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JAN 26 1924" UNITED STATES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PLANNING AND PUBLICATIONS CAPTAIN D. N. CARPENTER, MEDICAL CORPS, U. S. NAVY IN CHARGE EDITED BY LIEUTENANT COMMANDER W. M. KERR, MEDICAL CORPS, U. S. NAVY JANUARY, 1924 (MONTHLY) Compiled and published under authority of Naval Appropriation Act (or 1924, approved January 23, 1923 WASHINGTON GOVERNMENT PRINTING OFFICE 1923 KAVY DEPARTMENT, Washington. JI m·ch to, 1907. This UNITED STATES NAVAL MEDICAL BULLETIN is published by direction of the department for the timely information of the Medi- cal and Hospjtal Corps of the Navy. TRUMAN H. :NEWBERRY, A cting S ec1·eta1·y. Owing ro the exhau tion of certain numbers of the B-c;LLETIN and the frequent demands from libraries, etc., for copies to complete their files, the return of any of the following issues will be greatly appreciated: Volume VII, No. 2, April, 1913. Volume VIII, No. 1, January, 1914. Volume VIII, No. 3, July, 1914. Volume VIII, No. 4, October, 1914. Volume X, No. l, January, 1916. Volume XI, No. 1, January, 1917. Volume XI, No. 3, July, 1917. Volume XI, No. 4, October, 1917. Volume XII, No. 1, January, 1918. Volume XII, No. 3, July, 1918. • SUBSCRIPTION PBICE OF THE BULLETI:I'. Subscriptions should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. rearly subscription beginning January 1, $1.50; for foreign subscription add $1.00 for postage. Single numbers, domestic, 15 cents; foreign, 24 cents, which includes foreign postage. Exchange of publications will be extended to medical and scientific organiza- tions, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, Unlted States !\aYy, Washington, D. C. II - TABLE OF CONTENTS. Page. PREF ACE --------_ -----------------------_ ---------- - -------------- V NOTICE TO SERVICE CONTRIBUTORS____________________________ VI SPECIAL ARTICLES: CLIMATIC Buno. By Commander C. S. Butler, Medical Corps, U. S. Navy______ 1 NOTES ON 350 APPENDECTOMIES. By Lieut. Commander Lucius W. Johnson, Medical Corps, U. S .. NaVY------------------------------------------------------ 7 CLINICAL TRIAL OF THE ELLIS TEST FOR TUilEltCULOSIS. By Lieut. D. Ferguson, Medical Corps, U. S. Navy____________ 17 CANCER IN ST. CROIX, VIBGIN ISLANDS. By Lieut. C. B. Van Gaasbeek, Medical Corps, U. S. Navy______ 31 SUGAR IN URINE. Lieut. Commander C. W. 0. Bunker, Medical Corps, U. S. Navy, and Pharmacist's Mate R. L. Thrasher, first class, U. S. NavY------------------------------------------------------ 3J CLINICAL NOTES : ENDOTHELIOMA. By Lieut. L. H. Williams, Medical Corps, U. S. Navy__________ 39 GLANDERS IN MAN. By Lieut. L. H. Williams and Lieut. R. C. Satterlee, Medical Corps, U. S. Navy_________________________________________ 41 ACUTE APPENDICITIS WITHIN A HERNIA SAC. By Lieut. C. B. Van Gaasbeek, Medical Corps, U. S. Navy______ 43 CHANCRE OF THE PALMAR SURFACE OF THE HAND. By T.ient. (J. G.) J. E. Root, jr., Medical Corps, U. S. Navy____ 44 RECURRENT DIFFUSE SCLERODERMA, A CASE OF. By Lieut. C. W. Lane, Medical Corps, U. S. Navy_____________ 45 ACUTE YELLOW ATROPHY OF LIVER, A CASE OF. By Lieut. G. L. McClintock, Medical Corps, U. S. Navy________ 49 NOTES AND COMMENTS: Meeting of the Association of Military Surgeons.-Protection of capital ships against poison gas.-Thomas ,vakley and the Lan- cet.-Diathermy in pneumonia.-Prophylactic injection of normal serum against measles.-Lamblial dysentery treated with carbon tetrachloride.-Endocrine survey________________________________ 53 NAVY NURSE CORPS--------------------------------------------- 75 INSTRUCTIONS TO MEDICAL OFFICERS: Shortage in petty-officer ratings in Hospital Corps.-Hremostatic forceps and surgical needles carried in stock at the medical supply depot-Form N. M. S. F. (revised) .-Policy of U. S. Employees' Compensation Commission regarding employees suffering from oc- cupational diseases; now considered compensable and entitled to treatment.-Hospital accounting.-Examiaation report, Hospital m IV TABLE OF CONTENTS. INSTRUCTIONS TO MEDICAL OFFICERS-Continued. Page. Corps, U.S. Navy; Form N. M. S. H. C. 1.-Analysis of the naYal hospital ration for 1923 (continental hospitals only).-Reprints of the bureau's circular letters for office files.-Additional data re- quired on the Form F card in all cases of injury.-Health records retained in •files.-Wampoles hypno-bromic compound.-Wampoles hypno-bromic compound, analysis reqi1estecL_____________________ 81 BOOK NOTICES---------------------------------------------------- 103 PREVENTIVE MEDICINE, STATISTICS: PNEUMONIA, RRO;,CHITIS, AND TONSILLITIS SEASON. HOUSING, VENTILA· TIOK, AND CONTACT. By Lieut. Commander J. R. Phelps, Medical Corps, U. S. Navy__ 107 ?.lass immunity to diseases.-Human intestinal parasites in Guam.- Prevention of ,enereal disease in England.-Vital statistics_______ 127 ,. PREFACE. The United States Naval Medical Bulletin was first issued in April, 1907, as a means of supplying medical officers of the United States Navy with information regarding the advances which are continually being made in the medical sciences, and as a medium for the publication of accounts of special researches, observations, or experiences of individual medical officers. It is the aim of the Bureau of Medicine and Surgery to furnish in each issue special articles relating to naval' medicine, descriptions of suggested devices, clinical notes on interesting cases, editorial com ment on current medical literature of special professional interest to the naval medical officer, reports from various sources, historical essays, notes and comments on topics of medical interest, and reviews or notices of the latest published medical books. The bureau extends an invitation to all medical officers to prepare and forward, with a view to publication, contributions on subjects of interest to naval medical officers. In order that each service contributor may receive due credit for his efforts in preparing matter for the Bulletin of distinct origi nality and special merit, the Surgeon General of the Navy will send a letter of commendation to authors of papers of outstanding merit and will recommend that copies of such letters be made a part of the official records of the officers concerned. The bureau does not necessarily undertake to indorse all views or opinions which may be expressed in the pages of this publication. E. R. Stitt, Surgeon General United States Navy. V NOTICE TO SERVICE CONTRIBUTORS. When contributions are typewritten, double spacing and wide margins are desirable Fasteners which can not be removed without tearing the paper are an abomination. A large proportion of the articles submitted have an official form, such as letterheads, numbered paragraphs, and needless spacing between paragraphs, all of which require correction before going to press. The Bulletin endeavors to follow a uniform style in headings and captions, and the editor can be spared much time and trouble and unnecessary errors can be obviated if authors will follow in the above particulars the practice of recent issues. The greatest accuracy and fullness should be employed in all citations, as it lias sometimes been necessary to decline articles otherwise desirable because it was Impossible for the editor to understand or verify references, quotations, etc. The frequency of gross errors In orthography in many contributions Is conclusive evidence that authors often fail to read over their manuscripts after they have been typewritten. Contributions must be received two months prior to the date of the issue for which they are Intended. The editor is not responsible for the safe return of manuscripts and pictures. All materials supplied for illustrations, if not original, should be accompanied by a reference to the source and a statement as to whether or not reproduction has been authorized. The Bulletin intends to print only original articles, translations, in whole or in part, reviews, and reports and notices of Government or departmental activities, official announcements, etc. All original contributions are accepted on the assumption that they have not appeared previously and are not to be reprinted elsewhere without an understanding to that effect. VI U. S. NAVAL MEDICAL BULLETIN Vol XX. JANUARY, 1924. No. L SPECIAL ARTICLES. CLIMATIC BUBO. By C. S. Botlbb, Commander, Medical Corps, United States Navy. Definition.—An adenitis affecting the lymph nodes of the groin and characterized by prolonged course, slight fever, and a tendency to necrosis on the part of the nodes involved. Synonyms. —Tropical bubo; nonvenereal bubo; adenitis tropi- calis; Klimatische Bubonen (Ger.) ; les bubons climateriques (Fr.) ; bubone climatica (Ital.) ; bubo climatica (Span.). Etiology. —Though natives are affected, the condition is much more common among white people, and among men it occurs much more frequently than among women ; in fact, it is rarely seen in the latter. This prevalence of climatic bubo among white men and its absence among white women in the tropics lends support to the prevailing idea that the disease is venereal in origin. In nearly all cases of cli matic bubo there is a history of a recent immoral contact, and gener ally this has taken place with a native woman. When we eliminate the usual causes of inguinal bubo, such as gonorrhea, chancroid, syphilis, and sepsis, not to mention plague, septic absorption from sores on the feet, from wounds and from mycotic affections of the feet and crotch, from filarial disease and from trypanosomiasis, there still remains a group of inguinal bubos for which physicians practicing in the tropics are unable to assign a distinct cause, though it is evi dent that the condition is due to a living germ of some sort. We are unable to say, then, whether tropical bubo is a distinct disease or whether it is one of the usual agencies acting in an unusual way. The disease has its greatest incidence among white soldiers and sailors serving in the hot, humid conditions which prevail in many parts of the tropical world. It is not, however, confined to the Tropics, as is shown by Inspector General Godding's figures for the British Navy and by Scheube for Kioto, Japan (35° N). In the United States Navy there are cases of apparently nonvenereal inguinal bubo which occur in northern climates. These cases are ■2 VoI.*SX- BUTLER—CLIMATIC BUBO. inci-eased in incidence for ships stationed in the Tropics and for the personnel of many tropical shore stations. Heiner (Nav. Med. Bulletin, 1913, p. 12G) published 18 cases of climatic bubo, in all of which a sexual exposure had occurred (usually about three -weeks previously). In 13 of these cases smears from the excised glands showed the presence of organisms resembling gonococci. In this connection it may be stated as immunologically conceivable that, with a uretha locally immune from a former gonorrhea, a gonor- rhceal lymphangitis eventuating in an inguinal adenitis might occur from inoculation with a new strain of gonococcus which would pro duce little or no urethritis. Again the bacillus of Ducrey might conceivably gain entrance to the lymphatics and cause adenitis, the portal of entry having healed without being noticed. In each of these hypothetical cases, culture of the material from the bubo upon the ordinary culture media of the laboratory would give negative results. Nearly all investigators have reported the primary culture of tropical bubo material as negative. The majority of naval medical officers who have seen this so-called climatic bubo are firm in the belief that it is usually venereal in origin, though they are unable to explain how the virus gets to the inguinal lymph nodes without leaving some local evidence of its point of entry. We know, however, that adenitis, other than inguinal adenitis, does occur, and that it is often impossible to find the point of entry of the infecting germ. Thus, in plague, the first evidence of infection may be the bubo and there may be no lymphangitis in the area drained by the node involved nor any papule or vesicle indicating the probable point of entry of the bacillus. It may be well to men tion here that B. pestis has been thought to be the cause of climatic bubo. Cantlie was formerly of this opinion. Other authorities have attributed climatic bubo to malaria. Each of these views is erroneous, and it may be positively stated that neither plague nor malaria has anything to do with the cause of the condition we are speaking about. Twenty years ago Scheube wrote " The question of the cause of climatic bubos, according to the material at present obtainable, is impossible to answer, and its explanation must be left for reply to future investigation. Only this much may be said, that the affection is caused by some still unknown factor that has undoubtedly some connection with the climate." At present, the status of the etiology of climatic bubo is substantially as he gave it for the year 1903. Pathology. —The inguinal or the femoral glands on one or both sides may be involved. Usually the glands above Poupart's ligament are the ones affected, unilaterally as a rule, but occasionally on both sides. One or several nodes may be enlarged, and. in the latter case, No. 1. 3 BUTLER—CLIMATIC BUBO. one of the series may become much larger than the others. After subsidence of the adenitis, there may be relapse on the same side or the process may occur^on the other side, leaving the nodes first in volved alone. The size of the inflamed nodes varies from that of a filbert to that of a hen's egg. The nodes are congested, edematous, and may soften and give a sense of fluctuation. Often the reaction extends to the capsule and causes a periadenitis. Culture of mate rial taken by gland puncture is usually negative, as stated above, when ordinary culture materials are used. We are not aware of any special methods or media having been employed in the study of this condition. If cultures in the early cases are positive, the organisms usually recovered are staphylococci. When the bubos have been sup purated, as occurs in about 40 per cent of the cases, or when the glands have been dissected out, of course we get the ordinary pus organisms in our cultures. Letulle and Nattan-Larrier (Bull, de la Soc. de Path, exot., v. 3, 1910, p. 758) describe the histologic changes in climatic bubo as : 1. Dislocation of the glandular tissue. 2. Plasma cell infiltration, diffuse and patchy. 3. Insular necrosis of the reticular tissue of the gland. They were unable to stain any bacteria in the single node which they studied. As regards the leucocyte reaction in climatic bubo, it seems that in the early stage of the condition there is a slight leucocytosis. Not all cases, however, give this. Counts vary from normal to 25,000 and over per cubic millimeter. As a general thing the leucocytosis is between 10 and 20 thousand. Certain authors, as, for instance, Clayton (Jn. Trop. Med. Jan. 2, 1905) and Phillips (Nav. Med. Bui., July, 1912), have called attention to what would seem to be a rather constant eosinophilia in climatic bubo In their cases apparently they excluded the things which ordinarily give an eosinophilia, such as intestinal parasites. One of Clayton's cases showed as high as 22 per cent of eosinophiles. Another case showed 8 per cent of eosino- philes, while in both of Phillips's cases the percentage of eosinophiles was around 8. Phillips suggested that climatic bubo might be due to some protozoan on account of the eosinophilia. This probably has no etiological significance. It may, however, be of some diagnostic significance, in that plague, with which climatic bubo may be con fused, has no eosinophilia. In the case of plague, however, the leucocyte counts are very much greater. Climatic bubo, if the gland suppurates, gives a polynucleosis as does any other abscess. One of Clayton's cases gave the following white counts on different days of the disease: November 24, 11,200; December 12, 18,200; January 4, 10,000; and February 15, 45,000. On the whole, there isn't much 4 Vol. XX. BUTLER CLIMATIC BUBO. that we can say about blood counts in climatic bubo except that there seems to be primarily in most cases a slight leucocytosis. Symptomatology. —The period of incubation of climatic bubo is approximately three weeks. As regards its symptomatology, fever (slight) usually remittant in type, occurs in the majority of cases. Malaise and some pain in the region of the affected gland is almost constantly noted. Glands vary in size from a filbert to a hen's egg and often give the impression of fluctuation. If the disease lasts for 4 to 6 weeks there is usually some anemia developed. At times the disease runs the course without fever. At other times the fe brile reaction seems to precede the enlargement of the lymph nodes. The course of the disease is from 10 days to 4 to 5 months. Chilly sensations and pain in the back and legs are occasionally complained of when the disease begins. Some authors have described a general adenopathy accompanying the inguinal enlargement. In the writer's experience this is unusual. Diagnosis-—Conditions from which climatic bubo are to be differ entiated are mild forms of plague in regions where plague occurs ; from venereal bubos where the venereal evidence is slight; from Hodgkin's disease showing primary inguinal involvement. Usually the diagnosis is easily made. In case of plague, while about 70 per cent of plague bubos are inguinal, the other symptoms are more marked and graver than in the case of climatic bubo. The leucocy tosis, the greater tenderness of the bubo, and the mental condition of the patient should serve to differentiate. Gland puncture and laboratory study, will demonstrate B. pestis. As regards the dif ferentiation from Hodgkin's disease, it is not usual for the primary enlargement of the lymph nodes in Hodgkin's disease to be inguinal. The blood picture is different: and though there may be periods of fever in Hodgkin's disease, the course of this disease is quite different from that of climatic bubo, and there is no tendency on the part of the glands to undergo necrosis in pseudoleukaemia. Prognosis. —Thirty-six cases of climatic bubo published by Ruge showed 60.5 per cent of the swellings absorbed, notwithstanding their size, without operation, while 39.5 per cent had to be operated upon. Climatic bubo appears not to be primarily dangerous to life. Secondary infections, however, may cause the death of the patient. Treatment.—The treatment of climatic bubo deserves considerable study. From the figures published above—that is. that 60 per cent of these swellings may be absorbed without operation —it is evident that the expectant treatment has considerable to be said in its favor. The shortening of the course of the disease and getting the patient off the sick list are not necessarily the main considerations. If by the expectant treatment we can obtain the cure of more than half .No. 1. 5 BUTLER CLIMATIC BUBO. the cases and at the same time leave the lymphatic structures intact it would certainly seem worth while to try this treatment out. Once the glands have been dissected out they can not be replaced, but na ture's repair to the nodes, as is often effected if she is given a chance, probably leaves a large part of the gland structure and gland con nections in as good condition as before. To this end the patient should be put to bed and ichthyol applied on gauze by means of a firm bandage. If the glands suppurate it is probable that the next best treatment is to open up only those nodes that are broken down. This radical treatment consists in dissecting out all of the dis eased glands and closing the wound thus made in the hope that it will heal with the least possible loss of tissue. There is little doubt that this radical operation shortens the course of the disease con siderably. There is grave doubt, however, as intimated above, that it is best in the long run. Internal medication by salicylates, quinine, and the usual array of " specifics " is useless. Rest, laxatives, and tonic are the general measures indicated. The author of this paper submitted it to Capt. Raymond Spear, Medical Corps, United States Navy, and to Lieut. Commander J. R. Phelps, Medical Corps, United States Navy, for comment. Comments by Capt. Raymond Spear. —" In my experience with climatic bubos, I do not believe 60 per cent of real tropical bubos recover without operation. One point in tropical bubo I think you have not mentioned, is the involvement of the skin. Personally I believe if the glands are much involved and the skin is red and the patient is running a temperature, the quicker the glands are removed the better. It is really wonderful how a man who is suffering from absorption from the infected glands and who has been in bed two or three weeks, or possibly longer, will recover when the diseased tissues are removed. From this point alone it looks to me as if the disease were entirely a local one. Many times it is of course difficult to diagnose these cases before operation, but at the operation the ap pearance of the glands in tropical bubos is typical. They resemble tonsils involved in an acute follicular tonsillitis. " The operation of choice, to my mind, is to make a clean dissec tion of the glands with the idea of removing all the overlying skin and not to make any attempt at sewing the wound up. In a series of about 10 cases that I operated on while in Guantanamo, Cuba, the cases having originated in Haiti, I did this operation and short ened the convalescence, I am sure, by exposing the wounds directly to the air and sunlight and protecting them by a wire-mesh guard which was held in place by a strap around the waist and one around the thigh." 6 Vol. XX. BUTLER CLIMATIC BUBO. Comments by Lieut. Commander J. B. Phelps. —" The United States Navy Nomenclature of Diseases and Injuries at present con- tains no diagnostic title intended specially to cover so-called climatic or tropical bubo The general title, "Lymphadenitis, acute, Clasa XIV, Diseases of the lymphatic system," is the only term now avail able for cases which after careful consideration appears to belong in such a group. " In the last analysis, the validity of morbidity statistics depends- upon the judgment of the medical officer who returns the case mor bidity report. He is the one who sees the patient, studies the case,, and makes the diagnosis. The nomenclature is but an alphabetical list of approved names and approved spelling. The case occurs and a diagnostic title must be selected. If there is not a special term available that will accurately describe the case and differentiate it from all or many other conditions, the medical officer must choose the diagnostic title that best serves the purpose. " The inclusion of the nomenclature of such a term as climatic bubo has been regarded as objectionable by the Bureau of Medicine and Surgery on the ground that a high percentage of erroneous diag noses would contribute to make the figures for the title inconclusive or without value. It all goes back to the care exercised by each medical officer concerned and the accuracy of his observations. These cases at present are returned for the most part under the diagnosis, acute lymphadenitis, without specification as to anatomical location. Obviously no conclusions of epidemiological importance can be drawn from the figures under such classification. Consequently, the question of classification is of secondary importance in this instance,, there being no class specifically representing either a pathological or epidemiological entity to protect from the statistical standpoint. " Therefore, the title, ' Inguinal bubo, nonvenereal,' has been in cluded in the revised edition of the Nomenclature, which, it is hoped,, will be ready for adoption before the new year. But it will not be wise to take figures compiled from reports returned under this head ing at their face value. Doubtless, some cases that are really venereal in origin will be included either because of the lack of evidence of venereal infection altogether or because the infected individual is given the benefit of the doubt. The term will be used for all in fections regarded as nonvenereal in origin; not simply for idio pathic cases or those regarded as due to the often indeterminate influence of climate or geographical location. It is not considered practicable for statistical purposes to provide a more specific term. Until climatic bubo has been placed upon a more exact clinical basis through experimental studies or epidemiological investigation, sta tistical studies can not be relied upon for additional direct informa tion." So. 1. 7 JOHNSON NOTES ON APPENDECTOMY. NOTES ON 350 APPENDECTOMIES. By L. W. Johnson, Lieutenant Commander, Medical Corps, United States Navy. It is customary to begin an article on appendicitis with an apology for writing anything further on a subject about which everything worth while has already been written. Such an apology would be appropriate if all cases of the disease were alike ; but its most strik ing feature, and the one which justifies articles on the subject, is its protean nature, its tendency to disguise itself as something else. This is evident not only in the operating room and the ward but also in the literature, where surgeons of equally great experience will be found to hold radically different views as to the causes and symp toms of appendicitis. No effort will be made in these random notes to cover the field of diagnosis or treatment in a systematic manner. I desire merely to discuss certain points which have proved useful or interesting to us in our work. The operations were done in naval hospitals, hospital ships, and other naval vessels, as well as a few in civil hospitals. With a few exceptions, the patients were men or officers of the Navy, a group from which the physically unfit are supposedly excluded, so it may be expected that our statistics will be somewhat different from those whose patients include all classes of people. SYMPTOMS. Fever. —Morison says (Lancet, Vol. CCIII, No. 5167, September, 1922, p. 553) : " It is probably true to say that sudden, severe abdom inal pain attended by a rise in temperature means mischief in the appendix." This is true when fever is present, but in an equally great number of cases there is no rise in temperature during the first 24 hours, when diagnosis is most difficult and most important. If the fever goes above 102° during this period, one should search care fully for other infections which may be present either with or with out appendicitis. In this series more than one-half of the acute cases had no rise of temperature up to the time of operation. Most of these were mild, but several were very severe, obstructive, or gan grenous. Most of the acute cases with fever had temperatures between 100° and 102°. Those with temperatures above 102° were all found to have abscess, general peritonitis, or some complicating condition, usually in the lungs, which would account for the high fever. Abscence of fever means little, but if present it suggests to some extent the pathology that is present. Pulse rate. —In the early stages of the disease the pulse rate offers little help in diagnosis or prognosis. It is seldom above 100 unless there is gangrene, obstruction of the lumen of the appendix, or a 8 JOHNSON —NOTES ON APPENDECTOMY. Vol. XX. complicating infection, such as bronchitis. The very rapid pulse belongs to the later stages and is the result of complications or exten sion of the disease, frequently there is no increase in the rate, and even very severe cases with rupture or peritonitis are seen with the pulse rate remaining normal. In the early stages of the disease the pulse rate is more constantly affected by the severity of the pain than by any other factor. Nausea or vomiting. —This is one of the early and constant symp toms of the disease, usually appearing within three or four hours after the initial pain. The vomiting is usually not marked or per sistent, though nausea may continue. Persistent, severe vomiting is due to some complication. We have very frequently observed that vomiting is a much more prominent symptom in cases of obstructive appendicitis with pus under pressure distal to an obstruction of the lumen. While nausea and vomiting are very constant as a symptom, we had 3 cases of severe, fulminating, gangrenous appendicitis in which this symptom was absent. If there is any rule which is uni versally true in appendicitis, it is that if the vomiting appears before the pain it is not appendicitis. Next to the pain, nausea or vomit ing is the most constant and reliable symptom. Leukocyte Count.—Many of the operations were done in such places or under such conditions that no reliable blood counts were re corded, but in 131 of the acute cases this was noted. The absolute leukocyte counts were distributed as follows : Per cent. Group 1 (8,000 or below) 5.3 Group 2 ( 8,000 to 15,000) 41.2 Group 3 (15,000 to 20,000) 38.6 Group 4 (20,000 or over) 1ft 8 In groups all cases were mild : none had pus under tension in the appendix. One case, with 7,500 leukocytes and 47 per cent polynuc- Jears, had no appendicitis, but hyperplastic tuberculosis of the lower ileum. In group 2, all were acute, severe appendicitis with distinct gross pathology. All recovered except one (No. 348) which reached the hospital on the 11th day of the disease and died 16 days later. Eighteen per cent of these cases had pus under tension in the appen dix and 14 per cent were found to be ruptured. In group 3, about 60 per cent had pus under tension in the appendix ; 20 per cent had rup tured; 12 per cent had infections in other organs which probably affected the white cell count. All had acute, severe appendicitis. One died of streptococcus septicemia. In group 4, 80 per cent had gangrenous or ruptured appendices and 20 per cent had acute appen dicitis with bronchitis as a complication. ^o. 1. JOHNSON—NOTES ON APPENDECTOMY. 9 The differential count is of greater value. The rules laid down by Hewitt (Ann. Surg., 1917, Vol. LXVI, p. 143) cover this very well: " First, the absolute count, when taken alone, is of questionable , value. " Second, the polynuclear count alone is, in the great majority of instances, a reliable index in diagnosis. " Third, the correlated absolute and polynuclear counts are of greater value than either count taken alone, especially as regards prognosis. "A high absolute count with a high polynuclear count means usually a good prognosis (e. g., absolute, 35,000; polynuclear, 95 per cent) . A high absolute count with a moderately low polynuclear (e. g., absolute, 30,000, polynuclear, 80 per cent) means usually a very good prognosis. A low absolute count with a high polynuclear count (e. g., absolute, 7,000, with polynuclear 95 per cent) indicates a grave prognosis (speaking generally). A low absolute count with a low polynuclear count means (e. g., absolute, 7,000, with poly nuclear 65 per cent) usually no infection, or that the acute condi tion is due to anatomical or mechanical causes; in other words, that the infection, if one be present, has not stimulated the resisting powers of the body sufficiently to produce a leukocytosis. " Fourth, normal or subnormal figures do not necessarily indicate the absence of suppuration, gangrene, or their sequels. " Fifth, catarrhal cases, fulminating cases, moribund cases, and walled-off abscesses frequently do not stimulate leukocytosis." At the San Francisco session of the American Medical Association in June, 1923, Ochsner said (Journ. Amer. Med. Assoc., vol, 81, No. 8, Aug. 25, 1923, p. 631) : "A leukocyte count is invariably made — and never looked at until after the operation has been completed. It is not well to cloud one's judgment by paying attention to it be forehand. * * * The plan followed by many surgeons of always operating immediately in case of a high leukocyte count or a rising count is bad practice because the judgment is then controlled by a minor factor, which is inconstant and unreliable, instead of being based on history and physical examination." Other surgeons present took exception to this, saying that the leukocyte count was valuable in diagnosis and in indicating the treatment, especially in children where the high count suggests pneumonia rather than appendicitis. In our cases the white-cell count proved of considerable value. Those with a count of 8,000 or below were all mild. Those above 15,000 were more serious than those below that figure, and those above 20,000 were all gangrenous, ruptured, or had bronchitis as a complication. 10 Vol. XX. JOHNSON —NOTES ON APPENDECTOMY. Chronic Appendicitis. —At the present time this occupies a much larger place in medical literature than does the acute condition. This is largely due to the fact that a very great number of operations for chronic appendicitis do not relieve the symptoms. Since this lesion may mimic disease of any organ of the abdomen, including the urinary organs, and since lesions of many organs may cause pain in the right iliac region, chronic appendicitis must be considered as a possibility in nearly every case of chronic abdominal distress. There is a strong tendency to blame the appendix for every case of chronic indigestion in which the diagnosis is difficult. This is largely because we know of a definite thing to do for that condition —remove the appendix. The danger of making this quick and easy diagnosis before eliminating all the other possibilities is shown by the fre quency of postoperative persistence of symptoms. The following rules have proved very useful to me in diagnosis: (a) Most cases of chronic appendicitis follow acute attacks which have recovered without operation. It is stated that there is no chronic appendicitis without a previous, definite, acute attack. Hence a careful history is important, (b) While pain in the right iliac region is the most important single symptom, if pain is limited entirely to this region it is probably not chronic appendicitis, (c) Practically every case of chronic appendicitis gives a history of pain and digestive disturbance. The more difficult it is to deter mine the cause of chronic indigestion, the more likely it is to be the appendix. It has been our custom, whenever possible, to study our interval or chronic cases thoroughly before operation, by gastric analysis, X ray and opaque meal, urethral catheterization, pyelography, or other suitable means. When they come to operation a large rectus incision is usually made in order to explore the gall bladder, pylorus, and other organs. The X ray has been of the greatest help by show ing abnormalities of the stomach, gall bladder, pylorus, or kidney. Assuming that the normal appendix fills and empties about twice per hour while the cecum is full, prolonged retention or absence of the opaque material from the appendix suggests an abnormal condi tion. Excessive mobility or fixation of the cecum can often be demonstrated by the X ray and may cause symptoms resembling chronic appendicitis. In several cases where there was no appen diceal shadow and the symptoms approached a definite neurosis the appendix was found to be of the obliterative type. Bastedo's test for chronic appendicitis is made by passing a tube about 10 inches into the rectum and injecting air by means of a bulb. As the air pressure increases, the pain and tenderness are greatest near McBurney's point if there is chronic appendicitis. Several surgeons have written in praise of the test, while others have not No. 1. 11 JOHNSON—NOTES ON APPENDECTOMY. found it reliable. Rosehbloom (Surg., Gyn. and Obstet., November, 1916, p. 538) found the test positive in each of 14 cases of chronic ap pendicitis and negative in each of 26 cases not having this condition. We tried this test in 22 cases of suspected chronic appendicitis, but the results were so inconstant and so difficult to interpret that we found it of little value. It was present in several cases where there were dense adhesions or a heavy veil about the appendix. OPERATION. Choice of Operation. —The McBurney gridiron incision was used in 66.8 per cent of the cases, a rectus incision in 22 per cent, a low midline incision in 1.5 per cent, and 9.7 per cent were removed through a herniotomy incision. It has been our custom, in males, to use the McBurney incision in all acute cases where the presence of rupture or abscess is suspected. For interval and chronic cases we use the rectus incision and examine the gall bladder, pylorus, and other organs that may be involved. We customarily remove the appendix in any laparotonry unless there is some good reason for leaving it. The advantages of using the McBurney incision when pus is present are many. It gives quick and easy access to the appendix without soiling other peritoneal areas. All manipulations are done in the safe region to the outer side of the cecum and one can avoid spreading infection to the dangerous region median to the cecum. Drainage through the operative wound or by a stab wound in the flank is easily arranged through the gridiron incision. Two-stage operation.—There are certain cases where, after the peritoneum is opened, it is seen to be inadvisable to remove the appendix during the acute stage. When rupture has occurred, re sulting in a walled-off abscess and removal of the appendix in volves breaking down the wall; when free pus is found and the appendix can not be removed without much manipulation and soil ing of new areas, then it is best to drain and get out as quickly as possible. When the appendix has ruptured it has already done the worst of which it is capable, but the surgeon who takes pride in fetching home an appendix every time he goes after one may greatly increase the damage by spreading the infection with his meddlesome fingers. Treves is quoted as saying, " When you strike pus, quit," and if one follows this rule he will save a greater num ber of his desperate cases. Local anesthesia or nitrous oxid may be used in these operations if the condition is known in advance, and the drain should be inserted as quickly as possible, with the least handling of the intraperitoneal tissues. 69826—23 2 12 Vol. XX. JOHNSON — NOTES ON APPENDECTOMY. In this series there were nine such cases, in which rupture had occurred, pus was present, and the appendix could not be removed without manipulation. Each was drained and returned as quickly as possible to the ward, where Crile's method of treatment was followed. All of them were desperate cases; three of them died. Appen dectomy was later done in five of the survivors. When operating to remove the appendix after rupture it will frequently be found to have amputated itself. This condition was found in three cases, the appendix in one case (No. 607) being found attached to the omentum 5 inches away from the cecum, which showed a scar where the appendix had sloughed off. A large concretion was still present in the lumen and a new blood supply had been established from the adjacent tissues. Such an occurrence might account for some of the cases in which no ap pendix is found at operation. Adhesions will be found to vary greatly after rupture and purulent peritonitis. Some cases operated a month after rupture will be found entirely free from adhesions, while others, after the same interval, will have very dense adhesions. Routine removal.—In 52 cases the appendix was removed as a routine measure in the course of laparotomy for other conditions. Thirty of these showed gross pathology : 22 were considered normal : 14 contained concretions. The appendix is usually removed in right side hernias if it is found in the sac or can be brought down without difficulty. In 28 cases it was so removed, being found in the sac three times. Fourteen of these appendices showed no gross pathology; eight contained concretions ; four showed chronic inflammation ; one was surrounded by a heavy veil ; and one was of the obliterative type. Eleven were removed during gastroenterostomies for peptic ulcer and all showed gross pathology. Five contained concretions; four had heavy veils two were chronically inflamed and adherent. Eight were removed during cholecystectomies and only one appeared normal. Four had concretions and were chronically inflamed ; two were acutely inflamed; one was kinked within a heavy veil. It is interesting to note that of the nineteen removed from patients with cholecystitis and peptic ulcer, all but one showed gross lesions. Four appendices were removed during gynecological operations and one during operation for acute intestinal obstruction. All of these appeared normal. Drainage.— When to drain, by what route, and what materials to use as drains are subjects on which surgeons differ widely. As one's experience increases, fewer and fewer cases are drained. A good rule is, when in doubt, do not drain. Blake (Ann. Surg., Vol. No. 1. JOHNSON—NOTES ON APPENDECTOMY. 13 LXXV, No. 4, April, 1922, p. 385) says that drains into the peri toneal cavity are unnecessary when, after elimination of the cause of the peritonitis, there is no great difference in the appearance of one part of the peritoneum from another. In other words, a dif fuse peritonitis, no matter how bad, does not require drainage, but a localized peritonitis or abscess should be drained. A necrotic or gangrenous appendix does not require drainage if all of the necrotic tissue is removed. The resistance of the peritoneum to infection is very much greater than that of the tissues of the abdominal wall. When the tissues have been soiled during removal of the appendix it is safe to close the peritoneum and leave a drain down to it. A mural abscess may develop, but I have never seen peritonitis develop in such a case. A rubber band, size 32, is suitable for such a drain. If infection develops it makes a hole large enough to insert a small Carrell tube, and if there is no infection it can be removed in 24 to 48 hours without interfering with the healing of the wound. Turbid fluid or plastic exudate is not sufficient reason for drainage. When a walled-off abscess is found within the peritoneum the Carrell-Dakin method, properly applied, will clean it up much more quickly than any other method I have seen. When the abscess is superficial to the peritoneum, in the tissues of the wall, this method is even more valuable because of its ability to dissolve necrotic tissue and remove the sloughing aponeurosis which usually delays the healing process. This property of dissolving necrotic tissue belongs to Dakin?s sodium hypochlorite solution and not to chlorazene. Drainage by a stab wound through the flank is of value in large abscesses, as it allows fluids to escape by gravity. For drainage through the anterior abdominal wall it is better to use a stab wound than to pass the drain through the operative incision, because the extension of infection along the muscle planes and resulting damage to the wall are much less by the former method. How long shall drainage be continued? Opinions and customs vary widely in this. I have seen much damage done by drains being left in too long, but none by removing them too early. Twenty-four to forty-eight hours is long enough for the drain to remain within the peritoneal cavity. If the patient has defensive reaction enough to recover from his infection, the tube will be thoroughly walled off within 48 hours and any further fluid which may appear will be poured out in an effort to float away the irritat ing drain. The drain through the muscle layers, down to the peritoneum, is a different thing, for the contraction of the muscles constantly tends to close the opening, and here the drains will be required for a longer time. When it is probable that an infection 11 Vol. XX. JOHNSON—NOTES ON APPENDECTOMY. of the wall will develop it is well to place the tubes at the time of the operation so that injections of Dakin's fluid can be started without delay. In nearly every case where drainage is found necessary, the Carrel! -Dakin treatment can be used to advantage. Several times, when we have found walled-off abscesses within the peritoneum, we have aspirated the pus, filled the cavity with 2 per cent solution of mercurochrome —220. and closed the peritoneum without drainage. Whether or not the drug made any difference in the recovery is ;i hard question to answer. In this series of cases, 29 (8.2 per cent) were drained. At least 9 of the earlier cases would not have been drained if my experience had been greater at that time. Soft rubber drainage tubes were used and removed in 24 to 48 hours. Buryino the Stump. —The stump of the appendix was buried, in verted, or otherwise given special attention, in 231 cases (66 per cent). It was done in most of the earlier cases and in few of the later ones. Training of younger surgeons is one of the most im portant features of our work, and the desire to give them practice in intestinal sewing usually furnished the motive when the stump was buried. We were unable to observe anything in the convales cence or later history of any of the patients in whom this step was omitted that would lead us to believe that it made any difference to the patient whether or not the stump was buried. Many cases are met in which it greatly increases the difficulty and length of the operation. Extensive adhesions, extreme friability, and induration of a large area of the cecum about the base of the appendix fre quently make it inadvisable to bury the stump. GROSS PATHOLOGY. Concretions.—These were noted in 135 cases (38.6 per cent) . Many times they evidently played a large part in the etiology, and they must always be considered as dangerous. The frequent presence of concretions in appendices which were kinked or distorted by adhe sions or veils was very impressive, and those conditions which inter fere with the normal filling and emptying of the organ evidently have something to do with the formation of fecaliths. Ulcers are frequently seen in contact with concretions. Recently I have seen 37 cases of acute appendicitis in which the lumen was blocked by a con cretion and fluid was under pressure in the distal portion. In 7 cases concretions were found free in the peritoneal cavity after rup ture of the appendix. Gangrene in an inflamed appendix is fre quently seen to be beginning at the site of a concretion. Appendiceal Obstruction. —Dieulafoy maintained (Proges Medi- cale. No. 11. 1896) that appendicitis is always due to conversion of the No. 1. 15 JOHNSON NOTES ON APPENDECTOMY. appendix into a closed cavity. This may be due to concretions, fibrous stricture, kinks, or other causes. Pitzman (Ann. Surg., Feb. 1920, p. 149) contends that there is " no surgical appendicitis without organic stricture," and submits much evidence, both clinical and pathological, in support of this belief. He calls attention to the fre quency with which fluid under tension is found in the appendix distal to a stricture which was evidently pervious until just before the at tack. Since reading Pitzman's article I have looked for this con dition, and in 62.7 per cent of cases of acute appendicitis have found it to be present. Pitzman mentions only fibrous stricture as the cause of the obstruction, but in our cases 71.8 per cent was caused by con cretions, 21.8 per cent by fibrous stricture, and the remainder by kinks. It is quite possible that in those cases where a calculus was the obvious obstructing agent a fibrous stricture was also concerned, the calculus being dislodged from its usual position and forced against the stricture so as to block it. Cases are frequently seen with the lumen obstructed by a stone and the distal portion enormously distended and gangrenous, so that rupture is imminent. By push ing the concretion toward the tip and milking the pus past it into the cecum the pressure can be relieved and the danger of rupture lessened. Pitzman also calls attention to the difference in symptoms in those cases having a definite stricture and those which definitely have none, those with strictures having characteristic sharp attacks with much pain. I have frequently observed this and also that when colicky pain and vomiting (the principal symptoms of intestinal obstruction) are unusually prominent, there will be found an ob struction of the lumen of the appendix. Behan, in a study of experimental appendicitis in rabbits, noted (Am. Jour. Med. Sci., vol. 162, No. 5, November, 1921, p. 705) that the only time acute inflammatory changes in the appendix occurred was when the lumen of the appendix was entirely obstructed. When the obstruction extended beyond the mucosa a very marked reactive inflammation resulted and gangrene of the appendix took place. The bacteria which normally are present in the appendix are harm less while all its tissues are healthy and the lumen is free; but when it is inflamed and the outlet obstructed they develop great virulence, like the gunpowder which burns harmlessly in the open air but develops tremendous force when confined in a closed space such as the chamber of a gun. Obstruction may not be always present, but undoubtedly it is a most important factor in the great majority of cases. Abnormal positions.—In 87 cases (24.8 per cent) the appendix was found in an abnormal position. The retrocecal variety was most common, 58 being of this type. Six others reached to the mid line 16 Vol. XX. JOHNSON —NOTES ON APPENDECTOMY. posteriorly ; 3 rested on the psoas muscle ; 4 were found high up in the fetal position with incomplete rotation of the cecum; 3 were in the pelvis; 8 reached to the mid line anteriorly, and 3 of these were adherent to the bladder; 3 were found in hernial sacs; 3 were found at a distance from the cecum, having sloughed off during a previous attack. These amputated remnants retained their char acteristic structure and had acquired new blood supply in their new locations. One was attached to the parietal peritoneum near the sacroiliac joint : one to the posterior wall of the cecum 2 inches from its original attachment; the third was attached to the mesentery of the ileum 5 inches away from the cecum. Unusual positions were frequently suggested by the symptoms. Several of those in the retrocecal fossa had pain in the flank sugges tive of ureteral colic. Appendiceal pain when walking or jumping was noted in those which had the appendix resting on the psoas muscle. Bladder irritation was present in those having the appendix in contact with the bladder. It is an interesting game to prophesy from the signs and symptoms what will be the location of the appen dix and its pathology. Once in a while a correct guess will be made. When the appendix is in an abnormal position and hard to reach it will be made easier if a tape is passed through the mesenteriuin and used for traction. Then the appendix can not escape while the tip is being freed, and it saves much handling of the intestine. If the base is movable and the tip is fixed, it is well to cut off the appen dix at the base, push the cecum away, and then work toward the tip. Many of the adherent, retrocecal appendices can be reached more easily by going posteriorly, outside the parietal peritoneum, as if for exposure of the ureter, and cutting through the peritoneum alongside the attachment of the cecum. Complicating Conditions. —The following conditions were noted as being present before operation: Tonsillitis in 4 cases, epilepsy in 2, acute cholecystitis in 3, gastric ulcer in 8, and mastoiditis in 1. At operation heavy veils or dense adhesions were found in 53 cases (15.1 per cent) and persistent vitelline duct in one case. Postopera tive complications were: Pulmonary tuberculosis, 8; intestinal ob struction, 3; pneumonia, 7; endocarditis, 2; measles, 1; pyelo- nephrit is, 3; delirium tremens, 1 ; phlebitis of leg, 2. Bronchitis was a very frequent complication, especially while on the hospital ship. At certain seasons nearly every patient coming to us had bronchitis and the rest developed it after operation. Appendicitis following an acute tonsillitis was observed several times, and it was also noted that epidemics of food poisoning with intestinal toxemia usually produced a case or two of appendicitis. It seems remarkable that the custom of giving a cathartic for pain in the belly is still so prevalent. Countless writers and speak No. 1. 17 FERGUSON —THE ELLIS TEST. ers have reiterated for years the warning that appendicitis must be excluded before it is safe to give a cathartic in such cases. Yet a great number of patients, on arrival at the hospital, state that they went to the sick bay with pain in the belly and the medical officer or corpsman gave them salts or castor oil without examining them. One gets the impression that this dangerous, if not criminal, catharsis is still regarded as the proper routine treatment of appen dicitis. A CLINICAL TRIAL OF THE ELLIS TEST FOR TUBERCULOSIS. By David Ferguson, Lieutenant, Medical Corps, United States Navy. INTRODUCTION. The early diagnosis of pulmonary tuberculosis is a problem which has long confronted the medical profession.1 Upon it is not only dependent the expectancy for an early and complete recovery, but also the prevention of infection in those with whom the tuberculous patient is in close contact. It is a well-known clinical fact that early tuberculosis may be suspected from the presence of certain symptoms long before physical findings are demonstrable and also that the reverse may obtain. Too frequently the appearance of tubercle bacilli in the sputum may be greatly delayed. The indeterminate clinical picture which incipient phthisis may present has stimulated search for useful diagnostic aids. In 1891 Koch demonstrated the difference in the reaction to tuberculin in healthy and tuberculous animals, and recommended the sub cutaneous administration of tuberculin for diagnostic purposes. Calmette, Moro, and Mantoux developed the tests which bear their names. In 1907 Von Pirquet and Schick developed the cutaneous tuberculin test. The Tuberculin Reaction. —The high degree of specificity of the tuberculin reaction is generally accepted. False positive reactions are obtained in leprosy, due to the biological similarity of the causa tive organism. They also occur in clinically healthy individuals having either a small hidden tuberculous lesion or a healed focus. False negative reactions are usually found in (a) the terminal cachectic stages of tuberculosis and in fulminant miliary disease in which the patient is so saturated with the tubercle toxin produced by the disease that it can not react to further artificial amounts; (&) the early stages of infection in which insufficient antibody or hyper- sensitiveness has developed; (c) tuberculous individuals who have 1 An excellent resume1 of diagnostic methods and procedures was published In the Naval Medical Bulletin of June, 1023. 18 Vol. XX. FERGUSON —THE ELUS TEST. only slight hypersensitiveness to tuberculin; (d) from trauma, at tendant on the application of the various cutaneous tests, which may result in redness and swelling; (e) the nonspecific skin reaction to foreign proteid. There has been much discussion concerning the mechanism of the tuberculin reaction. Wassermann and Brack accepted the antigen and antibody the ory of Ehrlich. This explanation assumes that those cells at the periphery of the tuberculous focus were possessed of increased re ceptor for tubercle antigen. Because of this, tuberculin would be concentrated at these cells, the result being an increased activity of the lesion and accentuation of the systemic symptoms. This theory does not explain the positive reactions occurring in those who have healed tuberculous lesions. Zinsser regards the mechanism of the tuberculin reaction as a gen eral tissue hypersusceptibility of the nature of anaphylaxis. Mam- vagaries of tuberculin tests may be explained on this assumption. Yon Pirquet found that an individual giving a negative test at first, on retesting in a few days may give a frank positive response. By using his left arm repeatedly for the tuberculin test. Von Pirquet could obtain a positive reaction with a tuberculin dilution of 1-1,000, whereas his infrequently used right arm gave a negative reaction to dilutions of 1-100. Kohn showed that while the first instillation of tuberculin in the eye of a normal person gives no reaction, the eye will not only re act positively to a second instillation but the same positive response is obtained if the second dose of tuberculin is given subcutaneously. Kolmer believes that acquired hypersusceptibility is more analo gous to true serum anaphylaxis than to toxin hypersusceptibility be cause tuberculin in itself is but slightly toxic. The Limitations of the Von Pirquet Test. —Nageli and Burkhart's statistics show that the incidence of tuberculous infection increases with advancing years. Demonstrable tuberculous foci are present in 4 per cent of infants, 70 per cent of children under 14 years, and in 90 per cent of those over 18 years of age. As healed or quiescent foci will give, in the large majority of cases, a positive skin reaction, the usefulness of the Von Pirquet test is greatly limited. At present its value is largely confined to a negative reaction in an infant, which argues strongly against the probability of tubercular disease. The Ellis Modification of the Von Pirquet Test. —In a recent sur vey of the European Clinics, Lieut. Commander W. A. Bloedorn. Medcial Corps, United States Navy, visited Ellis's clinic at London and was very favorably impressed by the thoroughness of the clini cal, laboratory, and X-ray work carried on there. Mo. 1. 19 FERGUSON THE ELLIS TEST. Ellis developed a test for active tuberculosis a number of years ago, and in checking it with his clinical and laboratory staff he found it to be an accurate indicator in 90 per cent of cases. I am indebted to Doctor Bloedorn for the following data on the Ellis test: This test has been used by Ellis in a large number of cases, and he considers it of great help in the diagnosis and prognosis of pul monary tuberculosis. The original von Pirquet test, according to Ellis, was unreliable in that the papillary layer of the skin was not penetrated. Von Pirquet states specifically that in performing this test, blood should not be drawn. Ellis:s investigations lead him to regard the papil lary layer of the skin in which the smaller blood vessels run as the most keenly sensitive to tubercular reaction. He considers that the specific reaction which takes place in the deeper epithelial layer explains to a large extent the erratic results obtained by von Pir- quet's superficial cutaneous method, as when the papillary layer was accidentally injured, much more definite results would be obtained than when it was uninjured. The method of procedure and performing the test of Ellis is as follows : Three dilutions of old tuberculin are used, namely, 1-10, 1-100 and 1-500, the diluent in each case being one-half of 1 per cent carbolic acid in normal saline. The skin of the flexor surface of the forearm is considered the best site for the test. A small drop of each dilution is placed on the forearm, commencing just below the elbow, about an inch apart. Then, using a lancet with a round, very sharp point, a few quick movements are made through the drop and the superficial layer of the epidermis, about one-quarter of an inch long. The blood does not often appear until after the scarification at one point has been finished. The lancet is wiped, and the same procedure is carried out in the control, which is made without tuberculin, making four in all. The essential points are that the bleeding layer must be penetrated, the scratch must be made through the solution, and the knife must be wiped so that no solu tion is carried over to the next dilution, and so vitiate the results. The lancet must be properly sharpened, and there must be at least five small scratches alongside each other at each dilution, or the result is unreliable. The whole is then covered with a small absorbent pad which is retained in position for two days by strips of adhesive plaster around the arm. The procedure causes little inconvenience or discomfort, and the whole process takes less than two minutes; there are no uncom 20 Vol. XX. FERGUSON THE ELLIS TEST. fortable after effects. It is wise to tell the patient that the pro cedure is performed for the doctor's information, and will not cause any general reactions. At the end of the second day, the dressing is removed, and the reaction read. If the reaction is acute, the point of inoculation will be red and swollen. The next characteristic will be the dis appearance of the cut marks in contrast with the control. The swelling ma}7 be quite considerable, and is best appreciated by run ning the finger over the skin. The color varies in two directions. The brighter it is, the more active and recent is the tubercular in fection. When the swelling is considerable, the color is driven out, and the skin assumes a lighter edematous appearance, suggesting a tendency to blister, and the bright color reaction invades the neighboring skin, extending to quite a considerable distance. When the swelling is slight or absent, the color of the reaction is much darker, and is often delayed in appearance, in which case it is advisable to see the. patient again in three days before arriving at a definite conclusion. A darker reaction usually means an old in fection. It may be so dark as to be nearly black, and that means that the case is old, quiescent, or one which will terminate fatally be cause of little or no resistence. The general condition of the patient will easily decide which of the two interpretations is to be recorded. A positive reaction with the 1-100 dilution is one that is con sidered as showing presumptive evidence of active tuberculosis, when it is definitely of a color as bright as the lips, and when definite swelling has occurred. A positive reaction with the 1-500 dilution generally means good resistance and more or less recent extension, except when glands or skin tissues are involved, as these practically always give a positive reaction with this dilution. The darker colored reaction either means failing resistance, a very serious sign in a case possessing other evidences of tuberculous degeneration, or, when the case shows no signs of activity, a condition of very satisfactory stabilization. This often shows itself by a positive reaction in the 1-10 dilution but with dark color, and with the 1-100 dilution showing no swelling and slight dark discoloration. According to Ellis, a positive reaction with the 1-100 dilution is a presumptive evidence of the existence of active tuberculosis in the ratio of 9 to 1, or, in other words, 90 per cent of all cases will show evidence of active tuberculosis. In cases showing a negative or slight reaction, the evidence is against active tubercular disease. One must be careful not to in 3io. 1. 21 FEKGUSON —THE ELLIS TEST. elude a delayed color reaction as entirely negative, and cases showing delayed reaction should be further investigated. COMMENT ON THE ELLIS TEST. Krause showed in experimental tuberculosis that the cutaneous hypersensitivity to tuberculin is increased in progressive disease, is diminished by healing and increased by reinfection. Krompecker and Romer demonstrated that the more virulent the infection the greater is the degree of hypersensitivity to tuberculin in animals. However, they also showed that no such fixed relationship exists in man, and this has been confirmed by other observers. Apparently, in Ellis's hands, this definite relationship in man may be demonstrated by his modification of the von Pirquet test. The disirability for such a test is inestimable. Valuable as it would be as a routine recruiting procedure, its usefulness as a rapid diag nostic method in school children, in industrial medicine, and general out-patient work would make it of greater value than the comple ment-fixation test for lues. Actuated by these considerations, the Bureau of Medicine and Sur gery made arrangements for a clinical trial of the efficacy of the Ellis test. Scope of investigation. —As originally planned, on the basis that we could duplicate Ellis's reactions, it was proposed to use the test on a series of several hundred tuberculous patients in various stages of the disease and on two hundred nontuberculous individuals as controls. \ However, in the first 100 patients tested it was found that the test was not showing anything near the degree of accuracy which Ellis claims for it. Because of the possibility that a faulty technique might be responsible for these results, it was decided to make various minor changes in the application of the test, and to obtain, if pos sible, results approximating those of Ellis before gathering the originally proposed number of cases. A short protocol was made of each case, consisting of name, age, nativity, color, length of time tuberculous, and present condition. Under the present condition symptoms and signs of activity, pro gression or quiesence were recorded together with laboratory find ings. The tuberculous cases are roughly divided into three clinical groups — (1) acutely failing, (2) slowly failing, (3) stationary. All were in the advanced stages and none had active surgical or skin tuberculosis. Following is a tabulation of each group, with a summary and dis cussion of results. 22 Vol. XX. FERGUSON —THE EIXIS TEST. In addition there is tabulated the reactions obtained in two non- tuberculous control series, and another table showing the results of a 24-hour inspection of the reaction for 4 days. In the tables will be found 15 tuberculous and 14 nontuberculous cases in whom the test was repeated. Summary of Table 1. Dilutions. Reaction. 1-500 1-100 1-10 Number. Per cent. Number. Per cent. Number. Per cent. Positive (red and swollen) 4 9 9 21 14 32 Negative (no redness; no 24 56 11 25 6 14 Indeterminate (pink and 12 27 17 39 17 39 Negative: indeterminate (color without swelling or swelling 3 7 6 14 6 14 Summary of Table 2. Dilutions. Reaction. 1-500 1-100 1-10 Number. Per cent. Number. Per cent. Number. Per cent. Positive (red and swollen') 14 32 17 39 19 44 Negative (no redness; no swell ing) 5 1 11 3 7 0 0 Intermediate (pink and swol I len) 23 j 52 22 50 22 50 Negative; indeterminate(eolor I without swelling or swelling 2 1 4 2 4 3 6 Summary of Table S. Dilutions. Reaction. 1-500 1-100 1-10 Number. Por cent. Number. Per cent. Number. Per cent. Positive (red and swollen) .... 11 26 17 42 20 48 Negative (no redness; no swell- 7 17 2 4 0 0 Indeterminate (pink and swol- 22 52 21 50 20 48 Negative; indeterminate (color without swelling or swelling without color) 2 5 2 4 2 4 No. 1. 23 FERGUSON THE ELLIS TEST. Discussion of reactions in acti/ve tuberculosis.—According to Ellis, we should have obtained in Table 1 frankly positive reactions in 90 per cent of the cases in all three dilutions, and essentially the same results in Table 2. We should, however, expect many of the black reactions of failure in Table 1. In Table 3 there should be a distinct change in that the 1-500 di lution should show few positives, but the 1-100 and 1-10 dilutions should again give 90 per cent of frankly positive reactions. Here, too, we should expect to find many of the black l-eactions —those in dicative of good resistance in this case. A survey of the summarized tables will show how utterly we failed to even approximate Ellis's results, in that we obtained but 34 per cent of positives in contrast to the 90 per cent which Ellis reports. However, if by long experience in studying this skin reaction one could place in the positive class those reactions attended by swelling and a color we described as pink, the percentage of positives in the 1-100 dilution in Tables 1, 2, and 3 would be, respectively, 60, 89, and 92 per cent. The reactions occurring in the controls are ascribed to trauma or hypersensitiveness to the phenol in the diluent. The test was deliberately applied to the second series of negative controls with a knife that was comparatively blunt. The traumatic element in the reaction may be partially judged by a comparison of the control readings in the two series of negative controls. It will be noticed that a reaction in the control is relatively more frequent in the cases after 114, in the retests, and in the second series of negative controls. This is undoubtedly due in part to the fact that when the tests referred to were performed the drops were approximately eight times the size of the drops used on the cases prior to 114 and'on the first series of negative controls. It is highly probable that the number of persons reacting to the infinitesimal quantity of phenol in the smaller drop is appreciably increased when the larger sized drop is used. Although Ellis specifies a small drop of the different solutions in performing the test, we used larger drops in one of the several modi fications tried because of the possibility that amounts used in the earlier tests were too small. In all repeated tests, except case 7, Table 1, an area as near as pos sible to the first test was used. The tests were repeated after an in terval of approximately two weeks, as many of the first reactions did not subside until then. Von Pirquet's observations would indicate that we should expect a more intense reaction following the second test. This occurred in the majority of instances, though not universally. 24 Vol. XX. FERGUSON —THE ELLIS TEST. Summary of Table 4- Dilutions. Reaction. 1-500 1-100 1-10 Number. Per cent. Number. Per cent. Number. Per cent. Positive (red and swollen) 3 9 5 14 8 22 Negative (no redness; no swelling) 12 34 10 28 7 19 Indeterminate (pink and swollen) 6 17 7 lit 8 22 Nogative; indeterminate (color without swelling or swelling 15 42 14 39 13 37 Summary of second series negative control. Dilutions. Reaction. Positive (red and swollen) Negative (no redness; no swelling) Indeterminate (pink and swollen) Negative; indeterminate (color without swelling or swelling without color) 1-500 1-100 1-10 Number. Per cent. Number. Per cent. Number. Per cent. 1 5 3 16 7 3» 0 0 1 5 1 5 7 39 8 44 10 55 10 55 6 33 0 0 Dismission of reactions in the nontuberculous.—In the series of negative controls in Table 4 we should have obtained 90 per cent of negative reactions in the 1-100 dilution instead of the 28 per cent recorded. The reactions of swelling without discoloration, and vice versa, are undoubtedly negative reactions. It is also possible, as indicated above, tbat one highly skilled in determining the more subtle color gradations might find sufficient justification to place those reactions of swelling with pink color among the negative reactions. Then, in combining tbese figures with those of the frankly negative responses, we would have, instead of 28 per cent, an accuracy of 86 per cent. The doubtful shades of red and pink in reactions were invariably checked by other persons, and no distinguishing features could be observed in the indeterminate reaction in active tuberculosis and that in the nontuberculous. Three of the four nontuberculous controls giving frankly positive reactions in the 1-100 dilution were investigated especially for evi dence of active tuberculosis. No symptoms or signs of active tuber culosis were present, though in two (Xos. 23 and 25) physical signs of an old. inactive, apical infiltration were present, which was con No. 1. 25 FERGUSON —THE ELLIS TEST. firmed by X ray. The third patient, a case of tertiary lues, had no lung symptoms or signs. As none of the cases were coughing, sputum examination could not be made. For further proof of their being nontuberculous, subcutaneous tuberculin was considered, but because of the possibility of a reaction from the tuberculin administered by the Ellis test it was not given. The retested cases in this series gave substantially the same rela tive reaction as in the cases of active tuberculosis. No conclusions can be drawn from the second series of negative controls, as all the reactions are masked by the reaction of trauma. It is merely appended for comparison. Table 1.—Acutely failing adrunced tuberculosis. Control. 1-500 1-100 1-10 Negative. do... do... do.. ....do ....do ....do ....do Red; slight swelling Pale red; slight swelling Negative do Pink; slight swelling. Negativ Red; slight swelling... Pale red; more swelling. Red; swollen Pink; swollen Negative. ....do Pink; slight swelling.. ....do .do. Negative No color; slight swelling Pink; more swelling... do ..do. ..do. ..do. ..do. Negative. ....do. . . .,..do... Pink; slight swelling. . Negative. Pink; i .do. ....do ....do ....do ....do ....do ....do R«d; no swelling. Negativo do Pink; slight swelling.. Negative. do... Pink; slight swelling.. Negative No color; slight swell ing. Negative do. . slight swelllnc No color; slight swelling Pink; more swelling.. Red; slight swelling Negative ....do ....do ....do Brown; slight swelling. Negative ....do ..do.. . -do. . ..do.. ....do ....do ....do ....do ....do ....do Pink; no swelling Brownish; no swelling Pink; no swelling ....do Negative ....do .do. oiling swelling . Pink; no swellln Pink; slight Negative Pink; no swelling Negative do ....do Slight brown; slight swelling. Pink; slight swelling. . Negative Pink; slight swelling . . Negative do do do Brown; slight swelling Pink; no swelling do Brownish: no swelling Pink: slight swelling . . Red; slight swelling Negative Pinkish brown; slight Hi Pink; slight swelling. Negative No color; more swelling. Negative Red; no swelling Red; slight swelling Pink; more swelling Negative Pink; no swelling Red; slight swelling Brown; no swelling Negative More brown; more swelling. Pink; more swelling. . . Pink; slight swelling. . . More pink; more swell ing. Negative Red; slight swelling Negative do Brown; more swelling Red: slight swelling Pink: no swelling Brownish; no swelling More pink; more swell ing. Red; swollen Brownish pink; slight swelling. Pink; more swelling Negative Red; still more swell- Ing. Do. Red; more swelling. Pink; more swelling. Do. Red; slight swelling. No color;moreswell!ng. Pink; still more swell ing. * Blackish; same swell ing. Pink; slight swelling. Negative. Pink; more swelling. No color; more swell ing. Pink; still more swell ing. Red; more swelling. Slight discoloration; no swelling. Pink; slight swelling. Negative. No color: slight swell ing. Negative. Red; no swelling Red: slight swelling. Pink; still more swell ing. Red; slight swelling. Pink; no swelling. Red; more swelling. Brown: slight swelling. Pink; slight swelling. More brown; still more swelling. Pink; mvich swelling. Red; more swelling. Slight more pink: slight more swelling. Negative. Same reaction. Negative. Brown: slight swelling. Pink; more swelling. Red; swollen. Pink: no swelling. Brownish; no swelling. Slight more; pink; slight more swelling. Red: more swelling. More reaction. Pink; still more swell ing. Negative. 26 Vol. XX. FERGUSON —THE ELLIS TEST. Table 2. —Slowly failina advanced tuberoulonig. Case No. 93 97 102 103 Mt 107 Ills 110 113 113 ;::! Control. Negative . do... do... .do. .do. .do. .do. Red; slight swelling.. Negative do do do .do. .do. .do. .do. .do. .do. .do. 1-500 Red; slight swelling. . Pink; slight swelling. ....do .do. Red; slight swelling. . . Slight pink; slight swelling. Red; slight swelling.. . Pink; slight swelling.. do Pink; no swelling Pink; slight swelling. . .do. 1-100 Red; more swelling . . Pink; more swelling.. do .do. 1-10 Light brown swelling. Red; slight swelling ....do slight .do. .do., .do., .do., .do.. .do., .do., .do.. .do.. Brown; slight swelling. . Slight red; slight swell ing. Negative Pink; slight swelling. . Slight brown; slight . swelling. Negative 1 Pink; slight swelling. . . Brownish pink; slight swelling. Red; slight swelling Red: more swelling Pink; more swelling. .. . Red; slight swelling.... Slightly more reaction.. Pink; inore swelling — Red; more swelling Red; slight swelling. .. . Pink; more swelling — Deeper pink; more swelling. Pink; .-.light swelling. . . Red; more swelling Red; swelling Red; more swelling Pink; more swelling. .. Slight red; more swell ing. Slight pink; slight .-.'welling. Pink: more swelling .do i Negative. Re? more swelling Same color, more swell ing. Red: more swelling Pink; slight swelling. . Brown; no swelling Pink; slight swelling. Red; no swelling Red; swelling Pink: no swelling Pink: slight swelling. Brown: no swelling... Negative. do Negative/. Pink: more swelling. . . Brownish pink; slight swelling. Pink: swelling ..) Negative. Red ; slight swelling . . Red: swelling Brownish nink; slight swelling. Pink; swollen Brownish pink; slight swelling. Pink; swelling Red. swollen Pink: more swelling. . ....do Red: more swelling. More reaction Pink; more swelling. Red : more swollen . . . Pink; slight 'welling. .do.. .do.. Slight brown: swelling. Negative slight Deeper pink; more swelling. Same reaction Negative. .do.. ...do Slight brown: no swell ing. Pink: no swelling Negative .do.. Brown; no swelling... Negative No color; slight swell ing. Slight brown: slight swelling. Red: slight swelling — Brownish pink: slight swelline. Pink; s .ght «wel.lng. . . Red; slight swelling Biown. s ight swe iing. . j Pink: slight swelling . . . | Negative More reaction Same color; more swell Ing. Pink: swel.ing Red: more swei ing Blown more wei ing.. Pink; more swelling No '•olor; slieht -well ing. Red; still more swell ing. Pink: still more swell ing. Deeper pink; still more swelling. Pink; more swelling. Red; still more swell ing. Deeper pink; still more swelling. More red; same t veil ing. Still more reaction. Pink; still more swell ing. Red; same swelling. Do. Pink; still more swell-, ing. Same color; still more swelling. Deeper pink; more swelling. Red; still more swell ing. Deeper red; more swell ing. Red; still more swell- '"fin. Do. Pink; more swelling. Pink still more swell ing. Deeper pink: still i swelling. Red: swollen. Red: still more swell ing. Deeper color; still more swelling. Red: still more swell ing. Brownish pink: slight swelling. Red; more swollen. Piuk; still more swell ing. Pink; still more swell ing. Red; still more swell ing. still more reaction. Red: still more swell ing. Red; further swlling. Pink: 'light swelling. Darker pink; still more swelling. Ssme reaction. Slight swelling; no color. Same. Still more reaction. Same reaction. Pink; more swelling. Red still more swell ing. Brown, still more swell ing. Pink: -till more swell ing. No color: more swell ing. No. 1. FEKGUSON —THE KT.TJS TEST. 27 Table 2.—Slowly failing advanced tuberculosis —Continued. Case Control. 1-500 1-100 1-10 No. 122 Pink; slight swelling... Pink; slight swelling. . . Pink; more swelling Pink; still more swell ing. 128 130 do. Fink; slight swelling . . . Pink; swelling Pink; more swelling. Do. Table 3.— Stationary active tuberculosis. Case No. 27a so 64 65 67 6« 69 73 77 79 SO *4 ss 105 111 120 113 114 123 124 125 127 12* 129 131 132 133 134 Control. Negative. do ....do.. ....do.. .do., .do.. .do.. .do.. Pink: slight swelling. . Negative. . . do do....... 1-500 Red; slight swelling. . . Negative Pink; slight swelling.. Red; slight swelling. . . Negative Brown; slight swelling Negative Pink; slight swelling.. Red; more swelling Red; slight swelling Negative Pink; slight swelling.. ....do Pink; no swelling. ....do.... Negative. do.... do... do... ....do... .do.. .do. .do. .do. .do. Red; slight swelling Pink; slight swelling... Red; slight swelling. . . do do Negative Brownish pink; slight swelling. Pink; slight swelling. . . 1-100 Red; slight s-nuiling Slight black; no swell ing. Pink; swollen Red; more swelling Pink; slight swelling... Darker brown; more swelling. Brownish pink; slight swelling. Pink; more swelling Red: still more swell ing. Red; more swelling. . . . Negative Pink; more swelling... do Red; more swelling. l-io .do. .do. .do. Brownish pink; slight swelling. Negative ....do ....do Pink; no swelling Negative Slight brown; no swelling. Pink; no swelling Negative. ....do... .do. .do. .do. Pink; no swelling Negative Brownish pink; no swelling. Negative do do Pink; no swelling do Negative Same color; more swell ing. Brown; slight swelling. Pink; slight swelling. . . Negative Pink; slight swelling. . . Red; slight swelling — More brown; no swell ing. Light red; slight swell ing. Brownish pink; slight swelling. ....do ..do ..do ..do ..do i Negative Same color; more swell ing. Pink; more swelling Red; more swelling Pink; more swelling. . . . Pink; slight swelling. . . Same color; still more swelling. Pink; more swelling Red; swollen Pink; swollen Red; more swelling. .do. More brown; no swell ing. Red; more swelling Samo reaction.. Negative ; Slight pink: slight swelling. Pink; slight swelling .do. .do. Same color; slight swell ing. Red; swollen Pink; slight swelling... Brown; no swelling Pink; slight swelling. . . do Red; swollen Same color; more swell ing. Pink; slight swelling. . . Slicht pink; more swell ing. Pink; more swelling . . . ....do ....do Pink; swollen. Red ; more swollen. . Red; swollen Pink; swollen Red; swollen Pink; swollen Red; more swollen. Red; more swelling. Same. Pink; more swelling. Red; still more swell ing. Pink; more swelling. Red; more swelling. DO. Pink; more swelling. Red; still more swell ing. Do. Red; slieht swelling. Red: still more swell ing. Deeper pink; still more swelling. Red; still more swell ing. Do. Do. Do. Do. Red; swollen. Same color; still more swelling. Darker pink; still more swelling. Red; still more swell ing. Deeper pink; still more swelling. Deeper pink; more swelling. Reddish brown; still more swelling. Brownish pink; still more swelling. Red; more swollen. Pink; more swelling. Red: still more swell ing. Do. Brownish pink; no swelling. Red; still more swell ing. Same reaction. Pink; still more 'well ing. Pink; slight swelling. Slight pink; still more swelling. Pink; still more swell ing. Do. Do. Pink; more swelling. Red ;still more swollen . Red; more swelling. Pink; more swollen. Red; more swollen. Pink: more swollen. Red; still more swollen. 69826—23 3 28 Vol. XX. FERGU80K —THE ELilS TEST. Table 4. — Controls nontuberculous. Control. Negative, .do. Red ; slight swelling. . Negative Deep red: no swelling. Pink; no swelling Negative .do. 1-500 do do .....do Pink: no swelling. .. do Brown: no swelling Negative Pink; noswelling. . Rrd: noswelling... Negative .do. Negative do Same Negative Deep red: noswelling. . . Red; noswelling Light pink: slight swell ing. Pink; slight swelling.. . . Negative Plight red; noswelling. Negative Pink: noswelling Brown; slight swelling. Pink; swollen Slight pink: no swell ing. Negative do Pink: noswelling Brown: noswelling. . . Pink; noswelling Negative ....do Pink: no swelling. . Brown; swollen. . . Negative. ....do.... Pink: slight swelling. . Red: noswelling Pink; slight swelling. . Negative Slight pink; no swell ing. Negative do Pink; noswelling Brown; no swelling Pink: noswelling NegHive Slight pink; slight swelling. Pink; noswelling Red; swollen 1-100 110 Negative, do... More. Negative Deep red: no swelling. . Pink; no swelling More pink: more swell ing. Red; more swelling Negative Slight red; no swelling . do Pink; no swelling do Pink: more swelling . . . do ..do. Negative Pink; more swelling. . Brown; no swelling. . . Negative Pink; noswelling ' Brown; no swelling Slight red; no swelling. Pink; slight swelling. . . Slight pink; no swell- Slight brown; no swell ing. Red; very slight swell ing. Brown; no swelling. . . Slight pink; slight swelling. Pink; no swelling Brown; slight swelling. Slight red; noswelling. . Red; more swelling Slight pink; no swelling. slight Negative. do ....do.... ....do.... .do. .do. .do. Slight brown; no swell ing. Slight pink: no swell ing. Slight red; no swelling. Pink; no swelling Slight pink; swelling. Negative Pink; noswelling. Negative ....do do Red; slight swelling Pink; slight swelling. . Negative Slight pink; slight swelling. Brown: slight swelling. . Negative Pink; noswelling Brownish j)lnk; swollen Pink; noswelling Slight red; no swelling. . Slight pink; more swelling. Red; noswelling Red; more swelling Red: slight swelling. Negative. More. Negative. Deep red: no swelling. Red; no swelling. Less pink; same swell Ing. Red: s i; still more swell ing. Negative. Slight red; no swelling. Do. Pink: slight swelling. Pink; noswelling Pink: same swelling. Pink: still more swell- taDo. Slight brown; no swell ing. Pink-brown; slight swelling. Slight red; noswelling. . Red; slight swelling Red; more swelling.. Slight brown; no swell ing. More red; very slight swelling. Brown; no swelling Red; slight swelllDg Red; swollen do itred;noswelling. . Red; still more swelling. Slight pink; no swelling. Slight pink; more swell ing. Negative Pink; no swelling Negative do Fink; slight swelling Red; more swelling Pink; more swelling Slight brown; no swell ing. P-iuk-brown more swelling. Slight red; noswelling. . Negative Pink; still more swell ing. Negative. Slight pink; slight swelling. Brown: more swelling. Red; slight swelling. Pink: noswelling. Pink; more swelling. Pink noswelling. Slight red: no swelling. Slight pink; still more swelling. Red; no swelling. Red; still more swell ing. Slight brown; no swell ing. Still nmore red; very slight swelling. Brown; no swelling. Red; more swelling. Red; swollen. Red; more swelling. Slight red; no swelling Red; further swelling. Slight pink; no swell- ing. Slight pink; still more swelling. Negative. Pink; noswelling. Negative. Slight pink; no swell ing. Pink; still more swell ing. Red; still more swell ing. Pink; still more swell ing. Slight brown; slight swelling. Pink-brown; still more swelling. Slight rod; slight swell ing. Red; still more swell ing. No. L 29 FERGUSON —THE ELLIS TEST. Second series of controls with modified technique. Case No. 4 ft 6 7 8 9 10 11 12 13 14 15 16 17 IS 19 Control. Brown; no swelling . Pint; no swelling . . . do. Brown; no swelling. Pink; no swelling Brown; no swelling. do do do do Pink; no swelling.... Negative Brown; no swelling. . do do Pink; no swelling Slight pink; no swell ing. Brown: no swelling. . 1-500 Pink; slight swelling... Brownish pink; slight swelling. Pink; no swelling do Red; slight swelling Brown; no swelling. . Red; no swelling Brownish pink; ni swelling. Pink; no swelling Pink; slight swelling, do. Negative. Pink; slight swelling.. Brown; no swelling . . . do. Pink; slight swelling.. ..'.do Brown; no swelling. 1-100 Pink; more swelling More reaction Pink; no swelling ....do Red; slight swelling. .. Brown; slight swelling Red; no swelling Brownish pink; no swelling. Red; slight swelling. . . More reaction do Negative Pink; slight swelling.. Brown; no swelling— do More reaction Pink; more swelling... Pink; slight swelling.. J More reaction. 1-10 Pink; still more swell- swelling. Red; swollen. Pink; slight swelling. Red; slight swelling. More red; slight swell ing. Brown; swollen. Red; slight swelling. Pink; slight swelling. Moro reaction. Still more reaction. Red; swollen. Negative. Pink; more swelling. Pink; slight swelling. Do. Still more reaction. Do. Table 5.—Reaction read at H-hour intervals. Cas* No. Reaction. 24 hours. 48 hours. 72 hours. Con trol. 1-500 1-100 1-10 Con trol. 1-500 1-100 1-10 Con trol. 1-500 1-100 1-10 5 /Color P T p P P R P R P R P R Swelling 0 0 0 0 0 0 0 0 0 0 0 0 s Color P BP p p 0 P R R 0 P p P Swelling 0 0 ss s 0 4 9 11 0 4 9 11 9 Color p P p p P P P P P P P P Swelling 0 0 0 0 0 0 0 SS 0 0 0 S 10 Color p R R R Br Br p P BP BP R R Swelling 0 ss 8 MS 0 4 7 8 11 p p P P P P P P 0 P P P 0 ss s MS 0 5 7 7 0 4 8 10 15 Color p p p P 0 0 ISr Br 0 0 Br Br 0 0 ss MS 0 0 SS MS 0 0 0 SS 17 p p R R Br Br BP P lir Br BP BP Swelling 0 0 S MS 0 0 4 7 0 0 7 7 21 Color p R R R B R R R Br R R R Swelling 0 vss s MS 3 3 5 7 0 4 7 10 A* 23 Color R R R R B B B B B BP P P 0 0 ss MS 0 0 0 0 0 0 (l 0 „, Color PB R R R B B R R 0 0 R R 75 0 VSS S MS 0 SS 10 18 0 0 8 10 20 Color P p p R P R R R FP R R R s MS SMS SMS 3 4 6 9 0 5 5 7 27 (Color p P P P FP FP FP FP Br R R R 1Swelling 0 0 n S 0 4 7 11 0 5 7 11 35 Col .r p R R R FP PB PI! PB I! BP BP BP Swolling 0 0 8 MS 0 5 0 7 0 5 9 20 38 Color p R R R P R R R Black. Black. Black. Black. 0 S MS SMS 0 5 7 12 0 5 7 15 Exp'anation of Table 5.—The letters used to describe the color of the reaction, FP, BP, P, Br, B, and R indicate, respectively, faint pink, brownish pink, pink, brown, and red. Black when occurring is written out. The letters used to describe swelling —VSS, SS, S, MS, and SMS—indicate, respectively, very slight swelling, slight swelling, 30 FERGUSON —THE ELLIS TEST. Vol. XX. swollen, more swollen, and still more swollen. Despite the fact that it was exceedingly difficult in some cases to determine exactly the extent of the reaction, the diameter of the reaction was measured in millimeters and recorded in the 48 and 72 hour readings. The later readings were made without consideration of former ones. The discrepancies in cases 10 and 23 may be due to the read ing attempted in a poor light. The change in the third reading of case No. 36 is undoubtedly one of trauma. This patient, a hyper sensitive neurological case, complained of intense itching after the second reading and rubbed and bruised the reactions through the dressings in an effort to alleviate the irritation. The result was the only really black reaction obtained. This table is instructive in that it shows the marked variation in the reaction of the organism to the Ellis test. All these cases had a previous Ellis test, as they were selected from the first series of negative controls described in Table 4. CONCLUSIONS. 1. In a series of 136 known cases of active, advanced, pulmonary tuberculosis the Ellis test gave only 34 per cent of definite positive reactions. 2. In a series of 36 clinically nontuberculous individuals it gave 28 per cent of definite negative reactions and 14 per cent of positive reactions. 3. It was shown to react positively in the presence of healed, in active, apical infiltration. 4. No prognostic conclusions could be inferred from the test. The following statement of Thomas Lewis regarding special tests is peculiarly apropos to the matter under consideration : "A medical man does well who pins his faith to clear signs of dis ease, discountenancing such signs as are of more dubious value. An other consideration affects the views expressed to a not unimportant extent; it is that the value of a method of diagnosis is to be as sessed, not by the success with which it is employed in specially trained hands, but by its success when employed by the average man. When a professed expert introduces a new diagnostic test or revives an old one, even though he may be able to show that in his hands it has great value, which is not always the case, yet by its advertisment he will do more harm than good unless he is able to state the method of his test so clearly, and unless the test is so simple that it is easily acquired and used by the majority of his professional brethren. Assuredly the method will be attempted on his authority, whether rightly used or not; as is perfectly well No. 1. VAN GAASBEEK —CANCER IN ST. CROIX. 31 known in specific instances, the test may be improperly applied and quite erroneous conclusions drawn from it." I wish to express my most appreciative thanks to Dr. Walter H. Conley, medical superintendent of the Metropolitan Hospital, New York City, for making possible this clinical trial of the Ellis test in an institution with such abundant and excellent clinical material. To Dr. N. W. Thompson, assistant medical superintendent; Dr. G. L. Raynor, chief of the visiting medical staff; and Dr. J. R. Lisa, visiting pathologist, I am most deeply indebted for their very cordial . interest, hearty cooperation, and many valuable suggestions. CANCER IN ST. CROIX, VIRGIN ISLANDS. By C. B. Van Gaasbbek, Lieutenant. Medical Corps, United States Navy. The object of this paper is to discuss the incidence of cancer in St. Croix, based upon the mortality during the past two and one half years, and to offer an explanation of the infrequency of the disease in St. Croix. The statistics quoted in this paper were obtained from the clinical records of the Christiansted Municipal Hospital and the Frede- riksted Municipal Hospital and the official death certificates and the writer's own observation of some of the cases. During the past two and one-half years, i. e., from January 1, 1921, to July 1, 1923, among the 5.720 patients treated in the hospi tals on the island there have occurred 16 cases of cancer. Of these, 2 cases may safely be disregarded, since the diagnoses were evidently erroneous, and a third case was very doubtful. One case diagnosed carcinoma of the stomach proved on autopsy to be gastric ulcer. The second case was diagnosed carcinoma of the testis with metas tases to the inguinal glands. In this case the testis and some of the glands were removed. The operative wound later broke down and gonococci were obtained in the discharge. This patient is living and well two years later. The third case was diagnosed gastric car cinoma on clinical signs alone. He was sick only 45 days when he died. No autopsy was performed. However, this third doubtful case is included in the list of cancers. Of the 14 authentic cases of cancer, the distribution was as follows: 4 epitheliomata, including 1 of tlie tongue, 2 of the face, and 1 of the anus: .3 carcinomata of the breast; 5 carcinomata of the uterus; 1 carcinoma of the liver, metastasized from the head of the pancreas; and 1 carcinoma of the stomach. The age limits varied from 19 years to 87 years, with an average age of 51.1 years. The youngest was the epithelioma of the anus and the eldest was an epithelioma of the face. 32 VAN GAASBEEK CANCER IN ST. CROIX. Vol. XX. Of this group of 14 cancers, 4 occurred in males while 10 oc curred in females, a ratio of 2 to 5. Although this is a high ratio of female and male cancer, it is not at all uncommon, since cancer is so prone to develop in the female reproductive organs. Five cases occurred in negroes, 8 in mixed races, and 1 in a white man. The principal occupation of both the male and female population of St. Croix is field labor in the cultivation of sugar cane. But in this group of cancer cases there were but three field laborers; the re maining 11 cases occurred in people of a relatively higher vocation, such as fishermen, housemaids, housewives, seamstresses, and pas ture men. It is of interest to note that of the 5 cases of uterine cancer, four of the women have been married and the fifth had borne children. The population of St. Croix in 1922 averaged about 13,500 inhabi tants. Of this total number there were less than 650 white people. This would give a total cancer mortality of 41.2 per 100,000. In Charleston, S. C, the cancer rate for the white population is 73.2 per 100,000, while the rate for the black people is 36.6. In the District of Columbia the cancer rate for whites between the years 1901-1910 was 175.4, while for the blacks during the same period it was 125.1. It is interesting to note that in the United States prior to the Civil War, cancer among the negro population was relatively rare. But at the present time, under the conditions of unrestrained per sonal freedom, the difference in cancer mortality, decidedly less pro nounced, though as a rule the general cancer rate is still consider ably in excess of the cancer death rate of the negro. For the years 1910-1912, the cancer rate of the negro in all the United States was 56.1, while the rate for the white people was 76.7. Hence, it is shown that cancer generally is less prevalent among the negroes. In our sister island, St. Thomas, the cancer rate from 1905 to 1914 averaged about 80 per 100,000. To account for the low cancer rate of St. Croix as compared with the various districts of the States and with the United States as a whole and even with St. Thomas, it is necessary to consider the causes or rather influences which seem to effect the production of cancer. The true cause of cancer is as yet unknown. Guerin insists that we must recognize the infectious origin of some cancers, irritation or trauma as a factor in others, and an embryonal origin of still others. In the present state of our knowledge, however, a specific microbic origin of cancer is generally not accepted. No. 1. 33 VAN GAASBEEK CANCER IN ST. CROIX. It is certain that precancerous conditions do exist. They are all of the keratotic type, are inflammatory, result from long-standing irritation, and end either in ulceration or hyperplasia. According to Parker Sims, benign tumors, chronic ulcerations, chronic inflammations, and abnormal tissues, such as scars, are fore most among precancerous conditions. Greer, in his treatise " Industrial Diseases and Accidents," states that the relation of injury to the development of cancer has received a great deal of attention, the result being that we are in a position to give traumatism a place among the factors which influence the pro duction of malignant growths. The real cause, however, is unknown. At present we have a number of observations which lead us to sus pect that continued local irritation can determine the development of malignant growths. Under this type we recognize the chimney sweep's cancer, clay-pipe cancer, X-ray cancer, Kangri cancer of Kashmir, and the betel-nut cancer of India. In a great number of deep cancers, such as those of the abdomen, bone, or muscles, there is not a history of continued irritation but rather of a single injury. In this same respect, Oliver says that there is no doubt that cancerous tumors develop after an accident, close to the site of the injury, and that one is the direct sequence of the other. Cancer is especially common among gardeners and agriculturists. This is supposed to be due to handling infected earth. The condi tion generally occurs upon the skin. In this respect it would seem remarkable that there is not a greater incidence of cancer in St. Croix, when it is considered that the greater part of the population go without shoes and, besides, work in the cane fields, where they sustain many cuts, bruises, and ulcers that remain months and some times years without healing. Thirty per cent of our cancers were of the epithelioma type. But, strange to say, while ulcers and injuries to the feet and hands were so common, there was not a case of epithelioma of these parts. Neither did an epithelioma occur in a field worker, and only one in a negro, while two were in patients of mixed blood and one was in a white man. It would seem that there is something protective in the negro, although precancerous conditions are abundant. The latest theories hold more toward the traumatic or irritative cause of cancer. Credit is due to Yamagiwa and Ichikawa, of the University of Tokyo, who first produced cancer experimentally by the application of tar to the skins of rabbits. Other investigators and experimenters, notably Leitch, Murray, Dellman, and Roussy, have more recently corroborated these findings. Passey has pro duced cancer by means of quicklime mixed with soot. 34 Vol. XX. VAN GAASBEEK CANCER IN ST. CROIX. It is believed that solar irritation may be a factor in th<i production of cutaneous cancer. Gougerot regards the action of sunlight as an important factor in the production of cancer. Sunlight may be a fac tor, but surely is not causative, for the sun shines every day for nearly the entire day on St. Croix ; and were this the cause of cancer, every one would be cancerous. After considering the above it would seem that most of the factors which are believed to influence the production of cancer are present. There is an abundant sunlight, a goodly number of benign tumors, many traumatic causes, and a great number of chronic irritations from long-standing inflammation in the field laborers who are en gaged in the cane fields. And yet the cancer rate is very low. The majority of people of St. Croix are negroes. They are poor and for the most part ill fed, living upon fungi and fish, and are consequently poorly nourished. Although in former days, prior to the advent of prohibition, alcohol was indulged in, it was rarely used to the extent seen in more prosperous people. Smoking has always been common. The clay pipe is generally employed for this pur pose. Although the younger generation use beautifiers, cosmetics, powders, etc., the elderly people who are in the cancer age have never known these luxuries, many of them having been slaves. In St. Croix large families live together in one room. The people have little or no ideals and live only for the day. They approach the lowest social stratum. It is probable that their physical condition, habits, and mode of living exempt them in a large extent from can cer. Hoffman says that the rarity of cancer among the native races suggests that the disease is primarily induced or at least increased in relative frequency by the conditions or methods of living which typify our modern civilization. It will be seen that in our series of 14 cases, 11 occurred in people somewhat above the average of field laborers, both in living and eat ing . This fact would make it appear that people living under primi tive conditions are relatively immune to cancer. Roger Williams states that although it can not be said that per sons of any rank or station of life are exempt from cancer, there are, nevertheless, some remarkable differences in the incidence of the disease among the various social strata. There is a greater prev alence of cancer among the well-to-do than among the less prosper ous of the industrial classes. Bulkley states that even though some fundamental cause may lie in back, nevertheless it- is recognizable by all that the tissues de velop and are maintained by nutrition derived from food and drink taken, and tumors all grow by the same means. No. 1. BUNKER AND THRASHER SUGAR IN URINE. 35 Gunsburg as early as 1853 held that conditions responsible for corpulence were the same as those for carcinoma. He attributed the abnormality of the metabolism to the excess of albuminoid diet. Hollo Russell found that cancer was eight times more prevalent among inebriates than among the population of the country at large. Williams found that cancer was rare among people predominately poor and of necessity frugal, subsisting on an alimentation compris ing but little protein food. Sir George Cheattle, at the Institute of Hygiene, London, de precates the use of soaps, face powders, coloring matter, cream, bath salts, etc., as conducive to cancer by irritation of the skin. He considers soaps and powders especially dangerous since they gain access to the glands of the skin. It has been noted by Pitchford that the increase in cancer is due to the diminution of protection to light and the increased exposure to illumination. Woolen garments have been replaced by cotton, and black and brown clothes by white. Streets are wider and brighter. This theory may explain why the dark-skinned races are less liable to malignant disease than white races in the tropical and semitropi- cal climates. In conclusion it may be stated that the people of St. Croix appear to be relatively less susceptible to cancer probably because of (1) their black color protecting them from the rays of the sun. the darker the individual the greater the protection; (2) simple diet, especially lacking in the highly seasoned protein foods; (3) lack of alcoholism; (4) nonuse of powders and in many cases of soap; (5) and especially their physical conditions and modes of living. SUGAR IN TTRINE. Bj C. W. O. Bunkbe, Lieutenant Commander, Medical Corps, United States Navy, and R. L. Thrasheb, Pharmacist's Mate, first class, United States Navy.' Benedict's qualitative test (1) for sugar in urine has proved very useful and reliable, and we have been curious as to whether results from its use have any quantitative significance. The method of Folin and Berglund (2) for the estimation of sugars in normal urine offered a simple means of deciding the question, and we have applied it to 190 urines, 109 of which were negative by Benedict's tests, while 81 showed greenish turbidities. Depending upon the density of this greenish turbidity, we have subdivided the group into traces, slight traces, and very slight traces. Table I shows the results. 1 From the laboratories of the U. S. Naval Medical School. Reprinted from the Journal of Laboratory and Clinical Medicine, September, 1023. 36 BUNKER AND THRASHER—SUGAR IN URINE. Vol. XX. It will be noted that 88 per cent of the negative results were with urines containing 0.1 of 1 per cent or less of sugars. No sharp line, however, could be drawn as to the amount of sugars that would or would not give a positive result, although there was a tendency for the density of the greenish turbidity to vary, in general, propor tionately to the amount present. Neither did we find the occurrence of a reddish precipitate that settled to the bottom of the tube had any quantitative significance. Folin and Berglund (3) contend that the copper-reducing sub stances remaining in normal urine after the removal of coloring matters, uric acid, creatine, and creatinine by means of the alkaloidal reagent consist of a "motley variety of carbohydrate products and carbohydrate derivatives including di- and polysaccharides." If we consider that Benedict's test is sensitive to some of these but not to others, we can understand why values as low as 0.04 of 1 per cent could produce either a positive or a negative result, depending upon the composition of the mixture present in the urine. It may also be that the relative proportions of fermentable to nonfermentable copper-reducing substances enter into the question, but we did not attack it from that standpoint. Since a positive result was obtained with as little as 0.04 of 1 per cent of sugar, Benedict's qualitative test must be considered as having at least that sensitiveness. CONCLUSIONS. 1. Benedict's qualitative test of sugar in urine has quantitative significance in only the most general terms. 2. Greenish turbidities secured in this test demand care in their interpretation, and are to be considered pathologic only when othei features of the case warrant such an assumption. Xo. 1. BUNKER AND THRASHER—SUGAR IN URINE. TABLE I. Milligrams Stjoab per 100 c. c. Foind with the following Qualitative Results. Negative. Very slight trace. Slight trace. Trace. 8 10, 11, 11, 13 13 20, 22, 23, 23 26,29 31, 32, 33, 35 35, 37, 38 40, 40, 40, 40 40, 43, 43 43, 43, 46 46, 46, 46 47 40, 42 60, 50, 50, 50 52, 53, 53 54,54,54 54, 57, 67 57 1 60, 60, 60. 60 60, 60, 60 63, 63,63 66, 66, 66 66, 66, 66 67 66 70, 71, 71, 72 72, 73, 75 75, 75 70, 70, 75, 75 80, 80, 80, 85 85, 86, 86 71 80, 80, 80, 80 80, 80, 80 80 80, 80, 85 85, 85,85 86, 86, 86 86 92, 92, 92 91, 95 90, 92, 92, 95 95, 95 100, 100, 109 109, 109 109 100, 100, 100 100,100 100, 100 109, 109 104, 109, 109 110, 110, 114 114 110, 111, 114 114 120, 120, 120 120 120 120, 120, 120 128, 128 133, 133 142 133, 133, 133 133, 133, 136 150 150 150, 150, 150 150, 150, 150 150, 155 163 190 171. 171. 171 171, 171 180, 180, 180 188 218 240 200,200 224 257, 257 500 BIBLIOGRAPHY. (1) Benedict, S. R.: Jour. Am. Med. Assn., 1911, lvii, 1193. (2) Folin, O., and Berglund, H.: Jour. Biol. Chem.. 1922, li, 209. W Tbid, p. 213. 39 ENDOTHELIOMA OF PERITONEUM. CLINICAL NOTES. ENDOTHELIOMA. « By L. H. Williams, Lieutenant, Medical Corps, United States Navy. The term endothelioma includes a number of tumors of uncertain origin. Much confusion has arisen due to the uncertainty as to what should be termed endothelium. The lining cells of lymph channels and blood vessels are accepted as such, but the origin of the cells which constitute the endothelium lining the dura, pleurae, and peritoneal cavity is in dispute. This uncertainty is caused by the failure to demonstrate the origin of the coelom in higher vertebrates. MacCallum states that in prac tically no case has the origin of a tumor from endothelium been proven ; and that a mere continuity of tumor cells with endothelium at the margin of the tumor is no proof of their identity. The endothelial cell is placed with the connective tissue group and is properly recorded as a modified cell of that type of tissue. En dothelial cells resemble squamous epithelium in that they are flat tened, with flattened, oval or nearly round nuclei, are polyhedrical in shape, and are in a single layer united by intercellular cement substance; the borders are wavy and often serrated. The quantity of intercellular substance is small and special staining methods are necessary to bring it out; this is just the opposite with connective tissue- Bushman states that the term endothelioma is a compromise be tween the morphologic and histogenetic classification of tumors. The endothelioma is histogentically of mesoblastic or connective tissue origin, but morphologically its cellular unit most closely resembles the epithelial cell of ectodermic or entodermic origin. Various opinions are offered as to the origin of the endothelial tumors. The cell rest theory is held by many, but as in the case of other malignant tumors their origin is unsettled. A tumor of endo thelial origin may undergo a rest, or while retaining its capillary characteristics it may grow by infiltration into surrounding struc tures; it may become compact and solid, or become cavernous. Ket tle has shown that there is no physiological connection between the blood spaces of the tumor and the vessels of the host. There is no true circulation of blood in the tumor. Small capillaries rupture and form cisterns into which the blood oozes. 39 10 WILLIAMS —ENDOTHELIOMA. Vol. XX. The degree of malignancy of endothelioma depends not on mor phology, histology, or type of original cell but on the behavior of the original cell. The richer the tumor is in undifferentiated cells the higher is its degree of malignancy. The clinical history of most endotheliomas shows them to be slow growing tumors. The loca tion is important. If situated in a highly vascular area or one rich in lymphatics metastases occur more readily. The case presented herewith as one of endothelioma of peritoneum has the following history : In December, 1922, the patient had severe pain in both groins, without vomiting; felt feverish; in bed for six days. Pain lasted all this time ; took no drugs. At the end of this period he noticed a tumor mass in the lower abdomen. Since then he has steadily lost weight and has had pain coming in attacks, severe, cramplike, going quickly as it came, without apparent cause and unrelated to eating, to urination, or to bowel movement. With the pain there was often vomiting. He had frequency of urination with occasional burning during day but only got up once at night. This has been the case since 1918. No blood, no cloudiness, no gravel in the urine. He restricted his diet, avoiding especially meats, fried foods, and sours. He was not constipated and had no symptoms re ferable to the kidney or heart. * Physical examination. —-Chest: Sibilant rales both bases. Heart normal. Blood pressure, 120/90. Abdomen : Tumor, size and shape of enormously distended bladder; hard and tense, but tympanitic. Rectum : Mass felt region of bladder ; smooth, hard, tense. On April 16, 1923, he was prepared for an exploratory operation. X-ray examination of the chest on this date showed fibrotic changes about the hilus. Operation. —An inoperable growth involving the peritoneum was discovered on abdominal section. The descending colon was found adherent to the peritoneum and cut into when opening the peritoneal cavity. A glass tube was inserted and secured to the edges of the gut by a purse string to allow fecal drainage. A small nodule about 4 millimeters in diameter was taken from the peritoneum for histo logic examination. It was found to be composed of stroma made up of closely packed connective tissue cells. Cell inclusions of larger cells with large pale nuclei were seen everywhere in specimen. A few mitotic figures were made out in the large nuclei. The patient gradually lost weight and strength, though retaining a remarkable mental balance and spirit, and died 11 days after opera tion with symptoms and signs of broncho-pneumonia. At autopsy broncho-pneumonia was found to be immediate cause of death. All layers of peritoneum were greatly thickened, in some places as much as 1 centimeter in thickness, hard and grayish yellow in color. The No. 1. WILLIAMS AND SATTERLEE —GLANDERS. 41 thickened peritoneum was found adherent to the intestines in the lower part of the abdomen, with the result that there was a matting together of the lower part of the colon, rectum, adjacent small intes tine, mesentery, and floor of pelvis. The mesenteric lymph glands were found studded with metastatic nodules about 3 millimeters in diameter. The spleen was compressed and had a few metastatic nodules on surface. The pancreas and kidneys were apparently nor mal. The bladder appeared to be completely inclosed in dense, firm masses of thickened mesentery, with rigid ligaments running away to the mass of intestines. Summary. — 1. The case presented demonstrates the malignant in volvement which may occur with so little interference with the func tions of the intestines or bladder. Aside from a slight frequency of urination, nothing grossly abnormal occurred in the functioning of the abdominal contents. 2. The constant pain complained of, with marked loss of weight— over 30 pounds in six months—and the boardlike abdomen suggested malignancy. 3. The nature of the malignant condition was determined only by an exploratory incision and histologic examination. 4. Bushman states that according to the interpretation placed on the morphology or histogenesis of endothelial cells the tumor may be regarded as of connective tissue origin, histogenetically a sarcoma, or it may be considered as composed of cells resembling epithelium and morphological carcinoma. 5. The term endothelioma represents a compromise between mor phologic and histogenetic views of tumor classification. 6. The tumor herewith presented appears a good example of the reason for the term. REFERENCES. Kettle, E. H. : Tumors arising from endothelium. (Proc. Roy. Soc. Med., Path. Sect: 19-34, 1918.) Bushman, O. J.: Malignnnt endotheliomas with cutaneous Involvement (Archives of Derm, and Syph. December, 1922, vol. 6, pp. 680-700.) MacCallum : Textbook of pathology. GLANDERS IN HAN. By L. H. Williams and IC. C. Satterlee, Lieutenants, Medical Corps, United States Navy. Glanders in man is relatively rare. Seventeen deaths were re ported in the literature from 1905 to 1909. Since then many more cases have been diagnosed. Clinically glanders can be easily con fused with the various manifestations of syphilis, eczema, typhus, cadaveric poisoning, pernicious anemia, nasal polyp, tuberculosis, 42 WILLIAMS AND SATTEKLEE GLANDERS. Vol. XX. rheumatism, typhoid, ague, and sarcoma. The mortality among the human cases is about 50 per cent in the acute form. The chronic form may run on for years. The infectious agent is the B. mallei. The hypothetical paths of infection are through inoculation of a wound, hair follicle, or inhalation. Practically it is difficult and usually impossible to ascertain the definite point of inoculation. Animals appear to be the most prolific source of infection. Among them the horse and ass are the most frequently infected. Cattle are immune ; but sheep are susceptible. Domestic pets do not entirely escape; the dog and cat are occasionally found to be harboring chronic glanders. The nasal mucous membrane in horses infected with glanders secretes a thin, virulent mucus which is exceedingly infectious. The period of incubation after inoculation is four to five days. B. mallei is a small gram negative bacillus. It grows profusely on potatoes with a characteristic slimy brown growth. Pathology. —The characteristic lesions are infective granulomata in the skin, nares, lungs, and subcutaneous tissues. These break down and form abscesses. The abscesses vary in size from that of a pea to areas of necrosis 7 to 9 inches across, with ragged edges. The pus found in the glanders abscesses is usually red in color and gelatinous in appearance. The infection is apt to remain local, and when it spreads does so along lymph channels. Visceral lesions occur in the chronic form. Lesions in the lungs and liver are diffi cult to diagnosticate unless the superficial ulcerations lead to proper interpretation. They occur in the chronic form and are the terminal stage. The principal points in diagnosis are: (1) Isolation of B. mallei in pure culture from local lesions; (2) positive agglutination test of both bacilli isolated with known serum and a known culture by patient's serum; (3) guinea pig inoculation with isolated bacilli with consequent localization of infection in testes which leads to destruc tion of testes; (4) negative blood culture. The patient reported here is a veteran of the World War in voca tional training. He was admitted to the United States Naval Hos pital, Brooklyn N. Y., April 14, 1923, with symptoms of acute exacerbation of an old osteomyelitis of the head of the left humerus. He received a gunshot wound in the left shoulder October, 1918. while in battle. The head of the bone was shattered. The bullet was removed by operation three days after injur}'. A second opera tion was performed two weeks later to remove splinters of bone. The wound of the second operation healed completely with non union of fragments of the humerus. Partial ankylosis of the shoulder resulted from the injury. No pain or swelling was noticed after final healing until five weeks ago, when strain was put on ; No. 1. 43 VAN GAASBEEK-—APPENDICITIS. the shoulder while at work. The next day pain, stiffness, and swelling were noticed in the shoulder. He was given massage and diathermy without relief. The soreness and swelling increased steadily; pain was never acute. On admission fluctuation was made out in the area of a large scar over the deltoid, extending under the latissimus dorsi and into the antero-axillary area. No fluctuation was found in the region of the anterior scar. White blood count, 15,300; temperature, 104; pulse, 108; respiration, 20. Incision into scar released about 2 ounces of bloody pus. A culture and smear of pus was made. Car- rel-Dakin technique was instituted. Improvement was rapid and continuous. After a week fluctuation appeared in the region of the anterior scar. Incision here released about half ounce of pus, after which the patient's temperature became normal and remained so. The culture was reported positive for a gram negative bacillus, prob ably B. mallei. He was continued under treatment with Dakin's solution, heat, and rest in bed. The discharge rapidly diminished and the sinuses healed completely. The guinea pig inoculation with culture of B. mallei obtained from the pus developed typical lesions of glanders in testicles. Bacteriological report. —All cultures inoculated with pus from the wound showed a gram negative bacillus in almost pure culture. This organism was nonmotile, nonacid fast, did not liquefy gelatin, or produce gas in glucose or any of the sugars. The brownish growth on potato was characteristic of B. mallei. A male guinea pig inoculated intraperitoneally with 5 c. c. of a 24-hour broth cul ture showed at the end of 10 days the typical ulceration of the testi cles. Cultures of the pus from these ulcerations recovered the same gram negative bacilli. Complete fixation tests were not done. This organism does not seem to be very virulent inasmuch as the guinea pig did not die at the end of about two weeks as was ex pected, but the ulceration on the testicles healed slowly and at the end of six weeks the pig was in apparently normal condition. Summary. —This case seems to have been one of infection with a relatively avirulent B. mallei; the original focus, a bullet wound, having been healed for several years before the osteomyelitis that it caused gave symptoms calling for medical attention. ACUTE APPENDICITIS WITHIN A HERNIA SAC. By C. B. Van Gaasbeek, Lieutenant, Medical Corps, United States Navy. The following occurrence of acute appendicitis within a hernia sac is deemed of sufficient rarity and interest to warrant the re porting of the case. Although it is not at all uncommon to find 69826—23 4 44 Vol. XX. BOOT CHAKCrE OF HAND. the appendix and cecum present in the sac of right-sided inguinal hernias, especially those very large hernias of long duration, never theless, it is uncommon to find the appendix acutely inflamed and causing symptoms similar to those of an ordinary incarcerated hernia. Case: Mr. I. E., aged 40 years, single, grocer by trade, stated on July 22, 1923, that for the past 10 years he had had a hernia which could be reduced and retained by a truss. Three days previously he had attempted to lift a heavy barrel. While engaged in this act he felt something give way and his hernia came down farther than it had ever come before and he culd not reduce it. Within a few hours he had a sickening pain located over the neck of the sac, felt feverish, was nauseated, and vomited. Dm-ing the interval of three days he suffered more or less pain and fever, and finally sought aid. Physical examination was negative except for the hernia. It was a complete right inguinal hernia, the size of a large grapefruit, hard and somewhat dull to percussion. The mass was tender over the internal ring and could not be reduced by taxis. There was slight tenderness across the entire lower abdomen, but there was no pain or tenderness over McBurney?s point and no right rectus rigidity. Temperature was 99° and pulse 88. Diagnosis of incarcerated hernia was made. Operation 40 hours later disclosed a large right indirect inguinal hernia, incarcerated at the internal ring. The sac contained ileum, cecum, appendix, and part of the ascending colon. The appendix was kinked upon itself, swollen, injected, and friable, and attached to the neck of the sac. ' The upper part of the hernia was of the sliding variety, with the meso-appendix continuous with the wall of the sac. The appendix was removed and the stump buried and the usual radical repair of the hernia performed. Convalescence was un eventful, and the patient left the hospital 21 days after the opera tion, completely cured. In this case, although there was an incarceration of the hernia, and that together with the trauma the probable cause of the appen dicitis, nevertheless the pathology present in the appendix was un doubtedly the major factor in producing his symptoms. CHANCRE OF THE PALMAR SURFACE OF THE HAND. By J. B. Root, Jr., Lieutenant (J. g.), Medical Corps, United States Navy. The patient, age 27, single, white, was admitted to the United States naval hospital, Norfolk, Va., August 11, 1923, chief complaint being " ulcer of right hand." 41 CHANCRE OF HAND. No. 1. 