours use of disinfecting agents of more drastic type such as tincture of iodine were relatively ineffective. Interesting features of calomel ointment are reported by this investigator. He found that the prophylactic effect of this chemical was dependent upon applying it as an inunction. When applied to the genatile mucosa without rubbing it was not pro tective. When thoroughly rubbed in it gave a high percentage of protection, and was even protective when the virus was not applied to the treated area. The inference of this work is that the efficacy of calomel is probably due to its systemic spirochaeticidal action. It would seem from this experimental work that our present system of prophylaxis, consisting of soap and water wash followed by calomel inunction has a sound scientific background. To be effective this method demands prompt application, preferably within the first hour after initial exposure, and thorough inunction of the calomel ointment. ARTICLES ON PROFESSIONAL SUBJECTS Recently several articles on professional subjects have been sub mitted to the Navy Department for permission for publication. Article 113 ofNavy Regulations and General Order No. 9 do not require this permission. Authors are required by these references to publish no secret or confidential information or information that would support a claim against the Government. These regulations carry two additional specific provisions. Any published article represents the personal views of the writer and not those of the Navy Department and shall so state. Second, when the article is accepted for publication a copy shall be forwarded to the Navy Department for information and file. To this should be added the advice to avoid domestic and foreign politics, and comment that is derogatory to the service. NOTES AND COMMENTS 123 A naval officer on his own personal responsibility is permitted to present his article to a publisher for publication. The Navy Depart ment does not exercise censorship on such material; it, on request, merely advises as to propriety of publication. When under the provisions of reference regulations the author has doubts as to the advisability of dissemination of information to the general public of any matter through the medium of books, magazines, press, or radio, he may submit his article to the Navy Department. This must be done prior to submission to the publisher and the ac companying letter of transmittal shall designate the specific passages about which doubt exists and the reasons for said doubt. The Navy Department will then inform the author as to the propriety of pub lishing the designated passages. ARTICLES OF SPECIAL MERIT, 1937 It has become an established practice for the Surgeon General to present letters of appreciation to authors who have contributed articles of outstanding merit to the Naval Medical Bulletin. The Surgeon General takes this opportunity to express to all con tributors his satisfaction with the excellence of their articles and his appreciation of their support of the Bureau's publication. For the calendar year 1937 the following authors have received letters of appreciation. Lt. Albert R. Behnke, (M. C.), U. S. N. The Application of Measurements of Nitrogen Elimination to the Problem of Decompressing Divers. April 1937. Lt. H. O. Cozby, (M. C.), U. S. N. Naval Delinquency. April 1937. Lt. Comdr. Paul F. Dickens, (M. C.), U. S. N., and Lt. Omar J. Brown, (M. C.), U. S. N. Present Day Concepts of Endocrinology. January 1937. Lt. Comdr. W. W. Hall, (M. C), U. S. N. Active Immunization Against Tetanus with Tetanus Toxoid. January 1937. Commander F. S. Johnson, (M. C.), U. S. N., and Arthur G. Vallee, Phar macist's Mate, First Class, U. S. N. Liquid Insecticides, Report of Comparative Study of. July 1937. Commander R. P. Parsons, (M. C.), U. S. N. An Estimate of Arsenox- ide (Mapharsen) in the Treatment of Early Syphilis. April 1937. NEW MEMBERS AMERICAN COLLEGE OF PHYSICIANS The Secretary of the American College of Physicians has notified the Surgeon General that the following naval medical officers have been elected to membership in the American College of Physicians: To Fellowship Comdr. John Harper (MC), U. S. N. Comdr. Frederick L. McDaniel (MC), U. S. N. TO ASSOCIATBSHIP Comdr. Earl Richison (MC), U. S. N. Comdr. William P. Mull (MC), U. S. N. Lt. Comdr. James G. Dickson (MC), U. S. N. Lt. Bartholomew W. Hogan (MC), U. S. N. Lt. Julian Love (MC), U. S. N. BOOK NOTICES Publishers submitting books for review are requested to address them as follows: The Editor, United States Naval Medical Bulletin, Bureau of Medicine and Surgery, Navy Department, Washington, D. C. (For review.) The Practice of Medicine, by Jonathan Campbell Meakins, M. D., L. L. D.; professor of medicine, McGill University; physician in chief, Royal Victoria Hospital, Montreal, etc. Cloth. 1343 pages. 5050 illustrations, including 35 colored plates. C. V. Mosby Co., St. Louis. Price $10. This book is really a unique volume in many respects. The author has set out to write a clear concise treatise on the practice of medicine in one volume, which in itself in this day of specialization would at first appear to represent a heroic task. He has succeeded in producing a work of inestimable value to the internist, general practitioner, and medical student, in that without discussing the various diseases in monographic form, he has covered the field of medicine in a nearly encyclopedic manner, and at the same time, due to this extremely concise and clear English, and especially due to his faculty of stressing essentials, he has compiled what amounts to a system of medicine in one volume. In a large way this book reflects considered opinions of a master of medicine whose perspective has been widened and deepened by many years of clinical experience and teaching. The numerous and well-chosen illustrations constitute a novel feature of great value. An Introduction to Medical Science, by William Boyd, M. D., M. R. C. P. (Edinburgh), F. R. C. T. (London), professor of pathology in the University of Manitoba. 307 pages, illustrated with 108 engravings. Lea & Febiger, Philadelphia. 1937. Price $3.50. This is, as the author well states in his introduction, an "aeroplane review of diseases." It is intended for the premedical student, nurse, and the intelligent laymen who desire to gain a general picture of the human body, the diseases which afflict it, and the defenses which it makes against them. The whole is well- told in a brief way and with a number of simple but excellent illustrations. 125 126 BOOK NOTICES Clinical Alleroy, Manifestations, Diagnosis, and Treatment, by Albert H. Rowe, M. S., M. D., lecturer in medicine in the University of California Medical School, San Francisco, Calif.; chief of the Clinic for Allergic Diseases of the Ala meda County Health Center, Oakland, Calif.; president of the Association for the Study of Allergy, 1927-28. Published by Lea & Febiger, Philadelphia. Price $8.50. This book contains 16 chapters and an appendix, with a total of 706 pages of subject matter. In addition there is a most extensive and complete bibliography of 80 pages. Dr. Rowe has covered the subject of allergy exceptionally well, especially the part foods play in allergic conditions. He stresses the fact that a particular food may be the causative factor in an allergic condition, yet give a negative skin test by both the scratch and intradermal methods. The chapter dealing with "Rowe's Elimination Diet" and other diatetic manage ment of food allergy is very valuable as an aid and guide in treatment. Operative Surgery, by J. Shelton Horsley, M. D., LL. D., F. A. C. S., attending surgeov, St. Elizabeth's Hospital, Richmond, Va. and Issac A. Bigger, M. D., professor of surgery, Medical College of Virginia. 1,350 pages with numerous cuts, illustrations, photographs, charts, and drawings. 2 vols. (4th edition). Publishers, C. V. Mosby & Co., St. Louis. Cloth. $15. This is the fourth edition of a work on operative surgery which, since 1921, has been recognized as belonging in the front rank of works of this kind. Dr. Horsley has secured the services of five contribut ing authors, all well known in surgical writing, for this newest edition. The result is a two-volume set which is very beautifully and expertly done. The paper, and especially the type, are exceptionally good. The chapters on intestinal surgery, operations on the chest, plastic operations on the face, flap transplantation, grafts, and brain tumors are most interesting. We should like to have seen more emphasis laid upon the transurethral method of prostatectomy, as we are acquainted with one large clinic which performed but two suprapubic operations in a series of over 500 cases in 1 year, with a very high degree of success. We recommend these two books, without reserve, to all surgeons desiring a neat, compact, and competent account of modern operative technique. Preoperative and Postoperative Treatment, by Robert L. Mason, A. B., M. D., F. A. C. S., assistant in surgery at the Massachusetts (Jeneral Hospital. 495 pages, 123 illustrations. W. B. Saunders Co., Philadelphia. 1937. Price S6. Dr. Mason presents a valuable and very useful book covering the pitfalls of both the patient and surgeon in and out of the operating room. With brilliant contributions by his Harvard and Massachu setts General Hospital associates, he has developed a book that covers, in general, the preoperative and postoperative management of the surgical patient. Estimation of the surgical risk, anesthesia, shock, blood transfusion, water balance, diet, and immediate and secondary complications are dealt with in a practical yet thorough manner. BOOK NOTICES 127 The chapter devoted to burns is outstanding in merit. Then, in masterly fashion, part 2 takes up regional surgical problems, presents many excellent guides for the surgeon. Handbook of Orthopaedic Surgery, by Alfred Rives Shands, Jr., B. A., M. D., associate professor of surgery in charge of orthopaedic surgery, Duke University School of Medicine; in collaboration with, Richard Beverly Raney, B. A., M. D., instructor in orthopaedic surgery, Duke University School of Medicine. 593 pages. 169 illustrations. The C. B. Mosby Co., St. Louis. 1937. Price $5. The need for a complete handbook of orthopedic surgery is definite, not only for undergraduate orthopedic instruction but for the general practitioner as well. Dr. Shands in collaboration with Dr. Raney gives us a text book, elementary in type yet rich in helpful diagnostic guides and useful therapeutic suggestions. The book has been care fully prepared and covers the entire scope of congenital and acquired deformities. Each chapter has been critically reviewed before publica tion by leading American instructors in orthopedic surgery. The work covers well the needs of this important field of surgery. Injuries and Diseases qf the Hip, by Fred H. Albee, M. D., LL. D., F. A. C. S., past president, American Orthopedic Association., assisted by, Robert L. Preston, M. D., associate in orthopedic surgery, Columbia University. 298 pages. 100 illustrations. Paul B. Hoeber, Inc., New York. Price So. 50. A master bone surgeon delves into 30 years of pioneer experience in the difficult field of hip joint diseases and injuries. From wisdom born of operative and teaching experience unexcelled in the field of orthopedic surgery, he presents the first book ever written devoted entirely to the treatment of hip conditions. Twelve brilliant chapters detail his conservative and operative procedures. The book stresses the merits of his famous bone graft and the advantages obtained by the development of motor-driven tools, the modern fracture ortho pedic table, and the double plaster spica. Diseases of Infants and Children, by J. P. Crozer Griffith, M. D., Ph. D., emeritus professor of pediatrics, University of Pennsylvania, and A. Graeme Mitchell, M. D., B. K. Rachford professor of pediatrics, College of Medicine, University of Cincinnati. One octavo of 1154 pages, with 293 illustrations, in cluding 18 in colors. Second edition thoroughly revised. 1937. W. B. Saunders Co., Philadelphia. Price $10. This work, by two eminent authors, contains a wealth of informa tion, well organized, well written, and well edited. It covers the whole field, clearly and concisely, without undue verbiage and is printed in a style that makes easy reading. The discussions of many topics have been expanded, including dis turbances of the acid-base balance, diabetes mellitus, and dehydration in gastroenteritis. The matter of artificial feeding has been put on a simpler basis in a 65-page monograph and particular attention has been devoted to the sections concerning growth and development and anatomy and physiology. 128 BOOK NOTICES Medical Treatment of Cataract, by A. Edward Davis, M. D. F. A. Davis Co.. Philadelphia, Pa. 161 pages. Price $3. This volume is mostly concerned with senile cataract. The author advances the idea that senile cataract is a pathological process con sisting of chemical changes in the protein of the lens fibers and not a physiological change incident to old age like graying of the hair or wrinkling of the skin. These chemical changes are the result of toxins acting upon the individual fibers of the lens. The toxins are engendered mainly by faulty metabolism which may result from some general disease, overeating, malnutrition, insufficient calcium, phos phorus, potassium or vitamines, or by endoctrine disturbance, especially the thyroid or parathyroid. In the treatment the author stresses early diagnosis and claims that the progress of this type of cataract can be arrested in about 81 percent of the cases. Treatment consists of subcutaneous injections of the lens antigen in increasing doses over a period of 6 months with local hot com presses and instillations of dionin. Diet is considered important, also plenty of vitamins and water. The ideas advanced, if proven correct, should prove a valuable adjunct to our treatment of cataract. The Ocular Fundus in Diagnosis and Treatment, by Donald T. Atkinson, M. D., F. A. C. S. 258 pages with 106 illustrations, including 58 plates in natural colors. Lea & Febiger, Philadelphia, 1937, Price $10. This is said to be the only book in English covering this subject in which the illustrations are wholly the work of the author. There are 142 pages of printed matter, divided into 8 chapters, viz: (1) The Ophthalmoscope, (2) The Normal Fundus, (3) The Retinal Vessels, (4) The Optic Nerve, (5) The Vitreous Humor, (6) The Retina, (7) The Choroid, (8) Usual Ophthalmoscopic Mani festations in Special Disease. The subject matter is each chapter is briefly and concisely discussed. There is a short discussion of the anatomy, the anomalies, diseased conditions, their appearance, and a few words on the latest methods of treatment. The 58 natural-color illustrations are beautifully done. Each illustration is accompanied by an adequate description. The book should prove a very useful and practical addition to the ophthalmologist's library. Microscopical Technique. Edited by C. E. McClung, Ph. D., professor of zoology and director, Zoological Laboratory, University of Pennsylvania. Cloth. Second edition, revised and enlarged. 698 pp., with 82 illustrations. Paul P>. Hoeber, Inc., 1937. Price $8. There are 34 well-known, highly specialized contributors to this excellent volume. BOOK NOTICES 129 The various procedures and other data are given in a clear and concise manner. The bibliography is ample and well selected. In the opinion of the reviewer some of the most valuable additions of the second edition are a complete, new dioxan technique for paraffin sections, methods of staining boutons terminaux, the fused quarta rod method of illuminating living structure, microincineration, the centrifuge microscope, and fluorescent microscopy. This book should be of particular interest and great value to workers in microscopic anatomy, bacteriology, cytology, embryology, histology, and pathology. Flying Vistas. —The human being as seen through the eyes of the flight surgeon. By Isaac H. Jones, M. A., M. D., military aeronautics, U. S. A., during the World Wor; medical examiner. Bureau of Air Commerce, U. S. Department of Commerce. 250 pages, 9 illustrations. J. B. Lippincott Co., Philadelphia and London. Price $2. The book presents an interesting review of the problems confronting aviation at the beginning of the World War, together with the accom plishments of the War Department in devising and standardizing the physical requirements for flying, under the able direction of General Lyster. It explains in an interesting manner the various aspects of the physical examination for flying, and gives to the aviator and lay man a practical understanding of the examination and the reasons therefor. The development of the specialty of aviation medicine and the flight surgeon are described. The book is nontechnical and is of particular interest to the flyer. Dental Pharmacology and Therapeutics, J. R. Blayney, B. S., D. D. S., M. S. Second edition. C. V. Mosby Co., St. Louis, Mo. Price $4. In the text of this volume, the names and compositions have been made to conform with those of the eleventh edition, United States Pharmacopoeia, and the sixth edition, National Formulary. The text is divided into three parts. Part 1 is devoted to a general consideration of drugs, principle action, methods of administration, average doses, and prescription writing, in which the author recom mends the use of English, the only exception being the use of some common Latin abbreviations; therefore, he has eliminated medical Latin from this volume. Each main division of part 1 is followed by a number of problems which will make this work of especial value to the student. In part 2, the consideration of drugs arranged according to their chief dental uses, still maintaining the usual pharmacologic grouping, which will be appreciated by both student and practitioner. The author presents an interesting and valuable introduction to each group of drugs as to their mode of action and standardization of efficiency. Part 3. The student will find ia this part valuable and interesting laboratory exercises. 130 BOOK NOTICES This is an excellent presentation of the subject for the purpose intended. Its size alone will recommend it to those who would not undertake a more extensive discussion of the subject. The printing is good, large type, well spaced, and well-selected illustrations bring it up to the usual standards of the publisher. Essentials or Oral Surgery, by Blair and Ivy. Second edition, 606 pages, illustrated. C. V. Mosby & Co., St. Louis, Mo. Price $6.50. This edition brings up to date the advances that have been made in the surgery of the mouth and jaws since publication of the first edition. The order in which the different subjects are presented has been changed, primarily as an aid to the undergraduate, but should prove equally helpful to the general practitioner, who should be stimulated to recognize and better understand the many conditions of the mouth requiring surgical treatment. The chapter on fractures of the jaw will be of invaluable assistance to many who are nowadays called upon for this service to their patients in this fast-moving age. The chapter on surgical preparation of the mouth for artificial dentures is a concise presentation of a subject that should be of benefit not only to the oral surgeon but equally to the general practitioner, as well as the prosthodontist. This volume is well written, spendidly illustrated, and the printing and binding are of the usual high standard of the publishers. THE DIVISION OF PREVENTIVE MEDICINE C. S. Stephenson, Commander, Medical Corps, United States Navy, in charge TOXIC EFFECTS OF ARSENICAL COMPOUNDS EMPLOYED IN THE TREAT MENT OF DISEASE IN THE UNITED STATES NAVY, 1936 By C. S. Stephenson, Commander, Medical Corps, United States Navy, and E. H. Winoo, Chief Pharmacist's Mate, United States Navy Since November 1924 medical officers of the Navy have been required to make monthly reports of the number of doses of arsenicals ad^ministered and a separate account of each case in which ill effects are noted. During the 12 years, 1925-36, in which this information has been compiled 1,202,261 doses of arsenicals have been administered and 924 reactions have been reported. Previous articles dealing with the information obtained from these reports were published in the September 1925, January 1927, January 1929, July 1930, October 1931, October 1932, April 1933, October 1933, October 1934, January 1935, October 1935, January 1936, October 1936, January 1937, and October 1937 numbers of the United States Naval Medical Bulletin. Cases of arsenical dermatitis occur ring during the year 1936 were published in the October 1937 number of the Naval Medical Bulletin. The present article deals with all cases, except arsenical dermatitis, which were reported during the year 1936. . Comparative figures from the experience of previous years are also presented. Table 1.—Arsenical reactions, 1936 Arsphenamine, neoarsphenamine, sulphars- phenamine, aml tryparsamide reactions Classification MUd Severe Fatal Total Arsenical dermatitis ' 14 18 2 34 28 1 0 29 4 0 0 4 1 2 0 3 1 1 0 2 0 1 1 2 0 1 0 1 0 1 0 1 TotaL 48 25 3 76 1Case histories were published in the October 1937number of the Bulletin. Included in the above table is 1severe reaction caused by arsphenamine, 4 reactions, 2 mild and 2 severe, caused by sulpharsphenamine, and 1severe reaction caused by tryparsamide. 131 132 PREVENTIVE MEDICINE Table 2.—Arsenicals administered during the year 1936 for all diseases, including syphilis Drug Dose 0.9 to 3 grams 0.9 gram 0.6 to 0.9 gram Less than 0.6 gram Total Acotarsone: 0 0 0 140 140 Arsphenamine: 0 0 0 0 0 0 0 0 2,603 2,603 0 0 0 8 8 Bismnrsen: 0 0 0 341 341 Mapharsen: 0 0 0 68 68 0 0 0 1,555 1,558 Neoarsphenamine: 0 0 0 747 747 0 275 32,046 46.826 79, 147 Silver arsphenamine: 0 7 3,560 10,193 13,760 0 0 0 61 61 Sulpharspbenamine: 0 0 0 14 14 0 0 98 1,456 1,554 Tryparsamide: 0 0 0 971 971 4.148 0 0 0 4,148 924 0 0 0 924 6,072 282 35,704 64,983 106,041 Table 3.—Arsenicals administered during the 5-year period, 1932-38, for all diseases, including syphilis Drug Don 0.9 to 3 grams 0.9 gram 0.6 to 0.9 gram Less than 0.6 gram Total Acetarsone: 0 0 0 140 140 Arsphenamine: 0 0 76 729 805 0 0 81 9,121 9,202 Bismarsen: 0 0 0 111 111 0 0 0 752 752 All others 0 0 1 548 549 Mapharsen: 0 0 0 1,993 1,993 All others 0 0 0 882 882 Neoarsphenamine: 0 4,758 198,435 284,296 4S7.489 Sliver arsphenamine: 0 380 24,584 78,969 103,933 0 0 0 340 340 Sulpharsphenamine: 0 0 0 204 204 0 18 241 6,801 7,060 Tryparsamide: 0 3 43 8,810 8,856 15,931 0 0 10 15,941 8.970 8,965 0 0 5 24,896 5,159 223,461 393,711 647,227 PREVENTIVE MEDICINE 133 Table 4.—Deaths and severe reactions following the administration of 1,087,083 doses neoarsphenamine, 1925-86. Ratio of deaths and severe reactions to doses Classification Deaths Number Ratio to doses 1to - Severe reactions Number Ratio to doses 1to - Deaths and severe reactions Number Ratio to lto- Hemorrhagic encephalitis -- Arsenical dermatitis Vasomotor phenomena Blood dyscraslas Acute renal damage Acute yellow atrophy of the liver. . Vascular damage (prohable renal hemorrhage) Liver damage... Jaxisch-Herxheimer Polyneuritis -— Border-line hemorrhagic encepha litis Arsenical neuritis Oastrointestinal Optic neuritis -- Total 72,472 108,708 181,181 217,417 543,542 543,542 1,087,083 1 170 5C 18I 0 0 14 2 1 1 1 2 1 1,087,083 6,395 19,412 60,394 217,417 77,649 543,542 1,087,083 1,087,083 1,087,083 543,542 1,087,083 16 180 02 23 7 2 67,943 6,039 17,534 47,264 155,298 543,542 1,087,083 77,649 543,542 1,087,083 1,087,083 1,087,083 543,542 1,087,083 26, 514 272 3,997 313 3,473 Table 5.—Deaths folloieing administration of arsenical compounds, 1919-86 Year Arsphen- amine Neoars phenamine Total Year Arsphen- amine Neoars phenamine Total 1919 3 0 3 1929 0 3 3 1920 1 1 2 1930 0 3 3 192i 3 1 4 1931 0 0 0 1922 0 4 4 1932 0 4 4 1923 0 1 1 1933 0 7 7 1924 1 2 3 1934 0 3 3 1925. 0 2 2 1935.... 0 2 2 1926 0 4 4 1936 0 3 3 i£:v:: : 1927 1 0 4 6 5 6 Total.... 9 50 59 NUMBER OF PERSONS TREATED FOR SYPHILIS AND OTHER DISEASES Annually on December 31 each activity records and reports to the Bureau of Medicine and Surgery, on N . M. S. Form A, the number of persons in that command who have a history of syphilis, and the num ber of those in the command who were treated during the year with an arsenical compound, heavy metal, or other antiluetic treatment. The census also requires the recording and reporting of the number of persons who were treated during the year with an arsenical compound for a disease other than syphilis. This census does not take into account those individuals who left the service during the year. In the table which follows, treatment data have been separated into that given to active service personnel and that given to all others. The term "All other" includes Veterans' Administration patients, dependents of naval personnel, retired naval personnel, and native populations of insular possessions. 134 PREVENTIVE MEDICINE Table 6.—Syphilis and arsenicals, U. S. Navy, 1986 United States Navy and Marine Persons Corps All other Total Strength, Dec. 31, 1936 126,583 14,427 126,583 .4,427 Syphilis census, Dec. 31, 1936 Number of persons treated for syphilis with— Arsenicals: Arsphenamine 163 16 141 5,402 23 25 101 1,173 2 42 71 178 40 242 6,575 8 209 296 Jltsmarsen . Neoarsphenamine Silver arsphenamine . . Sulpharsphenamine . 167 225 Heavy metal compounds: 6,110 1,437 7,647 Mercury compounds 6,289 527 142 214 863 36 6,152 563 142 224 Mixed treatment (specific mixture, etc.)... -. 10 Total persons treated with heavy metal compounds 6,172 909 7,081 Number of persons treated for disease other than syphilis with arsenicals: 30 164 1 1, 199 74 30 1,363 75 193 192 Total persons treated with arsenicals 387 0 1,273 69 1,660 69 Heavy metal compounds: Bismuth compounds In table 6 it will be noted that 387 service personnel and 1,273 nonservice personnel were treated for diseases other than syphilis with arsenical compounds during the year 1936. Of the 387 naval personnel, 323 were treated for Vincent's infection, 8 for furunculosis, 6 for dermatitis herpetiformis, 5 for acne, 5 for yaws, and 9 for other diseases. Of the 1,273 persons in the group "all others," 1,195 were treated for vaws, 76 for Vincent's infection, and 2 for other diseases. VASOMOTOR PHENOMENA Neoarsphenamine. — (35— 1936.) This patient (supernumerary, native of Guam) was given a diagnosis of syphilis because of clinical and serological findings. Arsenical treatment began December 18, 1935, with a 0.25 gram injection of neoarsphenamine. Two hours after the injection the patient developed chills and headache, a temperature of 103.4° F.; pulse, 120; and respirations, 28. Recovery within 24 hours. Arsenical treatment was continued and after the fourth injection of neoars phenamine the patient developed severe exfoliative dermatitis and died 20 days after the onset of the first symptoms. (Case No. 33-1936 —U. S. Naval Medical Bulletin, October 1937). (36— 1936.) After exposure to infection February 10, 1936, a patient developed several small abrasions on the shaft of the penis. One month later he was given a diagnosis of syphilis because of secondary rash and a 4-plus Kahn blood test. PREVENTIVE MEDICINE 135 Arsenical treatment was begun and he received three injections of neoarsphena- mine, a total of 1.5 grams, and six injections of bismosol between March 9 and 26, and 0.45-gram injections of neoarsphenamine on April 2, 9, and 16. About 1 hour after the last injection, and after eating dinner, the patient developed chills with a numblike sensation over the entire body, followed by nausea and vomiting. He was given 1 gram of sodium thiosulphate intravenously. Recovery within 6 hours. Arsenical treatment was continued and he received a 0.2 gram injection of neoarsphenamine and a 0.2 gram injection of bismosol on April 23 and a 0.3 gram injection of neoarsphenamine on April 30. Five hours after the last injection of neoarsphenamine the patient developed symptoms similar to the previous reaction, followed in 3 days by a severe exfoliative dermatitis. (Case No. 18-1936—U. S. Naval Medical Bulletin, October 1937). (37— 1936.) A patient, exposed to infection November 1, 1935, developed a lesion on the penis. Repeated dark-field examinations were negative for Tre ponema pallidum. He was given a diagnosis of syphilis 2 months later because of a 3-plus Kahn blood test. Arsenical treatment began January 30, 1936, with a 0.25 gram injection of neo arsphenamine. Six hours after the injection he developed nausea and vomiting. Temperature 102.4° F. He was given 1 gram of sodium thiosulphate intravenously. Temperature returned to normal within 6 hours. Recovery within 24 hours. (36, 39— 1936.) This patient (supernumerary, native of Guam) experienced two mild vasomotor phenomena reactions during the first course of arsenical treatment. The patient was given a diagnosis of yaws because of an ulceration on the left foot, lymphadenopathy, and a 4-plus Kahn blood test. Arsenical treatment was started December 27, 1935, with a 0.25 gram injection of neoarsphenamine. Two hours after the injection the patient developed a severe headache. Temperature 103° F.; pulse, 110; and respirations, 26. Recovery within 24 hours. Arsenical treatment was continued with a 0.4 gram injection of neoarsphenamine January 8, 1936. Two hours after this injection the patient developed moderate chills and headache. Temperature of 102° F., pulse, 106; and respirations, 26. Recovery within 24 hours. (40— 1936.) This patient (supernumerary, native of Guam), was given a diagno sis of yaws because of clinical and serological findings. Arsenical treatment began January 30, 1936, with a 0.25 gram injection of neoarsphenamine. Two injections of bismosol were given as concurrent treatment. Three hours after the injection of neoarsphenamine the patient developed chills, headache, nausea, and vomiting. Temperature 105° F.; pulse, 150; and respira tions, 45. One gram of sodium thiosulphate was given intravenously. The following day the patient complained of slight headache, had four liquid stools during the day. Temperature 102.8° F.; pulse, 100; and respirations, 26. Recovery in 2 days. (41 — 1936.) A patient, exposed to infection March 1934, developed a primary lesion on the penis May 1, 1934, and was given a diagnosis of syphilis because of clinical and serological findings. Arsenical treatment was instituted June 5, 1934, with a 0.2 gram injection of sulpharsphenamine, followed by a 0.4 gram injection on June 12. From July 3, 1934, to July 23, 1935, he received 30 injections of neoarsphenamine, a total of 17.4 grams, and 40 injections of bismuth salicylate as concurrent treatment. On October 25, 1935, the fifth course of arsenical treatment began with a 0.3 gram injection of neoarsphenamine, followed by a 0.45 gram injection on November 1, and 0.6 gram injections on November 22, 29, December 6, 13 and 23, 1935, and a 0.3 gram injection on January 4, 1936. 136 PREVENTIVE MEDICINE During the progress of the last injection, the patient complained of Sching in the arm followed by slight faintness and nausea. He was given 0.5 cubic centi meter of adrenalin hypodermatically. The patient continued to complain of the arm aching. There was no evidence of leakage into the tissue. He was treated locally with sodium thiosulphate. All symptoms other than the pain in the arm subsided. Red blood count, 4,450,000; white blood count, 11,300; hemoglobin, 90 percent; segments 63; lymphs, 21; bands, 13; juveniles, 3. Recovery in 6 days. (42—1936.) A patient who was exposed to infection February 10, 1931, devel oped a small indurated ulcer on the penis which was positive for Treponema pallidum. From March 7, 1931, to May 18, 1934, he received 33 injections of salvarsan and 33 injections of bismuth salicylate (total amount not recorded) ; from March 8 to November 8, 1935, 22 injections of neoarsphenamine, a total of 11.8 grams, and 10 injections of bismuth salicylate as concurrent treatment; and on January 16, 1936, a 0.45 gram injection of neoarsphenamine, the first injection of the seventh course of arsenical treatment. Twenty minutes after the injeotion he suffered a severe chill and complained of a choking feeling. Temperature 100.8° F.; pulse, 100; and respirations, 19. He was given 1 gram of sodium thiosulphate intra venously, and 1 gram by mouth, repeated the following day. All symptoms disap peared within 3 hours after sodium thiosulphate was administered January 16. Recovery in 1 day. (43—1936.) The source of infection in this case is unknown. The patient was given a diagnosis of syphilis because of general adenopathy, falling hair of the eyebrows and head, and repeated 4-plus Kahn blood tests. He was given a 0.25 gram injection of neoarsphenamine on January 16, 1936, and a 0.3 gram injection on January 23. Two injections of bismosol were given as con current treatment. Five hours after the last injection of neoarsphenamine the patient developed a slight chill, followed by a temperature of 103.6° F.; pulse, 108; and respirations, 25. Examination showed injected conjunctivae and flushed face. He complained of dizziness and intense aching of the joints. One-half cubic centimeter of adrenalin was administered subcutaneously. White blood count, 10,800; bands 8; segments, 68; lymphs, 17; monos, 5; eosins, 2. It was believed that the patient had a mild reaction coincident with catarrhal fever. All symptoms disappeared within 3 days. He was given 0.1 gram of sulpharsphenamine intramuscularly on February 2, 1936. Six hours later he complained of slight headache and chills. Examination showed the eyes injected and mucous membranes of the mouth and throat injected and edematous. Temperature, 99° F.; pulse, 80; and respiration, 20. White blood count, 16,200; bands, 14; segments, 75; lymphs, 5; monos, 5; eosins, 1. Symptoms disappeared the following day and the patient felt well. The patient was considered recovered in 13 days but was kept on the sick list 20 additional days for observation and treatment with sulpharsphenamine. No reaction occurred following the next four injections of sulpharsphenamine. (44— 1936.) A patient was given a diagnosis of syphilis because of positive dark- field examination of a sore on the penis, general adenopathy, and secondary skin rash. From March 26 to May 11, 1936, he received eight injections of neoarsphena mine, a total of 4.5 grams, and eight injections of bismosol. The second course of arsenical treatment was started June 15, 1936, with a 0.3- gram injection of neoarsphenamine, followed by a 0.4-gram injection on June 22, and 0.6-gram injections on June 29, July 6, 13, and 20. He was given six injections of bismosol as concurrent treatment. PREVENTIVE MEDICINE 137 Two minutes after the last injection of neoarsphenamine the patient became dizzy, weak, and faint. The face was flushed, pulse rapid, and blood pressure low. Recovery within 6 hours. (45— 1936.) A patient exposed to infection October 11, 1934, developed several Email ulcers on the glans penis which were positive for Treponema pallidum. The glands were moderately enlarged and a Kahn blood test was 4-plus. From November 27, 1934, to February 26, 1936. he received a total of 8.6 grams of neoarsphenamine and 4.19 grams of arsphenamine (number of injections not recorded). As concurrent treatment he was given 23 injections of bismosol, 20 mercury inunctions, and potassium iodide daily for 2 months. The fourth course of arsenical treatment was begun January 22, 1936, with a 0.3-gram injection of neoarsphenamine, followed by a 0.35-gram injection on January 28; 0.3 gram of arsphenamine February 8, 0.4 gram February 15, and 0.3 gram February 20; and 0.27 gram of neoarsphenamine February 26. Three and one-half hours after the last injection of neoarsphenamine the patient reported complaining of chills and fever. Examination showed convulsive movement of the right arm, which he was not able to control. His temperature rose to 103° F. and fell rapidly after he received 5 minims of adrenalin intramus cularly, and 1 gram of sodium thiosulphate. Recovery in 1 day. (46— 1936.) A patient who was exposed to infection on January 28, 1934, developed a small ulcer on the penis and glandular adenopathy. Repeated Kahn blood tests were 4-plus. From March 20 to May 29, 1934, he received eight injections of neoarsphena mine (total amount not recorded). From November 6, 1934, to October 22, 1935, he was given 24 injections of neoarsphenamine, a total of 13.05 grams. Thirty injections of bismosol and 13 injections of mercury bichloride were given as concurrent treatment. The fifth course of arsenical treatment began January 7, 1936, with a 0.3-gram injection of neoarsphenamine, followed by a 0.45-gram injection on January 14 and 0.6-gram injections on January 21, 28, February 4, 11, 18, 27, and March 2. Within V/i hours after the last injection the patient developed a sense of chillness, mild headache, and a heavy feeling in the abdomen. One-half hour later he had a distinct chill, after which he slept for 2 hours. Recovery within 6 hours. (47— 1936.) A patient was exposed to infection August 1934. Two months later he developed a secondary skin rash and generalized adenopathy. The Kahn blood test was 4-plus. From October 19, 1934, to October 17, 1935, he received 20 injections of neo arsphenamine, a total of 9.9 grams, and 15 injections of bismuth salicylate as concurrent treatment. The third course of arsenical treatment began January 30, 1936, with a 0.3- gram injection of neoarsphenamine, followed by a 0.45-gram injection on February 6, 0.6-gram injections on February 13 and 20, and a 0.3-gram injection on March 12, 1936. Three minutes after the last injection he became nauseated and vomited bile-stained stomach contents. He complained of weakness and aching of the spine and extremities; the eyes were dilated and conjunctivae injected; the face was cyanotic; the heart beats were barely noticeable, the radial and temporal pulse not obtainable; respirations were slow and shallow; involuntary urine and bowel movement. The patient presented a typical picture of profound shock. He was apparently unconscious for about 10 minutes and was in a semiconscious condition for 1 hour. Red blood count, 4,910,000; white blood count, 16,400; hemoglobin, 90 percent; myelocytes, 3; juveniles, 8; bands, 34; segments, 47; lymphs, 8. He was given 24140—37 10 138 PREVENTIVE MEDICINE 0.5 cubic centimeter of adrenalin and 1/100 grain of atropin subcutaneously at intervals as appeared to be indicated. The patient felt normal the following day. Recovery in 4 days. (48— 1936.) A patient, exposed to infection on November 14, 1934, developed a sore on the penis which was positive for Treponema pallidum. From November 19, 1934, to November 16, 1935, he received 16 injections of neoarsphenamine, a total of 6.9 grams; 10 injections of arsphenamine, a total of 3.7 grams; and 33 injections of bismuth as concurrent treatment. The fourth course of arsenical treatment began February 29, 1936, with a 0.3- gram injection of arsphenamine, followed by a 0.3-gram injection on March 7, and a 0.3-gram injection of neoarsphenamine on April 7. Thirty minutes after the injection of neoarsphenamine the patient developed weakness, nausea, and light vomiting. Recovery within 5 hours. The patient complained of slight reaction following each attempt to give neoarsphenamine but had no complaint after receiving arsphenamine. (49—1936.) This patient was exposed to infection in November 1935. He was given a diagnosis of syphilis January 18, 1936, because of secondary skin rash, mucous patches in the mouth, generalized adenopathy, positive dark-field examina tion of a penile lesion, and a 4-plus Kahn blood test. From January 21 to March 3, 1936, he received 6 injections of neoarsphenamine (amount not recorded) and 10 injections of bismuth salicylate. The second course of arsenical treatment began May 21, 1936, with a 0.3-gram injection of neoarsphenamine, followed by a 0.45-gram injection on May 28, and a 0.11-gram injection on June 4. Seven injections of bismuth were given as con current treatment. Approximately 1 minute after the last injection of neoarsphenamine was started, and after receiving 0.11 gram of the 0.6-gram dose, the patient remarked that the neoarsphenamine must be stronger than usual because he could taste it much more than before. It was noted that he was becoming somewhat cyanotic and the injection was stopped. The patient collapsed a few seconds later losing consciousness. Breathing became stridulous and difficult, the face cyanotic and puffed. He was given 5 cubic centimeters of adrenalin hypodermatically, re peated in 3 minutes. Breathing became easier and he recovered consciousness within 5 minutes. He complained of a choking sensation and severe pain in the right chest and was given 0.7 gram of sodium thiosulphate intravenously. In 40 minutes there was a slight chill and a temperature of 101° F. Recovery within 24 hours. (50— 1936.) The diagnosis of syphilis in this case was not established. Physical examination showed no evidence of primary or secondary lesions in the skin, mucous membranes, or glandular involvement. The patient had negative monthly Kahn blood tests during the past year and a half while on the donors' list. A Kahn blood test was 3-plus May 2 and 4-plus May 4 and 5. Treatment began on May 7 with a 2 cubic centimeters injection of bismuth sodium tartrate, followed by 2 cubic centimeters injections on May 8, 12, 15, 19, 22, and 26. Arsenical treatment began with a 0.35-gram injection of neoarsphena mine on May 12, followed by a 0.35-gram injection on May 19, and a 0.7-gram injection on May 26. Three days after the last injection of neoarsphenamine the patient complained of sore throat, fever, and general malaise. He stated that he had not felt well the past week or 10 days, and thought it was the after effect of a spinal puncture. Examination revealed the throat and gums slightly reddened, tonsils elevated, and a temperature of 103° F. He was given 1 gram of sodium thiosulphate intraven PREVENTIVE MEDICINE 139 ously twice daily for 9 days. All symptoms subsided by June 7, 1936, and the patient felt well. The patient was considered recovered in 8 days, but he remained on the sick list 21 days for observation and treatment with bismuth compounds. The admin istration of sodium thiosulphate was continued and he received 1 gram intraven ously daily for 5 days, a total of 32 grams within 21 days. (51— 1936.) After exposure to infection in May 1927 this patient developed a penile lesion which healed under local treatment. He was given a diagnosis of syphilis 3 months later because of repeated 4-plus Kahn blood tests. He received seven injections of neoarsphenamine during the months of August and September 1927 (amount not recorded). From October 5, 1927, to September 5, 1933, he received 73 injections of neoarsphenamine, a total of 48.6 grams; 65 injections of bismuth salicylate; 14 injections of bismosol; 12 injections of mercury salicylate; and 37 mercury inunctions. From January 15 to November 26, 1935, he was given 19 injections of tryparsamide, a total of 57 grams, and 21 injections of bismosol. The thirteenth course of arsenical treatment began with a 0.3-gram injection of neoarsphenamine on May 5, 1936, followed by 0.6-gram injections on May 12, 19, and June 2. Forty-five minutes after the last injection the patient complained of weakness and dyspnea. Examination revealed anxiety, suffused skin, rapid pulse, and a temperature of 101° F. He was given 1 gram of sodium thiosulphate intravenously and 1 cubic centi meter of adrenalin hydrochloride subcutaneously. Recovery within 24 hours. (52— 1936.) A patient, exposed to infection January 6, 1936, developed a lesion on the prepuce which was positive for Treponema pallidum,. The inguinal glands were enlarged and discrete and a Kahn blood test was 4-plus. From January 27 to March 24, 1936, he received eight injections of neoarsphena mine, a total of 4.7 grams, and three injections of bismuth. The second course of arsenical treatment began June 2, 1936, with a 0.35-gram injection of neoarsphenamine, followed by 0.7-gram injections on June 9, 16, and 30. Thirty minutes after the last injection the patient complained of general malaise, nausea, and vomiting. Examination otherwise essentially negative. The patient stated that he had felt chilly, ached all over, and had sometimes been nauseated following the three previous injections of neoarsphenamine. Recovery within 18 hours. (53— 1936.) This patient experienced two mild vasomotor phenomena reactions during the first course of arsenical treatment in 1934 (Case no. 12, U. S. Naval Medical Bulletin, January 1936). He was given a diagnosis of syphilis because of repeated 4-plus Kahn blood tests, inguinal lymphadenopathy, and a healed pri mary lesion of the glans penis. From February 23 to April 5, 1934, he received 13 injections of neoarsphena mine, a total of 5.45 grams. The reactions followed the last two injections; the first followed a 0.45-gram dose and the second followed a test dose of 0.3 gram. Recovery in both cases was within 48 hours. From April 12 to June 11, 1934, he was given 18 injections of bismosol. From February 8 to May 28, 1935, he was given 17 injections of mercury succinimide, a total of 3.4 grains. The second course of arsenical treatment (five injections of neoarsphenamine, a total of 1.8 grams) was given between June 5 and July 11, 1935. Neoarsphena mine was discontinued because of slight reactions following the fourth and fifth injections. From July 12, 1935, to June 12, 1936, he received 30 injections of bismuth salicylate and 20 injections of mercury succinimide. 140 PREVENTIVE MEDICINE A third course of arsenical treatment was attempted on July 8, 1936, with a 0.15-gram injection of neoarsphenamine. On July 15, \){ hours after a 0.3-gram injection of neoarsphenamine had been administered, the patient developed headache, burning of the eyes, and general weakness. Temperature 100° F. Two hours later he became nauseated and vomited several times. He was given 1 gram of sodium thiosulphate intravenously. Recovery within 10 hours. (54— 1936.) This patient gives a history of repeated exposures to infection sev eral weeks prior to the appearance of a lesion on the glans penis on June 20, 1936. Repeated dark-field examinations of the lesion were negative for Treponema pallidum. A Kahn blood test on June 23 was 4-plus. Arsenical treatment began with a 0.6-gram injection of neoarsphenamine on June 29, followed by 0.6-gram injections on July 6, 13, 20, and 27. As concurrent treatment he was given six intramuscular injections of bismosol. Immediately following the last injection of neoarsphenamine the patient com plained of feeling weak, dizzy, and faint, following which he became nauseated and vomited. Examination showed the face flushed, pulse rapid, and blood pressure low. He was given 1 gram of sodium thiosulphate intravenously and kept on the sick list for observation and complete rest. On August 10 the patient was given a 0.6-gram injection of neoarsphenamine, following which the patient suffered a mild shock, became nauseated, and vomited. One-half gram of sodium thiosulphate was given intravenously. Recovery in 16 days after onset of the first symptoms. (55-1936.) The source of infection in this case is unknown. The patient denies venereal infection though he admits exposure to infection during the past 12 weeks. He was given a diagnosis of syphilis because of repeated 4-plus Kahn blood tests. Arsenical treatment began with a 0.3-gram injection of neoarsphenamine on June 29, 1936, followed by a 0.4-gram injection on July 6, 0.6-gram injections on July 13 and 20, and a 0.3-gram injection on July 27. Five injections of bismosol were given as concurrent treatment. Immediately following the last injection of neoarsphenamine the patient vomited and suffered shock, fall in blood pressure, and pulse rate. The eyelids and lips showed angioneurotic edema. He developed difficulty in breathing, cyanosis, and weakness. He was given 1 gram of sodium thiosulphate intra venously, followed by 1 cubic centimeter of epinephrine hydrochloride every 15 minutes for three hypodermic injections. Recovery within 48 hours. (56 and 57— 1936.) This patient experienced two mild vasomotor reactions during the first course of arsenical treatment. He was infected on August 23, 1936, and 14 days later developed a lesion on the penis which was positive for Treponema pallidum. He received a 0.3-gram injection of neoarsphenamine, and a 0.13-gram injection of bismuth salicylate on September 8, 1936. Twelve hours after the injection of neoarsphenamine the patient complained of headache. Temperature 103.6° F. The face was flushed and the mucous membranes were injected. Recovery within 24 hours. Arsenical treatment was continued with a 0.15-gram injection of neoarsphen amine on September 14. Seven hours after this injection the patient complained of headache. Temperature 99.8° F. The following morning his temperature was normal and all symptoms had subsided. Recovery within 24 hours. Neoarsphenamine was discontinued and bismarsen administered intramuscu larly. There were no signs of further reaction. PREVENTIVE MEDICINE 141 (58— 1936.) A patient exposed to infection in October 1927 developed a lesion on the penis which was positive for Treponema pallidum. From May 10, 1927, to April 7, 1928, he received 16 injections of neoarsphen- amine (amount not recorded) and from May 10, 1930, to July 17, 1936, 36 injections of bismuth compounds. The third course of arsenical treatment began September 1, 1936, with a 0.1- gram ' injection of neoarsphenamine, followed by a 0.3-gram injection on Sep tember 4, and a 0.45-gram injection on September 8. About 10 minutes after the last injection the patient became nauseated and vomited profusely, followed by severe chills and collapse. The skin was flushed and pulse weak and rapid. He was given 1 gram of sodium thiosulphate intravenously and 5 cubic centimeters of adrenalin subcutaneously. Recovery within 24 hours. (59— 1936.) This patient was exposed to infection in December 1931. He stated that a small sore developed on the penis 3 weeks after exposure and healed without treatment. He was given a diagnosis of syphilis on June 1, 1932, because of 4-plus Kahn blood tests and old scar on the glans penis. From June 8 to August 3, 1932, he received eight injections of neoarsphena mine and eight injections of bismuth salicylate; from September 7 to October 11, five injections of neoarsphenamine; and from November 30 to December 27, five injections of neoarsphenamine (total amounts of the above treatment were not recorded). The patient stated that the second and third courses of arsenical treatment were discontinued after the fifth injection, because of slight gastro intestinal upsets, and fever. From October 12, 1933, to July 24, 1936, he was given 22 injections of bismosol, 15 injections of bismuth salicylate, and 12 injections of mercury. The fourth course of arsenical treatment began with a 0.3-gram injection on August 12, 1936, followed by a 0.45-gram injection on August 19, 0.6-gram injec tions on August 26 and September 16, and a 0.3-gram injection on September 23. One hour after the last injection the patient complained of headache, became nauseated, and vomited. He vomited at frequent intervals for 2 hours. He was given 1 cubic centimeter of adrenalin subcutaneously and 1 gram of sodium thiosulphate intravenously. Recovery in 2 days. (60— 1936.) This patient was exposed to infection on March 26, 1934, and developed an indurated ulcer of the glans penis which was positive for Treponema pallidum. From April 17 to June 19, 1934, he received 8 injections, a total of 3.6 grams of neoarsphenamine; from June 19 to July 9, 4 injections of sulpharsphenamine, a total of 1.3 grams; and from April 17, 1934, to January 15, 1935, 36 injections of bismosol On February 5, 1935, he received a 0.3-gram injection of sulpharsphenamine, followed by a 0.4-gram injection on February 12 and a 0.3-gram injection on February 19. A mild vasomotor phenomena reaction followed the last injection. Recovery within 5 hours. (Case no. 42— 1935, U. S. Naval Medical Bul letin, January 1937.) From January 15, 1935, to September 22, 1936, he received 74 injections of bismuth compounds. On September 29, 1936, he was given a 0.045-gram injection of neoarsphenamine, followed by a 0.09-gram injection on October 13. Five minutes after the last injection the patient complained of headache, and pain in the epigastrium, back, and legs. He vomited several times, followed by three watery bowel movements within 2 hours. One and one-half hours later he developed a severe chill and temperature of 101.4° F. He was given 5 minims of epinephrine hydrochloride, 142 PREVENTIVE MEDICINE 1-1000 solution subcutaneously, followed by 1 gram of sodium thiosulphate intravenously. Recovery within 24 hours. (61-1936.) A patient, exposed to infection on March 10, 1936, developed three indurated ulcers on the glans penis which were positive for Treponema pallidum. Arsenical treatment began with a 0.3 gram injection of neoarsphenamine on April 20, 1936, followed by 0.4 gram injections of arsphenamine on April 23 and 30. From May 6 to June 3 he received five injections, a total of 2.55 grams of neoars phenamine. On June 13 he was given a 0.4 gram injection of arsphenamine and on June 25, a 0.3 gram injection of neorasphenamine. From September 12 to October 3, 1936, he received four injections of arsphenamine, a total of 1.2 grams. As concurrent treatment he was given 10 injections of bismuth salicylate. On October 12, 1936, the patient was given a 0.27-gram injection of neoarphcna- mine and 15 minutes later he complained of general weakness and pains in the epigastrium. He became nauseated and vomited. He vomited twice and passed three watery stools within 1 hour. He developed a chilly sensation which lasted 45 minutes. Temperature, 99.4° F. Recovery within 24 hours. (62-1936.) After exposure to infection this patient developed a small punched- out ulcer on the inner surface of the foreskin which was positive for Treponema pallidum. Arsenical treatment began with a 0.3 gram injection of neoarsphenamine on November 27, 1936. Two days after the injection the patient was admitted to the sick list with a temperature of 102° F. and pulse 120. Examination revealed a bubo in the right inguinal region, probably the result of the chancre and the cause of the elevated temperature. The patient had no other complaints or symptoms. Temperature returned to normal within 2 days. 'Arsenical treat ment was continued and he was given a 0.6 gram injection of neoarsphenamine on December 3, 1936, without signs or symptoms of further reaction, followed by a 0.6 gram injection on December 10. Three hours after the last injection the patient complained of general malaise. Temperature, 103° F.; and pulse, 120. Examination negative other than high fever. He was given 1 gram of sodium thiosulphate intravenously. The patient slept confortably during the night and the following morning his temperature was 100° F. He was given the second 1 gram intravenous injection of sodium thiosulphate. Temperature gradually returned to normal. Recovery in 8 days. Sxdpharsphenamine. — (63-1936.) This patient was given a diagnosis of syphilis on June 24, 1932, because of a secondary skin eruption, large indurated inguinal glands, 4-plus Kahn blood tests, and a history of exposure and a primary lesion of the penis in April 1932. From June 24, 1932, to July 12, 1933, he received 28 injections of arsenical compounds (type and amount not recorded) , 42 injections of bismuth compounds, and 19 injections of mercury. It was noted in the health record that arsenicals were discontinued in 1933 because of severe reaction to treatment. During the years of 1934 and 1935 he was given 54 injections of bismuth compounds. On February 11, 1936, he was given a 0.1 gram intramuscular injection of sulpharsphenamine, followed by a 0.2 gram injection on February 19. One hour after the last injection the patient developed a chill which lasted 1% hours. Temperature, 101.2° F. Three hours after the injection he became nauseated and vomited. The patient complained of a slight headache the following morning. Recovery in 2 days. PREVENTIVE MEDICINE 143 GASTROINTESTINAL Sulpharsphenamine. — (64— 1936.) The source and date of infection in this case is unknown. The patient was given a diagnosis of syphilis because of a secondary skin eruption and repeated 4-plus Kahn blood tests. Arsenical treatment was instituted and from March 17, 1933, to May 4, 1934, he received a total of 11.65 grams of arsenical compounds (type and number of injections not recorded), 24 injections of bismosol, and 10 injections of mercury. From January 14 to August 3, 1936. he was given 16 injections of bismuth com pounds. He was given 0.3 gram intramuscular injections of sulpharsphenamine on August 11 and 17, 1936. One-half hour after the last injection of sulpharsphena mine the patient developed nausea, followed by vomiting and diarrhea. The vomitus contained macroscopic blood. One gram of sodium thiosulphate was administered intravenously. Two days later he developed slight bleeding from the gums and rectum. Physical examination otherwise negative. Red blood count, 4,100,000; white blood count, 5,650; hemoglobin, 80 percent; bands 33; segments 42; lymphs 17; monos 5; eosins 2; juveniles 1. Blood platelets, 341,000. Recovery in 11 days. Neoarsphenamine. — (65— 1936.) This patient was exposed to infection on March 27, 1929, and developed a primary lesion on the prepuce which was posi tive for Treponema pallidum. A Kahn blood test was 4-plus. From May 7, 1929, to November 9, 1930, he received three courses of neoars phenamine, a total of 15.9 grams, and 6 grains of mercury intramuscularly. The fourth course of arsenical treatment began with a 0.3 gram injection of neoarsphenamine on June 6, 1936, followed by a 0.4 gram injection on June 13. On June 22, 1936, the patient reported for the third injection of this course of neoarsphenamine. He stated that slight nausea and vomiting followed the injec tions given on June 6 and 13. He was given 1 gram of sodium thiosulphate intravenously followed in 1 hour by a 0.4 gram injection of neoarsphenamine. Immediately after the injection of neoarsphenamine he became pale and nau seated, followed by abdominal colic and watery stools. The patient was in moderate shock, with a temperature of 97° F.; pulse weak and rapid and the skin pale and cold. He was given 1 gram of sodium thiosulphate intravenously the following day. Recovery in 9 days. JARISCH HERXHEIMER (66 — 1936.) This patient was exposed to infection December 18, 1935, and developed a lesion on the penis which was negative for Treponema pallidum. Under treatment, the lesion healed within 10 days. He was given a 0.6 gram injection of neoarsphenamine on January 21, 1936. One hour after the injection the patient complained of general body pains and chills. Temperature, 102° F. He was given 0.5 cubic centimeter of adrenalin hypodermatically at 2 p. m. and 4:30 p. m. Temperature normal the following morning. A typical secondary skin rash present. Recovery within 10 hours. (67-— 1936.) This patient, exposed to infection on December 20, 1935, devel oped two small lesions on the penis which were positive for Treponema pallidum. A Kahn blood test was 4-plus. Arsenical treatment began with a 0.3 gram injection of neoarsphenamine on January 30, 1936, followed by 0.45 gram injections on January 7 and 14. He was given three injections of bismuth as concurrent treatment. 144 PREVENTIVE MEDICINE One hour after the last injection of neoarsphenamine the patient developed nausea, followed by a temperature of 101.2° F., flushed skin, and a typical Herx- heimer skin reaction. He was given 1 gram of sodium thiosulphate intravenously. Recovery within 48 hours. (68— 1936.) After exposure to infection this patient developed a small sore on the penis. He stated that he treated the sore for some time but it would not heal. Examination showed a small ulcer on the penis, generalized lymphadenopathy, and a generalized secondary skin rash. A Kahn blood test was 4-plus. He was given a 0.25 gram injection of neoarsphenamine on April 21, 1936, and experienced a mild therapeutic shock and a decided flare-up of the rash the follow ing morning. Temperature, 102.2° F. Recovery within 24 hours. The patient was given 0.4 gram injections of neoarsphenamine on April 25, 30, and May 7, 1936, without signs or symptoms of further reaction. (69— 1936.) The source of infection in this case is unknown. The patient was given a diagnosis of syphilis because of several lesions in the mouth which were posi tive for Treponema pallidum, general adenopathy, and a healed scar on the penis. Arsenical treatment began with a 0.34-gram injection of neoarsphenamine August 18, 1936, followed by 0.45-gram injections on August 21 and 25. Twenty hours after the last injection the patient complained of chills and general malaise. Temperature 104° F.; pulse, 140; and respiration, 40. A slight papular rash appeared over the trunk the following day; subsided within 2 days. Temperature gradually returned to normal. Recovery in 8 days. LIVER DAMAGE (70— 1936.) This patient, exposed to infection on November 5, 1935, developed a lesion on the penis which was positive for Treponema pallidum. Repeated Kahn blood tests were negative. Arsenical treatment began with a 0.3-gram injection of neoarsphenamine Decem ber 19, 1935, followed by a 0.45-gram injection on December 24, a 0.6-gram injec tion on December 27, 1935, and a 0.45-gram injection on January 3, 1936. He was given six injections of bismuth salicylate as concurrent treatment. About 4 hours after the last injection of neorarsphenamine the patient com plained of nausea. Temperature 103° F. Several hours later a mild skin rash appeared and the conjunctivae were injected. The following day the conjunc tivae continued to show redness, there was slight fever, and a subsidence of the skin rash. He was given 1 gram intravenous injections of sodium thiosulphate on January 4 and 6. January 15: The skin and conjunctivae show marked increase in jaundice. Red blood count, 3,880,000; white blood count, 8,100; hemoglobin, 85 percent; segments, 61; bands, 4; juveniles, 2; lymphs, 25; eosins, 8. Urinalysis: Color, dark amber; reaction, acid; specific gravity, 1.020; bile, positive, with dilution 1-50; much mucus; many leukocytes; many epithelial cells. Icterus index, 48. January 23: Icterus index, 37. January 27: Red blood count, 3,600,000; white blood count, 12,150; hemo globin, 75 percent; segments, 40; bands, 16; lymphs, 28; eosins, 8; monos, 7; basos, 1. Icterus index, 28. Urinalysis, negative. February 5: The patient shows rapid improvemnt. Icterus index, 10. The patient's condition gradually improved and he was returned to duty 50 days after the last injection of neoarsphenamine. PREVENTIVE MEDICINE 145 BLOOD DYSCRASIAS (71 — 1936.) Two months after exposure to infection this patient developed a lesion on the glans penis which was positive for Treponema pallidum. From March 7 to September 8, 1936, he received 16 injections of neoarsphen amine, a total of 7.5 grams, and 23 injections of bismuth salicylate. The third course of arsenical treatment began with a 0.3-gram injection of neo- arsphenamine December 1, 1936, followed by a 0.45-gram injection on December 16, and 0.5-gram injections on December 22 and 29. Immediately following the last injection the patient became nauseated and dizzy, and there was slight bleed ing from the gums. Examination showed a single purpuric spot on the right buccal mucous membrane. December 30: There are several small purpuric spots in the mucous membrane of the mouth and blood is oozing from the gingival lines. The skin on the inter nal surface of the thighs and legs bears a mass of purpuric spots which at some points are so close together they form purpuric patches. Red blood count, 4,330,000; white blood count, 9,550; bands, 6; segments, 70; lymphs, 24. He was given 1 gram of sodium thiosulphate intravenously. December 31: The purpuric spots are fading and the oozing of the blood from the gums has gradually decreased during the past 24 hours. The patient has no complaint. Recovery in 4 days. (72— 1936.) The source of infection in this case is unknown. The patient was given a diagnosis of syphilis because of a general body rash, inguinal adenopathy, injected pharynx and soft palate, and an indurated ulceration at mucocutaneous border of anus anteriorly. Repeated dark-field examinations of the ulceration were negative for Treponema pallidum; Kahn blood test was 4-plus; and a Wasser- mann test was strongly positive. Arsenical treatment began with a 0.3 gram injection of neoarsphenamine December 24, 1935, followed by 0.45 gram injections on December 31, 1935, and January 7 and 14, 1936. Four injections of bismuth salicylate were given as concurrent treatment. About 50 hours after the last injection of neoarsphenamine the patient com plained of general malaise and slight chills. Temperature, 99.8° F. January 17: The patient complains of sore throat. Examination shows some injection of the pharynx and soft palate, infected ingrowing toenail, and lymphan gitis of dorsum. January 18: The patient continues to complain of sore throat and slight chilliness. January 19: The patient complains of sore and painful gums. Temperature, 102° F. He was given saline mouth washes every 2 hours, and hot baths and hot water bottles to induce sweating. January 20: The patient's condition is about the same. Laboratory reports revealed absence of granular type cells. He was given 1 gram of sodium thiosul phate intravenously, 3 cubic centimeters of liver extract, Fischer's solution, 500 cubic centimeters by Murphy drip, and 250 cubic centimeters of blood, by direct method. January 21: Treatment continued as above, including 250 cubic centimeters of blood. The patient's temperature ranges from 100.4° F. in the mornings to 103.6° F. in the afternoons. The gums show ulceration at the margin of the teeth. The soft palate is injected and mildly edematous. The sublingual lymph glands are swollen and tender. 146 MEDICINE January 22: The patient's condition is about the same. Temperature, 104.2° F. He complains of pains in the teeth and neck. Above treatment continued, except the blood transfusion. January 23: The patient continues to complain as above. Morning tempera ture, 102° F. Two ulcerated areas of the hard palate opposite the molars noted. Above treatment continued, including X-ray therapy to the glands of the neck. January 24: The patient's general condition is about the same. Above treat ment continued. A small spot of erythema appears at each point of injection of hypodermic needle. There is an extension of ulceration of the gum on the upper left side into the hard palate. January 26: The patient's general condition shows improvement. The greater part of the brachial vein is involved. January 28: The patient shows marked improvement. Semisoft diet. Intake and output satisfactory. Temperature ranges between 98.6° F. and 99.6° F. February 1: The patient continues to improve. Temperature normal through out the day. Some residual induration about the left brachial vein. General condition excellent. Blood Red cell count White cell count ' Hemoglobin Segmented Lymphocytes | Eosinophlles Basophiles Mouocytes Juveniles Myelocytes J5 i Turck's cells Keticulocyte count Date .S g 8 = 8 1 January 20, 1936 5, 240,000 5, 450,000 4. 930,000 5, 500,000 4, 680,000 4, 940,000 4, 400,000 4,850,000 4, 350,000 4. 550,000 4,650,000 8,500 3, 500 2,600 2,900 1,700 3, 300 5,000 6.000 18,000 8,200 6.000 90 100 95 100 90 95 85 90 90 80 90 14 16 11 19 1 1 1 1 2 83 83 88 80 72 33 14 17 2 8 19 M January 21, 1936 January 23, 1836 . January 23, 1936 January 25, 1936 26 "i" 0.3 January 27, 1936 9 16 10 13 18 22 40 57 64 46 8 8 3 1 1 6 6 7 1 6 2 6 4 1 1 January 28, 1936 2^ 21 14 22 21 January 29, 1936 .... 1 February 3, 1936 February 4. 1936 4 2 8 February 29, 1936 s The patient's condition gradually improved and he was returned to duty 27 days after onset of the first symptoms. (73— 1936.) After exposure to infection this patient developed a penile lesion which was positive for Treponema pallidum. From May 26 to June 16, 1928, he was given two injections of ncoarsphenamine (amount not recorded), and daily mercury inunctions. October 31, 1935: Examination showed a secondary skin eruption and general ized adenopathy. Although the patient presented no primary lesion this was considered to be a reinfection. A Kahn blood test was 4-plus. From November 2, 1935 to February 5, 1936 he received 16 injections of neo- arsphenamine, a total of 9 grams. Twelve injections of bismuth and an unstated amount of mercury inunctions were given as concurrent treatment. The third course of arsenical treatment began April 14, 1936, with a 0.3 gram injection of neoarsphenamine, followed by 0.6 gram injections on April 21, 28, May 5, 12, 19, 26, June 2, 9, and 16. As concurrent treatment nine injections of bismuth salicylate were given. Following the last injection of neoarsphenamine the patient complained of headache, dizziness, and general lassitude. Spinal fluid examination was essen tially negative. The patient stated on July 7, 1936 that he was not able to do his work, and became very tired on little effort. Also stated that he often developed headaches in the evenings and had lost weight due to loss of appetite. Physical examination PREVENTIVE MEDICINE 147 was negative except for signs and symptoms of severe anemia and marked pallor of the skin and mucous membrane. Further examination revealed an anemia of the aplastic type with depression of all formed elements of the blood. At intervals there was bleeding from the gums and petechial hemorrhages. There was no pathology of the heart or lungs. Urine examination was negative. In spite of the treatment indicated below there was little improvement in the anemia until about November 11, 1936, when evidence of blood regeneration appeared. This improvement was gradual but continuous and was associated with a complete disappearance of symptoms. At the time of discharge the red blood count was 3,400,000, with 69 percent hemoglobin. Response to exercise was normal and the patient experienced no fatigue. His weight was slightly above the normal level. The patient was discharged to duty under observation and treatment 165 days after onset of the first symptoms. Treatment.—Throughout hospitalization the patient received whole liver three times a week with 20 grams of liver extract, equivalent to 200 grams of whole liver daily; ferrous carbonate, 2 grams daily; ultra-violet radiation, three times a week; 15 blood transfusions, a total of 6,440 cubic centimeters of blood; from August 16 to September 3 he received 8 injections of pentnucleotide, 10 cubic centimeters, and 0.5 cubic centimeter of adrenalin twice daily. Blood Rod coll couut White cell count Hemoglobin T5 Lymphocytes Monocytes 2 Reticulocyte count o a 2 a Juveniles Date ■ C on B § E '§ M 1 si s OS e DQ m July 7, 1936 1.810.000 2,660,000 2.360.000 2,070,000 2,000 2,700 60 75 70 52 52 56 56 56 48 64 47 51 60 46 50 49 3 10 25 38 69 45 3 3 4 July 10, 1936 (') Jaly 13, 1936 Aug. 13. 1936 Aug. 21. 1936 1. 790,000 1, 810,000 2, 310,000 2,680,000 2.100,000 2,960,000 1,980,000 2,180.000 2,990,000 2. 470,000 2,900 1,850 2,250 2,300 2,800 3.550 1,800 9 19 14 34 24 34 31 40 29 27 67 51 51 64 50 60 69 Aug. 2S, 1936 1 4 i 0.6 .4 .4 .8 .7 .5 .15 .3 Sept. 4, 1936 1 Sept. 11, 1936 5 10 Sept. 18, 1936 Sept. 25. 1936 6 2 2 1 Oct. 2. 1936. 4 Oct. 9, 1936 Oct. 16, 1936 Oct. 23. 1936 Oct. 30. 1936 2, 780.000 2,700,000 Nov. 6, 1936 Nov. 10. 1936 2.5 Nov. 12. 1936 X M0. 000 2,340.000 2,880,000 3,080,000 3,200,000 3.400.000 55 41 64 60 69 66 ^iS::::::::-::::: .9 Dec. 11, 1936. . Dec. 18. 1936 Jan. 4. 1937 1 Blood picture: Red blood count: Anisocytosis, moderate with macrocytes predominating. Poikilocy- tosis, very mild. Hypochromasia, absent. Other than the above there is no abnormality in the red cells. White blood count: No toxic degeneration. Marked leukopenia, with lymphocytosis and mildeosinophilia. Platelets, decreased. HEMORRHAGIC ENCEPHALITIS (74— 1936.) After exposure to infection on November 22, 1935, this patient developed a lesion on the glans penis which was positive for Treponevia pallidum. Arsenical treatment began with a 0.3 gram injection of neoarsphenamine December 24, 1935, followed by 0.4 gram injections on December 31, 1935, and January 7, 1936, and a 0.45 gram injection on January 15, 1936. He was given 4 injections of bismuth, a total of 0.52 gram, as concurrent treatment. 148 PREVENTIVE MEDICINE On January 20, 1936, the patient was admitted to the sick list because his room mates complained that he had been acting peculiarly for 3 days. The patient refused to talk to any one except to say "I am sick." Upon admission the patient looked ill, his eyes were glassy with a staring expression, and his beard showed about 3 days' growth. He stated that he had been sick for 3 days, complaining of pains in the abdomen, vomiting and diarrhea, and had not urinated during this period. Examination revealed a large tumor-like mass in the region of the urinary bladder. He was catheterized and 1,150 cubic centimeters of urine obtained. The tumor-like mass disappeared. The patient was oriented as to place and position but completely disoriented as to time. On further questioning, it was plainly evident that his story could not be relied upon. January 21: The patient appears somewhat clearer mentally but disoriented as to time. He has vomited about three times since admission, the vomitus con sisting of clear undigested food. He was catheterized at 10 p. m. last night and again this morning, after he had made numerous unsuccessful attempts to void. The right nostril is obstructed by nasal secretion and watery pusy secretion, with edema of the mucous membrane and turbinates. The soft palate and pharynx show injection and inflammation with a slight foul odor to the breath. January 22. The patient complains of headache which prevented his sleeping during the night. Spinal puncture done, prone position; initial pressure 22 milli meters of mercury, with a fall and rise to 34 millimeters of mercury on bilateral jugular pressure. The fluid is clear throughout and possibly 30 to 35 cubic centi meters withdrawn. Spinal fluid cell count, polys, 13; lymphs, 82; monos, 1, and unclassified, 4. The spinal pressure was 6 millimeters of mercury. The patient stated his headache left him after the spinal fluid withdrawal. The impression of this case is that it is possibly a reaction of neoarsphenamine with cerebral edema and meningovascular syphilis involving the basal portion of the brain, as there is a disburbance in the patient's speech and his ability to enunciate clearly. Possi bility of brain abscess. January 23. The patient stated that he feels better than he has for several days. Complains of mild headache, which prevented him from sleeping well. Examination shows injection and edema of both nerve heads with tortuosity of the vessels. The bowels have not been evacuated or the bladder emptied since admis sion, there being an overflow when the bladder becomes distended. Temperature, normal; pulse, 60. January 24. The patient had a comfortable night, sleeping most of the time. During the late part of the morning he complained of increasing headache, stating "It is worse than it has ever been before." Temperature 97° F., pulse between 48 and 50; respirations, 16 to 18. There is still present an injection of the mucous membrane of the nasal pharynx and the Boft palate with a catarrhal discharge from the posterior pharyngeal wall. The patient is still unable to empty the bladder or bowels voluntarily. Spinal puncture done and 25 to 40 cubic centi meters of clear spinal fluid withdrawn. Initial pressure, 36 millimeters of mercury. Jugular compression of the right side failed to bring about any rise in the mercury column, on the left side the mercury rose 2 millimeters to 40 millimeters. The patient stated that the headache disappeared following the withdrawal of the fluid. Blood pressure, 102/70. January 27. The patient feels well. He is sleeping satisfactorily and has a good appetite. He was able to empty the bladder last night and this morning. The patient's condition gradually improved and by February 8 he was able to urinate and control the bowels without difficulty. By February 18 he was up and about, eating and sleeping well, correctly oriented at all times, and has no com plaints. He was returned to duty March 20, 1936, 64 days after onset of the first symp toms. PREVENTIVE MEDICINE 149 (75-1936.) This patient was exposed to infection October 26, 1935, and 7 weeks later a lesion appeared on the glans penis. Repeated dark-field examina tions of the lesion were negative for Treponema ,pallidum. Kahn blood tests were 4-plus, December 16, 1935, and January 6, 1936. A spinal fluid examination showed 1,174 cells and gold curve, 1222222343. Arsenical treatment was instituted January 8, 1936, with a 0.3-gram injection of neoarsphenamine, followed by a 0.3-gram injection on January 10, and a 0.6-gram injection on January 17. Four intramuscular injections of bismuth salicylate were given as concurrent treatment. Approximately 56 hours after the last injection of neoarsphenamine the patient complained of slight headache and nausea. Temperature of 100° F. January 19: The patient felt better at morning sick call. Headache and nausea had subsided. Temperature, 99.2° F. Several hours later the patient appeared to be disoriented and restless. His temperature rose to 101° F. at noon and returned to normal within 6 hours. The patient was seen by the medical officer of the day at 10 p. m., and he appeared quiet and comfortable. He had no complaint and slept through the night. January 20. At 8:30 a. m. the patient was semiconscious, did not understand or answer questions, and could not be aroused. Examination showed: Heart sounds, normal; blood pressure, 130/78; lung sounds, negative; pupils, dilated; Babinski, Kernig's, ankle clonus, and knee jerks, negative; and biceps reaction, positive. Spinal puncture shows clear fluid, not under pressure, dripping very slowly, and about 10 cubic centimeters drained. Patient's unconsciousness became gradually more profound. During the morning he appeared better after the injection of epinephrine hydrochloride, and the pulse and blood pressure were good. Urinalysis: Color, amber; reaction, acid; specific gravity, 1.024; albumin, 2 plus; few fine granular casts; few cylindroids; few leukocytes; few epithelium. Autenrieth's test, negative. Blood: 11 a. m.—Red blood count, 4,500,000; white blood count, 4,800; hemoglobin, 90 percent; monos, 2; lymphs, 12; segments, 68; bands, 18; platelets, 160,000. I p. m.—Red blood count, 4,610,000; white blood count, 22,500; hemoglobin, 90 percent; lymphs 7; segments, 73; bands, 17; juveniles, 3; platelets, 170,000. 7 p. m.—Red blood count, 4,200,000; white blood count, 17,200; hemoglobin, 80 percent; segments, 72; lymphs, 9; bands, 19. During the afternoon the blood pressure dropped steadily. He was unconscious and the lower limbs paralyzed. At 6 p. m. breathing was of the Cheyne-Stokes type, the pulse weaker and more rapid. Treatment given January 20, 1936: 9 a. m.—Epinephrine hydrochloride, 1-1000 solution, 1 cubic centimeter subcutaneously. Two ounces of magnesium sulphate by mouth. 