45 LAKE DIFFUSE SCLERODERMA. His present illness began about eight weeks ago with a blister on the palmar surface of the right hand at the base of the middle finger. This was caused by cranking a car. The blister disappeared in about seven days. About three weeks later the patient noticed a swelling and hardness at the base of the right middle finger on palmar surface of hand where the blister had been located. This swelling was first thought to be a corn. A few days later this area was incised and a small amount of seropurulent material was evacuated. Alcohol dressings were applied for several days but the wound would not heal and a slowly spreading ulcer developed. Examination on August 11, 1923: Patient well nourished, weight 150, heart and chest negative; gastro-intestinal, genito-urinary, and nervous system negative. No scars on penis or other evidence of venereal disease. On the right hand there is an ulcer about the size of a dime, at the base of the middle finger, palmar surface. The. ulcer is indurated, the induration being rounded, thin, and circum scribed, slightly elevated above the surface, which is eroded and smooth. The color is " raw meat " red. There is no pain in con nection with lesion. There is also a triangular ulcerated area on the proximal side of the round ulcer. On August 18, 1923, when the accompanying photograph was taken, the two ulcers had formed into one, about the size of a 25-cent piece. The right forearm from just below the elbow to the upper third of the arm is red and swol len. There is adenopathy in the cubital fossa and lymphangitis of the medial side of the arm. There is no glandular involvement elsewhere. The dark field examination for Treponema pallidum was nega tive on August 9, 1923, but the Wassermann was strongly positive. On August 13, 1923, another dark field examination was made, which was positive for Treponema pallidum. The first negative result was probably due to the fact that alcohol dressings were used for several days. In the interval between the dark field ex aminations normal saline dressings were employed. From the above history, examination, and laboratory report, a diagnosis of syphilis was made, the initial lesion being a chancre of the right hand, at the base of the right middle finger, palmar surface. The source of infection is unknown. The condition re sponded promptly to antisyphilitic treatment. REPORT OF A CASE OF RECURRENT DIFFUSE SCLERODERMA. By C. W. Lane, Lieutenant, Medical Corps, United States Navy. Scleroderma is defined as a rare, chronic disease, characterized by a peculiar hard, leather-like condition of the skin occurring in sharply circumscribed patches or in diffuse areas. The circumscribed 46 Vol. XX. LANE DIFFUSE SCLERODERMA. form is the type generally found, and is also called morphea. This disease is more often seen in females than males and the diffuse form is quite rare. Diffuse scleroderma begins either acutely or insidiously with slight stiffness of the skin, which usually presents a certain amount of swelling and hardness. Prodromal symptoms of any kind are generally wanting. Gradually, the induration and stiffness of the skin spread over large areas, and occasional cases have been reported where practically the entire surface has become involved. There appears to be a substitution in the subcutaneous tissue of fibrous tissue for fat. The patient feels a decided tension to the integument, and generally the function of the glands in the skin is checked. The skin is decidedly inelastic. Movement becomes restricted when the skin about the various joints is affected. The face is expressionless, motionless as if covered with a mask, and the mouth opens with some difficulty and to a very limited degree only. Respiration is impeded, if the skin over the thorax is attacked. Complications are atrophy of muscles from disuse ; ulcerations over joints due to stretching of an inelastic skin and consequent pressure; abscess from infection; claw fingers; and there may be actual ankylosis of joints. Nothing is definitely known as to the etiology. Lewin and Heller collected 435 cases in all and found that 292, or 67 per cent, were in women. Some think the thyroid is at fault. Some have noted a positive Wassermann in a small number of cases; while some hold to a conviction that the condition is a trophoneurosis. This latter view seems most logical. Diffuse scleroderma is quite rare in the Tropics. Prognosis. —Unfavorable. The disease may last for years and gradually clear up. These patients are a ready prey to infectious diseases and may be carried off in this manner. Frequently, if the disease subsides, atrophy of muscles is so pronounced that a very prolonged convalescence is in order. Contractures and ankyloses are not infrequent. A contusion may lead to an abscess which may be fatal. In the cases collected by Lewin and Heller, a cure took place in 16 per cent, improvement in 30 per cent, and death in 25 per cent. The balance were considered unimproved. Treatment.—First, steps are taken to improve general health. Good readily digested food that will form fats is indicated, as are proper clothing to protect the patient from sudden changes in tem perature, hydrotherapy, electrotherapy, administration of thyroid extract, and sodium iodide in large doses. The case here reported is a particularly interesting one. The patient, a male, age 19, was admitted to the naval hospital, League Island, Pa., April 30, 1923, with a diagnosis of myositis, acute. 46--1 DIFFUSE SCLERODERMA SHOWING RIGIDITY OF FACE. No. 1. 47 LANE—DIFFUSE SCLERODERMA. Nativity, United States. Eace, white. Former occupation, bank clerk. Date enlisted. September 20, 1922. Family history. —Father living and well. Mother living, but has diabetes. No history of any chronic illness except as mentioned. No history of any scleroderma in family. Past pergonal history.—Measles, mumps, and chicken pox when a child. Tonsillitis, December, 1922. Operation : Compound fracture left ulna when 6 years old. At the same age he also had adenoi- dectomy and tonsillectomy. Chief complaint. —Stiffness of body. History of present illness.—The patient stated that when he was a child he had a similar trouble and upon communicating with his family physician, we received the following reply : "According to my records, young " B " at the age of about 6 years received a fracture in the upper third of the ulna with a misplaced fragment that had to be compounded for reduction. He had been a healthy child from birth until this time ; had no complications at birth. A short while after the healing of his fracture, he showed the first symptoms of his scleroderma which at that time was in his cheeks, but within 60 days had spread over his entire body. It was my opinion that it was from toxin following his compound fracture which showed no infection at the time. At that time we advised his mother to take him to a higher and drier climate and put him on graduated doses of sodium iodide. We gave the mother a very unfavorable prognosis. I have no record of this treatment, but think the iodides were extended to something like a dram a day, which was enormous for this youngster. To our surprise, he seemingly made a complete recovery." The patient states that he fully recovered and enjoyed good health. "When he enlisted in the Navy, he was apparently in excellent health, and there was no evidence of scleroderma objectively or subjectively. The first part of December, 1922, he had a slight sore throat, which was probably a mild attack of tonsillitis, but he did not feel ill enough to turn in. December 20, he went on leave and first noticed stiffness of his abdominal muscles about that time. About 10 days later his neck became stiff, and this stiffness and tight sensation pro gressed gradually until practically his entire integument was in volved. It was then that he was admitted as a patient to this hos pital. He never had any edema preceding or accompanying this attack. There was no pain and there was practically no pigmenta tion. He felt well on admission, but was uncomfortable and complained chiefly of slight repiratory difficulty, as his chest seemed immovable and felt as if it were held in a vise. His face was expressionless and masklike ; he could open his mouth part way but could not pro 48 Vol. XX. LAXE DIFFUSE SCLERODERMA. trude his tongue beyond the teeth. His face on palpation felt hard and highly resistant everywhere. His eyes could not be widely opened, although the lids were not as involved as the rest of the face. This leatherlike hardness and inelasticity of the skin was found over his entire body with the exception of the inner surface of both thighs and the genitals. The pahns of the hands and soles of the feet were involved, but to a much less degree. The skin was dry; there was no scaling or pitting; there were no areas of anes thesia or hyperesthesia or edema. The skin could not be pinched up into folds, but seemed firmly adherent to the musculature immedi ately beneath it. The color and capillary circulation were apparently unchanged. The head was held in one position and could be moved about only with exertion. The chest was drawn in and seemed quite rigid, and this gave him a decided " round shouldered " appearance. The arms could not be abducted above the shoulder level. There was resistance to any motion attempted, and the skin seemed tight over all joint surfaces. He perspired very little except from the palms of his hands and soles of his feet and the inner aspect of his thighs and over the lower lumbar region. These localities were the least affected by the pathological condition. Mentally, he was not affected, and the remainder of his physical examination was negative. Blood, Wassermann negative. Absolutely no history of syphilis. Blood pressure: Systolic, 116; diastolic, 60. Thyroid showed no changes. Hemoglobin, 80 per cent; R. B. C, 3,320,000; W. B. C, 6,150; 61 per cent polys.; 36 per cent lymphocytes; 3 per cent large mononuclears and transitionals. Feces was negative for parasites, ova, or blood upon several examinations. Urine was normal. He has not noted any definite loss in weight. His temperature, pulse, and respiration show no variation from normal. He was placed on a substantial diet plus cod liver oil emulsion and local inunctions of olive oil. Later, he was given thyroid extract, but it seemed to have no bearing on the progress of the case. In June, he was given hydrotherapy and electrotherapy and it ap pears that the latter helped him some. It was noted that the skin over the thighs (outer portion) and the skin over the back recovered some of its elastic quality and softened and he perspired over a larger area than previously. Sodium iodide up to 110 grains a day was given, but the patient noted very little improvement. He was invalided from the United States Naval Service July 18, 1923. Several weeks later a letter was received from him stating that he noted no improvement up to that time. It will be noted that at about the time he had his first attack he had a tonsillectomy. A definite history of tonsillitis could not be No. 1. 49 McCLINTOCK —ACUTE YELLOW ATROPHY. obtained, and the patient could not recall whether this preceded, accompanied, or followed his scleroderma. He gives a definite his tory of sore throat with perhaps slight fever immediately preceding his second attack. He has tonsil stumps and it is possible that the etiological factor lies there. He did not wish tonsillectomy, and from the appearance of the throat the tonsils did not depict a definite focus. This case is of special interest in view of the fact that diffuse gen eralized scleroderma is rare and very seldom affects the palms of the hands and soles of the feet ; and more interest is added by the fact that it is a recurrence or complete new cycle after a period of 13 years, during which interval the patient had no symptoms of the disease and enjoyed perfect health. The illustrations show the patient with mouth as widely opened as possible, with the tongue protruded as far as teeth. They also show the " round shouldered " vise-like position of the chest. A CASE OF ACUTE YELLOW ATROPHY OF LIVER. By O. L. McClintock, Lieutenant, Medical Corps, United States Navy. H. F. C, machinist's mate, first-class, United States Navy, was ad mitted to the hospital December, 30, 1922, with primary lues. A dark field examination was positive for Treponema pallidum. The patient was given small doses of salvarsan. He was discharged as improved January 16, 1923, the primary lesion having healed. Mer cury rubs were instituted. On January 31, 1923, he was readmitted, with the diagnosis cholangitis acute. Jaundice was pronounced. Antiluetic treatment was discontinued. A complete physical exami nation showed the patient also to have bilateral active pulmonary tuberculosis. The sputum contained numerous tubercle bacilli at each examination. Traces of albumin and occasional granular and hyaline casts were found in the urine. Indican was found in one specimen and bile was present in all specimens examined. Specific gravity of the urine ranged from 1.009 to 1.027. Blood examination showed hemoglobin 70 per cent, anticomplementary to Wassermann test. Blood chemistry in milligrams per 100 mils was as follows: Nonprotein nitrogen, 34.3; urea nitrogen, 11.2; urea, 24.0; uric acid, 3.0 ; creatinin, 1.8 ; and glucose, 98.6. Feces examination was negative. The patient's temperature ranged from 97° to 99° to the day of his death, when it was 101°. Pulse and respiration were normal until just prior to death. The jaundice was at first thought to be due to salvarsan ; but as the patient developed intense nausea and vomit ing, and as the jaundice deepened, he became progressively worse in spite of all dietetic and therapeutic measures used for his relief. The 50 Vol. XX. McCLINTOCK—ACUTE YELLOW ATROPHY. condition was believed due to acute yellow atrophy of liver. Death occurred February 11, 1923. Autopsy findings (only pertinent findings are recorded). —Body embalmed 36 hours prior to autopsy. Entire body had a distinct greenish color, due to the action of embalming fluid on extremely jaundiced tissues. Pleuria, both cavities completely obliterated by firm adhesions and in the right these adhesions were considerably calcified. Lymph nodes, none enlarged, firm but not necrotic. Lung, tuberculous cavitation extensive in both apices, few scat tered tubercles in rest of lung. Liver, small, capsule smooth, and in many areas the tissue beneath showed green. The organ was sectioned throughout and the cut surfaces all showed extensive green and gray areas, the green oc curring in strands as if in the bile ducts, the liver tissue between being gray. Where the liver was more normal in appearance and light brown in color the markings were obscured. There did not ap pear to be any cirrhosis, congestion, or infected foci. The gall bladder contained about 10 c. c. of mucoid bile and the ducts were patent. Spleen, of moderate size, capsule slightly thickened, pulp dark red in color. Kidneys, large, swollen, congested organs, capsules stripped readily; cortices greatly swollen and the architecture was much obscured. Vessels and ureters normal. Stomach and intestines, the stomach contained about 150 c. c. of fluid and semifluid material of coffee-ground appearance. The rest of the intestinal tract contained blood-stained material, and in the colon, sigmoid, and rectum were fluid and coagulated blood in large quantities. The gastric mucosa appeared normal, and the rest of the tract presented a much injected and generally deep red mucosa, most marked in the colon. Evidently there had been extensive ecchymosis with considerable escape of blood into the lumen of the bowel, as there were no ulcers and no localized lesion from which the blood could have escaped. The appendix was about 6 cm. long, retrocecal and lightly bound ; normal. Frozen section of liver showed all degrees of necrosis present with some attempt at replacement; many small, dark, nucleated cells present. No staining for organisms done. Weights of organs (embalmed). Liver grams 1, 005 Spleen do 215 Heart do 345 Left lung do 1,095 Right lung grams 1, 220 Kidney, right do 2(30 Kidney, left do 207 Body weight pounds 129 No. 1. 51 McCLINTOCK—ACUTE YELLOW ATROPHY. Anatomical diagnosis.—Acute yellow atrophy of liver. Tuber culosis, pulmonary. Fibrous pleuritis. Congested spleen. Paren chymatous nephritis acute. Congestion and ecchymosis of intestine and hemorrhage into lumen. Secondary syphilis from history. Came of death. —Acute yellow atrophy of liver. Contributanj cause.— Syphilis, secondary; tuberculosis, pulmo nary. G. Lepehue (1) in a discussion of the etiology of this disease says: " Nothing positive can be said. E. Frankel in a case of jaundice with hemorrhagic enteritis demonstrated a cholangitis caused by a parasitic typhoid bacillus in the walls of the gall bladder and bile duct; injection of the patient's serum into a guinea pig resulted in the same clinical picture. Fermentive autolysis of the liver cells is the assumed immediate cause of atrophy of liver. Solomom sug gests this is due to absorption of a pancreatic ferment. Pick and Hashimoto proved by chemical tests the occurrence of autolysis in a guinea pig following the giving of small doses of albumin. They also showed that tins did not occur in the guinea pig when the spleen had been previously extirpated. Other investigators have shown that necrosis of liver cells subsequent to chloroform poisoning or injection of hemolytic sera could be prevented by extirpation of the spleen. Eppinger removed the spleen in three patients ; one quickly recovered from the operation with the icterus cured, the other two died shortly after operation." W. Hayashi and T. Kibata (2) report a typical case of yellow atrophy in which they found a species of spirochete in the liver and other affected organs. Long threadlike organisms, 10 to 12 microns in length, in necrotic area in the intestines. In the liver similar organisms, and in addition numerous small bodies, diphtheroid or diplococcoid in type. In the kidney, in addition to the two types found in the liver, there were present a spiral organism in the neu rotic epithelium of the tubules. In the pancreas coccoid bodies, some of which were elongated, approached the threadlike forms found in the liver. The occurrence of two or more chromatic spots and positive reaction to the Levaditi method would seem to indicate the coccoid body is not a bacterium. These authors think the three bodies described represent the stages in the life cycle of a single species of organism, namely, a spirochete. Icterus development during the treatment of syphilis is rather uncommon and Bodin (3) thinks it is due to variation in toxicity in the various lots. In a series of 251 cases, icterus developed in 0.78 of 1 per cent; in a second series, icterus in 1.77 per cent, whereas in 472 cases, the third series, there were 7 per cent of the cases icterus. In these three series different lots of arsephenamine were used. 52 McCLINTOCK—ACUTE YELLOW ATROPHY. Vol. XX. Of special interest to this case is one reported by Ravant (4). Impressed by the argument of Milan that icterus developing in syphilis is more likely due to the disease than to the arsephenamine, Ravant resumed treatment in a case of items that had developed two months after cessation of arsephenamine therapy. This resump tion of treatment led to icterus gravis and death. On autopsy there was evidence of syphilitic lesion of the liver. The author thinks the patient died of toxic hepatitis. (It is regrettable that a fuller autopsy report of this case is not available.) In this case the immediate cause of death —acute yellow atrophy of liver—was in all probability due to a toxic condition due to pul monary tuberculosis, lues, and probably in an indirect way the Salvarsan received. REFERENCES. L Duetsch. Med. Wchnschr., July 14, 1921. 2. Jour. Infect. Dis., January, 1922. Practical Med. Series, vol 1, 1922. 3. Bull. Soc. franc, de dermat. et syph., No. 6, 1921. 4. Ibid., No. 2, 1921. Practical Med. Series, vol. VII, 1921. NOTES AND COMMENTS. MEETING OF THE ASSOCIATION OF MILITARY SURGEONS. The annual meeting of the Association of Military Surgeons was held at the United States Army Medical Field Service School; Carlisle, Pa., October 4^6, 1923. The rotation of office of president provides for the administration of the association each year by a representative of the Army, Navy, Public Health, or National Guard. The meeting at Washington, October, 1922, was essentially naval, with Capt. F. L. Pleadwell, Medical Corps, United States Navy, presiding. It was to be expected, therefore, that this year, with Col. Charles Lynch, of the Medical Corps of the Army, president, the duties of medical officers with troops would be emphasized. Such was the program in general, but for us of the Navy it was an excellent demonstration of the importance of training civilian doctors to render then! more efficient as military surgeons on an active or reserve status. The Medical Department of the Army fully realizes that in times of peace a " skeleton " organization must be maintained with provision for expansion in time of war to per haps 30,000 medical officers. To accomplish this mission a com prehensive program of organization and training of a large Reserve Corps was instituted. Medical officers entering the active corps are given a four months' course at the Field Service School before they are sent to the Army Medical School in Washington. The course for the reserve officers and those from the National Guard is of six weeks' duration, supplementing a correspondence course or graded instruction in class A medical schools. At present in the R. O. T. C. units there are basic and advanced courses in 24 medical, 6 dental, and 4 veterinary schools. At the end of the two years' basic course the student has an opportunity to join the Reserve Corps, and during the two years of the advanced course receives as emolument the value of a commuted ration. On graduation he is also offered an interne- ship in the Army Hospital with commission and opportunity at the end of this service to enter the Medical Corps of the Army. It is believed that this training of students provides for a valuable method of recruiting the Medical Corps for active or reserve duty. An important feature of the Carlisle meeting was the development of the fraternal spirit of the organization. This was accomplished by having the delegates and members quartered in the officers' homes 53 54 Vol. XX. NOTES AND COMMENTS. or at the post club. Informally at meals and at the several social events there was abundant opportunity to discuss and hear of the work of the different services. This association is the one organiza tion in which military surgeons can meet on a common platform to promote fellowship and coordination of effort. Delegates and mem bers who attend the Carlisle meeting were fully impressed with the value of membership to every medical officer, whether in Army, Navy, Public Health, Reserves, or National Guard. The practical demonstrations given at this Field Service School can not always be a feature of every annual meeting, but it was evi dent that they are very desirable. It was also the expressed opinion that articles in the journal should always be on military-medical subjects. Many members who can not attend the annual meetings keep in touch with the other branches of the service through the medium of this journal. Those of us in the Navy have our Medical Bulletin for timely information, and also see the Public Health re ports. The military surgeon's magazine is the principal source of information concerning recent advances in the Army Medical De partment. The by-laws of the association provide for a literary committee composed of members from each branch of the service. It is believed that the success of the association depends to a great degree on maintaining this committee, and if possible every number of the magazine should include articles concerning the work of each service. The value of membership is not appreciated by many medical offi cers in the Navy, largely because they are not informed of the aim and object of the association. At present we have 184 members, of which 86 are in the active corps and 98 in the reserve or retired. By reading the by-laws one can readily decide if he considers it worth while and also his duty to support a society that endeavors to pro mote the greater efficiency of all military surgeons of the United States. The cost of membership is very little and the annual dues a nominal sum ($1). The military surgeon is to-day a specialist more than ever before, and to maintain this specialty it is necessary to keep informed on many subjects. In time of war we must serve together and coordinate our work, hence mutual understanding is a necessity. History is full of the records of joint campaigns where cooperation has failed. The success of our transport operations during the re cent war depended on a close liaison with the Army Medical Depart ment. The value of the expert knowledge of Public Health officers was shown when we utilized their services in every naval district. The program of this thirty-first annual meeting at Carlisle was as follows : Xo. 1. 55 NOTES AND COMMENTS. October 4. First session, S.SO a. m. \ Business meeting (for members only). Reports of— Executive committee. Secretary-treasurer. Boards of award. Necrology committee. Appointment of— Nominating committee. Auditing committee. Committee on resolutions. Miscellaneous business. Second /tension, 10J5 a. m. General meeting. Music. i 1. Address of welcome. Lieut. Col. Charles R. Reynolds, M. C, United States Army, commandant Medical Field Service School. 2. Address of the president. Col. Charles Lynch, M. C, United States Armyi 3. Presentation of badges of honorary membership to foreign delegates. Maj. B. E. Hume, M. C, secretary, 4. Addresses by Maj. Gen. Merrltte W. Ireland, Surgeon General, United States Army; Rear Admiral E. R. Stltt, Surgeon General,- United States Navy; Surg. Gen. H. S. Gumming, United States Public Health Service. Music. 5. Addresses. Generul organization of the treatment and evacuation of wounded with fractures in the area of the front. Le mGdecin principal de 1"" classe Duguet, l'Armee Francaise, professeur a Val-de-Grace. (a) Statistical data relating to the French Medical Service during the war 1914-1918. (6) Organization of the French Medical Service during the operations of August, 1917, at Verdun ; historical account. Le medecin principal de 1*" classe Visbecq, meclecin chef de la section technique du service de sante l'Armee Francaise. Third session, 1 p. m. Demonstration of new equipment for medical troops and units. On the athletic field. Inspection of Medical Field Service School. 5 p. m. Parade and review. Unveiling of bronze tablet commemorating the services of officers, nurses, and enlisted men of Medical Department who lost their lives during the World War. Brig. Gen. John M. T. Finney, Medical Officers' Reserve Corps. 9 p. m. Reception and dance, post gymnasium. October 5. Fourth session, 8.20 a. m. All-day demonstration of lines of medical aid from the firing line back to and including the field hospital. Chemical-warfare demonstration. 8.30 p. m. Smoker, post gymnasium. 56 Vol. XX. NOTES AND COMMENTS. October 6. Fifth session, 9.S0 a. m. 1. Report of auditing committee. 2. Report of committee oh resolutions. 8. Report of nominating committee. 4. Election and installation of officers. 5. Unfinished business. Adjournment. 12.30 p. m. Visit to the Gettysburg Battle Field. It will be noted that the only papers presented were by two French medical officers. The one on statistical data and the organization of the French medical service during the World War was especially of interest and will appear in the Journal. It is well for members to realize that because of the practical features of this meeting there were not the usual number of papers. Throughout the coming year loyal support by the association can be shown by contribution of articles on the various activities of the corps. Although we must maintain the efficiency of our own Bulletin, yet there are certain papers more suitable for the association journal and no doubt would be welcomed by the editor, Maj. E. E. Hume, secretary and treasurer,. United States Army Medical Museum, Washington, D. C. During the third session of the meeting a demonstration of new- equipment included several units of special interest to the Naval Medical Department. A modified Stokes splint stretcher for avia tion service and trench warfare has the advantage of being lighter, but the removal of support for the feet places the strain of the patient's weight on his perineum. A " combat " wagon has been evolved by Major Fletcher, attached to the school, and will be a valuable addition for the medical battalion with the marines. It can carry the equipment of a battalion aid station or two field litters and also transport 14 men, G on each side and 2 in front. If the equipment is not carried, then two additional litters may be transported. This wagon has rubber-tired wheels of the same standard size, is animal drawn for use at the front, and has greater security in turning than the present escort wagon. A " Delco " lighting unit for the field hospital was shown. This year during the marine maneuvers the medical battalion had a smaller " Delco " unit for the field hospital 'section and it proved to be satisfactory. Major Fletcher has also devised a new model of field kitchen that is lighter and better than the one in general use. A field hospital tent was shown that has certain features that make it worthy of consideration for use for an advanced base hospital. It will pro vide shelter for nearly twice as many patients as a standard Alladin " knock-down " building, and the weight and space occupied is much Vo. 1. 57 NOTES AND COMMENTS. less. The cost is about the same. It is provided with windows, has a " ceiling cloth " to render it cooler in summer, and the roof beam has lateral supports instead of center poles. Last winter the weather- proofing of the canvas was thoroughly tested and found satisfactory. An inspection of the Medical Field Service School followed the demonstration of equipment. The tactical room contained models of the terrain about Carlisle so that problems could be studied in doors. In the section where field sanitation and hygiene are taught there are models of the various types of incinerators, latrines, fly trap, etc., to demonstrate the accepted methods in use. Several of our naval medical officers have availed themselves of the opportunity to take this course at Carlisle and found it very profitable. The all-day demonstration of the lines of medical aid from the firing line to and including the field hospital was an indication of the detail involved in solving the problems of evacuation of wounded. Automobiles and ambulances transported the members of the asso ciation to the selected terrain and the problem was given to each of us in order that we might follow the solution. Each unit was equipped as it would be in action, and treated cases with simulated wounds. At noon, upon arrival at the collecting station and ambu lance " head," we were given a field luncheon from a " rolling " kitchen. A critique of the problem solved by the staff of the school was then conducted, after which we returned to the barracks and inspected the field hospital. The chemical warfare demonstration illustrated the conditions we must experience if the nations which did not sign the Washington agreement should utilize gas and chemicals in warfare. Nontoxic smokes were principally exhibited, but a lachrymatory gas was in cluded that gave a touch of reality. In naval warfare there will be problems for us to solve if such chemicals are ever used, and there fore every naval medical officer should have a knowledge of these " gases " and the methods of protection and treatment. Following a parade and review of the student officers and Hos pital Corps personnel, a bronze tablet was unveiled commemorating the services of officers, nurses, and enlisted men of the Medical Department of the Army who lost their lives during the World War. Brig. Gen. John M. J. Finney, Medical Officers' Reserve Corps, and professor of surgery at Johns Hopkins, delivered a stirring oration in which he eulogized the devotion and service of those who had died. The final business meeting and election of officers for the coming year was held on October 6, after which the battlefield of Gettys burg was visited and the positions of the contending troops desig nated. It was the unanimous opinion that this Carlisle meeting 58 Vol. XX. NOTES AND COMMENTS. was one of the most instructive and satisfactory ever held, and re turning delegates were fully impressed with the value of member ship. THE PEOTECTION OF CAPITAL SHIPS AGAINST POISON GAS. It has been said that throughout the whole history of warfare, no weapon that had once proved to be successful had ever been aban doned so long as it continued to be efficient. Chemical Warfare, a magazine devoted to the activities of the Chemical Warfare Service of the Army, in its September, 1923, issue recalls the fact that only eight years have passed since chemical warfare was introduced. This method of combat proved successful, and consequently it will be used in future wars. The armies and navies of the world have recog nized the efficiency of this comparatively new weapon. They realize that to be safe in the event of future wars, a knowledge of chemical warfare and how to protect against it must not be neglected. In this connection the following article on " The protection of capital ships against poison gas," by Lieut. Paul W. Hains, Con struction Corps, United States Navy, originally appearing in the United States Naval Institute Proceedings of July, 1923, is of inter est to naval medical officers. " In 1917, during an action between German and British destroy ers off the Belgian coast, the Germans laid down what appeared to be an ordinary smoke screen through which it was necessary for the English ships to proceed. Their flotilla leader, the Botha, had no sooner entered than her crew were overcome —the Germans had mixed in poison gas, or, more correctly speaking, toxic smoke of some kind. Entirely unprotected against such a weapon, the English suf fered badly; and although the Botlia passed entirely through the smoke screen in about a minute, in that short time every man on the ship was thrown into paroxysms of nausea and suffered a most violent headache, even for some time after. " It is not reported whether or not the Germans were victorious as a result of their using toxic smoke, nor is this information im portant for our present purpose. The point to note is that poison gas has been used in at least one naval battle. And it can be used in other ways than by being mixed with a smoke screen. It can be dropped from airplanes in bombs; it can be projected upon an enemy in shells; it can be strewn in the path of an oncoming enemy by using floating containers which may be set off by a time fuse and which do not explode but emit the deadly gas slowly over a period of five minutes; it can be dropped from the stem of a retreating fleet to prevent pursuit ; it can be sprayed from airplanes flying at low alti tude far enough ahead of an enemy's fleet to be out of danger from No. 1. 59 NOTES AND COMMENTS. gunfire and yet close enough for the spray to settle to the surface of the water just as the enemy reaches that point. Other means may be developed by foreign countries about which to-day we know nothing. " And if poison gas can be used to work havoc upon an .enemy's fleet, it will be so used. The United States Navy can not afford to sit back in complacency, secure in the knowledge that the Wash ington Peace Conference has abolished the use of gas in war. Actual gas protection must be provided our ships, in addition to the poten tial protection they now have. History has shown too often the im- potency of an agreement, written or understood, when some na tion's desires are thwarted by that agreement. When that nation, with whom we may be at war, believes that it can bend us to his will by using poison gas on our naval forces, it may help us little to recall to his mind an old agreement not to use gas. What we will need then is protection, positive and actual. Did Belgium fail to build forts around Brussels because Germany had agreed to keep out of Belgium domain? No, and the world is thankful. And that is the risk also that we can not take. Of what then does the ideal protection for our Navy consist? It will be attempted only to de scribe a system for our battleships. With modifications, the system can be applied to the other types of ships in the service. Our funda mental requirement is that every man on the ship should be provided with and drilled in the use of a gas mask. There should be provided for men doing manual labor the type now found on certain battle ships, having the canister carried on the wearer's head so as to per mit free motion of the arms. Men who are required to speak in the performance of their duties should be provided with a diaphragm mask. Men wearing telephones should have an adapter to fit over the mouthpiece of the telephone and the diaphragm of their mask. No separate ' telephone ' mask is seriously needed. There should be provided what might be called an ' optical ' mask to be used by men required to sight the enemy. Pointers, trainers, range-finder men, spotters, turret officers, etc., require this type. The mask should in variably be made an integral part of the sighting instrument, the eye-pieces of the mask and of the instrument being combined into one piece. The canister should be carried on the optical instrument, so that the gas mask would be in all respects a part of the instru ment. The angle tube of the mask should be fitted with a two-way valve> the manipulation of which should permit the wearer to breathe either directly from the atmosphere or through the canister, as ne cessity required. The advantages of this mask are twofold. First, the wearer would become highly efficient in its use, because he would 69826—23 5 60 Vol. XX. NOTES AND COMMENTS. have to use it at every drill. Second, at a time of battle when a gas attack is expected, there would have to be no cessation in his duties— no need of taking his eye from the instrument, putting on and ad justing a gas mask, and then again picking up the enemy. Officers appreciate the difficulties of spotting, training, etc., under the most normal conditions. Imagine the multiplication of these difficulties when wearing a cumbersome gas mask which is not attached in tegrally to the telescope. Finally a combination of diaphragm and optical mask should be provided for spotters, range finders, and fire- control officers. It is believed that these four types of mask fully cover the requirements of the service. " Not only must every man on board ship have his gas mask, but also he must be provided with protective clothing of some sort, clothing that will protect him against such vesicant fluids as mustard and lewisite. These fluids and their vapors cause no immediate burns when they impinge upon the skin, and often require 12 hours or more to produce a casualty, and they therefore probably will never be used in a major engagement where immediate casualties are of more import. Nevertheless, they have an important use in the case of fleets lying at anchor or in the case of detached engage ments where warships are used to cover landings or to bombard ports. A case in point occurred at Gallipoli during the World War. There, if the Turks had been able to sprinkle the British ships with mustard, using airplanes for the purpose, the British undertaking would have come to an abrupt halt, for the personnel of the British forces were not protected by impregnated clothing. Every man touched by the liquid would have been incapacitated to some degree. Every deck and every gun that had been bathed with the chemical would have been out of commission for days, because of the horrible burns that would have resulted from walking on the one or manipu lating the other. And another case is that of the use of mustard gas by the Germans on the British fleet in Scapa Flow. Such a blow would have given the German fleet immediate superiority on the high seas —their enemy being reduced from the mighty British armada to the few ships that probably would have escaped the deluge of mustard. " The need for protective clothing is there. Then the question is, Should the clothing be a separate article for war only at battle stations, or should it consist of a set of underclothing, shoes, socks, trousers, and blouses to be worn always when, in war, the fleet is in reasonable danger of being gassed with a vesicant agent ? ' It is believed that the former type is far better suited to the requirements of the service for the following reasons : First, because this hooded over all would be worn only in action and at enough drills to get No. 1. 61 NOTES AND COMMENTS. the ' feel ' of them, and would therefore outlast the other type, which would very likely be worn at any old time the owner found his clean laundry supply getting low. Although impregnated cloth ing can be laundered, the process after a few washings seriously reduces the protection the clothing can give against vesicant agents. Second, because it is easy for a divisional officer to see at once if his men are wearing protective clothing when a battle is imminent and if they are not doing so to enforce the rule. It would be far from a simple matter to inspect each man's undershirt and socks before going into action to see that he was properly gowned with the correct set. And this matter can not be left to the men themselves. Their contempt for such a suit of clothing would be only too marked. Due to their ignorance regarding the horrible burns that occur when mustard gas or lewisite gets on a man's body, they would be prone to go into action as they felt most comfortable; and 'damn the torpedoes—we'll take our chances with mustard.' The hooded over all is a veritable signal that shows the desired information. With the ordinary clothing impregnated, an officer would have to content himself with warning his men that they ought to be wearing their impregnated outfit. And the third reason is that shoes, mittens, hood, and main body covering can be incorporated into one garment, giving complete, protection, in the over-all type, whereas, in the other case, separate mittens, shoes, and hood must be on hand. In one case just 1,200 complete suits must be accounted for; in the other case 2,400 shoes, 2,400 mittens, 1,200 trousers, 1,200 shirts, 1,200 hoods, etc., must be looked after at all times in order to have them at hand when needed. "Although masks and protective clothing should be supplied for all men, the protection they afford should be resorted to only in a case of emergency. Other protection, protection to the compartments themselves, should be provided wherever possible. It is undesirable for men to have to wear their masks because their efficiency is thereby cut down, and especially is this true in the case of men doing manual labor. The mask is cumbersome; it is difficult to breathe through for any length of time; and it produces considerable discomfort from perspiration and body heat. The amount of drop in a man's effi ciency is a mooted question, as it is a matter that does not lend itself to accurate calculation. But that there is a drop can not be denied, nor can it be said that it is so small as to be negligible. The writer has played a game of baseball wearing a gas mask, and the heat, d iffi- culty of breathing, and general lack of ' pep ' were marked. He has likewise gone to the other extreme of writing while masked; and there also,' though in a lesser degree, the same effects were produced. So we say that there is a loss in a man's efficiency. What does this mean on a ship? 62 Vol. XX. NOTES AND COMMENTS. " It means that the rate of fire from the ship is going to be slower, due to the cumulative drop in efficiency throughout the ship. The men in the powder and shell handling rooms do not get the ammuni tion to the hoists quite so fast; the loaders have just a little more lag in their work; the pointers, trainers, sight setters are all just a little slower at their work; and so on up the line. The result is bound to be felt. And therefore it is entirely reasonable to expect that the fleet which must go into battle with its men gas-masked throughout, against any enemy unmasked but still fully protected, all other things being equal, is going to be defeated. " The consideration of this additional ' compartment ' protection is facilitated by dividing the battle stations on a ship into four types. In the first place there are those battle stations which are fully ex posed to any kind of attack, gas included. Signal stations, the gun crews of antiaircraft guns, first-aid parties, and miscellaneous transient personnel fall under this head. Second, there are such spaces, as turrets, secondary batteries, handling rooms, and ammuni tion passageways all of which may be termed semiolosed, in that, although they are fully protected by armor and are even, some of them, deep in the bowels of the ship, yet they are not air-tight and can not readily be made so, due to the necessary passage of ammuni tion through them. Third, there are the fully closed spaces, such as steering-engine rooms, central stations, torpedo rooms, switch rooms, sick bays, distribution rooms, and radio rooms. Under this heading also are included fighting tops, conning towers, plotting rooms, and other spaces which, though normally not fully closed, could be made perfectly air-tight, with modifications in their design. The fourth type of space embraces all spaces that have boilers or propelling machinery or its auxiliaries in them, dynamo rooms, and evaporator rooms. " The personnel in the first, the fully exposed type of battle sta tion, can be given no protection additional to that furnished by their masks and their protective clothing. " The men in the second type, the semiclosed type of battle station, constitute our hardest problem, and the one most demanding a solu tion —for these men furnish our offensive power. Briefly stated, the solution offered is this. To close all such spaces as tightly as possible, and to keep them under a small head of air pressure, the air being obtained from some sort of purifier. By keeping these spaces under pressure the contaminated air outside can not get into them. Two subproblems are encountered : First, how to make a turret or a secondary battery tight enough to enable a reasonable-sized blower to keep the space under a few inches head of pressure; and, second, what sort of air purifier is there that will remove chlorcetephenone, No. 1. 63 NOTES AND COMMENTS. chlorpicrin, phosgene, or chlorine gas from contaminated air. The complete details of the means by which a secondary battery can be made reasonably air-tight are quite impossible of any considerable amplification without its occupying undue space, but that such is possible we believe. Briefly the proposition would be to isolate each set of two guns in the secondary battery from the rest of the ship by decks or splinter bulkheads pierced only by water-tight doors. Such u scheme (possibly, .however, not with the same goal in view) has been used on the Japanese battleship Mutsu. The gun ports of course could not be the open type we now have on the Pennsylvania and later ships. A development of the old type of sliding shield port would have to be used with, possibly, some sacrifice in result ing arc of train. The gun shield would have to fit the decks and the side of the ship snugly and be fitted with a sort of felt scraper. The opening in the shield for the gun would be closed by a gun buckler of some type and opening for sights minimized to the utmost. Turrets would be made tighter by inserting felt scrapers between the cylindrical-shaped piece now used on the three-gun, 14-inch turrets and the turret front plate ; by minimizing the openings for trainers' sights; by closing up completely the fifty-odd 1-inch holes in the overhang; and by providing felt sliding pieces between the barbette and the turret. The suggestions as here offered are crude, but they do point out the general scheme that it would be necessary to follow in order to make these semiclosed spaces tight enough to make possible the maintenance of a few pounds of air pressure within them. " The pressure required will not be great, just enough to prevent any wind that is likely to be met under battle conditions from blowing the gas into the turret through the few openings that, of necessity, can not be closed. If we assume a maximum wind velocity likely to be met in battle of 25 miles per hour, and a total projected area perpendicular to the wind direction of a few square inches, the necessary pressure within the turret will not be greater than about 8 pounds per square foot; that is, 1^ inches of water. Escape of air through the guns when the breeches are opened would not alter the effectiveness of this scheme of protection because the pressure of the wind outside when high would tend to lower the velocity of air escaping through the guns, and when low would not require such a high pressure as \\ inches inside the turret to keep the wind out. " So much for the tightness of semiclosed spaces and the neces sary air pressure within them. The next step is to procure a purifier for the ventilating system of such spaces, and for this purpose the Seco spray is recommended. This machine is a product of the Chemical Equipment Co., of Chicago, and finds its use in industry as 64 Vol. XX. NOTES AND COMMENTS. a deodorizer, an evaporator, a gas cooler, a gas absorber, and an air washer. Its essential features are a horizontal revolving disk upon the top of which a liquid is continuously poured and by reason of the whirling motion the liquid is thrown out in a thin sheet or spray. On the underside of the disk are fan blades set at such an angle that any gas which is fed in at the bottom and upward to the middle of the fan is whirled outward into the liquid spray. Surrounding the machine is a metal wall in the shape of a truncated cone. The gas and liquid are intimately mixed during the time of flight from disk to the wall. At the wall they are quickly separated by the action of impinging thereon and the gas passes out at the top and the liquid at the bottom. The machine is simply a mechanical mixer and separator of a liquid and a gas. Now by using the proper alkali solution as the liquid and a given chemical warfare gas it becomes an excellent air purifier suitable for our use in the Navy. A small laboratory machine at Edgewood Arsenal has successfully removed 95 per cent of various poisonous gases from contaminated air. The remaining 5 per cent, it is hoped and fully expected, can be removed by using an auxiliary disk and spray above the main one, all inclosed in the same wall. " However, since the removal of this last 5 per cent of gas has not crystallized as yet, we will assume that the Seco spray can remove only 95 per cent of the gases. This means that for the few minutes at the most that a ship will be in a gas cloud the concentration neces sary to produce lethal or lachrymatory effects in a turret must be twenty times the concentration required if there were no purifier. And such a concentration it is practically, if not absolutely, im possible to produce under ' field ' conditions at sea. And thus the spray will serve our purpose. " The Seco spray is, built to-day for commercial use in three sizes up to a capacity of 3,000 cubic feet of air per minute. A turret on a ship of the Colorado class requires less than 1,000 cubic feet of air per minute for ventilation. We then have a machine about as big as a turbo-blower on a destroyer to be fitted in each turret's ventilat ing system. This would not seem to offer an insurmontable problem to the designer. Moreover, the method here outlined of protecting semi- closed spaces is practicable, involves no radical change in design, and does not interfere with the efficient operation of machinery, guns, or instruments. " The protection of the fully closed type of battle station, the third type, is rather more simple. Under this type are included the all- iinportant spaces, the fighting tops, the fire-control stations, and the conning tower. These spaces readily lend themselves to being glassed in, where now open, and thus to being made perfectly gas- tight. The scheme for all such places is to treat each one like a small No. I. 65 NOTES AND COMMENTS. submarine; completely to cut off any ventlating ducts that may be installed so that no gases can get in by any means so long as the com part remains intact ; and to keep the air inside pure. In this way the personnel could perform its duty under perfect conditions, unhamp ered by gas mask or protective clothing. When we cut off ventilation systems to these compartments, it becomes necessary, of course, to have some sort of air revitalizing apparatus within each such com partment, an apparatus that will not only keep the carbon dioxide content of the air low and supply oxygen, but also keep the humidity relatively low, and the body odors of the occupants of the compart ments from becoming obnoxious. Such an apparatus has been per fected and installed on a number of our submarines. It consists of a motor-driven fan which sucks the air in the compartment up through a container filled with a specially prepared soda lime. In passing through this chemical all carbon dioxide is removed, water vapor above a certain reasonable amount, and also body odors caused by perspiration. A charge of 40 pounds of soda lime will last for 16 hours running continuously. Pure oxygen is liberated from tanks which in our case could be stood in a corner of the compartment or else tucked under a table or desk out of the way. In the report of experiments conducted by the American University experimental station in 1917, it is stated that the apparatus kept the carbon dioxide content down to less than one-half of 1 per cent when 23 men were con fined in a submarine for 48 hours. At the end of the submergence the air was as pure as when the test started. Three charges of lime were used in the carbon dioxide removers, changes being made while the test was running. A little over 6£ tanks of oxygen were consumed. This was for a 48-hour submergence, it will be borne in mind. The needs of a ship will probably never exceed a continuous run of 12 hours. " The method outlined here for protection of closed spaces should be extended to embrace as many compartments as possible. Spaces which may even require considerable change in the design of minor parts of them should be so protected. Its advantages lie in the com plete independence of each compartment regarding its protection, the perfection of the protection, and the ease with which personnel therein can perform its duty. " The last type of space that requires consideration is that which embraces propelling machinery, electric generators, or heat machines such as the evaporators. It is not believed possible to provide purifiers in the ventilating systems in these compartments because the quantity of air required is too great. For instance, to refer again to the Colo rado class, each engine room requires 55,000 cubic feet per minute ; and the evaporator rooms 6,000 cubic feet per minute. Even the smallest 66 Vol. XX. NOTES AND COMMENTS. figure here would require two Seco sprays, each of 3,000 cubic feet capacity and about 5£ feet in diameter and 4i feet high. The largest figure would require 40 such purifiers and a tremendously compli cated system of air ducts. The question has at times been raised, Why not use a very large canister similar to that our doughboys used as an air purifier ? The reason is that one large enough to take care of the volume of air required would be about two-thirds as large as the ship itself. No such scheme can be used for engine rooms, or indeed for any other ventilation system. Nor can these spaces be protected by making them closed and gas-tight for very obvious reasons. We are left then with the proposition that air, contaminated or not, must be used in vast quantities in the ' black gang's ' domain. How to protect the personnel without forcing them to wear gas masks? " A system of inner compartments should be used, which should be made gas-tight and be provided with submarine methods outlined above for air renovating. It should be provided with adequate glass windows, and to it should be led all pipes, valves, switches, and levers, through gas-tight gaskets, necessary for the operation of the ship's compartment in which it is located. In short, each fireroom, engine room, motor room, generator room would have within it a central operating station, glassed in and air-tight, within which the personnel could be housed in perfect protection and still perform their duties. Then the ordinary blower system for supplying the necessary air to engines, boilers, and generators would be operated as usual. By such a system the men could work at maximum effi ciency without the necessity of wearing masks or protective clothing/' THOMAS WAKLEY AND THE LANCET. The centenary number of the Lancet appeared on October 6, 1923, and in it the present editor, Sir Squire Sprigge, has admirably chronicled the events of its career during the past hundred years. The first number of the Lancet was issued on October 5, 1823. Its founder was Thomas Wakley, a young practitioner of London, who resented the abuses and the injustice which were then rife in the medical profession. At that time, although the medical student might pay his fees and attend lectures at the London medical schools, these lectures were not delivered by the eminent men who received the fees, but by their assistants; presence at post-mortem examina tions was only secured by the clandestine feeing of porters in post mortem rooms; the lists of operations at the great London hospitals were not published to the students at large, but only communicated to the favored pupils of the staff, who knew what was going to be done by the great surgeons and at what time. A popular operator, No. 1. 67 NOTES AND COMMENTS. lecturer, teacher, or consultant could ask and obtain high fees from his pupils, therefore a command of money at the beginning of a student's career was necessary to insure success, while lack of money as a usual thing condemned a man to an inferior position in the medical world for the rest of his life. Wakley, himself a poor man, having lived as a student with other hard-working medical students of similar means, having shared their labors, knowing their trials, and estimating the amount of good they did and the amount of influence for good that they were able to exercise over the com munity, recognized that these men were set to one side and looked down upon by their privileged brethren, who had obtained their places in the profession by purchase and not by merit. Nepotism was rampant in the medical schools, and the system of teaching was faulty. The conditions were too special for treatment in the news papers of that day without a tedious amount of preliminary ex planation, but the medical men would have no difficulty in appreciat ing the need for reform. Therefore, influenced by a chance ac quaintance with William Cobbett, who at that time was publishing in his paper, the Political Register, his shrewd and eloquent criti cisms of rural conditions in England, Wakley determined to get his arguments for reform before the medical profession and the general public by means of a weekly medical periodical. For the first 10 years of its existence the Lancet was a dueling ground for a series of fierce encounters between the editor and the members of the privileged classes in medical practice. The lectures of certain of the prominent surgeons and physicians were reported in its pages, to the exasperation of the lecturers and the delight of the students and the profession at large. The lecturers feared that their fees as teachers in the London schools would diminish if the cream of their teaching could be bought for 6 pence a week instead of £5 a session. The meetings of the medical societies were reported at such length as their importance appeared to warrant —a proceed ing which the officials of the societies objected to as an infringement of copyright. These officials belonged to the class from which the honorary staffs of the hospitals were selected, and thus they were doubly outraged. Everyone who had anything to gain by the exist ing methods in school, hospital, or society looked with uneasiness at the new journal. A few of the privileged members of the profession became frightened at the exposures of abuses which were appearing in print, and they denounced the editor as a literary pirate and a disseminator of moral garbage. Wakley's replies were chiefly in the nature of reflection on the complete and fretful ineptitude of his denunciators. Following his assertion that the elections of the staffs of the various London hospitals were made at the instigation of pure nepotism, accounts were given of maladministration in the -68 Vol. XX. NOTES AND COMMENTS. medical schools and malpractice in the hospital wards. As a result the editor became involved in frequent lawsuits, in which he was always supported by public opinion and assisted by public subscrip tion. He next attacked the Royal College of Surgeons of England, whose by-laws made it compulsory for students to attend the lectures of certain hospital officials, some of whom charged very large fees for inferior instruction. This controversy was instrumental in causing Wakley to enter Parliament in an attempt to find a consti tutional remedy for the many defects present in medical training in England. His efforts in Parliament eventually led to the act under which the General Council of Medical Education and Regis tration was created. Among other subjects ventilated by Wakley in the pages of the Lancet during the early years of its existence were the administra tion of the poor law, the advocacy of medical coroners, the care of the insane, the adulteration of food, and body snatching. Early in his editorial career Wakley drew to the staff of the Lancet men of ability who had studied in Paris, and when the (10111368 of study at the London hospitals or the anomalies of English medical education were the subject of discussion the invariable habit of the paper was to draw comparisons between what happened at the Paris hospitals or at the University of Paris and what prevailed in Eng land. In this way a very close bond was set up between the Lancet and French practitioners. As a result of this entente translations of the lectures of the great French teachers appeared frequently. When Thomas Wakley died, in 1862, it was said that he had started principles of reform and in large part secured their realiza tion. Through his efforts the status of the medical practitioner had been advanced. He fought the battle of the medical student and the general practitioner at a time when universities and medical corpora tions seemed to regard both as persons who should pay fees but whose interests were otherwise of no consideration. He exposed impostors and denounced quackery, while he published medical information which would otherwise have been entirely lost, doing so in the first instance at considerable pecuniary risk, if not in defiance of the law at the time. DIATHERMY IN PNEUMONIA. Diathermy is the application of the bipolar high-frequency cur rent of D'Arsonval. It has been successfully employed in the treat ment of pathological conditions in which the application of heat to the tissues is indicated. The physiological effects of diathermy on living tissue naturally differ greatly from those of any form of No. L 69 NOTES AND COMMENTS. external heat. The heat produced by the D'Arsonval current de velops deeply within the tissues. Very little effect is obtained upon the skin with the use of proper technic. In the deeper tissues through which (lie current passes there is an acute temporary dila tation of the capillaries resulting in an outpouring of blood serum rich in repair material. In an area affected by the current there occurs an increase in all of the blood elements, the erythrocytes with their contained oxygen and phagocytes which enhance the local re sistance to bacterial invasion. A temporary active congestion is brought about and lymphatic drainage is augmented. The oscilla tions of the D'Arsonval current are so rapid that no ionic movement and no muscular contraction is induced. Pain is relieved by the effect of the current on sensory nerve endings within its pathway. Shortly after the war certain physicians who had seen the bene fits of diathermy as applied to various inflammatory processes sug gested its employment in pneumonia. It seemed reasonable to sup pose that a centrally located heat of from 110° to 120° F. developed in the affected lung without any cost to the body in instituting this rise in temperature should have a favorable effect on the pneumonic process. It was believed that this heat would dilate the pulmonary capillaries and lymphatics, and thus promote a more active circu lation. The results obtained in the early investigation of diathermy as applied to pneumonia were sufficiently favorable to justify continu ance of the study of this form of treatment. Prominent among the investigators was Dr. H. E. Stewart, of New Haven, Conn., who contributed a paper on the subject to the Rhode Island Medical Journal of October, 1923. Most of his observations were made in one of the hospitals con trolled by the United States Public Health Service. The patients were all adults, nearly all of them merchant seamen, averaging about 35 year of age, and many of them were moderate users of alcohol. Judging from mortality statistics, the death rate in such a class of men should be about 40 per cent. A group of 21 cases whose treatment did not include diathermy was used as a control test. In the groups treated by diathermy the mortality was less than 20 per cent ; in the control group it was 42.9 per cent. Among cases treated in private practice the average mortality was less than 12 per cent. Temper ature, pulse, respiration, and rate of resolution all seemed to be fa vorably affected by the treatment. Extension of the disease to other lobes, however, was not prevented. No contraindications to the treat ment have appeared. A period of lessened pain and dyspnoea, last ing in most cases several hours after the treatment, is in itself suf ficient to justify the use of diathermy in pnuemonia. 70 NOTES AND COMMENTS. Vol. XX. The technic of the treatment as outlined by Doctor Stewart is as follows : " To treat cases by diathermy the physician must have an efficient piece of apparatus delivering a good D'Arsonval current and sup plied with a meter. He must understand the physics and physiolog ical effects of the current and know his technique. While diathermy technique is not very complicated, it is rather exact. As in other types of treatment, the earliest possible administration of diathermy is desired once a diagnosis is made. As far as the writer is aware, no case has yet been lost in which diathermy was used before the third day. This does not mean that cases treated early will not be lost in the future, but it at least emphasizes the value of early treat ment. We do not have to wait until the sputum has been typed, as is the case in using serum, in Type I. The word " cure " is not used nor meant to be implied in this paper. It is the writers personal opinion that an adjunct which may be applied to all types of the disease, which will prove at least as effective on the average as serum has proven in Type I, has been found. "The D'Arsonval current is one of high voltage and relatively high amperage which oscillates with extreme rapidity. The appa ratus should by preference be supplied with a 110-volt, 60-cycle al ternating current. This current it " steps up " in voltage to many thousand, cutting down the amperage in direct proportion and in creasing the alternations to a million or more per second. The cur rent thus produced has been compared to water power, particularly to a stream coming from a fire hose through a spray nozzle, harmless yet with great power behind it. " The spark gap requires constant care in order that the current may be smooth in quality, frea from faradic effect, and of sufficient volume due to proper charging of the condensers. The milliampere meter consists of a wire in the circuit which expands by the heat pro duced, moving the needle on the scale. It indicates the total amount of current, the patient is receiving, but does not indicate with any exactness the amount of heat actually being generated in the tissues. This depends upon the. current density —that is, the number of mil- liamperes per square inch of electrode, and the density of the tissues through which the current passes. For instance, with 2,000 milliam- peres of current and 5 by 4 inch plates, we have a current density of 100 per square inch of electrode. This meter reading and these plates would develop far greater heat applied to the knee joint than to the abdomen or chef t. " If the plates were larger less heat would be developed in either locality. In the consolidated lung we have an intermediate condition of soft tissue density and use from 1,000 to 2,000 milliamperes of No. J. 71 NOTES AND COMMENTS. current by means of about "5 by 7 incb electrodes. It must be re membered that the heat produced varies as the square of the current strength, therefore slightly increased meter reading may mean con siderably greater heat production. "Apparatus.—Practically all of our work was done with small compact portable apparatus supplied with a meter. It is necessary to use one which will deliver a D'Arsonval current of good quality and up to 2,000 milliamperes. A machine which will show a high meter reading with a comparatively low spark gap is to be pre ferred. "Electrodes. —In all of our pneumonia work we have used com position 22-gauge flexible metal electrodes. This material comes in sheets at moderate cost and can be cut into convenient sizes and shapes. The edges should be sharply turned back and rolled flat with a slightly longer flap on one end for the attachment of the cord clip. Some prefer the thinner metal which may be doubled and still remain very flexible. " Technique. —With a pair of plates suitable in size to the involved area of the lung and the machine set up, we are ready for the treat ment The electrodes are covered with heavy, warm shaving-soap lather. The posterior one clipped to the cord and turned lather side up on a heavy folded bath towel. By depressing the mattress this electrode may be gently moved under the patient to the desired location without disturbing him in the least. The anterior plate is then clipped on and placed on the chest wall so as to include the affected lobe or lobes directly between the two plates. They should not approach each other on the lateral wall of the chest, otherwise an undue amount of current will pass between these near edges rather than through the affected lung. The posterior plate is secured by the patient's weight. The anterior one may be gently held on the chest or secured by adhesive plaster. Cords and clips should be covered so that they will not be torn loose by a restless or irra tional patient. With everything in readiness the rheostat and spark gap are slowly advanced until the desired amount of current, usually between 1,000 and 2,000 milliamperes, is reached after about 5 minutes. This is maintained from 15 minutes to an hour, usually 20 to 30 minutes, after which it is slowly reduced during a further period of 2 or 3 minutes to zero. If it is desired to localize the heat more sharply this may be done by using a slightly smaller elec trode nearer the point it is desired to reach. If any points of burn ing or tingling are complained of, turn the current slowly off, re insert more soap lather with finger or brush, press the electrode gently in place and again turn on the current slowly. As a rule the treatments are given twice a day, but there is no reason why 72 Vol. XX. NOTES AND COMMENTS. in the critical stage of the disease more frequent applications should not be made. One treatment a day is probably sufficient during the period of resolution." FOOD ALLERGY AS A CAUSE OF IERITABLE BLADDER. In an article on food allergy as a cause of irritable bladder, appear ing in the Southern Medical Journal of October, 1923, Dr. W. W. Duke calls attention to a condition with which most of us are un familiar. In some cases of frequent painful urination, the severity of the disorder seems out of all proportion to the lesions found after careful examination, and in spite of the symptoms resembling cystitis the urine may be free of both bacteria and pus. Treatment of the condition may give little relief and severe bladder symptoms may continue without remission for months or years. Bladder disorder of this sort is often the result, the writer believes, of hypersensitiveness to certain foods. The bladder mucosa does not ordinarily come in contact with foreign substances. Bladder symp toms of an allergic nature should occur theoretically, therefore, only as part of a general reaction after the offending substance is ab sorbed in some distant locality. A bladder attack of this nature would seem analogous in pathogenesis to asthma caused by the ingestion of egg rather than to asthma caused by direct contact be tween the bronchial mucous membrane and a pollen to which it is sensitive. The writer comments on a study of five patients who seemed to him to be examples of bladder allergy. Each of the five was subject to attacks of frequent painful urination. In these patients nothing was found by history, physical examination, Roentgen examination, or laboratory tests which could account for the severity of their symptoms except hypersensitiveness to certain foods. Each gave positive cutaneous or intracutaneous tests upon injec tion of small amounts of substances extracted from one or more foods which they were in the habit of eating, and in each a charac teristic exaggeration of the bladder symptoms followed the cutaneous tests or the subcutaneous injection of small amounts of extracts to which they gave positive cutaneous tests. Four of the five patients were completely relieved of bladder trouble by avoidance of the foods to which they were sensitive, and four had a return of the symptoms during a remission after eating, as a test, of foods to which they were sensitive. PROPHYLACTIC INJECTION OF NORMAL SERUM AGAINST MEASLES. On two occasions during the past year the Lancet has called atten tion to the work of Dr. R. Degkwitz, of Munich, who produced an No. 1. 73 NOTES AND COMMENTS. immunity against measles by injections of serum obtained from pa tients convalescent from the disease. We learn from the Lancet of September 22, 1923, that Dr. Gustav Salomon, in combating a severe epidemic of measles in the Waisenhaus and Kinderasyl in Berlin, found that the supply of convalescent serum was insufficient to fill his demand, and as the epidemic was a particularly severe one, and every child exposed to infection contracted it, he experimented with injections (10-15 c. c.) of serum obtained from adults who had had measles in their infancy. He had the opportunity of dividing his cases (all of whom had been exposed to infection) into three groups—namely, 60 children untreated, 62 treated with M. R. S. (Masern-rekonvaleszenten-serum), and 72 treated with adult serum. Of the 60 untreated cases all (100 per cent) became infected and 58 per cent died; of the M. R. S. children more than half (59.7 per cent) were protected, while 16 per cent died ; and of the adult serum cases 52.6 per cent remained immune and 13.8 per cent died. Out of the 44 deaths, 34 were consequent on broncho-pneumonia, and 10 died while the rash was out. Of the cases which recovered 13 developed broncho-pneumonia. This complication therefore attached in all 47 cases, 28 of the untreated, 13 of the M. R. S., and 6 of the adult serum cases. The course of the disease, when it occurred in those who have received prophylatic injections, appeared in most cases to be much milder, abated more rapidly, and showed a longer incubation period than the untreated cases. The M. R. S. used in this series was obtained from infants under one year, and was probably not so rich in antibodies as that used by Degkwitz, which was obtained from older children. This fact may account for the lower percentage of good reults as compared with his. The prophylactic injection of adult serum appeared to give approximately a similar protection against measles with regard to the incidence, mortality, course of the disease, and complications as the M. R. S. used in this series. LAMBLIAL DYSENTERY TREATED WITH CARBON TETRACHLORIDE. In an original communication to the Journal of Tropical Medicine and Hygiene of September 15, 1923, Khalil and Shawky report from Egypt their experience with carbon tetrachloride in the treatment of lamblial dysentery. Giardia {lamblia) intestinalis was the only pathogenic organism found in the cases reported. In the absence of any known specific treatment for lamblia infection, carbon tetra chloride was administered as an experiment. The immediate re sults were gratifying. The symptoms of dysentery in each case promptly disappeared, and examination of the stools failed to show the presence of either lamblia or their cysts. 74 Vol. XX. NOTES AND COMMENTS. Although the cases reported are too few in number to warrant any definite conclusion, especially since lamblia infection is characterized by intervals of freedom from diarrhea and occasional absence of the organism from the feces, yet the immediate relief from the symp toms after the administration of carbon tetrachloride justifies an extended trial of this remedy in this type of infection. THE ENDOCBINE SURVEY. The first issue of the Endocrine Survey, published at Glendale, Calif., appeared during October, 1923. This publication is a result of the consolidation of The Organo-therapeutic Review and The Inter national Digest of Organo-therapy, and will endeavor to present to its readers each month a part of the large amount of information appearing in current medical literature pertaining to the practical aspects of endocrinology and organo-therapy. The initial number contains readable abstracts of articles which have appeared recently in American and foreign journals, reviews of recent books dealing with the endocrine glands, letters from abroad, and answers to in quiries concerning problems arising in the practices of subscribers. NAVY NURSE CORPS. It is the bureau's desire that all members of the Navy Nurse Corps avail themselves of every opportunity to keep themselves informed of the advances taking place in the nursing profession; that they take an active part in local nursing organizations in proximity to their various stations of duty and thus become a vital factor in the nursing world. The Surgeon General offers every opportunity pos sible to nurses who desire to undertake special study in order to make themselves of more value to the naval service. Since October, 1922, 23 nurses have taken special courses in dietetics, advanced laboratory work, physiotherapy, and a course for instructors of nursing. Eleven nurses are at present taking courses in three of the above subjects. Courses in anaesthesia at the Lakeside Hospital, Cleveland, and Grad uate School of Medicine and Surgery of Pennsylvania will start in December and January. As time goes on and the naval hospitals be come equipped with these nurses, it is expected they will prepare others in their special lines and instruct the hospital corpsmen. The program is a big one and it will take time to carry it out in full, but if each nurse will take a personal interest in fulfilling her obligations, first, to her own self-respect and, second, to the advancement and high standing of the corps, she will find the reward rich in the respect shown to the individual as well as the whole. Some nurses have raised the question as to whether one who lias undertaken a special course and has perfected herself in a specialty would be under obligation to continue in this special line of work throughout her naval service. Some appear loath to undertake a line of work which might serve to isolate them from the general practice of nursing. It is the Surgeon General's wish that nurses who have received the advantages of special courses should render service in this special capacity for reasonable length of time, but he does not want nurses to feel that because of this study they are exempt from any duty which may be required of them in the naval hospitals ; also if a nurse has given a special subject a reasonable amount of time and wishes to have a change, her request will of course be given every consideration. The bureau feels that the best work is given where cooperation, interest, and enthusiasm abound. The Navy nurses never fail to handle every problem given to them with effi ciency and dignity and it is felt they will respond with equal energy to the call to advance and grow strong in the profession. 6982ft— 23 6 75 76 Vol. XX. NAVY NURSE CORPS. Many members of the Navy Nurse Corps have expressed a desire that the Navy Nurse Corps section, which formerly appeared each month in the United States Naval Medical Bulletin, be continued; therefore it should be a source of gratification to them to learn that with this issue the section starts once more on a career whose length and importance will be determined by the Navy Nurse Corps. The bureau feels that each Navy nurse should be sufficiently interested in this section to take an active part in its production and to make it so interesting that its appearance each month will be looked for with pleasant anticipations. Therefore, let each of us take a personal interest in this section, not by reading it as it is published, but by sending items of general nursing interest to the superintendent of the Nurse Corps for incorporation in the section. If you can not write or have nothing of interest to tell of your own work, look about and ask some prominent person in the nursing profession to give you an interesting bit that you know the corps will be delighted to read. We must be up and doing and let people know we are not drones, but thoroughly alive and alert. The American Nurses' Association, of which each Navy nurse either on the active list or honorably discharged is a member, meets next June in Detroit, Mich. There will be meetings of the special section of the association devoted to the nursing services of the Federal Government, and it is hoped that every Navy nurse who can attend these meetings will do so and will go to Detroit full of enthusiasm for the advancement of the Navy Nurse Corps and her profession. It would be kind if all those who read this would write to friends out of the service and ask them to attend, that it may not only be a meeting of strength, but somewhat of a reunion of the corps we love so well. The two following excerpts from letters recently received by the superintendent of the Navy Nurse Corps reflect some of the activities of that corps in our island possessions. The letter from Grace Pepe, the Nurse Corps' little Samoan pro tege, is peculiarly interesting. The sincere gratitude of the native nurses of Samoa for what the Medical Department of the Navy has done for them is clearly expressed. Pepe's letter appears just as she wrote it. " I'm glad to have this good chance to say thanks to all the Doctors and the Navy Nurses too who were here for duty from the beginning of the Training School for nurses until today. " I should tell the world how nice they are to the Samoan Nurses and what they have done for us, not for the nurses only but for all No. 1. 77 NAVY NURSE CORPS. our Native people who are under the care of the United States. Thanks very much for supporting us for all things we need down here. The Doctors and the Navy Nurses have done so much for the Samoan Nurses in many, many ways, I could not say all what they were, but you can see now how much we can write or say in English ; that is a great work the Navy Nurses taught us. It is a hard work to teach us and trying to show us how things should be done. They have done very well for us and I appreciate it very much. "We are very glad we came to this training to be educated; we have learned very many new things in this training, but we depend on the Doctors and the Navy Nurses for everything about this work. We are surely happy to leave with them for we can not do much without their help; we need them very much to be near us and to watch us and see how we would be coming along, and we are surely glad to work with them or help them for few things we could as they help us a lot. " I should say for this work it is very useful to us and for our people too, it is so interesting too; when I look back at the begin ning of my time in the training school till today. Sometimes while 1 am in training I felt discouraged hearing people say things to make us discouragecl but in other movement, when to get cooled off, won't listen to what they were saying, just kept on working or doing some to cheer up, and tried to forget the unhappy things. But sometimes I feel that I could do more little things to help among the sick people. " When our first class graduated we were glad that we had been taught in this training, and then when we came back from our leaves we received orders from the Doctors for the two of us to go out among the people in the district. I was a little discouraged to go out at first for not knowing how the people would treat us, and that would be our first out to the districts, had no idea how things should be done. But after all we went out with some instructions from the Doctors to be carried out in each place we stop. "At the first place I arrived in the Western District, spent few days to stay there and treated some eye cases and was trying to talked over with the women to show them a little how to take care their children; some of the women were very interesting and listen what they should do for their children.- I take this first place for a good example how things to be done in the district and that encourage me to do my work and I felt happy because I found something to do and still looking for more work in the future and the discouraged feeling is all finished. For the next place I had my thoughts pre pared and also things which would be used. The work is getting 78 Vol. XX. NAVY NURSE CORPS. interested for these few months outside, of course would feel lone some sometimes but would forget all about it if there is work to do. " In July, 1918, I found a very interesting ease; it was a little in fant was bom in the same place where I stopped for that time. After this poor infant was bom, the mother and the family were scared to touched, for she was too small, it should weigh only three pounds. So they sent for me; by the time I arrived, the cord has not being cut, not a thing was doing for the poor thing, didn't even cry or opened its eyes. So I started to do all what I could do for this in teresting, and after things done for it, then started to move a little and open its eyes. "I kept her wrapped in cotton for the first few months to wait and see how she would be coming along, and oiled with cottonseed oil twice a day in the morning and night before its bed time. I used medicine dropper to feed with from milk in a medicine glass which had been squeezed from the mother's breasts. Had been using the cotton-seed oil right along to bathe with for the first month and used boiled warm water to drink between feedings. I spent nearly two months to stay closed to watch her; while staying there, I was tickled to death to see it's improving each day. I was quite interested in my little pet. " The family of this baby were quite surprised to see this baby come out right along nice each day; before I left, the mother lias been taught how to take care this little pet. That gave this family a good idea how things done so lovely at the hospital, these people never thought the little thing would live for one day. Thanks to the Lord to save this baby, that would give the people a good example so they could follow it. I take that deep in my mind, it wasn't my good in the care of this infant, but for the Doctors and the Navy Nurses who taught me right here in this training. I should say that, for the people who have done a good work for the others will follow their good work for themselves. You could see now days the splen did work you Navy People done for us and all the kindness as we see down here; so we have to follow and try to do the same as we are being taught here. " In spending a few months at the Naval Hospital in Mare Island, I should thanks for the admitted of me there; there was none to make me discouraged, all I met just the smiling faces, and they were certainly treated me well. I have learned a lot, and there were many million of different things I had seen there than what we have here, had seen many things than what I have heard about it. . And I was interesting with all the new work and wished some of my training would be there with me to see how things were far different from our hospital. THE WEEKLY BABY CLINIC IN ST. CROIX. 78—1 INSPECTING THE SCHOOL CHILDREN IN ST. CROIX. 7S-2 A ROAD SIDE CLINIC IN ST. CROIX. No. L 79 SAVY NURSE CORPS. " I would love to watch every direction to movement while the people were working and done things so quickly, and they have done them so lovely too. By that way, was trying to open my eyes and ears and learned all as fast as I could before returned back to my own place. I had forgotten all about being tired from being work ing but felt happy to work for the suffering people. " Had more new experiences for few weeks at the Children's Hos pital, more interesting things they done and they did few things dif ferently that give me more new idea to learn and to know about the different ways. Had many things to learn while in the hospital there or going out from the hospital. " By the time I returned I have told many things to the Nurses and all my people whom I could meet, and was trying to show the nurses as I had seen there in the States. We are certainly glad that we are under the rules of America. " Will be very glad to write more to follow this sometime if (hey ■willing to. I am sending regards to all Doctors and Nurses who are good friends to Samoan Nurses. " Very Sincerely, " Grace Pei*e." Miss J's duty at Christiansted. St. Croix. Virgin Islands, seems to be that of a district nurse and she is greatly enthused over her work among the natives in their " villages," as the plantation labor er's quarters are called. She says : " With an attachment on the side of a Ford car, holding solu tion bottles, and an especially contrived medicine chest with parti tions and holders for medicines, ointments, gauze, bandages, and other necessities for usual dispensary clinics, we leave town every morn ing at 8 o'clock, going thrice weekly on each of the two routes through the Christiansted district, which embraces half of the ter ritory of the island, and returning around noon. " The colored graduate nurse, always accompanying the Navy nurse and giving all treatments, was a graduate under the earlier Navy nurses, and a credit indeed to her training. The greater pro portion of the work is the treatment of trachoma cases, which we are happy to find are beginning to respond to the blue-stone treatment, and lessen in number. Then there is the dressing of minor accidents, of ulcers and- old wounds ; the visiting of sick in their one-roomed shacks in the villages, including the school children referred by their teachers when ill; consultations all along the roadside, when la borers rush out from the cane fields and stop us as we come along; the dispensing of those medicines which it is usually a nurse's privi lege to administer, and the weekly examination and weighing of all babies under 2 years of age. 80 Vol. XX. NAVY NTJHSE COEPS. " Those Navy doctors specializing in obstetrics and eye work each make monthly rounds, between which the cases that we are unable to handle ourselves are referred in to them at the town dispensaries. " We grow to recognize and know the name of most of the people in the district ; and as their confidence in us deepens, we are able to do more and more. They are not an especially grateful people, yet they never show ingratitude, and accept directions and instruction willingly. The entire work must undoubtedly be one of the most in teresting in the service, and I am very glad to have had an oppor tunity to have 'carried on.' It has created for me an interest in dis trict work which I hope I shall some time have an opportunity to study and practice. There must be many nurses in the service who also would be glad of this opportunity if they but knew of it." INSTRUCTIONS ISSUED BY THE BUREAU OF MEDICINE AND SURGERY. Circular letter. ERSrLBH -P-15-42022. Serial No. 282-1923. Washington, D. C, 29 August, 1928. To : All medical officers. Subject: Shortage in petty officer ratings in Hospital Corps. 1. The following letter has been received from the Bureau of Navi gation : " No. 2157-2973. Navy Department, "N-6-Lo. Bureau of Navigation, " Washington, D. C, August 24, 1923. " From : Bureau of Navigation. " To : Bureau of Medicine and Surgery. " Subject : Vacancies in petty officer grades of Hospital Corps. " 1. The Bureau of Navigation desires to invite attention to the following conditions as existing in the petty officer grades of the Hospital Corps: " (a) On February 28, 1923, there were 1,066 vacancies in the various pharmacist's mates ratings. " (6) On July 31, 1923, the total number of vacancies had in creased to 1,186, distributed as follows: "C. Ph. M 28 "Ph. M. lc 193 " Ph. M. 2c 431 " Ph. M. 3c 534 " (c) During the six months' period in question the net loss in petty officer ratings of the Hospital Corps was 120, or an average net Joss of 20 per month. "(d) A survey of the petty officer situation for the fiscal year 1924 has recently been made, which takes into consideration existing short ages in petty officer grades, expirations of enlistments scheduled dur ing the year, estimated losses from other causes, and reenlistments based on the percentage experience of the past six months. The final result of this analysis shows that 1,463 nonrated men of the Hospital Corps must be recommended for advancement to the rating of pharmacist's mate 3c during the fiscal year, if the desired distribu 81 82 Vol. XX. INSTRUCTIONS. tion of the Hospital Corps is to be reached by 30 June, 1924, neces sitating an average of 122 recommendations in the Hospital Corps per month. , "(e) During the month of July a total of only 37 such recom mendations were received from the entire service. "(/) The eligibility list maintained in the Bureau of Navigation, so far as the ratings of pharmacist's mates lc, 2c, and 3c are con cerned, can not relieve the petty officer situation in the Hospital Corps, as authorizations for advancement in rating have been issued as fast as recommendations were received, and no men are on the eligibility list for these ratings at the present time. The shortage of petty officers in the Hospital Corps is continually growing worse, and is entirely out of proportion to other branches. " (g) The principal source of. supply at the present time for the training and recommendation of nonrated men to petty officer grades in the Hospital Corps is the naval hospitals. The number of recom mendations received during the past four months from this source is tabulated below : Naval hospital. Portsmouth, N. H Chelsea, Mass Newport, R. I Brooklyn, N. Y Philadelphia, Pa Annapolis, Md Washington, D. C Norfolk, Va Parris Island, S. C Key West, Fla Pensacola, Fla Great Lakes, 111 San Diego, Calif Mare Island, Calif Puget Sound, Wash Pearl Harbor, Hawaii Guam, M. I Canacao, P. I Yokohama, Japan Charleston, S. C Total recommendations received during period from Apr. 1 to July 31, 1923 Petty officers rec tor promo tion. 28 Nonrated men recom mended tor promotion to] pharmacist's mate. 0 7 0 0 0 0 7 2 3 0 0 0 12 4 0 2 0 1 0. 1 38 " 2. The above showing is in no way comparable with the results of other commands in the training and recommendation of nonrated men of general service ratings for advancement to petty officer No. ». INSTRUCTIONS. 83 grades; and it is requested that the Bureau of Medicine and Surgery issue such instructions to its medical officers as may be deemed advisable, to the end that a larger number of recommendations for advancement from nonrated to petty officer grades may be submitted. "/s/ A. T. Long." 2. Commanding officers of naval liospitals and all medical officers will a^t once take steps to remedy the situation shown in the above letter by examining all hospital corpsmen who now meet the require ments of Bureau of Navigation Manual, Bureau of Navigation Man ual Circular No. 21, of 1 August, 1923, and the latest Bureau of Navigation circular letters, for advancement in rating, and continu ing to examine hospital corpsmen for advancement in rating as soon as they become eligible. 3. The standard of examinations will not be lowered, but every effort shall be made to instruct and prepare men eligible for exami nation so that they may qualify for advancement in rating. E. R. Stitt. Circular letter. BEI 132679(83). Serial No. 283-1923. Washington, D. C., September G, 1923. To : All medical officers. Subject: Haemostatic forceps and surgical needles carried in stock at the medical supply depots. 1. The following haemostatic forceps are carried in stock at the medical supply depots: (a) Jones, 5-inch, straight. (6) Jones, 5-inch, curved. (c) Halstead, 5^-inch, straight. (d) Halstead, 5^-inch, curved. (e) Halstead mosquito forceps. (/) Ochsner-Mayo forceps, 5^-inch, 1 and 2 teeth. (</) Keen (Rochester-Pean), curved, 6-inch. 2. A study of these types of forceps, bearing in mind the various needs for haemostatic forceps for surgery in the Navy, will prove that they are sufficient for practically all purposes. 3. Many requisitions are submitted by medical officers at the dif ferent activities for unusual types of haemostats, and frequently the types requested are almost like those on the supply table. It is therefore directed that requisitions for haemostatic forceps be limited in every case possible to those carried in stock at the medical supply depots, and when haemostats of a very special and unusual type are 84 INSTRUCTIONS. Vol. XX. required, the requisition will be submitted to the Bureau of Medicine and Surgery with a letter explaining the necessity for the type of hsemostat required. 4. The five bottles of assorted needles now on the supply table contain an assortment sufficient to cover practically all ordinary surgical needs. In each assortment there are certain sized needles which are more frequently used than others, and this results in the sizes less frequently required being left as " dead stock." 5. To eliminate the necessity for issuing a full assortment of needles when a certain kind or size is required, the following needles will be carried in stock at the medical supply depots as available for issue in papers of 1 dozen each: (a) Hagedorn, round eye, straight, size No. 3; for suturing skin. (b) Hagedorn, round eye, half circle, No. 5; for skin sutures and for muscle quilting in amputations or closure of abdominal wounds. (c) Surgeon's needles, full curved, No. 6, for same purposes as (6), for surgeons preferring this type of needle. (d) Milliner's needles, straight, No. 5, for intestinal work. These needles are somewhat similar to Mayo's straight intestinal needle, but are not quite as long and have a smaller eye. They are used ex tensively by surgeons doing abdominal work. (e) Intestinal needles, taper point, half circle, plain eye, No. 2, for deep abdominal work where a straight needle can not be used to advantage. 6. When submitting requisitions for hsemostatic forceps or surgi cal needles medical officers should bear in mind the types furnished by the medical supply depots, as it is believed that the types pro vided are sufficient to do excellent work in connection with prac tically all the operative work usually done in the service. E. R. Suit. Circular letter. WHM-HCM SDS 124842(92). Serial No. 284-1923. Washington, D. C, September 17, 1983. From : The Chief of the Bureau of Medicine and Surgery. To : All medical officers. Subject: Form N. M. S. F (revised). Reference: (a) Bureau Circular Letter No. SDS: WHM-HCM 124842(73) of 18 July, 1922, serial No. 199-1922. 1. It is directed that paragraphs 2 and 3 of reference be disre garded and that the revised Form F be used exclusively after January 1, 1923. 2. Form K will become obsolete, and it is directed that all blank copies of that report be destroyed. :no. i. 85 INSTRUCTIONS. 3. The old Form F may still be used by hospitals to report super numeraries and Veterans' Bureau patients. E. E. Stitt. Circular letter. WSD: MG 127507(44). Serial No. 285-1923. Washington, D. C, September £6, 1923. To : All naval hospitals ; senior medical officer, all yards and stations : naval medical supply depots ; Naval Medical School. Subject: Policy of United States Employees' Compensation Com mission regarding employees suffering from occupational diseases; now considered compensable and entitled to treatment. Reference: M. and S. circular letter serial No. 254^1923, No. 127507(44), April 23, 1923. 1. The following communication, received from the United States Employees' Compensation Commission under date of September 10, 1923, in effect cancels the instructions contained in reference, limit ing treatment and compensation of civilian employees under the Federal compensation act to cases of accidental injury only; cases of occupational disease or conditions due to occupation may now be handled in the same manner as prior to April 16, 1923 : " Reference is made to the commission's letter to you dated April 16, 1923, in regard to the treatment of employees of the United States Government suffering from occupational diseases or condi tions due to occupation which can not be considered as accidental injuries. In that letter official superiors were requested not to refer such cases for treatment on Form C. A. 16, or for examination on Form C. A. 17, to Government or designated physicians. In the light of a recent opinion from the Attorney General of the United States, the commission now feels that such cases may be considered compensable and entitled to treatment. " It is desired to impress upon official superiors, however, the im portance of the utmost discrimination in the handling of such cases. An employee claiming compensation or medical treatment for any condition not an accidental injury should supply definite information of the most detailed character in regard to the alleged cause or causes of his condition. If the slightest doubt remains in the official superior's mind in regard to the validity of such a claim, the em ployee should be referred to the nearest Government or designated physician for examination only on Form C. A. 17; procedure may then be continued in accordance with the commission's regulations, paragraph 31, and full information concerning the claim should be immediately forwarded to the commission." E. E. Stitt. 86 Vol. XX. INSTRUCTIONS. Circular letter. WRJ-ML 125884(101). Serial No. 286-1923. Washington, D. C, 1 October, 192:}. To : Naval hospitals. Subject: Hospital accounting. 1. The bureau has received many questions from individual hos pitals regarding the new hospital accounting system, and in order that these questions and answers may be available for all hospitals they have been compiled and quoted herein. 2. It has been noted from an examination of the reports sub mitted that the hospitals do not uniformly understand the proper method to compute " sick days " and " subsistence days " for use. in connection with the preparation of the " Recapitulation." The total "sick days" should be the total sick days of all classes of patients for the month. No deductions should be made for absent days. The total " subsistence days " should be the total number of actual rations issued to patients (all classes), officers* mess, hospital corpsmen, nurses, marine guard, and civil employees. In the case of subsistence days, deductions should be made for all absent days, etc. The admission day of V. B. patients, which is shown on ration memo., should not be included in the number of subsistence days. 3. Several hospitals have submitted " Recapitulations " with a different amount shown under "Account 10. Operating expense " and the " Net operating expense " under "Analysis by departments." As the "Analysis by departments " is only a detailed analysis of "Ac count 10. Operating expenses," the amounts should agree. 4. Under " Statistics " on the reverse of the Recapitulation the " Daily average turnover " will be changed to "Average discharge ratio." The average discharge ratio will be obtained by dividing the " actual discharges " by the actual number of days in the month and dividing the quotient thus obtained by the average daily number of patients in hospital. Example : Total number actually discharged 352 Number of days in July 31 Number of patient days 14, 122 352 divided by 31 equals U-35 14,122 divided by 31 equals 455. 54 11.35 divided by 455.54 equals— 0.0249 2.49 per cent is the average discharge rate. 1. Q. Should capital account be changed if an error is discovered in the original entry ? A. No. Capital account should remain the same amount during the year. Any errors should be made a debit or credit to " Inventory No. 1. 87 INSTRUCTIONS. adjustments " and a debit or credit to " Equipment," " Stores," or Real estate, land and buildings," as the case may be. 2. Q. Should the number of sick days shown on the reverse of the " Recapitulation sheet " include all sick days in the hospital or •only Navy sick days? A. The total sick days should be shown regardless of the class of patient. 3. Q. Accounting instructions state that only the salaries of chauf feurs and mechanics and employees engaged on motor vehicles shall lie charged to transportation service, while it is noted that the cost -of operation of horse-drawn vehicles is also charged under this de partment. Information is requested as to whether the salaries of teamster and stable keeper should lie charged to " Transportation " or -to " Maintenance, B. and G." ? A. The salaries of teamsters and stable keepers will be charged to " Maintenance, buildings, and grounds." 4. Q. Artificial limbs, abdominal binders, etc.; shall these items be -charged to " Navy as a whole " and carried over in expense analysis under surgical appliances, operating room? A. To carry the charge for items chargeable to " Navy as a whole " . from the " Charge register " to the " Expense analysis register " (except where a space is provided for large items such as care of <lead) will result in the inclusion of charges that should be shown on the Recapitulation under " Navy as a whole " in the " operating ■expenses " of the hospital. It is not necessary to carry any items entered on the " Charge reg ister " as " Navy as a whole " to the " Expense analysis register " ■except under i; Care of dead." The total of the column " Navy as a whole " in the " Charge register " and the total of " Stores " issued on the " Expense analysis register " under department " Care of dead " should be the amount shown on the Recapitulation as " Navy as a whole." To bring the expenditure of stores issued into the account " Navy as a whole," the monthly entry passed through the journal should be as follows: (Substitute for last journal entry on sample journal.) For summary of stores issued during month as per details in expense analysis register. .r>. Q. With the closing of laundry the salary of the sewer is being charged to " Housekeeping " ; is this correct ? Operating expense- Navy as a whole__ _ $23,000.00 160. 00 To stores. .$23, 360. 00 88 Vol. XX. INSTRUCTIONS. A. As the sewer is performing the same work now as she did before the laundry was closed, it is evident that no change should be made in the manner of reporting this expense. 6. Q. What procedure is followed when material, of any nature, is to be shipped from an activity to some other place or activity ? A. The annual appropriation bill for the Navy Department carries, under the Bureau of Supplies and Accounts, an appropriation cap tioned " Freight," which reads as follows : " For all freight and ex press charges pertaining to the Navy Department and its bureaus, except the transportation of coal for the Bureau of Supplies and Ac counts." As the appropriation for all freight and express charges (except for shipment of remains) is under the cognizance of Bureau of Sup plies and Accounts, that bureau must authorize any expenditure un der such appropriation. The manner in which transactions of this nature are handled is as follows : The activity desiring to ship material should write a letter to the Bureau of Medicine and Surgery, giving contents of shipment, weight (if by water, cubic space), and destination. The Bureau of Medicine and Surgery will then prepare a shipment order NSA Form 564 and forward same to Bureau of Supplies and Accounts, who • will, in turn, direct shipment. As no Medicine and Surgen- appropriations are involved (except for shipment of remains), an allotment card or report of expenditure will not be necessary. No bills of lading, except for care of Navy dead, should be entered in any financial books of the hospital". 7. Q. If allotments for the preparation and burial of Navy and Marine Corps dead pertain only to those on active duty, in what manner are the expenses for similar services for retired officers and enlisted men of the Navy and Marine Corps paid? A. The appropriation bill for the current fiscal year does not pro vide for the burial of retired officers and enlisted men of the Navy. A bill will be submitted for the fiscal j*ear 1925 including this fea ture. Under the appropriation "Contingent, Marine Corps," is in cluded the following : " Funeral expenses of officers and enlisted men, and retired officers on active duty during the war, and retired enlisted men of the Marine Corps, including the transportation of bodies and their arms and wearing apparel from the place of demise to the homes of the deceased in the United States." Funeral expenses for retired marine officers who were on active duty during the war and for retired enlisted men is a proper charge against the appropriation " Contingent, Marine. Corps." It is not necessary to submit a requisi tion to cover this service, but the bills should be forwarded, properly certified, to Murine Corps Headquarters for payment. No. L 89 INSTRUCTIONS. 8. Q. What accounting procedure is made for flags used in drap ing caskets? A. Flags used in draping caskets are not a charge against any Medical Department appropriation. They, therefore, can not enter into the cost accounting system of the activity. For the purpose of recording transactions of this natu^ a memorandum book should be kept at each activity. 9. Q. What accounting procedure is necessary when material is received from any source without appropriational charge? A. Stores received with price (or when not priced, should be ap praised) but without appropriational charge should be taken up through the journal as a debit to "Stores," " Equipment," or " Real estate, land and building " and a credit to " Transfer vouchers re ceived." 10. Q. What accounting procedures take place when material is surveyed ? A. Material may be surveyed for several reasons, such as" wear, out of date, missing, destroyed by fire or other disaster, broken, etc. The recommendations of the board may be as follows : Destroy, re tain for repair, sale, return to M. S. D., or such other recommen dation as may be pertinent at that time. Material which is worn- out by service, rendered obsolete by age, broken during usage, or rendered unfit for further use by reason other than theft, fire, disaster, or similar causes, is considered as having properly ful filled its original purpose and is rightfully a charge against the operating expenses of the activity. Its disposition after survey does not alter this charge in any way. Equipment is credited with the book value of the items surveyed and this same value is a debit against " Operating expense." Material surveyed as the result of loss, destruction by fire or other disaster, is not a charge against operating expense inasmuch as the activity has not been benefited by its use. It is, therefore, a charge against " Contingencies and losses " ami a credit to " Equipment." 11. Q-jShall funeral expenses for Veterans' Bureau patients be placed under " Care of dead " ? A. That part of any funeral expenses for Veterans' Bureau pa tients that is paid from naval appropriations will be a charge against " Care of dead." If the cost of embalming, encasement, or other ex penses, including the issue of a Navy standard casket, is paid from naval appropriations the charge should be " Care of dead." Transportation of remains is not a charge to " Care of dead " (Vet erans' Bureau only) , as the bill of lading is made a direct charge to the Veterans' Bureau appropriations ; therefore would not be charged to any naval account. 90 Vol. XX INSTRUCTIONS. Transportation of the remains of Veterans' Bureau patients should not be reported on the " Recapitulation " nor should they be re ported on the " Report of expenditure card." It may also be stated that transportation of Marine Corps dead on bill of lading is not a charge to M. and S. appropriations, therefore should not be included in accounts or on " Report of expenditure cards." 12. Q. What disposition shall be made of charges received and paid after July 1, 1923, for items of stores and equipment taken up in in ventory July 1, 1923, received in fiscal year 1923? A. As the stores have already been included in the inventory of July 1, 1923. it would result in a duplication of charges if any entry was made in the charge register or through the journal. The amount should be entered in the old bill book under the fiscal year 1923 and no entry made in any of the books of the new accounting system, ex cept, of course, in the store or equipment ledger. 13. Q. What disposition shall be made of charges received and paid after July 1, 1923, for items of stores and equipment that were not taken up in inventory of July 1, 1923, order having been placed during fiscal year 1923? A. Entry should be made in " Charge register " in the same man ner as if stores or equipment were purchased on 1924 appropriations. The cost-accounting system does not take cognizance of yearly ap propriations. 14. Q. What disposition shall be made of salaries paid teachers of Veterans' Bureau patients? A. The amount will be included in the operating expenses of the hospital and will be shown on the reverse of the "Recapitulation" under "Analysis by departments" as a separate entry. The entry will be made on the vacant line next after " Staff quarters." Occupational therapy *** *** *** If any supplies are issued from stock, this should be shown under supplies. An additional sheet may be maintained in the Expense Analvsis Register for this purpose. E. R.'Stitt. Circular letter. Serial No. 287-1923. WWB-LBH F-l-42022. Washington, D. C, 9 October, 1923. To: All medical officers. Subject: Examination Report. Hospital Corps, U. S. Navy; Form N. M. S. H. C 1. 1. On all revised copies of the above form you will cause the following changes to be made in ink immediately upon receipt of this letter. Xo. t 91 INSTRUCTIONS. (a) Line 2 from bottom of page, left side, reading " Examine Ph. M. 3c. in subjects 1 to 6, inclusive," change " 6 " to " 7." (b) Last line, right side of page, reading "Dept., Art. D^4341, Bu. Nav. Manual," add following new sentence: "Candidates for pharmacist's mate, first class, not to be examined in subject 13, ad ministration." F. L. Pleadwell, Acting. Circular letter. AWD MET 125470(102). Serial No. 288-1923. Washington, D. C, 10 October, 1923. To : All naval hospitals. Subject: Analysis of the naval hospital ration for 1923 (continental hospitals only). Inclosures: (a) Photostats. 1. The bureau forwards herewith photostats of graphs of the cost of the ration at the various naval hospitals, and also of other tables in connection therewith, which are believed to be of interest to those connected with hospital administration. 2. The average cost of the hospital ration was $0.75, as compared with $0.78 for 1922. The average cost for the seven most active hos pitals (Group I) was $0.71, exactly the same as in 1922; in Group II (four hospitals), those of medium activity, $0.78, as compared with §0.88 in 1922; in Group III (five hospitals), inactive, $0.75, as com pared with $0.77 the previous year. This represents a saving of $64,229. From the above, it is deduced that the reduction in the cost of the hospital ration occurred at the smaller hospitals. In a measure the reduction is traceable to lowered contract prices, but it is be lieved this is not entirely accountable for it. The average cost of the ration for 1922 in the east coast hospitals, less those in Group III, was $0.75, in the three west coast hospitals $0,653, showing marked economical management in the later. There is no evidence that this lower cost is due to lower contract prices as is generally maintained, but in some measure may be attributable to the quite general em ployment of Chinese in the commissaries. The dominant factor, however, is contained in the following : 3. The caloric value of the hospital ration. —In the bureau's cir cular letter of 12 March, 1923, paragraph 2, the statement is made that 3,500 to 4,000 calories is believed to be adequate. This opinion is sustained by the fact that in some hospitals the ration is approach ing this figure and, according to observation, reports, and general reputation, is satisfactory and adequate. The average caloric value of all the continental hospital rations is 5,900 : of the west coast hns 92 Vol. XX. INSTRUCTIONS. pitals 4,800, and of the east coast (less Group III) 6,000. The high est food value of Group I was New York, 7,000 ; of Group II, New port, 6,700. The lowest calories purchased was in Group I, San Diego, 4,900 calories; Group II, Puget Sound, 4,100. It is evident that if the personnel can be well nourished on a ration equivalent to 4,900 calories at San Diego, 5,500 at Mare Island, that Norfolk does not require 6,200, nor New York 7,000. It is equally evident that if Chelsea, situated in a high latitude, subsists on 5,600 calories, Norfolk does not require 6,200, nor New York 7,000. If Puget Sound, Wash., and Great Lakes find 4,100 to 5,800 calories ample, there is no apparent reason why Newport requires 6,700 and Annap olis 6,200. 4. In order that criticism may be constructive, it is desirable to further analyze the ration by comparing the purchases of foods of a high caloric value at the highest and lowest of each group. By reference to Chart 5, it is seen that the New York hospital paid for the equivalent of 2,400 quarts of milk per man for the year, while San Diego purchased but one-third that amount. The excessive issue at New York was due largely to the ordering of double cream (40 per cent). In Group II, the equivalent of 1,590 pounds of milk per man per annum was delivered at the Newport hospital, while Washington, equally active, purchased 820, and Puget Sound, the lowest in total ration calories, but 325 pounds. Group III shows an excessively high ration value, 8,900 calories for Charleston, and a moderately low one for Key West, but the overturn of patients is so small as to make deductions of little value. It, is evident that both the cost and caloric values at Charleston are traceable to a heavy issue of all classes of foods except eggs and butter. At Key West, the foods used show recourse to eggs rather than milk and meats. Meats. —The New York hospital had the highest rate in Group I for meats, over 1^ pounds per patient per diem, while the lowest, San Diego, practically 1 pound per day. The lowest rate for meats was at Parris Island, approximately one-half pound, which ap parently met the requirements, the caloric value being kept up by carbohydrates. Flour, wheat, products, and potatoes. —The use of these articles of diet appear to be complimentary to the amount of fresh vegetables used. 5. Comparison of graphs by groups: Group I.— (a) Naval hospital, San Diego, Calif. The dietary of this hospital, with the market prices unchanged from the previous year, shows a slight rise in caloric value due to increased issue of the principal constituents of the ration, and a slight rise in the per diem cost. »«• 1- INSTRUCTIONS. 93 (b) Naval hospital, Mare Island, Calif. With an average market cost, there is lessened per diem expenditure of food and a reduction of $0.07 in ration value, apparently due to a judicious selection of food; lowered proteid feeding. (c) Naval hospital, Chelsea, Mass. Market costs lowered, but is offset by an increased amount of food purchased, the ration value remaining the same. The milk issue is practically unchanged; meats lowered ; slight increase in the use of eggs. (d) Naval hospital, League Island, Pa. As above, a lower market price has been met by an increase in the amount of food bought, apparently due to increased issue of milk or cream. The issue of meat has been markedly lowered, and is below most east coast hospitals. (e) Naval hospital, Norfolk, Va. This hospital shows a reduc tion in the cost of ration amounting to $0.04, but also has- the ad vantage of lowered contract prices. There is an increase in the caloric value of the already excessively high. ration. This increase in calories is not traceable to any one class of foods, which would indicate a general loss possibly due to the nonuse of the cafeteria service, which is generally employed in the other hospitals. (/) Naval hospital, New York, N. Y. With a lowered market the cash value of the ration has increased $0.07, due to excessive issues of milk, cream, meats, and flour products. The caloric value of the ra tion is far in excess of any requirement. {g) Naval hospital, Great Lakes, 111. The cost of food, the caloric value and valuation of the ration are practically the same as during the previous year. As compared with others of this group, the mar ket costs and the caloric value are about the average. The cost of commissary service is very high. Group II.— (a) Naval hospital, Puget Sound, Wash. With the highest market price for foods and slightly increased over the pre ceding year, the cost of the ration has been reduced $0.11, accompanied by a marked decrease in calories purchased. The nutritive value of the ration closely approaches that believed to be suitable for a hos pital of medium activity, and may well serve as a model. The amount of milk, meats, eggs, and carbohydrates is moderate but ample, being supplemented by a liberal issue of fresh fruits and vegetables. (b) Naval hospital, Annapolis, Md. This hospital shows a most marked drop in the ration costs, from $1.17 to $0.81, due slightly to lower food prices, but evidently largely due to less food expended, the caloric value falling from 7,200 to 6,215. The graphs indicate a more moderate issue of all classes of foods except milk. (c) Naval hospital, Washington, D. C. This hospital, with an average market price practically the same as 1922, shows a decrease in ration caloric value, and an increase in ration cost. The issue of 94 INSTRUCTIONS. Vol. XX. milk has been decreased, but the amount of meat used is high— above the average. Apparently high cost is due to expensive food articles issued. (d) Naval hospital, Newport, R. I. This hospital shows a fairly- low market and ration price but a high caloric value, which is trace able to an increased use of milk, meats, eggs, and carbohydrates. There was a marked fall in the amount of butter used as compared with 1922. Group III.—Conditions under which these hospitals operate are so varied or abnormal that no remark will be made other than to invite attention to the excessive cost of the ration and the abnormally high caloric value at Charleston, and to contrast this with that of Parris Island, where an ample ration is served at a cost of $0.56. Some of this low cost is traceable to a low price of provisions. G. In conclusion, the bureau desires to invite attention to the fact that what economy has been effected in the administration of the commissary at the various hospitals has occurred in the smaller hospitals, and that the savings would have been much more had there not been unduly high rationing in some of the hospitals of major activity. It is a well-recognized fact that it is possible to ration a large number somewhat more economically than a small number. There is evident at many hospitals an increasing attention given to the commissary department, and it is believed that by careful super vision on the part of those responsible, unless there be a notable increase in the purchase price, the cost of the hospital ration during the current fiscal year can, without detriment to the personnel, be so reduced as to effect a total saving of $150,000. On the part of this bureau it is purposed to give those officers detailed and showing capability as commissaries more opportunity to acquire special in struction in their duties. Under present instructions the chief nurse at each hospital is given the supervision of the special diets. This in a measure removes the operation of the diet kitchens from the control of the commissary officer, and the best efforts on the part of either the commissary officer or the dietitian may be offset by ineffi ciency, extravagance, or indifference on the part of the other. For efficiency, there must be cooperation, and in the ultimate analysis the responsibility rests with the commanding officer. F,. R. Stitt. Circular let ter. WMK : MFD 125660 ( 102 ) . Serial No. 289-1923. Washington, D. C. October 12, 1923. To: All medical officers. Subject : Reprints of the bureau's circular letters for office files. 1. The bureau's circular letters issued since the appearance of the last edition of the Manual of the Medical Department were reprinted Ho. 1. 95 INSTRUCTIONS. in the United States Naval Medical Bulletin of October, 1923. Re prints of these circular letters and of those which will appear from time to time in forthcoming issues of the bulletin will be sent to all ships and stations for office files. 2. As these circular letters contain information of importance in •connection with the administration of the Medical Depatment of the Navy, the bureau directs that a file of these reprints be kept in the main office of the medical department of all ships and stations where it shall be available for the use of Medical Department personnel. E. R. Stitt. Circular letter. SDS WHMr-HCM 124842(103). Serial No. 290-1923. Washington, D. C, 15 October, 1923. To : All medical officers. Subject: Additional data required on the Form F card in all cases of injury. 1. In order to increase the value of injury statistics, the folkwing plan will be adopted January 1, 1924. This will require little or no additional work except the typing of three short statements on the back of the Form F card in every case of injury or poisoning. The information necessary for this purpose, practically, will have been obtained by the medical officer in order to write up the case properly in the health record. 2. Many injuries occur in the naval service while the individual is on leave or liberty. In such cases there is no immediate connection with the work of the Navy. In other cases, although the injury oc curs on board ship or within a naval station, the injured person is not engaged in any form of work and not actually performing any particular kind of duty at the time. He may be resting, playing, or skylarking. Often, in such cases, the injury is properly recorded as having originated in line of duty. The statement of origin refers only to pension status and does not go far enough for statistical pur poses. If the Form F cards are to have full value in revealing the felative importance of different kinds of accident hazards and in suggesting the need of preventive Pleasures, the data given thereon must first of all permit proper classification. The cards must con tain the information that will make it possible to separate the sta tistics for injuries received ashore, where very likely the hazards were not different from those experienced by civilians. A distinction must be made between injuries where a true occupational hazard is involved and others which, although occurring on board ship, do not actually depend upon the performance of any particular kind of work or duty. 96 Vol. XX. INSTRUCTIONS. In other words, statistics compiled from Form F cards have not been satisfactory for the study of conditions and circumstances sur rounding injuries in the Navy. Therefore, in addition to the key letter heretofore used on the face of the card it will be necessary to require three brief statements numbered 1, 2, and 3, on the back of the card, supplemented by further remarks if deemed necessary. The chart presented below indicates the facts desired and it shows the exact words which must be used in every case of injury and like wise of poisoning, to give those essential facts; i. e., circumstances under which the injury occurred. The words to be used are under scored or indicated in parentheses. 3. Key letters are to be used on the face of the card as heretofore. They are required primarily for translation of injuries into terms of the International List of Causes of Sickness and Death. 4. In addition to the key letter the specific cause of the injury or of the accident resulting in injury, hereinafter spoken of as the " causative agent," must be stated on the face of the card. To facili tate classification for statistical purposes the attached alphabetical list of causative agents has been prepared for the guidance of medi cal officers. The title "Others: Specify" has been provided for causes not found herein ; a suitable term will be substituted for these words. If necessary for accuracy or clearness, titles on the list may be combined. 5. This required additional information will not be reported on Form F (smooth). 6. However, it must be entered in the health record as a part of the medical history of the case for the information of other medi cal officers in case of readmission. 7. The scheme may be summarized as follows : CONDITIONS AND CIRCUMSTANCES OF OCCURRENCE, ALL INJURIES- Report on the face of the Form F card : Causative agent. Key letter. Specialty letter. (No change has been made in the practice so far as the face of the card is concerned, except that an approved list of causative agents is now furnished by the bureau.) Report on the back of the Form F card: Classification "A" — 1. Whether within the command or on detached duty when injured. 2. Whether or not connected with work or actual per formance of duty. 3. Negligence factor. No. L 97 INSTRUCTIONS. Classification " i?."— 1. Whether on leave, liberty, or unauthorized absence. 2. Whether or not intoxicated at the time. 3. Misconduct factor. It will be seen that every injury must come either under classi fication "A" or " B." These two divisions are separate and distinct. If the man was at work or actually engaged in the performance of some form of duty at the time of the injury, all the information for the required three statements will be found indicated under classi fication "A." If, on the other hand, the. injury was received while on liberty, the required three statements will be prepared in ac cordance with the outline shown under classification " B." The attached chart shows exactly what information must be fur nished. 8. Examples: (a) Injury on board ship due to the bursting of gauge glass on one of the boilers. Report: (On face of Form F card.) Wound, lacerated right eye and face. Explosion of gauge glass. Key letter " H." (On back of Form F card.) 1. Within command. 2. Work. 3. Faulty material and lack of safety device. 4. Brief remarks, if any. (b) Injury ashore in an automobile accident while on liberty. Report : (On face of Form F card.) Fracture, right radius and ulna, simple. Automobile. Key letter "L." (On back of Form F card.) 1. Liberty. 2. Intoxicated. 3. Result of own misconduct. 4. Brief remarks, if any. (c) Injury of mail orderly ashore in street railway accident. Report: (On face of Form F card.) Wounds, multiple, lacerated, about head and face. Street car. Key letter " I." (On back of Form F card.) 1. Within command. 2. Work. 3. Negligence of others. 4. Due to broken glass in street car accident. The latter is an example of the value and use of brief remarks. It will be seen that in this case all required data were correctly given yet the nature of the accident was not apparent. ^ Stitt ■5S 21 =>t? > Q> 2 E SI? C O (3 OSE >«E — i- o o a) o «i| 5 Si '"If E-~ E "n ■ o E2 O id « ti« > . O Kt8>U CcO "5 u o * — ™« "° _ ^ «j E°- ™Q.w) (D-C"5 *-*c ta £>*2 E « 3 Bf « 3 -= ~ UJ CS3 — To E sills D o o eS M O - "<-° a e &>E~ 0-5,0 £ □I fc o O O w ">,E^ W C ^- O ■ • o o „ 3 .'> «jo £ O "° O »» ■ £ 5 £ a £ £ * £ « n 3 «■ > ?«i " (JO — O „ 3 o _ o 3 a a o e i cato c :no. i. 99 INSTRUCTIONS. APPROVED LIST OF CAUSATIVE AGENTS. .Animals. Specify. .Aerial bombing. -Airplane (if crash, so state). (Not to include seaplane.) -Athletics, other. Specify. A.utomobile, passenger. Automobile, truck. Balloon. Baseball. Bayonet. Blank cartridge. Blow torch. Boats, power. Boats, handling of. Other than power boats. Boxing. •Cargo hatch. Cargo sling. Chemical. Specify. Club. Coaling ship. Cold, excessive. State nature. Collision of ship. Conflagration. Specify. Cutting and piercing instrument, other. Specify. Depth charge. Dirigible. Drilling, except great guns. Drilling, great guns. Drug. Specify. Electric current. Emery wheel. Electric generator. Electric motor. Explosion of. Specify. Fall of material or thing. Specify! Fuel oil. Fighting, general. (Brawl with another person in naval serv ice.) Fighting, general. (Brawl with person not in naval service.) Flaming liquid (war). Flareback (oil burners). Football. Gauge glass. Gas (war). Specify. Gasoline. Glass. Grounding of ship. Hammock, fall from, accidental. Hammock, fall of, due to defec tive ropes, clews, or billets. Hand grenade. Handling stores, other than ex plosives and projectiles. Handling of explosives and pro jectiles. Handling of material. Hatchway and ladder. Heat, excessive. State nature. (Sun, engine room, etc.) Hot liquid. Specify. Jumping. Lacrosse. Land mines (war). Land or snow slide. Lifting. Lightning. Lines and cables. Machinery. State kind. Marching. (Not to include or dinary drill.) Mess table. Mines, laying or sweeping of. Motor cycle. Nail. Others. Specify. Parachute. Pistol (revolver) ball. Railroad accident. Rifle ball. 100 Vol. XX. INSTRUCTIONS. Saber. Sea or hydroplane (if crash, so state). Shell. Shell fire. Shoes, ill-fitting. Shrapnel. . Sinking of ship by. Specify. Sinking of submarine due to defective mechanism. Skylarking. Slice bar. Slipping. Splinter. Staging (also boatswain's chair). Steam. Stone. Storm at sea. Storm on land. Street car. Stumbling. Swimming. Tank. Target practice, small arms. Target repair party, great gun practice. Torpedo. Tractor. Vehicle, other. Specify. Wrestling. Circular letter. WEE : SS 124680 ( 103) . Serial No. 291-1923. Washington, October 19, 192,3. To : All medical officers of ships and stations. Subject : Health records retained in files. 1. It has come to the attention of the bureau that health records are being retained in the files on board ships and at stations, not only when men have completed their enlistments but also when they have been discharged from the service for other reasons, or have been transferred. 2. This practice has resulted in the loss, or absence, of the health records not only on board ships and at stations but in the Bureau of Medicine and Surgery where they are required for the best interests of the Government; it has also resulted in the preparation of dupli cate records which are frequently incorrect and which unnecessarily fill the files. 3. It is therefore directed that all medical officers shall imme diately check over all health records in their custody, and that all records shall be forwarded, when necessary, to this bureau or to the ships or stations to which it may be ascertained the individuals have been transferred. E. K. Stitt. In spite of stringent laws governing the distribution of habit- forming drugs, the fact that they may be procured easily by the initi ated addict is often brought to notice in an unexpected manner. The No. 1. INSTRUCTIONS. 101 following letters concerning a preparation, the indiscriminate sale of which should be prohibited by law, are self-explanatory. From : Commanding officer, hospital station. To: Commandant, fifth naval district. Subject: Wampole's hypno-bromic compound. Inclosure: 1 sample. 1. I am sending you an ounce bottle of Wampole's hypno-bromic compound. This was taken from an enlisted man at Dell's locker room, opposite the naval Y. M. C. A., Norfolk, Va., by an acting petty officer of the hospital station. He saw this enlisted man about to drink the contents of this bottle and forcibly took it from him. The identity of the enlisted man and his station are not known. 2. It appears that the use of this compound is very general among the men of this district, and is known by them as "concentrated alcohol." It apparently can be bought in any amount by the men. It is perhaps needless to say that this is a highly "poisonous com pound, and 1 ounce might cause the death of two or possibly three men. * * * (Signed) George Pickbell. From : Bureau of Medicine and Surgery. To : Base medical officer, United States naval operating base, Hamp ton Roads, Va. Subject : Wampole's hypno-bromic compound ; analysis requested. Reference: (a) Letter from Capt. George Pickrell (M. C), United States Navy, to commandant, fifth naval dis trict, dated 17 October, 1923. (b) Letter from base medical officer to Bureau of Medi cine and Surgery, #124920 (103), dated 20 Oct ober, 1923. 1. The justification for Captain Pickrell's letter of warning will be found on page 430 of The Propaganda for Reform in Proprietary Medicines, volume 2, 1922, American Medical Association, which reads as follows: "A physician in Vermont writes: "'This is simply a word of inquiry —and of possible warning to other practioners —regarding a preparation known as hypno-bromic compound manufactured by H. K. Wampole & Co. This compound is dispensed by druggists without prescription and contains in each 0UnCe: Grains. Cannabis lndlca 1 Morphine J Potassium bromide 48 Hyoscyamus 1 Chloral hydrate 96 102 Vol. XX. INSTRUCTIONS. " ' I have at the present time three young women who are addicts to this preparation as the result of thoughtless prescriptions from physicians. This mixture evades the working of the Harrison Act and may be dispensed freely at the discretion of the druggist and, as a result, these three cases of mine have been able, by visiting at the various drug stores in town, to keep an ample supply on hand at all _ times.' " Hypno-bromic compound is more than an unscientific mixture; it is a dangerous product and should not be sold indiscriminately over the drug counter. Before the Harrison narcotic law went into effect, hypno-bromic compound contained half a grain of morphine sulphate to the ounce instead of its present one-fourth grain. Phy sicians remember that section 6 of the Harrison law contains a joker —put over by the " patent medicine " interests—that exempts proprietary remedies containing one-fourth grain of morphine or less to the ounce from the restrictions of that act. While it is illegal for a pflysician to write a prescription which contains mor phine, no matter how small the amount, unless he conforms in all ways to the requirements of the Harrison narcotic law, " patent medicine " concerns can sell indiscriminately nostrums containing morphine up to this amount and the public can buy them without let or hindrance. No reputable druggist would sell a layman over 700 grains of chloral hydrate or 2 grains of morphine or 8 grains of ex tract of cannabis indica without a prescription, yet, the druggist may hand over 8-ounce bottles of hypno-bromic compound, which contain 768 grams of choral hydrate, 2 grains of morphine sulphate, 8 grains of hyoscyamus, and 384 grains of potassium bromide. Physicians who prescribed such products as hypno-bromic com pound and druggists who indiscriminately sell such stuff are dis gracing two honorable professions. (From the Journal, A. M. A., Feb. 7, 1920.) 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.) Books received for review will be returned in the absence of directions to the contrary. Diseases of the Skin, by Richard L. Sutton, M. D., LL. D., professor of dis eases of the skin, University of Kansas School of Medicine. Fifth edition, C. V. Mosby Co., St. Louis, 1923. The first edition of this well-known work appeared in 1916. The author, one of the most indefatigable workers in the field of dermato- logical research, at that time aimed to present the entire subject of dermatology in a comprehensive and concise manner. That he suc ceeded in his attempt is made evident by the popularity of the work, necessitating five editions of the book since its first appearance. The present volume is an admirable exposition of the author's ability as a teacher of dermatology. All recognized dermatoses are discussed in a logical manner according to their relative importance and frequency. As in former editions, particular emphasis has been placed on differential diagnosis, pathology, and treatment, making the work especially valuable to the general practitioner. A notable feature is the inclusion of over 1,000 photographic illustrations, among which are some noteworthy photomicrographs, the work of the author's son, Richard L. Sutton, jr. These, with some excep tionally realistic colored plates, present a complete pictorial record of the diseases of the skin. Manual on Ship Sanitation and Fuist-Aid for Merchant Seamen, by Robert W. Hart, passed asssitant surgeon, United States Public Health Service. Prepared under the direction of the Rev. Archibald R. Mansfield, D. D., superintendent Seamen's Church Institute of New York, in cooperation with the United States Public Health Service, Washington, D. C. Second edition. Seamen's Church Institute of New York, 3928. This manual has been prepared to meet the need of seafaring men, who will find in it much valuable information on general ship sanita 103 104 Vol. XX. BOOK NOTICES. tion and hygiene and on the common medical and surgical conditions which occur on shipboard, together with clear directions for the treatment of diseases and the care of injuries. As some merchant ships are often long at sea without a doctor on board, the author has included in this book practical information concerning bedside nurs ing and instructions which will enable the sailor to cope with those medical and surgical emergencies which frequently arise at sea. Sanitary conditions on merchant ships are often not all they should be, due not so much to willfulness as to ignorance regarding even the most elementary rules of sanitation and hygiene; therefore it is pleasing to note that the manual opens with a clear and practical dis cussion of general sanitation and hygiene as related to conditions on shipboard. This is followed by chapters on anatomy and physiology, the ship's sick bay and medicine chest, medical first aid and surgical first aid. An appendix contains excerpts from Eegulations, United States Public Health Service, and from the latest United States navi gation laws, .with which every seaman should be familiar. The Seamen's Church Institute of New York deserves great com mendation for the unique' service it renders to sailors of all nationali ties who visit the port of New York and especially for the prepara tion of this manual, which should be in the sea bag of every member of the American merchant marine. , Peinciples of Bacteriology, by Arthur A. Eisenberg, A. B., M. D., director of laboratories, St. John's Hospital, pathologist to Lakeside Hospital, and serolo- gist to St. Ann's Sospital, Cleveland, Ohio. Second Edition. C. V. Mosby Co., St. Louts, 1923. This compact little volume was first prepared by the author as a textbook for the use of the nurses of St. Vincent's Charity and St. John's Hospitals, of Cleveland. It represented, with some additions, the syllabus of lectures delivered by the author at the training schools of these hospitals. Designed for nurses, the book was written in very similar language, incorporated all the established facts of bacteriology, and stressed the principles of bacterial prophylaxis. As there is an ever-present need for nurses capable of serving as laboratory assistants and technicians, the author gave a minute de scription of the simpler technical procedures and cultural diagnosis. The book proved to be useful and popular and the first edition was soon exhausted. In the preparation of the second edition the author has included many additions to our knowledge of bacteriology which have been made during the past five years. Among these one notes a discussion of D'Herelle's phenomenon —one of the most important contributions No. L 105 BOOK NOTICES. to bacteriology since the days of Ehrlich and Bordet —descriptions of some of the newer technical procedures, such as Paltouf s modifi cation of Gram's method of staining, Pappenheim's method and some culture media, a description of the newer precipitation and floccula- tion tests for the diagnosis of syphilis, a discussion of the new colorimetric method of titrating culture media, a description of the pretransfusion blood tests, including a discussion of the blood typing of Jansky and Moss, and a discussion of anaphylaxis, Besredka's desensitation methods, and the application of anaphylaxis to the diagnosis of hay fever and bronchial asthma. Habitual Constipation, Its Causes, Consequences, Prevention, and Rational Treatment— Set Forth in Non-Technical Language, by Ismar Boas, M. D., professor of medicine in Berlin. Translated by Thomas L. Stedman, M. D. Funk & Wagnalls Co., New York, 1923. Medical writers in recent years have turned their attention to the problem of educating the public in medical matters with a view to decreasing pathological conditions which may be avoided by one pos sessing a knowledge of them. As indicated by the title page, this book on habitual constipation, which affects all classes and all ages, is written for the general public. The treatment of constipation, as the author makes clear to the reader, belongs to the province of the physician ; but the management of a case " presupposes an under standing of the nature, the causes, the consequences, and the compli cations of the disease. And, further, since prevention and a rational treatment can not be carried out successfully without the cooperation of the patient, he must have such knowledge as to supplement the physician's advice and render it intelligible." The book is written with this end in view. Ordinarily constipa tion is a subject difficult to present to the lay reader, but in this in stance both author and translator have handled it in an admirable manner. Obstetrics for Nurses, by Charles B. Reed, M. D., obstetrician to Wesley Memorial Hospital, Chicago, III. Second Edition. C. V. Mosby Co., St Louis, Mo., 1923. In this book the various processes of midwifery are presented with that fullness of information, conciseness of expression, and emphasis due to important subjects which characterizes the author's courses of instruction in the training school for nurses with which he is connected. In addition to the chapters which deal with preg nancy, labor, and the peurperium, there are excellent chapters on the care of the child, infant feeding, cleanliness and sterilization, diets and formulae, and therapeutics. 68326— 23 8 106 Vol. XX. BOOK NOTICES. A Textbook of Chemistry for Nurses by Fredus N. Peters, A. it., Ph. D. Second edition. C. V. Mosby Co., St. Louis, Mo., 1923. This is the story of the science of chemistry told in a simple manner by one who has devoted many years of his life to teaching chemistry. The book begins with a consideration of substances familiar to all and leads up to those not so well known. The author has avoided the extremely technical, and chemical theory has been introduced only when it would add greatly to the understanding of the phenomena under discussion. The volume will be found use ful to the hospital corpsmen of the Navy. THE DIVISION OF PREVENTIVE MEDICINE. Lieut Commander J. H. Phelps, Medical Corps, United Statos Navy, in charge. Notes on Preventive Medicine for Medical Officers, United States Navy. THE PNEUMONIA. BRONCHITIS, AND TONSILLITIS SEASON: HOUSING, VENTILATION, AND CONTACT. By J. R. Pheli'S, Lieutenant Commander, Medical Corps, United States Navy. During the winter months climate and weather make it necessary to live almost altogether indoors under shut-in conditions in various parts of the United States where health conditions among the people directly or indirectly affect the health of a very considerable per centage of the naval personnel. The principal effect, of course, is upon the prevalence and spread of the common infectious respiratory diseases and the other communicable diseases, including the acute exanthemata, which are transmitted by mouth and nose secretions. Unhygienic housing conditions are definitely responsible for a con siderable part of the seasonal increase in the prevalence of these diseases. Changeable climate, cold weather, wet weather, and vari able weather need not cause disease and frequently do not where living conditions and the habits of the people do not lead to herding indoors. Of course, it is the weather primarily that drives people indoors. After they have taken up the winter routine of social and business life, bad habits of personal hygiene, it may be argued, are largely responsible for illness. The demand for an excessive amount of artificial heat and the wearing of unnecessarily thick clothing next to the skin when practically the entire day is to be spent in over heated buildings are matters of personal habit, to be sure, but matters of personal hygiene can not always be separated from the subject of housing. The regulation of heat and ventilation more often than not are beyond the control of the individual. Furthermore, the whole question of the free exchange of mouth and nose secretions is intimately related to housing and housing conditions. Increased hazards of infection are naturally of interest to the individual ; in a larger way, they concern the community. Year after year a regular cycle of increasing morbidity and mor tality goes on, the measurable increase beginning several weeks after 107 108 DIVISION OF PREVENTIVE MEDICINE. Vol. XX. the shut-in conditions of cold weather begin. Death rates are ele vated considerably in December; they increase sharply in January and February and begin to fall decidedly in April. The various causative agents of respiratory diseases are transferred from person to person with increasing regularity and frequency throughout the bad health season—in small groups here and in large groups else where. With the rapid transfer of microorganisms which have pre viously found lodgment in more or less susceptible noses and throats, wherein they have been able successfully to invade the tissues and produce infections of various degrees, the virulence of the prevail ing types of organisms increases steadily to the height of the season. Travel from city to city and congregation of large numbers of peo ple in theaters, in places of business, etc., from all parts of the com munity, facilitate the passage of microorganisms of elevated viru lence from one large or small group to another. Thus, so far as the causative agents and their carriers are concerned, we have the mak ings of the regular winter epidemics. These events lead to vicious circles of increasing virulence and a tendency to increasingly serious grades of infection, followed in turn by still greater virulence of microorganisms scattered by per sons later infected. On the other hand, natural laws are also at work to bring about the immunization of human hosts, or at least to insure survival of the immunologically fit. Barriers against the spread- of these diseases thus appear and become increasingly effec tive as the season wears on in all communities where infection pre vails, more or less, it seems, in proportion to density of population, size of the community, and the extent and degree of mingling among the people. Undoubtedly mass immunity has a great deal to do with keeping death rates from respiratory diseases low, and probably morbidity rates are also affected. Attempts artificially to immunize large numbers of healthy per sons against pneumococci and other organisms that cause infections of the respiratory tract have not resulted in measurable success, and at first thought it appears that health officials are powerless to do anything that will ,affect the introduction, the occurrence, or the spread of these diseases. Little or nothing can be done under ordi nary circumstances to keep the causative agents out of the com munity. Travel, business, and social relations must go on. The occurrence of disease can be affected more or less by educational measures if carried on during the dangerous season with sufficient intensity and thoroughness to keep before the minds of the people (1) matters relating to personal hygiene that seem to have a bear ing upon resistance and susceptibility, (2) the meaning of good ventilation and the effect of bad housing conditions upon the preva No. 1. DIVISION OK PKEVENTIVE MEDICINE. 109 lence and spread of disease in the community, and (3) personal measures that are necessary to check the spread of disease-producing organisms by direct and indirect contact and by means of the drop let spray. Personal hygiene. —Conflicting opinions are readily evoked by a discussion of what is meant by good habits of personal hygiene. Of course, this subject offers a splendid field for faddists and all sorts of refinements in definition are possible. Many fastidious cus toms and habits are doubtless desirable from certain limited view points or for social reasons. Also, when the discussion comes to such things as clothing, diet, and exercise, the personal equation looms large and what is one man's meat may very likely be another's poison. Apart from such considerations, there are certain general princi ples covering the reactions of individuals to their environment that should receive particular attention from the standpoint of com munity health during the bad health season. In the Navy, as elsewhere, something can be accomplished by so- called public health education, which usually means the dissemi nation of information as free from controversial opinion as it can be made. Constant reiteration of fundamental rules of health is necessary if the method is to carry with it much or anything of real educational value. But in the Navy it is possible and indeed necessary to go much further than this, for naval organization and routine activities re quire modification of personal habits, comparatively close supervi sion of the men, and a great deal more in the way of regulation of living conditions and habits than is possible in civil institutions, not to mention the general public. At the same time, when the particu larities of living are administratively regulated for numbers of in dividuals in groups, certain potential dangers are liable to creep in. These dangers must be kept in mind by the medical officer, who in his capacity as advisor to the administrative heads of the organiza tion in health matters can correct or have corrected, as a rule without serious interference with necessary service activities, many of the conditions which may involve avoidable health hazards. For ex ample, the bluejacket has little choice in the matter of clothing; or dinarily, he must wear the uniform of the day. If he falls in on the upper deck at quarters without a sweater or overcoat and is kept standing at attention or at ease shivering in a cold wind while vari ous parts of the ship are being inspected, how can it be logically maintained that no chances are being taken with his health ? At the naval training station, Great Lakes, 111., during the World War many thousands of recruits were sometimes assembled in parade formation no Vol. XX. DIVISION OF PREVENTIVE MEDICINE. to receive a distinguished visitor and were then kept waiting in line by delay in his arrival. The morbidity statistics of the station in dicated that such occurrences were followed by a definite increase in the incidence of respiratory diseases, including pneumonia. Again, if the men are not given opportunity to change their clothing promptly after a wetting, and often if they are not made to change, risks are taken. At home there are mothers and sisters to insist upon such things as overshoes and getting out of wet clothes. Doubtless unnecessary fuss is often made about such matters, but most men need watching or they will frequently or occasionally take chances that really have a bearing upon infection. The human body can adapt itself to a wide variation from the optimum temperature downward, but not suddenly. It is possible for man to accustom himself to going naked in the woods in extremely cold weather or to swimming in ice water. However, the average individual, when thinly clad and moist with perspiration, can not adapt himself to a sudden change from an artificially heated space into cold outside air without overtaxing the circulatory adaptability power of his mucous membranes and heat-regulating functions of his skin to a de gree th«t is liable to lower the barriers against infection by microor ganisms which, perchance, he already harbors. Another point to be remembered is that the uniform order for the day should be sufficiently flexible or subject to timely modification where sudden changes in the weather occur, as in San Francisco, to permit the wearing of garments suitable after the change has taken place. It is necessary to plan ahead sometimes to insure adequate protection of liberty parties which are to be absent from the ship or station for several hours. More often than not the exposure of en listed personnel to cold or wet weather without ample protection in the way of suitable garments is due to oversight or thoughtlessness rather than to stringency of orders regarding the uniform of the day. Because such details may be overlooked in the rush of the day's work and few or many men suffer in consequence, the medical officer must keep such hazards in mind and be quick to make suitable recom mendations. An important principle regarding clothing is that it should be porous and as light as may be worn comfortably at the low tempera tures to be encountered, particularly the layers next to the skin. Of course, circumstances of work and exposure alter conditions. A man may keep himself aglow and comfortably warm in a light under shirt and running trunks if he keeps running. A sentry standing still or pacing a short beat must wear heavy woolen underwear and heavy outer garments when exposed to a cold wind if he is to avoid severe or dangerous chilling. When a change in the weight of under no. a. Ill DIVISION OF PREVENTIVE MEDICINE. wear is made according to the calendar rather than in preparation for the task of the hour and in accordance with weather conditions, the skin tends to lose its power of ready adaptability to the varia tions in temperature and relative humidity that are unavoidable in winter. Susceptibility to colds seems to be increased thereby. Cer tainly women who go about lightly clad as to underwear and pro tection of the throat in cold weather seem, by and large, more re sistant to infections of the respiratory type than men experiencing the same weather conditions. Much depends upon the layer of air surrounding the body. This is a blanket of warm, moist air—warmed by contact and radiation from the body and moistened by the output of the sweat glands. If the skin is to function properly and at the same time maintain proper power of adaptability this layer of air must be changed at a fairly uniform rate with considerable rapidity by ventilation through the several layers of garments to the skin. The necessary renewal of air can not take place in the comparatively still air of an overheated room through thick underwear saturated with moistures The subject of bathing also has its important practical considera tions. Unless the men can wash themselves and bathe in properly heated spaces and have water that is not uncomfortably cold during cold weather they will not bathe regularly or as often as they should. It is all very well to say that cold water is good for them and that thejT are used to drafts and blasts of cold air on board ship. The average bluejacket is not very different from the average run of men ; indeed, a considerable percentage of the men in any organization have so recently joined the Navy that they are not thoroughly seasoned and accustomed to service hygiene. Some men are accustomed to cold baths and are stimulated by them and enjoy them; and some, activated by ostentatious vaporings of the subconscious mind, claim that they enjoy an icy plunge or cold shower in cold weather, when in reality they do not. Most men do not, and the cold bath is likely to be harmful if the skin does not react promptly afterwards. Of course, one may become accustomed to cold water, but that is not the point. The majority of men in the group will bathe more regu larly and more frequently if convenient facilities are provided where they may strip and dry themselves in a state of comparative com fort; otherwise, no. Similar statements apply to toilet facilities. The intestines are quick to form habits, bad habits quicker than good habits, it often seems. Unless water-closet seats are available where the men may find a place and be fairly comfortable without waiting in line and without having to walk a considerable distance to get there, calls of nature are going to be neglected, and presently the habit of con stipation is formed. Of course, other factors are involved, notably 112 Vol. ^ DIVISION OF PKEVENTIVE MEDICINE. an unbalanced ration lacking in cellulose and perhaps in fat; more particularly, bad habits in eating—that is, the food which the in dividual himself selects from the meal prepared for him and the manner in which he eats it. A fixed habit of bolting the food is bad. Deficiency in fat can not be charged against Navy messes, as a rule; on the contrary the average bluejacket is likely to eat more fat than he really needs. It is beyond the scope of this paper to dis cuss the diet, but it may be said that comparative deficiencies in fresh leaf}' vegetables and fruits among the general population, especially the poorer classes, during the winter season very likely constitute one of the factors which bear directly upon the develop ment of the infectious diseases that have their greatest prevalence during the winter and spring. The difficulty of supplying regu larly, at sea, green leafy vegetables and palatable roughage in suffi cient quantity is well known. Whatever contributes to cause consti pation becomes a factor in the etiology of respiratory disease by interference with the normal processes of elimination. Doubtless, by increasing the load on the kidneys, skin, and circulation a definite effect is exerted upon the delicately balanced entity that determines personal immunity. In the case of an individual habitually consti pated, compensations have been made so that he usually feels as well as one whose bowels move regularly every day, and probably delay in the evacuation of the lower bowel does not particularly lower the resistance of his tissues to invasion by microorganisms. In other words, occasional or intermittent failure of the bowels is more signifi cant than confirmed laziness. The laundry question is an important one. The larger the crew the more important the question of sanitary washing of clothing becomes. With 1,400 or 1,500 men on board a battleship there is much congestion with close personal contact and other evils of over crowding. These must be given great weight in considering all epidemiological factors that make for the occurrence and spread of infectious diseases of the respiratory type on board ship. The larger the group the more difficult it is to keep the men well. With increase in numbers, communicable disease hazards increase out of proportion to the numbers of men added. Large ships fortunately have laundries. The underwear, handkerchiefs, and other articles subject to contamination by body discharges and by nose and mouth secretions should be handled for the crew by the ship's laundry, where they can be disinfected by the washing process. It appears that some prejudice still exists in the service against per mitting the bluejacket to profit by this ordinary and essential sani tary feature of modern civilization. The public health value of this method of systematically destroying vast numbers of virulent microorganisms on board large ships should be given more weight Ho. 1. 113 DIVISION OF PREVENTIVE MEDICINE. than traditions which require that every bluejacket must scrub his own clothes. This is a valid public health requirement because with their large crews the menace of communicable diseases is far greater on board battleships of to-day than on board capital ships in days gone by. Incidentally sickness rates and death rates were much higher in those days than they are to-day. Low death rates and the comparative freedom from disease now experienced did not just happen to come about. The men are just as liable to get sick. The difference is due to the gradual acquisition of knowledge and its ap plication with increasing effect. Much remains yet to be learned about the control of respiratory diseases, but we do know that proper disinfection of contaminated wearing apparel is an important public health measure. There is something to be said about exposure incident to scrubbing clothes on deck in cold and inclement weather. The men should be watched and warned against dangerous exposure upon coming directly from heated compartments, lightly dressed, for the purpose of scrubbing clothes. Conditions on outside scrub decks particularly should be watched during the winter and spring at naval training stations. The men under training have not undergone any great de gree of seasoning to such environmental influences. Ventilation. —As a result of the work of the New York Ventilation Commission and other recent studies it is now possible to discuss this subject in simple terms. The object of ventilation is the removal of body heat, body moisture, and body odors by the constant supply and circulation of good air in sufficient quantity to accomplish all three purposes. Deleterious effects can no longer be attributed to carbon dioxide in excessive amounts or to the presence of organic effluvia. Good air means: (1) Fresh outside air when possible, and in any event air that is cool but not uncomfortably so. (2) Air in which the relative humidity is not excessively high in relation to air temperature in the occupied ventilated space. It is of less importance but preferable that the relative humidity, likewise considered in conjunction with room temperature, should not be too low. (3) Air that is in motion but without sufficient movement to create a disagreeable draft; preferably motion that varies from moment to moment, accompanied by slight fluctuations in temperature —condi tions which produce an agreeable and stimulating effect upon the human body. ( Winslow.) (4) Air free from offensive odors. (5) Air free from poisonous fumes or gases. (6) Air free from excessive amounts of dust. We are principally concerned here with cold weather conditions. The necessity for artificial heat is presupposed. Therefore, the 114 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. uncomfortable and even serious effects of high relative humidity in combination with high temperatures —75° to 95° F. or higher —need not be considered for the moment. Instead the air is likely to be too dry for comfort. Exaggerated statements are often made about the bad effects of excessive dryness in artificially heated air. Over heating is more likely to be the real cause of discomfort and pre disposition to respiratory disease rather than the lack of moisture in the air. Dr. C. E. A. Winslow, in view of the findings of the New York Ventilation Commission, states that such results as are avail able in regard to the supposed harmful effect of dry air per se are almost wholly negative. The drying effect of such air is in proportion to the movement of the air. It is true that when the air is so dry as to injure leather and furniture it produces an uncomfortable effect upon the skin and causes the mucous membrane of the nose to feel dry. Naturally, the drying effect is much greater if the air is moving rapidly, as may be the case in the vicinity of furnace registers and usually is the case at considerable distances from blower terminals through which heated air is supplied at high velocity. No one has been able to make out much of a case against the hot-air furnace as a producer of disease in the home, but the more rapid movement of the air in various parts of a room or com partment where centrally heated air is delivered by a plenum system of ventilation may intensify the drying affect to such a degree as to cause marked discomfort. As a rule, this effect is associated with over heating, and probably the discomfort and certain injurious effects which have been attributed by various medical officers in their sanitary reports of conditions on board battleships heated by the combined system of plenum ventilation together with remote heating of the air, have been due to overheating and rapid movement of the warm or hot air rather than to the low relative humidity. In other words, the low relative humidity would not matter very much if the air were comparatively still. These factors can not very well be studied separately in actual practice. It is not practicable to add much moisture to the air on board ship, and such regulation as is possible becomes a matter of controlling the temperature and modifying strong currents of warm air by better distribution of incoming air. The principle here involved is that there should be small and numerous inlets, preferably one of proportionately small area (14 to 16 square inches) for each person, situated low down with outlets located overhead so as to secure the benefits of the up ward system of distribution within the ventilated space. That is out of the question on board ship. It is the approved method of ventilating and heating theaters, where an individual mushroom- shaped inlet may be placed under each seat. It is possible to change the air in the auditorium every two minutes without producing No. 1. 115 DIVISION OF PREVENTIVE MEDICINE. uncomfortable drafts. We start with the outside air at given tem perature and given relative humidity and then raise the temperature to the point where the air will feel comfortably warm to the occu pants of the space. That is the end result whether the heating be done in the space itself by steam radiators or centrally prior to distribution by the blower. The relative humidity depends entirely upon the room temperature and is the same in either case, but it can not be denied that the air is more uncomfortable when delivered by the blower at high velocity. In this case a somewhat higher temperature is necessary if the average individual is to feel com fortable. From the health standpoint, therefore, local heating by steam radiators is preferable because overheating is an important factor among the contributory causes of respiratory disease. The effect is due to the strain put upon the temperature-regulating mech anism of the body and particularly upon vasomotor control in the mucous membranes of the nose. Upon going from an overheated space into cold air the mucous membranes of the nose become pale. The tissues of the lower turbinates may or may not contract. Often the blood vessels contract, but the mucous membranes are left other wise in adjustment for the high temperature; they remain swollen and covered with secretion. Before adjustment can take place the temporary condition of inadequate blood supply may result in lowering the local barrier against invasion by disease-producing microorganisms. Studies in New York seemed to indicate quite definitely that overheating of schoolrooms was responsible for a higher incidence of respiratory disease among the pupils in over heated rooms than among children in rooms were care was regularly exercised to prevent overheating. Rooms in which a temperature above 70° F. is maintained may be regarded as overheated. It is desirable not to raise the temperature above 68°, but many persons feel uncomfortable with the tempera ture below 70° F. unless they are working or moving about. Much depends upon the relative humidity and air movement. If the rela tive humidity can be kept up to 30 per cent and excessive movement is avoided, lower temperatures will be found comfortable. Natural ventilation is preferable. Where the fresh outside air can be taken in naturally through windows equipped with glass ven tilator plates of the Fairfield type set at an angle to deflect the in coming cold air upward, with a steam or hot-water radiator beneath the window to assist in dispersing the cold air, it is possible to main tain more wholesome air conditions than can be secured with forced ventilation. The air feels better to the skin because the temperature fluctuates a little, and the rate of movement is also variable as the air circulates through the room; cross currents vary in intensity from moment to moment. Thus, the skin and mucous membranes are 116 Vol. XX- DIVISION OF PREVENTIVE MEDICINE. agreeably stimulated and the air feels pleasant, more like outside- air. The uniform rate of change with the plenum system is not so- good, but, of course, many rooms and compartments can not be ven tilated by natural means. The next best thing is to combine natural ventilation with the plenum supply if it can be done. It is often pos sible to do this to good advantage in office buildings, schoolrooms, hospital wards, and in some compartments on board ship. Sometimes natural openings can not be used without serious intereference with the efficiency of the mechanical system. For example, in a theater the blower supply frequently fails to change the air uniformly if the doors are left open. The air then becomes overheated in certain parts of the auditorium, pockets form, and strong drafts are set up elsewhere. Where forced ventilation must be used, it is desirable in cold weather to distribute the incoming air, if heated, through many small rather than one or two large terminals. If terminals can not be located in the floor or deck, the hot air should enter the space as low as possible and be directed downward to be dispersed over the floor before it rises. Cold air should be delivered high so that it will be diffused overhead before it sinks. Local conditions in each com partment, of course, determine how the air can best be distributed. The best attainable results can not be secured with any mechanical system of ventilation without constant attention and change of pro cedure to meet varying weather conditions. The question of using venturi tubes on terminals in cold weather should be considered. By such means the incoming air, whether cold or heated, may be mixed with the room air by aspiration and thus tempered as it leaves the terminal. A cone-shaped device might also- be placed in the terminal to reduce the velocity of the incoming air by directing it laterally in all directions instead of forward in one direction. Overheating should be avoided and men should not work or sleep in the vicinity of blowers where they will be exposed to strong cur rents of hot air or to blasts of cold air. Extreme conditions are encountered on board ship. In warm weather the ventilation problem resolves itself into a question of getting rid of excessive heat. Solar heat is transmitted through the metal of the ship's hull, and wild heat is transferred through bulk heads into compartments in the vicinity of fireroom and engine room spaces. Sometimes this heat is also carried by air currents into distant compartments. Volumes of air greatly in excess of amounts necessary to remove body heat, body moisture, and body odors fail to maintain comfortable atmospheric conditions. Strong currents of air are appreciated at such times, and while it is not agreeable as a Xo. 1. 117 DIVISION OF PREVENTIVE MEDICINE. rule to sit or work with an electric fan blowing directly upon one, •conditions are so much worse without fans that they are generally kept running at full speed and often more fans than are available <M>uld be used to good advantage. In cold and moderately cold weather the presence of wild heat is usually advantageous. Such heat furnishes agreeable warmth in living spaces, even in compartments that have hot bulkheads in them, because nearly always it is possible to regulate the amount of cold air entering the compartment. A large area of heated surface helps •diffusion and tempers the air. The standard capacity of plenum ventilating systems on board ships of the Navy is 50 cubic feet of air per capita per minute— 3,000 cubic feet per hour. That seems like a liberal provision inas much as 2,000 cubic feet per person per hour, or even 30 cubic feet per minute, is sufficient in buildings ashore. However, this supply is often entirely inadequate in warm weather, as indicated above. Not infrequently better results would be secured in certain loca tions on board ship with blowers of greater capacity than those in stalled. Generally it appears that most parts of the ship are well ventilated, but certain compartments are poorly ventilated. Some times this is due to the fact that more men must now be quartered in such a compartment than was anticipated when the ship was built. Dirt collects in fans, trunks, and ducts and on the screens of terminals so that the amounts of air delivered are often less than the calculated amounts. Motors do not always turn up to their rated speeds. Terminals should be kept clean. Blower casings are accessible, but it is not always practicable to keep the closed air lines clean. An increased supply should be made available in any living compartment which by actual experience is found to be poorly ventilated, frequently or usually, whether the unsatisfactory con dition of the atmosphere is due to wild heat or to an excessive num ber of occupants quartered therein, provided essential service con ditions preclude reduction in numbers. The removal of wild heat by forced ventilation of the over rated living compartment is an expensive proposition. Practically, more air than is required for most ventilation purposes must be supplied, but better results can be secured by insulating heat-conduct ing bulkheads in conjunction with a supply of air moderately in ■excess of ordinary requirements. The need for heat-insulating ma terial and a satisfactory job should be stressed in making recom mendations for the correction of this sort of defective ventilation. These warm-weather conditions have no direct connection with the almost opposite conditions which it is the purpose of this paper to discuss. But they are worth considering by way of contrast in •order that the limitations of mechanical ventilation systems may be 118 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. clearly appreciated. Any installed apparatus that is capable of maintaining tolerable air conditions in warm, humid weather will furnish an adequate supply of air in cool and cold weather to re move body heat and body odors, provided the requisite amount of air is allowed to flow. That will always be the case if the occupied space is adequately heated by any means other than the heat liberated by the occupants themselves. The capacity of the ventilating apparatus is based on the esti mated number of men who will occupy the various compartments. When more men are in the compartment than the blowers were planned to take care of, the actual number of cubic feet per capita available diminishes, of course, in proportion to the increase. With double the number of occupants there is only half as much air per individual flowing through the compartment. The immediate effect of overcrowding is to spoil the ventilation. This is an inevitable result with the usual provisions, even with the plenum system. The resulting conditions are much worse in barracks, dormitories, and other large rooms ventilated by natural means. But even in a theater that is very well ventilated in fair weather, if filled only to its normal capacit}^, the air becomes very bad if the auditorium is overcrowded. DefecthTe ventilation in living compartments is more serious than in spaces temporarily occupied in so far as the effects: of unhygienic physical properties of the air are concerned. There is another side to this question, and a very important one indeed. It concerns the transfer of pathogenic microorganisms from person to person in countless ways. All ways and means are included under the headings, direct contact, indirect contact, and transmission by means of the droplet spra;/. Simply through the presence of more people in a given institution or ship than can be accommodated without lowering the standards of personal hygiene by overtaxing the facilities for idling, sleeping, eating, bathing, etc., overcrowding results in greater personal con tact and increased rates of transfer of disease-producing micro organisms both by direct and indirect means. The bacteriological results of overcrowding were verified at several naval stations during the war by plating out the organisms harbored in the nose and throat among thousands of healthy recruits —at least they were free from symptoms when the cultures were made. The results of that work are well expressed in the aphorism, " Under conditions of over crowding the bacterial flora of the nose and throat tends to become unifrom throughout the personnel." Every health officer knows that bad housing conditions and over crowding are together responsible for much of the communicable dis ease that he is trying to control. The tenement districts, over crowded lodging houses, and districts where excessive numbers are No. 1. DIVISION OF PREVENTIVE MEDICINE. 119 crowded into separate dwellings are the great breeding places for epidemics, and they serve as reservoirs of infection that keep up endemic prevalence. H. W. Palmer, writing in Health Forum, Melbourne, Australia, notes that history is full of instances proving that the greater the overcrowding the higher the general death rate. Although over crowding in civil life is generally due to poverty and poverty usually brings with it poor food, the conclusion is that overcrowding alone is harmful aside from the problem of poor food. Doctor Farr, of Edinburgh, reported in 1914 that improvement in housing condi tions resulted in a drop in the death rate from 45 to 15 per 1,000 while the tuberculosis death rate fell from 3.8 to 0.4 per 1,000. In Liverpool under similar conditions the tuberculosis death rate fell from 4 to 1.9 per 1,000. The only improvement in each case was in housing, consequently that improvement alone was responsible for the change.1 In practical public health work to-day we do not give serious consideration to the idea of air-borne infection. In general, air car riage of virulent pathogenic microorganisms plays little or no part in the spread of disease beyond the 6 or 7 foot range of the droplet spray. The drops themselves and the particles of dust upon which they settle drop out of the air almost immediately. Under these cir cumstances the microorganisms quickly lose their disease-producing power by drying. Expensive use of the Chapin technique for isolat ing a case of communicable disease in an open hospital ward wherein patients ill with different communicable diseases are simultaneously being treated, has confirmed Chapin's conclusion that it is possible, although not the method of choice, to treat two or more diseases in the same room with little likelihood of cross infection. Under these conditions the ventilation must be good and there must be no over crowding. There must be at least 8 feet of separation between cen ters of beds, and preferably cloth screens should be interposed be tween beds to block the propulsion of microorganisms by droplet sprays. With overcrowding, the conditions are quite different. If many persons are present in the space, talking and laughing, and some coughing and sneezing, the air becomes pretty well loaded with fine spray and droplets. Under such circumstances it can not be taken for granted that individuals beyond the limits of propulsion for any given burst of spray will not breathe in particles carrying micro organisms. If ventilation is maintained by mechanical means, the air is rapidly renewed, with anywhere from twelve to thirty changes 'Leslie C. Prank, Public Health Engineering Abstracts, U. S. Public Health Service, Oct. 6, 1023. 120 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. per hour. Swift currents are present here and there to carry the finer droplets for a considerable distance before they settle out of the air. With natural ventilation the air can not be changed many times in an hour in cold weather without causing disagreeable cold drafts and perhaps lowering the temperature of the room to an uncom fortable degree. Ordinarily the limit is about six changes per hour, but much depends upon the arrangement and numbers of inlets and outlets, the presence of window ventilators, and the adequacy and location of radiators below the inlets. The amount of fresh air required for each person per hour is commonly estimated to be 2,000 cubic feet. Smaller amounts are quite sufficient under certain •conditions. The lower the temperature of the outside air the less will be required for the removal of body heat and moisture. The amounts required for the removal of body odors will naturally depend upon the individuals occupying the space. Oxygen and carbon dioxide readings need not be considered. The standard, 2,000 cubic feet of air per hour, was originally based on the assumed desirability of keeping the carbon dioxide content down to 6 or 7 parts per 10,000. Winslow, in looking at the question from the removal-of-body-heat viewpoint, has shown that when the entering air has a temperature of 60° F. 2,000 cubic feet per capita per hour will be required to prevent the heat liberated by persons in the room from raising the temperature of the outgoing air above 70° F., the desired room temperature. He states that at a low estimate (that of Pettenkofer) the average adult gives off 400 British thermal units per hour. Five cubic feet of air will have its temperature raised from 60° F. to 70° F. by 1 B. t. u. Gatewood maintained that the standard for the Navy should be 3,000 cubic feet per capita per hour. That was a wise provision, because atmospheric conditions and the numbers of persons occupy ing a given space are changeable, while the facilities for ventilating remain more or less constant, especially in the case of mechanical ventilation apparatus which is limited by its maximum capacity. Ashore, more windows may be opened, but there is a limit to that because with increasing numbers of occupants the cubic air space available for each becomes so little that the required allowance of air can not move through the limited space in an hour without producing a disagreeable draft when the weather is cold. In warm weather but little movement can take place anyway. In other words, good ventilation that assumes well-conditioned air is further conditional upon the amount of free cubic space that is available to the occupants of the room or compartment. An indi vidual can breathe rapidly moving cold air out of doors without dis comfort. He can work in a diving suit with but little air space No. J. 121 DIVISION OF PREVENTTVE MEDICINE. about his body and handle his rapidly moving supply of air very well. But one can not sit about indoors with any great degree of comfort in rapidly moving cold air. In stipulating 3,000 cubic feet of air per hour Gatewood had in mind warm as well as cold weather conditions. The subject of ventilation is closely linked with the question of personal contact and other epidemiological factors that bear upon the transfer of pathogenic microorganisms. Unless each individual has approximately 500 cubic feet of free air space, good ventilation can not be maintained by natural means alone during a considerable portion of the year. And, furthermore, unless this amount of space is provided per capita in barracks, dormitories, and other spaces used as sleeping compartments the dissemination of disease-produc ing microorganisms, if present, can not be controlled within limits that are shown by practical public health experience to be necessary if communicable disease hazards are not to be out of all proportion to the assumed necessity or advantage of overcrowding the personnel to meet the exigencies of war. Proportionately less risk is justifiable in time of peace. Available floor area is the important consideration from the standpoint of contact, and practically also from that of ventilation because great height of ceiling is not advantageous. During the war practical considerations made it advisable to adopt 450 cubic feet of air space per capita as the minimum stand ard free air space in naval barracks. Good ventilation requires 6 to 7 renewals of the air per hour with such spacing. Economic con siderations demanded a height of 9 feet in some temporary barracks. That is really ample. Epidemiological considerations demanded more floor area per individual than could possibly be secured. The absolute minimum that could be defended as a sanitary standard was 50 square feet. This standard pertains only to rooms or compart ments used for sleeping purposes. The Medical Departments of the Army and Navy used every effort to prevent departures from this standard. In this they were only partly successful, and it is regret table that the excess of morbidity and mortality resulting from such departures can not be measured. In barracks 20 feet wide the allotment of 50 square feet to each occupant would naturally result in an area 10 by 5 feet, giving a separation of 5 feet between the centers of beds or cots. Recogniz ing that the tendency would be for men to move their cots or ham mocks close together to clear a free space and that all free space would immediately be taken for more cots and hammocks with the arrival of more men than the building was planned to accomodate, the Bureau of Medicine and Surgery maintained that a distance of 5 feet between centers of cots or hammocks in barracks ashore represented a minimum standard for safety in this respect. 69826—23 9 122 » Vol. XX. DIVISION OF PREVENTIVE MEDICINE. Proper housing conditions are not necessarily secured by the acceptance of standards relating to free air space, floor area, and separation between beds. Such minimum standards are of course very important, but even if they- are followed in the construction of barracks, health and living conditions will not be satisfactory unless additional space is included for the men to move about in without encroaching upon the space actually occupied by cots and lockers. On board ship such space is available even with considerable over crowding —passageways, offices, platforms in upper handling rooms, engine room, shops, etc., where the men may sit about in the evening if the weather on the upper deck is forbidding. No standards will avail after the barracks are placed in service unless the permissible number of occupants is strictly limited to the number for which the building was planned and constructed. From the hygienic standpoint it would be highly desirable if the per missible number of occupants could be certified and marked in every sleeping compartment or room to be used as a dormitory, just as the spaces are certified in merchant ships. It is a debatable question to what extent communicable diseases are spread under sleeping conditions. The requirement that there' shall be 5 feet of separation between cots in barracks does not assume that it is of first importance to prevent transference of infection by means of the droplet spray while the men are occupying their cots. That is an important consideration in hospital wards, to be sure, and doubtless it is important in barracks too. But disease-produc ing microorganisms are exchanged among the personnel of a ship or station in a multitude of waj's. Proper separation of cots is but one item in good sanitation. The requirement that there shall be not less than 50 square feet of floor area per occupant in sleeping quarters is the paramount con sideration. Not only does this requirement insure adequate provi sions for ventilation —with proper construction —but it limits over crowding under practically all existing conditions of indoor life at the station, assuming that adequate mess hall, drill hall, and work spaces are provided for the needs of the station. Lofty ceilings are of no particular advantage to ventilation, and where they exist 12 feet is to be taken as the figure for practical purposes in computing the air space per capita. That assumes that greater height serves no useful purpose so far as ventilation is concerned. In unceiled rooms in low buildings with peaked roofs the height is to be calculated as the distance from the floor to a point midway between the peak of the roof and the eaves. In such buildings over head outlets are an advantage and almost a necessity. Patent venti lator cowls are not necessary, but protection against the beating in Xo. 1. 123 DIVISION OF PREVENTIVE MEDICINE. of rain is essential. Movable cowls that automatically revolve with change in the direction of the wind are sometimes advantageous in that the escape of heated air is somewhat quickened by aspiration when the outside temperature is high. The chief consideration is working area. The total outlet area should be. 50 per cent greater than the combined working inlet area. Inlets should be numerous and small rather than few and large, especially in long dormitories. In other words, windows should be opened all along the room at regular intervals to the required extent ; not one or two windows opened wide. There should be one working inlet space to not more than four occupants, and preferably fewer. With a cold strong wind blowing it may be desirable to open windows only on the lee side, but through and through ventilation is desirable when practicable. Ventilation depends also upon the adequacy of heating arrangements. Hot-water or steam radiation naturally should have sufficient radiat ing surface to maintain the room temperature at 68° F. and still permit the admission of enough fresh outside air in the coldest weather likely to be encountered to provide for at least six re newals per hour, and under all circumstances for enough fresh air to remove odors liberated from the bodies of occupants and from clothing stowed in the room. With adequate heating arrangements and the radiators hot. little is to be gained by opening the windows at night so wide that the room temperature falls below 55° F. If that is done some of the men will most likely be exposed to cold air blowing over the head of the bed and down under the bedding on to the chest. To insure hygienic conditions, the ventilation of barracks must be supervised and regulated in accordance with changes in the weather. Proper instructions must be given and enforced. If left to the men the desires of those most capable of backing up their opinions with physical force are likely to prevail. With proper ventilation the air moves sectionally from numerous inlets toward the outlets so that the same air does not flow through the entire room. Measures designed to check the spread of disease-producing micro organisms. —Overcrowding of the ship or station as a whole may be, and usually is, unavoidable so far as local authority is concerned. In practice it becomes necessary to make the best of existing condi tions. Something can be done toward mitigating the dangers of overcrowding in overcrowded ships by distributing the crew to the best advantage. That means allowing men to sleep in spaces not primarily intended for berthing spaces, such as on platform decks in handling rooms, in well-ventilated offices, shops, and certain spaces in the engineering department. If the men are allowed to keep their 124 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. effects or some of their effects in such spaces they naturally form groups that are separated to a greater or less degree from the larger sections of the crew, and thus tend to prevent large groups from being still larger and still more closely housed. Other things being equal, all conditions make for safety that tend to divide the crew into small groups, such as the presence of separate gun rooms in which sections of the deck divisions are quartered instead of alto gether in a single large compartment. The men quartered in a gun room have their effects there, take pride in the cleanliness and upkeep of the room, feel their responsibility for its condition more keenly, and perhaps have their own phonograph. They tend to stay in there to read or write, and altogether spend a considerable part of their leisure time in their own group. The same is true of office forces and men of certain other ratings if they are allowed to " hang out," as it is said, in their own part of the ship. Epidemio logical^ it is important that each of as many groups as possible have a part of the ship that can be called its own. It is unfortu nate that toilet facilities, especially urinals for the crew, are not located at several different points in parts of the ship that serve as living quarters for the crew. Such provisions would do much to promote natural tendencies to form groups and lessen personal and crowd contact. The lighting of heated spaces should receive attention. The ob ject should be to provide adequate intensity and proper distribution of artificial light in comfortable places where small groups of men can read and write, play games, sew, or attend to other personal work. Properly illuminated areas for such purposes should be made avail able all through the crew's living spaces, not concentrated in the form of a reading room and a few other areas that tend to be overcrowded. Casual and temporary overcrowding occurs particularly on the gun deck in the vicinity of the canteen, post office, barber shop, and sick bay. Men in line awaiting turn at sick call are likely to in clude a number acutely ill with tonsillitis, bronchitis, or other in fections of the respiratory type. In other words, active carriers of virulent disease-producing microorganisms are likely to be concen trated at this point every morning and possibly at other times during the day. This should be recognized and steps should be taken to see that overcrowding in the vicinity of the sick bay at such times is not permitted. If the barbar shop, tailor shop, canteen, issue room, executive office, pay office, or some other office or shop, in front of which men must congregate, is located near by, arrangement should .be made whereby overcrowding is prevented, either by a change in hours, or by forming the lines of waiting men in such directions as will prevent intermingling. Ample space and waiting facilities should be provided for the sick-call line. A suitable routine should So. L 125 DIVISION OF PREVENTIVE MEDICINE. be adopted whereby men who are likely to infect others will be spot ted promptly by the hospital corpsman handling the line so that they may be admitted without delay and the danger limited at once by confinement to bed and the prompt institution of bedside disinfection in cases where admission to the sick list is indicated. Conditions on the gun deck with open hatches leading to the deck above are a mixture of outdoor and indoor conditions. Cold air in large volumes enters through various hatches, sometimes with con siderable force. At the same time heated air is being delivered by blowers, or else there are hot radiators, and the air is also being warmed in the vicinity of bulkheads that surround heated spaces such as the upper spaces over engine rooms, firerooms, evaporator rooms, etc. This mixture of air states witli respect to heating, ven tilation, and hot and cold currents of air is of some epidemiological importance in the presence of overcrowding. Some of the men in line or otherwise congregated on this deck are at work and some are idle. Some have come from heated spaces below and are lightly clad; others have come from the upper decks and are wearing sweaters and perhaps overcoats. A good deal can be accomplished toward preventing casual over crowding under shut-in conditions both ashore and afloat by regu lating work so that all men are kept busy and preferably employed as much as possible in the open air in such manner as will make for the least contact between groups and avoid loafing in crowded spaces on board ship or in buildings. Other things being equal, a busy crew will have less sickness from communicable respiratory diseases, least of all the crew of a ship of such type as to require a great deal of work on the upper deck or over the side in proportion to the size of the crew. Ventilation and artificial heat should be regulated with special care to avoid overheating, blasts of cold air at high velocities, or subjection of the personnel in their work or leisure alternately to excessively heated air and cold outside air when dressed for indoor conditions, and especially when moist with perspiration from work. Care should also be taken to see that men are not billeted in the vicinity of blowers, where they must sleep in a current of hot dry air. Sterilization of mess gear and all other practicable methods for limiting the indirect or direct transference of mouth and nose secre tions naturally have their greatest value during the pneumonia, ton sillitis, and bronchitis season. The use of wash buckets by two or more men in common for bath ing their bodies, washing their clothes, and sometimes for scrubbing their teeth is a practice that should be stopped. Finally, something can be accomplished by efforts to make the men themselves understand the methods by which these diseases are 126 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. spread or induced. The conditions should be explained in simple terms on the bulletin board. Incomplete or exaggerated statements do not carry far; plain facts couched in simple dignified language always receive attention and provoke discussion. A ship order call ing attention to the methods by which disease-producing germs are disseminated and directing the crew to protect themselves from the infectious mouth and nose secretions of other men will cany some weight. For psychological reasons little or nothing can be accom plished by such dicta as urging men to cover the mouth and nose when coughing or sneezing. Man is not by instinct concerned with what happens to his neighbor except in so far as his neighbor's wel fare concerns his own pleasure or profit. But tell him to guard him self against harm from the careless or insanitary habits of others and his interest may be aroused. The men should also be directed to protect themselves against chilling and to change promptly into dry clothing when wet. Despite the lesser return to be expected from an appeal to protect the health of others, the convenient means afforded for carrying in struction out among the crew generally by men seen at sick call are not to be OArerlooked. A printed slip briefly informing him that he is temporarily a menace to others because of his infectious secretions and positively directing him to avoid contact and protect other men, may be handed to every man who receives treatment for a cold, sore throat, or cough. In that way the idea that such conditions are com municable and may in part be avoided by refraining from unnec essarily close contact, use of toilet articles in common, swapping cigarettes, etc.. can be made gradually to permeate through the crew with very little effort by the medical department. To a certain extent the control of communicable respiratory dis eases is analogous to the control of yellow fever or any other in sect-borne disease. It isn't necessary to kill every mosquito; indeed that is impossible, but comparatively little reduction in the numbers of the insects is accompanied by a definite reduction in the number of human cases. In a similar way, with the forces of immunization at work among the crew or population, the general but not to be measured reduction in contacts resulting from educational measures, supervision of personal hygiene, maintenance of good sanitation, early detection of infection, temporary or partial isolation with med ical treatment, and concurrent disinfection can be expected to reduce the prevalence of respiratory diseases very decidedly below the inci dence that would be experienced without the intelligent use of pre ventive measures. Reduction can be expected only in proportion to the painstaking application of all essential measures. Unfortu nately, satisfactory standards for comparison do not exist. No. 1. 127 DIVISION OF PREVENTIVE MEDICINE. These diseases are universally prevalent in civil communities and the degree of exposure can not be measured with any exactness. Service factors such as overcrowding, rate of turnover among the crew, char acter of the routine, etc., are variable and can seldom be used in mak ing comparisons for a given period of increased prevalence. It is particularly unfortunate that the very ship that tries the hardest to prevent disease fortuitously encounters conditions and cir cumstances that result in high admission rates. On the other hand, there are few organizations in which credit is more quickly given for good work and earnest efforts or given in greater measure than in the Navy. mass manmiTY to diseases. The editor of Health News, the monthly bulletin of the New York State Department of Health, makes the following comment on the subjoined article on " Some of the factors which lead to the increase and decline of communicable diseases among men and animals," by William H. Park, M. D., which appeared in the August issue of that useful periodical : " With that simple clarity of expression which is one of his hap piest gifts, Dr. William H. Park summarizes in this issue the recent researches which have advanced our understanding of the virulence of disease germs. Experiments on mice confirmed by observations of human cases indicate that carriers of diphtheria, for example, •who get their germs from other carriers are less dangerous than carriers who become such by contact with diphtheria cases or who are themselves recovered cases. In other words, in measure as the germs radiate away from the original case and pass through other hosts without starting up new cases, they lose virulence, though fortunately still able to -create some degree of immunity in the people in whom they lodge. " The result of this process is that, in large cities particularly, a considerable number of people become immunized in varying degrees against certain infection. Doctor Park even found a certain para doxical value in modern rapid-transit crowding, creating as it does a general meeting ground of germs and people, where a constant process of benign inoculation is going on, developing immunity in discriminately in rich and poor, saving alike the believer and the un believer, the rationally minded and the antivaccinationist. " There is a corollary, however, to this widespread process by which man slowly meets and overcomes his microscopic enemies. Animals carrying these mildly infectious germs ordinarily showed no signs of ill health, but they succumbed readily and in great numbers when subjected to insanitary conditions, improper food, and the like. No 128 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. less do human beings fall before ordinarily harmless attacks of infection when normal conditions of the environment give place to stress, strain, and resistance-lowering factors of war, famine, earth quakes, and similar emergencies. At the same time an epidemic brings rapidly increased virulence of the microbes as they pass directly from the many new cases to the many new victims. " Referring again to the effect of overcrowding cars it is unfortu nately true that the strap hanger becomes inoculated not only with germs which have lost their virulence but also with virulent ones which conic from incipient or convalescent cases of infectious disease. " Public health workers will find solid scientific comfort in Doctor Park's argument. Their work, he implies, is what keeps up normal resistance and suppresses the beginning outbreaks which so soon magnify the potency of disease germs and start the spreading vicious circles of an epidemic. Even such conservative critics as Raymond Pearl do not deny that the modern public health move ment has won distinct triumphs. Doctor Park points out from a new angle the reason why civilized communities living normally under the modern public health regime exhibit such definite evidences of progress in the reduction of infectious diseases. SOME OF THE FACTORS WHICH LEAS TO THE INCREASE AND DECLINE OF COMMUNICABLE DISEASES AMONG MEN AND ANIMALS.' By W. H. Pabk, M. D., director of laboratories. Now York City Department of Health. We are all aware that during the past 50 years in New York State there has been a great and steady decrease in the number of advanced cases of tuberculosis and of severe cases of scarlet fever. In fact there has been a declining death rate in all the communicable diseases. Beyond the fact that we have discovered antitoxins, learned new diagnostic procedures, applied better forms of treat ment, and safeguarded our water and food supplies, there is evi dently some general underlying cause for this improvement. When a country is unsettled and health organization is disorganized and personal hygiene discarded, the results are the opposite. For instance, in Russia a very serious and very extensive epidemic of malaria has developed during the past five years. It is estimated that 9,000,000 cases have occurred and that there have been at least 2,000,000 deaths. Since 1918, there have been 30,000,000 cases of typhus and over 3,000,000 deaths. Tuberculosis, cholera, and other communicable diseases have to a somewhat less extent increased in severity and frequency. « Reprinted from Health News, the monthly bulletin of the New York Stnte Department of Health, August, 1923. Xo. 1. 129 DIVISION OF PREVENTIVE MEDICINE. The decrease or increase in the severity and amount of communi cable diseases is due to a number of causes, such as the virulence of the microorganisms, the resistance of the people, the number of susceptible individuals in a community, and the degree of protection of the host from contact with the microbes. Before taking up the main topic I want to speak for a few moments on the virulence of microbes. I know that I have only lately come to realize how complex is this quality of virulence. Perhaps you who are health officers nad nurses have, like me, not fully realized how many forms of virulence there are. The virulence which is indicated by the power to produce toxins allows of intoxication as in tetanus and diphtheria if the microbes are able to fasten on the tissues and increase. The virulence which allows a microbe to grow on the surface of the mucous membranes allows the development of carriers of certain organisms such as the pneumococcus and diphtheria bacillus. The virulence which allows of growth in the tissues permits infection in operative and accidental opening up of the body cavities and tissues to contamination. The virulence whicli permits the invasion through the intact coverings of the body permits the development of epidemics. We now realize that when we speak of the quality of virulence in germs we must consider those which grow on the surface of the membranes, those which grow in the tissues, those which make tox ins, and those which just, being swallowed or inhaled cause disease. Topley, of Manchester, who has done a great deal of work with animal plague, suggests that we give these different forms of viru lence different names: Supragliscence —the power of multiplication on the mucous mem branes. Intragliscence —the power to multiply in the tissues. Perfringens—the power to break through the barrier opposed by the healthy epithelial surface. Whether we use the words suggested by Topley to designate these different kinds of virulence is not of great importance, but the rec ognition of the fact that a microorganism may have one form of virulence without the others is of great value. To a certain extent diminshed virulence of a microbe can be replaced by an increase in quantity. Flexner and Amoss have developed this in their mice ex periments. The severity of an outbreak of a communicable disease will be determined by the relative susceptibility of the individuals making up a population, the type of virulence and degree of viru lence of the microbe, the degree of exposure and the health and living conditions of the people. Some of the factors in the development of disease can be studied better in animals than in man. We can fix the conditions under 130 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. which a group of mice are exposed to infection so as best to serve our purpose. It would be most improbable that we would ever have the chance to study an outbreak of a communicable disease in such an exact way. For much of the experimental work done in mice a bacillus belonging to the paratyphoid group has been used. Topley has reported some very interesting experiments on the conditions of the mouse population which allow an epidemic to develop and again on the conditions which cause germs from healthy carriers to lessen in virulence on passing to other carriers. For a general outbreak to occur the majority of the mice in a colony must be susceptible. If, either through survival from an outbreak or because of immunization, the number of susceptible individuals in a group is small, it is impossible, unless the bacteria have great invasive virulence, to develop an epidemic If, however, an epidemic is started in a new group of mice and survivors of a previous out break are added, it is found that many of the latter will succumb. The rapid growth of the microbes in case after case in the epidemic has so increased the invasive power and the quantity of the microbes that the relative immunity of many of the survivors is insufficient to protect them. It has also been noted by many observers that under conditions of crowding, fatigue, insufficient food, improper food, lack of ventilation, etc., the relative immunity of the animals which would suffice to save them from microbes of a moderate in vasive power is so lessened that infection and disease readily occur. Before passing to human communicable diseases I want to touch on the gradual loss of virulence in pathogenic bacteria multiplying in carriers. Topley proved that, in mice at least, some microbes lose their power to spread disease by natural means when as surface growers in the carrier state they have passed through three suc cessive animals. This experiment was carried out in the most pains taking manner. He took a group of mice suffering from an intes tinal infection epidemic in nature. After the outbreak had passed a few mice survived and certain of these mice were known to be carriers. He took two of them and put them with five healthy mice. They were allowed to spend two days together so that the healthy mice would become infected from these two carrier mice (carriers after recovery from disease or from direct contact with dis eased mice) and then he took these five fresh mice which were shown to have become infected and put them with a second lot of mice. This second lot of healthy mice were as before, simply in contact with the first lot for two days; then the second lot were taken out before the first lot developed disease and put with a third lot of healthy mice, and in two days the third lot of healthy mice were taken away and were put with a fourth lot of healthy mice. For 10 different tests he allowed just enough time to permit the ex No. 1. 131 DIVISION OF PREVENTIVE MEDICINE. posure of fresh mice to the carriers before the latter developed disease. The interesting thing is that of the five mice that were in contact with those, three developed the disease and died; then of the third lot that were in contact with the second, two developed the disease. The fourth lot that had been put with the third lot remained well, although they became carriers. For the rest of the 10 lots the organisms in the carriers had so lost their invasive power that no longer were the healthy mice attacked. The im portant lesson is that cases of disease and direct contact carriers are more dangerous than carriers infected by carriers. The further the carrier is from a case of disease the less virulent the microbes. Even then if resistance is lowered disease may occur. All of us who use large numbers of laboratory animals know that especially in winter and early spring when animals have not been fed on fresh vegetables, shipping them on the railroads tends to bring out diseases which did not occur at the farms. This is because through loss of food on the way, overcrowding in the crates, and lack of ventilation the animals lose their natural resistance to carrier germs to which they did not succumb when in health, but with health lessened by ex posure and fatigue the animals become diseased. The loss of viru lence in carrier germs as they pass from mouse to mouse is also exemplified by diphtheria in man. Some very interesting work by Doctor Frost has been going on in Baltimore and I have repeated it in New York City. One of the students working for a degree took this as a subject: "What dan ger is there from a diphtheria carrier of virulent diphtheria bacilli, who has not, so far as we know, had any contact with a diphtheria case ? " This student has followed 20 families during the winter for from two to four and a half months, and in no instance in the 20 families with one or more carriers has diphtheria developed. The same thing is true in Baltimore. We all know that carriers, whether these be nurses or physicians or parents who developed as carriers from contact with a diphtheria case, do frequently transfer diph theria ; in the instances cited the carriers were without known con tact with cases of diphtheria but in all probability had been carriers from carriers, etc., for a long time. They did not start disease in their families although a number of the members were Schick posi tives. This bears out the work on the mice that the germs from the carrier are less dangerous than those from the case itself and that the germs at each transfer are getting less and less virulent. There is a very hopeful side to this because undoubtedly to some degree, at least, these carrier microbes which, while still producing toxin, have lost much of their virulence are still able to immunize. The only reason we know of as to why children in the city have a higher per 132 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. centage of Schick negatives than children in the country is that in the city at any one time at least 1 per cent of the people are car riers of diphtheria bacilli and that probably these carriers are con stantly changing; consequently although only few children develop diphtheria a great many become immune. When we ride in over crowded cars, we doubtless breathe in germs from the respiratory tracts of our neighbors, yet only a few of us develop disease. In stead, many of us get a certain amount of immunity, for there is a tendency for some of the microbes to develop in the respiratory passages of those who have inhaled them and so become parasites and the hosts thus become carriers. If we do our utmost to keep the general health conditions as good as possible this carrier immuniza tion tends to lessen disease. Under bad living conditions, just as the laboratory animals lose their resistance we lose ours and thus suc cumb to infection instead of developing a partial or complete im munity. This is well illustrated in an epidemic of bubonic plague that developed in Manchuria 2 years ago. You probably remember that some 12 years ago there was a very virulent epidemic of pneumonic plague in China and a great many thousands of individuals died. After the epidemic the disease practically disappeared. A certain proportion of the rats in certain localities were still infected, but only once in a while a single case of plague developed. Then a new epidemic developed in 1920-21. A woman, presumably infected by a rat, developed the first case of plague. It was of the bubonic type, as the bacilli were not yet virulent enough to cause septicemia. Some of the Chinese in contact with her contracted the disease. Pre sumably this infection was caused by infected fleas from her. These cases were a little more virulent, because the bacilli were not from the rats but from a patient. The severity of the disease gradually increased as cases developed, so that in a month the cases were septicemic from the start ; the bacilli now passed through the glands without stopping, and within 24 hours of the first symptoms many of the patients died. The virulence of the bacilli kept on increasing. In another month the cases were of the pneumonic type, and now patients infected others by direct passage. The dread of the disease became so terrific that the nation summoned its forces to try to stamp it out. From the first locality the plague passed out to other Manchurian towns. Among these was one where there were 6.000 workers engaged in a mine. Two thousand of the miners were Rus sians and lived in attractive little houses, well lighted and ventilated, and had good food. Four thousand were Chinese, and they lived under what to us were the most unhygienic conditions imaginable. In order to save heat in the winter the houses were built two-thirds underground and one-third above the surface. These barracks were. No. 1. 133 DIVISION OF PREVENTIVE MEDICINE. I think, 20 by 60 feet and 60 people occupied each. All the lighting was obtained through a few small skylights. Ventilation was through the door leading to the steps. In the barracks some 4 feet above the ground was a platform upon which these men ate and slept and lived. They were thus huddled together; they had no ventilation, but little light, and poor food. From the town in which the outbreak of bubonic plague already described had occurred some of the residents escaped to this town, and a number of cases sud denly broke out. The authorities made every effort to stop the out break, but 1,087 of the 4,000 Chinese died, while only 5 of the Rus sians died. The officials attempted to enforce the same health regula tions in both populations, but how could you bring about suitable conditions when confronted with the ignorance and dirtiness of such people as in those crowded hovels. Sanitary conditions were readily enforced among the others. This example is very instructive as showing that under bad conditions an outbreak is inevitable, while under good conditions an outbreak is improbable. In New York State we have a settled and intelligent population who submit to the measure put into effect by wise health authorities. What have been the results? We are conquering disease gradually and what we gain we hold. Think of tuberculosis. If you look back you will find that about 50 years ago the slightly upward trend of tuberculosis ceased and for 50 years in New York, Vermont, and Massachusetts there has been a slow and almost continuous improve ment. That began before we had any actual knowledge of the tuber cle bacillus; before we had pasturization ordinances, spitting ordi nances, etc. I have no idea that if we dropped back to the early un hygienic conditions that tuberculosis would jump immediately to the height of 50 years ago. This drop of two-thirds in the mortality, and in the severe cases, is not only because of what we are doing in lessening the exposure and in improving the resistance of the popu lation, but because there is a loss of virulence of the tuberculosis germ growing in our bodies and an increase in the average immunity. Take another disease —scarlet fever. Probably even here many do not realize that in 50 years the annual mortality has dropped from 100 in each 100,000 population down to 4 in the city of New York, and probably to the same degree in the State. With better methods of treatment and a little better isolation the number of cases has only dropped one-third so that it is fair to assume that the scarlet fever virus has lost in virulence and the community has gained in re sistance. So we have a lessening of the virulence of the scarlet fever virus and a slight increase in the resistance of the remaining popu lation. This tremendous difference between scarlet fever now and scarlet fever 50 years ago must be due not to what we are doing to day, but to the fact that the average virulence of the germs has les 134 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. sened. Even in a disease where we have specific means of cure and prevention, such as diphtheria, there is no question but that the disease would be less severe even if we had done nothing in the way of immunization, because, even before we had discovered antitoxin, before the work of von Behring and others, the rate had already begun to drop. I think many feel that deaths from pneumonia are as numerous as they were 30 or 40 years ago, but when we look at the statistics we find that pneumonia has lessened. We have now a yearly average of one-third less than we had 30 years ago, so it would seem that pneumonia germs must be lessened in virulence and that we have in creased resistance through being immunized to a considerable de gree by these carrier germs which are spread everywhere. In such diseases as typhoid fever and malaria, to combat which we pasteurize the milk and sterilize the water and drain the land, we have removed the germs of disease to such an extent that we can not attribute the lessened mortality to lessened virulence in the germs or increased immunity in man. Curiously enough in typhoid fever I do not think there is any evidence that the typhoid germ in carriers has lessened in virulence, possibly because every typhoid carrier is really a convalescent typhoid patient in whom a chronic disease of the gall bladder lias remained. One disease is an apparent exception to all that I have been say ing—influenza. You will notice that there has been an increase in the amount of influenza reported. I doubt very much if there has been a real increase. I have a very clear conviction that the term influ enza as now used simply covers a respiratory infection accompanied by certain symptoms. The infection may be due to any one of sev eral germs. It is a dignified thing to tell anyone that he has influ enza—the physician and patient are both satisfied. Many diseases are called influenza now which would not have been called that sev eral years ago. We all know that a great deal of investigation is being done on the etiology of influenza, and if we could find the germ that makes the pandemics we could then identify cases of true influenza. I wish that the brilliant work being done by Olitsky and Gates could be accepted as final, but they themselves do not claim absolute proof that B. pneumosintes is the genu. Olitsky has found a virus in a few cases, but there is no real proof yet that it is the cause of influenza, so, of course, we can not yet use it in diagnosis or to make vaccine. Because of Doctor NicolFs request I will, before closing, say a few words on the treatment and prevention of diphtheria and tetanus. When the characteristic symptoms of tetanus develop it is already a late stage of the disease, for by this time the poisons have been absorbed and the central nervous system has been at Mo. 1. 135 DIVISION OF PREVENTIVE MEDICINE. tacked; it is almost too late to do anything. Therefore we must see the importance of trying to prevent infection. Every health officer, nurse, and physician will realize that any penetrating wound should be thoroughly cleaned of all foreign material and laid open, under an anesthetic if necessary. If tetanus has developed, then we should treat the wound more actively, applying iodine, etc., to destroy the toxins that may be there. Treatment is what I wanted to speak about. If tetanus has developed, we need to get the antitoxin to the toxin at the very first moment and there should be no delay in a doubtful case to wait for the symptoms to become more clear. It is unfortunately true that some of the best surgeons wait 6, 8, or 12 hours to be sure of their diagnosis. This is almost criminal. Even if antitoxin be given at the first symptoms, it may be too late in an acute case. Should we give it intravenously or intraspinally ? Some years ago when Doctor Nicoll and I were working together, we found that the intra spinal injection would save where the intravenous would not and the intravenous would save where the subcutaneous would not. The best treatment is to give the antitoxin both intravenously and intra spinally. The dose varies according to the size of the individual and the seriousness of the case. For a first intraspinal injection, 3,000 to 5,000 units in a child of 70 pounds and the same amount intra venously will suffice. Intraspinal doses should be repeated at the end of 12 and 24 hours and a subcutaneous dose on the third and sixth day to keep the supply of antitoxin in the blood at a high level. In an adult the amounts should be doubled. A total of 50,000 units should suffice for any case. Of course when we give a preventive dose we must remember that the antitoxin disappears in the course of 12 days to 3 weeks and, therefore, if we are going to do any further operating on the wound or if the wound remains open and possibly infected beyond 12 days, we must give another dose. "When you give only one dose a good many patients develop late tetanus, but when you continue to give dose after dose7 as long as the wound remains possibly infected, you prevent the development of tetanus. The same principles apply to diphtheria as to tetanus. In a light case of diphtheria you have simply a little local toxemia, but you have no constitutional poisoning by the toxin itself. Therefore, you can give antitoxin intramuscularly or subcutaneously, because within 20 minutes a small amount of antitoxin reaches the blood and all toxin later entering it will be neutralized. Although the patient will not get well as rapidly after a subcutaneus as after an intravenous injection, he will get well, and you haven't the annoyance of the chill ■which may follow the intravenous injection. The chill is very annoy ing, but probably it does no harm. In a bad case of diphtheria and in every case of tetanus I would omit the desensitizing dose. The need is so urgent that it is better to run the slight risk than to have 136 Vol. XX. DIVISION OF PBEVENTIVE MEDICINE. the delay. We have lately been using intraperitoneal injections. These seem perfectly safe. Absorption from the peritoneum is about three times as rapid as from the muscle. Just a word about toxin-antitoxin and the Schick test. In New York City, where we have been studying active immunization for the past nine years, we have pretty generally employed the Schick test before giving the toxin-antitoxin treatment, because in New York City the majority of the children are already immune. Then again, if you do not give the Schick test either before or after the injections, you never really know whether or not the child is immune. It may interest you all to know that, partly because of having tested some 500,000 children in New York City and injected the nonimmunes, and partly because we have issued to every school child a circular about diphtheria to take home to the family, diphtheria morbidity and mortality have been lessening with really striking rapidity. The deaths during the first six months of this year are 295 less than last year and 500 less than they were four years ago. You probably would like to hear of the reason why we changed the formula of the toxin-antitoxin mixture that we were using in New York City. We first started using a preparation which had in each dose about 120 M. L. D. of toxin and to that we added 3 units of antitoxin. This we still belive to be a good mixture, and there is no reason to think that it has any less immunizing power than the new one. We found, however, that the reaction caused in some of the children was sufficient to prevent their taking the remaining injec tions and in a few instances was enough to keep them home for one of two days. These observations led us to try and lessen the reaction. We realize that we can immunize children with unaltered diphtheria toxin, but wo have to give six or seven doses to get the same effect that we get with two or three of the toxin-antitoxin. By adding the antitoxin we nearly neutralize each molecule of toxin. This prevents the toxic action of the toxin on the tissue and we can give more toxin. We began with a very large amount of toxin (120 fatal doses) because we thought that with proper neutralization it would be a little better mixture than a small amount would make, but we have found on retesting that we could get just as good an immuniz ing result with this new mixture with only four fatal doses of toxin in an injection, so we prefer it because of the lessened protein con tained. There is no radical difference between the two mixtures except there is a little more tendency on the part of the new one to deteriorate. This mixture, which is practical for distribution in New York City with a concentrated population, might not be so practical in the State. Properly made it is potent for about six months. The whole idea is to avoid the annoying protein reactions. If the new preparation is a little too toxic, it gives a reaction something like No. 1. 137 DIVISION OF PREVENTIVE MEDICINE. unmodified toxin. This is absolutely unnecessary, for the mixture can be so adjusted that it will give the same immunizing results with much less annoyance than the old mixtures. We have given over 100,000 injections of the new preparation. In closing I want to emphasize that the fact that the common com municable diseases and the microbes which cause them lessen in virulence in communities in which the people try to carry out the - directions of capable public health authorities is very encouraging to us. For, even if we can not destroy the microbes or vaccinate the people, we can hope under favorable conditions to finally conquer the endemic communicable diseases. Only when the conditions of orderly life are changed as in war or revolution or famine do the microbes regain their virulence and human beings lose for the time part of their resistance. It is only then that many of the endemic diseases increase in virulence and number and tend to become epidemic. HUMAN INTESTINAL PARASITES IN GUAM. The following report was submitted July 3, 1923, to the governor of Guam by the health officer, Lieut. Commander Edwin U. Reed, Medical Corps, United States Navy : In May, 1918, Dr. John B. Grant, of the International Health Board of the Rockefeller Foundation, conducted a survey of hook worm infestations in Guam, with the results and recommendations noted in the governor's annual report for 1918. During the last three months the assistant health officer, Lieut. A. H. Dearing, Medical Corps, United States Navy, has conducted a survey of the human intestinal parasite infestations in the island, the results of which are given below. The survey has been in ad dition to other duties at the naval hospital and as sanitary officer and, owing to the limited time and personnel available for the work, the examinations have, as a rule, been limited to one slide from each specimen submitted, so the light hookworm infestations have often undoubtedly been reported as negative. Navy and Marine personnel and Specimens examined. Round. Whip. Hook. Uninfested. their families: In Guam over 6 months— Per cent. Per cent. Per cent. Per cent. Per cent. Adults 182 7. 1 3.3 5.0 87.3 Children 29 68.9 31.0 20.6 24.1 In Guam less than 6 months — 64 0 0 0 100.0 6 0 0 0 100,0 281 12.0 5.3 5.3 83.4 69826—23 10 138 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. The much greater incidence among children is attributed to greater opportunities for contamination by polluted soil and closer contact with native servants ; practically all of whom harbor intestinal para sites. Families and servants should go to the hospital or the sick bay at Sumay every six months or oftener, when indicated, for ex amination and for treatment when needed. Native population: (a) Villages— Agat Aean Piti Dededo Sumay. . . . Merizo Jona I nam j an . . Umatac Approxi mate population.! 757 :S4<; .581 175 665 668 439 698 346 Specimens obtained. Round. no 135 169 92 61 179 66 288 109 Per cent. 98.7 96. 3 97. 6 100.0 88.5 91.0 97.8 96. 1 88.0 Whip. Per cent. 61.2 71. 1 79.8 66. 3 68.8 68. 1 72.7 57. 6 66.8 Hook. Percent. 29.0 34.0 36.0 32.3 14. 7 46.9 25. 7 22.2 49.5 Uninfested. Percent. '8.60 6.30 0.55 1.50 1.00 Total. 4,725 1,215 93. 8 67.0 31.2 1.5 (6) Agana districts—] Santa Cruz . . . Julale Bilibic. . San Ramon San Antonio.. . San Nicolas . . . Togao and San Ignacio Total 9,500 (c) Total na tive popu lation 14,175 114 131 116 138 138 105 95.6 100.0 93.9 99.2 97.8 98.0 742 97.5 1,957 95.2 71.9 7G.3 85.3 79.7 78.9 75.2 13.1 16.0 25.0 15.1 17.3 17.1 78.1 17.2 71.2 25.9 0. 9C Round and whip worm percentages were slightly higher in native children than in adults, while hookworm infestations ranged from 19.7 per cent for under 7 years to 27.9 per cent for over 30 years. Several round worms were recently found at autopsy in the intes tines of a native boy 26 days old. Very little variation as to incidence was found between the sexes. In addition to the round worms (Ascaris lumbricoides) , whip worms (Trichuris triehiura), and hookworms (Nccator americanus) , Strong?/ loides stercoralis embryos and Oxyuris vermicularis (pin worm) ova have been frequently observed. Two cases of amoebic dysentery have also been treated at the naval hospital during this period. Soon after the American occupation of Porto Rico efforts were inaugurated to combat the ravages of the hookworm there. In 1904 an anemia commission was appointed, and from that time to 1920, No. 1. 139 DIVISION OF PREVENTIVE MEDICINE. $357,000 had been appropriated for the control of hookworm disease. In spite of the great amount of work that has been done, surveys show that this parasite is still widely spread and present in large numbers. A recent survey by Doctor Grant found the incidence to be from 90 to 100 per cent in a number of localities and records an average of 80.8 per cent for the entire island. In Antigua, British West Indies, surveys and a treatment cam paign have been conducted under the auspices of the International Health Board of the Rockefeller Foundation. During the original campaign of 1915-1917, 7,477 persons were examined in an area ■which has since been resurveyed. Of this number, 2,229 (29.S per cent) were found infested with the hookworms. Of these. 1,972 ■were cured, so far as this could be determined, by giving thymol until no hookworm ova could be found in the stools. When the treatment campaign was practically finished, the authorities of Antigua built pit latrines throughout the area and appointed part- time sanitary inspectors to see that they were properly maintained. During the resurvey in 1922, 1,234 (62.6 per cent) of the 1,972 per sons cured in 1915-1917 were reexamined for hookworm ova and 262 (21.2 per cent) were again found to be infested. A group of 300 persons who were free of hookworms in 1915-1917 were also examined and 16.3 per cent were found to be infested. In general, the persons who were treated and cured in 1915-1917 did not, in 1922, show a markedly decreased incidence of intestinal parasites other than hookworm, as compared with persons who were not treated in 1915r4917. It should also be remembered that dogs, pigs, and perhaps other animals may also cam- and disseminate intestinal parasites patho genic for man. By use of carbon tetrachloride it is believed that the number of persons infested, and especially the severity of the infestations, can be materially reduced; but in view of the above experiences and many others in this field of medicine, it is not believed that human infes tations can be eradicated from Guam. Fully as important as the use of carbon tetrachloride in this en deavor is the use of sanitary latrines and privies, and enforcement of Executive General Orders 194, 251, 261, and 298 is therefore necessary. It is planned to spend two or three months in educational propa ganda, thorough sanitary inspections, and in experimentation at the naval hospital with carbon tetrachloride and oil of chenopodium to determine which or what combination of the two will be most effective for mass treatments of the native population. It is believed j 140 DIVISION OF PREVENTIVE AIEDICINE. Vol. XX. 1 by the medical officers now here that much more disability in Guam is due to round worm than to hookworm infestations. When a sufficient supply of carbon tetrachloride lias been received, it is planned to give, under medical supervision, treatments to the inhabitants of one village or district at a time until all in the island have had an opportunity to take such treatments. In view of the facts that only relative results are expected and that the treat ments are not entirely devoid of danger, it is not believed that the treatments should be made compulsory, but that all persons should be reached by the educational campaign and be advised and given opportunity to take the treatment. This campaign should be repeated yearly. PREVENTION OF VENEREAL DISEASE IN ENGLAND. In considering ways and means of attacking the venereal -disease problem in England it appears in the main that two contra-minded factions or opinionated groups recently came into existence. Heated controversy arose principally over the question of medical prophy laxis, or, as the English prefer to designate it, skilled or unskilled disinfection, according to whether disinfection is self-applied or ad ministered by a trained person. Associated moral and ethical con siderations in particular apparently furnished subject matter for acrimonious debate from which, according to the British Medical Journal, the great body of the medical profession held aloof. Finally a committee of inquiry on venereal disease was appointed, witli Lord Trevethin chairman. The report of that committee has recently been published by the ministry of health. The World's Health, a monthly review pub lished by the League of Red Cross Societies, summarized the report and commented editorially upon it in the August number, as follows: " Readers of the International Journal of Public Health will re member the diverse points of view held by distinguished specialists in England on the subject of self-disinfection. This controversy may now be said to have been submitted to a judicial decision—the report recently made public by the ministry of health of the com mittee of inquiry on venereal disease. " The committee point out that medical measures are not alone likely to be effective. The extension of knowledge as to the nature of venereal disease and its consequences is of the greatest importance. The following list of facts which should be made widely known are quoted from their report : " '(«) Thai promiscuous intercourse is the main cause of the prev alence of venereal disease. Xo. 1. 141 DIVISION OF PREVENTIVE MEDICINE. "'(&) Tliat there is no absolute preventive except continence, and u single exposure may result in infection. " '(c) That a large number of the sufferers from venereal disease are innocent persons, especially women and children. '"(d) That syphilis is a disease of great gravity which, if not treated in its early stages, may have serious results, including af fections of the circulatory system and of the nervous system, as, for example, general paralysis of the insane. "'(e) That syphilis is transmissible by a mother to her children, and is a frequent cause of miscarriages, stillbirths, and death in early infancy, and in children who survive, of mutilating deformities, mental disease, and other defects. "'(/) That gonorrhea is a more serious disease than is commonly believed, and, if not promptly treated, may have serious after con sequences. Ui(ff) That gonorrhea is a frequent cause of sterility and serious pelvic disease in women and a cause of blindness in children born, of women suffering from gonorrhea. '"(A) That the presence of these diseases in the community is a menace to the maintenance and advancement of the physical and in tellectual standard of the race.' "As regards strictly medical measures of prophylaxis they con clude that properly and promptly applied disinfection in the case of an individual man would almost certainly prove effectual, but that so far as the community at large is concerned, no sufficient case has been made to justify the introduction at the public expense of a gen eral system of facilities either for self-disinfection or skilled disin fection, and wherever there is a limited amount of public money available, they have no doubt that money spent on (a) treatment of disease; (6) continuous education of the community in regard to the nature and dangers of venereal disease and the importance of seeking prompt and skilled treatment; and (c) the elimination of those conditions of life which tend to foster promiscuous intercourse and the spread of disease will be money better spent than any money expended on establishing a general system for affording facilities for disinfection." The British Medical Journal, July 21, 1923, reports as quoted be low, the action of the Society for the Prevention of Venereal Disease at its fourth annual meeting in adopting a resolution expressing agreement with and approval of the Trevethin report. The resolu tion is of interest in that it treats of the value of self-disinfection and records the favorable attitude of the society toward that pre ventive measure: " Lord Willoughby De Broke, the president, gave an address point ing out that the Trevethin report amounted to a complete vindica 142 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. tion and indorsement of the society's policy, and proposed the fol lowing resolution: " ' That the Society for the Prevention of Venereal Disease accept the Trevethin report as a document supporting the six essentials of the policy of the society, namely, that : " ' 1. A man who after exposure is properly and thoroughly dis infected by disinfectants of appropriate nature and strength, runs little risk of infection. " ' 2. An intelligent man, if furnished with reasonable instruc tions, can, in favorable conditions, effectively disinfect himself. " ' 3. The adoption of skilled disinfection (in disinfecting centers) is not to be recommended as part of any general system, for reasons of time, cost, and impracticability. " ' 4. The instruction by medical officers of venereal disease clinics of male persons attending such clinics, in the preventive use of dis infectants, offers a useful means of educating the community. " ' 5. There is no evidence of facts in support of the view that any system of disinfection would tend to increase the number of exposures and raise the disease rate. " ' 6. The law should be altered so as to permit properly qualified chemists to sell ad hoc disinfectants provided such disinfectants are sold in a form approved and with instructions for use approved by some competent authority. " ' And also in view of the unqualified acceptance of the Trevethin report by the National Council for Combating Venereal Diseases, that the Society for the Prevention of Venereal Disease is prepared to form a joint committee with the National Council for Combating Venereal Diseases under the chairmanship of Lord Dawson of Penn, to watch and further the policy based on the terms of the Trevethin report.' " Dr. J. H. Sequeira, in seconding the resolution, said that as one who had served on the Trevethin committee he had been struck by the unanimity of the evidence in favor of immediate self-disin fection, which had greatly impressed the committee as a whole. Lady Askwith, chairman of the women's committee, in supporting the resolution said that she looked upon that day as the greatest in the society's existence, and considered that the Trevethin report offered great hopes that at last something would be done for the protection of the health of women and children. Mr. Basil Peto, M. P., urged that immediate steps be taken so as to insure that the necessary bill to amend the venereal diseases act, 1917, should be presented in the autumn session. Mr. Frank Souter said he had just returned from a visit to the Far East, where branches of the society had been established, with the result that venereal disease had been greatly reduced, to the immense benefit of local production and trade. " The resolution was carried unanimously." No. 1. 