9:30 a. m.—One gram of sodium thiosulphate intravenously. II a. m.—Epinephrine hydrochloride, 1-1000 solution, 1 cubic centimeter subcutaneously. Two ounces of magnesium sulphate by mouth. 11:30 a. m.—Twenty cubic centimeters of 50 percent glucose intravenously. 1 p. m.—Epinephrine hydrochloride, 1-1000 solution, 1 cubic centimeter subcutaneously. 2 p. m.—Epinephrine hydrochloride, 1-1000 solution, 0.5 cubic centimeter subcutaneously. 3 p. m.—Epinephrine hydrochloride, 1-1000 solution, 0.5 cubic centimeter subcutaneously. Fischer's solution, 125 cubic centimeters by proctoclysis, at the rate of 30 drops per minute. 4 p. m.—Epinephrine hydrochloride, 1-1000 solution, 1 cubic centimeter sub cutaneously. 150 PREVENTIVE MEDICINE 6 p. m.—Epinephrine hydrochloride, 1-1000 solution 1 cubic centimeter sub cutaneously. 8 p. m. —Twenty cubic centimeters of 50 percent glucose intravenously. Epine phrine hydrochloride, 1-1000 solution, 1 cubic centimeter subcutaneously. 9 p. m. —Fischer's solution, 125 cubic centimeters by proctoclysis, at the rate of 30 drops per minute. 9:30 p. m.—Epinephrine hydrochloride, 1-1000 solution, 1 cubic centimeter subcutaneously. 11:30 p. m. —Epinephrine hydrochloride, 1-1000 solution, 1 cubic centimeter subcutaneously. The patient died at 12:25 a. m., January 21, 1936, within 4 days after the last injection of neoarsphenamine. Autopsy findings: (1) Acute hemorrhagic encephalitis. (2) Acute congestion of all viscera. Tryparsamide. — (7(5— 1936.) This patient (supernumerary, retired, U. S. Navy) was given a diagnosis of syphilis because of clinical and serological findings. The patient stated he was probably infected in 1920. From March 25 to April 29, 1935, he received 12 injections of bismuth salicylate; from May 2 to July 2, 1935, 8 injections of neoarsphenamine, a total of 4.2 grams; and from July 16 to November 12, 1935, 16 injections of bismuth salicylate. He complained of vomiting when he was admitted to the sick list on December 20, 1935, stating that the vomiting occurs early in the morning and is followed by four or five retching spells. Physical examination essentially negative. The patient was kept under observation and treatment. He was given 1.5 grams of tryparsamide on December 27, 1935, and 3 grams on January 7. Six days after the last injection of tryparsamide the patient stated that he could not see and read well. Eye examination —Vision: O. D. 20/40—1, J 14; O. S. 20/50 +4, J 18. Ophthalmoscopic examination shows vitreous humor clear, except for round floating vitreous opacity in left eye, and disks paler than normal. Fields for form decreased concentrically 4/8. It is believed that the color of disk may be accounted for in part by the age of the patient and some loss of field by ametropia. January 27. Vision: O. D. 20/50-1, J 14; O. S. 20/70, J 16. Visions and fields continue to decrease. No change in fundus picture. February 11. Fields for form V. O. D. has increased approximately one-third over last report; V. O. S. approximately the same size. March 2. The vision about the same. The patient is up and about the ward. He can read newspaper captions but not the ordinary print. March 17. The fields for form V. O. D. has increasedly markedly over the last report, within 20° circle and V. O. S. increased with 30° circle. March 27. Vision: O. D. 20/50 + 4; O. S. 20/70—1. The fields are virtually stationary. It is considered that further diminution will probably not take place or that improvement will progress further. He has received 20 injections of bismuth salicylate, 2 grains each, between December 31, 1935, and April 21, 1936. The patient was transferred to the Naval Home, Philadelphia, Pa., 78 days after the onset of the first symptoms, with diagnosis "optic neuritis, from try parsamide, condition stationary." ANTITETANUS TOXOID By O. S. Siephknson, Commander, Medical Corps, United States Navy and W. W. Hall, Commander, Medical Corps, United States Navy Active immunity in man animal against tetanus can be developed by the injection of tetanus toxoid as demonstrated a few years ago by Ramon of the Pasteur Institute Ramon had developed diphtheria PREVENTIVE MEDICINE 151 toxoid and later the refined alum-precipitated diphtheria toxoid was developed, now so universally used in immunization of children against diphtheria. Evidence from both animal and human immunization with alum- precipitated tetanus toxoid (quite analogous to that of diphtheria) indicates that a satisfactory active immunity can be developed against tetanus by two injections 8 weeks apart. The immunity thus produced diminishes gradually but persists at a satisfactory protective level for at least 2 years and probably much longer. In handling wounded patients who have been previously immunized against tetanus by toxoid injections, it is now recommended that they be given a stimulating or "pick-up" injection of alum-precipitated tetanus toxoid in case there is any doubt about the immunity level. Immunized individuals even those with very low antitoxin titers, respond to a secondary immunization by a sharp rise to high levels within a week. This sharp rise on secondary stimulation means ample protection against possible tetanus at the time, and a higher level of immunity for the future. Possibly, lifetime immunity may result after two or more "pick-up" shots. Work which supports the above has been published by Ramon (France), Sneath and Kerslake (Canada), Bergey and Etris (United States), Hall (U. S. Navy), and more recently Leach, Zia, and Lim (China). Tetanus toxoid is thermostable —not deteriorating when exposed to heat, as for example with expeditionary forces. Tetanus toxoid is serum free, not producing reactions, anaphylaxis, or serum sickness. As there is no simple means of estimating immunity against tetanus such as the Schick test in diphtheria, patients must be bled and the serum titrated for antitoxic strength by the protection it affords test animals against known amounts of tetanus toxin. Because of these difficulties, the data from work with man is accumulating slowly, though much animal experimental data are available. Mass-immunization and data on tetanus incidence in the protected group, compared with unprotected groups, will be convincing. Such work is now in progress in the United States. In France this method of immunization against tetanus has, by recent legislation, been made mandatory in the Army for men and animals. Accurate data ob tainable only by animal titration of serum antitoxin are needed and can only be accumulated by the efforts of many laboratories. The Medical Department, United States Naval Academy, and the Naval Medical School are now cooperating in the study of a group of 137 volunteers, including the football squad at the Academy who were immunized early this year by two injections of alum-precipitated tetanus toxoid. 152 PREVENTIVE MEDICINE FOOD POISONING ON BOARD THE IT. S. S. "NEVADA" The outbreak occurred among the enlisted personnel on June 26, 1937, and involved 131 men. All men reporting and those found sick about the ship were treated, admitted to the sick list, and put to bed in the ward and adjoining compartments assigned for the purpose. From those affected it was found that the first symptoms, consisting of nausea and mild abdominal cramps, began approximately 2 hours after eating the noon meal. The symptoms gradually became more severe, until at the end of 3 hours most of the men began vomiting and complained of severe abdominal cramps. Four of the men were unconscious when brought to the sick bay and one of these four had not vomited, 7 hours after eating. His entire body was rigid and at intervals respiration would cease for an alarming period of time. His pupillary reflexes were present and the pulse was of normal rate, full and regular. Following the induction of emesis he responded to the routine treatment. Hysteria was considered a factor in this case. All of the first vomitus consisted of ham and other articles of food from the noon meal. In some cases after the food had been ejected, retching would continue and some bloody material was vomited. The usual symptomatic treatment was instituted and response in all cases was satisfactory. On June 28, the second day after the outbreak, all patients were examined and it was necessary to retain only one man on the sick list. He was discharged to duty the following day. The following menu was served for noon meal on June 26. Opposite each item on the menu is indicated the number of men eating that article of food, who became ill: Bean soup 46 Turnips 17 Boiled ham .. 131 Potatoes. 71 Boiled cabbage 59 Pickles 70 Carrots and peas 52 Bread, butter, and coffee 99 It will be observed that 131 men became ill, all of whom ate ham. Ten of these men ate only ham sandwiches and did not partake of anything else served. All messes except the chief petty officers' were involved, from 1 to 15 men per mess becoming ill. A total of 636 men were on board for the noon meal, 505 of whom suffered no ill effects. The men who did not become ill partook of the foods on the menu to the same extent as those who did become ill. This is indicated by the following summary: Bean soup 180 Turnips 150 Boiled ham 476 Potatoes 399 Boiled cabbage 256 Pickles 452 Carrots and peas 238 Bread, butter, and coffee 476 Forty-two hams were boiled Thursday afternoon, June 24, and cold water poured over them to cool them off. One hour later the water was drained off and the hams left until 4 a. m., June 25, at which PREVENTIVE MEDICINE 153 time they were removed to steep tubs. Between 10 and 11 a. m. they were skinned and boned and four of the hams given to the chief petty officers' cook. The tubs of hams were left on the galley deck until field-day was completed. At 4:30 p. m. the hams were put in a cool oven where they remained until about 11 a. m. the next day, at which time they were removed, sliced, and issued to the various mess cooks for the noon meal. From the foregoing it is obvious that the ham was responsible for the outbreak. The ship's cook who boned the hams was found upon examination to be a carrier of the organisms of food poisoning group (staphylococcus albus-poisoning strain). Bacteriological examination of specimens obtained from cooked hams from the same lot served for the meal in question showed no contamination by organisms of the food-poisoning group. The opinion of a board appointed to investigate this outbreak was: "That during the process of skinning and boning on June 25, 1937, the hams which had been cooked on June 24, 1937 became con taminated." 24140—37 11 STATISTICS HEALTH OF THE NAVY The following tables are summaries of morbidity rates per 1,000 for the second quarter of 1937 in comparison with rates for the corresponding quarter of the preceding 5 years: Entire Navy Year diseases ah Injuries Poison ings All causes Communicable diseases Venereal diseases A B 470 51 0.33 521 (') (') 141 1933 407 62 1.51 470 18 76 100 1S34 385 67 .45 452 35 116 64 371 66 1.88 438 28 85 62 1936 337 49 .07 386 30 140 42 1937 276 36 .31 313 18 98 59 FOBCES ASHORE 1932. 1933. 1634. 1935.. 1936. 542 44 0. 31 586 (') (') 92 480 - 78 .91 565 23 96 79 621 87 1.15 709 76 230 58 491 78 1.53 571 54 110 45 518 50 .09 568 59 226 26 312 36 .50 347 34 131 27 FORCES AFLOAT 431 64 0.34 486 (') (0 369 54 1.80 424 16 64 271 57 . 11 328 15 62 312 58 2.06 372 16 72 229 49 .05 278 13 89 256 37 .20 293 8 78 1932. 1933 1934. 1815 1936 168 111 (57 71 51 78 ' Not available. Common infectiom diseases of the respiratory type. —A total of 2,617 admissions for these diseases were reported from the entire Navy during the second quarter of the year 1937, or a 68-percent decrease from the number of cases notified for the preceding quarter. Ca tarrhal fever was responsible for 1,645 of the total admissions for these diseases. Ships and shore stations reporting the largest number of cases were as follows: April May June Total Naval Training Station, Newport, R. I - Naval Training Station, San Diego, Calif Naval Training Station. Norfolk Va -- - Marine Corps Ban, San Diego, Calif - U. S. 8. Oklahoma Naval Training Station, Great Lakes, Hi Naval Academy, Annapolis, Md. (other than midshipmen; Fourth Marines, Shanghai, China Naval Air Station, Pensacola. Fla Naval Air Station. Norfolk, Va Marine Barracks, Quantico, Va 0. S. S. TtKMUtt Marine Detachment, Peiping, China U. S. S. Lexington --- 105 S3 57 21 12 11 13 8 IT, Ill 10 12 240 194 79 ,i3 48 47 46 45 42 z; 35 35 35 155 156 STATISTICS Of the 2,617 admissions for the entire Navy, 1,401 admissions were reported by forces ashore and 1,216 for forces afloat. Influenza was the cause of two deaths, complicated in one instance by pneumonia, broncho (U. S. Naval Hospital, Chelsea, Mass.), and in the other by meningitis, cerebrospinal, acute (U. S. S. Tennes see). Tonsillitis, acute, was recorded as the primary cause of one death, the contributory cause being abscess, lung. Several rather severe cases of gastrointestinal influenza occurred during the month of June at the Navy Yard, Charleston, S. C. The medical officer of the United States Naval Training Station, San Diego, Calif., comments as follows in the sanitary report for June 1937: The health of the personnel during the month of June has been good. Al though the personnel has been increased approximately 20 percent over the previous 2 years the acute respiratory infections (bronchitis, acute) which required hospitalization has increased approximately 60 percent. This is attrib uted to the more severe type of respiratory infections over the previous 2 years and to the climatic conditions. Cerebrospinal fever. —Seven cases of cerebrospinal fever were re ported in April, May, and June 1937, as follows: Rate Age Place of original admis sion Date of admission Length of service Disposition Yrt.Moa. Seaman, first -class 21 24 24 26 20 20 21 U. S. S. Nerada Apr. 7, 1937 .... do 1 6 8 7 Duty, June 22, 1937. Duly, June 4, 1937. Dutv, July 17, 1937. Duty, June 28. 1937. Duty, July 20, 1937. Duty, Sept. 14. 1937. Duty, July 8, 1937. Seaman, first-class U. S. S. Chaumont May 13,1937 do 2 3 7 6 Seaman, first-class.. . U. S. S. Hanger Seaman, second-class... Seaman, first-class U. S. S. Trenton May 12,1937 June 14.1937 June 8,1937 0 6 2 7 U. P. S. Dobbin U. S. S. Pope 1 6 Mumps. —One hundred and sixty-six cases of mumps were reported for the quarter. The United States naval training station, Norfolk, Va., reported 28 cases in April, 34 in May, and 21 in June; the U. S. S. West Virgmia, 13 in May and 16 in June; the Marine detachment, Peiping, China, 16 in April and 1 in May; the Submarine Base, New- London, 11 ; the Marine Barracks, Quantico, Va., 6; the naval training station, San Diego, Calif., 3; the naval training station, Great Lakes, 1ll., naval air station, San Diego, Calif., naval air station, Seattle, Wash., and the fleet air base, Pearl Harbor, Territory of Hawaii, 2 each; and 1 each from 9 shore stations. The Sanitary Report for the month of April from the United States naval training station, Norfolk, Va., stated that "mumps, which has been highly prevalent in the population of Norfolk, increased and affected widely scattered units." German measles. —The Fourth Marines, Shanghai, China, reported eight cases of German measles in April and two in May; and the naval training station, San Diego, Calif., two in May. STATISTICS 157 Scarlet fever. —One case of scarlet fever was reported from the third naval district headquarters, New York, N. Y., in April, and one each from the Receiving Ship, San Diego, Calif., and the Marine detachment Peiping, China, in May. Chickenpox. —Ten cases of chickenpox were reported for the quarter as follows: In April, one each from the Marine Corps base, San Diego, Calif., Navy Yard, Mare Island, Calif., and the Marine detachment, Peiping, China; in May, one each from the Naval Research Labora tory, Anacostia, D. C, United States Naval Academy, Annapolis, Md. (other than midshipmen), Receiving Ship, New York, N. Y., naval training station, Great Lakes, 11l., naval training station, San Diego, Calif., and the U. S. S. Argonne; and in June, one from the Navy Yard, Washington, D. C. Typhoid fever. — A fireman, third-class, 23 years of age, with 8 months' service, was admitted on June 2, 1937, to the U. S. S. Ranger with diagnosis "Undetermined (typhoid fever)." The patient was transferred to the United States Naval Hospital, San Diego, Calif., on June 11, where the diagnosis of typhoid fever was established and he was discharged to duty on August 31, 1937. Probable place of infection was Honolulu, Territory of Hawaii. One course of typhoid prophylaxis had been completed November 2, 1936. Malaria. —The general health conditions of the Submarine Base, Coco Solo, Canal Zone, during the month of June 1937, were satis factory, except for malaria. The rainfall for this month has been exceeded in amount in only 1 year in the past 30. The Senior Medical Officer reports: Eleven cases of malaria were placed under treatment for the moiith of June, nine from this base and two from the U. S. S. Hannibal. During the correspond ing month in 1936 there were 2 cases from shore activities on this side of the Canal, but no cases from the U. S. S. Hannibal or U. S. S. Nokomis. There were no relapses during the month. It would appear that the outlook regarding ad missions for malaria during the coming months is bad. The station medical officer of the United States naval station, Olongapo, P. I., reports: Twelve cases of malaria treated at the Camilla Simpson Hospital during the month. Of these six can trace their infections to towns in the northern part of the Province, where they have been employed in mines and in lumber camps. Five of the cases apparently received their infections in the heavily wooded out lying barrios, which afford a harborage of mosquitoes close to the dwellings.. In one case the source of infection cannot be traced. Venereal diseases. —The medical bulletin of the Battle Force for the month of July 1937 announces: That the venereal rate in ships of the Battle Force is steadily declining. The annual rate per 1,000 for the calendar years 1934, 1935, and 1936 was 111, 92, and 58, respectively. For the first half of 1937 the rate shows a slight decrease 158 STATISTICS over that of 1936, and it is hoped that the second half of the year will show an even greater reduction. The following data for the first half of 1937 are submitted : (a) Annual rate per 1,000 for all venereal diseases for entire Battle Force for the period January 1 to June 30, 1937, inclusive, was 49 as compared with 58 for 1936. (b) Monthly average number of gonorrheal infections for the entire Battle Force during the first 6 months of 1937 was 100.6 as compared with 118.8 for 1936. (o) The highest total number of admissions for gonorrheal infections during any one month was 128. There were 2 months in which this high rate, occurred, namely, January and June. (d) Thirty-five admissions represented the lowest total for any one month; this was during the month of May 1937. The following table of statistical data for battleships and larger vessels of the Battle Force indicates the frequency of occurrence of venereal diseases during the second quarter of 1937, as reported in monthly reports of communicable diseases received in the Bureau: Ship Arizona California Cincinnati Colorado Concord Idaho Marhlchead . . . Maryland Memphis Milwaukee Mississippi Nevada. New Mexico... Oklahoma Omaha .* Pennsylvania.. Richmond Tennessee Trenton West Virginia. Annual ad* mission rate per 1.000,2d quarter, 1937 63. 18 .18.95 0 83.93 1I. 77 57.23 74.07 38.38 112.56 .'12.17 79.30 17.11 71.30 63.94 168.19 30.88 72.58 78.18 06.38 59.18 Annual ad mission rate per 1,000,2d quarter, 1936 43.58 84.42 78.77 61.67 38.91 91.21 112.31 53.79 291.73 51.17 54.69 43.16 56.48 76.85 92.82 41.33 60.34 60.05 101.75 58.97 Weighted average per 1,000, 2d quarter. 1933-36 84.55 105.15 71. 17 123.63 90.87 104.99 120.69 99.85 154.40 79.74 107.98 79.90 89.18 95.05 82.19 81.74 176.47 92. 15 135.73 88.76 Food poisoning.— In the monthly sanitary report for June 1937, the post surgeon of the Marine Barracks, Quantico, Va. reported: On June 28, seventy-seven men were brought to sick quarters from F. M. C. R. camp suffering from abdominal cramps, nausea, and diarrhea; many vomited. All returned to duty next morning save three, two of whom had three sick days and one of whom had four sick days. Staphylococci alba were cultured from stomach contents,, feces, and from minced ham used in sandwiches, cf which all had eaten about 12:30 p. m. on June 28. INJURIES AND POISONINGS Admissions for Second Qttartek Ending June 30, 1937 The following table, indicating the frequency of occurrence of accidental injuries and poisonings in the Navy during the second quar ter, 1937, is based upon all Form F cards covering admissions in those months which have reached the Bureau: STATISTICS 1.59 Admissions, April, May, and June, 1937 Admission rata per 100,000 per annum Admission rate per 100,000, INJURIE" year 1937 Connected with work or drill 520 398 257 1,010 1,232 796 2,513 1.924 1,760 Occurring within command bat not associated with work .. . Incurred on leave or liberty or while absent without leave 1, 175 3.R3S 6,197 Industrial poisoning POI"ONINGS 4 12 16 3 7 211 18 Occurring within command but not connected with work... Associated with leave, liberty, or absence without leave.. . . 5 1 10 31 236 Total injuries and poisonings 1,185 3,669 6,434 Percentage relationships Connected with the performance of work, drill, etc. Occurring within command Not connected with work or pre scribed duty Occurring out side command -leave, liberty, or A. W. O. L April, May, and June 1937 Year 1931! April, May and June 1937 Year 1936 April.May. and June 1937 Year 1936 Percent of all injuries 44.2 40.0 40.6 33.9 50.0 31.0 89.5 21.9 10.0 28.4 7.5 Percent of all poisonings Percent of total admissions, injury and poisoning titles 3.0 44.2 39.2 34.0 33.2 21.8 27.6 Notm. —Poisoning by a narcotic drug or by ethyl alcohol is recorded under the title "Drug addiction" or "Alcoholism," as the case may be. Such cases are not included in the above figures. Three members of service personnel 'sustained injuries when the German airship Hindenburg burned at the naval air station, Lake- hurst, N. J., on May 6, 1937. MORBIDITY Summary for the Second Quarter Ending June 30, 1937. Forces afloat, 81,417 Forces ashore, 47,781 Entire navy, 129,198 Admis Rate per Admis Rate per Admis Kate per sions 1,000 sions 1,000 sions 1,000 All causes 5,967 293. 1G 4,140 346.58 10.107 312.92 5.201 255.62 3,721 311.50 8.922 276.23 Injuries 762 37.44 413 34.57 1, 175 Wi.38 Communicable diseases transmissible by 4 .20 6 .50 10 .31 oral and nasal discharges (class VI11): (A) 166 8.16 404 33.82 570 17.65 (B) 1,590 78.41 1,560 130.60 3,156 97.71 1,584 77.82 317 26.54 1,901 58.86 160 STATISTICS DEATHS During the Second Quarter Ending Junb 30, 1937 Cause Navy Marine Corps Nurse Corps Total Primary Secondary or contributory Offi cers Mid ship- men Men Offl- cers Men DISEASE 9.670 1,994 99.080 1,304 16,754 396 129,198 1 Aerogcnous capsulattis In fection, thigh. 1 1 2 1 do 1 1 1 Carcinoma, liver . ... .do Endocarditis, acute ulcera tive (malignant). Arthritis, acute, wrist and phalangeal. 1 Oonococcus infection, ure thra. Endocarditis, acute ul cerative (malignant). 1 1 Hyperthyroidism. 1 1 2 1 Do Meningitis, cerebrospi nal, acute. 1 i Otitis, media, acute Meningitis, cerebrospi nal, acute. I Nephritis, chronic . 1 Do.. 1 Pancreatitis, acute, hemor rhagic. .. .do 5 1 1 1 1 1 1 1 1 2 Do Do Do . 1 Sarcoma, pubis and ischium. Thrombosis, cavernous sinus. Do do Otitis, media, acute Do Tonsillitis, chronic 1 Thrombosis, coronary artery. None 2 3 Myocarditis, chronic 1 1 1 Tuberculosis, pulmonary, chronic, active. Tuberculosis, peritone um. Do Hemorrhage, duodenum Hemorrhage, intestines.. Peritonitis, general, acute. 1 1 1 Do Do 1 Valvular heart disease, com bined lesions, aortic and mitral. 1 INJURIES AND POISONISOS 7 1 34 2 6 1 51 Crush, chest... 1 1 1 .. ..do 1 . ..do 4 11 2 1 15 3 1 Fracture, compound, sttull. do 1 Do Meningitis, ccrebrospl- nal, acute. Fracture, compound, tem poral. 1 1 Fracture, simple, temporal.. iremorrhage, traumatic, 1 1 intracranial. Edema, lung Do Intracranial injury. - 1 2 1 1 2 I Do Rupture, traumatic, lung. STATISTICS 161 Deaths During the Second Quarter Ending June 30, 1937 — Continued Cause Navy Marine Corps Nurse Corps Total Primary Secondary or contributory Offi cers men Mld- ship- Men Offi cers Men INJURIES AND POISONINgS— continued Fracture, simple, vertebrae, 1 cervical. Injuries, multiple, extreme do 1 1 1 4 1 1 3 Strangulation, neck Do Wound, gunshot, abdomen.. 1 1 1 Wound, gunshot, chest do 1 Wound, gunshot, head do 1 1 1 3 1 2 do Poisoning acute, carbon Totaljor Iniuries and Grand total do 2 10 31 1 8 50 Annual death rate per 1.000: 17 1 65 3 14 1 101 7.03 2.90 1.8S 2.01 2.01 2.62 1.37 .44 .08 .73 9.20 6. 13 3.34 1.43 10.10 10.10 3.13 1.58 .46 .06 2.48 3.07 1.91 1.02 MENTAL AND PHYSICAL QUALIFICATION OF RECRUITS Statistics for Second Quarter Ending June 30, 1937 The following statistics were taken from sanitary reports submitted by naval training stations: April, May, and June, 1937 Recruits received during the period Recruits appearing before Board of Medical Survey Recruits recommended for discharge from the service... Recruits discharged by reason of medical survey Recruits held over pending further observation Recruits transferred to the hospital for treatment, oper ation, or further observation for conditions existing prior to enlistment United States naval training station— Norfolk, Vs. Newport, R. I. Great Lakes, Hi. San Diego, Calif. 1,421 754 810 1,471 1 0 9 0 1 0 9 0 3 0 0 0 0 0 0 0 0 18 84 74 The following table was prepared from reports of medical surveys in which disabilities or disease causing the surveys were noted existing prior to enlistment. With certain diseases, survey followed enlist ment so rapidly that it would seem that many might have been eliminated in the recruiting office. 162 STATISTICS Cause of survey Absence, acquired, teeth. Acne, vulgaris.. Amblyopia, both eyes Arterial hypertension • Arthritis, chronic. - . Asthma - Astigmatism Cardiac disorder, functional Caries, teeth Chorea, progressive, chronic Color blindness Congenital heart disease Constitutional psychopathic Inferior ity, without psychosis Constitutional psychopathic state, emotional instability Curvature, spine Deafness, bilateral Deafness, unilateral Deformity, acquired, left leg Dementia praecox. Ellort syndrome Enuresis - - -- Epilepsy Flat foot Oastroptosis Oonococcus Infection, epididymis Oonococcus infection, urethra Hernia, inguinal Hernia, inguinal, recurrent after opera tion Hydrocele, spermatic cord Malformation, congenital, cervical rib. Number of Cause of survey Malformation, congenital .left kidney. . . Malocclusion, teeth Montal deficiency, moron Meta tarsalgia Migraine Myopia Myositis, chronic Nephroptosis - Narcolepsy Otitis, media, chronic... Pes cavils - Prostatitis, chronic (nonveuereal) Psychoneurnsis, hysteria Fsychoneurosis, neurasthenia Psychoneurosis, psychasthenia Pyelitis, chronic, left Somnambulism Sprain, sacroiliac Joint Stammering Strabismus Syphilis Tic Union of fracture, faulty Urethritis, chronic (nonvenereal) Valvular heart disease, combined lesions, aortic and mitral Valvular heart disease, mitral insuf ficiency Valvular heart disease, mitral stenosis.. Varicocele -- Vincent's infection, oral Wart Number of 11 o Volume XXXVI APRIL 1938 Number 2 United States.. Naval ip. Medical Bulletin Published for the Information of the Medical Department of the Navy THE MISSION OF THE MEDICAL CORPS OF THE NAVY • TO KEEP AS MANY MEN AT AS MANY GUNS AS MANY DAYS AS POSSIBLE Issued Quarterly by the Bureau of Medicine and Surgery Washington, D. C. Vol. XXXVI APRIL 1938 No. 2 UNITED STATES NAVAL • MEDICAL BULLETIN Published Quarterly for the Information of the Medical Department of the Navy t Issued by DIVISION OF PUBLICATIONS THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT Compiled and published under the authority of Naval Appropriation Act for 1937-38, approved April 27, 1937 * UNITED STATES GOVERNMENT PRINTING OFFICE WASHINGTON : 1938 For sale by the Superintendent of Documents, Washington, D. C. See page n for price Navy Department, Washington, March 20, 1907. This United States Naval Medical Bulletin is published by direction of the Department for the timely information of the Medi cal and Hospital Corps of the Navy. Truman H. Newberry, Acting Secretary. Owing to exhaustion of certain numbers of the Bulletin and the frequent demands from libraries, etc., for copies to complete their files, the return of any of the following issues will be greatly appreciated: Volume IX, 1915, No. 1. Volume X, 1916, No. 2. Volume XI, 1917, No. 3. Volume XII, 1918, Nos. 1 and 3. Volume XXIV, 1926, Nos. 1 and 4. Volume XXV, 1927, No. 1. Volume XXVII, 1929, Nos. 3 and 4. Volume XXVIII, 1930, No. 3. Volume XXXIV, 1936, Nos. 1, 2, and 4. Volume XXXV, 1937, No. 1. Subscription Price op the Bulletin Subscription should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. Yearly subscription, beginning July 1, $1; for foreign subscriptions add 35 cents for postage. Single numbers, domestic, 25 cents; foreign, 35 cents, which includes foreign postage. Exchange of publications will be extended to medical scientific organizations, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy, Washington, D. C. ir TABLE OF CONTENTS Page PREFACE v NOTICE TO SERVICE CONTRIBUTORS vi SPECIAL ARTICLES: Logistics: Interrelation of the Medical Service Aboard Ship and Tactics. By Rear Admiral Perceval S. Rossiter, Surgeon General, United States Navy 163 Medical Supply Procurement in the Navy. By W. H. Michael, commander, Medical Corps, United States Navy 168 Medical Department Function in a Naval Engagement. By C. J. Holeman, captain, Medical Corps, United States Navy.. 179 Fleet Medicine. By George F. Cottle, captain, Medical Corps, United States Navy. 193 Hospital Ships. By Lucius W. Johnson, captain, Medical Corps, United States Navy 197 The Making op a Bluejacket. By Griffith E. Thomas, captain, Medical Corps, United States Navy 233 Compressed-air Illness. By Charles W. Shilling, lieutenant, Medical Corps, United States Navy 235 NAVAL RESERVE 261 NOTES AND COMMENTS: The Thirteenth Surgeon General, United States Navy—International Congress on Military Medicine and Pharmacy —Classified matter — New members American College of Surgeons —Hospitalization of dependents 263 BOOK NOTICES: Clinical Allergy, Tuft —Introduction to Dermatology, Sutton and Sutton —Approved Laboratory Technic, Kolmer and Boerner — Diseases of the Blood and Atlas of Hematology, Kracke and Garver — Atlas of Hematology, Osgood and Ashworth —The Cerebrospinal Fluid, Merritt and Fremont-Smith —Clinical Urinalysis and Its Interpretation, Kilduffe—Embryology, Jordan and Kindred—Dis eases of the Nose and Throat,Thomson and Negus—Practical Meth ods in the Diagnosis and Treatment of Venereal Diseases, Lees and Lees—The Treatment of Gonorrhea and Its Complications in Men and Women, Robinson 271 ill IV TABLE OF CONTENTS PREVENTIVE MEDICINE: United States Navy Submarine Service. By W. C. Harrison, New York Life Insurance Co., New York, Paga N. Y 277 Observations on Staphylococcus Food Poisoning. By E. M. Wade, lieutenant, Medical Corps, United States Navy.. 306 Food Poisoning, United States Naval Station, Guantanamo Bay, Cuba. By W. D. Small, commander, Medical Corps, United States Navy 316 STATISTICS: Health of the Navy.. 319 Injuries and Poisonings - 322 Morbidity 322 Deaths 323 Mental and Physical Qualification of Recruits 324 PREFACE The United States Naval Medical Bulletin was first issued in April 1907 as a means for supplying medical officers of the United States Navy with information regarding the advances which are continually being made in the medical sciences, and as a medium for the publication of accounts of special researches, observations, or experiences of individual medical officers. It is the aim of the Bureau of Medicine and Surgery to furnish in each issue special articles relating to naval medicine, descriptions of suggested devices, clinical notes on interesting cases, editorial com ment on current medical literature of special professional interest to the naval medical officer, and reports from various sources, notes, and comments on topics of medical interest. The Bureau extends an invitation to all medical and dental officers to prepare and forward, with a view to publication, contributions on subjects of interest to naval medical officers. In order that each service contributor may receive due credit for his efforts in preparing matter for the Bulletin of distinct origi nality and special merit, the Surgeon General of the Navy will send a letter of appreciation to authors of papers of outstanding merit. The Bureau does not necessarily undertake to endorse views or opinions which may be expressed in the pages of this publication. P. S. Kossiter, Surgeon General, United States Navy. 7 NOTICE TO SERVICE CONTRIBUTORS Contributions to the Bulletin should be typewritten, double spaced, on plain paper, and should have wide margins. Fasteners which will not tear the paper when removed should be used. Nothing should be written in the manuscript which is not intended for publication. For example, addresses, dates, etc., not a part of the article, require deletion by the editor. The Bulletin endeavors to follow a uniform style in heading and captions, and the editor can be spared much time and trouble, and unnecessary changes in manuscript can be obviated if authors will follow in these particulars the practice of recent issues. The greatest accuracy and fullness should be employed in all citations, as it has sometimes been necessary to decline articles otherwise desirable because it was impossible for the editor to understand or verify references, quotations, etc. The frequency of gross errors in orthography in many contributions is conclusive evidence that authors often fail to read over their manuscripts after they have been typewritten. Contributions must be received at least 3 months prior to the date of the issue for which they are intended. The editor is not responsible for the safe return of manuscripts and pictures. All materials supplied for illustrations, if not original, should be accompanied by reference to the source and a statement as to whether or not reproduction has been authorized. The Bulletin intends to print only original articles, translations, in whole or in part, reviews, and reports and notices of Government or departmental activities, official announcements, etc. All original contributions are accepted on the assump tion that they have not appeared previously and are not to be reprinted elsewhere without an understanding to thai effect and that editorial privilege is granted to this Bureau in preparing all material submitted for publication. Eben E. Smith, Editor, Commander, Medical Corps, United States Navy. VI "I— 2 DEPOSlTED BY THE UNITED STA icS OF AMERICA APR t 8 1938 U. S. NAVAL MEDICAL BULLETIN Vol. XXXVI April 1938 No. 2 SPECIAL ARTICLES LOGISTICS INTERRELATION OF THE MEDICAL SERVICE ABOARD SHIP AND TACTICS i By Rear Admiral Perceval 8. Rossiter, Surgeon General, United States Navy There can be no logistics if we do not have trained personnel to develop them. A perfect system of logistics for mobilization of personnel and material and for our casualty evacuation is impotent without professionally competent personnel to apply them. Hence, in developing its logistic policy the Medical Department of the Navy places primary emphasis and dependence upon officers skilled in their profession. Applicants for commission are carefully chosen. Members of the corps after indoctrination, primarily as naval medical officers, are encouraged to advance themselves professionally in their chosen medical specialties. This is necessary because we must man ships and dispensaries and hospitals continually and we endeavor to do a high class of work. However, great as is the contribution of our Navy to national life in peace time, we must never lose sight of its primary objective to successfully execute national policy in case of war. When a national emergency develops, our armed forces serve as a nucleus around which a much larger number of reserves and civilians may crystallize. It, therefore, behooves the regular service officer, particularly in the latter half of his career, to obtain a well-grounded experience in military medicine. He must be prepared, should war come, to surrender his purely professional detail to a readily available, equally competent specialist of the reserve and assume duties requiring long, well-grounded military experience. Since the World War the Navy has developed a well-organized reserve. This reserve includes medical officers, some of considerable service experience, who would be immediately available in case of a national emergency. Organization of these reserves by naval dis tricts facilitates a peace-time training program and simplifies mobili zation. Many of these officers have had active duty training with regular and reserve forces. Our service anticipates no difficulty in obtaining sufficient medical officers during a national emergency. • Address by Rear Admiral Percevil S. Rossiter, Surgeon General, U. S. Navy, delivered October 4, 1937at The Ninth Annual Medico-Military Symposium, held In Rochester, Minnesota. 163 164 ROSSITER—LOGISTICS No system of logistics can succeed which ignores the simple but fundamental problem of trained personnel. Another essential factor is morale. In a Naval engagement, particularly, it is a reasonable assumption that vessels of the defeated fleet will suffer most severely and it is well recognized that morale will be an important, possibly crucial, factor in determining the victor. Morale is an intangible sentiment that requires a careful and long build-up. It is the fruit of a leadership that inspires con fidence, trust and enthusiasm in a crew. The psychology of a crew is difficult to analyze or predict. The men live in close contact, information is contagious and they have a surprisingly accurate estimate of the military situation and of their superior officers. Few officers aboard ship can contribute more to the upbuilding of morale than a medical officer who has the trust and good will of the men. High morale makes a combat unit more effective and, when such a unit suffers damage, tends to minimize casualties by more prompt and efficient action. Morale is one of the important intangible and unpredictable variables in our logistic equation. Incidentally, one of the modern effects of war is to make the morale of our civilian population of increasing importance. Recent developments would indicate that in future wars enemy objectives will include attacks on civil populations in an effort to break down morale. Offense and defense are so delicately balanced with the odds sufficiently in favor of defensive forces that war is becoming a matter of attrition of a nation's entire resources rather than defeat of its armed forces. Military science is a progressive dynamic force. It presents an ever-changing picture of eventualities in which obsolescence of equip ment appears conspicuously. If reports from the Spanish front are to be credited, an antitank projectile has been developed which pene trates the tank and explodes with disintegrating effect on tank and crew. Should a high explosive shell penetrate a turret or magazine the effect would be comparable. Logistics are of slight utility in such eventualities. The fleet that gains air control can anticipate comparatively few casualties from gas of men exposed in the superstructure. The opposing fleet will be less fortunate. Light unarmored forces like destroyers, submarines, and cruisers are likely to be either sunk or escape with little damage. Heavy and unpredictable casualties may be anticipated in our air force. Here, too, probably few casualties will require treatment or evacuation. Comparatively speaking, a badly damaged battleship will not present a worse casualty list than that of a regiment after a hard drive. The enemy's objective is to put it out of action. He will very probably be too busily engaged to expend the additional effort neces sary to sink it. This will tend to minimize the number of casualties on ROSSITER—LOGISTICS 165 the one hand and to increase the number of survivors on the other. The battleship is still the backbone of the Navy. If this were not so nations would encourage each other to build bigger and more costly dreadnaughts, instead of laying special stress on their limitations. When two fleets meet for decisive action this type of vessel must absorb much punishment. They are built to take it. However, a fair percentage of the crew must man battle stations in the super structure, that is, above the armored deck. Casualties in this force will be unavoidably high. Should the ship survive the engagement those injured will present a problem. The medical organization is aware of this possibility and is disposed and drilled to handle the emergency, each battleship acting as an independent self-sufficient unit. Prompt evacuation of such casualties would be ideal. Unfor tunately, the action is too likely to occur far from a protected base, the train which includes our hospital ships is too likely to be at a dis tant point or destroyed, for us to base our plans on the premise that these casualties can be promptly evacuated. Therefore, each vessel must be prepared to care for its own casualties and hope subsequently for assistance from more fortunate vessels in the vicinity. The function of a front line fighting unit is intimately connected with, and dependent upon, its source of supply. It is not practical to consider these two items separately. The Bureau of Medicine and surgery is organized with the objective of solving the medical problems and supplying the medical needs of the fleet. To this end it maintains divisions for war plans, personnel, and supplies. The Planning Divi sion is advised of characteristics of ship types projected by the general board and makes recommendations and takes necessary measures to coordinate Medical Department policy with anticipated Navy needs. This division also coordinates Medical Department war plans with those of the Office of the Chief of Naval Operations. Naturally this involves solution of many intricate, detailed, and confidential problems affecting both personnel and materiel. This work is never ending, due to continuing development of the plans. In general, it may be stated that the whole problem of procurement of supplies and equipment is on a far better footing than that which obtained during the last war. It is primarily in this division that our logistics are developed. The details are too involved to permit discussion in the brief time I have. Most of these details would prove an uninteresting recital of factual material were I at liberty to discuss them. Furthermore, should I give a detailed report now, my account would soon be inaccurate due to a high obsolescence factor. The Navy maintains a close liaison with the Army in our procure ment program. This includes assignment of naval medical officers as students at the Army Industrial School. 166 ROSSITEK—LOGISTICS We maintain medical supply depots at Brooklyn, San Francisco, and at Cavite in the Philippines. These bases keep a substantial supply of consumable and nonconsumable supplies. The former we speak of as supplies, the latter equipment. These depots are manned by personnel experienced in procurement and testing of material for quality. This organization can be readily expanded to meet the needs of our fleet. With few exceptions, our needs in an emergency will be as at present, except for quantity. In fact, the tendency will be to simplify stock to permit carrying of larger quantities of essentials. The objective of this entire organization is to promote the fitness of the fleet for action. There is a close coordination between the Bureau of Medicine and Surgery and other shore activities and the fleet. This is effected through the fleet surgeons and reports from the fleet medical officers. The Bureau receives a large volume of reports from forces ashore and afloat which is correlated by the Bureau and permits an accurate ap preciation of fleet conditions and serves as a basis for estimating future needs. There is a medical officer on the staff of the commander in chief of each fleet. He is in a strategic position where he can anticipate fleet movements and consequently estimate Medical Department needs. Through reports and personal contact he has intimate knowledge of the medical activities in the fleet. He maintains liaison with the Bureau and with military and civilian medical activities ashore. After action he is in a position to make sound plans and recommendations as to procurement and disposition of personnel and supplies and mo bilization of relief forces and disposition of casualties. In addition to information from the fleet surgeons, the Bureau receives reports from all medical officers afloat. These officers submit many practical suggestions of great value in formulating Medical Department logistics. Obviously, Medical Department logistics must be predicated on the type of campaign anticipated. The brief time at my disposal and the nature of the subject require that I limit my comments to a general discussion. Therefore, we will consider our logistics from the stand point of a first-line vessel. To man this vessel will require, as a maxi mum, an increase of about one medical officer and six enlisted men. The Bureau maintains a liberal policy toward the fleet in the alloca tion of supplies and the variety is such that few, if any, new items should be necessary. It is the present policy of the Bureau to main tain aboard each ship a stock of all items which will never fall below the requirements for 6 months under normal conditions and in addition a reserve of the supplies necessary for operation of battle dressing sta tions and for first aid at the various battle stations. To outfit the ships for war service it will only be necessary to augment the stock on ROSSITER—LOGISTICS 167 hand sufficiently to provide for the increased rate of usage which will result from war conditions. Provision has been made whereby this augmentation may be accomplished expeditiously for mobilization. Equipment in addition to that normally aboard should not be neces sary. The war stock is based on the presumption that while the vessel may be required to subsist for months on medical stores aboard, it will, prior to resupplying, experience only one major engagement. There fore, provisioning a ship for action with medical supplies presents no serious problem, particularly in view of the fact that our hospital ships will accompany the train of the fleet and serve as a source of supply. Preparation for action will include intensive training of the crew in first-aid measures. During action the duty of all hands is to promote the offensive and defensive power of the ship and as many effectives as possible, or necessary, must be kept at their battle stations. The Medical Department is equipped and deployed to promote this objec tive. After action casualties will be collected at the most accessible dressing station. We make only a generalizing attempt to predict the number or nature of the casualties. The important issue is to provide each ship with competent medical officers and ample supplies. That we can do and have the confidence that whatever happens the Medical Department will render the best service that conditions permit. Evacuation will depend on directions from the higher command on consultation with the fleet surgeon. The Medical Department of a vessel may be required to accompany a landing force. The fleet is prepared to put armed forces ashore. When Long Beach was paralyzed by an earthquake in March 1933, the fleet had a patrol force of more than 1,000 armed men ashore in less than an hour. The organization of this force is very similar to that of the Army. Each first-line vessel furnishes a battalion accompanied by a medical officer, hospital corpsmen, and stretcher bearers. Equip ment consists of medical and surgical supplies packed in cases and first-aid pouches provided and reserved for this particular use. Should a large force be involved, the hospital ships will carry supplies and equipment, including tentage, to set up field hospitals ashore. Our planning division has devoted much effort to developing landing force equipment which was recently reviewed by a board to effect improve ment and modernization. Duty with marines has proven an excellent field test for this equipment, and excellent training for our medical personnel. Many of our medical officers have served with marines and some I regard as experts on field service. On service of this type also we must be opportunists. Few con tingencies, or the means of meeting them, can be anticipated with exactitude. For instance, the Managua earthquake was a tragic affair in which one of our experienced medical officers was killed. i 168 MICHAEL—MEDICAL SUPPLY PROCUREMENT IN NAVY This emergency was met by flying medical personnel and supplies to Managua from one of our large aircraft carriers which fortunately was not far off the coast at that time. This emergency assistance was later augmented by reenforcements from the hospital ship. You have probably noted that I have quoted few figures. There are some that I dare not quote; there are others that I frankly do not know. In either case they will probably soon be obsolete. My real concern is with policy, personnel, and practice. If I can keep the Medical Corps soundly grounded in these I have confidence that our logistics will be effective. MEDICAL SUPPLY PROCUREMENT IN THE NAVY By Commander W. H. Michael, Medical Corps, United States Navy Naval medical procurement began for the then un-United States when, in 1776, Massachusetts built 10 sloops of war and provided a surgeon for each. The captain at first picked his surgeon, and the surgeon procured his medical and surgical "case." The literature contains many curious descriptions of the drugs and the formidable array of instruments, tools would be a more exact word, that the sur geon's case should contain. What it actually did contain was left to the surgeon and the captain. In sailing-ship days if the sailmaker needed canvas for a sail, or the ship's surgeon peruvian bark, each would tell the "old man." The purser had charge of the ship's moneys. Accordingly, if the "old man" approved, he would authorize the sailmaker and the surgeon to see that the purser bought for them what they wanted. Today the Navy buys few sails and no peruvian bark. The purser's title has been changed to supply officer. In routine cases the "old man" usually delegates some of his authority to his executive officer. "Plus ga change, plus e'est la mime chose." The centralized procure ment for the ship remains the same. And because the wants of the Navy are presented as ship's wants, the centralized procurement for the ship has been extended to centralized procurement of the Navy. This centralized procurement is largely achieved by the Purchase Division of the Bureau of Supplies and Accounts. The head of that Division put it essentially this way: "The Bureau of Supplies and Accounts is a service organization: to coordinate the needs of the Navy; to unwind the required 'red tape' in procurement contracts to the satisfaction of Navy regulations and the Comptroller General; to fore cast from our accumulated data where and how wants can be satisfied ; and to make purchases to the best advantage through our many pur chasing officers. We make no pretense of having the necessary technical knowledge. We get that from the requiring bureaus by turning over bids to them, or in simpler cases, talking over the case by telephone." MICHAEL —MEDICAL SUPPLY PROCUREMENT IN NAVY 169 The Purchase Division of the Bureau of Supplies and Accounts is divided into the following subdivisions: 1. Schedule section, which receives requisitions and, if they cannot be satisfied by transfer from existing Government stocks, determines where purchase is to be made. Schedules are prepared if standard specifications do not exist. These schedules are sent out to listed bidders by the mailing subsection. If standard specifications and contracts exist for the item, the requisition is handled by the specifica tion subsection. 2. Award section, which opens bids and places contracts, or consults with a technical bureau and is guided by the recommendation of that bureau in placing awards when the lowest bidder is offering an alter nate item or an item not meeting the required specifications. 3. Contract section, whose function is evident. 4. Adjustment section, whose function is best portrayed by its unofficial name "Grief section." Being centralized and experienced in the various difficulties arising between contractors and bureaus, usually through misinterpretation of specifications, this section is especially qualified to adjust differences. Central Control of Procurement Central control of procurement for the Medical Department of the Navy is the function of the Finance Division of the Bureau of Medicine and Surgery. This office operates under the direct supervision of the Assistant Chief of the Bureau, assisted by chief pharmacists and phar macists. These officers have invariably been trained by long experi ence in the Medical Department and most have had special instruction in purchasing and accounting. Many in the naval hospitals and all holding important positions in the Finance Division of the Bureau of Medicine and Surgery hold diplomas in their specialty of accounting and commercial law. This division has the following sections. 1 . Administrative, including preparation of Bureau annual estimate of expenditures. 2. Procurement, which reviews and recommends action on all medical requisitions, except emergency requisitions. 3. Auditing, which controls the accuracy and form of all medical expenditures. 4. Bookkeeping, which has its obvious function. Annual Estimate of Expenditures The Constitution of the United States empowers the Congress to appropriate the general funds of the Treasury for public expense. This power is coupled with a corresponding duty, namely, to provide the general funds. This situation gives birth to the two-sided device commonly known as the "Budget." The Bureau of the Budget, a 170 MICHAEL—MEDICAL, SUPPLY PROCUREMENT IN NAVY division of the Treasury Department, was created by an act of Con gress in 1921. This office, under the direction of the President, is charged with the duty of assembling, arranging, and presenting the National Budget to the Congress. This act also required the head of each governmental department and establishment to designate a "budget officer" to assemble, arrange, and present that activity's estimates to the Bureau of the Budget. The Chief of the Bureau of Medicine and Surgery is charged with the preparation of an annual estimate of expenditure for funds needed to carry out the duties of the Bureau for the following fiscal year. The preliminary estimate of expenditure by the Bureau of Medicine and Surgery for probable requirements for a fiscal year is based upon past experiences, Navy policy, operating force plan, and the advance year estimates of expenditures which the Bureau requires to be sub mitted by each activity, except ships, for sums desired to carry out their respective duties. These field estimates must be prepared and submitted on or before March 1, 16 months prior to the fiscal year. They are presented in a form closely resembling that submitted by the Bureau of Medicine and Surgery to the Bureau of the Budget. These estimates are examined carefully, due weight being given to past performance, probable future duties, and supporting data. Unsupported estimates for nonrecurring items are given little attention. Detailed informa tion concerning these items is necessary to favorable action. On the basis of this correlated data the preliminary annual estimate of expenditures is prepared for the Surgeon General by the Division of Finance. It is submitted to the Navy budget officer who prepares and presents a summarization of all estimates to the Secretary of the Navy for approval. Here the policy of the Navy Department is determined and conflicting interests adjusted. The limit of all esti mates is fixed and each bureau is instructed to revise its estimates if such is indicated. The final draft of the preliminary estimates is then prepared by the respective bureaus, returned to the Navy budget officer, where they are summarized and presented with supporting data, break-downs, and other informative facts to the Director of the Budget about September 1, prior to the fiscal year concerned. The estimated ex penditures of all bureaus comprising the Navy are then grouped into one "bill" and referred to the congressional subcommittee on Naval Appropriations. Each chief of bureau appears before the subcom mittee to clarify or substantiate the estimates. After the "bill" be comes an "act" the Treasury Department issues a warrant to the effect that the funds appropriated by Congress have been, or will be provided, subject to the limitations imposed by the act. Then, and not until then, may the funds be obligated. MICHAEL —MEDICAL, SUPPLY PROCUREMENT IN NAVY 171 The Bureau then compares the funds allocated by act of Congress with the revised estimate of expenditure. If the latter exceeds the former, adjustment downward of the tentatively approved estimates becomes essential and these estimates are again reviewed. The less desirable items are deferred in order to reduce the total to approxi mate the funds available. Allotment cards are then prepared and mailed to field activities, authorizing expenditure of funds for specified purpose. Allotments as employed by the Bureau of Medicine and Surgery may be classified as (a) money credits and (6) material credits. Money credits are actual allocations of funds from a specific congressional appropriation for the current fiscal period. Material credits are authorizations for withdrawal of supplies and equipment from stock (naval medical supply depots) measured in terms of money for the sake of convenience. The actual cash expenditure for supplies and equipment issued from stock may involve either current or past appropriations. Thus, requests for nonstocked material under supply depot allotments (material credits) require a rearrangement of Bureau procurement plans and additional allocation of funds to the procuring agency, United States Navy Medical Supply Depot, Brooklyn, N. Y. Example of Equipment Procurement The method of purchase and installation of a new X-ray equipment for a naval hospital will serve both to illustrate the functions of the Purchase Division in its relations with medical procurement, and to show the steps taken by the Medical Department itself. While the procurement of many medical supplies is almost automatic, the follow ing example represents the painstaking procedure that must be fol lowed for procurement of equipment: 1. The commanding officer of a hospital first justifies replacement of the present X-ray equipment on account of obsolescence, costly maintenance, unsatisfactory performance, or other sufficient cause and places in the hospital advance year estimate a budget item of $7,000—$12,000 for a new outfit. The Bureau reviews the recom mendation, approves the replacement, and incorporates the item in the annual estimate of expenditure for the hospital. 2. The chief surgeon, the roentgenologist, and the materiel officer have already studied available catalogs and have written up specifica tions to cover type of outfit required by the hospital. The command ing officer examines these, and as an example, adds the requirement that the bidder guarantee certain servicing conditions. He then for wards the requisition, floor plans, and other essential details to the Bureau of Medicine and Surgery and appoints a board of survey to recommend disposition of the old equipment. 3. The Finance Division examines the specifications, and other data submitted, gets technical advice from the medical supply depot, 172 MICHAEL —MEDICAL SUPPLY PROCUREMENT IN NAVY engineers, and manufacturers, consults with the Bureau inspector of Medical Department activities, and investigates all the features of procurement preparatory to laying the proposition before the chief of bureau who passes upon all prospective replacements of such a nature. If the chief of bureau approves the procurement the requisi tion may be forwarded directly to the Purchase Division of the Bureau of Supplies and Accounts, or if the specifications have been modified, it may first be returned to the hospital for concurrence in the modifications. 4. The schedule section of the Purchase Division of the Bureau of Supplies and Accounts verifies the form of the specifications and prepares schedules inviting bids from the several X-ray firms on the accepted list. The mailing subsection sends them out. The bidders make up their bids, execute a bond, and send in both. 5. On the day specified in the schedule, the bids are opened and classified by the award section of the Bureau of Supplies and Accounts and are sent to the Bureau of Medicine and Surgery for recommenda tion. The latter bureau finds that the lowest bidder, "A," does not assure sufficient protection against radiation and that the next lowest bidder, "B," does not have satisfactory service and replacement facilities near the hospital. Therefore the Bureau returns the specifi cations to the Bureau of Supplies and Accounts recommending bidder "C." 6. The award section of the Bureau of Supplies and Accounts may assure itself of the Comptroller General's approval, if there is doubt about the reasons for refusing "A" and "B." 7. The contract section draws up the contract because the amount is over $500. The contractor executes a performance bond which begins at 50 percent of the contract price at $500 and decreases inversely with the amount of the contract, to 10 percent. The contract is then signed by the contractor and by the Bureau of Sup plies and Accounts. The original signed copy is filed. Copies are circulated to all concerned. 8. The X-ray apparatus is installed. It is inspected and demon strated by the roentgenologist who knows how it should function, and by the material officer aided by an electrician, probably borrowed from Yards and Docks, to check the details of the specifications. 9. If difficulties are encountered in installation, test, or performance, the matter is taken up directly with the contractor, and then if nec essary, through the adjustment section of the Purchase Division, Bureau of Supplies and Accounts. The contract price is paid when the commanding officer of the hospital states that the installation satisfactorily meets specifications. 10. The amount is paid by the Bureau of Supplies and Accounts out of the Bureau of Medicine and Surgery's appropriation and the MICHAEL—MEDICAL SUPPLY PROCUREMENT IN NAVY 173 amount is reported as an expenditure by the hospital. The same amount is taken up on the hospital inventory as representing the cost of X-ray equipment. 11. The Board of Survey can recommend either that the old X-ray equipment be destroyed as of no value, or estimate it's value and recommend that the apparatus be turned over to the supply officer for sale. This survey report is made on the appropriate supply and account form and forwarded to the Bureau of Medicine and Surgery either with or prior to submission of requisition for new equipment. 12. The equipment is disposed of as directed by the Bureau of Medicine and Surgery endorsement on the form returned to the activity initiating the request. This is essential because: "The medical officer in command of each hospital and the medical officer of each station and ship shall be responsible and accountable for all public property under his control belonging to the Medical Depart ment of the Navy." Approximately the same procedure is followed in all important nonstandard installations. Should the serviceability of any construc tion or installation be questionable (particularly in naval hospitals), the Bureau of Yards and Docks (which is charged with all construction ashore) should be called upon to inspect, and make estimates and recommendations as to repairs, replacements, and improvements. The commanding officer of the hospital will then act on his estimate of the situation, by forwarding to the Bureau of Medicine and Surgery the recommendation of the public works officer and his own recom mendation. These recommendations will be considered by the Navy Department and the public works officer will be authorized to effect such changes as the Department approves. The cost will be charged to appropriate funds. Payment in all cases: "All purchases and payments therefor shall be made under direction of the Bureau of Supplies and Accounts and orders directing such purchases and payments shall be given only by that Bureau. When purchase requisitions have been approved by chiefs of bureau, they shall be transmitted to the Bureau of Supplies and Accounts for action." Supply officers represent the Bureau of Supplies and Accounts. In medical activities attached to Marine Corps units, the quartermaster of the Marine Corps exercises for the medical activity the same local functions as would the supply officer of a naval unit. Role, Bureau of Medicine and Surgery: But although the Bureau of Supplies and Accounts procure, the Bureau of Medicine and Surgery "shall require for all supplies, medicines, and instruments used in the Medical Department of the Navy. It shall have control of the preparation, reception, storage, care, custody, transfer, and issue of 46202—38 2 174 MICHAEL—MEDICAL, SUPPLY PROCUREMENT IN NAVY all supplies of every land used in the Medical Department for its own purposes." Medical Supply Depots: To facilitate these functions as regards medical materials the Bureau of Medicine and Surgery has created the following central sources of supply: Naval Medical Supply Depot, Brooklyn, N. Y. Naval Medical Supply Depot, Mare Island, Calif. Naval Medical Supply Depot, Canacao, P. I. The Brooklyn Depot is the main supply depot and keeps on hand Supply Table and Supplementary Supply Table material. There are specified limitations on the items kept in stock by the other depots. Certain special supplies, itemized in the Supplementary Supply Table, as antigens, culture material, bacterial emulsions, containers for specimens, typing sera, and colloidal gold, are prepared and sup plied by the Naval Medical Center in Washington, D. C. The medical supply is predominately automatic. These supply facilities render almost automatic the acquisition of at least 90 percent of medical supplies used by the various medical organizations. This is accomplished by the supply table, adopted in 1926 and revised in 1938. In addition to individual items it lists a score or more of as sembled outfits, viz: Aircraft first aid, emergency surgical, box medical, chest operating and expeditionary outfits, etc. It includes a complete list of ordinary dental supplies. Requisitions from each activity for every need on the supply tables are made on the prescribed form. This shows the amount of the items on hand and the amount required. The requisition is forwarded to the Bureau of Medicine and Surgery where it is approved or revised and forwarded to a medical supply depot for execution. An emer gency requisition goes direct to the supply depot for execution and a copy goes to the Finance Office for record, or it may be made by radio and the red tape unwound at leisure. Medical supply depots re plenish their supplies by requisition approved by the Bureau of Medicine and Surgery and procured by the Bureau of Supplies and Accounts, usually in New York City markets. Factors governing requisitions: There must be a specified minimum of supplies on hand in each activity and aboard combatant ships and an additional reserved stock of such unopened, original units of sup plies and items as may be specified by the Bureau of Medicine and Surgery. This minimum stock for ships is 6 months' supply, based on a 3-year average consumption. For hospital ships and all shore stations, the minimum prescribed is 1 year. An "order point" has recently been established. The stock of an item has reached the order point when it has been reduced to a point that, considering average consumption and time required to requisi tflCHAEL—MEDICAL SUPPLY PROCUREMENT IN NAVY 175 tion and receive new stock aboard, the stock on hand would be de pleted to the minimum supply on estimated date of replenishment. Routine orders for deficient items should be made following quarterly inventory with such minor variations to facilitate delivery, as are dictated by the movement of the ship. On receipt of supplies, that portion of the reserve supply which deteriorates should be replaced by new material and the old reserve removed and designated for cur rent use. In other words, always use the oldest stock, first. A careful attention to this method will bring about a decrease in dead stock and insure fresh material in reserve. Formerly there was often an ac cumulation of unreasonable supplies. An inspection of one hospital revealed a supply of quinine hydrochlorosulphate sufficient at the average rate of use for several hundred years. The medical officer is expected to requisition what he needs pro vided his requirements do not exceed his annual allowance for supply depot items. This allowance may be increased on request, in emer gency, by the Bureau of Medicine and Surgery. He is expected to be governed by the prospective mission of his ship, his own methods of treatment and other conditions affecting his requirements. If he is a genitourinary specialist he will order his favorite catheters from the Supply Table. If his ship is going up the Yangtze he will order cholera vaccine; if she is going on a long "shake down" cruise, he may wish to take along a couple of caskets for the care of the dead. Supply Depot material awaiting transfer to ship or station is deliv ered to the Supply Department which supervises shipment and delivery and pays transportation costs. The Medical Department of a naval unit obtains material from sources and by methods other than on regular supply depot requisi tion. In emergency medical material may be transferred directly from one Navy medical activity to another on regular transfer form a copy of which is forwarded to the Bureau of Medicine and Surgery. In case of transfer of equipment prior permission should be obtained from the Bureau or, in case of emergency, an explanatory letter should accompany the copy of property transfer. Numerous items of sick bay equipment such as office furniture, lockers, steam and electric sterilizers and various ward installations are the property of other divisions. They are issued to the medical division on custody receipt signed by the senior medical officer. Cleaning gear and other sanitary supplies are issued by the first lieu tenant on signed request without charge to the Medical Department. The Bureau of Medicine and Surgery has endeavored to be suffi ciently liberal in the variety of supply table and supplementary supply table items offered and the allocation of funds for their acquisition. It views with disfavor the indiscriminate use of emergency and other irregular forms of requisition. For the exceptional situation that 176 MICHAEL —MEDICAL SUPPLY PROCUREMENT IN NAVY demands irregular procedure one of the following described methods of obtaining material may be employed: (a) Supply table items may be obtained in emergency by making requisition on regular form or by radio directly on the nearest supply depot. Copy of requisition with explanatory letter should be for warded to the Bureau of Medicine and Surgery. (6) For ships and stations essential materials not listed on the Supply Table or Supplementary Supply Table may be obtained by forwarding a special requisition, using the standard form, to the Bureau of Medicine and Surgery. If funds are available and the requisition is approved, the Bureau will direct a medical supply depot to make procurement. If a detailed explanatory letter accom panies the requisition the Bureau of Medicine and Surgery will be in a better position to evaluate the necessity for providing the special material. (c) Material may be obtained on purchase requisition approved by the commanding officer and purchased by the supply officer. Actually, in this type of emergency procurement, the purchase is usually made immediately by the supply officer and the necessary red tape is unwound afterward. (d) Procurement by "improvision" is a method of importance, especially aboard ship, by which the efficient medical officer obtains material through the cooperation of other departments. If in great emergency he wants a baking box for stiff joints, a violet-ray lamp, a walking splint for a broken femur, a suspension apparatus for a broken back, or even an oxygen tent for a pneumonia patient, he has only to exercise the necessary diplomacy and ingenuity. Procurement by improvision has played an important part in the Medical Department of the Navy. The first two naval hospitals and the first hospital ship were of natural or improvised birth. Edward Cutbush, surgeon of the Constellation then operating against the Barbary States, established and conducted the first United States Naval Hospital, in Syracuse, Sicily, 1806. In 1810 Surgeon Lewis Heerman was sent to New Orleans. Seeing the necessity, and fortified by a personal fortune, as an adjunct to a lucrative practice he purchased a suitable house and a few slaves and started the second naval hospital. The first hospital ship was a Confederate vessel on the Mississippi captured during the Civil War. This ship, the Red Rover, was equipped by Admiral Porter and put under the command of Surgeon Pinkney. Insofar as procurement by improvision represents a constructive and expedient opportunism for the good of the service and to meet local emergency and unanticipated needs, the Bureau of Medicine and Surgery cannot object to this method, but cautions that use of this expedient should be reserved entirely to meet such needs. MICHAEL —MEDICAL SUPPLY PROCUREMENT IN NAV? 177 Dental equipment and supplies are furnished in the same ways as medical supplies and the dental officer has the same responsibilities in regard to them as has the medical officer in regard to medical materials. Procurement Functions of Medical Department Units Medical activities which make up what might be called the "con suming echelon" of the Navy Medical Department vary in importance from the Naval Medical Center, through hospitals, sickquarters, field hospitals, sickbays, and dispensaries, to the medical officer of a recruiting station. The first two procure everything necessary for a separate self-sustaining command; the last buys only a few things from the nearest drug store. With the exception of the medical officer on recruiting duty (who does not require a requisition form for medical supplies though he is furnished a recruiting outfit), the procurement of purely medical material is the same and has been explained. But there is considerable nonmedical procurement by medical activities which a short description of the procurement organization of a naval hospital and of the installation of the sickbays aboard a ship and ashore should clarify. Naval Hospital: The procurement functions of a naval hospital are vested, under the commanding officer, and executive officer in: (a) The first lieutenant, who has general supervision and upkeep of buildings and grounds. Improvements and repairs, beyond the capacity of the hospital force, are estimated by a representative of the Bureau of Yards and Docks and paid for out of the hospital allowances by the supply officer. (6) The property officer, who is responsible for storage, property cards, and requisitions. He obtains medical supplies as described above. Other supplies are obtained by stub requisition from the supply officer; bid and purchase with or without contract; or purchase requisition for specified limited amounts, usually $50. The hospital if authorized by the Bureau can procure the professional services of a civilian specialist. Naval hospitals procure and maintain their own ambulances and other vehicles. (c) The commissary officer supervises the purchase, storage, prepa ration and cash accounting of commissary material. He uses the local contracts of the supply officer, or makes small open purchases as above. (d) The accounting officer, who in addition to accounting for and submitting the required financial returns, keeps the commanding officer informed of the relation of allocations to expenditures under the various appropriations. Frequently two, or even three, of these functions are filled by one officer. 178 MICHAEL MEDICAL SUPPLY PROCUREMENT IN NAVY Ship: When a Navy ship is being put in commission the Medical Department is furnished only the standard medical and surgical equipment for that type of ship plus any additions which the medical officer might deem necessary. However, the Bureau of Construction and Repair (or the contractor) installs in the sickbay and in the dressing stations, not only the ordinary living accommodations (lights, bunks, plumbing, etc.), but also sterilizers (except dental sterilizers), bacteriological incubators, and operating-room lights, as specified by the ships' design. Even splint stretchers are charged against the Bureau of Construction and Repair as is the material necessary for the fumigation of ships. The wise medical officer will constitute himself as procurement and property officer. He will, as required by regulation, keep personal custody of the medical storeroom key and personally supervise custody and issue of alcohol and narcotics. He will assign property accounting to a reliable corpsman and will assure himself beyond doubt that the property records are accurate, that the stock conforms with Bureau policy and has not deteriorated. Shore station: Like the sickbay of a ship, shore sickbays and dis pensaries are furnished certain items by other departments than the Bureau of Medicine and Surgery, because these medical activities are considered an integral part of the naval establishment. The items include buildings, furniture, light, heat and water, cleaning material, floor polishers, etc. The Medical Department's problem of procurement for shore sta tions is simplified by a system of 3-year planning. In March, each year, the estimates for the following fiscal year are reported in detail. Later, provisional estimates for the following 2 years are submitted. In this way the Bureau reduces unpleasant suprises to the minimum. This 3-year estimate is not required of ships whose yearly expendi tures vary somewhat, but ship variations do not assume the fantastic proportions as do those of some hospital and other shore station estimates. Source of Funds The funds of the Bureau of Medicine and Surgery are derived from : 1. Annual appropriations for "Medical Department," "care of the dead" and "salaries, Bureau of Medicine and Surgery." 