143 DIVISION" OF PREVENTIVE MEDICINE. HEALTH OF THE NAVY. November morbidity reports reveal an 18 per cent increase in the incidence of the common respiratory diseases over the figures for October. Admission rates were 37.37 per 1,000 per annum for acute bronchitis and 37.98 for acute tonsilities. However, these figures are not especially high for the month of November. Certain other classes of disease which, according to the vital statistics of previous years •do not vary in close correlation with the seasons, also increased during November. These were venereal diseases, diseases of the digestive system, and certain classes of noninfectious diseases. Influenza admissions increased in number only by 15 per cent for the entire Navy. The admission rate was 15.05, as compared with 13.03 per 1,000 per annum, the five-jear median rate for November. Comparatively few cases of pneumonia occurred. Only 19 were Teported, making the admission rate 1.9, which is 45 per cent less than the five-year median rate for November. Two of the cases occurred at naval training stations and two were reported from the United States Fleet. The remainder were scattered among all other forces. Admissions for mumps also declined in numbers. The cases that were reported occurred mostly in the Battle Fleet and Scouting Fleet. No case occurred among forces ashore in the United States either in October or November. That is very unusual. Scarlet fever has not been prevalent. Four sporadic cases occurred at the naval training station, Hampton Roads, Va., and two at the Great Lakes station. Dengue continued more or less prevalent in Haiti and Santo Domingo. There were 62 cases among approximately 4,000 marines, as compared with 80 in October. Admissions for malaria decreased somewhat in November. Fewer cases occurred throughout the summer and autumn this year than in any recent year. From the entire service there were reported 159 cases in August, 93 in September, 74 in October, and 63 in November. The admission rate for venereal diseases, entire service, increased from 99.25 to 132.26 per 1,000 per annum. From the statistical evi dence more effective employment of prophylaxis appears to be indicated. Admissions for injuries also increased during November, making an admission rate of 76.77 per 1,000 per annum for injuries and poisoning, which is higher than the rate for several months. The three-year median rate for the corresponding month is 59.4. The following table contains the rates per 1,000 per annum for the principal communicable diseases. November, 1923. For com 144 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. pari son, corresponding median rates are given for the same month, years 1918 to 1922, inclusive: November, 191S-1922. November, Cerebrospinal fever Diphtheria- German measles— Influenza Malaria.- Measles Mumps.. Pneumonia Scarlet fever Smallpox Tuberculosis Tvphoid fever 0.13 0 .74 0.10 .42 .41 13.03 15.48 9.40 6.41 3.00 4.79 13.52 11 .51 3.47 1.94 .47 1.83 0 0 3.74 2.14 .10 0 VITAL STATISTICS. Tlie Monthly Health Index, which is published on the 15th of each month, contains the statistical data for individual ships and shore stations. The statistics appearing in this Bulletin are sum maries compiled from those published in the Monthly Health Index. Annual rates, shown in the succeeding statistical table, are ob tained as follows: The total number of admissions to the sick list or the number of deaths reported during the period indicated is multiplied by or or 12, depending upon whether the period includes four or five weeks or a calendar month. The product, is then multiplied by 1,000 and divided by the average complement. Table No. 1.— Monthly report of morbidity in United States Navy and Marine Corps for the month of November, 1923. Forces afloat. Forces ashore. Entire Navy. Marine Corps. 75,040 42,805 117,845 21,160 2,640 422.1fi 2.824 791.6S 5,464 LOOT 667.80 556.34 2,226 355.96 2,484 696.36 4,710 479.57 951 584.24 288 46.06 262 73.44 ,150 .56.00 142 87.24 741 118.97 418 117.IS 1,162 118.31 256 157.27 414 340 754 76.77 136 86. 20 95.32 83.55 AvernKe strenfrth All causes: Number o( admissions Annual rate per 1,000 Disease only: Number of admissions Annual rate per 1,000 Communicable diseases, exclusive of venereal disease: Numlxr of admissions Annual rate per 1,000 Venereal disease: Number of admissions Annual rate per 1,000 I njuries and poisons: Number of admissions Annual rate per 1,000 No. 1. 145 DIVISION OF PREVENTIVE MEDICINE. Table No. 2.—Number of admissions reported by Form F cards for certain diseases for the month of November, 1923. Diseases Injuries ami poisons Total admissions Class III: Appendicitis, acute Autointoxication, intestinal. Cholangitis, acute Cholecystitis, acute Colitis, acute Constipation Enteritis, acute Gastritis, acute catarrhal Gastroenteritis Hemorrhoids Pharyngitis, acute Ulcer of duodenum Ulcer ot mouth Ulcer of stomach Class VII: Varicocele . . Class VIII: Chicken pox. Diphtheria.. German met! Influenza Measles Mumps Pneumonia, broncho. Pneumonia, lobar Total.... Class IX: Dysentery, Dvsentery. ent Typhoid (ever Total Class X: Dengue Malaria Total Class XI: Tuberculosis (all forms) . Class XII: Chancroid Gonococcus Infection Syphilis Laryngitis, acute Pleurisy, acute fibrinous. . , Rhinitis, acute Tonsillitis, acute follicular.. Total XX: Forces afloat, Navy Forces ashore. Navy '1',1.1 /ntmn»4V. and Marine Corps and Marine Corps i ocai (strengtn, 117,845). (strength, 75,040). (strength, 42,805). Number Annual Number Annual Number Annual of ad rate per of ad rate per of ad rate per missions. 1.000. missions. 1,000. missions. 1,000. 2,226 355.96 2,484 696.36 4, 710 479.57 414 66.20 340 95. 32 754 76.77 2,640 422. 16 2,824 791.68 5,464 .V*. 34 26 4. 16 42 11.77 68 6.92 12 1.92 11 3.08 23 2.34 14 2.24 10 2.80 24 2.44 3 .48 3 .84 6 .61 4 .64 1 .28 5 .51 17 2.72 17 4.77 34 3.46 8 1.28 51 14.30 59 6.01 3 .48 10 2.80 13 1.32 29 4.64 37 10.37 66 6. 72 IS 2.88 24 6.73 42 4.28 7 1.12 37 10.37 44 4.4S 1 .16 2 .56 3 .31 1 .16 0 .00 1 .10 0 .00 2 .56 2 .20 143 22.87 217 69.24 390 39.71 9 1.44 7 1.96 16 1.63 5 .80 2 .56 7 .71 0 .00 1 .28 1 .10 3 .48 1 .28 4 .41 108 17.27 44 12.33 152 15.48 8 1.28 39 10.93 47 4.79 10S 16.79 8 2.24 113 11.51 2 .32 2 .56 4 .41 <i .96 9 2.52 15 1.53 1 .16 17 4.77 18 1.83 238 38.06 123 34.48 361 36. 76 0 .00 5 1.40 5 .51 4 .64 2 .56 6 .61 0 .00 1 .28 1 .10 4 .64 8 2.24 12 1.22 31 4.96 62 17.38 93 9.47 8 1.28 55 15.42 63 6.41 30 6.24 117 32.80 150 15.88 7 1.12 14 3.92 21 2.14 182 29. 10 111 31.12 293 29.83 191 78.52 249 69.80 740 75.35 71 11.35 58 16.26 129 13. 13 744 118.97 418 117.18 1.162 118.31 142 22.71 225 63.08 367 37.37 6 .96 10 2.80 16 1.63 9 1.44 4 1.12 13 1.32 12 1.92 8 2.24 20 2.04 19S 31.66 175 49.06 373 37.98 367 58.69 422 118.30 789 80.34 21 3.36 22 6.17 43 4. 38 146 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. Table No. 3.—Summary of annual admission rates for venereal disease reported from ships for October and from various shore stations for the four- week period November 4 to December 1, 1023. Annual rate per 1,000, October. Average rnte since July 1, 1923. Mini mum rate. Mean rate. Maxi mum rate. Mini mum Mean rate. Maii- iuunl- rate rate. All ships 0 135.18 875.54 0 147.36 585.37 Battleship divisions: 38.08 0.27 95. :.9 97.71 SIX 81 204.78 74.40 101.35 109.76 147.17 181.86 205.29 Destroyer squadrons: 0) 0 0 54.31 274.18 214.90 875.54 0 0 75.38 202.73 278.35 557.23 Miscellaneous: ' 0) 0 0 72.70 115.08 soo.kw 0 0 104.07 125.28 287.42 395.60 Scouting Fleet 526.31 Asiatic Fleet (•) 0 229.40 319.10 173.24 344.05 298.96 505.26 606.06 537.31 853.08 554.62 0 213.31 221.36 164.89 127.21 238.61 356.43 306.41 Special service squadron, based on Panama . lf.9. 01 0 0 0 67.23 98.36 318.25 585.37 571.75 0 0 Annual rate per 1.000, Nov. 4 to Pec. 1. 1923. Average rate since July 1, 1923. All naval districts in the United States 0 0 0 61.10 36.84 49.79 76.58 53.17 46.33 0 393.94 393.94 132.27 121.01 66.70 163.87 0 0 65.89 52.96 71.63 101.99 62.61 56.17 0 220.94 210.39 115.38 59.39 78.53 220.94 0 First naval district 21.IS 0 28.08 13.85 22.27 0 35.43 0 0 43.03 0 Ninth naval district 92. f.2 23.81 72.3ti 83.33 58.69 92.62 48.22 133.51 92.36 67.97 92.62 58.82 218.91 102.36 16.38 101.11 22.52 39.32 48.12 48.13 101.11 35.47 92.92 91.83 56.67 101.11 Twelfth naval district 88.29 173.01 156.01 No. 1. 147 DIVISION OF PREVENTIVE MEDICINE. Table No. 3. —Summary of annual admission rates for venereal disease re ported from ships for October and from various shore stations for the four- week period November } to December 1, 19S3 —Continued. RATIO OF GONOCOCCUS AND SYPHILIS INFECTIONS TO TOTAL CASES OF VENEREAL DISEASE. Per cent, October. Percent since July 1,1923. Gono- coccus. Syphilis. Gono- Syphilis. coccus. All ships Battleship divisions: 68.61 8.09 69.20 8.26 82.54 77.97 11.11 8.47 86.85 71.43 8.48 6.70 Destroyer squadrons: (■) 84.00 71.28 8.00 2.13 90.44 61.03 5.15 5.03 Miscellaneous: * (') 83.87 54.54 9.68 14.54 88.03 63.72 5.63 14.42 48.27 45.45 55.00 70.73 69.44 8.62 15.15 5.00 0 61.06 53.00 63.25 68.13 63.72 6.64 6.00 5.12 5.49 8.85 Miscellaneous and district vessels 8.33 Percent Nov. 4, to Dec. 1, 1923. Percent since July 1, 1923. All naval districts In the inited States First naval district 81.08 83.34 88.89 50.00 76.09 70.00 0 9.46 8.33 0 79.01 81.82 73.13 74.58 74.22 70.91 0 9.57 15.15 11.94 12.50 10.86 10.00 10.17 10.55 7.27 0 0 100.00 92.86 92.31 78.95 0 85.00 ' 85.39 85.11 84.51 97.50 0 7.14 7.87 8.51 7.04 2.50 Twelfth naval district 100.00 7.69 21.05 0 1Report contained in Monthly Health Index for Jan. 15, 1924. ' Vessels of train, base, air squadrons, etc. 148 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. Table No. 4. — Summary of admissions reported b\i Form F cards and annual rates per 1,000, entire Navy, for the four-week period November 4 to Decem ber 1, 1923, inclusive. Navv (strength, Marine Corps Total (strength, 96,685). (strength, 21,160). 117,845). Number Annual Number Annual Number Artnu3i of admis rate per of admis rate per of admis rate per sions. 1,000. sions. 1,000. sions. 1.000. n 0 n 0 0 0 Diseases of circulatory system 21 2.82 8 4.91 29 3 20 Diseases of digestive system 43S 58. 89 165 101.37 603 66.52 Diseases of ductless glands and spleen 1 .13 1 .61 2 .22 Hi 8.20 19 11.67 SO 8.82 Diseases of genito-urinary system (non- f)0 8. 07 11 6.76 71 7.83 Communicablc discuses transmissible by 90 12.1Q 19 11.67 109 12.02 oral and nasal discharges 29.') 39.66 50 30.72 345 38. OS Communicable diseases transmissible by intestinal discharges 6 .81 7 4.30 13 1.43 Communicable diseases transmissible by 61 8.20 82 50.38 143 15.77 Tuberculosis full forms) 10 2.15 3 1.84 19 2.10 Venereal diseases 943 12(1.79 256 157.27 1,199 132.26 Other diseases of infective tvpe 219 2(1.44 60 36.86 279 30.78 39 5.24 19 11.67 58 6.40 Diseases of mind 20 2.69 9 5.53 29 3.20 Diseases of motor system 56 7.53 15 9.23 71 7.83 Diseases of nervous syst em 26 3.50 7 4.30 33 3.64 Diseases of re.spinttorv system 797 107.16 151 92. 77 948 104.57 Diseases of skin, hair, and nails 75 10.OS 15.97 101 11.14 Hernia 30 4.03 4.30 37 4.08 Miscellaneous disposes and conditions 247 33.21 23 14.13 270 29.78 Parasites (fungi and certain animal paru- 109 14.66 13 7.99 122 13.46 Ttunors X. 11 1.48 ii 0.(10 11 1.21 554 74.49 120 73.72 674 74.35 lti 2.1.5 lfi 9.83 32 3.53 4,191 563.48 1,087 667.80 5,278 582. 22 _ _ _ — _ . _ Table No. 5. —heaths reported, entire Nary, for the four-week period November lt to December 1. 1928, inclusive. Cause. Nary (strength 96,685). Influenza Pneumonia: Broncho Lobar Tuberculosis, chronic pulmonary Malignant growths Other diseases Drowning Other accidents and injuries Poisons Total Annual death rate per 1,000, all causes. .. Annual death rate per 1,000. disease only 31 ■1IT 1 IS Marine Corps (strength. 21,160). o r5 FEB 1 5 1924 VOL XX NO. 2 UNITED STATES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PLANNING AND PUBLICATIONS CAPTAIN D. N. CARPENTER, MEDICAL CORPS, U. S. NAVY IN CHARGE EDITED BY LIEUTENANT COMMANDER W. M. KERR, MEDICAL CORPS, U. S. NAVY FEBRUARY, 1924 (MONTHLY) Compiled and published under authority of Naval Appropriation Act for 1924 approved January 23, 1923 WASHINGTON GOVERNMENT PRINTING OFFICE 1924 TABLE OF CONTENTS. PREFACE------- -- - - - - -- --- - - -- - --- - - -- - -- - ---- ------------ - - -- - soTICE TO SERVICE CONTRillUTORS --- -- -- -- -- - - --- -- - - -- - PECIAL ARTICLE : DETECTION OF THE PSYCHOPATH AND CLASSIFICATION OF NAVAL RE- CRUITS IN ACCORDANCE WITH THEIR INTELLIGENCE. By Lieut. A. W. Stearn, Medical Corps, United States Navy __ I!IISULL.'- TREATMENT OF DIABETES .MELLITUS. By Lieut. Commander W. D. Owens, :\1edical Corps, United States Navy _________________ -.-- ______________________ _ XoVOCAINE A:SESTBESIA. By Lieut. Commander G. F. Cottle, Medical Corps, United States l\avy __________________________________________ _ Ou ERYATIONS CoNCERNING YAws DI HAITI. By Lieut. P. W. Wilson, Medical Corps, United States Navy __ _ RELATION OF THE CLDIICAL LABORATORY TO THE MODERN HOSPITAL. By Lieut. H. S. Sumerlin, Medical Corps, United States Navy __ GA l\.fasK FOR HEAD AND CHEST INJURY CASES. Page. V VI 149 170 1 4 190 196 By Lieut. F. F. Lane, Medical Corps, United States Navy_____ 200 CLIXICAL ~ OTES: IllPROVED TECHNIC IN SPINAL PUNCTURE. By Lieut. Commander T. W. Raison, Medical Corps, United 'tate Navy___________________________________________ 205 TRA UllfATIC liEMATOMA OF SPERMATIC CORD. By Lieut. L. H. Williams, Medical Corps, United States Navy__ 206 CYSTOSCOPY A'.IID REPORT OF THREE UNUSUAL CASES. By Lieut. L. B. Marshall, :\1edical Corps, United States Navy__ 207 XOTE ' A~D COMMENTS: Value of p ychometric tests in the Navy-Need of physiotherapy- Two physicians of Tortola-The all-purpose canister gas mask- Etiology of gout-Bulletin of the National Board of Medical Exam- iner·-Practical objectives in health work-Alcohol taxation and alcoholism in Denmark-Revision of the pharmacopreia-Phlebot- omy in the monasteries-New method of treating syphilis-Oper- ating-room lighting_____ ______ ____ ____ __ ___ ____ __ ___ __ ___ ____ 213 X"GR E CORPS: .1. 'ur ing in the Philippine Islands-Cooperation with all departments_ 231 BOOK ~ ·oncES ___ --- --- ____ __ -- __ -- _ --- _ --- __ -- __ -- __ -- _ --- _ _ _ 235 PREVE~-TIVE :\1EDICINE, STATISTICS: ERADIC.-\T[ON OF VERMIN ON BOARD SHIP_______________________ 247 UPPLE:UENTARY REPORT: REVIEW OF LITERATURE RELATING TO PROPHYLAXIS OF MEASLES. By Dr. T. W. Kemmerer, United States Public Health Service__ 268 SWIMMING PooLS IN DETROIT---EPIDEI\UOLOGICAL CONSIDERATIONS__ 271 ADOPTION OF NEW HOUSING ORDINANCE BY THE CITY OF SAN DIEGO, CALIF_________________________________________ ____________ 274 MEDICAL DEPARTMENT ACTIVITIES AT NAVAL TRAINING STATIONS__ 275 Ill PREFACE. The United States Natal Medical Bulletin was first issued in April, 1907, as a means of supplying medical officers of the United States Navy with information regarding the advances which are continually being made in the medical sciences, and as a medium for the publication of accounts of special researches, observations, or experiences of individual medical officers. It is the aim of the Bureau of Medicine and Surgery to furnish in each issue special articles relating to naval medicine, descriptions of suggested devices, clinical notes on interesting cases, editorial com ment on current medical literature of special professional interest to the naval medical officer, reports from various sources, historical essays, notes and comments on topics of medical interest, and reviews or notices of the latest published medical books. The bureau extends an invitation to all medical officers to prepare and forward, with a view to publication, contributions on subjects of interest to naval medical officers. In order that each service contributor may receive due credit for his efforts in preparing matter for the Bulletin of distinct origi nality and special merit, the Surgeon General of the Navy will send a letter of commendation to authors of papers of outstanding merit and will recommend that copies of such letters be made a part of the official records of the officers concerned. The bureau does not necessarily undertake to indorse all views or opinions which may be expressed in the pages of this publication. E. R. Stitt, Surgeon General United States Navy. v NOTICE TO SERVICE CONTRIBUTORS. When contributions are typewritten, double spacing and wide margins are desirable. Fasteners which can not be removed without tearing the paper are an abomination. 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Contributions must be received two months prior to the date of the issue for which they are intended. The editor is not responsible for the safe return of manuscripts and pictures. All materials supplied for illustrations, if not original, should be accompanied by a reference to the source and a statement as to whether or not reproduction has been authorized. Only the names of actual reviewers for a current number appear. The Bulletin intends to print only original articles, translations, in whole or in part, reviews, and reports and notices of Government or departmental activities, official announcements, etc. All original contributions are accepted on the assump tion that they have not appeared previously and are not to be reprinted elsewhere without an understanding to that effect. U. S. NAVAL MEDICAL BULLETIN Vol. XX. 1 FEBRUARY, 1924. No. 2. SPECIAL ARTICLES. THE DETECTION OF THE PSYCHOPATH AND THE CLASSIFICATION OF NAVAI RECRUITS IN ACCORDANCE WITH THEIR INTELLIGENCE. By A. W. STKAKN8, Lieutenant, Medical Corps, United States Naval Reserve Force. The writer of this paper has been asked frequently to describe certain methods, developed by him during the late war, for the detection of the psychopath and the classification of naval recruits in accordance with their intelligence. These inquiries have come from naval medical officers and from physicians interested in indus trial establishments; therefore it has seemed wise to prepare a short description of these methods and to discuss their advantages to the naval service. During the war large numbers of young men representing all degrees of ability, education, and training entered the Navy. The number who sought service was so large that no method of estimating the worth of the individual seemed possible, yet it was highly desirable that some sort of classification be made in order that each man might as far as possible be used to the best advantage by the Govern ment. The first rough grouping was made at the recruiting offices, but there the work had to be done quickly and imperfectly, and so an accurate classification at the training stations became important. The writer was detailed at one of the large naval training stations as psychiatrist for the purpose of detecting those recruits who by reason of mental defect or instability were not qualified for the naval service. In order to detect defectives, a brief life history of each recruit was obtained upon his arrival at the station and recorded on a card which will be described later. These history cards were filed, the careers of doubtful individuals followed, and special study was made of those who failed to adjust themselves to naval life. A small percentage of mentally unfit was found. In general, lack of success by psychopathic individuals seems to be due to one of three factors: (1) Inability to learn, (2) disciplinary troubles, (3) sickness. In the course of this history taking a mass of information was accumulated concerning the entire personnel. Gradually, and at first informally, different departments began to make use of this information. The public-works officer, always on the lookout for artisans, began to consult the history files. The executive officer, seeking college men as possible material for the commissioned officers' school, found the same cards useful, and instructors in the various 149 150 Vol. XX, STEARNS —INTELLIGENCE TESTS. schools frequently referred to them in connection with their prob lems. This demand grew to such an extent that it seemed advisable to devise a scheme by which the whole mass of military raw material might be classified and indexed. In starting such a classification, it was somewhat difficult to know where to begin and where to stop. The first question to be answered was, What facts concerning a man .are of fundamental importance to the Navy 1 With simplicity as well as utility in mind four things were chosen as of primary importance. First. Physical condition, including health in general. —This needs no discussion here, as the Bureau of Navigation does not recognize graded service and so it is presumed that every man accepted is physically fit for general service; those not so found are supposedly eliminated as soon as detected. From the experience of several thousand physical examinations it appeared to the writer that some improvement could be made in tins field if a history were taken and if more emphasis were placed upon function and less upon anatomical findings. Second. Mental condition, including capacity as well as health. — Here, again, all accepted were supposed to be free from mental disease or defect This, however, was not the fact. Some examining physicians advocated accepting feeble-minded and psychoneurotic patients; others made no attempt to detect them. Any one advo cating the use of mentally handicapped patients for military purposes can not be familiar with such cases and from the writer's experience every attempt should be made to exclude them. Therefore the first step aiming toward classification must be the detection of the mentally unfit. Having eliminated the unfit, those accepted would range in mental capacity from dull, through normal to the most brilliant. The Navy in time of war can use men of all degrees of intelligence above the feeble-minded, but it is obviously wise to use them for different work. Rather dull men can be used for general detail and in the fireroom. Brighter ones are needed to enter the various schools and the brightest would naturally be officer material. If time enough were available, each man would probably find his level, but the "trial and failure" method is neither efficient nor economical, providing some other can be devised. Recommenda tions of company commanders vary in reliability as they are depend ent upon a fallible personal opinion and oftentimes upon meager information. Educational qualifications are not enough. It is probable that psychological tests, imperfect though they may be, offer the best method of forming a general estimate of a man's capacity. Third. Formal education. —Though the amount of formal educa tion received is not a fair index of a man's possibilities, it does help toward forming an estimate of his worth. College men have had No. 2. 151 STEARNS —INTEUUGENCE TESTS. certain special studies making them more available for intensive training as officers and, though no illiterates are received in the Navy, those with a meagre education are hardly able to do the work required by the schools. Fourth. Industrial training. —The rapidity with which the Navy expanded during the war made it essential that any special skill acquired prior to enlistment be known and utilized. If all recruits entering the service were classified in accordance with their ability, men possessing special skill could be located easily. It is of great value in estimating a man's capacity to know the degree of his indus trial success. These four things, then, seemed of enough importance to warrant their accurate determination in the case of each recruit. Each ship or station by having men so classified could use its man power to better advantage. Properly indexed, this information would become readily accessible, and when a man's subsequent record is at hand it may truly be said that a beginning has been made in the "measure of a man." THE DETECTION OF THE UNFIT. The function of a physician in a military establishment is some what different from that in civil life. In the latter we are accustomed to think of his work as humanitarian, while in the former the first reason for his presence is to help maintain the efficiency of a fighting machine, and the results of his humanitarian efforts, however great they may be, are a by-product of his total activity. Fortunately these two functions usually coincide. Roughly speaking, his work may be divided into three phases which interlace but are somewhat distinct : (1) Selection and preparation of recruits. (2) Maintenance of health of personnel. (3) Repair of casualties incident to service. Obviously, barring contagious diseases and wounds, the extent of the second problem is dependent on the thoroughness of the first and that of the third upon the second, and so when a recruit is selected the law of probabilities is used; that is, the problem involves the determination of which persons, if accepted, will be most likely to be healthy and fit when actually needed for military operations. In civil life an individual with a handicap can regulate his work to counterbalance the ill effect of such a handicap; in military service this is not possible, so the question to settle is, Which individual will be most likely to be continuously fit so that he may be available at any moment when required? This is quite a complicated problem compared, for instance, with examination for life insurance, which has to consider length of life alone. In the naval service not only the likelihood of disability and the degree of such disability, but the 157 Vol. XX, STEAKNS —INTELLIGENCE TESTS. amount of effort necessary to care for the individual while disabled and the chance of his restoration to duty must be considered. I think it can be shown that nervous or mental disease in an individual is more apt to result in disability, that the disability is greater and presents more difficulty in care with less chance of cure than almost any other class of disease. Furthermore, in many cases these condi tions are due to a congenital, incurable defect. In others when a cure is brought about, a recurrence is to be expected. It is not possible to show the full extent of the psychiatric problem in the naval service by statistics, because the most numerous class of cases does not come to the attention of the medical department, but re mains at present a problem of training and discipline. This, of course, is the feeble-minded group. Many studies, both in and out of the naval service, have shown the sameness of individuals who are classed as inapt, undesirable, intractable, incorrigible and defective. Again, the next group in size and importance, and in case of large military operations, if one may judge from the figures of European armies, perhaps the largest and most important group is the psy choneurotic group. Statistics also fail to show the importance of this group in the service for two reasons : First, they are often ambula tory patients and so not recorded ; and, next, when admitted they are often classified under some prominent symptom, such as headache, tachycardia, insomnia, etc. Nevertheless, statistics show the prob lem to be a large and constant one. The relative damage by different groups is shown by the following table, being an average of a four-year period, 1913, 1914, 1915, and 1916, as taken from the reports of the Surgeon General: Table 1 —Four-year average: 1913, 1914, 1915, 1916. Class. Division. Damage. 8 8 20 3 14 12 11 7 13 5 2 6 17 16 15 18 10 21 10 4 1 Infective type (nonvenereal) Infective type (venereal) Wounds and other injuries Digestive system Respiratory system Motor system Mind Genito-urinary system (nonvenereal) 606.72 479.14 322.35 258.62 156.87 151.75 115.45 112.64 111.34 89.99 87.98 76.91 74.53 58.83 39.59 31.59 29.22 19.11 13.13 9.76 2.92 Circulatory system . Eye and adnexa Miscellaneous diseases and conditions Hernia; Skin, hair, and nails Parasites Lymphatic system Poisons NO. 2. 153 STEARNS —INTELLIGENCE TESTS. Table 2. ' : Cases: Total for the year.. 45, 516. Total damage.. 2,955.50 men, or 6 per cent. Infectious diseases (nonve- Damage 722.43 men, or 6 per cent. neral) 11,106. Infectious diseases (vene- Damage . 546.95 men, or 5 per cent. real) 10,261. Diseases of the mind ..235. Damage 119.62 men, or 50 per cent. Diseases of the nervous Damage 92.33 men, or 21 per cent. system 427. Nervous and mental dis- 221.95 men, or 32 per cent. - 662. This relatively large damage is due to the large percentage of nervous and mental cases which were invalided from service. Table 3.—Cases invalided from the service during the fiscal year 1918. Number invalided. Per cent. 445,516 cases 1,156 200 2 662 nervous and mental cases 33 This shows that a person with a tendency to nervous or mental disease is 16 times more likely to be invalided from the service than a man having disease in general. These figures do not include several rather large groups of nervous diseases, such as neurosis of the bladder, intestinal neurosis, etc., which are classified in other groups. Neither do they include the tremendous damage from feeble minded and subnormal individuals discharged for disciplinary reasons. This loss can not be definitely shown, but can be estimated from the report of the Judge Advocate General of 1916. Table 4. Discharged as undesirable for inaptitude or with ordinary discharge, not recommended for reenlistment 1, 000 Discharged with dishonorable discharge 2,296 Total 'desertion for the year 1,681 Total prematurely lost to service, or 7.88 per cent of the total number of men handled for the year 5,733 Major Edgar King 1 has estimated that mental disease causes 39.0 per cent of discharges for delinquency for the Army. One certainly takes no risk in assuming that mental disease, especially defect, is* a large factor in military delinquency. The case against nervous and mental disease is a strong one, and there is abundant evidence to show that when present it usually exists prior to enlistment or appears soon afterward. Its greater frequency in recruits would indicate this. In King's analysis it is ' King, Edgar. Tin- military delinquent. Quoted in Mental Hygiene, July, 1917. 154 Vol. XX. STEARNS INTELLIGENCE TESTS. stated that 90 per cent existed prior to enlistment. All of the con genital conditions, of course, exist at time of enlistment. Becker's ■ figures showing the frequency of occurrence of mental disease in the German Army illustrate this fact. Table 5. Percent. Cases occurring in the first 3 months of service 37.8 Cases occurring in the second 3 months of service 28.2 Cases occurring in the third 3 months of service 21.6 Cases occurring in the fourth 3 months of service 12.4 In a series of cases invalided from service during 1917 collected by the author,3 34 out of 35 existed prior to enlistment. Also a series of 2,000 consecutive arrivals examined at a training station showed the following conditions : Table 6. Diagnosis. Feeble-minded Psychoneurosis Psychosis . Epilepsy Stammering Chronic alcoholic Psychopathic personality _ Defective delinquent Per cent. Total. 40 2.00 17 .85 2 .10 4 .20 5 .25 2 .10 2 .10 2 .10 3 .15 4 .20 81 4.00 The medical causes for the rejection of recruits for the year 1916 were as follows: Table 7. Errors of refraction 5, 360 Underweight -- 4,507 Defective teeth 3, 935 Flat or weak feet 3,534 Deformities 2,822 Varicose veins for varicocele 2,331 Under height - 1.623 Heart affections - 1,439 Color perception defective , 1,352 Genito-urinary (venereal) 914 Tuberculous or suspects — 657 Mental disorder - SSI Nervous condition io ' Becker, Theophil. Der angeboreno Schwachsinn In scinen beiichungen turn Mllitardlenst. Berlin, 1910. Quoted In Mental Hygiene, October, 1917. ' Stearns, A. W. The psychiatric examination of recruits. Jour. Am. Med. Assn., Jan. 36, 1918. No. 2. 155 STEABNS —INTELLIGENCE TESTS. If the writer's percentages hold in the case of the 14,727 men enlisted in 1916, and there is every reason to suppose that they do, 588 of them had nervous or mental diseases, 294 were feeble-minded, and 130 were psychoneurotic. Some reference should be made to the lessons learned through the European war. This can best be done by quoting from the admirable report of Maj. Thomas W. Salmon, M. R. C* No medico-military problems of the war are more striking than those growing out of the extraordinary incidence of mental and functional nervous disease (shell shock). Together, these disorders are responsible for not less than one- aeventh of all discharges for disability from the British Army, or one-third, if discharges from wounds were excluded. * * * By their very nature, more over, these diseases endanger the morale and discipline of troops in a special way and require attention for purely military reasons. The proper attitude toward most cases of nervous and mental dis eases can be summed up in two dicta: (1) Prevent enlistment, if possible; (2) dismiss from service as soon as detected. In considering the general medical problem of recruiting, three facts must be studied : (1) The source and quality of material available. (2) Present methods and equipment for selecting material desired. (3) Undesirable types usually not detected. This problem is quite analogous to the employment of help in civil life, except that the relative importance of certain factors making for desirability is reversed. If a man wishes a job with a large corpora tion, three factors are considered with the relative importance of each, as follows: (1) Fitness for special work required (i. e., Is the applicant a machinist ?) . (2) General fitness for work (i. e., record of previous jobs). (3) Physical fitness (i. e., Are you healthy?). Now, in the Navy the relative position of these factors is: (1) Physical fitness. (2) Fitness for special work required. (3) General fitness for work. For the "unskilled labor" classes in the Navy, physical examina tion was in practice during the war, the sole basis of selection. Studies of the occurrence of nervous and mental disability in the general population show that a nearly constant percentage of such disorders is to be found. For instance, the Nassau County survey5 shows that 1.72 per cent presented evidence of such disability. The fact that many of these disabilities are most common in child hood and in old age would make a smaller percentage for those ages eligible for naval service. Yet a study of 2,000 consecutive arrivals ' Salmon, T. W. Mental Hygiene, October, 1917. ■ Quoted In Mental Hygiene, October, 1917. 156 Vol. XX. STEARNS—INTELLIGENCE TESTS. at a naval training station " showed approximately 4 per cent of ner vous or mental abnormalities. The estimates of the feeble-minded in the general population run close to one-half of 1 per cent. In this series 2 per cent were found, showing that feeble-mindedness is four times as common in the Navy as in the general population. To be sure, many with such a handicap manage to get along in the service. But why should the Navy- enlist any man with a handicap when it can get the best ? There are certain factors which tend to drive the unfit into service. Of first importance is economic necessity. I have the word of several prominent social workers that military service of certain individuals during the war took many most troublesome problems off their hands. The adult probation department 7 for the city and county of San Francisco pointed with pride to the fact that nearly 10 per cent of its probationers were in the service. Dr. Walter E. Fernald of the Massachusetts School for the Feeble-minded in a personal communication told me that many feeble-minded under his care were in the service. My own experience in the out-patient depart ment of the Boston Psychopathic Hospital has shown me that the changeable, unsettled psychopaths are often the first to seek service. I have already shown the attitude of some courts during the war in an article in the United States Naval Medical Bulletin* and have called attention to the custom of granting freedom to convicted men on condition of enlistment, as there was a general impression that military discipline would reform an incorrigible or cure a psycho neurotic. There is a very prevalent idea that nervous and mental disease is especially difficult to detect. My own opinion is that no type of disease so definitely marks a man as mental disease, however slight. The marks are quite different from those of physical diseases and must e especially sought to be detected. From the study of the reports of the Surgeon General and Judge Advocate General and of the liter ature pertaining to military psychiatry, as well as from my own exper ience in naval service, the special psychiatric problems of the Navy are : (1) Feeble-mindedness. (2) Psychoneurosis. (3) Abnormal personalities. (4) Epilepsy. (5) Demential precox. (6) Other psychoses and neuroses. (7) Alcohol and drug addiction. (8) Bed wetting and stammering. (The last two conditions are seen most frequently in neurotic and unstable individuals.) «Loc. clt ' Annual report of the adult probation department for the city and county of San Francisco for the year ending Dec. 31, 1917. » The detection of undesirable candidates for enlistment, by Passed Asst. Surg. A. W. Stearns, U. S. Naval Reserve Force, U. S. Naval Medical Bulletin, July, 1918,Vol. XII, No. 3. No. 2. STEARNS —INTELLIGENCE TESTS. Now, the problem is, How may physicians not especially trained in psychiatry detect those with nervous and mental disease ? Obvi ously, not by physical examination. No class of disease handicaps to the extent which mental diseases handicaps, and therefore those affected can best be detected by the determination of their social and economic fitness. Psychiatric studies in the past few years have done much to throw light upon the cause of certain social problems. Especially has it shown the relation between crime, vagrancy, drug and alcohol addic tion, pauperism and unemployment, and mental disease or defect. The sociological classification of abnormal subjects in the Nassau County survey, quoted above, is of interest. Table 8. Per cent. Retardation in school ' 10.6 Truancy, unruliness, etc 1-3 Sex immorality 7.3 Criminal tendency . 5-0 Vagrancy 0.1 Dependency 17.6 Inebriety 20. 1 Drug habits 0.3 Domestic maladj ustment -- 0.9 Medical cases 3.6 Other groups 23.0 No maladjustment 10.2 Total 100.0 This social and economic fitness can be determined by any intelli gent man by analysis of a brief history. Medical officers at recruit ing stations, if they have such histories, will soon become expert in their interpretation. In the report for 1917 of the Surgeon General, the fleet surgeon, Atlantic Fleet,9 deplores the lack of details in his tory of former diseases in the health record and states that it is "too often made in a perfunctory manner." The history taken on the application for enlistment is even more perfunctory and is of little medical importance at present. An exact psychiatric diagnosis is not essential. If an applicant appears to be a social or economic problem, it does not matter especially whether this is due to tuberculosis, dementia praecox, feeble mindedness, abnormal personality, or what not. His problem should not be shouldered by the Navy until man power gets to be a much more serious question than at present. The entire absence of the feeble-minded group among such recruits as hospital apprentices, second class, landsmen for yeomen, and landsmen for electricians (radio) shows that where discrimination is made in selecting the • Annual report of the Surgeon General, 1917,p. 36. 158 Vol. XX. STEARNS —INTELLIGENCE TESTS. applicants no defectives are recruited. As for the other groups, many men are now rejected as the result of a superficial judgment upon their fitness, when analysis would show their desirability. The following scheme for determining the social and economic fitness of recruits is suggested: A minimum life history of each candidate for enlistment should be taken. The following card proved satisfactory at the United States Naval Training Station, San Francisco, Calif., where the writer was stationed during the war. Name Date No Age Civil cond Rate Home Enlisted P. E._ Appearance School Occupation Medical history Ale. Arrests Symptoms Fitness 1-2-3 As each question is asked, clues should be followed. The factors of special importance in forming an estimate of the individual seem to be: 1. Age. —A considerable percentage of the 18-year-old boys are either 16 or 17 years old. This often means that they have run away from home or have enlisted fraudulently; also many of the bed wetters are on this 18-year-old group, so a little closer attention should be paid to the 18-year old than to others. Also the men above 30 need a little closer inspection, because of the greater fre quency in them of cerebrospinal syphilis and chronic alcoholism. 2. Civil condition. —Men who are separated or divorced should have a little closer scrutiny because of the association between domes tic difficulties and psychopathy. 3. Relation between home and place of enlistment. —This is quite important, especially in younger applicants. It is unlikely that a boy under 20 would be applying for enlistment in a distant part of the country if his home life and social relations are normal. 4. Appearance. —Under this heading general attitude and manner should be included. Although appearances are very deceptive, one soon learns to detect the dull, childlike reaction of the imbecile, and > No. 2. STEARNS —INTEIiJGBNCE TESTS. the dulled, apathetic reaction of the epileptic or dementia precox case. 5. School.—The grade reached in school and history of retardation is very important in detecting the feeble-minded and epileptic. The eighth grade usually, and high school always, rules out mental defect. Very few epileptics and psychopaths graduate from high school. One should not confuse the rustic with the imbecile, but differential diagnosis is necessary to make the distinction. 6. Occupation. —A permanent, responsible job held by a man usu ally rules out nervous and mental diseases. The imbecile's activities are confined to unskilled labor, and his terms of employment are very short. The psychoneurotic, insane, and epileptic rarely hold a position long. 7. Medical.—At least half the epileptics will admit attacks if properly questioned. The same applies to bed wetters. Practically all of the psychoneurotics give a history of previous ill-defined pains, dizzy attacks, or weakness. 8. Arrests.—The relation between delinquency and nervous and mental diseases is well known. A history of arrests for minor offenses and of reform-school residence is easy to obtain. As a result of the above analysis it is possible to place candidates for enlistment in three groups : (1) Those obviously suffering from neither nervous or mental diseases, comprising at least 80 and probably 90 per cent of applicants. (2) Those suspected to be suffering from mental diseases, comprising from 5 to 15 per cent of applicants. (3) Those obviously suffering from nervous or mental dis eases, comprising from 1 to 5 per cent. As a result of this the definite cases should be rejected. The doubtful ones should be more thoroughly studied. Usually by con sulting police records of the home town, insisting upon the refer ences being bona fide and investigating these references, one can determine the desirability of the candidate. If the above method of history taking could be put into operation in all recruiting offices some would use it well and some poorly, but it would unquestionably result in a tremendous diminution in the number of psychopaths received by the Navy, and would require very little additional effort. CLASSIFICATION OF RECRUITS. Mental capacity. —The accuracy with which a man's mental capacity can be estimated by psychological tests has not been finally determined. Opinions vary from that which says that life itself is 74450—24 2 160 Vol. XX. STEARNS —INTELLIGENCE TESTS. the only test to the one which presumes to give final judgment by some pet test. The Binet-Simon scale has everywhere been accepted as an aid in determining feeble-mindedness, and certain tests have proved of value in educational work. It also seems to be quite generally agreed that there is a high correlation between the score made on mental tests and general capacity. Tests for special ability have probably not been so successful. During the war the use of a scale to be given to groups was made a part of the Army routine and the psychological department graded every soldier. The Navy problem is somewhat different from that of the Army because of the absence of illiterate and non-English speaking men. As there is no provision by which specially trained men can be obtained to do test ing in the Navy, it is necessary to have a scale which can be used by assistants only slightly trained. In choosing individuals tests for a series it seemed to the writer that the Trabue language scale offered the best already standardized material. After more or less initial experiments Trabue scale C was chosen as a nucleus for a series. It has been used exactly as directed in Trabue's book, "Language Scale Tests." To this have been added four other tests, making the the series as follows : (1) Trabue C. , (2) Dissected sentences from Binet-Simon scale. (3) Cancellation test. (4) Memory span for numerals. (5) Healy code. As the Trabue was scored on a basis of 20, the others have been standardized to this. Three dissected sentences were given in the second test and credit was given only for perfectly constructed sentences. If one was correct, a mark of 6 was given, 13 for two, and 20 for three. Time of three minutes was allowed for the three sentences. For the third test a piece of prose containing 42 "c's" was used and one minute given for canceling the "c's." One was deducted from 20 for each "c" missed, and if less than 22 were can celed a mark of zero was given. For the fourth test three attempts of 5, 6, 7, 8 numerals were given. A credit of 5 was made for one correct series making a total of 20. In the fifth, the Healy code, a sentence of 20 letters was required to be written and credit of 2 given for each correct letter. Thus a total perfect score will be 100. The distribution of 4,000 scores was plotted. These were at first divided into quarters, which fell at 57, 75, and 86. For utilitarian purposes these groups have been somewhat modified and are now divided as follows: Group 1 : Below 65, inferior. Group 2: 65 to 75, low average. Group 3 : 75 to 85, high average. Group 4: 85 to 100, superior. No. 2. 161 STEARNS —INTELLIGENCE TESTS. It will be seen that the score covers the whole range of intelligence, being easy enough so that the most stupid can get something and difficult enough to tax the most brilliant, there being but two zeroes and fourteen 100's in the series of 4,000. The most important questions to be determined were the meaning of the result of this test and its application. Assuredly there is some difference between the man scoring 65 and the man scoring 85. In order to get the relation between the score and the actual capacity of the man, all recruits entering several schools were graded. Then as they succeeded or failed, completing the course in the school being considered a success and being dismissed from the school being con sidered failure, this result was correlated with the score. It was soon apparent that there was a tendency to fail on the part of the low men and to succeed on the part of the high. A difficulty en countered was that the schools maintaining a high standard took few low men, while those with a low standard graduated nearly all who entered. It is apparent that those below 65 (group 1) are so apt to fail in whatever school they may enter that it is wise economy to reject them. It appears from experience with this method that it is more accurate and more fair than either a written school examination, an educa tional requirement, or a company commander's recommendation. No claim should be made that it is a method of individual study, but it can be said that, with large groups of men and no time for painstaking individual study, it is a method by which success or failure can be predicted in a large enough percentage of cases to make its use expedient. Its use standardizes admissions to the various schools in the Navy as no other form of examination could possibly do. Besides being of use as a standardized requirement of school entrance, it is necessary from time to time to judge men accurately and no one point is of more value than this score. Educational classification. —This is relatively unimportant and yet is of some value in estimating a man's worth. During the war there was need of college men on account of their having studied higher mathematics and other things needed by the Navy; and it was noted that those men with meager education were not so readily trained in the various schools. It appears from this that there is a tendency on the part of college men to make high scores and on the part of those with less than eighth- grade education to make low scores, yet it is impossible to predict a man's score by his education because certain of those with little education make high scores and vice versa. There is some justifica tion in having an educational requirement for admission to the schools, but from our figures it appears that this is not as reliable as the result of a psychological test. There was some difficulty in grad 162 Vol. XX, STEARNS—INTELLIGENCE TESTS. ing men according to education because of the diversity of educa tional institutions in different parts of the United States. As with mental capacity and industrial training, it was desired to put them in four groups—No. 4 was given to college men, and this group com prised all men who had formal education in excess of four years' high school; No. 3 was given to men who had been to high school; No. 2 was given to men who had finished the eighth grade; No. 1 to those who had not finished the eighth grade. Figure 9 shows relative number of each group. Industrial classification. —The kind of work which an individual has been doing previous to enlistment is of value for two reasons: In the first place it gives an idea of the capacity of the individual; in the second place there is a constant demand in the Navy for men who have had some particular sort of training. Starting with a list including practically all occupations, and another list including the occupations of 10,000 recruits, a final classification including 53 differ ent occupations was used. The vast majority of recruits are rela tively unskilled. Many of those who have special skill are of no particular value to the Navy because of this training, so those occu pations selected for a place on the list wore taken either because there was a demand from the heads of departments for men with a particular training or because it seemed that men with certain occu pations ought to be used for special work. Although on the history card what each man was doing prior to enlistment was recorded, only those who have worked a year or more at a particular kind of work were classified. Large groups of unskilled men, such as students and farmers, being of no special value to the Navy, were grouped as "miscellaneous, untrained." Those having skill in some occupation which might be of some use to the Navy, but which rarely occurs, have been grouped as "miscellaneous, trained." The list finally was reduced to 53 different occupations, all of which were at some time or other of use at the training station. Groups were made as follows: (1) Industrial misfits, such as vagrants, criminals, or those continually shifting work. (2) Unskilled. Such as farmers and students or day laborers. (3) Experienced. Those who, although they have not a trade and so would not be considered trained, have had enough experience at a given occupation to make them possibly worth while. (4) Trained. Embracing highly skilled individuals who have learned a trade or have a profession or business. In connection with this first group, certain occupations seem to be made up to quite an extent of rolling stones; among these may be No. 2. 163 STEAHNS—INTELLIGENCE TESTS. mentioned hotel and pool-room attendants, longshore workmen, barbers, teamsters, etc. Each one of the 53 occupations was a given serial number which could be used in place of the name when it is desired to express a man's formula numerically. The following is a list of the occupations chosen, preceded by the serial numbers: 1. Actor. 2. Architect. 3. A&sayer. 4. Attorney. 5. Auto and motor-truck driver. 6. Athlete. 7. Baker. 8. Barber. 9. Blacksmith. 10. Boilermaker. 11. Bricklayer. 12. Butcher. 13. Carpenter. 14. Cabinetmaker. 16. Chemist. 16. Civil engineer. 17. Cement worker. 18. Cook. 19. Clerk, office. 20. Clerk, store. 21. Clei-k, drug. 22. Clerk, post office. 23. Coppersmith. 24. Electrician. 25. Engineer. 26. Foundry worker. 27. Fireman. It was customary to tabulate the arrivals at the training station, classified by occupations, every month and to send this list to the heads of departments, as these men often select persons from this list which they would not otherwise use; also, a cross index by occu pations was kept of the entire population of the station and was accessible in case men are wished of any particular trade. CONCLUSION. From the foregoing it will be seen that each man was graded according to a standard on a basis of 1-2-3-4, as follows : Mentally — (1) Inferior. (2) Low average. (3) High average. (4) Superior 28. Interpreter. 29. Jeweler. 30. Machinist. 31. Musician. 32. Motor mechanic. 33. Miscellaneous, trained. 34. Miscellaneous, untrained. 36. Motion-picture-machine operator. 36. Newspaper editor, reporter. 37. Optician. 38. Photographer. 39. Painter. 40. Patternmaker. 41. Plumber. 42. Printer. 43. Pipe fitter, steam fitter. 44. Stonemason. 45. Ship wright. 46. Ship fitter. 47. Sheet-metal worker. 48. Shoemaker. 49. Tailor. , 50. Telegrapher. 51. Tinsmith. 52. Toolmaker. 53. Welder. 164 , STEARNS—INTELLIGENCE TESTS. Vol. XX. Educationally — (1) Less than eighth grade. (2) Eighth-grade graduate. (3) High-school students. (4) College. Industrially— (1) Misfits or failures. (2) Unskilled. (3) Experienced. (4) Skilled. In addition each occupation was given a serial number from 1 to 53. This made it possible to give every man a numerical formula representing his capacity and training. The serial number repre senting his occupation was put at the right of a decimal point, as it denotes a qualitative factor, the others being quantitative. For instance 444.4 would represent a man of superior intelligence, col lege education, and highly skilled, his occupation being an attorney. Also 111.34 would mean inferior intelligence, less than eighth-grade education and industrial failure, his work being odd jobs. This made possible a simple index by which men could easily be located and evaluated. Also each number served as a check upon the other, as a man with a 4 in his formula must be taken seriously, while a 1 means that he should be suspected of incapacity. As a matter of fact the formulas are very consistent, it being rare to find both a 1 and a 4 in the same formula. APPENDIX A. Blank Form for Test. Trabue Language Scale C. 1. The sky blue. Score 2: is, was, became, turned, looks, appears, seems. Score 1: got, is very, is not. Score 0: are, light, very, dark. 2. Men ■ older than boys. Score 2: are, act, look, appear, seem. Score 1: grow, were. Score 0. be, see. No. 2. 165 STEARNS —INTELLIGENCE TESTS. 3. Good boys kind their sisters. Score 2: are to. Score 1: were, must be, should be, will be, act, is, to. are with, toward, like, also, and. say words to. Score 0: are for, as, by. 4. The girl fell and her head. Score 2: hurt, injured, bruised, cut, hit, struck. Score 1: bumped, knocked, came down on, crushed, fractured, broke. Score 0: split, busted, on, bunked. 5. The rises the morning and at night. Score 2: sun in, during, sets, sinks, disappears. Score 1: temperature in falls. boy, bird, in sleeps, rests. tide in also, falls. falls, goes, leaves, lowers, sits, moon. sun in goes down, set, not descends, drops, dies. Ithe moon, fades, never. Score 0: sun in sometimes. sun every sets. 6." The boy who hard do well. Score 2: works, tries, studies, thinks, will. Score 1: tries can, may, does, shall, should, could, must. worked, tried, did, will, can. plays, hits, work, will. Score 0: tries sometimes, surely, often. id- work did, does work, work did. 7. Men more to do heavy work women. Score 2: are /able, competent, willing 1 th&n linclinded, apt, ready, likely / have ability, strength, inclination, power, than. Score 1: (•prepared, anxious, eager, liable, fitted equal, accustomed, suited, satisfied, are •!capable, used, adapted, wanted, fit, ) than. required, taken, healthy, qualified, built, stronger, suitable, useful, are rambition, energy, time, tools 1 than> (.muscle, right, business, I try, like, ought, often than. earn money than, has ability than. know how than, eat food than. need tools, money than, appear X than. 166 Vol. XX, STEARNS —INTELLIGENCE TESTS. Score 0: are made, asked, good, active, than. are useful, able for, work hard than. thinking than, have brains, work — that one can not directly — do — 8. The sun is so great discomfort to the eyes. Score 2: brilliant, dazzling, (look, gazel radiant, bright Istare, J Score 1: blinding, intense, strong light, than. — causing at- it- without. XX - at without. - without, without. powerful, glary, hot, red fiery, highJ x endure, bear, stand, its rays • x xx into, toward, towards, it - x blinding, intense, xx at it unless, for if. x even look up without. Score 0: warm, far, low xx at it without. x xx at it because, thus. x se it so without. 0. The knowledge of use fire is of important things known by but unknown ■ Score 2: how- Score 1: how - why -to- -one- the,many several man, eman, us, by, mankind, among, people to. to- - we ■ •one - - one • — x persons, scouts, h X XX XXX. when, having, the way, to one x how to considered, rated, thought, x - how to one most xx xxx Score 0: how to often x xx xxx. - XX - xxx. — xxx. the 10. knowing One ought to — bad habits — Score 2: ) proper, correct careful, .important, skillful, great how to one x — great care to the right — — it to get away from them one - -xxx XX • -of- use, take, exercise form, choose, acquire, gain, cultivate, develop, adopt, establish, I learn, teach, tbegin (has, gains, contracts, forms, acquires (sort, V_ Ikind,/ - xxx. - for one who - habits - Contracts, ']—— tt hard, difficult. •xx • - habits - (living, life, working, work, studying, study, speaking, Bpeech, thinkings- thought, learning, mind, procedure, action, attention, acting xx. No. 2. 167 STEAKNS —INTELLIGENCE TESTS. Score 1: obtain, get possess, use 1have, pursue, Unake, lead, fxx Ihabits habits 1 — xxx/"- - finds - -XXX. xx- st — -xx- -xxx- - habit ■XX - /xxx habits! '_ lhabits xxx/ )finds(lmP088ible' i Ipays. /has \ ImakesJ xx' have! |habits giver- xx |habits. XXX XXX XXX finds • take - x — X X X Score 0: be '—— xxx speech xxx person ■ ■ x finds x finds — xxx. xx habits {moralitr.l manhood/ x — begin way living x finds do xxx things x finds — ■do thing course x finds - xxx. finds xxx. - XX. xxx. /get x ido- 1. Hour for — the. - start • ■thing - lifel life/" ■early - at- - finds ■ •park - xxx. ■an • ■started 3 asked —— exercise my ——- teacher —— correct my I. defends - dog good —— his courageously master. 3. A One hears very different judgments in the value of life. Some say it is good, others say it is bad. It would be more correct to say that it is mediocre; because on the one hand it brings us less happiness than we want, while on the other hand the misfortunes it brings are less than others wish for us. It is the mediocrity of life that makes it endurable; or still more, that keeps it from being positively unjust. APPENDIX B. I Instructions fob Giving Steabns Test. In giving the directions for these tests, it is essential that every point be clearly understood by everyone who is capable of understanding. This can be assured in no other way than by giving the directions slowly and distinctly with proper expression and emphasis. Before being given it should be seen that the test is clearly understood. In order that the meaning of each sentence may be fully grasped, it should be followed by a pause. A good rule is to allow a pause of two seconds after every sentence. The procedure may only be considered as standardized on the condition that the examiner adheres to this rule uniformly throughout the testing. Introductory. —This examination is given as an aid in finding for what special work you are best qualified. These papers [indicating] will be passed to you, printed side down. Do not turn them over until you are told to do so. 168 Vol. XX. STEARNS —INTELLIGENCE TESTS. Has every man a paper? Has every man a pencil? Now at the top of the blank side of the paper write, (1) your full name, (2) your rate and company number, (3) the highest grade you completed in school, (4) your occupation before entering the Navy. Everyone should now have, the name, rate, company num ber, extent of schooling, and occupation recorded on the sheet. This examination consists of five different tests. You will do one test at a time. At the order "Begin writing" you will turn your paper over and begin work. You will be allowed a reasonable time to complete each test, so do not hurry through them, but keep your mind on the tests and work steadily. Am soon as you have completed the test or when the command "Papers over" ia given you will turn your paper over "printed side down." Test I (Trabue Language (J). This test is to see how quickly and how accurately you can complete 10 sen tences, which have certain words omitted. Place one word only in each blank space. "Ready to begin." "Begin writing." "Paper over" (after 7 minutes). Test II (Dissected Sentence) . The next test consists in seeing how quickly and how well you can rearrange three groups of words into sentences. The words comprising each sentence are now transposed so they do not make sense. To make a sentence of these words they should be placed in natural order. Use every word which you find under each group. "Ready to begin." "Begin writing." "Paper over" (after 3 minutes). (Score 6 for one correct sentence, using all words but once, 13 for two, and 20 or three sentences.) • Test III (Cancellation Test). The next test consists in seeing how quickly and how accurately you can cross out all of the "E"s in a paragraph of reading matter taken from a newspaper. Draw a line through each letter "E." "Ready to begin." "Begin writing." "Paper over" (after 1 minute). (Deduct 1 from 20 for each "E" omitted. Score 0 for less than 22 cancelled.) Test IV (Memory Test). The first order for this test is for you to hold your pencils up, resting your elbow on the table. Now turn your papers over, keeping your pencils up. This test consists in seeing how many numbers you can remember. First I will read five numbers. When I have finished reading, at the command " Write" you will write the figures on the first part of the first line. Then you will hold your pencils up and I will give you five more numbers which you will write on the middle part of the first line, and then five more which you will write on the last part of the first line. " Ready to begin. " 47395-^" Write. " "Ready." 58379— " Write. " "Ready." 85264— " Write. " No. 2. 169 STEARNS —INTELLIGENCE TESTS. Now I will give you six numbers which you will write on the second line. "Ready to begin." 854726— "Write." "Ready." 274681— "Write." "Ready." 941738— "Write." Now I will give you seven numbers which you will write on the third line. "Ready." 2947376— "Write." "Ready." 1695847— "Write." "Ready." 9285164— "Write." Now I will give you eight numbers which you will write on the fourth line. "Ready." 28574692— "Write." "Ready." 27859513— "Write." "Ready." 83962754— "Write." "Papers over" (no time limit). (Score 5 if one of three of 5 digits is entirely correct. Then the same with 6, 7, 8 figures.) Test V (Observation Test). Sometimes in war it is necessary to send secret messages. For this purpose codes or ciphers are used. I am going to give you a code used by the southern army in the Civil War and later ask you to write words using the code from memory. (Place code on blackboard.) Each letter is represented by the lines which inclose it, i. e. : A, B, C, etc., S, T, U, V. You will observe that the second group of squares is distinguished from the first group by the dot in each angle, and likewise the second group of crosses is dis tinguished from the first by the dot in the angle. Observe further that the let ters in the first two groups run from top to bottom and in the second two groups in a counterclockwise fashion. Now let me illustrate the use of the code. We write the word "war" thus [indicating]. I am going to ask you to write a phrase on the bottom line of your paper op posite number "5" using the code as you remember it. "Ready to begin." " Write"— "Caught a spy. " " Paper over" (after 3 minutes) . (Score 2 for each letter given correctly.) The total possible score for all tests is 100. 170 Vol. XX. OWENS —INSULIN. THE INSULIN TREATMENT OF DIABETES MEIUTUS.' By W. D. Owens, Lieutenant Commander, Medical Corps, United States Navy. In recent years internal medicine has made remarkable progress, but there has been none greater than in the clinical investigation and scientific treatment of diabetes mellitus. Since the classical observa tion of Thomas Willis in 1675, that the urine in diabetics contained sugar, until the announcement of the discovery of insulin by Banting and Best of the University of Toronto, probably no other disease has been the object of so much combined clinical and laboratory study. The discovery by Banting and his coworkers of an effective non toxic pancreatic extract must undoubtedly be regarded as an epoch in the therapy of diabetes and as one of the greatest medical achieve ments of the time. Nevertheless, their work can in no way distract from the importance of the investigations of Allen, Joslin, Woodyatt, Newburg, and Marsh, whose clinical and laboratory studies in the dietetic treatment of diabetes mellitus had even before the discovery of insulin accomplished far-reaching results. This may be appre ciated by presenting the following statistics ot Joslin: Between the years 1814 and 1914 the death rate from diabetes in patients who were treated in the best hospitals was 28 per 100 per year. The year 1914 marked a significant advance in the dietetic management. Allen's undernutrition treatment was adopted, and in patients so treated the death rate had fallen to 4 per 100 each year. To-day the possibilities of treatment are even greater, and by the use of insulin the death rate from diabetes should be reduced to the neighborhood of zero. Patients who would otherwise remain chronic invalids, subjected to frequent fast days and undernutrition, may be sufficiently restored to health to take their rightful place in the world, earning their living and free to enjoy some of the pleasures of life. In the management of diabetes there are five objects to be attained : (1) The patient should be kept continually free from sugar in the urine, and the blood sugar should be within normal limits. (2) The patient should be kept continuously free from acidosis. (3) The patient should be nourished as evidenced by a satis factory weight. (4) All sources of chronic foci of infection should be deter mined, and where practicable they should be eliminated. (5) Gastric analysis should be accomplished because achylia may be the cause of the failure of the pancreas to func tion. i This paper deals with a series of 12cases of diabetes mellitus treated with insulin by the stall of the naval hospital, San Diego, Calif. No. 2. 171 OWENS —INSULIN. D-1S D-17 D-10 Before undertaking'rthe treatment of diabetes one should under stand the blood changes which occur, and thoroughly master the principles of the dietetics involved. To attempt a serious discussion of the blood sugar of the normal indi vidual and of the dia betic is beyond the scope of this paper, but a few of the fundamentals may be advantageously indi cated. In the normal healthy individual the blood , when examined three or four hours after a meal, or in the morning before breakfast, will be found to contain about 0.1 per cent of sugar. Un der certain circumstances it may be a little higher or a little lower than this, but the normal figure of 0.1 per cent (100 milli grams per 100 c. c.) of blood siigar may be ac cepted as the normal for the average person. After an ordinary mixed meal the blood su gar rises very considera bly within the first half or three-quarters of an hour; it then decreases, and within one and a half to two hours after taking a meal it again returns to the region of the normal value. A sugar curve ob tained from a normal indi vidual is shown in Figure 1 ; here 50 grams of glu cose were administered. This chart emphasizes that one should take specimens for blood sugar estimations at least three hours after the ingestion of a meal, because a blood-sugar report of 0.17 taken a hah* hour after a meal would have no value whatsoever. D-15 D-H D-13 D-12 D-ll D-10 D-09 D-08 Minutes 30 60 90 120 FW- 1.— Blood sugar curve of normal individual. 172 Vol. OWENS—INSULIN. The extent to which the blood sugar can be raised in the diabetic person varies somewhat with different individuals, but it may be accepted that the maximum concentration which can be present in the blood without the occurrence of glycosuria is 0.18. In the normal individual sugar will not appear in the urine by feeding with an excess of glucose. The maximum value of 0.18 per cent is known as the renal threshold value for sugar and represents the concentration below which no sugar is excreted with the urine. One may infrequently encounter cases presenting a low renal threshold and this condition is known as renal glycosuria. We have had one such case admitted into this hospital during the past year. The blood sugar estimation was normal and a sugar tolerance test failed to give the characteristic diabetic curve. The patient was finally discharged as with no disease. In the diabetic individual the blood sugar is above normal when one makes an estimation immediately or several hours after the taking of a mixed meal, and Figure 2 shows the curve obtained from a moderately severe case of diabetes after the eating of 50 grams of glucose. It will be noted that the blood sugar is 0.23 four and one- half hours after the administration of glucose. The highest blood sugar in our series is 0.5, taken three hours after meals. This patient has an internal cataract in the left eye and severe retinitis in both, eyes. In a communication received from Doctor Joslin he states that one can not expect much change in retinitis with insulin therapy. From what has been said it is evident that when glycosuria occurs in diabetes the blood sugar must be more than 0.18. When it goes to a slightly lower level, then the glycosuria at once ceases. In some diabetic patients, however, and more especially in elderly individuals, the renal threshold value for sugar may be considerably raised so that even 0.3 or more sugar may be present in the blood without glycosuria. In such patients urine examinations are most deceptive and frequent blood sugar estimations are necessary to properly estimate the condition. One case of this character has been under observation and for a time greatly puzzled Doctor Sumerlin and myself. The absence of sugar in the urine, therefore, does not tell us whether the blood sugar is subnormal or in the neighborhood of normal or possibly higher, and it is for this reason that the administration of insulin at certain times may bring on symptoms of hypoglycemia. Whenever the blood sugar goes as low as 0.07 definite symptoms of hypoglycemia may appear, and should the blood sugar reach as low as 0.03 death will occur. It would seem that one of the greatest benefits which the staff of the hospital has derived in the treatment of this series of cases with insulin has been to stimulate an interest in the art of dietetics. No. 2. 173 OWENS—INSULIN. The advent of insulin has not rendered the dietetic treatment of diabetes of less importance, but of more importance. Much can and should be done to advance dietetics in the naval service. The Surgeon General appreciates the situation, and he has recently organized a class of nurses to be given dietetic instructions in Boston. Hours 1 2 3 4 S Fig. 2.— Diabetic (upper) curve compared with normal (lower) curve. In order to meet the situation temporarily at this hospital, I have been giving lectures and practical demonstrations to groups of nurses, and eventually all the nurses will have an intelligent understanding of the fundamentals of the dietetics involved in the treatment of diabetes. I wish to take this opportunity to thank Miss Cox and 174 Vol. XX, OWENS—INSULIN. the nurses for their cooperation and interest in our efforts in this direction. Diets are now scientifically estimated, properly weighed, and their caloric value recorded. Figure 7 shows a diet order used at the Mayo Clinic and adopted by us. Fig. 3. —Insulin diabetic diets. Test.. Maintenance. Diet. Total diet. T. D. 1 T. D. 2 T. D.3 T. I>. 4 Cl-PFl C2-PF2 C3-PF3 C4-PF4 C5-PF5 C6-PF6 C7-PF7 Cft-PFB C9-PF8 C10-PF10.... C11-PF11.... C12-PF12.... Carbohydrate (C). 1,304 931 MB n',r, 38t 497 667 752 930 1,179 1,29« 1,426 1,(106 1,771 2,07i 2, IS' 300 300 300 300 300 300 300 300 300. 300 100 600 100 600 200 600 200 til*l 200 600 300 600 300 600 300 600 300 601) 300 600 Protein and fat (PF). Cream. 4 240' 2 120; 2 i'.'.'.'. ■2.... 2.... 2 m 2 240 120 120 120 12i) 120 iK) CO to BO 120 120 12,1 ISO in 240 a- 30 30 30 30 30 60 SO1 30) 90 30 30 SO 30 45 90 30 45 120 30] 45 120 The dietetic fundamental requirements in the treatment of diabetes mellitus may be briefly stated as follows: By means of test diets, such as Joslin's (Fig. 3), one determines the minimum amount of food which will enable the patient to become free from glycosuria and, if possible, from acetonuria. To do this it is necessary to ascertain what amounts of the three ordinary classes of food—carbohydrates, proteins, and fats—should be present in the diet in such quantities as to keep the patient's urine sugar free and the body sufficiently nourished. In order to accomplish this one must think of food values in terms of calories. For clinical purposes it is sufficiently accurate to assume that 1 gram of carbohydrate equals 4 calories; 1 gram of protein equals 4 calories; 1 gram of fat equals 9 calories, and that a patient will re quire, roughly, from 12 to 15 calories for every pound of body weight. Thus, a man weighing 140 pounds would require as a minimum 1,700 to 2,000 calories. The average requirements of people concerned in the less strenuous occupations is 3,000 calories daily. Troops during war frequently get as high as 5,000 calories, and a hard laboring man needs fully 6,000 calories daily. In the treatment of diabetes when the maintenance diet is low in caloric values it is frequently necessary to keep the patient in bed, as it requires from 20 to 50 per cent increase in calories when the patient is up and about, depending on the physical exercise or occupation permitted. Having determined the number of calories necessary, it is now essential to decide what amount of the different classes of foods should No. 2. 175 OWENS —INSULIN. be given to make the requisite calories. The protein foods must be administered in sufficient quantity to maintain health. This amount is generally estimated at about half a gram of protein per day for each pound of body weight. Thus, the patent weighing 140 pounds will need 70 grams of protein. The carbohydrates are the great sugar formers and it is evident that an enfeebled carbohydrate mechanism should be treated with the utmost consideration and that the carbohydrates should be decidedly restricted. One should now select some method of starva tion and carbohydrate restriction in order to determine the point when the urine will become sugar free. Fig. 4.—Foods arranged according to carbohydrate content. 1-3 per cent. 3-5 per cent. 10 per cent. 15per cent. 20 per cent. VEGETABLES (FRESH OK CANNED). Lettuce. Tomatoes. Brussels sprouts. Wator cress. Sea kale. Okra. String beans. Oreen peas. Artichokes. Parsnip. Potatoes. Shell beans. Baked beans. Oreen com. Boiled rice. Boiled macaroni. Cucumbers. Pumpkin. Spinach. Turnip. Asparagus. Kohlrabi. Canned lima beans. Rhubarb. Squash. Endive. Cauliflower. Beets. • Marrow. Eggplant. Carrots. Sorrel. Cabbage. Onions. Sauerkraut. Radishes. Green peas, canned. Leeks. String beans, canned. Artichokes, canned. FRUITS. Ripe olive (20 per Watermelon. Raspberries. Plums. cent fat). Orapetnilt. Strawberries. Currants. Bananas. Lemons. Apricots. Prunes. Cranberries. Pears. Peaches. Apples. Pineapple. Huckleberries. Blackberries. Blueberries. Gooseberries. Cherries. Oranges. 30 gm. 1 oz. contains approximately— Carbo hydrates. Protein. Fat. Calories. Oraitu. Grams. Qrami. Qtamt. 20 5 2 118 23 3 0 104 10 1 1 53 1 1 12 116 1 1 6 82 1.5 1 1 19 2 5 20 208 4 6 1 49 0 8 5 77 0 8 3 59 0 5 15 155 0 8 11 131 0 6 6 78 1 .5 0 6 2 .5 0 10 6 1 0 28 18 3 0 84 0 0 25 225 0 0 30 270 0 6 0 24 0 0 3 Oatmeal, dry weight shredded wheat Uneeda biscuit", two Cream, 40 per cent Cream, 20 per cent Milk Brazil nuts - Oysters. «tx . Meat (cooked, lean) Chicken (cooked, lean) Bacon Egg, one Vegetables, 5 per cent ground up Vegetables, 10 per cent ground up Potato Bread Butter OU Pi«h: Cod, haddock (cooked) Broth 176 Vol. XX, OWENS—INSULIN. The proteins and carbohydrates having been ascertained, the intended value in calories is made up from fats. Woodyatt, whom I recently heard talk at the American Medical Association conven tion in San Francisco, has for many years opposed the views advanced by Allen, that fats must be rigorously restricted in diabetic diets and the very excellent clinical results obtained by Newburgh and Marsh since 1920 have gone far to prove Woodyatt's contention. To-day the high fat diet is accepted and we have followed Woodyatt's formula; i. e., that the amount of fats is not to exceed twice the car bohydrates plus one-half the protein. We have a patient on a diet consisting of 108 grams of carbohydrates, 65 protein, and 240 fats, and although he frequently shows acetone in his urine there have been no unhappy effects. It may be of interest in connection with this patient, who happens to be a Veterans' Bureau case, to recite the following instance: This man, in order to be transferred east, wrote to friends and made certain unfavorable comments in regard to the quantity and character of the food he was receiving. The com manding officer in reply to the correspondence very aptly showed that this patient was receiving a scienti6c diet based on the metaboUn requirements of the body in accordance with Wilder's charts. He also was able to remark that under the dietetic restriction and 80 units of insulin daily the patient had gained 32 pounds in six weeks. About a year ago Wilder described a system of planning diets which include a lowering of the metabolic rate without loss of body tissue, low protein, low carbohydrate, and a safe ratio between the ketogenic and antiketogenic substances, and recently we have used Wilder's method to guide our treatment. Figures 5 and 6 explain Wilder's charts and may be purchased from Sanders & Co. for $1 for each set. More recently, in an article entitled "The use of fat in diabetes mellitus and the carbohydrate fat ratio," by Ladd and Palmer, which appeared in the archives of Internal Medicine, the authors advocate that fats may be given in the proportion of carbohydrates 1 to fats 4, but so far we have only employed Woodyatt's formula. In this connection Dr. Max Kohn, of Beth Israel Hospital, of New York, has announced the production of a new fat preparation having 17 carbon items to the molecule, intermediate between the ordinary fat containing 16 and 18 carbon atoms and incapable of breaking down in acid products as do natural fats. This substance is named intarvin and is now being manufactured and will soon be placed on the market. One of the most important functions of an institution in the man agement of diabetes is the education of the patients and the person nel assisting in the care of these patients. Either the patient or some member of the family should be fully instructed in the funda No. 2. 177 OWENS —INSULIN. mentals of dietetics. The patients should know enough to plan and weigh their meals in accordance with some standard diet table, such as Joslin's (shown in fig. 4). The patients should be persuaded to study special books on dietetics, such as Joslin's or the Mayo Clinic volume. They should be taught the fundamentals of insulin therapy, the time and frequency of administration, also the symptoms and treat ment of an overdose of insulin. Before discharge, they should be able to do a Benedict test for glycosuria and know the significance of the various reactions. It has been my experience that when patients are required to perform their own Benedict test one is sure to have a more intelligent dietetic cooperation, and the patient soon shows as great concern for a positive reaction as the physician. One of my patients, a lady who has a very intelligent idea of dietetics, called me on the telephone and with some alarm informed me that her urine showed a trace of sugar that morning. This patient was taking 5 units of HlO insulin twice daily. I questioned her as to any dietary indiscretions. After considerable persuasion it was learned that she had indulged in two fresh figs. I estimated that the sugar-forming value of two figs would require approximately 1 extra c. c. of HlO insulin. This instance emphasizes the importance of dietetics when giving the insulin treatment for diabetes. Each unit of insulin can assimilate so many grams of sugar formers and no more, and if one strays from a given diet, one needs more insulin. The patient should be instructed in regard to the relation of chronic foci of infection to diabetes ; the necessity of having the teeth, tonsils, and sinuses investigated; the relation of boils, carbuncles, and other infections to diabetes, and the effective action of insulin controlling these infections. To accomplish this educational plan we have invited patients or members of their families to attend the course of lectures given to the nurses, and the value of these talks have fully compen sated for the work involved. So far I have discussed the general management of diabetes. In employing insulin in the treatment of diabetes mellitus there are four conditions that should be satisfied: (1) The sugar-forming or utilizing power of the insulin in grams per cubic centimeter should be known. (2) The patient's natural tolerance should be determined in grams of sugar formers. (3) The exact value of the proposed diet should be known. (4) The dosage of the insulin may then be adjusted to make up the difference between the sugar formers of the proposed diet and those of the patient's natural tolerance. When estimating the sugar formers of the three classes of foods and the metabolizing power of insulin, we would do well to keep in mind that the values obtained are not definite. Even with the present 178 Vol. XX. OWENS—INSULIN. standardization of iletin, and supplemented by clinical tests, the finished product may vary from 5 to 10 per cent. Therefore one should gradually approach the administration of the determined dose of insulin while keeping the blood sugar and urine under observation. In the treatment of this series of cases, we have employed the HlO and H20 Eli Lilly iletin. On October 15, 1922, Lilly & Co., in accordance with directions from the insulin committee of the Uni versity of Toronto, released a new issue of iletin having a potency 40 per cent higher than heretofore. The new issue will replace the HlO and H20, which will henceforth be known as UlO and U20. The calculations here presented are based on the new values of UlO and U20. The sugar-burning or utilizing power of the insulin should be known. Eli Lilly's iletin is evaluated in rabbit units. Their units have a fairly constant value, since they use between 300 and 400 rabbits in the standardization of each lot. It is estimated that each unit is worth a little more than 1} grams of sugar metabolizing power. The U20 product which indicates 20 rabbit units in each c. c. has a sugar metabolizing power of approximately 35 grams. The UlO has a metabolizing power of approximately 17$ grams. The U20 iletin is of advantage where one desires to give the larger doses, say, over 2 c. c. a day. Knowing the sugar-forming power of iletin, one must next deter mine the value in sugar formers of the diet which the patient is able to maintain without the occurrence of glycosuria and the value in sugar formers of the diet which it is intended to give the patient in conjunction with iletin. The reduction of food values and tolerances to the common de nomination sugar formers materially simplifies our calculations. The sugar formers of the diet are 100 per cent of carbohydrates, 5S per cent of proteins, and 10 per cent of the fats. The patient's tolerance may be determined by diet alone, or by diet plus insulin. When diet alone is used, the patient is dosugarized by partial starvation. When sugar free, diet additions are gradually made. (Fig. 3.) A diet is eventually found upon which the patient can remain continuously free from sugar in the urine, and with a normal blood sugar. Suppose such a diet contains 35 grams of carbohydrate, 33 grams of protein, and 83 grams of fats. In estimating the sugar formers of the three classes of food, the carbohydrates are 100 per cent sugar formers, the proteins 58 per cent, and the fats are 10 per cent. Thus the diet containing 35 grams of carbohydrate would yield 35 grams of sugar formers, the 33 grams of protein would yield 19 grams of sugar formers, and the fats 8 grams, making a total of 62 grams of sugar formers. Hence the natural tolerance for this patient would be 62 grams of sugar formers. NO. 2. 179 OWENS—INSULIN. The caloric value of such a diet is 1,400 calories or hardly enough to meet the patient's body requirements necessary to perform a certain occupation. It is estimated that this patient will require 2,000 calories of food or an increase of slightly over 30 per cent in the caloric value. It is therefore proposed with the assistance of 3H ... * hi s 3 WRCCTIONS-- PLACt. TW CHART0« A TLAT SMOOTH TAN.L USC ONLYA RULtAWITH A 1RUCSTRAU1T COOT. DO NOT DRAW LINtS ON TMt CHART BUf Mtmv •OCATC TMC* K»(TION» BY Tnt STRAIGHT CDGt Or THC RVA.CR. LOCATC THC "JAROUS POMTJ BY mcans or nccous (pw stuck, thrcwgh thc - CRASCR OT A LCAO PtNCIL). LOCATC TVC PATCNT5 VCCMT ON SCALE 1 and his heksht on Scale E. The rvlcb jonnc Treat tw> pontj MTtnitcTi Scale n at tic VATCNT'SyjHrfCC ATCA. LOCATE Ttt ACE ANO SCt Of THE RA.TCNT CM SCALE H. A RULER JOMXC T*S PONT VfTH THt PATENTS SURrACt AREA ON SCALE j] CROSSES SCALE 'SZ AT THE RCQUKEDTOTAL rOOO CALORI3 TOR BASAL MAINTENANCE. no. 5 —Diabetic diet. Chart No. 1 insulin to give this patient 80 grams of carbohydrates, 70 grams of protein, and 145 grams of fats, having a total caloric value of approx imately 2,000 calories. The sugar formers of such a diet is 135. We have already estimated that the sugar formers of the maintenance diet is 62; hence the patient will need 135 less 62, or 73 grams of insulin assistance, in order to accommodate the diet having a value 180 Vol. XX. OWENS—INSULIN. of 2,000 calories. If 73 is divided by 35, it will indicate the number of c. c. of U20 Lilly iletin required, and would amount to 2 c. c. in round numbers. If the UlO is used, one needs to administer 4 c. c. of insulin daily. p -1-60 + 73 -+-T0 -Ms +60 ■S3 •50 S ± 5 t49k -40 + 35 --30 +23 ■20 ■13 -J- 10 no 105^3 KM 93^ 90 00- M 30tOO K - § 65-= 60-; 30-^ 45 40- 33-E 24100 " 00 23 W22§00 J lO100 < : £ it; oo *~ 16}00 00 1 14400 r [-300 -290 -290 zn 260 -230 -240 -2JO 210 K'O -200 MJOO 83-00 t- •190^ •180b ■IT0g -160§o -ISO -140 -130 -120 -no -103 -90 -to 00 43-f- £ so 23 20- DIRECTIONS: (l)FOR. BAiAL MAINTCHWC OCT. I.6S TO I RATIO DCTCRMINCBASAL MAINTCNANCCCALORICfttauRCMCNT(TOTAL BASAL CALOMES PCR DAY)TO TMC PROPCP.HCIGnTAND vtiCMT, AGC ANDSCX Or TnE PATJCNT ON CHARTI AS PCR OlfttCTIONSOIVCN TnCRC. On CmaRTD LOCATC Tr* CALOACSTHUS DCTCRMJNCO, fSCALCM) LOCATC TMC GRAMS OT PROTCINON 3CALCP. BCTVCCN 40 Of*A GRAM AND AND I ORAMOr PROTCINPcft KILOGRAMor BOOT "wCIGHTARC OCSlAABLC. A AULCR CON" NCCTWGTHCSC T\*> POINTS OIVCS TMC GRAMSor CA60HYDAATCANDTMC ORAMSOT TAT AT TH£ POINTSON 5CALCSC AMDT RCSPCCTtVCLYV/MCrC IT CHOJSES THEM. AT TMC imtcrscctionvrm scale 0 rr owes thc sugar vrlue or the chct w orams. The roOOMUTUACTHUS ESTIMATEDMAS A *ETOGCNC-ANTinCTOCCNC RRTD OT 1.85 TO I. (8 Tor MaximumCaloric Oct (insulin). hav1n0 0ctcrhneo on scale c tnc sugar value ot the basal maintcnancc oct, ado the number or grams or olucosc to bc balancco by msuln locatc this valuc on scalc 0. ' Any straight unc NTtroCCTWO SCALE 0 AT THIS PONT AND CROSSINO TMC OTHER SCALES UR.L ONE A OCT THAT HAS A riCTOGCNC- ANTIACTCCCniCRATH) OT 163 TO I. Fio. 8.— Diabetic diet. Chart No. 2. In our experience weThave found that in the majority of patients with a fairly equal distribution of food between the three meals of the day five-eighths of the total dose should be given before breakfast and three-eighths before supper. In this instance we would give No. 2. OWENS —INSULIN. 181 li c. c. before breakfast and £ c. c. before supper. When starting the insulin treatment, it is well to begin with only one unit of U10 iletin, as Joslin states that even one unit of UlO has dangerously reduced the blood sugar. One of my patients prefers to take only two meals a day and the noon meal is the heavy one. As the result of insulin treatment, the patient's tolerance has increased and the insulin has been reduced from 2 c. c. to J c. c. daily. This amount administered before the first meal satisfactorily meets the require ments of both meals. In the discussions of blood-sugar changes I indicated that when the patient's blood sugar reached as low as 0.07 certain symptoms of hypoglycemia appeared. # Symptoms incident to an overdose of insulin were of frequent occurrence during the early stages of investi gation, when insulin was not so accurately standardized, but even now one may encounter them, particularly during the early weeks of treatment, when by keeping the patient continuously free from acidosis and urinary sugar the tolerance usually increases very rapidly. Under these conditions the symptoms of an overdose are usually mild and easily treated, especially if the patient is taught to recognize them early. ' The symptoms of hypoglycemia are as follows: Hunger: As a patient's blood sugar falls he usually experiences a keen appetite. In this connection it must be realized that all diabetics are naturally hungry. Slow mentality: The patient may complain that he can not think clearly. Extreme weakness and dizzy feelings: These symptoms of overdosage are frequent and are probably the most reliable early symptoms. Rapid pulse and respiration are fairly common. Visual disturbances: These may be double vision, and dark spots may appear before the eyes. Shaky feelings: The words "shaky" or "the shakes" have been established by the patients themselves and seem to describe in a satisfactory manner the patients' own feelings. 182 Vol. XX. OWEN&—INSULilf'. Fig. 7. — Diabetic diet orders. No Name Date BedNo__- Table No... Diet Rx COH Prot Fat - Grams. Food. Breakfast. Dinner. Supper. 10% fruit Total grams. COH. Prot. Fat. Meat ■ Total grams Food value of the diet: Calories. Grams COH at 4 equals Grams prot. at 4 equals Grams fat at 9 equals Total Convulsions: If a patient is seriously overdosed he becomes unconscious. The treatment of overdosage consists of immediately giving the patient food rich in sugar formers. We instruct our patients to have on hand a supply of little squares of Baker's sweet chocolate, and the nurse keeps oranges available, because orange juice is an excellent remedy and quickly relieves the milder symptoms. When the symptoms are more urgent, adrenalin may be administered hypo- dermically and will cause the body to rapidly change large quantities of glycogen into sugar. In the severer forms of overdosage, where unconsciousness occurs and the patient can not swallow, glucose should be given intravenously at once. It is well to have available for administration 100 c. c. of sterilized 50 per cent glucose and a 25 c. c. syringe ready for instant use. Insulin should always be administered just before meals so that the sugar formers of the food may neutralize the insulin and the danger of overdosage diminished. With an intelligent regard for scientific dietetics and a properly standardized preparation of insulin, one need not experience con cern when the patient presents symptoms of hypoglycemia. It not infrequently occurs that patients are glad to indulge themselves in a candy spree after possibly years of abstinence. It is the old story of the snake bite sufficiently up to date to meet the requirements of the eighteenth amendment. No. 2. 188 OWENS —INSULIN. Since the publication of Banting and his associates of the first reports of the clinical effects of insulin in diabetes mellitus a sufficient number of cases have been observed throughout the world to justify the statement that when insulin is administered subcutaneously in adequate dosage it is capable, in a remarkably short time, of remov ing the cardinal symptoms of the disease for a period of several hours (approximately 10 or 12). To suppress the symptoms perma nently, however, the injection must be repeated at least twice a day. So long as administration is continued the patient is able to assimilate much more carbohydrate than previously, and he begins to gain weight, and with it both physical and mental vigor. The blood sugar is lowered and maintained at a normal level; ketones disappear from the blood and urine. Craving for food disappears, and nervous and mental symptoms are abated or abolished; whether the diabetic condition is in any way cured by the rest which is given to the damaged pancreatic function by insulin can not as yet be stated. One of our cases of severe diabetes, which during the early treat ment required 20 units of H10 insulin, has advanced in such a satis factory manner that for a period of five weeks insulin was not needed. Authorities agree that the best results have been obtained in the adolescent forms of the disease, but there can be no doubt that when insulin comes more into general use its administration, along with intelligent control of the diet, will have the same beneficial results in all serious forms of the disease. In cases of threatened coma its value is undoubted, and this is also the case in which it is used as a precau tionary measure against postoperative risk in surgical procedure. In a paper read before this conference several months ago entitled "Advances made in our professional work during the past year" it was stated that one of the objects of the hospital should be to make it possible for naval medical officers ashore and afloat in this vicinity to keep in touch with the latest diagnostic and therapeutic procedures. Thus, from time to time the commanding officer has invited eminent civilian physicians to give talks on timely subjects to the Army and Navy medical officers and the civilian physicians of San Diego. In March Dr. Bernard Smith, of Los Angeles, a pioneer worker with insulin, delivered at this hospital a lecture detailing his clinical and laboratory experiences. We had already accomplished considerable work in blood chemistry and had developed an intelligent under standing of its possibilities. We had also made an intensive study of the relation of chronic foci of infection to systemic manifestations, and some of our investigations in this particular field were original and have been reported before the conference. Thus with the arrival of the first shipment of iletin in April from Lilly & Co. we were pre pared to* go ahead, and it would seem that we have considerable reason for gratification in being able to report this series of 12 cases of diabetes mellitus treated with insulin. COTTLE —NOVOCAINE ANESTHESIA. Vol. XX, NOVOCAINE ANESTHESIA. By G. F. Cottle, Lieutenant Commander, Medical Corps, United States Navy. The history of the development of the art of surgery during the past half century is inextricably bound up with the history of the development of the use of anesthetics. The aseptic era made modern surgery possible, but anesthesia made people willing to submit to operations. The type of anesthetic available greatly influenced the typo of surgery performed. It often influenced the method of surgical attack and not infrequently the anesthesia used determined the final result. Before the days of ether, when partial anesthesia with large doses of alcohol and morphine was used, great speed was of vital importance in surgery to lesson the duration of pain which reflexly brought on shock. Often gentleness in handling tissues was subordinated to the vital requirement of speed. Ether and chloroform with their abolition of consciousness and of pain were accepted at first as the final solution of the problem and surgery took great strides ahead. More complicated procedures became possible and more persons were willing to submit to them. As experience grew, the dangers of these drugs became known. Chloro form, except in a few special localities, was practically discarded. The method of ether administration became modified; less was given and a less deep degree of narcosis maintained. It was found that the general anesthesia which lasted more than an hour was fraught with danger to life; that for the debilitated, the aged, and the very sick even less than one hour was often very dangerous to life. Gas and ether became the vogue; gas-oxygen and ether came to be used in sequence and in combination. Ether with scopolamine, morphine, atrophine, and other drugs was used. Ether with magnesium sul phate per rectum and many other combinations of drugs were tried and thought to be better and safer than straight ether. Ether vapor was warmed by complicated apparatus; it was given through tubes in the mouth, the nose, the pharynx, and the trachea. It was placed in fluid form in the rectum. Specially trained experts, men and women, made the administration of these drugs their life work, and the professional anesthetist came into vogue. State laws prohibited any but licensed physicians from giving general anesthetics. The Mayos advocated the open-cone method of ether by the drop method. Crile developed his theory of anoci association with its combination of peripheral nerve block and gas-oxygen-ether anal gesia. Patients still died occasionally of the immediate effects and not infrequently postoperative recovery was jeopardized by the after effects. The aged, the renal, the cardiac, the seriously anemic, the goitrous, fand the debilitated were still bad anesthesia risks. Sur geons still found speedy operations necessary and often insisted on most complicated methods of anesthesia aclministration. Trans No. 2. 185 COTTLE —NOVOCAINE ANESTHESIA. fusion before operations, less strenuous methods of anteoperative preparation, a carefully developed technique to lessen anteoperative psychic apprehension, the use of alkaline and glucose rectal and subcutaneous solutions to combat acidosis and renal stasis, all these have had their advocates and have taken their place permanently as adjuncts to surgery and partial antidotes to the dangers of anesthesia. If a study is made of the use of anesthetics at that great surgical center, the Mayo Clinic, the chapters in the history of modern anes thesia are illustrated by the varying practice of the staff at the present time. The oldest group of surgeons feel that a highly trained anesthetist, preferably a nurse, administering ether by the open-cone method is best and will suffice for any surgical procedure, even for exopthalmic goiter. The next younger group of surgeons favor gas- oxygen-ether administered by a highly trained expert. The next younger surgeons occasionally use and often speak of the advantages of spinal, caudal, paravertebral, block, and infiltration local anesthe sia for certain procedures, as, for instance, the Kraske excision of the rectum, prolonged bone graft operations, the long dissections for the repair of ventral hernia, thyroidectomy for exopthalmic goiter, and they use the specialist in local anesthesia, who injects the novocaine solution for them prior to operation. The youngest group of sur geons use the specialist in novocaine more frequently and themselves use the block and infiltration methods of local anesthesia as part of their own surgical procedure, especially in exopthalmic goiter, the cachexia and starvation of cancer, the debility of gastric retention, and the dangers of thoracotomy and thoracoplasty. If we look elsewhere, we find Shields, of New Orleans, and Fair, of Minneapolis, using local anesthesia for almost every operation of general surgery. In Vienna and in France we hear of total and partial gastrectomy beiag performed with local anesthesia alone. Aboard ship, in the field with the regiments of the United States marine forces and at naval stations, operations are of necessity per formed occasionally and not as a rule every day or even every week. The occasional operator must work with an ever-changing crew. The flow of personnel in the service is so rapid and the changes so un avoidable that the naval surgeon is often forced to perform his sur gical operations with a different team of assistants at each operation. Not infrequently must he operate with assistants of unknown abil ity and at times with assistants inexperienced in any but the rudi ments of the surgical art. Seldom does he have the services of a trained and experienced anesthetist, and not infrequently he must use an anesthetist of unknown ability or one with insufficient experi ence. Often the naval surgeon must not only perform the operation but closely supervise or perhaps direct the administration of the anesthetic as well. 186 Vol. XX, COTTLE —NOVOCAINE ANESTHESIA. Local anesthesia does away with the dangers of this situation. In the naval hospital, aboard hospital ships, and at certain naval stations operations are performed at more frequent intervals, and there is a more permanent staff. However, even in these larger centers of naval medical activity, doctors come and go, nurses are of necessity moved to other duties than those of operating room, hos pital corpsmen must rotate frequently in their duties to speed up their training. Change, change, change of personnel is a rule of the service that can not be altered because of conditions peculiar to and inherent in it. Even in that fortunate naval hospital where the serv ices of a highly trained and capable anesthetist are available, un avoidable occurrences interfere with continuity of this service. An emergency operation or a case especially in need of the services of the trained anesthetist comes along and for one reason or another the surgeon finds it impossible to avoid using an anesthetist of un known ability, thus adding to the complexity of his work and adding perhaps occasionally to the risk the patient must take. Local novo- caine anesthesia simplifies this situation, and while it does not do away with the need for the well-trained anesthetist for those cases in which general anesthesia is required, it does make it easier for the surgeon to bridge over deficiencies in this staff which so often un avoidably occur. For years in the active service afloat and in the field, the open- cone and the drop method of ether administration has been the usual, the favorite, almost the standard procedure. For many reasons, in spite of the difficulties caused by ever-changing personnel, this method has proven successful. The majority of persons in the active service operated upon outside the naval hospital or hospital ship are young and often unusually robust individuals with a large reserve of physical energy; seldom do they come to the surgeon debilitated by disease. The open-cone method is safe for these patients with ordinary care in administration. It requires the simplest apparatus, everywhere available, and this method of administration of ether can be supervised by the surgeon while he is operating. It is perhaps the safest method of general anesthesia in the hands of the comparatively inexperienced. In naval hospitals and on hospital ships, efforts to have on hand the more complicated forms of apparatus for general anesthesia have been successful, but years of effort have not succeeded in assuring the naval surgeon of the continuous presence of a specially trained anesthetist at ail hours and every day in the year to aid him in his work. Local anesthesia will lessen the responsibility of the surgeon, who must otherwise not infrequently, because of these service conditions, not only operate upon his patient, but almost give the anesthetic in addition. Local anesthesia will permit the naval surgeon to shorten the duration of ether narcosis in debilitated subjects or when performing operations that can not be done in a No. 2. 187 COTTLE —NOVOCAINE ANESTHESIA. comparatively short time, for it enables the surgeon to begin and end an operation without ether, thus greatly reducing the time of narcosis and greatly reducing the anesthetic risk to the patient. The surgeon who wishes to succeed in the use of local anesthesia in general surgery must take care to estimate prior to operation each patient's psychic state and must be able to instill each patient with confidence in his ability to operate in this manner without giving him too heavy a burden of pain. He must acquire a knowledge of the surgical topography of the peripheral nerves. He must learn to cut and not to tear the tissues. He and his assistants must be gentle in handling tissues, especially so in traction. To these, add a quiet operating room, any standard book on the subject of local anesthesia (Lebat or Farr) , sharp needles and knives, patience, persistence, and the opportunity to practice the method and success will attend the surgeon's effort. At the naval hospital, New York, during the past three years, novocaine anesthesia has been used in an increasing proportion of cases operated upon. Its use has been extended from month to month to a greater variety of procedures. Patients in the surgical wards now seldom insist on ether before an operation and almost without exception after an operation are enthusiastic about local anesthesia. Those who at some former operation have had ether occasionally have to be won over to local anesthesia, but these patients are loud in their praise after operations under local. That limitations exist beyond which general anesthesia is necessary, is certainly true. Increasing experience, however, make these limitations less and less. That local anesthesia has proven its worth at this hospital is indicated by the fact that it has lived beyond the days of the pioneers here and has become the accepted routine practice to be given up for other anesthetics only when contraindications to its use exist. Somewhere between the ultraenthusiasts who feel that all surgery should be done under local and those ultraconservatists who condemn the method before sufficient experience has shown them its advantages, there is a middle ground upon which the seed sown by its early advocates will surely take root and grow as a great aid to surgery and a boon to surgical patients. In the United States Naval Medical Bulletin for June, 1923, King describes in detail many of the outstanding features of the technique of local anesthesia. It was his enthusiasm for this method coupled with his gentle and anatomically careful surgical technique that wore away the ether habit at the United States naval hospital, New York, and established the novocaine anesthesia as the usual preferred method. All credit for its development an'd establishment there belongs to him and to the support and encourage ment given him by his chief of service, Commander Old. During the six months' period, April to September, 1923, inclusive, the surgical staff of the United States naval hospital. New York has 188 Vol. XX. COTTLE —NOVOCAINE ANESTHESIA. performed 173 major operations, of which 99 were performed under novocaine anesthesia, 23 under comb.ned anesthesia; i. e , novocaine plus general anesthesia. The remaining 51 were done under general anesthesia alone. Except for one death from cachexia and ex haustion on the 12th day postoperative of a case of advanced retro peritoneal endotheliomia all the operations have resulted in cure or sufficient improvement to warrant discharge from the hospital. It is the belief of the surgical staff that local anesthesia contributed materially to the sucess attending these operations and that it ma terially reduced the risk to life. In these 99 cases in which local anes thesia was used and in the 23 in which it was used in combination with ether or gas-oxygen-ether wound healing was not delayed. Not one serious infection occurred, though there were a few stitch abscesses, but not in a greater number of cases than occurred with straight ether. No evidence of toxicity from the drug injected was noted. The patient's anteoperative apprehension except in a few highly- neurotic individuals was lessened. They advised fellow patients to ask for local. Postoperative care was much lightened for attend ants and nurses, convalescence was quieter and happier; postopera tive catheterizations less frequent, postoperative gas pains less severe, postoperative vomiting eliminated, and thirst not present. It may not be out of place to define here briefly the terms frequently used to describe the type of local anesthesia administered: Spinal. —Injection of the anesthetic solution into the space be tween the spinal cord and its sheath, the space bathed by cerebro spinal fluid. All sensory impressions of pain which emanate from the periphery supplied by nerves given off at or below the level of in jection, generally the third or fourth lumbar interspace, are thereby- blocked. Caudal. —Injection of the anesthetic fluid through the hiatus sacralis on the posterior surface of the sacrum a little above the sacro-coccygeal articulation. The fluid bathes in this situation that leash of nerves called the cauda equina, thus blocking sensory im pressions or pam ordinarily received from their peripheral distribu tion. Para Vertebral. —Injection of the anesthetic solution into or around the spinal nerve at its emergence from the intervertebral foramen. Peripheral Nerve Block— Injection into the sheath or in the tis sues immediately around the sheath of a peripheral nerve some where between its origin and the periphery. Infiltration. —Injection into the tissues and generally means in jection into skin, subcutaneous tissues and deep fascia, muscles, nerves, etc., at or around the immediate site of operation. Intradermal Wheal. —Produced by injection between the deep and superficial layers of the epidermis. The solution used is procaine 1 per cent in normal saline freshly- made each day, sterilized by boiling and autoclave, four drops of No. 2. 189 COTTLE —NOVOCAITfE ANESTHESIA. adrenalin being added to each ounce just before use. The spinal and the caudal injections used are those described in Labat's book on local anesthesia, and these methods are used only when definitely indicated, because there are at times unpleasant reactions not seen in the usual infiltration procedure. The needles and syringes used are those listed on the Naval Medical Supply Table. A little patience, a little care in relearning the surgical topography of peripheral nerves, gentleness in handling tissues, anatomically guided dissections with cutting, not tearing, a willingness to study the nervous and psychic state of each patient prior to operation, these combined with an opportunity to practice this method of anesthesia will, if persisted in, after the first few partial failures, make an en thusiast of any surgeon and will greatly minimize the patient's anteoperative apprehension and postoperative discomforts and will lessen the dangers of surgery. The naval surgeon who becomes an enthusiastic and reasonably capable practitioner of this not difficult art will find it a boon to his patients and a great aid to his surgical success. Table of illustrative catet. Cue Initials. No. 1 J. J 2 K. A. J... 3 B 4 F.E .- W 6 S. £ 7 D. R.A... 8 A 9 R. A. J.... 10 0. E. F... 11 12 McL 13 W. 0. V . . 14 R 15 C E. W... 17 18 A. L. J.... 19 20 AW.. .. 21 F.C. F.... Condition and operation. Cancer of lip and varix of leg, Mayo operation. Incarcerated scrotal hernia , Senile gangrene, postamputa- t ion thigh. Subphrenic abscess, first stage, rib resection. Rib Type of inesthosla. Indications for local. Local Ago 69, oral sepsis, debility. Rib resection, 6 ribs, second stage of graded thorocoplasty. of ribs 22 M Ii.. 23 O'B... Excision of duodenal ulcer. Chronic appendicitis Fistula in ano Block dissection, neck.. ...do.... Spinal. .do.. ..do.. ..do.. Local and ether. Local.... ....do Cystoma, neck Thyroglossal cyst Excision teno synovitis, wrist and loose fragment old com muted fracture, scaphoid. Hallux valgus, bilateral General peritonitis, acute gan grenous appendicitis. Nephrolithiasis ureterolithoto my. Foreign body near lesser tro chanter of femur. Recurrent Inguinal hernia, in guinal hernia. Recurrent inguinal hernia fol lowing infection. Ventral nernla hernia Caudal.. ..do ...do ...do ...do ...do ...do.... ...do.... Local and ether. Local ..do.... ..do.... Femoral ..do.. ..do- Ago 75, chronic alcoholism. Ago 81, advanced arteriosclerosis, oral sepsis, and senile emaciation. Chronic sepsis, emaciation, anaemia, 40 pounds below normal weight. Active pulmonary T. B. C; chronio sepsis, pyopneumothorax, weight 98 pounds. Quioscent pulmonary T. B. C.; old em pyema, tuberculous. Recurrent old war-time empyema, acutely ill, chronic sepsis. Chronic pulmonary T. B. C, under weight, undernourished. Arrested pulmonary T. B. C, under weight. Arrested pulmonary T. B. C. Tuberculosis of lymph nodes, old si nuses and fibrosis, prolonged dissec tion. Do. Aid to dissection. Do. X-ray evidence fibrotic changes, both apices. No after effects of ether necessary. Acute illness. Acute Illness, high fever, 30 pounds un derweight, acute hydronephrosis. Prolonged dissection. Long dissection. Do. Da Poor physique, underweight. note.— This group of 23 cases selected from the 171 major operations periormed at the United States Naval Hospital, New York.N. Y., during the six months' period April to September, inclusive, Illustrates the range of surgical procedures carried out under local or combined anesthesia. Of the 23. 1 was spinal, 1 caudal, 2 combined local and other, and 19 local. Of the entire 173, 96 were local, 1 splnr 23 combined anesthesias, and 51 general. Under the heading "Indications for local" are gi the reasons local was considered Indicated In these cases. For the two combined anesthesias 1 ether wu used after the Incisions were completed because of the special need for retraction. 190 Vol. XX, WILSON —YAWS IN HAITI. OBSERVATIONS CONCERNING YAWS IN HAITI. By P. W. Wilson, Lieutenant, Medical Corps, United States Navy. This paper is not in any sense an exhaustive study of yaws, nor is any attempt made to draw any conclusions concerning the relation ship between yaws and syphilis. There is no doubt that both diseases exist here in abundance, and the excellent opportunity offered for the study of the two in parallel should stimulate further research. Our own brother medical officers in Guam and Samoa have contrib uted considerable information, and they are quoted in nearly every article on the subject, but no one has yet proved conclusively whether Treponema pallidum and Treponema pertenue are the same organism or not. It has been, and is still, held by some distinguished authorities that yaws is syphilis modified by race and climate. From Manson's^ Tropical Diseases, 1921, the following quotations may not be out of place: "Yaws is practically confined to the Tropics and sub-Tropics and even there is absent at high altitudes, but owing to its great similarity to syphilis, and the extent to which these two diseases overlap, it would appear to be impossible to define its exact limits. Probably some reciprocal immunity between the two diseases exists, for wherever yaws is widespread—as, for instance, in the Pacific Islands — there syphilis appears to be unknown." "Opinions differ with regard to the exact morphology of T. pertenw, but later observ ers, including Dobell, have been unable to distinguish any structural differences between this treponema and treponema pallidum of syphilis." "The disease was originally reproduced in the big apes in Sumatra by Neisser, Baermann, and Halberstadter, who found no reciprocal immunity in these animals when subsequently infected with syphilis; but this view is opposed to the work of Lavaditi and Nattan Larier." It is interesting to refer briefly to the early history of yaws and syphilis. Diaz de Isla, a Spanish physician of some note practicing in Lisbon, in his book written between 1510 and 1520, states that syphilis was unknown in Europe before 1493 and that, as far as Europe was concerned, it had not made its appearance until Colum bus's crew brought it to them from the Isle of Espanola. He also states that the majority of Columbus's crew returned to Spain infected with the disease, which they had acquired in Haiti, and that he himself treated several of the syphilitic sailors, including the pilot, Pinzon de Palos, and that after the arrival of Columbus in Barcelona in 1493, syphilis spread among the inhabit ants. His statements are confirmed by Olviedo and Las Casas, both of whom visited the New World a few years later. Olviedo, in a report to Emperor Charles V, states that it is certain that syphilis originated in the West Indies, but was a milder type than in Europe. Concerning the history of yaws Manson states that it seems probable that yaws Now 2. 191 WILSON — YAWS IN HAITI. was originally an African disease and, so far as America and the West Indies are concerned, that it was introduced by negro slaves. In the days of West Indian slavery the specific and infectious nature of yaws was thoroughly recognized, and the planters controlled it by instituting yaws houses and similar measures, but since the emancipa tion of the negro the disease has again become very prevalent. In tropical Africa, particularly on the west coast, yaws is very common. The original Indian inhabitants practically disappeared fram Haiti toward the close of the sixteenth century or within 100 years after the first coming of the white man. About 1505 the first negro slaves were imported into the island where they increased at their usual rate and their numbers were further augmented by large importa tions from the west coast of Africa until within a century after the arrival of the first negro they had practically replaced the native population. One of the earliest writers concerning the West India Islands, in speaking of the malignant fevers, says: "The bad air was brought there by some ships which came from the west coast of Africa." History tells us in a rather indefinite way that the native Indians were unable to stand the hard work imposed upon them by their Spanish masters. But right here it is interesting to ask ourselves some questions. Was the Indian killed off by cruelty of the Spaniards or by yellow fever from Africa? Why did the negro thrive so well in contact with the syphilitic Indian? Was he wholly or partially immunized to1 syphilis by yaws ? It is impossible to answer these questions conclusively, but it is believed that Haiti was the first country where the two diseases were present at the same time. One frequently hears the remark from both laymen and physicians that 80 per cent of all Haitiens are syphilitic. Lieutenant Choisser obtained 71.2 per cent positive Wassermanns on patients admitted to the Haitian General Hospital, and while these findings are excep tionally high yet no one can say what proportion of that number were syphilitic and what proportion had had yaws. The writer has only seen 19 cases of yaws in the secondary stage during nine months residence in Haiti, but the number of cases seen in the tertiary stage is well over 200. The doubt will be imme diately raised as to whether a good proportion of such a large number of tertiary lesions were not luetic instead of grambesial, and in answer to the supporters of the luetic diagnosis the balance of this paper is devoted. For all Haitians, regardless of degree of color, intelligence, or social position, "pian," or yaws, is a disease of shame. Don't ask a Haitian, "Have you ever had yaws?" Ask him, "How old were you when you had yaws?" If he comes from the country, keep insisting, and if there are no bystanders listening he will probably 74458— 24— -4 192 Vol. XX, WILSON —YAWS IN HAITI. admit the disgraceful fact, or he will reply that he has not yet had it. Why is there such an opprobrium attached to this disease? Does it date back to the time of the yaws houses where the unfortunate sufferer was isolated as a leper and where he spent many long months in company with other outcasts from society? At any rate the readiness with which a patient admits a past yaws infection seems to vary greatly in different parts of the country. At Aux Cayes, for example, it is understood that it is almost impossible to get an affirmative answer. The disease in the secondary stage is practically unknown inside the city limits of Jacmel, and for a good reason. Since early times no cases have been allowed to remain in town once they have been discovered. Only two cases in the secondary stage have been seen in the outpatient clinic. One was a young adult on his way out of the city and he only stopped at the hospital because it was on his road. He had been told by several citizens not to remain in town overnight or he would be driven out if he was discovered the following morning. The other case was a little girl whose lesions were mostly hidden by her clothing, and she escaped unnoticed. Inquiry has been made from several of the older inhabitants and they all substantiate the story of the fugitive, "No early yaws cases are ever allowed to remain in the city." Many of the tertiary cases come to the city and are allowed to remain, for it is the popular opinion that such people are either lepers or syphilitics, and as such they are considered harmless. What happens to the primary or secondary case in the country? Often he is put in a house apart from the rest of the family and he is so ashamed of his condition that he keeps himself hidden without persuasion. If you meet him on an out-of-the-way trail he will either move quickly into the nearest cover of underbrush, which is usually close at hand, or he will so wear his hat or hide his lesion with his hand or arm that you will not see his condition. This is not only true when he passes a white man but he acts the same in passing any stranger. What treatment do such people employ? First of all, they must not get well too quickly, for it is generally accepted that a quick disappearance of the lesions can mean only one of two things —a quick death or some "inward disease" more difficult to cure than the yaws. The question has been frequently asked in different sections of the district concerning the treatment employed, and the answer is always the same. "Daily baths in clear, cold water." These patients never seek medical assistance. Seventeen cases have been personally invited to come to the hospital for treatment, and it has also been carefully explained that by early treatment they could avoid the "crab," or foot yaws, the disfiguring mutilation of the nose Xo. 2. 