2. Naval hospital trust fund: This trust fund derives its revenues from within the naval service, namely: 20 cents a month levy on all naval personnel, fines and forfeitures, pensions relinquished during hospitalization, forfeitures by deserters, and the ration value of all naval patients. "Every expense for the proper establishment and maintenance of a naval hospital may be paid from this fund except as Congress may provide for certain expenses by specific appropriations." The revenues of this fund approximate $800,000 annually. HOLEMAN MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT 179 Procurement Preparedness The minimum supplies required at all naval activities and the "1 year, plus procurement time" minimum required (and exceeded especially in strategic drugs) at naval medical supply depots, would furnish a substantial outlay on M-day. Ships actually have prepared and sterilized a reserve supply of shell-dressings. War plans are pre pared for the naval districts with complete requisitions to take care of expansion. It is believed that these requisitions can be promptly filled with the exception of about a score of items of technical nature. An effort is being made to provide such items but, owing to the rapidity of their obsolescence, this acquisition, even if authorized, will be limited to 5 years peacetime consumption. The medical department is prepared to equip the fleet and the auxiliary ships. Gaps in the shore establishments can be filled later. MEDICAL DEPARTMENT FUNCTION IN A NAVAL ENGAGEMENT By Capt. C. J. Holeman, Medical Corps, United States Navy As stated on the cover of this Bulletin the Mission of the Medical Department is "To keep as many men at as many guns as many days as possible." Surg. H. E. R. Stephen, R. N., has thus defined the duty of a naval surgeon aboard a fighting ship: "To render the ship an efficient fighting unit as far as lies in his power." This is true, but such a definition might be applied to every person aboard a fighting ship. Specifically, the medical officer should, in peace time, bring the crew of his ship to the best possible physical condition and the ship itself to conformity with highest possible sanitary standards. By his pre- battle arrangements he should seek to maintain these levels of fitness during action. By the execution of his previously prepared, and sufficiently rehearsed, battle plan he must strive to keep the greatest possible number of officers and men in physical condition to execute their assigned tasks unhampered by those rendered unfit for further service by severe injuries. Hence, for the medical department of a naval vessel in battle there might properly be assigned the MISSION To Sustain the Physical Fitness of the Personnel in Order to Maintain the Fighting Efficiency of the Ship To accomplish this mission three major tasks devolve upon the medical department. 1. To preserve the highest level of physical fitness at all battle stations, 2. To promptly and efficiently care for the wounded during lulls in action or after battle, 3. To evacuate noneffectives. 180 HOLEMAN—MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT Progress in naval architecture whereby, as the result of an extensive system of compartmentation, fighting ships have gained greatly in floatability ; improved weapons of such power that the watertight integrity of compartments may not be impaired without hazard; and probable use of chemicals, which has added requirements of fume tightness, have led to the development of the present system of damage control on ships of the Navy. These have complicated the arrange ments of preparing the medical department for battle, and drastically modified its functioning during action. During the past 3 years this matter has been made the subject of study by many boards and individual officers in the fleet. The latest study has resulted in the promulgation of Fleet Memorandum 29M-37, by the commander in chief, during November 1937. In this memo randum two fundamental principles were enunciated: (1) The watertight integrity of the ship, regardless of wounded, must be preserved. (2) Fire power, as delivered by the batteries of the ship, regardless of wounded, must be maintained. These principles must determine methods employed to accomplish the tasks enumerated. Analysis op the Tasks Task 1. To preserve the highest level of efficiency at battle stations With rigid enforcement of regulations governing watertight and fumetight integrity, not only during actual fighting but during the periods when conditions Affirm or Baker must be maintained, mem bers of the crew at most battle stations will be isolated from the medi cal department personnel of the vessel. Hence, the only manner in which the medical department can contribute to sustaining physical efficiency of the combatant force during these phases is : (a) By careful and thorough (pre-battle) instruction of all hands in first-aid treatment of wounds, burns, and contact with chemical agents, so that first-aid may be effectively applied by the injured man or by a shipmate at his battle station; (6) By having adequately stocked first-aid outfits at all battle stations; (c) By providing a team of well-equipped competent first-aid men attached to each damage control party who shall, whenever these parties gain access to a battle station, inspect personnel casualties, administer or correct defects in first-aid treatment, do everything possible to combat shock and relieve pain, and, if practicable, remove the seriously wounded from the compartment. HOLEMAN—'MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT 181 Task 2. To promptly and efficiently care for the wounded during lulls in action or after battle The execution of this task will demand the maximum of effort, skill, and judgment on the part of every officer and man of the medical department. In the proper performance of duty at this time the medical department has, perhaps, its greatest opportunity to con tribute directly to military efficiency of the ship. This contribution consists not only of a manifest conservation of man power but of a strong support to morale at a critical period. The operations necessary are: (o) To restore to fighting efficiency the wounded, men made ill by prevailing battle conditions, and those incapacitated by the milder effects of chemical agents. These will find their way by designated routes to the proper dressing stations. (6) To clear the gun and other battle stations of the more seriously wounded. These must be helped or carried in litters to the battle dressing or chemical decontamination stations. (c) To treat those whose injuries incapacitate them for duty. These operations are set down in the chronological sequence in which they must be completed; actually there will be some overlap in their execution. Task 8, To evacuate the noneffectives This consists of two phases : (a) Clearance at first opportunity from battle stations. (6) Evacuation after treatment from the ship to a hospital ship or hospital. Detail as to the manner in which these major tasks are to be accom plished must be worked out for each ship by its medical officer. Approval by the commanding officer must be obtained as a matter of routine. Such planning and approval, however, must not be perfunctory for the successful execution of the tasks demands com plete cooperation between the medical department and other depart ments aboard ship. Instruction in first-aid of the nature required demands joint interest of the medical officer and division officers; treatment and clearing of patients during action requires full coopera tion between the medical officer, damage-control officer, and central control, and when the battle is over, between the medical department and practically all hands. Means of Accomplishing the Tasks Task 1 (a). — Training in first aid assumes, under present conditions, greater importance than has been heretofore attributed to it. Its value in controlling hemorrhage, guarding against infection, dimin ishing mortality rates and lessening total sick days must be clearly 182 HOLEMAN MEDICAL, DEPT. FUNCTION IN NAVAL ENGAGEMENT explained to all hands. But the two fundamental principles enun ciated by the commander in chief impose a new responsibility upon medical officers to instruct and division officers to know that their men understand not only the value of first aid but that each member of a gun crew or other unit engaged in fighting the ship knows the use and mode of application of every item in the battle station first-aid locker or bag. Fleet Memorandum 29M-37 prescribes that men detailed to serve as collecting parties of stretcher men shall be "sufficiently trained in first aid to act as relief hospital corpsmen in emergencies, especially the emergency of battle." During battle, persons attached to repair parties will, when access to compartments is gained, provide the maximum relief that the medical department can afford at this phase of the battle. Treatment of shock is of such vital importance that careful pro vision should be made therefor. This implies, at the present state of our knowledge, immediate use of morphine. There may be cases in which seriously wounded will have a considerable wait before help may be brought to them. Decision should be reached as to whether or not first-aid instruction to officers, to leading men in battle stations where no officer may be present and to the collecting parties should include the administration of morphine. Task 1 (b) —Battle station first-aid material. —Major ships are now provided with metal containers for the first-aid outfits of battle stations. Greatest care should be exercised to see that an outfit is provided for every isolated group of men. The problems of storage at a central point for issue at general quarters or their permanent distribution throughout the ship, periodic overhaul, keeping them stocked with material in no wise deteriorated or keeping them partially stocked in peace time with earmarked material in the storeroom to complete their allowances, are all matters for individual ship decision. Unless containers are kept locked they will be broken into and undesirable self-treatment will spring up. Since they may be used in minor emergencies during drill with benefit, on several ships a scheme of sealing them with easily broken seals, the damage to which is easily observable has proven satisfactory. In any event, a certain number must be used for instruction purposes. No useful purpose would be served by listing contents of the lockers. Provision must be made for wounds from projectiles, burns, damage from chemicals (whether thrown aboard by the enemy or from gases generated by explosion of enemy shells or by own propulsive charges), contusions and other injuries by mechanical devices. Types of injury most likely to occur at each battle station should be considered and the locker for that station fitted up accordingly. HOLEMAN MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT 183 The relative importance of burns should be borne in mind. At the battle of Jutland, omitting killed, the ratio of burns to wounds on major ships was as 154.5 : 100. This ratio is not due to especially large contributions by fireroom and engineroom casualties but rather to the flash of enemy shell explosions within the ships. At present the tannic acid treatment of burns is in favor and has much to recom mend it. Quick availability, simplicity of application, sufficiency without waste or jeopardy to stock by haste or nervousness were the indica tions which led to the adoption of item Sl-190, tannic acid jelly, for inclusion in the supplementary supply table. Should service test prove the value of this item, it offers an excellent solution to the problem of caring for burns. Reports on its use will, therefore, be appreciated by the Bureau. Medical officers should give immediate attention to the segregation of sufficient stores for their battle station outfits. By Bureau's Circular Letter, Serial No. 640-1937, ships are directed to maintain a minimum stock plus a working stock in addition to their reserve stock stored at battle dressing stations or in other emergency units. Task 1 (c)—First-aidmen.— Provision of nonmedical first-aid personnel for collecting parties has been considered under (a) above. It is highly desirable that to each such party there be assigned a pharmacist's mate who shall be in charge of the task of caring for personnel casualties in any compartment to which the damage con trol party may gain access. The administration of morphine is a matter in which the judgment of a hospital corpsman is apt to be safer than in less experienced hands. The presence of a member of the hospital corps in whom his shipmates feel a degree of confidence, directing these operations, will tend to support morale. Furthermore, the training of the corpsman is such that remedial measures known to him may be used to add to the safety and comfort of the wounded or those made ill by prevailing conditions. Task 2.— Treatment of wounds at the earliest possible moment is important in reducing mortality rates, shortening duration of ineffec tiveness, and relieving pain, and requires no comment. Likewise that efficiency of medical officers and methods employed contribute directly to such results is patent to all. Yet there must be some definition of efficiency since personnel and facilities are limited at best and the first may be reduced by casualties while the latter may be well nigh destroyed. Furthermore, in precisely those cases where faculties are most completely wrecked the task confronting the medical department is apt to be greatest. The percentage rates of wounded vary greatly on individual vessels, and by ship types ; in fleet actions as opposed to single ship duels and most appallingly as between victorious and vanquished units. 184 HOLEMAN—MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT It has long been assumed that for a victorious ship engaged in a decisive fleet action a fair assumption of total casualties would be 20 percent of complement, of these that 4 percent would be killed, that 8 percent would be seriously wounded. That in single cruiser encounters approximately 15 percent would be killed or wounded, the ratio of killed and wounded being about the same. At Jutland total British casualties fell considerably below expected rates. Of the total strength of the fleet the percentage of casualties was 11.16 (10.04 killed and 1.12 wounded). These figures over emphasize a trend, which had previously been noted, toward a greater ratio of killed to wounded. It must be remembered, however, that Jutland was an undecisive battle, all ships did not participate and the death rates were greatly increased by the explosions and sinking of major ships with all hands aboard. Differences in armor protection accounts for variances in casualty rates, in proportion of killed to wounded and the nature of casualties. H.M.S.Zion, a battle cruiser had a percent casualty rate, at Jutland, of 11.85 (7.7 killed, 4.15 wounded); H. M. S. Barham, a battleship, had a percent casualty rate of 6.04 (1.93 killed and 4.11 wounded). Burns by flash, appear, on the other hand, to increase in relation to wounds by projectiles in direct proportion to the thickness of armor. As for difference between rates for victorious or vanquished ships they may be practically zero on the one hand and approach 100 percent on the other. At Tsuishima the defeated Russian force had about 30 percent casualties, while 16 percent has been assigned a? the prob able Japanese rate for the whole campaign. In the single ship action between the Sydney and Emden, the former had 4 men killed and 12 wounded, the defeated Emden had 40 percent casualties. These data are introduced here only for the purpose of calling attention to the possible magnitude of the task presented. Faced with the immediate care of 16 percent of the crew, obviously efficiency of immediate treatment precludes the possibility of finished surgery. Of this Fleet Surgeon Christopher L. W. Bunton, M. B., R. N., says: My experience in a double role, that of an operating surgeon in a hospital receiving wounded from ships after an action, and that of a surgeon in charge of a ship sustaining many casualties in the battle of Jutland, leads me to deprecate strongly the performance in dressing stations of operations which could be deferred with safety till patient had been transferred to the more favorable conditions obtaining in a hospital ship or shore hospital. The surgery best adapted for dressing stations during or immediately after an action would seem to be an amplified first-aid treatment. Operations should be strictly confined to those of an imperative nature, and all efforte be directed to rendering wounds as aseptic as possible, with a view to facilitating the work of the surgeon who eventually receives the case. * * * Provided they are not causing untoward or dangerous symptoms from their presence, pieces of shell deeply embedded are better left in situ. * * * HOLEMAN—MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT 185 The question of amputation of limbs is certainly best postponed till the patient is transferred to a hospital or hospital ship. Of course, where a limb is practically severed, and all hope of its preservation out of the question, it may be quickly snipped off with a view to facilitating patient's locomotion. * * * Task 2 (a)—Restore effectives to battle stations. —It is assumed that the personnel of the medical department are thoroughly indoc trinated regarding the imperative necessity of giving immediate attention to those, whose wounds being properly dressed, may carry on. To accomplish this during lulls in battle will be of direct military importance. Will there be a lull in action? Estimates of the probable dura tion of a battle between modern fleets vary from 20 minutes to 1 hour, such estimates are predicated upon favorable weather conditions and a desire to fight to a finish on the part of both commanders. In such event probably no lulls of sufficient length to warrant relaxation in enforcement of strict watertight integrity would occur. But, at Jutland, the only engagement in which entire modern fleets have participated, the battle largely consisted of lulls punctuated by minutes of fighting. Under such conditions, subject to central con trol, on vessels equipped with modern quick-acting doors, moderately wounded might well have their wounds dressed, men made ill by com bustion gases or with eyes inflamed by tear gas might receive attention. Task 2 (6)—Evacuation of casualties. —Under the same conditions as would permit the slightly wounded to have their injuries dressed during a lull, the battle stations might be cleared of the seriously wounded. The movement of all collecting parties is subject to central control. The need for special training of the collecting parties is again emphasized for most important tasks devolve upon them in recognition of injuries from chemical agents, in transporting or aiding such cases to the decontamination stations, in avoiding contamina tion of themselves, and in guarding against taking contaminated Utters into the battle dressing stations. Fortunately, if the battle be of short duration most of the cases injured by the now-known vesicant chemi cals will not be incapacitated until after the fight is concluded. Task 2 (c)— Treatment of noneffectives. —The fact that the para mount duty of the medical officer is to promptly restore to his station every man capable of fighting the ship does not mean that the suffer ing of the seriously wounded shall be ignored. The battle-dressing station country must be in readiness so that men may lie down. Blankets, hot water bottles, morphine (or perhaps, stimulants) must be distributed to control shock as necessary. Their dressings must be inspected and hemorrhage checked if this has not been accom plished at their battle stations or if moving them has disturbed their dressings or tourniquets. Also care must be taken that tourniquets are not left too long in situ. 186 HOLEMAN MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT These tasks must, of course, be performed by hospital corpsmen until such time as the medical officer and his immediate assistants complete task 2 (a). The nature of the surgical work to be undertaken has been considered. There may be cases in which something more radical than high-grade first aid is clearly indicated. The probable time when clearance to a hospital ship or hospital may be accomplished should be carefully considered, and if the delay would be too prejudi cial, formal operations decided upon should be thorough and per formed in strict accordance with approved technique. Task 3 (a)—Evacuation of noneffectives from battle stations. —Evacua tion of seriously wounded from their battle stations should be accom plished, as indicated under task 1 (c) at the earliest opportunity in order that morale of gun crews (or other working units) may not be impaired by their continued presence in the compartment, and in order that the best treatment possible may be promptly initiated. Task 3 (b) —Evacuation of noneffectives from the ship. —At first thought evacuation of casualties from the ship might not be con sidered as falling within the purview of a study of "Function in battle" since, of necessity, the battle is over before it is undertaken. But to omit it would be to fail in fully considering the duties of the medical department incident to the battle. The care of casualties in reality consists of three phases: 1. First-aid treatment at a battle station. 2. More thorough first-aid treatment at a battle dressing station. 3. Definitive treatment in a hospital or aboard a hospital ship. Only in such exceptional instances as those cited under task 2 (c), or when it is impossible to evacuate the casualties should definitive treatment be conducted aboard a fighting ship. Fleet Surgeon Bunton, previously quoted, says that after Jutland evacuation was accomplished in 48 hours and adds: I should be inclined to consider this period as representing the maximum delay of wounded on board, since to more or less exceptional circumstances the fleet remained for a considerable time in the vicinity of the original action with a hope of cutting off the enemy for his base and resuming the engagement. Under ordinary circumstances a period of 24 or 36 hours would probably be the more usual time to count on as available for examining and dressing the wounded. Supporting Measures Personnel. —Restudy of personnel requirements on naval vessels has been undertaken by the Bureau of Navigation and requirements of hospital corpsmen to carry on battle activities will doubtless re ceive careful consideration. The article on Logistics by the Surgeon General in this issue of the Bulletin refers to the necessity for about six more corpsmen on battleships. Such an increase would make HOLEMAN—MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT 187 available 19 or 20 hospital corpsmen. A logical apportionment of these would appear somewhat as follows: It is evident that men detailed to accompany collecting parties will later be available for other duty and perhaps the decontamina tion station may not be needed. On the other hand, that station may receive many cases and require additional assistance; also as cases accumulate there or at the battle dressing station more men will be needed as nurses; furthermore, no allowance is made for casualties in this tabulation. As a result of the study, both exten sive and intensive, which the efficient employment of medical depart ment personnel in connection with effective damage control during action, has received, a considerable volume of opinion has arisen to the effect that the Medical Department's work begins after battle or during a major lull therein; and that, therefore, all such personnel should seek refuge behind armor until the action is over when they should emerge and begin the performance of their duties. Such conception is repugnant in that, were it accepted, morale would unquestionably be lowered in a force thus isolated without information as to progress of the battle and with no tasks directly connected with fighting the ship. Furthermore, such a conception falls short of a visualization of requirements to accomplish the mis sion of the Medical Department in battle. During action, on many ships, repair parties are stationed in spaces immediately adjacent to or, indeed, actually in the area assigned battle dressing stations. When their collecting parties succeed in evacuating seriously wounded patients from battle stations they may be brought in for treatment immediately. While it would be most desirable to have a medical officer detailed to supervise treatment of all injuries at battle stations and the transportation of the more seriously wounded, the principles of economy of force and security prohibit such employment. Medical officers must perforce stand by the battle dressing stations. These stations must be kept manned and equipped, in constant readiness to— (a) in the event of a lull in action, immediately treat those capable of restoration to duty, and (b) attend to the immediate needs of noneffectives brought in by the collecting parties. Throughout the action hospital corpsmen attached to collecting parties must be alert to maintain the physical efficiency of men at battle stations and to assist in evacuation of noneffectives from these stations. To assist the operating surgeons at battle dressing stations To receive and care for sick and wounded To accompany collecting parties To man the chemical decontamination station (s) 1 or 2 10 2 6 188 HOLEMAN —MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT Battle dressing station.—Modern battle dressing stations are the result of a continuous evolution through the years of development of modern navies to reach the proper solution of the dual problem of best caring for the wounded and supporting morale of survivors. Fleet Surgeon Bunton stated (about 1 year after Jutland) that a battle dressing station "should be fully protected, easily accessible, thoroughly ventilated, and have a good supply of both hot and cold water with fixed basins and effective water service." To this should be added: "Adequate space for the injured to lie down and to be cared for in" (Fleet medical officer's comments on Medical Depart ment in battle): fixed sterilizers or at least facilities for plugging in portable instrument sterilizers and water heaters, and storage facili ties for complete logistic support of the station. Do the existing battle dressing stations possess these character istics? As planned on newer battleships they did. At present they are protected by armor and review of plans of battleships indicates that battle dressing stations are as accessible as any place thus pro tected could be. They are generally well located one deck below the sick bay, where exists the greatest likelihood of conservation of their facilities— lights, water supply, and sterilizers. Access is reasonably free by companionways from the upper decks, and quite generally crew's living spaces are near at hand. In peace time, except for drill purposes, the Medical Department requires but a fraction of the original battle dressing area assigned by approved plans of the vessels. In fleet medical officer's comments on Medical Department in battle, July 1, 1937, reference was made to "dual purpose assignment" of space. This dressing station space is a most pertinent instance of the value of such a conception. Con servation and efficient use of space does not permit allocation to the Medical Department for its exclusive peace time use all the space that it will require in action. However, the dual function of the area assigned to battle dressing stations on approved plans of all ships should be such that the deck space may be used as necessary by other departments until the battle dressing stations begin to function. After battle the need for exclusive use of the entire space by those engaged in personnel rehabilitation will probably be imperative. In order that traffic through battle dressing stations may be re duced to a minimum after battle, the allocation of storerooms should be carefully studied. Those used for storage of items which will be required for material repairs should not open into these areas. Re view of battleship plans shows that, in many cases, material which will be immediately needed is now stowed in rooms opening into the battle station areas; while nearby storerooms, equally commodious, are used HOLEMAN—MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT 189 for supplies and accounts stores which would not be immediately required. A judicious interchange could probably be effected. Sufficient battle dressing station space and storage facilities in con nection therewith will be provided on new construction. If, on exist ing ships, encroachments upon battle dressing stations and their required storage space, without due regard to the principle of "dual function" have occurred, medical officers should exert themselves to effect an adjustment with other departments aboard their ships to reestablish the adequacy of their battle dressing stations. In order that such adequacy may be demonstrated it is suggested that periodi cally there should be held drills in which the number of personnel casualties handled as directed in Fleet Memorandum 29M-37, shall equal 16 percent of the crew. Ventilation presents a problem new since 1918. With ships' venti lating systems shut down obviously they could not be considered well ventilated —with the ship opened up after action, with the system functioning and its intakes uncontaminated by chemicals, they are as well ventilated as any regions on the third deck. A matter demanding special study is the protection of battle dressing stations against chemical contamination. The Bureau of Construc tion and Repair is giving this careful consideration in planning new construction. Contamination must be guarded against in two ways: (1 ) The best defense obtainable must be provided by regulation of the ventilating system and such structural protection as may be devised. (2) Prevention of contamination by entering personnel. This has been touched upon when instruction of litter squads was discussed. A corollary to the rule excluding chemical casualties from battle dressing stations is that chemical decontamination stations must be provided. Such stations, either as designed for new ships, or extem porized on older vessels must meet minimum requirements of: (a) Best possible protection compatible with easy access from upper decks. (6) A space for disrobing and disposition of contaminated clothing. (c) A treatment room. (d) Showers and soap to permit abundant lathering. Fresh water is highly desirable, but abundant salt water and salt water soap are preferable to a scanty supply of fresh water faculties. (e) Space for dressing in fresh clothing. Water is supplied to the battle dressing stations and water heaters are provided. As a safety precaution the stations have reserve tanks —the rule for these being that the capacity of tanks at the for ward and after stations shall be 1 gallon per man for 20 percent of the complement; for the amidships station the capacity is approxi mately one-half this amount. 45202—88 8 190 HOLEMAN —MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT Quite generally a cargo light is included in the prescribed equipment for operating table illumination — the remainder of the space must be left to the ship's lighting circuits. In case of failure, battery operated lanterns must be provided. In response to a recommendation of the commander in chief, the Bureau of Engineering has developed a special lighting fixture for the operating table, two experimental units of which have been sent to the fleet for service test. In an excellent study made by Commander H. L. Jensen (MC), in December 1937, particularly in reference to the battle dressing stations on the Maryland and incidentally to those of other battle ships, that officer stated that: "The storeroom which formerly was a part of the after dressing station has now been taken away from the medical department and turned over to the damage control officer. * * * The floor space available (at the forward dressing station) will just permit the erection of a dressing table with two men working on each side. There is no floor space left on which to deposit stretcher cases before or after operation." To this statement is added data concerning the over-running of this area by personnel of other departments. The statement regarding the available space was verified by examining blue prints of the Mary land. While the area described is somewhat irregular in outline, the present assigned deck space appears to be less than 20 percent of that allotted thereto on the original plan of the vessel. Encroachments on these spaces have occurred on other battleships. Accepting the practical obliteration of useful battle dressing stations as a fail accompli, Jensen adds: "It is assumed that a naval engagement today will mean great material damage, what with hits by major shells, bombs, and tor pedoes. Obviously then, it would be a great mistake to concentrate the medical activities, particularly instruments and dressings, in any certain parts of the ship without making ample provision for the rapid transfer of these activities to some other part of the ship less seriously injured." From these considerations he concluded "* * * that permanently equipped dressing stations and per manent storerooms should be abolished on the newer ships in new construc tion * * *." The solution presented was: that after battle the two surgical teams, each headed by a medical officer should seek out "A suitable area on the second deck or above, set up his outfit and go to work. The area chosen must have sufficient space in which to work advantageously, be readily accessible to that end of the ship and be off the main arterial routes. On the newer ships in the Navy, there is no such space below the second deck." "A mop-up squad" headed by the dental surgeon or other competent person was also described whose duty it was to bring the wounded to the selected stations. To equip these extemporized battle dressing stations. * * * "In lieu of storerooms medical equipment should be stowed in lockers, the largest consistant with portability. There should be a minimum of 14 such lockers, scattered about the ship near access hatches, so that after the battle, certainly some of them would be left intact. Each locker should contain as a minimum the following: (a list of proposed contents was here supplied by the author). Two men can easily carry such a locker (one has been made upon this ship and portability proven) and can quickly bring them to the areas chosen by the medical officers as dressing stations. Each locker would be a complete small surgical dressing outfit in itself, and, with several of them, a large number of wounded can be cared for. * * * Likewise HOLEMAN MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT 191 several portable operating tables, on the order of the present field table would have to be provided, six would be sufficient. It must be remembered that no great or finished surgery would be undertaken immediately after the battle, merely enough to preserve life until the patients could be evacuated to a hospital or hospital ship, or until the wounded have all been treated, and then, if time permits, a more finished surgical outfit could be provided for more finished work." Concerning water it was stated that it "* * * could be put up in tins and scattered throughout the ship. Not only is it imperative to have water at the dressing tables, but drinking water will be at a premium. These cans of solu tions can be sterilized in the large mattress sterilizer, 30 or more at a time. The inside of the cans would probably need some sort of plating or other protection, but that is a minor technical problem." The merit of the suggestion, which has been voiced by other officers than the author quoted, that fixed battle dressing stations be abol ished should be critically examined. In favor of portable outfits and the setting up of the stations at sites to be selected after battle in the manner suggested are: (a) The assumed greater probability that a number of small portable outfits scattered throughout the ship would escape destruc tion than that fixed battle dressing stations would so escape. (6) The assurance of great flexibility and mobility of the medical department. (c) The ease with which stocks of dressings and other surgical material may be concentrated at places chosen for setting up the dressing stations. (d) Adequate space, off main arterial routes accessible to both ends of the ship may be found on the second deck or above while crowded conditions and general inaccessibility of present dressing stations render them worthless. In favor of battle dressing stations as at present provided are: (a) The locations are known to the crew and with well-marked access routes, ambulant patients may promptly report for treatment. (6) Ample dressings, operating facilities and water reserve are localized. (c) Manifest provision for care of wounded will support morale and tend to promote efficiency. (d) Protected by armor (on major ships), unless the vessel suffer excessive damage, at least one station will probably remain fit for use. It is believed that: (a) Prompt and effective treatment may best be achieved by planned rather than extemporized facilities. (6) The value of permanently located battle dressing stations has been clearly demonstrated in modern naval warfare. (c) Interludes in battle may permit access to these stations where wounds may be treated, effectives restored to duty, and lives saved. This will be facilitated if the slightly wounded and the stretcher 192 HOLEMAN MEDICAL DEPT. FUNCTION IN NAVAL ENGAGEMENT bearers know precisely where medical officers will be found and how to reach them by established clearly blazed routes. The record of British ships at Jutland would seem to fully justify the existence of battle dressing stations—in fact there would seem to have arisen no doubt in the minds of their medical officers as to their efficacy. From descriptions given they were no more accessible and certainly no better equipped than those in our own Navy. In any event it has been decreed that on new major ship construc tion battle dressing stations, with adequate storerooms at the forward and after stations and locker space amidships shall be provided and that they shall be retained on ships now in being; that on cruisers two stations with sufficient locker space shall be provided. This decision has been made by the Chief of Naval Operations on the recommenda tion of the Commander in Chief, Bureau of Construction and Repair and the Bureau of Medicine and Surgery. Additional dressing station facilities. —While permanent battle dressing stations are considered essential, to provide against the destruction of one or more of them, by joint action of the Bureaus of Construction and Repair and Medicine and Surgery there is being developed, along the line of the postulates prescribed by Jensen, a portable locker-type outfit to contain sufficient material for setting up one or more dressing stations in such spaces as may be found suitable. The present intention is to provide about six such lockers for battle ships and a proportionate number for cruisers. It is also the intention to place one such locker in a convenient place upon each new destroyer. While battleships only have been considered in discussion of battle dressing stations, quite similar arrangements are provided on aircraft carriers. On cruisers such deviation from the principles enunciated as exist are based upon lack of protection by armor and comparative crowding of general facilities. Since armor protection is not available the sick-bay area is the best possible battle dressing space. Because deck space is at such a premium, officers' or chief petty officers' pantries and living spaces are generally utilized for the other station. Such fixtures as reserve water tanks, water heaters, and lockers are installed in these areas as may be required. On destroyers, in suit able locations, at each end of the ship, water heaters and outlets for a small sterilizer are provided. It is assumed that on these vessels the wardroom will be used as a battle dressing station; the fittings in crew spaces are provided in event of the officers' country being rendered unusable. Battle station facilities. (a) First aid lockers have been sufficiently considered. (6) Water should be provided for drinking. Should the battle be prolonged all hands will probably need it, but particularly will the wounded demand it. Canteens will hold a sufficient quantity; COTTLE —FLEET MEDICINE 193 however, a 10-gallon container with faucet and hooks for hanging it upon a bulkhead is being considered. The additional weight and demand for storage space may prevent its adoption. (c) A sanitary stool, capable of being lashed down, has also recently received consideration, but again weight and storage problems will probably debar it. In any event buckets provided for this purpose should be lined with impervious paper, to be immediately thrown overboard after use. The Bureau of Construction and Repair has given attention to production of a type of lining to fit the regulation Navy bucket. Necessity of guarding battle stations from gross con tamination require no comment. (d) Protective clothing and gas masks are not the responsibility of the medical officer; but, as all preventive measures against disease and injury are within his province to the extent that appropriate recommendations are to be made by him if occasion demands, observa tion as to adequacy and cooperation in maintenance of efficiency of these items should not be neglected. FLEET MEDICINE By Capt. George F. Cottle, Medical Corps. United States Nuvy Fleet medicine is founded on the need to liberate medical activity through cooperation, to strengthen it by coordination, to harmonize it with naval administration, to fit it to the requirements of naval tactics and to make it contribute to the success of naval strategy. It seeks to interpret medical principles to naval commanders and to explain naval requirements to medical personnel. It is practiced through inspections, through study of problems, through conferences, and through indoctrination. It attempts to lessen the number of casualties due to disease and accident, to build positive health and vigor in naval personnel, to enhance morale and to find how to select persons able to stand the stress and strain of naval warfare. Fleet medicine deals with ships, divisions, squadrons, flotillas, and forces. It includes preventive medicine, emergency medicine, hos pitalization, and medical logistics. It encompasses aviation, sub marine, and field medicine. It provides for medical disaster relief and for the care of war time casualties. It studies the causes of fleet morbidities and mortalities. It considers diet, food, clothing, bedding, living conditions, work schedules, athletics, and recreation. It takes into consideration safety devices, safety mechanisms, and habits. It studies the ebb and flow of quarantinable and other communicable diseases in the ports visited by the units of the fleet. It is interested in hygiene, sanitation, quarantine, and pratique. It is interested in immunology and epidemiology, in liaison with health departments and with medical activities ashore. It is interested in the distribution of 194 COTTLE —FLEET MEDICINE medical personnel, in the environment provided for medical personnel at sea, in the sufficiency and economy of medical supplies and equip ment. Fleet medicine strives to study medical problems, to give timely information on medical matters, and to be prepared to provide consultation when indicated. From the day when lime juice pushed scurvy off the sea to the day when a few tablets of common salt stopped the incidence of heat cramps in fire rooms, fleet medicine has year by year seen morbidities and mortalities reduced and eliminated. The seven quarantinable diseases, including smallpox, yellow fever, and cholera no longer enter the Navy because fleet medicine has long been coordinated with the activities of the United States Public Health Service through whose activity those diseases are kept at bay. Typhoid fever has been almost eliminated by inoculation, dysentery by precautions surround ing the supply of drinking water and food in ships. Attention to safety precautions and devices while men are at work, to living condi tions aboard ship, to athletic and recreational opportunities have in combination with improved methods of control of the spread of disease, reduced morbidities and mortalities year by year and encour aged healthy, wholesome, normal, ambitious young men to enter the naval service and to remain in it. Fleet medicine attempts to develop fleet medical sufficiency, the ability to meet the emergencies of surgery, of medicine, and of preven tive medicine. It provides for intership consultations, for transfer of the sick and injured at sea. It hopes to so influence its ships' medical officers that the fleet, each force and even each ship will be able to complete its assigned task, perform its tactical mission without the disturbance that can be produced by inability to handle medical emergencies. Fleet medicine attempts to visualize its war mission. It studies the history of naval warfare, the battle of Jutland, the overseas combined operations at Gallipoli, the history of transportation over seas of troops from Australia, Canada, India, and the United States. It realizes that sick lists in transports rise to 5 percent of all on board, that attempts to seize defended beaches result in 20-40 percent of casualties which must be evacuated along lines of naval communica tion without too great slowing of the military and naval advance. It discusses the movement of hospital ships, the preparation and place ment of field hospitals. It takes cognizance of the professional ability of naval reserve medical personnel and prepares to give them an understanding of the seagoing environment in which they are ex pected to function. Naval personnel at sea live within the iron walls of ships where workshops, enormous power plants, complicated machines, high- tension electricity, guns large and small, high explosives, airplanes, COTTLE—FLEET MEDICINE 195 small boats, tall masts, contain the threat of accident even of disaster. On deck, fog, rain, snow, sleet, storm, heat, and cold produce their effect. Inside the ship, officers and men eat, sleep, bathe, play, work, study, and drill crowded together too close for comfort. Fleet medi cine is interested in the prevention of disease transmission, in the prevention of accidental injury. Closed tight against storm and wet or against enemy attack the ventilation, heating, and cooling of living and working spaces require study and supervision of a special sort. Fleet medicine is interested in the medical care available to families of officers and men on shore. The better medical care available loved ones ashore the more free from worry and the more able a crew becomes for the work at sea. Fleet medicine is interested in health conditions at and near shore bases and ports of call. The efficiency of public health officials ashore directly effects the health of the fleet. Fleet medicine learns of the incidence of world-wide disease through reports of the United States Public Health Service. It learns of local disease incidence through scanning the weekly and monthly reports of State, city, and county health boards. Thus it can anticipate, slow up, or perhaps even pre vent sudden unexpected entry of epidemic disease to the fleet. Some of its problems can be solved by the receipt and dissemination of news, some by study and indoctrination, some are capable of solution in the fleet only in part, some wait upon solution of public health problems ashore, some must wait until new therapies, new preventives are found. Nearly one-half of the total yearly incidence of disease and injury in the Navy is due to causes that are not directly within fleet or Navy control. Of the 55,614 primary admissions to sick list in the year 1936, 17,725 were due to communicable diseases transmissible by oral and nasal secretions the great majority of which were of the "common cold" or according to the Navy nomenclature "catarrhal fever"; S,148 primary admissions to sick list were due to the venereal diseases and 802 were caused by accidents from vehicles. The dangers of crowded living conditions are constant. Cleanliness of mess gear, of food handling, scuttle butts, clothing, persons, bed ding, supervision of ventilation, of heating, of laundries, of barber shops; these and other hygienic mechanisms reduce somewhat the opportunity for rapid spread of many diseases but the common cold still sweeps unhindered through ships and fleets and influenza is still entrenched behind its power to fell large numbers of men and even to slay a few. Medical literature is scanned in vain to find a preventive of value against this foe to fleet efficiency, this invader which returns year after year to bother, and to disturb, to initiate, and to do damage. Against the second common cause of fleet disease incidence, the venereal diseases, we have some useful weapons and of late some hope of better days ahead. To attempt control of these invaders we teach 196 COTTLE —FLEET MEDICINE and warn our men, we give them ready access to chemical and mechani cal preventives. We improve our therapy as it improves in civil life. We are ever alert to find and use new remedies. We have achieved a degree of success. For 4 years the incidence of these diseases has been continuously lowered each year. Further reduction depends upon successful action in civil communities where these diseases ebb and flow practically uncontrolled. However, hope is here, civilian com munities are awakening, out of the dark of defeatism a new day ia dawning. The light of this new day has for 10 years been shining in the Scandinavian countries where the incidence of venereal disease has been falling, where syphilis has become a rarity. The light of this new day has penetrated to England. It has reached the Common wealth of Massachusetts, the State of New York. Reflected from the brilliant service of Doctor Parran, the Surgeon General of the Public Health Service, it is spreading throughout the United States. The new light has begun to glow where inertia, ignorance, false piety, silence, let well enough alone policies have lived in darkness. Gover nors, legislators, cities, towns, and counties have taken notice. State boards of health have turned from discouragement to hope, old laws have been given new life, new laws have come into being. The people have begun to listen, to open their purses, to lend their support. News papers, periodicals, books, and people have become articulate. The battle is on in earnest, in the open. These age-old enemies must be and will be conquered when the citizens and physicians are stirred to act in line with public health leadership. In 1936, 860 of our officers and men were striken on the public high ways and 56 of them died from this cause. The fleet can exert but slight control over the hazards of the highway. Condemnation and punish ment of offenders, in occasional instances, warning against careless ness, are the limits of our control, hope for reduction in these losses of man power lies only in civil life. Fleet medicine is interested in human conduct, in the prevention of mental aberration and mental disease. Our aviation specialists tell us that there is a recognizable type that cannot take the stress of aviation. We feel that there is opportunity to study human behavior more intensively, to find and try out more exact measurements of psychic and emotional states among officers and men. Every year we see suicide, discharge from the service for mental disease, and dis charge from the service for disciplinary reason. Fleet medicine faces this problem of the ability of human beings to become adjusted to naval life with the firm belief that some of these losses of man power originate in types that are emotionally unstable. It is believed that some of them can be discovered and eliminated from the service before their conflicts and maladjustments reach the tragic end of suicide, JOHNSON—HOSPITAL SHIPS 197 mental disease, or disciplinary discharge. In statistical form the losses for the year 1936, from these causes were: Suicides 29 Separated from service for mental disease 241 Separated from service by disciplinary discharge 919 The senior medical officer of a ship, the division medical officer of a group of destroyers sees fleet medicine from his station aboard one ship. He is absorbed in the care of the sick, in attempts to influence ship hygiene, to control the spread of disease, to save life and limb. In this outline of fleet medicine he may find a widening horizon. He may find a means to focus his attention on the unsolved problems that persist. He may find a way to lead us forward one more step toward reduction of the morbidities and mortalities not yet eliminated from the sea. HOSPITAL SHIPS ' By Capt. Lucius W. Johnson, Medical Corps, United States Navy Introduction Down through the centuries there has been gradual development of a mental concept that has been aptly termed the Ked Cross idea. This idea, briefly stated, is that adequate care for the sick and wounded of naval and military forces is not only good as a humanitarian act, but it is of distinct advantage to the organization. It prevents the spread of disease, restores men to the ranks who would otherwise be lost, and helps to maintain morale. In remote times it was customary for military leaders to take with them to war, but only for their own personal service, men who com bined the duties of barbers and surgeons. Their soldiers, when wounded or sick, were left to the tender mercies or the evil devices of the camp followers. Ambroise Pare, best of the early military surgeons, describes an impressive incident which occurred at Turin in 1563. He saw an old sergeant cut the throats of three of his wounded men, gently and without malice, remarking that he hoped somebody would do as much for him if he were ever in their condition. Numerous historical records leave us in no doubt that the lot of the wounded soldier of that day was not a happy one. By the middle of the eighteenth century, most governments had begun to feel the obligation to protect the health of their soldiers and to organize for the care of the sick and wounded. As the general standards of medical and surgical care and hospital treatment have i The conclusions reached and the opinions expressed are entirely those of the author. They must not be regarded as in any way representing the official opinions or administrative policies of any bureau or govern mental department. Editor's note.— The author is particularly competent to write on hospital ships. His service Included duty as senior medical officer of a large troop transport and as senior medical officer on the U. S. 8. Relief, and he has obviously made a thorough study of his subject. This article as submitted included an excellent historical review which the Bulletin was unable to use. 198 JOHNSON—HOSPITAL SHIPS advanced through the decades, provisions for the care of men in the armed forces have made parallel progress. (1) We have it on the au thority of no less a personage than Sir John Pringle that, in 1743, before the battle of Dettingen, the Earl of Stair proposed to the Duke of Noailles, of whose humanity he was well assured, that both the English and French hospitals should be considered as sanctuaries for the sick, and mutually protected. This was readily agreed to by the French general, who took the first opportunity to show a particular regard for this engagement, and it was strictly observed on both sides. The idea continued to spread and finally, through the persistent efforts of Mons. Henri Dunant, a Swiss, culminated in the Geneva conven tion of 1864. (2) A series of conferences and conventions at Geneva and The Hague followed, with The Hague convention of October 18, 1907, giving special consideration to the evacuation of the wounded in naval warfare, and to hospital ships, which is our present interest. This recognition of hospital ships, and the clarification of their status, marked an important step in their evolution. It focussed the eyes of the military world on a matter that had been gradually taking form for centuries —floating hospitals for naval personnel. Some of the most commendable of humanitarian ideas weave them selves so gradually into the fabric of human thought that their presence is not even suspected until long after they have become thoroughly incorporated into the pattern of community opinion. They are usually brought to the fore when somebody discovers that they are not only of philanthropic interest, but of great practical value. Thus the hospital idea germinated very gradually for more than 250 years and then burst into full bloom about the turn of the century, when the practical importance of conserving the lives of trained naval and military men began to be appreciated by governmental authorities. We have made great advances since the days when the dead and seriously wounded in naval battles were thrown overboard, to avoid weakening the morale of those who continued to fight. The trail of our progress is marked by numerous publications dealing with hospital ships, and so extensive is the literature on the subject that more than 200 books and articles were read in assembling material for this dis sertation. Two of them are of sufficient importance to deserve special mention. Hidden away under the title "Medical Tactics in Naval Warfare" is the most complete and authoritative study of hospital ships and their employment that I have been able to find. In this book, which was published by Capt. W. L. Mann, Medical Corps, United States Navy, in 1926, there are 80 pages devoted to consideration of the subject of floating hospitals. His profound research and clear reason ing have produced a work which no student of this topic can afford to underestimate. It has been of the greatest assistance to me, and I JOHNSON—HOSPITAL SHIPS 199 am reminded of a passage written by a distinguished professor of biology in the University of Cambridge. In the 1909 edition of Mendel's Principles of Heredity, Professor Bateson recounts an inci dent of his early years in research. "I well remember receiving from one of the most earnest of my seniors the friendly warning that it was a waste of time for me to study variation, for Darwin had swept the field." I have some hesitation in approaching the matter of hospital ships, where Mann has swept the field, but am encouraged to continue and to test the old adage that "fools rush in and win where angels fear to tread." Surgeon-Rear Admiral Edward Sutton, R. N., is the author of the other outstanding book. It is entitled "The Fitting-Out and Admin istration of a Naval Hospital Ship," and was published in 1917. Hi3 experience in command of H. M. S. Rewa and H. M. S. Drina during the world war formed the background for this excellent work. In 1918 he was in command of the naval hospital at the navy yard, Haulbowline, Queenstown, Ireland, and the many medical officers of the United States Navy who made his acquaintance there have reason to remember with pleasure and gratitude his helpful and courteous demeanor. There are also many important articles by Pickthorn, McNabb, Chambers, zur Verth, Pleadwell, Holcomb, Chastang, Averous, and others, which the student of this subject must not fail to read. They will be found listed among the references. I am greatly indebted to the Army medical library for the loan of many books and periodicals which could not be found in any of the west coast libraries to which I had access. Particular thanks are due to Commander L. H. Roddis, Medical Corps, United States Navy, for tracking down many elusive references. This is being written during a 2-year cruise on the U. S. S. Relief, much of the time remote from sources of information. In such a case, one needs a friend who is familiar with the libraries where naval and medical history may be found. Dr. Roddis has been such a friend and has seldom failed to dig up the information that was needed. A leading nation, engaged in a major naval war, will require several types of hospital ships, each differing from the others in certain impor tant characteristics. There should be fleet hospital ships, floating hospitals for advanced bases, hospital transports, perhaps rescue ships and small craft for inland waterways. Each of these demands accen tuation of certain details that are most important for the work that it is called upon to do. We have examined, sometimes with a critical eye, the hospital ships of the past. It is with no disrespectful thought that we summon back those forgotten ships, to learn from them the secrets of their failures and successes, of their good and bad features, hoping to observe them 200 JOHNSON—HOSPITAL SHIPS with that nicety of discrimination that will enable us to take profitable advantage of their virtues while avoiding their faults. A hospital ship, like every other human achievement, represents a series of com promises between the ideal and the practical. This point is empha sized by Mahan, in commenting on the design of combatant ships. You cannot have everything. If you attempt it, you will lose everything; by which I mean that in no one quality will your vessel be as efficient as if you had concentrated purpose on that one. On a given tonnage * * * there cannot be had the highest speed, and the heaviest battery, and the thickest armor, and the longest coal endurance, which the tonnage would allow to any one of these objects by itself. This principle applies equally to hospital ships. You cannot have the highest speed, the greatest steadiness, the largest bed capacity, economy of operation, and the most efficient arrangement of medical department spaces, all combined to the maximum degree in any one ship, so compromises will be required to make the individual ship best fitted for its purpose. I. The Fleet Hospital Ship The fleet hospital ship should be, above all other things, a ship specially built for its intended function which is to accompany the fleet and provide it with hospital facilities. The hospital transports may well be converted liners, but the ship that is to serve as hospital for a fleet has requirements that cannot be completely met except by special construction. No one would expect a house or a factory on shore to be converted into an ideal hospital, for there would have to be many makeshift arrangements which would reduce its usefulness. Even more is this true of ships, and writers on hospital ships have repeatedly criticised their converted vessels, stating that the highest efficiency would never be reached until a specially designed and built ship was provided. Our experience with the Relief, the only hospital ship afloat that was designed and built especially for this purpose, indicates that the useful life of such a ship will be at least 30 years, and any first-class nation would find that the specially built hospital ship had paid large dividends, which would justify the money invested, long before its period of usefulness was ended. Size is a very important consideration, which has been discussed by many writers and with very little agreement. But it is notice able that, whereas before the World War most authorities recom mended ships of 3,000 to 5,000 tons, recent writers advise ships of 8,000 to 10,000 tons. The disadvantages of oversize were clearly shown by the France IV (29,000 tons), the Aquitania and Mauretania (30,000 tons), and the Britannic (47,000 tons), which were employed during the Gallipoli campaign. They were too large to enter the harbors at Alexandria and Malta and their capacity was so great JOHNSON— HOSPITAL SHIPS 201 (3,500 to 4,000 patients) that a full load of sick was not always avail able, resulting in uneconomical employment. Their daily consump tion of coal and water was so enormous that it was difficult to supply their needs. The Maine, of the British fleet, and the Relief, of ours, have proved to be sufficient in capacity for the needs of the fleet in times of peace, and reasonably economical in cost of operation. They are both approximately 10,000-ton ships. In time of war, rapid evacuation by hospital transports and hospital facilities on shore at an advanced base would be necessary, in addition to the fleet hospital ship, if overcrowding were to be avoided. A large ship provides steadiness, which is valuable for the comfort of the patients, for surgical operations, and other procedures, and it is easier to bring patients aboard a large steady ship. Capacity is closely related to size, and must always be considered as being very elastic, varying with the requirements of the moment. Recent hospital ships have accommodated one patient for each 20 to 40 tons and, if the requirement of 300 to 500 cubic feet of air space for each patient is met, this proportion cannot be greatly exceeded. It must always be borne in mind that the level of efficiency of medical care falls rapidly as the normal capacity is approached or exceeded. For this reason, prompt evacuation, before the hospital ship becomes overcrowded, is very important and will save lives. Speed should be sufficient to enable the hospital ship to maintain her place with the train, and a few knots in addition. It would be highly desirable to give her speed enough to keep up with the fastest unit of the fleet, but this would entail such great sacrifice of capacity and cruising radius that it must be relinquished in favor of more essential features. High speed also entails increased vibration and greater unsteadiness in a seaway, both undesirable attributes for a hospital ship. None of those who have written on the use of hospital ships during the World War has mentioned high speed as being necessary while several have spoken of its disadvantages. Sutton makes the important comment that high speed, inasmuch as it implies greater cost, absorption of space and production of heat, larger crews, and increase of discomfort in bad weather, is undesirable, and war experience has shown it to be unnecessary. He regards a cruising speed of 10 or 12 knots, with an extra 3 or 4 for emergencies, as suitable for a hospital ship. Ability to remain with the fleet includes the requirement that she be so constructed that she can darken ship at night and still maintain habitable conditions in wards, clinics, operating rooms, machinery, and living spaces. This condition cannot be completely obtained unless the ship be designed and built with this feature in mind. A very large part of her usefulness to the fleet is lost if she cannot re main with it by night as well as by day, and if she can darken ship 202 JOHNSON—HOSPITAL SHIPS only with intolerable discomfort to patients and workers, it will quickly be reflected in the death rate on board. Electric-power production should be greatly in excess of that ap parently necessary at the tune of construction of the ship. Count less new electrical gadgets of all sorts have been installed in the Relief since she was commissioned, and there is nothing to suggest that this flood of new devices will slacken in the future. Both alter nating and direct currents will be necessary and outlets will be re quired in all wards, clinics, and rooms for such machines as portable electrocardiograph, short-wave diathermy, ophthalmoscope, radio, portable X-ray, vacuum cleaner, deck polisher, and others. An auxiliary lighting system, entirely independent of the main power plant and assuming the load automatically whenever the voltage drops below a certain level, will be an essential. It should supply the operating room, engine room, and bridge. In most other parts of the ship the necessary work can be carried on by lantern or flash light if the main circuit fails. Distilling capacity should be greatly in excess of that provided for other ships of similar size. Care of the sick requires much more fresh water than a similar number of well persons would need and a very large quantity will be consumed in the laundry, laboratory, and other activities. Baths and other outlets will be much more numer ous than on ships of other types. The fleet hospital ship should be entirely independent of outside sources in the matter of fresh water. The hospital spaces should be concentrated amidships. Clinics, offices, treatment rooms, laboratory, operating rooms, convalescent wards, and other activities in which patients do not spend their whole time, may well be located below the main deck. Wards for the sick should all be located on or above the main deck and should have open deck space immediately adjacent to them. This is one of the most essential features and should be the last to be sacrificed when compromises are necessary. Both open deck space and glassed-in solaria will be required and it is important that they be made as accessible as possible, so that patients can be wheeled out on deck without too much handling. Throughout the parts of the ship which are devoted to hospital use, the ladders, elevators, passages, and doorways should be so de signed that they give convenient passage to patients on hand or wheeled stretchers, in wheel chairs or on crutches. Wide doorways with low coamings are essential and should be installed wherever the naval constructor will allow them. Stairways, instead of ladders, will make going about much easier for convalescent patients. Rooms for patients will need to be large enough and have doors wide enough so that a wheel stretcher can be brought inside the room and alongside the bed for transfer of the patient. A narrow door into JOHNSON—HOSPITAL, SHIPS 203 a small room requires a great deal of awkward handling of the patient between stretcher and bed, and this may be a very serious thing if the patient be severely wounded, in shock, or in a plaster cast. The height of rooms and wards should be 7% to 8 feet, to allow for satis factory ventilation. Air space of 300 to 500 cubic feet per patient is the present standard but, with more advanced air conditioning, it is probable that this amount may be reduced considerably and still maintain adequate aeration. Laundry capacity should be very large. On the Relief, with 200 patients present, about 2,000 pounds of Medical Department linen are sent to the laundry each day. This activity, together with the galley, bake shop, butcher shop, blacksmith shop, morgue, and other spaces which are likely to give off wild heat, unpleasant noises, or undesirable odors, should be located well aft, where they will cause the least possible annoyance to patients. Boats, davits, and all gear associated with them should receive the most careful consideration. They are important for bringing patients aboard, and doubly import ant for rapid evacuation in case it becomes necessary to abandon ship. Public opinion will not easily be appeased if there is unnecessary loss of life among the patients, in case of a disaster to a hospital ship. Elevators are essential equipment and separate ones are desirable for patients, provisions, baggage, and contagious cases. Elevator wells are to be completely enclosed, so as to make them as nearly noiseless as possible. Careful study is required to have the wards, clinics, and passageways so grouped that they will be most con veniently accessible from the main elevator which is to be used by patients. Indirect lighting is most desirable for the wards, and separate read ing lights are needed for the bunks. Lights near the deck, similar to those used in theaters, are required for night use by attendants. Out lets for attachment of individual radios, or head sets connected with a central receiving station will provide amusement for the patients and help to keep them contented. Some type of silent call system with a push button at each bunk and an annunciator in the nurse's office will be a necessary part of the equipment. Entry ports should be constructed in the hull, at least one in each side, to permit easy entrance of patients. A gangway 60 inches wide will be found to aid greatly in the handling of patients on stretchers. Several cranes especially designed and fitted for hoisting-in patients will be necessary. Boats in large number are required, for it may be necessary to take aboard many patients from sinking ships or from those whose boats have been shot away. All possible provisions should be made for rapid reception of large numbers of patients or ship wrecked men. 204 JOHNSON HOSPITAL, SHIPS A study of the records of the Relief for the past 16 years, giving consideration to the patient loads at different times of the year, in port and at sea, indicates that the following percentage distribution of beds in the different wards will be most satisfactory: Perctnt Officers 3 Contagious and acute medicine 10 General medicine 9 Operative surgery 15 Traumatic surgery 15 Eye, ear, nose, and throat 7 Insane 1 Urological and skin 15 Convalescent wards 25 Total --- 100 Plans are to be prepared in advance for rapid shifting of patients and reassignment of beds in emergencies, such as epidemics of con tagious disease, a large influx of badly burned men, or many suffering from exposure after shipwreck. These are among the everyday hazards of life at sea and they provide the best test of the efficiency of the organization and the ability of the staff of the hospital ship. If suitable spaces are available, it will be found very advantageous to make special provisions for certain types of cases which need special care, such as the insane, tubercular, patients in plaster cases, those with cardiac and renal disorders and patients requiring skeletal traction. The most modern equipment is required for X-ray, elec trocardiography, basal metabolism, bronchoscopy, physiotherapy, photography, cystoscopy, dental clinic, and laboratory. No attempt will be made here to list the individual items of equipment or supplies, because they will vary so much, according to the time and place of outfitting the ship and the stock that may be available. The most important thing is that they should be the articles best suited for the persons who are to use them. A library of recent medical books and periodicals is a very important adjunct. A list of the work done on a hospital ship in active commission will undoubtedly bring to the mind of the interested reader many details which have not been mentioned here. The Relief provides the fol lowing figures for the first 10 months of the calendar year 1936: Total patients hospitalized — 2, 027 Total sick days --- 39,903 Major operations 475 Eye, ear, nose, and throat operations 320 Eye, ear, nose, and throat treatments 2, 197 Total laboratory examinations. 