193 WILSON —YAWS IN HAITI. and face, the painful leg ulcers and bone deformities. They always say, "Yes; I will come," but none of them have arrived. Of the more than 200 cases of tertiary lesions seen at the Jacmel Hospital every one coming from the country districts has given a history of yaws. Most of the adults state they had the yaws when they were children and that their present trouble is due to "a fall from a horse," "an attack of cholerine," "that it followed immedi ately after the smallpox," or " that some enemy has placed a curse on them." The last explanation is probably the most common. It is practically impossible to convince any of them that their condi tion is a result of yaws. They say that they have already had yaws, which never comes a second time. In only one case was a history of both yaws and syphilis obtained, and this patient stated that his yaws was contracted in town ; that he was forced to go to the mountains on account of it, and he remained there four months. Shortly after his return he contracted what was called a chancre and he now has a perforation of the hard and soft palate. The diagnosis of either condition in this patient may have been incorrect. Certainly he has had one or the other of the two diseases, but to say that he had both may be readily doubted. It is impossible to give an estimate of the amount of syphilis present in the Jacmel district. It is believed, however, that while yaws is essentially a rural disease, syphilis, though it is not confined to the towns, yet certainly it is more generally found in the city and villages. Only one case of undoubted syphilis with primary and secondary lesions has been seen in a patient living and working in the country; he denied yaws and stated he obtained his infection in town. Five cases of aortitis have been diagnosed, all of whom were city dwellers, four of whom admitted syphilis, and they all denied yaws. Three cases of hemiplegia occurring in young adults have been seen, one of whom admitted syphilis and lived in town; the other two were from the country and both admitted yaws and denied chancre. The writer is not qualified to diagnose border-line cases of iritis, but up to date no typical cases have been seen in patients admitting yaws. The teeth of nearly every patient coming into the out-patient clinic have been examined for evidences of hereditary syphilis, but no suspicious or characteristic syphilitic teeth have as yet been recognized. It has been observed that syphilis is more prevalent among the mulattoes than those nearly or entirely black. Two factors may explain this—mulattoes are generally considered to be cleaner in their personal habits than the blacks and perhaps for that reason have not contracted yaws which might immunize them against syphilis; and the proportion of mulat toes is greater in the city, whore they are more exposed to syphilis than in the country. 194 Vol. XX. WILSON — YAWS IN HAITI. Of the tertiary yaws lesions most frequently seen, those resembling tubercular syphilides with ulceration are by far the most common. Periostitis and osteitis of the bones of the leg with ulcerations of the skin are the next in order of frequency. Destruction of the bones of the nose and posterior portion of the hard palate are the next in order, and where the nose itself has disappeared the patient usually gives a history of the infection having progressed into the nares from skin lesions on the face, and the abundant scarring of the face substantiated such a history. In this connection Kerr urges the disuse of the term "gangosa," and to place the ulcerations which the term was employed to describe into the category of late syphilis or late yaws. Twelve cases of saber-shaped tibia have been observed, each one of whom gave a history of yaws occurring prior to the leg pains and later deformity. The clavicle, scapula, radius, ulna, and small bones of the hand and foot are not infrequently involved. One case of epiphysitis of the knee joint, unilateral, has been seen, and this was the only case where the femur seemed to be involved. The humerus also seems to be exempt, and the same may be said of the ribs and vertebrae, but in this connection one case of what appeared to be spondylitis reacted so well to one treatment of neo- salvarsan that he insisted he was entirely well and refused to wait further treatment and study. It is reported that "crab," or foot yaws, is very common, but it occurs during the secondary stage or very soon afterwards; the natives recognize it as being of yaws origin and for that reason they do not come in for treatment. But one case has been seen in the out-patient clinic, and she came 5 miles over the mountains for "chills and fever," and the "crab" was found when an inquiry was made into the cause of her limping walk. She strenuously denied that it was the "crab" until she saw that we were too positive in our attitude to be dissuaded, but she stubbornly refused to receive treatment for it, stating that she only wanted treatment for her fever. One of the principal difficulties encountered in treating tertiary cases is the inability to keep patients long enough or have them return for treatment after they have once left the hos pital; they feel so much better after one dose of salvarsan that they leave in spite of advice to the contrary, and will roturn again after 9 or 10 months have elapsed when they have another exacerbation. It would appear that not less than three salvarsans at weekly inter vals should be given all tertiary cases; and, on the other hand, it would appear that there is but little clinical improvement after the fourth injection has been given. This lack of response beyond a certain stage of improvement is probably due to blocking of the circulation by cicatricial contraction and new bone formation, to malnutrition or secondary infection, and usually all three of these conditions exist. No. 2. 195 WILSON —YAWS IN HAITI. The epidemiology of the disease will not be discussed but it is desired to call attention to one fact : The Haitian countryman hardly ever uses soap in bathing his body, and in place of soap he uses leaves or grass for a wash rag. The mulatto needs to use soap in order to see the real color of his skin, but the black man's skin tells him but little no matter how thoroughly he may scrub himself. In this connection we only need to remember that soap solution is one of the best prophylactic agents against infection by the trcponema pallidum. In view of such close resemblance to treponema pertenue in morphological and cultural characteristics and the clinical tertiary manifestations in the bones and skin, may we not assume soap to be equally effective against both organisms? To give even an approximate estimate of the amount of secondary, tertiary, and latent yaws in the district of Jacmel is, of course, impossible, but several of the more intelligent residents who have been familiar with rural conditions for a long period have been questioned, and their replies may be worth considering. The lowest estimate of the number of cases of primary and secondary yaws now existing in the Jacmel district was 1 per cent of the rural population, while the highest estimate was 18 per cent; for those who have had yaws the lowest estimate was 25 per cent, and the highest was 80 per cent. Some suggestions concerning methods of combating this malady may not be out of place here. The present custom of waiting for the case in its most infectious stage to come to the hospital for treat ment is accomplishing nothing. The lack of money, and indirectly, the insufficient supply of neosalvarsan together with the limited bed capacity of our hospitals docs not give us the means to care adequate ly for the tertiary cases who always require more treatment and hos pitalization than an early one. Mercury is slow; it is difficult for patients to come from a distance for repeated injections; cases of stomatitis following mercury are frequent, and when they occur, tend to discourage not only the patient himself but any others who may learn of his condition. This tendency to stomatitis may be attributed to bad teeth and the almost universal habit of eating some acid fruit nearly every day. It is suggested that here is an abundant field to give sulpharsphenamine a good trial. It is difficult to give neosalvarsan under conditions existing in the country. Most of the early secondary cases are in children, and a relatively painless subcutaneous or intramuscular method of administering arsenicals of sufficient therapeutic efficacy would be most welcome to patients and public health officers alike, and it would greatly simplify work done in the field. Voegtlin, Johnson, and Dyer, of the United States Public Health Service, in their experimental work on sulphars phenamine have found that it is as well tolerated when injected intravenously as is arsphenamine ; that intramuscular injections of 196 SUMERLIN —THE LABORATORY AND THE HOSPITAL. Vol. XX, concentrated solutions cause some local reaction, which is, however, much less severe than that following similar injections of arsphen- amine or neoarsphenamine ; that it can be injected subcutaneously with impunity, provided that for full therapeutic doses the concen tration is kept high (20 to 30 per cent) ; that aqueous solutions of sulpharsphenamine are very stable, which is in striking contrast to solutions of neoarsphenamine; that the toxicity and parasiticidal value of sulpharsphenamine shows that the chemo therapeutic index, or margin of safety, is at least as good as that of the most potent drug so far known, namely arsphenamine. In conclusion it is considered : 1. That syphilis is more prevalent in the towns than in the country districts. 2. That yaws is very prevalent in all rural sections of the district of Jacmel. 3. That yaws is the most frequent cause of crippling and facial mutilation, and, as such, it is a constant economic drain on the Government. 4. That any campaign against yaws involves the curing of the early cases during the infectious stage, which means that at first the treatment must be taken to the patient rather than waiting for him to come to the hospital or dispensary. 5. That in order to facilitate such field work sulpharsphenamine should be given a thorough trial, with the hope that it will prove to be a remedy that can be given quickly and easily in the field. THE RELATION OF THE CLINICAL LABORATORY TO THE MODERN HOSPITAL. By H. S. Sumeblin, Lieutenant, Medical Corps, United States Navy. Progressive development of laboratory methods for the study and diagnosis of disease has resulted in an increasing demand for accurate and reliable bacteriologic, serologic, pathologic, and chemical exam inations, and for the preparation of biologic products as diagnostic aids and therapeutic measures. The past few years have seen a rapid multiplication of clinical laboratories particularly in connection with hospitals. Due to the financial saving, a large number of institutions depend almost entirely on technicians for the conduct of their laboratories, with little or no supervision, a condition which can do nothing but lower the standing of the clinical laboratory. A course in medicine is not necessary in preparation for the technical side of the work; however, for the interpretation of laboratory findings, especially serology and tissue pathology, a medical education is essential. To be of the highest service to the hospital, the laboratory must be in No. 2. SUMERLIN THE LABORATORY AND THE HOSPITAL. 197 close cooperation with all of the other lines of medical work done in the institution. This demands that a physician be in charge of it, and that he be a consultant of the clinician to interpret the significance of laboratory finding and to suggest additional laboratory procedures . Furthermore, his relation to the laboratory should be more than supervisory, he should devote his entire time to it. Problems are constantly arising in connection with the routine work which the technicians are unable to solve. The laboratory chief should be present in order that these problems may be referred to him. The efficiency of the laboratory is dependent also in no small degree upon the caliber of the technicians, as a large volume of the routine work is performed by them. Technicians must be taught the abso lute necessity of honesty in reporting findings. I have known a technician to change the result of a blood count to conform with the patient's diagnosis, thinking he might have made a mistake. The functions of the laboratory are as follows: First, to give what aid it can in solving the diagnostic problems confronting the physician; second, to aid in the prognosis of many cases, including the estimation of operative risk, by means of routine procedures, blood chemistry and basal metabolism determinations; third, by the same procedures, to show the effect of treatment; fourth, to detect unsuspected pathological conditions; fifth, to prepare biologic products such as autogenous vaccines and Swift-Ellis serum as therapeutic aids; sixth, to perform post-mortem examinations as a means of advancing our knowledge of disease and as a necessary step in cases where diagnosis is in doubt; seventh, to conduct original investigation and research. A chemical and microscopic urinalysis on each patient admitted into the hospital should be routine. It may detect an unsuspected pathological condition or correct a mistake in diagnosis. Too often a chemical analysis is done and the microscopic omitted. It is not infrequent that the detection of blood cells in the urine will lead to a change of diagnosis from acute appendicitis to stone in the kidney or ureter. A blood Wassermann on each case admitted will disclose many cases of unsuspected syphilis, and the information gained is worth the extra work which this requires. A spinal fluid analysis on every case of syphilis is now a recognized procedure; this includes cell count, globulin, Wassermann, and colloidal gold. I do not believe that the Lange colloidal gold reaction gives any information when the other tests are negative, and it is our custom to do this test only on known syphilitic spinal fluids. The value of this test lies in its ability to differentiate between paretic and cerebrospinal types of syphilis. A complete blood count on each case admitted is ideal, but when the facilities will not permit of this, I would omit routine blood counts. 198 SUMERLIN THE LABORATORY AND THE HOSPITAL. Vol. XX. Stitt (1) says regarding routine blood examination: "As a practical point, it is very rare that a red count is indicated. There is one point not sufficiently recognized by physicians, and that is that a routine blood examination is not apt to be as carefully conducted as one calling for a specific feature. Without disparaging the necessity of routine examinations of urine as well as blood, it is a fact that the internist who knows what he wants gets better results from the laboratory." 1 can see nothing to justify a routine white count on each case admitted; a routine red count or a routine hemoglobin estimation would be of just as little value. I would condemn the practice of making a red cell count alone; it gives no more informa tion than a hemoglobin estimation alone, is more subject to error, and more time consuming. Either will indicate anemia; both are necessary in differentiating primary and secondary types. In addition to the usual pathologic, bacteriologic, serologic, and chemical examinations, the clinical laboratory of the modern hospital must be prepared to do blood chemistry, basal metabolism estima tions, immediate diagnosis of tissue by frozen sections, dark field microscopy, blood grouping for transfusion, and possibly skin sensi tization tests. Chemical examination of the blood gives practical information in nephritis and diabetes in which older methods of blood examination gave little information. Only by blood sugar determination is the differential diagnosis made between diabetes mellitus and renal diabetes. We have seen several officers who have been placed on the retired list as diabetics because sugar was found in the urine. These cases showed normal blood sugar both under fasting conditions and after a carbohydrate test meal. In diabetes mellitus the hyper glycemia is the condition to which the attention should be directed, the excretion of sugar by the kidney being simply one of the body's many factors of safety. An advanced case showing nephritic symp toms may show a large increase of sugar in the blood without its appearance in the urine. The importance of blood chemistry is seen in the fact that insulin, the pancreatic extract used in the treatment of diabetes, was first placed in the hands of those only who could carefully control its use by blood sugar determinations. Estimation of the nonprotein-nitrogen content of the blood gives accurate information as to the permeability of the kidneys. Frontz and Geraghty (2) state that practically all the information of clinical value gained by the estimation of total nitrogen, nonprotein-nitrogen, uric acid, and creatinine is furnished by the estimation of the blood urea alone. The prognosis in a case of chronic nephritis is indicated by the blood creatinine, as figures over 3.5 mg. per 100 c. c. should be viewed with grave concern while anything over 5 mg. almost invariably indicates an early fatal termination. This does not hold No. 2. 199 SUMEELIN —THE LABORATORY AND THE HOSPITAL. true in acute renal conditions such as acute nephritis, bichloride pois oning, or acute exacerbations of chronic renal disease. The blood urea nitrogen has been found to be a very valuable preoperative prog nostic test in cases of prostatic obstruction. When the figures are between 25 and 30 mg. per 100 c. c. of blood, the patient should be operated on with caution, while anything over 30 mg. indicates a poor operative prognosis. The dark-field microscope is one of the most valuable instruments we possess, for by its use a positive diagnosis of syphilis can be made in almost 100 per cent of cases when the primary lesion is seen early and before any antiseptic has been applied. Since the diagnosis is more or less uncertain when the lesion has been treated, the impor tance of a dark-field examination of every venereal sore before insti tuting treatment can not be overemphasized. No laboratory is complete without facilities for the immediate diagnosis of fresh tissue. That the tissue pathologist is an essential factor in clinical diagnosis is shown by McCarthy and Broders (3), in whose series of mammary carcinomata the surgical pathologist dis covered 22 per cent during operation which the clinician and surgeon had diagnosed benign or doubtful conditions. Harper (4) gives the result of two years work on tissue at the Naval Medical School as follows: Clinical diagnosis correct 57 per cent, incorrect 9 per cent, clinical diagnosis undetermined 34 per cent. The number of doubt ful and undetermined diagnosis shows how much the surgeon and clinician depend upon the tissue pathologist. One of the most recent additions to the field of the clinical labora tory is the determination of basal metabolism. Pickard (5) states that the determination of basal metabolism in thyroid disease is like the use of the thermometer in febrile diseases and answers the same purpose of diagnosis, measuring the severity and marking the course of the disease and the effect of treatment. He states that basal metabolism estimation should be made (1) in cases with goiter to ascertain possible toxicity, (2) in cases with or without goiter having symptoms of thyrotoxicosis, (3) in similar cases with symptoms of thyroid deficiency, (4) in cases of obesity to differentiate those due to thyroid and pituitary disease, (5) for an accurate measure of the effect of treatment of thyroid disease. This is a very valuable preoperative prognostic test. When the rate is high, rest, hot- water injections, or ligations are resorted to preliminary to thyroidectomy. It must be the aim of the clinical laboratory to establish a reputa tion for accurate and reliable work in order that the clinician and surgeon may be able to place full confidence in every report they receive from it. It is said that there is an increasing tendency, especially among the younger physicians, to lean more on laboratory and instrumental 200 Vol. XX, LANE—GAS MASK. aids than on strictly clinical methods of examination. It is also said that many men are accepting laboratory reports without fully appre ciating the possibilities of error both in the tests themselves and in their interpretation at the bedside. In some cases, on the basis of history and examination alone, a certain diagnosis is impossible; in other cases, the laboratory reports are misleading; but as a general rule, the clinical laboratory is one leg upon which the diagnosis must rest. The other legs are the X-ray, the history obtained, and the physical findings. REFERENCES. 1. Practical Bacteriology, Blood Work, and Animal Parasitology, fifth edition, p. 224. 2. Jour. Am. Med. Assn., Oct. 21, 1922. 3. Surgy. Gynec. and Obst., December, 1917. 4. U. S. Nav. Med. Bull., January, 1922. 6. Jour. Lab. and Clin. Med., August, 1922. A OAS MASK FOR HEAD AND CHEST INJURY CASES.' By F. F. Lane, Lieutenant, Medical Corps, United States Navy. The objects to be accomplished by a mask suitable for such cases are as follows : 1. It must be an efficient substitute for the present mask, which could not be worn in such cases, but its protective qualities need not be of such a lasting nature. 2. It must be light, strong, and durable, to withstand folding, rolling, and field conditions. 3. It should be of one uniform size. As small and compact as possible when not in use but must fit the largest or smallest man. This would obviate the necessity of carrying several sizes and con fusion in issue and application. 4. It should not disturb any first-aid dressings which would be applied on the field. 5. It should be easy to make replacements or carry spares. Easy to handle on the field, easy to put on an unconscious man who is on or off the stretcher. 6. The stretcher bearer should be able to observe the patient. 7. The patient should be able to wear it without removing while changing from stretcher to stretcher or stretcher to ambulance. 8. It should be easy and cheap to manufacture. The mask. —This is to be hood or sack shaped, about 36 inches long and 60 inches in circumference at the open end. The closed or head end should be shaped in to fit the head and neck closely. The material to be of thin rubber and covered with nonolastic stock inette. This rubber and stockinette to be of the same specifications as the present gas mask but the rubber about one-fourth as thick. >Reprinted from Chemical Warfare of Nov. 15, 1923. No. 2. 201 LANE—GAS MASK. In the closed or head end will be the usual present-day nonshatter- ing glass eyepiece with metal rings and fittings; a metal angle tube fitted with a gas-tight joint for connecting or disconnecting the cor rugated tube, such as is used in the aviator's mask; the flutter valve and guard, but without the usual rubber or metal Y tube or air deflector. The open end will have a 4-inch webbing belt, 50 inches long, fitted with a friction-lock metal buckle, similar to the present issue belt buckle. This belt to be sewed on the outside, about 1 inch above the bottom, for 1 5 inches on each side of the mid line of the back with the remaining 10 inches of each end of the belt to be loose in front. On the inside of the hood at the open end and centered beneath the webbing belt outside, will be a thin rubber tubular ring about 2 inches in diameter covered with elastic stockinette and fitted with a valve and mouthpiece for inflating by mouth. Corrugated tuoe.—To be similar to the present tube, 18 inches long and with an air-tight joint connection for attaching to the face piece. Canister. —To be of the same construction and to have the same contents as the present olive-drab or blue canister but about one- half as large, that is about 1$ by 2\ by 4 inches. The carriers.— 1. Headpiece carrier: A flap of heavy canvas about 18 inches long and about 8 inches wide, firmly attached to bottom of the wooden side piece of the regular Army stretcher. One long edge should be firmly fixed to the bottom just inside the metal foot and the other fitted with snap buttons to fasten the upper edge of the side piece. The hood and corrugated tube may be folded, rolled up, and carried in this canvas tube, and easily removed. The cor rugated tube to run from the canister around the metal foot of the stretcher into this roll. 2. The canister carrier: This is to be a heavy canvas pocket, into which the canister will just fit, fastened securely beneath the wooden side piece of the stretcher, just outside of the metal foot. General discussion. —The gas mask just described appears to be one solution of the problem which will satisfactorily answer all the requirements set forth in the beginning of this paper. It should be easy to manufacture, since there are no new materials involved and many of the present stamps, dies, and molds may be used. The material described might be changed to some substitute for rubber when discovered or it would be much thinner and less bulky if made from rubber-coated cloth such as was used in the old issue black poncho or the very thin rubberized cloth of which the present-day housewife's apron is made, if these substitutes would give sufficient protection. The hood, if made of the present, but much thinner 202 VoL XX. LANE—GAS MASK. material, would be strong and durablo, easily folded, and rolled into a cylinder of about 2 inches in diameter, and it would have sufficieDt stiffness to allow it to be drawn over the head, shoulders, arms, chest, abdomen, and back down to the hips of an unconscious or semiconscious man without very great difficulty either on or off th.e stretcher. The hood, with the wide webbing belt and inflated rubber ring, will be as gas-tight as is possible. In small men the excess material in front may be folded carefully so that the lower edge will be entirely included under the tightened belt. Whatever small openings are left due/ to the contour peculiarities of the individual and any open ing left from time to time by abdominal breathing may be filled up by inflating the rubber ring. If this inflation is interfered with by the weight of the man lying on it, lifting the patient momentarily by the hips will obviate this difficulty. It is made in one large size, so that it will fit any and every man as the stretcher bearers come to them on the field. The dimensions and sizes given are only approximate, so that statistics and practice may make a larger one necessary or a smaller one more feasible. It is made long to the hips in order not to interfere with abdominal or chest breathing or allow openings to occur with respiration. One objection to this large size on a small man would be the pos sibility that, due to the large cubical contents of the hood, the patient might breathe the air in the hood over and over again and not breathe through the canister. This could be eliminated by tucking the excess material under the patient's back or having several straps or elastic bands on the outside to take up this slack. It is convenient and easy to carry, being fastened to the stretcher, and does not need to add to the individual load of the stretcher bearer. It will add, probably, only about 5 pounds to the weight of the stretcher. It does not need to be carried unless gas casualties are expected. Two outfits may be carried with each stretcher, one at the right hand side of each end when facing the center of the stretcher. This will add 10 pounds to the stretcher but allow for a spare canister and mask. It will allow the stretcher bearers to protect two men at once upon their arrival, leaving one behind on the field with the mask, tube, and canister, while the other is carried to the rear. Immediate protection would be given to two men instead of one. The detachable feature of the corrugated tube would allow either the canister or the mask to be canted or removed from the stretcher separately. The hood might be carried away from the stretcher to put on a patient under circumstances in which it would be impossible or inconvenient to do otherwise, or the man could be put in an ambulance with the mask on, with or without the canister. So. 2. 203 LANE GAS MASK. The first-aid dressings could be put on before the mask is adjusted, and then the hood would not disarrange, rub, or wet them as would be the case in a hypohelmet or other such contrivance which depends upon solutions for its protective powers. The only reason for the eyepieces is to afford a means for the stretcher bearer to observe the patient's condition. The material is thin enough to allow its manipulation to clear eyepieces of moisture or to lift the eyelids or open the mouth. The canister is made small because, first, a long-continued or great amount of protection is not needed, since the patient is removed from the gas -infested area with as much speed as possible, and, secondly, it is more compact and easy to stow on a stretcher, being equal in width to the wooden side piece . and will be protected by the metal foot from injury and tearing off by brush. A gas-mask outfit as described above would give efficient and com plete protection to men with head, chest,' or abdominal injuries and any combination of these three types of wounds complicated by gas, in which it would be impossible or inconvenient to use the usual face mask. If difficulty was experienced with the canister or with the bellows action of the hood in respiration or if it was thought advisable because practically all cases would be gassed by lung irritants, the flutter valve, the inflated rubber ring, and the canister could be done away with and a small oxygen tank substituted for the canister. In this way the patient would begin breathing pure oxygen immediately and the increase of gas pressure within the mask would overcome the atmospheric pressure outside, allowing the contained gas to escape outside and establish a current of flow outward, thus effectually seal ing off the hood from any entrance of poisonous gas. CLINICAL NOTES. IMPROVED TECHNIQUE IN SPINAI PUNCTURE. By T. W. Raison, Lieutenant Commander, Medical Corps, United States Navy. Spinal puncture in many conditions is indispensable as a diagnostic measure. Using the ordinary technique the procedure frequently is followed by severe headache and prostration to such an extent that the patient is confined to bed from one to several days. Owing to the depth of the spinal canal, from 4 to 6 cm. from the surface, and the resistance of the tissues encountered, a needle of sufficient size and rigidity to obviate the danger of breakage must be employed. Under ordinary technique in making spinal puncture, the obturator is placed in the needle, and when the dura is encountered, owing to the size of the needle a tear is produced which remains open until healing takes place. MacRobert1 asserts that sometimes the arachnoid is pulled through this opening as the needle is withdrawn, and that this causes a constant leakage of spinal fluid, which, by temporarily destroying the "hydraulic support" of the brain, is responsible for the head aches which so frequently follow lumbar puncture. With a punc tured wound of the dura with a fine needle, trauma is greatly mini mized. In the technique of spinal puncture devised by Randal Hoyt, M. D., assistant attending physician, New York Skin and Cancer Hospi tal, a special needle is employed. This technique was first described in an article entitled "An apparatus for withdrawing spinal fluid without postpuncture reaction," 1 but has since been modified by the improvement of the needle making the whole apparatus self- contained. The improved needle is manufactured by Becton, Dickinson & Co., Rutherford, N. J. The appliance consists of two needles, one slipping into the other. The outer needle is the ordinary type of lumbar puncture needle with a set-screw inserted in the shoulder to hold the inner needle so that its point is flush with the bevel of the outer needle during insertion. When the set-screw is loosened, the inner needle can be projected for about a quarter of an inch (6 mm.). The proximal end of the outer needle is arranged as a fitting for a Luer syringe, whereas the proximal end of the inner needle is arranged for a Record syringe. After the apparatus is arranged for introduction, lumbar puncture is made in the usual way up to the point of piercing the dura. At 'MacRobert, R. O.: The cause of lumbar puncture headache. J. A. M. A., 70: 1350, May, 11, 1918. 'Hoyt, Randal. J. A. M. A., 78: 428, Feb. 11, 1922. 205 206 Vol. XX, WILLIAMS —HEMATOMA OF SPERMATIC CORD. this place there is a distinct feeling of resistance. When the sensa tion of resistance is encountered, the set-screw is loosened and the inner needle pushed forward as far as it will go, making a punctured wound in the dura. The obturator is withdrawn from the inner needle and a Record syringe attached and the spinal fluid withdrawn. If a spinal treatment is to be administered, this is injected by a second syringe. To remove the apparatus, the obturator is inserted in the inner needle, the inner needle drawn into the outer needle, and the whole apparatus withdrawn. The common error is to carry the insertion of the outer needle too far and pierce the dura, thus performing an ordinary puncture. This can be obviated by stopping the insertion of the outer needle as soon as a feeling of firm resistance is encountered and projecting the inner needle, should spinal fluid not be obtained, the outer needle can then be shoved in as far as the slide and the inner needle again projected. The dura offers scarcely any appreciable resistance to the fine inner needle, and if firm resistance is encountered it is at once evident that technique is wrong and a bony wall encountered; the point of the inner needle would probably be broken if pressed with force against a bony wall. Should the inner needle strike a nerve root, it causes exquisite pain, therefore it should be inserted with great gentleness. From the observation of a large number of patients, it would appear that postpuncture reactions are seldom encountered, bloody taps are obviated, and the entire procedure hardly more serious than an ordinary venous puncture. Patients are advised, however, to rest quietly for the remainder of the day following the puncture; hospitalization is unnecessary. TRAUMATIC HEMATOMA OF SPERMATIC CORD. By L. U. Williams, Lieutenant, Medical Corps, United States Navy. The case reported herewith is interesting because of its origin and rarity, in addition to the confusion in diagnosis which was established only at time of operation. The patient, a marine on active duty, was admitted to the hospital with diagnosis of strangulated hernia, left inguinal. He complained of pain and swelling in left inguinal region and stated that while wrestling some two hours previous to admission he felt a sudden acute, tearing pain in that region. Swelling was noticed at external ring almost immediately. On admission an attempt was made to reduce the tumor by taxis. No impulse at external ring was made out on coughing. Tempera ture, pulse, and respiration were normal; and there was no evidence of shock, save paleness. No. 2. 207 MARSHALL—CYSTOSCOPY. Immediate operation was decided upon because of the irreducible swelling and pain. Through the classical incision for hernia a greatly swollen and hemorrhagic spermatic cord was exposed. The hemorrhagic mass extended from internal ring to testicle. It was dull red and held together by tunics of the cord. The blood-filled tissues along with several engorged veins of pampiniform plexus were removed. No bleeding points were seen. No sac was demon strable. Wound was closed by layers without drainage. The cord was not displaced. Recovery was uneventful. CYSTOSCOPY AND REPORT OF THREE UNUSUAL CASES. By L. B. Marshall, Lieutenant, Medical Corps, United States Navy. Cystoscopy is defined as the examination of the urinary bladder with the cystoscope. The instruments used may be direct view, indirect view, air dilating or water dilating, and electric lighted. The best instruments are the direct and indirect water dilating cystoscopes. These instruments may also be used in urethroscopy. Indications for cystoscopy are many, such as frequent and painful micturation —if there are no urethral conditions, nocturia, blood in the urine, enlarged prostate, stones, pain over kidney and bladder region, anuria, and many others. More and more is the cystoscope becoming a recognized and an mperative aid in diagnosis. Many baffling and obscure cases can be easily cleared up with the aid of a trained urologist. Of course the use of the cystoscope is only one part of a thorough urological examination. It is a good plan to go over the entire genito-urinary tract in every patient referred for examination. This examination should include inspection, palpation, and percus sion to exclude conditions that may be so demonstrated. There should be macroscopical, chemical, and microscopical examinations of the urine; rectal examination in the male, and both the rectal and vaginal examination in the female; X-ray plates, urethroscopy, and cystoscopy. The technique of cystoscopy is simple after one has established a certain routine and adheres strictly to it. Most anyone can pass a catheter or even a cystoscope after a bit of practice and through a normal urethra, but to pass an instrument through a strictured urethra or over an enlarged prostate is a different matter and requires skill, patience, and a good anatomical knowledge. The operator first must know the appearance of a normal urethra and normal bladder before he can recognize pathology. In exam ining he must be slow, careful, and thorough in his work. He must 7445»—24 5 208 Vol. XX. MARSHALL CYSTOSCOPY. look for and be able to recognize the stones, tumors, enlargement of any or all lobes of the prostate, diverticula, trabeculations, and sacculations, tubercles, scars of previous surgery or injury, cystitis, foreign bodies, gaping of ureteral orifices, blood issuing from the ureters, inflamed ureters, and so on. The technique of cystoscopy described below is simple, easy to carry out; and if followed the examination is made thoroughly and rapidly and with the minimum of discomfort to the patient. The patient should be given a cathartic the night before so that fecal masses will not interfere with the passage of the cystoscope. The bladder should be emptied just before getting on the table. The patient is divested of all clothing below the waist and has on a large gown or bath robe; he is placed in the lithotomy position, with head raised, hips on the edge of the table and slightly elevated. The feet are supported on stirrups swung well outward. In females the geni talia are washed thoroughly with warm water and tincture of green soap. In males the glans and meatus are cleansed with alcohol and covered with a piece of sterile gauze. Sterile sheets are draped so that all surrounding parts are covered. The examiner, in sterile gown and gloves, introduces into the meatus a cotton applicator dipped in sterile 10 per cent solution of cocaine, a little K. Y. jelly is picked up on the applicator for lubrication. Two applicators are introduced, one following the other. Allowing sufficient time for anes thesia, 10 to 15 c. c. of a sterile 4 per cent solution of cocaine is intro duced with a curved syringe long enough to reach the vesical neck. This anesthetizes the urethra, vesical neck, and bladder and makes in strumentation practically painless. Direct or indirect cystoscopes are used according to preference. The scope is then well lubricated and, in almost the same fashion as introducing a sound, passed carefully into the bladder. The urine remaining in the bladder is then evacu ated, sterile warm water or boric acid is passed through the cysto scope, and the bladder washed out. The light is turned on and the examiner, sitting on a low stool, thoroughly explores the bladder surface. The ureters are then catheterized, the cystoscope removed, and specimens of urine from each kidney collected for chemical and microscopical examination and for cultures. The functional test of each kidney follows, using phenolsulphonepthalein intravenously. After the functional test, pyelograms are made with the catheters in place and kidney injected with sodium iodide, 33J per cent. Par ticular attention must be taken not to allow the patient to move while the ureteral catheters are in place or they may drop down into the ureters and the pictures be unsatisfactory. If considered neces sary, cystograms are also made. The contraindications of cystoscopy are practically none except, of course, acute inflammatory conditions and a few cases with No. 2. 209 MARSHALL—CYSTOSCOPY. extreme pain in which the symptoms might be aggravated by cystos copy. In these cases it is better to wait and let the symptoms subside. There might be an anuria following cystoscopy, but very seldom. It is wise to have the patient remain quiet for an hour or two following cystoscopy because some cases have a slight reaction. There may be nausea and vomiting, malaise, and even a slight chill and temperature, but this does not happen in the vast majority of cases and soon disappears with symptomatic treatment. The urologist now has an absolute and positive knowledge of the genito-urinary tract and is able to make his diagnosis and plan his treatment with the confidence of getting the results he expects. The technique of cystoscopy described is the one used by Dr. Oscar Owre, chief of the urological services of the Swedish and General Hospitals, Minneapolis, Minn., and the cases reported are from his service. I am indebted to him for the opportunity of observing and obtaining the case reports. These cases show the importance of cystoscopy in any condition referable to the genito-urinary tract and especially those in which surgery is contemplated. Case 1.—Mrs. M. J. Age 28 years, white. Admitted to the genito-urinary service of the General Hospital of Minneapolis, May 20, 1923. Principal complaint, painful and frequent urinations with bright red blood in urine. Pain over kidney regions. Urination well controlled but severe nocturia. Duration two weeks, except with some little discomfort two months ago. Physical examination practically negative. Sound introduced into the bladder, seemingly encountered some object. X ray.—Mass in bladder region, about the middle, shaped like a large section of rubber tube, not very dense, mass lying with long diameter in transverse diameter of bladder. Tentative diagnosis — foreign body in bladder with calcification around it. Cystoscopy requested. Cystoscopy. —Bladder had thick coating over all its walls, more marked along ureteral ridge and trigone. Ureters markedly in jected and covered by dense flaky masses. Large mass, oblong in shape, apparently green in color noted. No metallic sound elicited. Mass freely movable. Too large to be drawn through cystoscope, in fact pieces of the mass pulled away with the forceps when removal was attempted. Cystotomy decided upon. Cystotomy.—Suprapubic incision under gas anesthesia. Peri toneum reflected and bladder opened in usual way. Foreign body delivered was 3 inches long and three-fourths of an inch wide and one-eighth of an inch thick, resembling a piece of pork rind. Wound 210 MARSHALL—CYSTOSCOPY. VoL XX, closed. Laboratory report, slippery-elm bark. Patient discharged, well, June 27, 1923, following an attack of measles. Case 2.-—Mrs. R. H. Age 29 years, white. Admitted to the gynecological service of the General Hospital, Minneapolis, Minn., May 29, 1923. Principal complaint, pain in lower abdomen, back ache, and bleeding from the vagina. About three months pregnant. The patient was a very obese woman with negative history and negative examination, except for the above symptoms and history of attempted abortion with a piece of slippery-elm bark. Following failure of symptomatic treatment, cystoscopy was requested. X-ray examination showed shadow, but it was not definitely determined whether fecal material in rectum or foreign body in the bladder. Cystoscopy. —The bladder had a thick coating and film over pos terior wall. Considerable flaky material floated in fluid. A mass observed in right posterior portion of the bladder. Freely movable. Size through cystoscope about 1£ inches long. Mass apparently smooth. Metallic sound not elicited. Mass too large to be drawn through cystoscope and cystotomy decided. Cystotomy. —Suprapubic incision under local anesthesia. Bladder opened in usual way and foreign body removed. The mass was about 12 inches long, three-fourths of an inch wide, and one-fourth of an inch thick. Laboratory report, slippery-elm bark. Patient later died after aborting, followed by septicemia. This patient had evidently tried to abort herself with the piece of bark and had introduced it into the urethra and so on into the bladder. It was remarkable in this case that there were no severer symptoms pointing to a bladder condition. Case 3.— Rev. L. Age 57 years, white. Admitted to the Swedish Hospital, Minneapolis, Minn., for a cystoscopy, requested by his attending physician. Principal complaint, nocturia and retention of urine, so much so that several times it was necessary to catheterize him. Some pain on urination. Cystoscopy. —Dilated bladder. Enlargement of two lobes of prostate. Diverticulum just above and to the left of right ureteral opening large enough to admit the tip of the cystoscope. Small papilloma on right posterior wall of the bladder. Trabeculations and sacculations. A small phosphatic calculus behind the enlarged prostate and lying in one of the sacculations. Four distinct patho logical conditions being revealed. This case shows how extremely important it is to always cysto scope before attempting surgery on the genito-urinary tract. Should a prostatectomy have been done without cystoscopy, it is very prob able that the stone, papilloma, and diverticulum would all have been missed, and not even a suspicion aroused as to their presence, for the No. 2. 211 MARSHALL—CYSTOSCOPY. blood and water would have obscured vision. And not only would the'pathology have been missed but it is very.likely that the papilloma would have taken on new and sudden growth and extended down into the prostatic area, possibly becoming malignant and necessitating a subsequent operation, with perhaps loss of life. This case has not yet come to operation but it will, and it will be a very interesting one to observe. In this case a cystogram should also be made to determine the size and position of the diverticulum. The first two cases show some of the things that may be found in the bladder. The last case shows how many different types of pathology may be found in a single bladder. NOTES AND COMMENTS. THE VALUE OF PSYCHOMETEIC TESTS IN THE NAVY. In connection with the article on "The detection of the psychopath and the classification of naval recruits in accordance with their in telligence" by Lieut. A. W. Stearns, Medical Corps, United States Naval Reserve Force, which appears elsewhere in this number of the Bulletin, it is interesting to note the substance of a report made to the academic board of the United Stated Naval Academy giving the results of the psychometric tests devised by Doctor Stearns as ap plied to 731 midshipmen comprising the fourth-year class during the academic year 1922-23. This report sustains Doctor Stearns's claims concerning the utility of the test. The value of the test to the academic board in the future will be in giving some indication at the end of the first term of the advisability of retaining in the service a midshipman who had "bilged," as it was found that in every instance the ability of the midshipman as revealed by this test corresponded closely to his class standing. As a result of the psychometric tests the midshipmen were arranged in six groups. The number in each group, the number who failed at the end of the academic year, and the percentage of failures in each group are shown in the following table. it 117/ Grouping. Number In each group. Failed. Percentage. A. 95-100... B. 90-95-.. C. 85-90 D. 80-85... E. 75-80—. F. Below 75 132 159 162 124 78 76 3 14 20 17 14 15 2.2 8.8 12. 7 13.0 18. 7 19. 3 It will be noted that there are 291 marks of 90 or above. However, making allowance for the special preparation which most candidates undergo prior to admission to the Academy which may have resulted in the passing of many midshipmen of low intelligence at the end of the term, the ratio of intelligence, if plotted on a curve, will be seen to be progressive. This test will be repeated at the end of the present term and it will be interesting to note whether more of the Group D, E, and F men fail after the effect of early coaching has disappeared. For some time the Bureau of Medicine and Surgery has been en deavoring to find a simple test that could be used to detect the men 213 214 VoL XX, NOTES AND COMMENTS. tally unfit at recruiting offices. The tests that have been suggested are either so complex that they require more time than can be given to each recruit, or else demand interpretation by a trained psychia trist. Lieutenant Stearns believes that in the physical examination of recruits " improvement could be made if a history were taken and if more emphasis were placed upon function and less upon anatomical findings." In his article he describes a history card that comprises the data that is already included on the present application for enlistment and enrollment used at recruiting stations. On the back of this blank is the record for medical examination, and therefore the medical officer has accessible the answers made by the applicant. Following Doctor Stearns' suggestions as to interpretation of a similar questionnaire the medical officer at a recruiting station should be able to use this data to determine the grossly unfit. Clues can be followed by further questioning during the medical examination. It is well to remember, however, that Doctor Stearns very practi cally recognizes that the Navy can use men of all degrees of intelli gence above the feeble minded, but it is obviously wise to use them for different work. Rather dull men can be used for general detail and in the fireroom. Brighter ones are needed to enter the various schools. When Lieutenant Stearns came to the Naval Academy to demonstrate the method of conducting his intelligence test, several line officers who had used it at training stations spoke of its value in choosing applicants for the special schools. It has a practical eco nomic value as well as in promoting efficiency and should be used at every training station. This intelligence test can be given by a chief petty officer if necessary, and even the marking and scoring with a little training can be readily mastered by the layman. The attention of medical officers is therefore especially directed to this article by Lieutenant Stearns, and it is hoped that the methods advocated will be fully tried and reported upon. THE NEED OF PHYSIOTHERAPY. "A department of physiotherapy may not be needed by every hospital, but every hospital needs physiotherapy and a physio therapist." Thus did Dr. John Harvey Kellogg, superintendent of the Battle Creek Sanitarium, begin one of the most significant papers read at the twenty-fifth conference of the American Hospital Asso ciation, which was recently held at Milwaukee. "Within the last half century," says the author of this paper, which appears in The Modern Hospital of November, 1923, "a most remarkable evolution, one may even say revolution, has occurred in methods of dealing with the sick. The marvelous light thrown upon life processes, normal and pathological, by the revelations of physi No. 2. 215 NOTES AND COMMENTS. ology, bacteriology, and physiological chemistry, and the exposures of the fallacies of old therapeutic notions, and the inertness or in adequacy of the great majority of drugs made apparent by experi mental pharmacology and clinical observation checked up by modern instruments of precision, have so completely transformed the practice of medicine that the war of the ' pathies' ceased years ago for lack of anything of interest to war about. Everybody knows, nowadays, that sick people are not cured' by either big pills or little pills, but by the vis rwdicatrix naturse. * * * We have a very few specific drugs which cure by destroying parasites of some sort; but with very few exceptions the agents which are really potent in combating disease are those which modify the blood or the blood supply, and these agents are almost wholly those which belong to the domain of physiotherapy, which includes all therapeutic measures other than drugs and psychic influences. " The modern general hospital is supposed to be a place where the sick may receive the benefit of every curative method and resource recognized by scientific medicine, and there seems to be no good reason why the modern general hospital should not realize this ideal in its equipment and the personnel of its staff of physicians and nurses. " If the question of expense is raised, the objection is easily answered by the fact that for a very efficient application of physiotherapy very little expensive or special equipment is actually required. The great essentials of physiotherapy, in addition to diet, are air and water at different temperatures, light and exercise, active and passive. These most potent of all means of modifying metabolism and nutrition may be applied in a thoroughly efficient manner and with most satisfactory results without the use of very expensive or elaborate apparatus. The most important part of a physiotherapeutic equipment is a thorough, theoretical knowledge of physiotherapy. With this, great results may be attained with little or no special equipment; without it, the most elaborate equipment is useless. * * * The teaching of physiotherapy in our medical schools is still so inadequate and inefficient that the student has no opportunity to become sufficiently familiar with the technic to be able to make an intelligible prescription. Although now recognized as the chief part of therapeutics, it receives the least attention. * * * This neglect of physiological thera peutics by our medical schools is without doubt responsible for the existence of osteopathy, so-called chiropractic, and a dozen other medical cults." Physiotherapy has come to be the greater part of therapy and all medical officers should become familiar with the methods and appli ances for employing the various physical agents by which the body functions may be influenced. Physiotherapy equipment, which has 216 Vol. XX, NOTES AND COMMENTS. been found of value in naval practice, has been installed in our naval hospitals and several medical officers, and nurses have made a special study of its use. This branch of therapeutics affords an opportunity for profitable specialization, as the time is probably not far distant when the physiotherapy department with a spacially trained personnel will be just as essential in the equipment of the naval hospital as is the operating room, laboratory, or diet kitchen. TWO PHYSICIANS OF TORTOLA. Medical officers who have served in the Virgin Islands will recall the British island of Tortola, which is separated by a narrow channel from the island of St. John. On Tortola from 1741 to 1786 there was a colony of settlers belonging to the Society of Friends. According to the British Medical Journal of October 20, 1923, Mr. Charles F. Jenkins, of Philadelphia, has made it a labor of love to collate all available material bearing on these peace-loving worthies, and the result is a very interesting little book called Tortola: A Quaker Experi ment of Long Ago in the Tropics, published last year. "For the medical historian," says the British Medical Journal, "Tortola has the lure that hore (or at least on the islet Little Jost Van Dykos, reckoned as a part of the larger island) was born in 1744 Dr. John Coakley Lottsom, who became later known to fame as the distinguished London physician and founder of the Medical Society of London. Ho dressed plainly and simply after the manner of Friends of the day, and was formally received by the King on more than one occasion, without the required court dress or sword. * * * His many activities gavo him little time for Quaker activities, yet ho always regarded himself as a member. 'I was born a Quaker,' he tells a correspondent, ' and what is still more strange I was born so within the Tropics. ' Eleven years before his death he said, ' I am no bigot, even thinking as well of other religions and sects as I do of that in which I was born and now remain— as I believe, the only Quaker in the world a West Indian. ' He is said to have been one of the seventh pair of boy twins born to his mother, of which number he and his brother Edward were the solo survivors. Sent home as a boy of 6, he only once revisited the island (in 1767), to take over his father's estate, and one of his first acts was to free all the slaves ho had inherited. His youngest son, Pickering Lettsom, was named after John Pickering, the Quaker governor of Tortola. Pickering was eventually superseded during the war with Spain because, with other Friends, he would not 'engage an enemy or use offensive weapons. ' The younger Lettsom settled on the island and practiced his profession as a lawyer there. Doctor Lettsom is buried in Bunhill Fields Friends' burying ground, with George Fox and Edward Burrough. Another medical Tortolian was Dr. William Thornton, a Xo. 2. 217 NOTES AND COMMENTS. son of one of the active early members of the Tortola meeting. He was sent to England for education, became a druggist's clerk at Ulverston, and studied medicine, like Lettsom (whose friend and warm admirer he became), at Edinburgh. After completing his studies he returned to Tortola, and succeeded to an ample fortune; later he went to Philadelphia, where he was fired with a desire to repatriate personally the free blacks of the North, as well as the 70 slaves who had come to him by inheritance at Tortola. One or more ill-fated expeditions had already sailed with this object from England to Sierra Leone, and Doctor Lettsom dissuaded him from the venture, so Thornton remained in New England furthering his repatriation plans from Philadelphia. Here ho married, and, having considerable — although entirely untrained— skill as an archi tect, produced, in competition, the winning plan of a new building for the Philadelphia Library which Franklin had founded some years before. This building still stands, though used for other purposes- After a time he returned to Tortola and practiced for a considerable period as a physician. In 1792, while still there, an advertisement by Thomas Jefferson, Secretary of State, for plans for the President's house and for the Capitol drew Thornton again to Philadelphia to submit his designs. Although he was late and the competition closed, none of the 14 plans submitted hail proved satisfactory. President Washington, on seeing and admiring Thornton's drawings, got the commissioners to accept them, and the Capitol building, ' probably the best known and most imposing structure in America, ' was erected substantially from his design. Thornton became the friend of Washington, was made one of the three commissioners for building the city, and in 1802 was appointed first Commissioner of Patents, which post he held till his death in 1828." THE ALL-PURPOSE CANISTER OAS MASK. At the Twelfth Annual Safety Congress, Capt. L. M. McBride, Chemical Warfare Service, United States Army, delivered an address on the "Uses of the all-purpose canister gas mask at sea" before the marine section of the National Safety Council. Although the uses of the gas masks are familiar to all naval medical officers it is interesting to note how necessary this appliance, as a part of the equipment of merchant vessels, has become. The following abstract of Captain McBride's remarks are reprinted from the National Safety News of November, 1923: "In considering the use of all-purpose canister gas masks on board ships, for protection against such gases as may be encountered in ordinary service, it is first necessary to understand the nature and occurrence of these gases and what protection is necessary and available. 218 Vol. XX. XOTES AND COMMENTS. " Conditions on board ship resemble those of a city, since the ship requires practically all the conveniences and utilities necessary for normal living conditions. A ship has her stores of food, fuel, and other commodities, facilities for cooking, heating, lighting, refrigeration, and ventilation. Due to her hazardously isolated position at sea, whereby the ship must rely on her own resources, it is essential that she be equipped with every necessary device to maintain the safety of passengers and crew against all contingencies. Among the foremost of safety measures is the fire-fighting equipment. Since practically all the gases met in fighting fire on land may be encountered in fires at sea, it is essential that the seamen be fully equipped with the most efficient means of protection against gas. "Gases, however, may be encountered at other times as well as during fires. The nature of the service requires operations which cause the generation of dangerous gases and fumes. Cargoes may consist of every known commodity, which, in- the advent of accident or fire, are sources of danger. Such gases, smoke or fumes, may result from accidents to machinery, burning out of electrical insulation, improper combustion of oil in engines and boilers, and other sources. "Acetone, alcohols, aniline, benzine, carbon bisulphide, ether, turpentine, naphtha, toluene, and other substances enter into the manufacture of rubber, dyes, paints, varnishes, lacquers, shellac, insulation, celluloid, chemicals, and other materials which may be part of the cargo or the ship's equipment, while listed below are the more common gases against which protection should be provided: "Acid fumes, ammonia, carbon bisulphide, carbon dioxide, carbon monoxide, carbon tetrachloride, carbonyl chloride (phosgene), chlorine, chloroform, chloropicrin, cyanogen chloride, formaldehyde, petroleum fumes, hydrogen chloride, hydrogen cyanide, nitrogen peroxide, and sulphur dioxide. "Consideration should be given to the fact that many of the poison ous gases are heavier than air and, therefore, tend to settle in the hold, from which they must be removed by artificial means. "Among these gases are a few against which the standard Army gas mask gives no protection. The most common and the most insidious among them is carbon monoxide, which is responsible for more deaths in civil life than all other gases combined. Carbon monoxide has no odor, taste, or color and it gives no warning of its presence by irritation of the eyes or throat. It is a product of fires due to incomplete combustion of carbonaceous materials, from fur naces and similar sources. It is most likely to occur on shipboard from smoldering fires in cargoes, holds, or coal bunkers. "No provision was made during the war to develop a gas-mask absorbent to protect against it as a war gas. There was, however, a demand for such an absorbent for use by the U. S. Navy in sub No. 2. 219 NOTES AND COMMENTS. marines and in the gun turrets of battleships. This demand was met by the development of a carbon-monoxide mask containing an absorbent known as hopcalite which acts catalytically on carbon monoxide, causing combination with the oxygen of the air to form carbon dioxide, which may be breathed to the extent of 2 or 3 per cent without harmful results, whereas about one-half of 1 per cent of carbon monoxide would be fatal. "Ammonia is encountered in industry, principally around refrig eration plants. An early means of protection against ammonia was the use of pumice stone impregnated with sulphuric acid. This had many disadvantages and was superseded by the development of pumice impregnated with copper sulphate and known as kupramite. Silica gel has also been developed as a gas-mask absorbent to give protection against ammonia. " With these developments available, the Bureau of Mines designed a gas mask to give protection against all noxious gases met with in ordinary industrial, chemical, and metallurgical practice and for use by city fire departments. This mask is known as the universal gas mask. A short time later, the Chemical Warfare Service was called upon to furnish such a mask for use by various Government departments. This mask uses hopcalite to give protection against carbon monoxide and cobaltous chloride as an ammonia absorbent. This mask is known as the all-purpose mask. There is also a com mercial mask which embodies the above principles and is known as the all-service mask. The construction and operation of all of the foregoing masks are similar. "Another common source of danger from gases aboard ship is from those remaining after fumigation. "The U. S. Public Health Service has recently adopted a new method of ship fumigation, consisting of the generation, in place, of a mixture of cyanogen chloride and hydrogen cyanide. Bilge water will absorb about 100 milligrams of cyanogen chloride per liter for an exposed surface of 27 inches. Cyanogen chloride will condense on brass at the rate of 42 milligrams per 1,000 square inches of surface, and on steel at the rate of 125 milligrams, at an average temperature of 54^° F. Consequently, these gases are likely to be present after fumigation and it is unsafe to enter any closed space for some time after fumigation without a gas mask. ' Gasoline and other petroleum vapors are more dangerous than commonly supposed. On account of their low boiling points, these liquids evaporate rapidly upon exposure to air. An empty gasoline or oil tank wdl give off dangerous fumes and there is usually a small quantity of the liquid left in the bottom of the tank, even after steaming or other methods of cleaning have been resorted to. The remaining sludge, when stirred up in cleaning, inspecting, or repair 220 Vol. XX. NOTES AND COMMENTS. ing the tank, will give off dangerous quantities of gas. The inhala tion of benzine, gasoline, or other petroleum vapors causes headache, dizziness, and frequently an intoxication in which the person becomes excited and hysterical. Higher concentrations will cause uncon sciousness or even death. Such tanks should be entered with extreme caution and seldom, if ever, without some means of protection. "The all-purpose mask will give protection against these vapors for a short time only, the time depending upon the concentration of gas. To be safe, one should not remain in the tank for more than 5 or 10 minutes at a time. If a longer period is necessary to complete the work, the men should go out and change masks. It has been found that thin rubber and rubberized cloth are per meable to gasoline and similar vapors: hence the mask should be thoroughly aired before it is again used. "The safest equipment to use in such tanks is either the oxygen breathing apparatus of the type approved for protection against the penetration of gasoline vapor, or the hose mask, which consists of a face piece of the Tissot type with hose attached which leads to fresh air. Both types are now available commercially. In any event, no person should enter a tank without having a stout rope attached to him so that he can be removed if overcome. " Chemical fire extinguishers, especially those of the carbon-tetra- chloride type, should be used in closed spaces only when the opera tor is protected by a gas mask, owing to the toxic gases by the action of heat on the contents of the extinguisher. The basic gas is neces sarily heavy in order to blanket the fire and consequently hard to dissipate. "Gases and dusts emanating from fires in cargo and bunker coal or as an after result of explosions require some means of gas pro tection. Two analyses of the gas from samples of coal made by the Bureau of Mines showed two and three per cent of carbon dioxide and 12 and 39 per cent of methane (fire damp) in addition to other gases. There is no adequate absorbent for methane, but this gas is harmless in itself unless present in sufficient quantity to reduce the oxygen content of the air below 13 per cent. A gas mask is no protection when the atmosphere is deficient in oxygen. In such cases an oxygen apparatus or hose mask should be used. "The all-purpose gas mask consists of three principal parts, the face piece, the canister, and the carrier. The face is of the Tissot type, without nose clip or mouthpiece, and is made of rubber stock inette. Adjustable bands form a head harness which holds the mask firmly and comfortably in place. Purified air from the canister enters the face piece through a corrugated flexible tube attached to a metal angle tube in the face piece. Attached to the angle tube on the inside of the face piece is a rubber deflector which distributes No. 2. 221 NOTES AND COMMENTS. the incoming air over the lenses to prevent dimming from condensa tion of moisture on the glass. Expired air is exhaled through a rubber flutter valve attached to a separate opening through the angle tube. The canister is a modification of the present Army type. "The life of the canister depends upon a number of variable conditions, such as the concentration of gas, the rate of flow of air through the canister, which is in proportion to the exertion by the wearer, the temperature and humidity of air, etc. Under ordinary conditions and concentrations the canister lias a life of from four to six hours' continuous use. "All gases except carbon monoxide may be detected by odor when the canister 'breaks, ' that is, permits gases to pass through. How ever, the canister gives protection beyond the point and permits the wearer to withdraw to a safe atmosphere. "The number of gas masks required for ship equipment may be closely estimated by the extent of the fire-fighting equipment. There should be a sufficient number available to equip all men required to go into any part of the ship in case of a serious fire. Masks should be so distributed that regardless of where a fire may break out or an accident happen masks and extra canisters will be available. There should be at least one mask with each chemical extinguisher. "Extra masks should be maintained adjacent to ammonia re frigeration equipment, in boiler rooms, and wherever it is necessary to enter any confined space after fumigation. Extra canisters should be maintained to meet any emergency. Gas masks should be kept where the canister will be dry, but not in a place where the rubber parts will deteriorate, such as adjacent to steam pipes or places where the temperature is high. Extra canisters should be kept hermetically sealed as when received and in dry cool storage." THE ETIOLOGY OF GOUT. The elucidation of the etiology of gout has vexed the minds of many thoughtful physicians from time immemorial and we to-day are far from a solution of the pathological mystery of this disease. However, Dr. R. Llewellyn Jones Llewellyn, of London, advances some inter esting speculations on the subject in a paper which appeared in the New York Medical Journal of November 21, 1923. That a predisposition to gout is hereditary is beyond question. This hereditary predisposition Doctor Llewellyn assumes to be the result of protein sensitization and this assumption explains many of the clinical phenomena peculiar to the disease, such as asthma, urti carial and exzematous eruptions, and food idiosyncrasies. "The food idiosyncrasies of the gouty," says the writer, "are pro verbial, not eclipsed even by the asthmatic. Some appear hypersen 222 VoL XX. NOTES AND COMMENTS. sitive to beef, others to pork or veal, some to shell fish, others to certain vegetables or fruit, e.g., strawberries. The almost fulminant swiftness of the response in some instances frankly suggests that the gouty outbreak is due to the absorption of unaltered protein, and, moreover, the digestive derangement of the gouty would seem to favor the intru sion of unaltered protein or cleavage products." The well-known effect of alcoholic beverages on gouty subjects, according to the writer, is not due to the alcohol per se, but to the proteins such as hordein in malt liquors or the protein material con tained in the yeast cells in wine. In those following the occupations which have always been considered as contributing to gout, namely, coachmen, grooms, stablemen, farm laborers, maltsters, brewer's laborers, and so forth, the predominant incidence of gout is due prob ably to the fact that those in whom the disorder develops are sensi tized to some protein incident to the occupation. According to this writer, who bases his opinion on the researches of Dale, the articular and abarticular phenomena of gout are due not to the direct action of toxins generated by organisms in some local focus of infection, as has been claimed, but they are the outcome of an anaphylactic reaction to the proteins of the said organism. The salient features of anaphylaxis, as Dale has shown, are spasms or tonus of unstriped muscle, e. g., the bronchioles, and poisoning of the endothelial cells of the capillaries. One or the other of these effects may predominate in different species of animals, and thus give rise to symptoms, which though superficially dissimilar are yet funda mentally due to the same species of morbid action. That they are due to one common type of poison is, in Dale's opin ion, further confirmed by the fact that these same symptom complexes may be produced by a whole group of natural poisons —partial cleav age products of protein formed by bacterial or other ferments. In like fashion in man, under natural conditions of life, there may occur that particular sequence of events essential for the artificial induction of animal anaphylaxis; in other words, an entry into the blood of unaltered or incompletely digested proteins, an interval, then a second entry with resulting explosion. When such occurs, the salient features of anaphylaxis are reproduced, and find clinical expression in asthma, skin eruptions, arthropathies, vascular hypo tension and eosinophilia. In some individuals urticaria, in others bronchial asthma, or arthropathies, may be the predominant mani festation. The varied clinical phenomena of serum sickness or anaphylaxis in man certainly resemble gout, in its regular and irregular aspects. In both joint swelling, asthma, skin eruptions, vascular hypotension and eosinophilia occur. No. 2. 223 NOTES AND COMMENTS. The writer believes that the initial change in the joint in acute gout is a toxic poisoning of the endothelium of the vessels and capillaries in the joint area producing a cellular sensitization. The writer concludes the paper with a summary which is quoted in part as follows: " In attempting to summarize my views on this vast subject—the etiology of gout—I would remind you that Dale holds that sensitiza tion—in anaphylaxis —is cellular and not humoral in location. In other words, that in vascular endothelial poisoning, the anaphylactic symptoms are not due to collision of the antigen and antibody in the blood stream. For his researches show that the antibody is located in the cell, and that it is there in the cell body itself that the reaction with the corresponding protein or antigen occurs. Hence the anaphylactic symptoms —possibly the result of intracellular precipitation. "On this basis the pathological groundwork of gout resides in a tendency to cellular sensitization. The same may remain latent, but once established it will—given contact with the related protein or antigen —-at any moment explode. The explosion takes the form of vascular endothelial poisoning, and as the same operates through the medium of local ischemia and venous stasis, it is not surprising that the clinical manifestations thereof should be extremely diverse, for the symptoms will naturally vary with the regional distribution of the circulatory stasis, and the structure and function of the organ or tissue implicated. "If situated in a joint, it results in regular gout; if in the lung, asthma; if in the skin, urticaria, or eczematous eruptions, viz, irreg ular gout. Accordingly, if we accept cellular sensitization as the>basal pathological change in gout, and that the same achieves its malign effects through vascular endothelial poisoning, we seem to glimpse the inward meaning of the clinical mosaic presented by the regular and irregular manifestations of gout. " Incidentally, too, much of the mystery attaching to gouty metas tases disappears, even the much maligned retrocedent gout becomes intelligible. Thus, if an acute gout in the toe suddenly abort, and alarming gastric symptoms as suddenly ensue, viz, intense abdominal pain, collapse, vomiting, sometimes of blood, may not these gastric symptoms be due to a local endothelial poisoning, a gastrostasis ? "Conversely, in those authentic instances where an aphasia, an amnesia, or a hemiplegia, disappears with the onset of frank gout, may not the cerebral symptoms be due to temporary stasis in the related cortical vessels ? "Again, may we not find herein a facile and no less a rational solu-v tion of those many recorded examples in which a fleeting erythemata or urticaria has, like a bout of asthma, vanished with the sudden out- 74459—24 6 224 Vol. XX NOTES AND COMMENTS. break of acute classical gout ; or alternated therewith in that dramatic fashion so graphically portrayed by the older physicians, to whose masterly clinical insight modern research ever brings increasing tribute ? " Lastly, it seems to me that this conception of the etiology of gout opens up an encouraging vista for more efficient and, I would fain add, more scientific therapy. May not skin protein tests, if applied to the gouty, yield as rich a harvest of information as has already been gleaned in asthma? May not withdrawal of the offending protein, whether vegetable, animal, or bacterial, prove as prophylactic in the one as in the other? May not our sheet anchor—colchicine—even act as a desensitizer ? " BULLETIN OF THE NATIONAL BOARD OF MEDICAL EXAMINERS. The first issue of the National Board Bulletin appeared in October, 1923. The National Board of Medical Examiners began the publi cation of this periodical for the purpose of keeping the board's can didates and others interested in its work more fully informed of its program and progress. From the first. issue we learn that during the past year seven State boards of medical examiners have perfected arrangements for the acceptance of the certificate of the national board, in lieu of their own examination of candidates for licensure. The States are as follows: Illinois, Maine, Massachusetts, New York, South Carolina, Tennessee, and Texas. In Illinois, Massachusetts, New York, and Texas it was necessary to amend the medical practice acts so as to give the State boards authority to take discretionary action. In the other States the present laws were sufficiently broad to permit recognition by direct action of the board. In Maine the State board will give candidates holding the national board's certificate a brief examination, which may be oral and practical in nature. In several States, including New York and South Carolina, the State boards reserve the privilege of reviewing each candidate's credentials. Several other States are giving favorable consideration to recogni tion of the national board certificate, and are ready to extend coopera tion as soon as amendments to their medical practice laws can be secured or a plan of acceptance worked out which will accord with the provisions of the present statutes. The States accepting the national board's certificate now total 28, and are as follows: Alabama, Arizona, Colorado, Connecticut, Dela ware, Georgia, Idaho, Illinois, Iowa, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nebraska, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, Virginia, Wash ington. No. 2. 225 NOTES AND COMMENTS. PRACTICAL OBJECTIVES IN HEALTH WORK. At the National Conference of Social Work held in Washington, D. C, May 17, 1923, the late Dr. Hermann M. Biggs delivered an address on "Practical objectives in health work during the next twenty years." According to Health News, the monthly bulletin of the New York State Department of Health, this was the last public speech by Doctor Biggs. At the end of the address he sum marized some of the most important health objectives as follows: 1. Establishing the custom of obtaining periodic physical examina tions of every individual made by competent physicians. 2. Provision of systematic instruction in elementary physiology and hygiene and in health habits in the primary and secondary schools, and more extensive instruction in the normal schools and universities. 3. Further reduction in the death rate from the common infective diseases, such as tuberculosis, diphtheria, typhoid fever, scarlet fever, diarrheal diseases of infancy, etc. 4. Postponement of the age at which death occurs from the cardiovascular diseases and the other diseases of later life, through physical examination and instructions as to methods for retarding or arresting their progress. 5. Continued efforts, through research, to solve the problems con nected with the causation and prevention of the acute respiratory diseases and cancer. 6. Continued efforts to prevent and cure certain diseases of nutri tion and metabolism, such as diabetes, scurvy, rachitis, and gout. 7. The prevention by education and law enforcement of new infections in the venereal diseases, and provision for more adequate treatment of syphilis. 8. The extension of the educational work of the public health authorities as a most effective means to promote the preservation of health and the prevention of disease. • 9. Better and more extensive organization of the prenatal, mater nity, and infant work, and the care of the preschool child. 10. The extension of the work in mental hygiene and oral hygiene, including ample facilities for treatment. 11. The efficient development and extension of medical school inspection, and its follow-up with the provision of adequate facili ties for the treatment of the diseases and defects found in school children. ALCOHOL TAXATION AND ALCOHOLISM IN DENMARK. In connection with a review of Dr. V. S. Vecki's book on "Alcohol and Prohibition," which appears elsewhere in this issue of the Bctlle 226 Vol. XX, NOTES AND COMMENTS. tin, it is interesting to note some of the aspects of prohibition as revealed by other countries. According to the British Medical Journal of November 3, 1923, "each of the four Scandinavian coun tries is at present conducting different legislative experiments in the control of alcohol consumption. While one country rations the supply of alcohol, another attempts to enforce prohibition, and a third —Denmark —attempts to encourage sobriety by making the cost of alcohol almost prohibitive. The year 1917 was one of legis lative ventures in Denmark. For a very brief interval the total prohibition of spirits was attempted, the law of February 27 for bidding the sale and serving of spirits. This law was revoked on March 23 of the same year, since when, there has been no prohibition in Denmark. But in that month the retail cost of spirits was doubled by taxation, and on December 21, 1917, the taxation of spirits was further raised so that a bottle of spirits which had cost 70 ore before the war could not be bought for much less than kr. 10. In a paper recently published by Dr. K. H. Krabbe an attempt has been made to investigate the influence of this legislation on the sobriety of the Danish nation. He observes that it is difficult to compile statistics . dealing with chronic alcoholism, partly because there are no hard and fast lines within which this condition can be defined, and partly because the personal equation (that is, the opinion of the individual physician) is variable. But there can be no mistake about the diagnosis of acute alcohol poisoning or delirium tremens, which seldom occurs in an abortive form. The actual number of such cases may not be an index to the number of cases of chronic alcoholism in the same community, but a study of the yearly fluctuations in the number of cases of delirium tremens should afford a rough guide to the fluctuations in the incidence of chronic alcoholism. At any rate this is Doctor Krabbe's opinion. His statistics deal with the number of cases of delirium tremens admitted every year to his hospital since 1903. In the period 1903-1916 this number ranged from a minimum of 249 in 1915 to a maximum of 447 in 1907, the average for this period being 321 a year. In the period 1913-1922 the number of these cases ranged from a minimum of 9 in 1918 to a maximum of 26 in 1921, Che average being 15 cases every year. (In 1922 there were only 11 cases.) It will thus be seen that 95 per cent of the anticipated incidence of delirium tremens had been elimi nated. Doctor Krabbe considers there can be little doubt that this decline in the incidence of delirium tremens did not merely coincide with the imposition of heavy taxes on spirits, but was the direct outcome thereof. He raises the question: Would it be possible by total prohibition to eliminate the remaining 5 per cent of the anticipated cases of delirium tremens? He answers this question in the negative, assuming that this 5 per cent dreg represents those No. 2. 227 NOTES AND COMMENTS. members of the community who must have their liquor at all costs, and who, if spirits are prohibited by law, obtain it by smuggling or distilling it at home. Failing these alternatives, there is yet the possibility of drinking methylated spirits or ether. The lesson which Doctor Krabbe draws from his figures and from a comparison of conditions in Norway and Denmark is that high taxation of spirits has quite as sobering an effect on a community as prohibition, the circumventing of which has a demoralizing effect, encouraging a contempt for the law of the land." REVISION OF THE PHAKMAC0PO3IA. Two lists of proposed "admissions" and "deletions" from the forthcoming revision of the United States Pharmaccepia (tenth) have been published in the Bulletin during the past two years. Addi tional titles have since been proposed for inclusion as follows: Acetum scillae. Althsea. *Ammonii salicylas. •Bismuthi subsalicylas. 'Caffeina citrata. *Calcii glycerophosphas. Carbon tetrachloride. Ceratum. Ceratum cantharidis. •Cimicifuga. 'Diacetylmorphinae hydrochloriduni. Emplastrum belladonnse. Emplastrum cantharidis. 'Extractum cimicifugae. 'Extractum malti. Fluidextractum belladonnse foliorum (new— not in U. S. P. IX. The Fluidextract of the root is also official) . 'Fluidextractum sarsaparillse. Fluidextractum ecillse. Fluidextractum uvae, ursi. Ipomoea orizabensis (to replace Scam- mony). Liquor zinci chloridi. *Maltum. Massa ferri carbonatis. Pilulae phosphori. Quinidinae sulphas. Quinine ethyl-carbonate ("Euqui- nine"). ♦Sarsaparilla. Spiritus setheris nitrosi. ♦Syrupus sarsaparillse compositus. Terebenum. Tinctura cantharidis. Tinctura limonis corticis. Tinctura lobelias. Tinctura tolutana. Tinctura Valerianae ammoniata. Tinctura zingiberis. Unguentum hydrargyri nitratis. The following general articles will be included : Infusa. Suppositoria. Tincturae. Triturationes. Aquas. Aquae aromaticse. Decocta. Extracta. Fluidextracta. In the above list of admissions, there are a few titles marked with an asterisk which were reported as "deletions" in earlier lists but which have been admitted through the action of the referee committee on scope, after considering the comments received from those who objected to their deletion. 228 Vol. XX. NOTES AND COMMENTS. The following list consists of other titles, official in the United States Pharmacopoeia IX, but not recommended for inclusion in the new Pharmacopoeia: The referee committee on scope have carefully considered every comment submitted, have rediscussed a number of titles, and voted to reverse the original decision on the titles indicated. Other titles are yet before them for final decision. Dr. E. Fullerton Cook, the chairman of the committee of revision, 636 South Franklin Square, Philadelphia, Pa., invites comments on these additional lists. As reported in the British Medical Journal of October 27, 1923, " at the meeting of the section of the history of medicine of the Royal Society of Medicine held on October 17, Dom Louis Gougaud, O. S. B., made an interesting communication on phlebotomy in the monas teries. In mediaeval times bloodletting was very common through out the monastic houses, and nuns as well as monks were periodically bled. The frequency of this practice may have been due to the sedentary and unhealthy mode of life in the cells and cloisters, and to the need for an effective prophylactic against the temptations of the flesh. In some religious houses it was done monthly, except when a feast intervened ; in others the monks were bled every six or seven weeks; in others three, four, or five times a year, according to the rule of the order. In particular the Canons Regular had fixed days for phlebotomy. Often the procedure was laid down with much precision with regard to place and time of day, the prayers and ritual to be observed, the person who should perform the opera tion, and even the costume to be worn by the patient. Bandages of special material wore occasionally prescribed, and directions given for preliminary warming of the arm. Detailed instructions governed the patient's diet and regimen during the period of rest after phle- Acidum oleicum. Collodium cantharidatum. Extractum aconiti. Extractum gentians. Extractum opii. Fluidextractum aconiti. Fuidextracturn gentians. Fluidextractum lobeliae. Fluidextractum mucis vomicae. Fluidextractum veratri viridis. Linimentum terebinthinse. Liquor sodii glycerophosphatis. Oleatum hydrargyri. Oleoresina cubebae. mcBa orizabensis). Serum antidiphthericum siccum. Serum antitetanicum siccum. Spiritus juniperi compositus. Tinctura cannabis. Tinctura cinnamomi. Trochisci cubebae. Trochisci potassii chloratis. Oleum scsami. Opium deodoratum. Pilulae ferri iodidi. Pilulae rhei compositus. Pulvis aromaticus. Scammoniae radix (replaced by Ipo- PHLKBOTOMY IN THE MONASTERIES. No. 2. 229 NOTES AND COMMENTS. botomy, and his relief from the full rigour of monastic discipline. The mediaeval chronicles examined by Dom Louis Gougaud indicate that this relaxation from discipline after bloodletting often succeeded in loosening the patient's tongue and sometimes led to unwonted confidences. Both the Consuetvdo of St. Augustine's Canterbury, and that of the Augustinian priory at Barnwell, near Cambridge, throw much light on phlebotomy as performed in English religious houses in the Middle Ages. The records of the practice go back to the seventh century; the Venerable Bede (A. D. 674-735) left a treatise on bloodletting. By the tenth century periodical bleeding was definitely accepted as a monastic custom, and it prevailed for several hundreds of years afterwards." A NEW METHOD OF TREATING SYPHILIS. The Southern Medical Journal of November, 1923, comments editorially on some of the newer methods of treating syphilis, among which may be mentioned "stovarsol" (oxyaminophenylftrsenic acid), which may be given by mouth instead of by hypodermic injection. As reported in the Annales de l'Institut Pasteur, Paris, Levaditi and his colleagues have made use of this new arsenical compound and have found it in animal experiments to cure quickly syphilitic affec tions. They demonstrated also that it possessed strong prophylactic effects against syphilis in rabbits exposed to infection by the sexual route. Later experiments on human beings confirmed the results of animal tests. It was found in a carefully controlled case that if two grams of stovarsol were given by mouth within five hours after exposure to infection, no infection occurred. Through the treatment of clinical syphilis by these French observers has thus far been limited, the results reported seem promising. They claim that in 30 cases the primary lesion was healed by stovarsol administration in from five to fourteen days. In secondary syphilis the therapeutic effects were also prompt and favorable; the skin eruptions disappeared after a short period of treatment. Tertiary lesions also have yielded promptly to treatment with stovarsol. In administering the new drug tablets are used, each containing 0 25 grams, giving 1 gram per day every other day until from 12 to 16 grams have been' administered in the course of a month. It would be unwise to arrive at the conclusion that we have in this new preparation a thoroughly satisfactory method of treating syphilis by means of a drug administered by mouth. However, since the report of the observations emanates from the Pasteur Institute, it would seem to deserve serious consideration and to merit careful testing in organized clinics. 230 NOTES AND COMMENTS. VoL XX. Marchoux (Bull. Soc. Path. Exot., May 9, 1923) reported success with daily doses of 0.25 grams of stovarsol in the treatment giardia infection and in amebic dysentery. OPERATING-ROOM LIGHTING. In the Stadtisch Krankenhaus, located in the free city of Danzig, one of the operating units is equipped with a novel artificial lighting apparatus. The source of the light is a powerful searchlight, situated outside the operating room, which sends its rays in through a glass window. The ra}rs are directed toward seven circular glass mirrors arranged at different angles, which reflect the* rays to six mirrors suspended from the ceiling; these mirrors in turn reflect the rays to the operating table and the immediate vicinity about it, producing a splendid lighting effect. The system is an enlargement of the idea made use of in the "Shamberg" dental lighting fixture. NAVY NURSE CORPS. NURSING IN THE PHILIPPINE ISLANDS. When nurses begin to weep for more worlds to conquer it would seem that the Philippine Islands would offer scope for the activi ties of earnest workers for some years to come. In 1921 it was esti mated that there was one graduate nurse for every 13,000 persons in the islands —surely enough to keep her very busy! The Filipino women are rising to the situation splendidly, but when we consider that there are only thirty-odd hospitals in the islands and that only 11 of these have training schools, with about 700 nurses in training, it is easy to see that it will be some time before the supply is adequate to the demand. It was naturally to be expected that when General Wood, trained in tropical hygiene and sanitation and with his excellent record in Cuba and elsewhere, was appointed Governor General, much atten tion would be paid to public health, and this expectation has in no wise been disappointing. It is chiefly through his efforts that the Rockefeller Foundation was induced to extend its work here. Other agencies are the public-welfare commission, health centers under the Government health service, and the Red Cross, all of which cooperate. As always in public-health work, the public-health nurse is an important factor, andxthe hospitals can not turn them out fast enough. There is an excellent course in public-health nursing at the University of the Philippines, the second term of which began May 15, 1923. Sixty-five nurses entered this term and it is hoped that there may be an increased accommodation for the next class. In this course nurses get theoretical instruction in the usual subjects and have prac tical work with the above-mentioned public-health activities. A particularly broad-minded feature is the taking of foreign students. "Special pains will be taken to give foreign students emphasized training in those branches which may be most useful to them on their return to their own country. This offer is made in order to give nurses from neighboring countries the opportunity to train in public-health nursing if such opportunities are not to be found in their own countries." The Rockefeller Foundation provides scholarships for post graduate work for some nurses in schools in the United States and the Govern ment has a fund for pensionados, some of whom are nurses. The training school of the Philippine General Hospital, an insti tution of over 600 beds, is under the auspices of the university. It is 231 232 Vol. XX, NAVY NURSE COKPS. delightful to see the spirit of earnestness and enthusiasm among the nurses there. For the past seven years this institution has been entirely under Filipino management, although American physicians take their patients there and American nurses may be called on special duty. The requirements for entrance to the training school are a minimum age limit of 18 years and one year of high school. The nurses have a beautiful home, built with high ceilings and wide- open ventilation, as is suitable in a tropical climate. The pupil nurses sleep in dormitories but the graduate nurses have their rooms. The nurses have an eight-hour duty, a physical directress, a very creditable library for which they themselves have bought most of the books, a fine large sitting room, well-equipped classrooms—in short, the same things which are being provided for nurses in American schools. There are some 300 pupils, about one-third of whom are male. This seems a large number in proportion to the number of patients, but the service is a very active one and there is a large out-patient department, besides which the Government is desirous of giving the training to as many as possible because of the great need for graduates. There is a great demand for graduate male nurses in public-health work, as they can go to outlying districts where women could hardly go on account of poor transportation and lodging facilities. The women, however, also show courage and fortitude, going to far-away districts for periods of two or three years and having no communication by mail or otherwise with their homes during this time. Formerly the male nurses were given genito-urinary work at the same time that the female nurses were getting their obstetrics, but when the male graduates got out into the Provinces where there were no physicians available they were called upon to help in so many obstetrical cases that they began to ask to como back and get instruction on the subject ; of course this was gladly given and it is now included in their curriculum. The next largest training school is the St. Luke's Episcopal Mission, which has grown from a very small beginning to a school having 56 pupil nurses. It is soon to be enlarged by the opening of two more buildings, one for obstetrical cases and one for isolation. Here the training is in the hands of six American nurses who are doing a real missionary work in caring for the sick and teaching the Filipino girls at the same time. Other hospitals in Manila are the San Lazaro, contagious; the San Juan de Dios and St. Paul, conducted by Spanish Sisters of charity; the Chinese General Hospital; and the Mary J. Johnston Methodist Episcopal Mission. In the provinces the training schools are smaller; in some cases there is only one graduate nurse, so it may be imagined how varied Xo. 2. 233 NAVY NURSE CORPS. her duties are. These send their nurses to affiliate with the Philippine General, and all go to San Lazaro for their contagious work. Then there is the Culion leper colony. On December 31, 1922, the population of this colony was 4,973. The results of the modern treatment of this disease are said to be very encouraging and the patients go there with good hopes of being restored to their homes. In April of each year, visitors' boats take the families of a number of the lepers to visit them. All of the training schools have been standardized and an effort is being made to obtain reciprocity with American Associations by the Filipino Nurses' Association, which is a very active organization. The Filipinos have many qualities which go to make good nurses. They are naturally quiet, gentle, and friendly, nonirritable, and inherently courteous. No doubt this urbanity of the Filipino people comes from their long association with the Spanish, and it is to be hoped that it will not be displaced by American hustling. Governor General Wood seems to recognize the great value of nurses as educational agents and he even has a project on hand for opening a training school for Igorot girls. The Igorots are the least civilized of the tribes of Luzon and it is his idea that their confidence can be best gained through their own people. To quote from his address to the National Conference on Infant Mortality and Public Welfare : " The needless loss of life in the Philippines must be stopped. The percentage of infant mortality is one-third of all births, very much greater than it should be, very much greater than is necessary. * * * We need in our campaign money, better work, and more nurses. But we have only 920 graduate nurses. * * * I wish that there were 10 times more than the graduates we have. * * * Encourage the profession of nursing. * * * We need more doctors and more nurses to build up in the islands at once, organi zations of women, or women's clubs, which will take up this matter. * * * God bless your efforts." In closing, we will quote from the biennial report of the Mary J. Johnston Hospital as showing the spirit of these missionaries and some of their difficulties: "Disease and despair have come, and in the main have been vanquished; the hospital doors have ever been open to the needy, and the only card of entrance, so long as there is room, is: 'I am sick.' * * * There are so many silly and even harmful superstitions which we try to combat; these superstitions many times lead to such neglect as to sin away the day of grace in which a poor baby might be treated and saved ; we had a poor little boy brought in with a terrible dropsy, and in talking about him with his mother we elicited the statement that it was a good sign on the days when his nose swelled, for on those days his father was sure to have great success at his occupation, gambling? Little Leonora was 234 Vol. XX. NAVY NURSE CORPS. brought in and promptly deserted by her mother; she is 8 years old and has tubercular glands of the neck; she did weigh 25 pounds, but now she weighs 26 after about a hundred days in the children's ward. * * * Many young mothers in their early twenties are so bowed down by illness, weakness, and neglect as to look middle aged ; thin, starving, neglected little children are brought in arms, many of them hopeless. * * * "The three years in the hospital, although busy and sometimes strenuous ones for the nurses, are happy, sheltered years, and many of the girls try very hard to take advantage of every opportunity to improve themselves; others are apparently content to remain medi ocre ; but all go out to such hard, responsible livos with so many tempta tions, we are anxious to pour into their lives the best* that is in us, that they may go out not only equipped with their professional training, but that they may have the strength of character sufficient to safeguard them when they leave the protecting hospital roof." COOPERATION WITH ALL DEPARTMENTS. In order that the work of the hospitals will run smoothly and efficiently, it is necessary to have cooperation, not only in our own department, but with all departments. The following instance shows where a spirit of cooperation could be very helpful : A doctor, visiting one of the hospitals, noticed the dietitian watching the trays as they came back from the patients; upon asking her why she was watching them so closely, she replied that she wished to take note of what food was generally eaten, and what was left practically un touched, and in this way be able to eliminate waste by observing the taste of the majority, also to ascertain if the uneaten food were bad or had been improperly prepared. The doctor said, "I know why those peas were not eaten; they are as hard as bullets." She inquired what to do to avoid repetition of this waste and he told her to take the matter up with the commissary officer. In this way, the attention of the purchasing officer was called to the necessity of investigating the nature of tinned goods before they are used. In many instances, a great deal of needless waste may be eliminated by such investigations. This is but one instance where a little cooperation between two departments brought about a benefit to many, and at all times the willingness on the part of the nurses to cooperate with the heads of other departments will result in dispelling troubles and doubts which in time might grow to be quite serious. Cooperate at all times and with all, and the result will be most satisfactory to yourself as well as to others. BOOK NOTICES. Publishers submitting books for review are requested to address them as follows: The Editor, U. S. Naval Medical Bulletin, Bureau of Medicine and Surgery, Navy Department, Washington, D. C. For review. Books received for review will be returned in the absence of directions to the contrary. H06PITAL Corps Handbook, United States Navy, 1923. Published by the Bureau of Medicine and Surgery under the authority of the Secretary of the Navy. Government Printing Office, Washington, D. C, 1923. This book presents in epitomized form certain subjects and facts which are of assistance to members of the Hospital Corps of the Navy in the performance of their duties ashore or afloat. It is compiled from articles prepared by members of the Medical, Hospital, and Nurse Corps of the Navy who have had special experience in the subjects about which they have written. The volume opens with a brief sketch of the history of the Hospital Corps of the United States Navy whose ancestor by direct descent was the "loblolly boy," the individual who, as far back as the seven teenth century, was specifically detailed to assist the surgeon in the care of the sick and wounded on board British vessels of war. This historical account is followed by carefully prepared and excel lently illustrated chapters on anatomy and physiology, first aid and minor surgery, bandaging, dental first aid and nursing. The chapter on nursing, prepared by three members of the Navy Nurse Corps, deals with the management and general supervision of wards in a naval hospital, general nursing procedures, the general principals governing the care of patients, surgical nursing, surgical dressings, and baths. This chapter includes an excellent presentation of the operating room and surgical technic use in the Navy, of anes thesia, physiotherapy, food, and dietetics. In the Navy emphasis is placed on the prevention of disease; hence we find much space devoted to preventive medicine, hygiene and sanitation. This section contains succinct discussions of the communicable diseases, disinfection and disinfectants, maritime quarantine, air, ventilation, heat and housing, food and water and 235 236 Vol. XX, BOOK NOTICES. their relation to health and disease, disposal of sewage and refuse, personal hygiene, vital statistics concerning the Navy, field sanita tion, the venereal diseases, and embalming. There are practical chapters on chemistry, pharmacy, materia and toxicology. The chapter on bacteriology, blood work, and immunity outlines the principles involved, the general methods employed, and the prac tical application of the more common laboratory procedures. The animal parasites of man are described in an interesting manner. There is a chapter devoted to a discussion of special activities which fall to the lot of the hospital corpsman and certain information which he should possess. In this chapter the hospital corpsman's duties when serving on independent duty, such as on destroyers, mine layers, mine sweepers, tugs, isolated radio stations to which no medical officer is attached, are considered. The hospital corps- man's duty with the Warship's landing force, with a ship's shore patrol, and with expeditionary forces are indicated in a readable manner. This chapter also contains discussions of such subjects as roent genology, chemical warfare, deaths and medicolegal matters, recruiting. The volume closes with a lengthy chapter on administration. In it we find a presentation of the general plan, arrangement, and manage ment of naval hospitals, and the organization of the Navy with special reference to the medical department. Much space is properly devoted to a discussion of the clerical work in the medical department of the Navy in which is explained the method of correspondence, the use of the filing system adopted by the Bureau of Medicine and Sur gery for use in all medical department activities, the use of blank forms and returns, the requisition and voucher forms employed, and accounting and property accountability. An important portion of this chapter is that devoted to a discussion of the management of the commissary department at naval hospitals in which the preparation of menus in accordance with our present knowledge of food values is clearly explained. How provisions are procured in the Navy, how they are issued, the various standard cuts of meat, food inspection, stock keeping and accounting, and the duties of the commissary department personnel are all carefully considered. From the foregoing account of the contents of this hand book one may see that the subject matter covers a wide field. The book is a splendid indication of the high educational standard set for the hospital corpsman by the medical department of the Navy. No. 2. 237 BOOK NOTICES. A Treatise on Orthopaedic Surgery, by Royal Whitman, M. D., M. R. C. S., F. A. C. S., surgeon to the Hospital for Ruptured and Crippled, consulting orthopedic surgeon to the Hospital of St. John's Guild, to St. Agnes Hospital for Crippled and Atypical Children, White Plains, to the New York Home for Destitute Crippled Children, to the Darrach Home for Crippled Children, and to the New York State Board of Health. Seventh edition. Lea and Febiger, Philadelphia, Pa., 1923. During recent years much change has taken place in that special branch of medical science known as orthopedic surgery. It has de veloped by means of the ever-increasing application of surgical pro cedures to the many deformities of the body and defects in the loco motive function which were formerly regarded as hopeless or amen able to relief only by conservative treatment. It has become a specialty deservedly because of the time-consuming character of the work and because of the technical difficulties it involves. The author of this volume, or the treatise itself, needs no introduc tion to the medical officers of the Navy, as the work long has been a standard guide of orthopedic practice. In the present edition the selection of subjects and the space allotted to each have been determined primarily by their relative importance in the hospital service with which the author is connected, and it is interesting to note that about half of the volume is concerned with the treatment of those pathological conditions produced by the tubercle bacillus. The author's material has been drawn from every department of medicine and it is assembled necessarily in groups unrelated in eti ology and pathology. The only factor common to all is mechanical disability, the correction of which the writer presents in his well- known practical manner. As the majority of orthopedic conditions are first encountered by the general practitioner, the author has carefully outlined the methods of systematic physical examination that lead to early diagnosis, and, by making clear the relation of causes to consequences, he indicates in natural sequence the principles of preventive treatment. In his extensive hospital practice certain procedures have become stand ardized. These are described in detail. The volume ends with a chapter on what the author calls "Collateral orthopaedics," which he has added to supplement the bibliographical, statistical, and clin ical data that qualify the volume as a book of reference. This chap ter deals mainly -with military orthopedics and includes outlines for the treatment of fractures and nerve injuries, amputations and the adjustment of artificial limbs, and a discussion of the so-called " atti tudes of election" or the standard position for each joint which best adapts the limb for functional usefulness when motion is lost or seriously impaired. 238 Vol. XX, BOOK NOTICES. Modern Aspects of the Circulation in Health and Disease, by Carl J. Wiggers, M. D., professor of physiology in the School of Medicine of Western Reserve University, Cleveland, Ohio. Second edition. Lea & Febiger, Phila delphia, Pa., 1923. Many phenomena of the circulation, normal and abnormal, remain undetected by our unaided senses, no matter how accurate our powers of observation may be. Therefore in late years various instrumental methods have been developed which supplement our direct observa tions either by recording the functions of the circulation graphically or by translating them into numerical terms which one may readily comprehend. This book deals with the procedures by which the application of laboratory methods to the physical examination of the patient has led to the elucidation of many obscure conditions, to the recognition of new diseases, and to the institution of new forms of treatment. Eight years have passed since the first edition appeared, during which time many noteworthy contributions have been made to our knowl edge of the circulation in health and disease and many of our earlier conceptions have become altered. In the present edition the author has not only included the advances made, but he has carefully evaluated the various phases of the subject, fitting in what is revolu tionary in the new knowledge with that which we already know to be safe and conservative. The subject matter is treated in three sections, the first of which represents to the reader the modern conception as to how the circu lation is maintained in health, a matter of fundamental importance to a proper understanding of abnormal conditions. The second sec tion deals with the various instruments and procedures which are available for studying the circulation of man, and in it the author places a correct valuation upon the different forms of apparatus and points out their limitations and errors. In the chapters comprising the third section the data obtained by experimental investigation of abnormal conditions in the laboratory has been correlated with the results derived from the application of instrumental methods at the bedside, relating these in turn with the simpler signs and symptoms displayed by the circulatory system. The present edition contains new chapters on the efficiency and adaptability of the heart, vascular control of the circulation, prin ciples and practice in the optical registration of mechanical pulsations in man, the functional disturbances of the heart, and the dynamic consequences of arrhythmias and chronic heart disease. Among the important topics discussed in the second portion of the book are those relating to the arterial and venous pulse, to the electrocardiogram, to the investigation of heart sounds and murmurs by means of the phonocardiogram, to sphygmomanometry, the roent genogram, and the orthodiagram. No. 2. 239 BOOK NOTICES. In the third section of the book the chapters on the diagnosis and significance of abnormal cardiac rhythms, the dynamic consequences of abnormal cardiac rhythms, the valvular lesions of the heart, and the dynamic consequences of chronic heart disease are especially instructive. The Elements of Public Health Administration, by 0. S. Luckett, A. B., M. D., director of public health, Stale of New Mexico; and H. P. Gray, B. S., M. S., Gr. P. H., chief, division of sanitary engineering and sanitation, New Mexico Bureau of Public Health. P. Blakiston's Son & Co., Philadelphia, Pa., 1923. The writers of this readable small volume state frankly that there is little that is new or unusual in the contents, the material being partly a condensation and combination of other textbooks and partly a presentation of the practical experiences of the authors, nevertheless they have produced a manual which meets a need especially in small communities. The book is an incident in the establishment by the authors of a new State health department in a region where no organized central health agency had previously existed. Among the many problems encountered during the development of this organi zation was that of instructing the newly appointed local part-time health officers in their duties. To furnish these men with a back ground of general principles " there was needed an elementary text book on public-health administrative methods, a simple condensed summary that could be used as a ready reference by the practicing physician who was acting as health officer and who had no time to read the larger works." As no textbook suitable for this purpose existed at the time the writers prepared a series of "lessons" with the object of telling the inexperienced health officers the "how" and "why" of their official duties in such a way that they could immediately apply this knowl edge. The book is an outgrowth of these "lessons." The material is treated in three parts the first of which deals with public-health administrative measures other than for communicable diseases; the second part concerns the preventable diseases, while the third the writers consider as an appendix in which they have placed a variety of unrelated useful data, such as a plan for county health work, a form of statistical report, instructions to public-health nurses, a plan of emergency organization for relief in epidemics, a course of instruction for midwives, a dairy score card and instructions for its use, a school chart of the common communicable diseases for the use of teachers, the technic of the Schick test, disinfection, delous- mg methods, and suggestions for various blank forms which have been found useful in small health departments. The interest of this book to the naval medical officer will probably center in that portion which deals with administrative methods, 74459—24 7 240 Vol. XX. BOOK NOTICES. although if he does not possess a good working knowledge of epi demiology much of value will be found in the section which concerns the preventable diseases. In considering administrative methods the writers discuss in a very practical manner the relations of the health officer to the physician, the organization and functions of a local health department, finance and office management, registration of births and deaths, maternal, infant, and child hygiene, water supply, sewage disposal, wastes disposal, sanitation and housing, milk, food and food poisoning, education and publicity, public-health law, and the organization and functions of State and Federal health agencies. Every health officer has to face two problems of the utmost im portance. One is the obtaining of funds to carry on his work. The other is the management of these funds to secure the best results. Success in getting funds depends to a large measure on public opinion, and in the chapter on finance and management the authors make some pertinent remarks in connection with methods for creating a public opinion favorable to an adequate support of health work. However, the success of a health department depends not so much upon its financial resources and equipment as upon the character of the man at its head. His personality, intellectual make-up, and human understanding are the determining factors in organizing and popularizing his program. Among the characteristics that are found in the effective health officer the authors mention patience, tact, perception of the viewpoint and intelligence of those with whom he comes in contact, sincerity coupled with industry which create in the public mind the conviction that the health officer has the community good at heart, firmness and decision in carrying through a determined policy, thorough knowledge of his specialty, good judg ment in dealing with questions of policy and administration, fairness to all, and courtesy always—truly an array of characteristics worth cultivating. Nervoos and Mental Re-Education, by Shepherd Ivory Franz, director of laboratories, Si. Elizabeths Hospital (Government hospital for the insane), Wash ington, D. C; professor of psychology, George Washington University. The Macmillan Co., New York, 1923. This book will, no doubt, be welcomed by those who have to do with the problems of readjustment of the individual, an inevitable result of the World War. The author endeavors to solve some of these problems, and to show medical men, not specialists, and also the laity the general principles and method of applying them in the neuroses and psychoses. There is a refreshing directness of style that renders the book attractive and instructive. The replacement of bad habits with better habits is the object of nervous and mental reeducation. The first two parts of the book discuss the formation No. 2. 241 BOOK NOTICES. of habits in the normal life of the individual and also the abnormal conditions of disease. Habits are classed as motor, sensory, and delayed reactions, and are acquired with different degrees of celerity, depending on the differences in kind. Usually the motor and sensory reactions follow the stimulus, but in the delayed reaction it does not do so immediately. When the adjustments are fine and numerous, the habit is only acquired after considerable practice. When the movements are gross and few the habits are learned quickly. The time element will vary with the individual as well as the kind of habit; also the delay of reaction will make a habit hard to form. From disuse a habit shows a loss in directness, fineness, or speed. Self-preservation and sex play important parts in education and also in reeducation. Hope and helpfulness are integral parts of re habilitation and a "will to get well" must be created if it does not exist. This is especially true in the psychoses. Amusements, games, and friendships in hospitals are to be encouraged. Coopera tion of patients, family, and the community are very necessary. All three kinds of habits are utilized in reeducation. Motor habits are concerned largely with paralysis, sensory habits with tabeties, and delayed reaction habits with aphasias. Analysis of movement show that the elements of strength, extent, and time are intimately re lated. An accurate movement is the adequate combination of all Any one element may be difficult and need reeducation. Previous tudies have overemphasized strength in comparison to extent of movement. The various types of "protractors" to measure "extent" are described by the author. The different spring dyna mometers, commonly used to measure strength, are also discussed. The measurement of time of movements requires special apparatus which can only be used after practice. By means of "tapping movements" and a stop watch a fairly accurate determination of speed can be made. Various devices in reeducation are described for exercising the legs, hands, and arms. The author also utilizes all the applicable methods of electrotherapy, hydrotherapy, and physiotherapy, which he discusses as to relative value—kineso- therapy (active and passive movement, including massage) also has its uses in different cases. The dangers of overfatigue to weaken the muscles is warned against. The use of braces and casts must be left to the orthopedic surgeon but rigid splints are to be depre cated; whenever possible flexible splints should be used. The importance of records, especially moving pictures, to show progress, warrants the expense, and other records can be obtained by measure ments or observation. These records are used not only to encourage the patient but are of importance in determining the continuance of treatment. There are two sources of error in these records, 242 Vol. XX, BOOK NOTICES. however, which must be considered, the first being error of observa tion of the instructor who records the measurement, and tbe second is the variability in the activity of the patient who may be able to do a little more or less at a given time. Both can be compensated for. Part three of the book discusses in detail the application of the reeducational methods in neurological and mental cases, especially infantile paralysis, locomotor ataxia, cerebral paralysis, speech defects, and the psychotic. In this latter group are classed the neurasthenic, or psychosthenic, and the hysteric whose main mani festations are mental; also those who are commonly considered insane. In every case there is an outward expression of a so-called inward state, including motor and sensory disturbances. The normal habits are inefficient or there are perverted reactions. These patients do not respond to reeducation unless the "insight" is sufficient to recognize his abnormalit}*. The desire to get well must also be present and sufficient confidence in himself and his physician to use every means at hand. Much more tact, patience, kindliness, and forbearance are required than in dealing with organic cases. On the other hand too much sympathy may cause him to exaggerate his condition. Suggestion in all its forms plays a large r6le in most of the reeducation procedures. A mental "catharsis" to rid himself of peculiar ideas that are burdens to him may necessitate disclosures and confidences, but extensive psychoanalytic measures need not be carried out. Well-known therapeutic measures, especially those directed toward the elimination of toxins, should be used. Electro therapy must be cautiously applied in order that delusions or fears are not originated by the treatment. Currents with high voltage causing considerable skin pain have been found very useful, probably from their suggestion. Occupation therapy, such as mat making, basket weaving, raffia work, etc., may be of great value. It may be a means of preparation for future occupation in case the patient has to earn his own living, and is also an introduction to other occu pations. Often the reverse of the patient's previous occupation will be necessary to maintain health, and these replacements are part of the reeducation. Alcohol and Prohibition in Their Relation to Civilization and the Art of Living, by Victor G. Vecki, M. D. J. P. Lippincott Co., Philadel phia, Pa., 1923. The publisher's opinion of this book, as stated on the outside cover, is that it is "a fair and unprejudiced presentation of truths." The author evidently endeavors to be unbiased and fair, and succeeds fairly well in the first two chapters. The remainder of the book is a compilation of all that could be found to sustain the author's very evident antipathy to prohibition. It does not require the statement by himself of this fact in the chapter on "The medical profession" No. 2. 243 BOOK NOTICES. to convince the reader that the author is anti-Volstead. If one is looking for arguments against prohibition, this book will help him find evidence, but it is disappointing to those who are seeking a fair discussion for this very vital question of the day. The last chapter " What should be done" is a more reasonable discussion of both sides of the question. Sir James Crichton-Browne's statement is quoted: " That acquirement of self-control is one of the main objects of educa tion, the exercise of it a chief part of the discipline of life, and to sub stitute for it grandmotherly legislation is to debilitate human nature and court disaster." Again he quotes from Monin: "Prohibition laws will be really effective when the desire for drink is subdued; and this can only be accomplished by individual social education." The author believes the public school is the first place where the danger of alcoholic abuses must be impressed upon the child's mind, " but real facts, not exaggerations, must be taught." No doubt education has its value, but there is no evidence in the past or present to indicate that it is a solution of the problem. In presenting " real facts" it would be well also to bring out what the author omits in this book, the results of the eighteenth amendment in the reduction of crime, poverty, and disease, especially insanity, in various parts of the country. From equally reliable sources, such as the author quotes, there is abundant evidence to show the beneficial effect on the very ones that should be helped by this law, the " backbone of the country," the workman and laboring man. The abolition of the saloon, if for no other reason, should commend this law to the thought ful man. By comparison to the pre-Volstead days, how often do we see drunken men in the streets and public places? The chronic alcoholic with bleary and watery eyes and injected nose so commonly seen in the past is now a curiosity. There is no doubt that the law is being defied secretly and openly, but for the most part by those who lead reckless lives without serious thought of law and order. If protective laws are ever just, surely one can find enough reasons for the Volstead law. In fact it was " self-protection " that caused so many Southern States to go "dry" before the eighteenth amend ment was considered. It is only a further extension of these reasons that called for a constitutional amendment. Whether we believe that we, personally, need this protection is not the issue, any more than it is with many other protective laws that we acknowledge and obey. The question resolves itself into whether we, as loyal citizens of a country where majority rule is the accepted form of government, shall be law-abiding, even though it is contrary to one's personal belief. Defiance of one law is only a step to breaking others, and it is this factor that is considered the most deplorable feature of the attitude of many toward prohibition to-day. 244 Vol. XX. BOOK NOTICES. Those of us who have been many years in the Navy remember the agitation when beer was taken away from the enlisted men, yet it was soon seen that a marked and beneficial change occurred. Again, in 1914 the abolition of the officers' wine messes aroused even greater resentment which continued for some time, yet it is believed that if both these questions were put to vote to-day that the officers and enlisted men would not wish to restore either the "canteen" or wine mess. As a reflection of the average community toward liquor and drugs it seems fair to compare the habits of the personnel of our Navy at the present time. Again for comparison we must go back a number of years, and by so doing it is safe to say there has never been a time when the Navy has consisted of so many clean-cut, self- controlled, fine types of manhood as it does to-day. Diseases op the Skin, by Frank Crozer Knowles, M. D., professor of dermatology, Jefferson Medical College; dermatologist to the Philadelphia General, the Presby terian, the Children's and the Babies' Hospitals; chief of clinic, dermalological department, Pennsylvania Hospital. Second edition. Lea & Febiger, Phila delphia, 1923. This is a practical manual of diseases of the skin, of nearly 600 pages, which the author has revised considerably in the preparation of the present edition. The volume begins with a section devoted to a discussion of the anatomy and physiology of the skin, and the symptomatology, etiology, pathology, diagnosis, types, and the gen eral principles of the treatment of skin diseases. A useful inclusion in this section is an outline of the regional distribution of the common skin diseases and the types of lesions tending to involve certain areas. The discussion of the special methods of treatment employed in the practice of dermatology is complete and embraces descriptions of the use of autoserum and foreign proteids, vaccine treatment, photo therapy (Finsen light and actinotherapy), radium treatment, X-ray therapy, fulguration, electrolysis, and refrigeration. The writer has followed the usual practice in the preparation of textbooks on dermatology in that he has divided his subject matter into convenient classes. This classification includes 13 divisions as follows: Hyperemias, Inflammations, Hemorrhages, Hypertrophies, Anomalies of pigmentation, Atrophies, New growths, Neuroses, Diseases of the skin caused by vegetable organisms, Diseases caused by animal parasites, Diseases of the appendages, Diseases of the mucous membranes, and Acute eruptive fevers. The description of each disease is short and clear, and the treatment recommended, as a rule, is that which the author has found to be most effective in his practice. As in most modern textbooks on dermatology, numerous carefully chosen illustrations are added to elucidate the author's text. No. 2. 245 BOOK NOTICES. Rhus Dermatitis (Poison Ivy), Its Pathology and Chemotherapy, by James B. McNair. The University of Chicago Press, Chicago, 111., 1923. This book is a very valuable contribution to medical litera ture on this subject and may well serve as a guide in the study of clinical cases as well as in the application of rational treatment to the condition. The specialist as well as the general practitioner will find food for thought in these pages. The author gives a quite complete botanical description and com parison of plants under the general term of rhus diversiloba. He sets forth the technique of the numerous methods of experimentation and investigation whereby he arrives at his conclusions which seem well founded. The "principal dermatitant" is given the name of lobinol and is considered, if pure and not a mixture, to contain " an unsaturated compound of the aromatic series containing carbon, hydrogen, and. oxygen * * * and to be a poly-hydricphenol." Several chapters are devoted to the pathology resulting from the irritant, a differential diagnosis, a discussion of the immunity to the dermatitis, and a very complete presentation of methods of treatment and remedies to be found in medical literature. An appendix of case histories descriptive of typical cases, symptoms, and the course of the skin manifestations is most instructive, and a bibliography of extraordinary length is to be found at the end of the book. Rubber and Gutta Percha Injections, by Charles C. Miller, M. D. Oak Printing A Publishing Co., Chicago, 111., 1923. This small book is a preliminary report of the use of rubber and gutta percha subcutaneously for the purpose of correcting various tissue deficiencies and facial deformities. By the use of excellent illustrations and short descriptive chapters, the author describes the types of material, method of preparation, and the special syringes required for this work. THE DIVISION OF PREVENTIVE MEDICINE. Lieut. Commander J. K. Phelps, Medical Corps, United States Navy, in charge. Notes on Preventive Medicine for Medical Officers, United States Navy. ERADICATION OF VERMIN ON BOARD SHIP. Vessels that have been in commission for some time are very likely to be infested with rats, bedbugs, and cockroaches. The most practical method of attacking the vermin problem on board a large ship is by the organization of a sanitary squad. Such a squad should include a properly instructed hospital corpsman and two or three other men, one of whom, preferably, should be a car penter's mate or other man sufficiently trained in the use of the necessary tools to get at places in which rats commonly build their nests, and to remove woodwork which conceals bedbugs and deposits of their eggs. With a sanitary squad, efforts at eradication usually prove more or less fitful. In the absence of such a squad an order that bedbugs will not be tolerated on board at best accomplishes but little in the way of permanent relief. Such an order seldom reaches bugs in their innermost retreats. The truth is that rats and bedbugs come aboard from time to time ; rats, over lines or gangways in spite of lights and sentries, and rat guards which are subject to disarrangement. Rats are also brought on board with provisions and other stores. Bedbugs are brought on board with more or less regularity while in port. To one who is not fully informed it may appear a simple matter to free a ship of these pests. Such is not the case, and feverish activity over a brief period of time can not accomplish as much as calm and steady work by three men systematically employed every week in the year. Unless such a squad is organized, the various divisions must be depended upon to look after their own parts of the ship. Generally, it becomes everybody's business to keep the ship free from vermin. It means that the first lieutenant and chief master-at-arms must continually keep after compartment cleaners, storeroom kecpers> commissary force, messmen, mess attendants, etc. This may be a good plan in theory, but the tendency is for everybody's business to become nobody's business. In practice the work in different parts of the ship is not coordinated. Disinfestation does not proceed in 247 248 VoL XX. DIVISION OF PREVENTIVE MEDICINE. orderly fashion, but rather in spasmodic efforts from time to time to clean up this or that part of the ship. As indicated below, the distribution of vermin and the methods by which they spread from one part of the ship to another are such as to make efforts at eradica tion unsuccessful unless a logical plan of attack is adopted and executed systematically and continuously by a small group of men who understand the habits of rats and the insects to be exterminated, and who have been trained to make effective use of traps, chemical agents, and steam as required in practical disinfestation. A workable scheme is to have a locker for the sanitary squad's gear in the vicinity of the sick bay. Tools, rat traps, spray guns, and adequate quantities of cresol, kerosene, turpentine, sodium fluoride, and other chemical agents, if employed, should be stowed here. Solutions may be prepared in large quantities in the dis pensary. Materials should be issued by the first lieutenant's office somewhat in advance of needs. The medical officer should estimate the quantities of materials that will be required during the year in order to make certain that the supply officer or first lieutenant will have them in stock when required. It is particularly desirable to provide liberally for the replacement of rat traps and spray guns. The sanitary squad should work under the direction of the medical officer, but in the interests of cooperation the first lieutenant and chief master-at-arms should send work orders directly to the leading man of the squad. In practice any direct notification of the dis covery of bedbugs in an officer's room or in the chief petty officers' quarters should secure immediate attention. The hospital corpsman in charge of the squad should be required to keep a journal showing orders for work and work performed- The book, posted to date, should be kept on the medical officer's desk. Each day there should be entered the number of rats trapped and a brief account of work undertaken and accomplished the preceding day. The leading man should regularly inspect the laundry, crew's head, bathrooms, hammock nettings, pantries, and other places where cockroaches or bedbugs may be found. He should investigate loca tions where rats have been seen running in an effort to discover their breeding places. He should note the location and condition of receptacles for rubbish in living compartments and observe whether they are being emptied regularly and promptly so that rats will not have a supply of food in the form of remnants of articles purchased ashore or at the canteen. He should talk with compartment cleaners and teach them the best methods of destroying cockroaches and bed bugs, and learn from them whether any rats or insects have recently been seen in the compartment. Likewise, he should talk with storeroom keepers, cooks, bakers, and stewards and instruct them so that they may work effectively and furnish all necessary assistance. No. 2. DIVISION OF PREVENTIVE MEDICINE. 249 RATS. There are several species of domestic rats; all introduced —none native to America. Order: Kodentia; genus, epimys. The most common in the United States are : (1) Mus muscvlus, the common house mouse. (2) Epimys norvegicus, the brown rat, sewer rat, gray rat, Norway rat (most numerous and widely distributed, except the mouse). (3) Epimys rattus, the black rat. (4) Epimys alexandrinus, the palm or roof rat. The common brown rat is the most destructive. It has extended its range and steadily increased in numbers in spite of such attempts at extermination as have been made by man. It has supplanted and nearly exterminated the less robust black rat. Dominance is due to great fecundity and ability to adapt itself to all sorts of surroundings. Breeding.—Mice and black rats produce smaller Utters than the common sewer (brown) rat, but the period of gestation, about 21 days, and the number of litters, six or more per year, are the same for all species. The brown rat produces from 6 to 12 or more young in a Utter— average, 10. The females begin to breed when only three or four months old. At this rate, assuming that no deaths occur and that equal numbers of males and females are bred, one pair breeding uninterruptedly can produce in one year a posterity of more than 39,000 rats. Habits.—Rats and mice are practicaUy omnivorous. They feed upon all kinds of animal and vegetable matter. They are often cannibaUstic. Rats travel extensively. They migrate from place to place in the same city and also follow routes of travel from city to city by way of freight cars or ships. Not infrequently they are found in boxes, crates, or packing cases. The brown rat is a burrowing animal. It makes its home in the open field, in hedges, along river banks, in stone waUs, piers, and in all kinds of buildings. This rat is a good swimmer and a good fighter, and wUl kUl off the less ferocious black rats and palm rats in time. Both of the latter are good jumpers and climbers and are therefore found normally in the roofs of houses and in trees. The brown rat destroys grains while growing in the field and stores of grains in stock all along the Une from producer to consumer; in the granary, miU, elevator, or ship's hold. It invades stores and ware houses and attacks dry provisions, fruits, vegetables, furs, laces, silks, carpets, and leather goods. It destroys eggs and young poultry. In general, it destroys by poUution ten times as much as it eats. 250 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. It causes conflagrations by gnawing the insulation on electric conduits; floods, by gnawing lead pipes, and causes damage to foundations, embankments, floors, doors, and furnishings of dwell ings. The common house mouse does not confine its activities to the inside of buildings. It is often found in open fields. In warm climates the black rat and palm rat are able to maintain themselves against the brown rat by living in trees and other high places. These rats are frequently brought to our sea ports but seldom become very numerous. Epidemiological considerations. —On board ship rats are always a potential menace to health. Bubonic plague is primarily a disease of the rat from which it is transmitted to man through the agency of the rat flea. The rat may also serve as the host for other parasites, such as Trichinella spiralis. An epizootic in rats precedes an epi demic of plague in man. The appearance of sick rats or the dis covery of dead rats apart from a poisoning campaign should at once arouse suspicion that B. pestis has been introduced among the local rat population. All dead rats should then be examined for the morbid anatomy of plague, followed up with bacteriological examination in case suspicious lesions are found. Disinfe station on board ship. —The object of a systematic and continuous campaign is to keep the rat population of the ship reduced to negligible numbers. Destruction of all rats is usually or nearly always out of the question. Even under favorable conditions, total extermination can scarcely be expected from fumigation with hydrocyanic acid gas, the most deadly fumigant. The plan of attack should include: (1) Invariable use of rat guards on all lines; lights and sentries at gangways. (2, Rat proofing of store rooms, issue rooms, canteen, offices, and staterooms. (3) The keeping of refuse, remnants, table leavings, and all articles or substances that may serve as food, away from the rats. (4) Measures planned to destroy rats— (a) Trapping. (b) Rat hunting and destruction of nests. (c) Poisoning. (d) Fumigation with sulphur. Measures to prevent rats from coming aboard. —Gangways are fre quently left unprotected at night. Rats will not be deterred by a bright cargo light in the absence of a sentry. Rat guards are liable to become disarranged or bent. Not infrequently they are put on in such a way as to leave an opening along the line or a foothold that No. 2. 251 DIVISION OF PREVENTIVE MEDICINE. will allow the rat to pass over the guard. The possibility of rat harborage should be borne in mind when crates of potatoes and large cases of provisions are brought on board. Rat proofing. —Openings in meshed wire around piping and ven tilation ducts leading into storerooms, issue rooms, bakeshop, offices, and staterooms, as well as closed spaces in which rats may build their nests undisturbed, should be closed with metal strips or by inter weaving with heavy wire. When the mesh is coarse enough to per mit rats to pass through, tight steel plates should be erected inside, or the openings should be reduced in size by weaving in heavy steel wire up to a point that is beyond jumping distance. These methods for closing openings are not altogether effective because rats on board ship learn to climb so well that they can make their way vertically up a comparatively smooth surface in a corner and they find no diffi culty in climbing up an open meshed fencing. But, as a rule, if the rats have been gaining entrance to a room or space through openings around pipes the closing of those openings will keep them out. Usually rats are not found in storerooms, or if they do gain access they do not find it possible to leave and return. Most storerooms below decks are rat proof because water-tight integrity must be main tained. Rats seldom enter while the doors are open because men are working in the room or in the passageway just outside. Keeping food from rats. —Well-fed rats mature quickly, breed often, and have large litters. Poorly fed rats reproduce less frequently and have smaller litters. It is therefore of primary importance to starve the rats as much as possible by keeping all stores of foods protected against invasion and by destroying all refuse, table leavings, and rem nants of articles purchased at the canteen, so that rats will not have access to them during the night or at any time in temporarily unoccu pied rooms or spaces. Unless immediate or frequent removal and destruction is practiced, such articles should be collected in metal containers kept closed by tight fitting covers. To determine whether rats are present in unoccupied spaces an apple may be intentionally left here or there. Characteristic tooth marks will show that the apple has been gnawed. Rats will often eat soap; therefore supplies of soaps in storerooms and elsewhere should be protected. DESTRUCTION OF RATS. Trapping. — Rats are highly suspicious and cunning animals. This is especially true of rats dwelling on board a naval vessel, prob ably because they must exist and shift for themselves with human beings constantly near by. It is difficult to trap them, yet trapping persistently followed is the most effective way of destroying rats on board a battleship or other vessel of the Navy, because fumigation of the entire ship is ordinarily out of the question, and local fumiga tion is usually not worth while. 252 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. Comparatively few rats will be caught unless they can be deprived of food. Trapping is likely to result in almost complete failure when food is abundant. The cheap and common "guillotine" or spring trap is far and away superior to the cage trap for use on board ship ; in fact where both typos are employed it will usually be found that no rats are being caught in the cage traps, although consistently large daily catches continue with the spring traps. Guillotine traps made entirely of metal are supposed to be superior to those having a wooden base, but the latter properly handled and baited are effective. A common mistake in trapping for rats is to use only a few traps when dozens are needed. Not less than 100 and preferably more traps should be kept baited and set at all times in a battleship when rats are known to be on board. House mice are less suspicious than rats and are much more easily trapped. The traps must not be put out in trapping locations with any lingering rat smell or human smell about them. When they are brought in for rebaiting they should be cleansed by dipping in scalding hot water. The man who handles them should wear freshly washed rubber gloves. The last may bo an unnecessary precaution, but it is not likely that a trap which has mangled a rat will catch another until it is entirely free from rat odor. Cheese, preferably toasted, is probably the most convenient and satisfactory form of bait. The cheeso should be cut into small cubes on a clean towel or shoot of muslin. Each cube should be enclosed in a single thickness of gauzo to prevent the rat from getting it away from the holder without springing the trap. This is conveniently done by cutting the gauze into a small square, placing the cheese in the center, and tying the neck of the little sack so formed with a piece of thread. When this is secured to the bait holder it is almost impossible for a rat to get at the cheeso without springing the guillotine. An other method of insuring release of the spring is to bend the end of the bait-holding wire around so that it points back towards the bar of the spring. Thus baited, the rat in working at the bait is likely to get his nose under the loop formed by bending the wire. If the bait is lifted the spring is released. Small pieces of Vienna sausage (wionerwurst) or fried bacon are said to be excellent baits. Other baits recommended are oatmeal, fish, fish offal, fresh liver, raw meat, apples, carrots, corn, squash, or pumpkin seeds. Ripo tomatoes, green cucumbers, and other fresh vegetables are said to bo very tempting to rats in winter. Loca tion of traps. —Rat runways suggest the numbers of traps to be used and the places where they may be placed to tho best advantage As a rulo tho trap should bo placed where it can be left undisturbed for two or threo days at a time. When the rats decrease in numbers as a result of successful trapping so that they are no longer observed No. 2. 253 DIVISION OF PREVENTIVE MEDICINE. running about at night, traps should be set in all places where it ia possible or likely that they will be caught, relocating them every few days. The number of traps in use should not be reduced as the daily catch falls off. Destruction of nests. —Rats have been found to prefer such places on board ship in which to build their nests as spaces under transoms or built-in bunks, when there is a small opening around a pipe or in a corner through which they can gain access; in blower casings, air ducts, or oven in large voice tubes. Any space ordinarily inacces sible to human beings that has a small opening or a devious path of approach may be selected as the home and breeding place by the rat family. As many nests as possible should be located by inves tigating openings and possible spaces behind sheathing, equipment, and furnishings, in compartments where rats are known to run. Favorite runways include overhead I beams, ventilation trunks and ducts, and any overhead piping along which the rats can travel through bulkheads. The closing of such openings puts the rats at a disadvantage and makes it more difficult for them to provide for their families. Destruction of the females and young in their nests is an important part of the campaign, inasmuch as it greatly limits the number of adults that would otherwise exist in the rat popula tion a few months subsequently. This operates together with bio logical, disease-causing, nutritional, and environmental factors, and perhaps family and interfamily quarrels to limit the birth rate very definitely. There is, of course, a limit to the size of the rat popula tion on board even in the absence of organized efforts to exterminate rats. The simple smoke-producing apparatus sold for use in smoking , out bees, when it is desired to drive them from one hive to another, may be used to good advantage at times to determine whether there are rats in certain concealed places without tearing down plating or furnishings. It consists of a bellows, burner, and delivery tube. A mixture of cotton and woolen rags, when burned, will give a dense smoke that will quickly drive the rats from their hiding places. The smoke may be pumped by the bellows through a flexible tube introduced through the suspected rat hole or opening. Wool and cotton smoke is more effective than sulphur fumes for this purpose. Poisoning. —While the use of poison is the quickest way to get rid of rats and mice, the odor from the dead animals makes the method impracticable in occupied houses, and as a rule on board ship. Poison should never be placed in open or unsheltered places. This applies particularly to strychnine and arsenic. The principal poisons recommended for killing rats are barium carbonate, strychnine, arsenic, phosphorus, and squills (sea leek, ScUla maritima). 254 Vol. XX, DIVISION OF PHEVEXTIVE MEDICINE. Barium carbonate.—This agent is without taste or smell and it is one of the cheapest and most effective poisons for rats. In the small doses fed to rats it is harmless to domestic animals. It has a corrosive action on the mucous membrane of the stomach. It is a useful poison in buildings ashore because it acts slowly, and if exit is possible the rats usually leave the premises in search of water. Frequently, but not always, it may be used in dwelling houses with out disagreeable consequences. Barium carbonate may be fed in the form of dough composed of one part of the mineral and four parts of meal or flour. Ordinary oatmeal together with one-eighth of its bulk of barium carbonate may be mixed with water to form a fairly stiff dough. Sometimes the barium carbonate is spread upon fish or bread and butter, or upon moistened toast. The prepared bait should be placed in rat runs, about a teaspoonful at each place. Strychnine. —The action of this drug is too rapid to make its use desirable in occupied houses; elsewhere it may be employed effec tively. Dry crystals of strychnine sulphate or nitrate may be in serted in small pieces of meat, sausage, or toasted cheese, and placed in rat runs. A sirup may be prepared to moisten oatmeal, wheat, or corn, by dissolving the strychnine in boiling water in the proportion of oneounce to the quart, adding an equal quantity of thick sugar sirup and stir ring thoroughly. The grain to be used as bait should be soaked for several hours in the strychnine sirup. Arsenic—This is the most popular of the rat poisons. It is low in price, but measured by results obtained it is probably more costly than strychnine. It is said to be variable in its effects; if the rats survive a first dose it is very difficult to induce them to take another. Powdered white arsenic (arsenous oxide, arsenous anhydride, arsen- ous acid) may be fed with any of the baits mentioned above. Phosphorus.—The phosphorus pastes on the market are usually yellow phosphorus mixed with glucose and other substances, varying in proportion from one-fourth of 1 per cent to 4 per cent. The stronger mixtures are dangerously inflammable and the weaker mix tures are not effective. The popular belief that rats poisoned with phosphorus do not die on the premises is erroneous; likewise the belief that the bodies of rats killed with phosphorus dry up without giving off odors. Squills. —One ounce of powdered squills may be mixed with 4 ounces of toasted cheese, or with butter and meal, and put in rat runs. The rats are said to eat it readily. It is rapid and deadly in its action. It is worthy of trial in places where the dead bodies of the rats will not create a nuisance. No. 2. DIVISION OF PREVENTIVE MEDICINE. 255 Fumigation. —The objections against poisoning also apply to fumi gation. The method is not generally applicable on board ship unless the dead rats can be found and removed. Fumigation of the holds in a cargo carrier is practicable; likewise fumigation of compartments that are likely to harbor rats in a passenger-carrying merchant ship. It is a different proposition with a battleship or other type of fighting ship. Unless all parts of the vessel are simultaneously disinfested a 90 per cent reduction in the rat population can not be expected. For effective fumigation it is necessary that all human beings leave the ship and that elaborate preparations be made in the way of opening up all spaces and moving stores, equipment, etc., in order that the gas may diffuse through all spaces and reach rats in their retreats. Special circumstances may indicate limited fumigation but syste matic trapping should make such measures unnecessary unless there is danger that bubonic plague may be introduced, and in that event the ship should be completely fumigated if possible. Hydrocyanic acid gas is too dangerous to be used without the facilities of a quarantine station and the employment of trained per sonnel under the direction of an experienced medical officer to whom absolute authority is granted. Even under those conditions there would still be considerable danger of overlooking a few men who have not left the ship or have escaped notice and returned at the last moment to attend to some forgotten detail only to be overcome and killed before they can escape. Sulphur dioxide is almost as effective as hydrocyanic acid gas with a sufficiently long period of exposure. The fumigation standards adopted by the United States Public Health Service require the burning of 3 pounds of sulphur per 1 ,000 cubic feet of space with exposure for six hours in superstructure spaces, partially filled storerooms, and empty holds. For well-filled storerooms and compartments packed with materials the time of exposure should be doubled. Rat viruses. —Neither the United States Public Health Service nor the Department of Agriculture recommends the use of any rat virus. No virus has been discovered that has uniformly high viru lence which can be maintained. The virulence of cultures decreases with age, warm weather, and sunlight. Moreover, the effect depends not alone upon the virus but is essentially the result of biological reactions between the virus and the rats. If the infected rat is not killed, it is immunized. The establishment of mass immunity in the rat population makes the particular virus useless after a short time. The infections are not very communicable and do not spread to any great extent by contact of diseased with healthy rats. A few reports of the effective use of rat virus on board ships of the Navy have been received, but it is to be borne in mind that any 74459—24 8 256 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. 0 intensive campaign against rats on board ship, whether by simple trapping or poisoning, for a short time will result in a temporary reduction of the rat population so that survivors will seldom be seen at large and it may be prematurely concluded that rats have been gotten rid of unless systematic trapping is carried on. The use of virus must be followed up with continuous trapping. Therefore little is gained because the early and striking reduction in a large rat population can be secured with an adequate number of traps as well as by the use of a virus, or, for that matter, by any of the simple poisons. THE BEDBUG. This insect may gain access to a dwelling house, hotel, or ship in spite of all reasonable precautions. It gets into trunks, suit cases, and satchels of travelers; into packages or baskets of laundry; and into clothing while being worn. Bedbugs have been brought on board ship along with a considerable variety of articles, including rolled up newspapers. The bedbug is quite capable of migrating from house to house on its own legs. They will often continue to come from an adjoining house, sometimes for a period of several months, gaining entrance daily, especially if their original home is left vacant so that they are deprived of their usual source of food. They are able to make then- way along walls, water pipes, and gutters, and gain entrance through windows or cracks. On board ship at times they migrate by their own powers of locomotion to a considerable extent across the ship, into adjoining compartments, or from one stateroom to another. In other instances they seem to have little tendency to migrate; staterooms on both sides of an infested room may remain free from the bugs for long periods. It is not a disgrace to be visited by bedbugs, but failure on the part of anyone to institute immediate efforts toward eradication indicates a lack of common sense or a mistaken sense of shame. Fail ure to notify the medical officer frankly and at once when bedbugs are discovered is to be condemned on the grounds of sanitation. The bedbug appears to have had its characteristics since the beginning of recorded history and has accompanied man wherever he has gone. Order: Rhynchota {Hemittera) . To this order also belong the "blood-sucking cone nose" Triatoma (Conorrhinus) , a winged member of the order, the suctorial lice and the bird lice. This order includes the true bugs, piercing insects characterized by possessing a piercing and sucking beak. Like nearly all the insects that are parasites of animals it is degraded structurally, its slight necessity for extensive locomotion have resulted in the loss of wings in the course of evo lution. No. 2. 257 DIVISION OF PREVENTIVE MEDICINE. Designated "Cimex" by the Romans, the common bedbug belongs to the genus known in recent years as Acanthia but now definitely renamed Cimex. It is a semiparasitic insect. Several species of this genus have been described, two of which, the common bedbug {Cimex lectularus) and the Indian bedbug {Cimex rotundatus) , are parasites of man. Other species have been described; namely, Cimex kirundinis, which attacks swallows; Cimex columbarius, which attacks pigeons; and the Cimex pinistrelli, which is found on bats. Characteristics. —Before feeding, the adult is much flattened, oval, rust red in color, and the abdomen is more or less tinged with black. When the body is flattened, it can pass into the smallest crack. When engorged, the body becomes much bloated and elongated as well as brightly colored from the ingested blood. The wings are represented by the merest rudiments, barely recog nizable pads. The bedbug has two compound eyes but the additional simple eyes of most true bugs are lacking. The antennae are four- jointed. The proboscis is long and stout, and while at rest is carried under the ventral surface. Ordinarily it does not feed on the hairy parts of the body, as it is not adapted to making its way through the hairs. A characteristic feature is the familiar and disagreeable "buggy" odor. This very distinct odor is not limited to the bedbug but is characteristic of most plant bugs also, including the common chinch bug that affects small grains and the squash bug, all of which possess the odor, and it is quite as pungent with these plant-feeding forms as with the human parasite. The odor is a fortunate characteristic as it is of considerable assistance in detecting the presence of bedbugs. It comes from glands, situated in various parts of the body, which secrete a clear, oily volatile liquid. Although the odor is a means of protection of the true bugs against their enemies, which are kept away by it, the cockroach, which sometimes feeds on bedbugs, is evidently not deterred by it. Habits. —The bedbug, normally nocturnal in habits, displays a marked degree of caution and intelligence in keeping itself hidden during the day. When very hungry, it will come out into the open in a well-lighted room at night, and it has been known to attack human beings in broad daylight under stress of hunger. As soon as it be comes engorged it leaves its victim at once and retires to its place of concealment —cracks in a wooden bedstead, inside spiral springs, inside tubular piping of bunk frames, in lockers, wardrobes, behind drawers of furniture, under the metal straps of trunks, behind wain scoting, under loose wall paper, in cracks behind mop boards, or any other likely place that offers security. In such places it manifests gregarious habit by collecting in masses. The inherited experiences of many centuries of association with man, during which it has always found its host an active enemy, has 258 Vol. XX, DIVISION OF PREVENTIVE MEDICINE. resulted in an intimate knowledge of the habits of man and led to craftiness, as exemplified by its habit, not infrequently observed, of leaving the bed entirely and going to distant quarters for hiding during daylight hours. Life history. —The eggs are oval, white, or grayish bodies with a rim or lidlike top at one of the ends — a small projecting rim. The eggs are deposited in batches of from 6 to 50 in the cracks and crev ices where the bugs go for concealment. In the case of females under observation, eggs are deposited almost daily for a period of two months or longer, at the rate of from 1 to 5 eggs a day. Some times larger hatches are laid. As many as 190 eggs have been obtained from a single captive female. The eggs hatch in from 7 to 10 days in the hot weather of mid summer. Longer periods are required in cold weather. Cold may check development altogether. The young escape by pushing up the lidlike top with its projecting rim. At first they are yellowish white and nearly transparent. The young closely resemble the adult forms except that they are pale in color and the various regions of the body differ in proportions. Metamorphosis is incomplete, in that distinct larval and pupal stages are absent. The young grow to adult form normally through five successive moltings, or shedding of the skin, the color becoming darker and darker until fully grown. With the last molt the minute wing pads, characteristic of the adult insect, make their appearance. The life cycle is subject to great variation depending upon tempera ture and food supply. In warm weather, with food available, there is ordinarily an average period of 8 days between moltings. About 8 days are also required in warm weather for the egg to hatch, so that a period of about 7 weeks is required from the time the egg is de posited to maturity of the adult insect. They are capablo of living for a long period of time, a year or longer, without food in any stage of development. Molting periods are usually shorter in the earlier stages and lengthen in the later stages. Without food the bedbug may remain unchanged in any of the immature stages for an indefinite time, and such checking of development by starvation may result in additional molting periods. If the insect feeds but once between molts, it must puncture its host five times before becoming mature, and at least once afterwards before development of eggs. Additional meals may be taken between molts under favorable circumstances. The bug devotes from 5 to 10 minutes to sucking its fill of blood when undisturbed, and it then retires to its place of concealment for a period of 6 to 10 days for peaceful digestion of its enormous meal and subsequent molting, or reproduction if it has reached the adult stage. No. 2. 259 DIVISION OF PREVENTIVE MEDICINE. With reasonable allowances for lack of food and unfavorable temperature the expectation is that there will be at least four suc cessive broods during the course of a year in an occupied ship or house that is kept well heated in winter. Influence of temperature. —Eggs and newly hatched larvre do not survive a temperature below freezing for a period longer than from two to four weeks. At temperatures below 60° F. the insect remains quiescent and in semihibernation. The temperature range favorable for activity is between 60° and 98° F. Therefore the bedbug will remain active in heated houses or ships during the winter. It is most active at temperatures between 60° and 75 °F. In a tempera ture of 96° to 100° F. with high relative humidity, newly hatched bedbugs die within a few days. If the temperature is raised to 1 13° F. they will be killed in a few minutes. This temperature also destroys the eggs. The relative humidity is of lit tle importance at tempera ture higher than 113° F., dry heat having an equally prompt lethal effect. The bite of the bedbug. —The majority of persons are sufficiently sensitive to bedbug bites so that the presence of the bugs is sufficient to make sleep and rest impossible. Considerable swelling and inflammation, lasting for several days, occurs at the site of the bite in some individuals. However, many persons are not troubled at all by bedbugs, and their presence may be overlooked unless stains that re sult occasionally from the accidental crushing of an engorged bug are found on the bed linen. The bedbug does not seem to secrete any special poisonous sub stance and the inflammation that occurs in the case of a sensitive person probably results from the traumatism caused by the sharp serated piercing elements of the mouth parts. Epidemiology.—The bedbug is believed by some to be responsible for the transmission of Kala-azar. It has been incriminated in con-" nection with European and African relapsing fever, Chagas fever of Brazil, tropical sore, plague, and leprosy. The bedbug has been instrumental in carrying plague bacilli direct from man to man in certain circumscribed outbreaks of bubonic plague. Because of its limited range of movement it is not likely to give rise to widespread epidemics of any of the diseases in which it is a potential carrier; that is, the possibilities of dissemination are not anything like as great as with arthropod vectors whose habits are more migratory, such as ticks, fleas, and mosquitoes. In the diseases mentioned, the bedbug, when it is a vector, shares responsibility for spreading the disease with other bloodsucking arthropods such as body lice and fleas. When disease is transferred by the bedbug, successful inoculation is probably due to accidental carriage of the causative agent on the mouth parts. 260 Vol. XX, DIVISION OF PREVENTIVE MEDICINE. ERADICATION OP BBDDUQ8. As in the case of the rat, the best possible results in a campaign against bedbugs are not likely to be obtained without continued employment of a small but efficient sanitary squad. The job can never be considered as finished because of the importation of bugs from time to time. General measures.—Frequent or weekly inspections should be made of places where bedbugs are likely to be harbored. Careful and regular inspections should be made to detect bedbugs in the ship's laundry, chief petty officers' quarters, sick bay, first lieutenant's storeroom, transoms in the wardroom, cabins, and otber messrooms, lockers or other places in which life preservers are stowed, cushions of motor boats, hammock nettings, and offices in which men sleep. A member of the sanitary squad should be present every week if practicable while dirty clothes are being received in the laundry. In any case the laundry men should watch carefully and report the sources from which bedbugs are received. Every week after the laundered articles have been distributed, the shelving and lockers should be inspected and flooded with live steam from a hose if the laundry is under suspicion as a distributing center, which almost in evitably it will be if there are bugs on board. Reports of the discovery of bedbugs in staterooms, chief petty officers' quarters, or elsewhere should be followed up at once. In the case of an infested room a careful daily inspection should be made of the bunk and bedding, particularly of pipe frames, springs, seams and tufting of mattresses, and all cracks and crevices about the bunk, by the officer concerned. As a rule the bugs do not penetrate kapok mattresses and pillows. They are more likely to breed in hair mat tresses because of the open spaces in the comparatively loose hair. It is usually possible to exterminate the bugs in any given room in one week at the most by the thorough application of a cresol-kerosene mixture, repeated once during the week. In the case of an officer's room, one or two members of the sani tary squad should go into the room as soon as the officer or the mess attendant who takes care of the room reports that it is infested. The room boy should be present to look after clothing and give all neces sary assistance. Woodwork around the bunk should be removed, and spaces under the bunk, behind furniture, and around drawers in the desk and bureau should be opened up. Disinfestant solution should be painted thoroughly and freely into all cracks and openings. The mattress and pillow should be taken up on deck and dosed thor oughly with cresol-kerosene mixture if they can not be subjected to heat in a disinfector or steaming room. They should be dried by several hours' exposure to fresh air and sunlight. It is well to treat the mattress and pillow, although failure to exterminate the bugs by No. 2. 261 DIVISION OF PKEVENTIVE MEDICINE. the first attempt at disinfestation is much more likely to result, because all insects and eggs have not been destroyed in some place of concealment around the bunk or elsewhere in the room or in an ad joining room rather than because they were overlooked in the mat tress or pillow. The bunk spring should be disinfested with particular care. It is well to dose it thoroughly with cresol and kerosene, pouring the mixture into the piping if there are any holes. Then it should be exposed to heat if a wash room or other small room that can be flooded with steam is available where a temperature above 120° F. can be maintained for an hour or more. It is worth while to make such a room available if several bunks are to be disinfested at the same time. However, thorough application of cresol and kerosene alone is usually effective. The blowtorch may be used, but the flame damages the finish, and a great deal of time is required to make certain that all parts of the spring have been heated to a killing temperature. A canvas-bag disinfector such as that described below should prove most useful. Usually the chief petty officers' quarters present the most difficult problem to solve in connection with the extermination of bedbugs on board ship. There are several reasons for this. In the first place they are usually overcrowded, and a considerable number up to 70 or more occupy the same room. They have more clothing to stow away than the bluejackets and often they are permitted to keep suit cases in quarters. Bedbugs find places of concealment in these and in and about lockers, as well as in bunk frames. The suit cases can be - taken care of by regular inspections, so it is not altogether necessary that the men be deprived of this privilege, but such articles must be kept in mind. Some of the chief petty officers are sensitive to bed bugs and some are not. Too often the former are at the mercy of the latter, who cannot be expected to take as much interest in efforts to get rid of the bugs as those who are deprived of rest and sleep. There is but one way to handle the situation effectively and that is to put a sanitary squad into these quarters and clean up the entire compartment in a single day. The chief petty officers should help, but if the job is left to them it will not be done thoroughly. Some will not take enough interest in the matter to go over their bunks and effects thoroughly; many will be on watch at the time they are needed, and a few will have been shipmates with bedbugs so often or so long that they have reached a belief that it is impossible to get rid of them. So what is the use of trying ? If bugs or eggs are left in some of the bunks or in some of the lockers, they will be widely distributed again throughout the quarters in the course of a few weeks. 262 Vol. XX, DIVISION OF PREVENTIVE MEDICINE. Very likely more bugs will be brought on board during liberty and leave periods, and it will be necessary in any case to disinfest these quarters from time to time, but that is no reason for not making a thorough clean-up each time. The comfort of those who can not rest when bugs are present demands that much consideration. It is also very important to stop the transfer of bedbugs from the chief petty officers' quarters to the laundry, whence they are likely to be distributed to the sick bay and officers' rooms. While the compartment is being disinfected it is preferable that all removable bunk springs and mattresses be removed to the upper deck for thorough treatment and prolonged sunning. Suit cases and bags should also be removed for careful inspection and treatment. Every locker in the room should receive attention. If the work is thoroughly done no complaints of bedbugs will be heard for several weeks at least. It is desirable, of course, that disinfestation be repeated once within a week in warm weather. Heat. —If practicable, mattresses and pillows may be exposed to steam in a steam disinfector or flooded with steam in a canvas bag closed to confine the steam, or placed on a grating and sprayed with steam in some space where a steam hose can be used. In view of the bedbug's habits it is more important to apply heat to the bunk springs and piping than it is to steam the mattress. It is more important to heat hair mattresses than kapok mattresses. Steam flowing from a hose in the open air is not likely to heat the interior of the mattress. To kill the bugs and eggs it is merely necessary that they be ac tually exposed to a temperature above 113° F. for a few minutes. It has been found practicable to raise the temperature of an entire house in the summer to 160° F. by shutting all doors and windows and making up a good fire in the furnace. It is comparatively easy to maintain a temperature between 120° and 130° F. for several hours, and thus destroy all bedbugs and eggs in the house. It is often possible on board ship to find a space where mattresses and bunk frames can be exposed for several hours to the necessary degree of heat, either in a washroom which may be closed and heated by flood ing with steam or in an engine room or fireroom space that is naturally hot. At times exposure in the middle of the day to the radiant heat of the sun may raise the temperature of metal parts to the thermal death point. Prolonged, frequently repeated sunning is a good general measure in any case. Heating the metal bunk frame, springs, and piping by means of the gasoline torch is effectivo provided the flame is applied long enough and with sufficient care to heat all parts to the required temperature. If there are holes in the tubing it will generally be found that such bunk frames are favorite hiding places for bugs. No. 2. 263 DIVISION OF PREVENTIVE MEDICINE. Bureau of Construction and Repair specifications now require that the tubing of bunk frames shall have no perforations through which bedbugs can gain access to the interior. Some of the older ships still have frames that are not bedbug proof. Steps should be taken by such ships to obtain bunks of approved design for the sick bay and chief petty officers' quarters. Scalding hot water can sometimes be employed where it is imprac ticable to use a steam hose. Ashore, hot water may be poured over beds and into accessible cracks. It should be practicable to construct a bag disinfector on board ship of heavy canvas into which either a mattress or a bunk spring can be put and the bag hung up. The upper end should be closed permanently by sewing. There should be a small opening at the top for the introduction of the nozzle or end of a steam hose. The lower end should have grommets so that it can be closed tight enough to confine the steam partially at least. Such a simple type of port able steam disinfector was described in detail by Lieut. Commander R. F. Jones, Medical Corps, United States Navy, and Lieut. P. Richmond, Medical Corps, United States Navy, in the September, 1922, number of this Bulletin. They tested the "sack" steam disinfector invented by Col. P. S. Lelian, R. A. M. C, and found that when low-pressure steam was introduced through the steam hose that cultures of B. coli, staphylococci, and bedbugs were killed within 15 minutes after steam began to flow freely from the partially closed lower end of the sack. The steam was taken from a steam line in which the pressure was approximately 5 pounds per square inch. Hotter steam (10 to 25 pounds' pressure) is almost always available. It required about 20 minutes to get a full flow of steam through the mouth of the sack. Hence, 35 minutes should be allowed for sure destruction of bedbugs and their eggs. Such a bag should be highly effective against bedbugs in view of the com paratively low temperature required to destroy them— 113° to 120° F. Fumigation. —This is a quick and effective method of disinfecting a room or entire building, compartments on board ship or the entire ship if circumstances make fumigation practicable and desirable. Ordinarily fumigation is not indicated because the bugs can be gotten rid of by less disagreeable means. Hydrocyanic-acid gas is the most effective fumigant, but can not be used in an occupied vessel. Sulphur may be used without danger and to good advantage in the case of a room that can be sealed up without much trouble provided it is so located that escaping fumes will not be objection able. If it is considered advisable to fumigate, it is worth while to use a concentrated gas. Therefore, 3 pounds of sulphur per 1,000 cubic feet should be burned. Smaller amounts are sometimes recommended. The exposure period should be at least six hours. 264 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. Mattresses and bedding should be hung up in the room; lockers should be opened; bureau drawers pulled out; furniture moved; and other arrangements made that will insure free circulation of the gas to all cracks and crevices. Ports should be tightly closed. Holes in bulkheads and cracks around doors should be sealed. Sul phur-dioxide fumes destroy the insect in all stages, including the egg. Other gases and vapors are of little value. Chemical agents.—Powders are of little value because of the dif ficulty of getting them into crevices and places where the bugs conceal themselves. A not uncommon source of annoyance to those engaged in a campaign for the extermination of bedbugs is the smart individual who has personally gotten rid of all bedbugs sometime or other by sprinkling some marvelous powder about—or perhaps it was some wonderful patented liquid preparation. An effective and useful solution that may be prepared in large quantities is a mixture of kerosene and cresol with or without the addition of turpentine. So far as chemical agents are concerned this can well serve as the only solution used for the destruction of cockroaches as well as for the extermination of bedbugs. A mix ture of 1 part of crude cresol to 9 parts of kerosene is effective. That is a 10 per cent cresol mixture. A 5 per cent mixture is often recom mended. A 15 per cent mixture can ordinarily be used without damage to paint work, mattresses, and furniture. A strong mixture (10 per cent at least) is indicated against cockroaches; if weaker mixtures are used the cockroaches fall down when the spray hits them, but if left alone some of them eventually recover and scurry- away. Instead of straight kerosene, 10 to 20 per cent of turpentine may be added to the kerosene before the cresol mixture is made. The odor is perhaps less disagreeable to most people with the tur pentine added, and turpentine is in itself an effective agent against bedbugs. The mixture should be used liberally. Walls, mattresses, and pil lows may be sprayed, but the solution should be introduced freely into cracks by painting in with a flat varnish brush. It may be poured through piping and over bunk springs. Corrosive sublimate is of value if a strong solution is used. The following solution has been used with apparent success: Ounces. Sodium chloride J Bichloride of mercury J Water 2 Alcohol.. - 2 Spirits of turpentine 6 This solution may be used on mattresses around the tufts and along seams. When large quantities are used the possibility that enough of the sublimate will volatilize at room temperature to cause symp toms of mercurial poisoning should be borne in mind. No. 2. 265 DIVISION OF PREVENTIVE MEDICINE. COCKROACHES. Roaches are insects belonging to the order Orthoptera, the family Blattidae. There are a number of genera coming within this family, the members of which are mostly wild. At least four species, how ever, have become domesticated and have been household pests for many hundreds of years; all are found in the United States. The domesticated species are as follows: The oriental roach (Blatta orientals) . This is a common roach in Europe as well as in this country. It is a large species, very dark in color, and sometimes called in Europe the "black beetle." The German roach, or Croton bug, a European species, small in size (Blattella germanica) . The Australian roach, a native of Australia (Periplaneta am- iralasise) . The American roach of subtropical and tropical America (Peri planeta americana). House roaches are brown or dark brown in color; the body is rather broad and flattened antero-posteriorly; the head is bent under the body and the mouth parts are directed backward, the eyes downward. The antennae are very long and slender. The insects have two pairs of wings, the outer pair being leathery. In some species the females are almost wingless, notably the oriental cockroach. The mouth parts are well developed and adapted to biting. Metamorphosis is incomplete. The eggs are not laid separately, but are gathered to gether within the abdomen and inclosed in a horny capsule, which is then deposited in dark cracks and crevices. When the eggs de velop the capsule is split and the young emerge. The egg capsule is often carried by the mother until the eggs are about ready to hatch. Newly hatched insects resemble the adult forms very closely, and pass through a variable number of molts. It probably takes from six months to a year to reach full development, depending upon the species. The Australian roach may be differentiated from the others by the brighter and more definitely limited yellow band on the back between the head and wings, and by the yellow markings on the sides of the upper wings. Roaches of different species are rarely found together, although roaches of the same species live together on very amicable terms. Ordinarily not more than one generation per year is produced. Reproduction occurs principally during the warm weather, as roaches are particularly sensitive to cold. The abundance of roaches is apparently not accounted for so much by rapidity of multiplication as by very unusual ability to preserve themselves from ordinary means of destruction. 266 Vol. XX, DIVISION OF PREVENTIVE MEDICINE. The are nocturnal in habits and their numbers are often not realized unless they are surprised in their midnight feats. During the day they conceal themselves wherever protection from natural enemies and from light is afforded. Because of their shape they can squeeze into very small crevices. Occasionally they migrate, and this accounts in part for the way in which new houses and offices are invaded. They are also transported with supplies. When surprised, they seek shelter with a scurrying gait and usually escape. They are practically omnivorous. The mouth parts and jaws are strong, enabling them to eat all sorts of substances — dead animal matter, cereals, and in fact any form of food material; woolens, leather, and cloth or leather bookbindings. Occasionally they turn cannibal. Probably dead roaches frequently disappear in this way. Roaches by preference infest bakeries, kitchens, pantries, store rooms, and toilets. They follow water and drain pipes. Roaches are a sanitary menace, because they are potential carriers of infection mechanically by means of their feet and bodies. They soil everything they come in contact with, leaving a nauseous, roachy odor. The possibility of the transfer by cockroaches of microorganisms belonging to the meat poisoning group—B. enteritidis and others— from one contaminated piece of meat or other source to meat in storage or to food undergoing preparation for cooking, should be borne in mind. DESTRUCTION OP COCKROACHKS. On board ship cockroaches are usually numerous and trouble some, the moisture and heat of the vessel being particularly favor able to their development. Total elimination of roaches is difficult . Scrupulous cleanliness and the keeping of food and food remnants in places and containers inaccessible to the roach is of prime impor tance. All corners, cracks, and imperfections in structure in store rooms, galleys, bake shops, pantries, hammock nettings, toilets, etc., which favor breeding or furnish hiding places must be eliminated or treated with roach poison. The chemical agents serve all practical purposes —sodium fluoride for use in powdered form and the cresol- kerosene antibedbug mixture for use in the spray gun. It should be remembered that cockroaches are brought on board from time to time with stores. The logical place to begin the attack is in the various storerooms. Little headway can be made by spasmodic efforts to get rid of roaches in the galley, bakeship, pantries, etc., unless the storerooms are disinfested. Cooks, bakers, stewards, mess attendants, and compartment cleaners should, of course, be required to keep after the roaches in their spaces. But the sanitary squad should with the cooperation and assistance of storeroom keepers proceed against the insects in the storerooms. No. 2. DIVISION OF PREVENTIVE MEDICINE. 267 The attack may well be opened with a heavy spray of the cresol- kerosene mixture. That usually brings to light more roaches than were thought to be in hiding. The spray is dangerous to them and they scurry from their places of concealment into the open where the spray can be driven directly upon them. Large numbers of roaches can be killed in a few minutes in that way. Sodium fluoride should then be sprinkled about on the shelves, in corners, into cracks, and anywhere it appears likely the roaches will walk or climb. The powder should be sprinkled particularly in places where it can be left undisturbed for several weeks. It is too expensive to throw around where it will be swept up in a day or two. Ik acts slowly, as a rule. The roaches walk in it and then lick it from their feet, in this way it acts as a stomach poison which eventually kills. According to the United States Department of Agriculture, Bul letin 658, on cockroaches, - it is not definitely known whether the sodium fluoride acts through the breathing pores or as a stomach poison, but probably it acts in both ways, inasmuch as it has been found to kill caterpillars fed on foliage dusted with it. The Depart ment of Agriculture recommends it as one of the most effective simple means of ridding premises of roaches. "Numerous practical tests have been conducted in lunch rooms, bakeries, milk-bottle exchanges, etc., and these have shown that with the use of this substance roaches can be completely exterminated in such places with very little trouble and cost." The sodium fluoride may be blown over shelves and floors and into cracks by means of a powder blower or dust gun. It also has an immediate effect, causing many of the roaches to come out of their retreats and rush about more or less blindly, showing evidence of dis comfort, to be followed in the course of a few hours by their death. Some consider the use of sodium fluoride in this way more effective than a spray of cresol-kerosene. The latter has the advantage in killing almost immediately and of being easier to handle as a spray. The former has the advantage of being the material that must be used as the final agent in either case, and if it is blown into places where it may be left for continuous action, the job is finished by the one operation. Disinfestation is to be accomplished by the same means in all parts of the ship. The campaign resolves itself into an organized effort to go after the roaches wherever they are seen by means of the 8Pray and by dusting the powder along shelves, behind dishes, books, ete-; in drawers of desks, tables, and lockers, and in spaces under the drawers; on overhead piping; along I beams; etc. The sanitary squad should fill and issue spray guns and powder to compartment cleaners, stewards, cooks, and bakers, and see that 268 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. these men know how to make the most effective use of them. Places which are particularly subject to infestation, such as storerooms, galleys, issue room, bakeshop, and pantries should have their own spray guns ready for use when cockroaches are seen. Such places should be inspected occasionally at night when the roaches are likely to be out in numbers. Food may be left out to attract them. Spray guns should be ready so that when the light is turned on suddenly they may be killed by the spray before they can escape. Large numbers may be destroyed in places heavily infested by means of traps. A simple form of trap consists of a deep smooth basin or jar, with a stick leading up to the top as a runway from which they slip into the trap. The trap may be baited with sweetened meal or other food material. However, little progress toward extermination can be made by such expedients on board ship, although they are of some value in buildings ashore. Other chemical agents recommended for use against cockroaches include borax, sulphur, arsenic, and phosphorus. Arsenic does very little good, as roaches are wary and shun the poisonous bait. Phosphorous paste, containing 1 or 2 per cent of phosphorus, has been used successfully in offices to free desks from cockroaches, but sodium fluoride powder is equally if not more effective. Borax is more or less repellant in action and somewhat poisonous. It enters into the composition of many of the so-called roach powders. Pyrethrum powder is at best only a temporary expedient. Sulphur is effective as a repellant. Fumigation. —Sulphur-dioxide gas is of course effective against roaches, but it may not destroy the eggs. Carbon-bisulphide fumes are effectively insecticidal, but the indications for its use are limited as it, like hydrocyanic-acid gas, is poisonous to human beings. Also, the vapor when concentrated is violently explosive in the presence of a fire. In preparing the above paragraphs relating to rats, bedbugs, and cockroaches, the following articles published by the United States Department of Agriculture have been freely quoted : Farmers' Bulletin 896, House Rats and Mice, by David E. Lantz, assist ant biologist. Farmers' Bulletin 754, The Bedbug, by C. L. Marlatt, entomologist and assistant chief of bureau. Farmers' Bulletin 658, Cockroaches, by C. L. Marlatt. SUPPLEMENTARY REPORT: REVIEW OP LITERATURE RELATING TO PRO PHYLAXIS OF MEASLES. By T. W. Kemmebeb, M. D., Bacteriologist, Hygienic Laboratory, United States Public Health Service The experience of Solomon (1923) is that the serum of adults is nearly as efficacious as that of convalescents. He was unable to obtain a sufficient quantity of convalescents' serum and was forced No. 2. 269 DIVISION OF PREVENTIVE MEDICINE. to use that of adults. There were 198 infants over 3 months of age in the hospitals who were exposed to measles. Sixty received no prophylactic serum; all developed measles and 35 (58.3 per cent) died. Sixty-two received convalescents' serum; 25 (40.3 per cent) developed measles, and 4 (16 per cent) died. Seventy-six received serum (10 to 15 c. c.) of adults who had had measles in childhood; 36 (47.4 per cent) developed measles and 5 (13.8 per cent) died. There were 42 infants under 3 months of age of whom 14 developed measles in a light form. The low percentage of protection afforded by convalescents' serum may be due to the fact that he was compelled to use the serum of infants, which perhaps does not contain as much antibody as that of older individuals. Nicolle and Conseil in a recent publication (July, 1923) state that in their early researches, begun in 1911, they inoculated children with blood from monkeys sick with measles, the blood being either unmodified or modified by heat or otherwise. The resulting disease never exceeded in severity that of mild measles and they never noted any complications. In the use of convalescents' serum, it is advisable to use a mixed serum and to inject at least 10 c. c. The duration of the immunity conferred by convalescents' serum does not exceed a few weeks. Serum kept on ice remains active for at least two years. They have recently substituted serovnccination, which consists in successive inoculations of convalescents' serum (10 c. c.) and, 24 hours later, the blood of a measles patient (1 c. c). The method is harmless and the immunity obtained is without doubt more lasting. They state that the period of contagion in measles coincides with the period of observable illness—from the beginning of the fever, before the eruption, to the day after the disappearance of the fever. The accepted opinion that measles is never contracted a second time is' exaggerated. An individual who has recovered from measles may be reinoculated within two years or at any later time. The new attack is either typical or benign, or there may be a transient rise in temperature without an eruption. It is difficult to explain, with the conception of a lasting immunity in convalescents, the conserva tion of the virus in nature and the return of the epidemics. The supposition that there is a regular passage of the virus every 14 days at the farthest from sick children to new children fails. It is easy to comprehend the permanent conservation of the virus in our species after it is proven that convalescents from measles can contract a new infection. It is only the benignity of the attack which hinders the recognition of its nature. Certain transient colds are second attacks of attenuated contagious measles. They claim to be able to present evidence of the presence of the virus of measles in the blood of persons who have recovered and who have not received a new inoculation. 270 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. Savini (1923) uses a syringe containing a 5 per cent solution of sodium citrate to withdraw an equal quantity of blood from a measles patient. The mixture is then heated at 56° for 15 minutes. A method which is equally good and is simpler is to add 1 per cent of phenol to the citrate solution, making the final phenol content of the mixture 0.5 per cent; 4 to 5 c. c. are injected subcutaneously morning and evening on three successive days; 1 to 2 c. c. is sufficient for an infant. The immunity obtained is very effective, since injection of virulent blood a week later will not produce infection. This is an active immunization and is superior to passive immuniza tion in that it is more effective and lasting. The injection of the vaccine produced no local or general reaction. He has never observed anaphylaxis or hemolysis. The subject is not exposed to the danger of the specific infection nor to accidental infection (syphilis, malaria) . This method is also applicable as a prophylaxis against typhus and scarlet fever. His series of cases is rather small. He has immunized 30 against typhus, 36 against scarlet fever, and only 7 against measles. Hermann (1923) presents further evidence that infants under 2 months of age of mothers who have had measles are immune; immu nity becomes less marked as they grow older, but that even at 4 or 5 months of age only 25 per cent are infected. From this time on the relative immunity quickly diminishes so that infants over 9 months of age are as susceptible as older children. When young infants are infected with measles, the disease runs a mild course. Ratnoff (1923) presents his personal experience in over a hundred cases immunized by convalescents' serum. There was not a single case of fully developed measles. In perhaps a fifth of the children there was some trifling phenomena, such as a faint scattered rash or slight rise of temperature. BIBLIOGRAPHY. Hermann, C. 1923. The relative immunity of infants under 5 months of age to infection with measles. Arch. Pediat. XL: 678-682. Nicolle, C, and Conseil, E. 1923. Acquisitions nouvelles sur la rougeole. (Vaccination preventive. Conditions de la contagion.) Compt. rend. Acad. d. Sci. V. 171: 160-162. Ratnoff, H. L. 1923. Serotherapy in measles. Arch. Pediat. XL: 683-691. Savini, E. 1923. Essais de vaccinotherapie preventive dans le typhus exanthematique, la scarlatine, et al rougeole. Compt. rend. Soc. de, biol. V. 89: 694-696. Solomon, G. 1923. Die prophylaktische injektion von normalserum als masernschutz. Deutsch. med. Wchnschr. Jahr. 49: 1151-1152. (Ab. Brit. Med. Jour. V. 2, epitome 45-46.) No. 2. 271 DIVISION OF PREVENTIVE MEDICI XE. SWIMMING POOLS IN DETROIT— EPIDEMIOLOGICAL CONSIDERATIONS. The following discussion relating to Detroit's swimming pools is of interest in connection with the problem of preventing the spread of disease in Navy swimming pools at naval training stations, Naval Academy, etc. The article is taken from the Weekly Health Review for weeks ending November 12 and November 17, 1923, published by the city of Detroit, department of health, and edited by Carl E. Buck, D. P. H., epidemiologist: '' Until comparatively recently swimming, with the exception of a few club and commercial pools, has been confined to the outdoors during the warm summer months. During the past few years, with the ever-broadening scope of education, with its inclusion of the physical along with the mental development of the child, schools have felt the need for swimming pools, with the result that swimming is fast becoming an all-the-year-round sport. It is the hope of the board of education to gradually increase its number of pools to the point where all school children may be required to learn to swim. At present there are in Detroit 21 swimming pools in daily operation, with a daily average attendance of upwards of 5,000. There are 4 club pools. 3 pools operated by the department recreation, and 14 school pools. Two additional school pools are to be opened in the very near future. School pools are used by the children during school hours. Very wisely the use of these pools has been continued on into the evening when, under the direction of the department of recreation, classes are held for adults. " Knowing how to swim may at some time prove of very practical use to us. This combined with the fact that swimming is one of the very best possible forms of exercise and one which can be continued throughout life make the project of increasing our swimming facilities a most commendable one. It does, however, present a sanitary problem of considerable importance. We must see to it that we have clean bathers and clean water. With this object in view careful record has been kept of swiniming-pool water as far as bacterial content is concerned. "The following table gives the relative standing of each pool for the past year as computed from the bacterial content of the water: 74459—24 fl 1 272 DIVISION OF PREVENTIVE MEDICINE. - Vol. XX. Detroit swimming pools from November 1, 1922, to November 1, 1923. I Order of standing and poo]. 1. D. A.C 2. McWcheal, girls' 3. Halch 4. Y. M.C. A 5. Cass 6. Hutchii s, girls' 7. Barbour, boys' 8. Hutchins, boys' . 9. 1). Y.C 10. Northwestern 11. K. ofC 12. Tlarbour, girls' 13. McMichcal, boys' 14. Northeastern 15. Elmwood 18. Southwestern 17. Northern 18. Clara Arthur 19. Atkinson 20. Central 21. Southeastern Presonce of eoloi; . Sam ple No. Median bac terial count. Aver age num ber per 100c. c. Per cent of sam ples: More than 10per 100c.c. Actual average colon count. 178 184 1.64 3.17 4.33 125 1,372 1.58 1.36 2.85 II.-, 2,868 1.32 1.54 2.75 165 802 3.20 5.13 13.20 85 3,825 1. 12 1.25 2.25 113 1,335 2.15 6.63 15.08 97 4,437 2.80 .64 3.37 1"X 372 2.95 9.28 33.93 31 316 4. 52 7.72 30.25 1211 2,373 775 3.33 15.70 22.72 2S -1. (X) 13.00 40. 75 % 6,690 3,331 2.20 7.44 33.86 116 4.13 11.58 13.90 86 4,743 3.55 7.80 18.27 44 12,569 3.77 2.63 7.78 Ml 7,213 1. 47 9.08 47.20 111 4,518 3.73 9.87 28.65 C>< 14,S77 3.59 5.88 8.84 ',)(] 12,886 3.04 10.05 13.20 5, 196 3.41 11.76 47.72 111 8,116 4.30 12.30 23.98 Daily Type of treatment. 100 i V. R., S 125 I Do. 375 I Chi., S. F 250 52:. 225 260 2i 5 4011 125 2111 220 200 V, 350 ion Mi 201 1 4511 bo. Chl., S. F. V. K..S. F. Do. Do. V.R.,8. r Do. Emptied weekly. Chl., S. F. V. R.. S. F. Einp_ti^d daily. V.R., S. F. Emptied daily. Emptied. V. R., S. F. Emptied daily. 450 : Emptied twice a week. "The standing of each pool has been determined by averaging its relative standing as to bacterial content and the several items listed under "Presence of colon," giving equal weight to each. "The yearly standing, as given above, is an average of the monthly figures. "Median count means the number of bacteria actually found in that sample which lies halfway between the high and low samples when all samples are arranged in sequence as to numbers of bacteria contained. " Average number per 100 cubic centimeters refers to the average number of colon found in that amount of water, counting any presence of colon, whether it be 10 or 1,000 per 100 c. c, as 10 per 100 c. c. " Actual average colon count is the total number of colon found in all samples divided by the number of samples taken. "Under 'Type of treatment' V. R. means violet ray; S. F. means sand filtration; Chl. means chlorinization. With the exception of the No. 2. DIVISION OF PREVENTIVE MKDICINE. 273 Y. M. C. A. pool, which has liquid chlorine equipment, chlorinization means merely the addition of hypochlorite from time to time. Those pools which are listed as emptied have no treatment other than cleansing of the tank. " Bacterial counts, of course, refer to the average number of all kinds of bacteria found in each cubic centimeter of water as deter mined from their growth on agar plates at 37 C. High bacterial counts may be due to one of a number of things; inadequate bathing on the part of the users of the pool —in other words, dirty bathers— tracking dirt into the pool, or possibly the failure of the pool's sanitary equipment to function properly. In pools having no filtration or sterilization the greatest care must be taken to let out all the water and to thoroughly clean the tank. High bacterial counts are usually the fault of the bathers, often partially and sometimes wholly due to negligence on the part of the personnel engaged in the care of the pool ; seldom are they due to the actual breaking down of filtration or sterilization plants. Spitting, coughing, and blowing the nose in the water instead of in the gutters sometimes gives rise to high bacterial counts. " Colon counts show the presence of intestinal organisms of the colon group. They are always due to fecal pollution, either tracked in or actually introduced into the pool. "Adequate supervision of a pool, both with respect to the bathers and the cleansing and care of the pool itself, will insure clean water. Water should always be kept at such a height that there is a constant slight overflow into the gutters. "We find that according to the bacterial standards agreed upon by the conference of State sanitary engineers all of Detroit's pools should be closed. We feel, however, that these standards are un necessarily strict and are inclined to adopt a much more lenient one. The reasons for deciding upon a less stringent standard are two : "1. After a careful investigation of Detroit's swimming pools, their equipment, the operation of equipment, the cleanliness of the pool, the shower and locker rooms, the supervision of the pool and its users, including exclusion of persons with colds or skin eruptions, or who have failed to take proper showers, we believe that the majority are being conducted in a reasonably sanitary and satisfactory manner, notwithstanding the fact that according to the strictest standards all of them should be closed. "2. The bacterial standard is not an absolutely accurate index of the safety or danger of a swimming pool. It therefore seems unwise to exert all our efforts in attempting to enforce an impractical standard, and in so doing lose sight of other important factors. "Under present conditions there is not so much danger of typhoid fever or other intestinal diseases as there is of eye, ear, nose, and 274 Vol. XX, DIVISION OF PREVENTIVE MEDICINE. throat infections. These infections are caused by secretions from the nose and throat and their presence is not accurately reflected in either the general bacterial or colon count. In other words, it is possible to get an eye, ear, nose, or throat infection in a pool having a low bacterial content. " In an effort to reduce to a minimum this type of infection, in addition to the bacterial standard, the observance of two rules will be insisted upon : " 1. All persons having colds shall be refused admission to the pool. "2. The water shall at all times be sufficiently higb to insure a constant slight overflow into the gutters. " While many of our pools are being conducted in a reasonably sanitary and satisfactory manner there is still room for improvement and some of the pools, especially the last 10 on the list, will have to make very decided improvements if they are to continue to operate. "In the future all pools must observe, in addition to rules already adopted, such regulations as mentioned in this paper together with the following tentative bacterial standards: "A median monthly bacterial count of not over 2,000. ''Not over 50 per cent of the samples during any given month shall show the presence of colon. '"Not over 20 per cent of samples during any given month shall show a colon count of over 10 per 100 c. c. ''While it is impossible to analyze the pools according to type of treatment with sufficient accuracy to say that this or that treatment is eminently more satisfactory than another, we can, perhaps, make two rather definite statements: "1. That while the violet-ray treatment has in some instances proven very satisfactory, in certain other instances the operation of the plant has been decidedly unsatisfactory, due at least in part to the fact that the violet-ray equipment has not been operated con tinuously. "2. That, in general, the pools which are merely emptied and cleaned are not in a satisfactory condition and must show a decided improvement if the}' are to continue to operate." ADOPTION OF NEW HOUSING ORDINANCE BY THE CITY OF SAN DIEGO. CALIF. The monthly Bulletin of the Department of Public Health, City of San Diego, Calif., indicates that overcrowding incident to inade quate and insanitary housing is recognized in that State as a danger ous factor making for the spread and development of communicable diseases. No. 2. 275 DIVISION OF PREVENTIVE MEDICINE. A new ordinance makes it obligatory for every owner or lessee of a hotel or lodging house having six or more guest rooms, or an apart ment house or a flat occupied, or where provision is made for the occu pancy, by three or more families, to make application in writing to the board of health for an inspection and a permit of occupancy. The ordinance also provides that every owner or lessee of a hotel or a lodging house having ten or more guest rooms, or an apartment house (or flats) occupied or where provision is made for occupancy by five or more families, shall pay an annual inspection fee, as formerly, ranging from $3 per year for houses of 15 rooms or less to $5 per year for houses of more than 30 rooms. The State housing laws adopted in 1917 exempted from the defi nition of "tenement house" any building not more than two stories in height to be occupied by not more than four families living inde pendently of each other. The new State law which became effective in August, 1923, tnakes no such exemption. The term " apartment house" was substituted therefor and is defined as any building or portion thereof more than one story in height, which is designed, built, rented, leased, let, or hired out to be occupied, or which is occu pied as the home or residence of three or more families living inde pendently of each other and doing their cooking in the said building. It is to be hoped before this country is again involved in war that health officials generally will have been successful in overcoming political and economic objections to the enforcement of proper housing laws, and that a sufficiently strong public opinion will have been developed to prevent the exposure of Army and Navy personnel to the very potent dangers of overcrowding in barracks during the days of mobilization and intensive training. The substitution of the term "apartment house" for tenement house is logical. While they range through all degrees of elegance, apartment houses from the standpoint of community health are essentially tenement houses. MEDICAL DEPARTMENT ACTIVITIES AT NAVAL TRAINING STATIONS. Newport, R. I.—Sanitary reports show that health conditions have been unusually good during recent months. Freedom from diseases is credited in large part by the medical officer to hard training and drills judiciously combined with athletic sports in the open air plus a good commissary department, these factors making for a spirit of content ment and physical well being. The incidence of communicable diseases has remained low in spite of continued increase in the per sonnel resulting from increased recruiting activity. In general, the quality of recruits received in recent months hasjbeen above the rcvaage, although morethan usual numbers of the men recieved have 276 DIVISION OF PREVENTIVE MEDICINE. Vol. XX. boon found physically unfit or relatively undesirable. Ten per cent of the total number received during October should not have been enlisted, and were recommended for discharge from the service because of the following defects: Number of cases. Flat feet, extreme.- 3 Underheight • Underweight.. * Underweight and underheight 6 Constitutional inferiority, mental 1 Genu valgum * Incontinence of urine <» Epilepsy (grand mal) - * Deformity, right arm 1 Atrophy of testicle * Deafness * Stammering * Colorblindness / * Defective and deficient teeth 1 Hernia, inguinal * Eczema, chronic — 1 Besides these, 1 4 were relatively undesirable but were retained for corrective treatment. These also were cases where the men should have been rejected in the recruiting office, as indicated by the follow ing list: Number of esses. Eczema, chronic 1 Scabies, treated at naval hospital 6 Phimosis, complete, operated upon at dispensary 2 Hernia, inguinal, operated upon at naval hospital 2 Varicocele, operated upon at naval hospital 1 Hypertrophy of tonsil, operated upon at naval hospital 2 As a result of lack of attention to the mouth in the recruiting offices, more work continually presses upon the dental department of the station than can possibly be accomplished during the period of training. During August 52 per cent of recruits transferred from the station left with dental caries; in September, 56 per cent; and in October, 48 per cent. Hampton Roads, Va.—The swimming pools have been wutched closely as in previous months. Recently they have caused less anxiety, partly because they have been emptied and cleaned weekly and partly because the water in some of them has been chlorinated. The full complement of mercury tubes for the ultra-violet-ray system of purification has not been available. Therefore, no reliance has been placed upon that system. From observations and laboratory tests made at various times the efficiency of ultra-violet-rays for this purpose is doubtful, or so it appears to the medical officer. Efforts have been made to obtain from the manufacturers of the system definite information concerning results of bacteriological tests, but No. 2. 277 DIVISION OF PREVENTIVE MEDICINE. only general statements and recommendations from interested parties have been forthcoming. In connection with the campaign against mosquitoes and mos quito breeding, considerable use has recently been made of nitre cake obtained from the Naval Proving Ground, Indianhead, Md. This material is acid sodium sulphate with an excess of sulphuric acid. It has been used to prevent mosquito development in pools of water which were not accessible for spraying with oil. The nitre cake proved effective where a solution of sufficient strength was used. Experiments made in the station laboratory indicated that nitre cake is an effective larvacid when used on the basis of 1 pound for each gallon of water. As nearly as possible it has been applied according to this ratio, and it is believed results will prove satisfac tory. A careful survey of the base was made for the purpose of locating all places where mosquitoes might possibly breed. No such places were discovered. It is therefore believed that property located outside of the base is the great source of trouble, and it is felt that so long as the authorities who have jurisdiction over that territory do not take steps to destroy the breeding places there it will be impossible to free the base of mosquitoes. There were seven cases of malaria during the month of October; four in September. San Diego, Calif. —The morbidity rate continues high at this station. The daily average of sick increased from 5.1 in September to 8.1 in October. The increase was largely due to survey cases carried on the sick list and not to any increase of sickness resulting from communicable diseases. Of 686 recruits received during the month, 80, or 11.6 per cent, had disabilities for which they should have been rejected in the recruiting office. The following table shows the number of recruits received from each of the several recruiting stations and the number from each group which it was found necessary to transfer to hos pital for observation, as with "no disease": Station. Seattle. Salt Lake Citv Portland . Kansas City... Houston Denver San Francisco. -New Orleans.. Dallas Omaha Angeles... Total.. Number of recruits. To hospital. Percentage. 34 10 29.41 62 10 10.12 45 7 15.55 124 17 13.70 23 3 13.00 56 6 10.71 71 7 9.86 12 1 8.33 49 4 8.16 53 4 7.54 157 11 7.00 686 80 11.66 278 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. The sanitary report for October states that the necessity for eliminating over 10 per cent of all recruits received reveals deplorable conditions at recruiting stations, for it is felt that the station has not been unduly severe in the matter of elimination. Of 690 recruits received, 41 were found physically unfit, 212 relatively undesirable. 144 not especially desirable, 41 were transferred to hospital, and only 252 were manifestly desirable. The medical officer believes that the percentage of "inaps" could be materially reduced by ordering medical officers to training stations for a period of from two weeks to a month prior to assignment to recruiting duty. It is thought they would quickly learn the cause of the large majority of rejections and that they would then be able to eliminate such cases in the recruiting office. The dental department of the station is confronted with the same difficulty as the corresponding department at Newport, R. I. Because of dental defects found in a high percentage of all recruits received it is impossible to complete necessary work. In the cases of 714 men transferred from the station during October there were 1,062 cavities left unfilled. Practically all recruits transferred were still in need of dental service. It is believed that all recruits transferred to the fleet should be dentally fit but this is not possible with the present volume of work. HEALTH OF THE NAVY. This report covers the month of December, 1923. The usual seasonal increase in the prevalence of common respiratory diseases begins every year in November, so that comparatively high admission rates are to be expected in December, although these diseases usually do not reach their greatest incidence in the Navy until February. The December admission rate for common diseases of the respira tory type—acute bronchitis, laryngitis, pleuritis, rhinitis, and ton sillitis was 93.2 per 1,000 per annum. There is very little difference between this figure and the median December rate for the preceding five years, viz, 94.1. Admissions for influenza increased to a total of 228. This figure represents an increase of 50 per cent over admissions for November. The resulting admission rate, 23.1, is almost twice as great as the five-year median rate for December, 12.7 per 1,000 per annum. The figures are rather significant even when clue allowance is made for the fact that other infections of the upper respiratory tract are not infrequently designated as influenza. Outbreaks of influenza occurred in the Navy during the months of January and February, 1919, 1920, and 1922. Epidemics during the winter of 1919 represented a con tinuation of prevalence following the pandemic period during the No. 2. DIVISION OF PREVENTIVE MEDICINE. 279 autumn of 1918. It will not be surprising if the disease becomes epidemic during the next three months. The Weekly Health Index, published by the Bureau of the Census, which' is based on telegraphic reports of deaths from 72 representative cities in the United States, does not reveal any increase in mortality above what is to be expected at this time of year. In fact the combined death rate of these cities was lower for the week ended January 5, 1924, than for the corre sponding week in any of the preceding three years. During December 23 cases of pneumonia were reported for the entire Navy as compared with 19 cases in November. These 23 cases make an admission rate of 2.3 per 1,000 per annum. The median December rate for the preceding five years is 3.9. One case of cerebrospinal fever occurred at the naval training station, Newport, R. I., December 1. No case has been notified since then from any ship or station. Measles cases were reported in increasing numbers during the month, the admission rate for the entire Navy increasing from 4.8 in November to 13.0 per 1,000 per annum in December. The five- year median rate for December is 4.7. Naval training stations accounted for most of the increase, with 57 cases at the naval training station, Hampton Roads, Va., and 47 at the naval training station, San Diego, Calif. Only 2 cases were notified by the United States Fleet. Movements of ships have interfered with regular correspond ence and more cases may have occurred than are accounted for by monthly communicable disease reports received. One death from measles was reported in December among the cases occurring at Hampton Roads, Va. Five sporadic cases of scarlet fever occurred at naval training sta tions, as follows: Hampton Roads, Va 1 Great Lakes, 111 2 San Diego, Calif 1 San Francisco, Calif 1 One case occurred in the receiving station, San Francisco, and 1 on board the U. S. S. California. Seven cases of diphtheria were notified during the month; 4 among forces ashore and 3 afloat. These were all sporadic cases. Mumps was less prevalent than in previous months. Eighty-five cases were reported, 76 of which occurred on board ship. This incidence is only about one-third as great as median experience for the month of December. Dengue continues about as prevalent in Haiti and Santo Domingo as in recent months, 55 cases occurring among approximately 4,000 marines. The admission rate for malaria continues at a lower level than in recent years. Sixty-two cases were notified in December, making the 280 Vol. XX, DIVISION OF PREVENTIVE MEDICINE. admission rate for the Navy 6.3 per 1,000 per annum for the month. The five-year median rate for December is 22.8. The following table shows rates per 1,000 per annum for the principal communicable diseases, December, 1923. For comparison, cor responding median rates are given for the same month, years 1918 to 1922, inclusive: Cerebrospinal fever Diphtheria German measles — Influenza Malaria Measles Mumps. _ Pneumonia Scarlet fever Smallpox Tuberculosis Tvphoid fever | December, 1918-1922. December. 1923. 0. 08 0. 10 . 99 . 71 . 63 . 51 12. 70 23. 12 22. 81 6. 29 4. 68 12. 98 24. 44 8. 62 3. 91 2. 33 . 54 . 81 0 0 2. 92 2. 0J . 08 0 VITAL STATISTICS. The Monthly Health Index, which is published on the 15th of each month, contains the statistical data for individual ships and shore stations. The statistics appearing in this Bulletin are sum maries compiled from those published in the Monthlv Health Index. Annual rates, shown in the succeeding statistical table, are ob tained as follows : The total number of admissions to the sick list or the number of deaths reported during the period indicated is multiplied by ^^-r or -a^- or 12, depending upon whether the period includes four or five weeks or a calendar month. The product is then multiplied by 1,000 and divided by the average complement. E. R. Stitt. Table No. 1.— Monthly report of morbidity in the United States Navy and Marine Corps for the month of December, 1923. Forces afloat. Forces Entire ashore. Navy. Marine Corp?. 75,406 42,928 118,334 21,660 All causes: 2,889 459.73 2,805 i 5,694 784.08 577.37 1, 196 574.25 Disease only: 2,529 2,534 5,063 1,071 Communicable diseases, exclu-ivr of venereal diseases: Number of admissions Annual rate per 1,000 Venereal disease: Number of admissions Annual rate |>er1,000 Injuries and poisons: Number of admissions Annual rate por 1.000 389 108.74 402 112.37 271 75.75 664 67.34 1,217 123.40 631 63.98 168 80.66 26^ 124.84 125 60.02 No. 2. DIVISION OF PREVENTIVE MEDICINE. 281 Table No. 2.— Number of admissions reported by Form F cards for certain diseases for the month of December, 1923. Forces afloat, Navy and Ma rines (strength, 75.400). Forces ashore, Navy and Ma rines (strength, 4.',958\ Total (strength, 118,334). Number Annual rate per 1,000. Niimlxr Annual rate rer 1,000. Number Annual rate i>er 1.000. of ad missions. of ad missions. of ad missions. Diseases 2, 529 360 402.44 2,534 70S.33 5,063 513.39 57.29 271 75.75 63.98 Class IH: 2,889 459.73 2,803 781.08 5,094 577.37 39 6. 21 36 10.Oti 75 7.61 7 1.11 8 2.24 15 1.52 26 4. 14 28 7.83 51 5.48 1 .16 0 0 1 .10 Cholelithiasis 1 .16 1 .28 •) .20 3 .48 1 .28 i .41 10 1.59 14 3. 91 21 2.43 11 2. S3 21 5. 87 35 3.55 4 .64 10 ;.80 14 1.42 38 0.05 :u 7. 'il 64 6.49 19 3. 02 15 4.19 31 3.45 13 2.07 -:o 11.18 53 5.37 2 .32 0 0 2 .20 0 0 1 .28 1 .10 1 .10 0 0 1 . 10 Total 178 28.33 ■-01 56.19 379 38. 43 Class VII: Varicocele 10 1.59 0 U68 10 1.62 Class VIII: 0 0 l .28 1 . 10 7 1.11 u 1.68 13 1.32 Diphtheria 3 .48 4 1. 19 7 .71 German measles 3 .48 2 .56 5 .51 Influenza 113 17.98 115 '32. 15 228 23.12 16 76 5 3 2.55 12.09 112 9 31. 31 128 85 12.98 8.62 2.52 .80 .48 3 12 .144 3.35 8 15 .81 1.52 1 . 16 0 0 1 . 10 Scarlet fever 1 .16 7 1.96 $ .81 Total 22S 36. 28 271 75. 75 499 50.60 Class TX: 0 0 5 1.40 5 .51 6 .95 1 . 28 7 .71 Class X: 6 .95 6 1.68 12 1.22 Dengue 19 3.02 .50 13.98 09 7.00 Malaria!:::::::::::::::::::::::::::::: 0 0 3 .84 3 .31 11 1. 75 51 14.26 62 0.29 Class XI: 30 4.77 104 29.07 131 13.59 Class XII: 11 1.75 9 2.52 20 2.03 229 36.44 83 23.20 312 31.64 491 78.61 211 67.37 735 7'. 53 92 14.64 78 21.80 170 17.24 Total 815 129.69 402 112.37 1,217 123.40 Class XVIII: 121 19.25 230 64.29 351 35.59 4 .64 17 4.75 21 2.13 » 1.43 8 2.24 17 1.72 24 3. 82 8 2.24 32 3.24 320 50.92 178 49.76 498 50.50 Total 478 76.00 441 123.27 919 93. 19 Class XX: 15 2.39 27 7.55 42 4.26 282 Vol. XX, DIVISION OF PREVENTIVE MEDICINE. Table No. 3.—Summary of annual admission rates for venereal disease reported from ships for November and from various shore stations for the five-week period December 2, 1923, to January 5, 1924. Annual rate per 1,000, November. !Miolmum rate. All ships Battleship divisions- Battle Fleet Scouting Fleet Asiatic Fleet Destroyer squadrons — Battle Fleet Scouting Fleet Asiatic Fleet Miscellaneous —1 Battle Fleet Scouting Fleet Asiatic Fleet Naval forces, Europe ■■ Special service squadron, based on Panama Naval transportation service Special duty Miscellaneous and district vessels All naval districts in the United States First naval district Third naval district Fourth naval district Fifth naval district Sixth naval district Seventh naval district Eighth naval district Ninth naval district Eleventh naval district Twelfth naval district Thirteenth naval district 9.74 43.01 '0 0 0 I 118.81 0 0 l 0 0 0 0 0 0 Mean jMaximum rate. rate. 160.91 1,8 75.68 84.25 703.20 52.92 131.77 806. 20 113.14 122.80 314.85 170.05 178.32 179.23 211.07 186.14 106.36 129.83 1,125.00 533.33 475.25 1,250.00 360.00 333.33 1,400.00 473.68 307.69 768.00 1,882.35 394.37 Average i 1923. ■July 1, Minimum rate. Mean rate. Annual rate per 1,000, Dec. 2. 1923,to Jan. 5, 1924 61.62 95.33 135.44 0 0 123.08 0 0 0 0 158.53 96.36 0 0 150.27 102.81 134.81 583.31 70.87 188.33 514.91 106.19 124.73 333.64 204.82 213.86 168.01 145.12 230.98 rate. 1,254.90 153.04 180.54 850.39 293.99 487.26 1,254.90 273.97 297. 52 1,139.66 361.44 295.80 391.64 406.42 517.24 0 61.45 237.34 0 66.73 212.56 0 37.46 195.49 25.30 51.53 212.56 13.67 23.97 37. 82 15.40 64.51 103.99 84.97 114.83 142.68 34.33 106.70 170.45 80 75.34 165.74 0 66.94 93.78 43.33 48.37 106.67 11.15 58.11 203.01 0 0 0 0 0 0 66.41 69.03 107.44 51.19 52.96 61.98 104.92 104.92 104.92 103.71 103.71 103. 71 18.25 25.83 73.59 22.23 34.33 68.22 30.03 95.73 237.34 38.58 95.51 184.70 59.54 74.89 94.55 51.69 90.88 147.27 RATIO OF QONOCOCCUS AND SYPHILIS INFECTION TO TOTAL CASES OF VENEREAL DISEASE. All ships Battleship divisions- Battle Fleet Scouting Fleet Asiatic Fleet Destrover squadrons — Scouting Fleet . Miscellaneous f— Battle Fleet Scouting Fleet Asiatic Fleet Naval forces, Europe Special service squadron, based on Panama. Naval transportation Special dutv Miscellaneous and district vessels ' Month of October, 1923. ' Vessels of train, base, air squadrons, etc. Per cent, Novem ber. Per cent since July 1, 1923. Gonococ- cus. Syphilis. Gonococ- cus. Syphilis. 59.73 11.49 67.03 9.00 86.27 72.91 10.78 6.25 20.37 86.76 71.61 38.91 9.82 6.65 17.68 i 37.04 79. 17 67.39 152.56 12.50 4.36 1.28 88.75 64.51 52.02 6.25 4.94 4.93 76.59 62.29 ' 50.94 34.09 58.82 56.92 68.29 53.33 19.15 16.39 22.64 22.73 5.88 9.23 2.44 20.00 85.18 63.40 50. 42 56.67 53.85 61.78 68.18 62.50 8.99 14.85 16.81 9.26 5.98 6.05 4. 17 10.64 No. 2. 283 DIVISION OF PREVENTIVE MEDICINE. Table No. 3.— Summary of annual admission rates for venereal disease reported from ships for November and from various shore stations for the five-week period December 2, 1923, to January 6, 1924 —Continued. RATIO OF GONOrOCCnS AND SYPHILIS INFECTION TO TOTAL CASKS OF VENEREAL DISEASE— Continued. All naval districts in the United States. First naval district Third naval district Fourth naval district Fifth naval district Sixth naval district Seventh naval district Eighth naval district Ninth naval district Eleventh naval distrirt Twelfth naval district Thirteenth naval district Percent, Dec. 2, 1923,to Jan. 5, 1924. Per cent since Julv 1, 1923. Gonococ- cus. Syphilis. Gonococ- cus. Syphilis. 80.57 10.86 79.29 9.80 78.57 14.29 81.42 15.04 40.00 40.00 70.83 13.89 71.43 21.43 73.97 12.33 SO.52 9.09 75.68 10.21 90.90 0 74.24 6.06 0 0 0 0 83.33 0 84.62 0 100.00 0 87.62 (',.(,7 70.00 78.57 20.00 82.46 10.53 7.85 83.S3 8.24 87.50 12.50 95.81 4.17 Table No. 4.— Number of admissions reported by Form F cards and annual rates per 1,000, entire Navy, for the five-week period, December 2, 1923, to January 5, 1924, inclusive. Naw (strength, 96,674). Diseases of blood Diseases of circulatory system Diseases of digestive system Diseases of ductless glands and spleen Diseases of ear Diseases of eve and adnexa Diseases of "genito-urinary system (non- venereal) Communicable diseases transmissible by oral and nasal discharges Communicable diseases transmissible by intestinal discharges Communicable diseases transmissible by insects and other arthropods Tuberculosis (all forms) Venereal diseases Other diseases of infective type Diseases of lymphatic system Diseases of mind Diseases of motor system Diseases of nervous system Diseases of respiratory system Diseases of skin, hair, and nails Hernia Miscellaneous diseases and conditions. . . . Parasite (fungi and certain animal para- ""») MS lea ms Total Number of admis sions. 1 31 537 2 M IIS 143 500 84 22 1,136 260 52 45 61 49 1,108 80 37 301 187 525 (14 5,395 Marine Corps (strength 21,660). Annual Number Annual rate per ofadmis- rate per 1,000. | sions. 1.000. 0. 11 3.66 57.77 .22 9.14 7.31 15.38 53.79 ,76 9.04 2.37 122.2(1 27.97 5.59 4.81 6. 56 5. 27 119.19 a 61 3.98 32.38 20.12 .75 56.47 6.88 n 7 !50 0 13 22 2(1 SO s2 1 260 77 Ifi 11 16 11 21(1 22 12 27 16 4 114 II 0. on 3.36 72.02 .00 ('..24 10..56 9.60 38.41 2.40 39.37 .48 124.84 36.97 7.68 5. 2S 7.«v 5.28 105.15 10.56 5.76 12.96 7.68 1.92 54.74 5.28 Total (strength, 118.334). Number Annual of admis- j rate per sions. 1,000 1 11 6S7 2 '.iv 91) 166 21 1,396 337 6N 5fi 77 00 1,327 102 4" 32s 2(1: II 63!' 75 580.34 1,196 571. 6,591 (I.09 3.60 00. 37 .18 \ c I 7.91 14.32 50.97 1.05 14.59 2.02 122.68 29.62 5.98 4. 92 6. 77 27 116.62 8.96 4.31 28.82 17.84 .97 56. 16 6.59 579.22 284 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. Table No. 5.— Deaths reported, entire Navy, for the five-meek period, December 2, 1923, to January 5, 1924, inclusive. Caused. Dysentery, baciUary Dysentery, entaiuebic Measles Pneumonia, broncho Pneumonia, lobar Tuberculosis, chronic pulmonary Scarlet fever Malignant growth.* Other diseases Drowning Other accidents and injuries Poisons Total Annual death rate per 1,000. all causes.... Annual death rate ;jer 1.000, diseases only Navy (strength 96,674). 1.51 Marine Corps (strength. 21.WW). :t. V. . is VOL. XX NO. 3 . UNITED STATES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PLANNING AND PUBLICATIONS CAPTAIN D. N. CARPENTER, MEDICAL CORPS, U. S. NAVY IN CHARGE EDITED BY LIEUTENANT COMMANDER W. M. KERR, MEDICAL CORPS, U. S. NAVY MARCH, 1924 (MONTHLY) Compiled and published under authority of Naval Appropriation Act for 1924, approved January 23, 1923 WASHINGTON GOVERNMENT PRINTING OFFICE 1924 TABLE OF CONTENTS. Page. PREFACE v NOTICE TO SERVICE CONTRIBUTORS- VI SPECIAL .\RTICLES: • AVIATIONACCIDENTS AND METHODS OF PREVENTION. By Lieut. J. F. Neuberger, Medical Corps, U. S. Navy__________ 285 NOTES AND COMMENTS : A 1·iation a<·cidents.-Aeroplane accidents from the British view- point.-The estimation of physical efflciency.-The air ambulance in war.---Gas warfare in the air.-Ophthalmology in its relation to 11viatlon.-Notes on aviation medicine in France.-Fellowship in the .\merican College of Surgeons.-Vaccination against small- pox -The instruction of hospital corpsmen__ 331 NAVY NURSE CORPS: NOTES ON A COURSE FOR INSTRUCTORS OF NURSING-- 363 PREVENTIVE MEDICINE, STATISTICS: REM ARKS ON THE EPIDEMIOLOGY OF SMALLPOX AND THE PREVENTIVE VALUEOF VACCINATION WITH COWPOX VIRUS.- MEDICAL OFFICER RECOMMENDS ADOPTION OF A REGISTER FOR COWPOX VACCINATIONS.- REPORT OF A CASE OF CEREBROSPINAL FEVER AT THE UNITED STATES NAVAL TRAINING STATION, NEWPORT, R. I.-MEDICAL BULLETIN OF THE DESTROYER SQUADRONS OF THE BATTLE FLEET.-PROPHYLAXIS OF VENEREAL DISEASE.-BACILLARY DYSENTERY IN GUAM.-PORTABLE CANVAS SACK STEAM DISINFECTORS AVAILABLE ___________ m PREFACE. The United States Naval Medical Bulletin was first issued in April, 1907, as a means of supplying medical officers of the United States Navy with information regarding the advances which are continually being made in the medical sciences, and as a medium for the publication of accounts of special researches, observations, or experiences of individual medical officers. It is the aim of the Bureau of Medicine and Surgery to furnish in each issue special articles relating to naval medicine, 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, reports from various sources, historical essays, notes and comments on topics of medical interest, and reviews or notices of the latest published medical books. The bureau extends an invitation to all medical officers to prepare and forward, with a view to publication, contributions on subjects of interest to naval medical officers. In order that each service contributor may receive due credit for his efforts in preparing matter for the Bulletin of distinct origi nality and special merit, the Surgeon General of the Navy will send a letter of commendation to authors of papers of outstanding merit and will recommend that copies of such letters be made a part of the official records of the officers concerned. The bureau does not necessarily undertake to indorse all views or opinions which may be expressed in the pages of this publication. E. R. Stitt, Surgeon General United States Navy. v NOTICE TO SERVICE CONTRIBUTORS. When contributions are typewritten, double spacing and wide margins are desirable. Fasteners which can not be removed without tearing the paper are an abomination. A large proportion of the articles submitted have an official form, such as letterheads, numbered paragraphs, and needless spacing be tween paragraphs, all of which require correction before going to press. The Bulletin endeavors to follow a uniform style in headings and captions, and the editor can be spared much time and trouble and unnecessary errors can be obviated if authors will follow in the above particulars the practice of recent issues. The greatest accuracy and fullness should be employed in all citations, as it has sometimes been necessary to decline articles otherwise desirable because it was impossible for the editor to understand or verify references, quotations, etc. The frequency of gross errors in orthography in many contributions Is conclusive evidence that authors often fail to read over their manuscripts after they have been typewritten. Contributions must be received two months prior to the date of the issue for which they are intended. The editor is not responsible for the safe return of manuscripts and pictures. All materials supplied for illustrations, if not original, should be accompanied by a reference to the source and a statement as to whether or not reproduction has been authorized. The Bulletin Intends to print only original articles, translations, in whole or in part, reviews, and reports and notices of Government or departmental activities, official announcements, etc. All original contributions are accepted on the assumption that they have not appeared previously and are not to be reprinted elsewhere without an understanding to that effect. fl U. S. NAVAL MEDICAL BULLETIN Vol. XX. MARCH, 1924. No. 3. SPECIAL ARTICLES. AVIATION ACCIDENTS AND METHODS OF PREVENTION. By J. F. Neubebger, Lieutenant, Medical Corps, United States Navy. No subject in preventive medicine as it relates to the military and naval establishments is of greater importance to the medical officer than that of aviation accidents. In looking over the literature deal ing with aviation accidents and fatalities, one is surprised to note how little information is at hand, not only regarding the actual statistics and accurate accounts of these accidents, but also concerning suggestions and methods for their prevention. In the United States flying on a large scale has been carried on since 1917, both in the Army and Navy, and it is interesting to review the data available regarding accidents as well as the measures undertaken for their prevention. The qualities that make up the successful flyer have been of interest to the world since flying became established. Many bizarre notions of these qualities have gained credence among the laity, who were prepared by their own ignorance or appetite for the romantic to accept as true fantastic notions on the subject. Flight itself ap peals strongly to the imagination, therefore what could be more natural than to let fancy roam unrestrained when contemplating the man who does the flying? However, we are now divesting the aviator, little by little, of the glamor that shrouded his first appear ance and are coming to know him more as he is, not as a different type, or a peculiar type, but as a normal human being endowed with quick judgment and resolute decision. These are the qualities that must be preeminent in the flyer. To these superlatives must be added certain physical requirements and the psychologist will ap pend his demands for certain nervous standards. Aviation is divided into two branches, namely, heavier than air and lighter than air. Each branch has its accidents with their particular causes. Heavier-than-air machines are very much in the majority at present and probably will be so in the future. The 285 286 Vol. XX, NEUBERGER —AVIATION ACCIDENTS. statistics given in this article deal mostly with accidents to heavier- than-air machines, but the lighter-than-air accidents are included. The United States Navy uses, in addition to sea and hydroplanes, a large number of machines of the land-plane type and therefore the lessons learned by the Army, air mail, and civil organizations must be considered and the statistics of the accidents taken into account. In describing the causes of aircraft accidents the following classi fication was made by some of the early writers on this subject : 1. Mechanical imperfection of plane or motor. 2. Bad flying judgment. 3. Weather conditions. 4. Collisions. Army medical officers have added a fifth cause, namely, propeller accidents. W. G. Anderson, in his book on " Medical and Surgical Aspects of Aviation," classifies the causes of aviation accidents as follows : 1. Defects in airplane. 2. Error in judgment in flying. 3. Loss of head. 4. Brain fatigue or lethargy. 5. Fear. 6. Physical illness. 7. Unavoidable causes. The rotation of this classification is not in accordance with the frequency of the occurrence of the accidents, as Anderson, in another classification, gives the following statistics in a series of 58 crashes r Number of crashes. Cause. (1) (2) (3) (4) (5) (6) (7) Airplane defect (a) Breakage. lb) Engine failure. Error of judgment — Loss of head Brain fatigue Fear -- Physical illness Unavoidable Total With Injury to pilot. 15 Without in- Jury to pilot. 38 1 1 0 0 3 43 Total. 42 r 4 o o 4 58 According to the writer's experience, aviation accidents can be classified in accordance with the frequency of occurrence as follows: 1. Physical and mental defect in the pilot. 2. Insufficient knowledge and experience in the science of aviation. 3. Mechanical imperfection of plane or motor. 4. Weather conditions. No. 3. 287 NEUBERGER —AVIATION ACCIDENTS. 