13, 949 X-ray examinations and treatments 2, 002 Dental examinations and treatments 5, 639 Dental plates, splints, and other devices made. 341 Physiotherapy treatments 4,366 JOHNSON—HOSPITAL SHIPS 205 These figures are for active service with the fleet, both at sea and in port, during peace times. In time of war we should anticipate greatly increased demands on the fleet hospital ship. Thousands of newly-recruited men will join the fleet and this will inevitably be followed by epidemics of contagious diseases, perhaps crippling the combatant ships unless the sick can be removed to the hospital ship. The new men will develop numerous physical weaknesses as a result of their new activities, and many of them will require hospitalization. Advanced bases will probably be established overseas, at places where there are no hospital facilities on shore, and so the fleet will become completely dependent on the hospital ship. Prolonged cruises are likely to occur, with the hospital ship accompanying as a part of the train. All these activities will add to the work load. Shall female nurses be employed on the fleet hospital ship? In time of peace, their presence is desirable. They create an atmosphere more conducive to recovery and their presence ensures the main tenance of a higher level of nursing efficiency. In time of war, they will be needed on the hospital transports, but with the fleet hospital ship, accompanying the fleet on long cruises, or remaining for long periods at an advanced base, they might easily become a liability. A French writer, discussing this problem, refers to the many tempera mental and sentimental episodes which occurred on his ship and con cludes that, if female nurses are allowed on hospital ships, they should be not only physically sound, professionally able and morally strong, but also of very advanced age. The writer has much sympathy with his point of view. If provision is to be made for them, each nurse should have a separate room; there should be elaborate bathing and toilet facilities and also a space where they may launder and iron their clothing. Deck space, where they may relax and sun them selves in privacy, is an essential. One must not forget to arrange an interior route to the wards so that they can go back and forth between their quarters and their duties without being exposed to inclement weather. Ample provision should be made for storerooms and large ones, centrally located, will be found better than numerous, scattered, small spaces which require more room, more time and more clerical work. There should be separate spaces for bulk medical stores and open stock for issue. The linen room should have plenty of shelf room and a very large table for sorting, also ample floor space, for this is one of the busiest places on the whole ship. It should be con venient to the laundry and to the wards. One should plan to carry a year's supply of medical stores and linen, for the ship may be away from sources of supply for indefinite periods and, in war times, it may be impossible to replenish stocks of essential items. Cold storage rooms should be ample in size and conveniently located. Special 45202—38 1 206 JOHNSON—HOSPITAL SHIPS compartments axe required for cold storage of biological preparations, a large stock of which will be necessary to provide for prolonged absences from sources of supply, and for cold storage of the dead. A strong room for alcohol and narcotics will reduce administrative difficulties in their care and issue. A tent hospital to be set up on shore when needed, is a valuable adjunct, for which many uses will be found. A disaster in an ad jacent civil community, an expeditionary force landed on a foreign shore, an epidemic of contagious disease that overtaxes the facilities of the ship, or any other condition that requires additional hospital work on shore can well be served by a tent hospital carried by the ship. Plans should be laid to make it as independent of the ship as possible, in the matters of commissary, fresh water, personnel, and medical supplies. Plenty of deck space, both open and covered, is a prime requisite. It is essential, both for their own health and for proper administra tion of the wards, that ambulant patients be kept out of the wards as much as possible during the day, so it should be made as easy as possible for them to get on deck and take advantage of the sunlight and fresh air. A comfortable recreation room, where the convales cent patients and the crew in their time off duty may read, write, and play games will aid greatly in maintaining morale. Consideration should be given to the harmful effects of noise and the increased suffering which it may cause the sick. Soundproofing of the decks and bulkheads will help to reduce this. Cranes, winches, and other machines should be removed as far as possible from the spaces for the sick and every effort made to have the most silent type of machines installed in such a way as to reduce noise and vibration to the minimum. Ratproofing, telephones, facilities for showing moving pictures, air conditioning of wards and rooms, equipment of galleys and diet kitchens, quiet rooms, plumbing fixtures, plaster room, venereal treat ment room, bronchoscopic facilities, floor coverings, and canteen are a few more of the myriad details that must be considered when plan ning the construction or the conversion of a hospital ship. In general, our aim should be to provide a vessel having all the facilities, all the equipment and the trained personnel of a completely modern shore hospital. In addition, it should carry a reserve of stores for issue to other ships, a field hospital to be set up on shore to serve an expeditionary force or to aid in case of disaster in the civilian community, and equipment for rescuing those who are required to abandon sinking ships. Employment. —It is universally recognized that, in time of peace, the sole function of the fleet hospital ship is to provide a complete, mobile, base hospital for the fleet, whether in port or at sea. In JOHNSON—HOSPITAL, SHIPS 207 carrying out this function it helps combatant ships to avoid danger of epidemics by removing their cases of contagious disease. It provides facilities for disinfection, special laboratory work, consultation with recognized specialists, and care of the dead. It benefits the morale of fighting ships by removing their sick and wounded. Sir Cyprian Bridge, in the Art of Naval Warfare, recommends that the base hos pital facilities be mobile, in the shape of hospital ships, rather than stationary on shore, which could not readily be expanded and would doubtless be too remote from the scene of battle. He also states that: The problem of expanding sufficiently the Medical Department of the Navy When war comes, will be most effectually solved by the employment of hospital ships in time of peace, provision being made for an increase of their number as soon .as hostilities are imminent. Hospital ships steadily worked in peacetime will habituate the service to their use in war. This will go a long way toward rendering « fleet or squadron independent of fixed bases which it may be impossible to form .except at inconveniently distant points. It will perhaps appear more costly than the plan of establishing Government hospitals at fixed bases; but in the first place this ie not certain, and in the second place the excess of cost, if any, may be justifiably incurred, because it will be due to the adoption of a plan promising increased efficiency in war. These are the benefits which flow from the employment of hospital ships with the fleet in time of peace, as the Relief is now employed. In time of war, the functions of the fleet hospital ship will be con siderably expanded. Not only will she provide hospital facilities while the vessels remain in port but when the fleet, or an expedition ary force, goes to establish an advanced base, she will accompany them, to provide the necessary establishment for the care of the sick and wounded at that base. When the fleet moves on to another base the hospital ship will accompany the train, perhaps leaving behind, in the field hospital set up on shore, those unable to resume duty, for return to the home bases by the hospital transports. Prac tically all writers agree that, like the other auxiliaries, the hospital ship lias no place with the fleet during battle or when it is imminent. Mahan writes that the proper disposition of the transports and hospital ships, until the end of the battle, is to dismiss them out of mind and presence. If beaten, the loss of them will not be of the slightest consequence; if successful, they can be summoned from an appointed rendezvous. Before and after the engagement, however, the hospital ship may play her most important role. When contact with the enemy force impends, all disabled men should be cleared from the combatant ships. This will save such men from the discomforts and anxiety they would suffer as nonparticipants in the midst of the battle; it will improve the morale of those left to fight; it will make the whole hospital space of the ship available for the injured after the battle. The battle being over, every effort will be made to remove the disabled from the fighting ships as quickly as possible, and this in 208 JOHNSON HOSPITAL SHIPS volves the consideration of a multitude of varying conditions, suclr as rough or smooth sea, the distance of the fleet from the base, pres ence or absence of enemy submarines, decisive or indecisive outcome of the battle, victory or defeat for our fleet, number of wounded, and the number of seaworthy boats left for their trans-shipment. It may be advisable for the hospital ship to proceed and join the fleet; or for both to proceed to the base before transferring the patients; or to send medical officers and supplies from the hospital ship to the sur viving ships to aid in the work, instead of bringing the patients to the hospital ship. No rules for this work can be laid down in ad vance because of the myriad conditions that may influence the choice of the means to be adopted. Arrangements for loading and unloading patients deserve long study. No completely satisfactory method or device has yet been developed. Ever since the Battle of Beachy Head in June 1690, the importance of this problem has been recognized and dozens of schemes have been tried, but no completely satisfactory method or device has been developed. When the Relief was built, an elaborate apparatus was installed for hoisting patients aboard; but its use was abandoned, and it was eventually removed because it worked too slowly and it failed to raise the two ends of the stretcher at the same rate of speed. At present we are using a very simple means; a davit is swung out and from it a twofold fall is dropped. At its lower end are four finger ropes, each with a snatch hook at its end. The hooks are secured to the four corners of the Stokes stretcher, and it is then hoisted hi by hand. The Stokes splint stretcher has been the Navy's standard for more than 25 years, and it is still regarded as the best for moving disabled men. Transportation of patients from ship to ship at sea is best accom plished by using a motor whale boat and putting the patient in it before lowering. When patients are received from or discharged to a dock or a lighter alongside, cradles carrying two or more stretchers may be employed. Countless devices have been tried, but still there is no satisfactory means of transferring wounded men from ship to ship in a rough sea. This fact, and the possible presence of enemy submarines, impose the most important limitations on the usefulness of the fleet hospital ship after a battle. Mann has suggested that over-age destroyers be fitted out for the work of carrying patients from combatant ships to the hospital ship, and that they accompany the fleet for this purpose. II. Fleet Hospital Ship, United States Ship "Relief" This is the only hospital ship maintained permanently with a fleet in time of peace. She is the only modern hospital ship to be designed and built, from the keel up, for this single purpose. Since her recent extensive overhaul, she represents the most advanced ideas in hos JOHNSON—HOSPITAL, SHIPS 209 pital ship arrangement and equipment. For these reasons, consider able space will be devoted to a detailed description. The sentiment has often been expressed by those writing of hos pital ships, that a vessel designed for carrying cargo or passengers had many limitations when the time came to convert her to care for the sick. Even the most costly and extensive alterations produced a result far from ideal. Many have wished for the opportunity to design and build a hospital ship which should approach perfection. The United States Navy finally did build such a vessel, and it was the happy lot of Commanders E. M. Blackwell and R. C. Holcomb, ,of the Medical Corps of the Navy, to put their dreams on paper and to see them transformed at last into the substance of the U. S. S. Belief. The present ship was named for the earlier Relief, a converted liner which served the same purpose during the Spanish-American War, the Philippine Insurrection, and the Boxer uprising. On August 29, 1916, the act of Congress which authorized the construc tion of the new hospital ship was passed and, on the same day, the contract was awarded to the Philadelphia Navy Yard for the con struction. While the World War continued, other building was con sidered more important and the work on the Belief lagged. The keel was laid on July 14, 1917; the first frame was erected on May 15, 1918, and she was launched on December 23, 1918. Mrs. William C. Braisted, wife of the Surgeon General of the Navy, was her sponsor. On December 28, 1920, she was finally commissioned. The hull of the Relief is built on the standard naval-auxiliary plans and it is 484 feet over all, 61 feet beam, 20 feet 6 inches draft, and 9,750 tons full-load displacement. The twin screws are driven by Parsons- type geared steam turbines of 5,000 horsepower. The steam used by these turbines is generated by three Babcock and Wilcox, oil-burning boilers, which have a capacity of 5,500 horsepower. The extra 500 horsepower generated by the boilers is used to run the auxiliary ma chinery, such as the two 300-kw generators, steam pumps for various uses, galley, laundry, heating circuits, sterilizers and evaporators. There is an auxiliary lighting system for the operating room, two dressing rooms, engine and fire room. When the generators fail, or the voltage drops, it switches automatically to the 300-ampere batteries, which are sufficient for 6 to 8 hours at 120 volts. In addition, there is a generator driven by a Kohler four-cylinder gasoline engine, which is sufficient to light these same spaces for an indefinite time. A40-kv-a steam-turbine driven generator furnishes alternating current elec tricity for the X-ray machines, radios, and short-wave therapy ma chines. This arrangement is not as satisfactory as a large rotary con verter would be. Installation of additional electrical devices from year to year has taxed the capacity of the generators to the limit, and 210 JOHKSON —HOSPITAL SHIPS this suggests that generous provision for such expansion should be made when planning hospital ships. Two passenger and two freight elevators are provided. The main elevator runs through all decks from the medical storeroom in the hold to the superstructure deck. It serves the convalescent mess hall, the medical and surgical wards, the operating room, sick officers' quarters, and the cabins on the superstructure deck. Its rated capacity is 3,500 pounds and it is large enough to accommodate wheeled stretchers, food carts, and other vehicles. A second passenger elevator connects the contagious wards with the main deck, so that patients can be ad mitted directly to those wards. A freight elevator, of 2,500 pounds capacity, runs from the main deck down to the cold-storage spaces and the morgue. An additional lift for baggage runs from the main deck down to the bag room. The ship has four decks in the hull, including the hold; two above and two below the water line. There are four decks above the hull, including the bridge deck. The spaces on the respective decks, which relate to the Medical Department, are as follows: On the superstructure deck, from forward aft, are quarters for the executive and senior medical officers, the commanding officer, 6 line officers, and the quarters for 12 nurses. On the extreme after part of this deck, four sets of officers' quarters have recently been constructed, to provide for two more medical officers, one dental and one line officer. On the upper deck are located the operating suite, the sick officers' quarters with 9 rooms and the wardroom, with quarters for 11 staff officers. Then comes a well which is 6 to 12 feet in width, separating the main superstructure from the contagious wards. Abaft these are a locked ward with four beds and then the animal house. The last provides cages for white mice and guinea pigs. The main deck has, under the forecastle, carpenter and paint shops, canteen, crew's recreation room, barber shop, seamen's quarters, and ship's service store. Abaft this comes the quarter-deck, 30 feet fore and aft. Here are the hatches leading to the wards below, and a cargo hatch leading to the medical store room. Then comes the dental clinic, running athwartship, with the X-ray clinic on the port, and the eye, ear, nose, and throat clinic on the starboard side. Abaft these are the medical record office, dispensary, galleys, and various ship's offices. Then comes the well which separates the contagious wards from other parts of the superstructure. In the after deck house we find a ward with eight bunks and three quiet rooms, which is used for the overflow from the contagious wards or from sick officers' quarters. Then comes the laboratory, the autopsy and embalming room, the large steam disinfectors, and the incinerator. Covered deck space, about 15 feet wide, extends from the quarter-deck to the stern on each side of the superstructure, on the upper and main decks. JOHNSON—HOSPITAL SHIPS 211 The second deck, which is the first deck within the hull, is devoted largely to the wards. Under the forecastle are quarters for the hospital corps men and the crew. Then come 2 wards with 29 bunks and 1 quiet room in each. On the starboard side is the medical ward and on the port side is the eye, ear, nose, and throat ward. Abaft there is an athwartship passage, with a cargo port in each side of the ship for reception of patients. Doors in the after bulkhead of this passageway give access to the 2 large surgical wards of GO beds each, on the port side for operative surgery and on the starboard for trau matic surgery. Along the wing passages outboard of the engine-room uptake are, on the port side, the physiotherapy clinic, scullery, and messroom; on the starboard side, the cystoscopic room, special diet kitchen, and post office. Abaft this, on the port side, is the urological ward. The first platform has quarters for crew and hospital corpsmen, 2 convalescent wards with 56 and 64 bunks, mess room for hospital corpsmen and convalescent patients, bag room, laundry, and refrig erating space. The second platform has a large storeroom for medical department supplies in bulk, 33 feet fore and aft, and extending the full width of the ship. There is a second storeroom, nearly as large, used as an issue room. Then comes a large space used for storage of patients' baggage. Abaft the engineroom bulkhead are rooms for storage and handling of linen, also large cold-storage spaces. Certain of these compartments have features which deserve special mention for various reasons. They will be considered in the same order that they have appeared in the preceding paragraphs. Tho comments are not to be considered as criticisms reflecting unfavorably on those who have had to do with the designing, construction, or alterations of the ship. It is now more than 20 years since the plans of the Relief were approved and, during that time, there have been many changes in the requirements of hospital ships. The relative importance of many of the characteristics has altered. Details which were considered to be of paramount importance in earlier days have dwindled, while new developments, then unthought of, have made necessary many adjustments. I purpose to emphasize the good and bad points of the ship, and thus provide a useful guide for those who may be called upon to design and build similar structures. The nurses' quarters are inadequate. They are placed two in a room, which is unsatisfactory. Privacy is a matter of small moment to most men, but to women it is predominant. The size of the room is of less importance than the fact that each nurse should have a room to her self. There is no way by which the nurses can descend to the wards without going out on deck and down an exposed ladder. The wet garments which result are uncomfortable during the hours of duty and 212 JOHNSON HOSP1TAL SHIPS also endanger their health. In spite of these defects, they consider duty on the hospital ship as desirable and appear to enjoy it. Their presence on the ship certainly maintains the standard of nursing at a higher level and I feel that none of us would want to run a hospital of this nature, where patients remain for long periods, without them. The operating suite fits its purpose admirably, but space is wasted which could be better employed. The operating room is 17 feet fore and aft, and 45 feet from side to side. The height is 13.5 feet. There are 75 deadlights, 18 inches in diameter, to provide natural light. These are fitted with shades and inner glass sashes to control light and dust. Two operating tables with Operay lights overhead are fixed, one on each side, and a third may be placed in the center line if needed. There are tile decks throughout the suite. The equipment is complete in every imaginable detail. From the outside, the operating room structure gives the ship an unconventional appearance and navigators complain that, when coming alongside a dock with a wind blowing, it acts as a sail. This provides an excellent alibi for a poor landing. Natural light, for which such elaborate provision was made, is now entirely disregarded and the deadlights have been painted over to make them opaque during darken-ship maneuvers. The inner shades and sashes were controlled by a mechanism so elaborate that it was constantly out of repair. They are now drawn and fixed. The height is greater than necessary, though it undoubtedly aids proper ventilation and makes it more comfortable for the surgeons. I believe that it would be better to place the operating suite below the main deck, amidships, where the motion of the ship would be at a minimum, and that two separate rooms, about 12 by 15 feet each, would be better than the one large space. Accessory areas in the operating suite are the scrub room, 11.5 by 10 feet; sterilizer room, 10.5 by 15 feet; etherizing room, 11.5 by 10 feet, and linen-room, 10.5 by 15 feet. A central fore-and-aft passageway gives access to all the spaces. The most important change in this area since construction of the ship is the installation of a shower bath for the use of the surgeons. Considered a dangerous fixture for an operating suite at that time, it required 16 years of intermittent effort to secure this very important detail. The sick officers' quarters have a central lounging space and mess- room, 18 feet fore-and-aft by 17 feet athwartship. Outboard of this are, on the port side, 5 rooms and the toilet facilities; on the starboard side, 4 rooms and the office of the chief nurse. The forward room on the starboard side has its own toilet and bath, being two rooms con verted into one for high-ranking officers. At the forward end is the main elevator and, in the after part, is the pantry. The latter is fitted with electric refrigerator and electric range. A dumb-waiter JOHNSON—HOSPITAL SHIPS 213 formerly ran from this pantry down to the passageway abaft the galleys on the deck below. About 1926, this dumb-waiter was re moved because it was inconveniently placed and the mechanism was so frequently out of order. The rooms average 10 by 8 feet 8 inches, with doorways only 30 inches wide. This makes it impossible to bring a patient into the room on a wheeled stretcher, so a great deal of awk ward handling is necessary in getting a helpless patient in or out. The rooms are fitted with iron beds, 30 inches wide, having sliding sides like a baby's crib. The contagious area consists of 5 separate wards. The forward one runs athwartship and is fitted for 22 bunks. On the starboard side is an 18-bed ward, while on the port side are 8-bed, 4-bed, and 2-bed wards. The diet kitchen is equipped, like those of all the wards, with electric refrigerator, electric stove, and running water. It also has a large utensil sterilizer for dishes and other gear. When the ship was designed it was intended that access to the con tagious wards should be only by the special elevator, which runs from the main deck. But, about the time she went in commission, a bridge was constructed at the level of the upper deck, which gives access to those wards. Many modern contagious-disease hospitals no longer segregate such diseases in different wards. They may be safely placed in adjacent beds, and with proper screening and precautions on the part of the attendants, no more cross-infection will occur than if they were in different wards. So the elaborate precautions that were taken to isolate this entire area from the rest of the ship are no longer con sidered necessary. The forward ward, running athwartship, is usually used for pneu monia and other respiratory infectious diseases. The four-bed ward is mostly occupied by sporadic cases of cerebrospinal fever. This leaves three wards for the other exanthemata, and when we have four or five such diseases, it constitutes a very lively problem. It would be much better for a hospital ship which serves a fleet as large as this, to have more space for contagious diseases. In suitable weather, the wide decks outside the wards may have a dozen or more patients on cots, the overflow from the wards. The locked ward has four bunks, two of them within an inner space which is separated from the other two bunks by a heavy wire-mesh partition and a door which also locks. Thus violent patients can be separated from each other. This ward has its own toilet and wash basin. A watch is constantly maintained when there are patients in this ward, and the man on watch remains at all times in the ward. He is provided with a whistle and there is a button on the bulkhead which rings a loud gong outside, for use if help is needed. The X-ray, dental, and eye, ear, nose, and throat clinics are grouped on the main deck, with separate entrances so that out-patients can 214 JOHNSON—HOSPITAL SHIPS be treated without entering the ward areas. The laboratory was originally located here, but the clinics proved too small for the work they were called upon to do, which has increased from year to year. So the laboratory was moved and the clinic space rearranged in 1935. The dental clinic has four cubicles, each containing a standard navy dental chair and other equipment. One of them has a modern shock-proof X-ray outfit. There is also a prosthetic laboratory with complete stock of everything necessary for making plates, crowns, bridges, splints, and inlays. Until very recently, the hospital ship provided prosthetic service for the entire fleet. The eye, ear, nose, and throat clinic is located on the starboard side, and is divided into two compartments. The forward one, 24 feet long, is used for eye examinations. The after room, 14 by 18 feet, has a tile deck and is used for operative and bronchoscopic work. The X-ray clinic has a main radiographic room, 14 by 16 feet, in which the apparatus is installed. The walls, floor, and overhead are lead lined. Forward of this are the viewing room and the dark room. New types of apparatus, developed since the ship was commissioned, have been installed and so the space is quite crowded. In designing a hospital ship, allowance of space must always be made for new de vices that will be evolved during the life of the ship. A ward with 1 1 bunks and 4 quiet rooms is located aft on the main deck, and is used for the overflow from the contagious wards or from the sick officers' quarters. One of the quiet rooms contains the in stallation for electrocardiographic and basal metabolism estimations. The laboratory was moved from its former position to its present location, well aft on the main deck. It is 12 by 30 feet, and has a tiled annexe, 5 by 9 feet which contains the still, and a refrigerator for the emergency stock of biologicals. The furniture for the laboratory was designed and built for this space and is very satisfactory. It is equipped to perform all the tests required of a public-health laboratory in a large city, in addition to many purely naval requirements. The autopsy and embalming room, adjacent to the laboratory, is a tiled compartment, 9 by 16 feet. The table is of the pedestal type, with slate top. Since this room is seldom needed for its designed use, it serves as an adjunct to the laboratory. The two large steam disinfectors are of the Kinyoun-Francis type. A soiled linen chute on the port side leads down to them from the contagious wards above. After disinfection, the articles are removed from the starboard side. One of the two large wards on the second deck was originally de signed for a medical ward, but the great amount of traumatic surgery, largely due to motor-vehicle accidents, has made it necessary to em ploy both of these large wards for surgery. A smaller, 30-bed ward suffices for medical cases. The surgical ward on the port side has a JOHNSON—HOSPITAL SHIPS 215 tiled room, 10 by 16 feet, which is used for dressings or for minor operations. On the starboard side, a room, 8 by 16 feet, is used for a plaster room, and is fitted with the latest type of fracture table. The physiotherapy clinic is equipped with several types of lights and diathermy machines, and a tub for continuous baths. The two large medical storerooms are a source of constant joy and, since it is the policy to carry at all times a 2-year supply of all Medical Department supplies and equipment, we are fortunate to have so much storage space. In the forward storeroom is a complete 50-bed tent hospital, with all necessary articles, ready to be put ashore for duty with an expeditionary force, or to give aid in a civil disaster. In the after storeroom is a steel locker, 6 by 10 feet, which is used for alcohol, narcotics, and dental gold. Throughout the ship, the wards are fitted with pipe-frame bunks hung on vertical stanchions. The hooks on the stanchions are so arranged that either one or two bunks may be rigged. The single bunk hangs 33 inches from the deck, the same height as the standard hospital bed. When two bunks are in place, the lower one is 18 inches and the upper 55 inches from the deck. Nursing care is very awkward with the double-bunk arrangement, so this is reserved for use with convalescent patients. The patient capacity of the Relief is: Sick officers' quarters 9 Urological and skin 40 Contagious 52 Convalescent wards. 120 Eye, ear, nose and throat 30 Overflow ward 8 General medical 30 Operative surgery 60 Total 409 Traumatic surgery 60 When an emergency demands more beds, there are folding cots and hammocks which can be used to bring the capacity to 500 or more. Ordinarily, only about 300 bunks are kept rigged, since nursing is more conveniently done with only one bunk rigged on the stanchions. The capacity of the ship has always been adequate, and the propor tion of bunks assigned to the different services is about correct. Occasionally, during the first 3 months of the year, contagious diseases provide more patients than there are bunks in the isolation wards. This temporary demand is met by combining other groups of patients, so that another ward is made available for contagious patients. Messing is on the cafeteria plan. Each man takes a tray with plate, bowl, and cup, and passes along a counter on which are the food containers set in a steam table. He indicates which articles of food he desires and they are served to him by the mess cook behind the counter. He then sits down at a table, on which are bread, butter, coffee, condiments, dessert, and other special items. This system has 216 JOHNSON—HOSPITAL SHIPS proved most satisfactory since it provides hot food in just the quan tity desired, and reduces waste. Mess rooms for the deck force and the engineer's force are located aft on the second deck. Convalescent patients and men of the hospital corps are fed in the convalescent mess hall. Cripples are sent down by the elevator in advance of others. Bed patients are served with trays, which are prepared in the diet kitchens. Each ward has three lighting systems: Ceiling lights for general illumination, night lights placed near the deck and portable utility or reading lights, attached to outlets near each bunk. A general antenna system has recently been installed, with outlets in wards and rooms, where individual radios may be plugged in. There are 27 different ventilation systems, with blowers which pass the air over steam pipes for heating. Several spaces, such as the special diet kitchen, sterilizer room and laundry, have exhaust blow ers, recently installed, to ameliorate conditions of excessive heat. In the wards there are supply louvers overhead and exhaust openings near the deck. Heads and diet kitchens have exhaust ventilation only. In the Relief, as in other hospital ships, a number of pet gadgets were installed at considerable cost which have proved of little utility. Just forward of the boiler room is a space 18 by 35 feet and 14 feet high, in which it was planned to place a gyroscopic stabilizer to reduce the amplitude of the ship's motion in rough weather. The stabilizer was never installed, but this 7,820 cubic feet of space remains unused, because the requirements of water-tight integrity will not permit the necessary openings to be made for access to it. There is little need for a stabilizer, for she is a very steady ship, and also she is reputed to be a very lucky ship as regards rough weather. I know of only one occasion, off New Zealand, in 1925, when she encountered a storm severe enough to interfere with her normal work. There was also an elaborate vacuum-cleaning system, with four sets of motor-driven exhausters and piping running to outlets throughout the ship. It had 15 sets of vacuum-cleaning tools, thirty-five 50-foot vacuum hoses, and 35 hose-and-tool lockers. For a number of years it had been out of use and, in 1935, the machinery and a large part of the piping were removed. It seems probable that it was too complicated and had too many accessories to get lost and to wear out, and so it fell into disuse after the first enthusiasm faded. The modern portable electric vacuum cleaner has proven far superior to this system. A very complete and costly hydrotherapeutic equipment was also provided. This was later removed because it required more fresh water than the distilling capacity of the ship. Salt water could not be used because the ship remains, for a large part of the year, in JOHNSON—HOSPITAL SHIPS 217 harbors that are too heavily polluted for the water to be used in this way. Swinging cots were also provided in some of the wards, with the idea that their motion would neutralize that of the ship. This is a most persistent delusion for, as far back as 1873, they were installed in Great Britain's hospital ship, Victor Emanuel, and I have read a recent article in which a theorist suggests their use in hospital ships. It is recorded that, in the Victor Emanuel, the swinging cots swung too much and the patients were thrown out on deck, and so the cots had to be fixed. On the Relief there was a similar experience. One has only to watch these cots swing, to understand why they fail. Their motion is governed by the law of the pendulum, but their oscillation period is not synchronous with that of the ship, and so, when a certain combined motion of the two occurs the swing of the <;ot is accentuated and the patient is violently ejected. One medical officer suggested that a gyroscopic stabilizer be installed in each swinging bunk, and perhaps that would be the best solution of the problem. The idea of swinging cots seem so plausible that we will surely see it proposed for future hospital ships, and other enthusiasts wall rejoice that they have originated the wonderful project of swing ing cots for the comfort of the sick on board ship. But all the defects of the Relief have proved to be minor ones and most of them were easily corrected. She has served with complete satisfaction as the hospital for the fleet during 16 years and her material condition is such that she may well continue for as many years more. Those who had to do with her design and building may regard with complacency the success of their work. Personnel. —Present allowance tables provide for 9 line officers, 10 medical officers, 3 dental officers, 2 supply officers, 1 chaplain, 7 war rant officers, 10 nurses, and 349 enlisted personnel, of which 124 are attached to the hospital corps. During the year 1935 there were 1,814 patients hospitalized on the Relief, with a daily average of 110 patients and average sick days per patient 15.88. Three hundred and fifty-one were transferred to hospitals ashore; 1,237 returned to duty; 59 were returned to their ships to complete convalescence, and there were 17 deaths. Four hundred and eighty-one operations were performed in the main oper ating room and 417 in the eye, ear, nose, and throat clinic. There were 3,266 examinations and treatments in the eye, ear, nose, and throat clinic, 13,865 laboratory examinations and tests, 5,423 physio therapy treatments, and 2,915 X-ray examinations and treatments. In the San Pedro-Long Beach area there are no naval hospital facilities on shore, although a large number of navy ships are based there. The Relief acts as base hospital for these ships and spends 218 JOHNSON HOSPITAL, SHIPS several months each year in this port. When the fleet goes on a cruise, the hospital ship accompanies it. It is the policy to transfer to shore hospitals only those patients who will probably never return to duty or who, for climatic or other reasons, may be benefited by treatment in other hospitals. The Relief is equipped and staffed to offer definitive treatment for all conditions. III. The Hospital Transport The purpose of this chapter is to provide a guide for those who may be charged with the duty of converting merchant vessels into hospital ships. The experience of others shows that there are many details which greatly effect the efficiency and usefulness of the ship and may easily go unnoticed or receive scant consideration while the work is being done. It is only after the vessel is commissioned and has entered on her new duties that important defects appear, at a time when it is too late to correct them. Those who planned and carried out the alterations have seldom been present after the ship was com missioned, to learn of her faults, and so the same errors have been repeated over and over. Articles listing and commenting on tbe good and bad points of the individual vessels have usually appeared after the end of a war, at a time when everybody was too fed up with the whole thing to bother any more about details, and wanted only to be allowed to forget it. When the next war came along, the lessons of the old one were forgotten and nobody had time to look up the maga zine articles and books in which those lessons were embalmed. So- similar faults recur from war to war, with each complaining medico believing himself the first to be so plagued. Those countries which have been far-sighted enough to plan intelli gently in times of peace for the hospital ships needed when war comes were indeed wise and fortunate. Such planning has usually followed one of two lines. Arrangement was made with commercial steam ship companies whereby certain of their ships would be delivered to the government immediately on the declaration of war. Complete plans of all necessary structural alterations were made, and the required equipment was assembled at the dockyard where the altera tions were to be accomplished. The other plan involved a govern ment subsidy at the time of building the ship. Compromises were made in hull design and arrangement of spaces, which would best fit her for the dual role of passenger liner in time of peace and hospital ship in time of war. The subsidy to the owners compensated for her faults as a commercial vessel and they agreed to deliver her to the government upon the outbreak of war. Both of these plans worked very well during the World War. But it happens in every large warr that governments, relief societies and other organizations are called upon to provide hospital ships without such previous arrangements. Handling Stretcher Cases. 214-1 Clerical OFFice. 218—2 I Surgical Ward. 218—3 JOHNSON—HOSPITAL SHIPS 219 The persons put in charge of the work are frequently inexperienced, some knowing little of ships, others unfamiliar with hospital require ments. My hope is to aid them to avoid the more serious blunders. Before we can decide anything about the details of the hospital transport, we must know what work she will be called on to do. Her function is to transport the sick, from the fleet, from an advanced base, or from an expeditionary force to the base hospitals at home. She may be required to remain with the fleet to supplement the facilities of the fleet hospital ship, or be attached to a home base to provide additional hospital beds. Contrast these duties with the mission of the fleet hospital ship, which is to provide complete mobile hospital facilities for the fleet, and you will better understand the differences in characteristics and equipment of the two types of ships. Selection of the ship. —If possible, one should choose a vessel which is adapted to the part of the world where she will probably be em ployed. Thus, a vessel designed for tropical cruises would not be ideal for duty as a hospital ship in the Aleutian area in winter; and one which was designed for the transatlantic run might be too large to enter the harbors of the Pacific Islands. The size should bear some relation to the duty she is to perform. If she is to serve a fleet or an expeditionary force which is operating near a home base, two or more smaller vessels may serve better for this work; while if she is to operate in distant waters, a vessel of 10,000 tons or larger should be chosen. But, too often, the one who has to select the ship does not have com plete information about her projected use, and the choice of ships may be very restricted. An oil-burning ship has many advantages over a coal burner for hospital purposes, but one must always consider the availability of oil or coal in the area where she is to operate. On one shore of the Pacific, for instance, oil is cheap and abundant while, on the other, coal is cheaper and more easily available than oil. Speed is an important matter but it is not likely to be the deciding factor in choosing one ship or another. The greater the distances over which voyages are to be made, the more important is speed. Freedc m from vibration at the higher speeds must be considered since coustant shaking adds greatly to the discomfort of the sick. A passenger ship is infinitely more desirable than a cargo carrier. The latter, with her large holds, could perhaps carry more patients for the same tonnage, but the lack of heating, ventilation, toilet, and lighting facilities would give rise to many serious problems in the care of the patients. And the matter of cargoes previously carried is not to be ignored. We may agree with Thomas Moore that you may break, you may shatter the vase, if you will, but the scent of the roses will hang around it still; however, few of us appreciate the tenacity with which the aroma of copra, guano, hides, horses, and other fragrant commodities can cling round a ship. Flies, ants, roaches, and other vermin, not forgetting 220 JOHNSON—HOSPITAL SHIPS the cimices, should be sought and the degree of infestation estimated. Adequate measures should be taken to free the ship from such pests before placing her in commission as a hospital ship, otherwise her use fulness may be seriously impaired. Careful attention should be given to the auxiliary machinery and, if possible, a ship should be chosen that has plenty of reserve power in excess of that required for propulsion. Heat, light, distilled water, cold-storage plant, laundry, and hot-water circulating system will all have greater loads to carry while the ship is functioning as a hospital than during her passenger-carrying days. A passenger vessel is likely to be much better equipped with these facilities than is a cargo ship. Twin-screws are reputed to cause less vibration than a single pro peller, while turbines produce less noise and vibration than reciprocat ing engines. Fuel capacity should be sufficient to give a steaming radius of at least 8,000 miles. Steadiness in a seaway is a most important attribute in a hospital ship, and careful inquiry should be made to determine the reputation of the vessel in this respect. If she is unsatisfactory because of exces sive or abrupt motion in rough weather, an expert should be employed to determine the cause, whether or not it can be corrected, and at what cost. Changes in ballast, bilge keels, and other devices will often be sufficient to correct this defect. Since mines and torpedoes are the principal war-time danger to a hospital ship, one that is subdivided by many strong water-tight bulk heads offers much greater security than one which has large undivided spaces below the water line. In the World War, several of the hospital ships that were sunk by torpedoes or mines had very little or no loss of life because their construction was such that they sank slowly. If the ship is not satisfactory in this respect she should be made so before being used as a hospital ship. After the choice of the ship is made, the next consideration will be alterations that are necessary. Before making decisions in this matter, we must try to get some idea of the service that she is to perform. If she is to make only short runs, up to 3 or 4 days, very much less space will be needed for laundry, fresh-water storage, operating room, com missary and medical store rooms, X-ray, dental clinic, physiothera peutic equipment, and many other items; and so room will be available for a large number of additional beds. It is a generally-accepted rule that the farther away from the home base she operates the more com plete her hospital equipment and facilities must be. Thus it follows that the longer the run the smaller is the patient capacity, and the larger the number of ships required to carry a given number of patients. But it is seldom possible to predict with accuracy just what duties the hospital ship will be called upon to perform, and so compromises will JOHNSON—HOSPITAL SHIPS 221 have to be made that will allow her to play various roles with reason able success. One of the first steps to be taken is to have some competent person inspect the bulkheads and partitions to determine which ones are structurally necessary and which ones represent false work that can be removed. Only a few cabins should be retained, aside from those necessary for the personnel attached to the ship. By removing the partitions and making several cabins into one ward for 10 or more patients much space can be saved, and one nurse can care for several times as many patients in one ward as she can if they are separated in individual rooms. A feature often overlooked is accessibility. A bed in a room with a narrow door wbich one must approach down a narrow corridor is accessible only to an ambulant patient and the number of such rooms should be reduced to the minimum. Every effort should be made to arrange it so that a wheeled stretcher can be brought alongside every bed. Assignment of spaces. —The main deck is extensively used for ship's work, handling stores and lines, musters and drills, so it is likely to be noisy and active, and sick patients will be disturbed if placed there. But it is a suitable place for lounging rooms and convalescent wards for ambulant patients, the admitting office and ward, baggage room and other activities that have to do with the receiving and discharge of men and supplies. Below the main deck should be the operating suite, X-ray, dental and other clinics, treatment rooms, store rooms, and offices for the various departments. Here also may be located wards for convalescents and quarters for the ship's officers. In general, the spaces below the main deck are utilized for activities where those engaged are not present throughout the 24 hours, while those above that deck are reserved for the sick who cannot leave their beds to seek light and air in the open. Activities which give rise to wild heat, much noise, or disagreeable odors should be grouped well aft of the wards. This applies to the bakery, galleys, laundry, butcher shop, vegetable lockers, blacksmith shop, and incinerator. The forward part of the ship should be reserved for quarters for the ship's company and the innumerable things which have to do with the running and upkeep of the ship. With this arrangement, all wards containing bed-fast patients will be concentrated in the center of the ship, above the main deck. This location of the wards will, in most cases, place them adjacent to open or glassed-in deck space, and it is important to arrange the corridors and doorways so that beds, stretchers, and wheel chairs may be moved out on deck with the least possible trouble. This means that doorways should be wide and sills low. Access to the fresh air and sunlight on deck will give great satisfaction and com fort to the patients and will aid greatly in their recovery. It is our 45202—38 5 222 JOHNSON—HOSPITAL SHIPS experience with patients invalided home from France, the Philippines, Guam, and Hawaii, that a large proportion, even of the most serious cases, improve wonderfully during the voyage home and there is little doubt that this rule will hold in the future. Sea air, sunlight and the mental effect of "heading for the barn" are powerful remedial agents and should be used to the utmost on our hospital ships. Even the ship travels faster when headed for the home port, believe it or not. Every available inch of deck space should be devoted to the use of the patients whenever the weather is suitable and one should plan to make access to the deck as easy as possible. It is essential, both for their own health and for the administration of the wards, that ambulant patients be kept out of the wards and on deck as much as possible during the day. This will be made simpler if several spaces are glassed in with types of glass used for this purpose which do not exclude ultraviolet rays. On a hospital transport it will not be necessary to make such a rigid assignment of special wards for surgical, medical, or other patients. As a rule they will have already received initial diagnosis, operation and dressing before being evacuated from the fleet hospital ship or base hospital on shore to the hospital transport, and continu ance of the nursing care will be the essential thing. Usually it will make little difference if medical and surgical cases are in the same ward. It is customary to provide a separate place for sick officers, and a few cabins may well be reserved for those of higher rank and for sick nurses. Somewhere well aft, and on one of the highest decks, a small space should be reserved for contagious diseases that may develop on board during the voyage. It is better not to accept con tagious diseases for transportation if it can be avoided. Another group requiring special consideration is the venereal. In all the hospital ships I have seen they have been located down deep in the hold, between the laundry and the steering-engine room, or wherever there was the most noise and heat, and the least comfort. Many of our very best soldiers will be found in this group and I strongly believe that they should receive the same consideration as others when wards are assigned. The most modern facilities should be provided for their treatment. Mental patients will also require a special ward with elaborate provisions for their care and safety. A great number of men who probably would cope successfully with the daily routine of civil life become mentally unbalanced in the process of adjustment to the irregularities and hardships of a military regime. Even those who are aware of this fact habitually underestimate the number of insane, so it is well to provide lock wards for at least 5 percent of the bed capacity of the ship. If not needed for that purpose they are avail able for general use. It is better to have too many than too few, for JOHNSON—HOSPITAL SHIPS 223 it is a source of never-ending astonishment, the number of annoying and dangerous things that a hyperactive insane man can think of to do to himself, to others, and to the ship, in a single unguarded moment. A few large wards can be administered more easily and with fewer doctors and nurses than can many small ones. Sixty-bed wards have proved to be very convenient administrative units. One doctor, one nurse and 8 to 12 orderlies or male nurses can care for 60 bed patients of the type that will probably be carried by a hospital transport. Most passenger liners have large saloons and dining rooms which can be converted into excellent wards. Smaller wards will also be ar ranged by removing cabin partitions. Wherever a ward or a room for a patient is placed, one should make certain that patients can easily be brought alongside each bed in a wheeled or hand-borne stretcher. Unless absolutely necessary, do not place bunks in corners or against bulkheads, where they can be approached from only one side. This arrangement makes nursing care difficult and the patients are likely to be neglected. If it is deemed necessary to install such bunks, they should be reserved for convalescent patients who require little care, or who are able to leave their beds during the day. The space along the bulkheads can be used to better advantage for traffic and circulation of air. Passageways between the rows of bunks should be at least 3 feet wide, for if narrower than this it will be found extremely difficult to transfer the patients from stretchers to beds. One ward should be provided with 4-foot alleys for patients in plaster cases, double spicas, and elaborate suspension apparatus. Several standard types of bunks will be found available on the market. Most of them have upright metal stanchions which support metal bunks on each side. For the convalescent wards those with either two or three tiers of bunks, such as are commonly used on transports, are suitable, but for those patients requiring nursing care, who must remain in bed day after day, something more comfortable is required. A reference to the photographs of the wards of the Relief will give a clear idea of her equipment, which is very satis factory. The bunk frame should be 36 x 78 inches with the mattress large enough to fit snugly within the frame and not leave several inches of empty space between it and the frame. Whether that space be at the head, the foot, or the side, the patient's whole body seems always to be trying to gravitate into the empty place. The bunks should be hinged so that they can be turned up out of the way when vacant. A few standard type hospital beds and a few fracture beds should be installed in one of the smaller wards, and these must be very firmly secured to the deck for there is a powerful lateral thrust at the end of a heavy roll that few shoreside people appreciate. Before the end of the first trip, the doctor in charge will know exactly what cases he wants in these special beds, and he will be very grateful for them. 224 JOHNSON HOSPITAL SHIPS All buuks should be securely fixed in place. Do not allow anybody to induce you to have swinging bunks installed. The idea is so plausible that, as soon as it is suggested, everybody is willing to accept it at once as being just the thing. But experience says, "No, they do not work." If the movement of the ship were a simple, rhythmic, to-and-fro motion, they might do ; but the real movement is a combination of an up-and-down, a lateral, a forward-and-back motion with an irregular corkscrew jerk for which no bunk, unless hung in gimbals, could com pensate. Each ward should have a diet kitchen with shelf room enough so that trays can be set up for at least one-third of the patients at one time. Refrigerator, stove, sink, and drain board must not be for gotten. In this and many other items, an experienced nurse can provide an infinite number of practical suggestions that no mere man would ever think of, so this source of information should never be neglected. Generous provision must be made for toilet facilities and they must be near at hand. It has been a common fault in converted hospital ships, that the few toilets were at a long distance from the wards. This means more orderlies, more bed pans to be carried, more un pleasant odors in wards and passageways, also more discomfort for patients. There is no milestone on the road to recovery that is more eagerly anticipated by the patient than his first trip to the head, and it is a feeling worthy of encouragement. Many doctors, writing about their hospital ships, have warned against the error of insufficient toilets distant from the ward. For 60 beds there should be 4 toilet seats, 3 urinals, and 2 showers. Bath tubs should be replaced by fresh-water showers, for the tubs are seldom used; they require much work to keep them clean and they serve fewer men in a given time. The showers are better liked by the men; a shower uses only about one-tenth as much water as a tub bath, and 3 showers can be installed in the space required for a bath tub. All pipes and plumbing should be out in the open and easily accessible. Armies recruited in an emergency always contain a goodly number of men from remote places who are unfamiliar with the use of modern sanitary devices, and some who take pleasure in causing inconvenience to others. Between them, they will keep the ship-fitter's force busy unstopping toilets, wash basins, and urinals. So all toilet fittings should be chosen and installed with this in mind. A large stock of spare parts should be carried. It can be regarded as certain that the ventilation existing in the ship will be found inadequate for ward purposes. In spaces contin uously occupied, one should allow 300 to 500 cubic feet of space per man, and there must be a continuous flow of air, not only for respira tion, but to remove odors. Natural openings, such as windows, ports, and skylights will seldom be sufficient and must often be closed, so JOHNSON—HOSPITAL, SHIPS 225 blowers and ducts will be required. It is not worth while to enter here into the mathematics of cubic feet per second, for the knowledge of air conditioning is progressing so rapidly that it is better to employ the best talent available in this specialty and follow his advice. But be sure that your expert is familiar with shipboard conditions. Supply ventilation should being the fresh air into the wards while the exhausts remove it to the topside from the heads, diet kitchens, and other spaces where odors may arise. This may seem too elementary to need men tion, but more than one ship has been rigged so that the air flowed the other way. Lighting should be indirect in the wards, or so arranged that the man as he lies in his bunk, does not gaze into a brilliant light, either over head or at the side. Sufficient fllumination must be provided so that the patient can read easily, for that will be his chief diversion. Night lights, similar to those used to illuminate the aisles of theaters, will be necessary to allow the work of the ward to be carried on at night with out disturbing the sleep of the patients. Every ward and room will require alternating current and direct current outlets conveniently placed so that one can plug in the portable X-ray, electrocardiograph, ophthalmoscope, diathermy machine, floor polisher, vacuum cleaner, infrared or ultraviolet lamp, dental apparatus or any of the thousand and one gadgets that we depend upon in our daily work. Most pas senger liners have an independent lighting system on an upper deck, to take over the load in case the engine room is flooded. This system should be employed and extended to take in the operating room, and perhaps certain of the offices, so that work can be continued during emergencies, if the usual source of light should fail. The radio has become a daily necessity and this fact should be recognized by install ing either an antenna system to which individual radios can be at tached, or a central receiving set with outlets to plug in individual ear phones. If some such action is not taken, the ship will be festooned with individual aerials hanging from every porthole and attached to every stanchion on the open deck. Consideration should be given to the harmful effects of noise on the sick and the increased suffering caused by it. Worn gears on cranes, winches, and other deck machinery can set up a vibration throughout the ship that will make the sick men writhe in agony. This matter should be investigated and steps taken to correct it if neces sary. Sound proofing should be employed in partitions and bulkheads when spaces for the sick are adjacent to noisy activities that cannot be subdued. Diet kitchens, lounging, and smoking rooms are noisy most of the time and partitions separating them from wards should be covered with material to deaden sound. Elevators will probably be found already in the ship and their loca tion will largely govern the assignment of wards and clinics. It is 226 JOHNSON—HOSPITAL SHIPS essential that the main elevator be large enough to carry stretchers and allow the bearers to stand at the ends of the stretcher with the elevator doors closed. Since the elevator is the main avenue of communication between the wards above and the clinics and operating room below, it is necessary that there be wide corridors on all decks so that patients on stretchers can be conveniently handled. A careful study of the routes from one space to another should be made before finally decid ing on the location of the various activities. It should never be neces sary to use any ward or clinic as a passageway to some other compart ment. Nothing is more likely to produce friction among the personnel. The operating suite should be amidships, below the main deck, and so located that patients can conveniently be brought to it by elevator from the surgical wards and the admitting ward. The operating facilities need not be so elaborate as those of the fleet hospital ship, but must be adequate for any emergency of a surgical nature that is likely to occur. Sterilizing equipment should be generous in capacity for it is probable that a very large part of the patients carried on the ship will require surgical dressings. As the efficiency of the medical department of an armed force increases, the cases of preventable diseases will be fewer and the percentage of battle casualties among the patients will increase. So, the higher the ratio of wounded among the patients received on our ship, the more satisfaction we may feel in the sanitary work of our colleagues. Do not forget to provide toilet facilities and a shower bath for the operating-room personnel. A large steam disinfector is an essential. It is probable that a large proportion of the patients received from a force engaged in active warfare on the beach will be filthy and lousy, as was the case during the Gallipoli campaign. Sterilization of clothing and bedding is likely to be a continuous process during the homeward trip, and so adequate facilities must be provided. Dental work will consist largely of prosthetic appliances for injuries about the face, so a dentist skilled in such work should be selected. Generous provision for this work should be made, because the modem organization of units for the care of maxillo-facial injuries requires that continuous care be given such patients, from the front-line trenches until they reach the special hospitals at home. Our hospital ship will be an important link in that chain. The same principle applies to provisions for the care of fractures. A very large part of the cases will probably be compound fractures, of all degrees of severity. Selection of staff and equipment should reflect consideration of this fact. Care of such patients will require more than the average number of nurses and orderlies, as well as doctors. The chief surgeon should select his staff carefully and be sure that there are plenty of the special types of apparatus that he prefers. JOHNSON—HOSPITAL SHIPS 227 Much thought must be given to the matter of receiving and dis charging patients. It is likely that several hundred disabled men will be put aboard and disembarked each trip. They may be brought to the gangway in boats; or a ship may come alongside with them. Shipwrecked men may be swimming or clinging to wreckage. Small boats may bring them in a rough sea. All of these require different methods and different apparatus. Special davits should be rigged for hoisting in patients. A large number of Stockes stretchers, or similar devices, should be provided and the crew constantly trained in methods of embarking and disembarking large groups of patients in stretchers. What shall be the source of personnel for our hospital transport? Most of those of the past have been under command of a medical officer, with a sailing master to run the ship. Hospital transports will be notified to the enemy as complying with the requirements of The Hague Conference of 1907, concerning the immunities of hospital ships. It has always been accepted as good practice not to -have combatant officers or men on such ships, even though there is nothing in the convention that prohibits them. The Red Cross Society has frequently been called upon to provide the doctors, nurses, and other professional personnel of such vessels and these persons have always been accepted as being noncombatants. Reserve naval officers have sometimes been employed to run the ships, but it is not likely that the enemy would discriminate between regulars and reserves, so far as their combatant status is concerned. Most nations have played safe by removing all combatant officers and men from duty on their hospital transports, so that there might be no question of their neutrality. Suggestions for supplies and equipment can always be obtained by addressing the Red Cross Society, the army or the navy medical authorities of any country. It is very important that, after the staff is selected, the members study the lists of supplies to make sure that the articles they are accustomed to work with are provided IV. Organization and Administration No matter how intelligently designed and structurally perfect the hospital ship may be, defective principles of organization may nullify its good features; for no machine can run smoothly or efficiently if its gears do not mesh. So far as the internal affairs of the medical de partment are concerned, there should be little difficulty, because hospital administration is now so completely standardized, in the United States and Canada at least, that doctors, nurses, dietitians, orderlies, and others, assembled from widely scattered hospitals, will find few details that differ from their accustomed routine. It is in 228 JOHNSON—HOSPITAL SHIPS the relations between the medical department and the ship's officers and crew that friction is most likely to develop. It is commonly observed among us that the naval point of view and the medical point of view move along widely divergent lines, and both are sufficiently inflexible that it is found to be very difficult to bend them to a focus on the common objective. The medical officer thinks first of the patient and his welfare, while the line officer thinks first of the ship, and of the organization that enables it to carry out its mission with safety and certainty. Each is likely to react with impatience to any interference in his field, so a kindly sense of humor in one or both is devoutly to be wished. The harmonizing of the two points of view, without too much dominance by either, is the prime essential of hospital-ship administration. It is the rock upon which have found ered the success and good will of several vessels that started out under most favorable auspices. To avoid such failure, there must be agree ment on all details of command and authority before patients are received on board. Fleet hospital ship Fleet hospital ships, being direct agencies of the governments which they serve, will usually be organized in accordance with the regulations of their respective navies. Their personnel, composed in large part of officers and men accustomed to work under those regulations, will experience only slight changes from their peace-time activities, and so there should be relatively little friction. In the administration of the Relief, a detailed scheme has been worked out which is very satisfactory for a fleet hospital ship of the United States Navy, though probably not appropriate for those of other navies. A list of the chapter headings of the ship's regulations of the Relief will suffice to indicate some of the problems that will arise, and on which early decision will be required. They are : Organization —policy— personnel . Berthing and stowage. Messing. Deck spaces and assemblies. Divisional duties and details. Ship handling—ship's routine. The medical department. Emergency drills. Field hospital and mobile emergency unit. Leave and liberty —disciplinary procedures. Communications. General regulations. JOHNSON—HOSPITAL, SHIPS 229 Hospital transport Organization and administration of a hospital transport is likely to be quite a different proposition. Since these vessels will probably be required to make long voyages without protection of a convoy, it is important that no slightest act or condition should be permitted that may in any way jeopardize their immunity under the tenth convention of the Second Peace Conference, at the Hague, 1907. Therefore they should not be officered or manned by combatant personnel. While nothing in the convention expressly forbids combatant persons in a duty status on the hospital ship, belligerent nations in recent wars have gone to considerable trouble to make it known to the world that all the officers and men on their hospital ships were noncombatants. It appears to be the universally accepted belief that the presence of combatants would cause them to forfeit the immunities granted to hospital ships. For this reason, hospital transports will probably be run by officers and men of the merchant marine. The medical and nursing staff may be army or navy personnel or they may be assembled from civil life. At present there are, in many countries, organized units of doctors and nurses, trained to work together and ready to respond at once, if needed for war-time service on hospital ships or on shore. This should greatly simplify the task of organizing the group for duty on such vessels. The Red Cross Society has been very active in aiding the work of hospital ships, and many vessels in past wars have been staffed and equipped by this admirable organization. The Hague Convention of 1907 provides rules for hospital ships belonging to philanthropic societies, as well as for government vessels. It has usually been found advisable, when a merchant ship is taken over for hospital duties, to retain her officers and men. When the medical personnel report on board, the question immediately arises, which is the tail and which is the dog; who has authority to give orders to whom? This must be definitely settled, and a clear under standing reached at the outset, or else the resulting friction will be reflected in the quality of work of the ship. A review of the historical chapters will show that most hospital ships have been under command of the medical officer, while the captain was held responsible for the navigation and the safety of the ship. In other words, the doctor decided when and where to go, and the rest was up to the captain. Most of the friction and difficulties of the past have arisen between these two. Seagoing men resent being placed under a landsman, and the doctor, with his unaccustomed authority, can easily be tricked into an embarrassing and humiliating position by hostile ship's officers. One of the principal arguments in favor of placing the medical officer in command is that this method is generally accepted as best comply 230 JOHNSON—HOSPITAL, SHIPS ing with the spirit of The Hague convention of 1907, and insuring the neutrality of the hospital ship. Other matters that may be fruitful causes of disagreement are berth ing of the ship's crew and the hospital attendants, stowage of ship's gear and personal effects, responsibility for cleaning various com partments, fuel and fresh water supply, use of ship's boats for trans portation of patients and crew, assignment of spaces for ship's work and for recreation of patients, fire and abandon-ship drills, liberty for crew and patients, disciplinary procedures, upkeep of plumbing and other fixtures, handling of communications, uniform, pay, authority of the officer of the deck, and management of visitors. Many of these questions would find the landsman entirely unprepared to decide them. The essential thing is that the duties and responsibilities of each department of the ship should be clearly decided and put in writing before the vessel starts to function as a hospital ship. In emergencies, when everybody and everything is put aboard at once and the ship shoves off immediately, such an arrangement in advance is not possible, but one should insist on it whenever it is practicable. Examples of the disadvantages of uncertain or divided responsi bility are found in several hospital ships in the past. The Victor Emanuel had a naval officer, Captain Parkyn, in command, with Surgeon-Major Dr. Bleckly of the Army in medical charge, while the War Office authorities contributed a military commandant and an adjutant. The London Lancet, in an editorial (1873, 11:824) comments satirically on this arrangement, "Whom is the major to command and what will be the official or clerical duties of the adjutant? We presume that the former is to have morning parades of the Army Hospital Corps, and that the adjutant has strict instructions to see that there is no waste in drug department. In fact, we can hardly imagine two fish so very much out of water." The numerous authori ties represented here would afford ample opportunity for friction that would interfere with the administraton of the vessel and the care of the sick. The Bay State was fitted out under the direction of 25 different committees, while another committee decided on policies and directed the movements of the ship. Dr. Burrell was surgeon-superintendent, with orders placing the vessel entirely in his charge. The safety of the ship, from the navigation standpoint, was in the hands of the master. The point to which the vessel should go, and the immediate control of the ship whenever it involved the welfare of the patients, in these, the master was placed under the surgeon-superintendent. It is recorded that many difficulties arose from this divided responsibility. The steward's department and commissary were under the master, while the cleanliness of the ship "was suggestively controlled by the Medical Department, except in parts of the ship directly controlled by JOHNSON HOSPITAL SHIPS 231 them." Here are fertile sources of constant bickering and, as one might anticipate, disagreements were frequent. It is to be regretted that we do not have more detailed information concerning the actual working of this strange and complicated organization, which must have been highly charged with political cross currents. The brief duration of the war alone would permit such an enterprise to end harmoniously, unless the heads of the committees, the surgeon- superintendent, and the master were supermen of tact and diplomacy. Nishi relates that, in Japanese hospital ships, the chief medical officer takes charge of medical affairs and sanitation of the ship, and has the right to direct and command the captain as to the movements of the ship. The medical personnel of these ships have been supplied by the Ked Cross Society. Volunteer personnel, serving without pay, have been employed on some hospital ships, but this is not to be recommended. Extensive ex perience in disaster-relief work has taught the writer that the fine enthu siasm with which people throw themselves into such well-advertised hu manitarian en terprises la sts for 1 0 days or less. As soon as the work slacks a little, and the volunteer workers have time to look about them, and to see others doing less work or receiving more compensation than themselves, the mantle of self-sacrifice wears thin and human nature begins to show through. Therefore, free service, or service for less than the standard wage, should be regarded as a very temporary thing. It is better to inform those who desire to donate their services that they will be paid the same as other workers, but may return the money to the organization if they so desire. Such organizations as the Volunteer Aid Detachment and Women's Auxiliary Army Corps in England, and the American Red Cross in America have proved invalu able for their work in recruiting and organizing people for such enter prises as hospitals and hospital ships. One who has been given the task of organizing the medical depart ment of a hospital transport, or a hospital ship under the control of a philanthropic society, without previous experience in such work, will do well to follow standard hospital procedures with the least possible adjustment for conditions on board ship. Such a book as Dr. Mac- Eachern's, on hospital organization and management, will prove a very useful guide, and should be followed as closely as possible. Prac tically all the details can be safely left to the chief nurse and the doc tors in charge of the wards, and they will work better if not interfered with by the senior, whose first few hours would be more profitably spent if he immediately went into a huddle with the captain of the ship. Here are some of the things which they should discuss. Each man should be assigned a bunk, mattress, and a locker for his clothing. Bags, suit cases, and other containers are not to be kept in sleeping quarters, but in a storeroom provided for the purpose, and to 232 JOHNSON HOSPITAL, SHIPS which they can have access at stated hours. Unless the steward's department of the ship is prepared to carry the whole burden of prepar ing and serving food, 1 man in each 20 should be detailed for this pur pose. Peeling and preparing vegetables, washing dishes, cleaning the mess room, and other chores will keep them busy. Special arrange ments will be necessary for preparing and serving diets for the sick, and the hours at which the various groups will have their meals must be arranged so that they will not conflict. Night and day watches, and hours for liberty for all departments must be arranged, and it will be found that they all are interdependent. A cleaning bill should be worked out which will show in detail just who is responsible for cleaning every compartment of the ship, other wise there will be continual friction and complaints. Who is to notify whom, when there is a leaky spigot, a stopped toilet, a burned-out sterilizer, or a broken chair to be fixed? Who has charge of the incin erator and the disinfector? Definite deck spaces are to be assigned to ship's company, hospital attendants, patients, nurses, and doctors, and notices posted so that there may be no trespass. Running-boat schedules, telephone watches, cleaning and inspection routines require careful consideration. Preparation must be made to meet emergencies such as fire, col lision, and shipwreck. Drills should be held frequently, until each person knows just what is his station and duty in any case. The mat ter of getting patients in and out of the boats, and bringing them aboard from boat or from dock requires constant practice. Abandon- ship drill should be carefully planned, with a definite place assigned for each patient, as well as for those attached to the ship. A lifeboat which is rated as carrying 30 persons will accommodate only about 7 or 8 stretcher patients. Each boat should be tested with the stretchers actually in place to determine its capacity in terms of stretcher pa tients, together with the necessary boat's crew and attendants for the sick. Each time the ship puts to sea, the abandon-ship drills should be repeated until each knows his station and duties. This discussion gives some idea of the countless details that will oc cupy much of the time of the senior doctor during the first few weeks of his duty on the hospital transport. It is to be hoped that he and the captain of the ship will be able to establish a friendly and considerate understanding, so that all of these points may be arranged in an ami cable manner. Bibliography Siegfried, C. A. Hospital Ships, The Bay State. Boston M. & S. Journ. 139: 125, August 11, 1898. Burrell, H. L. The Hospital Ship Bay State. Boston M. & S. Journ. 140: 53, 13 July 1899. Kishi, I. Hospital Ships and the Transport of the Wounded. Proc. 17th. Internat. Cong, of Med., London, 1913. Sec. 20, p. 18. THOMAS AND PARKER —THE MAKING OF A BLUEJACKET 233 MacEachern, M. T., Hospital Organization and Management. Physicians' Rec ord Co., Chicago. 1935. U. S. S. Relief, Ship's Regulations. 1935. THE MAKING OF A BLUEJACKET By Capt. OsirriTB E. Thomas, Medical Corps, United States Navy, and Lieut. Charles M. Pareer, Medical Corps, United States Navy How many stop to consider the factors concerned in transforming the average man into a bluejacket, what he must be made of, and what he must do? That the picture may be made clearer let us dissect the entire process and show how it is done. Statistics quoted in this article are based on recruiting statistics compiled by the Recruiting Division of the Bureau of Navigation and the Recruiter's School at the United States Naval Training Station, San Diego, Calif. Although not accurate to the fraction, they are close enough to make clear our purpose. About one-third of the men entering a recruiting station are "sight seeing" and have no desire to enter the naval service. Out of 100 men who visit the recruiting office we shall take just 64 for this paper. Of 64 men applying to a recruiting station for enlistment, 32 will be rejected for physical defects, distributed as follows: Eyes Face Spine Chest Ears Mouth Lungs Heart Nose Throat Pharynx Blood Vessels Height Weight Pelvis Abdomen Skin Teeth Genitals Nervous System Head Neck Mind Extremities Of the 32 who qualify physically, 13 will fail to meet the educa tional requirements, and 6 others will be rejected for a record of the following : Dishonesty. Record of Court Conviction. Vagrancy. Unsatisfactory Environmental Factors. Intemperance. Family History of: Criminal. (a) Insanity. Bad Character. (6) Incurable Disease. The remaining 13 men will be accepted and sent to a naval train ing station, where again they will be examined and the probability is that one will be rejected for defects either overlooked at the recruit ing station or which developed while en route to the training station. Twelve will be vaccinated and placed in quarantine for the next 3 weeks. After they have received their clothing allowance their training begins. They are observed carefully for communicable diseases, scabies, venereal disease, ringworm, trichophytosis, and other dis eases. They are re-vaccinated until a primary reaction takes place or the Medical Department is satisfied regarding their immunity to 234 THOMAS AND PARKER THE MAKING OF A BLUEJACKET smallpox. They receive typhoid prophylaxis and are treated for any ailments they may have acquired. They are instructed in care of the feet and, as their training progresses, in other hygienic measures. Meanwhile the Training Department has begun instructions ac cording to the following schedule: Drill field; rolling clothing and bag inspection; lectures on what to do and what not to do to be a blue jacket; mess cooking; scrubbing clothing and policing up; study periods; watches; recreation periods spent mostly in well-equipped libraries. The station chaplains assist during this period, as shown by the following schedule: Holy service, Catholic and Protestant, each Sun day; lectures on morals and marriage; advice to the men on Govern ment insurance; places to go and places not to go, while on liberty; sponsor a happy hour every Tuesday evening for singing and an amateur show; allot periods for personal interviews to help men solve their problems. Our 12 men, at the end of 3 weeks, are transferred from quarantine to another unit and start more vigorous training. Having been told about the evils and many vices confronting them and informed by a medical officer of the loss of health as well as time and money by venereal disease, they are allowed liberty on week-ends. By this time they have a general idea of what to expect and what is expected of them. The Medical Department continues to observe them and their surroundings as it did during the quarantine period and cares for injuries and ills as may be required. The Red Cross stands ready to be of assistance, the Army and Navy Y. M. C. A. in the city exerts its every effort to help and, should it be necessary, the Navy Relief Society stands ready to lend a helping hand. The Training Department works at double pace to make all possible preparations for the sea cruise, near at hand. The schedule incor porates: Seamanship, boat instruction; ordnance instruction; landing force instruction; mess duties; guard duties; general and special details. During the last 2 months of training the selection officer looks over the men and gives examinations, so that the outstanding men may be sent to a trade school for special training, then they complete the 3 months' training period. About this time the probability is that one will be discharged from the Navy, due to inaptitude, bad conduct, or as an undesirable. One of the men selected for special training, will not care to take the examination. Two of the men taking the examinations will qualify for the trade school and when completing the required course will be sent to sea. The others will be given 10 days' leave and upon their return, sent to sea. inspection personnel. inspection, bag, in White. 234—1 234-2 SHILLING COMPRESSED-AIR ILLNESS 235 Each year 100 appointments to the United States Naval Academy are allotted to the enlisted personnel of the Navy, and each man knows he may take examinations for entrance, if he qualifies. The qualifications for entrance are as follows: He must have not less than 2 years lugh-school education, 9 months at sea, and be under 20 years of age on April 1 of the entering year. A recent report shows that of the 78 enlisted men who in April 1937 took the entrance examinations at the Naval Academy Preparatory School, United States Naval Training Station, Norfolk, Va., G6 attained passing marks in all subjects. From among those recommended, candidates who could not com plete the required 9 months of sea service in time to be assigned to the Naval Academy Preparatory School, 15 were successful in passing the entrance examinations while at sea. This total of 81 successful candidates is the greatest number of enlisted men qualifying by examination for entrance to the Naval Academy since 1931. Much lies ahead of this man we call a bluejacket. As 2 men go to trade schools and the other 9 climb the gangway, wo bid them good luck, turn to start a new group, but for a moment we pause to think of the 53 men who started, but failed. COMPRESSED-AIR ILLNESS 1 By Lieut. Charles W. Shilling, Medical Corps, United States Navy III. Symptoms of Compressed-Air Illness Since the presence of free gas in the blood or tissue fluids is the cause of the illness, it is evident that the variety and severity of the symp toms will depend upon: (1) The location of the gas set free and, (2) the volume of this free gas. Thus, unconsciousness, collapse, and early death may result from emboli in the pulmonary or coronary arteries, or in the vessels supplying the vital centers of the brain. Pain may result from bubble formation in any unyielding tissue such as ligaments, fascia, periosteum, muscle spindles, or nerve sheaths. Air embolism either of the vessels or white matter of the spinal cord may cause paraplegia; while involvement of the cerebral vessels or tissues may lead to monoplegia, hemiplegia, aphasia, or sensory paralytic symptoms. Symptoms rarely develop from bubbles in the liver, spleen, kidneys, adipose tissue or veins. These "silent" areas far outnumber the "painful" areas, which in turn outnumber the "vital" areas; so except in cases of massive bubbling, the chances of serious involvement are slight. Time of on set .—Symptoms have been known to occur during decompression, however, they are most commonly observed during the first few minutes following the completion of decompression, »Continued from January 1938issue . 236 SHILLING COMPRESSED-AIR ILLNESS although the onset may be delayed several hours. The old adage, "You don't pay until you leave," aptly expresses the usual sequence. Erdman (1913) in an analysis of 3,692 cases occurring at the East River tunnels found that 50 percent occurred within 30 minutes and 95 percent within 3 hours, but that 1 percent were delayed over 6 hours and 4 cases were said to have occurred between 15 and 23 hours after decompression. A previously mentioned report by the same author on 1.419 cases places the onset of symptoms within the first 30 minutes in 43 percent of the cases, and between 30 to 60 minutes in 32 percent of the cases, that is 75 percent in the first hour. Classification of symptoms. —In the studies of Heller, Mager, and von Schrotter (1897), Hill and Macleod (1903), Keays (1909), and Bassoe (1911), the symptoms were classified according to the type and frequency with which they occurred. In this study it is felt that it is more advisable to consider symptomotology as it relates to the various recognized body systems, that is: (1) Cerebrospinal system (2) cardiovascular system (3) pulmonary system, (4) visceral and urogenital system, (5) structural system (to include oseous, connective, muscular and fatty tissues), and (6) dermal system. 1. Cerebrospinal system. —Many of the early authors thought that this was the only system involved in the illness. Audibert (1906) says, "Diver's paraplegia is a single form and the variability of details should not be permitted to obscure the regularity of the main clinical stages." However, in the same year, Boinet (1906) reports cases of paraplegia, monoplegia, hemiplegia with aphasia, quadroplegia, and facial paralysis. Previously, Boinet and Audibert (1905), jointly presented many cases of which the following are typical: paresia of the left upper limb with itching and a sense of pressure; transitory paraplegia with hyperesthesia, anesthesia, general sensory involve ment, or with spasmotic contractions; permanent paraplegia with re tention of urine and obstipation; hemiplegia, transient or permanent, with facial paralysis, or with aphasia and temporary insanity; and quadriplegia. Cazamian (1912) gives a most complete and interesting history of a case of this illness characterized by spasmotic paraplegia. Bassoe (1913) presented four cases: one showing permanent sensory loss in the left ring and little finger; another, permanent analgesic area on forearm; another, persistant pain in legs and precipitate mictura- tion; and another, permanent increased reflexes and sensory disturb ances of lower legs. Rise in temperature is considered by some as an important symptom associated with cerebrospinal system involve ment. Clark (1870-71) presented 35 cases (predominately paralysis) which occurred during construction of the St. Louis bridge. Further presentation of cases is unnecessary for it is evident from the foregoing that symptoms produced by compressed-air illness can simulate those due to almost any other injury of the cerebrospinal system. Thus SHILLING COMPRESSED-AIR ILLNESS 237 we may expect anything from numbness and tingling of an extremity to complete unconsciousness and collapse. Envolvement of the special senses may also occur and many cases of labyrinthine and apoplectiform deafness have been recorded. In fact Meniere's symptom complex is relatively common and vertigo, either alone or associated with other symptoms is frequently noted. Involvement of the eye is relatively uncommon but diplopia, nystag mus, and transient blindness have been reported. Also Callan (1907) reported a case of double chocked disks, Genet (1933) one of optic atrophy, and Pflimlin (1934) one of occular involvement with cataract formation, all due to compressed-air illness. If these cases terminate fatally, death usually occurs weeks or months after the exposure and is the result of complications such as pneumonia, cystitis, pyonephritis, bedsores, exhaustion, etc. 2. Cardiovascular system. —It is difficult to classify the symptoms due to involvement of this system for the changes in any part of the body may be due to blocking of the arteries in that locality. For example, the blocking by air emboli of any endartery in the cerebro spinal system might lead to infarction in that area and a train of symptoms similar to those mentioned under involvement of the cere brospinal system. There is ample evidence to show that embolism of coronary or pulmonary vessels may precipitate cardiac failure, col lapse and death ; or massive embolism may cause fatal cardiac dilata tion. The bluish mottling of the skin in severe cases is undoubtedly due to embolism of superficial vessels with consequent stasis. Viguier and Jean (1918) report a case of embolism of the gluteal artery neces sitating surgical removal of the resultant necrotic area, but usually the emboli involve the smaller arteries. Rupture of the overdistended small arteries may occur and the resultant eccymosis cause tissue damage. Lymphatic damage may explain the small superficial areas of localized swelling or edema sometimes seen. 3. Pulmonary system. —Dyspnoea resembling an asthmatic attack and called "chokes" by the men, occurred in 1.5 percent of the 3,692 cases reported by Erdman (1913) and is undoubtedly due to multiple small gas emboli in the pulmonary vessels with resultant edema. This is always considered a grave symptom for it is evidence of massive embolism. 4. Visceral and urogenital systems. —The internal organs such as the liver, spleen, and kidneys do not usually give any signs or symp toms although involvement may be found at autopsy. Nausea, vomiting, and epigastric pain are often encountered and are probably due to embolism of the omental, mesenteric or gastric arteries. These are usually considered to be grave symptoms for they are also sug gestive of extensive embolism. "Girdle pain" is probably associated 45202—38 6 238 SHILLING COMPRESSED-AIR ILLNESS with spinal cord involvement as is constipation, retention of urine, and impoteney. 5. Structural system (to include osceous, connective, muscular, and Jatty tissues). —Involvement of these tissues is almost invariably associated with pain; and pain is by far the most common symptom in this illness —occurring in from 85 to 90 percent of all of the cases, either alone or associated with other symptoms. In about 70 percent of the cases, the pain is in the lower extremities, usually in the region of the knees, and in the majority of the remaining cases in the elbows or shoulders, with occasional cases involving the trunk. Swelling of the muscles or joints is sometimes noted. The myalgias, arthral gias and ostalgias are described as tearing, boring, gnawing, or lancing in character and when severe, only recompression seems to give relief. Mild attacks of pain are experienced at one time or another, by almost everyone who "takes pressure," but they usually clear up without treatment and leave no residuals. However, Bornstein and Plate (1911-12) report that chronic arthri tis can result from repeated attacks of compressed-air illness, through bone necrosis from arterial emboli and nutritional disturbances in the surrounding bony parts. Bassoe (1913) reports several cases of arthritis deformans resulting from compressed-air illness; Twynam (1888) reports a case of bone necrosis; Plate (1912) reports cases with joint symptoms, muscular atrophy and X-ray evidence of bone pathology; and Christ and Basel (1934) report bony changes due to repeated air embolism, leading to joint pathology. 6. Dermal system. —One of the most common symptoms of com pressed-air illness is pruritis or formication which is often the first and may be the only symptom noted. This is probably due to air bubbles in the subcutaneous tissues or in the sweat glands. Hemor rhagic areas are noted and a rash is frequently- seen resembling that of scarlet fever. Lividity or marbling of the skin, as reported by Mellinghotf (1934), is associated with many of the serious cases and is probably due to air embolism of cutaneous vessels. Areas of swell ing, subcutaneous emphysema, and crepitation occur in occasional cases. Diagnosis. —In spite of the multiplicity of symptoms, a diagnosis of compressed-air illness can usually be made if the history shows exposure to air pressure, under conditions capable of producing the illness, during the preceding 12 hours. It must be constantly borne in mind, however, that other injury or illness may occur; thus, a care ful differential diagnosis is always necessary. For example, the author knows of a case of acute appendicitis, one of fracture of the femur, and one of oxygen pneumonia which were erroneously treated by recompression, and of one man with paraplegia due to a fractured spine who was transported 38 miles in a touring car seeking recom SHILLING COMPRESSED-AIR ILLNESS 239 pression, because he had been diving—into the water from the super structure of his yacht! In most cases the men working under pressure carry cards advising anyone who finds them unconscious or acting queerly, to return them at once to the company doctor or the recom pression chamber. In commercial work simulated accidents and hystero- traumatism must be kept in mind. Pathology. —The pathology of compressed-air illness is almost as varied as the symptomatology, but the fatal cases logically fall into two groups: a rapidly fatal group, or those who die within a few hours after coming out of pressure; and a delayed fatal group, or those who develop cerebrospinal symptoms and die from secondary complications after several days, weeks, or months. Von Schrotter (1898) summarized 137 fatal cases occurring between 1854-97 and 70 cases with 18 properly reported autopsies in the rapidly fatal group, and 36 cases with 26 autopsies in the delayed death group. In the 18 autopsies on the rapidly fatal group he found 11 which showed free gas in the circulatory system and in the other 7 congestion of the lungs, liver, etc., which in some resembled suffocation. Heiberg (1878), Gerard (1884), Nikiforoff (1893), and lie (1904), all de scribed autopsies on early death cases with findings similar to those above. Rudge (1907), Nordmann (1928), and Ghose (1930) have described autopsies on early death cases in which not only was there bubble formation in the circulatory system and in the tissues, and marked congestion of the visceral organs; but there was also micro- and macro-scopic hemorrhage throughout the tissue of the cerebro spinal system. Necrosis due to emboli blocking the circulation, and actual tearing and separation of the fibers due to local bubble forma tion have also been noted in the cerebrospinal system. Boycott and Damant (1908) in an exhaustive experimental study demon strated that bubble formation was more frequent in the blood than in any other tissue or fluid, although bubbles are found in lesser quantity in all the body fluids. Since the greater the circulation the more rapid the elimination of excess gas, it follows that in bodies dead of compressed-air illness the bubbles would be found more numerous in the parts with sluggish circulation and less commonly in organs with an abundant blood supply. Thus, bubbles are seldom found in the tissues such as glands or muscles, but are usually found in the fat, the white matter of the cord and the myelin sheaths of the nerves —all tissues with a poor blood supply. Another factor in this connection is that fat dissolves more than 5 times as much nitrogen as water or blood at body temperature. As regards the segments of the cord, the bubbles appear to vary in number in inverse proportion to the blood supply, while necrosis is more or less directly propor tional to bubble incidence. In resume^ the characteristic patho logical findings in the early deaths are: Air embolism (bubbles) in 240 SHILLING— COMPRESSED-AIR ILLNESS the various arteries and veins, more commonly in the smaller end arteries, but in cases a massive embolism filling larger vessels. Second ary to this embolism there may be infarction, necrosis, edema of the lungs, or dilation of the heart. Bubbles are also found in the various tissues of the body causing stretching and tearing (which in life resulted in pain or, if in the cerebrospinal system, altered sensory and motor function). Marked congestion of the various internal organs is also often found and frequently hemorrhagic areas are noted in the cerebrospinal system. The delayed or chronic deaths occur as the result of secondary infection following paraplegia or other persistent paralysis. Ex haustion and septic infection from bed sores account for the three deaths reported by Sewall (1915). The spinal cords in these patients showed many areas of "softening and disorganization" in the lumbar and lower thoracic regions. Complete degeneration of the ascending fibers in the posterior columns was noted in one case and destruction of the descending tracts in the lateral area in another. Blick (1909) noted fatal urinary tract infection in several of his paraplegic cases. Bauer (1870) presents an autopsy showing spinal cord softening throughout the length of the lumbar segment in "the posterior columns, posterior cornua of the gray substance, and the lateral column of one side." Granjon (1880) reported a case with softening of the gray substance of the cord in the upper lumbar region, about 2 centimeters long, and with a spot of complete necrosis in the center. This man had paraplegia, retention of urine and bed sores and "stead ily became worse," dying after 5 weeks. In a case reported by Chau- baud (1883), dying after 1 month of paraplegia and urinary retention, an area of softening, 2.5 centimeters long, was found in the grey matter of the cord at the lumbar level. Similar autopsy findings of chronic death cases were also reported by Sharples (1894), Schaeffer (1898), Zografidi (1907), and Noica and Paroulescu (1933). Of course no bubbles of gas or acute congestions are found in the autopsies of these delayed death cases, for the pathology is limited to softening, degeneration or infarction of the cerebrospinal system with occasional infarcts of other tissues, and evidences of secondary infection. Extensive experimental work was performed by Curcio (1899) and Battaglia (1904), who not only found the usual cord pathology but demonstrated nerve cell changes due to the action of compressed air even in the absence of embolism. Cases bibliography. —Many authors presented one or more eases of compressed-air illness with a very general discussion of the nature of the illness, which, although falling logically in this section, did not appear to add materially to the detailed discussion of symptoms. These comprise an additional or third bibliography which follows the primary and secondary bibliographies of this section. SHILLING COMPRESSED-AIR ILLNESS 241 Primary Bibliography Audibert, L. La Paraplegie des Scaphandriers. Montpellier, 8°, 1906. Bassoe, P. Compressed Air Disease. J. Nerv. and Mental Dis., 38: 368-369, 1911. Bassoe, P. The Late Manifestations of Compressed-Air Disease. Internat. Cong. Hyg. and Demog., Tr. 15, 1912. Wash., 3: 626-638, 1913. Battaglia, D. M. Alterazioni traumatiche primitive delia Cellula Nervosa. L Alterazioni per azione dell'aria compressa. Ann. di Med. Navale, 2: 701- 709, 1904. Bauer, L. Pathological Effects upon the Brain and Spinal Cord of Men exposed to the Action of a largely increased Atmospheric Pressure. St. Louis Med. and Surg. J., 7: 234-245, 1870. Blick, G. Notes on Diver's Paralysis. Brit. Med. J., 2: 1796-1798, 1909. Boinet. La Maladie des Scaphandriers. Bull Acad, de Med., Paris, 55: 756- 764, 1906. Boinet and Audibert. Les Paralysies des Scaphandriers. Arch. gen. de med., Paris, 2: 2689-2710, 1905. Bornbtein, A, and Plate. Ueber chronische Gelenkveranderungen, entstanden durch Presslufterkrankung. Fortschr. a. d. Geb. d. Rontgenstraklen, Ham burg, 18: 197-206, 1911-12. Boycott, A. E., and Damant, G. C. C. Some Lesions of the Spinal Cord pro duced by Experimental Caisson Disease. J. Path, and Bact., Cambridge, 12: 507-515, 1908. Callan, L. W. Double Choked Discs associated with Compressed-Air Diseases (Caisson Disease). Arch. Ophth., N. Y., 36: 509-512, 1907. Cazamian. Hematomyelie par Decompression brusque Chez un Scaphandrier; Paraplegie Spasmodique. Arch, de med. Nav., Paris, 98: 212-224, 1912. Chabaud, N. Des Accidents observes dans les Appareils a Air Comprime. Quelques Moyens practiques d'g remedie. Paris, 4°, 1883. Christ, A, and Basel. Ueber Caissonkrankheit, mit besonderer Berucksichti- gung einer typischen Erkrankung des Huftgelenkes. Munchen. med. Wchnschr., 81: 843, 1934. Clark, E. A. Effects of Increased Atmospheric Pressure upon the Human Body. Medical Archives, St. Louis, 5: 1-30, 295-300, 1870-71. Curcio. Sulle alterazoni delle Cellule Nervose del Midollo consecutive alia Rapida Decompressione. Ann. di Med. Navale, 2: 979-1021, 1899. Erdman, S. The Acute Effects of Caisson Disease. Int. Cong. Hyg. and Demog., Tr. 15, 3: 619-625, 1913. •Genet, L. Partial Optic Atrophy and Caisson Disease. Bull. Soc. d'opht. de Paris, 318-321, 1933. Gerard. Lea Accidents dans les Travaux a l'Air Comprime. Rev. San de Bordeaux, 2: 5-10, 1884. Chose, N. H. Death from Compressed Air Sickness in India. Indian Med. Gaz., 65: 698-699, 1930. Granjon, R. Etude sur l'Etiologie des Accidents observes chez les Hommes travaillant dans l'Air Comprime. Paris, 4°, 1880. Heiberg, E. T. Autopsie d'un Malade Mort en sortant de l'Air Comprime. Gaz. Med. de Paris, 7: 540, 1878. Heller, R., Mager, W., and von Schrotter, H. Zur Kenntniss der Todesur- sache von Pressluftarbeitern. Deutsche med. Wchnschr., Leipz. and Berlin, 23: 375-379, 1897. Hill, L, and Macleod, J. J. R. Caisson Illness and Diver's Palsy; an Experi mental Study. J. Hyg., Cambridge, 3: 401-445, 1903. 242 SHILLING COMPRESSED-AIR ILLNESS Keays, F. L. Compressed-Air Illness, with a Report of 3,692 Cases. Dept. of Med., Publications of Cornell Univ. Med. Coll., 2: 1-55, 1909. Lie, H. P. Uber die Veranderungen des Ruckenmarkes bei Tauchern. Vir- chows Arch., 178: 142—, 1904. Mellinghoff, K. Cutaneous Phenomena in Caisson Disease. Ztschr. f. klin. med., 127: 457-459, 1934. Nikiforoff. Beitr. z. pathol. Anat. u. z. allg. Pathol. 12: — , 1893. Noica and Paroulescu, N. Hematomyelia prin Decompresiune. Spitalul, 53: 99-101, 1933. Nordmann, Martin. Hirnbefunde bei Presluftkrankheit. Virchows Archiv. f. Path. Anat. und Physiol., 268: 484-491, 1928. Pflimlin, R. Beteiligung des Auges bei der Caissonkrankheit, insbesondere Kataraktbildung. Klin, monatsbl. f. augenh., 92: 54-58, 1934. Plate. Gelenkerkrankungen durch Pressluft. Deutsche Med. Wchnschr., Leipz. und Berlin, 38: 1768, 1912. Rudge, F. H. A case of Caisson Disease. Lancet, Lond., 2: 1675, 1907. Schaeffer, E. Scktionsbefundc bei Pressluft-Arbeiten. Ztschr. F. Med.- Beamte, Berl., 11: 389—, 1898. von Schrotter, Herman. Zur Aetiologie und Pathologic der Decompres- sionserkrankungen (Caissonkrankheit). Abstr. Klin.-therap. Wchnschr., Wien, 5: 1539-1540, 1898. Sewall, R. J. Caisson Disease on the Cuyuna Iron Range. The J.-Lancet,. 35: 265-269, 1915. Sharples, C. W. Contribution to the Pathology of the Spinal Cord in Divers'' Palsy. J. Nerv. and Ment. Dis., N. Y., 21: 636—, 1894. Twynam, G. E. A case of Caisson Disease, Prince Aldred Hospital, Sydney, New South Wales. Br. Med. J., 1: 190-191, 1888. Viguier and Jean, G. Embolie Gazeuse de l'Artère Fessiere (Accident de Decompression). Bull. Acad. de Med., Paris, 80: 377-378, 1918. Abs. J. A. M. A., 71: 2109, 1918. Zografidi, S. Contribution a l'Etude des Accidents de Decompression ches les Plongeurs a Scaphandre., Rev. de Med., Paris, 27: 159-187, 1907. Secondary Bibliography Babington, T. H. Paralysis caused by working under compressed air. Dublin Quart. J. of Med. sc., 35: 312-318, 1863. Barrington, J. L. Caisson Disease (Diver's Palsy). J. Trop. Med., Lond.. 9: 286, 1906. Basboe, P. Compressed-Air Illness. 111. Med. J., Spgfld., 17: 462-469, 1910. Berillon and Gosset. La "Maladie de Caisson" Presentation de Maladie. Rev. de psychotherap., Paris, 28: 144-146, 1913-14. Bertillon. Travaux executes dans l'Air Comprime. Union Med., 10: 346- 350, 1861. Bignami. La Paralisi dei Lavoranti nei Caissoni ad Aria Compressa. Ann. di Med. Navale, 1899. ' Boinet and Audibert. Les Paralysies des Scaphandriers. Marseille Med. 41: 693-694, 1904. Cannady, R. G. Double Hemiplegia in an Old Case of Caisson Disease. Old Dominion J. Med. Soc, Richmond, Va., 22: 90-91, 1916. Cabnot, Le Coup de Pression. Presse med., Aug., 1906. Charpentier, M. Sur in Accident Professional Survenu chez un Scaphandrier. Ann. d'Hygiène, Paris, 9: 365-367, 1883. SHILLING COMPRESSED-AIR ILLNESS 243 Charpentier, M. Observation d'Ataxia Locomotive, consecutive a des Ac cidents de Decompression Brusque par Rupture dun Scaphandre. Union Med., 36: 261-266, 1883. Focrnay and Berbuyer. Le Coup de Pression. Bull. Med. Aug., 1904. Gaudoin, G. R. Spinal Paralysis due to Deep-Sea Diving. Indian M. Rec, Calcutta, 14: 358—, 1898. Hodgen, J. T. Effects of Compressed-Air upon the Human Body. Med. Arch. St. Louis, 5: 219-226, 1870-71. Lepine, G. Sur les Lesions Medullaires de la Decompression Atmospherique Brusque. Comp. rend. Soc. de Biol., 2: 873, 1900. Lerebotjllet, P. Les Accidents de l'Air Comprime; Semeiologie et Pathogenie. Progress Med., Paris, 29: 587-593, 1913. Lewis, G. L. The Effects of Compressed-Air upon the Human System. Trans. Med. Soc. of Kansas, 11: 10-21, 1875. Littleton, T. Effects of Submarine Descent. Assoc. M. J., London, 1: 127, 1855. Magoire, R. Caisson Disease. T. M. Soc. Lond., 23: 351, 1899-1900. Oliver, T. Caisson Disease. Northumberland and Durham M. J., Newcastle- upon-Tyne, 13: 21, 1905. Pagano, F. Contributo alio Studio delle Malattie dei Cassoni. Med. d'egli inf. del Lav., Perugia, 2: 384-388, 1909. Pepper, W. Caisson Disease. Med. Bull,. Phila., 8: 239-240, 1886. Perez- Vento, R. Caisson Disease o Paralisis de los Buzos. Rev. de med. y circug. de la Habana, 17: 417-419, 1912. Rozsahegyi, A. A Munkalkodas Comprimalt Levegoben. Kozez. es Torveny, Orvos, Budapest, 73-81, 1881. von Schrotter, H. Zur Kenntnis der Decompressionser-krankungen. Beitr. z. innere Med. Festchr. d. cong. f. in Karlsbad 1899, Wien, 4: 20, 1900. von Schrotter, H. Zur Pathologischen Anatomie der Decompressionser- krankungen. Verhandl. d. Dtsch. pathol. ges. 1904, Jena. G. Fischer, 1905. Scott, E. J. Diver seriously affected. Customs Med. Rep., Shanghai, 1878. Scott, E. J. Deep- Water Diving, a Curious Paralytic Affection. China Imp. Custom Med. Rep., Shanghai, 1887. Silberstern, P. Zur Casuistik der Caissonkrankheit. Wien. Med. Wchnschr., 30: 1305-1308, 1895. Taylor, F. Clinical Lecture on Divers' Paralysis. Clin. J., Lond., 12: 1-5, 1898. Taylor, F. Diver's Paralysis. Lancet, 1: 1549, 1898. Veselitskago, I. A. Caisson Disease. Nevrol. Vestnik., Kazan, 19: 244- 277, 1912. Cases Bibliography Aguglia, E. Su d'un Caso di Malattia del Palombari. Riv. Ital. di Neuropat., Psichiatria ed Ellettroterapia, 13: 52-57, 1920. Alorich, C. J. Compressed-Air Illness or Caisson Disease. Int. Clin. Phila. 10-s, 2: 73-88, 1900. ^ Archambeault, C. P. Fatal Case of Caisson Disease. U. S. Nav. Med. Bull. 19: 167-168, 1923. Barbe. Accidents de Paralysie Spasmodique observe's diez les Pecheurs- d'Esponge. Arch, de Med. Nav., Paris, 73: 460-465, 1900. Boinet, M. Hematomyelie observe chez un Pecheur de Moules. Sitsungsber. d. Assoc. franc, pour l'av. des Sc. Congres de Marseille, 2: 756, 1891. Bondet. Paraplegie chez un Scaphandrier. Sitzungsber der Soc. med. des- Hopitaux de Lyon, 13: 1905., vgl. Lyon Med., 26: 1046, 1905. 244 SHILLING COMPRESSED-AIR ILLNESS Bondet, M. and Piery. Sur un Cas de Maladie des Plongeurs. Lyon med.. : 1406, 1905. Cayler and Powell. Diver's Paralysis. Middlesex Hosp. Rep., London, 37: ; 1898-99. Damant, G. C. C. and Thomas, E. R. L. A Case of Compressed-Air Illness cured by Recompression. Brit. Med. J., 2: 881, 1909. Drasche, A. G. Ueber Luftdrucklahmungen. Wein. med. Wchnschr., 48: 1-7, 1898. Ellis, R. Diver's Paralysis with Scarlet Fever. N. Y. Med. J., 84: 1273, 1906. Express. Ein ungewohnlicher Fall plotzlicher Dekompression. Ref. in der Neuen Freien Presse, 14583: 8, 1905. Freidricu. Ein Fall von Taucherkrankheit. Sitz-Ber. d. Phys. Keil, 1906. Fremont, J. P. La Maladie des Caissons. Bull. med. de Quebec, 14: 145-161, 1912. Grant, C. G. and Edin, S. A Few Cases of Compressed-Air Illness. Brit. Med. J., 1: 1567-1568, 1908. Hall, M. On the Fatal Accident to the American Diver. Pract. Obs. and Suggestions, 2: 301-305, 1846. Hoche. Zwei Falle von Ruckenmarkserkrankung bie Caissonarbeitern. Deutsche med. Wchnschr., Leipz. Ver.-Beil., 24: 14, 1898. Hoskyn, D. T. A Case of Caisson Disease. J. Roy. Nav. Med. Ser., 1: 473-475, 1915. Klienberger. Ueber luftdruckerkrankungen bein Bau der grunen Brucke in Konigsberg. Deutsche med. Wchnschr., Leipz. u Berlin, 33: 1316-1318, 1907. Ladd, L. W. A Case of Caisson Disease with Unusual Hypopyrexia and Recov ery. Cleveland Med. J., 1: 251-253, 1902. Lapukhina, V. D. Two Cases of Caisson Disease. Nevrol. Vestnik. Kazan, 20: 655-664, 1913. Mackinlay, A. Case of Death from Syncope caused by Caisson Disease. Statist. Rep. of the health of the Navy, London, : 102, 1901. Minkoubki. Caissonkrankheit. Berlin klin. Wchnschr., 49: 39, 1912. Moriani, G. Di un Esito Eccezionale di Malattia die Cassoni. Riv. di med leg., Pisa, 9: 175-187, 1919. Oliver, T. Caisson Disease (Case). Northumberland and Durham M. J., Newcastle-upon-Tyne, 7: 8-11, 1899. Patrick, H. T. Caisson Disease. 111. Med. J., Spgfld., 7: 13-14, 1905. Smith, A. H. Cases of Caisson Disease. Pres. Hosp., N. Y., 1: 28-40, 1896. Stettner, E. Ueber Caissonkrankheit mit Pathologischanatomischer Beschrei- bungeines Falles. Wurzb. Abhandl. a. d. Gesamtgeb. d. prakt. Med., 11: 285- 326, 1910-11. Thompson, W. G. Notes on the Caisson Disease. Med. Record N. Y., 45: 133- 134, 1894. Van Der Kevast, T. H. Eenige Ziekteverschijnselen, die bij den Caisson- Bouw in 1905 te Sluskil zijn voorgekomen. Nederl. Tydschr. v. Geneesk., Amst., 44: 1097-1106, 1908. Watson, A. E. Case of Divers' Paralysis. Lancet, 1: 1063-1064, 1893. von Wenusch, F. Ueber einen Fall von Tauchertod. Wien. klin. Wchnschr., 9: 774, 1896. White, W. Hale and Bainbridge, F. A. A Case of Diver's Paralysis. Lancet, 4285: 1101-1102, 1905. Wondra, A. L. Ueber Zwei Falle von Caissonkrankheit. Konigsburg, 8°, 1908. SHILLING COMPRESSED-AIR ILLNESS 245 IV. Treatment of Compbessed-Air Illness The treatment for this illness is recompression, that is, a return of the patient to compressed air either by lowering him in the water again, returning him to the working chamber, or placing him in the medical lock or recompression chamber and raising the air pressure. The relief obtained by a return to compressed air was noted by the laborers as early as 1854, and yet 70 years later an author (1924) says of two cases showing paralysis, "Treatment was with potassium iodid, hexamethylenamin, massage, and tepid baths." One case improved after a month's treatment; the other showed no improve ment. A great variety of treatment was suggested by Corning (1890) including morphine, catharsis, electrical stimulation, com pression of the blood vessels of the lower extremities, dry cups to the spine, and the use of ergot. The benefit derived from the use of ergot was also enthusiastically reported by Knapp (1891 —see sec. II). The use of antipyrine as a method of ameliorating the pain was sug gested by Sene (1895-96). Many authors recommended massage, friction, and heat in one of the following forms: Wet compresses, baths, sand bags, and hot drinks. Various salves were recommended as well as numerous drugs for both external and internal use. Recom pression was recommended by many of the early writers only for the most serious cases, and several wrote, "The treatment is mainly a question of prophylaxis." The first recompression chamber or medical lock in the United States was installed at the New York North River tunnel works in 1894 and its success was reported as complete. From this time on, with but few exceptions, recompression was the treatment used wherever pressure work was conducted. An excellent summary of cases treated by recompression is made by Wright and Brady (1932 — see introduction, p. 11) in which they show that of 3,067 cases treated by recompression 89.3 percent were completely relieved, 9.9 percent partially relieved, and only 0.5 percent showed no relief. Medical treatment of 211 cases gave no relief in 13.7 percent — a very definite demonstration of the superiority of recompression. Another report presents 47 cases of prostration (the most severe type of illness) treated by recompression with relief or cure in 38 cases. The recorded opinion is unanimous that the treatment recompression should be started as soon after the onset of symptoms as possible, for it is felt that the benefits derived from recompression are largely dependent upon its early institution; although treatment has been known to be effective even when instituted many hours after the onset of symptoms. Kropveld (1907), who successfully treated 77 of his 98 cases by recompression, says that the greater the delay after the onset of symptoms the higher the pressure necessary to relieve them. And as pointed out by Langlois (1911 —see sec. VI), a delay 246 SHILLING COMPRESSED-AIR ILLNESS in recompression may lead to permanent cord lesions due to long con tinued anemia caused by blockage of tbe circulation. Certain mild cases will of course recover without treatment, but as it is impossible to predict when these mild cases will suddenly become severe it is best to treat all definitely diagnosed cases by immediate recompression. Although there is complete agreement on the advisability of imme diate recompression there is great divergence of opinion on the man agement of recompression. The first point of difference concerns the rate of application and the amount or degree of pressure to be employed for the recompression. Some state that the pressure should be applied slowly, but the majority of opinion is in favor of rapid re compression. Concerning the degree of pressure, one observation is that the pressure be raised only until the symptoms are relieved, another that the pressure be raised to one atmosphere beyond the point of symptomatic relief. Ryan (1909) (1912) contends that the pressure must never exceed two-thirds that of the original working pressure, but the cases he cites in support of this plan did not respond to his treatment. Cazamian (1912 —see sec. Ill) recommends rapid recompression to three or four atmospheres and if there is no amelio ration of the symptoms the pressure may be raised to double that amount—nine atmospheres having been used for one case. The pre dominance of opinion, however, favors recompression to a pressure at least equal to that to which the worker was exposed. Keays, Born- stein, Dominquez, Stott, and many others, all of whom have been previously cited, recommend this recompression. Sakai (1934), after extensive research, offers two alternatives: One that the pressure should be raised to the same height as that of the working chamber and held at least 45 minutes at that level; the other that it should be raised 10-15 pounds higher than the working pres sure, thus hastening the reabsorption of the gas bubbles and allowing the time of treatment to be shortened. Normura (1929), in animal experiments, also found that response to treatment was better when the recompression was carried to a pressure "slightly higher" than that of the original exposure. Opinion differs greatly as to the length of time the patient should be held at this maximum treatment pressure. Oliver (1934) recom mends slow recompression to the original working pressure and then holding the pressure at this level for as long as 4 hours; but Cazamian (1912 —see sec. II) says a wait of over 2 hours is useless and if paralysis does not clear in that time the pressure should be lowered. Born- stein (1912— see introduction) says that under no circumstances should the pressure be lowered at once but should be held at the maxi mum level at least 20-30 minutes and sometimes much longer; but Keays (1912 —see introduction) says that after reaching the working pressure the treatment decompression should be started "soon." SHILLING COMPRESSED-AIR ILLNESS 247 Many of the authors do not mention any time element in this connec tion but the majority suggest waiting until the symptoms subside, or for at least 20-30 minutes. The greatest difficulty in the treatment of the illness by air pressure is encountered in determining the type and length of the treatment decompression — that is, the return to atmospheric pressure from the treatment recompression. Among the authors already mentioned the following are some of the methods suggested for lowering the pressure: "2 minutes per pound," "2-3 minutes per pound," "about a minute per pound," 60 to 100 minutes per atmosphere —in nervous conditions much longer," "% pound per minute," "quickly to 10-15 pounds and then slowly at -the rate of 2 minutes per pound," "very slow decom pression," and "long continued in ominous cases." The United States Navy official treatment tables (United States Navy Diving Manual) are of the continuous decompression type and recommend rapid reduction of pressure down to 60 pounds, 1 pound per minute from 60 to 45 pounds, 1 pound in 3 minutes from 45 to 30 pounds, 1 pound in 5 minutes from 30 to 15 pounds, 1 pound in 10 minutes from 15 to 0 pounds (gage pressure). However the proposed new treatment tables are of the "stage decompression" variety. French (1916) gives a good description of the United States Navy method of treatment, and Johnson and Bradlow (1925) present a case treated by the British Navy method. As pointed out by several authors it may be neces sary to stop during the decompression because of the reappearance of symptoms and again raise the pressure. The author visited in the former Cunningham Sanitarium in Cleveland and saw patients who had spent months continuously at a pressure of 30 pounds (gage) with no ill effects, so it is evident that if symptoms do reappear during the return to atmospheric pressure, the pressure may again be raised slightly or held indefinitely. The use of oxygen in conjunction with recompression to hasten re- absorption of the nitrogen was suggested 40 years ago in an article by Zuntz (1897 —see sec. II) ; but because of the known toxicity of oxygen at high concentrations its use was not widely accepted. However, von Schrotter (1906) (1907) again suggested its use at low partial pressure to hasten decompression, and Boinet (1907) recommends its use in the treatment of "diver's disease." More recently Behnke and associates (1936) (1937), in extensive animal experiments, studied the use of oxygen in the treatment of compressed-air illness and highly recommended its use in conjunction with a special form of recompres sion outlined by them. The use of mixtures of oxygen and helium in the treatment of com pressed-air illness was suggested by Sayers, Yant, and Hildebrand (1925). Because of the physical nature of helium it is ideal for use in displacement of excess nitrogen and thus is equally as effective as pure 248 SHILLING COMPRESSED-AIR ILLNESS oxygen in addition to being nontoxic (the usual oxygen concentration of this mixture is approximately 20 percent that of atmospheric air). Adjuncts to. the treatment by recompression were suggested by Pelton (1907) as follows: Artificial respiration, exercise, massage with various concoctions, electric stimulation, ironing muscles with a hot iron, analgesics for pain, hyperdermics of strychnine, adrenalin, caffein, and general nursing care. He recommends breathing oxygen only at atmospheric pressure. Others have suggested: Hot baths, hot wet dressings, ergot injections, ether injections, camphorated oil rubs, intracardiac injection of adrenalin, etc. It is evident that much of this treatment is handed down from early times but even among more recent writers there seems to be quite general agreement that, in addition to and during treatment decompression, exercise is desirable, that hot applications and massage to the affected parts are of benefit, that stimulation by drugs may be indicated in some cases, that oxygen or helium-oxygen breathing is valuable, and that general nursing care is always to be carried out. In summarizing the treatment of compressed-air illness we con clude: That recompression should be started at once and carried rapidly to at least the pressure of the original exposure, that this pressure should be maintained until symptoms disappear or for a minimum of 30 minutes or a maximum of 2 hours, that the treatment decompression should be at a rate of not less than an average of 3 minutes per pound reduction (the better type would be a stage de compression calculated for maximum saturation of the slowest tissue at the depth of original exposure), that oxygen or oxygen-helium mixtures should be breathed, that massage and exercise are indi cated, and that stimulation may be needed along with other nursing care as becomes necessary for each case. Primary Bibliography Behnke, A. R., Shaw, L. A., Messer, Anne, Thomson, R. M., and Motley, E. P. The Circulatory and Respiratory Distuibances of Acute Compressed-Air Blness and the Administration of Oxygen as a Therapeutic Measure. Am. J- of Phys., 114: 526-533, 1936. Behnke, A. R. and Shaw, L. A. The Use of Oxygen in the Treatment of Com- pressed-Air Illness. U. S. Nav. Med. Bull., 35: 61-73, 1937. Boinet. Traitement de las Maladie des Scaphandriers. Marseille Med., 44: 357-370, 1907. Corning, J. L. Observations on the Caisson or Tunnel Disease. Medical Record, N. Y., 37: 513-521, 1890. French, G. R. W. Diving Operations in Connection with the Salvage of the U. S. S. F-4. U. S. Nav. Med. Bull., 10:74-91, 1916. Johnson, J. E. and Bradlaw. A Case of Caisson Disease. J. Roy. Nav. Med~ Ser., 11:293-295, 1925. Kropveld, A. Het een en ander omtrent Caissonziekten, Waargenomen aan het Westelijk Viaduct te Amsterdam. Med. Weekbl., Amst., 13: 354-356, 1907. SHILLING COMPRESSED-AIR ILLNESS 249 Nomura, M. Experiment for Prevention and Treatment of Caisson Disease. Bull. Nav. M. A. Japan, 18: 2-4, 1929. Oliver, T. Compressed-Air Illness in Colossal Bridge Building. Arch. f. Gewerbepath. u. Gewerbehyg 5: 313-318, 1934. Pelton, H. The Treatment of Compressed-Air (Caisson) Illness. Am J. Med. Sc. 133:679, 1907. Ryan, L. M. Compressed-Air Disease from a Clinical Aspect. N. Y. Med. J., 90: 193-198, 1909. Ryan, L. M. Compressed-Air Illness in Caisson Work. Ann. Labor Legisl. Rev., N. Y., 2: 350-355, 1912. Sakai, Y. Forschungen uber Vorbeugung und Behandlung der Caissonkrank- heit. Mitt. d. med. Gesellsch. zu Tokio., 48: 73-76, 1934. Sayers, R. R., Yant, W. P. and Hildebrand, J. H. Possibilities in the Use of Helium-Oxygen Mixtures as a Mitigation of Caisson Disease. Report of Investigations, Dept. of Int. R. I. No. 2670, Feb. 1925. von Schrotter, H. Der Sauerstoff und der Prophylaxie und Therapie der Luftdruckerkrankungen. A. Herschewald, Berlin, 1906. von Schrotter, H. Referat uber die Berufskrankheit der Kaissonarbeiter. Sitz. ber. d. sektion IV & XIV Int. Kong. Hyg. & Demog. Berlin, Sept., 1907. Bene. Accidents produits par l'Air Comprime. Cong. Franc, de Med. Paris, 2: 480-485, 1895-96. Sjoblom, J. C. Caisson Disease. Finska Lakaresallskapets Handlingar Hel- singfors, 66: 398, 1924. Abs. J. A. M. A., 83: 654, 1924. Secondary Bibliography Lividas, S. Sur la Maladie des Scaphandriers et son Traitement. Bull. Soc. de Med. Athens, 1905, J. de la Sante, 22: 1137, 1905. Merget, M. Damming of the Thames —Caisson Disease. Lancet, 4261: 1173, 1905. Mourilyan, E. P. Compressed-Air Illness and its Treatment by the Inhalation of Oxygen. J. Trop. Med., London, 9:286, 1906. Muto, P. I. Nota circa un Palombara Colpito da Embolia gassosa tardiva. Ann. di med. Nav., Roma, 2: 155-158, 1923. von Schrotter, H. Ueber die Bedeutung der Recompression bei Luftdrucker krankungen. Monatschr. f. Unfallheitk. Leipz., 5: 341-343, 1898. V. Prognosis of Compressed-Air Illness The incidence of this illness is almost 100 percent, if the trivial as well as the severe cases are counted. In fact, in building a bridge over the Eider in 1885, at a pressure of 2.6 atmospheres above normal, there were 380 cases of illness in 140 men. In 1840 in the Strepy-Braqueg- nies mine (+2.7 atmospheres) all except one worker suffered the illness and in the pressure work for the Bayonne bridge over the Adour, 90 percent of the workers suffered. Silberstein in 191 1 (all authors in this section are mentioned in the bibliographies of other sections) reported an annual morbidity of 200 percent among his workers. Keays in 1909 reported 3,692 cases among 10,000 men, that is 36.92 percent; however, on the basis of man-shifts or individual exposures (557,000) the percentage of illness was only 0.66 percent. Mortality in this illness is remarkably low at the present time due to the almost miraculous results of recompression treatment, whereas 250 SHILLING COMPRESSED-AIR ILLNESS prior to its use the mortality rate was frequently very high. Blick in 1909 said that 60 out of 200 severe cases among pearl divers were dead before they reached a doctor and others died later. Jeminet in the St. Louis bridge work reported 119 cases of illness with 52 developing permanent paralysis and 14 dying, or a mortality of nearly 12 percent. Dominquez reported that among 550 men working on the foundations of a building there were many mild cases, 106 cases of serious paralysis and 14.9 percent deaths. In the construction of the Brooklyn bridges the mortality was nearly 3 percent. The value of recompression is well illustrated by the work on the Hudson River tunnel where the mortality dropped following the installation of the medical lock from 25 percent to 1 percent. In the extensive work on the New York East River tunnels over a period of 2 years the mortality rate was 2 percent on the basis of men employed but on the bais of working shifts was only 0.0035 percent. In England during the construction of the Blackwall tunnel there were 200 cases but no deaths. It is of course evident that the prognosis is much graver in a case showing early collapse or unconsciousness than in one with only pain in a joint. Also cases with severe paralysis are quite likely to be diffi cult to cure and may end by having permanent paralytic changes (6 percent in one series). Even here, however, the prognosis is much better in cases of paraplegia due to compressed-air illness than in paraplegia due to other causes. From the foregoing it is clear that if proper treatment is given in cases of compressed-air illness the prognosis for complete cure is favor able and the mortality rate is negligible. VI. Prophylaxis of Compressed-Air Illness In discussing the cause of compressed-air illness in section 11, it was stated briefly that tissue nitrogen saturation was determined by the depth of pressure and the length of exposure to this pressure. In a closer analysis we find that in addition to these factors there is the very complex factor of body tissues and their physiology. This prob lem was taken up in great detail by Boycott, Damant and Haldane (1908), who considered such factors as blood volume, blood velocity, heart rate, volume of blood passing thru the lungs and volume of air breathed per minute under circumstances of rest or exercise, proportion of blood to the rest of the body, proportion of fat, and the relative solubility of nitrogen in the various tissues. They evolved, after much calculation, a logarithmic curve which demonstrated the progress of saturation with nitrogen for any part of the body. They concluded that for practical purposes they would divide the body into those tissues which attained 50 percent saturation (total saturation time for any tissue is difficult to determine because it approaches infinity as a limit) in 5, 10, 20, 40, and 75 minutes. From experimental observa SHILLING COMPRESSED-AIR ILLNESS 251 tions it was found that, for practical purposes, after an exposure of 5 hours saturation was complete. It is of course evident from further review of section 11 that the cause of compressed-air illness is the failure to properly eliminate the nitrogen which has been stored in the tissues. Thus prophylaxis de pends upon the safe elimination of this nitrogen, and this process is called decompression. Whether or not the results of decompression are satisfactory will depend upon the following factors: (1) The ex tent to which the blood and tissues have become saturated — (2) the extent to which they have become desaturated during the stages of decompression, and (3) the degree to which the tissues will stand supersaturation. By supersa titration is meant the property of the tissues and tissue fluids to hold in solution excess amounts of nitrogen gas, absorbed under increased air pressure, after the external air pressure has been lowered. The phenomenon which makes this pos sible is probably the colloidal nature of the tissue fluids. By extensive experimentation it has been shown that supersatura tion to the extent of about 1.25 atmospheres above normal atmospheric pressure can be borne without the risk of nitrogen emboli formation— which is to say that a diver can safely return to the surface from a depth of approximately 41 feet sea water without the necessity of decompression. Therefore decompression should be sufficiently slow so that even the slowest tissues do not have, at any time, a super- saturation greater than 1.25 atmospheres excess pressure, but in order to reduce the amount of exposure the decompression must be as rapid as possible. Boycott, Damant, and Haldane (1908) state — A pressure of 1 to 1.25 atmospheres above normal corresponds to from 2 to 2.25 times the normal atmospheric pressure; but the volume (not the mass) of gas (measured at the existing pressure) which would be liberated if the whole excess of gas present in supersaturation were given off is the same whether the absolute pressure is reduced from two to one atmospheres, or from four to two, or from eight to four. Hence it seemed probable that, if it is safe to decompress suddenly from two atmospheres of absolute pressure to one, it would be equally safe to decompress from four atmospheres absolute to two, from six atmospheres absolute to three, etc. * * * The process of desaturation can therefore be hastened very greatly by rapidly reducing the absolute pressure to half, and so arranging the rest of the decompression that the saturation in no part of the body shall ever be allowed to correspond to more than about double the air pressure. On the basis of these facts new "stage" decompression tables were calculated for various times and depths of exposure and appear as Tables I and 11 of Appendix IV of the above article. These tables are still in use by the United States and British Navies as well as in other diving activities. Haldane (1908) (1922) describes the method of calculating the tables and demonstrates the superiority of stage over continuous or uniform decompression. It is evident that when the reduction of pressure has been completed there is still excess nitrogen held in supersaturation, which is given 252 SHILLING COMPRESSED-AIR ILLNESS off according to the same curve as that of saturation, provided no bubbles have formed. Thus, as pointed out by Stewart (1913), Perry (1923), and many others, a second exposure before all of the excess nitrogen has been eliminated is dangerous and will require a longer second decompression. Although most cases of compressed-air illness are due to faulty or difficult decompression the examples of the illness given by Earl (1924), Baske (1929), and Beeching (1930), are considered sufficient for illustration. A study of 46 cases of experimentally produced compressed-air illness was presented by Shilling, Hawkins, Polak, and Hansen (1935), in which the tissue saturation of the theoretical 5-, 10-, 20-, 40-, and 75-minute tissues was accurately determined and it was found that the saturation of the 5- and 10-minute tissues had no bearing on the production of the illness, and that the saturation of the 20-minute tissues might be allowed to reach a ratio of 2.8 to 1 before symptoms appeared, rather than the 2.25 to 1 ratio advocated by Boycott, Damant, and Haldane (1908). On the basis of these findings a new method of calculating decompression tables was suggested by Haw kins, Shilling, and Hansen (1935), which materially shortens the time of decompression for short and low pressure exposures. Numerous other modifications have been suggested: Morrison (1933) demon strated the method of calculating decompression tables and suggested shortening the last stop; Kagiyama (1934) on the basis of a study of the nitrogen content of the urine following pressure exposure sug gested shortening the tables; Shilling and Hawkins (1936), in an analysis of 2,143 "lung" escapes, found that it was possible to stay 37 minutes at 100 feet, 18 minutes at 150 feet, etc., and then safely come to the surface without any decompression. Hawkins and Shil ling (1936) presented experimental results demonstrating the feasi bility of surface decompression, that is, bringing the diver directly to the surface and then immediately giving him the decompression for his dive in a recompression chamber. Dorello (1934) and Bchnke, Thomson, and Shaw (1936) studied the rate of nitrogen elimination in men breathing commercially pure oxygen, calculated desaturation curves, and suggested changes in the decompression tables. Ham and Hill (1905), Zuntz (1909), Born- stein (1910), and Hill (1910), all suggest oxygen breathing in order to shorten decompression as well as prevent the development of compressed-air illness. The breathing of helium-oxygen mixtures to shorten decompression was suggested by Sayers, Yant, and Hilde- brant (1925, see sec. IV), the Editor of "Umschau" (1925), Sayers and Yant (1926), and Yant (1927). Official regulations have been drawn up by various countries as well as several of our states. German regulations are reported by SHILLING COMPRESSED-AIR ILLNESS 253 Heller (1898), Salessky and Libow (1901), and Leymann (1921); Russian by Zalieski and Liboff (1901); French by Wasserberg (1905 and Silverstern (1910); Dutch by Wintgens (1907); Swiss by the Swiss National Accident Insurance Department (1933) ; New Jersey and New York regulations by Erdman (1918); Detroit tunnel reg ulations by King (1910); and New York regulations by Japp (1913), and Levy (1917). Other than these official regulations governing the conduct of pres sure work there are many excellent general articles concerning the problem of prophylaxis. De Mericourt (1868) (1869) suggested the necessity of a very careful choice of divers on the basis of physical fitness, the regulation of the diet during diving operations, quick descent, not over 2 hours exposure at 30 meters, slow decompression, and the presence of a doctor on the premises of the diving operations. Langlois (1906) (1910) (1911) discusses the value of the varius types of decompression and suggests the use of oxygen inhalation and exer cise as adjuncts to the stage method of decompression. Plesch (1910) recommends the use of stage decompression and stresses the physical examination strongly, saying that not only should they "reject cripples, weaklings, persons with infectious diseases, tubercu losis, alcoholism, lung, heart, nerve, kidney, and stomach ailments," but also special attention should be paid to circulatory efficiency, and that fat men, men with heart failure or vasomotor weakness, chloro sis, anemia, diseases of the central nervous system, nephritis, or those with ear disease should be barred from pressure work. Glibert (1912) (1914) discusses at length the value of the uniform method, the Holland method, and the stage method of decompression and decides in favor of the stage method. Stewart (1913) considers the following points important: adequate air supply, rapid descent, limiting time on the bottom, stage method of decompression, and careful physical selection of divers. "Hygiene of divers" is discussed in two articles by Moschini (1934). Cazamian (1927) discusses the French regula tions and stresses the necessity for medical control and supervision, careful physical selection, and periodic reexamination, abstinence from the use of alcohol, and many other general and specific prophy lactic measures. Rigid physical selection and frequent reexamination is required of deep-sea divers in the United States Navy (1924) (1927). Not only are the men carefully selected according to the physical standards laid down by the Medical Department but "qualified divers shall be examined physically periodically and special examination shall be made in the case of all men prior to all deep diving operations (in excess of 36 feet)." Age is considered as important and divers are automati cally disqualified when becoming 40 years old. The British Navy (1930) also requires high physical standards and even says, "If the 45202—38 7 254 SHILLING COMPRESSED-AIR ILLNESS slightest doubt exists as to the physical fitness of a candidate he should be rejected." According to the British Admiralty (1933) they also require annual medical examination as well as medical examination before each dive. Abstinence from the use of alcohol has been stressed by most of those writing on prophylaxis. In the United States Navy it is the custom to not only examine before each deep dive but also to take a short his tory of the previous 24 hours to determine whether there is present an upper respiratory infection, if alcohol has been consumed, if the bowels are moving normally, and if the diver feels fit. No diver is permitted to dive who is not, or does not feel, physically fit. In summary the written opinion seems to be that careful physical selection of divers is most important, periodic reexamination is essen tial, medical supervision of pressure operations is desirable, descent or entrance into pressure should be rapid, time under pressure (single or multiple exposures) should be held within safe limits, the stage method of decompression is the method of choice, and that oxygen inhalations and exercise during decompression hasten the elimination of nitrogen. Primary Bibliography Baske, H. F. A. Caisson Disease Resulting from Disregard of Published Instruc tions and Established Practice. U. S. Nav. Med. Bull., 27: 514-518, 1919. Beecbing, C. L. A Case of Caisson Disease Resulting from Insufficient De compression. U. S. Nav. Med. Bull., 28: 236-241, 1930. Bebnke, A. R., Thomson, and Shaw. The Rate of Elimination of Dissolved Nitrogen in Man in Relation to the Fat and Water Content of the Body. Am. J. of Phys., 114: 137-146, 1936. Bornstein, A. Versuchc uber die Prophylaxe der Pressluftkrankheit. Berlin klin. Wchnschr., 47: 1272-1275, 1910. Boycott, A. E., Damant, G. C. C., and Haldane, J. S. The Prevention of Compresscd-Air Illness. J. Hyg., Cambridge, 8: 342-443, 1908. British Admiralty. Divers —Examination and Selection —Medical Regulations. J. Roy. Nav. Med. Ser., 19: 141-142, 1933. British Navy. Medical Qualifications for Men Volunteering for the Non substantive Rating of Deep Diving. A. F. O., Deep Diver, 2449, 1930. Cazamian. Plonges en Scaphandre. Arch, de med. et Pharm. Nav., 117: 105-129, 1927. Dorello, F. La Dcazotazione nel Paloinbaro. Ann. di. med. nav. e Colon., 40: 650-662, 1934. Earl, R. Caisson Disease Resulting from Complete Disregard for the Mandatory Instructions. U. S. Nav. Med. Bull., 21: 719-721, 1924. "Editor." Helium fur Taucher. Die Umschau, 29: 820, 1925. Erdman, S. Standards for the Prevention of Compressed-Air Illness. Am. J. Pub. Health, Concord, N. H., 8: 431-434, 1918. Glibert, D. Contribution a la Prophylaxie du "Mai des Caissons." Bull. Acad. Roy. de Med. de Belg., Brussels, 26: 640-662, 1912. Glibert, D. La Prophylaxie du "Mai de Caissons." Bull, de l'assoc. Beige de Med. Soc, Brussels, 2: 1-18, 1914. Haldane, J. S. The Hygiene of Work in Compressed-Air. J. Soc. of Arts., 16 : 214-226, 1908. SHILLING COMPRESSED-AIR ILLNESS 255 Haldane, J. S. Respiration. Yale Univ. Press. 1922. Ham, C, and Hill, L. E. Oxygen Inhalation as a Means to Prevent Caisson and Diver's Sickness. Proo. Phys.'Soc, London, June, 8, 1905. Hawkins, J. A., Shilling, C. W., and Hansen, R. A. Suggested Change in Cal culating Decompression Tables for Diving. U. S. Nav. Med. Bull., 33: 327-338, 1935. Hawkins, J. A., and Shilling, C. W. Surface Decompression of Divers. U. 8. Nav. Med. Bull., 34: 311-317, 1936. Heller, R. Hygienische Vorschriften fur Arbeiten in Comprimirter Luft mit Ausschluss der Taucherarbeiten. Monatschr. f. Unfallheilk., Leipz., 5: 140-144, 1898. Hill, L. Compressed air illness. Brit. Med. J., 2: 785-786, 1910. Japp, H. Caisson Disease and its Prevention. Tr. 15 Internat. Cong. Hyg. and Dmog., 1912, Wash., 3: 639-654, 1913. Kagiyama, S. Studies on Prevention of Caisson Disease. J. Kumamoto Med. Soc, 10: 562-564, 1934. King, D. M. Compressed-Air Illness, Caisson Disease, bends, diver's palsy. J. Am. Inst. Homoeop. N. Y., 2: 106-111, 1910. Langlois, J. P. Projet de Reglementation du Travail dans l'Air Comprime. Hyg. Gen. et Appliq., Paris, 1: 324-339, 1906. Langlois, J. P. La Reglementation du Travail dans l'Air Comprime. Prcsse med., Paris, 18: 681, 1910. Langlois, J. P. La Prophylaxie des Accidents dans l'Air Comprime. Rev. Gen d. Sc. Pures et Appliq., Paris, 22: 54-60, 1911. Levy, E. Workers in Compressed-Air; Precaution" Adopted by the N. Y. Pub. Ser. Comm. for Protecting Their Health. Scient. Am. Suppl., N. Y., 84: 73, 1917. - Leymann, G. 0. Die Verordnung zuni Schutze der Pressluftarbeiter vom 28. Juni, 1920. Zentralbl. f. Gewerbehyg., 9: 30, 1921. deMericourt, Le Roy. Considerations sur l'Hygiene des Pecheurs d'Eponges. Bull, de l'Academie de Med., 33: 786-789, 1868. deMericourt, Le Roy. Hygiene des Pecheurs d'Eponges. Annales d'Hygiene Publ. et de Med. Legale., 31: 274-286, 1869. Morrison, J. K. Decompression of Divers. U. S. Nav. Inst. Proc, 59: 1695-1703, 1933. Moschini, M. Igiene del Palombaro. Ann. d'ig., 44: 554-572, 646-660, 1934. Perry, W. R. Case of Caisson Disease or Diver's Paralysis Treated by Com pressed Air. J. A. M. A., 80: 1455, 1923. Plesch, J. Zur Prophylaxe und Therapie der Caissonkrankheit. Verhandl. d. Deutsch. Kong. f. Innere Med., Wiest., 27: 254-263, 1910. Plesch, J. Zur Prophylaxe und Therapie der Presslufterkrankungen. Berlin Klin. Wchnschr., 47: 709-712, 1910. Salessky, S. J., and Libow, B. A. Arbeiten der Komission zur Verhfltung der sog. Kaissonkrankheit. Ref. erstattct anl. der V. Tag. der russ gesell. f. Volk. Woyenaje Med. J. No. 10, 1901. Sayers, R. R. and Yant, W. P. Value of Helium-Oxygen Atmosphere ia Diving and Caisson Operations. Anesth. and Analg., 5: 127-138, 1926. Shilling, C. W., and Hawkins, J. A. The Hazard of Caisson Disease In Indi vidual Submarine Escape. U. 8. Nav. Med. Bull., 34:47-52, 1936. Shilling, C. W., Hawkins, J. A., Polak, I. B., and Hansen, R. A. Caisson- Disease and Its Relation to Tissue Saturation with Nitrogen. U. S. Nav. Med. Bull., 33: 434-444, 1935. Silber8tern, P. Gesetzlicher Arbeiterschutz bie Caissonarbeiten in Frankreiob.. Amst.-Arzt., Leipz. and Berlin, 2: 21-23, 1910. 256 SHILLING COMPRESSED-AIR ILLNESS Stewart, R. W. G. Caisson Disease. Tr. Int. Cong. Med., London, Sect. Nav. and Mil. Med., 19: 147-154, 1913. Swiss Nat. Accident Ins. Dept. The proposed Swiss Regulations. J. Ind. Hyg., 15: 83-84, 1933. U. S. Navy. Physical Qualifications of Divers. U. S. Navy, Dept. Bureau of C. and R. Diving Manual, Sec. 13, Art. 3680 and 3681, 1924. U. S. Navy. Physical Examination of Personnel Selected for Deep Diving. U. S. Navy Manual of the Med. Dept., Art. 1535, 1927. Wasberbebg, E. Essai de Reglementation Sanitaire du Travail dans 1'Air Comprime. Paris, 8°, 1905. Wintgenb, E. Bericht uber das Vorkommen der Kaissonkrankheit in Holland. Sitz. d. Sek. IV and XIV. Int. Kong. f. Hyg. u. Demog., Berlin, 1907. Yant, W. P. Helium in Deep Sea Diving. Ind. and Eng. Chein., News. Ed., 5: 4, 1927. Zaliebki, S. I., and Liboff, B. A. Report of the Commission for Finding Measures to Prevent Caisson Disease. J. Russk. Okhran. Narod. Zdrav., St. Petersburg, 11: 345-353, 1901. Zuntz, N. Die Verhutung der Erkrankungen Nach Aufenthalt in Komprimier- ter Luft. Fortschr. d. Med., Berlin, 27: 561-563, 1909. Secondary Bibliogbaphy Blattneb and Zanggeb. Beitrag zur Frage der Prophylaxe der Taucher- krankheit. Schwez. Med. Wchnschr., 60: 1104-1106, 1930. Cabdon, G. Contributo alio Studio Medico-Legale della Malattia da Lavoro in Aria Compressa. Ramazzini, Firenze, 2: 362-373, 1908. Kuhneb, A. Caissonarbeiten. Gesundheit, 20: 322-323, 339-340, 354-355, 1895. Layet, A. Hygiene des Plongeurs. Rev. san. de Bordeaux, 3: 67, 1886. Muller, H. Die Gefahren der Gewerblichen Arbeit unter Kiinstlich Erhohtem Luftdruck. Monatschr. f. Unfallheilk, Leipz., 25: 4-14, 1918. Rees, O. Comm. Bericht iiber Experimentelle UntersUchungen zur Prophylaxe der Taucherkrankheit. Erst, im Auf. der Adm. der Kgl. eng. Kriegsmarine, 1907. von Schrotteb, H. Zur Prophylaxie der Taucherlahmung. Sitz. de Cong. intern, per le Malattie del Lavoro, Mailand, 1906. Schmittz, N. A. Caisson Air Hygienically Considered. Vrach., St. Petersb., 8: 847-870, 1887. Schmittz. N. A. Sanitary Conditions for Work Performed in Caisson. Vrach., St. Petersb., 9: 225, 245, 263, 1888. Silberstein, P. Hygiene der Arbeit in Komprimierter Luft. Jena, 8°, 1901. Sulikowbki, F. Condition of the Health of the Caisson Workmen. Czasopismo lek., Lodz, 4: 97-101, 1902. Sviontetske, I. O. Caisson Work from a Sanitary Viewpoint. Vestnik Obshtsh. Hyg., Sudet. i. Prakt. med., St. Petersburg, 2: 981-1005, 1900. Waller, G. De Hygiene der Caisson. Amsterdam, 12°, 1904. Zburzhinbkiy, K. Sanitary Conditions in Work of Divers. Voen. san. delo 10: 1*6-37, 1932. Unclassified Bibliography (These references do not logically fall in any particular section and are given here merely for the sake of completeness.) Abadir, F. Caisson Disease on New Kasr el Nil bridge. J. Egyptian M. A., 16: 811-825, 1933. Aldrich, C. J. Caisson Disease. Cleveland Med. Gaz., 14: 279-295, 1899. SHILLING COMPRESSED-AIR ILLNESS 257 Belli, C. M. Bericht uber Kaissongrankheit. vgl. Wien. klin. Rudsch., 41: 760, 1906. Bigoar, H. F. The Bends; Caisson Disease, or Diver's Paralysis. Tr. Am. Inst. Homoeop., 1900, N. Y., 268-299, 1901. Billstrom. On Divers Malady. Svens Lak-Sallsk Ford-handling, Stockholm, 83-88, 1910. Brand, J. D. Over Ngevallen bij Pheumatische Fundeeringen. Nederl. Tydschr. v. Geneesk., Amst., 2 r. XLI., d., 2: 34-40, 1905. Bbintizer, J. Die Erkrankungen der Taucher und ihre Beziehungen sur Unfall- versicherung. Hamburg, Ackermann & Wulff, 8°, 1913. Gaffe, P. L. B. Du Travail dans l'Air Comprime. J. D. Conn. Med. Prat., 30: 385, 401, 415, 1863. Carre, L. Les Maladies de l'Air Comprime. Nature, Paris, 30: 303-304, 1902. Cattaneo, F. La Malattia dei Cassoni ad Aria Compressa. Gaz. med. Lomb., Milano, 71: 33-37, 1912. Charbostin, M. N. Labors in Water and the Diseases of Divers. Med. pribav. k. morsk. sborniku, St. Petersb., 68: 126, 1888. Clark, H. E. On Caisson Disease with some Speculations as to its Causation. Glasgow, M. J., 40: 17-28, 1893. Dominquez, A. G. Caisson Disease o Paralysis de los Buzos. Rev. de med. y. cirug. de la Habana, 17: 359-368, 1912. Editor. Caisson Disease. J. A. M. A., 29: 392-394, 1897. Elizalde, P. I. Acoidents Producidos por Aire Comprimido (Malades des Caissons). Rev. Assoc. med. Argent., Buenos Aire, 23: 1018-1034, 1915. Englebach, P. Les Accidents Consecutifs au Coup de Compression. Rev. med. de Normandie., Rouen, 3: 57-63, 1902. Fontaine, M. Accidents et Maladies causes par le Travail dans l'Air Comprime au Havre de 1900-1906. Rapport #20515, 4 Feb., 1907. Friedrich, W. and Txuszk, F. Caisson-Munkasok Megbetegedeseirol. Orvosi heitil., Budapest, 40: 149, 162, 173, 186, 1896. Friedrick, W. and Tauzk, F. Die Erkrankung der Caissonarbeiter. Pest. med. chir. Presse, Budapest, 32: 674, 701, 722, 747, 1896. Glibert. Rapport sur les Traveaux du Service Medicale en Belgique IV. Influence du Travail a l'Air Comprime sous Faible Pression. Rapports ann. de. l'inspection du Trav., 11: 318, 1906. Haaland, M. & Schaaming, C. K. Dodsfall hos Dykkere. Med. rev., Bergen, 49: 260-276, 1932. Haldane, J. S. Experimentelle Untersuchungen uber die Taucherkrankheit. In Druck J. Hyg., 1907. Halliday, C. H. Deep Sea Diving and its Relation to Caisson Disease; an Abstract of the Literature. Am. J. Trop. Dis., New Orleans, La., 3: 502-512, 1915-16. Heermann, G. Ueber Caissonkrankheit. Samml. klin. Vorto., n. F., Leipz., No. 334, 1902. Chir. 95: 385-404, 1902. Heller, R. et al. Vorlaufige Mitthelung eber Caissonarbeiter. Wien. klin. Wchnschr., 8: 475, 1895. Hermel, E. Des Accidents Produits par l'Usage des Caissons ou Chambres a l'Air Comprime dans les Travaux Sous- Terrains et Sous-Marins. Paris, 8°, 1863. Hill, L. The Physiology of Submarine Work. Rep. Britt. Assoc. Adv. Sc., London, 634-647, 1911-12. Houderville, L. Contribution a l'Etude des Accidents du Travail dans l'Air Comprime. Paris, 8°, 1901. Kluge, A. Caissonpsychose oder Simulation. Monatschr. f. Unfallh., 40: 286-291, 1933. 258 SHILLING COMPRESSED-AIR ILLNESS Kober & Hayhurst. Industrial Health. By Blakiston. Kropveld, A. Eenige Twijfelachtige punten bij Caissonzeikte. Nederl. Tijdschr. v. Geneesk, Amst., 2: 1398-1404, 1907. Kropveld, A. Caissonziekte. Nederl. Tysdchr. V. Geneesk., Amst., 1: 675- 683, 1907. Kropveld, A. Bekopte Mededeeling omtrent den Aard en het Aantal der Ziektegevallen die Zich Hebben Voorgedaan bij den Caissonarbeid voor de Nieuwe Westelijke Viaduct te Amsterdam. Nederl. Tijdschr. v. Geneesk., Amst., 1: 1672-1675, 1908. Langlois, J. P. Referat uber die Berufskrankheit der Kaissonarbeiter. Sitz. der Sekt. IV des XIV Int. Kong. f. Hyg. u. Dem., Berlin, Sept. 1907. Leefman, H. Compressed Air Illness. Diet and Hyg. Gaz., N. Y., 13: 447—449; 1897. von Mouilland, R. Ueber Caissonkrankheiten und Caissoneinrichtungen. Deutsche Vrtljschr. f. off. Gsndhtspfl, Brnschwg., 36: 549-552, 1904. Mummery, N. H. Diving and Caisson Disease; a Summary of Recent Investiga tions. Brit. Med. J., 1: 1565-1567, 1908. Oliver, T. A Clinical Lecture on Caisson Disease or Compressed Air Illness. Lancet, London, 1: 354-357, 1899. Oliver, T. Discussion on Compressed Air Illness, or Caisson Disease. Brit. Med. J., London, 2: 317-321, 1904. Oliver, T. Compressed Air Illness or Caisson Disease. Vort. geh. in der Genoot. ter Bevord. van Nature, Genees en Heel-Kinde, Amsterdam, Oct., 1905. Oliver, T. On Compressed Air Illness. Nederl. Tijdschr. v. Geneesk, Amst., 41: 1463-1476, 1905. Oliver, T. Maladies Caused by the Air We Breathe Inside and Outside the Home, Including Caisson Disease or Compressed Air Illness. London, Baillaire, Tindall 4 Cox, 1906. Oliver, T. Accidents Causes par l'Air Comprime ou Maladie des Caissons. Ann. d'hyg. et de Med. Legale, Paris, 5: 385-410, 1906. Oliver, T. L'usage des Caissons dans la Construction des Fonts et les Accidents de l'Air Comprime. Bull, et Men. Soc. Med. d. Hop. de Paris, 23: 539-558, 1906. Oliveb, T. The Physiology and Pathology of Work in Compressed- Air. Lancet. London, 1:297-301, 1909. Parkin, A. Caisson Disease or Compressed-Air Illness. U. Durham Coll. Med. Gaz., Newcastle, 3-4: 81-88, 1902-04. Pettazzi, A. Osservazioni Cliniche e Considerazioni Medico Legale sulla Pathologia del Lavoro in Aria Compressa. Ramazzini, Firenze, 9: 118-152, 1915. Poledne, V. Diseases of Divers. Casop. lik. eesk., Praze, 52: 1635-1637, 1913. Rosendo, PI, D. Efermedad de los Buzos. Rev. de cien. med., Barcel., 13: 487-519, 1887. Roucayrol. Les Accidents de l'Air Comprime. Paris med., 5: 289-291 , 1911-12. von Schrotter, H. Vereichnis der seit dem Jahre 1900 erschienenen Literatur uber Kaisson und Taucherkranke. Hyg. Zentralbl., Leipz., 3:397-403, 1907. Sheinpain, M. G. Caisson Works on the Big and Little Bolda rivers in Astrak han, and Diseases Connected with Them. Izviest. Obsk. Astrakhan Vrach., 8: 1-7, 1908. Silberstern, P. Zur Cauistik und zur Prophylaxe der Caissonkrankheigt. Wien. med. Wchnschr., 66: 1894-1898, 1942-1945, 1896. Silberstern, P. Referat uber die Berufskrankheit der Kaissonarbeiter. Sitz. d. sck. IV & XIV Int. Kong. Hyg. & Demog., Berlin, Sept., 1907. SHILLING COMPRESSED-AIB ILLNESS 259 Silberstern-, P. Die Berufskrankheit der Caissonarbeiter. Oesterr., San.- Wes., Wien., 21: 125, 133, 1909. Silberstern, P. Die Gefahren der Caissonarbeit. Tr. 15, Int. Cong. Hyg. A Demog., 1912, Wash. 3: 610-619, 1913. Smith, A. H. The Physiological, Pathological, and Therapeutical Effects of Compressed- Air. Published by G. G. Davis, 1886. Skell, E. H. Compressed-Air Illness or So-Called Caisson Disease. London, 8°, 1896. Stephens, H. N. Accidents and Diseases Caused by Diving Operations. Report of Health of the Navy, London, 1900. Stott, A. A. Caisson Disease. Maine Med. J. 25: 24-28, 1934. Terni, C. La Malattia dello Scafandro. Ramazzini Firenze, 5: 616-619, 1911. Thienen, G. T. Zur Frage dur Kaissonkrankheit in Holland. Sitz. der sek. IV & XIV Int. Kong. Hyg. & Demog., Berlin, Sept. 1907. Thorst. Caissonkrankheit. Deutsche Med. Wchnschr., Leipz. & Berl., 37: 1101, 1911. Umber. Kaissonlahumung. Zeit. f. arztl. Fortbild, 3: 22, 1906. Unknown. Caisson Work. Ind. Med., 3: 42-43, 1934. Unknown. Project de Decret Reglementant le Travail, dans l'Air Comprime. Comm. de Hyg. Ind., France, 1906. Unknown. Regulativ der Hollandsschen Regierung fur die Arbeiten in Kom- primierter Luft. Staat van het Kon der Neider, 20: 1907. Vilmos, F., and Tauszk, F. Caisson-Munkosak Megetegedeseirol. Orvosi Heti. Szemle, Budapest, 20: 177, 1896. Wainwrioht, F. R. Observations on Compressed-Air Illness. Lancet, London^ 2: 1792-1799, 1900. NAVAL RESERVE PROMOTIONS, FOURTH QUARTER, 1937 Clarence Andrew Berger, 3015 Cherry Street, Toledo, Ohio, promoted to com mander, MC-V (G), U. S. N. R., November 20, 1937. Rutherford B. H. Gradwohl, 3514 Lucas Avenue, St. Louis, Mo., promoted to commander, MC-F, U. S. N. R., November 18, 1937. Joseph Henry Cannon, lOili Rutledge Avenue, Charleston, S. C., promoted to lieutenant commander, MC-V (S), U. S. N. R., December 17, 1937. Sam Ardinger Bassett, 1250 Big Bend Boulevard, St. Louis, Mo., promoted to lieutenant, MC-F, U. S. N. R., November 15, 1937. Charles Bunch, 2214 East Seventh Street, Charlotte, N. C, promoted to lieu tenant, MC-V (S), U. S. N. R., November 8, 1937. Matthew Remey Furman, 230 West Seventy-ninth Street, New York City, N. Y., promoted to lieutenant, MC-V (G), U. S. N. R., November 16, 1937. Robert Farjeon Legge, 3135 Webster Street, Oakland, Calif., promoted to lieutenant, MC-V (S), U. S. N. R., November 18, 1937. Duncan Tracy McEwan, Orlando, Fla., promoted to lieutenant, MC-V (G), U. S. N. R., November 9, 1937. Harry Carpenter Watkins, Jr., Aberdeen, Wash, promoted to lieutenant, MC-F, U. 8. N. R., November 12, 1937. RESIGNATIONS, FOURTH QUARTER, 1937 Moses H. Baker, 6045 Bunkerhill, Pittsburgh, Pa., lieutenant commander, MC-V (S), U. S. N. R., resignation accepted December 2, 1937. Horace W. Byers, 509 Woodlawn Road, Baltimore, Md., lieutenant commander, MC-V (G), U. S. N. R., resignation accepted October 28, 1937. Carl E. Dunaway, Huntington Building, Miami, Fla., lieutenant commander, MC-V (S), U. S. N. R., resignation accepted November 19, 1937. Orion Timberton Finklea, 405-9-16 Florence Trust Building, Florence, S. C., lieutenant, MC-V (S), U. S. N. R., resignation accepted November 5, 1937. Vonnie Monroe Hicks, Raleigh, N. C., lieutenant, MC-V (S), U. S. N. R., resig nation accepted November 4, 1937. Frank C. Hodges, P. O. Box 1469, Abilene State Hospital, Abilene, Tex., lieutenant, junior grade, MC-V (G), U. S. N. R., resignation accepted November 4, 1937. Gilbert H. Mankin, 1726 Eye Street NW., Washington, D. C., lieutenant com mander, MC-V (G), U. S. N. R., resignation accepted October 28, 1937. Earl A. Orwig, 2467 Hempstead Avenue, Toledo, Ohio, lieutenant commander, MC-F, U. S. N. R., resignation accepted December 14, 1937. Samuel B. Potter, Republic Building, Denver, Colo., lieutenant, junior grade, MC-V (S), U. S. N. R., resignation accepted November 2, 1937. John Hollum Rathbone, 121 East Sixtieth Street, New York City, N. Y., lieu tenant, MC-V (S), U. S. N. R., resignation accepted November 4, 1937. Sydney K. Smith, 230 Grand Avenue, Oakland, Calif., lieutenant commander, MC-V (S), U. S. N. R., resignation accepted November 2, 1937. 