5. Unavoidable causes, such as accidents due to fire or breaking of propeller while the machine is in the air. Propeller accidents are not included in the classification, as the writer does not consider it purely an aviation accident. Stepping into a propeller with resulting injury is no more a flying accident than stepping into a deck winch on board a ship or into the flywheel of an engine in a factory. Physical and mental deject in the pilot. —It will be noticed in the above classification, that no mention is made of error in judgment. The writer includes those fatalities occurring as an error of judg ment under mental defects. In selecting a man for aviation duty a» psychological examination must be made and his judgment deter mined. While this seems a very difficult task, it is not as difficult as it seems. Close observation of the man and his behavior during examination, his reaction toward the examiner, his previous per sonal and family history and psychological tests will help the exam iner to get a fairly accurate opinion of the applicant for aviation duty. It was noticed by the writer during his tour of training at the air station at Pensacola that numerous officers and men. who had been passed by the medical officer, were disqualified later bv the instructors on account of slowness in reaction or some other mental defect, which in ordinary walks of life does not hinder the indi vidual. These men without exception were efficient officers in some other branch of the service, but they did not possess the character istics necessary to make them successful aviators. At the air sta tion at Pensacola,' after the applicants have passed the physical examination, they take a course in ground work on aviation subjects. This work is commonly spoken of as the "ground school." The writer knows from personal experience that it would be an excellent procedure to have a flight surgeon take this course with every class, for an experienced flight surgeon can pick out a number of men in the ground school whose mental faculties are such as to make them unfit for aviation duty, and which may prove dangerous when actual flying activities begin. This course in the ground school lasts about six weeks: then the student begins actual flying. Every student is given 10 hours' instruction, after which time he must " solo " or fly alone. Most apt students solo after six or eight hours. If a student does not solo in 10 hours he is brought before an advisory board consisting of three experienced fliers, who decide if the student has possibilities as a flier; if he has desirable qualifications he is given three hours' additional instruction. This brings up a very interest ing point in connection with the mental faculties of individuals for flight training. The writer, at the time of his course at Pensacola, 288 Vol. XX, ' NEUBERGER AVIATION ACCIDENTS. had often wondered why and how the 10-hour standard was adopted, and he has talked this point over "with a number of instructors and officers in charge of flight training who have had a great deal of experience in flying instruction. The argument put forward against this time limit was that there are many men who are slow in learning, but when they have learned a thing they retain it and use it at all times to best advantage. A number of instructors agreed with this statement and stated that such had been their experience with a great number of men. The explanation given for the 10-hour standard by the majority of officers in charge was about as follows. It has been the experi ence of most instructors that most students can learn to solo in less that 10 hours, and that students who fail to solo in 10 hours will not make, as a rule, very good fliers. Of course, there are a few ex ceptions to this rule. I believe, considering it from a psychological point of view, that the last explanation and observation is very good and one that should be followed. If the student does not learn to fly in 10 hours then his judgment and learning capacity are not as good as those that do learn in the stipulafed time, and while his power of retention may be just as good, he lacks speed in learning and shows to some degree a mental slowness, which is one of the things making him unfit for aviation duty. Quickness of judgment is one of the prime requisites in flying, and slow-thinking individuals had better stay on the ground, although they may be intellectually superior to those actually flying. The writer brings up this point, because error in judgment is frequently given as the cause of acci dents and the above facts will help to explain the reason why the writer classifies error of judgment under mental defects; slowness in forming judgment is certainly a mental defect considered from an aviation point of view. Physical and mental defects of the pilot are given in the above classification as the most frequent cause of aviation accidents, and the statistics in this article substantiate its deserved place. The English stated that in the first year of the war, when examinations were not carried on by a medical officer especially trained to conduct these examinations, that over 90 per cent of the accidents were due to physical and mental defects of the pilot. And while at present these figures are somewhat reduced, the majority of accidents, if minutely scrutinized will be found to be still due to the same cause. The remedy is simple and can be expressed in two sentences, namely, the most rigid physical and psychological examination of all flying personnel and specially trained medical officers to conduct the examinations. The examina tion for flying personnel has been described in a previous article and the writer therefore does not wish to discuss any detail of this No. 3. 289 NEUBERGER —AVIATION ACCIDENTS. •examination, but wishes to emphasize again that the examination must be rigid, especially for candidates just entering the aviation service. After the student has finished his aviation training and is qualified as a pilot, his physical and mental efficiency must be main tained, a task more difficult than the original examination. The importance attached to this task is realized by the Navy Department and has resulted in the following letter from the Secre tary of the Navy to all aviation activities : 1. The department expects every member of the Naval Establishment to maintain himself in the best possible physical condition in order that he may be prepared to render efficient service under the most strenuous conditions. It is particularly necessary that officers and men who are engaged in active flying duty maintain themselves in the best possible physical condition at all times. 2. Any man is justified and right in taking a chance which may cost him his life, provided the ends to be obtained are commensurate with the risks in volved. The department expects such action from all members of the Naval Establishment. However, one of the oldest military maxims is that unneces sary sacrifice of life is a crime against the service. This should be constantly borne In mind by all who are engaged in duty involving flying; for if these .men neglect to maintain the best possible physical condition they Jeopardize not only their own lives but the lives of such others as work with them. 3. The department desires that all commanding officers take necessary steps to insure that men who are not in proper physical condition, regardless of the ■cause from which such condition may arise, be not permitted to engage in •flying. Edwin Denby. The task of keeping fliers fit and seeing that they do not fly if they are not fit, causes the flight surgeon a great deal of embarrassment, as he may be called upon to recommend suspension from flying duty of one of his best friends which usually causes a certain degree of ani mosity. The most violent protests and arguments are put forth on these occasions. An officer of rank recently tried to convince me that the staying out until 6 o'clock in the morning would not interfere with his flying the same morning and that his physical condition was just as good as the day before, and that he was in fit condition to fly, on which point, however, we could not agree. The officer maintained that he had not drank anything, which I knew positively to be a fact, as he has never been known to do so, and he for that reason, insisted •upon being in excellent shape and fit to fly. It may be possible that this officer who is very strong, athletic and healthy, may have had sufficient reserve energy to carry on an extensive flight. He may Tiave been fit, but I do not consider it a wise policy to fly after prac tically no sleep at all and besides, it is a bad precedent for other officers. Regarding the maintenance of the flier, I wish to state again that too much indulgence in alcohol and the bright lights of a great city, 290 Vol. XX. NEUBERGER —AVIATION ACCIDENTS. with a tendency toward overexertion in many ways, has been the cause of the loss of many good fliers to the service. Clouded brains from hang overs are not fit to direct an air or sea plane. Close at tention should be paid to the pilot on Monday mornings and the days following other holidays. The medical officer of the United States Naval Air Station, Pensacola, Fla., informed the writer that 66 per cent of all accidents within the past two years occurred on Monday or on days following holidays. The reason for this is quite obvious. The question then is asked, how can we determine the exact physical condition of a certain pilot on a certain Monday morning? On the U. S. S. Wright, flagship of the Aircraft Squadrons, Scout ing Fleet, we determine each pilot's exact normal circulatory effici ency rating, commonly known as the Schneider index. In the No vember, 1922, issue of the United States Naval Medical Bulletin, appeared a description of the physical efficiency rating scheme devised by Dr. Edward C. Schneider. The description of this test appeared in the Bulletin in response to the following question submitted by a medical officer: What is the best method of ascertaining the effi ciency of the cardiovascular system of the individual when the electro cardiograph or other such instruments are not available? In pre paring the answer to this query the editor utilized the Schneider index as published in the Journal of the American Medical Associa tion, May 29, 1920. Since the publication of this article some changes have been made in this index by Schneider, as the result of observations made on a great number of persons. The changes made were instrumental in making the index much more reliable. The Schneider index is of special use in aviation, as we have to deal more with temporary than permanent ailments, because men with marked physical defects are weeded out before they reach the stage of flying ; furthermore, we encounter in aviation as well as in other walks of life, a condition known as staleness. While this condition is not very serious in persons in civilian life, in aviation it may have very fatal consequences. There are a number of other tests to be found in the literature, but for practical purposes, and as a short and simple test, the Schneider index seems to be the best effort in this direction. As the test was minutely described in the Naval Medical Bulletin, no further dis cussion of it is necessary except to mention the changes mentioned above. The procedure in making observation is as follows: 1. The patient reclines for live minutes, in) The heart rate is then counted for 20 seconds. When two consecutive 20-second counts are the same, this is multiplied by 3 and recorded. The score is noted according to Part A, Table 1. (b) The systolic blood pressure is next taken by auscultation; two or three- readings are made as a check. No. 3. NEUBERGKR —AVIATION ACCIDENTS. 291 Table 1.— Points for grading cardiovascular changes. A. Reclining pulse rate. B. Pulse rate increase on standing. Rate. Toints. 0-10 beats. 11-18 beats. 10-26 beats. 27-34 beats. 35-«2 beats. Point* Points. 3 Pointt. 2 Points. Points. 50-60 3 3 1 0 61-70 3 3 2 1 0 -1 71-80 2 3 2 0 -1 -2 81-90 . 1 2 1 -1 -2 -3 91-100. 0 1 0 -2 -3 -3 101-110 -1 0 -1 -3 -3 -3 C. Standing pulse rate. D. rube rate increase Immediately alter exercise. • Rate. Points. 0-10 beats. 11-20 beats. 21-TO beats. •U-40 beats. 41-VI beats. Points. Points. Points. Points. 1 Points. 60-70 3 3 3 2 0 71-80 3 3 2 1 0 0 81-90 - - - 2 3 2 1 0 -1 91-100 1 2 1 0 -1 -2 101-110 1 1 0 -1 -2 -8 111-120 0 1 -1 -2 '-3 -3 121-130 0 0 -2 -3 -3 -3 131-140 - -1 0 -3 -3 -3 -8 E. Return of pulse rate to standing normal alter exercise. F. Systolio pi essure. standing, comp reclining. it*1 with Seconds. Toints. Change In millimeter. Points. BKadu-ui-'i— 3 Rise of 8 or more 3 2 Rise of 2-7 2 S^w.i- 1 No rise 1 91-120 0 Fall of 2-5 0 After 120 (2-10 beats above nor- 'USM). -1 Fall of G or morn -1 After 120 (11-30 beats above normal). -2 2. (o) The patient stands at ease for one or two minutes to allow the pulse to assume a uniform rate. When two consecutive 20-second counts are the same, this is multiplied by 3 and recorded. The score is obtained by use of part C, Table 1. The difference between the standing and reclining pulse rates is scored then by use of part B, Table 1. (6) The standing systolic pressure Is next taken. The difference between this and the reclining systolic pressure is then scored by part F, Table 1. 3. The patient next steps on a chair about 18 inches high, five times in 15 seconds, timed by a watch. To make this test uniform, lie stands with one foot on the chair at the count one ; this foot remains on the chair and Is not brought to the floor again until after the count five. At each count he brings the other foot on the chair and at the count " down " replaces It on the floor. This should be timed accurately, so that at the 15-second mark both feet are on the floor, (a) Immediately, while he stands at ease, the 292 Vol XX. NKUBERGER AVIATION ACCIDENTS. pulse rate is counted for 15 seconds ; this is multiplied by 4 and recorded. (i>) Counting is continued in 15-seeond intervals for two minutes, record being made of the counts at 60, 90. and 120 seconds. The dura from (a) will be scored by part D, Table 1. taking the difference between this exercise pulse rate and the standing rate. The data in (6) are scored according to part E, Table 1. As seen from the above table. 18 represents a perfect score. Schneider assumes, with very good reason indeed, that a score of 9 or less indicates that there is something wrong with the individual and that n thorough physical examination should be made. Aboard this ship a pilot on first reporting for duty has his index determined on three consecutive days, taking into consideration the amount of sleep and exercise. The average of the three days is registered as his normal index and this figure gives the medical officer something to go by in the future. The index is taken weekly or whenever it is considered necessary. We have a blackboard in the sick bay with the names of all pilots, and on this board is registered his index, the amount of sleep and exercise, and the daily and weekly flying hours. We therefore have figures for com parison. If a pilot, for instance, has an average index of 14, and on two consecutive weeks shows an index of 10, we know that he is not up to normal and something must be wrong, and he is imme diately examined with the view of locating the difficulty of what ever character it may be, physical or mental. This is done weekly on all pilots and on others whenever the medical officer thinks it necessary, and it is considered an excellent procedure. Last year during the fleet maneuvers at Panama, where an immense amount of flying was carried on by the aircraft squadrons, this index was of valuable assistance. As a matter of fact, it was the only method for practical use, as it only takes a few minutes to perform and does not therefore interfere too much with the pilot. During the flight to Panama, and during the maneuvers, it became necessary on several occasions to temporarily suspend pilots from flying duty and one pilot had to be permanently relieved. It is my conviction that accidents would have occurred had this procedure not been instituted, and the Schneider index gave the first indica tion that something was wrong. As a result, I am able to give the following recapitulation of all flying done during the past winter by planes of the Scouting Plane Squadron and I am glad to say that there was not a single accident. Total number of flights 1,187. Total flying time 2,650 hours 47 minutes. Total mileage flown 170,000 miles. The above flying was divided as follows : No. 3. NEUBERGER AVIATION ACCIDENTS. . 29S Hours, utes. Test flights 106 19 Passage flights 1,793 37 Scouting flights 319 25 Maneuvers, spotting, etc . 286 22 Escorting fleet 33 30- Photographic flights 111 3* I believe it is remarkable that we did not have a single accident when one considers that these planes, 18 in number, flew from Norfolk, Va., to Panama, leaving Norfolk in the midst of winter, when it was exceptionally cold and much difficulty was experienced in starting the motors. The writer wishes to state further, that at the writing of this paper, October, 1923, the aircraft squadrons of the Scouting Fleet has not had a single accident. The writer does not wish to be too optimistic, but he believes that with thorough supervision of the personnel the accidents in any aviation unit will ultimately be markedly reduced. It takes time and ingenuity to make improvements in designs of planes and en gines, and accidents due to mechanical failure are not so easily eliminated; but in considering the statistics given in another por tion of this paper we note that there is a small percentage of fatalities resulting from mechanical failure compared with those from other causes. Thorough supervision of the personnel is the answer at present for the prevention of accidents. This is not easy, but must be done. It is difficult for the flier, as well as the medical officer. It entails a lot of personal sacrifice on the part of the pilot,, and anyone making application for aviation training should under stand this point. The author realizes how difficult it is to leave an evening entertainment in order to obtain the necessary amount of sleep for flying next morning. Anyone who is not willing to give up a certain amount of pleasure and make some personal sacrifices had better wait before taking up flying until the mechanical per fection of the plane has reached a stage where the personal and human element have no longer any influence and flying is absolutely safe. This stage of perfection is something we all are looking for ward to, but probably will never reach. One of the most common defects found on original examination, as well as on annual examination of pilots, is overweight. In the Manual for the Medical Department, United States Navy, the average body weight for height and age are given as standards. It is true that certain allowances must be made for differences in the weight of the bony and muscular structures. A variation of 10 per cent in either direction will for practicable purposes account for any excess or deficiency" in body weights due to normal differences in the weights of the bones and muscles. Ten per 294 Vol. XX, NEUBERGER AVIATION ACCIDENTS. cent or more above the average should constitute a physical de fect. While excess fat may not have an immediate apparent detrimental effect upon the physical efficiency, its presence will favor the development of serious degeneration and organic disease. Furthermore, an officer, by permitting himself to become overweight, has displayed a lack of interest in his physical condition which is far from being in accord with the duty he owes the service and which is itself an evidence of inefficiency. Overweight will not de velop except as a result of improper habits of living on the part of the individual. In fact, overweight is always, except in rare in stances, due to eating too much or to exercising too little, or both, and such habits are diametrically opposed to the precepts of mili tary training. In practically all cases excess fat can be removed by the in dividual himself, if he so desires. In a few cases, such as the older officers who have been overweight for a number of years and who have already developed other physical defects, rapid reduction in weight might not be advisable and possibly could not be accom plished without a great deal of discomfort and some danger to health. However, in aviation, where we have the younger and more active officers, there is no excuse for overweight. Every cell in the body is derived primarily from the food, and excess fat simply rep resents excess food consumed. There is no other source of fat than the food and drink taken in through the mouth. The body processes of certain persons are such that they convert excess food into fat much more readily than do others. This does not justify the consumption of more than the amount required by the body merely to gratify the appetite. The body requires food for the purpose of rebuilding or repairing the worn tissues and providing energy for the muscular activities, and excess foodstuffs, especially fats and carbohydrate;-, have to be deposited in the tissues as fats. The maintenance of the proper body weight is then a question of balance between the intake of fat and carbohydrates and the energy expended in muscular exercise. In an overweight person, if the amounts of fat and carbohydrates consumed are less than required for the daily activities of the body, a reduction in weight will occur. All overweight officers should be given appropriate advice by the medical officer or should obtain some good scientific book on this subject. Not only officers assigned to aviation, but all officers of the Navy should watch themselves carefully, so as not to acquire an excess amount of fat. The relation of the medical examiner to the naval officer should be one of help and assistance. Where formerly it was almost the sole duty on physical examination to cull out the physically unfit 294—1 294—3 294—1 294—5 291—r, No. 3. 295 NEUBERGER —AVIATION ACCIDENTS. and initiate action which might lead to retirement, or in aviation, to suspension from flying duty, the medical officer and the flight sur geon of to-day plays the role of medical adviser to the examinee, whose interest it is his duty to protect, by rendering it possible to remove those conditions which might ultimately lessen his efficiency, cause his retirement, or shorten his life. Insufficient knowledge and experience in, the science of aviation. — While causes of aviation accidents, except physical and mental de fects, do not belong to the sphere of the flight surgeon, a short discussion of them is considered not to be out of place in an article of this sort. Inexperience is a very common cause of accidents. Reference has been made above to the method of training students in aviation in the United^ States Navy. Applicants, after passing the required standard physical examination, are sent to the United States Naval Air Station at Pensacola, where they receive a course in the ground school work, and after about six weeks flying is begun. The student is given 10 hours of dual instruction and then begins to solo in a certain type of plane. He is then taught acrobatics, which is, despite many opinions to the contrary, absolutely necessary. It is not only necessary in combat work, but a plane may go into a spin, and the pilot must know how to straighten his machine. The learn ing of acrobatics is not always a pleasant experience, and the writer, on his first and second instruction periods in this sort of work, be came extremely ill. The sudden and rapid turning of the machine caused dizziness, nausea, and vomiting, and, fortunately for the writer, the instructor took the controls, otherwise he would not be here to tell the story. As far as he was concerned, he felt so ill it did not matter to him where and when the plane landed. However, after awhile, one overcomes this feeling. After the instruction in the training plane is finished, instruction is given in larger flying boats, such as the types used by the aircraft squadrons. After this, a certain number of the students are trained in torpedo and land planes. In the land-plane training the student is taught combat work. This involves mastery of the tactics and acrohacy involved in actual fighting. The student is taught how to attack, how to fight, and how to extricate himself if attacked by superior numbers. To the young, ardent, and unimaginative flying officer of our services will naturally fall the carrying out of this work. Youthful pilots, by virtue of keenness of vision, sensitive reflex action, and lack of imagination, which, for the peculiar requirements of aerial pursuit and combat work, is a most desirable asset, are unquestionably best equipped mentally and physically to take the fast flying, fast landing combat planes into the air. Every student officer, after completing the course, should be selected for the duty for which he is best fitted 78693—24 2 296 Vol. XX, NEUBERGER —AVIATION ACCIDENTS. at the time—either combat, scouting, bombing, or other duty. This selection for special duty will give him additional experience and eventually make him a seasoned flier. At Pensacola certain rules and regulationc are issued covering flying which protect both the student and the instructor. These rules were formulated as a result of experience and careful investigation. For instance, no one is allowed to perform acrobatics below 3,500 feet, and stunting can only be done in the stunt field, a place especially laid aside for the purpose. Machines will be taken off and landed against the wind only, and there are many other rules too numer ous to mention. It is surprising how often these rules are violated, not only by students but also by fliers of long experience, not only at Pensacola but many other places. Not very long ago the writer saw a seasoned flier of long experience perform stunts at an altitude so low that he could be seen actually hitting the tops of trees. Engine or other structural failure, in circumstances of careless flying and stunting at low altitudes, almost invariably causes fatal crashes resulting in the loss of expensively trained personnel and valuable material not to mention the deleterious effect on the morale of the aviation service as a whole. Severe and prompt discipline should be meted out to those flying officers who, through childish desire to be recognized as pilots of exceptional skill and daring, unduly hazard their lives, the Government equipment with which they are intrusted, and the integrity and efficiency of the aviation units of which they form a part. There is an old slogan in aviation, which should be carried in one's mind at all times, " Be the oldest, not the boldest aviator." Skill and knowledge are especially essential in formation flying. With the construction of large numbers of planes and their use in large groups in time of war, formation flying becomes essential. This type of flying is very dangerous and requires infinite care and watchfulness, especially in executing turns. Collisions are very liable to occur and may result in several deaths, since almost without fail the planes are so badly damaged that they are entirely out of control. In a formation one poor flier is a menace to the entire squadron, and erratic fliers should not be present. Blind angles of the machine, crowded conditions of flying centers, small flying fields, neglect of regulations, momentary inattention, or slight faults in maneuvers in formation flying are frequent causes of collision. Mechanical imperfection of plane or motor.—The number of crashes in the United States Navy during the year 1921-1922 due to engine or structural failure was 24, making a percentage of 22.5 of all the total number of crashes. The prevention of this type of crash CHART No. !.-Statistics of injuries to aviation personnel from 1917 to 1921, inclusive. :,;o-rE.- Key lctln n ~ Aeronuuiic duiy. C-R (conflngration); D-R (drowning); G-R (traumatism by Call); H-R (irsumatism by machines); l-R (trsumatisrn by other crushing; F-R (traumatisrn by explo.qion); E-R (iraurnatism by firearms); L-R (traumatism due to other causes). - - - ---- - - ~ ~ ~ : ~ ~ . - C-R n:·' Ot- · , _. ! F-R I E-R L-R i~;,::;FF 1 ,-R I F-R I E-R I L-R C-R I "tt-"!' R : 't-· : L-R I ~ I D-R 0-R ! H-Rj'-· F-R _':'.'_! L-R ~~ I Gt -· i '-• i ·-· ."::"_I L-R 3 6 2 2 Crush: , I ' 1 I 789G3-U. (Face p. 297.) so. 3. XEUBERGER-A YIATIOX ACCIDEXTS. • 297 . essentially an engineering problem, and it is believed its accom- \~hnient is a matter of time. It involves the employment of the ~ill'hest grade of mechanical ingenuity, skill in design and construc- ti;1 of the plane, and the utilization of only the best material ob- tainable. One of the flight surgeons of the United States Army, a trained pilot, stationed at McCook Field, recently lost his life while flying, "°hen for some reason one of the wings of his plane crumbled to pieces while in mid-air. Weather conditions.-The most important weather conditions en- countered by the flier are clouds, fogs, winds, and rains. Fogs ab- solutely prohibit flying and great care should be taken in flying Jon!!'. distances. It has often happened that a flying squadron leav- in/ one place where the weather was delightful and the sun shining brirrhtly suddenly encountered fog, making further flight danger- ou;. Landing in a dense fog is almost impossible and if a suc- ('P~~ful landing is made it is a matter of Juck. In flying long dis- tances, accurate weather reports should be obtained before starting the flight. This is always possible in time of peace but not in time of war. [11Wcoidable causes.-Under this heading we include such acci- dents as fire in the air and the breaking of a propeller with damage to thP plane. Gas and oil are extremely inflammable and the danger of fire is therefore ever present in planes. The relative locations of motors and gas tanks are of great importance. There is no position in which the pilot finds himself so helpless, and there is no spectacle that affects the morale of those seeing it, as the burning of a plane in the air. There are, however, quite a number of cases on record, in which burning planes landed and no injury to the personnel re- sulted, and also where fires in mid-air were extinguished by the occupants of the plane. Pyrene should be carried by every plane. Propeller accidents are quite frequent. A propeller may break in the air and portions of it pass through the wings or fusilage, not only damaging the plane to such an extent as to make further flight im- possible. but also doing actual injury to the personnel. Cases are on record in which pilots were rendered unconscious by portions of a broken propeller. Well remembered is the accident of last year which occurred to a civilian plane flying between Miami, Fla., and one of the adjacent islands, in which the propeller broke forcing the plane down in a rough sea. All the passengers, four in number, were lost, and the pilot was picked up unconscious, tied to a piece of wreckage. 298 NEUBERGER AVIATION ACCIDENTS. Vol. XX. Chart No. 2. 1917 1918 1919 1920 1921 Total. ■i ; i 1 ■ Fatalities and causes: 28 298 96 66 61 ■ ^ 10 2 4 1 it 21 16 3 12 11 5 13 8 H 80 96 Explosion 8 1 2 8 Total 7 102 39 26 26 200 Percentage of deaths per year from different causes: 28 68 11.54 46.15 42.31 19.23 60.00 Drownings 67.11 14.28 36.29 68.83 6.88 63.86 41.03 6. 12 Fall and crushing 30.77 Percentage of death to injured 26 8 34.2 406 46.4 42.7 The percentage of death to the injured for the five year period 1917-1921 was 37.24 per cent, divided as follows : Per cent. Bums , 1. 86 Drowning 16. 01 Fall and crushing 17. 87 Explosion 1. 50 Total 37.24 The total number of deaths for the five year period 1917-1921 was 200, divided according to percentage as follows: Per cent Burns 5 Drowning 43 Fall and crushing 48 Explosion 4 Total 100 Statistics of the United States Navy from 1917-1921. —In chart No. 1, the statistics regarding injuries to aviation personnel from 1917 to 1921 inclusive are given. In chart No. 2, it will be seen that the total number injured for the entire five year period was 537, out of which 200 died. They were either killed at the time of the crash or died a short time afterwards. It will be seen at a glance, that 43 per cent of the total number of deaths were due to drowning, and 48 per cent were due to multiple injuries caused by fall and crushing. It is surprising to note that only 5 per cent were caused by fire and burns; the total number of deaths from burns being only 10 in five years, and half of these were the result of the ZR-% disaster. I believe this is a remarkable record and speaks well for the mechanical construction and the precautions taken against fire. It would be well to bring this fact to the attention of all pilots in the service, as injury from fire is dreaded more than any other, and one hears of lots of stories of how one plane or another caught fire in the air. One prominent No. 3. 299 NEUBERGEK —AVIATION ACCIDENTS. factor stands out in these statistics, namely, the largest percentage of fatalities of any individual cause are from fatal submersion or drowning. While in the charts noted above, fall and crushing gives 48 per cent of the total fatalities, this figure includes practically all other injuries, as will be seen from chart No. 1. The high percentage of deaths from drowning teaches a lesson, namely, provision for rendering prompt first-aid to those unfor tunate pilots who are pinned in the wreckage. This will be dis cussed under prevention. The percentage of deaths to the number of injured during the five year period was 37.24 per cent, a little over one-third. In other words, out of every three crashes with injury, one crash was fatal. However it is to be understood that the above statistics do not include all crashes. They only include those crashes in which injuries or fatalities occurred. During the year 1921, in which we had 26 deaths, there were 1,498 officers and men who took one or more flights. During this period there were 61 injuries, making the annual admission rate per thousand for injuries 40.72 and the annual death rate per thousand 7.36. In that year, 42.7 per cent of those who were injured died, and 50 per cent of all deaths were caused by drowning. Up to the year 1921, statistics in the United States Navy were kept, as shown above. For the year 1922, the Bureau of Aeronautics kept accurate accounts, not only of the injuries, but also of the number of men who took flights, the number of hours in the air, as well as the total number of flights made during the year. Analysis of Airplane Crashes in the United States Navy during the Fiscal Year 192%. (The total number of crashes reported was 108, in which 15 were killed and 8 seriously injured.) Flying hours. Crashes. Killed. Seriously injured. NAVY. Atlantic Fleet Pacific Fleet-. Anacostia 2, 775 6, 905 1, 287 968 273 62 5 12 9 0 0 0 12 0 0 28 14 0 0 1 3 0 0 o l 0 0 3 1 0 0 0 0 0 0 0 1 0 0 5 2 0 2, 516 144 447 Pensacola. San Diego Langley detachment 13, 266 2, 931 757 1 Total 32, 331 80 8 300 Vol. XX. NEUBERGER —AVIATION ACCIDENTS. Analysis of Airplane Crashes in the United Mates Navy fairing the Fiscal Year 1922—Continued. MARINES. Flying hours. Crashes. Killed. Seriously injured. 95 2 0 0 429 0 0 0 Port au Prince 1, 661 5 0 0 2, 744 14 6 0 2, 078 7 0 0 Total 7, 007 28 6 0 Total Navy 32, 331 80 9 8 7, 007 28 6 0 Grand total 39, 338 108 15 8 CAUSES OF CRASHES. Hazards of operation. Bad landing 25 Spin 15 Collision 6 Taxi-tag (collision on wuter) 6 Side slip 5 Weather conditions 4 Banting of plane (in air) 1 Burning of plane (on ground) 1 Gasoline exhausted 2 Nose dive 2 Stall 2 Glassy water - Bad take-off 1 Poor pilotage 1 Splraled into water 1 Failure to recover from deliberate spin I Skid — 1 Total number due to hazards of operation 76 Engine failure. Structural 5 Loss of oil pressure 4 Stoppage in gas feed 3 Ignition system .— 2 Structural failure. Not known 2 Overheating 1 Total number due to engine failure 17 Pontoon 4 Hull 1 Landing gear 1 Rib 1 Total number due to struc tural failure 7 Not known 8 Total number of crashes, 108. Number Percent- of age of crashes, total. Hazards of operation 76 70 Engine failure 17 16 Structural failure 7 61 Not known 8 7J Total 108 100 One death per 3,278 flying hours. One death or serious injury per 1,967 flying hours. No. 3. 301 NEUBERGER —AVIATION ACCIDENTS. CAUSES OF Atlantic Fleet. Gasoline exhausted _ . Bad landing Poor pilotage Weather condltions- Not known Total number of crashes- Pacific Fleet. Bad landing . Collision Engine failure (structural) Structural failure (rib) Not known Total number of crashes — Anacostia. Collision Bad landing Engine failure (loss of oil pres sure) Spin Side slip Structural failure (pontoon) 5 2 1 1 S 12 Total number of crashes — 0 Hampton Roads. Bad landing 5 Spin 2 Stall 1 Glassy water 1 Engine failure (overheating) 1 Engine failure (stoppage in gas feed) 1 Not known 1 Total number of crashes 12 Pensacola. Spin Bad landing Nose dive Structural failure (pontoon). Engine failure (structural)- Skid Side slip 1 Bad take-off Stall BY ORGANIZATIONS. Pensacola —Continued. Glassy water 1 Spiraled into water 1 Failure to recover from deliberate spin 1 Taxi-ing (collision in water) 1 Structural failure (hull) 1 Not known 1 Total number of crashes 28 San Diego. Taxi-ing (collision on water) 5 Bad landing S Spin 3 Structural failure (pontoon) 1 Side slip 1 Burning of plane (in air) 1 Total number of crashes 14 Parri* Island. Engine failure (stoppage in gas feed) 1 Engine failure (Ignition system). 1 Total number of crashes — 2 Port An Prince. Engine failure (loss of oil pres sure) 2 Side slip 1 Engine failure (structural) 1 Engine failure (cause unknown)— 1 Total number of crashes 5 Quantico. Bad landing 4 Collison 2 Burning of plane (on ground) 1 Weather conditions 1 Gasoline exhausted 1 Engine failure (stoppage in gas feed) 1 Engine failure (loss of oil pres sure) 1 Engine failure (structural) 1 Not known 2 Total number of crashes-. 14 302 Vol. XX. H EU BERGER AVIATION ACCIDE N TS. causes of crashes BY organizations —continued. San to Domingo. Santo Domingo —Continued. Bad landing 2 Structural failure (landing gear) _ 1 Weather conditions 2 Engine failure (cause unknown)- 1 Side slip 1 Total number of crashes 7 In arranging these crashes in accordance with the classification given in another part of this article, we arrive at the following statistics: (Error in judgment is included under physical and men tal defect.) Physical Insuffi cient Mechan ical or struc tural. Westh condi J tion. Un avoid able. and mental defect. knowl edge. Un known. Total. Atlantic Fleet 2 7 4 9 12 1 1 1 5 12 Pacific Fleet 2 • 3 3 Anacostia 2 9 12 14 Hampton Roads 2 1 1 San Diego 1 Parris Island 2 4 3 2 2 Port au Prince 7 3 16 1 1 1 2 5 14 7 Santo Domingo . 2 Pensacola 6 5 1 28 60 10 24 2 8 108 The above figures speak for themselves. Except for the United States Naval Air Station, Pensacola, no allowance can be made for a bad landing, collision, side slip, bad take-off, spin, or poor pilotage. Pilots of experience should know how to get a machine out of a spin, and students should not be allowed to solo until they know how to handle a plane in a spin. Statistics of crashes in the United States Army Air Service.— The statistics and charts given previously for the, crashes in the United States Naval Aviation Service referred to a large degree to seaplanes. During the period of 1917-1921 most of the flying in the United States Navy was carried on in seaplanes. With the construction of airplane carriers and the use of their decks for taking off and landing, land planes will be used altogether, not mentioning the numerous other activities in which the Navy is now engaging land planes. The statistics of the United States Army Air Service are therefore of immense importance to the Navy. A total of 1,250 crashes was reported in the United States Army from various flying fields from the beginning of the war in 1917 up to January, 1920. While these crash returns are incomplete, owing to the fact that many fields did not report their crashes, it is thought that the 1,250 reports are representative and show valuable data No. 3. 303 NEUBERGER AVIATION ACCIDENTS. bearing on the causes leading up to the crashes, injuries suffered by the pilot, extent of damage to plane, and other information of in terest. According to the nature of the crash 1,211 are listed as follows: Nature of crash. Bad landing All spins Collision (other than with ship) . Stall (engine trouble) Side slip- Burning of plane "Taxing (collision on ground) Nose dives Collision (in air with ship) Unknown Number. Per cent of total. 1 563 46. 48 160 13. 21 120 9. 90 .i 97 8. 00 1 64 5. 28 58 4. 78 49 4. 04 46 3. 79 45 3. 71 9 . 81 Total. 1, 211 100 A summary of crashes, as given by the United States Army, ac cording to cause, is shown below : Cause of crash. ——_—_ Bad judgment Engine trouble Unavoidable- . Inexperience Body of plane Vertigo Acute physical impairment Chronic physical impairment Unknown Total. Classifying these crashes according to causes given by the writer, we arrive at the figures given herewith : Physical and mental defect (bad Judgment). Insufficient knowledge. \fechanical structural failure. Weather Unavoid able. Unknown. Total. Number 622 49. 8 45 300 23. 94 225 17. 91 58 4. 86 1,250 100 Percentage... 3. 59 The above classification was made by the writer in accordance with his views concerning the causes of crashes. It is perfectly obvious that much depends upon the viewpoint of the person mak 304 NEUBERGER AVIATION ACCIDENTS. Vol. XX. ing the special crash reports. In studying in detail the reports given by the Array, the above classification was worked out. Prac tically 50 per cent of the crashes were due to physical and mental defects and bad judgment. This figure corresponds very closely to that of the Navy. It is believed that these figures for the Army as well as the Navy, are still too low; and if a complete and thorough analysis could be made of each crash, the percentage of crashes due to physical and mental defects, including error in judgment, would be still higher. In the Army's reports, 594 crashes are given as a result of bad judgment and 225 as unavoidable. It is believed that the number of crashes given as unavoidable is entirely too high and some other cause and explanation should have been given. This statement is verified by the reports of the Army Crash Board and the Army flight surgeons, which reports are not in accord, showing that evi dently some differences of opinion and doubt as to the cause of the crashes existed. Taking up the question of age and its possible bearing on the cool judgment and resourcefulness so necessary in the case of a flier, it is interesting to note that the percentage of crashes attributed to bad judgment on the part of the pilot shows a steady decline from the young pilot of 18 or 20 to the more mature judgment of the flier of 30 to 35 years of age. In reverse ratio is the percentage of crashes listed as unavoidable, which shows a percentage of only 12.08 of all crashes occurring among pilots from 18 to 20 years, and rises to 26.81 per cent of all crashes among pilots from 27 to 30 years of age. Number of crashes and percentages of total, in which the cause was shown as bad judgment or unavoidable, are given below: Age of pilot. Bad Judgment. Cause of crash. Unavoidable. Number. Per cent of total.' Number. Per cent of total." 34 226 160 58.63 51. 71 44. 12 41. 36 40. 98 50. 00 60. 00 53. 09 7 70 67 59 14 12.08 16. 02 24 to 26 years 17. 91 26. 81 22. 95 27 to 30 years - 91 31 to 35 years 25 36 to 40 years- . 6 3 43 41 to 45 years 1 20. 00 8. 64 7 Total 694 47. 62 225 18. 00 ■Percentage of total crashes chargeable against each age group. No. 3. NEUBERGER AVIATION ACCIDENTS. 305 Brief summary of injuries by type of plane is given herewith. Type of plane. Killed. Injured. Uninjured. Unknown. Total. De Haviiand 105 13 7 5 5 269 19 5 8 1 1 669 52 3 2 1, 092 96 16 35 16 5 Scout.. . 4 22 10 Unknown 4 Total 135 303 10. 80 ; 24. 24 807 64. 56 3 1, 250 100. 00 Percentage 0. 40 It is remarkable to note that in 1,250 crashes only 10.89 per cent of the personnel were killed and 24.24 per cent were injured, and 64.56 per cent escaped without any injury. This is rather an excep tional record. It is believed, however, that those classified as un injured, had some sort of slight injury, not sufficient to take the pilot off the flying list. The writer has seen a great number of accidents in the Navy and in practically every case, some sort of an injury was sustained. It is interesting to note the distribution of fliers by age for the year 1918, as published by the Army. .4 Distribution of Flierx by Age for the Year 1918. Ak.>. 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years 27 years 28 years Per cent of total. 0. 6 4. 9 8.9 12. 7 13. 7 12. 9 11. 8 10. 0 6. 8 5. 8 Age. Per cent of total. 29 years. 30 years _ 31 years . 32 years, 33 years- 34 years. 35 years. 4. 5 3. 6 2. 2 1. 2 . 6 . 5 .2 Total 100. 00 In the year 1920, the United States Army Air Service had a total number of crashes of 312 and in 1921, a total of 330, distributed as follows (author's classification) : Physical uud mental defects _ 46 Insufficient knowledge and experience 6 Mechanical imperfection of plane or motor 56 Weather conditions 6 Unavoidable causes 24 Unknown 70 No crash board 104 Total , 312 NEUBERGER AVIATION ACCIDENTS. Vol. XX, In the total of 312 crashes listed above, 34 were killed, giving a percentage of 10.89, 13 were severely injured and 48 were slightly injured, giving a percentage of 19.87. The total number of pilots in the Army Air Service in June, 1920, was 720, and on December 31, 1920, the number was 580. The average number for the year 1920 is 650. Therefore, 5 23 per cent of all pilots were killed; 9.38 per cent of all pilots were injured. A total of 14.61'per cent of all pilots were either killed or injured. There were 650 officers as an average for the year and 312 crashes. Practically one out of every two officers had a crash in 1920. Statistics of the United States Army for the year 1921. Physical and mental defects 59 Insufficient knowledge and experience • 1 Mechanical imperfection of plane or motor 41 Weather condition 12 Unavoidable causes 29 Unknown 27 No crash board 161 Total 330 Of the 330 crashes listed above, 38 were killed, or 11.54 per cent ; 40 slightly injured, 14 severely injured, or 16.36 per cent. The total number of pilots in the United States Army on De cember 31, 1921, was 861 air service officers with flying ratings. Out of 861 air service officers, 330 must have crashed. It is noted that among those crashed were 13 enlisted men, which would make 317 crashes by officers, or 36.8 per cent of all officers of the Regular Army with flying ratings, had a crash in 1921. In other words, one out of every three had a crash. Taking the officer personnel of 861, it will be noticed that 4.41 per cent were killed and 6.27 per cent were injured, making a total of 10.68 per cent either killed or injured, which is lower than the figures of 1920. Crashes according to rank of pilot. Crashes. Lieutenant colonel 4 Foreign officer 5 Marine Corps officer 2 Naval officer 1 Crashes. Not given 1 Enlisted 13 Cadet 62 Second lieutenant 31 First lieutenant :— 147 Captain 43 Major 21 The results of crash for passengers in the United States Army Air Service were as follows: Total 330 No. 3. 307 NEUBERGER —AVIATION ACCIDENTS. Result of crash for passengers. ■ Passengers. Passengers. No passengers 100 Severely Injured 13 Uninjured 185 Killed 31 Slightly injured 26 Total 355 There were six passengers, including two civilians, killed in one ■crash, and also one passenger severely injured and one (civilian) killed in one crash. One other civilian passenger was killed, making a total of four civilians killed who were flying as passengers in Awny airplanes. Three passengers were killed and one severely injured in a single crash, and in another crash two passengers were killed. Statistics of accidents in the American Expeditionary Forces during the World War. Fatalities at the signing of the armistice: Killed in combat with enemy 169 Killed while training 203 Killed in accident at the front 42 Total 414 Prior to the signing of the armistice, there had been listed in all 5,646 pilots and observers in the American Expeditionary Forces, of whom 2,141 were still under training. The following chart pre sents the comparison of the flying hours, accidents, and fatalities for the training centers of the American Expeditionary Forces from January until the end of October, 1918. The number of crashes was 550, and of fatalities 184. The number and extent of injuries sus tained by pilots in crashes are not given, but it is reasonable to pre sume that most of them received some sort of injury, varying in degree, from which they recovered. During the first part of the year, the fatalities were relatively small, and for some unknown reason they doubled in May and quadrupled in August. The average number of flying hours per crash showed a marked progressive de crease after April, whereas the number of average flying hours per fatality showed a general tendency to increase, 721 hours per fatality in October as compared with 464 in January. (See chart No. 3.) 308 Vol. XX. NEUBERGER —AVIATION ACCIDENTS. hi < .a &3 es. o1 10 ■< "5 V "C Cs 1 "5 J e O X S cot; 2 inIo 5 000'K 005'H; ooo't-z ok'ez ooo'ez m'zz ooo'zz oov'tr. ooo'u ooe'oz 000'tK 0O5'6I 000'61 oos'si OOO'SI 009'il 000'il oos'si OOO'OI 009'SI OOO'SI OOS'H OOO'ft OOS'EI OOO'CI oos'r.i OOO'SI OOS'll OOO'OI OOS'6 ooo'a cos's ooo's 009'L 000'I OOS'9 ono'9 oos's OOO'S OOS^ 000't 00?'E OOO'E oos'z ooo'z 009'I 000'I 009 ft < 3 NEUBERGER—AVIATION ACCIDENTS. s O .| d-3 = •£'3.2 310 NEUBEKGER —AVIATION ACCIDENTS. Vol. XX. Casualties at the American front. Killed In combat 137 Missing 59 Prisoners 119 Killed in accident 40 Died of disease 2 Wounded 109 Interned 3 Casualties of the American fliers loith the Allies. Killed in combat 32 Missing 13 Prisoners 17 Killed in accident 2 Died of disease 2 Wounded 18 Summary of American casualties at the front. American Expedition With Allies. Total. t ary Forces. Killed in combat with enemy 137 32 169 40 2 42 59 13 72 119 17 136 Interned 3 3 Died of disease.. . 2 2 4 109 18 127 Total 469 84 553 Lieut. Col. L. G. Rountree, Medical Corps, United States Army, who completed the statistics for the American Expeditionary Forces, makes the following comment: Statistics such as these Indicate the enormity of the problem. When it is realized that for every 100 trained pilots leaving the training institutions of France for work at the front, 15 had succumbed to accidents in training ; that in October, 1918, when our training schools were at the maximum of efficiency, a crash occurred in the school of the American Expeditionary Forces for every 241 hours flown and a fatal accident occurred for every 721 hours flown, the importance of the accident problem becomes manifest. When it is further realized that many of the student fliers entering the school in France had been already trained in the United States, and that even a larger number had already succumbed to accidents in training there, the problem assumes even greater importance. Finally, when it is realized that one man was killed by accident for every three trained pilots arriving at the front, and thnt three fliers were killed in accidents for every one killed in combat, the accident problem establishes itself as the most important medical problem of aviation. Comparison of Army, Navy, and Expeditionary Forces. —In com paring the Army and Navy crashes from 1917 to 1921, inclusive, we obtain the following data: 310— 4 310-6 No. 3. 311 NEUBERGER —AVIATION ACCIDENTS. ARMY. Pilots: 1917-1919 1920 1921 Total. Killed... 135 34 38 207 Injured 303 61 54 418 Passengers : Killed Not given. 12 31 43 Not given. 56 39 95 Total 438 163 162 763 NAVY. 1917 1918 1919 1920 1921 Total. Killed 7 102 39 26 26 200 Injured 26 298 96 56 61 537 Total 33 400 135 82 87 737 A. E. F. (AMERICAN EXPEDITIONARY FORCES). During the W orld War. Killed.. Injured. 414 127 Total of actual trained pilots. Killed. Injured. Total. Total Army, 1917-1921 207 200 414 418 625 737 541 Total Navy, 1917-1921 _ 537 127 Total, A. E. F. (during war) .... The figure 127, under injured, is the number wounded at the front and does not include injuries to the pilots while training at air sta tions in France. The total number of injuries could not be obtained. Mail 8ervice and civilian aviation activities.—In the United States two other activities could be taken into consideration when consid ering aviation accidents, namely, the United States Mail Service and civilian aviation activities. However, the- statistics of accidents and fatalities of the above organizations are not of importance to the military and naval units, as the flying carried on by these units is of an entirely different character. Military tactics require a close formation of airplanes in bombardment, observation, and photo graphic flights. Stunt flying is compulsory in training for combat, pursuit, and scout work. Reconnaissance and cross country flights 78693—24 3 312 Vol. XX. NEUBERGER AVIATION ACCIDENTS. are necessary in unfamiliar territory. In commercial aviation there is never any necessity for flying in formation, and in cross country flights the pilot is familiar with the territory, as he has gone over it numerous times and he knows that such and such a place would make an excellent landing field and a possibility of collision with other planes is practically nil. The writer, however, does not wish to be misunderstood. Flying of any kind is always dangerous. The United States Mail Service pilots have done a wonderful lot of flying. They are often com pelled to fly in stormy weather and in fog. Mountain ranges are traversed, the Alleghanies, the Rockies, and Sierras, over which may be found the worst possible flying conditions. Statistics as to the injuries and fatalities in the United States Mail Service are not at hand. The aircraft yearbook gives the forced landings of the Air Mail Service from 1918-1922. The forced landings are given under two causes, namely, mechanical failure and other causes. Forced landings United Sidles Mail Service. Mechanical Other 1918 I 22 1919 ! 69 1920 I 434 1921 I 632 1922 , 206 I Total 1,374 24 97 385 841 367 1, 741 It would be interesting to know how many fatalities and how many injuries resulted from these forced landings. These data were not available at the time of writing of this article. It is stated that during the 12 months ending July 18, 1922, the United States Mail Service operated without a single serious accident. This is indeed a remarkable achievement in flying. Different, however, is the story of civilian activities, and these pilots were not quite as fortunate, although they have done re markably well, considering the circumstances under which they operate. The Aircraft Year Book of 1923 gives the following sta tistics for 1921 and 1922. Accidents. Fatalities . Injuries. . 114 40 126 62 100 Total. 252 288 Xo. :s. 313 X KCBERGER AVIATION ACCIDENTS. It is estimated that during the year 1921, 1,200 aircraft were en gaged in civil flying in the United States and that these flew 6,500,000 miles and carried 250,000 persons. It is interesting to note the statement made regarding the accidents in 1921, by the editor of the Aircraft Year Book, the statement coinciding with the views expressed by the writer in this as well as other articles : Each of rlie 114 accidents was caused by deficiency In one or more of the six necessary requisites of safe flying. Forty-nine were attributed directly to the pilot, perhaps through carelessness, perhaps incompetence, perhaps bad judgment combined with other factors. There is no doubt that a good pilot can guide a poor machine to safety with greater chance of success than a poor pilot can operate a first-class aircraft. Therefore, at the very top of the list of gov ernmental needs is the Federal examination and licensing of pilots The knack of flying can not be retained perpetually without practice, nor can it be maintained at a high degree of competency without regular examination on a common standard for all flying through out the United States. The same is true of aerial navigators. Both pilot and navigator are of equal importance in safeguarding the lives of travelers by air. The writer believes that the low percentage of fatalities and in juries in both activities, air mail and civilian aviation, are due to the fact that most of these pilots are ex Army or Navy fliers who have had a great number of hours in the air and a lot of experience in flying. Furthermore, the Army and Navy have to train con stantly new men for flight duty, and during this training a great number of accidents occur, it being the most dangerous time. It is believed that this fact accounts for the greater number of fatalities in military and naval aviation. Of the 114 accidents in civilian aviation, 29 occurred during stunt ing; 20 persons were killed and 3(5 injured in these 29 crashes, more than 40 per cent of the total casualties. Stunt flying in unrestricted areas was responsible for almost as many casualties as all other ele ments combined. The writer has heard many persons in the service as well as in civilian life criticize pilots for stunt flying and he therefore does not want to let this point pass unnoticed. Stunt flying is just as neces sary to a military or naval pilot as is straight flying. All pilots, military and civilian, must know how to stunt and should practice stunting at repeated intervals. If they do not know stunting they are going to meet sooner or later with disaster. But the habit of stunting for thrills and the use of planes not suited for stunting sooner or later spells disaster. Stunting should be practiced with certain types of planes, at certain altitudes and over certain areas, preferably over specified flying fields where a safe landing can be reasonably expected. , 314 Vol. XX. NEUBERGER AVIATION ACCIDENTS. SUGGESTIONS FOR THE PREVENTION OF ACCIDENTS AND FATALITIES. The duties of the flight surgeon in aviation units are, first, pro phylaxis or measures for the prevention of accidents and fatalities ; and, second, the surgical and medical care of the personnel in case of accident and injury. To fulfill these functions successfully is one of the problems of military medicine of to-day. To reach the stage where the human defects of the aviator, physical and psychological, can be entirely eliminated by practical and applicable tests is an achievement which many of us are striving to accomplish. The problem will involve an infinite amount of work, study, personal sacrifice, and diligence on the part of those engaged in this duty. Persons in aviation accidents often sustain multiple and mutilating injuries, and to repair them or even save the lives of the injured, involves skill and knowledge of the most up-to-date surgical principles. It was seen by the statistics that practically 50 per cent of all deaths in naval aviation within five years were due to drowning, it is therefore obvious that an efficient first-aid force is one of the prime, requisites of an active aviation organization, and it must be equipped with rapid means of transportation to reach the scene of accident with the least possible delay and return in the same manner. Let us therefore consider the organization of the medical unit with an aviation organization. First of all, each aviation organization, depending upon its size, must have one or more flight surgeons. This flight surgeon must be thoroughly 1rained in aviation medicine and aviation problems and he must be willing to fly with the pilots. Only in this manner can he obtain a broad aspect of the emotions, hardships, and diffi culties which a pilot in an active organization experiences. To assign a medical officer to an aviation unit who for reasons of his own is not willing to fly, and who is not enthusiastic about aviation, is a mistake, bound to have disastrous consequences. The duties of the flight surgeon in connection with the complicated physical ex amination and the maintenance of the pilot in perfect physical condition have been described by many writers and are well known. One of the prime necessities for an aviation ship or an air station is an efficient alarm system. At most of the air stations large wooden or steel towers, similar to radio towers, are constructed, on the top of which is a housing for the lookout. A bell system con nects the lookout with the speed boat or sea sled, the ambulance, and the sick bay. The lookouts are constantly on duty during the time No. 3. 315 NETJBERGEK —AVIATION ACCIDENTS. when flying is carried on and they are in communication by tele phone with the hangars and flight office. As soon as a plane takes the air, the number and the type of plane is transmitted to the look out. The lookouts are equipped with field glasses and are thor oughly instructed regarding their duties. These lookouts are of the greatest importance, and good reliable men should be selected for this duty. The towers are indispensable, especially at a training station, where all flying in training is carried on in the vicinity of the towers. The student can be carefully watched from this point and from it he receives his signals as to weather conditions, change of wind, and recall to the hangar. In case of a crash, the lookout notifies by means of a bell system, the sick bay, the speed boat, and the ambulance. All three must immediately respond and no excuse must be accepted for their delay, except an unavoidable cause, such as a mechanical failure of the boat or ambulance. A delay on the part of the personnel must not be tolerated. At the air station, Pensacola, where all the naval personnel receives its training, a speed boat is constantly on duty in the bay, secured to a buoy in the center of the course, around which the students fly, ready to go to a stu dent's assistance at a moment's notice, and these boats have saved the lives of many officers and men. The speed boats have in addition to the crew, which is thoroughly instructed in first-aid measures, a reliable pharmacist's mate. He has with a him a hospital corps pouch, a Stokes stretcher, a puhnotor for resuscitation in case ofj apparent drowning, a tool kit, and a number of cylinders containing pyrene. The ambulance is stationed in the vicinity of the sick bay, and as soon as the crash alarm is given a stretcher party in charge of a medical officer proceeds to the scene of accident. The ambu lance is of special importance on stations where land plane flying is being carried on, and the equipment should be the same as the speed boat with the exception of the puhnotor. The hospital corps must be thoroughly instructed in stretcher and first aid work and the crash organization of the Medical Department must be such that in case of accident no delay is encountered. When the crash alarm is given, the stretcher party must immediately secure the necessary equipment previously assigned to them and if one member of the party is absent for any reason on that day, another hospital corpsman must automatically step into his place. On stations where land plane flying is carried on, the fire depart ment of the station must also be connected by an alarm system to the tower. On some stations chemical fire extinguishers are con stantly kept within the vicinity of the flying field. If the field is a very large one, it should be divided into certain numbered areas 316 Vol. XX, XEVBERUER AVIATION ACCIDENTS. and the alarm should be given according to number. Ever}' one will then know the approximate location of the crash. Aboard aviation ships the organization is made up along the same lines. Lookouts are stationed on the bridge and a bell system is connected with the sick bay and the speed boat. It is advisable to have the sound of the alarm different from the one used for other drills on board, such as general and fire alarm. Life preservers are standard equipment in United States Navy boats, and in a crash it may become necessary for men to dive overboard to drag the ex hausted pilot out of the wreckage. These life preservers should be repeatedly inspected and kept in good condition and in easily acces sible places in the boat. The pulmotor is indispensable 1 and it also must be repeatedly inspected by the medical officer himself. The rubber in the bag has a tendency to rapid deterioration, especially at sea, and spare ones should be kept on hand. Without a good rubber bag the pulmotor is useless. Tbe first-aid bag, in addition to a surgical instrument set, must contain the following essential articles : 1. Morphine solution (ready for injection). 2. Aromatic spirits of ammonia. 3. Hypodermic tablets and sterilized hypodermic syringe. 4. Bottle of sterilized water. 5. Picric-acid solution, 1 per cent in strength. 6. Tourniquets, six in number. 7. A bottle of chloroform or a can of ether and a face mask. 8. Six large shell-wound dressings, six first-aid packages. 9. Sterile gauze and bandages. 10. A bottle of grain alcohol. Regarding the alcohol, a great number of men who were in crashes and who have been in the water for some time invariably asked for some sort of drink. Alcohol makes a very unpleasant beverage, no matter in what manner it is administered, and it is believed that whisky would make a better substitute. Even admitting that alcohol may be just as good as whisky, as far as the physiological action is concerned, it tastes very bad and does not produce the same psycho logical effect as whisk}', and the effect of the crash on the patient's mind is something to be reckoned with. It must be remembered in making up the above first- aid outfit that as many as four or five persons may be injured in one crash. In addition to the pouches in the boat and in the ambulance, another one should be in readiness for the medical officer, should.it become nec essary for him to go to the scene of the accident by airplane. 1 It la doubtful if the pulmotor is as advantageous as the Scliaefer method of artificial respiration In the resusitation of the apparently drowned. [Kd. ] No. 3. 317 NEUBERGER AVIATION ACCIDENTS. The tool kits should contain the following: 1. Two strong wire cutters. 2. One saw. 3. Two crowbars. 4. One hammer. 5. Two axes. 6. One strong cloth-cutting scissors. 7. A long, strong knife. These implements are necessary, as the pilot may be pinned under the wreckage, and difficulty is experienced in extricating him. Great caution must be exercised in doing so, as a simple fracture may be converted into a compound one by careless handling. In case of fire, this point must be disregarded and the man rescued without the slightest delay, regardless how extensive his injuries are. It is the only chance of saving him. While the first-aid organization of the medical department is at the scene of accident preparations must be made to receive the wounded in the operating room, where every thing must be by previous arrangement in readiness to perform the most complicated surgical operation. Every available facility for treating a severe case of burn, such as warm bath with the neces sary medicinal solution of bicarbonate of soda or acetic acid, must be got ready. As stated above, it sometimes becomes necessary to go to the scene of accident by either a sea or land plane. The F5L type of plane can be very readily used to go to an accident at sea. It has plenty of room for carrying two Stokes stretchers. To go to a land-plane accident is not always possible, on account of the difficulty in land ing. However, numerous land-plane ambulances are being developed in the United States, England. France, and Italy. The English are using these ambulances for expeditionary purposes. It is stated that France is organizing squadrons of air ambulances for rapid transportation and use in time of emergency. Goggles. —The question of goggles in relation to the prevention of aviation accidents is a very important one. If the eyes of the flier are not properly protected his usefulness as a flier will soon be at an end, and improperly constructed glasses are liable to lead to crashes and disaster. A number of goggles are in use, but none of them are entirely satisfactory in every respect. An effort is being made at present by the Navy Department to obtain a satisfactory goggle. A board has been appointed by the Chief of the Bureau of Aeronautics and a letter was sent out to all aviation activities for comment on the recommendation of this board. The bureau's letter and the writer's answer are given below. They are self-explanatory. 318 Vol. XX. NEUBERGER AVIATION ACCIDENTS. Navy Department, Bureau of Aeronautics, Washington, D. C, 19 July, ISiS. From : The Chief of the Bureau of Aeronautics. To: Commander Aircraft Squadrons, Scouting Fleet. Subject : Standard goggles. 1. The bureau has decided to adopt a standard type of goggles for aviation, and has appointed a board which recommends two types : (a) The present standard Navy goggles of resistal glass, except that a stiffener be placed in the webbing on the outboard side of each lens in order that the glass may be held away from the eyelashes. (&) No. 6 gogglette, as supplied by Meyerowitz & Co., of New York, except that the cloth nose bridge be replaced by adjustable metal nose bridge as in the other type of gogglettes. Furthermore, the lenses should, if possible, be made flat instead of curved, and should be of resistal glass. Before final decisidn, the bureau would like to have the opinion of the Com mander Aircraft Squadrons. 2. It is requested that reply be expedited. A. W. Johnson, Captain, V. S. N. By direction of the Chief of the Bureau. V. S. S. "Wright," Newport, R. I., August 19, 192S. From : Medical officer. Aircraft Squadrons, Scouting Fleet. To: Commander Aircraft Squadrons, Scouting Fleet. Subject: Standard goggles. Keference: BuAer Let.No.Aer-2-GB, 7-17, of July 19, 1923. 1. The Bureau of Aeronautics has appointed a board which has recom mended two types of goggles, namely, the present standard type of resistal glass and No. 6 gogglette, Meyerowitz, both with certain changes. 2. As the commanding officer, IT. S. S. Wright, has referred the letter men tioned in reference to this medical officer, he feels at liberty to express his views on this matter and set forth the type of goggles he considers best and the method by which they should be tried out and adopted for general use. 3. The board convened by the Chief of the Bureau of Aeronautics undoubtedly had considered all the advantages and disadvantages of all sorts of goggles and this officer therefore does not wish to go into all minor details of the structural make-up of them. But there are certain gross defects which are of great importance which if not corrected will eventually result in diminution of vision and Improper muscle balance of the eyes In fliers. This fact was noticed by fliers in this aircraft squadron during their long flight to Panama and a number of pilots are still suffering from the effects of long continued wearing of Improper goggles. 4. In the construction of goggles the following points should be taken Into consideration. (a) They should prevent strong currents of air coming in contact with the eyeball and its adnexa, should protect the eyes from dust, water and oil, insects, drying from wind, and exposure to cold. (If no goggles are worn, the strong air currents necessitate partial closing of the eyes and therefore causing a dim inution in vision.) (b) The lens should not obstruct the field of vision nor have any blind angles. No. 3. 319 NEUBERGER AVIATION ACCIDENTS. (c) The lens should be tinted, preferably yellow-green, as the colors absorb the light of short wave lengths and prevent ocular and nervous fatigue. (d) The lens should be nonshatterable. (With this statement, however, not all authorities agree, for reasons described later.) (e) The goggles must fit comfortably and should not cause undue pressure upon any portion of the head. (f) They must have ventilating space in order to prevent the formation of vapor at ordinary altitudes and the frosting at high altitudes. 5. The goggles recommended by the board have some of the above require ments but not nil of them. The writer is acquainted with both types men tioned and lias worn them repeatedly on flights. The reslstal type was worn by him on a long flight from Panama to Corrientes Bay, Cuba. It was no ticed that these goggles caused undue pressure on the head and could not be adjusted in such a manner as to relieve the pressure. The pressure was especially marked over the bridge of the nose and on the supra-orbital ridge. They also decrease the field of vision to a more marked extent then is ordi narily realized by the pilot. In order to obtain a good side view, one must turn his head. While the angle may be small close to the eye, this angle increases the further it extends from the original field of vision, and this obstruction to the field may prove of grave consequence to the pilot during battle. This medical officer has discussed this particular point with numerous pilots and we tested it out during a flight and found that the difference between the field of vision without goggles and the field of vision with goggles (resistal type) was almost an inch at the side of the head. Another point of im portance is that the present lenses tire the eyes greatly, which is either due to nonabsorption of short wave lengths or the improper focus of light rays, caus ing a fatigue of the eye muscle. This fatigue has been noticed by almost every pilot who has made a flight of long duration. (The pilots of the NC-1 in the trans-Atlantic flight spoke to the writer about this very point). Regarding the gogglettes No. 6, Meyerowitz, I do not consider them satisfactory under their present construction, their greatest disadvanage being rubber and metal fit tings which are uncomfortable and which chill the eyes by radiation in cold weather and at high altitudes. 6. In view of the above, this medical officer recommends a goggle be con structed of the following type : (a) Two large pieces of resistal glass (lens) inclosed in a metal frame rein forced by a large layer of wool padding. The lenses should be curved and large enough to obtain exactly the field of vision of the normal eye without lenses. The glass does not necessarily have to be of nonbreakable material, as ex perience has shown that injuries to the eyes when breakable glass is used are extremely rare. However, they can be made nonbreakable as an additional precaution, but it is not considered absolutely necessary. The lenses should have a yellow-green tint, but many pilots object to this coloring, claiming that they have difficulty in recognizing uniforms and in selecting the proper place in a forced landing. In such a particular case of emergency, the writer sees no reason why the pilot should not remove his goggles for a few minutes. Another point looms up in connection with the glass itself. The writer has noticed that many flyers have refractive errors, either myopic, hyperopia, or astigmatic. This condition is soon going to be of great importance to the Bureau of Aeronautics. It is a well-known fact in medicine that changes in "ccommodatlon take place with age. The question will then arise, will these Pilots be allowed to fly with corrected glasses or are they to be relieved from flying? If the latter, it will be a distinct loss to aviation. It is believed that 320 Vol. XX. NEVBERGER AVIATION ACCIDENTS. a glass with the refractive error corrected could be worn by pilots, and the officers who have u small refractive error could have special glasses fitted for theiu, and while it is rather expensive, certainly would save their eyes and may prevent a serious accident. The writer wishes, however, to state emphatically that he is only referring to small refractive errors. (6) The metal around the lens should be of the same material as used on the present type, but should be curved and fit closely to the lens. if) The nose bridge should be of metal and adjustable. This is a very important point, as the interpupillary distance varies with different individ uals. The padding should be of wool, but thicker than in the present resistal goggle. Tills thick padding would prevent the glass from coming too close to the eye. A stiffener can he placed in the webbing on the outboard side of each lens, but it is believed that this stiffener will not prevent the pressure upon the inner side of the supra-orbital ridge, hut a thick wool pad would prevent the pressure. 7. If the bureau intends to supply goggles which will ultimately lie of the greatest value, it is recommended that a certain number of a certain type be constructed and these be sent to the air forces for a try out. If they are satisfactory, they could then be adopted for general use : and if not, such improvements as are advisable and necessary could lie made. The writer does not believe that the goggles described in the bureau's letter will tie entirely satisfactory nor much of an improvement over the present type of resistal glass. He recommends that a small number of goggles of various types be constructed and tried out by the pilots and flight surgeons and the one which proves most satisfactory be adopted. The writer wishes to empha size that goggles are the most important equipment of an aviator, and this matter should be given deep consideration und some actual experiments should lie conducted along this line. J. F. Neuuebueb. Aibckaft Squadrons, Scouting Fleet. U. S. S. " Wbight," Flagship. Newport, R. I., 25 September. 1923. From : Commander Aircraft Squadrons, Scouting Fleet. To : The Chief of the Bureau of Aeronautics. Subject: Standard goggles. 1. Forwarded for the consideration of the bureau. The recommendations made by Lieutenant Xeuberger (MC), United Stutes Navy, in paragraphs 6 and 7 of his letter, to which this indorsement is appended, are concurred in. It is requested that the bureau take action accordingly. W. R. Ghebabdi. Ear protection. —The best method (if protecting the ear during flying is still a question, although many devices and substances are being used and have proved quite satisfactory. A number of pilots do not use any protection for the ears, which practice, it is believed, will eventually result in injury to the ear, especially in flying twin- motor and pusher types of planes. Not only does one sutler from temporary deafness, which may become permanent, but also infec tions of the external auditory canal and accumulation of wax, which cause a great deal of annoyance, are frequently found. The No. 3. 321 NEUBKRGER—AVIATION ACCIDENTS. wax becomes very hard and forms an obstruction to air currents. The Eustachian tube becomes involved, producing a train of un pleasant symptoms, such as tinnitus or ringing in the ears, dizziness, giddiness, pain, and diminished hearing. In the pusher type of planes, even though the ear is properly protected, a marked but temporary deafness is experienced. The writer on frequent occa sions after riding in an HS2 type of plane (pusher type), even after short flights, experienced marked disturbance in hearing. After long flights the deafness lasts from 24 to 36 hours and sometimes longer. All sorts of devices and chemical substances have been recommended, and after practically trying out all of them in this squadron we found only two things of value, namely, ordinary absorbent cotton, which is being used by the majority of fliers, and a second prepara tion made up in the form of a suppository, consisting of beeswax, lamb's wool, and parasine. This suppository has been found very useful. If it is held in the hand for a few moments before inserting it into the ear, it softens and it then can be shaped to fit the external auditor}7 canal. The consistency of this suppository varies with dif ferent seasons of the year. In winter we use one part of beeswax and five parts of parasine and a few strands of lamb's wool, and in summer two parts of beeswax and four parts of parasine and lamb's wool. This combination seems to be the best one we have at present. No one should fly without protection of some sort for his ears. The constant humming of the motor not only affects the transmission apparatus, but actually produces pathological changes in the internal ear and perception apparatus. If the cells in the internal ear, having become detached from their basic membrane, are not given an opportunity to regenerate, permanent injury is going to take place, resulting in marked diminution of hearing. Safety helmets. —Safety helmets are of great value, especially in aviation training schools. At the naval air station. Pensacola, two types of safety helmets are being used, one for instruction purposes and one for the student to wear for solo. Both helmets are made of thick heavy leather. The helmet used for instruction purposes Is known as " Gosport " helmet and differs from the other or crash helmet only in the attachment of a voice tube and two receivers for the ears. The instructor can, by means of this attachment, communi cate with the student and give him necessary orders. The student signals by means of his hands whether or not he understands the instructions. The student can not talk to the instructor, which is very often quite fortunate for both of them. Both helmets are so constructed that they can be made smaller or larger, but at best they are extremely uncomfortable by exerting a great deal of pres sure upon certain head surfaces. After an hour's flight, they pro duce headache and make one feel extremely miserable. These helmets 322 Vol. XX, . NEUBERGER —AVIATION ACCIDENTS. were being tried out at the time the writer took instruction at Pensa- cola. It is believed that they are of great value, provided improve ment is made in them with the view of relieving the pressure upon the head and making them in general more comfortable for wear. In a crash, they certainly help to prevent scalp wounds, and the side flaps protect the ears from injury. On one occasion, the crash helmet was responsible for the saving of a student's life, when he walked into a propeller. The blow from the propeller split the helmet and caused a slight scalp wound. There was no doubt in any one's mind who saw the accident that the helmet prevented a serious if not fatal injury. The helmets are worn only at training schools. Pilots engaged in other activities do not use them. Instead, a soft, fur-lined helmet is used in winter and a plain soft one in summer, and they are considered quite satisfactory at reasonable altitudes, with the exception that they afford no protection from the sun. Some of the pilots have leather visors stitched to the helmet, extending ai an angle over the goggles, and these visors are of particular benefit when flying in tropical countries. Crash Bars and Safety Belts.—A crash bar is a thin, soft-leather cushion, extending from one side to the other of the fuselage about the middle of the pilot's cockpit. When the pilot is seated in the cockpit, the bar is about parallel with the infraorbital ridge or eyeballs. These crash bars were installed on all training planes. It was found on investigation of numerous crashes that the students most frequently sustained face injuries, either to nose, forehead, tongue and lips, by falling forward onto the cowling on the impact of the machine on the ground or on the water. However, the writer never had any faith or confidence in these crash bars. It has al ways seemed to him that the force of the impact would be sufficient, should the pilot's head strike the crash bar, to cause a fracture of the cervical vertebras, which would be a much more serious injury than a cutting injury to the face or the head. One accident did occur on the station in which this exact injury was sustained. I have always believed that this man's fracture of the cervical verte brae was due to the tremendous force with which his head hit this crash bar. He went into a nose dive from about 3.000 feet and most likely the crash would have proven fatal even though he had not sustained the injur}' in question. These bars are not being used, as far as I know, anywhere else, but are still being tried out in Pensacola. It will be interesting to watch the results. A better substitute for the prevention of injuries to the head and face, caused by falling against the cowling or instrument board, would, in my opinion, be a properly constructed safety belt to be worn around the chest. The belts in use at present are worn around the waist. No. 3. NEUBEKGER—AVIATION ACCIDENTS. 323 It is also claimed by many that the waist safety belts are very liable to cause abdominal injury. The writer believes that the ideal belt would be a broad and resilient breast belt, attached to the frame work of the fuselage, and so constructed that it can be easily and quickly released. However, be it waist or breast safety belt, all pilots in single-motor planes should wear either one or the other and should put them on and secure them properly before leaving the ground. They should also know and practice how to release these belts quickly. In several accidents the belt was found to have given away. Therefore, strong but resilient cloth should be used in their manufacture. Both waist and breast safety belts are worn by some pilots. Another measure for the prevention of face and head injuries would be a padding around the front cowling of the cockpit. Not very long ago two pilots were in a collision about 2,500 feet in the air and both planes were so badly damaged as to make them uncontrollable. One of the pilots tried to climb out of the fuselage on to a wing and as his plane crashed he was killed. The pilot in the other plane had sufficient presence of mind to take the cushion from under his seat and hold it with his left arm against the front cowling of the cockpit. When he crashed, the only in jury sustained was a fracture of the left arm with which he was holding the cushion. Clothing. —The question of clothing has caused a great deal of argument and also embarrassment. A special uniform for aviation personnel existed up to July 1, 1922, at which time it was abolished by order of the Navy Department. Only the regulation blue service dress is supposed to be worn. This is almost an impossibility. After wearing a blue uniform on one or two long flights, it is ready for the discard. Certainly it can not be worn any more for Saturday morn ing's inspection or for any other occasion on which one is supposed to appear presentable. Of course, the order is being carried out without any question. The writer is not aware of the reasons for the abolishment of the original uniform, the only one suitable for actual flying. It was a forestry-green uniform, of heavy material, did not soil very readily, had a standing collar which kept the neck warm, and in general was well suited for aviation purposes. Dun garees are thin and do not keep the body warm. It is to be remem bered that the temperature of the air becomes 1° Fahrenheit colder for every 365 feet of climb, and at high altitudes very ex treme cold has to be endured. Clothes alone have been found at very high altitudes to be insufficient as a protection against the ex treme cold, and the warming of clothes by electrical means has been tried. But even at ordinary altitudes in certain seasons of the year extreme cold is encountered and a good, warm, serviceable uniform 326 Vol. XX. NEUBERGER AVIATION ACCIDENTS. Life preservers must be provided for every man aboard, in handy places and frequently inspected to assure their good condition. Food rations and water sufficient for two days for the comple ment of the plane must be provided. The rations in this squadron consist of the following per man : 1 pound baked beans. 1 pound brown bread. 1 quart water. This food ration is absolutely essential for large planes making long cruises over water. However, smaller land and sea planes must also be fitted with the above-mentioned necessities. That the above articles of food are necessary may be seen by a glance at the illus- I ration. Figure 11, in this article. This picture shows a land plane forced down at sea, but in this instance the pilot fortunately made his landing in proximity to a number of ships. All aviation personnel going on extensive cruises should wear the standard Navy identification tags. The wearing of these tags is considered by everyone more or less of a nuisance, but in organiza tions whose activities are almost entirely confined to the sea the wearing of tags is an absolute necessity. The Navy Regulations re quire that these tags be worn around the neck or around the wrist. However, the neck and the wrist are not considered the best places by many who know from experience, and it was suggested to the writer that the best place is around the waist. However, they should be worn as required by the United States Navy Regulations. If the individual desires to wear one around his waist, an additional tag can always be secured from the Medical Department. A great deal of difficulty is experienced by medical officers in case of serious or fatal accident in finding any information regarding the family of the individual to be notified in case of serious accident as required by Navy Regulations. It is true that the health record should contain the necessary data, but many officers change their address and fail to change it on their records. The writer has had several such experiences and he recommended to the commander air squadrons, Scouting Fleet, that an emergency slip (given below) be filled out by every officer and enlisted man and same be kept in the safe of the commanding officer. This emergency slip is confidential and is never referred to except in case of serious accident. If the pilot is transferred, ho calls for the slip and takes it with him to the next station. 3.Y.—2 »— 9ZS 3dCH3AN3 Nl «V31 Sn03NVXNCdS CI 300 QNV1 NO STBIOIdlQ dO QNIQNV1 QSOaOd— 81 '3|d ■«31VAA Nl SNIONVT asoaod v oniiviisssosn snaioidia v do 3dOi3AN3 shi ni av3X— n 'Sid \o. 3. 327 NEUBERGER —AVIATION ACCIDENTS. U. S. S. " Wbioht." From : To: Subject: Statement regarding wishes in case of serious or fatal accident. 1. Notify by telegram. Name. Relationship. Address. 1. 2. 3. 2. I request that _ inventory my effects. 3. I request that all my personal effects and papers be delivered to : Name. Address. Name. Address. 4. My life is insured in the following companies : Name. Location of policy. 5. I have accounts at the following banks : Name. Location of bank and check book. 6. 1 have safe deposit boxes at (name of location) : 7. I have a will at (location) : Note. —This certificate is confidential. Any other Information you would like to give, please do so In space below. Note. —Seal envelope and mark: From (John Smith) Lieutenant, to Com manding Officer, U. S. S. Wright.— Confidential. To be opened In case of serious or fatal accident. [Call for snuie In case of transfer.] High altitudes.—There is another important question in aviation which is a medical problem, namely, the effect of decreased amount of oxygen at high altitudes and of extreme cold upon the human body and the human mind. This is a subject in itself, and the writer hopes, as development of aviation medicine progresses, to gain some additional information and data on the effects of decreased oxygen supply on man, air sickness, altitude sickness, and staleness, and report on same some time in the future. Investigation of accidents. —It was surprising to note the different opinions regarding causes of accidents given by different observers of the same accident. One would give the causes as error in judg ment, and another would call it a skid, a slip, or something else. 78693—24 4 328 Vol. XX. NEUBERGER AVIATION ACCIDENTS. The writer has witnessed quite a number of accidents, and on each occasion, if there were 10 officers standing by watching it, there would be 10 different theories and opinions. It is believed that every accident should be thoroughly investigated. The board of investiga tion should consist of experienced aviation officers, not less than four in number, and one flight surgeon. The importance of this investi gation is not whether the crash occurred In the line of duty and how seriously the pilot was injured, but to find out what were the real causes of the accident. The information thus obtained should be utilized for the prevention of a repetition of the same accident. The medical officer should investigate the pilot's past medical record, find out if an accident occurred previously, whether waivers were granted for certain physical defects, what the psychological rating was at the time of the last physical, as well as previous physical, examina tion. Too many accidents are listed as "unknown." Only by thor ough and painstaking investigation can we learn any lessons and prevent the occurrence of the same accident over and over again. The writer expects that this article will call forth a lot of criticism and many will not agree with everything he has stated. He hopes such is the case. As an answer I wish to quote the words of Lieut. Page O. Northington, Medical Corps, United States Navy, who once wrote : It is a matter of ordinary medical observation that whenever man's genius and accomplishment provide a new vocation in a heretofore unaccustomed environment there is inevitably an accompaniment of its own peculiar ills and medical problems. That this country through the Army was first to establish a research laboratory and school for the purpose of investigating those pe culiar conditions to aviation and providing measures consistent with the best physical welfare of the aviator is praiseworthy and creditable. We would be credulous, however, in thinking that the present standard of qualification Is immutable and that the problems of care and classification have been solved to the ultimate satisfaction and best Interest of those concerned, and more over, it would be erroneous to maintain that in the field of application, other than partially beneficial results have been accomplished from the present accessible knowledge of medical aviation problems. As we know, the his tory of our service Is a noble one; honored traditions and customs have developed and become an Important, Inseparable part of it. May there be, however, no devotion to precedent that does not bespeak a farsighted policy when there comes a time for innovation, application of new principles, and the enlistment of the cooperation necessary for the best ultimate results in any untried undertaking. If the above statistics will be of value and the suggestions I have given will be instrumental in saving one human life, I shall feel fully repaid for the difficult and sometime seemingly impossible task of collecting the data. Many times during the writing of this article, my memory brought back to me many unpleasant experi ences, recalling the deaths of such men as Chevalier, Roth, Null, No. 3. 329 NEUBERGER —AVIATION ACCIDENTS. Ericson, Armstrong, Blackwell, Harrington, Brumbaugh. Hill, Mc- Fadden, and many others, not mentioning those permanently in jured, many of whom were my closest personal friends. We mourn them for making the supreme sacrifice and pray for their everlast ing peace. But like real sailors and soldiers, we must carry on, appreciating the bravery of all who do continue, with the hope that our country will adequately reward all who help America's defense in the air. NOTES AND COMMENTS. AVIATION ACCIDENTS. Doctor Neuberger's article on aviation accidents and the methods of their prevention, appearing in this number of the Bulletin, will no doubt be of great value to the Medical Corps. The rapid advance of aviation activities in the fleet demands that " aviation medicine " become a part of the general information of every naval medical officer. Although the airplane carriers, aeronautic training sta tions, and airplane squadrons will require medical officers who have been specially trained as flight surgeons, it will be manifestly im possible to provide such officers for every division of the fleet using airplanes. Ability to detect evidence of nervous exhaustion in an aviator calls for considerable knowledge of aviation medicine and the methods of examination. Doctor Neuberger discusses the Schnei der index, which appears to be the most practical test at present for functional activity. The importance of determining the normal standard for each aviator as a guide for continued observation is self-evident. The relation between the nervous system and over fatigue has been long recognized, but it is well to know the symp toms. The safety of the ship may depend on the efficiency of the aviator. We can not afford to ignore the demands made on his ner vous system and must be prepared to recommend action by the com manding officer to prevent disaster. The pilot himself is usually the last to recognize his condition. Preventive measures that have been found of value in maintaining the best physical condition of the aviator should be known and instigated by the medical officer. To day the most important factor in aeronautics is the human element. Doctor Neuberger's statistics are conservative, for it has been stated by well-informed authorities that 70 per cent of accidents are due to staleness or physical conditions that could be avoided. Previous figures for the United States Navy for accidents since 1919 stated that 96 per cent were due to pilots and 4 per cent to machines. The United States Army Division of Military Aeronautics published in 1919 a very complete report of The Air Service Medical, and in the Journal of the Military Surgeon for September, 1923, there is an excellent article on the development of aviation by Lieut. Col. W. R. Davis, of the Army Medical Corps. In the same number of this 331 332 Vol. XX, NOTES AND COMMENTS. magazine there is an interesting description of the training of flight surgeons at Mineola by Lieut. J. D. Benjamin, Medical Corps, United States Navy, now attached to the U. S. S. Langley. The previous articles by Lieutenant Neuberger that have appeared in the Bulletin cover the subject of aviation medicine in a most compre hensive manner. Every medical officer should feel indebted to him for this valuable information. Doubtless many have believed that only those who are trained as " flight surgeons " will be required to know aviation medicine, and therefore have not considered it neces sary to make a special study of the subject. With a limited number of planes on any unit of the fleet, it is even more imperative that the few aviators attached be carefully observed. AIRPLANE ACCIDENTS FROM THE BRITISH VIEWPOINT. At the annual meeting of the British Medical Association in 1923, among many interesting papers presented to the section of naval and military hygiene, one on airplane accidents by Dr. H. Graeme Anderson, surgical consultant, Royal Air Force Medical Service, is of interest in connection with Doctor Neuberger's paper wh.-ch appears elsewhere in this issue of the Bulletin. The following extract of Doctor Anderson's paper is from the British Medical Journal of November 17, 1923 : " The points to be considered in classifying airplane accidents are, first, the causes; secondly, the type or in which part of the flight the cause was initiated; and, lastly, the actual damaging factor. CAUSES OF AIRPLANE ACCIDENTS. " These may be considered under the following headings : •'(1) Defect in the airplane. "(2) Error of judgment in flying. "(3) Loss of head. "(4) Brain fatigue. "(5) Fear. "(6) Physical illness. "(7) Unavoidable causes. "(1) This cause amounts to mechanical failure of some part of the airplane, and can be subdivided into (a) breakage in the air, and (b) engine failure. If the engine fails in the air a forced land ing is compulsory, but given a fair height —2,000 feet or more —the pilot can usually select a good landing place. One of the commonest examples of airplane accidents is engine trouble just after leaving the ground, and in trying to turn back the pilot loses flying speed and the airplane falls to the ground. So. 3. 333 NOTES AND COMMENTS. "(2) Error -of judgment in flying is the commonest cause of airplane accidents, and of the many examples of this, perhaps the commonest is when on landing the pupil misjudges his distance from the ground and strikes the ground at a varying angle, usually over turning and wrecking the machine. It is difficult to estimate and account for these errors of judgment. In some cases the error may be due to insufficient instruction, and in other cases it may be found on examination that the pupil's standard of vision is below normal ; but, on the other hand, the pupil may be physically fit, have normal vision and good balancing power, and in the latter cases it may be a case of delayed reaction times. "(3) Loss of head occurs fairly frequently and accounts for a con siderable number of accidents. The pupil in his new occupation of flying is at high tension, and under the sudden strain of an emergency his power to reason and act synchronously may momentarily lapse, and there is seldom time to correct the error made. " (4) In contradistinction to loss of head, the pupil in brain fatigue reaches the stage where he has neither the power to reason, decide, or act ; a state of mental inertia supervenes. This is due to repeated stimuli received by his brain in rapid succession in his flight—he feels alone and that he can not manage to control the airplane; he feels helpless, and in a stupor awaits events and takes little part in the airplane's control. As a rule, if it occurs, the pupil, even if he should escape injury, soon gives up flying; he is not of a temperament suit able for flying. "(5) Fear, at least in a degree sufficient to disturb flying, is rarely experienced in the air on the first few solo flights, the mind being far too much occupied and concentrated on details of flying and watching the various instruments. "(6) At an air station medical inspection of the pilots and pupils at regular intervals reveals any organic disease that might lead to loss of consciousness in the air. Flying on an empty stomach may cause faintness, and as in schools flying commences at dawn, all pupils are first provided with a good meal, while on long flights pilots are provided with tabloid forms of nourishment. "(7) From time to time unavoidable causes of accidents arise. The terrain in certain areas may be unsuitable and conceal obstacles, while in some airplanes the view of the ground in certain positions may be limited. "type of accidents. " The term ' type of accidents ' has been suggested to describe the part of the flight in which the cause of the accident was initiated. A flight may be divided arbitrarily into three parts : First, the get ting off the ground into the air; second, in the air, with the various 334 Vol. XX. NOTES AND COMMENTS. turns, figures of 8, spirals, etc.; and third, the landing. The com monest type of accident is on landing. "actual damaging Forces in airplane accidents. " The injuries sustained are akin to most high- velocity accidents, but are usually more severe, as greater speed is used in aviation. They include the following: (1) Injuries due to crushing, where some part of the pilot's body gets crushed between parts of the wrecked airplane or between the engine and the earth. (2) Injuries due to collision with the ground, as when the pilot is thrown out or hits the ground with his head in turning over in and with the airplane. (3) Injuries due to impact with different parts of the airplane, as when the head is violently jerked forward and strikes the edge of the nacelle on the airplane's impact with the ground, (i) Injuries from fire. (5) Drowning and immersion effects in seaplane work. (6) Suspension effects, as when the pilot is suspended head down ward in an overturned airplane and is unable to loosen his safety belt; in many crashes the sudden impact of the pilot's body on the safety belt causes abdominal injuries. (7) Poisoning from petrol fumes. " safety belts, helmets, and goggles. " With regard to the use of safety belts, endless discussion has taken place among aviators. My own opinion is that before leaving the ground all aviators should see that their safety belts are fastened and should be familiar with the method of their quick release. The belts should never be undone in the air, but a difficult question arises whether to release the belt near the end of a glide before landing. Safety helmets are of undoubted value in school work and should be worn by all pupils. In a crash they certainly prevent scalp wounds and the side flaps protect the e/irs from injury. Most aviators wear goggles, but there are still some who prefer to fly without them. I personally think that goggles should always be worn; there is no doubt that flying without goggles is apt to set up a spasm in the eyes. " first Am at an air station. " The sick bay or dressing station should be in full view of the airplane, with a lookout man supplied with field glasses always on duty during flying hours. Immediately a crash or forced landing occurs the lookout man telephones to the sick bay, notifying the steward of the exact site of the occurrence, and proceeds with a stretcher to the accident. With the stretcher is taken an emergency tool case, which includes crowbars, wire cutters, saw, fire extin guishers, etc. The steward dispatches the ambulance with which No. 3. 335. NOTES AND COMMENTS. two sick-berth attendants go, and with them is a bag containing morphine, hypodermic syringes, chloroform, brandy, first-aid and picric acid dressings, etc. If the injured person is conscious and in much pain morphine should be injected and the patient conveyed quickly to the dressing station, where his injuries should be examined and treated ; chloroform may have to be given, as it acts more quickly than morphine. " THE NATURE OF THE INJURIES RECEIVED. " Surgical work in connection with aviation in general differs but little from that in military and civil life. The difference is mainly one of degree, in that one is mostly called upon to deal with the lesults of high-velocity accidents associated with falls at varying angles and from various heights. Burns are among the most severe forms of injury. The cold at high altitude is extreme, and aided by the rapid transit through the air is apt to cause frostbite easily. In a large proportion of airplane accidents the occupants receive injuries to the face, owing to the impact throwing their heads for ward. Fractures of both bones of the leg and fractures involving the ankle joint are very common." THE ESTIMATION OF PHYSICAL EFFICIENCY. The estimation of physical efficiency is an ever present problem in aviation medicine. A paper recently read before the section of Naval and Military Hygiene of the British Medical Association by Uroup Captain Martin Flack, Royal Air Force Medical Service, con tains, according to the British Medical Journal of November 17, 1923, the following remarks on the chief points to which attention must be paid in the assessment of physical efficiency and bodily en durance, namely, (1) respiratory efficiency, (2) circulatory effi ciency, and (3) general nervous stability, as regards control through the centers of respiration and circulation and cerebral and psychical control. " Respiratory efficiency. —The practice of measuring the upper chest expansion on inspiration should be abolished or at least com bined with a measurement at the level of the floating ribs, which is more important. Correct inspiration consists in the contraction of the diaphragm attended with an upward movement of the lower ribs, and is the type prevalent in individuals who possess the greatest bodily endurance. If inspiration be properly performed correct ex piration naturally follows, but it should be borne in mind that ex piration is under muscular control, and it has been shown that it is. on the expiratory rather than the inspiratory side that individuals 336 Vol. XX. NOTES AND COMMENTS. tend to fail as the results of strain. With regard to the value of spirometry in the assessment of physical fitness there is no doubt that the usual instrument gives very inconstant results, and there is, moreover, still a divergence of opinion as to what constitutes the normal vital capacity. It is, however, a distinct advantage to be able approximately to estimate the vital capacity, and for this purpose the author compares Dreyer's tables with one prepared from the results of Cripps, Greenwood, and Newbold. In this way an idea is obtained as to what vital capacity should be for the standing height, sitting height, weight, and chest circumference of the individual in regard to Dreyer's figures. The vital capacity should equal his class A, or, preferably, exceed this class by 300-500 cubic centimeters. When the vital capacity falls much below this, respiratory insuffi ciency is certainly present. Observation proved that officers who could not fly high possessed a small vital capacity, and especially those who were suffering from flying strain. In the latter the diminution in vitul capacity was shown to be to an inability to expire sufficiently to empty the lungs to the full extent. The fit individual is possessed of a good vital capacity mainly because he has this power of ade quately emptying his lungs by expiration. In the individual who is respiratory inefficient the vital capacity is considerably reduced by prolonged physical effort and his ' ventilation capacity ' is de creased (residual air increased, and the ratio of vital capacity to residual air diminished). Thus the respiratorily fit person is one who, in response to physical effort, is able to maintain his ' ventila tion capacity ' at a relatively high level over the whole period of performance. Diminution in ventilation capacity further involves a relative increase of carbon dioxide and decrease of oxygen in the alveolar air. "The partial pressure of carbon dioxide and oxygen plays a con siderable part in determining the time over which an individual can hold his breath. In the fit subject it requires a considerably greater diminution of the partial pressure of oxygen to induce symptoms of respiratory instability and circulatory embarrassment (violent desire to breathe, quickened heart rate, increased blood pressure, congestion of the face) than in one who is suffering from fatigue or lowered efficiency. Similarly with an increased percentage of carbon dioxide, both the 40 millimeter Hg test and the breath- holding test may, therefore, be taken as affording indications of the ventilation capacity of the individual and of his susceptibility to changes in the alveolar partial pressures. Stable control by the respiratory center is an important factor in bodily endurance, and the above tests are of value in assessing respiratory efficiency in this respect. In an individual of adequate respiratory capacity the time .No. 3. 337 NOTKS AND COMMENTS. of holding the breath without undue discomfort is, in the breath- holding test, 69 seconds; in the 40 millimeter Hg test, 50 to 55 seconds. The expiratory force test is of value as showing the con dition of the expiratory musculature; generally respiratory insuffi ciency is indicated when the reading falls below 110 millimeter Hg, and it is certainly significant of general physical inefficiency when it fails to reach 80 millimeter Hg. "Circulatory efficiency. —A pulse rate, at rest, above 84 (not due to temporary excitement) is characteristic either of nervous insta bility or of physical insufficiency. As regards the latter, it was found, for instance, that by special exercises for one month the average standing pulse rate of number of 'weedy' recruits was re duced from 95 before training to 79 after training. A quick pulse rate (96 or above) is frequently an expression of nervous instability, particularly a quick pulse associated with a respiratory rhythm. Such persons are not, generally speaking, suitable for arduous-serv ice duties, and frequently break down. "The arterial pressures afford important information. If in the absence of any clinical signs of disease in a person of 20 to 25 years * of age, the systolic and diastolic pressures are persistently high and the pulse pressure exceeds 50 millimeter Hg (for example, SP 160, DP 104, PP 56), the individual may be regarded as having a 'nervous temperament' and as not likely to stand great physical and mental strain. In certain cases such pressures are due to ex cessive indulgence in alcohol over a prolonged period, and the other tests for physical efficiency, particularly those for nervous stability, will then be found to give unsatisfactory results. As regards low diastolic pressures, one below 70 millimeter Hg combined with a pulse pressure of more than 50 millimeter Hg is indicative of lack of physical stamina for flying duties. Such subjects are particu larly liable -to faint in the air and the same holds true to a less extent as regards physical endurance on the ground. The fit indi vidual is one in whom the margin of fall of the diastolic pressure is in the neighborhood of 30 millimeter Hg (that is, a diastolic pressure of 80 millimeter Hg) before the fainting pressures is reached. In subjects with a low diastolic pressure a contributory factor of great importance, and one that is insufficiently appreciated, is the accumulation of blood in the abdominal veins in the upright posture. In this condition the systolic output is reduced and becomes insufficient to maintain an adequate diastolic pressure, although the arterial systolic pressure remains normal. As affording information of this condition the pulse response during the 40 millimeter Hg test is of great service. In a fit subject there is little alteration of the initial pulse rate over a period of 50 to 60 seconds, and the 338 Vol. XX, NOTES AND COMMENTS. arterial pressures are not greatly raised (30 to 40 millimeter Hg to 160 to 170 millimeter Hg). In the less fit, on the other hand, the test produces a greater and more rapid elevation of the arterial pressures (for example, to 180-200 millimeter Hg), while the pulse rate rapidly increases to 120-130 or more. This increase is main tained when the total rise of pressure is not abnormally high, but is' succeeded by a marked and often abrupt fall of pulse rate when .'the arterial pressure is increased to a high point —for example, 220-240 millimeter Hg, a point which appears to be constant for each individual. The fall is possibly due to reflex slowing of the heart rate owing to stimulation of the depressor nerve endings in the aortic arch through raising of the blood pressure due to the in creased flow of blood to the right side, caused by the abdominal effort necessary to sustain the column of mercury. "Certain subjects display a combination of these results as regards arterial-pressure readings—namely, a high systolic and a low dias tolic pressure; for example, SP 150, DP 60, PP 90. Such individuals are 'highly strung' as regards nervous stability and markedly ineffi cient as regards physical stamina. From the point of view of air work, such subjects present an interesting response to rotatory move ment; when they are rotated 10 times in 20 seconds the pulse is greatly increased in rate, the SP pressure rises but the DP falls, and fainting may ensue. In certain individuals who are relatively physi cally efficient the rotation induces a marked rise of both systolic and diastolic pressures, and such individuals are probably liable to suffer from nausea and vomiting in the air. "The abdominal wall plays an important part in counteracting the influence of gravity in producing abdominal venous congestion in the upright posture, and it is impossible to overestimate the im portance of a good-toned, mobile abdominal wall in maintaining effi cient circulation and respiration and thereby preserving physical efficiency. "When the abdominal wall is lax and ineffective the supply of blood to the heart during exercise will be insufficient, owing to the large abdominal pooling of blood, and the heart will therefore, to meet the demands of the body, be obliged to pump a relatively small supply of blood at a quicker rate. Such increased heart rate is frequently regarded as a sign of myocardial insufficiency, whereas in many such cases it is due to an efficient heart making the best use of a poor supply of blood. Such a condition is often found in persons who have returned from the Tropics. "The ill effects of gravity are further counteracted by the tonic- contraction of the splanchnic arterioles. Information as to the tone of these vessels is afforded by the pulse when the subject rises from No. a. 339 NOTES AND COMMENTS. the sitting to the standing posture. Generally speaking, it may be taken as true that the greater the increase in pulse rate, and the more prolonged the quickened rate, the greater the insufficiency. " Circulatory efficiency may be assessed as follows : ( 1 ) A normal steady heart beating about 72 a minute, not unduly increased in rate by exercise and returning quickly to normal steady rate. (2) A pulse pressure of 40-50 millimeters Hg associated with a well-sus tained diastolic pressure (about 80 mm. Hg). (3) Absence of abdominal pooling in the venous reservoir due to the effects of gravity on the circulation owing to poor tone of the abdominal belt of musculature. > " Stability of general nervous control.—The importance of stabil ity of the circulatory and respiratory centers in the maintenance of physical efficiency has been indicated above. General nervous stabil ity plays a great part as regards bodily endurance. The tests em ployed in the Royal Air Force are considered to be sufficient to reveal the condition of physiological or psychical control. Thus tremor is evidence of some disordered functional state. Tremors of the eyelids alone are usually indicative rather of a highly strung disposition or the result of legitimate stress, such as overwork or strain of occupation ; tremors of fingers and hands rather of illegiti mate stress, such as excessive indulgence in tobacco or alcohol ; while tremor of both eyes and fingers generally signifies nervous instabil ity due to a combination of the above causes. As regards the knee jerk, a so-called brisk or exaggerated response is not in itself neces sarily an indication of nervous instability, but a condition not infre quently called 'exaggerated knee jerk,' attended by a convulsive movement of the whole body, indicates loss of general control and has nothing to do with tendon reflexes. This ' exaggerated knee jerk ' is usually associated with a state of anxiety, conscious or subcon scious. The tests of standing on one foot with the eyes closed and of balancing a rod on a flat board elucidate the condition of central control rather than the condition of 'muscle sense' or 'vestibular stability"; failure in them, therefore, indicates some want of afferent or efferent control. "In many instances it is the failure of the control through the medullary centers which predisposes to breakdown of the higher centers." THE AIR AMBULANCE IN WAR. According to the British Medical Journal of October 20, 1923. Air Commodore D. Munro, in his presidential address to the war section of the Royal Society of Medicine on October 8 last, discussed 340 Vol. XX. NOTES AND COMMENTS. the possible uses of the airplane in the medical services in future warfare. " The history of the air ambulance, he said, began necessarily with improvisations, by which he meant the temporary use of an ordinary service airplane to carry sick and wounded, either with no special arrangements at all or only primitive ones, or with a special kind of stretcher adapted to the machine, or a special adaptation of the ma chine to take the ordinary stretcher. During the retreat of the Serbian Army in 1915 the French made some arrangements for air convoy of wounded. At the end of 1920 the French in the Levant organized an air ambulance in which 80 cases were carried to hos pital during a period of four months. For this purpose the ma chine guns were removed from airplanes and the patients strapped in their place. In May, 1923. during an epidemic of dysentery among the British forces in Kurdistan, 198 cases were conveyed by air to Bagdad. The distance was 100 miles as the machine flies, and was much longer by mountain track, which would have had to be taken had the airplanes not been available. The operation was difficult owing to bad weather and the lack of suitable landing places, but it was carried out quite successfully in 98 flights; the time oc cupied in the evacuation was 128 hours 45 minutes. Unfortunately the only airplane specially designed for this work had to make a forced landing and was put out of action, so that the task was com pleted by improvised machines. The special kind of stretcher used with the service airplane was of a naval pattern, adapted to air plane purposes by the use of an extra lining. It consisted of bam boo sticks in canvas, with a head cushion, a blanket cloak, and a head and face mask. The squadrons in Egypt and Iraq were now supplied with these stretchers for use in emergencies. They were strapped onto the fuselage, and the machine-gun fitting was used for fixing in position. If necessary, two patients could be carried in the one machine. " The adaptation of the airplane itself to accommodate the or dinary stretcher was carried out during the Somaliland expedition of 1919-20, when a machine, known among the troops as the ' blood- wagon,' was altered so as to take one stretcher and an attendant. The French in Syria and in Morocco had a regular service of such adapted machines, and it was reported to the French Colonial Con gress of Public Health in 1922 that in the former country 105 cas ualties and in the latter country 168 had up to then been conveyed in this manner without mishap. In 1921 the French Minister of War put into commission a type of machine which carried two ■stretcher cases, a doctor, and a nurse, and had a roomy cabin where emergency operations could be performed, for which apparatus and equipment were installed. In the British designs there was no pro- \ No. 3. NOTES AND COMMENTS. 341 I vision for the performance of operations, but chief attention was paid to suitable seating accommodation. In the Vickers- Vernon air plane two stretchers were run in on rails through the nose of the machine, and there was provision for seating eight patients on deck chairs arranged along the inner wall of the fuselage. There was provision also for an ice and food box, sanitary conveniences, and an electric kettle and sterilizer. The machine was well venti lated, smooth-running, and the engine note not disagreeable. There were three of these machines at present established, and the number was being increased; another type was in building, to take two stretchers, and to be specially suitable for going out to the scene of a crash in such a country as Mesopotamia. In future these air ambulances would have their own medical personnel, and mechanics and pilots would be told off for them. In warfare it would be pos sible to form aerial convoys for use between the front and the base hospital, and the method would suggest itself particularly for the bringing in quickly of abdominal and head casualties." GAS WARFARE IN THE AIR. The possibilities of gas warfare in the air is pointed out by Mr. Ernest Jones in the following article which appeared in Interna tional Aeronautics of September, 1923: "The carrying chemical warfare into the air is a perfectly logical development. A greater amount of gas can be carried a greater distance into enemy territory by aircraft than by gunfire; and gas can be laid down with greater effect, under certain circumstances, than that of shells. " Gas is especially suitable for distribution by airplane. Weight for weight it is even more effective against personnel than high explosives. In distribution over an area, the vapors are carried by the wind and direct hits are not necessary. Against gas, build ings, dugouts, hollows, and other natural conditions offer no pro tection. It may be used against trenches, dugouts, headquarters, roads, artillery positions, supply depots, fortifications, strong points, naval craft, coast fortifications, shops, munition plants, and others, with a wide range of possibilities. " Tactical uses by air services. —In an air attack, a nonpersistent gas, such as phosgene, could be put down in a heavy, lethal concen tration in one locality where troops were massed and secure many casualties before gas masks could be adjusted. The gas from bombs even penetrates masks in the vicinity of bursts. " Such a gas would be utilized where friendly troops are expected to make use of a place immediately after the attack, as the entire enemy works might fall into opposing hands ready for operation. 342 NOTES AND COMMENTS. Vol. XX. " With the persistent type of gas there would be a field for large bombs against lines of communication and approaching railheads, large terminals, concentration camps, depots, ammunition dumps, and important crossroads. Gases of the mustard type would make such spots untenable and prevent all use of the locality. Any pene tration of this area by troops or transportation equipment would mean casualties, even if the gas only penetrated the uniform. While efforts are being made to treat fabrics so that gas will not penetrate, the protection afforded will last but a comparatively short time be fore another treatment is again necessary. " The effect of such a gas attack would be comparable to that of an equal weight of high explosives. In a troop center the effect would be even greater than that produced by high explosive shells. In the case of the gas, the effect of the gas would continue for another week, or even two, while the high explosive's effect is completed after the first one or two seconds. " High explosive destroys. Gas will put a railhead out of com mission by the effect on personnel but it does not destroy. High explosive would blow up a crossroad, kill personnel, but the hole would be filled up and transportation and movement would be resumed. Gas produces no destruction of the surface but does cause many casualties. The mustard-type gases stay and effect those who follow. The only defense is evacuation. "Airplanes will use heavy smoke concentrations to protect against antiaircraft gun fire and permit descent to a low altitude where bombing is extremely accurate and in attacks on observation bal loons. Smoke screens the plane against antiaircraft attack. It can be made toxic and accomplish the first purpose as well as secure casualties among the enemy. " Aviators of the future will undoubtedly be equipped with masks and such are now being experimented with. A pilot jumped by an enemy flight would launch his toxic smoke screen and force pur suers to don masks. The mask might also be needed upon landing. •' In adjustment of antiaircraft fire, the airplane can use small smoke boml>s to simulate antiaircraft bursts and puzzle the enemy. This was done, in a way, by the French when German long range artillery was bombarding French railroad guns and correcting fire by aerial observation. Here the French produced simulated bursts short or over the gun and the air observer, even though he knew the expected time of the bursts, become confused. Such deception can easily be carried into the air. " Airplanes are invaluable in the launching of incendiary bombs to create fires as a weapon against lines of communication, railheads, concentration camps, storehouses, barracks, vessels, etc. No. 3. 