261 262 NAVAL RESERVE Frank W. Smythe, 899 Madison Avenue, Memphis, Tenn., lieutenant com mander, MC-V (S), U. S. N. R., resignation accepted December 2, 1937. Carl G. Swendseen, 603 Syndicate Building, Minneapolis, Minn., lieutenant commander, MC-V (G), U. S. N. R., resignation accepted November 19, 1937. Charles C. Thomas, 257 Park Avenue, Rochester, N. Y., lieutenant, MC-V (G), U. S. N. R., resignation accepted December 2, 1937. HONORARY RETIRED LIST, FOURTH QUARTER, 1937 George P. Lingenfelter, 1616 Tremont Place, Denver, Colo., lieutenant com mander, MC-V (G), U. S. N. R., honorary retired list December 1, 1937. William A. Dalton, 243 West Seventieth Street, New York City, N. Y., lieu tenant commander, MC-V (S), U. S. N. R., honorary retired list December 1, 1937. DEATHS, FOURTH QUARTER, 1937 Andrew J. Minaker, 200 Granville Way, San Francisco, Calif., lieutenant com mander, MC-V (G), U. S. N. R., died November 22, 1937. Charles V. Townsend, 101 Dauphin Street, Mobile, Ala., lieutenant, MC-V (S) U. S. N. R., died October 28, 1937. NOTES AND COMMENTS PRESLEY MARION EIXEY By Commander Louis n. Roddis, Medical Corps, United States Navy The thirteenth Surgeon General, United States Navy, and the seventeenth Chief of the Bureau of Medicine and Surgery, was really the father of the modern Medical Corps of the Navy. He served as Surgeon General from 1902 until 1910, through most of the period during which Theodore Roosevelt was President. A recent naval historian put their relationship and the result of their work as respects the Navy, in the following significant sentences: "Roosevelt was for a great Navy, Rixey was for a fine Medical Department; they were both successful." Some of the important advances which were made during his term of office included the renovation and modernization of all the naval hospitals, the construction of new ones at Puget Sound (1903), Canacao, P. I. (1903), Las Animas, Colo., for tuberculosis cases (1906), the Naval Hospital, Great Lakes, 11l. (1907), and the Naval Hospital, Guam (1910). He also established the medical supply depots at Brooklyn, San Francisco, and Cavite, P. I., an extremely farsighted provision which during the World War proved of tremendous value and would again be of inestimable benefit during a time of national emergency. No Surgeon General has been more awake to the needs of the Medi cal Corps and the Medical Department. Under his regime the strength of the Corps was doubled and he brought to it specialization and postgraduate training. One of his first acts was to establish the Naval Medical School where new medical officers could receive post graduate instruction in services pertaining particularly to naval medi cine. This school is today the only center of naval medicine in the Western Hemisphere, and its library the only important repository of naval and maritime medicine in the New World. He sent medical officers abroad to study tropical medicine, a particular need of the Navy and of the greatest value in the administration of our then newly acquired tropical possessions. He instituted the practice of sending medical officers to important civilian medical institutions for postgraduate training in the leading professional specialties such as surgery, internal medicine; eye, ear, nose, and throat; psychiatry, and the medical sciences. In addition to their special training they brought back to the Navy the latest advances in their profession and 263 264 NOTES AND COMMENTS new viewpoints in the prevention and treatment of disease. He established the female Nurse Corps in 1908, these nurses being em ployed at our naval hospitals, on the hospital ships, and at the nurses training schools for native nurses in our island possessions, as well as in the Hospital Corps training schools. He attempted repeatedly to establish a Dental Corps, and, although this was not done until 1912, his efforts had much to do with its early authorization after his term of office had ended. Under his regime the United States Naval Medical Bulletin was founded (1907). This is a journal devoted to naval medicine, and, again, is the only important one in the Western Hemisphere. The bound volumes of this journal, which has now been published for nearly a third of a century, constitute an important archives of naval medicine. Dr. Rixey's great energy and ability dur ing a long, active, and useful life were devoted to the improvement of the Navy and the making of its medical service something of which the Navy could be proud. Dr. Rixey was the personal physician of two Presidents. He was the White House physician when President McKinley was struck down by an assassin's bullet. He took entire charge of the care of Mr. McKinley, was present at the operation, and gave untiring professional attention to his distinguished patient. His report of this case consti tutes an important medical historical record. He was also the personal physician of President Theodore Roosevelt as well as his trusted and intimate friend. Admiral Rixey was born at Culpeper, Va., July 14, 1852, and died June 17, 1928. He was commissioned an Assistant Surgeon in the Medical Corps of the Navy on January 28, 1874, his commission being signed by General Grant. He served through all the grades, and was appointed to the office of Surgeon General on February 5, 1902. His term as Surgeon General of the Navy ended February 4, 1910. In conclusion we may quote the emphatic message of Admiral Dewey addressed to Surgeon General Rixey. "He (Admiral Dewey) especially requested us to inform you that you are not only the best Surgeon General the Navy has ever had, but you have done more for the Medical Department and its development than all of them. He was very emphatic in his praise of you and the most excellent work accomplished by you as Surgeon General of the Navy. It is practi cally impossible for us to convey his message to you in the same forcible manner in which he expressed himself to us." INTERNATIONAL CONGRESS ON MILITARY MEDICINE AND PHARMACY' The Bureau of Medicine and Surgery is in receipt of a report on the Ninth International Congress on Military Medicine and Pharmacy held in Bucharest, Rumania, June 1937. The objective and function ' Compiled and presented by Capt. William Seaman Bainbridge, M. C.-F., U. 8. Naval Reserve (re tired). United States delegate to the Congress and member of the permanent committee. NOTES AND COMMENTS 265 of this organization are tersely stated by Captain Bainbridge as: "So that the lessons of the past war are not lost, and to make them avail able for any future hostilities, and during peace when virtually every type of wartime injury and disease is ever present, the International Congress of Military Medicine and Pharmacy was created in 1921. There have been meetings of the Congress every other year since then. Its far-reaching importance and eminent value are unchallenged in the minds of those who have come in contact with the work of the organization. Delegates, rich in experience, come from many coun tries to present their viewpoints. Such an interchange of ideas and knowledge will eventually lead to the physical betterment of mankind." The permanent committee of the Congress contributes very ma terially to the success of its meetings and functions as its agent during the interval between sessions. It organizes the Congresses, publishes the Int€rnational Bulletin of Military Medicine, develops relation ships with interested organizations, has organized a Medico-Legal Commission, and has under its International Office of Medico-Military Documentation the duties of sending speakers abroad, replying to international inquiries, arranging conference sessions, and keeping a bibliographic index up to date. The Congress received official reports from delegates of the nations represented. The following comment presents a very inadequate summary of the material presented in these reports. Organization and Functioning of the Medical Service in Combined Military and Naval Operations This report was submitted by Capt. William L. Mann, Medical Corps, United States Navy and Lt. Col. Edgar Erskine Hume, Med ical Corps, United States Army, of the United States of America delegation. It deals with regulating the relationship between medical units of land forces and sea forces when they function with a common objective. Cooperation and coordination are the prime requisites for success, and to secure these conditions each medical service must consider the general and special situation and effect complete under standing. Mere cooperation is not enough. The following principles should govern combined operations : 1. There must be unity of medical control. 2. The maintenance of proper liaison rests with the medical service not in actual control. 3. The senior medical officer (administrative) of each medical service is as signed the responsibility of initiating and preparing medical plans and arrange ments for submission to superior authority for approval. 4. Medical organizations with their equipment should be maintained and transported intact, insofar as practicable. 5. Measures for prompt relief of human suffering can be rendered more effective by the standardization of material, thus providing mutual logistic support. 266 NOTES AND COMMENTS 6. Common indoctrination of the medical services in medical procedures, arrangements, and practices. 7. For borderline situations supreme medical control should be prearranged. Standardization of supplies and equipment is essential to permit interchange between land and sea forces at points of embarkation and debarkation. Supplies should be loaded in reverse order to that in which they will be required, so that the last material loaded will be the first available for use. Quarters at ports for troops in transit should conform as nearly as possible with accepted sanitary standards. On troop transports, all medical organizations and troop functions should be under control of the Navy. Bed accommodations of the sick bay should be computed on the basis of 2 percent of the total number of crew and troops carried, with an additional 1 percent for isolation facilities. While the vessels are en route, if not before, the senior medical officers of the transport and of the troop contingents should be made fully acquainted with all the details of the plan to be followed upon arrival at the destination. Among other matters to be considered by these medical officers and approved by the staffs of the respective services prior to arrival at anchorage, are : 1. The patient capacity of each ship. 2. The types of cases each ship is to receive and retain temporarily during the early stages of the campaign. 3. The adequacy of the medical supplies aboard ship for the patient load to be accommodated. 4. The kinds and quantities of additional supplies that may be needed. 5. How and when such supplies are to be sent aboard at anchorage. 6. The sufficiency of the naval medical personnel aboard, including those to remain afloat during the period of the landing operation. 7. The number and kind of replacements that may be needed in order to care for patients to be allotted to the ship. The medical units attached to each combatant organization will debark with such organization. The medical regiment will not be landed until the force is fairly well established ashore. Shore hospi tals should not be established until warranted by conditions ashore. The first medical supplies sent ashore should be only those necessary under existing conditions for the personnel there. Each unit debark ing should leave behind a representative whose sole duty it would be to check, from a specially prepared list, all the property of the unit as it goes ashore. The casualties should be collected at points at the beach head that will not interfere with disembarking troops. One of the general principles of evacuation is to keep casualties separated from the com bat troops. For purposes of morale particular care should be taken to prevent the contact of troops with the unsightly wounded. While waiting evacuation every effort should be made to shelter the casual ties from gunfire to prevent shock. Ambulant casualties are apt to NOTES AND COMMENTS 267 cause considerable difficulty and confusion unless they are closely controlled. The land force's administrative responsibilities cease when it has collected and assembled the casualties on the beach ready for loading. Army medical personnel should, however, assist in the actual loading under the direction of the Navy. A naval medical officer should be attached to the staff of each beach master as medical embarkation officer. He will decide on the time and mode of evacua tion by boats to the ship. A naval medical officer should be similarly assigned with the senior army medical officer to assist in proper liaison. The prompt evacuation of casualties from the beach is often a military as well as a humanitarian necessity. Slight and serious cases should not be placed in the same boat. The sick and wounded of troops while being transported on a naval vessel are subject to Navy regulations and their treatment should be supervised under the direction of the medical officer of the transport. Prior to debarkation all troops should be inspected for vermin and communicable disease and those affected should be segregated, nota tion made in their health records, and reported to the proper author ity at the port of debarkation. Disposition of the sick and wounded on arrival at the port of debarkation is in accordance with the orders of the Commanding General of the port. Coordination of the medical service of the air forces with that of land and sea forces presents some problems unsolved by actual ex perience. The same principles as discussed above should govern their solution. Increased use of aircraft for ambulance duty may be anticipated. When used for this purpose they should be manned by noncombatant personnel and the plane should otherwise conform with Geneva Convention provisions. Space permits only a brief review of the other excellent official reports presented at this Congress. Transportation, Hospitalization, and Treatment op the Gas Wounded The question of the transportation, hospitalization, and treatment of those who have been gassed is dominated by the condition and character of the lesions. Their transportation involves no special problem. It is possible to assure treatment and hospitalization either in a medical formation for the gassed, provided with surgical service, or, in the surgical service, provided with a section for the gassed. As the surgical technic requires a great specialization with adequate equipment and supplies, it would seem that the second is the better solution. If circumstances point to the possibility of a large number of gas wounded, the creation of specialized medical formations for them should be faced. The treatment of toxic poisoning of gassed individuals belongs properly to the Medical Service, whether it is a question of prophylactic measures or other treatment. 268 NOTES AND COMMENTS Organization and Functioning of the Surgical Service in Motorized Troops With swift moving motorized units, often isolated and accomplish ing difficult duties independently, it is necessary that the attached medico-surgical formations follow at the same speed, and be com pletely equipped and abundantly provided with supplies, in order to conserve their independence. Cases of urgency will be treated, but in unfavorable tactical situations, the principal activity will consist of rapid mass evacuations to some suitable medical formation. It is especially important that the chiefs of motorized medical formations should have, besides their necessary technical qualifications, adequate military knowledge to enable them to adapt themselves rapidly and without error to the changing conditions of battle. The Use of Colorimetric Methods of Analysis Colorimetric methods offer the advantage of often permitting the analysis of minimal quantities of substances, impossible to accomplish by ordinary methods, as is the case in toxicological, biological and even industrial analyses. In order to obviate the inconveniences of colorimetry, the volumo-colorimetric method or that of the photo electric cell may be adapted, according to the necessities of the case involved. Edentates in the Armies — Definition —Treatment —Prosthesis; Military Employment in Times of Peace and War From the military point of view, an edentate is a man whose func tional lack of denture is liable to react on his state of general health and diminish his fitness for service. Partial or total loss of the teeth is not a cause for exemption from military service, if it can be effec tively compensated for by prosthesis, disregarding all questions of esthetics. The preferable treatment, indispensable from the func tional point of view, is the installation of adequate prosthetic equip ment, after having put the buccal cavity in good condition by remov ing septic foci of infection. The artificial denture ought to be made and repaired within the army zone. A Comparative Study of the Supply of Food Stuffs and the Alimentation of the Sick and Wounded in Times of Peace and War It is impossible to standardize rations, but it is very desirable to list and classify them. Conditions vary with the economic resources of each country and, above all, with national habits. The alimenta tion of the sick and wounded ought to benefit by the progress of science and the research in alimentary physiology by giving an im portant place to protective foods. The preparation and serving of food should be by especially trained personnel provided with modern equipment for conserving and preparing food stuffs. NOTES AND COMMENTS 269 Tenth Congress Meets Here in 1939 The International Congress of Military Medicine and Pharmacy accepted the cordial invitation of the Government of the United States of America to hold the Tenth Congress here in 1939. The following subjects by title and nation have been selected for study and presentation at the Tenth Congress: 1. Organization and Functioning of the Medical Service in Colonial Expedi tions. (Official reporters: Italy —United States of America.) 2. Forecast of War Casualties and Methods of Computation. (Official re porters: Germany —United States of America.) 3. Practical Procedures in Anesthesia and Analgesia in War Surgery. (Official reporters: Brazil—United States of America.) 4. Organization and Functioning of the Military Cheniico-Pharmaceutical Service. (Official reporters: Argentine —Czechoslovakia.) 5. Urgency Treatment and Basic Apparatus for Maxillary Fractures in War. (Official reporters: France —United States of America.; 6. Technical Specialization of Administrative Officers in the Medical Service. (Official reporters: Mexico — United States of America.) CLASSIFIED MATTER Members of the Medical Department in the performance of their official duty and through their service contacts have frequent occasion to acquire information of a classified nature. It is, therefore, essential that personnel of this department be familiar with the nature of and the regulations governing the custody of classified matter. Careless disregard of these safeguards permits the ever present possibility of compromising the Naval Service. Classified matter is a generic term used in the Naval Service to compromise matter of a secret, confidential, or restricted nature. Secret matter is matter of such a nature that its disclosure might endanger the national security, or cause serious injury to the interests or prestige of the nation or any government activity thereof. Infor mation as to the existence, nature, or whereabouts of secret matter shall, except as specifically authorized by the Chief of Naval Operations, be disclosed only to persons in the Government service whose official duties require such knowledge and to persons not in the Government service under conditions of absolute necessity. It is exclusively for the official use of the persons to whom it is divulged and its distribution or dissemination must be confined to the absolute minimum. Confidential matter is matter of such a nature that its disclosure, while not endangering the national security, would be prejudicial to the interests or prestige of the nation or any government activity thereof. Confidential matter may be disclosed to persons in the Government service who must be informed, and to other persons when, under special circumstances, such disclosure is to the interest of the Navy. 45202—38 8 270 NOTES AND COMMENTS Restricted matter is matter of such a nature that its disclosure should be limited for reasons of administrative privacy; or, is matter not classified as confidential because the benefits to be gained by a lower classification outweigh the value of the additional security obtainable from the higher classification. Restricted matter may be disclosed to persons of discretion in the Government service and to persons not in the Government service under special circumstances when it appears to be in the public interest. The responsibility for maintaining the proper security of classified matter rests upon each person having custody or knowledge thereof, no matter how obtained. Any person having knowledge or suspicion that secret or confidential matter has been compromised or come to the knowledge of unauthorized persons is required to make a full report of the facts to the Chief of Naval Operations via his commanding officer. In case restricted matter is compromised report shall be made to the administrative head charged with custody of the subject matter who shall take appropriate action. Classified matter shall not be discussed in the presence of persons not authorized to have knowledge thereof. An officer, by virtue of his commission alone, is not authorized to have knowledge of secret or confidential matter. Persons within the Naval Service who receive matter originated by another government agency and designated by that agency as having any degree of confidentiality shall safeguard such matter in the same manner as if it had been so designated by naval authority. NEW MEMBERS, AMERICAN COLLEGE OF SURGEONS The Bureau of Medicine and Surgery has been informed that the following naval medical officers have been elected to Fellowship in the American College of Surgeons. Comdr. Jack S. Terry (M. C), U. S. N.; Lt. Walter F. James (M. C), U. S. N.; Lt. Charles R. Wilcox (M. C), U. 8. N.; Lt. William S. Cann (M. C), U. S. N.; Lt. Warran G. Wieand (M. C), U. S. N.; Lt. Charles R. Moon (M. C), U. S. N. HOSPITALIZATION OF DEPENDENTS Bureau of Navigation Naval Reserve Bulletin No. 82 of January 15, 1938 states: The Secretary of the Navy has approved an opinion of the Judge Advocate General that dependents of Naval Reserve and Marine Corps Reserve personnel on active duty may lawfully be hospitalized in certain designated naval hospitals under the same restrictions and conditions in all respects as now apply to the authorized hospitalization of dependents of naval personnel on the active list. The Chief of the Bureau of Medicine and Surgery will issue appropriate instruc tions to the several naval hospitals which have been authorized to hospitalize the dependents of naval personnel. BOOK NOTICES Publishers submitting books for review are requested to address them as follows: The Editor, United States Naval Medical Bulletin, Bureau of Medicine and Surgery, Navy Department, Washington, D. C. (For review) Clinical Allergy, by Louis Tuft, M. D., Chief of Clinic of Allergy and Applied Immunology, Temple University Hospital; Associate in Immunology, Temple University School of Medicine; Director of Laboratories, Pennsylvania Depart ment of Health, Philadelphia, First edition. 711 pages, illustrated. W. B. Saunders Company, Philadelphia, 1937. Price $8. The author has written an excellent text on a very interesting, con fusing, and important subject. Having reduced the perplexing terms, and what is known about the various phenomena in connection with allergy! to simple understandable and workable language, he has pre pared a book which is easy to read as well as easy to understand. The section on "General principles" is especially well done and would repay any one interested in the subject for the time spent in the study of this section. The various theories of the mechanism of hypersensi- tiveness have been gathered together and arranged in an orderly manner. Introduction to Dermatology, by Richard L. Sutton & Richard L. Sutton, Jr.; Kansas City, Mo.; Second edition, 566 pages. 190 illustrations. C. V. Mosby Company, St. Louis, Mo. 1937. Price $5. In the preface to the first edition the author states: "This book is intended primarily for students. We have endeavored to combine judiciously the old and the new, retaining the original lattice work of the fundamental facts which contribute so much to the value of the parent, and omitting much descriptive and statistical matter which is of interest to only the research worker and the specialist." This was admirably done. In the preface of this edition the changes, such as reclassification, additions of new diseases and illustrations with the up-to-date methods of treatment are pointed out. The first seven chapters are devoted to anatomy, embryology, phys iology, general etiology, general symptomatology and pathology, 271 272 BOOK NOTICES general diagnosis and treatment. Chapter VIII covers the new classi fication. Sixteen classes are given. The rest of the book, chapters IX to XXIV, is devoted to a discussion of the various diseases coming under each of the 16 classes. The illustrations are clear and the dis cussions on etiology, symptomatology, diagnosis, and treatment are to the point. It is an excellent book for the student and general practitioner. Approved Laboratory Technic Clinical Pathological, Bacteriological, Mycologi- cal, Parasitological, Serological, Biochemical and Histological by John A. Kolmer, M. D., Dr. P. H., LL. D., L. H. D., F. A. C. P.; Professor of Medicine, Temple University and Fred Boerner, V. M. D.; Assistant Professor of Bacteriology, School of Medicine and Graduate School of Medicine, University of Pennsylvania. Second edition; 893 pages, 12 plates and 380 illustrations. D. Appleton-Century Company, New York and London. 1938. Price $7.50. The aim of the first edition was to promote the practice of scientific medicine by a wider application of clinical laboratory methods to the diagnosis of disease and to encourage a closer cooperation between the practitioner and the clinical pathologist by the presentation of approved methods covering the field of clinical pathology. That it attained this objective has been amply demonstrated by the wide acceptance and the high regard this excellent text has held. The second edition represents a complete revision of all chapters in which the many new methods which have been developed and which have proved their value in the past 7 years have been included. Many new figures and illustrations have been added. In the first edition the technic of the methods given were approved by committees selected from members of the American Society of Clinical Pathologists. In this edition they have been approved by members of a group of 28 collaborators as well as, in many instances, by the authors of the methods themselves. Approved Laboratory Technic is, in its second edition, again a book no well equipped clinical pathological laboratory will want to be without. Diseases of the Blood and Atlas op Hematolooy, by Roy R. Kracke, M. D., Professor of Bacteriology, Pathology, and Laboratory Diagnosis and by Horlense Elton Garver, M. S., Instruclor in Laboratory Diagnosis, both of Emory Uni versity School of Medicine, First edition, 532 pages, illustrated. J. B. Lippen- cott Co., Philadelphia, 1937. Price $15. The section of the book dealing with the diseases manifested in the blood is an excellent summation of the current opinion as to etiology, haematological findings, and treatment. The style in which it is written makes it very readable. The book contains a section on technique which gives workable tests covering the entire practical field of haematology. The chapter giving the normal blood pictures of the common laboratory animals will be found useful. BOOK NOTICES 273 In short, the Atlas completely covers the morphology of blood cells. In the matter of illustration, however, it must be noted that the nuclear details are somewhat schematic and the colors are not quite true reflections of the usual Wright's strain. It is to be regretted that so excellent a text should not have a bind ing of corresponding quality. Atlas of Hematology, by Edwin E. Osgood, M. A., M. D., Assistant Professor of Medicine and Head of Experimental Medicine and by Clarice M. Ashworth, Medical Illustrator, both of the University of Oregon, First edition, 225 pages, illustrated. J. W. Stacey, Inc., San Francisco, 1937. Price $15. Upon examination of this book one is immediately favorably im pressed by the excellent quality of its binding and paper. As the title states, it is truly an Atlas of Hematology, profusely illustrated with colored plates. True shades of colors are extremely difficult to repro duce, and, as a whole, the plates in this volume are the best that we have seen to date. While there was no intention upon the part of the authors to make the book a text of hematology, it nevertheless contains numerous useful differential diagnostic tables, excellent descriptions of most of the blood dyscrasias, and a section on hematological technique. It is well indexed, and the same identification numbers of the cells on the colored plates are used in the descriptive matter throughout the book. Unfortunately several new names for cells have been introduced by the authors in place of the ones in common use, thus tending to further confuse an already overburdened nomenclature. However this does not detract from the value of the Atlas. Any laboratory worker dealing with hematological problems will find this book invaluable, particularly in the identification of blood cells, although, contrary to the author's system for cell identifica tion, no degree of experience will permit one to claim that he is capable of designating the type to which every immature cell belongs. A comprehensive list of references is given. The Cerebrospinal Fluid, By H. Houston Merritt, M. D., Assistant Professor of Neurology, Harvard Medical School; Director of the Cerebrospinal Fluid Laboratory, Boston City Hospital; and Frank Fremont-Smith, M. D., formerly Assistant Professor of Neuropathology, Harvard Medical School; formerly Director of the Cerebrospinal Fluid Laboratory, Boston City Hospital. With a foreword by James B. Ayer, M. D., Octavo of 333 pages, illustrated. W. B. Saunders, Co., Philadelphia. 1937. Cloth, Price $5. This new book is based on 21,000 spinal fluid examinations done by the authors, together with 1,000 especially selected fluids from Dr. James B. Ayer's laboratory at the Massachusetts General Hospital. The chapters include anatomy, physiology, chemistry, and patho logic physiology, technic of lumbar and cistern puncture, routine examination of the fluid, cerebrospinal syndromes, therapeutic use of 274 BOOK NOTICES lumbar puncture, roentgenography of the ventriculosubarachnoid space, and methods of spinal fluid examination. The chapter on spinal fluid syndromes takes up 1 15 diseases and condi tions. This chapter alone is well worth the price of the book. An exceptionally fine bibliography is furnished. Clinical Urinalysis and its Interpretation, by Robert A. Kilduffe, A. M., M. D., F. A. S. C. P.; Director of Laboratories, Atlantic City Hospital. 428 pages and 40 illustrations. F. A. Davis Co., Philadelphia. 1937. Price, $4. This book, by a master clinical pathologist, covers the field of urine examinations for clinical purposes in a most complete and satisfactory manner. Practical proven methods have been selected for each test or examination; alternates are given where it would seem advisable. Technic in each case has been completely detailed. Interpretation is briefly and clearly given. Especially valuable for the physician or technician in tllls field will be found the fact that the inherent fallacies of methods are pointed out and the possible causes of false and misleading results given. The book will be found a most valuable tool in the clinical urinal ysis laboratory. Embryology, by Harvey Ernest Jordan, A. A/., Ph. D., Professor of Histology and Embryology and by James Ernest Kindred, M. A., Ph. D., Associate Professor of Histology and Embryology, both of the University of Virginia. Third edition, 613 pages, Illustrated. D. Appleton-Century Company, Inc., New York. 1937. Price, $7. This book is primarily a student's textbook of embryology, for which purpose the subject matter is excellently presented and well arranged. There is included a most useful chapter of laboratory exercises. It is almost needless to say that any physician at times will find it necessary to refresh his memory of embryology and, upon such occasions, will find this book of value. The chapters dealing with teratology, the recapitulation theory, or the so-called biogenetic law, and eugenics touch so lightly upon these subjects that they might well have been omitted. The chapter on sex determination and that part of the one on teratology, concerning twinning, are of general interest. The book contains 504 illustrations, most of which are schematic. The volume is well bound and printed. Diseases of the Nose and Throat, by Sir St. Clair Thomson, M. D., F. R. C. P., Lond., F. R. C. S. Eng., L. L. D. (Hon.) Winnipeg, Medicine diplomi en Suisse and V. E. Negus, M. S. Lond., F. R. C. S. Eng.; fourth edition revised; Buck ram, 920 pages, 386 figures, 13 color and 16 radiographic plates, Index. D. Appleton-Century Company, Inc., New York. 1937. Price, $14. This fourth edition (first in 1911) by Thomson with the coopera tion of Negus, has modernized what has been described by Chevalier Jackson as, "the greatest textbook on nose and throat ever published." BOOK NOTICES 275 It expresses not only the experience of the authors in minute detail but also gives the opinion ol world-wide authorities, as quoted or set down in the footnotes of nearly every page. This and a complete bibliography makes the book an excellent reference. Clarity of description and concise presentation provide a veritable storehouse of knowledge of diseases of the nose and throat in a very readable form. The contents are divided into 15 parts, namely: Introduction, dis eases of the nose, diseases of the accessory sinuses (paranasal sinus diseases), tumors of the nose and accessory sinuses, diseases of the nasopharynx, diseases of the pharynx and tonsils, diseases of the larynx, diseases of the trachea and bronchi, diseases of the oesophagus, chronic infective diseases, acute specific fevers in the nose and throat, the nose and throat in some general affections, foreign bodies, peoral endoscopy, some operations, and formulae. Each of these 15 parts has its subdivisions, the whole subject being related in 61 chapters. There is an excellent index of 56 pages. In his preface to the third edition the author quoted Samuel John son's Preface to his Dictionary of the English Language, 1775, as follows: "In this work, when it shall be found that much is omitted, let it not be forgotten that much likewise is performed." Again, in his preface to the fourth edition Sir St. Clair quotes Bacon, "Were it not better far for a man in a fair room to set up one great light, than to go about with a rush light into every dark corner?" In end ing his preface to this edition he concludes, "My task has consisted chiefly in trying to exercise the right judgment which we all pray for in all things, no easy matter in medicine, even after 55 years of practice, of which 44 have been entirely devoted to laryngology." Any student after reading this book will feel that the author has fulfilled his ideals and "well done" can be applied to the completion of his task. Practical Methods in the Diagnosis and Treatment of Venereal Diseases, by David Lees, Third edition, edited and reviesd by Robert Lees, M. B., F. R. C. P. (Edinbourgh) . Cloth, 608 pages, 85 illustrations, appendix on pharmacopoeia, index. William Wood & Co., Baltimore, Md. 1937. Price $5. The subject of venereal diseases, from a clinical point of view, is well and extensively covered. The colored plates and illustrations should be of value to the medical practitioner and student. On page 220, the following statement is made relative to the treat ment of syphilis: "There appears to be little essential difference between 'continuous' treatment, and 'intermittent' treatment in which the drugs are given in a series of injections with a rest interval between courses." This is not in agreement with the finding of the cooperative clinical group of this country. This group found con tinuous treatment to be the most efficient method. On page 330, 276 BOOK NOTICES the author gives a good evaluation of the complement fixation test in gonorrhea. From the text following this evaluation, one is apt to get the impression of more importance being placed on the test than is justified from the evaluation. In the treatment of gonorrhea, espe cially its complications, emphasis is placed on the value of vaccine therapy. This should be taken as an opinion of the author and not as an entirely accepted fact. The Treatment of Gonorrhea and its Complications in Men and Women, by William J. Robinson, M. D., Fourth edition enlarged. 331 pages. Eugenics Publishing Co., Inc., New York, N. Y. 1933. Price $3. The author states in the Preface: "The book is distinctly a personal book, and represents how Dr. Robinson treats gonorrhea and its complications and not how A., B., and C. treat them." This thought is carried through the entire text and this reviewer is of the opinion that exaggerated emphasis of this thought detracts from some of the valuable information contained therein. According to the title the book was written for the general practitioner. However, the unini tiated in this specialty should read the text critically and accept the author's statements cautiously. For instance, after giving a good description of making a proper smear and staining with Loeffler's solution of methylene blue the following statement is made: "And if the typical diplococci are present, the patient presents the ordinary history and symptomatology of gonorrhea, the diagnosis is settled, and no further investigations are necessary." THE DIVISION OF PREVENTIVE MEDICINE Commander O. S. Stephenson, Medical Corps, United States Navy, in charge UNITED STATES NAVY SUBMARINE SERVICE ' By W. C. Harrison, New York Life Insurance Company, New York, N. Y. It is to John P. Holland, who launched his first boat in 1875, that credit is given by the authorities for bringing the submarine to its present state of practical value. The earlier diving boats of the Hol land type had a reserve buoyancy of only about 6 percent, which meant that they practically ran awash in the surface position. These early level-keel torpedo boats were designed wholly for under water work and made shallow dives by means of horizontal rudders. Later the submersible type was developed. This was characterized by a reserve buoyancy of 30 to 40 percent permitting more rapid and steeper dives. Such distinctions are not applied in the present-day submarines, as these two types have been modified now by merging into one type the level keel and reserve buoyancy submerging principles. Holland boat, No. 9, known as the Holland built and thoroughly tested over a 2-year period, 1898-1900, was the first submersible com bining these two principles. When turned over to the Navy, it proved to be the first really practical submarine and served as a model for the early American and British submarines. The boat was 53 feet in length, 11 feet wide at midship, had a single propeller and usual stern diving rudders. It was driven by gasoline motor on the surface, and batteries when below water. This boat utilized for the first time the principle of dividing the ballast tanks into compart ments permitting better handling. Surface cruising radius was 1 ,500 miles; while submerged, about 40 miles. As no periscopes were available the boat was brought to the surface for observations. It had no clinometers to determine the diving angle, this device being invented in the next year, however. Another device originating in this boat was the compensating tank, which filled immediately when a torpedo was discharged. It is interesting to know that the building, ' Editors Note.— This article in original form was not written for the service. It has been edited with apology to the author, by eliminating some historical material and items of less interest to the Bulletin read ore. 277 278 DIVISION OF PREVENTIVE MEDICINE operating, and testing of these nine experimental Holland boats were completed with no serious accident, and no loss of life. In preparation for the first fleet of submarines for our Navy, another experimental boat named the Fulton was constructed by Holland. Based on this craft the first submarine flotilla was con structed in 1903, composed of seven submarines, the Adder, Moccasin, Porpoise, Shark, Grampus, Pike and the reconstructed Plunger (Holland No. 7). These boats incorporated the first early form of periscope. The average length of these boats was 65 feet, with submerged displacement of 120 tons. In 1905 three more submarines of 170 tons, known as the B class were added. The Octopus, first of the C class boats, was launched in 1906 and was considerably larger being 105 feet long and 270 tons displacement. This craft was tested at 200 feet depth, the first sub marine to withstand this pressure and also remained under water for 24 hours with full crew aboard. The B boats and the Octopus com prising the second flotilla of the Navy were the last to use gasoline, the Government requiring Deisel engines in later boats to eliminate danger from gasoline, and resulting in a doubling of the radius of action because of the fact that with the heavier fuel the number of horsepower- hours was twice that from a like quantity of gasoline. The third flotilla was comprised of four boats of the C type and three of the D class, accepted in 1909. This last class registered a further advance, being 340 tons submerged. These boats accomplished a submerged run of 150 miles, coming to the surface at night to re charge. One of these made the first open sea trip of 1,500 knots from Boston to Bermuda and back under its own power. From 1909 to 1912 six additional submarines were acquired, the two E boats Skip jack and Sturgeon and the F-l to F-4. Great improvements had been made and although submarines seldom travel at a depth of more than 100 feet, they are built to stand 200 feet of pressure with a safety factor of two, yet the F-l made a cruise of 6 hours at a depth of 283 feet. In these last boats the displacement had increased to 550 tons, the surface speed to 14 knots and the underwater maximum to 10 knots. These submarines were divided with bulkheads, had 4 torpedo tubes and a 4-inch gun on the superstructure. During the next few years the G, H, and K series of submarines were built. These were the submarines used in the World War and their operations extended over both oceans. They were sold, dis mantled, or otherwise put out of commission in 1922. The somewhat larger boats designated as the L series were also employed during the World War. The R series came next and in cluded some 30 boats, a few of which were constructed in time to see some service in the war. This series has practically been decommis DIVISION OF PREVENTIVE MEDICINE 279 sioned with the exception of six which are now used at New London for training purposes. Between 1919 and 1922 some 50 boats of the S series were built and added to the service. They average 1,000 tons displacement and are powered by twin engines of approximately 1,000 horsepower each. The latest and largest of the submarines, the V type such as the Cachalot, Narwhal, etc., are from 260 to 370 feet long and with dis placement of 1,700 tons to 4,000 tons. The power plant comprises four Diesel engines installed in each boat totaling some 8,000 horse power. The Diesel engine has made possible the development of the submarine and conversely the necessity of building lightweight, high speed Diesels for submarines has been a great factor in bringing this type of engine to its present compactness and reliability. The old marine standard of some 200 revolutions per minute has been in creased by the Diesel engine in submarines to 600 revolutions per minute. To summarize, we find the Navy now (as of July 1, 1936) possesses 87 submarines. Six are of the fleet cruiser type. These are the largest submarines in our Navy and average 350 feet in length with 2,700 aver age tons displacement. This tonnage represents the total displace ment when submerged. They mount two 6-inch guns and have six torpedo tubes. These boats are expected to accompany the battle fleet. They must, therefore, possess seaworthy qualities of a fairly high order, have good habitability, excellent surface speed, and a large radius of action, though fuel supplies could be obtained from the sur face vessels, preferably from auxiliaries. Included in this group is the mine-laying submarine Argonaut, which together with its guns and torpedoes, also carries mines. The next group in size is made up of cruising submarines which run from 800 to 1,600 tons. They are large enough to remain at sea for a month or two and operate independently for long distances from bases. These boats generally carry 4 officers and a crew of from 35 to 50 men. The smaller submarines, 30 in number, average 600 tons, carry an average crew of 3 officers and 30 men, and are generally assigned to coast defense. They are designed to operate from a base which is near at hand so that the cruising radius and habitability can be sac rificed without loss of efficiency. There are no quarters for officers or crew, all possible space being devoted to machinery and torpedoes. As an indication of the rapid growth of submarining from 1900, when only a few experimental craft were in existence, to 1914, the 280 DIVISION OF PREVENTIVE MEDICINE first war year, and with further comparison to July 1936 the following figures for the various navies are illuminating: War submarines July 1914 Lost dur ing war As Of July 1936 Built Building Built Building United States 44 31 0 87 12 78 22 54 60 16 64 22 14 80 « 13 2 0 59 8 Russia 30 19 20 50 20 Italy... - 19 8 8 72 12 Germany 27 18 203 22 14 From 1900 to the opening year of the World War (1917, United States; 1914, other powers) the following submarine disasters have occurred where lives were lost or injuries sustained. (Figures in parentheses are injuries.) Submarine Owned by- Deaths and in juries 1904.. 1904. 1905. 1905. 1905. 1906. 1909. 1909 1909. 1910 1910. 1911.. 1912. 1912. 1912.. 1913. 1914. 1915.. Fulton. A-l.... ....do.. Delphine. A-5 A-8 Farfudct-. Lutin Foca Kambola.. C-ll No. 8 Pluvioso. . U-3 A-3 V'cndemaire. n-2 K-5 A-7 F-4. United States. British ....do Russia. . British.. ...do... French... ....do... Italian. .. Russian. British... Japan French... German. British French British do ....do United States. (4) (i) n a 4(7) 14 14 13 13 20 II 14 38 3 14 24 15 3 11 Battery gas explosion. Gas oxplosion due to motor. Collision due to faulty periscope. First major submarine disaster. Swamped by swells from passing steamer enter ing open hatch. Gasoline explosion through neglect of closing vents when filling tank. Sudden dive and filling through open hatch. Foundered by water entering open hatch. Sank stern first. Sprung leak in hull. Gas explosion, sparking in Collision with hattleship. Collision at night. Sluice-valve mechanism broke. Collision, periscope not adequate. Ventilator left open; 27 men aboard, all but 3 escaped through torpedo tubes. Collision. Collision. Run down while emerging. Collision at night. Battery explosion. Exceeding critical speed on surface caused 21 Battery corrosion; cblorine explosion. For over 15 years the submarine forces of our Navy operated with out a serious catastrophe in great contrast to the records of other navies. The loss of the F-4 during underwater maneuvering near Honolulu Harbor was caused through corrosion of the lead lining of the batteries permitting the acid to weaken rivets in the side of the ship. The sea water entered, evolving chlorine gas by reaction with battery acid, causing an explosion which admitted more water. Rig orous inspection and adequate equipment have prevented the recur rence of this type of accident, the only one of its kind recorded over a 36-year period in our submarines. DIVISION OF PREVENTIVE MEDICINE 281 From 1919 through 1936 the following peacetime submarine acci dents have occurred. (Figures in parentheses injuries.) Submarine Owned by- Deaths and in juries Cause K>5.. H-42. 0-5 L-24 Veniero. S-51 M-l H-29— - S-4 - F-14 Ondine H-17 No. 9 Poseidon.. M-2 Promethee. Porsee L-28 Ariane... Nautilus. B-3 U-18 British. do- Japanese United States. British Italian United States. British ....do United States. Italian French British Russian British ....do.. French.. ....do British French United States. Russian. Oerman 2(27) 2 09) (12) (11) 55 8 Lost on a dive. Collision. New boat lost during undersea maneuvering. Collision. Do. Unknown. Collision. Do. Misunderstood order resulted in incorrect han dling ol submarine apparatus. Collision. Do. Do. Collision with submarine L-12. Unknown. Collision with Chinese merchant steamer "Yuta" in China waters; 36 men were saved, some by using the submarine "lung." Lost on dive —cause unknown. Lost off Cherbourg during under-water maneu vers. Explosion. Explosion and tire. Explosion. Crankshaft explosion. Collision with warship. Sank during torpedo practice. The submarines generally operate from four main bases: New Lon don, Conn.; Coco Solo, C. Z.; the Hawaiian base at Pearl Harbor, and in Asiatic waters from Cavite, P. I. There are, of course, other naval bases both in this country and in Asiatic waters from which our boats may operate. The policy of the Navy high command, however, is to use these four bases as headquarters for the several submarine divisions and squadrons. The base at New London is used as a training school and has 7 submarines with 30 officers and 195 men. Other craft located here relating to submarine work are the U. S. S. Falcon and U. S. S. Sommes which are submarine salvage and rescue vessels whose officers and men are engaged in diving and salvage work not strictly submarine duty. There is also a mine depot and torpedo school here, an activ ity not necessarily involving submarine duty. At the Coco Solo base there are 6 submarines with a personnel of 30 officers and 240 men. There are also rescue vessels and miscel laneous craft for service to submarines. The largest fleet of submarines is stationed at Pearl Harbor in the Hawaiian Islands. Thirty submarines are stationed here, the force allotted being 76 officers and some 1,500 men. Most of the experi mental work in submarine rescue and efficiency is carried on here due to the favorable factors of the comparative warmth and calmness of the adjacent waters. A complete equipment of a large dry dock, 282 DIVISION OF PREVENTIVE MEDICINE rescue and experimental vessels, diving tank, and training school, make this station one of the largest and most thoroughly equipped submarine bases in the world. The Asiatic squadron of 6 submarines manned by 25 officers and 228 men work from the base at Cavite just outside Manila. The above location of the submarine personnel brings to our atten tion the fact that this duty requires practically all the men in the service to be stationed for periods in tropical ports. This fact need not be unduly stressed, however, as most of the men are in the Hawai ian Islands where, of course, no real tropical conditions apply. Real tropical conditions are prevalent at Coco Solo and Cavite where men generally stay for 2 years only. Submarines are either single, or double hulled. In general, the single-hull type submerges more quickly, the double hull is heavier and costs much more. The single type hull is now limited to the smallest submarines, the double type to the largest, while the intermediate size has a partial double hull. In the single hull type of submarine, the ballast tanks are located inside the hull, whereas in the double-hull type, the space between the two hulls is used for ballast tanks. By t he removal of these ballast tanks from inside, the double hull type has increased capacity for other purposes. In addition, better speed for surface propulsion and added seaworthiness are attained from the better shape of the outer hull. On the earlier submarines there were no watertight subdivisions. On the later types the hull is subdivided to the maximum extent, experience having proved the value of the feature in case of accident. The superstructure consists of a light structure built above the outer hull. Cable holders, boats, and other equipment are stored here because they would bring undue resistance when submerged were they not housed. This superstructure is also fitted with a deck including a raised portion amidships which is used for a navigating bridge. This is reached from inside the submarine by a conning tower. The super structure is generally "free flooding," that is, it is flooded and vented when submerged through open holes along its sides, the air escaping through numerous holes in the superstructure deck. The periscope, or eyes of the submarine, projects up through the conning tower. Before 1902, when the periscope was first introduced, submarines had to come to the surface to do their navigating. In those days the circular tower, as it was called, was fitted with glass windows around its circumference. Then came the periscope consist ing of a long tube with a window and a glass prism at the top and a similar arrangement at the bottom. Various lenses are fitted in the tube to increase the strength of the image. By rotating the periscope the entire horizon can be scanned. Today's submarines carry two and sometimes three periscopes, some of them 35 feet long. The use of DIVISION OF PREVENTIVE MEDICINE 283 aircraft in fighting submarines has made it necessary to fit periscopes with a prism which will give a vertical view as well as a horizontal one. In order to submerge the modern submarine several tanks known as "main ballast tanks" are completely flooded. Since these filled tanks sink the vessel from the surface to under water, their total volume is the reserve of buoyancy of the submarine when on the surface, hence is a measure of her seaworthiness. To maintain proper balance and buoyancy lost through the consumption of fuel oil, shells, and tor pedoes, auxiliary ballast or compensating tanks are provided. The main ballast tanks are the most important since their filling destroys all positive buoyancy. There is a valve at the bottom for entry or exit of water; a vent-valve at the top for the escape of air; a pipe through which the compressed air enters the tank and drives out the water. Some tanks also have drain pipes for emptying by pump ing. Modern warfare necessitates quick submersion so these valves have been increased until 1 or 2 minutes is generally sufficient to put the submarine below the surface. The compressed air for blowing tanks and for torpedo service is stored in reservoirs, or air bottles at 2,500 pounds per square inch. The reservoir capacity varies, but is in the neighborhood of 3 cubic feet and this compressed air is sufficient to blow the ballast tanks three times. At least two motor-driven pumps, capable of pumping against any pressure, up to the pressure at the greatest depth the ship is designed to navigate, are also provided. After the submarine is submerged, the batteries supply current to the motors for propulsion. Their batteries are of the lead pasted type. In small submarines, two batteries of 55 to 60 cells are installed and in the larger, two or three of 110 to 120 cells each. For convenience and transfer, the cell containers have standardized dimensions. When the battery is being charged, hydrogen is evolved and to obviate explosions, exhaust fans discharge this into the open. All charging is done either at the base, or while running on the surface. Safety Measures and Devices Medical supervision. —Officers and enlisted men who are candidates for submarine service are given a careful physical examination, as detailed in the Manual of the Medical Department, paying special attention to the conditions which are cause for rejection. The medical officer attached to submarine activities makes periodical inspections and examinations of the submarine and its personnel, and he accompanies the submarine occasionally to observe the function of personnel and materiel. He checks on ventilation of the submarine under: (1) Surface conditions. The adequacy of air supply to all compartments when cruising on the surface with all hatches closed, except the conning tower. (2) Submerged conditions. Air purifica tion apparatus. Depending on the size of the boat and personnel, air 284 DIVISION OF PREVENTIVE MEDICINE purification will be required after a definite period, the upper limits of C02 being set at 2 percent. The hydrogen detector supplied to each submarine is used under conditions of exceptionally long submergences and during and after charging the batteries. About 4 percent hydro gen in the air is considered the critical point. In view of the physical requirements and medical care, there can be no doubt but that this group is a select one and under the most rigorous health supervision. Submarine escape appliance. —Safety devices on a modern submarine are many and varied. Safety devices come under the cognizance of the Bureau of Construction and Repair. This Bureau and its publi cations, especially its manual and circular letters, should be consulted for the latest information relative to safety regulations and appli ances. In. 1928 a special Navy board was appointed to study these safety measures and reviewed in the neighborhood of 5,000 sugges tions. The most valuable device in the opinion of the board is the Momsen submarine "lung." This is in effect a miniature diving apparatus which, when worn, permits the wearer to rise safely from a sunken submarine without danger of suffocating or drowning. Train ing and experiments with this lung are carried out at Washington, D. C, Navy Yard in a vertical cylindrical diving tank, 10 feet 1 inch in height and 9 feet 10 inches in diameter with walls of 2-inch steel, tested to a pressure of 400 pounds per square inch. When in use the tank is filled with water to a height of 8 feet to allow an air pocket above the water. It is fitted with an airtight hatch on the upper end which opens downward into the tank. There are six 4.5-inch ports in the side for observation purposes. The tank on the inside is well lighted by electric lights and is equipped with loudspeakers and telephone. The men are exposed in the diving tank to air pressures equal to various depths of sea water. During the exposure time they breathe in the air pocket and exercise by swimming in the water. Prior to the end of the exposure the man puts on the submarine escape appliance, charges it with oxygen or air, submerges completely in the water and breathes into the appliance for 2 minutes after which ascent is simulated at the rate of 50 feet per minute by reduction of air pressure. It should be borne in mind, however, that experi mental work is done only by the Experimental Division, and that men studying for submarine assignment at New London and Pearl Harbor do no experimental work with this apparatus. All they are given is enough training to familiarize themselves with this escape lung. Training tanks. —The diving tanks and training of submarine per sonnel at New London and Pearl Harbor is described in the following official report: The training tank is a structure about 130 feet in height and 18 feet in diameter. It is filled with heated salt water. Escape locks are located at points 18 and 50 feet from the top. A cylinder at the bottom of the tank represents a submarine compartment with standard door for entering and a standard hatch for escaping. DIVISION OF PREVENTIVE MEDICINE 285 At the top a diving bell is suspended by a wire cable. The bell is operated by an electric motor so that it can be raised or lowered in the water. Its capacity is three men. Normally t wo men and an instructor go down in the bell to the desired depth when the men are sent out to practice the escape. The student first goes into the decompression chamber and is subjected to a pressure of 50 pounds. Men with sinus trouble, chronic ear disease are usually eliminated at this stage, having to come out before the first atmosphere or 14 pounds, is reached. Should the man not be able to stand the pressure he is eliminated at this stage. After passing this test the student is taken to the top of the tank and learns to use the lung by practising on the ladders, which extend about 15 feet into the water from the top of the tank. When he has done this to the satisfaction of the instructors, he is taken down to a depth of 10 feet in the diving bell and escapes up a line to the surface. After completing this, he is taken down in the bell to a depth of 18 or 20 feet or into the 18-foot lock, and escapes up a line to the surface, making one stop on the way up. At the present time the applicant for submarine qualification is only required to make two 18-foot escapes. If the man wishes he may take further training at the 50-foot and 100-foot depth. If so two 50-foot escapes are next made, either from the diving bell or the 50-foot lock. In coming up from this depth he makes three stops, the first at 30 feet, where he counts 10 breaths, at 20 feet, for 20 breaths, at 10 feet for 30 breaths, and then to the surface. This amount of decompression is not necessary at this depth, but it is given as practice for the next step, which is 100 feet. When ready for the 100-foot escape, the man goes into the 100-foot compartment and escapes up a line to the surface, making the same stops as in coming up from 50 feet. Since training with the submarine escape apparatus was instituted there have been two fatalities directly or indirectly attributable to this training. One case, a quartermaster, first class, 24 years of age, occurred while undergoing instruction at Pearl Harbor in May 1930. During the morning the man made two descents to depths of 7 and 15 feet, respectively. On the third escape the diving bell was sub merged to 28 feet with pressure within of about 12.4 pounds. The length of time required for the descent of the bell and in the inflation of the lung by the man preparatory to emerging was approximately oli minutes. The other fatality occurred on May 22, 1931, at San Diego, Calif. In this case the deceased made an escape from a depth of 15 feet in 3 seconds. After appearing on the surface he closed the shut-off valve and reached the ladder to ascend the float, but was unable to grasp it. On being rescued he breathed a few times and expired. It is the consensus of opinion among authorities that exposure to 1 atmosphere gage or 33 feet of sea water does not involve any danger of caisson disease even with unlimited exposure. The standard diving tables do not prescribe decompression even for 42 feet if the exposure does not exceed 3 hours. The above-mentioned fatalities cannot, therefore, be ascribed to caisson disease. Lt. Comdr. I. B. Polak, Medical Corps, United States Navy, discusses the causes of accidents which occurr in submarine escape training as follows: 45202—38 S 286 DIVISION OF PREVENTIVE MEDICINE Etiology (1) The symptoms and fatalities resulting during lung training are not due to failure of the right ventricle from inability to cope with high pulmonary blood pressure. (2) Increased intrapulmonic pressures causing overdistcntion of the lungs, sufficient to rupture alveolar walls, are the factors concerned in the produc tion of air embolism. (3) Air emboli originating in the pulmonary circulation are carried to the left side of the heart and then distributed through the systemic circulation. This alone is the cause for the accidents that have occurred. (4) Se verity of the symptoms from air embolism depend on the amount of air in the circulation and the vital areas involved. (5) Position of the body determines the distribution of these emboli. (6) Under experimental conditions in animals and under natural conditions in man air embolism can be prevented, except under extremely abnormal conditions of pressure, by limiting the chest distention. Prevention (1) All men being trained in the use of the submarine escape apparatus should become thoroughly familiar with the problem of breathing while wearing the "lung" under water prior to attempting an escape. (2) It should be emphasized that continuous and rapid breathing must go on during the ascent. (3) The men should be completely familiar with the method and purpose of venting the "lung" through the flutter valve. Treatment (1) Absolute rest with the body in modeiate head-down position. Warmth. (2) Immediate compression to at least 6 atmospheres gage. (3) Artificial respira tion. If necessary oxygen COJ inhalation may be used. (4) Intravenous adrenalin 0.5 cubic centimeters physiological saline. Submarine escape, chambers. —All submarines are fitted with two escape chambers which are built in fore and aft and rise from the floor of the ship to the outer casing, through which a hatch opens direct!}' to the sea. There are two escape lungs supplied each man on a sub marine one at each end of the boat. The method of escape from a sunken submarine as outlined by Lt. C. W. Shilling, Medical Corps, United States Navy is as follows: (1) The "lungs" are distributed individually and tested for working condition. (2) The "hatch skirt" is then placed in position under the escape hatch so that an air pocket may be maintained. The newer type submarines have the "hatch skirt" permanently attached. (3) The hatch is undogged so that it will spring open when the external and internal pressures become equal. (4) Flooding the compartment with sea water is now started and continued rapidly until the inside pressure equals the external pressure at which time the hatch opens and water pours in and air escapes until the level of the water in the compartment leaches the lower edge of the "shirt," air above the water level in the compartment thus being trapped. (5) A buoy carrying a line is released and when it reaches the surface the end of the line in the submarine is secured. (6) The "lung" is now charged with oxygen, the individual ducks under the edge of the "shirt" and grasp ing the line slides slowly up through the hatch to the surface. It is evident that a hazard of caisson disease is incurred under this condition of continuous ascent. A study was undertaken to determine how long an individual could remain at a given depth, as in a submarine during preparation, flooding, DIVISION OF PREVENTIVE MEDICINE 287 and escape described above, and then make continuous ascent to the surface, at the rate of 50 feet per minute, without developing caisson disease. As a result of this study "it was found safe under experimental conditions to remain 37 minutes iit a simulated depth of 100 feet, 18 minutes at 150 feet, 17 minutes at 167 feet, 14 minutes at 185 feet, and 13 minutes at 200 feet, the subjects coming to the surface at the rate of 50 feet per minute." Other safety devices and appliances, —Another safety measure is that salvage air connections to ballast tanks and all compartments are permanently located on the deck of the submarine. This enables divers to make the proper connections easily and "blow" the sub marine to the surface. A large closed pressure "bell" is part of the equipment of Navy salvage ships. This rescue chamber can be lowered to the sunken submarine where contact is completed and the men may be taken out through the motor room hatch or the torpedo room hatch. Each compartment of a submarine is supplied with a high-pressure air cock so that the compartment struck will have avadable all of the ship's high-pressure air to help hold the water out while repairs or plugging of the hole is attempted. Quick-closing doors are pro vided so as to rapidly isolate the damaged section. Pontoons are available at each submarine base for the raising of a sunken submarine which cannot be raised by the blowing in of salvage air. Buoys are carried by the submarine which may be released from inside the ship. This buoy carries a telephone cable for communi cation with the surface. It would prove of material aid in the loca tion of a sunken submarine. Signal bombs are also carried in con nection with this device. Sound devices for the detection of an approaching ship or obstruc tion arc built in on all our submarines. For shore or longer range communication the antennae must be above the surface and the wireless used. Two types of gas masks are provided the men aboard all submarines, one chlorine gas mask and one general protective mask. Duplicates are placed at each end of the ship. Chlorine only escapes when salt water comes in contact with the batteries which can only occur in the event of an accident to the boat. No special chlorine detector is used or needed as the odor is so characteristic that it would be immediately noted. A hydrogen detector is permanently located in each of the two battery compartments. It is run constantly during the charging of the batteries. A C02 detector, known as the Higgins-Marriott is supplied to every submarine and the men are all qualified in its use. 288 DIVISION OF PREVENTIVE MEDICINE Training and Submarine Service Requirements Department records show that the average duration of continuous service on submarine for officers is approximately 5 years. There is no set limit as to the time an officer or enlisted man may spend on submarine work. The desire of all-around experience on other types of vessels, however, generally so acts as to limit Ins submarine- service time to this 5-year period. The average age for this group is indicated by the facts that of the 1936 personnel of 302 officers, 76 were lieutenants with an average age of 34 or 35 years, and 189 lieutenants, junior grade, with an average age of 28 or 29 years. These two ranks comprise approximately 90 percent of the officers attached to submarine duty. Officers after volunteering are ordered to the submarine school at New London for a 6-months' period of instruction. Then they are assigned to a submarine where they must serve aboard for a period of 1 year, not counting navy yard overhaul periods, before they are eligible for examination for submarine qualification. Apparently officers of the rank of lieutenant, junior grade, are in the great major ity in applying for this training. Torpedo instruction is given at Hew London. After an officer is qualified he will spend 3 years on submarine sea duty between the intervals of shore duty. When an officer qualified for submarine command or assignment goes on shore duty he is not, for the time spent on shore duty, technically assigned to the sub marine service. While on shore duty he does not receive his extra submarine pay but he never loses his submarine qualification except for physical disability. Extra pay for the qualified submarine officer on active submarine duty is 25 percent increase of the base salary. The average shore duty is 2 years. Submarine officers with the rank of captain have little occasion to actually be aboard or ride in a submarine. In very rare cases a captain might ride but not in any repeated routine manner and probably only during fleet exercises. Submarine officers with the rank of commander have little occasion for routine submarine trips but would ride a little more frequently. At present each submarine division has a division commander who may be an officer with the rank of commander. There would not be over seven such officers in the Navy at one time. In 1936 there were only two captains and four commanders assigned to submarine executive duty. Navy doctors assigned to the supervision of submarine personnel usually ride the tender or the salvage ship accompanying the submarines and occasionally make trips on these boats. A submarine officer of lower rank than the above when on sub marine duty is generally stationed aboard the submarine. His assignment to any one submarine generally lasts for 2 years per boat. DIVISION OF PREVENTIVE MEDICINE 289 The turn-over of officers on any particular submarine is generally about two changes in officer personnel per year. At the present time the enlisted man qualified for submarine duty receives extra pay of $25 to $30 a month depending on his rating while on such assignment. Men volunteering for this work attend the submarine school at New London for a 6-weeks' period. Some of the higher ratings such as machinist mates may spend as long as 36 weeks there. Then these men are ordered to some submarine and after serving aboard satisfactorily for 6 months are eligible for sub marine qualifications after they have passed an examination. I was advised that men came from all branches of the service into this submarine work and that there was no noticeable tendency of a greater proportion of men from the submarine tenders and supply vessels to enter this service than other general officers and men. The average yearly turn-over of petty officers and other enlisted men on a particular submarine would be over 100 percent, although some men might stay aboard for several years. There would prob ably be a turn-over of two chief petty officers per year. No warrant officers are ever attached to submarines. While this paper is not being prepared to cover Navy divers as such, I thought it would be of interest to include at this point some information about Navy divers. In reply to a question as to whether Navy diver applicants were likely to be qualified submarine men, or whether the diver applicants are just as likely to be from the general fleet, I was advised that all divers come from the fleet. I was also informed that the Navy has "30 officers who are on diving duty but who practically never dive; several of these are doctors who may have to take pressure in case of the development of compressed-air disease in one of the divers. Then there are 21 master divers, 91 first-class divers, and 484 second-class divers allowed in the entire Fleet. This quota is approximately filled. This group will dive an average of at least 20 dives a year, including their qualification and requalification dives and their salvage dives. So in all we would average about 12,520 dives per year by the 626 qualified divers and you will see that in the Statistics of Disease and Injuries in the United States Navy for the Calendar Year of 1936 there were listed 15 cases of caisson disease (we prefer to call it compressed-air disease) and 1 death. Now this in itself is not a bad average but if you go into it further you will find that all of this trouble, i. e., the caisson disease and the one death occurred at the experimental diving unit where the work we were doing forced us to carry the experiments to the stage of producing caisson disease in a certain number of the subjects in order to know when the end point in the experiment had been reached. I think you will find that out in the regular diving game in the fleet 290 DIVISION OF PREVENTIVE MEDICINE there was no trouble whatsoever. Experimental work is always hazardous, as you know, but even there we had but one death in over 6 years of constant daily diving." Mortality and Morbidity Record Beginning with the calendar year 1919 and extending through 1936 we were able to obtain a complete record of deaths among submarine officers. These deaths were divided into occupational accidents, non occupational accidents and disease, the findings summarized, and a tabulation made in table I. A similar summary was made for the enlisted men over a period 1922-36 in table II. A morbidity and invaliding record for submarine men over the years 1923-32 was prepared and contrasted with the general Navy average. The details for the respective years follow. For the calendar year 1922 three occupational deaths were recorded, one accidental death on leave, and two deaths from disease. In 1923 there were 25 admissions for accidental injuries associated with duty on board submarines. These were all that were reported under the key letter "S," denoting connection with submarine duty. The instructions regarding the use of this letter are that it shall be used for disease as well as injuries incidental to peculiar living con ditions aboard the submarine and to actual maneuvering of, or acci dent to the vessel. There were no admissions for disease reported as dependent upon living or working conditions in submarines. Of the 25 cases of accidental injuries recorded, 7 cases were fatal. Four of the deaths were caused by drowning, and the other three, resulting from multiple injuries, were all caused by an explosion of hydrogen gas in the after battery compartment of the U. S. S. SS7. Three of the men drowned were lost when the U. S. S. 0-5 was rammed and sunk by a merchant vessel in the harbor of Cristobal, Canal Zone. The other man who lost his life by drowning was at tached to the U. S. S. R-23. He fell overboard while the boat was at sea, striking his back on the hull of the boat. No one attached to the submarines was reported as invalided from the service. In addi tion there were two accidental drownings on leave and one death from disease. In 1924 there were 18 admissions for injuries recorded from sub marine hazards. One man injured in a battery explosion was sub sequently discharged for permanent disability. There were 502 sick days. There wore no admissions from disease of any kind incident to the peculiar living conditions aboard submarines. Three occupa tional deaths were recorded, one caused by bursting of a Diesel engine, one from gasoline explosion, and one drowning. In addition two fatal nonoccupational accidents and three deaths from disease. DIVISION OF PREVENTIVE MEDICINE 291 Iii 1925 the S-5t was rammed by the steamship City of Rome off Block Island on the Atlantic seaboard. The history of this disaster and the diving activities connected with the salvage work are de scribed in Commander Ellsberg's book "On the Bottom." Six officers and 27 enlisted men were drowned. Apart from this disaster there was one other occupational death due to a fall. There were 17 admis sions from submarine hazards. One man was injured by a fall through a hatch and nine were for injuries caused by submarine engines, other machinery, and batteries. The remaining seven admissions were attributed to hazards more or less peculiar to living or working con ditions on submarines. The injuries in these cases were burns, or lesions of minor importance resulting from falls, or stumbling over obstacles on board. One case of heat exhaustion occurred which was the only admission other than for injuries, there being no admis sion for disease attributable to the working and living conditions of submarines. There were nine accidental deaths among the men on leave or liberty, one suicide, and one death from disease. One suicide was also recorded among officers. Injuries of a minor nature were more completely reported during the year 1926 and injuries resulting from falls on board submarines and those caused by like hazards, which might be encountered in any type of vessel, have been charged to submarine hazards, whereas formerly they were in some cases simply recorded as caused by falls. These changes in practice largely account for the increased number of admissions and sick days in 1926. Of the 59 admissions for this year, only 23 were for injuries occurring while submarines were operat ing, but in all except 2 of the 59 cases, the injured person was working when the accidents occurred. One enlisted man was invalided from the service because of faulty union of a fracture caused by an explosion of hydrogen gas from storage batteries in the U. S. S. S-49. The ex plosion occurred while the vessel was moored alongside the dock at the submarine base, New London, just as a pilot cell cover was being removed for the purpose of testing the specific gravity of the electro lyte. The battery deck was blown up. Twelve enlisted men were injured. Three died a few hours after the accident from multiple in juries and one man died 4 days later. Two other occupational deaths occurred this year. An enlisted man who was working on the bridge of a submarine anchored at sea outside of San Francisco Bay lost his footing when the vessel took a sudden roll, fell overboard, and was drowned. Another fell overboard from submarine in port and was drowned. Injuries making up the total of 59 admissions were caused by machinery, engines, falls, and other miscellaneous accidents. One case of heat exhaustion was reported. In addition there were two 292 DIVISION OF PREVENTIVE MEDICINE accidental deaths among the men on leave and two deaths from dis ease. There were no deaths recorded among officers. Of the 90 admissions in 1927, 54 were injuries occurring while sub marines were operating, and in all except 5 instances the injured per sons were working when the accidents occurred. Thirty-eight of the ninety admissions occurred in connection with the sinking of the U. S. S. S~4, which resulted through the collision with the United States Coast Guard cutter Paulding. The submarine was running submerged during standardization trials in Cape Cod Bay near Provincetown, Mass., at the time. The cause of death was recorded as asphyxiation in the case of 1 officer and 5 enlisted men, and as drowning in the case of the remaining 4 officers and 28 men. One other occupational death reported for the year occurred near Tsingtao, China; an enlisted man lost his balance and fell overboard while lift ing a guard rail on a submarine. He could not swim and was drowned. The remaining injuries resulted from operating machinery and engines, falls, heavy seas, striking against objects, and so forth. Another case of heat exhaustion in the engine room was also reported. Four enlisted men were invalided from the service. A contusion of the leg received while handling lines in mooring a submarine led to invaliding in one case, and injuries received on board a submarine in 1926, during an explosion of hydrogen gas from storage batteries, in three cases. In addition there were six nonoccupational accidental deaths and four deaths from disease. In 1928, 69 admissions were reported. Twenty-six were for in juries occurring while submarines were operating and in all except one instance the injured persons were working when the accidents oc curred. There were 43 admissions for injuries received while sub marines were moored. The accidents show the typical miscellaneous distribution of causative agencies, i. e., machinery, engines, falls, etc. There were no deaths and no person invalided from the service on account of injuries due to submarine hazards. There were four acci dental deaths on leave and five deaths due to disease. Of the 73 admissions in 1929, 26 were for injuries occurring while submarines were operating and in all except 2 instances the injured persons were working when the accidents occurred. There were 47 admissions for injuries received while submarines were moored. There were two deaths from drowning caused by falls overboard, one while the submarine was at sea, and the other while moored. At this point I would note that in examining these miscellaneous injuries that only a very small percentage were caused by work around batteries. Prac tically all of the injuries were sustained through general hazards of operating a boat which could just as well have been experienced on any craft as well as on submarines. In addition three fatal accidents oc DIVISION OF PREVENTIVE MEDICINE 293 curred on leave and two deaths from disease among the men. One death from disease was recorded for a submarine officer. The 57 admissions in 1930 showed 22 occurring while submarines were operating and 35 while moored. There docs not seem to be any tendency for more injuries to be sustained while maneuvering the sub marine than while moored along the dock. One death occurred from drowning, washed overboard. There are only a few admissions from injuries sustained while handling torpedoes in the record for these years. Apparently no more than might be caused in the ordinary gun drill. No deaths have resulted from torpedo drill or handling in submarines for the years under review. There were also five acci dental deaths on leave and seven deaths due to disease, including one from caisson disease. One death from disease was recorded among officers. 1931 had 65 admissions, 20 for injuries while submarines were operat ing and 45 while moored. There were two deaths from drowning, caused by falls overboard. No invalidings were reported. There were three nonoccupational accidental deaths and one due to trau matic air embolism while using the training "lung." For 1932 there were 62 admissions, 17 while operating, 45 while moored. One death was caused by electric shock while the submarine was at dock. There were three accidental deaths on leave and one death among officers was of accidental nature while on leave. After 1932 no separate record of admissions and sick days for the submarine service as distinct from the general navy figures is recorded in the Annual Reports of the Surgeon General so it was thought advisable to summarize the data at this point in the following table. Admissions, sick dnys, invalided, due to submarine service hazards Year N'umber of officers and men Admis sions Rate per 1,000 Sick days Rate per 1,000 Invalided from the service Rate per 1.000 1923 2,472 2.925 3,292 3.332 3. 245 3.447 3.44.1 25 18 50 59 90 69 73 640 502 290 1,947 1.560 1.419 1.007 908 2, 193 790 0 1 0 1924 1926 1927 4 0 0 0 2 0 1928. 3 5M 57 1931 2, 70S 2.468 65 62 1932 3,089 57 18 1, 132 354 0.8 0.26 We may compare these figures to a general average for the entire Navy, if we take the results for 1933 which are very close to the Navy means for the preceding 5 years. 294 DIVISION OF PREVENTIVE MEDICINE Your Number officers and men Admis sions Rate per 1,000 Sick days Hate per 1.000 Invalided from the service Rate per l.0C0 1933 108,183 6.800 63 15,661 1.448 139 128 As presented above the figures exclude homicidal injuries and suicides (both actual and attempted) and poisoning by food. These figures for the Navy should be further adjusted to obtain a picture more nearly similar with that of the submarine service. For this purpose Mie figures for accidents occurring on "leave or liberty" were deducted from the Navy totals leaving only the exposure occurring "within command" and similarly for sick days and invalidings from service. Year Number officers and men Admis sions Rate per 1,000 Sick days Rate per 1,000 Invalided from the service Rate per 1,000 1033 108,183 4,671 44 89,474 820 55 0.51 This permits a comparison for accidents and accidental poisonings for a 10-year period of submarine service and the same for a 5-year period for the entire Navy. We find that the rate per thousand, for admissions in the submarine service was 18; for the Navy 44. The rate per thousand for sick days in the submarine service was 354, while the Navy figure is 820. Invaliding from the service was 0.26 per thousand, from submarine hazards and 0.51 per thousand for the entire Navy from causes occurring "within command." These results while by no means conclusive indicate very definitely a favorable comparison for the submarine service as against the figures for entire Navy service. This may be due in some measure to the care exercised in selecting men for the submarines and to the very rigorous application of all safety measures. There is also the prob ability that these men as a class are more seasoned in safeguarding themselves against the average nautical accident as there is a great preponderance of technical men among them. They are all experts in their particular line as must necessarily be the case for those connected with submarines where carelessness or inexperience could not be tolerated. Continuing the mortality data we note for 1933 two accidental deaths on leave among enlisted men and one suicide. There were also two nonoccupational accidents for officers and one disease death. In 1934 an enlisted man was killed by an explosion of a signal shell. There were three nonoccupational accidents and three deaths from disease. No deaths among officers. In 1935 one occupational, three nonoccupational, and one suicide among enlisted men. No deaths for officers. For 1936 there was one nonoccupational accident and one DIVISION OF PREVENTIVE MEDICINE 295 death from disease. Among officers the only death recorded resulted from an airplane accident. Table I.—Officers — United States Submarine Service MORTALITY DATA Year Num ber of officers 1919 1920 1921 1922 1923 1924 1925 1925 1925 1925 1925 1925 1925 1926 1927 1927 1927 1927 1927 1928 1929 1930 1931 1932 1933 1933 1933 1934 1935 1936 245 266 252 250 272 306 309 314 321 333 370 382 325 313 297 300 302 Rank Station or ship Lt Ens Lt., J. G. Lt., J. O Lt., J. G Lt., J. O. Lt., J. G Lt. Com. Lt., J. O. Lt. Com. Lt., J. G Lt., J. G. Lt., J. G. Lt., J. O Lt., J. O Lt., J. O. Lt., J. G. Lt , J. O. Lt S-51. S-51. S-51. 8-81. S-51. S-51. S-51. S-4.. s-c. S-4.. s-«. S-4.. S-34 8-47 New Lon don. Dolphin. Age at death Accidental deaths Occupational None do do ....do do do Collision— drowned do do ....do do do None do Collision— drowned ....do do. do do None ....do do ....do.... do do do ....do ....do Airplane crash. Nonoccupational None. . ....do. ....do. do ....do... ....do... .— do... ....do... ..-do... ....do... ....do... ....do... tin -1" ....do ....do ....do ....do do ....do .- ....do ....do ....do Auto accident— leave None Auto accident —leave do. None Disease None. Do. Do. Do. Do. Do. Do. Do. Do. Da Do. Do. Suicide. Nunc. Do. Do. Do. Do. Do. Do. Osteomylitis. T. B. Septicemia. None. Streptococcus. None. Do. Do. Do. Do. Years Total ex posed Average age at death Total occu pational Total non occupa tional Total dis ease 18 5,467 29 12 3 5 Over the 18-year period 1919-36, inclusive, we have a total life years of exposure for officers of 5,467. The average age at death was 29. There were 12 occupational deaths, 6 lost on the S-51 in 1925, 5 lost on the S-4 in 1927 and 1 death as a result of an airplane crash in 1936. The accidental occupational death rate is 2.2 per thousand. Over this period there were three accidental deaths due to nonoccu pational causes, all automobile accidents while on leave. The result ing rate being 0.55 per thousand. The total accidental death rate was 2.75 per thousand. There were five deaths as a result of disease all differing as to cause. The percentage of active officers in the various ranks was determined to be as follows: Ensigns 3 percent, age group 20-24; lieutenants, junior grade 60 percent, age group 25-29; lieutenants 25 percent, age group 30-34 ; officers of higher rank 9 percent, average age group 35-39. On this basis and using the J. O. S. Basic Table 1915-26 for compari 296 DIVISION OF PREVENTIVE MEDICINE son, the succeeding table was drawn. In each case the fifth year of duration was assumed as representative. (1) Exposed to risk (2) Actual dead (3) Expected dead Rank Age Ratio per cent (2)+3 Pcrcrnt Ensign 20-24 164 3.444 1 0.44 224 157 45 100 Lieutenant commander 25-29 30-34 35-39 1,367 492 15 2 2 9.5« 4.38 2.02 Commander . .. 5,467 20 16.40 122±18 If the hasic table 1920-34had been used, the mortality ratio would have been 129percentile DIVISION OK PREVENTIVE 297 MEDICINE ■,8 X ^ "3 5 3 r.:: COig "3 «"0 - - > 2 E ciSo - Stj ©> c a5| if £ .* - - sec •c* * o o o Is? J- 2fiQ M © o - h § £!.§,§ 30"O ' IT OS , E o , so : *5 ai ss 4,8 S * c32 S 1S?! S ?i ~i ri ri « ^7^ ~ ri ri roVi ~»~j 'f'i ri ^ ^ ^ ^ ri ?] — rl 1-J > O . »o* ' . ' cs« ,' —.J , i i , ! — ,' t JaS JOOrn-nOaSoliOM3 0Of--i>iOO r r r f r i i i r 71X COX 73X X COCO I 298 DIVISION OF PREVENTIVE MEDICINE -2: ^ a n 'Z a & Pi 1 - a | Si} M [1 fl« I —3 . ° 1 -a .-^ o « o . a c « 0 3.8,93 J I* SJ?f?33 T ? 3 T 7? 7 7 . T 7 T T „ . X X X X X X X V.X X X X XvX X * X X X X * •>ai7^TT7.' "77TT7 ""T^TT x^i:naiai-^flCajaiMxtn O 3*aoO « x 8 oOo o : : Ph i : idci o : 3 b i aid0. oo a. a; l5^iMsltfillrfl»'aflllilj P ;° gaaaaaaaaaaaaaaasaaaagssr.sr, sss sssssg DIVISION OF PREVENTIVE MEDICINE 299 is c e!c « m£ ■ 3 a ° as 3"° - O O C 0 o cocccocco ssd a si si "i sv s^n si si 333.3-J. J. I 3: 3:e si 3:31313>si I si 3i si I. I 3.I si I ai ^ 34s c*.si J. ? o a J- 5 3. as»' DIVISION OF PREVENTIVE MEDICINE H .8 "3 if « Iffl . ^ UN SP 2o < Q 9 g E .2 = 3 2 I o ! o B I -os is oJ o - - 7.- 1 3 at« O CJBCD■cc1 3 , . 9 c Sa 1 «ElSfl 21asa: > O vi ccC > i£ > x > cnSSO 'h X. IP"P"aossisifis Smite line o x P"x- £ abx otci P3< JJ s >< 2: — 5 5 £"H:£:^ i-" £: 2 Hj £: I £: £i £- I £: £: r £ £; £: £; £| -~-I- - ' I- ^ Ii I- ^ - I - DIVISION OF PREVENTIVE MEDICINE a , a §g a 5 o S - ?i ~5?i ct c't? 313 C ~' 3 Grand total disease 3 Grand total nonoccupational Grand total occupational 3 Orand total exposed 39,061 45202—38 -10 302 DIVISION OF PREVENTIVE MEDICINE Enlisted men— United States Submarine Service MORTALITY DATA Chief [Jetty officers Petty ofBcers Other enlisted men Year Total Occu pational Non- occupa- lional acci dents Occu pational acci dents Non occupa tional acci dents Occu pational acci dents Non occupa tional acci dents ex posed acci dents Dis ease Dis ease Dis ease 1922 2.554 1 None 2 2 1 None 1 None None None 1923 2,200 None 1 None None 4 •i 3 None None 1924 2,619 None 1 None 2" 2 3 None None None 1925 2.982 4 None 6 3 1 1926 3,018 1 1 None 4 3 3 1 1 3 1927 2.924 3 None 1 19 6 12 None 1 1928 3, 114 None 1 None None 1 4 None 1 1929 3.073 1 Xuri,. 1 None 1 3 1 1 None None 1930 3. 172 None None None 4 7 None None 1931 2.384 None None Nunc None None 1 2 None 1932 2. 155 None None None None 2 j 1 1 None 1933 2. 115 None None None None 1 2 1 Nono Nono None 1934 2.200 None None* None 3 3 None None None 1935 2.250 None None None None 2 None 1 1 1936 2.300 None None 1 None None None None 1 None Total 39,001 11 3 5 54 37 c 28 24 12 7 The total life years of exposure for enlisted men was 39,061 over the period 1922-36. There were 89 accidental deaths due to occu pational hazards. Nonoccupational deaths of accidental nature while on "leave or liberty" totaled 52. There were 40 deaths due to disease, among which only 2 may be directly ascribed to occupational conditions. These two deaths occurred during training with the submarine "lung" and have already been considered. In this service approximately 10 percent of the enlisted personnel are chief petty officers of age group 35-39. These are the highest ranking enlisted men in submarine work, there being no warrant officers assigned to this branch. Among this group of chief petty officers there were 11 occupational accidental deaths, 3 nonoccupational, and 5 deaths due to disease. The percentage of petty officers is very high in subma rine service, approximately 65 percent of the enlisted personnel having a petty officer's rank. Among this group there were 54 occupational accidental deaths, 37 nonoccupational accidents, and 28 deaths due to disease, the age group being 25-29. Other enlisted men, such as seamen, firemen, mess attendants, and cooks third class, represent 25 percent of the service enlisted personnel. Among this group with ages 20-24 there were 24 occupational accidents, 12 nonoccupational, and 7 deaths from disease. The above figures are summarized in the following table with the J. O. S. 1915-26 basic table for approximate comparison. DIVISION OF PREVENTIVE MEDICINE 303 Rats Age group Exposed to risk (1) Actual dead (2) Expected dead (3) Ratio, percent, 2-5-3 Petty officers... 35-39 25-29 20-24 3,906 25.390 9,765 19 119 43 16.2 70.5 25.9 117 169 166 Total 39.061 181 112.6 159 The chief petty officers evidence a ratio of 117 percent. The five deaths due to disease were from varied causes. The occupational accident rate was 2.81 per 1,000, the nonoccupa tional accidental death rate 0.77. The total accident rate 3.58 per 1,000. Among petty officers the ratio is 169 percent, 45 percent of the deaths being caused by accidents from occupational hazards, with a rate of 2.12 per 1,000. Nonoccupational accidents caused 31 per cent of the deaths, with a rate of 1.46 per 1,000. As a matter of coincidence the total accidental death rate is 3.58 per 1,000, the same as for chief petty officers. Deaths due to disease are low in this petty officer group, comprising only 24 percent of the total deaths. The higher death ratio being practically entirely due to accident. Of the 28 deaths resulting from disease there were 5 due to tubercu losis of the lungs and 1 case of tuberculosis other than pulmonary. The pulmonary tuberculosis rate is well under normal, being 0.20 per 1,000. Exposure deaths, such as pneumonia and influenza, were low and the other disease deaths were evenly distributed over a variety of miscellaneous causes. Other enlisted men had an occupational death rate of 2.46 per 1,000 and a nonoccupational rate of 1.23, comprising a total rate of 3.69 per 1,000. On the basis of the J. O. S. there were expected 19.5 deaths from disease, whereas the actual was 7, indicating the higher death rate to be due to accident. Seventy-five percent of the fatal occupational accidents among officers and men occurred as the result of collisions. There were seven deaths due to the explosion of hydrogen gas from the batteries. This hazard has apparently been minimized by safety precautions and is probably no greater than explosions from various agencies on other war vessels. For the purpose of comparing the accidental death rate for officers and men of the submarine service with that of the entire Navy the following material is added. 304 DIVISION OF PREVENTIVE MEDICINE ACCIDENTAL DEATH RATE Commissioned Personnel entire Navy Year Exposed Deaths Rate per 1,000 0) (2) (3) (1) (2) (3) 1923 7.704 8.058 8.210 8,839 8. 742 S. 793 16 5 12 7 8 5 S 9 1924 28 29 21 29 34 1925 1928 . 1927 1928 1929 8.925 19 1930 . 9.013 9, 184 9. 503 9, 458 22 14 14 41 3 1931 8 7 1932... 1933 +9 Total 94.227 267 | 80 89 2.8 0.83 0.93 This table of officers excludes those of the Marine Corps, midship men, and cadets, but includes warrant officers. Column (1) under deaths includes all casualties from injury, poisoning, suicide, and homicide. Here the result is 267 deaths with rate per 1,000 of 2.8. Under column (2) deaths from aviation, both lighter and heavier than air, suicide, and submarine activity, are excluded. This naturally brings the rate down substantially and we have SO deaths with the rate of 0.83 per 1,000. The final figure for comparison purposes is under column (3); here the figure in column (2) has been adjusted to include 25 percent of the suicides. This final figure under column (3) indicates a fatal accident rate among Navy officers of 0.93 per ] ,000, as against 2.75 for submarine officers. For the purpose of record I have listed hereunder the deaths from aviation and suicide used in obtaining this final figure. Suicides entire Navy and Deaths due to Navy Aviation Aviation deaths Suicide Year Officers Men Officers Men 1923 8 7 3 18 1924 14 12 2 22 1925 11 14 4 13 1926 13 2 0 11 1927 17 12 2 21 1928 20 8 5 13 Aviation deaths Suicide Year Offl cers Men Officers Men 1929 s 6 2 13 1930. 13 5 6 13 1931 4 9 2 12 1932. 4 11 3 13 1933 26 66 8 20 DIVISION OF PREVENTIVE MEDICINE 305 Similarly for enlisted men the following table is added : Enlisted Personnel entire Xary Year Exposed Deaths Rate per 1,000 (1) (2) (3) (1) (2) (3) 1923 85.217 87.442 84.467 83.461 84.672 84,940 85,999 85.813 81.274 81.534 79.726 194 162 180 107 104 109 119 107 119 138 110 112 1924 215 161 122 177 138 127 138 161 135 199 1925 1926 1929 1930. 1931 1932 1933... +42 1.409 Total 924,545 1.767 1.367 1.9 1.48 1.53 The fatal accident rate here is 1.53 for enlisted men in the Navy as compared with an average of 3.60 for enlisted men in submarine serv ice. The difference is a little less than 2 extra deaths per 1,000. The mortality other than from accident appears to be low for both officers and men in the submarine service. Bibliography Vital statistic* Annual Reports, Secretary of the Navy. Annual Report*, Surgeon General of the Navy. Statistics of Diseases and Injuries in the U. S. Navy, Navy Department, Bureau of Medicine and Surgery, Annual. Medico-Actuarial Mortality Investigation, 1913. Joint Occupation Study, 1928. Mortality of the Army and Navy, John S. Thomson, T. A. S. A., Vol. XXX. Underwriting Military and Naval Risks, Samuel G. Hopkins, H. O. L. U. A., Vol. V. Safety and health studies Report on Submarine Safety, U. S. Submarine Board, 1928. Traumatic Air Embolism in Submarine Escape Training, U. S. N. Medical Bull., Vol. 30. The Physiological Effects of High Pressures, Journal of Industrial Hygiene and Toxicology, Vol. XVIII, No. 8, October 1936. Circulatory and Visual Effects of Oxygen at 3 Atmospheres Pressure, Journal of Physiology, Vol. 114, No. 2, Jan. 1936. A Study of the Convulsive Seizures Caused by Breathing Oxygen at High Pressures, C. W. Shilling and B. H. Adams, U. S. N. Medical Bull., Vol. 31. The Psychological Effects From Breathing Air at 4 Atmospheres Pressure, American Journal of Physiology, Vol. 112, No. 3, July 1935. Studies of the Effects of High Oxygen Pressure, American Journal Physiology, Vol. 107, No. 1, January 1934. 306 DIVISION OF PREVENTIVE MEDICINE A Pressure Chamber Installation for Studying Physiologic Effects of Pressures, etc., Journal of Industrial Hygiene, Vol. XIV, No. 2, Feb. 1932. Caisson Disease and Its Relation to Tissue Saturation With Nitrogen, U. S. N. Med. Bull., Vol. 33. The Influence of Increased Barometric Pressure on the Pulse Rate and Arterial Blood Pressure, U. S. N. Med. Bull., Vol. 34, No. 1. Medical Aspects of Submarine Lung Training, U. S. N. Med. Bull., Vol. 29. Distention of Lungs During Training With Escape Apparatus, U. S. N. Med. Bull., Vol. 29. Observations on Submarine Lung Training, U. S. N. Med. Bull., Vol. 29. Analysis of Accidents Occurring in Training With the Submarine Lung, U. S. N. Med. Bull., Vol. 30. Traumatic Lung Lesions Produced in Dogs by Simulating Submarine Escape, U. S. N. Med. Bull., Vol. 31. The Hazard of Caisson Disease in Individual Submarine Escape, U. S. N. Med. Bull., Vol. 34. Breathing Resistance of New Submarine Escape Apparatus, U. S. N. Med; Bull., Vol. 34. General information and history of submarine development Submarine Warfare, Herbert C. Fyfe, 1902. Our Many-Sided Navy, R. W. Neeser, 1914. The Submarine Torpedo Boat, Allen Hoar, 1916. Submarines and Sea Power, Charles Domville-Fife. Submarines of the World's Navies, Charles Domville-Fife. The Submarine in War, Charles Domville-Fife. Submarine Engineering of Today, Charles Domville-Fife. The Birth and Development of the American Submarine, Frank T. Cable, 1924. On the Bottom, Edward Ellsberg, 1929. I Like Diving, Thomas Eadie, 1929. The Story of the Submarine, Farnham Bishop, 1929. The Romance Of The Submarine, G. G. Jackson, 1930. Proceedings, U. S. Naval Institute, Annapolis, Annual. U. S. Navy Register, Annual. U. S. Navy Directory, Annual. Jane's Fighting Ships, Annual. Brassey Naval Annual. Army and Navy Uniforms and Insignia, Colonel Dion Williams. U. S. Navy Diving Manual. OBSERVATIONS ON STAPHYLOCOCCUS FOOD POISONING REPORT OF AN OUTBREAK By Lieutenant, E. M. Wade, Medical Corps, United States Navy A number of cases of acute gastroenteritis which occurred during the years 1909-13 on a certain farm in Nueva Ecija Province, Luzon, P. I., were investigated by Barber (1) and wyere reported by him in 1914. His investigations revealed that only occasional attacks occurred in American residents and Filipino employees of the farm, but more often visitors were attacked. It was observed that cream from the milk of one particular cow had been ingested in each instance before the at tack, the attacks were limited to warm summer months, and no re DIVISION OF PREVENTIVE MEDICINE 307 frigerating facilities were in use on the farm. Bacteriological anaylsis of samples of fresh milk revealed numerous colonies of both staphylo coccus albus and aureus. Transfers were made from pure cultures of each organism into milk, incubated at 36.5° C. for 8% hours, and a 50-cubic centimeter dose of the inoculated milk was ingested by Barber himself on successive days. In 1% hours after ingestion of the milk inoculated with the yellow variety of staphylococcus, an acute gastro enteritis appeared, with violent symptoms lasting between 7 and 8 hours. Subsequent to the report of Barber, little mention of the staphylo coccus as a cause of food poisoning appeared in the literature until 1930. Following this date numerous outbreaks have been observed, a number of which have been reported and are hereinafter listed : Author Food Year Hack et al (t) Jordan (.1) Ramsey and Tracy (4) Jordan and Hall (6) Jordan (6) Tanner and Ramsey (7) McDurney M) Jordan and Burrows (9) Crabtree and Lltterer (10) Corpening and Foxhall (II) — Oeiger et al. (It) Deck ot al. (IS) Dcnison Ui) Shaughnessy and Grubb (16)- Sponge cake Cheese - Milk Chicken gravy Cake Milk Chocolate eclairs.. Custard-filled hakery goods, hakery goods, custard- filled coffee cakes, doughnuts, chocolate eclairs (5 outhreaks). Milk Custard-filled cake Ice cream Tongue sandwiches Cream pun's — Milk Custard cake 1930 1930 1931 1931 1931 1932 1933 1934 1934 1935 1935 1935 193fi 193G 1937 An outbreak of food poisoning involving over 250 men at the marine base, Quantico, Va., was mentioned in the section on preventative medicine in a recent issue of this publication {17). The first symptom in the majority oT cases occurred 4 hours after eating the suspected food, which in this case was ham that had been cooked the night before, and had been left overnight in the container to gradually cool. A staphylococcus albus was isolated from a whole ham. A report of an additional outbreak of staphylococcus food poisining due to in gestion of cold boiled ham which wae contaminated with a hemolytic staphylococcus aureus, involving 124 men aboard the U. S. S. Arizona on December 12, 1936, will be included in this article. Of particular significance is the constant observation that in the outbreaks of staphylococcus food poisoning that have been reported in the literature, the infected food was unchanged in appearance, odor, and flavor. In their work in experimental staphylococcus food poisoning, Kelly and Dack (18) found that there was no change in the taste, appearance, or odor of meat and bread inoculated with staphylo cocci and incubated for 5 hours at 37° C, confirming an observation of numerous investigators of actual outbreaks of this condition. 308 DIVISION OF PREVENTIVE MEDICINE Clinical Picture of Staphylococcus Food Poisoning With Important Differential Points There are two important differences between the staphylococcus type of food poisoning and the more familiar type due to the sal monella group. First, from a clinical standpoint, the incubation period in staphylococcus food poisoning is commonly between 2 and 4 hours, while in salmonella food poisoning the onset of symptoms average between 6 and 12 hours after ingestion of the infected food. In many cases of the salmonella type the incubation period is more than 24 hours. The second, and perhaps most important difference between the staphylococcus and salmonella types of food poisoning is that staphylococci isolated from the former type have certain cul tural characteristics which will be described subsequently, and from which a sterile broth filtrate may be obtained which, when swallowed in small amounts by human volunteers, reproduces the symptoms of an acute gastroenteritis. Large amounts of bacteria-free filtrate from salmonella cultures have been fed to humans without producing any symptoms (19). The history, subjective symptoms, and objective signs in an attack of food poisoning due to a staphylococcus are quite uniform, and except for the uniformly short incubation period do not differ in any large measure from attacks due to other organisms. The onset is characterized by severe nausea and abdominal cramps, followed by vomiting and diarrhea. The patient may vomit from a few to 20 or more times during a period of a few minutes to 8 or more hours. At times the vomitus may be streaked with blood. During the vomiting stage, frequent watery stools are passed. The appearance of blood in the stool is common. Early there is normal or subnormal temperature with cold sweating and marked prostration. Severe cases may show an elevation of temperature up to 100° F. on the second day. Oc casionally severe cases will suffer with cramps in the flexor muscles of the legs. The acute symptoms generally last from 1 to 8 hours, although some weakness may be present for 1 or more days. Prompt recovery is the rule, no fatal cases having been reported. The treat ment is symptomatic. Experimental and Laboratory Viewpoint of Staphylococcus Food Poisoning Live cultures of staphylococci which were isolated from milk were swallowed by Barber (1) with reproduction of the symptoms of acute gastroenteritis. It was not until 1930 when Jordan (S) fed human volunteers bacteria-free filtrates from cultures of staphylococci iso lated from a sponge cake which caused an outbreak of gastroenteritis reported by Dack et al. (2), with duplication of the characteristic clinical picture. DIVISION OF PREVENTIVE MEDICINE 309 For many years there has been a degree of uncertainty regarding the unicity or multiplicity of the toxic factor in staphylococcus fil trates. It is now believed that the hemolytic, dermonecrotic, and lethal components are the attributes of a single factor. Dolman (20) studied bacteria-free filtrates from 200 different strains of staphylo cocci. In each instance the filtrate obtained was found to possess a staphylococcus exotoxin of specific pathogenic and antigenic proper ties. Forty-two human volunteers drank bacteria-free staphylococcus filtrates on 110 occasions with relative impunity. It was found that only occasional strains were capable of producing a filtrate containing a factor that produced gastroenteritis in human volunteers, suggesting thereby that the "enterotoxic" factor is distinct from the hemolytic, dermonecrotic, and lethal components, and is characteristic of only certain strains of staphylococci. Jordan (6) reports that he observed a strain of staphylococcus that retained the ability to produce an enterotoxic factor for as long as 1 year. Other investigators have found that the ability to produce this enterotoxic factor may be lost after repeated transplantation of certain strains. Jordan and Burrows (21) found that by the use of starch or custard media, it was possible to produce bacteria-free filtrates containing enterotoxic substances from certain strains which had not yielded enterotoxic filtrates in previous laboratory tests. In addition, strains that apparently had lost the power to produce entero toxic filtrates through successive transfer, although originally positive, were found to regain that characteristic when transferred to custard medium or to ordinary medium to which starch had been added. Whereas negative results were obtained by Woolpert and Dack (22) in Macacus rhesus monkey feeding experiments using staphylo coccic filtrates which were definitely toxic to humans, positive results were obtained when a filtrate was prepared from organisms cultured in an atmosphere of 20-25 percent carbon dioxide. One of the most important experimental observations on the toxic effects of staphylococcus filtrates was reported by Borthwick (23) in 1933. Using rabbits and guinea pigs, he obtained uniformly nega tive results in feeding experiments except when the hydrogen ion concentration of the stomach was previously adjusted to pH 7.3. Positive results were obtained with intrarectal injection of toxin, only when the rectum had been irrigated with saline and the reaction adjusted to pH 7.3. He also found that staphylococcus toxin when added to gastric juice in vitro, a slightly acid (pH 6.8) or a slightly alkaline (pH 7.8) reaction impaired its activity, while there was no attenuation when the reaction of the juices was pH 7.3. This work suggests one of the possible causes of the infrequency of this type of gastroenteritis in humans, and the frequent failures in human and animal feeding tests. 310 DIVISION OF PREVENTIVE MEDICINE Dack et al (2) report that the viability of staphylococci is destroyed by exposure to 80° C. for 15 minutes, while the potency of the toxic factor is slightly attenuated but not eliminated in filtrates subjected to 100° C. for 30 minutes, as tested by subsequent intravenous in jections in rabbits. Jordan's work (3) indicated that staphylococcus toxin is destroyed by boiling, although he further reports (6) that sterile toxic filtrates retain their original strength when stored at low temperatures for 3 to 4 weeks, and that the toxic qualities aro not altered by strong chlorine solutions. Jordan and Burrows (21) and Stritar and Jordan (24) conclude in their reports published in 1934 and 1935, respectively, that the ability to produce an enterotoxic substance is not limited to any particular kind of staphylococcus, and that food poisoning strains possess neither biochemical, hemolytic, or agglutinative characteristics to indicate any degree of homogeneity. A brief report of what is believed to be the first practical cultural method of differentiating enterotoxic and nonenterotoxic strains of staphylococci, which was developed by Stone (25), appeared in 1935. It had been known for some time that upon a combined agar and gelatin medium there could be demonstrated zones of altered gelatin around the colonies subsequent to incubation. Stone and others found that the characteristic liquefication was variable when occurring in the usual beef and veal infusion, or 0.3 percent beef extract, but was specific when beef extract alone was included in a high concen tration with the gelatin. With a combination of 3 percent beef extract, 3 percent gelatin, and 1.5 percent agar, he found an improved method using ammonium sulphate solution as a developer, for the demonstration of this characteristic principle. Tlus work has not been published, but the results of his studies are incorporated in the new Difco medium, Bacto-Stone's gelatin agar. Detailed method of preparing this medium and developer, with interpretation of reactions is quoted (26) : 1. Procedure.— (a) The medium is prepared for use by slowly addiug 7.5 grams of Bacto-Stone's extract gelatin agar to 100 cc of distilled water in an Erlenmeyer flask. The flask should bo rotated gently to assure a thorough wetting of the powder and to avoid the formation of lumps.1 Sterilize in the autoclave for 20 minutes at 15 pounds pressure (250° F.). If larger individual units are prepared it is recommended that the medium be heated to the boiling point immediately before autoclaving. 1 If basic ingredients are used in preparing this medium, the following procedure is recommended by Stone in a personal communication to the author: 1. 3 percent Difco (Dacto) beef extract (other beef extracts have not been compared with the Difoo product by Stone). 2. 3 percent Difco granular gelatin. 3. 1M percent granular agar. 4. Dissolve ingredients in boiling distilled water. Sterilize in autoclave for 20 minutes at 15pounds pres sure. Do not adjust for pH. Do not include other ingredients unless salt and blood are used for a blood agar base. DIVISION OF PREVENTIVE MEDICINE 311 (b) Plates can be poured for streaking suspected foods on in the study of pure cultures. Care should be taken to pour the medium at a temperature (45-50° C.) at which it will flow but at which excessive water of condensation is avoided. The use of porcelain tops on petri dishes is recommended. When time permits, such plates for Btreaking can be kept for a day or more in the refrigerator before using, in order to secure a dry surface, discouraging the development of spreaders. Plates should be streaked so that in some portion of the plate well-developed isolated colonies will appear. (e) Incubate plates for 24 hours at 37.5° C. Pigmentation is quite vivid on this medium. After incubation the developer is poured gently upon the surface of the medium so that all colonies are completely covered. Let plate stand until the reaction is well defined. Typical reactions are complete, as a rule, in less than 5 minutes. 2. Preparation of developer. — (a) Place 1 pound of C. P. ammonium sulphate in & 1,000 cc graduate. Add distilled water at 70° C. to bring the volume to 1,000 cc. Stir with glass rod until solution is complete. This developer should be stored in glass-stoppered bottles. Vaseline on the stoppers prevents freezing of the stopper within the bottle neck. 3. Reaction.— (a) After developing not over 5 minutes, the background of the medium assumes an opaque, yellowish color. Colonies producing "gastro- enterotoxic substance" are surrounded by a clear zone of transparent medium which approximates a radius at least one-eighth fr>ch from the edge of the colony. Experience to date indicates that zoning of a lesser degree is significant, but not necessarily definitely positive. The large definite clear zone parallels active liquefication of Stone's original beef extract gelatin medium, and the weaker zoning colonies parallel slow liquefications or slight liquefications in the same medium. (6) Since the ammonium sulphate does not destroy the viability of the organ isms, zones colonies can be picked direct and planted onto two new culture plates. Such spot colony planting can be observed by developing one culture and using the undeveloped correlated culture plate for pure culture study later. Con tamination of one colony by rinsing organisms from adjacent colonies does not seem to be a serious hazard to pure colony isolation. Care should be exercised to avoid too active stirring when introducing the platinum loop during colony picking. (c) B. subtilis, yeast, and possibly other organisms, give active zoning. Gram staining of the suspected staphylococci colonies is therefore essential as a primary step in working with all unknowns. 4. Feeding experiments. — (a) The beef extract gelatin agar does not represent a better "toxin" producing medium. It simply provides a practical, and so far specific cultural reaction for typing. For animal feeding tests, starch medium is generally considered superior to other methods. (b) In checking zone reactivity against animal or human feeding tests, com parison should be conducted concurrently rather than some weeks apart. Old cultures occasionally lose both their animal and cultural reactions, and if a feeding test positive strain some time later is checked for zone reactivity, a failure in such a zone behavior should bo substantiated with another feeding test. 5. Reactions on blood agar. — (a) The addition of 0.9 gram of sodium chloride per 100 cc of medium provides an excellent base for uncooked blood agar. Degrees of hemolysis are first noted, then the plate is developed with ammonium sulphate. This method must be used with caution until the combination of reactions that can occur is fully understood. In the study of staphylococci suspected of produc ing "gastro-enterotoxic substance" one may note the following reactions: (1) No hemolysis, no zoning. (Considered "potentially nontoxic") 312 DIVISION OF PREVENTIVE MEDICINE (2) No hemolysis, moderate to active zoning. (Considered "potentially toxic") (3) Hemolysis, no zoning. (Considered "potentially nontoxic") (4) Hemolysis, moderate to active zoning. (Considered "potentially toxic") Source op Staph ylococc us Contamination in Food Poisoning It has been shown that milk obtained from the udders of apparently healthy cows contains varying numbers of organisms, including various strains of the staphylococcus. A number of outbreaks have been investigated wherein the suspected food was found to have been pre pared under generally insanitary conditions, including improperly cleaned equipment, nearby insanitary toilets, excessive handling of the food, numerous flies, and other factors. While human carriers of staphylococci are legion, no attack of this type of food poisoning has been traced to such potential foci of infection as chronic purulent otitis media, chronic tonsillitis, chronic pulmonary disease, osteomy elitis, furunculosis, or other suppurative processes. Contamination of food, other than milk, presumably takes place during manufacturing and cooking processes. It appears that the common modes of con tamination include respiratory droplet infection, handling of food and equipment with contaminated hands, use of previously infected ma terials, improperly cleansed and sterilized equipment, and transfer of organisms by flies and other insects. Prevention of Staphylococcus Food Poisoning in the Navy Adequate supervision of the handling, storage, preparation, and consumption of all foods will reduce the incidence of all types of food poisoning. The absence of flies, roaches, and vermin in commissary spaces is of great importance. Personnel involved in the preparation and serving of food should be educated on this subject with special reference to personal cleanliness and hygiene, the avoidance of han dling food with their hands, proper refrigeration of all foodstuffs, the necessity of thorough and recent cooking, and the importance of promptly reporting all personal illness including skin diseases to the medical officer. In the Naval Establishment, particularly in the general messes of ships afloat, outbreaks of food poisoning have occurred at various times. In such outbreaks there has been noted a fairly uniform and characteristic history and sequence of events. The most common story is that of the preparation of various articles of meat, meat prod ucts, gravies, custards, and various other items with a high protein content, from 6 to 24 or more hours before consumption, with exces sive handling and slow cooling at room temperature in the galley, and neglected refrigeration before being served. The noon meal on Satur day aboard numerous ships will be found to consist of cold boiled ham with vegetable salads or perhaps boiled vegetables. In some instances DIVISION OF PREVENTIVE MEDICINE 313 the ship's cook is allowed to boil the hams for Saturday dinner during the Friday morning watch. Such a practice doubtlessly has a tend ency to make the galley appear more orderly during the regular Saturday morning inspection, but also provides the basis for not in frequent outbreaks of acute gastroenteritis due to the various food poisoning organisms. This is particularly true when the meat it allowed to cool slowly, then handled in the process of removing the bone, and subsequently allowed to remain in a warm atmosphere until served 20 or more hours later. If boiled ham is to be served, it should first be boned, and then placed in the boiler for cooking at such a time that it may be served hot, immediately after having been cooked. If it is desired to serve it cold, the hams should be transferred from the boiler immediately after having been cooked to a refrigerator with a temperature of about 32° F., to remain there until just before meal time, when it may be removed for the necessary slicing. Outbreaks of food poisoning due to infected salads that contain chicken or turkey meat left from a previous meal demonstrates what has been mentioned as excessive handling of food. Frequently such left-overs have not been stored in the chill room, but have been al lowed to remain in some part of the galley where the temperature is favorable to contamination and to the rapid growth of bacteria. This type of meat provides an even better culture medium when it is cut in small pieces and mixed with the various ingredients characteristic of such salads. Experience has long since shown us that hash made from materials cooked on the previous day, is liable to produce an explosive outbreak of vomiting, abdominal cramps, nausea, prostra tion, and diarrhea. It is important to supervise the preparation of box lunches provided rifle-range parties, target-repair parties, picket- boat crews, and other groups that commonly leave their station early in the morning, and do not have the facilities to properly store highly perishable articles of food. The manufacture of custards and custard fillings in the Navy must be given attention to insure the use of fresh materials, properly cleansed and sterilized equipment, adequate cooking, prompt cool ing, avoidance of unnecessary handling, and other possible sources of contamination, and the adequate storage of the finished product under refrigeration with early consumption. These same precautions also apply to the local manufacture of ice cream. Due to their highly perishable nature and the frequency with which they are involved in outbreaks of food poisoning of varying mag nitude, the source of commercially produced bakery goods, including items with cream or custard fillings, all types of sandwiches, and ice cream, should be investigated and their sale in the ship's service stores regulated by competent medical authority. 314 DIVISION OF PREVENTIVE MEDICINE Report on an Outbreak On December 12, 1936, while at anchor at San Pedro, Calif., an outbreak of acute gastroenteritis occurred aboard the U. S. S. Arizona involving 124 members of the ship's company. All individuals that applied for treatment gave a history of eating cold boiled ham for dinner aboard the ship on the day of the outbreak. The onset of symptoms was sudden, between 2% and 3J-2 hours after ingestion of the suspected ham, and was characterized by adbominal cramps followed by nausea and vomiting. Prostration was marked, and an occasional man suffered with severe cramps in the flexor muscles of the legs. Although the symptoms of gastroenteritis were violent in the majority of cases, except for some weakness, all but two men were well within a period of about 8 hours. Two individuals vomited frequently and passed watery stools repeatedly for about 24 hours, fol lowed by marked weakness which gradually subsided on the third day. Treat ment consisted of saline catharsis, camphorated tincture of opium, bed rest, external heat, and bland diet, depending upon the severity of symptoms. Laboratory study: 1. Suspected ham: Under sterile precautions, specimens of meat were obtained from a whole ham immediately after the onset of the outbreak. Samples of ham were examined in the laboratories of the city of Long Beach, Calif., using Stone's differential medium. Colonies of a food poisoning type of hemolytic staphylococ cus aureus were obtained. Colonies of this staphylococcus were transplanted from Stone's medium to broth, which in turn was fed to a kitten, producing an acute diarrhea in approximately 3 hours. 2. Stool examination: Cultures from stool specimens obtained from two cases with severe symptoms were reported negative for food poisoning organisms of the salmonella group. 3. Serum agglutination tests: Serum agglutination tests made on sera obtained from two cases of marked severity were reported positive in dilutions as follows: Case 1 Case 2 Serum ob Serum ob Serum ob Serum ob tained 8 tained M tained 6 tained 14 days after days after days after attack days after attack attack attack E. typhi 1:32 1:20 1:64 1:20 1:16 1:20 1:16 1:10 S. schottmulleri 1:16 1:10 1:16 1:20 Facts regarding the suspected ham: The suspected hams were purchased under contract No. N 244 S 1935-6, and were received on board ship in acceptable con dition on December 1, 1936. This shipment totaled 1,906 pounds, and was composed of sweet-pickle cured hams, type 1, regular or short cut, grade No. 2. Although these hams were of the "cured" variety, upon receipt aboard ship they were placed in a cold storage room, the temperature of which is maintained between 14° and 22° F. At 3 p. in. on December 10, 1936, about 500 pounds of this ham were removed from cold storage anil placed in the butcher shop adjacent to the galley for thawing. On December 11, 1936, these hams were boiled from 9 a. m. to 1 p. m., then allowed to cool until about 3 p. in., at which time they were boned and placed in open pans on gratings in a passageway adjacent to the galley, where they reamined until about 10 a. m. on the following day, December 12, at which time they were returned to the galley for slicing and were served to the general mess at noon of that date. DIVISION OF PREVENTIVE MEDICINE 315 Interview of the personnel involved in the boiling, boning, slicing, and handling of this ham revealed no instance of diarrhea, upper respiratory tract infection, furnnculosis, boils, or other presumptive source of staphylococcus infection Flies were not present in the galley, but occasional cockroaches had been noted. In addition to the general mess, all special messes of the ship served ham ob tained from the same lot on the same day of the outbreak, although they were cooked in different galleys, and were handled in a somewhat different manner. The hams used by the wardroom mess, junior officers' mess, and chief petty officers' mess were boiled on December 11, but were again baked on December 12, before being served. The hams used in the warrant officers' mess also boiled on December 11, were placed in a refrigerator until served at noon of the following day. No individual who ate ham in any of these special messes suffered from symptoms of food poisoning. The remaining portion of the specified shipment of ham was consumed in the general mess during the subsequent 3 weeks at approximately 500 pounds per week, without untoward symptoms. Summary 1 . Staphylococci are frequently the causative organism in outbreaks of food poisoning and in isolated cases of acute gastroenteritis. Prac tically any food may be infected with staphylococci, although such infection ordinarily causes no change in the appearance, odor, or flavor of the food. Fresh milk, custards, and unrefrigerated cooked meats are frequently incriminated. 2. Differences between staphylococcus type and salmonella type of food poisoning include: (a) Incubation period in staphylococcus food poisoning is between 2 and 4 hours as a rule, while in salmonella infection the period of incubation is commonly 6 to 12 hours. (6) From the staphylococci isolated from that type of food poisoning may be obtained a bacteria-free filtrate, which when swallowed by human volunteers reproduces the symptoms of an acute gastroen teritis. Bacteria-free filtrates from salmonella cultures have been fed in large amounts to humans without producing any symptoms. 3. Only certain strains of staphylococci are capable of producing an enterotoxic substance and this characteristic is not entirely constant in any one strain. Staphylococcus enterotoxin is neutralized when added to gastric juice with a slightly acid reaction, suggesting one of the possible causes of the infrequency of this type of food poisoning in relation to the widespread presence of this organism. 4. A detailed quotation of Stone's cultural method of differentiating the enterotoxic and the nonenterotoxic strains of staphylococci is given. 5. The source of infection in this type of food poisoning is generally unknown, although respiratory droplet infection, contact with hands or objects contaminated with the discharges from various suppurative processes, and the transfer of organisms by flies and other insects have been implicated. Staphylococci have appeared in large numbers in the milk from apparently healthy cows. 316 DIVISION OF PREVENTIVE MEDICINE 6. The watchwords in the prevention of staphylococcus food poisoning are cleanliness and freshness of all foods, thorough cooking with a minimum amount of subsequent handling, pasteurization of milk, and the careful protection and refrigeration of all foodstuffs. 7. An outbreak of food poisoning due to ham, which was found by cultural and feeding tests to have been infected with a hemolytic Staphylococcus aureus, is reported. Bibliography (1) Barbeb, M. A. Philippine J. Sec, 9: 515,- 1914. (2) Dack, G. M., Carey, W. E., Woolpert, 0., and Wiggers, H. J. Prev. Med., 4: 167, 1930. (3) Jordan, E. O. J. A. M. A., 94: 1648, 1930. (4) Ramsey, R. J., and Tracy, P. H. Proc. Soc. Exper. Biol. & Med., 28: 390, 1931. (5) Jordan, E. 0., and Hall, J. R. J. Prev. Med., 5: 387, 1931. (6) Jordan, E. O. J. A. M. A., 97: 1704, 1931. (7) Tanner, F. W., and Ramsey, R. J. Am. J. M. Sc., 184: 80, 1932. (8) McBurney, R. J. A. M. A., 100: 1999, 1933. (9) Jordan, E. O., and Burrows, W. Am. J. Hyg., 20: 604, 1934. (10) Crabtree, J. A., and Litterkr, W. Am. J. P. H., 24: 1116, 1934. (//) Corpening, A., and Fqxhall, E. P. Am. J. P. H., 25: 938, 1935. (12) Geiger, J. C., Crowley, A. B., and Gray, J. P. J. A. M. A., 105: 1980, 1935. (13) Dack, G. M., Bowman, G. W., and Harger, R. H. J. A. M. A., 105: 1598, 1935. (14) Denison, G. A. Am. J. P. H., 26: 1168, 1936. (15) Shaughnessy, H. J., and Gruhk, T. C. J. Infect. Dis., 58: 318, 1936. (16) Geiger, J. C. Public Health Reports, 52: 765, 1937. (17) U. S. Naval Med. Bul., 35: 148, 1937. (18) Kelly, F. C, and Dack, G. M. Am. J. P. H., 26: 1077, 1936. (19) Dack, G. M., Carey, W. E., and Harmon, P. H. J. Prev. Med., 2 : 479, 1928. (20) Dolman, C. E. J. Infect. Dis., 55: 172, 1934. (21) Jordan, E. O., and Burrows, W. J. Infect. Dis., 57: 121, 1935. (22) Woolpert, O. C, and Dack, G. M. J. Infect. Dis., 52: 6, 1933. (23) Borthwiok, G. R. Brit. J. Exper. Path., 14: 236, 1933. (24) Stritar, J., and Jordan, E. O. J. Infect. Dis., 56: 1, 1935. (25) Stone, R. V. Proc. Soc. Exper. Biol. & Med., 33: 185, 1935. (16) Bacto-Stqnk's Extract Gelatin Agar, Difco Laboratories, Detroit. Mich. FOOD POISONING, UNITED STATES NAVAL STATION, GUANTANAMO BAY, CUBA By Commander C. \V. D. Smill. Medical Corps, United States Navy On August 12, 1937, an outbreak of food poisoning occurred among men subsisted at the receiving barracks branch of the general mess of this station. The suspected food was corned-beef hash served for breakfast on that day. Members of no other mess were affected. The menu in that mess was as follows: Fresh milk and cereal, corned-beef hash, catsup, hot cakes and sirup and coffee. The hash was prepared in the following DIVISION OF PREVENTIVE MEDICINE 317 manner: 12 pounds of potatoes were boiled at 1600, August 11, and placed in the refrigerator overnight. At 0530, August 12, the hash was prepared from one 6-pound can of issue corned beef which appeared intact and the contents of which presented no unusual features to the cook on duty; 12 pounds of potatoes prepared as shown above; four fresh onions (U. S.) ; two 2-pound cans of tomatoes which appeared normal in all respects; Yi pint of Navy issue catsup. The hash was baked for 1 hour in an oven temperature of 350° to 400° F. and served over a period from 0650 to 0830. There was about half of a platter of hash left over at the conclusion of the meal, but, by the time patients began to report for treatment, this had been collected with the garbage and consumed by the hogs. It was therefore impossible to secure samples of the suspected food. Out of a total of 55 men who ate breakfast in that mess on August 12, 20 reported as having eaten the hash in varying amounts. Of these 20, 16 were admitted to the dispensary for treatment, and while there was considerable variation in the other articles of food consumed at the meal, all 16 ate the hash. The earliest appearance of symptoms was recorded as 0930 and the latest 1200. Those report ing early appearance and greatest violence of symptoms were quite consistently those who consumed the greater amounts of hash. Of general clinical features the following figures were obtained from the 16 men admitted for treatment: Chills 6 Bitter taste 13 Fever 12 Vomiting 12 Headache 9 Diarrhea 15 Faintness 13 Treatment given was symptomatic, eliminative, and supportive. One man who had eaten considerable amounts of the hash developed alarming symptoms of collapse but responded promptly to appropriate treatment. Two men lost suffi cient fluid to require intravenous normal saline for the relief of severe muscle cramps. All patients were sufficiently recovered to be able to resume their duties early the following morning and were consequently carried on the binnacle list for August 12. Although a sample of the suspected food could not be obtained, cultures were made on similar cans of ingredients in the galley. All were negative. Numerous cultures of vomitus and stools were made in nutrient broth and on plates of Endo's Media but all were negative. The epidemiological features and clinical aspects of the outbreak, however, were considered consistent with an infection by Sal monella enteritidis. Agglutination reactions done August 18, 6 days after the outbreak, on the three patients who were most severely affected gave results as follows: From all data obtained, the following conclusions are drawn: 1. The contaminated food was corned-beef hash. 2. The causative organism was Salmonella enteritidis. 3. There was no direct evidence of contamination of any particular ingredient of the hash, but suspicion falls strongly on the corned beef. 4. There were no irregularities in the method of preparation of the Case No. 1.. Salmonella enteritidis positive agglutination. Case No. 2 do Case No. 3 do Dilution 1-640 1-320 1-320 hash. 45202—38 11 STATISTICS HEALTH OF THE NAVY The following tables are summaries of morbidity rates per 1,000 for the third quarter of 1937 in comparison with rates for the correspond ing quarter of the preceding 5 years: ENTIRE NAVY Year 1932. 1933. 1934. 1935. 1936. 1937. All dis- 549 .101 51(1 373 33R 377 Injuries Poison ings 0. 63 7. ID 4.28 .29 7.18 .40 All causes (Ki4 47f1 580 420 41M 4311 Communicable diseases (0 hi; 120 92 88 101 FORCES ASHORE 544 85 0.93 629 Cl (') 107 1933 382 74 10.81 468 7 66 72 637 91 1.35 730 31 181 64 1935 426 57 .20 484 14 127 43 416 60 19.19 486 29 120 38 1937 508 63 .50 571 31 168 37 FORCES AFLOAT 1932 552 37 0.45 590 (0 (') 159 414 61 5.32 481 10 95 136 1934 44P 53 5.69 507 16 91 125 1935 343 51 27 395 11 72 92 1936 291 66 !so 357 21 70 55 1937 302 60 .43 362 13 63 72 ' Not available. Common infectious diseases of the respiratory type. —There were 2,406 admissions for these diseases reported from the entire Navy for the third quarter of the year 1937 — 1,214 from forces afloat, 1,043 from shore stations in the United States, and 149 from foreign shore stations. Catarrhal fever was responsible for 1,626 of the admissions. 319 320 STATISTICS Ships and shore stations reporting the largest number of cases were as follows: July 1 August September Tota Naval Traming Station, San Diego, Calif. Naval Training Station, Newport, R. I. . . Naval Training Station, Norfolk, Va Biigade Hospital, Shanghai, China Marine Barracks, Quantico, Va. Naval Training Station, Great Lakes, Hi ll. S. S. Tcnntstte U. S. S. Sara/osa (fleet air detachment) U. S. S. Ranger Marine Corps Base, San TMego, Calif Fleet Air Base, Pearl Harbor, Hawaii 2M is: 121 >.? 84 SI SI Mumps. —The U. S. S. West Virginia reported 39 cases of mumps during the quarter, 12 in July, 19 in August, and 8 in September; the U. S. S. Tennessee, 2 in July, 12 in August, and 5 in September; and the Naval Training Station, Norfolk, Va., 6 in July, 12 in August, and 1 in September. Chickenpox. —Eight cases of chickenpox were reported for the quarter, as follows: In July, 1 each from the U. S. S. Idaho, U. S. S. Medusa, U. S. S. Oklahoma, and the Submarine Squadron No. 4; and in August, 2 from the U. S. S. Detroit, 1 from the U. S. S. Pensacola, and 1 from the U. S. S. Smith. Cerebrospinal fever.—Two cases of cerebrospinal fever were reported for the quarter. An apprentice seaman, 19 years of age, with 4 months' service, was transferred from the U. S. S. Tuscaloosa on August 13, 1937. No disposition has been made of this case at the end of the third quarter. A midshipman first class, 20 years of age, was transferred from the U. S. S. New York to the Norfolk Naval Hospital, Portsmouth, Va., on August 13, and discharged from the sick list on September 4, 1937. Typhoid and paratyphoid fevers.—A moderately severe case of typhoid fever (a fireman, first class, 26 years of age, with 7 years and 9 months' service) was admitted to the sick list at the Naval Proving Ground, Dahlgren, Va., on September 23, 1937, and transferred to the Naval Hospital, Washington, D. C. Two courses of straight typhoid vaccine had been completed in January 1930 and March 1935. The questionnaire in this case states: Place and source of infection unknown. There had been an epidemic of typhoid fever in the county and the patient had been drinking questionable water. Relative to the incidence of typhoid fever in this section of Vir ginia, the medical officer of the Naval Proving Ground, Dahlgren, Va., under date of August 3, 1937, reports as follows: During the past 2 weeks, an epidemic of typhoid fever has occurred in King George County, Va. It was first reported to this office by a member of the county board of health on July 27, 1937. As closely as could be estimated, there are 27 cases * * * all about 15 miles distant from this station. STATISTICS 321 One mild case of paratyphoid fever B, without complication, was admitted to the sick list from the Marine detachment, American Embassy, Peiping, China, in July. A course of typhoid vaccine had been completed in December 1935. Poliomyelitis, anterior, acute. —One case of poliomyelitis occurred in an enlisted man while on leave from the United States Naval Air Station, San Diego, Calif. The senior medical officer of the Naval Training Station, Great Lakes, 11l., reports that "he is being carried at this station while a patient in the United States Army Hospital, Fort Leavenworth, Kans." During the month of September 1937, three cases of poliomyelitis, anterior, acute, occurred in one company on the Naval Training Station, San Diego, Calif . The first case was admitted on September 8 and transferred to the hospital on September 11 where diagnosis was confirmed. The swimming pool was closed; the entire company and company commanders were placed in strict quarantine; separate messing facilities were provided; members of the company were ex amined by a medical officer twice daily, and a nasal spray given daily for 3 successive days and weekly for the following 2 weeks; contacts were placed in quarantine; all bedding was aired and sunned daily; and the men were encouraged to restrict close or intimate contact with each other. On September 13, the day quarantine was established, another member of this company complained of general malaise and symptoms of a common cold. A complete physical examination at this time by the medical officer of the day showed normal reflexes and no symptoms other than those indicated above. He was transferred to the hospital and diagnosis of poliomyelitis was established. He developed paralysis of the muscles of deglutition, then of the deltoids, and later of the muscles of respiration, and died on September 16. The third case was transferred to hospital on September 15. The patient complained of nausea and general malaise and later developed stiffness of the lumbar muscles. In summarizing, the medical officer reported as follows: 1. Three cases of poliomyelitis were found in one company of recruits containing 97 men. 2. The source of infection points to San Diego and vicinity where 39 cases have been reported during the last 3 months. 3. The value of the preventive measures employed is not known. Scarlet fever.—One case was reported in July by the U. S. S. West Virginia and one case in August by the Naval Training Station, San Diego, Calif. Diphtheria.—In July, a private, Marine Corps, 25 years of age, with 2 years and 1 1 months' service, was admitted to the sick list with diphtheria from the Marine detachment, American Embassy, Peiping, China. He was discharged to duty after 8 sick days. 322 STATISTICS INJURIES AND POISONINGS Admissions Fob Third Quarter Ending September 30, 1937 The following table, indicating the frequency of occurrence of accidental injuries and poisonings in the Navy during the third quarter, 1937, is based upon all Form F cards covering admissions in those months which have reached the Bureau: Admissions, Admission Admission July, August, rate per rate per and Septem 100,000,per annum 100,000,year ber. 1937 1937 INJURIE" Connected with work or drill 744 2,264 2,513 Occurring within command but not associated with work 544 1.960 1.924 Incurred on leave or liberty or while absent without leave 615 1,872 1.760 All injuries 2.003 6,006 6. 197 POI"ONING" Industrial poisoning 2 6 7 Occurring within command but not connected with work 9 27 211 Associated with leave, liberty, or absence without leave 4 12 18 15 46 236 2,018 6.142 6,434 PERCENTAGE RELATIONSHIPS Connected with the performance of work, drill, etc. Occurring within command Not connected with work or pre scribed duty Occurring out side command — leave, liberty, or A. W. O. t. July, Au gust, and September, 1937 July, Au gust, and September, 1937 July, Au gust, and September, 1937 Year 1936 Year 1936 Year 1936 Percent of all injuries 37.1 40.6 32.2 31.0 30.7 28.4 Percent of all poisonings 13.3 3.0 60.0 89.5 26.7 7.5 Percent of total admissions, injury and poisoning titles 37.0 39.2 32.3 33.2 30.7 27.6 Note.— Poisoning by a narcotic drug or by ethyl alcohol is recorded under the title "Drug addiction' "alcoholism," as the case may be. Such cases are not included in the above figures. MORBIDITY Summary for the Third Quarter Ending September 30, 1937 Forces afloat, 83,195 Forces ashore, 48,238 Entire navy, 131,433 Admis Rate per Admis Rate per Admis Rate per sions 1,000 sions 1,000 sions 1,000 7,532 362.14 6,884 570.84 14.416 438.73 6,275 301.70 6, 123 507.73 12.39S 377.32 1,248 60.00 755 62.61 2,003 60.96 Communicable diseases transmissible by 9 .43 6 .50 15 .46 oral and nasal discharges (class VI11): (A) 272 13.08 370 30.68 642 19.54 (B) 1,300 62.50 2,026 168.00 3,326 101.22 1,495 71.88 445 36.90 1,940 59.04 STATISTICS DEATHS Durino the Third Quarter Ending September 30, 1937 Cause Navy Marine Corps Nurse Corps Total Primary Secondary or contributory Offi cers Mid ship men Men Offi cers Men Average strength. 9,813 2,190 100,651 1,335 17,045 MM 131,433 DISEASE Abscess, intra-abdominal Peritonitis, general, acute. 1 1 1 Addison's disease 1 Alcoholism, acute . Exhaustion from over exertion. None 1 Appendicitis, acute 1 Do.. Obstruction, intestinal, from spastic or para lytic causes. 1 1 Do Peritonitis, general, acute. Arteriosclerosis, general Heart block 1 1 Carcinoma: Lung. None Pancreas . - do 1 1 1 Cellulitis, face Embolism, mesenteric ar tery- Endocarditis, suhacute Varicocele, leg None. - 1 i do Hodgkin's disease do 1 1 1 1 Leukemia ...do Myocarditis, chronic Arteriosclerosis, general. Otitis media, chronic Pneumonia, lohar None 1 Poliomyelitis, anterior, acute Thermic fever (therapeutic). . do 1 1 Oonococcus Infection, joint. None . 1 Thrombosis, coronary ...do i l Do Arteriosclerosis, general. Tonsilitis, chronic Abscess, lung Tuberculosis, pulmonary, chronic. Do None. - 2 1 l Tumor, malignant, mixed, (adenocarcinoma) stomach Meningitis, cerebrospi nal, acute. None i do 1 Sarcoma, thymus, heart and do 1 1 pericardium. Ulcer, stomach.. Atelectasis 5 21 6 1 33 INJURIES AND POISONINOS Burn, entire body (steam).. None .. .- 1 1 1 1 17 1 6 1 do Drowning do 3 1 1 12 2 Fracture, compound, frontal. do Fracture, compound, skull ...do .. 4 1 Fracture, compound, femur— Fracture, compound, ribs — Hemorrhage, traumatic, 1 Fracture, compound, tem poral. femoral artery. Hemorrhage, pulmonary 1 1 1 1 2 Fracture near joint with dis location, cervical vertebrae. Fracture simple, hyoid Intraspinal Injury 1 1 Fracture, simple, occipital.. Fracture simple skull None 1 1I 1 1 1I 1 Do Intracranial injury 1 Fracture, simple, vertebrne, None . ... 1 cervical. Injuries, multiple, extreme do 8 1 9 3 20 1 Aerogenes capsulatus Infection, ankle. 324 STATISTICS During the Third Quarter Ending September 30, 1937 — Continued Cause Navy Marino Corps Nurse Corps Primary Secondary or contributory Offi cers Mid ship men Men Offi cers Men Total INJURIES AND POI SONINGS— Continued Intracranial injury None 2 2 2 Intraspinal injury do 1 3 Rupture, traumatic, liver do Rupture, traumatic, lung-... Sunstroke Emphsyema, traumatic, mediastinum. None Strangulation, neck do I 1 Wound, gunshot, chest do Do Hemorrhage, traumatic, Wound, gunshot, heart axillary artery. None Wound, gunshot, head do 1 Wound, lacerated, abdomen . do Wound, lacerated, perineum Poisoning, acute, sulphani- lamide. do Total for injuries and poisonings. Agranulocytosis and gon- ococcus infection. I5 40 14 75 Orand total. 20 67 211 1 108 Annual death rate per 1,000: All diseases. 8.15 2.04 1.22 2.06 .83 .48 .04 4.69 1.41 .47 10.03 10.03 3.29 1.00 .52 Disease only. . Poisoning Other injuries 4.89 1.31 2.83 MENTAL AND PHYSICAL QUALIFICATIONS OF RECRUITS Statistics for Third Quarter Ending September 30, 1937 The following statistics were taken from sanitary reports submitted by naval training stations : United States naval training station July, August, and September 1937 Norfolk, Newport, Great San Diego, Va. R.I. Lakes, 1ll. Calif. Recruits received during the period. -. 983 745 851 1,274 Recruits appearing before Board of Medical Survey 6 0 7 0 Recruits recommended for discharge from the service... 6 0 7 0 Recruits discharged by reason of medical survey 4 0 (') 0 Recruits held over pending further observation. 0 3 0) 0 Recruits transferred to the hospital for treatment, opera tion, or further observation for conditions existing 0 20 58 56 1Not reported. The following table was prepared from reports of medical surveys in which disabilities or disease causing the surveys were noted existing prior to enlistment. With certain diseases, survey followed enlist ment so rapidly that it would seem that many might have been elimi nated in the recruiting office. STATISTICS 325 Cause of survey , periapical Absence, acquired, teeth. Acne, chronic Adhesions (intestinal) Adhesions, right leg Amblyopia Ankylosis, tarsal, metatarsal, and ankle joints - Arterial hypertension ill.il iti:. . Astigmatism. Atrophy, muscle. Bronchitis, chi Caries, teeth.. Cholecystitis, Cicatrix, skin Colitis, chronic Congenital heart disease Constitutional psychopathic inferiority, without psychosis Constitutional psychopathic state, emo tional instability Constitutional psychopathic state, Inade quate personality Constitutional psychopathic state, para noid personality Deafness, unilateral Defective physical development Deformity, acquired, left shoulder Deformity, acquired, loss of flexion, finger. Deformity, acquired, right femur (old fracture) Deformity, acquired, left ankle (old frac ture) Num ber of surveys Cause of survey Dysinsulinism Effort syndrome Enuresis Epilepsy Flat foot Goiter, exophthalmic Glycosuria - Hemorrhoids Malformation, congenital Malocclusion, teeth M igraine Myopia - Xepiiritis, chronic Neurosis, traumatic Otitis, me'lia, chronic Perforated nasal septum Pes cavus - Pollomyol.tis, anterior, chronic Prostatitis, chronic (non venereal) Psychoneurosis, hysteria Psychoneurosis. neurasthenia — Rhiniti-, atrophic Somnambulism Stammering- Strabismus - Syphilis Trichophytosis Tuberculosis, pulmonary, chronic, active, moderately advanced- Union of fracture, faulty Valvular heart disease, mitral insufficien cy Valvular heart disease, mitral stenosis — Varicocele Num ber of 27 o United States Naval Medical Bulletin Published for the Information of the Medical Department of the Navy THE MISSION OF THE MEDICAL CORPS OF THE NAVY • KEEP AS MANY MEN AT AS MANY GUNS AS MANY DAYS AS POSSIBLE Issued Quarterly by the Bureau of Medicine and Surgery Washington, D. C. Vol. XXXVI JULY 1938 No. 3 UNITED STATES NAVAL MEDICAL BULLETIN Published Quarterly for the Information of the Medical Department of the Navy Issued by DIVISION OF PUBLICATIONS THE:BUREAlT OF MEDICINE AND SURGERY NAVY DEPARTMENT Compiled and published under the authority of Naval Appropriation Act for 1937-38, approved April 27. 1937 UNITED STATES GOVERNMENT PRINTING OFFICE WASHINGTON: !938 For sale by the Superintendent of Documents, Washington, D. C. See page II for price Navy Department, . Washington, March 20, 1907. This United States Naval Medical Bulletin is published by direction of the Department for the timely information of the Medi cal and Hospital Corps of the Navy. Truman H. Newberry, Acting Secretary. Owing to exhaustion of certain numbers of the Bulletin and the frequent demands from libraries, etc., for copies to complete their files, the return of any of the following issues will be greatly appreciated : Volume IX, 1915, No. 1. Volume X, 1916, No. 2. Volume XI, 1917, No. 3. Volume XII, 1918, Nos. 1 and 3. Volume XXIV, 1926, Nos. 1 and 4. Volume XXV, 1927, No. 1. Volume XXVII, 1929, Nos. 3 and 4. Volume XXVIII, 1930, No. 3. Volume XXXIV, 1936, Nos. 1, 2, and 4. Volume XXXV, 1937, No. 1. Subscription Pbice of the Bulletin Subscription should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. Yearly subscription, beginning July 1, $1 : for foreign subscriptions add 33 cents for postage. Single numbers, domestic, 25 cents ; foreign, 35 cents, which includes foreign postage. Exchange of publications will be extended to medical scientific organizations, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy, Washington, D. C. TABLE OF CONTENTS Page PREFACE T NOTICE TO SERVICE CONTRIBUTORS vi SPECIAL ARTICLE: Field Sanitation. By Capt. W. L. Mann, Medical Corps, United States Navy 327 NAVAL RESERVE 413 NOTES AND COMMENTS: The Fourteenth Surgeon General, United States Navy—Yellow Fever —Observations on Burns Due to Explosion —Commendation — The New York Academy of Medicine Graduate Fortnight—The American Board of Radiology- — American College of Hospital Administrators — New Naval Medical Center —Committee to Study Serodiagnostic Tests for Syphilis 415 BOOK NOTICES: Practical Tropical Sanitation, Kirk —Organization, Strategy, and Tactics of the Army Medical Services in War, Nicholls 423 PREVENTIVE MEDICINE: The Effect of the Age of Neoarsphenaxtine on Reaction Ex pectancy. By Commander C. S. Stephenson, Medical Corps, United States Navy, Associate Pharmacologist T. F. Probey, and Senior Surg. W. T. Harrison, United States Public Health Service. . . 425 The Effect of Moisture and Age on Stability of Neoarsphen- amine. By Associate Pharmacologist T. F. Probey, and Senior Surg. W. T. Harrison, United States Public Health Service, Washington, D. C 429 Insecticidal Powders, a Comparative Study. By Commander F. S. Johnson, Medical Corps, United States Navy, with the technical assistance of Pharmacist's Mate First Class A. G. Vallee, United States Navy 435 A Presumptive Test for the Potency of Cow-Pox Virus. By Lt. Comdr. J. B. Moloney, Medical Corps, United States Navy 445 STATISTICS: Health of the Navy 447 Injuries and Poisonings 450 Morbidity 451 Deaths 452 Mental and Physical Qualification of Recruits 453 Ul PREFACE The United States Naval Medical Bulletin was first issued in April 1907 as a means for supplying medical officers of the United States Navy with information regarding the advances which are continually being made in the medical sciences, and as a medium for the publication of accounts of special researches, observations, or experiences of individual medical officers. It is the aim of the Bureau of Medicine and Surgery to furnish in each issue special articles relating to naval medicine, descriptions of suggested devices, clinical notes on interesting cases, editorial com ment on current medical literature of special professional interest to the naval medical officer, and reports from various sources, notes, and comments on topics of medical interest. The Bureau extends an invitation to all medical and dental officers to prepare and forward, with a view to publication, contributions on subjects of interest to naval medical officers. In order that each service contributor may receive due credit for his efforts in preparing matter for the Bulletin of distinct origi nality and special merit, the Surgeon General of the Navy will send a letter of appreciation to authors of papers of outstanding merit. The Bureau does not necessarily undertake to endorse views or opinions which may be expressed in the pages of this publication. P. S. Rossiter, Surgeon General, United States Navy. IV NOTICE TO SERVICE CONTRIBUTORS Contributions to the Bulletin should be typewritten, double spaced, on plain paper, and should have wide margins. Fasteners which will not tear the paper when removed should be used. Nothing should be written in the manuscript which is not intended for publication. For example, addresses, dates, etc., not a part of the article, require deletion by the editor. The Bulletin endeavors to follow a uniform style in heading and captions, and the editor can be spared much time and trouble, and unnecessary changes in manuscript can be obviated If authors will follow in these particulars the practice of recent issues. The greatest accuracy and fullness should be employed in all citations, as it has sometimes been necessary to decline articles otherwise desirable because it was impossible for the editor to understand or verify references, quotations, etc. The frequency of gross errors in orthography in many contributions is conclu sive evidence that authors often fail to read over their manuscripts after they have been typewritten. Contributions must be received at least 3 months prior to the date of the issue for which they are intended. The editor is not responsible for the safe return of manuscripts and pictures. All materials supplied for illustrations, if not original, should be accompanied by reference to the source and a statement as to whether or not reproduction has been authorized. The Bulletin Intends to print only original articles, translations, in whole or in part, reviews, and reports and notices of Government or departmental activi ties, official announcements, etc. All original contributions are accepted on the assumption that they have not appeared previously and are not to be reprinted elsewhere without an understanding to that effect and that editorial privilege is granted to this Bureau in preparing all material submitted for publication. Eben E. Smith, Editor, Commander, Medical Corps, United States NavV. v U. S. NAVAL MEDICAL BULLETIN Vol. XXXVI July 1938 No. 3 SPECIAL ARTICLE HELD SANITATION 1 By Captain W. L. Mann, Medical Corps, United States Navy. Health is necessary in war, and cannot be replaced by anything else —Napoleon IHTBODUCTION One of the prime requisites for victory is health. An army to fight has figuratively and literally to "take the field," consequently field hygiene and sanitation is one of the most important subjects for military sanitarians, because the laws of preventive medicine are then made applicable to war as a matter of military economics and this adaptability to wartime conditions is the supreme test of all military efficiency. The functions of a military medical organization may be roughly divided into (a) prevention of disease and (b) treatment of disease and injury. Prevention of disease is of vast importance to the mili tary personnel, and this function only will be considered in this article. To a well informed person, the laws of field sanitation may appear so elementary that a study of them would seem unnecessary and probably a waste of time, but when one stops to consider, for example, that the simple measure of mosquito control alone made the building of the Panama Canal possible, one may obtain a slight idea of the vast economic importance of such a preventive measure. It has been stated that in the construction of the 28-mile railroad across the Panama Isthmus, the number of wooden railroad ties approximated 1 Author's Note. —The major portion of this information was originally prepared for instruction purposes at the Marine Corps Schools, Marine Barracks, Quantlco, Virginia. The writer wishes to acknowledge the assistance received from Lieutenant H. E. Olllesple, Medical Corps, United States Navy, and Chief Pharmacist R. N. Cheetham, United States Navy, in the compilation of these data. Editor's Note. —This article presents the author's prolonged experience and extensive research in a Held which has been his primary service interest. It is a major revision of material published by the Bulletin in 1023 which has since served as an authoritative reference and is particularly valuable in that it presents a compilation of Information relatively inaccessible to naval medical officers. This material is based on experience gained by medical officers on field service. Much credit is due and is extended with appreciation to the medical services of the U. S. Army and His Majesties medical officers serving with the British Army for the wealth of information on military medicine they have made available. 