343 NOTES AND COMMENTS. " There might be an occasion, in spotting long range naval gun fire, to make visible, by a smoke cloud, the location of an airplane at a distance where it would not of itself be seen. '* Another development is the putting down of a smoke screen on the water to hide the fleet, using the airplane in this instance as a possible substitute for the destroyer. " An army screen would cover the movement 6f troops or artillery along a road. "A large area might require gassing from the air, a fortified town in which the defenders are all below ground and the location is beyond the reach of artillery. " The use of a slow-burning type of bomb, with tear gas filling, would offer an excellent weapon to cause evacuation of an area by mobs, native troops, etc., without causing casualties. For training purposes, they may be simulated an area made untenable by a chem ical warfare agent. "The airplane furnishes the means for heavy concentrations of all types of gas at points which can not be reached in any other way. Munitions plants, dumps, barracks, depots, railheads and all cen ters of activity far in the rear can be reached. " With the increasing size, or weight-carrying ability of airplanes there will be further development of tactical uses; 4,000-pound bombs are already being produced; it will be possible to develop and use 5,000-pound bombs, or even larger. " Areas which may be covered. —It has been figured that a square 10 miles on each side containing 100 square miles, would take 3,000 tons or 30 tons to the square mile, to render the area uninhabitable almost immediately after the laying down of mustard type gas. A thousand tons of mustard gas more or less evenly distributed would make the same area seriously uncomfortable, with numerous casual ties and ultimate evacuation. This amount would start taking effect in 30-45 minutes after release. " If this amount were distributed by bombs, the gross weight to be carried by airplanes would be doubled as the weight of the con tainers themselves would probably be about equal to the weight of the gas. "However, if the mustard gas were sprayed the intensive effect could be gotten with about 1,500 tons or the harassing result with 500 tons, not counting the weight of containers and spraying ap paratus. Spraying certainly appears the more efficient means of distribution if practicable under given circumstances. " In using phosgene, a heavy concentration would result in casu alties almost instantly but it would not be used simply to hara&s personnel as it will remain but about 30 minutes after being re- 78693—24 5 344 Vol. XX. NOTES AND COMMENTS. leased. To obtain an intensive lethal concentration of phosgene for an area of 100 square miles, 3,000 tons would be required. " Using a tear gas, the same area of 100 square miles could be covered with but 62 tons of gas. This amount would make life veiy disagreeable, would require the continuous wearing of masks and the effect would last 3 to 7 days. " This area, of course, may be considered as a stretch of front 100 miles long and a mile deep or a strip 2 miles wide by 50 miles long. " For various results, various methods and materials in different amounts will be utilized. " There are toxic and nontoxic smokes, persistent and nonpersist- ent gases, toxic solids, and incendiary solids and liquids. " Forms of chemical warfare agents. —Gas for use may be either in solid or liquid forms. When released to the atmosphere the solid or liquid becomes a gas or a cloud of solid particles such as smoke. "An advantage of certain solid chemicals is that the effects are not destroyed by detonation of an explosive. Combined with high explosive a demolition effect can be produced in addition to that of the gas alone. " The pressures required to maintain many of the types of gases liquid at ordinary temperatures are very high. While the pressure aids in distribution it adds difficulties in manufacture, storage, and handling. " Carbon monoxide, for instance, would be a perfect, highly effec tive gas for most uses, as it is odorless, colorless, tasteless, and highly toxic, but the enormous pressure and extremely low temperature required to liquefy it makes it impracticable at present. "Kinds of chemical warfare agents. —Mustard-gas types are ex tremely effective in causing casualties and their use results in casualties after some hours, even if masks are worn. Their great persistency makes protection very difficult, and the toxic effects may last from one to two weeks, or even longer. They can not be used where friendly troops are expected to shortly occupy the gassed position except in small areas or with possible change in wind direction. This type of gas can be put down by bombs or by sprinkling. "Phosgene and other nonpersistent gases are lethal but less deadly, weight for weight, than those of the mustard type and, unlike mus tard gas, they do not produce casualties by effect upon the skin but must be breathed in relatively heavy concentrations. But these gases are rapidly vaporized and high concentrations may be secured so that the resulting cloud is far more lethal. They are used for surprise attacks where almost instantaneous results are desired. "Toxic, nontoxic, and other nonsmoke type agents put down by bombs. —Lachrymatory gases are usually not lethal in any field con No. 3. NOTES AND COMMENTS. centrations, but they have an almost instantaneous effect upon the eyes and force the wearing of masks. Only a very small quantity is necessary to be effective. Some of them are very persistent. They may be put down by bombs or by sprinkling. "Incendiary agents include thermit, solid oil, and phosphorus. It may be recalled that phosphorus bombs were used in the Ala bama experiment. "While not as effective an incendiary as thermit or solid oil, phosphorus has the added advantage of inflicting casualties and at the same time producing a highly efficient smoke screen. "Smoke-screen agents may also be used, such as oleum, titanium tetrachloride, phosphorus, or the standard slow-burning smoke mix ture of the chemical welfare service, which is effective. Smoke mixtures may be carried in a tank on the airplane and injected in the engine exhaust. They may also be used in bombs. One bomb has a small bursting charge which gives an instantaneous smoke cloud upon impact. Another type is one which does not explode but in which the smoke mixture burns and gives off smoke over an appreciable period of time, an example of which is the floating smoke bomb used in the Alabama experiments. Smoke bombs are of the scatter type, to be used in quantity, or may be in 25 and 100 sizes. Phosphorus may be used in these bombs both for the smoke- producing effect arid for the casualty and incendiary effects. " Methods of gassing. —In general there are two methods of laying down chemical warfare agents from aircraft—bombing and spraying. All but one of these agents can be used in bombs. For spraying, so far as known now, only gases of the mustard type and lachrymators may be used. " The airplane method of spraying toxic gases is to equip the machine with containers for toxic liquids and install a suitable mechanism to allow the liquid to fall as rain. One man can dis tribute a great amount. The excess weight carried is probably small in proportion to the total bulk of the liquid and this method allows uniform distribution of the toxic liquid. In spraying, the liquid merely falls to the ground like rain and is a more efficient means than shells. " In the development of gases for airplane use the following items must be considered: " The development of a nozzle to obtain the best distribution on the ground. " Largest tank that can be safely carried by the plane chosen for the work. Baffle plates in the tanks might be required, for instance. "Prevention of leakage of gas on the plane itself, as even a few drops on the plane might injure those handling the machine. 346 Vol. XX. NOTES AND COMMENTS. " Possibility of having to land "with full tank or empty. In case of a crash, a releasing device might be a necessity. " The amount of liquid which would reach the ground from vari ous elevations. " Study toxicity within and surrounding the area gassed to de termine safe distance for friendly troops. " Possibility of bursting bombs at predetermined heights in the air. "It has been found in tests that the liquid must be driven out from the tank in a direction opposite to that in which the airplane is moving and at a speed within 20 miles of that of the airplane. This tends to cause the speed of the plane to be nullified and the drops to fall as though in still air. This must be done if the air plane is at an appreciable height, say, 1,500 feet. Otherwise the drops do not reach the ground, but remain in the air as vapor. " Various methods of discharging the gas have been proposed. British pilots now doing sky writing force the liquid into the engine exhaust. Another method would be to use an auxiliary tank of some other gas under pressure. " Experiments are now being conducted by the Air Service in the discharge of gas materials furnished by Chemical Warfare Service. "An air service can undoubtedly use chemical bombs filled with at least six chemical-warfare agents —mustard, phosgene, toxic smoke, lachrymatory, incendiary, and screening smoke types. " With mustard and lachrymatory gases the object is to have very small concentrations of the chemical agent over a more or less ex tended territory distributed by small bombs with high bursting charge to insure fair distribution or by sprinkling. "With those of phosgene type the object is to obtain exceedingly high concentration on some small target. The wind would sweep the gas cloud away from the spot and the concentration would lessen as the cloud progressed. Bombs for this type would be large and fitted with least possible bursting charge. All would probably be equipped with percussion fuses, as the desirable burst is one at the surface, except where possible air bursts might be desired under particular conditions, for which purpose a different fuse would be arranged. " The possibilities of toxic smoke are being considered. "Effective clouds may be secured from bombs loaded with phos gene and fired on impact with water. The Navy may operate with these in deep water only, while the Army may want these for shallow- water use as well, so that it is probable designs will have to allow for firing on impact with but 25 feet of water. "Smoke bombs may be of two types. One is a slow-burning smoke bomb designed to function upon water impact only and No. 3. 347 NOTES AND COMMENTS. while floating on the water give out smoke for a period of about three minutes. These would be of the scatter type and used inv quantities. The other is a phosphorus bomb in 25-pound and 100- pound sizes, probably, or even larger. The objects of this bomb are to injure personnel through the scattering of the burning phos phorus, obscure observation, and obtain incendiary effects. These function on contact with solid matter. In the case of an attack on a ship there is the advantage over the first-mentioned smoke bomb in that the burning phosphorus is carried along with the vessel. This time of burning of the phosphorus bomb might be 5 to 15 minutes. " Bombs giving an instantaneous smoke screen but without in cendiary or casualty effect may also be considered in a study of aerial warfare with chemical agents. These use oleum or titanium tetrachloride as a smoke-producing agent and have a small burst ing charge. These are used where it is desired to produce instan taneously a smoke cloud upon the release of the material. This could be used for producing a cloud above a battleship in order to obscure the approach of the plane or to produce a cloud on impact with water. " The wind bears heavily on the use of gas. Its direction on the ground can be found from the airplane by dropping a smoke bomb, after which the bomb load may be dropped on the windward side of the target. " Present knowledge would indicate that chemical bombs for aircraft will be produced in the following sizes: 8 ounces, 25, 50y 100, 300, 500, 1,000, 2,000, 3,000, and 4,000 pounds. " Cooperation of other arms. —In the development of aerial war fare with chemical agents the tactical needs are the subject of study by the Army and Navy Air Services. The Ordnance Depart ments of the Navy and Army cooperate with Chemical Warfare Service of the Army in the design and production of bombs and containers. The Chemical Warfare Service is charged with the development of the chemical agents themselves in their application to aerial warfare." OPHTHALMOLOGY IN ITS RELATION TO AVIATION. At a recent meeting of the section of ophthalmology of the British Medical Association the relation of ophthalmology to the military and naval services was discussed. Among the papers presented were the two following, relating to aviation. They are reprinted from the British Medical Journal of October 13, 1923. 348 Vol. ST. NOTES AND COMMENTS. I.— SOME EYE PROBLEMS SPECIAL TO THE SERVICES, WITH PARTICULAR, REFERENCE TO FLYING. By David Munro, Air Commodore, R. A. P. M. S. " With the advent of flying the functions performed by the eyes in coordinative movements have assumed particular importance. To the cricketer whose eye is not ' in ' nothing worse than a ' duck ' can happen; to the aviator it may moan anything from a bad landing to a fatal ' crash.' A single-seater service airplane approaches the ground to land at a high speed, and to perform the evolutions re quired in landing the pilot has to alter the course of the machine from the gliding angle at which it is descending to a horizontal position— what is called ' flattening out.' He has to judge the exact moment at which to ' flatten out,' and the judgment is dependent on his estimation of the pace of his machine in relation to its dis tance from the ground. If he flattens out too high up he will lose flying speed before he reaches the ground, and gravity — the vertical component of the parallelogram of forces which is producing his diagonal glide—will take the upper hand. The machine then will fall vertically in the latter part of its course. If he neglects to flat ten out till too late he will fly into the ground at an angle. " This correct estimation of pace and distance seems to depend on * eye ' exactly as in games the estimation of pace and distance in hit ting a ball depends on 'eye.' What does ' eye ' in this connection mean? Doubtless in the act of landing an airplane, just as in other complicated coordinative acts, the brain takes note of afferent stimuli other than those which it gets through the eye. " Tactile sensation from the skin through the pressure of the wind on the face assists the pilot for an estimation of pace, also pressure of body against seat of machine. Muscular sense also is of the highest importance; as in riding, 'hands' make all the difference. The sound of the engine tells its tale to the man who knows, ye* in the main it is through the eye that the brain gets information and makes its controlling judgment. " Briefly we affirm that for a pilot it is necessary that the whole optic tract should be functioning normally. We lay stress on good visual acuity in both eyes, for two emmetropic eyes are more likely to work together than two eyes of unequal refraction; but we lay most stress on the coordinative machinery by means of which ac curate binocular vision is automatized. Inequality in function be tween the two eyes we regard as dangerous. Hence I venture to say that while there may be many good players of ball games who have indifferent visual acuity there are few if any who have any marked degree of inequality in functions between the two eyes. No. 3. 349 NOTES AND COMMENTS. " The essentials for good binocular vision would seem to be: " 1. Correct coordinative movements of the eyeballs as performed by the extrinsic ocular muscles. " 2. Unison in the associated movements of convergence and accommodation as performed by both extrinsic and intrinsic muscles. " 3. An optio tract which transmits faithfully the two retinal pictures which the brain has to fuse. " 4. A cortex which forms concise pictures of the two retinal images—that is, what is known as good fusion sense. " A man who is suffering from imperfect coordinated action of his extrinsic ocular muscles is said to be heterophoric —in extreme cases he squints. Many men, probably the majority, have one eye that lags behind the other to a greater or less degree in coordinated movements. It is part of what we mean when we say a man has a ' master eye.' But it is not alt—to find the cause of his hetero- phoria one must go back probably to infancy. One eye begins by being better than the other, and the worse eye gets careless and ' neglects.' No one, I suppose, can explain why one eye is born worse than the other or in what developmental fault the difference consists. It may, I presume, be one or more of several parts of the machinery which are defective. " Whatever it is, if there is inequality the better eye tends to do the work. Thus to us the word ' heterophoria ' connotes more than merely ' latent squint,' an unequal action of extraocular muscles moving the eyeballs. It means some of the above conditions are causing bilateral disharmony. " Thus in the treatment of heterophoria we aim not only at exer cising eye muscles —for example, by use of the amblyoscope —but also at reeducating neglecting eyes and teaching them to observe —for example, by Wells's stereoscopic charts. In our view, a man with one eye, or with one totally neglecting eye, who has learned to judge stereoscopically by other means —namely; experience of dis tance light, and shadow, parallax, or alternating head movements — is less dangerous than a two-eyed man whose one eye only occasion ally strikes work. " To Whig Commander Clements (ophthalmic specialist to the Royal Air Force) belongs the chief credit of realizing the impor tance of orthophoria among aviators. Under his supervision, or ganized treatment is undertaken in the Royal Air Force for flying personnel suffering from heterophoric conditions. Bad landers, suffering from manifest signs of heterophoria, are sent to the school. The results so far encourage us to believe that real improvement is effected. Indeed, we know that real improvement has been effected in a number of cases of heterophoric bad landers, but we have not yet got controlled statistics to show how far this improvement can 350 Vol. XXr NOTES AND COMMENTS. be definitely proved to be due to the methods of eye training pur sued, and to those only —or as to how long improvement is main tained. " The effects of glare are also of great importance in connection with heterophoric conditions. No doubt the importance of these conditions is not confined to air force flying, but in the other serv ices ; those engaged in work such as range finding have to be watched similarly. I know that it has been considered in the Navy. " Recent experience seems to show that for the pilot the most im portant effect of glare is to cause lack of convergence and accommo dation, thereby making visual judgment difficult and causing diffi culty in landing. The other effects of glare, such as retinal as thenopia, headache, conjunctivitis, etc., being later and more ob vious effects, were not of such immediate importance to the pilot. According to the Report on glare in Egypt, by Squadron Leader Rippon, in which 150 cases were dealt with, supported by orthotele- meter examination, and to Flight Lieutenant Livingston's reports on 50 cases in India, the main effects were: (1) Fatigue of the cili ary muscle; (2) lack of convergence and accommodation associ ated in some cases with spasm of accommodation; and (3) aggra vation of any existing imbalance of ocular muscles. It was em phasized that the chief effects of glare were produced on the ground and only became dangerous factors when the pilot went into the air." H.—JUDGMENT OF DISTANCE. By Cecil Clements, Wing Commander, It. A. F. M. S. " The part played by the eyes in the judgment of distance has al ways keenly interested me, and in the British Medical Journal of December 8, 1906, I called attention to errors of vision as a factor in motar car accidents. " Observation before the war of private and hospital patients en gaged in certain occupations showed that in every case their dis abilities were associated with ocular muscle imbalance and by em ploying a modification of existing treatment with the 'Worth-Black' amblyoscope and the stereoscope the normal balance was again re stored within recourse to prisms or glasses, and when this was at tained the associated physical symptoms vanished. " During the latter part of 1916, as ophthalmic specialist to the Fourth Northern General Hospital, I came into contact for the first time with large numbers of officers and cadets of the flying serv ices. It became increasingly evident on examination that these conditions were present in those officers and cadets whose judgment of distance was faulty, and also in a certain number of gunnery offi cers complaining of similar symptoms. No. 3. 351 NOTES AND COMMENTS. " Investigations at the flying schools revealed the fact that 80 per cent of all crashes in training squadrons occurred while landing machines. An independent inquiry by Graeme Anderson gave al most identically the same figures in two different series, while Rip- pon found the proportion was 65 to 70 per cent at Hendon Aero drome. " At this time I had no special experience of flying and knew little of the visual requirements of aviation. Permission was therefore requested and obtained to study such conditions. It was found that, of all parts of elementary flying instruction, 'landing' provided the greatest difficulties, and that these increased with the newer types of machine which, owing to increased engine power, landed at greater speeds. ' The conclusions arrived at were: " 1. Correct judgment of distance was a necessity in aviation. "2. That failure to land machine correctly was mainly due to faulty judgment of speed and distance, which was associated with lack of ocular muscle balance and with poor binocular vision. " 3. That from financial consideration alone apart from injury to pupils and pilots it was uneconomical to train such pupils owing to (a) damage to machine, (b) waste of instructors' time, unless something could be done along the lines of my previous experience to help these bad landers to do better, and thus enable them to con tinue their training and to remain in the flying service, which was then urgently in need of men to meet the combination of war wast age and expansion. " The following is a brief description of the routine tests used to discover and estimate these ocular conditions which I will not label as ' heterophoria ' and so wander into discussion of definitions, but will simply designate together as ' X.' " Test for convergence -power.—Hold a pencil in front of the patient at about 1 foot from his eyes, with point on a level with the root of his nose. Tell him to fix the point, then steadily move it forward, watching what happens to his eyes as they converge. What may happen is : (1) Both eyes may converge fixing the pencil until it gets within an inch or two from the root of the nose—that is, no want of convergence; (2) one eye may continue to fix up to an inch or two from the root of the nose, but the other will cease to follow and may turn outward at any distance from the nose—he may or may not see double; (3) on convergence break ing down neither eye may fix and he may look into the distance, stating he sees double anywhere inside 10 inches; further, he may resist by throwing back his head and complaining that it hurts him. In No. 2 he has learned to become monocular and such a response is taken to mean that he has had the trouble for some time. 352 Vol. XX. NOTES AND COMMENTS. In No. 3 the trouble is recent and he has not yet learned to fix with one and ignore the other confusing eye. This condition is found after crashes, influenza, fatigue, and debilitating diseases. Conver gence power is estimated by giving the following values : Two inches or under, very good, possibly excessive ; 2 to 3 inches, good ; 3 to 4 inches, fair; 4 inches and over, poor. " Cover test for muscular defect. —Again ask the patient to fix a pencil held in a similar manner and with the other hand cover one eye with a card, move the pencil from side to side and then uncover; watch whether the eye moves on uncovering. Repeat the test for the other eye in a similar manner. A perfectly balanced pair of eyes will remain fixed on the pencil whether one is covered or not, whereas movement inward or outward on uncovering shows some lack of balance. If there is a convergent or divergent latency, it is described as slight, medium, or marked, and the response to the uncovering may be rapid, medium, slow, or no recovery. This to us signifies a good, bad, or indifferent reflex arc. "Red-green test at 20 feet. —The essential feature is that a suitable tint of red glass in one eye will cut out any rays of light from a green glass and, vice versa, green glass in the other eye will cut out red rays. A slot one-half inch wide by 5 inches long is glazed in the upper 2£ inches with red glass and the lower 2| inches with green. The person under examination —wearing a pair of reversible frames, glazed red in one eyepiece and green in the other—-is told to look at the slot illuminated from behind and asked to state what he sees, and in event of both red and green being perceived, what are their relative positions. A displacement of more than 0.5 of a degree of arc (about 2} inches at 20 feet) is not considei'ed good. An exophoric case may give at first an esophoric displacement owing to overcompensation, but as fatigue sets in the red image appears to swing through normal to the exophoric position. Hyperphoria or hypophoria combined with exophoria or esopnoria exaggerates any liability to bad landings. Tendency to neglect one or other eye or each alternately is a marked and frequent feature in bad landers. "Bishop Harmon's movable diaphragm test.—This test has proved invaluable as a check on the others above mentioned. It has been found that a reading of 3 is a ' border line ' one, and 5 is bad. First-class landers usually give a reading below zero ; average landers, 0 to 2; doubtful landers, 2 to 3; while those giving read ings of 3 to 5 or more fall into the category of bad landers. Most of the individuals who landed badly had normal visual acuity and little if any error of refraction. " I wish to emphasize one point —namely, that I am considering the subject in terms of conditions ' in the air,' and I would ask No. 3. 353 NOTES AND COMMENTS. readers to keep an open mind and not judge my remarks too crit ically by standards which operate ' on the ground.' I ask this for these reasons: " 1. From birth upward all our judgments of distance have been made with one known quantity —our contact with the ground. When, however, the airplane wheels leave the ground the pilot is in space, and this previously known quantity is immediately lost. What is more, before he can successfully land his machine he must make as correct an estimate as possible of the distance he is from the ground. " 2. From the air all verticals are foreshortened and the known size of objects therefore varied from those which we have learned as normal on the ground. "3. The action of centrifugal force on ocular muscle balance during turns, spins, loops, etc., has to be taken into consideration. If flying in tight spiral, looking in the direction of the airplane's course, or toward the center of the ' funnel ' down which one may be traveling, no unpleasant effects will be felt; but if one looks outward —that is, away from the center of rotation —the pain of having one's eyes apparently pulled out of the head is agonizing and a more comfortable position will be rapidly taken up. On coming out of a spin the horizon will appear to be going round in the reverse direction, and if the action has been excessive the pilot may be under the impression that he is not yet out of the spin, and make some further adjustment which results in his resuming spin ning in the opposite direction with possible damage to himself, or •even fatal results. If a pilot has some tendency to imbalance, then it would seem that rotation will be likely (by putting undue strain on the affected pair) to increase such tendency and to make his judgment faulty. "In conclusion I would like to make the following observations: The independent investigation of Group Captain Flack, made on air ministry instructions in the war, showed 80 per cent of successes from eye training, and that by only treating suitable cases this per centage has improved since that time. Not only is greater profi ciency in landing obtained but also in game shooting and all fast ball games, as the patients attest. The course only occupies a short time daily for three to five weeks. " The air ministry after careful investigation of results now sanc tions the training of service officers who develop the defect ; and bad visual judgment, even though visual acuity is up to standard, is now a definite cause of rejection for candidates. Lastly, instructors are sufficiently satisfied with the results to apply at once for an opinion where a pupil shows signs of inability to land." 354 Vol. XX. NOTES AND COMMENTS. NOTES ON AVIATION MEDICINE IN FRANCE. In the issue of L'Aerophile, a French aviation journal, dated July, 1923, appears an account of the inauguration on June 19, 1923, of the Physiological center for medical examination and study of fliers and equipment at the aeroport of Bourget, France. The inauguration was characterized by appropriate ceremonies, in which due credit was given Doctors Garseaux and Behague for their efforts in creating and equipping the center. The equipment is complete, thoroughly modern, and includes a large low-pressure chamber with a refrigerating device for the purpose of simulating conditions at high altitudes. The purpose of this laboratory comprises not only the periodical physical examination of fliers, as provided for by the international convention, but also researches of the physiological problems in volved, continuing the study undertaken during the war by Doctor Garseaux. The various devices for the protection of fliers may be tested and developed at this place, thus giving greater security and comfort to aerial navigation. Although the center is not a part of the military or naval estab lishment, nevertheless it indicates the important place held by avia tion medicine in France. FELLOWSHIP IN THE AMERICAN COLLEGE OF SURGEONS. As is quite generally known throughout the service, each year a certain number of medical officers of the United States Navy who have specialized in surgery and who are recommended by the Bureau of Medicine and Surgery, may be admitted, by a unanimous vote of the board of regents, to fellowship in the American College of Surgeons on recommendation of the committee on examinations. In order to meet the high standard of professional fitness set by the college, the bureau demands that all naval medical officers who are candidates for fellowship comply with the requirements for ad mission imposed by the college on candidates in civil practice. Certain of these requirements are met by all candidates for admis sion to the Medical Corps of the Navy prior to commission. Other requirements which the naval medical officer must meet are the fol lowing : " To be eligible for fellowship without technical examination the candidate shall be a graduate of a medical school approved by the American College of Surgeons. " The candidate shall give evidence that he has served at least one year as interne in a creditable hospital and two years as surgical assistant, or he shall give evidence of apprenticeship of equivalent No. 3. 355 NOTES AND COMMENTS. value. Five to eight yeai^s after graduation in medicine, devoted to special training and to practice, are normally the time requirement for eligibility to fellowship. Due importance is attached to labora tory and research work. " The moral and ethical fitness of the condidate shall be de termined by reports of surgeons whose names are submitted by the candidate himself, and by such other reports and date as the credentials committee and the administration of the college may obtain. "The professional activitiy of the candidate shall be restricted to the study, diagnosis, and operative work in general surgery or in special fields of surgery, such as eye, ear, nose, and throat, genito urinary, orthepedics, and gynecology and obstetrics." As evidence of his qualifications in the technique of surgery, the candidate is required to submit in complete detail, through official channels, the case records of 50 consecutive major operations which he has performed himself. In addition to the complete records of 50 consecutive major oper ations, the candidate is asked to submit in brief abstract a report of at least 50 other major operations in which he has acted as assistant or which he has performed himself. The senior medical officer, with whom the candidate is serving, when forwarding these case records and the abstract of major opera tions in which the candidate has assisted, shall forward by means of an appropriate indorsement his estimate of the candidate's qualifica tions for fellowship. VACCINATION AGAINST SMALLPOX. A letter discussing the duration of an " immunity " reaction in cowpox vaccination written by the senior medical officer of a hospital ship was recently received by the bureau. In this letter were the following passages concerning a phase of vaccination in which all medical officers are interested : " I have claimed that ' immunity ' disappears at various times and thus after four years, the enlistment period, cases showing an ' im munity ' reaction should be revaccinated each year in order to de termine if still immune, and if not to repeat vaccinations until suc cessful. I find many medical officers are entirely ' hazy ' in regard to ' immunity,' some seeming to think that it is as of long duration as a ' positive,' whereas there is a period influenced by the individual equation, climate, etc., when the ' immunity ' disappears. Should there not be more definite instruction in regard to vaccinating in cases of ' immunity ' ? I have felt that the rule I followed in vac cinating each year in cases of ' immunity ' was a safe measure and 356 Vol. XX. NOTES AND COMMENTS. might avoid in some, cases the existence of nonimmunes, and then possible smallpox. " I would ask advice as to whether the bureau wishes me to follow my present opinion." The Surgeon General's reply to this letter follows and it indicates the bureau's opinion in the matter. December 15, 1923. My Dear Doctor: In reply to your letter of December 7, 1923, it may be said that your opinion regarding the indications for repeated vaccination are essentially those held by the bureau. Testing those already protected by vac cination once a year would undoubtedly serve to maintain a greater degree of protection against smallpox among the naval personnel than revaccination every two, three, or four years. However, conditions and circumstances vary, so that It would seem preferable not to establish a fixed rule requiring revac cination every year. In practice the medicnl officer, in order to mnke sure that the crew, for whose health he is in this respect responsible, is thoroughly protected against smallpox, will naturally look at the arms and health records of nil men join ing the organization. In all cases where there Is nny doubt as to protection he will Tevaccinate. He will, of course, have more confidence in immunity reactions observed and recorded by himself or one of his assistants than In those recorded elsewhere. A pitted scar, together with an entry in the health record, indicating that the primary take occurred at a naval training station or elsewhere in the service within two, three, or even four years, make it probable that the man has still a higher degree of immunity. A pitted scar resulting from a primary take in primary-school years does not furnish as strong evidence of protection, and a test for immunity by revaccination is of course Indicated. It is proper enough to trust a signed entry Indicating a reaction of immunity within a year. Besides the regular routine handling of drafts of new men coming aboard circumstances usually arise wherefrom a fleet or force order is issued for revaceinntion preparatory to touching at some port where there is known or supposed to be unusual danger of exposure to smallpox. It therefore happens that most officers and enlisted men while on sea duty will be looked over every year or so. It does not seem advisable to fix definitely by regulation one year as the period which may elapse before revaccination is required. Your question as to how long Immunity lasts can not, of course, be answered without citing exceptions to the Kcneral rule. In the majority of cases suffi cient protection to prevent the development of smallpox after exposure to any but an unusually virulent focus of infection probably lasts for several years — four to seven years anyway. But that can not be foretold in the case of any- given individual. A few lose protection rapidly. Cases have been recorded where exposure to smallpox even in mild form has developed within a few months after successful vaccination, as indicated by a primary take. Infection has also occurred in some instances where exposure has followed revaccination within a few months. Exposure to a virulent case of smalli>ox is more likely to lead to Infection than exposure to the type of the disease generally encoun tered In the United States and West Indies. In general, the protection against smallpox conferred by vaccination seems to be greater than the protection against vaccination itself. From studies made in the United States and from observations made in Germany during epidemics in recent years it seems as if No. 3. 357 NOTES AND COMMENTS. the slight reaction which we call the reaction of inmunlty in a protected indi vidual also serves to increase the protection still more. This is true only when a potent virus is used -to excite the immunity reaction. The final conclusion is that no procedure will give absolutely uniform and perfect protection, but the incidence of smallpox may be reduced almost to the zero point by recent vaccination with potent virus. Your statement that you find many medical officers entirely hazy in regard to " immunity " suggests the desirability of preparing another paper on the sub ject of smallpox and vaccination. A paper will therefore be prepared for early publication in the Bulletin wherein the epidemiology of the disease and the preventive and control value of vaccination will be discussed briefly in an attempt to clear up some of these doubtful points. Very truly yours, E. R. Stitt, Burgeon Oenoral, V. S. Navy. THE INSTRUCTION OF HOSPITAI CORPSMEN. In September, 1923, the following letter relative to the instruc tion of hospital corpsmen was sent to the commanding officers of all naval hospitals. This letter sets forth the need of continuing at hospitals the instruction given at the hospital corps training schools, outlines the bureau's wishes in this matter, explains how the desired results might be attained, and summarizes the apparent defects in the method of instructing hospital corpsmen at present employed in the various hospitals. Department of the Navy, Bureau of Medicine and Surgery, Washington, D. C, 19 September 1923. To : Commanding officer, Subject: Instruction of hospital corpsmen. 1. Reports received in the bureau indicate that the policy of the bureau in regard to the training of hospital corpsmen is not clearly understood through out the service. In view of the serious loss of experienced hospital corpsmen and the recent enlistment of a large number of inexperienced recruits, it is considered essential that the methods of instruction should be developed to a high state of efficiency throughout the medical department. 2. Owing to the short period of Instruction In the two Hospital Corps train ing schools, it is impossible for recruits to be given any instruction other than In the fundamentals of the duties which they will be required to perform^ Upon this groundwork must be built the practical knowledge and experience which can be obtained only in the hospitals. It therefore has been the policy of the bureau to transfer graduates of the four months' course at the training schools to the naval hospitals where advanced Instruction and practical ex perience is obtainable during the remaining eight months of the first year in the Hospital Corps. The apparent failure to realize that the training in the hospitals should be a continuation of the work of the schools has resulted in a lack of progressive development after the completion of the school course. The Immediate consequence of the failure to continue the training of the hospi tal corpsmen In the hospitals is seen In the numerous failures reported in the 358 Vol. XX, NOTES AND COMMENTS. cases of those who have taken the required examinations for advancement in rating. This Inability to qualify for advancement in rating has resulted in a stagnation of promotions and an excessive number of. vacancies in the phar macist's mates ratings. The lack of experienced hospital corpsmen is being seriously felt throughout the service and has been the subject of a recent com munication from the Bureau of Navigation. 3. Opportunities for obtaining practical knowledge and experience in the hospitals are unlimited. In addition to the prescribed hours of instruction required by the Manual of the Medical Department and the Bureau of Navigation Manual, medical officers in charge of wards, laboratories, and other departments of the hospital, chief pharmacists, pharmacists, nurses, and the more experienced hospital corpsmen should personally instruct the hospital corpsmen under their Jurisdiction. Such instruction can be given daily during ward visits, application of dressings, administration of routine and special treatments, preparation of dressings and of the patient for operation, adminis tration of anaesthetics, preparation of the operating room for the various types of operations, etc. The majority of these duties can be performed by the hospital corpsmen under the supervision of the medical officer or the nurse, after sufficient instruction has been given in the various methods employed. Without this practical experience and responsibility, hospital corpsmen will never acquire that knowledge of their duties which is absolutely necessary if they are to be of any value to the Navy at smaller stations and on Independent duty to which no medical officer Is attached. Without this instruction hospital corpsmen are unable to acquire the knowledge required for their advancement to higher ratings in which there are so many vacancies at the present time. Personal interest on the part of officers and nurses in the instruction and advancement of the hospital corpsmen will be repaid by the greater interest and more intelligent performance of duty on the part of the hospital corpsmen themselves. 4. From reports received in the bureau, the apparent defects in the present methods of instruction may be briefly summarized as follows : (a) Instruction Is not a progressive continuation of the training received in the Hospital Corps training schools. (6) Constant repetition of the subject matter contained in the present Handy Book causes loss of interest on the part of both the Instructor and the hospital corpsmen. (c) The attempt to instruct hospital corpsmen of various degrees of ex perience, in one group, results either In needless repetition for the older men with consequent loss of interest, or in too advanced instruction for the younger inxperienced men whose previous training does not qualify them for the work. (d) Failure to utilize opportunities for individual practical instruction in the wards, laboratories, operating room, dispensary, and other departments retards the development of the hospital corpsman's training and sense of responsibility. (e) Lack of confidence in the ability of the hospital corpsman to perform the most elementary nursing duties in which he has received training causes loss of interest and of the desire to progress in his work. (f) The present tendency of medical officers and nurses, themselves, to per form ordinary nursing duties, such as the administration of hypodermic medication and the application of simple dressings, etc., results in assigning to hospital corpsmen only those duties usually performed by orderlies in civilian hospitals. As a result of this practice, hospital corpsmen naturally lose interest In their work and fail to acquire the necessary experience which they should obtain before being transferred to the fleet, foreign stations, or to independent duty where the advice and services of a medical officer may not be obtainable. No. 3. 359 NOTES AND COMMENTS. 5. In accordance with the policy of the bureau as Indicated above, com manding officers of hospitals are directed to bring this letter to the attention of all officers and nurses under their respective commands and to issue at once such instructions as will insure adequate, continuous, and progressive instruction to hospital corpsmen. It is further directed that a copy of the instructions Issued In compliance with the above order be forwarded to the bureau. B. R. Stitt, Surgeon General, V. 8. K. Copies of the comments and schedules of instruction placed in effect submitted to the bureau by commanding officers of two naval hospitals are appended. The Surgeon General considers that the formulation of these schedules shows a most commendable spirit of cooperation. If these schedules are adhered to and a personal in terest taken in the education of hospital corpsmen by the instructors and medical officers generally marked improvement in the efficiency of the Hospital Corps should result. United States Naval Hospital, October 5, 19SS. From : Commanding officer. To: All officers and chief nurse. Subject : Training of enlisted men and recommendation for advancement In rating. Reference: (a) Bu. Nav. Letter N-6-Lo 4111-1413-3 of 21 August, 1923. (6) Bu. M & S Letter No. P-172-42022, ERS/JBC of 19 September, 1923. (c) Bu. Nav. Letter No. N-6-Lo 4111-1413-4 of 25 September, 1923. (d) The instruction of hospital corpsmen directed in conference of all medical officers and chief nurse, under date of October 3, 1923. 1. Referred for the information of all concerned with the request again that all medical officers and chief nurse make every effort possible to train our corpsmen, give them every opportunity for practical work, and when qualified recommend their advancement in rating. 2. There Is no more Important duty confronting the officers and chief nurse attached to this hospital. It Is the commanding officer's earnest desire that each and every person charged with this Important duty do their utmost to make the conference result In a satisfactory issue. It is felt that if every person concerned will perform the duties as outlined In conference that our corpsmen will acquire the necessary knowledge and experience, not only to make them a real value to the service but will Insure their promotion to higher ratings, increase their morale, and make them a credit to the Hospital Corps. 3. Let everyone do their duty and do it well and then our efforts will be crowned with success. Perfunctory instruction and indifference will result in failure. This duty is vital, urgent, and most important. 4. After reading please initial and return to the undersigned. E. F. G., Captain (MC), V. 8. If. 78693—24 6 360 Vol. XX. NOTES AND COMMENTS. Octobee 2, 1923. Instruction to Hospital Corpsmen. Instruction will be given to hospital eorpsmen on Monday, Tuesday, Thurs day, and Friday. Medical and surgical nursing Nurse. Materia medica and practical pharmacy Medical officer. Emergency surgery, first aid, application of splints, dress ing and bandaging Medical officer. Anatomy and physiology Medical officer. Transportation methods Pharmacist's mate. Hyg'ene, sanitation, and prophylactic methods Medical officers. Medical records, care of instruments and medical stores — Chief pharmacist. Asceptic operation, drill sterilization, and preparation of patient for operation .— Medical officer. A notation of the time, nature of the instruction given, the name of the Instructor and the hour shall be furnished the officer of the day for entry into the journal by the officer concerned. The master-at-arms will muster the men of the liberty watch at 1 p. m. on the designated days in the recreation room. Class work will continue until 1.30, when the class will be broken into sec tions for practical work according to the following schedule. This section work will continue until 2 p. m. Each section will have two weeks' instruction In one department before being shifted to the next. SECTIONS. One. Two. Three. Four. Five. First and second weeks . Laboratory.... Dispensary.... X ray and 0 perati n g room. physiothera py- Third andfourth weeks. Dispensary.... Office X rav and phvsiother- Operatin g room. Laboratory. Fifth and sixth weeks. . Office X ray and Operat i ng room. Laboratory.... Dispensary.... Dispensary. Office. physiother apy. Seventh and eighth X rav and physiotherapy. Operating room. Opcratl ng room. Laboratory.... wp^ks Ninth and tenth weeks Laboratory . . . Dispensary. . . . X ray an d physiother apy. REPEAT. In addition to the above formal and practical Instruction, all medical officers, nurses, and senior eorpsmen will embrace every opportunity daily in the wards, dressing rooms, and special activities to aid and instruct in all those things which they will be expected to know when they are sent on independent duty, and to supervise their doing of the same, viz, a corpsman on ward duty should know not only how to keep a ward clean, but also how to make beds, care for the sick, keep bedside records and clinical charts, administer hypodermic and oral medication, give anemas, apply dressings, etc. Furthermore, it Is the policy to rotate duty, so that each corpsman may, so far as conditions permit, become familiar with all phases of the work B. C. D., Commander (M. C), United States Navy. Approved : E. F. G., Captain, M. C, United States Navy. No. 3. 361 NOTES AND COMMENTS. U. S. Naval Hospital, 12 November, 1923. From : Commanding officer. To : Bureau of Medicine and Surgery. Subject : Instruction of hospital corpsmen. Reference : Bureau's letter P-172-^2022, ERS/.TBC, 19 Sept., 1923 1. In reply to paragraph 5 of reference, the bureau is informed that intensive methods are being instituted at this hospital to instruct the hospital corpsmen in all the duties required of them, especially giving them all the practical work possible in the wards, laboratory, dispensary, operating room, etc. It should be remembered, however, that the practical work at this hospital is somewhat limited, but at the same time we have a sufficient amount to enable us to insti tute very material instruction. 2. The commanding officer realizes very fully the need of adequate instruction for the members of the hospital corps. There is a tendency among many of the members of the corps to minimize the importance of the instructions, and we are trying to eliminate this spirit. We have instituted a series of rewards to those who do well in the classrooms and who show an interest in their work and develop improvement, and to those who do not show an interest methods are to be taken to create an interest. For example, the commanding officer in a talk before the hospital corpsmen stated that it was the plan to give those members of the hospital corps who showed by their Interest and as a result of the examinations that they had done good work several days leave at Christ mas time and at New Years, one-half going one time and the remainder later. The hospital corpsmen who did not do well in the school work would receive no leave whatever. If this is not sufficient to create an interest in the work, other methods, such as curtailing liberty at the hospital, will be Inst tuted. In other words, it is planned to force these hospital corpsmen to develop themselves whether they want to or not. 3. It is realized that books are not available for all subjects so that each man can have his own book. Of course, they can have the Hospital Corps book. To eliminate this defect somewhat, we have decided to give each student a mimeographed copy of the lecture or other instructions which it Is desirable for them to memorize, to be kept in a bound form which they can read at their leisure. This will form the basis of a series of examinations which we propose to hold every four weeks on the work gone over during that period. 4. It is fully realized that in a lecture before hospital corpsmen. many of whom are not accustomed to receive instruction in that way, that they do not retain much of the subject matter, and in order to better insure the retain ing of the essential points of the lecture or talk they will have these mimeo graphed copies of the lecture to aid them. It is thought that this will be of material advantage. It is found that we have two or three corpsmen who ap parently will be unable to master any kind of instruction, not as a result of any unwillingness to learn, but simply through the fact that they are mentally not qualified to understand or retain much that is of value. It is planned to> submit a letter to the bureau relative to the ultimate disposition of one or two of these cases. 5. There is a tendency among some of the hospital corpsmen to offer all kinds of excuses, such as sickness, duties, etc., so that they may be excused from school. We have practically obviated this feature, as everyone is required to attend the school daily, and if not there promptly disciplinary measures are immediately instituted. It is found that this is necessary in order to insure 100 per cent attendance in the school. 362 Vol. XX. NOTES AND COMMENTS. 6. The officers at this hospital are taking Interest In the work and it is believed that considerable advance can be attained in a very short time, and I am sure that this Is exactly what the bureau desires. H. I. J. U. S. Naval Hospital, SO October, 192S. Schedule of instructions for hospital corpsmen. Instructor. Monday, from 1.30 to 2.30 p. m Officer of the clay. Tuesday, from 1.30 to 2.30 p. m Chief pharmacist. Wednesday, from 1.30 to 2.30 p. m Officer of the day. Thursday, from 1.30 to 2.30 p. m Chief nurse. Friday, from 1.30 to 2.30 p. m Officer of the day. Saturday, from 1.30 to 2.30 p. m Officer of the day. The subjects for the instructors are: [Emergency surgery,, first-aid, bandaging, aseptic op erations, sterilization, preparation of patient for operation, etc. Hygiene and sanitation, prophylactic methods, etc. Anatomy and physiology. Materia medica, pharmacy, records, clerical proce dure, transportation methods, etc. Chief nurse .Medical and surgical nursing. All hospital corpsmen will attend these lectures dally except Sunday. The master-at-arms will muster the corpsmen In the classroom and report their presence to the Instructor. All instructors will become familiar with Bureau of Medicine and Surgery letter P-172-42022, 19 September, 1923. H. I. J.. Captain, Medical Corps, V. S. N., Commanding. Medical officer. Chief pharmacist NAVY NURSE CORPS. MOTES ON A COURSE FOB INSTRUCTORS OF NURSING.1 NURSING. Notes on theoretical Instruction, given by Miss White at Lcland Stanford University summer course, June 19 to July IS, 1028. FAULTS ENCOUNTERED IN NURSING EDUCATION. 1. Low entrance requirements. Students do not have sufficient education to grasp the re quired studies. 2. Lack of teaching atmosphere. The demands of the hospital tend to obliterate the essen tial school atmosphere. 3. Faults of instructors. The instructors do not have the proper enthusiasm for their work, and are unable to arouse interest in the student. 4. Lack of knowledge on the part of the teacher. Not being thoroughly familiar with her subject, the teacher loses her hold on the class. 5. Lack of the knowledge of teaching. Through lack of educational advantages in regard to teach ing, the instructors are unable to impart the necessary knowl edge. 6. Lack of time on the part of instructors to make the proper preparation for classes. Carefully planned instruction demands time for prepa ration. 7. Lack of time for the students to prepare their lessions. No definite study periods are set aside for the student, and study is neglected. 1During the past year the Bureau of Medicine and Surgery has approved and financed "Pedal courses for 34 Navy nurses, consisting of courses in dietetics, physiotherapy, laboratory work, anesthesia, and courses for instructors of nurses. These courses have been greatly appreciated, attended with enthusiasm, and the naval hospitals have been benefited by the additional help these nurses have been able to give. The accompanying notes were compiled by Hiss Elizabeth M. O'Brien, nurse. United Btates Navy, while attending the course for Instructors of nursing given at Stanford Uni versity, California, from June 19 to July IB, 1923, and it is felt that they will be a helpful guide to not only those who are Instructors but to the hospital corpsmen In their •todies. 363 364 vol. ^x. NURSE CORPS. 8. Inadequate teaching facilities. Suitably equipped classrooms must be provided in order to cany out the needed instruction. 9. Methods of teaching do not suit the equipment of the ward. Only confusion results in the use of different equipment for ward and classroom. 10. Lack of correlation of theory and practice. Correlation of theory and practice stimulates interest and makes the subject better understood. 11. No resources to refer to, to broaden the work. Properly equipped libraries should supply the needs of instructors and pupils. . 12. Too close use of the textbook. The textbook supplies information but gives little to stimulate thinking. References : Brief course in teaching process, by Strayer. Chapter 10, The recitation. Teachers and teaching by Miss Pfefferkorn, American Journal of Nursing, volume 22. page 350. Stimulating students in cl iss work, by Miss Ink, Modern Hospital, volume 15, page 522. Why I teach, by M ss Watson, American Journal of Nursing, May, 1023. TYPES OF CLASS EXERCISES. 1. Lecture method. (a) Advantages of the lecture method: 1. A quick way of getting facts over. All the principal points of the subject are col lected in the lecture, and can be given very quickly to the student. 2. Better organization of the subject matter. Careful preparation of material tends to carry the lecture along logical and systematic lines. 3. A good way of putting forth new theories. New phases of work can be introduced without disorganizing the subject. (b) Disadvantages of the lecture method: 1. No scope for active and creative work on the part of the student. No incentive for thinking. The instructor has solved all the problems that the subject presents, and the class takes the ma terial as it is given to them. 2. The lecture degenerates into a dictation exercise. 3. There is no way of telling just how much the stu dent is getting out of the lecture. Students of poor discernment may miss impor tant points of the lecture. Disadvantages may be overcome by a quiz period. No. 3. 365 JsUKSE CORPS. 2. Recitation method. Study precedes this method. 1. Reporting to teacher by students of the facts they have gained. The teacher has an opportunity of finding out just how much of the assigned lesson is comprehended by the student. 2. Time for clearing up obscure and difficult points. By example and illustration the teacher can overcome the difficulties that confront the class. ' Two general forms of the recitation method: 1. Question and answer method. Ask questions about the important parts of the assigned lesson. 2. Topical method. Have students arrange material of assigned lesson for issue and discussion. 3. Drill method : For purposes of forming habits of thought and action. Technique is governed by the formation of habits, which are the result of continued practice. The more a pupil realizes the need of good habits, the more attention he will give them. He must know what to do. There must be a repetition with attention. Practice must be accurate. Accuracy is hindered by covering too much ground : mental confusion results. Drill must be discontinued gradually. 4. Review method : Gather points in a series of lectures and organize them into a larger system. This gives the class a clearer view of the topics studied. Review preceding lessons. Review that counts is one in which the teacher instructs the pupil, rather than the one where the teacher sits in judgment. Special emphasis on the main facts of the reviewed lesson will enable the pupils to under stand better the necessity of study. 5. Demonstration method : The teacher does the work. The purpose of demonstration work is to make things clearer. In laboratory work the pupil does the work. It makes them acquire skill, it gives them a clearer knowledge of the subject, it proves hypothesis, it stimulates observation, it gives self-confidence, it increases interest and manual dexterity. 366 Vol. XX. NURSE CORPS. 6. Class conference: For advanced classes. It gives pupils an opportunity to ex change opinions. 7. Project method : The pupils must have a problem to solve. The problem or project method involves a satisfying interest and correct think ing. Unless the problem is interesting and the process of solution satisfying nothing can be accomplished by way of the project method. 8. The study method : The teacher must be a study expert in order to teach the pupils how to study. NOTE TAKING AND NOTEBOOKS. Help the student to find the best method of taking notes. Sug gestion. Put on the blackboard an outline of the lesson, or place in the student's hand a mimeographic copy of the outline. LESSON PLANS. The purpose of lesson plans is to keep interest from lagging and to keep from wandering off the subject. The main object of lesson plans is to obtain the desired result with the minimum amount of time and labor. PLAN FOR A LESSON. Find out the aim or problem that confronts the class. Assemble subject matter. (Be sure to have a thorough knowledge of the subject treated.) Proceed with your lecture. Summarize your lecture. Make provision for references. Make provision for illustrations. Ask certain pivotal questions that will make the pupil think. Word these questions carefully so that the answer is not evident. Avoid asking questions by using the words of the book. The words of the book hold too much of a suggestion for the answer. Questions should be clear. Be sure that the questions need no revision to be grasped by the class. Do not ask questions in regular order. The pupils are apt to form a habit of counting up to the question that will come in their turn. No. 3. 367 NURSE CORPS. Do not name the student before asking the question. The attention of the class is held when the student does not know just when he will be called upon to answer. Do not pick the better students for the answer. The practice of calling on the better students for an answer makes it easy for the teacher, but it accomplishes nothing toward making the backward pupil interested. Do not repeat the answer after the student. It makes students less keen when they know that the teacher will supply whatever of the answer escapes their scant attention. Do not accept incomplete and vague answers. Pupils become careless when they realize that a mere inkling of the lesson is sufficient to tide them over a quiz period. Do not encourage guessing. Hit or miss answers show very little study. Reference : Miss Hawklnson. American Journal of Nursing, Volume 10. CARE OF WARD, GALLEY, HEAD. Subject: The hospital ward. Topic : Care of ward, galley, head. Class: A. Teacher's aim : To impress upon students the importance of clean liness and order in the ward, galley, head. MAIN TOPICS. A. Ward: 1. Ventilation. (a) Definition. (6) Temperature. (c) Movement of air. (d) Pure air. 2. Lighting. 3. Heating. 4. Cleanliness. (a) Definition. (b) Why removal of dirt is essential. 1 . It endangers health. 2. It has a depressing effect upon the patient. 3. It causes irritation of the mucous membrane. 4. It spreads disease. 5. Order. 6. Weekly field day. 7. Summary. 368 Vol. XX. NURSE COEPS. B. Galley: 1. Daily cleaning of galley, including care of dishes, cook ing utensils, food containers, ice chest, stove, etc. 2. Accumulation of food. 3. Disposal of garbage. 4. Extermination of insects and mice. C. Head: 1. Cleaning of bowls, hopper, and enamel ware, bathtubs, nickel ware, and other equipment of head. Care of floors. 2. Necessity of frequent inspection. 3. Care, of plumbing. Article necessary. 1. Basin or bucket of water. 2. Soap, soap powder, Bon Ami, metal polish. 3. Cleaning cloths. 4. Broom, brush, polisher, swab, or whatever is re quired for the cleaning of the particular kind of deck used in the ward. A. Ward: 1. Ventilation. (Definition —temperature— movement of air—pure air.) i Defined as continuous introduction of pure air, into a room or building, the mixing of it with the contained air, and the simultaneous extraction of a like quantity of impure air. State average temperature of ward during day or night (64 to 68 degrees). Effects of heat upon the pulse rate. Necessity of movement of air; regula tion of air currents. Illustrate by example. Pure air, free from gases and other forms of combustion. 2. Lighting. State necessity of light regulation after eye opera tions. Soothing effects of darkness as an aid to sleep and rest. 3. Heating: Analogous to temperature; overheating causes bad ventilation : overventilation causes loss of heat. 4. Cleanliness: Definition. Why removal of dirt is essential. It en dangers health—depressing effect on the patient—causes irritation of the mucous membrane2 — spreads disease. Removal of dirt. Explain how " bacteria ride on par ticles of dust." State how the art of cleaning is included in, and inseparable from, the art of nursing. No. 3. 369 NURSE CORPS. A. Ward—Continued. 4. Cleanliness—Continued. Proceed to illustrate the method of cleaning the ward. Emphasize the import of removing dirt from corners and obscure places. Pixplain care of cleaning cloths and the disposal of cloths that are worn and soiled from metal polish. 5. Order: Illustrate proper position of lockers and locker content; position of chairs, beds, and other ward furniture. B. Galley: 1. Daily cleaning of galley; including care of dishes, cook ing utensils, food containers, ice chest, stove, etc. Demonstrate proper washing of dishes, cleaning and polishing of cooking utensils and food containers. Supervise cleaning of ice chest. Teach proper care of whatever type of stove is in use. 2. Accumulation of food. Emphasize the necessity of caring for food and the waste of food through decomposition. 3. Disposal of garbage. Garbage to be placed in proper receptacle and removed from galley at stated times. 4. Extermination of insects and mice. Tell about cockroaches and ants, and the proper use of insecticides. Freeing the galley of mice by the use of traps. State how cleanliness and the proper disposal of garbage assist in keeping the galley free of pests. C. Head: 1. Cleaning of bowls, hopper, enamel ware, bathtubs, nickel ware, and other equipment of head. Care of floors. Illustrate proper cleansing agents for the different types of plumbing fixtures. Emphasize the destructive effect of verdegris. Teach proper cleaning of floors according to the particular type of floor used. 2. Xecessity of frequent inspection. In order that an accumulation of towels, soiled pa jamas, and articles of clothing are not left lying around by patients. In order that bathtubs and bowls will be kept in proper condition. In order that patients be not allowed to linger for conversation and smoking. 3. Care of plumbing. Reporting of leakage, and other defects in fixtures. Weekly field day : Thorough cleaning of ward and articles contained therein. Galley, head, quiet rooms, and all articles contained therein to 370 Vol. XX, NURSE CORPS. Weekly field day—Continued, be entirely freed from dirt and dust. Inspect each student's detail and make class feel responsible for the general appear ance of the ward. Summary. —Main points of the lesson. Ventilation, cleanliness, order. Method of cleaning. Reference: Textbooks on nursing. (Harmer, Pope, Maxwell.) CARE OF PROPERTY. Subject: The hospital ward. Topic : The care of property. Class: A. Teacher's aim: To teach the necessary care of ward property. Outline of main topics : 1. Expendable property. 2. Nonexpendable property. 3. The ward property book. 4. How to count property. 5. Wasteful expenditure of property. 6. Summary. 1. Expendable property : Use for examples, the expendable property kept in the ward. 2. Nonexpendable property : Emphasize the care and importance of nonexpendable prop erty. Illustrate by example the disposal of nonexpendable property that is unfit for use. 3. The ward property book : Point out the importance of correct entries for the reception of additional property, and the disposal of property for sur vey or for storage. Show how to account for property that is sent to be repaired. 4. How to count property: Impress upon students the necessity of careful counting of property. Discourage any method that tends toward guesswork. Illustrate by example. 5. Wasteful expenditure of property : Cite different ways in which linen, gauze, cotton, and other ward material, is improperly used. Try to make students realize the necessity of proper regard for property under their care. 6. Summary: Review main points of the lesson. No. 3. 371 NURSE CORPS. The following lesson plan was a class assignment, and the in structors criticism is noted. Subject: Bacteriology. Topic: Introductory lesson. Class: Elementary. Teacher's aim : To interest the pupils in the study of bacteriology. Outline of main topics: 1. Definition. 2. Why nurses study bacteriology. a. To learn protection of self. b. To learn to protect the patient. c. To educate the patient. d. To educate the community. 3. Conditions controlling infection : a. Condition of the skin. b. How bacteria enter body. c. Normal protective agencies. 4. Effects of bacteria upon the body : a. Destruction of body tissues. b. Toxins. c. Fever. 5. History of bacteria. 6. Unharmful bacteria. 7. Summary. 8. Assignment. 1. Definition: Microscopic forms of plant and animal life called microbes, microphites, micro-organisms, bacilli, micrococci, " bugs," etc. Botanists use name schizomycetes. Briefly explain the technical meaning of different groups of bacteria. Illustrate on blackboard single cell, etc. 2. Why nurses study bacteriology : Protection of self, patient, community. Illustrate by examples. 3. Conditions controlling infection : Pathogenic and nonpathogenic bacteria. Condition of skin (broken skin, cuts, pin pricks). How bacteria enter body (mucous membranes, abnormal tonsils, adenoids, respiratory and alimentary tracts. Malarial infection by mosquito). Normal protective agencies (substances in the blood and lymph that destroy bacteria). Ask questions; have pupils state their own observation of clean and infected wounds. 372 Vol. TvX. NURSE CORPS. 4. Effects of bacteria upon the body : Inflammation. Destruction of body tissue (suppuration). Toxins (effect). Fever (defensive reaction to combat bacteria and toxins). Show by diagram invasion of bacteria on body and resistance by fever. 5. History of bacteria: Important forms of bacteria, known by Muller in 1773, con sidered interesting by a few experts, called curiosities of the microscope. Ehrenberg advanced scientific grouping in 1830. Sixteen species in four genera were known in 1838. Classifi cation published by Cohn in 1875. In 1876 Cohn had seen spores germinate. Koch and others confirmed this discovery in various species. Tn 1873, Lancaster theory that different kinds of bacteria occur in one life history. Billroth, in 1874, said that various ba'cteria are different states of one organism. Discus sions arose. Agreement finally that the majority of forms are uniform, showing one type of cell throughout life history. In 1837 and 1843 Schwann and Helmholtz showed that fermenta tion and putrefaction were intimately connected with organ isms derived from air. First named animalculae—confounded with other small organisms. Cohn's classification still dominates study of bacteria. Explain. Explain meaning of spores and emphasize import of spore discovery. Illustrate by dia gram on blackboard the main points of the controversy. Preservation of putrescible substances depend on this principle. Illustrate by example. In 1857 Pasteur discovered lactic ferment. Pasteur and Cohn proved ammoniacal fermentation of urea, due to micrococcus ureae. In 1862, analogies between fermenta tion and disease began to be understood. In 1745 by Needham, and in 1777 by Spallanzani. heat experiments on bacteria. Unsuccessful. Specimens swarmed with bacteria a few hours after heating process. Between 1862 and 1872, Pasteur and Cohn made a complete ex planation of earlier anomalies of heat experimentation. Eesult, no putrefaction takes place without the presence of bacteria or some other living organism. Lister, Koch, and others applied the results of germ experimentation to surgery, and observations of the highest value were noted. Illustrate micrococci of Pasteur and Cohn. Briefly ex plain sterilization, and show the faulty technique that was probably employed in experiments. State a few of the early steps in surgical technique, and contrast with present-day methods. No. 3. 373 NURSE CORPS. 5. History of bacteria—Continued. At different times the resemblance of fermentation and dif ferent diseases had been noted. The idea of virus or contagium, in the nature of minute organisms capable of spreading and reproduction. P. F. O. Rayer in 1850 found anthrax bacilli in dead animals. Also observed by Pollender in 1855. In 1863, with ideas on Pasteur's researches in fermentation, Davaine put forth the opinion that anthrax bacilli caused splenic fever. In 1876 Koch published these observations. In 1870 Pasteur proved that the disease of silkworms was due to bacteria. In 1871 Oertel proved that a micrococcus, already known to exist in diphtheria, was intimately concerned in producing the disease. In 1872 Cohn grouped together a number of pathogenous bac teria, and out of this grew the modern germ theory of dis ease. Progress up to the present day. Explain contagium, from Latin contagio. Give short his tory of contagious diseases, and stress the value of the germ theory. 6. Unharmf ul bacteria : Nonpathogenic. Bacteria that produce flavor in cheese and butter. Illustrate by example. 7. Summary: Main points of the lecture. 8. Assignment : First lesson in bacteriology. — Smeeton. Brief sketches of the life and characters of the men most noted in the early bacteria experiments. —Encyclopedia Brit- tanica. Criticism by Miss White : Don't you think that only that part of the history which will arouse interest should be given at this time? They appreciate the history in detail more at the end of the course. Reference : Curriculum, Standards and methods of good teaching. Ameri can Journal of Nursing. Volume 19, Preparation of the lesson plan, by Miss Hawklnson. THE USE OF TEXTBOOKS. Textbooks used as a tool. Contain means of having on hand necessary data. Present definite organization of material. Furnishes pertinent subject matter. Presents a view which one may use as a basis for elaboration. Presents definite problems. Indicates trend of educational thought. Is an aid to the teacher in saving time. It meets the demands of the conservative and progressive. 374 Vol. XX. NURSE CORPS. Selection of texts. We should not be influenced by the author. Because the writer of a textbook is considered an authority, it does not follow- that the book contains the presentation of material that is suitable for your class. The person who selects the textbook should have a wide knowledge of the subject and also a knowledge of the mind of the pupil. He should not be influenced by the salesman nor by the appearance of the book. The general appearance of the book, however, should be substantial and artistic, paying due attention to the contents. The statement that a book is widely used requires investigation to find out whether it is gaining or losing ground. Cost of textbooks. Not the cost of the book, but the worth of the book, should be the prime factor of consideration. Persons trained in the required subjects should make the selec tion of textbooks. The books should come under the authority of the superin tendent in coordination with the teachers who use the books. Sometimes a book is tested before it is adopted. Standards for selection. Exhaustive examination of a text should be made by a competent committee before it is selected. Standards should be applied to the content and organization of the book. The main justification of a textbook is that it meets the needs of the user. The purpose of the author is usually stated in the preface. A textbook should be examined from the standpoint of accuracy and reliability of material. It should be free from bias and dogmatism. Relative values of subject matter should receive consideration. It should be in harmony with the school cur riculum. The amount of material contained should be checked. The illustrations should be given attention. The date of the copyright should be noted. TEACHING OF SCIENCES. Content of course. There should be a careful selection of subject matter. The choice of subject matter should fall on such elements as are useful in the pursuit of practical application. All material should be simple enough to be comprehensible. • It should be associated with the situation in which it is needed. Teaching. Teaching of sciences is important as a basis for nursing education. No. 3. 375 NURSE CORPS. Benefits derived from study of sciences. Training in accuracy and observation of statement. Training in manual dexterity. Trains student to draw conclusions. Gives a knowledge of certain specific sciences and laws. Defects in scientific instruction. Lack of time for teaching. Instructors who are not, trained in teaching sciences. Lack of preparation on the part of the instructor. Lack of application to work. Lack of laboratory equipment. References: The Textbook, Hall-Quest. How to judge a textbook. The selection of textbooks, by Maxwell. Chapters 1 and 2. TEACHING CHEMISTRY. Reasons for study of chemistry. , It is necessary for the teaching of physiology. It is used as a basis in materia medica. Used in teaching cookery. It should be taught early in the nursing course. Introductory lesson. Point out the aim of the course for the pupil. Show the relation of chemistry to life. Illustrate changes in matter. Method of presentation. Lecture. , Textbook and recitation. Lecture method. Covers more ground. Gives color and emphasis to special points. Explains difficult points. Gives more vital illustrations. Eliminates tilings that are not vital. Textbook method. Textbook method requires an adequate textbook. It requires working over a large amount of material. The advantage of the textbook method is that students get more than one point of view, and it makes them more independent. Laboratory and demonstration method. Laboratory method is preferable. Laboratory exercises should coincide with material that precedes or follows the current lecture. It provides a means of answering a question or ques tions that are presented in the lecture. 78693—24 7 376 Vol. XX. NURSE CORPS. Method of presentation—Continued. Textbook and recitation —Continued. Laboratory and demonstration—Continued. It compels careful observation and thought. Not too many exercises should be selected for labora tory work. The exercises should be easy to manipulate. Teachers should demand that students be accurate and draw conclusions. Method of giving laboratory directions. Laboratory manual. Not practical. It does not offer opportunities for special application. Oral directions. Result in confusion and waste of time. Writing directions on blackboard. Fairly good. Blackboard locations are not suitable for the accommodation of all the class and time is lost in attempt ing to read the notes. Giving directions on mimeograph sheets. This is the best method, and the one most easily follower! by the pupil. All laboratory notes should be kept. Entries in notebooks should be made as soon as possible after experiment has been tried out. Pupils should know something of approximate measurements, because paying too strict attention to nonimportant meas urements detracts from the lesson. Distribution of supplies. As far as is practicable have individual bottles of supplies for each student. Laboratory equipment. Stationary desks 33 inches high, 33 inches long, 22 inches deep. Wood with valspar finish is very practicable for desks. The drain should be at the end of the desk rather than in the center. The window lights should be good. There should be plenty of blackboard room. Hints about buying. Deal with reliable firms. Make out a list of requirements and ask for an estimate. Have a list of prices ready for consideration. Orders should be sent in annually or semiannually. Card catalogue all articles bought. Date bought, amount, price, name of firm. Be careful that corks bought fit the bottles, test tubes, and flasks. In ordering glass tubing, order it to fit the holes No. 3. 377 NURSE CORPS. Method of giving laboratory directions—Continued. Hints about buying —Continued. in the corks. Order chemically pure chemicals. Keep triplicate copies of orders. Laboratory equipment (for the individual student). Test-tube brush. Bunsen burner. Evaporating dish. Wire gauze, 6 by 6 inches. Rubber tubing, 2^ feet. Ring stand and rod. Clamp (Burett). Large ring. Beaker, 250 cubic centimeters. Two wide-mouth bottles, 8 ounces. Funnel. Two cover glasses, 2 by 2 inches. Six test tubes. Thistle tube. Glass tubing, 12 inches. Glass rod. Asbestos square, 12 by 12 inches. Deflagrating spoon. Rubber tubing, small. Rubber stoppers. Florence flask, 500 cubic centimeters. Test-tube holder. Test-tube rack. General equipment. Plumbing. Lead pipes are preferable, as acid destroys zinc. Balance and weights. Reagent bottles, 8 sets, 5 bottles to each set. Liebigs condenser, for distilled water. Electrolysis outfit. Cork borer. Wire cutter. Thermometers, centigrade and Fahrenheit. Hand lens. Magnet. Spoons. Spatula. Textbooks (Smead, McLeod, Ottenberg, Peters). Reference: Rockefeller report, pages 249 to 292, Chemistry. Standard curriculum, Chemistry. American Journal of Nursing, volume 16, page 1208, Needs of chemistry in the training schools, by Miss Parker. 378 Vol. XX. NURSE CORPS. TEACHING BACTERIOLOGY. Reasons for teaching bacteriology : Pupils learn to protect themselves. They learn to protect the patient, to educate the patient and the community. The students have greater appreciation for technique. Interest is aroused by way of laboratory work. There is a better under standing of technical terms employed by doctors in regard to disease. Powers of observation and a scientific attitude is developed. Economic as well as disease phases of bacteria should be taught. The study should be taken up in the preliminary course of nursing. By whom taught. Bacteriology should be taught by a properly trained nurse in structor. Not only should the students be taught bacteriology, but they should also be taught microbiology. Method of teaching. Lecture method (quiz) assigned topics in connection with labora tory work. One hour lecture. Two hours laboratory and demonstration. Divide class in sections for laboratory work. Ten pupils are a sufficient number for one class. With a larger class microscopical work is difficult to teach. Forty-five hours are necessary for a course in bacteriology. Content of course. Only that which is most vital to the nurse should be taught. General knowledge, including relation of microbiology to gen eral biology. Agencies used to check bacteria, method of growth, etc. Emphasize study of pathogenic bacteria. Tell how organisms enter body. Result of invasion. Question of immunity. Transmission of disease. Two classes of students may be working at one time; one class may have demonstration of different types of culture media tubes, while the other class may be inoculating culture media. The students should be taught the mechanism of the microscope before they are permitted to use it. Have students draw what they see through the microscope. Consider all organisms pathogenic. No. 3. 379 NURSE CORPS. Laboratory equipment. Microscopes, high and low power. (One microscope for every two pupils. Good light for microscopes. Tables, comfortable height for the use of microscopes; stools to sit on while examining specimens. Running water. Blackboards. Autoclave. Ice chest. Incubators. Individual equipment. One thumb forceps. One platinum needle or loop. One medicine dropper. Slides. Cover glasses. Cotton. Lens paper. Filter paper. Scalpel. Soap dish, with glass and drain. Alcohol lamp or Bunsen burner. Stains. Oil for oil-immersion lens. Petri dishes. Test tubes. Fermentation tubes. Culture media. One set of stains is sufficient for every three or four pupils. References: American Journal of Nursing, volume 16, Teaehlng of bacteriology. Modern Hospital, volume 9, Teaching of bacteri ology. Textbooks: Coons, Marshalls, Buchanan, Jordan, Smeeton). Yeasts and molds, by Conns. Applied biology, by Bigelow. How we resist disease, by Broadhurst. Sources and modes of infection, by Chapin. Bacteriology, by Hiss and ZInser. Preventive medicine and hygiene, by Rosenau. Time must be had to prepare the lesson. The lesson must be practical. Lesson must be illuminating to the problem at hand. DRUGS AND SOLUTIONS. Arithmetical difficulties. It is best to assume that the class know nothing about arithmetic. Make your plans as simple as possible for teaching the systems of measurement. It is best to teach the apothecaries' system first, then teach the metric system. 380 / Vol. XX. NURSE CORPS. Class periods should be for If hours. . Give 30 minutes to common drugs, different types and prepara tions; 1 hour should be given to laboratory work. Later on in the class, give 45 minutes to the action of drugs, and 45 minutes to laboratory work. At the end of the class give more time to the commoner drugs and less time to laboratory work. N Equipment (chemistry or bacteriology laboratory). One set for every two students. Scales. Apothecaries' and metric weights. Graduates, glass, various sizes. Graduates in apothecaries' units. Graduates in metric units. Measuring spoons. Medicine droppers. Minim graduate. Glass rod. Pitchers. Hypodermics. Reference: Standard curriculum, Drugs and solutions. Modern Hos pital, Volume 15, A symposium on pharmacy for nurses. TEACHING HYGIENE. Teaching hygiene is often a failure because the proper facilities for carrying it out are not available. Public sanitation can be enforced. Personal hygiene must be convincing. Aims of personal hygiene. It succeeds in establishing in the students, habits that will lead to health. It makes them understand the laAvs of health better, and thus they become better health teachers. They should be made to feel their social obligation. It arouses a sentiment in the school toward those who become ill through their own fault. The teacher of hygiene should be enthusiastic over her subject. The proper teacher is a physician who is interested in the pupils. The pupils should be graded according to the amount of practice they carry out. Teach hygiene during the first year. Introduce whatever an atomy and physiology is necessary for illustration. References: Personal hygiene applied, by Williams. Physical educa tion, by Williams. Public and personal health, by Ritchie and Emerson. How to live, by Fisher and Flsk. Standard curriculum, Chemistry. Pamphlet by Doctor Storey, A general outline and syllabus on hygiene. No. 3. 381 NURSE CORPS. NURSING. 1 Notes on practical procedures, given by Miss Walsh at Leland Stanford University summer school, June 19 to July 15, 1923. OUTLINE OF COURSE FOR STUDENT NURSES. Admission, transfer, and discharge of patients. According to plan of hospital ward and room; ventilation, light, heat; furniture and utensils; cleaning soaps and polishes; methods of cleaning, dusting. Linen : Care of soiled linen ; removal of stains, demonstrated. Linen closet, care and arrangement. Care of torn linen. Laundry. Hospital supplies: Cost; necessity for conservation. Care and handling of dressings; care of dressings after use. (All gauze is washed and sterilized for further use.) Central supply room. (A large, centrally located room, for issue and accountability of supplies.) Garbage, source and waste. Bed making: Various kinds of beds. Care of bed after dismissal of patient. Devices used in bed for the comfort of the patient. Appliances, use and care. Care of patient : ; _ ,• Care of clothing and valuables. Baths, bed and tub. (Care of head, hands, feet, and nails.) Dressing and undressing. Moving and lifting. Application of binders. Evening care. Care after death. Bed sores: Immediate and predisposing causes of bed sores. Preventative and other treatment. Observation of symptoms : General appearance of patient on admission, deformities should be noted. Objective and subjective symptoms. Preparation of a patient for general examination. Enemata : Purpose. Various kinds used. Condition of patient. Intestinal irrigation. Colonic irrigation. 382 Vol. XX. NURSE CORPS. Proctoclysis. Douches. Temperature : Production of heat in the body. Varieties of fever. Method of taking temperatures. Pulse : Respiration. Charting. Counterirritants. Collection of specimens. Medicines. Practical administration of medicines. Advanced nursing procedure. Hypodermics. Catheterization. Anatomy of the urinary organs. Bladder irrigationy Preparation for surgical dressings. Preparation of patient for operation. Postoperative care. Lavage and gavage. Alcohol and tepid sponges. Packs, hot and cold. Partial packs. Preparation for different forms of surgical treatments. Aspiration. Transfusion. Blood cultures. Lumbar puncture. Giving of arsphenamine. Giving of neo-arsphenamine. Additional discussion. Structures involved in acts of skill. How far to make nursing practice automatic. General possibilities of teaching nursing. Present situation and difficulties of teaching. References: The psychology of management, by Gilbreth. The prin ciples of scientific management, by Gilbreth. Theory and practice of scientific management, by Thompson. Education for initiation and originality, by Thorndyke. Modern hospital, June, 1919, pos sibilities of standardizing hospital technique. Modern hospital, June, 1923, teaching practical nursing, by Miss Harmer. Nursing textbooks, Pope, Maxwell, Saunders, Jamme, Wheeler, Harmer. Bodily effects; pain, hunger, fear and rage, by Cannon. Night ingale notes on nursing in the hospital, by Henley. Method of teaching, by Parker. No. 3. 383 NURSE CORPS. CATHETERIZATION AND BLADDER IRRIGATION. Review anatomy of the urinary tract. Give reasons for catheterization; stitches, preoperative, postop erative, etc. Retention and suppression of urine. Concentration test, ratio, urea. Means used to induce patients to void; psychology, drinks, etc. Reasons for sterilization ; bacteria. Trays : Use if possible white enamel trays. White enamel solution basin, containing boric acid (2 per cent). Instrument container for the sterilization of catheters. Catheters. Use a short piece of rubber tubing on the end of glass catheter. Curved basin for soiled sponges. Hemostat or sponge forceps. Have tray covered with a sterile towel. Procedure : Drape patient with top sheet in the form of a V. Use chest blanket for warmth. Scrub hands from three to five minutes. Cleanse parts around the meatus, using boric solution. Use forcep to handle sponges. Gently insert the catheter. (Never collect less than 4 ounces of urine for a specimen.) After catheterization and before removing catheter, attach triumph syringe, and inject silver nitrate or argyrol. Note. —Have solution of silver nitrate or argyrol in a medicine glass, pour through syringe Into the bladder. Do not use plunger on the syringe. Bladder irrigation. Give reasons for bladder irrigation. If possible have glass irrigator for solution. Glass is an ad vantage in that the amount of solution going into the bladder can be seen. Have temperature 105°. Sterilize thermometer by wiping it with alcohol. Catheterize patient. Without removing catheter, attach tubing from irrigator, and be sure that the bladder is well filled with solution before allowing it to empty. This is important in order that all parts of the bladder lining be reached; 12 to 14 ounces is usually sufficient to fill the bladder. After irrigation allow argyrol or silver nitrate to run into the bladder. Use rubber gloves for isolated cases. Have students read the urinary reports. 384 Vol. XX. NURSE CORPS. Collection of urine. 1. The bedpan or other receptacle must be clean. The ordinary specimen bottle, holding from 4 to C ounces, must be clean, and securely corked. The specimen slip should be filled out in every detail, and attached to the bottle when sent to the laboratory. 2. An admission and preoperative specimen is collected for every patient, except when otherwise ordered. 3. Other specimens collected only as per order. 4. Labeling of urine collections: a. In all cases note and record the time the collection com mences, as well as the time it finishes. b. Especially in short time urine collections, over a period of from one to six hours, it is of the greatest impor tance that the record be most accurate. Example. —A series of two hourly collections are to' be made, beginning at 6 a. m. It is unlikely, even with the best of care, that it can be collected exactly at 8 a. in., 10 a. m., 12 m., etc. If the accurate time is given, however, the proper corrections for these unavoidable irregularities can be made in the labo ratory. This can only be done if the report is accurate. Labels should read something like this: 6.02 a. m.- 7.58 a. m. 7.58 a. m.-10.03 a. m. 10.03 a. m.-12.01 p. m. 5. Twenty-four-hour specimens of urine: a. Start collection at 6 a. m. Have patient void a few minutes before starting collection. Discard this first urine. Save all urine for the following 24 hours. b. All 24-hour specimens of urine must be collected in gal lon bottles, containing the proper preservative. 1. Diabetic : Bottle must contain 20 c. c. of sulphuric acid 5 per cent. 2. Albumen : Bottle must be rinsed with 40 per cent formaldehyde. 3. For other urine collections no preservative is re quired. c. Each specimen bottle must be tagged with patient's name, room, bed number, doctor's name, date. d. Get definite order as to laxative; purgatives are often contraindicated in the collection of a 24-hour specimen. e. Send whole specimen to laboratory. Record time on bedside chart. 6. Concentration test. a. First day: 1. Patient to have breakfast. After breakfast, dry diet. No fluids are given during the day or night. No. 3. 385 NURSE CORPS. Collection of urine—Continued. 6. Concentration test—Continued. " a. First day—Continued. 2. At 6 p. m. patient voids. Discard this urine. 3. After 6 p. m. until next a. m. patient is not to void, but if urine can not be retained, have patient void into a specimen bottle prepared for the purpose. b. Second day. Have patient void into a specially prepared specimen bottle. c. Send whole specimen to laboratory, properly labeled. Record time on bedside chart. 7. Concentration and ratio test. a. Follow first day routine of concentration test. b. Second day. 1. 6 a. in. collect specimen of urine. 2. No breakfast. a. Male patient voids directly into bottle specially prepared. b. Female patient is catheterized. 3. After collection of 6 a. m. specimen, patient drinks slowly 500 c. c. of water, in which a varying amount of urea has been dissolved. The patient then drinks 250 c. c. of water, making 750 c. c. in all. 4. At 7 a. m. have patient void; discard urine. The patient then drinks 500 c. c. of water. 5. At 8 a. m. have patient void; discard urine. The patient then drinks 500 c. c. of water. 6. At 8.45 a. m. nurse takes patient and specimen of urine to laboratory. 8 Phenolsulphonephthalein test. a. Have patient drink at least 500 c. c. of water. b. Have patient void as soon as possible after drinking water, discard the urine. c. From 15 to 45 minutes after patient drinks water the nurse injects phthalein 1 c. c. into lumbar muscle or into deltoid muscle, using record needle. Important points to remember : 1. The amount of phthalein must be very accurately measured. 2. The injection must be really into the muscle and not into the subcutaneous fat. 3. A long needle is necessary. An unusually Jong one for fat people. 386 Vol. XX. NURSE CORPS. Collection of urine—Continued. 8. Phenolsulphonephthalein test—Continued. c. From 15 to 45 minutes, etc.—Continued. 4. The needle must be directed at right angles to the body surface. It is often necessary to drive it into the hilt in order to be certain that the muscle is really reached. d. As soon as needle is withdrawn, record time on chart. This must be accurate to within one minute. e. One hour and five minutes later instruct the patient that the first collection of urine is to be made in a few minutes, and try to get the patient to completely empty the bladder, exactly 1 hour and 10 minutes after injection. Label this specimen No. 1, and record time of injection and collection of urine. Example. — Specimen No. 1; Injection 3.05 p. m. ; collection 4.15 p. m. /. Have patient drink at least 250 c. c. of water. g. Exactly one hour after collection of specimen No. lr have patient void. Label this urine specimen No. 2, and record time during which collection was made. Example. —Specimen No. 2 ; 4.16 p. m. to 5.15 p. m. ; accurate to- within 1 minute. h. Patient may have meals during treatment, including fluids in generous quantity. i. Send the two specimens, each properly labeled, to the laboratory. Record time on bedside chart. CYSTOSCOPY PREPARATION. a. Liquid or light breakfast, include milk. b. Water by mouth 250 c. c. 1 hour before cystoscopy. Repeat just before going to cystoscopy room. c. No local preparation required. PROCEDURE FOR FRACTIONAL REMOVAL OF STOMACH CONTENTS. Two methods employed. Articles necessary : Rhefus tube, attached to rubber tubing with silk thread. Small basin with cracked ice for rhefus tube. Curved basin for mouth discharges. Triumph syringe. Four sterile specimen bottles, plugged with cotton. Flask with 500 c. c. of 2 per cent barley water. No- 3- NURSE CORPS. 387 Procedure : Kinse mouth with cold water. Tube to be swallowed to a given mark. After 10 minutes attach triumph syringe to tube and remove stomach contents. Tube to be left in . place, clamped off with a forcep. Give barley water drink without removing tube. Fifteen minutes after taking barley water the second speci men is removed. Fifteen minutes after the second specimen, a third speci men is taken. Fifteen minutes after the third specimen, a fourth specimen is obtained. The four bottles are correctly labeled, and sent to the labora tory for examination. The students are taught to read the reports that come to the ward. REMOVAL OF STOMACH AND DUODENAL CONTENTS, LYON METHOD. Articles necessary: Tube packed in ice. Three bottles with perforated corks. 100 c. c. of sterile magnesium sulphate 25 per cent solution. Litmus paper. Curved basin for mouth discharge. Procedure : If possible turn patient on right side. Tube to be swallowed to a given mark. Fasting contents to be removed by aspiration. First specimen to be marked " fasting contents." (Tube to be clamped off and remain in place.) Elevate foot of bed, or fix hips higher than head. Have patient drink a glass of water, and while water is being drunk, push the tube on into the duodenum. It takes about 15 minutes to get the tube through to the pylorus. One syringe of air is forced through the tube to inflate the duodenum. The syringe is removed and the second bottle is attached to the tube. The bottle is then placed on a low stool by the bedside. The fluid is tested to be sure it is not acid. The color of the fluid should be a pearly gray ; 1 or 2 c. c. should be collected. This makes specimen No. 2. Between 50 and 100 c. c. of megnesium sulphate is now in jected through tube. The third bottle is attached ; aspiration is made with bulb syringe, and from 10 to 20 c. c. of bile flows into bottle. This makes specimen No. 3. The tube is re moved and the patient put in a comfortable position. 388 Vol. XX. NURSE CORPS. Cleansing of tube: To be washed with cold water, flushed out with syringe, washed in warm soap and water, dropped into boiling water for a minute or so. NASAL FEEDING. Determine whether tube is in the trachea or esophagus, by placing end in a glass of water. Bubbles will appear in the water if the tube is in the trachea. INSULIN. In January, 1922, insulin was first used. It is a solution of the active principle of the beef pancreas. H 10 was the first prepara tion. H 20 is the preparation now in use. It is administered sub- cutaneously, never intermuscularly. Iodine should be used in the skin preparation, alcohol causes insulin to coagulate ; 1 c. c. of insulin contains 1 unit. It is given in increasing doses, 15 minutes before, or 15 minutes after meals. Sample chart for insulin cases. Name. Day. • Date. Hour. Dosage. c. c. 1 Tuesday 1. 2 Patient. The dosage of insulin is figured out according to age, height, weight, sex. Diet: Atwater's table is used in diet. Bran cakes, agar jellies, thrice-cooked vegetables, mineral oil mayonnaise, coffee, tea. A twenty-four hour specimen of urine is collected from each patient every day. Urine analysis, and analysis for blood sugar, are important. The doctor guides the. dose of insulin by the decrease of sugar in the blood and urine. Reaction is indicated if the blood sugar falls to 0.05. Symptoms of reaction : The patient is very hungry, very thirsty : there is profuse perspiration and possibly hysteria. Treatment for reaction : Large dose of insulin. Glucose 1 table- spoonful in lemon or orange juice. Sweet chocolate. The effect of this treatment is instantaneous. Treatment for coma : Large dose of insulin ; Epenephrin, 1-1000 solution. Effect : Decreases sugar in the blood and urine. No. 3. 389 NURSE CORPS. LESSON PLANS FOR PRACTICAL PROCEDURES. Object of lesson plans : 1. Arousing interest. 2. Developing thinking power. 3. Promoting observation of patient. 4. Developing right attitude toward patient. 5. Help in development of habits of system. Outline for lesson plan : 1. Object. 2. General or local effect. 3. Important points to remember. 4. Articles required. 5. Preparation of patient. 6. Procedure. 7. Result. 8. Observations. 9. Charting. LESSON PLANS ACCORDING TO THE ABOVE OUTLINE. Hypodermic injections. Subcutaneous. Object : For prompt action of a drug. When a drug can not be taken by mouth. General or local effect : Hypnotics, usually for general effect or remote local effect. Local anesthetics. Important points to remember : Needle to be sharp and straight. Sterilization of needle and syringe. Avoid injection over a bony prominence, or in the course of blood vessels and nerves. Articles required : Alcohol lamp, or other apparatus for use in sterilization. Spoon. Hypodermic syringe. Sharp needle. Alcohol 70 per cent. Cotton or gauze sponges. Whatever drug is to be administered. Procedure : Sterilize needle by boiling. Sterilize syringe by immersion in alcohol or by boiling. Dissolve tablet by dropping into spoon containing 10 or 15 minims of sterile water ; draw solution into syringe. 390 Vol. XX. NURSE CORPS. Procedure—Continued. Sponge fleshy part of upper arm with alcohol; hold flesh be tween ringer and thumb; insert needle almost full length into the skin; force solution from syringe; gently withdraw needle. Hold sponge over point of injection for a few minutes. Result: According to medicine given, note result. Observations: Observe idiosyncrasy for drug, or other unusual manifestations. Charting: Record time when hypodermic is given; record result and observations. Note. —This lesson plan is limited. It can be made very extensive by in troducing the subject of bacteria to emphasize the importance of sterilization ; anatomy to point out the reason for choosing a special part of the body for the injection ; the effects of different drugs to stimulate observation. Sponge bath. Object : For cleanliness. General or local effect: Local effect on the skin. General effect on the system, producing a feeling of comfort and refreshment. Important points to remember : Unnecessary exposure of patient. The body is to be kept well covered, except the part that is being bathed. Exhaustion of patient. Bath to be discontinued if signs of weakness occur. Thorough cleansing and drying of the body surface. Do not prolong the bath. The patient should be bathed as quickly and thoroughly as possible. Articles required : Bath blankets, two. Hot water bag and cover. Bath towels, two. Hand brush, orange stick, scissors. Soap. Wash cloth. Foot tub with hot water. Preparation of patient: Have room warm; remove bedclothes except top sheet; pass a bath blanket under patient; cover patient with the second bath blanket, and slip out top sheet from under blanket. Put hot water bottle to feet. Procedure: Tuck towel under chin. Wash face, neck, and ears, dry thoroughly. Place towel under arm; wash arm from shoulder to wrist ; dry. Put hand in basin, scrub nails with brush, use orange stick, trim if necessary. Treat other arm and hand in like manner. No. 3. 391 NURSE CORPS. Cleanse chest and abdomen down to pubic region, being careful to extend well over side toward back ; dry. With bath towel under leg, wash from hip to ankle. Bathe other leg in the same manner. Put foot tub in bed, immerse feet in water, scrub toe nails with brush, cleanse with orange stick, trim if necessary. Change water. Turn patient on side; press towel along back close to the bed; wash and dry back. Lastly, thoroughly cleanse genitalia. Remove bath articles and make patient comfortable. Note.—If the patient has heen neglected, and the skin requires unusual cleansing, the bath water must be changed as is necessary. If the patient Is bathed every day or every other day, and can be easily moved in bed, proceed with the bath in this manner : Wash face, ears, neck ; arms and hands ; chest and abdomen ; back ; legs and feet ; genitalia. This procedure is simple, and most desirable when many baths have to be given, as it obviates the delay occasioned by changing bath water. Result: Patient should feel rested and comfortable after bath. Observations: Note exhaustion or unusual effects of bath. Note abnormal skin conditions. Charting: Record time bath is given. Record observations. Eye irrigation. Object: Cleansing and antiseptic. General or local effect : Local. Important points: Before irrigation the lids should be carefully cleansed to re move any secretions or particles of dust adhering to the lashes, which would otherwise be carried into the sac. The lids should be gently but well separated with the thumb and forefinger. Avoid pressure on inflamed lids. In irrigating just sufficient force to dislodge secretions should be used. The fluid should be directed from the inner to the outer angle of the eye, so as to avoid fluid or discharge flowing into the lachrymal duct. Avoid touching eye with irrigator. After irrigation cleanse and dry lids. Articles required: Irrigator. Boric solution 2 per cent, or other medication as ordered. Curved basins, two. One for return solution. One for soiled sponges. Cotton pledgets. 78683—24 8 392 Vol. XX. NURSE CORPS. Preparation of patient: If in bed the patient should be in a dorsal recumbent position, with the head turned slightly to the side to be irrigated. The lighting should be placed so that the nurse can see suffi ciently what she is doing, without allowing a glare on the sensitive eyes of the patient. Irrigation of the eyes is more effectively carried out if the patient is lying down, instead of sitting up in a chair. Procedure: Cleanse all secretion from lids and eyelashes. Sepa rate lids with thumb and forefinger. Have patient hold curved basin against cheek to receive return solution. Direct a gentle stream of lukewarm solution from the inner to the outer angle of the eye. Cleanse any secretions that adhere to lids and eyelashes. Wipe dry with cotton pledget. Result : Amount of discharge or any foreign matter removed by irrigation should be noted. Observations : Condition of eye as result of treatments. Charting : Record time of irrigation, result, and observations. Note. — In the treatment of an Infected eye, lay particular stress on the danger of carrying the infection to the clean eye. Where both eyes are Infected, emphasize the importance of cleanliness and care of articles used for treat ment, also care of nurse's hands and the danger of infecting herself. Reference: Textbooks on nursing, Maxwell-Pope, Harmer, Sanders. PREPARATION OF PATIENT FOR OPERATION. Shave. Cleanse with green soap. Apply sterile dressing. The application of the sterile dressing is merely for its psychological effect upon the patient. Shaving : One inch beyond the hair line should be shaved for a mastoid operation. Paste oiled silk along hair line to hold hair away from incision. All shaving should be done with particular care and regard for patient. Interest pupils in the preparation of patients by telling of per sonal experiences in preparing patients for operation. To be emphasized : Soap for shaving. The area that is to be shaved. Drinking of water. Fluids to be taken up to 6 a. m. the morning of the operation. Intake of fluids before an operation lessens thirst after the operation. Drinking of alkaline waters, counteracts acidosis. The morning of the operation the patient is to go to the surgery in as calm a state of mind as possible. No- 3. NURSE COKPS. 393 i Postoperative care of patient : Greatest danger occurs during first half hour after operation. Do not allow a probationer to watch an ether case. In an emergency call the doctor. Use artificial respiration. Use tongue forceps if patient swallows tongue. For circulatory failure, adrenalin or epenephrin. Pneumonia jacket during the first 24 hours after operation. Patient to be left between blankets until evening, when the opera tion is performed in the morning. A corresponding number of hours should elapse if the patient is operated upon later in the day. Temperature of the room should be 68°. It should be well ven tilated to accommodate the ether that is eliminated by the lungs. THE DIVISION OF PREVENTIVE MEDICINE. Lieut. Commander J. R. Phelps, Medical Corps, United States Navy, in charge. Notes on Preventive Medicine for Medical Officers, United States Navy. REMARKS ON THE EPIDEMIOLOGY OF SMALLPOX AND THE PREVENTIVE VALUE OF VACCINATION WITH COWPOX VIRUS. A few weeks ago a medical officer whose advice is sought from time to time about health measures in the Scouting Fleet wrote to the bureau and asked, should there not be more definite instructions re garding vaccination, with especial reference to the time that should be permitted to elapse before again revaccinating men who have given immunity reactions? He stated that he has found many medi cal officers entirely hazy on the subject of immunity reactions, and he feels that the rule followed by him to revaccinate each year makes for safety and may be the means of preventing an occasional ease of smallpox. That is undoubtedly true. As Leake has pointed out, " Vaccination is like oil on a good machine ; it should be applied little and often." Revaccination in the case of an individual who has given a re action of immunity within a year or two is without danger and causes either no physical discomfort at all or such a trivial amount that no individual can raise plausible objection on these grounds if vaccination is properly performed, as it should be, with a minimum degree of traumatism. Nevertheless, many people do object to the frequent repetition of such procedures even though they be but little inconvenienced thereby. When all is said and done, unless revaccination every year can be justified as a measure of necessity, or unless it can be logically main tained that everybody must and should be revaccinated every year to insure the prevention of an occasional case of smallpox that would otherwise occur, it is hardly advisable to promulgate regula tions or instructions to that effect. Circumstances necessarily alter cases. Many of the personnel, enlisted men as well as officers, for long periods are not subjected to exposure to smallpox in such viru lent form as to overcome the protection afforded by successful vac cination two, three, or even several years previously. On the other hand, regardless of whether last vaccinated 12, 24, or 36 months ago 395 396 Vol. XX. DIVISION OF PREVENTIVE MEDICINE. it may become advisable at any time to revaccinate the personnel at some particular station, or the crew of a ship, or all members of the command in an entire fleet, because unusual danger of exposure to smallpox is known or presumed to exist. In fact, when smallpox is present in epidemic form or known to be endemic and actually prevalent it is justifiable to require revaccination even though the individual may have had an accelerated take or an immunity re action within 12 months. General instructions must provide for all contingencies. It is not desirable that they be unnecessarily rigid in their requirements. In civil public health practice revaccination of the entire population every seven years would be regarded as a great step toward com plete protection against smallpox. Revaccination every four years would be wonderful. The last is a natural requirement for enlisted men of the Navy. As a matter of fact, in the ordinary course of events the majority of men attached to crushing ships or serving at foreign stations will be revaccinated every year or so. Medical officers are expected to make sure that every man who joins the organization is protected against smallpox. If the man's health record does not contain a signed entry for an immunity reaction within a year or so, revac cination should be performed to determine that he is immune. A record of a take within two or three years furnishes presumptive evidence of protection, but, as a rule, in such cases it is desirable to test for immunity reaction since, it is little trouble to revaccinate and it causes the man little or no discomfort. It is natural also to revaccinate every new man coming on board whose health record does not indicate recent vaccination, in order that the vaccination record may be brought up to date, the health record placed in the permanent file and no further thought be required on that account for a long time to come. The rate of personal turnover brings so many new men to the organization that this course alone continu ously insures that most of the crew will be found at any time to have been revaccinated within two years at the most. So many circum stances arise and lead to revaccination from time to time on ac count of supposed danger of smallpox, and so many circumstances would interfere or make it inadvisable to revaccinate at the expira tion of a definitely fixed period, that it is better to rely upon the discretion of the medical officer of the organization who naturally is expected to inform himself as to the proper course to follow. It is the purpose of this article to assist those who have not com pletely formulated their ideas regarding the value of the immunity reaction and its use from the administrative standpoint. The manual of the Medical Department requires that officers shall be revaccinated at least once in every seven years. That conforms No. 3. 397 DIVISION OF PREVENTIVE MEDICINE. to good civil public health practice, barring the presence of an epidemic, but many individuals lose immunity in the course of seven years to the extent that some degree of accelerated take instead of an immunity reaction will result when revaccinated. It is generally considered that immunity established against cow- pox virus means at least equal protection against smallpox virus. In fact, there is some evidence, epidemiological in nature, that the immunity conferred by the various degrees of reaction to cowpox virus is even more certain to protect against smallpox virus than against cowpox itself. However, it would certainly be unwise for a person who has not been revaccinated in six or seven years to expose himself to smallpox. The age of the individual must be taken into consideration. Officers as well as enlisted men will be revaccinated more frequently in their earlier years, so that by the time they reach middle life they will have had their immunity stimulated several times and most of them will have responded repeatedly with immunity reac tions. The intervals can then be lengthened with comparative safety. Revaccination should be performed regardless of age if exposure to smallpox is likely to occur. When an individual, sometime in the past immunized to cowpox virus, is exposed to smallpox under natural conditions, infection will depend upon at least two factors of determining importance besides the existing state of immunity. The first is dosage —the mass of virus finding lodgment in a portal of entry. The second factor is the degree of virulence of the invading virus. The term is used here in the broadest sense to include ability to adapt to the juices of the host and multiply as well as ability to invade the tissues and produce disease; that is, the power to cause a severe clinical type of smallpox rather than a mild infection. Doubtless the question of repeated exposure is also of importance, since it is conceivable that local tissue barriers or chance conditions in the portal of entry may serve at one time to prevent actual invasion of the tissues, whereas at another time effective barriers may not attend exposure. After the primary take, as a rule, immunity is retained for many years, at least to a degree that prevents an accelerated reaction when potent cowpox virus is inoculated into the skin. In other words, for many years after successful first vaccination the rule is that only re actions of immunity will follow subsequent inoculations. There are exceptions, of course. Some individuals have reacted with accelerated takes in less than four years after the primary take, and there are cases of smallpox on record which were contracted from a few months to three years after successful vaccination. For that matter, a second attack of smallpox can occur within a few months. 398 Vol. XX, DIVISION OF PREVENTIVE MEDICINE. More rarely, individuals are- seen who give no reaction with pre sumably potent virus, several times repeated —neither an immunity reaction nor any degree of accelerated reaction. Once in a while such an individual will be found with a typical pitted scar indicative of a primary take. More often there is no scar. A number, perhaps a majority, of those who fail to have any kind of reaction give a definite or presumptive history of smallpox. These negative reactors appear to be more common among negroes and Filipinos than among whites. Whether such an individual has some kind or degree of immunity to smallpox can not very well be determined. If there is a pitted scar a certain amount of protection is probable, and it is pos sible that the individual would not become infected if exposed to smallpox. There is no way of telling short of actual inoculation with smallpox virus. Furthermore, if that were done and inoculation into the skin led to a mild case of smallpox, it could not be concluded that the individual would have had a mild attack if infected by natural means with the virus gaining entrance, presumably, through the mouth or nose. Information furnished by those who have had smallpox after unsuccessful attempts at vaccination is of interest in this connection, although of course it can not be determined that a potent virus was used or that the technique was beyond question. However, it does seem likely, in some cases at least, that the virus was potent and the inoculation satisfactory. A number of Filipino mess attendants who have failed repeatedly to react to cowpox virus have given such histories. Those referred to were vaccinated on board ship with different lots of virus, presumably potent, although it was not practicable to determine potency. It seldom is possible to vouch for the potency of virus on board ship, because very few men get on board without having been successfully vaccinated, and conse quently no susceptibles are available to demonstrate primary takes. No lot of virus can be regarded as fully potent unless it is giving 100 per cent of primary takes in a series of previously unvaccinated individuals, preferably children. A complete explanation of the meaning of the various degrees of takes is not to be found in the demonstrable results of experimental work. It is necessary to turn to general theories of immunity. For practical purposes, all the various reactions, from the primary take (vaccinia) down through decreasing grades of accelerated takes and finally the reaction of immunity, are to be regarded altogether as rep resenting merely differences in degree and not different types of re actions. If the vaccinated individual is sufficiently immune, the reaction of immunity reaches its height of intensity within 24 hours. With less immunity the reaction begins less promptly, as a rule, but in any event more time will elapse from the moment No. 3. 399 DIVISION OF PKEVENTIVE MEDICINE. of inoculation to the day of greatest intensity. The chief considera tion is the time when the reaction reaches its greatest intensity. We are indebted to Leake, of the United States Public Health Service, and to Force, of California, for extensive studies of the phenomena of vaccination as well as for the collection of much evi dence relating to the preventive value of cowpox virus and review of literature concerning smallpox. We are also indebted to Lieut. …