327 328 FIELD SANITATION MANN the number of men dying from malaria and yellow fever, diseases transmitted by the mosquito. In other words a death resulted for every few feet of construction. It is not improbable that the World War would have been terminated by epidemic diseases in the second year had not certain, apparently simple, sanitary measures of waste disposal been observed. The care of the feet and shoe fitting consti tute other simple field measures that assume great magnitude from a military standpoint. At least 25 percent of a marching command may suffer from foot injuries, and the European Armies estimate 10 percent of the marching army will be incapacitated from "sore" feet when an army first takes the field. Tact and a certain amount of technical ability are necessary quali fications for a successful sanitarian. Sanitation is so closely inter related with cleanliness that the major portion of the duty of a sani tation officer consists in the supervision of cleanliness. To induce other individuals to maintain their persons and premises in a clean condition, without arousing a certain amount of friction and antagonism, is not always an easy matter, hence the modus oper andi should depend upon the circumstances. As a rule friction is exceedingly rare and there is complete cooperation of the combatant forces in enforcing all necessary sanitary recommendations. How ever, if cooperation is not as prompt as desired, there should be no quibbling over details, but a receptive attitude should be cultivated. The majority of the functions of the sanitation officer are considered purely advisory, and here his responsibility ceases. As a general rule sanitary recommendations should be reduced to a minimum and should be concise as possible. All recommendations should be carefully considered, and those which are not of essential importance should be omitted. If practicable, preface sanitary recommendations with an explanation, as commanding officers usually desire to know the reasons for promulgating orders and placing restrictions on personnel. Preventive medicine is not an exact science nor is it possible to obtain 100 percent efficiency. However, if by careful attention to the minor details the sanitation officer is able to increase military efficiency from 96 percent to 98 percent, he has not gained a mere increase of 2 percent as it may seem, but has effected a gain of 50 percent —that is, the noneffective rate has been reduced from 4 per cent to 2 percent. It is this little difference which sometimes may be the deciding factor between victory and defeat. Field sanitation contrasted with sanitation of garrisons. —The differences between field sanitation and sanitation of garrisons are marked. WAR AND BIOLOGY 329 1. Field sanitation is easier to institute. For example, the devices used for the disposal of waste are of simple construction, whereas the installation of a water-carriage sewerage system requires more expert engineering knowledge, takes longer to construct, and by reason of its permanent nature is more expensive. 2. Constant vigilance is required to maintain field sanitary devices in proper sanitary condition. 3. Field sanitary appliances are a potential menace, if not properly maintained. In established garrison life, with water-carriage waste disposal, an adequate and potable water supply, permanent housing facilities, protective screening for insect control, and similar modern develop ments, the duties of the sanitation officer are comparatively simple and more or less routine. In the field, the conditions are such that the field sanitary devices require constant and painstaking personal super vision from both the line and the medical officers in order that there may not be a weak link in the chain of sanitary measures. Barracks life may give us comparatively little concern, but when ,we take the field, vigorous sanitary measures must be instituted and maintained and, if possible, improved from day to day. The commanding officer of an organization is responsible for the health of his command and the enforcement of sanitary measures. The British Field Service Regulations state: "Every officer is re sponsible that all orders affecting the health of an army are rigidly carried out by the troops under his command. Neglect of sanitary precautions inevitably results in great loss of life and efficiency." The regulations of United States Army and United States Navy are equally explicit on this subject. The medical department acts in an advisory capacity. The medi cal officer is charged with the initiative in making necessary recom mendations to the commanding officer tending to the promotion of health and prevention of disease. For instance, the medical officer should recommend the type, number, and regulation of sanitary devices, but the responsibility for the actual construction and the maintenance of the same in a sanitary condition rests with the respec tive unit commanders. Likewise the collecting company of the med ical battalion exercises supervision over sanitation, but the latrines, urinals, incinerators, etc., should be constructed by a detail from other units. War and biology.—Almost without exception, it is characteristic of all animal life to be gregarious. As density of congregation in creases, natural laws tend to limit excessive multiplication by the reaction of infectious and autogenous toxic products upon the mass. 330 FIELD SANITATION —MANN Otherwise any species, increasing as it does by geometrical progres sion, would in a short period of time, relatively speaking, tend to inhabit the earth to the exclusion of all other species. There is a constant combat of species for existence, each species exists in its own little niche, and excessive multiplication tends to be limited by other species. In order to demonstrate the excessive productiveness of a single species, a biologist has computed the unrestricted fecundity of the elephant, the slowest propagating mammal. This authority claims that if a pair of elephants were allowed to multiply under optimum and unrestricted conditions for 2,000 years, there would not be stand ing room in the world for their descendants. If we assume the number of generations of a breeding female fly as nine in a normal season, then a single fly laying 150 eggs at a time might conceivably become ancestress to 5,000,000,000,000,000,- 000,000,000,000,000 descendants in one season. The student may compute the bulk of this mass and picture what would happen in 10 years, if the fecundity of this single fly were not halted by biologic laws. All species, including man, multiply in geometrical progression, but the best we can expect of the increase in food supply is arith- metrical progression, according to the Malthusian doctrine (T. R. Malthus, 1766-1834). To show that natural laws must inhibit human productiveness, it has been stated that a man and wife at the time of Christ with two children and each of their descendants have two children, and no intermarriages of descendants take place, allowing 34 years for a generation, or a total of 57 generations, the human offspring now alive would total 72 quadrillion persons. If this number passed in review, at the rate of 8 million persons iier hour, the parade would last for a million years. Rather fantastic but true. Limitation of food supply, the spread of contagious diseases, war, and conflict of races, are methods of restriction of excessive multi plication of the human species. When we place a million men in the field and prevent decimation from disease, we are defying one of the biological principles that tends to prevent over-crowding of a species. The methods at our disposal to combat these fundamental biological principles are not complicated and may be classified and will be discussed as follows: — 1. Proper food. 2. Potable water supply. 3. Hygiene of the march. 4. Conservancy —waste disposal. 5. Insect control —fly, mosquito, louse, etc. WAR AND EPIDEMIOLOGY 331 MODEKN PREVENTIVE MEDICINE Wars are lost by generals and won by epidemics Victory, success in a military endeavour, is intimately interrelated and dependent upon personnel losses; in fact, the wastage from diseases frequently assumes such magnitude as to cause military cam paigns to terminate in disaster. According to one writer, the body louse, transmitter of typhus, won the World War. For example, the Austrian Army feared to invade Serbia in 1915 due to an epidemic of typhus which killed 150,000 persons in 6 months of that year; and, again, in Russia 25,000,000 cases with 3,000,000 deaths from this disease aided the spread of revolution and the complete collapse of Russia's huge army. "Typhus and allied diseases have decided more campaigns than Caesar, Hannibal, Napoleon, and all the generals in history. The epidemics get the blame for defeat; the generals the credit for victory. It ought to be the other way around." As examples of the influence of different diseases upon the out come of military ventures the following are cited. Yellow fever. —At the beginning of the last century (1802) 50,000 out of an Army of 58,000 died on Santo Domingo island from yellow fever. Typhoid fever. —In the Spanish-American War, the American forces lost about 10 times as many men from typhoid fever as were killed in combat. After compulsory vaccination against typhoid only three cases, and no deaths, occurred in the entire American Army of 90,000 men over a period of 5 years. Cholera. —In the Balkan War, the Turks lost as many as 500 men daily from cholera. The allies lost 10,000 men from cholera in Crimea in 1854. Plague.—The Persians under Xerxes were defeated in an attempt to invade Greece by an epidemic of plague; Athens was forced to surrender as a result of this disease, and the sieges of Syracuse in 414 B. C. by the Athenians, and in 396 B. C. by the Carthaginians were failures caused by the plague in these armies. In the war be tween Russia and Turkey in 1828, plague killed over 6,000 Russians in 1 month, and from all causes the Russian Army of 100,000 suf fered 85,000 deaths, and at one time had half of its total strength in the hospital. Typhus.—In the 1566 campaign against the Turks, Maximillian II of Germany failed on account of typhus. A typhus epidemic among the Austrian defenders of Prague in 1741 enabled the French to capture this city. In the Bavarian Army of 28,000 men in 1812, 332 FIELD SANITATION MANN 25,000 died of typhus fever. After the battle of Plovna, the Rus sians lost 60,000 men from typhus out of a strength of 120,000. Napoleon lost 40,000 from typhus during his retreat from Moscow and after arrival in Paris. Malaria. —Malaria, probably introduced in ancient Rome during the Carthaginian invasion, so debilitated the Roman forces that they succumbed to the inroads of the Barbarians. In the Walcheren Campaign of 1809, the English forces had 10,000 sick and 4,000 died from malaria. The English at Ashanti in 1864 "were defeated" by malaria before an enemy was seen. The French expedition at Mada gascar (1895) had a death rate of 320 per 1,000 from malaria, yet suffered only 15 deaths in action. In Macedonia, the British forces had 162,517 admissions to hospitals from this cause; one division reported 5,000 cases in 1 month. The highest annual rate was in South Africa in 1917, when the rate per thousand was 1,422.84. Malaria caused the death of 15,000 soldiers in the Civil War, while we lost only 25 during the World War from this cause. Beri-beri. —This was once a disease dreaded by the forces afloat, and has been a factor in deciding naval ventures. Not so long ago, one of the modern navies showed an incidence rate of 35 percent from this malady, which was reduced to a negligible rat© by the introduction of vitamin "B" in the sea ration. In the Russo- Japanese War, 1905, the Japanese army had 200,000 cases of beri-beri. Scurvy.—In one of Commodore Anson's naval ventures 19 out of every 20 men failed to return to England, the majority dying of scurvy. The American frigate Macedonia, from April to September 5, 1827, lost 101 men out of a crew of 376. In the Crimean War (1854-56) 23,000 cases of scurvy occurred among the French troops alone; in the American Civil War (1861-65) 30,174 cases were diag nosed. In the siege of Port Arthur, during the Russo-Japanese War, 85 percent of the Russian garrison suffered from scurvy. Dysentery. —The siege of Bagdad by the Saracens in 1439 failed as a result of an epidemic of dysentery. Metz was saved from Charles V partly on account of dysentery. Frederick Wilhelm II of Prussia in 1792 was unable to fight the Army of the French Revolution and was forced to retreat into Germany because of dysentery among his troops. Dysentery caused 1,342 deaths and 38,000 cases of sickness during the South African War. At Gallipoli, during August and September 1915, 78 percent of the British troops were suffering from dysentery and other intestinal complaints. Smallpox. —Mecca was saved by smallpox which decimated the Saracens. Smallpox was one of the causes of the military failure of Benedict Arnold's campaign against Quebec. In 1870 the French lost 23,000 men from this disease, whilst the Germans who were exposed WAR AND EPIDEMIOLOGY 333 to the same contagion, but were efficiently revaccinated, lost only 200 men— a striking illustration of the military value of vaccination. Smallpox took over 7,000 lives during the Civil War ; in the World War it took only 14 lives in our troops. Beginning with the Russo-Japanese War, the ratio of deaths from disease began to decrease due to improvement in modem field sani tation. This change is particularly evident when this war is com pared with the Chino-Japanese War occurring 10 years earlier. The following table demonstrates the striking improvement of health of military forces due to employment of modern sanitary measures. Ratio of killed in action to deaths from disease in various campaigns' Approxi mate aver Ratio per 1,000per annum Campaign agestrength during Killed in Died from Crimean War— 1854-56: campaign action disease 301,000 30.6 114.7 United States Civil War— 1861-65: 111,000 IS. 8 87.3 Austro- Prussian War 1870-71: 600,000 38.3 75.9 Chino-Japanese War 1894-95: 437,000 61.1 88.2 Madagascar, 1895: 227,000 7.3 88.1 Spanish-American War 1898: 18,000 .48 373.3 Boer War, 1899-1902: 270,000 2.5 32.6 British troops 208,226 12.7 25.6 Russo-Japanese War 1904-05: Japanese troops 420,000 88.5 40.8 Russian troops - 490,000 61.3 35.8 German S. W. Africa 1903-06: German troops 18,000 13.5 12.9 Note,.—In France and Flanders, during the World War, the British forces lost 585,533men killed by the enemy and during the same period only 32,098died from disease. FOOD IN THE FIELD An army fights on its stomach —Napoleon In war the supply of food is most important. The men attached to an organization on field duty are not likely to have opportunity to supplement the military ration by purchases from civilian restaurants or other eating places to supply any deficiencies in their daily ration. Hence, it is important that the field ration be well balanced in fats, proteids, and carbohydrates and must have the required vitamin content. An extended discussion of the component parts of a well balanced ration would be a departure from our subject and, as such data may be found in textbooks, only certain aspects of a military ration which are related to field conditions will be considered. 334 FIELD SANITATION MANN Caloric value of the military ration.—It has been found that a ration consisting of 3,700 Calories is insufficient for troops in the front line. It has been experimentally proved that troops on a test march can maintain weight on a ration of 4,100 Calories. If troops must entrench after a day's hike, a total of 5,000 to 6,000 Calories per day is required. It is often impractical for a soldier to assimilate such a large number of calories per day, and consequently, in time of war soldiers are allowed a greater amount of food (often at the expense of the civilian population) so that they may have a reserve supply of fat in the body to enable them to temporarily with stand the unusual expenditure of foot-pounds of energy. It is stated that 20 pounds of reserve fat in a man's body will supply 3,000 addi tional Calories per day for a period of 30 days. The following is the caloric value of the United States Army ration : Oaloriet 1. Reserve (haversack ration) 2,825 2. Mobile 3, 500 3. Normal 4, 125 4. Special - 4, 850 The heat of hot drinks and hot food supply additional calories, 1 pint of hot tea adding 50 Calories of direct heat to the body. Hence the stimulating effect of hot tea, coffee, soup, and broth after a long march. A soldier at hard work requires 24 ounces of food, daily, exclusive of water, made up as follows: OuflOM Proteins 4 Carbohydrates 17 Fats 3 In terms of articles of food, the above is represented by the follow ing field ration : Beef ounces^- 11 Sugar ounces 2 Cheese do 3 Jam do 2 Bread do 16 Sago do 4 Potatoes do 10 Milk pint % The nitrogenous foods (proteins) serve for the building and re pairing of tissues, and also serve for the maintenance of heat and energy. The carbohydrates and fats yield heat and energy. The salts are essential to life and health, and for the formation of the skeleton and tissues. Water is as essential a food as the foregoing, and serves for the solution and conveyance of food to the various parts of the body, and also for the removal of the waste products formed in the FOOD IN THE FIELD MENU 335 body, viz the solid and liquid excreta. Water alone, by its evaporation from the skin, assists in stabilizing the temperature of the body. A part of the water required by every one is contained in the solid food taken, of which it forms a very large proportion; meat, for instance, contains about 75 percent water, some vegetables as much as 90 percent, and bread about 38 percent. The amount and the particular kind of foodstuffs required by an individual will vary with his age, his build, his work, and the climate in which he works. In cold climates a man will require more of the heat-producing foods, especially fats, and in a hot climate he needs less of the nitro gen-containing foods and fats, and more of the vegetable food stuffs. The greater amount of muscular energy required, the greater will be the amount of food necessary to supply this energy. Energy value is generally expressed in calories, a Calorie (kilo calorie) being the energy in the form of heat, required to raise the temperature of 1 pound of water 4° F. (Or 1 kilogram of water 1° C.) It has been found by experiment that 1 gram of protein or carbo hydrate is capable of yielding, by its oxidation in the body, 4.1 Calories, and 1 gram of fat, 9.3 Calories. The British army ration gives the following : Protein 175 grams X 4.1 equals 717 Calories. Fat 218 grams X 9.3 equals 1, 927 Calories. Carbohydrates 515 grams X 4.1 equals 2, 111 Calories. equals 4, 755 total Calories Daily menu. —It is advisable to prepare the daily menu at least 24 hours in advance. The medical officer should carefully scrutinize the menu, and not only inspect the food as to quantity and quality, but the necessary precautions should be taken to see that there is a variety of food prepared. ' There is often a tendency for cooks to prepare an excess of stews, which may cause dissatisfaction among the men. When on the march or otherwise heavily worked, the men will have a craving for sweets; a liberal amount of jam should be provided to satisfy this craving. The presence of much refuse food in the garbage can is a good indication that the men are not receiving the proper kind of food, that it is not palatably cooked or served, or the quantity is excessive. The field ration should contain tomatoes, lemon or orange juice whenever practical. Potatoes should be cooked and eaten unpeeled, thus supplying additional vitamins. Fruit and vegetables which are to be eaten raw and unpeeled, should have the exterior surface steri 336 FIELD SANITATION MANN lized by temporary immersion in boiling water whenever there is suspicion of soil contamination being present. Every effort must be made to vary the field diet to the greatest possible extent, changing the food substances as well as the manner of cooking. The guard at night should have coffee and bread before going on duty, and this should apply to relief parties. Field kitchens.—The use of rolling kitchens on the march has superseded the old method by which each man cooked his own food. One rolling kitchen supplies food for 200 to 250 men. The field kitchen should be located on the opposite side of the camp from the latrines and urinals. Some means should be used to protect the food from dust and sand. If circumstances permit, the kitchen should be screened; if not, other precautions should be taken to protect food from flies and other insects. Burlap sacking may be used for screening when more suitable material is not available. There should be on hand at all times a sufficient supply of pure water and material for cleaning purposes, such as soap, soda, and soap powder. Scouring material, boiling water, and dishcloths should be available. If the kitchen has a dirt floor it may be oiled with used motor oil to control dust. The cooks and other attendants working in the kitchen and han dling food should be instructed in personal hygiene. Rigid supervi sion is necessary to prevent the cooks from becoming lax in personal cleanliness, especially in keeping the hands and finger nails clean. Physical examination of all food handlers should be made at regu lar intervals; and if the laboratory facilities permit, an effort should be made to detect and eliminate any disease carriers among them. Routine venereal inspections should be made. Liquid and solid refuse should be disposed of as soon as practical. The outside of all garbage cans should be kept clean, and covered at all times. The object of cooking processes is— (n) To make food more digestible and appetizing. (J) To destroy germs and parasites. Mess halls.—The mess halls should be located near the kitchen. Make the necessary provisions to protect the food in the mess halls from flies, dust, and sand, using wire screening if available. Clothes and toilet articles must not be stored in kitchens or mess halls. The mess tables should be cleaned and sunned at regular intervals and care must be taken to see that food particles do not collect in the cracks of the tables. FOOD IN THE FIELD—SAFEGUARDS 337 One of the best methods to prevent the collection of food particles in the cracks of the tables is to construct the tables with a removable center board which may be lifted off, and thus permit the cleaning of the cracks between the boards. Another method is to construct the tables with a 2-inch space between the boards. Washing mess gear in the field. —After meals all mess gear should be sterilized in boiling water. In a semipermanent camp the mess gear may be placed in wire racks and washed by immersion for 5 minutes in water that is kept boiling. On the march and under conditions where the mess kits from the haversack are in use, the following method of washing the individual mess gear is employed : Immediately after the men have finished eating they should form a line and pass a garbage can or pit where the refuse liquid and solid food are disposed of. After disposing of this refuse food each man inserts his mess gear successively in three cans. These cans are placed over a trench in which a fire is burning. The first and second cans contain boiling soapy water, while the third can contains boil ing clear water. A few moments insertion in each of these cans is usually sufficient to cleanse and partially sterilize the utensils. After insertion in the third can. the mess gear dries by its own heat almost immediately and no wiping is necessary. Care should be taken to see that the water in each can is kept at a boiling point, as luke warm dishwater is a potent factor in the dissemination of saliva- borne diseases. It appears that the military sanitarians have waged a successful battle against intestinal disease, but during the Great War sputum- borne diseases of the respiratory tract, such as influenza and pneu monia, did not always yield so readily to preventive sanitary measures. During the Civil and Spanish-American Wars the intestinal dis eases were prevalent, while in the recent world conflict more persons died from respiratory diseases than any other group of diseases. Protection, storage, and inspection of food supplies. —Surplus and reserve food supplies should be protected from insects such as flies and roaches, from dust and dirt, and from rats and mice. Per ishable foods should be stored at a temperature that will inhibit the growth of moulds and bacteria. For camps of less than 1 week's duration, storage devices for preservation of food are not necessary. 1. In temporary camps food may be stored in watertight contain ers and immersed in springs or streams, care being taken to prevent water contamination. Food may be buried below the surface of the ground where the temperature is lower, lining a pit with burlap, and placing boards on the bottom. In addition, food containers 64743—88 2 338 FIELD SANITATION MANN suspended from trees or tripods and underground ice boxes provide satisfactory means of protecting and storing food. A suspended food container consists of a screened box that permits free circulation of air but prevents contamination by insects. The cooling effect is increased by wrapping the box in burlap which is kept damp. Fresh meat, bottled milk, and vegetables may be tem porarily stored in such a container. It should not be used where the air contains any considerable amount of dust. 2. In semipermanent camps fresh or cured meats, milk, and vege tables should be kept in an underground storage room constructed similar to an old fashioned root cellar. The floor consists of well tamped earth, or boards may be used. The walls should be boarded. Ventilation is secured by windows at the ends or an outlet through the roof. Vegetables should be kept in vegetable bins, constructed of spaced slats to permit the circulation of air. The bottom should slope sufficiently to permit the older vegetables to be used first. Canned goods should be kept in the storeroom adjacent to the kitchens. Bread boxes which permit aeration of the contents should be used. Quality of meat can be recognized by the appearance, odor, and texture. Good meat is firm to touch, moist but not wet, and is red in color for beef, pinkish brown for veal, dark pink for mutton, and light pink for lamb and pork. Good meat has a fresh, agreeable odor. The fat should contain no watery juices or jelly, and should be firm and white. The fat interposed between the muscle fibers gives the meat a mottled appearance. In the field we are liable to be called upon for inspection of the freshly killed carcass. The most likely place to look for signs of disease is the chest cavity, and to a lesser extent the abdominal cavity; adhesions of the lining membrane indicate inflammation, probably tuberculosis. When decomposition of meat is suspected trim off the tainted parts of the quarter of beef and sink a probe into the shoulder or hip joint. The odor of the probe will determine whether decom position has set in. A whole quarter of beef should not be condemned because part of it has begun to decompose, as it is often possible to trim off the tainted portion and serve the remaining wholesome portion. The Eber test (ammonia test) is used to detect decomposition. Place 2 cc of reagent (1 part ether, 1 part concentrated hydrochloric acid, and 3 parts absolute alcohol) into test tube and shake. A small piece of meat to be tested is lowered to within one-fourth inch of surface of reagent. If ammonia is present white ammonia chloride fumes will appear around the specimen. ;— - r. - : FOOD IN THE FIELD VITAMINS 339 Meat may be hung in cold storage but it should not be stacked in the refrigerator until it has been thoroughly chilled, preferably frozen thoroughly. When warm meat is stacked in the refrigerator decomposition develops in the center part of the stack before it can be frozen. The hind quarters and fore quarters should be stacked to permit issue alternately. In the field a percentage of the rations is issued in tin containers, which, due to improper preparation, exposure to excessive heat, and lack of care in handling, frequently undergo decomposition and are especially dangerous to health if their use is permitted. Therefore a. careful inspection of all canned goods should be required. The terms "springers" and "swells" are applied to bulged, blown, or swelled cans. These cans, when pressure is applied at the ends give a crackling sound. "Springers" are caused by overloading the can, and though not desirable, the contents are fit for use. "Swells" are caused by the formation of gas, due to decomposition and may be differentiated from "springers" by a splashing sound when the can is shaken, and a hollow note when the can is gently tapped. These should be condemned. Occasionally the inside of a can may present a blackened appear - ence —so called "can burn." This condition is not due to putrefac tion, but is caused by the precipitation of stannous sulphide in an acid medium. Formerly a can with two solder holes was indicative of a "swell" which had been punctured to let out the gas and then resoldered, but now many manufacturing firms use two solder holes in sealing their cans. It is well to reject cans with three solder holes. Vitamins. —Vitamins are accessory food factors that occur in minute amounts in natural foods and are in varying degree essential for normal body growth and maintenance. They are complex organic compounds which the body is unable to synthesize. Recent researches directed particularly to determining the chemical nature and synthesis of these compounds has been extensive, and present literature on this subject is voluminous. Information on their nature and physiological effects is changing progressively. Consequently the reader must refer to the latest current literature for reliable information on this subject. Due to much confusion as to terminology and the prominence this subject has attained in the popular mind it is discussed more fully than its importance as a food factor merits. At present writing vitamins, A, By C, D, E, and F, have been classified as accessory food factors. The following discussion is a brief and incomplete summary of present information on these vitamins : 340 FIELD SANITATION MANN Vitamin A.—This is a fat soluble compound obtained normally from green leafy and yellow pigmented vegetables, milk, butter, and eggs. A rich concentrate is obtained commercially from the livers of codfish and halibuts. This vitamin is commonly associated with vitamin D and these two vitamins may be administered together to advantage. Chemically it is closely related to carotene. It is moder ately stable when subjected to heat. Deficiency of this vitamin causes xerophthalmia and subclinical deficiency is best determined by biophotometer test for nyctalopia. Deficiency also causes epithelial changes of the skin and mucous membranes. There is no proof that deficiency is a primary factor that increases susceptibility to infec tion. The average diet which includes vegetables, dairy products,, and eggs, provides an ample supply of this vitamin. Vitamin B.—This water soluble vitamin has been identified as a vitamin complex of which at least six compounds have been isolated with reasonable certainty. Early investigations that deal with vita min B as an entity therefore present inconsistent findings. Vitamin B was classified as heat stable. However, the components of this complex vary in resistance to heat. B2 is more stable than Bt in this respect. Heat that renders Bs inactive does not effect B^ 1. Thiamin Chloride (Bi).—This is the antineuritic vitamin. De ficiency causes beri-beri, peripheral neuritis, gastrointestinal atony, nausea and anorexia, and altered carbohydrate metabolism. It is obtained from the following natural foods : Pericarp of cereals, wheat germ, tomatoes, eggs, yeast, prunes, and meats. It has been obtained in pure crystalline form having antineuritic activity. 2. Riboflavin (B,). — The history of this vitamin is interesting and confusing. Goldberger in his researches on pellagra demonstrated that his pellagra-preventing factor differed from vitamin B and he designated it as the P-P factor. Other investigators have designated this factor as vitamin G. Therefore, vitamin B3> P-P factor, and vitamin G are synonymous. However, vitamin B2 and riboflavin may not be identical. Recent work indicates that vitamin B2 may have two components (a) riboflavin, also called lactoflavin, and (b) a sup plementary substance designated as B„. Riboflavin has been obtained in pure crystalline form, identified and synthesized. In water solution it produces a yellow-green fluorescence. It is widely distributed. Recent reports indicate that it is a cell enzyme concerned with cell respiration. It is normally obtained from yeast, dairy products, eggs, leafy vegetables, and meats. Deficiency is manifested as sore mouth and dermatitis of the scrotum. 3. Vitamin Bs.—This vitamin occurs in whole grains, malt, yeast, and liver. Deficiency causes a loss of weight and prevents growth. It has not been identified chemically. Recent work indicates that this vitamin may have two component factors. FOOD IN THE FIELD VITAMINS 341 4. Vitamin Bt.—This factor has not been identified chemically. It has been found to be intimately associated but not identical with adenine. It occurs naturally in yeast, dairy products, whole wheat, liver, and lettuce. Deficiency, experimentally, causes retarded growth, muscular weakness, and incoordination, with spastic gait. 5. Vitamin Z?5. —This is a slightly water soluble factor obtained from yeast. Like Bs it is concerned with growth but it differs in that it permits only maintenance of weight. 6. Vitamin B9.—This is the supplementary substance found associ ated with vitamin B2. This factor is probably identical with or essentially similar to vitamins reported by various investigators under other alphabetical designations. In summary, the vitamin B complex has only two components, thiamin chloride and riboflavin that need to be considered, and these occur in the foods commonly included as elements of the service ration. The other alleged components of this complex require con firmation. The special actions attributed to Bsand B4 may be due to a larger supply of Bj. Vitamin C—Cevitamic acid. —This food factor is antiscorbutic and has been definitely identified as 1-cevitamic acid. The "d-form" of this acid is inactive and the "iso-form" possesses little activity. The present international unit of 1-cevitamic acid is 0.05 milligram. This is the equivalent of 0.1 cubic centimeter of lemon juice. The daily needs of this vitamin are about 250 units. Scurvy is the typical clinical manifestation of vitamin C defi ciency. The natural siurces of cevitamic acid are all citrous fruits and green vegetables including peas and spinach. It is produced synthetically. It is water soluble and easily destroyed by heat. •Clendenning lists the following foods as containing more than 100 units of vitamin C per pound : Cabbage, raw 320 Parsley 240 Grapefruit 240 Peppers 400 Lemons 240 Spinach, raw 400 Oranges 240 Strawberries 160 -Tangerines 240 Tomatoes, raw and canned 240 Vitamin C differs from vitamins A, B complex, and D in that little reserve is stored in the body tissues. Hence, an adequate daily intake of this factor is particularly important. Approximately 70 percent of quantities in excess of body needs are reported to be excreted in the 3-hour period following intravenous injection. Vitamin D.—This antirachitic vitamin promotes the deposition of calcium and phosphorus in bone formation. Consequently it is needed primarily during the years of growth. It is a product of ultra violet radiation. This antirachitic effect may be obtained by direct exposure of the body or a product having a high degree of antirachitic effect is obtained by irradiating ergosterol. The irra 342 FIELD SANITATION MANN diation apparently alters the molecular structure of ergosterol. An antirachitic crystalline substance has been obtained from irradiated ergosterol. Vitamin E.—This vitamin occurs in yeast, wheat germs, and lettuce. It promotes normal reproductive function. Vitamin F.—This vitamin appears to be essential for the production of linoleic acid, an unsaturated fatty acid. Conservation of food vitamins. —Several simple but important facts must be remembered in providing troops with an adequate in take of vitamins. Personnel charged with preparing food for con sumption should be familiar with these facts and conserve food vita mins. The vitamin content of foodstuffs decreases with age and ex posure to heat, light, oxygen, and alkali. Since vitamins are water or fat soluble, the water or fatty liquids in which foods are preserved or cooked contain vitamins and other beneficial extractives which should be incorporated in the ration, if possible, rather than dis carded as waste products. Prolonged cooking, such as is apt to occur with field kitchens, tends to destroy the vitamin content of the ration. The vegetables for stew should be cooked separately and not longer than 30 minutes; then they should be added to the meat, which requires about 2 hours of cooking. Avoid the use of alkali, e. g., sodium bicarbonate, when cooking green vegetables as this also tends to destroy the vitamins. In Mesopotamia during the late war over 11,000 cases of disease due to food deficiency developed in 6 months —hence the practical import since of medical supervision of the field ration. British troops in Mesopotamia during the late war, eating white bread, suffered from beri-beri, while the Indian troops, eating unmilled wheat, escaped. During the seige of Kut the reverse was the case, the British lived largely on fresh meat, while the vegetarian Indians lived largely on white bread. During the late war an outbreak of scurvy occurred in the British Army among the men of the South African Labor Corps. Without the alteration of their diet, the period of cooking was reduced from 6 hours to 45 minutes, and the outbreak was immediately arrested. The vitamin-containing foods of an exclusive military ration should weigh at least 30 percent of the total. WATER IN THE FIELD Officers responsible for water supply.—The quartermaster is responsible for the procurement of water rights and for the delivery of water to the camp site. The medical officer is responsible, in an advisory capacity, for the quantity and the quality of the water at the source as well as at the ultimate point of consumption. The unit WATER IN THE FIELD SOURCE 343 commander is responsible for the proper distribution of the water within the organization. Water consumption.—Water constitutes 60 percent of the body weight, or the equivalent of 10 gallons, which equals 100 pounds approximately in the average man's body. The loss of one gallon of this water has serious consequences; if iy2 gallons are lost, the result is fatal. The quality and quantity of the water supply is a vital factor during field operations. In a war of movement the supply of water is very apt to be inadequate, which may mean that the consumption of water will have to be restricted to a minimum. The minimum allowance of water for the needs of men and ani mals varies according to the amount of daily labor performed and also the conditions of the weather. The following may be taken as an absolute minimum : Each man, 1 gallon per day, to be used as follows —iy2 quarts for drinking, 2y2 quarts for cooking and drink ing with meals. In combat, a soldier can maintain physical efficiency for 2 days only on one-half gallon of drinking water each day. The above is the minimum for soldiers on the march and in bivouac, and provides no allowance for the washing of person or clothing. In camps of more than one-night duration the following minimum allowance should be furnished: Gallons In barracks 20 In camps 5-10 Drinking and cooking only 2 The daily requirements for animals are : Gallons Horse 10 Mule or donkey 6 Source of water. —The sources of water are divided into (a) surface waters, such as lakes, ponds, rivers, streams, etc.; (b) under ground waters, which include wells, springs, etc. ; all these vary in degree as to purity and potability. Rain water is usually the most satisfactory of all natural waters. Large bodies of water are more likely to contain pure water than small ones, because of the greater dilution of the contaminating material. Water which is obtained from the center of a large lake is very apt to be pure, especially where the sun shines upon it. One should always be suspicious of all surface waters as the ap pearance of water is no index to its purity. Water should be con sidered contaminated until tests prove it potable. Also, water found potable may become contaminated subsequent to test. Consequently, water used for drinking and cooking purposes should be guarded and tested frequently for contamination. 344 FIELD SANITATION —MANN Wells are of two varieties, "deep" and "shallow." Water taken from shallow wells is always suspicious, while water taken from deep wells and deep springs is usually fit for human consumption. 1. If water from a running stream is used, it should be taken from a point where there is considerable depth, and where the current is strong, always upstream, or in other words, above the camp site. Upon arrival in camp, a guard should be posted over the water sup ply and the stream should be inspected and marked for use. Begin ning upstream the water should be assigned for use as follows: (a) Drinking and cooking water. (b) Water for animals, (c); Water for bathing, (d) Water for laundry purposes. To compute the volume of water of a flowing stream the following may be used as a guide : Sectional area in square feet, multiplied by 0.8 velocity in feet per minute, multiplied by 7.48, equals gallons per minute. 2. Rain water, though not very palatable, is the safest and purest of waters. In warm countries it may be necessary to use it for drink ing purposes but it must be properly collected and stored. Rain water is easily collected from the roofs of houses or other prepared surfaces. These surfaces must be kept free from pollution, such as excrement of birds, dust, decayed leaves, etc. The first washing of the rain should never be used as it will probably contain some pol lution from the roof. In storing the rain water, the containers should be well covered and ventilated, and frequently cleaned to pre vent pollution. One inch of rainfall produces 22,500 gallons of water per acre. The number of gallons of rain water expected to be recov ered from a roof may be determined by the following formula: Area of roof in square feet, multiplied by one-half the rainfall in inches, equals number of gallons. 3. Well water usually comes from two sources. The greater por tion filters in from the deeper strata of the soil and may be considered as free from contamination. However, wells are rarely properly en cased near the surface and properly covered as protection against surface water drainage and other pollution. Therefore all wells should be regarded as contaminated and should be cleaned and dis infected prior to use by employing the following measures: (a) Remove all refuse from well. (b) Pour into well about half-barrel of a solution of freshly burned lime (or a 1 percent solution of chlorinated lime can be used). (c ) Scrub sides of well with above solution. (d) Wait 2 hours, pump well dry. and repeat above procedure. (e) Wait 24 hours, pump out well, allow to refill. WATER IN THE FIELD STORAGE 345 (/) Continue to pump out until all taste of lime has dis appeared. (g) Sterilize water in well by adding a solution of chlorinated lime —30 grains to every 100 gallons of water in well. (h) To compute number of gallons in well use formula : The square of diameter of well in feet multiplied by 0.7854, multiplied by depth of well in feet multiplied by 6.25 equals gallons in well. Transportation and storage. —Water carts employed in the trans portation of water should be subjected to the following sanitary measures : (a) The tank of water cart should be scrubbed out every 4 days with a 1 percent solution of chlorinated lime. (b) Water carts should never be devoted to other purposes than to provide drinking water for men. (c) A half-teaspoonful of chlorinated lime—30 grains—well dissolved as a paste, added to 100 gallons of water will produce approximately 1 part per million of free chlo rine, and is sufficient to sterilize this quantity of water. The best storage containers are those made of concrete, slate, or galvanized iron. Wooden containers will, after a time, give the water a very disagreeable taste. Water receptacles should be well covered. As the ground in close proximity to a water faucet is likely to be wetted, it is best to build a sand or gravel pit, 2 feet square and 1 foot deep, to absorb the waste water. The receptacles should be cleaned daily with boiling water, or rinsed with a solution of potassium permanganate (one-third tea- spoonful to 1 gallon of water). A solution of chloride of lime is also very good for this purpose, in proportion of 1 to 1,000. These solutions are harmless and more certain in their action than boiling water used alone. Canteens, when not in use, should be emptied, dried, and cleaned, with one of the above solutions. Weak tea has been highly recom mended for drinking purposes in canteens; it should be boiling hot when poured in, thus insuring the sterility of the canteen as well as of the contents. Common drinking cups should not be used ; however, if individual drinking cups cannot be supplied, lip drinking should be practiced. Should conditions arise which make it absolutely necessary to use common drinking cups, a certain degree of safety can be insured by keeping the cup immersed in a solution of formalin (1 percent). Data regarding water. —The maximum density of water is at 4° C, which explains the fact that ice is lighter than water. One milli liter of water at 4° C. weighs 1 gram. Water when frozen liberates 346 FIELD SANITATION MANN 80 Calories of latent heat, and expands 9 percent in bulk ; the latter fact explains the bursting of water pipes in winter. The addition of salt to water raises the boiling point and lowers the freezing point. One cubic foot of water equals 7.48 gallons. One gallon of water equals 10 pounds, or 70,000 grains. One liter of water equals 0.26418 gallon. Water Pubification Purification of temporary water supplies. General.—The water supply for moving troops, for temporary camps and installations, or for troops in the theater of operations frequently must be purified under conditions which do not permit the installation of permanent or semipermanent water purification works. The agencies employed generally for this purpose are: (1) Chemical. (2) Heat. (3) Filtration. Chemical purification. —Chlorination is extensively practiced today. Hypochlorite of calcium, commonly called bleaching powder, is the substance used, and is issued by the quartermaster in small glass tubes. The ordinary calcium hypochlorite (Calx Chlorinata) or bleaching powder contains 33y3 percent, of available chlorine when freshly prepared, but is an unstable substance, so that the supply received may contain but little chlorine. There are hypochlorites available, however, and now recommended for use, which contain well above 60 percent available chlorine, are very stable and easily miscible. Bleaching powder tends to form small, hard lumps when placed in water. In preparing a hypochlorite solution just sufficient water should be added to the powder to permit the easy formation of a smooth thin paste, which is then diluted as required and placed in the chlorinator. Twenty-five pounds of ordinary bleaching powder added to 1,000,000 gallons of water give one part per million of chlorine. If 4,000 gallons of water are to be chlorinated one-tenth pound of hypochlorite is sufficient. A drip chlorinator may be used in a small stream, the size of the containers and the strength of the solution being determined by the rate of flow of the stream, how ever the drip chlorinator is not recommended. In case water is so turbid as to make it unsatisfactory for use, it may be clarified by allowing it to stand for some time in a reservoir and clarification may be has'.ened by the addition of chemicals. Alum, lime, and soda ash are used for this purpose. Chlorinating water for small detachments. — Small detachments separated from the main body of troops and its pure water supply may be provided with safe water by chlorination of canteen water. WATER IN THE FIELD STERILIZATION 347 The contents of one tube of calcium hypochlorite is dissolved in 1 quart of water and preserved in a glass bottle. A metal container is not used as the concentrated calcium hypochlorite has a chemical nction on the metal. One teaspoonful of this solution added to 1 canteen of water and allowed to stand for 30 minutes renders the water safe for drinking. If the tubes are not available, then dissolve 1 teaspoonful of chlorinated lime, taken from a freshly opened con tainer, in 1 quart of water and label this "stock solution." This solution deteriorates very rapidly and fresh solution should be prepared every fourth day. One teaspoonful of this stock solution added to each gallon of water and allowed to settle for 30 minutes will insure the destruction of most bacteria. Sterilizing water by iodinization. —Two and one-half teaspoon- fuls (10 cc) of 7 percent tincture of iodine added to a sterilizing bag of water will purify it in 30 minutes. Two drops of the tincture added to one canteen of water and allowed to stand for 30 minutes will render it pure. There are two objections to this method of sterilization: 1. There is no reliable method for titrating the iodine in a test for sufficiency of the amount added. 2. This method is more expensive than the hypochlorite method. (The excess of iodine may be neutralized by adding 1 gram of sodium thiosulphate.) Water sterilizing bag. —The water sterilizing bag, often called the Lyster bag, is made of specially woven, waterproof canvas, weighing about 7 pounds, and can be folded into a compac t pack age. It measures 20 inches in diameter and 28 inches in length, hold ing about 36 gallons. Its sole use is as a stationary receptacle for water while being sterilized and distribution of same after steriliza tion, without dipping. This is accomplished by faucets which are arranged around the bottom of the bag. The Lyster bag is part of the Marine Corps field equipment and is issued on the basis of 1 bag for each 100 men or fraction thereof. (See fig. 1.) To use, this bag is suspended from a tripod and filled with water. To each bag of water (36 gallons) there is added the contents of one ampule of calcium hypochlorite. The calcium hypochlorite is issued in sealed glass tubes, one tube sufficing for one bag of water. The\ water is then allowed to stand for at least 30 minutes before using, as the sterilizing process is one of oxidation, and is not com plete in less time. In water that contains much suspended matter, or is very cloudy, the sterilizing action is not very satisfactory so that it is necessary to clarify the water before chlorination which may be accomplished by means of a small filter cloth provided with the bag. 348 FIELD SANITATION —MANN W1REHOOKTO SUPPORT CENTER OF COVER, WHICH GIVES * "PITCHED- ' EFFECT. 1. Arrange bag on tripod. Strain water and fill bag to within. about 4 inches of the top. 2. Procure a clean stick, or cut a limb from a tree for, use in stir ring of water. Place this in water and leave there during steriliza tion. 3. Break one of the glass ampules of calcium hypochlorite and shake the powder into a cup. Mix with water until a fine paste results, and then stir with a spoon, adding more water until the paste is entirely dissolved. 4. Add the hypochlorite solution to the contents of the bag and mix thoroughly with the stick provided for that purpose. Draw 3 cupfuls through each of the faucets (to clean and sterilize) and pour back •'nto the bag. 5. Draw off 1 cup of water and add to it the contents of one am pule of orthotolidine, stirring with a clean, dry spoon. As the water is stirred it turns yellow, the degree depending on the amount of hypo chlorite present. An orange or orange red color indicates a suffi- j\ I cient amount for sterilization. A ' ' canary yellow color indicates an in sufficient amount and hypochlorite should be added to the bag one tube at a time until the right color is obtained. The water is then al lowed to stand for 30 minutes and guarded to prevent use during this period. 6. Excess chlorine gives the water an unpleasant taste. This can be dispelled by neutralization with sodium thiosulphate. Sodium thiosulphate is provided in glass ampules. The contents of one am pule should be added to a cup of water, stirred until dissolved, and after sterilization of the contents of the bag is complete, should be poured into it. 7. The faucets should then be rewashed for the last time, running at least 5 cups of water through each faucet and returning the water to the bag. This treatment renders the water perfectly safe, even though it was previously heavily contaminated. FiaiRE 1.—Water hag. (Diagram pre pared by Lieut, (jg) James B. Butler, Medical Corps, U. S. Navy. WATER IN THE FIELD— STERILIZATION 349 8. Unless precautions are taken men will drink directly from the faucets. They should be required to use their individual mess-kit cups. 9. The bag cover may be supported in the center by means of a wire to the apex of the tripod support. This gives a pitched roof effect, allows rain water to run off the top and prevents sagging of the top and contamination of the contents. Mobile water purification unit. —The United States Marine Corps has procured two highly efficient mobile purification units, and has placed one on each coast. Essentially the unit consists of the following: 1. Gasoline engine driven centrifugal pump. 2. Pressure filter. 3. Chlorinator. 4. Soda ash feeding device. 5. Suction hose and discharge hose. The above is mounted on a circle steer highway trailer. The pump has the following capacities : 1. Twenty-five gallons per minute against a 10-foot delivery head through filter. 2. When filtration equipment is bypassed —in case the raw water is sufficiently clear —the pumping equipment and solution feed chlorinator will deliver 50 gallons per min ute of sterilized water against a 50-foot head. 3. When filtration and purification equipment is bypassed, and the unit used as a pumping device, then 100 gallons of water per minute can be delivered against a 75-foot head. Thus the mobile unit may be operated as : 1. A simple pumping unit. 2. A pumping and chlorinating unit. 3. A pumping and filter unit, with or without chlorinator. It is rather spectacular to watch the operation of one of these units with the suction hose placed in a muddy contaminated pond of water deliver a clear purified stream of potable water, at the rate of a barrelful each minute, at the discharge hose. Boiling. —Boiling is a simple and effective method of water sterili zation and may be used in the presence of an epidemic of intestinal disease, such as dysentery or cholera, and when materials are lacking for sterilization by other methods. Boiling was used effectively by the Japanese in the Russo-Japanese War in controlling water-borne diseases. 350 FIELD SANITATION —MANN However, boiling all drinking water entails a considerable amount of fuel and time. For 250 men nearly three barrels of drinking water are required each day and it would be a heavy task upon the rolling kitchen if the boiling is to be done there. Boiled water has a flat taste unless it is aerated after cooling. Its taste may be improved by the addition of tea or coffee. Each man can boil water in his canteen, by placing the canteen full of water in a fire, or upon hot coals until the water boils, after which it is removed and allowed to cool. Troops can, after a day's march, prepare their canteens full of boiled water for use on the next day. Field filters.—The barrel filter consists of a small barrel in serted into one of larger dimensions and separated from the bottom of the larger barrel by about 3 inches of fine sand. The smaller barrel having a perforated bottom, .is placed upon the sand in the larger barrel: then more sand is placed around the small barrel to the height of about 6 inches. A layer of charcoal and a layer of gravel may be placed above the sand. The barrel filter may be sunk into a lake or spring; water may also be filtered by pouring it into the larger barrel. In connection with drinking water, special attention should be given the following: 1. Regard all water in the field as contaminated unless proved otherwise. 2. Do not let the men fill their canteens from any unauthor ized source. 3. Place a guard at the source of the water supply to prevent its pollution. 4. Water discipline on the march should be rigidly enforced. 5. Remember that not only the quality of the water supply but also its quantity should be supervised by the medical officer. 6. The amount of water lost by evaporation, and otherwise, by a man marching for 1 hour, or 3 miles, is nearly 1 pint. 7. The results obtained by modern military organizations demonstrate that water-borne diseases are preventable. 8. The prevalence of a water-borne disease in a camp indi cates a weak link in the chain of sanitary measures. Summary points to be covered ani> reponted on in a wateb reconnaissance " 1. Location.—Sources and works should be shown on a map, or their location given by description. » From Pamphlet No. 3, Medical Field Service School, D. S. Army. WATER RECONNAISSANCE 351 2. Character of sources. —Well, spring, stream, lake, or pond. 3. Quantity of water available. — Eate of flow of streams. Rate of flow and capacity of wells. Rate of flow of springs. Dimensions and estimated depth of lake or pond and, if indicated, rate of inflow and outflow. 4. Quality of water. — Turbidity. Color. Taste. Result of bacteriological examination, if indicated, and if it is practicable to secure samples and have them analyzed. 5. Sources of bacterial contamination. — Character of sources. Location in relation to water supply. Control measures indicated. 6. Accessibility.— Accessibility of sources of water to troops by railroad, high way, improvised roads, trails, or hand carry. 7. Wells.— Diameter. Depth of well. Depth of water. Distance from surface of the ground to surface of the water. Type, condition, and depth of casing or lining. Kind of soil. Nature of impervious strata, if indicated, and ascertainable. Method of recovering water, i. e., pump, windlass, etc. 8. Springs. — Kind of spring. Protection provided, i. e., coping, watertight basin, ditching, etc. 9. Stream.— Mean velocity. Mean width. Mean and maximum depth. Nature of bed. Height of banks above surface of water. Method of recovering the water provided. 10. Existing installations. — Purification facilities —chlorinating apparatus, filters, eto. Pumps —number, size, type, speed, and capacity. 352 FIELD SANITATION —MANN Engines—type, size, speed, and horsepower. Electrical equipment. Storage facilities —type and capacity. Pipe lines—length, size, and material. Present condition (description). 11. Proposed developments. — Description. Material available. Material required. Time required. FIELD CONSERVANCY "Field Conservancy" is a technical term employed to designate the disposal of waste products in the field. The disposal of waste products is one of the most important field sanitary measures, and the importance of proper waste disposal was known to the ancients. Burial was the earliest means of disposal and is instinctive in many of the lower animals, since animals such as dogs and cats bury their dejecta. Moses —from his experience with a plague of flies in Egypt —in his advice to the Israelites, in Deuteronomy xxii, 12-14. lays down the sanitary directions, "Thou shalt have a place also without the camp, whither thou shalt go forth abroad, and thou shalt have a paddle upon thy weapon; and it shall be, when thou wilt ease thyself abroad, thou shalt dig therewith and shall turn back and cover that which cometh from thee." Suppose that no precautions were taken to accomplish sanitary disposal of waste products in the field, then the danger of the spread of contagious diseases in an army would be in direct ratio to the size and density of the aggregation. Thus when an army takes the field the danger from epidemics would increase with the square of the number of men. In other words, under conditions in which the measures of preventive medicine were not employed, the possi bility of an individual soldier acquiring an infectious disease in an army of 1,000.000 men would be approximately one thousand times greater than in a regiment of 1,000 men acting independently. Various other factors enter into consideration that tend to render these statements not mathematically exact; however, they are suf ficiently accurate for purpose of illustration. Field sanitary measures of modern military preventive medicine has reached a stage in development in which it is now possible to assemble a million men in the field and prevent decimation from FIELD CONSERVANCY 353 epidemics. It is interesting to note that this achievement has been consummated only in comparatively recent years. As an example of this compare the ratio of death rate in battle to the mortality rate from diseases during the Civil War (1 to 2) to the ratio exist ing in the World War (1 to 0.06). Waste products may be divided as follows: 1. Refuse: (a) Garbage. (b) Rubbish (boxes, paper, etc.) 2. Excreta: (a) Night soil (urine and feces). (b) Manure (stable litter). Or they may be classified as follows : 1. Solids: (a) Human feces. (6) Kitchen garbage. (c) General camp rubbish. (d) Stable refuse. 2. Liquids: (a) Urine. (b) Kitchen sullage. (c) Ablution water. The proper disposal of waste constitutes one of the most important functions of the field sanitarian. In the disposal of waste the following objectives are involved: 1. Prevention of insect breeding. —To change the nature or loca tion of waste matter so that fly breeding will be prevented, and also the breeding of other disease-carrying insects. 2. Destruction of microorganism*. —To destroy or otherwise elimi nate the presence of organisms which may cause disease. 3. Removal of a nuisance. —Waste matter and filth are almost synonymous terms; and, as such, the accumulation of waste creates a condition which is offensive to the senses of sight and smell. The methods for ultimate disposal of waste products can bo grouped into two main procedures, namely — 1. Burying: (a) Shallow —Temporary camps. (b) Deep —Semipermanent camps. 2. Burning —Permanent camps. In camps not of a permanent nature and with moving troops, burial is a more convenient and rapid means of waste disposal and is uni- 6t743— 3fs 3 354 FIELD SANITATION MANN versally practiced in our modern armies. Incineration has the ad vantage of complete destruction of all waste and is the better method, from a sanitary standpoint, for permanent camps. Collection and disposal or refuse. —Metal garbage cans, if avail able, should be placed at intervals in the company streets for the deposit of waste paper, burnt matches, cigarette stumps, fruit peel ings, etc. The use of receptacles of this sort accomplishes primary cleanliness of the camp and inculcates the habit of cleanliness in the men. If metal receptacles are not available, wooden or cardboard boxes may be employed. Garbage cans should be well covered and placed on raised platforms at least 2 feet from the ground. The soil beneath these platforms is easily contaminated by the overflow of drippings, and requires careful supervision to prevent pollution and fly breeding. The sur face beneath garbage cans should be scraped daily and shoveled into the garbage cans. Fresh dry earth should be spread over the scraped area. The promiscuous use of lime to cover filth is not recommended. Shallow burial. —The surface of the earth usually consists of bacterial soil varying from a few inches to a few feet in depth. The top layer of the earth's surface is inhabited by millions of friendly germs —the germs of decomposition —which break up or ganic matter into various gases and water, and so rid the earth of the debris which would accumulate on the surface. It is part of the scheme of nature that it must be so, for if constant breaking up of organic matters were not going on, the surface of the earth would become choked and we should find ourselves up to the middle in leaves, which fall and accumulate. The surface of the earth is always assisting in this destruction of organic matter. This layer of germ-charged earth is known as the live humus or living filter, because the germs not only destroy organic matter, but they prevent the passage of filth into the soil. The live humus varies in depth according to the nature of the soil, and is deepest where the soil is very light and where air can percolate through the surface. In this case it may reach to a depth of 2 or 3 feet. Usually, the depth of this humus-bearing soil is 1 to iy2 feet. Below the level of the live humus the earth is sterile or free from germs, and, if buried deep, organic matter such as excreta receives no assistance from the earth in the matter of decomposition. The live humus varies in its intensity from time to time, for if the germs are well fed they increase and multiply, whereas if they are starved they perish. Germs require food, moisture, and warmth for their growth, and if well supplied with these they will multiply in proportion to the amount of food they obtain. Thus the live humus varies in intensity LATRINES 355 according to the time of year, for in a very dry summer, when the surface of the earth becomes bone-dry, decomposition may be abso lutely arrested, and a body may become mummified or sun dried if it is covered with sand to keep off flies. (Moss-Blundell.) Latrines The allahabad system. —Nitrification of excrement in the sod is the sole aim of sanitary science, and the more intimately the excre ment is mixed with the dry earth the quicker will nitrification occur. The germs which cause nitrification are in the upper few inches of the soil and this fact is taken advantage of in the disposal of excreta by the so-called Allahabad system, as used in India. An area 16 feet long and 5 feet wide is excavated to the depth of 3 inches. The excavated soil is placed at one end. The denuded area is then loosened to a depth of nine inches. The area is sufficient, to dispose of sixty gallons of night soil, when dumped in the center.- The liquid waste is absorbed by the loosened soil. The solid matter is spread over the area, and then covered with the 3 inches of soil previously removed. This is tamped down. In a few weeks, depending on the temperature, the solid matter is completely decomposed and all pathogenic germs are destroyed. The Allahabad method is useful in permanent campsites —using the bucket system—where fuel is limited for incineration, but under the usual field conditions this method is of more academic interest than practical value. Shallow latrines. — On the march: A marching column is sup posed to rest for 10 minutes every hour on the march, and during the rest period the medical officer should see that some place is pro vided for the men to relieve themselves. As soon as the column halts, a sanitary detail from the company should immediately pro ceed to improvise latrines. A few narrow trenches about 8 inches deep and 1 foot wide will suffice, and can be hastily constructed with a sharp stick, spade, or bayonet. The sanitary detail should remain to fill in the latrines with earth when the march is again resumed. In temporary camps : Camps which are to be occupied for 15 days or less should be provided with "straddle trench" latrines with di mensions as follows : 1 foot wide, 2 feet or less deep, 3 feet long. The straddle trenches are also called the "One-two-three" latrines because of their dimensions. These shallow trenches are more effective in disintegrating solid waste than the deep trenches, as the germs of nitrification are found only in upper few inches of the soil. All excretion and disease pro ducing organisms, even the toilet paper, disappear in these shallow trenches in 4-5 weeks, as one investigator reports. 356 FIELD SANITATION MANN Straddle-trench latrines should be constructed parallel to each other and should be 3 feet apart; the loose earth should be heaped close to one end of the trench. A shovel, spade, tin, or other similar articles should be on hand, and each man should be required to cover his dejecta with loose earth after defecation. Often it is necessary to establish a guard in the sanitary area to prevent this •weak link in the chain of sanitation. The straddle trench latrine may be designated the open shallow latrine. Deep latrines. —The open deep latrines, similar to those used during the Spanish-American War. and which created such insani tary conditions and contributed to the spread of typhoid fever, will be omitted from discussion, for quite obvious reasons. In semipermanent and permanent camps, deep covered latrines are recommended. These latrines require more time and labor to construct than the shallow-trench latrines, but have the advantage that they are easier to make fly proof. The dimensions for deep latrines vary considerably, but the follow ing may be taken as a standard : 2 feet wide, 6 feet deep, 7% feet long. In loose soil it may be necessary to revet the latrine pit. The Army latrine box is an excellent type of cover for deep la trines. The exact specifications for building this box will be found in one of the diagrams in this chapter. The box consists essentially of an inverted open box built to a convenient height above the ground, containing pear shaped holes in the top, with lids covering these holes. The lids are made to open not over 85°, which will cause them to close automatically. A space of one-fourth inch should be left at the seat hinge to allow for the swelling of the wood. (See fig. 2.) . These deep latrines are usually intended for use over a long period of time. Most of the odors of latrines are due to ammoniacal and other decomposition of urine and the separator system is sometimes used to separate the urine from the feces. A urinal soakage pit is built close by, and by means of a tin gutter, built in front of and under the seat, the urine accompanying defecation is drained into the soakage pit. A urinal trough connected to a soakage pit should be constructed within the latrine enclosure. The latrine is improved by erecting it on a mound a foot high composed of earth removed from pit. This mounding of earth pre vents surface drainage into pit causing contents to overflow. La trines should be abandoned when filled to 1 foot from normal sur face level. They should be liberally sprayed with crude oil or LATRINES 357 covered with quick lime and mounted with earth. Each abandoned latrine should be labeled with a small wooden sign. When dug in wet soil a foot or two of water often appears in the bottom of the pit. Such water aids in absorption of the contents into surrounding soil and many such latrines exhibit septic action. /mouno ofearthV ( I" ABO"E Vgnound LE"EL / BURLAP SACK1NG V / SOAKED 1NCRUOE-O1iA I TO MAKE LATR1NE I \ LARVA PROOF. / Florae 2.—Modification of standard TJ S Army latrine box. Diagram prepared by Lieut, (jg) James B. Butler. Medical Corps, U. S. Navy. Bill of materials 1 box and enclosure 2 boxes and enclosures Top of box Front of box Rear of box Ends of box Beat covers Do.... - Battens and strips Frame for box.. Do Front plank under box. . Rear plank under box. . . End plank Do End strip Posts Boarding ' Battens. -if roof is used Do Rails Nails Do Do Strap hinges - Flat-bead screws . Qalvanized-iron urinal trough... Wrought-iron pipe --- Wrought-iron pipe bent as shown. L C. tin ™ Labor— Carpenter. 2 pieces 1" by 12" by 8'—0". 2 pieces 1" by 8" by 8"— 0".. 2 pieces 1" by 10" by 8'—0". 1 piece 1" by 8" by 8'—0"... 1 piece 1" by 12" by 7'—0".. 1 piece 1" by 2" by T—V'.... 8 pieces 1" by 2" bv 8'—0".. 1 piece 2" by 2" by 4'—6"..- 2 pieces 2" by 4" by 9'—0".. 1 piece 2" by 10" by 8'—0".. 1 piece 2" by 6" by 8'—0"-.. 1 piece 2" by 6" by 3'—0". . . 1 piece 2" by 12" by 3'—6".. 1 piece 1" by 6" by H— 9"..- 10 pieces 10'—0"... 48 pieces 1" by 12" by 6'—0" 48 pieces 1" by 2" by 6'—0". 2rolls.... 1 piece 2" by 0" by 14'—0".. 2 pieces 2" by 4" by 14'—0". 8 pieces 2" by 4" by 12'—0". 3 pounds twentypenny. 8 pounds 4 poui 4 pair 4 dozen No. 8 1 piece 6" by 6" by 3'—0". 1 piece 1" by by 1'—4' 1 piece 1" by by 4'—0' 1 sheet 20" by 28" 20 hours 4 pieces 1" by 12" by 8'—0". 4 pieces 1" by 8" by 8'—0". 4 pieces 1" by 10" by 8'—0". 2 pieces 1" by 8" by 8'—0". 2 pieces 1" by 12" by V—0". 2 pieces 1" by 2" by 7'—0". 16pieces 1" by 2" by 8'—0". 2 pieces 2" by 2" by 4'—6". 4 pieces 2" by 4" by V—0". 2 pieces 2" by 10" by 8'—0". 2 pieces 2" by 6" by 8'-I0". 2 pieces 2" by 6" by 3'—0". 2 pieces 2" by 12" by 3'—6". 2 pieces 1" by 6" by H—9". 12 pieces ir—0". 66 pieces 1" by 12" by 6'—0". 66 pieces 1" by 12" by 6'—0". 3 rolls. 1 piece 2" by 6" by 12'—0". 2 pieces 2" by 4" by 8'—6". 2 pieces 2" by 4" by 8'—6". 4 pounds twentypenny. 12 pounds tenpenny. 9 pounds eightpenny. 8 pair 4-inch. 4 dozen No. 8. 1 piece 6" by 6" by 3'—0". 1 piece 1" by IVi" by V' 1 piece 1" by by 4' 2 sheets 20" by —0". 32 hours. 1If T and O material is used omit battens. 11-inch boards or equivalent in other widths if boarding is used. 358 FIFXP SANITATION MANN Site and number of latrines. —Latrines should (a) be constructed at least 100 feet from the camp. Deep closed latrines may be con structed at a distance of 50 feet, (b) They should be constructed on the side of the camp opposite to the galley and kitchen, and (c) if practicable, located so as to drain away from the water supply, (d) They should be placed at a safe distance from ditches and gulleys to avoid the overflow which might be caused by a heavy rainfall, (e) Separate latrines should be constructed for officers and men. (/) They should be located to leeward of the comp, if practicable. The seating capacity of the latrine area, as given by various au thorities, ranges from 5 to 15 percent of the command, depending upon the conditions. For commands on the march, stopping for only one night in camp and breaking camp shortly after breakfast, a latrine frontage of 1 yard for every 10 men is not an excessive allow ance. It is not always practical to construct this number, and under such circumstances the medical officer should be satisfied with a 6- to 8-percent frontage, using the latter figure for commands under 500. In a semipermanent camp estimate one seat for every 15 men. The advantage of straddle-trenches is that the sides are not sub ject to contamination by urine. A trench lasts 1 to 2 days. For straddle-trenches the frontages required in yards is six times the complement in hundreds —that is, 200 men will need 12 yards of latrine frontage. The depth in yards is two-thirds the number of days stay in that camp. Care of latrines. —When deep latrines are filled to within 1 foot of the surface with excreta, they should be filled in with earth and abandoned. The filled-in latrines should be covered with a mound of earth and labeled with an l'L" if practicable. This marking of the abandoned latrines serves to inform future occupants of their site. The inside of deep trench latrines should be darkened by the use of tar paper, lampblack, or other suitable material. The use of a dark substance will prevent the entrance of ova-depositing flies. This depends upon the principle that flies usually avoid dark places. The box cover may be removed occasionally and the inside burned out with kerosene or crude oil. In order to prevent the egress of any fly larvae which may develop in the depth of the latrine and burrow through the ground around the mouth of the pit, an area of about 4 feet around the pit should be covered with crude oil, or a 5-percent solution of cresol. A better method is to cover the area with burlap sacking soaked with crude oil. It is very desirable that some provision be made for the men, especially cooks and other food handlers, to wash their hands SOAKAGE PITS AND GREASE TRAPS 359 after using the latrines. Sufficient toilet paper should always be available. In order to prevent the possible flooding of latrines by storm water, a shallow trench should be dug around the area occupied by the latrine. Latrines should be surrounded by a canvas screen or a screen made of shrubbery. Soakage pits.—Soakage pits are one of the greatest developments in improvised sanitary appliances. The writer has installed them in cells and other compartments of a tropical prison and found them easy to maintain in comparatively good sanitary condition over periods of months and years. These pits are designed for the ultimate disposal of liquid wastes, urine, sullage water and ablution water. These sanitary expedients should be considered in the establishment of semipermanent and permanent camps. Ant heaps, or nests of other termites have been used as ready- made soakage pits, and have been found capable of absorbing 300 gallons of waste in 24 hours. Soakage Pits and Grease Traps Ukinal soakage pits.— (a) Dig a pit 4 feet square—easily remem bered —fill to within 6 inches from surface with large stones, or empty perforated cans. (b) Insert 4 pieces of iron piping, 1 to 2 inches in diameter, and iLy2 feet long at each corner of the pit, so that the upper end is at a convenient height above the ground to serve as a urinal. If iron piping is not available, long tin or tar-paper funnels may be improvised for this purpose. (c) Cover stones with oil-soaked burlap sacking, tar paper, or other material. (d) Fill over burlap with earth. (e) Insert replaceable tin funnels in iron piping —preferably with screening over apex of funnel to catch cigarette butts and other debris. (/) Surround urinal pit with white-washed stones—to render more visible at night. (ff) A vent leading into the pit may be constructed to give exit to t he gases of fermentation and putrefaction. (h) In porous soil, one urinal soakage pit will dispose of urine of 100 to 200 men for an indefinite period. (See fig. 3.) Night crinals. —If the urinals are located some distance from the camp, it is a temptation to a man desiring to evacuate his bladder, 360 FIELD SANITATION MANN particularly on a cold night, to urinate upon the adjoining tent, and so on down the company street. To overcome this tendency, urinal cans should be placed in the company streets at night, with a lighted (Modified from "Lolcon") Figure 3.—Urine soakingc pit. lantern to mark the location. The cans used for urinals should be cleaned and sunned during the day. Figure 4 represents a simple and easily constructed night urinal, which we found most helpful in the early days at Quant ico. An ordinary garbage can top is per forated at the center, and a urinal trough is secured by solder. Placing this converted top upon the regulation garbage can makes a very satisfactory night urinal. Or a more simple type of night urinal can be improvised by making a hole in center of top of gar bage container and placing the inverted top over the garbage can. Stallage pits. —The sullage pit is for the disposal of water from kitchen garbage. These pits are 4 by 4 by 4 feet. They should be fitted with grease traps to remove the grease which tends to clog the interstices of the soakage pit. In very temporary camps, sand and gravel placed in a can or bucket with perforated holes at bottom will serve to remove the major portion of the grease. SOAKAGE PITS AND GREASE TRAPS 361 \/ / < rKinnn 1 innnofi L , • . J - J U U U U u3 i Figure 4.—Night urinal. The improvised bucket grease trap may be placed over the open soakage pit filled with stones. Ablution pits— If the ablution water is run through a box of fine sand, before entering the soakage pit, the major portion of the soap is removed. See Figure 5 for a combined soap and grease trap. (After "Ltlton") Figure 5.— Waste water and grease trap. 362 FIELD SANITATION MANN Ash barrel grease trap. …